Capitol Shocker: Democrats and Republicans Start Working Together on Health Care
by The Editorial Board - NYT - August 3, 2017
Something unusual and important is happening in Congress: Republicans and Democrats are working together to improve the health care system. And they’re doing so in defiance of President Trump, who appears determined to sabotage the Affordable Care Act and the health insurance of millions of people.
This surprising if modest burst of bipartisanship comes just days after the Senate failed to pass a Republican bill to repeal important provisions of the A.C.A., or Obamacare. On Monday 43 members of the House outlined a proposal to strengthen the insurance marketplaces created by the 2010 law. On Tuesday Lamar Alexander and Patty Murray, the Republican and Democratic leaders of the Senate Health, Education, Labor and Pensions Committee, said they would hold hearings and introduce a bill to cut premiums and encourage insurers to sell policies on the marketplaces for 2018.
It is, of course, impossible to know if such efforts will succeed. Even if they result in legislation, Republican leaders could refuse to bring it to the floor for a vote. Having treated Obamacare as a political piñata for seven years, Republicans might find it hard to actually help the program. Another danger is that Mr. Trump and his health and human services secretary, Tom Price, could try to pre-emptively weaken the marketplaces through administrative measures. Still, it’s good to see politicians actually doing their jobs. The sight of members of both parties working together in the public interest is uplifting, especially after the long partisan campaign to take insurance away from so many Americans.
Contrary to Mr. Trump’s tweets, Obamacare is not collapsing. But it needs work, and some insurance markets are in trouble. Insurers have said they will no longer sell policies in 20 counties in Indiana, Nevada and Ohio, and many are proposing to raise premiums because of the uncertainty created by Mr. Trump’s threats. Experts say insurers could withdraw from even more counties, especially in rural and suburban areas, if the president sabotages the law.
The biggest fear, one shared by Mr. Alexander and Ms. Murray, is that Mr. Trump will stop subsidies authorized by the A.C.A. to make health care affordable to low-income people. The government pays these subsidies, about $7 billion this year, to insurance companies every month. In exchange, the companies reduce the deductibles and co-pays for people who earn between 100 percent and 250 percent of the federal poverty line, or $12,060 to $30,150 a year for a single person.
House Republicans sued the Obama administration in 2014, arguing that the payments were illegal because Congress had not explicitly appropriated money for them. A Federal District Court judge ruled in the Republicans’ favor, and the case is now on appeal. If Mr. Trump stopped the payments, insurers say, they would have to increase premiums by about 20 percent. The government would have to bear much of this additional cost, since the A.C.A. also subsidizes premiums for people with incomes between 100 percent and 400 percent of the poverty line. If premiums go up, those subsidies would automatically increase. The Kaiser Family Foundation estimates that if Mr. Trump stopped the payments to reduce deductibles and co-pays, total government spending would actually increase by $2.3 billion next year.
The bipartisan groups say their proposals would appropriate money for the subsidy payments, at least temporarily. That would remove the legal threat over the program, and barring a veto by Mr. Trump, would reduce his ability to sabotage the law. The House group also wants to create a “stability fund” to help insurance companies cover the cost of treating very sick customers. Experts say such reinsurance programs can encourage insurers to sell policies in rural and high-cost areas and help drive down premiums.
A deadline looms; insurance companies will decide in the next few weeks whether they will sell Obamacare policies in 2018 and what premiums to charge. Congress has an important role to play. It can follow Mr. Trump’s lead, and treat Americans’ health care as a hostage in a purposeless political battle, or it can stabilize the health care market and help millions of people.
Let’s Stop the Bickering and Fix the Health Care System
by Josh Gottheimer and Tom Reed - NYT - August 4, 2017
If either of us were building the American health care system from scratch, we’d probably end up in different places.
We have contrasting ideas — one of us is a Democrat, the other a Republican — about what ails the system and how to reshape it. But this is not the time for more partisan fighting. It’s time to build a better system, even if incrementally, because that’s what the American people deserve. It’s time to put aside blame and stabilize a health care marketplace where premiums are expected to rise by more than 15 percent in most states and millions of people are worried about obtaining or affording coverage.
This week the 43-member House Problem Solvers Caucus — which we lead and which is almost evenly split between Democrats and Republicans — released a carefully drafted compromise to shore up the struggling insurance exchanges.
Ultimately, everyone had to give a little and endorse provisions that purists in both our parties may not like. This is how American democracy is supposed to work, even if it has not for quite some time.
Our proposal first focuses on the most urgent crisis: the skyrocketing cost of individual health insurance premiums. The Trump administration is considering suspending cost-sharing payments that defray out-of-pocket payments like deductibles and co-payments for people earning less than 250 percent of the poverty line. Because of uncertainty about this subsidy, insurers have said premiums could rise by 15 percent or more. On Aug. 16, insurers must submit their 2018 rates to state regulators for approval; many may be forced to leave the individual marketplace altogether.
Our plan would stabilize markets by making the cost-sharing payments mandatory and thereby prevent rates from rising sharply.
Second, we provide a relief valve to help states deal with the high cost of pre-existing and chronic conditions. The costliest 5 percent of patients account for nearly half of all health care spending in the country. We propose a dedicated stability fund — essentially a form of reinsurance — that states could use to reduce premiums and limit losses for providing coverage for these high-cost patients.
Third, our proposal provides relief to certain businesses from the mandate that they provide insurance to full-time employees. It also defines “full time” as a 40-hour workweek to discourage businesses from manipulating employees’ weekly hours to skirt the mandate. More than 90 percent of large businesses offered health care before the Affordable Care Act, and studies show that they would continue to do so under this change; others would move to find employee coverage in the individual marketplace.
Fourth, our plan eliminates the Medical Device Tax, an excise charge of 2.3 percent that is often passed onto consumers and reduces funds for research and development. And finally, we provide states with additional flexibility to enter into agreements — such as enabling the sale of insurance across state lines — that would provide more choice and lower costs.
This proposal would not increase the federal deficit, offering several options to offset the new spending.
Our plan isn’t intended to rectify everything that’s wrong with American health care. We aim to solve an immediate problem and move past a seven-year stalemate in Washington that has featured Republicans trying to repeal the current health care law, Democrats trying to preserve it and neither side willing to discuss anything in between.
That approach has led us to our current moment, in which no one is happy with the status quo, least of all the American people, whose trust and confidence in Washington weakens every day that we spend fighting instead of solving real problems.
Health care is one of those problems — and a textbook example of why we formed the Problem Solvers Caucus this year. We all knew the partisanship in Washington had gotten out of control and felt the need to create a bipartisan group committed to getting to “yes” on important issues. We have agreed to vote together for any policy proposal that garners the support of 75 percent of the entire Problem Solvers Caucus, as well as 51 percent of both the Democrats and Republicans in the caucus.
If Washington does not act to stabilize the insurance exchanges, many families we represent will lose coverage or be hit with premiums they can’t afford. This isn’t conjecture.
If that does happen, people will be justifiably livid that Republicans and Democrats in Congress did nothing to stop a train wreck we all saw coming.
There is a growing recognition on Capitol Hill that something must be done, as evidenced by this week’s announcement from Senator Lamar Alexander — the Tennessee Republican who is chairman of the Senate Health, Education, Labor and Pensions Committee — that he will soon hold hearings focused on repairing the individual insurance market.
Our proposal isn’t perfect, but it represents the first and only serious bipartisan health care proposal released in this Congress. We hope our colleagues in the House and Senate, as well as the White House, will use our plan as the foundation for the health care solution that America desperately needs and deserves.
With Few Wins in Congress, Republicans Agree on Need to Agree
by Jennifer Steinhauer - NYT - August 4, 2017
WASHINGTON — Most people do not become United States senators to pass a resolution declaring National Lobster Day. But Congress has had to settle largely for small-bore victories since President Trump was sworn into office, ostentatiously failing to pass a bill to repeal his predecessor’s health care law and achieving little substantive policy legislation.
The floundering Republican agenda — particularly remarkable in a period when new presidents tend to be most productive with a Congress controlled by their own party — has attracted bipartisan scorn from lawmakers. It has also engendered some pity from those who see Congress as hamstrung by a dysfunctional White House.
But within the misery monsoon that has befallen Congress this year lies some potential silver linings.
After years of partisan fighting over the health care law that was President Barack Obama’s signature domestic achievement, Democrats and Republicans now admit that they will probably have to work together to make many of its much-needed fixes. “We’ve realized our limitations,” said Senator Jeff Flake, Republican of Arizona. “I think we will work together to get more bipartisan legislation. We’ve just got to.”
Republicans are deeply motivated to get a major tax bill passed and signed by the president and have returned to committee chambers — rather than the private back rooms of leaders’ offices — to get the process rolling.
Perhaps most important, Senate Republicans have begun to stiffen their spines against Mr. Trump, who has spent the better part of his presidency alternatively ignoring, undermining or outright denouncing the efforts of Congress to legislate. On Thursday, before leaving on a monthlong recess, the Senate set up a system to prevent the president from appointing senior administration officials to posts that require confirmation in the senators’ absence.
Among its more notable successes this year, and against Mr. Trump’s objections, Congress passed a tough Russia sanctions bill with a veto-proof majority, which the president begrudgingly signed this week. Congress also approved a law to help veterans get health care — a bipartisan, bicameral, messy but ultimately successful effort that came together with zero involvement from the administration.
A complicated debt ceiling fight may be averted now that Mr. Trump’s budget director, Mick Mulvaney, said on Thursday that Congress could lift the ceiling on the nation’s debts without having to make spending cuts in exchange.
“There is more good happening here than people know about,” said Senator Bob Corker, Republican of Tennessee. He added that he expected further bipartisan agreement on various policy efforts now that the Senate has dropped the health care battle and Republicans are gaining momentum on a tax package that they desperately need to win. As for the role of the president in all that, “I haven’t thought about it,” he said.
Indeed, most of the coming efforts in Congress run counter to what the White House has suggested ought to happen.
On the health care front, many lawmakers are already busy figuring out a way to stabilize the individual health insurance market and to fund the cost-sharing subsidies that Mr. Trump has threatened to end.
“I had Democrats bombard me right after the health care bill went down on that Friday morning,” said Senator James Lankford, Republican of Oklahoma, speaking of the dramatic 49-to-51 vote in the early hours of July 28. He said he was already knee-deep in work across the aisle on health care: “There was almost a quiet sense of hope.”
Mr. Trump’s budget requests have largely been ignored or rebuffed by the Senate, as were his administration’s notions on how to manage a bill to fund the Food and Drug Administration, which passed the Senate on Thursday.
While efforts to change the tax code have been hampered by the failure to repeal the health law, the motivation by congressional Republicans to work together and move beyond internal party disagreements has been, for now, bolstered by a deep desire to succeed.
“On the next big thing, we can’t fail,” said Senator John Thune of South Dakota, the third-ranking Senate Republican. “We have to double down on tax reform.”
There is no question the lift ahead is heavy. Congress has yet to pass a budget, something that should have been done this spring. Without measures to fund the government, a shutdown threat, which has become a feature as endemic to Washington as the annual cherry blossom run, will loom. Democrats in the House and Senate may make their own mischief with the debt ceiling, tying it to the Republicans’ tax bill.
Representative Nancy Pelosi, Democrat of California and the House minority leader, has expressed support for a clean debt ceiling hike. But her spokesman, Drew Hammill, said Ms. Pelosi “has also echoed the concerns that many House Democrats have about supporting such a move while Republicans simultaneously blow a multitrillion-dollar hole in the deficit with tax reform for the rich.”
“We are awaiting a plan from the Republican majority on how they plan to accomplish lifting the debt ceiling,” Mr. Hammill said.
It is not entirely clear that Republican leaders can deliver the votes on their own. What is more, Congress this fall must also tackle the reauthorization of the Children’s Health Insurance Program, which may well get entangled in other budget and tax issues.
As Republicans head to their respective states and congressional districts for recess, their lack of accomplishments hangs around their collective necks. Many small bills passed by the House were never considered by the Senate; that chamber pushed through a number of small measures on Thursday to give lawmakers something to brag about back home.
But some Republicans say legislative achievements will remain elusive without unity on a host of public policy issues that the party could not tackle during the eight years of the Obama administration. Within, and between, the two political parties remain massive gulfs.
“It’s not Congress’s job to see how many bills we can pass,” said Representative Trey Gowdy, Republican of South Carolina. “Otherwise there would not be working groups and task forces designed to study overcriminalization and overregulation. You can’t have it both ways, can’t pat yourself on the back for passing a law and four years later pat yourself on the back for repealing it.
“Our first challenge is to define those principles upon which are party is based, and then pursue legislation consistent with those principles,” Mr. Gowdy said. “I think we are still stuck on the first prong.”
Obamacare Rage in Retrospect
by Paul Krugman - NYT - August 4, 2107
I guess it ain’t over until the portly golfer sings, but it does look as if Obamacare will survive. In the end, Mitch McConnell couldn’t find the votes he needed; many thanks are due to Senators Susan Collins, Lisa Murkowski and John McCain (who turns out to be a better man than I thought), not to mention the solid wall of Democrats standing up for what’s right. Meanwhile, all indications are that the insurance markets are stabilizing, with insurer profitability up and only around 0.1 percent of enrollees unserved.
It’s true that the tweeter in chief retains considerable ability to sabotage care, but Republicans are basically begging him to stop, believing — correctly — that the public will blame them for any future deterioration in coverage.
Why did Obamacare survive? The shocking answer: It’s still here because it does so much good. Tens of millions have health coverage — imperfect, but far better than none at all — thanks to the Affordable Care Act. Millions more rest easier knowing that coverage will still be available if something goes wrong — if, for example, they lose their employer-sponsored plan or develop a chronic condition.
Which raises a big question: Why did the prospect of health reform produce so much popular rage in 2009 and 2010?
I’m not talking about the rage of G.O.P. apparatchiks, who hated and feared the A.C.A., not because they thought it would fail, but because they were afraid it would work. (It has.) Nor am I talking about the rage of some wealthy people furious that their taxes were going up to pay for lesser mortals’ care.
No, I’m talking about the people who screamed at their congressional representatives in town halls. People like, for example, the man who pushed his wheelchair-bound son, who was suffering from cerebral palsy, in front of a congressman, yelling that President Obama’s health care plan would provide the boy with “no care whatsoever” and would be a “death sentence.”
The reality, of course, is that people with pre-existing medical conditions are among the A.C.A.’s biggest beneficiaries, and would have had the most to lose if conservative Republicans had managed to repeal the law. And this should have been obvious from the beginning.
Beyond that, it’s now clear (as should also have been clear from the beginning) that very few people other than wealthy taxpayers were hurt by health reform, which was designed to disrupt existing health arrangements as little as possible.
Yes, around 2.6 million people who had individual policies with high deductibles and/or limited coverage were told that their policies were too skimpy to meet A.C.A. requirements. But they were offered the chance to buy better policies, and many of them probably received subsidies that made these better policies cheaper than their original coverage. Meanwhile, some young, healthy, affluent people saw their premiums rise. But predictions of mass harm were completely wrong.
Or if you regard statistical evidence as “fake news,” consider what happens every time Republicans call on the public to come forward with horror stories about how they’ve been hurt by Obamacare: The result keeps being an outpouring of support for the law, bolstered by tales of lives and finances saved by the A.C.A.
So once again: What was Obamacare rage about?
Much of it was orchestrated by pressure groups like Freedom Works, and it’s a good guess that some of the “ordinary citizens” who appeared at town halls were actually right-wing activists. Still, there was plenty of genuine popular rage, stoked by misinformation and outright lies from the usual suspects: Fox News, talk radio and so on. For example, around 40 percent of the public believed that Obamacare would create “death panels” depriving senior citizens of care.
The question then becomes why so many people believed these lies. The answer, I believe, comes down to a combination of identity politics and affinity fraud.
Whenever I see someone castigating liberals for engaging in identity politics, I wonder what such people imagine the right has been doing all these years. For generations, conservatives have conditioned many Americans to believe that safety-net programs are all about taking things away from white people and giving stuff to minorities.
And those who stoked Obamacare rage were believed because they seemed to some Americans like their kind of people — that is, white people defending them against you-know-who.
So what’s the moral of this story? There’s bad news and good news.
It’s certainly not encouraging to realize how easily many Americans were duped by right-wing lies, pushed into screaming rage against a reform that would actually improve their lives.
On the other hand, the truth did eventually prevail, and Republicans’ inability to handle that truth is turning into a real political liability. And in the meantime, Obamacare has made America a better place.
https://www.nytimes.com/2017/08/04/opinion/obamacare-rage-in-retrospect.html?
What’s Next for Progressives?
by Paul Krugman - NYT - August 7, 2017
For now, at least, the attempt to repeal the Affordable Care Act appears dead. Sabotage by a spiteful Trump administration is still a risk, but there is — gasp! — a bipartisan push to limit the damage, with Democrats who want to preserve recent gains allying with Republicans who fear that the public will blame them for declining coverage and rising premiums.
This represents a huge victory for progressives, who did a startlingly good job of marshaling facts, mobilizing public opinion, and pressuring politicians to stand their ground. But where do they go from here? If Democrats regain control of Congress and the White House, what will they do with the opportunity?
Well, some progressives — by and large people who supported Bernie Sanders in the primaries — are already trying to revive one of his signature proposals: expanding Medicare to cover everyone. Some even want to make support for single-payer a litmus test for Democratic candidates.
So it’s time for a little pushback. A commitment to universal health coverage — bringing in the people currently falling through Obamacare’s cracks — should definitely be a litmus test. But single-payer, while it has many virtues, isn’t the only way to get there; it would be much harder politically than its advocates acknowledge; and there are more important priorities.
The key point to understand about universal coverage is that we know a lot about what it takes, because every other wealthy country has it. How do they do it? Actually, lots of different ways.
Look at the latest report by the nonpartisan Commonwealth Fund, comparing health care performance among advanced nations. America is at the bottom; the top three performers are Britain, Australia, and the Netherlands. And the thing is, these three leaders have very different systems.
Britain has true socialized medicine: The government provides health care directly through the National Health Service. Australia has a single-payer system, basically Medicare for All — it’s even called Medicare. But the Dutch have what we might call Obamacare done right: individuals are required to buy coverage from regulated private insurers, with subsidies to help them afford the premiums.
And the Dutch system works, which suggests that a lot could be accomplished via incremental improvements in the A.C.A., rather than radical change. Further evidence for this view is how relatively well Obamacare, imperfect as it is, already works in states that try to make it work — did you know that only 5.4 percent of New Yorkers are now uninsured?
Meanwhile, the political logic that led to Obamacare rather than Medicare for all still applies.
It’s not just about paying off the insurance industry, although getting insurers to buy in to health reform wasn’t foolish, and arguably helped save the A.C.A.: At a crucial moment America’s Health Insurance Plans, the industry lobbying organization, and Blue Cross Blue Shield intervened to denounce Republican plans.
A far more important consideration is minimizing disruption to the 156 million people who currently get insurance through their employers, and are largely satisfied with their coverage. Moving to single-payer would mean taking away this coverage and imposing new taxes; to make it fly politically you’d have to convince most of these people both that they would save more in premiums than they pay in additional taxes, and that their new coverage would be just as good as the old.
This might in fact be true, but it would be one heck of a hard sell. Is this really where progressives want to spend their political capital?
What would I do instead? I’d enhance the A.C.A., not replace it, although I would strongly support reintroducing some form of public option — a way for people to buy into public insurance — that could eventually lead to single-payer.
Meanwhile, progressives should move beyond health care and focus on other holes in the U.S. safety net.
When you compare the U.S. social welfare system with those of other wealthy countries, what really stands out now is our neglect of children. Other countries provide new parents with extensive paid leave, provide high-quality, subsidized day care for children with working parents and make pre-K available to everyone or almost everyone; we do none of these things. Our spending on families is a third of the advanced-country average, putting us down there with Mexico and Turkey.
So if it were up to me, I’d talk about improving the A.C.A., not ripping it up and starting over, while opening up a new progressive front on child care.
I have nothing against single-payer; it’s what I’d support if we were starting fresh. But we aren’t: Getting there from here would be very hard, and might not accomplish much more than a more modest, incremental approach. Even idealists need to set priorities, and Medicare-for-all shouldn’t be at the top of the list.
Will a Mega-Billionaire Rescue America from GOP’s Insurance Mayhem?
by Ralph Nader - Common Dreams - August 3, 2017
Before recommending a practical way to reverse the devastating impact of Congressional Republicans’ attempts to strip tens of millions of Americans of health insurance coverage, and the non-stop anxiety and dread that comes with such cruel and vicious legislation, note the impact of having gerrymandered (the politicians pick the voters) Washington rulers.
The arrogant Republicans in Congress have good health insurance, life insurance, pensions, salaries and expense accounts paid by you the taxpayers. This perversely has led them to drop any empathy their residual consciences might have possessed before they came to Capitol Hill – many as millionaires.
At the same time, in a country that spends well over $3 trillion a year on ‘healthcare’, the GOP’s various bills leave millions of families fearing loss of insurance, reduced coverage, larger deductibles, unaffordable co-pays and inscrutable insurance and billing fine-print trap doors. This is producing serious fear, anxiety, depression and in many cases absolute terror for sick children and ailing parents.
We have the New York Times to thank for bringing this vast human toll, day after day, night after night, to their readers. In a recent article, reporter Jan Hoffman interviews people who are wondering “whether they would be able to continue screenings and treatment.” Hoffman writes that patients “are postponing” – so as not to set up a preexisting condition – “or accelerating major medical decisions, weighing whether to move to more insurance-friendly states” and worrying about “their own inability to control critical matters in their own lives.”
“‘I’m so done,’ moaned Cathy McPherson, 58, a retired court clerk in Sonora, CA, with hypertension…It’s what I think about all the time and I am totally burned out. They go over and over it. Can you stop? Just stop it for a little bit?’”
The Times also interviewed a psychologist, Nancy Molitor in Wilmette, IL, who describes “escalating anxiety about healthcare for all her patients. Many want to spend entire sessions about how to handle the stress and the feelings of fear, powerlessness, rage and frustrated paralysis.”
Perhaps Meghan Borland, who, with her husband, owns a small business in Pleasant Valley, NY, gives voice to this preventable despair in the USA most pointedly. They have a two year-old daughter, Amelia, receiving chemotherapy for leukemia. Meghan said, “For months it’s been: Here’s a bill, we’ll vote. No, we won’t. Now it will change. Maybe not. Will that one person in the Senate vote or not? Except for us, this is not a game.”
Well it’s a stupid, but lucrative, ideological game for the Republicans, whose various factions juggle their corporate paymasters and reactionary dogmas, as they try to give the rich and powerful another $800 billion in tax breaks at the expense of millions of their neighbors’ lives and livelihoods.
Without health insurance, about 35,000 Americans die each year; many more stay sick or injured because they cannot afford insurance to get diagnosed and treated in time. About 30 million people fall into that helpless, hurtful category.
Those tens of millions more Americans who are underinsured can barely figure out where they are covered and how much they have to pay or go without.
For the most vulnerable of these Americans, the choice is morbidly clear: pay or die.
In Canada, everybody has a Medicare card to use a system that is simple, affordable, comprehensive and universal. They hardly see a bill. They have better health outcomes, cover everyone and spend less than half per capita than does the corporate dominated US that excludes tens of millions of human beings from healthcare. Canadians do not have the anxieties, dread or fear of losing all their personal savings or bringing financial ruin on their families, as so many Americans do.
In Canada, no one has to decide whether to take or not to take another job based on health insurance factors. They are free to choose any physician or hospital – no narrow networks, with hidden charges, in that country.
In Canada, where there is public funding and private delivery of healthcare, profits are not the king, people come first. The large majority of citizens, liberals and conservatives, love their healthcare system, especially when they hear of the horrors going on south of their border in the US (Canadians need to be more alert to corporate forces trying to undermine, restrict budgets and bad-mouth their system, which is a shining example of what is possible with equitable public investment in healthcare).
A majority of Americans, including a significant number of conservatives, favor single payer, full Medicare for all. So do a majority of physicians and nurses, currently in thralldom to corporatist dictates.
How to get there from here? Listen to Warren Buffett, the multi-billionaire and sage from Omaha; he favors full Medicare for all as being more efficient and humane (A single payer system has far less administrative costs and billing fraud). Then he tells us the pathway to turning this whole madness and mayhem around. To paraphrase what he once said, there are only 535 members of Congress (100 senators and 435 representatives), and we’re over three hundred million people. Why can’t we control these legislators?
Imagine if a very rich, enlightened person pledged one billion dollars to fund the organizing of a few thousand serious volunteers in every Congressional District, each having four full-time advocates. Working with these volunteers, each dedicating 300 to 400 hours a year in Congressional watchdog associations, this watchdog initiative would immediately represent a majority of Americans. Within 36 months, with a consequential election in 2018, our country would have comprehensive, universal, affordable, simpler single payer (full Medicare for all), saving lives, livelihoods and endless family anguish and fear.
That would be quite an historical achievement for any one of numerous billionaires each worth at least $10 billion. Any takers?
Republican Senator Is on a Mission to Rescue the Health Care Law
by Carl Hulse - NYT - August 5, 2017
WASHINGTON — Senator Lamar Alexander voted to repeal the Affordable Care Act numerous times and wanted it gone. Now he is trying to save it — at least for the moment.
The Republican effort to overturn the law is in shambles and the insurance program itself is in serious trouble, leaving Mr. Alexander to try to pick up the pieces. And he is doing so in a way that is virtually unheard-of in today’s Washington — an overtly and unashamedly bipartisan approach.
“This won’t be easy to do,” acknowledged Mr. Alexander, 77, a Tennessee Republican and longtime public official who is chairman of the Senate health committee, “but we are going to do our best to do it.”
In an interview for The New York Times podcast “The New Washington,” Mr. Alexander added details to his emerging plan to shore up the health law and to his broader views on the underperforming Senate.
After Senate Republicans’ failure to repeal Obamacare, Mr. Alexander has set out on what he sees as a rescue mission to stabilize the insurance program by guaranteeing the consumer subsidies to insurance companies that President Trump has threatened to cut off, while granting states more flexibility to offer different insurance options.
He and Senator Patty Murray of Washington, the top Democrat on the panel who has been a productive negotiating partner with Mr. Alexander in the past, have agreed to convene hearings when the Senate returns in September and to try to push some minimalist legislation through Congress by the end of the month.
Even a small bill would be a feat in a Congress that has delivered so few results. But Mr. Alexander, a durable believer in the legislative process, sees it as a possibility, with the alternative being a failure that is certain to rock already reeling individual insurance markets.
“It has to be simple if we are to get bipartisan agreement by mid-September on an issue that has divided the parties so much,” he said. Stabilizing the markets for a year, he said, would provide breathing room to “tackle bigger issues” on health care.
Mr. Alexander’s political and policy challenges are formidable. First, he would have to get a consensus on his own committee, which ranges from Senator Rand Paul, Republican of Kentucky, on the right, to Senator Bernie Sanders, independent of Vermont, on the left, with a bit of everything else in between. Then he would have to get it through the full Senate, where nothing to do with health care has been able to attract a majority. Then the measure would go to the House, where resistance is even stronger to anything that resembles an effort to prop up the health care law.
Finally, there is the White House, where President Trump has suggested he might unilaterally terminate the funding Mr. Alexander wants to preserve and let the current health program collapse — an idea the senator thinks is a bad one. His opposition could put him in the line of fire from a president he barely knows.
But Mr. Alexander is the rare senator who has strong relationships with Senator Mitch McConnell, the Kentucky Republican and majority leader, as well as Senator Chuck Schumer of New York, the Democratic leader. Those ties could prove useful. But he is already under attack from conservatives framing his effort as a bailout for insurers — a critique meant to resonate with voters still angry about the 2008 bank bailout.
“The Senate’s inability to produce 51 votes for a piece of legislation that delivers on a seven-year campaign promise to repeal and replace Obamacare is not license for a bipartisan bailout of a failing law,” Michael Needham, head of Heritage Action, a conservative advocacy group affiliated with the Heritage Foundation, said. “Obamacare is becoming a zombie law, and throwing more taxpayer money at Zombiecare is unacceptable.”
Mr. Alexander, who has run for president twice, served as education secretary and was a two-term governor and a university president before joining the Senate in 2003, realizes he is going to come under fire for doing anything seen as sustaining the health care law. He is undeterred.
What would he tell an upset voter? “You are not going to think very much of me if I come up here and all I do is argue and never get a result,” he said.
In the end, he said, “the job is to get a result that can last and people respect that when we do.”
If he can be successful in this push, Mr. Alexander hopes it could provide needed momentum for the Senate, one that is admittedly finding it hard to produce because of intense partisanship.
After Senator John McCain, the Arizona Republican, last week called on the Senate to return to the more traditional approach of working together on national problems, Mr. McCain said he had “great faith” that Mr. Alexander and others could pull off a bipartisan feat. Mr. Alexander said he had embraced that praise as motivation.
“We have got a fractured country,” he said. “This is the most important institution for creating a consensus on tough issues like health care, like civil rights, like elementary and secondary education.”
“I think most of us understand that,” Mr. Alexander said of his colleagues, comparing them to an underachieving football program. “It is like a team of All-Americans that is not winning many games. We need to play better.”
Back in 2011, Mr. Alexander took the unusual step of surrendering his party leadership post in pursuit of more freedom to work across the aisle rather than hew to the partisan line required of Senate leaders. Even absent the title, he is going to need a large following if he is to bridge the seemingly intractable division over health care.
The Passion of a Congressional Health Care Battle
by Robert Pear - NYT - August 2, 2017
WASHINGTON — One of the remarkable features of covering the congressional battle over health care this year has been the way reporters pieced together a picture of what was happening from snippets of information extracted from members of Congress dashing through the Capitol.
At times, I felt as if I were in a time machine — reliving, in reverse, my previous reporting for The New York Times on the laborious legislative process that produced the Affordable Care Act in 2009 and 2010. Reporters roamed the halls like hunters and sprang into action with voice recorders in hand when a senator emerged from the Senate chamber, an elevator or a subway car, or an unmarked hideaway office.
It was not unusual to see more than a dozen reporters surrounding or chasing after senators who appeared to be thinking out loud as they responded last week to questions about the latest iteration of the Senate Republican health plan. Republican senators themselves often professed to be in the dark about crucial details. But from the scattered clues they offered — like tiles of a mosaic — journalists assembled a picture of what was happening behind the scenes.
Senator Bob Corker, Republican of Tennessee, for example, disclosed that Senate Republicans were planning to drop a tax cut for high-income people that had been included in a bill passed by the House and in a measure drafted by the Senate majority leader, Mitch McConnell of Kentucky.
Senator John McCain, Republican of Arizona, who eventually cast a decisive vote against the Republican health plan last week, had hinted at the bill’s problems in a corridor conversation with journalists a month earlier. Asked about the chances of a quick deal on health care, Mr. McCain remarked, “Pigs could fly.”
In bird-dogging senators, I worked with one of our ace congressional correspondents, Thomas Kaplan, who honed his skills prying secrets out of the New York State Legislature. We deployed two interns, Emily Cochrane and Avantika Chilkoti, to help track the fast-moving events.
The Senate vote occurred at 1:30 a.m. on Friday and lasted about 15 minutes. It was strange to watch such riveting drama in the middle of the night. But it was speedy compared with the all-nighter in November 2003, when the House approved a bill adding prescription drug benefits to Medicare. That vote started at 3 a.m. and lasted nearly three hours as Republican leaders quashed an uprising by committed conservatives.
In 2009 and 2010, President Barack Obama and congressional Democrats basically knew what they wanted: a government guarantee of health insurance for all Americans. They disagreed on some important details. But Democrats had much more consensus than today’s Republicans.
The differences between President Trump and Mr. Obama are obvious. Mr. Trump floated above the gritty details of health policy and took occasional jabs at Republicans slaving over the issue. Mr. Obama immersed himself in the details, and his top aides occasionally reached out to journalists to provide tart-tongued tutorials on the politics of health care.
In some ways, the collapse of Republican efforts to uproot the Affordable Care Act recalled the last days of the “Clinton Care” effort to remake the American health care system. It appeared to be moribund, but its champions vowed to keep trying. It finally expired on the Senate floor in 1994. (That defeat inspired Democrats to try again 15 years later.)
The four rounds of health care legislating have one thing in common: the passion that surrounds the issue.
Cancer survivors, children with disabilities and young adults with diseases converged on Congress in a bid to save the Affordable Care Act. Lawmakers, listening to their stories, were clearly moved. I had never heard members of Congress speak with such empathy on behalf of Medicaid beneficiaries or drug addicts, whose treatment was financed by Medicaid.
But for every such testimonial, Republicans could cite reports from constituents aggrieved by the law: people who said they were spending more on health insurance premiums than on home mortgage payments, and “victims of Obamacare” who could not afford to use their insurance because the deductibles were so high.
The lawmakers were, in a sense, deciding who would live and who would die — but they had alternate versions of reality that could simply not be reconciled.
Price Transparency in Medicine Faces Stiff Opposition From Hospitals and Doctors
by Rachel Bluth - Kaiser Health News - July 31, 2017
Columbus, Ohio—Two years after it passed unanimously in Ohio's state Legislature, a law meant to inform patients what health care procedures will cost is in a state of suspended animation.
One of the most stringent in a group of similar state laws being proposed across the country, Ohio's Healthcare Price Transparency Law stipulated that providers had to give patients a "good faith" estimate of what non-emergency services would cost individuals after insurance before they commenced treatment.
But the law didn't go into force on Jan. 1 as scheduled. And its troubled odyssey illustrates the political and business forces opposing a common-sense but controversial solution to rein in high health care costs for patients: Let patients see prices.
Many patient advocates say such transparency would be helpful for patients, allowing them to shop around for some services to hold down out-of-pocket costs, as well as adjust their household budgets for upcoming health-related outlays at a time of high-deductible plans.
At the Ohio Statehouse, the law's greatest champion in state government has been Rep. Jim Butler, a Republican and former Navy fighter pilot whose wife is a physician. He authored the legislation and has beat the drum for it since he got the idea in 2013, as he waited for a garage mechanic to repair his car and absorbed the shop's posted rates for brake jobs, oil changes and tuneups.
Opposition has been formidable, led by the goliath Ohio Hospital Association. It has filed a court injunction that is currently delaying enactment, peppered local news media with editorials, and lobbied Republican Gov. John Kasich, who has eliminated funding that would allow implementation from the latest state budget.
Joining the hospital association in its legal action are a wide range of provider groups including the Ohio State Medical Association, the Ohio Psychological Association, the Ohio Physical Therapy Association, and the Ohio chapters of the American Academy of Pediatrics, the American College of Surgeons, and the American Osteopathic Association.
These groups say that the law, which applies only to elective procedures, is too broad and that forcing providers to create estimates before procedures would slow down patient care. "The only way to even try to comply with the law is to delay care to patients in order to track down information from insurance companies, who may or may not provide the requested information," wrote Mike Abrams, the president and CEO of the Ohio Hospital Association, in an op-ed in The Columbus Dispatch in January.
But Jerry Friedman, a retired health policy adviser for the Ohio State University Wexner Medical Center, said the opposition doesn't stem from genuine concern about patients but from a desire to keep the secret rates that providers have negotiated with insurers under wraps. Transparency would mean explaining to consumers why the hospital charged them $1,000 for a test, he said, adding that providers "don't want to expose this house of cards they've built between hospital physician industry and the insurance industry."
Said Butler on his quest to see the law enacted: "The health care industry has a lot of political power and lots of money. It's hard to fight on behalf of people against this kind of force."
The law's next test will come in August, when the first court hearing on the association's lawsuit is scheduled. The Kasich administration said it couldn't comment on the law because of the pending litigation.
Greater price transparency has been a popular policy prescription for America's high health costs, especially at a time when many patients have high-deductible insurance plans and face larger copayments. Upfront estimates exist in other countries, such as Australia and, for patients facing out-of-pocket expenses, in France.
In Massachusetts, patients can get an estimate within two days of admission if they ask for it. Nebraska requires hospitals and surgical centers to provide a list of the average charges for services. New Hampshire has a website where consumers can compare costs.
Hospitals and doctors often oppose such measures. The American Hospital Association's position is that health plans -- not hospitals -- are responsible for telling insured patients about their out-of-pocket costs, according to its website.
Aimee Winteregg, 35, of Troy, Ohio, said she would have liked such information before five miscarriages in four years left her buried in unexpected medical bills. She and her husband became first-time parents in November. Though they are well insured, tests and treatment cost the couple $4,000 out-of-pocket, demanded in bills that were sometimes no more descriptive than for "medical service."
"We don't want to deal with this, especially when the doctor tells you stress is bad for the pregnancy," her husband, J.D., said. But imposing greater transparency has been controversial in both the medical industry and among some health care researchers, who say it puts patients in an untenable position.
The transparency law "was written by someone thinking about health care as a TV, and not as health care," said Sandra Tanenbaum, a professor of health services management and policy at The Ohio State University College of Public Health.
She said people could not shop for procedures as they would for a TV or car repairs, since they often lack information on the quality of doctors and hospitals, and make health care decisions based on much more than cost.
Consumers are more likely to base their decisions on their doctors' advice, not on cost alone, according to a report from the Health Policy Institute of Ohio.
Only around 10 percent of health care costs are even "shoppable" expenses -- procedures that can be scheduled in advance, like an MRI or elective surgery -- according to the HPIO.
Regardless, Butler maintains, the health care industry can give consumers better information upfront. "If you really want patients to be empowered, they really need the information," he said.
In support of such access, Butler has written letters to the Ohio Hospital Association, the Ohio attorney general and the Dayton Daily News, all in defense of the transparency law.
The Ohio Hospital Association, along with seven other Ohio health organizations, went to court last December to block the law, a month before it was supposed to take effect.
Butler said Gov. Kasich's administration is helping the hospital association stall by not writing regulations, eliminating funding for the law in the state budget, and declining to meet with Butler to discuss it.
State Rep. Michael Henne, also a Republican, has worked with Butler in the Ohio General Assembly on the transparency law. He called Butler a "driver" on the law, noting: "It's frustrating. You don't realize how much [influence] special interests have in the process."
Letter to the editor: ‘Medicare for all’ solves so much – and now is the time
Portland Press Herald - August 5, 2017
Kudos to Dr. Chuck Radis for his July 28 Maine Voices column (”Single-payer system – Medicare for All – is the only remedy for U.S.”). It gives an example of how our health care system is too expensive, too complicated and a failure on all counts. An expanded Medicare system would ensure all Americans good health care – a right every citizen in every other civilized country is entitled to.
Some facts about Medicare:
n It is not socialized medicine. One can choose their own physician or treatment center. Most people on Medicare are very pleased with the program.
n Some say Canadians have to wait for treatment, so they come to the U.S. Remember that we, too, have to wait for an appointment that does not require immediate attention. Some Canadians do come to the U.S. for certain specialized procedures, just as we Americans sometimes have to go to another state for special procedures. (Boston?) Emergency cases are tended to right away in both countries.
n Medicare would require a raise in taxes. Yes, but we would not be paying huge amounts for private health insurance. Also, the administrative costs for single-payer would be significantly lower than those of insurance companies.
n There are fears that insurance companies would go bust. As Dr. Radis pointed out, they could still provide supplemental insurance, and private insurance for those who might opt out of Medicare.
Big advantage of Medicare: It would provide bargaining power to drive down costs of procedures, treatments and prescription drugs.
Now is the time for universal health care. Let’s do the right thing.
Janet S. Houghton
Cape Elizabeth
Oregon Doesn’t Have Time For This Obamacare Repeal Nonsense
by Jennifer Bendery - Huffington Post - August 1, 2017
WASHINGTON ― Imagine a world where President Donald Trump and congressional Republicans don’t want to repeal the Affordable Care Act and strip health insurance from millions of people. They want to expand it. In this parallel universe, they pass laws to make sure every kid has health care coverage and every woman has access to full reproductive care, including abortion. That includes undocumented immigrants, too.
Well, that’s not happening. But this planet exists: it’s called Oregon.
The state’s lawmakers there just wrapped up their legislative session and passed health care laws that fly in the face of what is happening in the nation’s capital. While Congress was threatening people’s health care, Oregon passed a law that gives coverage to just about everyone, regardless of income level, citizenship status, gender identity or type of insurance. They passed another law ensuring that not a single child goes without coverage. This is in a state of 4 million people, of which roughly 420,000 get coverage through Medicaid.
Once these laws are fully implemented, 95 percent of adults and 100 percent of kids in the state will be covered.
“These conversations around the Affordable Care Act, I was committed to expanding access to health care and not going backwards,” Oregon Gov. Kate Brown (D) told HuffPost over hot chocolate in a recent interview. “What is happening federally makes me want to fight, fight, fight.”
This was no easy task, even in a state led entirely by Democrats. They had to come up with a way to pay for expanded health coverage and opted for a new tax that, in Oregon, requires a supermajority vote in the legislature. That meant Brown had to find Republicans to join Democrats to support the effort. It took most of the session to get it done.
The new laws mean 15,000 more children who previously didn’t have health coverage will now have it. Most of them are undocumented. Brown said she recently met with Health and Human Services Secretary Tom Price, who backed the House-passed Obamacare repeal bill that denied assistance to undocumented immigrants, and he asked who those 15,000 kids were. She told him.
“Uh, he didn’t have any reaction,” Brown said.
The governor also signed a bill codifying Roe v. Wade, the landmark federal ruling that protects a woman’s right to safe and legal abortion. The idea is that if the U.S. Supreme Court were to overturn the ruling, the state would already have the statute on its books and it would take effect immediately.
Beyond health care, Oregon lawmakers pushed through other progressive policies that completely counter what the president is trying to do.
While Trump is looking at downsizing national monuments to open up federal land to oil and gas drilling, Brown signed a law protecting 93,000 acres of state forest from being logged. When Trump renounced the Paris Accord on combatting climate change, Oregon committed to it on its own.
Brown also signed laws shielding transgender people from discrimination and beefing up policies to prevent racial profiling ― just as the president announced a ban on transgender people in the military and encouraged police officers to be “rough” on criminal suspects. (The White House later said he was “making a joke” on that last one.)
Brown said she doesn’t see herself as an antidote to Trump, despite being a female and openly bisexual progressive governor in the only designated sanctuary state for undocumented immigrants, where recreational marijuana is legal and any kind of Muslim registry is explicitly banned.
She demurred when asked if she expects Trump to keep his job for the full four years, amid his erratic behavior, the probe into his potential obstruction of justiceand general disarray at the White House.
“Who knows,” Brown said. “I didn’t think he’d make it four weeks.”
Your ZIP Code Might Be As Important To Health As Your Genetic Code
by Kristian Foden Vencil - Shots - August 4, 2017
When a receptionist hands out a form to fill out at a doctor's office, the questions are usually about medical issues: What's the visit for? Are you allergic to anything? Up to date on vaccines?
But some health organizations are now asking much more general questions: Do you have trouble paying your bills? Do you feel safe at home? Do you have enough to eat? Research shows these factors can be as important to health as exercise habits or whether you get enough sleep.
Some doctors even think someone's ZIP code is as important to their health as their genetic code.
That's why Shannon McGrath was asked to fill in a "life situation form" this spring when she turned up for her first obstetrics appointment at Kaiser Permanente in Portland, Ore. She was 36 weeks pregnant.
"When I got pregnant, I was homeless," she says. "I didn't have a lot of structure. And so it was hard to make an appointment. I had struggles with child care for my other kids, transportation, financial struggles."
The form asked about her rent, her debts, her child care situation and other social factors. On the strength of her answers, Kaiser Permanente assigned her what is called a "patient navigator."
"She automatically set up my next few appointments and then set up the rides for them, because that was my No. 1 struggle," McGrath says. "She assured me that child care wouldn't be an issue and that it would be OK if they came. So I brought the kids and everything was easy, just like she said it would be."
McGrath's navigator helped her get in touch with local nonprofits that helped her with rent, a phone and essentials for the baby — such as diapers and bottles — all in the hope that making her life easier might keep her healthier and, in turn, keep Kaiser's medical costs lower.
McGrath says her patient navigator, Angelette Hamilton, was a bureaucratic ninja, removing paperwork obstacles that kept her from taking care of herself and her family.
Patient navigators have been around for a while. What is new is the form that McGrath filled out and how hospitals are using the socioeconomic and other data the forms glean to serve patients. The details now go into a patient's file, which means providers such as Dr. Sarah Lambert have more information at a glance.
"I find it incredibly helpful because it can be very hard to find out," says Lambert, who is McGrath's OB-GYN and works at Kaiser Permanente Northwest. "Having it coded right there — we have this problem list that jumps up — really can give you a much better understanding as to what the patient's going through."
Federal officials introduced new medical codes for the social determinants of health a few years ago, says Cara James, director of the Office of Minority Health at the Centers for Medicare and Medicaid Services.
"More providers are beginning to recognize the impact that the social determinants have on their patients," she says.
Nicole Friedman, a regional manager at Kaiser Permanente Northwest, agrees. But she goes one step further.
She hopes giving doctors more information about the home life of each patient will push health care in a new direction — away from more high-priced treatments and toward providing the basics.
"My personal belief is that putting more money into health care is a moral sin," she says. "We need to take money out of health care and put it into other social inputs like housing and food and transportation."
Linking health organizations like Kaiser with nonprofit social services such as the Oregon Food Bank will help governments and medical providers see where their money can make the biggest difference, Friedman says.
For example, spending more on affordable housing for homeless people can also have health benefits, in turn saving the government money down the line.
Friedman says that when Kaiser started addressing people's social needs, one study found a 40 percent reduction in emergency room use.
McGrath was initially skeptical when doctors offered to help her with things like rent and transportation.
"I didn't want someone to see my situation and have it raise alarms," she says.
But ultimately she was glad to have shared that information.
"I'm able to look at life and not feel overwhelmed or burdened," she says, "or like I've got the whole world on my shoulders.
http://www.npr.org/sections/health-shots/2017/08/04/539757759/your-zip-code-can-be-as-important-to-health-as-your-genetic-code
http://www.npr.org/sections/health-shots/2017/08/04/539757759/your-zip-code-can-be-as-important-to-health-as-your-genetic-code
Take the Generic, Patients Are Told. Until They Are Not.
by Charles Ornstein and Katie Thomas - NYT - August 6, 2017
This article was written through collaboration between The New York Times and ProPublica, the independent, nonprofit investigative journalism organization.
It’s standard advice for consumers: If you are prescribed a medicine, always ask if there is a cheaper generic.
Nathan Taylor, a 3-D animator who lives outside Houston, has tried to do that with all his medications. But when he fills his monthly prescription for Adderall XR to treat his attention-deficit disorder, his insurance company refuses to cover the generic. Instead, he must make a co-payment of $90 a month for the brand-name version. By comparison, he pays $10 or less each month for the five generic medications he also takes.
“It just befuddles me that they would do that,” said Mr. Taylor, 41.
A spokesman for his insurer, Humana, did not respond to multiple emails and phone calls requesting comment.
With each visit to the pharmacy, Mr. Taylor enters the upside-down world of prescription drugs, where conventional wisdom about how to lower drug costs is often wrong.
Consumers have grown accustomed to being told by insurers — and middlemen known as pharmacy benefit managers — that they must give up their brand-name drugs in favor of cheaper generics. But some are finding the opposite is true, as pharmaceutical companies squeeze the last profits from products that are facing cheaper generic competition.
Out of public view, corporations are cutting deals that give consumers little choice but to buy brand-name drugs — and sometimes pay more at the pharmacy counter than they would for generics.
The practice is not easy to track, and has been going on sporadically for years. But several clues suggest it is becoming more common.
In recent months, some insurers and benefit managers have insisted that patients forgo generics and buy brand-name drugs such as the cholesterol treatment Zetia, the stroke-prevention drug Aggrenox and the pain-relieving gel Voltaren, along with about a dozen others, according to memos and prescription drug claims that pharmacies shared with ProPublica and The New York Times. At the same time, consumers are sounding off on social media.
Now it appears the practice is spreading to biosimilars, the competitors for expensive, complex biologic drugs that are beginning to arrive on the market.
Consumers have become increasingly angry over what they pay for drugs, and that outrage has caught the attention of lawmakers from both parties. Democrats have identified lowering drug prices as a pillar of their economic agenda, and President Trump has raised the issue repeatedly. But for now, solutions have proved elusive.
The continued success of the brand-name drug Adderall XR, long after generic competitors arrived on the market, is a case in point.
Dr. Lawrence Diller, a behavioral pediatrician in Walnut Creek, Calif., said he began noticing “very odd things” going on with Adderall XR and other attention-deficit drugs about two years ago. He began receiving faxes from pharmacies telling him that he had to specify that patients required brand-name versions of the drugs.
He had been practicing for 40 years, but until then had never had a pharmacy tell him that he had to prescribe a brand-name drug instead of a generic.
“It’s Alice-in-Wonderland time in the drug world,” he said.
Some insurers require members to have prescriptions filled with brand-name drugs and do not charge them more than for generics. But 29 percent of Americans with health insurance paid for by their employer have a high-deductible insurance plan. They acutely feel the cost difference between branded and generic drugs because they often have to pick up the full sticker price of medications until they have paid out thousands of dollars.
Naomi Freundlich, a Brooklyn writer, had been buying the generic version of Adderall XR for two years to treat her son’s attention-deficit hyperactivity disorder. Her family had a $3,000 annual deductible, and the relatively lower price helped keep medical costs down.
Then, in 2014, her pharmacist told her that her insurance plan would cover only the brand-name drug, which cost her family some $50 more a month than the generic. If she paid for the generic herself, it would not have counted toward her deductible. Ms. Freundlich complained to her insurer, UnitedHealthcare, but could not get a clear answer.
“It’s hard to explain because it doesn’t really make sense,” she said.
UnitedHealthcare has continued to favor Adderall XR and certain other brand-name drugs over generics, according to claims provided by independent pharmacists and reviewed by ProPublica and The Times. The insurer also recently told health providers that it preferred Remicade, the expensive rheumatoid arthritis drug made by Johnson & Johnson, over biosimilars that have a lower list price and are just beginning to come on the market.
A spokesman for UnitedHealthcare, Matthew N. Wiggin, said the insurer does at times prefer brand-name drugs. “By providing access to these drugs at a lower cost, we are able to improve affordability for our customers and members,” he said in an email.
Asked whether consumers sometimes ended up paying more because of these choices, he said pharmacies and doctors could seek an exemption from the insurer if they wanted the generic instead. Several patients said they had not been told of that option.
Shire, the maker of Adderall XR, and some other brand-name drug manufacturers are no longer content to allow sales of their products to plummet when generic competitors arrive on the market. Instead, they are negotiating deals with insurers and pharmacy benefit managers to give priority to their versions. Consumers are given no details about these deals.
A Shire spokeswoman said the company had been able to hold on to market share for Adderall XR by offering insurers and government programs prices that are competitive with those of generic manufacturers.
Adderall XR, the long-acting version of Shire’s popular treatment Adderall, had for years been the company’s top-selling product, bringing in $1.1 billion in sales in 2008, about one-third of its revenue that year.
But mindful that its blockbuster could soon face generic competition, Shire acted aggressively to protect its franchise.
First, in the mid-2000s, Shire sued generic drug companies to block them from bringing cheaper copies to the market, alleging patent infringement. Then, it made deals with two makers of generic drugs to sell authorized copies of its drug, a tactic in which the branded manufacturer supplies its product in exchange for a share of royalties. Those agreements soured after the two companies, Teva Pharmaceuticals and Impax Laboratories, accused Shire of not playing fair by failing to supply them with enough pills to compete in the marketplace. More lawsuits ensued, followed by settlements.
Then, a few years ago, Shire tried a new tactic: giving ever-larger discounts to pharmacy benefit managers and insurers for preferential treatment over the generics. That did not mean lowering the list price of the drug, but rather negotiating rebates that were paid not to the patients but to insurers and middlemen such as CVS Caremark.
Benefit managers and insurers have been passionate advocates of generic drugs, arguing that the cheaper products save patients and their employers billions of dollars. Indeed, generic drugs have come to dominate the market, and today account for nearly 90 percent of all prescriptions filled in the United States.
Shire has managed to hold on to a much larger share of the market through its deals than most companies do when their drugs come off patent and face generic competition.
Adderall XR, the brand-name version of extended-release mixed amphetamine salts, accounted for 29 percent of the 13.1 million prescriptions for the drug in 2016, according to QuintilesIMS, a health information company that purchases the data from pharmacies and sells it to clients that include drug companies. The average market share of brand-name products dwindles to less than 6 percent two years after the first generic competitor arrives, according to QuintilesIMS.
The list price of Adderall XR has remained $7.12 per pill since mid-2012. But according to data from SSR Health, a research firm that tracks drug prices, the portion that Shire keeps has steadily declined.
In the first quarter of 2017, SSR estimated that Shire kept only $1.73, down from $2.93 per pill in the first quarter of 2013. Shire does not break out how much it pays to each middleman in the system, from distributors to pharmacy benefit managers.
But Ryan Baum, an analyst at SSR Health, said it was clear that Shire’s declining share of the list price reflected “just a really aggressive instance of trying to hang on.”
“It’s irrefutable, really,” he added.
In contrast, the generics cost as low as $3.89 per pill, but that does not include unspecified concessions that generic makers offer to pharmacies and distributors, according to Truven Health Analytics, another research firm that tracks the prices wholesalers pay for drugs.
A spokeswoman for Shire, Gwendolyn Fisher, said that while Shire did not make decisions about how much patients paid in out-of-pocket costs, “Shire is helping to deliver cost savings to the system and greater patient access to an important medicine.”
Shire said last week that it was considering spinning off the portion of its business that sells attention-deficit drugs in order to focus on developing rare-disease treatments.
Generic drug makers say they have seen an increase in efforts by manufacturers of brand-name drugs to fight to retain sales after they lose patent protection.
“You definitely see a much more aggressive posture than you used to see,” said Christine Baeder, senior vice president for customer and marketing operations at Teva, the world’s largest generic drug manufacturer.
In December, CVS Caremark, one of the largest benefit managers, sent a memo to pharmacies informing them that some of its Medicare prescription drug plans would cover only brand-name versions of 12 drugs. Some of the drugs, such as the antipsychotic medication Invega, have had generic competitors for over a year.
Also on the list was Copaxone, a brand-name drug sold by Teva that treats multiple sclerosis and that recently lost patent protection on its daily injection. Though Teva primarily makes generic drugs, in a twist it has taken a page from brand-name manufacturers to preserve sales of one of its key products.
In a statement, Teva said many patients had moved to its three-times-weekly version of Copaxone, for which there is no generic, but said it wanted to ensure that patients who “wish to remain on therapy continue to have access.”
Consumers taking other medications said they had experienced the same phenomenon. Lisa Hopkins, a disabled food and nutrition supervisor in Pennsylvania, went to fill a prescription for the anti-inflammatory Voltaren gel this year.
Ms. Hopkins, 52, said her pharmacist had told her that her drug plan, CVS’s SilverScript, denied her claim because it was for a generic.
“I said to the lady at the insurance company, ‘That’s really, really odd to me,’” Ms. Hopkins said. “She said: ‘Yes. It’s happening more and more that the name brand is covered but the generic isn’t.’”
Ms. Hopkins has osteoporosis and bulging spinal disks and has been on disability for almost a decade. She is covered through Medicare and receives extra help from the government for her medications, lowering her out-of-pocket costs. That means that when her drugs cost a lot, taxpayers pay the bill. By law, Medicare cannot negotiate directly with drug manufacturers and instead gets a share of any rebates collected by insurers and benefit managers, like CVS Caremark, which operate Medicare’s drug plans.
In an email, a spokeswoman for CVS Caremark, Christine Cramer, said consumers never pay more in the rare instances in which the company favors a brand-name drug over a generic. “This generally occurs when there is limited or no competition among generics,” she said.
Pharmacists say they are noticing the trend, too, and it takes time to understand the denied claim and pursue a remedy, including sometimes calling the doctor. While favorable treatment for a brand-name drug doesn’t happen all the time, it is startling when it does, said Robert Frankil, president of Sellersville Pharmacy Inc. in Pennsylvania, which owns two pharmacies.
“There’s only one reason why they’re requiring you to use a more expensive product,” Mr. Frankil said. “Because somewhere down the road, somebody is earning more money.”
Medicare Advantage Spends Less on Care, So Why Is It Costing So Much?
by Austin Frakt - NYT - August 7, 2017
The Medicare Advantage program was supposed to save taxpayers money by allowing insurers to offer older Americans private alternatives to Medicare. The plans now cover 19 million people, a third of all those who qualify for Medicare. Enrollee satisfaction is generally high, and studies show that plans offer higher quality than traditional Medicare. But the government pays insurers more than they pay out for patient care — in some years, it turns out, a great deal more.
Concern about Medicare Advantage’s cost has found sharp expression in a recent suit brought by the Justice Department charging UnitedHealth with excessive billing of the government. While that suit plays out, research published by the National Bureau of Economic Research provides context.
The study, released in January, found that the revenue Medicare Advantage plans received in 2010 exceeded the amount they paid out for medical care by a hefty 30 percent. At more than $2,000 per enrollee per year, that probably topped $20 billion dollars, nearly all from federal payments, not enrollee premiums. The study relied on Medicare Advantage billing dataobtained from three large insurers across 36 states, a type of data the government doesn’t yet release.
Paradoxically, even though Medicare Advantage plans cost taxpayers more than traditional Medicare, they spend less on care. In fact, one of the motivations of the program is to capture that lower spending as savings for taxpayers. It hasn’t worked out that way.
“Our study found that health care spending for enrollees in Medicare Advantage plans is 10 to 25 percent lower than for comparable enrollees in traditional Medicare,” said Amy Finkelstein, an M.I.T. economist and one of the study’s authors. “Yet government payments to plans is far above their lower health care costs.” The study was also conducted by four economists at Stanford: Vilsa Curto, Liran Einav, Jonathan Levin and Jay Bhattacharya.
The analysis raises two questions: How do Medicare Advantage plans spend so much less on care? And, given that, how do we account for their higher costs to taxpayers?
One reason for the lower spending is that Medicare Advantage enrollees use less care or use lower-cost care. For example, compared with traditional Medicare patients, Medicare Advantage patients are more likely to go home after a hospital visit, rather than to a skilled nursing facility. Medicare Advantage patients see specialists relatively less often and receive fewer inpatient operations, but more outpatient ones, which are cheaper. All of these are what you’d expect from care management techniques used by Medicare Advantage: referral requirements and narrow networks of doctors, for instance.
Previous studies have also shown that Medicare Advantage enrollees use less of some kinds of care, including hospital care, versus traditional Medicare beneficiaries.
“This is exactly what Medicare Advantage plans were designed to do,” said Dr. Bruce Landon, a physician with Harvard Medical School. “They manage the utilization of services while also assuring that enrollees receive recommended care, all at lower cost to patients.” Dr. Landon’s research on the program found that Medicare Advantage enrollees use 20 percent to 30 percent less emergency department and outpatient surgical care, as well as receive fewer hip and knee replacements.
Medicare Advantage plans also attract enrollees who tend to be healthier than traditional Medicare beneficiaries, a feature that yielded intriguing results in light of the lawsuit against UnitedHealth. When the M.I.T.-Stanford team compared the two kinds of Medicare patients, they found that Medicare Advantage patients were 25 percent less costly than traditional Medicare patients. But when the team more rigorously matched the health of both sets of patients, the Medicare Advantage patients were just 10 percent less costly. This drop does not prove the suit’s claims of overbilling, but it allows for the possibility.
Why does the government pay Medicare Advantage plans so much more than it costs them to cover care? It’s partly an intentional, if controversial, design of the program. Congress has established payment formulas and authorized bonus programs intended to help the private market.
The government also pays insurers for administrative and marketing expenses. Yet even when these additional expenses are factored in, the government still pays plans an excess. According to the Medicare Payment Advisory Commission, federal payments to the plans exceeded health care costs and other expenses by 8.5 percent in 2010. Though the Affordable Care Act has reduced payments to plans and limits the amount they can attribute to administration and marketing, they still receive government payments in excess of their costs today.
Not all of the “excess” federal money goes to the insurers’ bottom line. Traditional Medicare entails significant cost sharing for beneficiaries; they are responsible for 20 percent of the costs of doctors visits, for example. Most Medicare Advantage plans don’t require as much cost sharing or out-of-pocket payments. And some of the influence of Medicare Advantage plans’ managed care techniques rub off on the traditional program, too, reducing spending — a spillover effect that partly explains the slowdown in growth of Medicare spending.
But is the cost of Medicare Advantage worth the benefits it delivers? It’s hard to know without knowing more about patients’ diagnoses, services used and other data. The Medicare program had been collecting such data since 2012 and was planning to release it, but, expressing concerns about its quality, recently put off doing so.
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