Health Care Reform Articles - March 1, 2017

Trump Sketches ACA Replacement Plan in Speech to Congress

Advocates Republican ideas including health savings accounts, Medicaid reform

by Joyce Frieden

WASHINGTON -- President Trump, during a speech to lawmakers on Tuesday evening, presented a broad outline of how the Affordable Care Act should be replaced -- incorporating many of the reform ideas traditionally offered by Republicans.

"Obamacare is collapsing -- and we must act decisively to protect all Americans," he told a joint session of Congress. "Action is not a choice -- it is a necessity."

The president began the Obamacare section of his speech by citing the plan's failures. "Mandating every American to buy government-approved health insurance was never the right solution for our country," he said. "Obamacare premiums nationwide have increased by double and triple digits ... One-third of counties have only one insurer and and they're losing them fast -- losing them so fast, and they're leaving, and many Americans have no choice at all."

"Remember when you were told that you could keep your doctor, and keep your plan? We now know that all of those promises have been broken," he said. "So I am calling on all Democrats and Republicans in Congress to work with us to save Americans from this imploding Obamacare disaster."

Trump outlined five principles that he said Congress should use in its legislation to replace the ACA:

• Ensure that Americans with pre-existing conditions have access to coverage, with a "stable transition" for those currently enrolled in the healthcare exchanges
• Help consumers purchase coverage using tax credits and "expanded" health savings accounts, "but it must be the plan they want, not the plan forced on them by our government"
• Give governors "the resources and flexibility they need with Medicaid to make sure no one is left out," said Trump
• Put in place legal reforms "that protect patients and doctors from unnecessary costs that drive up the price of insurance -- and work to bring down the artificially high price[s] of drugs, and bring them down immediately"
• Allow consumers to purchase health insurance across state lines -- which, the president said, "will create a truly competitive national marketplace that will bring costs way down and provide far better care. So important."

Still to come, though, is the legislation that fills in the details of how these goals would be accomplished.

Trump also mentioned a few other healthcare issues in his speech. During a section on making America a great country again, he said, "Heroic veterans will get the care they so desperately need." He also pledged to "stop the drugs from pouring into our country and poisoning our youth -- and we will expand treatment for those who have become so badly addicted."

Trump also criticized the FDA for its "slow and burdensome approval process." One of his guests at the speech was Megan Crowley, a 20-year-old woman with Pompe disease whose life was saved by a drug developed by a company her father founded.

"If we slash the restraints, not just at the FDA but across our government, then we will be blessed with far more miracles just like Megan," he said.

Former Kentucky governor Steve Beshear, who gave the Democratic response, criticized Trump's suggestions for ACA replacement. "Does the ACA need repairs? Sure it does," he said. "But so far, every Republican idea to replace the ACA would reduce the number of Americans covered, despite your promise to the contrary."

"These ideas promise access to care, but deny the importance of making care affordable and effective," he continued. "They would charge families more for fewer benefits and put the insurance companies back in control. Behind this is the idea that folks at the lower end of the economic ladder don't deserve healthcare -- that it's somehow their fault that their employer doesn't offer insurance, or they can't afford to buy expensive health plans."

"In 2010, this country made a commitment that every American deserved healthcare they could afford and rely on. We Democrats are going to do everything in our power to keep President Trump and the Republican Congress from reneging on that commitment, but we're going to need your help by speaking out," he added.

http://www.medpagetoday.com/PublicHealthPolicy/Washington-Watch/63482?xid=nl_mpt_DHE_2017-03-01&eun=g415976d0r&pos=0

Trump just moved the GOP’s health care consensus permanently to the left

by Ezra Klein - February 28, 2017

 Obamacare has permanently shifted America’s health care debate, and Donald Trump’s address to Congress proved it. 

In the speech, Trump laid out five principles any Obamacare replacement must meet. 

First, “we should ensure that Americans with preexisting conditions have access to coverage, and that we have a stable transition for Americans currently enrolled in the health care exchanges.”

Second, “we should help Americans purchase their own coverage, through the use of tax credits and expanded health savings accounts, but it must be the plan they want, not the plan forced on them by the government.”

Third, “we should give our great state governors the resources and flexibility they need with Medicaid to make sure no one is left out.”

Trump went on to propose, as his fourth and fifth principles, “legal reforms that protect patients and doctors from unnecessary costs,” as well as permitting insurers to sell plans across state lines. (See Sarah Kliff for much more detail on how Trump’s proposed policies work.)

It’s the first three that show how Obamacare has reshaped America’s health care debate. In those principles, Trump admits that any replacement will have to preserve most of the law’s gains — it will have to cover people with preexisting conditions, provide tax credits to boost affordability, and allow governors to keep the Medicaid expansion’s gains.

As always, the devil is in the details, and the paucity of details in Trump’s plan leaves much room for devilry. Trump’s rhetoric is plausibly consistent with the draft bill House Republicans have circulated — and a McKinsey analysis of a similar GOP plan suggested it could cut insurance in the individual market by 30 to 50 percent. But Trump promised tonight to “make health insurance available to everyone,” and his team knows that clip will be devastating if they have to send out cancellation notices to millions. 

Consistent with that, Trump’s speech weighed in on the most consequential debate among House Republicans: whether their replacement plan should have tax credits and a continued Medicaid expansion at all. House conservatives believe otherwise, and are already denouncing the GOP plans with those features as “a new health insurance entitlement with a Republican stamp on it.” Tonight, Trump dismissed their concerns, and moved the GOP’s health care consensus permanently to the left. 

With Obamacare and Trump’s speech, the debate on health care has moved from whether it should be the government’s responsibility to insure young, able-bodied people to how the government should insure young, able-bodied people, and how comprehensive the insurance should be. 

Democrats are arguing for more generous, income-based subsidies, and Republicans are arguing for less generous, but more universal, age-based subsidies. Both sides, to my surprise, appear to now agree on a vastly expanded role for Medicaid, as even many GOP governors now defend the program’s increased presence in their states. The differences are real, but the question has narrowed.

“In some ways I can't believe how much they have moved,” says Nancy-Ann DeParle, who served as President Obama’s top health aide during the Affordable Care Act’s passage. “They have moved to adopt our goals of getting everyone covered, reforming the worst abuses of underwriting such as preexisting condition exclusions, allowing children to stay on their parents' plans until they are 26, etc.”

As consequential as the GOP’s movement on the policy is, the bigger change is that Republicans are now prioritizing health reform. It is unimaginable, absent Obamacare, that a newly elected Republican president would make passing refundable tax credits to increase insurance coverage his top priority. The GOP is, and remains, deeply divided on health care, and much more committed to tax cuts. “Republicans never ever agree on health care,” former Speaker John Boehner saidlast week. 

It’s the GOP’s loathing of Obamacare that has forced them to at least try to come up with something they like better. The result is Obama’s successor is spending the beginning of his administration trying to figure out how to cover more people with better, cheaper insurance than the ACA provided, rather than focusing on the priorities that have traditionally obsessed Republican presidents. And it’s all due to Obamacare. 

“Republicans have generally not been proactive in health care debates, but have rather played defense,” says Larry Levitt, vice president at the Kaiser Family Foundation. “In some ways, Republicans are now forced into being proactive because of their desire to repeal the ACA.”

None of this means the Republican plan — if they ever converge on a plan — will pass. For now, its odds are poor. It’s not clear there’s any bill that could fulfill Trump’s principles and secure enough support from conservatives to clear the House. Any bill that did make it through the House would probably be too conservative for a critical number of Senate Republicans. And any bill that somehow satisfied Republicans in both chambers would still require eight Senate Democrats to become law, as the insurance regulations can’t be passed through budget reconciliation, and so the GOP will need to break a Democratic filibuster. All of that is unlikely. And if Republicans fail, they are left managing Obamacare.

“Disrupting the status quo in health care is always hard, and the ACA is now the status quo,” says Levitt.

http://www.vox.com/policy-and-politics/2017/2/28/14772616/trump-speech-congress-obamacare

The Fight for Obamacare Has Turned

by David Leonhardt - NYT - February 28, 2017

The campaign to let 20 million Americans keep their health insurance is working.

It still has a long way to go, and it’s not guaranteed to succeed. But the progress of the last couple months is remarkable.

Thanks in part to a surge of activism — town hall meetings, online postings, calls to Congress — the politics of Obamacare have flipped. Many Americans have come to realize that the care part of the law matters much more than the Obama part. As a result, the Republicans no longer have a clear path to repeal.

President Trump, in his speech to Congress on Tuesday night, will probably pretend otherwise. He may repeat the same magical promises to pass a bill that’s better and cheaper and covers everyone. Privately, though, he and his aides have begun to realize the mess they have made by promising the impossible.

On Monday, Trump himself lamented that health care was “complicated.” The clearest sign of anxiety came in a Washington Post report: Four top advisers — Stephen Bannon, Gary Cohn, Jared Kushner and Stephen Miller — “have emphasized the potential political costs to moving aggressively.” Those costs include taking the blame (fairly or not) for every problem in the insurance market.

Meanwhile, congressional Republicans have their own troubles. As of now, they don’t have the votes to pass a plan.

Unable to agree on a policy, the party’s leaders have settled on what The Wall Street Journal called a “gamble” and a “dare.” They will push ahead with a now-or-never repeal bill, hoping that party loyalty will ultimately overcome substantive disagreements.

Why are Republicans suddenly having such a hard time agreeing about their No. 1 priority? They’ve run into two obstacles: reality and public opinion.

Let’s start with reality. Republican leaders are now paying the price for their dishonest approach to fighting Obamacare.

To be clear, there are honest conservative attacks to make on Obamacare. Republicans could have said that Americans who can’t afford health insurance aren’t entitled to it, just as people are not entitled to own a home. Or Republicans could have tried to alter the law — say, with less generous insurance plans.

But Republican leaders chose the easy political route instead. They blamed Obamacare (sometimes fairly, mostly not) for almost every health care problem. They’ve promoted the same fallacy for which conservatives often mock liberals: the free-lunch fallacy.

There is no free lunch on health care. Your health “costs” pay for my health “benefits,” and vice versa. If Trump promises a less expensive system, he is also promising to eliminate some care. He could cut wasteful care — and should — but Republicans caricatured the Obama administration’s attempts as “death panels” without offering their own steps.

Now that they’re running the government, free-lunchism has consequences. Their promise to scrap taxes on the wealthy, for example, leaves them without money to cover people. That’s why the independent Congressional Budget Office keeps concluding that the various Obamacare replacement plans would deprive millions of people of insurance.

More Americans have begun to understand these realities, and everyone engaged in the grass-roots campaign to protect health insurance deserves to take pride in the change. People have seen YouTube clips of town hall meetings at which members of Congress have no good answers. Some people are also starting to see through Trump’s wait-till-next-month timetable.

Most Americans still have complaints about Obamacare. So do I. (Some subsidies are too small, as are the penalties for not signing up.) But they increasingly realize that no serious alternative exists — still. Getting rid of Obamacare means taking away health insurance, and medical care, from millions of people.

No wonder the polls have flipped, and more than half the country now supports the law.

One group to watch is Republican governors. They met in Washington this weekend and tried to come up with an approach that would help their colleagues in Congress. But they couldn’t. Too many Republican governors understand that a repeal would create major trouble. To their credit, some aren’t willing to fake it.

Still, this is no time for complacency. Republicans have spent so long promising repeal that failure would leave them vulnerable to primary challenges and make them look weak. They have many incentives to pass a bill.

But aficionados of irony will appreciate the fundamental source of their struggles. In drafting his health care plan, Barack Obama chose a moderate, market-based approach. It was to the right of Bill Clinton’s and Richard Nixon’s plans and way to the right of Harry Truman’s — and yet Republicans still wouldn’t support it.

Many liberals regret that decision. Obama, for his part, believes that a more left-wing version would not have passed. Either way, the version that did pass doesn’t leave Republicans much room to maneuver.

https://www.nytimes.com/2017/02/28/opinion/the-fight-for-obamacare-has-turned.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0

Trump Concedes Health Law Overhaul Is ‘Unbelievably Complex’

by Robert Pear and Kate Kelley - NYT - February 27, 2017

WASHINGTON — President Trump, meeting with the nation’s governors, conceded Monday that he had not been aware of the complexities of health care policy-making: “I have to tell you, it’s an unbelievably complex subject. Nobody knew that health care could be so complicated.”

The president also suggested that the struggle to replace the Affordable Care Act was creating a legislative logjam that could delay other parts of his political agenda.

Many policy makers had anticipated the intricacies of changing the health care law, and Mr. Trump’s demands in the opening days of his administration to simultaneously repeal and replace President Barack Obama’s signature domestic achievement made the political calculations far more complicated.

Governors of both parties added still more confusion on Monday when they called for any replacement to cover all the people already benefiting from the landmark law.

“Of course I am concerned,” said Gov. Brian Sandoval, the Republican governor of Nevada, where about 300,000 people have gained Medicaid coverage. “I am someone who elected to expand Medicaid. That’s been very beneficial to my state, and I want to be sure those individuals can keep their coverage.”

“Governors are all in agreement,” said Gov. Terry McAuliffe of Virginia, a Democrat who is the chairman of the National Governors Association. “We do not want one single one of our citizens to lose access to quality health care. We are all unified on that. Actually, we want to expand, so everybody has access to quality health care.”

With President Trump in office, the goal of repealing the Affordable Care Act is finally within reach for Republicans. Margot Sanger-Katz explains why repealing and replacing Obamacare may not be easy.

By SHANE O’NEILL and DAVE HORN on  February 10, 2017. Photo by Stephen Crowley/The New York Times. Watch in Times Video »

Mr. Trump brushed aside opinion polls suggesting that the 2010 health law was becoming somewhat more popular. “People hate it,” the president said, “but now they see that the end is coming and they’re saying, ‘Oh, maybe we love it.’ There’s nothing to love. It’s a disaster, folks.”

Because of the intricate procedures that govern budget legislation and the inherent complexity of health care, Republicans appear unlikely to undo the health law as quickly as they had hoped. Mr. Trump said Congress must tackle the Affordable Care Act before it can overhaul the tax code, also a high priority for Republicans. And those delays could slow work on other priorities like a billion-dollar infrastructure push.

“Statutorily and for budget purposes, as you know, we have to do health care before we do the tax cut,” Mr. Trump told governors.

After his session with the governors, Mr. Trump met on Monday with executives from health insurance companies. He apparently hopes they will stay in or return to the Affordable Care Act’s insurance marketplaces, where more than 10 million people obtained coverage last year.

If the governors’ meeting in Washington was supposed to clarify the future of the health law, it fell short. If anything, it exposed deep divisions among state executives, especially Republican leaders.

Gov. Gary R. Herbert of Utah, a Republican, said: “We did not expand Medicaid. Many states are divided on what the right approach is to take under the Affordable Care Act.” Some Republican governors, he said, are concerned about the “sustainability” of the Medicaid program, which covers more than 70 million low-income people.

And no governor was ready to say publicly that he or she could accept a replacement health law covering fewer people than the Affordable Care Act, which has extended coverage to 20 million Americans.

A bill drafted by House Republicans could cover fewer people. It would roll back the heath law’s expansion of Medicaid, eliminate tax penalties for people who do not have health insurance and end taxes imposed by the Affordable Care Act on certain high-income people, insurers, drug companies and manufacturers of medical devices.

To help people buy insurance, if they do not have coverage at work or under a government program, the bill would offer tax credits ranging from $2,000 to $4,000 a year, depending on age. But the credits would not fluctuate with a recipient’s income, raising the prospect that insurance might be less affordable for lower-income people. The House Republican bill would also eliminate minimum federal standards for “essential health benefits,” and it could require some people with particularly expensive employer-sponsored coverage to pay taxes on some of its value.

The emergence of that draft has produced cries of opposition among Democrats and nervousness in some Republican quarters. Conservatives added their objections on Monday, saying the tax credits could become a permanent entitlement. Representative Mark Walker of North Carolina, the chairman of the conservative Republican Study Committee, said he could not vote for the bill in its current form because it could create “a new health insurance entitlement with a Republican stamp on it.”

Mr. Herbert said he could support the Republican proposal to give each state an allotment of federal money with a set amount for each Medicaid beneficiary — what he and other officials described as a per capita cap. Some experts believe that could be “the best thing for us to do in Utah,” Mr. Herbert said.

But Democratic governors generally oppose efforts by congressional Republicans to give each state a fixed allotment for each beneficiary or a lump sum, known as a block grant, for its entire Medicaid program.

“Block grants or per capita caps would throw state finances into disarray” and shift costs to the states, Democratic governors said in a letter to congressional leaders.

Two House committees may try to vote next week on legislation to repeal the Affordable Care Act and put in place some elements of a replacement. But the disagreements among Republicans, in the Trump administration and on Capitol Hill, suggest a difficult road ahead.

In recent days, some senior White House officials have come to believe that the timetable House Republicans have laid out for the health care overhaul is overly ambitious, said one person who has been briefed on their thinking, given the apparent public opposition to what is known of the plan already and the likelihood that an independent cost-benefit analysis could make it even less attractive to low-income voters.

If the House plan fails, these officials may introduce a White House version of the repeal-and-replace legislation later in the year, with the hope that it will be better received, added the person briefed on the matter.

Gary Cohn, the director of the president’s National Economic Council, and his staff have spent significant time studying the Affordable Care Act and its weaknesses. Mr. Cohn and Jared Kushner, the president’s son-in-law and a senior adviser, have emerged as skeptics of the plan being developed by House Republicans, said the person briefed on the matter. The White House had no immediate response to a request for comment.

The White House chief of staff, Reince Priebus, is more aligned with the House speaker, Paul D. Ryan, and the secretary of health and human services, Tom Price, who are championing the current repeal-and-replace bill.

Mr. Trump’s Treasury secretary, Steven Mnuchin, said as recently as Thursday that the administration hoped to pass tax cuts for both businesses and middle-class Americans in time for Congress’s recess in August. But since health care must be addressed first, tax legislation could easily be pushed into 2018, according to members of Congress and administration officials.

https://www.nytimes.com/2017/02/27/us/politics/trump-concedes-health-law-overhaul-is-unbelievably-complex.html?smprod=nytcore-iphone&smid=nytcore-iphone-share

GOP’s New Plan to Repeal Obamacare: Dare Fellow Republicans to Block Effort 

GOP lawmakers gamble that setting bill in motion to strike Affordable Care Act will help break through intraparty disagreements

By

LOUISE RADNOFSKY, 

KRISTINA PETERSON and 

STEPHANIE ARMOUR - WSJ - 

Updated Feb. 27, 2017

Health Policy
GOP lawmakers gamble that setting bill in motion to strike Affordable Care Act will help break through intraparty disagreements
WASHINGTON—Republican leaders are betting that the only way for Congress to repeal the Affordable Care Act is to set a bill in motion and gamble that fellow GOP lawmakers won’t dare to block it.
Party leaders are poised to act on the strategy as early as this week, after it has become obvious they can’t craft a proposal that will carry an easy majority in either chamber. Lawmakers return to Washington Monday after a week of raucous town halls in their districts that amplified pressure on Republicans to forge ahead with their health-care plans.
Republican leaders pursuing the “now or never” approach see it as their best chance to break through irreconcilable demands by Republican centrists and conservatives over issues ranging from tax credits to the future of Medicaid.
The new strategy means the health-care law could be overhauled in three precarious steps—reflecting the difficulties of concurrently repealing and replacing the law, as President Donald Trump had sought.
Republicans can afford to lose no more than two GOP votes in the Senate and 22 in the House, assuming they get no support from Democrats. That means any GOP faction could torpedo the repeal effort by withholding its support—and members of each have threatened as much.
Advocates of the strategy hope that knife’s-edge math will be an asset rather than a liability. They are betting different groups of Republican lawmakers can be pacified with a handful of concessions, then will swallow hard and vote for a longstanding repeal pledge, first in the House, then in the Senate.
“You’re a Republican, you’ve been running to repeal Obamacare, they put a repeal bill in front of you... Are you going to be the Republican senator who prevents Obamacare repeal from being sent to a Republican president who is willing to sign it?” said Doug Badger, a longtime Republican leadership health policy adviser.
Mr. Trump, House Speaker Paul Ryan (R., Wis.) and Senate Majority Leader Mitch McConnell (R., Ky.) are staking almost everything on this bet, because their entire domestic policy agenda, including a highly prized tax overhaul, rests on the health-care maneuver paying off first.
GOP leaders hope to push through Congress along party lines a bill now being drafted in the House that would repeal major chunks of the health law, according to Republican aides and lawmakers. The move would require use of the “reconciliation” process in the Senate, which lets measures that are generally budget-related pass with a simple majority instead of 60 votes.
The first step also could enact some elements of a new system, such as expanded health savings accounts popular with many Republicans, GOP aides and lawmakers said. It could potentially include alternative forms of financial assistance for people with private coverage and states that want to maintain Medicaid eligibility for low-income residents. It would likely include a transition period designed to prevent people losing coverage abruptly.
Health and Human Services Secretary Tom Price could write rules designed to ease the way for members worried that their states’ fragile insurance markets could collapse amid, or because of, GOP changes to the health law.
Later, Republicans could look to pass other components of their health-care plan, potentially in a string of bills, which would need 60 votes and bipartisan support in the Senate.
The plan could be torpedoed by everything from Republican divisions to public backlash to Democratic resistance. House Democratic leader Nancy Pelosi of California said on ABC’s This Week on Sunday morning that she didn’t believe Republicans would be able to follow through with their repeal bid.
“They won’t be able to do that,” she said. “How can they do it? They do not have the votes.”
Republican leaders see little alternative but to try, especially since they are already facing criticism for failing to move faster. Some conservative advocacy groups, such as Heritage Action, have said swifter movement could have forestalled the town hall meetings and the polls showing increased support for the ACA that are now rattling some centrist Republicans.
The town halls have also invigorated some conservative lawmakers, who are eager for the fight. “Not everyone is going to get what they want,” said Rep. Scott DesJarlais (R., Tenn.). “I’ve been telling people back home if they don’t see major movement on this by Easter, there’ll be reason to be concerned.”
Republicans still have to overcome significant divisions on central issues.
The House GOP has splintered, for example, over what financial assistance, if any, to offer in place of the ACA’s tax credits. Republican leaders are leaning toward including a new tax credit that would be refundable, pegged to consumers’ age rather than their income, according to a draft GOP plan released earlier this month.
But some conservatives view that as little better than the ACA subsidies they decry. “It’s a long fancy title for an entitlement program,” said Rep. Jim Jordan (R., Ohio).
Equally divisive is a battle over Medicaid, the federal-state insurance program for the poor. Republican senators from states that accepted an ACA provision allowing them to use federal funding to expand Medicaid generally want to keep it. Those from states that rejected the expansion are just as determined to see a distribution of federal dollars that doesn’t punish them for turning down the enlargement.
Republicans also disagree over how to pay for the plan they settle on. Some are looking at capping how much of employees’ health benefits can be shielded from income and payroll taxes—a broad move that would affect as many as 178 million people. Others say such caps would disrupt a system popular among employers trying to recruit top talent and employees who welcome the tax break.
“It’s going to be hard for businesses to not continue to use that,” said Rep. Phil Roe (R., Tenn.).
Republican leaders said it may ultimately fall to the president’s megaphone to quell the intraparty rebellions that show no sign of dimming.
“The president’s going to be very pivotal in this,” said Rep. Dennis Ross (R., Fla.), a member of the House GOP whip team, which is charged with rounding up votes. “He’s got to go into these districts and give air cover to these members who are weak-kneed on some of these issues.”
At least one highly experienced Republican warned recently that the outcome is far from certain.
“In the 25 years that I served in the United States Congress, Republicans never, ever, one time agreed on what a health-care proposal should look like,” former House Speaker John Boehner (R., Ohio) said at a health-care conference in Florida. “Not once.”https://buy.wsj.com/wsjusbrexit17/?inttrackingCode=aaqo0kw4&icid=WSJ_ON_SPG_ACQ_NA
Why the GOP's alternatives to Obamacare are political time bombsby Noam Levey - LA Times - February 28, 2017

Republicans came into office this year promising to rescue Americans from rising healthcare bills by repealing and replacing the Affordable Care Act.

But the party’s emerging healthcare proposals would shift even more costs to patients, feeding the very problem GOP politicians complained about under Obamacare.

And their solutions could hit not only Americans who have Obamacare health plans, but also tens of millions more who rely on employer coverage or on government health plans such as Medicaid and Medicare.

House Speaker Paul D. Ryan (R-Wis.) and other congressional leaders, as well as new Health and Human Services Secretary Tom Price, favor bringing back slimmed-down health plans that were phased out under Obamacare. Such “catastrophic” plans typically offer fewer benefits and often require patients to pay much larger deductibles.

Many in the GOP also want poor people who rely on Medicaid to face more co-payments and higher premiums, citing the need for patients to have “skin in the game.”

Developing House Republican plans to replace Obamacare would scale back government insurance subsidies for millions of low- and moderate-income Americans who rely on the aid to buy coverage.

To fund a healthcare overhaul, Republicans are exploring ways to scale back tax breaks on health insurance, a move that could mean a tax hike for people who get coverage through an employer.

Meanwhile, other GOP plans to overhaul Medicare — which Ryan and Price have championed — would provide seniors with vouchers to shop for commercial health plans, an approach that independent analyses suggest could leave many patients paying more.

Those are politically risky ideas, said Robert Blendon, an authority on public attitudes about healthcare at Harvard University. “Skin in the game has been never popular,” he said. “It may be an economist’s dream. But it’s never been something people say they want.”

The GOP proposals — many bedrock conservative healthcare ideas — also could prove a major obstacle as Republicans labor to convince increasingly skeptical Americans that they have a better alternative to Obamacare.

Republican leaders like Ryan contend their ideas will transform healthcare markets across the country as government regulations are pared back, driving down costs.

“We believe in a patient-centered system, where individuals have the freedom to buy what they want and not what the government makes them buy,” Ryan told reporters at the Capitol recently. “It's really, really important to have choice and competition in healthcare because choice and competition lowers cost and increases quality.”

GOP lawmakers have tapped into fertile ground with their relentless attacks on rising costs. Though insurance premiums are generally increasing more slowly than they had in the past, many consumers are still seeing steep increases even as their deductibles also balloon.

The increases have been particularly dramatic on the insurance marketplaces created by the healthcare law, which serve only about 11 million people but have become the law’s most visible program.

This year, the average annual deductible for a silver plan for a single adult on the marketplaces hit $3,572, according to a survey by HealthPocket, an online insurance shopping tool.

Most experts believe high healthcare costs are being driven primarily by the high price of medical services in the U.S.

The average cost of a hip replacement, for example, is nearly twice that in Switzerland or Britain. Many brand-name pharmaceuticals cost two or three times what they do in other industrialized countries.

But most GOP proposals focus on getting patients to pay more out of their own pocket for medical care as a way to control rising premiums.

A favorite Republican strategy is to increase use of high-deductible health plans, coupled with tax-free health savings accounts, or HSAs, which consumers can use to set aside money for medical expenses.

“HSAs tied to high-deductible health plans are popular tools that lower costs and empower individuals and families,” House Republicans said in their “Better Way” blueprint for replacing Obamacare.  

Under current law, high-deductible plans can require single people to pay as much as $6,550 before their insurance kicks in. Families can face deductibles as high as $13,100.

Consumers who have qualifying high-deductible plans can put aside as much as $3,400-a-year in a health savings account, or $6,750 of they have a family health plan. Many Republicans favor allowing Americans to put away even more in these accounts.

Republicans similarly favor more cost-sharing in government safety net programs, such as Medicaid.

The federal government historically has limited how much state Medicaid programs can charge poor children, pregnant women, and elderly and disabled patients for medical care.

Trump has said he has no plans to alter Medicare, but senior officials in the Trump administration, including the vice president, helped pioneer broader use of premiums and co-pays for Medicaid patients in Indiana. Many in the GOP would like to see this approach broadened nationally, including the woman Trump has tapped to oversee the federal Medicaid program. Seema Verma also worked in Indiana.

Price, Trump’s Health secretary, has also called for changes to the Medicare programthat could hit seniors with higher medical bills through a practice called balance billing, which allows physicians to collect a surcharge from patients beyond Medicare’s fees. Balance billing is currently prohibited.

Even as Republicans envision patients paying a larger share of their medical bills, many GOP leaders are also calling for cuts in federal aid to help Americans pay their insurance bills.

Among other things, congressional Republicans are discussing plans to scale back subsidies made available by Obamacare that help about 8 million Americans buy health coverage on state insurance marketplaces created by the law.

These subsidies are linked to consumers’ incomes, with much more aid available to poor people. If the system is changed, millions could see their insurance premiums jump.

The effect of such cuts would be limited to the small fraction of Americans who rely on the marketplaces.

But Republicans are also eyeing changes that could affect health insurance costs for a growing share of the roughly 150 million people who currently get coverage through an employer.

Under plans being discussed by House GOP leaders, the federal government would scale back the tax break that employers and workers get on health benefits. For decades, health benefits have not been subject to income taxes or payroll taxes.

Changing that could make health insurance more expensive for many workers and families, and disrupt a highly popular system. In one recent survey, more than 8 in 10 Americans rated their employer-based coverage as excellent or good.

The GOP plans to shift costs to patients with high medical bills and less government aid are already generating skepticism among many experts, who question whether most Americans will be able to put aside more money to pay for their healthcare.

Nearly 70% of Americans in one recent survey reported having less than $1,000 in savings.

At the same time, it’s unclear that loosening government regulation of health insurance will produce the substantially cheaper health insurance that Republicans have promised.

“There is this assumption that premiums will fall a lot,” said Len Nichols, a health economist who heads the Center for Health Policy Research and Ethics at George Mason University. “I think they are going to be disappointed.”

Most immediately, GOP leaders face a more serious political problem of convincing Americans of the merits of their strategy. “Nobody ever says they want to spend more on their healthcare,” Harvard University’s Blendon said.

http://www.latimes.com/politics/la-na-pol-healthcare-republican-dilemma-20170228-story.html

Achieving Universal Coverage Without Turning to a Single Payer

Lessons From 3 Other Countries

Regina E. Herzlinger, DBA¹; Barak D. Richman, JD, PhD²; Richard J. Boxer, MD³

The most popular parts of the Affordable Care Act (ACA) are the most expensive. Universal coverage is a top priority not only for Democrats but also for President Trump. Both Republicans and Democrats want to preserve many costly coverage features of the ACA, including those that prevent insurers from precluding people with preexisting conditions and those that eliminate lifetime or annual coverage limits. The challenge is how to preserve these features and make insurance affordable.

A primary obstacle to achieving affordable universal coverage is the high costs of those with diseases or costly traumatic events—approximately 20% of individuals accounting for approximately 80% of health care spending. So, a key question is how to pay for their care.

Some nations in the Organisation for Economic Co-operation and Development (OECD) rely on a governmental single-payer model to achieve universal coverage, but this approach is politically infeasible in the United States. As the United States relies on private-sector insurance, 3 other countries that use private-sector insurance to offer affordable universal coverage provide some potentially helpful lessons.

Paying for Costly Patients

Some advocate creating risk pools for enrollees with preexisting conditions. This strategy removes individuals with high health care costs from the broad pool of enrollees and uses government funds to subsidize their insurance premiums. In turn, the cost of insurance is substantially reduced for the rest of those who are insured.

This strategy, however, requires substantial infusions of funds. In 2016, the costliest 5% of patients younger than 65 years (the age before Medicare begins) accounted for nearly 50% of all expenditures for that age group, yet their insurance premiums can realistically cover only a small fraction of their costs. Accordingly, when states experimented with high-risk pools before the ACA, the costs proved to be unsustainable: net losses for 35 state high-risk pools combined were more than $1.2 billion, or $5510 per enrollee, in 2011. The expenses forced states to limit enrollment in these high-risk pools, leaving out many costly patients. By the time the ACA was implemented, the combined enrollment in 35 state high-risk pools included only about 2% of non–group health insurance participants. By comparison, a recent report estimated that 27% of individuals in the United States younger than 65 years have health conditions “that would likely leave them uninsurable if they applied for individual market coverage under pre-ACA underwriting practices.”

If high-risk pools are part of the solution to attaining universal coverage, federal funding is essential. But federal policy makers are unlikely to commit a sufficient amount of funds to make this approach successful. One plan proposes $25 billion in state grants over 10 years to fund high-risk pools, but this sum is likely insufficient considering that insurance companies received $8 billion from the federal government through the ACA in 2014 and 2015 in reinsurance payouts for their costliest ACA patients.

Another strategy to pool costly patients would channel them into Medicare and rely on the federal government as the ultimate risk bearer. But Medicare premiums are artificially controlled by passing some present spending onto future generations. Trustees project Medicare’s 75-year total spending in excess of dedicated revenues at $27.9 trillion, and the Centers for Medicare & Medicaid Services Office of the Actuary projects this amount at $36.8 trillion. Adding costly individuals to Medicare would only exacerbate these intergenerational problems.

This leaves a third strategy: the individual mandate—or as the Supreme Court characterized it, an annual tax assessed against individuals who have not purchased qualified health insurance within the calendar year. Although vilified by some, the mandate is attractive for several reasons. It is relatively easy to implement, is effective in pooling risk, and reflects the values of individual responsibility. Coverage is primarily funded by the enrollees rather than by general taxation. For these reasons, some nations that are committed to a private health insurance sector have achieved universal coverage and effective risk pooling by mandating the purchase of insurance.

Examples of the Individual Mandate and Penalties

Switzerland, Singapore, and Germany have achieved universal coverage and made insurance affordable even for their citizens with highest health care costs by instituting an individual mandate. One major difference, however, is that unlike the ACA, the mandates instituted by these countries are reinforced with effective penalties for nonparticipation, thus ensuring that lower-cost enrollees—generally healthier individuals—balance out the costs of the others who require more medical resources.

• In Switzerland, citizens must purchase health insurance. If they do not, government authorities automatically enroll them, selecting the insurance provider on the individuals’ behalf. Moreover, insurers can implement debt enforcement proceedings against anyone failing to pay their premiums and collect a penalty in addition to back premiums. The Swiss government subsidizes premium payments for more than a quarter of the population, including retirees who purchase the same insurance as workers.
• Singapore institutes compulsory contributions from employers on behalf of their employees to create medical savings accounts. Employees maintain these accounts for health care expenses such as health and disability insurance premiums, hospitalization, surgery, rehabilitation, end-of-life care, and outpatient services. Those failing to pay their premiums are subject to garnished wages and other legal actions that can force payment of back premiums, penalties, and interest. Unemployed or low-income individuals are eligible for government subsidies that enable them to pay for the premiums.
• In Germany, insurance is funded by compulsory contributions to private insurers levied as 7.3% of income. Unemployed individuals have their contribution taken out of their unemployment benefits coupled with means-based sliding-scale subsidies, and uninsured self-employed persons who later attempt to purchase insurance face payment of back premiums for the period in which they were uninsured.

To be sure, these health care systems differ from that in the United States in other important ways. For instance, all allow individual tax deductions for health insurance expenditures and thus have evolved from an employer-based to a consumer-based system, whereas the United States limits the individual market with constraints on such deductions. In addition, these countries have many more insurers than the United States, and consumers benefit from vigorous competition among them. Germany in 2015, for example, had 124 sickness funds and 42 private health insurance companies, and the average resident of Switzerland in 2011 could choose from 59 health insurers offering coverage, with the 5 largest insurers covering 43% of the population. By comparison, in California, a state with approximately half Germany’s population, only 7 firms covered more than 95% of privately insured individuals in 2011, with the 3 largest firms covering 75%. In Massachusetts, with a population slightly smaller than Switzerland’s, 3 insurance companies enrolled 79% of individuals with private insurance.

As with the ACA, these nations provide financial support for insurance mandate purchases. Singaporean employers contribute to their employees’ medical savings accounts, and German employers match their employees’ payroll contributions to insurance premiums.

In sum, health insurance models in Switzerland, Singapore, and Germany suggest that an individual mandate, with adequate subsidies, can achieve affordable universal coverage. But the recipe for their success also includes firm penalties. They also suggest that the ACA’s individual mandate failed to pool risk adequately, in large part because its penalties were too weak. In 2014, approximately 7.5 million individuals paid the penalty rather than purchasing insurance, and of the approximately 15 million uninsured people who were ineligible for Medicaid, an estimated 7.1 million would pay a penalty lower than the cost of the least expensive plan. The Internal Revenue Service’s recent announcement that, to comply with President Trump’s January 20, 2017, executive order rolling back the ACA, it might not pursue individuals who fail to provide evidence of health insurance will further dilute the current individual mandate. Achieving universal coverage, like these 3 nations, requires a more forceful approach.

Conclusions

Although insurance mandates and penalties may seem unattractive, policies that induce citizens to purchase insurance are as old as the republic and as common as the most popular programs. In 1790, President George Washington required that ship owners purchase medical insurance for their seamen, and Medicare has long assessed penalties on healthy people who do not enroll by age 65 years. If the goal is universal health coverage that provides care even for patients with the highest health care costs without relying on public insurance programs, the financial burden must be spread across the whole population. This requires either massive government spending, whether through high-risk pools or Medicare, or requiring individuals to purchase insurance.

It is time to stabilize the premiums of the universal insurance market by neutralizing the political disagreements surrounding the ACA’s mandate and penalties. As these 3 countries demonstrate, maintaining the popular aspects of the ACA requires keeping its less popular part, and achieving the stated goal of universal coverage requires a serious commitment to individual responsibility.

http://jamanetwork.com/journals/jama/fullarticle/2607482

This CEO's Small Insurance Firm Mostly Turned A Profit Under Obamacare. Here's How

by April Dembosky - NPR - Dr. Mario Molina now runs Molina Healthcare, the small insurance company his father founded in 1994 in Southern California. Part of the firm's success, he says, stems from understanding the priorities of patients.

Courtesy of Molina Healthcare

Some large health insurance companies have suffered losses under the Affordable Care Act, leading to a few high-profile exits from the health exchanges. Humana is just the latest, announcing in January that it will stop offering health insurance on the Affordable Care Act exchanges at the end of 2017.

But the administrators of a smaller, California-based insurer — Molina Healthcare — managed to turn a modest profit in the early years of the health law. How did they do it?

"We understood the demographics of the people that we're serving a little better," says Dr. J. Mario Molina, CEO of Molina Healthcare, "because we've been doing it for so long."

Molina's father, David, also a doctor, first founded a network of medical clinics in southern California in 1980 that served mostly low-income patients. Sometimes when his dad's patients couldn't pay, they would trade services, or give him items from their homes instead of cash, the younger Molina recalls: a glass decanter, a pipe organ, even a dog.

"My father was old-fashioned," says the CEO. "He believed doctors had an obligation to take care of patients, and that the primary issue was not how they were going to get paid."

In 1994, David Molina started his health insurance company, focusing on getting care to patients on Medicaid — government health insurance for the poor and disabled.

That is what positioned Molina Healthcare to move into the Obamacare marketplaces so smoothly, Mario Molina says — most people who signed up for Obamacare plans are low-income.

"It's a different population most insurance companies haven't been interested in," he says.

For example, transportation is an issue for his company's customers. They often take the bus to medical appointments, he says, so would rather see a doctor close to home, than at an academic hospital 30 miles away.

"We don't contract with every hospital and every doctor," he admits. "It's not everyone, but it's enough so that you can find a doctor and the hospital and the services you need." His company now operates in 12 states and Puerto Rico.

While some have criticized narrow insurance networks for not offering consumers enough choice, especially of medical specialists, having fewer doctors in the Molina Healthcare network has meant lower costs for the company and its customers. That means the health insurance company has been able to earn a modest profit — roughly 1 percent in the first couple years of Obamacare.

Some larger insurers are accustomed to creating health plans for big companies, who often want more doctors and more benefits included, in hopes of attracting and retaining top employees. But plans like that cost more.

"They're looking at things sort of from the top down, and we're looking at things from the bottom up," Molina says.

He's used to running a low-cost, low-margin business, while big guys like Humana, Aetna and UnitedHealth aren't. Industry analysts say that's why some of the big players lost money with Obamacare.

"It's easier to work up from a low-cost position than it is to work down from a higher-cost position," says Josh Weisbrod, a health care consultant with Bain & Company. "For an insurer that is used to selling employer plans with rich benefit designs and broad networks, it is difficult for them to transition that to a narrow network of lower cost providers."

But Molina says there's been a serious downside to his company's success: a provision of the Affordable Care Act known as "risk transfer." The provision was designed to help insurance companies cover losses if they ended up with a lot of really sick, expensive patients. It works like this: Companies with fewer patients who have a chronic or serious illness pay some of their revenues to the companies that cover more patients who are sick.

It was a fine idea, Molina says, but the formula lawmakers came up with to calculate risk was all wrong.

"Let's put it this way," he says. "Currently Molina Healthcare is returning 25 percent of our premiums to the government, which are then distributed to our competitors. So we are really subsidizing our competitors and helping them, rather than forcing them to compete."

And that is one of the things that hit Molina's bottom line in 2016, resulting in much lower profits than originally projected for the year and a significant fourth quarter loss. Molina complains that the risk formula seems to punish efficiency rather than help those who had some bad luck.

"I think it was done by well-meaning people who had a theoretical knowledge, but not a practical knowledge of insurance," he says.

Still, Molina remains a fan of the Affordable Care Act overall, and hopes Congress will consult with him and other insurers as it debates the future of the health law.

"It doesn't need to be scrapped and replaced," he says. "It needs a tuneup."

If lawmakers need guidance on how to fix Obamacare, he adds, they should look at one state that really got it right: California.

California insurance regulators and health officials "forced everyone to really compete," Molina says, "and that made everyone kind of sharpen their pencils and do a better job," he says. "It's kept everyone on their toes, and, as a result, I think there's been more stability in the marketplace."

There's also more predictability. California may have more business regulations than other states, but Molina believes that's created a level playing field.

"The state doesn't make arbitrary decisions," he says. "We can plan from year to year. We understand the rules. Imagine if you're trying to play a game and the rules change in every quarter."

Molina is hoping newly-elected rule makers at the federal level will take his message to heart, too.

http://www.npr.org/sections/health-shots/2017/02/28/516495579/this-ceos-small-insurance-firm-mostly-turned-a-profit-under-obamacare-heres-how

Health Care Is Front and Center in Democrats’ Response to Trump Address

by Jonathan Martin - NYT - March 1, 2017

In responding to President Trump’s address to Congress on Tuesday, Democrats had to navigate between the expectations of their angry base in America’s cities and the need to appeal to a broader array of voters in parts of the country where the president is far more popular.

The party handed that task to former Gov. Steven L. Beshear of Kentucky, an emblem of the sort of largely rural state that Democrats lost in last year’s presidential election. Delivering the party’s official response, Mr. Beshear, dressed in khakis and a blue shirt, sat in a Lexington diner and offered down-home references to Friday night football, Sunday morning worship and life as a preacher’s kid.

Mr. Beshear noted that the Americans who had gained health insurance under the Affordable Care Act, a law he championed in his state, were the sort of “friends and neighbors” he surrounded himself with in the diner.

Before the law was passed, “they woke up every morning and went to work, just hoping and praying they wouldn’t get sick,” he said. “Because they knew they were just one bad diagnosis away from bankruptcy.”

Now, he vowed, “Democrats are going to do everything in our power to keep President Trump and the Republican Congress from reneging on that commitment.”

The decision by the congressional Democratic leadership to invite Mr. Beshear, 72, who has been out of office for more than a year, was a departure from tradition for the opposition party, which usually chooses a rising star to offer the televised response to the president’s speech.

But Democratic leaders are determined to make health care — particularly Medicareand the Affordable Care Act — the centerpiece of their attacks against Republicans leading into next year’s midterm elections. And as Mr. Beshear alluded to, he has a compelling story to tell about the effect of the health law in a conservative-leaning state.

But congressional Democrats are struggling to keep a tight grip on their most impassioned voices, just as Republicans did with the rise of the Tea Party in opposition to President Barack Obama.

So while Mr. Beshear devoted a substantial portion of his remarks to health care, he also turned away from his easygoing tone with strongly worded remarks on immigrants and refugees that he may have avoided were he facing re-election.

“President Trump has all but declared war on refugees and immigrants,” he said, adding, “We can protect America without abandoning our principles and our moral obligation to help those fleeing war and terror without tearing families apart.”

And Mr. Beshear castigated Mr. Trump over the president’s incendiary rhetoric.

“When the president attacks the loyalty and credibility of our intelligence agencies, the court system, the military, the free press, individual Americans simply because he doesn’t like what they say, he’s eroding our democracy,” he said. “And that’s reckless.”

The former governor was not the only prominent voice on the left responding to the president’s address to Congress. Senator Bernie Sanders of Vermont, who has perhaps the most intense following of any currently serving liberal, delivered a rejoinder via Facebook Live.

“The Republicans are now on the defensive, and we have to continue to push them back,” Mr. Sanders said, invoking issues such as climate change and mass incarceration, which Mr. Trump made no mention of but are particularly important to many liberals.

And Astrid Silva, an immigration activist who came to America as an undocumented immigrant, delivered the first ever Spanish-language response to such a presidential address, saying, “Immigrants and refugees are the heart and soul, and the promise, of this country.”

Mr. Sanders, a political independent, has been made a member of the Senate Democratic leadership, so his remarks were not of the same renegade nature as those delivered in 2011 by Michele Bachmann, a Minnesota congresswoman at the time, who offered a Tea Party-flavored speech after Mr. Obama’s State of the Union address. The Republicans’ official response that year was delivered by Representative Paul D. Ryan of Wisconsin.

Still, many rank-and-file Democrats, and some elected officials, believe Mr. Trump was illegitimately elected and are focused more on how to quickly expel him from office than on promoting a poll-tested message against him and other Republicans on health care.

Representative Maxine Waters, the veteran California Democrat, said the demands from liberal voters were growing only more intense.

“Even though many of my Democratic colleagues are not ready to talk about impeachment, in the grass roots I’m hearing a lot about impeachment — and treason,” said Ms. Waters, who boycotted Mr. Trump’s speech, adding that she shared their desire to drive him from the presidency.

“I believe he can be found guilty of high crimes and misdemeanors, with the interaction and the collusion that is taking place with Russia and the Kremlin,” she said. “And I’m going to keep on it, and I think I’m going to be proven to be right.”

Beyond Ms. Waters’s absence, there were other signs of quiet protest that illustrated how uneasy Democrats are with a historically unpopular new president. Many of the female Democratic lawmakers in the audience were clad in white to honor the women’s suffrage movement.

And some of the House Democrats known in the past to stage an endurance test to be seen on camera shaking the hand of the president bypassed the rite, leaving mostly Republicans to greet Mr. Trump when he walked down the center aisle to deliver his speech.

After his remarks, among the few Democrats to greet the president was a grinning Senator Joe Manchin III of West Virginia, perhaps the most conservative member of his party in Congress.

Representative Joe Crowley of New York, the chairman of the House Democratic Caucus, was less pleased.

“We don’t agree with much of anything he said tonight,” he said.

https://www.nytimes.com/2017/03/01/us/politics/steven-beshear-democratic-response.html?action=click&contentCollection=us&module=NextInCollection&region=Footer&pgtype=article&version=newsevent&rref=collection%2Fnews-event%2Fdonald-trump-white-house

How to Fight a Soaring Drug Price: Innovate

BY SHEFALI LUTHRA - NY TIMES - FEBRUARY 28, 2017

In January, amid widespread national concern over soaring prescription drug prices, Donald J. Trump, then the president-elect, told reporters that the industry was “getting away with murder.”

Indeed, some doctors — frustrated by what they see as unreasonable price tags and political stagnation — are coming up with their own do-it-yourself solutions. Their efforts to bring down costs for their patients highlight the arbitrary and often needlessly exorbitant prices of drugs in the United States, they say.

One striking example is the response of Dr. Cathleen London, a family doctor in Milbridge, Maine, to news that the pharmaceutical company Mylan had driven up the prices of its signature EpiPen, a branded auto-injecting device containing a preset dose of epinephrine, a lifesaving drug, to be used by people at risk of experiencing anaphylactic shock triggered by an allergy. “I thought: This is disgusting. There’s got to be another auto-injector,” she said. “I started Googling.”

She ended up devising a workaround for her patients who needed one.

“I basically build an auto-injector. I can do it for pediatric and adult dosing,” she said. “I found the right syringe. I put in the dose that I wanted. Whether it’s expired or used, people come back and refill it.”

The price of EpiPens has surged in recent years — an increase connected to the device, not the epinephrine, which is a hormone also known as adrenaline and costs pennies for a dose. A package of two EpiPens now costs more than $600, up from just over $100 in 2009. In response to public outcry and lawmaker scrutiny, Mylan last December released its own generic version of the device at about half the cost, but that’s still out of reach for many people.

Meanwhile, some insurers have dropped coverage of the pricey name-brand auto-injector pack or made sure customers have access to cost-effective alternatives, and the drugstore chain CVS reduced the price of a generic competitor. But all still cost at least $109.

Fixes like Dr. London’s can alleviate the pricing issue, but replicating this approach on a large scale could pose problems, since someone with medical expertise must do the refilling to avoid contaminating the device, meet quality standards for the device itself, and make the user aware of any safety issues that using the injector might pose.

Still, for customers with little money to spare, innovations like Dr. London’s might represent a path to more security. In addition to costing less, her process tackles a key issue. EpiPen auto-injectors aren’t reusable, and epinephrine expires after 18 months, so people with serious allergies must get a fresh device each year.

Dr. London charges her patients $50 for an initial device, and $2.50 for a refill.

“There’s value to the auto-injector, but it is not built in a way that’s refillable or reusable,” said Stephen Schondelmeyer, a professor at the University of Minnesota College of Pharmacy, who heads its department of pharmaceutical care and health systems.

Mylan points out, though, that the EpiPen is designed specifically to administer epinephrine quickly and properly in an emergency situation and quotes the Food and Drug Administration in saying that the “the device that delivers the medication is just as critical.” Nevertheless, critics say that doesn’t justify the skyrocketing of the price paid for a device that has remained unchanged for years.

In the past, insurance shielded consumers from most of the rising costs of prescription medicine. But that’s changed in recent years, as health insurance plans have increasingly required greater cost sharing — typically through the form of so-called high-deductible health plans in which beneficiaries pay more out of pocket before coverage kicks in. Many of the health care plans now under consideration by Republicans in their efforts to dismantle the Affordable Care Act emphasize this style of coverage, meaning that more allergy patients would experience directly the consequences of this price surge, which has already drawn scrutiny from the Senate Judiciary Committee. The issue also came up during a recent confirmation hearing for the Trump administration’s choice to head the Centers for Medicare and Medicaid Services, this time in regard to costs for federal health programs.

Dr. London helps her patients sidestep the costs of an EpiPen by purchasing reusable auto-injectors manufactured by the British company Owen Mumford. She fills it with epinephrine herself. (Both the auto-injector and hormone are approved by the Food and Drug Administration.) Patients can come in for an epinephrine refill after they’ve used the dose, or after it’s expired.

“It’s just a no-brainer to do this,” she said.

Experts say there’s no easy way to calculate what is spent annually on EpiPens that are thrown away because they are past their expiration date. But given the price tag, it’s likely to be many millions of dollars.

Workarounds like Dr. London’s can help individuals mitigate climbing costs, though they require extraordinary effort on the part of the doctor and trust on the part of the patient. Dr. London did a lot of research to find an auto-injector that was appropriate. The one she settled on is generally marketed for use with insulin syringes, but can also be used for many medications.

The strategy is also not without risks, noted Schondelmeyer, who worries about issues of sterility in a reusable device and other safeguards that come when products are made outside of the F.D.A.’s watchful eye. That’s why he is among those who caution against do-it-yourself remedies and against applying such approaches on a large scale.

Meanwhile, if a company were to try to market such a product, it would likely run into federal regulations and safety standards. Setting up a factory, or otherwise mass-producing the device, he added, would face regulatory hoops that could take years to jump through before the product would be available.

“These sound like simple solutions,” said Schondelmeyer. “But these aren’t market-based solutions that can work broadly.”

Other health professionals and government health agencies have found their own strategies to deal with the EpiPen’s escalating price tag. In at least a dozen states, pilot programs are either underway or being explored for emergency medical technicians to replace the EpiPens they carry with reusable syringes kits.

For example, participating emergency medical workers in New York State are given syringes, which can be filled with epinephrine on the spot. Analysts estimate that between $6 million and $10 million is spent annually by the state’s emergency medical crews on EpiPens “that are generally never used,” said Jeremy Cushman, an associate professor of emergency medicine at the University of Rochester who leads the New York effort. With refillable syringes, he said, the total yearly expense is less than $400,000.

“You’re looking at well over an order of magnitude of savings,” Cushman said.

This replacement makes sense for people with medical training, like emergency medical workers, but it won’t work for everyone, he said.

And some institutions, like school systems, have been slower to contemplate such replacement options — in part because they have less incentive to do so. At least 11 states require that schools keep epinephrine on hand, and schools often receive EpiPens from the manufacturer at heavy discounts or free.

The Baltimore County public school system, for instance, keeps about 400 EpiPens on hand in its 170 facilities. They record between 25 to 30 anaphylaxis cases annually, about two-thirds of which require stockpiled EpiPens. The rest are thrown away, said Debbie Somerville, the district’s coordinator for health services. It’s a similar story across the country. In San Francisco, the district’s public schools stock EpiPens and typically use fewer than 10 a year and dispose of about 120. Both systems receive the devices free.

In Baltimore, Somerville said, a switch to syringes and epinephrine has been discussed. But “it’s very hard to make the argument,” she explained, because emergencies can happen without a school nurse or medical professional on hand when a failure to administer epinephrine quickly and correctly could be fatal. That said, she added, “if we had to buy them at market rate right now, it would be a significant investment.”

Allergy patients who are advised to carry this emergency treatment also don’t necessarily have the specialized medical knowledge to fill a syringe on the spot. They need something easier, with less room for error. That’s why the EpiPen, and in particular the auto-injector, has become so popular.

But as cost-sharing grows and prices climb, interest in cheaper homegrown alternatives is catching on, said Jose Gomez-Marquez, an instructor at the Massachusetts Institute of Technology. He runs a lab that focuses on promoting do-it-yourself medical technology. His team, which started by researching how widespread this notion has become, found a growing interest among health professionals to create their own innovative solutions to patients’ problems. This work led to a broader online effort known as Maker Health, which works as a clearing house for such ideas.

For example, a nurse at one Texas hospital devised a portable and adjustable three-head shower that makes it easier to wash burn patients by keeping damaged skin tissue away from the water spray. Traditionally, nurses have spent hours washing these patients, manually moving around the showerhead. This fix saves labor, time, water and money.

“If you have extreme health care circumstances, you will find extreme health care ingenuity,” Gomez-Marquez said. “Five years ago nobody cared about pricing. Today, people are more price-sensitive.” Like London’s allergy patients — for whom those EpiPen price hikes matter a great deal.

“The ones who have no insurance, or whose insurance has no coverage“ for drugs “just go without,” he said. “They carry around the expired one. They think it’s going to work, and no, it isn’t.”

https://www.nytimes.com/2017/02/28/opinion/how-to-fight-a-soaring-drug-price-innovate.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

Short Answers to Hard Questions About Antibiotic Resistance

By SABRINA TAVERNISE, MAY 27, 2016

The idea of people dying from infections that were once easily cured may seem outlandish. But it is happening already — taking about 23,000 lives in the United States a year — and experts warn that things will get worse because bacteria are becoming resistant to antibiotics faster than we can make new drugs to fight back.

We have ourselves to blame, for overusing the drugs in people and squandering them on livestock. Now, a dangerous form of drug resistance has reached the United States, leaving us just one step away from infections that are completely untreatable.

What is antibiotic resistance?

It used to be that infectious diseases were the biggest killers of Americans — illnesses like tuberculosis and pneumonia. The invention of antibiotics, which were developed for medical use in the 1940s, changed all that. But they became overused, and the bugs they were invented to fight started to develop ways of resisting them. For some years now, infectious disease doctors have been warning that unless we rein in use of antibiotics in both people and livestock, there will come a day when they will be powerless against the most ferocious bugs, turning the clock back to the early years of the 20th century.

What is CRE?

CRE, which stands for carbapenem-resistant Enterobacteriaceae, is the most fearsome family of germs because it is resistant even to last-resort antibiotics.

The only drug that reliably treats CRE is colistin, an old and inexpensive drug that came on the market more than 50 years ago. This week researchers reported that they had discovered a gene in a bacteria that makes bugs resistant to colistin. It was found in a strain of E. coli in the urine of a patient in Pennsylvania. The patient was successfully treated, but if that gene makes its way into a strain of CRE, the bug would be unstoppable.

“We depend on colistin for the worst of the worst,” said Dr. James Johnson, a professor of medicine and an infectious disease expert at the University of Minnesota. “If it is knocked out, in most cases we really have nothing.”

Should I be scared?

Not yet. The discovery does not mean that an otherwise healthy person with a urinary tract infection is in danger of dying from it. (The Pennsylvania woman eventually recovered because her infection was treatable with antibiotics.) But the gene is mobile and can be picked up by other bugs — in sewer systems, in animal feed lots, in people’s guts or urinary tracts. That can make more bugs more resistant. The biggest worry is that a strain of CRE will pick up the gene. That could be devastating for anyone who is suffering from a CRE infection. “That is the combination we are all afraid of,” said Dr. Lance Price, a researcher at George Washington University.

For now, CRE is rare. The CRE germs cause about 600 deaths a year, usually strike people receiving medical care in hospitals or nursing homes, including patients on breathing machines or dependent on catheters. Healthy people are rarely affected.

How has antibiotic resistance changed medicine?

Dr. Johnson from Minnesota says the spread of resistant bugs means doctors are having to blast patients’ infections with increasingly stronger antibiotics. That has led to more patients coming in with infections caused by the C. difficile, a gut germ that flourishes when the patient has taken a lot of antibiotics. (The germ was estimated to cause almost half a million infections in the United States in 2011, and 29,000 people died within 30 days of the initial diagnosis.) Doctors now frequently send patients home with setups for intravenous antibiotics because pills no longer do the trick. Sometimes the specter of resistant infections can delay or cancel surgeries.

Why aren’t there more new antibiotics?

Most drug companies are not eager to make them. Compared with other drugs, antibiotics are not big moneymakers, and some manufacturers have gotten out of the business. Most people take antibiotics just once in a while, for a short time — unlike drugs for blood pressure, high cholesterol or diabetes, which most patients will take every day for the rest of their lives. When a new antibiotic comes out, doctors may hesitate to prescribe it, wanting to keep it in reserve for tough infections that older drugs cannot cure. Once the drug gets more widespread use, germs may become resistant to it, and doctors will quit prescribing it. So an antibiotic that required lots of time and money to develop may have a short life on the market. Infectious disease experts are working with Congress and the Food and Drug Administration to try to find ways to create financial incentives for drug companies to invest in making new antibiotics.

Is there anything I can do to protect myself?

A few simple steps can help reduce your risk of picking up a dangerous bug, says Dr. Brad Spellberg, chief medical officer for Los Angeles County+USC Medical Center. Wash your hands frequently. If you get sick, try not to use antibiotics. “What you should be doing is saying to the doctor, ‘Do I really need these antibiotics?’ ” he said.

Since hospitals are incubators of dangerous germs, if you end up in one, try to get out as fast as you possibly can. As for whether to avoid meat raised with antibiotics, Dr. Spelling says there is some evidence that such meat is more likely to have resistant germs, but those are avoidable with proper cooking.

Is there any real harm in taking an antibiotic for a cold?

There are several risks. An important one is based on the fact that healthy people normally carry billions of bacteria in their noses, throats, skin, genitals and gut. Antibiotics change the balance of those microbes, killing off susceptible ones and allowing drug-resistant ones to flourish. Even after a person finishes a course of antibiotics, the excess of drug-resistant bacteria can persist for months. If those drug-resistant bacteria find their way into the urinary tract — and normal gut bacteria are a common source of urinary infections — they can cause a drug-resistant infection that may be difficult to treat. In addition, people constantly pass bacteria — including drug-resistant ones — to their close contacts, so they may put others at risk.

Why are antibiotics given to livestock?

The vast majority of antibiotic use in the United States is in livestock —cows, pigs, chickens, sheep, even farmed fish — either for medical reasons, like treating or preventing disease, or to promote growth. Most of the antibiotics used for humans are also used for livestock, said Dr. Karin Hoelzer, a veterinarian and microbiologist at the Pew Charitable Trusts, who has extensively studied antibiotic resistance.

Antibiotics are believed by many in the food production industry to promote overall health, increasing the number of animals that can be sold for food and improving the quality of the meat.

How can the use of antibiotics in animals pose a risk to humans?

There are several ways. The genes that produce resistance to antibiotics can be easily transferred between bacterial species. So resistant bacteria can pass their resistance to other strains.

Humans can come in contact with resistant bacteria through eating insufficiently cooked meat or other food products: Manure from animals fed antibiotics is commonly used as fertilizer for crops. Farmworkers and people who work in slaughterhouses may also come in contact with the bacteria, providing an opportunity for genes to be exchanged.

Have bacteria resistant to the antibiotic colistin been found elsewhere?

Colistin-resistant bacteria have been found in humans or livestock in countries on every continent, including China, Malaysia, South Africa, Egypt, Italy and several South American nations. Scientists have also reported finding colistin resistance in CRE in some countries, said James Spencer, a senior lecturer in microbiology at Bristol University in England who was a co-author on a 2015 study that reported for the first time finding the colistin-resistance gene in a form that could be easily transferred to other bacteria. The study looked at the presence of the gene in food animals in China.

Has the Food and Drug Administration regulated the use of antibiotics in agriculture?

Under F.D.A policies that will take effect Jan. 1, antibiotics that are considered “medically important” for humans will no longer be approved for use to promote growth in livestock.

The policies also require that a veterinarian supervise the use of antibiotics in feed or water for livestock. Currently, many of the drugs are sold over the counter and do not require the involvement of a veterinarian.

Compliance is voluntary. But the 25 drug companies that manufacture about 283 antibiotics approved for use in livestock have all agreed to change their drug labels to reflect the requirements.

Some critics, however, say they are concerned that the new policies will leave loopholes that could allow food producers to circumvent them.

https://www.nytimes.com/2016/05/28/health/answers-antibiotic-resistance.html?action=click&contentCollection=Health&module=RelatedCoverage&region=EndOfArticle&pgtype=article