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Monday, February 8, 2016

Health Care Reform Articles - February 8, 2016

Everyone Hates Martin Shkreli. Everyone Is Missing the Point

BY 

On Thursday morning, the most reviled person in America arrived on Capitol Hill for a short but memorable engagement with the most reviled institution in America. The institution was the U.S. Congress, which Americans say they hate—though not quite enough, apparently, to stop reëlecting its members. And the person was Martin Shkreli, a pharmaceutical executive who loves to play the villain, and who can’t decide whether to be amused or outraged when he is treated accordingly. Donald Trump can rightly be called polarizing, but Shkreli cannot: he seems to have precious few fans to balance out his innumerable detractors.
Shkreli achieved notoriety when his company, Turing Pharmaceuticals, bought a drug called Daraprim, which is used to treat toxoplasmosis, a disease that can be fatal to H.I.V. patients. After buying the drug, Turing raised its price from less than twenty dollars per tablet to seven hundred and fifty dollars. This was too high, in the judgment of many people who knew the industry, and many more who did not. Experts called the increase “unjustifiable,” while those discussing the situation online used less measured language. Shkreli at first said he would lower the price, which scarcely mollified his critics. (One headline: “Martin Shkreli Lowers Drug Price, Is Still an Asshole.”) Then he said he wouldn’t, which increased the outrage—people were calling him “pharma bro,” the personification of a medical industry gone bad.
The word “bro” once evoked blithe white-guy gregariousness, but in interviews, and in the frequent online videos he broadcast from his darkened lair, Shkreli seemed brainy and somewhat awkward, like an evil genius. He spoke grandly about his plans and didn’t bother to hide his disdain for anyone too dense to understand why higher prices, and higher profits, could be a boon for the industry, and for patients, because the income could fund additional research and development. Then, in December, he was indicted on seven counts of fraud, related to a hedge fund he had co-founded, and he resigned as C.E.O. of Turing. But, by then, his villainy had taken a turn for the whimsical: it was revealed that he had paid two million dollars for an unheard, one-of-a-kind album by the Wu-Tang Clan, and then embarked upon a feud with the Clan’s greatest rapper, Ghostface Killah. It was clear that he wanted attention, even though it wasn’t always clear what he wanted to do with it.
No matter: on Thursday, the House Committee on Oversight and Government Reform resolved to give him some more of it. Congressional hearings always involve some amount of theater; Shkreli’s appearance, however, was nothing but theater, and a rather surreal form of it. Trey Gowdy, a Republican from South Carolina, took a lead role. He told Shkreli, “This is a great opportunity, if you want to educate the members of Congress about drug pricing, or what you called the ‘fictitious’ case against you.” Shkreli had been declining to answer the committee’s questions, so Gowdy tried a different approach. “We can even talk about the purchase of a—is it Wu-Tang Clan? Is that the name of the album—the name of the group?”
At that point, Shkreli’s lawyer, Benjamin Brafman, leaned forward, from a chair behind his client, and whispered something. Shkreli listened, then repeated the answer he had been giving all morning: “On the advice of counsel, I invoke my Fifth Amendment privilege against self-incrimination and respectfully decline to answer your question.”
Gowdy turned to the chairman of the committee, Jason Chaffetz, a Republican from Utah. “Mr. Chairman,” Gowdy said, soulfully, “I am stunned that a conversation about an album he purchased could possibly subject him to incrimination.”
The questioning continued this way, with Shkreli sometimes fidgeting, sometimes smiling, and sometimes furrowing his eyebrows, as if he couldn’t believe he had to sit through something so ridiculous. Brafman later explained that his client was suffering from a surfeit of “nervous energy,” but Shkreli himself provided a different account of his state of mind, via Twitter: “Hard to accept that these imbeciles represent the people in our government.”

Hillary Clinton Lobbied on Health Care as Secretary of State, Emails Show

By 


WASHINGTON — On Christmas Eve in 2009, Secretary of State Hillary Clinton was awake before dawn to personally monitor a critical moment in the nation’s history.
But Mrs. Clinton, the country’s top diplomat, was not observing a covert operation in the Middle East or tracking pivotal negotiations with a foreign power. Her television was tuned to C-Span, and she was watching the Senate vote on President Obama’s landmark health care law.
Emails released last week by the State Department that were found on Mrs. Clinton’s private server show that she was keenly interested in the administration’s push to win passage of the health care law.
When an aide, Miguel Rodriguez, contacted her to let her know that the Senate had approved the bill by a 60-to-39 vote, Mrs. Clinton was way ahead of him.
“Thx — I got up to watch it,” she wrote back. “What did Reid say while voting that caused laughter?” (The majority leader, Harry Reid, Democrat of Nevada, had inadvertently voted against his own bill, before quickly changing his vote.)
The email messages show that throughout the fall of 2009, as the health care push entered a decisive phase, Mrs. Clinton lobbied some members of Congress for votes and even debated sometimes-esoteric policy proposals with aides, some of whom had worked with her in the White House when she was first lady, after her own failed attempt to push a national health care overhaul.
The messages, with granular detail and sometimes boosterish tone, help explain why even among Democrats she remains one of the Affordable Care Act’s most ardent champions.
“Hope you’ve had a good, albeit busy summer and are a little rested up in prep for the full court health care push,” Mrs. Clinton wrote on Sept. 2, 2009, in a message to Neera Tanden, who had been her top domestic policy adviser in the 2008 race and had gone to work on health policy in the Obama administration.
“What’s happening on that front?” Mrs. Clinton asked. “Is there a new strategy? I know POTUS will speak on 9/9. Will we hear the specifics of what the Admin wants Congress to do? Let me know if I can help.”
One former senior administration official, however, said that if Mrs. Clinton was deeply interested in the health care law, she did not show it during cabinet meetings and other gatherings in the White House.
“I saw no evidence that she was interested or following, actually to the contrary,” said the former official, who requested anonymity in discussing events that were not public.
But Ms. Tanden, who started working for Mrs. Clinton in the White House in the 1990s and is now president of the Center for American Progress, a liberal think tank in Washington, said the continuing interest in health care was hardly a surprise.
“The thing that I think the emails show you is she’s secretary of state and super-focused on health care,” Ms. Tanden said. “I worked for Hillary for a really long time, at the beginning of when I worked for her, in the middle of the time I worked for her and at the end of when I worked for her, in her mind, health care is a right.”
During her campaign this year, Mrs. Clinton has shown similar resolve. “Now, before it was called Obamacare, it was called Hillarycare,” she told an audience last month in Clinton, Iowa.
Congressional officials who worked on the Affordable Care Act said that Mrs. Clinton was an important and effective advocate.
“She was helpful when we needed votes, having served in the Senate and still having friends and colleagues there,” said one former Senate adviser, who asked not to be identified in discussing internal deliberations. “She did have credibility. She was considered an expert.”
That expertise is clear in some of the email messages, in which, for example, Mrs. Clinton questioned a decision by Senator Max Baucus of Montana, a main drafter of the legislation, to use nonprofit health insurance cooperatives to compete with profit-making insurers, rather than a government-run health plan, known as the public option.
“But the ‘system’ let the Blues go public,” she wrote in a message to Ms. Tanden, referring to the health insurance giant Blue Cross/Blue Shield, after learning of the Baucus plan. “What’s to prevent the co-ops from incorporating down the road? The return of nonprofits would have to require no changes.”

The Big Problem With High Health Care Deductibles

Economic View
By    FEB. 5, 2016
When Bernie Sanders released his long-awaited health care plan last month, it was light on the details. But it did include one major, crowd-pleasing promise: Under his Medicare-for-all proposal, no American would ever have to pay a deductible or co-payment to receive health care again.
Deductibles and other forms of cost-sharing have been creeping up in the United States since the late 1990s. A typical employer health plan now asks an individual to pay more than $1,000 out of pocket before coverage kicks in for most services. The most popular plans on the Affordable Care Act exchanges require customers to pay several times as much. Even Medicare charges deductibles.
People tend to hate these features, but they were not devised to be cruel. Rather, they were fashioned with economic theory in mind.
Deductibles and co-payments are intended to make patients behave more like consumers in other parts of the economy. People who have to pay the full cost of magnetic resonance imaging on their knee, for example, might be more likely to shop around and pick the $500 one instead of the $3,000 one. Perhaps, they’ll decide to give their minor knee pain two weeks to see if it gets better on its own, and skip the M.R.I. The hospital offering the $3,000 M.R.I. might lose enough business that it will lower its price.
Those choices, over time, could reduce the amount of health care that is used and the price of services: If patients do not care about price, then they will not have any incentive to look for a bargain, and health care providers will not have an incentive to offer one.
A famous randomized experiment in the 1970s and ’80s helped demonstrate that at least part of this theory worked. Researchers from the RAND Corporation gave insurance with high cost-sharing to some people and lower cost-sharing to others. Over time, the researchers found that the people who had to pay more of their bills in cash used less health care and were no less healthy than people whose insurance covered everything.
“If you make something free, people will spend a lot on it,” said Michael Chernew, a professor of health policy at Harvard, who studies ways to control health care costs. Mr. Chernew and co-authors have argued that the emergence of plans that require more out-of-pocket spending is most likely responsible for part of a recent slowdownin the growth of health spending.
More recent research supports this idea. Employers who asked workers to pay a higher share of their bills have also seen overall spending decline. A particularly good case can be made that cost-sharing has helped steer patients away from brand-name drugs and toward identical generics, when they are available.
But the type of cost-sharing can make a big difference, and new research suggests that high deductibles in particular may not work as intended. A team of researchers at the University of California, Berkeley, and Harvard recently published a working paper on what happened when a large (unnamed) employer switched from a more generous health plan to one with a high deductible. The typical worker in the company was young and Internet savvy, and earned more than $125,000 a year. The company gave employees a web tool to compare health care prices, and a health savings account for the full amount of the deductible, so they wouldn’t actually have to pay any bills out of their salaries. Amitabh Chandra, an economist at Harvard, and one of the researchers, said he was convinced the study would prove the value of deductibles, at least for well-off and well-educated workers.
He was wrong. Over all, the workers did spend less on health care. Spending fell by about 12 percent, a remarkable decline. But the way workers achieved those savings gave the researchers pause. There was no evidence that workers were comparing prices or making wise choices on where to cut, even after two years in the new plan. They visited the same doctors and hospitals they always had. They reduced low-value medical services and medically important ones at about the same rate, raising questions about their long-term health.
Mr. Chandra said he was no longer convinced that deductibles turned patients into good consumers. “The best case was the theoretical case,” he said. “I was all for high-deductible plans before I wrote my paper.”

Insurers seek to limit risky policies ordered by Affordable Care Act


Anthem, Aetna and Cigna stop offering brokers incentives to sign up customers outside the normal enrollment period. 

BY JAY HANCOCKTRIBUNE NEWS SERVICE

Stung by losses under the federal health law, insurers are seeking to sharply limit how policies are sold to individuals in ways that consumer advocates say seem to discriminate against the sickest and could hold down future enrollment.
Anthem, Aetna and Cigna, all among the top health insurers, told brokers they will stop paying them sales commissions to sign up most customers who qualify for new coverage outside the normal enrollment period, according to the companies and broker documents.
The health law allows people who lose other coverage, families with new children and others in certain circumstances to buy insurance after enrollment season ends. In most states the deadline was Jan. 31.
Last year, these “special enrollment” clients were much more expensive than expected because lax enforcement allowed many who didn’t qualify to sign up, insurers said. Nearly a million special-enrollment customers selected plans in the first half of 2015, half of them after losing previous coverage.
In addition, Cigna and Humana, another big health insurer, have ceased paying brokers to sell many higher-benefit “gold” marketplace plans for individuals and families while continuing to pay commissions on more-profitable, lower-benefit “bronze” plans, according to documents and interviews.
Gold plans enroll sicker members than do less comprehensive policies, say insurance experts. As of June, more than 695,000 people had enrolled in gold plans. Those who want to buy individual and family plans can still do so directly through the Affordable Care Act’s online marketplaces or via navigators working for nonprofit groups.
But the retreat from broker sales, which includes last year’s decision by No. 1 carrier UnitedHealthcare to suspend almost any commissions for such business, erodes a pillar of the health law: that insurers must sell to all customers no matter how sick, consumer advocates say.
The insurance industry says it is not discriminating but adjusting to market realities including higher-than-expected medical claims and the failure of a government risk-adjustment program to cover much of that cost.

Here's why creating single-payer health care in America is so hard

To become politically feasible, an American single-payer system would necessarily replicate our current system’s most glaring defects.


Updated by  on January 16, 2016, 11:20 a.m. ET
The Hillary Clinton campaign is taking some hard knocks from liberals over its maladroit attacks on Bernie Sanders’ single-payer proposal. In one sense, the knocks are well-deserved. Even if single-payer markedly lowers medical expenditures, proponents such as Larry Seidman estimate that a tax increase of at least 8 percent of GDP would likely be required to finance it. That’s a heavy political lift. It’s about as much as the entire federal income tax on individuals.
Yet as proponents rightly observe, these taxes would replace many visible and invisible ways we now provide to support a health sector that consume more than 17 percent of our economy. The experience of peer industrial democracies suggests that a well-designed single-payer system would be more humane and markedly less expensive than what we have right now.
Such a system would certainly be less convoluted and bureaucratically hidebound. Aggressively deploying government power to rein in prices, a well-designed single-payer system would be more fiscally disciplined, and would probably be more effective in targeting resources to best promote public health. Sanders deserves credit for noting the real virtues of a well-executed single-payer system.
In another way, though, Clinton's critique raises uncomfortable questions that deserve greater attention. It’s commonplace (though true) to note that single-payer is beyond the current boundaries of American politics. But what if, by some miracle, liberal Democrats won comprehensive victories that created a window of opportunity in which single-payer becomes realistically possible?

Designing a single-payer system in America


Imagine what would happen were President Bernie Sanders to sweep into office backed by a Democratic congressional majority similar to what President Obama enjoyed in 2008. Imagine further that President Sanders were sufficiently fortunate and skilled after that victory to enact a single-payer system. I wonder how different our policy dilemmas would really be from what we now face in implementing the Affordable Care Act.
As I have  written at length in the Journal of Health Politics, Policy, and Law (and draw upon here), an American single-payer system would be more complex and kludgy than many proponents have considered or admitted. The source of these problems resides in American politics rather than the technocratic or ideological premises of our health care system. A different system operating through the same political mechanisms would produce  similar complexity and kludge.

The false charms of Bernie Sanders’s single-payer plan
  
Could Bernie Sanders’s “Medicare for all” proposal — national health insurance — be as good as he says? It’s doubtful. 
No one claims that today’s system is ideal. It’s complex, confusing, costly and incomplete. Even after the Affordable Care Act, about 30 million people remain uninsured. For decades, rapid spending increased health care’s share of the economy, estimated at 17.5 percent in 2014. And on many health outcomes — say, infant mortality — the United States does worse than some other advanced societies. 
Robert J. Samuelson writes a weekly column on economics. View Archive
To hear Sanders tell it, his single-payer plan (the government pays for most health care) would cure these ailments. Everyone would have coverage. People would go to doctors, hospitals and clinics as needed. There would be no deductibles or copayments to discourage them. Workers would not be locked into jobs they dislike because they fear losing employer-provided insurance. 
As for costs, the government would negotiate price cuts on drugs and eliminate private insurers’ high overhead costs. To be sure, paying for the plan would require new taxes. But for many middle-class families, these taxes would be less than today’s out-of-pocket expenses and their share of premiums for employer-provided insurance. A family of four with $50,000 of income could save nearly $5,800 a year, Sanders says. 
It sounds too good to be true, because it is.
For starters, even if Sanders became president, the prospect for his plan being enacted would be slim. That’s not a conservative wish but the view of many liberals. It’s politically unrealistic, they argue, to think that nearly a fifth of the economy could be totally remade. “As the old joke goes, ‘You can’t get there from here,’” writes economist Henry J. Aaron of the liberal-leaning Brookings Institution in Newsweek. There would be too much opposition and uncertainty.

Hospitals, doctors and drug companies would lobby for favored treatment — or resist punitive policies. Insurance companies would fight to survive. Americans with good insurance would worry that they’d lose their privileged position.
Billions of dollars would be at stake. Most employer-provided health insurance would disappear, saving companies (Aaron says) about $700 billion. Some of that would be drained by a new 6.2 percent payroll tax to pay for government insurance. But what would happen to any remainder? Would it fatten workers’ wages or shareholders’ profits?
Especially controversial would be cost savings. The Sanders campaign estimates that his plan would lower costs by about $1 trillion annually, but how this would occur isn’t clear. Controlling the “administrative costs [of insurers and providers] and drug prices,” as the campaign suggests, may not yield huge savings. 

Is Medicaid expansion near a tipping point? New president could make difference for Maine

By Christine Vestal, Stateline.org
Posted Feb. 07, 2016
WASHINGTON — Louisiana last month became the first state in the Deep South to make the politically charged decision to expand Medicaid health insurance to low-income adults under the Affordable Care Act.
At least one other state — South Dakota — is expected to extend Medicaid coverage this year. But in the lead up to the November presidential election, supporters of the ACA aren’t holding out much hope that more states will join in extending Medicaid coverage to more people — although the governors of Alabama, Virginia and Wyoming say they want to, as do key legislators in Maine and Nebraska.
Meanwhile, newly elected Republican Gov. Matt Bevin in Kentucky and Republican lawmakers in Arkansas are threatening to roll back or modify their states’ existing expansion programs.
After a new president is elected, the situation could change and more states could join in expanding coverage, predicted Joan Alker, executive director of Georgetown University’s Center for Children and Families, which advocates for greater health care coverage for the poor.
Ever since the Supreme Court’s 2012 decision making Medicaid expansion a state option, the issue has been more political than practical. Many Republican governors and lawmakers have rejected the deal, fearing they would lose their jobs if they were seen cooperating with President Barack Obama on a law most conservatives abhor.
With Obama out of office, that could change. “The ideological opposition to the president will have to start fading when he’s out of office,” Alker said. “At that point, the facts and the evidence will start to matter more.”
Matt Salo, executive director of the National Association of Medicaid Directors, agrees. If a Democrat is elected president, the new administration could be expected to continue the Obama administration’s approach of approving proposals from Republican-governed states to shape expanded Medicaid programs to fit their individual state needs and politics.
Even greater flexibility could come if a Republican is elected president, Salo said. In that case, the GOP-led states that have so far shunned expansion would likely seek authority to revamp their programs more radically than the Obama administration has allowed. Until then, Salo said, “Governors are probably thinking, ‘Maybe I’ll just keep my powder dry.’”

Financial despair, addiction and the rise of suicide in white America

Chris McGreal

Kevin Lowney lies awake some nights wondering if he should kill himself.
“I am in such pain every night, suicide has on a regular basis crossed my mind just simply to ease the pain. If I did not have responsibilities, especially for my youngest daughter who has problems,” he said.
The 56-year-old former salesman’s struggle with chronic pain is bound up with an array of other issues – medical debts, impoverishment and the prospect of a bleak retirement – contributing to growing numbers of suicides in the US and helping drive a sharp and unusual increase in the mortality rate for middle-aged white Americans in recent years alongside premature deaths from alcohol and drugs.
A study released late last year by two Princeton academics, Anne Case and Angus Deaton, who won the 2014 Nobel prize for economics, revealed that the death rate for white Americans aged 45 to 54 has risen sharply since 1999 after declining for decades. The increase, by 20% over the 14 years to 2013, represents about half a million lives cut short.
The uptick in the mortality rate is unique to that age and racial group. Death rates for African Americans of a similar age remain notably higher but continue to fall.
Neither was the increase seen in other developed countries. In the UK, the mortality rate for middle-aged people dropped by one third over the same period.
“This change reversed decades of progress in mortality and was unique to the United States; no other rich country saw a similar turnaround,” the study said.
Deaths from poisonings by drugs or alcohol have risen dramatically to push lung cancer into second place as the major killer with a sharp increase in suicides now a close third.
Lowney lives in Butte, Montana, where local officials see the Princeton study’s findings reflected in their community but struggle to explain them. The state has the highest rate of suicide in the US at nearly twice the national average and rising – up 7.3% in 2014. Those most likely to kill themselves are 45 to 65 years old.
“What’s been lacking in our town is an explanation for why this demographic in particular has been dying by suicide,” said Karen Sullivan, health director for Butte and the surrounding county, Silver Bow. “We want to take a look at what we’ve got going on in Butte. Is it economic in nature? Is it middle-aged white people discontented with where they landed in life? Is it isolation? A lack of a social network? Is it drug and alcohol issues? What do we have going on?”
Other officials see a number of interconnected forces at work and the rising rate of middle-aged deaths as indicative of crisis wider than those who kill themselves.
Growing economic inequality and increasing financial struggles are intertwined with other issues such as health and addiction. Some people living on low incomes hesitate to go to the doctor even if they have medical insurance because of the cost of out-of-pocket expenses. Chronic conditions can go untreated and become debilitating.
Pain is a driver of alcohol abuse and addiction to opioid painkillers, which in turn is feeding a growing heroin epidemic in the US. Stress and mental health issues are sometimes driven by constant worries about money and fear for the future as growing numbers of Americans look into a financial abyss at retirement.

What has changed?

Karl Rosston, Montana’s suicide prevention coordinator, said there are a number of constants that contribute to a historically high suicide rate throughout the Rocky Mountain region from social isolation to the availability of guns and a reluctance to seek mental health care.
But all of those are longstanding issues in Montana. So what’s changed to drive up the rate of people taking their own lives in recent years?
“Probably the biggest reason is socio-economic. We have about 150,000 people in our state that don’t have access to any type of healthcare, which is a major issue. We have a lot of people living in poverty. Wages are not going up at the same pace as rising health costs, rising cost of living and inflation,” Rosston said.
“Definitely you see a lot of people that all of a sudden they hit 45 or 50 and they don’t see retirement as a bonus. They see something that they’re going to have struggle with and they’re not going to be able to retire.”
Sullivan sees that as tied up with “the expectation that as a middle-aged white person you would outdo your parents economically and socially, and that didn’t occur”.
Lowney is typical of those baby boomers who have seen expectations dashed. His grandfather immigrated from Ireland to work as a miner when Butte was renowned as “the richest hill on earth” for the copper beneath. His father, Jerry, was raised in impoverished conditions but by the 1950s had moved up the social scale working as a civil engineer in a Butte hospital. He owned a house and a car. He had eight children, of which Kevin was the youngest, and retired on a comfortable pension without debt.


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