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Proposed Rule for Expanding Health Reimbursement Arrangements

Proposed Rule for Expanding Health Reimbursement Arrangements

Health Reimbursement Arrangements and Other Account-Based Group Health Plans

Notice of Proposed Rule Making

Department of the Treasury
Department of Labor
Department of Health and Human Services

Published in the Federal Register, October 29, 2018

Summary: This document sets forth proposed rules to expand opportunities for working men and women and their families to access affordable, quality healthcare through proposed changes to regulations under various provisions of the Public Health Service Act (PHS Act), the Employee Retirement Income Security Act (ERISA), and the Internal Revenue Code (Code) regarding health reimbursement arrangements (HRAs) and other account-based group health plans. (For simplicity, this preamble generally refers only to HRAs, but references to HRAs should also be considered to include other account-based group health plans, unless indicated otherwise.) Specifically, these proposed rules allow integrating HRAs with individual health insurance coverage, if certain conditions are met. The proposed rules also set forth conditions under which certain HRAs would be recognized as limited excepted benefits. Also, the Department of the Treasury (Treasury Department) and the Internal Revenue Service (IRS) propose rules regarding premium tax credit (PTC) eligibility for individuals offered coverage under an HRA integrated with individual health insurance coverage. In addition, the Department of Labor (DOL) proposes a clarification to provide plan sponsors with assurance that the individual health insurance coverage the premiums of which are reimbursed by an HRA or a qualified small employer health reimbursement arrangement (QSEHRA) does not become part of an ERISA plan, provided certain conditions are met. Finally, the Department of Health and Human Services (HHS) proposes rules that would provide a special enrollment period in the individual market for individuals who gain access to an HRA integrated with individual health insurance coverage or who are provided a QSEHRA. The goal of these proposed rules is to expand the flexibility and use of HRAs to provide more Americans with additional options to obtain quality, affordable healthcare. The proposed rules would affect employees and their family members; employers, employee organizations, and other plan sponsors; group health plans; health insurance issuers; and purchasers of individual health insurance coverage.

https://s3.amazonaws.com…

Administration Moves To Incentivize Health Reimbursement Arrangements

By Katie Keith
Health Affairs Blog, October 26, 2018

On October 23, 2018, the Departments of Health and Human Services, Labor, and Treasury issued a new proposed rule to expand the use of health reimbursement arrangements to fund access to health insurance and health care. The proposed rule was developed in response to President Trump’s executive order from October 2017 that directed the federal government to expand access to short-term, limited-duration insurance, association health plans, and health reimbursement arrangements (HRAs).

In the executive order, President Trump directed the Departments to “increase the usability of HRAs, to expand employers’ ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with nongroup coverage.” As expected by many health policy watchers, the new rule would reverse prior Departmental guidance by allowing HRAs to be used to fund both premiums and out-of-pocket costs associated with individual health insurance coverage.

The proposed rule would also create a new “excepted benefit HRA” option that employees could use to pay premiums for excepted benefits policies and short-term, limited-duration insurance policies.

From the Implications

The rule could lead the loss of coverage if employers stop offering group health plans in lieu of an HRA, and their employees do not accept the HRA or obtain other coverage. The rule could also affect individuals who currently qualify for and receive marketplace subsidies while working for an employer who does not offer health coverage. Under the proposed rule, the offer of an “affordable” HRA-IIHIC would make an employee ineligible to receive a premium tax credit. As a result, some employees could pay more for coverage under the HRA-IIHIC option than they were paying if they received a premium tax credit through the marketplace. Consumers may also face higher cost-sharing in the individual market relative to what they received through a group health plan, and the HRA-IIHIC option could impose higher administrative and compliance burdens on consumers who must navigate a seemingly new system.

Whether these changes would be good for the individual market risk pool remains to be seen and would depend largely on the risk profile of employees offered the new HRA-IIHIC option. The Departments repeatedly note the concern that expanding access to HRAs could lead to employers offering coverage options to employees in a way that discriminates based on health status. At one point, the Departments state their goal to “prevent large-scale destabilization of the individual market” through the proposed rule.

On the other hand, there is the possibility that employees who enter the individual market through an HRA-IIHIC would be healthier on average, which could lead to a better risk profile for the individual market, and thus lower premiums and an even more stable marketplace. This could be especially true if sicker employees hold on to their group health plans, which might be more comprehensive than individual market coverage.

Overall, the proposed rule comes at a seemingly odd time. In the preamble, the Departments describe the various market reforms and structure of the ACA as “intend[ed] to create a robust and competitive individual market, in part by ensuring that risk pools included both higher risk and lower risk individuals.” Given this, the Departments seem comfortable with incentivizing—or at least opening up the possibility for—employees to receive coverage through the individual market, thereby further expanding that market. They do so even as President Trump and senior political leaders continue to argue, as recently as yesterday, that the ACA and the individual market are deeply flawed and broken with “deteriorating market conditions.”

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

The Trump administration is now proposing expanding the use of health reimbursement arrangements (HRAs) with the intent of moving more individuals from employer-sponsored plans and into the individual market, fulfilling the administration’s ideological preference for competition in the private marketplace.

If you are really curious about the details of their proposal, you can read the couple hundred pages of the proposed rule, or the long article by Katie Keith, briefly excerpted above. But understanding this proposal is not the purpose of today’s message. Rather it is to get a glimpse of the bizarre machinations in health care by this administrations.

Without going into any of the boring details, they are greatly increasing the administrative complexity of health care financing through health reimbursement arrangements, employer-sponsored plans, and plans in the individual market – this by an administration that says that it wants to increase choice and competition, giving more freedom to individuals to exercise their choices in the marketplace.

Administrative complexity is one of the worst features of health care financing in the United States, and yet this administration continues to compound the problem, not only increasing the waste, but further disrupting the important insurance function of pooling risk as they continue to increase fragmentation in health care financing.

Right now they are celebrating CMS Administrator Verma Seema’s tweet: “this year’s scariest Halloween costume – a tee shirt emblazoned with ‘Medicare for All.'” She followed up with, “Did I get your attention? Good. Medicare for All isn’t a joke. It’s a multi-trillion dollar drain on the American economy that will bankrupt future generations. It’s government controlled health care that will strip choice away from millions. It’s a bad idea. And it IS scary.”

Seema Verma has the solution to our health care financing problems right in front of her in her own department, and she ridicules it. What’s really scary is leaving these people in charge.

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

Medicare Advantage Employer Group Waiver Plans (MA-EGWPs)

Continued Enrollment Growth in Employer-Group Medicare Advantage

Mark Farrah Associates, October 31, 2018

As of October 1, 2018, total Medicare Advantage (MA) membership stood at over 21 million, representing approximately 34% of the 63.3 million Americans eligible for Medicare. Medicare Advantage plans can either be acquired individually through direct purchase policies or through employer/group retiree programs, commonly known as Medicare Advantage Employer Group Waiver Plans (MA-EGWPs). Since the inception of Medicare Advantage in 2003, Individual MA policies have historically dominated the market as 17.1 million beneficiaries purchased MA plans as of October 1, 2018. However, despite a decrease over the years in the number of private sector employers offering retiree health benefits, membership trends in MA-EGWPs have demonstrated notable enrollment growth, especially within the past two years.

Since December 2017, employer-group Medicare Advantage enrollment has increased by over 443 thousand. In fact, over the past four years, group market enrollment has increased by approximately 1 million members, nearly a 125% increase in enrollment since December 2015. This brief provides insights about the current employer-group Medicare Advantage market and assesses membership trends over the past four years by carrier and state.

https://www.markfarrah.com…

Comment:

By Don McCanne, M.D.

The continued growth in enrollment in private Medicare Advantage plans should be of concern to those who support Single Payer Medicare for All. The privatized Medicare program would not be suitable for a single payer system for the obvious reason that it would be a multi-payer system using private sector insurance plans.

This report shows that there is even more rapid growth in Medicare Advantage Employer Group Waiver Plans (MA-EGWPs) – plans that are used for employer/group retiree programs. Locking retired employees into these plans would make it even more difficult to transition into Single Payer Medicare for All since retirees tend to be quite supportive and defensive of their health benefit programs.

Right now there is an intensive effort taking place to defer, perhaps forever, the enactment of Single Payer Medicare for All through a strategy to create a Medicare for Some by offering the purchase of Medicare as an option (a public option) for those currently not yet qualified for Medicare. It is highly likely that the public option will be private health plans comparable to the Medicare Advantage plans, just as the plans offered in the government exchanges under the Affordable Care Act are private health plans.

In the meantime, the traditional Medicare program is being neglected, likely by design, and, as such, it would be unsuitable for Single Payer Medicare for All without significant improvements. However, as the private Medicare Advantage plans become more pervasive within the system, there is great risk that the traditional Medicare program will be reduced to a Medicaid-style welfare program, if not entirely abandoned.

The more we accept these incremental changes such as the Medicare Advantage Employer Group Waiver Plans and the pending Medicare Advantage public option – Medicare for Some – the greater the likelihood that we will never see Single Payer Medicare for All. As a reminder, Single Payer Medicare for All corrects the major deficiencies in health care financing, making health care equitable, accessible, and affordable for everyone, whereas the Public Option Medicare for Some perpetuates our highly dysfunctional, fragmented, inequitable, and often unaffordable health care financing system and merely adds one more option that increases the administrative complexity of our system.

The Medicare Advantage Employer Group Waiver Plans may seem relatively benign and perhaps even an incremental benefit, but these creeping programs are locking in stone a privatized system that is not even worthy of the name “Medicare.” The longer we wait, and the more we tolerate creeping incrementalism, the less likely we’ll ever see Single Payer Medicare for All.

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

“Medicare for All” eliminates the health care middleman

By Samuel L. Rosenthal, M.D.
The New York Times, Letters, November 1, 2018

To the Editor:

Re “‘Don’t Get Too Excited,’” by Elisabeth Rosenthal and Shefali Luthra (Sunday Review, Oct. 21):

Although almost every major country in the world has medical care that is significantly less expensive than ours and most have medical outcomes that are as good or better than ours, your article is correct in pointing out that very few of these countries have what amounts to “Medicare for all.”

The most common systems involve taxpayer-funded, nonprofit insurance, provided by private companies that are regulated by the government. The insurance companies earn operating costs and salaries for their employees but not large profits. There is no benefit to denying coverage for pre-existing medical conditions or conditions that require frequent or extensive medical care. Prices for medical care, medical devices and drugs are usually determined by negotiation and are uniform throughout a country.

By contrast, we have unregulated for-profit medical insurance with a middleman whose “product” we must buy, a product that adds nothing to medical care except unnecessary hassle and enormously increased cost. Medicare for all addresses this problem by eliminating the middleman.

https://www.nytimes.com…

Faux ‘Medicare for All’ gaining traction

Exclusive poll: What voters want from “Medicare for All”

By Sam Baker
Axios, October 31, 2018

When you hear candidates talk about “Medicare for All,” what do you think they are proposing?

52% – Single-payer, universal, government-run
21% – Competitive, optional, government-run
24% – Neither

Which of the following health care options do you prefer?

34% – Single-payer, universal, government-run
33% – Competitive, optional, government-run
30% – Neither

Data: Survey Monkey online poll conducted Oct. 24-26, 2018 among 2,949 U.S. adults. Total margin of error is ±2.5 percentage points.

https://www.axios.com…

Comment:

By Don McCanne, M.D.

This new poll confirms that the label, “Medicare for All,” no longer refers exclusively to a single payer program that includes everyone, but, for many people, it refers to a competitive, multi-payer market of health plans that includes Medicare as an option (i.e., a public option). In fact, the polling indicates that just as many believe that they would prefer a competitive, multi-payer model of “Medicare for All” as would prefer a true single payer model of “Medicare for All” that actually includes absolutely everyone.

Single payer advocates understand the crucial distinction, though many of the public option advocates do not seem to understand the consequences of their choice. The single payer version of “Medicare for All” corrects the major deficiencies in health care financing, making health care equitable, accessible, and affordable for everyone. The public option version of “Medicare for All” perpetuates our highly dysfunctional, fragmented, inequitable, and often unaffordable health care financing system and merely adds one more option that increases the administrative complexity of our system. The differences are absolutely critical, but they are being glossed over by misuse of the “Medicare for All” label.

It is imperative that we educate the public as to the difference, but the labeling is a problem. “Single payer” is a somewhat wonkish term that often is still not well understood by everyone. In contrast, Medicare is a program that is almost revered, and most individuals can hardly wait until they are eligible to enroll in it. Although we have been using “Improved Medicare for All,” that does not distinguish it from a “Medicare for All” that supposedly has been improved by adding a public option.

Until there is a consensus on precisely how we should proceed, I would suggest in the interim the two following measures:

  1. We should keep the label simple, but to distinguish a bona fide single payer system, I would suggest calling it “Single Payer Medicare for All.”
  2. When others use “Medicare for All” when they mean only adding a public option, always call them on it. Insist that they label their model “Medicare for Some,” explaining that they are proposing Medicare for a few more but not for most of us who would still have to deal with the current dysfunctional system.

At the PNHP annual meeting November 9 & 10 in San Diego there will be a workshop on “Faux single-payer plans and legislative deficiencies,” presented by David Himmelstein and President-elect Adam Gaffney. Maybe we can reach a consensus on our strategy at that time.

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

More on RAND report and why pellets from a Skinner box won’t work

Response to Quote of the Day of October 29, 2018: "Payment models are stuck in carrots and sticks"

By Kip Sullivan
October 30, 2018

That was an excellent Quote of the Day, Don.

I want to emphasize the difference between what you and Alfie Kohn (the author of the NY Times essay) said, and what the RAND study authors said. You and Kohn said, “No more tinkering with P4P schemes, they don’t work, they make things worse.” The RAND study authors said, “Let’s keep tinkering, we can make P4P better.”

Here’s Kohn’s conclusion: “By now it should be clear that the trouble doesn’t lie with the type of reward, the schedule on which it’s presented, or any other detail of how it’s done. The problem is the outdated theory of motivation underlying the whole idea of treating people like pets — that is, saying: Do this, and you’ll get that.” In other words, the diagnosis underlying the entire P4P fad was wrong to begin with (it wasn’t merely “outdated”), ergo, the recommended solution — giving doctors little food pellets when they pull on the right lever and taking food pellets away when they fail to pull on the right lever — can’t work.

The RAND study is a useful contribution to the literature on what tended to be called P4P schemes from about 2000 to 2010, and since 2010 is more often called “value-based purchasing” (VBP) (The most important P4P/VBP schemes today are ACOs, medical homes, bundled payment, and the MIPS program.) The RAND study is useful because the authors actually went to the trouble of speaking to doctors — y’know, the people who treat patients who must cope with the useless feedback created by the proliferating VBP schemes imposed upon them by public and private insurers. It’s very rare to see a study that seeks to present the views of the creatures in the Skinner box created by VBP advocates over the last two decades (the Leapfrog Group, MedPAC, the Patient-centered Primary Care Collaborative, what used to be called the Institute of Medicine, the Robert Wood Johnson Foundation, Elliott Fisher, Stephen Shortell, Atul Gawande, Peter Orszag, Ezekiel Emanuel, members of both parties in Congress, etc.) The RAND study tells us that the creatures in the VBP Skinner box are confused and unhappy, and want out.

But the recommendations of the RAND study are ridiculous. They’re ridiculous because RAND has apparently totally ignored the research, accurately summed up by Kohn and Don, to wit, no amount of tinkering can fix a problem that was diagnosed incorrectly. (I say “apparently” because I have read only the summary of the RAND study.) RAND recommends merely:

  • reducing the rate at which Congress, Medicare and the insurance industry gin up more VBP schemes,
  • giving doctors some extra dollars to buy more IT hardware and software from Cerner and Epic so they can, in theory, make more sense of the white noise in the Skinner box, and
  • provide more “understandable performance data.”

These pathetic recommendations reflect profound confusion about (a) the cause of high US health care costs (it’s our high prices caused by administrative waste and galloping consolidation, not excessive volume triggered by the FFS payment method) and (b) the solution (we need a true single-payer system, not Bernie’s bill or any other bill that doubles down on VBP nostrums).

How did the VBP buffs and RAND get so confused about the correct diagnosis of the American health care crisis and the correct response? Who told them per capita US health care costs are double those of the rest of the world because American doctors (and only American doctors) are motivated by greed and, therefore, routinely cave into the FFS incentive to order unnecessary services? Who told them physician “merit” or “efficiency” (their cost and quality) can be measured so accurately that the Masters of the Skinner Box can send doctors precise signals — more food pellets for you, fewer for you — that will accurately tell doctors when they’re being inefficient and when they’re failing to exercise good medical judgement?

Quote of the Day of October 29, 2018 — “Payment models are stuck in carrots and sticks”:
https://www.pnhp.org…

Comment:

By Don McCanne, M.D.

Yesterday’s Quote of the Day message was too important to let it pass on without further comment. Government legislative and administrative officials and the policy community in both the public and private sector continue to lead us down the wrong pathway to reform. Their value-based purchasing models for health care reform (paying for value instead of volume) are failing because they are based on the incorrect assumption that physicians will repair our health care system if only they are presented with petty rewards or penalties. They completely miss the ethical and professional foundations of the science and art of medicine.

The RAND study is an important contribution because they actually looked at physicians and how they are responding to the current health care payment models. They showed that the models are increasingly complex, that they are changing at an accelerating pace, and that risk aversion is a consequence. The error that RAND makes is that they ignore their important findings and fall in line with the rest of policy community in recommending more of the same.

The article yesterday by Alfie Kohn shows us that the petty rewards or punishments of carrots or sticks, or success or failure of obtaining reward pellets from a Skinner box, “can never create a lasting commitment to an action or a value, and often they have exactly the opposite effect.” Value-based purchasing (MIPS, APMs, ACOs, etc.) reduces health care to a petty reward system that fails on goals of higher quality and lower costs, while creating harm, especially through physician burnout.

Yesterday’s Quote of the Day and today’s comments by Kip Sullivan present two rhetorical versions of the same concept just to be sure that everyone understands it: value-based purchasing is the wrong pathway to reform. Both will be posted on the PNHP website so that they will always be available to help educate others (https://www.pnhp.org/news/quote-of-the-day, Oct. 29 & 30, 2018).

After the midterm election the legislative proposals for Medicare for All will be undergoing refinement. We need to be sure that the architects are not deceived into thinking that the legislation needs updating by adding the flawed concepts of value-based purchasing. We cannot allow the ethics and professionalism of medicine to be replaced with the carrots, sticks, and Skinner box pellets of value-based purchasing.

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

Doctor’s Tip: Big Pharma needs fixing

By Greg Feinsinger, M.D.
Glenwood Springs (Colo.) Post Independent, October 29, 2018

Following the discovery of antibiotics 90 years ago, the medical field became pill- and procedure-oriented. Initially, the business of medicine was altruistic. For example, in 1955 Jonas Salk developed the polio vaccine, which saved millions of lives and prevented millions of cases of disabling paralysis worldwide. When Dr. Salk was asked who owned the patent, his reply was: “Well, the people, I would say. There is no patent. Could you patent the sun?”

In the last twenty-five years, American medicine (hospitals, the pharmaceutical/medical device industry, medical insurance companies, physician specialty societies) has become big business — all about making profits rather than about what’s best for the citizens of this country. Following are some reasons it has become easy — in this environment of greed — to dislike the pharmaceutical industry:

  • They have too much influence on Congress, through campaign contributions and lobbying — for example convincing them to make importing cheaper drugs from Canada illegal, convincing them to forbid Medicare from negotiating for better drug prices for seniors.
  • They have too much influence on medical education and on practicing physicians: Drug reps develop cozy relationships with doctors in their offices and convince them to use their products, even though better and cheaper alternatives often exist. Medical journals contain drug ads. Most speakers at medical conferences have ties to pharmaceutical companies (which they now have to disclose).
  • Pharmaceutical companies charge as much as they can get away with — especially for products that are critical for people with diseases such as M.S.
  • When patents on brand-name products are about to expire, drug companies make minor changes and sell these “new” products at brand-name prices. Or they pay potential generic competitors to delay making lower-priced products.
  • Although game-changing drugs have been developed over the years, most new drugs are “me too” drugs, that offer nothing new — a practice that isn’t allowed in most other developed countries. For example, losartan came out as an ARB drug for hypertension many years ago, but there are now several of these ARB drugs with no real advantage over the original losartan.
  • They market directly to consumers — a practice that is only allowed in the U.S. and New Zealand.
  • They justify over-charging for their products by saying that research and development is expensive — but they pay their CEOs inflated salaries and spend more on marketing than on R and D.

Can you imagine the altruism that Dr. Salk displayed in 1955 happening today? Now we have Goldman Sachs analysts warning biotech firms to stay away from drugs that offer “one shot cures.” They are referring to a new drug that cures hepatitis C, which “has gradually exhausted the available pool of patients.” The analysts suggest sticking to cancer drugs, “where the potential for a cure poses less risk to the sustainability of a franchise.” Drug companies benefit most from chronic diseases such as diabetes and hypertension, which — unless patients with these diseases make dramatic lifestyle changes — require medications for years. (As noted in previous columns, the U.S. doesn’t have a health care system, but rather a disease management system — we wait until diseases occur and then spend trillions trying to manage them. Big Pharma loves this dysfunctional system).

The PNHP (Physicians for a National Health Program) developed the following principles for fixing the pharmaceutical industry:

  • “Access to medications should be determined by medical need, not financial means.”
  • “Drugs must be affordable to society.”
  • “Drug development should be geared toward real innovation that maximizes population health.”
  • “The human right to health must take precedence over intellectual property rights (patents).”
  • “The safety and effectiveness of medications must be independently and rigorously evaluated.” (This refers to the pharmaceutical industry having undue influence on the FDA).
  • “Comprehensive and unbiased information on drugs should be available to prescribers and patients.”

Dr. Feinsinger, who retired from Glenwood Medical Associates after 42 years as a family physician, has a nonprofit Center For Prevention and Treatment of Disease Through Nutrition.

https://www.postindependent.com…

Payment models are stuck in carrots and sticks

Effects of Health Care Payment Models on Physician Practice in the United States

By Mark W. Friedberg, et al.
RAND, October 24, 2018

This report, sponsored by the American Medical Association (AMA), describes how alternative payment models (APMs) affect physicians, physicians’ practices, and hospital systems in the United States and also provides updated data to the original 2014 study. Payment models discussed are core payment (fee for service, capitation, episode-based and bundled), supplementary payment (shared savings, pay for performance, retainer-based), and combined payment (medical homes and accountable care organizations). The effects of changes since 2014 in the Affordable Care Act (ACA) and of new alternative payment models (APMs), such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program (QPP), are also examined.

Key Findings

Payment models are changing at an accelerating pace

Physician practices, health systems, and consultants find it difficult to keep up with the proliferation of new models, with some calling for a “time out” to allow them to better adapt to current APMs.

Payment models are increasing in complexity

Alternative payment models have become increasingly complex since 2014. Practices that have invested in understanding complex APMs have found opportunities to earn financial awards for their preexisting quality — without materially changing patient care.

Risk aversion is more prominent among physician practices

Risk aversion among physician practices was more prominent. Risk-averse practices sought to avoid downside risk or to off-load downside risk to partners (e.g., hospitals and device manufacturers) when possible.

For full document (96 pages):
https://www.rand.org…

RAND press release:
https://www.rand.org…

***

Science Confirms It: People Are Not Pets

Research on the efficacy of rewards tells us that we can’t bribe others into doing what we want.

By Alfie Kohn
The New York Times, October 27, 2018

The field of social psychology is sometimes accused of doing no more than ratifying common sense, so it’s worth paying attention when its findings are genuinely surprising. Case in point: the discovery that when we are rewarded for doing something, we tend to lose interest in whatever we had to do to get the reward.

This outcome has been confirmed scores of times with all sorts of rewards and tasks, and across cultures, ages and genders. Yet many teachers, parents and bosses persist in using versions of what has been called “sugarcoated control.”

Psychologists often distinguish between intrinsic motivation (wanting to do something for its own sake) and extrinsic motivation (for example, doing something in order to snag a goody). The first is the best predictor of high-quality achievement, and it can actually be undermined by the second. Moreover, when you promise people a reward, they often perform more poorly as a result.

Over the years, researchers have investigated some intriguing questions that stemmed from these basic findings. For instance: What if the reward is really large and luscious? (Answer: It’s apt to do even more damage to intrinsic motivation.) Are rewards destructive because they distract people from the task? (Apparently not, because other distractions don’t have the same negative effects.) Which is worse, giving people a set reward for doing something or making it contingent on how well they do it? (The latter, by a long shot.)

By now it should be clear that the trouble doesn’t lie with the type of reward, the schedule on which it’s presented, or any other detail of how it’s done. The problem is the outdated theory of motivation underlying the whole idea of treating people like pets — that is, saying: Do this, and you’ll get that.

The best that carrots — or sticks — can do is change people’s behavior temporarily. They can never create a lasting commitment to an action or a value, and often they have exactly the opposite effect … contrary to hypothesis.

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

There is much more here than a casual glance might imply. The search for value-based payment in health care, as opposed to paying for volume, has led to various payment models such as shared savings, accountable care organizations, bundled payments, pay for performance (P4P), medical homes, and other alternative payment models. How well is that working?

To date, most studies have been quite disappointing. Claims of cost savings are belied when considering the additional provider costs of information technology and human manpower devoted to these models, not to mention the high emotional cost of burnout. This RAND study shows that these models are increasing in complexity, making it difficult for the health delivery system to keep up. Even worse, they are inducing risk aversion. The health care providers are trying to avoid those who most need health care – the opposite of what our health care system should be delivering.

Much of the experimentation in delivery models has been centered around reward or punishment. But, as Alfie Kohn writes, “intrinsic motivation (wanting to do something for its own sake)… is the best predictor of high-quality achievement,” whereas “extrinsic motivation (for example, doing something in order to snag a goody)” can actually undermine intrinsic motivation. It has been observed by others that the personal satisfaction of achievement of patient health care goals is tremendously rewarding, whereas the token rewards based on meager quality measurements are often insulting because of the implication that somehow token payments are a greater motivator than fulfilling Hippocratic traditions. Even more insulting are the token penalties for falling on the wrong side of the bell curve simply as a result of making efforts to care for patients with greater medical or sociological difficulties.

Quoting Alfie Kohn again, “carrots or sticks… can never create a lasting commitment to an action or a value, and often they have exactly the opposite effect … contrary to hypothesis.” The RAND report suggests slowing down and working with these models some more while increasing investment in data management and analysis with the goal of increasing success with alternative payment models. No. These models are making things worse. It’s time to abandon them and get back with taking care of our patients. The payment model we need is an improved version of Medicare that takes care of everyone. Throw out the sticks and carrots.

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

SGIM Should Support a Single-Payer National Health Insurance Program

By Danny McCormick, MD, MPH; Oliver Fein, MD; Christopher J. Wong, MD; Scott Goldberg, MD; Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD
SGIM Forum, Perspective, October 2018

Despite improvements in health insurance coverage under the Affordable Care Act (ACA), 29 million Americans remain uninsured and millions with coverage are also unable to afford care. Meanwhile, in our healthcare institutions, the drive for profit increasingly trumps clinical imperatives, and even in not-for-profit organizations, mounting bureaucracy drains both funds and joy from patient care. None of the incremental reforms currently being debated would fix these problems. SGIM has supported the goals of universal access to care and health equity, but has never taken a position on how to achieve these goals. The time has come for our organization to endorse and advocate for the only viable way to ensure universal access to comprehensive care at an affordable price—a single payer reform.

Current State of Coverage and Access in the USA

The ACA implemented the largest health insurance expansion since the start-up of Medicare and Medicaid in 1966. Since 2013, 15.5 million Americans have gained coverage, with larger gains among the poor, Hispanics and African Americans, although these groups continue to suffer higher-than-average rates of uninsurance.1 Yet, 9.1% of Americans remain uninsured, and 13.0%—including 16.3% of black and 20.3% of Hispanic people—can’t afford a needed physician visit currently.2

But we have likely seen all the coverage gains achievable under the ACA. Unfortunately, the current administration is seeking to undercut the law, implementing policies that will erode existing coverage levels.3 Even without these setbacks, the Congressional Budget Office estimated that no further increases in coverage would occur through 2026.

SGIM’s Mission, Previous Work, and Role in Medicine

SGIM is an association of the world’s leading academic general internists whose members have expertise in health services and policy research, healthcare administration, clinical care, and ethics. This allows SGIM to play an important role in guiding the public and policy makers on which specific policy options to select to address key policy problems. Through its committees and the Council, SGIM works hard to advance its mission “to achieve health care delivery that is comprehensive…[and] is organized and financed to achieve optimal health outcomes and maximize equity”. SGIM’s stated values include “social responsibility and equity in health and healthcare”. In addition, SGIM’s Health Policy Committee affirms a commitment to “universal health care access”.

SGIM regularly supports specific policies, even controversial ones, by issuing white papers or public statements. As an organization, we have taken strong positions against physicians’ participation in torture and in support of providing care for undocumented immigrants. However, SGIM has yet to advocate clearly on how to achieve universal and equitable access to care. We believe it should now publicly support a single-payer program for the United States.

Why Should SGIM Support a Single-Payer Health Care System?

Merits of Single Payer

A single payer reform would replace the current welter of private and public insurance plans with one public plan covering everyone for all medically necessary care—in essence, an expanded and upgraded version of the traditional Medicare program. The potential health benefits of this approach are substantial. Numerous studies, many from SGIM members, have shown that being uninsured carries mortal consequences. Covering the 29 million Americans who are currently uninsured would likely save many thousands of lives annually, and would reduce the risks borne by many more patients who delay seeking care and skimp on medications to save costs.

The economic case for single-payer reform is also compelling. Private insurers’ overhead averages 12.4% versus 2.2% in traditional Medicare. Reducing insurance overhead to Medicare’s level would save approximately $220 billion this year. Even larger savings would accrue by sharply reducing provider overhead, including the substantial costs of billing and paperwork required to deal with multiple payers. By paying hospitals lump-sum operating budgets rather than forcing them to bill per patient, Scotland and Canada have held hospital administrative costs to approximately 12% of revenues versus 25.3% in the United States.4 Further, a single-payer program could use its bargaining clout to sharply reduce drug prices. Single payer’s savings on bureaucracy and drug profiteering would fully offset the added costs of providing universal, comprehensive first-dollar coverage. Indeed, even critics of single payer estimate that such reform would cut overall health expenditures by $2 trillion over a decade.5

Single Payer and SGIM’s Organizational Objectives

Single payer aligns well with SGIM’s organizational goals. We agree with SGIM’s support of the broad principles of access and equity. However, lacking any plan for how these goals can be realized effectively undermines advocacy efforts. SGIM’s not providing specific recommendations, leaves the impression that it believes that incremental reform is a plausible way to achieve universal coverage. The evidence does not support this belief.

We are also convinced that single payer is the best way to address SGIM’s mission of “improving the work and practice environment for general internists” and reducing
physician burnout. The simplified, uniform billing procedures under a single-payer system would reduce the time and effort physicians currently waste arguing with private, profit-driven insurers and providing documentation that is clinically superfluous but essential to justify payment.

The Moral Argument

Universal access to care is, fundamentally, a moral issue. As scientists, we must be attentive to research evidence, policy details and economic necessities. Ultimately, however, we must be guided by our conscience. Access to health care should not be dependent on one’s age, employer, wealth, or zip code; it is a moral failure that we do not guarantee the clear common good that is health care. A strong body of research in the United States and experience in other nations give clear evidence that a single payer system would dramatically expand access to care, including treatments for millions with chronic illnesses, saving thousands of lives annually. As physicians, we have an obligation to advocate for policies that evidence indicates are in the best interest of the public’s health. In light of this, we believe that advocacy for single payer reform is a professional duty.

Arguments Against SGIM’s Support for Single Payer

Some suggest that advocating single payer reform would commit SGIM to supporting a fringe proposal that would isolate us from the mainstream of political debate. Yet, recent surveys indicate that most Americans favor such reform. Single-payer bills in Congress have gained co-sponsorship from 123 members of the House and 16 in the Senate. All the leading Democratic party contenders for the presidency in 2020 openly call for single payer reform.

Some may also worry that SGIM support for single payer could alienate some current or potential members, or isolate us from other physician groups. Yet, as noted above, SGIM has not shied away from taking stands on other controversial and potentially divisive issues when it was clearly in the interest of the public’s health. Moreover, past polls of SGIM’s membership have found substantial support for “a single, consolidated financing mechanism,” and recent surveys indicate that a majority of physicians—and an even larger proportion of general internists—favor a single payer system.

Others may view an incremental strategy as a more practical route to universal coverage, citing nations such as Switzerland and Germany that have retained multiple insurers while achieving universal coverage. Yet those nations’ insurers are fundamentally different from ours. In Switzerland, for example, only non-profit insurers can offer the tightly regulated mandatory coverage and are required to pay providers identical rates. Transitioning to this or similar models would entail converting our for-profit insurers to heavily-regulated non-profits, a reform that insurers would vehemently oppose. Moreover, both insurance overhead and providers’ administrative costs in multi-payer systems are far higher than under single payer. While the incremental approach may sound appealing, it would sacrifice much of the administrative savings that makes universal coverage under a single payer system affordable and it would still require a head-on confrontation with America’s for-profit insurance giants.

Conclusion

SGIM supports universal access and the elimination of disparities in access to care. The only plausible way to achieve these goals is through adoption of a single payer
national health insurance program. Single payer would cover 100% of Americans, dramatically expand access to care, and improve access to needed treatments for millions with chronic illnesses, saving thousands of lives annually. Popular and political support for single payer is growing. SGIM should provide leadership in advocacy for such reform.

https://www.sgim.org…

References

1. Cohen RA, Zammitti EP, Martinez ME. Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2017. https://www.cdc.gov… Published November 2017. Accessed September 1, 2018.

2. BRFSS Web Enabled Analysis Tool. https://nccd.cdc.gov… Accessed September 1, 2018.

3. Collins SR, Gunja MZ, Doty MM, et al. First look at health insurance coverage in 2018 finds ACA gains beginning to reverse. http://www.commonwealthfund.org… Published May 1, 2018. Accessed September 1, 2018.

4. Himmelstein DU, Jun M, Busse R, et al. A comparison of hospital administrative costs in eight nations: US costs exceed all others by far. Health Aff (Millwood).
2014;33(9):1586-94.

5. Blahous C. The costs of a national single-payer health care system. https://www.mercatus.org… Published July 2018. Accessed September 1, 2018.

Author Affiliations

Dr. McCormick (danny_mccormick@hms.harvard.edu) is associate professor, Harvard Medical School/Cambridge Health Alliance, Cambridge, MA.

Dr. Fein (ofein@med.cornell.edu) is professor, Weill Cornell Medical College, New York, NY.

Dr. Wong (cjwong@uw.edu) is associate professor, Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA.

Dr. Goldberg (sgoldberg28@gmain.com) is resident physician, University of California San Francisco, San Francisco, CA.

Dr. Woolhandler (swoolha@hunter.cuny.edu) is distinguished professor, City University of New York at Hunter College, New York, NY. and lecturer in medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, MA.

Dr. Himmelstein (dhimmels@hunter.cuny.edu) is distinguished professor, City University of New York at Hunter College, New York, NY, and lecturer in medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, MA.

California Nurses Association calls for national Medicare for all

California nurses move their ‘Medicare-for-all’ fight to the national stage

By Angela Hart
The Sacramento Bee, October 26, 2018

The union representing 100,000 nurses across California has shifted its “Medicare-for-all” campaign from California to the national stage, perhaps relieving political pressure on Democratic gubernatorial candidate Gavin Newsom to fulfill what the union sees as his top campaign promise: Delivering a single-payer health care system in the nation’s largest state.

The California Nurses Association, which led the coalition behind the high-profile 2017 push for a single-payer system, has re-branded its campaign with the slogan “Fight to Win Medicare-for-All!” Its social media feeds reflect the new national scope of their efforts.

Until this month, the coalition, previously called “Campaign for a Healthy California,” was focused solely on passing a single-payer health care bill in California. Their campaign reached a fervor in late 2017 and early 2018, when nurses and single-payer activists stormed the California Democratic Party convention and later, the state Capitol, calling on Democratic lawmakers to approve their single-payer bill.

Representatives for the union, joined by its parent organization, National Nurses United, are now expanding their efforts to Congress and other states, such as Florida, Maine, Minnesota and Texas. They say they’re not letting up in California.

“We’re not conceding or taking a loss here. There will be a single-payer bill next year,” said Stephanie Roberson, a spokeswoman for the California nurses union. “Our aim is to put strategic pressure on states where we see opportunities to provide health care for all, so we can make that national shift.”

“California is a starting point,” Roberson said.

Still, individual states face steep challenges in creating, within their borders, a new health care system that operates under a different set of rules and laws than the nation as a whole, said Gerald Kominski, a professor of health policy at the UCLA Center for Health Policy Research.

He said the nurses’ new efforts to apply pressure on Congress, and national candidates, could also be an acknowledgment that California can’t do it alone.

To create and pay for a single-payer system, under which the government would be the sole “payer” of health care services, California would need multiple approvals from the federal government to both collect federal health care dollars for the state-run system and to bypass regulations on employer-based private health plans. It would also have to amend the state Constitution.

“I think it’s the realization that developing a single-payer system at the state level faces significant legal barriers that maybe they’ve acknowledged…are more substantial than they were willing to admit publicly a year ago,” Kominski said. “It also might be a recognition that you’re pushing the next governor out too far on a limb, where you’re likely to be left hanging.”

Newsom has shifted his tone on single-payer, a system under which government, generally, becomes the primary payer of all health care services. Before the primary he said of single-payer: “It’s about time, Democrats.” He now says universal health care is the ultimate goal.

Nurses say they plan to hold Newsom accountable on his earlier comments and expect him sign a single-payer health care bill into law should he become governor. But their shift to a national focus could also be an opening to letting Newsom off the hook, Kominski said.

“Part of what this shows is the fight really does need to take place in Washington,” he said.

Holly Miller, a spokeswoman for the national nurses union, said the expansion into other states also aligns the push for a nationwide single-payer system, championed by Sens. Bernie Sanders and Kamala Harris.

“We did the re-branding of the social media feeds so we could show the much broader focus of the ‘Medicare-for-all’ campaign,” Miller said. “We’re using the movements in California and Florida to talk about the national fight. We’re for single-payer health care, whether we get it at the state level, or nationally.”

Newsom has acknowledged the political and financial challenges he’d face should he and others lawmakers decide to push for a single-payer system.

“We need partners in the federal government, so I’m not Pollyannaish about any of this. I’m a hard-headed pragmatist about it,” Newsom said in an interview last month.

Still, he said, “I do believe single-payer financing, as broadly defined in (a) “Medicare-for-all” type system, is an advantageous system compared to our multi-payer system, and I’m deeply engaged in figuring out the how…I’m not walking away from this.”

https://www.sacbee.com…

***

Comment:

By Don McCanne, M.D.

This is not just another routine news report about Medicare for All advocacy. Rather it is a report of a milestone in the advancement of the single payer, Medicare for All movement, citing two of the most credible resources on the topic: 1) California Nurses Association/National Nurses United (CNA/NNU), and 2) UCLA Professor Gerald Kominski. Even the politically-guarded comments of the likely next governor of California – Gavin Newsom – provide valuable insight on the prospects for reform.

Although many Quote of the Day subscribers read just the comment (a wise time saver), this time I would suggest reading the lightly-edited Sacramento Bee article posted above. The nuances presented will hopefully calm down those who currently take a strong stand on whether single payer reform should be on a national or on a state basis.

I’ll step into it and say that the ultimate imperative remains a national improved Medicare for All. We want everyone throughout the nation in the system. Until that can be accomplished it is quite reasonable to do on a state level whatever can be accomplished to ensure that more people receive the health care that they should have.

If I were speaking instead of writing you would now hear me screaming as loud as I can that we cannot relax in the least with our mission to establish a national health program. State efforts must be in addition to and not in place of our national advocacy. CNA/NNU understands that. Gerald Kominski understands that. Gavin Newsom understands that. At PNHP it is even in our name: Physicians for a National Health Program.

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Enhancing the benefits of traditional Medicare

Medicare Benefit Redesign: Enhancing Affordability for Beneficiaries While Promoting Choice and Competition

By Cathy Schoen, Karen Davis, Christine Buttorff, and Amber Willink
The Commonwealth Fund, October 24, 2018

Abstract

Issue: Out-of-pocket expenses are capped for enrollees in Medicare Advantage (MA) plans but not for beneficiaries in traditional Medicare, which also requires a high deductible for hospital care. The need for supplemental Medigap coverage adds to traditional Medicare’s complexity and administrative costs. Shortfalls in financial protection also make it difficult to offer traditional Medicare as a choice for people under age 65, as some have proposed.

Goals: Describe alternative benefit designs that would limit out-of-pocket costs for traditional Medicare’s core services, assess their cost, and illustrate financing mechanisms.

Methods: Analysis of a $3,500 ceiling on annual out-of-pocket expenses for Parts A and B benefits and options for replacing Part A hospital cost-sharing with a $350 or $100 copayment per admission.

Key Findings: Estimates of the costs of the reforms are $36–$44 per beneficiary per month, assuming no behavioral or supplemental coverage changes. This could be financed by a $9–$11 increase in premiums combined with a 0.3-to-0.4-percentage-point increase in the Medicare payroll tax (split between employer and employees). Medicaid costs would decrease, while employers, retirees, and Medigap enrollees would see reduced premiums.

Conclusion: The reforms would improve affordability and put traditional Medicare on a more equal footing with MA plans. They would also make it easier to open traditional Medicare to people under age 65.

From the Conclusion of the Full Report

Implementing a ceiling on liability for traditional Medicare’s benefits would provide greater financial protection to people covered by Medicare only, while also reducing the costs of supplemental coverage for other beneficiaries — making all better off. If financed by a mix of premiums and payroll taxes, the savings from these reforms could be substantial. Because we did not offset the costs of an out-of-pocket limit with increased cost-sharing for other services, such an approach could gain beneficiaries’ support and make it possible for many to rely on Medicare alone for their health care coverage needs.

Improving Medicare’s core benefit design also could make it easier to offer Medicare as a coverage option to people under age 65 who are not eligible for the program. The marketplace for individual coverage nationwide is currently plagued by risk selection, premium instability, and the withdrawal of private insurers. Many markets also lack affordable plan choices: prices paid by private plans to hospitals and physicians for care continue to increase at rates much faster than Medicare, driving up premiums.

One option for ensuring more affordable plan choices to people under age 65 would be to offer an improved traditional Medicare plan in the private insurance market. Such a plan also could be offered in the small-group market. Medicare has the strong advantages of low administrative costs and broad provider networks. Improving traditional Medicare thus could help stabilize the insurance market for those seeking individual coverage or small-employer groups who are not yet eligible for Medicare. This could be especially attractive to older adults who are preparing for coverage under Medicare when they retire.

A viable Medicare option in the individual and small-business markets with predictable and affordable benefits would put pressure on private plans to generate value for the coverage they offer. A further step would be to require Medicare Advantage insurers to offer plans in individual marketplaces where they have substantial networks, bringing both their provider networks and ability to pay providers at near-Medicare rates. The enhanced leverage in negotiating provider payment rates, given the alternative of using Medicare provider payment rates for in-network and out-of-network providers, would help counter rising health care prices and costs.

A better Medicare benefit package, therefore, is an investment in more affordable coverage as well as lower health care costs across insurance markets. Not only would it ensure that beneficiaries can access the care they need, it also would simplify coverage choices and remove waste from the health system.

https://www.commonwealthfund.org…

Issue Brief (PDF):
https://www.commonwealthfund.org…

***

Comment:

By Don McCanne, M.D.

The Abstract defines the issue covered in this report: “Out-of-pocket expenses are capped for enrollees in Medicare Advantage (MA) plans but not for beneficiaries in traditional Medicare, which also requires a high deductible for hospital care. The need for supplemental Medigap coverage adds to traditional Medicare’s complexity and administrative costs.”

Simply stated, the marketing appeal of the private Medicare Advantage plans (MA) is that Congress and HHS have used our tax funds to pay the private MA plans enough extra so that they can cap the out-of-pocket costs and sharply reduce or eliminate the cost sharing – deductibles and coinsurance. If Congress truly believed in fairness and competition, then for the traditional Medicare program they would reduce the cost sharing requirements and place a cap on out-of-pocket spending. Why should we pay taxes for extra benefits for those in the MA plans, benefits that we are deprived of?

The differences are great enough such that those enrolled in traditional Medicare must obtain a Medigap plan, especially because of the potential for catastrophic losses (unless they have other additional coverage such as dual Medicaid coverage or a retiree plan). When we already have egregiously excessive administrative costs and complexity, why should we increase our administrative waste by adding another superfluous private plan – Medigap. Besides, if traditional Medicare had the same support as the private MA plans, then there would be no reason to have to put up with the narrow networks and extra administrative waste of the private plans.

For those who would like to see the addition of the choices of lowering the age for Medicare eligibility, or buying into Medicare, then it is almost imperative that a cap be established and cost sharing adjustments be made, otherwise the out-of-pocket costs would create too great of a financial burden for the new Medicare enrollees.

Incrementalists should be doing all they can to improve the traditional Medicare program if they truly believe in a Medicare buy-in or in lowering the age of Medicare eligibility. Those who wave the banner of Medicare for All but actually support incremental steps should be front and center in support of the proposals here.

That said, those of us who understand that incremental approaches are inadequate because they unnecessarily prolong suffering and financial hardship for those whose reforms are postponed until some unspecified future date, should continue to fight for uncompromising reform. An improved Medicare should eliminate all cost sharing and, instead, be fully funded through equitable tax policies. The other policies of the PNHP model of single payer reform also should be enacted and implemented as soon as possible.

It has been over fifty years since completing the first incremental step of enactment of Medicare with the intent of expanding it soon thereafter. Half a century! What moral basis is there for continuing on the incremental pathway when people are facing bankruptcy or suffering physically or even dying, when all we have to do is immediately take that last giant step to health care nirvana – enacting and implementing a well designed, single payer, improved Medicare for All?

For you incrementalists, Cathy Schoen and her colleagues are shining the light on the moral pathway to reform. But please excuse us when we pass you on the way there as we move forward immediately toward the full package of reform. We don’t want to stop you in case we stumble temporarily, but likewise we hope you’ll join us when you see that we are well on our way there. In fact, why delay? Join us now. We’ll get there faster.

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

Why a National Health System Is Needed to Slow the Opioid Crisis

By Michael Corcoran
Truthout, October 25, 2018

It is widely expected that by Election Day Donald Trump will sign the Support for Patients and Communities Act or opiate bill (H.R.6), that was finalized by Congress on October 3. There will surely be fanfare when the bipartisan bill — passed 99-1 in the Senate — is signed into law. The opioid crisis kills 115 people a day and has touched Americans everywhere. The Mayo Clinic calls it the “most important and most serious public health crisis” today. “We’ve stepped up to the plate,” boasted Sen. Shelley Moore Capito (R-West Virginia), seemingly pleased she could tell her voters that Congress took action.

The reality, however, is that the bill is woefully insufficient given the scale of the problem, according to a strong consensus of public health advocates. There are valuable provisions, but it is largely, as Rep. Peter Welch (D-Vermont) lamented, “a very energetic effort to pretend we’re doing something significant.”

The bill largely focuses on “supply side” enforcement. This includes an effort to stop fentanyl, the potent opiate that has caused a sharp spike in overdoses, through law enforcement and interdiction. It also encourages the development of non-opioid pain medications and launches a competitive grant-based pilot project for people transitioning to independent living.

The legislation also raises the cap on how many patients a doctor can prescribe an important treatment. Most doctors who are trained to prescribe buprenorphine (Suboxone) are limited to 100 patients, but under the new law, they could have 275. Medicare will also now cover methadone. In the past, methadone was not covered because it isn’t usually dispensed in a retail pharmacy, a requirement for Medicare Part D.

Many of these reforms are welcome, advocates say, but the bill does not do enough to expand treatment for people who need help now.

“The bottom line is, we need people to be alive if we want to help them,” said Nancy Nielsen, senior associate dean of health policy at the University of Buffalo, in an interview with Truthout.

Why Medication-Assisted Treatment Matters

Methadone and buprenorphine are considered the most effective treatments for chronic opiate abuse disorder. The medications are “partial opiate agonists,” meaning they do, like any opiate, bind to opiate receptors. The medication does not, however, provide euphoric effects for opiate-tolerant individuals. It also binds so strongly to receptors that it serves to block or minimize the effect of full opiates like heroin or oxycodone.

There is widespread consensus among public health experts that these medications are the most effective treatment for chronic opiate abuse. Evidence supporting the use of the medications are found in clinical guidelines and reports from the Substance Abuse and Mental Health Services Administration, the National Institute on Drug Abuse, and the Centers for Disease Control and Prevention, among others. Methadone and buprenorphine are especially important during an overdose epidemic since they can lower mortality rates by between 66 percent and 80 percent, as reporter Zach Siegel outlined at Slate. “We know how to treat opioid addiction,” he said, “but our antiquated conceptions of addicts prevent us from doing so.”

Advocates insist that making these medications available should be central in response to the crisis, and the new opiate bill falls far short of what is needed.

“We have treatment that works. The priority should be making it so anyone who wants help can go see a doctor or an ER and get on medication-assisted treatment,” said Bruce Trigg of the Harm Reduction Coalition. “We know of ways to help make this happen but Congress is not thinking big, not wanting to spend money.” The opiate bill has not been scored by the Congressional Budget Office, but the Senate version contained about $8 billion in new spending.

In a sense, this disappointment was inevitable. This is the United States: health care is a commodity, patients are “consumers.” It would be inconsistent to solve the grave opioid crisis by providing widespread coverage for vulnerable populations. A public, government-led expansion of care is a nonstarter for most of the GOP. There are an increasing number of Democrats embracing these policies, especially in the House. But the 115th Congress is still a very conservative body controlled by politicians who have been hell-bent on taking health care away from Americans.

After all, if enough members of Congress cared about moral, humane health policy, the US would probably already have a universal, national health system that was designed to put patient needs first. The US doesn’t have a health care “system” so much as a jumbled mess that makes a coherent national response to the opioid crisis essentially impossible. This is something advocates of a single-payer system point out.

“Single-payer makes health care about the patients. Our health system currently has nothing to do with patients. It is all about profit,” Trigg said.

Indeed, this crisis is very much rooted in greed. Pharmaceutical companies have been lobbying to make sure they are taken care of in the final bill. This profit motive is a major reason why the drug industry helped start (and is still profiting from) the epidemic. Under a single-payer Medicare for All system, which is supported by 70 percent of the country, the incentives would be different.

“In theory, you could have a single-payer system that negotiates drug costs but continues to allow pharma to market directly to patients [and] pay off and deceive physicians,” said Benjamin Day, director of Healthcare-NOW, in an interview with Truthout. “But, there’s a reason you don’t actually see that anywhere in the world — once you have a single-payer system, any policies that actually make people sicker you have to pay for down the road, so such systems naturally create incentives for preventive care and policies.”

In fact, the opiate crisis is a very “American problem,” as the BBC notes. In Europe, where health care is a right under international treaties, the opiate problem is not nearly as bad. The US has around 4 percent of the world’s population but about 27 percent of the world’s drug overdose deaths, according to the United Nations Office on Drugs and Crime. Notably, the US is also one of only two countries that allow prescription drugs to be advertised on television.

DrugChart2018

You will find more infographics at Statista.

Canada has a serious opiate problem, but not as extreme as in the United States. Interestingly, in Canada socialists have been trying to help, in part, by creating (sometimes unsanctioned) injection sites and building solidarity. Both countries have relatively weak welfare states and high inequality. (Canada’s health care system is understandably praised by Americans, but Canadian advocates note that the Canadian system is the only universal health care system without drug coverage.)

Federal Government Lags Behind

Overhauling how we finance health care is not the only change that must be made to confront the opioid crisis. There are many valuable tactics being used by county and state officials that help. But the tools are largely being ignored at the federal level and are largely absent in the new bill, Trigg said.

Some hospitals, for instance, will now offer patients medication-assisted treatment if they go into an emergency room for an opiate-related issue, such as an overdose or a withdrawal. Patients who come in with an overdose are also of a great deal of importance since about 7 percent of overdose survivors die within a year.

“We have these people who need help in the door, for whatever reason, and for years we have been tossing them to the street,” Trigg said. “It just doesn’t make any sense. They go out and within a year many of these people are dead.”

Nielsen notes that she is involved in a program in Buffalo that offers similar services. “Someone comes into the emergency room — might have been an overdose or an abscess or any number of things — and if they want help we have 13 hospitals that will give them a prescription that day,” Nielsen said. The program provides training to help doctors get waivers as well.

Some jails and state prisons have been increasingly offering various forms of medication-assisted treatment, though, of course, not nearly enough of them. Rhode Island is currently the only state prison system to offer all three of the major medications (buprenorphine, methadone and naltrexone) to prisoners, Trigg said. He noted that the federal prison system, in particular, offers very few opportunities for medication-assisted treatment (as Mike Ludwig has ongoingly reported for Truthout). Medical neglect is especially rampant in the world of corrections and law enforcement, and a lack of access to medication-assisted treatment is no exception.

“It is a wasted opportunity. You have all these vulnerable populations in these jails. Most of them probably don’t deserve to be there, but while they are there we should at least offer them treatment,” Trigg said.

The United States jails more people per capita than any other country on the planet, and 65 percent of prisoners fit the criteria for substance abuse disorder. Yet only 11 percent are given treatment (and those treatment options are often very limited). Outside of prisons, only 22 percent of people who qualify for the clinical definition of substance abuse disorder treatment receive treatment. Though not all of that is due to lack of treatment options, the most common reason for not getting treatment is cost (cited by 39 percent), according to a survey from the National Survey on Drug Use. A 2017 study published in the Annals of Family Medicine found that about 60 percent of rural counties in the United States (where much of the epidemic is located) don’t have a single physician who has a DEA [Drug Enforcement Administration] waiver to prescribe buprenorphine.

People on probation or parole may be denied treatment (or forced to taper off medication) by their probation officers, a practice which may violate discrimination laws aimed at protecting those with mental illness, according to the Legal Action Center. Congress has done nothing to eliminate these obstacles.

Constant Barriers Push People Away From Treatment

Eliza Tartell is a single mother of one who lives in Cape Cod and knows these kinds of barriers all too well. The area she lives in has been hit especially hard by the ongoing overdose crisis. It was called a “shoreline of addiction” by the Guardian as recently as May and the subject of a documentary as well. Tartell has been living with opioid abuse disorder and PTSD for much of her life, and she wants help.

Despite being insured and living in Massachusetts, a state that has more access to evidence-based treatment than most, Tartell tells Truthout she has continually been denied and/or dismissed when trying to get buprenorphine treatment for a variety of reasons. One time she was not given treatment due to a pregnancy (denying medication-assisted treatment based on pregnancy conflicts with protocols made by the American Society of Addiction Medicine).

“I’ve been sent away so many times because the doctor has too many patients,” said Tartell in an interview with Truthout. “I [have] had to commute hours and hours for weekly treatments that were nearly impossible…. I have been denied care because of my psych meds.”

Most recently, she dealt with two closures of outpatient suboxone programs at Arbour, the largest for-profit mental health provider in the state, within one year. She tried to transition into a different facility in Cape Cod, but they closed their outpatient program as well. Another provider refused to help her because of the medications she takes for anxiety and PTSD. After these denials, Tartell was left feeling panicked and overwhelmed with fear and frustration.

“My options were relapse or hospitalization, and I have a kid I need to take care of.” she said.

Out of reasonable options, she says, Tartell was forced to go off her medication and is attempting to stay off opiates without medication-assisted treatment. This is risky. “Retention in methadone and buprenorphine treatment is associated with substantial reductions in the risk for all cause and overdose mortality in people dependent on opioids,” concluded a study in the BMJ from 2017.

Doctors’ hesitancy to treat people on benzodiazepines (anxiety medication) may well be guided by a 2016 FDA warning that urged caution when mixing these drugs and medication-assisted treatment. But they have since updated that warning as evidence showed refusing treatment to these patients is significantly more dangerous than co-treating patients with both medications (which increases risk of respiratory depression but not in a statistically significant way, according to the FDA’s follow-up advisory). “The dangers associated with failing to treat an opioid use disorder can outweigh the risks of co-prescribing MAT [medication-assisted treatment] and benzodiazepines,” the FDA concludes.

In fact, only 322 deaths were reported to involve buprenorphine in 2014, despite the sinister media coverage of the drug, including The New York Times’s infamous “Treatment With a Dark Side,” article in 2013.

“My biggest regret as a doctor was, when I started prescribing buprenorphine 10 or 12 years ago I used to tell people with anxiety medication in their system to clean their system out and come back,” Trigg said. “But some of those people will never come back once you show them the door. And some of them will die.”

In some parts of the country, lower-income people face a massive barrier to ongoing medication-assisted treatment: 11 states have lifetime caps after which Medicaid stops paying for medication-assisted treatment after one or two years. In some states prior authorization may enable the treatment to continue — another barrier.

Given the nature of the treatment, time limits are a critical problem. The FDA’s guidelines instruct that “patients may require treatment indefinitely and should continue treatment for as long as they benefit and as long as the use of [medication-assisted treatment] contributes to their intended treatment goals.”

Sadly, the bill that Congress has passed, and which Trump is expected to sign soon, does very little to help Tartell and others in her situation. Even the best parts of the bill have limited utility, Trigg notes.

“It is great to allow doctors to see more patients and prescribe them medication,” he said. “But that doesn’t help if doctors are not getting trained, getting the waivers and taking these patients. And a lot of doctors don’t want these patients. The care can be costly, high-maintenance and more time-consuming.”

The Affordable Care Act mandates mental health and addiction as Minimum Essential Benefits, but it gives each state wide latitude to determine what coverage means. Some states cover medication-assisted treatment, others do not. Some states have lifetime caps or dosage limits and others do not. Some states cover inpatient detox, but not counseling. Other states do the reverse.

“The system is just so complicated. There are federal rules and restrictions and some states add their own, more strict regulations,” Trigg said, noting that medication should be easily accessible to all who need it.

If the US implemented an integrated, universal health care system, someone like Tartell would be in much better shape. When her treatment center closed, it was a decision made for financial reasons to serve the interests of board members of Arbour’s parent company who were located hundreds of miles away in central Pennsylvania. If patients were a priority over profits, this is not how business would be done, and Tartell would be less likely to keep running into (very sudden) closures.

Of course, even with a single-payer system that put patients first, there are still barriers created by stigma — from providers, from the community, and even from some aspects of the recovery community. So, a push toward national health care reform must also include efforts to educate providers, families and communities about ending stigma.

Lessons in Clinical Neglect and Human Folly

The medical term “iatrogenesis” describes a scenario in which injury or illness occurs because of medical care. It is from the Greek, meaning “brought forth by the healer.”

“It is a great word to describe the crisis,” Trigg said. “Drug companies, providers, physicians, policymakers — there is a lot of blame to go around.”

Indeed, the term can be used accurately to describe many historical efforts at practicing medicine. Until the 19th century, there was near-global consensus in favor of Humorism — a practice that involved bleeding patients to maintain the right balance of, “blood, phlegm, yellow bile and black bile.” This nonsense was the mainstream treatment for 2,000 years and not discarded entirely until the mid-19th century. It led to widespread bloodletting as treatment for countless ailments.

Humorism died in the 19th century as the scientific revolution occurred. But the fact that this pseudoscience survived two millennia should humble us all. Humanity is capable of wide-scale clinical negligence. In many ways, the US approach to the opiate crisis is more negligent because, unlike the doctors who practiced bloodletting in the 15th century, we have a solid grasp of the science of opiate abuse disorder and how to treat it. But the greed inherent in the market-based health care system of our capitalist society has many policymakers and providers ignoring evidence.

The federal government’s weak response to the opioid crisis is a sad contemporary example of this folly. More than that, it reflects one of the US’s true national tragedies: its lack of a national health system that prioritizes patients above all else. So long as greed is at the heart of American medicine, the country will face more tragedies like this opiate epidemic.

https://truthout.org…

Council of Economic Advisers brings out the socialist scarecrow

What Could Kill Booming U.S. Economy? ‘Socialists,’ White House Warns

By Binyamin Appelbaum and Jim Tankersley
The New York Times, October 23, 2018

Karl Marx. Vladimir Lenin. Mao Zedong. Elizabeth Warren?

The White House Council of Economic Advisers on Tuesday published a 72-page report criticizing what it described as the socialist ideas of leading Democratic Party politicians, and seeking to link President Trump’s political rivals with figures reviled by most Americans.

The document departs from the council’s long tradition of delivering sober, albeit partisan, studies on current questions confronting economic policymakers, such as the value of tax cuts or the effects of increased corporate concentration. Instead, the report seeks to tar Democrats by linking them with the failed economic policies of communist governments in China, the Soviet Union and other countries.

The word “socialism” appears 144 times — on average, twice a page.

In case the point was lost on anyone, the message was driven home by a follow-up release from the White House press office with the headline “Congressional Democrats Want to Take Money From Hardworking Americans to Fund Failed Socialist Policies.”

“There are proposals on the table, like the ‘Medicare for All’ proposal, that are very consistent with the design of socialism,” Kevin Hassett, the chairman of the council, told reporters during a conference call to discuss the report on Tuesday.

https://www.nytimes.com…

***

The Opportunity Costs of Socialism

The Council of Economic Advisers, October 2018

From the Introduction

The Nordic and European versions of socialized medicine have been viewed as so desirable by modern U.S. socialists that they have proposed nationalizing payments for healthcare — which makes up more than a sixth of the U.S. economy — through the recent “Medicare for All” proposal. This proposal would create a monopoly government health insurer to provide healthcare for “free” (i.e., without cost sharing) and to centrally set all prices paid to suppliers such as doctors and hospitals. We find that if this policy were financed out of current Federal spending without borrowing or tax increases, then more than half the entire existing Federal budget would need to be cut. If it were financed through higher taxes, GDP would fall by 9 percent, or about $7,000 per person in 2022. Evidence on the productivity and effectiveness of single-payer systems suggests that “Medicare for All” would reduce longevity and health, particularly among the elderly, even though it would only slightly increase the fraction of the population with health insurance.

(For details on Medicare for All, use the link to access the section, “Socialized Medicine: The Case of Medicare for All,” pages 39-53.)

Report – The Opportunity Costs of Socialism:
https://www.whitehouse.gov…

Council of Economic Advisors – Staff:
https://www.whitehouse.gov…

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Comment:

By Don McCanne, M.D.

No authorship is claimed for this document other than that it is a product of President Trump’s Council of Economic Advisers (CEA). It does seem to represent the conservative ideology of some of the prominent members and staff of the CEA. Specifically, it attacks as socialism the Medicare for All proposal that has become quite popular. It seems to be timed to suppress the vote for the candidates in the forthcoming midterm election who support the Medicare for All concept.

You should be prepared to hear from some of our conservative or libertarian politicians the highly biased rhetoric contained in this document.

They claim that the taxes required to finance Medicare for All would cause the GDP to drop by 9 percent. But under the PNHP model of an improved Medicare for All, the total spending would be about the same as it is now, and the volume of services also would be about the same since any additional care required for unmet needs would displace care that is of little benefit, simply because of the capacity limits of the system. The claim that diverting resources to health care suppresses the economy is without merit since health care is a robust sector of our economy. There should be no negative impact on the GDP.

They label Medicare for all as a monopoly when most economists consider it to be a monopsony – serving as a buying agent benefiting patients.

The report also claims that there is an opportunity cost (inability to use funds elsewhere) of paying the taxes required to fund Medicare for All. But the collective amount that we will be paying in taxes is no more than we are already paying in public and private funds, so there is no additional opportunity cost. If there were no taxpayer funded program and we instead were paying directly for health care, there would still be the same opportunity cost of not being able to spend those funds elsewhere.

In the full report, they make some preposterous statements designed to dismiss the benefit of recovering the hundreds of billions of dollars in our current administrative waste. By denying that, they are also, in effect, denying that we would be receiving greater value in our health care spending since that waste would be redirected to beneficial health care services.

Probably the most outrageous claim of all is that they say that Medicare for All would reduce longevity and health, particularly among the elderly. But our seniors would be receiving more and better services under a more efficient financing system. How could they claim that that would impair health and shorten life?

How many times do we have to say it? Can’t we just do away with the divisive politics and get down to the policy issues that would benefit all of us – like affordable health care for everyone? It’s really very simple, not to mention that it would place us on the moral high ground.

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