Friday, October 22, 2021

Health Care Reform Articles - October 22, 2021

Where President Biden’s economic plan appears to stand right now: From taxes to climate policy to Medicare to immigration

Jeff Stein, Rachel Roubein, Marianna Sotomayor - Washington Post - October 22, 2021

Even as negotiations over President Biden’s economic package continue, Democratic officials have started signaling which parts of the White House agenda could be cut from the legislation and which are likely to be approved.

Biden, for instance, said on Thursday night that his plan to create universal free community college had fallen out of the bill. The president acknowledged his new clean energy plan to incentivize utility firms to move away from fossil fuels is in danger of being jettisoned. By contrast, universal prekindergarten and a national child care program are widely seen as all but guaranteed to be included, enjoying the backing of the Democratic caucus.

The bill is also likely to retain significantly smaller versions of a wide range of Biden’s proposals, such as initial plans to provide roughly $300 billion for housing and homelessness, $400 billion on eldercare for seniors, and $450 billion for the child tax credit. Each initiative stands to be cut from anywhere from a third to a half of their initial proposed amounts, though estimates on how much vary by significant margins.

And while a higher corporate tax rate may be out of a deal, due to the demands of Sen. Kyrsten Sinema (D-Ariz.), a new tax on billionaires’ accrued wealth is newly in play as part of potentially significant shifts in Democrats’ tax plans to fund the legislation.

The emerging changes to the package come as President Biden this week told House Democrats the legislation may have to spend up to $1.9 trillion. The White House and Democratic officials initially agreed to a $3.5 trillion plan — itself smaller than what the administration had initially pitched — and House Democrats’ version of the bill costs as much as $4.5 trillion, according to budget experts.

Sinema and Sen. Joe Manchin III (D-W.Va.) have been adamant that overall spending figures must be dramatically cut, forcing difficult decisions about which programs to shrink or eliminate. But Democrats are also worried that failure to reach an agreement could lead to no bill at all being passed, a potentially calamitous outcome for the party.

Administration officials have been in regular contact with congressional Democrats about potential avenues for compromise in recent days, but many of those these are likely to change substantially before a final product emerges.

“I don’t think we know exactly where things stand,” said Marc Goldwein, a budget expert at the Committee for Responsible Federal Budget, a think tank in Washington. “The administration came back with some ideas. So the question is which of those stick, which can be massaged, and which have to go. We know it’ll probably be just short of $2 trillion, but what’s in and what’s out is up in the air.”

Below is a rough rundown of where key provisions surrounding the bill stand, based on interviews with more than a dozen congressional aides, lobbyists and administration officials with knowledge of the negotiations. These people, who spoke on the condition of anonymity, stressed that negotiations are moving very swiftly and key provisions could change.

Democrats search for alternative to key climate measure. The single biggest part of the spending bill has been hundreds of billions of dollars to fight climate change. Democrats have remained optimistic that most of the initial White House climate proposal — including $300 billion in clean energy tax credits — is likely to be approved in the final bill.

But Manchin’s demands appear to have forced Democrats to question whether they will have to jettison perhaps the linchpin of their climate initiatives: the Clean Energy Payment Program that would create financial incentives and penalties for utility companies to encourage them to transition to clean energy sources.

Some Democratic lawmakers have been adamant that they can still reach their carbon reduction targets even without the clean energy program. But others are skeptical, arguing that without the utility program, the plan will lack sufficient impact to mitigate catastrophic warming. A host of potential alternatives — including a carbon tax and emissions trading system for industry — have surfaced in recent days, but it is unclear whether these alternative options will end up in the bill.

The White House and multiple senior Senate Democrats are currently working through what policies could both get Manchin’s approval and provide adequate financial resources or new regulations to address the threat of climate change.

Biden told CNN on Thursday that the provision had not yet been eliminated but acknowledged Manchin’s opposition. He also suggested adding the $150 billion originally allocated for the Clean Energy Payment Program for new incentives to reduce fossil fuel intensive expenditures.

Early education programs appear secure with party support. Beyond the climate provisions, the bulk of the Democrats’ package is designed to expand federal safety net and social programs through new initiatives in health care, education, housing, child care, elder care, and other areas.

Of the social programs, the two that have consistently emerged as the safest are Democrats’ plans to establish a universal prekindergarten program and a new national child care program. Manchin has indicated his support for universal pre-K, for instance, which already exists in West Virginia. Biden initially proposed $200 billion to extend free and universal pre-K, as well as an additional $225 billion to subsidize child care, proposing to cap at 7 percent of income the amount families can spend on child care for children younger than 5.

These plans appear likely to pass largely intact, although a report in the People’s Policy Project, a left-leaning think tank, argued this week that the child care provision could dramatically increase costs for middle class families not eligible for the program’s new subsidies. Democrats have denied that claim.

Crown jewel of White House antipoverty efforts faces challenges. In its stimulus bill passed in March, the White House approved a one-year expansion of the child tax credit, so the benefit gave out substantially more money per child and was also extended to reach millions of children in poverty previously denied the payment. The White House proposed extending the more robust child benefit through 2025 at a cost of roughly $450 billion, a measure it has called necessary to achieve major reductions in child poverty.

The program now appears vulnerable. Manchin has called for new work requirements on government programs as part of the package, which could prevent parents who do not work from receiving the benefit. The administration has also discussed whether the child tax credit would only be extended for one additional year, after which Democrats would seek to extend it further, as they try to bring down the cost of the package overall. If Democrats lose the midterms in 2022, it could mean that Biden’s signature expanded child tax credit may die after only a brief trial run.

Yet the White House is still trying to seek approval to permanently ensure the program reaches the poorest families. The original expansion of the child tax credit from earlier this year was able to reach more families because it was extended to those families who had no earnings. The White House wants to ensure that change does not expire, as it is set to under current law. Biden said Thursday he does not support adding a work requirement to the child tax credit.

Democrats weigh massive changes to their tax plan. To pay for all the spending in the measure, the White House proposed trillions of dollars in new tax hikes on corporations and the rich. House Democrats advanced a roughly $2 trillion tax plan that similarly raised tax rates on individuals, corporations and wealthy investors, among other measures.

But due to resistance from Sinema, the administration is being forced to consider alternative approaches as the package inches forward. On a call this week with congressional Democrats, senior administration officials said they are discussing a series of measures that would not raise tax rates — which Sinema has opposed — but still raise trillions of dollars in new revenue, primarily from companies and the rich.

The measures discussed by the administration officials on the call included a new minimum tax on corporations, a plan to beef up tax enforcement through the Internal Revenue Service, a tax on companies issuing stock “buybacks” to company shareholders and, perhaps most surprisingly, a new tax on the assets held by American billionaires.

The White House has been adamant its spending package will be fully paid for with new revenue, meaning it likely has to reach a deal on the tax provisions for the proposal as a whole to advance.

Health priorities are putting senior Democrats at odds. While there is close to unanimous support among Democrats about the early education programs, party leaders are dramatically split on how to expand health care through the legislation.

Although left out of the administration’s initial economic plan, White House officials this summer agreed to back Senate Budget Chairman Bernie Sanders’ (I-Vt.) proposal to extend new dental, vision and hearing benefits to tens of millions of American seniors on Medicare. The initial provision cost as much as $380 billion, but Democratic lawmakers have suggested this week that the program may have to be cut to above $150 billion.

But including all three benefits is a “reach,” Biden said at a CNN town hall on Thursday. He said Manchin is opposed but that Democrats could cut a deal on an $800 voucher for dental care instead. On hearing benefits, Biden pointed to a new proposal from federal health officials to allow consumers to buy over-the-counter hearing aids as a way to make products more affordable without changing Medicare. On vision, Biden says there is no consensus yet.

Meanwhile, drafters of President Barack Obama’s Affordable Care Act, including House Speaker Nancy Pelosi (D-Calif.), have pushed hard for more robust subsidies for those purchasing insurance on the public exchanges. That measure could also prove expensive. Democrats are considering only extending the improved subsidies for Obamacare shoppers for only four years, though Pelosi wanted the plan approved for significantly longer.

Separately, other party leaders have pushed for the inclusion of an expansion of Medicaid to 2.2 million poor adults in mostly Republican-led states refusing Obamacare’s expansion. Lawmakers such as House Majority Whip James E. Clyburn (D-S.C.) and Sen. Raphael G. Warnock (D-Ga.) — Democrats in southern states that rejected the Obamacare expansion — have argued doing so is crucial to closing the racial inequities in the country’s health care system.

Most Democrats would support all three health care programs, but party officials differ on which should be funded with limited resources.

Drug pricing reforms face defections by Democrats. To pay for the health care spending, Democrats have pushed for changing existing law to allow Medicare to negotiate lower prescription drug prices, a measure aimed at both saving the government money and reducing seniors’ prescription drug costs.

But that plan is under fire from a trio of House lawmakers who support a more limited drug negotiation measure and voted against the bill during a key committee hearing in September. On the other side of the Capitol, a plan has not yet come together, as Senate Finance Committee Chairman Ron Wyden (D-Ore.) has worked for months to try to strike a balance between moderate and more liberal Democratic members.

Housing, elder care and paid family leave face downsizing. The White House is widely expected to be forced to cut a range of other programs — such as its proposals for housing, elder care for seniors, and paid family and medical leave — from its initial ambitions.

The administration’s initial housing plan included hundreds of billions of dollars to create millions of new housing units and to house hundreds of thousands of homeless Americans. The housing program also would have funded vouchers for low-income tenants and repairs to public housing units. The overall amount of spending on housing is expected to be cut dramatically, possibly from $300 billion to $100 billion. But it’s not clear which housing programs are on the chopping block.

Similarly, the White House initially pitched as much as $400 billion to help the elderly and those with disabilities receive in-home care from workers who often make below minimum wage. With the nation rapidly aging, the administration said the plan is necessary to help clear the backlog of thousands of people waiting years to receive in-home care from Medicaid. But the home care program may be cut by as much as a third or more.

Yet another White House program — $225 billion to create a national paid family and medical leave program — also faces major downsizing. Initially, Democrats had looked to create 12 weeks of benefits for families and sick workers, but that number is now down to four weeks, and the program might not start until 2024, well after the 2022 midterms. Biden confirmed the four-week plan on Thursday.

There remains some hope for immigration reform. Democrats have not given up on including immigration reform from the reconciliation bill, allotting $100 billion to the matter. But how it gets divided up still depends on what the Senate parliamentarian rules as germane to include in the sweeping budget proposal.

Democratic senators, led by Majority Leader Charles E. Schumer (N.Y.), Richard J. Durbin (Ill.), Alex Padilla (Calif.) and Robert Menendez (N.J.), are preparing their third proposal for the parliamentarian in the coming days. Unlike the previous proposals that focused on creating a pathway to citizenship for a broad swath of undocumented immigrants, current negotiations are focused on reforming the green card visa system to make it more accessible to certain undocumented groups like farm workers and recipients of Deferred Action for Childhood Arrivals. Division among Democrats on whether the parliamentarian’s word is final, with some pushing to override her recommendation.

“More and smaller” prevailing over “bigger and fewer.” When it became clear the White House would have to shrink its legislation by as much as 60 percent, administration officials faced a difficult choice: They could either pursue a plan that contains partial investments across a wide range of areas, or one that approved a handful of programs but each one done in a durable and robust way. Several administration officials privately said they prefer legislation that took aggressive and comprehensive action on only a handful of priorities.

Ultimately, however, the party appears to be pursuing the more diffuse approach. While free community college appears to be out of the plan, Democrats say they remain intent on pursuing virtually all of their biggest programs, at least for now. While, some administration officials agree that it would be better to implement a few large-scale programs, the White House needs every Democrat in the House and Senate to support the legislation for it to pass, and no Democrat wants his or her particular priority axed entirely.

Opinion | Why Is Raising a Child in the United States So Hard?

Spencer Bokat-Lindell - NYT - October 19, 2021

If you’re active on social media there’s a decent chance you came across this chart this month from a Times article about how much less the U.S. government spends on young children’s care than other rich countries.

The infrastructure and family plan that President Biden proposed and that’s now being negotiated in Congress is an attempt to shrink the gap through four key policies: a federal paid family and medical leave program, an extension of the child tax credit (in the form of a monthly payment) that debuted this year, subsidized day care, and universal pre-K.

Two weeks ago, however, the unofficial kingmaker of the Senate, Joe Manchin of West Virginia, said Democrats would have to choose only one of the first three proposals. “I don’t believe that we should turn our society into an entitlement society,” he said.

Why does the United States have such an exceptional approach to family and child care benefits, and what are the arguments against expanding them now? Here’s what people are saying.

As Mona Siegel, a historian at California State University, Sacramento, explained in The Times in 2019, the origins of paid parental leave programs date back to 1919, when the first International Congress of Working Women — a group of female trade unionists, feminists and allies from around the world — convened in Washington and called for 12 weeks of paid maternity leave as a medical necessity and a social right.

European and Latin American countries began enacting these policies over the next two decades, but the end of World War II accelerated the process, particularly in Europe, whose economies had been ravaged by mass death and destruction.

“Part of it had to do with fears of demographic decline — just the sheer population loss during World War II and what felt like the need to recover from those years and to ensure that there was a strong work force going forward,” Siegel told the BBC.

Having experienced fascism up close, European countries also looked to the welfare state as a means of safeguarding democracy against authoritarianism. In the United States, by contrast, opposition to the Soviet Union — and to any political program that might be maligned as socialist or communist — made building support for social insurance more difficult.

Where things stand today: Out of 185 countries with available data, the United States and Papua New Guinea are the only ones whose citizens are entitled to no paid parental leave. In Europe, on the other hand, parents have paid leaves of 14 months, on average, and children commonly start public school at age 3. Before that point, governments pay a significant portion of the cost of child care. A child allowance similar to the new child tax credit is also common among America’s peer nations.

The United States has made some changes to its family policies in the past century, as New York magazine’s Eric Levitz points out. In 1993, Bill Clinton signed the Family and Medical Leave Act, which requires most employers to provide workers with 12 weeks of job-protected, but unpaid, leave to care for a new child or gravely ill family member. About 40 percent of U.S. workers don’t qualify, however, and only 23 percent of private-sector workers have paid family leave through their employers.

Half of Americans live in places where there is no licensed child care provider or where there are three times as many children as slots. One in three children also doesn’t attend preschool; those who don’t are more likely to be Hispanic or from low-income families.

Debatable  Agree to disagree, or disagree better? Broaden your perspective with sharp arguments on the most pressing issues of the week.

As The Times columnist Jamelle Bouie explains, the “entitlement” critique that Manchin voiced this month is a running theme in the history of America’s opposition to a larger social safety net. At its root is a centuries-old tendency to sort the population into productive makers and unproductive takers, a binary that formed the basis of “producerism”: the idea that people who made and grew things were most valuable to society.

  • In the 19th century, producerism fueled revolts against corporations, which progressives argued were stealing the fruits of labor.

  • But in the 20th century, producerism was recast by conservatives and neoliberals: The taker was no longer a greedy employer or an enslaver but the government, expropriating its citizens’ hard-earned money through taxes and redistributing it to undeserving welfare cheats, who were often coded as Black.

“Entitlement” logic may be one reason the child tax credit is less popular than its proponents had hoped. When the Biden administration made all but the most well-off families eligible for monthly checks of up to $300 per child this summer, Democrats predicted that the program would be a big hit. But in a recent poll of registered voters, only 36 percent said it should be made permanent.

“The biggest divide may be on the importance of work,” writes Patrick T. Brown, a fellow at the Ethics and Public Policy Center who helped convene focus groups of working parents to discuss the issue. “The parents we talked to felt a tension between the obvious benefits a monthly benefit could bring but still wanting some kind of work requirement. Work made a family deserving of government support; without it, family benefits were seen as welfare.”

Matt Bruenig of the People’s Policy Project had a very different interpretation of the poll Brown cites, which also found that 53 percent of respondents supported making the child tax credit permanently available to households with no workers. You can read Bruenig’s analysis here.

Americans also have personal and social objections to universal day care. For some parents, their opposition is a matter of wanting to retain choice: In Brown’s focus groups, even the self-described more progressive parents tended to favor vouchers or tax credits to government-run child care programs.

But many Americans also have conflicted feelings about whether the government should be making it easier for parents — and mothers, specifically — to work outside the home. Most Americans say it’s not ideal for a child to be raised by two working parents, and in most opposite-sex couples in which one parent stays home, it’s the mother who does so.

In 1971, Congress passed a bill that would have laid the groundwork for a national child care program — but President Richard Nixon vetoed it, arguing that it placed the government’s authority on “the side of communal approaches to child-rearing” and “against the family-centered approach.”

Today, many social conservatives still oppose state-subsidized child care as a form of social engineering. “Democrats don’t want to put the option to stay home on equal footing with day care,” The Washington Examiner wrote in an editorial in May. “They know that, overwhelmingly, it would be mothers who choose to care for children full time, and these are the very complementary gender roles that they want to eradicate.”

It’s a similar story with opposition to universal pre-K. New research has shown that public pre-K programs have the potential to improve children’s development and long-term well-being, if not their standardized test scores.

But some argue that these benefits can be achieved through other methods — more time at home with a parent, for example — and that it’s not the government’s role to favor one at the exclusion of others. “People’s values and needs are extremely diverse,” Samuel Hammond, the director of poverty and welfare policy at the Niskanen Center, told The Times. “I would say: Just give the parents the money.”

[“Give Parents Money, Not Universal Pre-K”]

Worth noting: In some conservative intellectual circles, “entitlement” logic still shapes opposition to state-sponsored paid leave programs. “If the private sector doesn’t provide it and we have to go to the government to get it, then you’re relying on the government,” Rachel Greszler of the Heritage Foundation said in 2019. “You’re not relying on yourself.”

[“The Conservative Argument Over Paid Family Leave”]

But this argument may hold less sway with the American public on paid leave than it does with the child allowance: A recent CBS News/YouGov poll found that 73 percent of adults surveyed supported federal funding for paid leave. According to another poll conducted in May, 69 percent of respondents, including 55 percent of surveyed Republicans, would support such a policy even if it raised their taxes.

The Times recently asked 18 academics which of the four policies in the infrastructure bill they would make law if they had to pick only one. Public pre-K for children ages 3 and 4 was the winner, with half the experts choosing it. They said it was most likely to achieve multiple goals of family policy:

  • It could help decrease poverty and ease family life by making child care free for toddlers.

  • It could increase gender equality by enabling mothers to work.

  • It could decrease long-term inequality by giving children from different backgrounds the same preparation for kindergarten.

“When my collaborators and I have explored different outcomes — employment, wages, poverty — across a range of wealthy countries, the policy that has had the most powerful effect has been universal early childhood education,” said Joya Misra, a sociologist at the University of Massachusetts, Amherst.

Other policy analysts disagreed with the ranking:

Many experts, though, said it was a choice they would not want to make. “People need resources for coordinating family and employment across the life span,” said Joanna Pepin, a sociologist at the University at Buffalo. “Picking just one policy is akin to putting a fire out in one room of a house engulfed in flames and stopping.” 

The Unvaccinated May Not Be Who You Think

Back when a viral pandemic killing millions around the world was just the plot of a scary movie, the film “Contagion” was lauded for how accurately it depicted the way such an outbreak would occur.

On the science of viral contagion, it was quite sharp, clearly explaining things like R0 (the measure of how widely one infection could spread to others, on average).

Of the human dimension of contagion, it did not prove as prescient. In the movie, fearful nurses walked off the job at the start of the pandemic, which begins to end as soon as vaccines become available, with people lining up eagerly for their turn.

The opposite happened in real life. Despite enormous personal risk, almost all health care workers stayed on the job in the first months of the Covid pandemic. Despite vaccines being widely available since spring in the United States, tens of thousands of people are dying every month because they chose not to be inoculated.

The failure of the United States to vaccinate more people stands out, especially since we had every seeming advantage to get it done. As early as the end of April of this year, when vaccines were in dire short supply globally, almost every adult who wanted to get vaccinated against Covid-19 in the United States could do so, free of charge. By June, about 43 percent of the U.S. population had received two doses while that number was only about 6 percent in Canada and 3 percent in Japan.

Now, just a few months later, these countries, along with 44 others, have surpassed U.S. vaccination rates. And our failure shows: America continues to have among the highest deaths per capita from Covid.

Science’s ability to understand our cells and airways cannot save us if we don’t also understand our society and how we can be led astray.

There is a clear partisan divide over vaccination — Republicans are more likely to tell pollsters that they will not get vaccinated. Some Republican politicians and Fox News hosts have been pumping out anti-vaccine propaganda. The loud, ideological anti-vaxxers exist, and it’s not hard to understand the anger directed at them. All this may make it seem as if almost all the holdouts are conspiracy theorists and anti-science die-hards who think that Covid is a hoax, or that there is nothing we can do to reach more people.

Real-life evidence, what there is, demonstrates that there’s much more to it.

Almost 95 percent of those over 65 in the United States have received at least one dose. This is a remarkable number, given that polling has shown that this age group is prone to online misinformation, is heavily represented among Fox News viewers and is more likely to vote Republican. Clearly, misinformation is not destiny.

Second, reality has refuted dire predictions about how Americans would respond to vaccine mandates. In a poll in September, 72 percent of the unvaccinated said they would quit if forced to be vaccinated for work. There were news articles warning of mass resignations. When large employers, school districts, and hospital systems did finally mandate vaccines, people subject to mandates got vaccinated, overwhelmingly. After United Airlines mandated vaccines, there were only 232 holdouts among 67,000 employees. Among about 10,000 employees in state-operated health care facilities in North Carolina, only 16 were fired for noncompliance.

The remarkable success of vaccine mandates shows it is not firm ideological commitments that have kept everyone from getting vaccinated, and that the stubborn, unpersuadable holdouts may be much smaller than we imagine.

Let’s start with what we do know about the unvaccinated.

There has been strikingly little research on the sociology of the pandemic, even though billions of taxpayer dollars have been spent on vaccines. The assumption that some scientific breakthrough will swoop in to save the day is built too deeply into our national mythology — but as we’ve seen, again and again, it’s not true.

The research and data we do have show that significant portions of the unvaccinated public were confused and concerned, rather than absolutely opposed to vaccines.

Some key research on the unvaccinated comes from the Covid States Project, an academic consortium that managed to scrape together resources for regular polling. It categorizes them as “vaccine-willing” and “vaccine-resistant,” and finds the groups almost equal in numbers among the remaining unvaccinated. (David Lazer, one of the principal investigators of the Covid States Project, told me that the research was done before the mandates, and that the consortium has limited funding, so they can poll only so often.)

Furthermore, its research finds that the unvaccinated, overall, don’t have much trust in institutions and authorities, and even those they trust, they trust less: 71 percent of the vaccinated trust hospitals and doctors “a lot,” for example, while only 39 percent of the unvaccinated do.

Relentless propaganda against public health measures no doubt contributes to erosion of trust. However, that mistrust may also be fueled by the sorry state of health insurance in this country and the deep inequities in health care — at a minimum, this could make people more vulnerable to misinformation. Research on the unvaccinated by KFF from this September showed the most powerful predictor of who remained unvaccinated was not age, politics, race, income or location, but the lack of health insurance.

The Covid States team shared with me more than a thousand comments from unvaccinated people who were surveyed. Scrolling through them, I noticed a lot more fear than certainty. There was the very, very rare “it’s a hoax” and “it’s a gene therapy,” but most of it was a version of: I’m not sure it’s safe. Was it developed too fast? Do we know enough? There was also a lot of fear of side effects, worries about lack of Food and Drug Administration approval and about yet-undiscovered dangers.

Their surveys also show that only about 12 percent of the unvaccinated said they did not think they’d benefit from a vaccine: so, only about 4 percent of the national population.

In law, “dying declarations” are given special considerations because the prospect of death can help remove the motivation to deceive or to bluster. The testimony we’ve seen from unvaccinated people in their last days with Covid, sometimes voiced directly by them from their hospital beds, gets at some of the core truths of vaccine hesitancy. They are pictures of confusion, not conviction.

One woman who documented her final days on TikTok described being uncertain about side effects, being worried about lack of F.D.A. approval, and waiting to go with her family to get the shot — until it was too late.

Or consider Josie and Tom Burko, married parents who died from Covid within days of each other, leaving behind an 8-year-old daughter. They hadn’t taken the pandemic lightly. They were “100 percent pro-vaccination,” a close friend told The Oregonian afterward, but Josie reportedly had a heart murmur and chronic diabetes and worried about an adverse reaction. Tom reportedly had muscular atrophy, and similar worries. Afraid, they had not yet gotten vaccinated.

It’s easy to say that all these people should have been more informed or sought advice from a medical provider, except that many have no health care provider. As of 2015, one quarter of the population in the United States had no primary health care provider to turn to for trusted advice.

Along with the recognition of greater risk, access to regular health care may be an important explanation of why those over 65 are the most-vaccinated demographic in the country. They have Medicare. That might have increased their immunity against the Fox News scare stories.

One reason for low vaccination rates in rural areas may be that they are “health care and media” deserts, as a recent NBC report on the crises put it, with few reliable local news outlets and the “implosion of the rural health care system” — too few hospitals, doctors and nurses.

Plus, let’s face it, interacting with the medical system can be stress-inducing even for many of us with health insurance. Any worry about long-term side effects is worsened by a system in which even a minor illness can produce unpredictable and potentially huge expenses.

Then there is the health system’s long-documented mistreatment of Black people (and other minorities) in this country. Black people are less likely to be given pain medication or even treatment for life-threatening emergencies, for instance. I thought of those statistics while reading the poignant story of a Black physician who could not persuade her mother to get vaccinated because her mother’s previous interactions with the medical system included passing out after screaming in agony when a broken arm got manipulated and X-rayed without sufficient care for her pain.

While the racial gap in vaccination has improved over the last year — nonwhite people were more likely to express caution and a desire to wait and see rather than to be committed anti-vaxxers — it’s still there.

In New York, for example, only 42 percent of African Americans of all ages (and 49 percent among adults) are fully vaccinated — the lowest rate among all demographic groups tracked by the city.

This is another area in which the dominant image of the white, QAnon-spouting, Tucker Carlson-watching conspiracist anti-vaxxer dying to own the libs is so damaging. It can lead us to ignore the problem of racialized health inequities with deep historic roots but also ongoing repercussions, and prevent us from understanding that there are different kinds of vaccine hesitancy, which require different approaches.

About a month ago, the rap artist made headlines after tweeting that she was worried about vaccines because she had heard from her cousin that a friend of his had swollen testicles after being vaccinated. (Experts pointed out that, even if this had happened, it was most likely caused by a sexually transmitted disease.) She was justifiably denounced for spreading misinformation.

But something else that Minaj said caught my eye. She wrote that she hadn’t done “enough research” yet, but that people should keep safe “in the meantime” by wearing “the mask with 2 strings that grips your head & face. Not that loose one.”

“Wear a good mask while researching vaccines” is not the sentiment of a denier. She seemed genuinely concerned about Covid, even to the point that she seemed to understand that N95s, the high-quality masks that medical professionals wear, which have the “2 strings that grips your head & face,” were much safer.

Lazer said that the Covid States Project’s research showed that unvaccinated people who nonetheless wore masks were, indeed, more likely to be Black women. In contrast, those who were neither vaccinated nor masked were more likely to be Republicans, and more likely to be rural, less educated and white. (Among the vaccinated, Asian Americans were most likely to be still wearing masks.)

Lazer also highlighted an overlooked group with higher levels of vaccine hesitancy: young mothers. They were hesitant, both for themselves and their children, an alarming development especially if it starts affecting other childhood vaccinations. Similarly, from real-life data, we know that only a little more than one-third of pregnant women are vaccinated, which has led to many tragic stories of babies losing their mothers just as they are being whisked into the neonatal intensive care unit after an emergency cesarean section.

It may well be that some of the unvaccinated are a bit like cats stuck in a tree. They’ve made bad decisions earlier and now may be frozen, part in fear, and unable to admit their initial hesitancy wasn’t a good idea, so they may come back with a version of how they are just doing “more research.”

We know from research into human behavior but also just common sense that in such situations, face-saving can be crucial.

In fact, that’s exactly why the mandates may be working so well. If all the unvaccinated truly believed that vaccines were that dangerous, more of them would have quit. These mandates may be making it possible for those people previously frozen in fear to cross the line, but in a face-saving manner.

Research also shows that many of the unvaccinated have expressed concerns about long-term effects. Consider an information campaign geared toward explaining that unlike many drugs, for which adverse reactions can indeed take a long time to surface, adverse effects of vaccines generally occur within weeks or months, since they work differently, as the immunologist Andrew Croxford explained in The Boston Review. Medical professionals could be dispatched to vaccination clinics, workplaces and stores to get that point across. (Yes, medical professionals are overwhelmed, but the best way to reduce their burden is to vaccinate more people.) This would let some hesitant people feel like they had “done their research,” while interacting with a medical professional — the basis for more trust.

Finally, consider something hidden amid all the other dysfunction that plagues us: fear of needles.

Don’t roll your eyes. Prepandemic research suggests that fear of needles may affect up to 25 percent of adults and may lead up to 16 percent of adults to skip or delay vaccinations. For many, it’s not as simple as “suck it up”: It’s a condition that can lead to panic attacks and even fainting. During the pandemic, a study in Britain found that as many as one in four adults had injection phobia, and that those who did were twice as likely to be vaccine-hesitant. Research by Covid States shows that about 14 percent of the remaining unvaccinated mention fear of needles as a factor.

Countries with far higher rates of vaccination, Canada and Britain, have responded by mobilizing their greatest strength: a national health care system. Cities in Canada held clinics aimed especially at people with such anxiety, which included privacy rooms and other accommodations. Britain’s national health care system offers similar accommodations.

I’ve yet to find a systematic program in the United States addressing this fear. Worse, much of our public communications around the vaccines feature images of people getting jabbed with a needle, even though that can worsen anxiety.

In researching, I was inundated with stories from people who struggled with this fear and were often unable to find help. Some women said they were treated like drug seekers because they asked for a single anti-anxiety pill to get through a shot. (They also said their male family members and friends had an easier time.) It may seem hard to believe that people might risk their lives over seemingly small fears, but that’s exactly how people behave in many situations.

Of course, there are some people who it seems will never be persuaded. One strategy that has been shown to work is to highlight deceptive practices. In campaigns to keep teens from smoking, advertisements pointed out how the tobacco industry manipulated people. For Covid, the unvaccinated could be shown that they have been taken in by people who have misled them even while those people themselves got vaccinated.

Just recently, there was a brief glimpse at how Fox News actually looks behind the camera: Everyone in the office was wearing masks, even as the hosts have often talked about the alleged tyranny of it all. Stars like Tucker Carlson rant against vaccines, even as their network says that more than 90 percent of full-time employees have been vaccinated. Realizing that one may have been conned and manipulated by opportunists who do not practice what they preach may — just may — be the breakthrough for some.

Responding to our societal dysfunctions has been among the greatest challenges of this pandemic, especially since this includes a political and media establishment stirring up resentment and suspicion to hold on to power and attention in an increasingly unresponsive political system.

Anger — and even rage — at all this may be justified, but deploying only anger will not just obscure the steps we can and should try to take, it will play into the hands of those who’d like to reduce all this to a shouting match.

Instead, we need to develop a realistic, informed and deeply pragmatic approach to our shortcomings without ceding ground to the conspiracists, grifters and demagogues, and without overlooking the historic inequities in health care and weaknesses in our public health infrastructure. It’s not all fair, and it is not a Hollywood ending, but it’s how we can move forward.

    A 30-Year Campaign to Control Drug Prices Faces Yet Another Failure

    Democrats have made giving government the power to negotiate drug prices a central campaign theme for decades. With the power to make it happen, they may fall short yet again.

WASHINGTON — When a powerful Democratic Senate chairman assembled his Special Committee on Aging to confront what he called a “crisis of affordability” for prescription drugs, he proposed a novel solution: allow the government to negotiate better deals for critical medications.

The year was 1989, and the idea from that chairman, former Senator David Pryor of Arkansas, touched off a drive for government drug-price negotiations that has been embraced by two generations of Democrats and one Republican president, Donald J. Trump — but now appears at risk of being left out of a sprawling domestic policy bill taking shape in Congress.

Senior Democrats insist that they have not given up the push to grant Medicare broad powers to negotiate lower drug prices as part of a once-ambitious climate change and social safety net bill that is slowly shrinking in scope. They know that the loss of the provision, promoted by President Biden on the campaign trail and in the White House, could be the single most embarrassing defeat in the package, since it has been central to Democratic congressional campaigns for nearly three decades.

“Senate Democrats understand that after all the pledges, you’ve got to deliver,” said Senator Ron Wyden of Oregon, the chairman of the Finance Committee.

“It’s not dead,” declared Representative Richard E. Neal of Massachusetts, the chairman of the Ways and Means Committee.

But with at least three House Democrats opposing the toughest version of the measure, and at least one Senate Democrat, Kyrsten Sinema of Arizona, against it, government negotiating power appears almost certain to be curtailed, if not jettisoned. The loss would be akin to Republicans’ failure under Mr. Trump to repeal the Affordable Care Act, after solemn pledges for eight years to dismantle the health law “root and branch.”

And after so many campaign-trail promises, Democrats could be left next year with a lot of explaining to do.

“It would mean that the pharmaceutical industry, which has 1,500 paid lobbyists, the pharmaceutical industry, which made $50 billion in profits last year, the pharmaceutical industry, which pays its executives huge compensation packages, and which is spending hundreds of millions of dollars to defeat this legislation, will have won,” Senator Bernie Sanders, the Vermont independent and Budget Committee chairman, said on Wednesday. “And I intend to not allow that to happen.”

It is not clear how Mr. Sanders can pull that off. The length of the fight speaks to the durability and popularity of the issue, but also the power of the pharmaceutical industry.

Senator Pryor teed it up in the late 1980s, hoping to muscle through lower prices for Medicaid, with an eye on the bigger prize, Medicare. President Bill Clinton included government price negotiations in his universal health care plan in 1993, and throughout the 1990s, as Democrats pressed to add a prescription drug benefit for Medicare, government negotiations were central to holding the cost down.

Then in 2003, a Republican Congress and president, George W. Bush, secured passage of that drug benefit — but with an explicit prohibition on the government negotiating the price of medicines older Americans would purchase.

Repealing that so-called noninterference provision has been a centerpiece of Democratic campaigns ever since. Senator Chris Van Hollen of Maryland, a former head of House Democrats’ campaign arm, recalled that “Medicare shall negotiate drug prices” was one of the six planks in the “Six for ’06” platform that helped the Democrats win control of the House in 2006.

It has passed the House numerous times, including in 2019 with yes votes from the three House members now opposing it — Representatives Kathleen Rice of New York, Scott Peters of California and Kurt Schrader of Oregon — only to die in the Senate. Even Mr. Trump adopted the effort in his 2016 campaign, only to see it go nowhere.

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That futility is why Mr. Schrader said he opposed it: “Why do the same thing again and again and expect to have a different result?” he asked.

To proponents, defeat after defeat speaks solely to the power of the pharmaceutical industry and its attendant lobbyists.

But opponents say it reflects the complexity of the issue. Once lawmakers realize they could actually secure government price negotiations, they see how problematic that could be.

“If anyone thinks this is the easy political route for me, that’s just laughable,” said Mr. Peters, who has endured scorn and pressure from his Democratic colleagues but whose San Diego district includes almost 1,000 biotechnology companies and 68,000 jobs directly tied to pharmaceutical work.

Mr. Schrader and Mr. Peters said the House version of prescription drug price controls, tucked into the broader social policy legislation, would stifle innovation in one of the country’s most profitable global industries.

The Pharmaceutical Research and Manufacturers of America, known as PhRMA, also maintains that government negotiations would severely limit the types of prescription drugs that would be available to Medicare beneficiaries as companies withdraw their products from the program. With the good will the industry has accrued with its coronavirus vaccines and treatments, drug companies have pressed their case with key lawmakers, and roped in the larger business community.

American Action Network, a conservative group with business money, unveiled a new set of ads on Wednesday targeting vulnerable Democrats such as Representative Carolyn Bourdeaux of Georgia and decrying “another socialist health care plan to control what medicines you can get.”

“We are taking on the greed and the corruption of the pharmaceutical industry — I know their power, believe me, I know their power,” Mr. Sanders said. “But this is a fight we’ve got to win.”

Mr. Wyden insisted that any legislative effort to tackle rising drug costs must include government negotiating power, but alternatives are emerging.

Some simpler solutions would change the formula of the existing Medicare prescription drug benefit to limit out-of-pocket costs, especially in the event of a catastrophic health event.

Mr. Wyden is also pressing to resurrect legislation he drafted with Senator Charles E. Grassley, Republican of Iowa, that would force drugmakers to offer rebates to consumers on products whose prices rise faster than inflation. Mr. Grassley said he still supports the measure, as does Senator Bob Menendez, Democrat of New Jersey and a traditional ally of the pharmaceutical industry in his state.

Mr. Schrader and Mr. Peters said negotiations were progressing around their proposal, which would grant the government power to negotiate prices under Medicare Part B, which covers outpatient services and some of the most costly medications, once outpatient drugs like chemotherapy have outlived their patent exclusivity.

Their bill would also force rebates for drug prices rising faster than inflation, and limit out-of-pocket medication expenses for older Americans. That is projected to save the government $300 billion over 10 years, about half what the broader measure would save.

“Frankly, based on discussions we’ve had with the White House, senators and other members in our party, this could get done,” Mr. Schrader said. “That’d be huge.”

Ultimately, if any significant price controls survive, it will be the logic of the policy overcoming the power over the lobby, said Representative Ron Kind, a Democrat whose Wisconsin district is being hit with pharmaceutical industry advertising. Mr. Kind, an influential centrist, said he has been speaking with like-minded Democrats, trying to buck them up against the onslaught.

“Obviously, there’s some advertising,” he said. “But boy, public sentiment is overwhelming. They just don’t understand why the pharmaceutical industry is the only private industry the federal government’s refused to even discuss prices wit

Industry shapes battle over health costs

By Angela Hart and Samantha Young - San Francisco Chronicle - 10-17-21

SACRAMENTO — Gavin Newsom put California’s health care industry on notice when he was a candidate for governor, vowing in 2018 to go after the insurance companies, doctors and hospitals that leave many Californians struggling with enormous medical bills and rising insurance premiums.

He pledged to lead California’s single-payer movement, a high-stakes liberal dream that would eliminate private health insurance and slash how much providers are paid. The tough rhetoric continued after he was elected, when Newsom told insurers to “do their damn job” to improve mental health treatment or face fines, and he vowed to cut the health care industry’s soaring revenues.

“We’ve got to get serious about reducing health care costs,” the first-term Democrat said in January 2020 as he unveiled his proposal to establish an Office of Health Care Affordability that would do the unthinkable in a system powered by profits: set caps on health care spending and require doctors and hospitals to work for less money. “We mean business.”

Industry leaders were rattled. But rather than mobilize a full-throttle defense to sink Newsom’s effort to regulate them, they have used their political clout and close ties with the governor to devise a friendlier alternative that doctors, hospitals and insurance companies could live with.

When Newsom ultimately drafted legislation for the office, he took an idea health care executives had pitched and made it his own: Instead of capping prices or cutting revenues, he would allow industry spending to grow — but with limits.

Political infighting killed the legislation this year, but it is expected to come back in January and spark one of next year’s blockbuster health care battles.

“They’re fearful of what might happen to them, and they’re trying to protect their interests because they’re threatened,” David Panush, a veteran Sacramento health policy consultant, said about health care industry players. They know “there’s blood in the water and the sharks are coming.”

If Newsom’s plan to rein in health care spending succeeds, it could provide him some political cover as he campaigns for reelection next year, giving him a major health care win even as he sidesteps progressive demands such as creating a single-payer system.

But it could also cement the power of an industry that continues to wield immense influence — negotiating behind the scenes to protect its massive revenues and secure exemptions and side deals in exchange for its support.

“Every time we try to do something to reduce health care costs, it meets with huge opposition,” said state Assembly member Jim Wood (D-Santa Rosa), head of the Assembly Health Committee who is working closely with the Newsom administration on this proposal.

Industry power players have only pushed back harder as lawmakers have tried to take them on, Wood said. “Anybody or anything that disrupts the status quo is met with huge resistance and huge resources to fight it,” he said.

* * *

When Newsom took office in 2019, he knew public sentiment was turning against the health care industry. On average, health care costs were around $11,600 per person that year, up from $4,600 in 1999, according to federal data. In California, hospitals account for the biggest share of spending, nearly one-third, while 20% of health care dollars goes to doctors.

California consumers are demanding action, with 82% of state residents saying it’s “extremely” or “very” important for the governor and legislature to make health care more affordable, according to a 2021 poll from the California Health Care Foundation.

Much of Newsom’s tough talk on industry spending came early in his term. “We’re going to create specific cost targets for all sectors to achieve, and we are going to assess penalties if they don’t achieve those targets,” Newsom said in January 2020. “If that didn’t wake up members of the system, I don’t know what will.”

Newsom’s wake-up call came on the heels of tense legislative debates on bills that would have empowered the state to set health care prices and created a single-payer system. The measures gained surprising momentum but ultimately buckled under opposition from health care giants.

Then the covid-19 crisis hit and propelled the recall effort to oust him from office — and the wake-up call was met with a slap of the snooze button. The governor and his health industry allies nestled closer. Just as he needed them to be the state’s front line of defense, they needed him to keep hospitals from overflowing, to secure protective gear and to push vaccinations.

Health care titans became regular fixtures in Newsom’s orbit. His calendars, obtained by KHN, show that doctors, hospitals and health insurance leaders have routinely received access to the governor.

Carmela Coyle, head of the California Hospital Association, stood beside Newsom at the state emergency operations center in the early days of the covid crisis, and Paul Markovich, CEO of Blue Shield of California, obtained a lucrative no-bid state vaccination contract to implement Newsom’s vaccination effort.

Newsom did not respond to questions about the industry’s influence, but spokesperson Alex Stack said his proposal to regulate health care spending “is a priority for this administration, and we look forward to continuing to work on this issue to get it done.”

Doctors and Blue Shield have given Newsom millions of dollars to support his political career over many years, including a $20 million donation in September 2020 from Blue Shield for his homelessness initiatives.

The recall effort earlier this year only solidified Newsom’s relationship with health care executives. Industry groups wrote checks to the California Democratic Party, which fought to keep Newsom in office. It received $1 million each from Blue Shield and the hospital lobby and $875,000 from the doctors’ lobby, according to state campaign finance records.

* * *

Though Newsom vowed to go after industry, he hasn’t aggressively taken it on, and health care executives and lobbyists continue to wield their influence as they shape the debate over the Office of Health Care Affordability.

That could put Newsom in a political bind as he runs for reelection — first in the June 2022 primary and then the November general election — because he will face intense opposing political pressure from liberal Democrats who want him to keep his campaign promise and adopt single-payer.

Health and political experts say Newsom can help alleviate that pressure by adopting a strict law going after spiraling health care spending.

But it won’t be easy. After powerful industry leaders joined forces with organized labor and consumer advocates to propose a plan to the governor, they jammed negotiations with their demands, splintering the coalition and killing the effort this year.

With battle lines drawn, industry groups are poised for a major fight next year as Newsom and state Democratic lawmakers muscle through legislation. Their primary goal will be to protect their interests, said Mark Peterson, a professor of public policy, political science and law at UCLA.

“There’s no question this industry has power. The real question is what they do with it,” Peterson said. “They’re getting wins, and important ones.”


Friday, October 8, 2021

Health Care Reform Articles - October 8, 2021


Editor's Note -

The following clipping is what represents progress in the USA!

I guess you take what you can get. 



New Rule on Surprise Billing Aims to Take Patients Out of the ‘Food Fight’

Neutral arbiters are given guidance on how to settle disputes between insurers and medical providers.

by Sarah Kliff - NYT - October 6, 2021


The Biden administration released a rule Thursday that addresses one of the most fought-over provisions of a coming ban on surprise medical bills.

The rule details how a new class of medical billing arbiters will decide the fair price for emergency medical care, one of the largest sources of surprise bills. The rule received a positive reaction from consumer advocates and some legislators who drafted the law, but it “disappointed” emergency physicians, who fear it will lead to unreasonably low rates.

The ban on surprise medical bills was passed by Congress and signed into law by President Donald J. Trump last winter, but it is the Biden administration that has been fine-tuning the policy — amid intense lobbying from insurers, medical providers and advocates.

In a dispute between an insurer and a provider over an out-of-network bill, the rule directs the arbiters to focus first on the median price that other doctors and hospitals in the area have negotiated for that service.

This was the second major rule the Biden administration released on surprise billing this year, before the law takes effect in 2022. Taken together, the two regulations detail how the federal government will end what patients, academics and legislators often describe as one of the most exasperating practices in American medicine.

“We’re taking patients out of the middle of the food fight, and we’re also providing a clear road map on how you can resolve that food fight between the provider and the insurer,” said Xavier Becerra, secretary of Health and Human Services, in an interview.

Surprise medical bills happen when a doctor or other provider who isn’t in a patient’s insurance network is unexpectedly involved in a patient’s care. Patients may go to a hospital that accepts their insurance, for example, but get treatment from emergency room physicians or anesthesiologists who don’t — and who then send patients big bills directly.

Millions of Americans receive these type of bills each year. As many as one in five emergency room visits result in such a charge, and the rate of surprise billing is similar for women giving birth. Some coronavirus patients have received exceptionally high surprise bills. That includes a Pennsylvania woman who was unconscious and intubated when an out-of-network air ambulance transported her between hospitals. She was billed over $50,000 for the service.

Patients like that are essentially caught in the middle of a dispute between a doctor and an insurer, who disagree on the fair price for a given medical service. The new rule released Thursday lays out how newly hired billing arbiters will decide who, in those fights, is right.

Under the federal law, both the insurer and the doctor will tell an arbiter what they believe the appropriate price for the service should be. The arbiter will then look at a variety of factors to decide which of the two rates to pick.

The law that Congress passed has six factors the arbiters can consider. The rule released Thursday, however, directs the arbiters to focus on one of those factors as their starting point: the median prices that have been negotiated in the area for the same medical service.

The arbiter “must begin with the presumption” that this is “the appropriate out-of-network rate,” the rule states. They may consider other factors listed in the law, such as how sick the patient was or whether the hospital or doctor had made good faith efforts to join insurance networks, if they receive “credible information” from either party involved in the dispute on those subjects.

The administration on Thursday also opened applications for organizations to become arbiters. Applicants must have experience in “billing and coding” and “arbitration and claims management.”

The rules on how arbiters settle billing disputes are seen as especially important because they will determine whether the ban on surprise billing ultimately saves money for consumers, insurers and the federal government. The Congressional Budget Office estimated last year that the surprise billing ban would save the federal government $17 billion and reduce private insurance premiums 0.5 percent to 1 percent.

Most experts expect that starting from the in-network prices will ultimately lead to lower reimbursement rates. The Biden administration stated in the rule that the decision “will aid in reducing prices that may have been inflated due to the practice of surprise billing prior to the No Surprises Act.”

Trade groups representing health care providers, including emergency room physicians and hospitals, had generally urged the Biden administration to do something different: ensure that arbiters use all six of the factors listed in the law when they make up their minds. They argue that Congress intended for arbiters to have that broader deliberation, and that focusing on median in-network rates will lead to lower prices that are untenable.

“We’re pretty disappointed because this is entirely against congressional intent,” said Laura Wooster, senior vice president for advocacy at the American College of Emergency Physicians. “I’m not seeing how small physician groups will be able to work with this, and keep their doors open. Now is not the time to take away resources from emergency physicians.”

Congressional Democrats quickly applauded the new rule.

“Today’s rule implements the No Surprises Act just as we intended,” Senator Patty Murray of Washington and Representative Frank Pallone of New Jersey, who lead health committees in each of their chambers, said in a joint statement. “It establishes a fair payment resolution process between providers and insurers while finally taking patients out of the middle.”

Secretary Becerra said he expected the rule to generate “a lot of animated discussion on the part of the stakeholders in the industries” but felt the Biden administration had created a way to settle billing disputes that was straightforward and fair. “It will give patients some peace of mind that they don’t have to stand the chance of going bankrupt just because they had to go out of network,” he said.

Republican reaction to the rule wasn’t immediately available. Stakeholders are still reviewing the 521-page rule, and the administration will accept comments on it for the next 60 days. Given the relatively short timeline — the surprise billing ban is set to start in three months — major changes are not expected.

Sarah Kliff is an investigative reporter for The New York Times. Her reporting focuses on the American health care system and how it works for patients. 

A version of this article appears in print on Oct. 2, 2021, Section A, Page 17 of the New York edition with the headline: New Rule Steers How Arbiters Settle Disputes Over Surprise Medical Bills. Order Reprints | Today’s Paper | Subscribe


Maine Voices: We must hold hospitals, government accountable on health care costs

We’ve won the right to know prices – now we need robust enforcement, meaningful penalties and full disclosure. 

By Portland Press Herald - September25, 2021

We’ve won the right to know prices – now we need robust enforcement, meaningful penalties and full disclosure.

Since ancient times, one of the primary tenets of medicine has been that physicians should “first, do no harm” to our patients. Today, we also need to add “do no financial harm.” The best way to do that, and to protect our patients’ finances, is through complete price transparency.

The ability to see and compare prices would usher in price competition, which would bend the cost curve down for a change, allow patients to shop for the best value for their health care dollar and slow the unhealthy trend of consolidation in the health care industry.

Thankfully, as of the first of this year, a new hospital price transparency rule went into effect, giving Americans the right to know the price of their health care up front.

The problem is that many hospitals throughout our state are not complying with the federal law. A report released last month by a national nonprofit organization showed that the vast majority (94.4 percent) of hospitals, including most of those in Maine, were not following the rule.

They claim that they cannot comply because the information is not readily available, which insults the intelligence of the average Mainer. All these hospitals have multimillion-dollar billing systems that can, and do, generate bills to patients and insurance companies on demand. We all see the prices in the explanation of benefits we receive – after we get health care we cannot return. Obviously, they know the prices but are unwilling to disclose them. There is no reason that, upon request, hospital billing personnel couldn’t enter the procedure code of a particular service (called a CPT code), and display the price the hospital charges in advance. If hospitals really cannot do this, perhaps there should be intense audits of their accounting systems.

Although doctors are often blamed for rising health care costs, I assure you, we want what patients want. We want to know prices, too, but hospitals and insurers also keep us in the dark. That has always been unethical, and now it is criminal.

I have written to Maine Attorney General Aaron Frey asking him to help enforce the law and hold hospitals accountable. To do that, our government needs to dramatically increase the financial penalties imposed on hospitals that don’t follow the rule. Currently, the penalty is only $300 a day. Worse, the government has yet to fine a single hospital for not complying with the government’s own rule. What good is a law with no teeth? The fine should be 10 times that, or $300 a day per hospital bed, and be robustly enforced. We also need to eliminate the loophole in the rule that allows hospitals to simply provide estimates, not guaranteed prices. By their complacent inaction, government is sending the message that these hospitals, most of which are nonprofit, so don’t pay taxes, are above the law. Perhaps the state of Maine should re-examine the tax-exempt status of any hospital system that doesn’t comply with this very important consumer protection.

We have a long way to go to fix our broken health-care system, but demanding what is rightfully ours, the right to know the cost of care before getting a surprise bill, is an essential step. Mainers deserve nothing less and should demand nothing less. 

Editor's Note -

Dr. Ciampi, author of the preceding letter, is right to state that patients and doctors should know the prices of the products and services they use.  What he does not seem to realize is that the current system is designed to obscure or conceal prices He doesn't seem to understand that there is no such thing as "a price".  There are many prices for the same services, depending who the patient is, what insurance company they use, and many other extraneous factors.  

Even if accurate prices were available in advance, there is still the question of whether the products or services were appropriate for the patient's disorder or were necessary at all.  How do you know your doctor is acting on your behalf, and not succumbing to the pressure being applied by their employer to benefit their bottom line in our for-profit system?

The patient really doesn't have the knowledge necessary to make that judgement.  "Consumers" (we used to call them "patients") have no power, and more and more institutional "providers" (we used to call them doctors, nurses and hospitals) even if they are nominally non-profit-are behaving like for-profits. 

 If consumers have no power, markets cannot function.

That's one of the most important reasons markets do not, have not and will not ever work in healthcare.  Only in America would the notion of markets applied to healthcare have anywhere near the credibility it enjoys in the America.  A French friend of mine once made the statement "When it comes to healthcare, Americans are suckers".  

Regretfully, I agree.


While Democrats bicker, our unacceptable health-care status quo continues

Helaine Olen - Washington Post - September 30, 2021

For all of Americans’ political divisions, on some issues there is more agreement than many of us may realize. Medical care is one such area. A majority of Democrats, Republicans and independents want the federal government to negotiate with pharmaceutical companies over prices for prescription drugs covered by Medicare, polling this summer shows. Here’s another point of agreement: Most U.S. adults think Medicare should offer dental coverage.

Simply put: We need both. The United States is the only first-world country that does not negotiate or regulate what Big Pharma can charge for its offerings. Not surprisingly, Americans pay more for pharmaceuticals than citizens in other nations. Public Citizen reported this week that Americans shell out more for the top 20 bestselling prescription drugs than the total paid by every other nation on the planet combined.

As for dental care, the surgeon general warned back in 2000 of “a silent epidemic” of dental and oral diseases afflicting many Americans. A 2012 survey published in Health Affairs found that about half of all people on Medicare hadn’t seen a dentist in the preceding year. The issue was almost certainly cost. Those who had dental insurance were more likely to have sought care. As of 2020, at least 20 percent of adults reported delaying or skipping necessary dental care within the previous two years. Dental health is not a vanity issue — people with gum disease are at higher risk for heart attacks and strokes.

Despite public support for expanding coverage and limiting health costs for consumers, it’s quite possible Americans will remain stuck with the (unacceptable) status quo. The blame for such an outcome does not accrue only to the Republicans seeking to block President Biden’s agenda every which way they can. The other culprit is the corrosive role that special interest and corporate money plays in our politics, which is to say in both major parties.

Consider: Three Democratic members of the House Energy and Commerce Committee — Reps. Scott Peters of California, Kathleen Rice of New York and Kurt Schrader of Oregon — voted down a provision this month that would allow Medicare to negotiate drug prices with pharmaceutical companies. Good-government types pointed out that the trio themselves have collected about $1.5 million in campaign donations from Big Pharma.

The three, I am obliged to note, have denied that corporate money influenced their votes. They say that the legislation they voted against would lead the pharmaceutical industry to spend less on innovation and development. (Somehow, almost no one parroting this argument ever explains why the United States should bear the brunt of this financial burden.)

Instead, Schrader and Peters are championing a bill of their own, one that would permit government bargaining over prices of a significantly smaller number of drugs. Is this less-effective effort going anywhere? Well, Sen. Kyrsten Sinema (D-Ariz.) has told the White House that she can’t get behind any of these proposals to rein in the pharmaceutical industry.

Absent a negotiation provision — which the Congressional Budget Office has estimated would save the federal government $456 billion over 10 years — it’s quite possible that Medicare dental coverage won’t happen. That would certainly make the American Dental Association happy. The association has been fighting the proposed expansion, fearful that its members — that is, dentists — would not get paid enough by the federal government. (It is instead promoting a fig leaf of a plan that would offer dental coverage only to indigent and nearly indigent seniors.)

Notably, the dental benefits for seniors in the $3.5 trillion reconciliation package wouldn’t begin until 2028. That doesn’t help seniors in the here and now, so it’s hard to see how it would make for a winning campaign issue in 2022. Conversely, it’s easy to imagine that this timing would allow opponents to regroup, peddle false information about the plan and attempt to stop the benefits before they could take effect.

No one would need to write the playbook for this — it’s what happened with the Affordable Care Act.

This back and forth over popular reforms — ones that are urgently needed to improve Americans’ health and well-being — points to a bigger problem looming over our politics and the Democratic Party. Donald Trump pledged to “drain the swamp” — which, of course, he didn’t do. Biden’s pitch to Americans was that his long-term relationships with Republicans and with political and business power brokers would pay off for all of us.

But there’s a warning implicit in Democrats’ infighting over the president’s agenda. If Biden can’t wrangle enough members of his own party to deliver on initiatives as popular as cracking down on prescription drug prices and adding dental coverage to Medicare, it undercuts a huge selling point of his appeal. Will voters be patient? Or, disillusioned, will they turn to others who promise they can corral Washington and corporate interests — and deliver in a bottom-line way that improves peoples’ lives? 

Letter to the editor: Mainers deserve equitable health care system

In August, the Commonwealth Fund issued a report comparing health care in the U.S. to 10 other high-income countries. The U.S. compared dismally, ranking last in health care affordability and health equity. The U.S. health care system also has the highest rate of infant mortality and deaths that would have been prevented with good health care. Although Maine’s infant mortality and overall mortality rates are lower than the U.S. average, they are still significantly worse than the other 10 countries.

The report’s authors note, “Four features distinguish top performing countries from the United States: 1) they provide for universal coverage and remove cost barriers; 2) they invest in primary care systems to ensure that high-value services are equitably available in all communities to all people; 3) they reduce administrative burdens that divert time, efforts, and spending from health improvement efforts; and 4) they invest in social services, especially for children and working-age adults.”

It is long past time for us to improve our inequitable and overpriced health care system. Maine Healthcare Action is a group of dedicated Maine residents who are working on a ballot initiative, demanding that the Maine Legislature implement a publicly funded, equitable health care system for all Maine residents. Please sign their petition to put health care on the ballot in 2022. For more information, visit

Julie Keller Pease

Ban on 'surprise' medical bills to take effect Jan. 1

Patients who may have been surprised by a large bill when going to an out-of-network emergency room will soon get some protection.
RICARDO ALONSO-ZALDIVAR - Associated Press - September 30, 2021

The Biden administration on Thursday put final touches on consumer protections against so-called “surprise” medical bills. The ban on charges that hit insured patients at some of life's most vulnerable moments will take effect Jan. 1.

Patients will no longer have to worry about getting a huge bill following a medical crisis if the closest hospital emergency room happened to have been outside their insurance plan's provider network. They'll also be protected from unexpected charges if an out-of-network clinician takes part in a surgery or procedure conducted at an in-network hospital.

The rules released Thursday detail a key part of the new system: a behind-the-scenes dispute resolution process that hospitals, doctors and insurers will use to haggle over fees. When an insurer and a service provider disagree over fair payment, either side can initiate a 30-day negotiation process. If they still can't come to an agreement, they can take the matter to an independent arbitrator.

There's also a new way for uninsured people and certain patients who pay their own way to get an estimate of charges following an emergency procedure.

“We’re hoping to give folks a sigh of relief, who have been blindsided by billing,” said Health and Human Services Secretary Xavier Becerra.

Surprise medical bills have been a common problem for people with health insurance, all the more irritating because most patients might have thought they were protected. Charges running from hundreds to tens of thousands of dollars came from doctors and hospitals outside the network of patients' health insurance plans. It’s estimated that about 1 in 5 emergency visits and 1 in 6 inpatient admissions triggered a surprise bill.

Although many states already have curbs on surprise billing, federal action was needed to protect patients covered by large employer plans, which are regulated at the national level. A 2020 law signed by then-President Donald Trump laid out a bipartisan strategy for resolving the issue, and the Biden administration filled in critical details.

The idea was to take patients and their families out of the financial equation by limiting what they can be billed for out-of-network services to a fee that’s based on in-network charges. That amount gets counted toward their in-network annual deductible.

The new protections are aimed at:

— Protecting patients from surprise bills arising from emergency medical care. Protections apply if the patient is seen at an out-of-network facility, or if they are treated by an out-of-network clinician at an in-network hospital. In either case, the patient can only be billed based on their plan’s in-network rate.

— Protecting patients admitted to an in-network hospital for a planned procedure when an out-of-network clinician gets involved and submits a bill.

— Requiring out-of-network service providers to give patients 72-hour notice of their estimated charges. Patients would have to agree to receive out-of-network care for the hospital or doctor to then bill them.

Before the ban on surprise billing, patients usually had to take the initiative themselves to work out unexpected charges. In many cases the hospital or doctor would go back and forth with the insurance company until they reached an agreement. But there was no guarantee that would happen, and patients were at risk of being placed into collection proceedings in situations they had no control over. 


Health workers know what good care is. Pandemic burnout is getting in the way

Yuki Noguchi - Twitter - October 2, 2021

The desperate and frantic pace of hospital work in 2020 in New York, the epicenter of the U.S. pandemic at the time, was more chaotic than anything intensive care nurse Matthew Crecelius had ever seen. "It was like watching a bomb go off in slow motion," he says.

He was caring for double the usual number of critically ill patients and navigating hospital halls that looked more like construction zones, with giant fans and plastic tubing blowing a deafening level of extra ventilation. He couldn't hear his patients, or see them through the giant wooden doors of the negative pressure chambers.

"You shout out to somebody, 'Hey, can you check on my other people?' " he says. " 'I can't even see a monitor; I don't know how they're doing.' "

Once, while Crecelius tended to one COVID-19 patient, another ripped off his oxygen mask, triggering a heart attack. Alarms blared. Crecelius rushed to the room, swathing himself in a new gown, to try to revive the man -- who died clutching a photo of his daughter. As other nurses rushed in to help, other unattended patients started to crash.

Crecelius says he can recall numerous moments like this one, when the crush of work and burnout among health care staff had a direct impact on patient care.

"That plays out again and again, day by day, at many hospitals, and in my opinion, I think it's getting worse," says Crecelius, a traveling contract nurse who has worked in a dozen hospitals since the pandemic began.

Many health care workers surveyed say they feel burnt out and that is impacting patient care. The prolonged battle against COVID-19 has left many doctors, nurses, medical assistants, respiratory therapists and others on the front lines of care exhausted and overwhelmed, fueling greater levels of burnout that were already high. The advent of vaccines against the coronavirus sparked hope of a return to normal — only to be dashed by the latest surge of cases, driven primarily by people who aren't vaccinated.

Burnout is a common term many associate with sheer exhaustion. But the World Health Organization says it's also characterized by greater cynicism and reduced effectiveness at work. It was a huge problem in health care long before the pandemic. But now the short staffing and the crushing and unpredictable workload is contributing to epidemic levels of burnout.

"It's not good for their mental health; it's not good for the work environment. There's increased chance for mistakes, medication errors," says Ernest Grant, a specialist in burn care and president of the American Nurses Association. Many fellow nurses he talks to say they're at the end of their rope, which Grant says presents a hazard for any patient needing urgent care right now. "There is no health without nurses," he says.

Caregivers under extreme stress

But just how much burnout affects patient care is very hard to gauge. Multiple studies have linked burnout to lower quality of care. But many of those studies rely mostly on subjective measures, such as patient surveys and self-reporting by nurses and doctors. So drawing a cause-and-effect connection isn't easy.

What happened to Carolyn Dewa in California illustrates why.

After her father was hospitalized in April with cancer, Dewa had a hard time reaching his physicians. Pandemic-related restrictions at the hospital limited when family could visit, and the sheer volume of patients left the staff no time to call the family with updates or to explain treatments.

At one point, doctors treating Dewa's father halted his anti-stroke medication, thinking his throat might be too constricted to swallow the pills. "No one asked me," says Dewa, who had been taking care of her father before the hospitalization and knew he was still able to eat and swallow.

As doctors rushed between patients, she says, they were relying more than usual on numbers and charts to make decisions about how to care for each person.

A short time later, her father died of a stroke.

A painful irony that only adds to Dewa's grief: As part of her work as a professor at the University of California, Davis, she studies the effect of burnout on medical care. "I know what good care is supposed to look like," she says.

Speaking from a personal perspective, Dewa adds, she does feel burnout cost months of her beloved dad's life. But she also recognizes the extreme stress his caregivers were under. It would be very hard, she says, to pinpoint objectively how much that burnout contributed to his death.

"Medicine is a team sport," Dewa says. "So can you attribute it to one clinician? How many clinicians need to be experiencing burnout until we see an effect on quality?"

Not enough staff, no empty beds

Clearly, one huge problem is a shrinking field of seasoned professionals in medicine. Since the pandemic's start, some health care workers have retired early and many say they're considering leaving the field.

Crecelius, the traveling ICU nurse, says that increasing reliance on less-experienced health workers can hurt patients. At the small Michigan hospital where he works now, he recently discovered that a nurse on a previous shift had inadvertently put a heart attack patient on the wrong medication.

"She's a newer nurse and doesn't know this is completely inappropriate. Had someone more experienced been here, we would have been able to catch that," he says.

Crecelius says he used to think of such incidents as teaching moments. These days, he has no time or energy to mentor. He just complains to his colleagues, about his colleagues.

That shortness of time, staff and fuses can fuel still more burnout.

Recently in Indianapolis, for example, a combination of the latest surge in COVID-19 cases and a dire shortage of staff meant all the acute-care beds across the region were full. Lindsay Moore-Ostby, a family doctor in the city and member of the advocacy group Physicians for Patient Protection, says one doctor dealing with that crisis tried to transfer a patient, personally calling every hospital within several states — around 40 hospitals — she recalls.

This doctor was "trying desperately to find a bed for a patient who needed ICU care," Moore-Ostby says. At that point, the doctor told her: " 'Now I'm spending time trying to make this transfer happen — so, what if I can't provide the care I need to the other patients who need me?' "

"It's really a game of dominoes," adds Moore-Ostby, "where the doctor is just emotionally devastated because they can't fix it."

A few months into the pandemic, Moore-Ostby started her own concierge practice, cutting back on her roster of patients. She did so, she says, primarily because having no time to talk to patients robbed her of what had led her to the profession in the first place.

"That little bit of time connecting with the patients — that's what they like, that's what they need and deserve," she says. "And it's what I love about medicine."

Solutions are in the details

As the problem of burnout multiplies, some health care systems are trying to find solutions – discovering they often are found in the small details of the work.

For much of this summer, Tampa emergency doctor Damian Caraballo couldn't staunch the flow of unvaccinated COVID-19 patients coming in. Nor could he stop the stampede of co-workers — nurses, EMTs, and lab techs — who kept leaving, making the pace of work more frantic for those who remained.

"Even things as simple as registration; we're short registration people, and that puts a delay on everything," Caraballo says. The average waiting time in his ER ballooned to over 10 hours. "So it has a downhill effect."

On balance, the pandemic has made all the normal bureaucratic hassles of the medical system that much more grating, Caraballo says. But he can also point to recent changes that have made a difference: His hospital started allowing remote monitoring of some COVID-19 patients.

"I've been able to send people home" if they have sufficient internet connectivity, says Caraballo, who is a member of patient-advocacy group Physicians for Patient Protection. Florida also recently relaxed rules about where patients could receive IV infusions of monoclonal antibodies to treat COVID-19, a move that also eased Caraballo's patient load. "All those things would take stress off the hospital because we wouldn't have to admit these patients."

Certainly, chronic short-staffing and overwork are huge factors intensifying burnout. But better management can also help alleviate it, even under extreme conditions, says Christina Maslach, a psychologist at the University of California, Berkeley, whose Maslach Burnout Inventory is the basis of the World Health Organization's definition of the workplace syndrome.

"We have to get past this notion that the job is what it is and you can't fix it, you can't change it, you just have to deal with it no matter what," Maslach says.

Often it is a collection of irritants at work that make people feel undervalued, disregarded and eventually burnt out, she says: "Little stuff. What are the chronic pebbles in your shoe?"

She says the fixes, therefore, are often small and targeted.

One of the most common complaints health care workers talk about, Maslach says, is a perfect example: not having a functioning copier.

That might seem minor, she says. But what makes the broken Xerox so toxic is that it taps into a simmering rage that health care staff universally bemoan: The byzantine paperwork and insurance forms that suck up their after-hours and weekends. So having to hunt down a copier that isn't out of ink or jammed doesn't just make the patient backlog worse, it ignites an existing fury within.

Maslach says she's seen huge morale boosts just from hospital management buying a new copier. In addition to making the work faster, "it gives people the sense they are being listened to, that they're being taken seriously," she says.

And she says combating burnout means identifying and tackling these kinds of problems that plague the workplace.

"People keep saying, 'What is the one thing we can do?' " she says. "There is no one solution. There are many."

Implementing staff ideas for fixes

Often the best suggestions come from those who do the work.

Massachusetts General Hospital realized that early in the pandemic.

As the nation's supply of rubber gloves ran critically low, a triage nurse came up with an idea for a plexiglass wall at a patient's bedside. It had arm holes cut into it, where a set of sleeve-like rubber gloves could be attached. That way, caregivers could slide their arms through and adjust a patient's oxygen line or check a pulse — it was quicker and safer and didn't require a new pair of gloves.

"I thought it was a great idea, so we implemented it very quickly," says Ali Raja, executive vice president of emergency medicine at Mass General. "And the triage staff absolutely loved it."

One of the things they loved about it, Raja says, is that adopting staff ideas gave them a sense of agency over their work lives. "Implementing as many ideas as possible — especially if they're not very expensive — can definitely not only acknowledge the staff's expertise and what they're going through, but quite honestly can give you some really good solutions that the leadership just won't have thought of, because they don't have boots on the ground."

He says staff came up with other ideas: to set up a COVID triage unit outdoors in the ambulance bay and to give iPads to patients, so they could more readily communicate with staff, who then didn't have to suit up in personal protective equipment.

Another critical way of fighting burnout is addressing the mental health challenges that come with it. Officially or unofficially, many hospitals and workers talked about the importance of camaraderie.

Some hospitals converted waiting rooms left vacant because of visiting restrictions, into staff lounges or to be used for peer counseling. Talking about the difficulties of managing work and life sometimes led to staff volunteering to cover for one another in family emergencies.

"I've been asking my friends for help when I've needed it," says Raja, and his co-workers urged him to seek therapy for the first time. "That's not something I would've been willing to do, but the fact is, so many of my colleagues have acknowledged that same burnout and told me how much that helped."

ER doc Damian Caraballo says he encourages the same at his hospital in Tampa: "Offer moral support for them. In the short term, I think that's the best we can do."

For the most part, there are not too many quick ways to solve burnout, he says. It doesn't help knowing the crush of work these days is largely preventable; two-thirds of patients he sees are people with COVID-19 who didn't get vaccinated — even though they could have — often young people. That fact, combined with staff shortages, " it just creates this really tough environment that makes burnout even worse," Caraballo says.

Losing passion for the field

The worst part, say health care workers like traveling nurse Crecelius, is that burnout is robbing them of their sense of purpose — making it harder to care about the work itself.

"Last year this time, I had a greater sense of 'This is kind of my duty,' " says Crecelius, who says he's always had an instinct to run toward disaster — wherever help is most needed. While working in the hotspots during the early months of the pandemic, he says, he told himself: " 'I'm able, I'm young; I can make a difference. Let's go and see if we can put this fire out.' "

In those days, he donned a kind of emotional armor, he says — muscling through shifts during which he lost patient after patient, then prepared them for the morgue.

Then, on a road trip this summer in an RV he built with his wife, Crecelius was standing in line at a grocery store, waiting to buy bananas and yogurt, when he glanced at a tabloid with a cover story about the pandemic.

"And it had a picture of someone loading zipped-up bodies onto a truck," he remembers. "I lost it."

He trembled as he looked at the picture, flooded with memories of volunteering to load bodies into the morgue. He thought of the families he'd helped say goodbye, holding a phone to the ear of his patient.

The work feels different to him now, Crecelius says. Though he's a fifth-generation nurse, he is looking to switch careers.

"Now that there is a vaccine, people aren't getting it," he says. Nursing has changed for him. "I'm not interested anymore."