Health Care Reform Articles - December 15, 2021

Editor's Note -

In June of 2017, a conference about medical professionalism and its importance in an age of increasing corporatism in health, sponsored by the Maine, Vermont, and New Hampshire Medical Associations, the Lown Institute and a variety of  was held in Portsmouth, N.H. During my limited speaking role introducing the actor Michael Milliken to perform his one-man play "Side Effects", I tried to make the point that true health care reform was about much more than who pays the bills. 

Since that conference, almost four years ago, not much has changed as a result of it, although the Maine Medical Association is now in the process of "reviewing" their position on health policy, but has not yet agreed on definitive changes to their existing policy.

 A clipping in my most recent posting (December 11, 2021) seems to have struck a nerve with several of the readers of this bog. The story about the increasingly important role for-profit publicly traded American insurance companies is playing in Britain's revered National Health Service has demonstrated that true health care reform is about much more than who pays the health care bills. True reform is about the basic mission of a health care system that is a true public good - not just one more commodity.  In other words, true reform also about  the soul of what we want a healthcare system to be.  It is about the "Clash of Missions" when the interests of investors in for-profit entities are superimposed on and prioritized ahead of the humane healing missions of doctors, nurses and other health care workers.

The following link is to a recent documentary about the corrosive and corrupting effects the participation of an American-style health insurance company on a system that has long been a poster child of health care as a human right, and how fragile that concept can be.

Please take the time (about 2 hours) to watch this film, "The Great NHS Heist" when you get the chance. It is a cautionary tale that illustrates how important it is to get health care right.

Accordingly, this blog posting is about not only expanding health care coverage to everyone and getting control health care costs, but also the importance of preserving the soul of medicine in the process. Toward that goal, I have re-posted a number of articles from previous blogs.

Enjoy the movie - if you can.

 https://www.youtube.com/watch?v=kwlvLe-X27o

 

US Empire Seizes UK’s National Health Service

It is safe to say that, far from being overstated, the Americanization of the NHS is very nearly complete, write Stewart Player and Bob Gill.

by Stewart Player and Bob Gill - Consortium News - December 6, 2021

One of the recent roles of the Parliamentary Healthcare Committee has been to reassure the British public that any claims regarding the ‘Americanization’ of the National Health Service (NHS) were wildly overstated, “creating a climate that risks blocking the joining up of services in the interests of patients.”

In fact, the penetration of the healthcare system by the giant U.S. insurer UnitedHealth reveals the opposite to be true, with the full extent of its influence capable of surprising even seasoned NHS watchers.

The Health and Care Bill making its way through official channels simply reinforces this, with the bill’s centerpiece, the 42 regional-scale Integrated Care Systems (ICSs), aimed at bringing together GPs, hospitals, mental healthcare and council services. It is being effectively designed and fast-tracked by the private UnitedHealth.

The U.S. healthcare system is of course a thing of nightmares. Insurance payments extract almost half the income of an average family, in return for which the nation consistently ranks last for access, equity, and outcomes of care in periodic studies by the Commonwealth Fund.

Not content with employer — or individual-based customers — giant insurers now see as much as 50 percent of their revenues coming from federally-funded services, with studies from Texas revealing the greatest profits within the privatized Medicaid system resulting from denying care to medically fragile children and the severely disabled.

Fraud, scandal, bloated executive salaries and minimal care constitute the norm, yet, owing to the state-capital symbiosis that defines the U.S., the cyclical clamor for reform only sees the industry emerge stronger every time.

This was nowhere more evident than the Affordable Care Act (ACA) of 2010 – also known as Obamacare. Less one thinks this is a digression, it is arguable that one can’t understand the position of the British NHS without also understanding the ACA.

According to BusinessWeek, the leading role in ensuring that ‘reform’ doesn’t happened and that ACA proved a bonanza for health insurers was played by the largest of them, UnitedHealth.

While superficially progressive, those newly insured under Obamacare were all channelled either to subsidized marketplaces or to privatized Medicaid to the extent that within a few years these programs had become the main artery of corporate profits.

The Role of Simon Stevens

Serving as point man in the process was the Briton Simon Stevens. Newly promoted as UnitedHealth’s vice-president, he was also charged with leading the company’s “strategic positioning for national health reform.” The company was nothing if not forward thinking when it also appointed him head of UnitedHealth’s Global Health Division.

With capital’s position secure in the heartland, United began to think of further expansion. In his new role, Stevens first helped set up in September 2011 the Alliance for Healthcare Competitiveness, a high-level lobby group with the aim of deregulating trade laws and forcing other nations to open up their health systems to U.S. for-profit insurers, hospitals, pharmaceutical firms, IT companies and other investor-owned firms.

However, it makes little sense to open up national systems unless these conform to standardized templates, and within the year, Stevens was acting as project steward within the World Economic Forum’s (WEF) project on sustainable health systems.

Advocating new care models – though in effect rebranded U.S. Health Maintenance Organizations (HMOs) – the WEF envisaged a climate where “health schemes and insurance markets boom as people seek to cover their health costs,” while governments “focus on regulating large integrated health providers in a complex expanding global marketplace.”

It only remained for Stevens to return to Britain – “my heart is in the NHS and in U.K. public services,” he said – and in October 2013 he was duly appointed as chief executive of NHS England. Since then he has pursued to the letter the aims of the World Economic Forum and U.S. capital’s.

These include the Five Year Forward View, the New Care Models Programme, the Sustainability and Transformation Partnerships, and, ultimately, the 42 Integrated Care Systems.

A Mixed Economy of Care

In the process, UnitedHealth’s influence has extended across the board. Take commissioning of NHS patient care, for example. Under the terms of the 2012 Health Act, this was to be led by general practitioners but few family doctors had a clue (why should they?) and those that were involved were in it for the extra income and to rubber-stamp decisions made by the commissioning ‘support’ market. (The health care act removed responsibility since 1948 for running the NHS from the health secretary to clinical commissioning groups (CCG), providing an entry for private insurers.)

Serving as chair of the Commissioning Support Industry Group from May 2013, and also providing its secretariat, was UnitedHealth. The group also involved U.S. consultancies, KPMG, McKinsey, EY and PWC. UnitedHealth paid for an annual trip for “senior-level executives from across the U.K. health system” to find out how the company operates in the U.S. and to “explore their applicability in the U.K.”

Since then, this has meant amassing major contracts not only in commissioning support, but also in clinical governance, communications, human resources and workforce development, medicines management, and in implementing Personal Health Budgets.

Groomed By US Capital

As well as bankrolling the largest primary care network, Modality, it has also meant a near-monopoly in data analytics for United, particularly those relating to population health management and the risk stratification of patient cohorts – all exercises in assessing insurance risks and their subsequent costing as the system moves to a mixed economy of care. 

But most importantly it has meant United playing the lead role in both defining and fast-tracking ICSs as they await formal legal status. Launched by NHS England in January 2018, the Optum Alliance – consisting of United and PwC – delivered a “major capabilities building programme” to “facilitate the move to whole system working” for the most advanced ICSs.

This included those in Birmingham, Warwickshire, Northumbria, West Yorkshire, Devon, Dorset, and Cumbria, and involved developing capabilities in care redesign – including “radical transformation of outpatient services” and developing primary care networks – financial management, effective leadership, integrated contracting, governance and delivery, as well as building sustainable, value-based, strategies.

For the program, UnitedHealth fielded its most senior partners and directors, all of whom were “experienced leaders in complex business systems.” Under the lead of ICS and clinical commissioning groups, hospital CEOs, finance officers, and local authority chief executives, worked alongside the Optum Alliance and NHS England. But as the director of commissioning for the West Midlands, Alison Tonge, pointed out, it was “UnitedHealth and PwC, who led the sessions.”

As such, despite the talk in policy circles of emerging leaders being brave, innovative, and capable of “high learning agility within new healthcare ecosystems,” it would instead appear they are dutifully being groomed by U.S. capital. Indeed, it is safe to say that, far from being overstated, the Americanization of the NHS is very nearly complete.

The Harm Caused

The Health and Care Bill will essentially provide legislative lock-in for the changes already embedded throughout the NHS. Patients will be denied care to generate profits for the ICS, over which their family physician or hospital specialist will have no influence, while the growing unmet patient need will have to be serviced either through out-of-pocket payments, top-up private insurance, or not at all.

The inevitable harm and suffering endured by patients without the money to pay for treatment will affect their families, carers, clinicians and society as a whole. Healthcare professionals working in this two-tier system will themselves be exploited, made to work beyond the competence, offered perverse incentives to act against the interests of patients to generate profits and in doing so fundamentally betraying the healing relationship.

The NHS will, in the immediate future, resemble ‘Medicare Advantage’ or ‘Medicaid Managed Care’, a basic, publicly funded, privately controlled and delivered corporate cash cow repurposed to make profit, though in time the full range of the organizational options found in the U.S. will follow.

All this will increase the total cost of healthcare, deliver less, harm thousands, enrich foreign corporations and destroy what was once Britain’s national pride.

Stewart Player is a public policy analyst and co-author (with Professor Colin Leys) of The Plot Against the NHS (Merlin, 2011).

Dr. Bob Gill is a GP and producer of the feature length documentary The Great NHS Heist.

https://consortiumnews.com/2021/12/06/us-empire-seizes-uks-national-health-service/

Book Review 

by Philip Caper, M.D.

The heart of power: Health and politics in the oval office 

by David Blumenthal and James A. Morone 

University of California Press, Berkeley, 2009, 484 pp., $26.95, ISBN: 978-0520260306

Journal of Public Health Policy (2010) 0, 000–000. doi:10.1057/jphp.2009.46

The opening paragraph of The Heart of Power by David Blumenthal and James Morone describes a conversation that Blumenthal, then an undergraduate at Harvard College, had with Richard Neustadt, the noted presidential historian and one time member of John F. Kennedy’s White House staff. Blumenthal credits Neustadt, his course on the American presidency, and their subsequent long friendship with the inspiration for his and Morone’s new book.

I’m certain that professor Neustadt would be proud of the product he inspired. In this readable, well-documented, and comprehensive study, the authors lucidly explore how presidential personalities, priorities, political philosophy, and personal health experience have influenced their approaches to health policy. They analyze legislative and policy successes and failures in 11 US presidential administra- tions, ranging from Franklin D. Roosevelt to George W. Bush. (They omit only the brief presidency of Gerald Ford.)

From FDR’s New Deal to George W. Bush’s Ownership Society, Blumenthal and Morone explain how each president, cognizant of the unique history, political opportunities, and risks they faced, learned (or didn’t) from their predecessors and built on what had gone before. Their source material includes presidential library archives plus interviews with former presidential staff, and staff of the libraries.

Despite my lifelong involvement in and study of American health- care policy, I learned a great deal from this book. I was not fully appreciative, for example, of the depth and passion of Truman’s commitment to a social insurance model of national health insurance, nor was I aware of the level of detailed involvement by Lyndon Johnson in the birth of Medicare, the federal insurance

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program for the elderly. It was part of a conscious strategy on Lyndon Baines Johnson’s (LBJ) part to give Representative Wilbur Mills most of the credit for passing that landmark legislation in 1965. Flattery, it turns out, is an important policy tool. There are many other examples. The final chapter called ‘Eight Rules For The Heart of Power’ is thoughtful and thought-provoking. I won’t spoil the ending by listing them here.

Most important, the authors drew on their own experiences as political scientist and physician, as scholars, researchers, and participants in our chaotic and bewildering policy process. Together, they have created a fascinating story of health policy development over a period of more than 75 years. This book is well worth reading by anyone interested in the role of US presidents and the presidency in the development of American health policy.

Still, after reading the book, I was left with the feeling that an important set of issues – legitimately beyond the scope of The Heart of Power – were left unaddressed. As this book makes clear, in the health field strong presidential leadership is critical to enacting major legislation. Yet, even the most skillful, determined, and powerful president is limited by the political environment of the day. Contrary to the rhetoric, politicians are usually followers, not leaders of popular sentiment. There is only so much any leader can do before he runs up against the barriers to change inherent in the political environment of the day.

What are the barriers to reform of the American health-care system? Why has it been so difficult for American politicians to create a statutory right to health care for Americans – a right that every other affluent democracy created years ago?

First and most basic, the concept of health care as a right remains a polarizing concept in the United States. As Lewis Carroll once said, ‘If you don’t know where you’re going, any road will get you there’. The wisdom of that observation is clear to anybody watching Congress struggle with the issues raised by the most recent health- care reform effort.

Second, Americans are inherently suspicious of central authority – secular or religious. Thomas Paine’s concept of government as ‘a necessary evil’ is alive and well. Establishing a right to health care requires a stiff dose of that necessary evil. Our political institutions are designed to decentralize power.

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Third, the idea that America is exceptional and not governed by the rules most other countries follow is still widely held in the United States, however misguided. That makes it difficult for Americans to learn from experience in other nations, or even to be told that there are lessons to be learned from others.

Fourth, only in America has corporatism engulfed so much of medical care and come so close to dominating the doctor–patient relationship. Publicly traded, profit-driven entities now dominate the financing and delivery of medical care in the United States to an extent seen nowhere else in the world. This may be the single most distinguishing characteristic of the modern American health-care system, and the one that has had the most profound impact on it since the early 1980s. The theology of the market and the strongly held belief that the problems of American health care can be solved if only the market could be perfected have most effectively obstructed the development of a rational, efficient, and humane national health- care policy.

Special interest lobbying has, for a long time, played an important role in the development of such a policy in the United States. But its influence has dramatically increased during the past 30 years.

For most of the twentieth century, the medical profession (mainly through the American Medical Association) has opposed the creation by the government of a statutory right to medical care, fearing government controls on medical practice and doctors’ incomes. But as Paul Starr pointed out more than 30 years ago, while American physicians were resisting a ‘takeover’ of medicine by the government, they were gradually being taken over by private corporations.1 That takeover is now almost complete. Each year, fewer truly independent medical practitioners remain in the US. Most now work for profit-making and non-profit corporate entities. Many American physicians have agreed to a Faustian bargain, exchanging their autonomy as independent professionals for higher incomes. More than a few are now beginning to regret that bargain. Nowhere in the world are doctors’ decisions subject to more scrutiny, second-guessing, and micromanagement by unaccountable private entities than in the United States.

During the more than 75 years covered by this book, massive changes in the nature of medical care have occurred. During the Roosevelt administration (1933–1945) medical care in America was

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a cottage industry, comprised of individual doctor-entrepreneurs who were focused on treating and, they hoped, healing individual patients. The tools at their disposal were primitive by present standards. Hospitals were far less important than today. The pharmaceutical and medical device industries were poorly devel- oped. Most medical enterprises were privately owned and not- for-profit. And most importantly, their dominant focus was their mission of curing patients.

The financing of medical care in America was once the exclusive domain of public and non-profit entities. Beginning in the mid- 1980s, through a process of consolidation and acquisition that accelerated during the 1990s, health care financing became domi- nated by publicly traded corporations. These corporations are not health-care companies, as they would like to portray themselves, but rather financial services companies that happen to concentrate on the health-care business. Their primary focus is not the provision of appropriate medical care, but rather the endless pursuit of increased shareholder value.

The direct delivery of health-care services has also become corporatized. Beginning in the mid-1970s with the founding of the Hospital Corporation of America, for-profit entities began, in a major way, to enter into the direct provision of medical services.2 Again, the main focus of these investor-owned for-profit entities (and the only one legally required of them) is increased shareholder wealth. In other words, money, not health care, is their mission. The behavior of this sector of the hospital industry, although a small proportion of the total, has infected even the most prestigious academic hospitals. Even these not-for-profit institutions emulate their proprietary brethren.

The pharmaceutical industry has undergone a similar transforma- tion. When George Merck founded his company in 1891, his philosophy was, ‘If we develop medicine that cures human disease, the money will take care of itself’.3 The pharmaceutical and medical device industries have exploded since then. More important, they have shifted their focus from Merck’s ideal of discovering and marketing curative medicine to becoming huge marketing machines, publicly traded, and obsessed with shareholder value. They aggressively seek ways to develop and market wildly profitable ‘blockbuster’ drugs that control signs or symptoms or treat lab tests.

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Ideally, patients must take them for the duration of their lives. Statins, beta-blockers, and other anti-hypertensive drugs and many drugs used for the treatment of psychiatric patients are examples.3 Curing disease may be good for the patient, but from the point of view of the drug company, it effectively kills the customer. Curing has become a poor business strategy.

America now has this powerful block of special interests, together called the medical–industrial complex – powerful and wealthy enough to mold public policy to its wishes. Only in America have for-profit corporations come to exert so much influence on health- care politics and on the development of government health-care policy. It is no coincidence that only in America is the profitability of health-care companies (such as drug and device manufacturers) unrestrained by price controls or other regulation.

But the most disturbing effect of out-of-control corporatism in health care is not corruption of our policy-making process. The most damaging effect is corruption of the seed corn of professionalism, the integrity of the medical literature itself.4

Pharmaceutical and medical device companies have successfully created a widespread ‘rent-an-expert’ industry, persuading opinion leaders among medical academicians to rent their credibility in exchange for outsized consulting fees and lavish resort-based conferences. Prestigious medical opinion leaders routinely give industry-produced, canned lectures that are designed to influence their colleagues’ prescribing patterns. Highly regarded and visible academicians outsource the production of scholarly articles to industry-funded marketing firms. These articles have appeared in some of the best-known and widely read American medical journals. These corrupt activities are funded out of enormous corporate marketing budgets.4

Even the most independent and well-meaning doctors no longer fully trust the medical literature.4 Where are doctors to obtain objective, unbiased information about how best to treat their patients? The ubiquity of industry money in academic medical centers, continuing medical education programs, and even the National Institutes of Health5 has now attracted the attention of Congress and has been widely dissected in the lay media.6 Perhaps more than anything I have seen, these developments destroy the basis of the public’s trust in their doctors.

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The shift in focus from mission to money has also led to a deterioration of the curing and healing elements of modern American medicine.7 More and more doctors are encouraged by their own economic aspirations, and by those of their corporate employers to make medical decisions intended to maximize revenue rather than to provide appropriate care to patients.7–12

Doctors are under mounting pressure to meet revenue targets as a condition of continued employment. That, together with the rising costs of medical education and consequent indebtedness of medical graduates may explain the decline (and I think, probable future disappearance) of primary care practitioners in America. There’s just not enough money in it.

This transition from a healing mission to a money mission is a dominant (if not the dominant) factor driving the explosion of health-care expenditures. Combining sophisticated direct-to-consumer marketing of pharmaceuticals and ‘gee-whiz’ medical technology with the open-ended nature of third-party financing has lead to the rapid and recession-resistant increases in medical care expenditures we are now witnessing.

As a result, the lack of affordability, not just of insurance, but also of the underlying medical care is fueling growth in the number of un- and under-insured Americans. This growth has accelerated as a result of the economic downturn, creating enormous suffering and growing pent-up demand for medical care.13

This increasing commercialization of medicine also undermines patient confidence. They sense the role money plays in influencing physicians’ clinical decisions and become disenchanted with their medical care. As a result, many are seeking alternatives to our expensive, fragmented, and impersonal medical industry.

The frustration doesn’t end with patients. Doctors are caught between demands to produce more billable events (visits, procedures, lab tests and so on) and barriers to payment thrown up by insurance companies. Both demands to earn more and controls to restrain payments conflict with their medical training and ethics. Both contribute in a big way to physicians’ dissatisfaction with medical practice. They have lead to a growing and premature exodus of senior physicians from the workforce.

The current debate about health-care reform in the United States represents a fork in the road for the American health-care system.

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If we have enough national solidarity, we will take the left-hand fork. In doing so, we will embark on a path to strengthen our public sector system of financing and delivering health care. We will do this by embracing either a social insurance model similar to those in Taiwan and Canada, or a highly regulated not-for-profit public utility model similar to those in Germany, The Netherlands, Switzerland, and other European countries. Either way, we will join the rest of the industrialized world in creating a statutory right to health care for all people.

Only then will we be able to begin the long, difficult process of driving the profit motive out of the direct provision of medical care and recovering the lost art of healing. It goes without saying that members of the medical–industrial complex are determined to thwart any legislation that moves in that direction.

If we take the right-hand fork, we will reinforce the notion of health care as a privilege, boost the role of and encourage the further expansion of the corporatization of American medicine that Paul Starr predicted. Stratification of access to medical care according to income will grow even more rapidly. That will signal a retreat from the ideal of health care as a right.

Everybody seems to agree that we can’t fail to act. If we continue ahead with no change in course, we will drive into a ditch as costs continue to explode and access to care further deteriorates.

Whatever the outcome, the story of the evolution of the health- care system in the United States holds important – and cautionary – lessons for other nations, as they too struggle to strike the suitable balance between expenditure, quality, and access to health care compatible with their own cultures.

The Heart of Power is a valuable contribution to better under- standing that story. But it is not the entire story. Perhaps Blumenthal and Morone could apply their considerable talents to writing a sequel to The Heart of Power that examines the issues raised by the relentless corporatization of medical care in the United States. Maybe they could call it The Heart of Darkness, had Joseph Conrad not used the title already.

I have a recurrent dream, and not a pleasant one. I wander the temple of medicine seeking Asclepius, but find instead only Mammon. It doesn’t have to be that way, even in exceptionalist America.

Stay tuned.
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References

1. Starr, P. (1982) The Social Transformation of American Medicine. New York: Basic Books.

2. Mahar, M. (2006) Money Driven Medicine: The Real Reason Health Care Costs So Much.

   New York: HarperCollins.

3. Peterson, M. (2008) Our Daily Meds. New York: Farrar, Straus and Giroux.

4. Angell, M. (2009) Drug companies and doctors: A story of corruption. New York Review

   of Books 56(1), 25 January.

5. Willman, D. (2004) The national institutes of health: Public servant or private marketer?

   Los Angeles Times 22 December.

6. Abelson, R. (2008) Cleveland clinic discloses doctors’ industry ties. The New York Times 3

   December.

7. Lown, B. (1999) The Lost Art of Healing: Practicing Compassion in Medicine. New York:

   Ballantine Books.

8. Bezruchka, S. (2003) Health and wealth. Alternative Radio. 9 December 2003.

9. Bezruchka, S. (2006) Damaged care. Alternative Radio broadcast. 4 February 2006.

10. Relman, A. (2008) A Second Opinion. New York: Century Foundation Books.

11. Brownlee, S. (2007) Overtreated: Why Too Much Medicine Is Making Us Sicker and

    Poorer. New York: Bloomsbury USA.

12. Guwande, A. (2009) The cost conundrum. The New Yorker 1 June.

13. Sered, S.S. and Fernandopulle, R. (2005) Uninsured in America: Life and Death in the

    Land of Opportunity. Berkeley, CA: University of California Press.

Further Reading

1.

2. 3. 4. 5. 6.

Moyers, B. (2009) Interview with Wendell Potter, ‘Bill Moyers Journal’, PBS, 31 July http://www.pbs.org/moyers/journal/07312009/profile.html.
Angell, M. (2004) The Truth about Drug Companies. New York: Random House. Kassirer, J. (2005) On the Take. New York: Oxford University Press.

Avorn, J (2004) Powerful Medicines. New York: Avorn Books.
Law, J. (2006) Big Pharma. New York: Carroll & Graf.
Abramson, J (2004) Overdosed America. New York: Harper-Collins.

Philip Caper Independent Consultant, Brooklin, Maine, USA

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Opinion: Trump had a scheme to privatize Medicare. The Biden administration isn’t stopping it.

by Helaine Olen - The Washington Post - December 13, 2021

Donald Trump claimed to be a staunch supporter of Medicare. Yet he repeatedly attempted to slash the program’s budget while promoting an increased role in Medicare for insurers and other private businesses. But President Biden isn’t turning out to be the champion of Medicare activists had hoped.

At issue is a Trump administration-initiated program that many health-care reformers argue is essentially a backdoor attempt to further privatize Medicare. Almost no one realizes it’s going on — except, that is, corporate interests and private equity investors, who are lined up like pigs at the trough to get their hands on taxpayer dollars.

Medicare is administered in one of two ways: traditional fee-for-service Medicare and Medicare Advantage — private insurance offered in place of and through the Medicare system. The dispute is over something called the Direct Contracting pilot program, designed by the Center for Medicare and Medicaid Innovation as a new way of managing benefits in the fee-for-service program. Supporters say it will reduce the amount of money the government spends on traditional Medicare fee for service while improving the quality of patient care.

But many left-leaning health-care advocates say it’s a slippery slope version of Medicare Advantage. That program, as Just Care USA President Diane Archer points out, costs taxpayers more per patient than traditional Medicare, in part because of aggressive upcoding of risk assessments that determine how much money the insurer receives for covering the patient. And a 2018 report by the Department of Health and Human Services inspector general found “widespread and persistent” problems with Medicare Advantage programs inappropriately denying care. Opponents of the Direct Contracting program predict it will run up the government’s tab, add corporate bureaucracy, increase the financial strain on the Medicare trust fund and do nothing to improve patient outcomes.

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The lure of Direct Contracting for these companies is potential profits. The limits on the amount of money a Direct Contracting entity can keep that’s not used for a patient’s medical needs is significantly more generous than those imposed by Medicare Advantage.

And while patients choose to sign up for Medicare Advantage themselves, with Direct Contracting, the primary care doctor, not the patient, enrolls in the program. And why would a doctor sign on? Well, one participant, Clover Health Partners, says doctors can earn upward of 40 percent more on primary care visits through the program. (When I asked about that, a spokesperson for Clover told me the higher pay did not affect how much Clover earned from Medicare.)

Once their doctor is enrolled, patients receive a letter from the Direct Contracting company informing them of their participation. They are assured they are still in Medicare’s fee-for-service program and can still see any doctor they wish in the Medicare program. “Your doctor asked Clover Health Partners to see that you get the right care at the right time,” reads the missive sent out by that company. “We will coordinate your care according to your individual medical needs and treatment choices.” The program will, it adds, “work to reduce duplicate tests and duplicate paperwork that cost you time and money.”

The technical term is to say a patient’s care is being “aligned” by the Direct Contracting entity. Heath-care activists use another phrase. “It’s Medicare Advantage by another name but suddenly it’s not voluntary,” Archer says. She argues that doctors in the program can also be incentivized to refer within a particular network or recommend a particular regimen of care. And unlike in Medicare Advantage, the patient won’t necessarily understand that there is a corporate monitor.

The Biden administration did put at least a temporary stop this year to an even more egregious version of this program, which would have auto-enrolled almost all those in Medicare fee for service in a particular preselected geographic area. But CMS, HHS and, ultimately, the White House are continuing to press ahead with Direct Contracting, even though they could end it if they chose.

So how could something like this fly so under the radar? Well, the details are very technical, so, many people receiving notice of the change likely didn’t comprehend it. The program itself has not received much attention from the media. And information about it isn’t all that easy to come by. We don’t even know for sure how many people are experiencing “aligned” care; CMS says that data won’t be available till next year.

But here’s what we can say: An undetermined number of people enrolled in traditional fee-for-service Medicare are now taking part in an experimental program designed during the Trump administration to increase the role of big business in their medical care. And the Biden administration, which could easily stop this, is instead continuing to enable Trump’s scheme. That’s a big mistake — one that it could easily fix.

https://www.washingtonpost.com/opinions/2021/12/13/medicare-direct-contracting-privatization-health-care/?

 

Medicine Has Become the Great Patient Handoff

— Patients pay the price for our fragmented healthcare system

by Kathleen A. Hallinan, MD, MPH - MedPage Today - November 21, 2021

Americans have become the commodity in their own healthcare system. A patient has gone from being a person who has a relationship with a physician to a sheep that is herded through, with the corporate medical world making money off them with every move. Gone are the days when a physician would do rounds in the hospital in the morning, see patients in the office, follow them into the nursing home, and do home visits as they came to the end of their journey.

"Care" has now become a fragmented web of hospitalists, intensivists, and mid-level care that only remotely reflects the relationships that were the bedrock of the American medical system just 20 years ago.

What is the most substantial impact of this fragmented care? No one provider is the sole caregiver with total responsibility. Medicine has become the great handoff, with no one seeing the whole picture of the person in front of them. Patients have become a conglomeration of body systems and body parts to be fixed or addressed in a fragmented fashion, reminiscent of an assembly line.

Pretend for a moment you're a patient and you go to the emergency room for an acute issue. There, staff need only to verify that you will not expire within 24 hours, and out you go. If the risk is too high, then they hand you off to the hospitalist who will admit you, but if your condition worsens, there is often another handoff to an intensivist who manages the ICU. If more than one or two organ systems are affected then subspecialists will come and pore over the computer (rarely over the human) to see if the numbers in the electronic medical record are within their wheelhouse.

Gone are the days when the ER doc would come up to the ICU the next day to chat with the primary physician about how their other patients are doing and confirm the ultimate diagnoses. Gone are the days when the primary physician would see patients though their entire hospital course and remain responsible for them on discharge.

Technical advances -- while aimed at bettering diagnosis, treatment, and healing -- have simultaneously distanced doctors from physicians in other specialties who were once so closely linked. When X-rays and CT scans were all on film, physicians used to walk into the radiology department every day (imagine this!) where I worked, and pull the films on their patients from the day prior. Here, doctors of all specialties would often corner our radiology physicians to discuss the case, pore over films together, and both would then see the nuances of the patient from both the outside and the inside. The pathologist likewise was a few feet further down a hallway, where questions about biopsy specimens could be discussed. Should we do a different study? Is there a limitation of this stain on the results of the test? Questions and dialog were woven together with the patient at the core.

Nursing home care was also under the purview of the primary physician, who would do rounds and take phone calls, write orders, and talk with the family. Now, many nursing home facilities have no on-site provider, and for some, the facility's medical director is in another state altogether. A separate corporate system has sprouted like a weed, and has taken over as the remote "medical director of record" for nursing homes where there are too few staff, and where "standing orders" are an automated way of caring for any particular problem that may arise so as to minimize any thought or analysis of the problem.

We have paid a heavy price for medicine that is at once "at your finger tips" as well as broken and fragmented. Proponents will point to "best practice advisories" and "metrics" that our electronic medical records blip across the screen with dizzying speed. It does not matter if you know that Mrs. Smith's emotional eating is driven by her grief for her son's addiction problem and her 14-year-old cat who she recently put down. All that matters is you put her on the approved diabetes medications and her hemoglobin a1c is at target.

We no longer have a system that values attention to the person. We have a system that values a database that can be mined for profit and publication. Electronic medical record systems were built not for patient care but for billing and mitigating legal risk. Moreover, the young providers of today know nothing of generating orders in their mind and then putting them to paper. The computer provides (often inaccurate) proposals at each click for dosing, drug options, and diagnostic testing. It took years to get our own system to stop giving lactation warnings for my 90-year-old female patients. When ransomware hits a medical system, providers must scramble to learn how to generate orders and doses without a computer to prompt them.

Often in medicine there is an invisible pendulum that swings in wide arcs. It has an eerie resonance to the story by Edgar Allen Poe, with the patient at the edge of the blade. Our automation and convenience has come at a price. As our nation grapples with obesity, depression, anxiety, and addiction, we must seek to reconnect with people in our care. We must resist the urge to "click the box" and remember to look up at the person.

Unfortunately, the drivers of the corporate medical system are no longer the physicians. We are at the mercy of federal and state bureaucracies overlapped with big data companies and the pharmaceutical industry. They are all present with you in the doctor's office, manifested in the sound of the endless clicking, reflected in the light of the computer screen. Every day I miss the paper chart, the simple folder that never stood between me and the patient, that not once told me how to make someone better, and simply allowed me to practice the art of medicine.

Kathleen A. Hallinan, MD, MPH, is Internal Medicine Specialist in Corning, New York, and a Diplomate of the American Board of Obesity Medicine.

https://www.medpagetoday.com/opinion/second-opinions/95788?

  

Editor's Note -

The following clipping is a paper written by me and another member of a panel put together by the National Academy of Social Insurance to examine the implications of expanding Medicare eligibility.  In my judgment, the panel's final report did not do enough to emphasize the benefits of Medicare expansion, so Peter Arno and I wrote the following paper in response to the panel's final report.  

Here it is:

-SPC

Examining Approaches to Expand Medicare Eligibility: Key Design Options and Implications

A Report by the National Academy of Social Insurance March 2020

Additional Perspectives:

A Clash of Missions

Peter S. Arno, PhD

Senior Fellow, NASI
Director, Health Policy Research Political Economy Research Institute University of Massachusetts, Amherst parno@peri.umass.edu

Philip Caper, MD

Founding Member, NASI
Founding Board Chair, Maine AllCare pcpcaper21@gmail.com

The NASI panel report, “Examining Approaches to Expand Medicare Eligibility: Key Design Options and Implications,” is a workman-like, competent and technically oriented approach to the problem of healthcare reform. But there is a large elephant in the room that is completely ignored by this report: The transformation of the American healthcare system’s core mission from the prevention, diagnosis and treatment of illness—and the promotion of healing—to an approach dominated by large, publicly traded corporate entities dedicated to growing profitability and share price, i.e. the business of medicine.1

The problem is not that these corporate entities are doing something they shouldn’t. They are simply doing too much of what they were created to do—generate wealth for their owners. And, unlike any other wealthy country, we let them do it. The dilemma of the American healthcare system is due not to a failure of capitalism or corporatism per se, but a failure to implement a public policy that adequately constrains their excesses.

Since the late 1970s, American public policy regarding healthcare has trended toward an increasing dependence on for-profit corporations and their accompanying reliance on the tools of the marketplace—such as competition, consolidation, marketing and consumer choice—to expand access and assure quality in the provision of medical care.2

This commercialized, commodified and corporatized model is driving the American public’s demand for fundamental reform and has elevated the issue of healthcare to the top of the political agenda in the current presidential election campaign.

Costs have risen relentlessly, and the quality of and access to care for many Americans has deteriorated. The cultural changes accompanying these trends have affected every segment of the American healthcare system, including those that remain nominally not-for-profit. Excessive focus on healthcare as a business has had a destructive effect on both patients and caregivers, leading to increasing difficulties for many patients in accessing care and to anger, frustration and burnout for many caregivers, especially those attempting to provide critical primary care.

As a result, the ranks of primary care providers have eroded, and that erosion continues. One of the major reasons for burnout in this group is the clash between its members’ professional ethics (put the patient first and “first do no harm”) and the profit-oriented demands of their corporate employers.3,4 Applying Band-Aids can’t cure the underlying causes of disease in medicine or public policy. Ignoring the underlying pathology in public policy, as in clinical medicine, is destined to fail.

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Many of the symptoms of our dysfunctional healthcare system are not in dispute:

• We pay more than twice as much per person on total healthcare spending and on prescription drugs in comparison to other developed countries. This spending totals nearly 18 percent of our economy.5,6

• Between 2008 and 2018, premiums for employer-sponsored insurance plans increased 55 percent, twice as fast as workers’ earnings (26 percent). Over the same time period, the average health insurance deductible for covered workers increased by 212 percent.7

• An average employer-sponsored family health insurance policy now exceeds $28,000 per year, with employers paying about $16,000 and employees paying about $12,000.8

•Almost half (45 percent) of U.S. adults ages 19 to 64, or more than 88 million persons, were inadequately insured over the last year (either they were uninsured, had a gap in coverage, or were underinsured, i.e. they had insurance all year but their out-of-pocket costs were so high that they frequently did not receive the care they needed).9

• Compared to other developed countries, the US ranks near the bottom on a variety of health indicators including infant mortality, life expectancy and preventable mortality.10

We must therefore ask: How is it that we spend more on healthcare than any other nation, yet have arrived at such a sorry state of affairs?

The answer is that only in America has corporatism engulfed so much of medical care and come so close to dominating the doctor-patient relationship. Publicly traded, profit-driven entities— under constant pressure from Wall Street—control the financing and delivery of medical care in the United States to an extent seen nowhere else in the world. For instance, seven investor- owned publicly traded health insurers now control almost a trillion dollars ($913B) of total national health care spending and covers half the US population.11 In 2019, their revenue increased by 31 percent, while their profits grew by 66 percent.

The corporatization of medical care may be the single most distinguishing characteristic of the modern American healthcare system and the one that has had the most profound impact on it since the early 1980s. The theology of the market and the strongly held—but mistaken—belief that the problems of American healthcare can be solved if only the market could be perfected have effectively obstructed the development of a rational, efficient and humane national healthcare policy.

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There are three main reasons to pursue a public policy that embraces genuine healthcare reform:

1. 1)  Saving lives – To simplify our complex and confusing healthcare system while providing universal affordable healthcare coverage

2. 2)  Affordability – To rein in the relentless rise in healthcare costs that are cannibalizing private and pubic budgets

3. 3)  Improving quality – To eliminate profitability and share price as the dominant and all- consuming mission of the entities that provide healthcare services and products when that mission influences clinical decision-making

Given the dismal, inefficient, and costly state of healthcare today, what is the best approach to reform?

It is not an exaggeration to say that no reforms except publicly financed, single-payer universal healthcare will solve the problems of our healthcare system. This is true whether we are talking about a public option, a Medicare option, Medicare buy-in, Medicare extra, or any other half- measure. The main reason is because of the savings that are inherent only in a truly universal single-payer plan. Specifically, the administrative and bureaucratic savings gained by eliminating private insurers are the largest potential source of savings in a universal single-payer framework,12 yet all the “option” reforms listed above leave largely intact the tangle of wasteful, inefficient and costly private commercial health insurers. The second largest source of savings comes through reducing the cost of prescription drugs by using the negotiating leverage of the federal government to bring down prices, as is done in most other developed countries. The ability, will and policy tools (such as global budgeting) to restrain these and other costs in a single-payer framework are the key to reining in the relentless rise in healthcare expenditures and providing universal coverage.

The various “option” reform proposals will not simplify our confusing healthcare system, nor will they lead to universal coverage. None have adequate means to restrain healthcare costs. So why go down this road? Is it too complicated to overhaul our dysfunctional healthcare system when we know that every other developed country in the world has done so?

The stated reason put forth in favor of these mixed option approaches is that Americans want “choice.” But choice of what? Specific insurance companies or the choice of their own healthcare providers? Clearly it is the latter. We know with certainty from former insurance company executives such as Wendell Potter that the false “choice” meme polls well with the American public and was used to undermine the Clinton reform efforts more than 25 years ago. It is being widely used today to manipulate public opinion.13

But choice in our current system is largely an illusion. In 2018, 66.1 million workers across the country separated from their job at some point during the year—either through layoffs,

3

terminations or switching jobs.14 This labor turnover data leaves little doubt that people with employer-sponsored insurance are losing their insurance constantly, as are their spouses and children. And even for those who stay at the same job, insurance coverage often changes. In 2019, more than half of all firms offering health benefits reported shopping for a new health plan and, among those, nearly 20 percent actually changed insurance carriers.15 Trading off choice of doctors or hospitals for choice of insurance companies is a bad bargain.

The other major objection to a universal single-payer program is cost. Yet public financing for healthcare is not a matter of raising new money for healthcare, but of reducing total healthcare outlays and distributing payments more equitably and efficiently. Nearly every credible study concludes that a single-payer universal framework, with all its increased benefits, would be less costly than the status quo, more effective in restraining future cost increases, and more popular with the public—as 50 years of experience with Medicare has demonstrated.16,17

The status quo generates hundreds of billions of dollars in surplus and profits to private stakeholders, who need only spend a small portion (millions of dollars) to influence legislators, manipulate public opinion, distort the facts, and obfuscate the issues with multiple competing reform efforts.18

Conclusion
The real struggle for a universal single payer system in the US is not technical or economic but almost entirely political. Retaining the status quo (e.g. the ACA) is the least disruptive course for the existing medical-industrial complex, and therefore the politically easiest route. Unfortunately, it is also disruptive for most Americans and the least effective route in attacking the underlying pathology of the American healthcare system—corporatism run amok. Following that route will do little more than kick the can down the road, which will require repeatedly revisiting the deficiencies in our healthcare system outlined above until we get it right.

The American public and increasingly the business community are becoming acutely aware of the rising costs and inadequacies of our current system. It is the growing social movement, which rejects the false and misleading narratives that will lead us to a universal single-payer system— truly the most effective way to reform our healthcare system for the benefit of the American people.

###

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References

1 Caper, P. (2010). Review of “The heart of power: Health and politics in the oval office,” by D. Blumenthal and J.A. Morone. Journal of Public Health Policy, 31(1): 88-95.
2

3 Shem, S. “Why burned-out doctors despise electronic health records.” Boston Globe, February 5, 2020. http://bit.ly/2H4svIE

4 Garber, J. “The link between overuse and burnout.” Lown Institute, February 14, 2020. http://bit.ly/2SCE2FH

5 OECD (2020), Health spending (indicator). doi: 10.1787/8643de7e-en (Accessed on 19 January 2020).

http://bit.ly/30LTnqh

6 OECD (2020), Pharmaceutical spending (indicator). doi: 10.1787/998febf6-en (Accessed on 19 January 2020). http://bit.ly/2sJ01Rs

7 Claxton, G., Rae, M., Long, M., Damico, A., “2018 Employer health benefits survey,” Henry J. Kaiser Family Foundation
Educational Trust. https://kaiserf.am/2O6oSbd

8 Milliman. (July, 2019). 2019 Milliman Medical Index. http://bit.ly/2YBllC5; Employee costs include their premium contributions and out-of-pocket costs. The true costs to employees are understated here because employers’ contributions towards health benefits amount to a sizable tax deduction that appears as a line item in the federal budget paid for with taxpayer dollars, estimated to be more than $300 billion dollars per year. See: U.S. Congressional Budget Office. (2017). “Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2017 to 2027”. Table 2, p.10. http://bit.ly/CBOhcsub

9 Collins, S.R., Bhupal, H.K., & Doty, M.M. (2019). “Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured.”

U.S. Census Bureau, Population Division. (June 2019). Estimates of the Resident Population by Single Year of Age and Sex for the United States: April 1, 2010 to July 1, 2018. http://bit.ly/2GhwdOP

10

12 Recent studies have catalogued colossal administrative expenditures related to bureaucratic complexity estimated at about one-quarter or more of all U.S. healthcare spending. See for e.g.

Relman, A. S. (1980). “The new medical-industrial complex.” New England Journal of

Medicine, 303(17), 963-970.

Foster, G., & Whitmore, H. (October 2018).

Commonwealth Fund. http://bit.ly/2YHupWp. This study found that 45 percent of adults ages 19 to 64

and Health Research &

were inadequately insured. According to the Census Bureau in 2018 there were 88.7 million persons in

this age group. See

Schneider, Eric C., Dana O. Sarnak, David Squires, and Arnav Shah. (2017). “Mirror, Mirror 2017:

International Comparison Reflects Flaws and Opportunities for Better US Health Care.” Commonwealth

Fund. http://bit.ly/2zVXFS2

11 Livingston, S. “Publicly traded health insurers’ revenue nears $1 trillion mark.” Modern Healthcare, February 18, 2020.

Rogstad, T. L., & Parekh, N. (2019). “Waste in the US health care system: estimated costs and potential

Jama, 322 Jama, 322

(15), 1501-1509; Berwick, D. M. (2019). “Elusive waste: the Fermi paradox in

Shrank, W. H.,

for savings.”

US health care.”

(15), 1458-1459; and Himmelstein, D. U., Campbell, T., & Woolhandler, S.

(2020). “Health Care Administrative Costs in the United States and Canada, 2017.”

Medicine. doi:10.7326/M19-2818.

Annals of Internal

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13 Potter, W. “How the Health Insurance Industry (and I) Invented the ‘Choice’ Talking Point.” The New York Times, January 14, 2020. https://nyti.ms/2RVlzme

14 U.S. Bureau of Labor Statistics. “Job Openings and Labor Turnover Summary (JOLTS),” May 7, 2019.

http://bit.ly/2MdfxOu

15 Claxton, G., Rae, M., Damico, A., Young, G, McDermott, D., “2019 Employer health benefits survey,” Henry J. Kaiser Family Foundation.

16 See e.g.

PLoS medicine, 17 Galvani, A.P., Parpia, A.S., Foster, E.M., Singer, B.H., & Fitzpatrick, M.C. (2020). “Improving the prognosis of health care in the USA.” Lancet, 395: 524–33; Pollin R, Heintz J, Arno PS, Wicks-Lim J. & Ash M. (November 2018). “Economic Analysis of Medicare for All,” Political Economy Research Institute, University of Massachusetts-Amherst. http://bit.ly/PERI_Medicare4All; Blahous, C. (2018). “The Costs of a National Single-Payer Healthcare System” Mercatus Center, George Mason University. http://bit.ly/2vVNlEY. One exception is a recent Urban Institute report:

relatively high costs can be explained by the study’s assumptions about excessive utilization increases and lower administrative and

prescription drug savings, which are unsubstantiated in the literature. Further critical discussion of the report’s relatively high costs can be found here: Pollin, R. (2020). “Alternative Medicare for All Cost Estimates: PERI (2018) vs. Urban Institute (2019). 7th Annual Global Health Economics Colloquium, UC Berkeley. http://bit.ly/2OGrAmh

In addition, more than 250 economists have signed an open letter to Congress and the American public in support of a single-payer Medicare for all health insurance system and its ability to reduce overall health care spending: “As economists, we understand that a single-payer “Medicare for All” health insurance system for the U.S. can finance good-quality care for all U.S. residents as a basic right while still significantly reducing overall health care spending relative to the current exorbitant and wasteful system. Health care is not a service that follows standard market rules. It should therefore be provided as a public good.” November 19, 2019. http://bit.ly/3122djw

17 Gawande. A. (2017). “Is Health Care a Right?” The New Yorker. http://bit.ly/37NTWSO

18 For example, in 2018 the Center for Responsive Politics reported that 861 lobbyists (of whom 74 percent were former government employees) spent more than $171 million dollars lobbying on behalf of the pharmaceutical industry. See: Center for Responsive Politics. “Industry Profile: Pharmaceutical manufacturing.” http://bit.ly/3aIdJFe

& Whitmore, H. (2019).

http://bit.ly/2l9vhFt

Cai, C., Runte, J., Ostrer, I., Berry, K., Ponce, N., Rodriguez, M., ... & Kahn, J. G. (2020).

“Projected costs of single-payer healthcare financing in the United States: A systematic review of

economic analyses.”

(1), e1003013. http://bit.ly/2uD99Yk;

Gangopadhyaya, A., Garrett, B., Shartzer, A., ... & Arnos, D. (2019). “From Incremental to

Blumberg, L. J., Holahan, J., Buettgens, M.,

Comprehensive Health Insurance Reform: How Various Reform Options Compare on Coverage and

Costs.” The Urban Institute. http://bit.ly/37ATLdy. In this report the

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Philip Caper received his BA, MS and MD degrees at UCLA, and was trained in Internal Medicine on the Harvard Medical Unit at Boston City Hospital. He has held professorships at Dartmouth Medical School and the University of Massachusetts Medical School (where he was also Vice-Chancellor for Health Affairs, Chief of the Medical Staff and Hospital Director), has been an adjunct lecturer on Health Policy and Management at the Harvard School of Public Health, a Research Associate at Harvard’s Kennedy School of Government and an Associate in Health Policy and Management at the The Johns Hopkins School of Public Health.

From 1971 to 1976, he was a professional staff member on the United States Senate Labor and Public Welfare’s subcommittee on Health, chaired by Senator Edward Kennedy. Dr. Caper was a charter member of the nation’s top health-care advisory panel, the National Council on Health Planning and Development (created by PL93-641) from 1977 to 1984, chairing the panel from 1980 to 1984. He was also founder and chairman of the Codman Group (1986-2001), a health-care software and consulting company with an international reputation and clientele. Codman pioneered the use of PC-based statistical data to provide its clients with detailed information about the costs and quality of medical care used by defined populations. Clients included over 20 Blue-Cross/Blue Shield companies, and over a dozen state health departments, data agencies and Medicaid programs. In 1992, The Codman Group was named one of the 100 most innovative companies in the world by The Wall Street Journal.

Dr. Caper is a founding member of the National Academy of Social Insurance. For 20 years, he was a member of the Board of Directors of The Medical Foundation (now Health Resources in Action), a Boston-based health care organization whose mission is the promotion of public health and advancement of medical research. He currently serves on the Board of Maine AllCare, the PNHP chapter in Maine, a group advocating for a universal improved Medicare-for-All program for the state of Maine and has been a member of the national board of Physicians For A National Health Program.

He has published numerous articles in professional journals, including The New England Journal of Medicine, The Journal of the American Medical Association, Business and Health, The American Journal of Public Health, The Journal of Public Health Policy and Health Affairs where he served on the Editorial Advisory Board from its founding to 2003. He has also written numerous letters to the editor and op-ed articles advocating for a publicly run universal health care program for Maine and the U.S., and from 2011 to 2015 was a regular monthly columnist for the Bangor Daily News, Maine’s second largest paper, where he writes about health policy.

Economist Peter S. Arno, PhD is a Senior Fellow and Director of Health Policy Research at the Political Economy Research Institute at the University of Massachusetts-Amherst, a Senior Fellow at the National Academy of Social Insurance, and recently served on the Board of Directors of the National Committee to Preserve Social Security & Medicare Foundation. He received his doctorate in economics at the New School for Social Research and was a Pew Postdoctoral Research Fellow at the Institute for Health Policy Studies and the Institute for Health and Aging at UCSF, a Scholar of the American Foundation for AIDS Research, and a recipient of the Robert Wood Johnson Investigator Award in Health Policy.

In addition to Dr. Arno’s current work on the economic and financial analysis of universal health care proposals for California, New York, and the US, his recent research has examined the impact of Social Security and the Earned Income Tax Credit on population health, integrating social determinants of health with treatment and prevention, food insecurity and the elderly, economics of long-term care, social and geographic determinants of obesity, and regulation and pricing practices of the pharmaceutical industry. His 1992 book with Karyn Feiden, Against the Odds: The Story of AIDS Drug Development, Politics &Profits, was nominated for a Pulitzer Prize. Dr. Arno has testified before numerous U.S. House and Senate committees on areas related to his research.

Democrats’ plan to cap insulin prices faces GOP threat, skeptical advocates

Touted by Biden, a proposed $35 monthly limit on co-pays could fall in Senate review

by Dan Diamond - Washington Post - December 13, 2021

Democrats promise they’ll soon fix a problem that has tormented diabetics for years — the soaring price of lifesaving insulin that has forced some patients to choose between filling a prescription and paying for food, housing or other essentials.

“If you’re one of those Americans that are paying too much for insulin, my ‘Build Back Better’ plan is going to change that … because we’re going to guarantee you pay no more than $35 a month,” President Biden said last week.

But it’s a pledge Democrats may be unable to keep, as they seek to speed their massive social spending package to the Senate floor for a vote, which could happen as soon as this month. Senate Republicans are eyeing a procedural move to prevent the insulin cap from applying to privately insured Americans, seeking to deny Democrats a talking point heading into next year’s midterm elections — even if it means that some patients will go without relief.

“There’s definitely an expectation that Republicans are going to challenge the provision,” said Lauren Aronson, a Democratic strategist and the executive director of the Campaign for Sustainable Rx Pricing.

Senate Republicans repeatedly declined to comment on whether they would use the “Byrd rule” — which governs legislation enacted through the budget process — to knock out part of Biden’s insulin plan. “We aren’t commenting on any part of the Byrd challenge process at this time,” Melanie Lawhorn, a spokesperson for Sen. Mike Crapo (R-Idaho), the top Republican on the Senate Finance Committee, wrote in an email.

At least 19 Senate Republicans have previously signed on to legislation to lower drug costs for diabetics, but Senate Minority Leader Mitch McConnell (R-Ky.) has pushed the GOP to oppose the Build Back Better Act as a bloc. And even Republicans who have written legislation to limit the price of insulin, such as Sens. Charles E. Grassley (Iowa) and John Neely Kennedy (La.), have been tight-lipped about whether they would support efforts to stop Democrats’ cost controls.

“Senator Grassley and his office are going to reserve comment at this point,” spokesperson George Hartmann said.

Politicians from both parties have promised for years to find ways to lower the skyrocketing price of insulin — a drug that more than 7 million Americans depend on to keep their bodies functioning, according to the American Diabetes Association. But bipartisan pledges, investigations and even new government policy under President Donald Trump have produced little tangible effect, as pharmaceutical companies continue to patent tweaked versions of a drug that dates to a century-old medical breakthrough.

One branded insulin drug called Humalog, which cost about $21 per vial when Eli Lilly introduced it in 1996, lists today at about $275 in the United States — an increase that has mystified and angered public health experts, who say the drug formula has not changed, even as its price has multiplied. Patients may need several vials per month of the medicine, which is available at a fraction of the cost overseas. Although Eli Lilly debuted a half-price generic version of the drug in 2019, experts faulted the move as insufficient.

“As I researched this topic, I found that 25 to 30 percent of Americans ration their insulin because of high cost,” said S. Vincent Rajkumar, a Mayo Clinic physician who has studied the drug’s prices and who said reforms are desperately needed.

“The ability to keep increasing the price every year on the same product happens only when there is no market force” to keep drugmakers in check, he added.

Biden and his allies are also getting pushback from some advocates and policy experts who argue that the focus on a $35 monthly limit has oversold what the legislation would deliver. Democrats’ planned price cap applies to insulin co-pays and, therefore, doesn’t extend to uninsured Americans, who face the highest sticker prices when trying to purchase drugs.

“We worked our butts off to make insulin the poster child for drug-price gouging,” said Laura Marston, an attorney who lives with diabetes. “It feels like the Democrats are acknowledging what’s going on, but then they’re not willing to actually push forward to take real action to make it right” for the uninsured.

As jockeying over the spending bill continues, diabetics have appeared on Capitol Hill to share their stories about spending hundreds of dollars per month on insulin — or going without and suffering disastrous consequences. Mindy Salango, a patient advocate from West Virginia, on Friday told reporters at a news conference convened by Democrats and Protect Our Care, an advocacy group, that she spends about $350 monthly to cover her insulin needs, despite having private health insurance through her employer.

“I’ve met people in a parking lot to provide them with insulin and supplies that they need to survive,” Salango said. “This is not health care. This is survival of the richest.”

Biden insists his legislation will finally deliver for diabetics. Under the version of the Build Back Better Act that passed the House last month, insulin co-pays for all Americans with private health insurance coverage or those enrolled in Medicare, the government’s insurance program for seniors, would be capped at $35 per month beginning in 2023. In addition, Medicare would begin negotiating with manufacturers over the drug’s price, which officials say will help reduce future increases.

The insulin provisions were added to the package after liberal Democrats rebelled against Biden’s initial framework for the legislation in October, which excluded drug price policies, as the White House sought to win 50 votes in the Senate. The administration initially did little to publicly promote the changes, focusing instead on measures such as expanding child care and tackling the climate crisis.

Prominent liberals have since implored Democrats to tout the insulin provisions, saying it’s a winning issue and a long-sought and important achievement.

“If you can’t message ‘we took insulin from $500 to $35,’ get out of politics. And if you can’t deliver that for people, get out of politics,” MSNBC host Chris Hayes said on his prime-time show on Nov. 19.

The White House subsequently amped up its promotion of the insulin plan on Twitter and in speeches this month.

But whether the measure will survive, and in what form, is unclear amid the threat of parliamentary challenges from the right and demands from the left to make it more robust.

Rep. Pramila Jayapal (D-Wash.), chair of the Congressional Progressive Caucus, Rep. Cori Bush (D-Mo.) and 95 other House lawmakers last week urged the Senate to amend the bill so the insulin price cap would take effect next year and apply to diabetics who are uninsured.

“Being uninsured, even for a short period during a job transition or marriage status change, can be deadly for a person with diabetes, who will have to pay full retail price for their insulin during that time,” the House lawmakers wrote.

Policy experts are similarly concerned that the plan leaves out the neediest patients. Although some seniors have strained to pay for insulin, most Medicare patients don’t struggle with the cost of the drug, said Juliette Cubanski, deputy director of the Medicare policy program at the Kaiser Family Foundation.

“There is real benefit here,” she acknowledged, “… but at the same time, I think it’s important to also focus on what isn’t being addressed here: the high cost of insulin for people who don’t have insurance.”

Democrats counter that the insulin provisions, if enacted, would still be a significant achievement and that other provisions of the spending measure would greatly reduce the number of uninsured.

“Insulin has cost too much for too long, and too many people depend on this drug for us to let this moment pass,” Sen. Patty Murray (D-Wash.), who chairs the Senate Health, Education, Labor and Pensions Committee, said last week.

Administration officials note the Build Back Better Act includes coverage expansions that would allow millions of uninsured Americans to enroll in Medicaid or purchase low-cost plans through the Affordable Care Act’s insurance exchanges, which will extend new and existing protections to uninsured diabetic patients. Medicaid, the safety-net health program for low-income Americans, charges no or minimal out-of-pocket costs for insulin.

“The single most important policy factor affecting access to affordable insulin for adults ages 18-64 is Medicaid expansion,” the Commonwealth Fund wrote in a report last year.

Meanwhile, Republicans have been meeting with the Senate parliamentarian to determine whether the bill’s health provisions would technically qualify under budget reconciliation, a legislative maneuver that allows Democrats to avoid a GOP filibuster and enact policy changes with a simple majority, so long as the legislation is linked to the federal budget. Under the Byrd rule, lawmakers can challenge individual provisions in the bill.

If Senate Republicans challenge the insulin provision, some policy experts say they expect the parliamentarian will determine that the plan to cap insulin costs for privately insured Americans is “merely incidental” to the federal budget. In that case, Republicans could call a point of order to strip the provision from the bill.

Although the Senate could overrule the parliamentarian, that would require 60 votes — the entire Democratic caucus plus 10 Republicans — and McConnell has already made clear: His caucus will vote to oppose the Build Back Better Act and its provisions.

Any GOP challenge to the provision could provoke a serious Democratic response, Senate Majority Leader Charles E. Schumer (D-N.Y.) warned last month, saying that he will fight to preserve the insulin price caps.

“To those in the GOP who want to say, ‘Kill this provision,’ I say stand down, stand with the American people,” Schumer said in a news conference.

Diabetic patients say they’ve grown frustrated with drug price politics and are desperate for a solution that ensures low insulin costs for all.

“I hope none of you have to go to the pharmacy and walk out without your lifesaving medication,” said Salango, the patient advocate from West Virginia. “I hope you never feel that terror.”

https://www.washingtonpost.com/health/2021/12/13/35-dollar-cap-insulin-build-back-better-act/