A Labor-Based Movement For Medicare for All
by Michael Lighty - The Sanders Institute - March 15, 2018
Healthcare is the crossroads where the assault on workers meets the juggernaut of “crony capitalism.” That’s the term used by the mainstream neo-classical and Nobel prize-winning economist Angus Deaton to describe the coziness between the healthcare industry and its government “regulators.” In fact, Deaton argues, how healthcare is financed and delivered is a driver of inequality.
Registered Nurses see that inequity everyday in hospitals and clinics, where the standard of care patients receive depends on the quality (and cost) of the health plan they buy. Not only the benefits but access to treatments, prescription drugs, certain facilities, the latest technologies, all depend on what you can pay. And guess who has the money to buy the best: the wealthy. So for the first time, after the Great Recession two unprecedented trends occurred: the 1% increased their share of income spent on healthcare, and the average life expectancy people in the US declined.
"So for the first time, after the Great Recession two unprecedented trends occurred: the 1% increased their share of income spent on healthcare, and the average life expectancy of people living in the US declined."
Historically, the labor movement has stepped into this breach of injustice and inequality. Yet in 2017, the union membership rate overall in the US was just 10.7%. In the private sector it was 6.5% and in the public sector it was 34.4%. Unions established the system of job-based health benefits after World War II, in part to provide better coverage to encourage new memberships, and now employers run it for the benefit of the insurance industry’s bottom line.
“Controlling” healthcare costs for businesses has meant a huge cost shift to workers. Rather than pay the annual double-digit insurance premium increases out of their profits – soon to go up under the tax bill – companies raise the workers’ share, increase deductibles and co-pays, and promote employee-funded health savings accounts. Though it expanded coverage for low-wage workers, the ACA also lessened the “union advantage” in health benefits, established new taxes on union plans and created incentives via an excise tax to lessen benefits.
"Historically, the labor movement has stepped into this breach of injustice and inequality. Yet today only 7% of all workers belong to a union."
The decades of incremental erosion of health benefits, escalating costs, deferring wages in favor of funding benefits, and the thousands of strikes over just keeping the health plans workers have fought to win, has taken a huge toll on the quality of those plans and on attitude toward unions. In short, “unions have become the bearers of bad news,” unable to stem the tide of concessions. And the incremental progress – expansions of insurance for kids, limits on the worst abuses by HMO’s, expanded private coverage under Medicare for prescription drugs, the ACA itself – none has slowed the increasing costs or the decreasing numbers of employers providing benefits, or the decline in membership of unions.
A defensive posture and incremental demands have not worked. Let’s play offense instead. In the face of existential threats to unions’ ability to fund their operations, and the continuing assault on health benefits, let’s unite with the growing public demand for Medicare for All. We don’t need insurance, we need healthcare. This is the strategy that can turn the tide: building a broad movement of workers to demand economic and health justice. That’s not an alliance with insurers and employers to “fix” the system in order to stabilize the healthcare industry. Rather, based on the economic interests of workers, we need to make healthcare a public good. Only if it is not compromised by high premiums, deductibles, and co-pays, without narrow networks and “gatekeeping” that restrict access, can we guarantee healthcare as a human right. Parsing out healthcare through insurance based on ability to pay simply means we’ll only get the healthcare we can afford.
"A defensive posture and incremental demands have not worked. Let’s play offense instead."
The labor movement exists to stop money from being the metric of value and power. Healthcare is exhibit A for money as the metric (see Elizabeth Rosenthal’s book, “American Sickness”). Unions derive power from members, engaged in fights to win a better life at work, home and in society. Medicare for All enjoys strong majority support among the general public, and overwhelming support among union members and Democrats (70-80% in recent polls). Medicare works and is popular. A movement led by labor, inspired like the Fight for 15 by a broad, popular demand for fairness and security, can build the solidarity we need. A movement positioned as the 99%, can assert that all workers are part of the labor movement.
Let’s understand this movement moment: the uprising in Wisconsin, Occupy Wall Street, Black Lives Matter and now #MeToo have created social movements and a political/ideological context that infused the Sanders campaign for President, and provides the well-spring for a broader health justice demand, linked to and reinforcing the demands for social and economic justice. Medicare for All can be the health wing of the broader justice movements.
"A movement led by labor, inspired like the Fight for 15 by a broad, popular demand for fairness and security, can build the solidarity we need."
In the most personal area of public policy – whether we will get the healthcare we need – Registered Nurses, who are predominantly women, bring the values of caring, compassion and community to work and to their advocacy. Let that inspire others to join this movement for guaranteed healthcare based on our shared humanity. Promoting these values combined with organizing workers for health and economic security can overcome the deep pockets of the healthcare industry; it is only through mobilizing public opinion that people have overcome politically powerful economic forces.
In demanding guaranteed healthcare through Medicare for All, we are demanding a more just and humane society. Socio-economic status is the major factor in determining health status, and disparities based on race are rampant in healthcare access and outcomes. Here we see the confluence of addressing race-specific barriers to equality in healthcare and in society and the need for economic and health justice. Addressing the causes of poverty, overcoming structural racism, establishing $15/hour as the minimum wage, building more affordable housing and winning guaranteed healthcare are necessarily linked – we cannot achieve them individually in isolation. A fighting labor movement – that encompasses the broadly defined working class - is in the best position to make those connections and organize on a multi-racial basis to win. Medicare for All not only motivates millions to organize for justice, but winning it would help win justice for all.
A Quiet Drug Problem
Among the Elderly
by Paula Span - NYT - March 16, 2018
At first, the pills helped her feel so much better.
Jessica Falstein, an artist living in the East Village in Manhattan, learned she had an anxiety disorder in 1992. It led to panic attacks, a racing pulse, sleeplessness. “Whenever there was too much stress, the anxiety would become almost intolerable, like acid in the veins,” she recalled.
When a psychopharmacologist prescribed the drug Klonopin, everything brightened. “It just leveled me out,” Ms. Falstein said. “I had more energy. And it helped me sleep, which I was desperate for.”
After several months, however, the horrible symptoms returned. “My body became accustomed to half a milligram, and the drug stopped working,” she said. “So then I was up to one milligram. And then two.” Her doctor kept increasing the dosage and added Ativan to the mix.
Now 67, with her health and stamina in decline, Ms. Falstein has been diligently working to wean herself from both medications, part of the class called benzodiazepines that is widely prescribed for insomnia and anxiety. “They turn on you,” she said.
For years, geriatricians and researchers have sounded the alarm about the use of benzodiazepines among older adults. Often called “benzos,” the problem drugs include Valium (diazepam), Klonopin (clonazepam), Xanax (alprazolam) and Ativan (lorazepam).
The cautions have had scant effect: Use of the drugs has risen among older people, even though they are particularly vulnerable to the drugs’ ill effects. Like Ms. Falstein, many patients take them for years, though they’re recommended only for short periods. The chemically related “z-drugs” — Ambien, Sonata and Lunesta — present similar risks.
Now the opioid epidemic has generated fresh warnings, because pain relievers like Vicodin (hydrocodone with Tylenol) and OxyContin (oxycodone) are also frequently prescribed for older people. When patients take both, they’re at risk for overdosing.
“Why are opioids dangerous? They stop you from breathing, and they have more power to do that when you’re also taking a benzo,” said Keith Humphreys, a Stanford University researcher and co-author of a disturbing editorial about overuse and misuse of benzodiazepines last month in the New England Journal of Medicine.
Numbers from the Centers for Disease Control and Prevention tell the story: In 1999, it tallied just 63 benzodiazepine-related deaths among those aged 65 and older. Almost 29 percent also involved an opioid. By 2015, benzo deaths in that age group had jumped to 431, with more than two-thirds involving an opioid. (Benzo-related deaths in all age groups totaled 8,791.) In 2016, the Food and Drug Administration issued a black-box warning about co-prescribing benzodiazepines and opioids, including those in cough products.
Even patients taking the drugs exactly as prescribed can unwittingly wind up in this situation, since both sleep problems and chronic pain occur more frequently at older ages. “A psychiatrist puts a woman on Xanax,” Dr. Humphreys said. “Then she hurts her hip, so her primary care physician prescribes Vicodin.”
But fatal overdoses — which are a comparatively tiny number given the size of the older population — represent just one of many longtime concerns about these medications.
“Set aside the opioid issue,” said Michael Schoenbaum, an epidemiologist at the National Institutes for Health. “Way too many older Americans are getting benzos. And of those, many — more than half — are getting them for prolonged periods. That’s just bad practice. They have serious consequences.”
Probably the most serious: falls and fractures, already a common danger for older people, because benzos can cause dizziness. They’re also associated with auto accidents, given that they cause drowsiness and fatigue.
Moreover, “they have a negative effect on memory and other cognitive function,” says Dr. Donovan Maust, a psychiatrist at the Veterans Administration Ann Arbor Health Care System. Some studies have shown an association with dementia, though experts call the evidence to date inconclusive.
Yet when Dr. Maust and his colleagues looked at a broad national sample of older adults, they found that the proportion of primary care and psychiatry visits that resulted in benzo prescriptions rose from 5.6 percent in 2003 to 2005 to 8.7 percent just seven years later — including 11.5 percent of visits by patients older than 85.
A study by Dr. Schoenbaum as a co-author and published in JAMA Psychiatry reported nearly nine percent of adults aged 65 to 80 taking benzos in 2008.
In both studies, women used the drugs more than men.
Persuading older people that benzos can hurt them — and that alternative treatments like cognitive behavioral therapy and improved sleep hygiene can be as effective for insomnia, though they take longer — has proved an uphill fight.
Some people take benzos for years without increasing the dose, so describing them as “dependent” or “habituated” — let alone “addicted” — often causes angry reactions.
“Drug problems are deeply stigmatized,” Dr. Humphreys said. “People feel it’s insulting to say they might have a problem with a drug.”
Nevertheless, even people who have taken benzos for extended periods without noticing any problem face potential harms at older ages, Dr. Humphreys noted.
“There’s a parallel with alcohol,” he said. “Maybe you had a double Scotch before dinner without problems through your 50s. In your 60s, you get lightheaded” from the same amount, because older bodies metabolize drugs differently. (Alcohol, by the way, is another substance you don’t want to combine with benzodiazepines.)
Persuading users that they should stop is only the first step, however. “Weaning someone off these things when they’ve become habituated is incredibly difficult,” Dr. Schoenbaum said.
Significant declines in benzo use among older people in Ontario, Canada, in Australia and in the Veterans Administration health care system in the United States show that it can be done, with more cautious prescribing and programs to help users become ex-users.
But it’s not easy.
“You never, ever recommend that someone stop cold turkey,” Dr. Maust said. That can bring withdrawal symptoms that include nausea, chills, anxiety, even delirium. “You taper down very gradually.”
Canadian researchers have demonstrated that some older users can taper off with an informational booklet and a 21-week tapering protocol, an approach the Veterans Administration has begun using. Most patients should expect to spend six to 12 months detoxing, Dr. Maust said.
But some find it takes much longer, with rebound effects unlike those of other habituating drugs.
When Ms. Falstein began experiencing “jelly legs” that left her too weak to stand for long, increased panic attacks, extreme fatigue and other health problems, she and her psychopharmacologist agreed that she should begin tapering off her benzos.
“I thought I’d be off them in a year, maybe two,” Ms. Falstein said. But it has taken five so far, with the support of a Facebook group and a “taper friend” she speaks to almost daily. Using a method called liquid titration, she has been able to discontinue Ativan and cut back to less than a daily milligram of Klonopin.
Though she suffered a variety of debilitating symptoms, “I was determined,” she said. “I’m going as quickly but as safely as I can.”
She figures she has two years to go.
Health Care Spending in the United States and Other High-Income Countries
by Irene Papanicolous, Liana Waskie and Ashish Jha - JAMA - March 13, 2018
Key Points
Question Why is health care spending in the United States so much greater than in other high-income countries?
Findings In 2016, the United States spent nearly twice as much as 10 high-income countries on medical care and performed less well on many population health outcomes. Contrary to some explanations for high spending, social spending and health care utilization in the United States did not differ substantially from other high-income nations. Prices of labor and goods, including pharmaceuticals and devices, and administrative costs appeared to be the main drivers of the differences in spending.
Meaning Efforts targeting utilization alone are unlikely to reduce the growth in health care spending in the United States; a more concerted effort to reduce prices and administrative costs is likely needed.
Abstract
Importance Health care spending in the United States is a major concern and is higher than in other high-income countries, but there is little evidence that efforts to reform US health care delivery have had a meaningful influence on controlling health care spending and costs.
Objective To compare potential drivers of spending, such as structural capacity and utilization, in the United States with those of 10 of the highest-income countries (United Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland, and Denmark) to gain insight into what the United States can learn from these nations.
Evidence Analysis of data primarily from 2013-2016 from key international organizations including the Organisation for Economic Co-operation and Development (OECD), comparing underlying differences in structural features, types of health care and social spending, and performance between the United States and 10 high-income countries. When data were not available for a given country or more accurate country-level estimates were available from sources other than the OECD, country-specific data sources were used.
Findings In 2016, the US spent 17.8% of its gross domestic product on health care, and spending in the other countries ranged from 9.6% (Australia) to 12.4% (Switzerland). The proportion of the population with health insurance was 90% in the US, lower than the other countries (range, 99%-100%), and the US had the highest proportion of private health insurance (55.3%). For some determinants of health such as smoking, the US ranked second lowest of the countries (11.4% of the US population ≥15 years smokes daily; mean of all 11 countries, 16.6%), but the US had the highest percentage of adults who were overweight or obese at 70.1% (range for other countries, 23.8%-63.4%; mean of all 11 countries, 55.6%). Life expectancy in the US was the lowest of the 11 countries at 78.8 years (range for other countries, 80.7-83.9 years; mean of all 11 countries, 81.7 years), and infant mortality was the highest (5.8 deaths per 1000 live births in the US; 3.6 per 1000 for all 11 countries). The US did not differ substantially from the other countries in physician workforce (2.6 physicians per 1000; 43% primary care physicians), or nursing workforce (11.1 nurses per 1000). The US had comparable numbers of hospital beds (2.8 per 1000) but higher utilization of magnetic resonance imaging (118 per 1000) and computed tomography (245 per 1000) vs other countries. The US had similar rates of utilization (US discharges per 100 000 were 192 for acute myocardial infarction, 365 for pneumonia, 230 for chronic obstructive pulmonary disease; procedures per 100 000 were 204 for hip replacement, 226 for knee replacement, and 79 for coronary artery bypass graft surgery). Administrative costs of care (activities relating to planning, regulating, and managing health systems and services) accounted for 8% in the US vs a range of 1% to 3% in the other countries. For pharmaceutical costs, spending per capita was $1443 in the US vs a range of $466 to $939 in other countries. Salaries of physicians and nurses were higher in the US; for example, generalist physicians salaries were $218 173 in the US compared with a range of $86 607 to $154 126 in the other countries.
Conclusions and Relevance The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations. Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries. As patients, physicians, policy makers, and legislators actively debate the future of the US health system, data such as these are needed to inform policy decisions.
5 Doctors Are Charged With Taking Kickbacks for Fentanyl Prescriptions
by Benjamin Weiser and Katie Thomas - NYT - March 16, 2018
In March of 2013, Gordon Freedman, a doctor on Manhattan’s Upper East Side, fielded a request from a regional sales manager for the manufacturer of Subsys, a spray form of the highly addictive painkiller fentanyl.
Dr. Freedman was already a top prescriber of Subsys and also one of the company’s paid promotional speakers. Now the sales manager was telling him the company, Insys Therapeutics, would increase the amount of money it was paying him and asked that he increase the number of new patients he was prescribing Subsys.
“Got it,” Dr. Freedman replied, according to authorities. By 2014, they said, Dr. Freedman had become one of the country’s top prescribers of the painkiller drug — and also the company’s highest-paid speaker.
The exchange between the doctor and Insys was detailed in a federal indictment unsealed on Friday in Manhattan, charging Dr. Freedman, of Mount Kisco, N.Y., and four other New York doctors with participating in a bribery and kickback scheme that prosecutors said sought to increase the drug company’s sales and preyed on unwitting patients.
Insys paid the doctors, in some cases more than $100,000 annually, in return for prescribing millions of dollars’ worth of the company’s painkiller product, the indictment said. It charged that Insys funneled the illicit payments to the doctors through a sham “speakers bureau,” in which the doctors were paid for purportedly giving educational presentations about the drug that, in many cases, were mere social gatherings at high-end Manhattan restaurants.Such gatherings involved no educational presentation, and attendance sign-in sheets were often forged to include the names of health care practitioners who were not actually present, the authorities said.
“These prominent doctors swore a solemn oath to place their patients’ care above all else,” said Geoffrey S. Berman, the United States attorney for the Southern District of New York. “Instead, they engaged in a malignant scheme to prescribe fentanyl, a dangerous and potentially fatal narcotic 50 to 100 times more potent than morphine, in exchange for bribes in the form of speaker fees.”
Mr. Berman announced the charges along with William F. Sweeney Jr., the head of the F.B.I.’s New York office. The four other doctors charged in the New York case are Jeffrey Goldstein of New Rochelle, N.Y.; Todd Schlifstein of New York City; Dialecti Voudouris of New York City; and Alexandru Burducea of Little Neck, N.Y.
All five defendants pleaded not guilty in federal court on Friday afternoon and were released on $200,000 bond. None of the five responded to reporters’ requests for comment as they left the courtroom.
Mr. Berman’s office also disclosed that two former Insys employees — Jonathan Roper and Fernando Serrano — had pleaded guilty and were cooperating with the federal investigation.
Insys, which is based in Arizona, has come under intense scrutiny over its aggressive marketing of Subsys, a form of fentanyl approved in 2012. Subsys is sprayed under the tongue and approved for use only in patients who have cancer and who experience pain even though they are already on round-the-clock painkillers.
Fentanyl can be deadly if it is prescribed in large doses to someone who has not already become tolerant to opioids, yet the drug has been widely sold to a variety of patients. An analysis in 2014 for The New York Times by the research firm Symphony Health, for example, found that just 1 percent of prescriptions for Subsys were from oncologists.
Already, the federal authorities in Boston have brought charges against Insys’s founder and former chief executive, John Kapoor, as well as against several other top executives and sales managers. They have all pleaded not guilty.
The New York indictment offers further evidence that investigators have broadened their inquiry into doctors who were prescribing the drug to patients. Earlier this month, another top prescriber, Jerrold Rosenberg of Rhode Island, was sentenced to more than four years in prison after admitting he took kickbacks from Insys.
The company did not respond to a request for comment on Friday.
The indictment unsealed on Friday charged that the drug firm had used its speakers program "to induce a select group of practitioners,” including the five doctors charged in New York, to prescribe large volumes of the fentanyl spray. The selected doctors were often referred to within the company as “top docs,” the indictment said.
The company’s executives meticulously “tracked and circulated statistics for each speaker,” the indictment noted.
It also said Mr. Roper, then the district sales manager for a territory that included Manhattan, emailed sales representatives, reminding them to repeatedly tell their speakers of “one simple guideline” — if they did not write prescriptions, there would be no speaking engagements. As he put it, according to the indictment: “NO SCRIPTS. NO PROGRAMS.”
One of the defendants, Dr. Goldstein, sometimes did not even stay for a meal at the programs where he was the featured speaker, instead ordering food from the restaurant and leaving with it, according to the indictment.
Before one program in 2014, the indictment added, Dr. Goldstein wrote to an Insys sales representative, asking, “Is dinner take out or we expecting peeps?”
Which firms profit most from America’s health-care system
By Shumpeter - The Economist - March 15, 2018
It is not pharmaceutical companies
EVERY year America spends about $5,000 more per person on health care than other rich countries do. Yet its people are not any healthier. Where does all the money go? One explanation is waste, with patients wolfing down too many pills and administrators churning out red tape. There is also the cost of services that may be popular and legitimate but do nothing to improve medical outcomes. Manhattan’s hospitals, with their swish reception desks and menus, can seem like hotels compared with London’s bleached Victorian structures.
The most controversial source of excess spending, though, is rent-seeking by health-care firms. This is when companies extract outsize profits relative to the capital they deploy and risks they take. Schumpeter has estimated the scale of gouging across the health-care system. Although it does not explain the vast bulk of America’s overspending, the sums are big by any other standard, with health-care firms making excess profits of $65bn a year. Surprisingly, the worst offenders are not pharmaceutical firms but an army of corporate health-care middlemen.
In crude terms, the health-care labyrinth comprises six layers, each involving the state, mutual organisations and private firms. People and employers pay insurance companies, which pay opaque aggregators known as pharmacy-benefit managers and preferred provider organisers. They in turn pay doctors, hospitals and pharmacies, which in turn pay wholesalers, who pay the manufacturers of equipment and drugs. Some conglomerates span several layers. For example on March 8th Cigna, an insurance firm, bid $67bn for Express Scripts, a benefit manager. A system of rebates means money flows in both directions so that the real price of products and services (net of rebates) is obscured.
To work out who is stiffing whom, Schumpeter has examined the top 200 American listed health-care firms. Excess profits are calculated as those earned above a 10% return on capital (excluding goodwill), a yardstick of the maximum that should be possible in any perfectly competitive industry. For drugmakers the figures treat research and development (R&D) as an asset that is depreciated over 15 years, roughly the period they have to exploit patents on discoveries. The data are from Bloomberg.
Total excess profits amount to only about 4% of America’s health-care overspending. But this still makes health care the second biggest of the giant rent-seeking industries that have come to dominate parts of the economy. The excess profits of the health-care firms are equivalent to $200 per American per year, compared with $69 for the telecoms and cable TV industry and $25 captured by the airline oligopoly. Only the five big tech “platform” firms, with a figure of $250, are more brazen gougers.
Everyone hates pharmaceutical firms, but their share of health-care rent-seeking is relatively trivial, especially once you include the many midsized and small firms that are investing heavily. Across the economy, average prices received by drug manufacturers have risen by about 5% per year, net of the rebates. But their costs have risen, too. As a result, even for the 15 biggest global drugs firms, returns on capital have halved since the glory days of the late 1990s, and are now barely above the cost of capital. As employer schemes get stingier, employees are being forced to pay more of their drug costs; they are price-conscious.
Meanwhile the effectiveness of R&D seems to have fallen. Richard Evans of SSR, a research firm, tracks the number of high-quality patents (defined as those cited in other patent applications) that drug firms generate per dollar of R&D. This metric has dropped sharply over the past decade. Shareholders may groan, but for the economy overall the system seems to be working. Big pharma is still splurging on R&D but not making out like a bandit.
As the drug industry has come back down to earth, the returns of the 46 middlemen on the list have soared. Fifteen years ago they accounted for a fifth of industry profits; now their share is 41%. Health-insurance companies generate abnormally high returns, but so do the wholesalers, the benefit managers and the pharmacies. In total middlemen capture $126 of excess profits a year per American, or about two-thirds of the whole industry’s excess profits. Express Scripts earns billions while having less than $1bn of physical plants and no disclosed investment in R&D. This year the combined profits of three wholesalers that few outsiders have heard of are expected to exceed those of Starbucks.
The dark view is that pockets of rent-seeking have become endemic in America’s economy. Wherever products are too complex for customers to understand, and where subsidies and complex regulation add to the muddle, huge profits can opaquely be made. Remember mortgage-backed securities?
In the case of health care, consolidation has probably made things worse by muting competition. There are now five big insurance companies, three big wholesalers, three large pharmacy chains and three big benefit managers. The current vogue is for “vertical mergers” in which firms expand into different layers. As well as Cigna and Express Scripts, Aetna, another insurer, and CVS, a pharmacy and benefits manager, are merging. All these firms insist competition will be boosted. But they are also projecting the deals will boost their combined profits by $1.4bn.
Amazon and the health-care jungle
Yet perhaps capitalism is not broken and new contenders will eventually be tempted in. Amazon has acquired wholesale pharmacy licences in multiple states. It is also teaming up with JPMorgan Chase and Berkshire Hathaway to create a new health system for their staff. These initiatives are at an early stage, but investors are sufficiently worried that they value the intermediaries on abnormally low multiples of profits, suggesting earnings may fall. People often get upset when conventional industries are hit by digital competition. Few would lament it in the case of health-care middlemen.
‘I would not have survived’: Stephen Hawking lived long life thanks to NHS
Ian Sample - The Guardian - March 14, 2018
Stephen Hawking was a longtime champion of the NHS, but it was a glaring slip in the media that provoked one of his more memorable interventions. As the Obama administration sought to reform the US healthcare system in 2009, the US Investor’s Business Daily argued that Stephen Hawking “wouldn’t have a chance in the UK, where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless”.
It was duly pointed out that Hawking was not only born and educated in England, but received more care than most from the nation’s health service. “I wouldn’t be here today if it were not for the NHS,” Hawking told the Guardian at the time. “I have received a large amount of high-quality treatment without which I would not have survived.”
A very small percentage of people with motor neurone disease live for decades after their diagnosis. Hawking was one of those rare outliers: his disease progressed rapidly at first and then slowed dramatically. But it was the NHS, rather than medical good luck, which saved his life, notably with a tracheotomy in 1985, though the NHS kept him alive many times later too, in particular over the winters when he was vulnerable to respiratory infections.
Hawking’s robust defence of the NHS set the tone for the row to come.
When the NHS was plunged into crisis amid plans which critics claimed would amount to privatising the service, Hawking lashed out at the politicians he held responsible in a 2017 speech at the Royal Society of Medicine. He blamed ministers for funding cuts, pay caps and weakening the service through privatisation. He saw it all leading to a “US-style insurance system”.
He singled out Jeremy Hunt, the health secretary, for particular criticism. In arguing for a seven-day NHS, Hunt claimed that 11,000 patients a year died because of understaffing of hospitals at weekends. Hawking pointed out that of the eight studies Hunt had cited, four were not peer reviewed, and that 13 more that Hunt had failed to mention contradicted the view.
“Speaking as a scientist, cherrypicking evidence is unacceptable,” Hawking said. “When public figures abuse scientific argument, citing some studies but suppressing others, to justify policies that they want to implement for other reasons, it debases scientific culture.”
Q&A
What are the financial pressures on the NHS that have built up over the last decade?
Hawking’s speech prompted a swift response from Hunt, who accused the cosmologist of spreading “pernicious falsehoods”. But Hawking came back, arguing there was overwhelming evidence that NHS funding, and the numbers of doctors and nurses, were inadequate, and that the NHS was heading towards a US-style healthcare system run by private companies. Hunt, he pointed out, named Kaiser Permanente, the major US healthcare provider, as a model for the future budgetary arrangements of the NHS before the Commons health select committee in 2016. In response, Hunt insisted the NHS would “remain a single-payer, taxpayer-funded system free at the point of use”.
After what appeared to be a three-month cessation of hostilities, Hawking joined a lawsuit in December aimed at blocking Hunt’s plans for the NHS. The judicial review seeks to stop the introduction of the first accountable care organisations, or ACOs, into the NHS in April. Hawking said they appeared to be a way to reduce public spending, cut services and allow private companies to benefit by organising and providing services.
Prof Allyson Pollock, the director of the Institute of Health and Society at Newcastle University, who helped to bring the lawsuit, said: “Stephen Hawking understood better than anyone else what the NHS meant. It enabled him to live a long life. He understood how important it was.
“Over the last six months he remained completely committed to the fight to defend the NHS, to stop privatisation and its breakup. I can think of no better testament to his memory than to reinstate the NHS as a public service and that’s what he fought for until the end.”
• This article was amended on 16 March 2018 to clarify that the NHS was plunged into crisis with plans which critics claimed would amount to privatising the service.
Medicare Doesn’t Equal Dental Care. That Can Be a Big Problem.
by Austin Frakt - NYT - March 19, 2018
Many people view Medicare as the gold standard of United States health coverage, and any attempt to cut it incurs the wrath of older Americans, a politically powerful group.
But there are substantial coverage gaps in traditional Medicare. One of them is care for your teeth.
Almost one in five adults of Medicare eligibility age (65 years old and older) have untreated cavities. The same proportion have lost all their teeth. Half of Medicare beneficiaries have some periodontal disease, or infection of structures around teeth, including the gums.
Bacteria from such infections can circulate elsewhere in the body, contributing to other health problems such as heart disease and strokes.
And yet traditional Medicare does not cover routine dental care, like checkups, cleanings, fillings, dentures and tooth extraction.
After I wrote a recent article about the lack of coverage for dental care in many state Medicaid programs, I received a lot of feedback from readers saying Medicare was no better.
I have not had dental coverage since I retired 25 years ago. Any problems and I have to go to a foreign country to get treatment that I can afford. It is incredible that there is no coverage available in America for one of the most important aspects of health and wellness care for seniors. — Tom, La Jolla
Several of my elderly relatives have just let teeth fall out without being cared for or replaced because of expense. This is no way to care for our senior citizens. — Bronxbee, Bronx
Paying for dental care out of pocket is hard for many Medicare beneficiaries. Half have annual incomes below $23,000 per year. Those who have the means, but are looking for a deal, might travel abroad for cheaper dental care. Tens of thousands of Americans go to Mexico every year for dental work at lower prices. Many others travel the globe for care.
Although low-income Medicare beneficiaries can also qualify for Medicaid, that’s of little help for those living in states with gaps in Medicaid dental coverage.
According to a study published in Health Affairs, in a given year, three-quarters of low-income Medicare beneficiaries do not receive any dental care at all. Among higher-income beneficiaries, the figure is about one-quarter.
“The separation of coverage for dental care from the rest of our health care has had dramatic effects on both,” said Amber Willink, the lead author of the study and a researcher at Johns Hopkins Bloomberg School of Public Health. “As a consequence of avoidable dental problems, the Medicare program bears the cost of expensive emergency department visits and avoidable hospitalizations. It’s lose-lose.”
Traditional Medicare will cover dental procedures that are integral to other covered services. So if your Medicare-covered hospital procedure involved dental structures in some way, important related dental care would be covered. But paying for any other care is up to the patient.
Lack of dental coverage by Medicare is among the top concerns of beneficiaries. The program also lacks coverage for hearing, vision or long-term care services. However, many Medicare Advantage plans — private alternatives to the traditional program — cover these services.
For example, 58 percent of Medicare Advantage enrollees have coverage for dental exams. In receiving these benefits through private plans, enrollees are also subject to plans’ efforts to limit use by, for example, requiring prior authorization or offering narrow networks of providers. These restrictions can be problematic for some beneficiaries, and about two-thirds of Medicare beneficiaries opt for the traditional program, not a private plan.
Adding a dental benefit to Medicare is popular. A Families USA survey of likely voters found that the vast majority (86 percent) of likely voters support doing so. The survey also found that when people do not see a dentist, the top reason is cost.
Ms. Willink’s study estimated that a Medicare dental benefit that covered three-quarters of the cost of care would increase Medicare premiums by $7 per month, or about 5 percent. The rest would need to be financed by taxes.
The cost of such a benefit might be offset — or partly offset — by reductions in other health care spending, reflecting the fact that poor oral health contributes to other health problems.
Making a case for this in the political arena would not be easy, though. The initial cost would be an inviting target for politicians who express concern about fiscal prudence, regardless of any potential long-term gain. But expanding Medicare has been done before.
In 2006, a prescription drug benefit was added to the program. The law for that program was enacted in 2003, and in that same year, the surgeon general released a report calling for dental care to be treated and covered like other health care. Whether by Medicaid or Medicare, that wish is still unfulfilled.
Health care, other issues unresolved as congressional negotiators try to nail down spending bill
by Erica Werner and Mike Debones - The Washington Post - March 19, 2018
WASHINGTON — Congressional negotiators raced Monday to finalize a $1.3 trillion spending bill to keep the government running, with several thorny issues still unresolved ahead of an end-of-week deadline.
Health care remained a sticking point, as Republican Sens. Susan Collins, Maine, and Lamar Alexander, Tenn., pushed for inclusion of provisions aimed at lowering premiums for people purchasing health insurance in the Affordable Care Act’s individual marketplace. President Trump spoke with Collins and Alexander on a conference call Saturday and offered his support for their efforts, but a partisan dispute over abortion funding looked poised to derail the push.
House Republicans left a meeting to discuss the pending legislation late Monday with the understanding that the health-care provisions would not be included, several lawmakers said. In addition to the dispute over abortion language, Republican lawmakers were reluctant to sign off on provisions that shored up the Affordable Care Act, a law they all opposed.
“Nobody in that room voted for Obamacare, so the idea you’re going to vote for billions of dollars to stabilize a system you never supported in the first place – pretty hard to choke down,” said Rep. Tom Cole, R-Okla.
The “omnibus” spending bill spreading billions across all agencies of government was supposed to be released Monday night to allow time for passage through the House and Senate before a government shutdown deadline at midnight Friday.
But as evening arrived, bipartisan congressional leaders remained locked in negotiations on several issues and the eleventh-hour wrangling threatened to delay the bill’s release.
“We’re trying to get to agreement,” said Rep. Pete Sessions, R-Texas, chairman of the House Rules Committee. “And this is where it’s really good to measure three times and saw once.”
With conservatives expected to oppose the massive spending bill that funds the government for the remainder of the 2018 fiscal year, through Sept. 30, Democratic votes will be needed in both chambers to pass the legislation. That empowered Democrats to make demands on a variety of issues while resisting Republican priorities.
Overall, the legislation will bestow generous increases on domestic agencies and the military, following passage of a deal last month setting top-line government-wide budget numbers for this year and next. Longtime bipartisan congressional priorities such as the National Institutes of Health are expected to see significant increases, and greater funding is even expected for the IRS to help implement the new Republican tax law, after years of Republican efforts to slash the agency’s budget.
“I have not heard anything from any of my colleagues that would give me a whole lot of hope that there will be conservative wins,” said House Freedom Caucus Chairman Mark Meadows, R-N.C.
The government has shut down briefly two times this year, but there was widespread agreement on Capitol Hill that Congress would act in time to stave off a third shutdown this weekend.
On another front, it was looking unlikely that a deal could be made on immigration. The White House had been exploring trading border-wall funding for a temporary extension of protections for those enrolled in the Deferred Action for Childhood Arrivals (DACA) program.
But congressional appropriators have recommended only $1.6 billion in border-security funding for a tightly restricted set of infrastructure improvements. Barring a deal, the Trump administration cannot move forward in any significant way with the wall, the president’s top immigration priority.
The White House continued pushing through the weekend for more funding – $25 billion in exchange for extending DACA through September 2020 – according to two congressional aides familiar with the talks. But Democrats, who are seeking a permanent resolution to the issue, rejected that offer.
“There’s not doing to be DACA language in the bill. If there is, I’ve never heard a word of it. Not one syllable. If there’s a DACA fix out there, I haven’t seen it,” said Rep. John Carter, R-Texas, chairman of the Appropriations subcommittee on homeland security.
The health-care deal would have fulfilled commitments that Trump and McConnell had previously made to Collins. Collins cited those commitments when she voted in favor of the tax bill last year.
The parameters Collins and Alexander discussed in the Saturday call with Trump would have provided $30 billion over three years to allow states to set up high-risk pools for people with expensive health claims. The deal also would have restarted the “cost-sharing reduction” payments made to insurers under the ACA but ended by Trump in the fall. Those payments would have been made retroactively and continued for three years.
Collins and Alexander left an hour-long meeting with McConnell earlier Monday blaming Democrats’ abortion objections for the impasse.
Collins, one of the few Republican supporters of abortion rights in the Senate, said she was surprised by the opposition. “I really don’t understand why there are some who are hung up on that issue, and I say that as someone who has a very good record on choice issues from the perspective of the pro-choice groups,” she said.
Nicole Clegg, vice president of public policy for Planned Parenthood of Northern New England, attacked the Collins-Alexander bill for restricting abortion.
“This proposal is dangerous and part of a larger strategy to eliminate insurance coverage for abortion services. Accessing reproductive health care can be costly. That’s why insurance coverage is critical for women who are seeking an abortion. Without coverage, many women are forced to forgo or delay care,” Clegg told the Press Herald Monday night. “Once again, politicians are trying to insert themselves into a woman’s personal medical decisions about her pregnancy. This agenda has no place in any legislation, let alone efforts to keep insurance premiums low and stabilize the insurance marketplaces.”
Larry Levitt, senior vice president for health reform at the Kaiser Family Foundation, a Washington-based health policy think tank, told the Press Herald that the Collins-Alexander bill would greatly curtail abortion services for those on the marketplace. About 75,000 Mainers have marketplace plans.
“The proposal goes well beyond the current segregation of private and federal dollars in ACA insurance plans, and would mean that plans could not cover abortion at all, even with premiums paid by individuals themselves,” Levitt said.
Annie Clark, a Collins’ spokeswoman, said that Collins, a pro-choice Republican, is merely following federal law as it’s applied to other government health care programs, including Medicare and Medicaid, which do not permit federal funding of abortions.
“The health care stabilization package Sen. Collins introduced with Sen. Alexander to lower premiums and expand coverage retains the exact same Hyde protections that have applied to all federal funding since 1976,” Clark said in a statement. “In fact, our current health care benefits plan for all federal employees is actually more restrictive (for abortion) than this stabilization package.”
The abortion dispute is one that has flared on other health-related pieces of legislation, too. While federal funds cannot be spent on abortions, under the status quo – set out in the ACA and an executive order issued by President Barack Obama – insurers are free to offer plans that cover abortions and use segregated nonfederal funds to pay any abortion-related claims.
Under the proposed Republican approach, according to a Republican aide familiar with the plan, insurers could not use the stabilization funds to subsidize any plan that offers abortion coverage – whether or not the insurer uses the federal funds to pay for any specific claims. Republicans viewed the provision as adhering to the long-standing Hyde Amendment – a 40-year-old appropriations restriction that prevents federal funding for abortions – but Democrats viewed it as an impermissible expansion of abortion restrictions.
The aide spoke on the condition of anonymity to freely discuss private talks.
Another issue at play was a fix for a provision in the tax law that inadvertently favored farmer-owned cooperatives over agriculture corporations, allowing a substantially larger write-off for sales to cooperatives. Farm-state lawmakers had been pushing for a solution to be made part of the spending bill, but congressional aides said Monday it probably would not be included.
The spending bill has also sparked a fight between Trump and Senate Minority Leader Chuck Schumer, D-N.Y., over funding for a costly rail project between Manhattan and New Jersey that Trump has been urging Republicans to oppose. Resolution of that issue looked possible, though it remained uncertain exactly how it would play out.
But a push to change Capitol Hill’s system for reporting and adjudicating complaints of sexual harassment and other workplace misconduct in the wake of the #MeToo movement hit a roadblock after Republicans resisted including the policy language in the spending legislation.
And a handful of other issues remained outstanding, too, including a campaign finance provision sought by Majority Leader Mitch McConnell, R-Ky., to loosen federal restrictions on fundraising by political parties; and a provision exemption minor league baseball players from federal labor laws.
“I’d say the most frequently used term would be ‘on the table,’ ” said Rep. Brian Mast, R-Fla., as he left the House Republican conference meeting late Monday, referring to the overall uncertainty surrounding the bill hours before it was supposed to be made public.
What’s the Use of Protesting?
by Vanessa Barbara - NYT - March 20, 2018
SÃO PAULO, Brazil — It goes like this: The government announces another increase in the bus fare, so a few Brazilians take to the streets, march for a couple of miles, and then the police decide they’ve had enough. A kind of pyrotechnic exhibition ensues, with gas and explosions. Everybody goes home, some after a short stay at the local police station, others with purple bruises for souvenirs.
A few days later, there’s another demonstration. And then another. Rinse and repeat until everybody gets tired, demonized, traumatized or sufficiently intimidated. The bus fare remains outrageous, and it will rise again next year.
The plot has been the same for many other grievances in the recent years: labor reforms; the reorganization of public schools; an illegitimate, unpopular presidency; a costly, foolish World Cup; a catastrophic Summer Olympics. In the end, all of these things went forward, as if no one had lost their teeth protesting against them.
This routine started in June 2013, in what is now known as June Journeys. The events were sparked by demonstrations against raising public transportation fares. When the police cracked down violently, the protests grew. More than a million people across the country took to the streets.
These demonstrations gave birth to a small generation of anti-authoritarian, left-wing and nonpartisan militants, who kept protesting for subsequent years over all kinds of issues. They have been dismissed as thugs, vandals, political pawns or simply ineffectual. (That last accusation may not be completely inaccurate.) But now, they are also being held accountable for the right wing’s advance in Brazilian politics and for the impeachment of the former President Dilma Rousseff.
“We were hasty in thinking that 2013 was democratic,” Luiz Inácio Lula da Silva, the popular former president and an icon of the Brazilian left, said last year. “I sincerely believe that Ms. Rousseff’s impeachment would not have occurred were it not for the June Journeys,” wrote Fernando Haddad, the former mayor of São Paulo and a prominent figure in Mr. da Silva’s Workers’ Party. “In my opinion, it was when the coup started,” Mr. da Silva tweeted in January.
Why do these left-wing politicians see the decidedly left-wing protesters as agents of the right? Well, in part because it’s easy to feel anxious about an uncontrollable, leaderless, movement with pluralistic demands. But there’s another reason. After June 2013, some people protested against political corruption as a whole, including the Workers’ Party, which was in power at the time. This eventually resulted in five big right-wing street demonstrations demanding the ouster of Ms. Rousseff, the elected president who came from the Workers Party. The right-wing demonstrators got their wish in August 2016.
But there’s no straight line that runs from the 2013 protests to the 2016 impeachment. The street rallies weren’t the golden opportunity they were all waiting for to take down Ms. Rousseff, nor were they the main factor that finally enabled them to seize power. After all, many on the right worked with the Rousseff administration. (Remember that President Michel Temer was Ms. Rousseff’s vice president.) Nor did the right “hijack” an intrinsically anarchic movement, considering the fact that many other people have kept on holding their own progressive rallies, small but pretty inconvenient. (See, for example, the demonstrations against the 2014 World Cup. Back then, criticizing the event for any reason was considered an affront to the governing left.)
That view is simplistic and only serves to evade the burden of responsibility. In 13 years of Workers’ Party rule, the traditional left missed many crucial opportunities to effectively change Brazil. Now they need someone else to blame for their losses. And the current scapegoat seems to be the protesters of the far left — those who dared to criticize the Workers’ Party’s decisions in the past.
The truth is, the movement that began in 2013 has protested against bad policies from all governments, left or right, regardless of whether or not these protests could harm a particular political party. These protesters don’t necessarily align with other traditional social movements, like the landless or the homeless workers, labor unions or student organizations. They refuse hierarchical authority and they are impossible to control. And they bring up important issues, sometimes long before anyone else.
For example: The Free Fare Movement, the main group behind the 2013 protests, didn’t reduce transport fares, but it did force politicians and middle-class citizens to think seriously, for the first time, about the need to stop prioritizing cars and start investing in public transportation. Another example: Little by little, people are coming to understand that global sports events aren’t always a good idea after all, especially for the poor. The activists were the first ones to publicly discuss the issue in concrete terms of those who were being harmed — and the events proved them right. Despite the accusations of the Workers’ Party and its supporters, those were progressive claims.
Sometimes, nothing concrete is achieved right away, but new ideas are put into the realm of the plausible. Maybe later they’ll be promoted to the realm of necessary and, then, to the inevitable. For now, free public transport is still considered utopian, but universal health care and free public schools are not. Rallying could also be a form of raising a new collective conscience and fostering solidarity on a broader scale. From the perspective of a ruling party, nothing is more democratic than to accept this.
Protests could also have a kind of Kantian beauty, independent of their results. As Daniel Cohn-Bendit, a student leader of the 1968 protests in Paris, wrote: “We see something fleetingly, and it vanishes. But that is enough to prove that this thing can exist.” It is past time that Brazil’s main left-wing party stops blaming the streets and makes peace with 2013. Maybe then it can find different paths of action, a glimpse of possibility, new plausible utopias — and a viable alternative for the next presidential elections.
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