Health Care Reform Articles - December 29, 2019

Who’s Afraid of Medicare for All?

Not ordinary Democrats or independents — just insurance companies, lobbyists, and old-line politicians.

by Jim Hightower - OtherWords - December 11, 2019

Not ordinary Democrats or independents — just insurance companies, lobbyists, and old-line politicians.
We might expect that corporate billionaires and Koch-funded Republican right-wingers would be howl-at-the-moon opponents of a wealth tax, Medicare-for-All, and other big progressive ideas to help improve the circumstances of America’s workaday majority.
But Democrats, too? Unfortunately, yes. Not grassroots activists, but a gaggle of don’t-rock-the-corporate-boat, fraidy-cat elected Democrats.
These naysayers are the party’s old-line politicians, lobbyists, and other insider elites who are now screeching that Democratic candidates must back off those big proposals.
Why? Because, they squawk, being so bold, so progressive, so — well, so Democratic — will scare voters. As one meekly put it: “When you say Medicare for All, it’s a risk. It makes people afraid.”
Excuse me, but in my speeches and writings I say “Medicare for All” a lot — and far from cowering, people stand up and cheer.
In fact, the New York Times just reported that 81 percent of Democrats (and two-thirds of independents) support Medicare for All. Even apple pie doesn’t score that high! It’s simply a lie that the people are “afraid” of the idea of everyone getting public-financed health care.
So who really fears it? Three special-interest groups: Insurance company profiteers, Big Pharma price gougers, and the political insiders hooked on funding from those corporations.
Not only is it a pusillanimous fabrication to claim that the people oppose any changes stronger than corporate minimalism, it’s also political folly. If the Democratic Party won’t stand up for the transformative structural changes that America’s middle and low-income majority clearly wants and needs, why would those people stand up for Democrats?
As the 2016 presidential election taught us so painfully, a whole lot of the working class Democrats the Party counts on won’t.
https://otherwords.org/whos-afraid-of-medicare-for-all/

Betsy Sweet: ‘Medicare for All’ is the only solution to the U.S. health care crisis

In the U.S. Senate, I will fight for a system that puts people before profit and includes everybody. 

by Betsy Sweet - Portland Press Herald - December 21, 2019

I met a woman on the campaign trail who had recently been diagnosed with cancer. Her prognosis was positive, however, pending the traditional treatment regimens of radiation and chemotherapy. I wished her luck with the process, and then she told me she was not pursuing treatment.
“Why?” I asked.
“Because no matter how much time I have left, I refuse to spend the rest of my days fighting with my insurance company, stressed out about what’s covered and what I can afford. I’m going to live out my days in peace,” she said.
Here is a woman with insurance, diagnosed with cancer, with a positive prognosis and “access” to treatment, choosing to forgo that treatment so that she can spend the last of her days with those she loves instead of arguing with her insurance company.
How many of us have spent hours on the phone or online with our insurance providers? How many of us – including me – have spent hours on the phone or online trying to sign up for insurance via the insurance exchange, only to find that even the lowest-level plans are unaffordable and include ridiculous deductibles, co-pays and in-/out-of-network restrictions?
The health care system in this country is working as it was designed. It’s not broken. It’s “fixed” in such a way that our health is the least of industry’s concerns. It is designed to generate profit for the insurance and pharmaceutical industries.
It is unconscionable that in this country that we allow this industry to buy our politicians and our elections to maintain a system where their CEOs rake in millions while everyday Americans go bankrupt because someone in our family gets sick, is involved in an accident or needs round-the-clock care. This is not health care – it is wealth care.
“Medicare for All” is the foundational change we need. It covers everyone and every illness. It will cover long-term care, hearing aids, glasses and dental care.
And what industry fat cats and middle-of-the-road politicians don’t want you to know is that Medicare for All saves all of us and the country money. A conservative estimate is that Medicare for All will save us $2 trillion from what we spend now.
Medicare for All is not a pie-in-the-sky idea. It is simply transforming our current health care system – one that we are all currently paying for in multiple ways – into one where no one has to decide between paying rent and seeing a doctor.
“But some people love their private insurance and they don’t want to lose it,” opponents say. Not true. What people fear is losing the care that health insurance affords them. The truth is, the only things any of us will lose under Medicare for All are premiums, co-pays, deductibles, out-of-network charges and hidden fees.
“But how will you pay for it?” opponents ask. The answer: with a fair taxation system. We will start by making corporations like Amazon, Netflix and General Dynamics start paying taxes. We will stop allowing insane profits for the pharmaceutical companies. What I want to know is: How will proponents of a “Medicare for those who want it” system pay for what they are proposing? Without the savings from Medicare for All, how does Medicare “for those who want it” work? How does it lower Medicare costs and private insurance costs? How does keeping a for-profit model in the system ensure every single person is covered? The answer: It doesn’t.
Medicare for All is the only comprehensive option that will cover every one of us while actually saving money. Don’t fall for the fear mongering and lies from those who benefit from the current system. Know that the insurance, health care and pharmaceutical industries – along with the politicians they pay for – wouldn’t be fighting so hard to stop Medicare for All if they knew it wouldn’t turn out to be one of the most popular pieces of social legislation this country has ever seen.
I will continue fighting for a health care system that puts people before profit and that includes each and every one of us. I hope you’ll join me.

https://www.pressherald.com/2019/12/21/betsy-sweet-medicare-for-all-is-the-only-solution-to-the-u-s-health-care-crisis/

What Other Countries Can—and Can’t—Teach the United States
By William C. Hsiao - Foreign Affairs - January/February 2020
There are many statistics that illustrate the flaws of the U.S. health-care system. One in particular stands out. In 2017, Americans spent an average of $10,224 per person on health care, according to a Kaiser Family Foundation study. The equivalent figure across similarly wealthy countries that year was just $5,280. Yet despite spending almost twice as much as Australians, Canadians, Japanese, and many Europeans, Americans suffer from lower life expectancy, higher infant mortality rates, and a higher prevalence of heart disease, lung disease, and sexually transmitted infections.
This reflects the deep dysfunction in the U.S. health-care system. Experts estimate that around 30 percent of the money spent on health care in the United States—around $1 trillion a year—is wasted on inefficiencies, excessive administrative expenses, the duplication of services, and fraud and abuse in insurance claims. Meanwhile, huge numbers of Americans remain uninsured or underinsured. The 2010 Affordable Care Act (ACA) attempted to address such problems but has proved insufficient for many reasons—including the Trump administration’s efforts to hollow out the legislation.
It is true that some Americans have better access to advanced technologies and drugs than do most Canadians and Europeans. And in certain fields, such as cancer diagnostics and treatment, the United States offers unsurpassed care. What is more, on average, Americans experience shorter wait times for certain specialty services, such as orthopedic surgery. But the fact remains that when it comes to health care, Americans pay more and get less.
Establishing truly effective and affordable universal health care will require a dramatic overhaul. Just what sort of change will be necessary is the subject of fierce debate right now, especially within the Democratic Party. One alternative would be to shift to a single-payer system along the lines of the Medicare for All proposals introduced by Senator Bernie Sanders of Vermont and Senator Elizabeth Warren of Massachusetts, who are running for the Democratic presidential nomination. If properly carried out, such a plan would be cost-effective and would bring about major improvements in U.S. health care. But it is far from certain that it would prove politically possible, since it would require raising taxes and, even more controversial, abolishing most forms of private health insurance.
U.S. policymakers should adapt rather than adopt foreign health-care systems.
A less far-reaching, less cost-effective, but perhaps more politically achievable option would be a gradual transition that would maintain the multiple-payer model for two to three decades while steadily increasing the role and authority of government at the federal and state levels. The ultimate result would be a hybrid system in which a number of insurers, including private ones, would continue to exist but a single payer—a partnership between the federal and state governments—would predominate.
Proponents of major reform often point to the disparity between health-care costs and outcomes in the United States and those in other developed economies and argue that Washington should look abroad to fix what is broken at home. This is indeed a good idea—but only if U.S. policymakers choose the right foreign models. For examples of highly successful single-payer systems, they should look to Canada and Taiwan. For inspiration on a hybrid system that would not require scrapping private insurance right away, they should consider the German model. The governments and societies of those places differ in important ways from those of the United States, of course; in considering foreign health-care systems, U.S. policymakers should adapt rather than adopt. But any reform effort that ignores these successes would deprive Americans of solutions that would allow them to live longer, healthier lives.

A DIFFERENT KIND OF AMERICAN EXCEPTIONALISM
The United States is the only advanced economy that does not offer universal health-care coverage. For the past five decades, Washington has moved in fits and starts toward that goal but has never quite arrived. In 1965, major reforms to expand insurance coverage led to the establishment of Medicare (to cover the elderly and the disabled) and Medicaid (to cover the poor). That expansion was extended in 2010 by the ACA, or Obamacare, which made coverage accessible to the “near poor” (those making an income between the poverty line and 25 percent above it) and others without health insurance. Today, however, 28 million Americans remain uninsured, and 44 million are underinsured, meaning they spend more than ten percent of their incomes on out-of-pocket health-care expenses.
This has a profound effect on American society. The news media often focus on the more than half a million household bankruptcies that medical bills induce every year, but other substantial harms are less well recognized. The uninsured and the underinsured delay or even forgo treatment when they are ill, and their children often do not receive critical immunizations. This contributes to a pernicious form of inequality: on average, the top quarter of American earners live ten years longer than those in the bottom quarter. Making matters worse, the system is terribly inefficient. The amount spent in the United States on administrative expenses related to health care is three times as high as that in other advanced economies. That is because in a multiple-payer system, insurers offer many different policies, each one featuring distinct benefits packages, premium rates, and claim procedures. At the same time, insurers negotiate separately with hospitals and clinics, which means they pay different prices for the same services. So to file claims, health-care providers have to employ vast administrative staffs to sort out the various plans, rules, and prices.
Fraud and abuse also drive up the price of care, accounting for around $150 billion in unnecessary spending every year, according to the best estimates available. A cottage industry has sprung up to advise hospitals and physicians on how to game the claims system by fragmenting bills and “upcoding” services—exaggerating their complexity—in order to maximize payments. Large providers now employ workers whose main task is to find ways to pad charges. Some hospitals and clinics take a blunter approach: they simply file claims for services they have not actually performed.
The structure of the U.S. system also plays a role in driving up prices. Multiple payers lack the market power to negotiate effectively with pharmaceutical companies and providers for reasonable prices. When one insurance plan is able to negotiate a lower price, a company or a provider can adapt by simply charging other insurance plans higher prices. Indeed, the exact same service or medical procedure can vary in price by more than 300 percent. Meanwhile, in some places in the United States, hospitals enjoy a monopoly on most forms of medical care, which allows them to charge high prices. And even in places where competition exists, patients often mistakenly believe that higher prices indicate a higher quality of care.
The root of these problems is that as the United States became a prosperous, industrialized society in the early twentieth century, it chose to treat health care as a commercial product rather than as a social good, such as education. As a result, whereas government-mandated universal schooling had become the norm by the 1920s, health care still remains primarily a private-sector activity driven by the profit motive.
But the markets for health insurance and health care have failed in a number of serious ways. Consider, for example, the effects of the asymmetry of information between buyers and sellers of health insurance, what economists call “adverse selection.” Unhealthy people are much more likely to buy insurance than healthy people, which drives up premiums to unaffordable levels. Insurers, meanwhile, optimize profits by trying to sell coverage only to those they consider “good risks,” such as relatively young and healthy people, and by avoiding the unhealthy, the disabled, and the elderly. A similar asymmetry distorts the health-care market, because physicians (the sellers) have far superior medical knowledge compared with patients (the buyers), which puts the former in a dominant position in any transaction.
In a hybrid system, private insurers would continue to exist, but a single payer would predominate.
The system of employer-based health insurance that defines the current U.S. system blossomed during World War II. At that time, wages were largely frozen, and employers found that offering health insurance was one way to compete for scarce workers. After the war, the United States did not follow European countries in establishing universal health insurance programs owing in part to institutional opposition from powerful special interests that took advantage of the politics of the early Cold War period. In the late 1940s, President Harry Truman made a concerted effort to introduce national health insurance. But the deep-pocketed American Medical Association opposed the program, hoping to protect physicians’ superior market power and professional autonomy. The AMA mobilized its nationwide network of county medical societies to stir up fear that the plan would lead to “socialized medicine.” The AMA went so far as to call the plan “un-American” and deride the Truman administration as following “the Moscow party line.” Opponents of universal coverage have relied on variations of the same playbook ever since.
Slowly but steadily, however, public sentiment has shifted, resulting first in the advent of Medicare and Medicaid and later in the passage of the ACA. According to public opinion polls conducted by the Kaiser Family Foundation, between 2000 and 2019, the proportion of Americans with a favorable opinion of a single-payer, government-run health insurance system rose from 40 percent to 53 percent. The question, it seems, is no longer whether the United States will establish a single-payer system, or at the very least a hybrid system radically different from the one it has now. The question, instead, is how that change will take place and what kind of system it will produce. To help find answers, Americans should look to three places: Canada, Taiwan, and Germany.
HEALTHY, WEALTHY, AND WISE
Canada established single-payer universal health insurance in 1968. The Canadians opted for a one-tiered system built on the principle that coverage should be not just universal but also equal. Canada thus forbids private insurers from duplicating the benefits offered by the government and prohibits physicians and hospitals from serving both publicly insured patients and those with private insurance. Providers must choose to serve one group or the other.
In the Canadian system, the federal government sets national standards and funds 50 percent of the cost. The country’s 13 provinces fund the other half and run their own programs, acting as the single payer for their residents, determining payment rates to providers, and negotiating with pharmaceutical companies. This arrangement vastly reduces the potential for fraud and waste because the single payers maintain uniform records of each medical transaction and closely monitor every provider’s behavior. In 2018, Canada spent $4,974 per person on health care. Administrative expenses related to insurance accounted for just six to eight percent of overall spending because there is only one set of rules and procedures for filing claims. Likewise, hardly any fraud or abuse occurs because a comprehensive data-collection system allows authorities to monitor the performance of all providers. And the system is highly effective: life expectancy in Canada is 82 years, and the infant mortality rate is 4.5 deaths per 1,000 births—better on both counts than in the United States, where life expectancy is 79 years and the infant mortality rate is 5.8 deaths per 1,000 births.
Canada served as the most important model for Taiwan, which established universal health insurance in 1995. Like the Canadians, the Taiwanese set up a single-payer system in which people freely choose their providers, which encourages clinics and hospitals to compete on quality and efficiency. But there are some significant differences between the two approaches. As a small, densely populated island, Taiwan opted to centrally administer its program. Patients also have modest copayments to deter the overuse of services and drugs. In Canada, government budgets finance the program, which means that the level of support fluctuates, depending on the agenda of the political party in power at any given time. Taiwan, in contrast, adopted a more stable financing arrangement that relies on earmarked taxes, insulating the system from changes in the political landscape. Taiwan also took inspiration from the actuarial methods used by the U.S. Medicare program to assure its long-term sustainability.
Taiwan leapfrogged other countries with single-payer systems by developing innovative data technology to monitor patients’ care and to detect and deter fraud and abuse. For example, in the initial years of its program, Taiwan found that several physicians were submitting suspicious bills that, had they been accurate, would have required them to work 24 hours a day, seven days a week. Administrators turn over such suspect claims to a local committee of practicing physicians, which deals with fraudsters by applying sanctions—including, in serious cases, stripping them of their licenses to practice. During the first year in which this process was followed, the overall amount that physicians and hospitals charged the system fell by eight percent.
The Taiwanese system is remarkably cost-effective: in 2016, Taiwan spent $1,430 per person on health care, and only between five and six percent of that spending related to the administrative costs of the single-payer system. As in Canada, there is hardly any fraud or abuse. And as in Canada, life expectancy (81 years) is better than in the United States, as is the infant mortality rate (3.9 deaths per 1,000 births).
Should the United States treat health insurance primarily as a commercial product or as a social good?
Germany offers a different model—not least because its system has evolved over a long period of time. In 1883, German Chancellor Otto von Bismarck declared that industries, occupational guilds, and agricultural cooperatives would have to form nonprofit health insurance programs, called “sickness funds,” for their members. Numerous funds were established, each one offering distinct benefits packages, premium rates, payment rates to providers, and claim procedures. People could enroll in the fund of their choice. But many opted out and remained uninsured. Eventually, in 1914, Germany passed legislation compelling all workers in selected industries earning less than a certain amount to obtain coverage; those who earned more could voluntarily enroll or purchase private insurance. After World War II, West Germany continued that system, which was extended to the former East Germany after reunification.
Germany’s multiple-payer system, however, suffered from inefficiency and waste because separate groups of people were pooling their health risks, which led to highly variable premium rates. So in the 1990s, Germany’s legislature began requiring all funds to offer a standard benefits plan. The various funds pool the premiums they receive, which the central government then allocates to the funds based on the health risks of the people enrolled in them. Meanwhile, associations of sickness funds in each state negotiate with that state’s medical association to design a single set of claim procedures and a uniform payment rate for physician services. Likewise, all hospitals in a given state negotiate one uniform set of rules, procedures, and rates with that state’s hospital association. One result of these reforms has been a vast reduction in the number of sickness funds, from around 1,200 in 1993 to just 115 today.
Germany’s hybrid system now relies on doctors in private practice for physician services and a mixture of public and private hospitals for hospital care. Patients can freely choose their providers. The federal government sets the rules and negotiates with pharmaceutical companies, allowing Germany to keep drug prices relatively low. In 2017, Germany spent $5,728 per person on health care. Some fraud and abuse exist, but at far lower levels than in the United States. Life expectancy is better than that in the United States (81 years), and the infant mortality rate (3.4 deaths per 1,000 births) is lower.

THE PERFECT AND GOOD
A number of clear lessons for the United States emerge from these three places. Perhaps the most basic one is the need for a broad public consensus about the values that should shape any reform. Should the United States continue to treat health insurance primarily as a commercial product shaped by market forces and one that everyone can choose to either acquire or do without? Or should health insurance be understood more as a social good akin to primary and secondary education: guaranteed by the state, paid for primarily by taxation, and mandatory for everyone?
If Americans do decide to shift away from a market-based system, the cases of Canada, Taiwan, and Germany show that Washington would need to mandate that every citizen and permanent resident enroll in a health insurance plan that offers a standard benefits package. Otherwise, health risks would not be pooled across the healthy and the unhealthy, the rich and the poor. The U.S. federal government could fund universal coverage through a payroll tax on both employers and employees; the poor and the near poor would receive subsidies to offset the tax burden. A better method, however, would be taxes on income and wealth, which would be more progressive and therefore fairer. Moreover, payroll taxation is less effective than in the past because in contemporary economies formal employment has become less common as companies increasingly hire independent contractors rather than staffers. It’s for these reasons that Taiwan and Germany gradually shifted away from payroll taxes to fund their systems and adopted earmarked income taxes instead.
Proponents of Medicare for All should take a careful look at the German model.
Would Americans have to pay more for health care under a single-payer system similar to those in Canada and Taiwan? A definitive study published in 2018 by a team of researchers led by the economist Robert Pollin has determined that they would not. In fact, Americans would see a net reduction in overall health expenditures. According to the report, the United States could save more than $250 billion each year by establishing a single-payer system.
The plans put forward by Sanders and Warren incorporate many features of the Canadian and Taiwanese approaches: a single payer with one comprehensive standard benefits package for all, free choice of providers, uniform payment rules, and procedures that would vastly reduce administrative expenses and limit fraud and abuse. The savings would be great enough to pay for covering uninsured and underinsured Americans while still giving most Americans a reduction in their health expenses. The plans would raise taxes: some payroll, income, and wealth taxes would have to increase. But those increases would be offset by reductions in other taxes and by a vast drop in premiums.
Medicare for All, or a plan similar to it, would encounter strong opposition. People’s fear of a major change would be a paramount obstacle. Americans who are currently insured might worry that their benefits would be reduced. Physicians, nurses, and hospitals might see a threat to their incomes. The public would resist higher taxes, even though they would be paying less for health care overall. And insurance companies, pharmaceutical firms, and powerful interest groups such as the AMA and the American Hospital Association would lobby hard against a shift to genuine universal coverage. Although Americans have begun to take a more favorable view of single-payer systems in recent years, it’s far from clear that the idea has enough popular support to clear such hurdles.
Perhaps a more practical approach would be for the United States to follow Germany’s lead and to undertake reforms that would allow for multiple insurers but create a uniform system of payments and electronic records to help control waste and fraud. Such a system would also let insurers collectively bargain with major pharmaceutical companies for reasonable drug prices. These measures alone could save somewhere between $200 billion and $300 billion each year—savings that, along with modest tax increases, could be used to expand existing public coverage for the uninsured.
Over time, the United States could go further, as Germany did, and pool the enrollees of various private insurers into a state-level or federal-level risk pool and then introduce regional health budgets to control costs. This gradual approach might take two to three decades and would likely require additional taxes along the way, since the savings available under this hybrid system would not be sufficient to cover the uninsured and the underinsured. But the German alternative would not require the abolition of private insurance in the near term, thus sidestepping one of the most politically problematic aspects of Medicare for All.
It’s possible that public sentiment will continue to shift and that support for a straightforward single-payer system will gain enough momentum to overcome the institutional and political obstacles that stand in its way today. In the meantime, however, proponents of Medicare for All and other sweeping reforms should take a careful look at the German model. It may not achieve all their goals as quickly as they would like. But the perfect should not be the enemy of the good, and such an approach would put the United States on the road to an equitable, sustainable, and affordable system of health care for all Americans.
https://www.foreignaffairs.com/articles/united-states/2019-12-10/how-fix-american-health-care

‘Medicare For All’ May Not Be The Political Suicide Mission Moderates Say It Is

New polling suggests Medicare for All can withstand some of the most common attacks.

By Tara Golshan and Kevin Robillard - Huffington Post - December 20, 2019

New polling from a left-leaning think tank casts doubt on a key part of the Democratic establishment’s conventional wisdom on health care, and could bolster progressive arguments that a candidate who supports universal single-payer coverage, or “Medicare for All,” could defeat President Donald Trump next November.
The progressive think tank Data For Progress tested some of the most common criticisms of Medicare for All ― that Americans would be forced to switch to a government-run health insurance plan, and that their taxes would likely go up. The survey of 5,881 registered voters, conducted in late November and early December, found Medicare for All was still regarded more favorably than not, even when voters were presented with the partisan attacks.
Fifty-one percent said they’d still support Medicare for All, which would move all Americans onto a single government-run health insurance plan, if it were to be paid for through employer and wealth taxes. Support dipped slightly if the program were to be paid through payroll taxes on individuals, but still Medicare for All remained more favorable than not by a margin of 47% to 42%.

“The numbers aren’t where [Medicare for All] advocates want to them to be, but they’re also not where people who think Medicare for All will lose Democrats the election say they are,” Sean McElwee, who runs Data For Progress, said. “There is a message that Trump could use that would reduce support for a Medicare for All candidate but it never reduces them below a comfortable margin.”
The Kaiser Family Foundation, which has been tracking support for Medicare for All since 2017, found similar results. Fifty-three percent of adults said they support a national health plan, like Medicare for All, in November. That said, a larger share of Americans ― including, most notably, independents ― favor a public option plan over Medicare for All. Large majorities of Democrats support both plans, but among independent voters, 52% support Medicare for All, while 69% say they support a public option.
The Data For Progress release complicates the claims of moderate candidates in the Democratic presidential primary, like Vice President Joe Biden and South Bend, Indiana, Mayor Pete Buttigieg, who have lately been declaring victory on health care. They, along with industry groups and centrist Democrats, have argued that Medicare for All is unpopular and that pursuing it could squander a key advantage for Democrats. Earlier this month, Biden told reporters the American people were with him on the issue.
“I don’t think ... that’s where the center of the party is or the left or the right of the party,” Biden said, according to The Associated Press. “And I think ... people are gonna find some version of what I’ve been talking about for a long time, and it’s to build on Obamacare with a public option.”
Sen. Elizabeth Warren (D-Mass.), another presidential hopeful, has taken a recent dip in the polls, which is largely seen as a result of her proposal for how to finance Medicare for All. Her national polling numbers dropped from all-time highs in October, when she led the Democratic field, to third place by December — the same stretch of time her campaign became focused on health care. Buttigieg and Biden’s campaigns both attacked Warren for failing to find a way to cover the proposal’s $32 trillion price tag without raising taxes on the middle class, as she has promised.
Meanwhile, Buttigieg, who has doubled down on his “Medicare For All Who Want It” plan, expanding the Affordable Care Act to include a public option with automatic enrollment, has seen his stock rise in early states. He’s been running ads attacking Warren and Sen. Bernie Sanders (I-Vt.) on health care in Iowa, championing the public option with the tag line “Makes More Sense.”
But the analysis that Medicare for All is too politically dangerous for the general election might be premature. Sanders, who popularized Medicare for All in 2016 and is its most strident advocate in the presidential field, remains the most trusted candidate on health care among Democrats and Democratic-leaning independents, according to the KFF polling. A HuffPost/YouGov poll conducted from Dec. 12 to Dec. 14 similarly found that Democrats and independents agree most with Sanders, followed by Warren, on health care.
Measuring public opinion around Medicare for All policy is complicated. Its association with Medicare ― one of the federal government’s most popular programs ― usually means it polls well at first glance. But as a massive government overhaul that would cost tens of trillions of dollars, it also presents numerous potential vulnerabilities.
Moderates argue those vulnerabilities are too much of a risk when it comes to what voters say is their top issue. “If we pursue a health care policy that people find scary or bad, then we could forfeit a natural advantage,” said Matt Bennett, one of the co-founders of Third Way, a centrist think tank. “The minute you fire one shot at [Medicare for All], it kind of falls off a cliff.”
The HuffPost/YouGov poll attempted to test how much Democrats’ advantage on health care might shrink if their nominee ran on Medicare for All. Among registered voters, 44% said they would support Medicare for All, while 42% opposed it.
Asked if they would prefer Medicare for All or a GOP-sponsored alternative, 39% picked Medicare for All, while 37% backed a theoretical GOP plan. Asked if they would prefer sticking with the Affordable Care Act or a theoretical GOP plan, 44% wanted to stay with Obamacare, while 39% backed a GOP plan.
Some Democratic pollsters have examined the question in other ways. An October poll sponsored by the advocacy group Protect Our Care and conducted by Hart Research found that voters, by a 48% to 31% margin, would prefer that Democrats focus on working to “reduce excessive drug prices, protect people with preexisting conditions, and stop efforts by the Trump administration to roll back coverage” over seeking “major changes in the health insurance system to achieve universal health insurance.”
Democrats who are neutral in the primary are also increasingly arguing that the party would retain an advantage over Trump and Republicans on health care issues even if the nominee runs on Medicare for All. While not necessarily downplaying potential political drawbacks from Medicare for All, they argue that Trump’s positions ― which include his support for an unpopular Obamacare-repeal plan and his backing of a lawsuit aiming to kill the law ― will be toxic to voters regardless.
In the HuffPost poll, 52% of registered voters said they disapprove of Trump’s handling of health care, while just 38% approved of it. American voters have consistently looked down on Trump’s handling of the issue. The poll also found that voters still trust the Democratic Party more on health care by a 45% to 35% margin, though a significant chunk of voters remain undecided.
“Democrats are arguing between Sprint and Verizon, when Donald Trump is offering the American people two cans and a piece of string,” said Jesse Ferguson, a former top official at the Democratic Congressional Campaign Committee who has consulted health care advocacy groups.
https://www.huffpost.com/entry/medicare-for-all-polling-popular-attacks_n_5dfc1221e4b0843d35f8fece?ncid=newsltushpmgpolitics

This Maine man lost his ACA insurance because he got married. He’s not alone.

by Troy Bennet - Bangor Daily News - December 22, 2109

PORTLAND, Maine — It was no normal bagel-and-knife mishap that put Owen Marshall’s career and marriage in jeopardy.

Marshall, a musician by trade, had already sliced the bagel in half a couple days before, without incident. He then put the bisected breakfast treat in the freezer. Pulling it out again a few days later, Marshall picked up the same sharp blade and tried to pry the two frozen halves apart.

That’s when he slipped. The knife tip plunged into his left hand, severing both of his little finger’s flexor tendons. Marshall immediately headed for a nearby urgent care center.

“It didn’t bleed much,” he said, “But then they wanted to move my finger, and I almost passed out. The realization of what happened was crushing.”

The injury would eventually keep Marshall out of work for six months. It also led him into an insurance black hole known as the Affordable Care Act’s “family glitch.”

Marshall would soon lose his ACA insurance subsidy because he had just gotten married. Without the subsidy, his premiums and deductibles soared at the same time his medical bills piled up. Without work, Marshall’s friends had to organize a fundraiser to help him get by. He finally got back to work this month but still faces hard choices. The only sure way to get his affordable health care back, is to get divorced.

 Marshall makes his living playing and teaching Celtic music. Adept at both guitar and bouzouki, he’s a highly sought after accompanist. Marshall works with some of the most famous names in the genre. He tours nationally and internationally. Marshall grew up in Vermont but now calls Portland home.

Though it’s not used much in normal life, his little finger is vital to his music playing. Marshall was forced to cancel all his immediate gigs, including a tour and video shoots with Seamus Eagan — one of the best-known names in the business.

“When I was in the emergency room, they told me I was going to be out for four to six weeks,” Marshall said.

But the estimate kept going up. The surgeon who repaired his hand said six to eight weeks. His occupational therapist said 10 to 16 weeks.

Though discouraged at first, his surgery and physical therapy went well. By the end of August, he was cleared to play again.

That’s when things got worse.

“I had just started my first set of hand-strengthening exercises, and I heard a snap,” Marshall said. “It was a loud pop. I couldn’t move my finger at all. It was done.”

He was forced to go through the same surgery and therapy again. Just a few days before the setback, his wife, Liana Wolk, stumbled into the ACA family glitch.

Wolk called to tell insurance administrators about Marshall’s change of life status, from single to married. The officials asked if he was now eligible to go on her employer-provided insurance. She said he was but it would be far too expensive.

They said the cost did not matter. If he had access to other insurance, his was no longer qualified for his ACA subsidy. What’s more, they informed her his deductible would be reset — at a much higher number — immediately. With his second round of medical bills and time out of work about to double, the news was devastating.

“That was a bad week,” Wolk said, “Knowing the the system was just completely screwing us.”

Marshall’s subsidised plan had him paying $40 a month in premiums with a $700 deductible. If he had gone on Wolk’s insurance, provided by her employer, Portland Adult Education, that would have shot up to $1,300 per month to cover both of them. For her alone, it’s just $120 each month.

As a self-employed musician, Marshall’s only choice was to remain on the ACA, minus the subsidy. That puts his premiums at $415 a month with a deductible reset at a whopping $5,800.

“It was a real kick in the teeth,” Marshall said. “We weathered the first injury OK. We made it through two months of me not working — it was now going to be five or six months of me with no work.”

Marshall and Wolk are not alone in their struggle to navigate the ACA family glitch according to Kate Ende of Consumers for Affordable Healthcare, an advocacy and education organization based in Augusta.

Ende’s organization is currently trying to count the number of Mainers affected by the glitch and hopes to have the numbers in early 2020. She said current national estimates put the number between 6.1 and 10.2 million Americans caught in the gray zone. Those numbers include spouses and children.

“These are just working families that, through no fault of their own, become ineligible for the subsidies,” Ende said. “Even though, based on income, they should qualify.”

It’s called a glitch but it’s not clear whether the gap between coverages was intentionally woven into the ACA.

“I’ve heard it was an oversight, but I’ve also heard it was a cost-saving mechanism,” Ende said. “To be honest, I don’t know what is the truth.”

Regardless of its origins, Ende said there’s currently no good solution to the problem, no workaround and no national legislation in the works to fix it.

In a cruel twist, the only sure way for Marshall to get his ACA subsidies reinstated would be to divorce his wife of six months.

“Divorce seems to be the only solution,” Marshall said. “We don’t know what we’re going to do yet.”

“Which sucks,” Wolk said. “The system has decided we need to pay $10,000 a year more just because we’re married, and I have a job that offers health insurance.”

Ende confirmed that Marshall would again be eligible for his ACA subsidy if he were single.

“And we’ve seen people do that,” Ende said, “Which seems crazy — not that we advise them to do that, but we’re happy to walk people through various scenarios.”

Fortunately, for Marshall and Wolk, their friends came to the rescue, for now.

When word got out about Marshall’s worsening predicament, his musical friends started an online fundraiser that netted $23,000 in a week. Donations came in from six different countries. With the addition of a September benefit concert in Portland, the total jumped to $27,000. Their original goal was $17,000.

“It was crazy,” Marshall said. “It’s making me emotional right now, just thinking about it.”

The money covered all his outstanding bills, as well as his summer’s lost wages.

Doctors once again cleared Marshall for work at the beginning of December. Currently, he’s working with a celtic Christmas show out of Boston.

“I’ve been playing every day and it’s getting there,” Marshall said. “My hand is getting stronger.”

Marshall said he knows he’s lucky. The glitch could easily have bankrupted him — but it didn’t, thanks to his caring friends. He thinks a lot about other people, in the same predicament, who don’t have the same resources.

“It’s not hard to imagine someone who doesn’t have this amazing network and community of musicians. There’s so many people who would not be able to rebound from this sort of thing,” Marshall said. “In my case, I’m someone who has some recognition, a lot of stage time, I’m talented — and those are the things that made it OK for me. That’s really messed up.”

https://bangordailynews.com/2019/12/22/news/portland/this-maine-man-lost-his-aca-insurance-because-he-got-married-hes-not-alone/

Traveling the loneliest road 

by Eli Saslow - Washington Post - December 21, 2019

It had been 10 days since her last visit to see him, the longest they’d been apart in 63 years of marriage. He had Parkinson’s disease, which made it impossible for him to talk on the phone. She’d called the nursing staff for daily updates, and they said her husband seemed quiet, and he was losing his appetite.
“Why is it still so bad out here?” Marlene asked. Her feet skidded on the ice, and she wrapped her arm around her daughter’s shoulder as they moved closer to the car.
“Maybe it would be easier in a few hours, once the sun warms up,” said her daughter, Deb Kennedy, 51.
“No. I’m at the end of my rope already,” Marlene said. “Poor Earl’s probably wondering if we left him alone down there.”
In the first months after her husband’s fall, Marlene had helped Earl Kennedy move into a nursing home three minutes from their house in Broken Bow, a town of 3,000, close enough that she could visit him twice a day. But then that nursing home went bankrupt and closed in May, one of more than 260 rural nursing facilities across the country to shut down for financial reasons in the past three years, sending another family on a desperate search for the basic medical care that is disappearing from rural America.
Marlene tried to get Earl into the only other nursing home in Broken Bow, but that facility had managed to stay solvent in part by limiting the number of residents on Medicaid, as Earl was, because the federal program pays nursing homes in Nebraska about $40 less per day than the cost of providing care. The nursing homes in Ainsworth and Minden had already closed, and the one located next to a grain elevator in Callaway was running a waiting list. The best option Marlene could find was a shared room in the town of Cozad, more than 50 miles away down remote two-lane roads, and Marlene had been making the trip back and forth several times each week ever since.
This time, Deb had offered to drive her, and they rode away from the single-story house where Marlene and Earl had raised four children, and then past the grocery store where he had stocked shelves for 47 years. They continued beyond the feedlots on the outskirts of town, dense with cattle covering the hillsides. The road narrowed through a maze of cornfields. Frozen snow crunched beneath the tires and wind beat against the windows as they drove for miles without seeing another car.
“There’s a dip coming up here,” Marlene told her daughter, as the road climbed over a frozen creek.
“Where? I don’t see it.”
“Believe me. It’s there,” she said. “I’ve done this enough to know.”
She and Earl had rarely traveled outside of Nebraska, and they’d never been on an airplane. Many of their trips together in recent years had been medical trips, the escalating cost of a life spent in rural America, which in the past decade has lost at least 250 maternity wards, 115 hospitals, 3,500 primary care doctors, 2,000 medical specialists and hundreds of nursing homes. Marlene and Earl had traveled together to Lincoln for a heart operation, Kearney for an ankle, Grand Island for a hip, Omaha for corneal transplants, and then finally to Cozad in the back of a nursing home transport van for what Marlene feared would be Earl’s final trip. He was almost 88, and he could no longer walk or eat solid foods. Marlene had already paid for their adjacent cemetery plots in Broken Bow, where Earl had spent his entire adult life, but there was no place left in town where he could live safely until he died.
Deb slowed to pass a tractor. Marlene waved to the driver and then stared out the window, where rolling hills went on for miles. The prairie was empty except for hay bales and a few pieces of farming equipment left out in the snow.
“You all right?” Deb asked. “You seem quiet.”
“This drive always feels long,” Marlene said. “You spend your whole life tied up right next to somebody, and then you don’t get to be there for the hardest parts. It doesn’t seem natural.”
“You didn’t have a choice,” Deb said.
“No, but that doesn’t stop me from worrying about him,” Marlene said, because that was what she’d been doing for much of the past week and a half as she waited for the weather to improve. She’d worried that Earl’s bed was pressed too close to the window on subfreezing nights, and that the khakis she’d bought for him to wear weren’t thick enough, and that he was losing too much weight to keep himself warm, and that if he wasn’t warm he wouldn’t be able to sleep. She’d worried about what he might be doing if he wasn’t sleeping, since his eyesight made it difficult for him to read or watch TV or do much of anything except move back and forth from his bed to his wheelchair, in which case 10 days might have felt to him like forever. She’d worried he felt confused by her absence, or upset, or scared, or even abandoned.
“I’d be with him every day if I could,” Marlene said. “He knows that, right?”
“Of course. He knows we all want to be there,” Deb said. She drove by a large grain elevator and turned into the town of Cozad, parking in front of a small nursing home. She opened the passenger door and reached down to help her mother out of the car. “I bet you’ll feel better once you get a chance to visit with him,” she said.
“I don’t like being a visitor,” Marlene said. “I’m not a visitor to him.”
***
They walked down a tiled hallway with fluorescent lighting to a small room with an American flag taped beside the door. Marlene stepped into the front half of the room, which for the past 15 years had belonged to Earl’s new roommate, Oscar. He waved from his wheelchair, and then Marlene pulled back a curtain to reveal the back half of the room, where Earl was in the same position as she’d last seen him, 10 days earlier. He sat in his wheelchair with his body bent over to the right, wearing a baseball cap on his head and a kerchief to protect his shirt. He faced a TV that wasn’t on and a window with a view of snow-covered recycling bins. Marlene put her hand on his shoulder and leaned down to kiss his forehead.
“I missed you, Earl,” she said. “I missed you so bad I couldn’t stand it.”
He smiled at her and nodded. He reached over to his bed and picked up a holiday card he’d received from one of their great-grandchildren. He’d shown it to Marlene on her last visit, and now he handed it to her again.
“Isn’t that something,” she said, rubbing his back, pulling over a chair until it was pressed right up against his. She set the card down and rested her head against his shoulder.
“I missed you, Earl,” she said again. “Did you miss me?”
“Well,” he said. His lips tried to form more words, but they wouldn’t come. He’d been working with a speech therapist to fight back the advance of Parkinson’s and maintain his ability to eat, swallow and speak, but lately Marlene thought he had fewer good days than bad. She leaned in and tried to read his lips, smiling at him, waiting for him to talk as she rubbed his shoulders. His mind was still sharp, and some days his sentences came more easily as time went along. She believed the kind and respectful thing to do was to stay patient and wait through the silence, until after a few moments of watching Earl struggle, she decided the kinder thing was to break it.
“I wanted to come just about every day, but this weather had other ideas,” she told him. “You missed me, though, Earl. Didn’t you?”
“Well,” he said again. He smiled and reached over to wrap his arm around her shoulder.
“Yeah, I knew it,” she said. “You missed me. And what all did I miss here?”
“Well, the usual,” he said, beginning to find his voice. He pointed out toward the weekly schedule that was posted on the wall: a resident social hour at 8 a.m., three pureed meals in the cafeteria each day, bingo on Wednesdays and Fridays, Bible study on Tuesdays, “Wheel of Fortune” in the community room each night. Five residents had died in the past few weeks, and each time the nursing staff had made up the bed with a red rose and a copy of the same poem on the pillow: “I am home in heaven, dear ones; Oh so happy and so bright!”
“I suppose you didn’t miss much,” Earl said. “Life in a rest home. We rest.”
Marlene laughed. “You never were much of a complainer,” she said.
“No,” he said. “I guess not.”
They sat together holding hands as Marlene straightened Earl’s hat and smoothed the wrinkles out of his khakis. Sometimes during their visits, she took him into the cafeteria to play board games or read to him aloud from Philippians, but they spent most of their time together in silence.
“I like sitting with you like this,” Earl said.
His half of the room was barely large enough to fit a bed, a chair, and a handful of mementos. There were photos on the wall of his friends, his grandchildren, and his great-grandchildren, many of whom lived near Broken Bow and were too far away from Cozad to make regular visits. There was a prayer book from the country church where he’d met Marlene in 1954, and a few awards from the grocery store where he’d started out making $60 a week and then stayed on for nearly five decades.
“A life lived right,” read one of those employee plaques, which the store had given to him to commemorate his retirement at age 76, and Earl believed that declaration to be true. He’d raised four successful children, taught Sunday school, worked at the store six days each week, and come home most afternoons to eat lunch with Marlene. Their family had never earned more than $35,000 in a year, but somehow they had managed to send the children to college, stay out of debt, pay off their house, and even build up some savings — most of which had vanished in less than two years to pay for Earl’s nursing care in Broken Bow.
After that he was forced to rely on Medicaid, which meant that like most rural Nebraskans, he was dependent on a nursing system that was collapsing and scattering the poorest residents across the plains. Some of his friends from the home in Broken Bow had ended up in Omaha, Wyoming or North Dakota, and Earl had been moved out of a town where he knew almost everybody to a place where he knew almost nobody, and where the one constant was Marlene.
“It’s getting to be that time,” she said, as she looked out the window. They’d been sitting together for a few hours. The sun dipped down toward the cornfields, and the wind picked up and started whipping snow off the ground. Soon it would be dusk, when the roads started to refreeze and deer began to dart across the prairie.
“You should go,” Earl said. “I’m okay.”
“Another minute,” she said. She held his hand, and she thought she could feel it beginning to shake. She’d noticed that sometimes his Parkinson’s symptoms seemed to worsen at the end of their visits. “I’ll be back soon,” she said. “The weather coming up looks pretty good.”
“When you can,” he said. “I’ll be all right.”
“Soon,” she said again.
“Well,” he said. He patted her arm. He tried to say something more, but his hands were shaking harder now, and the words weren’t coming. Marlene leaned in and waited, watching his lips. “I’m okay,” he said again. “It’s okay,” he said, until finally Marlene squeezed his hand, forced herself up, and started walking out toward the car.
***
Earl watched out the window as the sky turned dark. His room was quiet, but in the hallway he could hear the sounds of oxygen machines and beeping call lights. Nurses wheeled residents into the cafeteria for bingo, and the food staff prepared creamy potatoes for dinner.
By all appearances, the nursing home was a place of routine and stability, but in fact it was facing the same financial pressures that had shut down 31 nursing homes in Nebraska in the past several years. A few months before, it had come within days of being the 32nd, after failing to meet payroll and making plans to transfer all 65 residents. The facility had been rescued out of bankruptcy at the last moment by a new ownership group from New York, and now the staff was trying help the nursing home save money however it could.
Lately, one strategy involved making trips to the shuttered nursing home in Broken Bow to salvage whatever supplies were left inside.
“I’ll be back in a few hours,” said Kiley Goff, the head administrator in Cozad, as she left a staff meeting and walked out to her truck to make her fourth trip to Broken Bow in the past month. Her bosses had purchased the building there, given her a key and allowed her to take whatever she needed for the nursing home in Cozad, which turned out to be almost everything. Their facility was almost 70 years old, and some of the rooms still had hand-crank medical beds. For one of her trips to Broken Bow, she’d rented a U-Haul and hired teenagers on the local high school wrestling team to help her load it with a dozen electric beds, a few couches, a washer and dryer, wooden doors, a bathtub, a fireplace, wall art and hundreds of pounds of linens.
This time she was hoping to find water pitchers, dishware and holiday decorations. “Any little thing we find is something we don’t have to buy,” she said.
She was a trained speech pathologist who had recently switched to management, and she’d spent the past year learning the difficult math of nursing home finances. The Medicaid reimbursement rate in Nebraska and most other states had stayed relatively flat for the past several years, even as medical costs rose by more than 20 percent. Her nursing home in Cozad received $152 per day for each Medicaid resident, far short of the $200-per-day cost of providing care. To make up for that loss, nursing homes typically charged much higher rates for people paying with their own money, a strategy that worked in urban areas where about half of residents could afford to pay out of pocket. But in rural Nebraska, only 35 percent of nursing home residents had money to pay for their own care, and in Cozad, it was less than 20 percent.
The result was that urban nursing homes had been able to remain relatively stable even as care disappeared from disproportionately older, poorer and rural areas of the country, where an elderly population that was projected to double in size over the next 20 years would have fewer places to go.
Goff drove by the feedlots on the edge of Broken Bow, stopped at the railroads tracks for a passing coal train, and then parked at a low-slung building across from a hardware store. Snow piled against the doorway and a broken-down medical van sat out front. She pushed open the front door and light streamed into the building. She could see down a long hallway, where medical lights flashed red against the walls and a broken fire alarm kept going off.
The nursing home had emptied out within just a few weeks in May once the closing was announced, as 46 residents and 65 staff members scrambled for places to go, but everything else had remained inside. There were wheelchairs in the front lobby, Bibles left open in the chapel, and plastic Easter eggs scattered in the hall. Goff grabbed an empty plastic bin from the front closet and started walking through the facility, opening closets and drawers to look for holiday decorations she could use in Cozad.
She found a stuffed Santa and some holiday lights in a closet. She went through the physical therapy room, the beauty parlor, and then into the secure memory care wing. “A Safe and Happy Forever Home,” read a framed cross-stitch near the entrance to what had once been the area for residents with Alzheimer’s or dementia, who tended to thrive on consistency, and who had since been uprooted to places all over Nebraska without understanding where or why.
Goff found a small Christmas tree in a closet and a package of unopened tablecloths in the cafeteria. Her phone rang, and she set down her bin to answer.
It was one of her staff members in Cozad, wanting to know when she’d be back. “I’m almost done,” she said. “It always feels weird in here.”
She pressed the phone to her ear, carried the bin of decorations out to her truck, and locked the nursing home’s front door.
“There’s still so much good stuff wasting away in here,” she told her employee. “We’ll need to come back with the trailer.”
A three-minute drive away, in a house at the center of Broken Bow, Marlene was sorting through her own belongings, trying to compile the story of her last 63 years with Earl, just in case. She wanted to pick out photos for his funeral program. She wanted to be prepared with a eulogy. She needed to call their bank and switch all of their joint accounts into her name.
“You’re smart to prepare early,” a banker was telling her now, on the phone. “This way you can do some of it together.”
“Actually, he’s not here,” she said. “It’s just me.”
The walls of her living room were decorated with photos of the grandchildren whom Marlene sometimes felt guilty visiting without Earl, and mementos from the church she didn’t like attending without him, and plaques from the grocery store where she still sometimes expected to see him when she shopped. One picture showed Earl at his retirement celebration, when some former co-workers came back from out of state and the store offered free cake to the entire town. A few hundred people had come through the store that day to say goodbye. “A small town turns out to support one of its own,” read one local news story about that day, but on this day, Marlene was thinking about the things Broken Bow could no longer support, and the closed nursing home, and all of the people Earl was no longer able to see. Aside from their family, she thought he’d had two visitors in the past six months.
She turned on the TV to check the weather report. She put her heart medication into her purse. She inched down the driveway and into their 20-year-old car.
Earl had usually been the one who drove during their marriage, but Marlene had put 14,000 miles on the car in the past several months. She drove out of Broken Bow and past the feedlots on the edge of town. She turned through the cornfields. She went over the frozen creek. She slowed for the dip. She waved to a tractor. She went by the grain elevator. She looked out the front windshield at the rolling prairie and counted off the long miles, until she was parked in front of the nursing home and walking into Earl’s room.
She saw him looking out the window and waiting in his chair, where she’d left him a few days earlier and would soon have to leave him again.
“I’m here,” she said, putting her arm on his shoulder. “I’ll stay for as long as I can.”
https://www.washingtonpost.com/national/traveling-the-loneliest-road/2019/12/21/f8ec26b2-21ca-11ea-bed5-880264cc91a9_story.html

 

Crisis Looms in Antibiotics as Drug Makers Go Bankrupt

First Big Pharma fled the field, and now start-ups are going belly up, threatening to stifle the development of new drugs.

by Andrew Jacobs - NYT - December 25, 2019

At a time when germs are growing more resistant to common antibiotics, many companies that are developing new versions of the drugs are hemorrhaging money and going out of business, gravely undermining efforts to contain the spread of deadly, drug-resistant bacteria.
Antibiotic start-ups like Achaogen and Aradigm have gone belly up in recent months, pharmaceutical behemoths like Novartis and Allergan have abandoned the sector and many of the remaining American antibiotic companies are teetering toward insolvency. One of the biggest developers of antibiotics, Melinta Therapeutics, recently warned regulators it was running out of cash.
Experts say the grim financial outlook for the few companies still committed to antibiotic research is driving away investors and threatening to strangle the development of new lifesaving drugs at a time when they are urgently needed.
“This is a crisis that should alarm everyone,” said Dr. Helen Boucher, an infectious disease specialist at Tufts Medical Center and a member of the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria.

The problem is straightforward: The companies that have invested billions to develop the drugs have not found a way to make money selling them. Most antibiotics are prescribed for just days or weeks — unlike medicines for chronic conditions like diabetes or rheumatoid arthritis that have been blockbusters — and many hospitals have been unwilling to pay high prices for the new therapies. Political gridlock in Congress has thwarted legislative efforts to address the problem.
The challenges facing antibiotic makers come at time when many of the drugs designed to vanquish infections are becoming ineffective against bacteria and fungi, as overuse of the decades-old drugs has spurred them to develop defenses against the medicines.
Drug-resistant infections now kill 35,000 people in the United States each year and sicken 2.8 million, according a report from the Centers for Disease Control and Prevention released last month. Without new therapies, the United Nations says the global death toll could soar to 10 million by 2050.
[Read our other stories in our series on drug resistance, Deadly Germs, Lost Cures.]
The newest antibiotics have proved effective at tackling some of the most stubborn and deadly germs, including anthrax, bacterial pneumonia, E. coli and multidrug-resistant skin infections.
The experience of the biotech company Achaogen, is a case in point. It spent 15 years and a billion dollars to win Food and Drug Administration approval for Zemdri, a drug for hard-to-treat urinary tract infections. In July, the World Health Organization added Zemdri to its list of essential new medicines.

By then, however, there was no one left at Achaogen to celebrate.
This past spring, with its stock price hovering near zero and executives unable to raise the hundreds of millions of dollars needed to market the drug and do additional clinical studies, the company sold off lab equipment and fired its remaining scientists. In April, the company declared bankruptcy.
Public health experts say the crisis calls for government intervention. Among the ideas that have wide backing are increased reimbursements for new antibiotics, federal funding to stockpile drugs effective against resistant germs and financial incentives that would offer much needed aid to start-ups and lure back the pharmaceutical giants. Despite bipartisan support, legislation aimed at addressing the problem has languished in Congress.
“If this doesn’t get fixed in the next six to 12 months, the last of the Mohicans will go broke and investors won’t return to the market for another decade or two,” said Chen Yu, a health care venture capitalist who has invested in the field.

The industry faces another challenge: After years of being bombarded with warnings against profligate use of antibiotics, doctors have become reluctant to prescribe the newest medications, limiting the ability of companies to recoup the investment spent to discover the compounds and win regulatory approval. And in their drive to save money, many hospital pharmacies will dispense cheaper generics even when a newer drug is far superior.
“You’d never tell a cancer patient ‘Why don’t you try a 1950s drug first and if doesn’t work, we’ll move on to one from the 1980s,” said Kevin Outterson, the executive director of CARB-X, a government-funded nonprofit that provides grants to companies working on antimicrobial resistance. “We do this with antibiotics and it’s really having an adverse effect on patients and the marketplace.”
Many of the new drugs are not cheap, at least when compared to older generics that can cost a few dollars a pill. A typical course of Xerava, a newly approved antibiotic that targets multi-drug resistant infections, can cost as much as $2,000.

“Unlike expensive new cancer drugs that extend survival by three-to-six months, antibiotics like ours truly save a patient’s life,” said Larry Edwards, chief executive of the company that makes Xerva, Tetraphase Pharmaceuticals. “It’s frustrating.”
Tetraphase, based in Watertown, Mass., has struggled to get hospitals to embrace Xerava, which took more than a decade to discover and bring to market, even though the drug can vanquish resistant germs like MRSA and CRE, a resistant bacteria that kills 13,000 people a year.
Tetraphase’s stock price has been hovering around $2, down from nearly $40 a year ago. To trim costs, Mr. Edwards recently shuttered the company’s labs, laid off some 40 scientists and scuttled plans to move forward on three other promising antibiotics.
For Melinta Therapeutics based in Morristown, N.J., the future is even grimmer. Last month, the company’s stock price dropped 45 percent after executives issued a warning about the company’s long-term prospects. Melinta makes four antibiotics, including Baxdela, which recently received F.D.A. approval to treat the kind of drug-resistant pneumonia that often kills hospitalized patients. Jennifer Sanfilippo, Melinta’s interim chief executive, said she was hoping a sale or merger would buy the company more time to raise awareness about the antibiotics’ value among hospital pharmacists and increase sales.
“These drugs are my babies, and they are so urgently needed,” she said.
Coming up with new compounds is no easy feat. Only two new classes of antibiotics have been introduced in the last 20 years — most new drugs are variations on existing ones — and the diminishing financial returns have driven most companies from the market. In the 1980s, there were 18 major pharmaceutical companies developing new antibiotics; today there are three.
“The science is hard, really hard,” said Dr. David Shlaes, a former vice president at Wyeth Pharmaceuticals and a board member of the Global Antibiotic Research and Development Partnership, a nonprofit advocacy organization. “And reducing the number of people who work on it by abandoning antibiotic R & D is not going to get us anywhere.”
A new antibiotic can cost $2.6 billion to develop, he said, and the biggest part of that cost are the failures along the way.

Some of the sector’s biggest players have coalesced around a raft of interventions and incentives that would treat antibiotics as a global good. They include extending the exclusivity for new antibiotics to give companies more time to earn back their investments and creating a program to buy and store critical antibiotics much the way the federal government stockpiles emergency medication for possible pandemics or bioterror threats like anthrax and smallpox.
The DISARM Act, a bill introduced in Congress earlier this year, would direct Medicare to reimburse hospitals for new and critically important antibiotics. The bill has bipartisan support but has yet to advance.
One of its sponsors, Senator Bob Casey, Democrat of Pennsylvania, said some of the reluctance to push it forward stemmed from the political sensitivity over soaring prescription drug prices. “There is some institutional resistance to any legislation that provides financial incentives to drug companies,” he said.
Washington has not entirely been sitting on its hands. Over the past decade, the Biomedical Advanced Research and Development Authority, or BARDA, a federal effort to counter chemical, nuclear and other public health threats, has invested a billion dollars in companies developing promising antimicrobial drugs and diagnostics that can help address antibiotic resistance.
“If we don’t have drugs to combat these multi-drug resistant organisms, then we’re not doing our job to keep Americans safe,” Rick A. Bright, the director of the agency, said.
Dr. Bright has had a firsthand experience with the problem. Two years ago, his thumb became infected after he nicked it while gardening in his backyard. The antibiotic he was prescribed had no effect, nor did six others he was given at the hospital. It turned out he had MRSA.
The infection spread, and doctors scheduled surgery to amputate the thumb. His doctor prescribed one last antibiotic but only after complaining about its cost and warning that Dr. Bright’s insurance might not cover it. Within hours, the infection began to improve and the amputation was canceled.

“If I had gotten the right drug on Day 1, I would have never had to go to the emergency room,” he said.
Achaogen and its 300 employees had held out hope for government intervention, especially given that the company had received $124 million from BARDA to develop Zemdri.
As recently as two years ago, the company had a market capitalization of more than $1 billion and Zemdri was so promising that it became the first antibiotic the F.D.A. designated as a breakthrough therapy, expediting the approval process.
Dr. Ryan Cirz, one of Achaogen’s founders and the vice president of research, recalled the days when venture capitalists took a shine to the company and investors snapped up its stock. “It wasn’t hype,” Dr. Cirz, a microbiologist, said. “This was about saving lives.”
.
In June, investors at the bankruptcy sale bought out the company’s lab equipment and the rights to Zemdri for a pittance: $16 million. (The buyer, generics drug maker Cipla USA, has continued to manufacture the drug.) Many of Achaogen’s scientists have since found research jobs in more lucrative fields like oncology.
Dr. Cirz lost his life savings, but he said he had bigger concerns. Without effective antibiotics, many common medical procedures could one day become life-threatening.
“This is a problem that can be solved, it’s not that complicated,” he said. “We can deal with the problem now, or we can just sit here and wait until greater numbers of people start dying. That would be a tragedy.”
https://www.nytimes.com/2019/12/25/health/antibiotics-new-resistance.html?action=click&module=Top%20Stories&pgtype=Homepage

 

In the U.S., an Angioplasty Costs $32,000. Elsewhere? Maybe $6,400.

A study of international prices finds American patients pay much more across a wide array of common services.

by Margot Sanger-Katz - NYT - December 27, 2019

Why does health care cost so much more in the United States than in other countries? As health economists love to say: “It’s the prices, stupid.”
As politicians continue to lament the system’s expense, and more Americans struggle to pay the high and often unpredictable bills that can accompany their health problems, it’s worth looking at just how weird our prices really are relative to the rest of the world.

The International Federation of Health Plans, a group representing the C.E.O.s of health insurers worldwide, publishes a guide every few years on the international cost for common medical services. Its newest report, on 2017 prices, came out this month. Every time, the upshot is vivid and similar: For almost everything on the list, there is a large divergence between the United States and everyone else.

Patients and insurance companies in the United States pay higher prices for medications, imaging tests, basic health visits and common operations. Those high prices make health care in the U.S. extremely expensive, and they also finance a robust and politically powerful health care industry, which means lowering prices will always be hard.
For a typical angioplasty, a procedure that opens a blocked blood vessel to the heart, the average U.S. price is $32,200, compared with $6,400 in the Netherlands, or $7,400 in Switzerland, the survey finds. A typical M.R.I. scan costs $1,420 in the United States, but around $450 in Britain. An injection of Herceptin, an important breast cancer treatment, costs $211 in the United States, compared with $44 in South Africa. These examples aren’t outliers.
There are so few cases where the United States price isn’t the highest that they jump out. Cataract surgery costs more in New Zealand; Kalydeco, a new drug for cystic fibrosis, costs more in the United Arab Emirates. But for most of the studied cases, prices for services and drugs in other developed countries are less than half of those in the United States.
“It is staggering how much the United States is more expensive,” said John Hargraves, the director of data strategy at the Health Care Cost Institute, a group that aggregates claims data from several large American insurance companies and provided the U.S. data to the study.

The international survey focuses on prices paid by private insurance companies; in many countries, public health programs pay less, meaning the gap in prices for many countries may be even larger if it took account of every patient. The survey doesn’t have information from every country, nor detailed prices for every medical procedure. Drug prices do not include rebates. But the report’s overall message is clear. Prices in the United States are higher for nearly everything — by a lot.

Researchers at Harvard conducted an exhaustive study last year of things that make health systems in developed countries different from one another. They determined that the United States is distinct in a few ways. But the clear finding of those researchers was that it’s this huge gap in prices, more than any other single factor — not the number of doctors’ visits or hospitalizations, not the quality of medical services, not differences in social service spending — that helps explain why the United States is such an expensive place to be sick. (I wrote an article about that study, if you’re interested in the details.)
Over the last decade, most of the political health policy debate has been about how to ensure broader insurance coverage for the public. (Another way the United States is unusual is in having so many residents without any form of health insurance.) But the debate among candidates for the 2020 presidential race has begun to tack slightly toward policies that will address price as well.
The single-payer plans Senators Bernie Sanders and Elizabeth Warren have proposed would use a large government insurer to set prices for all medical services. Both campaigns assume substantial savings would result as that government system lowered prices across the board: for doctors, hospitals, medical devices and drugs.
Even plans considered more moderate, like those from Pete Buttigieg, the South Bend, Ind., mayor, and Michael Bloomberg, the media executive and former mayor of New York, would impose some controls on health care prices, by limiting the amount that doctors and hospitals could charge in the situations where they typically charge the most.
President Trump, too, has pushed forward with an initiative to lower prices: Through an executive order and regulation, his administration is seeking to require health care providers to publicize the prices they have negotiated with insurance companies. The idea is to promote more competition through transparency, though researchers are divided on whether the measure will work. (The administration has also worked with bipartisan legislators to eliminate surprise billing, which occurs most commonly in medical emergencies at hospitals, though that effort has stalled.)

Higher prices are not new for the United States, but they have become newly salient, as more health insurance comes with high deductibles and other forms of cost sharing that require patients to pay a larger part of the bill or even the full cost of their care. The overall upward creep of prices has also led insurance premiums to rise, taking a bite out of tax revenue, wages and corporate profits, too.
There’s also been some recent bipartisan interest in taking on drug prices specifically — though few policies have gotten very far in Congress.
Any successful effort to tamp down American prices, of course, will mean reducing someone’s paycheck. The uniquely high prices for drugs in the United States help make pharmaceutical companies profitable. The high prices paid for hospital care keep large research hospitals and small rural providers afloat. The high prices help doctors pay off extensive education debt — but also help place them among the highest-paid professions in our economy. None of those groups particularly want a pay cut.

 https://www.nytimes.com/2019/12/27/upshot/expensive-health-care-world-comparison.html?action=click&module=Top%20Stories&pgtype=Homepage

Plan to give nurse practitioners greater role in patient care fuels debate

By Priyanka Dayal McCluskey  - Boston Globe - December 27, 2019

 

Her dilemma is at the heart of a political debate brewing on Beacon Hill. Governor Charlie Baker and dozens of lawmakers support legislation that would allow nurse practitioners in Massachusetts to treat patients and prescribe medications without supervision from a physician — as they can in every other New England state.

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Many public officials and health policy experts say this simple change would expand access to much-needed primary care, particularly for low-income and underserved communities. And it would contain health care costs, they argue, because with more access to providers, patients would be less likely to delay needed care or to seek treatment in expensive hospital emergency rooms.
But the idea remains controversial. Physician groups are lobbying to keep it from becoming law, arguing that nurse practitioners are not qualified to independently care for patients. Previous efforts to lift the restrictions have died in the Legislature.
Resistance tends to be strong in states such as Massachusetts that have a concentration of renowned doctors and academic medical centers, according to experts who follow the issue. And often, nurses are still thought of as support staff, not as independent care providers.
Nurse practitioners have a master’s or doctoral degree, receive additional clinical training, and must be certified as “advanced practice” nurses. They are trained to evaluate patients, order tests, diagnose medical conditions, and prescribe medications, and they can work in primary care or specialties.
Advocates of expanding authority for nurse practitioners say they already are trained to take care of patients on their own, but the law in many states, including Massachusetts, is holding them back.
Twenty-two states and the US Department of Veterans Affairs allow them to practice independently. In Massachusetts, nurse practitioners must find a physician willing to sign a collaborative agreement and oversee their prescribing practices.
It’s a cumbersome requirement that adds expense and uncertainty, while keeping nurse practitioners from working to their full ability, said Stephanie Ahmed, state legislative policy director for the Massachusetts Coalition of Nurse Practitioners.
“It’s absolutely slowing down the delivery of care,” she said.
And it’s not helping patients, said Jennifer Derkazarian, chief nursing officer at Atrius Health, which includes Harvard Vanguard and other medical practices.
“The state of Massachusetts is asking a physician to review retrospective prescriptions for a cohort of patients they’re not responsible for,” she said. “There isn’t any value in that. It becomes an administrative issue.”
In addition to its large roster of doctors, Atrius uses hundreds of nurse practitioners to treat patients. And, in a break from other physician groups, Atrius supports legislation that would allow nurse practitioners to work independently.
Several physician groups strongly oppose loosening the restrictions, arguing that nurse practitioners lack proper training to safely care for patients because they don’t have to spend years in residency as doctors do.
The Massachusetts Medical Society told legislators earlier this year that “physician-led” teams should take care of patients. Dr. Maryanne C. Bombaugh, president of the 25,000-member medical society, said nurse practitioners should work alongside physicians, not independent of them.
“It’s moving in a direction of siloing, versus a direction of integration and teamwork,” Bombaugh said. “It flies in the face of what we are trying to achieve in our state” in health care.
A national group called Physicians for Patient Protection also opposes such policies, even encouraging patients online to report incidences of harm suffered at the hands of nurse practitioners. The group was formed last year, as a result of concerned doctors who connected on Facebook, said cofounder Dr. Carmen Kavali, a plastic surgeon in Atlanta.
“It’s not an elitism thing,” said Dr. Michelle Martin, a vascular surgeon in Boston and member of the group. “It’s a training thing.”
Martin said nurse practitioners sometimes refer patients to her who don’t need to see a vascular surgeon, resulting in unnecessary appointments. “They don’t understand enough to know who needs to be seen by a specialist and who doesn’t,” she said.
But those who favor giving nurse practitioners more authority are quick to point to decades of research on the topic. Studies have demonstrated that nurse practitioners provide high-quality care, that they are more likely than primary care physicians to care for poor and underserved patients, and that they provide care at lower cost than physicians, according to Peter Buerhaus, a professor at Montana State University who studies the nursing workforce.
“I don’t think there’s legitimate concerns,” Buerhaus said. “There has always been resistance, but there has also been a growing acceptance by many, many physicians.”
The Massachusetts Health Policy Commission, a state agency that studies health care costs, examined the issue this year and determined that removing restrictions on nurse practitioners would probably expand access to primary care. The commission’s report noted that the national supply of nurse practitioners is growing more quickly than that of physicians.
In 2009, a RAND Corp. analysis predicted that Massachusetts could save on health care costs if it expanded the role of nurse practitioners, among other changes.
The Baker administration, in a lengthy healthy care bill filed in October, proposed lifting restrictions on nurse practitioners.
“It’s fair, it’s right, and it will increase access — which is what the governor’s health care bill is all about,” said Marylou Sudders, Baker’s secretary of health and human services. “I’ve seen no data to suggest the quality of care offered by nurses is anything other than excellent in other states.”
A majority of Massachusetts lawmakers — 88 representatives and 29 senators — also support legislation that would remove restrictions on nurse practitioners.
Many states have already done so, and “no state has ever gone backward or ever placed more restrictions,” said Tay Kopanos, vice president of state government affairs for the American Association of Nurse Practitioners.
The constraints in states such as Massachusetts are “a quirk of history that’s still on the books,” she said.
Meanwhile, Ronconi, the nurse practitioner who set up her practice in Vermont, said she still gets calls from former patients who are struggling to find a new provider.
“I left a population of over 450 patients in Massachusetts,” Ronconi said. “By not allowing nurse practitioners to practice to the full extent of their training, there are patients that are not being cared for.”
https://www.bostonglobe.com/business/2019/12/27/plan-give-nurse-practitioners-greater-role-patient-care-fuels-debate/QiuURmlXLkQfetyIokufnN/story.html

Hospital mergers across US have raised health care prices. Now, another is pending in Maine.

By Charles Eichacker - Bangor Daily News - December 28, 2019

 

Size matters when it comes to health care.

Just ask the leaders of Mayo Regional Hospital in Dover-Foxcroft, who have been forging ahead with a deal that they say is critical for the long-term survival of their 25-bed facility. They are close to becoming the 10th hospital to join Northern Light Health, the statewide network that employs almost 13,000 people and includes Northern Light Eastern Maine Medical Center in Bangor.

Northern Light Health is not paying a fee to acquire Mayo from the 13 towns that collectively own the institution — that’s one of the arguments in a new lawsuit seeking to block the deal. But supporters of the merger have said that it will nonetheless provide something for the people who use Mayo Regional Hospital and its affiliated practices: the weight of a larger health care organization.

After the facility suffered operating losses every year since 2010, its leaders have argued that joining Northern Light will allow Mayo Regional Hospital to stay open by giving it new resources to cut its operating costs and bring in additional revenue.

Yet evidence from around the country suggests that new revenue could come from charging people who use the Dover-Foxcroft facility more for the health care they receive there. That’s because large systems that do not have competition can use their size to negotiate higher payments from insurance companies.

In an interview earlier this year, Mayo Regional Hospital CEO Marie Vienneau cited Northern Light Health’s leverage over insurance companies as one of the reasons the merger could bring in additional revenue.

“We also would be able to access things that might be better than we have now, like payor contracts,” Vienneau said at the time, referring to the contracts that hospitals sign with insurance providers. “There are lots of things the system as a larger entity has: certainly much more leverage than a smaller freestanding facility has.”

However, it is patients who end up feeling the pain from higher prices because insurers simply pass them on through higher premiums, according to Glenn Melnick, a health care economist at the University of Southern California.

There is also evidence that mergers may help hospital networks to cut administrative costs, such as accounting and information technology, by centralizing them in the parent organization, according to Melnick.

“But the most common effect we see of these systems is that they’re able to get higher prices,” Melnick said. “We don’t really see an offsetting increase of quality and outcomes that goes along with it. It’s not to say it’s impossible or it doesn’t happen, but the evidence so far doesn’t support that good news story.”

For now, Mayo Regional Hospital’s merger isn’t complete. A group of taxpayers from the 13 communities that collectively own the institution has just filed a lawsuit seeking to block the deal on the grounds that it would be an unauthorized giveaway of public resources.

State regulators must also give their final approval to the deal, although they have already released a preliminary report that endorsed it. The board of Hospital Administrative District 4, the quasi-public entity that runs Mayo Regional Hospital, gave conditional approval to the merger on Dec. 18, and Northern Light’s board did the same on Dec. 10.

Dan Cashman, a spokesman for Mayo Regional Hospital, declined to answer questions about the effects of the merger, saying it would be “premature” without state approval.

Suzanne Spruce, a spokeswoman for Northern Light Health, declined to discuss how the system negotiates insurance prices for all of its member hospitals.

But Spruce noted that Mayo Regional Hospital cannot negotiate payments from Medicare and Medicaid. Together, those government programs were projected to provide just over half of the hospital’s patient revenue in 2019, or $48.7 million, according to the hospital. The remaining 47 percent — or $43.4 million — was expected to come from commercial insurers and patients paying out of pocket.

“We are committed to maintaining access to quality, affordable healthcare close to home for the people of Piscataquis County and other areas of Maine served by Northern Light,” Spruce said in a statement.

The Maine regulators who reviewed the merger pointed to research from the American Hospital Association, an influential lobbying organization for hospitals, that found consolidation can bring down costs to patients and insurers.

But many studies have reached the opposite conclusion, according to a summary of research that Carnegie Mellon University health economist Martin Gaynor presented to Congress in 2018. He pointed to a study from Harvard and Princeton universities that found the consolidation of hospitals from different markets within the same state can lead to price increases around 10 percent.

Despite the research on hospital consolidation leading to higher prices, Mitchell Stein, an independent health policy consultant based in Maine, said that it is hard to predict what impact a merger can have on local costs, particularly when medical spending across the Pine Tree State has already been growing at one of the fastest rates in the nation.

Between 1991 and 2014, the state’s per capita spending on health care grew by an average of 5.9 percent annually, according to the most recent data from the Kaiser Family Foundation. That was the fourth highest rate in the country. Charges from hospitals and physicians have generally accounted for about 60 percent of those costs.

“There are several factors at play,” Stein said. “The end result may just be that given the continuing upward pressure on the cost of care, this merger is not large enough to have a significant impact.”

The competition between Maine’s two largest health care networks, Northern Light Health and Portland-based MaineHealth, should theoretically work to drive down the state’s costs, Stein said, but he has not seen evidence that it has.

“I shudder to think that the competition has been effective and things would be even worse without it,” he said.

https://bangordailynews.com/2019/12/28/news/piscataquis/hospital-mergers-across-us-have-raised-health-care-prices-now-another-is-pending-in-maine/ 

For Her Head Cold, Insurer Coughed Up $25,865

by Richard Harris - SHOTS (NPR/Kaiser Health News) - December 23, 2019

Alexa Kasdan had a cold and a sore throat.
The 40-year-old public policy consultant from Brooklyn, N.Y., didn't want her upcoming vacation trip ruined by strep throat. So after it had lingered for more than a week, she decided to get it checked out.
Kasdan visited her primary care physician, Roya Fathollahi, at Manhattan Specialty Care, just off Park Avenue South and not far from tony Gramercy Park.
The visit was quick. Kasdan got her throat swabbed, gave a tube of blood and was sent out the door with a prescription for antibiotics.
She soon felt better, and the trip went off without a hitch.
Then the bill came.
Patient: Alexa Kasdan, 40, a public policy consultant in New York City, insured by Blue Cross and Blue Shield of Minnesota through her partner's employer.
Total bill: $28,395.50 for an out-of-network throat swab. Her insurer cut a check for $25,865.24.
Service provider: Dr. Roya Fathollahi, Manhattan Specialty Care.
Medical service: lab tests to look at potential bacteria and viruses that could be related to Kasdan's cough and sore throat.
What gives: When Kasdan got back from the overseas trip, she says there were "several messages on my phone, and I have an email from the billing department at Dr. Fathollahi's office."
The news was that her insurance company was mailing her family a check — for more than $25,000 — to cover some out-of-network lab tests. The actual bill was $28,395.50, but the doctor's office said it would waive her portion of the bill: $2,530.26.
"I thought it was a mistake," she says. "I thought maybe they meant $250. I couldn't fathom in what universe I would go to a doctor for a strep throat culture and some antibiotics and I would end up with a $25,000 bill."
The doctor's office kept assuring Kasdan by phone and by email that the tests and charges were perfectly normal. The office sent a courier to her house to pick up the check.
How could a throat swab possibly cost that much? Let us count three reasons.
First, the doctor sent Kasdan's throat swab for a sophisticated smorgasbord of DNA tests looking for viruses and bacteria that might explain Kasdan's cold symptoms.
Dr. Ranit Mishori, professor of family medicine at the Georgetown University School of Medicine, says such scrutiny was unnecessary.
"In my 20 years of being a doctor, I've never ordered any of these tests, let alone seen any of my colleagues, students and other physicians order anything like that in the outpatient setting," she says. "I have no idea why they were ordered."
The tests might conceivably make sense for a patient in the intensive care unit or with a difficult case of pneumonia, Mishori says. The ones for influenza are potentially useful, since there are medicines that can help, but there's a cheap rapid test that could have been used instead.
"There are about 250 viruses that cause the symptoms for the common cold, and even if you did know that there was virus A versus virus B, it would make no difference because there's no treatment anyway," she says.
(Kasdan's lab results didn't reveal the particular virus that was to blame for the cold. The results were all negative.)
The second reason behind the high price is that the doctor sent the throat swab to an out-of-network lab for analysis. In-network labs settle on contract rates with insurers. But out-of-network labs can set their own prices for tests, and in this case the lab settled on list prices that are 20 times higher than average for other labs in the same ZIP code.
In this case, if the doctor had sent the throat swab off to LabCorp ― Kasdan's in-network provider ― it would have billed her insurance company about $653 for "all the ordered tests, or an equivalent," LabCorp told NPR.
The third reason for the high bill may be the connection between the lab and Kasdan's doctor. Kasdan's bill shows that the lab service was provided by Manhattan Gastroenterology, which has the same phone number and locations as her doctor's office.
Manhattan Gastroenterology is registered as a professional corporation with the state of New York, which means it is owned by doctors. It may be the parent company of Manhattan Specialty Care, but that is not clear in its filings with the state.
Fathollahi, the Manhattan Specialty Care physician, didn't answer our questions about the bill. Neither did Dr. Shawn Khodadadian, listed in state records as the CEO of Manhattan Gastroenterology.
The pathologist listed on the insurance company's explanation of benefits is Dr. Calvin L. Strand. He is listed in state records as the laboratory director at Manhattan Gastroenterology and Brookhaven Gastroenterology in East Patchogue, N.Y. We tried to reach him for comment at both places.
Even though Kasdan wasn't stuck with this bill, practices like this run up the cost of medical care. Insurance companies base premiums on their expenses, and the more those rise, the more participants have to pay.
"She may not be paying anything on this particular claim," says Richelle Marting, a lawyer who specializes in medical billing at the Forbes Law Group in Overland Park, Kan., who looked into this case for NPR. "But overall, if the group's claims and costs rise, all the employees and spouses paying into the health plan may eventually be paying for the cost of this."
Marting says this is a common problem for insurance companies. Most claims processing is completely automated, she says. "There's never a human set of eyes that look at the bill and decide whether or not it gets paid."
Kasdan did pay her usual $25 copay for the office visit and a $9.61 fee to LabCorp for a separate set of lab tests.

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Resolution: "I made it very clear [to the doctor's office] that I was unhappy about it," Kasdan says. In fact, she told them she would report the doctor to New York state's Office of Professional Medical Conduct. Next, she reached out to Bill of the Month, a joint project of NPR and Kaiser Health News.
After a reporter started asking questions about the bill, Blue Cross and Blue Shield of Minnesota stopped payment on the check it issued and is now investigating.
Jim McManus, director of public relations for BCBS of Minnesota, says the company has a process to flag excessive charges. "Unfortunately, those necessary reviews did not happen in this case," he wrote in an email.
The takeaway: Surprise bills often arise when an in-network doctor or hospital involves another provider who isn't in the patient's insurance network, without the patient's consent. But it is often nearly impossible for a patient to detect when that is occurring.
Patients can try to protect themselves from surprise bills by asking for details at their doctor's appointments.
"I always ask where they're sending my labs or where they're sending my images [like X-rays], so I can make sure that's in network with my insurance company," attorney Marting says.
They can also probe why a test is being ordered: "It is OK to ask your doctor, 'Why are you ordering these tests, and how are they going to help you come up with a treatment plan for me?' " says Georgetown's Mishori. "I think it's important for patients to be empowered and ask these questions, rather than be faced with unnecessary testing, unnecessary treatment and also, in this case, outrageous billing."
If you're sitting on the exam table thinking, "I won't ask. How much could it be?" — the answer could be a lot.
New York state has a law to protect patients from surprise bills. The law requires doctors' offices to warn patients in advance that they are using an out-of-network provider and that patients may be responsible for excess charges. If a patient doesn't consent to the involvement of an out-of-network doctor, then the patient must be held financially harmless from the bill. But it doesn't prevent an out-of-network provider from sending a bill or collecting from an insurer.
Kasdan says she was not told that the throat swab was being sent out of network at the time of her appointment, though it's possible one of the many papers she signed included a broad caveat that some services might not be in network.
People who suspect that a bill is the result of a violation of law can report that to state authorities. In this case, New York state's Department of Financial Services investigates complaints.
https://www.npr.org/sections/health-shots/2019/12/23/787403509/for-her-head-cold-insurer-coughed-up-25-865