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Monday, March 16, 2015

Health Care Reform Articles - March 16, 2015

Reflections On The 20th Anniversary Of Taiwan’s Single-Payer National Health Insurance System

Abstract

On its twentieth anniversary, Taiwan’s National Health Insurance (NHI) stands out as a high-performing single-payer national health insurance system that provides universal health coverage to Taiwan’s 23.4 million residents based on egalitarian ethical principles. The system has encountered myriad challenges over the years, including serious financial deficits. Taiwan’s government managed those crises through successive policy adjustments and reforms. Taiwan’s NHI continues to enjoy high public satisfaction and delivers affordable modern health care to all Taiwanese without the waiting times in single-payer systems such as those in England and Canada. It faces challenges, including balancing the system’s budget, improving the quality of health care, and achieving greater cost-effectiveness. However, Taiwan’s experience with the NHI shows that a single-payer approach can work and control health care costs effectively. There are lessons for the United States in how to expand coverage rapidly, manage incremental adjustments to the health system, and achieve freedom of choice.

Pros and Cons of Obamacare:
Is It What the United States Needs?
THE AFFORDABLE CARE ACT AND MEDICAL LOSS RATIOS: NO IMPACT IN FIRST THREE YEARS
Benjamin Day, David U. Himmelstein, Michael Broder, and Steffie Woolhandler
The Patient Protection and Affordable Care Act (ACA) set limits on insurers’ overhead, mandating a medical loss ratio (MLR) of at least 80 percent in the individual and small-group markets and 85 percent in the large-group market starting in 2011. In implementing the law, the Obama administration introduced new rules that changed (and inflated) how insurers calculate MLRs, distorting time trends. We used insurers’ filings with the U.S. Securities and Exchange Commission to calculate the largest insurers’ MLRs before and after the ACA regulations took effect, using a constant definition of MLR. MLRs averaged 83.04 percent in the three years before reform and 83.05 percent in the three years after reform. We conclude that the ACA had no impact on insurance industry overhead spending.

Health care law did not end discrimination against those with pre-existing conditions.

by Kay Tillow

In 2010 the giant health insurance company WellPoint created an algorithm that searched its database, located breast cancer patients, and targeted them for cancellation of their policies.
A few years earlier Michael Moore’s stunning documentary, “Sicko,” showed an unending list of illnesses that had been used by insurers to refuse to sell people policies, to charge them much more, or to deny payment for “pre-existing conditions.”
The public became acutely aware of these harmful, widespread practices and sharply condemned them.  So it was not by chance that this insistent popular support resulted in inclusion of a ban on these practices in the Affordable Care Act (ACA) that was passed in 2010.
The government website explains.  “Your insurance company can’t turn you down or charge you morebecause of your pre-existing health or medical condition like asthma, back pain, diabetes, or cancer.  Once you have insurance, they can’t refuse to cover treatment for your pre-existing condition.”
Even some Republicans who are trying to repeal the ACA insist that they stand for keeping a provision against such discrimination.  “We would protect people with existing conditions,” say Reps. Paul Ryan, John Kline, and Fred Upton.
Regardless of opinions on mandates or the health reform law in general, the entire nation embraced the part of the legislation that outlawed discrimination on the basis of illness.
So we’ve won, right, at least this much reform?  Sadly, no.

A Visit with our Neighbor to the North

By Richard Dillihunt, M.D.
Maine Medicine, July 2014
For decades, I have admired the Canadian health care system, first while at a remote Northern Quebec fishing camp. There, impromptu sick call was held for the Cree, local aboriginal people with rights to this remote land. Members of this tribe had various complaints that we treated with our medical chest. Despite the difference in language in the elderly, the shyness barriers were easily overcome. They seemed completely confident in our medical abilities.
We felt privileged as caregivers to be given such confidence and warm doctor-patient relationships came forth. Over the years we saw burns from campfire mishaps, an acute gallbladder, and a mangled hand injured beyond our medical capabilities. We made radio calls to regional flying services, and patients were fetched and flown to various medical centers. There were no lawyers or insurance companies involved. The only physical evidence of health care coverage was a small card that each patient guarded carefully. This card admitted them to their national health care system. It provided quality medical care covering all 35 million Canadians scattered across the second largest nation on earth.
The patient with the injured hand was emblematic of this system. A radio call summoned a floatplane, and the patient was loaded and lugged across and down the 150 km of the Peribonka River to the medical center in Chicoutimi. After treatment, he was returned by air. That little card had covered all medical care and transportation. Imagine what such a journey would cost us!
This system of universal health care came into being in 1946. It is attributed to a Canadian native son, Tommy Douglas. As premier of Saskatchewan, he established a universal single-payer health care for all of Canada. After his death he was voted “Greatest Canadian” by the Canadian Broadcast Corporation viewers.
Although medical service for the Cree and Inuit have been difficult for the Canadian government to perfect, they have enjoyed great success. Given the vast territory, the nation does well to spread its resources over ten million square km, much of it being a harsh environment.
The Canadian system deserves careful scrutiny by every American who has concerns regarding our badly broken health care system. Inspection of how the Canadians have successfully developed their universal single-payer form of health care uncovers features that the U.S. needs to seriously consider.
Just recently Danielle Martin, a brilliant young Canadian physician, called attention to the superior provisions of Canada’s public system in her testimony before Sen. Bernie Sanders’ committee in Washington. She showed that the Canadian system is based on need, not on the ability to pay. Her interaction with Sen. Burr (R-N.C.) went viral, generating over 700,000 views on YouTube across North America. Many major media outlets focused on her evidence-based, intelligent, and energetic defense of Canadian Medicare.
Canadians take great pride in their medicare-for-all system. They know that Canada’s life expectancy rates and maternal and infant mortality figures are superior to America’s, and their quality of care is equal to ours. They are aware that, traditionally, wait times have been a source of intense criticism of their system. They understand that this is largely overblown by stateside special interest groups whose propaganda has brainwashed America about horrendous waiting times for referrals and elective surgery. The facts show differently. Canada has addressed wait time issues with a Wait Time Alliance. Through this alliance there has been much improvement, and changes have been uncovered to correct this problem.

Letter to the editor: Let’s battle Big Pharma to bring back imports of cheaper drugs

The breathtaking cost of prescription drugs is the epitome of money-grabbing, and a thoughtless financial squeeze on each of us directly or indirectly, perpetrated by the pharmaceutical industry.
Hiding behind the idea that prohibiting importation of stunningly less expensive drugs from Canada is protecting us from counterfeits is a classical lesson in phony propaganda.
The relief we enjoyed with the Maine Pharmacy Act, which controlled drug costs by allowing us to purchase medications from Canada and other approved nations, has been overturned by U.S. District Court Judge Nancy Torresen in Portland.
Translated, this means a victory for Big Pharma, achieved through intense lobbying in Washington and sweetened by campaign contributions to Congress.
But wait – let’s not sit back and allow them to celebrate this victory thinking we have surrendered unconditionally.
Let’s demand that Sens. Susan Collins and Angus King and Reps. Chellie Pingree and Bruce Poliquin stand up and be counted, without bobbing and weaving and without political mumbo-jumbo, in favor of the Maine Pharmacy Act. Let’s take heed that there are no “for sale” signs on our congressional members’ offices.
Then, after the drug companies have canceled their celebrations and called their legal beagles back from exotic vacationlands, let’s roll out Janet Mills, Maine’s attorney general, to do battle for us against Big Pharma.
Finally, let’s tell Gov. LePage that he’d be wise to stay out of this one.
Richard C. Dillihunt, M.D.
Portland

From Home Grown Democrat:

If we're lucky, we get old, and there is more dignity in old age today, thanks to Medicare. Ask my mother: she's 91...one large cornerstone in her life is Medicare, which, for the grand sum of of $58.70 a month, gives her quick access to physicians, a visit to the emergency room if need be... She ran up about $5000 in medical bills last year, of which she paid only $146....

Medicare is the creation of Democrats and it has changed old age. 

If you're old, you aren't expected to accept pain and misery as your cross to bear and sit quietly by the window and sink uncomplaining into the dark. You're allowed to totter off to a clinic and claim the attention of a doctor and recite your complaints and hope to feel better....This is new. Medicare says that even though you're not working and may need special help with the ordinary business of life, nonetheless you have value in this society. This is a Democratic idea. Be a howling right winger if it gives you pleasure, but nonetheless milk comes from cows and Medicare comes from Democrats.

And this:
...we are part of a social compact and expect our representatives to defend it. If they chop holes in the compact, there will come a day of reckoning.

The gaping hole in the compact is health care...millions of Americans have no health insurance and must jump through hoops in order to get treatment....Go to any inner-city emergency room and see suffering people filling out forms about their finances and waiting hour after hour, a primitive caste system of medicine in a Christian country.

National health insurance would simplify the system. The sick will be treated eventually - they won't be left to die in the streets - so why not do it  in a humane fashion with a modicum of dignity? We've left the dark fatalistic age of medicine when the doc was a kindly old coot who held your hand as you expired.

...now if...problems show up...we set out to fight the disease - and in this nation where tax-supported research propelled great advances, our denial of the benefits to so many is downright stone-hearted. There is health care for Republican dogs and cats superior to what people get in the charity ward.

Health care is a fundamental right: you go flying heedless through your youth on waxen wings, immune to illness, immortal, but then you fall to earth and need to be cared for and not lie broken on the gurney waiting for the accountants upstairs to decide if you're entitled to attention...

It will be a great day in America when we finally see that everybody can come see the doctor as needed, not be shunted to the back door and the charity ward.
 
 
--
Activism is the rent I pay for living on this planet.
   - Alice Walker
 

More Good News on the Deficit, This Time Because of Private Insurance Health Premiums

MARCH 9, 2015
Estimates for government health care spending keep coming down.
A few months, ago, we wrote about how a slowing trend in Medicare spending had led federal budget forecasters to make drastic reductions in their estimates of the program’s costs. On Monday, they made similar cuts in their forecast of what the federal government will spend on private insurance premiums.
The revisions reflect growing evidence that health care spending in the country — which has traditionally grown much more quickly than the overall economy — is entering a new, more moderate era. It is still rising, but not very much any more.
That could eventually be not only a boon for consumers, but it could also have big implications for the federal budget: If the Congressional Budget Office is right, the amount the federal government pays for health insurancein the coming years will be hundreds of billions of dollars lower than it recently forecast, meaning a much smaller federal deficit.
The precise mix of factors behind the slowdown is still not entirely understood, but reduced spending growth has been observed almost across the board in health care. Medical price inflation has fallen, while the use of certain types of costly care — like hospitalizations — has declined. The changes most likely reflect some mix of consumer behavior (as people try avoid more expensive kinds of care) and a change in how doctors and hospitals practice medicine (as they try to reduce waste and errors).
http://www.nytimes.com/2015/03/10/upshot/more-good-news-on-the-deficit-this-time-because-of-declining-private-insurance-costs.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&abt=0002&abg=0


Budget Office Again Reduces Its Estimate on Cost of the Affordable Care Act

By 
WASHINGTON — The Congressional Budget Office on Monday again lowered its estimate of the cost of the Affordable Care Act, citing slow growth of health insurancepremiums as a major factor.
Just since January, the budget office said, it has reduced its estimate of the 10-year cost of federal insurance subsidies by 20 percent, and its estimate of new Medicaid costs attributable to the law has come down by 8 percent.
Slower growth in health spending helps consumers and businesses, which shoulder most of the costs, and contributes to lower federal budget deficits.
The budget office now projects deficits totaling $7.2 trillion from 2016 to 2025, a decrease of 6 percent from the more than $7.6 trillion projected in January.
“The largest factor underlying that reduction is a downward revision in projected growth in premiums for private health insurance,” reflecting the fact that spending by private insurers in 2013 rose less than in preceding years and much less than expected, the budget office said in a new report.
The new estimates could help Democrats stave off Republican efforts to roll back the law. Even though millions of people have gained coverage, opinion polls show that unfavorable views of the law are still more common than favorable ones.


86 Percent of Health Law Enrollees Receive Subsidies, White House Says 

By 
WASHINGTON — The Obama administration said Tuesday that 11.7 million Americans now have private health insurance through federal and state marketplaces, with 86 percent of them receiving financial assistance from the federal government to help pay premiums.
About three-fourths of people with marketplace coverage — 8.8 million consumers — live in the 37 states served by HealthCare.gov, the website for the federal insurance exchange. The other 2.9 million people are in states that created and operate their own exchanges.
Sylvia Mathews Burwell, the secretary of health and human services, underlined the importance of subsidies for people in states using the federal exchange — subsidies that could be withdrawn if the Supreme Court rules against the Obama administration in a pending case.
Administration officials suggested that more than seven million people could lose subsidies, making insurance unaffordable, if the court ruled that such assistance was unavailable in the federal exchange. The plaintiffs contend that the Affordable Care Act does not allow subsidies in the federal exchange.
In Florida, nearly 1.6 million people have selected or been automatically re-enrolled in health plans — the largest enrollment of any state in the federal exchange — and 1.5 million of them qualified for subsidies in the form of tax credits, which averaged $294 a month.
In Texas, 1.2 million people selected or were re-enrolled in health plans, and one million of them qualified for financial assistance averaging $239 a month. In North Carolina, 560,400 people selected health plans in the federal marketplace, and 515,500 of them qualified for subsidies averaging $315 a month.
Consumers in the federal exchange paid an average premium of $101 a month after tax credits, and 55 percent of them paid monthly premiums of $100 or less after tax credits, the administration said in a new report.
For people in states using HealthCare.gov, tax credits averaged $263 a month and reduced the premium by 72 percent, on average. That is similar to the share of premiums paid by employers for their workers’ family coverage.

Better relations with Cuba might help American diabetics

Andrew Schneider
Updated 12:21 am, Thursday, December 18, 2014
HAVANA -- Every seven minutes, someone in the U.S. loses a limb to diabetes. Now, those likely to add to those horrifying statistics may be among the biggest beneficiaries of normalized relations with Cuba.
Entangled for years in the U.S. trade embargo has been a high-tech medicine, Heberprot, developed in 2006 by a Cuban research center. 
Diabetic wound specialists say Heberprot, described as a "recombinant human epidermal growth medication," may be the best chance to save the lives and limbs of tens of thousands of Americans. The drug restores areas where gangrenous tissue was cut away as the wound spread.
Studies in peer-reviewed medical journals say the limb-saving medication has been administered to more than 170,000 patients in 23 countries. But the U.S. policy forbade the developer of Heberprot, Cuba's Center for Genetic Engineering and Biotechnology, to bring the drug to the U.S. for comprehensive clinical testing needed to prove its safety and effectiveness.
"It just rips me apart to know that there may be something out there that has the potential to save limbs and we can't get a chance to test it because of politics rather than public health," Dr. David Armstrong said last week, after spending hours in operating rooms working to reconstruct the feet of two patients to try to prevent leg amputation.

The Supreme Court Has the Power to Deepen a National Health Divide


Margot Sanger-Katz
The Supreme Court has the potential to radically reshape the Affordable Care Act, creating a result profoundly different from that imagined by President Obama and the law’s drafters in Congress.
Three years ago, the court essentially limited the law’s ability to expand health insurance to low-income Americans in red states. A case it is considering on Wednesday might result in taking away insurance access for middle-income people, too.
Taken together, the two cases could lead to a sharp national division in access to health insurance, based on what state you live in. Instead of providing universal health insurance coverage to the country, the law would widen an existing rift in health care access.
Perversely, the states where the court could wind up reducing insurance coverage the most have the largest share of residents who would otherwise benefit. Many of the states with the largest number of uninsured residents could be shut out of the bulk of Obamacare’s insurance expansion while continuing to pay the law’s taxes and other costs. Meanwhile, richer states that had always insured more of their residents would reap the benefits of federal dollars to expand further.

Even With an Unfavorable Court Ruling, Much of Obamacare Would Live On

MARCH 4, 2015
Margot Sanger-Katz
The case before the Supreme Court this week will not wipe Obamacare off the books.
Unlike the case the court considered in 2012, which could have erased the Affordable Care Act entirely, this one concerns the application of only one provision of the law, and only to certain states. A ruling for the plaintiffs in the case, King v. Burwell, would carry huge consequences in many states, but 15 million of the people estimated to get insurance under the law would still get it, according to an Urban Institute estimate.
Major changes in the way Medicare pays doctors and hospitals, designed to make health care safer and more efficient, will continue. Workplaces will still need to provide places for lactating mothers to pump breast milk. Chain restaurants will still need to publish the calorie counts of their menu items. Drug companies will still need to report the money they pay to doctors.
Taxes on wages and health insurance and medical devices will remain in place.
Even the law’s expansion of insurance coverage to the uninsured — the piece directly challenged by the lawsuit — will not completely evaporate. If the law’s challengers win in court, subsidies that help middle- income people buy insurance in as many as 37 states could disappear. The result, according to an Urban Institute estimate, is that about eight million fewer people would have health insurance in 2016 than would if the law remained untouched.


The 'Un'-Affordable Care Act is a weak start

By David E. Drake, D.O.
The Des Moines Register, March 10, 2015
Potential 2016 presidential candidate Sen. Bernie Sanders has stated: "There is one major country on Earth that does not guarantee health care as a right for all. There is one major country on Earth that spends twice as much per capita on health care as almost any other. There is one major country on Earth where private insurance companies and drug companies earn huge profits. Guess which country."
As a physician in private practice I abhor each coming new year. This is the time when health care practices have to deal with patients with new insurance policies and former policies with stringent regulations. This year, more than any previous time, I'm noticing more and more folks who have high deductibles — allowed up to $6,600 with the Affordable Care Act (Obamacare). And for some folks that means they can't see me or they have to greatly limit the number of times they can receive services from me.
In some cases I have to refer middle-class folks with these high deductibles to places with sliding scales, places I used to refer indigent folks with no insurance. Not seeking or delaying care can lead to delayed diagnoses and possible tragic consequences. And as Michael Moore has pointed out, now it's the middle class who are hit with being under- or poorly-insured while more indigent folks now have an expansion of Medicaid. The confusing mix of deductibles, co-pays, co-insurance and limitations on what services can be provided are now daily frustrations with our lack of guaranteed health care for all.
A single-payer system of reimbursement for health care services has never seemed more in need, with 38 percent of Americans citing health care costs they pay out of pocket as a somewhat or significant level of stress, according to the physician website Doximity. 
Health care bills could go to one payer — an expansion and enhancement of Medicare — with a great reduction in administrative costs for paying the bills and for providers of health care and their offices. Single payer does not imply a system like the Veterans Administration, where all the providers are employees, but one that allows for private as well as employed practices.
Other Iowans join me in their support for moving the ACA past the private insurance companies as the regulating and paying source.
Maureen McCue, adjunct clinical professor at the University of Iowa, medical director of the Women's Clinic, and Coordinator of the Iowa Chapter of Physicians for Social Responsibility, wrote me:
"Tinkering at the edges doing little to rein in the excesses of the profit-driven insurance system, pharmaceutical and biotech industries, and others. While allowing more citizens access to health insurance, the complexity of the new insurance mechanisms means accessing the health system itself has become ever more confusing and obtuse."
Dr. McCue offers hope for a change. "It doesn't have to be this way. There are tried and true solutions. The world's healthiest populations pay far less for medical services."

A $10,169 blood test is everything wrong with American health care

Updated by  on March 10, 2015
A lipid panel is one of the most basic blood tests in modern medicine. Doctors use it to measure cholesterol levels in their patients, probably millions of times each year.
This is not a procedure where some hospitals are really great at lipid panels and some are terrible. There's just not space for quality variation: you are running blood through a machine and pressing buttons. That's it.
And that all makes it a bit baffling why, in California, a lipid panel can cost anywhere between $10 and $10,000. In either case, it is the exact same test."What we were trying to see is, when we get down the simplest, most basic form of medicine, how much variation is there in price?" says Renee Hsia, an associate professor at University of California, San Francisco who published the price data in a recent study.
"It shows how big the variation really is. We're not talking twofold or threefold differences, it's a completely different level of magnitude."
For this research, published in August in the British Medical Journal, Hsia and her colleagues compiled reams of data about how much more than 100 hospitals charged for basic blood work. The prices these facilities charged consumers were all over the map.
The charge for a lipid panel ranged from $10 to $10,169. Hospital prices for a basic metabolic panel (which doctors use to measure the body's metabolism) were $35 at one facility — and $7,303 at another.
For every blood test that the researchers looked at, they found pretty giant variation:

Blood tests aren't the only place with this variation

Hsia's previous research looked at the cost of an appendectomy in California and found similarly gigantic variation. For an appendectomy with no complications, she found that hospitals in the state would charge anywhere between $1,529 and $186,955.
One the issues with that study, she says, is that different hospitals might treat patients differently. "Some hospital might use more IV bags than others or one doctor could be ordering a lot of blood tests," she says.
The point of comparing an incredibly basic blood test, and its prices, was to distill down to a very basic test that offers no space for variation — but still has a huge range in how much hospitals will charge.
Not every patient pays the full charge rate: insurance companies, for example, typically negotiate a lower rate with the hospital. Medicare, which covers seniors, has a set fee schedule it uses. But these are the prices that an uninsured patient — who doesn't have a health plan bargaining on her behalf — could face.
"If I'm hospitalized, don't have insurance and my doctor orders three days worth of blood tests, this is what I'm getting billed for," Hsia says.

What this tells us about American health care

For one, there's not much price transparency: it's really hard to know whether one hospital is charging $10 or $10,169 because prices are rarely listed. For this particular study, Hsia literally had to hire a software engineer to collect the data and line up all the different hospitals against each other.
The $10,169 blood test tells us we're suckers: we've developed a health care system where its hospitals have pretty full authority to name their price with little protest from consumers.

Medicaid Expansion in Red States

By 
A number of states that had previously refused to expand their Medicaid programs for the poor are reconsidering that policy. They would be smart to embrace expansion as soon as possible to cover millions of people who would be left uninsured if the Supreme Court wipes out federal subsidies for low-income people buying insurance on the federal health exchanges.
The Affordable Care Act originally required all states to expand Medicaid to cover people with an income up to 138 percent of the federal poverty level, or $32,913 for a family of four, but in 2012 the Supreme Court made expansion optional. Twenty-eight states and the District of Columbia have expanded their programs, but 22 have not.
The federal government pays 100 percent of the costs of covering newly eligible people through 2016, shifting down to 90 percent in 2020 and future years. This is a huge benefit to the states, since more health coverage means a healthier population, fewer people losing jobs because of health crises, greater productivity at work, fewer people getting charity care at costly hospital emergency rooms, and less strain on hospital and clinic budgets.
States that have not expanded Medicaid say it will strain them to pay even 10 percent of the costs. They insist that if the federal government pulls back from paying 90 percent, they will have to pick up more of the tab — but there is no reason to believe that will happen, and if it does, it can be resolved when it arises.
Fortunately, more and more Republican governors support expansion. Michigan, Ohio and Indiana are among 10 states with Republican governors that have already expanded Medicaid in recent years. Indiana and Iowa used Medicaid dollars to pay premiums for private health plans for poor people, an approach that requires federal approval and under federal rules must be budget neutral and offer comprehensive coverage.
Other pragmatic Republican governors, however, have been wrestling with Republican-controlled legislatures that cannot see the folly of refusing to take the federal money.
http://www.nytimes.com/2015/03/16/opinion/medicaid-expansion-in-red-states.html?hpw&rref=opinion&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well&_r=0


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