It’s Cold, Dark and Lacks Parking. But Is This Finnish Town the World’s Happiest?
Finland Dispatch
A choir rehearsing at the Adult Education Center in Kauniainen, Finland.Lena Mucha for The New York Times
KAUNIAINEN, Finland — Jan Mattlin was having what counts as a bad day in Kauniainen.
He had driven to the town’s train station and found nowhere to park. Mildly piqued, he called the local newspaper to suggest a small article about the lack of parking spots.
To Mr. Mattlin’s surprise, the editor put the story on the front page.
“We have very few problems here,” recalled Mr. Mattlin, a partner at a private equity firm. “Maybe they didn’t have any other news available.”
Such is the charmed life in Kauniainen (pronounced: COW-nee-AY-nen), a small and wealthy Finnish town that can lay claim to being the happiest place on the planet.
At Moms, the town’s only late-night bar, a few soccer players were in a wry but subdued mood, commiserating after a loss earlier that evening.Lena Mucha for The New York Times
Finland was named the world’s happiest country by the United Nations Sustainable Development Solutions Network in April, based on polling results from 156 nations. And a second survey found that Kauniainen’s 9,600 residents were the most satisfied in Finland, leading the local mayor, Christoffer Masar, to joke that theirs was the happiest town on earth.
Some Finns were surprised; a few even unhappy.
In the global consciousness, the stereotypical Finn is melancholic, introverted and more prone to suicide than most other nationalities. Finns themselves buy into parts of the stereotype: If a stranger smiles at you in the street, goes a Finnish proverb, they’re either drunk, foreign or crazy.
“My trouble with the word ‘happiness’ is that we never know what we’re talking about when we talk about happiness,” said Professor Frank Martela, who researches well-being at the University of Helsinki, and grew up a few miles from Kauniainen. “We might mean life satisfaction, or being joyful every day. It’s a bit ambiguous.”
Kauniainen can lay claim to being the happiest place on the planet, but even here, parking spaces at the train station are at a premium.Lena Mucha for The New York Times
So can happiness really be measured? And if so, are Finns really that cheery?
To try to answer those questions, a trip to Kauniainen seemed mandatory.
The reasons for the town’s happiness are not immediately obvious upon arrival.
Kauniainen, which lies on the outskirts of Helsinki, the Finnish capital, is pretty, but not stunning: a collection of large detached houses, sprinkled throughout a thin fir forest, centered around an unremarkable town square.
At this time of year, the day doesn’t get light properly till after 9 a.m. The light fades again by 3:30 p.m.
Students at a school in Kauniainen. They get one grade per team.Lena Mucha for The New York Times
Ask a resident if they feel happy, and you get a measured response, but hardly an ecstatic one.
“What is happiness?” Mr. Masar, the mayor, asked rhetorically, over lunch last month at the town’s only deli.
At Moms, the town’s only late-night bar, a few soccer players were in a wry but subdued mood, commiserating after a loss earlier that evening.
“When we lose,” deadpanned Antti Raunemaa, a construction executive, “we’re only happy after the second beer.”
The local swimming pool. In this single small town, there are over 100 sports and cultural clubs, all of them subsidized in some way by the local council.Lena Mucha for The New York Times
The barkeep suggested another stop to find more smiles. “Maybe the McDonald’s at Espoo?” said Jenny Lindholm, nodding toward the next town along. “There’s nowhere else, really.”
And yet: There was. Just not where a happiness-hunter might initially expect it.
Kauniainen’s blandly named Adult Education Center, a tall building on the edge of town, did not sound promising. But it was here, not the bar, where large numbers of residents were having fun that evening.
In the basement, they were weaving carpets on vast looms, and making pottery. On the ground floor, a choir was singing. On the floors above, others were painting replicas of Orthodox Christian icons — or practicing yoga.
The mayor of Kauniainen, Christoffer Masar.Lena Mucha for The New York Times
Subsidized by both the state and the city, the center offers cheap evening classes to residents “in basically anything that people might be interested in,” said Roger Renman, the center’s director.
Around 15 percent of the town’s population are enrolled here at any one time, some paying less than a dollar per hour of tuition, depending on the course.
Similar centers are found across Finland, but Kauniainen’s is particularly active, especially for a town of this size.
The Adult Education Center, not a local bar, is where many residents were having fun one night.Lena Mucha for The New York Times
It’s this kind of service that makes the town cheerier than most, reckoned Seija Soini, a retired businesswoman taking part in a painting class.
“The main reason is that people have something to do — things like this!” Ms. Soini said, as she painted a portrait of her niece. “It’s like psychotherapy.”
And the education center was just the leading edge in the town’s activity options for residents. For what Kauniainen lacks in parking places, it makes up for with state-funded services.
Parents and children at a day care center. Finland has a good and cheap universal health care system, free university education and affordable child care.Lena Mucha for The New York Times
In this single small town, there are over 100 sports and cultural clubs, all of them subsidized in some way by the local council: clubs for the Swedish-speaking minority, clubs for the Finnish majority, a ski slope, a children’s music school, a children’s art school, an athletics stadium, an ice rink — and even a purpose-built set of outdoor stairs, known as a “kuntoportaat,” which allow people to keep fit by walking up and down.
When residents argued, two decades ago, whether they should build an ice hockey rink or a handball court, the council solved the dispute by funding both.
The only obviously absent institution is a police station: With minimal crime rates, there is no need.
Workout stairs in Kauniaisten known as a “kuntoportaat,” which allow people to keep fit by walking up and down.Lena Mucha for The New York Times
All this supplements a good and cheap universal health care system, free university education and affordable child care.
And a school system in which children are rarely tested, and teachers rarely inspected, but which, despite a recent dip, still ranks as one of the best in the world.
Strolling through her middle school, Leena-Maija Niemi, the head teacher, pointed out the classrooms and playgrounds that the students themselves had helped design, something she said that contributed to their sense of belonging.
Playing cards at the senior center.Lena Mucha for The New York Times
To pay for all this, taxes are high by American standards: Someone earning $45,000 might pay more than double the amount of tax in Finland as in some American states.
But residents said they can feel the dividend: a society with low inequality, high opportunity and a strong sense of solidarity.
“For me, happiness is about being contented with your life and the possibilities you have in life,” said Finn Berg, a former head of the town council. “And if you put it that way, then this is a happy place, because we have a lot of possibilities here.”
Wealth helps, too.
Though the proportion of low-earners in Kauniainen is about the same as in the rest of Finland, the percentage of high-earners is roughly double the national average, said Mr. Masar, the mayor.
Since the town’s municipal tax rates are fractionally lower than elsewhere in the country, Kauniainen has become an attractive destination for those with the means to move here.
But this has advantages for all residents.
Individually, the rich pay less tax. But collectively they create a larger tax yield, enabling the town council to spend about four times as much on cultural activities, per capita, than the average Finnish district, three times as much on sports, and 50 percent more on child care.
All this breeds some basic satisfaction, said an understated Mr. Berg, the former council chairman.
“I’ve been thinking about what happiness is, and happiness is about being contented with your life, and about not being miserable,” Mr. Berg said.
“And I’m not miserable.”
by Megan McArdle - The Washington Post - December 18, 2018
The program isn’t much like what its architects wanted; the insurance covers fewer people, with less-generous benefits, and higher premiums, than originally envisioned. But it also isn’t as dire as critics predicted. Though exchange enrollment seems to be declining, it’s on a gentle downward slope rather than the catastrophic death spiral that opponents were hoping for. Obamacare may well have reached the kind of perfect mediocrity to which Washington provides eternal safe harbor: not really doing what it was supposed to, but too complicated to fix and not quite bad enough to repeal outright.
But Republicans, despite having chickened out of actually repealing the thing, are not quite ready to admit they’re licked. Republican attorneys general and governors from 20 states are suing (yet again!) to overturn the law. On Friday, a federal judge in Texas obliged them. Reed O’Connor, an appointee of President George W. Bush, ruled that since the 2017 tax law has gutted enforcement of Obamacare’s mandate on citizens to buy insurance, it is no longer constitutional under the taxing power. And since the program’s architects predicated it on the mandate, O’Connor said, the entire law must be struck down.
To be blunt, this isn’t a good ruling. There’s a reasonable legal argument that a “tax” that raises no money isn’t really much of a tax. But neither policy nor legal precedent requires the court to strike down the rest of the law.
While it’s true that Obamacare’s architects thought the mandate essential, nine years in, their faith seems misplaced. The mandate was supposed to force healthy people into the insurance market, preventing prices from spinning out of control. But Obamacare’s mandate enforcement proved too weak to be very effective, which is one reason fewer people than expected are being covered. The people who are buying insurance seem to be motivated by other parts of the law, such as the subsidized tax credits, not by the mandate.
Of course, arguably what matters here are Congress’s intentions, not its ability to see the future. But even by that logic, O’Connor’s ruling is flawed, because it considers only the intent of the Congress that passed the program in 2010; the ruling ignores the intent of the 2017 Congress that repealed the tax penalty and presumably could have repealed the whole law if members wanted to.
Even many of the law’s opponents are dubious about the judge’s reasoning. Jonathan Adler, a Case Western Reserve University law professor who helped craft an earlier lawsuit challenging Obamacare, called the ruling “an exercise of raw judicial power, unmoored from the relevant doctrines” in an op-ed for the New York Times co-written with Abbe R. Gluck. Adler expects it to be overturned by a higher court in fairly short order.
If Adler is right, and I think he is, Republicans are going to have to decide how long they’re willing to fight this rear-guard action. There is clearly no real path to getting rid of the law either legislatively or judicially. At some point, they’re going to have to acknowledge that Obamacare is here to stay, and make peace with it as best they can.
They don’t have to like it. I thought Obamacare was a bad law in 2010, and the intervening years haven’t improved my opinion. It did little to address the biggest problems with the American health-care system, and a great deal to complicate an already disastrously complex and fragile market. I would have been pleased to see it defeated in Congress, or in earlier court battles.
But Obamacare is now part of the system. Markets have been rebuilt around it; voters have gotten used to it; the Supreme Court seems unwilling to strike it down. Republicans’ actions are starting to look less like Horatius at the bridge and more like Don Quixote at the windmills.
Battling windmills isn’t merely pointless but also diverts your attention from things worth doing. Obamacare is still a badly flawed program that needs fixing; the American health-care system remains overpriced, overcomplicated and overregulated.
Republicans could help the country, and themselves, if all the time and thought they pour into lawsuits were devoted to coming up with simpler, more market-friendly alternatives to today’s Rube Goldberg policy contraption. Alternatively, of course, they could keep on doing what they’re doing, ensuring that they waste a full decade on their fruitless quest.
Republican health care fumbles give Democrats a chance to be bold
by David Farmer - Bangor Daily News - December 19, 2018
For much of the 2018 campaign, Democrats ran hard on the issue of health care, determined to hold Republicans accountable for their efforts to take coverage away from millions of Americans.
Republicans, reading the tea leaves and the polls, had a death-bed conversion, particularly when it comes to protecting people with pre-existing conditions and ensuring that they are still able to get health care coverage.
After years of doing everything possible to destroy the Affordable Care Act, with literally dozens of votes to repeal it and it’s protections, Republicans tried with a straight face to say that they, too, cared about protecting people who are sick or have been hurt.
Voters weren’t buying i
US Rep. Bruce Poliquin lost his re-election – dropping from 55 percent support in 2016 – in part due to his votes to take health care away from millions of people and more than 100,000 Mainers by repealing the ACA. And Republicans lost their majority in the US House of Representatives in one of the more lopsided defeats in history.
Even so, the Republicans’ health care chickens are coming home to roost with an outlandish ruling out of Texas last week that declared the Affordable Care Act unconstitutional.
Nineteen GOP attorneys general and a Republican governor had challenged the law, proving the point of Republican complicity in trying to take away health care and other protections for people under the law.
Smarter people than me, including US Sen. Susan Collins, say that the ruling will be overturned. And in the short term, nothing changes with the ACA, which remains the law of the land.
But here’s what the GOP wrought with its lawsuit and the provision of the tax scam last year that removed the mandate for coverage from the law, which were the grounds for the judge’s ruling.
If it stands, Medicaid expansion, which covers more than 15 million people – and more than 70,000 in Maine once Gov.-elect Janet Mills expands coverage after her inauguration in January – would lose coverage. Gone.
Protection for people with pre-existing conditions. Gone.
Guaranteed coverage of preventative health care. Gone.
Coverage for essential health benefits. Gone.
Protections against lifetime limits. Gone.
Tax credits, which help millions afford insurance. Gone.
In other words, Republicans – including outgoing Maine Gov. Paul LePage who joined the lawsuit in her personal capacity – have brought the health care system to the edge of a massive, disastrous and deeply unpopular cliff.
As Washington Post columnist Jennifer Rubin put it, “Republicans looked somewhere between uncomfortable and mortified by the result.”
And what’s standing in the way? A conservative, Republican-dominated court of appeals or a conservative, Republican-dominated US Supreme Court.
President Donald Trump, beleaguered and desperate to talk about anything that doesn’t include campaign collusion with the Russians or one of the other scandals plaguing his administration, has already applauded the judge’s ruling.
Republicans own the outcome. No two ways about it. Now, they’re saying this is a chance to replace the Affordable Care Act with something better. But voters see through that scam. Republicans don’t have any ideas about how to improve access to health care or to reduce costs. Period.
With near monolithic devotion, Republicans have worked to dismantle one of the most effective health care reforms in terms of increasing the number of people with coverage since the creation of Medicaid and Medicare.
Into this disarray, Maine has an opportunity to once again become a national health care leader. Mills has demonstrated her commitment to expanding access to health care and with her very first cabinet nomination, she showed that she’s looking for innovation, big ideas and a leader with the firepower to stand up to the Trump administration and their health care rollbacks.
Mills nominated Jeanne Lambrew for commissioner of the Department of Health and Human Services. Lambrew is well-known in health care policy circles and spent more than seven years in the White House under President Barack Obama. She served as director of the Office of Health Reform at the US Department of Health and Human Services and as the president’s deputy assistant for health policy.
Republicans are in retreat on health care and looking a disaster in the face. Democrats, including Mills, have a chance to be firm, to be bold and to make a real difference in people’s lives.
When Hospitals Merge to Save Money, Patients Often Pay More
by Reed Abelson - NYT - November 14, 2018
The nation’s hospitals have been merging at a rapid pace for a decade, forming powerful organizations that influence nearly every health care decision consumers make.
The hospitals have argued that consolidation benefits consumers with cheaper prices from coordinated services and other savings.
But an analysis conducted for The New York Times shows the opposite to be true in many cases. The mergers have essentially banished competition and raised prices for hospital admissions in most cases, according to an examination of 25 metropolitan areas with the highest rate of consolidation from 2010 through 2013, a peak period for mergers.
The analysis showed that the price of an average hospital stay soared, with prices in most areas going up between 11 percent and 54 percent in the years afterward, according to researchers from the Nicholas C. Petris Center at the University of California, Berkeley.
The new research confirms growing skepticism among consumer health groups and lawmakers about the enormous clout of the hospital groups. While most political attention has focused on increased drug prices and the Affordable Care Act, state and federal officials are beginning to look more closely at how hospital mergers are affecting spiraling health care costs.
During the Obama years, the mergers received nearly universal approval from antitrust agencies, with the Federal Trade Commission moving to block only a small fraction of deals. State officials generally looked the other way.
President Trump issued an executive order last year calling for more competition, saying his administration would focus on “limiting excessive consolidation throughout the health care system.” In September, Congress asked the Medicare advisory board to study the trend.
But not only have big consolidations continued, the behemoths have further cemented their reach in some regions of the country by gobbling up major doctors’ and surgeons’ practices.
“You have to watch for these systems throwing their weight around,” said Xavier Becerra, the California attorney general whose office has sued Sutter Health, a sprawling system in the northern part of the state. “We are looking for cases where consolidation does nothing for efficiency and leads to distortions of the market.”
Ted Doolittle, who heads Connecticut’s Office of the Healthcare Advocate, has fielded angry complaints from residents, but he sees few options available to officials. “A lot of this is too little and too late,” he said.
Finding new paths for growth
The latest giant hospital consolidations continue to stir concerns. Dignity Health and Catholic Health Initiatives, two large chains, are expected to become one of the nation’s largest groups — with 139 hospitals in 28 states — by the end of the year. And two of Texas’ biggest systems, Baylor Scott & White Health and Memorial Hermann Health System, recently announced plans to combine.
The New Haven area has witnessed the most significant decline in competition. Yale New Haven Health, one of the largest hospital groups in Connecticut, took over the only competing hospital in the city and has also aggressively expanded along the state’s coast. The group recently added another hospital to its collection, merging Milford with its Bridgeport location.
Although the price of a hospital admission in the New Haven-Milford area was already three times higher than in other parts of the state, prices surged by 25 percent from 2012 to 2014, compared with 7 percent elsewhere in the state, according to the Petris Center.
In the national analysis, a third of the metropolitan areas experienced increases in the cost of hospital stays of at least 25 percent from 2012 to 2014, from roughly $12,000 to at least $15,000.
Prices rise even more steeply when these large hospital systems buy doctors’ groups, according to Richard Scheffler, director of the Petris Center.
“It’s much more powerful when they already have a very large market share,” said Mr. Scheffler, who recently published a study on the issue in Health Affairs. “The impact is just enormous.”
Thousands of Connecticut residents were stranded without a local hospital last year when another big hospital group, Hartford HealthCare, battled the state’s biggest health insurer over how much it would charge for patient care.
The merger of Yale New Haven and Saint Raphael in 2012 led to a 1,519-bed hospital with two main campuses.Christopher Capozziello for The New York Times.
Its six hospitals are clustered around the state capital and are the only resort for residents in broad swaths of the eastern part of the state. This month, it announced plans to add a seventh hospital to its network.
“These systems are empire-building, there’s no question,” said Jill Zorn, a senior policy officer for the Universal Health Care Foundation of Connecticut, which seeks to improve access for residents. “But to whose benefit?”
Numerous studies by economists and others have underscored how hospital consolidation is driving up the cost of medical care. “Within the academic community, there is near unanimity,” said Zack Cooper, a health economist at Yale University who is among a group of researchers that has looked at how dominant hospitals affect prices.
Some hospitals need a savior
The emergence of a one-hospital town is inevitable in many places, and the Parkersburg, W.Va., area is no exception. St. Joseph’s merged with neighboring Camden-Clark Memorial in 2011, and then they were consumed by what is now the state’s largest health system.
“We’ve got it down to a single campus,” said Albert L. Wright Jr., the chief executive of West Virginia University Health System. “Parkersburg is not big enough to support two hospitals.”
Residents can get most care locally but they go to Morgantown, where the academic medical center is situated, for complex conditions. “We’ve elevated the level of care,” Mr. Wright said.
But private insurers are paying more. In the Parkersburg-Vienna area, the overall price of a hospital stay increased 54 percent from 2012 to 2014, after the mergers. That is compared with 10 percent elsewhere in the state, according to the Petris Center.
Large systems “get paid better by some of the insurers,” Mr. Wright said.
Flailing hospitals often have little choice but to be acquired or go out of business, and a larger system can offer badly needed capital and management skills. “They can fix a hospital and benefit the community,” said Torrey McClary, a lawyer who specializes in mergers at King & Spalding.
When Yale New Haven Health took over the Hospital of Saint Raphael, a Catholic hospital six blocks away from its New Haven location, Saint Raphael was in danger of going under. Over the last six years, the system has invested more than $200 million in capital improvements at Saint Raphael, said its president Richard D’Aquila, including modernizing “everything behind the walls.”
Because it converted Saint Raphael into what is essentially a second 555-bed campus for its academic medical center, Yale New Haven Health defends the higher rates it charges private insurers as appropriate for a top-tier medical institution. Its community hospitals negotiate prices individually with insurers.
“Our focus is not on getting bigger,” Mr. D’Aquila said. He said Saint Raphael, which was half empty when it was taken over, is now seeing record numbers of patients.
Systems also say they are trying to improve the care for smaller communities. “We’re actively trying to move care toward places that are accessible,” Hartford’s chief executive, Elliot Joseph, said.
Patients wind up paying more
But patients rarely reap the rewards of lower insurance premiums or out-of-pocket expenses when mergers occur.
Hartford executives talk about reducing the total cost of care in the same breath that they discuss the need to charge insurers more. “The math for us is how we move the care out of the hospitals while maintaining our financial stability,” Mr. Joseph said.
To defend higher rates, many hospitals cite low reimbursements from government sources, particularly Medicaid, and highlight their role as a safety net. “We’re left with no choice,” Mr. D’Aquila said.
Others, like Hartford, negotiate prices as a single entity, forcing health insurers to include all of their hospitals in a network or risk losing access in areas where there are no alternatives.
Hartford “has taken over so many hospitals and practices that, with the Anthem dispute, we felt we had no choices at all,” Sharry Goldman, a Storrs, Conn., resident, told state lawmakers. Although Hartford and Anthem Blue Cross, the insurer, eventually reached an agreement, Connecticut passed a law this year requiring hospitals and insurers to extend previous contracts for two months to protect consumers when the parties are at an impasse.
While patients may pay more for a well-known brand, like Yale, it is not clear that the higher price tags lead to better care, said Francois de Brantes, a health care executive who once worked at General Electric, which is headquartered in the state.
Since the merger, Yale New Haven has defended the higher rates it charges private insurers as appropriate for a top-tier medical institution.Christopher Capozziello for The New York Times
“We have more lower-rated hospitals in Connecticut than in other New England states,” he said, pointing to an analysis he did at the time of the Anthem-Hartford dispute.
What happens when mergers are opposed
In the Albany, Ga., area, where the Berkeley researchers found a rare decline in hospital prices, the Federal Trade Commission had unsuccessfully attempted to block HCA, the for-profit hospital chain, from selling its hospital to its only local competitor in 2011. But the merger took place, and the F.T.C. reached a settlement with the parties involved.
While Berkeley researchers foundarea prices dropped, another study by two former F.T.C. employees, Christopher Garmon and Laura Kmitch, found that certain hospital quality measures declined. The merger “highlights the problems that can occur when competition is reduced,” the authors said.
The hospital group, Phoebe Putney Health System, dismissed the findings. “Phoebe has made great strides in enhancing the quality of health care available to the people of southwest Georgia,” Dawn Benson, Phoebe’s general counsel, said in a statement.
To foster competition, Lee County is planning a new 60-bed hospital within the Albany area.
In some cases, state regulators have opposed actions they consider illegal and anti-competitive. In Washington, state officials accused CHI Franciscan Health, based in Tacoma, of using its ties to two doctors’ practices to raise prices and decrease competition on the Kitsap Peninsula, according to a lawsuit filed last year.
The regulators argue that CHI wanted to wield its newfound clout by shifting some operations and imaging from less expensive outpatient settings to hospitals where they could charge more.
“I am all for taking advantage of hospital-based pricing, if we think it is doable in the market and the market can support it,” a CHI executive is quoted as saying in the lawsuit. “It would be great to drop a couple of million more to our bottom line.”
CHI Franciscan said the attorney general’s allegations were “misguided and unfounded.”
In California, Mr. Becerra, the state attorney general, brought a lawsuit against Sutter in March, claiming that its actions led to significantly higher prices in Northern California.
Sutter says it adopted methods encouraged by the federal health care law, by combining hospital services with care delivered outside the hospital to better meet patients’ needs.
But Mr. de Brantes, the health care executive in Connecticut, and others wonder why many mergers were allowed in the first place. “The puzzling part for many of us in the state is why anyone would allow these oligopolies to form,” he said.
Maine hospital sues US health department over Medicare payment cuts
by Deborah McDermott - The York Weekly - December 20. 2018
YORK, Maine — York Hospital is a plaintiff in a lawsuit filed by the American Hospital Association against the Department of Health and Human Services over reduced Medicare payments to hospitals with off-campus clinics.
The hospital is one of three joining the AHA and the Association of American Medical Colleges in seeking redress in the courts from a DHHS decision they say countermands the 2015 Budget Act. In that law, Congress passed language to pay a higher reimbursement rate to off-campus hospital clinics in operation before 2015.
The lawsuit claims such clinics are essentially grandfathered, according to law. Any clinics built after 2015 are reimbursed at a lower, physician practice rate. At issue is the fact that the DHHS Centers for Medicare and Medicaid Services in November ruled that all clinics, grandfathered or not, receive the lower rate. That rule is expected to go into effect Jan. 1.
CMS is phasing this in over two years, resulting in a payment reduction nationwide of $380 million each year in 2019 and 2020, according to the lawsuit.
President Jud Knox said he was precluded from speaking about the lawsuit, as it was a pending legal matter.
According to the lawsuit, York Hospital has 14 off-campus clinics that are grandfathered. Further, 54 percent of the hospital’s patients are receiving Medicare. The clinics, according to the suit, offer a range of services including psychiatric, oncology, urology, diabetes and cardiovascular care.
The lawsuit states that the higher rate is necessary, because these clinics offer much more than a doctor’s office does, often having specialized equipment on site so that patients in outlying areas do not have to go to the main campus for certain services.
“York will suffer immediate and concrete harm from the outpatient payment reductions set for in the Final Rule” of the CMS, the lawsuit states.
The lawsuit states that Congress, “to balance concerns of the differing payment rates and the trend toward hospitals acquiring physician practices, created two classes of off-campus providers.” Those acquired or built before 2015 were “deemed ‘excepted’” and were to be paid Medicare rates under the old system.
CMS in its rulemaking, according to the suit, “took the view that Medicare costs could be lowered if these same outpatient services were furnished in a less-expensive physician office setting” regardless of when they were built. The clinics can then be uncoupled from the main hospital and run independently. The CMS as of this week had not filed a written reply to the lawsuit, filed Dec. 4.
The AHA and the plaintiffs argue CMS is in essence ignoring a Congressional directive regarding pre-2015 clinics, which is “in clear violation of its statutory authority.”
“These hospitals were chosen for their geographic diversity to help the court understand the real-world impact of this policy on patients and communities across the country,” an AHA spokesperson said in a statement. “Hospitals could face some tough decisions about how best to continue providing services to their patients and communities in the face of the significant payment reductions imposed by the rule. These could include limiting hours of service or consolidating services at certain locations, which would mean that patients might have to travel greater distances to get the same services that they now get closer to home.
“These cuts violate the clear intent of Congress to protect hospital outpatient departments because of the real and crucial differences between them and other sites of care and HHS does not have the authority to substitute its own policy preferences for judgments of Congress.”
The plaintiffs are seeking a judicial order that the CMS’ action was illegal. Moreover, they are seeking a temporary and permanent injunction against CMS instituting its rule on Jan. 1. To date, there has been no judicial action on a temporary injunction.
Democrats can fix the Affordable Care Act
by John Kingsdale - The Boston Globe - December 20, 2018
Federal District Judge Reed O’Connor’s determination last Friday overturning the entire Affordable Care Act won’t actually affect much — unless it is upheld at the Supreme Court, probably not until 2020 — but it ought to spark a substantive legislative response from House Democrats.
President Trump was quick to gloat and to invite Democrats to negotiate a replacement. With more and more Democrats dreaming of “Medicare-for-all” and the remaining Republicans in Congress after 2018 representing the far right, the prospects for “negotiating” a replacement are nil. This is simply an opportunity to blame Democrats for failing to “step up” and negotiate their own defeat.
Which is one reason that newly empowered House Democrats should use O’Connor’s radical decision as a call to action — specifically, to pass a bill they can put on the table now and campaign on in 2020.
That’s smart politics. There’s a substantive reason to act as well. Unfortunately, ACA enrollment has peaked, leaving 28 million Americans uninsured, and marketplace enrollment in private plans now falling. Premiums are too high and consumer choice too limited in many parts of the country.
It is time to put a real fix on the table, recognizing that this probably cannot become law until Democrats regain control of the Senate and White House. Simply proposing Medicare-for-all may galvanize the Democratic base, but it might not even pass the House and could well cost Democrats dearly in the 2020 election. But Medicare is popular, and the ACA can be improved by borrowing from it.
First, let’s be clear about objectives: The ACA needs to cover more people and bring down premiums. Both goals require addressing the root cause of runaway health care spending: prices.
The United States spends twice the average per person of our peer countries, not because we use more medical services, but because of higher prices for the medical services we do use. In fact, we see the doctor far less often, use half the hospital days, and swallow roughly the same number of pills as Europeans and Canadians. We pay on average twice what other advanced economies do for each visit, day, operation, scan, or pill.
Medicare-for-all would change that, but it is still a bridge too far for many voters, even moderate Democrats. Having come so close with the ACA — 91 percent of Americans are covered — a wholesale switch would be very disruptive. Rather, a reinvigorated ACA should build on tested elements of existing federal programs, just as the ACA built on tested elements of Massachusetts’ reform, to achieve the twin goals of coverage and cost.
Here are three relatively simple fixes that would materially improve the ACA, building on some of the best policies in other programs:
First, concede the individual mandate. Get rid of this unpopular “stick” and increase the ACA’s carrots. For 12 years now, Massachusetts has offered higher subsidies than the ACA’s national schedule of tax credits. As a result, nearly everyone (97 percent) in the Commonwealth is covered. So let’s replace the mandate with more generous premium subsidies under the ACA and, if some sort of stick is still required, then the ACA should allow insurers to surcharge premiums for those who wait until they get sick to buy coverage, just as Medicare drug plans do now.
Second, to ensure competition and choice in marketplaces across the country, bring back the “public option” that was originally considered for the ACA. This doesn’t have to be government-run insurance; rather, we could deploy private Medicare Advantage plans on the ACA marketplace. These private plans now enroll half of all newly eligible Medicare beneficiaries. They combine competition and relatively low (Medicare) pricing levels for hospitals, doctors, and other care providers. (Remember, it’s high pricing that accounts for our high total medical spending.) So let’s have these same Medicare replacement plans compete for younger individuals in the ACA marketplace.
Third, let the government negotiate drug prices, as the Veterans Affairs department and so many of our peer countries do, both for Medicare and private Medicare replacement plans. The VA pays far less than commercial insurers for the same drugs. Let’s share those savings with current Medicare enrollees and the individuals who chose Medicare replacement plans in the ACA marketplace.
These are three easy-to-understand, workable fixes for the ACA. Are they controversial? Of course. Lowering the costs of coverage means taking money away from powerful interests, including people who save lives for a living. We revere them — when we’re not cursing them for overcharging.
But America now faces the choice of making coverage affordable or halting recent coverage gains — likely to slide backwards in the next recession. Or we can build on the ACA, using some proven health policies from the federal tool chest.
Jon Kingsdale is senior strategy adviser at Wakely Consulting and associate professor of the practice at Boston University School of Public Health. He was the founding executive director of the Commonwealth Health Insurance Connector Authority.On Politics With Lisa Lerer: Republicans Got Their Health Care Wish. It Backfired.
by Lisa Lerer - NYT - December 17, 2018
For eight years, Republicans dreamed of repealing the Affordable Care Act.
Now, they’re finding that eliminating the health care law may actually be more like their version of the nightmare before Christmas.
A ruling Friday by a federal judge in Texas striking down the entire law has forced Republicans into yet another difficult moment of confrontation, after an election season spent fending off a barrage of Democratic attacks over their former opposition to the law’s more popular provisions.
Already, the ruling has injected new pressure into the races of three Republicans running for governor in Louisiana, Mississippi and Kentucky next year. And Democrats hope they can keep up the drumbeat of attacks well into 2020, seeing the decision as a potent combination of two issues that they argue play well with the suburban women and blue-collar voters who could be crucial in the presidential race: protecting the health care law and attacking “activist” judges.
Andy Beshear, the Democratic attorney general of Kentucky challenging Gov. Matt Bevin, promised to take a “more vocal” role in a multistate lawsuit opposing the health care ruling, calling it a “matter of life and death.” Mr. Bevin, a Republican, shot back, accusing the man he calls “little Andy” of joining the suit for personal gain.
“Little Andy, he never sues on behalf of the people of Kentucky. He does it on behalf of his own political career, so anything he would do in response has nothing to do with what’s best for Kentucky,” Mr. Bevin said in an interview with a local television station.
During the final weeks of the midterm campaign, President Trump and Republican candidates promised to protect elements of the law, even as the administration backed a lawsuit brought against it. That lawsuit led to Friday’s decision — and, for Republicans, a new round of their political two-step on the issue.
In Washington, Democratic operatives are already thinking about how to use the ruling to undermine Republicans in the Senate. The first political advertisement focused on the ruling, released online Monday night by Protect Our Care, a group dedicated to preserving the Affordable Care Act, calls the decision a “disaster for American health care.”
Even more dangerous for Republicans is the possibility that if the ruling reaches the Supreme Court, arguments could happen during the 2020 spring term — right in the midst of the general election.
“Trump’s only path to re-election is winning the very voters who are harmed the most by his lawsuit overturning health care,” said Jesse Ferguson, a Democratic strategist who worked for several progressive groups that opposed the lawsuit. “You think you put a Band-Aid on the issue, and then the ruling rips the Band-Aid off and jabs it with a hot poker.”
The essential problem for the G.O.P. is that provisions of the law protecting millions of Americans with pre-existing conditions have grown increasingly popular since its passage in 2010. Thirty-six states have voted to expand Medicaid under the law, with three red states — Idaho, Nebraska and Utah — approving ballot measures last month to cover hundreds of thousands more low-income people.
Republicans are trying to cast this as a golden opportunity to rework the law. “We have a chance, working with the Democrats, to deliver great HealthCare! A confirming Supreme Court Decision will lead to GREAT HealthCare results for Americans!” Mr. Trump tweeted on Monday morning.
But there’s no indication that Republicans will be able to bridge any of the divides that prevented passage of previous efforts to overhaul the law, particularly now that they face the added political challenge of a Democratic-controlled House.
“We’ve done this play before,” said Thomas P. Miller, a lawyer and health economist at the American Enterprise Institute and a critic of the law. “Republicans can talk about working on legislation, but they are looking for exit doors. That’s where most of them are.”
But the decision will put new pressures on Democrats, as well. The continued threats to the health care law pushed Democrats to the left, expanding calls for a single-payer “Medicare-for-all” plan. Nearly all the serious Democratic contenders for president in 2020 already support such a system.
Some progressive activists see the ruling as an opportunity to push their party into a more aggressive stance against all of Mr. Trump’s judicial nominees.
“Part of the message we want to send to Democrats is that this radical decision is a prime example why you can’t let your guard down,” said Brian Fallon, executive director of Demand Justice, a liberal judicial advocacy group. “More Democrats are going to have unclean hands because they looked the other way or helped give consent to allow more and more of Donald Trump’s judges to get through the pipeline.”
States Ask Judge to Declare Health Law Still in Effect While Ruling Is Appealed
by Robert Pear - NYT - December 17, 2018
WASHINGTON — California and 15 other states asked a federal judge on Monday to protect current health care coverage for millions of Americans while courts sort out the implications of his ruling that the Affordable Care Act was invalid in its entirety.
The states, which support the health care law, said the ruling on Friday, by Judge Reed O’Connor of the Federal District Court in Fort Worth, had caused immense confusion about whether the law was still in effect, and whether consumers were still entitled to its benefits and protections.
The states asked Judge O’Connor to clarify whether he meant his decision to have “any immediate legal effect.”
In his sweeping decision, Judge O’Connor held that a provision at the heart of the Affordable Care Act — a requirement for most Americans to have health insurance known as the individual mandate — was unconstitutional and that other provisions of the law could not survive because they were inextricably linked to the coverage mandate. The sprawling law includes not only health insurance exchanges and an expansion of Medicaid, but also protections for people with pre-existing conditions, requirements for what insurance must cover and much more.
But Judge O’Connor did not issue an injunction barring enforcement of the law.
“In light of this ambiguity,” California and the other states asked Judge O’Connor on Monday to affirm that the Affordable Care Act was still the law and should be enforced while supporters and opponents of the measure continue their battle in court.
“The district court’s ruling poses a dangerous threat to the health care of millions of Americans,” said the California attorney general, Xavier Becerra. “Today’s filing makes clear that California and its partner states will do everything possible to challenge this reckless ruling.”
Caitlin Oakley, a spokeswoman for the Department of Health and Human Services, said Monday that because Judge O’Connor had not issued a final judgment or an injunction, the department “will continue administering and enforcing all aspects of the A.C.A. as it had before the court issued its decision.”
The lawsuit was filed by Texas and 19 other states. The individual mandate was enforced by a tax penalty on people who go without insurance, and the Supreme Court upheld it in 2012 as an exercise of Congress’s taxing power. But as part of the tax overhaul that President Trump signed last December, Congress reduced the penalty to zero dollars, starting in 2019. Texas and the other plaintiffs contend that the mandate will then lose its constitutional justification.
On Friday, Mr. Trump hailed the judge’s decision as “great news for America!”
But the coalition of states led by California told the judge on Monday that their citizens would face “devastating harm from the invalidation” of the Affordable Care Act.
“The law’s provisions are so interwoven in virtually every aspect of the public and private health care system that the elimination of the A.C.A. will cause grievous immediate and long-term harm to Americans’ health and financial security, to the health care system, and to federal and state budgets,” the coalition said in a legal brief.
“If the A.C.A. is invalidated, nearly 12 million Americans who gained coverage through the Medicaid expansion would become uninsured,” the coalition said. “An additional eight million low-income residents will lose access to billions of dollars in tax credits” that help them pay premiums for private insurance.
Judge O’Connor’s decision left several issues unresolved, but California and its allies said he should allow an immediate appeal on an important legal question: “whether the A.C.A. remains in force, wholly or in substantial part, after the passage” of the tax cut law.
Gov. Greg Abbott of Texas, a Republican, said on Monday that his state would try to devise a replacement for the Affordable Care Act.
“If Obamacare remains struck down on appeal Texas will be ready with replacement health care insurance that includes coverage for preexisting conditions,” Mr. Abbott said in a Twitter post.
Taking Surprise Medical Bills to Court
Some legal experts say contract law could provide consumers another avenue to challenge unexpected hospital bills.
by Julie Applebee - Kaiser Health News - December 18, 2018
Joaquin Lopez had emergency gallbladder surgery after rushing to an emergency room last year. He has been haggling with Baptist Memorial Hospital in Memphis over what he owes ever since.
The 37-year-old college professor was hit with a nearly $8,000 bill from the out-of-network hospital — that was after the $11,000 he and his insurer had already paid.
Consumers are increasingly vulnerable to such so-called balance bills, which represent the difference between what insurers pay and hospitals’ list prices. List prices can be several times higher than what the hospitals accept from Medicare or in-network insurers.
Congress is considering bipartisan legislation to limit balance billing. But some legal scholars say that patients should already be protected against some of the highest surprise charges under longstanding conventions of contract law.
That’s because contract law rests on the centuries-old concept of “mutual assent,” in which both sides agree to a price before services are rendered, said Barak Richman, a law professor at Duke University.
Thus, many states require, and consumers expect, written estimates for a range of services before the work is done — whether by mechanics and plumbers or lawyers and financial planners.
But patients rarely know upfront how much their medical care will cost, and hospitals generally provide little or no information.
While consumers are obligated to pay something, the question is how much? Hospitals generally bill out-of-network care at list prices, their highest charges.
Without an explicit price upfront, contract law would require medical providers to charge only “average or market prices,” Mr. Richman said.
In several recent cases, for example in New York and Colorado, courts have stepped in to mediate cases where a patient received a big balance bill from an out-of-network provider. They ordered hospitals to accept amounts far closer to what they agree to from in-network private insurers or Medicare.
“This is the amount they are legally entitled to collect,” said Mr. Richman.
Dr. Lopez’s bill came after he sought help at the emergency room following excruciating abdominal pain. Sent home with pain medication, he awoke hours later to a phone call from the hospital: Come back! A review of his tests showed he needed surgery. He didn’t stop to ask if the hospital was in his network, or for a cost estimate.
So, in an example like that, is there mutual assent?
Hospitals say yes, that signed admission forms, which include a promise to pay, constitute mutual assent, even if there was no price disclosed.
No, counters Mr. Richman. If a tax preparer provided no upfront estimate, he could not suddenly bill a client for $10,000 if the going rate for the service was $1,000 or less. The higher fee would never hold up in a court of law, since there was no “mutual assent” about price.
But what, if anything, should Dr. Lopez offer to pay? What is reasonable or average in a system where the price of a hip replacement can range from $15,000 to $150,000, or a blood test can be $5 to $500?
Based on the hospital’s list prices, Dr. Lopez’s bill came to nearly $21,000. His insurer, Cigna, using a formula it said is similar to what Medicare uses, said the maximum it would cover was $11,160. It paid 80 percent of that lower amount, and Dr. Lopez paid the remainder. Baptist Hospital is billing Dr. Lopez for nearly $8,000 more, saying it wants the full charges.
“I’m an economist,” said Dr. Lopez, who teaches at the University of Memphis. “I understand how abusive these practices are. There is not a single market price.”
Indeed. Healthcare Bluebook, a consumer website that uses claims data to estimate costs, shows gall bladder surgery in Memphis costs as little as $14,000, but could be tens of thousands more, with a “fair price” of about $18,000 — which is generally less than full billed charges, but more than in-network insurers would pay.
That complexity — and the cost of hiring an attorney — have made legal challenges to medical bills on the basis of contract law relatively scarce.
Also, “it’s not a well-settled area of the law,” said Mark Hall, director of the Health Law and Policy Program at Wake Forest University, who backs the contract law protection theory.
Even though hospitals have lost some cases, their arguments have also found traction.
The Virginia Supreme Court last year ruled in favor of a hospital, saying admission paperwork a patient named Glenn Dennis signed in the emergency room was a valid contract. The hospital had sued him over an $84,000 bill for his out-of-network care.
Still, the court left open the key question of just how much of that Mr. Dennis owed, sending that back to a lower court. That court previously ruled that Mr. Dennis owed only about $500 on top of the $27,255 his health insurer had paid. That reflected a discount the hospital commonly gave uninsured patients, the circuit court judge wrote. The two sides are still working on a settlement.
For those caught up in the disputes, determining a fair price is hard.
“That’s where courts struggle, creating health care prices,” said Mr. Hall.
One way is to look at what hospitals accept for in-network care from private insurers. But hospitals generally object to releasing that, saying it’s a trade secret.
A 2017 Texas Supreme Court ruling has, at least for now, broken through this position. It said that hospitals in some legal disputes must disclose those in-network rates they allow in-network insurers to pay.
“Hospitals are really trying to prevent this sort of thing because they are uncomfortable having someone ask them to justify” their charges, said George Nation, a law professor at Lehigh University in Pennsylvania, who filed a court brief in the Texas case on behalf of the patient’s argument.
In June, the hospital involved in the dispute asked for a rehearing, saying such disclosure would weaken its bargaining power. Several other hospitals are backing its request, illustrating the broad concern.
Dr. Lopez has hired a lawyer to fight his bill.
Consumers in some states might have legal backup under balance-billing laws. But rules vary, often don’t apply to all types of insurance and may cover only emergency medical treatment costs.
Tennessee’s law, which went into effect in July, requires hospitals to notify patients of estimated costs and that they could receive balance bills.
After getting a balance bill, consumers should attempt to negotiate a reduced amount, said Wendy Netter Epstein, a health law professor at DePaul University College of Law. Online look-up tools like Healthcare Bluebook or Fair Health can provide estimates of average costs for procedures.
Dr. Lopez said he offered to pay 20 percent of the disputed amount, but it has not — so far — been accepted.
Baptist Memorial Hospital encourages patients to file appeals and, if a better offer is made by the insurer, “we accept it and dismiss the patient’s balance,” said David Elliott, vice president of managed care and chief executive of Baptist Health Services Group, in an emailed statement.
Dr. Lopez has appealed twice to Cigna to cover more of the bill — without success.
For now, his lawyer has written to the hospital, disputing that Dr. Lopez owes more than was already paid by the insurer. The letter said Dr. Lopez planned to avail himself of any protection under state or federal law.
The Case for a Mixed Economy
by Paul Krugman - NYT - December 22, 2018
A mind is a terrible thing to lose, especially if the mind in question is president of the United States. But I feel like taking a break from that subject. So let’s talk about something completely different, and probably irrelevant.
I’ve had several interviews lately in which I was asked whether capitalism had reached a dead end, and needed to be replaced with something else. I’m never sure what the interviewers have in mind; neither, I suspect, do they. I don’t think they’re talking about central planning, which everyone considers discredited. And I haven’t seen even an implausible proposal for a decentralized system that doesn’t rely on price incentives and self-interest – i.e., a market economy with private property, which most people would consider capitalism.
So maybe I’m being dense or lacking in imagination, but it seems to be that the choice is still between markets and some kind of public ownership, maybe with some decentralization of control, but still more or less what we used to mean by socialism. And everyone either thinks of socialism as discredited, or pins the label on stuff – like social insurance programs – that isn’t what we used to mean by the word.
But I’ve been wondering, exactly how discredited is socialism, really? True, nobody now imagines that what the world needs is the second coming of Gosplan. But have we really established that markets are the best way to do everything? Should everything be done by the private sector? I don’t think so. In fact, there are some areas, like education, where the public sector clearly does better in most cases, and others, like health care, in which the case for private enterprise is very weak. Add such sectors up, and they’re quite big.
In other words, while Communism failed, there’s still a pretty good case for a mixed economy – and public ownership/control could be a significant, although not majority, component of that mix. My back of the envelope says that given what we know about economic performance, you could imagine running a fairly efficient economy that is only 2/3 capitalist, 1/3 publicly owned – i.e., sort-of-kind-of socialist.
I arrive at that number by looking at employment data. What we see right away is that even now, with all the privatization etc. that has taken place, government at various levels employs about 15 percent of the work force – roughly half in education, another big chunk in health care, and then a combination of public services and administration.
Looking at private sector employment, we find that another 15 percent of the work force is employed in education, health, and social assistance. Now, a large part of that employment is paid for by public money – think Medicare dollars spent at private hospitals. Much of the rest is paid for by private insurers, which exist in their current role only thanks to large tax subsidies and regulation.
And there’s no reason to think the private sector does these things better than the public. Private insurers don’t obviously provide a service that couldn’t be provided, probably more cheaply, by national health insurance. Private hospitals aren’t obviously either better or more efficient than public. For-profit education is actually a disaster area.
So you could imagine an economy in which the bulk of education, health, and social assistance currently in the private sector became public, with most people at least as well off as they are now.
Then there are other private activities that could plausibly be public. Utilities are heavily regulated, and in some cases are publicly owned already. Private health insurance directly employs hundreds of thousands of people, with doubtful social purpose. And I’m sure I’m missing a few others.
By and large, other areas like retail trade or manufacturing don’t seem suitable for public ownership – but even there you could see some cases. Elizabeth Warren is suggesting public manufacture of generic drugs, which isn’t at all a stupid idea.
Put all of this together, and as I said, you could see an economy working well with something like 1/3 public ownership.
Now, this wouldn’t satisfy people who hate capitalism. In fact, it wouldn’t even live up to the old slogan about government controlling the economy’s “commanding heights.” This would be more like government running the boiler in the basement. Also, I see zero chance of any of this happening in my working lifetime.
But I do think it’s worth trying to think a bit beyond our current paradigm, which says that anything you could call socialist has been an utter failure. Maybe not so much?
Editor's Note:
From the above article, we can now see that even the notoriously incremental Paul Krugman is beginning to get the idea!
-SPC
Misconceptions About Health Costs When You’re Older
by Austin Frakt - NYT - December 24, 2018
Some significant expenses decline as we age: Most mortgages are eventually paid off, and ideally children grow up and become self-supporting.
But health care is one area in which costs are almost certain to rise. After all, one of the original justifications for Medicare — which kicks in at age 65 — is that older people have much higher health care needs and expenses.
But there are a few common misunderstandings about health costs when people are older, including the idea that money can easily be saved by reducing wasteful end-of-life spending.
No, Medicare won’t cover it all. There are gaps.
Half our lifetime spending on health care is in retirement, even though that represents only about 20 percent of a typical life span. Total health care spending for Americans 65 and older is about $15,000 per year, on average, nearly three times that of working-age Americans.
Don’t expect Medicare to provide complete protection from these expenses.
Traditional Medicare has substantial gaps, leaving Americans on the hook for a lot more than they might expect. It has no cap on how much you can pay out of pocket, for example. Such coverage gaps can be filled — at least in part — by other types of insurance. But some alternatives, such as Medicare Advantage, aren’t accepted by as many doctors or hospitals as accept traditional Medicare.
On average, retirees directly pay for about one-fifth of their total health care spending. Some spend much more.
One huge expense no Medicare plans cover is long-term care in a nursing home.
Over half of retirement-age adults will eventually need long-term care, which can cost as much as $90,000 per year at a nursing home. Although most who enter a nursing home don’t stay long, 5 percent of the population stays for more than four years. You can buy separate coverage outside the Medicare program for this, but the premiums can be high, especially if you wait until near retirement to buy.
Medicaid plays a bigger role than expected
Although Medicare is thought of as the source of health care coverage for retirees, Medicaid plays a crucial role.
Medicaid, the joint federal-state heath financing program for low-income people, has long been the nation’s main financial backstop for long-term care. Over 60 percent of nursing home residents have Medicaid coverage, and over half of the nation’s long-term care is funded by the program.
That isn’t because most people who require long-term care have low incomes. It’s because long-term care is so expensive that those needing it can frequently deplete their financial resources and then must turn to Medicaid.
A recent working paper from the National Bureau of Economic found that, on average, Medicaid covers 20 percent of retiree health spending. The figure is larger for lower-income retirees, who are more likely to qualify for Medicaid for more of their retirement years.
It’s really hard to predict when someone will die
A widely held view is that much spending is wasted on “heroic” measures taken at the end of life. Are all the resources devoted to Medicare and Medicaid really necessary?
First, let’s get one misunderstanding out of the way. The proportion of health spending at the end of life in the United States is lower than in many other wealthy countries.
Still, it’s a tempting area to look for savings. Only 5 percent of Medicare beneficiaries die each year, but 25 percent of all Medicare spending is on individuals within one year of death. However, the big challenge in reducing end-of-life spending, highlighted by a recent study in Science, is that it is hard to know which patients are in their final year.
The study used all the data available from Medicare records to make predictions: For each beneficiary, it assigned a probability of death within a year. Of those with the very highest probability of dying — the top 1 percent — fewer than half actually died.
“This shows that it’s just very hard to know in advance who will die soon with much certainty,” said Amy Finkelstein, an M.I.T. economist and an author of the study. “That makes it infeasible to make a big dent in health care spending by cutting spending on patients who are almost certain to die soon.”
That does not mean that all the care provided to dying patients — or to any patient — is valuable. Another study finds that high end-of-life spending in a region is closely related to the proportion of doctors in that region who use treatments not supported by evidence — in other words, waste.
“People at high risk of dying certainly require more health care,” said Jonathan Skinner, an author of the study and a professor of economics at Dartmouth. “But why should some regions be hospitalizing otherwise similar high-risk patients at much higher rates than other regions?”
In 2014, for example, chronically ill Medicare beneficiaries in Manhattan spent 73 percent more days in the hospital in their last two years of life than comparable beneficiaries in Rochester.
“There absolutely is waste in the system,” said Ashish Jha, director of the Harvard Global Health Institute. But, he argues, waste is present throughout the life span, not just at the end of life: “We have confused that spending as end-of-life spending is somehow wasteful. But that’s not right because we are terrible at predicting who is going to die.”
Of course, beyond any statistical analysis, there are actual people involved, and wrenching individual decisions that need to be made.
“We should do all we can to push waste out of the system,” Dr. Jha said. “But spending more money on people who are suffering from an illness is appropriate, even if they die.”
Up To A Third Of Knee Replacements Pack Pain And Regret
by Liz Szabo - Kaiser Health News - December 25, 2018
Danette Lake thought surgery would relieve the pain in her knees.
The arthritis pain began as a dull ache in her early 40s, brought on largely by the pressure of unwanted weight. Lake managed to lose 200 pounds through dieting and exercise, but the pain in her knees persisted.
A sexual assault two years ago left Lake with physical and psychological trauma. She damaged her knees while fighting off her attacker, who had broken into her home. Although she managed to escape, her knees never recovered. At times, the sharp pain drove her to the emergency room. Lake’s job, which involved loading luggage onto airplanes, often left her in misery.
When a doctor said that knee replacement would reduce her arthritis pain by 75 percent, Lake was overjoyed.
“I thought the knee replacement was going to be a cure,” said Lake, now 52 and living in rural Iowa. “I got all excited, thinking, ‘Finally, the pain is going to end and I will have some quality of life.’”
But one year after surgery on her right knee, Lake said she’s still suffering.
“I’m in constant pain, 24/7,” said Lake, who is too disabled to work. “There are times when I can’t even sleep.”
Most knee replacements are considered successful, and the procedure is known for being safe and cost-effective. Rates of the surgery doubled from 1999 to 2008, with 3.5 million procedures a year expected by 2030.
But Lake’s ordeal illustrates the surgery’s risks and limitations. Doctors are increasingly concerned that the procedure is overused and that its benefits have been oversold.
Research suggests that up to one-third of those who have knees replaced continue to experience chronic pain, while 1 in 5 are dissatisfied with the results. A study published last year in the BMJ found that knee replacement had “minimal effects on quality of life,” especially for patients with less severe arthritis.
One-third of patients who undergo knee replacement may not even be appropriate candidates for the procedure, because their arthritis symptoms aren’t severe enough to merit aggressive intervention, according to a 2014 study in Arthritis & Rheumatology.
“We do too many knee replacements,” said Dr. James Rickert, president of the Society for Patient Centered Orthopedics, which advocates for affordable health care, in an interview. “People will argue about the exact amount. But hardly anyone would argue that we don’t do too many.”
Although Americans are aging and getting heavier, those factors alone don’t explain the explosive growth in knee replacement. The increase may be fueled by a higher rate of injuries among younger patients and doctors’ greater willingness to operate on younger people, such as those in their 50s and early 60s, said Rickert, an orthopedic surgeon in Bedford, Ind. That shift has occurred because new implants can last longer — perhaps 20 years — before wearing out.
Yet even the newest models don’t last forever. Over time, implants can loosen and detach from the bone, causing pain. Plastic components of the artificial knee slowly wear out, creating debris that can cause inflammation. The wear and tear can cause the knee to break. Patients who remain obese after surgery can put extra pressure on implants, further shortening their lifespan.
The younger patients are, the more likely they are to “outlive” their knee implants and require a second surgery. Such “revision” procedures are more difficult to perform for many reasons, including the presence of scar tissue from the original surgery. Bone cement used in the first surgery also can be difficult to extract, and bones can fracture as the older artificial knee is removed, Rickert said.
Revisions are also more likely to cause complications. Among patients younger than 60, about 35 percent of men need a revision surgery, along with 20 percent of women, according to a November article in the Lancet.
Yet hospitals and surgery centers market knee replacements heavily, with ads that show patients running, bicycling, even playing basketball after the procedure, said Dr. Nicholas DiNubile, a Havertown, Pa., orthopedic surgeon specializing in sports medicine. While many people with artificial knees can return to moderate exercise — such as doubles tennis — it’s unrealistic to imagine them playing full-court basketball again, he said.
“Hospitals are all competing with each other,” DiNubile said. Marketing can mislead younger patients into thinking, “‘I’ll get a new joint and go back to doing everything I did before,’” he said. To Rickert, “medical advertising is a big part of the problem. Its purpose is to sell patients on the procedures.”
Rickert said that some patients are offered surgery they don’t need and that money can be a factor.
Knee replacements, which cost $31,000 on average, are “really crucial to the financial health of hospitals and doctors’ practices,” he said. “The doctor earns a lot more if they do the surgery.”
Ignoring Alternatives
Yet surgery isn’t the only way to treat arthritis.
Patients with early disease often benefit from over-the-counter pain relievers, dietary advice, physical therapy and education about their condition, said Daniel Riddle, a physical therapy researcher and professor at Virginia Commonwealth University in Richmond.
Studies show that these approaches can even help people with more severe arthritis.
In a study published in Osteoarthritis and Cartilage in April, researchers compared surgical and non-surgical treatments in 100 older patients eligible for knee replacement.
Over two years, all of the patients improved, whether they were offered surgery or a combination of non-surgical therapies. Patients randomly assigned to undergo immediate knee replacement did better, improving twice as much as those given combination therapy, as measured on standard medical tests of pain and functioning.
But surgery also carried risks. Surgical patients developed four times as many complications, including infections, blood clots or knee stiffness severe enough to require another medical procedure under anesthesia. In general, 1 in every 100 to 200 patients who undergo a knee replacement die within 90 days of surgery.
Significantly, most of those treated with non-surgical therapies were satisfied with their progress. Although all were eligible to have knee replacement later, two-thirds chose not to do it.
Tia Floyd Williams suffered from painful arthritis for 15 years before having a knee replaced in September 2017. Although the procedure seemed to go smoothly, her pain returned after about four months, spreading to her hips and lower back.
She was told she needed a second, more extensive surgery to put a rod in her lower leg, said Williams, 52, of Nashville.
“At this point, I thought I would be getting a second knee done, not redoing the first one,” Williams said.
Other patients, such as Ellen Stutts, are happy with their results. Stutts, in Durham, N.C., had one knee replaced in 2016 and the other replaced this year. “It’s definitely better than before the surgery,” Stutts said.
Making Informed Decisions
Doctors and economists are increasingly concerned about inappropriate joint surgery of all types, not just knees.
Inappropriate treatment doesn’t harm only patients; it harms the health care system by raising costs for everyone, said Dr. John Mafi, an assistant professor of medicine at the David Geffen School of Medicine at UCLA.
The 723,000 knee replacements performed in 2014 cost patients, insurers and taxpayers more than $40 billion. Those costs are projected to surge as the nation ages and grapples with the effects of the obesity epidemic, and an aging population.
To avoid inappropriate joint replacements, some health systems are developing “decision aids,” easy-to-understand written materials and videos about the risks, benefits and limits of surgery to help patients make more informed choices.
In 2009, Group Health introduced decision aids for patients considering joint replacement for hips and knees.
Blue Shield of California implemented a similar “shared decision-making” initiative.
Executives at the health plan have been especially concerned about the big increase in younger patients undergoing knee replacement surgery, said Henry Garlich, director of health care value solutions and enhanced clinical programs.
The percentage of knee replacements performed on people 45 to 64 increased from 30 percent in 2000 to 40 percent in 2015, according to the Agency for Healthcare Research and Quality.
Because the devices can wear out in as little as a few years, a younger person could outlive their knees and require a replacement, Garlich said. But “revision” surgeries are much more complicated procedures, with a higher risk of complications and failure.
“Patients think after they have a knee replacement, they will be competing in the Olympics,” Garlich said.
Danette Lake once planned to undergo knee replacement surgery on her other knee. Today, she’s not sure what to do. She is afraid of being disappointed by a second surgery.
Sometimes, she said, “I think, ‘I might as well just stay in pain.’”
Insured, But Indebted: Couple Works 5 Jobs To Pay Off Medical Bills
by Jonel Allecia - Kaiser Health News - December 26, 2018
Robert and Tiffany Cano of San Tan Valley, Ariz., have a new marriage, a new house and a 10-month-old son, Brody, who is delighted by his ability to blow raspberries.
They also have a stack of medical bills that threatens to undermine it all.
In the months since their sturdy, brown-eyed boy was born, the Canos have acquired nearly $12,000 in medical debt — so much that they need a spreadsheet to track what they owe to hospitals and doctors.
"I'm on these payment arrangements that are killing us," said Tiffany Cano, 37, who has spent her lunch hours from her job at a regional bank on the phone negotiating payoff plans that now total $700 a month. "My husband is working four jobs. I work full time. We're a hardworking family doing our best and not getting anywhere."
The pair, who earn nearly $100,000 a year, are insured and have had no major illnesses or injuries. Still, the Canos are among the 1 in 4 Americans who reportin multiple polls that the high cost of health care is the biggest concern facing their families. And they're at risk of joining the 62 percent of people who file for bankruptcy tied to medical bills.
"Oh, yes, that worry is always in the back of my mind," Tiffany said.
The family is part of a struggling group: Middle-class folks who have followed the rules and paid for employer-based medical insurance, only to find that soaring health care costs — combined with high deductibles, high copayments and surprise medical bills — leave them vulnerable.
"I thought we'd be covered, and it's just not enough coverage at all," she said.
Robert Cano, also 37, had family health insurance for 2018 through his job as a manager at a large-chain retail store, for which he pays nearly $500 per month. The plan's $3,000 annual deductible and 40 percent coinsurance fees have added up faster than the Canos anticipated.
First came the nearly $4,000 bill from the in-network hospital where Brody was born Jan. 2, followed by separate fees from the anesthesiologist and the doctor who performed the routine delivery. Then, at 2 months, Brody was hospitalized with breathing problems doctors said could be related to allergies or asthma. In May, Tiffany came down with a stomach virus that sent her to the ER for drugs to treat nausea and dehydration. Last month, the baby developed a bad case of bacterial conjunctivitis, or pinkeye.
"It's been, like, $300 here, $700 there," said Tiffany. "We had a hospital bill for him being sick of, like, $1,800."Unable initially to find a pediatrician she liked, Tiffany has agonized over whether to use the ER when Brody gets sick. When he had pinkeye, she debated whether to take him in, hoping it would get better on its own.
Then he got worse, she said, pulling up a photo on her phone of her son with half-moons of red, puffy flesh under his dark eyes.
"I let him suffer for a day like that," she said.
The Canos lost their first child, a girl, midway through her pregnancy in 2016. Tiffany acknowledges that experience has left her more anxious than the average first-time mom.
"It gave me so much fear that something would happen to him," she said.
As for their own health care needs, the couple put themselves lower on the priority list. Tiffany has used a prosthetic limb since childhood, when her lower left leg was amputated because of a birth defect.
She needs a new prosthesis because her body changed during pregnancy, but she can't see how to afford it.
A model suitable for the busy life of a working mom would easily cost $10,000 to $15,000, according to Tom Fise, executive director of the American Orthotic & Prosthetic Association.
"I try to push through," Tiffany said. "I put on that brave face of just walking, but it's so painful to walk. I have bruises all over my leg. I get blisters all the time." Lately, she's been wearing an old prosthesis, one she used in high school, because it's a little bit more comfortable.
The Canos don't know how exactly they fell into such debt, since they tried hard to make responsible decisions. After meeting three years ago, they knew quickly that they wanted to marry and have a family.
"I waited until I found the right guy," said Tiffany, who was thrilled when, in 2016, they were able to afford a 2,500-square-foot, two-story home in one of the stucco-and-tile neighborhoods an hour outside Phoenix.
But, taken together, the medical payment plans and premiums are almost as much as their $1,300 monthly mortgage. All told, the Canos spend about 15 percent of their annual income on health care, almost three times the averagefor non-Medicare households in the U.S.
That leaves too little for day care, car payments, gas, food and dozens of other domestic expenses, Tiffany said.
For 17 years, Robert had comprehensive health insurance through his job as a soldier in the Army Reserve and paid little or nothing for medical care. He left the Army in 2017, however, after he learned he would be deployed for an extended time away from his wife and new son.
"I told them, 'I have to be at home,'" he recalled. The Army insurance ended on Dec. 31, two days before Brody was born.
That meant moving to his employer's insurance plan. Like more than 40 percent of 152 million Americans who get health insurance through work, the Canos are enrolled in a plan that demands thousands of dollars before any coverage kicks in.
The couple discovered that they earn too much to qualify for financial assistance from medical providers, or for subsidies if they shifted their insurance to a plan under the federal health insurance exchange. She is a full-time bank compliance officer. He is a full-time store manager.
Tiffany wrote to Kaiser Health News after seeing stories about sky-high medical bills on TV.
Dr. Merrit Quarum, the chief executive of WellRithms, a health care consulting firm, reviewed the family's medical bills and the responses from their health care providers.
Though Quarum had questions about some of the fees in the itemized bills — $4 for a 600-milligram ibuprofen tablet? $3,125 to place an epidural? — he found the charges were legitimate under the terms of the contract between the hospital and the Canos' insurer.
Tiffany's only recourse was to set up the five payment plans she navigates each month.
"I wish I could say it wasn't so, but it is," Quarum said.
Mostly to pay off that health care debt, Robert has taken several part-time gigs this year — as a substitute teacher, a nighttime security guard and delivering sandwiches for a fast-food chain in Scottsdale, 40 miles away, where tips are better. He said he sometimes works up to 120 hours in a week.
"I'm not ashamed or embarrassed, even as old as I am, to deliver sandwiches," he said, pulling on his retail chain polo shirt before rushing to a Saturday morning shift. "I know people, they'd rather get food stamps and feel sorry for themselves. But I'm a fighter. I will not give up ... If I can bring in an extra $400 a week or $800 a month, she can get what she needs for the baby."
Often home after midnight, he keeps shampoo and shaving cream in his car and naps in parking lots between jobs, relying on Red Bull to stay alert.
That means on many nights, when Tiffany picks up Brody from day care after her 90-minute commute, she handles most of the chores at home.
"Sometimes I feel like a single mom because my husband is never around," she said.
She carefully tracks the family's medical expenses, trying to juggle them with ordinary outlays that can't wait — like $500 for the brakes that went out on her car this month.
At the rate they're going, the bills won't be paid until Brody is 3, Tiffany said. The Canos are getting older and they'd like to have another baby before it's too late, but, for now, that seems impossible.
For 2019, the couple have decided to switch to a different plan offered through Tiffany's employer. The premium is higher — $650 a month — but the deductible is $1,500 with just 10 percent coinsurance.
"It is going to be a lot more per paycheck, which is going to hurt us," Tiffany said. "But after what just happened, I want to make sure we are prepared in case anything does occur."
How to fix a health care system that burdens middle-class families so heavily is beyond her, she said.
"The only thing we can do is just keep working." Tiffany said. "I always wonder: How does everybody else do it?"
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