Health Care Reform Articles - January 9, 2020

Report claims healthcare plan could reduce costs, cover everyone in Maine

by Ruth Leubecker - Machias Valley News Observer - December 29, 2019

An all-encompassing healthcare proposal could save Maine $1.5 billion in healthcare spending, according to a new analysis released by Maine AllCare.
“When every Mainer is covered, and there is never a bill to patients. When doctors are paid promptly, and everyone contributes on a sliding scale, we will truly have a caring and cost-effective system,” says Joe Lendvai, stressing the plan’s simplicity and fairness.
Lendvai is a founding member of Maine AllCare, a nonprofit, nonpartisan organization founded in 2012 as a chapter of Physicians for a National Health Program. The report, “Assessing the Costs and Impacts of a State-Level Universal Health Care System in Maine,” was commissioned by Maine AllCare to determine how such a system could be financed.
Historically, there has never been the political will to attack such a formidable project. “When the subject comes up, people always ask ’How are you going to pay for it?’ but the truth is we already pay more for health care than any other developed nation,” says Henk Goorhuis, MD, and board chair of Maine AllCare. “We’re doing this while families continue to skip doctor’s visits, or otherwise forgo necessary care because they can’t afford it.”
Under the model studied by MECEP (Maine Center for Economic Policy), federal programs like Medicare and Medicaid would remain intact, and a state-operated program would cover the remaining 652,000 uninsured and underinsured Mainers, while

also picking up those inadequately covered by private insurance. Covering coverage gaps and eliminating out-of-pocket expenses, the proposal also provides dental, vision and hearing benefits to every Maine resident.
About 80 percent of this new publicly funded system would be financed by funds now being spent on premiums, deductibles and out-of-pocket costs. The remainder, estimated at $1 billion by MECEP in the report, would be paid for by raising taxes. However, several potential revenue sources could make this tax more palatable. Those 80 percent would see an appreciable net gain in their family net income due to the absence of premiums and additional costs at the pharmacy counter. Municipalities and counties would see a savings of $214 million, or 8.3 percent in property tax, which translates into a reduction of 1.5 mills.
The report also claims that employers would pay the same or less than they do today. Workers Compensation would be cut in half, and employers would eliminate the cost of choosing and managing their healthcare coverage.
Hospitals would be paid promptly and directly at Medicare rates. It follows that over 2,900 administrative jobs in healthcare would be lost, due to the simplified system, but the model assumes that retraining costs would become part of the transition.
“I think the only thing we’re lacking is the political will to do it,” says Lynn Cheney, longtime board member and champion of Maine AllCare. “I’ve been an ACA navigator since the beginning, and I’m really worried about the underinsured.
“The ACA bronze plan, for instance, comes with a $6,000 deductible. I don’t even call that health coverage.”
When hearing about the Maine AllCare proposal, for most people the immediate assumption is that it is unaffordable. Recognizing Maine as the oldest state in the nation and rapidly growing more so, Cheney says they decided to take action.

“We decided to do this study for Maine, and thanks to a Stephen King grant we could do that,” she explains. “I think it’s very doable, but it’s a political thing. On December 16, we had a meeting in Augusta and that raised a lot of good questions.”
That meeting was well attended by members of the Joint Committee on Health Coverage, Insurance and Financial Services. Although a necessary first step, a lot of road work in the form of dispensing information remains.
“I think Jeanne Lambrew has impressive credentials and Gov. Mills understands the need, but this will be bogged down in the politics,” says Cheney. “I think it’s going to take more push from the bottom. The voters.”
The study supporting the analysis looked at health care cost scenarios based on seven different families, of varying sizes and incomes, ranging from $10,000 to $500,000. All but the highest would see savings under the analyzed model, with the state-level plan bringing significant benefits to Maine residents. An accompanying survey will be released later this month. 
https://machiasnews.com/report-claims-healthcare-plan-could-reduce-costs-cover-everyone-maine 

Every American family basically pays an $8,000 ‘poll tax’ under the U.S. health system, top economists say

by Anne Young - Washington Post - January 7, 2020

SAN DIEGO — America’s sky-high health-care costs are so far above what people pay in other countries that they are the equivalent of a hefty tax, Princeton University economists Anne Case and Angus Deaton say. They are surprised Americans aren’t revolting against these taxes.
“A few people are getting very rich at the expense of the rest of us,” Case said at conference in San Diego on Saturday. The U.S. health-care system is “like a tribute to a foreign power, but we’re doing it to ourselves.”

The U.S. health-care system is the most expensive in the world, costing about $1 trillion more per year than the next-most-expensive system — Switzerland’s. That means U.S. households pay an extra $8,000 per year, compared with what Swiss families pay. Case and Deaton view this extra cost as a “poll tax,” meaning it is levied on every individual regardless of their ability to pay. (Most Americans think of a poll tax as money people once had to pay to register to vote, but “polle” was an archaic German word for “head.” The idea behind a poll tax is that it falls on every head.)
Despite paying $8,000 more a year than anyone else, American families do not have better health outcomes, the economists argue. Life expectancy in the United States is lower than in Europe.
“We can brag we have the most expensive health care. We can also now brag that it delivers the worst health of any rich country,” Case said.
Case and Deaton, a Nobel Prize winner in economics, made the critical remarks about U.S. health care during a talk at the American Economic Association’s annual meeting, where thousands of economists gather to discuss the health of the U.S. economy and their latest research on what’s working and what’s not.
The two economists have risen to prominence in recent years for their work on America’s “deaths of despair.” They discovered Americans between the ages of 25 and 64 have been committing suicide, overdosing on opioids or dying from alcohol-related problems like liver disease at skyrocketing rates since 2000. These “deaths of despair” have been especially large among white Americans without college degrees as job options have rapidly declined for them.
Their forthcoming book, “Deaths of Despair and the Future of Capitalism,” includes a scathing chapter examining how the U.S. health-care system has played a key role in these deaths. The authors call out pharmaceutical companies, hospitals, device manufacturers and doctors for their roles in driving up costs and creating the opioid epidemic.

“Deaths of despair” have risen rapidly in the United States since 2000 for 25-to-64-year-old Americans without college degrees. (Chart courtesy of economist Anne Case).

In the research looking at the taxing nature of the U.S. health-care system compared with others, Deaton is especially critical of U.S. doctors, pointing out that 16 percent of people in the top 1 percent of income earners are physicians, according to research by Williams College professor Jon Bakija and others.
“We have half as many physicians per head as most European countries, yet they get paid two times as much, on average,” Deaton said in an interview on the sidelines of the AEA conference. “Physicians are a giant rent-seeking conspiracy that’s taking money away from the rest of us, and yet everybody loves physicians. You can’t touch them.”
As calls grow among the 2020 presidential candidates to overhaul America’s health-care system, Case and Deaton have been careful not to endorse a particular policy.
“It’s the waste that we would really like to see disappear,” Deaton said.
After looking at other health systems around the world that deliver better health outcomes, the academics say it’s clear that two things need to happen in the United States: Everyone needs to be in the health system (via insurance or a government-run system like Medicare-for-all), and there must be cost controls, including price caps on drugs and government decisions not to cover some procedures.
The economists say they understand it will be difficult to alter the health-care system, with so many powerful interests lobbying to keep it intact. They pointed to the practice of “surprise billing,” where someone is taken to a hospital — even an “in network” hospital covered by their insurance — but they end up getting a large bill because a doctor or specialist who sees them at the hospital might be considered out of network.
Surprise billing has been widely criticized by people across the political spectrum, yet a bipartisan push in Congress to curb it was killed at the end of last year after lobbying pressure.
“We believe in capitalism, and we think it needs to be put back on the rails,” Case said.
https://www.washingtonpost.com/business/2020/01/07/every-american-family-basically-pays-an-poll-tax-under-us-health-system-top-economists-say/?
  

Let nurse practitioners work alone

Mass. should join other states in clearing a key hurdle to primary care.

By The Editorial Board - Boston Globe - January 8, 2020

What do patients really want when they have a bad sore throat or relentless back pain? To schedule a medical appointment without a ridiculous wait, get a referral to a specialist if needed, and escape with minimal financial damage — and, by the way, to get better.
Here’s what they don’t care about: which tribe within the medical community gets paid.
Legislation currently pending on Beacon Hill would move Massachusetts into the mainstream by loosening the restrictions on nurse practitioners, highly trained professionals who are certified to provide primary and specialty care and could easily be treating more of those coughs and muscle cramps than they do now. The bill would give patients more options, and could be especially important in underserved parts of the state where finding primary care remains a challenge. And by strengthening primary and preventative care, the legislation should improve public health and save money, too.
Nurses complete a master’s or doctorate degree and undergo extensive training to be licensed as nurse practitioners. They are trained to make diagnoses, order tests, and prescribe medicines. Right now, though, the roughly 10,500 nurse practitioners in Massachusetts must work under the supervision of an MD who has to review any prescriptions they write.
Massachusetts is one of the most restrictive states for nurse practitioners in the country. Doctors often exact hundreds or thousands of dollars in monthly fees from the nurse practitioners under their supervision — for doing work that the nurse practitioners are perfectly capable of doing on their own.
It’s an arrangement that doctors are battling hard to keep, arguing that nurse practitioners aren’t as well trained as MDs. But in states that allow nurse practitioners to operate independently — including every other New England state — there has been no documented damage to patient outcomes. On the contrary, studies compiled by the California Health Care Foundation suggest allowing nurse practitioners to work alone leads to fewer preventable hospitalizations and emergency room visits.
Superficially, the need for this reform in Massachusetts may not strike the Legislature as pressing. After all, when it comes to primary care, Massachusetts definitely is in better shape than most states. In fact, according to federal statistics, it had the largest surplus of primary care doctors in the country (Texas, meanwhile, had the biggest deficit). But the statewide statistics are skewed by the concentration of doctors in the medical mecca of Greater Boston. In rural parts of Western Massachusetts, some towns reported having no primary care physicians at all, and the federal government considers some areas of the state (including some parts of Boston) medically underserved.
Those are just the sort of areas that see more service when states allow nurse practitioners to operate independently, a 2018 study found.
It’s also worth it to curb the growing health care costs in the Commonwealth. The state’s medical costs watchdog, the Massachusetts Health Policy Commission, has recommended the state “amend scope of practice laws that are restrictive and not evidence-based.”
The agency has also noted, “These laws may represent an unnecessary barrier to cost-effective care.” Allowing advanced nurses to operate more freely and without making payments to doctors, it projected, would lead to a large increase in their numbers in the state.
Historically, as the Globe’s sister publication STAT has pointed out, laws restricting the scope of practice for nurses have carried a sexist tinge. Doctors have generally been male, and nurses generally female. Whatever their origins, such holdover laws just put up needless obstacles to health care access. Massachusetts may not have the same struggle as other states to attract primary care doctors but, even here, pockets of the Commonwealth are underserved and need the extra care that nurse practitioners could provide.
https://www.bostonglobe.com/2020/01/08/opinion/let-nurse-practitioners-work-alone/

Black distrust deepens against the medical community

Too many black people were forced to suffer by doctors more attuned to their own biases than their patients’ pain.

by Renee Graham - Boston Globe - January 7, 2020

As emergency medical technicians took my father to an ambulance, my mother, concerned about the temperature’s wintry bite, draped his favorite leather jacket over him for warmth.

“Oh, don’t worry about the cold,” a female EMT told her. “He won’t feel it.”

What I didn’t know then was how common it is for those who pledge to “first, do no harm” to discount black people’s capacity for pain.

This grievous act of racist malpractice is well-documented, most recently regarding the opioid crisis. According to “Trends in Black and White Opioid Mortality in the United States, 1979–2015,” published in Epidemiology, black patients were prescribed painkillers at a lower rate than their white counterparts. Analyzing the data, The New York Times concluded that had the numbers been equal, more than 14,000 black people would have died during that period from prescription opioid-related causes.

To be clear, doctors weren’t safeguarding black patients from the highly addictive drugs. Researchers say physicians’ motives were often driven by racial stereotyping, not medical magnanimity. Some worried that black people would sell their medication, or had a greater susceptibility to addiction.

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But mostly, they believed these black lives mattered less. Patients were forced to self-medicate, sometimes with illegal drugs, because pain does not discriminate. They missed work, pushing them toward financial ruin. They died in pain that their doctors refused to recognize or under-treated.
Now with deaths of black people from opioids skyrocketing, the medical community has found yet another discriminating twist: black people addicted to opioids are less likely to receive drugs that alleviate cravings and decrease fatal overdoses.
This has deepened the canyon-wide and centuries-old distrust many African-Americans have toward the medical community.
Those suspicions have roots in white medical and scientific malfeasance. In the 19th century, Louis Agassiz, a Harvard professor, promoted junk science claiming different races were separate, unequal species. The goal, of course, was to render African-Americans as less than human. It was an Ivy League justification of white supremacy as the natural order.
In the infamous decades-long “Tuskegee experiment,” hundreds of poor black men, told they were receiving free medical care, went untreated for syphilis so doctors could track the disease’s progression. Even after penicillin was introduced as a treatment, these men were given only aspirin or placebos. Some died, others went blind or suffered severe mental disabilities as the disease affected their brains.
For decades in New York’s Central Park, a statue honored Dr. J. Marion Sims, often called the “father of modern gynecology.” Many of the experiments that led to his groundbreaking work were conducted — without anesthesia — on enslaved black women, who had no agency over their bodies. As the debate about the removal of Confederate statues roiled in 2018, Mayor Bill de Blasio finally ordered that Sims’s statue be relocated to the Brooklyn cemetery where he is buried.
Anyone convinced such medical horror stories are consigned to the past ignores its echoes today — from the under-prescribing of painkillers to the high rates of pregnancy-related mortality among black women.
No one disputes the tragic effect that the massive over-distribution of prescription opioids has had on this nation. The number of deaths may be shrinking, but tens of thousands still perish every year. Yet there’s also no denying that too many black people were forced to suffer by doctors more attuned to their own biases than their patients’ pain.
When I finally arrived home on that bitter February morning, my mother, wearing my father’s leather jacket and suddenly a widow, tearfully shared her story about the EMT. Nearly 20 years later, I still wonder if the callousness of that woman’s comment foreshadowed how my father would be treated in his time of dying. Did he receive unequal care? If he was in pain, did the attending physician do anything to comfort him?
Would my father have lived if he were a white man?
https://www.bostonglobe.com/2020/01/07/opinion/black-distrust-deepens-against-medical-community/

Can We Please Stop Fighting About ‘Medicare for All’?

One policy proposal has defined this Democratic race. It’s time to move on. 

by Michelle Cottle - NYT - January 8, 2020

With strong support among the Democratic Party’s base, “Medicare for all” has emerged as a test of progressive bona fides in the race for the Democratic presidential nomination.
It has also emerged as something of a political morass into which the candidates keep stumbling.
Most recently, the businessman Andrew Yang faced scrutiny over his position on the idea of creating a government-run health insurance system that essentially would eliminate private coverage.
Mr. Yang has expressed support for Medicare for all and, in the fall, ran ads that advocated moving toward such a system. But when he released his health care plan last month, it turned out not to include even a public option, much less an overhaul of the whole system.
“Your ad is explicit. Your ad says, Medicare for all. Your plan is not Medicare for all,” ABC’s Jonathan Karl pressed Mr. Yang in an interview on Dec. 29. “It’s not even Medicare for some, because in your plan there’s not even a public option.”

“Medicare for all is not the name of a bill” but the basic goal of universal coverage, argued Mr. Yang, noting that his plan “would be based on Medicare and expanding it over time to more and more Americans.”
Mr. Yang’s perceived slipperiness led to backlash on social media and beyond. “Andrew Yang’s Lies About Supporting Medicare for All Exposed as Journalist Corners Him Live on Air,” charged a headline on the progressive website AlterNet.
Amid all this confusion, Mr. Yang was right about one thing: When announcing his plan, he warned that Democrats were “having the wrong conversation on health care” and “spending too much time fighting over the differences between Medicare for all” and other ideas, such as expanding the Affordable Care Act or establishing a public option to operate alongside private plans, a hybrid model that another Democratic candidate, Pete Buttigieg, has called Medicare for all who want it.
The American health care system is, no doubt, deeply flawed, and health care was a hot topic in the 2018 midterm elections. But Medicare for all has dominated the Democratic race for too long, serving neither the candidates nor the electorate well.
A plan to blow up that system and throw 149 million people off their private insurance, while embraced by progressives, is viewed more skeptically by moderates and swing voters. A poll conducted in the fall by the Kaiser Family Foundation and the Cook Political Report found that 62 percent of swing voters in the former “blue wall” states of Michigan, Minnesota, Pennsylvania and Wisconsin consider Medicare for all a “bad idea.” The foundation’s C.E.O., Drew Altman, wrote in Axios, “If the Democratic nominee comes to be defined by the idea of Medicare for all, that could be a political problem in key battleground states.”

One could argue that it has already proved problematic for Senator Elizabeth Warren, who has been one of Medicare for all’s top champions in this race, along with Senator Bernie Sanders, who has been touting the idea nationally since his 2016 presidential run. Under pressure to explain how she would pay for her proposal, in November Ms. Warren released a detailed accounting of where the estimated $20.5 trillion that her plan would cost over 10 years would come from.
Her financing plan drew heavy fire as misguided and unrealistic, including from some of her Democratic competitors. Former Vice President Joe Biden’s campaign dismissed it as “mathematical gymnastics,” while Mr. Sanders charged it wasn’t progressive enough and would “have a very negative impact on creating jobs.” Around this time, Ms. Warren’s poll numbers and fund-raising took a turn for the worse.
Even among Democrats, Medicare for all polls worse than the less revolutionary alternatives of the sort being offered by Mr. Buttigieg and others, including Mr. Biden and Senator Amy Klobuchar.
And yet, the fight goes on. Many observers have noted that the Democratic debates — especially the first ones, which felt like a rolling seminar on medical insurance policy — have devoted a disproportionate amount of time to the candidates slashing at each other over who has the political courage — or naïveté — to go big on health care.
This has produced some fiery clashes, as when, in the October debate, Ms. Klobuchar suggested that Ms. Warren didn’t know “the difference between a plan and a pipe dream.” But more broadly, it is miring the Democrats in an unnecessary fight over a policy proposal that is divisive and that would require a political miracle to achieve without a progressive takeover of the Senate. And even then, it would most likely be difficult — remember how hard it was to pass Obamacare even with Democrats controlling both chambers?
Yes, the Democratic candidates need to talk about health care. Polls show that it is a top — if not the top — policy concern for their voters, and the issue was a pillar of the party’s successful platform to win control of the House in 2018. But there are other health care matters that could use more attention, such as surprise medical bills, reproductive rights and the Republicans’ continuing efforts to dismantle Obamacare — which have gained far more traction than many people predicted, threatening coverage for millions of Americans.
With the Iowa caucuses less than a month away, Democrats need to move beyond the Medicare for all fixation. Enough time has been spent bickering over the particulars of an electorally risky proposal that is unlikely to come to pass, no matter who wins the White House.
https://www.nytimes.com/2020/01/08/opinion/medicare-for-all-democrats.html?smid=nytcore-ios-share