Robert Reich on Medicare for All
Wait Lists Grow as Many More Veterans Seek Care and Funding Falls Far Short
One year after outrage about long waiting lists for health care shook the Department of Veterans Affairs, the agency is facing a new crisis: The number of veterans on waiting lists of one month or more is now 50 percent higher than it was during the height of last year’s problems, department officials say. The department is also facing a nearly $3 billion budget shortfall, which could affect care for many veterans.
The agency is considering furloughs, hiring freezes and other significant moves to reduce the gap. A proposal to address a shortage of funds for one drug — a new, more effective but more costly hepatitis C treatment — by possibly rationing new treatments among veterans and excluding certain patients who have advanced terminal diseases or suffer from a “persistent vegetative state or advanced dementia” is stirring bitter debate inside the department.
Agency officials expect to petition Congress this week to allow them to shift money into programs running short of cash. But that may place them at odds with Republican lawmakers who object to removing funds from a new program intended to allow certain veterans on waiting lists and in rural areas to choose taxpayer-paid care from private doctors outside the department’s health system.
“Something has to give,” the department’s deputy secretary, Sloan D. Gibson, said in an interview. “We can’t leave this as the status quo. We are not meeting the needs of veterans, and veterans are signaling that to us by coming in for additional care, and we can’t deliver it as timely as we want to.”
Since the waiting-list scandal broke last year, the department has broadly expanded access to care. Its doctors and nurses have handled 2.7 million more appointments than in any previous year, while authorizing 900,000 additional patients to see outside physicians. In all, agency officials say, they have increased capacity by more than seven million patient visits per year — double what they originally thought they needed to fix shortcomings.
But what was not foreseen, department leaders say, was just how much physician workloads and demand from veterans would continue to soar — by one-fifth, in fact, at some major veterans hospitals over just the past year.
According to internal department budget documents obtained by The New York Times, physician workloads — as measured by an internal metric known as “relative value units” — grew by 21 percent at hospitals and clinics in the region that includes Alabama, Georgia and South Carolina; by 20 percent in the Southern California and southern Nevada regions; and by 18 percent in North Carolina and Virginia. And by the same measure, physician care purchased for patients treated outside the department grew by 50 percent in the region encompassing Pennsylvania and by 36 percent in the region that includes Michigan and Indiana.
Those data include multiple appointments by individual patients and reflect the fact that patients typically now schedule more appointments than they did in the past. But even measured by the number of individuals being treated, the figures are soaring in many places: From 2012 to 2014, for example, the number of patients receiving treatment grew by 18 percent at the Las Vegas medical center; by 16 percent in Hampton, Va.; and by 13 percent in Fayetteville, N.C., and Portland, Ore.
Mr. Gibson said in the interview that officials had been stunned by the number of new patients seeking treatment even as the V.A. had increased its capacity. He said he was frustrated that the agency was running short of funds. “We have been pushing to accelerate access to care for veterans, but where we now find ourselves is that if we don’t do something different we’re going to be $2.7 billion short,” he said.
He said he planned to tell Congress this week that the agency needed to be able to shift funds around to avoid a crisis this fiscal year. That includes using funds from a new program that was a priority for congressional Republicans called the “Choice Card,” which allows certain veterans to obtain taxpayer-funded care from private doctors. That money would be used to pay for hepatitis C treatments and other care from outside doctors.
Anthem reveals $54-billion bid for Cigna after merger talks break down
By CHAD TERHUNE
althcare giant Anthem Inc. stepped up its pursuit of rival Cigna Corp. with a $54-billion takeover bid amid an industrywide merger frenzy that could dramatically reshape the insurance market.
Anthem, the nation's second-largest health insurer, said Saturday it had offered $184 a share for Cigna in cash and stock, or $54 billion, including debt. But Anthem expressed frustration that talks had broken down in recent days over the future role of Cigna’s chief executive.
The public move by Anthem caps weeks of speculation about a flurry of potential mega-mergers among the industry's biggest players. It’s possible another suitor could vie for Cigna, based in Bloomfield, Conn.
Anthem said its combination with Cigna would have $115 billion in annual revenue and serve 53 million members. That would make it bigger than industry leader UnitedHealth Group Inc. in terms of membership.
Cigna has been pursuing a deal of its own for Humana Inc., which is prized for its strong Medicare Advantage business. Meanwhile, UnitedHealth has approached the third-largest company, Aetna Inc., about a merger.
The companies are looking to bulk up to better take advantage of rising revenues from the Affordable Care Act and the growing privatization of Medicare and Medicaid.
The sector has benefited from the health law's expansion of subsidized, private coverage and Medicaid, the joint state-federal insurance program for the poor.
But expanding membership and revenue haven’t translated to bigger profits for much of the industry. Health insurers are hoping consolidation enables them to squeeze out more costs and negotiate better prices with hospitals, doctors and drugmakers.
Many health experts worry those savings won’t be passed along to employers and consumers. These deals might also run into antitrust scrutiny from federal officials worried about reduced competition.
Saturday, Anthem expressed confidence that its proposed merger could satisfy regulators and help drive down healthcare costs.
By going public with its offer, Anthem is trying to pressure Cigna to drop its demands concerning top management and reach an agreement. Anthem said its offer represented a 35% premium to Cigna's closing price on May 28, when deal rumors sent many health insurance stocks soaring.
Anthem said it has been exploring a deal for Cigna since August. This month alone, it submitted four different bids, starting at $174 a share and raising it to $184 now.
But a big sticking point appears to be a future role for Cigna Chief Executive David Cordani.
Anthem Chief Executive Joseph Swedish said he would serve as chief executive of the combined company for two years. Cordani would be his No. 2 as president and chief operating officer.
After that period, Cordani would be a candidate for the top job — but nothing is guaranteed, according to Anthem.
“We were stunned that the Cigna board continues to insist on a guaranteed CEO position for Mr. Cordani over choosing to allow its stockholders to realize the significant premium being offered,” Swedish said in a letter to Cigna's board Saturday.
“With the cooperation of Cigna management and board of directors, we expect that we could reach a mutually agreeable and negotiated transaction by the end of June,” Swedish added.
A Cigna spokesman declined to comment Saturday.
Anthem sells Blue Cross plans in California and 13 other states. It also has a big Medicaid managed-care business in many states.
States Take Few Steps to Fill Gap if Supreme Court Blocks Health Subsidies
WASHINGTON — As the Supreme Court prepares to rule on whether to block health insurance subsidies in 34 states that use the federal insurance exchange, Pennsylvania and Delaware are the best prepared. They have submitted detailed plans for creating their own exchanges by next year, a move intended to keep subsidies flowing to their residents, though possibly with an interruption.
Mississippi’s insurance commissioner, Mike Chaney, says he has a tentative plan for establishing a state exchange, but federal officials would have to loosen the rules. In Illinois, the state hospital association laid out options for quickly establishing an exchange in a blunt memo to Gov. Bruce Rauner and state legislators this month.
But in the vast majority of states that rely on the federal exchange, HealthCare.gov, there is little or no evidence that anyone has a plan to preserve the subsidies that help more than six million residents of those states afford their insurance premiums. Most of the affected states have Republican governors, and many, including Scott Walker of Wisconsin, Rick Scott of Florida and Dennis Daugaard of South Dakota, insist it is Congress’s job to come up with a remedy if the subsidies disappear.
Michael O. Leavitt, who was secretary of health and human services under President George W. Bush, tried to nudge more federal exchange states into action in a letter to their governors and legislators last week.
“They’re not scrambling as of yet over this,” Mr. Leavitt said. “But when the force of millions of people who are going to have their insurance affected begins to influence this debate, it’s going to look different to those who are feeling the pressure. And I think it will be the governors.”
The case before the Supreme Court, King v. Burwell, focuses on a section of the Affordable Care Act that says subsidies should flow to insurance customers “through an exchange established by the state.” The plaintiffs argue that this language means only people who use state-run exchanges, not the federally run HealthCare.gov, can receive subsidies. At this point, only 13 states and the District of Columbia fully run their own exchanges. Three other states have a “federally supported state exchange” and may also not be affected by the decision.
Health Insurers Brace for Supreme Court Ruling
By REED ABELSON
Their industry already upended with the passage of the federal health care law, insurance companies are facing another upheaval if the Supreme Court rules that millions of Americans are not eligible for subsidies to help defray the cost of their coverage.
The court is expected to decide by the end of June or in early July whether it agrees with the plaintiffs in King v. Burwell that the language in the Affordable Care Act allows the government to offer subsidies only in those states that have established their own insurance marketplaces.
About 6.4 million people who now have insurance could be affected if the court rules with the plaintiffs. Without financial assistance, millions of them would probably drop their policies. And insurers would scramble to rethink the assumptions they made in setting their prices, and even whether to continue selling individual policies at all.
“Anything that impacts who’s signing up creates a lot of risk for the carrier, and lots of uncertainty and challenges in the future,” said David V. Axene, a health actuary in Murrieta, Calif.
How insurers in states without marketplaces would react is unclear, and what they would do depends heavily on the steps taken by individual states, some of which may rush to create them, and whether Congress and the Obama administration can agree on a solution to address the potential loss of coverage and market instability.
“Plans will look at their own markets,” said Alissa Fox, a senior vice president at Blue Cross Blue Shield Association. “They will ultimately make their own decisions.”
The immediate challenge to insurers will be to try to assess what is likely to happen at the state and federal levels. “We’ll want to have answers as soon as possible,” Ms. Fox said. Plans will “want to hear from regulators how to move forward.”
But whatever changes they would need to make to their plans and their prices would take time, she said, noting it has taken years for insurers to become comfortable with selling policies under the health care law, which requires companies to offer coverage to everyone, including people with costly medical conditions, and not charge them higher prices if they are sick.
Medical Insurance Is Good for Financial Health, Too
People who have health insurance have less health-related financial stress. That’s a not-so surprising finding from a recent survey from the Centers for Disease Control and Prevention.
There’s good reason to expect the Affordable Care Act to reduce financial strain. Exposure to health care costs fell for those who gained coverage, as it has for those whose coverage became more generous, too.
But even those families whose health insurance coverage didn’t change may have benefited. In 2013, 32.2 percent of uninsured families had problems paying medical bills, but that dropped to 31.2 percent in 2014. There may have been less need for people to pitch in if their formerly uninsured family members obtained coverage.
Another possibility is that those who obtained coverage may have been in a better position to financially assist family members who still lacked it. This could partly explain why the financial condition of even the uninsured improved after the Affordable Care Act’s coverage expansion. Other factors, like an improving economy, could also help explain the changes.
The C.D.C. looked at data from more than 370,000 people collected through the National Health Interview Survey. It found that in the six months after the introduction of the Affordable Care Act in January 2014, the percentage of people under age 65 who were in families having problems paying medical bills was lower than it had been before — 17.8 percent vs. 19.4 percent in 2013. Smaller reductions in financial strain from medical bills had occurred in prior years, perhaps because of slow improvements in the economy after the end of the Great Recession.
The C.D.C.’s findings are consistent with another recent survey by the Commonwealth Fund, as reported by my colleague Margot Sanger-Katz. It found that the percentage of adults experiencing trouble with a medical bill or medical debt declined to 35 percent in 2014 from 41 percent in 2012.
Coverage expansions that predate the Affordable Care Act were also associated with reductions in health-related financial difficulty. After Oregon expanded its Medicaidprogram by lottery in 2008, out-of-pocket medical expenses exceeding 30 percent of income fell more than 80 percent, according to analysis published in The New England Journal of Medicine.
Posted June 21, 2015, at 11:31 a.m.
The four words “established by the state” could come to mean the difference between affordable health insurance and no insurance to millions of people in the coming days. Those 6.4 million people probably never suspected four words could determine whether they can afford a doctor’s visit and have to put off needed care.
Those four words are the crux of the latest Supreme Court challenge to the federal Affordable Care Act, King v. Burwell, on which the court will rule by the end of this month. A ruling in favor of the plaintiffs would endanger a key mechanism in the sweeping health care law that makes health insurance affordable to millions of Americans.
Those 6.4 million people live in the 34 states, including Maine, that opted not to establish their own online health insurance marketplaces where residents could shop around for the best insurance plan and qualify for federal subsidies to defray the cost. They relied instead on HealthCare.gov — a system that mostly worked well once the federal website overcame its disastrous 2013 rollout.
They don’t receive health insurance through their jobs or through a government program. They’re low- to middle-income people who required federal assistance in order to bring their monthly premiums down to a manageable level.
They include nearly 61,000 in Maine who depend on that federal assistance to cover, on average, $337 per month of their health insurance premium, or 78 percent of the cost. Their premiums cost them, on average, $97 per month with the assistance factored in. Before the Affordable Care Act, Maine residents who bought from the individual insurance market paid $336 per month on average.
But the King v. Burwell plaintiffs argue that these 61,000 Maine residents and millions of others aren’t eligible for federal help to defray their premiums because of four words. The text of the Affordable Care Act, they argue, makes subsidies available only to people purchasing insurance from a marketplace “established by the state.”
There’s a strong argument to make that the King v. Burwell case should never have been taken seriously as a legal challenge to the Affordable Care Act. It relies on what amounts to a drafting error. It contorts an expansive federal law to mean what Congress clearly never intended. There’s enough context in other parts of the law, supporting analyses and regulations to indicate that those four words never represented Congress’ intent.
Nevertheless, policymakers must plan for a Supreme Court decision that could invalidate 6.4 million people’s assistance.
Such an outcome would likely affect more than just the 6.4 million people who receive subsidies. It could destabilize the individual insurance market in those 34 states without insurance exchanges. The Urban Institute has projected a negative ruling could force 8.2 million to join the ranks of the uninsured next year and force individual market premiums up 35 percent in those 34 states as millions of healthy people leave an insurance market rendered unaffordable. In other words, much of the Affordable Care Act — designed deliberately, with each element depending on another — could come tumbling down, likely the plaintiffs’ intent.
In Maine, lawmakers are advancing a bill, LD 1344, that would have the state establish its own health insurance marketplace if the Supreme Court issues a negative ruling. It has bipartisan support, but it’s sponsored by a Democrat, Rep. Linda Sanborn of Gorham, meaning Gov. Paul LePage would likely veto it. If that happens, lawmakers should override the veto.
In Congress, Republicans have proposed a range of contingency plans that leave subsidies in place in one form or another until the politically convenient date of 2017. After that, those Republican bills start to put in place inferior Obamacare alternatives that don’t guarantee comparable coverage with comparable protections. Congress, of course, could opt for a simple fix and strike the four relevant words from the law, but that’s unlikely in a Republican-controlled House and Senate.
The best outcome would be a Supreme Court finding that the words “established by the state” don’t derail a carefully constructed law that has, for the first time, brought meaningful insurance coverage to millions who didn’t previously have it, taken important steps to start reining in the cost of health care and lowered budget deficits.
Precarious future for primary care
By Karen D. Brown GLOBE CORRESPONDENT
SPRINGFIELD — Dr. Katie Jobbins rested her forehead in her hand, tapping her fingers rapidly as she waited for a crisis counselor on the other end of the phone to pick up. It was a busy spring day at the clinic on High Street, and one of Jobbins’s regular patients needed help.
“I have a patient . . . who is actively suicidal and homicidal, who I’m going to send to the ER,” she said urgently into the phone. As nurses buzzed around, Jobbins searched for the right admission forms.
Jobbins was frustrated. For a year, she’d been treating this patient for depression and thought they had made progress. Still, she was relieved the patient knew to seek her help.
At 30, Jobbins is new to front-line medicine, and is still deciding whether to stick it out. She was among nine junior doctors at Baystate Medical Center training in primary care at a time when young doctors are more drawn to lucrative specialties than life as a family doctor. The Association of American Medical Colleges predicts a shortage of 45,000 primary care doctors by 2020.
The consequences hit everyone. As veteran doctors leave primary care faster than they can be replaced, waiting times for appointments stretch longer, and coordination of care becomes more haphazard.
“If you get people before medical school and even at the beginning of medical school, there’s a huge interest in primary care,” Baystate residency director Dr. Michael Rosenblum said. “And then we see that kind of peter off.”
Rosenblum was delighted when the Affordable Care Act included money for new residency programs in primary care — including about 500 new residency slots each year nationally and training programs at community health centers. He considered it an opportunity to immerse young doctors in primary care, rather than just give them a taste of it while on multiple rotations.
With that investment, Baystate Medical Center, affiliated with Tufts University School of Medicine, launched its primary care residency program in 2011.
But most of the federal money for primary care training runs out later this year, even as the exodus from the field continues. Fewer than one-third of doctors in the United States today work in primary care, and that number is slipping, according to Dr. Fitzhugh Mullan, a George Washington University policy researcher.
That leaves educators redoubling their efforts to win over medical students before the system’s incentives pull them another way.
Supreme Court Ruling on Health Law Will Shape Obama’s Legacy
WASHINGTON — The night his administration’s Affordable Care Act passed in 2010, President Obamadescribed the victory the way he hopes historians will: as a “stone firmly laid in the foundation of the American dream.”
But Mr. Obama’s prospects for a legacy of expanding health care coverage in the United States for generations have never seemed as uncertain as they do today. The Supreme Court is expected to rule by the end of the month on a critical provision of the Affordable Care Act — insurance subsidies for millions of Americans — and even Mr. Obama’s closest allies say that a decision to invalidate the subsidies would mean years of logistical and political chaos.
“Will that have, in the history books, an impact on the president?” said Kathleen Sebelius, who as secretary of health and human services led the fight in Congress to pass the health care law. “I’m sure. I know Republicans like to focus on how this would be a great blow to the president. But for heaven’s sake, they would have a mess on their hands.”
Fewer Poor Uninsured, Study Finds in Health Law
WASHINGTON — The share of poor Americans who were uninsured declined substantially in 2014, according to the first full year of federal data since the Affordable Care Act extended coverage to millions of Americans last year.
The drop was largely in line with earlier findings by private polling companies such as Gallup, but was significant because of its source — the National Health Interview Survey, a long-running federal survey considered to be a gold standard by researchers. The findings are being released on Tuesday.
The survey also registered a sharp decline in the share of black Americans who were uninsured, which fell by nearly a third to 13.5 percent from 18.9 percent in 2013. That was the largest annual change for any racial or ethnic group since the survey began in 1997.
The survey shows the impact the law has had as a far-reaching ruling on it by the Supreme Court nears. If the court rules against the government, it would have the effect of eliminating a large share of the subsidies that have enabled many lower-income people to afford health insurance.
The gains were particularly significant for poor Americans in part because a larger share of them lacked health insurance to begin with. But the poor also benefited from the subsidies, and from a vast expansion of Medicaid, the government insurance program for the poor. More than 20 states refused to expand the program, and many experts said the gains would have been even larger had they done so.
While black Americans under the age of 65 made the biggest gains, Hispanics in the same age group also benefited substantially, with the share of uninsured dropping by nearly 17 percent from 2013 to 25.2 percent. The share of whites who were uninsured fell to 9.8 percent, down from 12.1 percent in 2013.
“The law has had a more pronounced effect in covering African-Americans than whites,” said Larry Levitt, a director at the Program for the Study of Health Reform and Private Insurance at the Kaiser Family Foundation, a health research organization. He said part of the reason was that blacks were more likely to be poor, and the law specifically targeted poor Americans for help with coverage. “If all states were expanding Medicaid, you’d see an even bigger effect.”
Blood Pressure, the Mystery Number
By GINA KOLATA
Almost half a century after rigorous studies showed medicines that lower blood pressure prevent heart attacks, strokes and deaths, researchers still do not know just how low blood pressure should go. More than 58 million Americans take these drugs, but this fundamental question remains unresolved.
“We all know treating hypertension is good, but we don’t know how aggressive we should be,” said Dr. Michael Lauer, the director of the Division of Cardiovascular Sciences at the National Heart, Lung and Blood Institute.
The institute is seeking definitive answers as part of its mission to drive down deaths from cardiovascular disease, continuing the decades-long plunge in mortality rates from this leading killer.
The results of a large and rigorous study, called Sprint, are expected in 2017. Researchers are following 9,000 middle-age and older adults with high blood pressure. Half were randomly assigned to get their systolic pressure — the top number that measures pressure when the heart contracts — to below 120 while the others were to get to below 140. The study will measure not just heart attacks, strokes and kidney disease, but also effects on the brain. Do people think better and avoid dementiawith lower pressure?
In the meantime, doctors are making decisions in a fog of uncertainty.
What about a patient like Glenn Lorenzen, 67, whose systolic pressure was a frightening 220 in October? On a chilly day in December at the cardiovascular clinic at the Boston Veterans Affairs hospital, he had received the good news that drugs and weight loss had lowered his reading to 124. Should he be happy? Should he aim to be below 120? Or should he ease up on the medications a bit and let his pressure drift toward 140 or even 150?
Putting Stents to the Test
By GINA KOLATA
Millions of Americans have had stents — small wire cages — inserted in their coronary arteries to prop them open. And many are convinced the devices are protecting them from heart attacks. After all, a partly blocked artery is now cleared, and the pain in a heart muscle starved of blood often vanishes once the artery is open again.
But while stents unquestionably save lives of patients in the throes of a heart attack or a threatened heart attack, there is no convincing evidence that stents reduce heart attack risk for people suffering from the chest pains known as stable angina. These are people who feel tightness or discomfort walking up a hill, for example, because a partly blocked coronary artery is depriving their heart of blood. But the pain or tightness goes away if they stop and rest or just stay still. And there is a reasonable argument that drugs — cholesterol-lowering statins in particular — might be just as good at reducing such pain.
“It is kind of amazing that we don’t have the evidence,” said Dr. David J. Maron, the director of preventive cardiology at Stanford.
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