The Affordable Care Act at 5 years

By David Blumenthal et al.
New England Journal of Medicine, June 18, 2015

Just over 5 years ago, on March 23, 2010, President Barack Obama signed the Affordable Care Act (ACA) into law. … In this article, we [review] the two basic thrusts of the law: its expansion of health insurance, and its reforms of the health care delivery system.

CMS estimates the savings [of the Medicare Shared Savings ACO program] at approximately $700 million. [p. 2454]

The secretary of health and human services reports that the Pioneer [ACO] program saved $385 million in the first 2 years. [p. 2454]

The ACA has supported a variety of programs to improve the delivery of primary care. An example is the Comprehensive Primary Care Initiative. … Initial evaluations show that the program overall has reduced monthly Medicare expenditures per beneficiary by $14, or 2%. [p. 2454]

Managed care proponents suffer from the free-lunch illusion – the illusion that the managed care interventions they support are free or, at worst, cost so little those costs can be totally ignored in reporting the alleged savings achieved by the intervention. This illusion is rarely questioned by reporters or editors of professional journals.

Here is a simple illustration of how the illusion works. Nathan Eagle, a professor at Harvard’s School of Public Health, told Harvard Magazine about an experiment he set up in Kenya that failed because he succumbed to the free-lunch illusion. Eagle was looking for an opportunity to use information technology to improve a public program in a Third World country. He hit upon the idea of using cell phones to monitor blood banks maintained by hospitals in Kenya. He persuaded the Kenyan ministry of health to ask nurses in each of Kenya’s hospitals to send text messages to the ministry every day describing how much blood they had in their blood bank.

The program was a “huge success” for the first week, but within a month the program had failed – nurses had stopped sending text messages. Eagle quickly realized his error: He had assumed text messaging was free. Of course, it is not. “The technical implementation was bulletproof,” Eagle later observed. “It failed because of a fundamental lack of insight on my part. … What I failed to appreciate was that an SMS [text message] represents a fairly substantial fraction of a rural nurse’s day wage. By asking them to send that text message we were asking them to essentially take a pay cut.”

The identical error is occurring at epidemic levels in American health policy. A paper published in the June 18 issue of the New England Journal of Medicine (quoted above) vividly illustrates the problem. In this paper, David Blumenthal et al. sought to assess the effectiveness of the Affordable Care Act five years after its enactment. Blumenthal et al. made these claims:

• CMS’s Medicare Shared Savings Program (MSSP) has saved $700 million;
• CMS’s Pioneer ACO program has saved $385 million;
• CMS’s Comprehensive Primary Care (CPC) Initiative (a “medical home” experiment) has cut Medicare expenditures by 2 percent.

Not one of these claims is true. They are not true because they ignore the cost to CMS of running these programs. The largest of the ignored costs are the payments CMS makes to the participating entities – bonus payments to ACOs (aka “shared savings” payments) in the case of the MSSP and Pioneer ACO programs, and subsidies to “medical homes” in the case of the CPC program. CMS incurs administrative costs as well, but I will ignore them in this comment and focus solely on the bonus payments to ACOs and subsidies to “homes.”

According to CMS’s own data, the payments CMS is making to ACOs and “homes” under the MSSP and CPC “medical home” experiments exceed the savings by large amounts. These two programs are raising Medicare costs. As for the third program – the Pioneer ACO program – CMS data indicate CMS bonus payments are almost as large as the savings ACOs achieve for Medicare.

Here is the CMS data in more detail.

MSSP ACO program. The latest data from CMS (an April 10, 2015, letter written by CMS’s chief actuary) indicates the MSSP ACO program raised Medicare spending by .2 percent in its first year. The letter stated that CMS’s bonus payments raised Medicare spending by .7 percent while the ACOs saved Medicare .5 percent, for a net increase in Medicare spending of .2 percent.[1] Blumenthal et al. did not cite a study for their claim that the MSSP program has saved Medicare $700 million.

Pioneer ACO program. The same April 10 letter from CMS’s chief actuary stated that the Pioneer ACO program lowered Medicare spending by .2 percent in 2012 and .5 percent in 2013. Specifically, CMS’s bonus payments raised Medicare spending by 1.0 percent in 2012, which was .2 percent less than the 1.2 percent savings achieved by Pioneer ACOs that year, and in 2013 bonus payments totaled .8 percent of Medicare spending while savings achieved by ACOs came to 1.3 percent.[2] Blumenthal et al. cite a paper by Nyweide et al. for their claim that the Pioneer ACO program has cut Medicare spending by $385 million. But that paper turns out to be another example of ACO proponents (Nyweide et al. are all employees of CMS) laboring under the free-lunch illusion: Nyweide et al. reported only gross savings and totally ignored CMS’s bonus payments to ACOs.[3]

CPC (“medical home”) program. Blumenthal et al. cite a report by Mathematica (which evaluated the first year of the CPC project) for their claim that the CPC initiative “has reduced Medicare expenditures … by … 2 percent.” It is true that the report states the CPC program lowered Medicare medical spending by 2 percent, but the report also states that CMS has paid out subsides to “medical homes” that total 3 percent of Medicare spending. The correct statement, then, is that the CPC initiative has raised Medicare expenditures by about 1 percent.[4]

What accounts for Blumenthal et al.’s decision to report only gross savings figures? On June 26 I sent an email to Dr. Blumenthal and a colleague asking that question. The colleague replied but didn’t address this question. Two days later I replied to the colleague and noted he failed to address my question. Neither he nor Dr. Blumenthal has replied.

Nathan Eagle, the Harvard professor I discussed above, quickly realized that he had made a mistake – he thought his “bullet-proof” intervention was free when in fact it cost money. He was willing to discuss his error publicly. Why can’t advocates of ACOs and other managed care fads do that?


1. Here is how CMS’s chief actuary put it: “[T]he MSSP beneficiaries in the program’s first performance period (covering April 2012 through calendar year 2013) exhibited total spending that was only 0.5 percent below the combined benchmark, or slightly less than the offsetting cost of resulting shared savings payments (net of shared losses) that represented about 0.7 percent of the combined benchmark.” (p. 4)

2. Here is how the chief actuary put it: “Total Pioneer aligned FFS Part A and Part B claims costs were approximately 1.2 percent below the combined expenditure benchmark in 2012 and 1.3 percent below benchmark in 2013; these results exceeded the combined shared savings payments (net of shared losses) of approximately 1.0 percent of benchmark in 2012 and 0.8 percent in 2013.” (p. 4)

3. Nyweide et al. based their paper on a simulation of the Pioneer program, not the actual program (see my discussion of this problem here). They also chose to simulate only the gross savings. They made no effort to simulate the bonus payments that would have been triggered by those gross savings.

4. These data appear in Table ES-2, p. xxi, of the report. Mathematica also reported the savings and cost figures in per-member-per-month (PMPM) terms: Medicare’s subsidies to participating clinics equaled $20 PMPM while savings came to only $14 PMPM. For more details on the Mathematica report, see my comment on this blog.

Kip Sullivan, J.D., is a member of the board of Minnesota Physicians for a National Health Program. His articles have appeared in The New York Times, The Nation, The New England Journal of Medicine, Health Affairs, the Journal of Health Politics, Policy and Law, and the Los Angeles Times.

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Baicker and Chandra on cost sharing

Posted by on Wednesday, Jul 8, 2015

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

The Veiled Economics of Employee Cost Sharing

By Katherine Baicker, PhD; Amitabh Chandra, PhD
JAMA Internal Medicine, July 2015

This year, once again, millions of people in the United States who get health insurance through their employers received the unwelcome news that cost sharing would increase.

At first blush, it might seem that cost sharing is just a way of dividing up whether employers or employees pay the bills, but decades of evidence show that lower cost sharing leads patients to consume more care of limited health value—such as unnecessary tests—and that this consumption leads to higher health insurance premiums. Cost sharing can thus mitigate the premium increases that would be needed to expand coverage to new services—many of which may particularly benefit patients with serious illnesses.

The potential usefulness of cost sharing does not, however, mean that we would all be better off with across-the-board increases in cost sharing. First, insurance provides crucial financial protection against potentially catastrophically high health expenditures. Patient cost sharing erodes the value of the risk protection that health insurance provides. The benefit of reducing the overuse of medical services that is inherent in subsidizing health care must be balanced against the cost of losing financial protection when it really matters. A disproportionate share of health spending is for a relatively small number of people requiring very expensive care. Any insurance plan with adequate protection against catastrophic out-of-pocket spending (such as an annual out-of-pocket maximum of $10 000) will leave a substantial share of health care expenditures in excess of that maximum, and thus not subject to cost sharing. Second, as we have discussed, a given dollar amount of cost sharing has different implications for people with different incomes, suggesting that optimal cost sharing might increase with income. At present, this feature is seen more in cost-sharing subsidies for low-income enrollees in some public plans than in employer-sponsored health insurance. Third, patients facing higher deductibles and copays may reduce care of high value (such as adherence to effective medications) along with the care of low value (such as tests that are not recommended). The evidence suggests that more sophisticated cost sharing, such as higher copays for care of questionable health benefit, might encourage higher-value health care spending and stem the growth of health insurance premiums. Examples are “carve-outs” that protect preventive care from copayments and “value-based” insurance plans that subsidize medications that help keep patients out of the hospital.

These caveats do not mean that cost sharing should be eschewed as a tool to improve value—but rather that cost sharing should be deployed in a more nuanced way than it is now. If enabled by regulatory changes and health care system reforms, cost sharing based on the value of care and scaled by income could improve health, slow increases in health insurance premiums, and increase take-home pay.


Tracking Trends In Provider Reimbursements And Patient Obligations

By Katherine Hempstead, Iyue Sung, Joshua Gray and Stewart Richardson
Health Affairs, July 2015

ACAView attempts to capture how health reform affects the day-to-day practice of community-based medicine. The project has collected data on more than seventeen million visits to nearly 15,000 providers in 2013 and 2014.

Patients’ payment obligations rose for all specialties, and deductibles were the largest category of increased patient spending.

From the Conclusion

Coverage expansion in the United States has benefited millions of people. However, the high out-of-pocket expenses that many people are facing may cause some to forgo nonurgent care. The overall implications for providers are unclear. Increased bad debt is one potential outcome.

It will be important to monitor changes in patient obligation and provider reimbursement as the effects of coverage expansion, risk contracting, and narrow networks continue to unfold. The degree to which these changes may affect access to care for low-income insured patients and debt levels for providers in particular deserves close scrutiny.

Can we balance the benefit of spending reductions associated with high deductibles and other cost sharing with the potential reduction in beneficial health care services that can result from patient exposure to out-of-pocket expenses as a prerequisite for health care access? Perhaps a better question is, should we?

Although Katherine Baicker and Amitabh Chandra support high deductibles and other cost sharing as a means to slow the increase in health care spending, they do recognize the problems with this approach to cost containment, for example: 1) the erosion of protection against the financial risk of essential health care services, 2) the ineffectiveness of cost sharing for most of health care spending – the catastrophic costs of the minority who have major health care problems, 3) the negative impact of cost sharing on those with lower incomes, and 4) the decrease in the use of high value care because of the financial barriers of cost sharing.

Rather than abandoning their support of the consumer-directed approach of increasing patient sensitivity to health care costs through out-of-pocket cost sharing, Baicker and Chandra recommend improving cost sharing by taking into consideration income levels, chronic disease status, and the relative value of the health care services provided. As if applying cost sharing was not already administratively burdensome, imagine applying these three adjustments to each patent’s cost sharing. Even then, the benefits of these adjustments would be only relative since you cannot eliminate 100 percent of the financial hardships, nor ensure that patients would receive 100 percent of the essential health care services that they need.

When you consider that most health care spending (about 80 percent) is not subject to cost sharing, you really have to give more thought as to whether this decades-long experiment in cost sharing is worth continuing.

It is not as if we don’t have a far better option. With a single payer system, monopsonistic price setting would obviate the need for patient price shopping. So then the only purpose for cost sharing would be to reduce the use of “low value” services. Beneficial services that some may consider to be of low value, but not of no value, are commonplace today, and who is to say that we should establish policies that impair access to that care?  On the other hand, services that clearly have absolutely no diagnostic nor therapeutic benefit would simply be excluded from coverage.

The system would be 100 percent effective in preventing financial hardship due to medical bills and 100 percent effective in removing financial access barriers, while slowing the rate of increases in health care spending down to that of other industrialized nations. You would have the cost containment that we need without the injustices and profound administrative waste of our fragmented, multi-payer system.

Perhaps Harvard’s Baicker and Chandra, with their PhDs, should sit down with Himmelstein and Woolhandler, with their MDs, and have a frank discussion of priorities in reform – like placing the patient first, as a single payer system would.

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New drugs fail to align benefits, risks and costs

Posted by on Tuesday, Jul 7, 2015

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Serious Risks And Few New Benefits From FDA-Approved Drugs

By Donald W. Light
Health Affairs Blog, July 6, 2015

Over the past year, the U.S. Senate and The New York Times have been investigating the failure of the nation’s auto safety regulators to protect citizens from cars with occasionally dangerous faulty devices.

But neither august institution has paid attention to the Food and Drug Administration’s (FDA) failure to protect the 170 million Americans who take prescription drugs from adverse reactions that are killing more than 2,400 people every week. Annually, prescription drugs cause over 81 million adverse reactions and result in 2.7 million hospitalizations.

This epidemic of harm from medications makes our prescription drugs the fourth leading cause of death in the United States. Including hospitalizations and deaths from prescribing errors, overdosing, and self-medication, drugs move up to third place.

Below I describe the biases that appear throughout the drug development process, from initial research to FDA review and approval. I conclude with recommendations that would reduce drug development costs and ensure that drugs are only approved if they are safe and significantly more effective than already existing medications.

Figure 1. Few Clinical Advances in a Decade and Hundreds of Other Drugs Approved for Promotion
Number of New Drugs, 2002-2011
2 – Breakthrough
13 – Real Advance
61 – Some Advantage
918 – Little or No Improvement

(The exhibit focuses on France, a country whose consumer-oriented drug market features an array of products similar to the U.S.)

Flooding the market with hundreds of minor variations on existing drugs and technically innovative but clinically inconsequential new drugs, appears to be the de facto hidden business model of drug companies. In spite of its primary charge to protect the public, the FDA criteria for approval encourage that business model. The main products of pharmaceutical research are scores of clinically minor drugs that win patent protection for high prices, with only a few clinically important advances like Sovaldi or Gleevec.

This business model works. Despite producing drugs with few clinical advantages and significant health risks, industry sales and profits have grown substantially, at public expense. Companies spend 2-3 times less on research than on marketing to convince physicians to prescribe these minor variations.

The Center for Drug Evaluation and Research (CDER) is the FDA division responsible for determining whether new drugs should be approved. Its funding, however, now largely comes not from taxpayers but from the companies submitting their drugs to CDER for review.

This clear conflict of interest and approving so many new drugs with few clinical benefits serve corporate interests more than public interests, especially given the large risks of serious harm. Direct and indirect costs to society far exceed the cost of funding the FDA as a public, independent review body.

Peer-reviewed studies already demonstrate how pharmaceutical companies manipulate FDA rules to generate evidence that their new drugs are more effective and less harmful than unbiased studies would show. The industry then recruits teams of medical writers, editors, and statisticians to select and repackage trial results into peer-reviewed articles that become accepted as reliable medical knowledge.

Based on his investigations, Marc Rodwin concludes, “Scholarly studies have revealed that drug firms design trials that skew the results and that they distort the evidence by selective reporting or biased interpretation.”

New FDA policies to get more drugs reviewed faster so that they can reach patients sooner result ironically in even more drugs being approved with less evidence that they are either safer or more effective. Faster reviews mean the chance that a drug will generate an FDA warning of serious harm jumps from one in five to one in three.

To protect the public from unsafe and ineffective drugs and earn public trust, the FDA and Congress must acknowledge the biases described here that result from pharmaceutical corporations financing the public regulator. They should also require two changes: that new drugs demonstrate patient-based clinical advantages through comparative trials, and that these trials be based on the population that will actually take a drug.

These changes would reduce the flood of minor variations shown in Exhibit 1 and the subsequent billions spent on them.…

Outrageously high pricing is not the only problem we face with new pharmaceutical products. We are inundated with new drugs that provide little or no improvement over existing products. This exposes us not only to the higher prices driven by new patents, but also to the potential of serious adverse effects that may not be recognized until the new drugs have been on the market for a period of time.

Under a single payer system, drug formularies should include only those products are reasonably effective, comparatively safe, and cost effective. Since the industry does not provide us with those assurances, it is the responsibility for the government to step in and do so.

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In his recent celebratory remarks after the Supreme Court (SCOTUS) upheld the legality of subsidies/tax credits under the Affordable Care Act (ACA), President Obama had this to say: “Five years ago, after nearly a century of talk, decades of trying, a year of bipartisan debate—we finally declared that in America, health care is not a privilege for a few, but a right for all.” (1)

It would be good if this were true, but it is not. Health care as a right has been debated over many years, but is still not in place for all Americans as this country remains an outlier among advanced industrial countries around the world. Instead, despite the ACA, we continue to have a patchwork of ever-changing programs assuring access to health care for some people some of the time.

Let’s look at what we do have in this respect. In the 1960s, Congress  established a broad right to health care under statutory law by enacting Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) for the elderly, disabled, people living in poverty, and children. In the 1980s it passed the Emergency Medical Treatment and Active Labor Act (EMTALA) requiring all Medicare-funded hospitals with emergency departments to provide appropriate emergency and labor care. More recently, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2013, which assures a right to equal access to care for patients with medical and mental health problems. SCOTUS has established a right to health care for prisoners and has protected some limited rights for women’s reproductive care (2), but has never interpreted the Constitution as guaranteeing a right to health care for all Americans. In fact, the words “health,” “health care,” “medical care,” and “medicine” do not appear in the Constitution. (3)

It is disingenuous to claim that health care is a right in the U. S. when we consider these inconvenient facts:

•  35 million uninsured, plus another similar number underinsured.
•  The first question asked of us in seeking care is “what is your insurance?”
•  21 states have opted out of Medicaid expansion under the ACA.
•  Medicaid eligibility and coverage varies widely from one state to
another, in many cases falling far short of necessary care.
•  As the costs of insurance and health care continue to rise and shift
more to patients, a growing part of the population cannot afford either and forgo seeking care.
•  More than 40 million Americans now have an account in collection for medical debt. (4)

This situation stands in sharp contrast to elsewhere in advanced societies. Health care has been recognized as a right since 1948 when the General Assembly of the United Nations adopted a Universal Declaration of Human Rights including access to health care. (5) The right to health care was also later adopted by the World Health Organization (WHO) in its Declaration on the Rights of Patients. (6) As a result, most of Western Europe, Scandinavia, the United Kingdom, Canada, Taiwan, and many other countries have one or another form of national health insurance assuring access to care for their populations. Here we spend twice as much and still have no universal access to health care.

Can we ever see this country coming around to universal access to health care based on medical need, not ability to pay? The record shows that we never can, or will, as long as we permit corporate stakeholders in our medical-industrial complex to call the shots, and as long as they succeed in perpetuating our exploitive for-profit system. There is a fix—single-payer national health insurance, as embodied in H. R. 676, Expanded and Improved Medicare for All.

1. Obama, President Barack. Read Obama’s full remarks on Supreme Court Ruling. U. S. News.

2. Curfman, G. King v. Burwell and a right to health care. Health Affairs Blog, June 26, 2015.

3. Ruger, JP, Ruger TW, Annas, GJ. The elusive right to health care under U. S. law. New Engl J Med, June 25, 2015.

4. Hillebrand, G. Consumer advisory: 7 ways to keep medical debt in check. Consumer Financial Protection Bureau, December 11, 2014.

5. Adopted by the General Assembly on December 10, 1948. Printed in: von Munch, I, Buske, A. (eds). International Law: Essential Treaties and Other Relevant Documents, 1985: 435ff.

6. Carmi, A. On patients’ rights. Med Law 10 (1): 77-82, 1991.

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What do the projected health insurance premium increases mean to us?

Posted by on Monday, Jul 6, 2015

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Health Insurance Companies Seek Big Rate Increases for 2016

By Robert Pear
The New York Times, July 3, 2015

Health insurance companies around the country are seeking rate increases of 20 percent to 40 percent or more, saying their new customers under the Affordable Care Act turned out to be sicker than expected. Federal officials say they are determined to see that the requests are scaled back.

The rate requests, from some of the more popular health plans, suggest that insurance markets are still adjusting to shock waves set off by the Affordable Care Act.

It is far from certain how many of the rate increases will hold up on review, or how much they might change. But already the proposals, buttressed with reams of actuarial data, are fueling fierce debate about the effectiveness of the health law.

A study of 11 cities in different states by the Kaiser Family Foundation found that consumers would see relatively modest increases in premiums if they were willing to switch plans. But if they switch plans, consumers would have no guarantee that they can keep their doctors. And to get low premiums, they sometimes need to accept a more limited choice of doctors and hospitals.

Marinan R. Williams, chief executive of the Scott & White Health Plan in Texas, which is seeking a 32 percent rate increase, said the requests showed that “there was a real need for the Affordable Care Act.”

“People are getting services they needed for a very long time,” Ms. Williams said. “There was a pent-up demand. Over the next three years, I hope, rates will start to stabilize.”

Sylvia Mathews Burwell, the secretary of health and human services, said that federal subsidies would soften the impact of any rate increases. Of the 10.2 million people who obtained coverage through federal and state marketplaces this year, 85 percent receive subsidies in the form of tax credits to help pay premiums.

In an interview, Ms. Burwell said consumers could also try to find less expensive plans in the open enrollment period that begins in November. “You have a marketplace where there is competition,” she said, “and people can shop for the plan that best meets their needs in terms of quality and price.”

In their submissions to federal and state regulators, insurers cite several reasons for big rate increases. These include the needs of consumers, some of whom were previously uninsured; the high cost of specialty drugs; and a policy adopted by the Obama administration in late 2013 that allowed some people to keep insurance that did not meet new federal standards.

“Healthier people chose to keep their plans,” said Amy L. Bowen, a spokeswoman for the Geisinger Health Plan in Pennsylvania, and people buying insurance on the exchange were therefore sicker than expected. Geisinger, often praised as a national model of coordinated care, has requested an increase of 40 percent in rates for its health maintenance organization.

Federal officials have often highlighted a provision of the Affordable Care Act that caps insurers’ profits and requires them to spend at least 80 percent of premiums on medical care and related activities. “Because of the Affordable Care Act,” Mr. Obama told supporters in 2013, “insurance companies have to spend at least 80 percent of every dollar that you pay in premiums on your health care — not on overhead, not on profits, but on you.”

In financial statements filed with the government in the last two months, some insurers said that their claims payments totaled not just 80 percent, but more than 100 percent of premiums. And that, they said, is unsustainable.…

Although it will be about three months before we have the final health insurance premiums for 2016, the information we have already can warrant a few preliminary observations.

  • The Affordable Care Act appears to have failed on delivering its promise of controlling global health care costs. The primary reason given by the insurers when submitting requests for much higher premiums for 2016 is that health care costs were much higher than their actuaries anticipated.
  • Some complain that new enrollees were less healthy and thus drove spending up, but under the individual mandate, increases in enrollment were across the board and not concentrated amongst the less healthy.
  • There may have been some pent up demand amongst new enrollees (e.g., joint replacement) but that is only a transient surge which does not warrant long term premium increases. Much of the pent up demand will have been ventilated as most of the remaining uninsured are ineligible by immigration status or by personal hardship. The numbers who are eligible but decline coverage will only trickle in as health care needs develop.
  • It appears that the increases in the benchmark silver plans will not be as great as the increases currently receiving considerable publicity. Requests over a ten percent increase were required to be made public whereas increases under ten percent will not be known until plans are marketed prior to the November 1 beginning of open enrollment.
  • Because rate increases vary considerably amongst the plans, many individuals will be forced to choose between paying higher rates by staying in their current plans or changing to plans with lower rates but with different narrow provider networks thereby potentially sacrificing continuity of care.
  • Respected institutions such as Geisinger in Pennsylvania and Scott and White in Texas are asking staggering premium increases, indicating that the supposed cost containment features of ACA are having a negligible impact on legitimate spending.
  • Little is being said about the insurance underwriting cycle. Large, well capitalized insurers are able to price their products more competitively, decreasing the market presence of less competitive insurers. Once market dominance is established, insurers are free to drive up premiums as much as 20 to 40 percent, as reported in this New York Times article. The regulated medical loss ratios are generous enough to allow market performance (profits) to excel, as confirmed by current Wall Street activity in health insurance equities.

So are we going to wait until October when the premium rates are announced, and then do nothing other than continue to stand back and observe because the insurers will reassure us that silver benchmark plans didn’t go up that much – maybe 4.4 percent – even if it means that the enrollees have to switch plans and find new providers in a different narrow network? Is this the good that’s coming out of all of this? What about those who want to continue with their current providers, but face a 20 to 40 percent premium increase? Will the death spiral bleed over from insurers to patients?

Enough. Single payer.

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Cream skimming under “perfect” risk scoring

Posted by on Friday, Jul 3, 2015

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Beyond Statistics: The Economic Content of Risk Scores

By Liran Einav, Amy Finkelstein, Raymond Kluender, and Paul Schrimpf
National Bureau of Economic Research, June 2015, NBER Working Paper No. 21304

From the Conclusions

Our objective in this paper was to highlight the fact that risk scores that are commonly used in credit and insurance markets are not merely statistical objects, as they are generated by economic behavior. We illustrated this point empirically in the specific context of Medicare Part D, the public prescription drug insurance program that covers over 30 million individuals, and explored their implications theoretically. We exploited the famous “donut hole” where insurance becomes discontinuously much less generous at the margin.

Using this research design, we empirically illustrated two conceptual points. First, analyzing the average demographic and health characteristics of individuals as a function of annual drug spending, we showed that spending differences across individuals reflect not only heterogeneity in underlying health but also heterogeneity in the underlying behavioral response to the insurance contract. Second, we show that the current (statistical) risk scores – which are designed to predict spending under a given contract – do not capture this second dimension of heterogeneity.

In the second part of the paper, we use a highly stylized theoretical example to explore some of the potential implications of these findings for the standard use of risk scores: to predict outcomes out of sample under other contracts and use these predictions to set reimbursement rates. We showed that standard risk scoring can create incentives for private insurers to cream-skim individuals whose (unpriced) behavioral response to the contract they offer will make them lower cost than what is predicted by the risk score that was generated under a different contract. A key point is that, when there is heterogeneity in the behavioral response to the contract, these cream-skimming incentives can still exist even in the presence of “perfect” risk scoring under a given contract.

A innate characteristic of a fragmented, multi-payer system of health care financing is that health risks vary between insurance pools, creating an opportunity for private insurers to profit by cream skimming healthier population subsets. Risk scoring is used to compensate for this heterogeneity, but this study shows that even when risk scoring is “perfect” under current standards, opportunities for cream skimming still exist.

A single payer system creates a single “homogenized” risk pool which eliminates cream skimming – another compelling reason to dismiss the private insurers and expand an improved version of Medicare to cover everyone.

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Is it time to nationalize the drug industry?

Posted by on Thursday, Jul 2, 2015

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Novartis to test new pricing model with heart failure drug

By Ben Hirschler
Reuters, June 30, 2015

Novartis plans to test a novel pricing model with some customers when it launches its keenly awaited new heart failure drug Entresto, the Swiss company’s head of pharmaceuticals said on Tuesday.

Entresto, also known as LCZ696, is the first new drug in decades for helping patients whose lives are in danger because their hearts cannot pump blood efficiently. As a result, it is widely expected to generate billions of dollars in annual sales.

How the product should be priced, however, is a dilemma for Novartis, since the company wants to reach as many patients as possible and it knows it will be competing with very cheap – though less effective – older medicines.

David Epstein said he was talking to several healthcare customers about a system under which they would get the drug at a discount but then pay Novartis more if, as expected, it successfully reduces the need for costly hospital visits.

“We are beginning to share the risk,” he said in an interview.

The idea of moving from a simple pay-per-pill model to one based on clinical outcomes is being considered by several drugmakers, and Novartis already has such a system in place for one customer using its multiple sclerosis drug Gilenya.

But Entresto could be an important test case because the drug will push up immediate drug costs markedly for a large number of patients, while having the potential to reduce their long-term medical bills.

The issue of drug pricing has come to a head recently, thanks to the launch of extremely expensive new medicines for cancer and hepatitis C, which are straining healthcare systems and adding to co-payment costs for patients.

Epstein, whose team is in the final stages of deciding the price for Entresto, declined to detail a likely cost per pill. But he said it would take into account “cost offsets”, such as fewer hospitalizations, as well as the value added from improving patients’ lives.

“We going to try and be fair and reasonable,” he said.…


Cost-Offsets of Prescription Drug Expenditures: Data Analysis Via a Copula-Based Bivariate Dynamic Hurdle Model

By Partha Deb, Pravin K. Trivedi and David M. Zimmer
Health Economics, October 2014


In this paper, we estimate a copula-based bivariate dynamic hurdle model of prescription drug and nondrug expenditures to test the cost-offset hypothesis, which posits that increased expenditures on prescription drugs are offset by reductions in other nondrug expenditures. We apply the proposed methodology to data from the Medical Expenditure Panel Survey, which have the following features: (i) the observed bivariate outcomes are a mixture of zeros and continuously measured positives; (ii) both the zero and positive outcomes show state dependence and inter-temporal interdependence; and (iii) the zeros and the positives display contemporaneous association. The point mass at zero is accommodated using a hurdle or a two-part approach. The copula-based approach to generating joint distributions is appealing because the contemporaneous association involves asymmetric dependence. The paper studies samples categorized by four health conditions: arthritis, diabetes, heart disease, and mental illness. There is evidence of greater than dollar-for-dollar cost-offsets of expenditures on prescribed drugs for relatively low levels of spending on drugs and less than dollar-for-dollar cost-offsets at higher levels of drug expenditures.

With the marketing success of outrageously priced drugs, the pharmaceutical industry is now devising schemes to be sure that their new products that are protected by patents will continue to be introduced with similar outrageous prices. This concept of adding “cost offsets” to the pricing is not new, but it now has a label that supposedly legitimizes its inclusion in pricing decisions.

In the past, pharmaceutical firms have cited the high costs of drug research as an excuse for high prices of new products (though the high prices of the past were nothing compared to the five and six digit prices of today’s new products). As the public discovers that the drug industry’s advertising budgets are typically three times their research budgets, and much of the research is funded through government programs such as those of the NIH, the firms apparently have decided that this argument is no longer as persuasive, and so they have to find another reason to justify outrageous pricing.

“Cost offsets” is a convenient label for adding to the the research, marketing, administration and profit costs of the products. These “cost offsets” include such concepts as money saved by fewer hospitalizations, fewer expensive interventions for progression of disease processes, and for the added value of prolonged lives or the added value of higher quality lives.

Think about that. What gall it takes for these pooh-bahs of the pharmaceutical world to suggest that they are entitled to capture, for themselves, not just the costs and legitimate profits, but the value of the benefits of their products, through higher consumer prices, whether paid individually or through some form of public or private insurance.

This perverse type of thinking is not limited to Novartis’ David Epstein. Bayer’s Marijn Dekkers 18 months ago said, about their expensive cancer drug, Nexavar, “we did not develop this product for the Indian market – let’s be honest – we developed this product for Western patients who can afford this product, quite honestly.”

Perhaps more despicable is this entry from a draft of the infamous Trans-Pacific Partnership Agreement, which contains the following in its statement of principles: “(d) the need to recognize the value of pharmaceutical products and medical devices through the operation of competitive markets or by adopting or maintaining procedures that appropriately value the objectively demonstrated therapeutic significance of a pharmaceutical product or medical device.”

Not only did the pharmaceutical industry buy off Congress when they went the route of the market-based Affordable Care Act instead of an efficient single payer Medicare for all, they have demonstrated to us that their primary goal is to achieve the greatest returns for their executives and shareholders no matter the cost to the ultimate consumers – the patients.

There could not be an industry that cries out more for government intervention to protect consumers than the pharmaceutical industry (oh wait, the private insurance industry, of course, but that’s another topic). Many suggest that it is time to demand negotiation of drug prices, or even to dictate fair prices. But should that be our opening position? How about calling for nationalization of the industry, at least their U.S. subsidiaries. That should get their attention. They have to know that we’re serious about wanting relief from their greed.

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Sound the alarm: The private insurance exchanges are coming!

Posted by on Wednesday, Jul 1, 2015

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Towers Watson merges with London-based consulting firm in $18 billion deal

By Aaron Gregg
The Washington Post, June 30, 2015

Towers Watson, the Arlington-based professional services company that operates a private health insurance exchange covering about 1.2 million people, announced an $18 billion all-stock merger with Willis Group Holdings, a London-based insurance and benefits firm.

The merger is the latest in a series of what Willis chief executive Dominic Casserley called “carefully targeted mergers and acquisitions” to expand his company’s international footprint. Last month, Willis Group acquired Evolution Benefits Consulting, a Pennsylvania health and welfare benefits advisory firm, and in late April it announced it would fully acquire Gras Savoye, one of France’s largest insurance brokerage firms.

Casserley said in a news release that the new company “will advise 80 percent of the world’s top-1,000 companies,” operating as a one-stop shop for large employers managing complex aspects of their human resources mix, benefits such as employer-provided health insurance and a range of other costs that affect companies’ bottom lines.

Because the new company will be based in Ireland, Towers Watson’s corporate tax rate will drop from 34 percent to a projected 25 percent.

This merger “is driven by business purpose, not from a tax planning standpoint but from serving customers,” said John Greene, chief financial officer of Willis. “The tax benefits that are derived just happen to be a nice consequence of the transaction.”

Towers Watson Chairman John Haley will lead the new company as chief executive, and Casserley will serve as president and deputy chief executive of the new company, which will operate under the name Willis Towers Watson.

Casserley said in a conference call that the merger was first conceived while Willis worked in partnership with Towers Watson on a health exchange.

The exchange “has rapidly grown to serve more than 1 million members in the United States,” Casserley said. “Many independent analysts believe that this is just the start, and that the business is at an inflection point, with the total market likely to grow significantly within five to seven years.”…

This mega-merger of benefits consulting firms is designed to capture the rapidly expanding market in private health insurance exchanges. Why should we be concerned?

The Affordable Care Act (ACA) was designed to protect the sectors of health care coverage that allegedly were functioning well – especially employer-sponsored health care plans. The greater changes enacted in ACA were aimed at the much smaller sector of dysfunctional individual and small group plans, plus expanding Medicaid for low-income individuals and families.

So how has it gone for the stable, well functioning employer-sponsored plans? Not so well. Even though there has been some slowing in the increase in health care costs, the increases have been in excess of inflation, and there appears to be a return to an accelerating pace of cost increases. Most employers are very concerned about the costs of their employee benefit packages, and they are already taking action to slow their nominal portion of the increases (though most economists contend that the employers’ portion is actually paid by the employees in forgone wage increases).

The most important measure already taken by many employers is to increase cost sharing, especially by requiring high deductibles that must be paid before most benefits kick in. This reduces the insurance premiums (or the contributions to the self-insured health trust) for the employer-sponsored plans since a significant portion of actual health care spending is shifted to the employees and their families. Other innovations such as tiering of drugs also shift more costs away from the employer. Plan beneficiaries also are reducing their utilization of beneficial health care services when they are exposed to high deductibles – a perverse disincentive that reduces spending.

The use of narrower provider networks also helps to reduce the employers’ contribution to health care payments. The employers’ representatives are able to contract for lower provider rates in exchange for a promise of oligopolistic exclusivity. Also the responsibility for payment of costs for care obtained outside of the networks is shifted almost entirely to the employees. In addition, providers known for managing expensive chronic disorders can be excluded from the networks, impairing the ability of patient beneficiaries to obtain the care that they need.

The employers are still not satisfied. Some are now beginning to implement the use of private insurance exchanges. In this model, the employer no longer offers an employer-sponsored health plan but instead provides the employee with a voucher or voucher-equivalent to purchase from a selection of plans in the private insurance exchanges. Since the value of the voucher is fixed, the employee must bear the additional costs of plans that have greater benefits. Thus this is a shift from a defined benefit program to a defined contribution program; by controlling the value of the voucher, the employer is able to shift much of the future health care cost increases onto the employees.

If you look at the insurance exchanges set up by ACA, you will see that the standard plans are low actuarial value plans. The benchmark silver plan has an actuarial value of 70 percent – the patient is responsible for paying an average of 30 percent of the costs (though many qualify for subsidies). The bronze plans have an actuarial value of only 60 percent. Employer-sponsored plans formerly had an actuarial value closer to 90 percent, but with the plans offered in the private exchanges, employees usually will select plans that the voucher will cover. This is a great opportunity for employers to gradually shift the value of the voucher so that it would cover 60 or 70 percent actuarial value plans, just like in the ACA exchanges (except that no government subsidies would be available for the private exchange plans).

This move to private insurance exchanges represents a tremendous business opportunity for benefits consulting terms, as today’s article indicates (not to mention offshoring to Ireland!) That’s just what we need: more administrative complexity and costs in our system already tremendously overburdened with administrative excesses. These benefits consulting firms are selling health insurance products without bearing any of the insurance risk of those products. The private insurers, with all of their administrative waste and insurance product perversions, remain prominent players in the system.

These benefits consulting firms tout choice. The employees are free to upgrade to a high actuarial value Cadillac health plan if they so desire. Little does it matter that most of them have hardly enough funds to be able to purchase a low actuarial value roller-skate health plan.

As if the deterioration in employer-sponsored plans has not already been enough, this switch to using a defined contribution voucher in private insurance exchanges will be a disaster for affordable health care for employees and their families.

Rather than accelerating the move toward private health insurance exchanges, we need to accelerate the transition to a single-payer improved Medicare for all program. Or do we just sit back and watch people go broke and suffer?

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Did you miss the important PNHP statement on the King v. Burwell decision?

Posted by on Tuesday, Jun 30, 2015

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

‘Subsidies upheld, but health needs still unmet’: doctors group

Physicians for a National Health Program, June 25, 2015

Although the Supreme Court has upheld the premium subsidies under the Affordable Care Act, the law remains incapable of remedying the U.S. health crisis, physician group says

Physicians for a National Health Program, an organization of 19,000 doctors who support single-payer national health insurance, released the following statement today:

Today’s decision by the Supreme Court in King v. Burwell to uphold the Affordable Care Act’s premium subsidies in about three dozen states will spare more than 6 million Americans the health and financial harms associated with the sudden loss of health insurance coverage.

For that reason alone the decision must be welcomed: Having health insurance is better than not having coverage, as several research studies have shown.

That said, the suffering that many Americans are experiencing today under our current health care arrangements is intolerable, with approximately 35 million people remaining uninsured, a comparable number underinsured, and rapidly growing barriers to medical care in the form of rising premiums, copayments, coinsurance and deductibles, and narrowing networks.

The unfortunate reality is that the ACA, despite its modest benefits, is not a remedy to our health care crisis: (1) it will not achieve universal coverage, as it will still leave at least 27 million uninsured in 2025, (2) it will not make health care affordable to Americans with insurance, because of high copays, deductibles and gaps in coverage that leave patients vulnerable to financial ruin in the event of serious illness, and (3) it will not control costs.

Why is this so? Because the ACA perpetuates a dominant role for the private insurance industry. Each year, that industry siphons off hundreds of billions of health care dollars for overhead, profit and the paperwork it demands from doctors and hospitals; denies care in order to increase insurers’ bottom line; and obstructs any serious effort to control costs.

In contrast, a single-payer system – an improved Medicare for All – would achieve truly universal care, affordability, and effective cost control. It would put the interests of our patients – and our nation’s health – first.

Single payer is simple: everyone in the U.S. would be covered for all medically necessary care in a single program financed by equitable taxes.

By replacing multiple private insurers with a single, nonprofit agency like Medicare that pays all medical bills, we would save approximately $400 billion annually by slashing the administrative bloat in our current private-insurance-based system. That money would be redirected to clinical care. Copays, coinsurance and deductibles would be eliminated.

Further, such a single, streamlined system would be able to rein in costs for medications and other supplies through the system’s strong bargaining clout – again, to our patients’ benefit.

A single-payer system would also be legally robust.

Because of the ACA’s administrative complexity and flaws – largely reflecting its accommodation to the private health insurance industry and other corporate, profit-oriented interests in U.S. health care – it is particularly vulnerable to the kind of legal challenge we saw today.

Our patients, our people and our national economy cannot wait any longer for an effective remedy to our health care woes. The stakes are too high. We need to move beyond the administratively wasteful, complex and inadequate ACA to a more fundamental, rational single-payer national health program.

Contrary to the claims of those who say we are “unrealistic,” a single-payer system is within practical reach. The most rapid way to achieve universal coverage would be to improve upon the existing Medicare program – which is celebrating its 50th anniversary this year, showing it has stood the test of time – and expand it to cover people of all ages. There is legislation before Congress, notably H.R. 676, the “Expanded and Improved Medicare for All Act,” which would do precisely that.

What is truly unrealistic is believing that we can provide universal and affordable health care in a system dominated by private insurers and Big Pharma.

The American people desperately need a universal health system that delivers comprehensive, equitable, compassionate and high-quality care, with free choice of provider and no financial barriers to access. Polls have repeatedly shown an improved Medicare for all, which meets these criteria, is the remedy preferred by two-thirds of the population. A solid majority of the medical profession now favors such an approach, as well.

We pledge to step up our work for the only equitable, financially responsible and humane cure for our health care ills: single-payer national health insurance, an expanded and improved Medicare for all.…

Before the release of the Supreme Court decision on King v. Burwell, there was extensive speculation on the relatively narrow topic of what would happen if some individuals lost their subsidies for purchasing plans in the insurance exchanges. Following the decision supporting the subsidies, much of the reporting has shifted to the view that the Affordable Care Act (ACA) is here to stay; the inherent infrastructure of ACA will guide further reform. Unfortunately, this framing of the issues has diverted us from the conversation that we need to be having.

When considering what needed to be done, ACA fixed very little of our health care financing system. This victory being celebrated now upheld premium subsidies that will allow less than two percent of the population to keep their ACA exchange plans – mostly low-actuarial-value underinsurance plans. To characterize this as the make-or-break Supreme Court decision for health care reform is entirely missing the essence of an equitable health care financing system.

On the day that the Supreme Court decision was announced, a link to the PNHP statement was included in the Quote of the Day message. That was not enough. The PNHP statement does catch the essence of the problem and thus is being distributed in full as today’s message. It should be shared widely with others since true health care equity is what the nation now needs to be talking about.

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The long-awaited ruling by the U. S. Supreme Court (SCOTUS) supporting subsidies/tax credits for the Affordable Care Act (ACA) has been hailed by the mainstream media (even including MSNBC) as a landmark event showing the success of health care reform. Granted, the ACA after five years has brought new coverage to 16 million people through the exchanges and expanded Medicaid, and has established some limited insurance reforms, such as banning insurers from denying coverage based on pre-existing conditions. But as the media celebrate and hype this event, we need to ask some hard questions about where we now find ourselves in reforming our dysfunctional system.

First, as to numbers, there were 50 million uninsured Americans in 2010, when the ACA was enacted; that number today is still 35 million. (1) Tens of millions more are underinsured, and we will never achieve universal coverage under the ACA. Even with insurance, one in three Americans cannot afford necessary health care, with many foregoing care and being forced into debt or bankruptcy. The ACA does not address underlying causes of medical debt, including high cost-sharing in many plans, little or no coverage for out-of-network care, and limits on essential health benefits. (2) Despite the original intent of the ACA to provide new insurance protections, insurers can still discriminate against the sick through inadequate provider networks, high deductibles, restrictive drug formularies, deceptive marketing practices, and other means. (3)

Uncontrolled inflation of health care costs continues unimpeded as insurers, hospitals, drug companies, and others in the medical-industrial complex embrace expanded and subsidized new markets with minimal oversight. This problem is growing worse as insurers and hospitals consolidate, gain near-monopoly market shares, and raise their prices to what the traffic will bear. Meanwhile, the bureaucracy and cost of the ACA’s infrastructure continues to grow.

This SCOTUS decision is yet another bailout of a dying private health insurance industry that would be gone without federal subsidies—from us, the taxpayers. In describing the rationale for the Court’s ruling, Chief Justice John Roberts said: “Congress passed the Act to improve health insurance markets, not to destroy them.”  America’s Health Insurance Plans (AHIP), the industry’s trade group, had previously filed an amicus brief with the court in King v. Burwell that described a calamitous outcome for the industry unless subsidies were continued. (4)

This makes me ask: who was the patient that SCOTUS was trying to help—the insurance industry or everyday American real patients? This latest ruling props up a dying industry for another period of time. Despite the ACA’s successes to date, we are still left with uncontrolled inflation of health care costs that are unaffordable for much of the shrinking middle class, continued erosion of employer-sponsored insurance (ESI) as many employers shift employees to the exchanges or defined benefit plans, and increasing cost-shifting to patients.

We need to recognize the failures of the insurance industry even as they receive their second bailout from SCOTUS. These examples illustrate how inadequate the industry is in handling health care financing in this country:

  • Almost one-half of physician networks for plans sold on the exchanges include less than 25 percent of physicians in their region; patients receiving out-of-network care are subject to high costs without coverage. (5)
  • There are inadequate price controls in the ACA, thereby giving insurers, hospitals, pharmaceutical companies, and other corporate stakeholders in the medical-industrial complex expanded subsidized markets with minimal oversight.
  • More than 20 states rejected Medicaid expansion under the ACA leaving about 8 million people uninsured; as a result of their foregoing necessary care, it is estimated that the number of deaths in opt-out states will range between 7,115 and 17,104. (6)
  • There are still about 18 million Americans who are eligible for coverage under the ACA but have not purchased coverage, in many cases because of its high costs. (7)
  • According to the Centers for Medicare and Medicaid Services (CMS), the expanding bureaucracy under the ACA will take up one quarter of federal spending and add almost $274 billion in new administrative costs heading into 2022. (8)

We can expect this next stage of the ongoing debate over health care reform to be heated as both political parties adapt their messages to this latest development in the 2016 election cycle. But we need to keep in mind who the patient is as the debate goes forward—it should be real patients, not the self-interest of giant corporate stakeholders in our medical-industrial complex.

SCOTUS has bailed out the private insurance market once again, as it previously did in 2012. The government continues to subsidize a bloated and failing market. We can expect to see increasing premiums and less value of coverage in the next few years as insurers maximize profits over service. What will we do about the next dire call by the health insurance industry about the “death spiral? We have already tolerated too many years of its false arguments for its central role in health care financing. We can no longer afford its inefficiencies, profiteering, and disingenuous statements of its necessity. It is time to move on to real health care reform, with single-payer, not-for-profit financing of the U. S. health care system.


1. Radofsky, L. Meet the health-law holdouts. Wall Street Journal, June 25, 2015.

2. Pollitz, K, Cox, c, Lucia, K et al. Medical debt among people with health insurance. Kaiser Family Foundation, January 2014.

3. Patient advocacy groups. Letter to Sylvia Burwell, Secretary of Health and Human Services, July 28, 2014.

4. Potter, W. Insurers’ arguments key to Supreme Court decision. Commentary: upholding Obamacare only way to avoid ‘death spiral’. Center for Public Integrity, June 25, 2015.

5. Andrews, M. Study finds almost half of health law plans offer very limited physician networks. Kaiser Health News, June 26, 2015.

6. Dickman, S, Himmelstein, DU, McCormick, D et al. Opting out of Medicaid expansion: The health and financial impacts. Health Affairs Blog, January 30, 2014.

7. Rau, J. Having survived Court ruling, insurance markets still face economic threats. Kaiser Health News, June 25, 2015.

8. Himmelstein, DU. Woolhandler, S. The post-launch problem: the Affordable Care Act’s persistently high administrative costs. Health Affairs Blog, May 27, 2015.

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