Big Pharma Quietly Enlists Leading Professors to Justify $1,000-Per-Day Drugs
As it readies for battle with President Trump over drug prices, the pharmaceutical industry is deploying economists and health care experts from the nation’s top universities. In scholarly articles, blogs and conferences, they lend their prestige to the lobbying blitz, without always disclosing their corporate ties.
Over the last three years, pharmaceutical companies have mounted a public relations blitz to tout new cures for the hepatitis C virus and persuade insurers, including government programs such as Medicare and Medicaid, to cover the costs. That isn’t an easy sell, because the price of the treatments ranges from $40,000 to $94,000 — or, because the treatments take three months, as much as $1,000 per day.
To persuade payers and the public, the industry has deployed a potent new ally, a company whose marquee figures are leading economists and health care experts at the nation’s top universities. The company, Precision Health Economics, consults for three leading makers of new hepatitis C treatments: Gilead, Bristol-Myers Squibb, and AbbVie. When AbbVie funded a special issue of the American Journal of Managed Care on hepatitis C research, current or former associates of Precision Health Economics wrote half of the issue. A Stanford professor who had previously consulted for the firm served as guest editor-in-chief.
At a congressional briefing last May on hepatitis C, three of the four panelists were current or former Precision Health Economics consultants. One was the firm’s co-founder, Darius Lakdawalla, a University of Southern California professor.
“The returns to society actually exist even at the high prices,” Lakdawalla assured the audience of congressional staffers and health policymakers. “Some people who are just looking at the problem as a pure cost-effectiveness problem said some of these prices in some ways are too low.”
Even as drug prices have come under fierce attack by everyone from consumer advocates to President Donald Trump, insurers and public health programs have kept right on shelling out billions for the new hepatitis C treatments, just as Precision Health Economics’ experts have urged them. With a battle looming between the industry and Trump, who has accused manufacturers of “getting away with murder” and vowed to “bring down” prices, the prestige and credibility of the distinguished academics who moonlight for Precision Health Economics could play a crucial role in the industry’s multipronged push to sway public and congressional opinion.
While collaboration between higher education and industry is hardly unusual, the professors at Precision Health Economics have taken it to the next level, sharpening the conflicts between their scholarly and commercial roles, which they don’t always disclose. Their activities illustrate the growing influence of academics-for-hire in shaping the national debate on issues from climate change to antitrust policy, which ultimately affect the quality of life and the household budgets of ordinary Americans — including what they pay for critical medications.
The pharmaceutical industry is digging in, with one of its trade groups raising an additional $100 million for its “war chest.” For years, it has spent millions of dollars lobbying politicians, hoping to enlist their support on a wide range of legislation. It has similarly wooed doctors, seeking to influence what they research, teach and prescribe. Now, it’s courting health economists.
“This is just an extension of the way that the drug industry has been involved in every phase of medical education and medical research,” said Harvard Medical School professor Eric G. Campbell, who studies medical conflicts of interest. “They are using this group of economists it appears to provide data in high-profile journals to have a positive impact on policy.”
The firm participates in many aspects of a drug’s launch, both advising on “pricing strategies” and then demonstrating the value of a drug once it comes on the market, according to its brochure. “Led by professors at elite research universities,” the group boasts of a range of valuable services it has delivered to clients, including generating “academic publications in the world’s leading research journals” and helping to lead “formal public debates in prestigious, closely watched forums.”
Precision Health Economics may be well-positioned to influence the Trump administration. Tomas Philipson, an economist at the University of Chicago and the third co-founder of Precision Health Economics, reportedly served briefly as a senior health care adviser for the Trump transition team. He did not respond to requests for comment. Dr. Scott Gottlieb, reported to be a candidate for commissioner of the Food and Drug Administration, is a clinical assistant professor at New York University School of Medicine and a former “academic affiliate” of Precision Health Economics, according to its website.
Although it’s hard to gauge the firm’s precise impact, associates of Precision Health Economics have often waded into the political fray. Last fall, big pharma spent more than $100 million successfully defeating a California referendum that would have controlled the prices of both generic and name-brand drugs. Testifying in September at a state Senate hearing on a generic drug, co-founder Goldman steered the discussion to name-brand drugs, such as the hepatitis C treatments, arguing that their prices should not be regulated.
“We have to ensure access to future innovation, and that’s going to require some recognition that if someone develops an innovative drug, they’re going to charge a lot for it,” Goldman said.
Prescription drugs on average cost more than twice as much in the U.S. as in other developed nations. That’s mostly due to name-brand drugs. They represent 10 percent of all prescriptions but account for almost three-quarters of the total amountspent on drugs in the U.S. Their prices have doubled in the past five years.
The U.S. grants drugmakers several years of market exclusivity for their products and remains one of the only industrialized countries that allows them to set their own prices. These protections have allowed the pharmaceutical industry to become one of the economy’s most profitable sectors, with margins double those of the auto and petroleum industries.
To justify the value of expensive drugs, the professors affiliated with Precision Health Economics rely on complicated economic models that purport to quantify the net social benefits that the drugs will create.
For one industry-funded hepatitis C study, Lakdawalla and nine co-authors, including three pharmaceutical company researchers, subtracted the costs of the treatment from the estimated dollar value of testing all patients and saving all livers and lives. By testing and treating all patients now, they concluded, society would gain $824 billion over 20 years.
Critics have at times questioned the assumptions underlying the consultants’ economic models, such as the choice of patient populations, and suggested that some of their findings tilt toward their industry clients. For example, some have tried and failed to reproduce their results justifying the value of cancer treatments.
Precision Health Economics allows drugmakers to review articles by its academics prior to publication in academic journals, said a former business development manager of the consulting group. Such prior review is controversial in higher education because it can be seen as impinging on academic freedom.
“Like other standard consulting projects, you can’t publish unless you get permission from the company,” the former employee said. Carolyn Harley, senior vice president and general manager of the firm, said that pre-publication review was not company policy, but “in some cases, client contracts provide them the opportunity for review and comment before submission.”
“I have never published anything that I am not comfortable with or prepared to defend, nor have I ever been asked to,” said Lakdawalla about his firm’s research.
Goldman says the firm’s research is independent, and its clients don’t influence its findings. “From my perspective it’s very clear: I say things that piss off my sponsors, I say things that piss off the detractors,” he told ProPublica. “People are coming to us because they have an interest in sponsoring the research that’s generated. These are our ideas. This is how you get your ideas recognized.”
He said his consulting work does not involve setting prices of specific drugs, and his academic research focuses only on categories of drugs, rather than on particular brands.
The professors’ disclosure of their ties to the firm and to the pharmaceutical industry in scholarly articles is inconsistent: sometimes extensive, sometimes scanty. Members of Precision Health tend to reveal less about their paid work in blogs, public forums like conferences, and legislative testimony. At the Capitol Hill briefing last May on hepatitis C drugs, Lakdawalla didn’t mention his affiliation with Precision Health Economics, though it was listed in the journal issue, which was provided to attendees.
“Conflicts are always a concern, which is why it is important to be transparent about study methods — that way they can be scrutinized and debated in the academic literature,” said Lakdawalla, adding that he has disclosed his ties to the firm in at least 33 publications over the past three years.
Goldman said he and other academics at Precision Health Economics disclose their ties whenever appropriate, but typically journal editors and conference sponsors decide how to make that information available. “I wear two hats,” Goldman said in an interview. “And I try to reveal what that might mean in terms of perceived conflict of interest.”
The issues at stake aren’t just academic. Goldman says that pharmaceutical companies need to reap financial rewards from the enormous time and expense they invest in developing better medical treatments. Yet the high prices of some drugs have left government health programs strapped, or forced them to limit coverage. For example, one promising hepatitis C treatment is so expensive that some state Medicaid programs have chosen to cover its cost for only the sickest patients.
“Triage, triage, triage,” said Emily Scott, a Tennessee factory worker with hepatitis C who was denied coverage for the new treatment. “They set their price so high that we poor folks can’t afford it.”
Despite such cases, four researchers from Precision Health Economics warned in an article last month that any government controls on drug prices could actually shorten the average American’s life by two years by discouraging development of new drugs.
“As the pace of innovation slows, future generations of older Americans will have lower life expectancy relative to the status quo,” they wrote. The article, funded by the pharmaceutical trade group PhRMA, was published in Forum for Health Economics & Policy, of which Goldman is the editor-in-chief and co-founder. More than half of the editors listed on its masthead are current or former consultants at the firm.
Just after Precision Health Economics co-founder Dana Goldman completed his Ph.D. in economics at Stanford, in 1994, he was diagnosed with type 1 diabetes. He was 29 years old. With a pump he wears every day, he takes insulin to treat the disease.
“I would pay hundreds of thousands of dollars if I could take one pill that would make me better,” Goldman said.
His desire for a cure led to a new scholarly interest: the economics of medical innovation. Because there were few government funders for research in the field, he turned to industry. In 2005, Goldman established the firm with Lakdawalla and Philipson.
The headquarters of Precision Health Economics sits in a West Los Angeles office building flanked by palm trees, about 10 miles from Goldman’s academic center at USC. Goldman’s assistant at USC is also an executive assistant at the consulting firm. Daniel Shapiro, director of research compliance at USC, said that both Goldman and Lakdawalla were in compliance with the university’s standards on consulting.
Precision Health Economics has counted at least 25 pharmaceutical and biotech companies and trade groups as clients. The roster includes Abbott Nutrition, AbbVie, Amgen, Biogen, Bristol-Myers Squibb, Celgene, Gilead, Intuitive Surgical, Janssen, Merck, the National Pharmaceutical Council, Novartis, Otsuka, Pfizer, PhRMA, rEVO Biologics, Shire and Takeda. The firm has 85 staff members in nine locations.
Over the years, the founders recruited an impressive cadre of high-profile academics to consult for these clients. Early in 2016, the firm boasted more than two dozen academic advisers and consultants from top universities on its website. (The site later stopped identifying professors by their university affiliations.) The list of associates has also included some policy heavyweights who recently left the government, including a top official from the Congressional Budget Office, a senior economist from the White House’s Council of Economic Advisors, and an FDA commissioner. About 75 percent of publications by the firm’s employees in the past three years have either been funded by the pharmaceutical industry or have been done in collaboration with drug companies, a ProPublica review found.
Some academics worry that a tight relationship with industry might suggest bias. “I personally find, when your enterprise relies so substantially on a particular source of funds, you will tend to favor that source,” said Princeton economist Uwe Reinhardt.
Goldman says his industry connection has helped him ask better questions.
“The right way to do these things is not to push away the private sector, but to engage them,” he told ProPublica. “If we end up with a world where everyone who has a voice in a debate must be free of perceived bias, we lose the importance of the diversity of ideas.” In a later interview, he added, “You have to separate the appearance of the bias with actual bias.”
These ideas were recently echoed in an op-ed that he wrote with Lakdawalla in the online publication The Conversation.
“To be sure, collaboration with industry supplements our income through consulting fees. But no matter who funds our research — foundations, government, or companies — we apply the same template to our work,” wrote Goldman and Lakdawalla. “The ivory tower is not always the best place to understand the social benefits of treatments, the incentives for medical innovation, and how aligning prices with value can aid consumers.”
Engaging the private sector has indeed boosted Goldman’s income. According to federal conflict of interest forms filed last year, when he served on an advisory panel to the Congressional Budget Office, Goldman earned consulting income from the firm in the range of $25,000 to $200,000, on top of his income as a USC professor. He also has more than $500,000 in equity in the firm. Precision’s Harley says Goldman and Lakdawalla each have equity stakes of less than 1 percent, indicating that the firm is worth at least $50 million. Lakdawalla and Philipson have not publicly disclosed their consulting incomes.
In April 2015, Precision Health Economics was acquired by a privately held biotech company, Precision for Value. Terms weren’t disclosed.
Precision Health Economics raised its profile in 2013 when the president’s annual economic report cited a cancer study by several of the firm’s principals and consultants. To some critics, though, the study showed how industry funding can taint academic research.
As the study acknowledged, it was funded by Bristol-Myers Squibb, a company that at the time was developing a much-anticipated cancer treatment. It was priced at more than $150,000 per year when it eventually came on the market. All three founders of Precision Health Economics were listed as authors of the Health Affairs article, alongside one of their employees, yet none of the founders disclosed their ties to their consulting firm in the published study. In an interview, Goldman said this might have been an “oversight.”
Goldman later emailed ProPublica to clarify that the journal was aware that the study was a Precision Health Economics publication and that Goldman and his co-founders were affiliated with the firm. Goldman has published more than 25 articles and letters to the editor in Health Affairs since co-founding Precision Health Economics, and only five have listed the connection.
“This affiliation is clearly not a secret and I include it where relevant,” Goldman wrote in the email. “The bottom line is that disclosure policies vary across journals, journal editors, and over time. Definitions of what is ‘relevant’ are also subject to their own judgments.”
Donald Metz, executive editor of Health Affairs, said the journal followed its policy of leaving disclosure to the “authors’ discretion.” Its editorial staff did not exclude any information on conflicts or affiliations that the authors provided alongside their draft, he said.
As the cancer study gained national recognition, its methodology and findings came under fire. Researchers from Dartmouth College tried and failed to reproduce the results. Cancer care in the U.S., their research found, may actually provide less value than cancer care in Europe, considering cost.
“We know that [the U.S. health care system] is more disorganized and disorganization is more expensive, so it’s surprising to believe that the U.S. would perform better in a cost-effectiveness sense,” said Samir Soneji, one of the authors of the counter-study and an assistant professor of health policy at Dartmouth. The science in the original study, Soneji says, was “questionable.”
Soneji was not alone in his criticism. Aaron Carroll, a pediatrics professor at the Indiana University School of Medicine, reviewed the methodology and concluded that the Precision Health Economics researchers had used a measure that can frequently be misinterpreted. Instead of relying on mortality rates, which factor in a patient’s age of death, the study employed survival rates, looking at how long people live after diagnosis. Cancer screening, which can increase survival rates, is more frequent for some cancers in the U.S. than in other countries, Carroll says.
“When they wrote that paper using survival rates, they were clearly cherry picking,” Carroll told ProPublica. “If the arguments are flawed and people keep using them, I would be concerned that they have some other motive.”
The founders of Precision Health Economics defended their use of survival rates in a published response to the Dartmouth study, writing that they “welcome robust scientific debate that moves forward our understanding of the world” but that the research by their critics had “moved the debate backward.”
Precision Health Economics has become a prominent booster of a new way of setting drug prices — based on their overall value to society. Value is determined by comparing the drugs’ cost with their effectiveness in saving lives and preventing future health expenses.
Pharmaceutical companies have traditionally justified their prices by citing the cost of research and development, but recent research on drug pricing has challenged this argument. Many of the largest drug companies spend moreonsales and marketingthan on developing their drugs. And notably, one researcher has found that about 75 percent of new molecular entities, which are considered the most innovative drugs, trace their initial research funding back to the government.
“There is substantial evidence that the sources of transformative drug innovation arise from publicly funded research in government and academic labs,” said Dr. Aaron Kesselheim, an associate professor at Harvard Medical School whose research looks at the cost of pharmaceuticals. Pharmaceutical pricing, he says, is primarily based on what the market can bear.
Many early proponents of value pricing, including American health insurers, saw it as a way to rein in drug prices. Some nations, particularly those with national health systems, like the U.K., rely on official cost-effectiveness analyses to decide which drugs to pay for. Overpriced drugs are sometimes denied coverage. This powerful negotiating tool has helped keep drug prices down abroad.
Efforts to establish similar practices in the U.S., however, have been stymied by lobbying from patient groups, many of them funded by the pharmaceutical industry, contending that value pricing could lead to rationing of health care. More recently, though, the industry has used academic consultants to help it redefine the concept of “value” to justify its pricing.
At the congressional briefing on the new hepatitis C drugs, Harvard Medical School associate professor Anupam Jena, a Precision Health Economics consultant, suggested that part of a drug’s value is earning enough profit that pharmaceutical companies are enticed to develop treatments for other diseases. Otherwise, Jena said, “you don’t incentivize innovations that actually deliver value, and so the next cure … may not be developed.”
Princeton’s Reinhardt said pricing drugs based on this notion of value could give the industry carte blanche to charge whatever it wants. “If you did value pricing and say it’s OK for the drug companies to charge up to what the patient values his or her life to be, you are basically saying that the pharmaceutical companies can take your savings,” he said. “American society will not stand for that.”
Not long after the controversy over its cancer research, Precision Health Economics became embroiled in another academic spat related to a client’s product. This time, it was over a breakthrough treatment that, injected one to two times per month, could help millions of Americans with high cholesterol. At the $14,000-per-year price set by one of its makers, Amgen, the PCSK9 inhibitor could also hike the nation’s annual prescription drug costs by an unprecedented $125 billion, or 38 percent. Its price in the U.S. is twice as much as in the U.K.
The U.S. price of the drug has come under vigorous attack from the nonprofit Institute for Clinical and Economic Review. ICER, which began as a small research project at Harvard Medical School, studies the cost-effectiveness of drugs, balancing their value to patients against the impact of their cost on society. The Centers for Medicare and Medicaid Services proposed a new rule in March 2016 that includes the use of value-based pricing studies, specifically citing the work of ICER.
The industry has attacked many of the institute’s studies, particularly those that find a treatment is overpriced. Some patient groups have contended that ICER emphasizes cost savings because it receives funding from health insurers. However, foundations are ICER’s biggest source of funding, and it is also supported by the pharmaceutical industry and government grants. The pharmaceutical lobby has similarly attacked the Drug Effectiveness Review Project, a coalition of state Medicaid agencies and other payers, accusing it of using its studies to justify “rationing.”
ICER concluded in 2015 that the new cholesterol treatment, the PCSK9 inhibitor, should cost about one-fifth what Amgen is charging. A few months later, Philipson, the Precision Health Economics co-founder, and Jena wrote an op-ed in Forbes, citing the institute’s research and deriding its approach to value pricing as “pseudo-science and voodoo economics.” Only Philipson disclosed his ties to Precision Health Economics, and neither academic disclosed that Amgen was a client of the firm.
After being asked by ProPublica about the lack of transparency, Forbes added a disclosure statement to the op-ed. “Manufacturers of PCSK-9 inhibitors and novel treatments for hepatitis C, such as Amgen, Gilead, and Abbvie, are clients of Mr. Philipson’s consulting firm, Precision Health Economics, for which Dr. Jena also works,” the publication noted. “In general, the pharmaceutical and biotechnology companies which retain Precision Health Economics benefit from higher drug prices.”
Goldman, along with Precision Health Economics employees and two Harvard professors, including Jena, published their own study on the cholesterol drug in the American Journal of Managed Care, where Goldman serves on the editorial board. They found that the new cholesterol drugs were indeed cost-effective at the listed prices. The article disclosed the authors’ ties to Precision Health Economics and the source of funding: Amgen.
The drug is “not cheap, but it’s a good deal” for patients who need it, Goldman said, after his team’s economic models calculated its net value between $3.4 trillion and $5.1 trillion over 20 years.
ICER’s finding that the PCSK9 inhibitor was overpriced was later affirmed in a related study published in the peer-reviewed Journal of the American Medical Association, or JAMA. Associates of Precision Health Economics again rushed to Amgen’s defense. Philipson and an Amgen executive wrote a letter to the editor of JAMA to dispute the study’s conclusion that the price should be about $4,500 per month, less than a third of the drug’s average price.
The two studies made different assumptions that shaped their conclusions. Dr. Dhruv Kazi, one of the authors of the JAMA study and an associate professor at the University of California San Francisco, said that the Precision Health Economics study assumed that there were fewer eligible patients who would take the drug, lowering the cost to society. It also posited that they had a higher risk of cardiac events, like heart attacks, boosting the drug’s value as measured in lives saved.
“This is an example where you would end up assuming that the population is at higher risk than is true for the real world population and that would make your drug look better,” Kazi said. “It’s not a wild idea to think that a cost-effectiveness study funded by industry would look more favorable” to the industry’s viewpoint, he said. “If that weren’t the case, they wouldn’t fund it.”
Jena said the patient population for the Precision Health Economics study more accurately reflected the real world. One should not automatically assert that a study is “invalid or flawed” because of industry funding, he added.
The JAMA study “over-exaggerated the cost” of the drug and “unnecessarily rang ‘alarm bells,’” said Amgen spokeswoman Kristen Neese.
Amgen has ties to all three founders of Precision Health Economics. Working for other firms, Philipson has twice testified as an expert witness for Amgen, defending the company’s rights to drug patents, according to his curriculum vitae. The other two founders, Goldman and Lakdawalla, are principals at the Leonard D. Schaeffer Center for Health Policy and Economics at USC, which received $500,000 in late 2016 from Amgen for an “innovation initiative,” according to public disclosures. Goldman said the funds were unrestricted and could be used at the center’s discretion. Robert Bradway, the CEO and chair of Amgen, is on the advisory board of the university center, and Leonard Schaeffer, a professor at USC and the namesake of the center, sat on Amgen’s board of directors for nearly a decade.
With funding from Amgen, the Schaeffer Center hosted a forum in Washington, D.C., in October 2015 on the affordability of specialty drugs. Before a panel focused on the new cholesterol treatment, Goldman cautioned against lowering drug prices.
“We know that the pricing of these treatments is often controversial,” he told the crowd of policymakers, which included Sen. Bill Cassidy, R-La., a physician who sits on the Health, Education, Labor and Pensions Committee. “If we dropped all the prices today, in the long run, we wouldn’t have any innovation.”
The PCSK9 inhibitor’s price inhibits access for some patients who need it. Scott Annese, a 50-year-old computer technician from South Daytona, Florida, has diabetes and a total blood cholesterol level topping 260. After he suffered a heart attack and had two stents inserted in his left coronary artery, his doctor prescribed a statin, a low-cost drug to lower cholesterol. However, the statin combined with his diabetes to cause painful side effects, including muscle aches, cramping, and soreness in his legs that incapacitated him, he said. Amgen’s drug, his doctor told him, was the only other option.
But Annese, who makes $13.50 an hour, couldn’t afford the new drug. He doesn’t have health coverage through his job and says Obamacare, especially with its rising premiums, is too expensive for him. He tried to get insurance through Medicaid, but he earns too much to qualify. His last option, he said, is Amgen’s patient assistance program, which he has applied for. His application is pending.
“If you’re in the industry to help people, you’re not helping them if you raise the drugs to the point that they can’t afford it,” said Annese. “The drug companies are hurting the people who need it most.”
Gilead Sciences’ $84,000 list price for its highly effective treatment for the hepatitis C virus prompted dozens of state Medicaid programs and prison systems to restrict treatment to only the sickest patients. A congressional investigation in 2015 found that Gilead, which purchased the drug from a smaller pharmaceutical company, had set the price of the treatment at the peak it thought the market could bear, more than double what the drug’s original developers had suggested.
“Gilead pursued a calculated scheme for pricing and marketing its hepatitis C drug based on one primary goal, maximizing revenue, regardless of the human consequences,” said Sen. Ron Wyden, D-Ore., when he presented the findings of the congressional investigation.
While Precision Health Economics often portrays itself as an advocate for wider access to vital medications such as the hepatitis C drugs, the high price of those drugs forces some payers, such as the Medicaid programs, to ration them. As a result, the professors may influence who ultimately gets the drug and who doesn’t. The impact is reverberating in the rugged hills of eastern Tennessee, where hepatitis C is spreading due to the opioid epidemic. Because the virus can be asymptomatic for years, only a fraction of those infected know they are carriers, leading many to spread the potentially fatal liver disease unknowingly, mostly by sharing needles.
Over the past seven years, the number of acute cases of hepatitis C in Tennessee has tripled. The state has estimated that more than 100,000 residents are likely to have a chronic version of the disease without realizing it. Just last year, the state issued a public-health advisory addressing the crisis, but the rates of infection continue to rise.
It took years for Emily Scott, the factory worker from the Cumberland Gap region of eastern Tennessee, to find out she had the virus. After donating blood in January 2016, she received a certified letter from the blood bank informing her that her blood could not be accepted because it had tested positive for hepatitis C.
She didn’t believe the letter at first, hoping they had mistaken her blood with that of another donor. After all, she had never experienced any symptoms. But a local doctor reran her blood work and her diagnosis was confirmed.
Like many in her community, Scott had battled an addiction to drugs, mostly painkillers, and she had used syringes in the past for her highs. She’d been clean for the past four years but believes that she contracted the disease through her drug use.
“I made some mistakes,” said the 26-year-old Scott. “But I didn’t ask to be sick.”
Shortly after her diagnosis, Scott learned from a television advertisement that the new drugs had a cure rate of 90 percent. But getting the treatments would prove elusive.
Raising her two sons on her own, Scott barely supports the family with her weekly income of about $350 from sewing shirts at an apparel factory. She is one of more than 11,000 Tennesseans on Medicaid who have been diagnosed with hepatitis C, according to the most recent state data. If all of them received the new medication, the state estimated that it would cost over $1.6 billion, more than double what Tennessee’s Medicaid program spends on drugs in a year.
“There isn’t an endless bank account,” said Darin Gordon, Tennessee’s former Medicaid director, who was in charge when the hepatitis C cure was launched. “States have to balance budgets, and this came in and hijacked our budget.”
Tennessee quickly limited the treatments to the sickest patients. After reviewing the scientific literature, Gordon’s medical team determined that it was only medically necessary to treat patients whose livers had begun to show scarring, a sign that the disease had progressed beyond the initial latent stage. Even if patients’ conditions stabilize while they await the treatment, they are still contagious. Once the treatment is finished, they no longer can spread the virus.
Under this policy, less than 10 percent of diagnosed Medicaid patients have been treated, still costing the program more than $100 million in the past two years. Patients like Scott, whose liver has no significant scarring, were forced to wait for the disease to progress before being prescribed any of the new drugs.
The state denied Scott’s request for the cure in March 2016. But she wouldn’t let that stop her. She appealed and was granted a hearing in Knoxville, which she had to attend by phone because it was two and a half hours’ drive from her home. She explained to the judge that she was a single mother of two young boys and could not risk her health declining. A few days later, she received a court order in the mail, denying her access to the treatment.
By forcing Tennessee Medicaid and other public payers to delay coverage, the high price of the hepatitis C drugs incurs a social cost. While waiting to become sick enough for treatment, patients may transmit the disease. Some, including Scott, begin to feel symptoms like fatigue and muscle pains, which may hinder their ability to work.
“The drug companies do not have people’s interest in mind, they have money in mind,” Scott said. “It’s not fair that they are playing with people’s lives.”
Since the firm’s sale in 2015, Precision Health Economics’ three founders have taken roles in its parent company. Goldman is an executive economist at Precision for Value and chairs an advisory board focused on “value and evidence.” Lakdawalla is the chief scientific officer, and Philipson is listed as chief economist and the chair of the strategy and innovation board.
On its website, Precision for Value lays out how it can help biotech companies with “preliminary pricing, access, and evidence strategy” and “launch price strategy.” The company says that it can “pressure test” a company’s proposed messaging strategy on value with key stakeholders and determine how willing the market might be to pay future drug prices.
Under its new ownership, Precision Health Economics recently launched a groupfocused explicitly on assessing the value of innovative drugs. The firm’s three founders are involved with this Innovation and Value Initiative, which bills itself as an “unparalleled convergence of academic leaders and scientific experts.” Lakdawalla serves as executive director of the initiative. On the initiative’s health advisory panel, which is supposed to steer the research agenda, Goldman and Philipson sit alongside mostly executives from pharmaceutical companies and trade groups.
The initiative also has a scientific advisory group for internal peer review. All of its members are current or former Precision Health Economics consultants or staffers. Lakdawalla said in an email that all of its projects “either undergo academic peer review at a journal, or include an external peer reviewer outside [the firm].”
To promote the new initiative, Precision Health Economics has launched an extensive advertising campaign, sponsoring content in Health Affairs, writing op-eds in The Washington Post and Forbes, and even buying ads on Google.
In a phone conversation, Goldman was asked whether the stratospheric drug prices bolstered by the professors at Precision Health Economics deprive low-income patients, like Emily Scott, of vital treatments. He responded that it’s important to take a longer-term view.
“You worry about access for the people for whom there is a treatment,” he said. “I’m worried also for the access for people for whom there isn’t a treatment.”
When asked why he robbed banks, the legendary bank robber Willie Sutton said, “Because that’s where the money is.”
That’s also why the Dana-Farber Cancer Institute holds fund-raisers at Mar-a-Lago, the posh Palm Beach resort that serves as President Trump’s Florida home. It’s where the money is. The most recent gala, held over the past weekend, raised $2.2 million.
All for a good cause. But at what cost?
Some Dana-Farber staff members and a group of Harvard Medical students protested the connection with the Trump brand, and an online petition calling for a change in locale garnered more than 2,700 signatures. In response, Dana-Farber said it was too late to change destinations this year, but would avoid “controversial venues” in the future.
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Perhaps that means Dana-Farber will stay away from Mar-a-Lago as long as a Trump presidency is controversial. But staying away isn’t enough. Hospital leaders should also be speaking out against Trump policies that run counter to fundamental precepts of the medical profession. The most well known, from ancient times, translates to: First, do no harm. A more modern oath calls upon physicians to remember, “that I am a member of society, with special obligations to all my fellow human beings.”
In declining to relocate this year’s event, Dana-Farber said it wanted to “stay out of politics.” So much for that goal. Trump showed up, to cheers and applause. And with the president in the house, the juxtaposition between his agenda and the medical mission couldn’t be more stark.
Trump is promising to repeal the Affordable Care Act and replace it with a yet-to-be-determined plan, which will have broad consequences for patients everywhere. Massachusetts is not immune, even with the old Romneycare model to fall back on. The plan, implemented under former governor Mitt Romney, relied heavily on federal aid, and there’s no guarantee of what will happen to the flow of money under Trump and a Congress dominated by Republicans. A plan pushed by Speaker of the House Paul Ryan would reportedly take away the current Obamacare-related incentives for states to provide health insurance to low-income people.
Trump’s revamped executive order on immigration could also affect patients and the medical-research universe. After Trump’s first executive order, Colleen Farrell, a Harvard medical student and one of the Mar-a-Lago protest organizers, wrote in STAT that the president’s immigration mission “clashes with a core value of medicine, that all patients are welcome and deserving of medical care.” She called upon Dana-Farber to take a moral stand against Trump’s policies.
Dana-Farber is not alone in facing this challenge. The American Red Cross and Cleveland Clinic, among other nonprofits, have run into similar controversies over fund-raisers scheduled to be held this winter at Mar-a-Lago. They all stuck with the venue.
In the long run, a willingness to speak out against Trump’s policies is more important than changing locations. No one wants to be added to Trump’s enemies list, especially with so much at stake in the health care field. But if the best and brightest are too afraid to challenge Trump, who will? Speaking up for the poor and the displaced from around world isn’t about mere politics. It’s about life and death.
The willingness of wealthy people to donate big money to causes like cancer research is admirable. But as they celebrate one another’s generosity, surely they can savor their herb-marinated filet of beef someplace other than Mar-a-Lago. And if they really care about the health of the nation, they can urge the leaders of great institutions like Dana-Farber to speak out against policies that hurt the weakest and poorest.
VP Pence: ‘America’s Obamacare nightmare is about to end’
by Philip Rucker - Washington Post - February 23, 2017
Vice President Pence defended the Trump administration's plans to repeal and replace the Affordable Care Act, during a speech he delivered at CPAC on Thursday night. (Priya Mathew/The Washington Post)
Vice President Pence forcefully defended on Thursday night the Trump administration's plans to repeal and replace the Affordable Care Act, saying the law known as Obamacare is a “nightmare” and that the administration is committed to “an orderly transition” to a new health-care system.
Addressing a gathering of conservative activists in the Washington area, Pence sought to minimize the voices of the hundreds of people who have demonstrated against changes to the law at congressional town hall meetings across the country.
“America's Obamacare nightmare is about to end,” Pence said at the Conservative Political Action Conference. “Despite the best efforts of liberal activists around the country, the American people know better. Obamacare has failed, and Obamacare must go.”
Pence said he and President Trump are committed to giving every American “access to quality, affordable health insurance,” and want to replace the current system with one that allows people to purchase health coverage across state lines as they would insurance for their automobiles.
“We'll have an orderly transition to a better health-care system that finally puts the American people first,” Pence said.
In his 21-minute speech, Pence ticked through issues on which the administration has acted or plans to act soon, including cutting taxes, rolling back regulations, ending illegal immigration, expanding the military and restoring what he termed the “culture of life.”
Pence spoke of Trump as a historic figure in American politics, saying he is a modern-day Ronald Reagan. “Men and women of the conservative movement, this is our time,” Pence said.
Like the president, Pence voiced disdain for the media and sought to portray news organizations as the administration's political opponent.
“The media, the elites, the insiders, everybody else who profits off preserving the status quo, they dismissed our president,” Pence said. “They're still trying to dismiss all of us.”
He added, “This is not a government of the elites, by the media or for the establishment. What Nov. 8 showed, even if they didn’t listen, is this is still a government of the people, by the people and for the people.”
Cancer patients, survivors fear GOP efforts to dismantle the Affordable Care Act
by Laurie McGinley - Washington Post - February 23, 2017
Ashley Walton was 25 when a mole on her back turned out to be melanoma. She had it removed, but three years later she discovered a lump in her abdomen. She was then unemployed and uninsured, and so she put off going to a doctor. She tried to buy health insurance. Every company rejected her.
By the time Walton finally sought medical help, the melanoma had spread to her brain, lungs and elsewhere. And she eventually became eligible for California’s Medicaid program, which had been expanded under the Affordable Care Act. Two major surgeries, radiation and immunotherapy did not cure the cancer — but did beat it back.
The 32-year-old Oakland resident credits her survival to the ACA. Without it, “I would likely be dead, and my family would likely be bankrupt from trying to save me,” she said. Her greatest concern is that Republican assaults on the law will imperil that coverage.
“For cancer survivors, we literally live and die by insurance,” Walton said.
As the battle over the law escalates, cancer patients and survivors are among the most vocal of groups raising alarms about the GOP’s repeal effort. They are calling congressional offices and showing up at their representatives’ town hall meetings with angst-filled stories about a pre-ACA world in which they couldn’t get individual health plans because of their medical histories.
A woman who said the Affordable Care Act allows her to care for her terminally ill husband lashed out at Sen. Tom Cotton (R-Ark.) at a town hall event in Springdale, Ark. (Youtube/Springdale Public Schools)
Lawmakers seem to be hearing the message, especially on the issue of preexisting conditions, and they are reiterating promises to protect people with health problems in any replacement legislation. So far, though, Republicans have yet to identify a plan that would do that and still sustain insurers’ economic viability.
The fate of patient protections in the fight over the health-care law looms especially large for the cancer community because of the disease’s prevalence and the enormous cost of treatment. More than 15 million people in the United States are patients or survivors, with millions more affected as family members. And although new therapies offer much promise, the disease remains the second-leading cause of death in this country.
When The Washington Post recently asked readers how they may be affected by changes in health-care policy, a striking number said they or family members were fighting cancer and outlined an array of concerns.
“People are scared out of their minds,” said 34-year-old Erin Price Schabert, who seven years ago was treated for breast cancer. She frets whether that history would make her “uninsurable” in the individual market if she were to leave her job.
Indeed, many people described a kind of existential dread that matches their fear of cancer. Some worry that the law’s likely dismantling may put the latest oncology treatments, which can run $10,000 a month, out of reach. Others point to research showing that insurance status affects cancer patients’ survival. Still others are apprehensive about a possible end to the Medicaid expansion, which has covered millions of lower-income Americans in 31 states.
Even amid complaints about plans’ high premiums and deductibles, most people said they would rather see the imperfect law fixed than torn apart.
The issue affects Schabert professionally as well as personally. She works in Washington with young adults at a local cancer support organization, Smith Center for Healing and the Arts. Most are too old to stay on their parents’ insurance, and many are independent contractors and so aren’t covered by employer-based insurance.
“The ACA has been their lifeline,” she said.
The 2010 law included several protections for people with preexisting conditions such as cancer, asthma or diabetes. It required insurers to accept all applicants and prohibited them from setting premiums based on health status. It also barred them from setting limits on annual and lifetime benefits — a critical provision for cancer patients.
None of that was the case before the ACA, when insurers in the individual market routinely rejected sicker, more-expensive patients or charged them much more. “Many cancer patients were unable to get coverage . . . or could only get inadequate coverage,” J. Leonard Lichtenfeld, deputy chief medical officer of the American Cancer Society, told lawmakers at a recent House committee hearing. “Cancer patients need to know that they have insurance.”
This month, House Energy and Commerce Committee Chairman Greg Walden (R-Ore.) introduced legislation that would continue several patient protections included in the ACA. His bill would require health plans to accept all applicants and prohibit them from excluding benefits for preexisting conditions. It would also ban insurers from setting premiums based on people’s health status.
“The push to rebuild our health care system is all about patients, which is why we are making this commitment to protect patients living with preexisting conditions — it’s only fair,” Walden said in a statement.
Kirsten Sloan, senior director for policy analysis at the American Cancer Society Cancer Action Network, said it would be “a plus” if protections for people with preexisting conditions were maintained. But looking at the whole picture is crucial, she added.
“What we don’t know is what happens to the [premium] subsidies, to Medicaid, to all the other components,” she said.
House Republicans last week released a policy statement designed to show where they are headed on health care. It called for major changes in those federal subsidies, which have helped the vast majority of people with ACA policies afford their plans. The statement also talked up a drastic Medicaid overhaul and touted a “next generation” of state high-risk health insurance pools for people with big medical bills.
The latter idea sets Herbert Malamut of Southampton, N.J., on edge. He remembers the old insurance pools, which dozens of states used before the ACA as a fallback for people who couldn’t get coverage.
“Those pools were poorly funded and had high premiums and skimpy benefits,” said Malamut, 61, who was diagnosed with non-Hodgkin’s lymphoma in 2012. “I don’t know why we would go back to them.”
The GOP intends to eliminate the law’s mandate that most Americans be insured, but leaders have not detailed how they plan to motivate healthy people to sign up. Without a balance of healthy and sick enrollees, premiums can skyrocket and insurers opt out, putting the individual market at risk of collapse.
One potential approach would require individuals to maintain health insurance or face some kind of financial penalty when they next seek coverage, although insurers still could be blocked from charging higher premiums based on health status. Some experts note the negatives of a continuous coverage requirement for people dealing with a disease such as cancer. Individuals may have gaps in coverage because they are too sick to work or have unexpected expenses, or lose insurance because of a divorce or spouse’s death.
“Some people will fall through the cracks,” said Larry Levitt, senior vice president at the Kaiser Family Foundation.
The swirl of Republican ideas is only stoking the cancer community’s anxiety.
Elizabeth Alcorn, 56, and her husband have a small-group policy through her dental practice in Charlottesville. Because she has severe arthritis, she wants to retire early but is worried about coverage in a post-ACA world. “How are we going to manage this?” she said. “We are too young for Medicare.”
Her husband, who is 60, shares her concerns. He’s dealing with prostate cancer that just recurred after several years. “I have had good security with [the ACA],” Gerry Corridon said, “and now we don’t know how this is going to end up.”
In Thousand Oaks, Calif., the law’s bleak future is weighing heavily on 61-year-old Maryann Hammers, too. Diagnosed with ovarian cancer three years ago, the freelance writer underwent surgery and chemotherapy and often couldn’t work. The disease recurred seven months later, and now blood tests suggest that it’s back yet again.
“I know what’s coming next,” she said. “And it’s a friggin’ nightmare.”
There’s one thing she hasn’t had to worry about: paying for her treatment. Since January 2014, Hammers has been covered by an ACA health plan. She’s “completely panicked” about the Republicans’ plan to repeal the law and what that could do to her coverage next year.
“Without coverage, I don’t get care, and without care, I die,” she said. “So, to me, the people trying do away with the ACA are the ultimate death panel.”
Commentary: Repealing Obamacare will create harm for millions
HOW CAN A physician oppose people getting health care? It's a puzzle to me.
The nomination and confirmation of Dr. Tom Price - widely described in the media as a fierce Obamacare critic - as secretary of Health and Human Services set my physician mind to thinking how two people (Price and I) both trained as physicians, yet have come to dramatically different conclusions on what Americans want and need as patients.
Price once ran the orthopedic clinic at Emory Hospital in Atlanta. I once ran a primary care clinic at a Philadelphia hospital. Patients in both these settings are usually low-income - uninsured, if the clinic will take them, or insured by Medicaid. Before the Affordable Care Act - or "Obamacare," as it has come to be known - low-income working adults were not eligible for Medicaid.
Without Medicaid either for the individual patients, or under a program of support to hospitals serving low-income populations, there is no care for these folks. The Affordable Care Act - in states that chose to do so - expanded Medicaid to the low-income working population. Repealing Obamacare would end this insurance.
In my training as a physician, I rejoiced to see my patients able to receive care for diabetes, hypertension and cancer.
Tell me, Dr. Price: If you oppose Obamacare and Medicaid expansion, do you envision the poor of Atlanta (or Pennsylvania) letting fractures heal without medical care or anesthesia? In your world, will only those able to pay be allowed to have a new knee or a new hip?
In my primary-care practice, patients and I made decisions together about the best treatment. I can't remember a single instance - in over 30 years in practice - where the government (Medicare or Medicaid) interfered with that decision, except when a woman wanted an abortion and Medicaid did not pay. But I can think of numerous instances where private insurance companies - the very companies Price wants to strengthen - interfered with my decision-making. And most of the successful appeals were based on government regulations that safeguarded the rights of patients when private insurance ran amok.
So when Price is concerned that the government has "commandeered medical decision-making" - I ask him how? By protecting our seniors from astronomical medical bills because Medicare limits what physicians can charge? I was taught in medical school to put my patients first. Price, under the clever phrase of "empowering patients," wants to put physicians first.
In medical school, I was taught to respect all patients, to take care of all those who needed care, regardless of income. Price must have been absent that day. I can't imagine otherwise how he can propose a health-care system that discriminates against the sick, will be unaffordable for the more than 20 million people who have gained insurance under Obamacare and will favor doctors over patients.
Is there anything on which we might agree? He wants to "modernize" Medicare. But if we look closely, Price aims to replace Medicare - the most popular health-insurance plan in the country - with vouchers that will let people buy the amount of care "they need." He doesn't say whether we can all buy crystal balls, along with the vouchers, to see into the future. And me? I'd like to see improved Medicare for All - without private insurance companies, co-pays or deductibles. It would save our country, and individuals, billions of dollars. And allow all of us doctors to take care of everyone. I'd rather have that dream than the nightmare I see with Price in charge of health care.
It's too late to send Price back to medical school to learn what it means to really support patients. But the prescription I write today is for everyone to let their elected officials know that health care for all is important - that we need to improve on Obamacare, but that the health of our state and nation will not be improved with millions losing health care.
Gene Bishop is clinical professor of medicine at the Perelman School of Medicine, University of Pennsylvania.
U.S. life expectancy will soon be on par with Mexico’s and the Czech Republic’s
by Lenny Bernstein - Wasington Post - February 21, 2017
Life expectancy at birth will continue to climb substantially for residents of industrialized nations — but not in the United States, where minimal gains will soon put life spans on par with those in Mexico and the Czech Republic, according to an extensive analysis released Tuesday.
South Korean women and Hungarian men are projected to make the largest overall gains (with South Koreans second among males). There is a better-than-even chance that South Korean women will live to an average of 90 years old by 2030, which would be the first time a population will break the 90-year barrier, according to the research published in The Lancet.
Not so in the United States. “Notable among poor-performing countries is the USA,” the researchers wrote, “whose life expectancy at birth is already lower than most other high-income countries, and is projected to fall further behind, such that its 2030 life expectancy at birth might be similar to the Czech Republic for men, and Croatia and Mexico for women.”
Countries are listed by median projected increase in life expectancy, largest to smallest, from 2010 to 2030. The red dots show the median increase at the end of that period. (Source: The Lancet)
Americans will gain only a couple of years of life expectancy between 2010 and 2030, the study predicted, keeping life spans in the early 80s for women and late 70s for men. The study projects a life expectancy of 83.3 for women in the United States and 79.5 for men in 2030, up from 81.2 for women and 76.5 for men in 2010.
The reasons for the United States' lag are well known. It has the highest infant and maternal mortality rates of any of the countries in the study, and the highest obesity rate. It is the only one without universal health insurance coverage and has the “largest share of unmet health-care needs due to financial costs,” the researchers wrote.
Tellingly, the United States was the first high-income country to see a halt to the pattern of increasing height in adulthood, a reliable indicator of improving public health, according to Majid Ezzati, a professor of public health at Imperial College London, who led the research team.
Some Americans get a “bad start to life in nutrition and education” and suffer “high rates of homicide,” Ezzati said. “And then lack of universal insurance. Some people probably get diagnosed too little and too late.
“If you have good insurance and you live on the East Coast and the West Coast, you probably get the best health care in the world,” he added. “It’s not the technical quality of it, which is superb. It's the spread of it.” In many parts of the country, top health care simply isn't available.
In December, the U.S. government reported that life expectancy had declined in 2015 for the first time since 1993 as death rates for eight of the 10 leading causes of death, including heart disease, rose.
The Post's Lenny Bernstein explains a new report that shows life expectancy for Americans has declined for the first time since 1993. (Monica Akhtar, Gillian Brockell/The Washington Post)
In 2015, research by Princeton University economists Anne Case and Angus Deaton brought worldwide attention to the unexpected jump in mortality rates among white middle-aged Americans. That trend was blamed on what are sometimes called diseases of despair: overdoses, alcoholism and suicide.
Demographer Sam Preston, a sociologist at the University of Pennsylvania who has conducted numerous studies on this subject, cited the prescription opioid epidemic, homicides, obesity and the lingering effects of smoking — the latter now declining among many groups in the United States — as primary causes for the poor showing.
“It's very worrisome,” said Preston, who was not involved in the new research. “The U.S. is at the bottom of the barrel among [Organization for Economic Cooperation and Development] countries, and its relative position is worsening, not improving.”
The results released Tuesday echo some earlier analyses, including a report from the United Nations. Ezzati's group approached the task in a somewhat different way, running the numbers through 21 statistical models, combining the results and attaching probabilities to the conclusions.
Like other researchers, they found that women's advantage in life expectancy over men will continue to narrow, the result of more injuries, lung cancer and cardiovascular disease among women. In most places, gains in life span will come more from postponing death among older people, rather than eliminating killers of the young and middle-aged, such as infections. The analysis does not link specific causes of death to various countries' life expectancies.
Nations such as China, Russia and India were not included, because they did not have adequate historical data, Ezzati said.
In contrast to the United States, South Korea “has a remarkable investment in early childhood nutrition,” has been taking advantage of medical advances and technology across its population and has some of the world's lowest obesity and hypertension rates, Ezzati said. The researchers said there is a 57 percent chance that the nation's women will live an average of more than 90 years by 2030 and a better than 95 percent chance that its men will survive beyond 80 (along with men in Australia and Switzerland).
“They seem to be getting a lot of things right at the same time, and getting them right for almost everyone,” he said.
Across the country, Republicans have been facing crowds demanding to know how they will protect the 20 million Americans who gained health insurance thanks to the Affordable Care Act, and will lose it if the act is repealed. And after all that inveighing against the evils of Obamacare, it turns out that they’ve got nothing.
Instead, they’re talking about freedom — which these days is the real refuge of scoundrels.
Actually, many prominent Republicans haven’t even gotten to the point of trying to respond to criticism; they’re just whining about how mean their constituents are being, and invoking conspiracy theories. Talk about snowflakes who can dish it out but can’t take it!
Thus, Representative Jason Chaffetz insisted that the public outcry is just “a paid attempt to bully and intimidate”; Sean Spicer, the White House press secretary, calls all anti-Trump demonstrations a “very paid, AstroTurf-type movement.” And the tweeter in chief angrily declared that protests have been “planned out by liberal activists” — because what could be worse than political action by the politically active?
But perhaps the saddest spectacle is that of Paul Ryan, the speaker of the House, whom the media have for years portrayed as a serious, honest conservative, a deep thinker about how to reform America’s safety net. That reputation was never justified; still, even those of us who long ago recognized him as a flimflammer have been struck by his utter failure to rise to this occasion.
After years to prepare, Mr. Ryan finally unveiled what was supposedly the outline of a health care plan. It was basically a sick joke: flat tax credits, unrelated to income, that could be applied to the purchase of insurance.
These credits would be obviously inadequate for the lower- and even middle-income families that gained coverage under Obamacare, so it would cause a huge surge in the number of uninsured. Meanwhile, the affluent would receive a nice windfall. Funny how that seems to happen in every plan Mr. Ryan proposes.
That was last week. This week, perhaps realizing how flat his effort fell, he began tweeting about freedom, which he defined as “the ability to buy what you want to fit what you need.” Give me consumer sovereignty or give me death! And Obamacare, he declared, is bad because it deprives Americans of that freedom by doing things like establishing minimum standards for insurance policies.
I very much doubt that this is going to fly, now that ordinary Americans are starting to realize just how devastating loss of coverage would be. But for the record, let me remind everyone what we’ve been saying for years: Any plan that makes essential care available to everyone has to involve some restriction of choice.
Suppose you want to make insurance available to people with pre-existing conditions. You can’t just forbid insurance companies to discriminate based on medical history; if you do that, healthy people won’t sign up until they get sick. So you have to mandate the purchase of insurance; and you have to provide subsidies to lower-income families so that they can afford the policies. The end result of this logic is … Obamacare.
And one more thing: Insurance policies must meet a minimum standard. Otherwise, healthy people will buy cheap policies with paper-thin coverage and huge deductibles, which is basically the same as not buying insurance at all.
So yes, Obamacare somewhat restricts choice — not because meddling bureaucrats want to run your life, but because some restrictions are necessary as part of a package that in many ways sets Americans free.
For health reform has been a hugely liberating experience for millions. It means that workers don’t have to fear that quitting a job with a large company will mean loss of health coverage, and that entrepreneurs don’t have to fear striking out on their own. It means that those 20 million people who gained coverage don’t have to fear financial ruin if they get sick — or unnecessary death if they can’t afford treatment. For there is no real question that Obamacare is saving tens of thousands of lives every year.
So why do Republicans hate Obamacare so much? It’s not because they have better ideas; as we’ve seen over the past few weeks, they’re coming up empty-handed on the “replace” part of “repeal and replace.” It’s not, I’m sorry to say, because they are deeply committed to Americans’ right to buy the insurance policy of their choice.
No, mainly they hate Obamacare for two reasons: It demonstrates that the government can make people’s lives better, and it’s paid for in large part with taxes on the wealthy. Their overriding goal is to make those taxes go away. And if getting those taxes cut means that quite a few people end up dying, remember: freedom!
As a medical resident working 30-hour shifts, I quickly came to cherish those rare moments when I could duck out of the bustling and brightly lit hospital corridors and lay my head on a pillow.
Granted, it was often in a barren call room with a stiff mattress and a rumbling heater. There I’d lie, counting the seconds before an alarm sounded to alert me that a patient might have shifted in bed or an IV medication finished, or an overhead page called some doctor (please, not me!) to some floor to deal with yet another issue.
But as hard as it might be for doctors to rest in the hospital, it’s infinitely harder for patients.
I see this every time I trudge from my call room to a patient’s room. I tiptoe past Bed A to Bed B, where a patient might be moaning in pain or coughing uncontrollably. The patient is not the only one suffering: His roommate, typically separated by a flimsy curtain, also can’t sleep a wink all night.
As a doctor, I’m struck daily by how much better hospitals could be designed. Hospitals are among the most expensive facilities to build, with complex infrastructures, technologies, regulations and safety codes. But evidence suggests we’ve been building them all wrong — and that the deficiencies aren’t simply unaesthetic or inconvenient. All those design flaws may be killing us.
It’s no secret that hospital-acquired infections are an enormous contributor to illness and death, affecting up to 30 percent of intensive care unit patients. But housing patients together very likely exacerbates the problem. Research suggests that private rooms can reduce the risk of both airborne infections and those transmitted by touching contaminated surfaces. One study reported that transitioning from shared to private rooms decreased bacterial infections by half and reduced how long patients were hospitalized by 10 percent. Other work suggests that the increased cost of single-occupancy rooms is more than offset by the money saved because of fewer infections. Installing easier-to-clean surfaces, well-positioned sinks and high-quality air filters can further reduce infection rates.
Falls in the hospital are another major problem, leading to serious injuries, longer hospital stays and significant costs. Trying to navigate the unfamiliar space of a hospital room, often while disoriented by pain and medications, makes many patients susceptible to falling. A number of design factors contribute: poorly lit areas, slippery floors, toilets that are too high or too low. How quickly staff members can reach patients also makes a difference. For example, decentralized nursing stations that are closer to patient rooms and allow nurses direct lines of sight to beds can reduce the risk of falls and injuries.
There’s also much we can do to improve the patient experience, which, of course, is inextricably linked to how well patients rest and recover. Privacy remains a challenge in hospitals, despite laws like the Health Insurance Portability and Accountability Act, a federal law known as Hipaa meant to protect patient privacy. As doctors, we’re taught not to talk about patients in elevators, yet we routinely discuss their sexual or drug history in rooms while a stranger on the other side of a curtain can hear every word. Research has found that almost all physicians breach confidentiality in this way, and that patients in curtained spaces are more likely to withhold parts of their medical history or refuse parts of the physical exam.
And then there’s the problem of noise. The average noise level in hospitals far exceeds guideline-based recommendations, making it hard for patients to sleep. Reducing exposure to noise — through earplugs, sound-absorbing acoustic panels, quieter staff conversations, and fewer unnecessary alarms — can improve the quality of patients’ sleep.
Some of the most interesting research on the way hospitals are built examines the role of nature to promote healing. Research pioneered by Roger Ulrich, now a professor of architecture at the Center for Healthcare Building Research at Chalmers University of Technology in Sweden, suggests that when it comes to recovering from illness, the more nature the better. But too often patients and physicians find themselves cooped up in dim rooms and sterile hallways with little access to natural light or views of nature: too much concrete, not enough jungle.
Dr. Ulrich’s early work explored how patients recovered after gallbladder surgery based on whether they were assigned to a room with a window that had a view of nature or of a brick wall. The study, now one of the most widely cited in the hospital design literature, found that patients looking out at trees had shorter hospital stays and took fewer pain medications than those viewing a brick wall.
Dr. Ulrich said the idea for the study came from his personal experience with illness. “As a teenager, I had some serious illnesses that forced me to spend time at home in bed,” he told me. “My window was my compass of stability. Every day, I watched the trees in the wind. There was something endlessly calming about it.”
Similar research has found that patients with bipolar disorder who are randomly assigned to brighter, east-facing rooms with morning sunlight had hospital stays nearly four days shorter than those with west-facing rooms. Even just images of nature may be beneficial. One study found that psychiatric patients tend to require far fewer medications for anxiety and agitation when photos of landscapes hang on hospital walls compared to walls adorned with abstract art or left bare. And people watching videos of nature seem to have higher tolerance for pain, more positive emotions, and lower heart rates and blood pressure.
“Hospitals can be dangerous and unpleasant,” Dr. Ulrich said. “But there’s a lot we can do to keep patients safe and help them recover.”
Research supports an urgent need to change the way we build, maintain and work in hospitals, and many facilities could do more to promote rest and healing while preventing stress and infection. It’s clear that evidence-based medical care will require evidence-based hospital design.
With Coverage in Peril and Obama Gone, Health Law’s Critics Go Quiet
by Jonathan Martin - NYT - February 19, 2017
WASHINGTON — For seven years, few issues have animated conservative voters as much as the repeal of the Affordable Care Act. But with President Barack Obama out of office, the debate over “Obamacare” is becoming less about “Obama” and more about “care” — greatly complicating the issue for Republican lawmakers.
Polling indicates that more Republicans want to make fixes to the law rather than do away with it. President Trump, who remains popular on the right, has mused about a replacement plan that is even more expansive than the original. The conservative news media are focused more on Mr. Trump’s near-daily skirmishes with Democrats and reporters, among others, than on policy issues like health care. And the congressional debate, as well as the paid advertisements on both sides, is centered on the substance of the law rather than its namesake, draining some of its toxicity on the right.
As liberals overwhelm congressional town hall-style meetings and deluge the Capitol phone system with pleas to protect the health law, there is no similar clamor for dismantling it, Mr. Obama’s signature legislative accomplishment. From deeply conservative districts in the South and the West to the more moderate parts of the Northeast, Republicans in Congress say there is significantly less intensity among opponents of the law than when Mr. Obama was in office.
“I hear more concerns than before about ‘You’re going to repeal it, and we’re all going to lose insurance’ because they don’t think we’re going to replace it,” said Representative Mike Simpson, a Republican who represents a conservative district in Idaho.
Since Mr. Obama signed the Affordable Care Act into law, about 20 million Americans have gained insurance because of it. And millions more who had pre-existing health conditions have been able to obtain coverage under the law. At the same time, many Americans have seen their premiums rise or their choices of insurance carriers dwindle.
But it was not until now, with the Republicans taking control of the federal government, that the debate fully shifted from the theoretical to the tangible. It was easy for conservatives to rally against a law identified with a president they despised when he was capable of vetoing any repeal. Now that he is gone and the law’s benefits appear to be on the chopping block, the people who stand to lose the most are the most vocal.
“I’ve heard from constituents who have been harmed by the Affordable Care Act over the course of its being in existence,” said Representative Leonard Lance, Republican of New Jersey, whose affluent district Mr. Trump narrowly lost last year. “More recently, because of our discussions on repairing it, I’ve heard from those who do not wish to have the act amended. More recently, that is the preponderance of those who have contacted me.”
It is a longstanding rule of politics that rallying opposition to a proposal is usually easier than galvanizing support. And never is this more the case than when a widely distributed benefit is at risk of being taken away.
“I was here in 2009 and 2010, and we’re not getting the anti-Obamacare calls like that,” said Representative Brett Guthrie, a Kentucky Republican who is on one of the committees tasked with rewriting the law. “I think people are going to hold us accountable for making sure we not only repeal, but we have a law in place that creates a better opportunity for people.”
The demands from conservative-leaning constituents in districts like Mr. Guthrie’s are plainly shifting. In a nationwide CBS News poll last month, 53 percent of Republicans said they wanted to change the law to make it work better while 41 percent said they wanted to abolish it.
Overhauling the law, however, is far more politically complicated than simply scrapping it. Congressional Republican leaders were met with a backlash from their own ranks after it emerged that they were considering financing a new law by ending the longstanding practice of letting employers exclude from taxation the health benefits they offer.
“Our voters do expect action, but as you make changes you become vulnerable to attack,” Representative Tom Cole of Oklahoma said. “This is fraught with difficulties, no doubt about it.”
Adding to the anxiety is Mr. Trump, who is a wild card on the health law. His health secretary, Tom Price, signaled to House Republicans at a private meeting on Thursday that the administration would let Congress draft a replacement bill, Mr. Cole said.
But the president has said multiple times that he is uneasy about depriving anybody of health insurance, and he may bridle if Democrats attack any Republican plan that may lead to that.
As Democrats note, Mr. Trump owes his victory in part to voters who have benefited from the law.
“A lot of economically vulnerable Republican voters have come to rely on government’s involvement in making sure they have affordable health care,”said Geoff Garin, a Democratic pollster.
And with Mr. Trump and Republican lawmakers facing less pressure from the right than the left, conservative groups worry that the party will not ultimately have the stomach to repeal the law, which Republicans have been running against since 2010.
“Voters gave Republicans the charge to repeal and replace Obamacare, and the continued delays and discussions about repairing Obamacare need to stop,” David McIntosh, the head of the Club for Growth, a conservative advocacy group, said last week.
Pen Bay doctors worry that switch to single board could cause problems
They fear service cutbacks and a loss of local control at the Rockport hospital if MaineHealth directors make all the decisions instead of a local board.
by Stephen Betts - Portland Press Herald - February 22, 2017
ROCKPORT — Doctors at Pen Bay Medical Center are concerned that a proposal by parent corporation MaineHealth to create a single board of directors could mean a loss of local control and potentially cuts in services at the Rockport hospital.
The president of the Pen Bay medical staff voiced the concerns in a Jan. 9 letter to employees that summarized a Jan. 5 meeting of physicians. A similar letter was sent in November by the physicians at Waldo County General Hospital in Belfast.
MaineHealth has proposed creating a single board of trustees that would make decisions for all of its member hospitals and affiliated organizations, such as nursing homes and home health agencies. Currently, each member organization has a separate board.
Pen Bay Healthcare and Waldo County General, which became a MaineHealth member in 2009, merged in 2015 into a single organization and board called Coastal Healthcare Alliance, which remains a member of MaineHealth.
“For clinicians at PBMC, we do not have a good recent history of alignment and confidence in the local administration, nor have we had good support” from MaineHealth, said the letter from Dr. Stephanie Lash, president of the medical staff.
Lash said the medical staff recognizes the need for more regional planning of health care services, but that there are significant differences between health care in the urban/suburban environment of Portland and rural Maine.
“The floated governance model of a single board, of which 50 percent is Portland-based, raises real concerns about preserving a rural voice, as only one small hospital would have to vote with Portland to create a majority on any issue,” she wrote.
“Moreover, as PBMC is now rolled into (Coastal Healthcare Alliance), it appears there would be only one board member for both PBMC and Waldo, meaning in essence that PBMC, one of the largest smaller hospitals, would have a one-half vote on the proposed new board. How this one-half person could adequately and fully represent all of the needs/nuances of our hospital is not clear.”
Lash also said that physicians have concerns about the finances at Pen Bay.
“And finally, coming to the cost/financial issues, there is a deep sense of frustration and even anger re the financial position of PBMC. While easy to cast blame elsewhere in any situation, the financial problem for this hospital is something physicians care about, but not something we can fix,” she said.
Coastal Healthcare Alliance reported a $3.26 million operating loss in the 12 months ending Sept. 30, out of a total annual budget of $228.5 million. A source told the Courier-Gazette in December that the loss was because of Pen Bay, and would have been greater if not for a surplus at Waldo County General.
MaineHealth confirmed in December that Pen Bay lost money in the most recent fiscal year, but said the final numbers had not been audited and a bottom-line figure was not available.
The last financial information available for PBMC separately was for 2013-14, when it reported a $4 million loss and had a $111 million budget.
Pen Bay physicians would like to see much clearer evidence of how creating a single board of trustees would improve Pen Bay’s financial situation, rather than just allowing MaineHealth to absorb an old loss from PBMC, which they fear would result in cuts or collapse of clinical services going forward, according to the Pen Bay medical staff letter.
The letter also cited problems with the installation of a health care record-keeping computer system known as EPIC as an example.
“All of our struggles with the EPIC system have probably been the most disruptive and difficult direct effect on our practice we can remember. And this product, rolled out by (MaineHealth), is still not working well in the ambulatory setting. It has also been vastly more costly than was originally promised,” Lash said.
A Courier reporter attended a MaineHealth meeting with Pen Bay physicians on Dec. 15, but was asked to leave. MaineHealth officials said the meeting was private and the first opportunity for doctors to hear MaineHealth’s presentation on creating a single board. No public meetings on the proposed unification have been held in the region.
GOP Considers Trimming Health Law's 10 Essential Benefits
Maine Public - February 22, 2017
As Republicans look at ways to replace or repair the Affordable Care Act, many suggest that shrinking the list of services that insurers are required to offer in individual and small group plans would reduce costs and increase flexibility.
That option came to the forefront last week when Seema Verma, who is slated to run the Centers for Medicare & Medicaid Services in the Trump administration, noted at her confirmation hearing that coverage for maternity services should be optional in those health plans.
Maternity coverage is a popular target and one often mentioned by health law critics. But other items also might be watered down or eliminated in the GOP revision.
There are some big hurdles, however. The Affordable Care Act requires that insurers who sell policies for individuals and small businesses cover at a minimum 10 "essential health benefits," including hospitalization, prescription drugs and emergency care, in addition to maternity services. The law also requires that the scope of the services offered be equal to those typically provided in the coverage that businesses offer their employees.
"It has to look like a typical employer plan, and those are still pretty generous," says Timothy Jost, an emeritus professor at Washington and Lee University Law School in Virginia who has studied and written about the health law.
Since the 10 required benefits are spelled out in the Affordable Care Act, the law would have to be changed to eliminate entire categories or to make them less generous than typical employer coverage. And since Republicans likely cannot garner 60 votes in the Senate to do that, they will be limited in changes that they can make to the ACA. Still, there's room to "skinny up" the requirements in some areas by changing the regulations that federal officials wrote to implement the law.
Habilitative services
The law requires that plans cover "rehabilitative and habilitative services and devices." Many employer plans don't include habilitative services, which help people with developmental disabilities such as cerebral palsy or autism maintain, learn or improve their functional skills, via speech or occupational therapy or other support services. Federal officials issued a regulation that defined habilitative services and directed plans to set separate limits for the number of covered visits for rehabilitative and habilitative services. Those rules could be changed.
"There is real room for weakening the requirements" for habilitative services, says Dania Palanker, an attorney and assistant research professor at Georgetown University's Center on Health Insurance Reforms, who has reviewed the essential health benefits coverage requirements.
Oral and vision care for kids
Pediatric oral and vision care requirements, another essential health benefit that's not particularly common in employer plans, could also be weakened, says Caroline Pearson, a senior vice president at the consulting firm Avalere Health.
Mental health and substance use disorder services
The health law requires all individual and small group plans to cover mental health services and treatments for substance use disorders. In the regulations, the Obama administration said that means those services have to be provided at "parity" with medical and surgical services, meaning plans can't be more restrictive with one type of coverage than the other regarding cost sharing, treatment and care management.
"They could back off of parity," Palanker says.
Prescription drugs
Prescription drug coverage could be tinkered with as well. The rules currently require that plans cover at least one drug in every drug class, a standard that isn't particularly robust to start with, says Katie Keith, a health policy consultant and adjunct professor at Georgetown Law School. That standard could be relaxed further, Keith says, and the list of required covered drugs could shrink.
Preventive and wellness services and chronic disease management
Republicans have discussed trimming or eliminating some of the preventive services that are required to be offered without cost sharing. Among those is covering birth control without charging women anything out of pocket. But, Palanker says, "if they just wanted to omit them, I expect that would end up in court."
Pregnancy, maternity and newborn care
Before the health law passed, just 12 percent of health policies available to a 30-year-old woman on the individual market offered maternity benefits, according to research by the National Women's Law Center. Those policies that did offer such benefits often charged extra for the coverage and required a waiting period of a year or more.
The essential health benefits package plugged that hole very cleanly, says Adam Sonfield, a senior policy manager at the Guttmacher Institute, a reproductive health research and advocacy organization.
"Having it in the law makes it more difficult to either exclude it entirely or charge an arm and a leg for it," Sonfield says.
Maternity coverage is often offered as an example of a benefit that should be optional, and that's what Verma has advocated. If you're a man or too old to get pregnant, critics of the requirement say, why should you have to pay for that coverage to be included in your policy?
But that a la carte approach is not the way insurance is designed to work, says Linda Blumberg, a senior fellow at the Health Policy Center at the Urban Institute. Women don't need prostate cancer screening, she points out, but they pay for the coverage anyway.
"We buy insurance for uncertainty and to spread the costs of care across a broad population so that when something comes up, that person has adequate coverage to meet their needs," Blumberg says.
Repeal of Health Law Faces Obstacles in House, Not Just in Senate
by Jennifer Steinhauer - NYT - February 23, 2017
WASHINGTON — Ever since Republicans got down to the business of repealing the Affordable Care Act, the Senate has been singled out as the likely problem. Any plan that could zoom through the House would hit roadblocks among Senate Republicans, many of whom have resisted a wholesale repeal of the health law without a robust replacement plan.
But after weeks of loud protests, boisterous town hall meetings and scores of quieter meetings with health care professionals, patients, caregivers and hospital managers in their districts, it is becoming increasingly likely that a consensus in the House may be just as hard to reach.
The most conservative House members are pushing for a fast repeal of the health law with only a bare-bones replacement to follow, possibly just bigger incentives for people to open health savings accounts to fund their own health needs. Other Republicans are more interested in taking their time to come up with a replacement plan that, as of now, they have failed to cobble together beyond a menu of options.
Among the increasingly concerned Republicans are those who represent the 24 congressional districts that Hillary Clinton won in the presidential election — roughly the numerical edge Republicans hold over Democrats in the House — and another dozen in districts that President Barack Obama took in 2012 but President Trump won in November. If 25 conservative hard-liners oppose any robust replacement plan, and 30 swing-district House members demand a more generous plan, passage of a compromise bill will be in jeopardy.
“For the first time Republicans need to demonstrate what they are for and not just being against Obamacare,” said Doug Heye, who served as the deputy chief of staff to former Representative Eric Cantor of Virginia when he was majority leader. Mr. Cantor and House Republican chairmen labored in 2014 to bring a replacement bill for Republicans to get behind, Mr. Heye said, and got nowhere, even with no stakes.
“Republicans are going to come back to Washington next week and say what they’ve heard on the ground, at hospitals, at restaurants, at events where people have been concerned about where they go from here,” he said. “How much that shapes things over the next months remains to be seen.”
Further, recent polls show increasing enthusiasm for the health law as Americans see its repeal on the horizon; an NBC News/Wall Street Journal poll found last month that more people viewed the law as a good idea than as a bad one for the first time since 2009, when the poll commenced.
For Republicans in swing districts in California, New Jersey, New York and other states, the combination is a wicked brew: Those members need to build a winning coalition of base voters who hate the law and independents and crossover voters who have recently cottoned to it.
While the 218 votes needed in the House to get the ball rolling remains likely, it is no longer the slam dunk that Republicans had with previous bills to repeal the law, when lawmakers knew their efforts would die in the Senate or on Mr. Obama’s desk.
Some Republicans are trying to keep a low profile back home, like Representatives Darrell Issa of California, Martha McSally of Arizona and Will Hurd of Texas, to avoid the hot seat on health care.
Others, like Representative Greg Walden of Oregon, are smoothing their terms of engagement, increasingly referring more to “repairing” the law than repealing it.
“When you talk about ‘repeal,’ you have just used a word that is very polarizing,” said Representative Tom MacArthur, Republican of New Jersey, who meets weekly with moderate Republicans and Democrats of equal number. “When you go to Democrats and say, ‘Help us repeal,’ that puts them in a box. If you say, ‘Would you help us repair something?’ people start listening in a whole other way.”
Others are simply taking credit for the law’s popular provisions, like the one that prohibits insurers from denying coverage for pre-existing conditions. Representative Marsha Blackburn, Republican of Tennessee, applauded some of them in a town hall this week and claimed they were added to the law thanks to her party — a claim that is simply not true.
Representative Scott Taylor, Republican of Virginia, when asked about a House Republican health care plan that would not provide maternity coverage, said he would push for such coverage to be included in any replacement plan, one of many examples where Republicans are likely to divide on policy and provisions. “There’s discussion,” Mr. Taylor said of the plan promoted by the House speaker, Paul Ryan. “It’s not set in stone yet.”
Republicans have been worrying about this long before constituents and protesters began jamming their town hall meetings. Shortly after the election, during a Republican retreat in Pennsylvania, many members privately complained about using the repeal as an avenue to defund Planned Parenthood or repealing without a clear replacement plan, according to a recording of the meeting anonymously provided to The New York Times, The Washington Post and other newspapers.
On Tuesday night, Mr. MacArthur — one of only nine Republicans to vote against the initial bill to begin the repeal process last month — met with protesters who have been standing outside his office, largely to discuss health care.
After the meeting, Mr. MacArthur found himself outside a basement room where a group of local Democrats had gathered, and he wandered in to chat, he said.
“We had a really good impromptu discussion,” Mr. MacArthur said. “There are very sincere people in my district who are deeply concerned about where the country is headed and doing what they should do, which is to go to their closest federal representative.”
“I think first you do the right thing for the country,” he added, “and then you think about the political ramifications and in this case doing the right thing would be less polarizing.”
Commentary: High risk pools are simply not a real replacement for Obamacare
Far from a better way, these plans were total failures before the ACA and will fail again.
by William Seligman and John McDonough - Portland Press Herald - February 23, 2017
BOSTON — As President Trump presses to repeal the Affordable Care Act (also known as “Obamacare”), congressional Republicans are facing the challenges of developing a replacement, putting 75,000 Mainers at risk of losing health care.
With Maine independent Angus King’s U.S. Senate seat up for grabs next year – along with the fragile Senate Republican majority on which the fate of Obamacare depends – Mainers have an opportunity to shape the national health care debate.
While Sen. Susan Collins, R-Maine, has helped craft and present a plan to give states the flexibility to decide whether or not to keep Obamacare provisions, House Speaker Paul Ryan advocates complete repeal of the health insurance provisions, which have covered about 20 million Americans.
The speaker’s hands may be tied by President Trump’s stated wish to ban the use of pre-existing condition exclusions in determining who can get health insurance. The only way, though, in which insurers can take all customers regardless of their medical history is some form of an individual mandate or penalty for individuals who can afford coverage and choose not to buy it.
Insurers previously saved money by not covering folks who were likely to cost a lot (mostly those with pre-existing medical conditions). How would Trump make sure that these patients were covered?
Both President Trump and Speaker Ryan are advocating a system in which individuals excluded from insurance because of a pre-existing condition could get coverage in his or her state’s high-risk pool. These pools cover individuals who can’t get group coverage because they have or are likely to have high medical expenses; healthier people are insured under standard insurance at group rates.
This is how Republicans want an estimated 230,000 Mainers with pre-existing conditions to obtain insurance in the post-ACA era.
Though Speaker Ryan calls this plan “A Better Way,” there’s nothing new about high-risk pools. Before the ACA’s signing in 2010, high-risk pools covered about 200,000 patients in 35 states. The history of these pools tells us that they are no panacea for anyone. High-risk pools prior to 2010 were a catastrophic failure that left most uncovered or with tight coverage restrictions.
Because of the pools, insurers were allowed to reject individuals likely to have high expenses.
Most states had far more people applying than they had resources to support, so lengthy waiting lists were common. In Washington state, over 80 percent of those referred to the high-risk pool never got health insurance, The New York Times recently reported, while California had an endless waiting list. Richard Figueroa, a senior administrator for the California program, recalled in an interview with the Times that “there were people literally dying on the waiting list.”
Most state pools had lifetime and/or annual benefit caps on payments for medical care, something now illegal because of the ACA. But doing away with benefit caps in state high-risk pools would make them economically unviable.
What are the “pre-existing conditions” that get excluded? Every insurance company developed its own list. Here are just a few of the hundreds of commonly used reasons to exclude or limit health insurance: acne, AIDS, arthritis, artificial joints, asthma, bipolar disorder, cancer, chronic obstructive pulmonary disorder, coronary artery disease, diabetes, domestic violence, drug abuse, emphysema, fertility treatment, insulin use, kidney failure, leukemia, multiple sclerosis, pacemakers, pregnancy, rape, rheumatoid arthritis, sleep apnea, suicide attempts and being either overweight or underweight.
Sen. Collins’ plan to give states authority to decide whether or not to keep the basic provisions of Obamacare is attractive to some as a compromise.
Still, it dodges the crucial question: How will insurance companies provide coverage to all, regardless of current or past medical conditions, without some requirement for everyone to purchase health insurance? High-risk pools are not the answer.
While we wait to see a Republican plan to replace Obamacare, more than 20 million Americans and over 75,000 Mainers wait to see whether they will lose the health insurance the ACA gave them. The 2018 mid-term elections for the Senate and House of Representatives in 2018 will be crucial.
In the meantime, Mainers who care about protecting health care for all Americans should join the coalition of moms, dads, kids, physicians, hospital workers and others working to protect their care at familiesusa.org/initiatives/ protect-our-care.
Health Savings Accounts: Don’t Leave Money on the Table
by Ann Carrns - NYT - February 22, 2017
It is tax-filing season, and people looking for ways to lower their 2016 tax bills might want to consider funding health savings accounts.
Eligible filers can make a tax-deductible contribution to a health savings account, or H.S.A., for the 2016 tax year up until the federal filing deadline — April 18 this year.
There are no income restrictions, and the deduction is taken “above the line” on your Form 1040 tax return, reducing your adjusted gross income, said Patrick Stark, director of financial planning for RS Crum Inc., a fee-only wealth management firm in Newport Beach, Calif. “Even people who don’t itemize,” he said, “are able to take advantage of an H.S.A. deduction.”
Only certain health plans with high deductibles and other specific criteria qualify to work with an H.S.A., however, so you will need to check your plan’s details before opening an account, said Roy Ramthun, an H.S.A. consultant. (Typically, the health plan will have language noting that it is H.S.A.-eligible.)
Health savings accounts, which have been around for more than a decade, have been getting more attention lately as Republicans weigh changes to health insuranceunder the Affordable Care Act. As of mid-2016, there were more than 18 million health savings accounts holding nearly $35 billion in assets, according to the tracking firm Devenir. The market is expected to top 27 million accounts holding more than $50 billion by the end of 2018, the company projects.
Here is how a health savings account works: If you have an eligible, high-deductible health plan, you can establish an H.S.A. and set aside funds, tax-free, to pay for medical expenses that your insurance doesn’t cover, including co-payments and your deductible — the amount you have to pay out of pocket before insurance begins paying. You can have funds withdrawn pretax from your paycheck, or you can make contributions directly and deduct them on your tax return.
Funds in the account may be invested, and they grow tax-free. (Most plans, however, require minimum balances — say, $1,000 — before allowing investments.)
Withdrawals are not taxed as long as the funds are spent on medical or health expenses. There is no deadline for withdrawing the funds; unused balances roll over year to year. And H.S.A.s are portable: If you change employers, the plans go with you.
While H.S.A.s may be a good last-minute option for those seeking a tax deduction, Mr. Stark said he preferred that clients contribute regularly to the account each month, if they can. That is easier for many people, he said, than coming up with a large lump sum.
Here are some questions and answers about health savings accounts:
What is the minimum deductible for an H.S.A.-eligible health plan?
For 2016, and again for 2017, qualifying health plans must have a deductible of at least $1,300 for individual coverage, and $2,600 for family coverage. Other criteria apply.
For 2016, you can contribute up to $3,350 if you have individual health coverage, and $6,750 if you have family coverage. (For 2017, the individual maximum rises by $50, to $3,400, while the maximum for family coverage remains the same.) You may also make an extra $1,000 “catch up” contribution annually when you turn 55.
I am covered by my wife’s family health plan and H.S.A., and I turned 55 last year. Can I make a catch-up H.S.A. contribution for 2016?
In general, yes, said Mr. Ramthun, the consultant, provided the $1,000 catch-up contribution goes into a separate health savings account in the spouse’s name by the April 18 deadline. Money in both accounts can be used for expenses for either spouse. “H.S.A. funds can always be used tax-free for eligible expenses incurred by a spouse,” Mr. Ramthun said. “So the accounts can be used interchangeably for their expenses.”
We created Medicare for the elderly. Why not do the same for children?
by Kurt Newman - Washington Post - February
With all eyes focused on the nation’s health-care system, our leaders have an opportunity to put the health and future of America’s children first. Congress should consider building a tailor-made national health-care plan just for children.
Just as we created Medicare for the elderly, we need an approach to pediatric health care that not only provides coverage to every child but also ensures adequate funding for essential services that meet child-specific needs.
Our current patchwork system addresses only the first half of that equation. Right now, Medicaid and the Children’s Health Insurance Program form the country’s pediatric health-care safety net, together serving children across the nation’s urban, rural and suburban communities. These programs provide vital access to health services that more than 36 million American children need and cannot afford to lose.
But they are force-fit solutions for children in a health-care system designed for adults.
We know that kids have the best chance at getting and staying healthy when they receive specialized pediatric care that is tailored to their needs. The medical community and parents alike embraced that concept long ago. That’s why we bring children to pediatricians and surgeons with specialized pediatric training when they are sick. It’s also why dedicated children’s hospitals and clinics have become such an important part of our pediatric care delivery network.
Now we need a health-care system with infrastructure and resources to support specialized pediatric medicine. One promising approach is to carve children out of the Medicaid mix and build a separate plan just for kids.
Children make up 50 percent of today’s Medicaid population but account for just 20 percent of Medicaid spending. Our children are competing for a shrinking share of a funding pool that also supports a growing number of adults, seniors and disabled individuals — whose needs are often much more expensive.
In today’s model, children of the same age and family income often qualify for different levels of care just because they live in different states. A cohesive national plan just for children could standardize the eligibility criteria for health coverage, offering every child access to the same level of care — no matter where he or she lives.
Such a plan would provide stability for a patient group that requires unique services, treatments and therapies. It would provide infrastructure and security for children’s hospitals and pediatric specialists who scramble to operate within a system built for adult medicine.
It would also make good economic sense for our country’s future. The most common adult chronic diseases cost the U.S. economy more than $1 trillion every year. In addition to direct health-care costs, these illnesses hurt the labor supply, reduce productivity and diminish gross domestic product.
But when diagnosed and managed during childhood, many chronic adult illnesses and their symptoms can be treated, improved or prevented. And often, the most aggressive interventions work better in children than in grown-ups. The fact that cells multiply exponentially faster in growing young bodies means that kids are decidedly more responsive to cancer treatments than adults. Bone marrow transplants, forinstance, often yield more successful outcomes in pediatric leukemia patients than adults, because children can tolerate more intensive treatment regimens.
We are entering a formative period in which the fundamental nature of our health-care laws will be debated and potentially reshaped. We owe it to our children — the next generation of American workers — to make sure that any new policies or changes to our health-care laws put their needs first.
Congress has an opportunity to keep children’s health out of partisan politics by focusing specifically on the initiatives that help them grow up stronger. It isn’t just the right thing to do; it’s also a smart investment in our country’s future.
Editor's Note: The following articles is specifically about immigrants experiencing chronic anxiety in today's uncertain environment. However, I believe it is equally true among any population experiencing chronic discrimination and uncertainty.
-SPC
Living in fear of deportation is terrible for your health
New studies show the harmful medical effects of disrespect, discrimination and detention.
by James Gordon - The Washington Post - February 10, 2017
For the past few weeks, the young man’s heart has been racing. His hands are sweaty. During the day, he has flashbacks of the world he fled in El Salvador: gang members chasing him, threatening murder. Nightmares of the same scenes disturb his sleep. He’s not a patient in my psychiatric practice. Just another young guy studying for his high school equivalency diploma at the Latin American Youth Center in Washington. Like the 4,000 other kids taking classes there, he’s been worrying as he watches what the center’s chief executive, Lori Kaplan, calls “the big reality show . . . on cable news — and the tweets.”
In St. Paul, Minn., Sharif Mohamed’s children are also “paying attention” to the TV news, he says. Mohamed is an imam, a spiritual leader of the Somali community there and a U.S. citizen; he came as a refugee 20 years ago. Every day, Muslim women and children tell him about being verbally abused on the street and in schools. The nearly 100,000 other east Africans in Minnesota are painfully aware of the president’s recent temporary ban on refugees and visa-holders from their homeland and other predominantly Muslim countries, and of the administration’s public statements: Michael Flynn, President Trump’s national security adviser, has called Islam “a cancer.”
Sharif says his fellow Somali immigrants “love [our] country and can accept the incredible burdens” of rising out of poverty. He is proud of his community’s “working people, soldiers, police officers, politicians, business leaders, doctors and teachers.” But now his children worry that they will never again be able to visit overseas relatives. They worry, even more, that they may not be able to stay in this country, the only home they’ve ever known.
These and other fears are now the daily bread of large numbers of the 42 million immigrants in this country — including the children who, years ago, immigrated and became citizens. Physicians, therapists and community leaders such as Mohamed have for years been using my Center for Mind-Body Medicine’s model of self-care and group support to help this population deal with their stress. They tell me now that fears and powerlessness and uncertainty are causing many to be increasingly anxious and angry, depressed and withdrawn. Over time, such chronic stress, unaddressed, will make them far more vulnerable to heart disease, asthma, diabetes and post-traumatic stress disorder.
We’re learning that disrespect, discrimination and detention can have long-term physical and psychological consequences — on those who observe as well as those who experience them. Over the past few years, surveys and qualitative research have begun to reveal the extent of the physical and emotional effects. And a study published last month in the International Journal of Epidemiology by University of Michigan researchers provides hard biological evidence that these changes can be transmitted to the next generation.
The study found that Latino babies born in the 37 weeks following a federal immigration raid in Postville, Iowa, in 2008 had a 24 percent greater risk of low birth weight than the babies who were born to Latina women in the same period a year earlier. (Previous years, too, showed normal rather than depressed birth rates.) Low birth weight is associated with long-term risks to physical health and mental health, cognition and academic performance. What is most troubling, as well as surprising, about the study is the extent of the effect. Low birth weight and its risks were, perhaps predictably, high among undocumented immigrants, but they were just as high among Latinas across the state who were legally in the United States. In spite of their apparent safety, their bodies were reacting as if they, too, could soon be deported. Years before the latest presidential threats and actions upped the immigration ante, fear was overriding immigrants’ faith in the dependability of their legal status.
Undocumented immigrants, who have long lived in fear of deportation, are probably the most profoundly affected. Among them are the 800,000 “dreamers ,” the young people who came to the United States as undocumented children and are now all but indistinguishable from U.S. citizens in high schools and colleges, as they serve in the military and work and marry and raise their own children. In 2012, when President Barack Obama created the Deferred Action for Childhood Arrivals program, he granted them a measure of relief, allowing them to apply every two years for continuing permission to stay in the United States. These dreamers know that the platform Trump ran on contains a different kind of promise: to “immediately terminate” their status.
The green-card holders and immigrants who became citizens are worried, too. Over the years, they’ve watched roundups and deportations of people who share their history, speak their language and work in their communities. In recent months, Trump’s threats and promises have reawakened fears and physical symptoms that patients of mine, long-ago refugees from tyrannical regimes, thought they’d left behind. Like the Salvadoran youth studying for his GED, memories of the danger and dictatorships they fled are intruding on their thoughts and agitating their bodies. During the past week, many of my and my colleagues’ patients have been panicked by stories of people with green cards prevented from returning to the United States.
The damage to the next generation may be compounded by other, less obvious assaults on their biology and psychology. Research by Rachel Yehuda and her colleagues at Mount Sinai Hospital in New York has demonstrated that the consequences of Holocaust survivors’ extreme trauma can be passed down to their children and grandchildren, making them exquisitely sensitive to the ordinary stresses of relatively safe lives. Yehuda and other researchers believe that these are “epigenetic” effects, modifications in the ways genes express themselves, which transmit vulnerabilities to stress from one generation to the next. Though the mechanisms are not completely understood, animal studies as well as those on human adults who were abused as children demonstrate similar changes.
“There is no short-term fix for this kind of damage,” Lori Kaplan commented sadly, thinking about the young people and their families who are anxiously calling her and her colleagues, reporting physical and emotional distress, looking for answers. “We’ve been dealing with the trauma of the immigrant experience for so long,” the flight from violence, the loneliness, the poverty, the struggle to survive in a strange land and the longing for home. “Obama was deporting people, sure, and there was anxiety, but he also gave us hope. And now the roof’s been blown off.”
As Trump orders more border guards and detention centers , and as the wall looms large, the fears of young people and their parents at the Latin American Youth Center grow. Perhaps they’ll be denied housing; fired from their jobs; maybe their health care will disappear. Latino immigrant parents in the Washington area are desperate for their kids to get an education, explains Angelica Garcia-Ditta, a counselor at the center, and they’re still sending their children to school. But, she says, they worry that “immigration authorities will seize them.”
Still, amid a national clamor that diminishes and isolates them, immigrants are organizing. Spiritual leaders, lay counselors, kids, families and friends are joining circles of support, they tell me. They are sharing sadness and fears, using self-care techniques to lower stress, and finding connections to others who have similar concerns. The children of Latino immigrants, Kaplan tells me, now understand that Black Lives Matter is about them, too.
“Our anxiety is very high,” says Sharif Mohamed. “We come together as families in our mosques. We are praying together” and using self-care techniques, hoping to relieve stress and forestall long-term psychological and biological damage. “It gives us the capacity to address our anxiety, our hopelessness and our anger in a profoundly healing way. I and every other Muslim parent is guiding our children to hold close to our faith, to God’s love, to kindness, to a deep belief that we are all here on earth to love and respect.”
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