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Wednesday, January 20, 2016

Health Care Reform Articles - January 20, 2016

Sanders' Medicare-for-All Plan Takes Aim at For-Profit Healthcare System

It is 'time for our country to join every other major industrialized nation on Earth and guarantee health care to all citizens as a right, not a privilege.'
by
Deirdre Fulton
Just before Sunday's Democratic primary debate in South Carolina, Bernie Sanders released the details of his Medicare-for-All universal healthcare proposal, saying it is "time for our country to join every other major industrialized nation on Earth and guarantee health care to all citizens as a right, not a privilege."
The plan (pdf), also known as single-payer healthcare, builds on the successes of both Medicare and the Affordable Care Act (ACA), "eliminating expensive and wasteful private health insurance," and saving taxpayers money by "dramatically reducing overall health care costs and bringing down skyrocketing prescription drug prices which are far greater in the United States than in any other country."
According to the Sanders campaign:
The shift to universal health care would be paid for with a 2.2 percent health care premium (calculated under the rules for federal income taxes); a 6.2 percent health care payroll tax paid by employers; an estate tax on the wealthiest Americans and changes in the tax code to make federal income tax rates more progressive.
Under the plan, individuals making $250,000 to $500,000 a year would be taxed at a rate of 37 percent. The top rate, 52 percent, would apply to those earning $10 million or more a year, a category that in 2013 included only the 13,000 wealthiest households in the United States.
An academic analysis (pdf) released alongside the proposal shows that it would save $6 trillion over the next 10 years compared to the current system."The net savings from single payer come from reduced spending on administrative activities, in both private insurers and providers’ offices, reduced spending on monopoly prices for pharmaceuticals and medical devices, and a slowdown in the growth of spending because of controls on administrative costs and drug prices," University of Massachusetts Amherst economics professor Gerald Friedman states in the analysis.
Friedman's calculations show that the typical family earning $50,000 a year would save nearly $6,000 annually in health care costs. "The average working family now pays $4,955 in premiums for private insurance and spends another $1,318 on deductibles for care that isn’t covered," the campaign said in a statement. "Under Sanders' plan, a family of four earning $50,000 would pay just $466 per year to the Medicare-for-all program."
Heralding his plan during Sunday's debate, Sanders "spoke to Democratic heroes and liberal values," Paul Waldman wrote at the Washington Post.
"What a Medicare-for-all program does is finally provide in this country health care for every man, woman and child as a right," Sanders said. "Now, the truth is, that Frank Delano Roosevelt, Harry Truman, do you know what they believed in? They believed that health care should be available to all of our people."

Dems Debate Moves Healthcare to Center Stage

Sanders: 'Healthcare is a right'

by Joyce Frieden

The Democratic presidential candidates sparred over their differing visions of healthcare reform Sunday night at a candidates' debate in Charleston.
"The Democratic party in the U.S. worked since Harry Truman to get the Affordable Care Act (ACA) passed," said former Secretary of State Hillary Clinton. "We finally have a path to universal healthcare; we've accomplished so much already. I don't want to see the Republicans repeal it and I don't want to see us start over again with a contentious debate. I want to defend and build on the ACA and improve it."
Sen. Bernie Sanders (I-Vt.) disagreed. Repeatedly calling healthcare "a right," Sanders also had an alternate view of history: "[President Franklin Delano] Roosevelt and [President Harry] Truman, they believed healthcare should be available to all our people," he said at the debate, which was sponsored by the Congressional Black Caucus Institute and broadcast on NBC and YouTube.
"I was on the committee that wrote the Affordable Care Act ... I voted for it. But right now, what we have to deal with is the fact that 29 million still have no health insurance ... What my 'Medicare for all' program does is finally provide healthcare for every man, woman, and child as a right ... We're not going to tear up the ACA, but are going to move on top of that to a 'Medicare for all' system."
Former Maryland governor Martin O'Malley used a different tack. "We should talk about things that are actually working," he said. "In our state we moved to an all-payer system; we now have moved all of our acute care hospitals away from fee-for-service and pay them based on how well they keep patients out of the hospital. We need to build on the Affordable Care Act, do things that work, and reduce costs and increase access."
Clinton piggybacked on that answer. "What Governor O'Malley just said is one of the models we'll be looking at," she said. "We do [want to] limit a lot of the unnecessary costs we still have in the system. But to start over again with a whole new debate I think would set us back."
Debate moderator Andrea Mitchell of NBC asked Sanders about the cost of his "Medicare for all" proposal, noting that Sanders' own state of Vermont tried to implement a single-payer system but later backed away because it would require tax increases. Sanders declined to engage in the discussion, saying instead, "You might want to ask the governor of the state of Vermont why he could not do it -- I'm the senator from the state of Vermont."
Sanders then took the opportunity to talk about what he considered the real reason why the U.S. doesn't yet have a single-payer system.
"You know why we can't do what every other major country on earth is doing? Because we have a campaign finance system that's corrupt; we have SuperPACs, we have the pharmaceutical industry pouring hundreds of millions of dollars into campaign contributions and lobbying, and the private insurance companies as well ... This is about whether we have the guts to stand up to the private insurance companies and all of their money, and to the pharmaceutical industry as well."
The war on drugs -- and the drug abuse that's fueling it -- also was a topic during the debate. "I have tried to come out with a comprehensive approach that does tell states, 'We will work with you from the federal government, putting more money -- about $1 billion a year -- to help states have a different approach to dealing with this epidemic,'" said Clinton.
"Police officers must be equipped with [the overdose reversal drug] narcan and should be able to administer it ... We have to move away from treating the use of drugs as a crime and move it to where it belongs, as a health issue. And we need to divert more people from the criminal justice system into drug courts, into treatment, and recovery."
Sanders agreed with Clinton, but added," It is a responsibility of the part of the pharmaceutical industry and the drug companies producing all of these drugs and not looking at the consequences of it. We need a revolution in this country in terms of mental health treatment. People should be able to get the treatment they need when they need it and not 2 months from now, which is why I believe in universal healthcare."
Healthcare became an issue even before the debate started; earlier on Sunday, Sanders released financing details of his "Medicare for all" plan.
The plan would be paid for by increasing taxes for all Americans, especially the wealthy, according to a press release posted on Sanders' website. "Sanders' Medicare-for-all plan would save $6 trillion over the next 10 years compared to the current system, according to a detailed analysis by Gerald Friedman, an economist at University of Massachusetts at Amherst who is a leading expert on health care costs."
The plan would be paid for by a 6.2% tax on employers and a 2.2% income tax on U.S. households, based on their income. Marginal tax rates would also increase -- for example, families with incomes between $250,000 and $500,000 would have a marginal tax rate of 37%, a few percent more than what they currently pay, while those with incomes of more than $10 million -- a group which includes 0.01% of taxpayers -- would have a marginal tax rate of 52%, up from their current 39.6%.
last updated 

For Now, Bernie Sanders’s Health Plan Is More of a Tax Plan

by Margot Sanger-Katz
If you read the news articles over the weekend about Senator Bernie Sanders’s new single-payer health reform plan, you might have thought you were reading about tax policy, not health care.
That’s because the plan, released two hours before Sunday night’s Democratic debate, was full of details about the taxes that would be collected to finance it. The plan would charge a special income tax, called a premium, increase payroll taxes and raise a variety of taxes on high-income Americans, including income and capital gains taxes. Those are big, specific changes, worthy of detailed coverage.
Missing, however, were more than a few sentences about how the proposal would change the health care system in the United States.
Mr. Sanders wants what is called a single-payer program, a major change to our current system. The health care policy described by his white paper would replace all health insurance programs in the United States with coverage for everyone in the country provided by the federal government, the single payer. Large, new categories of services would be covered, including dental and nursing home care. It would eliminate co-payments and deductibles.
Mr. Sanders has branded the program as “Medicare for all.” But the program he describes isn’t an extension of the existing Medicare program, which provides health insurance for older people and the disabled. Medicare includes premiums, co-payments and deductibles, and excludes coverage for long-term care or dentistry.
A lot of important details have been left out. Here are some things it doesn’t say: What would the new system pay doctors and hospitals for their services? How would it decide which medical treatments it should and shouldn’t cover? What strategies would it use to contain health care costs and keep the system affordable? Who would make the decisions, big and small, about how the program would work?
I spoke with Gerald Friedman, a professor of economics at the University of Massachusetts at Amherst, who provided the campaign with estimates of the program’s cost. Mr. Friedman sent detailed tables explaining his calculations. He assumes that spending in some categories of health care would go up, as more Americans can afford access. Others, he said, would drop because the single-payer system would give the federal government improved bargaining power and lower administrative costs. On balance, he estimates that the single-payer system would cost the country less over time than the existing health care system.
Mr. Friedman calculates, for example, that the cost of physician services in a single-payer system could be lowered by 10.7 percent — his estimate of how much doctors currently spend on billing and administration staff that they would no longer need. I asked him how the payer would get to that number — would the government pay lower prices for treatments, or change which treatments it paid for, or switch doctors to a system in which they earn government salaries?
He couldn’t say with certainty. “The pleasure of being an academic is I can just spell things out and leave the details to others,” he said. “The details very quickly get very messy.”
That doesn’t preclude a single-payer system that could be devised to hit the estimates provided by the campaign. Many other countries run single-payer health care systems that provide more health care coverage than the United States while costing far less. Mr. Friedman’s estimates don’t suggest that the United States could cut its health care bill in half, making it similar in size to the French system. He instead finds more modest savings that could come from lowered administrative costs and better prices on prescription drugs.
But the absence of the “very messy” details in the Sanders plan is telling. He wants to make major reforms to the health care system, and those changes will come with costs and uncertainties. Enacting his plan could make health care more affordable and less complicated for many Americans, especially those earning low incomes. But it would require wrenching, disruptive change. As Hillary Clinton and her surrogates have noted, the plan would involve eliminating Medicaid and the Children’s Health Insurance Program. It would also eliminate Obamacare marketplaces and the private health insurance that most American receive from their employers. Despite its name, it would make substantial changes to Medicare.


Mr. Sanders needs to come clean about the funding for his health-care plan

Washington Post Editorial Board
PREVIOUSLY A non-starter in American politics, democratic socialism is gaining traction due to the presidential campaign of Vermont Sen. Bernie Sanders, a nominal independent running as a Democrat. If Mr. Sanders is to close the sale with voters, he must show he has learned from socialism’s mixed history abroad and devised an updated version that will work in the United States. Judging by the sketchy single-payer health-care plan he unveiled just before Sunday’s Democratic debate, Mr. Sanders is not up to the challenge. 
He would replace existing federal health programs, as well as employer-paid group plans and the individual insurance market just expanded by Obamacare, with one big program, at a 10-year cost of $41 trillion, or $13.8 trillion more than the government would have spent over the next decade under current law. He says the new system would pay for itself, partly, by eliminating the current tax exclusion for employer-paid insurance, along with company profits and administrative overhead — and by fully exploiting the government’s buying power to lower costs. Some $10.7 trillion in new money would have to be raised, through a 2.2 percent premium from households, a 6.2 percent payroll tax and a grab bag of stiff tax increases on upper-income Americans. 
When all is said and done, Mr. Sanders maintains, a typical family of four making $50,000 will save $5,807 per year , and get full medical, dental and vision coverage with no co-payments or deductibles in return: “All you need to do is go to the doctor and show your insurance card.”
Put aside Mr. Sanders’s lack of political realism, or his dubious choice to tap the rich for huge amounts of revenue and spend it all, with nothing left for deficit reduction or the underfunded Social Security program. Mr. Sanders’s fundamental problem is how to prevent the costs of so much coverage expansion from outstripping even the huge overhead savings he claims and the huge new revenue stream he seeks. His plan contains two sentences on cost control; the gist is that government would have the power to “negotiate fair prices.” But what if those prices are not high enough to support the current level of infrastructure and services and some hospitals have to close? Mr. Sanders promises patients “no more fighting with insurance companies” about who and what to cover, and he’s probably right; those fights would move to Congress and the bureaucracy.
Health-care costs have been moderating in recent years, a fact the Sanders plan relies on to balance its books. However, a major reason for that cost containment has been the rise of high-deductible plans of precisely the kind Mr. Sanders wants to eliminate; cost-sharing encourages people to avoid unnecessary tests and other wasteful expenses. Branded, misleadingly, “Medicare for All,” the Sanders plan is actually unlike the existing Medicare for retirees, which has significant cost-sharing — but no coverage for routine vision or dental care.
Single-payer systems do indeed have some of the advantages Mr. Sanders touts for his plan — separating employment from insurance being one of them. Yet they all require an authority to tell patients they can’t have everything they want when they want it — just as private insurers must sometimes do in the United States. Honest proponents of the single-payer system level with the public about that. So far, Mr. Sanders has not.



The dream of Medicare for all: Here's why the Sanders health plan is more hope than change

by Michael Hiltzig - LA Times

Otto von Bismarck's famous definition of politics as "the art of the possible" gives us a good assessment of the single-payer health proposal unveiled by Democratic presidential candidate Bernie Sanders on Sunday: impossible.  
That's not to say that the "Medicare for All" plan offered by Sen. Sanders (I-Vt.) is worthless. Quite the contrary. As an aspirational document it serves the valuable purpose of placing single-payer healthcare firmly in the forefront of our political debate. A single-payer system like the one Sanders envisioned is impossible today in part because it's routinely dismissed as impossible. By making the proposal a centerpiece of his Democratic primary campaign, Sanders has begun the process of stripping single-payer of its image as a pipe dream.
But it's only a start, and a halting one at best, because Sanders isn't candid about the reasons single-payer is a difficult goal for American reformers today or about the immense difficulties of managing a single-payer system even if it could be enacted. These difficulties aren't solely the result of profiteering by insurance companies or opposition from vested interests, as Sanders implies. They also arise from Americans' deeply held thoughts about healthcare rights and political goals, and from the political structure that exists today. As Larry Levitt of the Kaiser Family Foundation remarked on Twitter, "It's very hard to analyze Sen. Sanders' health plan, because you have to imagine a political environment in which it could actually pass."
Before examining a few examples, let's outline the Sanders plan. His federally administered program would "cover the entire continuum of health care, from inpatient to outpatient care; preventive to emergency care; primary care to specialty care," plus vision, hearing, and oral care and prescription drugs. Patients would show their Medicare card to the doctor of their choice -- no more networks -- and receive treatment with no more deductibles or co-pays. "No more fighting with insurance companies when they fail to pay for charges," the Sanders plan says.
Sanders attributes the high cost of healthcare in the U.S. to two main features: the role of private insurers and the inability of government agencies to negotiate prices, especially with pharmaceutical companies. He would eliminate both obstacles to cost control, saving $6 trillion over 10 years, compared to the current system. The annual healthcare costs for a sample family of four with $50,000 in household income would fall to $466 a year from nearly $6,300 in current premiums and deductibles.
The program would cost $1.38 trillion a year, financed by converting today's flow of premiums, co-pays, and tax breaks into an employer tax of 6.2%, household tax of 2.2%, higher income taxes on income of $250,000 and above and on capital gains and dividends, and the elimination of tax breaks for the rich.
Obviously the political obstacles to these financial arrangements alone would be massive. Sanders' typical $50,000 family is right at the median of U.S. income, but the half of all taxpayers who earn more have a disproportionate political voice, and they won't like this. Even if the higher taxes make up for premiums and other outlays dollar-for-dollar (and it's not clear they would), the Sanders plan shifts the responsibility for paying for healthcare sharply upward on the income scale. Raising taxes on the wealthy is a superhuman feat. 
Does Sanders really intend to cover every conceivable treatment sought by American patients, as his plan implies? That's a formula for an explosion in healthcare spending, with little indication it will lead to better health. 
To at least a certain extent, insurers rejecting claims or treatments impose a limit on rising costs by demanding some evidence of cost-effectiveness. It's an imperfect process, certainly, and hard to distinguish from mere profit-seeking, but it would have to be replaced by a government-administered version.
Americans almost certainly aren't prepared to have the government rather than insurance companies saying "no." In countries such as Britain, an entire bureaucracy, known as the National Institute for Health and Care Excellence, or NICE, exists to set limits on spending, rejecting treatments judged to be not worth the money. The process isn't always pretty and often politically charged.
Telling cancer or cardiac sufferers that they can't have a supposed wonder drug because it won't extend their lives by enough per dollar of cost will be difficult enough. What about areas where medical policy conflicts with religious or moral scruples? As healthcare policy expert Harold Pollack wrote last year, "Imagine the national policy debate over abortion, contraception, HIV prevention, immigration policy, and other matters in a national Medicare plan."
Pollack points to myriad other disruptions that would make healthcare even more of a political football than it is today. "We would require new care models for complex patients," he observed. "We would face the economic, organizational, and human challenges of end-of-life care. We would make difficult decisions about network adequacy and patient cost sharing and face difficult questions in designing essential health benefit provisions for autism, substance use disorders, and cancer. ... We would face our society’s tenuous commitment to the well-being of our most disadvantaged citizens."
Every  major government reform produces winners and losers. That would be true in the healthcare transformation envisioned by Sanders. The losers would be health insurers; doctors, hospitals and drugmakers facing government price-cutting; and employees with company health plans subsidized by tax breaks. They would be richer and far better organized than the winners, who would include middle- and working-class families.
These are among the realities that killed healthcare reform campaigns going as far back as the Truman administration and animate the continued attacks on the Affordable Care Act. For years, U.S. politicians have nurtured an anti-government mood among voters; that mood was exploited by well-financed and well-organized opponents of a California single-payer initiative in 1994, resulting in its overwhelming defeat -- and it has only become more intense.
There's no question that single-payer is "the only logical solution" to America's fractured healthcare system, as the late healthcare expert Arnold S. Relman told me in 2013. But he understood that achieving the goal would be "a slow and painful process."
The Affordable Care Act is potentially the first step in that process. But throwing it out and starting over with a single-payer reform, as Sanders proposes, won't work. The result would be no Obamacare and no reform. That's the goal of the ACA's opponents on the right, but while Sanders has a more inclusive and more just goal in mind, his good intentions won't help him achieve it. 
The Affordable Care Act's flaws and inadequacies resulted from the compromises necessary to get it passed at all. What's most striking about the Sanders plan is that he more or less wishes those compromises away or covers them with magic asterisks. But they haven't gone away. Any healthcare reform plan will have to confront them, and Sanders' plan will intensify them. 
Sanders has done a great public service in putting single-payer up for debate in the heat of a Presidential campaign. But his plan evokes the other part of Bismarck's adage, which is that politics is also "the art of the next best." At this stage in the maturity of America's debate on healthcare reform, the Affordable Care Act is the next best thing to single-payer. It may be years before the next step can happen.


Democrats’ more likely success: Maximizing Obamacare, not Medicare for all

Editorial - Bangor Daily News

Think of medical care without the worry your doctor won’t accept your insurance because she isn’t in the insurance company’s network of providers. Think of not having to worry about losing your health insurance if you ever lose your job. As an employer, think of the prospect of not having to pay ever-increasing and unpredictable premiums to maintain health insurance for your employees. And imagine the end of a confusing web of existing coverage options, which differ depending on the state where you live, your income, your age and your employment status.
It’s all theoretically possible. And if designed right, a single-payer health care system could drastically reduce the bureaucratic inefficiency of the current system and rein in health care costs through the government’s effective use of its buying power.
But is it realistic?
That’s at the heart of a debate right now, as former Secretary of State Hillary Clinton and Vermont Sen. Bernie Sanders compete for the Democratic presidential nomination. Should Democrats be content to fight to maintain the integrity of Affordable Care Act and improve upon the most significant health care legislation in a generation? Or should they keep their eye on what is the ultimate prize for many in their party: universal, single-payer health care?
As New York Times columnist Paul Krugman recently pointed out, the Affordable Care Act is a “kludge.” It’s “a somewhat awkward, clumsy device with lots of moving parts. This makes it more expensive than it should be, and will probably always cause a significant number of people to fall through the cracks,” he writes.
The Affordable Care Act is a kludge because American politics made it that way. In order to secure support from the incumbent players who could easily derail any reform — health insurance companies, health care providers, pharmaceutical companies and others — the law’s architects kept them at the heart of the American health care system. They did what they could to produce the most meaningful health care reform they could without rocking the boat too much.
The result is a health insurance mandate (a guaranteed base of customers for health insurers) and a confusing web of health insurance options — basically, a system that covers more people without changing the core of the American system. But the Affordable Care Act represents progress. Just 9.2 percent of Americans lacked health insurance last year, compared with 16 percent in 2010, according to U.S. Centers for Disease Control data released in Augusta.
Still, 29 million people remain uninsured.
The appeal of the single-payer system Sanders is proposing revolves around simplicity — no choosing a plan, no annual enrollment periods, no complicated formulas to determine the size of your health insurance marketplace subsidy, no health provider networks — and its universal nature.
But what’s to prevent Sanders’ “Medicare for all” proposal, which still has many details that need filling in, from becoming a kludge, writes health care expert Harold Pollack on Vox? Say a single-payer proposal becomes even remotely politically realistic. The incumbent players would undoubtedly wield their power in any political debate and extract a result that, undoubtedly, becomes more complicated and costly than the ideal.
Sanders says his single-payer system would be “federally administered,” though he has previously proposed a state-based model. What’s to prevent state officials from clamoring for some measure of influence over the system, either through the legislative process or through the courts? State-by-state variations of a national health care program — reminiscent of some states’ refusal to embrace portions of the Affordable Care Act, such as Medicaid expansion — would further resign it to a kludgy nature.
The result? A system with different benefits for Americans depending on where they live and the willingness of local politicians to carry out the idea of universal, single-payer health care.
Sanders is proposing ideas worth debating — both his health care proposal and the tax changes he has proposed to fund it. But Democrats are more likely to find success in maximizing the effectiveness of Obamacare than in, once again, entirely subjecting health care reform to a legislative process that could derail the progress of the past five years.




Hillary Clinton’s Single-Payer Pivot Greased By Millions in Industry Speech Fees

by Zaid Milani

Hillary Clinton’s sudden attack on Bernie Sanders’ single-payer health care plan is a dramatic break with Democratic Party doctrine that the problem with single-payer is that it is politically implausible — not that it is a bad idea.
Single-payer, the Canadian-style system in which the government pays for universal health care, takes the health insurance industry out of the picture, saving huge amounts of money. But the health insurance industry has become so rich and powerful that it would never let it happen.
That was certainly Clinton’s position back in the early 1990s, when she was developing her doomed universal coverage proposal for her husband, Bill.
But in the ensuing years, both Clintons have taken millions of dollars in speaking fees from the health care industry. According to public disclosures, Hillary Clinton alone, from 2013 to 2015,  made $2,847,000 from 13 paid speeches to the industry.
This means that Clinton brought in almost as much in speech fees from the health care industry as she did from the banking industry. As a matter of perspective, recall that most Americans don’t earn $2.8 million over their lifetimes.

New Guidelines Nudge Doctors to Give Patients Access to Medical Records

By 
WASHINGTON — The Obama administration is tearing down barriers that make it difficult for patients to get access to their own medical records, telling doctors and hospitals that in most cases they must provide copies of these records within 30 days of receiving a request.
In theory, patients have long had a right to obtain copies of their records, but federal officials say they receive large numbers of complaints from consumers frustrated in trying to exercise that right.
In new guidelines, issued this month, the administration says doctors and hospitals cannot require patients to state a reason for requesting their records, and cannot deny access out of a general concern that patients might be upset by the information.
“Based on recent studies and our own enforcement experience, far too often individuals face obstacles to accessing their health information,” said Jocelyn Samuels, the director of the Office for Civil Rights at the Department of Health and Human Services, which enforces federal health privacy standards. “This must change.”
When patients can see their medical records, the administration said, it is easier for them to participate in their health care. They can, for example, review what they were told by their doctors and, perhaps, consider other options for care.
Christopher S. Moore of Alpharetta, Ga., said he had great difficulty obtaining hospital records for his 4-year-old son, Oliver, who has a rare genetic disorder and has seen at least eight medical specialists in Atlanta, Cincinnati and Boston.
“The hospital in Atlanta was very slow to respond,” Mr. Moore said. “We had to escalate our request to the hospital leadership to get the records.”
Mr. Moore said insurers had spent $800,000 on care for his son, generating several thousand pages of medical records.
“Some doctors seem to believe that medical records are intended only for doctor-to-doctor communication, and that patients would not understand those records,” Mr. Moore said. “We want the records so we have control over them — so we can provide them to any doctor who sees our son.”
Under the new guidelines, a health care provider cannot require patients to pick up their records in person if they ask that the records be sent by mail or email. A health care provider cannot deny a request for access to health information because a patient has failed to pay medical bills. A doctor or a hospital may charge a fee to cover the cost of copying, but cannot charge for the cost of searching for data and retrieving it.
Dr. Francis S. Collins, the director of the National Institutes of Health, said consumers needed access to their records so they could “take more control over decisions regarding their health,” follow treatment plans and correct errors in the files.
In addition, Dr. Collins said, some people want access to their records so they can contribute information to biomedical research projects like President Obama’s “precision medicine” initiative.
Researchers working on the project will collect data on the health, genetic characteristics and lifestyle habits of a million or more volunteers.
The same rules that protect the privacy of medical records also give patients a right to see a broad array of health information about themselves. The rules were issued under the Health Insurance Portability and Accountability Act of 1996.


Study: Under Obamacare, some people still pay 25 percent of their income on health care

By Michelle Andrews, Kaiser Health News
Posted Jan. 18, 2016,

Even with subsidies to make coverage more affordable, many people who buy health insurance on the marketplaces spend more than 10 percent of their income on premiums, deductibles and other out-of-pocket payments, a recent study found. Among those hit hardest, the researchers said, are people who spend nearly a quarter of their income on health care expenses.
“There’s been a lot of talk about how high deductibles and out-of-pocket costs are in the Affordable Care Act, and a lot of anecdotes about that, and this [study] quantifies that in a more systematic way,” said John Holahan, a fellow at the Urban Institute’s Health Policy Center who co-authored the study.
The study used a model to estimate expected household spending on health insurance premiums and out-of-pocket expenses by individuals and families at different income levels using the marketplaces in 2016.
The analysis incorporated tax credits that are available on a sliding scale to people with incomes between 100 and 400 percent of the federal poverty level ($11,770 to $47,080 for an individual) to help subsidize the cost of premiums. It also included cost-sharing reductions that lower out-of-pocket spending for people with incomes up to 250 percent of the federal poverty level ($29,425 for one person) if they purchase silver plans on the online marketplaces.
Despite the financial assistance provided by the health law, people with modest incomes and average medical expenses have relatively heavy financial burdens for health care, the study found.
For example, among marketplace enrollees with incomes between 300 and 400 percent of poverty ($35,310 to $47,080), half face total spending that’s greater than 14.5 percent of their income, the study found.
For people with significant medical needs, the financial burden can be heavy. Ten percent of people with incomes between 200 and 500 percent of poverty ($23,540 to $58,850) will pay at least 21 percent of their income toward premiums and out-of-pocket costs, the study found.
Older people can get hit especially hard, as the combination of higher premiums based on age and higher out-of-pocket health care costs boosts the total financial burden to 24.5 percent of income for exchange customers age 55 to 64 in the top 10 percent based on spending.
Unless policymakers address the affordability issues, it could deter people from buying coverage, Holahan said. One solution might be to tie premium tax credits to gold rather than silver plans, the researchers suggest. Gold plans provide more generous coverage than silver plans, including lower deductibles, potentially leading to lower out-of-pocket costs. Another option would be to improve the cost-sharing reduction subsidies available to lower income enrollees.
Both options could increase government spending and would need congressional approval, an option that seems unlikely under Republican control.
“Assuming you want the law to work and be broadly acceptable to people, you’re going to have to do some of these things,” Holahan said.


U.S. Toughens Rules for Latecomers Trying to Enroll in Health Care Act

By 
The Obama administration, responding to complaints from insurance companies, announced several steps on Tuesday that will make it harder for consumers to obtain health insurance after the annual open enrollment period.
Insurers say many consumers have belatedly signed up for coverage under the Affordable Care Act when they become sick and need care. Those latecomers drive up costs for people who sign up during the regular open enrollment period, insurers say. Open enrollment ends this year on Jan. 31.
The administration, which had created more than 30 “special enrollment” periods, sent emails to millions of Americans last year urging them to see if they might be eligible to sign up after the annual open enrollment deadline. But, insurers and state officials said, the federal government did little to verify whether late arrivals were eligible.
Kevin J. Counihan, the chief executive of the federal insurance marketplace, said Tuesday that special enrollment periods “are not allowed for people who choose to remain uninsured and then decide they need health insurance when they get sick.”
Mr. Counihan said the administration would eliminate six of the special enrollment periods, including two for certain lawfully present noncitizens who experienced “system errors” and “processing delays” when they used HealthCare.gov. In addition, he said the government would clarify eligibility standards and step up enforcement to prevent abuse of special enrollment periods.
The actions appeared to have several purposes: to motivate consumers to sign up by the Jan. 31 deadline; to prevent an influx of large numbers of sick people into the market in the middle of the year; to persuade insurers to enter or stay in the public insurance marketplace; and to minimize rate increases in 2017 and later years.
Federal officials said nearly 950,000 people used special enrollment periods to get coverage through HealthCare.gov from late February to the end of June 2015. In some cases, insurers said, consumers dropped coverage soon after receiving costly medical services.
The marketplace must be attractive not only to consumers, but also to insurers, Mr. Counihan said. “Building an attractive marketplace starts with establishing a predictable, stable set of rules that help to keep the risk pool balanced,” he said, referring to the mix of healthy and unhealthy customers.
Most of the special enrollment periods will still be available, for example, when people marry, have a baby, lose job-based coverage or become ineligible for coverage under a parent’s health plan at the age of 26.

Insurer Rewards Push Women Toward Mammograms

By HARALD SCHMIDT
A 53-year-old woman on Medicaid in Washington State who has never had a mammogram elects to get one in return for a $15 gift card.
A 35-year-old woman in Florida chooses to get her first mammogram because her insurer, Aetna, offers a $50 payroll check.
In Iowa, a 46-year-old woman who has been getting mammograms every other year opts to get them annually because Wellmark Blue Cross Blue Shield will pay her $50 to do so.
All three of these women have average risk profiles, and none have family members with breast cancer. Who made the right choice?
It’s a trick question. The real question is whether employers and health plans should really be offering incentives to women to get frequent mammograms.
Women hear all the time that “mammography saves lives,” a message the American College of Radiology and various breast cancer charities have been repeating for years. But the advice does not apply to all women — at least it shouldn’t.
Just last week, the United States Preventive Services Task Force again recommended that women at average risk for breast cancer begin getting regular mammograms at age 50, and then every other year until age 74. The American Cancer Society recommends yearly mammography from ages 45 to 54, then screenings every other year afterward.
Other groups hew to still other positions, although all acknowledge that women must be able to choose for themselves when to start. The diversity of opinions is entirely understandable. The data is anything but clear, and that raises tough questions about whether incentives to get screened are appropriate.
We do know that regular screening reduces the chances of dying from breast cancer, but the reduction seems to be small. For all deaths averted, according to the task force, at least twice as many women will have received entirely unnecessary treatment and the anxiety that comes with it.
In truth, estimates of the benefits and harms of screening are all over the map; researchers themselves do not agree on the facts.



Reducing Unnecessary C-Section Births

By 
 
You are about to give birth. Pregnancy has gone smoothly. The birth seems as if it will, too. It’s one baby, in the right position, full term, and you’ve never had a cesarean section — in other words, you’re at low risk for complications.
What’s likely to be the biggest influence on whether you will have a C-section?
• (A) Your personal wishes.
• (B) Your choice of hospital.
• (C) Your baby’s weight.
• (D) Your baby’s heart rate in labor.
• (E) The progress of your labor.
The answer is B. In California, for example, hospitals’ rates for cesarean sections performed in low-risk births range from 11.2 per cent to 68.8 per cent. (pdf) The rest of the factors do influence the decision. But the hospital determines how these factors are treated.
Some hospitals consider very big babies to be automatic C-sections. Some don’t. A pattern on a fetal heart rate monitor might prompt a C-section in one hospital, and a “watch and wait” at another. Doctors’ choices matter, of course, but a hospital can set rules that limit those choices.
“One view is,‘Gosh, this patient’s just not progressing,’” said David Lagrew, an obstetrician who is the chief integration and accountability officer for MemorialCare Health System in Southern California. “’She’s going to have a C-section in a couple of hours anyway, so let’s get it over with. The patient won’t suffer more, and I can go home and I won’t get replaced by someone else.’ Or, you can say, ‘Let’s wait another hour or two.’”
C-sections save lives — when needed. But the enormous variation in rates, with very little variation in outcomes, shows that a great many of them aren’t necessary. In the last 15 years, the rate of C-section has gone up by 50 percent in the United States. According to Jeffrey Ecker, chairman of the American Congress of Obstetricians and Gynecologists’ committee on obstetric practice, that rise “has not been paralleled by any important fall in rates of things like cerebral palsy” — in other words, outcomes that C-sections are often performed to prevent.
C-sections themselves pose some risks to babies, and can create serious complications for mothers, such as hemorrhage, infection and post-partum depression. Having a first baby by C-section leaves a woman with a 90 percent chance that subsequent births will be by C-section as well. And with each C-section, the risk of serious complications rises.



Is It Better to Die in America or in England?


We frequently hear complaints about how people near the end of life are treated in America. Patients are attached to tubes and machines and subjected to too many invasive procedures. Death occurs too frequently in the hospital, rather than at home, where they can be surrounded by loved ones. And it is way too expensive. Each year, the care of dying seniors consumes over 25 percent of Medicare’s expenditures.
Death in America is frequently compared unfavorably with death in other countries, where people may not be as focused on extending life with every possible intervention. As Ian Morrison, the former president of the Institute for the Future, once wrote: “The Scots see death as imminent. Canadians see death as inevitable. And Californians see death as optional.” He added, “Americans and the American health care system are uncomfortable with the inevitability of mortality.”
But is it actually true that end-of-life care in America is more invasive and expensive than in other countries?
Today we published in the Journal of the American Medical Association the first systematic international comparison of end-of-life care for patients dying with cancer. We focused on cancer because, in developed countries, it is the second leading cause of death and the most expensive per patient. The good news is that, despite perceptions, the United States is actually not the worst when it comes to caring for these patients. In fact, on some important measures, we provide the best in end-of-life care.
We found that in 2010, the most recent year with available data, just 22 percent of Americans dying with cancer died in the hospital, a lower rate than in Canada, England, Norway, the Netherlands, Belgium and Germany, the six other nations we studied. (If we include patients dying in skilled nursing facilities, the rate rises but is still under 30 percent.) Similarly, in the last six months of life, Americans spent the fewest days in the hospital, on average about a week and a half, compared with nearly four weeks in some other countries.
In Canada, 52 percent of patients with cancer died in the hospital, and in the last six months of life, nearly 90 percent were admitted to the hospital for an average of around three weeks.
But in other areas, the United States doesn’t look so good. Take admissions to the intensive care unit. In 2010, over 40 percent of Americans dying with cancer were admitted to the I.C.U. in the last six months of life — more than double any of the other countries we studied. On average, Americans dying with cancer spent twice as many days in the I.C.U. as patients from any other country.



How the Epidemic of Drug Overdose
Deaths Ripples Across America

By HAEYOUN PARK and MATTHEW BLOCH
Deaths from drug overdoses have surged in nearly every county across the United States, driven largely by an explosion in addiction to prescription painkillers and heroin.
Some of the largest concentrations of overdose deaths were in Appalachia and the southwest, according to new county-level estimates released by the Centers for Disease Control and Prevention.
The number of these deaths reached a new peak in 2014: 47,055 people, or the equivalent of about 125 Americans every day.
The death rate from drug overdoses is climbing at a much faster pace than other causes of death, jumping to an average of 15 per 100,000 in 2014 from nine per 100,000 in 2003.
The trend is now similar to that of the human immunodeficiency virus, or H.I.V., epidemic in the late 1980s and early 1990s, said Robert Anderson, the C.D.C.’s chief of mortality statistics.
H.I.V. deaths rose in a shorter time frame, but their peak in 1995 is similar to the high point of deaths from drug overdoses reached in 2014, Mr. Anderson said. H.I.V., however, was mainly an urban problem. Drug overdoses cut across rural-urban boundaries.
In fact, death rates from overdoses in rural areas now outpace the rate in large metropolitan areas, which historically had higher rates.
Drugs deaths have skyrocketed in New Hampshire. In 2014, 326 people died from an overdose of an opioid, a class of drugs that includes heroin and fentanyl, a painkiller 100 times as powerful as morphine.
Nationally, opioids were involved in more than 61 percent of deaths from overdoses in 2014. Deaths from heroin overdoses have more than tripled since 2010 and are double the rate of deaths from cocaine.
In New Hampshire, which holds this year’s first presidential primary, residents have repeatedly raised the issue of heroin addiction with visiting candidates.
“No group is immune to it — it is happening in our inner cities, rural and affluent communities,” said Timothy R. Rourke, the chairman of the New Hampshire Governor’s Commission on Alcohol and Drug Abuse.
Most of the deaths from overdose in the state are related to a version of fentanyl. “Dealers will lace heroin with it or sell pure fentanyl with the guise of being heroin,” Mr. Rourke said.
But fentanyl can be deadlier than heroin. It takes much more naloxone, a drug that reverses the effects of an opioid overdose, to revive someone who has overdosed on fentanyl.
Mr. Rourke said that high death rates in New Hampshire were symptomatic of a larger problem: the state is second to last, ahead of Texas, in access to treatment programs. New Hampshire spends $8 per capita on treatment for substance abuse. A state like Connecticut spends twice that amount.
Appalachia has been stricken with overdose deaths for more than a decade, in many ways because of prescription drug addiction among its workers.
West Virginia and neighboring states have many blue collar workers, and “in that group, there’s just a lot of injuries,” said Dr. Carl R. Sullivan III, the director of addiction services at the West Virginia University School of Medicine.
“In the mid-1990s, there was a social movement that said it was unacceptable for patients to have chronic pain, and the pharmaceutical industry pushed the notion that opioids were safe,” he said.
A few years ago, as laws were passed to address the misuse of prescription painkillers, addicts began turning to heroin instead, he said. Because of a lack of workers needed to treat addicts, overdose deaths have continued to afflict the states like West Virginia, which has the highest overdose death rate in the nation.
“Chances of getting treatment in West Virginia is ridiculously small,” Dr. Sullivan said. “We’ve had this uptick in overdose deaths despite enormous public interest in this whole issue.”


Just Saying Yes to the Politics of Drugs

Emma Roller  JAN. 19, 2016


EARLIER this month, former Gov. Jeb Bush of Florida opened up on a subject he had once chided reporters for asking about: his daughter, Noelle, who, he said, “was addicted to drugs.”
In a video released by the campaign, Mr. Bush speaks plainly about his daughter’s struggle, her time in jail and drug court, and her recovery. “I can look in people’s eyes and I know that they’ve gone through the same thing that Columba and I have,” he said, referring to his wife.
Mr. Bush is not the only candidate to share this sort of painful personal experience. Carly Fiorina, the former chief executive of Hewlett-Packard, has spoken out about losing her stepdaughter, Lori Ann Fiorina, to “the demons of addiction” at the age of 35. And Gov. Chris Christie of New Jersey spoke candidly and emotionally about a law school friend who died of a Percocet overdose.
What’s behind this newfound willingness on the candidates’ part to talk about the personal toll of addiction?
New Hampshire, and the sobering statistics on drug overdoses there, is probably part of the answer.
Every day, 44 people in the United States die as a result of overdose on prescription painkillers. Every day, nearly 7,000 people are treated in emergency rooms for abusing painkillers. Overdose deaths have been creeping upward since the beginning of the 21st century — especially deaths from opiate abuse. In New Hampshire, overdose deaths linked to opiate abuse have more than doubled over the past two years.
Ted Gatsas, the Republican mayor of Manchester, N.H., said he had had many opportunities to talk to Republican candidates, including Mr. Bush, Mr. Christie, Donald J. Trump, Senator Rand Paul of Kentucky and Gov. John Kasich of Ohio, about the heroin and prescription-painkiller abuse in his state. He thinks that the overdose problem has been severely underestimated, not just in his city and state, but nationwide.
“I just don’t think anybody, until you put the numbers and talk to them about it, knows that it’s this bad across this country,” he said.
Nearly 50 years into the “war on drugs,” which both Republican and Democratic leaders have waged in various ways, with various disastrous outcomes, drug overdoses reached a record high in 2014. From 2001 to 2014, the United States had more than a threefold increase in deaths from opioid pain relievers, and a sixfold increase in heroin overdoses, according to the National Institutes of Health. During the same period, overdose deaths from prescription drugs like Valium and Klonopin — sedatives called benzodiazepines — increased by five times.
In speaking about their own experiences, Republican candidates are not only allowing themselves to be vulnerable in front of voters, they’re also straying from the just-say-no message of Ronald Reagan, whose legacy includes a tough legislative stance on drugs and drug sentencing. They’re also hoping that voters, especially in early primary states, will empathize.
Grant Smith, a lobbyist with Drug Policy Action, said it was remarkable how much airtime addiction was getting. “If you look over the last two decades, we’ve definitely seen a transformation in how elected officials talk about people who use drugs,” he said. Now there’s more empathy, less scolding. He is glad to see the new rhetoric about addiction, but notes that candidates have become more open about this issue as it has started to take a real toll on largely white communities.
“There’s no question that the shift in who is being impacted by overdose and the attendant harms of drug use to rural and suburban communities has made lawmakers as well as candidates for office more comfortable talking about these issues,” he said. “It’s just that African-American communities have endured high overdose rates for decades, and few lawmakers in Washington cared.”
At a forum at Southern New Hampshire University earlier this month, Governor Kasich spoke with refreshing candor about what some call this “gentrification of addiction.”
“Sometimes I wonder how African-Americans must have felt when drugs were awash in their community and nobody watched,” he said. “Now it’s in our communities, and now all of a sudden we’ve got forums, and God bless us, but think about the struggles that other people had.”

NHS Health Check study estimates 2,500 heart attacks and strokes prevented over 5 years

The first major evaluation of the NHS Health Check in England, led by Queen Mary University of London, finds that the program is effectively identifying people at risk of developing a major cardiovascular incident such as heart attack or stroke
QUEEN MARY, UNIVERSITY OF LONDON
The first major evaluation of the NHS Health Check in England has found that the programme is effectively identifying people at risk of developing a major cardiovascular incident such as heart attack or stroke, and is estimated over first five years to have prevented 2,500 cases from treatment following the check, as well as helping diagnose commonly linked conditions, including type 2 diabetes, high blood pressure and chronic kidney disease. 
The study, led by Queen Mary University of London, also found that those from the most deprived areas and black and minority ethnic groups, who are at greatest risk of cardiovascular disease, are more likely to attend an NHS Health Check. This makes a positive step towards tackling health inequalities in England. 
The NHS Health Check programme is the first in the world to tackle prevention of heart attacks and strokes by offering a free check to every adult aged 40-74 years. It provides a personal review of the behavioural factors, such as harmful drinking and obesity, that might increase the risk of developing a heart attack or stroke and offers professional advice on lifestyle change and treatment to reduce the risk. It also identifies any new or undiagnosed serious conditions such as hypertension, diabetes and chronic kidney disease. 
The study is based on robust data from 655 GP practices with 1.7 million eligible people in the nationally representative QResearch database. In addition to the 2,500 people avoiding a major cardiovascular incident, the programme has also successfully identified:
  • a new case of hypertension in every 27 appointments;
  • a new case of diabetes in every 110 appointments;
  • a new case of chronic kidney disease in every 265 appointments;
  • 14% of attendees referred to lifestyle interventions due to obesity, smoking, alcohol or blood pressure compared to just 6% of those who were referred through standard care; 
  • Six times more people with high alcohol consumption than those who do not attend, offering brief advice and support.
However, the number of eligible people having an NHS Health Check still needs to increase for the programme to reach its full potential. The most recent annual data from Public Health England shows that about 48 per cent of all eligible people attend when invited. PHE is continuing to work with local authorities to help them deliver the programme more effectively and increase the numbers taking up their NHS Health Check.
The study also shows that there is still room for improvement. The latest evidence suggests the programme is most effective at targeting the older end of the eligible population (those aged over 60) and more work is needed to encourage uptake among the younger age group (aged 40- 60). However, as cardiovascular risk increases with age, this evidence suggests that the programme is effective in identifying and providing an NHS Health Check for those with the highest risk and not just the 'worried well'. 
Study lead Dr John Robson from Queen Mary University of London said: 
"The NHS Health Check programme is the first of its kind anywhere in the world and our study demonstrates a modest but successful start. We estimate that the programme could help identify 44,000 new cases of hypertension, 10,000 new cases of diabetes and 4,500 new cases of kidney disease in England every year. In the first five years of the programme, an estimated 2,500 people were also prevented from having a stroke or heart attack through treatments following their NHS Health Check.


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