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Saturday, January 31, 2015

Health Care Reform Articles - January 31, 2015

Barriers to More Healthcare Reform Are Numerous

Apathy and fear are among the biggest stumbling blocks, experts say.


WASHINGTON -- The lack of greater movement toward universal healthcare coverage -- especially a single-payer system -- in the U.S. can be boiled down to four letters: AFIG, according to Philip Caper, MD.
The "A" stands for Apathy, Caper said Wednesday during a briefing on barriers to healthcare reform sponsored by the National Academy of Social Insurance (NASI). Caper is with Maine AllCare, an organization devoted to getting universal healthcare in Maine.
The attitude of many people is "'I've got mine; why should I worry about anyone else?'" said Caper, a founding member of NASI, whose mission is to increase public understanding of how social insurance contributes to economic security.
"Or think of young invincibles, who think it's worth the risk to go uncovered," continued Caper, who was speaking by phone from Maine. "Perhaps apathy is the result of our emphasis on personal liberty and personal responsibility."
The "F" stands for fear, Caper continued -- "fear of change; the fear of losing coverage they already have; or the fear of loss of income or profitability" on the part of those working in the healthcare industry.
"I" is for ignorance, he said, making it clear that he was not equating ignorance with stupidity, rather a lack of information and understanding. "Most Americans don't understand the healthcare system and don't understand there are better ways of financing this," Caper said.
"I definitely include doctors in this group," he added. "I can tell you from personal experience that it's almost impossible to get health policy into the medical school curriculum, where the focus is rightly on clinical medicine."
And finally, there is the "G" -- for greed. "This may seem harsh [but] the widely accepted view of healthcare as just another business is uniquely American, at least in degree," he said. "I have heard some people say the healthcare system is becoming a wealth extraction machine. This view is reinforced by news stories of opportunistic pricing of drugs for chronic diseases such as hepatitis."
Satisfied With the Status Quo
Another barrier to changing the way health insurance is delivered comes from the fact that many people are satisfied with their employer-provided health insurance, said Laurence Seidman, PhD, professor of economics at the University of Delaware in Newark.
"But they don't seem to realize two things," he continued. "First, what would happen if they lose their job? And second, [they don't realize] that the rising premiums for medical care that their employers are paying is a key reason why their wage and salary growth has been so low."


Did Obamacare Just Have Its Best Week Ever?

byJessicaAdair
But at America’s kitchen tables, or more likely, at family computers, a different story is unfolding – and enrollment success stories are popping up in the places you’d least expect.
According to new data released by HHS, more than 9.5 million people had signed up for a Marketplace plan by January 18th. That figure does not include millions more enrolled in Medicaid. Given that the Administration’s own goal was 9.1 million enrolled, this year’s Open Enrollment period is looking quite rosy. One more sign of growing interest in health care: 42% of this year’s enrollees have selected plans for the first time on the federal Marketplace.  
In states where elected officials tried to position themselves as skeptics of affordable health care during 2014 campaigns, their constituents have chosen to enroll regardless, indicating a shift in political tides.
In Florida, for example, Governor Rick Scott spent millions painting his opponent as an Obamacare supporter in his race for the Governor’s seat. Since then, Florida has led the nation in enrolling residents: 1.2 million Floridians have signed up for a plan. One zip code outside of Miami holds the record of the most enrollees in the country.
Other states where anti-Obamacare in past years ran deep, such as North Carolina, Georgia, Idaho and Virginia have also seen higher than average percentages of eligible residents sign up for coverage. In North Carolina, Senator Kay Hagan lost her seat after enduring millions of dollars worth of ads pillorying her support of the ACA. The state is now 6% above the national average in percentage of eligible residents enrolled. In Georgia and Kentucky, senatorial candidates Michelle Nunn and Alison Lundergan Grimes refused to even say whether they would’ve voted for the law for fear of being tied to it. Despite their reluctance, both still lost their elections. Now, both states have seen above average enrollment percentages.


Don't Trade Away Our Health

By JOSEPH E. STIGLITZ
A secretive group met behind closed doors in New York this week. What they decided may lead to higher drug prices for you and hundreds of millions around the world.
Representatives from the United States and 11 other Pacific Rim countries convened to decide the future of their trade relations in the so-called Trans-Pacific Partnership (T.P.P.). Powerful companies appear to have been given influence over the proceedings, even as full access is withheld from many government officials from the partnership countries.
Among the topics negotiators have considered are some of the most contentious T.P.P. provisions — those relating to intellectual property rights. And we’re not talking just about music downloads and pirated DVDs. These rules could help big pharmaceutical companies maintain or increase their monopoly profits on brand-name drugs.
The secrecy of the T.P.P. negotiations makes them maddeningly opaque and hard to discuss. But we can get a pretty good idea of what’s happening, based on documents obtained by WikiLeaks from past meetings (they began in 2010), what we know of American influence in other trade agreements, and what others and myself have gleaned from talking to negotiators.

First U.S. doctors' strike in decades

By 
A handful of doctors providing medical services to students at UC San Diego — and their colleagues at nine other University of California campuses — went on strike Tuesday.
It's the first time in 25 years that fully licensed doctors are picketing a U.S. employer, according to the Union of American Physicians and Dentists, which represents the physicians at the UC schools.
The work stoppage began at 7:30 a.m. and is scheduled to last one day. It involves 150 health center doctors who manage the primary care and mental health needs of students.
UC San Diego said there are 10 such physicians on its campus. Dr. Amol Doshi, a staff physician at UC San Diego, said five of them work full time while the others are part-timers.
Doshi, one of four doctors in the union’s bargaining team, said the strike is needed because the UC system refuses to provide enough financial information on student health services for the union to make accurate judgments about whether resources are well-allocated.
He also said many doctors are concerned that staffing levels are not high enough to meet students’ needs, especially in the mental health area.
“This isn’t a strike about salary,” Doshi said Monday.

Indiana Will Allow Entry to Medicaid for a Price

By 
WASHINGTON — After a lengthy back-and-forth, the Obama administration has agreed to let Gov. Mike Pence of Indiana, a Republican, expand Medicaid on his own terms, including some that have not been allowed before under federal rules.
The plan will extend coverage to an additional 350,000 Indiana residents with incomes of up to 138 percent of the federal poverty level — about $16,100 for a single person and $27,310 for a family of three — starting next month. As in the 27 other states that have expanded Medicaid under the Affordable Care Act, the federal government will cover the entire cost through this year and at least 90 percent in future years.
But Mr. Pence, like several Republican governors before him, insisted on adding a conservative twist to the expansion, mostly by requiring beneficiaries to pay something toward their coverage. Under his plan, most people will have to pay monthly premiums equaling 2 percent of their household income — between about $3 and $25 a month for a single childless adult — for coverage that includes dental and vision benefits.
At the Obama administration’s insistence, people who earn less than the poverty level will not have to pay premiums. But if they do not, their coverage will be downgraded to exclude dental and vision benefits. And they will owe co-payments for medical care, including $4 for a doctor’s visit and $75 for a hospitalization.
“There are a lot of first-in-the-nation aspects to this,” Mr. Pence said in an interview. “It gives Hoosiers the dignity to pay for their own health insurance, and that transaction is important to starting people on a path toward really embracing greater ownership of their health care.”
In another unusual concession, the Obama administration will let Indiana lock some people out of coverage for six months if they stop paying monthly premiums. This provision will not apply to people earning less than the poverty level or to those deemed “medically frail.” Still, it is a first for Medicaid coverage, which has not permitted lockout periods until now.

The Goal Was Simplicity; Instead, There’s a Many-Headed Medicaid


The Affordable Care Act was supposed to simplify Medicaid’s myriad programs across the country to provide a more uniform medical safety net for poor Americans in every state.
It hasn’t worked out that way. In fact, Medicaid programs now vary more widely state to state and even within states than they did before. Some states have scaled back their Medicaid programs, while others have expanded to new groups of people. Among those that have expanded, many are pursuing new policy experiments instead of expanding their existing programs. This may result in confusion — for administrators and clients alike.
Indiana has become the latest Republican-led state to expand its Medicaid program as part of the Affordable Care Act. As has become the pattern, it was done with a series of waivers from particular federal requirements. Beginning next week, anyone in Indiana earning less than around $16,000 a year can sign up for the government health insurance program.
When the state’s governor, Mike Pence, announced the news on Tuesday, the focus of his speech was less about his state’s decision to embrace this part of Obamacare than about the special concessions he’d been able to extract from the Obama administration.

Sick Child’s Father Seeks Vaccination Requirement in California

By 
In the latest salvo in the vaccination wars that have shaken California since a measles outbreak originated at Disneyland last month, the father of a 6-year-old boy with leukemia has asked the superintendent of his Marin County school district to keep unvaccinated children out of school.
“I respect people’s choices about what to do with their kids, but if someone’s kid gets sick and gets my kid sick, too, that’s a problem,” said the father, Carl Krawitt of Corte Madera, Calif., whose son, Rhett, was found to have leukemia in 2010. “What we need to do, for all our children, is increase the herd immunity.”
Rhett is in remission now, but four years of chemotherapy have left him vulnerable to infection and unable to be vaccinated. Until his immune system strengthens, his best protection from infectious diseasesis the so-called herd immunity of a community where almost everyone has been vaccinated.
But he lives in a part of the Bay Area where an unusually high number of parents refuse vaccinations for their children. Over all, about 7 percent of the children at Rhett’s school, Reed Elementary, are unvaccinated — a rate that is higher than the statewide average but far lower than at some other schools in the county, where fully half of the students are not vaccinated, according to Dr. Matt Willis, the county health officer.

More Than 1,000 in Arizona Are Watched for Measles

By 
DENVER — Arizona health officials on Thursday were tracking more than 1,000 people, including at least 195 children, who might have been exposed to measles as part of an outbreak that began at Disneyland in Southern California and has grown to 67 cases in seven states.
Arizona has seven confirmed cases of measles, and officials in three counties in the Phoenix area — Maricopa, Gila and Pinal — are asking residents who have not been vaccinated and who might have been exposed to stay home from school, work or day care for 21 days.
The announcement comes as thousands of people are arriving in Phoenix for the Super Bowl on Sunday.
“This is a critical point in this outbreak,” the state health director, Will Humble, wrote on his blog. Any missed cases, he wrote, could cause “a long and protracted outbreak.”
In a conference call with reporters, a Centers for Disease Control and Prevention official advised anyone with symptoms not to attend the Super Bowl. “The very large outbreaks we’ve seen around the world often started with a small number of cases,” said the official, Dr. Anne Schuchat, director of the agency’s National Center for Immunization and Respiratory Diseases.

Doctors as Advocates for Family Leave

By 
 
Birdlike and in his 80s, the patient had come to the hospital complaining of a new cough. But it was not he whom my colleagues and I found most disquieting.
It was his middle-aged daughter. 
With a practiced dexterity, she had managed to wheel her father in the clinic, hoist him on to the examining table, smooth his hair, wipe his brow and tuck blankets around his legs to keep him warm without pause as she simultaneously fielded nearly a dozen calls and texts on her cellphone.
Still, every time her cellphone rang, buzzed, gurgled or popped, she jumped and sometimes even clutched her chest. After examining her father, I asked if she was O.K.
The woman’s eyes widened; she looked as if she was going to cry. 
Her father, she began to recount, had moved in with her and her husband a few years earlier to help with their young children. But over the last few months, his health had begun to fail, and she found herself spending more and more time taking care of him. An occasional doctor’s appointment escalated into frequent emergency room visits and missed workdays so she could watch over him at home. Now, with her own sick days used up, her vacation day stockpile dwindling and the goodwill of her colleagues and boss dissipating, she tried to do as much work as she could by phone. 
“I’m trying to do my best to take care of my father, but I can’t afford not to get paid,” she said, pushing away the strands of grey and brown hair that had fallen loose from her ponytail. 
“But thanks, anyway,” she added, “for asking.” 
I remember smiling in response. Asking, and listening, I thought, was the best I could do for someone who was a family caregiver and not my patient. 
But over the last few months, I have begun to think differently, thanks to a New England Journal of Medicine editorial by two pediatricians who argue that doctors and other health care providers can do more, by acting as patient advocates and supporting broader family leave policies.

For V.A. Hospitals (and Patients), a Major Health Victory

by Tina Rosenberg
Earlier this month, the Centers for Disease Control and Prevention announced that the United States is making modest progress in bringing down rates of hospital-acquired infections.
Progress is good, but modest is not. Hospital-acquired infection is one of the country’s leading causes of death, killing 75,000 people per year — more than car accidents and breast cancercombined. As antibiotic resistance increases, we are already seeing infections no drugs can cure. And these infections are preventable. Still, one in 25 patients who goes into the hospital without an infection will get one there.
Yet hospitals have only started to take prevention seriously in the last decade, most in the last five years. The bulk of the effort, and the progress, has come with infections associated with devices, especially central vein catheters. But device-related infections make up only a quarter of hospital-acquired infections. Hospitals have had far less success with other types of infections.
One hospital group, however, has done more than all others. It is not the Mayo Clinic’s hospitals, nor the Cleveland Clinic’s, nor Kaiser Permanente, nor Sutter, nor Geisinger. These are all hospital chains known for their quality, but another big name leaves them in the dust: the V.A.
Veterans Affairs Medical Centers have been in the news lately, but not for their high quality of care. It’s for endless waiting times, falsification of wait-time data and labyrinthine bureaucracy. Yet in the matter of “first, do no harm,” the V.A. stands out. (Here and here are other studies showing the V.A.’s edge in patient care.)
The C.D.C.’s survey of (non-V.A.) hospitals nationwide found the following improvements: in the last five years, bloodstream infections associated with a central line fell by 46 percent, and surgical site infections fell by 19 percent. Infections associated with a urinary catheter rose by 6 percent, although they may now have started to decrease.
That’s infections by site. Now by type of bug: Hospital-acquired infections from Clostridium difficile — a superbug so determined that even hand sanitizer doesn’t kill it — dropped by 10 percent between 2011 and 2013. And bloodstream infections from the resistant staph bacteria known as MRSA dropped by 8 percent between 2011 and 2013.
The C.D.C.’s baseline for this survey is 2007/2008. Since that point, invasive MRSA infections acquired in the hospital have dropped by 30.8 percent. We’re moving in the right direction, and that’s notable especially because MRSA infections in the community have risen, which means more people come to the hospital already infected.
But the V.A. shows how much faster we could go.

Medicare Payments Surge for Stents to Unblock Blood Vessels in Limbs

By  and 
At a time of increasing scrutiny of procedures to open blocked heart arteries, cardiologists are turning to — and reaping huge payments from -- controversial techniques that relieve blockages in the arms and legs.
Unlike heart procedures, which must be done in a hospital or outpatient facility, where oversight is typically more intense, the opening of the peripheral arteries and veins of the arms and legs can be done in a doctor’s office.
Medical experts are questioning the necessity of some of these treatments, and many believe the condition is more safely treated with drugs and exercise. Nonetheless, some of the nation’s most highly reimbursed cardiologists are making millions of dollars from Medicare for performing these procedures, as payments for relieving blockages in the heart have fallen.
Earlier this month, the Justice Department said it joined two whistle-blower lawsuits accusing one of these doctors of performing unnecessary procedures, including placing a stent in the leg of a patient who later died of complications.
The cardiologist in question, Dr. Asad Qamar of Ocala, Fla., was paid $18 million by Medicare in 2012, making him the top-billing cardiologist in the country, according to an analysis by The New York Times of Medicare data. Dr. Qamar was also the leader in billing for procedures to treat peripheral blockages.
Nationwide, the shift in doctors’ emphasis is significant. The number of procedures to open blockages in heart vessels fell by about 30 percent from 2005 to 2013, to about 323,000 for patients covered under Medicare. Over the same time, the number of similar procedures for vessels outside the heart soared by almost 70 percent to 853,000, according to the Advisory Board Company, an analytics and research firm that analyzed Medicare payment data.
The Times’s analysis of the 2012 billing records for the 10 top-billing cardiologists in the country showed that eight of the doctors made about half of their reimbursements from Medicare by performing procedures to ease the narrowing in an artery or vein in patients’ arms or legs. Some continue to do a high number of coronary interventions.
These types of lucrative procedures — in 2012, Medicare paid nearly $12,000 for one type of these operations — have been the focus of a turf battle among specialists.
The county’s top billers for these procedures included a handful of vascular surgeons and radiologists in addition to the cardiologists.
The doctors who perform the procedures say they are saving Medicare money by doing them outside a hospital, that they reduce the number of more serious conditions, and that the Medicare payments are justified to cover their high expenses.
While there is considerable agreement among specialists about how and when to treat heart blockages, there is far less consensus in the treatment of blockages elsewhere.



King v. Burwell: Nurses, Doctors and Working People Tell U.S. Supreme Court: Millions of Americans Counting on Tax Credits for More Affordable Healthcare Premiums

Healthcare Professionals, Joined by SEIU, File Amicus Brief Dismantling 'Carrot and Stick' Argument
WASHINGTON - A group of healthcare professionals and SEIU members submitted an amicus brief in King v. Burwell on Wednesday to the U.S. Supreme Court on behalf of working families throughout America. The case under consideration challenges the power of the Internal Revenue Service (IRS) to issue tax credits to millions of working Americans who enroll in private health insurance through the federal healthcare exchange. The tax credits have meant that millions of working women and men in approximately 36 states have gained affordable, quality healthcare under the law and can now see a doctor, afford lifesaving prescription drugs, and be free of the fear of medical bankruptcy.
"As a postpartum nurse, I know firsthand that the tax credits the law provides are important to ensuring the health of mothers and their babies," said Marilyn Ralat-Albernas, RN, of Miami. "We should be looking for ways to expand affordable access to good prenatal care, not putting this care at risk."
The healthcare professionals are members of the Service Employees International Union (SEIU), America's largest healthcare union, which joined them in filing the brief.
The "friend of the court" brief takes apart the so-called "carrot and stick" premise presented by the petitioners of the court by making it clear that Congress never intended to present a "carrot" to incentivize states, nor a "stick" to penalize Americans in states that did not create and run their own state exchanges. Furthermore, the brief shows this theory is simply a politically motivated fabrication, not supported by the text of the law, by its purpose, by its legislative history, or by the understanding of any state when making the choice whether to create and operate its own state exchange.

Study Finds H.I.V. Drugs Priced Out of Reach 

    By KATIE THOMAS
    JANUARY 28, 2015
    Drugs to treat H.I.V. and AIDS are being priced out of reach for many patients enrolled in insurance plans through the new health care exchanges, despite warnings that such practices are illegal under the Obama administration’s health care law, according to a new analysis by Harvard researchers.
    The study, to be published on Wednesday in an article in The New England Journal of Medicine, looked at 48 health plans in 12 states and found that a quarter of the plans showed evidence of what researchers called “adverse tiering,” or placing all of the drugs used to treat H.I.V. in a specialty tier where consumers are required to pay at least 30 percent of the cost of the drug.
    The financial impact can be drastic, the researchers found: A patient taking a common H.I.V. treatment, Atripla, would pay about $3,000 more a year in a restrictive plan compared with someone enrolled in a more generous plan, even after accounting for the fact that the more restrictive plans tended to charge lower monthly premiums.
    “That’s really a large cost difference, and really is a very significant financial constraint for those with chronic conditions, particularly H.I.V.,” said Douglas B. Jacobs, the lead author of the study, who is pursuing degrees in public health at the Harvard T. H. Chan School of Public Health and medicine at the University of California, San Francisco.
    The study, which did not name the insurers whose plans it analyzed, looked only at the midlevel, or silver, plans offered in the marketplaces because they are the most popular plans among consumers. More comprehensive plans, known as gold and platinum plans, are often more generous in coverage but carry higher premiums. Insurers have said that these may be a better choice for people who have serious medical conditions.
    Clare Krusing, a spokeswoman for America’s Health Insurance Plans, an industry trade group, said that a crucial component of the marketplace was consumer choice, and that the study should have included an analysis of the gold and platinum plans. “Individuals have diverse health and financial needs, and health plans have designed a wide range of coverage options, including those with lower cost-sharing, so individuals can pick the policy that is best for them,” she said.


    Budget Office Slashes Estimated Cost of Health Coverage

    By 
    WASHINGTON — The Congressional Budget Office on Monday significantly lowered its estimate of the cost of providing health insurance coverage to millions of Americans under the Affordable Care Act.
    Douglas W. Elmendorf, the director of the budget office, said the changes resulted from many factors, including a general “slowdown in the growth of health care costs” and lower projections of insurance premiums that are subsidized by the federal government.
    In March 2010, when President Obama signed the health care law, the Congressional Budget Office estimated that the expansion of coverage would cost the federal government $710 billion in the fiscal years 2015 through 2019, Mr. Elmendorf said.
    “The newest projections indicate that those provisions will cost $571 billion over that same period, a reduction of 20 percent,” he said. The Affordable Care Act not only subsidized the purchase of private insurance, but also authorized a major expansion of Medicaid, the federal-state program for low-income people.
    The Supreme Court ruled in 2012 that the expansion of Medicaid was optional for states, not required, as Democrats in Congress had intended. Nearly two dozen states have yet to expand eligibility. And in states that did expand Medicaid, projections of federal Medicaid spending per beneficiary are lower than expected, the budget office said.



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    Tuesday, January 27, 2015

    Health Care Reform Articles - January 27, 2015

    To Collect Debts, Nursing Homes Are Seizing Control Over Patients

    By 

    Lillian Palermo tried to prepare for the worst possibilities of aging. An insurance executive with a Ph.D. in psychology and a love of ballroom dancing, she arranged for her power of attorney and health care proxy to go to her husband, Dino, eight years her junior, if she became incapacitated. And in her 80s, she did.

    Mr. Palermo, who was the lead singer in a Midtown nightclub in the 1960s when her elegant tango first caught his eye, now regularly rolls his wife’s wheelchair to the piano at the Catholic nursing home in Manhattan where she ended up in 2010 as dementia, falls and surgical complications took their toll. He sings her favorite songs, feeds her home-cooked Italian food, and pays a private aide to be there when he cannot.
    But one day last summer, after he disputed nursing home bills that had suddenly doubled Mrs. Palermo’s copays, and complained about inexperienced employees who dropped his wife on the floor, Mr. Palermo was shocked to find a six-page legal document waiting on her bed.
    It was a guardianship petition filed by the nursing home, Mary Manning Walsh, asking the court to give a stranger full legal power over Mrs. Palermo, now 90, and complete control of her money.
    Few people are aware that a nursing home can take such a step. Guardianship cases are difficult to gain access to and poorly tracked by New York State courts; cases are often closed from public view for confidentiality. But the Palermo case is no aberration. Interviews with veterans of the system and a review of guardianship court data conducted by researchers at Hunter College at the request of The New York Times show the practice has become routine, underscoring the growing power nursing homes wield over residents and families amid changes in the financing of long-term care.
    In a random, anonymized sample of 700 guardianship cases filed in Manhattan over a decade, Hunter College researchers found more than 12 percent were brought by nursing homes. Some of these may have been prompted by family feuds, suspected embezzlement or just the absence of relatives to help secure Medicaid coverage. But lawyers and others versed in the guardianship process agree that nursing homes primarily use such petitions as a means of bill collection — a purpose never intended by the Legislature when it enacted the guardianship statute in 1993.
    At least one judge has ruled that the tactic by nursing homes is an abuse of the law, but the petitions, even if they are ultimately unsuccessful, force families into costly legal ordeals.
    “It’s a strategic move to intimidate,” said Ginalisa Monterroso, who handled patient Medicaid accounts at the Mary Manning Walsh Nursing Home until 2012, and is now chief executive of Medicaid Advisory Group, an elder care counseling business that was representing Mr. Palermo in his billing dispute. “Nursing homes do it just to bring money.”
    “It’s so cruel,” she added. “Mr. Palermo loves his wife, he’s there every single day, and they just threw him to the courts.”

    Single-Payer: It's What the People Want

    New poll shows majority of Americans support such a system.
    by
    Andrea Germanos, staff writer

    A majority of Americans support a single-payer, Medicare-for-all healthcare system, a new poll shows.
    The results showed that just over 50 percent of the 1,500 likely voters surveyed indicated support for a single-payer system. Almost 80 percent of Democrats supported such a plan, while 25 of Republicans did.
    The findings were first shared with The Hill by the Progressive Change Institute, an arm of the Progressive Change Campaign Committee.
    The new poll comes on the heels of Vermont Governor Peter Shumlin's abandoning what was seen as a trailblazing plan to create a single-payer healthcare system in his state. The move was derided by Dr. Andrew D. Coates, president of Physicians for a National Health Program, who said, "Vermonters throughout the state understand that an equitable health care system must be truly universal and must remove all financial barriers to medically necessary care. They recognize that a public single payer is an essential incremental step toward these goals."
    "The time for a single-payer system is now. Our patients in every state urgently need it," Coates added.
    That sentiment is widely shared.

    Costs derail Vermont’s dream of a single-payer health plan

    By Jay FitzgeraldGLOBE CORRESPONDENT  

    For decades, liberal activists yearned for a European-style, single-payer health system that they argued would lead to more affordable, efficient, and comprehensive medical coverage for all citizens. When Vermont four years ago enacted a landmark bill to establish the nation’s first single-payer health care system, they saw their long-sought dream about to be fulfilled.
    But reality hit last month. Governor Peter Shumlin released a financial report that showed the cost of the program would nearly double the size of the state’s budget in the first year alone and require large tax increases for residents and businesses. Shumlin, a Democrat and long-time single-payer advocate, said he would not seek funding for the law, effectively tabling the program called Green Mountain Care.
    “In my judgment, now is not the time to ask our Legislature to take the step of passing a financing plan for Green Mountain Care,’’ Shumlin said.
    The decision not only stunned and angered supporters in Vermont, but also signaled that the dream of universal, government-funded health care in the United States may be near its end. Vermont’s experience, analysts said, shows how difficult — and costly — it can be to shift from a system long-dominated by private health insurance, and that the future of universal health care lies within the private market.
    In short, if a liberal state electing a Socialist (US Senator Bernie Sanders) to Congress can’t or won’t put a single-payer system into place, then who will?
    “The idea of single-payer, or a Medicare-for-all type program, has always been a cherished dream for many in the Democratic Party,” said Henry J. Aaron, a senior fellow at the Brookings Institution, a liberal-leaning Washington think tank. “In truth, there had never been a hard, developed plan to implement such a dream. In Vermont, they finally developed a plan, and look what happened.”
    A single-payer system has been the Holy Grail for progressives since the end of World War II, when President Harry Truman unsuccessfully pushed for a government-run National Health Insurance Plan to provide medical coverage for all Americans. In the 1970s, the late Senator Edward M. Kennedy of Massachusetts vainly battled for a variation of Truman’s national insurance plan.
    In the 1990s, President Bill Clinton turned to the private market to provide universal care, requiring that employers furnish health insurance for their workers. But that plan was rejected, too. Finally, in 2010, after a momentous congressional battle, President Obama signed into law the Affordable Care Act, achieving universal coverage by expanding Medicaid, the government health care program for the poor, and mandating private insurance for others.
    Vermont took Obamacare a step further. In 2011, Shumlin proudly signed a bill to establish a publicly financed, single-payer system. The law required Shumlin to submit a detailed financial plan by 2013.
    Shumlin missed the deadline, raising fears among supporters and critics alike that single-payer health care would cost much more than anticipated. Those fears were realized on Dec. 17, when Shumlin, two years late and just a month from narrowly winning reelection, released the financial analysis.
    The numbers were stunning. To implement single-payer, the analysis showed, it would cost $4.3 billion in 2017, with Vermont taxpayers picking up $2.6 billion and the federal government covering the rest. To put the figures into perspective, Vermont’s entire fiscal 2015 budget, including both state and federal funds, is about $4.9 billion.

    Bernie Sanders Got Republicans To Make His Argument For Universal Health Care

    WASHINGTON -- In their ongoing efforts to roll back or hamstring Obamacare, Republicans probably weren't hoping that the first Senate hearing on the matter this year would feature a self-described "democratic socialist" getting GOP witnesses to back a key argument for universal health care.
    Thursday's hearing of the Committee on Health, Education, Labor and Pensions was devoted to the question of moving the full-time work standard under the Affordable Care Act from 30 hours a week to 40 hours, and whether more workers would be hurt by the higher or lower limit.
    But to Sen. Bernie Sanders (I-Vt.), who has long supported the creation of a universal health care system, battling over that particular point began to seem absurd, and he opened his remarks by noting that in every other developed country, such a debate would make no sense at all.
    "The argument of whether you provide health insurance to people who work 30 hours a week or whether they work 40 hours a week -- whoa," Sanders said. "In every major country on Earth, health care is a right of all people."
    With that as his premise, he then asked three of the hearing's witnesses -- two business owners and a school superintendent -- whether their lives and daily endeavors would be improved if government lifted from them the burden of providing health care to their workers.
    The panel's only Democratic witness, Joe Fugere, founder of the Seattle-area Tutta Bella Pizzeria chain, readily answered that it would.
    And despite all the GOP's cries and criticisms of "socialized medicine" when the Affordable Care Act was making its way through Congress years ago, the two Republican panelists agreed nearly as readily.
    "A question like that -- sure," said Betsy Webb, who runs the Bangor School Department in Maine. "But what is the reality?"
    "The reality is that maybe it should not have to be the responsibility of the Bangor school district to provide health care, that maybe it should be a right of all of our people, whether they work at McDonald's in Bangor, whether they work for the school district, to have health care," said Sanders, before taking up the question with the next witness, Andrew Puzder, the CEO of CKE Restaurants, which runs the Carl's Jr. and Hardee's chains.
    "If what you're saying, Senator, is that if we had a bill that was debated, that was vetted through congressional committees, and we looked at the health care system and really tried to come up with a more rational solution, I would say you're absolutely right," Puzder said.
    He allowed that he and Sanders "might not agree on the ultimate solution," but when Sanders pressed Puzder on whether he would rather not have to worry about providing health care and instead focus on his products, the CEO was emphatic.
    "From your lips to God's ear," he said.




    End Obamacare, and people could die. That’s okay.

    We make such trade-offs all the time.

    Michael R. Strain is a resident scholar at the American Enterprise Institute.
    Say conservatives have their way with Obamacare, and the Supreme Court deals it a death blow or a Republican president repeals it in 2017. Some people who got health insurance as a result of the Affordable Care Act may lose it. In which case, liberals like to say, some of Obamacare’s beneficiaries may die.
    During the health-care debates of 2009, Rep. Alan Grayson (D-Fla.) brought a poster on the House floor: “The Republican Health Care Plan: Die Quickly.” In the summer of 2012, when Obamacare was threatened by a presidential election, writer Jonathan Alter argued that “repeal equals death. People will die in the United States if Obamacare is repealed.” Columnist Jonathan Chait wrote recently that those who may die are victims of ideology — “collateral damage” incurred in conservatives’ pursuit “of a larger goal.” If these are the stakes, many liberals argue, then ending Obamacare is immoral.
    Except, it’s not.
    In a world of scarce resources, a slightly higher mortality rate is an acceptable price to pay for certain goals — including more cash for other programs, such as those that help the poor; less government coercion and more individual liberty; more health-care choice for consumers, allowing them to find plans that better fit their needs; more money for taxpayers to spend themselves; and less federal health-care spending. This opinion is not immoral. Such choices are inevitable. They are made all the time.
    Consider, for example, speed limits. By allowing people to drive their cars at speeds at which collisions result in death, our government has decided that the socially optimal number of traffic fatalities is not zero. Some poor souls die: There were more than 30,000 traffic fatalitieson America’s roads in 2013. If we didn’t accept that risk, we’d lower the speed limit to a rate at which accidents simply don’t kill, such as 10 mph. Instead, we’ve raised it periodically over the years, and you can now go as fast as 85 mph on a few highways. 
    It is tragic that thousands of people die each year in car crashes. At the same time, there are huge (if dispersed) benefits to a 70 mph speed limit over a 10 mph limit: a transportation sector that can deliver goods quickly across the country; increased productivity, because millions of commuters can spend more time at work than in transit; and more time at home with our children.

    Health insurers may face tougher rules on Obamacare doctor lists


    The proposed legislation also calls on state regulators to craft a standard format for directories to make the information simpler to use.
    "In a world where we compel people to purchase health insurance," Hernandez said, "we must empower consumers to make accurate and informed decisions about the plans and policies they are choosing."
    A health insurance trade group said companies are willing to work with lawmakers on the issue, but they noted that medical providers play a major role in giving patients accurate information.
    "Health plans and providers have a shared responsibility in ensuring directories are updated in a timely manner," said Charles Bacchi, president of the California Assn. of Health Plans. "We look forward to working with Sen. Hernandez on his bill."
    The rollout of Obamacare in California was marred by consumer frustration over limited networks and the inability of many people to find a doctor who accepted their policy.

    In November, the California Department of Managed Health Care weighed in and said two major insurers had violated state law by overstating the number of doctors available to patients.



    Can This Treatment Help Me? There’s a Statistic for That

    By  Austin Frakt and Aaron E. Carroll
    In his State of the Union address last week, President Obama encouraged the development of “precision medicine,” which would tailor treatments based on individuals’ genetics or physiology. This is an effort to improve medical care’s effectiveness, which might cause some to wonder: Don’t we already have effective drugs and treatments? In truth, medical care is often far less effective than most believe. Just because you took some medicine for an illness and became well again, it doesn’t necessarily mean that the treatment provided the cure.
    This fundamental lesson is conveyed by a metric known as the number needed to treat, or N.N.T. Developed in the 1980s, the N.N.T. tells us how many people must be treated for one person to derive benefit. An N.N.T. of one would mean every person treated improves and every person not treated fails to, which is how we tend to think most therapies work.
    What may surprise you is that N.N.T.s are often much higher than one. Double- and even triple-digit N.N.T.s are common.
    Consider aspirin for heart attack prevention. Based upon both modifiable risk factors like cholesterol level and smoking, and factors that are beyond one’s control, like family history and age, it is possible to calculate the chance that a person will have a first heart attack in the next 10 years. The American Heart Association recommends that people who have more than a 10 percent chance take a daily aspirin to avoid that heart attack.
    How effective is aspirin for that aim? According to clinical trials, if about 2,000 people follow these guidelines over a two-year period, one additional first heart attack will be prevented.
    That doesn’t mean the 1,999 other people have heart attacks. The fact is, on average about 3.6 of them would have a first heart attack regardless of whether they took the aspirin. Even more important, 1,995.4 people would never have a heart attack whether or not they took aspirin. Only one person is actually affected by aspirin. If he takes it, the number of people who remain heart attack-free rises to 1996.4. If he doesn’t, the number remains 1995.4. But for 1,999 of the 2,000 people, aspirin doesn’t make any difference at all.
    Of course, nobody knows if they’re the lucky one for whom aspirin is helpful. So, if aspirin is cheap and doesn’t cause much harm, it might be worth taking, even if the chances of benefit are small. But this already reflects a trade-off we rarely consider rationally. (And many treatments do cause harm. There is a complementary metric known as the number needed to harm, or N.N.H., which says that if that number of people are treated, one additional person will have a specific negative outcome. For some treatments, N.N.T. can be higher than the number needed to harm, indicating more people are harmed than successfully treated.)
    Not all N.N.T.s are as high as aspirin’s for heart attacks, but many are higher than you might think. A website developed by David Newman, a director of clinical research at Icahn School of Medicine at Mount Sinai hospital, and Dr. Graham Walker, an assistant clinical professor at the University of California, San Francisco, has become a clearinghouse of N.N.T. data, amassed from clinical trials. Among them, for example, are those for the effects of the Mediterranean diet.

    Anatomy of a Health Care Mess 

    Steven Brill Tackles Health Care in ‘America’s Bitter Pill'

    By Abigail Zuger

    Never sign up for a tour of the sausage factory, not if you want to keep eating sausage. In the case of health care, unfortunately, no one gets to abstain. Journalists and legislators, doctors and nurses, reformers and reformed alike, all eventually land on the conveyor belt that feeds those grinding gears.
    Is it better to go through the machinery with some understanding of how it works (or doesn’t)? Individual preferences will vary. For those who believe forewarned is forearmed, the veteran journalist Steven Brill has put together a comprehensive and suitably furious guide to the political landscape of American health care circa 2014 — a tour de force inspection of both sausage and factory.
    Mr. Brill began his muckraking early in the rollout of the Affordable Care Act, with a comprehensive indictment of American health care costs that occupied an entire issue of Time magazine in early 2013. He continued to comment in the pages of Time on the disastrous debut of the act’s health insurance marketplaces that fall and the widespread repair work that still continues.
    All this reporting reappears in the book, sometimes verbatim, reframed by several new sections. At the beginning comes a long back story detailing the years of politicking that created the new legislation. At the end, Mr. Brill offers a series of personal insights provoked in large part by his recent, unexpected detour from reporter to patient, and suggestions for how it might all be fixed.
    Full disclosure here:  It became clear early in the creation of the Affordable Care Act that my definition of the word "reform" differed substantially from that of our political leaders.  After that, I stopped paying a lot of attention to the political Kabuki — a disgraceful if all too common reaction among us beleaguered sausage-makers.
    Hence, I cannot assess the accuracy of Mr. Brill’s account of the negotiations that created Obamacare, but I found it persuasive, shocking and very sad. It is not an easy story to follow, a little like plowing through a long description of every can of paint flung onto a Jackson Pollock canvas. Still, the difficulty and occasional tedium of the narrative themselves inform the subject.
    As Mr. Brill tells it, the legislation was from the very beginning all about profit, with all the relevant industries, from insurers to drug makers to hospitals, methodically seduced aboard with promises of big returns. The politicos spoke of broader insurance coverage, but what they actually meant was more health care dollars to spread around. The nonprofit “public option” never had a chance, and vanished.
    The final legislation was a truly remarkable triumph of fiscal diplomacy. No wonder the act’s political parents were so exhausted by its creation that implementation took second place. The initial result: a deeply flawed federal enrollment website and phone banks of confused people diligently dispensing misinformation. Mr. Brill details these mishaps in full, along with the months of mopping up required.

    Supreme Court Rules Against Retirees in Union Health Benefits Case

    By 

    WASHINGTON — The Supreme Court on Monday ruledthat a chemical company may be able to cut the health benefits of its retired workers, unanimously reversing an appeals court ruling that said the benefits had vested for life.
    “Courts should not construe ambiguous writings to create lifetime promises,” Justice Clarence Thomas wrote for the court, adding that “retiree health care benefits are not a form of deferred compensation.”
    The Supreme Court returned the case to the appeals court, telling it to use ordinary principles of contract interpretation to determine whether the collective bargaining agreement at issue had granted free lifetime health care.
    The appeals court erred, Justice Thomas wrote, “by placing a thumb on the scale in favor of vested retiree benefits in all collective bargaining agreements.”
    The case concerned a union contract at the Point Pleasant Polyester Plant in Apple Grove, W.Va. Like many other collective bargaining agreements, it did not directly say whether health benefits for retirees would vest for life.



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    Californians received $3.2 billion in Obamacare premium subsidies


    Californians received $3.2 billion in Obamacare premium subsidies - LA Times

    Californians received $3.2 billion in Obamacare premium subsidies during the rollout of the federal health law last year.
    That federal aid went to about 800,000 California households, state officials said Monday. Those individuals and families paid $1.1 billion in premiums themselves, meaning for every dollar they spent the federal government paid an additional $3 to their health insurer.
    Nearly 90% of enrollees in the Covered California exchange qualified for financial help based on their income. The average monthly subsidy was $436 per household, according to the state.
    The taxpayer subsidies are a linchpin of the Obama administration's effort to make health insurance more affordable for millions of Americans. Individuals earning up to $46,000 annually and families of four making up to $94,000 qualified for assistance.
    Health policy experts said the fact that subsidies covered such a large share of Californians' premiums suggests that most people who signed up in the first year of the Affordable Care Act were lower income.
    State officials have said one of their big challenges now is signing up more middle-income people during the second open enrollment that ends Feb. 15.
    "That's one of the reasons why the remaining uninsured are harder to reach," said Larry Levitt, a senior vice president at the nonprofit Kaiser Family Foundation. "They most likely have somewhat higher incomes and therefore qualify for smaller subsidies."










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