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Democrats should let GOP own Obamacare repeal

By Froma Harrop
Herald Net, December 13, 2016

What if Republicans abruptly repealed Obamacare, chaos ensued and Democrats sat on their hands and watched? Democrats would be doing the right thing, both for the American people and for themselves.

Donald Trump has vowed to repeal Obamacare on day one of his administration. What would he replace it with? “Something terrific.” Vice President-elect Mike Pence concurs: “We’re going to repeal Obamacare lock, stock and barrel.” Good luck to them.

And they’ll need it. The Republicans’ sly repeal-and-delay gambit — repealing the Affordable Care Act right away while delaying the effective date until after the midterms — wouldn’t work. Just the act of setting a kill date for Obamacare would unleash pandemonium in the insurance market.

Democrats are wisely sending their regrets. “If they repeal without a replacement, they will own it.” incoming Senate Minority Leader Chuck Schumer said. Democrats will not join them in a “half-baked solution that we will partially own.”

So what would happen if Obamacare came crashing down? Wouldn’t that hurt the very people Democrats have vowed to defend? Yes, but if Democrats participated in a sloppy repeal, they’d get blamed without fixing anything.

Better that an inflamed electorate sweeps Democrats into power and they build a new, simpler model for universal health care. They already have something terrific lined up, something called Medicare for all.

With Medicare, there are no annoying mandates, no gaming by insurers. Taxes pay most of the bills. Medicare employs a rational means of controlling costs, and the public already loves it.

Suppose Democrats approved Medicare for all and Trump were still president. Trump has said nice things in the past about Canada’s single-payer system. Chances are good that he would sign the bill.

A lot of what-ifs here, but one strongly suspects that on this issue, Trump really doesn’t care.

http://www.heraldnet.com…

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Comment:

By Don McCanne, M.D.

The scenario here is quite unrealistic, but it ends with Medicare for all, so it’s nice to take a break and fantasize for a moment.

Even though the Republicans might pass a resolution to “repeal Obamacare” at some unspecified date far into the future, it would only be a resolution that they can file away once interest wanes. They certainly will not risk the backlash that would occur by causing maybe 30 million people to lose their insurance coverage. Even if there were a backlash and the Democrats took control of Congress, they would not enact Medicare for all. Some single payer supporters in Congress have become almost belligerent when asked if they would lead on single payer reform. It is not on the political horizon at this time. And even if Donald Trump were still president after Democrats gained control of Congress, he has already shown that his populist approach was a fraud as he surrounds himself exclusively with extreme conservatives.

Well, enough fantasizing. Let’s get back to the basics: education, coalition building, and grassroots organizing. It’s hard work, but it’s got to be done. D.C. won’t lead on this. The people have to.

One In Five Inpatient Emergency Department Cases May Lead To Surprise Bills

By Christopher Garmon and Benjamin Chartock
Health Affairs, December 14, 2016

Abstract

A surprise medical bill is a bill from an out-of-network provider that was not expected by the patient or that came from an out-of-network provider not chosen by the patient. In 2014, 20 percent of hospital inpatient admissions that originated in the emergency department (ED), 14 percent of outpatient visits to the ED, and 9 percent of elective inpatient admissions likely led to a surprise medical bill.

From the Discussion

We found that roughly one in five inpatient ED admissions and roughly one in seven outpatient ED visits were likely to result in a surprise medical bill. So were almost one in ten elective inpatient admissions. These results are consistent with past surveys that found that, while most patients receive care from in-network providers, those who receive out-of-network care are often surprised by the bills for that care.

Our data were sampled from patients with employer-sponsored health insurance, who account for 56 percent of the nonelderly population. Many Marketplace plans have narrow hospital and physician networks, and many Marketplace customers are unaware of the network configurations of offered plans. Thus, surprise medical bills may be more common for patients with Marketplace plans than for patients with employer-sponsored insurance.

We found that admissions of patients with more severe diagnoses were more likely to result in surprise medical bills. This is troubling because one objective of insurance is to offer proportionately more protection in situations that are extreme and costly. However, our results suggest that prolonged exposure to relatively high numbers of physicians and services increases the likelihood that a patient will receive a surprise medical bill.

http://content.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

There has been considerable publicity about insured patients facing unexpected medical bills in hospitals and emergency departments because some care was provided by out-of-network professionals even though the facility was within the insurer’s network. This report adds to our knowledge by quantifying the extent of this problem.

The study was of patients with employer-sponsored plans, so this is a problem independent of the implementation of the Affordable Care Act, though the authors note that the plans in the ACA exchanges (Marketplace) have narrower hospital and physician networks and thus patients may be even more prone to receiving unexpected medical bills.

Further, patients with more severe diagnoses receive more care from a greater number of physicians and thus are even more likely to receive surprise medical bills. This defeats one important goal of insurance which is to provide greater protection for individuals who require more costly care.

This is clearly unfair to patients who fulfilled their responsibility to obtain health insurance, and used facilities that were in the insurers’ networks.

To correct this injustice, states are beginning to require that out-of-network providers accept from the patient only copayments or coinsurance that the patient would have paid if the provider had been in the network. Thus the patient who dutifully obtained insurance is not harmed.

The out-of-network provider must then turn to the insurer to receive payment. Does the insurer have the right to limit payment to what contracted providers receive? If so, the private insurers would have no reason to contract with physicians who hold out for higher rates. The insurers then become a private sector administrator of price controls, which is even worse than government price controls since the government has a responsibility to consider some degree of fairness in its price setting. Although this may set rates for out-of-network providers in a covered facility, it does not do anything about high prices charged by these providers in circumstances where the patient is not captive. Another possibility is that the out-of-network provider may be granted the ability to negotiate higher rates from the insurer as long as the patient does not have to pay any more. With the insurer paying more, that would be reflected in higher insurance premiums that the patient or employer would have to pay. Besides, there is some fundamental unfairness with an insurer being able to keep a professional out of its network yet demand low payment rates for which the professional never contracted.

The problem with this solution for out-of-network balance billing is that the assumption is made that the correction must be made within the confines of our dysfunctional, fragmented financing system that has only been perpetuated by the Affordable Care Act. That complicates the solution when it really is this financing infrastructure that needs to be repaired, or actually replaced. With a well designed single payer national health program – an improved Medicare for all – the patients simply receive care, and appropriate payments are made directly to the professionals and institutions by the public payer. The patient is never caught in a trap with surprise bills.

Congress Just Quietly Handed Drug Companies a Dangerous Victory

By Adam Gaffney
New Republic, December 14, 2016

Last week, the Senate followed the House in passing the 21st Century Cures Act. Though this bill has been lauded by liberals for providing much-needed funds for medical research, its real impact will be elsewhere. Whereas drug approval traditionally required the demonstration of real clinical benefit in a randomized clinical trial, under the Act drug firms will increasingly be able to rely on flimsier forms of evidence for approval of their therapies (incremental steps in this direction, it is worth noting, have already occurred). The Act, by reconfiguring the drug regulatory process, lowers the standards for drug approval — a blessing for drug makers, but an ill omen for public health.

In the Senate, a grand total of five senators — including Bernie Sanders and Elizabeth Warren — voted against it. The media, meanwhile, has for the most part done a poor job dissecting its actual contents. As a result, few now realize how detrimental the act is likely to be for drug safety, or appreciate the mix of conservative ideology and pharmaceutical industry greed underlying the longstanding campaign that brought it to fruition.

The 21st Century Cures Act allows “the potential use of real world evidence” to support the approval of a novel indication for an approved drug and “to help to support or satisfy postapproval study requirements.” That sounds rather reasonable: who could possibly oppose the use of “real world evidence”? The problem, however, is that “real world evidence” actually means here “really bad evidence.” The law defines “real world evidence” as “data… derived from sources other than randomized clinical trials,” which is to say uncontrolled observational data.

This is perhaps the bill’s most dangerous clause Randomized clinical trials are — in the vast majority of cases — the only way to know if a drug actually works, as observational studies can be notoriously unreliable in determining the efficacy of drugs.

Randomized clinical trials are not perfect, especially when they are conducted by pharmaceutical companies with a vested interest in distorting trial methodology (or hiding trials results when they don’t go as planned). But they are the best we have when it comes to assessing drug efficacy. With this new provision, however, randomized clinical trials can — in some instances — be skirted altogether, leaving both doctors and patients forever in the dark as to a drug’s actual therapeutic utility for a particular indication. Their profitability, in contrast, will be rather more clear.

Adam Gaffney is an Instructor in Medicine at Harvard Medical School and a board member-elect of Physicians for a National Health Program.

https://newrepublic.com…

More on this topic by Trudy Lieberman:
http://www.healthnewsreview.org…

And winners and losers by Sheila Kaplan:
https://www.statnews.com…

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Comment:

By Don McCanne, M.D.

We did not have to wait for the incoming, anti-government administration to take over. Yesterday President Obama signed the 21st Century Cures Act. It will reduce government oversight of drugs – allowing on the market products that may not be effective and might even be dangerous.

Yes, there were some good things in the legislation, but some of the appropriations were deferred until future years – under control of a Congress that has already demonstrated that it is quite willing to refuse to appropriate funds for existing programs. This could be an empty promise.

The politics is depressing. As the concerns of Sen. Warren and Sen. Sanders were beginning to gain coverage in the media, the Congressional leadership called in Joe Biden to give an emotional appeal on behalf of his cancer moonshot that was included in this legislation. And to top it off, one section of the legislation was renamed after his son, Beau Biden, who tragically died in his prime of brain cancer. How could a member of Congress be so heartless as to vote against this legislation?

In reality, those members of Congress voted for countless deaths and suffering that will occur from defective drugs and devices. That is truly heartless. They also voted for an open conduit of money flowing to the pharmaceutical and medical device industries – our money, whether through taxes, insurance premiums, or direct consumer purchases. Heartless greed, pure and simple.

Wait until the billionaires are in charge of our government, not they they don’t already own it. We likely haven’t seen anything yet.

Working Paper 22917; Improving the Quality of Choice in Health Insurance Markets

By Jason Abaluck and Jonathan Gruber
National Bureau of Economic Research, December 2016

Abstract

Insurance product choice is a central feature of health insurance markets in the United States, yet there is ongoing concern over whether consumers choose appropriately in such markets – and little evidence on solutions to any choice inconsistencies. This paper addresses these omissions from the literature using novel data and a series of policy interventions across school districts in the state of Oregon. Using data on enrollment and medical claims for school district employees, we first document large choice inconsistencies, with the typical employee foregoing savings of more than $600 in their insurance plan choice. We then consider three types of interventions designed to improve choice quality. We first show that interventions to promote more active choice are unlikely to improve choice quality based on existing patterns of plan switching. We then implement a randomized trial of decision support software to illustrate that it has little impact on plan choices, largely because of consumer avoidance of the recommendations. Finally, we show that restricting the choice set size facing individuals does significantly reduce their foregone saving and total costs. This is not because individuals choose worse with larger choice sets, but rather because larger choice sets feature worse choices on average that are not offset by individual re-optimization.

The full paper can be downloaded for free at this link (69 pages):
http://www.nber.org…

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Comment:

By Don McCanne, M.D.

Superficially this seems to be another boring research paper on health insurance markets. But, without intending to do so, it challenges the fundamental concept that we can improve health care financing by offering individuals choices in a marketplace of health plans – a fundamental concept advanced in the Affordable Care Act.

This study was done of plan selection by school district employees throughout the state of Oregon, so the findings are not limited to the ACA exchange plans, nor to a menu of employer-sponsored plans, but they also apply to the choices in the private plan insurance marketplace at large.

This paper confirms the well known fact that individuals do not select plans that would be best for their individual circumstances, “with the typical employee foregoing savings of more than $600 in their insurance plan choice.”

So the authors looked at three policy interventions that might improve employee choices in health plans.

One method would be to promote active choice of plans as opposed to defaulting enrollment to passive inertia, perhaps by forcing re-enrollment. That was done in 2013 and that did not improve quality in choice of plans. In fact, they found that “across all plans, both active and forced switchers do worse than new entrants.” “The major takeaway from these results is that promoting switching is unlikely to have an important effect in reducing choice inconsistencies.”

They then used a randomized trial of decision support software but found that there was consumer avoidance of the recommendations and thus it had little impact on plan choices. They concluded, “information interventions do not appear to significantly reduce foregone savings.”

The third intervention is perhaps the most revealing on why promoting plan choice is a flawed policy intervention. They looked at limiting the number of options available to individuals who are choosing plans. They show that, “restricting the choice set size facing individuals does significantly reduce their foregone saving and total costs. This is not because individuals choose worse with larger choice sets, but rather because larger choice sets feature worse choices on average that are not offset by individual re-optimization.”

When a narrower selection of plans is offered, inferior or inappropriate plans tend to be rejected by the administrators of the panels. In fact, this is what California did when implementing the ACA exchanges. Plan selection improved because the individuals were denied the option of choosing inferior plans.

Choice in health plans is nonsense. Instead of being offered a filtered selection of plain vanilla plans, everyone should be enrolled the plan that is designed to work best for all of us. Of course, that would be an efficient, equitable and affordable single payer national health program – an improved Medicare for all.

From the very beginning CHOICE was a con job. We wanted choices of our health care professionals and institutions, and instead they sold us on choices of private health plans that take away our choices in our actual health care.

What’s The Story With Obamacare?

By Katherine Baicker and Amy Finkelstein
Health Affairs Blog, December 9, 2016

States, patients, and voters are wrestling with the pros and cons of dramatic changes in public health insurance coverage, including extending, maintaining, or rolling back Medicaid expansion under the Affordable Care Act (Obamacare) — an often emotional topic of debate. The stories that are told about the effectiveness—or lack thereof—of coverage in improving health and health care usually relate compelling personal experiences, putting a human face on an otherwise abstract argument.

Policies are not enacted in the abstract; they affect real people’s lives, and we should all be concerned with how policy changes help or harm them. Unfortunately, as moving as those stories can be, they can just as easily lead us in the wrong direction as the right one. What we need is evidence, not anecdote.

Medicaid Coverage And Care Use

A key question in the Medicaid debate is whether expanded coverage reduces the use of the Emergency Department (ED) — getting people into the doctor’s office earlier, improving health, and reducing health care spending. Solid evidence is very hard to come by, but we had an opportunity to evaluate the impact of expanding Medicaid using scientifically rigorous methods rarely available in answering public policy questions.

In 2008, Oregon used a lottery to allocate a limited number of Medicaid slots — generating, in essence, a randomized controlled trial of Medicaid. This let us gauge the effects of the program itself, isolated from the usual confounding factors, and allowed us to collect thousands of stories—otherwise known as data!—about people’s experiences on and off of Medicaid.

We found that, contrary to many people’s expectations, Medicaid increased use of the ED by 40 percent. New research tells us that this increase persisted for at least two years, and that Medicaid did not make patients more likely to substitute a visit to the doctor for one to the ED.

In addition to this evidence, gleaned from a randomized evaluation of the experiences of tens of thousands of uninsured and newly insured Oregonians, we also conducted hundreds of interviews to learn how people felt that having Medicaid—or not—affected their lives. These individual narratives were invaluable for deepening our understanding of the experiences of those in study. But they also underscored how easy it is, in the absence of solid evidence, to find an anecdote to match any “answer.”

Conflicting Anecdotes About Medicaid

This is an all-too-common situation. The Oregon experiment has produced a wealth of data and rigorous evidence on the impact of Medicaid on people’s lives. We found that Medicaid increases health care use, improves financial security, improves self-reported health, and reduces rates of depression. For nearly every outcome of interest, we heard stories of experiences that matched the average effect of the expansion on the newly covered population, as well as compelling stories that did not.

Anecdotes Cannot Substitute For Rigorous Research

It’s tempting to think that we can recognize which anecdotes are most representative of the “real story” when we hear them — but we really can’t. We might be more likely to believe the story that is more poignant. Or maybe the one that lines up with our prior beliefs.

This is why, wherever possible, we need to rely on evidence from rigorous research—rather than compelling anecdotes—to get an accurate assessment of a policy’s effects

The Oregon example highlights that it is possible to use randomized evaluations to investigate important health policy questions. As researchers, we need to do a better job of providing the public with that evidence. Policymakers need to be receptive both to partnerships in building the evidence and to using the evidence to make better-informed policy decisions. And the media needs to resist the urge to allow unsubstantiated anecdotes to stand in for real evidence — despite the fact that readers may be drawn in by anecdotes.

Personal narratives can yield vital insight into how policies affect people’s lives, humanizing the stories behind the numbers and suggesting important areas for further research. Dismissing these compelling stories as “mere anecdotes” in favor of more rigorous—but impersonal—data analysis can seem heartless. But making policy based on unrepresentative anecdotes can inflict much greater harm on many more people. We hope that use of rigorous evidence will become the norm rather than the exception in health policy.

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Reader Comment:

By Don McCanne, M.D.

As Professors Baicker and Finkelstein indicate, rigorous research in health policy provides a foundation based on fact for making policy decisions – certainly valuable in our contemporary scene driven by political ideology. But it is imperative that the valid facts be applied with care and not to the exclusion of non-research based knowledge of health policy.

As an example, the Oregon natural experiment provided helpful but limited data. The authors would surely disagree with some statements made by a few politicians and other individuals in the policy community to the effect that the Oregon experiment proved that Medicaid is a wasteful program and should be abandoned, with even at least one saying that Oregon Medicaid patients were worse off than the uninsured. Part of the problem is that the study was underpowered – an unavoidable consequence since is was a natural experiment.

Another example is the RAND HIE. It was a study of cost sharing in workers and their families – a relatively healthy subset of our population. Since the study was for a relatively short time during the healthy years of their lives, the intrinsic validity of this study does not necessarily have extrinsic validity, so the findings should not be extrapolated to apply to the entire population. Yet that is exactly what has been done, especially with the escalation in the use of high deductibles in insurance plans.

The purpose of cost sharing is to reduce spending, but it can be harmful, both because it causes individuals to forgo beneficial health care services, and it creates financial hardships for people in need. Yet ideologues have largely ignored the harm and have pushed this as a means of making patient-consumers more responsible purchasers of health care. One advocate has carried this to the extreme that cost sharing should be inflicted on poor people with no disposable income – a heartless public policy – and she is about to become administrator of CMS.

We do not need rigorous research studies to show us that a well designed single payer system can slow the rate of health care spending while including absolutely everyone and making it affordable for each individual through equitable progressive tax policies. Other nations already do that – providing health care at a fraction of what we are spending through our dysfunctional health care financing system.

There would still be plenty of research opportunities for Baicker and Finkelstein in a single payer system, but at least it would be within a system designed to serve, above all, the health care needs of patients, rather than a system designed to support the administrative excesses and egregious pricing of the stakeholders in our current system.

Incidentally, studies on administrative waste and excess pricing have already been done. We should use them.

http://healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Katherine Baicker and Amy Finkelstein are correct. Rigorous policy research can provide a beneficial input to the policy making process. But there is the risk that policy science can lead only to minor tweaks in the health care financing system when comprehensive overhaul is an imperative.

For instance, many studies have been done that have determined whether various factors influence the numbers of individuals who remain uninsured. Based on these results, the financing system can be tweaked to encourage greater enrollment. But all of these measures combined have still left about 29 million people uninsured.

Suppose instead of doing a study, you simply approved legislation that would automatically enroll everyone, for life, in a national single payer program. What policy study would you need to carry out to determine whether that would be effective in including many or most of the remaining uninsured? Well, you don’t need a rigorous policy study. All of the remaining uninsured would be covered automatically. If someone slipped through the cracks, they would be enrolled at the time they accessed the health care system.

When you look at the various policies being applied in either the public or private sectors, you see that many are based on research that has been narrowly focused on our current fragmented, dysfunctional financing system – simply trying to fix an irreparably broken system.

You do not need research when the system is designed to specifically meet reform goals. Besides requiring that it be truly universal, financing can be made affordable for each individual through equitable, progressive tax policies. Resource allocation can be improved through central planning, which improves access. Administrative efficiency is achieved by eliminating the multitude of expensive, superfluous financing intermediaries. You do  not need to study this. You just do it.

The Oregon health insurance experiment (OHIE) – a study conducted by Baicker and Finkelstein – produced some interesting results. But how much impact has it had in reducing the major, fundamental deficiencies in our current health care financing system? I do not recall having seen any policy changes resulting from it. That is not to say that it was an inappropriate study. Being a natural study, it was a rare opportunity to advance policy science, and it was quite appropriate that the study was done.

The point is that the policy community buries itself in these studies that really do have very little impact on the major problems facing us in health care financing today. Besides, the studies would be more valuable done within a health care financing infrastructure that was designed to serve patients rather than to meet medical-industrial business goals, including fine tuning a wasteful private insurance industry that should be discarded instead.

Let’s replace the financing infrastructure with one that meets our goals and then study it to see what beneficial tweaks we can provide.