Health care is too expensive. Medicare for all is the solution.
by William Babson - Bangor Daily News - March 16, 2021
I am responding to two articles in the March 11 issue of the Bangor Daily news. One is a column by Dale Crafts of Lisbon, a Republican nominee for Maine’s 2nd Congressional district in 2020, titled “Public option will make health care system worse.” The other is an “Other Voice,” an editorial from the March 9 issue of the Los Angeles Times, titled “Make health insurance affordable.”
Crafts recognizes the serious challenges to our health care system brought on by the pandemic but goes on to say that “a new government-run health insurance system, like the ones recently proposed by some politicians in Washington will create more problems than it solves.”
The Times editorial states that “a health insurance system that relies on employer-sponsored policies is poorly equipped to handle a disease-induced recession.” Millions of Americans who lost their jobs no longer have health insurance. “Combined with steadily rising deductibles, high premiums have been one of the biggest challenges not just for the ACA but for the entire health system.” The editorial goes on to say that President Joe Biden is providing a COVID-19 relief bill that is a big albeit temporary improvement in affordability.
So we have a Republican, whose party has misled us for many years saying that they will improve our health care system. And what have they done? They have made it worse by trying to destroy the Affordable Care Act in the courts and making it harder for poor people to get Medicaid.
In essence, Crafts is saying that we need to go back to the old private insurance-based system that is not working. Hospitals in Republican states that have not accepted Medicaid expansion are more likely to close than in states that accepted Medicaid expansion. In addition, while disparaging government-run health care, Crafts conveniently does not mention that Medicare has worked well since 1965 and is a government-run system with much less administrative costs. As a surgeon who worked in the system for 32 years, I can tell you that my Medicare patients received excellent care — and they appreciated it.
The LA Times editorial is more aligned with the facts of our current system. However, it admits that Biden’s efforts can only be temporary.
The only answer to our health system’s problems is single-payer Medicare for all. And the biggest and most overwhelming reason is that it eliminates private for-profit health insurance and huge costly administrative control and paperwork. It also channels money to where it is needed — not building hospitals that cater to the rich with rooms with great views and lavish entrances — but by building much-needed emergency rooms, etc.
I recommend to those of you who want to understand the issue a book published this year titled Medicare for all: A Citizen’s Guide.
At Last, Democrats Get Chance to Engineer Obamacare 2.0
The Biden administration is trying to make the health care law more generous and closer to its original design, but may disappoint progressive allies hoping for more.
Sarah Kliff and
Ever since the Affordable Care Act became law in 2010 — a big deal, in the (sanitized) words of Vice President Joseph R. Biden Jr. — Democrats have itched to fix its flaws.
But Republicans united against the law and, for the next decade, blocked nearly all efforts to buttress it or to make the kinds of technical corrections that are common in the years after a major piece of legislation.
Now the Biden administration and a Democratic Congress hope to engineer the first major repair job and expansion of the Affordable Care Act since its passage. They plan to refashion regulations and spend billions through the stimulus bill to make Obamacare simpler, more generous and closer to what many of its architects wanted in the first place.
“This is the biggest expansion that we’ve had since the A.C.A. was passed,” said Representative Frank Pallone of New Jersey, who helped draft the health law more than a decade ago and leads the House Energy and Commerce Committee. “It was envisioned that we’d do this periodically, but we didn’t think we’d have to wait so long.”
The Affordable Care Act has expanded coverage to more than 20 million Americans, cutting the uninsured rate to 10.9 percent in 2019 from 17.8 percent in 2010. It did so by expanding Medicaid to cover those with low incomes, and by subsidizing private insurance for people with higher earnings. But some families still find the coverage too expensive and its deductibles too high, particularly those who earn too much to qualify for help.
Tucked inside the stimulus bill that the House passed early on Saturday is a series of provisions to make the private plans more affordable, at least in the short term.
The legislation, largely modeled after a bill passed in the House last year, would make upper-middle-income Americans newly eligible for financial help to buy plans on the Obamacare marketplaces, and would increase the subsidies already going to lower-income enrollees. The changes would last two years, cover 1.3 million more Americans and cost about $34 billion, according to the Congressional Budget Office.
For certain Americans, the difference in premium prices would be substantial: The Congressional Budget Office estimates that a 64-year-old earning $58,000 would see monthly payments decline from $1,075 under current law to $412 with the new subsidies.
It was a blow to Obamacare’s authors when the Supreme Court allowed states to refuse to expand Medicaid, the health law’s primary tool for bringing comprehensive coverage to poor Americans. Multiple states have joined the expansion in recent years, some via ballot initiative, but some Republican governors have steadfastly rejected the program, resulting in two million uninsured Americans across 12 states.
The stimulus package aims to patch that hole by increasing financial incentives for states to join the program. Though Democrats are offering holdout states larger payments than they’ve contemplated in the past, it’s unclear whether it will be enough to lure state governments that have already left billions on the table. Under current law, the federal government covers 90 percent of new enrollees’ costs.
Republican critics of the law contend that Democrats are seeking to install long-sought permanent policies through a temporary stimulus plan.
“Suffice it to say, this is not Covid relief,” said Senator Bill Cassidy of Louisiana, who helped write a prominent Obamacare repeal bill in 2017. “It’s fulfilling the agenda of the Biden administration under the guise of Covid relief.”
Mr. Cassidy fears that short-term spending increases on Obamacare will prove difficult to undo. He cited a quotation from former President Ronald Reagan: “Nothing lasts longer than a temporary government program.”
The White House and the Department of Health and Human Services (H.H.S.) have already begun to advertise insurance options and make them easier to get. On Feb. 15, the Biden administration opened a special enrollment period so that uninsured people could sign up for coverage right away, publicizing it widely. Officials have also begun rolling back Trump-era work requirements in the Medicaid program.
Other regulatory changes are also planned. Xavier Becerra, Mr. Biden’s choice to lead H.H.S., testified about his ambitions on Capitol Hill this week. Officials are hoping to resolve the “family glitch” problem, which makes Obamacare insurance expensive for the children or spouses of workers who get insurance only for themselves at their job. Officials plan to tighten the rules for private short-term insurance plans that are not required to cover a full set of benefits. And they are considering a long list of technical changes aimed at making plans more comprehensive.
“Any one of these changes individually is moderate, but stack one on top of another and you get a big boost to the Affordable Care Act,” said Jonathan Cohn, author of “The Ten Year War,” a new history of the health law. “It doesn’t change the law’s structure, but it does make it much more generous.”
Those close to the effort say its ambitions — and its limits — reflect the preferences of those leading the way. Mr. Biden, who was involved in the passage and rollout of Obamacare as vice president, ran on the idea of expansion, not upheaval. And leaders in Congress who wrote Obamacare have been watching it in the wild for a decade, slowly developing legislation to address what they see as its gaps and shortcomings. Many see their work as a continuing, gradual process, in which lawmakers should make adjustments, assess their effects, and adjust again.
“When you think about where we thought the A.C.A. was headed four years ago, and contrast that to where we are right now, on the cusp of a massive expansion of affordability, it’s pretty exciting,” said Christen Linke Young, deputy director of the White House Domestic Policy Council for Health and Veterans Affairs.
But Bob Kocher, an economic adviser in the Obama administration who is now a partner at the venture capital firm Venrock, said that beyond the current changes, Mr. Biden’s mission on Obamacare seemed more modest, more like “don’t break it.”
“I don’t think he has any ambition in mind beyond managing it,” he said.
To aid in the effort, President Biden has recruited a host of former Obama administration aides. His picks for top jobs at the Centers for Medicare and Medicaid Services, the Office of Management and Budget, as well as key deputies at H.H.S., all worked on the first rounds of Obamacare policymaking. Many key congressional aides working on health care now also helped write the Affordable Care Act.
Frequently Asked Questions About the New Stimulus Package
The stimulus payments would be $1,400 for most recipients. Those who are eligible would also receive an identical payment for each of their children. To qualify for the full $1,400, a single person would need an adjusted gross income of $75,000 or below. For heads of household, adjusted gross income would need to be $112,500 or below, and for married couples filing jointly that number would need to be $150,000 or below. To be eligible for a payment, a person must have a Social Security number. Read more.
Buying insurance through the government program known as COBRA would temporarily become a lot cheaper. COBRA, for the Consolidated Omnibus Budget Reconciliation Act, generally lets someone who loses a job buy coverage via the former employer. But it’s expensive: Under normal circumstances, a person may have to pay at least 102 percent of the cost of the premium. Under the relief bill, the government would pay the entire COBRA premium from April 1 through Sept. 30. A person who qualified for new, employer-based health insurance someplace else before Sept. 30 would lose eligibility for the no-cost coverage. And someone who left a job voluntarily would not be eligible, either. Read more
This credit, which helps working families offset the cost of care for children under 13 and other dependents, would be significantly expanded for a single year. More people would be eligible, and many recipients would get a bigger break. The bill would also make the credit fully refundable, which means you could collect the money as a refund even if your tax bill was zero. “That will be helpful to people at the lower end” of the income scale, said Mark Luscombe, principal federal tax analyst at Wolters Kluwer Tax & Accounting. Read more.
There would be a big one for people who already have debt. You wouldn’t have to pay income taxes on forgiven debt if you qualify for loan forgiveness or cancellation — for example, if you’ve been in an income-driven repayment plan for the requisite number of years, if your school defrauded you or if Congress or the president wipes away $10,000 of debt for large numbers of people. This would be the case for debt forgiven between Jan. 1, 2021, and the end of 2025. Read more.
The bill would provide billions of dollars in rental and utility assistance to people who are struggling and in danger of being evicted from their homes. About $27 billion would go toward emergency rental assistance. The vast majority of it would replenish the so-called Coronavirus Relief Fund, created by the CARES Act and distributed through state, local and tribal governments, according to the National Low Income Housing Coalition. That’s on top of the $25 billion in assistance provided by the relief package passed in December. To receive financial assistance — which could be used for rent, utilities and other housing expenses — households would have to meet several conditions. Household income could not exceed 80 percent of the area median income, at least one household member must be at risk of homelessness or housing instability, and individuals would have to qualify for unemployment benefits or have experienced financial hardship (directly or indirectly) because of the pandemic. Assistance could be provided for up to 18 months, according to the National Low Income Housing Coalition. Lower-income families that have been unemployed for three months or more would be given priority for assistance. Read more.
Born in the Great Recession, the Affordable Care Act was drafted with a focus on costs. Political compromises and concerns about runaway deficits kept the law’s overall 10-year price tag under $1 trillion, and included enough spending cuts and tax increases to pay for it. Those constraints led its architects to scale back the financial help for Americans buying their own coverage. Staffers who wrote the formulas said they ran hundreds of simulations to figure out how to cover the most people within their budget.
Those who wrote the regulations that interpreted the law also recall drafting rules that erred on the side of spending less to avoid blowback or litigation.
Republicans, who spent a decade dead set on repealing the law, blocked any policies to expand its reach. And the fiscal politics of the Obama years would have foreclosed the kind of subsidy expansion under discussion now, even if the law had been less politically divisive.
Now, with Democrats back in control of Congress and the White House, there is new enthusiasm for expanding health coverage. Against the background of the pandemic and changing views about federal debt among many economists, lawmakers are less concerned about deficit spending than they used to be.
But the Biden health project still faces challenges, and it may disappoint his allies. The new proposed spending, which would bring the law’s subsidies in line with early drafts of the Affordable Care Act, is temporary. Making those changes permanent could cost hundreds of billions over a decade, a sum that may spook moderate Democrats once the economy is in better health.
And for many Democrats, the overhauls do not go as far they had hoped. Mr. Biden ran not only on subsidy expansions and technical fixes, but also on a lowering of the Medicare eligibility age and the creation of a so called public-option plan, government insurance that people could choose in place of private coverage. Members of Congress have introduced Medicare expansion and public-option bills, but neither type of proposal appears likely to move soon.
Mr. Becerra has previously supported a single-payer system. He faced questions about his commitment to that idea from Senator Bernie Sanders, who has repeatedly introduced Medicare for All legislation, and from Republican senators who oppose the idea. In each case, he responded similarly: The Affordable Care Act is the president’s focus, and his own as well.
“I’m here at the pleasure of the president of the United States,” Mr. Becerra said. “He’s very clear where he is — he wants to build on the A.C.A. That will be my mission.”
Pramila Jayapal, a Democratic congresswoman from Washington State, who led a joint Biden-Sanders policy task force during Mr. Biden’s presidential campaign, says she is heartened by the measures the administration is taking — but concerned that the current efforts don’t yet match the promises made to progressives during the campaign. She said she would keep pushing for more generous health plans and an expansion of Medicare to cover more Americans, among other measures.
“I believe we’re going to do so many things in this package, and I do think it’s a good package,” she said. “But I believe we haven’t done enough to help everyone who has fallen into the cracks.”
The Health 202: States are eyeing public option health plans. Many obstacles stand in the way.
by Alexandra Ellerbeck - Washington Post - March 22, 2021
This year, Washington became the first state to offer a public option.
Several other states may be close behind. Advocates and lawmakers in Colorado, Oregon, Nevada, Connecticut, and New Mexico are exploring public option proposals of their own. The idea is to provide consumers with a lower-cost option that can also compete with private health plans and hopefully drive prices down throughout the individual marketplaces.
But pushback to the public option from the health-care industry and insurance companies is fierce, and the experiment in Washington is already off to a rocky start, with some backers disappointed that it has done little to bring down premiums.
Washington’s experience shows how hard it is to implement a state-level public option.
Beginning in the 2021 open enrollment period, Washington residents on the individual insurance market could take part in the nation’s first public option.
Not many of them chose to do so. Less than 1 percent of state residents in the individual health insurance market opted for one of the 15 public option plans offered by five private insurers, according to initial data from the state.
Although some of the low uptake probably stems from consumers who were auto- enrolled in the same plan they had the previous year, the public option plans also did little to control costly premiums.
The average public option plan premiums across all offerings was 4 percent higher compared to average 2020 Obamacare premiums, according to a presentation by Christine Gibert, a policy director at the Washington Health Benefit Exchange.
Cynthia Cox, the vice president of the Kaiser Family Foundation and director of its Affordable Care Act program, points out that if you control for the generosity of the plans, the public options are actually a little cheaper on average. But that’s not something consumers often realize.
“People aren’t always making that apples-to-apples comparisons when they’re shopping online; they’re looking at the premium first,” Cox said. “Suffice it to say, the idea that a public option could significantly lower premiums did not play out well.”
The state found it extremely difficult to set payment rates lower.
The high premiums for the public option plan stemmed from a failure to cap payment rates to health-care providers, said Washington state Rep. Eileen Cody, who sponsored the bill and chairs the state House’s health-care committee.
When Cody initially proposed the bill, she proposed capping payments at the rate that Medicare pays. Later, lawmakers increased that to 160 percent of what Medicare pays. Even with the higher rates, the state struggled to get health-care providers to agree to participate in the plan. That’s because hospitals are used to receiving much higher payments from private insurance plans than from Medicare — an average of 247 percent more, according to a Rand Corp. study.
“The hospitals just would not take lower rates,” Cody said.
Cody said the public option rollout didn’t go the way she had planned.
“In some ways, I would say it’s been a disappointment,” Cody said. “The rates did not come in where we hoped.”
It could be easier for the federal government to sell a public option plan.
States can’t run deficits to fund health-care subsidies and may face pressure from health-care providers who threaten to leave if reimbursements drop too low, according to Ge Bai, an expert on health-care policy at Johns Hopkins Bloomberg School of Public Health. The federal government, in contrast, has much more clout and financial leeway.
“The bargaining power is so much bigger at the federal level,” Bai said.
Still, Bai and other experts cautioned that it’s too early to judge the success or failure of Washington’s public option. Backers of public option proposals may bank on being able to gain more negotiating power over time as the public option gains a foothold in politics and the market.
“They expect this to be a process that will go over a number of years where slowly over time, they’ll be able to introduce changes or alterations,” said Jerome Dugan, an expert on health insurance models at the University of Washington.
That seems to be the case in Washington: Cody said that lawmakers are working on legislation that would force more health-care providers to take the public option and are looking into whether the state could also increase subsidies down the line in an attempt to bring down premiums.
Opposition to public options is fierce.
The Partnership for America’s Health Care Future, an alliance of hospital, health insurance and pharmaceutical lobbyists, is spending $1 million to combat a plan in Colorado that would trigger the creation of a public option if the health-care industry cannot bring down costs on its own before 2024.
This year’s television ad buy in Colorado comes after the group already poured $5 million into the state to attack a separate public option proposal last year, the Colorado Sun reports.
The group also has campaigned against a state plan in New Mexico. In the District, Maine and Montana, it is promoting ad spots tying a federal option to increased prices.
An ad from the Partnership for America's Health Care Future opposing a federal public option:
In Connecticut, Democrats pushing a public option have run into opposition from the insurance industry. State ethics filings show that insurance giants Aetna, Cigna and Anthem spent nearly half a million dollars lobbying the statehouse and executive branch in the 2019-2020 period, NPR reports.
Frances Padilla, the president of the Universal Health Care Foundation of Connecticut, said this opposition has been the biggest force scuttling efforts to introduce a public option in a state that has been nicknamed the “insurance capital of the world.”
Padilla, a proponent of a public option in the state, is optimistic that this year could be different after the pandemic shone a spotlight on health equity issues. But not, she says, without “a drag-out fight.”
If a public option succeeds on the state level, it could pave the way for national action.
Democrats at the state level have a warning for lawmakers looking to push a federal public option: Prepare for a bruising fight.
They will probably face much of the same opposition from hospitals and industry, said Cody, of Washington. “Everyone has a hospital in their district,” she added.
Still, Cody thinks that efforts in Washington and other states, if they succeed, could make it easier for national lawmakers to follow suit.
“Usually the states try things and then the feds take what seems to be a good idea and try to build on it,” she said.
https://www.washingtonpost.com/?reload=true&_=1616412867316
Private Equity and Physician Medical Practices — Navigating a Changing Ecosystem
Jane M. Zhu, M.D., M.P.P., M.S.H.P., and Daniel Polsky, Ph.D., M.P.P. - NEJM - March 18, 2021
In 2011, a group of scientists traveled to an archipelago in the Bahamas to begin a multiyear experiment. They sought to learn what would happen when new predators were introduced into an ecosystem of lizards. Classic ecologic theory suggests that certain predators contribute to a healthy ecosystem, increasing ecologic diversity and promoting the coexistence of competing species. The scientists, however, found a notable counterexample: when they introduced curly-tailed predator lizards, other species responded by rapidly changing their behavior, which intensified competition and undermined the species’ ability to coexist.1
The ecosystem of physician-owned medical practices has been similarly inundated with larger forces that are driving health care toward consolidation, corporatization, and administrative management. Between July 2016 and January 2018, hospitals and health systems acquired more than 8000 practices, a process that was shepherded by regulatory shifts, changes in payment and delivery models, and uncertainty in the health care market. Roughly 14,000 physicians left private practice to become hospital-affiliated employees.2 These structural changes have shifted competitive dynamics for medical practices in two principal ways. First, remaining independent practices must now compete against much larger entities, which benefit from economies of scale. Second, to remain competitive, independent practices increasingly require new sources of capital. During the Covid-19 pandemic, revenue losses for many smaller practices have magnified financial pressures. Amid these changes, private-equity firms have emerged as influential players, offering a lifeline to smaller groups needing a competitive edge in a consolidating market. The rapid growth of private-equity investment throughout medical specialties3 has generated intense interest in potential adverse effects on physicians and patients.
Private-equity firms offer practices an alternative source of investment capital outside public ownership and distinct from hospitals and health systems, principally by allowing physicians to continue to hold equity and benefit financially from future transactions. To yield annual returns exceeding 20% on a typical investment horizon of 3 to 7 years, private-equity firms generally use a combination of expansion, establishment of new lines of business, and restructuring. For investments in physician practices, one core strategy involves acquiring and scaling up “platform” practices — usually established, brand-name companies with market reach and a good clinical reputation — before selling the practice to a larger investor. For example, when the New York–based urgent care group CityMD was acquired by private-equity firm Warburg Pincus, it already had 68 locations; it has since acquired other local urgent care groups, expanded to 100 locations, and merged with Summit Medical Group, a physician-owned multispecialty practice with more than 80 sites in New York and New Jersey.
Some of the value created by private-equity firms may be viewed in the context of a zero-sum game — one that results in winners and losers in an ecosystem serving a finite number of patients. A platform practice may roll up an entire portfolio of small practices, including regional competitors and practices in its referral networks, to be able to redirect more referrals to internal clinicians and increase its market share. Although this approach creates value for the growing practice, it may reduce competition and result in loss of patients and revenue for other practices. Acquired practices may also leverage market power in negotiations with insurers, which can lead to higher margins for the practice and potentially higher costs for patients and payers.
At the same time, private-equity firms may create value by means of operational improvements that enhance efficiency. Investors may improve administrative processes, enhance quality and revenue-cycle management, fuel the adoption of clinical metrics and compliance systems, help practices meet reporting requirements, reduce input costs, and share industry knowledge with smaller practices. Capital infusions may also promote the adoption of technology infrastructure such as electronic medical records, help practices assume risk as part of value-based payment arrangements, and facilitate practice modernization. These changes may ultimately benefit patients by improving patient experience and the value of care delivery.
As in any ecosystem, however, the introduction of new forces can have unintended and undesirable consequences. An important concern is that private-equity firms’ goal of maximizing short- to medium-term profits may place undue pressure on physicians. Although a sale to a private-equity firm may yield an up-front lump sum for practice partners, changes in physician-compensation structures and professional autonomy may substantially alter performance incentives, practice conditions, career prospects, and job satisfaction, particularly for younger physicians. Each subsequent sale — to other private-equity firms, health services groups such as Optum, or large health systems — may further chip away at clinical autonomy and introduce new management influences.
From a societal standpoint, the net effect of private-equity investments in physician practices on downstream costs, value, and quality of care is unclear. The experiences of some private-equity–backed clinics4 suggest that there is pressure to expand certain revenue streams by conducting more elective procedures and providing more ancillary services, and to engage in “upcharging.” Practices acquired by private-equity firms may also be given incentives to prioritize care for commercially insured patients to maximize reimbursement; to deliver more streamlined, low-complexity care (e.g., perform more skin biopsies or screening colonoscopies) rather than meeting complex care needs; or to situate new offices in higher-income communities instead of in socioeconomically disadvantaged ones. These possibilities raise important questions about the implications of such investments for health equity and larger health system goals.
Early evidence suggests that hospitals that are acquired by private-equity firms perform higher on financial-performance measures, but research on quality of care and patient outcomes has been largely inconclusive,5 in part because of data limitations. Private-equity firms aren’t required to publicly disclose acquisitions or sales, and the widespread use of nondisclosure agreements further contributes to opacity about practice ownership and the nature of transactions. Rigorous evaluation relies on accurate descriptions of practice ownership to identify both private-equity–backed practices and appropriate comparison groups. Without more transparency surrounding private-equity activity in the physician-practice sector, the net effects of these changes will remain unknown. As financial transactions become increasingly complex and pervasive throughout health care, transparency is also needed to permit regulators to bring enforcement actions in cases of improper conduct, to understand the incentives driving care decisions, to hold practices accountable for quality and safety, and to help patients make informed decisions about where they seek care.
As in other areas, there are probably good and bad actors in private equity. Greater standardization, monitoring, and enforcement of safeguards might help constrain nefarious practices that could unduly influence clinical care. All states, for instance, should have a comprehensive corporate practice of medicine doctrine, which prohibits medical management companies from exerting control over clinical judgment and practice. Nearly 20 states don’t have such a rule, and those that do vary substantially in the types of financial and contractual arrangements that they permit. As a result, private-equity firms frequently exploit loopholes, such as by structuring a parent company to have financial control of a practice while naming the physicians as owners.
Policy guardrails could also include revisiting the size-of-transaction threshold for U.S. Federal Trade Commission review, which is intended to prevent mergers and acquisitions that reduce competition and lead to higher prices or lower-quality services; private-equity acquisitions of physician practices have been largely exempt from such review. And although the recently passed No Surprises Act offers consumers welcome protection from surprise medical bills — which have been linked to some private-equity–backed practices — policies are also needed to more closely monitor billing practices, protect access to care, and redress anticompetitive actions in the face of consolidation.
Finally, physicians should be aware that private equity’s growth is emblematic of broader disruptions in the physician-practice ecosystem and is a symptom of medicine’s transformation into a corporate enterprise. For some practices, outside investment may help facilitate growth and extend a lifeline that allows them to compete with larger players in an increasingly consolidated market. But this trend may also contribute to practices getting squeezed. As more investors enter health care and drive value creation, it’s worth considering for whom value is being created. How physicians respond — and the extent to which they retain core values in the service of patients — will ultimately determine the ecosystem’s resilience in the face of stressors.
https://www.nejm.org/doi/full/10.1056/NEJMp2032115
How ACA fuels corporatization of American health care
By Dr. Philip Caper - Bangor Daily News - Nov. 20, 2014
A new Harvard study has found that Americans’ trust in the medical profession has dropped dramatically in recent years and lags behind that in many other wealthy countries. At the same time, doctors are becoming increasingly unhappy with our profession. In his new memoir, “ Doctored,” Dr. Sandeep Jauhar eloquently explains why: More and more doctors are coming to view our profession as just another job.
We now have a situation where patients are losing confidence in their doctors, while doctors are losing confidence in our ability to do the right thing for our patients. We have a health care system becoming more hostile to doctors and patients and more friendly to health care corporations.
These trends are collateral damage caused by another trend: our increasingly corporatized, commodified and commercialized U.S. health care “industry” that is being put into hyper drive by the Affordable Care Act. The ACA is accelerating an ongoing wave of hospital consolidations and acquisition of doctors’ practices by large corporations, such as Eastern Maine Healthcare Systems and MaineHealth.
As we continue down this road, doctors see our clinical autonomy disappearing as more and more of us become corporate employees subject to pressure to meet corporate financial goals that often differ from what is best for our patients. Patients sense that pressure as they are rushed through exams and are subject to more tests and procedures, some of them of questionable clinical value. They can almost hear the cash registers ringing as they move through their doctors’ offices, as more wealth is transferred from patients to those selling health care goods and services.
Why is American medicine, once the crown jewel of American professionalism and a proud and respected calling, becoming just another commercial enterprise? In his 2010 book “ Hijacked,” Dr. John Geyman, chairman emeritus of the department of family practice at the University of Washington, explains how during the year-long Congressional debate leading up to enactment of the ACA, the interests of the public, including doctors and patients, were subverted to those of large health care corporations.
The highjacking of health care reform is paying off handsomely. Robert Pear of the New York Times recently described how the federal government and the commercial health insurance industry have morphed into one big fan club for the ACA. He quotes the libertarian Cato Institute’s
Michael Cannon explaining that since the ACA’s enactment, “Insurers and the government have developed a symbiotic relationship, nurtured by tens of billions of dollars that flow from the federal Treasury to insurers each year.”
Pear goes on to report that, “Since Mr. Obama signed the law, share prices for four of the major insurance companies — Aetna, Cigna, Humana and UnitedHealth — have more than doubled, while the Standard & Poor’s 500-stock index has increased about 70 percent.”
Pharmaceutical companies also have done very well. The ACA contains no authority for the government to negotiate pharmaceutical prices but continues the federal prohibition on the importation by U.S. residents of lower priced prescription drugs from many foreign countries.
This situation won’t change anytime soon. Congress is gridlocked. What is widely recognized as a drafting error in the ACA — which, in saner times, could have been fixed quickly without attracting much attention — is now headed to the Supreme Court.
Of course, health care is just one of many examples in which the welfare of corporations has been put ahead of the interests of the public, but it may be the poster child. Health care is now more than a sixth of our economy, and human lives and dollars are at stake.
Corporate stranglehold of our public policy traces back to the increasingly corrupt way our political campaigns are financed. The recent midterm elections were a stark reminder of that, setting record levels for corporate spending, even on local races, and saturating voters with negative, intrusive and often obnoxious messages.
What’s at stake is the future of health care and many other issues that will determine what kind of a country our children will live in. That future depends on how active and informed the public is willing to become in electing public officials who place the welfare of their constituents ahead of the wishes of their corporate contributors.
The results of the recent elections are not encouraging. But what’s becoming clearer is that our struggle is not between Democrats and Republicans, liberals and conservatives, or occupiers and tea partiers. It is between real American people and corporations.
I, for one, intend to continue pointing that out. That’s where our attention should be focused.
Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com or through his website at philcaper.net.
https://bangordailynews.com/2014/11/20/health/blogs-and-columns/how-aca-fuels-corporatization-of-american-health-care/
Maine Democrats’ bills aim to hold down prescription drug prices, health care costs
Their 5 bills include proposals to reduce price gouging by pharmaceutical companies and help consumers who have trouble paying for insulin.
by Joe Lawlor - Portland Press Herald - March 23, 2021
Maine Democratic lawmakers are proposing a suite of bills that will attempt to rein in the cost of prescription drugs and lower health care costs.
Lawmakers, including Senate President Troy Jackson, held a news conference Tuesday to roll out the five bills, two of which are designed to prohibit price gouging by pharmaceutical companies. The Maine Attorney General’s Office would review drug price increases and halt the increases if prescription prices skyrocket for certain drugs.
Maine is one of at least 18 states that has prescription drug price-gouging laws on the books or under consideration, including Massachusetts, according to the National Conference of State Legislatures. The most comprehensive and effective price-gouging laws are in Massachusetts, New York and Maryland, according to a 2019 study published in the Journal of Health Care Policy and Law.
Senate Republicans are so far declining to weigh in on the bills, said Tom Desjardin, spokesman for the Senate caucus.
During the media briefing, Jackson said that he’s heard too many stories of Mainers who are priced out of their prescription drugs, or have to make difficult choices between rationing drugs, buying groceries or getting behind on their bills.
“No one should have to live like this,” Jackson said. “We know too many Mainers who live this reality.”
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Susan Kinney of Belgrade said at the media briefing that her adult daughter, Marissa, has Crohn’s disease, and the medication is expensive, costing them thousands of dollars every month out-of-pocket. Kinney said her daughter is on a low dose now, but she could need a higher dose in the future.
“We are fortunate the medicine is working,” Kinney said. “But if the dose increases, so does the cost, by thousands of dollars.”
Retail prescription drug spending in the United States rose from $298 billion in 2014 to $369.7 billion in 2019, a 24 percent increase, according to federal statistics. And there have been some high-profile examples of out-of-control price increases, such as EpiPen, a common allergy medication, going from $100 in 2009 to $600 in 2016.
Jasmine Gossett, a spokeswoman for the Pharmaceutical Research and Manufacturers of America trade association, said that the group agrees that “health care should be more affordable for Mainers.”
“Unfortunately, this package overlooks what’s contributing to the challenges families are facing, like their rising out-of-pocket costs because of a broken insurance system,” Gossett said. She said the bills are “filled with dangerous ideas that could make it harder for patients to get the medicines they need” by threatening “crucial innovation” in the pharmaceutical industry.
The price gouging bill by Jackson would trigger a review by the Attorney General’s Office if a drug price increased by more than $30 for a 30-day prescription of a generic drug, or for non-generic drugs the prices increased by at least 15 percent when compared to the wholesale acquisition costs of the drugs.
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A bill by Sen. Ned Claxton, D-Auburn, would require drug manufacturers to justify prescription drug price increases or pay a fine. Claxton said his bill, paired with the price gouging bill, would give drug companies “an extra hoop to jump through.”
“To try to corral pharmaceutical prices we need a multitude of different approaches,” Claxton said.
Another bill would establish the Office of Affordable Health Care, which would study why health care costs increase, and offer policy solutions to lawmakers based on its findings.
A bill by state Sen. Cathy Breen, D-Falmouth, modeled after a law in Minnesota, would mandate that those without insurance or who can demonstrate that they have trouble paying for insulin be able to purchase an emergency 30-day supply for $35. And a bill by state Sen. Eloise Vitelli, D-Arrowsic, would mandate more transparency in how drug companies price medications.
This is the second major push by Democrats to try to control the cost of prescription drugs in Maine, following a series of bills that were signed into law by Gov. Janet Mills in 2019.
Jackson said that while those bills have had some success, more needs to be done.
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One of the laws approved in 2019 would allow for wholesale importation of drugs from Canada, but a federal waiver to do so has yet to be approved. Another law that capped the price of insulin at $100 per month was helpful, said Breen, but some have difficulties affording $100 per month.
“This bill is about saving lives in Maine right now,” Breen said.
Lindsay Crete, a spokeswoman for Mills, said the governor is evaluating the bills, and “appreciates their commitment to addressing the important issue of health care.” The bills will be up for a public hearing at 10 a.m. on March 30 before the Health Coverage, Insurance and Financial Services Committee.
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