Drop in U.S. life expectancy is an ‘indictment of the American health care system’
by David Blumenthal - STAT News - January 4, 2018
The economy may be growing and the stock market booming, but Americans are dying younger — living shorter lives than previous generations and dying earlier than their counterparts around the world.
It is easy to place the blame squarely on our nation’s opioid epidemic, but if we do that we miss seeing the abysmal new life expectancy data from the Centers for Disease Control and Prevention for what they are — an indictment of the American health care system.
According to the CDC, the average life expectancy at birth in the U.S. fell by 0.1 years, to 78.6, in 2016, following a similar drop in 2015. This is the first time in 50 years that life expectancy has fallen for two years running. In 25 other developed countries, life expectancy in 2015 averaged 81.8 years.
There’s no question that a big culprit is the opioid epidemic, which contributed significantly to an increase in death rates for Americans aged 15 to 64 years. At first glance, substance abuse would seem more a social and economic problem than one of health care, and there is no question that socioeconomics are a major player in causing the so-called deaths of despair associated with substance abuse.
But, we cannot let our health care system off too easily.
The epidemic of drug abuse and overdose deaths has not affected other developed countries the way it has ours. With 4 percent of the world’s population, the U.S. accounts for 27 percent of the world’s overdose deaths. The European Union, with a population of 507 million, reported 6,800 overdose deaths in 2014, compared to 47,055 in the U.S. That disparity exists even though many other developed countries have faced even greater economic challenges than we have. In 2016, France and Spain had unemployment rates of 10.1 and 19.6 percent, respectively, compared to 4.9 percent in the U.S.
Why has it been it so much worse here? One reason is that the U.S. doesn’t have strong social safety nets that buffer the effects of recessions and job loss as other nations do. Another reason is the way the U.S. health care system functions.
The profitability of drugs in the United States, a result of sky-high and skyrocketing drug prices, has made the aggressive marketing and sale of new prescription opioids an almost irresistible temptation for American pharmaceutical companies. Bombarded by clever advertising, U.S. physicians have, in turn, become quicker on the draw in prescribing opioids than physicians in other developed nations. The role of pharma is most clearly illustrated in the case of Purdue Pharma, which has been sued thousands of times over OxyContin, a prescription painkiller. The company settled one case for $600 million after the federal government accused it of making false claims about the drug’s risk of addiction and denying its potential to be abused. A raft of new suits by cities and states claiming that drug companies have profited from a product they knew to be dangerous are now pending.
The opioid epidemic is not the only area in which the U.S. health system lags. In 2015, life expectancy at age 65 in the U.S. ranked 26th among the 37 members of the Organization for Economic Cooperation and Development, which includes most developed nations. It is widely accepted that the accessibility and quality of medical services strongly affect life expectancy among the elderly and elderly Americans fall behind their counterparts overseas when it comes to being able to get and afford the health care they need.
This may seem surprising given that Americans over 65 enjoy universal health insurance coverage under Medicare. But as valuable as Medicare is, it provides far less protection against the cost of illness, and far less access to services, than do most other Western countries. In a recent cross-national survey, U.S. seniors were more likely to report having three or more chronic illnesses than their counterparts in 10 other high-income countries. At the same time, they were four times more likely than seniors in countries such as Norway and England to skip care because of costs. Medicare, it turns out, is not very good insurance compared to what’s available in most of the western world.
We are the wealthiest nation on earth, but far from the healthiest, and things are getting worse, not better. The CDC report is yet another call to action for fundamental health system change that should include, among other things, reforming our pharmaceutical markets and making good health insurance available to all Americans. These need to be urgent priorities in 2018 for a government that should care as much about the health of Americans as their wealth.
David Blumenthal, M.D., is president of the Commonwealth Fund.
The Case for More Medicare
by David Leonhardt - NYT - January 5, 2018
Health care has been the top policy priority of each of the past two Democratic presidents. It should not be so for the next Democratic president.
Why not? Because those past two Democrats made substantial progress on health care, mostly through Obamacare and Bill Clinton’s expansion of children’s health insurance. And because the country has other pressing problems, like climate change, corporate consolidation, the tax code and education. (Education, by the way, also improves public health.)
But even if health care shouldn’t be the first Democratic agenda item of the future, it needs to be somewhere on the agenda. It’s too important, both politically and substantively. Yesterday, Paul Starr, the eminent health scholar, published a persuasive essay, through a joint project of The American Prospect and Century Foundation, about the future of health policy.
The core of his idea is Midlife Medicare: opening up the highly popular and successful program to Americans starting at age 50, rather than 65.
The idea is more politically feasible than single-payer Medicare for All, which would involve forcing many people to give up their current insurance plans. As Starr notes, the forcible switching of health plans has been a repeated political loser in this country. And yet single-payer advocates, like Bernie Sanders’s many supporters, may still be willing to support Midlife Medicare as “a first step toward their larger goal,” Starr writes.
In his proposal, Americans would be able to buy into Medicare at age 50 if they were not offered coverage through their jobs. Today, many people in their 50s and early 60s struggle to afford insurance that covers their needs.
Expanding Medicare makes more sense than further expanding Medicaid, because the Supreme Court has turned Medicaid into a patchwork program that varies greatly by state. Focusing on Medicare also makes more sense than enlarging Obamacare’s private markets, given the repeated Republican efforts to undermine those markets (as I explain here). Medicare both works better than they do and is on more solid political ground.
A larger Medicare could also have an enormous secondary benefit: The program holds down medical costs more than any other part of the health care system. The No. 1 reason medical costs are so much higher in the United States than anywhere else is the price, rather than the volume, of treatments. A famous 2003 journal article on this subject was titled, “It’s the Prices, Stupid.” More recently, Sarah Kliff explained the problem.
Starr’s new article goes into much more detail on both politics and policy. Health care wonks will want to read the whole piece; others should consider reading at least parts of it.
His proposal isn’t the only one worth considering for improving health coverage. But it does fall into the broad category that I think is the only one worth considering: It tries to expand public programs, not the less popular private ones, and it takes political constraints into account. Strange as it may seem, the current moment — with President Trump in the White House — is actually the right time for Democrats to formulate policy ideas. When they retake power, be it in 2021 or later, they will need to be ready to get a lot done.
Luck of the draw. The Republican candidate in a tied Virginia statehouse district won a random drawing yesterday, giving Republicans control of the chamber.
Larry Sabato of the University of Virginia notes that Democrats won the popular vote across all of Virginia’s statehouse districts by a “landslide” margin — 55 percent to 45 percent — yet failed to win control of the chamber. Dave Wasserman of the Cook Political Report says that outcome is a reminder that Democrats should campaign hard in every single House of Representatives district in 2018.
Virginia Democrats, Wasserman writes, “probably didn’t seriously contest as many GOP seats as they should have” in 2017.
A New Strategy for Health Care
by Paul Starr - The American Prospect - January 4, 2018
With the Trump era only a year old and its full impact on health policy as yet unclear, it may seem premature to discuss what ought to come next. But, driven by new enthusiasm among progressives for Bernie Sanders’s single-payer plan, the debate has already begun, and if the past is any indication, supporters of reform will turn to proposals long in gestation when they are finally able to act.
When that time comes, Democrats don’t want to discover they have locked themselves into commitments on health care that they cannot fulfill, just as Donald Trump and Republicans did in 2016. Democrats are justifiably angry today about the Republican efforts to sabotage the Affordable Care Act and cut Medicaid that have put health care for millions of people in jeopardy. Supporters of a universal system also have good reason to believe that the ACA was too limited and a stronger government role is necessary. But going to the opposite extreme and nationalizing health insurance has its own problems. Even by Sanders’s own estimate his plan would require a larger increase in federal taxes than the United States has ever had in peacetime. For that reason alone (and there are others), Democrats need to look at a broader menu of alternatives.
So, imagine it is January 2021, and a Democrat is ready to assume office as president along with a new Democratic Congress: What priority should health care get, and what policies should a new administration push for?
In Trump’s wake, many other legitimate concerns will be clamoring for attention and resources. For four years, the Trump administration will have neglected and in some cases aggravated America’s real problems, including economic inequality and insecurity, climate change, and the decaying public infrastructure that Trump shows no signs of fixing. The two previous Democratic presidents made health care their top priority for reform in their first year. Although Bill Clinton failed to pass his Health Security Act, Barack Obama succeeded in passing the ACA. But both of them faced a backlash driven in part by their health policies, lost Democratic congressional majorities after two years, and from then on faced severe limits on what they could accomplish.
I supported Clinton’s and Obama’s decisions to make health care the early focus of reform in their presidencies, but I’d be hard-pressed to make that argument a third time. That’s not to say the Democrats’ presidential candidate in 2020 should ignore or downplay health care. The Trump era’s damage to national health policy will call for an answer, and the party’s primary voters care intensely about the answer their nominee will give. Democrats, however, ought to learn from experience and focus on health-care priorities that make sense as both policy and politics and build popular support over time. Those priorities will have to deal with core concerns about health care yet not absorb every last dollar of revenue a new administration might hope to raise.
Repairing whatever is left of the ACA, if anything is left, will be important but insufficient. Although the ACA has gained in popularity since Trump’s election, the law’s limitations have also become increasingly apparent. A new Democratic administration should focus on one or two signature health-care proposals that advance the long-term objectives of universal coverage and cost control and respond to people who have insurance but still face financial stress from medical bills. Two ideas could meet these criteria: making available a new Medicare plan for people aged 50 to 64—a program I call “Midlife Medicare”—and directly attacking America’s excessive health-care prices. Although the two ideas are independent, they’re closely related, since attacking prices also involves an extension of Medicare, in this case the extension of Medicare rates to out-of-network providers in private insurance.
Limits of the ACA
Advocates for broader access to health care have rightly defended the ACA from Republican attacks, but facing up to its limits is crucial for figuring out what to do next. The law has worked well, but it hasn’t worked well enough. From 2010 to 2016, it cut the proportion of Americans without health insurance almost in half, from 16.3 percent to 8.8 percent, and it did that without causing the economic havoc that opponents predicted. But it hasn’t effectively addressed the underlying problem of rising costs and consequently hasn’t assured a stable and affordable system. Although millions have received care they wouldn’t have gotten, Gallup data indicate that 29 percent of Americans—37 percent of women compared with 22 percent of men—still put off medical treatment due to cost in 2017, not significantly different from before the ACA. While seeing improvements in the scope of coverage such as the elimination of annual and lifetime caps, many Americans with private insurance now face much higher deductibles than in the past. The sense of many people who previously had good health benefits that their own insurance is deteriorating may account for much of the dissatisfaction with the ACA.
Moreover, the two means by which the ACA has extended health insurance—the expansion of Medicaid and reform of the individual insurance market—ran into problems even before Trump took office. Some of those difficulties stem from the Supreme Court’s decision about Medicaid and red-state resistance to the program, while others reflect limitations of the ACA itself, now aggravated by Trump’s policies.
In 2012, when the Supreme Court made the ACA’s Medicaid expansion optional for the states, it put in question an incremental strategy for expanded coverage that reformers had followed for more than two decades. In the 1980s, Congress began increasing Medicaid eligibility for low-income pregnant women and children. If states wanted to get any federal funds for Medicaid (and all states did), they had to cover the new beneficiaries and services that federal law mandated. Congress thereby gradually ratcheted up a program that originally covered only special groups among the poor—the disabled, blind, aged, and single-parent families on welfare. But many low-income people continued to be left out of Medicaid, especially in Southern states that severely restricted eligibility.
In 2010, the ACA took the next step in turning Medicaid into a general health-care program for low-income people by extending eligibility to all those with incomes up to 138 percent of the federal poverty level. (In 2017, that’s $16,643 for an individual.) The new national standard would have gone into effect in 2014 if the Supreme Court had not ruled—for the first time since Medicaid’s enactment in 1965—that Congress could not condition all federal Medicaid funds on a state’s agreement to include a new group of beneficiaries.
The Court’s decision hasn’t just allowed 19 Republican-led states to reject the ACA Medicaid expansion; it also prevents Congress in the future from ratcheting up national standards for Medicaid coverage as it did in the past. Indeed, the ratchet now will work in the other direction. If Republicans cut the traditional Medicaid program when they are in power, Democrats cannot later restore coverage, much less expand it, and count on states being effectively required to comply.
Leaving Medicaid coverage up to the states has a big impact on low-income people who live in Republican areas. During the first half of 2017, the share of adults aged 18 to 64 who were uninsured was 19 percent in the states that did not expand Medicaid, compared with 8.8 percent in the states that did.
Medicare also has other advantages that make it a stronger platform than Medicaid for the next phase of health-care reform.
Although Medicaid will continue to be central to financing health care, it is hard to see how it can serve as a firm basis for universal coverage. Democrats can reduce reliance on Medicaid, however, by shifting to the other national framework for coverage established in 1965—Medicare. Many of Medicare’s original supporters hoped to use it eventually to cover everyone, and in 1972 Congress extended it to cover those on disability insurance as well as patients with end-stage renal disease. By incrementally expanding Medicaid in the 1980s and then creating the Children’s Health Insurance Program (CHIP) in 1997, Congress was able to offload some of the cost of expanded coverage onto the states. With that route to a universal system now effectively cut off, reformers need to turn back to Medicare, which as a national program doesn’t give Republicans in the states a veto point. As a result of its popularity and success in both controlling costs and providing broad access to providers, Medicare also has other advantages that make it a stronger platform than Medicaid for the next phase of health-care reform.
BESIDES EXPANDING MEDICAID, the ACA has increased coverage by helping people afford private insurance. Instead of trying to restructure all private insurance and put a lid on its total costs—as the 1993 Clinton health plan had sought to do—the ACA leaves employer-based health plans for the most part unchanged and focuses primarily on reforming the individual (or “non-group”) market.
Before the ACA went into effect in 2014, insurers priced policies for individuals according to the beneficiaries’ health and age and limited the scope of coverage through caps and exclusions, including the exclusion of pre-existing conditions. People who bought insurance directly on their own got poor value for money, and millions of individuals remained uninsured because they couldn’t afford the rates, were deemed uninsurable, or took the risk of going without coverage and depending on charity care if they got seriously ill.
The ACA deals with these problems through new rules and new subsidies. While allowing for considerable patient cost-sharing, the new rules require insurers to cover all applicants for a list of “essential health benefits” at rates not based on their health and only to a limited extent based on their age. A financial penalty for failing to carry a minimum level of coverage—the so-called “individual mandate”—was supposed to motivate the healthy to insure, deterring people from opportunistically buying insurance only when they needed it. The new sliding-scale tax credits for premiums, available only through state-based marketplaces, go to people with incomes up to four times the federal poverty level, while subsidies for deductibles and co-pays go to insurers for the benefit of people with incomes up to 250 percent of the poverty line.
After an encouraging start in 2014, the individual-market reforms look increasingly inadequate. The premium tax credits have been too low and the penalty for failing to insure has been too small and too weakly enforced to get many healthy people to sign up. The unpopularity of the individual mandate made it a perfect point of attack for Republicans against the whole structure. Insurers have been able to skirt the requirement to sell individual policies at the same community rate by designing separate plans to be sold outside the state marketplaces to lower-risk individuals (a problem that Trump’s policies will exacerbate). Some supporters of the ACA had expected the marketplaces to work so well that they would become a desirable alternative to employer-based insurance. Instead, because of limitations in their design, the marketplaces suffer from adverse selection (disproportionately high-cost enrollment), and the plans they offer typically provide access to a more limited list of doctors and hospitals than Medicare or a good employer plan provides.
The problems of high prices and limited insurance options have intensified in the past year as major insurers have dropped out of many of the ACA’s marketplaces. In much of the country, only a single insurer offers coverage, and rates have soared as a result. Lacking even a fallback public option—a public insurance plan triggered by the lack of private competition—the enrollees in the marketplaces have had to settle for whatever remains available to them.
In retrospect, the ACA has neither been generous enough (in its subsidies) nor tough enough (in the individual mandate) nor realistic enough about the market (in its lack of a public option).
In retrospect, the ACA has neither been generous enough (in its subsidies) nor tough enough (in the individual mandate) nor realistic enough about the market (in its lack of a public option). But the biggest limitation of the ACA’s market reforms is that they don’t address the underlying problems in health-care prices.
It’s the Prices, Stupid
In 2016, the United States devoted nearly 18 percent of national income to health care, compared with about 11 percent for peer countries such as Germany, France, and Sweden and an average of 9 percent for the 35 member nations of the Organization for Economic Cooperation and Development. Although national health spending generally rises with per capita income, the United States is an outlier, spending vastly more on health care than its per capita income predicts. The excess is not the result of Americans going to the doctor or hospital more often or using more drugs or generally consuming more medical services than people in the other economically advanced societies. The single biggest factor is that Americans pay higher prices for health care, as Gerard F. Anderson, the late Uwe E. Reinhardt, Peter S. Hussey, and Varduhi Petrosyan argued in a 2003 article in Health Affairsmemorably titled “It’s the Prices, Stupid.” It is the price system, particularly for patients with private insurance or no coverage, that lies at the heart of the cost problem of the American health system.
While other countries regulate health-care prices or budgets, the United States leaves prices in the private market to insurers and providers, a system that has failed to create any effective check on what providers charge. The sources of market failure arise from the structure of health care and insurance and from trends toward monopoly power that have made a bad situation worse.
Health-care spending is concentrated—I realize this is shocking—among the very sick. In any given year, the most costly 10 percent of a population typically accounts for about two-thirds of total costs. When people face serious health problems, they often have urgent needs and ties to particular physicians that limit their practical options. It’s not realistic to expect most patients in those circumstances to shop around and compare prices, and even if they tried, they usually wouldn’t be able to find out beforehand how much different hospitals and other providers would charge.
Imagine if buying gas for your car worked like hospital care. If it did, when you pulled into a gas station, no prices would be posted. What you’d pay would depend on your car insurance, but no one could tell you what those prices or the total cost would be. It would depend on what several different mechanics—not all of whom would necessarily be “in-network”—determined your car needed. The bill would be incomprehensible, and most of it would be paid by your employer’s plan. Eventually, the full cost would come out of the wages you and your fellow employees were paid, although you wouldn’t be able to do anything about it. One thing we could say for sure: Gas prices would be very high under this system.
In the mid-1990s, when managed care was on the rise, insurers did hold down prices and costs for a while, but the effect was short-lived. Partly in response to managed care, health-care providers at the local and regional level began consolidating into massive health systems that have enabled them to regain market power and jack up prices. Consolidation has also taken place on the insurer side and in other segments of health care, such as pharmacy benefit managers, all to the disadvantage of consumers. Insurers have passed on higher provider costs to employers, who have passed them on their workers, with the sharp increase in deductibles being one of the consequences.
The one relatively bright spot in the American system has been the Medicare program, which has a system of federally set prices.
The one relatively bright spot in the American system has been the Medicare program, which has a system of federally set prices. That system, although far from perfect, has kept down Medicare costs relative to private insurance yet still preserved access to nearly all doctors and hospitals for Medicare beneficiaries. So, just as we should think about using Medicare to achieve universal coverage, we should also think about expanding the use of Medicare prices to control costs and sustain a universal system.
The Case for Midlife Medicare
In her 2016 presidential campaign, Hillary Clinton had policies on nearly every issue confronting the country, while Trump had only a few simple positions. Clinton’s nuanced command of the issues was admirable, but many voters were unsure what she would do as president, whereas everyone knew exactly what Trump was promising. If Democrats learn one thing from Trump’s success, it should be focus. While candidates ought to have extensive and detailed knowledge, they need a small number of easily grasped focal ideas that define what their candidacy is all about. With that concern in mind, I am suggesting only two focal points for an agenda in health care—making a new part of Medicare available to people at age 50 and controlling health-care prices. Although the details will be complicated to work out, people won’t need to be experts to understand what they stand to gain from those policies.
Recent Republican alternatives to the ACA hit older adults in the individual market particularly hard. The legislation passed by Republicans in the House in May would have allowed insurers to charge older adults five times as much as younger adults (instead of three times as much under the ACA) and would have provided much smaller premium subsidies with little adjustment for income. According to the Congressional Budget Office, in a state that carried out the law without any special waivers, the House bill would have raised the net cost of insurance for a 64-year-old with an income at 175 percent of the federal poverty level from $1,700 to $16,100—an 847 percent increase. In September, Republicans in the Senate fell one vote short of passing their own repeal-and-replace legislation, which would have converted all premium subsidies as well as funds for the Medicaid expansion into block grants to the states. Under that bill, if Republican-led states adopted the same principles that their representatives in the House supported, older adults now getting marketplace coverage would also have faced such radical increases in premiums that many of them would have become uninsured. Since Republicans keep promising to carry out their policies one way or another—through federal legislation, administrative waivers, and state policies—the threat to older adults has not disappeared.
Older adults are particularly concerned about health insurance because of the onset of health problems in midlife. Moreover, as the economists Anne Case and Angus Deaton have shown, rates of illness and death have been increasing in recent decades for Americans in midlife, especially for non-Hispanic whites with a high school education or less. The human costs of deindustrialization are being recorded in their lives. For many of them, finally becoming eligible for Medicare at age 65 is a moment of tremendous financial relief.
The idea of moving that age up to 55 through an early “buy-in” to Medicare has been around since President Clinton proposed it in 1998. In 2017, a group of Democratic senators, led by Debbie Stabenow of Michigan, introduced a bill for a Medicare buy-in beginning at age 55, while a group of Democrats in the House proposed a buy-in starting at age 50. But reform efforts haven’t focused on the potential of the buy-in idea, and there has been no recent effort to cost out the different ways of designing it. The term “buy-in” may suggest an option wholly financed by premiums, but since many of the people interested in early access to Medicare will have retired before age 65 because of health problems, a program entirely financed by premiums would be unaffordable.
Midlife Medicare, as I imagine it, would be a new part of Medicare for people aged 50 to 64, financed by general revenues as well as by premiums. The general revenue would be set roughly to offset adverse selection and to match the value of subsidies in the ACA, scaled up for a standard Medicare plan, including pharmaceutical coverage. (Like Medicare Part B, it would not draw on the Medicare Trust Fund.) The program would be open to older adults who do not have employer-sponsored insurance and were not offered it, and it would consequently be smaller and more fiscally manageable than a single-payer plan. Yet it would still be an important breakthrough not only for the people who would enroll in it but for others as well because it would significantly reduce costs for the remaining, younger pool in the individual market.
Focusing on Midlife Medicare would respond to political realities that advocates of “Medicare for all” have hoped to elide. Shifting all Americans into a federally financed program, as I mentioned earlier, would require a staggering increase in taxes. Advocates say that because of savings people would pay less than they do now in premiums, but this argument ignores several problems. First, many people such as seniors and veterans who are satisfied with their coverage would see the new taxes as an extra burden. Second, employees with health benefits would have to trust that their employers would pass along savings in the form of higher wages and that the resulting wage increases would offset the new taxes—an impossible calculation for them to make. Third, a single-payer plan would require people to give up their current private coverage, and as long experience has shown, Americans are fearful of doing so, especially once a mobilized private health-care industry has had a chance to raise anxieties about change. Single-payer proposals have gone down to defeat in state referenda three times in recent decades: 73 percent to 27 percent in California in 1994, 79 percent to 21 percent in Oregon in 2002, and 80 percent to 20 percent in Colorado in 2016—all blue states, and the margins were not even close.
General expansions of Medicare, such as Jacob Hacker’s proposal for a new part of Medicare open to everyone (including employee groups), would also raise concerns about open-ended costs and risk alienating a crucial group—seniors. Many of the elderly see Medicare as their own program, earned through taxes they have paid over their working years, a view they have long been encouraged to hold by Medicare advocates. Midlife Medicare would have a far better chance of winning seniors’ support. The leading organization representing seniors, AARP, welcomes all Americans 50 years of age and older as members and seeks to represent them as a single constituency. People aged 50 to 64 have also paid Medicare taxes over their working years and can equally be said to have earned Medicare benefits. Since Social Security already has a provision for obtaining pension benefits early (at age 62), the idea of early eligibility is a familiar one. Public opinion data on a Medicare buy-in for 55- to 64-year-olds are encouraging. According to an April 2017 YouGov survey, seniors approve a Medicare buy-in at nearly as high a rate (71 percent) as all age groups combined (82 percent).
Americans who resist publicly financed health care in the abstract often seem more willing to support it when the issue is more specific to an age group. That is how we got Medicare and CHIP. Age-based public programs may not be ideal, but they are not an intolerable compromise. They have the political virtue of creating an identifiable group of beneficiaries whose problems are readily understood and whose families can be mobilized to defend their rights.
Like “senior” Medicare itself, Midlife Medicare would likely receive support from those too young to enroll who would see it not just as someone else’s protection but as someday their own. People with an employer-sponsored plan would know that if they decide to retire early, they could continue to get good health coverage. By removing older adults from the individual market—in effect, siphoning off much of the high-cost population—Midlife Medicare would also make premiums for younger people more affordable. An additional step, eliminating the two-year waiting period for Medicare currently facing people already deemed eligible for Social Security Disability Insurance, would contribute to still-lower premiums in the individual market for the population age 49 and younger.
Politically, Midlife Medicare represents a possible point of convergence between the left and center in the Democratic Party.
Politically, Midlife Medicare represents a possible point of convergence between the left and center in the Democratic Party. Advocates of Medicare-for-all might support an extension of Medicare to age 50 as a first step toward their larger goal, while others could see it as a positive step on its own. Even if Midlife Medicare didn’t lead to any further expansions of Medicare, it could help show how to make the rest of the system work better. Here it’s important to understand why the Medicare program works better than the ACA and how the latter might be fixed with the benefit of Midlife Medicare’s example.
SEVERAL DIFFERENT IDEAS for expanding Medicare are now in circulation. A key distinction among them is whether they involve expanding Medicare as a plan or Medicare as a program. The distinction is crucial.
When most people think of expanding Medicare, they think of expanding access to the public Medicare plan, as in Sanders’s single-payer, “Medicare for all” bill. But the Medicare program is not actually a single-payer; a third of beneficiaries use it to sign up for one of the many private Medicare Advantage plans. Medicare is now a framework for choice of plan—a marketplace for public-private competition. Expanding use of that framework has distinct advantages over the ACA marketplaces, even if the latter included a public plan.
It’s not only Sanders’s single-payer bill that calls for expanding the use of Medicare as a plan rather than Medicare as a program. Some public-option proposals do the same. Senators Michael Bennet and Tim Kaine have proposed a new Medicare plan, which they call Medicare “X,” for “extra,” that would be offered as an option in the ACA’s individual marketplaces, beginning in 2020 with counties that have one or no private plans, extended three years later to all individual marketplaces, and the following year to small business. The Medicare-X plan would meet the ACA’s requirements for essential health benefits and be financed through premiums, supported by the same subsidies as other marketplace plans.
Medicare-X has advantages over public options that are supposed to be “like Medicare” but unconnected to the Medicare program itself. If stand-alone public plans had to negotiate rates with providers, the plans might not have much bargaining power, and even if they used Medicare rates, many providers might refuse to participate. But participation in Medicare-X at Medicare rates could be required of providers who want to continue participating in “senior” Medicare, as nearly all would. If Bennet and Kaine’s proposal had been part of the ACA, it might have averted some of the problems in the marketplaces today. But, as an adjustment to the ACA, it also reflects some of the law’s limitations.
To appreciate those limitations, consider the differences between the framework for choice of plan in the Medicare program and in the ACA. The key differences have to do with how plans pay health-care providers, and how much consumers pay for different plans. The federally set provider prices for public Medicare also effectively cap what private Medicare Advantage plans pay providers. In Medicare Advantage, out-of-network providers are paid no more than Medicare rates and are prohibited from billing beneficiaries for any additional amount (so-called “balance billing”). As a result, in-network providers have an incentive to offer insurers even lower prices in order to get an increased number of patients.
The result is that the Medicare market is similar to European health systems that have multiple insurance funds but more unified payment rates. Even though the cap on out-of-network charges in private plans may seem a small detail of Medicare, it achieves a large effect in protecting Medicare beneficiaries from rising costs.
The other key aspect of Medicare is the dominant role of Medicare’s public plan. Public Medicare doesn’t just offer an “option”; public Medicare’s costs are the basis (or “benchmark”) for determining how much beneficiaries pay for Medicare Advantage plans. But while public Medicare covers roughly 80 percent of expected average costs for beneficiaries, the benchmark in the ACA marketplaces is the second-lowest-cost “silver plan,” which covers only 70 percent of expected average costs. For the same level of coverage, ACA beneficiaries pay a lot more themselves. The difference has had a huge impact on the plans in the ACA marketplaces that consumers choose. The system has driven enrollees toward plans with relatively high deductibles and narrow networks and generated only ambivalent support for the program. In addition, the complete cut-off of subsidies for people with incomes above four times the poverty level has also created a significant group of middle-class people who don’t have their premiums capped and often resent the ACA for forcing them into a risk pool and plans that require them to pay more for insurance than they previously did.
In contrast to the insurer monopolies in many ACA marketplaces, the terms established by Medicare give seniors access to both an affordable public plan and a variety of private options. The Medicare system works as well as it does because it has both a dominant public plan and price regulation on the private side. In contrast, Kaine and Bennet’s Medicare-X proposal calls only for a public plan as an option in the ACA marketplaces, not the price regulation that enables private plans to compete in Medicare Advantage. Insurers will argue that they cannot compete with Medicare-X under those circumstances, and they’re probably right. Although it may seem ideologically inconsistent, insurers need price regulation (that is, of providers) in order to compete with a public plan that sets rates.
Midlife Medicare would have all the features that enable Medicare to work better than the ACA—the strong public Medicare plan, the use of that plan as a benchmark, and provider price regulation in private Medicare Advantage options. All those elements would come as part of the now-established Medicare structure. Reformers could also try to introduce these features into the ACA marketplaces if the ACA survives the Trump era.
But regardless of what happens with the ACA, one idea deserves wider consideration as a general cost-control measure: using Medicare rates to cap out-of-network charges in private insurance.
The New Case for Regulating Prices
Health-care reformers and political leaders need to take a new look at an old idea—price regulation in health care.
Health-care reformers and political leaders need to take a new look at an old idea—price regulation in health care. As of 1980, more than 30 states regulated hospital rates, but during the following two decades nearly all of them eliminated rate-setting in the belief that managed care and the free market would solve the problem of high health-care costs. Instead, prices and costs have continued to rise to far higher levels than in other peer countries, and waves of consolidation in the health-care industry have created monopoly provider systems in many areas. Relying on the market to limit health-care costs was never likely to work, but it is even more implausible today than it was before.
The new case for price regulation isn’t based only on the growth of monopoly power in health care. After 30 years of unregulated private rates and regulated Medicare rates, the evidence is in: Medicare has held down prices more effectively than private insurance. The use of Medicare rates as a cap on out-of-network charges in Medicare Advantage has also demonstrated the value of a limited but strategic intervention to control costs without imposing uniform price controls. A legitimate concern about traditional price regulation is that it would lock in the fee-for-service payment system. But a cap on out-of-network fees still allows insurers to work out contracts that reward in-network providers for better performance. Out-of-network caps can be a spur to moving the entire health-care system away from fee-for-service. The Obama administration began moving public Medicare itself toward alternative payment methods, and while those methods have so far not yielded big savings for Medicare (and are being eroded under Trump), they have created the basis for a payment system that combines cost containment with incentives for improvements in the quality of care.
Capping out-of-network charges would also hardly be an unpopular idea. At a time when deductibles have been rising and patients are often hit by “surprise” medical bills (for example, from an out-of-network physician at an in-network hospital), provider payment caps would directly address problems that even the relatively well-insured are facing. The out-of-network caps then would also constrain in-network costs, since they would reduce the bargaining power of the monopoly systems.
Out-of-network prices could be limited in two general ways. Direct regulation based on Medicare rates would be the stronger approach. Commercial rates for hospital care today vary from roughly 130 percent to 200 percent of Medicare; one estimate puts the average for hospital prices at about 175 percent of Medicare. According to a study of private insurance claims by Yale University’s Zack Cooper and colleagues, applying Medicare rates to all private insurance would reduce total private spending on inpatient hospital care by 31 percent. If the cap were set at 110 percent of Medicare, spending would drop by 24 percent; if at 130 percent of Medicare, spending would fall by 11 percent. Hospitals have generally been doing very well lately, with average margins of around 7 percent; nonprofit hospitals are a very profitable business. Even so, simply extending Medicare rates would be too severe. A somewhat higher cap—perhaps varying by region, and gradually tightening over time—would be an effective way to keep costs down.
A second approach would be to require hospitals to follow Medicare’s relative prices and post a single figure indicating where they stood in relation to Medicare. For example, one hospital might choose to offer care at Medicare rates, another at 130 percent of Medicare, and a third at 200 percent of Medicare. Insurers have not had success in controlling costs by providing their subscribers with tools for price transparency. As I suggested earlier, many patients are not in a position to shop around. But a simplified system based on Medicare ratios might have a significant impact, if only because of the force of public opinion on the institutions charging the highest prices. If it’s too difficult to reinstitute rate-setting, requirements for simple transparency would be a good second choice.
WHENEVER DEMOCRATS GET another shot at health reform, that effort will have to fit within a larger national agenda and other demands facing the country. My proposals for Midlife Medicare and price regulation are a guess about what might be both desirable and feasible at that point. If the ACA marketplaces survive in a weakened form, Midlife Medicare could help reduce the burdens on them and demonstrate how a restructured marketplace with a strong public plan can work. If Republicans have succeeded in destroying the ACA, it may be hard to persuade people to revive that model, and Midlife Medicare could offer another practical way forward, as CHIP did in the wake of the defeat of the Clinton health plan.
Since the lower health-care costs of other countries are mainly the result of more effective price restraint, we could get a lot of the benefit of single-payer from adopting caps on provider payment. But price regulation doesn’t have to wait for a change in national politics. State governments could undertake that function as they once did, focusing now on out-of-network charges as a key point of leverage. State experiments with different strategies for regulating health-care prices could then prove valuable for policy at the national level.
Of course, the struggle over preserving the gains of the ACA isn’t over. States may be able to step in to make up for some of the Republican sabotage at the national level. But it is also not too soon to think about the alternatives that lie ahead when new opportunities for reform emerge.
Ben Jealous calls for single-payer health care in Maryland
Ovetta Wiggins - The Washington Post - December 6, 2017
Democratic gubernatorial candidate Ben Jealous wants to establish single-payer healthcare in Maryland, a plan that would make government pay residents’ medical care and get rid of the out-of-pocket expenses that residents pay.
In a 19-page proposal that echoes U.S. Sen. Bernie Sanders’ national plan for the government to cover everyone’s health insurance through Medicare, Jealous said a state-run, single-payer system would be the next logical step for a state like Maryland, which has an all-payer system, but he offered no specific details on how the government would cover the cost of the ambitious plan.
A similar plan was debated, but later shelved, in California this year.
“We’re in a better position than any other state; we’re more than half way there,” Jealous said noting the all-payer system and hospital waiver that are currently in place in Maryland. “We believe it’s attainable. It just comes down to getting the stakeholders around the table.”
Jealous said the state has saved more than $400 million under its all-payer system and a move toward single-payer would only lead to greater cost savings, money that could help pay for the program. He also did not rule out an increase in sales or income taxes to pay for the universal coverage.
“The key factor is this will save us money,” Jealous said. “We’ll get a better deal from big Pharma. . . And we are talking about a savings for most employers and most people.”
Jealous’ plan is more progressive than his opponents vying for the Democratic nomination.
State Sen. Richard Madaleno (D-Montgomery) and tech entrepreneur Alec Ross have each called for a state-run public option, under which the state would set up a health program to compete with private insurance rather than the state providing the coverage.
Attorney Jim Shea said he prefers a federal single-payer system. In Maryland, he said the state “should look for ways to improve quality and control costs through preventative care initiatives within the current all-payer system.”
Jealous said he doesn’t support a public option because, he said, research has found that it “won’t do much.”
Sanders will join Jealous in Baltimore on Wednesday night at a rally to promote Md-Care, Jealous’ healthcare proposal, and his own national healthcare plan.
Why Maine’s governor and voters are in a fight over Medicaid expansion
by Hari Sreenavasan - PBS - January 28, 2017
Read the Full Transcript
- Hari Sreenivasan:The battle over repealing the health care law occupied much of the national political agenda this year.The individual mandate for coverage was repealed through the tax bill starting in 2019. But Republican efforts to repeal the expansion of Medicaid failed, at least for now.Yet, even as that debate played out, voters in Maine overwhelmingly approved a ballot measure last month to expand Medicaid there to most low-income adults. The victory has reinvigorated advocates looking to expand Medicaid in other states.But as special correspondent Sarah Varney reports, the battle is not yet over in Maine.Our story was produced in collaboration with our partner Kaiser Health News.
- Sarah Varney:Donna Wall cares for her three adult autistic children at her home in Lewiston, Maine. It’s a full-time job. Her sons Christopher and Brandon have frequent outbursts, and the stress of tending to them can be overwhelming.When her sons turned 18 a year-and-a-half ago, Maine’s Medicaid program dropped her health insurance. Wall is considered a ‘childless adult’ in Maine and other states that didn’t expand Medicaid, and so she isn’t eligible for coverage. She can no longer get her anti-depression and anxiety medications. She can’t see her psychologist or a doctor to check up on a troubling spot on her eye.She needs to stay whole, she says, for her kids.
- Donna Wall:I’m 60 years old. Things start going wrong when you get older, and I haven’t had a Pap smear or breast exam in two years. I’m just worried something will happen to me, because who is going to take care of them? It’s a big job. It really is.I mean, if I put the boys in a home, it would cost the state a lot more to take care of them than it would be to pay my medical.
- Sarah Varney:Even on frigid, wintry nights, Wall delivers newspapers, earning $150 a week when her kids are asleep.
- Donna Wall:I go out about 2:00 in the morning. And it usually takes me four to five hours. And I try really hard not to fall, but I have had a few accidents. One of them was on black ice last winter.
- Sarah Varney:At one point, Wall thought she might have broken a rib. But she stayed away from the emergency room for fear of a costly medical bill.At least 70,000 low-income Maine residents, like Donna Wall, should gain Medicaid health insurance because of the ballot measure that passed last month. Advocates collected signatures to put the question to voters, and, in November, Maine became the first state to get approval at the ballot box to expand Medicaid, passing with 59 percent approval.But even though voters here in Maine decided to expand Medicaid, the law’s fate is still unclear. Republican Governor Paul LePage says opening up the program to more poor adults threatens the state’s financial stability and that lawmakers shouldn’t raise taxes to pay for it.
- Gov. Paul LePage:You have to pay for the law. It’s going to cost money. And I intend to implement it, and the legislature is required to fund it. If they do not fund it, it will not be implemented.
- Sarah Varney:LePage has been in power for seven years, and, because of term limits, is heading into his final year in office. He vetoed five Medicaid expansion bills passed by the legislature before voters approved it at the ballot box.LePage says lawmakers must now pay for the new law without raising taxes or dipping into the state’s rainy day fund. And he warns that the expansion could threaten services for people with disabilities and the elderly.
- Gov. Paul LePage:When able-bodied people, who are able and should be working, choose not to work, then I don’t think it’s society’s responsibility to cover their insurance at the expense of our mentally ill, our disabled, and our elderly.We’re asking hardworking Maine families to pick up the extra tab for people who should be working, but elect not to be.
- Sara Gideon:Wow, well that’s just simply not true.
- Sarah Varney:Sara Gideon, a Democrat, is the speaker of Maine’s House of Representatives.
- Sara Gideon:Let’s start with the population of people who will actually be eligible for health insurance now. We’re talking about people, almost 70 percent of whom are people who are actually in the workforce, who are earning a living, but not actually able to afford health care with the low income that they earn.
- Sarah Varney:Gideon says LePage must follow the law. Moreover, she’s confident the legislature will find a way to fund the state’s share of $54 million and keep its promises to the elderly and disabled.
- Sara Gideon:It’s not a choice between people, one group of people over another. It’s a false choice that this governor is trying to present. And we say, we’re not going to make that choice. It is the law. And we’re simply going to make sure that that law is implemented.
- Marie Vienneau:Our rural hospital is struggling. We don’t make money. We lost a million-and-a-half dollars the last two years.
- Sarah Varney:Marie Vienneau, CEO Of Mayo Regional Hospital in Dover-Foxcroft, says money from the Medicaid expansion can’t come fast enough. Maine’s rural towns and their hospitals have been hard-hit. Factories have closed and many residents have moved away.
- Marie Vienneau:We’re going to go by what was Moosehead Manufacturing. They made furniture that was very well known throughout the country, as well as Dover. And then, of course, paper mills were huge in all of this area.
- Sarah Varney:As workers lost their jobs, more uninsured patients turned to rural hospitals desperate for medical care but unable to pay. While Mayo is facing financial uncertainty, at least three rural hospitals in Maine have closed in recent years.Deanna Chevery was laid off after 25 years when the Dexter Shoe factory closed in Dexter, Maine. Now 60 years old and uninsured, she’s recovering from an addiction to pain pills prescribed by her doctor for back pain.She overdosed five times, costing Mayo Regional Hospital over $200,000 in unreimbursed care. Before Chevery found the charity recovery program at Mayo Regional, she says she was turned away when she sought help because she couldn’t pay.
- Deanna Chevery:You can only go so many places. Nobody will take you. I mean, they don’t care if you’re crawling on the ground. I’m just fortunate Dover helps me.
- Sarah Varney:But Vienneau says the hospital cannot keep up with Maine’s growing opioid epidemic and ever-rising costs without expanded Medicaid.
- Marie Vienneau:You can only go so many years in a row where your business doesn’t lose money, before you depreciate to the point that you have to start closing services, decreasing services. And then access goes away.
- Sarah Varney:Medicaid advocates, like Maine Equal Justice Partners, are pressuring lawmakers to put the new law into effect quickly.
- Robyn Merrill:The law’s on our side. The facts are on our side. The reality of people’s lives are on our side. Did I say the law is on our side?(LAUGHTER)
- Sarah Varney:Victoria Rodriguez says people like Donna Wall, with her autistic children, need help quickly.
- Victoria Rodriguez:It’s really stressful to hear these stories from people who are literally just one accident away from being buried in medical debt and their families being devastated by that.
- Sarah Varney:The group has been receiving postcards from around the country congratulating them on becoming the 32nd state to expand Medicaid.
- Chris Hastedt:So, this one’s from Virginia. “Greetings from Virginia. Thanks, y’all, for your efforts. The majority of voters in Maine have resoundingly approved expanding Medicaid for 70,000 low-income people. Wahoo!”
- Sarah Varney:And advocates in many other red states that refused to expand Medicaid are eying their own ballot measures, including Nebraska, Utah, Idaho, Florida, and Missouri.Patrick Willard, a senior director at Families USA, a progressive advocacy group based in Washington, says after years of Republicans attacking the Affordable Care Act, voters are beginning to shift their views.
- Patrick Williard:What we have heard is that other states suddenly see an opportunity now to figure out a way that they can get around legislatures that have been holding this up.
- Sarah Varney:As state lawmakers in Maine work out the details of the new law, many disagree with LePage about how much it will cost. His administration estimates the price tag will be twice what the legislature’s nonpartisan Fiscal Office has projected.LePage says, if they can’t resolve the impasse, he will take legal action, if necessary.
- Gov. Paul LePage:We will go to court, because I know — listen, one thing that I know better than the legislature is financial responsibility. And I have proven it over the last seven years.
- Sarah Varney:Advocates say those who are eligible for Medicaid could enroll as early as this summer. But if there are delays, they too will sue.Just days after our interview, Donna Wall fell during her middle-of-the-night paper route and broke her ankle. She still doesn’t have health insurance and is unsure how she will care for her autistic children and uncertain what the future will bring.For the “PBS NewsHour” and Kaiser Health News, I’m Sarah Varney.On November 14, 2017, more than 200 activists, clinicians, policy makers and patients came together on Beacon Hill for what has been described as the largest demonstration of citizen support for the right to health - single payer health care - in recent memory in Massachusetts. Building off a day-long “Right to Health Organizer Bootcamp” training, activists came armed with skills, stories and tools for lobbying their State Representatives and Senators to push them in support of Improved Medicaid for All bills, S.619 and H.596.
The advocates gathered at the State House at ten o’clock for a preparation meeting and heard from speakers about the current moment in the right to health struggle in Massachusetts, a breakdown of how to engage in a successful advocacy lobby visit, and members of the State Legislature who urged the audience to keep up the fight. “When we get together for Thanksgiving and you sit around the table - and trust me, the kids are listening and everybody’s watching - talk about single-payer and why it’s important,” Senator Paul Feeney told participants. “I got that crazy uncle - everybody’s got that crazy uncle - ‘You’re a socialist, it doesn’t work, Paul.’ Now he says, ‘You’re a socialist, it doesn’t work, Senator.’”
for Medicare and Medicaid Services and a past candidate for Governor.Following the prep meeting, the right to health advocates gathered at the Grand Staircase and heard from a number of speakers including the sponsors of the bills, Senators James Eldridge and Julian Cyr, Representatives Barbara L’italian and Denise Garlick. The final keynote speaker was Don Berwick, MD, former head of the Centers
Now, we have a chance to build on this success. We need to build local teams of volunteer activists who can engage their local communities in conversations about what matters most to them in healthcare. We need to train local organizers in advocacy tactics such as lobby visits, direct action, and letter and op-ed writing. And we need to continue to articulate to the many members of the Legislature who are not yet on our side that we are growing a movement that will - someday soon - win the right to health for all people in the Commonwealth, and those across the United States as well. - Jon ShafferThe Lobby Day built on the remarkable victory of the State Senate’s including and passing Sen. Julian Cyr’s amendment to the omnibus healthcare spending bill that charges the state with measuring its annual health care spending against the projected costs of a single-payer system that “offers continuous, comprehensive, affordable coverage for all Massachusetts residents regardless of income, assets, health status, or availability of other health coverage.” If single-payer proved to be less expensive, officials would have to develop a plan to put that model into place.
“This is truly a huge progressive step forward for the Commonwealth and will help set the stage for the nation,” said Executive Director of Mass-Care Ture Turnbull. Mass-Care, the statewide campaign fighting for the creation of a single payer healthcare system, has been working for this for the last 22 years. “The last time this language was debated in the Senate was in 2012 and lost 15-22. This victory shows not only how far the Senate has come to progressive values but also where the conversation is across the Commonwealth. I want to thank Senator Cyr, Senator Eldridge, Senate President Rosenberg and all the advocates in Massachusetts fighting for healthcare justice.”Victory: Senate Passes a real pathway to Single Payer! Now on to the House!
In an historic move, on November 9th 2017 the Massachusetts Senate voted to bring the Commonwealth one step closer to more affordable, accessible and high-quality health care. The Senate adopted an amendment sponsored by Senator Julian Cyr that charges the state with measuring the impact a single-payer system would have on the cost and delivery of health care in Massachusetts. The amendment was adopted as part of a larger healthcare reform bill under consideration by the Senate.
It’s important to have a thorough cost analysis on single payer, including how it would compare to the current profit-driven system. Thorough analysis will show that single payer will save money while guaranteeing care for all residents.The amendment requires the state’s non-partisan Health Policy Commission to assess the potential performance and impact of a single-payer healthcare system. The state would collect data through the Center for Health Information & Analysis (CHIA) in order to develop a “single-payer benchmark,” the projected total cost of providing healthcare to all residents of Massachusetts. CHIA, the Health Policy Commission and the Division of Insurance would then be responsible for compiling a report on the performance of the single payer benchmark as compared to actual state spending on healthcare. If the benchmark is determined to outperform actual health care spending, the Health Policy Commission would be charged with submitting a “Single Payer Healthcare Implementation Plan” to the Legislature for consideration.
‘Forget About the Stigma’: Male
Nurses Explain Why Nursing
Is a Job of the Future for Menby Clair Cain Miller and Ruth Fremson - NYT - January 4, 2018Jake Creviston, a nurse practitioner, has been repeatedly mistaken for a doctor.Adam White says the veterans he cares for as a student nurse at the V.A. hospital feel comfortable around him because “I’m a big burly guy with a beard.”Glenn Fletcher, after being laid off from a lumber mill during the financial crisis, found a new career in nursing. And with it, “a really good feeling putting your head on the pillow realizing you’ve helped other people.”The experiences of male nurses offer lessons that could help address a problem of our time: how to prepare workers for the fastest-growing jobs, at a time when more than a quarter of adult men are not in the labor force.Only 13 percent of nurses in the United States are men, but that share has grown steadily since 1960, when the number was 2 percent, according to a working paperpublished in October by the Washington Center for Equitable Growth.“It’s not a flood, but it’s a change,” said Abigail Wozniak, an economist at the University of Notre Dame, who wrote the paper with Elizabeth Munnich, an economist at the University of Louisville. The biggest drivers, they found, were the changing economy and expanding gender roles.We talked to a dozen male nurses, with various career paths and specialties, working in the Pacific Northwest, where recruitment efforts have focused on bringing men into nursing. Some were drawn to the caregiving, others to the adrenaline of the work. It’s a reliable, well-paying job at a time when that’s hard to come by, they said, but also one they feel proud of.
“I’m sort of an adrenaline junkie, but it’s also the satisfaction of being able to help people, like when you have someone come in who’s overdosed and you treat them and see them turn around just like that.”J.R. McLain, 50Emergency department nurse; former Navy mechanic and truck driverJake Creviston, a nurse practitioner, has been repeatedly mistaken for a doctor.Adam White says the veterans he cares for as a student nurse at the V.A. hospital feel comfortable around him because “I’m a big burly guy with a beard.”Glenn Fletcher, after being laid off from a lumber mill during the financial crisis, found a new career in nursing. And with it, “a really good feeling putting your head on the pillow realizing you’ve helped other people.”The experiences of male nurses offer lessons that could help address a problem of our time: how to prepare workers for the fastest-growing jobs, at a time when more than a quarter of adult men are not in the labor force.Only 13 percent of nurses in the United States are men, but that share has grown steadily since 1960, when the number was 2 percent, according to a working paperpublished in October by the Washington Center for Equitable Growth.“It’s not a flood, but it’s a change,” said Abigail Wozniak, an economist at the University of Notre Dame, who wrote the paper with Elizabeth Munnich, an economist at the University of Louisville. The biggest drivers, they found, were the changing economy and expanding gender roles.We talked to a dozen male nurses, with various career paths and specialties, working in the Pacific Northwest, where recruitment efforts have focused on bringing men into nursing. Some were drawn to the caregiving, others to the adrenaline of the work. It’s a reliable, well-paying job at a time when that’s hard to come by, they said, but also one they feel proud of.
“When my wife told her grandfather that I graduated from nursing school, he just laughed. But I think there are more men who are less afraid to take on what have traditionally been considered feminine roles.”John-Flor Sisante, 38Recent nursing graduate interested in hospice nursing; former musician
“Walk around our hospital and all the call lights have pictures of females on them. I guess it was never thought of at the time that there might be a guy in here some day.”Glenn Fletcher, 49Operating room nurse; former lumber mill workerWomen have been entering male-dominated fields for decades, but it’s less commonfor a predominantly female occupation to have a substantial increase in its share of men. Yet the jobs that are shrinking tend to be male ones, and those that are growing are mostly female.Nursing is no paragon of gender equality: Even though men are a minority, they are paid more than women. The stigma against men still runs deep, particularly among older patients and in parts of the country with more traditional gender roles, nurses said. (Several said the movie “Meet the Parents,” in which Ben Stiller played a nurse whose girlfriend’s father wasn’t thrilled about his career, didn’t help.)But for some men, the notion that caregiving jobs are women’s work is outdated. Progressive attitudes about gender roles, as measured by the General Social Survey, were associated with more men who entered nursing, the new paper found.“This narrative that men can’t provide care in the way that women can is part of that broad cultural narrative that misunderstands what nursing’s about,” said Mr. White, the V.A. hospital student nurse, who is earning his nursing degree at Oregon Health and Science University in Portland. “We need to talk with young people about caring as a gender-neutral idea, but also as something that’s rooted in skills, in expertise.”
“When we notice that our boys are gifted in math and science and they say, ‘I want to be a doctor when I grow up,’ we could say, ‘That’s great, you could even be a nurse if you wanted to!’ ”Adam White, 35Nursing student; former banker
“You’re a caregiver, providing quality, dignified care. It’s not you doing it as a male or a female, but just generally as a caregiver.”Justin Kuunifaa, 41Family practice nurse; former in-home caregiverThe researchers also found that economic factors have played a role — a decline in some jobs because of automation, trade and the housing crisis, and a growth in jobs and wages in health care. Nursing is growing much faster than the average occupation, and wages have increased steadily since 1980. The median salary is $68,450, about the same as the median salary for college-educated workers over all.“A lot of those manufacturing jobs and things of that nature just aren’t there anymore,” said David Baca, an emergency department nurse in Medford, Ore. “We get paid a really livable wage, and I think that is now starting to attract more male nurses.”
“It’s a good profession because it’ll always be there. They’ll always need nurses. It can’t be outsourced, it can’t be automated.”David Baca, 37Emergency department nurse; former handyman
“My mother’s a nurse, but for some reason it had never occurred to me to become a nurse until I had a conversation with another man, who used to be an E.M.T. but became a nurse, and something just clicked.”Peter Stach, 36In-home palliative care nurse; former server and bartenderThe paper used census data about men who were born in the United States and turned 18 between 1973 and 2013. They found that the increase in male nurses was largely uniform across the country, although black and Hispanic men and those in rural areas were less likely to become nurses.Nursing is a career that both men and women often start later in life, in part because it’s possible to become certified midcareer and without a bachelor’s degree. But as hospitals increasingly require nurses to have a four-year degree, it could become a barrier for men who want to enter the field, the researchers said.“We learned that workers can take a very long time to settle into occupations, but that is not the traditional path that we think of when we think about training our work force,” Ms. Wozniak said.Male nurses are more likely than females to have worked as emergency medical technicians, military nurses or lab technicians, and to work in acute care in hospitals rather than primary care clinics. Nearly half of nurse anesthetists, one of the highest-paying nursing jobs, are men.In interviews, men said they liked the variety of work: Nurses can be bedside caregivers, surgery assistants, educators, technicians or administrators.
“Forget about the stigma. The pay is great, the opportunities are endless and you end up going home every day knowing that you did something very positive for someone else.”Jorge Gitler, 50Oncology nurse manager; former business owner
“Men desire to be caring, and you get a chance to have a career that allows you to care for people meaningfully.”Graham Seaton, 41Hospital infection prevention and neuro-trauma nurse; former retail and nonprofit workerSeveral said they felt an advantage in applying for nursing jobs because men are a minority in the field. Hospitals and patients benefit when nurses more closely reflect the patient population, research shows.Sometimes patients prefer a nurse of a certain sex, particularly for procedures like inserting a catheter, nurses said, and some men feel more comfortable talking openly with another man.“I work on this floor with people who just had urology surgery or amputations, and they have told me that when I come in the room and shut the door behind me, they feel more understood and can drop the tough guy attitude,” Mr. White said.Nursing became a woman’s job because women were seen as natural caregivers, said Patricia D’Antonio, a nursing historian at the University of Pennsylvania. But until the second half of the 19th century, men were assigned nursing jobs that required physical strength and bravery, like caring for patients during a dangerous epidemic. That began to change when Florence Nightingale brought a group of female nurses to the Crimean War in 1854.Nursing became such a gendered profession that men were barred from serving in the Army Nurse Corps during the two world wars. Not until the 1960s did the nursing field begin trying to better reflect its patients in terms of both gender and race, Ms. D’Antonio said.
“It’s not just a job. You have this sense of purpose, this sense of service, that you’re in this to really help improve people’s lives.”Jonathan Auld, 44Clinical nurse leader and nursing Ph.D. student; former elementary school teacherThe Oregon Center for Nursing, a work force development group, began recruitingmale and minority prospects to nursing in the early 2000s. It started a marketing campaign — “Are you man enough to be a nurse?” — that spread nationwide. Posters showed male nurses carrying a snowboard or wearing a motorcycle jacket.“It was just rethinking how we describe the work and focusing on the kind of person it takes to be a great nurse,” said Deborah Burton, who founded the center and is now chief nursing officer at Providence St. Joseph Health, a health care system in the West.More recently, efforts to recruit male nurses have focused less on gender and more on the rewards of the career, with the slogan, “Do what you love and you’ll love what you do.”Nurses said they welcomed the change. “I don’t think we’re doing any favors to society by conveying this message that nursing is this super masculine thing,” said Mr. Creviston, a psychiatric nurse practitioner and mental health nursing professor in Portland, Ore. “If your motive is to bring the right men into the field, show how rewarding it is to hold the hand of a dying person.”Susan Collins Moves The Goalposts (Again) On Her Health Care Demands
by Alice Ollstein - TPM - January 4, 2018When Sen. Susan Collins (R-ME) first announced she would support the GOP tax bill that killed Obamacare’s individual mandate, she insisted that three separate health care measures to prop up the Affordable Care Act and protect Medicare recipients be passed before she cast her vote. She then amended her demand, saying the bills had to pass before the tax bill came back from the House-Senate conference committee. She then insisted—after voting for the tax bill—that the policies pass by the end of 2017. When it became clear that wasn’t possible in the face of staunch oppositionfrom House conservatives, she expressed confidence they would become law in January.Now, Collins is moving the goalposts yet again.In an interview with Inside Health Policy published Thursday, Collins said she hopes the policies she proposed will pass and be implemented before 2019, when the repeal of the individual mandate is expected to shrink the individual insurance market by several million people and drive up premiums by at least 10 percent.“When the mandate is repealed in 2019, we must have other health care reforms in place in order to prevent further increases in the cost of health insurance,” Collins’ office said in a statement. “Senator Collins believes that averting these price spikes, particularly for low-income families, should be a goal that members of both parties can embrace.”One of the bills—dubbed Alexander-Murray after its bipartisan Senate authors—would restore government subsidies to insurance companies, known as cost sharing reduction (CSR) payments, that the Trump administration cut off earlier this year. The other would send states $500 million in 2018 to set up a reinsurance or high-risk pool program, and then $5 billion a year for 2019 and 2020.But it remains in dispute whether the two policies have any hope of passing Congress this year—considering prominent House members have characterized them as “welfare” and a “bailout” for insurance companies—or whether they would actually make in difference in stabilizing the health care market and lowering premiums.On the first, the ship may have sailed.Alexander-Murray was drafted before the Trump administration cut off the insurers’ subsidies, a move that surprisingly ended up giving millions of people access to better and cheaper plans than in previous years due to how state insurance officials adjusted their programs in response to President Trump’s decision. Though some middle class, un-subsidized Americans did see painful price hikes, the vast majority of people in the individual market were protected from premium increases by the Affordable Care Act’s subsidy structure. Adding the CSR payments back in now could cause even more disruption in the market.Even the policy’s original author, Sen. Patty Murray (D-WA), said in late December that it would not come close to mitigating the damage of repealing the individual mandate. “The bipartisan bill I originally agreed on with Chairman Alexander will not make up for this latest round of Republican health care sabotage,” she said. “In fact, there are changes that now need to be made to ensure it meets its intended goals of keeping premiums down and stabilizing markets.”As for the reinsurance-high-risk pool bill, health care experts have said it may prevent some premium increases, but would do nothing to prevent millions more people from becoming uninsured following the mandate’s repeal. Additionally, having already cast her vote for the tax bill, Collins’ leverage to get these measures past has significantly diminished.Remember Trump’s Pitch on Health Care Associations? Now We Know What He Meant
by Margot Sanger-Katz - NYT - January 5, 2018
When President Trump claimed last week that “I know the details of health care better than most, better than most,” it now appears he had a point in at least one area.
His meandering comments about health care and “associations” were confusing, and not totally accurate. But, in his remarks to Michael Schmidt of The New York Times, Mr. Trump previewed several tenets of a major regulation that was proposed by his Department of Labor on Thursday. And he articulated how the rule could interact with other health policy changes — and the consequences that could follow.Since his days as a candidate, Mr. Trump has consistently said that he wants to expand insurance access across state lines. And he has repeatedly argued that the decline and failure of Obamacare’s insurance markets would spur Democrats to come to the table and negotiate on some new plan. Thursday’s rule, amid other recent changes, aligns with both of those goals.The proposed rule is designed to make it easier for groups of individuals and small businesses to band together and buy the kind of insurance that large companies offer their workers. That kind of insurance is regulated under federal labor law and isn’t subject to all the requirements and consumer protections that apply to individual and small business insurance under Obamacare.Here’s what Mr. Trump said last week:Now here’s the good news. We’ve created associations, millions of people are joining associations. Millions. That were formerly in Obamacare or didn’t have insurance. Or didn’t have health care. Millions of people. That’s gonna be a big bill, you watch. It could be as high as 50 percent of the people. You watch. So that’s a big thing. And the individual mandate. So now you have associations, and people don’t even talk about the associations. That could be half the people are going to be joining up.As the proposal itself notes, “millions” of people might sign up for association plans, which could be made available to people who currently get insurance through a small business policy or buy it for themselves on the individual insurance market, as well as many people who currently lack health insurance.The Department of Labor identifies about 44 million people that it thinks would be eligible. (Fifty percent of the people is a stretch.) Those people include self-employed business owners who buy their own insurance, people in the small group insurance market, and people who do not get insurance, but might, if their company could find a cheaper option.The association rule is also likely to combine with other policy changes, as Mr. Trump notes. Congress recently repealed the Affordable Care Act’s individual mandate, which means that Americans who decline to buy insurance won’t face a penalty, beginning next year. Another regulation is expected soon that would permit insurers to offer short-term plans for longer periods, perhaps for a year. Mr. Trump is right that the associations are part of a larger set of policies meant to chip away at Obamacare, and are likely to destabilize its markets for individual and small business insurance.The degree of disruption these policies will cause remains unclear. But they are likely to work together. The individual mandate is believed to have pushed some healthy, reluctant shoppers to buy insurance, and they may no longer feel the nudge when it goes away.The rise of short-term policies that cover fewer benefits and charge higher prices to sick customers might pull some healthier customers out of the Obamacare markets. And the association plans, which, under the proposal, would be open to small businesses and self-employed sole proprietors, may also pull some healthier, younger customers from Obamacare plans.As Alice Ollstein at Talking Points Memo noted on Thursday, the rule says that the individual mandate will mitigate negative effects from associations and then mentions in a footnote that the mandate will go away next year. (That’s just one of a few conflicts and factual errors in the proposal.)Under the proposal, which may face legal challenges, associations aren’t allowed to explicitly discriminate against individual applicants on the basis of their health history. But experts say there are a number of subtle tools they can use to attract healthy customers and shun sick ones.Associations may become a more attractive coverage option for industries with lots of young, healthy workers — say, dog walkers — and less attractive for industries where workers are older and sicker, like, say, roofers. That’s because Obamacare premiums are designed to be the same for everyone who signs up, regardless of their health status. Over all, healthier people tend to pay more in the current market than they would in an association of similar people, but sicker people don’t.The association plans for workers in a shared industry could be across state lines, in keeping with Mr. Trump’s goal. The rule also allows associations to set geographic limitations on enrollment, allowing unrelated businesses in a similar geographic area to join together. (Rural areas, which tend to be expensive, could be excluded.)In many cases, associations would also be free to customize their benefits packages, and avoid covering expensive treatments. A plan that doesn’t cover substance-abuse treatment or medications for rheumatoid arthritis might be cheaper, but would push people who know they need those therapies into the Obamacare market instead, where all plans have to cover a set of “essential health benefits.”Most dog walkers who do not have arthritis or psychiatric illnesses may not mind — or even notice, unless their health status changes.Some proponents of the package of Trump administration policies say they will not make a big enough difference to upend the markets that remain, but say that the new options will provide more affordable coverage to people who have stayed uninsured under the current system.But Obamacare advocates are very worried. Mr. Trump has said many times that Obamacare’s death would bring about cooperation from Democrats in creating an alternative. In his Times interview, he specifically says that the policy brew of associations and mandate repeal could be what it takes to prompt bipartisan compromise.“I believe that because of the individual mandate and the associations, the Democrats will and certainly should come to me and see if they can do a really great health care plan for the remaining people,” he said.Maine restoring public health nursing workforce
by Joe Lawlor - Portland Press Herald - January 5, 2018Maine’s public health nursing workforce will more than double in the coming months and take on expanded duties – such as responding to the opioid crisis, according to the commissioner of Maine’s Department of Health and Human Services.The public health nursing staff – front-line nurses who respond to infectious disease outbreaks and perform a number of health prevention duties – has been slashed by more than half under Gov. Paul LePage’s administration, declining from 59 in 2011 to about 25 positions in early 2017.The staff increase for 2018 is being driven by a new law sponsored by Sen. Brownie Carson, D-Brunswick, that requires Maine to have at least 50 public health nurses on staff, a measure originally opposed by the LePage administration but now supported by DHHS.It’s an about-face from last spring, when state health officials testified against the bill in April and LePage vetoed it. The Legislature overrode the veto last summer.Ricker Hamilton, DHHS commissioner, told the Press Herald in an interview Wednesday that he has “always known the value of public health nursing” in his 41-year career with the department.“Public health nurses have always been a high priority for me,” Hamilton said. “We’re re-committed and re-energized with this process. We want it to succeed and it will.”Advertisement
Hamilton, a career DHHS employee, became acting commissioner in June after Mary Mayhew announced she would seek the 2018 Republican nomination for governor. Mayhew is a conservative who is closely aligned with LePage and worked on reforming public health and welfare programs during her tenure in his administration.Hamilton was nominated and confirmed as permanent DHHS commissioner in October, after having served the department in a number of capacities under Democratic, Republican and independent administrations since the 1970s. He said he worked closely with public health nurses when he was the program director for adult protective services many years ago.“They are true educators, and they’re very much connected to their communities,” Hamilton said. “They’re essential, a tremendous asset.”Seven of the nursing positions have been filled so far, and the department has received more than 30 applications during a nursing shortage. The salary range is $40,000 to $55,000, depending on education and experience.“We’re having a great response. What we’re finding is there’s a passion for this kind of work,” Hamilton said.He said some previous criticism of the system was correct in that there was not enough documentation of what public health nurses were doing, which may have helped feed a perception that the positions could be cut back.Advertisement
Dr. Dora Anne Mills, vice president of clinical affairs at the University of New England and former Maine Center for Disease Control director, said that Hamilton is well-positioned to restore the service because “he understands public health nursing in a way that many would not.”“This is fantastic news, particularly for infants and their families,” Mills said, pointing out that one of the roles for public health nurses is to help at-risk new and expecting moms. About one out of every 12 babies born in Maine is drug-affected, according to the Maine CDC, and Mills said public health nurses could play a vital role in bringing those numbers down.Mills said public health nurses “saved many lives” during the 1998 ice storm, going door-to-door in hard-hit areas without power, making sure families knew about the dangers of carbon monoxide poisoning from improperly vented alternative heating sources. She said the nurses also came through running vaccine clinics during the H1N1 flu epidemic in 2009.Hamilton said details of how the nurses’ role might change will be forthcoming once the staff is at full strength, but he anticipates that in addition to their normal duties, the nurses will work on the opioid crisis, and issues such as elder abuse, child abuse and helping those with intellectual disabilities.He said the nurses will keep tabs on “emerging health problems” and will respond when needed.Carson, the bill’s sponsor, said it’s “hugely important” to have the administration on board with boosting the public health nursing workforce, and not doing the minimum to comply with the law.Advertisement
“For them to recognize the value of public health nursing is extraordinary,” Carson said.He said a key to raising awareness last year was getting Republican state lawmakers who represented rural areas on board. Once they recognized the value, mandating that the administration hire more was an easier sell.“There’s a lot of isolated, frail elderly people in rural Maine who rely on public health nurses for well visits,” Carson said. “These positions had been set aside in the budget for seven years, but they weren’t being filled. The only way to get them filled was to pass legislation requiring it.”http://www.pressherald.com/2018/01/05/maine-restoring-public-health-nursing-workforce/
Diabetes Shouldn’t Bankrupt You
by Elizabeth Rosenthal - NYT - January 6, 2018If there was one thing that doomed the Republican proposals to remake health care last year, it was the great uncertainty about how they would cover patients with chronic illness and pre-existing conditions.Throngs of people with a wide range of ailments staged dramatic protests in and around the halls of Congress during the debate. Night after night, Jimmy Kimmel, whose infant son was born with a serious congenital heart defect, took up the cause on his talk show.Only one in five people approved of the last failed Republican bill, Graham-Cassidy. A big reason: 87 percent of respondents, including 79 percent of Republicans, said in one poll that insurers should be required to cover people with pre-existing conditions. The bill could have allowed insurers in certain states to charge more for such coverage.Who doesn’t have a family member or friend with a long-term or potentially recurring medical condition, whose life is maintained by expensive treatments — patients with diseases like Type 1 diabetes, multiple sclerosis, rheumatoid arthritis, heart failure, cystic fibrosis and cancer? They are grateful for medical innovations that allow them to lead long, productive lives but afraid of financial ruin or an inability to get good coverage.But there is one large group of patients whom the federal government long ago effectively immunized against these now-widespread fears. Through a quiet act of Congress in 1972, people on dialysis with end-stage kidney failure can gain automatic Medicare coverage.When the law passed, dialysis patients probably seemed pretty exceptional: They needed a lifesaving treatment, at a potentially bankrupting price, for the rest of their lives. But today people with many diseases fit that description. That’s why, as the United States attempts to rein in its $3 trillion annual medical bill and revamp its health care system, any plan must involve a solution for people with serious chronic illness, like the one developed for kidney failure almost half a century ago.“This is an increasingly important issue as we get better at treatments and the risk and costs of chronic illnesses get more predictable,” said Mark McClellan, a former head of the Centers for Medicare and Medicaid Services and the Food and Drug Administration under President George W. Bush, who is now a professor of business, medicine and policy at Duke University.The high cost of treating chronic illnesses poses a problem for every country. In the United States, it once meant that commercial insurers rejected such patients or charged them sky-high rates. The Affordable Care Act made such practices illegal, but even now insured people with chronic illnesses often face unaffordable costs in an era of high deductibles and co-payments.With varying success, other countries have found their own solutions, though mostly starting from different places.“If you have a chronic disease, you shouldn’t be burdened by the cost,” said York F. Zöllner, professor of health economics at Hamburg University of Applied Sciences, explaining the German approach. “It’s not your fault.” He and others note that conventional insurance is meant to cover unpredictable costs. But the costs of chronic illnesses are predictably high.Germany offers people with chronic disease better-than-standard coverage. Every German is required to have insurance — and guaranteed access to it — typically through more than 100 public nonprofit insurers. People can pick which “sickness fund” to join, and the system is financed through a “contribution” equal to roughly 15 percent of their income — nearly half coming from their employer and the rest from their paycheck. The total payment is capped at about 650 euros per month for adults, which includes coverage for dependent relatives.While co-payments exist — for prescriptions and hospital stays, for example — they are capped at 2 percent of gross earnings, and people with chronic disease pay half of that, according to Dr. Zöllner, with their out-of-pocket spending on health cost capped at 1 percent of income.Since expensive prescription drugs are a big component of many treatments, Germany’s state health insurers have been negotiating prices with drugmakers since 2011, and drug prices there are generally lower than in the United States. The patient contribution for any prescription is five to 10 euros.Kaitlyn West, an American with Type 1 diabetes who recently moved to Germany for graduate school, said that in the United States she had been paying on average $400 per month in out-of-pocket expenses — close to $5,000 each year. The amount fluctuated wildly depending on how her insurance policy at the moment covered her pumps and medicines.On German public insurance, the monthly contribution is about $105 and her yearly out-of-pocket spending is capped at about $140 for supplies and $45 for insulin. “There are no fees for doctors’ visits, no fees for my blood draws and no hassle getting things done,” she said. “This system allows me to live a normal, stress-free life.”The German health system is based on the principle of solidarity, not individuality, Dr. Zöllner said. But reframed to appeal to current American concerns, it might translate: “There but for the grace of God go I,” since at this point there are so many treatable chronic diseases. The congressional logic that led to the 1972 kidney-care exception could apply to any of those conditions.In the 1960s, outpatient dialysis clinics and kidney transplantation were relatively new and too expensive for most patients, leaving insurers and employers to make hard choices about whether to pay for treatment.Against that backdrop, kidney specialists and lobbyists, including from the National Kidney Foundation, pressed for funding of treatment. One protest featured a patient being connected to dialysis on the House floor. An amendment to a Social Security bill in 1972 allowed kidney patients to enroll in Medicare.“It is one of the most interesting cases in health care because it’s unique in how we treated a chronic condition,” said Tonya Saffer, senior health policy director at the foundation. “It’s been lifesaving.”While protecting patients from death and financial ruin, the program has also come with lessons. Once people with kidney disease had Medicare coverage, outpatient dialysis centers popped up across the country to serve a new cohort of paying patients. As the business of medicine grew, treatment was progressively taken over by a small number of for-profit companies with which Medicare and commercial insurers have been locked in a perpetual tug-of-war over potentially exploitative billing. Dialysis centers, for example, were billing not just for the dialysis but also for expensive drugs that were sometimes overused.To prevent abuses, Medicare today reimburses dialysis by paying a set amount for each treatment session, with a typical limit of three per week, although advocates question whether that number is sufficient. This model, where providers get a “bundled payment” for each treatment session or a per-person payment for each month of care, could be used to cover all sorts of chronic diseases while controlling costs, whether through Medicare or not, Dr. McClellan said.In 1972, when Congress passed the amendment, many assumed that the kidney entitlement was a temporary measure, and that the United States would soon have some kind of national health system. But Richard Rettig, a historian of medicine, wrote that, in the end, it “was added to Medicare because the moral cost of failing to provide lifesaving care was deemed to be greater than the financial cost of doing so.”Isn’t that just as true now?Humira’s Best-Selling Drug Formula: Start at a High Price. Go Higher.
by Danny Hakim - NYT - January 5, 2018Humira is the best-selling prescription drug in the world. You may have seen the commercials.Because of Humira, a woman with rheumatoid arthritis can wash her puppy in the bathtub, another with colitis can stroll happily through a fair packed with food vendors, while a third suffering from psoriasis can go to the gym without hiding her neck.But they probably wouldn’t all look so relieved if they saw the bill. The price of Humira, an anti-inflammatory drug dispensed in an injectable pen, has risen from about $19,000 a year in 2012, to more than $38,000 today, per patient, after rebates, according to SSR Health, a research firm. That’s an increase of 100 percent.Pharma bosses probably miss Martin Shkreli, the reigning villain of the industry. If you’ll recall, Mr. Shkreli, as chief executive of Turing Pharmaceuticals, acquired Daraprim, a drug used to fight infections in AIDS patients, and then raised the priceovernight to $750 a pill from $13.50. He also trolled critics and spent $2 million on a one-of-a-kind Wu Tang Clan album, before his conviction on three securities fraud charges last year.For a time, Mr. Shkreli’s antics, along with the soaring price of EpiPens, sold by Mylan, deflected attention from the rest of the industry. A more typical play for drug companies — the Humira play — is to start at a high price and keep raising it ever higher, but incrementally.“What they have done with Humira is just as unfair, just as morally wrong, but they did it over five years,” said Ben Wakana, a former Obama administration spokesman who became executive director of Patients for Affordable Drugs, an advocacy group, because his younger brother couldn’t afford Humira without the financial support of their parents.“People are skipping doses, people are rationing, people are going into bankruptcy because of this drug,” he said in an interview, arguing that Humira is both more expensive per dose and has a far higher volume than Daraprim.AbbVie, which was spun off from Abbott Laboratories in 2013, declined to comment.How much you actually pay out of pocket, and whether you can afford Humira at all, depend on your insurance and eligibility for discounts.Anne Marie Garza, 51, an administrative assistant in Houston who suffers from colitis and Crohn’s disease, said she had held off buying her latest dose because her insurer had changed. She was trying to see if she could avoid an out-of-pocket payment of more than $1,200, one of two she would have to make this year, on top of her rising expenses for vitamins and supplements to manage the disease. She has relatively good insurance, but the payments will strain her budget.“During the holidays, I was contemplating what am I’m going to do,” she said. “I was thinking should I just go on a liquid diet, because I can’t afford this.”It’s a difficult choice.“It does give you your life back,” she said of the drug. “I literally couldn’t go away from the house or very far from a bathroom, 20, 25 times in the bathroom all day long, I can’t imagine living like that,” she said, adding, “I was becoming a hermit because I was so sick.”Humira, which accounted for nearly two-thirds of AbbVie’s $25.6 billion in revenue in 2016, was not simple to develop. It is among a new class of drugs known as biologics, which are made from living cells rather than synthetic chemicals. The industry has argued that high American prices are needed to fund drug development, but a 2016 study published by the Journal of the American Medical Association found “no evidence of an association between research and development costs and prices; rather, prescription drugs are priced in the United States primarily on the basis of what the market will bear.”Competitive pressures have been muted. Copies of biologic drugs, known as biosimilars, are not as easy to produce as normal generic drugs, and AbbVie’s aggressive patent strategy has allowed it to further push off rivals. While there are name brand competitors to Humira, they are not exactly alike, complicating efforts by doctors or insurers to switch a patient from one drug to another.Looking at the international picture tells its own story about drug costs. A prefilled carton with two syringes costs $2,669 in the United States, compared with $1,362 in Britain, $822 in Switzerland and $552 in South Africa, according to a 2015 reportfrom the International Federation of Health Plans.“You’ve got the largest market for pharmaceuticals, which has the highest prices,” said Christopher Raymond, senior biotech analyst at Piper Jaffray. “That doesn’t make any sense.”But it is typical. Other countries have single-payer systems, like Britain’s National Health Service, that negotiate with drug companies or governments that exert price controls.AbbVie has put some of its earnings to work lobbying against efforts at price controls in the United States, recently in California. The industry also successfully lobbied in 2006 to bar Medicare from negotiating over drug prices. While President Trump once talked about taking action on drug prices, his administration did not follow through in the health care debate last year.By contrast, Britain’s National Health Service, while strained of late, has more formidable negotiating leverage.“I do think we need something like that in the United States, not the N.H.S. broadly, but some means of dealing with the extreme pricing instances,” said Richard Evans, founder of SSR Health.An analysis by the Institute for Clinical and Economic Review found that Humira’s list price would need to be discounted by at least 55 percent to be cost effective for rheumatoid arthritis, its originally approved use.Dr. Steven D. Pearson, the founder of the institute, which provides cost benefit data to health plans, said competing drugs were overpriced as well.“Even in a space like this, where there is a lot of competition, we don’t see the prices coming down,” he said. “That speaks to the fact that it doesn’t often function like a free market usually would.”For now, Americans have to rely on the generosity of the drug industry, such as it is. I took a spin through AbbVie’s corporate Code of Conduct, entitled “Inspired by Integrity.” It’s a lofty document. “WE ARE COMMITTED TO IMPROVING PATIENTS’ LIVES,” it says, in all caps.It even makes a point of saying that AbbVie supports the United Nation’s Universal Declaration of Human Rights. That declaration, if you read it, says, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care.”AbbVie joined a few of its rivals in saying it would limit price increases to single digits this year, and so only raised Humira by another 9.7 percent this month, roughly four and a half times the inflation rate. For the drug industry, that counts as generosity.
Care Suffers as More Nursing Homes Feed Money Into Corporate Webs
by Jordan Rau - NYT - January 2, 2018MEMPHIS — When one of Martha Jane Pierce’s sons peeled back the white sock that had been covering his 82-year-old mother’s right foot for a month, he discovered rotting flesh.“It looked like a piece of black charcoal” and smelled “like death,” her daughter Cindy Hatfield later testified. After Mrs. Pierce, a patient at a nursing home in Memphis, was transferred to a hospital, a surgeon had to amputate much of her leg.One explanation for Mrs. Pierce’s lackluster care in 2009, according to financial records and testimony in a lawsuit brought by the Pierce family, is that the nursing home, Allenbrooke Nursing and Rehabilitation Center, appeared to have been severely underfunded at the time, with a $2 million deficit on its books and a scarcity of nurses and aides. “Sometimes we’d be short of diapers, sheets, linens,” one nurse testified.That same year, $2.8 million of the facility’s $12 million in operating expenses went to a constellation of corporations controlled by two Long Island accountants who, court records show, owned Allenbrooke and 32 other nursing homes. The homes paid the men’s other companies to provide physical therapy, management, drugs and other services, from which the owners reaped profits.In what has become an increasingly common business arrangement, owners of nursing homes outsource a wide variety of goods and services to companies in which they have a financial interest or that they control. Nearly three-quarters of nursing homes in the United States — more than 11,000 — have such business dealings, known as related party transactions, according to an analysis of nursing home financial records by Kaiser Health News. Some homes even contract out basic functions like management or rent their own building from a sister corporation, saying it is an efficient way of running their businesses and can help minimize taxes.Contracts with related companies accounted for $11 billion of nursing home spending in 2015 — a tenth of their costs — according to financial disclosures the homes submitted to Medicare.These arrangements offer an additional advantage: Owners can arrange highly favorable contracts in which their nursing homes pay more than they might in a competitive market. Owners then siphon off higher profits, which are not recorded on the nursing home’s accounts.The two Long Island men, Donald Denz and Norbert Bennett, and their families’ trusts collected distributions totaling $40 million from their chain’s $145 million in revenue over eight years — a 28 percent margin, legal documents show. In 2014 alone, Mr. Denz earned $13 million and Mr. Bennett made $12 million, principally from their nursing home companies, according to personal income tax filings. Typical nursing home profits are “in the 3 to 4 percent range,” said Bill Ulrich, a nursing home financial consultant.In California, the state auditor is examining related party transactions at another nursing home chain, Brius Healthcare Services, regarding reimbursements from the state’s Medicaid program. Rental prices to real estate companies related to the chain of homes were a third higher than rates paid by other for-profit nursing homes in the same counties, according to an analysis by the National Union of Healthcare Workers.Dr. Michael Wasserman, the head of the management company for the Brius nursing homes, called the subject of corporate structures a “nonissue” and said, “What matters at the end of the day is what the care being delivered is about.”Such corporate webs bring owners a legal benefit, too: When a nursing home is sued, injured residents and their families have a much harder time collecting money from the related companies — the ones with the full coffers. Courts set a high bar for plaintiffs to bring these ancillary companies into their cases.After the Pierce family won a rare verdict against the nursing home owners, Mr. Denz and Mr. Bennett appealed, and their lawyer, Craig Conley, said they would not discuss the case or their business while the appeal was pending.“For more than a decade, Allenbrooke’s caregivers have promoted the health, safety and welfare of their residents,” Mr. Conley wrote in an email.Networks of jointly owned limited liability corporations are fully legal and widely used in other businesses, such as restaurants and retailers. Nonprofit nursing homes sometimes use them as well. Owners can have more control over operations — and better allocate resources — if they own all the companies. In many cases, industry consultants say, a related company will charge a nursing home lower fees than an independent contractor might, leaving the chain with more resources.“You don’t want to pay for someone else to make money off of you,” Mr. Ulrich, the consultant, said. “You want to retain that within your organization.”But a Kaiser Health News analysis of inspection and quality records reveals that nursing homes that outsource to related organizations tend to have significant shortcomings: They have fewer nurses and aides per patient, they have higher rates of patient injuries and unsafe practices, and they are the subject of complaints almost twice as often as independent homes.“Almost every single one of these chains is doing the same thing,” said Charlene Harrington, a professor emeritus of the School of Nursing at the University of California, San Francisco. “They’re just pulling money away from staffing.”Early Signs of Trouble
Martha Jane Pierce moved to Allenbrooke in 2008 in the early stages of dementia. According to testimony in the family’s lawsuit, when her children visited they often discovered her unwashed, with an uneaten, cold meal sitting beside her bed. Mrs. Hatfield said in court that she had frequently found her mother’s bed soaked in urine. The front desk was sometimes vacant, her brother Glenn Pierce testified.“If you went in on the weekend, you’d be lucky to find one nurse there,” he said in an interview.After a stroke, Mrs. Pierce became partly paralyzed and nonverbal, but the nursing home did not increase the attention she received, said Carey Acerra, one of Mrs. Pierce’s lawyers. When Mrs. Pierce’s children visited, they rarely saw aides reposition her in bed every two hours, the standard practice to prevent bedsores.“Not having enough staffing, we can’t — we weren’t actually able to go and do that,” one nurse, Cheryl Gatlin-Andrews, said in a deposition.Kaiser Health News’s analysis of inspection, staffing and financial records nationwide found shortcomings at other homes with similar corporate structures:■ Homes that did business with sister companies employed, on average, 8 percent fewer nurses and aides.■ As a group, these homes were 9 percent more likely to have hurt residents or put them in immediate jeopardy of harm, and amassed 53 substantiated complaints for every 1,000 beds, compared with 32 per 1,000 beds at independent homes.■ Homes with related companies were fined 22 percent more often for serious health violations than independent homes, and penalties averaged $24,441 — 7 percent higher.For-profit nursing homes utilize related corporations more frequently than nonprofits do, and have fared worse than independent for-profit homes in fines, complaints and staffing, the analysis found. Their fines averaged $25,345, which was 10 percent higher than fines for independent for-profits, and the homes received 24 percent more substantiated complaints from residents. Overall staffing was 4 percent lower than at independent for-profits.Ernest Tosh, a plaintiffs’ lawyer in Texas who helps other lawyers untangle nursing company finances, said owners often exerted control by setting tight budgets that restricted the number of nurses the homes could employ. Meanwhile, “money is siphoned out to these related parties,” he said. “The cash flow gets really obscured through the related party transactions.”The American Health Care Association, which represents nursing homes, disputed any link between related businesses and poor care. “Our members strive to provide quality care at an affordable cost to every resident,” the group said in a statement. “There will always be examples of exceptions, but those few do not represent the majority of our profession.”‘Piercing the Corporate Veil’
The model of placing nursing homes and related businesses in separate limited liability corporations and partnerships has gained popularity as the industry has consolidated through purchases by publicly traded companies, private investors and private equity firms. A 2003 article in the Journal of Health Law encouraged owners to separate their nursing home business into detached entities to protect themselves if the government tried to recoup overpayments or if juries levied large negligence judgments.“Holding the real estate in a separate real-property entity that leases the nursing home to the operating entity protects the assets by making the real estate unavailable for collection by judgment creditors of the operating entity,” the authors wrote. Such restructuring, they added, was probably not worth it just for “administrative simplicity.”In 2009, Harvard Medical School researchers found the practice had flourished among nursing homes in Texas, which they studied because of the availability of state data. Owners had also inserted additional corporations between themselves and their nursing homes, with many separated by three layers.To bring related companies into a lawsuit, attorneys must persuade judges that all the companies were essentially acting as one entity and that the nursing home could not make its own decisions. Often that requires getting access to internal company documents and emails. Even harder is holding owners personally responsible for the actions of a corporation — known as “piercing the corporate veil.”At a conference for executives in the long-term health care industry in Nashville in 2012, a presentation slide from nursing home attorneys titled “Pros of Complex Corporate Structure” said, “Many plaintiffs’ attorneys will never conduct corporate structure discovery because it’s too expensive and time consuming.” The presentation noted another advantage: “Financial statement in punitive damages phase shows less income and assets.”A lawyer in Alabama, Barry Walker, is still fighting an 11-year-old case against another nursing home then owned by Mr. Denz and Mr. Bennett. Mr. Walker traced the ownership of Fairfield Nursing and Rehabilitation Center back to the men, but he said the judge had allowed him to introduce the information only after the Alabama Supreme Court ordered the judge to do so. That trial ended with a hung jury, and Mr. Walker said a subsequent judge had not let him present all the information to two other juries, and he dropped the men from the lawsuit. The home closed a few years ago but the case is still ongoing, after two mistrials.“The former trial judge and the current trial judge quite frankly don’t seem to understand piercing the corporate veil,” he said. “My firm invested more in the case than we can ever hope to recover. Sometimes it’s a matter of principle.”The complexity of the ownership in Mrs. Pierce’s case was a major reason it took six years to get to a trial, said Ken Connor, one of the lawyers for her family. “It requires a lot of digging to unearth what’s really going on,” he said. “Most lawyers can’t afford to do that.”The research paid off in a rare result: In 2016, the jury issued a $30 million verdict for negligence, of which Mr. Denz and Mr. Bennett were personally liable for $20 million. The men’s own tax returns had bolstered the case against them. They claimed during trial they delegated daily responsibilities for residents to the home’s administrators, but they reported on their tax returns that they “actively” participated in the management. The jury did not find the nursing home responsible for her death later in 2009.The appeal brought by Mr. Denz and Mr. Bennett challenges both the verdict and their inclusion. They argue that Tennessee courts should not have jurisdiction over them since they spent little time in the state and neither was involved in the daily operations of the home or in setting staffing levels. Their lawyers said jurors should never have heard from nurses who hadn’t cared directly for Mrs. Pierce.“No way did I oversee resident care issues,” Mr. Bennett said in a deposition.Deficient in the End
Whoever was responsible for Mrs. Pierce’s care, her family had no doubt it had been inadequate. Her son Bill Pierce was so horrified when he finally saw the wound on his mother’s foot, he immediately insisted that she go to the hospital.Mrs. Hatfield said the surgeon had told the family that “he had never seen anything like it.”“He amputated 60 percent of the leg, above the knee,” she said.After the amputation, Mrs. Pierce returned to the nursing home because her family did not want to separate her from her husband, who was also there.At the trial, the nursing home’s lawyers argued that Mrs. Pierce’s leg had deteriorated not because of the infection but because her blood vessels had become damaged from a decline in circulation. The jury was unpersuaded after nurses and aides testified about how Allenbrooke would add staffing for state inspections while the rest of the time their pleas for more support went unheeded.Workers also testified that supervisors had told them to fill in blanks in medical records regardless of accuracy. One example: Allenbrooke’s records indicated that Mrs. Pierce had eaten a full meal the day after she died.Medical Research? Congress Cheers. Medical Care? Congress Brawls.
by Robert Pear - January 6, 2018WASHINGTON — They cannot agree on subsidies for low-income people under the Affordable Care Act or even how to extend funding for the broadly popular Children’s Health Insurance Program — two issues requiring urgent attention as Congress returns to work.But a more exotic corner of the medical world has drawn rapturous agreement among Republicans and Democrats: the development of new treatments and cures through taxpayer-funded biomedical research.For the third straight year, lawmakers are planning to increase the budget of the National Institutes of Health by $2 billion. In the process, they have summarily rejected cuts proposed by President Trump.The push for additional funding reflects a fascination among legislators with advances in fields like molecular biology, genetics and regenerative medicine, even as they wage bitter battles over just how large a role the government should play in financing health care and providing coverage.At a recent hearing, Senators Lamar Alexander of Tennessee and Tim Scott of South Carolina, both Republicans, and Maggie Hassan of New Hampshire, a Democrat, pressed scientists to explain exactly how gene editing technology could lead to new treatments for sickle cell anemia, H.I.V., cystic fibrosis, Alzheimer’s and other diseases.Ms. Hassan wanted to know the relative merits of different techniques for editing DNA and RNA — what she called “this incredible cutting-edge technology.”Why is medical research so much less contentious than fundamental issues like health insurance coverage?Anthony J. Mazzaschi, a lobbyist at the national organization representing schools of public health, said that “the charisma of the cure, the hope and promise of curing disease, seems to excite members of Congress,” including some in their 70s and 80s who are “facing the prospect of disease and disability head-on.”And that prospect is bipartisan. “Disease doesn’t impact just Republicans or Democrats,” said Representative Diana DeGette, Democrat of Colorado. “It impacts everybody.”While the search for new treatments and cures is advancing at breakneck speed, ideas about how to help patients pay for them lag far behind. And Republicans who sometimes laud the N.I.H. as the National Institutes of Hope also support dismantling the Affordable Care Act, which could limit access to the new treatments.“If we are spending billions to incentivize the development of new drugs, I think we also have to ensure that patients can afford those drugs,” said Representative Jan Schakowsky, Democrat of Illinois. “It is almost cruel to find a cure and then have it priced so high that a patient can’t afford it.”The challenges facing patients and policymakers were illustrated this past week when a Philadelphia company said it would charge $850,000 for a new gene therapy to treat a rare inherited form of blindness. (The company, Spark Therapeutics, said it would pay rebates to certain insurers if the medicine, given in a one-time injection, did not work as promised.)Members of Congress have friends, relatives and constituents who suffer from cancer, Alzheimer’s and other diseases, but lawmakers may have less interaction with people who are uninsured and unable to afford doctor visits or prescription drugs.“Sadly,” said R. Alta Charo, a professor of law and bioethics at the University of Wisconsin at Madison, “the cynic in me says it’s because of the prevalence of selfishness. We all want to know there’s something out there that will cure us if we need it, but many of us are quite reluctant to pay for somebody else to get cured when they need it.”Sherri J. Bale, a geneticist who worked at the N.I.H. for 16 years before founding GeneDx, a genetic testing company in Gaithersburg, Md., said: “Gene therapy has fabulous promise. We will soon be able to treat and even cure people with genetic diseases where we previously had nothing at all to offer them. But where are they supposed to get the money to pay for these treatments — thousands of dollars a month?”“What good is the research if all you do is treat people in a clinical trial and publish a few papers?” Ms. Bale asked. “I’m afraid that patients will be left in the lurch.”With huge bipartisan majorities, Congress in 2016 passed the 21st Century Cures Act, to speed the discovery of cures and the approval of new drugs and medical devices. Senator Mitch McConnell of Kentucky, the majority leader, called it “the most significant legislation” passed by Congress in 2015-16.Nine-year-old Max Schill of Williamstown, N.J., who has a rare genetic condition known as Noonan syndrome, which causes heart defects and growth delays, was the public face of patients who could benefit from that legislation.“Max bravely visited nearly every senator’s office with handmade drawings asking for support,” said Senator Robert Menendez, Democrat of New Jersey.But while a few children with rare diseases can sometimes elicit an outpouring of concern, millions of Americans continue to lack health insurance.A month after President Barack Obama signed the medical cures bill in December 2016, surrounded by members of both parties, Republicans in Congress ramped up their campaign to demolish the Affordable Care Act — a law that Mr. McConnell once described as “the single worst piece of legislation that has been passed in the last half-century.”Republicans in Congress and the Trump administration appear uncertain whether they want to repeal what remains of the Affordable Care Act or stabilize insurance marketplaces created by the law. They cannot agree among themselves, much less with Democrats, over the future direction of federal health policy.Funds for the Children’s Health Insurance Program, which serves nearly nine million children, and for community health centers, which serve more than 24 million patients, are in limbo because of inaction by Congress.The partisan divide was evident last week when Mr. Trump proposed to relax certain health insurance rules. Senator Alexander and other Republicans hailed the move as a way to reduce costs for 11 million small-business employees and self-employed people.But the House Democratic leader, Nancy Pelosi of California, said the president’s proposal was a recipe for “junk health insurance” that would strip consumers of vital protections provided by the Affordable Care Act.Bipartisan Senate efforts to stabilize insurance markets face long odds in the House.Mr. Alexander, the chairman of the Senate health committee, and Senator Patty Murray of Washington, the senior Democrat on the panel, drafted a bill to continue paying cost-sharing subsidies to insurance companies on behalf of low-income people.But their bill met fierce resistance from conservative House Republicans, who said it would prop up the health law and bail out insurers.By contrast, the appeal of biomedical research often appears to transcend politics. In a decision applauded by scientists, Mr. Trump decided to retain the director of the National Institutes of Health, Dr. Francis S. Collins, who led the government’s 15-year effort to map the human genome and inspires lawmakers with his infectious enthusiasm for medical research.When Dr. Collins and Scott Gottlieb, the commissioner of the Food and Drug Administration, appeared at House and Senate hearings to assess progress under the Cures Act, one theme ran through questions from members of both parties: What more can we do to help you?The N.I.H. has an annual budget of roughly $34 billion, and over 80 percent of it goes out in grants to more than 300,000 scientists at universities, medical schools and other research institutions that can lobby local members of Congress.Dr. Matthew H. Porteus, a pediatrician and stem cell biologist at Stanford University who testified at the Senate hearing on gene editing, said he was impressed with the level of congressional interest and surprised at the lack of partisanship.“The senators’ questions were spoken as if they were experts,” he said. “If you didn’t know what party each senator belonged to, you’d have no idea, based on the questions they asked.”At the same time, Dr. Porteus said, “it’s really disappointing” that Congress has been unable to find money for a long-term extension of the Children’s Health Insurance Program.“If you can’t provide the best possible care for people today, and CHIP is an essential part of that for millions of children,” Dr. Porteus said, “you’ll be in a poor position to provide advanced care to people in the future.”
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