Health Care Reform Articles - February 23, 2020

My $145,000 Surprise Medical Bill

What my brief glimpse into the financial abyss taught me about the American health care system.

by Jennifer Finney Boylan - NYT - February 2, 2020

“Well,” I said to my wife. “We’re wiped out.”
She’d called me late in the day to let me know she’d received a bill for our child’s hospital stay. The bill was for $145,000.
“What are we going to do?” she asked.
“I’m sure it’s just a mistake,” I said.
“But Jenny,” she said, “what if it’s not?”
The bill in question was for a procedure that had been scheduled months before. We’d consulted with the provider, who, indeed, was out of network, but our doctors had assured us that the total cost would nevertheless require nothing but a modest co-payment.
But in this our doctors appeared to be wrong. Now we were looking at a bill for $145,000.
I believe this is what people refer to as a “surprise medical bill.” About 20 percent of Americans receiving elective surgery are now on the receiving end of these bombshells. This month, I got one.

I went to bed that night not knowing whether we would have to declare bankruptcy in the morning.
In the House of Representatives, two bills have been proposed recently to address crises like the one now facing our family. The Ban Surprise Billing Act, sponsored by Lloyd Doggett, Democrat of Texas, would require hospitals to notify patients and get consent if they will be receiving any out-of network treatment. And last week, the Ways and Means Committee sent the Consumer Protections Against Surprise Medical Bills Act to the House floor. This would also flag potential out-of- network costs for patients, and require insurers and providers to settle disputes through arbitration.
I have no idea how these bills will fare in the Republican-controlled Senate (and they have not yet even been passed by the full House), although I will note that the Senate is the same institution which devoted itself in 2017 to the noble dream of taking away health care coverage from 29 million people by repealing the Affordable Care Act. That effort failed by a single vote, of course — the last great political act of John McCain, who, although no fan of Obamacare, hated even more the idea of bullies picking on the little guy.
The bully in this instance being — well, you know.
The presidential election will give us a chance to end bullying of many different varieties. If Senator Elizabeth Warren winds up not becoming the nominee, it is possible that one reason for this was voter uncertainty about her “Medicare for all” proposal. Apparently whenever Americans consider this idea, we are thrown into a panic by the possibility that we will lose our health care insurance, and that it will be replaced by some governmental entity.
Such as Medicare, which people like, by a wide margin.
Ronald Reagan denounced Medicare, back in 1961, as socialized medicine. If Medicare wasn’t blocked, he said, “one of these days we are going to spend our sunset years telling our children and our children’s children, what it once was like in America when men were free.” Before Medicare, only 54 percent of Americans 65 and over had hospital coverage; three years after its passage, 96 percent of older Americans did. Eighty percent to 90 percent of recipients really like Medicare — and these older Americans are the most conservative voters in the country.
Which makes you think.
I admit I have never quite understood the hatred Reagan had for Medicare, nor the hatred today’s Republicans have for Obamacare (itself modeled on Romneycare, a Republican idea). Is it just that they cannot abide the idea that government sometimes — even if only as a last resort — does good things?

I contacted our doctor the day after we got our $145,000 bill and he very kindly told me not to worry. “Doctor’s orders!” he added, which I thought was nice. Later, another doctor in the practice told me that even when procedures are pre-authorized (as my child’s was) insurers often deny them anyway. His understanding was that insurance companies often respond to preapproved claims with denial and delay, hoping that consumers will somehow just give up.
Fortunately for our family, my child’s doctors did not give up. The bill was fixed, and our family is not, as I feared, wiped out.
It would be nice if the members of Congress — looking at you, Republican Senate — had this same devotion. It would be nice if they came to understand that there are worse things in the world than making people’s lives better.
Sometimes I fear American health care has contracted the capitalist equivalent of a condition called Cotard syndrome — the unshakable conviction that you are dead. One of my aunts suffered from it, in fact. “I’m dead,” she announced one day. “Don’t worry, it doesn’t hurt.”
The cure for my aunt was antidepressants; the cure for American health care is the kind of universal coverage that virtually every other civilized nation has. Have our health care insurers really been so angelic to us that we cannot possibly imagine something better?
We hate our insurance companies. We hate them more than lima beans. We hate them more than spin class. We hate them more than colonoscopies. We hate them more than jellyfish.
And yet somehow, the prospect of losing them is the thing that fills us with terror.
It would be nice just once if our insurance companies were filled with terror by the prospect of losing us.
https://www.nytimes.com/2020/02/19/opinion/surprise-medical-bill.html?action=click&module=Opinion&pgtype=Homepage

The Next Hurdle for Bernie Sanders: Nevada’s Top Union Dislikes ‘Medicare for Allby Jennifer Medina and Jonathan Martin - nytimes -February 16, 2020

 His Democratic rivals are trying to capitalize.

LAS VEGAS — Senator Bernie Sanders is a longtime supporter of “Medicare for all.” “I wrote the damn bill,” he said on a debate stage last summer, and his support for universal health care has helped propel him to the front of the 2020 Democratic field.

But in Nevada, where the race heads next, his signature policy is a liability with the largest labor union in the state. And the union has enthusiastic allies in Mr. Sanders’s opponents.

On Friday morning, moments after Senator Amy Klobuchar finished a tour of the health care facility run by the culinary workers’ union, she began to lace into Mr. Sanders and his focus on the proposal, which would effectively eliminate union members’ current health care system.

It is unwise and unrealistic, she argued, to eliminate the private health insurance that millions of Americans now use — or to think such a measure could pass.

“Since we’re in Vegas I’d say if your number is not on the wheel, maybe you don’t want to bet on that number,” Ms. Klobuchar said.

A night earlier, former Mayor Pete Buttigieg of South Bend, Ind., raised the issue at a forum for Latino voters. “Who are we to tell them that they have to give up those plans?” Mr. Buttigieg said of the culinary workers’ health care coverage.

Then there’s Tom Steyer, the billionaire self-funder, who is competing aggressively in Nevada and has started airing a commercial that says “unions don’t like” Mr. Sanders’s plan and includes a vow to protect “union negotiated plans.”

The flurry of attacks against Mr. Sanders in Nevada illustrates his growing strength — and the urgency his Democratic rivals feel about the need to stop him from winning the most votes in a third consecutive contest next Saturday. If no Democrat slows Mr. Sanders in the caucuses here, he will gather what may be unstoppable momentum heading into next month’s Super Tuesday states.

But the offensive against the Vermont senator also highlighted some of his most glaring vulnerabilities: The culinary union, which represents many of the workers in Las Vegas’s casinos, is opposed to his single-payer plan. And after its leaders stated that opposition, they were met with the sort of scathing and personal invective that critics of Mr. Sanders often receive.

Culinary Workers Local 226, which is 60,000 members strong and over half Latino, is perhaps the most powerful force in Democratic politics in this state. And there is no benefit its members cherish more than the health care coverage they’ve won in their contract negotiations.

“For their membership, that is the key issue, that is the 800-pound gorilla,” said Richard Bryan, a Nevada Democrat who served as governor and senator.

Mr. Sanders argues that Medicare for all is the only way to guarantee universal coverage, lower costs and bring the nation in line with other industrialized nations, making it both more competitive and just. In Nevada, as he has around the country, he is pitching it as a core part of his agenda for the working class.

Supporters of Medicare for all argue that everyone should be entitled to the same kind of care for which union members negotiate. At a town hall event with culinary union members late last year, Mr. Sanders said that they could expect more money in their paychecks if they did not bargain with employers over health care.

But leaders of the culinary union say his plan would hurt members and their families. After years of organizing, difficult negotiations and multiple strikes, the union won a generous private health insurance plan that leaders are loath to give up. They are wary of the idea that Medicare for all, should it ever pass, would be better than the private plan they have now.

Their unease is shared by other unions, but it’s particularly important because of the culinary union’s clout in Nevada, this pivotal moment in the primary calendar and because it complicates Mr. Sanders’s overarching message — that he’s running on an agenda that’s best for workers.

Suzanne Poquiz, 61, a resident of Las Vegas who was visiting the union health care clinic Friday morning, said she was still undecided but knew she would not vote for Mr. Sanders because of his stance on health care.

“That’s the most important issue to me, being able to come here and get what I need,” Ms. Poquiz said.

What could prove just as problematic to Mr. Sanders, though, is not his split with the culinary union over policy — but over how his supporters handled the dispute.

The fight began last week after the union began distributing fliers to members, comparing the candidates’ stances on policy.

“End Culinary Healthcare,” reads the first bullet point beside Mr. Sanders’s name on a flyer.

It was an unwelcome criticism, made worse by the reaction among some of Mr. Sanders’s supporters. Geoconda Argüello-Kline, the union’s secretary-treasurer, said she received hundreds of emails, phone calls and texts calling her names and threatening her. Her home address was posted online, she said, and her adult children were worried about her safety.

“I believe in the democratic process, and to have this happen is very scary,” Ms. Argüello-Kline said. “After many years as an activist, after many strikes, I have never felt that way in my life. And we are not telling people how to vote — they can make their own decision.”

The vile language prompted Mr. Sanders to issue a statement, in which he said “harassment of all forms is unacceptable to me” and urged “supporters of all campaigns not to engage in bullying or ugly personal attacks.”

But his general reference to “all campaigns” only further angered some of the union leaders, who, like many of the rank-and-file members, are women of color. Ms. Argüello-Kline said that she wished Mr. Sanders would have spoken out sooner to help quell the threats.

“He understands the world we live in, where there can be a shooting anytime at a church or a school or a casino — that’s the environment we’re in,” she said.

A top aide to Mr. Sanders, Ari Rabin-Havt, declined to discuss how the culinary union’s opposition may affect the campaign in the state, saying only that the senator has ”the utmost respect for them.”

By Saturday, though, former Vice President Joseph R. Biden Jr. was seizing on the matter on NBC’s “Meet the Press,” condemning “vicious, malicious, misogynistic” statements by Sanders supporters even as the senator’s aides pointed to his comment that “anybody making personal attacks against anybody else in my name is not part of our movement.”

The response in Nevada to Mr. Sanders’s stance on Medicare for all also shows a split among two of his bases — union members and young Latinos. Several other local hospitality unions have endorsed Mr. Sanders, and young Latinos often cite his health care plan as a key reason for their support.

Even among culinary union members, there is a strain of quiet support for Mr. Sanders. In interviews with several union members over the weekend, several said they were backing Mr. Sanders regardless of what the union’s leadership said. Some said they felt stuck in their jobs because leaving would mean losing coverage, and they wanted family members to have access to care as well. “I think his medical plan is really good, I think it is good for everybody,” said Laura Alvarez, 44, a housekeeper at the Aria who voted in the early caucus at the union’s hall Saturday. “We deserve to have a good medical plan. If it’s going to be for everyone, I think that would be the best thing we could have.”

Even as the culinary union’s leaders criticize Mr. Sanders, their decision to not offer an endorsement of any leading alternative may have only helped him — a fact that has irked some of Mr. Biden’s leading Nevada supporters.

If no single rival to Mr. Sanders emerges in the days before the caucuses, Nevadans could render the same muddled or narrow verdict as their predecessors in Iowa and New Hampshire, a result that would benefit Mr. Sanders.

And veterans of Nevada politics say that’s looking even more likely in part because of the presence of a candidate who has spent more than $10 million in television advertising here but was less of a factor in the first two states: Mr. Steyer.

“For a lot of people, that’s all they’ve seen is Steyer, Steyer, Steyer,” said Megan Jones, a Democratic strategist in the state, who said her father had received about “16 pieces of Steyer mail.”

Ms. Jones said that Mr. Sanders’s dedicated supporters, Mr. Steyer’s spending, the residual organizational strength of Mr. Biden and Senator Elizabeth Warren and the new attention Ms. Klobuchar and Mr. Buttigieg were enjoying were likely to lead to another split decision.

“I don’t see a scenario in which anybody gets more than 30 percent,” she said.

A poll taken last week and published Friday by The Las Vegas Review-Journal captured the fractured nature of the field: Mr. Sanders leads the field, but all six of the top candidates were in double digits.

One big open question among many in Nevada is turnout. With the culinary union not backing a specific candidate, it is unclear whether its operation will encourage members to show up to the caucuses in droves.

D. Taylor, the president of Unite Here, the national union that Culinary is affiliated with, said that despite the direct involvement of the union in Nevada, many labor leaders throughout the country wanted to stay out of the primary and instead focus on defeating President Trump in the fall.

“It doesn’t take a rocket scientist to say it looks like there’s a split between the progressive and moderate wing of the party,” he said. “I don’t know that there’s a whole lot of benefit for us to get into that.”

https://www.nytimes.com/2020/02/16/us/politics/sanders-nevada-medicare-for-all.html

The View From Here: Unions shouldn’t fight health care reform

A Nevada union's self-interested campaign puts it on the side of an unworkable status quo. 

by Greg Kesich - Portland Press Herald - February 16, 2020

I am a union member. I have health insurance provided by my employer. I fought for it at the bargaining table.
And it stinks.
I feel I need to say this because too often I hear politicians claim that the reason America shouldn’t have universal health care similar to national programs in other prosperous societies is that it would be unfair to union members who have bargained for better plans over the years.
So before this goes any further (I’m looking at you, Joe Biden, Pete Buttigieg, Amy Klobuchar, Michael Bloomberg), it’s just not true that “160 million people like their private insurance.”
I’ve got insurance and I’m not happy with it, and neither are most people I know.
We are glad we have insurance, as opposed to no insurance, but I don’t know anyone who likes dealing with high deductibles, cost-sharing, maximum out-of-pocket limits that reset every Jan. 1, or surprise bills from out-of-network doctors who you didn’t even know were treating you.
It’s bad enough to hear Democratic presidential contenders make this argument, but to hear union leaders egg them on is infuriating.
The latest comes from the Culinary Workers Union in Nevada, which is spending serious money attacking the idea of “Medicare for All,” as proposed by Bernie Sanders, the front-runner in the Democratic presidential primary campaign.
They are not saying that his health care proposal would be bad for the the working class or an inefficient way to manage what have been out-of-control costs that top $3 trillion a year.
No. They are against Medicare for All because it would replace the better-than-average health insurance benefits that their workers enjoy. In other words, they are making the same kind of argument that the “One Percenters” make against higher taxes – I’ve got mine, you get yours.
Unions should not play this game.
First, it’s a bad look: Union members make up less than 10 percent of the workforce, even less in the private sector. It’s hard for the other 90 percent of the workforce to forget our selfish attitude when there are national policy issues that affect only unions.
 pocket

Improving the prognosis of health care in the USA
Alison P Galvani, Alyssa S Parpia, Eric M Foster, Burton H Singer, Meagan C Fitzpatrick 

Although health care expenditure per capita is higher in the USA than in any other country, more than 37 million Americans do not have health insurance, and 41 million more have inadequate access to care. Efforts are ongoing to repeal the Affordable Care Act which would exacerbate health-care inequities. By contrast, a universal system, such as that proposed in the Medicare for All Act, has the potential to transform the availability and efficiency of American health-care services. Taking into account both the costs of coverage expansion and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health-care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than US$450 billion annually (based on the value of the US$ in 2017). The entire system could be funded with less financial outlay than is incurred by employers and households paying for health-care premiums combined with existing government allocations. This shift to single- payer health care would provide the greatest relief to lower-income households. Furthermore, we estimate that ensuring health-care access for all Americans would save more than 68 000 lives and 1·73 million life-years every year compared with the status quo.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)33019-3/fulltext

 Editor's Note -

Follow the hot-link above to see the entire article in Lancet. (It may be behind a paywall.)

The American Health Care Industry Is Killing People

Yes, transitioning to a more equitable system might eliminate some jobs. But the status quo is morally untenable.

by Farhad Manjoo - NYT - December 4, 2019

Won’t you spare a thought for America’s medical debt collectors? And while you’re at it, will you say a prayer for the nation’s health care billing managers? Let’s also consider the kindly, economically productive citizens in swing states whose job it is to jail pregnant women and the parents of cancer patients for failing to pay their radiology bills. Put yourself in the entrepreneurial shoes of the friendly hospital administrator who has found a lucrative new revenue stream: filing thousands of lawsuits to garnish sick people’s wages.
And who can forget the lawyers? And the lobbyists! Oh, aren’t they all having a ball in America’s health care thunderdome. Like the two lobbyists who were just caught drafting newspaper editorials for state representatives in Montana and Ohio, decrying their party’s push toward a “government-controlled” health care industry. It’s clear why these lobbyists might prefer the converse status quo: a government controlled by the health care industry. If we moved to a single-payer system, how would lobbyists put food on the table, and who would write lawmakers’ op-ed essays?
Welcome to the bizarre new argument against “Medicare for all”: It’s going to cost us jobs. Lots of jobs. Good, middle-class, white-collar jobs in America’s heartland, where Democrats need to win big to defeat Donald Trump.
The argument is specious and morally suspect. Last week, health researchers reported that American life expectancy is declining for the first time in half a century, and some of the leading causes have to do with the ruinous health care system. Even if it is the case that reforming American health care might eliminate some jobs, it would seem to be a good trade for the likely benefit: More people might gain access to affordable health care and get to keep living.

But I worry that the jobs argument might sway moderate politicians, centrist pundits and much of the establishment, because it plays on one of the major fault lines of health reform: that in fixing the system so that more people benefit, those who now enjoy a privileged slice of American health care might end up worse off than they are today.
As a matter of ethics and equality, this should be O.K.; sticking with a system that is the source of so much death, debt and financial ruin just because you like your doctor or your insurance company or your medical-billing job is not really a defensible position.
On the other hand, in America, “I’ve got mine and I don’t want to lose it” is always pretty good politics.
The jobs argument goes like this: There’s a lot of fat in the American health care industry, and any effort to transform it into a simpler system in which everyone is covered would necessarily eliminate layers of bureaucracy and likely reduce overhead costs. Every year Americans collectively pay about $500 billion in administrative costs for health care — that is, for things like billing and insurance overhead, not for actual medical care.
These costs are significantly higher than in most other wealthy countries. One study on health care data from 1999 showed that each American paid about $1,059 per year just in overhead costs for health care; in Canada, the per capita cost was $307. Those figures are likely much higher today.

Wouldn’t lowering overhead costs be an obviously positive outcome?
Ah, but there’s the rub: All this overspending creates a lot of employment — and moving toward a more efficient and equitable health care system will inevitably mean getting rid of many administrative jobs. One study suggests that about 1.8 million jobs would be rendered unnecessary if America adopted a public health care financing system.
So what if some of these jobs involve debt collection, claims denial, aggressive legal action or are otherwise punitive, cruel or simply morally indefensible in a society that can clearly afford to provide high-quality health care to everyone? Jobs are jobs, folks, as Joe Biden might say.
Indeed, that’s exactly what Biden’s presidential campaign is saying about the Medicare for all plans that Senators Elizabeth Warren and Bernie Sanders are proposing: They “will not only cost 160 million Americans their private health coverage and force tax increases on the middle class, but it would also kill almost two million jobs,” a Biden campaign official warned recently.
Note the word “kill” in the statement. That word might better describe not what could happen to jobs under Medicare for all but what the health care industry is doing to many Americans today.
Last week, the medical journal JAMA published a comprehensive study examining the cause of a remarkably grim statistic about our national well-being. From 1959 to 2010, life expectancy in the United States and in other wealthy countries around the world climbed. Then, in 2014, American life expectancy began to fall, while it continued to rise elsewhere.
What caused the American decline? Researchers identified a number of potential factors, including tobacco use, obesity and psychological stress, but two of the leading causes can be pinned directly on the peculiarities and dysfunctions of American health care.
The first is the opioid epidemic, whose rise can be traced to the release, in 1996, of the prescription pain drug OxyContin. In the public narrative, much of the blame for the epidemic has been cast on the Sackler family, whose firm, Purdue Pharma, created OxyContin and pushed for its widespread use. But research has shown that the Sacklers exploited aberrant incentives in American health care.

Purdue courted doctors, patient groups and insurers to convince the medical establishment that OxyContin was a novel type of opioid that was less addictive and less prone to abuse. The company had little scientific evidence to make that claim, but much of the health care industry bought into it, and OxyContin prescriptions soared. The rush to prescribe opioids was fueled by business incentives created by the health care industry — for Purdue, for many doctors and for insurance companies, treating widespread conditions like back pain with pills rather than physical therapy was simply better for the bottom line.
Opioid addiction isn’t the only factor contributing to rising American mortality rates. The problem is more pervasive, having to do with an overall lack of quality health care. The JAMA report points out that death rates have climbed most for middle-age adults, who — unlike retirees and many children — are not usually covered by government-run health care services and thus have less access to affordable health care.
The researchers write that “countries with higher life expectancy outperform the United States in providing universal access to health care” and in “removing costs as a barrier to care.” In America, by contrast, cost is a key barrier. A study published last year in The American Journal of Medicine found that of the nearly 10 million Americans given diagnoses of cancer between 2000 and 2012, 42 percent were forced to drain all of their assets in order to pay for care.
The politics of Medicare for all are perilous. Understandably so: If you’re one of
the millions of Americans who loves your doctor and your insurance company, or who works in the health care field, I can see why you would be fearful of wholesale change.
But it’s wise to remember that it’s not just your own health and happiness that counts. The health care industry is failing much of the country. Many of your fellow citizens are literally dying early because of its failures. “I got mine!” is not a good enough argument to maintain the dismal status quo.

https://www.nytimes.com/2019/12/04/opinion/healthcare-industry-medicare.html?referringSource=articleShare

Doctors Win Again, in Cautionary Tale for Democrats

Surprise billing legislation suddenly stalled. Like “Medicare for all,” the proposal would have lowered the pay of some physicians. 

by Margot Sanger-Katz - NYT - December , 2019

Democratic voters eager to see “Medicare for all” or some other major health overhaul pass the next time they control the White House may want to take a close look at what happened this week in Congress.
Leaders from both parties had unveiled legislation to stop surprise medical bills, the often exorbitant bills faced by patients when they go to a hospital that takes their insurance but are treated by a doctor who does not. The White House and major consumer groups had also endorsed the plan, which was to be included in the year-end spending bill.
But to the negotiators’ consternation, the spending package that emerged on Monday — and was passed on Tuesday by the House — had nothing about surprise bills. The proposal’s apparent demise was not a result of partisan division, but instead reflected certain lawmakers’ reluctance to pursue an approach that would reduce doctors’ pay. Several of the key lawmakers who scuttled the deal were Democrats.
In many ways, the debate over surprise bills is a miniature version of the coming fight over major health reform. The kinds of big plans that Democratic presidential candidates are pitching combine consumer protections — lower premiums, lower deductibles, more benefits — with lower pay to medical professionals. The surprise billing legislative package has this mix, too. It would protect patients from receiving surprise bills from doctors, but it would most likely result in pay cuts for certain doctors.

Medicare for all, which Bernie Sanders and Elizabeth Warren have championed on the campaign trail, would offer all Americans generous government-run insurance, while sharply reducing pay to doctors, hospitals and pharmaceutical companies. Plans from other candidates, including Joe Biden and Pete Buttigieg, would set up a “public option,” a government health plan that individuals could buy. That plan would also pay doctors and hospitals less than they earn now.
Both Democratic approaches poll fairly well. But a policy to end surprise medical billing, a smaller endeavor, polls even better, and it has emerged as a top voter concern. In a recent survey from the Kaiser Family Foundation, 78 percent of adults said they wanted the surprise billing problem fixed, and 57 percent said they would still support a solution even if it meant lower pay for health care providers.
Health care providers, of course, do not want their pay to be lowered.
When the legislative process heated up this summer, so did a fierce lobbying effort from doctors and hospitals. Doctor Patient Unity, a dark money group funded by two large private- equity-funded physician staffing companies, spent tens of millions on television advertisements and direct mail, urging lawmakers to oppose the bill. Lobbyists for doctors, hospitals, air ambulance companies and private equity funds also began making the rounds. Doctors have argued for a different solution to the surprise billing problem that would not cut their pay.
Research has shown that a small minority of doctors send surprise bills, and they are clustered in a handful of specialties where patients cannot choose their own doctor, including emergency medicine and anesthesiology. But the ability to send surprise bills affects the negotiating dynamics between that subset of doctors and insurance companies.
The surprise billing legislation in the recent deal would set a default payment to doctors for situations in which they were not in an insurance network, with the ability to appeal larger bills to an independent arbitrator. According to the Congressional Budget Office, the approach would tend to lower pay for doctors in those specialties by an average of 15 percent to 20 percent, because it would shift negotiating leverage in favor of insurers.

Although most lawmakers who have written legislation on the issue endorsed the proposal, a few did not. The bipartisan leaders of the House Ways and Means Committee said last week that they hoped to introduce a competing bill in the future, and released a one-page paper last week describing a framework that is more aligned with the preferences of doctors’ groups.
In a final meeting last week, leaders in the House and the Senate met to decide what legislation would end up in the year-end spending bill. Surprise medical billing didn’t make the cut. Several people close to the negotiations said it did not have strong enough support from the Democratic leadership.
The repeal of taxes that hit the medical device and health insurance industries, on the other hand, were included.
“When you’re going into a world when Democrats actually want to push things that special interests do not want, not getting surprise bills done does not bode well,” said Shawn Gremminger, a lobbyist for the consumer group Families USA, who described surprise medical bills as the “most obvious market failure” in health care. “We couldn’t even get that done.”
Some advocates remain hopeful. The spending deal has several health care provisions set to expire next May. That deadline may provide an opportunity for lawmakers to try again, and some time to build consensus between the authors of the recent deal and more skeptical lawmakers.
Greg Walden of Oregon, a Republican and the ranking member of the House Energy and Commerce Committee, said he was “disappointed” that the bill did not advance. “But I’m not dejected, and I’m not throwing in the towel,” he said. “It was the first locomotive to leave the station, but it will not be the last.”
But that optimism is not universal among the people who worked on the abandoned legislation.
Compared with Medicare for all, surprise billing would seem to have certain political advantages. For one, it targets only certain sectors of the health care industry. Medical specialty groups, private equity firms and hospitals disliked the bill, but insurance companies and large employer groups fought for its passage. They, too, spent millions on ads and lobbying.

The insurance industry would not treat a large expansion of public insurance coverage so kindly. And the pharmaceutical industry, another deep-pocketed health lobby that would fight the health plans from the main Democratic presidential contenders, had nothing to say about surprise bills. Even among doctors, there were many specialties that were unaffected; they also stayed quiet.
The surprise billing legislation had another crucial political ally that the proposed Democratic overhaul efforts won’t: Republicans.
https://www.nytimes.com/2019/12/17/upshot/surprise-billing-democrats-2020.html?referringSource=articleShare

Where the Frauds Are All Legal

Welcome to the weird world of medical billing.

by Elizabeth Rosenthal - December 7, 2019

Much of what we accept as legal in medical billing would be regarded as fraud in any other sector.
I have been circling around this conclusion for this past five years, as I’ve listened to patients’ stories while covering health care as a journalist and author. Now, after a summer of firsthand experience — my husband was in a bike crash in July — it’s time to call out this fact head-on. Many of the Democratic candidates are talking about practical fixes for our high-priced health care system, and some legislated or regulated solutions to the maddening world of medical billing would be welcome.
My husband, Andrej, flew over his bicycle’s handlebars when he hit a pothole at high speed on a Sunday ride in Washington. He was unconscious and lying on the pavement when I caught up with him minutes later. The result: six broken ribs, a collapsed lung, a broken finger, a broken collarbone and a broken shoulder blade.
The treatment he got via paramedics and in the emergency room and intensive care unit were great. The troubles began, as I knew they would, when the bills started arriving.
I will not even complain here about some of the crazy high charges: $182 for a basic blood test, $9,289 for two days in a room in intensive care, $20 for a pill that costs pennies at a pharmacy. We have great insurance, which negotiates these rates down. And at least Andrej got and benefited from those services.

What I’m talking about here were the bills for things that simply didn’t happen, or only kind-of, sort-of happened, or were mislabeled as things they were not, or were so nebulously defined that I couldn’t figure out what we might be paying for.
To be clear, many of the charges that I would call fraudulent — maybe all of them — are technically legal (thanks sometimes to lobbying by providers), but that doesn’t make them right. And no one would accept them if they appeared on bills delivered by a contractor, or a lawyer or an auto mechanic. There were so many of these charges that I came up with categories to keep track of them:
1. Medical Swag
In the trauma bay, someone slapped a hard brace around Andrej’s neck until scans confirmed that he had not suffered a grievous spinal injury. It was removed within an hour.
The medical equipment company that provided that piece of plastic billed $319. Our insurer paid $215 (90 percent of its discounted rate of $239). We were billed $24, our “patient responsibility.”
Companies are permitted by insurers to bill for “durable medical equipment,” stuff you receive for home use when you’re in the hospital or doctors’ office. That yields some familiar marked-up charges, like the sling you can buy at Walgreens for $15 but for which you or your insurer get a bill for $120 after it is given to you at urgent care. The policy has also led to widespread abuse, with patients sent home with equipment they don’t need: My mom’s apartment, for example, holds an unused wheelchair, a walker and a commode paid for by Medicare, by which I mean our tax dollars. It’s as if you were given a swag bag at a conference and then sent a bill for hundreds or thousands of dollars.
At least with swag, you get to keep it. My husband’s hardly worn neck brace didn’t even come home with us as a souvenir.

2. The Cover Charge
The biggest single item on Andrej’s E.R. bill was a $7,143.99 trauma activation fee. What was that for, since every component of his care had been billed and billed handsomely?
Among the line items: $3,400 for a high-level E.R. visit. $1,030 for the trauma surgeon. Between $1,400 and $3,300 for five purported CT scans. And I say “purported” because one trip into a scanner examined the head, upper spine and maxillofacial bones, but was billed as three separate things. There was also an administration fee of more than $350 each for four injections.
Trauma activation fees have been allowed since 2002, after 9/11, when the Trauma Center Association of America, an industry group, convinced regulators that they needed to be compensated for maintaining a state of “readiness.”
Wait. Isn’t the purpose of an E.R. to be “ready”? Isn’t that why the doctors’ services and scans are billed at higher rates when they are performed in an emergency department?
Despite scrutiny from researchers about whether trauma fees are deserved, trauma activation fees have only grown in size, 15 percent annually in recent years, and can reach into the tens of thousands of dollars. (On average, Medicare pays a fee of about $1,000.) Some have likened trauma activation fees to a cover charge for being wheeled into an E.R. with major trauma. But does a cover charge typically cost more than the meal?
3. Impostor Billing
We received bills from doctors my husband never met. Some of these bills were understandable, like for the radiologist who read the scans. But others were for bedside treatment from people who never came anywhere near the bed to deliver the care.
Andrej had a small finger fracture with a cut that needed some stitches, which a resident, a surgeon-in-training, sutured. But the $1,512 billed came in the name of a senior surgeon, as if he had done the work.

Physicians and many other health professionals are allowed to bill for the work of “extenders” — stand-ins with less training who see patients and work under the supervising doctor. These might be residents, physician assistants or nurse anesthetists, for example. For billing purposes, this allows the senior providers to be in two, three, sometimes more than half a dozen places at once, often even when they are physically miles away.
The resident did a fine job on my husband. But if an assistant did the work, shouldn’t it be billed for less? At law firms, the hourly rates for paralegals and junior attorneys are lower than those for partners.
On a website called Clinical Advisor, a reimbursement expert himself seemed to wonder at the profession’s luck that such billing is tolerated: “I hear people ask, ‘How can I do that? The doctor never saw the patient, never had any interaction with the patient and yet I can still bill this service under the physician?’”
4. The Drive-By
The day before Andrej left the hospital, a physical therapist visited and asked a few questions. From that brief encounter, the therapist noted “ambulation deficits, balance deficits, endurance deficits, pain-limiting function, transfer deficits.” That translated into a bill of $646.15 for what was recorded as a P.T. evaluation “1st session only (billable).” He said he was there for 30 minutes, but he was not. He said he walked Andrej up 10 steps with a stabilizing belt for assistance. He did not. There was no significant health service given. Just an appearance and some boxes checked on a form. It’s a phenomenon called drive-by doctoring.
More shockingly, the drive-bys continued at our home, presaged by a call on Andrej’s cellphone a day after he was discharged. A physical therapist from a private company wanted to visit him for at-home therapy. In his discharge instructions, no one had mentioned this service, and his injury was clearly too fresh to benefit. She came. She didn’t know which body part had been injured and concluded he was in too much pain to participate.
The same company called twice more the following week to schedule visits. By the third time, I told Andrej not to open the front door. Nonetheless, our insurer was billed — and paid — for three visits.
It’s as if Alexa noticed that my dishwasher makes too much noise (it does) and took it upon herself to send over a repair guy. But if I turned him away at the front door, saying I’m O.K. with the racket (I am), would I still be billed for the visit?

5. The Enforced Upgrade
One Monday when Andrej was in pain and out of pills, the trauma doctor suggested we meet in the emergency room, because the trauma clinic was open only from 8 to 10:45 a.m. on Wednesdays and Thursdays.
So we met the trauma doctors in the E.R., and they talked to Andrej, who remained in his street clothes. They gave him a prescription. Because the interaction — which could have happened in the lobby — happened in the E.R., it resulted in an E.R. visit charge of $1,330. But when the trauma clinic is open less than six hours a week, billing for an E.R. visit that doesn’t tap into any of the emergency room resources feels like a scam. Is an E.R. visit determined by the content of the services rendered, or merely by the location?
Andrej had a similar experience when his broken finger was treated with a plastic splint that folded over his fingertip. He complained because the upper layer pressed on the fracture. At a follow-up visit, someone took a pair of scissors and cut off the upper half of the splint and taped the lower half back in place. That translated into a $481 charge for “surgery,” in addition to the $375 charge for the office visit and a $103 facility fee. Doesn’t surgery, by definition, involve cutting into flesh or an animate object — not a piece of plastic?
Sure, it sounds fancy to upgrade a meeting to an E.R. visit, or to call the tweaking of a splint “surgery,” but if an airline overbooks my flight and puts me on another flight where the only seat available is in first class, it does not charge me for the more expensive ticket.
My insurer paid for most of these questionable charges, though at discounted rates. But even a discounted payment for something that never really happened or didn’t need to happen or that we didn’t agree to have happen is still, according to common sense, a fraud.
Why do insurers pay? Partly because insurers have no way to know whether you got a particular item or service. But also because it’s not worth their time to investigate the millions of medical interactions they write checks for each day. Despite the advertised concern about your well-being, as one benefits manager enlightened me: They’re “too big to care about you.” Electronic records, which auto-fill billing boxes, have probably made things worse. For example, the birth of a baby boy may automatically prompt a bill for a circumcision; having day surgery may prompt a check for sedation.
So what is the appropriate payment for swag I didn’t ask for, outrageous cover charges, stand-in doctors, drive-by visits and faux surgery? In some cases, zero; in others, far less than was paid. And yet, these are all everyday, normal experiences in today’s health care system, and they may be perfectly legal. If we want to tame the costs in our $3 trillion health system, we’ve got to rein in this behavior, which is fraud by any other name.
https://www.nytimes.com/2019/12/07/opinion/sunday/medical-billing-fraud.html?referringSource=articleShare

The Americans forced into bankruptcy to pay for prescriptions

Millions of Americans can’t afford the prescription drugs they require to survive, forcing them into bankruptcy, trips to Mexico or cutting off utilities

Michael  Sainato - The Guardian - February 14, 2020

As a teenager, John Miller was diagnosed with Crohn’s disease, an inflammatory bowel condition that required several major surgeries to remove part of his intestine.
Miller, now 39, has been physically unable to work full-time since his last major surgery in 2014. He struggled to obtain disability insurance, having to live with and rely on family during the appeals process until it was finally approved.

But now Miller, of Chicago, is stuck in a cycle of having to regularly file for bankruptcy due to the debt he accrues every month from the co-pays of his medication.
Every month he gets an infusion of the drug Entyvio, which is used to treat Crohn’s.
“The cost before insurance is $1,800 per infusion. My disability insurance only covers half of that. My co-pay is $900 a month, which is more expensive than my rent,” said Miller.
“I’m expected to pay $900 for an infusion that I need. It is a necessary medication for my disease. It’s my main medicine. I’ve also been refused my infusions due to insurance refusing to authorize it even though I’m disabled.”
He said missing a single dose would disrupt his treatment and cause his disease to worsen.
He filed bankruptcy last year to discharge the debts from his monthly bills for the infusions and plans to do the same again this year because he has no way of paying for it with just social security disability income to live on. “My disease destroys my physical abilities and at the same time really dampens my mental health. It’s really hard to stay optimistic when you feel helpless,” added Miller.
Miller is just one of millions of Americans who struggle to afford the prescription drugs and medical supplies they require to survive.
According to a poll conducted by the Kaiser Family Foundation in February 2019, 24% of adults and 23% of senior citizens report difficulty in affording their prescription medications. A Gallup poll published in November 2019 reported 22.9% of Americans could not afford their prescription medications at least once over the past year.
The high costs of prescription drugs in the United States are being driven by excessive drug prices set by pharmaceutical corporations, which continue to increase prices of hundreds of drugs every year. In 2018, pharmaceutical companies reaped 63% of all profits in the US healthcare system, despite collecting only 23% of the industry revenue.

‘We drained all our bank accounts’

LaDawn Stuben of Tempe, Arizona, drives to Mexico twice a year to fill up on her asthma medication, where it costs a fraction of the price, even with health insurance coverage.
“My maintenance inhaler, Symbicort, costs $110 a month here after insurance. In Mexico it’s $20. My rescue inhaler, albuterol, is not covered by my insurance plan and would be $75 out-of-pocket. In Mexico they’re $3 each,” Stuben said. She has been making the trip over the past five years, saving thousands of dollars in doing so.
Kristy Sullivan Pardeck and her husband, both high school teachers in Fenton, Missouri, have struggled to afford the prescription medicines and medical supplies their five-year-old daughter, who was born with spina bifida, requires to live. Their daughter’s catheters and enemas cost $2,000 a month out of pocket, on top of the medical care expenses and medication costs over the past few years not covered by their insurance.
“We could never catch up. We had to alternate which utility bills would get paid. Our electricity was turned off once or twice. We overdrafted every month for several years,” said Sullivan Pardeck. Her family and employer have held several fundraisers over the past few years and she’s been able to find a few different charities to help cover current bills, but still struggles to afford her required medical supplies and the couple have thousands of dollars in credit card debt from medical expenses when her daughter was first born.
“We are still recovering from draining all our bank accounts and charging the bills that first year,” she said.
Katya Grey, a single mother in Atlanta, struggles to afford the several medications she requires to treat her epilepsy, allergies and a heart condition.
“My current monthly cost for my medications is $375,” said Grey, who also pays a $250 monthly premium for health insurance. Her Epipen is expired because she can’t afford the $385 it costs. “Things happen that cause me to forgo my monthly medications. I have had to break pills and skip doses just to make them stretch a little longer.”
In December 2016, Grey was hospitalized after stretching a one-month supply of epilepsy medication for three months, where she was put in a medically induced coma to stop a series of seizures.
“After those events, I had to make sure I had those medications no matter what. There are months where I do run short because of costs, but I’ve gotten better at just reducing doses, rather than skipping them,” added Grey. “It’s a monthly stressor.”

Most expensive drugs in the developed world

Americans spent $1,220 per person annually in 2017 on pharmaceutical medications according to the latest data from the Organization for Economic Cooperation and Development, by far the most of any developed nation in the world.
A report published in the journal Health Affairs in January 2019, found drug costs are driven largely by year-on-year price hikes made by pharmaceutical manufacturers on drugs already on the market rather than innovation, as often claimed by the pharmaceutical industry. “Our results are relevant from a policy perspective because they show that price increases do not necessarily reflect innovation or money spent on research and development,” said Dr Inmaculada Hernandez, an assistant professor of pharmacy at the University of Pittsburgh and lead author of the study.
Democrats and Republicans in Congress have voiced support for passing legislation to address high costs of prescription drugs in the US, but have yet to come to an agreement on legislative action. President Trump has wrongly claimed prescription drug prices have decreased under his administration, while struggling to enact administrative reforms to lower prescription drug costs.
For the first two years of their daughter’s life, Britany LiButti and her husband of Buffalo, New York, had to pay nearly $3,000 for prescription medications despite having health insurance coverage. Their daughter was born with a congenital disorder at birth, vesicoureteral reflux, and was only recently taken off medication for it.
“Even after insurance our medical bills from our child’s medications, surgeries and hospital stays have forced us to crowdfund for help, and we are still tens of thousands of dollars in debt. Medications and lifesaving medical care in this country have financially ruined our family,” said LiButti. “We are still constantly getting calls, emails and reminders that we owe various places money.”
https://www.theguardian.com/us-news/2020/feb/14/americans-bankruptcy-pay-medications-pharmaceutical-industry

Iowa and New Hampshire Voters Show Medicare for All and Climate Crisis Top Issues for Democrats in 2020

"Bernie's victory in New Hampshire shows just how ready we are as a country to elect Green New Deal leaders at all levels of office," declared an organizer with the youth-led Sunrise Movement.

by Jessica Corbett - Common Dreams - February 12, 2020

Entrance and exit polling from the first-in-the-nation Iowa caucuses on Feb. 3 and New Hampshire primary Tuesday shows that healthcare and the climate crisis are among the top issues for 2020 Democratic voters and the majority of them support bold action on both fronts.
The Washington Post's entrance poll in Iowa and exit poll in New Hampshire found that in those states—Sen. Bernie Sanders (I-Vt.) won the popular vote in both—voters said their "most important" issue was healthcare (42% and 37%), followed by climate change (21% and 25%). The other two options were foreign policy and income inequality.

Iowa:

New Hampshire:

Waleed Shahid, who worked on Sanders' 2016 presidential campaign and is now a spokesperson for the progressive group Justice Democrats, highlighted the Post's New Hampshire polling in a Tuesday night tweet, noting that Sanders won the state's largest share of voters who selected healthcare as the most important issue.
Healthcare is a key topic that sets Sanders and Sen. Elizabeth Warren (D-Mass.) apart from the other candidates in the race. Although they have different plans, both senators support replacing the nation's current for-profit system with a Medicare for All program. Other candidates propose retaining private insurance and expanding coverage with a public option, such as the widely pilloried "Medicare for All Who Want It" proposal introduced by former South Bend, Indiana Mayor Pete Buttigieg.
Adam Gaffney is the president of Physicians for a National Health Program (PNHP), a single-payer advocacy organization. In response to Shahid's tweet, Gaffney said late Tuesday that "a deciding factor in the outcome of the primary—and potentially in the general—could very well prove to be healthcare."
In terms of issues that matter most to voters, early exit polls that CNN conducted in New Hampshire lined up with the Post's results. CNN reported that more than a third of voters said "healthcare was the most important issue in determining their vote," followed by about three in 10 who named climate change as their top concern.
"Sanders was the clear favorite" among voters most concerned about healthcare, according to CNN, "garnering support from more than three in 10." CNN also found majority support for a Medicare-for-All-style healthcare plan, reporting that "almost six in 10 New Hampshire Democratic primary voters today said they would support such a government plan."
Post reporter Jeff Stein noted on Twitter that his newspaper's exit poll showed similar support for Medicare for All in the Granite State, which also aligned with results from caucusgoers in Iowa.
As Stein reported after caucuses ended in Iowa on Feb. 3:
The preliminary exit polls, conducted by Edison Research, found that 57 percent of Iowa Democratic caucusgoers support a single-payer plan, and 38 percent oppose the proposal to eliminate private health insurance, leading some single-payer supporters to claim they were vindicated.

"The conservative wing of the Democratic Party has been telling us voters won't swallow Medicare for All once they learn they will lose their insurance," said Matt Bruenig, founder of People's Policy Project, a socialist think tank. "But these results show voters are ready for Medicare for All. What more is there to say?"

While the entrance and exit polling sends a clear message to the eight remaining Democratic presidential candidates about voters' priorities, acting on those issues requires first winning the party's nomination and beating President Donald Trump in November—which means the candidates must inspire enough people to turn out for primaries and caucuses as well as the general election.
In Iowa and New Hampshire, the greatest share of voters were aged 45–64; Buttigieg did best with those voters in both states. Sanders, the oldest candidate in the race at age 78, won over about half of all Iowa and New Hampshire voters under 30. He was followed by Buttigieg, the youngest candidate at age 38, who secured support from about a fifth of young voters in each state, according to the Post.

Iowa:

New Hampshire:

Turnout for the Iowa caucuses was, in the words of Vox's Emily Stewart, "pretty anemic," but Post entrance polling showed that the share of caucusgoers under age 30 in the state rose by a third relative to 2016—an outcome that was celebrated by the youth-led Sunrise Movement, which advocates for ambitious climate action and implementing a Green New Deal.
The Sunrise Movement said last week that the rising rates of first-time and younger caucusgoers in Iowa demonstrate that "there is a broad, widespread mandate for the Green New Deal." The movement also celebrated the efforts of its members in Iowa, who spent months working to convince climate-conscious Democrats and young people to participate in the caucuses.
Unlike Iowa, the voter turnout in New Hampshire surpassed that of not only 2016 but also the historically higher numbers in 2008. As NPR noted Wednesday, boosting turnout is a key strategy for many Democrats, but particularly Sanders. "The New Hampshire turnout should assuage some Democratic concerns," NPR reported. "But remember that the primaries there are semi-open, meaning independent voters can participate in either the Republican or Democratic primary."
While the race in New Hampshire was tight—so far, Sanders has just over 4,300 more votes than Buttigieg—Sunrise electoral organizers Sophia Zaia wrote in an email to movement supporters Wednesday that "Bernie's victory in New Hampshire shows just how ready we are as a country to elect Green New Deal leaders at all levels of office."
Zaia highlighted that organizers with the Sunrise Movement, which endorsed Sanders last month, "knocked 20,000 doors, made 33,000 thousand phone calls, and turned out in record numbers to the polls" in New Hampshire. Those efforts were also pointed out on Twitter Tuesday by movement co-founder and executive director Varshini Prakash and applauded by author and activist Naomi Klein.
The nominating contests in Iowa and New Hampshire—along with the Nevada caucuses on Feb. 22 and South Carolina Democratic primary on Feb. 29—are considered key early indicators of each candidate's chances of remaining in the race and securing the presidential nomination. Following those four contests, more than a dozen states will hold Super Tuesday primaries on March 3.
https://www.commondreams.org/news/2020/02/12/iowa-and-new-hampshire-voters-show-medicare-all-and-climate-crisis-top-issues?

Democrats Did Something Big On Health Care And Nobody Is Paying Attention

A bill that passed the House late last year would dramatically transform how the U.S. pays for prescription drugs

by Jonathan Cohn - Huffington Post - February 23, 2020

House Democrats passed a major health care bill last December, one that promises substantial, much-needed relief to Americans struggling with cost of prescription drugs.
Yet somehow, almost no one outside of Washington seems to be paying attention.
The most important provision of the bill would allow the federal government to negotiate directly with manufacturers over drug prices, as authorities in other countries do. That could slash the price of everything from insulin to cutting-edge, breakthrough treatments for cancer for the vast majority of Americans.
Steve Knievel, an advocate at Public Citizen’s Access to Medicines program says the bill is “the most impactful piece of drug legislation” to get through a house of Congress since the creation of the Medicare drug benefit in 2003.
Rachel Sachs, a law professor at Washington University in St. Louis and a widely published researcher on the drug industry, told HuffPost that the bill is “an enormous deal … a sweeping reform that would be highly beneficial to patients.”
The proposal has its gaps, as all legislation does. It also comes with trade-offs, mainly in the form of lower revenue for drugmakers ― which sounds great to industry critics angry over what they say are obscene pharmaceutical profits, just as it sounds lousy to industry defenders who say those profits underwrite the development of miracle cures.
But whatever its shortcomings and whatever its consequences, the legislation would represent a major, transformational shift in the relationship between government and one of health care’s most important and powerful industries.
The bill probably would have dominated the news cycle, and have more of a profile today, if the vote hadn’t taken place right when the country was focusing on impeachment ― and if the proposal’s natural champions in the progressive community, who fought with House Speaker Nancy Pelosi (D-Ca.) over its reach and eventually won some key concessions, had touted it more.

The bill would also have generated more buzz if it stood a decent chance of becoming law this year. It doesn’t. Senate Majority Leader Mitch McConnell (R-Ky.) has flatly refused to consider it and President Donald Trump has said he opposes it too.
But any time a policy initiative of this magnitude crosses a key legislative threshold, it’s closer to becoming law. And this bill passed with votes from virtually every Democrat, including vulnerable members in more conservative districts, many of whom are now touting it back home.
These members obviously saw a political upside in supporting the bill, even at the risk of incurring the wrath of drugmakers. If the industry isn’t nervous about that, it should be.

What The New Bill Proposes

H.R. 3, the “Elijah E. Cummings Lower Drug Costs Now Act,” is named for the Baltimore congressman who died last year and who had long championed efforts to help people pay for their medications. It has three main components.
The first is a set of provisions that would limit out-of-pocket drug spending, like copays at the pharmacy, for seniors in Medicare Part D, the program’s drug benefit. This is the least controversial part of the proposal because, in reality, it’s just throwing government money at the problem.
Although Republicans in the modern era have generally been looking to reduce, rather than increase, spending on anything other than defense, drug coverage for senior citizens has been a conspicuous exception ― in part, perhaps, because seniors are such an increasingly vital part of the GOP’s political coalition.
H.R. 3’s second component would limit the ability of drug companies to raise prices year after year, by tying price increases to inflation. These limits would apply both to drugs in Part D (which is for drugs people buy directly themselves) and Part B (which includes drugs that physicians and clinics buy, then administer directly to patients). The bill also calls for studying ways of applying these limits to drugs available to other buyers.
An impetus for this change are the widespread examples of drug companies raising prices of products like EpiPens, which are used to stop potentially deadly allergic reactions, even when the product itself hasn’t gotten better in any meaningful way.
The inflation caps have generated a lot more pushback from the drug industry, which opposes any federal intervention into what it can charge. But it’s not nearly as controversial or toxic to drugmakers as the third provision, which would give the federal government authority to negotiate prices directly with manufacturers.
Each year, following a short phase-in period, the secretary of Health and Human Services would pick at least 50 drugs that would be subject to negotiated prices. The 50 would come from a larger list of 250 single-source drugs (that is, drugs with no generic competition) on which the U.S. spends the most annually, taking into account both what government programs and private insurers buy.
The law also requires negotiation for one specific drug, insulin, as a response to widespread reports of diabetes patients rationing their own treatment ― occasionally, with tragic consequences.

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H.R. 3 doesn’t simply call for a negotiation. It sets financial boundaries for the discussions by requiring that the negotiated prices not exceed 120% of the average of what six other countries (Australia, Canada, France, Germany, Japan and the U.K.) pay. For newer drugs not yet available in other countries, the law has a separate set of guidelines.
The hard part of any proposal like this isn’t so much giving the government the right to negotiate. It’s giving drug companies reason to go along. There are a number of ways to do this, including threatening to exclude high-priced drugs from formularies and breaking patent rights (or having government manufacture drugs directly) when the drugmakers refuse to negotiate.
H.R. 3’s solution is slap drugmakers with a tax that would quickly rise to 95% of sales revenue any time manufacturers block a product from negotiation. The tax would not be deductible as a business expense ― which means, according to an assessment by the Congressional Budget Office, manufacturers could conceivably lose money outright in such instances, depending on the details and circumstances.
That threat would be enough to compel the drug industry to negotiate, the CBO predicted, and it would produce huge savings for the government: $456 billion over 10 years. An analysis by the independent firm Avalere found that the savings could be even bigger.
Under H.R. 3, the majority of that money would go right back into Medicare, in order to underwrite dental, vision and hearing coverage that the program lacks ― and to further subsidize some of the low-income seniors on the program. But a key provision of the law, one Pelosi prioritized, allows private insurers to use the negotiated prices, so that their beneficiaries can save money too.
Of course, drug companies could (and almost certainly would) find ways to game the system, perhaps by manipulating the way prices work abroad. And because the bill applies only to drugs that generate the most sales revenues, drugs that are expensive but serve small numbers of patients could fall outside its purview.
Those are among the reasons progressives weren’t more enthusiastic about the final product, even after Pelosi had adopted some of their ideas, although ultimately Reps. Lloyd Doggett (D-Tex.), Pramila Jayapal (D-Wash.), and Alexandria Ocasio-Cortez (D-N.Y.) ― three progressive leaders who had sparred with leadership over the bill ― all voted yes.

Why This Legislation Matters

For conservatives on and off Capitol Hill, the issue with the bill is its potential effects on innovation, although the magnitude of those effects, if any, are the subject of long-standing debate in the health policy community.
Any proposal to reduce what the government pays for drugs prompts the industry to say that innovation will suffer, even though there have been whole books written on the way drugmakers and their allies exaggerate those claims. At the same time, plenty of well-respected scholars think the claims have some merit ― that, without those high profits, pharmaceutical companies would innovate less because they would draw less investment capital.
The CBO in its assessment concluded that if H.R. 3 becomes law, the drug industry would probably develop 8 to 15 fewer drugs over a 10-year period. That’s a small fraction of the more than 300 drugs the CBO expects the industry to develop during that same span, although obviously the significance of that reduction would depend ultimately on what those 8 to 15 drugs might have been ― another unimpressive knockoff drug for reflux, or a breakthrough for hemophilia? ― and whether the CBO’s estimate, which necessarily involved a lot of guesswork, was on the mark.
What’s less ambiguous is that lots of people are suffering and in some cases dying right now because the status quo leaves so many unable to pay for their prescriptions. That is why drug pricing is getting so much attention, including from Trump, although he has sent characteristically inconsistent messages about what exactly he wants or how badly he wants it.
For more than a year, his administration has been preparing a regulation that would tie the price of Medicare Part B drugs (the ones doctors administer directly) to international prices ― which, conceptually, is similar to the way the House bill would use a global price index. But the administration has not yet proposed the regulation formally, despite constantly recirculating rumors that release is imminent, and it is under enormous pressure from industry and sympathetic Republicans on Capitol Hill to keep the proposal from going forward.
Trump has also praised a bipartisan bill from Sens. Chuck Grassley (R-Iowa) and Ron Wyden (D-Ore.). That bill includes the first two parts of the House bill, the extra financial assistance in Medicare and the limits on year-after-year price increases, but not the provision for price negotiation, which is a nonstarter with conservatives. Even without that provision, McConnell has so far resisted bringing a bill to the floor and, so far, Trump hasn’t prodded him to do so.
At one point, Trump also expressed interest in working with Pelosi. This fueled tensions inside the Democratic caucus, as progressives accused the speaker of scaling back her proposal in order to win White House support. The administration eventually turned on H.R. 3, releasing a report suggesting it would have dramatic, devastating effects on innovation ― and dispatching officials to call the House proposal “unworkable.”
Trump has also taken to attacking the “Do Nothing Democrats” on drug prices, which is a strange choice given that the House actually took action by passing its bill, when Trump has repeatedly whiffed on chances to make policy unilaterally or with Congress. At last month’s State of the Union address, House Democrats tried to make that point by standing when Trump mentioned drug pricing and holding three fingers in the air, for H.R. 3. The protest drew little notice.
But their December vote makes it more likely that the House could approve something similar a year or two from now, or whenever leadership in the White House and Senate changes. That is no small thing, no matter how much attention it gets.
https://www.huffpost.com/entry/prescription-drug-bill-house-democrats-hr3_n_5e4ddae5c5b630e74c4ff4e3?ncid=newsltushpmgpolitics

Maine moves closer to importation of medicine from Canada

A legislative panel approves rules from the Department of Health and Human Services that are a key step in implementing the new law. 

by Associated Press - Portland Press Herald - February 19, 2020

AUGUSTA — A committee of the Maine Legislature moved the state closer to wholesale importation of prescription drugs from Canada with a vote on Tuesday.
The committee unanimously approved rules from the Maine Department of Health and Human Services. Democratic Senate President Troy Jackson of Allagash said that’s a key step in implementing a new law on drug imports.
The state passed the new law last year, and the state now needs to send the federal government a plan and get approval to set up the program.
The health and human services department is required to submit the application to the feds by May 1.
Vermont, Colorado and Florida have also passed laws about wholesale importation.
Jackson said the change will give Mainers access to medications that are “a fraction of the price across the border.”
https://www.pressherald.com/2020/02/19/maine-moves-closer-to-importation-of-medicine-from-canada/