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Is There a Fox Guarding California’s Hen House?

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Is There a Fox Guarding California’s Hen House?

By Paul Y. Song, M.D., and Wendell Potter
The Huffington Post, Sept. 23, 2015

When the Affordable Care Act (ACA) became law in 2010, the individual health insurance market was highly concentrated, with little to no competition in most states. One or two insurers controlled the top 94 metropolitan markets in the United States. In 30 states and the District of Columbia, one major insurer had over 50% of the individual market and over 90% in Alabama alone.

The ACA implemented state-specific Health Insurance Exchanges, also called Marketplaces. These Marketplaces were intended to promote price comparison and competition in the individual and small group insurance markets through greater transparency. In the same time, consumers could obtain minimum essential coverage, receive federal subsidies, and be granted exemptions. With medical underwriting prohibited, premiums were easy to compare, focusing solely on competition of price. But in order for consumers to realize a maximum benefit from this Marketplace, there had to be ample choice and competition.

That is why it is so disturbing to see Peter Lee, the head of Covered California (California’s marketplace), publicly go out of his way to justify and advocate for the rapid wave of consolidation and mergers amongst the private insurance industry.

In a recent Wall Street Journal op-ed, Mr. Lee readily parrots the deep concern of the private insurance industry regarding the consolidation amongst hospitals and providers, but fails to mention his poor record on forcing participating insurers in California’s exchange to open up their narrow networks or the lack of effect such consolidations would have. It should be pointed out that Covered California has the 4th narrowest network in the U.S. and that 75% of all the policies negotiated by Mr. Lee already have 25% or fewer physicians in an area compared to 41% nationally.

While a dominant insurer may indeed be able to negotiate lower rates from hospitals, physicians, and big Pharma, there is absolutely no indication that these savings would be passed on to consumers. Mr. Lee claims savings would indeed be passed on because of the ACA provision that mandates insurers spend 80-85% of every premium dollar on consumer medical claims and activities that improve quality of care.

What Mr. Lee fails to mention, is that while the ACA does mandate a minimum level of spending on care, it fails to regulate the premiums that insurers can charge and poorly defines the activities that improve quality of care are. Does spending money on promotional ads really improve quality of care?

This is especially ominous in California where the private insurance industry and its allies spent over $55 Million to defeat a statewide initiative, Prop 45, which would have given the politically elected and publicly accountable California Insurance Commissioner the right to regulate such rates. Thus, while insurers are required to spend more of every healthcare dollar on actual patient care, they can make up for this lost revenue by charging higher unregulated premiums.

Due to the successful and expensive lies that were spread to defeat Prop 45, California consumers of which nearly half already find it difficult to pay their premiums, remain powerless, particularly when the politically appointed and unaccountable head of Covered CA appears to be an agent of the private insurance industry.

While Mr. Lee can claim smaller premium increases up to now in California compared to many other states, his recipe for insurance consolidation and a lack of insurance rate regulation will make sure that this will not endure. In the nine years prior to the ACA, California premiums increased 185% while insurers cherry picked the healthiest applicants and rejected many with pre-existing conditions or made coverage too cost-prohibitive, all the while issuing over 45.7 million denials. Now that they can no longer use pre-existing conditions to screen out and deny people coverage, it is only a matter of time before insurers find other ways to maximize profits.

A recent study from Harvard University’s Institute for Quantitative Social Science revealed that the largest insurer in each marketplace had a 75% higher premium increase from 2014 to 2015 compared to other same-state issuers. On average, the largest issuers raised rates by 23.9%, while the other issuers only raised rates by 13.7%. So, do we really want to increase the likelihood of this happening in California with less competition and choice through more consolidation?

It has been said that no one can serve two masters. It is clear by Mr. Lee’s op-ed who he serves.

Mr. Lee’s justification for consolidation in reality makes the de facto case for a single payer healthcare system. The real question is whether this single payer should be controlled by an entity that only makes money by denying patients care, or a government run Medicare for all system that has proven to be more cost effective, provide better coverage, and have greater patient satisfaction.

Finally, a word of caution to all who were fooled into voting against Prop 45. When you let the fox guard the hen house, there’s bound to be a lot of chicken dinners.

Dr. Song is a board certified radiation oncologist and the Executive Chairman of the Courage Campaign and Co-Chair for a Campaign for a Healthy California. Mr. Potter is a former Health Insurance Executive turned whistleblower, author, and an analyst at the Center for Public Integrity.

http://www.huffingtonpost.com/paul-y-song-md/is-there-a-fox-guarding-c_b_8171502.html

Lack of affordability is primary reason for not enrolling in exchange plans

To Enroll or Not to Enroll? Why Many Americans Have Gained Insurance Under the Affordable Care Act While Others Have Not

By Sara R. Collins, Munira Gunja, Michelle M. Doty, Sophie Beutel

The Commonwealth Fund, September 25, 2015

Exhibit 2.  Just under half of the adults who have visited the marketplace enrolled in a marketplace plan or Medicaid

52% – Did not select a private plan or enroll in Medicaid
30% – Selected a private health plan
15% – Enrolled in Medicaid
2% – Don’t know/refused

Exhibit 6.  Among market-place visitors who didn’t enroll, more than half said they couldn’t find an affordable plan

Can you tell me why you did not obtain a private health insurance plan or Medicaid coverage when you visited the marketplace? Was it because…?

Percent of adults ages 19-64 who visited the marketplace but did not select coverage

57% – Could not find a plan you could afford
51% – Obtained health insurance through another source
43% – Not eligible to enroll in Medicaid or for financial assistance
38% – Found the process of enrolling in a plan difficult or confusing
32% – Could not find a plan with the type of coverage you need
15% – Decided you did not need health insurance
14% – Did not know where to get help to sign up
23% – Some other reason

Affordability was a key reason people did not enroll in plans. More than half (57%) of adults who visited the marketplaces but did not enroll said they could not find a plan they could afford. Excluding the adults who also said they gained coverage elsewhere, the majority of those who did not enroll because they couldn’t find affordable plans had lower incomes. More than half (54%) had incomes in the range that made them eligible for subsidies (i.e., from 100 percent to 400 percent of the federal poverty level, or $11,670 to $46,680 in annual income for an individual). Thirty percent had incomes under 100 percent of poverty. An estimated 26 percent (and thus nearly all of those with incomes under 100 percent of poverty) were likely in the so-called Medicaid coverage gap. That is, they were living in states that had not expanded eligibility for Medicaid at the time of the survey and had incomes under 100 percent of poverty and thereby not eligible for marketplace subsidies. About 11 percent had incomes that exceeded the threshold that made them eligible for subsidies (i.e., 400 percent of poverty).

Many adults (43%) said they did not enroll because they were not eligible for subsidized coverage or Medicaid. Again, excluding those who gained coverage elsewhere, most people who gave this reason had lower incomes: 50 percent had incomes that made them eligible for subsidies, and 33 percent had incomes under 100 percent of poverty. An estimated 27 percent — most of those with incomes under 100 percent of poverty — were likely in the Medicaid coverage gap. About 14 percent had incomes above the threshold that made them eligible for subsidies.

Other adults who did not enroll were overwhelmed by the process. About four of 10 adults (38%) who did not sign up for coverage said they found the process of enrolling difficult or confusing.

http://www.commonwealthfund.org/publications/issue-briefs/2015/sep/to-enroll-or-not-to-enroll

***

Comment:

By Don McCanne, MD

Is the Affordable Care Act a misnomer? Although half of the individuals who visited the insurance exchanges and did not enroll obtained coverage outside of the exchanges, the other half did not enroll because they found the plans unaffordable.

Making health care affordable for everyone was the primary goal of reform. It didn’t happen. But it would if we were to enact a single payer national health program.

Medical students to hold National Day of Action for ‘Medicare for All’ on Oct. 1

FOR IMMEDIATE RELEASE
September 28, 2015

Contact:
Mark Almberg, (312) 782-6006, mark@pnhp.org
See student contacts at 30 medical schools at end of this message

MEDIA ADVISORY

Citing the persistence of thousands of preventable deaths each year due to lack of health insurance, students at more than 30 medical schools across the country will hold teach-ins, rallies and candlelight vigils on Thursday, Oct. 1, to bring national attention to ‘our failing health care system’ and the need for single-payer health reform

What

Students for a National Health Program (SNaHP), the student arm of Physicians for a National Health Program – working in coalition with the American Medical Student Association, WhiteCoats4BlackLives, the Latino Medical Student Association, Universities Allied for Essential Medicine, California Health Professional Student Alliance, and Pre-Health Dreamers – will hold teach-ins, rallies, and candlelight vigils at more than 30 campuses to remember the millions of people in the U.S. who remain uninsured, underinsured and underserved by our current health care system. They will also underscore the need for a more fundamental health reform – a nonprofit, publicly financed, single-payer health system.

When

Thursday, Oct. 1, various times (see the #TenOne Facebook page for individual event details, or contact students at participating schools – see list below)

Who

Medical students other health professional students, along with allies on their campuses and from surrounding communities. The public is welcome to attend.

Where

Medical schools and a few public venues across the country, including but not limited to the list at the end of this advisory.

Why

The United States is the only industrialized nation in the world that does not guarantee universal health care. Unfortunately, the Affordable Care Act is neither universal nor affordable. It will leave 30 million Americans uninsured and a comparable number underinsured, vulnerable to financial distress in the event of illness. Sharply rising deductibles and copays are deterring the insured form seeking care, and skyrocketing drug prices are putting medications out of reach. Tens of thousands of people will continue to die every year just because they lack health insurance. Medical problems are the leading cause of bankruptcy in the U.S., and research shows nearly 80 percent of those declaring bankruptcy due to medical debt had insurance at the onset of their illness. Our patients need and deserve better.

This year marks the 50th anniversary of Medicare. As medical students, part of our mission is to ensure that everyone who needs care gets it. One way to achieve this goal is by improving the Medicare program and expanding it to cover all Americans. There is a bill in Congress, H.R. 676, that would do precisely that.

We urge our fellow students and the public to join us for this #TenOne: Medicare-for-All National Day of Action on Thursday, Oct. 1, to bring national attention to our failing health care system and the need for single-payer health reform.

For more of the thinking behind the #TenOne initiative, including patient stories, please see these posts on SNaHP’s official blog by medical students Vanessa Van Doren and Bryant Shuey.

Media visuals: Many of these events will have medical students in white coats, candles for evening vigils, signs and banners. In some cases there will be rallies with multiple speakers.

#TenOne Local Events

Teach-ins, rallies, and candlelight vigils

*Participating campuses and their SNaHP chapter leaders are updated daily.

CALIFORNIA

Coordinator: Angelica Ramirez, California Health Professional Student Alliance
Touro University California: Matthew Musselman
UC Berkeley: Ana Ibarra 
UC Davis School of Medicine: Umer Waris, Keyon Mitchell, Callum Rowe
UC Irvine: Michelle Crespo
UCLA: Jonathan Gomez
UC San Francisco: Nicolas Barcelo
UC San Diego (undergraduates and medical students): Firooz Kabir 

ILLINOIS

Chicago Medical Schools Coalition:
University of Chicago: Scott Goldberg
University of Illinois at Chicago: Kieran Holzhauer
Rush Medical College: Jordan Centers
Chicago College of Osteopathic Medicine: Jillian Caldwell 

IOWA

University of Iowa Carver College of Medicine: Lisa Wehr

KENTUCKY

University of Louisville School of Medicine: Brandi Jones

MAINE

University of New England College of Osteopathic Medicine: Natasha Neal

MASSACHUSETTS

Boston University School of Medicine: Andy Hyatt

NEW MEXICO

University of New Mexico School of Medicine: Bryant Shuey

NEW YORK

PNHP NY METRO (coordinators): Becca Mahn and Katie Robbins

Albany Medical College: Justin Pegueros
Albert Einstein College of Medicine: Tauhid Mahmud and Dahlia Kenway
Columbia University Mailman School of Public Health: Michael Zingman
Cornell University (Ithaca): Christine Liu
Icahn School of Medicine at Mt. Sinai: Alice Shen
New York University School of Medicine: David Wang and David Collins
SUNY Downstate: Keriann Shalvoy 
Weill Cornell Medical School: Claire Kenney 

OHIO

Case Western Reserve University School of Medicine: Vanessa Van Doren 

PENNSYLVANIA

Philadelphia Medical Schools Coalition:
Temple University: Emily Kirchner
University of Pennsylvania: Tony Spadaro and Dorothy Charles

TENNESSEE

Lincoln Memorial University-DeBusk College of Osteopathic Medicine: Aron Haire
University of Tennessee Health Science Center College of Medicine: Diana Alsbrook
Vanderbilt University School of Medicine: Mitchell Hayes

VERMONT

University of Vermont College of Medicine: Kelsey Sullivan

WASHINGTON

University of Washington School of Medicine: Darius Fullmer

Physician says ‘Medicare for all’

By Russell Noblett, M.D.
The Roanoke (Va.) Times, Letters, Sept. 27, 2015

On Sept. 16, the Census Bureau reported that in 2014 the number of uninsured Americans dropped by another 9 million. The estimates are that as many as 16 million more people now have health insurance since the Affordable Care Act was passed.

In addition to this, everyone who has health care now benefits from: protection for pre-existing conditions, no lifetime cap, and basic preventive care such as contraception and colonoscopy. This is huge. It marks a change in social standards.

But the ACA was implemented as the regulation of a market-based system. So cost-shifting to the consumer is now taking place, as would be expected. This means higher deductibles and co-pays and cost-sharing, leaving a large number still under-insured even if they have coverage, and susceptible to financial stress, or illness due to postponing care.

As experience in other countries has demonstrated, affordable universal care is possible only through tighter market regulation approaching a single-payer model (such as Medicare or Canada’s system) or a single employer, such as the VAMC or the British system.

In 2014, the Commonwealth Fund reported that the British system, in comparison with the systems of 10 other countries (Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland and the U.S.), was rated the best in terms of efficiency, effective care, safe care, coordinated care, patient-centered care and cost-related problems, and second for equity.

It would seem wise to repeal Obamacare only after we are able to replace it with a similarly effective program: Medicare for all.

Dr. Russell Noblett resides in Roanoke.

http://www.roanoke.com/opinion/letters/noblett-medicare-for-all/article_58cea875-ff14-5f34-9f82-18d4a283f53e.html

Q&A: Head of physician group makes case for single-payer system

He points to ‘tremendous gaps’ years after passage of health act

By Jenny Deam
Houston Chronicle, Sept. 25, 2015

Dr. Robert Zarr, president of the Physicians for a National Health Program organization in Washington, D.C., was in Houston this week speaking to physicians and medical students at Baylor College of Medicine, promoting the idea of a single-payer system of health care in this country.

He sat down with the Chronicle to share his views. Edited excerpts follow.

Q: We are 5½ years into the Affordable Care Act. Has it been a success?

A: It depends a lot on who you are. It depends a lot on where you live. It depends a lot on what life was like before the passage of ACA. But in terms of hard numbers we know now, the U.S. Census Bureau has come out with another report, and we’re down to 33 million uninsured in 2014, and that’s down from 42 million the year prior. So from that sort of bird’s-eye view, yes, more people have an insurance card in their back pocket. So that’s great.

Q: It feels like there’s a “but” coming.

A: There are tremendous gaps. There are approximately 31 million Americans underinsured, and that’s not something we talk a lot about. We’re all happy that we have this increase in insured, but what does it fully mean to have insurance? Does it mean you’re going to get the care you need? Does it mean you’re not going to be medically bankrupt? Does it mean you’re going to stop worrying about whether you can afford to buy that medicine your doctor prescribed? And in large part, the answer is no.

Under-insurance is better understood by looking at medical bankruptcies. I love to point this out because it is a shocker: If you have about a million bankruptcies claimed every year, about 60 percent of them, 600,000, are medical bankruptcies. They couldn’t pay their bills. What’s even more interesting is that of those 600,000 every year, what percentage had insurance when they got sick? Seventy-five percent.

Q: That’s an amazing statistic. What does that mean for people in this country?

A: What the ACA has done is made under-insurance the new norm. At the end of the day, you and I would like to be assured when we need care, we get it and we don’t spend enormous amounts of our money out of pocket to get it. I think one of the biggest flaws of the ACA is it has relied more on private insurance. The reality is that ACA has bolstered the private insurance industry.

Q: What is the solution?

A: I sometimes say that what needs to happen is we’re going to have to hate the insurance companies more than we fear the government to get to a sensible system. Even if you hate ACA, you very likely believe in entrepreneurship, you believe in free choice, you believe autonomy, and the only way to get to those things is through single payer.

Q: How would single payer work in this country?

A: Single payer is very simple, and that’s why I love it. It’s simply a progressive tax system. You generate the funds through a progressive tax, and you take that money and put it into a fund and you allow the private delivery of health care. So if you have a solo practice, or you have a family-owned pharmacy, or whatever you are, you keep doing what you are doing – except all of the bureaucracy of these hundreds of insurance companies disappears and you are left with one.

Q: What if you have a catastrophic illness versus someone who has the flu?

A: A runny nose, or a heart attack, a stroke, a dismemberment, it all gets paid for by this national health insurance fund. As a taxpayer you pay into that. It is the reality for most industrialized countries.

Q: The argument has often been the United States has the best standard of care in the world. Would such wholesale change jeopardize that?

A: The truth is we don’t have the best health outcomes, in part because for every 1 million uninsured, we have 1,000 excess deaths every year. The World Health Organization has ranked us 37th in the world in a number of categories.

Q: But what if you are poor and don’t pay taxes?

A: It’s a progressive tax, so if you make zero income, you put in zero but you still get services.

Q: Isn’t that where it all falls apart?

A: One day there is a good likelihood you will find yourself in a situation like the person you are talking about. We live in a civilized society. We care for each other. We know that people go through ups and downs in their lives.

Q: As a nation, can we afford this?

A: There have been all kinds of cost analyses on single payer, and at the end of the day, 95  percent of the population is going to pay what they pay now or less to get a ton more, and 5 percent will pay a little bit more.

Q: Still, how do we get from where we are now to there, especially in such a politically divided climate?

A: We’ve been polling Americans for more than 15 years on this issue, and every poll I’ve seen says the vast majority of Americans want the establishment of national health insurance. We have polled physicians. People think physicians don’t support this. They do. The public is onboard, the physicians are onboard, the unions are onboard. We have a lot of our country that wants this. Part of the problem is we’re used to life as it is. We’re willing on some level to accept it, and we hope it will get better. It’s hard to find the extra energy to see what the future holds for us.

http://www.houstonchronicle.com/business/medical/article/Head-of-physician-group-makes-case-for-single-6530082.php

Medical students rally for single-payer health care

By Sam Rappaport
Hyde Park Herald, Sept. 24, 2015

On Oct. 1, students at the University of Chicago Pritzker School of Medicine will join thousands of other medical students across the country in rallying for universal, single-payer health care reform. The event is called TenOne Medicare-for-All National Student Day of Action and is being organized by Students for a National Health Program (SNaHP), the student branch of Physicians for a National Health Program (www.pnhp.org), an organization of over 19,000 physicians, health professionals and medical students.

The Pritzker School of Medicine will host a daytime rally from 12-1 p.m. on Thursday, Oct. 1, at 5812 S. Ellis Ave. The rally will feature speeches from physicians, nurses, students and patients.

Later that evening from 5:30-8 p.m., Pritzker students will join activists from UIC, RUSH and Midwestern to hold a nighttime march and candlelight vigil at Heritage Green Park, 610 W. Adams St.

Scott Goldberg, a fourth-year medical student at Pritzker who is helping to organizer the event, said that most people are misguided about the reality of our current health care system and harbor unfounded fears of a single-payer alternative.

“Tens of thousands of people die every year in this country just because they don’t have health insurance,” Goldberg said. “Medical problems are the leading cause of bankruptcy in the U.S. More absurdly, nearly 80% of those declaring bankruptcy due to medical debt already have insurance…This year marks the 50th anniversary of Medicare and our mission is clear–to institute truly affordable care by expanding Medicare to cover all Americans. The student single payer movement is growing with more than 650 members at 41 medical schools across the nation.”

For more information on the event, visit student.pnhp.org.

http://hpherald.com/2015/09/24/medical-students-rally-for-single-payer-health-care/

Premium is primary driver in plan selection

Are Marketplace Plans Affordable? Consumer Perspectives from the Commonwealth Fund Affordable Care Act Tracking Survey, March–May 2015

By Sara R. Collins, Munira Gunja, Petra W. Rasmussen, Michelle M. Doty, Sophie Beutel
The Commonwealth Fund, September 25, 2015

From the Conclusion

On average, larger shares of people with marketplace plans have high deductibles than those in employer plans, with the differences widest among enrollees with higher incomes. Among those with lower incomes, the cost-sharing reduction subsidies appear to have had the effect of narrowing the difference in deductibles between those in marketplace plans and employer plans. Still, a large share of people with low and moderate incomes in marketplace plans have deductibles of more than $1,000.

We know from the results reported in our companion issue brief that premium cost factors more heavily than do deductible size and copayments when people are choosing health plans.

Consistent with recent research by The Commonwealth Fund, the growing use and size of deductibles in both employer and marketplace plans as a means to lower premiums threatens to undermine the gains Americans have made in coverage since 2014

Adults in high-deductible health plans are less confident in their ability to pay for their care if they were to become seriously ill compared to those with lower deductibles. People with the lowest incomes in these plans are the most at risk of spending large amounts of their income on medical care. Their lack of confidence about the future suggests they are aware of their financial vulnerabilities. In an economy that is still struggling to deliver significant wage gains to working families, ever higher cost-sharing in health plans will further degrade their financial security.

http://www.commonwealthfund.org/publications/issue-briefs/2015/sep/are-marketplace-plans-affordable

Companion brief: http://www.commonwealthfund.org/publications/issue-briefs/2015/sep/to-enroll-or-not-to-enroll

***

Comment:

By Don McCanne, MD

How do people select their health plans? The most immediate concern to the plan purchaser is the premium that must be paid, and most will choose a plan with low net premiums. To gain greater market share, insurers will reduce premiums by shifting more of the health care costs to the patient, especially through higher deductibles.

It is not parsimony but rather an imposed frugality that motivates individuals to select plans with lower premiums. The high costs of health care and thus high premiums, combined with stagnant incomes, leave most individuals with little other choice.

People should not be have to be confronted with a decision that almost forces them to select a lower premium plan that could expose them to financial hardship should significant medical problems develop.

Under a well-designed single pager national health program, no decision would be necessary. Everyone would have the same comprehensive coverage with no need for premiums since the system would be funded through equitable taxes.

U.S. health care is overpriced

By Michael Huntington, M.D., and Bruce Thomson, M.D.
Corvallis (Ore.) Gazette Times, Sept. 4, 2015

The Money and Markets section of the Gazette-Times on Aug. 13 reported that stock values of the top four health insurance companies had increased 31 percent this year (S&P 500 companies were up “only” 5 percent). This news is welcome for some but bad for all, a perverse byproduct of an overpriced health-care industry.

We rarely can determine the likely cost of health care services before we receive them. Even if we could estimate price, when we are in crisis, we cannot comparison-shop. We essentially sign blank checks hoping that our insurance plan will cover the costs of care. The likelihood of adequate coverage diminishes each year as health-care costs escalate and insurance plans degenerate.

Furthermore, medical bills from hospitals and pharmacies are grossly inflated, not meant to be real. A neighbor’s hospital bill for his hip replacement last month was more than $50,000 (typical in the U.S. compared to $10,000 under publicly funded care in England or Switzerland). The insurance company followed industry standards by allowing a secretly negotiated “provider discount” of $42,000 and paid about $8,000 to the hospital, leaving the neighbor to pay $176 out-of-pocket.

But many people you may know have no insurance or poor insurance, even under the Affordable Care Act. They face much or all of a fully inflated health-care bill, and they risk their savings, credit ratings, dignity, and even their homes. Medical costs are still the leading trigger of personal bankruptcies. Most of the bankrupted families had health-care insurance they had trusted to protect them. 

Insurers make deals with pharmacies to involve insurance in prescription sales. Retail prices are set at three to six times those available in other countries and then “generously discounted” by the insurance plan. This appears to benefit patients but mainly benefits the insurance companies and pharmacies because of negotiated co-pay allowances. Some stores do forgo these insurance deals and offer customers $4 a month prescription plans. They can do this and still profit because the average wholesale price for most drugs is 3.5 cents per pill or about $1 a month (see Medicaid.gov, NADAC price list).

Ideal insurance would have each of us contribute money into a single risk pool so that when any one of us becomes ill or injured, there is more than enough money to pay for our treatments. But health insurance companies are not in business to pool our money and save it for our rainy days. They are in business to harvest our money from insurance premiums, and use as little of it as possible on our care. Thanks to the Affordable Care Act, insurance companies can no longer directly refuse to insure us, but they can and do bar us from care through unaffordable deductibles, denied/delayed claims, narrow provider panels, narrow drug formularies, hidden exclusions, and by driving doctors to despair and early retirement.

Please search online under price-gouging and bankruptcies in health care. Relevant reference sites are truecostofhealthcare.net, pnhp.org, hcao.org, mvhca.org, and foxbusiness.com (Feb. 18, 2014). These sites help us realize the need for a unified payment system that would allow the public to negotiate price with the health-care industry and assure transparency and accountability.

The cure for our tragic “sick care” system may come state by state. The Affordable Care Act allows states to design their own unified payer health-care plan if cost and services compare favorably with those of the act. HB 2828, approved by the 2015 Oregon Legislature, funds a study comparing several systems, one of which is a unified payer system. Please urge your legislators and acquaintances to study, compare, and then help create a unified system of payment for health care in Oregon. It’ll make us all better.

Michael Huntington is a retired radiation oncologist. Bruce Thomson is a retired family physician. Both live in Corvallis.

http://www.gazettetimes.com/news/opinion/as-i-see-it/as-i-see-it-u-s-health-care-is-overpriced/article_55f3b999-0cf1-5cc5-afb2-b472693d2fb6.html

Would single payer fix this physician’s problems?

Trapped in the System: A Sick Doctor’s Story

By Aaron E. Carroll
The Upshot, The New York Times, September 21, 2015

It’s true that the number of people with no insurance has gone down significantly since the Affordable Care Act was passed. But that’s only one measure of access. In many other ways, access is still surprisingly bad. I rarely use anecdotes to make my point, but in this column I’ll make an exception.

I have ulcerative colitis, and have had it for many years. When it was poorly controlled, I lived in constant fear of not being near a bathroom. The half-hour commute to my job often necessitated a stop on the way to work because I feared I would lose control of my bowels.

But a number of years ago, after I found that drug after drug didn’t work, my gastroenterologist suggested an older immunosuppressant. I’m a doctor, and I recognized it as a drug often used to treat cancer. It carried with it some significant side effects, most notably a small chance of myelosuppression, in which your bone marrow shuts down and produces too few blood cells.

That horrified my wife. But she didn’t appreciate that this was, to me, a small price to pay for the opportunity not to be constantly worried about my proximity to a toilet. I weighed the benefits versus the harms. I decided to give it a go.

The medicine changed my life. I have few, if any, symptoms anymore.

The medicine is old and it’s generic. It costs about $80 for three months even though I haven’t met my deductible. But this story isn’t about money. This is about the nightmare of how hard it is for me to get the drug.

Every three months, I run out of my medication. In order to get more, I need a new prescription. In order to get the prescription, I need to have lab testing to prove to my doctor that I don’t have anemia. This all sounds simple, and it’s the same process every three months. But it’s never the same, and it’s never easy.

Let’s start with the lab testing. At various times, my insurance plan (which is excellent, by the way) changes which laboratory facilities it will cover fully. Often, these are not labs that are housed in the huge health care system for which I work. I often have to go elsewhere to have my blood drawn. If I change facilities, I have to get a new prescription for the labs, since they can’t share with one another.

Further, even though my lab orders are good for a year — and I need to have them drawn basically forever — the labs recognize them for only six months. So sometimes I have to get in touch with my doctor and get a new lab order. Often, they send over the old order, because they think it’s good for a year, in which case I have to go back to them and ask for a newly written one, because the lab won’t recognize the really-still-valid old one. Worse, they often just fax the order to the lab itself, thinking they’re helping me, so that I don’t realize they sent over an old one until I’m already there, and it’s too late.

After I get that sorted out, I have my blood drawn and analyzed. But because the laboratory and my doctor are in completely different health care systems, the lab results won’t show up in my doctor’s electronic database. I have to beg the lab to remember to fax over the results — using paper — which it often fails to do.

My next step is to check if the pharmacy I use is still under contract with my insurance plan. The medication I use needs to be ordered at a mail-order pharmacy, because my insurance won’t cover it at a local facility. My insurance plan has changed its mail-order pharmacy of choice more than once in the last few years, which necessitates that I inform my physician about the change.

I also have to open a new account with the new pharmacy and give it my payment information so that it can process everything once it has the order from the doctor. I do this before getting the prescription called in because I don’t want anything to get slowed down. This is a good time to explain that I can’t do much else ahead of time because the pharmacy and the insurance plan both know I have a three-month supply of the drug and won’t authorize me to get more too much in advance.

It’s at this point that I try to get in touch with my doctor, previously through a phone message, and more recently through an online site. If I’m lucky, which usually isn’t the case, the doctor will already have the lab results. If not, I have to go back to the lab and beg it again to fax over the results. If the doctor has the lab results, and they’re normal (they always are), a nurse will then call in the prescription. This usually takes a few days.

Then the pharmacy will finally start to move. Even that is painful. Once my drug was on “back order,” and since it was the only pharmacy I was permitted to go to, I just had to wait. It always takes at least a few days for me to get the drug, though, because processing takes time. I always, no matter how hard I try, run out of medicine before I get the new bottle, during which I hold my breath and hope nothing goes wrong.

I do this four times a year. It’s always a stressful time for me, and stress isn’t a good thing for a person with my disease.

This could be so much simpler. Why do I have to get a new prescription for the lab testing every six months? Why can’t I get this simple blood test more conveniently? Why can’t the electronic systems of the labs and the clinical offices talk to each other? Why do I need a new prescription for this medication every three months? Why can I use only one pharmacy when the medication is generic and so inexpensive?

There is no bad guy here. I love the drug company that created this medication. The price is more than reasonable. I love the doctor who prescribed it to me. My insurance company has never refused to cover my care, and has always been honest with me. The laboratory personnel are professional and competent. It’s the system — the way all these things work, or fail to work, together — that’s the issue.

The Affordable Care Act, which seems so complicated to so many, was almost entirely about getting more people in the United States health insurance. That was just a first step, arguably an easy one, and we’re still fighting about it. Reforming the ways in which we actually deliver care and try to improve outcomes? That’s so much more important, and we barely talk about that at all. But that’s what matters to the people who use the system, and it’s why so many of them are frustrated.

Because of my job, I probably know more about the health care system and how it works than most people in the United States. Yet if this is how much trouble I have navigating a simple refilling of my medication, I don’t know how the rest of America does it, especially those with much more complicated issues than mine.

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Answers to your questions about “Trapped in the System: A Sick Doctor’s Story”

By Aaron Carroll
The Incidental Economist, September 23, 2015

I received more than my usual share of feedback from this week’s Upshot column. I thought I might answer some of the most common comments and questions here:

1. If we only had a single payer system. That would fix this, right?

Well, I’m not sure. I understand your impulse, but that would only solve some of the insurance problems. Medicare for all wouldn’t make it so that the lab, pharmacy, and doctor’s office shared an information system, or could even reliably share information. It wouldn’t change the fact that I need to jump through the order hoops, or the authorization hoops. It might make things easier, but it wouldn’t solve all of the problems. Ask people who have Medicare (which is much closer to single payer) if things are seamless. I doubt you’ll get a universally positive response.

Answers to your questions about “Trapped in the System: A Sick Doctor’s Story”

***

Comment:

By Don McCanne, MD

Dr. Aaron Carroll’s frank discussion of his chronic medical problem and the nuisances he faces in interacting with our health care system struck a chord with many – both for the empathy engendered because of his medical condition, and especially for the crying shame that this prominent physician has to go through hoops to make our health care system work for him, suggesting that it might not work well for any of us.

Of the over 700 responses that he received, a common theme was that he wouldn’t have these problems if we had a single payer system. He responds that he is not sure. He suggests that people on Medicare, as a proxy for single payer, may find that their care is not so seamless either. Well, he hasn’t experienced Medicare as a patient since he is still on his employer-sponsored plan, and he hasn’t experienced Medicare directly as a physician either since he is a pediatrician.

I think that I can help him on this. I am a family physician, now retired from practice, and I never had the problems with my Medicare patients that I had with my managed care patients – problems similar to those he describes. I also have a few chronic disorders myself that require interaction with the health care system. I am covered under the traditional Medicare program with a Medigap supplement. I have had none of the problems that Dr. Carroll describes, except for nuisance requirements and limitations for my Part D drug coverage – but then Part D, by design, is much more like the managed care coverage that creates barriers to care (restrictive formularies, limited choice of pharmacies, logistical hurdles in filling prescriptions, etc.).

He is correct that interoperability of computer systems remains a problem, but that is a failure of George Bush and David Brailer in insisting that interoperability issues be left to the private sector to address. Players in the private sector strive for dominance and depend on a lack of interoperability to keep competitors out. The government is now encouraging improvements in interoperability, but how do you fix the mess that has been created? At any rate, the prospects for improving interoperability would be much greater under a single payer – improved Medicare for all – than they are under our fragmented, competitive multi-payer system.

Dr. Carroll says there is no bad guy here, but that “It’s the system — the way all these things work, or fail to work, together — that’s the issue.” But that’s the point. Having our entire health care delivery system integrated under a well-designed single payer model would make the system work far better for all of us – patients and physicians alike.

(Aaron Carroll is a professor of pediatrics at Indiana University School of Medicine. He is a highly respected authority in health policy who blogs in The New York Times, The Incidental Economist, and JAMA. He is co-author of a widely-quoted study demonstrating that three-fifths of physicians “support government legislation to establish national health insurance.”)

Future Doctors Rising Up for ‘Medicare for All’

Why med students are taking action for single-payer on October 1

By Vanessa Van Doren
Common Dreams, September 24, 2015

For most of us in medicine, helping people live healthy, happy lives is at the heart of why we chose this career. We expound upon this in application essays, talk about it during interviews, and start medical school with this “calling” fresh in our minds.

Very early in our medical careers – on the wards and in the classroom – we learn that inequality, preventable illness, and death are an inherent part of our current private, for-profit-oriented health insurance system.

We see patients receive preventable amputations due to untreated diabetes. We see people permanently disabled by stroke because they were unable to afford their medications. College funds emptied out to pay for $100,000-a-year cancer treatments. Families bankrupted and lives destroyed.

We learn that, although the United States is one of the wealthiest countries on earth, we are also the only developed nation that does not provide health care to all of its citizens. We learn that we spend over 17 percent of our GDP – more than any country in the world – on this non-universal coverage. We learn that medical debt is the leading cause of bankruptcy in the United States.

We learn that, despite its title, the Affordable Care Act is not truly affordable. Even after the ACA, tens of millions of people are still unable to afford insurance, and tens of thousands die every year because of uninsurance. Millions more who have insurance are under-insured, risking financial distress in the event of serious illness and finding that their health policy’s high deductibles and co-pays prevent them from using it.

All of which leads most reasonable medical students to ask, what can we do about this?

Just as the problem is clearly mapped out, so is the solution.

There is an excellent model for universal health care – one that covers everyone, leads to better health outcomes, and costs taxpayers far less than the current U.S. system – implemented in dozens of countries around the world, including our next door neighbor, Canada. This model is called single-payer health care.

Implementing a single-payer system in the United States would be far from revolutionary. As part of its fragmented, multi-payer system, the U.S. also has a single-payer-like subdivision, which we call Medicare. It is efficient, cost-effective, and has stood the test of time, providing health insurance to all American seniors for the past 50 years.

By improving and expanding Medicare to cover all Americans, we can use this existing infrastructure to achieve universal coverage, better health outcomes, and better physician working conditions.

Medical students across the country have already joined the fight for universal, single-payer health care. Students for a National Health Program (SNaHP) currently has 650 members in over 40 chapters across the country. On Thursday, October 1st, SNaHP will lead over 30 universities across the country in a Medicare-for-All National Day of Action.

SNaHP will join together with members of the American Medical Student Association, WhiteCoats4BlackLives, the Latino Medical Student Association, Universities Allied for Essential Medicine, and the Pre-Health Dreamers in holding teach-ins, rallies, and candlelight vigils to remember the millions of people in our country who remain uninsured, underinsured and underserved by our current health care system.

We will also underscore the need for a more fundamental health reform – a nonprofit, publicly financed, single-payer health system.

We urge all our classmates and friends to join us in this fight. As future medical professionals, and as compassionate people who plan to devote our lives to caring for others, we cannot acquiesce to this unjust, senseless loss of life.

We have to do something about it.

Please join us for the #TenOne Medicare-for-All National Day of Action and help advocate for a more just system in which physicians can uphold our profession with integrity, compassion, and dignity.

Please join the #TenOne Facebook page to commit to this movement and get more information about your local actions.

Vanessa Van Doren is a second-year medical student at Case Western Reserve University School of Medicine and is the co-founder of the Students for a National Health Program (SNaHP) chapter at her institution.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License.

http://commondreams.org/views/2015/09/24/future-doctors-rising-medicare-all

Your Wallet or Your Life

A lifesaving drug’s overnight price hike shows why we must fight for a radically different health care system

By A.W. Gaffney, M.D.
Jacobin, Sept. 22, 2015

Two individuals — both infected by the single-celled parasitic protozoa Toxoplasma gondii — “showed prompt, dramatic responses” after being started on a two-drug cocktail.

One of the drugs was pyrimethamine, also known by its brand name, daraprim. A recent dramatic medical advance? Not quite. This report — one of the earliest reported uses of the regimen for toxoplasmosis — appeared in the New England Journal of Medicine in 1957. Daraprim has been a first-line treatment for toxoplasmosis — a serious threat to the immunocompromised and to the newborns of infected women — ever since.

But when Turing Pharmaceuticals CEO Martin Shkreli saw daraprim, he didn’t see an immutably inexpensive, age-old drug — he saw a gold mine.

As the New York Times reported on Sunday, the former hedge fund manager’s pharmaceutical startup bought the drug last August. It then promptly raised the price fifty-five-fold, from $13.50 to $750 a tablet (in fact, it was a mere $1 a tab prior to an earlier acquisition).

The circumstances of this money grab — an enormous increase in the price of a relatively ancient drug often relied upon by AIDS patients — might seem particularly pernicious. Yet this “gigantic overnight increase,” as the Times called it, should not be viewed as an isolated incident. As a perspective in the New England Journal put it late last year:

It is well known that new brand­ name drugs are often expensive, but US health care is also witnessing a lesser­ known but growing and seemingly paradoxical phenomenon: certain older drugs, many of which are generic and not protected by patents or market exclusivity, are now also extremely expensive.

An article in the Times last year, for instance, described exploding prices for a wide variety of generics, including the aged antibiotic doxycycline, which went from $20 to $1,849 a bottle.

The phenomenon of soaring pharmaceutical price tags is also not limited to the genus of the generics. On the contrary, the big headline-earners in recent years have been for new, extremely high-priced “specialty” drugs, whose patents effectively permit monopolistic pricing.

And this is why the story of galloping prices for decades-old medications is so revealing. Big Pharma apologists have long argued that high drug prices are a reflection of the cost of paying for drug research and development. Government interference will invariably inhibit innovation, the argument goes — and in the end we’ll all suffer.

But $750-a-tablet daraprim disproves this well-honed PR defense: Turing Pharmaceutical didn’t spend a dime on developing the drug or testing it in clinical trials. It is simply pricing the drug, as the saying goes, at “what the market will bear.” The “market” of Toxoplasmosis-sufferers is, of course, a particularly vulnerable one. But this is the essential explanation for rising prices among both generic and patented drugs, drugs for asthma and hepatitis C and cystic fibrosis.

In other words, the massive spike in the cost of daraprim is a result of the political economy of American health care. The profiteering of Turing and like-minded companies aren’t aberrations that can be dealt with by case-by-case shaming (and anyways, Shkreli seems unbothered by such castigation). The fundamental flaw is the system, not one admittedly repugnant CEO.

What, then, would a more just pharmaceutical framework look like?

A good first step would be to get rid of the statute, enshrined in the 2003 Medicare and Modernization Act, that prevents Medicare from bargaining with drug companies over prices, a reform that was left out of the Affordable Care Act to appease Big Pharma. According to a 2013 estimate by Dean Baker of the Center for Economic and Policy Research, allowing Medicare to negotiate drug prices down to what Canada or Denmark pays would save hundreds of billions of dollars over a decade.

Of course, we don’t all have Medicare, so this would only go so far. A single-payer national health program — with universal coverage and comprehensive benefits including drugs — would directly negotiate prices with pharmaceutical companies for everyone in the country, thereby producing much larger savings. Such a program would also eliminate drug copayments, which function as a “tax on sickness” that, as study after study has shown, deters people from taking important medications.

These changes would go a long way towards rationalizing drug prices and unburdening the sick. However, deeper reform — aimed not only at lowering the cost of drugs, but also at improving their overall therapeutic potential — is needed.

Some notable exceptions notwithstanding, pharmaceutical development in recent years has been rather disappointing. In a 2012 article in the British Medical Journal, health policy scholars Donald Light and Joel Lexchin laid out this criticism well, arguing that the pharmaceutical industry’s flawed approach towards drug development produces “mostly minor variations on existing drugs” that are usually “not superior on clinical measures.” The pursuit of truly innovative new molecules, in other words, is discarded in favor of highly lucrative, derivative drugs — a consequence of a “hidden business model,” as they describe it, that spends an estimated $19 on marketing for every $1 on basic research.

One potent fix would be direct public sponsorship of drug development, with therapeutic impact — not profitability — as the overall aim. Drugs would essentially become a public good. Without patent production, they could be cheaply produced throughout the world, increasing their accessibility in even the poorest countries.

The “conquest of disease,” if clichéd, should be a fundamental goal for a just society — one that’s far too important to be left to the likes of Turing Pharmaceuticals.

Above all, we should see the soaring price of daraprim as a symptom of a much deeper malady: a system based on the notion that health is not a social right, but instead a commodity that, in the very process of enriching some, impoverishes others.

https://www.jacobinmag.com/2015/09/daraprim-turing-pharmaceuticals-martin-shkreli-aca-obamacre-medicaid-medicine-single-payer/

Canada’s NDP supports path to Pharmacare

Tom Mulcair commits $2.6B to support pharmacare plan

CBC News, September 18, 2015

A New Democratic government would use the purchasing power of the federal government to negotiate lower prices for prescription drugs and pass those savings on to the provinces and territories, NDP Leader Tom Mulcair says. 

The NDP plans to spend $2.6 billion over the next four years to “work towards a plan to support universal comprehensive public drug coverage for all Canadians,” if it takes the Oct. 19 vote.

The party is not committing to implement full coverage by the end of its first mandate, but Mulcair said he hopes to achieve average savings of 30 per cent in prescription drug costs through bulk buying.

Once in place, the plan would save the provinces and territories up to $3 billion annually. 

Health care is a provincial and territorial responsibility, so an NDP government would have to negotiate precise arrangements with the other various governments. It would not have the power to impose a free coverage scheme. Some provinces, however, have been pushing for such a scheme for some time.

http://www.cbc.ca/news/politics/canada-election-2015-mulcair-seniors-medication-prices-1.3234173

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OECD

In US dollars, adjusted for price differences (PPP)

Total health expenditure, per capita:

$8,713 – United States (Ranks highest of 34 countries listed)
$4,351 – Canada (Ranks tenth of 34 countries listed)
$3,453 – OECD average

Expenditure on pharmaceuticals, per capita:

$1,034 – United States (Ranks highest of 31 countries listed)
$761 – Canada (Ranks second of 31 countries listed)
$517 – OECD average

http://www.compareyourcountry.org/health?cr=oecd&cr1=oecd&lg=en&page=2

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Pharmacare 2020

By Steven G. Morgan, PhD, Danielle Martin, MD, CCFP, MPP, Marc-André Gagnon, PhD, Barbara Mintzes, PhD, Jamie R. Daw, MSc, Joel Lexchin, MD, MSc
Pharmaceutical Policy Research Collaboration, University of British Columbia, July 15, 2015

We are pleased to present this report, Pharmacare 2020, which is the culmination of many years of research and collaboration involving academics, health professionals, policy-makers, and public interest groups.

The vision is of a public drug plan that follows four policy recommendations:

1. Provide universal coverage of selected medicines at little or no direct cost to patients through Pharmacare.

2. Select and finance medically necessary prescription drugs at a population level without needs-based charges — such as deductibles, coinsurance, or risk-rated premiums — on individuals or other plan sponsors (e.g., businesses).

3. Establish a publicly accountable body to manage Pharmacare, one that integrates the best available data and evidence into decisions concerning drug coverage, drug prescribing, and patient follow-up.

4. Establish Pharmacare as a single-payer system with a publicly accountable management agency to secure the best health outcomes for Canadians from a transparent drug budget.

Canada has been waiting for Pharmacare since the 1960s. The vision is now clear. Thus, the task turns to the art and science of program development and implementation. This will be difficult and will require political leadership and inter-jurisdictional collaboration — but it is not impossible, as Canadian Medicare has shown. This led to our fifth policy recommendation:

5. Fully implement Pharmacare — a public drug plan that is universal, comprehensive, evidence-based, and sustainable — by 2020.

http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_in_Canada.pdf

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Comment:

By Don McCanne, MD

The United States and Canada were following the same health care cost trajectory until Canada established single payer systems in each of their provinces. They elected not to cover pharmaceuticals. The OECD data demonstrate that this omission was a mistake.

The total health expenditure trajectories diverted, with the United States continuing to hold first place and Canada declining to tenth place amongst 34 OECD nations. But in pharmaceutical expenditures, Canada is second of 31 OECD nations, with per capita drug expenditures exceeded only by the United States.

Drug costs have become intolerable – now 17.5% of their health care spending (calculation using the OECD numbers). Although there has long been much interest in establishing a universal drug program in Canada, the efforts have intensified – culminating in the Pharmacare 2020 report prepared by some of Canada’s more gifted policy experts. The report makes a compelling case for establishing a Pharmacare program.

The concept has gained traction. Canada’s New Democratic Party (NDP), led by Tom Mulcair, has now committed to taking major steps toward making Pharmacare a reality. The three major parties – Conservative, NDP, and Liberal – are very close in the projected results for their election to be held October 19. Whether or not NDP wins, at least Pharmacare is now part of the national political discourse in Canada.

And the United States?