Follow the link at the end of this NEJM excerpt for a very nice summary of the history of medicare.
- SPC
HEALTH POLICY REPORT
Medicare at 50 — Origins and Evolution
David Blumenthal, M.D., M.P.P., Karen Davis, Ph.D., and Stuart Guterman, M.A.
January 14, 2015DOI: 10.1056/NEJMhpr1411701
Many Americans have never known a world without Medicare. For 50 years, it has been a reliable guarantor of the health and welfare of older and disabled Americans by paying their medical bills, ensuring their access to needed health care services, and protecting them from potentially crushing health expenses. However, as popular as Medicare has become, Congress created the program only after a long and deeply ideological struggle that still reverberates in continuing debates about its future. Nor was the Medicare program that was signed into law by President Lyndon B. Johnson on July 30, 1965, identical to the program we know today. As we mark the beginning of Medicare's 50th anniversary year, this first report in a two-part series recounts the history of this remarkable health care initiative and explains how it came to be, what it has accomplished, and how it has evolved over the past five decades. In the second report in the series, we will describe the ongoing challenges of the program and discuss proposals to address them.
ORIGINS OF MEDICARE
Medicare was born out of frustration, desperate need, and political opportunity. The intellectual and political architects of the program did not set out to create a health care system for the elderly (defined here as persons 65 years of age or older). Starting in the early 1930s, during President Franklin D. Roosevelt's New Deal, they sought a much grander prize: the enactment of universal national health insurance for all Americans. However, opposition from Republicans, conservative Democrats, and organized medicine frustrated those ambitions. Even after Harry Truman became the first president to unreservedly advocate national health insurance in 1948, his proposal stalled on Capitol Hill. Supporters reluctantly concluded they would have to pursue more modest goals, so they targeted health insurance for elderly Americans.
The logic for this new focus was compelling. The health care situation of retirees was desperate. Bills for health care in this population were roughly triple those of younger Americans, but retirees did not have access to employer-sponsored coverage and they were unattractive to private insurers in the individual health insurance market.1 In the early 1960s, only about half of Americans who were 65 years of age or older had any health insurance, and many of their policies did not offer meaningful health care coverage.2 Politically, the elderly were also an attractive constituency. They showed up at the polls, and even in the mid-20th century, demographic trends showed that their numbers would surge.
Why Republicans can't come up with an Obamacare replacement
Updated by Ezra Klein on January 16, 2015, 8:40 a.m. ET @ezraklein
In Philip Klein's new book Overcoming Obamacare, Cato's Michael Cannon scolds the right for getting outplayed, again and again, on health care.
"Conservatives are falling into the same trap now that they fell into with fighting the Clinton health plan ... they’re conceding the left’s premises that the government should be trying to provide everybody with health insurance, or the government should be trying to expand access to health insurance, or the government should be subsidizing health insurance, because some people need help and therefore the federal government should be the one to help them. The problem [comes] because once you accept those premises, all of your solutions look like the left’s solutions. They look like Obamacare. And so a lot of conservatives, as much as they want to repeal it and say they want to repeal Obamacare, they’re still pushing replace plans that amount to ‘Obamacare Lite.’"
Cannon is right. The basic project of health reform, at least as it's been understood in American politics in recent decades, involves the government giving money to poor people so they can buy health-care insurance. That money needs to come from somewhere. The government usually gets it from politically unsympathetic constituencies like the rich and corporations, both of which lean Republican. In the case of Obamacare, Medicare cuts were added to the package, meaning another Republican-tilting constituency — the elderly — absorbed the pain.
The problem for conservatives is that making sure poor people have health insurance is politically popular, at least in the abstract. But the plans that achieve it tend to be in tension with both broad tenets of conservatism — it raises taxes, it redistributes wealth, and it grows the government — and with key factions of the conservative coalition.
Rethink 'repeal and replace': Column
Robert Laszewski7:19 p.m. EST January 14, 2015
Obey health care customers, not political orthodoxy, when proposing Obamacare fixes.
The Republicans seem determined to "repeal and replace"Obamacare. They simply cannot bring themselves to consider fixing what they have come to revile.
Being against the president's namesake legislation has been a big winner in at least two out of the past three elections. But now that Republicans are in charge of the Congress, just attacking Obamacare won't work. They have to put something on the table.
However, they need to come up with something better. An effort to repeal and replace Obamacare would be a huge political mistake. There is no issue that presents a worse political minefield than health care. Each and every potential reform means somebody will be losing something and will be very motivated to stop it.
List of losers
Offer a new and complex system of tax credits to help pay for health insurance? Lots of people would be worse off — especially the poorest.
Kill the individual mandate and replace it with a system of high-risk insurance pools for those with pre-existing conditions? High-risk pools have been tried in plenty of states with the result being second-class insurance plans that cover less and cost more.
Rollback the Obamacare Medicaid expansion? That puts coverage in doubt for millions of people who now have it.
Any comprehensive health insurance or health care reform plan Republicans put on the table will create a whole new list of losers and lots of political trouble.
Customer-friendly Obamacare fixes: Column
Robert Laszewski7:24 p.m. EST January 14, 2015
Americans need a bipartisan fix to our health care system. Here's how to do it.
Health insurance reform can and should be fixed.
Obamacare is an overregulated monster of an insurance marketplace reform that violates a basic marketplace rule –– it doesn't meet most customers' needs because of its individual mandate and penalties, its limited choices, high deductibles, still high premiums and narrow provider networks.
But there are many parts of it that should be kept and built upon.
Health insurance reform can also become something that both Republicans and Democrats can support.
And, most importantly, a bipartisan fix can be something that meets customer needs, voters can embrace and consumers will buy.
Democrats have a point when they argue that ObamaCare was built on Republican ideas. The problem is that Democrats have layered too much complexity on top of those ideas.
There is a Republican chassis underlying ObamaCare.
Why Drugs Cost So Much
By PETER B. BACH
ELI LILLY charges more than $13,000 a month for Cyramza, the newest drug to treat stomach cancer. The latest medicine for lung cancer, Novartis’s Zykadia, costs almost $14,000 a month. Amgen’s Blincyto, for leukemia, will cost $64,000 a month.
Why? Drug manufacturers blame high prices on the complexity of biology, government regulations and shareholder expectations for high profit margins. In other words, they say, they are hamstrung. But there’s a simpler explanation.
Companies are taking advantage of a mix of laws that force insurers to include essentially all expensive drugs in their policies, and a philosophy that demands that every new health care product be available to everyone, no matter how little it helps or how much it costs. Anything else and we’re talking death panels.
Examples of companies exploiting these fault lines abound. An article in The New England Journal of Medicine last fall focused on how companies buy up the rights to old, inexpensive generic drugs, lock out competitors and raise prices. For instance, albendazole, a drug for certain kinds of parasitic infection, was approved back in 1996. As recently as 2010, its average wholesale cost was $5.92 per day. By 2013, it had risen to $119.58.
Novartis, the company that makes the leukemia drug Gleevec, keeps raising the drug’s price, even though the drug has already delivered billions in profit to the company. In 2001 Novartis charged $4,540, in 2014 dollars, for a month of treatment; now it charges $8,488. In its pricing, Novartis is just keeping up with other companies as they charge more and more for their drugs. They know we can’t say no.
But what if we didn’t require insurance companies to cover all drugs? We can see the answer in Europe. Many European countries say no to a handful of drugs each year, usually those that are both pretty ineffective and highly costly. Because they can say no, yes is not a guarantee. So companies have to offer their drugs at prices that make them attractive to these health care systems. A recent survey of cancer drug policies revealed you don’t have to say no very often to get discounts for saying yes. Of the 29 major cancer drugs included in the study that are available in the United States, an estimated 97 percent and 86 percent are also available in Germany and France, respectively.
Financial Distress Connected to Medical Bills Shows a Decline, the First in Years
Margot Sanger-Katz
After rising for a decade, the number of Americans experiencing financial distress from their medical bills has started to decline, a new survey has found.
The result provides new evidence that the Affordable Care Act, by providing uninsured people with health insurance, is also improving their financial security, a major goal of the law.
The large telephone survey, from the New York-based health research group the Commonwealth Fund, has been asking people about their medical bills every few years for a decade. In each survey through 2012, a higher percentage of Americans said they struggled to pay their medical bills, were paying off medical debt or had been contacted by a collection agency. The most recent installment of the survey, the first since the health law’s major provisions kicked in, shows a reversal in that trend.
The survey also found that fewer people were avoiding doctors’ visits because of concerns about cost.
“Health insurance really provides people with a financial means to get care,” said Sara Collins, a vice president at Commonwealth, who worked on the study. “We don’t know yet that the law is improving people’s health, but this is a first indication that people are affording care that they weren’t able to get in the past.”
Fewer Americans delayed needed medical care in 2014, survey says
The number of Americans who put off needed medical care fell substantially last year, according to a new survey that provides one of the fullest pictures of how the federal health law may be improving not only insurance coverage but also access to healthcare.
From 2012 to 2014, the share of consumers delaying a recommended test or treatment or not filling a prescription fell by nearly a third. And the percentage who reported problems with medical bills fell by almost a quarter.
Those are the first declines ever recorded by the biennial national survey by the nonprofit Commonwealth Fund, which began asking Americans about the affordability of medical care a decade ago.
"These declines are remarkable and unprecedented in the survey's history," said Sara Collins, the study's lead author. "They indicate that the Affordable Care Act is beginning to help people afford the healthcare they need."
The rise in reported access to care parallels a major expansion in health insurance coverage that began in 2014 through the health law often called Obamacare.
The law offers most Americans who don't get coverage through an employer the chance to buy a health plan on a new state-based marketplace where insurers must meet basic standards and cannot turn away customers. Low- and moderate-income consumers can get subsidies to offset the cost of their premiums.
In about half the states, very poor Americans can get government Medicaid coverage, largely for free. The remaining states have declined federal aid to expand their Medicaid programs.
Charles Lane: A country trapped in 1965’s ambitions
In the history of the American welfare state, no event was more consequential than the convening of the 89th Congress on Jan. 3, 1965, in which Democrats enjoyed huge majorities in both houses.
Followed 17 days later by the swearing-in of another Democrat as president, Lyndon B. Johnson, the seating of these lawmakers heralded one of the most productive legislative sessions in U.S. history, whose major actscontinue to set the terms of federal health care, education and labor force policy today: Medicare, Medicaid, the Higher Education Act, the Elementary and Secondary Education Act and, less famously but no less consequentially, expanded eligibility for Social Security disability insurance (SSDI).
So there may be some cosmic historical cyclicality revealed in the fact that, half a century later, almost to the day, a Republican-dominated 114th Congress, led by Mitch McConnell and John Boehner, has taken over on Capitol Hill — facing a national agenda defined in large part by the legacy of the 89th.
Transformative and beneficial though they were, and still are, the Great Society programs minted 50 years ago have mutated into sources of new and intractable problems, the most important of which is their unanticipated, enormous cost — which not only increases the national debt but also crowds out spending on other critical public needs from national defense to research.
Spending on Medicare, Medicaid, the two education laws and SSDI hit nearly $1 trillion in fiscal 2013, according to the Congressional Budget Office, or roughly 3 out of every 10 dollars Washington spent after interest payments. Future health-care costs, slated to grow in part due to Medicaid’s expansion under Obamacare, drive projected future federal deficits; SSDI’s trust fund is on course to run out of cash by fiscal 2017.
Meanwhile, evidence mounts that the great acts of 1965 now yield diminishing returns or, in some cases, have actually turned counterproductive.
Medicare and Medicaid have helped countless elderly and poor Americans and subsidized medical infrastructure and innovation. Yet U.S. health indicators are no better than those of societies that spend far less. SSDI may reduce incentives to work.
Health Insurance Prices: Highest In Alaska, Lowest In Sun Belt
In health insurance prices, as in the weather, Alaska and the Sun Belt are extremes. This year Alaska is the most expensive health insurance market for people who do not get coverage through their employers, while Phoenix, Albuquerque, N.M., and Tucson, Ariz., are among the very cheapest.
The best insurance deals by region and county
$166 Phoenix, Ariz. (Maricopa)
$167 Albuquerque, N.M. (Bernalillo, Sandoval, Torrance and Valencia count)
$167 Louisville, Ky. (Bullitt, Jefferson, Oldham and Shelby)
$170 Tucson, Ariz. (Pima and Santa Cruz)
$170 Pittsburgh, Pa. (Allegheny and Erie)
$179 Western Pennsylvania (Beaver, Butler, Washington, Westmoreland, Armstrong, Crawford, Fayette, Greene, Indiana, Lawrence, McKean, Mercer, and Warren)
$181 Knoxville and Eastern Tennessee (Anderson, Blount, Campbell, Claiborne, Cocke, Grainger, Hamblen, Jefferson, Knox, Loudon, Monroe, Morgan, Roane, Scott, Sevier, and Union)
$181 Minneapolis-St. Paul (Anoka, Benton, Carver, Dakota, Hennepin, Ramsey, Scott, Sherburne, Stearns, Washington, and Wright)
$184 Memphis and suburbs (Fayette, Haywood, Lauderdale, Shelby, and Tipton)
$189 North of Minneapolis (Chisago and Isanti)
(Premiums are for the lowest-cost silver plan for 40-year-olds, but in most cases, the areas with the highest and lowest premiums stay the same no matter the age.)
In this second year of the insurance marketplaces created by the federal health law, the most expensive premiums are in rural spots around the nation: Wyoming, rural Nevada, patches of inland California and the southernmost county in Mississippi, according to an analysis by the Kaiser Family Foundation, which has compiled premium prices from around the country. (KHN is an independent program of the foundation.)
The most and least expensive regions are determined by the monthly premium for the least expensive "silver" level plan, which is the type most consumers buy and covers on average 70 percent of medical expenses. Premiums in the priciest areas are triple those in the least expensive areas. The national median premium for a 40-year-old is $269, according to the foundation.
Along with the three southwestern cities, the places with the lowest premiums include Louisville, Ky., Pittsburgh and western Pennsylvania, Knoxville and Memphis, Tenn., and Minneapolis-St. Paul and many of its suburbs, the analysis found.
Starting this month, the cheapest silver plan for a 40-year-old in Alaska costs $488 a month. (Not everyone will have to pay that much because the health law subsidizes premiums for low-and moderate-income people.) A 40-year-old Phoenix resident could pay as little as $166 for the same level plan.
Medical journals are fairly dry reading, and it isn’t often that I come across an intriguing headline like “Green Eggs and Ham.” But there it was in a recent issue of Academic Medicine, with a story noting how Dartmouth’s medical school had been renamed in 2012 for one of the university’s most famous graduates, Theodor Geisel, or Dr. Seuss — a doctor, of course, of a different kind. Dartmouth Medical School had been rechristened the Audrey and Theodor Geisel School of Medicine, joining a growing list of medical schools that had been renamed after benefactors.
Since the authors’ earlier article on the topic in 2008, 10 more medical schools changed their names. Now 24 of the country’s 141 medical schools sport a donor’s name rather than the plain old university name. This trend is modest compared with the business schools — a whopping 80 percent are named for donors — but the pace is increasing, as are the number of eyebrows being raised.
The lead author of the article, Dr. Jay Loeffler, became interested in the topic while interviewing medical students for residency positions after the first few medical schools had changed their names. “These students were embarrassed that there was a rich person’s name on their diploma, with the university name tucked below in small print,” he said. Dr. Loeffler was concerned that medical schools were giving away their legacies — legacies often built up over a century or two — for one-time donations.
What does it actually cost to buy the name of a medical school? Ivy leagues and big ticket academic centers commanded the highest prices: The medical schools of Cornell and the University of California, Los Angeles, became the Weill Cornell Medical College and the David Geffen School of Medicine for $200 million each. East Carolina University became the Brody School of Medicine for a comparative bargain at $8 million. But the stakes just went up this fall when the Harvard School of Public Health became the Harvard T.H. Chan School of Public Health for $350 million.
The influx of cash that comes with the benefactors’ names can certainly help expand medical and educational resources at medical schools, especially during more difficult economic times. But is there an inherent conflict of interest in renaming medical schools?
California rejects UnitedHealth's bid to sell Obamacare statewide
by Chad Terhune
lifornia's Obamacare exchange rejected a bid from the nation's largest health insurer to start selling coverage statewide next year.
The Covered California board adopted new rules Thursday that sharply limit where industry giant UnitedHealth Group Inc. could offer policies to individuals.
Many consumer advocates backed the exchange's decision. But California Insurance Commissioner Dave Jones panned it, saying Californians deserve more choice and competition statewide.
Covered California's move to limit UnitedHealth could be a boost to the four largest health insurers already in the exchange. Led by Anthem Inc., they accounted for 94% of state enrollment in the first year.
The earliest UnitedHealth could sell statewide is now 2017. Covered California's decision came Thursday afternoon, and the company didn't comment on its immediate plans.
UnitedHealth had a chance to join Covered California when it launched in the fall of 2013 as part of the health-law rollout. Instead, the company exited California's individual insurance market and bypassed most of the Obamacare exchanges nationwide.
Peter Lee, executive director of Covered California, said established insurers shouldn't be free to come in right away. Those insurers, he said, should not be allowed to undercut rivals who stepped up at the start and made significant investments to sign up 1.2 million Californians during the first open enrollment.
Thursday, the state said more than 228,000 people had newly enrolled since Nov. 15, when the latest open enrollment began. It ends Feb. 15.
"United or other plans that were in the market in 2012 should have a higher bar" to joining the state exchange, Lee said. "We think the health plans that helped make California a national model should not be in essence undercut by plans that sat on the sidelines."
The board's newly adopted rules said UnitedHealth and other insurers that were operating prior to the health-law rollout are allowed to serve in only five of the state's 19 regions where there are fewer than three health plan choices.
Those areas are predominantly rural counties in Northern California, but they also include areas of Santa Barbara and San Luis Obispo counties.
Public health group slams LePage budget cuts to tobacco program, Maine CDC staffing
By Jackie Farwell, BDN Staff
Posted Jan. 15, 2015, at 12:14 p.m.
Health advocates are decrying proposed funding cuts in Gov. Paul LePage’s two-year budget that would “decimate Maine’s public health system,” including programs aimed at reducing smoking and staffing at the Maine Center for Disease Control and Prevention.
LePage’s budget “drastically” reduces funding for the state’s tobacco program and “all but eliminates” the Healthy Maine Partnerships, coalitions that address tobacco and other health problems in the community, the Maine Public Health Association said in a news release late Wednesday.
Although the group is still analyzing the details of the budget proposal, “the Maine Public Health Association and our partners are deeply concerned about the grave consequences proposed cuts will have on the health and safety of Maine children, families and elders,” said Executive Director Tina Pettingill.
Maine’s anti-smoking program — funded by the 1998 landmark tobacco settlement agreement with major cigarette makers — has ranked among the most successful nationally. Maine reduced cigarette smoking rates among high school students by 67 percent from 1997 to 2013, “saving thousands of lives and millions per year from our health care budget,” the release states.
But while Maine outperforms most other states, it has failed to fully invest in helping smokers quit and preventing children from picking up the habit, a 2014 American Lung Association report found.
“As children grow into adolescents and young adults they become the main target for the tobacco industry and these programs immunize them against these efforts during these crucial years,” said Becky Smith, director of government relations for the American Heart Association in Maine.
Maine funds its anti-smoking program, overseen by Maine CDC, and the Healthy Maine Partnerships with the tobacco settlement money and a tax on tobacco products. LePage’s budget redirects $10 million of those funds to support other health initiatives, including maintaining reimbursement rates for primary care providers and a program to better coordinate treatment for Medicaid patients who often rely on emergency care, which has reduced monthly costs for those patients by 29 percent, according to the Maine Department of Health and Human Services.
Such efforts will improve the health of Mainers, LePage said in his budget proposal.
“The DHHS budget proposal is continuing to prioritize limited resources in the best interests of the people of Maine,” DHHS Commissioner Mary Mayhew said in a statement. “The tobacco settlement funds must be evaluated for their effectiveness in meeting that goal just like any other dollar that is spent by state government. The governor’s proposal is seeking to invest in primary care to support prevention services and to fund better chronic disease management services, including individuals with tobacco-related illnesses.”
http://bangordailynews.com/2015/01/15/politics/public-health-group-slams-lepage-budget-cuts-to-tobacco-program-maine-cdc-staffing/print/
Supreme Court Rejects New Challenge to Obamacare Law
By REUTERS
WASHINGTON — The U.S. Supreme Court on Monday declined to take up another broad challenge to President Barack Obama's signature healthcare law.
The court rejected an appeal filed by the Association of American Physicians and Surgeons and the Alliance for Natural Health USA. The groups had challenged various aspects of the law known as Obamacare including the so-called individual mandate that requires people to obtain health insurance or pay a tax.
In March 2014, the U.S. Court of Appeals for the District of Columbia Circuit ruled in favor of the Obama administration. In 2012, a district court judge also ruled against the challengers.
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