The Fight Over Obamacare Was a Giant Political Charade
When the U.S. Supreme Court ruled on June 25 that the Affordable Care Act’s (ACA) subsidies for health insurance for the poor were indeed constitutional, liberals cheered. The last-ditch attempt by the right to gut President Obama’s signature act failed. In his weekly address, Obama triumphantly announced that “after more than fifty votes in Congress to repeal or weaken this law; after a Presidential election based in part on preserving or repealing this law; after multiple challenges to this law before the Supreme Court, we can now say this for certain: the Affordable Care Act still stands, it is working, and it is here to stay.”
The case at the heart of the ruling was King v. Burwell, a legal challenge that was based on a technicality. The Los Angeles Times explained that legal experts saw it “as a fatuous misreading of the law and a tortured effort to bend the process of statutory interpretation for ideological ends.” But the constant attacks on the ACA, including this last attempt, were less ideological than political, and in the end, the Supreme Court ruling was an affirmation of the supremacy of capitalism over human needs.
It is true that 6.4 million Americans currently receiving subsidies for insurance would have lost their coverage had the court not voted to preserve the ACA. The vote was 6-3, with conservative Chief Justice John Roberts joining swing voter Anthony Kennedy and the four liberal stalwarts (Sonia Sotomayor, Elena Kagan, Ruth Bader Ginsburg, and Stephen Breyer). The fact that Roberts voted for it, and wrote the majority opinion, speaks volumes about what the ruling really means. According to him, “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”
That single sentence clearly lays out the problem with what the right has sardonically named “Obamacare.” In voting to preserve the health care reform law, the court sought to “improve health insurance markets,” not access to health care.
Paul Y. Song is the executive chairman of the Courage Campaign, executive board member of Physicians for a National Health Program, and co-chair of Campaign for a Healthy California. He told me in an interview on Uprising that “this was really less about protecting patients and more about protecting the health insurance industry, hospitals and all of the medical corporations.” The subsidies at stake are our tax dollars filling the coffers of private corporations in exchange for profit-based “managed care.”
Song concurred, saying, “This is less of a government-run program, but it’s a corporate bailout. It really is giving people money to buy a product from a for-profit industry that only makes money by denying care.”
The right-wing attacks on Obamacare were always about attempting to delegitimize the president rather than the actual substance of a pro-corporate health reform law. Indeed, Republicans long ago suggested similar reform proposals, such as the health exchanges, to those at the heart of the ACA. “Had anyone else proposed this,” said Song, “I think the Republicans would have said, ‘Wow this is a great idea.’”
The GOP’s relentless attacks on the ACA left progressives in the awkward position of having spent the last five years defending a pro-corporate law that the right would have ordinarily salivated over. As Michael Moore wrote in the New York Times, “Obamacare is awful. That is the dirty little secret many liberals have avoided saying out loud for fear of aiding the president’s enemies.”
When the Supreme Court ruled to preserve the ACA, privately some Republicans expressed relief, knowing that if 6.4 million Americans relying on subsidies had suddenly lost them, the GOP would have paid a stiff political price.
The act of opposing the law at any cost has given Republicans legitimacy among their right-wing supporters for targeting Obama while ultimately getting what they want, which is a pro-corporate law. For Democrats, supporting Obamacare has given them the appearance of caring about medical bankruptcies and the plight of the uninsured. And Obama has won by achieving the seemingly impossible task of passing health care reform, while also propping up private industry. In the end, the fight over the ACA has resulted in wins for the Republican Party, the Democratic Party, the health insurance industry and the president.
Health Insurance Companies Seek Big Rate Increases for 2016
By ROBERT PEAR
WASHINGTON — Health insurance companies around the country are seeking rate increases of 20 percent to 40 percent or more, saying their new customers under the Affordable Care Act turned out to be sicker than expected. Federal officials say they are determined to see that the requests are scaled back.
Blue Cross and Blue Shield plans — market leaders in many states — are seeking rate increases that average 23 percent in Illinois, 25 percent in North Carolina, 31 percent in Oklahoma, 36 percent in Tennessee and 54 percent in Minnesota, according to documents posted online by the federal government and state insurance commissioners and interviews with insurance executives.
The Oregon insurance commissioner, Laura N. Cali, has just approved 2016 rate increases for companies that cover more than 220,000 people. Moda Health Plan, which has the largest enrollment in the state, received a 25 percent increase, and the second-largest plan, LifeWise, received a 33 percent increase.
Jesse Ellis O’Brien, a health advocate at the Oregon State Public Interest Research Group, said: “Rate increases will be bigger in 2016 than they have been for years and years and will have a profound effect on consumers here. Some may start wondering if insurance is affordable or if it’s worth the money.”
President Obama, on a trip to Tennessee this week, said that consumers should put pressure on state insurance regulators to scrutinize the proposed rate increases. If commissioners do their job and actively review rates, he said, “my expectation is that they’ll come in significantly lower than what’s being requested.”
The rate requests, from some of the more popular health plans, suggest that insurance markets are still adjusting to shock waves set off by the Affordable Care Act.
It is far from certain how many of the rate increases will hold up on review, or how much they might change. But already the proposals, buttressed with reams of actuarial data, are fueling fierce debate about the effectiveness of the health law.
A study of 11 cities in different states by the Kaiser Family Foundation found that consumers would see relatively modest increases in premiums if they were willing to switch plans. But if they switch plans, consumers would have no guarantee that they can keep their doctors. And to get low premiums, they sometimes need to accept a more limited choice of doctors and hospitals.
Some say the marketplaces have not attracted enough healthy young people. “As a result, millions of people will face Obamacare sticker shock,” said Senator John Barrasso, Republican of Wyoming.
By contrast, Marinan R. Williams, chief executive of the Scott & White Health Plan in Texas, which is seeking a 32 percent rate increase, said the requests showed that “there was a real need for the Affordable Care Act.”
“People are getting services they needed for a very long time,” Ms. Williams said. “There was a pent-up demand. Over the next three years, I hope, rates will start to stabilize.”
Sylvia Mathews Burwell, the secretary of health and human services, said that federal subsidies would soften the impact of any rate increases. Of the 10.2 million people who obtained coverage through federal and state marketplaces this year, 85 percent receive subsidies in the form of tax credits to help pay premiums.
In an interview, Ms. Burwell said consumers could also try to find less expensive plans in the open enrollmentperiod that begins in November. “You have a marketplace where there is competition,” she said, “and people can shop for the plan that best meets their needs in terms of quality and price.”
Blue Cross and Blue Shield of New Mexico has requested rate increases averaging 51 percent for its 33,000 members. The proposal elicited tart online comments from consumers.
“This rate increase is ridiculous,” one subscriber wrote on the website of the New Mexico insurance superintendent.
In their submissions to federal and state regulators, insurers cite several reasons for big rate increases. These include the needs of consumers, some of whom were previously uninsured; the high cost of specialty drugs; and a policy adopted by the Obama administration in late 2013 that allowed some people to keep insurance that did not meet new federal standards.
“Healthier people chose to keep their plans,” said Amy L. Bowen, a spokeswoman for the Geisinger Health Plan in Pennsylvania, and people buying insurance on the exchange were therefore sicker than expected. Geisinger, often praised as a national model of coordinated care, has requested an increase of 40 percent in rates for its health maintenance organization.
Insurers with decades of experience and brand-new plans underestimated claims costs.
Progressive Critics of Obamacare Are Still Not Happy: Is Glass Half Empty or Half Full?
By Steven Rosenfeld / AlterNet
July 1, 2015
Now that the U.S. Supreme Court has saved Obamacare—The Affordable Care Act—for the second time and signs of relief from its supporters have subsided, there is a certain amount of buyer’s remorse circulating in liberal media circles.
“In the post-A.C.A. era, you can be insured but have little or no coverage for what you actually need,” writes Trudy Lieberman in Harper’s July issue, in a feature entitled, Wrong Prescription? The Failed Promise of the Affordable Care Act. “The A.C.A.’s greatest legacy may finally be the fulfillment of a conservative vision laid out three decade ago, which sought to transform American health care into a market driven system.”
Writing in The Nation—and posted on AlterNet—Kai Wright listed three steps that must happen for a better “functioning and equitable healthcare system.” He cited expanding enrollment in Medicaid—state-subsidized care for poorer people—in the 22 states that have not done so; making sure the coverage offered is sufficient and is not undermined by unaffordable co-pays; and hoping that state insurance regulators will do more to prevent predatory price hikes.
Chief among the gripes, however, is that Obamacare is anything but the long-sought dream of universal health care—a right, not a privilege nor a profit center. In other words, now that Obamacare is not going to be swept away by Republicans who are unable to get past a White House veto or win in the highest courts, what remains is not so wonderful, affordable or even historic—unless what’s historic is the missed opportunity.
Whenever a federal reform involves one-sixth of the U.S. economy, which is the size of the health care sector, it’s always possible to cherry pick gripes and praise. But it seems like the latest whacks at Obamacare from the liberal left are a bit unfair, as they overly emphasize what’s long been dysfunctional in the political process, and in the insurance industry’s middleman role—while ignoring what the law has actually achieved.
For idealists like Harper’s Lieberman, Obamacare is not just a cup that’s more than half empty, it’s a trail of tears and fears and political cowardice. As she enumerates, nobody read the bill before it passed. The public doesn’t understand it. There’s been no criticism of it from the left. Its messaging was shaped by Democratic pollster Celinda Lake. It is not offering citizens what other industrialized nations have. Yes, it’s aimed at the poor, but Obama’s promise that nobody would lose coverage was a lie. It’s “fattening up the health care industry and hollowing out coverage for the middle-class.”
It’s hard to know if Lieberman realizes that her criticisms echo Republican talking points spread coast-to-coast by the Koch brother’s propaganda. She barely acknowledges multi-millions spent on political messaging trashing it—which shapes public misunderstanding. She grimaces that Democrats didn’t do more to stand up for a better reform, even though plenty of progressives absolutely called for Medicare-for-all, which Obama rejected.
But worst of all, she says it isn’t really helping the poor because even with subsidies, too many people can’t afford co-pays to get follow-up care. “Having failed a substantial part of the population it was actually designed to help, the A.C.A. is also wreaking havoc on the middle class, much of which had good insurance to begin with,” she writes.
I don’t what benevolent universe of wonderful middle-class health insurance policies she is refering to. I have been self-employed for most of my life. That meant ever-increasing premiums—with 25 percent or more spikes every five years after turning 50. That meant not being able to buy a new policy, because no one would sell one because of advancing age—the excuse was pre-existing conditions. That meant paying high COBRA rates—110-plus percent of you prior premium to keep a health plan. Plenty of my friends went years without any coverage, relying on diet and exercise and hoping they didn’t end up in a hospital. In all of those instances, Obamacare created options or softened blows.
The Choice Ahead: A Private Health-Insurance Monopoly or a Single Payer
by Robert Reich
The Supreme Court's recent blessing of Obamacare has precipitated a rush among the nation's biggest health insurers to consolidate into two or three behemoths.
The result will be good for their shareholders and executives, but bad for the rest of us -- who will pay through the nose for the health insurance we need.
We have another choice, but before I get to it let me give you some background.
Last week, Aetna announced it would spend $35 billion to buy rival Humana in a deal that will create the second-largest health insurer in the nation, with 33 million members.
The combination will claim a large share of the insurance market in many states -- 88 percent in Kansas and 58 percent in Iowa, for example.
A week before Aetna's announcement, Anthem disclosed its $47 billion offer for giant insurer Cigna. If the deal goes through, the combined firm will become the largest health insurer in America.
Meanwhile, middle-sized and small insurers are being gobbled up. Centene just announced a $6.3 billion deal to acquire Health Net. Earlier this year Anthem bought Simply Healthcare Holdings for $800 million.
Executives say these combinations will make their companies more efficient, allowing them to gain economies of scale and squeeze waste out of the system.
This is what big companies always say when they acquire rivals.
Their real purpose is to give the giant health insurers more bargaining leverage over employees, consumers, state regulators and healthcare providers (which have also been consolidating).
The big health insurers have money to make these acquisitions because their Medicare businesses have been growing and Obamacare is bringing in hundreds of thousands of new customers. They've also been cutting payrolls and squeezing more work out of their employees.
This is also why their stock values have skyrocketed. A few months ago the Standard & Poor's (S&P) 500 Managed Health Care Index hit its highest level in more than twenty years. Since 2010, the biggest for-profit insurers have outperformed the entire S&P 500.
Insurers are seeking rate hikes of 20 to 40 percent for next year because they think they already have enough economic and political clout to get them.
That's not what they're telling federal and state regulators, of course. They say rate increases are necessary because people enrolling in Obamacare are sicker than they expected, and they're losing money.
Remember, this an industry with rising share values and wads of cash for mergers and acquisitions.
It also has enough dough to bestow huge pay packages on its top executives. The CEOs of the five largest for-profit health insurance companies each raked in $10 to $15 million last year.
After the mergers, the biggest insurers will have even larger profits, higher share values, and fatter pay packages for their top brass.
There's abundant evidence that when health insurers merge, premiums rise. For example, Leemore Dafny, a professor at the Kellogg School of Management at Northwestern University, and his two co-authors, foundthat after Aetna merged with Prudential HealthCare in 1999, premiums rose 7 percent higher than had the merger not occurred.
The problem isn't Obamacare. The real problem is the current patchwork of state insurance regulations, insurance commissioners, and federal regulators can't stop the tidal wave of mergers, or limit the economic and political power of the emerging giants.
Which is why, ultimately, American will have to make a choice.
If we continue in the direction we're headed we'll soon have a health insurance system dominated by two or three mammoth for-profit corporations capable of squeezing employees and consumers for all they're worth -- and handing over the profits to their shareholders and executives.
The alternative is a government-run single payer system -- such as is in place in almost every other advanced economy -- dedicated to lower premiums and better care.
Which do you prefer?
With Merging of Insurers, Questions for Patients About Costs and Innovation
By REED ABELSON
The nation’s five largest health insurance companies are circling one another like hungry lions closing in on prey.
On Friday, Aetna said it would acquire its smaller rivalHumana to create a company with combined revenues of $115 billion this year. Anthem is stalking Cigna. UnitedHealth Group, now the largest of the five, is looking at its options. At the end of the maneuverings, three national behemoths are likely to emerge.
There is also a scramble among the smaller insurers. On Thursday, Centene, which specializes in offering Medicaid coverage, said it planned to buy Health Net, a for-profit insurer with headquarters in Los Angeles.
As insurers grow larger, will consumers benefit from the companies’ ability to bargain with hospitals and doctors for lower prices? Will diminishing competition translate to fewer choices of plans? And what effect will mergers have on innovation in health care?
The answers depend largely on how successfully the other insurers, particularly those that were created or attracted by the Affordable Care Act, can compete with these much larger companies.
“All politics are local,” the saying goes, and it is similarly so with insurance companies.
The big (and getting bigger) for-profit companies — which make most of their revenue from employer and Medicare and Medicaid plans — still face significant competition from the regional or state-based nonprofit Blue Cross and Blue Shield plans, particularly in the market for employer-based coverage.
“What people miss is the regional strength of regional Blue Cross plans,” said Paul H. Keckley, the managing director for the Navigant Center for Healthcare Research and Policy Analysis.
Blue Cross Blue Shield plans, including the for-profit versions owned by Anthem in 14 states, have traditionally dominated the markets for individuals and employers. In more than 30 states, a nonprofit Blue Cross sells the most policies to large employers, with almost a dozen capturing three-quarters of the market, according to 2013 data from the Kaiser Family Foundation, the latest information it has compiled.
The large for-profit insurers do not have a significant presence in about a dozen states, including Massachusetts, Minnesota, Oregon and Washington, according to the Kaiser data. “They have national share, but they don’t have big share in a lot of places,” said Gary Claxton, an executive with the Kaiser Family Foundation.
The picture is different outside the employer market, however. In the business of selling private Medicareplans, which the insurers offer as an alternative to the traditional Medicare program, the five companies — particularly UnitedHealth and Humana — command about half the market, according to Kaiser data from 2015. The big for-profits are frequently the dominant players in an individual state, and the proposed combination of Aetna and Humana will create a larger force in that market.
In an interview about the proposed combination of Aetna and Humana, Mark T. Bertolini, Aetna’s chairman and chief executive, emphasized the need to be large enough to invest the capital and resources necessary to be competitive in a rapidly changing environment.
“People who did not invest significantly enough in health care reform and a retail marketplace are going to struggle,” said Mr. Bertolini, who, at the combined company, would assume the same roles he has at Aetna.
The smaller companies will have a harder time accomplishing the transition, he said.
In Health Law, a Boon for Diet Clinics
By RACHEL ABRAMS and KATIE THOMAS
Dr. Michael Kaplan looked across his desk at a woman who had sought out his Long Island Weight Loss Institute and asked the question he often poses to new patients: “Where do you think you go wrong with food?”
The 38-year-old patient was about 20 pounds overweight and, as she described it, desperate. Weight Watchers, nutritionists — she had tried them all in vain. A physician like Dr. Kaplan, she reasoned, might be the only one left who could help her. “I’m really tired of it,” the woman said one recent afternoon, declining to give her name to a reporter. “I feel like something is off with me.”
Dr. Kaplan, a leader in the medical weight-loss industry, nodded sympathetically, interjecting questions that ranged from what she typically ate for breakfast (protein shake) to whether she felt depressed (sometimes). By the end of the 50-minute session, the woman had chosen Dr. Kaplan’s most expensive weight-loss plan: $1,199 for six weeks’ worth of meal-replacement products, counseling and vitamin supplements.
Then he delivered some good news: Her insurance would probably reimburse her for at least a small portion of the bill, thanks to a provision in the federal health care law that requires insurers to pay for nutrition and obesity screening.
The news was pleasing to the patient. But it has also created a financial opportunity for a corner of the diet industry that has often operated on the fringe of the medical establishment: for-profit diet clinics overseen by doctors.
“It’s really a game changer,” said John LaRosa, research director at Marketdata Enterprises, who has studied the weight-loss industry for more than 20 years.
Mr. LaRosa estimates that medical weight-loss programs, which include those run by hospitals as well as clinics, bring in $1 billion annually and that the market will grow about 5 percent a year through 2019.
The prospects are so lucrative that in March, Mr. LaRosa sponsored a seminar advising entrepreneurs how to open their own weight-loss clinics to take advantage of the new stream of insurance coverage.
And Dr. Kaplan recently started a consulting business to teach primary-care doctors how to bill insurers for obesity treatments.
“We’ve been in a rapid expansion mode as a result of the insurance companies covering obesity treatment,” Dr. Kaplan said. He estimated that a doctor could earn as much as $3,000 more a year for each obese patient, according to promotional materials for his new company, Obesity Management Systems.
But the prospect of rapid growth in the diet-clinic industry, fed by insurance payments, has exposed deep philosophical differences on the best ways to help patients lose weight.
Obesity specialists at major medical centers say the proprietors of diet clinics often employ unproven tactics — like vitamin injections, costly supplements and extreme diet plans — that lure customers but do not lead to lasting results. Diet-clinic owners contend that they are filling a needed role because the mainstream medical establishment pays little attention to patients’ struggles with weight.
Meanwhile, Americans keep piling on the pounds. In 2013, the American Medical Association classified obesity — defined as having a body mass index of 30 or higher — as a disease, and solving the obesity epidemic came to be viewed as one of the nation’s most pressing public health challenges. Beyond the federal requirement that insurers cover obesity screening, many states go further, requiring coverage that ranges from basic counseling to weight-loss surgery.
Sustained weight loss is notoriously difficult to achieve. Lasting results require long-term care and follow-up, said Michael D. Jensen, the director of the obesity treatment research program at Mayo Clinic in Rochester, Minn., who has studied the effectiveness of weight-loss programs.
“It just takes most people so long to make permanent changes in eating or activity habits,” he said. “There’s always this search for the quick fix, and usually you can find somebody who’s willing to sell it to you.”
Top-Selling Diet Drug Phentermine Is Cheap and Easy to Get
By KATIE THOMAS
The Food and Drug Administration has approved several new weight-loss drugs in recent years, but the best-selling diet pill in America isn’t among them.
That title belongs to phentermine, a generic drug that has been around for decades and has managed to hold its own despite the arrival of new competitors.
The drug is viewed as effective and relatively safe to help jump-start diets in patients who are obese. However, phentermine — a stimulant that can give users an inexpensive high — has a long history of misuse. It has also frequently flown under the radar of regulators, who tend to focus their resources on deadlier drugs like opioid painkillers.
Adding to the concern is the fact that many doctors have an incentive to recommend it: Phentermine is a mainstay of weight-loss clinics nationwide, prescribed by physicians who profit by selling the pill to patients. Fans of the drug trade tips on social media sites and websites like phentermine.com, where users refer to each other as “phrends” and share the names of doctors who will prescribe it with few questions asked.
“There’s just not enough resources to shut down everybody that should be shut down,” said Carmen A. Catizone, executive director of theNational Association of Boards of Pharmacy.
Phentermine’s staying power has persisted despite F.D.A. approval of four new weight-loss products since 2012, all of which arrived with great fanfare but whose sales have so far failed to live up to expectations.
Phentermine — approved in 1959 and now made by several manufacturers — commands 80 percent of the market for diet drugs, according to IMS Health, which tracks prescription drug use.
Phentermine is inexpensive, often going for about $30 for a month’s supply. The newer drugs, by contrast, can cost hundreds of dollars a month and are sometimes not covered by insurance.
California tax officials blast Blue Shield in audit
by Chad Terhune
In a scathing audit, state tax officials slammed nonprofit health insurer Blue Shield of California for stockpiling "extraordinarily high surpluses" — more than $4 billion — and for failing to offer more affordable coverage or other public benefits.
The California Franchise Tax Board cited those reasons, among others, for revoking Blue Shield's state tax exemption last year, according to documents related to the audit that were reviewed by The Times. These details have remained secret until now because the insurer and tax board have refused to make public the audit and related records.
Blue Shield's operations are indistinguishable from those of its for-profit healthcare competitors, the auditors found, and it should be stripped of the tax break it has enjoyed since its founding in 1939. The insurance giant does not advance social welfare, the key test for preserving its tax exemption, according to the records.
"Blue Shield is not operating exclusively for the promotion of civic betterment or social welfare," tax board officials Christie Maddox and Eddie Murillo-Corona wrote to the insurer in a 16-page report sent June 3, 2014.
The August 2014 revocation came to light when The Times reported the news in March. The tax board rejected a public-records request for the audit and related information on Blue Shield, citing the confidentiality of taxpayer information under state law.
Since the revocation became public, Blue Shield has come under increasing scrutiny from regulators, lawmakers and consumer groups over its massive financial reserves and its proposed purchase of a Medicaid insurer for $1.2 billion.
Blue Shield is the state's third-largest health insurer with 3.4 million customers, 5,000 employees and $13.6 billion in revenue last year.
Paying People to Be Healthy Usually Works, if the Public Can Stomach It
Few people seem comfortable with the idea of paying patients to do what we want them to do.
That’s unfortunate, because there’s a significant amount of research that says this works.
I’m not talking about things like wellness programs, which offer reductions in insurance premiums if you do what your employer wants. Those are really a means of cost-sharing in which expenses are shifted onto people who are less healthy. I’m talking about paying incentives directly to people in exchange for changes to their behavior or health.
A recent study published in the New England Journal of Medicine compared various programs that encourage people to quit smoking. The interventions were altered with subtle changes to see what types of programs might achieve better results. In the most successful one, people earned large monetary rewards — with a catch.
Smokers were enrolled in a smoking-cessation program in groups of six. They were checked at 14 days, 30 days, six months and one year. At each of the first three checks, participants received $100 for each group member who was still abstaining from smoking. They could earn up to $600 at each of three time points, as well as a $200 bonus available at six months. In other words, they could potentially earn up to $2,000 each for quitting, depending on how many in their group remained smoke-free.
These incentives worked. At six months, 16 percent of the participants in this program remained smoke-free compared with 6 percent of those who quit through other methods, without such payments. Although about half of these people reverted to smoking by 12 months, so did half of those in the control group, meaning that the program still resulted in significantly more people quitting smoking.
Bring Back Prostate Screening
By DEEPAK A. KAPOOR
FOR years, research on prostate cancer has sought an approach to screening that is more individualized than a one-size-fits-all measurement of the level of prostate-specific antigen in a man’s blood. These efforts are now paying off.
That’s why it’s time to re-evaluate the nation’s current approach to prostate cancer. Even though we anticipate 221,000 new diagnoses this year, and 28,000 deaths, recommendations drafted in 2010 and finalized in 2012 strongly discourage PSA screening men without symptoms for this disease.
Those decisions didn’t take into account adaptations that urologists have made to help better identify patients likely to develop deadly prostate cancers. Some tools, called PSA derivatives, were being developed as early as the mid-1990s, and all have been refined since.
The result: Rather than use the historical arbitrary cutoff of a 4.0 PSA reading to define abnormal, we now have tools to adjust our interpretation of readings for age (PSA levels normally rise with age); for race (this, too, affects what is considered normal); and for the size of a man’s prostate, which affects how much PSA he produces. We can test for how fast PSA levels rise over time. And we can analyze how PSA circulates in the bloodstream (free or bound to serum proteins), which can predict prostate cancer risk.
When we use these markers together, these varied interpretations of PSA levels give us a clearer picture of who does, or doesn’t, need further testing.
And we keep refining our approach. Already, a urine test can find and measure the presence of genes associated with prostate cancer. M.R.I. images can help identify high-risk prostate lesions. And tests for the presence or activity, or both, of genes present in prostate tissue can help distinguish which patients can safely defer therapy from those who cannot.
When prostate cancer is found, we also have better actuarial data to help identify those men likely to live long enough for that cancer to become a fatal risk.
Nevertheless, in 2012 the United States Preventive Services Task Force made official its recommendationthat no asymptomatic man undergo screening with a PSA test. And that decision grew in importance when the Affordable Care Act elevated the task force’s recommendations from advisory to a basis for Medicarepayment policies.
To be fair, measuring PSA as a stand-alone test is far from perfect. Cancer is just one of several conditions that can elevate PSA Using the test alone often led to painful biopsies that found no cancer. And we faced a more difficult problem: Even when a biopsy found cancer, uncertainty remained. If aggressive cancer was present, a decision to treat it was straightforward. But prostate cancer can grow slowly or remain dormant — indolent, in medical parlance. And until recently, we didn’t have the tools to determine whether cancers were likely to spread quickly enough to shorten the patient’s life.
S.F. officials worry about how Obamacare could affect vulnerable residents
Nearly 10 years ago, this county by the bay known for its progressive political leaps became one of the first in the nation to offer residents universal access to healthcare.
Now the federal Affordable Care Act has been rolled out nationwide with the same goal in mind. But in an ironic twist, officials in this city are worried the new law could adversely affect some of the most vulnerable San Franciscans.
The local health program known as Healthy San Francisco, which has served as many as 60,000 patients annually since its creation in 2007, is almost free.
Obamacare plans, however, are not. They come with government subsidies that bring down costs, but premiums, co-pays and deductibles can still add up to hundreds or thousands of dollars a year. That's more than many people can afford, health advocates say.
"It's definitely not a fix-all yet," said Elizabeth Sekera, a director of a long-established clinic in downtown that treats patients in Healthy San Francisco.
County officials here are weighing ways to help residents pay for insurance plans offered through Covered California, the state's health insurance exchange that was created through Obamacare. Some argue the plans won't be truly affordable, and the promise of healthcare reform won't be fulfilled, without the extra assistance.
The debate reflects one of the many challenges local leaders face as they seek to adapt to the sweeping changes prompted by the Affordable Care Act. With millions of Americans newly insured under the law, state and county governments have had to downsize or reorient public healthcare programs that previously served many of those patients.
In the process, they've also faced potentially costly and politically sensitive issues, such as extending coverage to people in the country illegally and deciding when to limit taxpayer expenditures on those who remain without insurance for various reasons.
Sekera works at Lyon-Martin Health Services, tucked away in a now-trendy corner of Market Street, with its brick sidewalks and overhead cables. Marked by a plain sign above the entrance, the clinic has operated here for more than 30 years, serving some of San Francisco's poorest residents.
