Alex Azar opposes setting drug prices by government fiat, while people die

Posted by on Tuesday, Sep 4, 2018

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.

Insulin’s High Cost Leads To Lethal Rationing

By Bram Sable-Smith
NPR, September 1, 2018

Diabetic ketoacidosis is a terrible way to die. It’s what happens when you don’t have enough insulin. Your blood sugar gets so high that your blood becomes highly acidic, your cells dehydrate, and your body stops functioning.

Diabetic ketoacidosis is how Nicole Smith-Holt lost her son. Three days before his payday. Because he couldn’t afford his insulin.

“It shouldn’t have happened,” Smith-Holt says looking at her son’s death certificate on her dining room table in Richfield, Minn. “That cause of death of diabetic ketoacidosis should have never happened.”

The price of insulin in the U.S. has more than doubled since 2012. That has put the life-saving hormone out of reach for some people with diabetes, like Smith-Holt’s son Alec Raeshawn Smith. It has left others scrambling for solutions to afford the one thing they need to live. I’m one of those scrambling.

My first vial of insulin cost $24.56 in 2011, after insurance. Seven years later, I pay more than $80. That’s nothing compared with what Alec was up against when he turned 26 and aged off his mother’s insurance plan.

Smith-Holt says she and Alec started reviewing his options in February 2017, three months before his birthday on May 20. Alec’s pharmacist told him his diabetes supplies would cost $1,300 a month without insurance — most of that for insulin. His options with insurance weren’t much better.

Alec’s yearly salary as a restaurant manager was about $35,000. Too high to qualify for Medicaid and, Smith-Holt says, too high to qualify for subsidies in Minnesota’s health insurance marketplace. The plan they found had a $450 premium each month and an annual deductible of $7,600.

“At first, he didn’t realize what a deductible was,” Smith-Holt says. She says Alec figured he could pick up a part-time job to help cover the $450 per month.

Then Smith-Holt explained it.

“You have to pay the $7,600 out of pocket before your insurance is even going to kick in,” she remembers telling him. Alec decided going uninsured would be more manageable. Although there might have been cheaper alternatives for his insulin supply that Alec could have worked out with his doctor, he never made it that far.

He died less than one month after going off of his mother’s insurance. His family thinks he was rationing his insulin — using less than he needed — to try to make it last until he could afford to buy more. He died alone in his apartment three days before payday. The insulin pen he used to give himself shots was empty.

A miracle discovery

Insulin is an unlikely symbol of America’s problem with rising prescription costs.

Before the early 1920s, Type 1 diabetes was a death sentence for patients. Then, researchers at the University of Toronto — notably Frederick Banting, Charles Best and J.J.R. Macleod — discovered a method of extracting and purifying insulin that could be used to treat the condition. Banting and Macleod were awarded a Nobel Prize for the discovery in 1923.

For patients, it was nothing short of a miracle. The patent for the discovery was sold to the University of Toronto for only $1 so that live-saving insulin would be available to everyone who needed it.

Today, however, the list price for a single vial of insulin is more than $250. Most patients use two to four vials per month (I personally use two). Without insurance or other forms of medical assistance, those prices can get out of hand quickly, as they did for Alec.

Depending on whom you ask, you’ll get a different response for why insulin prices have risen so high. Some blame middlemen — such as pharmacy benefit managers, like Express Scripts and CVS Health — for negotiating lower prices with pharmaceutical companies without passing savings on to customers. Others say patents on incremental changes to insulin have kept cheaper generic versions out of the market.

For Nicole Holt-Smith, as well as a growing number of online activists who tweet under the hashtag #insulin4all, much of the blame should fall on the three main manufacturers of insulin today: Sanofi of France, Novo Nordisk of Denmark and Eli Lilly and Co. in the U.S.

https://www.npr.org…

***

Remarks on Drug Pricing Blueprint

By HHS Secretary Alex M. Azar II
HHS.gov, May 14, 2018

You’ve probably heard before that Medicare could save tons of money by negotiating directly for drugs. This just isn’t true, and you don’t have to take my word for it.

The only way that direct negotiation saves money is by doing something this administration does not believe in: denying access to certain medicines for all Medicare beneficiaries, or setting prices for drugs by government fiat.

We don’t believe either of these proposals would put American patients first. They would move us toward the kind of socialized medicine systems that have such a notorious reputation for poor quality and access.

https://www.hhs.gov…

There could not be a more glaring example of our policy failures in the design of our health care financing system. The tragic, premature death of 26 year old Alec Raeshawn Smith would have never happened with a well designed, single payer, improved Medicare for All. You can read through his story and pick out each of the policy defects that should be completely unacceptable in the most expensive health care financing system in the world.

There are now a plethora of reports about the outrageous pricing of our pharmaceutical products, including many tragic stories about the gouging of diabetic patients for their life-saving insulin. Yet we have as HHS Secretary, Alex Azar, the former president of the U.S. subsidiary of Eli Lilly – a major producer of insulin – under whose reign Lilly’s prices skyrocketed.

So what does Alex Azar have to say about the outrageous pricing of these products? He says, “this administration does not believe in… setting prices for drugs by government fiat.” He says, this “would move us toward the kind of socialized medicine systems that have such a notorious reputation for poor quality and access.”

With that kind of uncaring, cruel attitude, it seems that it is time to nationalize our health care financing system. We already have the tools to do that in a civil manner: replace our current politicians with ones that will enact an improved Medicare for All.

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What Is Happening With Trumpcare?

Posted by on Tuesday, Sep 4, 2018

Before his inauguration in 2017, Trump made this promise: “We’re going to have insurance for everybody. People can expect to have great health care. It will be in a much simplified form. Much less expensive and much better”.  Now, a year and a half later, it is time to test the validity of this promise. Without any question, it is one lie after another.

Republicans and the Trump administration have failed to repeal the Affordable Care Act (ACA) after multiple attempts, but have sabotaged it in a number of ways. What we now have is chaos and confusion throughout the system, increasing numbers of uninsured and underinsured, health care costs going through the roof, worse patient outcomes as more people forgo care they cannot afford, and increasing bureaucracy as private insurers game the system for maximal profits at the expense of patients and their families.

This summarizes some of the many ways that Americans are worse off than ever in this increasingly unsustainable system that is TrumpCare, which places unfair and cruel burdens on a growing part of our population.

Crises throughout the system.
These are some of the impacts of TrumpCare that puts the U. S. health care system in crisis.

1. Inadequate access to care
According to estimates by the Congressional Budget Office, there are 28 million Americans uninsured today, with this number growing to 32 million in 2019 and 41 million in 2025. Tens of millions more are underinsured, especially as the Trump administration has relaxed many of the ACA’s requirements that have previously protected patients, such as banning insurers’ denials based on pre-existing conditions and offering short-term plans just short of one year with such limited coverage as to be considered “junk insurance.” Most of these short-term plans exclude coverage for preventive care, maternity care, mental health and substance abuse treatment, and pharmaceuticals. Some have annual deductibles up to $10,000 and copays up to 50 percent. Access to care has been further reduced by budget cuts to community health centers, Planned Parenthood, the Children’s Health Insurance Program (CHIP), and mental health care.

2. Increasing disparities
Disparities in access to health care can be based on many factors, including age, race/ethnicity, socioeconomic status, gender, disability status, and geographic location. They vary widely from one state to another. As one example, low-income adults in Alabama are almost seven times more likely than high-income people to skip care because of cost.

3. Unaffordable costs of care
There are no significant mechanisms to contain prices or costs of health care under TrumpCare, which was also true of the ACA. Both continue to rise at rates far higher than the cost of living, making health care unaffordable for much of the population. The 2018 Milliman Medical Index finds that the typical working American family of four covered by an average employer-sponsored preferred provider organization (PPO) pays an average of $28,000 a year for health care, insurance premiums, cost-sharing and forgone wage increases (for the employer contribution.) That is almost one half of the median income for families of four in the U. S. of about $59,000, obviously a crushing burden compared to the other necessities of life, such as food and housing. People in their 50s who are admitted to a hospital end up with a 20 percent drop in their income that can last for years, even when they have health insurance.

4. Inadequate quality of care
Despite spending far more on health care than any other country in the world, the U. S. continues to have major deficits in quality of care. According to the ongoing cross-national studies of the Commonwealth Fund of 11 advanced countries, the U. S. still ranks last or next to last on access, equity, health care outcomes, and administrative efficiency. ( There are many reasons for our poor quality of care, including large numbers of uninsured and underinsured, profiteering by hospitals, drug companies and other providers, the number of people who forgo necessary care because of costs, and big differences from one state to another in access to care. Privatized Medicare and Medicaid programs typically have lower quality of care as they emphasize profits over service.

5. Instability and volatility
Increasing consolidation through mergers of corporate stakeholders have rendered our system more and more volatile. As insurers buy up networks of clinics and hospitals, patients, even when insured often lose their choice of physician and hospital as continuity of care goes by the wayside. As one example, UnitedHealth, one of the nation’s largest health insurers, employs more than 30,000 physicians while owning 230 urgent care clinics and 200 surgery centers.  As insurers gain a freer hand under the Trump administration, they are at more liberty to deny coverage and services, even to the point of questioning the need for emergency room visits.

6. Deteriorating safety net
In the aftermath of the GOP’s tax cut bill in December 2017, the deficit has spiked, prompting Republicans and the Trump administration to make wholesale cuts in safety net programs. These groups are especially vulnerable and hard hit:

  • Retirees, who have depended on long-term care insurance coverage for nursing home care now find most of these insurers leaving the market.
  • Women, 40 million of whom are on Medicaid and typically are the primary caregivers of their children, are especially vulnerable to cuts in safety net programs. Despite this pressing need, the Trump administration has been reducing family planning funding, promoting short-term “insurance” programs without maternity coverage, cutting food stamps, imposing new work requirements for Medicaid, and proposing policies that would raise rents for low-income families.
  • Residents of rural areas are hurt because rural hospitals and physicians, especially dependent on Medicaid funding and essential for access to lifesaving services, maternity care, and care for chronic conditions, have suffered under TrumpCare as the number of closures of rural hospitals continue to rise.

A recent study by researchers at the University of California Berkeley and Stanford University has concluded that opposition to welfare has risen sharply among whites as racial anxiety appears to be driving conservatives’ calls for deeper cuts in safety net programs.

Conclusion
As Americans increasingly suffer under an out of control, profit-driven system and as corporate stakeholders, their CEOs, shareholders and Wall Street revel in their gains, when will we shift our priorities to the needs of patients and their families?

Adapted in part from my soon to be released book, Trumpcare: Lies, Broken Promises, How it is Failing, And What Should Be Done

visit: http://www.johngeymanmd.org

Abraham Lincoln on labor

Posted by on Monday, Sep 3, 2018

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.

By President Abraham Lincoln
First Annual Message, December 3, 1861

It continues to develop that the insurrection is largely, if not exclusively, a war upon the first principle of popular government–the rights of the people. Conclusive evidence of this is found in the most grave and maturely considered public documents, as well as in the general tone of the insurgents. In those documents we find the abridgment of the existing right of suffrage and the denial to the people of all right to participate in the selection of public officers except the legislative boldly advocated, with labored arguments to prove that large control of the people in government is the source of all political evil. Monarchy itself is sometimes hinted at as a possible refuge from the power of the people.

In my present position I could scarcely be justified were I to omit raising a warning voice against this approach of returning despotism.

It is not needed nor fitting here that a general argument should be made in favor of popular institutions, but there is one point, with its connections, not so hackneyed as most others, to which I ask a brief attention. It is the effort to place capital on an equal footing with, if not above, labor in the structure of government. It is assumed that labor is available only in connection with capital; that nobody labors unless somebody else, owning capital, somehow by the use of it induces him to labor. This assumed, it is next considered whether it is best that capital shall hire laborers, and thus induce them to work by their own consent, or buy them and drive them to it without their consent. Having proceeded so far, it is naturally concluded that all laborers are either hired laborers or what we call slaves. And further, it is assumed that whoever is once a hired laborer is fixed in that condition for life.

Now there is no such relation between capital and labor as assumed, nor is there any such thing as a free man being fixed for life in the condition of a hired laborer. Both these assumptions are false, and all inferences from them are groundless.

Labor is prior to and independent of capital. Capital is only the fruit of labor, and could never have existed if labor had not first existed. Labor is the superior of capital, and deserves much the higher consideration. Capital has its rights, which are as worthy of protection as any other rights. Nor is it denied that there is, and probably always will be, a relation between labor and capital producing mutual benefits. The error is in assuming that the whole labor of community exists within that relation. A few men own capital, and that few avoid labor themselves, and with their capital hire or buy another few to labor for them. A large majority belong to neither class–neither work for others nor have others working for them. In most of the Southern States a majority of the whole people of all colors are neither slaves nor masters, while in the Northern a large majority are neither hirers nor hired. Men, with their families–wives, sons, and daughters–work for themselves on their farms, in their houses, and in their shops, taking the whole product to themselves, and asking no favors of capital on the one hand nor of hired laborers or slaves on the other. It is not forgotten that a considerable number of persons mingle their own labor with capital; that is, they labor with their own hands and also buy or hire others to labor for them; but this is only a mixed and not a distinct class. No principle stated is disturbed by the existence of this mixed class.

Again, as has already been said, there is not of necessity any such thing as the free hired laborer being fixed to that condition for life. Many independent men everywhere in these States a few years back in their lives were hired laborers. The prudent, penniless beginner in the world labors for wages awhile, saves a surplus with which to buy tools or land for himself, then labors on his own account another while, and at length hires another new beginner to help him. This is the just and generous and prosperous system which opens the way to all, gives hope to all, and consequent energy and progress and improvement of condition to all. No men living are more worthy to be trusted than those who toil up from poverty; none less inclined to take or touch aught which they have not honestly earned. Let them beware of surrendering a political power which they already possess, and which if surrendered will surely be used to close the door of advancement against such as they and to fix new disabilities and burdens upon them till all of liberty shall be lost.

http://www.presidency.ucsb.edu…

There is a reason why we celebrate Labor Day rather than Capitalism Day. Although there was no Labor Day in 1861, President Lincoln’s astute and prescient words remind us why it is natural for our nation to celebrate labor.

And, yes, this message is very directly related to the issue of health care justice for all, even if unspoken.

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KFF: Public opinion on single payer, national health plan, and expanding Medicare

Posted by on Friday, Aug 31, 2018

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.

Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage

Kaiser Family Foundation

For many years, Kaiser Family Foundation has been tracking public opinion on the idea of national health plan. Since the 2016 presidential primary and Bernie Sanders’ rallying cry for “Medicare-for-all,” our polls have shown a modest increase in support for the idea of a national health plan (Figure 1), and broad support for proposals that expand Medicare (Figure 2). Overall, about six in ten adults favor a national health plan or Medicare-for-all plan (Figure 3). There is robust support among Democrats, and even somewhat among Republicans, for expansions of the Medicare program through a Medicare buy-in (Figure 6) or an “optional” Medicare-for-all proposal (Figure 7). Yet, it is unclear how much staying power this support has once people become aware of the details of any plan. Public support quickly erodes when people hear further explanation about potential tax increases or increased government control (Figure 8) and recent polling also shows many people falsely assume they would be able to keep their current health insurance under a single-payer plan (Figure 10), suggesting another potential area for decreased support.

While health care appears to be playing a role in the 2018 midterm campaigns (Figure 11) and single-payer has been a hot-button issue in some Democratic primaries, it is unclear that it will play a major role in the general election, with few voters saying a candidate’s position on a national health plan is an important factor in their vote (Figure 12). So while the general idea of a national health plan (whether accomplished through an expansion of Medicare or some other way) may enjoy fairly broad support in the abstract and it can be used as a rallying cry to motivate the liberal base of the Democratic party, it is unlikely to be a determining issue for most 2018 midterm voters.

12 Power Point slides which can be downloaded:
https://www.kff.org…

Kaiser Family Foundation has summarized in twelve Power Point slides the public opinion on single payer, national health plans, and expanding access to Medicare coverage. Over the last two decades support for “a national health plan in which all Americans would get their insurance from a single government plan” has gradually grown from 40 percent to 53 percent.

Support increases when those initially opposed are told that such a plan would “reduce health insurance administrative costs,” “ensure that all Americans have health insurance as a basic right,” or “reduce the role of all private health insurance companies in health care.”

Support diminishes when those initially in support are told that such a plan would “give the government too much control over health care,” “require many Americans to pay more in taxes,” or “eliminate or replace the Affordable Care Act.”

However the polling suggests that there is considerable support for more incremental approaches. When asked, “Do you favor or oppose letting some people under the age of 65 buy insurance through the Medicare program?”, 63 percent are in favor and 33 percent are opposed. When asked if they would favor “A national Medicare-for-all plan open to anyone who wants it but people whom currently have other coverage could keep what they have,” support is 75 percent as opposed to 59 percent who favor “A national health plan, or Medicare-for-all, in which all Americans would get their insurance from a single government plan.”

Thus it seems that support for a multi-payer system that expands the role of Medicare is greater than support for a single payer version of Medicare for all. This, of course, plays into the hands of those who support expanding the use of private Medicare Advantage plans – a concept that currently is being sold under the false label of “Medicare for All.”

A Medicare Advantage option for all has almost nothing in common with a bona fide single payer improved Medicare for all. The former perpetuates all of the injustices, waste, and excess costs of our current fragmented, dysfunctional method of financing health care, whereas the latter finally brings to us an efficient, effective, equitable method of removing financial barriers to care for absolutely everyone with a system that each of us could afford.

It is going to be very difficult to get this crucial message across when “let those who want to buy into Medicare do it” becomes the reflex response. The polling suggests that it may already be a meme.

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A.M. Best: ‘U.S. Government-Related Health Insurance Business Continues to Grow’

Posted by on Thursday, Aug 30, 2018

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.

Best’s Market Segment Report: U.S. Government-Related Health Insurance Business Continues to Grow Despite Risks

A.M. Best, August 13, 2018

The U.S. health insurance industry’s premium composition is increasingly shifting toward government-sponsored business, which exposes carriers to additional risks as the business is generally low-margin and results in a greater reliance on state and federal funding, according to a new A.M. Best report.

The Best’s Market Segment Report, “Government-Related Health Insurance Business Continues to Grow Despite Risks,” states that the health industry is generating an increasingly large share of premium from Medicare Advantage, Medicaid and individual commercial businesses. Medicaid reported the largest increase in net premiums written growth, to $224.0 billion in 2017 from $43.1 billion in 2007, owing to Medicaid expansion under the Affordable Care Act (ACA), and to more states turning to managed care to run traditional, pre-expansion Medicaid programs. Medicaid’s share of total industry NPW (Net Premiums Written) in that timeframe rose to 27.1% from 10.2%, although much of that growth occurred in 2014-2015. Medicare Advantage also has been a major source of premium growth for health insurers, with NPW increasing to $202.7 billion in 2017, representing 24.5% of overall industry premium, from $69.9 billion in 2007. Like Medicaid, growth in this business has flattened over the past few years.

According to the report, changes in the nature and financing of the individual market under the ACA have effectively turned this portion of the commercial market into government-sponsored business. At the same time, group commercial premium since 2014 has experienced lower growth because of relatively stable medical cost trends, the absence of material membership expansion and the transition to self-funded arrangements. As a result, many commercial carriers have a greater exposure to government-financed business without having increased their participation in Medicaid or Medicare Advantage lines. Increased exposure to the individual exchange business and its financial losses led to a decline in underwriting margins in the commercial segment from 2014 to 2016, but the market recovered in 2017, leading to historically high results for the overall commercial segment.

With health care remaining a controversial political issue, the regulatory regime is likely to remain volatile over the near to medium term, especially as it relates to the individual exchange segment.

As industry consolidation continues and as companies build massive operational infrastructures to service these programs, a quick exit, if need be, may be more difficult. However, the larger carriers, as well as some of the midsize ones, have been successful in adjusting to regulatory changes and revising business models to accommodate different population needs under the government programs.

https://news.ambest.com…

This sterile report from A.M. Best suggests that there are uncertainties for the health insurance industry in its participation in government programs, but the important message is that their government-related health insurance business is growing as they prove capable of accommodating to regulatory volatility.

The clear trend is further privatization of the government health insurance programs. With the strong public support for Medicare for All, the insurance industry realizes that there is a great opportunity to expand their markets though the public option of a private Medicare Advantage for All. If you listen carefully to the political candidates supporting Medicare for All, many of them slip in “through a public option,” simply meaning a private insurance option with a Medicare label. That’s what Medicare Advantage is.

Listen up. As we attempt to insert ourselves into the process again (we failed during the Clinton and the Obama administrations), we are going to be met with, “We got it; now get out of our way.” The incremental step of Medicare Advantage for All will ensure a solid rock foundation shoring up the medical-industrial complex, likely for decades to come.

We’re very good at inertia, and it is going to kill any semblance of a single payer, publicly-administered Medicare for all, as we perceive it. Are you just going to sit there? Are all of us just going to sit here?

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NHIS insurance statistics; don’t pop the champagne corks

Posted by on Wednesday, Aug 29, 2018

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 Coverage: Early Release of Estimates From the National Health Interview Survey, January–March 2018

By Robin A. Cohen, Ph.D., Michael E. Martinez, M.P.H., M.H.S.A., and Emily P. Zammitti, M.P.H.
U.S. Department of Health and Human Services, National Center for Health Statistics, August 2018

Highlights

* In the first 3 months of 2018, 28.3 million (8.8%) persons of all ages were uninsured at the time of interview—not significantly different from 2017, but 20.3 million fewer persons than in 2010.

* In the first 3 months of 2018, among adults aged 18–64, 12.5% were uninsured at the time of interview, 19.2% had public coverage, and 70.0% had private health insurance coverage.

* In the first 3 months of 2018, among children aged 0–17 years, 4.6% were uninsured, 41.9% had public coverage, and 54.6% had private health insurance coverage.

* Among adults aged 18–64, 70.0% (138.6 million) were covered by private health insurance plans at the time of interview in the first 3 months of 2018. This includes 4.2% (8.3 million) covered by private health insurance plans obtained through the Health Insurance Marketplace or state-based exchanges.

* The percent age of persons underage 65 with private health insurance enrolled in a high-deductible health plan increased, from 43.7% in 2017 to 47.0% in the first 3 months of 2018.

https://www.cdc.gov…

This annual NHIS study of the uninsured done by the National Center for Health Statistics gives us the most accurate status of health insurance coverage in the United States. A few observations can show us how our system is functioning, now that the implementation of the Affordable Care Act (ACA) has relatively stabilized:

* 28.3 million individuals (8.8%) remain uninsured, the same as last year, so net enrollment seems to have stabilized for the present, with still far too many remaining uninsured.

* Of adults aged 18-64, 138.6 million were covered by private insurance, though only 8.3 million of them were covered through the ACA exchanges, which makes you think that there must be a better option considering the administrative complexity of the program.

* For children aged 0-17, the increase in public coverage (Medicaid and CHIP) reduced their uninsured rate to 4.6%, but most of that increase was prior to the implementation of ACA. Although many consider an uninsured rate of 4.6% for children to be a policy success, we really should ask why we tolerate leaving 3.4 million children uninsured when a well designed single payer system would cover all of them, and everyone else.

* One statistic that is not stable is that the percentage of individuals under age 65 with private health insurance who are enrolled in high-deductible health plans increased from 43.7% to 47.0% in the last year alone, and is up from 25.3% in 2010. This may be the most shocking result reported this year since it demonstrates that the rate of underinsurance, with its consequential epidemic of financial hardship, is skyrocketing.

Although many in the policy community will celebrate these results as a success of the Affordable Care Act, these are actually terrible results. We could have had everyone covered in a program that we could all afford, but instead our policymakers rejected single payer Medicare for all and have left us with tens of millions uninsured, almost half of the privately insured with worsening underinsurance, and persistent unjust inequities in health care coverage. Are we nuts?

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Powerful coalitions forming against single payer Medicare for All

Posted by on Tuesday, Aug 28, 2018

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.

Doctor, hospital groups organize to oppose single-payer in California

By Angela Hart
The Sacramento Bee, August 28, 2018

A group of influential, deep-pocketed business and health care organizations that have long helped shape the legislative agenda in California have joined forces to oppose any future effort to craft a universal, single-payer health care system for the nation’s largest state.

The main focus of the coalition, called “Californians against the costly disruption of our health care,” is to kill any single-payer health care bill in the state Legislature, said Ned Wigglesworth, a political strategist for the coalition.

“As long as proponents plan to bring this back time and again, we think it’s important to have a strong, unified presence to oppose it,” Wigglesworth said, referring to Senate Bill 562, the 2017 single-payer bill pushed by the California Nurses Association that was shelved last year by Assembly Speaker Anthony Rendon.

The anti-single payer coalition includes powerful groups representing the interests in Sacramento of doctors, hospitals, insurers and businesses. Instead of single-payer, the coalition is expected to press for alternatives, which could include several legislative proposals on health care that failed this year and some under discussion, including expanding state insurance subsidies, allowing undocumented adults to sign up for Medi-Cal and creating a state-based individual mandate for everyone to have coverage.

“I think you’re going to hear our messaging loud and clear,” said Charles Bacchi, president and CEO of the California Association of Health Plans. “It’s going to be really focused around how expensive (single-payer) would be for California to do, and how disruptive it would be for people who currently receive health care coverage.

https://www.sacbee.com…

Partnership for America’s Health Care Future:
https://americashealthcarefuture.org

The coalition, “Californians against the costly disruption of our health care,” is basically a group of vested interests and their agents, with power and money, that intends to wipe out the single payer movement in California. A national coalition, “Partnership for America’s Health Care Future,” has even more power and more money and intends to snuff out the single payer Medicare for All movement throughout the United States.

The good news is that this shows that the Medicare for All movement is viewed as a very real threat to the sponsoring organizations, which shows how effective the single payer advocates have been to date. The bad news is that power and money can extinguish our flame.

What can we do? We may not have the money but we can harness the power of the people by continuing to do what we have been doing to bring the single payer Medicare for All movement to the forefront, but we need to do a lot more of it. Education, coalitions, grassroots efforts, community organizing, creating a presence everywhere using the spoken and written word, networking with our families, friends, associates, religious and civic institutions, and more. We need to be there and do it, and bring others with us.

These coalitions that intend to defeat single payer will try to present a positive front by offering expanded programs under our existing dysfunctional and fragmented system, but that will only perpetuate the waste and inequities, thus perpetuating the health care injustices that permeate our system, not to mention that such an approach is uniquely by far the most expensive model of health care reform the world has ever known. This can only perpetuate and compound the problem of lack of affordability of health care that is tormenting us in the United States.

Our message resonates much better: include everyone for life, providing free choice of physicians, hospitals and other health services and products, simplify the financing system to reduce the profound administrative waste unique to the United States, establish fair prices that are adequate to support the system while preventing gouging, and fund the entire system equitably such that each person pays his or her fair share based on ability. Thus our simple message is that all of us receive the health care we need, and none of us suffers financial hardship as a result.

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Winners and Losers under TrumpCare

Posted by on Monday, Aug 27, 2018

Before his inauguration, incoming President Trump made this promise about health care in the country: “We’re going to have insurance for everybody. People can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”  Today, eighteen months later, U. S. health care is worse off than ever after the Trump administration’s ongoing sabotage of the Affordable Care Act (ACA) which itself fell so short of universal coverage, cost containment, and improved quality of care.

Although Trump and congressional Republicans failed to repeal and replace the ACA, they own what has become TrumpCare. Their sabotage of the ACA includes repeal of the individual mandate, loosening of the ACA’s restrictions on health insurers, and state waivers that will allow states increased responsibility (with less federal money) to design their own Medicaid and other programs. Annual and lifetime caps on Medicaid coverage, together with increased cost sharing for its beneficiaries, are becoming common as 30 million Americans are uninsured and tens of millions more underinsured.

To be sure, there are both winners and losers with TrumpCare, both of which are built into this new, increasingly unaffordable system, with losers representing much of the population—the most important—patients, their families, and taxpayers. A look at both ends of this spectrum reveals how unfair, unsustainable and cruel TrumpCare is, as well as how health care will be a leading political issue as the midterm elections approach.

TrumpCare winners include large corporate mergers with growing market power to set their own prices, the drug industry which has again avoided any price controls, corporate CEOs and their shareholders, middlemen in our market based system such as pharmacy benefit managers, Wall Street and lobbyists. Private health insurers have been the big winners as they gain more ability to market short term, limited benefit plans that are really junk insurance, to avoid the ACA’s coverage requirements, and to deny coverage to sicker patients. Profit margins for the six top insurers for the first quarter of 2018 were the highest in ten years while their CEOs took in more than $17 million in 2017.

Patients are the biggest losers under TrumpCare, whether by losing the ACA’s protections, losing access to care because of unaffordable costs, increasingly restrictive coverage if insured, losing Medicaid through cutbacks, being underinsured, or losing coverage altogether. Women are disadvantaged by GOP and Trump attacks on reproductive health care and loss of maternity coverage in short term plans. Mental health care is poorly covered as many mentally ill continue to be jailed without treatment. Seniors lose by having to pay higher premiums as they increasingly face bankruptcy because of medical costs despite being on Medicare.

Residents of rural areas are at increasing risk as more and more rural hospitals are forced to close because of inadequate reimbursement and difficulty in recruiting physicians and other health professionals. Physicians lose by being buried in time-consuming billing and clerical tasks that reduce their time for direct patient care. The National Academy of Medicine reported last year that more than one-half of U. S. physicians are showing signs of burnout, including a “high degree of emotional exhaustion and a low sense of personal accomplishment.”

Is there a fix to this mess? Emphatically yes—through single-payer Medicare for All, as represented by H. R. 676 in the House and a similar bill in the Senate (S 1804), and that will be the subject of another Op-Ed.

Anthem refuses to cooperate with a federal false claims investigation

Posted by on Monday, Aug 27, 2018

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.

Feds want to force Anthem to comply with Medicare billing investigation

By Shelby Livingston
Modern Healthcare, August 21, 2018

Health insurer Anthem has refused to comply with the U.S. Justice Department’s investigation into its Medicare Advantage billing practices, according to federal court documents filed Tuesday.

So the Justice Department this week asked the U.S. District Court for the Southern District of New York to force Anthem to comply with a civil investigative demand issued in March to provide testimony about its chart review and risk-adjustment program for its Medicare Advantage plans.

The Justice Department initially demanded the testimony by April 13 but said Anthem has yet to provide a witness to testify. The court on Monday ordered Anthem to explain why it should not be forced to provide testimony. Anthem has until Sept. 4 to respond.

The Justice Department asked for Anthem’s testimony as part of an investigation into whether Anthem unlawfully obtained hundreds of millions of dollars in Medicare Advantage risk-adjustment payments in violation of the False Claims Act by submitting inaccurate patient diagnosis codes to the CMS.

The feds also want to know if Anthem deliberately disregarded its duty to ensure the diagnosis codes submitted were valid, and asked for testimony about the processes and people Anthem relied on to verify diagnosis codes obtained by providers and through a retrospective chart review.

An Anthem spokeswoman declined to comment.

http://www.modernhealthcare.com…

Anthem has an opportunity to demonstrate to the Justice Department that they have not been cheating the taxpayers out of hundreds of millions of dollars by upcoding diagnoses of their Medicare Advantage patients, thus qualifying for higher risk adjusted payments based on the fact that their codes indicate that the patients have more costly disorders than they actually have.

If Anthem is innocent, then why does it take the order of a federal court to produce the evidence that would clear them, after failing to comply with an earlier demand? Maybe they are just trying to work the float on the heavy penalties that they know they will eventually have to pay (investing money for their own profit – money that belongs to the taxpayers). Hey, the insurers keep showing us that do know how make a buck off of us, even in a bad situation. And we want to keep them in charge?

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The bull market is foretelling Medicare Advantage for All

Posted by on Friday, Aug 24, 2018

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.

An unlikely winner in the long-running bull market: Health insurers

By Bertha Coombs
CNBC, August 19, 2018

The bull market, which is about to become the longest running in recent history, has produced healthy returns for investors. The S&P 500 is up well over 300 percent over the last nine years, but health insurance stocks have logged even more impressive gains.

The S&P Managed Care sector, made up of the largest insurers, has gained more than 1,100 percent during the market’s bull run. That’s more than twice as much as the gains in the biotech sector.

Nine years later, two of the biggest health-care winners have seen large growth in part because of Obamacare.

The Medicaid boom

Medicaid expansion under the ACA has resulted in nearly 15 million people gaining coverage under the government health program for the poor and disabled. At the same time, over the last decade, states have increasingly turned to insurers to manage their Medicaid programs.

Medicaid insurer WellCare Health Plan’s shares have gained more than 4,000 percent since March 2009, and its annual revenues have nearly tripled from $6.9 billion to an estimated $18.7 billion this year.

Rival Centene’s shares have gained nearly 1,800 percent over the last nine years. Annual revenues have ballooned from $3.4 billion to an estimated $59.8 billion this year. Centene is up 42 percent year to date, trading near record highs.

At the same time that the Medicaid business has expanded, Medicare has seen big growth over the last decade as more baby boomers have aged into the government health plan for seniors.

For the major health insurers that has meant that their government business has grown faster than the commercial employer and individual insurance plan business. Government plans now account for more than 50 percent of the industry’s insurance revenues.

More diverse businesses

Government plans have been one of the growth drivers for the nation’s largest insurer, UnitedHealth Group, which is up 19 percent year to date, and has seen shares gain nearly 1400 percent over the last nine years.

United’s health plan membership has grown from 32 million to nearly 50 million over the last nine years; its Medicaid and Medicare membership has more than doubled, during the period.

But new business segments outside of health insurance have played a big role in growing the health-care giant’s annual revenues from $87 billion in 2009 to an estimated $225 billion this year. The health services and products under the Optum division have become a key driver of top-line growth.

United’s Optum unit now accounts for 20 percent of revenues, and includes data analytic services, pharmacy benefit management, physician practices and outpatient surgical centers.

Revenues from the services businesses are not subject to the ACA regulatory caps, which require insurers to spend at least 80 percent of premium revenues on medical care. That makes them more profitable.

United’s success has been part of the impetus behind the increasing number of vertical health insurer deals. More health plans have acquired health-care providers and services in order to have greater control over medical costs in their health plans.

Pharmacy benefit giant CVS Health’s $69 billion deal for Aetna and Cigna’s $54 billion deal to buy pharmacy benefit firm Express Scripts are both predicated on trying to driving cost efficiencies by having greater control over a wider range of members’ care.

Meantime, Democrats have revived the health reform debate over single-payer Medicare For All, nine years after investors were rattled by the prospect of single-payer health care under the ACA.

If either side gains traction, analysts say the major insurers have positioned themselves to adjust more readily to the shifting landscape over the last decade.

“Even if it’s Medicare for all, it would probably be Medicare Advantage for All,” with the government funding private Medicare plans, said Deep Banerjee, health-care credit analyst at Standard & Poor’s.

“Health care today is a public-private partnership … it’s very hard to see a system without a private player meaningfully involved,” he said.

https://www.cnbc.com…

Since enactment and implementation of the Affordable Care Act (ACA) we have heard stories about how tough it has been for the insurance industry. Congress and both the Obama and Trump administrations have responded with measures to ensure the viability of this industry (in spite of blowhard repeal activity of the Republicans that had essentially no detrimental impact on the insurers – they just raised their premiums). You really need to read this very brief summary of the past nine years to understand what a godsend this has been for the health insurance industry.

Much of the clamor has been over the ACA exchange plans. Yet in the overall picture that has been a very small part of what has really happened in the past decade. In fact, it has been such a small part that some of the largest insurers have pared back their involvement in the exchanges since they have been an insignificant contributor to their business successes.

So what has been the source of their success? The two government programs, Medicare and Medicaid, and the expansion and diversification of their industry.

The largest expansion as a result of ACA has been in the Medicaid program, and that has coincided with a massive shift into the private Medicaid managed care programs. The behavior of the Medicaid managed care stocks has demonstrated what a phenomenal business success this has been (even if it appears that this success has been made possible by the implementation of their business model that simply prevents their Medicaid patients from receiving much of the care that they should have). Since the private Medicaid managers have been successful in barely providing health care to huge numbers of Medicaid beneficiaries at a very low cost to the government, it its likely that this program is locked in place for the indeterminate future. The political process will be very resistant to any proposals that would increase spending on poor people – the low-income population that qualifies for Medicaid.

The success of the private Medicare Advantage plans has not been due to ACA but rather due to other programs that were set up in an effort to privatize Medicare. Again, Congress and the Bush, Obama and Trump administrations have all nurtured this program by providing them with very generous funding (much due to administrative chicanery) while at the same time giving the insurers regulatory backup to pay for health care at rates considerably below the rates paid by standard commercial plans. With high volume, generous funding, and low costs, it is no wonder that these insurance companies have become darlings of Wall Street.

What should be very alarming to us is the success that these insurance companies have had in diversifying their businesses. They are no longer just the insurers and administrators, they have now become an integral part of the health care delivery system with their acquisition of physician practices, outpatient surgery centers, pharmacy benefit managers, data analytic services, and other vertical acquisitions. Profits from these expansions are not limited by the ACA regulatory caps, and if there is anything that the private insurers understand, that is how to make a buck.

So where is the money coming from that has created this phenomenal success for the private insurers? Well, a large amount is from the taxpayers through the Medicaid managed care and private Medicare Advantage plans – part of the silent costs of health care that the taxpayers do not realize they are already paying. Some is coming from a diversion of funds from the health care providers into the coffers of the insurers. Some is coming from the Wall Street customers who are paying excessive amounts for stock purchases plus the cost of churning in this protracted bull market. And some is from the excessive administrative services that the insurers keep selling us. You can probably think of more sources of their enrichment.

We’ve been saying for three decades that it is urgent that we change to a publicly funded and publicly administered, single payer, improved Medicare for All. Not only have we wasted funds on the excesses of our current dysfunctional system, but also far too many have gone without essential health services, and tens of millions have faced unnecessary financial hardship.

But what has snuck up on us is that the insurance industry has taken over. They have planted themselves in a position to capitalize on the Medicare for All movement. Medicare for All has now become the rallying cry for the Medicare public option. Just as the private Medicare Advantage plans are engulfing the traditional Medicare program, the insurance industry is positioned to be sure that the Medicare public option will be a Medicare Advantage public option, and they will do it with the support of our politicians, including many who profess to be progressive or liberal or whatever label assuages their guilt.

The latest Reuters/Ipsos poll shows that 70 percent of Americans support Medicare for All, including half of Republicans. But, with the complicity of the neoliberals, the industry has latched onto the Medicare for All rhetoric and will use it to expand their business successes.

What can we do? Well if the public is really serious about wanting affordable health care for all, it will require massive community action – education, grassroots, coalitions, voter engagement – now! Otherwise, sit back and watch them implement Medicare Advantage for All. It’s almost here.

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