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Thursday, November 29, 2018

Health Care Reform Articles - November 29, 2018

Hospital Letter Urging Patient to Start 'Fundraising Effort' to Pay for Heart Treatment Seen as Yet Another Reason America Needs Medicare for All

"'You can't have a heart unless you do GoFundMe for 10K' is not a just 
by Jake Johnson - Common Dreams - November 24, 2018


Hospital Letter Urging Patient to Start 'Fundraising Effort' to Pay for Heart Treatment Seen as Yet Another Reason America Needs Medicare for All


"'You can't have a heart unless you do GoFundMe for 10K' is not a just system."



As progressive lawmakers and healthcare experts have frequently pointed out in recent months, few growing trends have laid bare the fundamental immorality and brokenness of America's healthcare system quite like the rise of GoFundMeand other crowdfunding platforms as methods of raising money for life-saving medical treatments that—due to insurance industry greed and dysfunction—are far too expensive for anyone but the very wealthiest to afford.
"Insurance groups are recommending GoFundMe as official policy—where customers can die if they can't raise the goal in time—but sure, single-payer healthcare is unreasonable."
—Rep.-elect Alexandria Ocasio-Cortez
Providing the latest example of this horrifying trend, a Michigan woman seeking a heart transplant publicized a letter she received from the Spectrum Health Richard DeVos Heart and Lung Transplant Clinic—named after the late father-in-law of Education Secretary Betsy DeVos—informing her that she is "not a candidate" for the procedure "at this time" because she needs a "more secure financial plan" to afford the required post-operation immunosuppressive medication.
The letter goes on to explicitly recommend "a fundraising effort of $10,000" to help pay for the drugs.
Hedda Elizabeth Martin, who posted the letter on Facebook, wrote that her situation encapsulates America's "price gouging, horribly overpriced, underinsured system," which affects millions each day in the richest country on Earth.
The letter, which Martin received shortly before Thanksgiving, began to go viral on Saturday and quickly caught the attention of progressives like Rep.-elect Alexandria Ocasio-Cortez (D-N.Y.), who identified Martin's situation as indicative of the broad failure of America's healthcare status quo—which produces tremendous profits for insurance and pharmaceutical giants and worse outcomes than the healthcare systems of other industrialized nations.
"Insurance groups are recommending GoFundMe as official policy—where customers can die if they can't raise the goal in time—but sure, single-payer healthcare is unreasonable," Ocasio-Cortez, an unabashed supporter of Medicare for All, wrote sarcastically.

https://www.commondreams.org/news/2018/11/24/hospital-letter-urging-patient-start-fundraising-effort-pay-heart-treatment-seen-yet

To patients’ surprise, a visit to urgent care brings steep hospital bill

 - Boston Globe - 

The complaints submitted to Attorney General Maura Healey’s office all described a similar scenario: Patients sought treatment in an ordinary physician office or urgent care center. But to their shock, they were billed for an expensive outpatient hospital visit instead.
After a routine checkup with a primary care doctor in Revere, one patient was charged an extra $372 “hospital’’ fee, according to one complaint. The practice is owned by Massachusetts General Hospital, 6 miles away. “I never set foot in the hospital,’’ the patient wrote. 
Another patient treated at the Patriot Place urgent care center in Foxborough complained about being charged far more than the $50 listed on the insurance card as the payment for urgent care visits. That is because the center’s owner, Brigham and Women’s Hospital in Boston, billed the patient for an outpatient hospital visit, the complaint said. “This is very misleading to consumers,’’ the patient wrote.
Charging facility fees for off-site care is a common practice at hospitals across the country that is coming under growing criticism. An investigation by Healey’s office into such fees charged by Partners HealthCare and its hospitals, including Mass. General and the Brigham, led to a settlement in September. It was the first investigation of facility fees that the attorney general has conducted, a spokesperson said.
Regulators alleged that Partners violated consumer protection law by failing to “adequately and fairly disclose’’ the fees, which generally are legal in the state. Partners denied the allegations and said it provides detailed billing information to patients, but agreed to improve disclosure by June as part of the settlement agreement filed in Suffolk Superior Court.
A state health care watchdog and a coalition of health insurers want the Legislature to go further and outlaw the practice in certain circumstances.
The attorney general’s office began probing Partners and Massachusetts Eye and Ear separately in 2016, but combined the inquiries when the hospital joined Partners earlier this year. The entities were also required to pay a total of $175,000 as part of the settlement.
Following the settlement, the Globe obtained patient complaints filed against Partners and Mass. Eye and Ear over facility fees since 2015 through a Freedom of Information request. The attorney general’s office released 22 complaints, removing patient names and other identifying details.
In a statement to the Globe last week, Partners said it “understands that in some circumstances the manner in which we bill patients for medical services can be confusing.’’ Hospital representatives said they cannot discuss specific cases because of patient privacy laws.
Partners spokesman Rich Copp said the company is committed to transparency and already has taken steps to implement the requirements outlined in the agreement. Those steps include “conspicuously and clearly’’ disclosing in notices at all outpatient facilities that patients may be billed hospital fees that could be higher than they would pay for the same medical services elsewhere. The company must include similar information on its websites, in new patient welcome packages, and with appointment reminders.
Partners, however, will continue to bill hospital facility fees for certain off-site care, a common practice in the hospital industry that is allowed by some insurance companies. The attorney general’s office declined to say whether it is investigating other hospital systems over failure to disclose facility fees.
These charges have become more widespread in the past decade as hospitals across the United States buy up physician practices in the community. The fees have drawn scrutiny from Medicare, some insurers, and consumers, who say that they are unfair and that hospitals are driving up health care costs.
The Massachusetts Health Policy Commission, an independent state agency that monitors health care spending, recommended outlawing facility fees in certain circumstances, but the Legislature’s response has been mixed. Some lawmakers agree with that approach, while others want to require only disclosure of the fees.

The commission’s executive director, David Seltz, said the agency has secured voluntary commitments from some hospitals not to charge facility fees at new doctors’ practices they have purchased. The agency reviews certain acquisitions.
Seltz said the attorney general’s settlement with Partners “is pretty consistent with what other states have done regarding transparency requirements and better information on the front end. We have recommended to go further and limit the ability of some of these sites to bill differently.’’
Consumers seem especially confused about urgent care billing at a time when the number of urgent care centers is soaring. With 18 urgent care centers, Partners and its hospitals own or are affiliated with more such facilities than any other hospital system in the state.
Patients complained about bills from the urgent care center in Foxborough, Newton-Wellesley Hospital’s urgent care center in Waltham, and a North Shore Medical Center-affiliated urgent care center in Danvers. They said they paid the amount listed on their insurance card for urgent care visits and thought they were all set. 
One woman received a $400 bill for treatment for an eye injury at North Shore Urgent Care in Danvers — far more than the $75 listed on her insurance card — because it was billed as an “outpatient clinic’’ visit, according to a complaint. 
“This is 100% false advertising,’’ her husband complained. “On both the website and the gigantic sign in the parking lot, URGENT CARE can be seen in big letters.’’
Patients also complained about billing for dermatology care. A patient who had several warts removed at a practice in Chestnut Hill was billed more than $800 for an outpatient hospital procedure, because the Brigham owns the practice, according to a complaint.
Hospital representatives said the institutions have been transparent with patients all along.
Newton-Wellesley spokeswoman Rachel Kagno said in a statement that “every patient seeking treatment receives a notice when they register that explains how we will bill for their visit, and our staff reviews the billing process with the patient. Notices are posted at the Urgent Care Center and the information is prominently displayed on our website.’’
Brigham spokeswoman Erin McDonough said the dermatology department tells new patients in writing that they “may be responsible for both a facility and a physician bill depending on the complex services that are rendered.”
Still, both said in statements, “there is always room for further improvement.’’

States Are Not Waiting on Congress to Expand Medicare to Cover Everybody

by Wendell Potter - Tarbell.org - August 10, 2018

With all the buzz over the past year about the United States moving to a Medicare-for-all type of health care system, what has not been talked about nearly as much are the different paths we as a country could take to get there. 
While Medicare-for-all bills in Congress have made headlines, far less attention has been focused on legislation that would create state-based publicly financed health care systems. 
It’s entirely possible, maybe even likely, that a state could lead the way. That’s exactly what happened in Canada back in the 1960s. It wasn’t federal lawmakers in Ottawa who got the ball rolling up there. It was the premier of Saskatchewan, thousands of miles to the west. 
If that’s how it takes off here, which state will be our Saskatchewan? 
It very possibly could be New York.
The New York State Assembly passed a bill in June that would provide comprehensive coverage for all New Yorkers. Although the bill, the New York Health Act, has not yet passed the Senate, it got a big boost a few days ago when the RAND Corporation, a global nonprofit policy think tank, released a study showing that the state’s residents, millions of whom are either uninsured or underinsured, would get better coverage—and pay less for it—if the bill became law. Overall, RAND said, the state would save an estimated $15 billion annually after 10 years compared with what it would spend under the current system.
Not only would most New Yorkers save money, their coverage would be considerably more comprehensive. Almost all health care services, including dental and vision, would be covered. (Long-term care is not currently in the bill, but the RAND study said it could be included and still cost less than the status quo after ten years.) Out of pocket spending would be cut in half. 
According to RAND, much of the savings would come from lower administrative costs. Because of our current mix of public and private payers, the United States spends far more on health care administration than any other developed country. RAND found that the New York Health Act would reduce administrative costs by $23 billion. That’s to a large extent what would enable the state to cover everyone and provide them with richer benefits. RAND said the state would actually spend $9 billion more on care than if the current system is still in place. 
The results of the study came as welcome news to the bill’s sponsors, Assembly Health Committee Chair Richard Gottfried and State Sen. Gustavo Rivera. 
“This is an important validation of the New York Health Act by one of the most prestigious analytical firms in the country,” Gottfried said in a statement. “RAND shows we can make sure every New Yorker gets the care they need and does not suffer financially to get it, save billions of dollars a year by cutting administrative costs, insurance company profit, and outrageous drug prices, and pay for it all more fairly.” 
Rivera said he believes the savings and benefits would actually be greater than what RAND estimates. He also noted that RAND found that the bill would also create new jobs in the state. 
Under the bill’s public financing of coverage, premiums that individuals and corporations now pay would be in the form of taxes. As Vox reporter Dylan Scott noted in a recent analysis of the RAND study, the “new tax payments would almost perfectly replace the premiums that people and their employers pay right now for private health insurance.”
While the great majority of New Yorkers would pay less for coverage if the law is enacted, people with incomes in the top 10 percent likely would pay more. As Jodi Liu, the associate policy researcher at RAND who led the study, noted, the progressive nature of the funding mechanism will not be without detractors. “One of the biggest challenges could be the design of the tax schedule, as policymakers seek a balance between affordability for lower- and middle-income households and potential tax avoidance behaviors by higher-income households.” 
The RAND study was commissioned by the New York State Health Foundation.

LePage plans to appeal court order for immediate steps to expand Medicaid

by Scott Thistle - Portland Press Herald - November 21, 2018

Justice Michaela Murphy says the governor can't ignore the will of the people who passed the law extending health care coverage to as many as 80,000 low-income Mainers.

Gov. Paul LePage plans to appeal a judge’s order that his administration immediately move forward with a voter-approved expansion of MaineCare, the state’s Medicaid system.
Kennebec County Superior Court Justice Michaela Murphy issued the order Wednesday, detailing seven steps the Maine Department of Health and Human Services must take to comply with the expansion law, which extends health care coverage to as many as 80,000 low-income Mainers. The law was approved by 59 percent of the state’s voters in November 2017, but LePage repeatedly has blocked implementation by vetoing legislation to fund the expansion and refusing to take administrative steps.
“Although the governor may believe implementation to be unwise and disagree with the (expansion law) as a matter of policy, he may not ignore the will of the people and refuse to take any action toward accomplishing the policy objectives of the (law),” Murphy wrote in her 21-page order.
LePage spokeswoman Julie Rabinowitz said in an email Wednesday that the governor plans to appeal Murphy’s order.
Governor-elect Janet Mills, a Democrat, has said she will make expansion of Medicaid under the voter-approved law the first priority for her administration when she takes office in January.
Murphy’s order, retroactive to July 2, requires the DHHS to file an amendment to paperwork already submitted to the federal government. The amendment must state that there are no legal or constitutional grounds for delaying the expansion. In the initial paperwork filed by the DHHS, during a process known as a state plan amendment or SPA, the LePage administration urged the federal Centers for Medicaid and Medicare Services to reject the state’s application.
The order directs acting DHHS Commissioner Bethany Hamm to “amend the eligibility SPA it submitted to the federal government on September 4, 2018, to reflect an effective date of the Expansion Act to be January 3, 2018; the effective date requiring coverage to be July 2, 2018; and to inform CMS that no constitutional or statutory impediment exists which prevents the commissioner from using existing appropriations to implement the Expansion Act. The commissioner must further take all necessary steps to ensure that approval of the SPA is retroactive to July 2, 2018.”
The order gives DHHS until Dec. 5 to comply.
WIN FOR VOTERS, RULE OF LAW
Robyn Merrill, executive director of Maine Equal Justice Partners, which sued LePage over his delays in implementing the law, called Murphy’s order a “huge victory” for the thousands of Mainers who have “been unfairly denied health care.”
“This is also a victory for the Maine voters and for the rule of law,” Merrill said in a written statement. “The executive branch has a duty to carry out all the laws, not pick and choose, and today’s ruling holds them accountable.”
In August, the Maine Supreme Judicial Court ruled against the administration when it sought to delay implementation of the expansion until the Legislature funded the state’s cost, estimated to be about $55 million a year.
Under the law, Mainers earning as much as 138 percent of the federal poverty level – $16,753 for an individual and $34,638 for a family of four – could begin applying for Medicaid coverage on July 2. Many did, only to receive letters of denial from DHHS.
“The governor’s excuses and obstructionism did not hold water with the courts,” Merrill said.
Jack Comart, litigation director for Maine Equal Justice Partners, said Wednesday that the practical implications of Murphy’s order for those who are eligible for MaineCare services under the law is that any covered services should be paid by the state and any costs they incurred with health care providers that accept Medicaid should be reimbursed. Comart said that anyone who was eligible for services as of July 2 should be reimbursed by the state if they paid for their medical costs out of pocket.
“This is tremendous news for anyone who applied for or was terminated from MaineCare on or after July 2 who meets the eligibility requirements for the expansion group,” Comart said. “The court now says that these people should receive MaineCare right away, whether or not the federal application for funds has been approved. We see no impediment to Maine receiving that approval, but as the court said, it will not hold up care for people who have already waited a long time.”
LEPAGE: ‘NOBODY CAN FORCE ME’
Comart said he did not believe that President Trump’s recent appointment of Mary Mayhew – the former DHHS commissioner under LePage – to head the federal CMS would have any bearing on whether the federal government approves Maine’s expansion plan or not.
Though LePage has argued that expansion was not funded by the Legislature, he vetoed a funding bill approved by lawmakers and the Legislature failed to override the veto in a July 9 vote.
LePage has consistently opposed Medicaid expansion, arguing that doing so would be financially disastrous for the state. In June, he said the Legislature’s $60 million funding bill contained “unsustainable budget gimmicks,” and he vetoed it. Before the ballot measure passed into law, LePage successfully vetoed legislation to expand the system five times. Once he even held a news conference to ceremonially veto an expansion bill even before it reached his desk.
And on a July radio show, LePage said he would rather go to jail than implement the expansion law because of his concerns about the potential impact on the state budget.
“The one thing I know is nobody can force me to put the state in red ink, and I will not do that,” the Republican said at the time. “I will go to jail before I put the state in red ink. And if the court tells me I have to do it, then we’re going to be going to jail.”
Mills, currently the state’s attorney general, has refused to represent the LePage administration in its legal efforts to stop implementation and instead sided with the plaintiffs in the case by filing an amicus brief in support of the expansion law in October.
Mills’ office did authorize LePage to hire a private attorney to defend the administration against the suit. Murphy previously rejected a separate court complaint that LePage brought against Mills over the costs to taxpayers of hiring outside counsel. Those costs, according to state records obtained by the Associated Press, likely exceed $200,000.
“This decision is a victory for the people of Maine,” Mills said of Murphy’s order in a statement issued Wednesday. “Medicaid expansion is the law of the land, and, as governor, I will implement the law.
“Not only will Medicaid expansion result in health care for tens of thousands of Mainers, it will also reduce health insurance costs, support small businesses, bolster our rural hospitals, and create jobs to expand our economy.”

Sanders unveils aggressive new bill targeting drug prices 

by Peter Sulliven - The Hill - November 20, 2018

Sen. Bernie Sanders (I-Vt.) and Rep. Ro Khanna (D-Calif.) on Tuesday unveiled a bill aimed at aggressively lowering drug prices by stripping monopolies from drug companies if their prices are deemed excessive. 
Sanders has long railed against drug companies for their prices, and this bill is one of the most far-reaching proposals aimed at lowering them. 
The bill would strip the monopoly from a company, regardless of any patents, and allow other companies to create cheaper generic versions of a drug if the price for that drug is higher than the median price in Canada, the United Kingdom, Germany, France and Japan.
“No other country allows pharmaceutical companies to charge any price they want for any reason they want,” Sanders, who could run for president again in 2020, said in a statement. 
“The greed of the prescription drug industry is literally killing Americans and it has got to stop,” he added. 
Drug companies argue that other countries, with price controls, lack the innovation that happens in the United States. 
The bill does not have a clear path forward in the next two years, given that Republicans will still control the Senate. 
But the measure shows how far progressives want to go on drug pricing and comes at a time when there is growing momentum for taking some action on the issue, even if it might not be as far-reaching.  
President Trump has also focused on lowering the price of drugs, and Democrats hope to be able to work with him in a bipartisan way.  
Khanna, a progressive who represents Silicon Valley, joins Sanders on the bill. 
“Today, we’re sending big pharma a message: Market exclusivity is a privilege, and when you abuse that by price gouging the sick and aging, then you lose that privilege,” Khanna said.  
https://thehill.com/policy/healthcare/417570-sanders-unveils-aggressive-new-bill-targeting-drug-prices?

Trump Administration Invites Health Care Industry to Help Rewrite Ban on Kickbacks

by Robert Pear - NYT - November 24, 2018

WASHINGTON — The Trump administration has labored zealously to cut federal regulations, but its latest move has still astonished some experts on health care: It has asked for recommendations to relax rules that prohibit kickbacks and other payments intended to influence care for people on Medicare or Medicaid.
The goal is to open pathways for doctors and hospitals to work together to improve care and save money. The challenge will be to accomplish that without also increasing the risk of fraud.
With its request for advice, the administration has touched off a lobbying frenzy. Health care providers of all types are urging officials to waive or roll back the requirements of federal fraud and abuse laws so they can join forces and coordinate care, sharing cost reductions and profits in ways that would not otherwise be allowed.
From hundreds of letters sent to the government by health care executives and lobbyists in the last few weeks, some themes emerge: Federal laws prevent insurers from rewarding Medicare patients who lose weight or take medicines as prescribed. And they create legal risks for any arrangement in which a hospital pays a bonus to doctors for cutting costs or achieving clinical goals.
The existing rules are aimed at preventing improper influence over choices of doctors, hospitals and prescription drugs for Medicare and Medicaid beneficiaries. The two programs cover more than 100 million Americans and account for more than one-third of all health spending, so even small changes in law enforcement priorities can have big implications.
Federal health officials are reviewing the proposals for what they call a “regulatory sprint to coordinated care” even as the Justice Department and other law enforcement agencies crack down on health care fraud, continually exposing schemes to bilk government health programs.
“The administration is inviting companies in the health care industry to write a ‘get out of jail free card’ for themselves, which they can use if they are investigated or prosecuted,” said James J. Pepper, a lawyer outside Philadelphia who has represented many whistle-blowers in the industry.
Federal laws make it a crime to offer or pay any “remuneration” in return for the referral of Medicare or Medicaid patients, and they limit doctors’ ability to refer patients to medical businesses in which the doctors have a financial interest, a practice known as self-referral.
These laws “impose undue burdens on physicians and serve as obstacles to coordinated care,” said Dr. James L. Madara, the chief executive of the American Medical Association. The laws, he said, were enacted decades ago “in a fee-for-service world that paid for services on a piecemeal basis.”
Melinda R. Hatton, senior vice president and general counsel of the American Hospital Association, said the laws stifle “many innocuous or beneficial arrangements” that could provide patients with better care at lower cost.
Hospitals often say they want to reward doctors who meet certain goals for improving the health of patients, reducing the length of hospital stays and preventing readmissions. But federal courts have held that the anti-kickback statute can be violated if even one purpose of the remuneration is to induce referrals or generate business for the hospital.
The premise of the kickback and self-referral laws is that health care providers should make medical decisions based on the needs of patients, not on the financial interests of doctors or other providers.
The Trump administration is calling its effort a “regulatory sprint to coordinated care.”Sarah Silbiger/The New York Times
Health care providers can be fined if they offer financial incentives to Medicare or Medicaid patients to use their services or products. Drug companies have been found to violate the law when they give kickbacks to pharmacies in return for recommending their drugs to patients. Hospitals can also be fined if they make payments to a doctor “as an inducement to reduce or limit services” provided to a Medicare or Medicaid beneficiary.
Doctors, hospitals and drug companies are urging the Trump administration to provide broad legal protection — a “safe harbor” — for arrangements that promote coordinated, “value-based care.” In soliciting advice, the Trump administration said it wanted to hear about the possible need for “a new exception to the physician self-referral law” and “exceptions to the definition of remuneration.”
Almost every week the Justice Department files another case against health care providers. Many of the cases were brought to the government’s attention by people who say they saw the bad behavior while working in the industry.
“Good providers can work within the existing rules,” said Joel M. Androphy, a Houston lawyer who has handled many health care fraud cases. “The only people I ever hear complaining are people who got caught cheating or are trying to take advantage of the system. It would be disgraceful to change the rules to appease the violators.”
But the laws are complex, and the stakes are high. A health care provider who violates the anti-kickback or self-referral law may face business-crippling fines under the False Claims Act and can be excluded from Medicare and Medicaid, a penalty tantamount to a professional death sentence for some providers.
Federal law generally prevents insurers and health care providers from offering free or discounted goods and services to Medicare and Medicaid patients if the gifts are likely to influence a patient’s choice of a particular provider. Hospital executives say the law creates potential problems when they want to offer social services, free meals, transportation vouchers or housing assistance to patients in the community.
Likewise, drug companies say they want to provide financial assistance to Medicare patients who cannot afford their share of the bill for expensive medicines.
AstraZeneca, the drug company, said that older Americans with drug coverage under Part D of Medicare “often face prohibitively high cost-sharing amounts for their medicines,” but that drug manufacturers cannot help them pay these costs. For this reason, it said, the government should provide legal protection for arrangements that link the cost of a drug to its value for patients.
Even as health care providers complain about the broad reach of the anti-kickback statute, the Justice Department is aggressively pursuing violations.
A Texas hospital administrator was convicted in October for his role in submitting false claims to Medicare for the treatment of people with severe mental illness. Evidence at the trial showed that he and others had paid kickbacks to “patient recruiters” who sent Medicare patients to the hospital.
The owner of a Florida pharmacy pleaded guilty last month for his role in a scheme to pay kickbacks to Medicare beneficiaries in exchange for their promise to fill prescriptions at his pharmacy.
The Justice Department in April accused Insys Therapeutics of paying kickbacks to induce doctors to prescribe its powerful opioid painkiller for their patients. The company said in August that it had reached an agreement in principle to settle the case by paying the government $150 million.
The line between patient assistance and marketing tactics is sometimes vague.
This month, the inspector general of the Department of Health and Human Services refused to approve a proposal by a drug company to give hospitals free vials of an expensive drug to treat a disorder that causes seizures in young children. The inspector general said this arrangement could encourage doctors to continue prescribing the drug for patients outside the hospital, driving up costs for consumers, Medicare, Medicaid and commercial insurance.


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Wednesday, November 21, 2018

Health Care Reform Articles - November 21, 2018

LOBBYIST DOCUMENTS REVEAL HEALTH CARE INDUSTRY BATTLE PLAN AGAINST “MEDICARE FOR ALL”

by Lee Fang and Nick Surgey - The Intercept - November 20, 2018

Now that the midterms are finally over, the battle against “Medicare for All” that has been quietly waged throughout the year is poised to take center stage.
Internal strategy documents obtained by The Intercept and Documented reveal the strategy that private health care interests plan to use to influence Democratic Party messaging and stymie the momentum toward achieving universal health care coverage.
At least 48 incoming freshman lawmakers campaigned on enacting “Medicare for All” or similar efforts to expand access to Medicare. And over the last year, 123 incumbent House Democrats co-sponsored “Medicare for All” legislation — double the number who supported the same bill during the previous legislative session.
The growing popularity of “Medicare for All” in the House has made progressives optimistic that the Democratic Party will embrace ideas to expand government coverage options with minimal out-of-pocket costs for patients going into the 2020 election. But industry groups have watched the development with growing concern.
Over the summer, leading pharmaceutical, insurance, and hospital lobbyists formed the Partnership for America’s Health Care Future, an ad hoc alliance of private health interests, to curb support for expanding Medicare.
The campaign, according to one planning document, is designed to “change the conversation around Medicare for All,” then “minimize the potential for this option in health care from becoming part of a national political party’s platform in 2020.”


A slide from Partnership for America’s Health Care Future presentation.

Behind the scenes, the group attempted to sway candidates during the midterms, encouraging several of them to focus on shoring up the Affordable Care Act instead of supporting single-payer health care.
The documents show that Partnership representatives spoke to the staffs of Democratic Sens. Bill Nelson of Florida and Joe Donnelly of Indiana, and received confirmation that both senators would maintain their “moderate position.” When the team met with Rep.-elect Lori Trahan, D-Mass., she said that although she does not speak about the issue, she agreed that “language around single payer should be tempered.” (None of the three politicians’ offices provided responses to inquiries from The Intercept.)
In several competitive races, the Partnership pressed candidates to use industry-crafted talking points when speaking about health care. In one internal planning document circulated with health care lobbyists, the Partnership touted its influence over Danny O’Connor, the Columbus, Ohio-area Democrat who ran for the 12th Congressional District, claiming that O’Connor used Partnership talking points “in national news interviews.” (O’Connor’s campaign did not respond to a request for comment.)
Several of the candidates who agreed to embrace the Partnership’s messaging and policy ideas, including Donnelly and O’Connor, came up short on Election Day. A recount ending on November 18 confirmed that Nelson received fewer votes than Republican challenger Rick Scott. But soon after Election Day results came in, the Partnership went on the offensive, informing reporters that candidates who embraced “Medicare for All” had also lost, pointing to the defeat of progressives such as Kara Eastman in Nebraska. The group also relied on research from the business-friendly Democratic think tank Third Way to argue that victorious pro-“Medicare for All” candidates couldn’t attribute their success to having supported “Medicare for All” because few Democrats explicitly mentioned the policy in their campaign advertisements.
“’Medicare for All’ didn’t win,” said Joel Kopperud, the vice president of government affairs at the Council of Insurance Agents and Brokers, one of the industry groups backing the Partnership. “I don’t think that the Bernie Sanders $32 trillion solution that’s going to eviscerate the insurance for 156 million Americans is really something that’s going to be helpful to the party in critical states,” he added in an interview with The Intercept.
Kopperud represents insurance brokers who sell employer-based health insurance coverage. He noted that his organization has a vested interest in backing the Partnership. “Medicare for All,” as some envision the policy, would eventually eliminate the need for most health insurance plans — a death knell for companies represented by the CIAB.
Private health care lobbyists are confident that they can prevent any federal expansion of Medicare in Congress, given Republican control of the Senate and the White House. In the states, CIAB and other private health groups have easily defeated measures to develop single-payer proposals, such as the ColoradoCare ballot question in 2016.
But the political calculus could be changing. Recent election gains by Democrats in state government could create new opportunities for proponents of expanded government-backed health care initiatives. Gov.-elect Gavin Newsom of California campaigned on single payer and is expected to have one of the largest Democratic supermajorities in recent memory in the legislature, though California has a notoriously complex state constitution that would likely require an amendment before any significant government plan could be created.
The growing momentum for “Medicare for All” could raise expectations for the next time Democrats are in full control of power in Washington, industry groups worry. They are already pressuring conservative-leaning caucuses in the House of Representatives, such as the Blue Dogs and New Democrats Coalition, to push back against insurgent progressives’ demands.


A slide from Partnership for America’s Health Care Future presentation.

Reframing the Debate

For industry opponents of expanded government health insurance, there are two main challenges. One is combatting growing public support for the idea. The other is shaping elite opinion within the Beltway.
Over the last two years, several opinion surveys show rising support for expanding Medicare. In March, the Kaiser Health Tracking Poll found that 59 percent of Americans support the idea, and by August, a poll conducted by Reuters-Ipsos found an astounding 70 percent of Americans support “Medicare for All,” including a majority of self-identified Republicans.
But the Partnership is quick to zero in on research that shows support for the idea drops precipitously when respondents are told that the plan would require ending employer-based coverage, tax increases, and increased government control.
The campaign has worked with advertising agencies to draw up a series of messages to convince select audiences. Several of the messages, categorized as “positive,” are dedicated to educating the public on more minimal reforms that do not include expanding Medicare. Other messages, categorized as “persuasion” and “aggressive,” are designed to instill fear about what could happen if “Medicare for All” passes.
In the coming weeks, the Partnership plans to ramp up a campaign designed to derail support for “Medicare for All.” The group, working with leading Democratic political consultants, will place issue advertisements to target audiences, partner with Beltway think tanks to release studies to raise concerns with the plan, and work to shape the public discourse through targeted advocacy in key congressional districts.
The Partnership has tapped consulting firms with deep ties to Democratic officials. Forbes-Tate, a lobbying firm founded by former officials in President Bill Clinton’s administration and conservative Democrats in Congress, is managing part of the Partnership coalition. Blue Engine Message & Media, a firm founded by former campaign aides to President Barack Obama, has handled the Partnership’s interactions with the media.
In one planning document circulated over the summer, the Partnership suggested a series of messages to wean Americans away from supporting single payer. The talking points emphasize that the current system provides “world-class care,” and that any move away from the Affordable Care Act would be “ripping apart our current system.”
The strategy exploits familiar themes that have long been used by business groups against new government health care programs, calling for allies to say lines such as “bureaucrats in DC have no understanding of a person’s medical situation and will be making decisions about your health care instead of doctors.”
The Partnership plans to form a speakers bureau of former Democratic elected officials who can leverage the media to make the case that expanding Medicare is bad politics and policy. The memo names former Democratic Majority Leader Tom Daschle, now a health insurance lobbyist at the law firm Baker Donelson, as one such potential surrogate.
The memo points to early success in shaping media coverage, citing several “earned media” columns such as one published in August by former Rep. Jill Long Thompson, D-Ind., which argues that Democrats should only focus on small reforms to the Affordable Care Act, and warns against wasting political capital on pursuing a “government-controlled health insurance system.” Thompson, now an associate professor at Indiana University Bloomington, did not respond to a request for comment.
Adam Gaffney, president-elect of Physicians for a National Health Program, a national coalition that advocates in favor of “Medicare for All,” said he is not surprised by the messaging.
“What we’re seeing is the wages of success: With single payer on the rise, it was only a matter of time before the insurance companies, big pharma, and other big-money groups came out swinging,” said Gaffney, who also serves as an instructor at Harvard Medical School.
“The smear of ‘socialized medicine’ has been used a thousand times and has lost its bite,” he added.


A slide from Partnership for America’s Health Care Future presentation.

Influencing the 2020 Democratic Field

“We’re all focused on 2020,” Lauren Crawford Shaver, a partner at Forbes-Tate who is helping to manage the Partnership campaign, recently told the National Association of Health Underwriters in a podcast produced by the group.
Shaver, a former top staffer for the Hillary Clinton presidential campaign, explained to the group that she is working to peel support away from the “Medicare for All” bill sponsored by Sen. Bernie Sanders, I-Vt. The Sanders bill is currently sponsored by several rumored 2020 Democratic presidential candidates, including Sens. Elizabeth Warren, D-Mass.; Kamala Harris, D-Calif.; and Kirsten Gillibrand, D-N.Y.
“The No. 1 thing we need to focus on is that there are a lot of likely candidates that currently support the Senate bill,” said Shaver. “We need to make sure we educate the public, we educate both parties, and we educate all the campaigns about both the policy and political challenges.”
Shaver encouraged health care companies concerned about the growing popularity of “Medicare for All” to mobilize opposition among clients, customers, and employees. Industry groups will likely have workers or customers residing in key districts who can be tapped to influence wavering lawmakers on Capitol Hill.
The Partnership plans to “take stories of how these proposals would directly impact your clients and the constituents of the policymakers who are voting for or against these proposals,” Shaver said.
The Partnership strategy echoes the health insurance industry’s campaign to shape the 2008 presidential primary. At that time, the health insurance lobby group known as America’s Health Insurance Plans, or AHIP, tapped the consulting firm APCO to develop an effort to label any government-run insurance option as an existential threat to Democratic political goals. The initiative emerged from a plan to minimize the impact of Michael Moore’s documentary “Sicko,” which was deeply critical of the American health care system.
The campaign involved planting studies with think tanks, mobilizing pundits on television, and sponsoring YouTube videos on “the horrors of government-run systems,” among other publicity tactics. The APCO-crafted blitz leaned on right-wing voices such as Fox News pundit John Stossel, conservative think tanks like the American Enterprise Institute, and centrist Democratic groups such as the Democratic Leadership Council, a now-defunct group associated with the Third Way. The 2008 campaign adopted a two-pronged strategy: position private health insurance as the only positive solution to America’s health care woes and “disqualify government-run health care as a politically viable solution.”
Now, the same lobby groups are involved in a similar effort. AHIP, the insurance trade group behind the 2008 plan, is also a sponsor of the Partnership’s 2020 campaign, along with the Federation of American Hospitals, Pharmaceutical Research and Manufacturers of America, the Blue Cross Blue Shield Association, the Biotechnology Innovation Organization, and the American Medical Association.


The View From Here: Health costs headed for a crisis

by Greg Kesich - Portland Press Herald - November 18, 2018

When 'the lucky ones' pay more each year for insurance that covers less, something's got to give.

So, I guess I’m supposed to have a crystal ball now. That’s what the health insurance rep told us last week at one of the company’s annual open enrollment meetings.
The trick to picking the right health insurance plan, he explained, is to start by looking at the premium to see what fits in your budget. But before signing up for the one with the lowest sticker price, you’re supposed to “take out your crystal ball” to determine how much health care you and your family might need in the coming year.
That way, you’ll know if you can save a little money with the high-deductible/low-premium plan, or shell out for richer coverage with a more expensive policy.
Here we go again. Another year, another health insurance information session, another season of frustration.
NOT A CLAIRVOYANT
I don’t blame the insurance rep – he didn’t design a system that requires me to be clairvoyant. But I shouldn’t have to be. And I don’t need a crystal ball to know there’s going to be more frustration in the year ahead as I find out what’s covered and what isn’t.
Every provider has a different price for every payer, and the difference between a no-cost test and a $1,000 bill is a little piece of code typed in by someone who probably can’t tell me how much I’ll have to pay.
I’m supposed to shop like a good consumer for services even though I don’t know how much they cost and, in many cases, I wouldn’t be in a position to walk away if I didn’t like the price.
I keep trying to tell myself that I’m one of the lucky ones because I have insurance through work.
When we debate health care policy, most of the focus is rightly on the people who don’t have coverage, like low-income people who don’t qualify for Medicaid, or self-employed people who can’t afford insurance because they make a little too much for an Obamacare subsidy.
I’m not one of the people who has to go to the emergency room for a toothache and gets painkillers, antibiotics and advice to see a dentist that I can’t afford. I don’t have to skip the tests my doctor orders or leave my prescriptions unfilled.
Like about half the people in the country, I have insurance through my employer, which means that I get left out of the discussion about health care reform because I’m supposed to be OK. But I would like to go on record to say that I am not OK, and I don’t think I’m the only one.
Health care costs are expected to grow by 5.5 percent next year, faster than the gross domestic product and twice as fast as wages. Workplace insurance coverage pays roughly $1.4 trillion of the nation’s annual $3.3 trillion health care bill.
The cost of private health insurance has tripled since 1990, also easily outpacing wages.
According to an annual study by the Kaiser Family Foundation, the full cost of the average individual plan in 2018 was $6,896, and $19,616 for a family. Most of that is paid by employers, but the average worker is responsible for about $1,100 a year for single coverage and $5,500 for a family plan.
Meanwhile, the amount that these people have to pay out of pocket before they can use their increasingly expensive insurance – the deductible – has also skyrocketed. Average deductibles have climbed 212 percent in the last decade, from just under $600 a year to more than $1,500. So, if you find that you are paying more of your stagnant wages for health insurance that doesn’t cover as much as it used to, you are not alone.
TIME FOR A CHANGE
These trends are what makes universal health care proposals like Medicare for All more politically palatable all the time.
Every other developed country manages to cover everyone at a lower cost with better results than we do in the United States. We waste billions on complexity that masquerades as choice. People say that government can’t be trusted to deliver health care, but I don’t hear a lot of seniors on Medicare pining for the days when they had private insurance.
Here’s my question for policymakers: Is what we’re doing now really the plan? Are we really expecting that most people will be able to pay more money every year for insurance that covers less, and requires them to blow through their savings when they get sick? And are we going to keep telling these people that since they have insurance they are “the lucky ones?”
Because I may not have a crystal ball, but I’m willing to predict that this plan isn’t going to work much longer.


Democrats, Don’t Procrastinate on America’s Health

by Harold Pollack - NYT - November 17, 2018


In nearly 800 days, a Democratic president and Congress may take office.
This is not as far away as it sounds. If Democrats want the chance to pass health reforms that will build on the Affordable Care Act and fix its defects, they need to start planning now.
The Democrats’ House victories in the midterms are an important step in that direction. Medicaid will expand in Idaho, Nebraska and Utah, thanks to ballot initiatives, and could expand in Kansas, Maine and Wisconsin, thanks to those states’ new Democratic governors-elect. Although Republicans picked up Senate seats, the 2020 and 2022 Senate maps still allow the possibility of a workable Democratic majority. Democrats must be ready. The process of writing the A.C.A. began years before it passed. Democratic legislators, activists and policy experts should be talking right now about how to build on it.
We already know a few things about what workable and worthy legislation will look like. First, it will be a straight Democratic bill. As Republicans did in 2017 on health care and taxes, Democrats will proceed unilaterally. Unlike Republicans, Democrats should put in the hard work to create a smart bill they actually intend to pass, one that commands broad public support.
Many Americans would prefer greater bipartisanship. So would I. But Democrats tried that, and look what happened. The A.C.A. was a good-faith effort to create a fiscally disciplined, ideologically moderate, market-based path to near-universal coverage. Max Baucus and other Democratic senators spent months fruitlessly negotiating with Republicans, who, it is obvious in retrospect, were cynically stalling. Republicans’ scorched-earth opposition to President Barack Obama and health care reform — not to mention the Trump presidency — have weakened the possibility that Democrats will do the same next time around.
The bill should go beyond simply fixing the A.C.A., though much certainly needs fixing. The insurance marketplaces are a godsend for 12 million people, particularly those with low incomes or chronic illnesses. Yet in many ways, the marketplaces proved disappointing. Middle-class families face high premiums and punishing out-of-pocket costs. 
It wouldn’t be hard to change this. Similar structures work well in Western Europe. The Urban Institute’s Linda Blumberg and John Holahan have proposed an excellent and economical set of improvements, including providing more generous subsidies to middle-class families and to people with high out-of-pocket costs. If our political system worked properly, such fixes would already have been made. But Republicans in Washington see greater advantage in undermining and disparaging the marketplaces than in bolstering them.
Millions of Americans — many of whom don’t consider themselves particularly liberal — want more radical change. Republicans’ efforts to bring down the A.C.A. ended up solidifying the public consensus behind it, behind Medicaid and behind the idea that every American deserves affordable, effective health coverage. Among Republican voters, large majorities favor greater federal health care spending. As we saw in the midterms, Medicaid expansion is popular even in deep Trump country.
One thing we won’t see: a leap to a single-payer system. Many Democrats have embraced Medicare for All. I’m sympathetic to that. A single-payer health system would be more functional, more economical and fairer than what we have. America may someday have a single-payer system, but we won’t get there in a single bill that phases out private health insurance, rewires our byzantine health care delivery and finance systems and markedly cuts payments to hospitals and other providers. 
Although a single-payer system would reduce overall health spending, it would require major tax increases as we moved private expenditures onto the federal tab. There is zero chance that any Congress taking office in 2021 would do all that — let alone that Democrats could do all that alone within the parliamentary confines of what would probably be a razor-thin party-line vote in the budget reconciliation process.
So what can Democrats do, when tweaking the Affordable Care Act is insufficient, and when leaping to Medicare for All is unrealistic?
Here’s one strong approach: Medicare Available to All. Three Senate bills introduced by Democrats would allow people to buy into Medicare or Medicaid, while maintaining a private insurance market. Millions of Americans want these public options, because they are fed up with private insurance. This is especially true in rural areas, and in uncompetitive markets with exorbitant marketplace plans.
Private experts propose other worthy plans. Paul Starr’s “Midlife Medicare” would expand the program to otherwise-uninsured Americans over age 50. Jacob Hacker’s “Medicare Part E” would be available to everyone, including within the menu of employer-sponsored coverage.
The Center for American Progress’s “Medicare Extra for All” provides another ambitious model, which would improve public and private coverage without requiring huge new federal tax revenues or smashing the private insurance system. Medicare Extra would be free to those with incomes below 150 percent of the federal poverty line. That’s about $31,000 for a family of three. In one stroke, this would insure millions of Americans who were shut out when their state rejected Medicaid expansion. Premiums and patient cost-sharing would gradually rise with income, but would be capped at an affordable level for everyone.
Employers could provide Medicare Extra for their workers alongside their private offerings. Compared with single-payer, these plans appear reasonable and realistic. By providing competition and better options for near-retirees and those with costly conditions, such an approach could also improve private marketplace coverage. It would include valuable disability components, too.
Whatever Democrats decide to do, they should start now, anticipating everything from the Congressional Budget Office’s deficit projections to the Senate parliamentarian’s reconciliation rules. Anyone who doubts the difficulty of this work might ponder Republicans’ rushed A.C.A. repeal effort, whose design was so shoddy that it alienated every patient and provider constituency around.
Much of the work that produced Obamacare was done well before President Obama took office. Between 2006 and 2009, groups like the Service Employees International Union and grass-roots activists began laying the groundwork for the A.C.A.’s passage. Activists, legislators, congressional staff members and constituency groups quietly met in forums such as Ted Kennedy’s “workhorse group” to make difficult political and policy decisions. Had a different Democrat been elected president, EdwardsCare or ClintonCare would have strongly resembled the A.C.A.
The next round will be different. Given all that’s happened, Democrats have an angrier, more partisan edge than they did then. The Democratic Party is also more unambiguously progressive. Ten years ago, conservative Democrats insisted on protracted negotiations and opposed the public option. For better and worse, these bridge figures are almost all gone. Progressive voters will be demanding a single-payer bill, and will be disappointed when they don’t get it. They are entitled to a feasible alternative they can genuinely be proud of.
Democrats must combine an ambitious progressive vision with sound policy and political realism. Their first opportunity, January 2021, is little more than two years away. There’s no time to waste.

Opinion

America Is Blaming Pregnant Women for Their Own Deaths

What is it like to face dying during childbirth in the richest country in the world in the 21st century?


by Kim Brooks - NYT - November 16, 2018

Thea was 35 years old and 40 weeks pregnant when she went to her doctor for her final prenatal appointment. She was in good shape, didn’t smoke and had received regular prenatal care, though she wasn’t thrilled with the obstetrics practice she’d chosen in Chicago. The doctors were “more interested in protocols than people,” she said. 
On that day, she was surprised to learn that her amniotic fluid was low, though the baby’s vital signs remained strong. The doctor informed Thea that she’d need to be induced right away. Thea questioned this directive, asking about the success rates for induction and whether she should consider a cesarean section instead. The doctor said she had no choice. She then asked if she could go home to get her overnight bag. She was told, she said, that if she left she could be “arrested for endangering the life of a child.”
Thea asked that I refer to her only by her first name because the details of her story are so personal. She also cautioned that “in trauma, memory can be fragmented and skewed.” But over a decade later, she remembers this confrontation with her doctor as the moment it became clear to her that in becoming a mother, she was no longer seen as a person: “I really felt like I was a piece of meat, like I was not being considered in this. It was all about the baby.”
I’ve been thinking lately about the remarkable ways in which American women continue to be devalued and disempowered through the prism of motherhood, even as we insist on the pre-eminence of mothers’ status. Alabama voters have just approved a constitutional amendment recognizing “fetal personhood,” a measure that could be used to further curtail the rights of pregnant women in favor of the safety of fetuses. 
Seventy years ago, Simone de Beauvoir wrote that pregnancy can be both “an enrichment and a mutilation”; the mother “feels as vast as the world, but this very richness annihilates her — she has the impression of not being anything else.”
For experts studying the United States’ maternal mortality and injury rates — which are estimated to far surpass those in other developed countries — and for women in labor, the failure to treat mothers as people is neither antiquated nor dystopian, but absolutely pressing. 
In September, USA Today published a major investigation into recent efforts to curb maternal death rates. A number of states have assigned panels of experts to review what went wrong in cases where mothers die. This sounds promising. Unfortunately, it hasn’t worked — rates have continued to rise — and the reason is hard to fathom.
“At least 30 states have avoided scrutinizing medical care provided to mothers who died, or they haven’t been studying deaths at all,” the newspaper said. “Instead, many state committees emphasized lifestyle choices and societal ills in their reports on maternal deaths. They weighed in on women smoking too much or getting too fat or on their failure to seek prenatal medical care.” Mothers, it seems, in addition to being held solely responsible for every facet of their child’s well-being, are also being held responsible for their own deaths.
Talk about blaming the victims.
According to USA Today, when asked about their decision not to scrutinize medical care, some doctors on the panels said they didn’t have the resources, and that hospitals don’t like to (and aren’t required to) hand over their dead patients’ charts. Lawmakers claimed that it wasn’t the job of the state to meddle with doctors’ decisions. And state officials argued that it was more important to focus on broader issues surrounding maternal health than on what may have gone wrong in specific women’s cases.
But it is hard to imagine some other scenario in which patients are dying in hospitals from complications of routine procedures — appendectomies, say — and instead of studying the care the patients received leading up to their deaths, review panels focus on the patients’ lifestyles in the year before their procedure. 
The problem isn’t that we don’t know how to make childbirth safer. Stephanie Teleki, who leads the maternity care portfolio at the California Health Care Foundation, put it this way in an interview: “Women know what they want when it comes to labor and delivery, and it turns out the things they want (midwives, doulas, fewer unnecessary interventions and cesarean sections) are less expensive and produce better outcomes.” The problem is not that pregnant women are uneducated or uninformed; the problem is that those in charge aren’t listening to them.
I wanted to know what it is like to experience this — to face one’s death during childbirth in the richest country in the world in the second decade of the 21st century. Obviously, I couldn’t talk to women who had died in childbirth. So I spoke to women who had almost died. That’s what led me to Thea.
After 36 hours of pitocin, a drug that induces labor, and three hours of pushing, Thearequired a cesarean because the baby had turned sideways. Prolonged exposure to pitocin can increase the risk of postpartum hemorrhaging. And that’s what happened a few minutes after her daughter was delivered. Thea bled for three hours, while she got intravenous drugs to promote clotting and signed forms in case she ended up needing an emergency hysterectomy.
“They kept telling me how healthy the baby was,” she told me, “but that only made me more terrified that now I might die.” She spent a week in the hospital.
“They did save me in the end,” she says, “but after they almost killed me.”
When Serena Williams spoke out about the medical emergency she endured after the birth of her child last year, and the psychological trauma she suffered as a result, she began a long-overdue debate on America’s abysmal rates of maternal death and injury, as well as the ways that women of color bear the brunt of subpar care. 
African-American women are nearly 3.5 times more likely than white women to die from pregnancy-related conditions. “Women are not being listened to,” Dr. Teleki told me. “But black women are the least listened to and it’s costing them their lives at a much higher rate.” 
Ms. Williams’s story offered a personal glimpse into an epidemic of preventable deaths that has long been ignored in this country. 
In 2000, United Nations member states issued a Millennium Development Goal of, by 2015, cutting the 1990 maternal death ratio by 75 percent. Through a large-scale international effort, maternal mortality was reduced by 43 percent worldwide during that period, and by almost 50 percent in developed countries. Meanwhile, the rates of American women dying from pregnancy rose.
Marian MacDorman, a research professor at the University of Maryland, told me that the United States was barely involved in the United Nations effort. “Nothing was being done, partly because nobody knew what was going on,” she said. “The data we had was bad, and people weren’t studying the data.” 
It wasn’t until 2003 that states started adding a pregnancy check box to death certificates, and some didn’t do so until the past two years. “This created a data mess where nobody could figure out what the national trends were,” she said. She described this as “a huge missed opportunity for intervention in conjunction with the Millennium Development Goal.” At the same time, “the National Center for Health Statistics, which is the government agency responsible for publishing maternal mortality data, completely stopped publishing it.” 
The only exception in the United States was California, where, in 2006, the Stanford University School of Medicine worked with the state to create the California Maternal Quality Care Collaborative. The initiative developed “quality improvement tool kits” that doctors and hospitals could download. They included detailed instructions about best practices for various preventable complications that can arise during or after pregnancy, like hemorrhaging and pre-eclampsia. 
This sounds simplistic, but it had a powerful effect. “What you have to understand,” Dr. MacDorman explained, “is that these emergencies are horrible and they happen too often, but still, they’re not common. An O.B. might easily go a year without encountering such an emergency.”
As a result of this initiative, between 2006 and 2013, California saw a 55 percent decrease in the maternal mortality rate, from 16.9 to 7.3 deaths for every 100,000 live births. During that same period, according to The Washington Post, the national rate increased — from an estimated 13.3 to 22 deaths in 100,000. 
These numbers, disturbing as they are, don’t account for the far greater number of women who are injured during delivery or suffer the trauma of near-death experiences. For many, this trauma can last a lifetime.
Claire, who also asked that I use only her first name, was 38 weeks into her fourth pregnancy in 1992 when she went into the hospital certain she was in active labor. She protested when the doctor decided that the baby wasn’t full-term and gave shots to halt the labor. A few weeks later the baby’s head descended and Claire returned to the hospital, but the baby was now so big that she labored unsuccessfully for 24 hours before undergoing an emergency C-section. 
This is how she described her experience: “They gave me an epidural and asked me if I could feel the knife and I said, ‘Yes, I can,’ and they didn’t believe me. They said that’s impossible. But I kept saying, ‘No, I can feel it.’” Then her blood pressure dropped. “I hear my husband say, ‘Look at her blood pressure.’ And the doctor said, ‘Oh, that must be a malfunction of the machine.’ Then I hear, ‘Oh, my God, she’s going into shock,’” she explained. “At one point I heard them say, ‘We’re going to lose her, we’re going to lose the baby’.”
Claire still remembers it as one of the most terrifying experiences of her life. “I never completely got over it,” she told me. “I have a daughter now who’s pregnant. I’d like to just be happy about it but I can’t be.”
Thea’s daughter is now 13. She decided not to tell her how terrible the experience of her birth was, for fear she won’t want to have kids herself.
There was another reason, though, she told me, in a follow-up email to our conversation: “I didn’t want my daughter to know that the joy of her birth was mixed with trauma and the fear of my own death.” She still finds herself feeling guilty for that fear, for “caring about myself and my mortality.” This, she wrote, “speaks to the way I, and probably many other women, was dehumanized and demeaned during the delivery,” and told that “our babies are much more important than we are.” 
“I was invested in maintaining that narrative as a way to love her,” Thea wrote.


DATA-DRIVEN MEDICINE WILL HELP PEOPLE — BUT CAN IT DO SO EQUALLY?


by Zeynep Zufekci - NYT - November 15, 2018

The promise of data-driven medicine is clear. Using the latest analytical techniques can lead to better health outcomes and — over time as data technology inevitably becomes cheaper and more widely available — help many more people. But as medicine moves from the kind of clinical practice that has informed centuries of treatment to the data-driven practices that have already transformed commerce, finance and the media, it will also find itself facing some of the same social challenges. In particular, big-data technology might seem like a social neutralizer or even a leveling force, but it can have a way of increasing divisions.
One hint at why this is comes from what communications theorists describe as a knowledge gap. Basically, people who already have better information are also better at getting more information, even if that information is in theory universal and available to all. We see this again and again in different fields. In my own research on schools and computers, for example, I often encounter students doing advanced and creative “technology” activities on the computers in well-off schools, and students doing rote learning and typing on the computers in poorer ones. That division means that later on, when the kids face a putatively even playing field, some will know better than others how to get ahead. Privileged kids get more resources not simply because they (or the schools) can afford to pay for them but because their parents are better equipped to advocate for their acceptance into gifted and talented programs, or to academically support them better through tutoring, attention and encouragement — harder tasks for a poor or single parent. There is also the effect of expectations and a lifetime of socialization: If you experience life as unfair, you are probably less likely to demand better when you encounter more injustice.
There is a great lesson here as we anticipate the rise of data-driven diagnostic and intervention techniques in health care. It’s not that new methods won’t help people; it’s that they will increase health inequality — not just among those who can afford it and those who cannot, but among those who can undertake the research and take advantage of the new techniques and those who cannot.
Further, these new data-driven medical techniques could lead to more discrimination. If there are no legal restrictions, for example, what’s to stop companies from trying to hire people who have fine-tuned their sleep patterns with biofeedback, who have better exercise outcomes thanks to genomic analyses or are less likely to develop cancer in the long run?
Legislators are not unaware of these problems. In 2008, the United States passed a landmark law called the Genetic Information Nondiscrimination Act, which bars companies from hiring, firing or promoting workers based on genetic-test results — or requiring such tests — and insurance companies from requiring or using such tests to decide coverage. But legislative protections are easily reversible. In fact, last year Republican lawmakers introduced a bill that would carve out several significant exceptions to the law.
It may seem perverse to worry about inequality when we are talking about something that can improve so many lives, but a society isn’t held together by making wonderful things available to just a few rich people. This isn’t an argument for holding back improvements in health care. It is an argument instead that we must focus on equitable outcomes for all of us: how to make sure that access to new forms of health care is fair and evenly distributed; how to make sure that we guard against new forms of discrimination that can emerge from all this data; and how we avoid a corporate-driven version of these shifts, in which health outcomes are mobilized not for our happiness and our well-being but to squeeze another hour or two from us at work.
Considering that the United States is alone among developed nations in its refusal to recognize health care as a fundamental right, it’s even more crucial to recognize that inequality risks poisoning the fruits of American medical ingenuity. The right measure for successful health care isn’t about the maximum possible for a few but the average for everyone, the median for a society and the minimum opportunities available to even those with the fewest resources and privileges. That’s not just fairness. That’s what a healthy society looks like.




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