Americans give U.S. health care system failing mark, AP poll finds
A majority of adults in the U.S. say health care is not handled well in the country.
by Amanda Seitz - AP - September 12, 2022
WASHINGTON — When Emmanuel Obeng-Dankwa is worried about making rent on his New York City apartment, he sometimes holds off on filling his blood pressure medication.
“If there’s no money, I prefer to skip the medication to being homeless,” said Obeng-Dankwa, a 58-year-old security guard.
He is among a majority of adults in the U.S. who say that health care is not handled well in the country, according to a new poll from The Associated Press-NORC Center for Public Affairs Research.
The poll reveals that public satisfaction with the U.S. health care system is remarkably low, with fewer than half of Americans saying it is generally handled well. Only 12% say it is handled extremely or very well. Americans have similar views about health care for older adults.
Overall, the public gives even lower marks for how prescription drug costs, the quality of care at nursing homes and mental health care are being handled, with just 6 percent or less saying those health services are done very well in the country.
“Navigating the American health care system is exceedingly frustrating,” said A. Mark Fendrick, the director of the University of Michigan Center for Value-Based Insurance Design. “The COVID pandemic has only made it worse.”
More than two years after the pandemic’s start, health care worker burnout and staffing shortages are plaguing hospitals around the country. And Americans are still having trouble getting in-person medical care after health centers introduced restrictions as COVID-19 killed and sickened millions of people around the country, Fendrick said.
In fact, the poll shows an overwhelming majority of Americans, nearly 8 in 10, say they are at least moderately concerned about getting access to quality health care when they need it.
Black and Hispanic adults in particular are resoundingly worried about health care access, with nearly 6 in 10 saying they are very or extremely concerned about getting good care. Fewer than half of white adults, 44%, expressed the same level of worry.
Racial disparities have long troubled America’s health care system. They have been abundantly clear during the COVID-19 pandemic, with Black and Hispanic people dying disproportionately from the virus. Black and Hispanic men also make up a disproportionately high rate of recent monkeypox infections.
Fifty-three percent of women said they are extremely or very concerned about obtaining quality care, compared to 42% of men.
While Americans are united in their dissatisfaction with the health care system, that agreement dissolves when it comes to solutions to fix it.
About two-thirds of adults think it is the federal government’s responsibility to make sure all Americans have health care coverage, with adults ages 18 to 49 more likely than those over 50 to hold that view. The percentage of people who believe health care coverage is a government responsibility has risen in recent years, ticking up from 57% in 2019 and 62% in 2017.
Still, there’s not consensus on how that coverage might be delivered.
About 4 in 10 Americans say they support a single-payer health care system that would require Americans to get their health insurance from a government plan. More, 58%, say they favor a government health insurance plan that anyone can purchase.
There also is broad support for policies that would help Americans pay for the costs of long-term care, including a government-administered insurance plan similar to Medicare, the federal government’s health insurance for people 65 or older.
Retired nurse Pennie Wright, of Camden, Tennessee, doesn’t like the idea of a government-run health care system.
After switching to Medicare this year, she was surprised to walk out of her annual well-woman visit, once fully covered by her private insurance plan, with a $200 bill.
She prefers the flexibility she had on her private insurance plan.
“I feel like we have the best health care system in the world, we have a choice of where we want to go,” Wright said.
A majority of Americans, roughly two-thirds, were happy to see the government step in to provide free COVID-19 testing, vaccines and treatment. Roughly 2 in 10 were neutral about the government’s response.
The government’s funding for free COVID-19 tests dried up at the beginning of the month. And while the White House says the latest batch of recommended COVID-19 boosters will be free to anyone who wants one, it doesn’t have money on hand to buy any future rounds of booster shots for every American.
Eighty percent say they support the federal government negotiating for lower drug prices. President Joe Biden this summer signed a landmark bill into law allowing Medicare to negotiate the price of prescription drugs. The move is expected to save taxpayers as much as $100 billion over the next decade.
“Medication costs should be low, to the minimum so that everyone can afford it,” said Obeng-Dankwa, the Bronx renter who has trouble paying for his medication. “Those who are poor should be able to get all the necessary health they need, in the same way someone who also has the money to pay for it.”
The poll of 1,505 adults was conducted July 28-Aug. 1 using a sample drawn from NORC’s probability-based AmeriSpeak Panel, which is designed to be representative of the U.S. population. The margin of sampling error for all respondents is 3.6 percentage points.
Letter to the editor: Facility fee bill only a stopgap – Maine needs universal care
Reporter Joe Lawlor’s recent article (Aug. 21) on the “byzantine” system of medical billing in Maine reflects only the “tip” of our dysfunctional health care system; a system that leaves 100 million people in the United States with crushing medical debt, a system that spends significantly more on health care than other wealthy countries but results in worse outcomes.
Last year, a group of Maine citizens who shared the common goal of achieving affordable, equitable, comprehensive health care for all Maine residents formed Maine Healthcare Action, a nonprofit organization. We proposed a resolve, approved by the secretary of state, mandating the Maine Legislature to draft a universal health care bill during the 2023-’24 legislative session. The resolve required 63,000-plus signatures in order to be placed on the November 2022 ballot. Unfortunately, cancellations of most outdoor and indoor events because of COVID-19 spread prevented us from reaching our goal.
Stopgap legislation, such as Senate President Troy Jackson’s reported intention to introduce a bill to regulate “facility fees,” is well-meaning but ignores the real issue of health care for Maine. With the November elections approaching, Maine voters should demand from every candidate running for state office to know their position on universal health care and how they plan to address the issue.
Larry Kaplan, M.D., MPA
Cape Elizabeth
Maine Voices: How to remove obstacles on our path to universal health care
Final approval or rejection of a state-based universal health care plan could be left to voters, rather than politicians.
by Daniel C. Bryant - Portland Press Herald - Sepctember 10, 2022
The recent excellent reporting on medical billing by Joe Lawlor has prompted a number of Press Herald letters, opinion pieces and an editorial in response. Writers have offered suggestions for improving our health care system: better communication between insurers and providers, legislative action to cap prices, improved transparency, etc.
However, as Dr. Larry Kaplan pointed out in his Sept. 7 letter (“Facility fee bill only a stopgap – Maine needs universal care”), “stopgap” changes to such a complex system are not enough. They’re unlikely, for instance, to improve the patient or physician experience, to control costs significantly, or to ensure everyone is covered. What they will almost certainly do is add to the complexity.
The resolve to which Kaplan referred in his letter would have directed the Legislature to draft a bill that would replace the present system, based on commercial insurance for the healthy and government programs for the poor, old, disabled, et al., with a universal health care system ensuring that all Maine residents had good, equitable health care.
As Lawlor mentioned in his report, some opponents of such reform cite the failure of voters in states where it has been proposed (Colorado, Vermont, California) to pass enabling legislation. That is less an indictment of those plans, though, than it is of the factors responsible for their rejection: failure to specify and explain the costs and funding of the plans, failure to educate voters about how the plans would work as opposed to how the present system works, and opposition by special interests (e.g., insurance and pharmaceutical companies) concerned about financial losses. Therefore, achievement of comprehensive reform of this type would require not only developing the plan itself and putting it into bill form, but dealing with the three factors that would otherwise doom the bill’s passage.
That could be done. Here’s one way.
Establish a legislative committee made up of members and consultants experienced in health care policy and devoted to development of a universal health care bill, not to representation of all stakeholders’ interests.
As more than 20 other states have developed universal health care plans, the committee could begin by reviewing those plans, along with plans that have been developed previously here in Maine (most recently, L.D. 1045 in the 130th Legislature).
It could also review the 30-odd fiscal studies of state-based universal health care plans, most of which have projected reduced health care expenditures once the plans are fully implemented. With that background in hand, the committee would then develop the plan, making the final bill detailed enough to allow for federal waiver applications and an objective fiscal analysis.
The bill would need to include several additional provisions:
• Its implementation would be contingent on obtaining the waivers and on commissioning and completion of the fiscal analysis, including the effects of the plan on specific demographics (employers, workers, health care professionals, retirees, et al.).
• It could be modified until the Legislature finds the analysis of the plan acceptable, including a projection that the total cost of the plan would be no greater than the present state health care expenditure.
• The citizenry would be kept informed about the contents of the bill during its development and have opportunity for comment. Final approval or rejection could be left to the voters rather than the politicians – they’re the ones to be affected by it, after all.
Such an approach to health care reform would ensure that the final plan would be assessed on its merits and that the countervailing factors would be minimized: Costs and funding would be front and center, the people would be enlightened about how the system would work, and as for the opposition of special interests, well, the voters would see through that soon enough.
Tackling cancer while battling the insurance system
Even plans that are supposed to save patients money can end up costing them dearly
by Anabelle Gurwitch - Washington Post - September 11, 2022
When you take up residency in Cancerland, as I did when I was diagnosed with Stage 4 lung cancer in 2020, you regularly hear yourself described as “battling” cancer. With my one-pill-a-day biomarker-directed therapy, I prefer to say that I’m “tackling” cancer. But if I am at war, it’s with an insurance system that works more like an extortion scheme.
In mid-January 2022, my phone rang early in the morning. This is my recollection of that call.
“Hi, this is Unintelligible Name from SaveOn.”
“Who? I don’t use Sav-On pharmacy.”
“We’re not Sav-On pharmacy, we’re SaveOnSP, specialty pharmacy.” SaveOn is pronounced exactly the same as Sav-On, just to be more confusing.
“I just changed insurers,” I said, “and I’ve been in close contact with my new plan. They contract with Express Scripts, who’ve assigned Accredo as my specialty pharmacy.”
“Yes, and we’re your specialty pharmacy’s specialty pharmacy. If you don’t sign up through us you’ll be charged the full amount of your co-pay of $4,500 every month for your specialty medication. We have all your information. You just have to verbally consent to let us manage your account.”
I was stunned and so sure this was a scam call that I neglected to ask how they had arrived at this $4,500 co-pay, and how that could even be possible because that number was larger than my plan’s deductible and out-of-pocket maximum.
“You’ll receive a bill, but don’t pay it,” my caller continued. “Working with us ensures that you have a zero co-pay.”
“Okay?” I replied. Was there a real choice? I’ve had lengthier consent discussions for a one-time hookup. I promptly forgot about the call and received no paperwork, but a few weeks later my monthly shipment of medication arrived along with an invoice from Express Scripts for $4,445. It noted that I might not owe this amount; nevertheless, it had a detachable payment slip, and a return envelope was provided. Remembering the caller’s assurances, I tossed the bill into my ever-expanding, supersize file I’ve labeled “insurance gobbledygook.” But when I visited an ATM the next day, my balance was significantly lower than I expected. $4,445 had been deducted by Express Scripts.
After I discovered that ginormous deduction from my account, I spent the majority of my waking hours that week ping-ponging between customer service representatives of my insurer, Express Scripts and Accredo. (The name SaveOnSP appeared neither on my invoice nor on my account portals at Express Scripts and Accredo.) I was transferred so many times in my crusade to satisfy the gods that govern the peculiar ecosystems of customer service call centers — which require you to offer up your member ID, Social Security number, date of birth, Zip code and sacrifice of the first born, and shriek “operator” over and over into the void — that I can’t remember which representative informed me that they didn’t show me as being enrolled with SaveOnSP.
Nor was I enrolled, they said, in the co-pay assistance program I had been participating in for more than a year — one sponsored by AstraZeneca, which manufactures my medication, osimertinib, which is sold under the brand name Tagrisso. Like many pharmaceutical companies, AstraZeneca offers several types of assistance designed to help patients pay for costly medications. The program I’m enrolled in provides up to $26,000 per patient per calendar year for Tagrisso, which retails at $14,000 per month.
(A representative of SaveOnSP later told The Post, “Plan participants sign up independently with copay assistance programs, not through SaveOnSP; SaveOnSP monitors consenting participants’ pharmacy accounts on behalf of plans.”)
My previous insurer had billed the AstraZeneca program and the funds they received were applied toward my deductible, and my insurance plan covered the remaining cost of the prescription. When I switched over to Express Scripts, they had initially done the same. If any of the math seems like it doesn’t make a lick of sense, it’s because insurers work out deals with pharma companies that are closely guarded secrets. What’s certain is that they’re not paying the sticker price for drugs like mine. My plan had a pricey monthly premium, but I’d never been charged an out-of-pocket co-pay, and the system operated so seamlessly that I felt fortunate.
Many hours of my cancer-shortened life span were expended before Express Scripts agreed to a refund and acknowledged the screw-up. I was issued a provisional credit, minus a bank-processing fee that came out of my pocket, natch, and it took several weeks before the refund was fully secured.
I was able to weather the $4,445 debit, but more than half of Americans can’t afford a $1,000 emergency. This could have had catastrophic consequences for another family who might have missed a mortgage payment or been unable to put food on the table.
Then, in mid-March, a representative from the AstraZeneca co-pay assistance program called me in a state of agitated confusion.
Previously, the program had been billed $250 a month in co-pay assistance for an annual total of $3,000; now it was being billed $4,500 every month. Had I changed insurers? “A third party is now adjusting my benefits,” I said, and she got very quiet and stopped asking questions. Now I wanted to know what had happened and what I could expect.
As I would learn from longtime industry observer Adam J. Fein, founder of Drug Channels Institute, I’d been entangled in an increasingly exploitative scheme. In what’s become a standard industry practice, pharmacy benefit managers (PBMs) contract with secretive third-party adjusters commonly called co-pay accumulators and maximizer programs to process “specialty medication” prescriptions, including biomarker-targeted therapies for lung cancer and other chronic and deadly diseases. Once a plan engages a co-pay accumulator or maximizer, these entities reclassify these medications (some of the priciest on the market) as “nonessential.” This allows plans to exploit a loophole in the Affordable Care Act: Coverage can be denied for therapies that a plan labels “nonessential,” and a plan can reset the member’s pharmaceutical benefit deductible and out-of-pocket maximum to any amount of their choosing.
Accumulators typically first bill the co-pay assistance program up to a patient’s deductible, and then, because they aren’t obligated to apply this to the deductible, double dip and bill the patient up to the amount of their deductible before providing coverage, often with a newly inflated co-payment rate. “Maximizers are even sneakier,” Fein explained. “They extract the maximum amount allowable from the assistance program before the plan picks up the rest of the cost” ($4,445 turned out to be the maximum amount billable per month from my co-pay assistance program).
“Patients are generally unaware of the complex and confusing benefit design,” according to Fein. Sure enough, I discovered that my co-pay assistance was no longer being applied to my deductible. Had I missed a mention of this program in my insurance plans’ summary of benefits? Nope. The information packet I received included no mention of a third-party maximizer. So much for shopping as an informed consumer in the insurance market.
Making matters more opaque, companies don’t refer to themselves as accumulators or maximizers. SaveOnSP describes itself as a “cost-saving healthcare solution” that focuses on “helping plan sponsors and their participants manage the skyrocketing costs of specialty pharmaceutical drugs.” At the same time, PBMs are pushing back on growing concerns. In a web posting titled “Copay Accumulator Programs Level the Out-of-Pocket Playing Field,” Express Scripts refers to its “Out of Pocket Protection Program” as a way “to ensure an equal benefit for all members.” It reads, “Plan sponsors believe it is not fair to allow one member to utilize outside funding to satisfy their deductible while another has to meet it entirely with their own money.” That’s like complaining that one person has a wealthy aunt who contributes to their care and another doesn’t, pitting plan members against one another like a hunger games. The purported benefit of signing up through SaveOnSP was that there would be zero co-pay for my specialty medication, but I’d already had a zero co-pay — and now it would take me longer to meet my deductible and out-of-pocket maximum, which meant an outlay of more cash for my other health-care costs.
(A representative of SaveOnSP told The Post, “Drug manufacturers keep increasing specialty drug prices. Employer-sponsored health plans bear most of those costs. Plans hire SaveOn to implement plan designs that take full advantage of drug makers’ copay assistance programs and ensure plan participants get specialty drugs for no or little cost. SaveOnSP is glad that the participant received a refund for the pharmacy’s erroneous charge and got her specialty drugs at no cost.”)
I began hearing similar horror stories from patient advocates, such as Carl Schmid, the executive director of the HIV+Hepatitis Policy Institute. “To me, co-pay accumulators very much seem like extortion,” Schmid told me. “And they lead to a decrease in adherence since people can no longer afford their drugs.”
“What’s more,” he said — and this was something I hadn’t realized — “the out-of-pocket obligations patients must pay to meet their deductible and any coinsurance are based on the drug’s undiscounted, pre-rebate list price, not the pharmacy’s actual negotiated price.” Not that anyone knows the rates insurers negotiate; it’s a more closely guarded secret than the identity of Satoshi Nakamoto, but we know it’s substantially less than the sticker price.
Anna Hyde, vice president of advocacy and access at the Arthritis Foundation, wasn’t surprised by my experience. Ever since co-pay accumulators entered the marketplace in 2017, she’s been hearing from patients worried about “interruptions in care and whose co-pays were ballooning.” Hyde alerted me to H.R. 5801, the Help Ensure Lower Patient Copays Act, introduced to Congress in November 2021 by Reps. A. Donald McEachin (D-Va.) and Rodney Davis (R-Ill.) along with more than 50 co-sponsors. The bill “requires health insurance plans to apply certain payments made by, or on behalf of, a plan enrollee toward a plan’s cost-sharing requirements.” In plain English, this means money that plans collect from a patient’s co-pay assistance fund must count toward the patient’s deductible and out-of-pocket maximum. Fourteen states already have banned co-pay accumulators.
Alas, California, where I live, is not one of those states, and H.R. 5801 is still pending in the House. In late August, the HIV+Hepatitis Policy Institute partnered with the Diabetes Leadership Council and the Diabetes Patient Advocacy Coalition to file a suit challenging the US Department of Health and Human Services May 2020 ruling that allows plans to avoid counting co-pay assistance toward deductibles and out-of-pocket maximums. But the difficulties remain in place for now.
“It’s always a scramble,” sighed Lia (who asked to be identified by only her first name out of fear of retribution from future insurers), who lives in Georgia and was diagnosed with lung cancer at age 49. She takes a specialty medication that’s similar to mine, and when her current insurer engaged a maximizer she lost her deductible credit, which has had a dramatic impact on the family’s finances. She has another preexisting condition that’s most effectively treated with a compounded medication that isn’t covered under her plan.
“Each time we change insurances, I hold my breath,” she told me.
“And we know that’s not easy!” I joked. This is what we call “living with lung cancer humor.”
Not long after I spoke with Lia, I learned that I’d have to change my insurance once again. The kicker: SaveOnSP ran through my annual allotment of $26,000 in assistance in only six months, which means I could face a gap period of vastly inflated medication costs. How could I even prepare? When I phoned another insurer, I was informed that they couldn’t determine the cost unless I was already enrolled in the plan. The representative’s best guess was that I’d be responsible for 20 percent of the cost of the medication, up to $750 dollars per order.
“Okay, do you contract with a maximizer?”
“I don’t know,” the customer service representative admitted. Based on my experience, the information is so siloed it’s possible that she really didn’t know.
Before collapsing into an exhausted sleep, I picked up my dog-eared copy of Yuval Harari’s “Sapiens.” I’d been rereading about ancient forager societies over the summer as a tonic to the slings and arrows of Cancerland contingencies. When an old woman in the Aché tribe, hunter-gathers who foraged the jungles of Paraguay, became “a liability to the band,” one of the younger men would sneak behind her and kill her with an ax-blow to the head. How far we’ve come, I’d marveled during my first reading in 2015, long before I learned that the cells in my body were conspiring against me. Now, as I weighed my options, it hit me: I’m the old woman in the modern retelling of this story, and to a PBM, I’m a liability, so until science finds a cure, I can expect many more soul-sucking hours of haggling over insurance benefits. Sometimes, an ax to the head seems preferable.
https://www.washingtonpost.com/outlook/2022/09/09/insurance-copay-specialty-medications-cancer/
Insulin costs increased 600% over the last 20 years. States aim to curb the price
by Steve Inskeep - NPR - September 12, 2022
Drug price reforms passed as part of the Inflation Reduction Act did not solve the problem of skyrocketing costs of insulin. States are taking their own action.
https://www.npr.org/2022/09/12/1122311443/insulin-costs-increased-600-over-the-last-20-years-states-aim-to-curb-the-price?utm_source=pocket_mylist
Editor's Note -
The preceding link should take you to an NPR story about the costs of insulin. If it doesn't take you to the story, go to the NPR.org website, and search for "Insulin". That should take you to Steve Inskeep's story about the costs of insulin, and California's proposed fix for the problem.
- SPC
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