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Monday, September 18, 2017

Health Care Reform Articles - September 18, 2017

Executive Summary of Sanders "Medicare-for-All Bill

Medicare-for-All: Making Health Care a Human Right
Since the administration of President Franklin Delano Roosevelt, there has been widespread discussion in this country about the need to guarantee health care to all as a fundamental human right. Today, at a time when every other major country on earth guarantees health care to every man, women and child it is time for the United States to ful ll that goal.
As important as it was to defeat Republican attempts to throw as many as 32 million Americans off of health care by repealing President Obama’s Affordable Care Act (ACA) that is not the end of our work. It is only the beginning.
The ACA made substantial improvements to our health care system. Thanks to this legislation, over 20 million Americans gained health insurance. Millions of Americans gained coverage through the expanded eligibility for Medicaid that now exists in 31 states. Young Americans can stay on their parent’s health plans until they’re 26. No American can be denied coverage because of a pre- existing condition or through a lifetime cap on bene ts.
But as signi cant as this achievement was, our job will not be completed until we build upon the success of the ACA through the establishment of a Medicare for All, single-payer health care system.
In America today, 28 million Americans are still uninsured and millions more are under-insured because of high deductibles and premiums. Thousands die each year because they can’t see a doctor in time and millions more suffer unnecessarily because of delayed treatment. Unbelievably, nearly one out of ve adult Americans are unable to afford the prescription drugs their doctors prescribe.
Meanwhile, despite so many uninsured and under-insured, the United States spends far more per capita on health care than any other nation. According to the OECD, in 2015, the U.S. spent almost $10,000 per person for health care, while the Canadians spent $4,644, the Germans $5,551, the French $4,600, and the British $4,192 even though all of these other countries guarantee health care to all of their people. Despite this huge expenditure, our life expectancy is lower than most other industrialized countries and our infant mortality rates are much higher.
52 years ago, the United States took an important step towards universal health care by passing the Medicare program into law. Guaranteeing comprehensive health bene ts for Americans over 65 has proven to be enormously successful and popular. Now is the time to expand and improve Medicare to guarantee health care to every man, woman and child in the country.
OFFICE OF U.S. SEN. BERNIE SANDERS
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The Medicare for All Act of 2017 Universal Health Care
This bill establishes a federally administered Medicare-for-all national health insurance program that will be implemented over a four year period.
The Transition
During the transition to universal health care, in the rst year this legislation will immediately improve traditional Medicare for seniors and people with disabilities by covering dental, vision and hearing aids which are not covered under current law. The Medicare eligibility age will be reduced to 55 and Medicare Part A, Part B and Part D deductibles would be eliminated.
Moreover, during the rst year, every child between the ages of 0-18 would become eligible to enroll in the Universal Medicare program.
A Medicare Transition plan would also be established during year one to provide affordable coverage for all Americans and to make sure that no one loses coverage.
During the second year of implementation, the Medicare eligibility age would be reduced to 45. During the third year, the eligibility age would be lowered to 35.
By the fourth year, every individual who is a resident of the United States will be entitled to bene ts for comprehensive health care services and will get a Universal Medicare card that they can use to receive the health care they need.
Freedom of Choice
Patients will have the freedom to choose their doctors, hospitals and other health care providers without worrying about whether that provider is “in-network.” They will also be able to get the care they need without having to read any ne print or trying to gure out how they can afford the out- of-pocket costs.
More Financial Freedom, More Security
Under this bill, Americans will bene t from the freedom and security that comes with nally sepa- rating health insurance from employment. As is the case in every other major country, employers would be free to focus on running their businesses rather than spending an enormous amount of time, energy and money trying to provide health insurance to their employees.
Further, our overall economy will bene t when working people no longer stay at jobs they dislike simply because of the health bene ts they receive from their employers. Every American, includ- ing those with serious or chronic illnesses will be able to afford the medications necessary to keep them healthy without worry of nancial ruin. Americans will no longer worry that a hospital stay or a medical emergency will bankrupt them or leave them deeply in debt.
OFFICE OF U.S. SEN. BERNIE SANDERS
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Getting Health Care Spending Under Control
Today, we have the most expensive, bureaucratic, wasteful and inef cient health care system in the world. Not only do we heavily outspend all other countries on health care, our medical spending continues to grow much faster than the rate of in ation. At a real danger to our economy, the United States now spends over 17 percent of its GDP on health care. If we maintain the current dysfunctional system that we now have it has been estimated that we will spend, as a nation, $49 trillion over the next decade on health care. That is simply unsustainable.
Medicare-for-All would fundamentally change that by creating a far simpler, more ef cient and more cost-effective system. Instead of wasting hundreds of billions of dollars trying to administer an enormously complicated system of hundreds of separate insurance plans, there would be one insurance plan for the American people with one single payer.
Negotiating with Pharmaceutical Companies to Lower Prices
One of the reasons that the United States spends far more on healthcare per capita than any other nation on healthcare is that we pay, by far, the highest prices in the world for prescription drugs. This legislation would substantially reduce the cost of prescription drugs for both the government and individuals by doing what every other major country on earth already does: negotiate with pharmaceutical companies to lower drug prices. This legislation will give the federal government the ability to stand up to drug companies and negotiate fair prices for the American people.
Comprehensive Coverage
This legislation will provide comprehensive health care coverage that includes:
1. Hospital services, including inpatient and outpatient hospital care, 24-hour-a-day emergency services and inpatient prescription drugs.
2. Ambulatory patient services.
3. Primary and preventive services, including chronic disease management.
4. Prescription drugs, medical devices, and biological products.
5. Mental health and substance abuse treatment services.
6. Laboratory and diagnostic services.
7. Comprehensive reproductive, maternity, and newborn care, including abortion. 8. Pediatrics.
9. Dental health, audiology, and vision services.
Long-term care for seniors and people with disabilities will continue as it is currently covered under Medicaid.FFICE OF U.S. SEN. BERNIE SAN

Putting People over Profits
Under this legislation, Americans will no longer have to pay premiums, co-payments, or deduct- ibles to private health insurance companies that put pro ts over the needs of the American people. Instead of writing a big check to private health insurance companies, most Americans and busi- nesses would be paying a much smaller percentage of their income to fund Medicare-for-all.
Keeping Our Promises to Veterans and Native Americans
Nothing in this legislation will impact the eligibility of veterans for the medical bene ts and services provided under the VA, or of Native Americans for the medical bene ts and services provided by or through the Indian Health Service. Those bene ts will remain the same.
It’s What the American People Want
Guaranteeing health care as a right is important not just from a moral and economic perspective. It also happens to be what the majority of the American people want. According to an April 2017 poll by The Economist/YouGov, 60 percent of the American people want to “expand Medicare to provide health insurance to every American,” including 75 percent of Democrats, 58 percent of Independents, and 46 percent of Republicans. 
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Sen. Sanders Medicare for All Act – The Time Has Come Today

by RoseAnn DeMoro - Common Dreams - September 13, 2017

dicare for All Act of 2017 the time has come today.
The dream of healthcare reformers for more than a century—and the incredible and unending work of nurses, especially National Nurses United members, to guarantee health care with comprehensive benefits and a single standard of quality care for everyone—is moving a huge step forward.
In a town where the healthcare industry is one of the biggest corporate spenders in campaign contributions and lobbying, and resistance to transformative reform was widespread, today 15 Senators have signed on as co-sponsors to Sen. Sanders bill, concurrent with a majority of House Democrats now co-sponsoring a longtime House single payer bill, Rep. John Conyers’ HR 676. 
The seismic shift is a direct product of how Sen. Sanders made Medicare for all, and healthcare as a human right, such a signature issue of his campaign. How his campaign, inspired, animated and activated millions of people, especially young people. And, how the enduring work of nurses and other healthcare activists over many years have laid the seeds for this day.
It’s also a reflection of the state of healthcare in the U.S. For every mean spirited proposal, laced with a callous “you’re on your own” ideology, advanced by those pushing to roll back the advances achieved under the ACA, there is a point to remember: The attacks on the ACA gained traction in part because there is an ongoing health emergency for millions of people—the 28 million who the latest census figures report remain uninsured, and the millions more who struggle every day with how to pay their medical bills and face the painful choice of what else to go without.
Here’s a story that one of our NNU leaders, Martha Kuhl, who works in a Northern California children’s hospital relates:
“We had a little girl with a brain tumor. Her parents were doing everything possible. But they were having great difficulty because not only did they not have great health insurance, but they lived far away from a large pediatric center that could give their daughter the care she needed. They had transportation issues, they couldn’t afford some of the medications their child would need.”
“But then, because they were doing everything they could to help their child, they came into the hospital one day and said ‘we just got evicted for not paying our rent’. So imagine a parent desperate for their child to get the care they need, desperate for their child to survive a very serious illness, then becoming homeless. That’s what a lack of healthcare can do.”
Sadly this family is not alone. There are far, far too many in our country who have been left behind by a system held in the iron grip of a ruthless healthcare industry whose priority is squeezing out as much profit as they can for their shareholders, or their executive pay packages, or their stock market rating.
t’s families like this that are the reason nurses will never stop fighting to guarantee everyone, regardless of age, gender, race, nationally, economic status or where they live is guaranteed safe, quality care when and where they need it.
Today’s bill introduction is the crest of a wave, but it’s also a new beginning.  Nurses will continue to press this issue, calling on all Senators to sign on, and to challenge those who will stand in the way of enacting the healthcare system we need.
We know, as polls have shown, the public is with us, now it is time for all elected leaders to take a stand because too many are continual harm under the present system and, as Bernie would say, "Enough is enough. Let’s enact Medicare for all.”

Unpacking The Sanders Medicare-For-All Bill

by Katie Keith and Timothy Jost - Health Affairs - September 14, 2017

On September 13, Senator Bernie Sanders (I-VT)—with 16 Democratic cosponsors—released the Medicare-For-All Act of 2017, intended to transition the American health care system to a single-payer system. In addition to the bill text, Senator Sanders released an executive summary, title summary, and white paper on financing options.
The Act would establish the Universal Medicare Program (UMP) and, in doing so, make sweeping changes to the health care system. Once the UMP went into effect (for children, on January 1 of the first calendar year after the bill is enacted and three years later for adults), most benefits would no longer be available under the traditional Medicare program, the Medicaid program, or the Children’s Health Insurance Program (CHIP). The bill would also end the Federal Employees Health Benefits Program, the TRICARE program, and the Affordable Care Act (ACA) marketplaces; it would prohibit the sale of private health insurance, employer-sponsored insurance, and retiree coverage if that coverage duplicates payment for any item or service covered under the UMP. (Insurers and employers could still offer coverage of additional benefits that are not covered under the UMP.) The Department of Veterans Affairs and the Indian Health Service would remain intact.
Consumers currently enrolled in coverage through the private health insurance market, Medicaid, Medicare, CHIP, and Title X family planning services could maintain that coverage until the UMP went into effect. But the bill would also create a comprehensive transitional Medicare buy-in option for eligible individuals and a transitional public option. The transitional public option plan would be available through the ACA marketplaces and offer platinum-level coverage. Any U.S. resident would be eligible to enroll in the transitional public option plan and remain eligible for premium tax credits and cost-sharing reductions. 
Although there is a fair level of detail about the transitional coverage options, the bill, despite its 96 pages, provides far fewer details about key UMP standards (such as eligibility and enrollment) and grants significant flexibility to the Secretary of Health and Human Services (HHS) to develop major program components. The Secretary is, for instance, directed to develop policies, procedures, guidelines, and requirements related to eligibility, enrollment, benefits, provider participation standards and qualifications, levels of funding, provider payment rates, medical necessity standards, planning for capital expenditures and health professional education, and regional planning mechanisms. 
The first half of this post discusses the UMP; the second half is devoted to the transitional coverage options for eligible individuals.

What’s In The UMP

UMP Eligibility 

The Act establishes a universal benefit entitlement for all U.S. residents, which would presumably include immigrants and potentially undocumented individuals. However, the residency eligibility requirements would be defined by the Secretary of HHS through regulations. The bill provides HHS with discretion to more broadly define eligibility requirements so long as rules inhibit travel and immigration to the U.S. for the sole purpose of obtaining health care services.

UMP Enrollment 

The Act includes few details about the UMP enrollment mechanism and largely defers the development of this process to HHS. HHS must, however, provide for automatic enrollment of individuals at birth in the U.S., upon immigration to the U.S., or upon gaining resident status in the U.S. Upon enrollment, each individual would be issued a universal Medicare card, which would not include an individual’s Social Security number, to facilitate identification and claims processing. 

UMP Covered Benefits and Services

The UMP benefit package is largely consistent with the 10 categories of essential health benefits (EHB) that are outlined in the ACA: 
  • hospital services (including inpatient and outpatient hospital care, emergency services, and inpatient prescription drugs); 
  • ambulatory patient services; 
  • primary and preventive services (including chronic disease management); 
  • prescription drugs, medical devices, and biologics; 
  • mental health and substance abuse treatment services (including inpatient care); 
  • laboratory and diagnostic services; 
  • comprehensive reproductive, maternity, and newborn care; 
  • pediatrics; 
  • oral health, audiology, and vision services; 
  • and short-term rehabilitative and habilitative services and devices. 
The bill further clarifies that services will be covered if they have been provided pursuant to a national practice guideline that has been recognized by HHS. Unlike EHBs under the ACA, HHS is not directed to define these benefits, a decision that HHS under the ACA ultimately pushed to state decisionmakers. 
HHS must regularly evaluate whether changes to the UMP benefit package are needed to reflect the most current medical practice and research, consult with stakeholders, and make recommendations to Congress to improve or adjust the benefit package. The bill allows each state to provide additional benefits so long as the state covers the expense of doing so. HHS is directed to make national coverage determinations with respect to experimental services and drugs, and the bill extends the Medicare appeals process to these coverage decisions. 
Under the bill, providers can enter into contracts with consumers for health care services, but must follow certain requirements before doing so and can only do so for services where the provider will not receive payment or reimbursement under the Act. For instance, contracts between providers and consumers would have to have been made in writing prior to when the service was delivered and cannot be entered into during an emergency health situation. Both parties must agree not to submit a claim under the UMP (even if the items or services would otherwise be covered under the UMP), and the provider has to file an affidavit with HHS within 10 days of entering into the contract. The affidavit must attest that the provider will not file a claim or receive reimbursement for any item or service provided to any UMP beneficiary for a one-year period. If the provider nonetheless knowingly and willfully submits a claim or receives reimbursement from the UMP, no payment or reimbursement would be made for any item or service furnished by that provider.
As noted above, most benefits would no longer be available under the traditional Medicare program, the Medicaid program, or the CHIP program once the UMP went into effect. The only exceptions are for patients in the midst of inpatient hospital services or extended care services, for Medicaid long-term care services, and for any other service covered by a state Medicaid program as of September 1, 2017 that is not covered under the UMP. States that provide these additional services would have to comply with maintenance of effort requirements with respect to eligibility standards and expenditures. 

UMP Ban on Cost-Sharing

The bill would prohibit all cost-sharing for consumers, stating that no deductibles, coinsurance, copays, or similar charges can be imposed for most benefits covered under the UMP. HHS could impose cost-sharing for 1) a new Medicaid long-term care program; and 2) drugs and biologics. The bill allows HHS to develop an evidence-based cost-sharing schedule but would cap annual cost-sharing for drugs and biologics at $200 per individual, adjusted for inflation. To incentivize the use of generics, HHS is allowed to exempt a brand-name drug from the $200 annual out-of-pocket limit if a generic version of the drug is available. The bill would also prohibit balance billing by barring providers from imposing an additional charge to beneficiaries for benefits provided under the UMP. 

UMP Provider Participation

To participate in the UMP, a provider must be licensed or certified, meet federal and state requirements to provide health services, meet existing Medicare provider standards (unless waived by HHS), and meet any additional minimum provider standards developed by HHS. The bill includes a list of optional areas that HHS could address in developing new minimum provider standards, such as facility quality, personnel training and competence, continuity of service, and patient satisfaction. 
As under the current Medicare program, providers must file a participation agreement with HHS and meet existing federal requirements related to accepting Medicare funds. Providers must be given a reasonable period to meet any new standards, and HHS is prohibited from banning a provider from participation for reasons other than their ability to provide covered services. In addition, providers that qualify to offer services through the Department of Veterans Affairs or the Indian Health Service automatically qualify as UMP providers. 
The bill also includes a broad nondiscrimination provision that mimics the protections outlined in Section 1557 of the ACA, which prohibits individuals from being excluded from, denied benefits, or subject to discrimination by health providers, programs, and activities. The bill, however, explicitly defines sex discrimination, which has been the subject of ongoing litigation under Section 1557, to include sex stereotyping and discrimination based on gender identity, sexual orientation, and pregnancy and related medical conditions, including termination of pregnancy. The bill also requires the establishment of an administrative adjudication process to address discrimination claims and authorizes a private right of action.

UMP And State Flexibility

States are allowed to set additional standards with respect to eligibility, benefits, and provider standards so long as these standards do not restrict eligibility or reduce access to benefits or services. Like HHS, states cannot prohibit a provider from participating in the program based on reasons other than provider’s ability to provide services, and states can adopt additional standards for providers in their state. 

UMP Payments To Providers 

Under the bill, HHS would be required to establish a fee schedule that establishes payment amounts for UMP benefits. This fee schedule would be developed in a manner that is consistent with the existing processes for determining Medicare payments. Any current planned or implemented payment reform activities or demonstrations, including reform activities or demonstrations under the ACA or the Medicare Access and CHIP Reauthorization Act of 2015, would be extended under the bill.
The bill would require more frequent reviews of the relative value of physicians’ services, direct the Secretary of HHS to consult with the Medicare Payment Advisory Commission, and require the development of a public, standardized process for reviewing the relative values of physicians’ services. This new process would include, at a minimum, the development of methods and criteria to identify and prioritize services for review, review stakeholder recommendations, and identify additional resources to consider during the review process. The bill would also require HHS to present Congress with 1) a written plan for using funds to collect and use information on physicians’ services in the determination of relative values; and 2) a proposed plan to track HHS’ review of the relative values of physicians’ services, including a timeline for tracking data such as when, how, and by whom services are identified for review, when relative values are adjusted, and when new services are reviewed or added.

UMP Payments For Prescription Drugs, Devices, And Equipment

HHS would annually negotiate the prices to be paid for covered pharmaceuticals, medical supplies, and medically necessary assistive equipment. HHS would be required to establish a prescription drug formulary system that would promote the use of generic medications to the greatest extent possible. Consumers and clinicians could petition for the coverage of a new pharmaceutical or to remove an ineffective or dangerous medication. HHS is also directed to promulgate rules regarding the use of off-formulary medications that would allow for patient access but would not compromise the formulary. 

UMP Financing And National Health Budget 

Funding for the UMP would be provided through a newly established Universal Medicare Trust Fund, which would receive appropriations that would have otherwise been used to fund Medicare, Medicaid, the Federal Employees Health Benefit Program, the TRICARE program, the maternal and child health program, vocational rehabilitation programs, programs for drug abuse and mental health services, programs providing general hospital or medical assistance, and any other federal programs identified by HHS and the Treasury that provide for the payment of health services. Although the bill itself does not include additional pay-fors, Sen. Sanders simultaneously released a white paper on options to finance the Act, which includes income-based payroll taxes, savings from health tax expenditures, higher personal income taxes for those with incomes over $250,000, and a new tax on the wealthiest 0.1 percent of households, among other funding mechanisms. 
The bill also directs HHS to establish an annual national health budget beginning with the year prior to the date on which UMP benefits first become available. The national health budget would specify the total expenditures for covered services, quality assessment activities, health professional education expenditures, administrative costs, innovation activities through the Center for Medicare & Medicaid Innovation, operating and other expenditures, capital expenditures, and prevention and public health activities. Recognizing that the UMP will be disruptive to the health insurance workforce, the bill allows up to one percent of the national health budget to be allocated to programs that provide assistance to workers in the field of health insurance administration who may experience displacement because of the Act. This budget allowance is authorized for the first five years that the UMP is in place. 
HHS must also establish and maintain a reserve fund to respond to the costs of treating an epidemic, pandemic, natural disaster, or other health emergency. Workers compensation carriers would have to reimburse the UMP for the cost of services if the UMP provides consumers with coverage for work-related injuries and illnesses.

UMP Uniform Reporting Standards 

The bill would require the Secretary of HHS to establish uniform reporting requirements and standards to develop a national database with information on providers, the cost of facilities, the quality of services, health care outcomes, and health equity. HHS must regularly analyze this information and define rules and procedures to allow researchers, scholars, providers, and others to access and analyze the data for quality and outcomes research. This data would be used to develop statistical studies, create and test delivery system reforms, and inform evidence-based policymaking. The information would be regularly audited and included in an annual report to Congress on the status of Act implementation, including information on enrollment, benefits, expenditures and financing, cost-containment measures, quality assurance, and opportunities for improvements. 

UMP Regional Offices And Beneficiary Ombudsman 

HHS is directed to establish and maintain regional offices to promote access to tertiary care facilities, equipment, and services. Regional offices must include a director appointed by the Secretary, one deputy director for each state in the region, and one deputy director to represent the Native American and Alaska Native tribes in the region. Regional offices would be responsible for providing an annual state health care needs assessment report, recommending changes in provider reimbursement or delivery system reform, and establishing a quality assurance program. The bill notes that the existing Centers for Medicaid & Medicaid Services (CMS) regional offices should be incorporated wherever possible.
HHS is also directed to appoint a beneficiary ombudsman to receive complaints, grievances, and requests for information with respect to any part of the UMP and assist consumers in seeking appeals or redeterminations. The ombudsman would be required to submit annual reports to Congress and HHS on the office’s activities along with recommendations for improving the Act.

UMP Office of Primary Health Care

The bill would establish an Office of Primary Health Care within the Agency for Healthcare Research and Quality. The Office would be tasked with functions that include coordinating health professional education policies, developing a system to track physician specialties and practices, and promoting policies that expand the number of primary care practitioners, registered nurses, midlevel practitioners, and dentists. The Office would also be required to develop national goals to increase access to high-quality primary health care, particularly in underserved areas and for underserved populations, no later than one year after the bill’s enactment. 

UMP Quality Standards 

Under the bill, the Center for Clinical Standards and Quality within CMS would take the lead in developing new quality standards and addressing health disparities. The Center would evaluate existing practice guidelines, quality standards, performance measures, and medical review criteria and adopt methodologies for profiling health care practice patterns and identifying outliers. The Center would also develop minimum criteria for external quality review entities, for example, by adopting conflict of interest standards to prohibit financial incentives that would favor one pattern of practice over another. The Center would annually report its findings on outcomes research and practice guideline development to inform the Secretary’s decisionmaking. 
The Center would also be required to evaluate approaches for ongoing, accurate, and timely collection of data on health disparities and health system performance on the basis of race, ethnicity, gender, geography, and socioeconomic status. The Center must identify these approaches in a report to Congress and HHS within 18 months after UM benefits become available. HHS would then be required to implement those approaches no later than 2 years after UMP benefits become available. The Center would submit similar reports to Congress and HHS with recommendations for improving the identification of health disparities on an ongoing basis thereafter.

Long-Term Care 

The bill requires state Medicaid programs to cover long-term care services, which are defined as 13 categories of services that include nursing facility services for individuals 21 years old and older, home health services, rehabilitative services, and inpatient psychiatric hospital services for individuals 21 years old and older. This requirement would go into effect for quarters beginning on or after the effective date of the UMP.

Transitional Coverage Options

Transitional Medicare Buy-In Option 

Because the UMP would not go into effect for adults for up to four years after enactment, the bill includes a transitional Medicare buy-in option for certain eligible individuals. The buy-in option would be available to U.S. citizens, nationals, and lawful aliens who meet age requirements and are not eligible for Medicare Part A benefits or eligible to enroll under Medicare Parts A or B. These age requirements begin at age 55 in the first year and phase down to age 35 by the third year. Thus a 55-year old who is not otherwise eligible for Medicare could enroll in the buy-in option beginning on January 1 of the first year after enactment; a 45-year old could do so during the second year after enactment; and a 35-year old could do so during the third year after enactment. 
Individuals enrolled in the buy-in option would be entitled to the same benefits and protections as an individual enrolled under Medicare Parts A, B, and D and would have the ability to enroll in a Medicare Advantage plan with qualified prescription drug coverage. HHS would define other program requirements, such as enrollment periods, and establish a monthly premium based on the average annual per capita amount for benefits and administrative expenses payable under Medicare Parts A, B, and D in the year for all buy-in enrollees. Buy-in enrollees could select a Medicare Advantage plan or a prescription drug plan which requires individuals to pay higher premiums and would be entitled to enrollment in Medigap policies on a guaranteed issue basis. However, buy-in enrollees would not be eligible for Medicare cost-sharing assistance. 
The bill would define coverage through the buy-in option as minimum essential coverage so enrollees would comply with the individual mandate. The bill also requires that the buy-in option be treated as a silver qualified health plan offered through the marketplace, meaning that buy-in enrollees who would otherwise be eligible for premium tax credits and cost-sharing reductions under the ACA could apply these subsidies towards the cost of the buy-in option. HHS would be required to determine the applicable second-lowest cost silver plan for purposes of calculating premium tax credits. Cost-sharing reduction payments—which would typically go to an issuer—would be directed to HHS.

Transitional Public Option

As an additional transitional coverage option, the bill requires CMS to establish and offer a public option—a Medicare Transition plan—through the ACA marketplaces beginning with the first plan year after enactment of the bill and ending once UMP goes into effect. The Medicare Transition plan would comply with the ACA’s consumer protections, such as the ban on preexisting condition exclusions, coverage of essential health benefits, and the coverage of preventive services without cost-sharing, as well as requirements that apply to qualified health plans. However, the plan would be available to any U.S. resident and would provide consumers with generous cost-sharing protections by requiring an actuarial value of 90 percent, equivalent to a platinum plan. 
Premiums for the Medicare Transition plan would vary based on family size, age, and tobacco use. This is largely consistent with the ACA’s rating rules except that rates for this plan would not vary based on geography, as is currently allowed under the ACA. Medicare Transition plan enrollees would be eligible for premium tax credits and cost-sharing reductions. 
However, the bill alters eligibility requirements for these subsidies in several ways, particularly for consumers in states that have not expanded their Medicaid program. First, premium tax credits for the Medicare Transition plan would be available to all eligible individuals, including those with incomes over 400 percent of the federal poverty line (FPL) in all states. Second, in states that have not expanded their Medicaid program, premium tax credits for the Medicare Transition plan would be available to those with incomes under 100 percent FPL. 
Third, the bill would adjust premium affordability thresholds for Medicare Transition plan enrollees from those found in the ACA, establishing a 2 percent threshold for those with incomes up to 100 percent FPL and a 4.08 percent threshold for those with incomes of 150 percent FPL and higher. Medicare Transition plan enrollees would also be eligible for cost-sharing reductions, which would be extended to those with incomes under 100 percent FPL in states that have not expanded their Medicaid program.
All current participating Medicare providers would be considered Medicare Transition plan participating providers, and CMS would establish a process to allow for additional participating providers. The Medicare Transition plan would reimburse providers at Medicare fee-for-service program rates for services provided under Medicare Parts A and B; for services not provided under Parts A and B, CMS would set its own reimbursement rates consistent with the way that the Medicare fee-for-service program sets its rates. CMS would negotiate all payment rates for prescription drugs or, if unable to reach a negotiated agreement, CMS would pay the lesser of the price paid by the Department of Veterans Affairs, the Department of Defense and other federal agencies, or by state Medicaid agencies subject to drug rebates.
In implementing the buy-in option, HHS must ensure that there is no effect on benefits for current Medicare beneficiaries and no negative impact on the Medicare Trust Fund. HHS must also consult with interested parties, such as groups representing beneficiaries, providers, employers, and insurers, in promulgating regulations to implement this section. 

Transitional Medicare Reforms 

Finally, the bill also includes additional consumer protections that would apply to the traditional Medicare program until the UMP goes into effect. These include 
  1. an annual out-of-pocket cost-sharing maximum of $1,500 for individuals entitled to or enrolled in Medicare Parts A and B; 
  2. elimination of Parts A and B deductibles; 
  3. a Part D annual out-of-pocket threshold of $305, with potential exceptions for brand-name drugs; 
  4. elimination of cost-sharing for covered prescription drugs; 
  5. coverage of dental services, vision services, and hearing aids and examinations; and 
  6. elimination of the two-year Medicare waiting period for individuals with disabilities. 
These changes would generally go into effect the year beginning January 1 of the year after enactment.

With Democracy So Sick, Medicare for All Will Be Uphill Battle

by Greg Coleridge - Common Dreams - September 15, 2017

The promotion of human health in all its dimensions (i.e. physical, mental, emotional) is among the most important single indicators of a just society. The availability and affordability of comprehensive health care to every person, regardless of income or other factors, is defined by many nations as a basic human right. This is the foundational principal of the Medicare for All Act introduced this week by Sen. Bernie Sanders.
Article 25 of the 1948 United Nations' Universal Declaration of Human Rights asserts, "[e]veryone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services." President Franklin Delano Roosevelt called for a Second Bill of Rights in 1944 that identified the “right to adequate medical care and the opportunity to achieve and enjoy good health” as one of several fundamental conditions to achieve human happiness and well being.
Recent polls indicate Americans feel health care is one of the nation’s biggest problems. The US spends the most per person on health care than any other nation, has the worst health care system among high-income nations, and has overall poor population health. Nearly 26 million Americans remain uninsured.
3 ways corporations have captured health care:
1. Framing health care as a commodity, not as a right
The U.S. health care industry defines health care within the domain of the private (i.e. corporate), not public realm. It’s created a mindset, if not culture, that that “the market” is the most efficient and affordable means to provide the highest quality health care in the world. It’s asserted that the prospect of mammoth profits from being the first to develop and patent drugs, procedures or devices are what drive corporations to new discoveries that the public sector would never achieve.
Health care is currently less a basic “right” than a commodity, less a public good than a corporate opportunity to peddle drugs, tests, equipment and procedures focused less on prevention (which isn’t profitable) and more on treatment (which is highly profitable, regardless of payer). The business model of so-called “health care” corporations is to minimize coverage and treatment while maximizing premiums, deductibles and co-pays – all of which maximize profits. Despite the rhetoric, insurance agents, not doctors or patients, largely determine basic health care decisions.
2. Investments in lobbying and political campaigns to gain political influence
The so-called “health care” sector was #1 in political spending in 2016, according to OpenSecrets.org. More than $500 million was raised to employ 2700 lobbyists to influence legislation. The money came from corporations representing pharmaceuticals/health products ($245,812,399), hospitals/nursing homes ($94,875,553), and health services/HMOs ($77,966,304). Health professionals chipped in another $84,829,148.
Campaign political “contributions” (more like investments) was a separate category. Health Care Political Action Committees (PACs) invested $55.7 million in federal candidate campaigns (60% to Republicans, 40% to Democrats) in 2016. An additional $53.8 million in “outside” political spending (e.g. largely for advertising) was invested, led by health care-related insurance corporations ($19 million) and pharmaceuticals/health products ($15.8 million).
What have these contributions/investments bought? We’ve seen laws promoting “tort reform,” limits on class action medical lawsuits, patent protection, and massive federal subsidies (i.e. government research) to the medical industrial complex. What we’ve not seen is neither a single payer system nor any form of “claw back” of excessive compensation of Big Pharma or insurance CEOs.
3. Misuse/abuse of corporate constitutional rights
Corporate constitutional rights have been used to promote corporate interests over human health and safety and/or to deny health coverage. Examples
  • 1st Amendment religious rights  
The Supreme Court in its Burwell v. Hobby Lobby decision prohibited the Department of Health and Human Services from requiring closely held, for-profit secular corporations to provide contraceptive coverage as part of their employer-sponsored health insurance plans under the Affordable Care Act if it violated the corporation’s 1st Amendment “religious rights and beliefs.” To extend and pretend that private, personal religious rights apply to entities such as business corporations is a breach of a constitutional firewall with potential widespread discriminatory implications.
  • 4th Amendment search and seizure rights.
Tens of thousands of deaths annually are attributed to occupational disease while several million people report work-related injuries and tens of thousands of work place fatalities. Corporate 4th Amendment search and seizure rights, affirmed in cases like Marshall v. Barlow which prevented inspectors from the Occupational Safety & Health Administration onto corporate property, threatens worker health and safety.
  • 14th Amendment due process rights
From 1905 until the mid 1930s the Court invalidated Approximately 200 regulations protecting the health and safety of workers, consumers and children were invalidated from 1905 until the 1930’s alone under various Supreme Court cases affirming corporate rights under the due process clause of the 14th Amendment
Current health care debate
The current “mainstream” political and media debate on health care place takes place within a narrow space – the entirety of which falls within the corporate sphere. Both the Affordable Care Act/“Obamacare” and various Republican Congressional proposals are all private, corporate-dominated systems that enrich all parts of the medical industrial complex – from hospitals, to drug corporations to insurance corporations.
Limiting the range of information, discussion and debate has been corporate “mainstream” media. Single payer health care is not on the table. Corporate agents have made this decision. Yet the public owns the airwaves. TV and media stations lease these public “commons” from us.
It’s in this political and media environment that the Medicare for All Act has been introduced. Pharmaceutical and insurance corporations will surely double down, if not quadruple down, on their political lobbying and political contributions/investments to protect their massively profitable sick-care industry.
"Corporations won’t give up their massive influence and profit without a massive fight."
The corporate media will do its part by disproportionately providing airtime to politicians, pundits and sick-care industry shills fear mongering about supposedly excessive taxes, inadequate treatment and government sticking its nose in between you and your doctor. The corporate media will also gladly accept the throngs of paid ads from the sick-care industry distorting, distracting and discombobulating the reality of the Canadian and other Western European health care systems – all of which provide much more universal, comprehensive and affordable health care to its residents. By contrast, the voices of advocates for the Medicare for All Act will be marginalized and drowned out.
Move to Amend and We the People Amendment
Healthy individuals and a healthy democracy are inextricable connected. Removing the corporate cancer from our health care system is possible without killing our body politic. Eliminating corporate influence and the incredible profits and human toll from private doctor-patient decisions, workplace safety decisions and all public policy decisions is the prescription. Ending corporate constitutional rights is the ultimate cure to our critically ill health care system and democracy. This requires much more than simply (un)elected public officials. It requires a constitutional amendment.
Move to Amend’s We the People Amendment to the U.S Constitution will make clear that only human beings have constitutional rights and end constitutional “personhood” rights of corporations as well as end the spending of money in elections as constitutionally protected “free speech.” It’s a fundamental elixir to achieving the basic public right to decide.
The powerful grassroots social movement directed at Congress in the spring/summer of 2017 to prevent the repeal of the ACA demonstrated both the universal concern of health care and the political power of organized people for a common cause. A larger social movement will be required to humanize and democratize our health care system in the direction of single payer, including the Medicare for All Act, which Senator Sanders acknowledged in calling for a “political revolution” to enact his bill. Corporations won’t give up their massive influence and profit without a massive fight. The same it true of the massive “corporatization” of education, transportation, energy, criminal justice, food and other basic spheres of our lives. Working against each of these single-issue examples of corporatization and for passage of the We the People Amendment reinforces and legitimizes one another.
The implication is clear: the need to join together to build and sustain a powerful and authentically diverse democracy movement that by eliminating corporate constitutional rights and money as speech, as well as other measures such as guaranteeing the right to vote, will guarantee just and peaceful policies and programs – including a universal, affordable, accessible and comprehensive health care system for every person.


Editor's Note:

I don't usually like to include video clips in my posts because, this being the USA (and a lot of readers live in Maine), a lot of you can't stream them. But this clip of Elizabeth Warren's questioning of the head of the Anthem insurance company is too good to ignore. It's also available on You-Tube. Search for "Elizabeth Warren Anthem":

-SPC



Why Bernie Sanders' single-payer push is great policy and even better politics
by Ryan Cooper - The Week - September 17, 2017
Bernie Sanders unveiled his latest version of a Medicare-for-all plan on Wednesday, to a highly unusual level of media attention and support within the Democratic Party. A third of the party's Senate caucus have come out as co-sponsors — although, unsurprisingly, neither Chuck Schumer nor Nancy Pelosi are backing it yet — and it looks likely that more will sign on soon.
The plan is extremely generous — indeed, much more so than many peer countries. But that only makes it great policy and better politics.
So first, the details: The plan would be phased in over a period of four years. In the first year, traditional Medicare would be expanded to cover dental, vision, and hearing aids, as well as people over 55 or under 18, while others would be able to buy in if they wish. In the second year, the age qualification would be lowered to 45, in the third year to 35, and then in the fourth year, everyone remaining would be included.
This upgraded version of Medicare would also be a lot more generous in terms of access. There would be no cost-sharing, except for prescription drugs. It is, as Paul Waldman argues, probably best understood as an opening bid — a symbolic maximal demand rather than the usual pre-compromised Democratic fare.
Sanders later released a sketch of a financing plan, which lays out several options to reduce costs and raise revenue, though it does not decide which is best. A more detailed discussion will inevitably have to be part of any Medicare-for-all bill. But there are some important things to be clear about. When talking about expanded public health programs, writers and analysts tend to mention "costs" in a way that can be rather misleading. Many skeptics cite Vermont, for example, which balked at the tax increases necessary to pay for a single-payer plan in the state.
Imagine a developing country that is just getting wealthy and organized enough to think about setting up a universal health-care system. There, costs would be a very important question, because a lower-income country can easily run into economic constraints. Therefore, one would have to carefully balance the generosity of the program against the country's ability to mobilize real resources — doctors, nurses, drugs, and so forth.
The United States, by contrast, is very rich, and already dedicates way more than enough resources to set up the world's most generous health-care system, and a lot more besides. We spend $3.2 trillion per year — literally twice as much as the OECD average as a share of the economy. We pay enough in health-care taxes alone — that is, the government revenue that goes to Medicare, Medicaid, the VA, and a few other things — to cover a Canada-style Medicare-for-all system for the whole U.S., and then that much again in private money. In other words, if we could simply copy-paste Canada's universal health-care system into America, taxes would actually godown.
All that means is that America doesn't have to worry much about costs; it has to worry about allocating existing spending properly. We already have a gigantic pool of resources dedicated to health care — about half private and half public. We just have to adjust that spending so it can support a single-payer system.
So on total spending, for example, BernieCare would have contradictory effects. No cost sharing would make going to the doctor much easier, which would increase spending, while on the other hand it would bring prices down a lot, cutting outlays. It's impossible to know for sure which effect will predominate until detailed studies can be done (and probably not for sure until it is actually implemented). But the fundamental reality is that we are already putting up way, way, way more than enough to pay for a really excellent universal health-care system. Any resource problems we run into along the way — and there is sure to be quite a lot of disruption during the transition period — can be solved by adjusting the pot of health-care resources around.
For example, Sanders' funding options present several ways you might finance Medicare for all and leave almost everyone money ahead. Administrative savings alone (due to the fact that Medicare is vastly more efficient than private insurance) would run to something like $500 billion per year. Negotiating drug prices might free up another $113 billion. Meanwhile, a 7.5 percent new employer-side payroll tax would raise $3.9 trillion, while cutting health-care expenses per employee by $9,000 on average. A new 4 percent income tax would raise another $3.5 trillion while saving a family of four making the median income about $4,400 after getting rid of premiums.
Some modeling will be needed to know if that all adds up, or if other funding mechanisms would be better. But the basic strategy is clear: cut out waste, get prices down, add a few new taxes, and use the resources thus freed up to cover every single American. Even if those details need to be adjusted, it definitely can work, and it will be a spectacular improvement.
That brings me to the politics. Centrist liberals have long been against Medicare for all, because milquetoast, incremental politics rules out such sweeping changes by definition. Hillary Clinton, for example, does not like Sanders' bill, pointing out that fears of people losing the health insurance they have through their employer helped kill her effort at health-care reform in 1994. President Obama, fretting about this same thing, incautiously promised that "if you like your plan, you can keep your plan" under ObamaCare, which while true for most people was not true for millions of others, simply because you can't make large changes to the health-care system without having that effect. That broken promise enraged people.
The truth is that while employer-sponsored insurance is okay for most people who have it, it is also terrible in many ways. First and most importantly, it means that if you lose your job, you lose your coverage — and perhaps so does your family. That is a huge problem both for people who lose employment — there were 60 million job separations in 2016 alone — and for people who are stuck in terrible jobs for fear of losing coverage (or "job lock"). Second, employer-based coverage has been getting worse over time, with the same increasingly higher co-pays, premiums, and deductibles, plus narrowing networks, that have afflicted the ObamaCare exchanges.
The way to get over people's fears of losing their (increasingly lousy) coverage is to promise them something so good that people can be certain they'll end up better off. The prospect of guaranteed, generous coverage at a reasonable price, that works everywhere and can never be taken away, that would abolish medical bankruptcyand the hell of insurance paperwork, fits that bill. What's more, most people are already very familiar with Medicare, and so will be resistant to scaremongering from conservatives and the insurance industry.
Fear of change and knee-jerk moderation is the thinking that made American health care such a disaster in the first place. But at some point America is going to 
http://theweek.com/articles/724334/why-bernie-sanders-singlepayer-push-great-policy-even-better-politics

Letter to the editor: Use Maine to test whether ‘Medicare for all’ will work

by Julie Pease and Henk Goorhuis - Portland Press Herald - September 18, 2017
In the course of human events, and the struggle for universal health care in the United States, 2017 will be a significant year. On Sept. 13, Sen. Bernie Sanders, along with 16 Senate co-sponsors, introduced Sanders’ Senate bill to provide “Medicare for all.”
Earlier this year, U.S. Rep. John Conyers reintroduced his House bill HR 676, the Expanded and Improved Medicare for All Act, which would transform our health care financing to one of universality and equity. The House legislation has been submitted every session since 2003. Rep. Chellie Pingree is one of the original co-sponsors. This session, the bill has a record 119 co-sponsors.
For Maine AllCare, the Maine state chapter of Physicians for a National Healthcare Program, these bills are markers of our goal of universal health care coverage for all. We believe every knowledgeable universal health care advocate would agree that a publicly financed and privately delivered national program modeled on Medicare would be preferable.
However, given the level of partisanship and deep philosophical divisions that exist in Washington, and the level of influence of the medical-industrial complex, it seems likely that a proof of concept in one or more states will be necessary before success will be achieved nationally.
We believe that Maine, because of our size and sense of fairness and community, is an excellent place to demonstrate the value and practicality of universal health care. Given the political will, we can develop the proof of concept with a publicly financed and privately delivered universal health care system on a state level.
We ask you to read and educate yourself about Sen. Sanders’ and Rep. Conyers’ legislation, consider the issues involved, urge Sen. Angus King to co-sponsor and call or email your elected officials in Washington and state legislators in support of health care for all.
Julie Keller Pease, M.D.
Topsham
Henk Goorhuis, M.D.
Auburn

Complacency Could Kill Health Care

by Paul Krugman - NYT - September 18, 2017

I haven’t yet read Hillary Clinton’s “What Happened,” but it seems pretty clear to me what did, in fact, happen in 2016.
These days, America starts from a baseline of extreme tribalism: 47 or 48 percent of the electorate will vote for any Republican, no matter how terrible, and against any Democrat, no matter how good. This means, in turn, that small things — journalists acting like mean kids in high school, ganging up on candidates they consider uncool, events that suggest fresh scandal even when there’s nothing there — can tip the balance in favor of even the worst candidate imaginable.
And, crucially, last year far too many people were complacent; they assumed that Trump couldn’t possibly become president, so they felt free to engage in trivial pursuits. Then they woke up to find that the inconceivable had happened.
Is something similar about to go down with health care?
Republican attempts to destroy Obamacare have repeatedly failed, and for very good reason. Their attacks on the Affordable Care Act were always based on lies, and they have never come up with a decent alternative.
The simple fact is that all the major elements of the A.C.A. — prohibiting discrimination by insurers based on medical history, requiring that people buy insurance even if they’re currently healthy, premium subsidies and Medicaid expansion that make insurance affordable even for those with lower incomes — are there because they’re necessary. Yet every plan Republicans have offered would do away with or undermine those key elements, causing tens of millions of Americans to lose health insurance, with the heaviest burden falling on the most vulnerable.
All this should be clear to everyone by now. So you might be tempted to assume that no plan along these lines can possibly pass, let alone one that, if anything, looks worse than what we’ve seen so far. But it’s precisely because so many people assume that the threat is behind us, and have turned their attention elsewhere, that health care is once again in danger.
The sponsors of the Graham-Cassidy bill now working its way toward a Senate vote claim to be offering a moderate approach that preserves the good things about Obamacare. In other words, they are maintaining the G.O.P. norm of lying both about the content of Obamacare and about what would replace it.
In reality, Graham-Cassidy is the opposite of moderate. It contains, in exaggerated and almost caricature form, all the elements that made previous Republican proposals so cruel and destructive. It would eliminate the individual mandate, undermine if not effectively eliminate protection for people with pre-existing conditions, and slash funding for subsidies and Medicaid. There are a few additional twists, but they’re all bad — notably, a funding formula that would penalize states that are actually successful in reducing the number of uninsured.
Did this bill’s sponsors — Lindsey Graham, Bill Cassidy, Ron Johnson and Dean Heller — manage to get through months of health care debate without learning anything about the issue? Maybe. But surely the rest of the Senate, not to mention much of the public, has wised up about false Republican promises. A huge majority of voters, almost two to one, consider it a good thing that previous attempts at repealing and replacing Obamacare failed.
Yet there is a real chance that Graham-Cassidy, which is similar to but even worse than previous Republican proposals, will nonetheless become law, because not enough people are taking it seriously.
As in the presidential election, we start from a baseline of extreme tribalism, in which 48 or 49 Republican senators will vote for anything, no matter how awful, that bears their party’s seal of approval. To make a bill the law, its sponsors only need to win one or two more votes.
The main reason Republican leaders couldn’t do that on previous health bills was public outrage and activism. Letters and phone calls, demonstrators and crowds at town halls, made it clear that many Americans were aware of the stakes, and that politicians who voted to take health care away from millions would be held accountable.
Now, however, the news cycle has moved on, taking public attention with it. Many progressives have already begun taking Obamacare’s achievements for granted, and are moving on from protest against right-wing schemes to dreams of single-payer. Unfortunately, that’s exactly the kind of environment in which swing senators, no longer in the spotlight, might be bribed or bullied into voting for a truly terrible bill.
The good news is that for technical reasons of parliamentary procedure, Graham-Cassidy has to pass by the end of this month, or not at all. The bad news is that such passage is a real possibility.
So if you care about preserving the huge gains the A.C.A. has brought, make your voice heard. Otherwise we may wake up to another terrible morning after.

Amid Opioid Crisis, Insurers Restrict
Pricey, Less Addictive Painkillers

by Katie Thomas and Charles Ornstein - NYT - September 17, 2017
This article was written through collaboration between The New York Times and ProPublica, the independent, nonprofit investigative journalism organization.
At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence, even as they provide comparatively easy access to generic opioid medications.
The reason, experts say: Opioid drugs are generally cheap while safer alternatives are often more expensive.
Drugmakers, pharmaceutical distributors, pharmacies and doctors have come under intense scrutiny in recent years, but the role that insurers — and the pharmacy benefit managers that run their drug plans — have played in the opioid crisis has received less attention. That may be changing, however. The New York State attorney general’s office sent letters last week to the three largest pharmacy benefit managers — CVS Caremark, Express Scripts and OptumRx — asking how they were addressing the crisis.
ProPublica and The New York Times analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year. Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval for them.
In contrast, almost every plan covered common opioids and very few required any prior approval.
The insurers have also erected more hurdles to approving addiction treatments than for the addictive substances themselves, the analysis found.
Alisa Erkes lives with stabbing pain in her abdomen that, for more than two years, was made tolerable by Butrans. But in January, her insurer, UnitedHealthcare, stopped covering the drug, which had cost the company $342 for a four-week supply. After unsuccessfully appealing the denial, Ms. Erkes and her doctor scrambled to find a replacement that would quiet her excruciating stomach pains. They eventually settled on long-acting morphine, a cheaper opioid that UnitedHealthcare covered with no questions asked. It costs her and her insurer a total of $29 for a month’s supply.
The Drug Enforcement Administration places morphine in a higher category than Butrans for risk of abuse and dependence. Addiction experts say that buprenorphine also carries a lower risk of overdose.
UnitedHealthcare, the nation’s largest health insurer, places morphine on its lowest-cost drug coverage tier with no prior permission required, while in many cases excluding Butrans. And it places Lyrica, a non-opioid, brand-name drug that treats nerve pain, on its most expensive tier, requiring patients to try other drugs first.
Ms. Erkes, who is 28 and lives in Smyrna, Ga., is afraid of becoming addicted and has asked her husband to keep a close watch on her. “Because my Butrans was denied, I have had to jump into addictive drugs,” she said.
UnitedHealthcare said Ms. Erkes had not exhausted her appeals, including the right to ask a third party to review her case. It said in a statement, “We will work with her physician to find the best option for her current health status.”
Matthew N. Wiggin, a spokesman for UnitedHealthcare, said that the company was trying to reduce long-term use of opioids. “All opioids are addictive, which is why we work with care providers and members to promote non-opioid treatment options for people suffering from chronic pain,” he said.
Dr. Thomas R. Frieden, who led the Centers for Disease Control and Prevention under President Obama, said that insurance companies, with few exceptions, had “not done what they need to do to address” the opioid epidemic. Right now, he noted, it is easier for most patients to get opioids than treatment for addiction.
Leo Beletsky, an associate professor of law and health sciences at Northeastern University, went further, calling the insurance system “one of the major causes of the crisis” because doctors are given incentives to use less expensive treatments that provide fast relief.
The Department of Health and Human Services is studying whether insurance companies make opioids more accessible than other pain treatments. An early analysis suggests that they are placing fewer restrictions on opioids than on less addictive, non-opioid medications and non-drug treatments like physical therapy, said Christopher M. Jones, a senior policy official at the department.
Insurers say they have been addressing the issue on many fronts, including monitoring patients’ opioid prescriptions, as well as doctors’ prescribing patterns. “We have a very comprehensive approach toward identifying in advance who might be getting into trouble, and who may be on that trajectory toward becoming dependent on opioids,” said Dr. Mark Friedlander, the chief medical officer of Aetna Behavioral Health, who participates on its opioid task force.
Aetna and other insurers say they have seen marked declines in monthly opioid prescriptions in the past year or so. At least two large pharmacy benefit managers announced this year that they would limit coverage of new prescriptions for pain pills to a seven- or 10-day supply. And bowing to public pressure — not to mention government investigations — several insurers have removed barriers that had made it difficult to get coverage for drugs that treat addiction, like Suboxone.
Experts in addiction note that the opioid epidemic has been changing and that the problem now appears to be rooted more in the illicit trade of heroin and fentanyl. But the potential for addiction to prescribed opioids is real: 20 percent of patients who receive an initial 10-day prescription for opioids will still be using the drugs after a year, according to a recent analysis by the C.D.C.
Several patients said in interviews that they were terrified of becoming dependent on opioid medications and were unwilling to take them, despite their pain.
In 2009, Amanda Jantzi weaned herself off opioids by switching to the more expensive Lyrica to treat the pain associated with interstitial cystitis, a chronic bladder condition.
But earlier this year, Ms. Jantzi, who is 33 and lives in Virginia, switched jobs and got a new insurer — Anthem — which said it would not cover Lyrica because there was not sufficient evidence to prove that it worked for interstitial cystitis. Ms. Jantzi’s appeal was denied. She cannot afford the roughly $520 monthly retail priceof Lyrica, she said, so she takes generic gabapentin, a related, cheaper drug. She said it does not manage the pain as well as Lyrica, which she took for eight years. “It’s infuriating,” she said.
Ms. Jantzi said she wanted to avoid returning to opioids. However, “I could see other people, faced with a similar situation, saying, ‘I can’t live like this, I’m going to need to go back to painkillers,’ ” she said.
In a statement, Anthem said that its members have to meet certain requirements before it will pay for Lyrica. Members can apply for an exception, the insurer said. Ms. Jantzi said she did just that and was turned down.
With Butrans, the drug that Ms. Erkes was denied, several insurers either do not cover it, require a high out-of-pocket payment, or will pay for it only after a patient has tried other opioids and failed to get relief.
In one case, OptumRx, which is owned by UnitedHealth Group, suggested that a member taking Butrans consider switching to a “lower cost alternative,” such as OxyContin or extended-release morphine, according to a letter provided by the member. Mr. Wiggin, the UnitedHealthcare spokesman, said the company’s rules and preferred drug list “are designed to ensure members have access to drugs they need for acute situations, such as post-surgical care or serious injury, or ongoing cancer treatment and end of life care,” as well as for long-term use after alternatives are tried.
.
Butrans is sold by Purdue Pharma, which has been accused of fueling the opioid epidemic through its aggressive marketing of OxyContin. Butrans is meant for patients for whom other medications, like immediate-release opioids or anti-inflammatory pain drugs, have failed to work, and some scientific analyses say there is not enough evidence to show it works better than other drugs for pain.
Dr. Andrew Kolodny is a critic of widespread opioid prescribing and a co-director of opioid policy research at the Heller School for Social Policy and Management at Brandeis University. Dr. Kolodny said he was no fan of Butrans because he did not believe it was effective for chronic pain, but he objected to insurers suggesting that patients instead take a “cheaper, more dangerous opioid.”
“That’s stupid,” he said.
Ms. Erkes’s pain specialist, Dr. Jordan Tate, said her patient had been stable on the Butrans patch until January, when UnitedHealthcare stopped covering the product and denied Ms. Erkes’s appeal.
Without Butrans, Ms. Erkes, who once visited the doctor every two months, was now in Dr. Tate’s office much more frequently, and once went to the emergency room because she could not control her pain, thought to be related to an autoimmune disorder, Behcet’s disease.
Dr. Tate said she and Ms. Erkes reluctantly settled on extended-release morphine, a drug that UnitedHealthcare approved without any prior authorization, even though morphine is considered more addictive than the Butrans patch. She also takes hydrocodone when the pain spikes and Lyrica, which UnitedHealthcare approved after requiring a prior authorization.
Ms. Erkes acknowledged that she could have continued with further appeals, but said the process exhausted her and she eventually gave up.
While Dr. Tate said Ms. Erkes had not shown signs of abusing painkillers, her situation was far from ideal. “She’s in her 20s and she’s on extended-release morphine — it’s just not the pretty story that it was six months ago.”
Many experts who study opioid abuse say they also are concerned about insurers’ limits on addiction treatments. Some state Medicaid programs for the poor, which pay for a large share of addiction treatments, continue to require advance approval before Suboxone can be prescribed or they place time limits on its use, both of which interfere with treatment, said Lindsey Vuolo, associate director of health law and policy at the National Center on Addiction and Substance Abuse. Drugs like Suboxone, or its generic equivalent, are used to wean people off opioids but can also be misused.
The analysis by ProPublica and The Times found that restrictions remain prevalent in Medicare plans, as well. Drug plans covering 33.6 million people include Suboxone, but two-thirds require prior authorization. Even when such requirements do not exist, the out-of-pocket costs of the drugs are often unaffordable, a number of pharmacists and doctors said.
At Dr. Shawn Ryan’s addiction-treatment practice in Cincinnati, called BrightView, staff members often take patients to the pharmacy to fill their prescriptions for addiction medications and then watch them take their first dose. Research has shown that such oversight improves the odds of success. But when it takes hours to gain approval, some patients leave, said Dr. Ryan, who is also president of the Ohio Society of Addiction Medicine.
“The guy walks out, and you can’t blame him,” Dr. Ryan said. “He’s like, ‘Hey man, I’m here to get help. What’s the deal?’”
Before tackling single-payer, save Obamacare
by E.J. Dionne Jr. - The Washington Post - September 17, 2017

Before supporters of universal health coverage get all wrapped up debating a single-payer system, they need to focus on a dire threat to the Affordable Care Act likely to come up for a vote in the Senate before the end of the month.
The latest repeal bill is an offering from Republican Sens. Lindsey O. Graham (S.C.) and Bill Cassidy (La.) that would tear apart the existing system and replace it with block grants to the states. Block grants — flows of money for broad purposes with few strings attached — are a patented way to evade hard policy choices. All the tough decisions are kicked down to state capitals, usually with too little money to achieve the ends the block grant is supposed to realize.
Because Graham and Cassidy are civil interlocutors and have sounded more reasonable than many of their Republican colleagues in talking about health care, there is an unexamined assumption that their proposal must be more sensible than other approaches to repeal.
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But it’s not. In fact, it would be disastrous. In certain respects, it’s even worse than earlier repeal measures, which at least kept some of the structure of Obamacare’s subsidies in place. This bill would simply blow them up.
It would also shift money around in ways that would, on the whole, hurt states that have been trying to get health coverage to their less-affluent residents. A report on the bill by the Center on Budget and Policy Priorities, a think tank devoted to the interests of less-advantaged Americans, concluded:
Sen. Lindsey O. Graham (R-S.C.) spoke about his proposal for health-care reform at a news conference on Sept. 13. (Reuters)
“In general, over time, the plan would punish states that have adopted the Medicaid expansion or been more successful at enrolling low- and moderate-income people in marketplace coverage under the ACA. It would impose less damaging cuts, or even raise funding initially, for states that have rejected the Medicaid expansion or enrolled few low-income residents in marketplace coverage.”
This should make the bill impossible for two brave Republicans, Sens. Susan Collins of Maine and Lisa Murkowski of Alaska, who stood up against July’s repeal effort. Both have said they would not be complicit in undermining health-care coverage in their states. The CBPP report showed that Graham-Cassidy would reduce federal funding for health coverage in Maine and Alaska and cut Medicaid overall.
Oh, yes, and the report also noted, with italicized emphasis, that as currently written, the block grant “would disappear altogether after 2026.” What happens then? The bottom line, said Jacob Leibenluft, a senior adviser at the center, is that Graham-Cassidy “punts all the problems to governors while giving them insufficient tools and resources to address them.”
This is a matter of urgency because the authority the Senate has to pass Obamacare repeal with just 51 votes expires Sept. 30. So if the bill comes up, it would probably hit the floor the last week of the month. All who care about the expansion of health-care coverage need to focus their energies on defeating this latest attack on Obamacare. However we eventually arrive at universal coverage, which we must, it will be far easier to get there by building on the ACA.
And assuming the latest repeal effort fails, last week’s push for a single-payer systemcould come to be seen as a useful initiative, provided that “Medicare for all,” as its supporters like to call it, is treated as a goal, not a litmus test. Defining the left pole of the health-care debate is helpful, in part because it shows how fundamentally moderate Obamacare is. It is not, as many conservatives have claimed, anything close to a socialist scheme.
And for those whose objective is single-payer, there are many options available that could gradually open the way for it. As the plan’s leading advocate, Sen. Bernie Sanders (I-Vt.), noted in an underappreciated tweet in July: “In the short-term, to improve the Affordable Care Act, we should have a public option in 50 states and lower the Medicare age to 55.” Many progressives and moderates who favor universal coverage but are not yet sold on single-payer would embrace options of this sort. Such measures would help a lot of people immediately and make any move to single-payer less disruptive.
What the country cannot afford is to go backward, which is where Sens. Graham and Cassidy would move us. Politics is about priorities, and the priority now must be to stop Congress from ripping health coverage away from millions of our fellow citizens.

The biggest thing single-payer has going for it
by Eugene Robinson - The Washington Post - September 14, 2017

The smartest, savviest people in Washington will tell you Bernie Sanders’s “Medicare for all” idea is dead on arrival, a waste of time and energy. But since those same smart, savvy people told you Donald Trump didn’t have a prayer of becoming president, I’d advise keeping an open mind.
What the Vermont senator’s bill has going for it is simple: It’s the right thing to do.
The issue is not whether we should have socialized medicine in this country. We already do — Medicare for everyone over 65; Medicaid for the indigent, the working poor and the disabled; the Children’s Health Insurance Program for minors in modest-income families. That’s a total of around 133 million Americans who already enjoy most of the benefits of a single-payer health-care system similar to those in other wealthy countries.
The philosophical debate about whether government should play a major role in medical care is over, as evidenced by the GOP’s “repeal and replace” fiasco. In trying vainly to get rid of the Affordable Care Act, Republicans argued about how to subsidize health insurance, not whether to do so. The most conservative approach — working through the existing free-market, fee-for-service health-care system mediated by private insurance companies — had already been tried. It is called Obamacare.
In the end, Republicans couldn’t pull the trigger. The question now is whether Democrats will continue to settle for half-measures or finally demand what the party has claimed to want for decades: fully universal health care as a right, not as a privilege.
Sen. Bernie Sanders (I-Vt.) introduced his "Medicare for All" plan to provide universal health coverage to all Americans on Sept. 13. The bill has 16 Democratic co-sponsors. (Reuters)
Sixteen Democratic senators have announced support for Sanders’s bill, introduced Wednesday, “to establish a Medicare-for-all national health insurance program.” It is no accident that among them are such potential 2020 presidential hopefuls as Kamala D. Harris of California, Elizabeth Warren of Massachusetts, Kirsten Gillibrand of New York, Cory Booker of New Jersey and Al Franken of Minnesota. They probably believe, as I do, that the party’s activist base is ready to go big on health care, even if the congressional leadership remains guarded and skeptical. Both Senate Minority Leader Charles E. Schumer (N.Y.) and House Minority Leader Nancy Pelosi (Calif.) are studiedly noncommittal. 
There is, of course, the not-insignificant fact that Republicans control both the Senate and the House. Even though Trump has to be considered a wild card — he has, over time, taken every conceivable position on health care — it is hard to imagine this Congress jumping on the universal health-care bandwagon.
But what Sanders did with his insurgent campaign for the Democratic presidential nomination was to bring “Medicare for all” in from the fringe and make it an acceptable topic for public debate. Medicare is enormously popular among seniors because it works. Why wouldn’t it work for the rest of us?
Critics reply that it would be ruinously expensive. They point to a 2016 Urban Institute study projecting that “Medicare for all” would cost a staggering $32 trillion over the next decade. However, this assumes the federal government would take over all current health-care spending by state and local governments, employers and individuals, which would add up to $26 trillion over that same period. Even if this money were paid to the government rather than to health providers and insurance companies, according to this analysis, there would still be a sizable gap to somehow fill.
During last year’s presidential campaign, Sanders estimated that offering Medicare to all would cost $14 trillion over a decade and be offset by tax increases. He has not yet placed a price tag on the bill introduced this week.
There is another way to look at costs, however. According to the Organization for Economic Cooperation and Development, in 2015 the United States spent $9,507 per capita on health care. That’s more than twice the amount spent per capita in Britain ($4,125), France ($4,530) or Canada ($4,533), all of which have universal health care. In rankings based on factors such as life expectancy and infant mortality, the United States lags behind countries that spend much less on health.
As Trump and the Republicans in Congress discovered, health care is difficult. The details are devilish, but the big picture is clear: Our system is too byzantine, too expensive, too unfair. Other advanced nations produce better outcomes with single-payer systems that their populations would never trade for ours.
The ACA was a giant step on the road that leads logically to something very much like what Sanders is proposing. Progressives should take the next step by loudly and proudly proclaiming the destination.

Susan Collins cites ‘concerns’ with latest Republican bid to kill Obamacare

by Michael Shepherd - Bangor Daily News - September 18, 2017
AUGUSTA, Maine — Republicans’ latest plan to repeal the Affordable Care Act looked to be in danger Monday, when a spokeswoman for U.S. Sen. Susan Collins said the Maine Republican has “concerns” about the proposal.
Collins hasn’t taken a formal position on the bill sponsored by Republican Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, but the road to passage may go through her. She was one of three Republicans who sunk the party’s last repeal bid in July.
The Graham-Cassidy bill is being touted by supporters as a moderate alternative to past repeal proposals. It would eliminate subsidies for Affordable Care Act exchanges and a higher reimbursement rate for Medicaid expansion states, replacing that with lower block grants.
But opponents merely see it as a massive cut. The liberal Center on Budget and Policy Priorities said the Graham-Cassidy bill that would cut federal health care coverage in Maine by more than $1 billion by 2027, but the nonpartisan Congressional Budget Office hasn’t yet weighed in.
In a Monday statement, Collins spokeswoman Annie Clark said her boss has “a number of concerns” with the proposal, including Medicaid cuts and impact to Affordable Care Act requirement that insurers cover people with pre-existing conditions.
The Washington Post reported Sunday that Republican leaders want a vote on the Graham-Cassidy bill by month’s end. Sen. Rand Paul, R-Kentucky, opposes it, so Republicans may need to woo Collins or Sen. Lisa Murkowski, R-Alaska, to pass it on a party line.
Gov. Paul LePage came out in support of the proposal in a Sunday email sent by the Maine Republican Party urging supporters to lobby Collins and independent U.S. Sen. Angus King to support the repeal bid, but neither supported the previous effort despite LePage’s urging in July.



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