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Wednesday, May 4, 2016

Health Care Reform Articles - May 4, 2016

I'm back from my trip. Please forgive the length of today's postings, but I had a little catch-up to do.

_ SPC

Is single-payer healthcare dead in the U.S., or only sleeping?

by Michael Hiltzig - LA Times
The dream of bringing single-payer healthcare to the United States is a hardy one. It's still with us despite years of disrespect by the general public, intense opposition from powerful stakeholders in the healthcare economic status quo, and the enactment of the very non-single payer system known as Obamacare.
Should we give up on the dream, already? That's the question raised by a provocative recent article in the New England Journal of Medicine by Jonathan Oberlander, a political scientist and health policy expert at the University of North Carolina, one of the most percipient critics of the U.S. healthcare system. 
The enduring appeal of Medicare for All is understandable, given the fragmented, inequitable, costly, profit-driven, and wasteful nonsystem that prevails in the United States.
Healthcare expert Jonathan Oberlander
His regretful answer is yes.
"Single-payer," he writes "has no realistic path to enactment in the foreseeable future. It remains an aspiration more than a viable reform program." Instead, he argues that "preserving and strengthening the ACA, as well as Medicare, and addressing underinsurance and affordability of private coverage" is "the best way forward now for U.S. medical care."
Oberlander's words may trigger an uproar among single-payer advocates, and not merely because they're passionate about their goal and convinced that it's the only sure way of bringing universal coverage to the U.S., but because they're probably right. 
Anyone seeking a clue to how passionate they are need only examine the controversy ignited recently by one of our most dedicated single-payer advocates, the Los Angeles oncologist and biotech executive Paul Y. Song.
Speaking at a New York rally for Bernie Sanders, the single-payer advocate running for the Democratic nomination for President, Song laced into the opponents of single-payer:  "Medicare for all will never happen if we continue to elect corporate Democratic whores who are beholden to big pharma and the private insurance industry instead of us," he said. The twitterverse decided he must have been calling Hillary Clinton a "whore," Sanders disavowed the statement, and Song issued a heartfelt apology.
Song is someone I know well and respect as a serious student of healthcare policy and a valiant crusader for single-payer healthcare (we've shared panel appearances on this and other healthcare topics). He was unfairly pilloried for his terminology; having been present at many single-payer debates, I find it perfectly plausible that Song was referring generally to Democrats of little faith. (His wife, the journalist Lisa Ling, is a Clinton supporter.)
What's worse, his basic point got obscured once the social media outrage machine went into overdrive. It's a sound one and hardly subject to dispute: the obstacles to single-payer include "big pharma and the private insurance industry," along with political leaders who allow those industries' interests to control the policy discussion. It's a safe guess that Hillary Clinton, still bearing scars from her experience trying to get healthcare reform enacted during her husband's Administration, wouldn't disagree.
Oberlander, for his part, is impressed that single-payer is at least back on the debate floor, thanks in part to Sanders, whose platform includes Medicare-for-all. I've analyzed the Sanders proposal critically, while acknowledging that single-payer deserves to be front-and-center in an discussion of U.S. healthcare reform.
Many healthcare experts faulted Sanders for failing to accept that the American political system simply isn't going to get over its hostility to single-payer any time soon. Oberlander's point is that a fixation on single-payer threatens to become a distraction from efforts to preserve the gains already made and enact achievable advances in reform.
The irony is that Oberlander acknowledges that "the enduring appeal of Medicare for All is understandable, given the fragmented, inequitable, costly, profit-driven, and wasteful nonsystem that prevails in the United States." He notes, too, the failure (so far) of Obamacare to bring relief to the unaffordability of medical treatment for many Americans and the presence of a population of uninsureds that still numbers 30 million.
But aspiring to solve these problems via single-payer healthcare sin't enough, he argues. "Single-payer supporters have not articulated a convincing strategy for overcoming the formidable obstacles that stand in its way."
Medicare for All "would trigger fierce resistance from conservatives and the business community and anxiety in many insured Americans fearful about changing coverage and the specter of rationing" Oberlander writes. "The ACA’s comparatively conservative reform approach inspired false charges of 'socialized medicine,' 'pulling the plug on grandma,' and 'death panels.' It takes only a little imagination — or a look back at the history books — to predict the reactions that an actual single-payer plan would evoke."
He might have added that enactment of Medicare for all wouold intensify, rather than quell, the politicization of healthcare in the U.S. To quote again healthcare policy expert Harold Pollack, as we did in our analysis of the Sanders proposal: "Imagine the national policy debate over abortion, contraception, HIV prevention, immigration policy, and other matters in a national Medicare plan."
No rational expert on healthcare doubts that some form of single-payer is the best device for true healthcare reform in the U.S.--although as Oberlander notes, there are almost as many forms of single-payer in existence as there are countries that claim to apply it, from Britain's government-owned healthcare system to Canada's privately-owned but government-insured system, to the hybrid versions in Germany and Switzerland.
Oberlander believes that some incremental steps toward single-payer are "conceivable" but that a viable full-scale transformation is simply not currently foreseeable. He's not so far apart from some of single-payers' most dedicated advocates, many of whom take the long view.
The possible paths are many, but the goal beckons from the very distant future. What drives the single-payer dream is an essential truth, articulated for me a few years ago by the late Arnold Relman, the reformist former editor of the New England Journal of Medicine: "It's the only logical solution."

Bernie Sanders’s Gift to His Party



Though some opinion polls on Tuesday’s primary in Indiana show Bernie Sanders and Hillary Clinton in a tight race, the plunge in Mr. Sanders’s latest fund-raising numbers makes clear what he doesn’t yet want to say. His campaign — for the presidency, anyway — is most likely nearing its end.
“We intend to fight for every vote and delegate remaining,” Mr. Sanders said in Washington on Sunday. While he continues to infuriate the Clinton campaign by battling for Mrs. Clinton’s superdelegates, his tone suggests that he’s no longer in it to win. He’s fighting to ensure that all his supporters get a chance to cast a ballot during the primary season ending in June, and most of all, that Democratic leaders pay attention to their views.
The Democratic Party and Mrs. Clinton are better off for Mr. Sanders’s presence in this race. His criticism, as Winston Churchill might say, was not agreeable. But it called necessary attention to unhealthy developments in the Democratic Party, including its at-times obliviousness to the lingering economic pain of the middle class and the young, and its drift toward political caution over aspiration.
“I like the idea of saying, ‘We can do much more,’ because we can,” Vice President Joseph Biden Jr., who deferred his own presidential hopes this year, said about Mr. Sanders recently. “I don’t think any Democrat’s ever won saying, ‘We can’t think that big.’”


South Dakota Wrongly Puts Thousands in Nursing Homes, Government Says

By MATT APUZZO
WASHINGTON — When patients in South Dakota seek help for serious but manageable disabilities such as severe diabetes, blindness or mental illness, the answer is often the same: With few alternatives available, they end up in nursing homes or long-term care facilities, whether they need such care or not.
In a scathing rebuke of the state’s health care system, the Justice Department said on Monday that thousands of patients were being held unnecessarily in sterile, highly restrictive group homes. That is discrimination, it said, making South Dakota the latest target of a federal effort to protect the civil rights of people with disabilities and mental illnesses, outlined in a Supreme Court decision 17 years ago.
The Obama administration has opened more than 50 such investigations and reached settlements with eight states. One investigation, into Florida’s treatment of children with disabilities, ended in a lawsuit over policies that placed those children in nursing homes. With its report Monday, the Justice Department signaled that it might also sue South Dakota.

Maine Med turns to plant-based dietary medicine to help stop problems before they start

A new residency program will teach about preventing disease and helping patients change habits and diets. 

BY AVERY YALE KAMILA
Instruction in plant-based dietary medicine is one part of a new residency program launching in July at Maine Medical Center in Portland. Maine Med’s two-year program, which joins a growing group of teaching hospitals offering the specialty, offers doctors board certification in preventative medicine, a master’s degree in public health and extensive nutrition education.
This branch of medicine aims to prevent disease rather than treat it, and a core part of maintaining health involves eating the right food.

How a tiny hospital has imperiled Mass. Medicare funds

By  GLOBE STAFF  

Simple math errors at a tiny Massachusetts hospital have created big problems for other hospitals in the state, contributing to a potential $160 million drop in federal Medicare payments over the next year.
A loss that steep — 10 percent of Medicare funding for the hardest-hit hospitals — could force layoffs of 2,000 staff, with cuts concentrated outside Boston, according to estimates by the Massachusetts Council of Community Hospitals.
The quaint 19-bed Nantucket Cottage Hospital, owned by Partners HealthCare System and considered the state’s only rural hospital, has for years had an outsized impact on hospital finances statewide — but usually for the better.
Under nearly impenetrable hospital payment rules, Medicare must reimburse a state’s urban hospitals for employee wages at least as much as it reimburses its rural hospitals. As a result, Nantucket sets the floor for wage reimbursements at hospitals across the state. And because Nantucket’s wages are high, due to its remote island location and steep cost of living, that has created bonuses for many other Massachusetts hospitals in recent years.
Not this year. Consultants hired by Partners made several errors that led to lower wages being reported to Medicare for Nantucket Hospital. They overestimated hours, thereby reducing the hourly rate, and did not include enough higher-paid physician hours and overtime pay, according to an e-mail from the Massachusetts Hospital Association obtained by the Globe.

Single-payer could set up legal clash over abortion, restrict access

If the citizens of Colorado pass Amendment 69, an initiative that would make the state a single-payer monopoly purchaser of health care services, it could set up a legal conflict that would significantly diminish the availability of abortion services throughout the state.
The language of Amendment 69 explicitly states that it would create a subdivision of the state called ColoradoCare, and that subdivision would be the sole payer of all medical services provided to citizens of Colorado.
However, in 1984, voters narrowly passed a measure that expressly prohibits the state – or any subdivision – for paying for abortion.
The language now in the Colorado Constitution as a result of that 1984 vote reads:
No public funds shall be used by the State of Colorado, its agencies or political subdivisions to pay or otherwise reimburse, either directly or indirectly, any person, agency or facility for the performance of any induced abortion, PROVIDED HOWEVER, that the General Assembly, by specific bill, may authorize and appropriate funds to be used for those medical services necessary to prevent the death of either a pregnant woman or her unborn child under circumstances where every reasonable effort is made to preserve the life of each.
The 1984 amendment to the state constitution sets up the proverbial conflict of the unstoppable cannonball versus the unmovable post, but at least one legal expert agrees that all health insurance in Colorado and the single-payer entity ColoradoCare would no longer cover abortion if Amendment 69 were to pass.
“It is already impossible for Coloradoans to receive abortion services which are directly paid for by state or local governments,” said David Kopel, a law professor at Denver University and research director at the Independence Institute.*
“Amendment 69 creates government monopoly control of health insurance, to be run by an organization called ‘ColoradoCare,'” Kopel continued. “Amendment 69 specifies that ColoradoCare is ‘a political subdivision of the state.’ For decades, the Colorado Constitution has forbidden all ‘political subdivisions’ to use public funds to pay for abortion, ‘either directly or indirectly.’ Because Amendment 69 would make  all health insurance paid for by public funds (taxes), Amendment 69 would make it unlawful for insurance programs to cover abortion, even in cases of rape or incest.”





Obamacare

The Neoliberal Model Comes Home to Roost in the United States—If We Let It


by  and 
As the Affordable Care Act (ACA, otherwise known as Obamacare) continues along a very bumpy road, it is worth asking where it came from and what comes next. Officially, Obamacare represents the latest in more than a century of efforts in the United States to achieve universal access to health care. In reality, Obamacare has strengthened the for-profit insurance industry by transferring public, tax-generated revenues to the private sector. It has done and will do little to improve the problem of uninsurance in the United States; in fact, it has already begun to worsen the problem of underinsurance. Obamacare is also financially unsustainable because it has no effective way to control costs. Meanwhile, despite benefits for some of the richest corporations and executives, and adverse or mixed effects for the non-rich, a remarkable manipulation of political symbolism has conveyed the notion that Obamacare is a creation of the left, warranting strenuous opposition from the right.
Abundant data substantiate that the failure of Obamacare has become nearly inevitable. Even after the ACA is fully implemented, more than one-half of the previously uninsured population will remain uninsured—at least 27 million people, according to the non-partisan Congressional Budget Office—and at least twice that number will remain underinsured.1 Due to high deductibles (about $10,000 for a family bronze plan and $6,000 for silver) and co-payments, coverage under Obamacare has become unusable for many individuals and families, and employer-sponsored coverage is headed in the same direction.2 Private insurance generally produces administrative expenses about eight times higher than public administration; administrative waste has increased even more under Obamacare, and remains much higher than in other capitalist countries with national health programs.3 These administrative expenditures pay for activities like marketing, billing, denials of claims, processing copayments and deductibles, exorbitant salaries and deferred income for executives (sometimes more than $30 million per year), profits, and dividends for corporate shareholders.4 The overall costs of the health system under Obamacare are projected to rise from 17.4 percent of GDP in 2013 to 19.6 percent in 2022.5 A conservative projection shows that premiums and out-of-pocket expenditures for the average family will equal half of the average family income by 2019 and the full average family income itself by 2029.6

Doctor, Warned to Be Silent on Abortions, Files Civil Rights Complaint

A doctor who performs abortions at a hospital in Washington, D.C., filed a federal civil rights complaint on Monday, charging that the hospital had violated the law by forbidding her, out of concerns for security, to speak publicly in defense of abortion and its role in health care.
The doctor, Diane J. Horvath-Cosper, 37, an obstetrician and gynecologist, has in recent years emerged as a public advocate, urging abortion providers not to shrink before threats. Last December, her complaint says, officials of the MedStar Washington Hospital Center imposed what she described as a “gag order,” but what the officials termed a sensible precaution against anti-abortion violence.
At odds in the case are sharply conflicting visions of how best to protect abortion providers and patients. The dispute comes at a time when legal restrictions on the procedure are tightening, many clinics are besieged daily by hostile protesters and an extremist fringe has sometimes made murderous attacks.
Dr. Horvath-Cosper is part of a national movement of physicians and other medical staff members who argue that silence about their work only feeds the drive to stigmatize and restrict abortion. Similar sentiments among some patients have led to a “Shout Your Abortion” campaign on social media.

Study Finds Wide Disparity in Maine Health Care Costs 

By  • APR 19, 2016

A conservative advocacy group has released a study that shows significant differences in what providers around Maine charge for the same medical procedures.

The Maine Heritage Policy Center says the findings illustrate the need to let consumers “shop around” for care. But there are differing views on how to solve the cost problem.

The study found some wide disparities in charges for common procedures. A knee replacement in Maine, including the surgery and pre- and post-operative care, ranged from just under $27,000 to just over $50,000. A blood test for electrolytes ranged from $33 to $111.
“Although many factors influence pricing it is clear that inadequate competition between providers contributes significantly to this variation,” says Liam Sigaud, an analyst at the Maine Heritage Policy Center who worked on the study.
Sigaud points to a key finding about the Maine health care marketplace.
“Patients are often unaware of price differences and are unmotivated to seek affordable care,” he says.
The study is similar to earlier reports done by Consumers for Affordable Health Care, the Maine Health Data Organization and others that also pointed to wide cost differences across the state for the same medical procedures.
The solution to the problem, says center CEO Matt Gagnon, is providing incentives to consumers to compare costs and shop around for the best deal. He says a bill to do just that, LD 1305, was defeated in the House last week.
“It attempted to incentivize decision making to give you a personal benefit in saving money. So if you, for instance, were to save $5,000 off of the average cost of a procedure, at least 40 percent of that savings would have come back to you either on your deductible, or a cash benefit or in some way shape or form coming to you as a consumer. So it incentivizes you to shop,” he says.
Gagnon says the bill would have encouraged consumers to shop around for the best deal, and he expects the legislation will be back before lawmakers next year.

States Can Contain Health Care Costs. Here’s How.

By RICHARD M. SCHEFFLER and SHERRY GLIED
MAY 2, 2016
THE architects of the Affordable Care Act counted on competition in the health insurance market to keep costs down and quality high. While the law has accomplished many of its coverage and cost-containment goals, its vision of a more competitive insurance market seems to be fading.
The nation’s second-largest health insurer, Anthem, is poised to acquire Cigna, the fourth- largest. Aetna, the third-largest insurer, is seeking to acquire Humana, the fifth-largest. If approved by the Justice Department, these mergers would produce companies controlling about 35 percent of the health insurance market. These mergers would likely leave that market with far fewer competitors — a disappointing result for those who hoped it would increase “choice and competition.” Yet our research suggests that this apparent failure obscures a potential path to success, one that lies between competition and a fully regulated market.

These hospitals make the most money off patients — and they’re mostly nonprofits

by Lena Sun - Washington Post

Seven of the top 10 most profitable hospitals in the United States are nonprofit facilities that each netted more than $150 million from caring for patients in 2013, according to a study published Monday.
Topping the list is Gunderson Lutheran Medical Center in La Crosse, Wisc., which earned $302.5 million in profit from patient care services that year, according to researchers from the Johns Hopkins Bloomberg School of Public Health and Washington and Lee University.
Other nonprofits in the top 10 include the Stanford Hospital in Palo Alto, Calif., which took in nearly $225 million, and the University of Pennsylvania's hospital in Philadelphia, which earned $184.5 million.
"Most hospitals lose money, but there are a few very profitable ones and we need to pay attention to why they are making so much" and how it affects consumers, said lead author Gerard Anderson, a Hopkins health policy professor.

Maine hospital lays off nearly two dozen employees

By Staff, CBS 13
Posted May 02, 2016, at 9:15 p.m.
FARMINGTON, Maine — A rural hospital is laying off nearly two dozen employees and making a number of other cuts as well.
Layoffs and a salary freeze are just some of the cost-saving measures being taken by the Franklin Community Health Network, which includes Franklin Memorial Hospital in Farmington.
Sen. Tom Saviello is concerned about cutbacks at the hospital and the 22 full-time employees who’ve been told they are being laid off. Another 18 vacant positions also won’t be filled for a total of 40 full-time positions that are being eliminated.
Despite the layoffs, former hospital employee Ava Reynolds doesn’t expect patient care to suffer.
“They have good nurses and they have good care,” Reynolds said.
Over the last five years, Franklin Community Health Network says it has lost more than $15 million.
Interim CEO Timothy Churchill blames it on Medicare and Medicaid reimbursements that don’t cover the full cost of care. He said the state failing to expand Medicaid under the Affordable Care Act also has hurt.
Saviello is one of the few Republicans who supported Medicaid expansion.
“The Medicaid expansion is going to be critical to keep hospitals stable,” Saviello said. “But somehow that message did not get across to my colleagues. And I guess sadly what the message will get across to them, as they see hospitals perhaps in their rural districts change dramatically, because of lack of reimbursement and because expansion didn’t go through.”

Researchers: Medical errors now third leading cause of death in United States

These common medical errors are major killers

A new study by patient safety researchers shows common medical errors may be the third leading cause of death in the U.S., after heart disease and cancer. (Deirdra O'Regan/The Washington Post)
Nightmare stories of nurses giving potent drugs meant for one patient to another and surgeons removing the wrong body parts  have dominated recent headlines about medical care. Lest you assume those cases are the exceptions, a new study by patient safety researchers provides some context.
Their analysis, published in the BMJ on Tuesday, shows that "medical errors" in hospitals and other health care facilities are incredibly common and may now be the third leading cause of death in the United States -- claiming 251,000 lives every year, more than respiratory disease, accidents, stroke and Alzheimer's.
Martin Makary, a professor of surgery at the Johns Hopkins University School of Medicine who led the research, said in an interview that the category includes everything from bad doctors to more systemic issues such as communication breakdowns when patients are handed off from one department to another.

"Figures Don't Lie But Liars Figure": The Disingenuous Obama Administration's Report That Claims Obamacare's Average Premiums Rose by Only 8% in 2015

The Obama administration is out with a report that the average 2015 Obamacare exchange premium increased by only 8% last year.

As best I can tell, that is a true statement.

It is also an incredibly disingenuous statement.

There is an old actuarial saying about how numbers can be manipulated to suite the author's agenda: "Figures don't lie but liars figure." That the 2015 Obamacare exchange rates rose by 8% is as close to a prefect example of this old adage that I can think of.

And, from all the press stories that went out with this as the lead, it appears lots of reporters bought it hook line and sinker.

Here is the operative statement in the report:
"Two thirds (67%) of HealthCare.gov consumers selected a new plan in 2016: all new consumers plus 43% of returning customers. Taking into account shopping, the increase in the average premium was 8% between 2015 and 2016."
Here's the catch: The administration mentions nothing about what kinds of health plans these 43% of returning consumers gave up to lower their increases.

When it comes to preventive health, car maintenance analogy breaks down

Jeff Jacoby’s analogy, comparing routine preventive health services to car maintenance, misses an important, and not too subtle, difference between the two. 
I can choose to keep my car tuned and the oil changed, and I may make those choices based on my financial situation. If I fail to maintain my car, the car may stop running or fail to pass inspection. Worst case, it’s sent to the junkyard.
If I cannot afford to take care of my health, and my body ceases to function normally, I will likely end up in a hospital, where I would receive necessary, and expensive, care, whether or not I (or my insurance) could pay for it. 
What’s more, my car has myriad lights and dashboard messages that tell me when something mechanical needs attention. Unfortunately, my body doesn’t have similar warning systems to tell me something is wrong before it’s too late for a small, inexpensive repair.
Diane Jette
Arlington

The power of the lone health care consumer is a free-market fantasy

JEFF JACOBY’S“Health insurance usurps consumer power” (Ideas, April 24) starts well but quickly veers into free-market fantasyland. Jacoby starts by talking about the lack of transparency in medical billing but ends up arguing that if if we stopped insuring routine medical care, consumers would force the cost of health care to fall. He writes, “It’s only when medical services aren’t reimbursed by a third party . . . that the consumer is king.” 

This is a fallacy for four reasons. First, when a person’s health or life is at stake, he or she is not the so-called rational economic actor that free-market economic theory requires.
Second, the individual consumer has virtually no bargaining power with hospitals and large medical practices. Want to feel powerless? Try buying medical insurance in the individual market.
Third, the stakes for individual consumers are simply too high for them to be rational economic actors. Medical expenses cause more consumer bankruptcies than any other single cause. 
Finally, even Jacoby believes that higher-priced medical expenses should be covered by insurance. (He likens this to the auto insurance we use “when the car is rear-ended or stolen.”) This would just exacerbate today’s two-tier system of medical practice, where family care physicians are lower-tier doctors than specialists, resulting in a significant shortfall of people willing to become family care doctors. 
Jacoby says that his prescription “seems odd.” Perhaps that is because it is.
Paul L. Criswell
Wellesley

Obamacare disaster will be Obama’s enduring domestic legacy

by Mark Thiessen - Washington PostHistorian David Maraniss notes, in Sunday’s Post, that President Obama came to office with the goal of changing “the trajectory of America” and leaving “a legacy as a president of consequence, the liberal counter to [Ronald] Reagan.” 
On the foreign-policy front, he is the anti-Reagan for certain. Reagan defeated Soviet communism and left us a safer world; Obama presided over the rise and metastasis of the Islamic State and left us a far more dangerous one. 
Domestically, Ronald Reagan told the American people: “The nine most terrifying words in the English language are ‘I’m from the government, and I’m here to help.’ ” Obama wanted to convince Americans that they were not terrifying. And the way he was going to do it was through the only great liberal legislative achievement of his presidency: Obamacare. 
He failed. Even before he leaves office, Obamacare has begun unraveling.

What Drug Ads Don’t Say

by Richard Friedman - NYT
DRUG companies are eager to tell you about their newest medicines. Turn on your TV or go online and there’s a new drug — with a hefty price tag — for whatever ails you, from antidepressants to painkillers to remedies for erectile dysfunction.
The pharmaceutical industry spends lavishly to get your attention: In 2014, drug makers poured $4.5 billion into so-called direct-to-consumer advertising, a 30 percent increase over two years. Drug makers claim they are educating the public with their ads, providing information that will help you make better choices about your medical care.
So in the spirit of education, let’s consider a recent online ad for Latuda, a new antipsychotic medication. A young woman rides a bike off into the sunas we are told that Latuda has been shown to be effective for many people with bipolar depression, followed by that staccato recitation of potential side effects that most viewers tune out.
http://www.nytimes.com/2016/04/24/opinion/sunday/what-drug-ads-dont-say.html?smprod=nytcore-iphone&smid=nytcore-iphone-share

The Dangers of ‘Polypharmacy,’ the Ever-Mounting Pile of Pills

by Paula Span

Dr. Caleb Alexander knows how easily older people can fall into so-called polypharmacy. Perhaps a patient, like most seniors, sees several specialists who write or renew prescriptions.
“A cardiologist puts someone on good, evidence-based medications for his heart,” said Dr. Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. “An endocrinologist does the same for his bones.”
And let’s say the patient, like many older adults, also uses an over-the-counter reflux drug and takes a daily aspirin or a zinc supplement and fish oil capsules.
“Pretty soon, you have an 82-year-old man who’s on 14 medications,” Dr. Alexander said, barely exaggerating.
Geriatricians and researchers have warned for years about the potential hazards of polypharmacy, usually defined as taking five or more drugs concurrently. Yet it continues to rise in all age groups, reaching disturbingly high levels among older adults.
“It’s as perennial as the grass,” Dr. Alexander said. “The average senior is taking more medicines than ever before.”
Tracking prescription drug use from 1999 to 2012 through a large national survey, Harvard researchers reported in November that 39 percent of those over age 65 now use five or more medications — a 70 percent increase in polypharmacy over 12 years.
http://www.nytimes.com/2016/04/26/health/the-dangers-of-polypharmacy-the-ever-mounting-pile-of-pills.html?smprod=nytcore-iphone&smid=nytcore-iphone-share

UnitedHealth to Pull Back From Insurance Exchanges, Citing Losses

By REED ABELSON
The UnitedHealth Group, one of the nation’s largest health insurers, told investors on Tuesday that it continued to lose hundreds of millions of dollars selling individual policies under the federal health care law. The company said it planned to pull out of a majority of states where it offered coverage and would offer policies on the public exchanges in “only a handful of states” for 2017.
UnitedHealth, which was a late and seemingly reluctant participant in the public exchanges, surprised investors last year when it announced its sizable losses, now estimated at more than a combined $1 billion for 2015 and 2016, because of its poor performance in the public exchanges. Policy analysts have been watching UnitedHealth closely as an indicator of whether the new individual market developed under the Affordable Care Act is sustainable.
Addressing investors, Stephen J. Hemsley, the company’s chief executive, continued to offer a pessimistic view. “The smaller overall market size and shorter-term, higher-risk profile within this market segment continue to suggest we cannot broadly serve it on an effective and sustainable basis,” he said. UnitedHealth estimated its losses from the exchanges would be $650 million this year.
UnitedHealth reported overall earnings from operations of $3 billion on revenue of $44.5 billion for the first quarter of 2016, compared with earnings of $2.6 billion on revenue of $35.8 billion for the 2015 quarter.
The company would not specify which states it planned to exit. It appears to be staying in Virginia and Nevada next year, but it is not known what other states remain attractive. A small unit of UnitedHealth, which offers exchange plans that feature a primary care clinic, is being tested in some states, including Georgia, where United says it is pulling out.

Immigrants, the Poor and Minorities Gain Sharply Under Affordable Care Act

By SABRINA TAVERNISE and ROBERT GEBELOFF
APRIL 17, 2016
LOS ANGELES — The first full year of the Affordable Care Act brought historic increases in coverage for low-wage workers and others who have long been left out of the health care system, a New York Times analysis has found. Immigrants of all backgrounds — including more than a million legal residents who are not citizens — had the sharpest rise in coverage rates.
Hispanics, a coveted group of voters this election year, accounted for nearly a third of the increase in adults with insurance. That was the single largest share of any racial or ethnic group, far greater than their 17 percent share of the population. Low-wage workers, who did not have enough clout in the labor market to demand insurance, saw sharp increases. Coverage rates jumped for cooks, dishwashers, waiters, as well as for hairdressers and cashiers. Minorities, who disproportionately worked in low-wage jobs, had large gains.
The health care law was one of the most bitterly contested pieces of legislation in the country’s history. It remains controversial because of its costs to both taxpayers and insurance customers. The high premiums and high deductibles of many plans still make coverage a crushing financial burden for some families.
And the law is not close to achieving the goal of universal coverage, in part because 19 states have declined to expand their Medicaid programs for the poor, an option the Supreme Court granted them in a landmark 2012 case. Nevertheless, the Times’s analysis shows that by the end of that first full year, 2014, so many low-income people gained coverage that it halted the decades-long expansion of the gap between the haves and the have-nots in the American health insurance system, a striking change at a time when disparities between rich and poor are growing in many areas.
“The law has clearly reduced broad measures of inequality,” said David Cutler, an economics professor at Harvard, who served in the Clinton administration and advised the 2008 Obama campaign on health issues. “These are people who blend into the background of the economy. They are cleaning your hotel room, making your sandwich. The law has helped this population enormously.”

Health Care Systems Try to Cut Costs by Aiding the Poor and Troubled

By SABRINA TAVERNISE
MARCH 22, 2015
“I’d go sometimes just to have a place to be,” he said.
He made 17 emergency room visits in just four months last year, a costly spree that landed him in the middle of an experiment to reinvent health care for the hardest-to-help patients here in Hennepin County.
More than 11 million Americans have joined the Medicaid rolls since the major provisions of the Affordable Care Act went into effect, and health officials are searching for ways to contain the costs of caring for them. Some of the most expensive patients have medical conditions that are costly no matter what. But a significant share of them — so-called super utilizers like Mr. Pate — rack up costs for avoidable reasons. Many are afflicted with some combination of poverty, homelessness, mental illness, addiction and past trauma.
A patchwork of experiments across the country are trying to better manage these cases. The Center for Health Care Strategies, a policy center in New Jersey, has documented such efforts in 26 states. Some are run by private insurers and health care providers, while others are part of broader state overhaul efforts. The federal government is supporting some, too, through its $10 billion Innovation Center, set up under the Affordable Care Act.
They raise a new question for the health care system: What is its role in tackling problems of poverty? And will addressing those problems save money?
“We had this forehead-smacking realization that poverty has all of these expensive consequences in health care,” said Ross Owen, a county health official who helps run the experiment here. “We’d pay to amputate a diabetic’s foot, but not for a warm pair of winter boots.”
Now health systems around the nation are trying to buy the boots, metaphorically speaking. In Portland, Ore., health outreach workers help patients get driver’s licenses and give them essentials, such as bus tickets, blankets, calendars and adult diapers. In New York, medical teams are trained to handle eviction notices like medical emergencies. In Philadelphia, community health workers shop for groceries with diabetic patients

Politics In Real Life: Rising Health Care Costs Weigh On Voters

by Alison Kodjak

When the health insurance premiums got to the point that they were higher than her mortgage, Renee Powell started to become cynical.
"There was something in me that just kind of switched," said the mother of two from Bartlesville, Okla. "I was OK with paying $750, but when it became about $100 more than my housing costs, it upset me."
Powell is an epidemiologist and used to work for the state in Oklahoma City. She had affordable insurance through that job.
But when her husband graduated from dental school, she stopped working, and the family moved to their current home, about 10 miles from the Kansas border.
She shopped for insurance through the Obamacare exchange and learned that rates in her new area were much higher than they had been in Oklahoma City. She bought a health plan from Blue Cross and Blue Shield of Oklahoma for $750 a month with a manageable deductible.
Then last year Blue Cross eliminated that plan — which is pretty common as insurers adjust to the Obamacare markets — and Powell was forced to buy the more expensive policy with a deductible of $3,000 for each person in her family. The insurance pays for checkups and prescriptions, but if anyone gets sick, Powell has to pay the full doctor bill until the deductibles are met.















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