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‘I can’t afford that’: A viral tweet shows why we need Medicare for all

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‘I can’t afford that’: A viral tweet shows why we need Medicare for all

By Helaine Olen
The Washington Post, July 5, 2018

The concept of “having skin in the game” is popular among those who still believe we can utilize the free market to rein in the cost of health care in the United States. The idea is that if people have to pay a decent percentage of the cost of medical care, they will turn into savvy medical shoppers when they need to see a doctor. This, in turn, will bring the costs down, ultimately resulting in a more affordable health-care system.

That’s the theory. The reality is different. Last week in Boston, Maria Cramer, a reporter for the Boston Globe, witnessed a horrifying accident on the city’s mass transit system:

A nurse who witnessed the aftermath of the accident said the victim most certainly needed an ambulance.

It seems almost beyond obvious to say that there is something cruel and out-and-out immoral about making people think about their financial skin in the game when their personal dermis is literally hanging off them. Other developed countries do not do this, and somehow they manage to spend less money overall on health care and often get better outcomes, too.

There is no real mystery about the United States’ sub-par performance. We are all but alone among developed countries in not offering universal health care. Most other comparable nations subsidize medical costs in some way or another, and they negotiate on behalf of all those they cover, too. Here we leave it to consumers, who despite having more and more “skin in the game” with each passing year still face increasing costs. More than 4 in 10 of those with private health insurance use a high-deductible plan, which means they are responsible for at least $1,300 in expenses before insurers will help with most of their medical bills.

The impact on household budgets is significant. According to a poll conducted earlier this year by the West Health Institute and Norc at the University of Chicago, 44 percent of those surveyed said they skipped visiting the doctor in the past year even when they thought they believed they needed the care, because of cost. Four in 10 also said they refused a doctor-recommended test or treatment because of the expense. More people said they were afraid of the cost of an illness than who said they were afraid of sickness itself. Another survey, this one by Ipsos for Consumers for Quality Care, found people more concerned about the costs of health care than those of college education, housing, child care or retirement. Cramer’s tweet demonstrates how this plays out in real time.

Little wonder. Costs are excessive, to say the least. Pfizer has raised the price of some of its pharmaceutical offerings by 20 percent since January of this year alone. Even the most determined consumer finds it all but impossible to price-check most medical services in advance, and that goes double in emergency situations. Surprise medical bills are a growing problem. Moreover, few know when they need a recommended procedure, further hindering their supposed ability to shop for health care. A study published last year in the Quarterly Journal of Economics of a firm where employees were switched over to a high-deductible health-insurance plan found that the workers and their families did indeed cut back on their medical spending — but they did it with seemingly no regard to need or quality.

Americans routinely say health care is one of the most important issues the country faces, and they have done so for years. When more than a few Democrats and Republicans responded to Alexandria Ocasio-Cortez’s surprise victory in a New York congressional primary by pointing out her support for Medicare for all would not play in other parts of the country, all they did was reveal how out of touch they are: Polls routinely find that a majority of voters support it. Many politicians are likely blinded to the reality of health care in the United States by money: The health-care industry is among the largest lobbies in Washington. A study by the nonprofit MapLight, which studies money in politics, found that Democratic senators who had not signed on to support Sen. Bernie Sanders’s Medicare-for-all bill received twice as much funds from the sector as those who attached their name to it.

Rising costs are shifting the health-care debate rapidly, and they would almost certainly would be doing so even if President Trump and the Republican Party supported the Affordable Care Act instead of ceaselessly undermined it. We are, I suspect, entering the end game for our free-market-dominated health-care system, shedding its skin, if you will, so we can regenerate it. Voters increasingly want no part of it. Doctors are increasingly likely to say they support a single-payer system. Insurance-company C-suite executives are known to claim they are open to discussing it, too. Even Trump, according to journalist Michael Wolff in his book “Fire and Fury: Inside the Trump White House,” asked after he was elected, “Why can’t Medicare simply cover everybody?” Why not, indeed.

https://www.washingtonpost.com…

Krugman redefines ‘Medicare for all,’ but gets it wrong

Radical Democrats Are Pretty Reasonable

By Paul Krugman
The New York Times, July 3, 2018

Alexandria Ocasio-Cortez’s upset primary victory has produced a huge amount of punditry about the supposed radicalization of the Democratic party, how it’s going to hurt the party because her positions won’t sell in the Midwest (and how well would Steve King’s positions sell in the Bronx?), etc., etc.. But I haven’t seen much about the substance of the policies she advocates, which on economics are mainly Medicare for All and a federal job guarantee.

So here’s what you should know: the policy ideas are definitely bold, and you can make some substantive arguments against them. But they aren’t crazy. By contrast, the ideas of Tea Party Republicans are crazy; in fact, Ocasio-Cortez’s policy positions are a lot more sensible than those of the Republican mainstream, let alone the GOP’s more radical members.

So, about Ocasio-Cortez’s positions: Medicare for all is a deliberately ambiguous phrase, but in practice probably wouldn’t mean pushing everyone into a single-payer system. Instead, it would mean allowing individuals and employers to buy into Medicare – basically a big public option. That’s really not radical at all.

https://www.nytimes.com…

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The “pleasant ambiguity” of Medicare-for-all in 2018, explained: Are we talking about single-payer health care or something else?

By Dylan Scott
Vox, July 2, 2018

Democrats across the country are running on three simple words, recognizable to every American: Medicare for all.

In Democratic primaries around the country, Medicare-for-all candidates are winning.

Even before these candidates started winning, polling was showing that Medicare-for-all is really popular: 62 percent of Americans liked the sound of it in last November. Almost every single rumored 2020 candidate in the Senate has backed Sen. Bernie Sanders’s Medicare-for-all bill. It’s clear the idea is in ascendancy among Democrats.

But someday, a reckoning will come. When Democrats hold power again — especially control of Congress and the White House — they will be expected to actually deliver on these Medicare-for-all promises. And when that day arrives, the party will have to decide whether they want to blow up America’s current health care system to build something new or figure out a less disruptive path, but risk falling short of truly universal coverage.

What does “Medicare-for-all” actually mean?

Historically, Medicare-for-all has meant single-payer health insurance, a national government-run program that covered every American and replaced private coverage entirely, similar to the government-run health care programs in Canada and some European countries.

Then-Rep. John Conyers (D-MI) first introduced the Expanded and Improved Medicare for All Act in 2003. It’s now sponsored by Rep. Keith Ellison (D-MN) and it is still a single-payer proposal.

But these days, other plans are falling under the Medicare-for-all umbrella. Some progressives are even comfortable with the term being applied to the various proposals to allow all Americans buy into Medicare. Some of those plans used to be branded as a “public option”; they would not end private insurance that more than half of Americans get, usually through work, as a true single-payer would. But these plans would also not provide the same guarantee of universal coverage that a single-payer system does.

“For anybody who supports Medicare-for-all single payer, what better way to debunk the right wing lies than to allow millions and millions of Americans to voluntarily opt into Medicare and love it?” (Adam Green, co-founder of the lefty Progressive Change Campaign Committee) told me. “As a political strategy, having Medicare-for-all be a broad umbrella where any candidate can embrace some version of it… that moves the center of gravity in the Democratic party.”

Medicare-for-all is uniting Democrats for now — but it could divide them later

That explains why there’s this fledgling competition over what Medicare-for-all is really describing.

The best example might be the health care plan from the Center of American Progress, which is, tellingly, called “Medicare Extra For All.” It’s a seriously ambitious plan, one that would achieve universal coverage through a combination of government plans and private insurance, while preserving employer-based insurance for those who want it. But it is not single payer. And it is notably produced by an organization closely aligned with the Democratic establishment.

The scars from the Obamacare reveal themselves in this debate. For all the health care law has achieved, it also showed the limits of incrementalism. Even Medicaid expansion, the closest thing the law had to a single-payer pilot, was undermined by the Supreme Court by allowing Republican-led states to refuse it. The Obamacare insurance markets have been susceptible to sabotage from Republicans in Congress and the Trump administration.

Yes, the uninsured rate has reached historic lows under Obamacare, but 10 percent of Americans still lack coverage. Democrats will be faced again, at some point, with a choice between a more incremental approach, like the Medicare public options introduced by some Democrats in Congress, or a sweeping overhaul like single-payer.

https://www.vox.com…

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Comment:

By Don McCanne, M.D.

“Medicare for all…would mean allowing individuals and employers to buy into Medicare – basically a big public option.” Who says? Well Paul Krugman and many others. This is not simply a debate about labels. This is a debate about fundamental policy. Are we going to accept the status quo with the tweak of a public option, or are we going to address the fundamental defects in our system that have driven up costs, perpetuated mediocrity, and left tens of millions vulnerable with impaired access to health care with all of its consequences and often with intolerable financial hardship?

This is similar to the debate that took place within the Democratic Party just before Hillary Clinton and Barack Obama began jockeying for the 2008 presidential nomination. The Democratic Party machine was in complete control of the policy debate on health care reform. The neoliberal party elite had decided that we were going to “build on what works” – employer-sponsored and union-supported plans – and reject single payer based on their concepts of what was politically feasible. Those of us advocating for the expanded and improved Medicare for all single payer approach were ejected from the conversations (often rudely so – they were in charge!).

Similarly, with the contest for the 2016 Democratic presidential nomination, the debate at the platform committee confirmed that the battle had not changed. The neoliberal leadership, represented by Neera Tanden, was successful in rejecting the single payer Medicare for all plank.

Tanden, of the Center of American Progress, has continued the fight for control of the policy debate by releasing their new proposal, “Medicare Extra For All.” Although some of the tweaks proposed seem beneficial, it basically continues the current dysfunctional, fragmented financing system, but with one important political change. They have stolen the “Medicare for all” label! This has contributed to the ubiquitous deception that the public option is Medicare for all. When the current candidates campaign on Medicare for all but behind the scenes are supporting an option to buy into Medicare while accepting campaign funds from the insurance and pharmaceutical industries, we need to call them on their deception.

It is no wonder the public is confused, even if they do not realize it. When Nobel laureate Paul Krugman jumps in and says Medicare for all is allowing individuals and employers to buy into Medicare as a public option, then we know that the political campaigns are corrupted with deceptions. How can we get the public to understand that a well designed, single payer national health program – a bona fide Improved Medicare for All – is the reform that they crave?

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Emergency departments: the ‘chewing gum and duct tape’ holding together U.S. health care

By Paul Seward, M.D.
STAT, July 3, 2018

The evolution of emergency care in the United States is a fascinating story. Sadly, what became a hugely successful solution to an important problem in health care is now being eroded by its misapplication to another problem.

The modern U.S. health care system began with so much promise. After World War II, the economy was booming and employers were quick to provide health care for their workers. The addition of Medicare and Medicaid in 1965 further fueled a dramatic expansion in the quality and availability of health care services.

Throughout this time, emergency care was still in its dark days. Ambulance services were operated mostly by funeral directors, with minimally trained helpers. Emergency rooms were commonly staffed by a nurse whose job was to conduct an initial evaluation of patients and then contact the on-call physician — who may or may not have had any training in the management of emergencies.

Soldiers and health care personnel who served in World War II, Korea, Vietnam, and our undeclared wars had experienced how effective a well-organized system for taking care of acutely injured people could be. Their knowledge put pressure on hospitals to look for a new way to manage emergency care.

In that new way, hospitals contracted with physicians to ensure that there was always a doctor in the emergency room. Beginning in 1976, I was one such physician.

I was a pediatrician at the time, with little experience treating adult patients. Fortunately, I could call any physician on the staff for help. Equally important, when they came in to assume care for the patient, I was there to help. In that way, I learned how to care for all sorts of emergencies.

One day, an ophthalmologist taught me how to remove small bits of metal from the surface of a metalworker’s eye. His instructions were simple: put some anesthetic drops in the patient’s eye; use a “spud,” a metal tool with a point on the end, to scrape out the metal fragments; then use a small electric burr, like a tiny sander, to buzz off the residual rust granules. The patient did fine, and I learned how tough an organ the eye really is.

I did that procedure entirely by myself. I had to: The ophthalmologist stayed home and told me what to do over the phone. That was also a part of emergency medicine.

During the 1970s and early 1980s, professional organizations formed; leaders emerged; the science of emergency medicine developed; new emergency procedures and better techniques for old procedures were invented; textbooks were written; and examination and certification procedures came into being. Emergency rooms became departments of emergency medicine. In 1983, I took and passed the second Emergency Medicine Board Examination ever given, making me certified in the new specialty of emergency medicine.

Today, if you are acutely ill or have experienced trauma, you can go to an emergency department anywhere in this country and receive immediate, excellent, lifesaving care from people who have spent their careers learning how it’s done.

That’s the good news.

The bad news is that, in parallel with the rise in emergency medicine, health care costs steadily surged upward. Today, medical debt is the most common cause for personal bankruptcy, particularly in the elderly. At the same time, health care insurance is becoming increasingly difficult to afford.

Until health care reform happens, the stopgap measure is the emergency department. Why? Because it is like mom and dad: When no one else will take you in, the emergency department can’t turn you away. It’s against the law to do that. But using emergency departments to create access to health care is like putting a snow plow on a Porsche. It costs much more, does a bad job, and it trashes the Porsche.

Although emergency departments are set up to handle anything, they can’t handle everything at once. As more and more people turn to the emergency department for non-emergency care, it is common, especially in metropolitan areas, to have waiting times in them measured in large parts of a day and to have patients kept in stretchers in the hallways after they have been admitted to the hospital because they cannot get an inpatient bed.

Wealth does not make people immune to being swallowed up by the emergency department. Here’s a story for the one-percenters out there. Several years ago, while working in the emergency department of a busy metropolitan hospital, I cared for a middle-aged Wall Street stockbroker. Certain he was having a heart attack, I admitted him to the cardiac care unit. Two days later, when I returned to work, he was still in the emergency department, standing amidst a collection of gurneys in front of the nurses’ station. Wires attached to his chest tethered him to a monitor 20 feet away. He was still there because no bed had opened up in the cardiac care unit.

People sometimes ask me how long I think it will be before our health care system collapses. There certainly are signs that it is coming apart: Our legislatures routinely block attempts to create a rational health care system. Old people are regularly financially ruined by the costs of illness. Health insurance is becoming increasingly unaffordable. And politicians, while decreasing taxes for wealthy people, are crying that federal health insurance must be cut back.

I believe that one reason our health system still functions at all is because emergency departments are the chewing gum and duct tape holding it together. That may work for a few more years.

Or maybe it won’t.

Dr. Paul Seward practiced medicine for nearly 50 years, mostly in emergency departments. He is the author of “Patient Care: Death and Life in the Emergency Room” (Catapult, July 2018).

https://www.statnews.com…

Tallinn Charter: Health systems for prosperity and solidarity

Health systems for prosperity and solidarity: Tallinn 2018

The Lancet, Editorial, June 23, 2018

Last week, ministers of health, policy makers in health and finance, patient organisations, and academic advisers met in Tallinn, Estonia, to discuss the future of European health systems. Under the stewardship of WHO’s Regional Office for Europe (WHO EURO), and hosted by Estonia’s President, Kersti Kaljulaid, and Minister of Health and Labour, Riina Sikkut, 250 or so representatives of WHO EURO member states celebrated the tenth anniversary of the Tallinn Charter and agreed on principles for building sustainable people-centred health systems.

In 2008, the Tallinn Charter shaped thinking about the importance of health systems and the inter-relatedness of health and wealth. The Charter committed signatory WHO EURO member states to improve health by investing in and strengthening their health systems, and to promote the shared values of solidarity, equity, and participation. Underpinning the Charter were the principles that high-performing health systems contribute to better health and economic development, and that no one should become poor because of ill health.

But later in 2008, the financial crisis hit, leading to hardship and widespread austerity measures in many member states and, in some, to deep cuts to health budgets. Tallinn Charter commitments were derailed, out-of-pocket health expenditure increased, and investment in health systems decreased in many countries. Nevertheless, the past decade has seen some metrics improve, such as life expectancy at birth and tuberculosis case detection. But progress is variable between and within countries, slow in many, and widespread inequalities persist.

Where now for the Tallinn Charter? Last week saw renewed commitment to the fundamental principles of the Charter through adoption of three themes to achieve faster and more equitable health gains. Participants agreed to “include, invest, and innovate” to strengthen their health systems. Ministers of health and policy makers agreed that the health needs of their populations can best be met by improving coverage, access, and financial protection; making the case for investing in health systems; and harnessing innovations in health care.

How to improve inclusion, to ensure universal health coverage, was discussed in the context of financial protection. Health systems play a crucial part in protecting individuals from the financial hardship caused when out-of-pocket payments for health, such as prescription charges or dental care, are greater than a household’s ability to pay. New evidence on financial protection was presented in Tallinn based on analyses across 25 European countries. Even with “universal health coverage”, up to 8% of households in Europe cannot afford to pay for basic needs (food, rent, utility bills) after paying out-of-pocket charges, especially for medicines and dental care. These costs are still causing people to fall into poverty or to do without care; for many in Europe, medicines or dental care, or other health-care costs, are simply not affordable. The risks are greatest where out-of-pocket payments are over 15% of total spending on health, especially if pro-poor policies are absent.

It is still necessary to make the economic case for investing in health systems. Competing demands upon ministries of finance serve to emphasise the need to demonstrate good stewardship of public resources, including measures to reduce health-system inefficiencies and waste, but there is now strong evidence that spending on health contributes to better health outcomes, promotes macroeconomic growth, supports societal wellbeing, and enhances fiscal sustainability of health systems.

It is important to strive for continuous improvement to health systems to benefit populations. Health systems have been slow to innovate in many countries, but key factors that help include supportive leadership, early involvement of clinical staff, dedicated resources including funding, staff, and time, and evaluation of the benefits and costs. Remembering the needs of the public and patient is paramount—innovations that are not needed, wanted, or are too complex will fail.

Inclusion, investment, and innovation are useful themes to build sustainable health systems for the future. The key message from Tallinn 2018 is European solidarity to improve health outcomes, decrease inequalities, and deliver universal health coverage. “Everything we do to improve health outcomes, decrease inequalities, and strengthen health security is fundamentally driven by our European social values of solidarity, equity, and universalism”, Hans Kluge (WHO EURO) told The Lancet. Health systems must be person-centred and flexible to allow change and innovation. Leadership from health ministers, policy makers, academics, and clinicians will be crucial to implementing the recommendations from Tallinn 2018.

https://www.thelancet.com…

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Comment:

By Don McCanne, M.D.

Ten years ago the Tallinn Charter established principles for building sustainable people-centered European health systems. Unfortunately the Great Recession prompted governments to implement austerity measures – a politically difficult time to increase investment of public funds in their health care systems, though Keynesians may not agree.

On the tenth anniversary of the Charter representatives of the WHO EURO member states met again in Tallinn in a renewal of European solidarity to improve health outcomes, decrease inequalities, and deliver universal health coverage. As Hans Kluge from WHO EURO told The Lancet, “Everything we do to improve health outcomes, decrease inequalities, and strengthen health security is fundamentally driven by our European social values of solidarity, equity, and universalism.”

Why should these be foreign concepts to the United States? We are already spending more than enough money to improve health outcomes, decrease inequalities, and deliver universal health coverage. Just think of what the European social values of solidarity, equity, and universalism could do for us.

As we celebrate Independence Day keep in mind that our American exceptionalism does not mean that we should reject solidarity and egalitarianism. Those have served our European friends very well, and at a much lower monetary cost. You would think that there would be considerable support for that.

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Health care spending in late life is usually appropriate

Predictive modeling of U.S. health care spending in late life

By Liran Einav, Amy Finkelstein, Sendhil Mullainathan, Ziad Obermeyer
Science, June 29, 2018

Abstract

That one-quarter of Medicare spending in the United States occurs in the last year of life is commonly interpreted as waste. But this interpretation presumes knowledge of who will die and when. Here we analyze how spending is distributed by predicted mortality, based on a machine-learning model of annual mortality risk built using Medicare claims. Death is highly unpredictable. Less than 5% of spending is accounted for by individuals with predicted mortality above 50%. The simple fact that we spend more on the sick—both on those who recover and those who die—accounts for 30 to 50% of the concentration of spending on the dead. Our results suggest that spending on the ex post dead does not necessarily mean that we spend on the ex ante “hopeless.”

From the article

In sum, although spending on the ex post dead is very high, we find there are only a few individuals for whom, ex ante, death is near certain. Moreover, a substantial component of the concentration of spending at the end of life is mechanically driven by the fact that those who end up dying are sicker, and spending, naturally, is higher for sicker individuals. Of course, we do not—and cannot—rule out individual cases where treatment is performed on an individual for whom death is near certain. But our findings indicate that such individuals are not a meaningful share of decedents.

These findings suggest that a focus on end-of-life spending is not, by itself, a useful way to identify wasteful spending. Instead, researchers must focus on quality of care for very sick patients—identifying the impact of specific health care interventions on survival rates and, just as importantly, on palliation of symptoms; such research should focus not just on averages but also on potentially heterogeneous impacts across different individuals.

http://science.sciencemag.org…

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Cut Spending In Final Year Of Life? MIT Study Finds Death Too Unpredictable

By Carey Goldberg
WBUR, June 28, 2018

Medicare, the federal health coverage mainly for people over 65, spends about $700 billion a year, and it’s estimated that about one-quarter of that spending on seniors goes to health care in the final year of life.

That end-of-life spending has drawn scrutiny as potentially wasteful, involving heroic measures taken even though death looms inevitably.

If health costs must be contained, the argument follows, why not cut that relatively futile end-of-life spending?

The answer, according to a new study that used machine learning on a huge trove of more than 6 million Medicare medical records to train a computer algorithm to predict deaths, is this:

In most cases, it’s not clear that the treatments are futile at the time. Because even with state-of-the-art artificial intelligence, it’s much harder than you might think to predict who’s going to die soon.

Question: So what are the policy implications?

Amy Finkelstein, co-author of the paper: First, it is true that we spend an enormous amount of money on people who die. What our research suggests is it isn’t obvious that that means it’s a waste. The implicit assumption is that we’re spending a lot of money on people we know are going to die in the next year or the next 30 days, and we show in the paper that’s just not true. So don’t focus so much on end of life spending as a symptom of waste, because it’s not obviously waste.

Second, there’s hard work we need to do rather than just point to spending at the end of life and say, “Let’s lop that off.” Instead, we need to figure out which medical interventions and health care policies are actually producing a lot of value and which aren’t. We need to look at specific interventions, both late life and at other points in life, and estimate with rigorous empirical methods what the benefits of those interventions are.

Question: You could do this study because you could use machine learning on great Medicare data, but what actually triggered you to do it?

Amy Finkelstein: Those two factors — and on the more casual or humorous side, I remember picking my son up from ski school, and he told me his instructor said you always need to be careful at the end of the day because most ski accidents happen on the last run of the day. And my immediate response was: “Of course they do, when you have an accident that becomes the last run!”

Obviously, that’s facetious, but it made me start thinking about it. In the ski example, I think the instructor is right. It is actually true that more accidents occur late in the day. But as framed, it sounds absurd in the same way as saying, “Look, we spend a lot on the dying, let’s stop spending so much on the dying.” It’s like, “Stop skiing your last run of the day.”

http://www.wbur.org…

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Comment:

By Don McCanne, M.D.

When our very high national health care costs are discussed, almost invariably the subject of wasteful spending at the end of life is brought up. This important study of predictive modeling shows that spending at what proves to be near the end of life is not obviously wasteful. It is usually appropriate, testimonials aside. Efforts to reduce spending by reducing end of life care will not be particular productive in management of our national health expenditures.

It is astonishing to see brought up repeatedly the same ill-advised, ineffectual, and sometimes harmful policies to control health spending, such as consumer-directed health care (very high deductibles), paying for value instead of volume (accountable care organizations), or taking away choices in care (narrow provider networks), when we know what does work – a single payer national health program, aka an improved Medicare for all.

Measures that would have a real impact on controlling spending include reduction in our profoundly wasteful administrative excesses, and controlling our “stupid” prices through public administration. Improved allocation of our health care resources through planning and capital budgeting might not make much of a dent in total spending, but it would redistribute funds to more effectively cover those who are currently uninsured or have excessive out-of-pocket health care expenses. Obviously these are beneficial policies that characterize a single payer health care financing system.

Instead of wasting more time and money on the wish lists of the market ideologues, we should move forward with what does work – improved Medicare for all. The good news is that, based on current election results, it appears that the word is getting out.

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Indiana’s impending health care crisis calls for action throughout the entire U.S.

Rob Stone, M.D. of Bloomington, Indiana has provided us with the following background information on the effort by twenty state attorneys general to invalidate the remaining elements of the Affordable Care Act (ACA). That is followed by an op-ed he wrote for the Bloomington Herald-Times on this topic and then by a Bloomington Herald-Times editorial in support of Rob Stone’s position.

Background Information

February 26, 2018: Indiana Attorney General Curtis Hill Jr. announced that Indiana had joined 19 other states* in a suit filed in Federal court in Texas to invalidate the remaining elements of the Affordable Care Act (ACA).  In his statement Hill said “The whole house of the Affordable Care Act must come crumbling down.”

The ACA helped over 340,000 Hoosiers obtain healthcare.  According to the nonpartisan Kaiser Family Foundation [kff.org] 1.1 million Hoosiers under 65 have pre-existing conditions that would have made them uninsurable before the ACA’s reforms were enacted.

June 6, 2018: US Attorney General Jeff Sessions announced the Justice Department would not defend against the suit from the 20 states and the provisions of the ACA that protect consumers with pre-existing medical conditions, meaning that insurance companies could again deny coverage or charge higher rates to Hoosiers with pre-existing illnesses like diabetes, cancer, or high blood pressure.

* The other 19 states [tell friends from those states]: Alabama, Arkansas, Arizona, Florida, Georgia, Kansas, Louisiana, Maine, Mississippi, Missouri, Nebraska, North Dakota, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia, Wisconsin.

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Lawsuit will hurt health of Hoosiers

By Rob Stone, M.D.
The Herald-Times (Bloomington, Ind.), June 19, 2018

This guest column was submitted by Rob Stone, M.D., of Bloomington, a practicing physician and director of Hoosiers for a Commonsense Health Plan.
 
Did anyone see the news release from the Indiana Attorney General’s office on Feb. 27 this year? The one where AG Curtis Hill announced that Indiana “has joined a 20-state coalition urging a federal district court in Texas to hold the Affordable Care Act’s individual mandate is unconstitutional.” In a speech at the Heritage Foundation in Washington, D.C., Mr. Hill went on to crow, “The whole house of the Affordable Care Act must come crumbling down.”
 
I admit I was not paying attention, either, until June 7 when the nation’s top lawyer, Jeff Sessions, announced that the Justice Department would not defend this lawsuit that Indiana is pursuing. The lawsuit aims to void the Affordable Care Act and crucial provisions in it that protect consumers with pre-existing medical conditions.
 
To be clear, anyone with a pre-existing health condition, whether it be a disability they were born with, cancer, heart disease, diabetes, high blood pressure, you name it, is in grave danger of losing their health insurance as a result of this action by Indiana’s attorney general.

We know that when people lose their health insurance it makes it difficult and expensive to receive testing and treatment, difficult to even find a doctor who will see you. We know that their health will deteriorate and people will die as a result. We know this will lead to disability, suffering and to medical bankruptcy.
 
I have practiced medicine in Indiana since 1983. For 28 years, I was an emergency physician, dealing daily with people who had no health insurance. They waited until they were desperate and in dire straights before coming into the ER for care, waited until their heart attack or their stroke was complete and no treatment would be able to reverse the damage.
 
I saw people die from delaying care because they couldn’t afford it. I saw the situation in our state get better after Obamacare. Indiana has seen a small but significant improvement in our state health rankings over the past few years. We are beginning to make progress on our infant mortality and opioid crises. All that progress could be lost if Mr. Hill is successful in his efforts as more Hoosiers lose coverage and access to care.
 
To make matters worse, Medicaid stands to be cut as well, and with Medicaid cuts, we will see rural hospitals close, which will even further aggravate problems like infant mortality and the shortage of addiction treatment options. Many rural hospitals are the largest employers in their communities.
 
Why did he feel this is something so important to pursue? How does taking health insurance away from Hoosiers come under the purview of the AG? Was he acting on his own, or at the behest of the governor?
 
I think Mr. Hill’s actions in this case are fundamentally inconsistent with the role of the attorney general and can be seen as a serious dereliction of his duty to protect the people of this state.

Either Mr. Hill should act to withdraw Indiana from this lawsuit, or else he should resign his position.

https://www.heraldtimesonline.com…

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Editorial: Indiana AG shouldn’t be cheering decision that could hurt Hoosiers

The Herald-Times (Bloomington, Ind.), June 22, 2018

Indiana Attorney General Curtis Hill has claimed victory for the state based on an action that could cost 1 million Hoosiers health insurance.

As covered in a guest column by Dr. Rob Stone in the Tuesday H-T, the issue in play here is the recent announcement that the Department of Justice will stop defending core provisions of the Affordable Care Act, otherwise known as Obamacare.

One provision is the guarantee that those with pre-existing medical conditions could get insurance coverage without paying exorbitant premiums.

Hill was one of 20 Republican attorneys general who filed a lawsuit that argues the ACA is unconstitutional since Congress got rid of the individual mandate, a tax penalty for people who did not buy health insurance.

In announcing it would no longer fight challenges to the ACA, which remains the law of the land, the Justice Department said it agreed with the lawsuit Hill is part of.

That’s terrific, says Indiana’s top lawyer.

The effect on real Hoosiers and tens of millions other Americans could be devastating.

The Kaiser Family Foundation, which focuses on national health care issues, estimates that 27 percent of adult Americans under age 65 have health conditions that the ACA guaranteed would be covered. That math adds up to the more than 1 million Hoosiers referenced above. Some of those Hoosiers will continue to be covered under employer plans or other government plans, but others could be considered uninsurable on the open market, as they were before the ACA protection.

As an aside, the Kaiser Foundation notes pre-existing conditions affect far more women than men.

The attorney general, in a news release, praised the Justice Department’s decision and suggested “Congress should allow Indiana and all the other states to exercise freedom in the ways they deal with the issue of health care for their own citizens.”

The fact is, Indiana has dealt with the issue of health care fairly well in recent years with the Healthy Indiana Plan and HIP 2.0. How did then Gov. Mike Pence come up with such a successful program?

Credit for that should go to the Affordable Care Act so widely disparaged by Hill and others in his party. The reason Indiana moved to develop a plan to cover 350,000 uninsured Hoosiers rather than the 40,000 it was covering was because the ACA provided funding to expand Medicaid or a similar program. State lawmakers never would have done that on their own.

Those in the state who want to continue to bash the ACA or Obamacare ignore the fact that hundreds of thousands of Indiana’s citizens have better access to quality health care because of it.

Hill and his GOP colleagues should not have added Indiana into this lawsuit — at least not if the health of Hoosiers matters to them.

https://www.heraldtimesonline.com…

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Rob Stone has initiated a petition at change.org directed to Indiana Attorney General Curtis Hill Jr. Individuals in the other nineteen states involved may want to consider initiating similar petitions:

https://www.change.org…

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Comment:

By Don McCanne, M.D.

Our number one imperative is to enact and implement a health care financing system that will bring health care justice to every single person in the nation – a well designed, single payer, improved Medicare for all – and we should not allow anything to distract us from that goal… with one major caveat.

Because of obvious political barriers, enactment of an improved Medicare for all does not seem to be imminent, though our efforts in support should continue at a level as if it is imminent. We cannot relax in the least in our advocacy for single payer reform. That said, in the interim it is important that we do what we can on a state level to protect and improve what we do have. As Rob Stone’s op-ed and the Herald-Times editorial indicate, this cruel lawsuit by the twenty attorneys general, if successful, will cause physical suffering and financial hardship and even result in death for far too many innocent residents of the United States, since an adverse outcome would apply to the entire nation and not just to the twenty states.

We must take up (virtual) arms against these attorneys general to ensure that their sick effort is defeated, this while we continue our march forward to win health care justice for all through the enactment of a single payer, improved Medicare for all.

Also keep in mind the utmost importance of casting your vote, even for the down-ballot offices such as attorney general.

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Iowa shows the nation how not to finance health care

The Road Not Traveled: How Policy, Business Decisions in Iowa Led to Higher Premiums

By Sabrina Corlette and Kevin Lucia
The Commonwealth Fund, June 28, 2018

This year, Iowa’s legislature took the extraordinary step of abdicating the state’s authority to regulate health insurance products. The bill, enacted in April, exempts health plans offered by the state’s Farm Bureau from state and federal insurance regulation, including Affordable Care Act (ACA) provisions designed to protect people with preexisting conditions and provide a minimum standard of benefits.

Proponents argue that such a law is needed to provide individual market consumers with cheaper health plan options than available under the ACA. Critics point out that younger, healthier consumers are most likely to benefit from these plans. And while details haven’t been provided yet, the Farm Bureau plans are expected to be medically underwritten, and not cover the ACA’s minimum set of benefits. As a result, older Iowans, those with preexisting conditions, and those who need comprehensive coverage are unlikely to find these plans affordable or attractive. And many could be denied enrollment outright. As enrollment in the ACA-compliant individual market becomes older and sicker, marketplace consumers who do not qualify for the ACA’s income-related premium subsidies will face increasingly higher premiums.

Iowa’s Farm Bureau statute is making a bad situation worse for the state’s individual market. Thanks to a number of decisions by state policymakers and the dominant insurance company – Wellmark Blue Cross Blue Shield – premiums in the state’s individual market are already among the highest in the country, with an average annual marketplace plan premium in excess of $10,000 in 2018.

A Study of Market Failure: Iowa’s Individual Health Insurance Market

The current dismal state of the ACA individual market in Iowa was not a foregone conclusion. In 2014, when the marketplaces launched, Iowa had four insurers competing in the ACA’s marketplace. In 2018, only one insurer is selling ACA-compliant health plans; it agreed to do so only after implementing an average 50 percent increase to unsubsidized premiums.

Iowa’s marketplace enrollment has also lagged that of other states. As of 2016, only 20 percent of eligible Iowans had enrolled (by comparison, that number was 40 percent in Illinois, 43 percent in Missouri, and 57 percent in Maine). Iowa is an outlier for a critical reason. Wellmark BlueCross BlueShield declined to participate in the marketplace for the first three years, entered only briefly in 2017 and then declined to participate in 2018, but is returning to the market in 2019. The insurer also maintained a large block of pre-ACA grandfathered and transitional, or “grandmothered,” health plans (see table).

Because the enrollees in these plans must pass a health screen before being allowed to enroll, they are relatively healthy. Because Wellmark was able to hang on to these healthy enrollees, the pool of people available for the ACA-compliant market was much smaller and sicker than it otherwise would have been.

Looking Ahead

Iowa’s experience offers important lessons. The more the individual market is segmented between healthy and the less-healthy consumers, the more likely unsubsidized enrollees are to face unaffordable premiums. Federal proposals such as those to expand the availability of short-term and association health plans, to the extent they are not limited by state policies, could result in more state individual markets resembling Iowa’s. The primary losers in such a scenario are the working middle-class consumers: entrepreneurs who run their own businesses, freelancers and consultants, farmers and ranchers, and early retirees who earn too much to qualify for the ACA’s premium subsidies.

https://www.commonwealthfund.org…

Wakely’s Analysis of Alternative Policy Decisions in Iowa’s Individual Market:
https://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

We know how to craft a health care financing system that is truly universal, accessible, comprehensive and equitably funded making it affordable for everyone. No state in our nation has achieved those goals, but some, such as Iowa, are far worse off than others, largely for ideological and parsimonious reasons. As a result, their people suffer – physically and financially.

The Affordable Care Act (ACA) was supposedly designed to address many of these health care financing issues. But look at ACA and compare it to a model that many of us said should have been used instead – Medicare, or actually an improved version of Medicare. The provisions of ACA did not ensure coverage for everyone whereas Medicare does ensure some coverage (Part A) for the designated population covered regardless of which state the beneficiaries live in (though the improved version would include absolutely everyone in every state). There are considerable inequities in health care financing under ACA, especially for those just above 400 percent of poverty, whereas the funding of Medicare is more equitable by virtue of using progressive taxes (though it could be even more equitable through better designed tax policies). Accessibility is highly variable under ACA whereas Medicare covers almost the entire health care delivery system and thus improves choice and accessibility (though with an improved Medicare, planning and budgeting of capital improvements would further expand access). But one of the more important differences is that ACA provides state bureaucrats greater leeway in implementing their health care financing systems, whereas Medicare is fairly standardized through the nation. This leeway for states under ACA is what has allowed Iowa and other states with similar political views to deprive their citizens of a more egalitarian health care system.

We are allocating a huge amount of federal tax funds for our health care system. Thus we have a responsibility to see that each individual in each state is treated well by their health care systems. The current experience has shown us that we cannot rely on states to design their own systems because too many will deprive their residents of the care that they should have. Like Medicare, a universal health care financing program should be a national program so that everyone who needs health care can benefit.

Yes, until we have a national, single payer, improved Medicare for all, states should continue to do what they can to improve their health care systems. But we cannot allow that to slow down our efforts to create the political environment that will facilitate the enactment of a universally accessible, equitable and affordable national health program. Iowa is showing us how not to do it.

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The role of health policy in presidential elections

Getting Ready for Health Reform 2020: What Past Presidential Campaigns Can Teach Us

By Jeanne M. Lambrew
The Commonwealth Fund, June 26, 2018

Abstract

Issue: The candidates for the 2020 presidential election are likely to emerge within a year, along with their campaign plans. Such plans will include, if not feature, health policy proposals, given this issue’s general significance as well as the ongoing debate over the Affordable Care Act.

Goal: To explain why campaign plans matter, review the health policy components of past presidential campaign platforms, and discuss the likely 2020 campaign health reform plans.

Methods: Review of relevant reports, data, party platforms, and policy documents.

Findings and Conclusions: Proposals related to health care have grown in scope in both parties’ presidential platforms over the past century and affect both agendas and assessments of a president’s success. Continued controversy over the Affordable Care Act, potential reversals in gains in coverage and affordability, and voters’ concern suggest a central role for health policy in the 2020 election. Republicans will most likely continue to advance devolution, deregulation, and capped federal financing, while Democrats will likely overlay their support of the Affordable Care Act with some type of Medicare-based public plan option. The plans’ contours and specifics will be developed in the months ahead.

Likely Republican Campaign Plan: Replace the ACA with Devolution and Deregulation

President Trump has indicated he will run for reelection in 2020. His fiscal year 2019 budget included a proposal “modeled closely after the Graham-Cassidy-Heller-Johnson (GCHJ) bill.” It would repeal federal financing for the ACA’s Medicaid expansion and health insurance marketplaces, using most of the savings for a state block grant for health care services. It would also impose a federal per-enrollee spending cap on the traditional Medicaid program. States could waive the ACA’s insurance reforms. The congressional bill also would repeal the employer shared responsibility provision (i.e., the employer mandate) and significantly expand tax breaks for health savings accounts, among other policies. The framework for this proposal — repealing parts of the ACA, replacing them with state block grants, reducing regulation, and expanding tax breaks — is similar to the 2016 Republican platform.

One policy initiative in the recent Republican platforms but not embraced by the president is Medicare reform. The idea of converting Medicare’s defined benefit into a defined contribution program and raising the eligibility age to 67 was supported by Vice President Mike Pence when he was a member of Congress and by Speaker of the House Paul Ryan.

Likely Democratic Campaign Plan: Improve the ACA and Add a Public Plan

It is possible and maybe probable that the ultimate Democratic Party platform in 2020 will resemble that of 2016: build on the ACA and include some sort of public plan option.

The Democrats will inevitably discuss a public plan in their platform, although the primary contenders will most likely disagree on its scale (e.g., eligibility) and design (e.g., payment rates, benefits). In September 2017, Senator Bernie Sanders introduced the Medicare for All Act (S. 1804). It would largely replace private insurance and Medicaid with a Medicare-like program with generous benefits and taxpayer financing. “Medicare for more” proposals have also been introduced: Medicare Part E (Merkley, S. 2708), an option for individuals and small and large businesses; Medicare X (Bennet, S. 1970), which is available starting in areas with little insurance competition or provider shortages; and a Medicare buy-in option, for people ages 50 to 65 (Higgins, H.R. 3748). A Medicaid option (Schatz, S. 2001), similar to Medicare Part E, offers a public plan choice to all privately insured people, aiming to capitalize on the recent popularity of that program. Publicly sponsored insurance plans have long been included in Democratic presidents’ platforms, although the government’s role has ranged from regulating the private plans (Carter, Clinton) to sponsoring them (Truman, Obama). It may be that the candidate who prevails in the primaries will determine whether the Democratic platform becomes “Medicare for all” or “Medicare for more.”

From the Discussion

The direction and details of the campaign plans for 2020 will be developed in the coming months and year. Given such plans’ potential to shape the next president’s agenda, now is the time to scrutinize, modify, and generate proposals for health reform.

https://www.commonwealthfund.org…

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Alexandria Ocasio-Cortez Defeats Joseph Crowley in Major Democratic House Upset

By Shane Goldmacher and Jonathan Martin
The New York Times, June 26, 2018

Representative Joseph Crowley of New York, once seen as a possible successor to Nancy Pelosi as Democratic leader of the House, suffered a shocking primary defeat on Tuesday, the most significant loss for a Democratic incumbent in more than a decade, and one that will reverberate across the party and the country.

Mr. Crowley was defeated by a 28-year-old political newcomer, Alexandria Ocasio-Cortez, a former organizer for Bernie Sanders’s presidential campaign, who had declared it was time for generational, racial and ideological change.

Mr. Crowley’s loss left Democrats in Washington stunned.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

The debate over health care will likely play a significant role in the 2020 presidential election. Jeanne Lambrew has considerable political experience in health reform, having worked for President Obama as deputy assistant for health policy. She has studied health care reform proposals in prior presidential elections. What does she predict for 2020?

Lambrew predicts that the Republicans will propose replacement of the Affordable Care Act with devolution and deregulation. She predicts that the Democrats will support improving the Affordable Care Act and propose adding a public plan, presumably a public option or perhaps a Medicare buy-in.

Yet public support for a single payer Medicare for all program is at an all time high. It may have played a role in the impressive victory of Alexandria Ocasio-Cortez over stalwart Democratic leader Representative Joseph Crowley in yesterday’s New York congressional Democratic primary. Ocasio-Cortez was an organizer for Bernie Sanders’s presidential campaign and supports progressive policies, including Medicare for all. Crowley is a cosponsor of the Medicare for All Act but is also “an outspoken supporter of Obamacare” according to his campaign website – a position inconsistent with advancing bona fide single payer legislation. The fact that Democrats in Washington were stunned by his defeat may awaken them to the fact that the voters really do want an improved Medicare for all.

Lambrew writes, “now is the time to scrutinize, modify, and generate proposals for health reform.” Actually it’s late for that, rather now is the time to show the politicians how strong the support is for Medicare for all. After the presidential campaign begins, the political parties will have already decided on their policy positions and it will be too late to change their strategies.

Don’t forget the Republicans. Medicare for All may be a welcome antidote for Trump fatigue.

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John Arensmeyer on association health plans

Association Health Plans Will Destabilize Small Group Market

By John Arensmeyer, Small Business Majority Founder & CEO
Small Business Majority, June 19, 2018

We are disappointed and disturbed that the U.S. Department of Labor released a final rule today authorizing the expansion of association health plans (AHPs) over the objections of virtually everyone who weighed in on the proposed rule, including small businesses. This is yet more evidence that this administration will do all it can to undermine the Affordable Care Act (ACA) regardless of the consequences. The new rule will allow groups of businesses to band together to buy insurance across state lines, which will be bad for small firms and their employees because it will lead to higher premiums, unbalanced risk pools and lower-quality insurance.

While the new rule may make it easier for a select number of small businesses with younger and/or healthier employees to purchase association health plans that might be cheaper in other states, the tradeoff is that this will cause the insurance market for small businesses to split in two, leading to major spikes in premiums for small firms that remain in the small group market.

What’s more, these multi-state plans will offer fewer consumer safeguards. In fact, they will not have to include protections for people with pre-existing conditions nor will they be required to cover things like maternity care because they will not be subject to certain rules established by the ACA.

The AHP rule is also redundant because small businesses are already allowed to work together to purchase health insurance. That system is called the small group market, and the more people we have in this pool, the lower premiums will be for its participants. Encouraging people to leave the small group market, however, will only harm small businesses by raising their premiums.

This administration has shown that it will do anything and everything possible to destroy policies it disagrees with, regardless of whether or not those policies are working for small businesses. It is simply fact that the ACA has helped millions of small business owners, their employees and solo entrepreneurs gain quality, affordable health insurance. Since the administration has no interest in improving healthcare for small firms, we implore states to do all they can to strengthen ACA marketplaces so that insurance remains affordable for America’s job creators.

http://www.smallbusinessmajority.org…

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Comment:

By Don McCanne, M.D.

John Arensmeyer is one of the most credible voices in the small business community. We should listen to him when he discusses the association health plans (AHPs) that are now being advanced by the Trump administration, supposedly to benefit small business owners.

The need is for affordable access to essential health care for the owners and employees of small businesses. AHPs may make the insurance product more affordable, but they will make health care access less affordable because of gaps in benefits and excessive out-of-pocket cost sharing, not to mention possible inability to obtain coverage because of preexisting conditions. The current problems with excessive cost sharing and impaired access due to narrow provider networks will only be made worse with these inadequate association health plans.

The small group market was previously in disarray and thus was one of the primary motivating forces behind the enactment of the Affordable Care Act. As healthier individuals leave the small group market to purchase cheaper association health plans, the small groups will experience adverse selection, driving premiums further up to even less affordable levels.

Arensmeyer provides us with one more reason to replace the current Congress and administration since the current people in charge seem to remain unresponsive to the nation’s needs.

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The fraud behind the expanded Medicare benefits for people with multiple chronic illnesses

Medicare Allows More Benefits for Chronically Ill, Aiming to Improve Care for Millions

By Robert Pear
The New York Times, June 24, 2018

Congress and the Trump administration are revamping Medicare to provide extra benefits to people with multiple chronic illnesses, a significant departure from the program’s traditional focus that aims to create a new model of care for millions of older Americans.

The changes — reflected in a new law and in official guidance from the Department of Health and Human Services — tackle a vexing and costly problem in American health care: how to deal with long-term illnesses that can build on one another, and the social factors outside the reach of traditional medicine that can contribute to them, like nutrition, transportation and housing.

To that end, the additional benefits can include social and medical services, home improvements like wheelchair ramps, transportation to doctor’s offices and home delivery of hot meals.

The new law is a rare instance of bipartisan cooperation on a major policy initiative, embraced by members of Congress from both parties. The changes are also supported by Medicare officials and insurance companies that operate the fast-growing Medicare Advantage plans serving one-third of the 60 million Medicare beneficiaries.

Under the new law and Trump administration policy, most of the new benefits will be reserved for Medicare Advantage plans, which will be able to offer additional benefits tailored to the needs of people with conditions like diabetes, Alzheimer’s, Parkinson’s disease, heart failure, rheumatoid arthritis and some types of cancer.

“This is a big win for patients,” said Seema Verma, the administrator of the Centers for Medicare and Medicaid Services.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Normally we should celebrate the fact that Congress and the Trump administration have decided to expand Medicare benefits for people with multiple chronic illnesses – essential benefits such as nutrition, transportation and housing that extend beyond the usual health care benefits. How could anyone criticize this, the Chronic Care Act?

The problem is that individuals who remain in the traditional Medicare program will be deprived of these benefits. The expansion is limited to individuals who sign up for the private Medicare Advantage plans. This is another blatant effort to privatize Medicare by providing more funds and better benefits through the private plans while depriving the traditional Medicare program of such funding.

Once enough Medicare beneficiaries transfer to the private plans, our government stewards can move forward with their plan to devitalize the traditional program, reducing it to a shrunken, underfunded welfare program if not totally shutting it down. At that point, they can convert the private Medicare Advantage plans into the premium support (voucher) program they have been dreaming of. But the nefarious scheme is that the value of the voucher will gradually be reduced “because Medicare is going bankrupt” (as they have claimed since the year it was enacted), and we can no longer afford to pay for it, they will continue to say.

Who favors this? It was the product of a “bipartisan” effort in Congress composed of conservatives and neoliberals, with the support of the Trump administration, but especially with the support of the private insurance industry. This is a windfall for the private insurers, with the promise of even more to come.

That improved Medicare for all we keep talking about is headed for the shoals. By infusing the private plans with ever more cash while depriving the traditional program of adequate funds, they will appear to have proved that competing private plans are superior to a public program, when, in fact, the private plans are being paid significantly more than is the cost of the public program for patients of comparable health status. The claim of lower costs through competition of private Medicare Advantage plans is a fraud. Why else would the champagne corks at Mar-a-Lago be popping?

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Don’t wait for Atul Gawande

Amazon, Berkshire Hathaway and JPMorgan Chase appoint Dr. Atul Gawande as Chief Executive Officer of their newly-formed company to address U.S. employee healthcare

Business Wire, June 20, 2018

Amazon, Berkshire Hathaway and JPMorgan Chase announced today the next step in their partnership on U.S. employee healthcare with the appointment of Dr. Atul Gawande as its Chief Executive Officer, effective July 9. The new company will be headquartered in Boston and will operate as an independent entity that is free from profit-making incentives and constraints.

Atul is a globally-renowned surgeon, writer and public health innovator. He practices general and endocrine surgery at Brigham and Women’s Hospital and is Professor at the Harvard T.H. Chan School of Public Health and Harvard Medical School. He is founding executive director of the health systems innovation center, Ariadne Labs. He also is a staff writer for The New Yorker magazine, has written four New York Times bestsellers: Complications, Better, The Checklist Manifesto, and Being Mortal, and has received numerous awards for his contributions to science and healthcare.

“I’m thrilled to be named CEO of this healthcare initiative,” said Atul, “I have devoted my public health career to building scalable solutions for better healthcare delivery that are saving lives, reducing suffering, and eliminating wasteful spending both in the US and across the world. Now I have the backing of these remarkable organizations to pursue this mission with even greater impact for more than a million people, and in doing so incubate better models of care for all. This work will take time but must be done. The system is broken, and better is possible.”

https://www.businesswire.com…

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Ariadne Labs founder Atul Gawande transitions to chairman and becomes CEO of new health care organization

Ariadne Labs

Ariadne Labs founder and Executive Director Dr. Atul Gawande has been named the CEO of the new Amazon, JPMorgan Chase, Berkshire Hathaway nonprofit health care organization and will transition to a new role as chairman of Ariadne Labs. He will remain a practicing surgeon at Brigham and Women’s Hospital and a professor at Harvard T.H. Chan School of Public Health and Harvard Medical School.

Ariadne Labs was founded in 2012 by Gawande and a team of leaders to find solutions to some of the most complex problems in health care, including life-threatening errors in surgery, maternal and neonatal mortality, failures in end-of-life care, and fragmented and ineffective primary health care systems. Leveraging a network of expertise across the Harvard-Brigham system, Ariadne Labs’ designs, tests, and spreads simple solutions to address failures in health care delivery worldwide.

Among Ariadne Labs innovations:

* The Surgical Safety Checklist

* OR Crisis Checklists

* The Safe Childbirth Checklist,

* The Delivery Decisions Team Birth Project

* The Serious Illness Conversation Guide

* The Primary Health Care Vital Signs

https://www.ariadnelabs.org…

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Promise unrealized: A birth checklist fails to reduce deaths in rural India

By Casey Ross
STAT, December 13, 2017

It was supposed to be a breakthrough moment in global health.

Atul Gawande, the physician and writer, was applying a simple tool he championed — the checklist — to improve birth outcomes in a rural part of India with some of the world’s highest infant mortality rates.

But his closely watched study, the BetterBirth Trial, has produced a disappointing result: Despite increased adherence to best practices, outcomes for babies and mothers did not improve with the use of a checklist and coaching on its implementation, according to data published Wednesday in the New England Journal of Medicine.

https://www.statnews.com…

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Head of New U.S. Corporate Health Plan Cites Surgery as Biggest Cost

By Reuters
The New York Times, June 21, 2018

“We are screaming right now about pharmaceutical costs … and that is just 10 percent” of total U.S. healthcare spending, Gawande said, noting how patients faced with a $200 drug co-pay see that as standing between them and their health.

But with surgery the single biggest healthcare cost, he outlined ways he has worked with hospitals to standardize procedures, resulting in lower costs and better results for patients.

“We need to act through data tracking … to see when treatments are benefiting and when they are not,” Gawande said.

https://www.nytimes.com…

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Health insurers support CEO pick to head Amazon-Berkshire-JPMorgan venture

By Greg Slabodkin
Health Data Management, June 21, 2018

America’s Health Insurance Plans, the national trade association representing insurers, gave its support for the selection of Atul Gawande, MD, as the chief executive officer to lead a new healthcare venture started by Amazon, Berkshire Hathaway and JPMorgan Chase.

“To Amazon, Berkshire Hathaway and JPMorgan Chase, here’s what we say—bring it on,” Matt Eyles, president and CEO of AHIP, told Wednesday’s opening session of its annual conference held in San Diego. “We are welcoming new voices that challenge us to think differently about healthcare.”

Atul Gawande contends that the objective of modern care is not to “rescue” patients from “catastrophic” health episodes—but an ongoing process that takes into account patients’ physical, cognitive and emotional life goals that clinicians never ask them about.

“To measure and manage that over time is going to be highly technologically enabled in order to make that possible,” Gawande said on Thursday at the 2018 AHIP Institute & Expo in San Diego. “We need to act through the data, tracking you with your life on how you’re doing against those goals, and when our treatments are benefitting and when they’re not.”

https://www.healthdatamanagement.com…

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Quote of the Day Comment:

By Don McCanne, M.D.
May 22, 2015

On “Overkill: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?”

By Atul Gawande
The New Yorker, May 11, 2015

Yesterday’s Quote of the Day discussed the harm done by our health care reform agenda that overemphasizes attacking overutilization while neglecting more compelling goals of reform. Atul Gawande has been one of the more credible and outspoken voices in raising the alarm on overutilization, especially with his widely referenced 2009 New Yorker article on the excessive use of health care services in McAllen, Texas. But where does Dr. Gawande stand when he is faced with health care utilization questions regarding his own patients?

In his current New Yorker article, “Overkill,” he describes the overtesting and overdiagnosis of thyroid carcinoma, which, in turn, results in overtreatment – all manifestations of overutilization of health care. For his own patient with a very small thyroid nodule, he recommended leaving it alone – a recommendation that is well supported in the medical literature.

Yet, apparently because the patient wanted something done, he elected to remove her thyroid gland. She did turn out to have a microcarcinoma, but he reports that it “was not a danger to her life, and would almost certainly never have bothered her.” She manifested two common problems of overutilization: 1) a post-operative complication (hemorrhage requiring a second operation), and 2) significant costs that were unnecessary but added to the very high costs of health care paid by all of us through taxes or insurance premiums.

Thus Dr. Gawande is himself an overutilizer while preaching the evils of overutilization.

https://pnhp.org…

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Is Health Care a Right?

By Atul Gawande
The New Yorker, October 2, 2017

Few want the system we have, but many fear losing what we’ve got. And we disagree profoundly about where we want to go. Do we want a single, nationwide payer of care (Medicare for all), each state to have its own payer of care (Medicaid for all), a nationwide marketplace where we all choose among a selection of health plans (Healthcare.gov for all), or personal accounts that we can use to pay directly for health care (Health Savings Accounts for all)?

https://www.newyorker.com…

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Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis

By Russell Mokhiber
Common Dreams, February 10, 2015

As for (Gawande’s) opposition to single payer, he remains steadfast.

In a q/a with New Yorker readers last week, Gawande defended his opposition to single payer now.

“Replacing the entire health-financing system with Medicare would require most working-age people to leave their current insurance plans,” Gawande writes. “It would change the finances of every hospital and doctor in the country overnight. It would require replacing the premiums we pay with a tax, with massive numbers of both losers and winners. It seems simple in theory, but in practice it never is. This would be a whole new path for health care. No country has swept away their health system and simply replaced it like that. As I said in the article, one would have to be prepared for an overnight change in the way people get 3.5 billion prescriptions, 900 million office visits, 60 million operations – because how these are paid for is critical to whether and how they are provided. Doing away with private insurance coverage is no less sweeping than saying we’ll do away with public insurance programs or do away with employer-paid health care. No major country has simply swept away the way so many people’s care is paid for. And the reason is that people have legitimate fears about what will happen to them.”

Dr. David Himmelstein, a founder of Physicians for a National Health Program, calls this argument “bogus.”

“Patients do not care what their insurance plan is – just that it pays for the care they need. A transition from a system where virtually everyone has only partial coverage to one where they have full coverage is not a disruption for patients,” Himmelstein said when we asked him to respond to Gawande. “Several nations have made abrupt changes in the financing of care. The UK instituted the National Health Service – eliminating insurance and private payment for care at a stroke. Each Canadian province went from a private insurance system very like ours to its current system virtually overnight — though not all provinces underwent the change simultaneously. Taiwan changed to a single payer system about 10 years ago at a stroke.”

“Medicare replaced private coverage for the elderly — who account for about 30% of all hospital patients — about nine months after its passage. That occurred in an era before computers. The entire task of enrolling tens of millions of patients, inspecting virtually every hospital in the nation — to certify that they were desegregated, which was mandated by the Medicare law — and set up a new payment apparatus was carried out using paper records. Why is a shift of the other two-thirds of our system more difficult?”

“The new payment system would be far simpler than the current one — hospitals would receive a global budget, which initially would be based largely on their previous year’s revenues. Medicare currently collects all of the financial info needed to do such budgeting at the outset. Per-patient billing for hospital care would be eliminated. For doctors, Medicare already has a fee schedule, which should be modified somewhat, but already serves as the benchmark for most private plans. Expanding this payment system to cover all fee-for-service billings would be trivial. Paying for drugs is similarly pretty simple and straightforward, with most of the needed infrastructure already in place.”

“In sum, his arguments are bogus unless you assume that we are far less competent than people in other nations, and than we used to be,” Himmelstein said.

https://pnhp.org…

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Comment:

By Don McCanne, M.D.

Warren Buffett, Jeff Bezos and Jamie Dimon are receiving praise for having selected Atul Gawande as the CEO of their joint effort to improve employee health care in the United States. Based on his writing and speaking eloquence, on the surface he seems like a good choice. Some have hopes that he may revolutionize health care for all of us. So how realistic are the prospects?

Perhaps Gawande’s most noted contribution was an article in The New Yorker describing overutilization of health care in McAllen, Texas. In response, the health care community in McAllen did a self-assessment and found that the largest difference was in home health care, and they made appropriate reductions, bringing them into line with other communities. Gawande is being given credit for reducing excess care throughout the United States, but our experience with accountable care organizations shows that little change has taken place. Regions with greater needs may well represent a normal distribution under the bell curve rather than inappropriate overutilization.

Ironically, in another article in The New Yorker Gawande describes having removed a thyroid lesion in a patient even though he had recommended that it be left alone. The fact that even Gawande can be an overutilizer indicates how difficult it is to reduce care that may be of lesser value or even detrimental, as it was in his case since complications occurred.

Gawande is also praised for his advocacy of checklists. I’m not sure why he is given so much credit for them when I’ve used them my entire medical career, and I graduated from medical school before he was born. Be that as it may, but the experience with BetterBirth checklists in India, which he championed, proved to be disappointing. Don’t get me wrong. Checklists are a very good idea. It’s just that he seems to have overstated his role when he says, “I have devoted my public health career to building scalable solutions for better healthcare delivery that are saving lives, reducing suffering, and eliminating wasteful spending both in the US and across the world.”

And I won’t even go into his Cheesecake Factory analogy.

He now seems to want to concentrate on data tracking, “to see when treatments are benefiting and when they are not.” This certainly seems to be a good idea – basic research – but it is a slow and arduous process of evaluation of minutiae. There doesn’t seem to be any earth shattering transformation in this approach, even though continuing research is certainly beneficial.

In another more recent article in The New Yorker he discussed whether people believe that health care is a right. Since views on this are divisive, it is no wonder that he concluded with a question: “Do we want a single, nationwide payer of care (Medicare for all), each state to have its own payer of care (Medicaid for all), a nationwide marketplace where we all choose among a selection of health plans (Healthcare.gov for all), or personal accounts that we can use to pay directly for health care (Health Savings Accounts for all)?” That certainly muddles the question.

The health-care-as-a-right article might represent a slight moderation of his more negative views expressed in a 2015 article from The New Yorker wherein he was quite dismissive of single payer. David Himmelstein explained then why he shouldn’t be.

Gawande says that he is data oriented. Well, we have plenty of data for him. Instead of merely dabbling with the health care system, he should take up the cause seriously and emphatically support a well designed, single payer national health program – an improved Medicare for all. That will do more good for the one million employees of Berkshire Hathaway, Amazon, and JPMorgan Chase than any amount of tweaking that he could accomplish within our current, dysfunctional system.

Above all, don’t wait to see what little bit Atul Gawande can do for us. Move forward immediately with all the forces you can muster to help bring health care justice to us all.

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Work requirements and health savings accounts in Medicaid

New Approaches In Medicaid: Work Requirements, Health Savings Accounts, And Health Care Access

By Benjamin D. Sommers, Carrie E. Fry, Robert J. Blendon, and Arnold M. Epstein
Health Affairs, June 20, 2018 (online ahead of print)

Abstract

Alternative approaches in Medicaid are proliferating under the Trump administration. Using a novel telephone survey, we assessed views on health savings accounts, work requirements, and Medicaid expansion. Our sample consisted of 2,739 low-income nonelderly adults in three Midwestern states: Ohio, which expanded eligibility for traditional Medicaid; Indiana, which expanded Medicaid using health savings accounts called POWER accounts; and Kansas, which has not expanded Medicaid. We found that coverage rates in 2017 were significantly higher in the two expansion states than in Kansas. However, cost-related barriers were more common in Indiana than in Ohio. Among Medicaid beneficiaries eligible for Indiana’s waiver program, 39 percent had not heard of POWER accounts, and only 36 percent were making required payments, which means that nearly two-thirds were potentially subject to loss of benefits or coverage. In Kansas, 77 percent of respondents supported expanding Medicaid. With regard to work requirements, 49 percent of potential Medicaid enrollees in Kansas were already employed, 34 percent were disabled, and only 11 percent were not working but would be more likely to look for a job if required by Medicaid. These findings suggest that current Medicaid innovations may lead to unintended consequences for coverage and access.

From the Discussion

Administrative costs

While our findings do not shed light directly on the costs of administering health savings accounts or work requirements, such costs are another consideration for Indiana’s POWER accounts and potential work requirements in Kansas or any other state. Implementing these alternative approaches requires additional resources. Even though the POWER accounts in Indiana built upon HIP 1.0, the predecessor of HIP 2.0, the expansion substantially increased per beneficiary administrative requirements. One study indicated that Indiana’s Medicaid managed care organizations had to increase administrative staffing ratios and devote more time to meet the state’s requirements for oversight of the POWER accounts. While Indiana officials have not released estimates of the program’s administrative costs, officials in Arkansas estimated that administrative costs for that state’s health savings accounts in Medicaid were over $1,100 per participating beneficiary per year.

The costs to states of these accounts may outweigh the relatively modest benefits noted among some Indiana respondents in our survey. Similarly, a work requirement that changes behavior for only a tenth of the population but requires verification of employment or exemptions for medical frailty and other hardships for the vast majority of beneficiaries also raises concerns about administrative efficiency.

Of course, these administrative costs may ultimately be outweighed in the Medicaid budget if total enrollment falls substantially as a result of these requirements, which may be another reason that states are considering these changes. While some people would lose coverage because they chose not to comply with the new requirements (for example, to look for work, contribute to a health savings account, or make premium payments), others may be dissuaded from applying or be removed from the Medicaid rolls because of the added administrative difficulty of applying or reenrolling, even though they may meet the program’s requirements.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

This survey looked at the impact of work requirements and health savings accounts (specifically Indiana’s POWER accounts) on Medicaid participation using three contrasting states as examples (Ohio, Indiana and Kansas). These innovative programs reduced coverage and impaired access while significantly adding to the administrative waste that characterizes the U.S. health care system.

Patient controlled health spending accounts and work requirements are conservative concepts in which individual responsibility becomes a precondition to receiving health care. Everyone should have health care irregardless of how responsible they may be. The reduction in coverage and impairment of access that these preconditions cause are the opposite of what a well designed health care financing system should be doing.

It is ironic that these results are labeled unintended consequences of these policies when it is clear that the reduction in enrollment or coverage is inevitable and thus should be considered an intended consequence – reducing government financed health benefits by implementing barriers to care. Vice President Mike Pence and CMS Administrator Seema Verma supported these devious concepts in the Indiana Medicaid program, and now they want them implemented throughout the nation, of course with the approval of the respective state governments (through Section 1115 waivers).

The administrative waste of these programs is particularly egregious since the United States already is infamous for creating a proliferation of administrative complexities related to our insistence on perpetuating our highly inefficient, fragmented system of financing health care, heavily dependent on a multitude of private insurance programs plus public programs hindered by the administrative complexity inherent in our dysfunctional multi-payer system.

Why we continue this insanity is perplexing when we know that we could institute a streamlined, highly efficient single payer national health program by improving our Medicare program and then expanding it to include everyone. Should we just concede that it is perplexing and walk away? Well, no. The inertia might be perplexing, but how to fix our system is not. Let’s just do it.

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