Hawaii Was Creating A Plan For Universal Health Care. It’s Time To Return To It
Even before the pandemic arrived on our shores, our health care system was in crisis.
In 2009 Hawaii passed a law to create the Hawaii Health Authority, or HHA, and charged the group with designing a universal health care system that would cover all residents of the islands.
The HHA evoked the fundamental questions at the core of health care in the United States today. Should health care be a commodity, sold by corporations to those with the ability to pay? Or should it be a public good that is assured for all, similar to roads, schools, national parks and national security?
I was an original member of the HHA, appointed by Gov. Neil Abercrombie. The HHA met regularly from 2011 until April 2013 but at that point the Abercrombie administration pivoted away from the HHA and toward the federal government’s Affordable Care Act. The ACA was largely written by the insurance industry in order to cement the industry’s central role in health care. At the heart of the ACA was a move to expand coverage by getting greater numbers of people on competing private healthcare plans.
So, what has happened to health care in Hawaii under the ACA?
In the past decade Hawaii’s per capita health care costs have doubled, and they continue to rise at a rate of about 7% per year with no end in sight. Our physician workforce has declined precipitously, decimated by reforms promoted by the Affordable Care Act.
Even before the pandemic arrived on our shores this year, our health care system was in crisis.
To begin to understand why that’s happened, let’s go back to what existed before the Affordable Care Act went into effect. At that point, a patient’s experience of seeing a doctor in Hawaii generally followed expectations. The doctor would talk to you and examine you, make at least a provisional diagnosis and explain it to you, and formulate a plan for further diagnostic tests and/or treatment of the diagnosed conditions.
Even if — unlike in every other economically advanced nation in the world — our health care was being financed largely through corporations, the system in Hawaii was relatively stable. Needed care was generally accessible, and monthly health insurance premiums in Hawaii were among the least expensive in the country.
At that time doctors were paid with fee-for-service: They provided a service and they got paid for it. In 1974 Hawaii set itself apart from the rest of the United States by passing the Prepaid Health Care Act, mandating that employers must provide health insurance to anyone working 20 hours a week or more. Both the Prepaid Act and federal Medicaid rules assured comprehensive benefits.
The Prepaid Act also required that all employer-based insurance must be equivalent to the benefits of the state’s largest health care plan (which was then as now HMSA), a requirement that has effectively banned deductibles and limited co-pays to 10% or 20% of fees. Doctors’ fees were largely standardized due to HMSA’s dominance; other smaller plans used physician networks and fees similar to HMSA. Kaiser had its own prepaid system.
Doctors practiced in small independent practices, and all of them accepted HMSA, other employer-based plans and Medicare. Most also accepted Medicaid. Our per capita Medicare spending was the lowest in the country in 2008.
In essence, things worked. Patients got care in the expected way, and doctors knew how and how much they would be paid. The only problem was that throughout the United States, health care costs were rising faster than the cost of living, and generally faster on the continent than in Hawaii.
The ACA In Practice
The ACA introduced payment reforms called “value-based payment,” founded on the idea that health care costs in the United States were the highest in the world because doctors, paid with fee-for-service, were providing unnecessary services to their patients to make as much money as possible.
This unfounded idea ignored the fact that in the United States the per capita rates of physician visits and hospital days are relatively low compared to other developed countries — in countries in which everyone has health care, fee-for-service payments are often used and the cost of health care per capita is around half of what the United States spends.
Despite claims to the contrary, patients in the United States see doctors less frequently than patients in many other countries.
Despite claims to the contrary, patients in the United States see doctors less frequently than patients in many other countries.
Despite the lack of any evidence of over-utilization of primary care services, value-based reform efforts have focused mainly on primary care. The “solution” to the non-existent problem of over-utilization has been to pay doctors and hospitals an up-front per patient fee, a system known as “capitation.” Since 2017 HMSA has paid primary care doctors a flat monthly fee for each patient attributed to the doctor’s practice.
Capitation introduces perverse incentives into the doctor-patient relationship. For example, a flat fee rewards doctors who skimp on care and it encourages the avoidance of sicker and more complex patients who may need more care.
There are efforts to counter these perverse incentives but they have devolved into a byzantine bureaucratic nightmare.
Under the system as it exists now, in order to receive adjusted payments, doctors are required to report detailed data on their patients so that insurers can measure the doctor’s quality of care and the patient’s severity of illness and likely cost of treatment. Doctors must now provide metrics, which necessitates their investing in extra staffing and computer systems.
Doctors who fail to provide these metrics face penalties — in the case of Medicare, a reduction in payment of 2% each year, which has caused the majority of independent Hawaii doctors to refuse new Medicare patients. In July 2019, Wallet Hub rated Hawaii 51st — worst in the nation — for finding doctors who would accept new patients with Medicare.
The ever increasing bureaucracy in the U.S. health care system is forcing doctors to spend more time with paperwork and less with patients.
In addition to being hugely cumbersome, these metrics fail to capture the true picture. Severity of illness depends on a lot more than diagnosis codes, and accurately predicting all of the factors that contribute to the cost of treatment turns out to be impossibly complex and expensive.
Doctors, hospitals and health plans can also game the system by including as many diagnoses as possible and choosing the most severe diagnosis codes — for example, classifying a patient’s illness as pneumonia with sepsis as opposed to simply pneumonia. In America today there is an entire industry of coding consultants to drive up revenues.
Here in Hawaii HMSA intended to base each doctor’s capitation rate on the doctor’s prior fee-for-service revenues but HMSA failed to account for the increased overhead necessitated by capitation. Three recent surveys found most Hawaii primary care doctors have seen their personal income decrease under capitation, many to the point that they can no longer continue an independent practice.
Coding determines how much money insurance companies will pay out. The system is ripe for fraud: Here, for example, the same patient is assigned different, more dire codes to create a much larger bill.
The only way that physicians can now maintain their incomes is to increase their number of patients, which means spending less time with each patient, which further amplifies the incentive to avoid sicker and more complex patients. A survey by Aimed Alliance just prior to the COVID-19 pandemic found 80% of Hawaii doctors blame HMSA’s capitation as a significant cause of our physician shortage. Prior to the pandemic, we were 25% short of needed doctors and losing 3% to 4% of our doctors per year. Now the losses are accelerating.
Meanwhile, with Medicaid: Our state government used to administer our Medicaid program, but by 2009 the state had turned the administration of Medicaid entirely over to insurance corporations. The corporations created numerous rules that blocked care and forced doctors to jump through all kinds of new hoops.
As a result, we have seen heightened inflation in Hawaii’s Medicaid costs, with rates rising at a rate 3% faster than the national average, and most independent Hawaii primary care doctors no longer accept Medicaid. On the neighbor islands, where many patients are on Medicaid, large number of doctors have stopped practicing altogether and departed.
Here Connecticut’s story suggests a solution. In 2000 Connecticut also contracted its Medicaid program out to competing private insurance companies. But in 2012 the state took Medicaid back. It used the resulting administrative savings to enhance fee-for-service payments to primary care doctors and to fund community-based programs for complex high-risk patients. Four years later, physician participation had improved substantially, per capita ER costs were down 25%, hospital costs were down 6% and overall per capita Medicaid costs had dropped 14%.
Where We Are
These days if a patient in Hawaii can still find a primary care doctor to see them, a typical visit starts with questionnaires about the reason for the visit, a medical history and questions required to satisfy metrics, all administered by the receptionist or medical assistant. The patient is prompted to get preventive health tests, such as colonoscopies and mammograms. They may see a physician assistant or nurse instead of the doctor.
In
the last half century, health care across the United States has been
smothered by bureaucracy — the number of health care administrators has
soared while the number of physicians has risen very slowly. Hawaii is
no exception to this trend.
If they do see the doctor, it is often briefly with little time to ask questions and minimal or no physical exam. Since the doctor is pressed for time, patients may be discouraged from coming to the office and treated over the phone, and they are more likely to be referred to urgent care or the ER, or for diagnostic imaging or to a specialist, instead of the doctor obtaining a thorough history and doing a physical exam.
Multiple studies show that the true reasons U.S. health care costs are so high are the excessive administrative demands of our current system, coupled with the fact that for-profit health care is riddled with parasites. In 2018 the CEOs of the three largest health insurance corporations each took in over $20 million in annual compensation. Some pharmaceutical company CEOs had even higher annual compensation that year, anywhere from $28.5 million to over $100 million each. The CEO of Regeneron, the company that two days ago supplied President Trump with experimental COVID-19 antibody treatment, was the highest paid CEO in the health care field that year: He took in $117.8 million.
In Hawaii, our system is actually less mercenary than in many other states. All of our hospitals are run as not-for-profit entities. All of our employer-based health care programs, while run by corporations, are not-for-profit. And three of the five corporations administering Medicaid for us are not-for-profit.
But our system is rife with huge amounts of administrative waste.
In Canada, administrative costs in the health care system are only a quarter of what they are in the United States.
The overall amount spent on health care in Canada is much lower than it is in the United States — and health outcomes in Canada are now superior to health outcomes in the United States.
The Way Forward
It is time to take another look at the recommendations of the Hawaii Health Authority.
Instead of starting with the system we have and asking, “How can we make it a little better while trying to keep all current stakeholders happy?” the HHA started by defining what a truly cost-effective system would look like and asked, “How can we get there from here?”
We recommended creating a comprehensive “all payer” system akin to what exists in several European countries, which would greatly simplify, unify and streamline health care in Hawaii.
Under this system, which would adhere to the state’s 1974 Prepaid Health Care Act, government regulation would ensure that every health plan in the state would offer the same benefits with no deductibles and minimal co-pays. Anyone who wasn’t covered by their employer or Medicare would be covered by Medicaid. Money would be saved by reducing administrative burdens and costs.
Using fee-for-service, all physicians would be paid the same fees in the same way by all payers, including Medicaid. Billing and payment would be kept as straightforward as possible. Management of care would be left to doctors and their patients. Collective negotiation between organized physicians and the state would keep physician fees reasonable for doctors, health plans and taxpayers.
The reforms recommended by the HHA would reduce overall health care costs, restore professional autonomy to physicians, assure reasonable fees and again make Hawaii an attractive place to practice medicine, including on the neighbor islands.
The HHA is already in Hawaii law as HRS 322H. All that is required now is the backing of Gov. David Ige to appoint new members who are committed to cost-effective universal health care and not the special interests of the health insurance companies.
If the governor empowers the HHA to fulfill its statutory mission, Hawaii could again have the most cost-effective health care system in the country and regain its reputation as a leader in health care.
A public health giant gives a scathing indictment of Trump’s pandemic response
by The Editorial Board - Washington Post - October 7, 2020
WILLIAM FOEGE, a legendary figure in public health who helped devise the strategy that curtailed smallpox in West and Central Africa in the late 1960s and who led the Centers for Disease Control and Prevention under Presidents Jimmy Carter and Ronald Reagan, wrote a letter Sept. 23 to the current CDC director, Robert Redfield. The letter has now been disclosed by USA Today and should be read by everyone concerned by President Trump’s dreadful response to the coronavirus pandemic and his corrosive politicization of public health.
Dr. Foege, an epidemiologist who received the Presidential Medal of Freedom in 2012, said he wasn’t sure what he would do in Dr. Redfield’s shoes, but the first thing “would be to face the truth.” Despite spin from the White House, “this will go down as a colossal failure of the public health system of this country. The biggest challenge in a century and we let the country down.” In the future, public health textbooks “will use this as a lesson on how not to handle an infectious disease pandemic.” The cause, he said, has been “the incompetence and illogic” of the White House.
Not placing the CDC in charge of the pandemic response violated “every lesson learned in the last 75 years that made CDC the gold standard for public health in the world,” he wrote. The need for a “coherent federal plan, the backbone of every former response, has been ignored,” leaving it to the states, often competing among themselves. The “absolute need to form and guide coalitions” was ignored, he wrote, and the need for global cooperation squandered. Dr. Foege recalled the lesson that “the best decisions are based on the best science while the best results are based on the best management.” In this case, he lamented, “the White House has rejected both science and good management.”
He said he initially thought White House officials would “see how disastrous their approach was and finally turn the job over to professionals. Now I know that won’t happen.” He bemoaned how the White House “manipulated the valuable reputation” of the agency by diluting its warnings of the virus’s dangers. Many current and former CDC employees think Dr. Redfield caved in to the White House’s orders “without sufficient resistance,” he asserted. He urged Dr. Redfield to come clean, apologize in a letter and declare his intention to lead the agency without meddling. “Don’t shy away from the fact this has been an unacceptable toll on our country,” he wrote. “It is a slaughter and not just a political dispute.”
Dr. Foege appealed to Dr. Redfield’s conscience, saying he should resign on principle if necessary, that he shouldn’t want to be remembered as “forsaking your role as a servant to the public in order to become a servant to a corrupt president.” Whether Dr. Redfield takes the advice or not, it is certainly long past time for him to reject the White House pressure on the CDC and embrace the primacy of science and expertise in managing public health.
Republican Judges Are Quietly Upending Public Health Laws
A catastrophic sequence of decisions has blocked states from responding to the pandemic.
by John Fabian Witt - NYT - October 15, 2020
Alongside growing controversy over judicial nominations, court reform and Covid-19 policies, American law is in the midst of a little-noticed paradigm shift in courts’ treatment of public health measures.
The Republican Party’s campaign to take over the federal and state courts is quietly upending a long and deeply embedded tradition of upholding vital public health regulations. The result has been a radically novel and potentially catastrophic sequence of decisions blocking state responses to the coronavirus pandemic.
For centuries, American constitutional law granted state governments broad public health powers. “Salus populi suprema lex,” the old saying went: The health of the people is the supreme law. Such authority went back to the beginning of the Republic. In the famous 1824 case of Gibbons v. Ogden, Chief Justice John Marshall defended the “acknowledged power of a State to provide for the health of its citizens.” States, he explained, were empowered to enact “inspection laws, quarantine laws” and “health laws of every description.”
Lemuel Shaw of Massachusetts, who was arguably the most respected state judge of the 19th century, supported vast public health powers and described states’ authority to control epidemics as central to the sovereign power of government. The Alabama Supreme Court agreed, citing the old dictum of salus populi, and courts in states like Georgia and Louisiana followed. In New York, the state’s highest court upheld disruptive health regulations like a ban on burials in urban church cemeteries. After the Civil War, New York’s courts upheld the Legislature’s decision to vest local boards with “absolute control over persons and property, so far as the public health was concerned.”
In 1900, when a suspected outbreak of bubonic plague led San Francisco authorities to quarantine the city’s Chinatown neighborhood, the U.S. Court of Appeals for the Ninth Circuit struck down quarantine and inoculation provisions that irrationally targeted Chinese residents, but ratified the city’s power to quarantine in general.
Five years later, the U.S. Supreme Court in Jacobson v. Massachusetts upheld mandatory vaccination programs. States, the court ruled, were empowered to establish general regulations “as will protect the public health.” As in the two Chinatown cases, however, the court aimed to preserved its authority to intervene in narrow circumstances. Justice John Marshall Harlan’s opinion observed that certain “arbitrary and oppressive” vaccinations might be unconstitutional.
Modest and careful judicial intervention was the norm in courts across the country. When courts in Illinois, Kansas, Michigan and Wisconsin overturned policies prohibiting unvaccinated children from attending school, for example, they did so on the ground that their state legislatures had not authorized such policies. Such decisions respected the salus populi principle by leaving the legislatures empowered to mandate vaccination if they saw fit to do so.
The basic outlines of this approach remained in place for more than two centuries. Today, however, the tradition of salus populi is in collapse. In state and federal courts alike, Republican-appointed and Republican-elected judges are upsetting the long-established consensus.
This month, a bare majority of four Republican-appointed justices on the Michigan Supreme Court struck down the state’s 75-year-old emergency powers law as an “unlawful delegation of legislative power to the executive.” In dissent, Chief Justice Bridget McCormack (who was endorsed by Democrats when she campaigned for election to the court) correctly identified the majority’s reasoning as “armchair history” that set aside decades of precedent.
Last month, a federal district judge in Pennsylvania appointed by President Trump struck down the state’s business closure rules and its limits on gatherings. The judge in the case, William Stickman, revived hoary ideas about freedom of contract and laissez-faire economic policy that once led the courts to strike down protective labor legislation like wage and hour laws.
And back in the spring, four justices connected to the Republican Party on the Wisconsin Supreme Court overturned their state’s common-sense emergency Covid-19 rules over the dissents of three colleagues.
The U.S. Supreme Court threatens to get into the action, too. In May, four conservative justices (Clarence Thomas, Samuel Alito, Neil Gorsuch and Brett Kavanaugh) dissented from an order in South Bay United Pentecostal Church v. Newsom allowing California’s Covid-19-related restrictions to remain in place for gatherings at places of worship. Then, in Calvary Chapel Dayton Valley v. Sisolak, decided at the end of July, those same justices dissented from a similar order leaving Nevada’s restrictions intact.
Next month, the court is scheduled to hear arguments on a startling and widely criticized decision from the U.S. Court of Appeals for the Fifth Circuit in Texas last year that offers yet another opportunity to strike down the Affordable Care Act. The health care of millions could be cast into question even as the pandemic rages.
All of this is a sharp departure from a long history of judicial solicitude toward state powers during epidemics. In the past, when epidemics have threatened white Americans and those with political clout, courts found ways to uphold broad state powers. Now a new generation of judges, propelled by partisan energies, look to deprive states of the power to fight for the sick and dying in a pandemic in which the victims are disproportionately Black and brown.
The results are already devastating.
https://www.nytimes.com/2020/10/15/opinion/coronavirus-health-
courts.html?
A $52,112 Helicopter Ride: Coronavirus Patients Battle Surprise Medical Bills
Congress was close to a solution before getting hit with millions of dollars of ads from private-equity firms. Then the pandemic struck.
by Sarah Kliff - NYT - October 13, 2020
An intubated coronavirus patient was declining rapidly when doctors decided to airlift her to a hospital with better critical care resources.
“It’s life or death,” the family of the 60-year-old woman recalled being told when it happened in April. “We have to transfer her now.”
The patient was flown by helicopter from one Philadelphia hospital to another 20 miles away. She spent six weeks at the new hospital and survived. When she came home, a letter arrived: The air ambulance company said she owed $52,112 for the trip.
Last year, Congress abandoned its attempt to prevent surprise bills like this one, and coronavirus patients are now paying the price. Bills submitted to The New York Times show that patients often face surprise charges from out-of-network doctors, ambulances and medical laboratories they did not pick or even realize were involved in their care.
The plan to ban these kinds of bills was popular and bipartisan, and it was backed by the White House. It fell apart at the 11th hour after private-equity firms, which own many of the medical providers that deliver surprise bills, poured millions into advertisements opposing the plan. Committee chairs squabbled over jurisdictional issues and postponed the issue. Then the pandemic struck.
‘How am I going to pay this all off?’
The Pennsylvania patient had no way of knowing that her helicopter, which transported her between two in-network hospitals, did not have a contract with her health insurance plan. Nor could she have known that the air ambulance service, owned by a private-equity firm, faces multiple lawsuits over its billing tactics.
Her health plan, Independence Blue Cross, initially said it would pay $7,539 of the bill, according to billing documents reviewed by The Times, but then rescinded the money. The patient, housebound because of lingering coronavirus symptoms, was left with the full amount.
“She was intubated and on a ventilator when her providers felt it was necessary that she be transferred,” said Leslie Pierce, a division chief at the Pennsylvania Insurance Department, who handled the complaint that the patient submitted to the agency. “She had no decision in the selection process.”
About 450,000 Americans have been hospitalized with coronavirus. Even for those covered by robust health insurance, hospitalization can generate significant medical bills. To understand the true cost of coronavirus hospitalizations, and the impact these medical bills have on patients, The Times has been inviting readers to share their bills, and you can do so here.
The resulting database, which now includes more than 350 reader submissions, shows coronavirus patients are encountering the same surprise medical bills that have plagued the health system for decades. While President Trump told the country “not to worry” about the disease after his three-day coronavirus hospitalization, other survivors say the cost of care causes tremendous anxiety at a moment when they want to focus on recovery.
Some patients report feeling overwhelmed by the pile of bills that greet them at home. One-third of coronavirus patients reported an altered mental state after contracting the disease, according to the largest randomized study to examine neurological symptoms. Many patients struggle to do basic tasks, such as cook or pay bills.
Alice Navarro, 40, spent 10 days in July receiving coronavirus treatment at an in-network hospital in Austin, Texas. Many doctors who saw her there were out-of-network, and her health plan has denied about $4,000 of their charges.
Ms. Navarro, 40, has been filing appeals with her insurance at the same time that she is suffering from short-term memory loss because of coronavirus.
“I think about the bills several times a day,” she said. “How am I going to pay this all off? My parents were like, ‘Don’t worry about this right now, focus on getting better,’ but that’s easier said than done.”
Surprise medical bills happen when patients receive care from an out-of-network provider they did not choose. These charges are common in certain corners of the health system like the emergency room, where 20 percent of patients are vulnerable to surprise medical bills.
Coronavirus Schools Briefing: It’s back to school — or is it?
The bills are especially pervasive after ambulance trips: One recent study found that as many as 71 percent of those rides could result in surprise, out-of-network bills.
“We were shocked to see that,” said Dr. Karan Chhabra, a surgical resident at Brigham and Women’s Hospital and the lead author of the study.
Gaps in the pandemic protections
After failing to pass comprehensive billing reform, Congress tried in relief packages passed this spring to shield coronavirus patients from surprise charges. It set up a $175 billion provider relief fund to aid hospitals and doctors on the front lines of battling coronavirus. As a condition of accepting those funds, medical providers agreed not to send surprise medical bills to their patients.
Many health insurers have promised to cover plan members’ coronavirus hospital stays in full, another effort to hold patients harmless.
But these protections leave significant gaps, as patients are beginning to find. While many hospitals and doctors received provider relief funds, a number of medical laboratories and ambulance services did not. That leaves those providers free to bill however they’d like.
Insurers’ policies that cover coronavirus hospital stays, meanwhile, sometimes do not include the ambulance ride it took to get there — or follow-up care to treat long-term symptoms.
“The government is telling people if you have coronavirus, you cannot get surprise-billed,” Dr. Chhabra said. “It’s incredibly counterproductive if people cannot trust the policies meant to protect them when they’re getting care for this illness.”
Air ambulance bills are often the most costly type of surprise medical bills. Dr. Chhabra found a median charge of more than $38,000, leaving the typical patient responsible for more than $21,000 after the insurance payout. The prices are quickly increasing, too, rising about 15 percent each year since 2015.
In recent years, numerous states have enacted laws that restrict surprise out-of-network billing similar to the one Congress nearly passed. But states cannot regulate air ambulance fees. Courts have repeatedly interpreted the 1978 Airline Deregulation Act as protecting air ambulances from any state rate setting.
Only the federal government can intervene by amending the Airline Deregulation Act. The congressional package would have done that, even though the air ambulance industry has generally opposed this policy.
The Pennsylvania patient, who asked not to be identified because she was recovering, was transported by Conemaugh Medstar, an air ambulance serving southwest Pennsylvania. The private equity firm American Securities owns its parent company, Air Methods, which is among the largest air ambulance services in the United States. Air Methods currently faces six separate class-action lawsuits in federal court, where patients describe expensive charges and aggressive debt collection tactics.
In one case, the company sought to garnish $53,034 from a patient’s bank account.
Air Methods contends that those bills are six to eight years old, and that it has since reformed its debt collection practices.
Ground ambulances, another source of surprise bills for coronavirus patients, have also largely escaped billing regulations. California passed legislation in 2017 that barred most types of surprise medical bills, but it excluded ambulances. The congressional deal that nearly passed also did not include ambulances. Legislators may be reluctant to regulate ambulances because many are run by local and municipal governments, which rely on the charges for revenue.
Widowed, and facing a bill
Lynne Lerner, the patient in California, was surprised to receive two $1,471 medical bills for the Los Angeles Fire Department ambulances that took her and her husband to a hospital one mile from their house.
Ms. Lerner had called the ambulance for her husband, Larry, when his coronavirus symptoms worsened in late March. The paramedics suggested that Ms. Lerner, who also had coronavirus, seemed ill enough to require hospital care as well.
The two were put in separate ambulances. Mr. Lerner died after nine days in the hospital. When the first ambulance bill arrived, Ms. Lerner thought, “Please let this be for the both of us.”
“They took us around the corner,” she said. “I could have walked.”
She had expected her insurance to cover all costs related to coronavirus. Instead, it ended up paying 90 percent of the ambulance bills, leaving Ms. Lerner with $294 to pay.
The Los Angeles Fire Department did not respond to multiple messages seeking comment.
Air Methods said the document received by the Pennsylvania patient, which stated the “amount due” above a box to write in a credit-card number, was not a bill but rather “an update on where things stood” with her insurance company. The company estimates it has transported 3,300 coronavirus patients over the course of the pandemic, and said that it had a “special process” for handling their billing.
“Our patient advocate teams work closely with our patients to ensure they have guidance through the reimbursement process,” said Doug Flanders, a spokesman for Air Methods.
The Pennsylvania patient ultimately filed a complaint with the state’s insurance commissioner, Jessica Altman. While Ms. Altman’s office has no authority to regulate air ambulance bills, her staff did make a phone call to the insurer. The situation then resolved quickly. Independence Blue Cross said in a statement that it had already begun reprocessing the claim by the time the regulator called.
The health insurer initially sent the patient documents stating, “You are responsible to pay the amount the provider may bill you.”
Shortly after the regulator’s inquiry, the patient learned the health plan would cover the bill completely.
https://www.nytimes.com/2020/10/13/upshot/coronavirus-surprise-medical-bills.html?
Even as the Economy Grew, More Children Lost Health Insurance
A new analysis shows that coverage levels fell for a third straight year. And that was before the pandemic struck.
by Margot Sanger-Katz and Abby Goodnough - NYT - October 9, 2020
The share of children with health coverage in the United States fell for the third consecutive year in 2019, according to census data, after decades of increases.
The decline occurred during a period of economic growth — before the coronavirus pandemic caused broad job losses that might have cost many more Americans their health insurance.
A report Friday by the Georgetown Center for Children and Families found that the ranks of uninsured children grew the most in Texas and Florida, and that Latino children were disproportionately affected. Nationally, the number of children without health insurance rose by 320,000 last year alone, to a total of nearly 4.4 million children, the report found.
“What’s so troubling about this data is we were making so much progress as a country,” said Joan Alker, the center’s executive director and an author of the report. “And now that progress is clearly reversing.”
The picture since the start of the pandemic is less clear. Many families have lost jobs that came with health coverage, which could increase the number of children without insurance. But national enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) has also swelled, aided by temporary policies to prevent families from losing coverage during the emergency. More current estimates for the uninsured rates among children will take time.
In recent years, falling enrollment in Medicaid and CHIP drove the overall changes, according to the report. Although those programs for low- and middle-income children are primarily managed by state governments, Trump administration policies could be playing a role: The administration has encouraged states to check eligibility more often, which advocacy groups say has caused many families to lose coverage because of paperwork errors and missed deadlines.
And the administration’s policies on immigrant families have caused some to end enrollment for their children even though they are eligible citizens, according to child welfare groups in several states with the largest drops. In particular, the “public charge” rule makes it harder for immigrants to be approved for green cards if they have received public benefits or are deemed likely to receive them in the future.
“They were coming to me saying: ‘Please close my case. I don’t want to get into any trouble,’” said Graciela Camarena, outreach program director in the Rio Grande Valley for the Texas branch of the Children’s Defense Fund, a group that helps enroll children in health coverage. Ms. Camarena said most clients would not be affected by the public charge policy if they signed up their children, but news of the rule had produced widespread concern.
The public charge policy was completed last summer but has been put into effect unevenly. For months, its enforcement was paused in several states by a court order. More recently, its implementation has been softened because of the public health emergency related to the coronavirus. Nevertheless, Latino children saw a disproportionate drop in coverage through 2019, according to the Georgetown report, an indication that their families were reacting to the policy.
The public charge rule does not take into consideration benefits used by citizen children. But Alison Yager, deputy executive director of the Florida Health Justice Project, said the pandemic had made it hard for her nonprofit organization to get that fact and other accurate information about the public charge rule to worried families.
“It’s significantly hampering education efforts,” Ms. Yager said. “It seems to be harder to spread accurate information than misinformation once it has taken hold.”
A large body of evidence has shown that children’s health insurance coverage has long-term benefits for children and their families, improving health outcomes, educational attainment and even adult earnings.
Last year, some state and federal officials suggested it was good news that more than a million children were dropped from Medicaid and CHIP enrollment from December 2017 to June 2019, arguing that more Americans were getting coverage from employers in an improving economy. But census data seems to counter the notion that many families gained employer insurance: The rate of uninsured children increased in some states with declining Medicaid and CHIP enrollment, including Tennessee, Texas, Idaho and Utah. The 2019 data shows that trend has continued for another year.
The Georgetown report found that the states with the biggest 2019 increases in the uninsured rate among children — all more than 1.5 percentage points — were South Dakota, Texas, Utah, Arkansas, Missouri, Delaware, Arizona and South Carolina. More than half of uninsured children live in the South, where most of the states have declined to expand Medicaid under the Affordable Care Act. Ms. Yager said Florida’s refusal to expand Medicaid had kept many children uninsured, too, along with low-income adults.
She said of expanding Medicaid: “That would bring a whole lot of families into Medicaid coverage who are kind of hanging out there in the coverage gap. We know that in general, kids of insured parents are more likely to be insured themselves.”
According to the report, the uninsured rate in 2019 for children living in states that had not expanded Medicaid was 8.1 percent. That was almost double the rate (4.2 percent) in states that had expanded.
In all, Medicaid and CHIP cover about 36 million children; that is nearly half the total number of children in the United States.
It is still unclear precisely how the pandemic has changed the number of uninsured children. The Urban Institute has estimated that 2.9 million people younger than 65 will become uninsured by the end of this year as a result of the recession, including 300,000 children.
Child welfare groups say they are worried that even though recent enrollment declines appear to be reversing, many families who have recently lost their employer-based insurance may be unaware they can sign up for public benefits.
It will be harder for children who are already enrolled to lose Medicaid, though, because under the emergency funding bill that Congress passed in the spring, states cannot terminate people’s Medicaid coverage or tighten eligibility rules during the public health crisis.
Preliminary data from the Centers for Medicare and Medicaid Services (C.M.S.) shows that Medicaid and CHIP enrollment grew by 1.4 million children between February and June, more than the programs lost in the previous two years.
A spokeswoman for C.M.S. said the agency was “committed to ensuring that eligible children are enrolled and retained in coverage,” adding that it had provided $48 million in grants for outreach and enrollment efforts last year.
https://www.nytimes.com/2020/10/09/upshot/children-losing-health-insurance.html?
Covid-19 Vaccines Are Chance at Salvation, Financial and Beyond, for Drug Makers
Big profits beckon for pharmaceutical companies, which are already using their work on vaccines to fight efforts in Washington to curb drug prices.
By Jesse Drucker, David Gelles and - NYT - October 13, 2020
For a long time, drug makers have been the most hated industry in America. Companies are blamed for gouging prices on lifesaving drugs and enriching themselves through the opioid crisis, among other sins.
Now, with pharmaceutical companies racing to find vaccines to end the coronavirus pandemic, the industry is hoping to redeem itself in the public’s mind.
The primary goal, of course, is to rescue the world from the grips of a vicious virus. But a big fringe benefit is to get public credit — and to use an improved image to fend off government efforts to more heavily regulate the industry.
Consider Johnson & Johnson, one of the world’s largest health care companies.
In recent years, its reputation has been battered by accusations that products like its artificial hips and talcum powder have harmed customers. In 2019, an Oklahoma judge ordered the company to pay $572 million for contributing to the opioid epidemic.
This spring, Johnson & Johnson jumped into the hunt for a Covid-19 vaccine; its candidate is now in the final stage of clinical trials. (On Monday, the company said it had temporarily paused the study after a participant became sick with an unexplained illness.)
Regardless of whether the vaccine ever comes to market, the company is looking to create a surge of positive publicity from its work. Its chief executive, Alex Gorsky, went on the “Today” show this spring and called Johnson & Johnson’s lab workers heroes. The company has produced a slick, self-promotional online video series, “The Road to a Vaccine,” featuring feel-good interviews with the company’s scientists and segments on issues like whether it is safe to send children back to school.
Johnson & Johnson’s efforts to develop a vaccine will show that “J&J is a company full of people with heart and soul who are doing this 24-7, with all their science and know-how,” Dr. Paul Stoffels, the company’s chief scientific officer, said in an interview. While the company’s image at times has been “trashed,” he said, “I hope that we can get to a better reputation.”
That is a widely held sentiment across the pharmaceutical industry. Companies are looking for public makeovers as a political battle over drug price controls looms. Others are seizing the once-in-a-generation opportunity to raise money for future projects from investors and the government.
For an industry demonized by consumers and politicians, the hunt for a vaccine “offers a path to redemption,” said J. Stephen Morrison, a senior vice president at the Center for Strategic and International Studies, a think tank in Washington.
Last fall, a Gallup poll found that drug makers had the worst reputation of any American industry. Americans were twice as likely to rate the industry negatively as positively. Drug companies were even less popular than the federal government.
The pandemic — and the high hopes for a fast, safe, effective vaccine — appears to be changing that perception, at least for now. This spring, other opinion polls showed that Americans’ views of the industry were improving.
When Gallup released the results of this year’s annual survey, conducted in the first half of August, the results confirmed that the pharmaceutical industry’s reputation had gotten a bit better. Now, it is second to last, having inched past the U.S. government.
Public opinion matters. The industry is facing a fight in Washington over price controls, which could take a bite out of companies’ profits in the United States. The latest salvo came last month when President Trump issued an executive order that called for capping the costs of some prescription drugs.
The industry’s largest trade group, the Pharmaceutical Research and Manufacturers of America, is fighting back by invoking the industry’s effort to fight the coronavirus. It denounced Mr. Trump’s executive order as “a reckless attack on the very companies working around the clock to beat Covid-19.”
Kim Monk, managing director of Capital Alpha Partners, a policy research firm in Washington, said finding a safe and effective vaccine could help drug companies in their campaign to stave off price controls. “You don’t even need to say it,” she said. “It’s part of the strategy.”
To be sure, the race for a coronavirus vaccine is much more than a public relations play. Scientists at pharmaceutical companies take great pride in their work to combat human suffering. And there is immense prestige involved in being among the first to successfully conquer a devastating global pandemic.
There are also potentially enormous profits on the line.
Vaccines are often thought of as the pharmaceutical industry’s sleepy, low-profit backwater, but that is not always the case, said Dr. David Bishai, a professor of health economics at Johns Hopkins University’s school of public health.
Prevnar, a vaccine to prevent pneumococcal disease, which leads to ear and sinus infections, is Pfizer’s top-selling product, responsible for nearly $6 billion in revenue last year.
Merck’s Gardasil, which protects against human papillomavirus, a sexually transmitted disease that can cause cervical cancer, generated close to $4 billion in sales last year, making it the company’s third-best seller.
While drug makers generally do not disclose what they earn on individual drugs, two of the world’s largest pharmaceutical companies, GlaxoSmithKline and Sanofi, have said in securities filings that the profit margins in their vaccine divisions are greater than in their other lines of business.
Ronny Gal, an analyst at Bernstein, estimated that sales from a coronavirus vaccine could be up to $20 billion in the first year alone. And since diseases are rarely eradicated, vaccines “tend to be a very long-term business,” he said.
Two leading drug makers have pledged to not profit from their vaccines. But those promises are laden with caveats.
Johnson & Johnson has said it will sell the vaccine on a “not-for-profit” basis for “emergency pandemic use.” But the company hasn’t explained in detail how it will define “not for profit.” In any case, when the “emergency pandemic” phase of the crisis ends, the company will no longer be bound by its pledge. Jake Sargent, a Johnson & Johnson spokesman, said the end of the emergency phase “will be defined at a future date by global health authorities.”
Another major drug company, AstraZeneca, has made a similar pledge not to profit on its vaccine, which is also in large clinical trials, during the pandemic. But in a contract with one of its manufacturers, AstraZeneca has suggested that it can declare the pandemic to be over as soon as July 2021 — around the time that a successful vaccine is likely to be sold worldwide, according to The Financial Times.
“The company has committed to supplying the potential vaccine at no profit during this pandemic period,” said an AstraZeneca spokeswoman, Michele Meixell. “It is too early to determine pricing post-pandemic.”
The Covid-19 vaccine business is likely to be unusually lucrative because much of the risk has been taken out of the equation. The federal government has entered into deals with companies totaling more than $10 billion to develop, manufacture and distribute coronavirus vaccines. Drug companies usually spend small fortunes to market their products. But that will probably not be required to generate public interest in a coronavirus vaccine.
“If you get a vaccine and it gets recommended by the C.D.C., you barely need a sales force,” said Geoffrey Porges, the director of therapeutics research at the investment bank SVB Leerink.
A successful vaccine could be a transformative moment for unproven companies like Moderna and Novavax, which have never previously brought vaccines to market. But even being involved in the race is proving financially fruitful for smaller firms.
The German biotech firm CureVac, which says it hopes to have a successful vaccine by the end of the year, raised $245 million in August when it began trading on the Nasdaq. It is now valued at nearly $10 billion, despite never having brought a product to market.
Ms. Monk of Capital Alpha Partners said drug makers large and small were likely to benefit from any association with fighting the coronavirus. “For an industry that is not viewed favorably by the public,” she said, “this is a real opportunity for them to put on a white hat and save the world.”
Maine Voices: Health care as a human right is on the ballot Nov. 3
‘I can’t remember the last time I saw a doctor. It’s probably been decades,” said a patient of mine who, for the purposes of protecting patient confidentiality I’ll call Jerry. This fifth generation Mainer came to my office to establish primary care with me earlier this year.
In exploring his medical, family and social histories I began to learn his story. The oldest of five originally from rural Maine, he is a former employee at a local mill and has been out of work the last six months amidst the COVID19 pandemic. With a 40-year history of tobacco and alcohol use, his nagging stomach pain began causing him to have difficulty swallowing. In beginning to work up his medical issues, we identified emphysema and cirrhosis, each a life-threatening illness affecting his lungs and liver, respectively. “It is what it is,” he tells me.
I wonder, though, what could have been if we’d seen him sooner, perhaps decades sooner? I also wonder what might be if MaineCare had not been expanded? In this turbulent election season and throughout the COVID19 pandemic, it is an understatement to say that we have a lot on our minds, as was this case for my patient. But if I can pivot your attention to the present judicial threat to the Affordable Care Act and MaineCare expansion in Maine, I want to remind you that health care is on the ballot on Nov. 3.
I work as a family and preventive medicine physician and serve as the medical director at the Central Maine Medical Center Family Medicine Residency program. Of the 7,000 patients we serve in Lewiston about 50 percent are enrolled on MaineCare, 25 percent are enrolled on Medicare, 20 percent are enrolled on commercial insurance with another 5 percent are uninsured. For our patients, MaineCare expansion has been a lifeline.
In delivering care to a socioeconomically diverse and underserved population, our patients make decisions every day between paying to put food on the table, childcare and medical bills while MaineCare expansion has helped allay some of the economic strain from the COVID19 pandemic. Newly enrolled patients on MaineCare frequently state that they haven’t seen a doctor in decades, and we welcome them into our patient-centered medical home delivering interdisciplinary primary care spanning behavioral healthcare, social work and pharmacy services. Too often, though, we uncover chronic diseases like coronary artery disease, chronic obstructive pulmonary disease (COPD), diabetes and cancer, which otherwise could have been addressed sooner or even prevented should they have had health insurance years prior.
Repeatedly over the last decade the Affordable Care Act has been attacked through the judicial system, most notably ending up in the Supreme Court in 2012 where Chief Justice Roberts’ vote to uphold the law assured the law’s healthcare protections. Through that decision, however, Medicaid expansion became optional for the states and it wasn’t until Gov. Mills implemented this in January 2019 that we’ve begun to see its benefits.
As of Sep. 3, the Maine Department of Health and Human Services notes that 61,539 people are currently enrolled through MaineCare expansion. They’ve accessed critical healthcare services including chronic disease management, mental healthcare, substance use treatment and preventive care. DHHS sites 4,775 people newly in treatment for diabetes, 28,370 newly accessing mental healthcare, 7,863 people newly accessing opioid use disorder treatment, 3,663 people newly being screened for breast cancer and 2,582 newly being screened for colorectal cancer. Just after this executive order was signed by Gov. Mills, the Portland Press Heraldr eported that Naomi Loss of Lisbon Falls commented “When I heard the news, it was such a huge sigh of relief. We have been putting off doctor’s visits because it’s just so expensive.”
The week after the coming November election, the Supreme Court is expected to hear the latest challenge to the Affordable Care Act. After the individual mandate was largely removed from the law through the Tax Cuts and Jobs Act of 2017, challenges have made their way to the Supreme Court where health insurance expanded to 20 million American by way of the Affordable Care Act is at risk, 12 million through Medicaid expansion. If the law is invalidated and MaineCare expansion disappears, health care costs will rise and poor health outcomes will result, as was the case for my patient given decades of delayed health care.
With so much at stake in this election, please remember that healt hcare is on the state and national ballot on Nove. 3. Nearly 70,000 Mainers will see their health insurance disappear if the Affordable Care Act is nullified. The peace of mind, financial stability and access to health care for our friends, family and neighbors have been afforded will be gone.
For my patient, we continue to work together to manage his emphysema and cirrhosis. We take one small step each time we meet to share what motivates him, what concerns him and how best he can provide for his family. In reflecting back about his years absent primary care, he has mentioned to me, “I’m glad I got my foot in the door.” Me too.
Please vote to protect MaineCare expansion and elect candidates who will assure that healthcare is a human right.
'I love this country': US doctors head to New Zealand as cure for America's ills
Number of physicians yearning for a move has increased substantially since the Covid-19 pandemic, recruitment firms say
No comments:
Post a Comment