Health Care Reform Articles - January 9, 2020

Report claims healthcare plan could reduce costs, cover everyone in Maine

by Ruth Leubecker - Machias Valley News Observer - December 29, 2019

An all-encompassing healthcare proposal could save Maine $1.5 billion in healthcare spending, according to a new analysis released by Maine AllCare.
“When every Mainer is covered, and there is never a bill to patients. When doctors are paid promptly, and everyone contributes on a sliding scale, we will truly have a caring and cost-effective system,” says Joe Lendvai, stressing the plan’s simplicity and fairness.
Lendvai is a founding member of Maine AllCare, a nonprofit, nonpartisan organization founded in 2012 as a chapter of Physicians for a National Health Program. The report, “Assessing the Costs and Impacts of a State-Level Universal Health Care System in Maine,” was commissioned by Maine AllCare to determine how such a system could be financed.
Historically, there has never been the political will to attack such a formidable project. “When the subject comes up, people always ask ’How are you going to pay for it?’ but the truth is we already pay more for health care than any other developed nation,” says Henk Goorhuis, MD, and board chair of Maine AllCare. “We’re doing this while families continue to skip doctor’s visits, or otherwise forgo necessary care because they can’t afford it.”
Under the model studied by MECEP (Maine Center for Economic Policy), federal programs like Medicare and Medicaid would remain intact, and a state-operated program would cover the remaining 652,000 uninsured and underinsured Mainers, while

also picking up those inadequately covered by private insurance. Covering coverage gaps and eliminating out-of-pocket expenses, the proposal also provides dental, vision and hearing benefits to every Maine resident.
About 80 percent of this new publicly funded system would be financed by funds now being spent on premiums, deductibles and out-of-pocket costs. The remainder, estimated at $1 billion by MECEP in the report, would be paid for by raising taxes. However, several potential revenue sources could make this tax more palatable. Those 80 percent would see an appreciable net gain in their family net income due to the absence of premiums and additional costs at the pharmacy counter. Municipalities and counties would see a savings of $214 million, or 8.3 percent in property tax, which translates into a reduction of 1.5 mills.
The report also claims that employers would pay the same or less than they do today. Workers Compensation would be cut in half, and employers would eliminate the cost of choosing and managing their healthcare coverage.
Hospitals would be paid promptly and directly at Medicare rates. It follows that over 2,900 administrative jobs in healthcare would be lost, due to the simplified system, but the model assumes that retraining costs would become part of the transition.
“I think the only thing we’re lacking is the political will to do it,” says Lynn Cheney, longtime board member and champion of Maine AllCare. “I’ve been an ACA navigator since the beginning, and I’m really worried about the underinsured.
“The ACA bronze plan, for instance, comes with a $6,000 deductible. I don’t even call that health coverage.”
When hearing about the Maine AllCare proposal, for most people the immediate assumption is that it is unaffordable. Recognizing Maine as the oldest state in the nation and rapidly growing more so, Cheney says they decided to take action.

“We decided to do this study for Maine, and thanks to a Stephen King grant we could do that,” she explains. “I think it’s very doable, but it’s a political thing. On December 16, we had a meeting in Augusta and that raised a lot of good questions.”
That meeting was well attended by members of the Joint Committee on Health Coverage, Insurance and Financial Services. Although a necessary first step, a lot of road work in the form of dispensing information remains.
“I think Jeanne Lambrew has impressive credentials and Gov. Mills understands the need, but this will be bogged down in the politics,” says Cheney. “I think it’s going to take more push from the bottom. The voters.”
The study supporting the analysis looked at health care cost scenarios based on seven different families, of varying sizes and incomes, ranging from $10,000 to $500,000. All but the highest would see savings under the analyzed model, with the state-level plan bringing significant benefits to Maine residents. An accompanying survey will be released later this month. 
https://machiasnews.com/report-claims-healthcare-plan-could-reduce-costs-cover-everyone-maine 

Every American family basically pays an $8,000 ‘poll tax’ under the U.S. health system, top economists say

by Anne Young - Washington Post - January 7, 2020

SAN DIEGO — America’s sky-high health-care costs are so far above what people pay in other countries that they are the equivalent of a hefty tax, Princeton University economists Anne Case and Angus Deaton say. They are surprised Americans aren’t revolting against these taxes.
“A few people are getting very rich at the expense of the rest of us,” Case said at conference in San Diego on Saturday. The U.S. health-care system is “like a tribute to a foreign power, but we’re doing it to ourselves.”

The U.S. health-care system is the most expensive in the world, costing about $1 trillion more per year than the next-most-expensive system — Switzerland’s. That means U.S. households pay an extra $8,000 per year, compared with what Swiss families pay. Case and Deaton view this extra cost as a “poll tax,” meaning it is levied on every individual regardless of their ability to pay. (Most Americans think of a poll tax as money people once had to pay to register to vote, but “polle” was an archaic German word for “head.” The idea behind a poll tax is that it falls on every head.)
Despite paying $8,000 more a year than anyone else, American families do not have better health outcomes, the economists argue. Life expectancy in the United States is lower than in Europe.
“We can brag we have the most expensive health care. We can also now brag that it delivers the worst health of any rich country,” Case said.
Case and Deaton, a Nobel Prize winner in economics, made the critical remarks about U.S. health care during a talk at the American Economic Association’s annual meeting, where thousands of economists gather to discuss the health of the U.S. economy and their latest research on what’s working and what’s not.
The two economists have risen to prominence in recent years for their work on America’s “deaths of despair.” They discovered Americans between the ages of 25 and 64 have been committing suicide, overdosing on opioids or dying from alcohol-related problems like liver disease at skyrocketing rates since 2000. These “deaths of despair” have been especially large among white Americans without college degrees as job options have rapidly declined for them.
Their forthcoming book, “Deaths of Despair and the Future of Capitalism,” includes a scathing chapter examining how the U.S. health-care system has played a key role in these deaths. The authors call out pharmaceutical companies, hospitals, device manufacturers and doctors for their roles in driving up costs and creating the opioid epidemic.

“Deaths of despair” have risen rapidly in the United States since 2000 for 25-to-64-year-old Americans without college degrees. (Chart courtesy of economist Anne Case).

In the research looking at the taxing nature of the U.S. health-care system compared with others, Deaton is especially critical of U.S. doctors, pointing out that 16 percent of people in the top 1 percent of income earners are physicians, according to research by Williams College professor Jon Bakija and others.
“We have half as many physicians per head as most European countries, yet they get paid two times as much, on average,” Deaton said in an interview on the sidelines of the AEA conference. “Physicians are a giant rent-seeking conspiracy that’s taking money away from the rest of us, and yet everybody loves physicians. You can’t touch them.”
As calls grow among the 2020 presidential candidates to overhaul America’s health-care system, Case and Deaton have been careful not to endorse a particular policy.
“It’s the waste that we would really like to see disappear,” Deaton said.
After looking at other health systems around the world that deliver better health outcomes, the academics say it’s clear that two things need to happen in the United States: Everyone needs to be in the health system (via insurance or a government-run system like Medicare-for-all), and there must be cost controls, including price caps on drugs and government decisions not to cover some procedures.
The economists say they understand it will be difficult to alter the health-care system, with so many powerful interests lobbying to keep it intact. They pointed to the practice of “surprise billing,” where someone is taken to a hospital — even an “in network” hospital covered by their insurance — but they end up getting a large bill because a doctor or specialist who sees them at the hospital might be considered out of network.
Surprise billing has been widely criticized by people across the political spectrum, yet a bipartisan push in Congress to curb it was killed at the end of last year after lobbying pressure.
“We believe in capitalism, and we think it needs to be put back on the rails,” Case said.
https://www.washingtonpost.com/business/2020/01/07/every-american-family-basically-pays-an-poll-tax-under-us-health-system-top-economists-say/?
  

Let nurse practitioners work alone

Mass. should join other states in clearing a key hurdle to primary care.

By The Editorial Board - Boston Globe - January 8, 2020

What do patients really want when they have a bad sore throat or relentless back pain? To schedule a medical appointment without a ridiculous wait, get a referral to a specialist if needed, and escape with minimal financial damage — and, by the way, to get better.
Here’s what they don’t care about: which tribe within the medical community gets paid.
Legislation currently pending on Beacon Hill would move Massachusetts into the mainstream by loosening the restrictions on nurse practitioners, highly trained professionals who are certified to provide primary and specialty care and could easily be treating more of those coughs and muscle cramps than they do now. The bill would give patients more options, and could be especially important in underserved parts of the state where finding primary care remains a challenge. And by strengthening primary and preventative care, the legislation should improve public health and save money, too.
Nurses complete a master’s or doctorate degree and undergo extensive training to be licensed as nurse practitioners. They are trained to make diagnoses, order tests, and prescribe medicines. Right now, though, the roughly 10,500 nurse practitioners in Massachusetts must work under the supervision of an MD who has to review any prescriptions they write.
Massachusetts is one of the most restrictive states for nurse practitioners in the country. Doctors often exact hundreds or thousands of dollars in monthly fees from the nurse practitioners under their supervision — for doing work that the nurse practitioners are perfectly capable of doing on their own.
It’s an arrangement that doctors are battling hard to keep, arguing that nurse practitioners aren’t as well trained as MDs. But in states that allow nurse practitioners to operate independently — including every other New England state — there has been no documented damage to patient outcomes. On the contrary, studies compiled by the California Health Care Foundation suggest allowing nurse practitioners to work alone leads to fewer preventable hospitalizations and emergency room visits.
Superficially, the need for this reform in Massachusetts may not strike the Legislature as pressing. After all, when it comes to primary care, Massachusetts definitely is in better shape than most states. In fact, according to federal statistics, it had the largest surplus of primary care doctors in the country (Texas, meanwhile, had the biggest deficit). But the statewide statistics are skewed by the concentration of doctors in the medical mecca of Greater Boston. In rural parts of Western Massachusetts, some towns reported having no primary care physicians at all, and the federal government considers some areas of the state (including some parts of Boston) medically underserved.
Those are just the sort of areas that see more service when states allow nurse practitioners to operate independently, a 2018 study found.
It’s also worth it to curb the growing health care costs in the Commonwealth. The state’s medical costs watchdog, the Massachusetts Health Policy Commission, has recommended the state “amend scope of practice laws that are restrictive and not evidence-based.”
The agency has also noted, “These laws may represent an unnecessary barrier to cost-effective care.” Allowing advanced nurses to operate more freely and without making payments to doctors, it projected, would lead to a large increase in their numbers in the state.
Historically, as the Globe’s sister publication STAT has pointed out, laws restricting the scope of practice for nurses have carried a sexist tinge. Doctors have generally been male, and nurses generally female. Whatever their origins, such holdover laws just put up needless obstacles to health care access. Massachusetts may not have the same struggle as other states to attract primary care doctors but, even here, pockets of the Commonwealth are underserved and need the extra care that nurse practitioners could provide.
https://www.bostonglobe.com/2020/01/08/opinion/let-nurse-practitioners-work-alone/

Black distrust deepens against the medical community

Too many black people were forced to suffer by doctors more attuned to their own biases than their patients’ pain.

by Renee Graham - Boston Globe - January 7, 2020

As emergency medical technicians took my father to an ambulance, my mother, concerned about the temperature’s wintry bite, draped his favorite leather jacket over him for warmth.

“Oh, don’t worry about the cold,” a female EMT told her. “He won’t feel it.”

What I didn’t know then was how common it is for those who pledge to “first, do no harm” to discount black people’s capacity for pain.

This grievous act of racist malpractice is well-documented, most recently regarding the opioid crisis. According to “Trends in Black and White Opioid Mortality in the United States, 1979–2015,” published in Epidemiology, black patients were prescribed painkillers at a lower rate than their white counterparts. Analyzing the data, The New York Times concluded that had the numbers been equal, more than 14,000 black people would have died during that period from prescription opioid-related causes.

To be clear, doctors weren’t safeguarding black patients from the highly addictive drugs. Researchers say physicians’ motives were often driven by racial stereotyping, not medical magnanimity. Some worried that black people would sell their medication, or had a greater susceptibility to addiction.

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But mostly, they believed these black lives mattered less. Patients were forced to self-medicate, sometimes with illegal drugs, because pain does not discriminate. They missed work, pushing them toward financial ruin. They died in pain that their doctors refused to recognize or under-treated.
Now with deaths of black people from opioids skyrocketing, the medical community has found yet another discriminating twist: black people addicted to opioids are less likely to receive drugs that alleviate cravings and decrease fatal overdoses.
This has deepened the canyon-wide and centuries-old distrust many African-Americans have toward the medical community.
Those suspicions have roots in white medical and scientific malfeasance. In the 19th century, Louis Agassiz, a Harvard professor, promoted junk science claiming different races were separate, unequal species. The goal, of course, was to render African-Americans as less than human. It was an Ivy League justification of white supremacy as the natural order.
In the infamous decades-long “Tuskegee experiment,” hundreds of poor black men, told they were receiving free medical care, went untreated for syphilis so doctors could track the disease’s progression. Even after penicillin was introduced as a treatment, these men were given only aspirin or placebos. Some died, others went blind or suffered severe mental disabilities as the disease affected their brains.
For decades in New York’s Central Park, a statue honored Dr. J. Marion Sims, often called the “father of modern gynecology.” Many of the experiments that led to his groundbreaking work were conducted — without anesthesia — on enslaved black women, who had no agency over their bodies. As the debate about the removal of Confederate statues roiled in 2018, Mayor Bill de Blasio finally ordered that Sims’s statue be relocated to the Brooklyn cemetery where he is buried.
Anyone convinced such medical horror stories are consigned to the past ignores its echoes today — from the under-prescribing of painkillers to the high rates of pregnancy-related mortality among black women.
No one disputes the tragic effect that the massive over-distribution of prescription opioids has had on this nation. The number of deaths may be shrinking, but tens of thousands still perish every year. Yet there’s also no denying that too many black people were forced to suffer by doctors more attuned to their own biases than their patients’ pain.
When I finally arrived home on that bitter February morning, my mother, wearing my father’s leather jacket and suddenly a widow, tearfully shared her story about the EMT. Nearly 20 years later, I still wonder if the callousness of that woman’s comment foreshadowed how my father would be treated in his time of dying. Did he receive unequal care? If he was in pain, did the attending physician do anything to comfort him?
Would my father have lived if he were a white man?
https://www.bostonglobe.com/2020/01/07/opinion/black-distrust-deepens-against-medical-community/

Can We Please Stop Fighting About ‘Medicare for All’?

One policy proposal has defined this Democratic race. It’s time to move on. 

by Michelle Cottle - NYT - January 8, 2020

With strong support among the Democratic Party’s base, “Medicare for all” has emerged as a test of progressive bona fides in the race for the Democratic presidential nomination.
It has also emerged as something of a political morass into which the candidates keep stumbling.
Most recently, the businessman Andrew Yang faced scrutiny over his position on the idea of creating a government-run health insurance system that essentially would eliminate private coverage.
Mr. Yang has expressed support for Medicare for all and, in the fall, ran ads that advocated moving toward such a system. But when he released his health care plan last month, it turned out not to include even a public option, much less an overhaul of the whole system.
“Your ad is explicit. Your ad says, Medicare for all. Your plan is not Medicare for all,” ABC’s Jonathan Karl pressed Mr. Yang in an interview on Dec. 29. “It’s not even Medicare for some, because in your plan there’s not even a public option.”

“Medicare for all is not the name of a bill” but the basic goal of universal coverage, argued Mr. Yang, noting that his plan “would be based on Medicare and expanding it over time to more and more Americans.”
Mr. Yang’s perceived slipperiness led to backlash on social media and beyond. “Andrew Yang’s Lies About Supporting Medicare for All Exposed as Journalist Corners Him Live on Air,” charged a headline on the progressive website AlterNet.
Amid all this confusion, Mr. Yang was right about one thing: When announcing his plan, he warned that Democrats were “having the wrong conversation on health care” and “spending too much time fighting over the differences between Medicare for all” and other ideas, such as expanding the Affordable Care Act or establishing a public option to operate alongside private plans, a hybrid model that another Democratic candidate, Pete Buttigieg, has called Medicare for all who want it.
The American health care system is, no doubt, deeply flawed, and health care was a hot topic in the 2018 midterm elections. But Medicare for all has dominated the Democratic race for too long, serving neither the candidates nor the electorate well.
A plan to blow up that system and throw 149 million people off their private insurance, while embraced by progressives, is viewed more skeptically by moderates and swing voters. A poll conducted in the fall by the Kaiser Family Foundation and the Cook Political Report found that 62 percent of swing voters in the former “blue wall” states of Michigan, Minnesota, Pennsylvania and Wisconsin consider Medicare for all a “bad idea.” The foundation’s C.E.O., Drew Altman, wrote in Axios, “If the Democratic nominee comes to be defined by the idea of Medicare for all, that could be a political problem in key battleground states.”

One could argue that it has already proved problematic for Senator Elizabeth Warren, who has been one of Medicare for all’s top champions in this race, along with Senator Bernie Sanders, who has been touting the idea nationally since his 2016 presidential run. Under pressure to explain how she would pay for her proposal, in November Ms. Warren released a detailed accounting of where the estimated $20.5 trillion that her plan would cost over 10 years would come from.
Her financing plan drew heavy fire as misguided and unrealistic, including from some of her Democratic competitors. Former Vice President Joe Biden’s campaign dismissed it as “mathematical gymnastics,” while Mr. Sanders charged it wasn’t progressive enough and would “have a very negative impact on creating jobs.” Around this time, Ms. Warren’s poll numbers and fund-raising took a turn for the worse.
Even among Democrats, Medicare for all polls worse than the less revolutionary alternatives of the sort being offered by Mr. Buttigieg and others, including Mr. Biden and Senator Amy Klobuchar.
And yet, the fight goes on. Many observers have noted that the Democratic debates — especially the first ones, which felt like a rolling seminar on medical insurance policy — have devoted a disproportionate amount of time to the candidates slashing at each other over who has the political courage — or naïveté — to go big on health care.
This has produced some fiery clashes, as when, in the October debate, Ms. Klobuchar suggested that Ms. Warren didn’t know “the difference between a plan and a pipe dream.” But more broadly, it is miring the Democrats in an unnecessary fight over a policy proposal that is divisive and that would require a political miracle to achieve without a progressive takeover of the Senate. And even then, it would most likely be difficult — remember how hard it was to pass Obamacare even with Democrats controlling both chambers?
Yes, the Democratic candidates need to talk about health care. Polls show that it is a top — if not the top — policy concern for their voters, and the issue was a pillar of the party’s successful platform to win control of the House in 2018. But there are other health care matters that could use more attention, such as surprise medical bills, reproductive rights and the Republicans’ continuing efforts to dismantle Obamacare — which have gained far more traction than many people predicted, threatening coverage for millions of Americans.
With the Iowa caucuses less than a month away, Democrats need to move beyond the Medicare for all fixation. Enough time has been spent bickering over the particulars of an electorally risky proposal that is unlikely to come to pass, no matter who wins the White House.
https://www.nytimes.com/2020/01/08/opinion/medicare-for-all-democrats.html?smid=nytcore-ios-share

 

 

 

Health Care Reform Articles - January 7, 2020

The U.S. Spends $2,500 Per Person on Health Care Administrative Costs. Canada Spends $550. Here's Why

by Abigail Abrams - Time Magazine  - January 6, 2020

Whether it’s interpreting medical bills, struggling to get hospital records, or fighting with an insurance provider, Americans are accustomed to battling bureaucracy to access their health care. But patients’ time and effort are not the only price of this complexity. Administrative costs now make up about 34% of total health care expenditures in the United States—twice the percentage Canada spends, according to a new study published Monday in Annals of Internal Medicine.
These costs have increased over the last two decades, mostly due to the growth of private insurers’ overhead. The researchers examined 2017 costs and found that if the U.S. were to cut its administrative spending to match Canadian levels, the country could have saved more than $600 billion in just that one year.
“The difference [in administrative costs] between Canada and the U.S. is enough to not only cover all the uninsured but also to eliminate all the copayments and deductibles, and to amp up home care for the elderly and disabled,” says Dr. David Himmelstein, a professor at the CUNY School of Public Health at Hunter College and co-author of the study. “And frankly to have money left over.”
Research has long shown that the U.S., which uses a disparate system of private providers and insurers, has higher administrative costs than other developed countries that use single-payer systems. But the Annals study puts a finer point on it: as the first major effort to calculate administrative costs across the U.S. health system in nearly two decades, the researchers found that the gap between the U.S. and Canada has widened significantly. 
The U.S. now spends nearly five times more per person on health care administration than Canada does. The U.S. administrative costs came out to $812 billion in 2017, or $2,497 per person in the U.S. compared with $551 per person in Canada, according to the Annals study.
Along with Himmelstein, co-authors Steffie Woolhandler and Terry Campbell examined administrative costs for insurance companies and government agencies that administer healthcare, as well as costs in four settings: hospitals, nursing homes, home care agencies and hospices and physician practices. For each category, the researchers determined which costs were administrative and conducted analyses to adjust comparisons between relative costs in the U.S. and Canada.
Insurers’ overhead, the largest category, totaled $275.4 billion in the U.S. in 2017, or 7.9% of all national health expenditures, compared with $5.36 billion in Canada, or 2.8% of national health expenditures. The American number included $45 billion in government spending to administer health care programs and $229.5 billion in private insurers’ overhead and profits, which covers employer plans and managed care plans funded by Medicare and Medicaid.
This insurance overhead accounted for most of the total increase in administrative spending in the U.S. since 1999, according to the study. While the share of Americans covered by commercial insurance plans has not changed much, private insurers have expanded their role as subcontractors handling what are known as “managed care” plans for Medicaid and Medicare. The study notes that most Medicaid recipients are now on private managed care plans and about one third of Medicare enrollees now have Medicare Advantage plans. Both of these types of plans have higher overhead costs than the publicly administered alternatives.
“We were struck, and frankly hadn’t expected it until we delved into the data, by the huge increase in insurance overhead,” Himmelstein told TIME.
Other reports, including one by the Center for American Progress published last April, have identified ways to reduce administrative costs without moving the U.S. to a single-payer health care system. But Himmelstein says his study shows that a public option that preserves private insurance wouldn’t provide the same savings as a traditional single-payer system. “We could streamline the bureaucracy to some extent with other approaches, but you can’t get nearly the magnitude of savings that we could get with a single payer,” Himmelstein says, adding, “If the Medicare public option includes the Medicare Advantage plans, it’s actually conceivable that the public option would increase the bureaucratic costs.”
Most of the public option plans proposed by Democratic presidential candidates are not detailed enough to determine exact costs, Himmelstein says. But overall, he believes they won’t result in significant cost savings.
In addition to their research, Himmelstein and Woolhandler have been longtime advocates for single-payer health care. They co-founded the group Physicians for a National Health Program, which advocates for a single-payer system. They also conducted the initial health administrative costs study on 1999 data and have published other studies comparing hospital administrative costs in the U.S. and other countries.
Himmelstein says his team’s estimates of total U.S. administrative costs in the Annals study are likely conservative. When estimating physicians’ administrative costs, the researchers relied on a 2011 study of time spent by physicians and their staffs interacting with insurers. And he notes that while 2017 data was often the latest available when they were conducting this study, 2018 health spending numbers have since come out showing further increases in insurance overhead.
“We can afford universal coverage with a single payer plan, not just universal coverage but first dollar coverage for everybody in our country if we adopted a single-payer Medicare for all approach,” Himmelstein says. “If you’re going to cover everybody without getting those savings you’re going to have to spend more or you’re going to have to have big co-payments and deductibles that deter people from getting the care that they actually need.”
https://time.com/5759972/health-care-administrative-costs/

Doctors, Nurses and the Paperwork Crisis That Could Unite Them

They don’t always get along. But they are both under siege by the bureaucracy of a failing health care system.

By Theresa Brown and Stephen Bergman -NYT - January 3, 2019

Broken, wasteful, inhuman, expensive, deadly. The problems with the American health care system, or non-system, are neither subtle nor unrecognized — especially by those of us doctors and nurses who actually provide the care. And yet we all too often feel the most helpless, seeing how much of the problem is driven by drug companies and hospital networks.
Too often, each profession sees the other as fighting separate battles, and sometimes against each other. Doctors blame nurses, and vice versa, for the failings of a system that punishes us all, and our patients.
Instead, the two of us are suggesting that nurses and doctors try something unusual. Let’s put our differences aside and work together to achieve real change, starting with a pernicious problem that drives so much of our mutual discontent: electronic health records.
The current system is pushing both doctors and nurses to the breaking point. Enough doctors in the United States commit suicide every year to fill two large medical school classes. A 2019 MedScape report found that 44 percent of physicians feel “burned out,” driving many to alcoholism and depression, or to leave the profession entirely.

Nurse suicides are not systematically measured and reported, but a 2017 study in England found a suicide rate among nurses that was 23 percent above the national average. Half of all nurses are considering leaving the profession, according to a 2017 study by RNnetwork.
Clinicians are notoriously overworked, but ask anyone on a hospital staff, and he or she will tell you that workloads have become heavier the last several years thanks almost entirely to the arrival of electronic health records — detailed reports about a patient’s medical history and care. Originally intended as a work-saving tool, the records have gone in the opposite direction, taking time away from patient care in the name of electronic box-checking.
A new report from the National Academy of Medicine says that on average nurses and doctors spend 50 percent of their work day treating the screen, not the patient, and that “increased documentation time” associated with electronic health records can lead to burnout. Burnout is also tied to finishing documentation at home, a necessity for many physicians, and for nurses who provide home care.
The use of electronic health records increased significantly with the 2009 passage of the Health Information Technology for Economic and Clinical Health Act, which offered financial incentives for hospitals to adopt them. Such records promised efficiency and better teamwork, but as they increasingly serve the needs of America’s corporate, profit-motivated health care, those promises remain mostly unfulfilled.
Insurance companies and hospitals demand ever more data to make decisions about payments and billing, so clinicians have to provide much more information about each patient at each interaction. Mounting regulatory requirements that get built into these records are described as insuring patient safety, but are ultimately tied to compensation, which means money. And in a system rife with legal risks, there is a strong incentive to overdocument everything.

This is why nurses and physicians must come together. We must acknowledge the harm done by these ever-increasing documentation requirements, without losing the core benefits of electronic record keeping.
One inspiration comes from a surprising place. Electronic health records are almost universally disliked, with one telling exception, those used by clinicians at the Department of Veterans Affairs. The reason: Billing concerns don’t shape the records at government-run V.A. hospitals. They document only what’s necessary to deliver better care.
Why can’t the rest of the health care system do the same? For example, some hospitals already have a periodic review of their electronic health records, paring items that do not relate directly to patients; more hospitals could do the same, and all could do it more aggressively. Another: A group of coders at Intermountain Healthcare in Utah is working on a more radical solution, called “activity-based design,” which updates records by voice, and offers helpful care algorithms to clinicians as they interact with patients.
Part of the reason for inaction is that not enough clinicians are making it loud and clear that change is necessary. Doing so requires a unified voice across our professions — and unfortunately, right now, doctors and nurses are anything but unified.
Physicians earn much more money than nurses and have much higher status in the medical hierarchy, which can lead to resentment from nurses when that higher status is abused. The gendered history of both professions also contributes to a view of nurses as fundamentally subordinate to physicians.
Most important, the experience of nurses is often invisible to doctors, even though they typically work alongside them. There are examples of respectful working friendships on the front lines, but the legacy of hierarchy persists, and keeps us from focusing on our common struggles.
Doctors would be wise to let nurses take the lead. For years, nurses have organized to improve hospital working conditions, in particular fighting for better staffing levels. The Service Employees International Union and National Nurses United represent nurses all over the United States, and in general are good at getting their demands met.

Doctors, on the other hand, have no similar organizations, no national unions and little experience in activism on workplace issues. Maybe it’s the myth of the single, heroic doctor that keeps them from recognizing the strength in collective efforts. Or maybe they believe their high status will protect them from the worst of the profit-focused excesses in American health care.
If so, those beliefs are collapsing, as most physicians are becoming painfully aware that no one will be spared, and that bureaucratic nightmares like electronic health records have impaired their ability to do their jobs well, much less enjoy them.
The millions of us, nurses and doctors, who directly attend to patients want the best for them, and yet are prevented from caring by profiteering and gross inefficiency. We need to restore caring to health care. For nurses, doctors, and even patients who take on this fight, the life you save may indeed be your own.
Theresa Brown is a clinical faculty member at the University of Pittsburgh School of Nursing and the author of “The Shift: One Nurse, Twelve Hours, Four Patients’ Lives.” Stephen Bergman is a professor of medicine at New York University and the author, most recently, under the pen name Samuel Shem, of the novel “Man’s 4th Best Hospital.”
https://www.nytimes.com/2019/12/31/opinion/doctors-nurses-and-the-paperwork-crisis-that-could-unite-them.html?action=click&module=Opinion&pgtype=Homepage 

Hospitals Go From Serving to Suing the Poor

An industry's fall from grace

by Martin Makary MD, MPH - Medpage Today - September 8, 2019

How did medicine transform from a charitable profession to one that has put one in five Americans into collections for medical debt? How is it that hospitals are scientifically advanced centers of academic genius, but can't even tell you what anything will cost? And how did the noble profession of healing lose control of its billing processes, allowing some hospitals to sue and garnish the wages of thousands of the people in the small town they serve?
The growing money games of healthcare today are threatening the public trust in the medical profession. I'm reminded of that public trust every day I walk through the historic front door of my hospital, where all who enter are greeted by a 9-foot statue of Jesus standing with arms wide open, and the words, "Come to me all ye who are heavy laden, and I will give you rest" engraved at His feet.
American hospitals were built with a mission to be a safe haven for the sick and injured. Most of these hospitals were sustained by charity and committed to great values of equality. In 1873, Mr. Johns Hopkins stated that the purpose of my hospital was to care for "the indigent sick of this city and its environs, without regard to sex, age or color, who may require surgical or medical treatment, and who can be received into the Hospital ... The poor of this city and State of all races, who are stricken down by any casualty, shall be received into the Hospital without charge."
The Johns Hopkins Hospital operated in the red for its first 8 decades. The annual deficits were covered by gifts from trustees and by dipping into the endowment. Their commitment to serve the community was unwavering. While many paid for their medical care, many landmark procedures and treatments at Hopkins were performed at no cost. The pioneering craniofacial operations and the separation of conjoined twins connected at the head were done gratis. For free.
I'm often inspired by our predecessors who sacrificed so much for the sake of helping patients. I think of Dr. Walter Dandy, a pioneer in neurosurgery who lived in the early 1900s. He developed the first ICU and performed the first vascular clipping of a cerebral aneurysm. Though considered a strict, firm-tempered man, he was also extremely generous. He often paid the hospital expenses of indigent patients. On one occasion, when he learned that the mother of a patient could not afford the train fare to bring her child to Baltimore, he not only paid her way but refused to take any compensation. Dr. Dandy, known as the father of cerebrovascular neurosurgery, routinely declined to accept payment from teachers, police officers, or firemen.
The day the polio vaccine was announced as safe and 90% effective, Jonas Salk refused to commercialize it or obtain a patent. He and polio vaccine developer Albert Bruce Sabin refused to make money from their discovery. Salk and Sabin had seen firsthand how polio paralyzed as many as 20,000 children each year, sentencing some to life in an iron lung machine. Our hospital had wards of them. But Salk and Sabin believed that the polio vaccine was the property of humanity. Because of their compassion, most of the world's children quickly had access to the medical breakthrough. Forbes estimates that Salk alone would have been richer by $7 billion if his vaccine had been patented. But Salk and Sabin were motivated by a higher vision than mere monetary gain. They stayed true to their medical calling to help people and considered their vaccines to be donated for the benefit of mankind.
Dr. Benjamin Rush, son of a blacksmith, never forgot growing up in a family without much money in Philadelphia. Serving as a voice for those with psychiatric disorders, he devoted his medical career to erasing the stigma of mental illness. Having mental illness often meant living in extreme poverty, so Rush would often serve his patients without being paid. Considered the forefather of psychiatry, he held strong views on equality, even publicly calling for the abolition of slavery, declaring it a crime. Dr. Rush would later become one of five physician signers of the Declaration of Independence. He was at George Washington's side during the crossing of the Delaware, and he treated injured soldiers behind enemy lines. Dr. Rush was among the first to call for equal rights for women, free education and healthcare for the poor, citywide sanitation facilities, an end to child labor, universal public education, prison reform, and an end to capital punishment. He was known to call out physicians when he observed greed and incompetence among them.
After his death, Thomas Jefferson said in a letter that he knew no one "more benevolent, more learned, of finer genius, or more honest." In comparing Benjamin Rush to Benjamin Franklin, President John Adams said, "Rush has done infinitely more good to America than Franklin. Both had deserved a high Rank among Benefactors to their Country and Mankind; but Rush by far the highest."
It's not just physicians of the past who embody medicine's noble ideals. I also think of Tom Cetena, MD, who decided that instead of practicing in the U.S. where he could serve thousands of patients, he would practice in war-torn Sudan where he serves a million people. He practices without the regalia of academics or the pay of a U.S. physician, but he loves his job. And his communities love him.
That kind of dedication and sacrifice is contagious. As we struggle today to address the issues driving up the cost of healthcare, let's remember the compassion that first drew us to medicine. The torch that Hopkins, Dandy, Sabin, Salk, and Rush carried has now been passed on to us. Through their example and teachings, they bequeathed to us a mission of a healing profession that values excellence, dignity, and equality. Regardless of circumstances, their mission was to take care of a fellow human being when they were vulnerable, and to be their advocate.
Over the last 3 years, my Johns Hopkins research team and I conducted a deep dive into the root issues corrupting healthcare and making it unaffordable. I present these findings in the new book The Price We Pay, detailing how pricing failures, middlemen, and inappropriate care have resulted in our bloated $3.5 trillion healthcare spend. I also profile the doctors and business innovators who gave me hope. They are hard at work to make healthcare more honest, efficient, and affordable.
The cost of healthcare is perhaps today's most divisive political issue. But many of the solutions needed are not partisan; they're American. We are at a pivotal juncture as spending on healthcare threatens every other national priority, ranging from education funding to affording groceries. The lack of honest prices in healthcare lines the pockets of the special interests of healthcare, while gouging millions. Money games and deceptive practices are eroding the public trust in the medical profession. All of us can play a part in driving badly needed reforms, both in the marketplace and in public policy. Transparency's time has come.
As hospitals consider making their prices more honest and their billing less predatory, we physicians can play a powerful role in advocating for what's best for our patients. Similarly, as policymakers now work to make public the secret negotiated prices between insurers and hospitals, doctors should have a voice of support. And as businesses consider how to provide healthcare for their employees, it's important that doctors become literate in the business of medicine to help them cut through the middlemen and contract with them directly.
Taking action will demand standing up to the powerbrokers of the medical establishment. But I'm emboldened by the pioneers of medicine who modeled a better way. I think of Hopkins, Dandy, Sabin, Salk, and Rush, and I believe there are many more like them practicing medicine today. We have already seen how a committed group of good doctors can make a huge difference for everyone. As Margaret Mead once said, "Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has."
Martin Makary, MD, MPH, is a professor at Johns Hopkins University and author of the new book The Price We Pay: What Broke American Health Care and How to Fix It (Bloomsbury Press, 2019)
last updated 09.09.2019
https://www.medpagetoday.com/publichealthpolicy/healthpolicy/82040

The Public Option Is Politically Superior to Medicare for All — But Only As a Sound Bite

by Eric Levitz - New York Magazine - December 28, 2019

The vast majority of Americans believe that every U.S. citizen has a right to quality, affordable health care, and that it is the federal government’s job to uphold that right.

But roughly 70 percent of Americans also believe that their own health-care coverage is either “good” or “excellent” (despite the fact that virtually all of us are getting ripped off). This perennial poll result reflects the fact that voters often evince status-quo bias and loss aversion, which is to say, they tend to fear losing what they have more than they long for something better. In the U.S., this tendency is likely exacerbated by the public’s (understandable) distrust in their governing institutions.

For these reasons, Democratic operatives argue that Medicare for All Who Want It is a safer campaign pitch than Medicare for All. The former, as described by Pete Buttigieg and Joe Biden, would achieve universal coverage by giving all Americans the option of enrolling in a high-quality, affordable public health insurance program, while allowing the loss-averse to stick with the lousy private plans they know and trust. Medicare for All, by contrast, would force all Americans onto a single government plan, an approach to universal coverage that would ostensibly be more socially disruptive and fiscally onerous than a public option.

And surveys suggest the operatives are right: When the debate is framed in the terms outlined above, a public option consistently outpolls Medicare for All — even among Democratic voters. In a recent New York Times–SurveyMonkey poll, 58 percent of Democratic respondents said that the statement “The U.S. should offer government-run insurance to anyone who wants it, but people should be able to keep their private insurance if they prefer it” matched their view on health-care policy, while just 25 percent said the same of the assertion, “The U.S. should adopt a national health-care plan in which all Americans get their insurance from a single government plan.”

This shouldn’t be surprising. It’s hard to see why anyone who isn’t a self-identified social democrat or progressive policy wonk would find the latter idea more appealing. In the poll’s framing, the public option is no risk, all reward; you can enroll in a government plan or “keep” the one you already have (a benefit that Americans don’t actually enjoy under the existing employer-provided insurance system). Single-payer, by contrast, offers risk without any specified benefit. Thus, unless you happen to be versed in the arguments for Medicare for All’s superiority to a public option, you’ll be liable to hear the question as, more or less, “Would you rather have your cake and eat it, too, or be forced to choose between those alternatives?”

But the actual choice that Democratic candidates are offering the public is far more complicated.

In truth, the kind of public option that Biden and Buttigieg are campaigning on — one robust enough to make universal health care a reality in the United States — would not allow all Americans to “keep their private insurance if they prefer it.” In fact, their plans would guarantee massive disruptions to private coverage. As a campaign slogan, “Medicare for All Who Want It” reconciles the electorate’s desire for universal coverage with its aversion to disruptive change. But as a policy, it doesn’t – because no policy can.

The reason is straightforward. Unlike most other OECD countries, the United States never imposed strict cost controls on its health-care sector. And since human beings are willing to pay most any price to avoid death or severe illness — and since insurance often masks the true cost of medical services — America’s hospitals, doctors, and drug companies have been able to secure payment rates several times higher than their peers in other nations. To appreciate how thoroughly we’re being hosed by our health-care sector, consider this: In 2018, Canada spent roughly 11 percent of its GDP on health care, which was enough to provide all of its citizens with premium-free access to the world’s 14th highest performing health-care system. That same year, the United States spent roughly 18 percent of its GDP on health care — which, in our system, was not sufficient to provide any form of insurance to nearly 30 million Americans, nor to prevent more than 50 percent of our people from delaying or forgoing medical care due to affordability concerns.

In this context, there is no way to provide all Americans with high-quality, affordable health care without radically disrupting the status quo. To extend quality coverage to the millions of Americans who are uninsured or underinsured, you either need to force providers to accept drastically lower payment rates — which is to say, upend the business models underpinning nearly one-fifth of the U.S. economy — or increase federal spending on health care beyond Bernie Sanders’s wildest dreams. The estimated price tag on the Vermont senator’s plan is (infamously) $32.6 trillion a decade. But that estimate assumes that the federal government would force large pay cuts on health-care providers, while securing administrative efficiencies through the elimination of redundant private insurance bureaucracies. A plan that sought to provide universal, comprehensive health coverage — without disrupting private insurers or imposing big pay cuts on hospitals and doctors — would be vastly more expensive.

Biden and Buttigieg haven’t filled in the fine details of their public options. But both suggest that their plans would be comprehensive, less expensive than comparable private plans, and available to all Americans. As the former vice-president puts it, “Whether you’re covered through your employer, buying your insurance on your own, or going without coverage altogether, the Biden Plan will give you the choice to purchase a public health insurance option like Medicare,” and, “As in Medicare, the Biden public option will reduce costs for patients by negotiating lower prices from hospitals and other health care providers.”

If this is an accurate description of Biden’s plan, then Biden’s plan will not allow most Americans to “keep their private insurance,” at least, not for long. Private firms will never have as much pricing power as the federal government, nor as much capacity to provide coverage at a loss. If Uncle Sam uses his singular market power to force down costs — and doles out sufficient subsidies to make his “public option” universally affordable — then the private insurance industry as we’ve known it will cease to exist. Meanwhile, to make the provider payment cuts sustainable, America’s approach to financing hospitals and medical schools would need to be radically restructured. And to make the public option fiscally sustainable — once the vast majority of Americans have enrolled in it — President Biden would need to propose tax increases nearly as large as those put forward by Sanders and Warren.

Mainstream news outlets (and Democratic debate moderators) have almost all either ignored or failed to comprehend these facts. This is likely because, in the Beltway’s popular consciousness, the phrase “public option” is still associated with the policy that Democrats nearly implemented under Barack Obama. In 2009, the House passed a version of the Affordable Care Act that would have established a public health insurance plan. But even if that public option had survived the Senate, it wouldn’t have been available to 90 percent of the already insured because the House bill restricted eligibility for that plan to the small minority of Americans who purchase insurance for themselves, rather than through their employers. What’s more, the 2009 public option did not seek to outcompete insurers by forcing big cuts on providers. In fact, the Congressional Budget Office estimated that the public plan would have higher premiums than most of its private competitors on the ACA’s exchanges, and that only about 6 million Americans would choose to enroll in it.

That kind of public option wouldn’t require hiking taxes or disrupting private insurance. It also wouldn’t ensure universal coverage. Biden and Buttigieg are, in essence, promising to deliver all the benefits of single-payer, at the political and fiscal cost of a marginal provision of the ACA. And the press has largely affirmed their “free pony” pitch. But the health-care industry isn’t fooled. The hospital, pharmaceutical, insurer, and physicians’ lobbies acknowledge no distinction between Medicare for All and a strong public option, and are already funding messaging campaigns against both.

All of which is to say, when Medicare for All Who Want It stops being a campaign pitch, and becomes a bill before Congress, it will face almost all of the same political obstacles as single-payer. Unless Biden and Buttigieg are misrepresenting the content of their plans, or their own commitment to universal coverage, then their health-care policies will require Congress to vote to (effectively) abolish the private insurance industry as we’ve known it, slash doctors’ salaries and hospitals profits, enact hefty tax increases, and disrupt the existing insurance coverage of millions of Americans.

Precisely because the health-care industry is such a gargantuan parasite on the U.S. economy, it will be willing and able to inundate the airwaves with negative messaging on a public option. Many doctors will likely warn their patients that those “clowns in Congress” are trying to disrupt their coverage, while many physicians’ groups will mount protests and lobbying campaigns. And the face of the opposition won’t just be high-paid hospital executives or millionaire surgeons. When you let an industry commandeer 18 percent of GDP, many millions of working-class Americans will owe their livelihoods to that industry. In cities throughout the country, (price-gouging) hospitals are the top employers. Private insurers provide jobs for 2.7 million Americans. Substantively, that is an indictment of the existing system, not a defense of it. Workers are a scarce resource, and the fact that millions currently labor for an industry that produces little to nothing of social value is an outrage. But politically, private insurance workers are a sympathetic interest group invested in the status quo. Sanders’s bill includes funds to help those displaced workers regain their footing in the labor market. Such workers would likely rally in opposition to Medicare for All, regardless; people typically do not like losing a source of stable employment, and the past three decades of trade policy have given American workers no reason to trust the government’s promises of retraining and reemployment. But Biden and Buttigieg’s plans don’t even offer such promises.

To be sure, the obstacles to getting a strong public option through Congress would not be identical to those of Medicare for All. The fiscal cost of the former would be much lower in the short term, and somewhat lower in the long term, as Sanders’s specific version of single-payer is exceptionally comprehensive in its benefits, and includes no cost-sharing. Further, although the public option’s broad popularity may be partially attributable to misunderstanding, those poll numbers are nevertheless politically helpful. And while Democratic candidates and the media are wildly underselling how disruptive a public option would be, the policy would still be less disruptive in the immediate term than Medicare for All.

That said, a strong public option would also present its own unique political liabilities. To achieve universal coverage through a premium-funded public option — as Buttigieg has proposed — you need to automatically enroll the uninsured in the plan, and then bill them for a service they never signed up for. As the Washington Post reported this week, this would ostensibly function as “supercharged individual mandate,” where (in the words of socialist policy wonk Matt Bruenig) instead of “paying a $695 fine at the end of the year for being uninsured, you are hit with a bill to pay an entire year of premiums that could be ten times that amount.”

Further, to the extent that public option proposals lack detailed transition plans for when they render private insurers uncompetitive, they’re liable to create more medium-term disruption than single-payer. And in the short term, unlike single-payer, a public option would not have all U.S. doctors in its provider network. In fact, if the new public plan is linked to Medicare – such that any doctor who accepts the latter must accept the former – it is possible that some physicians would stop seeing Medicare enrollees, so as to avoid having their practices flooded with patients whose insurance pays the low government rates.

But such hairsplitting is beside the point, which is that passing a strong public option — or any genuinely universal health-care plan — will require fomenting a nigh-unprecedented “political revolution.”

It will take a minor miracle for Democrats to secure a two-vote Senate majority in 2021; in which case, Kyrsten Sinema — a “Blue Dog” Democrat who has suggested that she might prefer Trump to a progressive in 2020 — will be the median Senate vote. This month, legislation outlawing the odious practice of “surprise billing” could not make it out of a House where Democrats boast a 36-vote majority. That bill had 78 percent support in opinion polls, and enjoyed the backing of the insurance industry. But hospitals and certain specialty physicians wanted to preserve their God-given right to charge $26,000 for a throat swab. So, they spent millions on a lobbying campaign to kill the provision. So, it died.

The honest, pragmatic argument for Democrats to campaign on Medicare for All Who Want It instead of Medicare for All in 2020 goes something like this: There is zero chance of enacting either policy in the near future because the health-care industry is too powerful, America’s governing institutions are too corrupt, the Senate is too biased against progressives, and the vast majority of enfranchised Americans are too healthy, ill-informed, or terrified of change to realize that their existing coverage is neither “excellent” nor “good.” Thus, universal health care ain’t happening in 2021, no matter what gets written into the 2020 Democratic platform. We’re just gonna have to let Big Health Care keep eating a larger and larger chunk of our economy, while nonaffluent residents of the world’s wealthiest country keep losing loved ones to preventable illnesses.

Nevertheless, for whatever reason, the mainstream media is both very hostile to single-payer and extremely friendly to a public option — so friendly, major news outlets routinely frame the latter as a policy that would end all disruption in the private insurance market, and give all Americans access to a high-quality, low-cost public plan. Given these realities, running on Medicare for All would marginally reduce the Democrats’ odds of winning the presidency in 2020, while doing nothing to meaningfully advance the cause of universal health care. And winning in 2020 does matter, even if it will be insufficient for achieving universal health care: With the White House and a slim Senate majority, Democrats could realistically be expected to make marginal improvements to the health-care system (perhaps, if we’re lucky, improvements that make the fight for universal a bit easier down the road); increase funding for clean-energy R&D; restore civil-rights enforcement at the DOJ; adopt more progressive labor, financial, and environmental regulations; and forestall the conservative movement’s complete domination of the federal courts, among other things. Therefore, Democrats should run on the more popular, politically impossible health-care plan.

I personally don’t find this argument 100 percent persuasive. But it does strike me as coherent and difficult to dismiss. Anyhow, if every moderate Democrat and center-left pundit started framing their preference for a public option in these terms, it might make the American public a bit less complacent about the status-quo health-care system, and a bit more sympathetic to calls for radical change. (Which may be one reason why we’re hearing so many dishonest arguments for the public option instead.)

The Public Option Is More Popular Than M4A — As a Sound Bite
https://nymag.com/intelligencer/2019/12/public-option-vs-medicare-for-all-debate-biden-buttigieg-sanders-polls.html

Hospitals Sue Trump to Keep Negotiated Prices Secret

The administration wants to require hospitals to reveal the rates they privately negotiate with insurers for all sorts of procedures, amid the public outcry over surprise medical bills. 

by Reed Abelson - NYT - December 4, 2019

The nation’s hospital groups sued the Trump administration on Wednesday over a new federal rule that would require them to disclose the discounted prices they give insurers for all sorts of procedures.
The hospitals, including the American Hospital Association, argued in a lawsuit filed in United States District Court in Washington that the new rule “is unlawful, several times over.”
They argued that the administration exceeded its legal authority in issuing the rule last month as part of its efforts to make the health care system much more transparent to patients. The lawsuit contends the requirement to disclose their private negotiations with insurers violates their First Amendment rights.
“We make the case that the burden placed on our members to come up with this information is extensive,” Tom Nickels, an executive vice president with the American Hospital Association, said in an interview.

The administration wanted the disclosure rule, which would go into effect in 2021, to allow patients to better shop for deals on a range of services, from M.R.I.s to hip replacements.
“Hospitals should be ashamed that they aren’t willing to provide American patients the cost of a service before they purchase it,” Caitlin Oakley, a spokeswoman for the Department of Health and Human Services, said in an emailed statement. “President Trump and Secretary Azar are committed to providing patients the information they need to make their own informed health care decisions and will continue to fight for transparency in America’s health care system.”
While the administration already requires hospitals to post some of their list prices, the public outcry over surprise medical bills and high out-of-pocket costs led the administration to seek even more detail on the discounted prices that are kept secret between hospitals and insurers.
Patients have long complained that they are completely in the dark about what a doctor’s visit or surgery will cost until after they receive the bill. Knee surgery, for example, can cost thousands of dollars more at one hospital than at another in the same region.
The administration clearly anticipated a legal challenge. In fact, when he announced the hospital price disclosure rule, Alex M. Azar II, the health and human services secretary, was adamant that the rule would withstand a court challenge. “We may face litigation, and we feel we are on a very firm legal footing,” he said last month.

“H.H.S. has been willing under this administration to test the limits of their authority, that would subject them to more litigation,” said Emily J. Cook, a health care lawyer in Los Angeles. While her firm is not representing any of the plaintiffs in the lawsuit, one of them is a client, she said.
At the heart of the administration’s efforts is an attempt to tackle rising hospital costs, which have outpaced the increase in physician prices, according to a recent study by health economists in Health Affairs. The economists estimated that hospital inpatient prices increased 42 percent from 2007 to 2014.
In an op-ed article published in The Chicago Tribune on Tuesday, Seema Verma, the administrator for the Centers for Medicaid and Medicare Services, promoted the administration’s efforts to benefit patients.
“The decades-long norm of price obscurity is just fine for those who get to set the prices with little accountability and reap the profits, but that stale and broken status quo is bleeding patients dry,” she wrote. “The price transparency delivered by these rules will put downward pressure on prices and restore patients to their rightful place at the center of American health care.”
The hospital groups, which also include the Association of American Medical Colleges, the National Association of Children’s Hospitals and the Federation of American Hospitals, which represents for-profit hospitals, argued in the lawsuit that the rule would not accomplish the administration’s aim of helping consumers avoid surprise bills. Three individual hospitals also joined the case.
“America’s hospitals and health systems remain committed to providing patients with the information they need to make informed health care decisions,” the lawsuit said. It contended that the rule “will generate confusion about patients’ financial obligations, not quell it.” The lawsuit was first reported by The Wall Street Journal.
The Trump administration has also proposed a rule requiring insurers to allow patients to get advanced estimates of their out-of-pocket costs before they see a doctor or go to the hospital. The industry’s major trade associations wrote a letter on Tuesday, requesting an additional 90 days to comment on the proposal, pushing the deadline to mid-April.

“The sheer volume of data that the government is proposing health plans disclose is staggering — dollar amounts for every single item or service, for every single provider and facility, for every single individual and employer plan,” wrote executives from America’s Health Insurance Plans and the Blue Cross Blue Shield Association.
The administration’s efforts to push the industry to make more information public to patients faces a real legal challenge, and it has been unsuccessful in other attempts.
When the administration earlier tried to require pharmaceutical companies to disclose the list price of prescription drugs in television ads, the drug companies argued that the Department of Health and Human Services had exceeded its regulatory authority and that the requirement also violated its First Amendment rights. A federal judge ruled last summer that H.H.S. had, in fact, exceeded its regulatory authority with the rule, which was seen as largely symbolic because list prices are not what patients typically pay. The decision is under appeal.
The hospitals have also been successful to date in other cases arguing that the agency lacks the authority to issue payment rules, said Ms. Cook, although the government could also win those cases on appeal.
The courts are displaying less deference to rule making by government agencies, said Douglas Hallward-Driemeier, a lawyer in Washington who works with clients to challenge administrative actions.
The hospitals could also succeed by raising First Amendment grounds, he said. “That argument has gained a lot of traction over last 10 years,” he said.
https://www.nytimes.com/2019/12/04/health/hospitals-trump-prices-transparency.html?smid=nytcore-ios-share

It Looks Like Health Insurance, but It’s Not. ‘Just Trust God,’ Buyers Are Told.

Some state regulators are scrutinizing nonprofit Christian cost-sharing ministries that enroll Americans struggling to pay for medical care, but aren’t legally bound to cover their members’ claims.

by Reed Abelson - January 2, 2020

Eight-year-old Blake Collie was at the swimming pool when he got a frightening headache. His parents rushed him to the emergency room only to learn he had a brain aneurysm. Blake spent nearly two months in the hospital.
His family did not have traditional health insurance. “We could not afford it,” said his father, Mark Collie, a freelance photographer in Washington, N.C.
Instead, they pay about $530 a month through a Christian health care sharing organization to pay members’ medical bills. But the group capped payments for members at $250,000, almost certainly far less than the final tally of Blake’s mounting medical bills.
“Just trust God,” the nonprofit group, Samaritan Ministries, in Peoria, Ill., said in a statement about its coverage, and advises its members that “there is no coverage, no guarantee of payment.”

More than one million Americans, struggling to cope with the rising cost of health insurance, have joined such groups, attracted by prices that are far lower than the premiums for policies that must meet strict requirements, like guaranteed coverage for pre-existing conditions, established by the Affordable Care Act. The groups say they permit people of a common religious or ethical belief to share medical costs, and many were grandfathered in under the federal health care law mainly through a religious exemption.
These Christian nonprofit groups offer far lower rates because they are not classified as insurance and are under no legal obligation to pay medical claims. They generally decline to cover people with pre-existing illnesses. They can set limits on how much their members will pay, and they can legally refuse to cover treatments for specialties like mental health.
“Nothing is guaranteed,” said Dr. Carolyn McClanahan, a physician who is also a financial planner in Jacksonville, Fla. “You have to depend on the largess of the program.”
The main requirement for membership is adherence to a Christian lifestyle. And the alternative sharing plans keep flourishing, especially now that the Trump administration has relaxed rules to permit alternatives to the A.C.A. that don’t provide such generous coverage.
But state regulators in New Hampshire, Colorado and Texas are beginning to question some of the ministries’ aggressive marketing tactics, often using call centers, and said in some cases people who joined them were misled or did not understand how little coverage they would receive if they or a family member had a catastrophic illness.

On Monday, Washington State fined one of the larger health-sharing ministries, Trinity Healthshare, $150,000 and banned it from offering its product to state residents because it was operating as an unauthorized insurer.
In December, Nevada insurance regulators warned consumers to beware of these plans. “They may seem enticing because they may be cheap, look and sound like they are in compliance with the Affordable Care Act (‘A.C.A.’), when in reality these plans are not even insurance products,” the department said.
The Texas attorney general brought a lawsuit last summer against Aliera Healthcare, which marketed Trinity’s ministry program, to stop it from offering “unregulated insurance products to the public.” The Houston Chronicle featured one couple who was left with more than $100,000 in unpaid medical bills. Trinity said most members are satisfied with its services.
Aliera, which says it has stopped offering its plans in Texas, said it is working with regulators to resolve their concerns. The company says it has taken steps to make sure its customers are not confused about what they are buying.

Because the groups are not technically considered insurance, they operate with no government oversight. “Regulators haven’t been willing to assert any control or regulatory authority over these plans,” said Katie Keith, who serves as a consumer representative to the National Association of Insurance Commissioners and teaches health law at Georgetown University. “They feel their hands are tied. At the end of the day, it’s not insurance.”
Families who have joined the groups recount winding up with medical bills not covered by the ministries, with no legal way to appeal decisions to reject coverage for care. Some groups ask their members to push hospitals and doctors to write off their bills rather than use members’ money to pay their expenses.

“These plans offer a false sense of security,” said Jenny Chumbley Hogue, who runs an insurance agency in the north Dallas area of Texas. She refuses to offer them to her clients.
Several states have taken action against one ministry they say has deceived people about what they are buying. “The nature of what we’re hearing from consumers around the state is absolutely heart breaking,” said Kate Harris, chief deputy insurance commissioner in Colorado, one state that is trying to prevent the ministry from operating there.
But health-share ministries have become particularly attractive to people like the Collie family who don’t qualify for a federal subsidy and can’t afford an A.C.A. plan. Even though premiums in the A.C.A. market have stabilized, critics of the law insist people need alternatives. “That’s the real driver behind the growth,” said Dr. Dave Weldon, a former Republican congressman from Florida who is president of the Alliance of Health Care Sharing Ministries, which represents the two largest groups.
When Dan Plato left his job to become self-employed as a consultant, he discovered that an A.C.A. policy for 2018 would cost his family around $1,300 a month. “It was very expensive and beyond our needs,” he said. Membership in Liberty Healthshare, a ministry established by Mennonites in Canton, Ohio, was less than half the price, according to Mr. Plato, who blogged about his experience.
But some Liberty members reported trouble getting their medical bills covered. Mr. Plato says a small bill for flu shots went unpaid and ended up in collection. At the end of the year, he was left wondering if Liberty would be able to cover the family in the event of a serious medical emergency. “It’s not something we could trust in that situation,” said Mr. Plato, who switched to one of the plans offered by United Healthcare also exempt from the A.C.A. rules for 2019.
Robyn Lytle, who works as an event planner in Chicago, joined Liberty for 2018, only to find that her daughter’s medical tests were never paid. “It’s been a year and a half, and I’ve been sent to collection,” said Ms. Lytle, who says Liberty had covered some of her family’s other expenses. She switched to an A.C.A. plan for 2019.
Liberty Healthshare declined to comment.
Other people complain that the ministries can be vague about coverage. Greg Snider and his wife joined Medi-Share, the program offered by Christian Care Ministry. Based in West Melbourne, Fla., Medi-Share says it has more than 400,000 members across the country.

Mr. Snider said he had just dropped traditional coverage when his wife was diagnosed with a heart condition, but he says he was assured by Medi-Share that her care could still be covered. She underwent surgery last year to address an abnormal heart rhythm. “After the procedure, the bills start rolling in,” Mr. Snider said, including $177,000 for the surgery alone.

Mr. Snider says Medi-Share urged him to plead with the hospital after determining he would owe more than $100,000. He said he had assumed the $800 a month he paid into a pool would help cover the expenses. After he tweeted his frustrations, the ministry told him that he would owe only $1,500 for the surgery because the hospital had forgiven the rest, he said. He now owes thousands of dollars in related medical bills and is unsure of their status.
If Medi-Share decides not to pay, Mr. Snider knows he has little recourse: “It is completely and solely up to them.” He has since gotten a job where he is covered under his employer.
Medi-Share says that more than 80 percent of the $774 million it collected last year went to members’ medical bills. “We take great care to ensure prospective members understand what is considered a pre-existing condition and what is eligible for sharing,” it said.
It does its part to reduce medical spending, it says, through negotiating with doctors and hospitals and claims it saved members more than $500 million last year. “We consider this process to be one way in which we contribute to the overall objective of reducing medical costs,” the ministry said in a statement.
Medi-Share says it has an extensive network of more than 700,000 providers. But even if a member goes to an in-network provider, the ministry may still decide not to pay the bill. “Fundamentally, we have found that there is often a lack of understanding of what is covered,” said Brendan Miller, an executive with MultiPlan, which arranges networks for Medi-Share as well as insurers.

That uncertainty has led some hospitals and doctors in the MultiPlan network to refuse to treat ministry patients rather than absorb unpaid costs.
Colorado is one of several states, including Washington, Texas and New Hampshire, that are trying to stop Trinity Healthshare, and its administrator, Aliera Healthcare, from operating in their states because they say the ministry is misleading its residents.
In a statement, Aliera said “it’s deeply disappointing to see state regulators working to deny their residents access to more affordable alternatives offered by health care sharing ministries.”
Trinity says its website makes clear that the ministry does not offer health insurance.
Regulators also worry about these plans siphoning off healthy individuals from the A.C.A. marketplaces, leading to higher premiums for Obamacare policies.
“The ministries have been very concerned about bad actors invading this space,” said Dr. Weldon, the alliance president, who says his members are very clear that they are not insurance companies. “They all operate call centers, and they all bend over backward to inform people inquiring that it is not insurance,” he said.
In the case of Samaritan, which says it covers 271,000 people, the ministry pointed to its Save to Share program, where members can contribute extra to cover more of their bills.
With Blake’s bills likely to far exceed the cap — Mr. Collie has not yet tallied them — he created a GoFundMe account to help pay for his son’s care.

Mr. Collie says the ministry remains a viable alternative, noting it paid for numerous medical bills before his son’s hospitalization. “Every single person has prayed for me and my family,” he said. But he was enormously relieved when he found out recently his son qualified for Medicaid, the state-federal insurance program, which will cover the boy’s full medical care.

In some states, officials are starting to consider requiring the groups to register, to obtain more information for consumers.
Peter V. Lee, a former Obama administration official who now runs the California A.C.A. marketplace, said ministries should be subject to some oversight, including disclosure of how much of the money collected is spent on care.
“There should not be a religious exemption for transparency — where the money goes and if it will be there if consumers need it,” he said.
California is also requiring brokers, who are paid hefty commissions by some of the ministries to enroll members, to make sure their clients understand they are not buying insurance.
Some ministries, like Samaritan, say they do not use brokers or agents. “We also have never, nor will we ever, use insurance agents or brokers to sell Samaritan because we don’t want people to confuse us with insurance,” it said.
https://www.nytimes.com/2020/01/02/health/christian-health-care-insurance.html?smid=nytcore-ios-share

Nurses Top Gallup Poll as Most Trusted Profession for 18th Consecutive Year

National Nurses United - January 06, 2020

“The public can count on nurses to stand up, show up, and speak up until the broken U.S. healthcare system is profoundly transformed.”

Nurses topped the 2019 Gallup Poll's annual ranking of how Americans view 22 major professions with 85% of the public, four in five Americans, rating their honesty and ethical standards as “high” or “very high.” Nurses have ranked first for 18 consecutive years and every year except for one since 1999 when Gallup started to survey public opinion on the honesty and ethical standards of various occupations.
“We are honored by this poll and what it reflects - that our patients, their families and the public know that they can trust and count on nurses to stand up for them. This year’s results have special meaning for us as we move into 2020, which the World Health Organization has declared the ‘Year of the Nurse and Midwife,’” said National Nurses United Executive Director, Bonnie Castillo, RN.
“With people and the planet under siege like never before, the public knows they can depend on nurses to use our collective power to advocate for our patients and the broader conditions that support health, justice and dignity for all people, especially the most vulnerable among us,” said Castillo.
“As nurses we know that to defend our patients and realize our vision for a better world our advocacy must encompass union organizing and legislative action. Our efforts in both of these areas have been very fruitful this year,” said NNU President Zenei Cortez, RN.
Despite growing efforts to undermine nurses’ ability to effectively advocate for their patients through union organizing, thousands of nurses voted in 2019 to join NNU affiliates, California Nurses Association (CNA), Minnesota Nurses Association (MNA), and National Nurses Organizing Committee (NNOC) in states across the country.
NNU’s legislative advocacy also moved into high gear with introduction of the Medicare for All Act of 2019 - H.R. 1384, a bill that would guarantee comprehensive health care to all. Thanks to growing grassroots activist pressure in support of the bill, it now has 120 co-sponsors and was considered in legislative hearings by four key congressional committees.
“The public can count on nurses to stand up, show up, and speak up until the broken U.S. healthcare system is profoundly transformed,” said RN and another NNU President, Jean Ross, who testified at a recent congressional hearing. "We will not settle for band aid-fixes. We want the real deal, comprehensive medical care for all, regardless of ability to pay.”
Nurses are also celebrating the U.S. House of Representatives’ bipartisan passage of a groundbreaking federal bill to protect health care and social service workers from extremely high rates of workplace violence—H.R. 1309, the Workplace Violence Prevention for Health Care and Social Service Workers Act. The bill is modeled after the gold-standard protections won previously by California Nurses Association/National Nurses United.
“This legislation will hold our employers accountable, through federal OSHA, for having a prevention plan in place to stop workplace violence before it occurs,” said NNU President Zenei Cortez, RN. “This is literally a life or death issue for our patients, their loved ones, and the nurses and health care workers that care for them.
This year the Registered Nurses Response Network (RNRN), a disaster relief program sponsored by NNU and the California Nurses Foundation, deployed 20 teams of volunteer registered nurses from around the country to provide basic medical care to asylum seekers at border shelters. In follow up to these border deployments, RNRN has released the report, Compassion Without Borders: RNs Report on the Public Health Crisis at the Border. The report outlines the health crisis at the border and can be viewed here.
NNU members have also continued to speak out for environmental justice, endorsing enactment of a Green New Deal and calling on policy makers to seriously address the climate crisis. Nurses have seen firsthand the grave consequences of this crisis as volunteers participating in medical missions to communities devastated by hurricanes and wildfires. This year, RNRN sent volunteers to Florida and Grand Bahamas in the wake of Hurricane Dorian.
Photos from RNR's Hurricane Dorian mission can be viewed here.
2019 was also the year CNA/NNU organized the Global Nurses Solidarity Assembly in San Francisco, California. The convening brought together nurses, labor leaders, and activists from across the globe, including representatives from 25 countries.
“While we may be from opposite sides of the globe, we know that as nurses we share a common mission and are all bound by the same fundamental convictions: to heal the sick and injured, and fiercely advocate for the well-being of our patients, our communities, and our planet,” said Bonnie Castillo, RN, CNA/NNOC and NNU executive director.
To view a short video made for the international gathering, Global Nurses United in Solidarity, visit: https://vimeo.com/357727371/c97645e7d1

https://www.nationalnursesunited.org/press/nurses-top-gallup-poll-most-trusted-profession-18th-consecutive-year 

The Americans dying because they can't afford medical care

Millions of Americans – as many as 25% of the population – are delaying getting medical help because of skyrocketing costs

by Matt Sainato - The Guardian - January 7,2019

Susan Finley returned to her job at a Walmart retail store in Grand Junction, Colorado, after having to call in sick because she was recovering from pneumonia.
The day she returned, the 53-year-old received her ten year associate award – and was simultaneously laid off, according to her family. She had taken off one day beyond what is permitted by Walmart’s attendance policy.
After losing her job in May 2016, Finley also lost her health insurance coverage and struggled to find a new job. Three months later, Finley was found dead in her apartment after avoiding going to see a doctor for flu-like symptoms.
“My grandparents went by to check on her, and they couldn’t get into her apartment,” her son Cameron Finley told the Guardian. “They got the landlord to open it up, went in and found she had passed away. It came as a complete surprise to everybody. It just came out of nowhere.
“She was barely scraping by and trying not to get evicted. She gets what appears to her as a basic cold or flu, didn’t go to the doctor and risk spending money she didn’t have, and as a consequence she passed away.”
Asked about Finley losing her job, Walmart declined to comment, saying personnel files from 2016 had been moved offsite.
Finley is one of millions of Americans who avoid medical treatment due to the costs every year.
A December 2019 poll conducted by Gallup found 25% of Americans say they or a family member have delayed medical treatment for a serious illness due to the costs of care, and an additional 8% report delaying medical treatment for less serious illnesses. A study conducted by the American Cancer Society in May 2019 found 56% of adults in America report having at least one medical financial hardship, and researchers warned the problem is likely to worsen unless action is taken.
Dr Robin Yabroff, lead author of the American Cancer Society study, said last month’s Gallup poll finding that 25% of Americans were delaying care was “consistent with numerous other studies documenting that many in the United States have trouble paying medical bills”.

US spends the most on healthcare

Despite millions of Americans delaying medical treatment due to the costs, the US still spends the most on healthcare of any developed nation in the world, while covering fewer people and achieving worse overall health outcomes. A 2017 analysis found the United States ranks 24th globally in achieving health goals set by the United Nations. In 2018, $3.65tn was spent on healthcare in the United States, and these costs are projected to grow at an annual rate of 5.5%t over the next decade.
High healthcare costs are causing Americans to get sicker from delaying, avoiding, or stopping medical treatment.
Anamaria Markle, of Port Murray, New Jersey was diagnosed with stage three ovarian cancer in 2017. A clerk for nearly twenty years at the same firm, her family says her employer laid her off after the diagnosis, with one year’s severance and health insurance coverage. When the insurance coverage ended, Markle struggled to pay for coverage through Cobra (a health insurance program for employees who lose their job or have a reduction in work hours), additional expenses, copays (an out-of-pocket, upfront fee for a medical service ), and medical debt not covered by insurance.
Laura Valderrama, Markle’s daughter, said: “It wasn’t financially sustainable to keep paying Cobra out of pocket. On top of the premiums you still have to pay the bills. We kept getting lots of bills for surgeries, chemotherapy, all these treatments, all these bills kept coming in.”
Markle decided to stop receiving medical treatment due to the rising costs and debt, and died in September 2018 at the age of 52.
“My mom was constantly doing the math of treatment costs while she was on the decline,” Valderrama said. “I really miss my mom. She shouldn’t have had to make the decision to stop her treatment based on financial costs.”

Families ‘should not have to make these choices’

A 2009 study conducted by researchers at Harvard Medical School found 45,000 Americans die every year as a direct result of not having any health insurance coverage. In 2018, 27.8 million Americans went without any health insurance for the entire year.
One of those Americans was the father of Ashley Hudson, who died in 2002 due to an untreated liver disease, an illness that went undiagnosed until a few weeks before his death. It was only discovered when he went to the emergency room because he was unable to afford to see a doctor due to lack of insurance coverage and inability to afford treatment out of pocket.
Now Hudson’s mother, Sue Olvera, who works at McDonald’s and has no insurance coverage, is facing similar cost barriers while struggling with kidney issues and type 2 diabetes.
“She’s had pain for a long time, but she doesn’t usually go to the doctor unless it gets excruciating because she can’t afford to go,” said Ashley Hudson.
The family is trying to raise money via GoFundMe to help cover the costs of Olvera’s surgery to remove kidney stones earlier this year, which Olvera was expecting to be covered under a charity program, but was denied and now is stuck with over $40,000 in medical debt.
Healthcare is one of the most contentious issues surrounding the 2020 presidential election as Democratic candidates battle over policies to expand healthcare access and lower costs, from Bernie Sanders’ medicare for all bill which would create a government funded healthcare system providing universal coverage to all Americans, while eliminating surprise medical bills, deductibles, and copays, to healthcare plans that focus on creating a public option under the Affordable Care Act. As Democrats debate solutions to America’s healthcare crisis, the Trump administration is delaying any plans for repealing the Affordable Care Act passed under Obama until after the 2020 election.
Several people the Guardian interviewed are currently avoiding medical treatment for serious illnesses or struggling to treat illnesses worsened by delaying medical care due to costs.
Substitute teacher Gretchen Hess Miller, 48, of Carlisle, Pennsylvania, was diagnosed with oral cancer in 2009 while pregnant. She has had surgery to remove the cancer, but is supposed to receive annual scans to monitor the cancer, but hasn’t received one in four to five years because her family can’t afford it.
“My doctor told me this is an aggressive form of cancer that will come back someday and I need to stay on top of it, but the deductible and the difficulty with dealing with the insurance keeps me from having it done,” said Hess-Miller.
Her insurance coverage currently requires a $5,000 deductible, and says she’s previously had to fight to receive coverage because medical care is constantly denied because insurance classifies oral care as dental rather than medical care.
“I have kids. I worry about our future. I want to be here for them,” she said. “We’re very thankful to have insurance at all, but families should not have to compromise on if I’m going to pay for my kid’s college or pay for a test to see if I have cancer. People shouldn’t be put in a position to make choices like that.”
Amy Keeling, 51, a paralegal in New Hampton, Iowa, avoided seeing a doctor for over a year due to her partner’s surgery costs in 2018 for triple bypass surgery.
“I hadn’t felt good for awhile, but I just thought it was my age. In September 2019, I got the flu, and ended up in the emergency room because I couldn’t breathe,” said Keeling.
She was diagnosed with Grave’s Disease, an autoimmune disorder.
“If I had been going in to the doctor and checking on this a lot sooner, we may have been able to do other alternatives and get a handle on this before it got this serious. I’m at the point where medication won’t control it and my only option is surgery,” she said.
Her insurance requires a $5,000 deductible. Having met it in 2019, she scrambled to have her surgery scheduled before 2020, when it would reset. All while her partner is looking to file for bankruptcy because he currently has around $40,000 in medical debt.

https://www.theguardian.com/us-news/2020/jan/07/americans-healthcare-medical-costs