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Saturday, March 7, 2015

Health Care Reform Articles - March 7, 2015

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

  1. Tsung-Mei Cheng1

    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.
    Lessons Learned

    The most important lesson of Taiwan’s experience is that the single-payer approach can offer all citizens timely and affordable access to needed health care on equal terms, regardless of the patient’s social, economic, and health status; sex; age; place of residence; and employment status.

    A second lesson is that a single-payer model such as Taiwan’s can control costs effectively. It is administratively simple and inexpensive and is the ideal platform for a powerful health IT system. It also facilitates global budgeting, if that is the only way to keep health spending in line with the growth of GDP.

    A third lesson is the importance of investing heavily, up front, in a modern IT infrastructure. A modern IT system such as Taiwan’s allows the government to have information about health utilization and spending in almost real time.

    Fourth, Taiwan’s case illustrates that health policy makers should not miss windows of opportunity for major health reform. Enabling factors include rapid economic growth, which makes it easier to redistribute resources; strong popular demand for reform; strong political leadership; a broad social and political consensus on the ethical principles that guide the health system; and the availability of a cadre of competent civil servants motivated and able to implement reform.

    Lessons For The United States

    Taiwan’s experience demonstrates that with competence and goodwill, the challenge of adding a large influx of newly insured citizens can be met. Health systems appear to be adaptive, and the case of Taiwan illustrates that incremental improvements on reform are possible.

    Taiwan’s experience also might induce Americans to think more deeply about the term freedom of choice. In health care, freedom of choice could mean choice among health insurance carriers and health insurance contracts, choice among health care providers, or both. For Taiwan’s citizens, freedom of choice among providers of health care trumped freedom of choice among insurance carriers and contracts. These citizens’ high satisfaction with their health system suggests that they still endorse that choice. By contrast, in the United States freedom of choice among insurance carriers and products ranks above freedom of choice among health care providers, which often is limited to narrow networks of providers.

    A growing body of literature has shown that by international standards, enormous human resources are used in the United States to facilitate choice among insurers and insurance products, process claims, and annually negotiate a payment system that results in rampant and bewildering price discrimination. Relative to the less complex health systems elsewhere in the industrialized world, the US system is a poor platform for the effective use of modern health IT.

    According to a recent report by the Institute of Medicine, the US system has excessive administrative costs that in 2009 amounted to $190 billion. That is more than it would cost to attain true universal health care in the United States.

    It is not this author’s role to prescribe what Americans should or should not do in regard to freedom of choice. But it is appropriate to invite readers to think more deeply about the relative benefits and costs of their choices. It is remarkable that in cross-national surveys, Americans have consistently given their health care delivery system relatively high marks, but their health system relatively poor ones.

    (Tsung-Mei Cheng is a health policy research analyst at the Woodrow Wilson School of Public and International Affairs, Princeton University, in Princeton, New Jersey.)

The Obamacare Challenge We Need? Improved, Expanded Medicare for All

How is it possible that in 2015 one of the richest countries in the world still does not guarantee every resident the right to health care?
by
Robert Zarr
As a primary care pediatrician who sees children of low-income families in Washington, D.C., I am reminded every day of the vulnerability of our children’s health to the ill-informed whims of our lawmakers and courts.
Those children will be on my mind as I gather with others outside the Supreme Court today.
Just yesterday, I saw my 16-year-old patient Mary, who suffers from Down’s syndrome and congenital heart disease, both conditions with lifelong disabilities. I have known Mary for the last 13 years.
Her family has been through some very rough times. I still distinctly remember listening to Mary’s mother tell me that her family was homeless, just a few years ago. Mary’s mother was in tears. They had no place to live, two children to feed, and both parents were unemployed.
To the best of my ability, I reassured Mary’s mother that despite hard times for her and her family, she would still have me as her child’s pediatrician, and Medicaid for her child’s health insurance.
At that moment I reminded myself that it takes a societal commitment to public institutions like Medicaid and community health centers to provide care to millions of Americans like Mary who would otherwise go without.
Yet when Mary turns 21, she might not qualify for Medicaid. Depending on what state Mary and her family live in, she may or may not have access to the doctors she will need for the rest of her life.
Children and their families need stability in their lives, and yet health insurance in our country remains prone to great instability and harsh surprises. Mary’s case is by no means unique.
How is it possible that in 2015 one of the richest countries in the world still does not guarantee every resident the right to health care? This question would not be necessary if we had a health care system worthy of the name – single-payer national health insurance, or an improved and expanded Medicare for All.

(Check out the comments on Robert Zarr's article)


The Supreme Court and the Fate of American Health Care

By 

In 2012, the chief justice of the United States, John Roberts Jr., saved the Affordable Care Act by a single, surprising vote. On Wednesday morning, the chief justice was again expected to hold the decisive vote as the Supreme Court heard extended oral argument in the latest assault on President Obama’s signature health care law.
The case, King v. Burwell, will determine the fate of legislation that has transformed the American health care system. But the argument provided few solid clues to how the justices will rule.
The chief justice remained virtually silent for the entire argument, while most of the others took predictable positions in questioning the government or the challengers. The surprise this time came from Justice Anthony Kennedy, who had voted with the dissenters from the 2012 decision that upheld the Affordable Care Act and appeared to have no interest in protecting the law.
Nevertheless, Justice Kennedy flagged a “serious constitutional problem” with the current challenge, which focuses on a single phrase — “established by the State” — embedded deep in a subsection of the act.
Michael Carvin, the plaintiffs’ lawyer, had been arguing — against all evidence and logic — that when Congress passed the act in 2010, it simultaneously undermined the law’s central goal of affordable health care for all Americans by supposedly denying tax-credit subsidies to all residents in the 34 states where the federal government runs the health care exchange.
A vast majority of the more than 11 million Americans signed up under Obamacare are eligible for these subsidies, and would be unable to afford health care without them.
The absence of these subsidies, in other words, would mean the collapse of the insurance markets in those 34 states — which did not for various reasons set up their own exchanges — and costs for individuals would be even higher than they were before the law passed.

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


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.
The list of policy changes that would be untouched by any legal ruling is very long. The law’sMedicaid expansion, now covering more than nine million poor Americans, will endure. Regulations on health insurance, limiting insurers’ ability to impose lifetime caps on coverage or exclude customers who have pre-existing illnesses, will remain.Young adults will still be able to stay on their parents’ insurance until they reach 26.
Major changes in the wayMedicare 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 countsof 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.
But that same model estimates that, even with a decision in favor of King, the law would still reduce the number of uninsured Americans by nearly 15 million people. And a large majority of Americans receive their health insurance from either an employer, Medicare or Medicaid — all systems that would experience little disruption from a court ruling.

That means that, even in the worst case for Obamacare, with a win for the King plaintiffs followed by no congressional, regulatory or state policy action, the law would still reduce the number of uninsured Americans by about two-thirds of what it would accomplish unchallenged.
http://www.nytimes.com/2015/03/05/upshot/even-with-an-unfavorable-court-ruling-much-of-obamacare-would-live-on.html?hpw&rref=upshot&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well&abt=0002&abg=0

The Supreme Court cannot hide on Obamacare

By Dana Milbank Opinion writer March 4, 2015

The Supreme Court, it would seem, did not want you to see what it was up to on Wednesday.
The robed nine were hearing oral arguments in King v. Burwell , a legal effort by conservatives to dismantle Obamacare and probably the most politically charged case to appear before the high court since Bush v. Gore. But, as always, there was no video of the proceedings and, curiously, the court chose not to release same-day audio of the argument, as it did in Bush v. Gore and has done in other high-profile cases since then.
I went to the argument, as I have for the last decade, to attempt to paint for readers a verbal picture of the atmospherics in the room, such as Samuel Alito’s eye rolls, Sonia Sotomayor’s hectoring and Clarence Thomas’s states of repose. But this time, court staff placed me in the back corner, three feet from the door; blocking my view of the justices were two red-velvet curtains, a marble pillar, another marble pillar, and a closed brass gate carved with images of acorns, oak leaves, dolphins, helmets and plumes, animal heads and the Ten Commandments.
Ultimately, though, there will be no hiding what happened in that chamber Wednesday morning. Ninety minutes of lopsided argument in favor of the Obama administration’s defense cast significant doubt on what had been a plausible challenge to Obamacare’s legality. The conservative majority could still knock down the law, of course, but given the ambiguity exposed Wednesday, it would now be a breathtaking surprise for the justices to cause such massive upheaval — taking health-care immediately from 8 million and causing a death spiral for the rest of Obamacare — based on such a slender legal reed.


Supreme Court appears split in challenge to Affordable Care Act
By  AND 
esident Obama’s healthcare law once again stands in legal peril after Supreme Court justices appeared sharply split along ideological lines during oral arguments Wednesday in a case that threatens to end insurance subsidies for more than 7 million Americans.
The four liberals among the court’s nine justices seemed ready to side with the Obama administration in rejecting the latest challenge to the Affordable Care Act. But it was unclear whether they would get a fifth vote from the conservative side.
Chief Justice John G. Roberts Jr., who helped rescue the law three years ago, gave no hint about how he might rule this time.
And Justice Anthony M. Kennedy, another possible swing vote, voiced some reservations about the challenge, but also said he was troubled by how the Obama administration had implemented the law.
The lawsuit — brought by a group of conservative and libertarian activists — argues that a strict reading of the statute makes health insurance subsidies available only in a handful states (including California) that established their own insurance marketplaces, also known as exchanges.
But 37 states elected instead to have the federal government fully or partially operate their marketplaces using the HealthCare.gov website.
In 2012, the Internal Revenue Service issued regulations making subsidies available for both state and federally run exchanges. Critics challenged the rule as illegal, citing a provision in the law that limits subsidies to an “exchange established by the state.”
Obama administration attorneys accused opponents of taking the provision out of context and argued that the overall law clearly intends to make the subsidies available nationwide.
In a worrisome sign for the administration, Kennedy questioned whether the IRS could make that decision on its own.

Forget Obamacare: Reform health care yourself

By Dr. Michael Noonan, Special to the BDN
Posted March 05, 2015, at 10:58 a.m.
Although the Affordable Care Act, aka Obamacare, has expanded coverage to many who were uninsured, it does little to actually reform health care.
Improving coverage for medical care does not fundamentally change the system. True health care reform is not likely to come from the government and even less likely to come from the health care industry. There is too much money invested in the current system, from pharmaceutical companies, manufacturers of medical devices, providers and insurers. There is great resistance to any change that would weaken their power and reduce profits.
If you really want to reform health care, adopting a wellness-based program would go a long way toward improving our country’s awful and worsening health and our increasing use of medications. It has worked for me and my patients who make the change.
Because the system is not likely to change any time soon, this means it is up to the patient to take control, to reform his or her own health care. This is not an easy thing to do. Patients trying to get off even one of their medications usually gets resistance from their family doctor, whose performance is rated in part by how many patients are on the “proper” meds. Add to that all the incorrect diet and lifestyle recommendations we have been given and the constant bombardment of drug ads, and you will be swimming upstream against the strong current of present-day medical thought in making any healthy changes.
Still want to reform your own health care? I have a few suggestions.
First, improve your lifestyle. There is no screening, drug, surgery or other medical intervention that will come close to a healthy lifestyle for preventing disease. In fact, none of those medical interventions will improve your health one bit. They may detect disease early but will not make you healthier — it’s not the same thing.
When it comes to healthy eating, I do not recommend eating a low-fat diet; it is very unnatural. Instead, eat lots of fresh, minimally processed veggies and fruit and meats and animal products from healthy animals not raised in a “factory farm.” Count chemicals, not calories.
Exercise regularly: 30 minutes a day is considered a bare minimum. If that is too painful, consider getting care for your pain instead of using drugs for relief.
Control stress. Just taking the time to sit quietly for 10 to 20 minutes a day can make a big difference in how stress affects you. It may not change the events of your life, but it can change how you react to them.
When you do get sick — it happens to the best of us — start with wellness care, unless it is a medical emergency. Consider chiropractic care, acupuncture, naturopathy or the rare medical provider who practices true wellness. When you start care, be patient. Because wellness care focuses on correcting the underlying problem and relies on natural treatments, it does not always produce the quick results drugs or surgery do. However, wellness care is largely free of the dangerous and sometimes deadly side effects that are taking such a toll on our society.
Be sure to let your friends in on your secret. Health care reform is too important to keep to yourself.


How the Obamacare Supreme Court ruling could affect Maine

Home
By 
The Supreme Court will hear arguments today in a case that could gut Obamacare.
The case will decide the fate of the health reform law’s financial subsidies, which help millions of individuals and families to afford coverage. In other words, Obamacare’s reason for being.
As we explained in our ACA 201 series, at issue is whether the subsidies apply only in states that set up their own health insurance marketplaces, or, as is the case now, also in states that use the federal marketplace.
More than half of all states, including Maine, use the federal marketplace Healthcare.gov. It’s geared toward people who buy their own health insurance rather than get coverage through work or the government. (Most Mainers don’t use the Healthcare.gov, they get health insurance through work or government programs like Medicaid or Medicare.)
The case hangs on some imprecise wording in the health reform law. If the court decides the subsidies, issued in the form of tax credits, can’t be issued to consumers in Healthcare.gov states, millions of consumers could drop or forgo insurance because it’s too expensive without the financial leg up.
Supporters of the ACA argue the law’s drafters clearly wanted everyone to have access to the subsidies. Opponents are exploiting the imprecise language in an attempt to undermine the law on a technicality, they say.
The plaintiffs in the case — King v. Burwell — contend that the law’s authors deliberately wrote that the tax credits are available through marketplaces “established by the State.” The intent was to compel states to set up their own marketplaces by holding the tax credits over their heads, they say.
Here’s what the ruling could mean for Maine:
  • Nearly all of the 75,000 Mainers who enrolled through Healthcare.gov for coverage in 2015 could lose their subsidies. About 90 percent qualified for financial assistance, according to U.S. HHS. People who can’t get affordable health insurance through their job and earn between 100 percent and 400 percent of the federal poverty level (between $23,850 and a $95,400 a year for a family of four) are eligible.
  • The Urban Institute and Robert Wood Johnson Foundation estimate that 62,000 Maine residents would lose subsidies worth $257 million come 2016, boosting the number of uninsured people in the state by 50,000. That’s exactly the opposite of the ACA’s intent, to expand coverage to millions more Americans.
  • Just over three quarters of Maine’s enrollees got coverage for $100 or less after tax credits, as of December 2014. Without the financial help, Mainers would be paying much more — $434 a month on average, according to HHS.
Losing the subsidies would make health insurance so expensive that many people would drop their coverage, experts say. Most of them are likely to be young and healthy, because people who aren’t sick are more inclined to skate by without insurance. But they subsidize the costs of older, sicker people in the insurance system, so without them, premiums will skyrocket, health experts predict. That “death spiral” could upend the entire insurance market, putting us right back to square one — lots of uninsured people seeking expensive care in emergency rooms that people with insurance foot the bill for.

By Scott Thistle, Sun Journal
Posted March 04, 2015, at 4:56 p.m.
AUGUSTA, Maine — Hospital executives and their representatives lined up Wednesday to tell legislators that the two-year budget offered by Republican Gov. Paul LePage would damage the state’s health care system and put hospitals deeper in debt if passed as is.
Members of the Legislature’s budget-writing Appropriations and Health and Human Services committees are meeting jointly this week to review LePage’s budget proposals as they relate to the Department of Health and Human Services.
DHHS is the state’s largest agency, spending about $3.9 billion in state and federal funds in 2014, of which about $1.8 billion comes from the state’s general fund.
Especially at risk, according to hospital officials and health care professionals who spoke Wednesday, are Maine’s smaller rural hospitals that serve as critical access hospitals.
Critical access hospitals are those that have fewer than 25 acute care beds available.
LePage’s proposal, presented by DHHS Commissioner Mary Mayhew, offers a complex set of changes that includes increasing Medicaid reimbursement rates for primary care physicians while reducing those rates for hospitals.
Jeff Austin, who represents the Maine Hospital Association, said combined with the loss of federal matching funds that LePage’s proposed changes would trigger, the state’s hospitals would lose at least $55 million a year.
Austin said that price tag does not include the new costs hospitals would face if LePage’s proposal to allow cities and towns to apply property taxes to nonprofits is enacted.
“This is a staggering amount of cuts to force hospitals to afford,” Austin said.
Austin also said the cuts were not being made to balance the state’s Health and Human Services budget but to redirect the money to other programs and initiatives.
“If the state wants to increase spending on other programs, it needs to identify new revenues to fund that spending and not cannibalize the rest of Medicaid,” Austin said.
Frank McGinty, executive vice president and treasurer for MaineHealth, a network of hospitals that includes Maine Medical Center in Portland, said LePage’s budget would result in fewer health care services for the communities they serve. The cuts would also lead to fewer health care jobs, especially in rural parts of the state, McGinty said.
The impact of those lost services and the availability of health care would fall heaviest on the state’s uninsured and its poorest residents, according to McGinty.
Charity care at the hospitals McGinty represents rose from $33 million a year to $44 million annually in the past four years, in large part because changes to eligibility standards for MaineCare removed roughly 60,000 individuals from the government-funded health care program.
The additional changes would only add to that tally, McGinty said.
“My colleagues and I urge you to think very carefully before allowing these changes in the MaineCare program’s policy to tear a gaping hole in the safety net for the more than 100,000 Maine residents who are uninsured,” McGinty said.
Both he and Austin said LePage’s efforts to provide higher reimbursement rates for primary care physicians were needed and “laudable,” but those rates shouldn’t be increased at a cost to hospitals.
Combined with the property tax proposals, the rate reimbursement changes would cost Maine Medical Center more than $36 million annually, according to McGinty.
Under the proposal, DHHS would reimburse hospitals for emergency department visits for nonemergency issues at the same rate as it reimburses primary care providers.
Mayhew noted collaborative efforts with hospitals to reduce the use of the emergency room by Medicaid patients with education and outreach have saved the state’s Medicaid program $9 million.
Mayhew said this reimbursement rate change would help reduce unnecessary emergency department visits but Austin said that’s an illogical assumption.
“This is a penalty imposed on hospitals, who, under federal law, must keep their emergency department open to all individuals 24 hours a day, 365 days a year,” Austin said. “Cutting hospital reimbursement is not a disincentive to Medicaid recipients to use the service.”
Mayhew has also said repeatedly that the state’s Medicaid budget, for the first time in decades, was balanced and not facing a financial crisis.
It was a point committee members also reiterated as they spoke in opposition to changes that could create dramatic financial hardships for the state’s hospitals, which are in many cases also the largest employers for a given region.
Rep. Linda Sanborn, D-Gorham, a doctor, said she hoped hospital executives, doctors and other well-paid individuals who were opposing the cuts in LePage’s budget would likewise oppose his proposals to reduce the state’s income tax and eliminate its estate tax.
“We’ve been talking about pitting one of these poor health care choices against another and the reality is, the state is not in the red, we are not in a crisis and we do not have to be making any of these cuts,” Sanborn said. “I think we keep missing that point and for the folks that have really good incomes in here, I hope that you will stand up against the income tax cuts and estate tax cuts that are proposed in this budget so we don’t have to decide who else in the health care world needs to be cut inappropriately.”
By Scott Thistle, Sun Journal
Posted March 04, 2015, at 4:56 p.m.
AUGUSTA, Maine — Hospital executives and their representatives lined up Wednesday to tell legislators that the two-year budget offered by Republican Gov. Paul LePage would damage the state’s health care system and put hospitals deeper in debt if passed as is.
Members of the Legislature’s budget-writing Appropriations and Health and Human Services committees are meeting jointly this week to review LePage’s budget proposals as they relate to the Department of Health and Human Services.
DHHS is the state’s largest agency, spending about $3.9 billion in state and federal funds in 2014, of which about $1.8 billion comes from the state’s general fund.
Especially at risk, according to hospital officials and health care professionals who spoke Wednesday, are Maine’s smaller rural hospitals that serve as critical access hospitals.
Critical access hospitals are those that have fewer than 25 acute care beds available.
LePage’s proposal, presented by DHHS Commissioner Mary Mayhew, offers a complex set of changes that includes increasing Medicaid reimbursement rates for primary care physicians while reducing those rates for hospitals.
Jeff Austin, who represents the Maine Hospital Association, said combined with the loss of federal matching funds that LePage’s proposed changes would trigger, the state’s hospitals would lose at least $55 million a year.
Austin said that price tag does not include the new costs hospitals would face if LePage’s proposal to allow cities and towns to apply property taxes to nonprofits is enacted.
“This is a staggering amount of cuts to force hospitals to afford,” Austin said.
Austin also said the cuts were not being made to balance the state’s Health and Human Services budget but to redirect the money to other programs and initiatives.
“If the state wants to increase spending on other programs, it needs to identify new revenues to fund that spending and not cannibalize the rest of Medicaid,” Austin said.
Frank McGinty, executive vice president and treasurer for MaineHealth, a network of hospitals that includes Maine Medical Center in Portland, said LePage’s budget would result in fewer health care services for the communities they serve. The cuts would also lead to fewer health care jobs, especially in rural parts of the state, McGinty said.
The impact of those lost services and the availability of health care would fall heaviest on the state’s uninsured and its poorest residents, according to McGinty.
Charity care at the hospitals McGinty represents rose from $33 million a year to $44 million annually in the past four years, in large part because changes to eligibility standards for MaineCare removed roughly 60,000 individuals from the government-funded health care program.
The additional changes would only add to that tally, McGinty said.
“My colleagues and I urge you to think very carefully before allowing these changes in the MaineCare program’s policy to tear a gaping hole in the safety net for the more than 100,000 Maine residents who are uninsured,” McGinty said.
Both he and Austin said LePage’s efforts to provide higher reimbursement rates for primary care physicians were needed and “laudable,” but those rates shouldn’t be increased at a cost to hospitals.
Combined with the property tax proposals, the rate reimbursement changes would cost Maine Medical Center more than $36 million annually, according to McGinty.
Under the proposal, DHHS would reimburse hospitals for emergency department visits for nonemergency issues at the same rate as it reimburses primary care providers.
Mayhew noted collaborative efforts with hospitals to reduce the use of the emergency room by Medicaid patients with education and outreach have saved the state’s Medicaid program $9 million.
Mayhew said this reimbursement rate change would help reduce unnecessary emergency department visits but Austin said that’s an illogical assumption.
“This is a penalty imposed on hospitals, who, under federal law, must keep their emergency department open to all individuals 24 hours a day, 365 days a year,” Austin said. “Cutting hospital reimbursement is not a disincentive to Medicaid recipients to use the service.”
Mayhew has also said repeatedly that the state’s Medicaid budget, for the first time in decades, was balanced and not facing a financial crisis.
It was a point committee members also reiterated as they spoke in opposition to changes that could create dramatic financial hardships for the state’s hospitals, which are in many cases also the largest employers for a given region.
Rep. Linda Sanborn, D-Gorham, a doctor, said she hoped hospital executives, doctors and other well-paid individuals who were opposing the cuts in LePage’s budget would likewise oppose his proposals to reduce the state’s income tax and eliminate its estate tax.
“We’ve been talking about pitting one of these poor health care choices against another and the reality is, the state is not in the red, we are not in a crisis and we do not have to be making any of these cuts,” Sanborn said. “I think we keep missing that point and for the folks that have really good incomes in here, I hope that you will stand up against the income tax cuts and estate tax cuts that are proposed in this budget so we don’t have to decide who else in the health care world needs to be cut inappropriately.”


By Emily Brostek, Kevin Lewis and Lisa Ryan
Posted March 04, 2015, at 11:01 a.m.
Wayne Edgerly, age 63 from Washington County, went without health insurance for years. Now he is able to get care following a hip replacement surgery thanks to a plan that costs him $1.64 a month and has a $200 deductible. He also has peace of mind that he will not lose his home because of medical bills.
Wayne is not alone. Nearly nine out of 10 Mainers who got coverage through HealthCare.gov qualified for tax credits and have an average monthly premium of less than $100. Thanks to these tax credits, millions of Americans who only dreamed of being able to protect themselves and their families now have comprehensive coverage.
Unfortunately, the U.S. Supreme Court could change all of that. The court’s decision on King v. Burwell will determine whether these tax credits can continue to flow to consumers in states such as Maine or if affordable insurance will be out of reach for millions. Repealing this centerpiece of the law would have severe consequences for Maine people and our entire health care market. This is a make or break issue for our health care system.
The Affordable Care Act is working in Maine and across the country. Ten million Americans have gained coverage since the law’s implementation, and our national uninsured rate is at a record low. A decision to strip tax credits would be disastrous for millions. Studies estimate that anywhere from 8 million to 10 million Americans would lose health insurance. Everyone who buys their own insurance would be affected, with an estimated hike in premiums of 35 to 47 percent.
Thankfully, there is no legal basis for the Supreme Court to take health coverage away from millions of Americans. When Congress wrote and passed the ACA, everyone — Republicans, Democrats and the Congressional Budget Office alike — agreed the tax credits would be available for people living in all states.
The stakes could not be higher. The sudden elimination of a key component of the ACA could cause substantial disruptions to the U.S. health care system. Here in Maine, our health care system successfully adapted to the law for the past five years, which is why we, Maine’s insurance companies, health care providers and consumer and patient advocates, stand together in support of the ACA today.
According to the Urban Institute, 62,000 people in Maine would lose an average of $4,150 in tax credits and cost-sharing reductions if the court rules in favor of the plaintiffs; that’s a total of $257 million. An estimated 50,000 Mainers would become uninsured.
As fewer and fewer healthy people are able to afford coverage and enroll, insurance in the individual market will become more and more expensive. Eventually this process, known as a “death spiral,” will cause insurance markets in some states to collapse, leaving more people without access to affordable coverage. The resulting chaos would ripple through the health care system, impacting consumers and providers across the country. Nationally, health care spending by the 8.2 million uninsured would drop by 35 percent, resulting in a devastating decline in revenues for providers paired with a $12 billion-per-year surge in uncompensated care. All consumers of health care will bear these costs.
While this plays out in Washington, we will continue the important work to strengthen our health care system to serve the people of Maine. Some 74,792 Mainers recently renewed or enrolled in health coverage during the latest open enrollment period. And we cannot forget the ACA also has provided coverage to people with pre-existing conditions, allowed young people to stay on their parents’ plans and ensured preventive care is available without out-of-pocket costs.
Together we are making health insurance more accessible and affordable. We are confident the Supreme Court will do the right thing and recognize the ACA is deeply embedded in our health care system in a way that cannot and should not be unraveled. In the meantime, we will continue to work to ensure affordable, quality health care is available to Wayne and the millions like him who deserve coverage.
Emily Brostek is executive director of Consumers for Affordable Health Care. Kevin Lewis is CEO of Maine Community Health Options. Lisa Ryan, DO, is president of the Maine Medical Association. The Maine Primary Care Association has also signed on in support of this OpEd.

Could negotiations, Canadian-style, have prevented Maine’s drug import pickle?

By Bloomberg View, Special to the BDN
Published March 05, 2015

Canada has a well-founded reputation for dangerous exports: dirty oil. Strong beer. The occasional bad pop song. Hockey fights. Hockey hair. The Canadian tuxedo.
Still, the U.S. pharmaceutical industry’s concern about a law that let Maine residents buy prescription drugs from Canada is a little odd. There’s no evidence that medicines from Canadian pharmacies pose any greater safety risk than those bought in the U.S. Yet industry trade groups last week persuaded a judge to overturn the law, on the narrow grounds that drug importations are a federal matter.
Drugmakers are probably more concerned with price than with safety. In Canada, drugs often cost much less than in the U.S. That’s what made the Maine law popular.
But consider what makes Canadian drugs so much cheaper in the first place. Canadians are no better than Americans at mixing and packaging chemical compounds. The difference is they let government health care plans use their purchasing power to negotiate lower drug prices.
If that strikes you as socialized medicine, consider that the U.S. Department of Veterans Affairs does the same thing. Medicaid, the federal-state program for the poor, does something similar, by demanding that drugmakers provide a rebate in exchange for participating in the program.
But those programs pale in size next to Medicare, which this year will spend an estimated $87 billion on prescription drugs. The 2003 law that created Medicare’s Part D prescription drug benefit included a “noninterference clause,” which specifically prevents the agency from negotiating lower prices.
Partly this was a sop to drugmakers, and partly it was meant to ensure that beneficiaries would have access to all drugs, not just those whose producers met Medicare’s terms. But Canada and the VA have shown that you don’t need to cover every drug to give beneficiaries the options they need.

Obamacare’s Inertia Problem

BY 

Obamacare has had a rough month: it’s being challenged in a Supreme Court case; House Republicans are trying to undermine it with a lawsuit; and its poll numbers are terrible. But on the ground the Affordable Care Act—which is starting its second open-enrollment period—looks robust. Most people in the program say they’re happy with their plans, and new insurers are entering the market. Prices are pretty good, too: estimates suggest that premiums for the second-cheapest of the “silver” plans, which is the benchmark used to set subsidies, have risen by an average of just two to five per cent. Still, one fundamental challenge remains: if Obamacare is to succeed in holding down premiums over the long run, it needs consumers to shop around.
People have no difficulty comparison-shopping and changing allegiance when it comes to, say, automobiles or consumer electronics. Companies in those markets face huge pressure to keep quality high and prices low. But there are also markets where consumers tend to stick with the same choice forever, even though switching could save them quite a bit of money. Energy bills are a classic example. We’ve long been told we can save money by leaving incumbent providers for newer upstarts, but the vast majority of us haven’t. Economists call it consumer inertia, and you can see it in many fields, including banking, credit cards, and health insurance. “History tells us that people are very sticky about health insurance,” Larry Levitt, a senior vice-president at the Kaiser Foundation, told me. “If you look at federal employees or at Medicare Part D, people generally don’t switch plans from year to year.”
When people first sign up for health insurance, price matters a good deal—most Obamacare enrollees chose lower-cost, higher-deductible plans. But inertia quickly takes hold. When the Netherlands introduced managed competition for insurers, in 2006, almost twenty per cent of the insured switched after a year. But, by 2012, less than four per cent did. Karen Lamiraud, an economics professor at ESSEC Business School, studied the insurance market in Switzerland and found that the average switch rate between 1997 and 2007 was three per cent. Such inertia can be expensive. Ben Handel, an economist at Berkeley, did a study of the insurance choices made by eighty-five hundred employees at a big company, and found that most ended up staying with their default option, even when it cost them serious money. “Consumers leave thousands of dollars a year on the table because of inertia,” he told me.

Did John Roberts Tip His Hand?

BY 

The Supreme Court oral argument on Wednesday in King v. Burwell featured thousands of words, dozens of provocative questions, two engaged and skillful lawyers—and one very striking silence. Chief Justice John Roberts, usually among the most active questioners on the court, scarcely said a word throughout the highly anticipated clash. The justices besieged Solicitor General Donald Verrilli and Michael Carvin, the lawyer for the plaintiffs, who are challenging a central provision of Obamacare, with so many questions that Roberts gave the pair ten extra minutes a side. The chief himself didn’t take up any of that time until practically the last moment.
Roberts’s one question may turn out to be extremely important. The issue in the case is whether the Obama Administration, in implementing the Affordable Care Act, violated the terms of that law. The plaintiffs assert that the A.C.A. only authorizes subsidies for individuals who buy health insurance on the fourteen state-run exchanges, or marketplaces. Under their reading of the law, the eight million or so people in the other thirty-six states who currently buy their insurance from the federal marketplace should be denied their subsidies. Most of the justices’ questions dealt with the issue of how to read the law correctly, but Roberts, in his single substantive question, took a different tack.
Anthony Kennedy had asked about “Chevron deference,” a doctrine of law that describes how much leeway the executive branch should have in interpreting laws. Verrilli, not surprisingly, said that the Chevron doctrine gave the Obama Administration more than adequate permission to read the law to allow subsidies on the federal exchange. “If you’re right about Chevron,” Roberts said, at long last, “that would indicate that a subsequent Administration could change that interpretation?” Perhaps it could, Verrilli conceded.

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

By Kay Tillow
Firedoglake, MyFDL, March 6, 2015
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 more because 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,” sayReps. 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.
Last July, over 300 patient advocacy groups wrote to Sylvia Burwell, Secretary of Health and Human Services, to express their concerns. “(W)e are increasingly aware of evidence that new enrollees, especially those with chronic health conditions, are still facing barriers to care,” the letter said.
The groups that signed the letter are well known. They include the American Lung Association, Epilepsy Foundation, The Leukemia and Lymphoma Society, National Alliance on Mental Illness, The Parkinson’s Association, Easter Seals, and the AIDS Institute. They praised the ACA for helping many of their members to finally get coverage. All of these groups supported the ACA prior to its passage and still do.
The letter urges action against discriminatory benefit designs that limit access for patients that were subjected to pre-existing conditions restrictions prior to the ACA. They spell it out. Some plans do not include all the drugs prescribed for enrollees. Some plans don’t cover critical medications including combination therapies. Plans can remove medications during the plan year. Some plans are restricting access to drugs by requiring prior authorization, step therapy, and quantity limits. The network of physicians and hospitals in some plans is so narrow as to deny patients the specialty care needed. Much of the information needed for patients to choose the most appropriate plan is not available.
The letter details the damage. High cost sharing means patients don’t get the drugs they need.  Some plans sold on the exchanges require patients to pay 30, 40 or 50% for drugs that go for several thousand dollars a month. HIV drugs, certain cancer medications, and multiple sclerosis drugs are among them.
The Leukemia & Lymphoma Society found exchange plans in several states that charged patients with blood cancer as much as 50% co-insurance rates.
Charis Hill, a biking enthusiast from Sacramento, California, counted on the medication Enbrel to keep her moving despite her diagnosis of ankylosing spondylitis.  But then the cost went up to $2,000, far more than she could afford. “Insurance companies are basically singling out certain conditions by placing some medications on high-cost tiers,” Ms. Hill said. She called it “pretty blatant discrimination.”
Julie Davis, a young wife and mother of two from Louisville, Kentucky, is struggling with the consequences of this failure to end the discrimination. Her epilepsy medication, Keppra, that had kept her stable and seizure free suddenly skyrocketed from $60 per month co-pay to $1,200.  The high price forced her to change medications in spite of the professional judgment of her physician. The seizures returned. With the problem not yet solved, Ms. Davis has written an Op Ed and testified before the Kentucky Senate Health and Welfare Committee. She and her organization, the Epilepsy Foundation of Kentuckiana, are publicizing the injustice and working to pass state legislation to cap drug co-pays in Kentucky.
HIV/AIDS patients have had to struggle to obtain the drugs crucial to their survival. Carl Schmid, deputy executive director of the AIDS Institute, asserted that “limited benefit coverage, cost-sharing for medications that can reach as high as 50%, and lack of transparency … mean many patients … are not receiving the care and medications they need.”
Even the insurance commissioner of the state of Washington, Mike Kreidler, said “there is no question” that “discrimination is creeping back.”
http://www.pnhp.org/print/news/2015/march/health-care-law-did-not-end-discrimination-against-those-with-pre-existing-condition




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