The Effects of Household Medical Expenditures on Income Inequality in the United States
by Andrea Christopher, David U. Himmelstein, Steffie Woolhandler and Danny McCormack - American Journal of Public Health - January 18, 2018
Objectives. To assess the effect of households’ outlays for medical expenditures on income inequality and changes since the implementation of the Affordable Care Act (ACA).
Methods. We analyzed data from the US Current Population Surveys for calendar years 2010 through 2014. We calculated the Gini index of income inequality before and after subtracting households’ medical outlays (including insurance premiums and out-of-pocket costs) from income, the financial burden of medical outlays for each income decile, and the number of individuals pushed below poverty by medical outlays.
Results. In 2014, the Gini index was 47.84, which rose to 49.21 after medical outlays were subtracted, indicating that medical outlays effectively redistributed about 1.37% of total income from poorer to richer individuals, a slightly smaller redistribution compared with the years before the ACA. Medical outlays reduced the median income of the poorest decile by 47.6% versus 2.7% for the wealthiest decile and pushed 7.013 million individuals into poverty.
Conclusions. The way we finance medical care exacerbates income inequality and impoverishes millions of Americans. This regressive financing pattern improved minimally in the wake of the ACA. (Am J Public Health. Published online ahead of print January 18, 2018: e1–e4. doi:10.2105/AJPH.2017.304213)
Britain’s N.H.S. in Crisis: ‘We Might Break’
Opinion - NYT - January 16, 2018
LONDON — Britain’s National Health Service, put in place by the country’s post-World War II Labour government, holds a unique place in the country’s psyche as both source of constant frustration, object of affection and — somehow — a central pillar of arguments both to leave and remain in the European Union. In a country riven over Brexit, at least most people can agree on the importance of the N.H.S.
What its future should be is less clear.
The N.H.S. suffered from staff shortages and tight budgets long before Brexit, but in the year following the referendum almost 10,000 nurses quit. In November, Simon Stevens, the chief executive of the service in England, said that after seven years of budget constraints “the N.H.S. can no longer do everything that is being asked of it.”
Amid a flu outbreak, colder weather and the continuing shortages of beds and staff this winter, some hospitals declared “black alerts,” meaning they were unable to deliver comprehensive care. Nonurgent surgeries were postponed and patients waited more than 12 hours in emergency wards before being tended to — undergraduate medical students were reportedly asked to volunteer to ease some of the strain.
In early January, Prime Minister Theresa May was asked if the service was in crisis, and responded that it was better prepared for winter than “ever before.”
In interviews over the last few months, we asked N.H.S. staff to describe what it’s like to work for the service now, and what they hope and fear for its future.
According to the staff we spoke to, the N.H.S. has come to a decisive moment: Is there still the political will and public support for universal health care in Britain? Or is a privatized system, similar to the United States, its future?
People aren’t getting the care they need
“Even until very recently, very few people opted out of the N.H.S. It was considered completely for everybody, really good quality, service and something that people could actually trust; you knew if you went through the N.H.S. system, you would get safe, good health care.
I think that’s starting to change, and people are starting to worry about whether that’s still the case.
Time and time again people said they voted for Brexit because they thought it would give more money to the N.H.S. and that was very quickly retracted from the Brexit campaigners the minute Brexit came through.
People are very, very angry that they felt that they were voting for more money for their National Health Service, and that’s not been happening.” — Francesca Silman
I want to fight to keep it
“I think it’s the best health care system in the world. And I want to fight to keep it that way. I think we should be spending more, in order to keep it equitable and make sure that everyone can get — make sure that everyone has freedom from fear, essentially. Because that’s what illness is. That’s what sickness and illness is. And if you don’t have insurance in America, you live in fear every single day for your life, for your family’s life, and that’s not a situation we ever want to get into. Anything that is a road to that situation I think we have to stop.
When you’ve had that idea that actually you can see the direction of travel, and it might not be there in the future, if things continue in the same way, that is absolutely terrifying.” — Ben White
If I was younger, I would have left
“More and more European nurses, more and more European doctors are leaving. And we don’t have new recruits coming. That’s what’s happening at the moment. And for example, one thing to happen in my hospital is that our numbers of nurses have declined, and we had one choice: We had to decide to put more patients for each nurse or to shut one ward. At the moment, we have decided to not compromise the quality and we have closed one ward.
If I was 10 years younger, I probably would have packed and left. Not because the hospital itself is not supporting me, it’s because it’s what the government is doing with the conditions, and the way that they make us feel unwelcome, and the uncertainty. It’s been nearly 550 days from Brexit, and I still don’t know what my rights look like.” — Joan Pons Laplana
This is not an affordability question
“I know of nurses who are on food banks. I know of nurses who can’t afford a house in London and stay in their car. And that’s wrong. These are hard-working people, who are putting everything that they can to serve and do something useful. They are working people and they shouldn’t be in a state where they cannot afford basic needs of life.
This is what my worry is. The whole N.H.S. is being made to deliberately fail. So that private entities can be put in to place. Fifteen years back, I can’t think of something private in the N.H.S. except maybe a coffee shop in the front. Now, parking is managed privately, cleaning is managed privately, kitchens are managed privately, hospital and estates and everything else are privately managed.” — Vikas Tripurneni
The N.H.S. is a thing that a lot of people aren’t going to appreciate until it’s gone
“After the Brexit vote, a lot of workers feel unwelcome.
They come here because they really admire the N.H.S. They’re slogging their guts out and they don’t even feel welcome.
We’ve reached the point where we’re not able to give more any more. People cannot give any more, and that’s what we’re starting to see.
I’ve never known anything other than the N.H.S., so for me the concept of becoming a doctor was never about money. I don’t know what it’s like in other countries, but here you don’t do it for the money, it’s a public service.
When you have grown up here and you’ve never known anything but the N.H.S., it’s easy to take it for granted. It never entered my mind that if I lived anywhere else, it wouldn’t be like this.” — Nadia Masood
We might break
“If we see a significant decline in nursing staff, in doctors, there’s no way we’re going to keep offering the services that we are at the moment.
We’re already working up to our eyeballs. I don’t think we can.
Personally, I do not have a British passport. I’ve got a German passport. I’m married to a British man, so of course I could easily get a British passport, but I thought it was never necessary. So when Brexit came about, the referendum and then all the talks, it made me physically sick.” — Michaela Scheuermann-Freestone
We don’t look at where people come from
“I mean, we provide care to people without looking at where they come from, and I think that’s something we need to preserve. And it’s sad to see that many people think that that might not be the case in a few years.
I think there are a lot of students who are reconsidering their future in medicine. Or thinking about alternative careers, or where they can go that’s not directly linked with clinical work. Because it just seems so, so pressured.” — Mita Dhullipala
https://www.nytimes.com/2018/01/16/opinion/nhs-britain-crisis.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-right-region®ion=opinion-c-col-right-region&WT.nav=opinion-c-col-right-region
Editor's Note:
The preceding article, while alarming, reminds us of the hazards of allowing the health care system become subject to the winds of politics in a system where some are able to buy into private health insurance for their basic needs. In interpreting its meaning for the United States, we must bear in mind that per-capita spending on health care in Great Britain is roughly 40% that in the United States. The UK has one of the lowest levels of spending as a percent of the GDP among all OECD countries, While the British NHS covers all British residents, it also (unlike Canada) permits a robust private system to co-exist alongside the universal public system for those able to afford to access it.
-SPC
Making Medicaid a Tool for Moral Education May Let Some Die
by Eduardo Porter - NYT - January 16, 2018
Apparently the plan to Make America Great Again will let some Americans die.
Kentucky rushed last week to become the first of the nation’s 50 states to impose a work requirement on recipients of Medicaid. Under the state’s HEALTH plan, most able-bodied 19-to-64-year-olds — excluding the pregnant, the medically frail and some others — will have to work, get job training or perform community service for at least 20 hours a week to qualify for coverage, starting in July.
They will have to pay for it, too — a premium starting at $1 per month for families living on up to one-quarter of the federal poverty line, or about $400 a month for a family of three (such families exist, apparently) and rising to $15 for those who manage to stay above the poverty threshold.
The initiative is, of course, not about saving the state money by pushing poor people off the insurance rolls. It is providing moral education. In the words of Gov. Matt Bevin, the HEALTH plan will free Kentuckians from the “dead-end entitlement trap” and give them “a path forward and upward” so they can fend for themselves.
But the fact remains that the plan is expected to reduce Medicaid spending by $2.4 billion over five years. Roughly half of the 350,000 able-bodied Medicaid beneficiaries in Kentucky currently do not meet the work requirements, by the government’s estimates, and could lose their benefits. Five years from now, the Bevin administration calculates, the change will have culled some 100,000 people from the rolls.
Kentucky won’t be the last. Arizona, Arkansas, Indiana, Kansas, Maine, New Hampshire, North Carolina, Utah and Wisconsin have already submitted their own similar proposals. Barring legal challenges, the Trump administration is eager to let them do it. Millions of Americans stand at risk of losing their health care. Many — the most fragile, the least great — could die as a result.
Mr. Bevin might care to glance south over the border. In 2005, Tennessee removed 170,000 people — almost one in 10 Medicaid beneficiaries in the state, mainly working-age adults without children — from its Medicaid program to save money. They didn’t do well.
The cuts didn’t just eat into poor Tennesseans’ finances. One study found that childless adults in Tennessee — especially the least educated — started delaying or forgoing visits to the doctor. They reported suffering more days in bad health and incapacitated. And they recorded more visits to hospital emergency rooms, which are required by law to care for all comers, regardless of their ability to pay.
Delayed care can kill. Breast cancer is the second-leading cause of cancer death among women. One of eight American women will get it. Detecting it early is critical. Specifically, the five-year relative survival rate for localized breast cancer is 98.5 percent when detected early, but only 25 percent when detected at a distant stage. Waiting for 60 days or longer to get treatment raises the risk of dying of breast cancer over five years by 85 percent.
Another study from Tennessee found that losing access to Medicaid led to delays in diagnosis, so more breast cancers were caught at a later stage. Women who lived in low-income ZIP codes were 3.3 percentage points more likely to receive a diagnosis of late-stage cancer than women living in high-income ZIP codes.
“We are ready to show America how this can and will be done,” Mr. Bevin said at a news conference in Frankfort. And yet Kentucky’s approach to Medicaid draws from a well-worn playbook, one from which both Republicans and Democrats have drawn to trim the social safety net over the years.
Kentucky was an eager participant in the last big so-called entitlement reform, visited upon the nation’s poor just over two decades ago. Under that 1996 program directed at welfare benefits, the entitlement to federal assistance was replaced by a hodgepodge of programs managed by the states and financed by a fixed dollop of federal cash. Work requirements became the norm. And people got less help.
The number of families in poverty in Kentucky has budged little since then, declining to 116,000 from 132,000. But the number of families getting cash assistance has fallen by two-thirds. Today, the Temporary Assistance for Needy Families program covers only one of five poor families in the state. For a single mother with two children, it provides $262 a month — a third less than it did two decades ago, adjusted for inflation.
And Kentucky is hardly the stingiest state. In 15 states, antipoverty cash benefits reach fewer than 10 percent of the families with children in poverty. In all of them, the change was sold as a way to encourage poor Americans to get off their backsides, get a job and prosper on their own — free of the clutches of the welfare state. Yet though it pushed many poor families into employment, it failed at mitigating their distress: Rarely do such families’ breadwinners earn enough to move out of poverty.
The problem with the latest twist in Republicans’ effort to pare the social safety net is that removing the poor’s health insurance may not just make their life more difficult.
It might kill them.
It is well known by now that health insurance saves lives. A review of recent researchin the Annals of Internal Medicine concluded that the odds of dying for non-elderly adults are between 3 and 41 percent higher for the uninsured than for the insured.
Work by Katherine Baicker, now at the University of Chicago, with Benjamin Sommers and Arnold Epstein at Harvard found that Medicaid expansions in the past significantly reduced mortality. Their research, they concluded, “suggests that 176 additional adults would need to be covered by Medicaid in order to prevent one death per year.”
It doesn’t take a leap of imagination to figure out what might happen if 100,000 people were to lose their coverage.
As Lawrence H. Summers, once President Barack Obama’s top economic adviser, noted about the Republican tax cut passed in December, thousands would die if the tax bill were to cut the health insurance of 13 million people, as the nonpartisan Congressional Budget Office has estimated.
These would be mostly lower-income Americans. Maybe they would be people from Kentucky — the state with the most cancer deaths and the most preventable hospitalizations, 45th out of 50 in the incidence of diabetes and 47th in terms of heart disease.
Would their deaths cause America to be greater?
Home Care Agencies Often Wrongly Deny Medicare Help To The Chronically Ill
by Susan Jaffe - NPR - January 17, 2018
Colin Campbell needs help dressing, bathing and moving between his bed and his wheelchair. He has a feeding tube because his partially paralyzed tongue makes swallowing "almost impossible," he says.
Campbell, 58, spends $4,000 a month on home health care services so he can continue to live in his home just outside Los Angeles. Eight years ago, he was diagnosed with amyotrophic lateral sclerosis, or "Lou Gehrig's disease," which relentlessly attacks the nerve cells in his brain and spinal cord and has no cure.
Because of his disability, he has Medicare coverage, but he can't use it for home care — as the former computer systems manager has been told by 14 home health care providers.
That's an incorrect but common belief. Medicare does cover home care services for patients who qualify but, according to advocates for seniors and the homecare industry, incentives intended to combat fraud and reward high quality care are driving some home health agencies to avoid taking on long-term patients, such as Campbell, who have debilitating conditions that won't get better. Rule changes that took effect this month could make the problem worse.
"We feel Medicare coverage laws are not being enforced and people are not getting the care that they need in order to stay in their homes," says Kathleen Holt, an attorney and associate director of the Center for Medicare Advocacy, a nonprofit, nonpartisan law firm. The group is considering legal action against the government.
Federal law requires Medicare to pay indefinitely for home care — with no copayments or deductibles — if a doctor ordered it and patients can leave home only with great difficulty. They must need intermittent nursing, physical therapy or other skilled care that only a trained professional can provide. They do not need to show improvement.
Those who qualify can also receive an aide's help with dressing, bathing and other daily activities. The combined services are limited to 35 hours a week.
Medicare affirmed this policy in 2013 when it settled a key lawsuit brought by the Center for Medicare Advocacy and Vermont Legal Aid. In that case, the government agreed that Medicare covers skilled nursing and therapy services — including those delivered at home —to maintain a patient's abilities or to prevent or slow decline. It also agreed to inform providers, those who audit bills, and others that a patient's improvement is not a condition for coverage.
Federal law requires Medicare to pay indefinitely for home care — with no copayments or deductibles — if a doctor ordered it and patients can leave home only with great difficulty. They must need intermittent nursing, physical therapy or other skilled care that only a trained professional can provide. They do not need to show improvement.
Those who qualify can also receive an aide's help with dressing, bathing and other daily activities. The combined services are limited to 35 hours a week.
Medicare affirmed this policy in 2013 when it settled a key lawsuit brought by the Center for Medicare Advocacy and Vermont Legal Aid. In that case, the government agreed that Medicare covers skilled nursing and therapy services — including those delivered at home —to maintain a patient's abilities or to prevent or slow decline. It also agreed to inform providers, those who audit bills, and others that a patient's improvement is not a condition for coverage.
Campbell says some home health care agencies told him Medicare would pay only for rehabilitation, "with the idea of getting you better and then leaving," he says. They told him that Medicare would not pay them if he didn't improve, he says. Other agencies told him Medicare simply did not cover home health care.
Medicaid, the federal-state program for low-income adults and families, also covers home health care and other home services, but Campbell doesn't qualify for Medicaid.
Securing Medicare coverage for home health services requires persistence, says John Gillespie, whose mother has gone through five home care agencies since she was diagnosed with ALS in 2014. He successfully appealed Medicare's decision denying coverage, and afterward Medicare paid for his mother's visiting nurse as well as speech and physical therapy.
"You have to have a good doctor and people who will help fight for you to get the right company," says Gillespie, of Orlando, Fla. "Do not take no for an answer."
Yet a Medicare official did not acknowledge any access problems. "A patient can continue to receive Medicare home health services as long as he/she remains eligible for the benefit," says spokesman Johnathan Monroe.
But a leading industry group contends that Medicare's home health care policies are often misconstrued. "One of the myths in Medicare is that chronically ill individuals are not qualified for coverage," says William Dombi, president of the National Association for Home Care and Hospice, which represents nearly half of the nation's 12,000 home care providers.
Part of the problem is that some agencies fear they won't be paid if they take on patients who need their services for a long time, Dombi says. Such cases can attract the attention of Medicare auditors who can deny payments if they believe the patient is not eligible, or they suspect billing fraud. Rather than risk not getting paid, some home health agencies "stay under the radar" by taking on fewer Medicare patients who need long-term care, Dombi says.
And those companies may have a good reason to be concerned. Medicare officials have found that about a third of the agency's payments to home health firms in the fiscal year ending last September were improper.
Shortages of home health aides in some areas might also lead an overburdened agency to focus on those who need care for only a short time, Dombi says.
Another factor that may have a negative effect on chronically ill patients is Medicare's Home Health Compare ratings website. It includes grades on patient improvement, such as whether a client got better at walking with an agency's help. That effectively tells agencies who want top ratings "to go to patients who are susceptible to improvement," Dombi says.
This year, some home care agencies will earn more than just ratings. Under a Medicare pilot program, home health firms in nine states will start receiving payment bonuses for providing good care and those who don't will pay penalties. Some criteria used to measure performance depend on patient improvement, Holt says.
Another new rule, which took effect last Saturday, prohibits agencies from discontinuing services for Medicare and Medicaid patients without a doctor's order. But that, too, could backfire.
"This is good," Holt says. "But our concern is that some agencies might hesitate to take patients if they don't think they can easily discharge them."
G.O.P. to Use Children’s Health Insurance as Lure for Averting Shutdown
by Thomas Kaplan and Robert Pear - NYT - January 16, 2018
WASHINGTON — With little hope of an immigration agreement this week, Republicans in Congress are looking to head off a government shutdown this weekend by pairing another stopgap spending measure with long-term funding for the popular Children’s Health Insurance Program, daring Democrats to vote no.
The bill would leave in limbo hundreds of thousands of young immigrants brought to the country illegally as children. But Democrats would still be left with a difficult political decision: withhold their votes unless the plight of such immigrants, known as Dreamers, is addressed and risk a government shutdown, or vote to keep the government open and fund the Children’s Health Insurance Program, which provides coverage for nearly nine million children.
The bill would set up another possible showdown in mid-February, with government funding set to expire Feb. 16. But it would give lawmakers time to continue negotiations on immigration and long-term government funding levels.
“With no imminent deadline on immigration and with bipartisan talks well underway, there is no reason why Congress should hold government funding hostage over the issue of illegal immigration,” Senator Mitch McConnell, Republican of Kentucky and the majority leader, said on Tuesday.
The plan, put forth by House Republicans on Tuesday, does not extinguish the suspense on Capitol Hill this week. House Republican leaders may be unable to secure passage of the bill with solely Republican votes, since Republicans eager to increase military spending have been frustrated with stopgap spending measures.
“This is just buying time,” said Representative Mark Sanford, Republican of South Carolina. “I think it’s the best of the available bad choices.”
House Democrats, most of whom voted against the last stopgap measure in December, are not likely to embrace this bill either, given the impasse on immigration — especially after President Trump was said to have made vulgar remarks in a meeting on immigration last week.
The drama over immigration continued to play out Tuesday in a hearing of the Senate Judiciary Committee, where Democrats castigated the homeland security secretary, Kirstjen Nielsen, for refusing to confirm Mr. Trump’s vulgarity. At one point, Senator Richard J. Durbin of Illinois, the No. 2 Democrat, had young undocumented immigrants protected by the Obama-era program known as Deferred Action for Childhood Arrivals, or DACA, stand in the hearing room as he recited their impressive résumés.
In the meantime, Dreamers and those who support them protested at Republican lawmakers’ offices.
“We want to keep the government open,” Representative Steny H. Hoyer of Maryland, the Democratic whip, said on Tuesday. “But we’re not going to be held hostage to do things that we think are contrary to the best interests of the American people.”
If Republican leaders can push the bill through the House this week, the Senate — where at least nine Democratic votes will be needed — is no sure bet. Some Democrats in that chamber — especially those considering a White House run — are expected to oppose any spending measure that does not protect the young undocumented immigrants.
But Democrats up for re-election this year may be reluctant to oppose the bill and risk being blamed for a shutdown.
Mr. Trump moved in September to end DACA but gave Congress until early March to come up with a legislative replacement. Last week, a federal judge ruled that, for now, the administration could not end the program, and the government has now resumed accepting renewal requests for it.
As a result, Senator Tom Cotton, Republican of Arkansas, argued on Tuesday that there was “no urgency right now to try to ram through a major change in immigration law by Friday.”
Mr. McConnell said lawmakers have “at least until March, at a minimum, and possibly even longer” to reach a DACA agreement.
In the bill to be passed this week to avoid a shutdown, Republicans would also suspend a tax imposed by the Affordable Care Act on medical devices, as well as a tax on providers of health insurance. In addition, it would delay the law’s tax on high-cost employer-sponsored health coverage, known as the Cadillac tax.
Having dithered for months, Congress has suddenly discovered a painless, cost-free way to extend the Children’s Health Insurance Program, or CHIP. The bill would extend the program’s funding for six years.
“I cannot see the Democrats voting against the Children’s Health Insurance Program,” said Representative Mo Brooks, Republican of Alabama, “but they’ll be given that option in this funding bill.”
Lawmakers were able to break a partisan deadlock on the program, started under President Bill Clinton, after they received a new estimate from the Congressional Budget Office showing that the cost would shrink over time and that extending the program for eight to 10 years could actually save money.
Members of Congress responsible for the program said the new estimate should clear the way for a swift renewal of the program.
The solution results almost entirely from a curious quirk in the way costs are estimated by the Congressional Budget Office — and from the unforeseen consequences of Congress’s decision to eliminate a pillar of the Affordable Care Act, the penalties for people who go without health insurance.
“Thanks to the repeal of the individual mandate tax, C.B.O. updated its score and gave us the momentum to push a long-term CHIP extension across the finish line,” said Senator Orrin G. Hatch, Republican of Utah and the chairman of the Finance Committee. “We must stop holding CHIP hostage.”
Funds for the program lapsed at the end of September. Congress provided a short-term infusion of money last month, and the Trump administration has shuffled money among states to help those with the most urgent needs. Nevertheless, some states have informed families that their children could lose coverage because of delays and inaction by Congress.
Extending CHIP for six years “may have no cost” to the federal government, said Representative Greg Walden, Republican of Oregon and the chairman of the House Energy and Commerce Committee.
Senator Ron Wyden of Oregon, the senior Democrat on the Finance Committee, said that extending the program for 10 years would save $6 billion, according to the budget office. “With this news,” he said, “securing kids’ health care for the long-term should be a no-brainer.”
The Children’s Health Insurance Program, created in 1997 with bipartisan support, is given credit for a big increase in the proportion of children who have coverage. But Republicans and Democrats have squabbled for months over how to pay for it.
In the tax bill signed last month by Mr. Trump, Congress eliminated the penalties for people who go without health insurance, starting in 2019. The Congressional Budget Office, like many health policy experts, believes that healthier people will be less likely to obtain insurance, so that people who remain in the health law’s marketplace — including children — will face higher premiums than they otherwise would.
Extending CHIP saves money, the budget office said, because it would be less expensive for the government than the alternatives — if many of those children enroll in Medicaid or in government-subsidized marketplace coverage.
The taxes on medical devices, health insurance providers and high-cost employer-sponsored health plans were all imposed by the Affordable Care Act, to help pay for the expansion of coverage under the law. All three would have been repealed under the bill passed last year by the House to dismantle that law.
Many Democrats have joined Republicans in opposing the device tax, which they describe as a threat to innovative medical technology. The bill would suspend it during two years, 2018 and 2019.
Health insurance companies have strenuously opposed the tax on insurance providers, saying the additional costs are generally passed on to consumers, businesses, state governments and taxpayers. The bill would suspend it for 2019.
The “Cadillac tax” is meant to help rein in the cost of employee health benefits. Instead of taking effect in 2020, it would be delayed until 2022.
https://www.nytimes.com/2018/01/16/us/politics/government-shutdown-immigration-childrens-health.html?
Diabetes Crisis Threatens to Undermine Health Care—While GOP Destroys It
by Amanda Marcotte - Salon - January 19, 2018
The first year of Donald Trump's presidency has been marked by repeated and unfortunately all too successful efforts to cut off health care access to Americans, particularly the young. Trump administration efforts to discourage people from signing up for health care meant that 2017 ending with 3.2 million fewer Americans with health insurance than in 2016. Canceling the insurance mandate is expected to result in millions more losing insurance, as insurance premiums soar. Now it seems Republicans are ready to pull the plug on the Children's Health Insurance Program (CHIP), ending insurance coverage for 9 million children.
Republicans love to portray cuts to health care spending as a money-saving maneuver, but the reality is far more complicated. Denying health care to people when they're young can lead to more health problems down the road and escalating costs, both on the private insurance market and in single-payer government programs like Medicare. This was already demonstrated by a Congressional Budget Office report showing that funding CHIP actually saves the government money.
A new report from LiveStories, a private company that crunches civic data for public officials and researchers, highlights the impact that diabetes is having on the health care system and how critical long-term prevention strategies are to reducing overall costs due to this chronic illness. Using data from the Centers from Disease Control, LiveStories researchers were able to map the prevalence of diabetes and even break down the data geographically to the zip code level.
The report details two general trends: The rate of diabetes diagnoses is actually flattening out and likely even declining, but the number of people living with the disease is actually soaring. That's because diabetes management has improved and people are living longer lives despite being diabetic. Diabetics are now 10 percent of the adult population, up from 4 percent in the early 1990s, even though the number of new diagnoses has been falling.
“Those are both really good things, and we set out to do those things in the 2000s," Adnan Mahmud, the head of LiveStories, told Salon. "We said, let’s try to have fewer cases of diabetes through education and that’s succeeding, and we also said that people that do have diabetes, let’s make sure they have a decent life.”
Unfortunately, he added, "because people are living longer with diabetes, there is a cost burden coming on health care.”
The report estimates that the amount of money spent on diabetes care through Medicare will rise 42 percent by 2030, up from the $100 billion the program spend in 2017.
Instead of letting people die, however, Mahmud suggests that the government should redouble efforts aimed at keeping people from developing diabetes in the first place. Unfortunately, Republican efforts to push people out of the health care system, especially younger people, will likely have the opposite effect. Under the Affordable Care Act, diabetes screening and nutritional counseling are covered without a copay, meaning that people at risk for developing Type II diabetes can often find out beforehand and take steps to prevent that from happening. But if people don't have health insurance, that screening and help will be unaffordable.
At Salon's request, the researchers at LiveStories broke down the diabetes data by geography. A state-by-state breakdown of diabetes rates of people over 65 — which means mostly Medicare patients — shows that the "Trump country" states are particularly hard hit.
(Thanks to LiveStories for providing the graph.)
While the numbers are complicated and there's not a direct one-to-one comparison, it's no surprise that there's some correlation between a conservative unwillingness to invest in health care for younger people and high diabetes rates for Medicare-age people. Of the 10 states with the highest diabetes rates, eight were slow to adopt the Medicaid expansion under the Affordable Care Act or have still not done so.
Similarly, a chart provided to Salon by LiveStories shows that people living in rural areas are particularly susceptible to dying of diabetes-related causes, while rates of diabetes mortality are falling faster for people in large metropolitan areas.
This kind of data underscores the need for early interventions and lifetime access to health care as a way to prevent and manage chronic illnesses like diabetes, so they don't get worse or more expensive.
Unfortunately, Republicans seem determined to structure the American health care system in the most counterproductive way possible, cutting people under 65, particularly younger people, out of health care while leaving Medicare spending untouched, at least for now. (Medicare will likely be untouched forever. Older people vote, and are highly likely to vote for Republicans, which means that cutting Medicare is political suicide for Republicans.) That is bad policy on a human level, and it also means that Medicare's ballooning costs will continue to expand unchecked. Letting a bunch of people get sick for no good reason and then waiting until they're elderly to start covering them is quite possibly the worst health care system that one could devise, short of having no health care system at all.
The good news, as this state and city-level data shows, is that there's much that local government can do to help reduce diabetes diagnoses. Diet and exercise impact diabetes rates, and more can always be done to improve both for local communities. Improving community health care and educational opportunities is within local control, and efforts like raising the minimum wage can help people make enough money to eat better food. States can step up efforts to improve health care coverage rates, by opting into the Medicaid expansion or doing more on the state level to fund programs like CHIP.
Ultimately, however, fighting widespread diseases like diabetes is going to require real investment in Americans' health from cradle onward. That change clearly will not happen as long as Republicans maintain monopoly control in Washington.
Fed Up With Drug Companies,
Hospitals Decide to Start Their Own
by Reed Abelson and Katie Thomas - NYT - January 18, 2018
For years, hospital executives have expressed frustration when essential drugs like heart medicines have become scarce, or when prices have skyrocketed because investors manipulated the market.
Now, some of the country’s largest hospital systems are taking an aggressive step to combat the problem: They plan to go into the drug business themselves, in a move that appears to be the first on this scale.
“This is a shot across the bow of the bad guys,” said Dr. Marc Harrison, the chief executive of Intermountain Healthcare, the nonprofit Salt Lake City hospital group that is spearheading the effort. “We are not going to lay down. We are going to go ahead and try and fix it.”
While Intermountain executives would not name the drugs they intend to make, hospitals have long experienced shortages of drugs like morphine or encountered sudden price increases for old, off-patent products like the heart medicine Nitropress. Hospitals have also come under criticism for overcharging for their services, including for some drugs.
Several major hospital systems, including Ascension, a Catholic system that is the nation’s largest nonprofit hospital group, plan to form a new nonprofit company, that will provide a number of generic drugs to the hospitals. The Department of Veterans Affairs is also expressing interest in participating.
In all, about 300 hospitals are now included in the group. Other hospitals are expected to join.
Dr. Harrison said they planned to focus only on certain drugs. “There are individual places where there are problems,” he said. “We are not indicting an entire industry.”
Dr. Kevin A. Schulman, a professor of medicine at the Duke University School of Medicine who has studied the generic drug market and is advising the effort, said: “If they all agree to buy enough to sustain this effort, you will have a huge threat to people that are trying to manipulate the generic drug market. They will want to think twice.”
The idea is to directly challenge the host of industry players who have capitalized on certain markets, buying up monopolies of old, off-patent drugs and then sharply raising prices, stoking public outrage and prompting a series of Congressional hearings and federal investigations. The most notorious example is of Martin Shkreli, the former hedge fund manager who raised the price of a decades-old drug, Daraprim, to $750 a tablet in 2015, from $13.50.
Hospitals have also struggled to deal with shortages of hundreds of vital drugs over the past decade, ranging from injectable morphine to sodium bicarbonate (the medical form of baking soda), shortfalls that are exacerbated when only one or two manufacturers make the product.
“We’re seeing an acceleration of both shortages and escalation of prices,” said Dr. Richard Gilfillan, the chief executive of Trinity Health, a large Catholic system that operates in nearly two dozen states and is part of the group. “There’s not been any effective push back on either of these.”
Intermountain executives would not discuss many details of the project, citing fears that competitors could shut them out of the market by quickly dropping the price of the drugs in question, then raising them again later. They said they would focus on drugs whose prices have risen sharply or that have been in short supply.
“We’re going to have to hold that very close to our vest,” Dr. Harrison said. The company will either rely on third-party manufacturers or decide to make the drugs themselves.
The new company will initially focus on selling to hospitals, but officials said they may eventually expand to offer the products more broadly.
Dr. Carolyn Clancy, the executive in charge of the Veterans Health Administration, said its pharmacy experts have consulted with the other systems about the project and is now working out the details of its possible involvement. “Our strong interest here is minimizing the impact of any shortages of generic drugs,” she said. While she said the agency is able to negotiate good prices for veterans, “we don’t necessarily control supply” and have experienced many of the same shortages, including the recent lack of saline fluids, as the other health groups.
“We are constantly scanning the horizon and constantly attentive to interruptions of supply chains of medicines,” she said.
In addition to Daraprim, several old, off-patent drugs have seen sharp price increases over the past several years. In 2015, Valeant Pharmaceuticals International became a Wall Street darling after it sold investors on its business model of buying up old drugs, then raising the prices precipitously. That year, it sharply raised the prices of two heart drugs, Nitropress and Isuprel, adding millions to hospitals’ drug bills almost overnight. Valeant’s practices led to a series of investigations and Congressional hearings as well as a shake-up of the company’s leadership.
Representatives for the generic drug industry have noted that many of the most high-profile cases have involved old, off-patent drugs for which there has been no generic competition.
The trade group for generic manufacturers, the Association for Accessible Medicines, said its members generally welcome competition. “The whole generic industry is premised on competition, and that competition brings dramatic savings for patients,” said Allen Goldberg, a spokesman for the group.
But generic drug makers have also come under scrutiny.
The hike in the price of doxycycline hyclate, an antibiotic, which increased to $3.65 a pill in 2013 from 5.6 cents in 2012, led to a congressional investigation as well as state and federal price-fixing inquiries into some of the industry’s biggest players. Last fall, a coalition of state attorneys general broadened a lawsuit over price fixing, accusing 18 companies of engaging in illegal practices involving 15 drugs.
Anthony R. Tersigni, the chief executive of Ascension, said he and other hospital executives felt they had little choice but to try to solve the problem themselves. “We took the position collectively rather than waiting and hoping for the generic drug companies to address it,” he said. “We have to address it head on.”
Intermountain executives said that they would seek approval to manufacture the products from the Food and Drug Administration, which has vowed to give priority to companies that want to make generics in markets for which there is little competition.
The project boasts a high-profile list of advisers, ranging from Bob Kerrey, the former Democratic senator of Nebraska, to Dr. Donald Berwick, a former administrator for the Centers of Medicare and Medicaid Services, as well as two former executives with Amgen, the drug manufacturer.
Erin Fox, a drug shortage expert at the University of Utah, said the idea of creating a nonprofit drug company is promising. “I think anything that increases the number of suppliers will help,” she said. She added that the trick will be in selecting the right third-party manufacturer to ensure good quality.
National shortage of IV bags has Maine hospitals on edge
by Meg Haskell - Bangor Daily News - January 18, 2018
Almost four months after Hurricane Maria devastated the U.S. island territory of Puerto Rico, its impact is still being felt in hospitals across the country, including in Maine.
Among the many casualties of the Sept. 20 storm were medical supply manufacturing facilities, an important component of the island’s economy. Now, a national shortage of intravenous fluid bags — including small pouches of sterile saline solution used to mix and administer antibiotics, pain medications, chemotherapeutic drugs and other IV medications — has hospitals scrambling.
“We’re in a crunch, and I’ve had some sleepless nights,” said Brian Hall, director of pharmacy at Millinocket Regional Hospital, a 25-bed facility.
He’s been dealing with the shortage of IV “mini-bags” since about a month after Puerto Rico lost its power grid and other infrastructure, forcing manufacturers out of production.
There have been no significant impacts on patient care at Millinocket Regional, Hall said, other than a few IV medication orders being changed to oral or injectable routes of administration. But not all patients can tolerate those forms, and some medications can only be delivered by IV, so the need remains steady.
The hospital routinely uses several hundred mini-bags each week. The most recent shipment arrived from a distributor warehouse last week and contained about 400 bags. About half have been used already, and Hall isn’t sure from where the next batch will come.
“So far we’ve been very fortunate,” Hall said. “Every time I’ve really thought we were going to run out of these bags, a shipment has come in.”
The shortage is affecting hospitals and other health facilities across the nation. Other medical supplies produced in Puerto Rico are also in short supply, including intravenous amino acid solutions, for providing essential nutrients to people who are unable to eat, and larger bags of saline and other solutions for treating dehydration. Intravenous hydration has been a key concern for some hospitals in the face of this influenza season, which health officials predict will be severe.
The federal Food and Drug Administration is monitoring the progress in getting medical manufacturers back on line in Puerto Rico. In a recent statement, FDA Commissioner Scott Gottlieb said many manufacturers there have reconnected to the power grid and are attempting to resume production.
“I’m optimistic that supplies of IV saline and amino acids will increase over the next few weeks and the stress of the shortage will begin to abate, even if the shortages will not be fully resolved immediately,” Gottlieb stated in the Jan. 4 announcement.
Hospitals and health systems across Maine are coping effectively with the shortage, a spokesman for the Maine Hospital Association said.
“It’s certainly a statewide issue, and a national issue,” said Jeffrey Austin, vice president for government affairs and communications.
Hospitals in Maine have been focused on monitoring and maintaining supplies of IV fluids and developing contingency plans in case the shortage grows more dire, he said.
Steps such as postponing certain procedures or sending patients to other facilities may have been part of some contingency planning, Austin said, but have not been implemented as far as he knew. Hospitals would likely notify the public if such changes were needed, Austin said.
The state’s hospitals have not wanted to stir up undue concerns about the situation, he said.
“They don’t want to scare people or make them think, “I can’t go to the hospital because they don’t have the medicine I need,’” he said.
At Eastern Maine Medical Center in Bangor, Pharmacy Operations Manager Thomas Moniz said the shortage has caused no significant change in intravenous drug or fluid prescribing.
EMMC uses thousands of mini bags each week.
“We have been able to procure the fluids we need where some other hospitals have not,” Moniz said.
He credits a team of pharmacists and nurses from each of the nine hospitals in the Eastern Maine Healthcare System network with developing contingency plans and maintaining adequate supplies at each facility. Miller Drug, also owned by EMHS, has different purchasing options that allowed it to contribute supplies to the hospitals, Moniz said.
At some points during the shortage, he said, the hospital had only about a 5-day supply of mini bags. Currently, there is about a 20-day supply, and Moniz feels the crisis is resolving. Reports of some hospitals being unable to provide adequate IV hydration to patients with influenza he passes off as “fear-mongering.”
Maine Medical Center in Portland provided a statement in response to a request for an interview.
“We have been actively managing the situation and working with our suppliers to stay ahead of any potential shortages,” the statement said. “Our primary focus continues to be ensuring that patients receive exactly the kind of care that they need.”
Back in Millinocket, Hall said the hospital is managing the situation well despite, and perhaps because of, its small size and its independence. The hospital is not affiliated with a larger health network.
“I can’t imagine the pressure [larger hospitals] must be under,” he said.
He sometimes has turned to a network of secondary distributors that specialize in obtaining scarce medical supplies.
They’re not cheap. Hall drew the line in a recent call from a company that wanted to sell him a much-needed case of 100 milliliter bags of saline. In normal times, he would pay about $175 for a case of 96 bags, or about $1.80 per bag.
“They wanted $1,650 for the case,” Hall said. “That’s almost 10 times my regular cost.”
He rejected the offer.
“I’m not going to be held hostage to this situation,” he said. “I’ve got enough work-arounds to get by.”
When States Make It Harder to Enroll, Even Eligible People Drop Medicaid
by Margot Sanger-Katz - NYT - January 18, 2018
In 2003, Washington State was facing a budget crisis and wanted to reduce spending on Medicaid. Instead of requiring people to establish their eligibility annually, the legislature began requiring them to do so twice a year, and added some paperwork. It worked: Enrollment in the health insurance program fell by more than 40,000 children in a year.
In the early 2000s, Louisiana wanted to maximize the number of eligible children who signed up for coverage, so officials simplified the sign-up process. It also worked: Enrollment surged, and the number of administrative cancellations fell by 20 percentage points.
In 2006, Congress asked states to verify the citizenship of beneficiaries by seeking their birth certificates. Across the country, children’s Medicaid enrollment dropped, despite scant evidence that ineligible children had been signed up. That policy was reversed as part of the Affordable Care Act in 2010.
The Trump administration’s decision to approve a first-of-its-kind work requirement for Kentucky’s Medicaid program last week has inspired concern that the program will leave behind Medicaid beneficiaries who are unable to find or keep work. But a large body of social science suggests that the mere requirement of documenting work hours is likely to cause many eligible people to lose coverage, too.
“Without being tremendously well organized, it can be easy to fail,” said Donald Moynihan, a professor of public affairs at the University of Wisconsin-Madison, who is writing a book on the effects of administrative burdens. Researchers have studied the ways complexity can reduce sign-ups for workplace pension plans, participation in food stamps and turnout in elections, he noted. “These sorts of little barriers are ways in which humans get tripped up all the time when they’re trying to do something that might benefit them.”
Anyone who has ever forgotten to pay a bill on time, or struggled to assemble all the necessary forms of identification before heading to the D.M.V., is likely to sympathize with how administrative hurdles can stymie someone. But these may be especially daunting for the poor, who tend to have less stable work schedules and less access to resources that can simplify compliance: reliable transportation, a bank account, internet access. There is also a lot of research about the Medicaid program, specifically, that shows that sign-ups fall when states make their program more complicated.
The Kentucky program won’t just create a work requirement for some beneficiaries; it will set up a broader obstacle course of administrative rules. Many beneficiaries will be asked to pay monthly premiums to the state to retain their coverage, as little as $1 a month for some very poor families, who are unlikely to have bank accounts.
They will be asked to notify Medicaid officials any time their income changes. Their benefits could rise or fall depending on whether they get an annual checkup, or take a financial literacy course. Beneficiaries who fail to renew their coverage promptly at the end of a year will be locked out for as long as six months. Beneficiaries who are “medically frail” can get an exemption from the work requirement, but they will need to submit a doctor’s note.
Kentucky officials argue that the changes will give beneficiaries more dignity and promote personal responsibility. But they also estimate that around 100,000 fewer people will be enrolled in the program by the end of five years. There are about 1.3 million Medicaid recipients in Kentucky.
Medicaid premiums are not unprecedented, and they’ve been studied. The results have typically been reductions in enrollment. Laura Dague, a professor of health policy at Texas A&M who has studied the effects of small premiums, found that both frequency and cost tend to cause drops in enrollment. “Any time the state requires more contact from the eligible population or enrolled population, you lose people at those places of contact,” she said.
Kentucky now will ask its beneficiaries to interact with the state monthly, both to pay premiums and to document the time they’ve worked or pursued work. A few missed premiums or work filings could cost them their coverage, even if they continue to work the required number of hours.
Renewals, historically, have also been associated with drops in enrollment, even among eligible people. Washington State officials were surprised by their experiment in checking families’ eligibility, said Mary Wood, an assistant director of the state’s Medicaid program. When the state asked the families why they were dropping coverage for their children, they learned that many families remained eligible but had simply lost track of the paperwork.
“If you were busy and you forgot to do it, you would lose coverage,” she said. Two years after making the policy change, Washington State reversed it, as part of a broader effort at simplifying the sign-up process. Since then, the state has invested heavily in making renewal a default for most families, by searching electronic databases to figure out who is eligible without having to ask them.
Other states have seen similar effects. Jason Helgerson, New York’s Medicaid director, was the Medicaid director in Wisconsin in 2008 when the state started using data from other public programs to sign up people for Medicaid.
“We picked up almost 100,000 people on our first day under the new rule,” he said.
Wisconsin and Washington haven’t been the only states to push for simplification. While states have typically tended to turn dials of complexity up or down depending on state budget constraints and political control, Medicaid programs started trending in the same direction in recent years.
Louisiana made enrolling every eligible child a priority, and, by making renewals easier, it was able to slash plan cancellations.
The Affordable Care Act helped codify that simplification, by requiring all states to use the same definitions of income, to use electronic databases whenever possible, and to eliminate other eligibility rules that made it harder and more time consuming for people to seek coverage. The goal of simplification has been to enroll as many eligible people as possible, and drive down the uninsured rate.
The Kentucky waiver will be a shift in the opposite direction, toward more rules, paperwork and ways for Medicaid patients to lose their coverage if they don’t keep up. Nine other states have asked to make similar program changes. Champions for the policy say the new rules will help teach low-income people to take more responsibility for their health.
Advocates for the poor are disappointed. “It’s sad to me that we’re going to have to go through this proof again if these things really get implemented,” said Judith Solomon, a vice president for health policy at the liberal Center on Budget and Policy Priorities. “There is no doubt in my mind that the experience will be the same.”
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