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Monday, February 25, 2019

Health Care Reform Articles - February 27, 2019

Editor's Note:

 Here is a link to the Jayapal press event announcing the introduction of her Medicare-for-All bill.

https://www.facebook.com/doctorsforsinglepayer/videos/1371063689712251/?eType=EmailBlastContent&eId=8b84317a-b0f0-4418-a1ea-c0ef59ecd965 

 -SPC 


Medicare-for-all: Rep. Pramila Jayapal’s new bill, explained

by Sarah Kliff - VOX - September 26, 2019

Rep. Pramila Jayapal (D-WA) is introducing the most ambitious Medicare-for-all plan yet — one that envisions a quick transition to a public health plan with a robust set of benefits.
The co-chair of the Progressive Caucus is releasing a proposal Wednesday to transition the United States to a single-payer health care system, one in which a single, government-run health plan provides insurance coverage to all Americans.
“We mean a complete transformation of our health care system and we mean a system where there are no private insurance companies that provide these core benefits,” Jayapal told reporters Tuesday. “We mean universal care, everybody in, nobody out.”
Jayapal’s bill envisions a future where all Americans have health coverage and pay nothing out of pocket when they visit the doctor or hospital. Her plan, the Medicare for All Act of 2019, describes a benefit package that is more generous than what other single-payer countries, like England or Canada, currently offer. The benefits in Jayapal’s bill are even more generous than those included in Sen. Bernie Sanders (I-VT) Medicare-for-all plan.
But where the Jayapal plan has great detail into what is covered, it does not get into a crucial question: how the government will pay for the new health care program.
The new proposal comes at a moment that Democrats are coalescing around a Medicare-for-all platform. Frontrunner candidates in the Democratic primary like Sens. Kamala Harris (D-CA), Cory Booker (D-NJ), and Elizabeth Warren (D-MA) have all signed on as co-sponsors to Sanders’s single-payer bill in the Senate.
The health care industry has already begun to gird for a major health care fight should a Democrat win in 2020, recently launching a new coalition of hospitals, insurers, and drugmakers to oppose the Medicare-for-all agenda. Jayapal says she’s ready: She’s already secured a promise from House Speaker Nancy Pelosi to hold the first-ever House hearings on Medicare-for-all later this year.
“We will be pushing it as hard as we can and as fast as we can,” Jayapal says. “Enough nibbling around the edges. We really need to transform the system.”

Jayapal’s Medicare-for-all plan has a very generous benefit package — and a quick transition to government-run health care

Jayapal’s single-payer proposal would create a universal Medicare program that covers all American residents in one government-run health plan.
It would bar employers from offering separate plans that compete with this new, government-run option. It would sunset Medicare and Medicaid, transitioning their enrollees into the new universal plan. It would, however, allow two existing health systems to continue to operate as they do now: the Veterans Affairs health system and the Indian Health Services.
Those who do qualify for the new universal Medicare plan would transition into the program over the course of two years. This would start with people under 19 and over 55 moving into the program one year after it became law — and everyone else one year after that.
It’s worth noting that this is actually a faster transition than what Sen. Sanders envisions in his proposal, which would give the United States four years to stand up to a government-run plan.
Eventually, though, everyone would all end up in the same plan, which includes an especially robust set of benefits. It would cover hospital visits, primary care, medical devices, lab services, maternity care, and prescription drugs, as well as vision and dental benefits. Jayapal’s bill would cover abortion services, as does the newest version of Sanders’s plan.
Jayapal’s plan also includes coverage for long-term care services for nursing services. The current Medicare program does not include this benefit, nor does Sanders’s single-payer plan in the Senate. That would make the health care system she envisions more generous than the one Sanders has proposed, but also more expensive.
The plan is also significantly more generous than the single-payer plans run by America’s peer countries. The Canadian health care system, for example, does not cover vision or dental care, prescription drugs, rehabilitative services, or home health services. Instead, two-thirds of Canadians take out private insurance policies to cover these benefits. The Netherlands has a similar set of benefits (it also excludes dental and vision care), as does Australia.

Javier Zarracina/Vox

What’s more, the Jayapal plan does not require consumers pay any out-of-pocket spending on health aside from prescription drugs. This means there would be no charge when you go to the doctor, no copayments when you visit the emergency room. All those services would be covered fully by the universal Medicare plan.
This too is not in line with international single-payer systems, which often require some payment for seeking most services. Taiwan’s single-payer system charges patients when they visit the doctor or the hospital (although it includes an exemption for low-income patients). In Australia, people pay 15 percent of the cost of their visit with any specialty doctor.
The Sanders plan is more generous than the plans Americans currently receive at work too. Most employer-sponsored plans last year had a deductible of more than $1,000. It is more generous than the current Medicare program, which covers Americans over 65 and has seniors pay 20 percent of their doctor visit costs even after they meet their deductibles.
Medicare, employer coverage, and other countries’ plans show that nearly every insurance scheme we’re familiar with covers a smaller set of benefits with more out-of-pocket spending on the part of citizens. Private insurance typically pops up to fill in these gaps — or to allow citizens to buy faster access to services that the government plan does cover (for example, to jump to the front of the line for an elective surgery).
The reason our peer countries went this way is clear: It’s cheaper to run a health plan with fewer benefits. The plans that both Jayapal and Sanders have proposed have no analogue among the single-payer systems that currently exist. By covering a more comprehensive set of benefits and asking no cost sharing of enrollees, it is likely to cost the government significantly more than programs other countries have adopted.

The big question Jayapal doesn’t answer: How do you pay for it?

The Jayapal plan goes into great detail on what kind of coverage a universal plan ought to offer. But it does not do any work explaining how to pay for such a generous benefit package.
Jayapal says that this is an issue that will get dealt with in the future. “Most bills don’t have that when they’re introduced, that comes later in the process,” she said of a financing plan. “I actually think the question is not about how we pay for it, the question is where is the will to make sure every American has the health care they deserve and have a right.”
Jayapal mentioned a wealth tax or repeal of Republican tax cuts as possible options for paying for the system.
Financing the health care system that both Jayapal envisions is an immense challenge. About half of the countries that attempt to build single-payer systems fail. That’s Harvard health economist William Hsiao’s estimate after working with about 10 governments in the past two decades. Whether he is in Taiwan, Cyprus, or Vermont, the process is roughly the same: Meet with legislators, draw up a plan, write legislation. Only half of those bills actually become law. The part where it collapses is, inevitably, when the country has to pay for it.
This is what happened when Sanders’s Vermont attempted to create a single-payer plan in 2014. Much like Jayapal, local legislators outlined a clear vision of the type of health plan they’d want to extend to all Vermonters. Their plan was arguably less ambitious; it did require co-pays when patients went to the doctor.
But Vermont’s single-payer dream fell apart when the state figured out how much it would need to raise taxes to finance its new system. Vermont abandoned the government-run plan after finding it would need to increase payroll taxes by 11.5 percent and income tax by 9 percent.
It’s true — in Vermont and in the United States — that these increased taxes don’t necessarily mean overall health spending is rising. It’s entirely possible that health spending will go down as taxes go up, with Americans no longer spending billions on premiums for employer-sponsored coverage.
Single-payer systems change who pays for health care, often shifting more of the burden onto wealthier individuals to create a more progressive system. The proposed 9 percent income tax in Vermont, for example, would be far more expensive for the $100,000 worker than the $30,000 earner.
But who pays how much more is a key question this Jayapal bill doesn’t answer. Until there is a version that does, we can’t know whether the health system the Vermont senator envisions could actually become reality.

What Would ‘Medicare for All’ Do to Medicare?

by Margot Sanger Katz - NYT - February 27, 2019

The basic idea of “Medicare for all” is that all Americans should get access to the popular, government-run program. But a new bill toward this goal, the first introduced in the current Congress, would also drastically reshape Medicare itself.
The bill, from Representative Pramila Jayapal of Washington and more than 100 Democratic House co-sponsors, would greatly expand Medicare and eliminate the current structure of premiums, co-payments and deductibles.
Americans would be able to see a doctor and take medicines without paying money beyond the taxes that would support the program. (The precise source of that tax revenue is, so far, unspecified.) The new Medicare envisioned by the bill would cover new benefits, including dental, vision and long-term nursing home care.
It would be wrong to think of the Jayapal bill as simply expanding the current Medicare program to cover more people and more benefits. It also would make major changes to the way doctors and hospitals are paid. This would change not just how Americans get their insurance, but it could also reshape the health care system in ways that are difficult to predict.
The Jayapal bill, to be introduced Wednesday morning, has no immediate chance of passing. Even if it should make it through committee and to a floor vote, it would not be welcomed warmly in the majority Republican Senate or by President Trump, who has turned away from his onetime enthusiasm for single-payer health care approaches.
But as interest in approaches to Medicare for all grows among Democratic legislators and presidential candidates, the detailed proposal is likely to help shape the debate about what kind of changes Democrats hope to make if they retake power.
Currently, Medicare (as well as most private insurance) pays most doctors and hospitals for each service performed. There’s one fee for a standard checkup, and another for appendicitis surgery, for example.
Medicare determines prices for those various services, and medical providers are paid for performing them. Then those doctors and hospitals are largely free to allocate the money they make as they see fit. For-profit hospitals may return some of the dollars to their investors. Nonprofit hospitals might use them to buy new gadgets or upgrade to private rooms — or provide charity care for people without insurance.
The Jayapal bill would upend that system. Instead of paying hospitals per treatment, Medicare would try to come up with an appropriate lump sum payment for every hospital and nursing home in the country — what the bill calls a “global budget” payment.
Hospitals would then determine how to offer the care its patients need under that budget. There are some release valves, like an emergency fund in case of an epidemic. The bill would also place restrictions on how hospitals could use the money. They wouldn’t be allowed to spend it on political donations or marketing, for example, or on bonuses to employees who hit productivity targets.
A separate fund, managed by another part of the reimagined Medicare, would provide funding for capital improvements. A hospital would not be allowed to, say, buy an M.R.I. machine with the money from its global budget.
This is similar to how Canadian provinces pay their hospitals. And there is one good model for the system in the United States: In Maryland, hospitals receive this type of budget for most of the care they provide.
But it would be a big change from the way Medicare works now. Hospital budgets would require a kind of government process that doesn’t exist now: a Medicare board that would decide the appropriate payment to every hospital and the set of priorities for hospital and nursing home capital improvements. The government would no longer set payment for each emergency room visit or knee replacement, but it would have to decide how much to pay one hospital versus another.
“This is really an important budgetary tool for cost containment,” Ms. Jayapal said in a conference call with reporters Tuesday. She described the change as simplifying Medicare’s payment system.
The bill imagines all this change happening very quickly. Within a year, the first budgets would be set for every health care institution in the country. By the end of two years, the system would be ready to cover the care of nearly every American. (A different proposal, introduced by Senator Bernie Sanders in 2017, would take four years to switch all Americans from the current system to single-payer.)
This change in budgeting is not intrinsic to a single-payer system. It is possible to imagine a Medicare for all system that instead sets prices for individual medical services, the way Medicare does now. But the Jayapal approach also wants to make changes under the hood of Medicare to contain costs and change some of the incentives around what patients receive.
Different bills will most likely propose different changes. Nearly every single-payer advocate wants to use the system to reduce the cost of health care in the United States — and saving money will almost certainly mean changes to the status quo.
The proposed Medicare changes are a good reminder that, while many politicians use the phrase Medicare for all, the title remains more of a buzzword than a precise description. The Jayapal bill clearly embraces the “for all” part of the message. But its “Medicare” would be a very different system, and its differences could ripple beyond insurance to reshape the kind of health care Americans receive.
https://www.nytimes.com/2019/02/26/upshot/what-would-medicare-for-all-do-to-medicare.html

 



Our View: Disparities in health care pricing show our system’s fundamental flaws

by The Editorial Board - Portland Press Herald - February 25, 2019

How much will you have to pay for a hip replacement? Depends on where you live.
If it’s the Bangor area, where the median family income is $50,853, your operation would cost $44,853. But if you lived in the Portland area, where the median income is $63,422, the same operation would cost as little as $26,824.
And if you live in the Boston area, where the median family income is $85,691, that new hip might cost as little as $16,150.
Americans spent $3.6 trillion on health care last year, which is far more than was spent in any other country – whether it’s calculated on a per capita basis, as a percentage of gross national product or just a lump sum.
You can’t fully appreciate how inefficient our system is until you take into account the perverse way those costs are allocated. In America, the poorer you are, the more you may have to pay.
These numbers were put together by Maine Sunday Telegram Staff Writer J. Craig Anderson, using data that providers are required to release in an effort to bring price transparency to consumers looking for the best value.
But what these data really expose is the way that our system, with multiple entities public and private, each looking out for its own interests, is driving up costs without providing any better outcomes.
The fact that a hip replacement costs nearly three times as much in Bangor as it does in Boston is a pretty good window into what is going wrong nationwide.
The price consumers pay is almost always out of their control.
Medicare, which covers everyone age 65 and older, and Medicaid, which provides coverage for people with low incomes, set the price they are willing to pay for a test or procedure, even if that’s less than what the provider needs to break even.
Providers also have to cover the cost of charity care and bad debt from uninsured patients. They do this by making their patients with private insurance pay more.
The mix of patients a provider has is a big driver in the kind of cost discrepancies we are seeing in Maine. Where the patients are elderly or poor, you have more unmet costs to make up. When you have fewer patients covered by private insurance, each individual’s part of the shifted cost is greater.
NARROW INTERESTS
This makes hospitals and other providers compete against each other for the pool of patients with private insurance. That can result in spending on equipment that may attract the desired patients while raising the overall cost of health care. Private health insurance premiums will rise to keep pace with the costs. And since employer plans are tax deductible, every time health care costs go up, less goes into the national treasury.
Health care costs that increase faster than inflation are unsustainable.
Single-payer coverage, or “Medicare for All,” is one solution that has been proposed, but it’s not the only one.
The state of Maryland is experimenting with an approach called “All-Payer.” It maintains the mix of public and private insurance coverage, but the state establishes prices, creating an incentive for providers to be more efficient. Germany has a system of regulated private health insurance that costs less than ours and produces better health outcomes.
We can do better than continuing to throw money into this inefficient system.
https://www.pressherald.com/2019/02/26/our-view-health-care-cost-shifts-show-our-systems-flaws/


It’s Time for Pharmaceutical Companies to Have Their Tobacco Moment

Elected officials have made a lot of noise about the cost of prescription drugs. Now they must demand answers from pharmaceutical companies.
by The Editorial Board - NYT - February 25, 2019

Twenty-five years ago, Congress hauled before it the top executives of the nation’s seven largest tobacco companies and forced them to make a number of long-overdue admissions about cigarettes — including that they might cause cancer and heart disease and that the executives had suppressed evidence of their addictive potential. In one dramatic exchange, when pressed by Representatives Henry Waxman and Ron Wyden, the executives denied that their products were addictive but admitted that they would not want their own children to use them.
The hearing ushered in a public health victory for the ages. In its wake, lawmakers and health officials enacted measures that would ultimately bring smoking rates in the United States to an all-time low.
With seven pharmaceutical executives set to testify before the Senate Finance Committee on Tuesday, one can only hope for a similarly pivotal moment for prescription drug prices. Like their predecessors in the tobacco industry, the drug makers will testify at a time of near-universal anger over industry antics.
Drug prices are soaring in a way that defies reason. A vial of insulin that cost less than $200 a decade ago now sells for closer to $1,500. Actimmune, a drug that treats malignant osteoporosis and sells for less than $350 for a one-month supply in Britain, costs $26,000 for a one-month supply in the United States. And the prices of many drugs — that treat cancers, high blood pressure, allergies and more — have risen so much that average consumers are rationing them, at grave peril. Not even experts seem to know how those prices are set or why they keep rising.
The industry’s own explanations — that other entities in America’s byzantine health care system are to blame for most price increases, and that its products are expensive and risky to make — are tough to swallow, given drug companies’ conspicuous profit margins. Its response to the crisis of soaring drug prices has been meager at best — and duplicitous at worst. Last year, several companies agreed to hold off on planned price increases, but only for six months, and only after President Trump chastised them on Twitter. Those same companies have aggressively resisted both state and federal efforts to enact formal changes to drug pricing rules.
Mr. Trump has not kept his campaign promise to “negotiate like crazy” with drug makers to lower the cost of their products, and his statement last May that the industry would soon announce “voluntary, massive” price cuts came to naught. But his bluster on the issue, along with his blueprint for resolving it, have at least helped to keep a spotlight on the pharmaceutical industry and its questionable practices.
If the members of the Senate Finance Committee want to make use of that spotlight, here’s what to ask executives on Tuesday:
How do you determine list prices for drugs? Who decides the factors that go into the companies’ drug-pricing formulas, and why can’t those formulas be made public? Senators should also ask Olivier Brandicourt, the chief executive of Sanofi — the only major insulin maker scheduled to participate in the hearing — why the cost of insulin continues to rise year after year, given that the drug has been available for roughly a century, and in many cases still enjoys patent protection. On Friday, Senator Chuck Grassley and now-Senator Wyden, the ranking members on the Finance Committee, opened an investigation into insulin prices.
What’s a fair profit margin for lifesaving products? A common lament among pharmaceutical executives has been that without enough profit from one drug, companies can’t afford to make the next one. That’s a fair point. Still, many leading companies enjoy billions of dollars a year in pure profit, even as lives are put at risk for want of basic medications. Insurers are subject to a 15 to 20 percent cap on profits and administrative expenses. Congress should consider a similar requirement for certain prescription drugs.
How much do you spend on research and development, and where do those dollars go? Pharmaceutical companies routinely argue that drug prices are high because research and development is expensive and because any successful drug is preceded by many failures. Industry critics, however, note that a good deal of basic research is funded by the federal government, through the National Institutes of Health, and not by the drug makers. Many leading drug makers spend most of their research dollars looking for new uses of existing drugs, not on risky innovations. And independent studies show that research and development costs for drug companies are not large enough to explain high drug prices.
Why would any drug need more than 100 patents? Patent protection enables drug makers to recoup the money they spend developing and marketing a new product. But most experts agree that leading drug makers have gamed this system: By applying for dozens of patents for minor technical tweaks that provide little clinical benefit, they stave off competition for decades.
Take Humira, which treats inflammatory disorders like arthritis and Crohn’s disease, and is the best-selling prescription drug in the world. In the two decades since the drug came on the market, its maker has applied for 247 patents, according the Initiative for Medicines, Access and Knowledge; it is currently protected from competition by more than 100 such patents. Richard Gonzalez, the C.E.O. of AbbVie, the company that makes Humira, will appear at Tuesday’s hearing. Can he justify that practice?
What will you change? The senators must not allow drug makers to point the finger elsewhere on Tuesday. Yes, insurance companies and other entities play a role in the drug cost crisis. But this hearing is not about them. It’s about the pharmaceutical companies. And those companies need to take meaningful steps toward lowering drug prices. If the Finance Committee members come prepared on Tuesday, they could finally force the industry to help relieve the strain.
https://www.nytimes.com/2019/02/24/opinion/drug-prices-congress.html?action=click&module=Well&pgtype=Homepage&section=Editorials


How C.E.O.s Are Using Your High Drug Prices to Fill Their Pockets

By William Lazonick and Öner Tulum - NYT - February 27, 2019

Drug company executives faced tough questions from Congress on Tuesday as they attempted to explain why, thanks to high drug prices, per capita spending on pharmaceuticals in the United States is double the average of other advanced countries. For decades, American drug makers have justified these high prices by asserting that the higher profits they generate fund research that accelerates the development of new medicines. Our data shows, however, that these companies spend every penny of their profits on distributions to shareholders in the forms of cash dividends and stock buybacks.
Because the greater part of management compensation is linked to stock price, the prime beneficiaries of this abuse of corporate profits are the executives who claim that high drug prices redound to the common good. At the same time, drug giants such as Merck and Pfizer seem to have become focused more on buying companies with successful new drugs rather than developing their own.
Congress has been raising alarms over drug prices for years. In 1985, Representative Henry Waxman, a California Democrat who was chairman of the House health subcommittee, accused the pharmaceutical industry of “gouging the American public,” driven by “greed on a massive scale.” But the escalation of drug prices has only gotten worse, as documented in various Senate investigations.
Despite their claims, the big American drug companies have not been using profits from high prices to ramp up investment in drug development. Our research shows that for 2008 through 2017, 17 pharmaceutical companies in the S. & P. 500 distributed just over 100 percent of their combined profits to shareholders, $300 billion as buybacks and $290 billion as dividends. These distributions were 12 percent greater than what these companies spent on research and development.
With most of their compensation coming from exercising stock options and stock awards, senior executives benefit immensely. We gathered data on the 500 highest-paid executives in the United States from 2008 through 2017. The number who came from the drug industry ranged from 21 (in 2008 and 2011) to 42 (in 2014). The total compensation of those 42 executives averaged about $73 million, compared with an average of an already over-the-top $32 million for all 500 in 2014.
A total of 88 percent of the 2014 compensation was based on stock. In 2017, 28 drug executives in the top 500 averaged more than $41 million in total compensation, with 83 percent stock-based. By jacking up product prices and distributing the increased profits to shareholders, executives lift stock prices and their take-home pay.
Our research for the Institute for New Economic Thinking demonstrates that these companies, even when they show substantial R. & D. spending on their books, do not have much to show for it.
For example, Merck distributed 133 percent of its profits to shareholders from 2008 to 2017, and Pfizer 107 percent. Although both companies recorded large sums spent on R. & D. — Merck $80 billion and Pfizer $81 billion over the decade — these companies generated most of their revenues by acquiring companies with patented drugs on the market, rather than by developing their own new drugs. Since 2001, by our analysis, Pfizer has had significant revenues from only four internally originated and developed products. Since Merck’s merger with Schering-Plough in 2009, it has had only two blockbuster drugs, of which only one was the result of its own research.
The public foots the bill for this behavior. Not only do we pay high drug prices, our tax dollars supply more than $30 billion per year for life-sciences research through the National Institutes of Health. Yet, like most American companies, the drug industry claims that its corporations need to pay lower corporate taxes to remain competitive globally.
European pharmaceutical companies such as Roche and AstraZeneca, on the other hand, have used the same American drug ecosystem — profits from high drug prices and scientific advances resulting from government research funding — to become leaders in medical innovation. Roche dominates the market for specialty drugs in oncology and immunotherapy, while AstraZeneca has a strong pipeline in the latest phases of development. Merck and Pfizer, in comparison, have fallen seriously behind.
Congress should put an end to this madness. The government funds medical research and grants the patents and other intellectual property protections that make the pharmaceutical industry’s products financially viable. It should therefore regulate drug prices.
The United States should also redesign executive pay to reward drug company leaders who actually bring new innovations to market, and ban most forms of stock buybacks, which are nothing but a manipulation of the stock market that makes the rich even richer. Reinvesting the hundreds of billions of dollars that American drug companies are squandering on buybacks would be a big step on the path to affordable health care for all.
https://www.nytimes.com/2019/02/26/opinion/drug-pricing-senate-hearing.html

The insulin story, a perfect example of corporations stealing the wealth of most of us
Egberto Willies - The Daily Kos -  February 27, 2019

I used the example of Pharmaceutical companies inflating the price of insulin to show how our economic system by design steals so much from everyday Americans that it stops the ability of most to build wealth. Instead, it systematically ensures it leaves most without wealth.
PLEASE Listen to the entire video. We must get more in-depth analysis, my friends.

The sad story about insulin pricing abuse.

While the insulin rip off is one example, it occurs in every segment of our economy. Indentured servitude by the masses is the outcome if we continue on the current path.
Recently I blogged about the advent of the standalone emergency rooms using their pricing power and dubious practices to rip off Americans in an article titled "These stories show legalized theft, the reason we need Medicare for All" that everyone should read.
There is a basic tenet we must recognize in our economic system that the article "Why our economic system is designed to keep most people broke by robbing us legally" explains.
Ultimately, those with unregulated and unlimited pricing power on products and services you must have, can ensure one can never accumulate wealth. They own you. They can extort from you.
The above reality defines our economy. And the proof is a continual decline in the wealth of the masses as the few gets a more significant percentage. Unchanged, math prevails. Welcome to indentured servitude.
Watch the entire Politics Done Right episode here.
https://www.dailykos.com/stories/2019/2/27/1838047/-The-insulin-story-a-perfect-example-of-corporations-stealing-the-wealth-of-most-of-us

Cat Bites The Hand That Feeds; Hospital Bills $48,512

by Elizabeth Rosenthal - NPR - February 26, 2019

Compassion for a hungry stray kitten led to a nip on the finger — and also took a bite out of Jeannette Parker's wallet.
In a rural area just outside Florida's Everglades National Park, Parker spotted the cat wandering along the road. It looked skinny and sick, and when Parker, a wildlife biologist, offered up some tuna she had in her car, the cat bit her finger.
"It broke my skin with his teeth," she recalls.
After cleaning off the wound, she did some research and began worrying about rabies since Miami-Dade County had warnings about that potentially fatal disease in effect at the time.
She then drove back to her home in the Florida Keys and called the health department, but it was closed.
So she headed to the emergency room at Mariners Hospital, not far from her house. She spent about two hours in the emergency room, got two types of injections and an antibiotic and says she never talked with a doctor.
"I went home happy as a clam," she said.
Then the bills came.
Patient: Jeannette Parker, a 44-year-old state fish-and-wildlife biologist. Insured through the American Postal Workers Union because her husband works for the federal government at Everglades National Park.
Total bill: $48,512, with $46,422 of that total for one preventive medication
Service provider: Mariners Hospital, part of Baptist Health South Florida, a faith-based nonprofit chain with eight hospitals and a variety of other facilities
Medical service: Parker's wound was examined, and she received the first in a series of rabies shots, as well as an injection of 12 milliliters of rabies immune globulin, an antibody that kick-starts the immune system to provide protection from the virus until the vaccine kicks in.
What gives: When you are potentially exposed to a fatal disease, you need treatment. In the moment, it's hard to shop around or say no to high prices.
The Centers for Disease Control and Prevention estimates that post-exposure preventive treatment for rabies, which includes the immune globulin and four doses of vaccine given over a two-week period, usually costs more than $3,000 on average. An estimated 40,000 to 50,000 people annually get such treatments following exposure to potentially rabid animals, the CDC says. Each hospital can set its own prices for treatment.
In Parker's case, the majority of the cost was for the rabies immune globulin. For that injection alone, the hospital billed her and her insurer $46,422. That's well above what's considered typical.
"I have never heard anything that high for immune globulin," said independent biomedical consultant Charles Rupprecht, a World Health Organization technical adviser on rabies who ran the rabies program at the CDC for 20 years. "How is that possible?"
Parker thought that seemed high after she requested and received an itemized bill from her insurer, so she Googled it.
"I saw that immune globulin was expensive, but it wasn't that expensive," she said. "I sat on it for a while because I was upset. Finally, I went by the hospital to confirm, and they said, 'Yes, that is right.' "
The rabies immune globulin is a complex product, made from blood plasma donated by volunteers who have been immunized against rabies. Three manufacturers make the product, and there are no shortages right now, the Food and Drug Administration says. Currently, the average wholesale acquisition price — the amount paid by wholesalers that then mark it up when they sell it to distributors or hospitals — is $361.26 per milliliter, according to Richard Evans, a drug industry analyst at SSR Health, part of the boutique investment firm SSR LLC.
Using that average, the cost for the 12-milliliter dose Parker received would have been $4,335.
Perhaps the hospital erred when billing, adding an extra zero?
No, said Baptist Health spokeswoman Dori Robau Alvarez in an emailed statement.
The $46,422 charge reflected list prices the hospital had in place on Sept. 22, 2018, when Parker was treated. Alvarez wouldn't disclose that rate, but simple math shows the hospital was billing $7,737 per 2-milliliter dose, which is how the immune globulin is often packaged.
Alvarez also noted that the month after Parker was treated, Mariners revamped its full price list, known as a "chargemaster." The hospital lowered its charge for rabies immune globulin to $1,650 per 2 milliliters, which would have made Parker's bill about $9,900 — still high, but not sky-high.
Hospitals revisit their chargemasters periodically. But it should be noted that this particular 79 percent cut came shortly before January, when new rules required all hospitals for the first time to post those previously hidden charge lists publicly on websites, part of the Trump administration's interpretation of the Affordable Care Act.
"Statements for patients who received treatment prior to the change would reflect the previous charge," Alvarez said.
She didn't respond to follow-up questions about the reasons for the price drop or the above-average price before the change.
Chargemaster prices are generally not what people with insurance pay. One benefit of having health coverage is that insurers negotiate discounts for in-network care. Parker went to an in-network hospital.
But not every service has a negotiated discount, said two experts on billing at America's Health Insurance Plans, the industry's trade lobby. And a discount from a very high charge remains a very large amount of money.
In Parker's case, her husband's union health plan paid $34,618 toward her total ER bill, including $33,423 for the immune globulin alone.
The health plan said it had requested an audit of the bill to check it for accuracy. In an emailed statement, the plan said not much else can be done. "Other than negotiated discounts, there is little the plan can do to challenge the hospital's charges. The charges do not rise to the level of being fraudulent," the statement concluded.
Resolution: After accounting for the insurer's payments, Parker had to pay $4,191 for the final $344 of her deductible for the year plus her 10 percent share of the charges accepted by her insurer.
"My funeral would have been cheaper," she said.
Parker learned after calling her insurer that the cat bite should have been considered an accidental injury and thus eligible for 100 percent coverage under her insurance plan, minus her remaining deductible. She is seeking to have the hospital resubmit the bill to the health plan to see if it will pick up the rest of her 10 percent share of the cost. The hospital hasn't offered to lower the price of the immune globulin to its current charge.
The takeaway: If you suspect you may have been exposed to rabies, get treated. "It's prudent that she sought immediate and appropriate medical care," said Rupprecht.
Many services that fall under the umbrella of public health can be obtained at no or low cost from local health departments. These range from vaccinations to post-exposure treatments for diseases like rabies. If possible, check with your health department to see if it offers treatment.
But with a serious disease like rabies, if those services aren't immediately available, don't wait. Head to a hospital, and make sure it's in your insurer's network, if you have a choice.
If you get a bill for what seems like an astounding amount, get the itemized bill from the hospital rather than just the summary. Moreover, now that hospital chargemasters are publicly available on hospital websites, use them.
They are long and complicated. For the moment at least, they are not written in plain English. But many are alphabetical, and it's not hard, for example, to find an entry for "Rabies IG" (rabies immune globulin).
Check how the price you've been billed compares with others in your area. (You may also be able to check for average prices on sites like HealthcareBluebook.com.) Share that information with your employer's human resources department, or use it to negotiate with your hospital and insurer.
  http://www.mainepublic.org/post/cat-bites-hand-feeds-hospital-bills-48512 

Small businesses are taking the rap on health care costs - The Boston Globe

by John B. Hurst - February 27, 2019

When it comes to health care in Massachusetts, there’s good news and bad news. The good news? The state recently announced that individuals who buy health care through the Health Connector, our health care exchange, pay the second lowest premiums in the country. The bad news? According to the Massachusetts Health Policy Commission, small businesses and their employees in the state have the second highest premiums in the country.
At first blush, the disparity doesn’t make a lot of sense. After all, Massachusetts has some of the highest health care costs in the nation. But the reason for the discrepancy is straightforward enough: Small businesses are effectively subsidizing individual health care premiums in Massachusetts. Employees of small businesses are required to pay more than their fair share so individuals can pay far less.
And it’s about to get worse. Next year, small businesses in Massachusetts with 50 or fewer employees will receive no pricing adjustment for purchasing health care in bulk for their employees, their lower administrative costs, or the fact that their employees are actuarially a better risk compared to individuals. And to go along with those unaffordable premiums, most of these employees will be forced into high deductible plans, joining the nearly 60 percent small-business level already seen, which requires sharing more of the cost with their employer compared with government and big-business work settings.
How did we get here? As with all things health care related, the story is complicated. But it began with a process a dozen years ago under RomneyCare. In 2006, Massachusetts combined individuals and small-business risk pools into one merged marketplace. The only state in the country — then and now — to do so, the goal was to help mitigate premium increases of individuals. And indeed, the law delivered large, double-digit premium reductions for individuals, subsidized by painful and damaging double-digit increases for those working for small firms.
Part of the political deal for the risk pool merger at the time was that state rating factors would be in place to protect small businesses and their employees, and to help ensure relatively fair premiums for all of those in the merged risk pool. Factors such as size, cooperative purchasing groups, industry sector, and participation rates did help make the premium increases a bit more affordable, and those factors also helped to more fairly distribute the costs.
Unfortunately, that deal was broken with the passage of the Affordable Care Act, which preempted these Massachusetts state rating factors intended to make premiums somewhat fairer for the employees of small businesses. To mitigate this pain, the federal government, in eliminating the state rating factors, granted Massachusetts a small group “premium glide path” through the end of 2019 in order to phase in premium increases for local small businesses and their employees. That afforded state officials the time to go back to separate nongroup and small-group risk pools like the rest of the country.
That hasn’t happened — and as a result, small businesses in the state find themselves staring down the barrel of no favorable premium pricing opportunities 10 months from now.
Notwithstanding the myriad twists and turns the story has taken, asking small businesses to pay more so individuals can pay less is unfair — and the wrong way to go about lowering health care costs. This is particularly true as individuals have migrated from MassHealth (the state’s Medicaid program) to taxpayer-subsidized coverage at the Connector, which is in the same risk pool as small employers, further increasing small-business premiums.
Making matters worse, this costly mandate falls only to those working for small businesses in Massachusetts. No employer with more than 50 employees is required to subsidize individuals through their premiums. Why should those who work for small businesses — who are just as healthy as those who work for government or big business — alone be required to pay more?
Already, small businesses compete every day with big businesses for customers and for employees. Forcing those who work for smaller firms to pay higher premiums for inferior coverage penalizes both them and the small companies they work for.
Small businesses need Governor Baker and the Legislature to fix this problem this year in order to avert the full-scale disaster facing us. Assisting Main Street Massachusetts must be Beacon Hill’s primary health care priority for 2019.
Jon B. Hurst is president of the Retailers Association of Massachusetts
https://www.bostonglobe.com/opinion/2019/02/26/small-businesses-are-taking-rap-health-care-costs/97WzWIHEKe1BdPaKIrIAnN/story.html?

We Don’t Need Private Health Insurance

by Adam Gaffney - The Nation - February 18, 2019 



Does achieving “Medicare for All” mean mostly eliminating private health insurance? Single-payer proponents say yes: After all, if a public plan provides comprehensive, no-deductible coverage for everyone, nobody would want—much less be willing pay for—duplicative private coverage.
Yet candidates who previously embraced single-payer sometimes seem a bit unsure. For instance, Senator Cory Booker, who co-sponsored Senator Bernie Sanders’s single-payer plan back in 2017, was asked whether he would “do away with private health care” recently, and he responded, “Even countries that have vast access to publicly offered health care still have private health care, so no.”
There are actually two distinct questions wrapped into one here. First is whether we want a universal public plan for everyone, or a hodgepodge of public and private plans that cover different parts of the population according to age, income, workplace, disability, and so forth, but that together cover everyone. Last year in Dissent, I made the case that a nation like ours—with enormous unmet medical needs, an inadequate safety net, and galling inequality—is a poor fit with a multi-payer system that divides the population into a hierarchy of public and private plans with inequitable levels of access, varied copays and deductibles, and unequal benefits and provider networks. This would never achieve the equity, universality, or efficiency of a public plan that provides complete coverage to everyone.
But there’s another question. Let’s assume we agree on the need for a universal public-insurance plan that covers everyone, as in Canada, Great Britain, or France. Would there still be a role for private insurance? If so, what would it be?
In nations that have universal public-insurance programs, private health plans fall into three categories: “duplicative” plans, “supplementary” plans, and “complementary” plans. “The debate over eliminating [private] health insurance is actually offering a false choice,” says Sarah Kliff of Vox.
Let’s start with “duplicative” coverage, which refers to private plans that “duplicate” benefits of the public plan, like covering doctor visits or procedures that are also covered by the single-payer plan.
At first glance, it might seem odd that insurers would offer such plans, much less that anyone would pay for them. You wouldn’t, for instance, buy a private plan hawked by a company that promises you “access” to Central Park. You already have that. Obviously, such plans must offer some advantage to be viable.
And they do: In the single-payer context, they let individuals jump to the front of the line, gaining wider or quicker access to physicians’ services or other care covered by the public plan. Consider a case from the intensive-care unit where I work. Assume it’s a busy day, and the ICU is crowded. Should a scarce bed go to a less sick person over a sicker one who needs it more, just because the former has better-paying insurance? Most, I believe, would find that appalling.
But essentially, that’s what duplicative plans promise, albeit usually for non-emergency care. Now, some might argue that allowing people to have preferential access to office appointments or elective surgery is less problematic than when it involves an ICU bed. But such distinctions are arbitrary. Various types of care can be lifesaving, or limb-saving. Whether you’re talking about access to a primary-care doctor or a specialist, a psychiatrist or a hospital bed, health—not wealth—should be the factor determining access.
It is true, as Kliff describes, that countries with universal coverage handle this differently. Great Britain has retained a small private-insurance market that gives some people a leg up in seeing the doctor. But Canada prohibits duplicative coverage, and, in fact, so does the United States. It has long been illegal to sell duplicative individual coverage to Medicare beneficiaries. I’ve never heard any older adults complain about this fact and pine for a private, marketplace plan; in fact, I’m guessing few are even aware of the exclusion.
Duplicative plans, in other words, are not desirable, but they are also unnecessary. We should not embrace them.
But how about “supplementary” coverage, the private plans that provide benefits for services not covered by the public system? As Kliff notes, in Canada, the public system doesn’t offer universal drug benefits or dental care, so people need supplementary private plans to cover their medicines and their teeth. Similarly, in the United States, Medicare doesn’t cover dental-care benefits, and until 2003 didn’t cover prescription drugs.
The single-payer bills in Congress do not ban supplementary private coverage. However, because both the forthcoming bill in the House and (with the exception of long-term care) the bill in the Senate have comprehensive benefits—including dental care, prescription drugs, and vision care—there is not much left for supplementary plans to cover. Perhaps cosmetic surgery, or trips to Swiss medicinal spas?
The only way these bills could make way for supplemental insurance would be to strip coverage benefits for the sole purpose of creating business opportunities for the private insurance industry. Surely, we could do that: We could remove coverage for dental benefits or kidney care, for colonoscopies or elbow surgeries, and perhaps a private insurance market would emerge to cover such services. But why would we possibly want to?
Consider that Canada’s exclusion of drug coverage from its public system is a major problem—it’s the reason why Canada has higher rates of people not taking their medication because of cost relative to other high-income nations, apart from the United States.
When fashioning any new health program, we should pick and choose the best policies. For instance, the United Kingdom does have universal drug coverage (mostly without co-pays) and, consequently, basically everyone gets the medicine they need. That should be our model. The underlying question is simple: Do we offer comprehensive benefits in the universal public system, or do we drop benefits at random so as to give Aetna and Cigna something to do? The answer, to my mind, seems clear.
Finally, many nations have “complementary” private plans, which cover the co-pays and deductibles imposed by some (but not all) public systems.
For instance, many Medicare beneficiaries take out so-called “Medigap” plans today, which cover that program’s often substantial out-of-pocket expenses. In France, almost everyone has a complementary plan that covers the cost-sharing (e.g., co-pays) imposed by the single-payer program. The United Kingdom and Canada, in contrast, have no co-pays for physician care, diagnostic testing, emergency-room care, surgical procedures, or hospital care.
In order to preserve a role for private insurers under any new single-payer scheme, legislators would have to add co-pays for the purpose of accommodating a publicly subsidized private insurance bureaucracy. And even if the single-payer bills were rewritten along those lines, insurers would still fight them tooth-and-nail, and the program would still be branded as a Soviet death-panel scheme by the right.
But far more importantly, let’s not forget how bad co-pays and deductibles are. It’s not just that they are unnecessary for cost control: Canada and the United Kingdom provide no-deductible universal coverage and have lower overall health-care costs. And it’s not just that they squeeze family budgets, effectively worsening inequality: By deterring the use of needed care, they are also harmful to health itself, including for those with heart disease, lung disease, diabetes, and multiple sclerosis.
The presence of complementary private plans requires the erection of unnecessary financial barriers to care. Without the latter, we won’t need the former.
In other words, the only way to make room for a significant role for private insurance in the American context is to make the public system paltrier or skimpier, to impose onerous co-pays and deductibles, or to let the rich preferentially displace working-class people from hospital beds and doctors’ offices. But it doesn’t seem to make sense to punch holes in your own floor just to create work for a carpenter. That is particularly true if your floor is your health care—and your carpenter is an extractive insurance giant.
https://www.thenation.com/article/we-dont-need-private-health-insurance/

  
Letters

Fixing Our Health Care System

Going forward, which changes make sense?
To the Editor:
Re “What’s Good Health Care Worth?” (editorial, Feb. 17):
Thirty-six thousand Americans die prematurely each year because they are uninsured. And more than half a million households declare bankruptcy each year because of illness or medical bills. Who could possibly benefit from such an inhumane system?
Private insurers.
High deductibles and co-pays, narrow networks of doctors, and prior authorization paperwork keep patients from getting the care they need, while funneling more money into the pockets of insurance companies. Private insurers add nothing of value to our health care system and drain billions of dollars that should be spent on patient care.
A single-payer “Medicare for all” system would end this needless loss of life and life savings.
Claudia Fegan
Chicago
The writer is the chief medical officer of Cook County Health and the national coordinator of Physicians for a National Health Program.
To the Editor:
As a member of a team of economists that conducted a comprehensive study of the costs of Medicare for all, I want to clarify several issues raised in your editorial.


First, both opponents and advocates of Medicare for all agree it would bring down national health care spending. The only area of disagreement is by how much. Ten-year savings estimates range from $2 trillion (Koch-funded Mercatus Center) to $5 trillion (our estimate). With no premiums, co-pays or deductibles, 80 percent of Americans will pay less for health care and be able to choose their providers as Medicare beneficiaries do today.
Second, our analysis invests $65 billion in job retraining, wage replacement and preserving pensions for those losing their insurance-related jobs — and we still find overall savings.
Third, Medicare buy-in proposals keep cost-sharing (coinsurance and deductibles) high, do little to rein in overall spending, and force people to make costly choices between needed care and significant medical debt.
Finally, who actually loves their private insurance? Not those who need medical care and discover they must confront insurers regarding restrictive provider networks, pre-approvals, denials in coverage and high out-of-pocket costs.
Peter S. Arno
Hastings-on-Hudson, N.Y.
The writer is a senior fellow and the director of health policy research for the Political Economy Research Institute, University of Massachusetts-Amherst.
To the Editor:
Medicare for all will be at center stage in the 2020 elections. But other approaches for universal coverage need not wait.
In California, we recently released a public/private plan to achieve universal coverage by expanding access to Medi-Cal and key features of the Affordable Care Act. It builds on California’s integrated care delivery models and is financed by a provider tax, a mandated employer tax on those who do not offer coverage to their workers, and a small share of state funds. This public/private approach can help frame the 2020 debate on universal coverage.
Richard M. Scheffler
Stephen M. Shortell
Berkeley, Calif.
The writers are professors at the School of Public Health, University of California, Berkeley.
To the Editor:
Your thoughtful editorial on health care insurance leaves out one crucial barrier to universal coverage: Wall Street. Not all health insurance companies are publicly traded, of course. But those that are — UnitedHealthcare, Anthem, Aetna, Cigna and Humana among them — deliver enormous dividends to investors. The dismantling of the health insurance industry is likely to have widespread and lingering repercussions for the overall national economy.
Although I am among those eager for universal coverage, patience and an incremental approach seem prudent.
Erika Rosenfeld
New York
To the Editor:
It’s telling that in the long editorial on options for health care policy, there is no mention of the needs of physicians or patients. The focus is on health “coverage” not actual health “care,” the assumption being that the latter depends entirely on the former.
Employers, the government and insurers have become the only stakeholders that matter, yet medical care takes place on an entirely personal level. And thinking about solutions that benefit the system first will always fail.
It’s not complicated. Guarantee access to health “care,” require price transparency and stop perverse incentives that add unnecessary costs.
Paula Muto
Lawrence, Mass.
The writer is a vascular surgeon
 

Boyd: The economic case for universal healthcare

by Ryan Boyd - The Daily Northwestern - February 10, 2019

As the 2020 campaign gets underway, it’s increasingly clear that almost all serious Democratic candidates are going to support universal healthcare coverage in one form or another.
There are many ways to achieve universal coverage — from single-payer proposals like Medicare for All to multi-payer models like those found in Germany and Switzerland. Once all candidates jump into the race and release their specific proposals, it will be important to analyze their plans. But for now, it is important to first examine the economic logic behind universal coverage as a policy goal and to understand why the Democratic Party’s long-overdue embrace of socialized medicine is such a promising development.
Beyond the compelling moral reasons for implementing a universal coverage scheme, the economic rationale is more than convincing. Comparing the current American system — which is really a bunch of different systems for different groups of people (people over 65, veterans, children, low-income, etc.) — to a single-payer system highlights how universal coverage is cheaper and more efficient than the status quo.
There are three questions to ask when evaluating each system: How much will the U.S. spend on healthcare, how many people will be covered and what will the quality of care be? A single-payer system achieves better results in every respect.
Proponents of single-payer systems typically tout two primary cost efficiencies that single-payer has over private insurance. First, administrative costs are lower — as highlighted in the New York Times, the New England Journal of Medicine estimated in 1999 that administrative costs make up 30 percent of healthcare expenditures in the U.S., but only 16.7 percent in Canada.
A more recent study from Health Affairs notes that administrative costs make up 25 percent of U.S. hospital spending; in Canada, that number is just 12 percent. These studies highlight a central advantage of single-payer — there is only one health insurance provider, which is the government. As the Times further notes, this means hospitals don’t need to employ massive billing departments that try to sort claims with many different health insurers, each of which has its own procedures, requirements and paperwork. Moreover, in a single-payer system, insurer marketing costs are almost completely eliminated from healthcare expenditures. In the current system, health insurers compete for customers, which requires significant advertising spending — but if the government is the only insurer, that expenditure is unnecessary.
The second main cost efficiency from single-payer systems comes from reduced prices for healthcare services through increased insurer bargaining power. The American health insurance industry is fragmented with many different players competing for market share. The result of this fragmentation is reduced bargaining power for each insurer. Because there is only one insurer in a single-payer system, there is massively increased bargaining power and, consequently, drastically reduced prices for healthcare services.
In testimony to the Ohio legislature, economics professor Gerald Friedman notes that “hospital prices paid by private health insurance are now nearly double what hospitals get from Medicare.” The reason is simple: The U.S. government can negotiate down Medicare reimbursement rates to a much greater degree than private insurers, resulting in significant cost savings for consumers of healthcare.
Even a study from the Koch-funded Mercatus Center recognizes these efficiencies. The Mercatus Center estimates that Bernie Sanders’ Medicare for All bill would cost $32.6 trillion over ten years, which The New Republic notes is a saving of $2.054 trillion compared to the current system.
Under the current, more expensive system, 12.2 percent of Americans are uninsured — more than 30 million people. A single-payer universal coverage scheme would bring that number to zero. That means nobody would have to put off visits to the doctor’s office, letting treatable illnesses fester into severe (and expensive) health episodes. It means no one would have to worry about a layoff costing them their health insurance. And it means that no one would have to rely on their GoFundMe going viral to pay for cancer treatment.
Amazingly, a single-payer system can achieve this universality while improving quality of care. Indeed, people who like their current doctors could keep their current doctors. And people who don’t have doctors would be free to choose whoever they feel is best for their healthcare needs, not whoever is cheapest. Because everyone is always insured — without interruption from job losses or financial issues — there is continuity of care, allowing doctors to develop trusting and informed relationships with their patients. With the government picking up the tab, people can get this better coverage without ever having to look at a bill or spend hours on the phone arguing with their insurance company.
As the healthcare debate heats up heading into 2020, it’s important to remember that the question is not whether single-payer makes more economic sense than the current system — we already know that answer. The real question in the debate over universal coverage is, “When will the U.S. finally do something every other industrialized nation has already done?”
https://dailynorthwestern.com/2019/02/10/opinion/boyd-the-economic-case-for-universal-healthcare/


Covering Pre-existing Conditions Isn’t Enough

by Douglas Jacobs - NYT - February 25, 2019

When patients enroll in health insurance, they are often met with a stark reality: Even with insurance, they can’t afford their treatment. With the Affordable Care Act and its protections for people with pre-existing conditions in limbo once again, it’s important to remember that those with such conditions need more than health insurance. They also need to be protected from discriminatory pricing so that they can afford the medications they need.
In 2015 I published a paper in The New England Journal of Medicine that detailed how some insurers were raising costs for H.I.V. medicines to dissuade H.I.V.-positive people from selecting their plans. Insurers frequently raise the price of certain medicines to encourage people to select cheaper alternatives, but these insurers raised the cost of every single H.I.V. medicine — leaving many enrollees with no affordable options.
The difference for someone with a pre-existing condition like H.I.V. was staggering (in some cases more than $10,000 annually for H.I.V. medicines in one plan compared with less than $1,000 in another). This practice was later recognized by the Department of Health and Human Services as a form of discrimination by insurers.
Unfortunately, pharmaceutical companies and insurers are still getting away with raising their prices in a way that has a disparate impact on those with pre-existing conditions. A 2019 report by Harvard Law School’s Center for Health Law and Policy Innovation found that some insurers continue to price all recommended H.I.V. regimens in a way that makes them prohibitively expensive. In Georgia, for example, three out of the four insurers place all recommended H.I.V. regimens on the most expensive tiers (costing more than $1,000 a month) or do not cover them at all.
As another example, the high price of hepatitis C medicines set by pharmaceutical companies caused many state Medicaid programs to institute discriminatory prior authorization requirements. Those requirements effectively barred people who had a diagnosis of alcohol use disorder and had not refrained from drinking for a specified period of time from treatment — even though we know that hepatitis C medicines are just as successful in people who drink alcohol.
In many cases, this administration has made matters worse. With the repeal of the A.C.A.’s individual mandate by the 2017 tax bill, healthy individuals can forgo insurance altogether, causing premiums to rise for everyone else. The Trump administration also made it easier to establish association health plans and short-term plans (often referred to collectively as “junk health plans” because they aren’t required to cover many services). This forces those with pre-existing conditions to either stay in their A.C.A. plan and see their premiums rise as healthy individuals move to junk insurance because it’s cheaper, or sign up for a junk plan and risk extreme charges when services they need are not covered.
While some association health plans have received positive press, these kinds of plans are notorious for cherry-picking healthy enrollees and even committing fraud. As for short-term plans, they are simply denying coverage to those with pre-existing conditions altogether.
Fortunately, with the shutdown finally over, both sides of Congress are getting to legislating, and an issue that both Republicans and Democrats campaigned on is the protection of those with pre-existing conditions. Safeguarding the A.C.A. — by supporting its existence and by eliminating the threat of junk insurance — is a first step.
But protection also means making sure that those who have pre-existing conditions can afford plans that cover the medications they need, which requires instituting policies aimed at both insurers and pharmaceutical companies. After all, what a consumer pays for a medicine is a mix of the price set by a pharmaceutical company, the cost assigned to the drug by the insurer and countless negotiations among pharmaceutical companies, insurers and the pharmacy benefit managers that serve as middlemen.
Accordingly, the administration’s announcement to tie Medicare Part B drug prices to an international drug-pricing index should be lauded and expedited. National policymakers should also emulate California, which will band together all state entities into a single purchaser of drugs, adding leverage to efforts to negotiate down drug prices. They could combine federal employee health benefits, Medicare, Medicaid, the Department of Veterans Affairs, Tricare (the health program for uniformed service members) and other public purchasers into the largest single purchaser of drugs our nation has ever seen, one with enormous leverage to reduce drug costs. And with prices lowered, they should require insurers to keep medications affordable.
Obviously, protecting the A.C.A. comes first. But to provide meaningful protections to people with pre-existing conditions, we need to go further. Lowering the cost of drugs achieves the same end: access to care for those who need it most.
Douglas Jacobs is an internal medicine resident at Brigham and Women’s Hospital and Harvard Medical School.
https://www.nytimes.com/2019/02/25/opinion/pre-existing-conditions-aca.html?


Maine woman, 25, learns she has cancer just before losing health insurance

by Hadley Barndollar - Portsmouth Herald - February 26, 2019

KITTERY, Maine — To be diagnosed with a chronic illness just months before losing her parents’ health insurance surely wasn’t something Alex Thayer ever expected.
At age 25, she relished the accomplishment of buying her own home, while working her dream job as a veterinarian technician and adoption coordinator at Kittery Animal Hospital, where she began as an intern in 2007. A motivated, active young woman, she enjoyed time with her boyfriend of many years, time outdoors, and her two cats and two dogs.
In December, Thayer was diagnosed with ovarian cancer.
Next month, she’ll turn 26, and as March expires, so will her eligibility for coverage under her parents’ health insurance. For insurance that will cover all four of her doctors, she’s looking at a $900 a month out-of-pocket premium.
An eight-week chemotherapy treatment can run up to an average of approximately $30,000, and most insurance companies may only pay an 80 percent dividend, leaving the remaining 20 percent as an out-of-pocket expense for the patient to pay.
Yet in the midst of a financial and medical whirlwind, Thayer’s motto is, “Just keep going.”
“I just gotta roll with it,” she said. “You can’t let it stop you in your tracks. You gotta get through it. I have a lot of people supporting me and you gotta stay positive.” Thayer grew up in Kittery, graduated from Traip Academy in 2011, and her parents both work for the school district.
In the weeks since her diagnosis, the greater Kittery community has essentially wrapped Thayer in a great big hug, her supporters calling themselves “Team Alex.” Currently on the Kittery Animal Hospital’s outdoor sign, it reads, “She fights, we fight. Team Alex.” On Saturday, March 2, coworkers and friends will host a benefit at the Portsmouth Harbor Events Conference Center featuring a silent auction, food and live music, to ease the financial burden of Thayer’s unexpected diagnosis.
At the Feb. 11 Kittery Town Council meeting, Councilor Charles Denault challenged his fellow councilors to donate their quarterly pay to the cause.
In December, Thayer first saw a doctor complaining of abdominal swelling and discomfort. Following an MRI, she was told she had a “very large cyst” stemming from one of her ovaries. She underwent surgery to remove it, and “right after, they knew it was cancer,” Thayer said. The cyst had weighed 16 pounds, and was determined to be a cancerous tumor.
Thayer is now undergoing six sessions of chemotherapy every three weeks. But she’s still working, taking care of herself, and remaining as active as possible.
“The first oncologist said it was pretty abnormal for someone this young to get ovarian cancer,” Thayer said. “They’re running some genetic testing to find out more.”
Thayer and her family are in the process of navigating the pains and intricacies of health insurance, weighing the pros and cons of insurance offered by the animal hospital, versus one that might provide better coverage for her treatments.
“It’s more than looking at monthly cost,” said Jen Thayer, Alex’s mom. “It’s co-pays, deductibles. You have to weigh it all out. One bill can just knock you out flat. With something that is so intense, it requires all of your focus.”
Jen Thayer said dealing with financials in the midst of a medical crisis “can wake you up in the middle of the night.”
“It has been a whirlwind,” she said.
Co-worker and friend Christine Morse is organizing the March 2 benefit. The impetus for the fundraiser was the idea that, ”(Money) should be the last thing she should worry about right now,” Morse said.
Just after Thayer’s diagnosis, working with so many clients on a day-to-day basis at her job, she was concerned about having to tell each person individually, on top of losing her hair.
“Knowing I was going to lose my hair was the hardest pill to swallow,” she said. “I have had long hair my whole life, it’s been a part of who I am. I took a few weeks to come to terms with it and shaved all my hair off to prepare myself for when it started falling out. That has made it much easier.”
Morse said to Thayer, “Let’s just rip (your diagnosis) off like a Band-Aid and throw it out there.” The animal hospital went public with it, and since, “It’s been amazing,” Morse said. “I still can’t believe what’s happening right now.” A GoFundMe page has raised more than $5,000.
“I love her, she’s like a sister,” Morse added. “To try to do something to help her, knowing insurance was a huge thing, and she just bought a house on her own. It was just a tornado. This couldn’t have happened at a worst time for Alex.”
Jen Thayer said going public with her daughter’s diagnosis has also brought them a wealth of information they likely wouldn’t have had otherwise.
“Having made it public makes it easier to talk about, and it’s OK to talk about it,” Jen Thayer said. “It shouldn’t be a shameful thing. I feel for people that don’t have that sort of support. Our community is wonderful. The Kittery Animal Hospital has been incredible.”
At the March 2 benefit, the Grim Brothers Band, featuring Thayer’s brother on the drums, will provide the live entertainment. Morse said the biggest item in the silent auction so far is a paddleboard donated by the Kittery Trading Post at a $2,000 value. All of the restaurants in town have donated gift cards, she said, and the donations continue to pour in. Tickets are $15 at the door, and the event starts at 6 p.m.
“I can’t describe the support from the community,” Thayer said. “It’s unbelievable. I’ve had people I don’t even know come to me and say, ‘I went through this, let me know if you need support.’”
Thayer added, “You have to stay positive, you have to take care of yourself.”
https://bangordailynews.com/2019/02/26/news/york/maine-woman-25-learns-she-has-cancer-just-before-losing-health-insurance/

 
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