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Again, medical bankruptcy is not a myth

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Again, medical bankruptcy is not a myth

On March 22, 2018, The New England Journal of Medicine (NEJM) published a Perspective article by Carlos Dobkin, Amy Finkelstein, Raymond Kluender, and Matthew J Notowidigdo titled “Myth and measurement — the case of medical bankruptcies” concluding, “our findings suggest that medical factors play a much smaller role in causing U.S. bankruptcies than has previously been claimed.”

Along with other background material, this was covered in the Quote of the Day for March 22, 2018:

https://pnhp.org…

Today, June 7, 2018, the NEJM has published a response by David Himmelstein, Steffie Woolhandler and Elizabeth Warren:

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Re: Myth and Measurement — The Case of Medical Bankruptcies

The New England Journal of Medicine, Correspondence, June 7, 2018

TO THE EDITOR

Dobkin et al. have made an important contribution in clarifying the relationship between health shocks and economic risk; like us, they have shown that health crises have major economic consequences for families and that even the insured are not adequately protected. However, in their Perspective article (March 22 issue), they mischaracterize our studies implicating medical problems as contributors to approximately 60% of personal bankruptcies, and their claim that medical bankruptcies are uncommon rests on methodologic choices that do not capture all medical causes of bankruptcy.

Contrary to their claim that our inferences about the causal relationship between medical bills and bankruptcy did not align with our respondents’ experiences, almost everyone we labeled “medically bankrupt” explicitly told us that medical problems caused their bankruptcy. For example, 41.8% of debtors interviewed specifically cited illness as a cause of their bankruptcy, 37.8% cited illness-related income loss, and 54.9% cited medical costs.

Dobkin et al. estimate the share of bankruptcies attributable to hospitalization from the change in slope of bankruptcy-filing trends after an index hospitalization. Yet, their data show that the rate began rising before hospitalization. Since the rate of bankruptcy does not increase with age, the increasing rate of bankruptcy before hospitalization could well be due to previous medical costs. Estimated bankruptcy rates based only on a change in filings after an index hospitalization are probably underestimates. In addition, they excluded anyone hospitalized in the 3 years before the study period, thus omitting many people with frequent hospitalizations — a group likely to be at high risk for medical bankruptcy.

The authors assume that hospitalization is the sole indicator of a medical problem that could lead to financial distress. But families can drown in medical debts without a hospitalization — they may spend hours in an emergency department after an accident, followed by months of physical therapy, or have chronic conditions requiring drugs costing tens of thousands of dollars. The authors explain that most people who incur high total medical expenditures have been hospitalized. Yet out-of-pocket — not total — expenditures are most salient to bankruptcy risk; an analysis of 2015 Medical Expenditure Panel Survey data reveals that only 18.2% of out-of-pocket spending was incurred by people hospitalized during the year. In effect, the authors excluded the people who incurred 81.8% of out-of-pocket costs.

Finally, the analysis by Dobkin et al. is not designed to measure bankruptcy associated with a child’s or spouse’s illness. However, a child’s terminal illness or a spouse’s long-term care can bankrupt a family.

Although they acknowledge the limitations of their analysis, the authors assert that their results “suggest that medical factors play a much smaller role in causing U.S. bankruptcies than has previously been claimed.” Yet medical bills account for a majority of unpaid debts sent to collection, and many other studies confirm that illness often inflicts financial suffering.

Debtors’ self-reports do have limitations. But hospitalization is only part of the story, and understanding medical bankruptcy requires multiple forms of empirical investigation, including asking debtors about their histories. Characterizing debtors’ self-reports as “myth” is demeaning to people struggling with health care costs, and artificially narrowing the definition of medical bankruptcy does not improve understanding of its causes.

David U. Himmelstein, M.D.
Steffie Woolhandler, M.D., M.P.H.
City University of New York at Hunter College, New York, NY

Elizabeth Warren, J.D.
U.S. Senate, Washington, DC

RESPONSE

The authors reply: Himmelstein et al. argue that if bankruptcy filers are asked what caused their bankruptcy, a large share will say medical expenses. But their approach is not a credible way to estimate the causes of bankruptcy. It is akin to asking patients with cardiac disease what caused their heart attack; they probably do not know whether it was poor genes, poor diet, stress, or other factors. A related problem is social desirability bias, which makes it hard to take at face value explanations reported by the bankruptcy filers.

Causal estimates require isolating a potential cause and its effect on the outcome of interest. This is why we examined the effect of hospitalizations on bankruptcy and why other, similar studies have examined the effect of automobile accidents or cancer diagnoses on bankruptcies. These studies corroborate our conclusion that medical bankruptcies are a very small share of personal bankruptcies.

Continuing to focus on medical bankruptcies distracts from the actual considerable economic costs of illness and injury. Our research highlights that for Americans — even those with health insurance — hospitalizations substantially decrease employment and income; by contrast, in Denmark, people are heavily insured against reduced earnings due to illness and injury. It is here that research and policy need to focus.

Amy Finkelstein, Ph.D.
Raymond Kluender, B.S.
Massachusetts Institute of Technology, Cambridge, MA

Matthew J. Notowidigdo, Ph.D.
Northwestern University, Evanston, IL

https://www.nejm.org…

***

Comment:

By Don McCanne, M.D.

It is difficult to understand why Amy Finkelstein and her colleagues are fixated on discrediting the landmark study on medical bankruptcy when they concede the “considerable economic costs of illness and injury.” There are a plethora of studies confirming the magnitude of medical debt and that our current health care financing system leaves far too many exposed to financial hardship.

Finkelstein et al make the very valid point that we we need to be insured against reduced earnings due to illness and injury – a point also made in the classic medical bankruptcy study by Himmelstein et al: “improved programs are needed to replace breadwinners’ incomes when they are disabled or must care for a loved one.” In focusing narrowly on income loss, it would be wrong to neglect the profound consequences of debt due to medical bills, even for those who are insured.

Suggesting that medical bankruptcy is a myth risks reducing the political support needed to revise our health care financing system so that it does not add financial hardship as an additional consequence of illness or injury. We emphatically do need a well designed, single payer national health program – an improved Medicare for all.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

There is a solution to rising health costs

By Jay Brock, M.D.
Fredericksburg (Va.) Free Lance-Star, June 7, 2018

Single-payer is the solution to rising healthcare costs

Your June 1 editorial [Obamacare premiums set to rise again] did a good job of pointing out the flaws in Obamacare: It is getting more expensive and unaffordable, especially for working and middle-class families who are self-employed or whose employers do not cover health care. And it’s failing to “bend the health care cost curve.”

What the editorial failed to do, however, is to present an alternative to the present dysfunctional health insurance system that you so rightly deplore.

In spite of your proclaiming that there is still no “cure” in sight, there is a viable alternative that has been successful in other advanced nations: A single-payer system such as National Improved Medicare for All.

NIMA would provide universal coverage to everyone living here, and do so while fixing many of the major flaws of the current system. It would decrease health care costs for 95 percent of hardworking American families, increase competition, decrease government interference, bend the health care cost curve, increase the number of people contributing into the system and be great for business.

Rather than complain about how bad the current system is (and you can blame interference from politicians for much of this), it behooves the Free Lance–Star to advocate for its replacement.

If you know a system that is better than National Improved Medicare for All, let’s hear it.

http://www.fredericksburg.com…

Myth and Measurement — The Case of Medical Bankruptcies

By David U. Himmelstein, M.D.; Steffie Woolhandler, M.D., M.P.H.; and Elizabeth Warren, J.D.
New England Journal of Medicine, June 7, 2018

To the Editor:

Dobkin et al.1 have made an important contribution in clarifying the relationship between health shocks and economic risk; like us, they have shown that health crises have major economic consequences for families and that even the insured are not adequately protected. However, in their Perspective article (March 22 issue),2 they mischaracterize our studies implicating medical problems as contributors to approximately 60% of personal bankruptcies,3,4 and their claim that medical bankruptcies are uncommon rests on methodologic choices that do not capture all medical causes of bankruptcy.

Contrary to their claim that our inferences about the causal relationship between medical bills and bankruptcy did not align with our respondents’ experiences, almost everyone we labeled “medically bankrupt” explicitly told us that medical problems caused their bankruptcy. For example, 41.8% of debtors interviewed specifically cited illness as a cause of their bankruptcy, 37.8% cited illness-related income loss, and 54.9% cited medical costs.4

Dobkin et al. estimate the share of bankruptcies attributable to hospitalization from the change in slope of bankruptcy-filing trends after an index hospitalization. Yet, their data show that the rate began rising before hospitalization. Since the rate of bankruptcy does not increase with age, the increasing rate of bankruptcy before hospitalization could well be due to previous medical costs. Estimated bankruptcy rates based only on a change in filings after an index hospitalization are probably underestimates. In addition, they excluded anyone hospitalized in the 3 years before the study period, thus omitting many people with frequent hospitalizations — a group likely to be at high risk for medical bankruptcy.

The authors assume that hospitalization is the sole indicator of a medical problem that could lead to financial distress. But families can drown in medical debts without a hospitalization — they may spend hours in an emergency department after an accident, followed by months of physical therapy, or have chronic conditions requiring drugs costing tens of thousands of dollars. The authors explain that most people who incur high total medical expenditures have been hospitalized. Yet out-of-pocket — not total — expenditures are most salient to bankruptcy risk; an analysis of 2015 Medical Expenditure Panel Survey data reveals that only 18.2% of out-of-pocket spending was incurred by people hospitalized during the year. In effect, the authors excluded the people who incurred 81.8% of out-of-pocket costs.

Finally, the analysis by Dobkin et al. is not designed to measure bankruptcy associated with a child’s or spouse’s illness. However, a child’s terminal illness or a spouse’s long-term care can bankrupt a family.

Although they acknowledge the limitations of their analysis, the authors assert that their results “suggest that medical factors play a much smaller role in causing U.S. bankruptcies than has previously been claimed.” Yet medical bills account for a majority of unpaid debts sent to collection, and many other studies confirm that illness often inflicts financial suffering.5,6

Debtors’ self-reports do have limitations. But hospitalization is only part of the story, and understanding medical bankruptcy requires multiple forms of empirical investigation, including asking debtors about their histories. Characterizing debtors’ self-reports as “myth” is demeaning to people struggling with health care costs, and artificially narrowing the definition of medical bankruptcy does not improve understanding of its causes.

https://www.nejm.org…

References

1. Dobkin C, Finkelstein A, Kluender R, Notowidigdo MJ. The economic consequences of hospital admissions. Am Econ Rev 2018;102:308-352. Crossref | Medline

2. Dobkin C, Finkelstein A, Kluender R, Notowidigdo MJ. Myth and measurement — the case of medical bankruptcies. N Engl J Med 2018;378:1076-1078. Full Text | Medline

3. Himmelstein DU, Warren E, Thorne D, Woolhandler S. Illness and injury as contributors to bankruptcy. Health Aff (Millwood) 2005;24:Suppl Web Exclusives:W5-63–W5-73. Crossref | Medline

4. Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical bankruptcy in the United States, 2007: results of a national study. Am J Med 2009;122:741-746. Crossref | Web of Science | Medline

5. Banegas MP, Guy GP Jr, de Moor JS, et al. For working-age cancer survivors, medical debt and bankruptcy create financial hardships. Health Aff (Millwood) 2016;35:54-61. Crossref | Medline

6. Consumer Financial Protection Bureau. Consumer credit reports: a study of medical and non-medical collections. December 2014 (http://files.consumerfinance.gov…).

The myth of Medicare’s projected insolvency

Headlines, June 5, 2018

The New York Times: Medicare’s Trust Fund Is Set To Run Out In 8 Years. Social Security, 16.

The Washington Post: A Crucial Medicare Trust Fund Will Run Out Three Years Earlier Than Predicted, New Report Says

The Wall Street Journal: Social Security Expected To Dip Into Its Reserves This Year

The Associated Press: Trustees Report Warns Medicare Finances Worsening

USA Today: Medicare, Social Security Face Money Challenges, Affordable Care Act

Modern Healthcare: Medicare Funds Drying Up Faster Than Estimated

Bloomberg: Medicare Fund Falls Short In 2026, Sooner Than Last Forecast

Politico: Medicare To Go Broke Three Years Earlier Than Expected, Trustees Say

https://khn.org…

***

Medicare Financial Outlook Worsens

By Phil Galewitz
Kaiser Health News, June 5, 2018

Medicare’s financial condition has taken a turn for the worse because of predicted higher hospital spending and lower tax revenues that fund the program, the federal government reported Tuesday.

In its annual report to Congress, the Medicare board of trustees said the program’s hospital insurance trust fund could run out of money by 2026 — three years earlier than projected last year.

Juliette Cubanksi, associate director of Kaiser Family Foundation’s Medicare Policy Program, cautioned that the report doesn’t mean Medicare is going bankrupt in the next decade but Part A will only be able to pay 91 percent of covered benefits starting in 2026.

She noted that Congress has never let the trust fund go bankrupt. In the early 1970s, the program came within two years of insolvency. But the 2026 estimate marks the closest the program has come to insolvency since 2009, the year before the Affordable Care Act was approved.

Joe Baker, president of the Medicare Rights Center, said Congress still has plenty of time to act without making changes that harm beneficiaries.

“I worry about fear mongering and the need to do something radical to the program,” he said.

https://khn.org…

***

Comment:

By Don McCanne, M.D.

Every year the Medicare trustees project the year in which the funds for Part A of Medicare will be inadequate to pay the full costs for that year, based on anticipated revenue and spending. Each year the media then report the pending insolvency of Medicare. This is nonsense.

Although revenues and demographics may change, adjustments are made to keep the program fully funded. Only if Congress were to decide to destroy Medicare would funding be reduced below sustainable levels. This is particularly ironic since this year the Republicans in their budget have already made a statement that we do not have to have adequate revenues to pay our bills – producing a budget with a trillion dollar deficit.

Our job is to elect representatives who support Medicare – not just for current beneficiaries but for everyone, in an improved version. The inevitable political support would ensure full funding forever.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Police arrest 20 protesters with Poor People’s Campaign at State Capitol

By Michael Aldrich and Jordyn Pair
The (Nashville) Tennessean, June 5, 2018

Twenty protesters from the Poor People’s Campaign were arrested Monday outside the governor’s office, according to the campaign. The protest was the campaign’s fourth consecutive protest over the past few weeks.

The Poor People’s Campaign is a grassroots movement with a broad platform that fights against systemic racism, economic inequality, environmental concerns and the overall moral state of the nation. The campaign is currently hosting a “40 Days of Moral Action” movement, with a mass rally in Washington, D.C., on June 23. Monday’s Nashville protest was part of more than 30 similar protests across the nation.

The Tennessee chapter has marched each Monday since May 14, focusing on a different topic each week and engaging in civil disobedience. Metro Nashville Police arrested 20 protesters last week and 21 people on May 21.

The protest began on the steps of the legislative plaza in downtown Nashville, where a group of around 50 people sang rally songs and gave speeches about health care and maintaining the environment.

The ecological arm of the movement’s platform includes a focus on renewable energy, fully-funded public water and sanitation, and protection of public lands, as well as bans on environmentally-dangerous mining of resources.

The protest is about “right to health and healthy environment,” said Beth Foster, 44, tri-chair of the Tennessee Poor People’s Campaign.

“It’s time the people be taken care of,” Foster said. “It is an honor to be able to do what we can.”

The weekly protests are part of the “40 Days of Moral Action,” a movement designed to shift national discussion away from issues like homosexuality and abortion — issues Foster calls “private, individual choices,” — and toward problems like systemic racism, poverty, the war economy, and ecological degradation.

“I think anybody who’s honest with themselves will know that these are immoral issues,” Foster said.

Foster has attended all three previous protests and been arrested twice.

Joe Fennell, 32, a freelance landscaper, said legislators need to support common people, not just the wealthy.

“We’re trying to communicate the message that lawmakers need to start putting Tennesseans first. Too many times they’ve handed out massive subsidies to big corporations while poor neighborhoods crumble,” Fennell said. “They’ll hear us in the streets, hear us in the courts or hear us in the voting booth.”

Fennel said he’d attended all four Nashville protests, but had only been arrested once.

Members of the Poor People’s Campaign say issues like health and being environmentally conscious are interconnected.

Amy Pragnell, 47, is especially passionate about people having access to fresh food.

“Being a chef, I understand food can be affordable,” Pragnell said.

Pragnell said densely urban and rural areas can struggle with food deserts, where there is a lack of accessible grocery stores with fresh food.

“Having affordable as well as accessible food for people all over is important,” Pragnell said. “Especially with children, they need affordable and accessible food.”

Pragnell said she did not plan to partake in the civil disobedience portion of the protest.

But she still supported their efforts.

“My heart will always be arrested with these people,” she said.

At 3 p.m., the crowd — carrying buckets of dirt, gardening tools and plants — moved to a patch of lawn down the street to create a “people’s garden.” A group of around twenty people spread the dirt out on the lawn and placed the plants in it.

A group of police stood by, although no arrests were made at the time.

The group then moved to the capitol building to attempt to see the governor. They were turned away at the office door.

Chants of “everybody’s got a right to live” and “everybody in, nobody out” echoed in the halls as roughly 35 members of the campaign sat outside the governor’s office.

“It’s a working office,” said Highway Patrol Trooper Brandon Smith, 35, who was part of a small group of troopers guarding the door. “They have to make an appointment to see the governor.”

The group then continued to chant and speak out on health care.

‘We’re all going to die,” Carol Paris, the president of the Physicians for a National Health Program, told the group. “We don’t need to die unnecessarily.”

Paris then asked if anyone had a “health care story to share.”

Tennessee state troopers told the group they had to leave the building when it closed at 4:30 p.m. They told protesters anyone who remained would be arrested.

Pragnell said it can be difficult to tell if legislators are even listening.

“There are few that do,” she said. “I can say that with confidence.”

https://www.tennessean.com…

Guns and Suicide

Violence Policy Center, May 2018

Guns claimed more than 38,000 lives in the United States in 2016. Yet unknown to most people is the fact that the most common type of gun death in our nation is suicide, not homicide. Equally unknown, and just as misunderstood, is the fact that the vast majority of suicides are preventable. People who use a gun to kill themselves aren’t necessarily more suicidal than those who use other means, they just have the tragic misfortune of having the most lethal means available to them in their time of depression and turmoil. Below are key facts regarding suicide and firearms.

In 2016 (the latest year for which complete national data is available) there were 44,965 suicides in the United States: 123 suicides per day; one suicide every 11.7 minutes. Of these 44,965 deaths, more than half (51.0 percent) used a firearm to take their own lives.

* Suicide is the 10th leading cause of death in the United States. Homicide is the 16th.

* Nearly three out of five people who die from gunshot wounds take their own lives.

* In 2016, the number of gun deaths by suicide in the United States was 22,938, whereas suicide by suffocation resulted in 11,642 deaths and suicide by poisoning resulted in 6,698 deaths.

A common argument is that a suicidal person will find a way to kill himself or herself no matter what — and a gun just happened to be available. However, the Harvard School of Public Health notes that “virtually every other method is less lethal than a firearm so there’s greater chance the person won’t die in their attempt…With a firearm, once the trigger is pulled, there’s no turning back.”

* Approximately 85 percent of suicide attempts with a firearm are fatal. Many of the other most widely used suicide attempt methods have case fatality rates below five percent.

* Guns, unlike other methods, require less preparation and planning. Nearly half (48 percent) of suicide attempt patients reported less than 20 minutes elapsed from first thought of suicide to actual attempt.

* “Attempters who take pills or inhale car exhaust or use razors have some time to reconsider mid-attempt and summon help or be rescued. The method itself often fails, even in the absence of a rescue.”

Every study that has examined the issue to date has found that within the United States, access to firearms is associated with increased suicide risk.

* “Merely having a gun in one’s home increases the likelihood that someone living there will commit suicide by a factor of 2 to 10.”

* States with higher rates of gun ownership tend to have higher rates of suicide than states with less gun ownership.

* One analysis found that, in total, there were almost twice as many suicides among people living in high- gun states as there were in low-gun states even though non-firearm suicides were about equal.

The Harvard School of Public Health created the Means Matter Campaign because “means reduction” has been proven to reduce suicide rates.

* When lethal means are made less available or less deadly (“means reduction”), suicide rates by that method decline, and frequently suicide rates overall decline. This has been demonstrated in a number of areas in the context of suicide: bridge barriers, detoxification of domestic gas, pesticides, medication packaging, and others.

* Firearm owners are not more suicidal than non-firearm owners; rather, their suicide attempts are more likely to be fatal because of guns’ heightened lethality.

* Nine out of 10 people who attempt suicide and survive will not go on to die by suicide at a later date.

* A lethal weapon available to a person in the depths of despair can end a life in an instant. Firearms are used in five out of 10 suicides in the U.S. Removing lethal means from a vulnerable person, especially a youth, can save a life.

http://www.vpc.org…

***

Comment:

By Don McCanne, M.D.

Although we desperately need to improve our health care financing system because of its high costs and mediocre performance, leaving too many out, we need to intensify efforts at improving public health and prevention. It would be great to have an improved Medicare for everyone, but that is of little help when presented with someone who just died from a self-inflicted gunshot wound. For that problem, prevention is an imperative.

Guns are a public health hazard. In 2016, guns claimed more than 38,000 lives, and almost 23,000 were by suicide. Understanding the facts, as listed in this report from the Violence Policy Center, lead to some obvious conclusions as to interventions that would help. Some can be accomplished in the private sector, but others clearly require public policies and regulations.

What do gun regulations and a single payer national health program have in common? We’ve known for decades the public policies in both of these realms that we need to enact in order to improve the protection and preservation of our health, and yet we have failed to act. Yes, we have many regulations for both health care and guns, but they are so feeble that they have failed us.

Are we going to continue to let America’s Health Insurance Plans (AHIP) and the National Rifle Association (NRA) obstruct the reforms that we need? Or are we finally going to let our elected representatives know that we are serious about wanting action now?

Today is election day in California. I’m about to vote, and these issues will certainly influence my selections. I hope that they will influence yours as well.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

The profound link between poverty and health

By Jessica Schorr Saxe, M.D.
The Charlotte Observer, June 1, 2018

On Monday, The Poor People’s Campaign: A National Call for Moral Revival will hold rallies in Raleigh and other state capitals focusing on health care and ecological devastation.

You might wonder how poverty relates to health. Profoundly.

In medicine, when we talk about risk factors and “risk factor reduction,” we usually mean conditions such as high blood pressure, diabetes, or high cholesterol as, for example, risks for heart disease.

Low income and low wealth are associated with lower life expectancy; higher rates of heart disease, diabetes, and other chronic illnesses; increased infant mortality; and higher rates of childhood conditions including asthma, heart conditions, hearing problems, digestive disorders, and elevated blood lead levels. “Socioeconomic status is the most powerful predictor of disease, disorder, injury and mortality we have,” says Dr. Tom Boyce, chief of Developmental Medicine at University of California at San Francisco.

The links between poverty and poor health include lack of access to health services, inadequate and unsafe housing, lack of nutritious food, and inadequate physical activity. And science shows that the stress of poverty leads to depressed immune systems. Poor children are more likely to have Adverse Childhood Experiences (ACEs), such as abuse, neglect, or exposure to substance abuse or mental illness. ACEs have been shown to increase the risk of later heart disease, cancer, and other illnesses as well as alcoholism and other detrimental behaviors.

In medical practice, I saw the risks of poverty daily. I saw patients who missed appointments or medication doses because they didn’t have the necessary money. I saw patients who wanted to exercise but whose neighborhoods weren’t safe for walking, couldn’t afford the gym or didn’t have transportation. I saw children so burdened with ACEs that their future was bleak.

Addressing issues related to poverty, an underlying and arguably the most important risk factor for disease, can make a difference. High-quality early childhood programs that support parenting lead to increased educational achievement, higher incomes and better health. One study showed that increasing the minimum wage was associated with a decrease in low birth weight babies and infant mortality. Another study showed that raising the minimum wage in New York in 2008 would have prevented thousands of deaths over the next 5 years. “Mincome,” a guaranteed minimum income experiment in Canada that gave money to low-income residents, decreased hospitalization rates and mental health diagnoses.

What to do? Join us at the Poor People’s Campaign in Raleigh on Monday.

If you can’t attend, learn about it at https://www.poorpeoplescampaign.org and support the demands that include living wage laws; Medicaid expansion, protection of Medicare, and single-payer universal health care; access to mental health professionals and addiction and recovery programs; equal treatment for people with disabilities; and immediate attention to policies that would end child poverty.

Fifty years ago, Martin Luther King led the Poor People’s Campaign against the triple evils of poverty, racism and militarism. Rev. William Barber II, one of the co-leaders of the current campaign which has added environmental degradation as a fourth evil, notes that this is not a commemoration, but a reconsecration.

Join this reconsecration to bring justice and equity — and health — to all.

Jessica Schorr Saxe is a retired Charlotte physician who is chair of Health Care Justice—NC. Contact her at hcjusticenc@gmail.com.

http://www.charlotteobserver.com…

Higher spending on brand-name drugs in spite of lower use in Medicare Part D

Increases in Reimbursement for Brand-Name Drugs in Part D

U.S. Department of Health & Human Services, Office of Inspector General, June 2018

What OIG Found

* Total reimbursement for all brand-name drugs in Part D increased 77 percent from 2011 to 2015, despite a 17-percent decrease in the number of prescriptions for these drugs.

* After accounting for manufacturer rebates, reimbursement for brand-name drugs in Part D still increased 62 percent from 2011 to 2015.

* Part D unit costs for brand-name drugs rose nearly 6 times faster than inflation from 2011 to 2015.

* The percentage of beneficiaries responsible for out-of-pocket costs of at least $2,000 per year for brand-name drugs nearly doubled across the 5-year span.

Conclusion

We found that, over a 5-year period, increases in Part D reimbursement for brand-name drugs outpaced inflation. Despite a decrease in utilization of brand-name drugs, these substantial increases in reimbursement led to greater Medicare spending and higher beneficiary out-of-pocket costs for these drugs. Specifically, total Part D reimbursement for all brand-name drugs increased 77 percent, from $58 billion in 2011 to $102 billion in 2015. To control for the possibilities that (1) increases in utilization or (2) newer, more expensive brand-name drugs may have affected total Part D reimbursement, we analyzed the number of prescriptions and unit costs for brand-name drugs that were reimbursed in every year from 2011 to 2015. Overall, we found that utilization decreased for the majority of these brand-name drugs, while the average Part D unit cost increased 29 percent from 2011 to 2015.

Increases in Part D unit costs significantly outpaced inflation; in fact, the average unit cost for brand-name drugs in Part D rose nearly 6 times faster than inflation from 2011 to 2015. We also found that Part D unit costs closely followed the upward trend in benchmark prices, which are typically reflective of manufacturer prices. Therefore—like the 2016 ASPE report, which suggested that increases in drug prices contributed to the growth in total prescription drug spending—we conclude that increases in unit prices for brand-name drugs resulted in Medicare and its beneficiaries’ paying more for these drugs.

We also found that the percentage of beneficiaries who were responsible for out-of-pocket costs of at least $2,000 per year for brand-name drugs nearly doubled across the 5 years. These trends are consistent with those described in the previous OIG report, which found increases in the number of beneficiaries who reached the catastrophic-coverage phase of their Part D benefits. In addition, we found that total beneficiary out-of-pocket costs were highest for brand-name drugs in three therapeutic classes of maintenance drugs (insulins, cholesterol reducers, and respiratory tract corticosteroids). Because maintenance drugs are typically used to treat chronic, long-term conditions, increasing reimbursement for these drugs will continue to affect Part D and its beneficiaries for years to come. OIG remains committed to examining these issues and working with CMS to ensure the integrity of the Part D program.

https://oig.hhs.gov…

***

Comment:

By Don McCanne, M.D.

Probably the most significant finding in this OIG study is that the unit costs (prices paid) for brand-name drugs in Medicare Part D rose six times faster than the rate of inflation. Although the use of brand-name drugs has declined 17 percent, the total reimbursement has increased 77 percent because of these unit cost increases.

These escalating unit costs are borne by both the taxpayers who fund Medicare and the patients who are paying higher out-of-pocket costs. The spending increases have been particularly burdensome for patients requiring maintenance drugs for chronic conditions.

We do not have to continue to put up with this. Last month, a group associated with Physicians for a National Health Program released a proposal that would ensure universal access to safer, more innovative, and more affordable drugs. The report can be accessed at the following link:

https://pnhp.org/pharma

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Instilling personal responsibility into prisoners through co-pays – another nutty idea

The $580 Co-pay

By Beth Schwartzapfel
The Marshall Project, May 30, 2018

For those in the outside world accustomed to paying $25 or more at every doctor’s visit, the idea of prisoners paying $2 to $8 to see a doctor seems nominal. Forty-two states plus the federal Bureau of Prisons charge a co-pay, according to the Prison Policy Initiative, a criminal justice think tank.

When you’re making pennies an hour, or nothing at all, a small co-pay can be the equivalent of hundreds of dollars.

Prisons charge co-pays for similar reasons as free-world health insurers: to cut down on unnecessary medical visits by requiring patients to share in the cost of their care. U.S. prisons spend between $3,000 and $10,000 per inmate per year on medical care — about 20 percent of total prison spending—according to a 2014 analysis by the Pew Charitable Trusts.

“We want a real-world environment for the prisoners because in the real world you and I would be required to have a copay,” Mark Myers, spokesman for the Oklahoma Department of Corrections, told the news site the Frontier. Prisoners in Oklahoma earn 5 cents per hour at the bottom of the wage scale, so the state’s $4 co-pay is roughly equivalent to $580 for a minimum wage worker on the outside, the Frontier reported.

Most states charge a fee for each visit, with a $3.47 national average, according to the Prison Policy Initiative’s 2017 analysis. At $8 per visit, Nevada’s prison co-pay is the highest in the nation. “Charging a co-pay encourages the inmates to develop personal responsibility for their health care, it helps manage the volume of unnecessary doctor appointments in the clinics and assists with a small portion of the medical costs,” said Brooke Santina, spokeswoman for the Nevada Department of Corrections.

Despite their toll on inmates’ individual finances, the fees don’t add up to much on prisons’ balance sheets. In Illinois, the $5 co-pay brings in about $400,000 per year — not enough to recoup the administrative costs of running the program, according to Department of Corrections spokeswoman Lindsey Hess.

Illinois lawmakers want to change that in their state. They voted last week to eliminate the $5 co-pay the state’s prisons have been charging for years. “When you’re denied your liberty, medical care is part of the deal. If you need it, you should get it,” said Jennifer Vollen-Katz, executive director of the John Howard Association, a state prison watchdog group that pushed the legislation. In letters and surveys, co-pays consistently emerged as one of prisoners’ biggest concerns, Vollen-Katz said, with more than half saying they avoid health care to avoid the co-pay.

https://www.themarshallproject.org…

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Comment:

By Don McCanne, M.D.

The insistence on charging prisoners who have essentially no income a co-pay for health care services is an example of how fixated our policymakers are on designing health care financing systems based on existing policies, no matter how flawed.

Who in their right mind really believes that a prisoner earning maybe a nickel an hour is  developing “personal responsibility” for health care by paying a four dollar co-pay for a medical visit? Yet this personal responsibility meme has permeated nearly our entire health care financing system resulting in adverse outcomes because of the financial disincentives to obtaining appropriate health care.

Although co-pays for prisoners are ridiculous on the face of it and should be eliminated, as you go up the scale of income and levels of cost sharing, the negative impact might lessen, but it is not eliminated except perhaps for the very wealthy. Numerous studies have confirmed that cost sharing for working families with good incomes can still result in financial insecurity and impaired access to care.

Our personal responsibility should be to obtain care for our family members or ourselves when it seems appropriate for preventive or therapeutic purposes. The burden of cost sharing conflicts with such personal responsibility – the opposite of what our policy goals should be.

A well designed, single payer improved Medicare for all gets the personal responsibility concept right so that everyone can receive appropriate health care when needed.

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Trump administration’s false rhetoric on the social determinants of health

Social Determinants Of Health: A Public Health Concept In Conflict

By Danielle Garrett, Ann Hwang, Clare Pierce-Wrobel
Health Affairs Blog, May 30, 2018

The new battlefront over health programs for the poor is taking place over what has historically been a progressive concept: social determinants of health. The new battlefront over health programs for the poor is taking place over what has historically been a progressive concept: social determinants of health.

This approach builds off of extensive public health research that shows changing health behaviors is most effective when paired with changes to the broader environment that enable those behaviors. In practice, this often involves removing barriers to services and increasing access to successful interventions.

Same Words, New Meaning

In January 2018, when the Centers for Medicare and Medicaid Services (CMS) announced that it would allow states to implement work requirements as a condition of receiving Medicaid coverage, the letter from CMS to state Medicaid directors employed language with seemingly familiar tones as it noted the many “determinants of health.” It went on to state that, “CMS recognizes that a broad range of social, economic, and behavioral factors can have a major impact on an individual’s health and wellness, and a growing body of evidence suggests that targeting certain health determinants, including productive work and community engagement, may improve health outcomes.”

Secretary of Health and Human Services Alex Azar echoed the letter from CMS when he noted that many state officials were discussing requests for work requirements. “It seems to be getting a great deal of excitement to deal with the social determinants of health,” Secretary Azar shared during a February press conference in Indianapolis announcing the federal government’s approval of a Medicaid work requirement waiver for the state of Indiana.

While described as being about social determinants of health, the proposed policy from CMS actually takes an antithetical approach. If a beneficiary doesn’t meet the work requirements, this policy imposes a barrier to health care access by locking that individual out of Medicaid coverage. Rather than addressing the underlying factors that might contribute to lack of employment, such as need for education, training, transportation, the availability of jobs in the community, and poor health itself, the policy utilizes a punitive approach.

All Sticks And No Carrots

Punishing people for not engaging in a desired behavior by removing their access to care has very real consequences for people’s health and might actually exacerbate undesired health behaviors. It is nonsensical for a policy that is pitched by policymakers as improving health to actually do the opposite, as people will lose access to health care. Such an approach will likely make it even more difficult for individuals to find employment in addition to impacting their health.

The history of safety net programs has shown work requirement policies to be unsuccessful in improving employment or health status. For example, when Wisconsin implemented a work requirement for their food support program, more than three people lost coverage for every individual who gained employment. Lack of health insurance coverage is associated with a variety of poor health outcomes and a lack of access to care.

Creating A New Barrier To Health

While truly addressing the social determinants of health involves removing barriers that prevent people from making healthy decisions, punitive policies such as work requirements create an environment where people face more barriers to making healthy decisions. Medicaid work requirement waivers currently under development also demonstrate how these policies can inequitably distribute these barriers. A proposal under consideration in Michigan, for example, would disproportionately enforce the requirements for urban centers and communities of color that are facing major health and employment crises—like Flint—while exempting mostly white, rural communities.

An agenda that attempts to change health behaviors by making it harder to make healthy choices runs the risk of actually worsening health outcomes, increasing disparities, and diverting investments away from evidence-based interventions that improve health. We should not be fooled by the contorted language from CMS about “social determinants” that is being used to promote policies that only make it harder for people to make the healthy choice.

https://www.healthaffairs.org…

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After Years of Trying, Virginia Finally Will Expand Medicaid

By Abby Goodnough
The New York Times, May 30, 2018

Virginia’s Republican-controlled Senate voted on Wednesday to open Medicaid to an additional 400,000 low-income adults next year, making it all but certain that the state will join 32 others that have already expanded the public health insurance program under the Affordable Care Act.

Republican lawmakers in the state had blocked Medicaid expansion for four straight years, but a number of them dropped their opposition after their party almost lost the House of Delegates in elections last fall and voters named health care as a top issue.

The House passed the Senate bill within hours; it will now go to Mr. Northam’s desk. The measure includes a requirement that many adult recipients who don’t have a disability either work or volunteer as a condition of receiving Medicaid — a provision that was crucial to getting enough Republicans on board.

“That is debt, and I have four kids who are going to be having to pay for that for the rest of their lives,” Senator Amanda Chase, a Republican from Chesterfield, said of the federal funds spent on Medicaid expansion, explaining her vote against it on Wednesday.

This year, Republican governors and state lawmakers, encouraged by the Trump administration, have focused on adding new requirements for Medicaid eligibility, such as requiring adults without disabilities to work or volunteer, and many beneficiaries to pay premiums.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

It is an outrage that Trump administration officials contend that taking away health benefits from individuals who are unable to find qualifying employment is a policy that “may improve health outcomes.”

We can be thankful to Danielle Garrett, Ann Hwang, and Clare Pierce-Wrobel for writing this article and for Health Affairs for publishing it. It is important that the nation understands what these policies really mean. As the authors state, “It is nonsensical for a policy that is pitched by policymakers as improving health to actually do the opposite, as people will lose access to health care.”

This is not some theoretical consideration; it is really happening. Virginia legislators have fought Medicaid expansion for years and now agree to it only because the work requirement was added.

We are seeing more pleas for everyone to come together to address these social problems for the betterment of all of us. But when a policy goal of accessible and equitable health care for all conflicts with a policy goal of erecting barriers to health care (work requirements, unaffordable deductibles, narrow provider networks, spartan plans, unaffordable benefit tiers, etc.), how can we ever find common ground?

Those supporting health care for all clearly hold the moral high ground. Those who would deliberately create barriers to health care for some should explain to the rest of us the moral basis for their positions that seem to rest on very shaky ground. They should provide us with a credible explanation of how they are sharing with us a firm moral footing. The fact that health care costs money is not an adequate excuse since we are already spending enough to provide care for everyone if we would just change our policies to those that work, such as with an improved Medicare for all.

Really. It is depressing to see our nation’s political leaders support these inherently cruel policies. What is it that the voters see in them? Aren’t we entitled to a reasonable explanation of why these legislators should be the ones to dictate policy?

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Everyone agrees: Trump’s new insurance rules are terrible

Trump's new insurance rules are panned by nearly every healthcare group that submitted formal comments

By Noam Levey
Los Angeles Times, May 30, 2018

More than 95% of healthcare groups that have commented on President Trump’s effort to weaken Obama-era health insurance rules criticized or outright opposed the proposals, according to a Times review of thousands of official comment letters filed with federal agencies.

The extraordinary one-sided outpouring came from more than 300 patient and consumer advocates, physician and nurse organizations and trade groups representing hospitals, clinics and health insurers across the country, the review found.

State insurance regulators from both political parties have also warned that the administration’s proposals could destabilize insurance markets, raise premiums for sick Americans and open the door to insurance fraud.

And dozens of industry leaders and other experts have called on the administration to rethink moves to scale back consumer protections enacted through the Affordable Care Act, often called Obamacare.

“Basically anybody who knows anything about healthcare is opposed to these proposals,” said Sandy Praeger, a former Republican state insurance regulator in Kansas and onetime president of the National Assn. of Insurance Commissioners. “It’s amazing.”

After the failure to repeal the healthcare law last year, the Trump administration is weighing two controversial new rules to loosen regulations governing health plans. One would expand the availability of short-term coverage plans that last less than a year. The other would make it easier for self-employed Americans and small businesses to band together to form so-called association health plans.

These plans — which administration officials say will be more affordable — would not have to offer the full set of health benefits required under the 2010 law and in some cases could turn away sick customers.

Altogether, more than 95% — or 266 of 279 — of the healthcare groups that filed comments about the proposed association health plan regulation expressed serious concern or opposed it, the Times analysis found.

And more than 98% — or 335 of 340 — of the healthcare groups that commented on the proposal to loosen restrictions on short-term health plans criticized it, in many cases warning that the rule could gravely hurt sick patients.

Among the groups were virtually every leading patient advocate in the county, including the American Lung Assn., the American Heart Assn., the Cystic Fibrosis Foundation, the March of Dimes, the National Multiple Sclerosis Society, Susan G. Komen, AARP and the advocacy arm of the American Cancer Society.

Not a single group representing patients, physicians, nurses or hospitals voiced support in the public comments for the two Trump administration proposals.

These concerns were echoed by the leading health insurance trade groups, as well as many individual health insurers that cautioned that rates would only increase as looser rules further destabilized insurance markets across the country.

The Trump administration has not indicated when it will finalize the proposed new insurance regulations.

http://www.latimes.com…

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Comment:

By Don McCanne, M.D.

Donald Trump, Alex Azar and Seema Verma just don’t get it. Everyone, expect for a few ideologues, agrees that the administration is mismanaging our nation’s health care policies. Obviously we need to change course.

The policies that would accomplish the goals of universality, access, equity, and affordability are not secret. They are those policies contained within a well designed, single payer, improved Medicare for all. We simply need an administration and Congress who agree and are willing to enact and implement such a system.

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Enough is enough. It’s time for single-payer health care.

By Jennifer Perkins, M.D.
Anchorage (Alaska) Daily News, May 29, 2018

How much longer will we tolerate incremental approaches to fix a broken health care system that feeds off disease and profits on the sick? Extremely high health care costs have become so common place that we rarely question them. News headlines flash about a “… plan to control drug prices,” or “Medicaid work requirements to cut state costs,” while casualties of the pharmaceutical-driven opioid epidemic pile up on the inside pages.

I am part of the problem. As a family doctor, I direct the flow of health care dollars through the drugs I prescribe, the tests I order and the specialists I refer to. I do not set the prices. In fact, as an employed physician, I often have no idea what they are. The incredible complexity of financing is a direct result of the “profit-driven disintegration of our health care ‘market.'”

I moved to Alaska to work for an innovative, nonprofit system truly committed to the health of its population. I love my work, my team and my patients. I am frustrated that all of us do not have access to this quality care. The health care system I imagine would focus on wellness, not just the absence of disease. When we got sick in this system, we would receive the appropriate care without the financial burden.

James worked three jobs for most of his life. Providing for an adult child struggling with addiction and aging parents, he had to choose between exorbitant health insurance premiums and paying the bills. He had the sense that something was wrong long before his nausea made eating impossible. He refused to go to the emergency room despite his wife’s pleas because he knew he couldn’t afford the evaluation. He fell. His wife called 9-1-1. He was diagnosed with Stage 4 colon cancer, dying from this preventable disease nine months later after multiple surgeries and bank-breaking medications. Mercifully, he never saw the hospital bills that claimed every last penny, including the roof over his family’s head.

Our health care system is killing us. Literally thousands of people die every year from lack of insurance. Figuratively, lives are forever altered by too many unnecessary, profitable medical procedures and too little focus on preventative health. Healthcare costs for families skyrocket, shifted from ever- wealthier insurance companies. Teachers fight tooth and nail for mediocre coverage while their wages stagnate. Small businesses flounder under the unpredictable burden of providing employee plans. Large businesses lose competitive advantage on the international stage. Health care consumes a dominant chunk of state budgets (35 percent in Alaska), while many of its hardworking residents remain without insurance or are inadequately covered.

James’s death could have been prevented by access to basic primary care. His financial ruin could have been averted. In other industrialized nations, hardship from medical expenses is rare. All provide some version of universal coverage, liberating citizens from the stress of medical bills when coping with accident or illness, and at a much lower cost. Our market-based system has failed us. The time for single payer is now.

In a single-payer system, everyone is covered by a comprehensive health plan that is publicly funded but privately delivered. This allows innovation in health care delivery by privately owned physician groups and hospital systems.  The government does not run your health care, they pay for it. In fact, they already are. The federal government spends more per person right now in the U.S. than in most countries that provide universal coverage. We match the federal dollars with individual contributions and still do not get better outcomes. Sweden, considered to have one of the best systems in the world, spends about half and pays people when they are sick. By centralizing the payer, we shift incentives from procedures to prevention and contain outrageous costs.

Some say that definitive reform is out of reach, that it is not politically viable. As Nelson Mandela said, “It always seems impossible until it’s done.” Yes, we are a country that contains extremes of values and opinions, of independence and free market priorities. And we all have bodies that may fail us at unpredictable times. It is time to demand a system that promotes our health and protects us from financial hardship when ill.

Dr. Jennifer Perkins is a family physician in Anchorage and founder of the Alaska chapter of Physicians for a National Health Program.

https://www.adn.com…