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Tuesday, October 10, 2017

Health Care Reform Articles - October 10, 2017

Why cost sharing should be abandoned

Down With the Copay

By Natalie Shure - Jacobin - October 6, 2017
In the week preceding the release of Bernie Sanders’s Medicare for All bill, the Vermont senator’s office was flooded with calls — so many, in fact, that the legislative aides on the other line often guessed callers’ purpose before being prompted. At issue was whether the single-payer health care system Sanders’s bill envisions should include copayments, out-of-pocket payments for health services at the point of care.
For the single-payer advocacy group Physicians for a National Health Program (PNHP), the answer was a resounding “no.” So upon discovering that copays remained in Sanders’s penultimate draft, they sprang into action. After a week of open letters, tweets and appeals from like-minded organizations, Sanders ultimately struck copays from the bill’s final version.
Earlier versions of Sanders’s bill probably included copays for doctors visits and prescription drugs for the same reason that economists like them: they drive down health care usage and costs. After all the attacks branding Sanders’s relatively pedestrian social-democratic platform as fantastical promises of ponies for all, perhaps Sanders’s legislative aides believed meager copays gave their proposal an air of seriousness.
But the obliteration of copays isn’t a bug in the thinking behind Medicare for All — it’s the feature.
“Cost-sharing” features like copays, coinsurance, and deductibles are major manifestations of market logic in the US health-care system. If we want to overturn for-profit health care’s rebranding of “patients” as “consumers,” we have to eliminate financial barriers at the point of care.
The cliched justification for charging copays is to relieve doctors’ offices of the burden of patients showing up at the first sign of a sniffle. (Never mind that we observe no such behavior among the wealthy, for whom copays are no barrier.) But we do know that even meager copays make people seek less care, and that the poor suffer worse health outcomes as a result.
“I spent my entire career taking care of low-income people, and trust me — a copayment will keep people away from a doctor. I’ve seen it again and again in my practice,” Dr. Steffie Woolhandler, the co-founder of PNHP, told me over the phone. “It’s a huge amount of money for a low-income person.”
While several countries with universal health care systems do charge copayments at the point of use, they don’t tolerate the amount of poverty that we do in the United States. No other wealthy country does. In a grotesquely unequal society, a copayment doesn’t create “better consumers” of care — it helps us scrimp by shoving the most powerless out of the system.
Over decades of bending over backwards to accommodate the internal contradictions of the private health insurance industry, few made the one point that really mattered: we never built an insurance system that strove to guarantee universal health care; we built one that strove to protect capitalists’ profits. We can build one based on addressing all people’s health care needs right now.
Medicare for All could create a universal health-care system designed to provide health care for everyone. The logic of the market has no place in such a system. Winning a truly universal system means zero deductibles and zero copays.
***

Physicians for a National Health Program, August 23, 2017
Dear Senator Sanders:
We are writing to express our concern about elements of your draft single payer legislation, especially the inclusion of copayments for medically-necessary care.

Copayments
Copayments undermine the goal of eliminating financial barriers to care, a goal that is at the heart of our single-payer advocacy. Copayments, even relatively modest ones, deter patients from seeking needed medical care.
For instance, in the Rand Health Insurance Experiment, compared to persons with entirely free care, those with copayments (as low as 16% of costs) reduced their use of essential and low-value medical services to a similar degree. Among non-poor adults, copayments reduced the use of “highly effective” care for acute conditions such as chest pain, urinary tract infections and fractures by 29% and “rarely effective” care (e.g. for a cold) by 22%. Highly-effective care for chronic conditions fell by 15%, and for acute-on-chronic conditions fell by 21%. For non-poor children, copayments reduced highly-effective care (e.g. for ear infections and strep throat) by 15%, and cut well-child visits by 21%. Cost sharing reduced prescriptions for several potentially life-saving medications such as insulin, asthma inhalers, and beta blockers by about 50% and oral contraceptive use by 25%. While the Rand Experiment was too small and too short to detect the expected deleterious outcomes of these shortfalls in care, it documented that copayments resulted in significantly worse control of blood pressure, a key cause of heart attacks, kidney failure and strokes.
More recent studies confirm the health-endangering effects of out-of-pocket charges for care. Among persons with employer-paid coverage, raising out-of-pocket charges cut care much more for those in poor health. When Medicare added new copayments, outpatient visits dropped but hospitalizations rose. Among insured post-heart-attack patients, eliminating medication copayments increased compliance, and (for minority patients), led to a 35% reduction in major complications such as recurrent heart attacks. Similarly, among insured school-age children with asthma, those with higher copayments used fewer medications but had a 41% greater risk of asthma-related hospitalization. For nearly one- third of lower-income asthmatic children with high-cost-sharing coverage through the Kaiser Health Plan, parents reported delaying or avoiding outpatient visits, and 14.8% reported non-adherence to medications because of cost. The low income group in the study included those with family incomes up to 250% of poverty, some of whom would be hit by copayments under the proposed legislation. In that study, 15.6% of all parents (including those with higher incomes) reported borrowing money or cutting back on necessities to pay for their children’s asthma care.
Paradoxically, the reduction in care-seeking because of copayments may fail to cut system-wide utilization, instead shifting care from sicker and lower-income persons to the healthy and wealthy. When lower-income patients avoid care, doctors and hospitals fill the empty appointment slots and beds with less price-sensitive patients, an example of supply-sensitive demand.
International evidence indicates that cost-sharing is neither necessary nor particularly effective for cost control. Canada, which outlawed copayments and deductibles in 1981, has seen both faster health improvement and slower cost growth. Notably, Canada experienced no surge in care when it abolished copayments. Similarly, in the U.S. there was no overall increase in doctor visits or hospitalizations when Medicare and Medicaid were first implemented in 1966; care shifted from more affluent and healthier persons to those who were sicker and poorer. Scotland, which has eschewed patient payments—even going so far as to abolish parking fees—has costs about half those in the U.S. Strikingly, the U.S. has the world’s highest health care expenditures despite its extensive patient cost sharing.
The inclusion of copayments would also undermine the breadth of support for single-payer reform. Many Americans would see no improvement in their current coverage. In 2014, about 28% of Americans incurred no out-of-pocket costs, and 84.3% had out-of-pocket costs of less than $1,000. For them, the proposed coverage would not reduce out-of-pocket costs, at least in the short run. About 5% of those with employer coverage—about 8 million people—currently have plans with zero deductibles and zero copayments. They would have worse coverage under the proposed reform.
Finally, retaining copayments would substantially diminish the administrative savings achievable through a single-payer reform. In order to implement copayments, the single payer insurer would need to track individuals’ changing incomes, family status (to calculate their income relative to the poverty level) and their copayments to date (to ascertain whether they’ve exceeded the out-of-pocket cap), and make that information available in real time to every hospital, clinic, lab, doctor's office, etc., in the U.S. Providers would need to collect the copays, and bill patients unable to pay at the time of a visit.
Conclusion
In sum, Physicians for a National Health Program cannot endorse or wholeheartedly advocate for a reform that includes copayments for medically-necessary services. While we would welcome the proposed reform as a useful step forward in advancing health justice, the persistence of copayments would unacceptably compromise the legislation’s ability to improve health and foster equality in care. We urge you to reconsider the inclusion of copayments.
Sincerely,
David U. Himmelstein, M.D., Co-founder PNHP
Carol Paris, M.D., President, PNHP
Steffie Woolhandler, M.D., Co-founder, PNHP
***

Comment:

By Don McCanne, M.D.
It is irrefutable that deductibles, copayments, and coinsurance cause patients to forgo beneficial health care services, and that often results in physical suffering and sometimes death. For those who cannot avoid health care, financial hardship is frequently a consequence.
A health care financing system should be designed to assist patients in getting the health care they should have by removing financial barriers to care. Since cost sharing has the opposite effect, it should be abandoned as a policy designed to reduce health care spending. There are other much more patient-friendly policies in a well-designed single payer system that are more effective in containing health care spending.
It is a specious argument that people who do not need health care will seek health care anyway simply because it is free. Some say that it would reduce low-value care, but what is low-value care? When a patient is legitimately concerned about his or her health but then doesn’t require any therapeutic intervention other than reassurance, is that low-value care? No. We want patients to come in to reassure them and ourselves that there isn’t anything more serious that requires medical intervention.
The letter by Himmelstein, Paris and Woolhandler provides an excellent explanation as to why cost sharing should be rejected - why individuals should be approached as patients rather than as consumers.
Their letter also demonstrates that it is imperative that we all continue to speak up with the truth about health care reform. Important people are listening.

Shouldn’t Doctors Control Hospital Care?

by Sandeep Jauhar - NYT - October 10, 2017

Who ultimately should be in charge of care at our nation’s hospitals — physicians or businesspeople?
In January 2016, the board of directors at Tulare Regional Medical Center, a small community hospital in central California, voted to terminate the elected leaders of its medical staff office. Medical staff offices help ensure that patient needs are kept separate from business imperatives, such as increasing hospital profits. They have historically operated independently of hospital administrators.
Citing deficiencies in the elected leaders’ performance, the Tulare board appointed new officers without an election. The board also passed new bylaws written without the input of the hospital’s physicians, including some stating that physicians’ “status” at the hospital would depend on the number of patients they admitted — in other words, their economic value to the facility.
Not surprisingly, Tulare’s doctors were furious; within six months, roughly half of them left the hospital. With the support of the California Medical Association, a lawsuit was filed calling for reinstatement of the original medical staff officers and bylaws. The association said that the Tulare board’s actions violated California law on medical staff self-governance and posed “an existential threat to independent hospital medical staffs.” The hospital countered that its actions were not only lawful but also needed to keep it operating properly.
The case, which went to trial but has been postponed because the hospital filed for bankruptcy protection, is ostensibly about protecting medical staff members from administrative interference. But it is a symptom of a much bigger problem in American medicine: the gradual loss of autonomy by physicians at our nation’s hospitals.
A generation ago, physicians actually ran most hospitals, and medical staff offices commanded great influence over how care was delivered. Doctors were able to leverage a cultural perception of high-minded knowledge for an unusual degree of professional independence.
But much has changed over the past several decades. As spending outpaced hospital budgets, business executives increasingly took over. There were also concerns about uneven clinical quality, for which doctors were held responsible and became subject to regulatory oversight. Once the epitome of independent professionalism, physicians watched their autonomy shrink rapidly.
Today, less than 5 percent of America’s roughly 6,500 hospitals are run by chief executives with medical training. Most hospital executive suites are disproportionately filled with lawyers or businesspeople. Indeed, the number of non-medically trained hospital administrators has gone up 30-fold in the past 30 years, while the number of physicians has remained relatively constant. Independent practices are also disappearing, as hospitals buy them up and put doctors on salary. The result for many physicians is the feeling that they are pawns of a big organization that does not want to hear, let alone act on, their concerns.
Doctors were once expected to scrutinize and, when necessary, challenge administrative actions on behalf of patients. No more.
The dispute at Tulare must be viewed in the context of this larger struggle. As hospital managers make decisions based on business, not clinical, imperatives, both patients and their care providers are getting squeezed. For example, doctors are being pressed to discharge patients quickly — sometimes too quickly — to maintain “throughput.” There is a focus on increasing the rates of profitable procedures, such as orthopedic and heart surgeries, at the expense of relatively poorly remunerated general medical care. Administrators are even exerting control over traditionally medical domains, such as the credentialing of new physicians with hospital privileges. If a hospital board can dismiss elected medical officers with impunity, as at Tulare, it will indicate to many doctors the increasingly tenuous nature of the position they currently hold.
The very best hospitals in America are still run by physician chief executives — Toby Cosgrove at the Cleveland Clinic, for example, and John Noseworthy at the Mayo Clinic. The Mayo Clinic says that it is physician-led because “this helps ensure a continued focus on our primary value” — namely, that “the needs of the patient come first.” Indeed, a study in 2011 found “a strong positive association between the ranked quality of a hospital and whether the C.E.O. is a physician.” Overall hospital quality scores were about 25 percent higher when physicians, not business managers, were in charge.
Of course, correlation does not prove causation; it is certainly possible that better hospitals choose physicians as their leaders. But when day-to-day decision making is done by people with clinical training, it appears that patients do benefit.
There are many factions to blame for the corporate takeover at America’s hospitals. Doctors need to accept some of the responsibility, too. If we had taken better care of our institutions, perhaps there would not have been a need for others to manage them for us.
How the court rules in the Tulare case, once it resumes, will have profound consequences for whether medical staffs can do their work independently of nonclinical administrators. And it will also provide an answer to the more important question of who should be in charge of hospital care.


Shifting attitudes among Democrats have big implications for 2020
by Dan Balz - The Washington Post - October 7, 2017
Partisan divisions are not new news in American politics, nor is the assertion that one cause of the deepening polarization has been a demonstrable rightward shift among Republicans. But a more recent leftward movement in attitudes among Democrats also is notable and has obvious implications as the party looks toward 2020.
Here is some context. In 2008, not one of the major candidates for the Democratic presidential nomination advocated legalizing same-sex marriage. By 2016, not one of those who sought the nomination opposed such unions, and not just because of the Supreme Court’s rulings. Changing attitudes among all voters, and especially Democratic voters, made support for same-sex marriage an article of faith for anyone seeking to lead the party.
Trade policy is another case study. Over many years, Democrats have been divided on the merits of multilateral free trade agreements. In 1992, Bill Clinton strongly supported the North American Free Trade Agreement (NAFTA) in the face of stiff opposition from labor unions and others. He took his case into union halls, and while he didn’t covert his opponents, he prospered politically in the face of that opposition.
By 2016, with skepticism rising more generally about trade and globalization, Hillary Clinton was not willing to make a similar defense of the merits of free trade agreements. With Sen. Bernie Sanders (I-Vt.) bashing the Trans Pacific Partnership (TPP) as a presidential candidate, Clinton joined the chorus of opponents. She ended up on the opposite side of then-President Barack Obama, even though she had spoken warmly about the prospects of such a treaty as secretary of state. 
Looking ahead to 2020, something similar is likely to take place on the issue of health care. Because of changing attitudes that already are underway within the party, it will be difficult for any Democrat seeking the nomination not to support some kind of single-payer health-care plan, even if big questions remain about how it could be accomplished.
Sanders used his 2016 presidential campaign to advocate for a universal health-care plan that he dubbed “Medicare for All.” The more cautious Clinton, who saw flaws in what Sanders was advocating, argued instead for focusing on improvements to the Affordable Care Act (ACA). 
Sanders has now introduced a “Medicare for All” measure in the Senate, and his co-sponsors include several other prospective candidates for the Democratic nomination in 2020. 
Meanwhile, a majority of House Democrats have signed onto a single-payer plan sponsored by Rep. John Conyers Jr. (D-Mich.) that goes much further. This has happened even though some of those who like Conyers’s idea in principle question whether it is ready for prime time, not only because of the potential cost and the absence of a mechanism to pay for it, but for other potential policy flaws as well.
The pressure to embrace single-payer plans grows out of shifts in attitudes among Democrats. The Pew Research Center found in June that 52 percent of self-identified Democrats now support a government-run health-care system. That is up nine points since the beginning of the year and 19 points since 2014. Among liberal Democrats, 64 percent support such a plan (up 13 points just this year) and among younger Democrats, 66 percent say they support it.
Health care isn’t the only area where Democratic attitudes are shifting significantly. They include such issues as the role of government and the social safety net; the role of race and racial discrimination in society; and immigration and the value of diversity.
A few days ago, the Pew Center released a comprehensive survey on the widening gap between Republicans and Democrats. The bottom line conclusion is summed up by one of the opening sentences in the report: “Republicans and Democrats are now further apart ideologically than at any point in more than two decades.”
This poll is the latest in a series of surveys dating back to 1994. Together they provide not just snapshots in time but an arc of the changes in public opinion. Republicans moved to the right harder and earlier than Democrats began moving left, and their base remains more uncompromising. But on a number or questions, the biggest recent movement has been among Democrats. 
In its new survey, Pew found the widest partisan gap ever on the question of whether government should help those in need — primarily because of recent shifts among Democrats. From 2011 to today, the percentage of Democrats who say government should do more to help those in need has jumped from 54 percent to 71 percent. 
Only a minority of Republicans (24 percent) say government should do more for the needy, and that figure has barely moved in the past six years. The Republicans shifted their views from 2007-2011, the early years of the Obama presidency, during which their support for a government role dropped by 20 percentage points.
Two related questions produce a similar pattern among Democrats. Three-in-four Democrats say that “poor people have hard lives because government benefits don’t go far enough to help them live decently,” up a dozen points in the past few years. 
Eight in 10 Democrats say the country needs to continue to make changes to give blacks equal rights with whites, up 18 points since 2014. And more than 6 in 10 say “racial discrimination is the main reason many black people can’t get ahead these days,” up from 4 in 10 three years ago.
Meanwhile, only a quarter of Republicans agree with the statement on government benefits, fewer than 4 in 10 say the country needs to continue to do things to provide equal rights for blacks and just 14 percent cite racial discrimination as the main reason many blacks can’t get ahead.
Members of both parties have become more positive in their attitudes about immigration in recent years, but the partisan gap remains huge — 42 points in the new survey. Today 84 percent of Democrats say immigrants strengthen the country through hard work and talents, up from 48 percent in 2010. In 2010, 29 percent of Republicans agreed with that statement; today that’s risen to 42 percent. . 
President Trump obviously found strong support for his controversial views on immigration, whether his called to build a wall on the U.S.-Mexican border or to bar refugees from countries mostly in the Middle East. Those pronouncements helped him win the presidency. But those policies and the rhetoric that often preceded them also produced a strong backlash from the president’s opponents.
The 2016 campaign ended up highlighting issues of national identity — on race and immigration and the shifting character and face of the country — in often divisive ways that unleashed the kind of ugliness seen in Charlottesville in August. 
The Democratic Party is being shaped by the Trump presidency and by the reactions to the president among rank-and-file Democrats. Party leaders have been taking notice since Trump was sworn in as president and have moved as well. 
Those who seek the party’s nomination in 2020 understandably will be guided by these sentiments. But they must find a way to harness the movement into a political vision that is attractive to voters beyond the Democratic base — a vision that is grounded not just in anti-Trump resentment but in fresh and sound policies as well. In such polarized times, that will not be easy.

The ‘Resistance,’ Raising Big Money, Upends Liberal Politics

by Kenneth P. Vogel - NYT - October 7, 2017

WASHINGTON — It started as a scrappy grass-roots protest movement against President Trump, but now the so-called resistance is attracting six- and seven-figure checks from major liberal donors, posing an insurgent challenge to some of the left’s most venerable institutions — and the Democratic Party itself.
The jockeying between groups, donors and operatives for cash and turf is occurring mostly behind the scenes. But it has grown acrimonious at times, with upstarts complaining they are being boxed out by a liberal establishment that they say enables the sort of Democratic timidity that paved the way for the Trump presidency.
The tug of war — more than the lingering squabbles between supporters of Hillary Clinton and Senator Bernie Sanders of Vermont — foreshadows a once-in-a-generation reorganization of the American left that could dictate the tactics and ideology of the Democratic Party for years to come. If the newcomers prevail, they could pull the party further to the left, leading it to embrace policy positions like those advocated by Mr. Sanders, including single-payer health care and free tuition at public colleges.
The upending of the left comes amid a broader realignment in American politics, with the Republican Party establishment also contending with a rising rebellion, driven by pro-Trump populists. Just as the new forces on the right are threatening primary challenges to establishment Republicans, some groups on the left have begun talking about targeting Democratic incumbents in the 2018 midterm elections.
Entrenched Democratic groups are facing growing questions about the return on the hundreds of millions of dollars they have spent over the years. Groups affiliated with Mrs. Clinton “spent so much money based on a bad strategy in this last cycle that they should step aside and let others lead in this moment,” said Quentin James, a founder of a political committee called the Collective PAC that supports African-American candidates.
Mr. James’s committee is among more than three dozen outfits that have started or reconfigured themselves since the election to try to harness the surge in anti-Trump activism. In addition to political committees, grass-roots mobilization nonprofits and legal watchdog groups, there are for-profit companies providing technological help to the new groups — essentially forming a new liberal ecosystem outside the confines of the Democratic Party.
While the new groups gained early traction mostly on the strength of grass-roots volunteers and small donations — and with relatively meager overall budgets — they are beginning to attract attention from the left’s most generous benefactors.
“We’re in a disruptive period, and when we get through it, the progressive infrastructure landscape may look different,” said Gara LaMarche, president of the Democracy Alliance, a club of wealthy liberals who donate at least $200,000 a year to recommended groups. “There may be groups that have been around that don’t rise to the challenge, and there may be some new groups that do rise to the challenge, while others fade away.”
The Democracy Alliance has helped shape the institutional left, steering more than $600 million since its inception in 2005 to a portfolio of carefully selected groups, including pillars of the Clinton-aligned establishment like the think tank Center for American Progress and the media watchdog Media Matters.
But this year, the Democracy Alliance hired Archana Sahgal, a former Obama White House official, to help the new anti-Trump groups, and it suspended its intensive vetting and approval process to recommend donations to a host of groups created since last fall’s election.
The Democracy Alliance distributed a “resistance map” to its donors in July including new groups focused on converting the anti-Trump energy into electoral wins, such as Flippable, Swing Left and Sister District, as well as legal watchdog groups and others focused on mobilizing protesters, such as Women’s March and Indivisible.
Perhaps no group epitomizes the differences between the legacy left and the grass-roots resistance like Indivisible. Started as a Google document detailing techniques for opposing the Republican agenda under Mr. Trump, the group now has a mostly Washington-based staff of about 40 people, with more than 6,000 volunteer chapters across the country. The national Indivisible hub, which consists of a pair of nonprofit groups, has raised nearly $6 million since its start, primarily through small-dollar donations made through its website.
Yet Indivisible has also received funding from the tech entrepreneur Reid Hoffman, as well as foundations or coalitions tied to Democracy Alliance donors, including the San Francisco mortgage billionaire Herbert Sandler, the New York real estate heiress Patricia Bauman and the oil heiress Leah Hunt-Hendrix.
And an advocacy group funded by the billionaire hedge fund manager George Soros, a founding member of the Democracy Alliance and one of the most influential donors on the left, is considering a donation in the low six figures to Indivisible. Mr. Soros has already donated to a host of nonprofit groups playing key roles in the anti-Trump movement, including the Center for Community Change, Color of Change and Local Progress.
Indivisible would “gladly” accept a check from Mr. Soros or his foundation, said an official with the group, Sarah Dohl. But, she added, the group is committed to ensuring that money from major donors does not become a majority of the group’s revenue “because we want to maintain our impendence both from the funders and from the party.”
The group may start a political committee that could support primary challenges in 2018 against Democratic incumbents, Ms. Dohl said.
“It’s not a secret that we would like to move the Democratic Party further left,” she said, adding that “the party will only get to where it needs to go if it has groups like ours pushing them to do the right thing.” She cited her group’s aggressive oppositionto Republicans’ initial efforts to repeal the Affordable Care Act at a time when she said Democratic congressional leaders “didn’t really have a strategy.”
Established liberal groups like the Center for American Progress haven’t always been as forceful, Ms. Dohl said, though she added that the think tank “has gotten better at calling on Democrats to stand up and speak more boldly than they have in the past.”
The think tank, known as CAP, has engendered resentment from others on the left for casting itself as a leader of the anti-Trump movement and raising money off the resistance nomenclature. Within a few weeks of the election, CAP’s sister organization, the Center for American Progress Action Fund, was offering T-shirts emblazoned with the word “Resist” in exchange for donations of $40 or more. The campaign raised about $450,000 for ThinkProgress, the journalism arm of the action fund, which had its lawyers look into trademarking the iconography.
Daniella Leger, a CAP official, explained in a statement that the group’s legal team was merely exploring “a standard question” about whether to trademark the logo. “The immediate response was no — resistance belongs to everyone,” she said.
But the embrace by CAP has some anti-Trump activists complaining privately that the group is anathema to the anti-establishment fervor animating the resistance, and it is siphoning away resources from the new groups.
The divisions have sometimes spilled into public view.
The leader of a group founded by Mr. Sanders called Our Revolution castigated the Democratic establishment as arrogant “dictators” who want to control the “terms of unity” after her group’s activists were met by barricades outside the Washington headquarters of the Democratic National Committee when they visited in July to deliver petitions supporting a liberal policy platform.
And Ms. Hunt-Hendrix has urged progressive donors to boycott Democratic establishment-aligned groups like the centrist think tank Third Way and the nonprofits spearheaded by David Brock, the former conservative journalist who became a leading Clinton supporter and founded Media Matters and the opposition research outfit American Bridge.
Those groups represent a “neoliberal wing of the Democratic Party” that embraces “broken tactics” and an “uninspiring” agenda “more focused on defeating the right than on creating an economy and society that lifts up all people,” Ms. Hunt-Hendrix wrote in an op-ed article this year for Politico.
Matt Bennett, an official at Third Way, challenged predictions that the new wave of resistance activism would substantially shift the axis of the party. “The idea that all the energy in the Democratic Party is on the far left is premature, and is going to turn out to be the worst prediction of the 2020 cycle,” he said.
Mr. Brock and Ms. Leger both said that their groups have been providing research, polling, training and other resources to the new groups, which they cast as a boon to the left, rather than a threat to more established groups.
“The resistance is strongest when everyone has access to our resources,” Mr. Brock said. Ms. Leger said, “These grass-roots groups play a different, unique role, and their energy is something the progressive movement hadn’t seen in decades.” And a D.N.C. spokeswoman, Xochitl Hinojosa, praised the new groups for their work to “bring about progressive change and elect Democrats.”
Yet one major Democratic donor, the Virginia real estate developer Albert J. Dwoskin, said the fluidity in the universe of liberal groups would cause some donors to sit on the sidelines “to wait to see which ones have any legs whatsoever.” And veteran Democratic operatives are concerned that the proliferation could further fracture the left, widening ideological divisions and leaving groups fighting for resources.
That doesn’t bother Dmitri Mehlhorn, a political adviser to Mr. Hoffman, the billionaire founder of LinkedIn, who has brought a venture capital approach to politics, seeding a wide array of new groups on the left.
“The Democratic Party has been fractured,” Mr. Mehlhorn said. “We believe that by investing in different people and groups to try different techniques that good ideas will emerge.”
Among Mr. Hoffman’s donations are at least $1 million each to two of the groups suing Mr. Trump’s campaign, his administration, businesses and associates — United to Protect Democracy, started this year by a former Obama White House lawyer, and Integrity First for America, which will be unveiled later this year by the pioneering New York trial lawyer Roberta A. Kaplan.
A Silicon Valley-like competition between start-ups might not be the best thing for the left right now, warned Rob Stein, a longtime Democratic strategist who helped create the Democracy Alliance to provide structure to the institutional left.
“Having a thousand flowers blooming at the beginning of a new era is generally a good thing,” Mr. Stein said. “But when you’ve got your back against the wall, too many new blooms can cause message and operational cacophony.”
He warned that the combination of ideological and structural divisions, along with a national party weakened by changes in campaign finance laws, could “make it very, very difficult for progressives and Democrats to drive a coherent message in 2018, and to align behind a single candidate in 2020.”

Bill to Rescue Children’s Health Program Hits Snag in House

by Robert Pear - NYT - October 4, 2017

WASHINGTON — Legislation to rescue the Children’s Health Insurance Program sailed through a Senate committee on Wednesday, but touched off a partisan conflict in the House, diminishing hopes that the popular program would be quickly refinanced.
Funding for the program expired on Sunday, and state officials said they would soon start notifying families that children could lose coverage if Congress did not provide additional money. It was impossible to say when Congress might pass a bill and send it to President Trump.
By voice vote, the Senate Finance Committee approved a bill on Wednesday that would provide more than $100 billion over five years for the program, which insures nearly nine million children.
The committee chairman, Senator Orrin G. Hatch, Republican of Utah, hailed the bill as “a prime example of what government can accomplish when both parties work together.” Mr. Hatch wrote the bill with the senior Democrat on the committee, Ron Wyden of Oregon, just as Mr. Hatch helped create the program in 1997 with Senator Edward M. Kennedy, Democrat of Massachusetts.
But in the House Energy and Commerce Committee, lawmakers brawled Wednesday over a similar bill to provide money for the children’s health program. Democrats strongly support the program, but complained that Republicans would take money from Medicare and the Affordable Care Act to offset the cost.
The House committee eventually approved the bill, by a vote of 28 to 23, with all of the opposition coming from Democrats.
One provision of the House Republican bill would require older Americans with income of more than $500,000 a year to pay higher Medicare premiums.
“Folks that earn a half-million dollars a year and are over 65, they can pay a little bit more for Medicare,” said Representative Fred Upton, Republican of Michigan. “And you know what? If they don’t want to pay, they don’t have to enroll. That’s a choice they will have.”
The House bill would also make it easier for states to eliminate Medicaid coverage for some low-income people who hit the jackpot in lotteries. Under current Medicaid rules, income received as a lump sum, such as lottery winnings, is counted as income only in the month when it is received.
This forces taxpayers to bear the cost of providing health care benefits for people who no longer need assistance, Republicans said.
But Democrats said it was outrageous for Republicans to demand such offsets for CHIP while pushing huge tax cuts that could add hundreds of billions of dollars to federal budget deficits.
The Republican CHIP proposals “will likely mean more delay and possibly no action in Congress until the end of the year as part of an omnibus appropriations bill,” said Representative Frank Pallone Jr. of New Jersey, the senior Democrat on the Energy and Commerce Committee.
Time is running short.
Minnesota received an emergency infusion of $3.6 million of federal cash on Monday, and Utah has filed an amendment to its CHIP plan that would allow the state to restrict eligibility or benefits if it runs out of cash. Minnesota and two other states are expected to exhaust their CHIP funds by the end of December, and 27 additional states expect to run out of money by March.
“People are scared, and they have every right to be,” said Representative Joseph P. Kennedy III, Democrat of Massachusetts.
Instead of providing money for CHIP, Mr. Kennedy said, “Republicans have focused solely for months on taking health care from millions of Americans” by trying to repeal the Affordable Care Act.
Representative Ryan A. Costello, Republican of Pennsylvania, said he had heard from constituents fearing that children would lose coverage. But in fact, he said, “every child who was eligible for this program as of a week ago is still in that program today.”
The Senate bill does not specify how the government would pay for extending the children’s health program. Republicans and Democrats are working together and expect to agree on financing before the bill goes to the Senate floor.
High-income Medicare beneficiaries already pay premiums of more than $400 a month. Representative Greg Walden, Republican of Oregon and the chairman of the Energy and Commerce Committee, said the House bill would increase premiums by perhaps $135 a month for people with annual incomes over $500,000.
Representative Jan Schakowsky, Democrat of Illinois, said the proposal was “a first step in eroding a social insurance program, Medicare, that has for many years been in the cross-hairs of the Republican Party.” It would, she said, be much better to save money for Medicare by attacking the “price gouging” of some pharmaceutical companies.
Senator Patrick J. Toomey, Republican of Pennsylvania, was the only senator who criticized the Senate bill, saying it provided more money than states could reasonably be expected to use — “a number that’s wildly in excess of what anyone thinks could plausibly happen.” Some of the money, he said, will be available as “a slush fund” for activities unrelated to health care for children.
“It is completely dishonest budgeting,” Mr. Toomey said. “It is unaccountable. It is meant to circumvent any caps” on spending.
But senators of both parties said that Congress could not wait.
“If you don’t get this addressed in a timely way, you put children at risk,” Mr. Wyden said. “These enrollment freezes and belt tightening and other emergency measures that states have talked to us about — they are not abstractions. They represent very real problems for kids and parents and families that are walking on an economic tightrope.”


States Gird for Worst as Congress Wrestles with Children’s Insurance Program

by Robert Pear - October 3, 2017

WASHINGTON — Federal officials on Monday approved a $3.6 million emergency infusion for Minnesota after the state’s human services chief warned that pregnant women and some children were at imminent risk of losing health care coverage under the Children’s Health Insurance Program.
Utah, meantime, has formally requested authority to “eliminate eligibility and services under CHIP” if the state does not have enough money to continue coverage.
In statehouses around the country, officials are preparing for the worst as lawmakers in Washington struggle to find money for the popular Children’s Health Insurance Program, which insures nearly nine million children but lost its spending authority on Sunday, with the start of the new fiscal year.
Congress has known for two years that federal funds for the Children’s Health Insurance Program were expiring this fall. But only on Wednesday are two congressional panels — the Senate Finance Committee and the House Energy and Commerce Committee — tentatively scheduled to vote on legislation that would provide money for the program for another five years.
And the two chambers have not agreed on how to pay for the measures.
“We know that there is a desire in Congress to provide the funds, but we have heard that same sentiment all through the spring and the summer,” said Nathan Checketts, the deputy director of the Utah Health Department. “Congress needs to get this done as soon as possible, so states do not have to begin notifying people that their coverage may end.”
The Utah program covers 19,000 children.
Most states still have unspent funds that will last several months. But some are drafting contingency plans in case Congress does what it has done so often: fails to reach an agreement. A federal panel that advises Congress on the Children’s Health Insurance Program says that more than half the states are expected to exhaust all their CHIP funds within six months.
By the end of this year, Arizona, Minnesota and North Carolina are likely to run out of money for their programs, according to the panel, the Medicaid and CHIP Payment and Access Commission.
By March 2018, it said, CHIP funds will be exhausted in 27 additional states, including California, Colorado, Connecticut, Florida, Massachusetts, New York, Ohio, Oregon and Pennsylvania. Another 19 states are expected to use up their money from April to June 2018, with one state exhausting its funds from July to September 2018.
Gov. Andrew M. Cuomo of New York, a Democrat, said Tuesday that Congress’s failure to act jeopardized coverage for 330,000 children in the state.
Representative Pete Sessions, Republican of Texas, said the need was “not dire or urgent.” Republicans, he said, intend to provide the funds, so “the money that is necessary to keep this program going is not in jeopardy.”
But Democrats accused Republicans of willful inattention.
“If making sure that every child in America has access to health care, if that is not a priority, what is?” asked Representative Jan Schakowsky, Democrat of Illinois. “Families are waiting anxiously while their health security is hanging in the balance.”
Action in the Senate was delayed for several weeks as Republicans made repeated unsuccessful attempts, in July and September, to pass legislation that would have repealed much of the Affordable Care Act.
CHIP is for children in families that make too much to qualify for Medicaid but not enough to afford other coverage. Nearly 90 percent of children in the program had family incomes less than twice the poverty level (less than about $40,000 a year for a family of three).
Even if congressional committees can agree, it is not clear how soon legislation will emerge from Congress. The Senate plans to be in recess next week, and the House is expected to be in recess in the following week.
The Senate bill is a bipartisan measure, drafted by Senators Orrin G. Hatch, Republican of Utah, and Ron Wyden, Democrat of Oregon. Mr. Hatch, now the chairman of the Finance Committee, helped create the child health program in 1997 and says he is eager to extend it.
In the House, some Democrats have expressed concerns about the bill drafted by House Republicans because, they say, it would pay for continuation of the CHIP program by cutting other health spending. Some House Democrats have suggested offsets that would instead reduce payments to pharmaceutical companies.
Under federal law, states receive annual allotments of federal CHIP funds. They have two years to spend their allotments, and unspent money is then available for redistribution to other states. The money sent to Minnesota this week came from that pool of unspent funds.
The Senate and House bills would each provide a total of $118.5 billion over five years, but under arcane budget rules, Congress needs to offset less than 10 percent of that cost. The Congressional Budget Office assumes that if the program ended, some children would become uninsured, but the federal government would help provide coverage for others, through Medicaid or through private insurance subsidized under the Affordable Care Act.
The federal government and the states have historically shared the cost of CHIP, with Washington paying approximately 70 percent of the cost in a typical state. The Affordable Care Act increased the federal share by 23 percentage points, with the result that the federal government has been paying the entire cost in 11 states.
The Senate and House bills would continue the 23 percentage point bonus in 2018 and 2019, cut it in half in 2020 and eliminate it in 2021 and 2022.

Trump reaches out to Democrats in bid for 'great' health law
by Ken Thomas - LA Times - October 7, 2017
Trying to revive health care talks, President Donald Trump tweeted Saturday that he had spoken to the Senate's Democratic leader to gauge whether the minority party was interested in helping pass "great" health legislation.
The answer back: Democrats are willing to hear his ideas, but scrapping the Obamahealth law is a nonstarter.
Trump's latest overture to Democrats follows GOP failures so far to fulfill their yearslong promise to repeal and replace the Affordable Care Act despite controlling the White House and Congress since January.
The president tweeted that he called New York Sen. Chuck Schumer on Friday to discuss the 2010 law, which Trump said "is badly broken, big premiums. Who knows!" Trump said he wanted "to see if the Dems want to a great HealthCare Bill."
Schumer said through a spokesman Saturday that Trump "wanted to make another run at repeal and replace and I told the president that's off the table." Schumer said if Trump "wants to work together to improve the existing health care system, we Democrats are open to his suggestions."
Trump has suggested before that he would be open to negotiating with Democrats on health care, but there have been no clear signs of a compromise between Republicans who have sought to scrap former President Barack Obama's law and Democrats who want to protect it.
Schumer said a starting point could be negotiations led by Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., who have been discussing a limited bipartisan deal to stabilize state-level markets for individual health insurance policies. People covered under the health law represent about half of those who purchase individual policies.
Trump irritated GOP leaders in Congress when he reached a deal with Schumer and House Minority Leader Nancy Pelosi, D-Calif., on a spending bill and the debt ceiling. The president has referred to those two Democrats as "Chuck and Nancy."
But the Trump administration announced Friday that it would allow more employers to opt out of no-cost birth control to women by claiming religious or moral objections. The move was one more attempt to roll back Obama's health overhaul, prompting Democrats to question whether Trump is committed to avoiding sabotaging the law.
http://www.latimes.com/sns-bc-us--trump-20171007-story.html

Trump Poised to Sign Order Opening New Paths to Health Insurance

by Robert Pear - NYT - October 7, 2017

WASHINGTON — Stymied in his efforts to repeal the Affordable Care Act, President Trump is poised to issue an order that could ease some federal rules governing health insurance and make it easier for people to band together and buy coverage on their own, administration officials said Saturday.
One official said the directive could move the president a step closer to one of his longstanding goals: allowing consumers to buy health insurance across state lines. Conservatives say that interstate sales could expand options for consumers, increase competition in the insurance market and perhaps lower costs.
The order, which the administration officials said was likely to be announced in the coming week, would instruct three cabinet departments to take actions to help individuals and small businesses join together to buy insurance through arrangements known as association health plans. Such plans could be sponsored by trade and professional groups and community organizations.
While the order could exempt association health plans from some federal and state rules that Republicans say drive up costs, the president could not unilaterally change the laws that regulate insurance, such as the Affordable Care Act of 2010 and the Employee Retirement Income Security Act of 1974, the foundation for employee health benefits. But, officials said, he can direct federal agencies to reinterpret key provisions of those laws and to revise rules issued under them.
The plan for the presidential order was first reported by The Wall Street Journal.
Some insurers, including Blue Cross and Blue Shield plans, oppose association health plans, saying they would skim off healthier consumers and leave traditional insurers with sicker, more expensive customers.
The National Association of Insurance Commissioners, representing state regulators, has long opposed association health plans, saying they are bad for consumers because they can operate outside some state consumer-protection laws. In addition, the state regulators said this year in a letter to Congress, proposals to allow such purchasing groups “could actually increase the cost of insurance for many small businesses whose employees are not members of an association health plan.”
But Mr. Trump has presented such plans as a potential solution for millions of Americans. He stated his intentions on Sept. 27 as he left the White House for a trip to Indiana.
“I am considering an executive order on associations, and that will take care of a tremendous number of people with regard to health care,” Mr. Trump said then. “I’ll probably be signing a very major executive order where people can go out, cross state lines, do lots of things, and buy their own health care. And that will be probably signed next week. It’s being finished now. It’s going to cover a lot of territory and a lot of people — millions of people.”
Senator Rand Paul, Republican of Kentucky, said he had been working with the Trump administration to clear the way for association health plans, which he said would allow more people to obtain good coverage at a lower cost.
“The health care debate is not over,” Mr. Paul said. “Conservatives are still fighting for free-market reforms to the health care system. I am excited to be working with President Trump on this initiative.”
“Association plans would let plumbers, carpenters, welders or any type of small business band together to get group health insurance,” Mr. Paul said recently, describing his vision. “Literally any group — your church, the National Rifle Association, the American Civil Liberties Union — any group of people who choose to do so could offer cheaper, better health insurance.”

A Health Care Plan That’s Universal and Bipartisan

by Ed Dolan - NYT - October 9, 2017

After the collapse of Republican efforts at one-party health care reform, many Democrats have embraced Senator Bernie Sanders’s Medicare for All proposal. Few liberals would object to this “single payer” plan if it could be enacted with a magic wand, but the political realities of getting it through Congress are daunting.
Could there be a way to preserve Medicare for All’s simplicity and its guarantee of universal health care access while cutting its cost and increasing its bipartisan appeal?
Universal catastrophic coverage just might be the idea that could bridge the gap. So far, the idea has gotten more attention in conservative circles, but if liberals would give it a careful look, they would find a lot to like.
The basic idea is simple. Everyone would have a policy that covered all medical expenses above a deductible amount. For those with very low incomes, the deductible would be zero. For others, routine health care would not be covered, but they would be protected against the truly unaffordable costs of chronic illnesses and severe accidents. For example, the plan would not cover the cost of a visit to a doctor’s office to make sure a bad cold is not something worse, but it would cover all costs of treatment above the deductible amount if the cold turned out to be lung cancer or a serious case of pneumonia. Ideally, a broad range of health care needs would be covered, including dental and mental health.
One appeal of universal catastrophic coverage to liberals: The annual deductible would be scaled to household income. For example, suppose the deductible is set at 10 percent of the amount by which a family’s income exceeds the Medicaid cutoff, now about $34,000 for a family of four. For a middle-class household with $80,000 in income, the deductible would be $4,600; for a family earning less than $34,000, zero; and for a wealthy family with an income of $1 million, $96,600. For larger families, deductibles could be capped at double the per-person level. The premium would be zero regardless of income.
Although conservative versions of universal catastrophic coverage typically envision coverage by private insurers, subsidized by the government, the policies could just as easily be issued by Medicare. For low-income families, the result would be identical to Senator Sanders’s plan — no premium, no deductible, no gaps in coverage.
For middle-income families, the plan would not provide first-dollar coverage, but it would be much more affordable than plans now offered on the Affordable Care Act exchanges. Today, a 40-year-old pays an average premium of $4,970 for an individual “silver” plan, according to a study by HealthPocket.com, and faces maximum out-of-pocket costs of $6,449. For a family of four, the maximum out-of-pocket cost would be $12,952, and the premium would be higher, too. That is far more than the $4,600 maximum exposure for a family earning $80,000 under the hypothetical universal catastrophic coverage formula outlined above. Subsidies under Obamacare reduce total costs for families with lower incomes, but their costs would be lower under the plan, too.
Of course, a $4,600 deductible is not trivial for a middle-class family. Some families would opt for supplemental insurance, like that now purchased by many Medicare beneficiaries, to cover costs incurred before universal catastrophic coverage kicked in. But premiums for this type of supplemental insurance would be far lower than for policies now sold on A.C.A. exchanges, because maximum claims would be capped at the deductible.
Another feature that should be especially attractive to liberals: universal catastrophic coverage would apply to everyone regardless of work arrangement. Under the current system, workers at large corporations enjoy employer-sponsored insurance, while employees of small businesses or the self-employed typically have to scrape together what coverage they can.
If employers thought it would help them attract good workers, they could offer supplemental coverage to help cover universal catastrophic coverage deductibles — although there would be no tax benefit for doing that instead of just paying higher wages. Ending the tax exclusion for employer-sponsored insurance would save the government about $235 billion per year, which would go a long way toward covering the cost of universal catastrophic coverage.
“But,” some readers may say, “why not go all the way to a single-payer system like they have in Europe?”
Part of the answer is that most health care systems are not, in fact, single payer. European health care systems include some where the governments pay medical bills directly and others where private insurers or nonprofit sickness funds play a role. Some provide first-dollar coverage, while others require deductibles and co-payments. In some countries clinics and hospitals are state-owned; in others they are private or nonprofits.
Even the Sanders plan is not true single-payer, since it allows both patients and providers to opt out if they think they can do better outside the system. Universal catastrophic coverage would bring the United States into the club of nations that provide universal, affordable health care without exactly copying any one system.
More important, what we should be asking is not whether we want single-payer health care but whether single-party health care reform will get us to universal access. The Democrats-only A.C.A. was a step forward, but one with deep technical flaws. Republican-only efforts to repeal and replace the A.C.A., had they been enacted, would have only worsened the problems of high costs and gaps in coverage.
Universal catastrophic coverage has the potential to be a compromise that could appeal to pragmatists in both parties and break the political stalemate.

Can the U.S. Repair Its Health Care While Keeping Its Innovation Edge?

by Aaron Carroll and Austin Frakt - NYT - October 9, 2017

The United States health care system has many problems, but it also promotes more innovation than its counterparts in other nations. That’s why discussions of remaking American health care often raise concerns about threats to innovation.
But this fear is frequently misapplied and misunderstood.
First, let’s acknowledge that the United States is home to an outsize share of global innovation within the health care sector and more broadly. It has more clinical trialsthan any other country. It has the most Nobel laureates in physiology or medicine. It has won more patents. At least one publication ranks it No. 1 in overall scientific innovation.
Strong promotion of innovation in health care is one reason the United States got as far as it did in our recent bracket tournament on the best health system in the world. Though the United States lost to France, 3-2, in the semifinals, it picked up its two votes in part because of its influence on innovation, which can save lives in the United States and throughout the world.
Now we shouldn’t delude ourselves into thinking Americans are inherently more innovative than people in other countries. In fact, many American innovators are immigrants who may or may not be citizens. Many technological and procedural breakthroughs in medicine have occurred in other countries.
Rather, the nation’s innovation advantage arises from a first-class research university system, along with robust intellectual property laws and significant public and private investment in research and development.
Perhaps most important, this country offers a large market in which patients, organizations and government spend a lot on health and companies are able to profit greatly from health care innovation.
The United States health care market, through which over one-sixth of the economy flows, offers investors substantial opportunities. Rational investors will invest in an area if it is more profitable than the next best opportunity.
“The relationship between profits and innovation is clearest in the biopharmaceutical and medical device sectors,” said Craig Garthwaite, a health economist with Northwestern University’s Kellogg School of Management, and one of the judges in our tournament. “In these sectors, firms are able to patent innovations, and we have a good sense of how additional research funds lead to new products.”
High brand-name drug prices, along with generous drug coverage for much of the population, fuel an expectation that large biopharmaceutical research and development investments will pay off. Were American drug prices to fall, or coverage of prescription drugs to retrench, the drug market would shrink and some of those investments would not be made. That’s a potential innovation loss.
This is not mere theory, economists have shown. Daron Acemoglu and Joshua Linn found that as the potential market for a type of drug grows, so do the number of new drugs entering that market. Amy Finkelstein showed that policies that made the market for vaccines more favorable in the late 1980s encouraged 2.5 times more new vaccine clinical trials per year for each affected disease. And Meg Blume-Kohout and Neeraj Sood found that Medicare’s introduction of a drug benefit in 2006 was associated with increases in preclinical testing and clinical trials for drug classes most likely affected by the policy.
Health care innovation can have direct benefits for health, well-being and longevity. A study led by a Harvard economist, David Cutler, showed that life expectancy grew by almost seven years in the second half of the 20th century at a cost of only about $20,000 per year of life gained. The vast majority of gains were because of innovations in the care for high-risk, premature infants and for cardiovascular disease. These technologies are expensive, but other innovation can be cost-reducing. For instance, in the mid-1970s, new dialysis equipment halved treatment time, saving labor costs.
Even with those undeniable improvements, there are questions about the nature of American innovation. Work by Mr. Garthwaite, along with David Dranove and Manuel Hermosilla, showed that although Medicare’s drug benefit spurred drug innovation, there was little evidence that it led to “breakthrough” treatments.
And although high prices do serve as incentive for innovation, other work by Mr. Garthwaite and colleagues suggests that under certain circumstances drug makers can charge more than the value of the innovation.
The high cost of health care, an enormous burden on American consumers, isn’t necessarily a unique feature of our mix of private health insurance and public programs. In principle, we could spend just as much, or more, under any other configuration of health care coverage, including a single-payer program. We spend a great deal right now through the Medicare program — often held out as a model for universal single-payer.
Despite the fact that traditional Medicare is an entirely public insurance program, there’s an enormous market for innovative types of care for older Americans. That’s because we are willing to spend a lot for it, not because of what kind of entity is doing the spending (government vs. private insurers).
In fact, some question whether the innovation incentive offered by the health care market is too strong. Spending less and skipping the marginal innovation is a rational choice. Spending differently to encourage different forms of innovation is another approach.
“We have a health care system with all sorts of perverse incentives, many of which do little good for patients,” said Dr. Ashish Jha, director of the Harvard Global Health Institute and the other expert panelist who favored the U.S. over France, along with Mr. Garthwaite. “If we could orient the system toward measuring and incentivizing meaningfully better health outcomes, we would have more innovations that are worth paying for.”
Naturally, the innovation rewarded by the American health care system doesn’t stay in the U.S. It’s enjoyed worldwide, even though other countries pay a lot less for it. So it’s also reason able to debate whether it’s fair for the United States to be the world’s subsidizer of health care innovation. This is a different debate than whether and how the country’s health care system should be redesigned. We can stifle or stimulate innovation regardless of how we obtain insurance and deliver care.
“We have confused the issue of how we pay for care — market-based, Medicare for all, or something else — with how we spur innovation,” Dr. Jha said. “In doing so, we have made it harder to engage in the far more important debate: how we develop new tests and treatments for our neediest patients in ways that improve lives and don’t bankrupt our nation.”

My child’s depression swallowed her whole. I took the steps to get her help. Then the bills came.

by Suzanne Carver - Bangor Daily News - October 9, 2017

Eighteen months ago, our pre-teen daughter’s depression and anxiety swallowed her whole. We watched her sink deeper and deeper each passing week, powerless to pull her back. Night after night, I lay awake terrified for my daughter’s well-being, her future, her very life.
We had been here before. The year before, she had been in such a bad place that school became impossible, and I began homeschooling her. She started medication and therapy, eventually improving enough to return to school the following year. But, as is so common with these issues, months later she was in darkness once again.
Given my daughter’s acuity this time, her pediatrician referred her to a psychiatrist. I used to work in the mental health field, securing services for patients, and I readied myself to do the same for my daughter. I knew of the staggering lack of pediatric psychiatrists in our rural area. I remembered tearful conversations with parents whose children were in crisis, and there was nothing I could offer them, referring them, as a last resort, to the emergency room at their local hospital.
We got lucky. There was a local clinic where she could be seen in six weeks. It was better than I had feared, but still an eternity for our suffering child.
Intake personnel and our insurance company’s database verified the clinic was in network, and we began treatment. My daughter saw a different psychiatrist each visit (they rotate through, often via telemedicine, to fill the enormous need), restarted weekly therapy sessions and new medications. She slowly improved and began to look like our daughter again.
Then the bills started coming.
Do you know what’s worse than lying in bed replaying the hour you spent holding your sobbing child on the floor and cataloging ways she could harm herself in your house? Lying in bed with all those thoughts, plus the concern of how to pay for the help she so desperately needs.
Each benefit statement from my insurance company was coded the same: out of network, above the usual and customary charge. I was told that the clinic was in network, but the providers she saw, inexplicably, were not.
I have spent the past year fighting these bills, searching in vain for answers to my questions about the proper channels I should have employed to get my daughter care. I filed two appeals with the insurance company, contacted the insurance specialist at the clinic, spoke to the Maine Bureau of Insurance, went in person to have a billing supervisor review our case, and contacted our benefits administrator who appealed on our behalf.
Finally, my insurance company agreed to cover the providers as in network. But the clinic did not have a contract with our insurance company specifically for the providers she saw, so they did not have to accept the contracted rate for those services. They could charge what they wanted and bill us for the remainder.
I was vigilant and involved, every step of the way. I am educated, have good insurance and experience in the field. I advocated for my daughter, did my homework and verified our coverage. If this was the outcome for me, what happens when those suffering from mental illness who don’t have moms who can make 100 phone calls on their behalf need services? How are those more vulnerable, less confident, less knowledgeable or uninsured people supposed to navigate this convoluted maze of referrals and coverage when they should be focusing on getting their loved ones, or themselves, better?
I still don’t know how I could have avoided this bill, how I could have checked on providers whose names I didn’t know until the moment they walked into the treatment room. And, worse, I don’t know what to do differently in the likely event that my daughter needs psychiatric care again.
Most importantly, I look in the now smiling eyes of my daughter and sleep at night knowing she is OK. I would fight for her 100 times over. But must it be this hard? Why can’t providers and insurance companies work as allies with the people they service? This experience has left me questioning the integrity of the field and the intentions of the institutions, the very people I need as my allies on the mental health journey.
Suzanne Carver is a former social worker, and now works as a massage therapist and writer. She lives in Hampden with her family.

Virginia Is for Haters

by Paul Krugman - NYT - October 10, 2017

Why is America the only wealthy nation that doesn’t guarantee essential health care for all? (We’ve made a lot of progress under Obamacare, but not enough, and the Trump administration is doing its best to kill it.) Why do we have much higher poverty than our economic peers, especially among children, and much higher infant mortality despite the sophistication of our medical system?
The answer, of course, comes down to politics: We are uniquely unwilling to take care of our fellow citizens. And behind that political difference lies one overwhelming fact: the legacy of slavery. All too often, white Americans think of the social safety net not as something for people like themselves fallen on hard times, but as a giveaway to Those People.
This isn’t idle speculation. If you want to understand why policies toward the poor are so different at the state level, why some states offer so much less support to troubled families with children, one predictor stands out: the African-American share of the population. The more blacks, the less compassion white voters feel.
The story gets even clearer if you look at the implementation of the Affordable Care Act, which allows states to expand Medicaid coverage at federal expense — that is, to provide health insurance to a large fraction of the population at no cost. You might think that this was a no-brainer, and so far 31 states and the District of Columbia have taken advantage of this opportunity. But only two of those states are among the 11 that seceded in 1861 to form the Confederacy.
Which brings me to Virginia, which is holding crucial state elections in just four weeks.
Until recently, Virginia seemed to be emerging from some of the darker shadows of its history. The state is becoming more ethnically diverse, more culturally open; it is, you might say, becoming more like America. For the “real America” is more than small towns and rural areas; it’s a place of vast variety, unified — or so we like to think — by a shared commitment to universal values of democracy and human rights.
Not accidentally, Virginia has also become politically more like America, at least in national elections: Like the electorate as a whole, it supported the Democratic presidential candidate in the last three elections.
But is Virginia’s apparent moral progress an illusion? And if it is, what does that say about America as a whole?
Virginia was, of course, the site of the infamous Charlottesville march by torch-carrying white supremacists — “very fine people,” according to Donald Trump — that ended with the death of a counterprotester. More important, perhaps, is the fact that despite its growing political moderation and its Democratic governor, Virginia is among the states still refusing to expand Medicaid, even though that refusal means gratuitous financial hardship for many and a significant number of people dying from lack of medical care.
How is this possible? Democratic-leaning voters are much less likely than Republican-leaning voters to cast ballots in state and local elections; as a result, a politically moderate state has a hard-right legislature. And there’s a real possibility that it may soon have a Republican governor, too.
Here’s how that might happen: Ed Gillespie, the G.O.P. candidate, is trying to pull off an upset by going full-on Trumpist, doing all he can — with assistance from the tweeter in chief — to mobilize the white nationalist vote. He’s accusing Ralph Northam, his Democratic opponent, of dishonoring the state’s Confederate heroes. (Funny how people who accuse their rivals of being unpatriotic worship men who engaged in armed rebellion against the United States.) He’s not only accused Northam of being soft on illegal immigration, but he’s insinuated that this somehow makes him an ally of a violent Central American gang.
These cynical ploys probably won’t change many minds in a state that disapproves strongly of Trump and all his works. But they might mobilize enough angry white voters to swing the election if Democrats don’t come out in equal force.
Whatever happens in Virginia, the consequences will be huge. If Gillespie pulls this off, all the worst impulses of the Trumpist G.O.P. will be empowered; you might think that things can’t get even worse, but yes, they can.
If, on the other hand, Northam wins and Democrats make big inroads in the state legislature, it won’t just probably mean that hundreds of thousands of Virginians will get health insurance, and it won’t just be an omen for the 2018 midterms. It will also encourage at least some sane Republicans to break with a man they privately fear and despise (see Corker, Bob).
For whatever reason, however, Virginia isn’t getting nearly as much play in national media or, as far as I can tell, among progressive activists, as it deserves.
Folks, right now this is where the action is: Virginia is now the most important place on the U.S. political landscape — and what happens there could decide the fate of the nation.

Steep Premiums Challenge People Who Buy Health Insurance Without Subsidies

by Julie Rovner - Kaiser Health News - October 7, 2017

Paul Melquist of St. Paul, Minn., has a message for the people who wrote the Affordable Care Act: "Quit wrecking my health care."
Teri Goodrich of Raleigh, N.C., agrees. "We're getting slammed. We didn't budget for this," she says.
Millions of people have gained health insurance because of the federal health law. Millions more have seen their existing coverage improved.
But one slice of the population, which includes Melquist and Goodrich, is unquestionably worse off. They are healthy people who buy their own coverage but earn too much to qualify for help paying their premiums. And the premium hikes that are being announced as enrollment looms for next year — in some states, increases topping 50 percent — will make their situations more miserable.
Exactly how big is this group? According to Mark Farrah Associates, a health care analysis firm, as of 2017, there were 17.6 million people in the individual market, 5.4 million of whom bought policies outside the health exchanges, where premium help is not available. Combine that with the percentage of people who bought insurance on the exchanges but earned too much (more than four times the federal poverty level, or about $48,000 for an individual) to get premium subsidies, and the estimate is 7.5 million, or 43 percent of the total individual market purchasers, according to insurance industry consultant Robert Laszewski.
Who are these people?
"They're early retirees," says Laszewski. "They're people working part time who have substantial outside income. They're people who are self-employed of any age, people who are small employers."
Melquist is one of those early retirees. He and his wife are both 59. He worked in the defense industry and retired at the end of 2016.
He always planned to retire at age 55 but ended up working longer, in part because he knew health insurance costs were rising. When he did retire and sought to purchase coverage for himself and his wife, he says, "I was shocked to find out how bad it actually was."
For a bronze-level plan with a health savings account, Melquist says, "we pay $15,000 a year [in premiums] and the first $6,550 [for health care expenses] for each of us comes out of our pocket. So basically you could be looking at $30,000 out of pocket before anything gets covered."
Insurance is important, Melquist says, particularly if a catastrophic health issue were to hit either of him or his wife. In the meantime, he can still pay the bills. But he's frustrated. "I'm not eating dog food, but I'm also not able to do stuff for my grandchildren," he says, like help with college costs. "It's not that my life is falling apart, but the [Affordable Care Act] has ruined a lot of things I'd like to have done."
The good news, if there is any, for Melquist is that premiums in Minnesota are going up by only small amounts for 2018, and in some cases going down, because of a reinsurance program passed by the state legislature that will help cover the costs for some of the state's sickest patients in the individual market. That move will help keep premiums from spiking even more.
But that won't be the case in Raleigh, where Goodrich and her husband, John Kistle, work as private consultants in the energy industry.
Goodrich, 59, and Kistle, 57, bought insurance through the ACA exchange in their state for three years. When premiums reached $1,600 per month with deductibles of $7,500 each, however, "it was just unbelievable. We decided just not to get insurance," Goodrich says.
Eventually, they bought short-term plans that cover only catastrophic illness or injury. That insurance is not considered adequate under the ACA, so the couple could be liable for a tax penalty as well.
Goodrich, who volunteers to help people with their taxes in her spare time, says she has run the numbers and thinks that insurance is so expensive where she lives that the couple will be exempt from the penalty. That is because the cheapest insurance would cost the couple more than 8.16 percent of their income. Under the health law's provisions, the penalty doesn't apply above that level because insurance is considered unaffordable.
"We try to be good citizens and do the right thing," she says. "Next year, we're trying to figure out how to make less than $64,000 so we can get subsidies." That amount is equal to 400 percent of the federal poverty line for two people, the cutoff for premium assistance because Congress assumed those who earned more could afford to buy affordable coverage.
Sabrina Corlette, a research professor at Georgetown University who specializes in health insurance, agreed that this is a population "that faced big hikes" in premiums when the health law took effect.
But, she says, in many cases, people in the individual market were previously paying artificially low premiums. Some of those old policies had substandard coverage. For others, however, the higher prices are the result of one of the fundamental changes enacted by the health law. "These are folks who were benefiting from a system that was affordable solely because insurers were able to keep sick people out," Corlette says, adding that they are now being asked "to pay more of the true cost of health care."
This is a population that is also more likely to vote Republican, says Laszewski, "which is one of the grand ironies now."
Republicans in Congress and President Trump haven't been able to "repeal and replace" the health law. But some of their efforts are undermining it — primarily the administration's threat to stop paying billions of dollars to insurers in subsidies to help some lower-income people pay their out-of-pocket costs. The uncertainty surrounding those subsidies has led insurers to boost premiums next year by an estimated 20 percent. Those who get premium help from the government won't have to pay more. But those who are paying the full freight will.
Also driving up premiums for next year, says Corlette, are the administration's threats not to enforce the individual requirement for insurance and its decision to cancel most advertising and outreach for the year's open-enrollment period that begins Nov. 1. Both of those provisions bring more healthy people into the insurance pool to help spread costs.
"One could argue that the 2014 premium increases were painful, but it was about getting us to a system that was more fundamentally fair and just," Corlette says. "Now, it's completely unnecessary price increases for unsubsidized folks that could so easily be avoided by a rational political system."
Kaiser Health News, a nonprofit health newsroom, is an editorially independent part of the Kaiser Family Foundation. Follow Julie Rovner on Twitter: @jrovner


New Law Challenges ‘Evils’ Of Pharma Profits, California Governor Claims

by April Dembosky - Kaiser Health News - October 9, 2017

California Gov. Jerry Brown defied the drug industry Monday by signing a sweeping drug price transparency bill that will force drugmakers to publicly justify big price hikes.
“Californians have a right to know why their medical costs are out of control, especially when pharmaceutical profits are soaring,” Brown said. “This measure is a step at bringing transparency, truth, exposure to a very important part of our lives. That is the cost of prescription drugs.”
The new law will require drug companies to give 60 days’ notice to state agencies and health insurers anytime they plan to raise the price of a drug by 16 percent or more over two years on drugs with a wholesale cost of $40 or higher. They must also explain why the increases are necessary.
The advance notification provisions take effect Jan. 1, while the other reporting requirements don’t kick in until 2019.
Brown said the bill is part of a larger effort to correct growing income inequality in the United States.
He called on top pharmaceutical leaders to consider doing business in a way that helps Americans who are spending large sums of money for lifesaving medications.
“The rich are getting richer. The powerful are getting more powerful,” he said. “We’ve got to point to the evils, and there’s a real evil when so many people are suffering so much from rising drug profits.”
The drug lobby fiercely opposed the bill, SB 17, spending $16.8 million on lobbying from January 2015 through the first half of this year to kill an array of drug legislation in California, according to data from the secretary of state’s office. For the pricing bill alone, the industry hired 45 lobbyists or firms to fight it.
The bill drew support from a diverse coalition, including labor and consumer groups, the hospital industry and even health insurers, who agreed to share some of their own data. Under the new law, they will have to report what percentage of premium increases is related to drug prices.
“Health coverage premiums directly reflect the cost of providing medical care, and prescription drug prices have become one of the main factors driving up these costs,” said Charles Bacchi, CEO of the California Association of Health Plans. “SB 17 will help us understand why, so we can prepare for and address the unrelenting price increases.”
Drug companies criticized the governor’s move, saying the new law focuses too narrowly on one part of the drug distribution chain — and ultimately won’t help consumers afford their medicine.
“There is no evidence that SB 17 will lower drug costs for patients because it does not shed light on the large rebates and discounts insurance companies and pharmacy benefit managers are receiving that are not always being passed on to patients,” said Priscilla VanderVeer, spokeswoman for the Pharmaceutical Research and Manufacturers of America.
Indeed, some experts have said transparency alone is not enough to bring down drug prices, and that California’s law may lack the muscle being applied in other states to directly hold drug prices down.
This year, at least two states have passed laws that may have a more immediate effect on consumer costs than the California measure. Maryland and New York, for example, adopted bills that use a variety of legal levers to impose financial penalties or require discounts if prices are too high.
But other policy experts argue that California’s law is part of a broader campaign to adopt stronger drug price measures across the country. So it makes sense to start with the source of the drug prices: the drugmakers themselves, said Gerard Anderson, a health policy professor at Johns Hopkins Bloomberg School of Public Health who tracks drug legislation in the states.
“The manufacturers get most of the money — probably about three-quarters or more of the money that you pay for a drug, and they’re the ones that set the price initially,” he said. “So they are not the only piece of the drug supply chain, but they are the key piece to this.”




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