Chided for Working Against It as President, Obama's Backing of Medicare for All Called 'Thrilling' Shift
by Julia Conley - Common Dreams - September 7, 2018
While progressives pointed out that it would have been worthy of more applause if the offer of support had come back when he had the actual power to do something about it, Medicare for All proponents applauded the huge paradigm shift denoted by the newest high-profile endorsement of the popular proposal: former President Barack Obama.
Speaking at the University of Illinois in his first explicit rebuke of President Donald Trump and what was seen as his first major campaign speech for Democrats in 2018, Obama said that progressives "aren't just running on good old ideas like a higher minimum wage, they're running on good new ideas like Medicare for all, giving workers seats on corporate boards, reversing the most egregious corporate tax cuts to make sure college students graduate debt-free."
The speech, noted journalist David Sirota, was a clear sign that in the two and a half years since Hillary Clinton predicted that single payer healthcare would "never, ever" happen, Sen. Bernie Sanders' (I-Vt.) and other universal healthcare advocates' efforts to push the Democrats to embrace the proposal have been a success.
In just 2 years, @BernieSanders & his grassroots movement have officially shifted the center of the Dem Party from Medicare for All "will never, ever come to pass" to Medicare For All is "a good new idea." This is an amazing shift, considering all the past establishment pushback.— David Sirota (@davidsirota)
Sanders himself expressed appreciation for Obama's support:
Thank you President Obama for supporting Medicare for All.— Bernie Sanders (@SenSanders)
His support takes us another step toward ensuring that no one in the richest country in the history of the world has to forego health care because they cannot afford it.
New York congressional candidate Alexandria Ocasio-Cortez also praised Obama's statement, and focused on what the endorsement means for the future of Medicare for All and the success of the grassroots groups that have led the charge demanding universal healthcare for decades—like Physicians for a National Health Program (PNHP) and Healthcare Now.
This headline would have been politically unthinkable just a few years ago. Grassroots organizing + kitchen table conversations have changed the tide on Medicare for All.— Alexandria Ocasio-Cortez (@Ocasio2018)
This is the power of movements: supporting change and advancing tenets of a modern + moral society.
But a number of progressives expressed deep frustration at the former president—who said in 2003, "I happen to be a proponent of a single payer universal health care program"—for casting Medicare for All as a "new" idea.
"Respectfully, Medicare for All isn't a new idea," tweeted Bonnie Castillo, executive director of National Nurses United (NNU). "Union nurses have been campaigning for universal health care for years, but we are thrilled that Medicare for All is a mainstream issue now."
Yes, it's welcome development to hear former President Obama describe Medicare For All as "good new idea." But it's terribly frustrating that he sees it as "new" when his admin worked against it as President.— Kevin Gosztola (@kgosztola)
Obama calls Medicare For All a “good new idea,” but it was one he said he supported before he was president and then actively worked against when he had the most power to potentially advance it.— Ben Spielberg (@BenSpielberg)
While working to reform the U.S. for-profit healthcare system as president—and with majorities in both the House and the Senate—Obama hastily rejected the possibility of adopting a single-payer plan, claiming it would "represent a radical shift" akin to right-wing proposals for all Americans to take on 100 percent of the responsibility of their healthcare costs. Medicare for All advocates have also argued that Obama and other Democratic leaders did not push hard enough for a public option to be included in the Affordable Care Act.
As Shane Ryan noted at Paste Magazine, Obama's vocal support Medicare for All comes after the majority of Americans have already expressed approval for the proposal. Two weeks ago, a Reuters poll found that 70 percent of all Americans now favor such a program, including nearly 85 percent of Democrats and 52 percent of Republicans.
"Look, sarcasm aside, this is fine—Medicare for all is a terrific policy, and maybe Obama's support will whip the last of the recalcitrant congressional Democrats into shape," wrote Ryan. "It would have been nice if he could lead from the front on an important issue, for once, but hey, that's life at the top of the Democratic party."
A Koch-Funded Think Tank Tries Hard to Pretend That it Didn't Find Savings From Bernie Sanders' Medicare Plan
by Michael Hiltzik - Common Dreams - August 22, 2018
The Mercatus Center at George Mason University, a libertarian think tank partially funded by the Koch brothers, appears to be mighty embarrassed about its finding in a recent paper that the Medicare for All proposal from Sen. Bernie Sanders (I-Vt.) might actually reduce Americans’ overall spending on healthcare.
We know this because Mercatus has sent out several emails pushing back against reports about the finding. And the paper’s author, Mercatus fellow Charles Blahous, took to the opinion page of the Wall Street Journal to complain that “some have seized on a scenario in my estimates showing a slight decline in projected total public and private health expenditures under Medicare for All.”
Among those who “seized” on the scenario is Sanders himself, who crowed about it on Twitter after the paper was published at the end of July, mischievously getting the Koch brothers into his tweet because, why not?
Blahous grouses that Sanders and his followers overlook his main point, which is that the Sanders plan would sharply increase government spending on healthcare. He’s got the support of several conservative commentators and not a few credulous journalists. We analyzed Blahous’s paper here.
The problem with Blahous’ complaint, as it happens, is that he actually did find that the Sanders plan could reduce overall healthcare costs. That conclusion is right there on page 18 of his 24-page paper. Under the assumptions in the Sanders plan, he writes, “aggregate health expenditures remain virtually unchanged: national personal healthcare costs decrease by less than 2%, while total health expenditures decrease by only 4%, even after assuming substantial administrative cost savings.”
According to his own math, under Medicare for All, national health expenditures would total $57.6 trillion through 2031. They’re currently projected to be $59.7 trillion. In other words, Medicare for All would reduce total U.S. spending on healthcare by 3.44% (a bit less than the 4% Blahous cited).
Mercatus in its emails cite several ostensibly objective journalism sources calling out Sanders for, in effect, “cherry-picking” Blahous’ results to make Medicare for All seem thriftier than it is. They include Washington Post fact-checker Glenn Kessler, the Associated Press, and Jake Tapper of CNN. Some of Sanders’ critics panned him for failing to give the context to Blahous’ finding; but it’s a little churlish to complain about someone leaving out details from a 185-character tweet, since Sanders has published all the details and assumptions underlying his proposal, and Blahous found them easily enough to use them.
Moreover, those sources engaged in a fair amount of cherry-picking of their own. And Blahous is dancing as fast as he can to minimize the implications of his own math.
Let’s get to the bottom of the controversy.
To begin with, all these estimates and projections of the cost of Sanders’ plan are dependent on the assumptions incorporated into the calculations — Sanders relies on some assumptions, Blahous on others, Kessler, et al, on yet others.
Blahous took Sanders’ assumptions as read and costed them out over time. Among those assumptions are that hospitals and doctors would be reimbursed for their services at Medicare rates, which are on average 40% below private insurance reimbursements (though higher than Medicaid reimbursements); that negotiating with drug companies and other price caps would reduce prescription costs by nearly $850 billion over 10 years; and that administrative efficiencies would save nearly $1.6 trillion over the decade.
Sanders made further assumptions about the cost of universal coverage, including dental and vision care for all, and the elimination of deductibles and copayments. The bottom line from all those assumptions, Blahous acknowledges, was the reduction of U.S. spending by $2 trillion over 10 years.
Much of the pushback in the press against Sanders’ plan is based on the theory that his assumptions are too aggressive. That’s Blahous’ argument too. (Blahous also tries to put his thumb on the scale by describing a $2-trillion reduction as “only” 4%. In other words, he’s making the assumption that people would consider $2 trillion to be a negligible number.)
The AP, for instance, says Sanders’ “scenario in which hospitals and doctors accept significantly lower payments for many patients … is a big asterisk, and one that Sanders fails to disclose.” It’s a little odd to claim that Sanders “fails to disclose” his reliance on lower payments for providers — since it’s explicitly part of his plan and was penciled out by Blahous. Did AP even read the plan, or just the tweet?
Kessler says the claim of lower spending requires “generously accepting Sanders’ assumptions that he could squeeze providers.” Also at the Washington Post, libertarian columnist Megan McArdle warns that implementing Medicare for All would require “hard choices.” (No kidding?)
Tapper fact-checked Sanders’ purported claim that Medicare for All would save the U.S. government $2 trillion and declared it “false.” But Tapper was the sloppy one: The Blahous calculation, repeated by Sanders, is that the program would save Americans, not the government, $2 trillion. Big difference. Tapper later corrected his video to get it right.
In any case, “never gonna happen” is the weakest and laziest argument anyone can make in a public policy debate. The assertion that provider reimbursements will never, ever be reduced is based on nothing but hot air. Not very many years ago, after all, legalization of gay marriage was unimaginable in the U.S. political system. In 1859, slavery looked like it was with us to stay; that assumption ended Jan. 1, 1863. On the morning of Nov. 8, 2016, it was widely assumed that no one as crass and unfit as Donald Trump could become president; by 9 p.m. that night it was reality.
In the first few years after 2010, running against Obamacare seemed to be a slam-dunk campaign winner for Republicans; today, more than 50% of the public regards the program positively and Democrats are preparing to hang Obamacare repeal around the necks of their GOP opponents in November.
A wholesale reduction in doctor and hospital fees may be difficult to achieve, but it isn’t “impossible” in the same sense that time travel, say, is impossible. One can mock those reimbursement cuts as unlikely, but given the evolution of Americans’ approach to healthcare, they’re not even implausible.
And, sure, creating a universal healthcare system, whether based on Medicare or otherwise, requires hard choices. If it were easy, Sanders would undoubtedly acknowledge, we would have it by now. Blahous picked at various assumptions underlying the Sanders plan, but he failed to invalidate the plan entirely, which was his goal.
Any national healthcare policy will have lots of moving parts, all subject to tweaking and negotiating. You can’t achieve all those savings in doctor and hospital fees? Then maybe you impose nominal deductibles and co-pays. You can’t squeeze drug companies as much as you’d like? Then maybe you create a tiered formulary or don’t cover every single drug combination Big Pharma cooks up.
See how this works? As Scott Lemieux of the Lawyers, Guns & Money blog observes, “’If you couldn’t solve every problem, you shouldn’t have tried to solve any problem’ is an idiotic way of evaluating legislation.”
What’s overlooked in all these cavils about Sanders’ crowing about Blahous’ finding is that the champion cherry-picker in the discussion is Charles Blahous. The cherry he picks is the cost of Medicare for All to the federal government, and he fills a bushel basket with his harvest. “Paying for every American’s healthcare expenses would increase federal spending by $32.6 trillion over the first decade,” he writes. “Even if Congress were to double what it collects in individual and corporate income taxes, there still wouldn’t be enough money added to the federal coffers to finance the costs of this plan.”
Notice what he did there? He pretended that the only economic effect of the plan would be to drive up government spending, without netting out the savings reaped by businesses and individuals by eliminating premiums, deductibles and co-pays. Nor does he factor in the value to individuals and society of the expanded services advocated by Sanders. Sure, giving everyone dental and vision coverage will cost money. But in return, everyone gets dental and vision care. Isn’t that a positive?
In other words, Blahous counted all the increases in costs and attributed them all to the government, without placing his government spending figures in the context of the reduced spending by individuals and businesses or the gains in health services. That’s some world-class cherry-picking right there.
Blahous’ analysis, both in his paper and his Wall Street Journal essay, depend on his own arsenal of unproven assumptions. In the Journal, he wrings his hands over the Sanders plan’s increase in “already unaffordable federal healthcare subsidies.”
“Unaffordable?” Sez who? If he’s talking about the Affordable Care Act tax subsidies, they’ve been in place since 2014, haven’t brought down the republic yet, and evidently have left plenty of room to enact a tax cut for the wealthy valued at more than $1.5 trillion over the next decade.
In his paper, Blahous estimates the cost of expanding coverage and services under Medicare for All to be as high as $5.6 trillion over 10 years. His basis for this estimate is buried in his footnotes, but it turns out that it’s an estimate built on assumptions, the same technique everyone flays Sanders for using.
So, sure, let’s acknowledge that Sanders built his Medicare for All plan on a foundation of assumptions about costs and savings. But Blahous built his attack on a foundation of assumptions about costs and savings, just a different foundation. To declare his assumptions credible and Sanders’ not is to give up the fight for universal healthcare before the bugle is even blown. That’s what Blahous was hoping for, and no one should let him get away with it.
Blame Emergency Rooms for the Out-of-Control Cost of Health Care
by Glen Melnick - NYT - September 5, 2018
There are many reasons Americans pay more for health care than citizens of any other country. But one of the most powerful forces driving cost increases is buried in a little-known set of regulations concerning emergency room care.
These regulations have granted hospitals what is essentially a monopoly over emergency room patients, allowing them to charge basically whatever they want.
Readily available emergency treatment is among the most fundamental services of our health care system. To ensure it, most states require health care plans to tell their members to go to the nearest hospital in an emergency and that insurance will cover the visit — even if their plan does not have a contract with that hospital and the emergency care they receive will be out of network. This provision is meant to assure timely access to needed care and, although some patients have to wait hours to be seen by a doctor, and some still get hit with additional charges, it generally works pretty well.
The problem is that the rules give hospitals tremendous pricing power when they’re negotiating with health insurance companies. Increasingly, hospitals have learned that if they demand higher prices from health plans and do not get them, the hospitals can just cancel their contract. They will still get paid for treating emergency patients under those plans — and in fact will be paid more, because those patients will be out of network. (While this applies only to emergency room patients, about half of all hospital admissions come through emergency rooms.)
When there is no contract, the hospital issues a highly inflated “billed charge.” What was a $500 E.R. visit under a contract can become a $5,000 billed charge. This greatly reduces the health plans’ ability to negotiate lower prices.
Data from California illustrate how hospitals have exploited this situation. From 2002 to 2016, total billed charges by hospitals rose by a staggering $263 billion, to $386 billion, even though the number of patients admitted did not increase. Billed charges to health plans grew from $6,900 per day to over $19,500 per day. This astronomical run-up in billed charges gave California hospitals leverage to demand and receive much higher prices for in-network patients, too. The average price paid by health plans to hospitals for all care grew almost 200 percent — to $7,200 per day from $2,500.
In effect, they could threaten: Pay us $7,200 per day to sign a contract or $19,500 per day for emergency admissions without a contract.
Many patients might not know or care about this fight between hospitals and insurers. But they should.Whenever insurance companies have to pay more, patients do too, in premium increases. In some cases, patients have to pay inflated out-of-network E.R. charges directly to hospitals in the form of “balance billing.” Hospitals are also expanding at a rapid pace, acquiring medical groups and other outpatient services, and they are using their E.R. power to gain higher rates for these other services, too.States urgently need to change their regulations to limit hospital prices for out-of-network emergency care.
Capping billed charges at 125 percent of contracted prices would keep hospitals from exploiting their E.R. advantage. Maryland has instituted a policy along these lines. This change alone would result in immediate price reductions and savings to consumers exceeding many billions of dollars. And it would begin to restore some competition that would help keep prices down in the long run.
An American family of four with an employer-sponsored P.P.O. health plan now pays on average more than $28,000 a year for health care. If nothing changes, health care prices and insurance premiums will continue to grow. This will mean lower take-home pay for millions of working Americans and increases in the ranks of the uninsured. Public policy and hospitals are supposed to help us in emergencies, not create them.
Legal Case to Smash Obamacare Hands the Democrats a Hammer
by Abby Goodnough - NYT - September 5, 2018
FORT WORTH — More than 1,000 miles from the caustic Supreme Court confirmation hearing of Brett M. Kavanaugh, a federal judge in Texas on Wednesday listened to arguments about whether to find part or all of the Affordable Care Act unconstitutional, in a case that may end up before a newly right-leaning set of justices.
The case has become not simply a threat to the landmark legislation. Democrats have sought to make it both a flash point in the battle over whether to confirm Judge Kavanaugh and a crucial prong in their strategy to retake control of the House and Senate in the midterm elections.
It has already made some Republicans jumpy, especially those in tight re-election contests, because the Trump administration explicitly said in a legal filing in Junethat it agreed with the argument of Texas and 19 other Republican-controlled states that the law’s protections for people with pre-existing medical conditions are not constitutional. The administration is refusing to defend those guarantees. In that sense, although the case threatens one of the Democrats’ proudest achievements, it is also proving to be something of an election-year gift to their party.
They have hammered away at the issue in millions of dollars of ads, at round tables with their constituents, and at this week’s confirmation hearings, where Judge Kavanaugh declined to answer a question from Senator Sheldon Whitehouse, Democrat of Rhode Island, about whether he would uphold those guarantees.
One ad, aimed at Senator Susan Collins, Republican of Maine, shows an imaginary news broadcast reporting that the Supreme Court has struck down the law, imperiling people with pre-existing conditions, and that the newly confirmed Justice Kavanaugh cast the deciding vote. “Susan Collins voted for Kavanaugh and now 548,000 Mainers could lose coverage,” it says.
“Senator Collins: You can stop this from becoming a reality,” the ad concludes. “Vote No on Brett Kavanaugh.”
Perhaps with political ramifications in mind, Brett Shumate, the lawyer arguing for the Justice Department in Fort Worth on Wednesday made a point of urging Judge Reed O’Connor not to issue a preliminary injunction putting the law on hold until the case is decided, as the Republican state plaintiffs have asked. He said such a move could cause “extraordinary disruption” in the Affordable Care Act’s open enrollment period. That begins Nov. 1, just before Election Day.
“We certainly don’t want people to lose their health insurance going into next year,” Mr. Shumate said.
With polls finding widespread bipartisan support for the law’s protections for people with pre-existing conditions, a group of 10 Republican senators pre-emptively introduced legislation last month to preserve them should the law be struck down. Their proposal would prohibit insurance companies from denying coverage or charging more for it based on someone’s health status. But the catch — which Democrats have shouted from the rooftops — is that insurers could still refuse to cover certain illnesses. They could also again charge more based on gender or line of work, as was legal before the Affordable Care Act, or raise rates for older people.
The central issue in the case is whether the law’s individual mandate, which requires most Americans to have health coverage or pay a penalty, became unconstitutional after the Republican-controlled Congress zeroed out the penalty as part of the tax overhaul that President Trump signed into law in December.
The Supreme Court had upheld the mandate in 2012 as an exercise of Congress’s taxing power, leaving most of the law intact. But the Republican-controlled states say the mandate, now that it carries no penalty, can no longer be justified as a tax and should be struck down. And if the mandate is gone, they argued in their suit filed in February, the rest of the law must also fall, including the popular requirement that insurers must cover people with pre-existing medical conditions.
Mr. Shumate, the Justice Department lawyer, told the courtroom, “To be clear, the current administration supports protections for people with pre-existing health conditions.” Yet he then asserted that they could not remain in the health law without the individual mandate.
Legal scholars on both sides of the partisan divide have said that the argument of the Republican-controlled states and the Trump administration is weak, but even so, the case could still take months or years to make its way through the courts.
In Wednesday’s hearing, Darren McCarty, a lawyer with the Texas attorney general’s office, argued that in getting rid of the tax penalty, Congress “severed that very thin thread that held together the Affordable Care Act.” He urged Judge O’Connor, a George W. Bush appointee on the federal court for the Northern District of Texas, to issue a preliminary injunction.
In June, the Trump Justice Department told the court that while it disagreed that the entire law should be struck down or that a preliminary injunction was necessary, it would no longer defend the individual mandate or several other central provisions, including the one for pre-existing conditions.
Since that meant the defendant in the case, the United States government, was effectively siding with the plaintiffs, a coalition of 16 states and the District of Columbia, led by Xavier Becerra, the attorney general of California, intervened as defendants to fight for the law.
Judge O’Connor for the most part appeared more skeptical toward those states than the Republican plaintiffs on Wednesday. In particular, he questioned California’s argument that the law no longer requires people to carry insurance just because the penalty had been eliminated.
“Why wouldn’t the law still require people to buy coverage moving forward?” he asked Nimrod Elias, a lawyer for the California attorney general’s office.
Mr. Elias and his colleagues also tried another argument: Since many people pay their taxes late, penalty revenues would continue trickling into the federal treasury for at least the next few years, validating the mandate’s tax status. Again, Judge O’Connor appeared not to buy it.
But the bigger question in the courtroom was whether the various provisions of the law would be unconstitutional — unable to be severed from one another — if the mandate were found to be unconstitutional. Mr. Elias argued forcefully against that logic, pointing out that Congress had preserved the rest of the statute when it zeroed out the penalty last year.
The “correct remedy,” Mr. Elias said, would be to simply eliminate the 2017 amendment that eliminated the penalty, not to get rid of the overall law.
But Judge O’Connor seemed more interested in the Texas position that he should look to the intent of the 2010 Congress that passed the health law, not the 2017 Congress that ended the penalty, in deciding whether to preserve the rest of the law if he tossed out the mandate.
“Why would I not” look to the intent of the Congress that enacted the health law, he asked Mr. Elias.
Much of the more than three hours of arguments centered on language in the Affordable Care Act that describes the individual mandate as “essential to creating effective health insurance markets” — language that the plaintiffs said made clear that the rest of the law, or at least the pre-existing condition protections, could not function without it.
“What better could you have than these express intents of the Congress?” Judge O’Connor asked.
Mr. Elias replied, “Whatever Congress may have believed in 2010, Congress in 2017 made a categorically different judgment,” deciding to remove the penalty without touching the rest of the health law. He also read quotes from Senators Orrin Hatch, Republican of Utah, and Tim Scott, Republican of South Carolina, who publicly emphasized when the tax bill passed last year that no other part of the health law would be eliminated.
“They certainly did not believe in any way, shape or form that they were taking away subsidies and pre-existing condition protections,” Mr. Elias said.
Judge O’Connor went on to ask whether Congress might have intended to force the courts to invalidate the entire health law by targeting the penalty, knowing it was the reason the Supreme Court held up the law as constitutional in 2012.
The judge, who said he would “get something out just as soon as I can,” also grilled Mr. Shumate about the Justice Department’s position that only the law’s provisions for the individual mandate and pre-existing conditions should be invalidated, instead of the entire law, as Texas wants.
He had the fewest questions for Mr. McCarty, the lawyer for Texas, although he did ask why it disagreed with the Trump administration that a preliminary injunction would be too disruptive.
“Our position,” Mr. McCarty said, “is it doesn’t throw the American health care system into chaos.”
Hospitals are fed up with drug companies, so they’re starting their own
by Carolyn Y. Johnson - Washington Post - September 6, 2018
A group of major American hospitals, battered by price spikes on old drugs and long-lasting shortages of critical medicines, has launched a mission-driven, not-for-profit generic drug company, Civica Rx, to take some control over the drug supply.
Backed by seven large health systems and three philanthropic groups, the new venture will be led by an industry insider who refuses to draw a salary. The company will focus initially on establishing price transparency and stable supplies for 14 generic drugs used in hospitals, without pressure from shareholders to issue dividends or push a stock price higher.
“We’re trying to do the right thing — create a first-of-its-kind societal asset with one mission: to make sure essential generic medicines are affordable and available to everyone,” said Dan Liljenquist, chair of Civica Rx and chief strategy officer at Intermountain Healthcare in Utah.
The consortium, which includes health systems such as the Mayo Clinic and HCA Healthcare, collectively represents about 500 hospitals. Liljenquist said that the initial governing members have already committed $100 million to the effort. The business model will ultimately rely on the long-term contracts that member health care organizations agree to — a commitment to buy a fixed portion of their drug volume from Civica.
While Civica did not disclose which drugs it’s focusing on for competitive reasons, Elie M. Bahou, chief pharmacy officer of Providence St. Joseph Health, a 51-hospital system spread across seven states and one of the members of the consortium, said the criteria include drugs that underwent price increases of 50 percent or more between 2014 and 2016 and essential medicines that were on national shortage lists.
A 2016 survey commissioned by hospital lobbying groups found that a third of hospital administrators reported that higher drug prices had a “severe” effect on their ability to manage their budgets.
Several hospital leaders said shortages and price spikes on old drugs are managed on a near-daily basis. The cost isn’t just the price of a drug, but the clinical and staff time spent tracking the supply, looking for alternatives and changing protocols. For hospital systems that are in multiple states, the shortage problems are often hyperlocal, too — in one state, morphine might be available while fentanyl is in shortage, while in another, the reverse could be true. So the one solution may not even work systemwide.
“There’s a whiteboard at every one of our pharmacies, and there are 10 to 20 drugs on the whiteboard and a number — that’s the supply they have on hand. And depending on what that number is, they’ll strategize: What are we going to do,” said Bob Ripley, chief pharmacy officer of Trinity Health, one of the health systems in the consortium.
Civica Rx’s first drug could hit the market next year, and the company has committed to a transparent pricing model, without secret rebates that are common throughout the pharmaceutical industry.
Martin VanTrieste, chief executive of Civica, worked in the traditional pharmaceutical industry for decades — most recently at biotech giant Amgen — and said that he came out of retirement to take on the role with two requirements: He’d work without pay, and the company had to remain focused on patients. The question of how big the company might grow, he said, depends on how the market reacts.
“We want the marketplace to take care of itself and work, so if the entrance of Civica with 14 drugs — and the threat we can do more, pretty quickly, makes the marketplace work better, probably we don’t grow much bigger than that,” VanTrieste said. “But if the marketplace is broken and can’t be fixed by adding just 14 drugs,” the company could expand much more.
There are risks to the idea. Civica’s leaders have discussed the possibility that other companies that make the generic drugs will temporarily cut their prices in an effort to maintain market share. But Civica leaders say the model of guaranteeing a steady supply at a fair, transparent price will be attractive to hospitals. Since the effort was first outlined in January, health organizations that represent a third of the nation’s hospitals have expressed interest.
“The risk of doing nothing is that we’ll continue with the same price escalations and shortages we’ve had,” said Amy Compton-Phillips, chief clinical officer of Providence St. Joseph Health. “The risk of doing nothing to me seems higher than actually trying creative solutions to solve the problem.”
https://www.washingtonpost.com/national/health-science/hospitals-are-fed-up-with-drug-companies-so-theyre-starting-their-own/2018/09/05/61c27ec4-b111-11e8-9a6a-565d92a3585d_story.html?
Manchin Counts on Health Care to Stave Off Republican Tide in West Virginia
by Trip Gabriel - NYT - September 9, 2018
MARMET, W.Va. — There were the beauty queens, ages 6 to 60, riding in style in the Labor Day Parade, including Teen Miss West Virginia Coal. There was the man driving a pickup truck memorial to 29 workers killed in a 2010 mine disaster, each victim’s portrait airbrushed on metal.
And there was Senator Joe Manchin, in a sky-blue shirt with the state’s craggy outline on its crest, walking the route and greeting voters who brought up his favorite issue themselves.
“Save our health care!” Barbara Miller shouted.
Mr. Manchin stopped to give her a hug. After he passed, she said she feared that Republicans in Washington will continue to try to repeal President Barack Obama’s health care law. “If they can’t overturn that, then they hope they can at least favor their big-insurance buddies by allowing them to block pre-existing conditions,” said Ms. Miller, a nurse educator. “I have a pre-existing condition.”
“We all do,” chimed in four other women seated with her on a porch.
In a state where approval of President Trump is near the country’s highest, Mr. Manchin, a Democrat, was once thought to be deeply endangered in his re-election this year. But the 71-year-old incumbent, who likes to say “Washington sucks,” has a 7- to 10-point polling edge over his Republican opponent, Patrick Morrisey. A lot can happen before Election Day, but for now, he is the envy of other red-state Democrats as the parties wrestle over control of the Senate.
For an explanation, look no further than the issue Mr. Manchin has made No. 1 in his campaign: health care, specifically protections enshrined in the Affordable Care Act, a once-vilified law that has grown increasingly popular now that its benefits are woven deeply into a state with high poverty and poor health. West Virginia has the highest share of its population covered by Medicaid, 29 percent, including about 160,000 who became eligible in the Medicaid expansion under the law.
Mr. Manchin, a former governor and the state’s dominant politician for more than a decade, rarely cites the law’s formal name, much less its toxic-for-West Virginia nickname, “Obamacare.”
But he has relentlessly raised the alarm over the potential loss of coverage for people with pre-existing conditions, about one in three West Virginians.
Mr. Morrisey, the state attorney general, practically handed him the issue by joining a new lawsuit seeking to repeal the health care law, which Mr. Morrisey calls “devastating” because of rising premiums in the individual market.
A federal judge in Texas heard arguments Wednesday in the case, which was brought by Republican state officials from around the country. If they win and the Affordable Care Act, or pieces of it, falls, an estimated 17 million Americans will lose coverage. And in a change that would affect far more people, insurers would once again be able to deny coverage to those with pre-existing conditions or charge them more.
Democrats have seized on the lawsuit to defend endangered senators in red states, including North Dakota, Montana and Missouri.
But few are using it to galvanize votes as aggressively as Mr. Manchin, whose state has epidemic levels of diabetes, heart disease and opioid addiction. His TV ads star West Virginians with pre-existing conditions. He hosts round tables on the topic. And in the Senate, he introduced a resolution to fight the Republican lawsuit.
Running on health care is designed to overcome his chief vulnerability: Mr. Trump’s 60 percent job approval here.
Jimmy Ulbrich, from nearby Dawes, is a prime target. “He is bringing America back the way it should be,” Mr. Ulbrich, 48, said of Mr. Trump. But Mr. Ulbrich, who is disabled, does not like the idea of overturning the Affordable Care Act. “I guess Joe Manchin gets my vote,” he said.
Mr. Morrisey accuses his opponent of engaging in “scare tactics.” He says he supports protecting people from losing coverage because of pre-existing conditions. “But to say you shouldn’t knock out a law that’s been utterly devastating West Virginia families with double-digit premium increases is ridiculous,” he recently said on West Virginia talk radio.
The Affordable Care Act, signed into law by Mr. Obama in 2010, barred insurance companies from denying coverage to those with pre-existing conditions, required all Americans to get health insurance, offered subsidies for many plans and allowed states to expand their Medicaid programs.
West Virginia benefited more than almost any state. The uninsured adult population dropped to 9 percent in 2015, down from 21 percent before the law’s enactment. “It’s probably the most important piece of legislation for West Virginians since the Great Society,” said Simon F. Haeder, a political scientist at West Virginia University.
In 2012, before the major provisions of the law kicked in, a poll of the state found 55 percent favored repeal. Five years later, a survey for the American Medical Association found West Virginians opposed by a 2-to-1 margin letting insurance companies charge higher rates to people with pre-existing conditions.
“Time heals and changes views when people see they have health insurance,” said Natalie Tennant, a Democrat who lost a race for the seat of retiring Senator Jay Rockefeller in 2014. In her campaign, she highlighted the issue of pre-existing conditions. “People pushed me aside and laughed,” she said. “‘Aww, you’re just talking about Obamacare.’”
Mr. Morrisey regularly attacks Mr. Manchin for voting against the Republican tax cut and its economic benefits. It is Mr. Manchin’s most vulnerable vote, and when pressed, he returns to health care. He says he opposed the tax cut bill, Mr. Trump’s major legislative achievement, because it zeroed out the penalty for not buying health insurance. That effectively kills the individual mandate, which experts say shakes the foundation of the health law.
In recent years, as other West Virginia Democrats switched to the Republican Party, Mr. Manchin has held out, a social conservative who believes in using government’s money and might to protect the needy. He won 60 percent of the vote in his last election, even as the Republican presidential nominee, Mitt Romney, carried every county.
But this year he will not have nearly as easy a time. That is why, at a rally for the United Mine Workers of America later on Labor Day, he invoked a biography many knew well. How he was raised in the tiny coal mining town of Farmington. How an uncle died in a mine disaster in 1968. He combined that with attacks that Mr. Morrisey, 50, despite two terms as attorney general, is an outsider, who once ran for office in New Jersey.
“I know what it’s like,” Mr. Manchin told the miners, most of them retired. “I’ve been there, I’m never going to leave y’all.”
“Pick the person you believe in,” he said. “Who’s going to be there for you, who’s going to fight for you, who understands how we were raised. Who understands the hardships we have.”
The challenge for a candidate running on health care in a red state is that Democrats long ago lost the messaging fight on Obamacare, which became an all-purpose epithet for the myriad deficiencies of American health care.
In fact, West Virginians covered under the Medicaid expansion don’t always believe they are benefiting from the law. They simply know they became eligible for a “medical card” entitling them to government benefits, which many neighbors and family members already had under more restricted programs.
David Johnson, 57, worked in a sawmill for decades, with two mangled fingers to show for it. In 2009, his employer canceled his insurance benefits, he said, and when he sought a policy on the open market the premiums were $1,700. He blames the Affordable Care Act, even though the law was not yet enacted.
At the Cabin Creek Health Center in Dawes, Mr. Johnson brought a letter from the state on Wednesday entitling him and his wife to Medicaid under the expansion, which they qualified for as low-income adults without dependent children. But he did not connect his benefits to the Affordable Care Act.
He plans to vote for Mr. Morrisey. “My dad would roll over in his grave to think I’d vote Republican,” he said.
The Cabin Creek clinic is part of a network of rural health care providers treating patients regardless of ability to pay. The health care law provided easier access to specialists and medications, and it pays for opioid addiction treatment in the state with the highest overdose death rate in the country.
One patient, Erica Honaker, 37, said the program saved her life. She had lost a job, her home and custody of a son after years of being a “textbook junkie.’’
She said she used the “medical card” she had as a low-income mother to enter Cabin Creek’s treatment program. It included group therapy and the anti-craving drug Suboxone. Ms. Honaker found a part-time factory job and was recently offered full-time work with health insurance. She has a court date this month to win back custody of her son, now five.
“I’m a functioning member of society again,” Ms. Honaker said. “I paid my taxes this year so the next person can get a medical card and get taken care of.”
Ms. Honaker plans to vote for the first time in many years. She has not yet tuned into the race. But she recalls paying close attention last year to the debate in Washington when Republicans tried, and failed, to repeal Obamacare. “Thank God that didn’t happen,” she said.
Stan Brock, 82, Intrepid Provider of Health Care in Remote Areas, Dies
by Sam Roberts - NYT - September 6, 2018
Stan Brock, a former British cowboy and co-host of the long-running television show “Wild Kingdom,” liked to tell of an exchange he had with the sixth man to walk on the moon.
He was recounting to that astronaut, Edgar D. Mitchell, what had prompted him to quit his job, sell all his belongings and found a volunteer mobile medical service for uninsured Americans and poor people in underdeveloped countries.
The organization, the Remote Area Medical clinic service, or RAM, initially established volunteer medics in the Amazon and has since provided free care for hundreds of thousands of needy patients.
As the genesis story goes, he was a teenager at the time living with the Wapishana Indians in what was then British Guiana, and they had given him a wild Spanish bronco as a gift. The horse, which had killed a previous owner on a wild ride, was only slightly more forgiving when Mr. Brock climbed on board.
The bronco bucked across the savanna and collided with a barbed wire fence. Mr. Brock was thrown to the ground, the 700-pound stallion landing on top of him.
“I was very badly injured, but the nearest doctor was 26 days away on foot, through a narrow trail in the rain forest where you couldn’t take horses,” Mr. Brock told the British newspaper The Independent in 2014.
“Ed said, ‘Gosh, I was on the moon and I was only three days from a doctor,’ ” Mr. Brock recalled. “Sure, I said, but for those people who lived in the Upper Amazon, and the 50 million people we’re now dealing with in the U.S., they might as well be on the moon for the opportunity they have to get the health care they need.”
Stan Brock died on Aug. 29 at RAM’s offices in Rockford, Tenn., where he had lived ascetically since he founded the nonprofit outfit in 1985. He was 82. Robert Lambert, a RAM spokesman, said the cause was complications of a stroke.
RAM began operating initially in British Guiana and then expanded to the United States in 1992, starting out with a single pickup truck that hauled a single dentist’s chair. It opened its first American clinic in Sneedville, Tenn., in 1992 and still runs an airborne ambulance operation in what is now the independent nation of Guyana.
The organization estimates that it has provided medical, vision and dental care to more than 700,000 patients since its founding, in areas ranging from Appalachia to New York City, and in Puerto Rico in the aftermath of Hurricane Maria.
Last year, about 1,400 health professionals volunteered to treat 2,300 people who showed up at one of RAM’s outdoor clinics at the fairgrounds in the western Virginia town of Wise. Some had camped out for three days to make sure they would be treated.
“The health fair reminded me of scenes I’ve witnessed in refugee camps in South Sudan,” Nicholas Kristof wrote in his Op-Ed column in The New York Times. “But here in America?”
RAM receives no government funding and is supported by contributions, which invariably escalated after potential givers learned in news reports about Mr. Brock’s unwavering commitment.
The organization was the subject of a photo essay in The Times in 2007 and was featured on network television programs like “60 Minutes.” Mr. Brock was profiled in a documentary film last year titled “Medicine Man: The Stan Brock Story.”
Stanley Edmunde Brock was born on April 21, 1936, in Preston, Lancashire, England, to Stanley and Irene (Mandley) Brock. His father, a civil servant who supervised telephone installations, was posted around the country and later deployed to British Guiana, a colony until 1966. When Stan was 17, he left Britain and the Canford School in Dorset to visit his parents over the summer and never returned to Britain, or to school.
“For five years I had been a prisoner of the establishment,” he wrote in a memoir, “All the Cowboys Were Indians” (originally published in 1969 as “Jungle Cowboy”), “strangled by a stiff white collar, black tie, gray drainpipe trousers and an ill-fitting jacket, herded like a convict, carrying armfuls of Chaucer, Homer and English history.”
He was married briefly, but said he had subordinated the relationship to his volunteer work.
“I’m trying to think of a way to put this — would I like to be married? Yes,” he told The Independent. “Would I like to have children? Yes. But I’ve got thousands of them now.”
He is survived by his brother, Peter, and a longtime friend, Karen Wilson, RAM’s former executive director.
Mr. Brock became a cowboy in British Guiana. There, from 1952 to 1968, he was the manager of the 4,000-square-mile Dadanwa Ranch, once the world’s largest cattle station, with 30,000 Longhorn cattle and horses.
His other books, including “Leemo: A True Story of a Man’s Friendship With a Mountain Lion” (1967), brought him to the attention of a BBC filmmaker. He was then invited to join “Mutual of Omaha’s Wild Kingdom,” the Emmy Award-winning NBC series, as a co-host with Marlin Perkins in the late 1960s. He appeared on the program for more than a decade.
He also appeared in an American sitcom, “The Corner Bar,” and acted in several adventure films, including “Escape From Angola” in 1976 and “Galyon” in 1980.
He was credited with discovering a rare species of bat, which was named for him, Vampyressa brocki. He was also a pilot, which enabled him to reach remote areas, and held a black belt in taekwondo.
Mr. Brock was instrumental in persuading Tennessee legislators to let licensed health care professionals from out of state volunteer to provide free medical services. RAM was nonpartisan in debates about health care, though, he said.
“I’m just the voice of the homeless and the underserved,” he said. “But unless they fix these basic things, we’re going to be doing this long after my lifetime.”
Asked in an interview about his legacy, Mr. Brock said, “I hope that a hundred years from now, nobody will remember me at all because this will be a thing of the past.”
“But,” he added, “there seems to be no end in sight.”
If You Don’t Believe Single Payer Can Work, See How They Do It In Taiwan
by Jonathan Cohn - Huffington Post - September 8, 2018
TAIPEI, Taiwan ― Yun Yen is one of Taiwan’s leading oncologists and, until last year, was president of its most prestigious private medical school. But Yen knows plenty about American health care, too. He trained at Thomas Jefferson University Hospital in Philadelphia, did a fellowship at Yale and then spent more than 20 years on the staff at City of Hope, the internationally recognized cancer hospital in Southern California.
While in the United States, Yen developed a deep respect for its history of medical innovation and how it benefits the rest of the world. One of his goals in coming back to Taiwan was to help build a research infrastructure that could produce similar breakthroughs.
“Most of the new cancer drugs come from the states,” he said as we talked in his office this summer. “The beauty of the U.S. is its high, advanced tech care.”
But Yen also saw the downsides of American health care: the volatility for patients who changed insurance plans and lost access to their old provider networks; who had no insurance at all and were left dealing with financial crises as well as medical ones; or who had missed out on screenings or preventative care that might have detected cancer earlier.
“This was not good medicine,” Yen said, shaking his head. “In this respect, Taiwan is better.”
Americans might want to pay attention. Taiwan has a universal health care system, which means that pretty much everybody can pay for their medical care and, with rare exceptions, nobody faces financial ruin because they get sick or injured. That’s true of most developed countries, and in the U.S. universal coverage remains the Affordable Care Act’s ultimate goal. But Taiwan is one of the few where the government provides insurance directly, rather than through some independent intermediaries or private carriers ― a true “single-payer system.”
And that matters, because single payer is suddenly getting political traction in the U.S., especially among progressives who are thinking less about defending Obamacare and more about improving upon it. Single payer was a centerpiece of Bernie Sanders’ presidential campaign, and fealty to the concept seems likely to be a requirement for the 2020 Democratic Party nomination. Polls suggest the basic idea is popular, even with Republicans.
But single payer’s critics are also starting to rally. Last month, a consortium of health care industry groups announced they were forming an organization to “educate” the public about single payer ― which, almost surely, means convincing people that it’s a terrible idea. Critics often point to the single-payer system that Americans know best, Canada’s, and the well-publicized long waits for specialty services that supposedly (but don’t really) send hordes of patients south across the American border for treatment.
Taiwan provides a valuable counter-argument to this claim because wait times are basically non-existent and patients can see whatever doctors they want, whenever they want. It’s just one of many features of Taiwan’s system that most Americans would probably find appealing, although would-be reformers in the U.S. should be careful about over-interpreting what it means for their efforts.
Taiwan’s system isn’t perfect and, even if it were, an American version of single payer wouldn’t be a mirror image. Taiwan’s system, like any other country’s, is a byproduct of its specific political, cultural and economic idiosyncrasies. A U.S. version would differ in ways Americans might find better or worse ― or both. And that’s assuming it could even become law in the first place.
How Taiwan Ended Up With Single Payer
While most developed countries created their national health systems in the early and middle parts of the 20th century, Taiwan had no universal coverage as recently as the early 1990s. Instead, it had a set of independent social insurance funds ― one for farmers, one for government workers, and so on ― that together covered roughly roughly 60 percent of the country. The other 40 percent had no insurance and struggled to find care and pay their bills.
“For some patients, they couldn’t come up with the money,” said Lee Po-Chang, a kidney surgeon who is now director-general for the National Health Insurance (NHI) system. “And so they would just accept it [and] go home to die.”
A political revolution changed that. In the late 1980s, the Chinese nationalists who had ruled the island since fleeing mainland communism ended martial law, allowing an opposition party to flourish and push for its core demands, one of which happened to be universal health care. Rather than fight the cause, the ruling nationalists co-opted it. They set up a commission and tapped a Chinese-born foreigner, Harvard economist William Hsiao, to run it.
Hsiao asked experts from a series of countries to prepare reports on their systems, figuring that Taiwan could learn from lessons abroad. The group’s mantra, as the journalist T.R. Reid recounted in his 2009 book, The Healing of America, was a Chinese proverb: “To find your way in the fog, follow the tracks of the oxcart ahead.”
Among the other experts who worked with the committee were Uwe Reinhardt and Taiwan-born Tsung-Mei Cheng, both from Princeton, who recommended single payer. They thought it would be the most efficient system because billing would be so straightforward and the government wouldn’t have to divert money to profit, marketing or overhead. More important, everybody would get the same basic insurance package, which was a priority for the Taiwanese.
“Their [Tawain’s] constitution actually stipulates that government should provide medical services to everybody on an equal basis,” Cheng told me recently, recounting how those discussions went. (Reinhardt, who was also Cheng’s husband, died last year, but not before winning Taiwan’s Presidential Prize for his contributions to the health care system’s development.)
The prospect of handing so much control to the government didn’t thrill everybody. Physicians, in particular, protested, citing the potential to reduce their pay. But with both of Taiwan’s political parties behind the concept and the clamor for action so loud, the proposal had just enough support to become law.
What The System Looks Like Today
More than 99 percent of people living in Taiwan now have insurance through the NHI. They pay premiums based on a sliding scale, with employers contributing additional premiums, and they have to pay modest out-of-pocket costs for everything from prescriptions to hospitalization.
That last part might surprise people who think that single payer necessarily means “free” health care. It doesn’t, though the NHI waives copayments and deductibles for several key populations: the poor, pregnant women, children younger than three and people with serious, long-term conditions like diabetes or cancer.
“It protects the disadvantaged, it protects the sick, really well,” Cheng said. “When they set up the program, they said, ‘We should feel sorry for those who are sick ― on top of that pain and suffering, it’s an awesome financial burden. We should take care of that.’”
It’s easy to see how such a system could get expensive. But the Taiwanese government establishes a hard limit on overall health care spending, then negotiates fees for every medical service and supply. It’s cost control by brute force, and it works. In 2016, the overall budget worked out to less than 7 percent of Taiwan’s gross domestic product, compared to 16 percent in the United States.
Some of the difference shows up in superficial ways, like Taiwan’s conspicuously spartan and utilitarian facilities. A popular pediatric clinic in northwest Taipei that I visited had curtains, not doors, on some room entrances, plus a waiting area that consisted of a bench crammed into a hallway. The large, cartoonish sign bearing the clinic’s name looked like it belonged on a fast-food restaurant or gas station.
But patients in Taiwan have the kind of access to medical care most Americans would envy. They can see any doctor or visit any hospital anytime they want, and pay just a small additional fee for specialty care without a referral.
“We get to the hospital without any burden ― it’s very easy,” Phoebe Chi, CEO of the Taiwan Association of Cancer Patients, explained while standing in the outpatient registration area of Shuang Ho Hospital, just south of downtown Taipei. About three dozen patients were sitting in chairs there. Most probably came on their own, Chi said, without referrals or appointments, and would have their tests and procedures done the same day ― usually within an hour or two.
“We go to the hospital like it’s the shopping mall,” she said.
Where Taiwan Gets Good Results ― And Where It Doesn’t
Of course, the real test of any health care system is how it performs on its core functions: protecting people from the financial shock of medical bills and, ultimately, improving health outcomes. Although there’s no reliable data on economic hardship because of illness, experts are unanimous that insuring everyone in Taiwan has dramatically improved financial security.
As for the NHI’s effect on health, that too is difficult to measure, as it’s a consequence of many factors that have nothing to do with health care. But as Chengand others have observed, Taiwanese life expectancy ― which had already been increasing in the 1990s as incomes rose ― improved even more after the NHI. There was also a decline in “mortality amenable to health care,” which is a statistic that attempts to measure how many people are dying because they didn’t get appropriate or timely medical care.
Taiwanese policymakers and experts nonetheless see plenty of problems in the way their system works. They have experimented with different payment models and talk more and more about introducing more aggressive referral requirements, on the theory that access to care has become too easy, leading to over-treatment. But they are also proud of some of their innovations, especially when it comes to Taiwan’s electronic medical record system ― which, although still a work in progress, is considered by some the world’s best.
Everybody in the country carries around an NHI card that speeds registration and billing and provides full access to patient records. Doctors and pharmacists get instant warnings about potentially dangerous drug interactions, and system administrators get real-time data about the utilization of services that can be used to adjust payments if they see patterns of overuse or underuse. It also provides public health officials an early warning system for epidemics.
Every health care system has its trade-offs, and in Taiwan one of those is the effect of low fees on physicians, who have basically tried to make up in volume what they can’t get in price. The Taiwanese end up seeing the doctor more frequently than people in most other countries but spend less time in the office when they do. Doctor burnout is becoming a problem and a small but growing group are making regular trips to clinics in mainland China, where they can make more money because the People’s Republic, desperate to meet their fast-growing population’s need for care, now offers better pay.
Another place Taiwan has saved money is on cutting-edge treatment ― in particular, the latest cancer drugs. Taiwan’s government negotiates pharmaceutical prices directly with manufacturers, as pretty much every country except the U.S. does. But it typically waits a year or two after the release of a new drug before approving it, and then bases its payment on a mix of what other, larger countries are already paying. That has the effect of steering more people to older, cheaper therapies, even when newer ones are available.
Those who want drugs the NHI won’t cover can pay for them out of their own pockets, and they can draw on private “indemnity” plans that pay cash benefits in case of illness, although the newest drugs cost so much that they can overwhelm even those added benefits. Advocates for cancer patients like Chi, who is a breast cancer survivor, say this is one reason the mortality rates for some cancers in Taiwan are middling by international standards. Many cancer doctors disagree, saying the newer treatments frequently offer little benefit.
Either way, the reality is that Taiwan could easily get quick access to the newest drugs if it was willing to commit a little more spending to the cause or consider partial payment for such drugs, an option Chi’s group has proposed. Even a significant bump in spending would still leave Taiwan spending way less on cancer treatment than the U.S. does.
What It All Means, And Doesn’t Mean, For The U.S.
The most difficult part of imagining single payer in the U.S. is conceiving of how it might come into existence in the first place. The circumstances are so different than what Taiwanese reformers faced 25 years ago when the expansion of coverage was purely additive: giving insurance to people who didn’t have it already and mostly leaving existing arrangements in place.
Proposals like the one Bernie Sanders has outlined envision wiping out private insurance, which would mean getting rid of the employer benefits through which the majority of working-age Americans now get coverage. It might be a change for the better, providing more comprehensive coverage, with no networks, and for lower cost overall. But making that case to the tens of millions who currently have employer benefits they like is difficult, and some people would inevitably feel, justly or not, like the transition left them worse off.
The best available estimates suggest that the Sanders bill would also reduce provider compensation by something like 10 percent, give or take a few percentage points. That might not sound like a lot, but that’s an average and it would inevitably hit some doctors and hospitals hard, especially if the cut took place within the span of just four years, as Sanders has proposed. Providers would fight hard, as they are already starting to do, and they would quickly find allies in the Republican Party ― which, alone among conservative parties in developed nations, opposes universal coverage on principle.
The question for single-payer advocates in the U.S. is how, if at all, they can overcome such obstacles. One possibility would be to roll out reductions in provider and drug and device reimbursements over a longer period of time, or introduce an optional government-run plan on the expectation that it would attract more people over time. Or they could think of single payer less as an all-or-nothing proposition and more as a series of interlocking policies to create and then strengthen independently, as political circumstances allow.
A good place to start might be taking the critical step that Taiwan did. Policymakers could make sure that people with cancer, diabetes and other chronic, economically-crippling conditions don’t face out-of-pocket costs ― protecting those people from financial duress and reducing the likelihood they postpone necessary care because of cost. Introducing fixed fees and global budgets slowly, as Maryland is already doing on its own and California is contemplating, might also work. That could also help insure that cuts were done in a way that didn’t deter important innovation.
Neither of those features is unique to Taiwan or even, as it turns out, to single payer. Many of the public-private hybrid systems in Europe have them too. One very real possibility is that a push for single payer could leave the U.S. with a system that looks more like what those other countries have, simply because the politics and policy of dislodging the current system would prove too difficult. It’d still be cheaper, and a lot more humane, than what exists now.
https://www.huffingtonpost.com/entry/single-payer-medicare-taiwan_us_5b9295ede4b0511db3e1d45a?
It’s Hard for Doctors to Unlearn Things. That’s Costly for All of Us.
by Aaron Carroll - NYT - September 10, 2018
We know it can be hard to persuade physicians to do some things that have proven benefits, such as monitor blood pressure or keep patients on anticoagulants. But it might be even harder to get them to stop doing things.
In May, a systematic review in JAMA Pediatrics looked at the medical literature related to overuse in pediatric care published in 2016. The articles were ranked by the quality of methods; the magnitude of potential harm to patients from overuse; and the potential number of children that might be harmed.
In 2016 alone, studies were published that showed that we still recommend that children consume commercial rehydration drinks (like Pedialyte), which cost more, when their drink of choice would do. We give antidepressants to children too often. We induce deliveries too early, instead of waiting for labor to kick in naturally, which is associated with developmental issues in children born that way. We get X-rays of ankles looking for injuries we almost never find. And although there’s almost no evidence that hydrolyzed formulas do anything to prevent allergic or autoimmune disease, they’re still recommended in many guidelines.
Those researchers had reviewed the literature on overuse in children before, looking at all the studies from a year earlier. They modeled the work on a set of papers in JAMA Internal Medicine that looked at overuse in adults through a review of the literature published in 2015, 2014 and 2013.
Overuse is rampant. And it can harm patients.
By the end of the 20th century, for example, research seemed to indicate that we wanted to keep patients in the intensive care unit in a tight range of blood glucose levels. The evidence base for these recommendations came from observational studies that showed that patients with such tight control seemed less likely to develop adverse outcomes like infections or hyperglycemia, and they seemed more likely to survive.
Researchers tested this recommendation prospectively in a randomized controlled trial in a surgical intensive care unit. The results, published in 2001, appeared to confirm the prior findings, that tight glycemic control saved lives.
The study wasn’t perfect. It wasn’t blinded, for instance, and there were downsides to the recommendations. About 5 percent of those who received the intensive therapy had severe hypoglycemia at least once. The mortality in the control groupwas higher than what might be expected. Finally, this was a study of mostly post-cardiac surgery patients, and it wasn’t clear how widely the findings could be generalized.
Nevertheless, this was a huge benefit, and given the severity of the population being treated (intensive care patients are usually very, very ill), many experts called for changes in treatment while further research was done.
That larger work was published in 2009. The study randomly assigned more than 6,000 patients admitted to an intensive care unit for more than three days — to either tight or traditional glucose control. This time, there was a significantly higher rate of death in the tight control group (27.5 percent vs. 24.9 percent), as well as a much higher rate of severe hypoglycemia (6.8 percent vs. 0.5 percent). These findings applied to patients over all and to subgroups (like surgical versus medical patients).
In light of this, guidelines changed again. Physicians were asked to stop the widespread tight glycemic control.
In 2015, some enterprising researchers set out to look at how this knowledge changed physician behavior. Beginning in 2001, they looked at how physicians adopted the recommendations to use tight glycemic control in patients admitted to intensive care units. Starting in 2009, they looked at how physicians absorbed new information telling them to stop.
From 2001 through 2012, they analyzed data on more than 377,000 admissions to 113 intensive care units in 56 hospitals. Before the first trial was published, in 2001, 17 percent of admissions used tight glycemic control. Beginning in that year, however, there was a slow but steady increase in its use. About 1.7 percent more patients were being treated with recommended practice each quarter.
It’s hard to change behavior, but over time, physicians did. By 2009, the use of tight glycemic control had increased to about 23 percent. Many might have hoped for more, but at least there was progress.
Starting in 2009, however, the reverse was recommended. Doctors were asked to stop. Tight glycemic control was associated not only with higher mortality, but also with more adverse events.
That didn’t happen. From 2009 through 2012, there was no decrease in tight glycemic control. The authors argued that “there is an urgent need to understand and promote the de-adoption of ineffective clinical practices.”
That is, of course, an understatement.
Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation, is entirely focused on the identification of care that physicians routinely recommend but shouldn’t. Almost 600 different tests, procedures or treatments, collected over the last six years, are currently listed on their website. Almost all the recommendations basically say “don’t do” them.
This overuse doesn’t provide a benefit. It can lead to harms. It can also cost a lot of money.
The public shares some culpability. Americans often seem to prefer more care than less. But a lot of it still comes from physicians, and from our inability to stop when the evidence tells us to. Professional organizations and others that issue such guidelines also seem better at telling physicians about new practices than about abandoning old ones.
I asked Daniel Niven, the lead author of the 2015 study, why it’s so hard to persuade doctors to discontinue certain practices. He said physicians have a hard time unlearning what they have learned, even when there’s newer and better science available. He said, “Even if the new contradictory science is accepted, providers often struggle applying this information in their daily clinical practice, not because they don’t want to, but rather, because they work within a system that doesn’t adapt well to changing evidence.”
He also said doctors might need to be more thoughtful about prevention: “We need to take a more cautious approach to technology adoption, and learn from mistakes of early adoption of health care technologies based on little or low-quality clinical evidence. This way we can prevent the need to ‘break up’ with the practice when the high-quality evidence shows that it is ineffective.”
Overuse represents a significant problem. As policymakers look for ways to save money without harming quality in the health care system, reducing overuse seems as if it should be a top option.
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