What It’s Like to Live in the Country Where Giving Birth Costs $60
by Gabriella Palella - New York Magazine - March 21, 2019
The same day that Finland was named
the world’s happiest country, they also became the focal point of a
debate about their robust, publicly funded health-care system.
It started when presidential candidate and longtime Medicare for All advocate Bernie Sanders tweeted
that it costs an average of $12,000 to have a baby in the United
States, compared to just $60 in Finland — at which point former U.N.
ambassador Nikki Haley decided to weigh in. “Alright @BernieSanders,
you’re not the woman having the baby so I wouldn’t be out there talking
about skimping on a woman when it comes to childbirth. Trust me! Nice
try though,” she replied, adding,
“Health care costs are too high that is true but comparing us to
Finland is ridiculous. Ask them how their health care is. You won’t like
their answer.”
Plenty
of Finns took this as an invitation to tell Haley that they did, in
fact, enjoy their health care, and her comments immediately made me
think of a book I read a few years back called The Nordic Theory of Everything: In Search of a Better Life. In it, Finnish journalist Anu Partanen
writes about moving to America and struggling to navigate numerous
perplexing cultural differences — the most striking of which was our
labyrinthine, exorbitantly priced, and fundamentally broken health-care
system.
So
I called up Partanen, who’s since moved back to Finland, to talk about
the realities of Finnish health care, what it’s like to give birth
there, and what Finns make of Haley’s recent comments.
Right off the bat, what did Haley get wrong in her tweet?
There are so many ironies there. First of all, I don’t know if she actually thought that Bernie Sanders had meant that Finland only spends $60 per woman. What he is saying is correct that for the person giving birth, when they go to the hospital, they only pay some $60 per night. So it’s not that Finland only spends $60 per night. So that just seemed really strange, if she actually did not understand that or was she purposefully misleading. That just seemed weird for somebody who’s been a U.N. ambassador.
There are so many ironies there. First of all, I don’t know if she actually thought that Bernie Sanders had meant that Finland only spends $60 per woman. What he is saying is correct that for the person giving birth, when they go to the hospital, they only pay some $60 per night. So it’s not that Finland only spends $60 per night. So that just seemed really strange, if she actually did not understand that or was she purposefully misleading. That just seemed weird for somebody who’s been a U.N. ambassador.
It’s
also extremely ironic that she would make that comment in relation to
childbirth because that is exactly the area where Finland and all of
Nordic countries really excel. I mean, if you ask any Finn the one part
of the health-care system that they are all really happy with
is the prenatal care that is free for the user. You don’t have to pay
anything, and typically people are very happy with the care they get
while giving birth and you just pay a minimal co-pay for the hospital
stay. Also, the American maternal-mortality rates
and infant-mortality rates are sort of shockingly high for the
wealthiest country in the world, practically. On the other hand, Finland
does, in those areas, particularly well — Finnish rates are among the
lowest in the world.
I know you recently had a baby — did you give birth to your child in Finland or the U.S.?
In the U.S. — not the smartest move! Our child was 1 when we moved to Finland. So I had the experience of having a child with American health care, and, now we are seeing Finnish doctors and pediatricians and so on.
In the U.S. — not the smartest move! Our child was 1 when we moved to Finland. So I had the experience of having a child with American health care, and, now we are seeing Finnish doctors and pediatricians and so on.
Can
you walk me through what the process was like having the child here,
and what it cost you, versus what the process would have been like had
you had your child in Finland?
Overall the care that I got in America was perfectly fine — my obstetrician was great, and all the nurses were really nice. We were freelancers, my husband and I, and then partway through, my husband got a job with health insurance, so we had sort of both experiences. But we were on the Obamacare plan when I got pregnant. So we immediately kind of had to — well, we employed a health-insurance broker, which to me was already kind of crazy, like what is this? He advised us that we had to move to a higher-premium plan, so that if you have complications when you give birth and so on and so on, you don’t end up with a huge bill. We really paid a lot, and it just seemed insanely expensive.
Overall the care that I got in America was perfectly fine — my obstetrician was great, and all the nurses were really nice. We were freelancers, my husband and I, and then partway through, my husband got a job with health insurance, so we had sort of both experiences. But we were on the Obamacare plan when I got pregnant. So we immediately kind of had to — well, we employed a health-insurance broker, which to me was already kind of crazy, like what is this? He advised us that we had to move to a higher-premium plan, so that if you have complications when you give birth and so on and so on, you don’t end up with a huge bill. We really paid a lot, and it just seemed insanely expensive.
It
was really hard to keep track of. And it was very stressful. And of
course then we worried about what if something goes wrong when I’m
giving birth. And that would be terrible of course for all the reasons,
but also terrifying for bills. But everything went fine. But it was just
very expensive and complicated and a lot of time spent on figuring out
doctors, and exams, and expenses.
In
Finland, I would have gone to the government-provided maternity clinic,
where most of the time you actually see a midwife-nurse. If you don’t
have a high-risk pregnancy, you don’t necessarily need to be checked out
by a doctor all the time. The nurses do a fine job. So I would have
gone there, and I wouldn’t have paid anything. And then when you go and
give birth, there’s family rooms in Finnish hospitals that you can book,
and then you pay a little bit more, but the cost is still minimal —
like a few hundred dollars for a family room. Compared to America, where
we also ended up getting a “family room,” but it still makes me laugh
because we paid extra for it, and it was this tiny jail cell-like room,
in which I had a bed, and my husband had sort of a reclining chair.
There wasn’t even another bed! Whereas when you go to one in Finland,
it’s like an actual queen-size bed, and so on. It was very bare bones,
my experience giving birth in America, even though we paid quite a bit
for it. I didn’t have any problems with the care itself.
And you get the baby box afterward in Finland, right?
My Finnish friends somehow did manage to get one and ship it to me, to the United States. I got it before the baby was born, and I just basically started crying when I was looking through it. It was emotional for me, because it’s a real institution in Finland. And all the stuff in it is really nice! It’s very cute and colorful and nice.
My Finnish friends somehow did manage to get one and ship it to me, to the United States. I got it before the baby was born, and I just basically started crying when I was looking through it. It was emotional for me, because it’s a real institution in Finland. And all the stuff in it is really nice! It’s very cute and colorful and nice.
Can you walk us through what’s in there?
It’s this big box that works as a bed. So there’s a little mattress on the bottom, so you could use it as a crib for the baby in the beginning. And it just has clothes, all kinds of clothes. It has bibs, and a thermometer, and it had cloth diapers, and it just has a bunch of baby equipment. I posted a photo of it on my Instagram when I got it at the time. There’s a snowsuit, and, you know, mittens, outdoor wear. You can get by a pretty long time with that stuff. Of course people buy their own clothes and get gifts and all that in Finland too, but it’s a really good start-up box for having a baby when you don’t really know what you need.
It’s this big box that works as a bed. So there’s a little mattress on the bottom, so you could use it as a crib for the baby in the beginning. And it just has clothes, all kinds of clothes. It has bibs, and a thermometer, and it had cloth diapers, and it just has a bunch of baby equipment. I posted a photo of it on my Instagram when I got it at the time. There’s a snowsuit, and, you know, mittens, outdoor wear. You can get by a pretty long time with that stuff. Of course people buy their own clothes and get gifts and all that in Finland too, but it’s a really good start-up box for having a baby when you don’t really know what you need.
And this is all free?
It’s all free, yeah. It’s taxpayer-funded. You pick it up basically, everybody who is pregnant and a resident of Finland gets one.
It’s all free, yeah. It’s taxpayer-funded. You pick it up basically, everybody who is pregnant and a resident of Finland gets one.
I
know you went into this in your book quite a bit, but if you had to sum
up, what was your biggest culture shock when it came to the health care
when you moved here, to the U.S.?
The biggest shock was to realize that health care is not an automatic right. That everybody doesn’t automatically have health care. You need to figure out an insurance and pay for it and that it is so confusing. I would go around asking people, “So how do you know what your insurance covers and doesn’t cover?” And then people would say, “Well I don’t really know. My employer offers me this, and I take it and I just trust it and hope that it covers everything.” I thought, “How can you live like that? How can you live with the insecurity that you are paying for something and cannot, in any reasonable manner, be sure what you are paying for, essentially, and whether it will help you when you really need it?”
The biggest shock was to realize that health care is not an automatic right. That everybody doesn’t automatically have health care. You need to figure out an insurance and pay for it and that it is so confusing. I would go around asking people, “So how do you know what your insurance covers and doesn’t cover?” And then people would say, “Well I don’t really know. My employer offers me this, and I take it and I just trust it and hope that it covers everything.” I thought, “How can you live like that? How can you live with the insecurity that you are paying for something and cannot, in any reasonable manner, be sure what you are paying for, essentially, and whether it will help you when you really need it?”
I
just did taxes, so I was reminded of how much I pay every year. And
there’s this frustration that it’s not going into the public good or
toward my health care. There is this idea that in Nordic countries,
you’re paying most of your salary toward taxes, but I remember in your New York Times health-care op-ed, you said your taxes are right around what you were paying when you lived in New York, right?
Yeah, I mean, of course it depends. In Finland, wealthy people do pay more in income taxes than they do in the United States. But for somebody with a fairly average wage, who lives in a place like New York City — I had to do my taxes for Finland and the U.S. for three years in a row, and the tax bill was pretty much about the same. It was also because I was self-employed and I had self-employment tax, which is 15 percent. So I think for somebody who makes fairly average wages, the difference is not huge. And in Finland, so much is included already in your taxes. I also had that experience in the United States, that I started kind of loathing paying my taxes, which I never did in Finland. Because I just felt like I’m paying all of this money in the U.S., and what am I getting in return? And on top of that I’m paying for my health care, and if I have a child for day care, and all that. Whereas at least in Finland, it was so clear what I’m paying for.
Yeah, I mean, of course it depends. In Finland, wealthy people do pay more in income taxes than they do in the United States. But for somebody with a fairly average wage, who lives in a place like New York City — I had to do my taxes for Finland and the U.S. for three years in a row, and the tax bill was pretty much about the same. It was also because I was self-employed and I had self-employment tax, which is 15 percent. So I think for somebody who makes fairly average wages, the difference is not huge. And in Finland, so much is included already in your taxes. I also had that experience in the United States, that I started kind of loathing paying my taxes, which I never did in Finland. Because I just felt like I’m paying all of this money in the U.S., and what am I getting in return? And on top of that I’m paying for my health care, and if I have a child for day care, and all that. Whereas at least in Finland, it was so clear what I’m paying for.
So what exactly is the impression of American health care in Finland?
I think people find it just shocking — the idea that everybody doesn’t automatically have the right to health care, and that health-care bills can bankrupt you. I think for a lot of people it’s just very hard to wrap their mind around that because we’re just so used to it. So what the United States is doing is just very strange and odd and cruel.
I think people find it just shocking — the idea that everybody doesn’t automatically have the right to health care, and that health-care bills can bankrupt you. I think for a lot of people it’s just very hard to wrap their mind around that because we’re just so used to it. So what the United States is doing is just very strange and odd and cruel.
The Fake Freedom of American Health Care
by Anu Partanen - NYT - March 19, 2017
Last week the nonpartisan Congressional Budget Office estimated that the new Republican health plan would increase the number of uninsured Americans by 24 million people within a decade, mostly because changes in regulations, subsidies and Medicaid coverage would make insurance too expensive for them.
Republican leaders seem unfazed by this, perhaps because, in their minds, deciding not to have health care because it’s too expensive is an exercise of individual free will. As Representative Jason Chaffetz, Republican of Utah, put it: “Americans have choices. And they’ve got to make a choice. And so maybe, rather than getting that new iPhone that they just love, and they want to go spend hundreds of dollars on that, maybe they should invest in their own health care.”
There is an appealing logic to such thinking. The idea is that buying health care is like buying anything else. The United States is home to some of the world’s best medical schools, doctors, research institutes and hospitals, and if you have the money for the coverage and procedures you want, you absolutely can get top-notch care. This approach might result in extreme inequalities and it might be expensive, but it definitely buys you the best medical treatment anywhere. Such is the cost of freedom. As House Speaker Paul Ryan put it in a tweet: “Freedom is the ability to buy what you want to fit what you need.” Vice President Mike Pence picked up that baton: “Obamacare will be replaced with something that actually works — bringing freedom and individual responsibility back to American health care.”
In practice, though, this Republican notion is an awfully peculiar kind of freedom. It requires most Americans to spend not just money, but also time and energy agonizing over the bewildering logistics of coverage and treatment — confusing plans, exorbitant premiums and deductibles, exclusive networks, mysterious tests, outrageous drug prices. And more often than not, individual choices are severely restricted by decisions made by employers, insurers, doctors, pharmaceutical companies and other private players. Those interest groups, not the consumer, decide which plans are available, what those plans cover, which doctors patients can see and how much it will cost.
And I haven’t even mentioned the millions of Americans who don’t earn enough to pay for insurance or a lifesaving treatment. If you can’t afford it, not buying it is hardly a choice.
Eight years ago I moved to the United States from Finland, which like all the Nordic nations is a wealthy capitalist economy, despite the stereotypes you may have heard. And like all those countries, Finland has invested in a universal, taxpayer-funded and publicly managed health care system. Finns constantly debate the shortcomings of their system and are working to improve it, but in Finland I never worried about where my medical care came from or whether I could afford it. I paid my income taxes — which, again despite the stereotypes, were about the same as what I pay in federal, state and local income taxes in New York City — and if I needed to see a doctor, I had several options.
For minor medical matters, I could visit a private physician who was provided as a perk by my employer. Or I could call the public clinic closest to my home. If I saw the private doctor, my employer picked up the tab, with the help of public subsidies. If I went to the public clinic, it might cost me a small co-payment, usually around $20. Had I been pregnant, most care would have been free.
If I had wanted to, I also could have easily paid to see a private doctor on my own, again with the help of public subsidies. All of this works without anyone ever having to sign up for or buy health insurance unless he wants additional coverage. I never had to worry whether I was covered. All Finns are covered for all essential medical care automatically, regardless of employment or income.
Republicans are fond of criticizing this sort of European-style health care. President Trump has called Canada’s national health care system “catastrophic.” On CNN recently, Senator Ted Cruz gave multiple examples of how patients in countries with universal, government-managed health care get less care than Americans.
In Europe, he said, elderly people facing life-threatening diseases are often placed in palliative care and essentially told it’s their time to go. According to the Republican orthodoxy, government always takes away not only people’s freedom to choose their doctor, but also their doctor’s ability to choose the correct care for patients. People are at the mercy of bureaucrats. Waiting times are long. Quality of care is dismal.
But are Republicans right about this? Practically every wealthy capitalist democracy in the world has decided that some form of government-managed universal health care is the most sensible and effective option. According to the latest report of the O.E.C.D. — an organization of mostly wealthy nations — the United States as a whole does not actually outshine other countries in the quality of care.
In fact, the United States has shorter life expectancy, higher infant mortalityand fewer doctors per capita than most other developed countries. When it comes to outcomes in some illnesses, including cancer, the United States does have some of the best survival rates in the world — but that’s barely ahead of, or even slightly behind, the equivalent survival rates in other developed countries. In breast cancer survival, for example, the United States comes in second, after Sweden. Third-best is Norway, then Finland. All three countries have universal, government-run health care systems.
For colorectal cancer, the five-year survival rate after diagnosis in the United States brings it to a not very impressive ninth place in the O.E.C.D. statistics. Ahead of the United States are South Korea, Israel, Australia, Sweden and Finland, all with some form of government-managed universal health care. And when it comes to cervical cancer, American women are at a significant disadvantage: The United States comes in only 22nd. Meanwhile, life expectancy at age 65 is higher in 24 other developed nations, including Canada, Britain and most European nations.
Americans might still assume that long waits for care are inevitable in a health care system run by the government. But that’s not necessarily the case either. A report in 2014 by the Commonwealth Fund, a private foundation specializing in health care research, ranked the United States third in the world in access to specialists. That’s a great achievement. But the Netherlands and Switzerland did better. When it comes to nonemergency and elective surgery, patients in several countries, including the Netherlands, Germany and Switzerland, all of which have universal, government-guided health care systems, have faster access than the United States.
It’s not just American patients who endure endless bureaucratic hassles. American doctors were also significantly more likely to report as major problems the amount of time they spent on dealing with administrative burdens related to insurance and claims, as well as on getting patients medications or treatment because of restrictions imposed by insurance companies, compared with doctors in most of the other 10 countries studied — including Sweden and Britain.
Overall, Americans spend far more of their hard-earned money on health care than citizens of any other country, by a very wide margin. This means that it is in fact Americans who are getting a raw deal. Americans pay much more than people in other countries but do not get significantly better results.
The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power. It is not like buying a consumer product, where choosing not to buy will not endanger one’s life. It’s also not like buying some other service tailored to individual demands, because for the most part we can’t predict our future health care needs.
The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care. And the point of having the government manage this complicated service is not to take freedom away from the individual. The point is the opposite: to give people more freedom. Arranging health care is an overwhelming task, and having a specialized entity do the negotiating, regulating and perhaps even much of the providing is just vastly more efficient than forcing everyone to go it alone.
What passes for an American health care system today certainly has not made me feel freer. Having to arrange so many aspects of care myself, while also having to navigate the ever-changing maze of plans, prices and the scarcity of appointments available with good doctors in my network, has thrown me, along with huge numbers of Americans, into a state of constant stress. And I haven’t even been seriously sick or injured yet.
As a United States citizen now, I wish Americans could experience the freedom of knowing that the health care system will always be there for us regardless of our employment status. I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures. I want the freedom to know that the system will automatically take me and my family in, without my having to battle for care in my moment of weakness and need. That is real freedom.
So is the freedom of knowing that none of it will bankrupt us. That is the freedom I had back in Finland.
Here is my appeal to Republicans: If you really want to free Americans and unburden American employers, why not try, or at least seriously consider, some form of government-managed health care, like almost every other capitalist democracy? There are many ways of giving people choice and excellent care under government management. Universal publicly managed health coverage would even free America’s corporations and businesses to streamline their operations, releasing them from bureaucratic obligations that to me, coming from Finland, I have to say look weirdly socialist. Would this mean they would have to pay more in taxes? Possibly.
Many countries require employers and employees to contribute to the health care system through payroll taxes, more than the United States does. But again, Americans are paying far more for health care than anyone else, and America’s businesses are stuck managing this mess. It’s true that in countries with universal health care the cost of hiring a new employee can be significant, especially for a small employer. Yet these countries still have plenty of thriving businesses, with lower administrative burdens. It can be done.
In wealthy capitalist democracies all around the world the government itself also has an essential kind of freedom. It’s a freedom that enables the government to do work on behalf of the citizens who elect it, including negotiating the prices of health care with providers and pharmaceutical companies — a policy that has led to lower drug prices in those countries.
Americans today are paying vastly more in money, worry and hassle for the same, and sometimes worse, care than people in other wealthy capitalist democracies. Some Americans have coverage that serves them well, but judging by the current mood, the number of Americans who think the system needs to change is growing. No health care system is perfect. But in a nation that purports to champion freedom, the outdated disaster that is the United States health care system is taking that freedom away.
https://www.nytimes.com/2017/03/18/opinion/the-fake-freedom-of-american-health-care.html
Medicare for All Would Abolish Private Insurance. ‘There’s No Precedent in American History.’
by Reed Abelson and Margaret Sanger-Katz - NYT - March 23, 2019
Unlike Obamacare, emerging plans would sweep away the private health insurance system. What would that mean for the companies’ workers, the stock market and the cost of care?
At the heart of the “Medicare for all” proposals championed
by Senator Bernie Sanders and many Democrats is a revolutionary idea:
Abolish private health insurance.
Proponents want to sweep away our complex, confusing, profit-driven mess of a health care system and start fresh with a single government-run insurer that would cover everyone.
But doing away with an entire industry would also be profoundly disruptive. The private health insurance business employs at least a half a million people, covers about 250 million Americans, and generates roughly a trillion dollars in revenues. Its companies’ stocks are a staple of the mutual funds that make up millions of Americans’ retirement savings.
Such a change would shake the entire health care system, which makes up a fifth of the United States economy, as hospitals, doctors, nursing homes and pharmaceutical companies would have to adapt to a new set of rules. Most Americans would have a new insurer — the federal government — and many would find the health insurance stocks in their retirement portfolios much less valuable.
Proponents want to sweep away our complex, confusing, profit-driven mess of a health care system and start fresh with a single government-run insurer that would cover everyone.
But doing away with an entire industry would also be profoundly disruptive. The private health insurance business employs at least a half a million people, covers about 250 million Americans, and generates roughly a trillion dollars in revenues. Its companies’ stocks are a staple of the mutual funds that make up millions of Americans’ retirement savings.
Such a change would shake the entire health care system, which makes up a fifth of the United States economy, as hospitals, doctors, nursing homes and pharmaceutical companies would have to adapt to a new set of rules. Most Americans would have a new insurer — the federal government — and many would find the health insurance stocks in their retirement portfolios much less valuable.
“We’re
talking about changing flows of money on just a huge scale,” said Paul
Starr, a sociology professor at Princeton University and author of “The
Social Transformation of American Medicine: The Rise of a Sovereign
Profession and the Making of a Vast Industry.”
“There’s no precedent in American history that compares to this,” he said.
Economists have begun wrestling with basic questions about what this sort of change would mean and disagreeing over whether it would cost more or less than the country’s current health care system.
No one has examined the full economic impact of such plans on jobs, wages, investors, doctors and hospitals — or the health insurance companies themselves. Such an undertaking would be difficult, given the vagueness of key parts of the proposals being discussed and the wide-ranging possible effects.
There are few international analogues to the Medicare for all proposals, but Canada, which provides similar doctor and hospital benefits for its residents, probably comes closest. Even there, people buy private insurance for benefits that are not covered by the government program, like prescription drugs and dental care.
“There’s no precedent in American history that compares to this,” he said.
Economists have begun wrestling with basic questions about what this sort of change would mean and disagreeing over whether it would cost more or less than the country’s current health care system.
No one has examined the full economic impact of such plans on jobs, wages, investors, doctors and hospitals — or the health insurance companies themselves. Such an undertaking would be difficult, given the vagueness of key parts of the proposals being discussed and the wide-ranging possible effects.
There are few international analogues to the Medicare for all proposals, but Canada, which provides similar doctor and hospital benefits for its residents, probably comes closest. Even there, people buy private insurance for benefits that are not covered by the government program, like prescription drugs and dental care.
Most other countries with single-payer
systems allow a more expansive, competing role for private coverage. In
Britain, for example, everyone is covered by a public system, but people
can pay extra for insurance that gives them access to private doctors. Most countries in Europe don’t have single-payer systems, but instead allow private insurance companies to compete under extremely tight regulations.
Legislators writing the bills acknowledge that people in
the health insurance industry would lose their jobs. Proposals in the
House and Senate would set aside large funds to help cushion the blow to
displaced workers, offering them training, benefits, and income
supports.
The health insurance industry is now composed of a mix of for-profit and nonprofit companies of various sizes. About 155 million Americans get private health coverage through an employer, but the reach of the industry extends into publicly funded insurance programs.
A third of Americans enrolled in Medicare, which insures older and disabled people, and four-fifths of those in Medicaid, which covers the poor and disabled, now get their benefits from a private insurer.
Simply talk of Medicare for all makes investors jittery. Shares of the large publicly held insurance companies, including Cigna, Humana and UnitedHealth, fell when Representative Pramila Jayapal, Democrat of Washington, introduced her bill in late February, but have largely rebounded.
The effective takeover of the health insurance industry in the United States would mean a huge hit to the companies’ stocks, although the companies, which have additional lines of business, would most likely survive.
While the bills would give relief to insurance industry workers, they would provide no such compensation for investors. Not surprisingly, the insurance industry and many other health care industries vociferously oppose these plans and plan to spend heavily in fighting them.
The health insurance industry is now composed of a mix of for-profit and nonprofit companies of various sizes. About 155 million Americans get private health coverage through an employer, but the reach of the industry extends into publicly funded insurance programs.
A third of Americans enrolled in Medicare, which insures older and disabled people, and four-fifths of those in Medicaid, which covers the poor and disabled, now get their benefits from a private insurer.
Simply talk of Medicare for all makes investors jittery. Shares of the large publicly held insurance companies, including Cigna, Humana and UnitedHealth, fell when Representative Pramila Jayapal, Democrat of Washington, introduced her bill in late February, but have largely rebounded.
The effective takeover of the health insurance industry in the United States would mean a huge hit to the companies’ stocks, although the companies, which have additional lines of business, would most likely survive.
While the bills would give relief to insurance industry workers, they would provide no such compensation for investors. Not surprisingly, the insurance industry and many other health care industries vociferously oppose these plans and plan to spend heavily in fighting them.
Many
supporters of this approach see elimination of private insurance as a
key feature, not a bug, meant to improve the program’s efficiency and
equity by streamlining the health care system and weakening profit
motives. With a single insurer covering every patient, hospitals and
doctors could spend less time and money complying with differing
policies, negotiating contracts, and filing forms to get paid.
“It’s worth it,” said Adam Gaffney, the president of Physicians for a National Health Program, which supports single-payer health care and helped design Ms. Jayapal’s bill. “Because we are not going to get to true universal health care without the greater efficiency of a single-payer system.”
This idea — once at the edge of Democratic politics — has moved to the mainstream of the debate among the party’s numerous presidential contenders. Mr. Sanders, independent of Vermont, ran on the idea in his 2016 campaign, and now five 2020 Democratic aspirants have co-sponsored one of the two Medicare-for-all bills.
Senators Cory Booker of New Jersey, Kirsten Gillibrand of New York, Kamala Harris of California, and Elizabeth Warren of Massachusetts co-sponsored Mr. Sanders’s bill in the last Congress. Representative Tulsi Gabbard of Hawaii is a co-sponsor on this year’s House Medicare for All Act.
The concept, in broad strokes, appeals to many Democratic voters. But overall support diminishes by a third or more when people are told that the plan would involve eliminating private insurance, raising taxes, or requiring waits to obtain medical care, according to surveys from the Kaiser Family Foundation.
And the approach is a big departure from the Democrats’ strategy in 2010, when Congress passed the Affordable Care Act. That law expanded coverage, but did so largely using private insurance carriers. It set up marketplaces for Americans who didn’t have coverage through work to buy insurance, usually with federal subsidies, and broadened access to the Medicaid program for the poor.
Obamacare was designed to build on the current system, patching its holes while minimizing disruption and avoiding the fierce opposition from industry that helped sink earlier attempts to change the health care system.
“It’s worth it,” said Adam Gaffney, the president of Physicians for a National Health Program, which supports single-payer health care and helped design Ms. Jayapal’s bill. “Because we are not going to get to true universal health care without the greater efficiency of a single-payer system.”
This idea — once at the edge of Democratic politics — has moved to the mainstream of the debate among the party’s numerous presidential contenders. Mr. Sanders, independent of Vermont, ran on the idea in his 2016 campaign, and now five 2020 Democratic aspirants have co-sponsored one of the two Medicare-for-all bills.
Senators Cory Booker of New Jersey, Kirsten Gillibrand of New York, Kamala Harris of California, and Elizabeth Warren of Massachusetts co-sponsored Mr. Sanders’s bill in the last Congress. Representative Tulsi Gabbard of Hawaii is a co-sponsor on this year’s House Medicare for All Act.
The concept, in broad strokes, appeals to many Democratic voters. But overall support diminishes by a third or more when people are told that the plan would involve eliminating private insurance, raising taxes, or requiring waits to obtain medical care, according to surveys from the Kaiser Family Foundation.
And the approach is a big departure from the Democrats’ strategy in 2010, when Congress passed the Affordable Care Act. That law expanded coverage, but did so largely using private insurance carriers. It set up marketplaces for Americans who didn’t have coverage through work to buy insurance, usually with federal subsidies, and broadened access to the Medicaid program for the poor.
Obamacare was designed to build on the current system, patching its holes while minimizing disruption and avoiding the fierce opposition from industry that helped sink earlier attempts to change the health care system.
But
107 Democratic House members are now co-sponsoring a Medicare for all
bill written by Ms. Jayapal. Mr. Sanders, whose update of his bill is
expected in the next few weeks, argues that only a single-payer approach
would resolve problems he sees as inherent in private insurance. Both
proposals are clear that a single, government-run insurer would replace
the private sector, but they are less detailed about exactly how the government program would pay for medical care.
Their plans would include nearly every doctor and hospital in the United States and provide generous benefits, including dental care and hearing aids, and would not require patients to pay any out-of-pocket cost to see a doctor. The federal government, of course, would have to cover those benefits, and would need to raise taxes to pay for them.
Gerald Friedman, a labor economist at the University of Massachusetts Amherst, who was close to Mr. Sanders’s 2016 campaign, estimated then that it could reduce the nation’s health care spending by $6 trillion over a decade, while the left-leaning Urban Institute said it might increase the overall bill by nearly $7 trillion.
Both Mr. Sanders and Ms. Jayapal said the switch to a government insurer would mean no loss in access to health care that private insurance provides.
“There is a reason why the United States is the only major country on earth that allows private insurance companies to profit off of health care,” Mr. Sanders said in an interview. “The function of private health insurance is not to provide quality care to all, it is to make as much money as possible for the private insurance companies, working with the drug companies.”
There are sharp disagreements among Democrats in Congress over whether Medicare for all or a more incremental approach is best — and presidential candidates co-sponsoring Mr. Sanders’s bill also support other, less sweeping measures.
Their plans would include nearly every doctor and hospital in the United States and provide generous benefits, including dental care and hearing aids, and would not require patients to pay any out-of-pocket cost to see a doctor. The federal government, of course, would have to cover those benefits, and would need to raise taxes to pay for them.
Gerald Friedman, a labor economist at the University of Massachusetts Amherst, who was close to Mr. Sanders’s 2016 campaign, estimated then that it could reduce the nation’s health care spending by $6 trillion over a decade, while the left-leaning Urban Institute said it might increase the overall bill by nearly $7 trillion.
Both Mr. Sanders and Ms. Jayapal said the switch to a government insurer would mean no loss in access to health care that private insurance provides.
“There is a reason why the United States is the only major country on earth that allows private insurance companies to profit off of health care,” Mr. Sanders said in an interview. “The function of private health insurance is not to provide quality care to all, it is to make as much money as possible for the private insurance companies, working with the drug companies.”
There are sharp disagreements among Democrats in Congress over whether Medicare for all or a more incremental approach is best — and presidential candidates co-sponsoring Mr. Sanders’s bill also support other, less sweeping measures.
Ms. Harris, asked directly about getting rid of private health insurance during a CNN forum in January, answered, “Let’s eliminate all that. Let’s move on.” But after her comments were characterized as extreme, her campaign quickly clarified that, while she continued to endorse the Sanders plan, she would also support more incremental expansions of health coverage.
During her CNN forum last week, Ms. Warren said she was open to various ways to get to universal coverage. “When we talk about Medicare for all, there are a lot of different pathways,” she said. “What we’re all looking for is the lowest cost way to make sure that everybody gets covered.”
Dr. David Blumenthal, a former Obama administration official who is now chief executive of the Commonwealth Fund, a nonprofit that funds health care research, voiced concern about the prospects for the most transformative approach. “I do think it’s an uphill battle to take things away from people in the name of giving them something better,” he said.
Believers in markets argue that consumer choice and competition among private health plans improve the quality of care. Others laud private industry’s relative nimbleness compared with Medicare, which can be bureaucratic and prone to political influence.
“Private plans have been able to evolve and test new models more quickly,” said Caroline Pearson, a senior vice president at NORC, a research organization at the University of Chicago. “The political process slows things down.”
In a Medicare-for-all world, private insurers might evolve into contractors for the big government system. They already perform various functions for Medicare, including helping the program manage paying its bills. The industry could retain that role, or take on new responsibilities.
“The government would have to build out infrastructure if they were to shut down all the private insurance companies,” said Mark Bertolini, the former chief executive of Aetna, now part of CVS Health. “It’s not that simple pulling all that apart.”
https://www.nytimes.com/2019/03/23/health/private-health-insurance-medicare-for-all-bernie-sanders.html
During her CNN forum last week, Ms. Warren said she was open to various ways to get to universal coverage. “When we talk about Medicare for all, there are a lot of different pathways,” she said. “What we’re all looking for is the lowest cost way to make sure that everybody gets covered.”
Dr. David Blumenthal, a former Obama administration official who is now chief executive of the Commonwealth Fund, a nonprofit that funds health care research, voiced concern about the prospects for the most transformative approach. “I do think it’s an uphill battle to take things away from people in the name of giving them something better,” he said.
Believers in markets argue that consumer choice and competition among private health plans improve the quality of care. Others laud private industry’s relative nimbleness compared with Medicare, which can be bureaucratic and prone to political influence.
“Private plans have been able to evolve and test new models more quickly,” said Caroline Pearson, a senior vice president at NORC, a research organization at the University of Chicago. “The political process slows things down.”
In a Medicare-for-all world, private insurers might evolve into contractors for the big government system. They already perform various functions for Medicare, including helping the program manage paying its bills. The industry could retain that role, or take on new responsibilities.
“The government would have to build out infrastructure if they were to shut down all the private insurance companies,” said Mark Bertolini, the former chief executive of Aetna, now part of CVS Health. “It’s not that simple pulling all that apart.”
https://www.nytimes.com/2019/03/23/health/private-health-insurance-medicare-for-all-bernie-sanders.html
Why Should Americans Be Grateful for $137 Insulin? Germans Get It for $55
by Elizabeth Rosenthal - NYT - March 21, 2019
This month, Eli Lilly and Company announced with some
fanfare that it was manufacturing a generic version of its own
best-selling insulin brand, Humalog, which it would sell for half off —
$137.35 versus about $275.
David Ricks, the chief executive of Lilly, said the company was making this seemingly beneficent gesture because “many patients are struggling to afford their insulin.”
But they’re struggling, in large part, because since 2001 Lilly has raised the price of a vial of Humalog to about $275, from $35. Other insulin makers have raised prices similarly.
In Germany, the list price of a vial of Humalog is about $55 — or $45 if you buy five at a time — and that includes some taxes and markup fees. Why not just reduce the price in the United States to address said suffering?
David Ricks, the chief executive of Lilly, said the company was making this seemingly beneficent gesture because “many patients are struggling to afford their insulin.”
But they’re struggling, in large part, because since 2001 Lilly has raised the price of a vial of Humalog to about $275, from $35. Other insulin makers have raised prices similarly.
In Germany, the list price of a vial of Humalog is about $55 — or $45 if you buy five at a time — and that includes some taxes and markup fees. Why not just reduce the price in the United States to address said suffering?
Instead, Lilly decided to come
out with a new offering, a so-called authorized generic. This type of
product is made by or under an agreement from the brand manufacturer.
The medicines are exactly the same as the brand-name drug — often made
in the same factory with the same equipment to the same formula. Only
the name and the packaging are different.
It is perhaps, a sign of how desperate Americans are for something — anything — to counteract the escalating price of drugs that Lilly’s move was greeted with praise rather than a collective “Huh?”
Imagine if Apple sold a $500 iPhone for $250 if it was called, say, a yPhone, and simply lacked the elaborate white box and the little Apple on back. That would be patently absurd. An iPhone in a brown paper bag is still an iPhone. And Humalog with a new name isn’t a generic — except according to the bizarre logic of the pharmaceutical industry. Like so many parts of our health care system, its existence has more to do with convoluted business arrangements than health.
Generics, as traditionally understood, are copies of brand name drugs made by competing manufacturers once the original patent protection has expired. To be approved by the Food and Drug Administration, they have to have the same active chemical ingredients as the brand drug, and be absorbed equally into the blood, though they could look different and contain different inactive additives.
Historically and in practice they tend also to be far cheaper, because the advent of generics often introduces robust competition into the market. That is why brand manufacturers sometimes produce an authorized generic once they lose patent protection. That way, they can compete at the lower price point, while preserving the original for those with extreme label loyalty.
It is perhaps, a sign of how desperate Americans are for something — anything — to counteract the escalating price of drugs that Lilly’s move was greeted with praise rather than a collective “Huh?”
Imagine if Apple sold a $500 iPhone for $250 if it was called, say, a yPhone, and simply lacked the elaborate white box and the little Apple on back. That would be patently absurd. An iPhone in a brown paper bag is still an iPhone. And Humalog with a new name isn’t a generic — except according to the bizarre logic of the pharmaceutical industry. Like so many parts of our health care system, its existence has more to do with convoluted business arrangements than health.
Generics, as traditionally understood, are copies of brand name drugs made by competing manufacturers once the original patent protection has expired. To be approved by the Food and Drug Administration, they have to have the same active chemical ingredients as the brand drug, and be absorbed equally into the blood, though they could look different and contain different inactive additives.
Historically and in practice they tend also to be far cheaper, because the advent of generics often introduces robust competition into the market. That is why brand manufacturers sometimes produce an authorized generic once they lose patent protection. That way, they can compete at the lower price point, while preserving the original for those with extreme label loyalty.
More recently, authorized generics
like Lilly’s stem largely from a different strategy — based on the
perverse ways money flows through our health system and who keeps the
cash.
Over the last 20 years, drug makers have continuously raised the price of some essential medicines in the United States because, well, they can in a country that doesn’t set drug prices. And they do — until the bad publicity catches up with them.
Mylan got hauled before Congress in 2016 for raising the price of an EpiPen. Now it’s insulin’s turn. The other two major brand makers of insulin products — Novo Nordisk and Sanofi — have raised prices in lock step with Lilly. But they are based in Europe, so the Indiana-based Lilly has been the primary focus of angry protests here.
Part of insulin’s price rise in the United States is because of the middlemen who buy the drugs on behalf of insurers and hospitals and negotiate discounts off the list price for their clients. So Lilly often doesn’t make the full $275 a vial (though, since rebates are secret, we don’t know how much less).
By selling an authorized generic, rather than merely lowering the brand’s price, Lilly is essentially doing an end-run around those middlemen and giving patients who don’t purchase through an insurer another option.
It is also making sure that if and when cheaper versions of Humalog emerge, it will have an offering to compete.
In fact, a “biosimilar” version of Humalog already exists. It was introduced to the United States last year. And yet it costs around the same price as the brand name drug. Why? It is made by Sanofi, which has no interest in starting a price war to lower costs.
Over the last 20 years, drug makers have continuously raised the price of some essential medicines in the United States because, well, they can in a country that doesn’t set drug prices. And they do — until the bad publicity catches up with them.
Mylan got hauled before Congress in 2016 for raising the price of an EpiPen. Now it’s insulin’s turn. The other two major brand makers of insulin products — Novo Nordisk and Sanofi — have raised prices in lock step with Lilly. But they are based in Europe, so the Indiana-based Lilly has been the primary focus of angry protests here.
Part of insulin’s price rise in the United States is because of the middlemen who buy the drugs on behalf of insurers and hospitals and negotiate discounts off the list price for their clients. So Lilly often doesn’t make the full $275 a vial (though, since rebates are secret, we don’t know how much less).
By selling an authorized generic, rather than merely lowering the brand’s price, Lilly is essentially doing an end-run around those middlemen and giving patients who don’t purchase through an insurer another option.
It is also making sure that if and when cheaper versions of Humalog emerge, it will have an offering to compete.
In fact, a “biosimilar” version of Humalog already exists. It was introduced to the United States last year. And yet it costs around the same price as the brand name drug. Why? It is made by Sanofi, which has no interest in starting a price war to lower costs.
Mylan effectively calmed its EpiPen PR crisis by introducing a cheaper authorized generic. Now Lilly, following a similar playbook, is hoping for a similar result.
Will it work? Politicians and patients will decide.
But they might well keep these two thoughts in mind: If the product being sold was electricity or gas for your car, a price rise of more than 600 percent over 15 years would be regarded as price gouging and wouldn’t be tolerated. And in Germany and many other developed countries, there is no need for a $137.35 vial of “authorized generic” for Humalog. At around $50 a vial, Humalog as Humalog costs far less.
https://www.nytimes.com/2019/03/21/opinion/diabetes-insulin-generics-humalog.html
F.D.A. Approves First Drug for Postpartum Depression
by Pam Belluck - NYT - March 19, 2019
The first drug for women suffering postpartum depression received federal approval on Tuesday,
a move likely to pave the way for a wave of treatments to address a
debilitating condition that is the most common complication of
pregnancy.
The drug works very quickly, within 48 hours — a significant improvement over currently available antidepressants, which can take two to four weeks to have an effect, if they work at all.
Experts say the new treatment will provide immediate relief for mothers whose depression keeps them from providing their babies with the care, bonding and nurturing that is crucial for healthy development. As many as one in seven American women experience depression during or after pregnancy.
“Postpartum depression is a serious condition that, when severe, can be life-threatening,” Dr. Tiffany Farchione, acting director of the Division of Psychiatry Products at the Food and Drug Administration’s Center for Drug Evaluation and Research, said in a statement.
The drug works very quickly, within 48 hours — a significant improvement over currently available antidepressants, which can take two to four weeks to have an effect, if they work at all.
Experts say the new treatment will provide immediate relief for mothers whose depression keeps them from providing their babies with the care, bonding and nurturing that is crucial for healthy development. As many as one in seven American women experience depression during or after pregnancy.
“Postpartum depression is a serious condition that, when severe, can be life-threatening,” Dr. Tiffany Farchione, acting director of the Division of Psychiatry Products at the Food and Drug Administration’s Center for Drug Evaluation and Research, said in a statement.
There are limitations to the new drug, brexanolone, which will be marketed as Zulresso. It is delivered by infusion over 60 hours, during which a new mother must remain in a certified medical center, under supervision should she get dizzy or faint, as several patients did in clinical trials.
The infusion will be expensive, averaging $34,000 per patient before discounts, according to Sage Therapeutics, the manufacturer. That does not include the costs of staying in a medical center for two and a half days. Company officials say they expect that insurers will cover the treatment; insurers said this week that they are evaluating the drug.
A pill made with a similar molecule, which would be much more accessible and easier for patients, is showing promise in its clinical trials and would be submitted for approval in a couple of years if the results are good, according to Sage.
The infusion is to be administered just once, and patients may also take standard antidepressants. Clinical trials of the drug, all sponsored by Sage, found that it produced a steeper decrease in symptoms in women with severe and moderate postpartum depression than a similar placebo infusion.
The
relief from depression continued for a month after the treatment. While
there were anecdotal reports that it extended beyond that period for
some women, there has not been systematic research on longer-term
results.
“The major thing is, of course, the rapid effect,” said Dr. Margaret Spinelli, a clinical professor of psychiatry at Columbia University, who treats and studies postpartum depression and was not involved in the research on brexanolone.
“That it’s the first that’s designed for postpartum depression is important and means it will probably be a segue to design other medications for postpartum depression to be administered in an easier way,” she added.
The treatment may be helpful for up to 30 percent of the 400,000 American women who develop postpartum depression each year, said Dr. Kimberly Yonkers, a professor of psychiatry, obstetrics, gynecology and reproductive sciences at Yale, who was not involved in the research.
Candidates for treatment would likely be those experiencing severe symptoms or who failed to improve on standard antidepressants, said Dr. Yonkers, who was not involved in the research.
“This brings up a lot of very complex public health issues,” she added, noting the expense of the treatment and the need for patients to be admitted to medical centers.
“The major thing is, of course, the rapid effect,” said Dr. Margaret Spinelli, a clinical professor of psychiatry at Columbia University, who treats and studies postpartum depression and was not involved in the research on brexanolone.
“That it’s the first that’s designed for postpartum depression is important and means it will probably be a segue to design other medications for postpartum depression to be administered in an easier way,” she added.
The treatment may be helpful for up to 30 percent of the 400,000 American women who develop postpartum depression each year, said Dr. Kimberly Yonkers, a professor of psychiatry, obstetrics, gynecology and reproductive sciences at Yale, who was not involved in the research.
Candidates for treatment would likely be those experiencing severe symptoms or who failed to improve on standard antidepressants, said Dr. Yonkers, who was not involved in the research.
“This brings up a lot of very complex public health issues,” she added, noting the expense of the treatment and the need for patients to be admitted to medical centers.
“It
may be worth it, if somebody has been treatment-resistant or they can’t
wait the two to four weeks for an antidepressant to kick in,” Dr.
Yonkers said. “Depression can be pretty miserable,” she added, harming
the entire family.
Stephanie Hathaway, 33, a
mother of two in South Windsor, Conn., had no history of depression. But
after giving birth to her daughters — Hadley, 4, and Brenley, 2 — she
began crying nonstop, and lost interest in doing things she loved, like
cooking and socializing.
“I started having intrusive thoughts that would not go away,” she recalled. “‘Your daughter deserves a better mom, and your husband deserves a better wife’ — that would just play on repeat.”
Ultimately Ms. Hathaway felt suicidal and feared she would harm herself if she stopped holding the baby. After Hadley’s birth, Ms. Hathaway, then living with her husband in China, spent two weeks under round-the-clock suicide watch at home.
The antidepressant she was prescribed, Zoloft, took three months, at increasing dosages, to eliminate her symptoms. Following Brenley’s birth, Zoloft didn’t help at all, Ms. Hathaway said, so about five months afterward, she volunteered for the brexanolone trial.
Between 12 and 18 hours after the infusion started, “I actually woke up from a nap and those intrusive thoughts that played on repeat, they were gone,” said Ms. Hathaway.
After leaving the hospital, “I felt like myself again,” Ms. Hathaway said. “I’m not going to say I was 100 percent, but I will say there was so much less of a gap to get there.”
“I started having intrusive thoughts that would not go away,” she recalled. “‘Your daughter deserves a better mom, and your husband deserves a better wife’ — that would just play on repeat.”
Ultimately Ms. Hathaway felt suicidal and feared she would harm herself if she stopped holding the baby. After Hadley’s birth, Ms. Hathaway, then living with her husband in China, spent two weeks under round-the-clock suicide watch at home.
The antidepressant she was prescribed, Zoloft, took three months, at increasing dosages, to eliminate her symptoms. Following Brenley’s birth, Zoloft didn’t help at all, Ms. Hathaway said, so about five months afterward, she volunteered for the brexanolone trial.
Between 12 and 18 hours after the infusion started, “I actually woke up from a nap and those intrusive thoughts that played on repeat, they were gone,” said Ms. Hathaway.
After leaving the hospital, “I felt like myself again,” Ms. Hathaway said. “I’m not going to say I was 100 percent, but I will say there was so much less of a gap to get there.”
She did not stop antidepressants altogether, but switched to a low dose of Effexor.
Dizziness and sleepiness were the most common side effects in the trials, each affecting about one in eight patients, including Ms. Hathaway. The most worrisome effect, the F.D.A. said, was fainting or temporary loss of consciousness, seen in five patients. All recovered within an hour and resumed getting the infusion.
Brexanolone is a synthetic form of allopregnanolone, a hormone produced by progesterone in the brain that may help ease depression and anxiety by dampening neural activity, said Dr. Samantha Meltzer-Brody, director of the perinatal psychiatry program at the University of North Carolina at Chapel Hill, who was the principal investigator for the brexanolone studies.
The research presented to the F.D.A. consisted of three clinical trials that were led by Dr. Meltzer-Brody and funded by Sage Therapeutics, which was also involved in the study design, data analysis, interpretation and writing of the reports.
The trials involved 247 women randomly selected to receive a placebo or brexanolone — a relatively small number of participants, compared to many other medical trials.
Still, the results were considered persuasive by a joint F.D.A. advisory committee last year, which recommended approval in near-unanimous votes.
The women in the trials had given birth within six months of getting the infusion and were experiencing severe or moderate depression that had started in the third trimester of pregnancy or within four weeks after childbirth. Participants could not have psychosis or bipolar disorder. Their symptoms could include suicidal thoughts but not a recent suicide attempt.
They were asked to stop breast-feeding during the infusion and for a few days after. But Dr. Meltzer-Brody said the drug appears safe for nursing mothers and babies, because very little of it seeps into breast milk.
Dizziness and sleepiness were the most common side effects in the trials, each affecting about one in eight patients, including Ms. Hathaway. The most worrisome effect, the F.D.A. said, was fainting or temporary loss of consciousness, seen in five patients. All recovered within an hour and resumed getting the infusion.
Brexanolone is a synthetic form of allopregnanolone, a hormone produced by progesterone in the brain that may help ease depression and anxiety by dampening neural activity, said Dr. Samantha Meltzer-Brody, director of the perinatal psychiatry program at the University of North Carolina at Chapel Hill, who was the principal investigator for the brexanolone studies.
The research presented to the F.D.A. consisted of three clinical trials that were led by Dr. Meltzer-Brody and funded by Sage Therapeutics, which was also involved in the study design, data analysis, interpretation and writing of the reports.
The trials involved 247 women randomly selected to receive a placebo or brexanolone — a relatively small number of participants, compared to many other medical trials.
Still, the results were considered persuasive by a joint F.D.A. advisory committee last year, which recommended approval in near-unanimous votes.
The women in the trials had given birth within six months of getting the infusion and were experiencing severe or moderate depression that had started in the third trimester of pregnancy or within four weeks after childbirth. Participants could not have psychosis or bipolar disorder. Their symptoms could include suicidal thoughts but not a recent suicide attempt.
They were asked to stop breast-feeding during the infusion and for a few days after. But Dr. Meltzer-Brody said the drug appears safe for nursing mothers and babies, because very little of it seeps into breast milk.
Depression improved
in the women receiving brexanolone and in those receiving placebo, a
phenomenon common in studies of depression treatments. But more women in
the brexanolone group showed improvement, and their improvement was
more substantial.
In one trial, severely depressed women started with scores of about 28 out of 30 on the Hamilton Depression Scale, a standard evaluation tool. After the infusions, the placebo group averaged about 14 while the brexanolone groups averaged at 9 or 10.
A person with a score of 7 or below is considered to be virtually without depressive symptoms. About twice as many women on brexanolone achieved that status, Dr. Meltzer-Brody said.
After a month, more brexanolone patients managed to keep depressive symptoms at bay, compared to those who received placebos. But in a study of moderately depressed women, those receiving placebos reported feeling as good as the brexanolone patients after 30 days.
That may mean that standard antidepressants finally began kicking in, Dr. Spinelli said. Or perhaps the subjects simply improved on their own.
“We’re going to have more data to understand what happens in a larger population after 30 days,” Dr. Meltzer-Brody said.
Dr. Jeff Jonas, the chief executive of Sage, who trained as a psychiatrist, said he believed the infusion would initially be delivered in hospitals, but “we are talking to family practitioners, we are looking at pediatricians, ob-gyns.”
Dr. Jonas said the experimental pill, given for two weeks in the clinical trials, seems to offer the same benefit as the infusion. It is being tested for treatment of major depression in addition to postpartum depression.
https://www.nytimes.com/2019/03/19/health/postpartum-depression-drug.html
In one trial, severely depressed women started with scores of about 28 out of 30 on the Hamilton Depression Scale, a standard evaluation tool. After the infusions, the placebo group averaged about 14 while the brexanolone groups averaged at 9 or 10.
A person with a score of 7 or below is considered to be virtually without depressive symptoms. About twice as many women on brexanolone achieved that status, Dr. Meltzer-Brody said.
After a month, more brexanolone patients managed to keep depressive symptoms at bay, compared to those who received placebos. But in a study of moderately depressed women, those receiving placebos reported feeling as good as the brexanolone patients after 30 days.
That may mean that standard antidepressants finally began kicking in, Dr. Spinelli said. Or perhaps the subjects simply improved on their own.
“We’re going to have more data to understand what happens in a larger population after 30 days,” Dr. Meltzer-Brody said.
Dr. Jeff Jonas, the chief executive of Sage, who trained as a psychiatrist, said he believed the infusion would initially be delivered in hospitals, but “we are talking to family practitioners, we are looking at pediatricians, ob-gyns.”
Dr. Jonas said the experimental pill, given for two weeks in the clinical trials, seems to offer the same benefit as the infusion. It is being tested for treatment of major depression in addition to postpartum depression.
https://www.nytimes.com/2019/03/19/health/postpartum-depression-drug.html
Don’t Make Health Care a Purity Test
by Paul Krugman - NYT - March 21, 2019
We’re now in the silly season of the Democratic primary — a
season that, I worry, may last all the way to the nomination. There are
many honorable exceptions, but an awful lot of reporting seems to be
third order — not about the candidates, let alone their policy
proposals, but about pundits’ views about voters’ views of candidates’
electability. It’s a discussion in which essentially nobody has any idea
what he or she is talking about.
Meanwhile, however, there are some real continuing policy debates. They’re not mainly about goals: Whoever the Democrats nominate will profess allegiance to a progressive agenda aimed at reducing inequality, strengthening the social safety net and taking action on climate change. But there are some big differences about how to achieve those goals.
And the starkest divide involves health care. Almost surely, the eventual platform will advocate “Medicare for TK.” But what word is eventually chosen to replace the placeholder “TK,” and more important, what that means in terms of actual policy, will be crucial both for the general election and for what comes after if Democrats win.
On one side, there’s “Medicare for All,” which has come to mean the Bernie Sanders position: replacing the entire existing U.S. health insurance system with a Medicare-type program in which the government pays most medical bills directly.
Meanwhile, however, there are some real continuing policy debates. They’re not mainly about goals: Whoever the Democrats nominate will profess allegiance to a progressive agenda aimed at reducing inequality, strengthening the social safety net and taking action on climate change. But there are some big differences about how to achieve those goals.
And the starkest divide involves health care. Almost surely, the eventual platform will advocate “Medicare for TK.” But what word is eventually chosen to replace the placeholder “TK,” and more important, what that means in terms of actual policy, will be crucial both for the general election and for what comes after if Democrats win.
On one side, there’s “Medicare for All,” which has come to mean the Bernie Sanders position: replacing the entire existing U.S. health insurance system with a Medicare-type program in which the government pays most medical bills directly.
The big difference from a Sanders-type plan is that people would be allowed to keep private coverage if they chose — but they or their employers would also have the option of buying into an enhanced version of Medicare, with substantial subsidies for lower- and middle-income families.
The most important thing you need to know about these rival plans is that both of them would do the job.
Many people realize, I think, that we’re the only advanced country that doesn’t guarantee essential health care to its legal residents. My guess is that fewer realize that nations achieve that goal in a variety of ways — and they all work.
Every two years the Commonwealth Fund provides an invaluable survey of major nations’ health care systems. America always comes in last; in the latest edition, the three leaders are Britain, Australia and the Netherlands.
What’s remarkable about those
top three is that they have radically different systems. Britain has
true socialized medicine — direct government provision of health care.
Australia has single-payer — it’s basically Bernie down under. But the
Dutch rely on private insurance companies
— heavily regulated, with lots of subsidies, but looking more like a
better-funded version of Obamacare than like Medicare for All. And the
Netherlands actually tops the Commonwealth Fund rankings.
So which system should Democrats advocate? The answer, I’d argue, is the system we’re most likely actually to create — the one that will play best in the general election, and is then most likely to pass Congress if the Democrat wins.
And there’s one big fact on the ground that any realistic health strategy has to deal with: 156 million Americans — almost half the population — currently receive health insurance through their employers. And most of these people are fairly satisfied with their coverage.
A Medicare for All plan would in effect say to these people, “We’re going to take away your current plan, but trust us, the replacement will be better. And we’re going to impose a bunch of new taxes to pay for all this, but trust us, it will be less than you and your employer currently pay in premiums.”
The thing is, both of these claims might well be true! A simple, single-payer system would probably have lower overall costs than a hybrid system that preserves some forms of private coverage.
But even if optimistic claims about Medicare for All are true, will people believe them? And even if most people do, if a significant minority of voters doesn’t trust the promises of single-payer advocates, that could easily either doom Democrats in the general election or at least make it impossible to get their plan through Congress.
To me, then, Medicare for America — which lets people keep employment-based insurance — looks like a much better bet for actually getting universal coverage than Medicare for All. But I could be wrong! And it’s fine to spend the next few months arguing the issue.
So which system should Democrats advocate? The answer, I’d argue, is the system we’re most likely actually to create — the one that will play best in the general election, and is then most likely to pass Congress if the Democrat wins.
And there’s one big fact on the ground that any realistic health strategy has to deal with: 156 million Americans — almost half the population — currently receive health insurance through their employers. And most of these people are fairly satisfied with their coverage.
A Medicare for All plan would in effect say to these people, “We’re going to take away your current plan, but trust us, the replacement will be better. And we’re going to impose a bunch of new taxes to pay for all this, but trust us, it will be less than you and your employer currently pay in premiums.”
The thing is, both of these claims might well be true! A simple, single-payer system would probably have lower overall costs than a hybrid system that preserves some forms of private coverage.
But even if optimistic claims about Medicare for All are true, will people believe them? And even if most people do, if a significant minority of voters doesn’t trust the promises of single-payer advocates, that could easily either doom Democrats in the general election or at least make it impossible to get their plan through Congress.
To me, then, Medicare for America — which lets people keep employment-based insurance — looks like a much better bet for actually getting universal coverage than Medicare for All. But I could be wrong! And it’s fine to spend the next few months arguing the issue.
So Democrats should try to make this a real debate, one about the best strategy for achieving a shared goal. Can they manage that? I guess we’ll find out.
https://www.nytimes.com/2019/03/21/opinion/medicare-for-all-democrats.html
Health care legislative forum crowd packs library
Penobscot Bay Press - March 21, 2019
On Sunday, February 17, a crowd of 71 people packed the Blue Hill Public Library for a Health Care Legislative Forum hosted by the Downeast Chapter of Maine AllCare.
Senator Geoff Gratwick and Representative Sarah Pebworth outlined health care proposals that are currently before the state Legislature, and responded to audience questions leading to a discussion of health care concerns, issues, and possible solutions. Maine AllCare Executive Director Phil Bailey moderated the event.
Some of the outlined proposals target specific fixes, such as tackling out-of-control drug costs. Others aim to improve the health care system in Maine as a whole. One is LD 52, proposed by Sen. Gratwick, which would create a not-for-profit health care trust “for the benefit of the people” as part of simplifying Maine’s health care system, making it more equitable, and reducing costs, according to a news release. Sen. Gratwick and Phil Bailey noted that administrative costs of the for-profit private insurance system are in the range of 10 to 20 percent, compared with 3 to 5 percent for Medicare.
When asked what Maine AllCare’s role would be in the legislative process, Phil Bailey stated that policy experts will review bills moving through the legislature and report on how they align with Maine AllCare principles. These principles include treating health care as a public good, similar to public safety, roads, and schools; reducing costs; and covering all Mainers. Bailey expects “forward progress” in the legislature this session, and urged attendees to get involved and make their voices heard by signing up for Maine AllCare’s Legislative Response Team and testifying at public hearings, in person or in writing.
Sen. Gratwick asked during the discussion, “Is health care a marketable commodity?” Maine AllCare founder and retired physician Phil Caper echoed this question, noting that corporations that seek to profit from health care are doing what they are chartered to do: maximize returns for their shareholders. But to maximize profit, they have to minimize costs, including paying for fewer health care services. Caper asked, “Do we really want a health care system that discriminates against sick people?”
Rep. Pebworth and Sen. Gratwick urged constituents to contact their legislators with questions and concerns about health care. Pebworth noted that during her campaign in 2018 she heard over and over about health care issues from people of all political views and socioeconomic status. Legislators want to hear from citizens, and they also may have access to resources that can help, she said.
https://penobscotbaypress.com/news/2019/mar/20/health-care-legislative-forum-crowd-packs-library/#.XJTpyC2ZPOQ
It Will Take More Than Transparency To Reduce Drug Prices, Economists Say
by Alison Kodjak - Maine Public - March 22, 2019
A new drug to treat postpartum depression is likely to reach the U.S. market in June, with a $34,000 price tag. The approval of the drug by the Food and Drug Administration comes on the heels of another approval, just two weeks ago, of a different antidepressant, whose retail price will be as much as $6,700 a month.Those giant list prices send shivers through the insurance industry and across the federal government and state governments, which pay for about 40 percent of prescription drugs sold in the United States.
The Trump administration is working to bring those prices down. The Department of Health and Human Services in recent months has proposed a series of regulations aimed at reshaping the prescription drug market. The goal, administration officials say, is to create more competition and lower costs.
But economists and analysts, who applaud the efforts to bring clarity to what is now a murky pricing system, doubt the effort will actually cut total spending on prescription drugs.
"They're trying to ... improve the function of the market," says Sara Fisher Ellison, a health economist at the Massachusetts Institute of Technology. "But, to be honest, they probably missed the mark."
The biggest change proposed by HHS Secretary Alex Azar would upend the entire system that sets the prices for medications that people buy at their local pharmacies.
Today those prices are negotiated in secret, as rebates between drug companies and middlemen known as pharmacy benefit managers. The PBMs often keep a share of the rebates for themselves, and when consumers have to pay for their medications, to meet a deductible for example, they have to pay that full pre-rebate price.
Azar says his plan would "replace today's opaque system of rebates, which drives prices higher and higher, with a system of transparent and upfront discounts delivered directly to patients that will finally drive prices down."
Those discounts would no longer be secret, and consumers who have to pay for some drugs would pay that discounted price.
The plan would not only help consumers at the pharmacy counter, Azar says, but also motivate drugmakers to lower their inflated list prices. HHS is accepting public comments on this proposed rule until April 8.
The change is revolutionary, says Dr. Walid Gellad, director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh.
"The competition between companies has been on how big a rebate they can give," Gellad says, "and the way that you give a big rebate is by increasing the list price. So the idea is to get rid of that so that companies can compete based on getting the list price lower."
But Len Nichols, an economist and the director of the Center for Health Policy Research and Ethics at George Mason University, doubts that the changes will end with overall prices being lower than the deals that pharmacy benefit managers get today.
"The truth is [the PBMs] still, on balance, lower prices from what they would be if they didn't exist," Nichols says. "Which is exactly why we need them."
The drug market is not like a normal retail market, Nichols says, because it's dominated by a few powerful companies — the PBMs — that are practically required to buy almost all the products offered by the drug companies.
In that type of system, price transparency can lead to higher prices, Nichols and other economists say.
"One way to think about it is ... imagine if what you wanted was for a cartel to work perfectly," he says. "One way a cartel works perfectly is if all members of the cartel know everybody else's price."
In October, Azar also proposed requiring drug companies to include the list prices of their medications in television and magazine ads — that proposal is still pending. Drugmakers oppose that requirement because, they say, those list prices are irrelevant precisely because of the rebate system. Nobody pays the actual list price, they argue.
But there is some evidence that drug companies don't want the huge price tags they put on their products to be widely publicized. That "naming and shaming" of companies can have an impact on their behavior, says MIT's Fisher Ellison.
Still, she says, while the focus on publicizing prices for consumers seems like it should work, it may not have much effect on overall spending.
That's because consumers not only don't pay list prices but also don't really choose which medication they're buying. That decision is in the hands of their doctor. And, unlike with toothpaste or soda, it's not easy for a consumer to switch brands of medicine.
"You can imagine a patient walking into a pharmacy, and he has a prescription for Lipitor and then finds out that Zocor, which is a similar drug, is a lot cheaper. Well, there's nothing he can do at that point," Ellison says.
When it comes to driving down prices, analysts say HHS's third proposal is likely to work. That plan would tie the price that Medicare pays for drugs that are administered in a hospital or clinic — such as IV drugs for cancer or arthritis — to the prices paid in other countries.
That proposed rule — which has received more than 2,700 public comments — is facing steep opposition from the U.S. Chamber of Commerce, which has been running an aggressive campaign against the proposal. It's unclear when the proposal might be finalized.
And doctors who administer the drugs are also opposed, saying it may hurt patients' access to medications.
"I've basically traveled the world ... looking at cancer care," says Ted Okun, the executive director of the Community Oncology Alliance, "and other countries do not have the access to the drugs that we have here."
But Azar dismisses that argument. He says the U.S. price for a drug will still be higher than prices paid elsewhere and says he doubts any companies will stop selling their products in the huge U.S. market just because prices are lower than they are today.
https://www.mainepublic.org/post/it-will-take-more-transparency-reduce-drug-prices-economists-say
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