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Why I’m at odds with my party on health care

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Why I’m at odds with my party on health care

By Jack Bernard
Georgia Health News, Aug. 18, 2016

“Not everything that is faced can be changed, but nothing can be changed until it is faced.” (James Baldwin)

With a proven record of cutting waste and reducing spending, I am a fiscally conservative Republican, as well as a health care professional. But the Georgia GOP legislative leadership and I have reached very different conclusions about Medicaid expansion and the Affordable Care Act (ACA).

Nationally, my party has passed legislation in the House more than 50 times to repeal the ACA, also known as Obamacare. The ACA was implemented anyway and shows no sign of going away. So, is the ACA working? And what about Medicaid expansion here?

I was a senior corporate and government planner. Planners evaluate programs in one of two ways, based on: 1) history, or 2) the ideal.

I will address the historical method first.

According to both federal officials and a 2014 Gallup report, there has been a precipitous drop in the number of uninsured people under the ACA. The U.S. Department of Health and Human Services states that the national rate of uninsured is 9 percent for the overall population and 12 percent for those under 65. According to HHS, the ACA has been responsible for covering 20 million more Americans since it was enacted.

Medicaid expansion was a key factor in realizing this drop in most states, although not here. Republicans, like other Georgians, should be concerned that Georgia now has the third-highest rate of uninsured in the nation.

Demographically, the national decrease is uneven. The rate dropped much more for Hispanics (from 42 percent down to 21 percent) and blacks (from 22 percent to 10 percent) than for whites (from 14 percent to 7 percent). It should be no surprise that, according to surveys, the ACA is more popular among Hispanics and African-Americans.

Likewise, according to Gallup, the drop in the rate of uninsured was greatest in those under $36,000 in household income (from 31 down to 25 percent). Among higher-income households, the drop was much less.

In Georgia, 74 percent of those in the “coverage gap” are minorities.

I do not know exactly what influences the thinking of the Georgia GOP leadership when it comes to expanding coverage. But I am very concerned when key legislators make unsubstantiated — and factually incorrect — statements, such as saying that Medicaid expansion would cover “Georgians who are fully capable of getting a job that would provide them with private health insurance.”

Of Georgians in the coverage gap (low-income people who don’t qualify for either Medicaid or ACA exchange discounts), 57 percent are in working families. Surely our GOP legislative leaders know some low-income working people. Do they seriously believe that these men and women do not want good jobs that provide them with health insurance?

Regarding the second evaluation method, comparing the ACA to the ideal is much more difficult. When researching the developed world for other insurance models, we find that there is no need for something like Medicaid expansion (or weird “waivers”). All of these nations cover everyone under a coordinated, comprehensive system.

There is the direct government delivery model. Britain has had a National Health Service since the end of World War II. Our experience with this format has not been as positive, as shown by the VA scandals.

Another system used in some European nations is to have a small number of highly regulated private insurance carriers, where everyone gets coverage. These nations all have lower costs and better outcomes than here.

Finally, there is the model in which the government provides insurance covering to all citizens. The Canadian system can be likened to a “Medicare for All” program here, where it would cover every citizen. Surveys have shown a high level of satisfaction among Canadians with their system.

But what about cost? Let’s look at a 2013 report from the Organization for Economic Cooperation and Development (OECD), which includes all the developed nations worldwide.

With our fragmented system, we spend 17.7 percent of our GDP on health care. Canada spends only 11.2 percent and covers everyone. Many other nations spend much less. Australia, for instance, spends just 8.9 percent. The average OECD nation spends only 9 percent.

Per capita, we spent $8,508 for health care in 2011. Canada came in at $4,522. The average OECD (developed nation) spent only $3,339 per capita!

Oddly, we spent more tax dollars on health care (VA, Medicare, Champus, Medicaid, etc.) than almost any other developed nation. We just do not spend our money as wisely. Pandora’s box regarding cost escalation was opened here a long time ago by Big Pharma and private insurance companies.

And, according to a 2013 report by the Institute of Medicine, of 17 high-income countries examined, we are at the bottom in many health indicators.

In 1960, life expectancy in the United States was 1.5 years above the OECD average. In 2011, our nation was 1.5 years below the other OECD nations.

So, what can we conclude about the ACA? First, it is much better than what we had before, regarding health care access and coverage.

Secondly, a Canadian-style “Medicare for All” system would cover everyone — and at less cost — clearly a better option than the current ACA and its Medicaid expansion provisions.

I agree with our state GOP leaders that the ACA is imperfect, but it is what we have in the short term to provide coverage to the uninsured. My question to these leaders is: “Why aren’t you advocating for Medicaid expansion instead of for depriving the working poor of insurance coverage?”

Jack Bernard is a former Director of Health Planning for the state of Georgia. He retired as an executive with a national health care corporation.

http://www.georgiahealthnews.com/2016/08/odds-party-health-care/

Medicare Advantage plans pay hospitals less than does traditional Medicare

By Laurence C. Baker, M. Kate Bundorf, Aileen M. Devlin and Daniel P. Kessler
Health Affairs, August 2016

Abstract

There is ongoing debate about how prices paid to providers by Medicare Advantage plans compare to prices paid by fee-for-service Medicare. We used data from Medicare and the Health Care Cost Institute to identify the prices paid for hospital services by fee-for-service (FFS) Medicare, Medicare Advantage plans, and commercial insurers in 2009 and 2012. We calculated the average price per admission, and its trend over time, in each of the three types of insurance for fixed baskets of hospital admissions across metropolitan areas. After accounting for differences in hospital networks, geographic areas, and case-mix between Medicare Advantage and FFS Medicare, we found that Medicare Advantage plans paid 5.6 percent less for hospital services than FFS Medicare did. Without taking into account the narrower networks of Medicare Advantage, the program paid 8.0 percent less than FFS Medicare. We also found that the rates paid by commercial plans were much higher than those of either Medicare Advantage or FFS Medicare, and growing. At least some of this difference comes from the much higher prices that commercial plans pay for profitable service lines.

From the Discussion

Knowing how Medicare Advantage prices compare to those of FFS Medicare is important for public policy. Health spending is the product of price and quantity. If Medicare Advantage prices are lower than those of FFS Medicare, then Medicare can obtain the same quantity of services for less money through Medicare Advantage than through FFS Medicare.

Contrary to conventional wisdom, we found that Medicare Advantage plans paid lower prices for hospital services than FFS Medicare — around 8 percent lower in both 2009 and 2012 — once the DRG and geographic-area mix of FFS Medicare was made comparable to those of Medicare Advantage.

If differences in hospital mix are also accounted for, Medicare Advantage’s hospital prices are about 5.6 percent less than those of FFS Medicare. Thus, about a third of the 8 percent difference is attributable to the narrower hospital networks in Medicare Advantage, compared to FFS Medicare.

Our results also show how Medicare Advantage can be used to get a better deal (at least from hospitals) for the Medicare program as a whole, by adjusting administered prices across geographic areas and DRGs to better reflect the market.

Finally, consistent with previous research, we found that the rates commercial plans pay to hospitals are significantly higher than those of either Medicare Advantage or FFS Medicare and that they are rising.

http://content.healthaffairs.org/content/35/8/1444.abstract

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Comment:

By Don McCanne, M.D.

The pro-market authors of this study have shown that the private Medicare Advantage plans pay hospitals less than traditional Medicare pays, concluding that the private plans “get a better deal for the Medicare program.” But that conclusion is not true if you look at the whole picture.

Because the private Medicare Advantage plans were being paid more than what was being paid for comparable care in the traditional Medicare program, Congress included in the Affordable Care Act adjustments to reduce the overpayments. However, the private plans have continued with their mastery of gaming the system to increase their payment rates, such as selective marketing to healthier populations and upcoding to receive greater payments through risk adjustment. This has been with the complicity of the people in HHS who have used innovative administrative tools and creative accounting to more than offset the required reductions. The private plans are still receiving greater payments than are being made for comparable patients in the traditional Medicare program.

Since the private plans are receiving larger payments, and, according to this study, are paying less for health care, the Medicare program is getting a worse deal, and it is the private insurers themselves who are getting a great deal, at a cost to taxpayers. This extra money that the insurers are siphoning out of the system is going to overpriced administrative services and, yes, to extra profits.

Although the private insurers are pulling out of the ACA exchanges because they cannot make their business model work there, they boast to their investors that their commercial accounts are highly profitable (employer-sponsored plans) and that their government accounts – especially the Medicare Advantage plans – are producing extraordinary returns for the investors (and humongous compensation packages for the corporate executives). We are paying for this through higher premiums for private plans and greater taxes for privately-managed government programs. A well designed single payer system should fix that.

To Sanders, Aetna’s Pull-Back from Affordable Care Act Markets Shows Need for Overhaul

By Laura Meckler
The Wall Street Journal, Aug. 16, 2016

Sen. Bernie Sanders, who mounted a strong challenge for the Democratic presidential nomination, said Tuesday that news that a major health insurer was pulling back its participation in the Affordable Care Act exchanges affirms the need for his single-payer, government-run program. He promised to introduce legislation creating “Medicare for all” again next year.

This week, Aetna Inc. said it will withdraw from 11 of the 15 states where it currently offers plans, the latest major national insurer to sharply pull back its participation.

Rather than minimizing the problem, Mr. Sanders cast Aetna’s decision is part of a trend.

“It is disappointing that Aetna has joined other large for-profit health insurance companies in pulling out of the insurance marketplace,” he said in a statement. “Despite the Affordable Care Act bringing them millions more paying customers than ever before, these companies are more concerned with making huge profits then ensuring access to health care for all Americans.”

He added: “The provision of health care cannot continue to be dependent upon the whims and market projections of large private insurance companies whose only goal is to make as much profit as possible.”

The statement makes clear that he intends to continue fighting for his agenda from the Senate, possibly in opposition to a future President Hillary Clinton.

The health exchanges have been attacked from the political right as too much government, but also criticized from the left as not going far enough. Throughout the Democratic presidential primary, Mr. Sanders argued that only a government-run system can guarantee affordable coverage for all. Former Secretary of State Hillary Clinton, who won the nomination, says more modest tweaks to the Affordable Care Act can address its shortcomings.

To win his endorsement, Mrs. Clinton also reiterated her support for a government-run insurance plan to compete with private insurers, but she has said little about that plan on the campaign trail.

http://blogs.wsj.com/washwire/2016/08/16/to-sanders-aetnas-pull-back-from-affordable-care-act-markets-shows-need-for-overhaul/

Bernie Sanders is not giving up on Medicare for all

Sanders Statement on Aetna’s Decision to Withdraw from Health Insurance Exchanges

By Senator Bernie Sanders
August 16, 2016

U.S. Sen. Bernie Sanders (I-Vt.) issued the following statement Tuesday after Aetna announced plans to withdraw from Affordable Care Act health exchanges in 11 of 15 states where it currently operates:

“It is disappointing that Aetna has joined other large for-profit health insurance companies in pulling out of the insurance marketplace. Despite the Affordable Care Act bringing them millions more paying customers than ever before, these companies are more concerned with making huge profits than ensuring access to health care for all Americans. 

“In my view, the provision of health care cannot continue to be dependent upon the whims and market projections of large private insurance companies whose only goal is to make as much profit as possible. That is why we need to join every other major country on earth and guarantee health care to all as a right, not a privilege. That is also why we need to pass a Medicare-for-all single-payer system. I will reintroduce legislation to do that in the next session of Congress, hopefully as part of the Democratic Senate majority.”

http://www.sanders.senate.gov/newsroom/press-releases/sanders-statement-on-aetnas-decision-to-withdraw-from-health-insurance-exchanges

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Comment:

By Don McCanne, M.D.

Since the Clinton Camp was successful in keeping single payer out of the Democratic Party platform, much of the media seems to believe that it has completely gone away as an issue. The good news is that Bernie Sanders assures us that it hasn’t. We need to do our part to be sure that the nation knows that.

Aetna Shows Why We Need a Single Payer

By Robert Reich
Common Dreams, Aug. 17, 2016

The best argument for a single-payer health plan is the recent decision by giant health insurer Aetna to bail out next year from 11 of the 15 states where it sells Obamacare plans.

Aetna’s decision follows similar moves by UnitedHealth Group, the nation’s largest insurer, and Humana, one of the other giants.

All claim they’re not making enough money because too many people with serious health problems are using the Obamacare exchanges, and not enough healthy people are signing up.

The problem isn’t Obamacare per se. It’s in the structure of private markets for health insurance –- which creates powerful incentives to avoid sick people and attract healthy ones. Obamacare is just making the structural problem more obvious.

In a nutshell, the more sick people and the fewer healthy people a private for-profit insurer attracts, the less competitive that insurer becomes relative to other insurers that don’t attract as high a percentage of the sick but a higher percentage of the healthy. Eventually, insurers that take in too many sick and too few healthy people are driven out of business.

If insurers had no idea who’d be sick and who’d be healthy when they sign up for insurance (and keep them insured at the same price even after they become sick), this wouldn’t be a problem. But they do know – and they’re developing more and more sophisticated ways of finding out.

It’s not just people with pre-existing conditions who have caused insurers to run for the happy hills of healthy customers. It’s also people with genetic predispositions toward certain illnesses that are expensive to treat, like heart disease and cancer. And people who don’t exercise enough, or have unhealthy habits, or live in unhealthy places.

So health insurers spend lots of time, effort, and money trying to attract people who have high odds of staying healthy (the young and the fit) while doing whatever they can to fend off those who have high odds of getting sick (the older, infirm, and the unfit).

As a result we end up with the most bizarre health-insurance system imaginable: One ever more carefully designed to avoid sick people.

If this weren’t enough to convince rational people to do what most other advanced nations have done and create a single-payer system, consider that America’s giant health insurers are now busily consolidating into ever-larger behemoths. UnitedHealth is already humongous. Aetna, meanwhile, is trying to buy Humana.

Insurers say they’re doing this in order to reap economies of scale, but there’s little evidence that large size generates cost savings.

In reality, they’re becoming very big to get more bargaining leverage over everyone they do business with – hospitals, doctors, employers, the government, and consumers. That way they make even bigger profits.

But these bigger profits come at the expense of hospitals, doctors, employers, the government, and, ultimately, taxpayers and consumers.

So the real choice in the future is becoming clear. Obamacare is only smoking it out. One alternative is a public single-payer system. The other is a hugely-expensive for-profit oligopoly with the market power to charge high prices even to healthy people – and to charge sick people (or those likely to be sick) an arm and a leg.

Robert Reich, one of the nation’s leading experts on work and the economy, is Chancellor’s Professor of Public Policy at the Goldman School of Public Policy at the University of California at Berkeley. He has served in three national administrations, most recently as secretary of labor under President Bill Clinton.

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

http://www.commondreams.org/views/2016/08/17/aetna-shows-why-we-need-single-payer

Aetna, UnitedHealth and Humana provide important lesson on feasibility

Aetna to Quit Most Obamacare Markets, Joining Major Insurers

By Zachary Tracer
Bloomberg, August 15, 2016

Health insurer Aetna Inc. will stop selling individual Obamacare plans next year in 11 of the 15 states where it had been participating in the program, joining other major insurers that have pulled out of the government-run markets in the face of mounting losses.

While the Affordable Care Act, known as Obamacare, has brought coverage to millions, the new markets have proven volatile for some of the largest for-profit insurers. Aetna said earlier this year that it expected to lose $300 million on the plans. UnitedHealth Group Inc. and Humana Inc., which Aetna has agreed to buy for $37 billion, are also pulling out after posting hundreds of millions of dollars of losses.

“The vast majority of payers have experienced continued financial stress within their individual public exchange business,” Aetna Chief Executive Officer Mark Bertolini said in the statement. “Providing affordable, high-quality health care options to consumers is not possible without a balanced risk pool.”

http://www.bloomberg.com/news/articles/2016-08-16/aetna-quits-most-obamacare-markets-joining-other-major-insurers

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Aetna to Pull Back From Public Health Care Exchanges

By Robert Pear
The New York Times, August 16, 2016

Kevin J. Counihan, the chief executive of the federal insurance exchange, said the marketplace would remain strong and vibrant despite Aetna’s decision.

“It’s no surprise that companies are adapting at different rates to a market where they compete for business on cost and quality, rather than by denying coverage to people with pre-existing conditions,” Mr. Counihan said Monday.

http://www.nytimes.com/2016/08/16/us/politics/aetna-health-care-law-marketplace.html

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Comment:

By Don McCanne, M.D.

Three of the nation’s largest insurers – Aetna, UnitedHealth and Humana – are pulling out of the ACA insurance exchanges because they have been unable to use their business model to make a profit. Although over fourth-fifths of enrollees are receiving government subsidies for these plans, that is not enough for the insurers. They also want the government to pay for those who need significant amounts of care (reinsurance). They want to abandon covering risk while they sell us wasteful administrative services.

The failure stems from the fact that our public administrators and legislators bent over backwards to try to make reform work for the private insurers, but health care is now so expensive that the insurers’ model requires unaffordable premiums and unaffordable deductibles and other cost sharing. They pushed the limit on premiums and deductibles and that has resulted in tens of millions remaining uninsured or unable to pay their out-of-pocket costs.

And the government’s response? The marketplace remains “strong and vibrant” because insurers compete on “cost and quality” rather than “denying coverage to those with pre-existing conditions.” Yet the nation’s largest insurers cannot compete on those terms.

It is difficult to believe that members of the administration and Congress are so dense that they cannot see that it is this model of health care financing that is creating so many of our problems. Mention a model that actually does work – single payer – and they plead that it is not feasible, that it is not capable of being done. But they have already proven that the fragmented system under ACA is not capable of covering everyone with affordable health care. It is not a feasible method of ensuring affordable health care for all. Single payer is.

TPP and pharmaceutical regulation in Canada and Australia

The Trans Pacific Partnership Agreement and Pharmaceutical Regulation in Canada and Australia

By Joel Lexchin and Deborah Gleeson
International Journal of Health Services, August 11, 2016

Abstract

The Trans Pacific Partnership Agreement (TPP) is a large regional trade agreement involving 12 countries. It was signed in principle in February 2016 but has not yet been ratified in any of the participating countries. The TPP provisions place a range of constraints on how governments regulate the pharmaceutical sector and set prices for medicines. This article presents a prospective policy analysis of the possible effects of the TPP on these two points in Canada and Australia. Five chapters of relevance to pharmaceutical policy are analyzed: chapters on Technical Barriers to Trade (Chapter 8), Intellectual Property (Chapter 18), Investment (Chapter 9), Dispute Resolution (Chapter 28), and an annex of the chapter on Transparency and Anti-Corruption (Chapter 26, Annex 26-A). The article concludes that the TPP could have profound effects on the criteria these countries use to decide on drug safety and effectiveness, how new drugs are approved (or not) for marketing, post-market surveillance and inspection, the listing of drugs on public formularies, and how individual drugs are priced in the future. Furthermore, the TPP, if ratified and enforced, will reduce future policy flexibility to address the increasing challenge of rising drug prices.

From the Conclusion

The final text of the TPP Agreement holds significant possible risks for pharmaceutical regulation and access to affordable medicines in both Australia and Canada. For Australia, the final provisions related to biologic products in the intellectual property chapter are worryingly ambiguous and unclear. This ambiguity was intended to be constructive, but it may have unintended effects if the United States insists on a certain interpretation, in the event of a dispute, or if the provisions have a chilling effect on future regulatory reform to bring biosimilars to the market more speedily.

Aside from the biologics provisions, there are a number of other provisions in the intellectual property chapter that will lock in existing policy settings and could potentially frustrate future reform efforts to reduce pharmaceutical expenditure in both Australia and Canada. Adopting detailed, prescriptive policy settings negotiated in a fraught political context—largely out of the view of stakeholders and involving bargaining and trade-offs between the objectives of different sectors—does not amount to sensible health or intellectual property policy making, which is attuned to current and future domestic needs.

The TPP’s investment chapter, and in particular its investor-state dispute settlement mechanism, also bring new threats to the affordability of medicines. It is likely that multinational pharmaceutical companies will quickly take advantage of this new avenue, along with the provisions in Chapter 8 on the Technical Barriers to Trade, to contest and frustrate Australia’s and Canada’s pharmaceutical policy making.

It is also worth repeating that the U.S. pharmaceutical industry was not satisfied with the outcome of the TPP negotiations, especially with respect to the provisions on intellectual property rights. As a result, it is likely the industry will be very aggressive in pushing for the strictest interpretation of the various provisions of the TPP that relate to medications.

http://joh.sagepub.com/content/early/2016/08/10/0020731416662612.abstract

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Comment:

By Don McCanne, M.D.

The Trans Pacific Partnership trade agreement (TPP) has raised concerns about giving private sector industries too much control over the public affairs of participating nations. In health care we are particularly concerned about the benefits that the agreement would provide to the pharmaceutical sector at a cost to the citizens of participating nations.

Some have suggested that adopting a single payer system would protect the United States since the government could negotiate as a monopsony to ensure availability and fair pricing of their products. But this article discusses the problems that Canada and Australia could face with ratification of TPP – problems that would not be prevented by their single payer systems.

In a previous post I had mentioned, as a typical concern, that the industry was successful in including in TPP the principle that they would be rewarded with the value that use of their products would provide to patients. Thus the drugs for hepatitis C that reduce morbidity and prolong life should command the high prices that they do simply because the pharmaceutical firms  believe that they should have ownership of the benefit of their products transferred to them regardless of the fact that research, production and distribution costs may be a very small fraction of the prices they wish to command. It takes a lot of gall to support the concept that “I saved your life therefore I own the value of your life.”

Although both leading presidential candidates have stated their opposition to TPP, there is considerable pressure to ratify TPP during the lame duck session – an approach which is supported by President Obama. Also Hillary Clinton, overwhelmingly favored to win the election, has previously supported TPP and likely will not give more than token verbal opposition to ratification, allowing leeway for President Obama to orchestrate the process.

If TPP is ratified, it is likely that the U.S. pharmaceutical industry would “be very aggressive in pushing for the strictest interpretation of the various provisions of the TPP that relate to medications.” As this article indicates, that would be harmful to Canada and Australia plus other participating nations, but it would also be harmful to the people of the United States as well, sacrificing our health for the wealth of the drug industry investors.

More generally, just because the presidential candidates of the two major parties have expressed token opposition, we should not relax our efforts to inform the public that the TPP is designed to make the rich much richer at the cost of working families in participating nations.

Race, Ethnicity Affect Kids’ Access To Mental Health Care, Study Finds

By Shefali Luthra
Kaiser Health News, Aug. 12, 2016

One in five Americans is estimated to have a mental health condition at any given time. But getting treatment remains difficult — and it’s worse for children, especially those who identify as black or Hispanic.

That’s the major finding in research published Friday in the International Journal of Health Services. The study examines how often young adults and children were able to get needed mental health services, based on whether they were black, Hispanic or white. Using a nationally representative sample of federally collected survey data compiled between 2006 and 2012, researchers sought to determine how often people reported poor mental health and either saw a specialist or had a general practitioner bill for mental health services.

“No one is necessarily bigoted — and yet we have a system that creates the kind of discrimination we see in the paper,” said Steffie Woolhandler, a professor at City University of New York School of Public Health, and one of the study’s authors. “Kids are getting half as much mental health treatment — and they have the same level of mental health problems.”

Young people in general aren’t likely to see mental health specialists. But the numbers fell further when racial and ethnic backgrounds were factored in. About 5.7 percent of white children and young adults were likely to see a mental health specialist in a given year, compared with about 2.3 percent for black or Hispanic young people.

Put another way: Even when controlling for someone’s mental health status, insurance and income, black and Hispanic children saw someone for treatment far less often than did their white counterparts — about 130 fewer visits per thousand subjects. Black young adults visited a mental health specialist about 280 fewer visits per thousand; Hispanics had 244 fewer visits per thousand.

But the data indicate that mental illness incidence rates are generally consistent across racial groups, according to the study. Of adults between the ages of 18 and 34, between 4 and 5 percent indicated having fair or poor mental health, regardless of racial background. For children, white and black subjects were reported to need care at about the same rate — between 11 percent and 12 percent — compared with about 7 percent of Hispanic children.

The paper outlines a few possible reasons for this disconnect. Different communities may attach greater stigma about mental health care, or they may place less trust in the doctors available. Plus, there is a shortage of child psychiatrists across the country, and black and Hispanic families often live in the most underserved areas.

“There are problems of access all around,” said Harold Pincus, vice chair of psychiatry at Columbia University’s College of Physicians and Surgeons. “We have to change the way we do things.”

The findings suggest that lawmakers have focused on trying to improve access to mental health care, but “we can’t rest on our laurels,” said Pincus, who wasn’t affiliated with the study. He also noted that treating white children’s level of access as the golden standard is probably unwise, since research suggests they also receive inadequate care.

One of the study’s clear messages, argued Woolhandler, is that racial minorities received markedly less care — regardless of socioeconomic or health status. The gap suggests a targeted intervention is needed.

The study highlights a need to ensure doctors know how to counsel patients of different racial backgrounds and will do so, said Benjamin Le Cook, an assistant professor of psychiatry at Harvard Medical School, who was also not affiliated with the study. Ending racial and cultural disparities in access to care is a more pressing concern than erasing the stigmas about mental illness in minority communities, he said.

That’s especially relevant given minorities are less likely to be treated by doctors of their ethnicity. In addition, research suggests that mental health specialists sometimes discriminate based on race when seeing patients.

“It has to do with experiences people in the community have had that haven’t matched their expectations or aligned with problems they’re having,” LeCook said. “Cultural stigma is a factor, but not the main one.”

Beyond better training, more funds are needed for resources like community health centers, which often serve black and Hispanic patients, Woolhandler said.

“I see these great people trying to work in community mental health, but they need more resources to do their job,” she said.

But, the research doesn’t account for other areas where minorities may access mental health services, Pincus noted. Churches and social service agencies, for instance, may be filling some of the void and wouldn’t be accounted for by the survey data.

Researchers and policymakers should explore those sectors, he said, to see if they could be better leveraged to help people get connected to care they’ll actually trust. As experts try to bolster the mental health system — both to improve access across the board and also to close race-based gaps — they need to use a multipronged approach, pulling in different kinds of caregivers than those who might normally treat mental illness.

“There’s all kinds of ways by which the mental health system doesn’t play a role in helping people,” he said. “Family and community supports, social services — they’re all part of the picture.”

http://khn.org/news/race-ethnicity-affect-kids-access-to-mental-health-care-study/

Shameful racial disparities in health and health care

Racial and Ethnic Disparities in Mental Health Care for Children and Young Adults: A National Study

By Lyndonna Marrast, David U. Himmelstein, Steffie Woolhandler
International Journal of Health Services, August 12, 2016

Abstract

Psychiatric and behavior problems are common among children and young adults, and many go without care or only receive treatment in carceral settings. We examined racial and ethnic disparities in children’s and young adults’ receipt of mental health and substance abuse care using nationally representative data from the 2006–2012 Medical Expenditure Panel Surveys. Blacks’ and Hispanics’ visit rates (and per capita expenditures) were about half those of non-Hispanic whites for all types and definitions of outpatient mental health services. Disparities were generally larger for young adults than for children. Black and white children had similar psychiatric inpatient and emergency department utilization rates, while Hispanic children had lower hospitalization rates. Multivariate control for mental health impairment, demographics, and insurance status did not attenuate racial/ethnic disparities in outpatient care. We conclude that psychiatric and behavioral problems among minority youth often result in school punishment or incarceration, but rarely mental health care.

From the Discussion

The under-provision of mental health care for minority children contrasts starkly with the high frequency of punitive sanctions that their behaviors elicit. Black children suffer excessive rates of school discipline, such as suspensions and expulsions, starting at preschool ages. Minority teens also have disproportionate contact with the juvenile justice system, with higher arrest rates for nonviolent, low-level offenses such as drug possession and for non-criminal misbehaviors such as truancy and curfew violations. Most relevant to our study, youthful transgressions that might result in referral for treatment among non-minority children more often incur criminal sanctions for minorities. Overall, blacks and Hispanics account for 63% of the children detained in juvenile facilities.

http://joh.sagepub.com/content/early/2016/08/11/0020731416662736.abstract

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Active Life Expectancy In The Older US Population, 1982–2011: Differences Between Blacks And Whites Persisted

By Vicki A. Freedman and Brenda C. Spillman
Health Affairs, August 2016

Abstract

Understanding long-range trends in longevity and disability is useful for projecting the likely impact of the baby-boom generation on long-term care utilization and spending. We examine changes in active life expectancy in the United States from 1982 to 2011 for white and black adults ages sixty-five and older. For whites, longevity increased, disability was postponed to older ages, the locus of care shifted from nursing facilities to community settings, and the proportion of life at older ages spent without disability increased. In contrast, for blacks, longevity increases were accompanied by smaller postponements in disability, and the percentage of remaining life spent active remained stable and well below that of whites. Older black women were especially disadvantaged in 2011 in terms of the proportion of years expected to be lived without disability. Public health measures directed at older black adults — particularly women — are needed to offset impending pressures on the long-term care delivery system as the result of population aging.

The residential concentration of blacks in the United States is high, and related inequities in neighborhood resources — including access to medical and long-term care — reinforce black-white disparities.

From the Discussion

Older blacks and older whites in the United States have experienced different disability patterns since the early 1980s, as longevity has increased. For older whites, disability has been postponed to older ages, and the proportion of life expected to be lived without disability has increased. However, for older blacks, longevity increases have been accompanied by smaller postponements in disability, and the proportion of remaining life to be spent active has remained stable — about two-thirds at age sixty-five and one-third at age eighty-five. Consequently, the proportion of life expected to be active for older blacks continues to remain well below the proportion for older whites.

Our analysis also suggests that the black-white gaps persisted during the study period in large part because of the lack of progress for older black women in gaining years of active life. This finding is consistent with previous research demonstrating that black women experience a unique disability trajectory in later life that reflects accelerated impairment at older ages. We add to this literature by pointing out that in the aggregate, older black women have not experienced the gains seen for other groups since the early 1980s in either the number of years of active life or the percentage of life expected to be active.

http://content.healthaffairs.org/content/35/8/1351.abstract

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Comment:

By Don McCanne, M.D.

These two new studies demonstrate that we still have far to go in reducing racial and ethnic disparities as they relate to health and health care.

Particularly shocking is the study that shows that “youthful transgressions that might result in referral for treatment among non-minority children more often incur criminal sanctions for minorities,” especially for young, black males. Behavioral problems in white kids get treated whereas black and Hispanic kids are thrown in jail.

Also, black adults, especially women, are more likely to spend their later years with significant disabilities than are whites. Although the reasons for the differences are not fully elucidated, it is known that “inequities in neighborhood resources — including access to medical and long-term care — reinforce black-white disparities.”

In a message earlier this week we were reminded that one of the most dramatic reductions in disparities occurred very rapidly as a result of government action. That was the compulsory end to segregation in hospitals with the implementation of Medicare. Our government can do so much more than the private sector has been willing to do.

We do not have to wait around for another series of historical events funneling down into a grand political action. We can create that history and that action ourselves. But it does require, yes, action on our part. Citizen inaction crushes social movements.

Reinhardt and Cheng: The ethical structure of sustainable health spending

THE NEXT DEBATE IN HEALTH CARE: Transforming the Ethical Structure of U.S. Health Care

A presentation by Uwe E. Reinhardt and Tsung-Mei Cheng
Altarum Center for Sustainable Health Spending, July 12, 2016

(Excerpts)

The theme of these Altarum symposia has been what can be done to make our health system – especially spending thereon – “sustainable.”

I. “SUSTAINABILITY” IN U.S. HEALTH CARE

“Sustainability” is a much-mouthed word, although few people using the word actually define it. We can think of at least two distinct meanings in the context of health care:

A. Economic sustainability – the ability of the macro-economy to absorb further growth in health spending;

B. Political sustainability – the willingness of families in the upper-income strata to subsidize through taxes or health insurance premiums the health care of families in the lower income strata.

Total health spending is the product of health-care utilization and prices.

Under our system of governance, in which the sympathy of politicians literally can be purchased retail, it has been very difficult to control prices overall, other than in government programs.

Indeed, because prices for identical services or products vary enormously across the U.S., within regions and even within cities, it is hard even to measure what prices actually are in this country. What price is representative?

So the focus of health-care cost containment in the U.S. naturally has been and will continue to be mainly on health-care utilization.

The question then becomes whose ox is likely to be gored in our quest to reduce utilization – that is, who will be asked to do most of the belt tightening in health-care.

That question will be the focus of our presentation.

We shall abandon erstwhile dreams of an egalitarian health-care system and instead develop platforms that will allow policy makers to ration health care by income class, without ever openly saying so or debating that policy. By 2030 at the latest these new platforms are likely to be cemented in place.

II. ETHICAL PERSPECTIVES ON U.S. HEALTH CARE

ALTERNATIVE VIEWS ON THE PROPER DISTRIBUTIVE ETHIC FOR AMERICAN HEALTH CARE:

U.S. Progressives: A PURE SOCIAL GOOD TO BE AVAILABLE TO ALL ON EQUAL TERMS AND TO BE FINANCED BY ABILITY TO PAY

U.S. Conservatives: A PRIVATE CONSUMPTION GOOD WHOSE FINANCING IS PRIMARILY AN INDIVIDUAL RESPONSIBILITY

Although anyone can clearly discern these sharply different views on the distributive social ethic of U.S. health care, Americans are invariably reluctant ever to debate them openly, because that could be divisive.

So we talk about the distributive ethic of our health system in code words where, for example, “freedom of choice” may be just code for “you should make do with whatever financial resources you may have, but you are free to deploy them any way you want.”

To progressives, the very idea of rationing health care by income class is anathema – hence their penchant for a single-payer system that at least tries to be egalitarian.

To conservatives, rationing by income of the timeliness, amenities and quality of health care does not seem anathema, because we routinely apply it to other basic necessities such as food, clothing, housing, education and even the administration of justice. Why should health care be different?

Between these more extreme views on the ethics of health care is the confused, large group of citizens without firm views, at least as long as they are healthy.

Correlated with the views on the distributive ethics of health care are views concerning the degree to which the supply side of the health care market should be allowed to extract the maximum revenue from the rest of society through their pricing policies.

Health policy in the past 40 years basically has been a civil war between the two more extreme views on health care, although, as noted, we have debated it mainly in code words, given our reluctance to confront ethics forthrightly.

On the ground, this civil war has taken the form of a myriad of small legislative skirmishes at the federal and state levels, giving victory sometimes to one side and at other times to the other side.

Overall, however, victory has gone to the conservative side.

III. BUILDING THE PLATFORM FOR RATIONING HEALTH CARE BY INCOME CLASS

So what do we need in the structure of a health system designed to ration health care by income – at least a good bit of it? We need two distinct platforms:

A. we need a platform for varying the quality of the health insurance policy by income class, and

B. we need high cost sharing by patients at point of service, to ration health care utilization when illness strikes.

If you think of it, we have been busily building these two platforms during the past 20 or so years, brick by brick.

A. TIERING INSURANCE PRODUCTS BY INCOME CLASS

Health insurance exchanges – public or private – are the ideal platforms for tiering the quality of health insurance by income class. ObamaCare explicitly acknowledges it with its metal tiers.

The instruments for tiering here are:

* narrowness of the network of providers
* narrowness of the drug-formularies
* limits on services covered
* other features of the benefit package

The often proposed conversion of the egalitarian Medicare program from its defined benefit structure to a defined contribution structure (the premium support model) is one of the bricks for the desired platform.

Likewise, the idea to move Medicaid beneficiaries out of that defined benefit program onto the insurance exchanges can be interpreted in the same way.

Finally, the conversion of employment-based health insurance from defined benefit to defined-contribution plans, coupled with private health insurance exchanges, is another brick in the strategy.

It will finally permit the quality of health-insurance coverage within a company to vary by income level.

B. TIERING HEALTH CARE BY INCOME CLASS AT POINT OF SERVICE

High-deductible health insurance policies are ipso facto an instrument for rationing health care by income class, unless the deductible were closely linked to income.

One does not need a Ph.D. in economics to realize that a low income family confronted with a high deductible will tighten its belt in health care much more than would a high income family confronting the same deductible.

Similarly, under our progressive income-tax structure, the idea of tax-preferred Health Savings Accounts (HSAs) ipso facto makes health care for high income people cheaper than for low income people – an amazing ethical proposition.

IV. U.S. HEALTH CARE CA. 2030

At this time, the gradual transformation of our health-care system into one that allows us to ration health care by income is not yet complete.

Part of the problem is that it is not yet politically correct for politicians or the policy wonks who advise them openly to state that rationing by income class is their goal.

The desired structure therefore has to be developed quietly, and so that the general voting public does not know what is happening to their health system.

Indeed, sometimes the steps toward this goal are marketed to the voting public in classic Orwellian lingo – e.g., “Consumer Directed Health Care” (CDHC) that will “enable consumers [formerly patients] to sit in the driver’s seat in health care to shop around for cost-effective care.”

Absent solid, consumer-friendly information on binding prices and the quality of health care produced by different providers of health care – still typically the norm in the U.S. – CDHC actually has turned out to be a cruel hoax.

For the most part, CDHC has been merely an instrument to ration health care by income.

We came across the following paper that goes along with our thesis on rationing: “Wealthy spending more on health care than poor and middle class, reversing trend”

V. CONCLUDING REMARKS

It is not our place to render a value judgment on the merits of this development. That is a matter of ideology and of ideas of what is a “just society.”

But register our amazement — almost our admiration — at the ease with which one faction of the nation’s elite has been able to further this transition – a development of which the voting public hardly seems aware (except when illness strikes).

It can be doubted that the general populace of other countries – France, Germany, the U.K., Canada – would accept this transition with such astounding equanimity.

It is only of recent that the American public seems to have lost faith in the wisdom and beneficence of the nation’s policy-making elite.

We shall see how far that elite can push rationing health care by income before the American public becomes fully alert to that policy.

In an honest referendum, with full knowledge of what is underfoot, the general voting public probably would not support a move to rationing more and more health care by income.

More likely the voting public would opt for a more egalitarian system, which can explain why it is not yet politically correct for politicians openly to advocate rationing health care by income.

“Americans Overwhelmingly Prefer This Presidential Candidate’s Healthcare Plan, Study Shows”

According to Gallup…the overwhelming favorite was the single-payer plan offered by Bernie Sanders. Overall, 58% of respondents favored the idea, with just 37% opposing it and another 5% having no opinion.

In a separate question, Gallup asked respondents to choose between putting a single-payer system in place versus keeping Obamacare in place,and single-payer won by an even broader margin — 64% to 32%.

http://altarum.org/sites/default/files/uploaded-related-files/12_Reinhardt_Special_ALTARUM%20JULY%202016%20XX%207-18-2016_1.pdf

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Comment:

By Don McCanne, M.D.

Everyone should master understanding the concept presented here. Should the distributive ethic in health care represent a social good for all or an individual responsibility for each of us?

We are transitioning further into the individual responsibility ethic through the platforms of tiering insurance by income (narrow networks and limited benefits) and tiering health care by income at the point of service (high deductibles, health savings accounts, and consumer-directed health care). Thus we are rationing health care by ability to pay, and that will only increase further as we expand our current health care policies. Too many people will not be receiving the care that they should have.

This slide set was expanded to include some of the narrative so that we can understand better how our current approach to sustainability is political rather than economic – supporting an ethic that preserves the wealth of the wealthy by suppressing redistribution, while making the health care system sustainable by making health care less affordable for the majority.

This presentation by the insightful team of Uwe Reinhardt and Tsung-Mei Cheng should be downloaded and shared with as many other concerned individuals as possible. We need to deliver the egalitarian message that the people of other nations take for granted: we can have health care for everyone in a system that is truly sustainable.

The role of Medicare in integrating the nation’s hospitals

1965: The Year That Brought Civil Rights To The Nation’s Hospitals

By Michelle Andrews
Kaiser Health News, August 9, 2016

In his new book, David Barton Smith takes us back to the mid-1960s, when a small band of civil rights activists-cum-government bureaucrats toiled to get the nascent Medicare program up and running. In the process, they profoundly changed the way health care is delivered in this country.

It stands in marked contrast to the political turmoil over health care of recent years.

“In four months they transformed the nation’s hospitals from our most racially and economically segregated institutions to our most integrated,” Smith writes in “The Power to Heal: Civil Rights, Medicare, and the Struggle to Transform America’s Health Care System.”

“In four years they changed patterns of use of health services that had persisted for half a century. The fundamental moral imperative — that those needing medical care should receive it — began for the first time to reflect actual use of services. A profound transformation, now taken for granted, happened almost overnight.”

Michelle Andrews: Over the course of several months, a small group of government workers implemented the Medicare program. From the start, they said that hospitals that discriminated couldn’t participate. How did they manage it?

David Barton Smith: Wilbur Cohen and the people in the Social Security Administration were absolutely masterful in pulling this together in such a short period of time. They knew exactly how to get things done and they paid attention to the details. It’s remarkable that without the computers that we have today or the Internet, they were able to do this all in 11 months. They were just good professionals.

Michelle Andrews: There has been talk at various times about creating “Medicare for All.” Given what you know, what are the odds of that ever happening here?

David Barton Smith: The odds are better now than a few years ago. Because of the ACA, but also because people are beginning to understand some of the limitations of a privately insured system. It’s more complicated, it’s more costly, it’s harder to get good competitive pricing from hospitals or from drug companies. And this idea is something that’s been resisted by the insurance industry. But I get the sense that people are getting a little bit more impatient. Although a lot of Republicans bash Obamacare, I don’t hear a lot of them bashing Medicare. The resistance would be strong, certainly. This is a very interesting year.

http://khn.org/news/1965-the-year-that-brought-civil-rights-to-the-nations-hospitals/

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Comment:

By Don McCanne, M.D.

The story of using Medicare to rapidly integrate our nation’s hospitals is inspiring. It should give us hope that an Improved Medicare for All could be used to leverage corrections of other health care injustices.

David Barton Smith reminds us that people are beginning to understand some of the limitations of a privately insured system and that they are becoming more impatient. Let’s leverage that.

What changes in ACA might the election bring?

Could Trump loss spur ACA deal with Clinton?

By Harris Meyer
Modern Healthcare, August 6, 2016

With Donald Trump’s presidential campaign faltering, Republican health policy experts are gaming out Plan B for working with a Hillary Clinton administration to achieve conservative healthcare goals.

Their focus is on a possible “grand bargain” that would give conservative states greater flexibility to design market-based approaches to make coverage more affordable and reduce spending in exchange for covering low-income workers in non-Medicaid expansion states. A key element, conservative experts say, would be for a Clinton administration to make it easier for states to obtain Section 1332 waivers under the Affordable Care Act. Those waivers allow states to replace the law’s insurance exchange structure with their own innovative models.

To win GOP backing for measures to stabilize the exchanges, Republicans will seek changes to make ACA coverage more attractive and affordable for younger people, said James Capretta, a conservative health policy expert at the American Enterprise Institute. That includes allowing lower premiums for young people, a wider range of benefit designs and premium subsidies for plans bought outside the exchanges and easing minimum benefit requirements.

Clinton’s best opportunity might be to persuade GOP governors and lawmakers in non-expansion states to accept Medicaid expansion by giving them more leeway on program design.

http://www.modernhealthcare.com/article/20160806/MAGAZINE/308069967

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Comment:

By Don McCanne, M.D.

Although elections can be unpredictable, this time we can make a couple of predictions that are a near certainty.

Donald Trump will not be able to change his image as a dangerous incompetent before the election, and Hillary Clinton will be elected by default, even though she will remain unpopular.

Gerrymandering as a result of the 2010 Census will remain unchanged in this election, so the Republicans will maintain control of the House of Representatives with Paul Ryan as the Speaker. Although the Tea Party faction will have been diminished in numbers, enough will be reelected such that Ryan will have to include them in legislative negotiations.

Although it is uncertain which party will hold the majority in the Senate, it is clear that each of the two major parties will still have the ability to block most legislation through the filibuster. For the Democrats, that means that they can forget about a Medicare buy-in starting at age 55, and they can forget about a government-administered public option to compete with the private plans. For the Republicans, that means that they can forget about a repeal of the Affordable Care Act, and they can forget about completing privatization of Medicare through premium support.

So for the time being, the Affordable Care Act is here to stay. Both sides will want changes in it, but only modest incremental changes will be possible, and they must satisfy both sides or they will not clear Congress.

Democrats will want expanded enrollment in the ACA exchanges and in Medicaid. Republicans will want less regulation in these programs. For the exchange plans both will want lower premiums to make insurance more affordable, and they may do that by easing the minimum benefit requirements, by allowing more flexible innovations in insurance design, by reducing premiums for young adults, and perhaps even by allowing premium subsidies for plans outside of the exchanges. For Medicaid, through waivers or through new legislation they may allow greater flexibility and further privatization to encourage non-participating states to join in the program to expand Medicaid.

These compromises will further reduce the numbers of uninsured and make health insurance more affordable, but affordable access to actual health care is already a major problem and these measures will make it much worse. Increasing the numbers of individuals who are nominally insured should not be considered a success when the tradeoff is the erection of financial and logistical barriers to essential health care services. Leaving patients sick and broke is not the direction in which we want to be headed.

What are the political prospects for single payer post-election? This January Hillary Clinton said, “I want you to understand why I am fighting so hard for the Affordable Care Act. I don’t want it repealed, I don’t want us to be thrown back into a terrible, terrible national debate. I don’t want us to end up in gridlock… People who have health emergencies can’t wait for us to have a theoretical debate about some better idea that will never, ever come to pass.”

Never, ever. The political barricade is up. It is up to us to break it down.