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Higher premiums, higher deductibles, and narrower networks in exchange markets

Higher premiums, higher deductibles, and narrower networks in exchange markets

The High Cost of Healthcare: Patients See Greater Cost-Shifting and Reduced Coverage in Exchange Markets 2014-2018

Physicians for Fair Coverage, Research by Avalere, July 2018

Executive Summary

The expansion in coverage due to the Affordable Care Act (ACA) increased the number of insured Americans by 20 million. Although access to health insurance has expanded significantly in recent years, and the ACA instituted important protections for patients, those who gained insurance through ACA health insurance exchanges are being offered plans that make them bear an increasing portion of their healthcare costs since the law was implemented. Access to health insurance is not sufficient if patients cannot afford to purchase coverage or utilize their benefits due to high premiums, high out-of-pocket costs, limited networks, and insufficient state and federal patient protections.

This paper outlines the key challenges facing patients in plans insurance companies offer through ACA health insurance exchange markets and details the changes in patient cost-sharing. This paper will demonstrate that:

1. Health plan networks have grown increasingly narrow, limiting patient access to in-network providers, with specialties like anesthesiologists, radiologists, and emergency physicians often out-of-network in exchange plans;

2. Non-subsidized exchange marketplace premiums have increased faster relative to other markets, such as employer-sponsored insurance and Medicare Advantage, since 2014;

3. Deductibles and maximum out-of-pocket limits (MOOPs) have grown across all payers, placing a higher financial burden on sicker patients;

4. Despite the growth in deductibles and MOOPs, cost-sharing for services after the deductible has remained relatively constant, though patients are increasingly required to pay coinsurance to access their care; and

5. Federal and state rules around network adequacy have not kept pace with the growing patient burden.

Key Stats

* In 2017, 68% of healthcare plans in the exchange market offered restrictive networks, compared with 48% in 2014.

* Average ACA exchange market premiums increased 28% from 2014 to 2017.

* Plans covered between 34% – 66% fewer providers than other markets.

* Almost 90% of enrollees in ACA exchange plans had deductibles above $1,300, the IRS definition of a high deductible plan.

* Several top insurance companies saw profit margins in Q1 for 2018 that were the highest in a decade, and all six of the largest insurance companies paid their CEOs over $17 million in 2017.

https://endtheinsurancegap.org…

Full report:
https://endtheinsurancegap.org…

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Comment:

By Don McCanne, M.D.

A decade ago the individual health insurance market was in total disarray and thus was one of the primary motivators to enact the Affordable Care Act (ACA). Under ACA these plans became more tightly regulated and subsidies inversely related to income were provided to make the premiums and cost-sharing more affordable. How is this working?

To try to keep premiums affordable, the more popular plans were designed to have low actuarial values – the insurers pay a lower percentage of the allowed charges – and the insurers were allowed to limit their networks enabling them to negotiate lower prices. This kept costs down for those eligible for subsidies and credits, but for middle-income individuals who were not eligible, out-of-pocket spending has been excessive and often not affordable.

Has the situation improved since the plans were first implemented? No, it’s worse now. Premiums have increased, high deductibles have become routine, and the use of restrictive networks has expanded, all this while profit margins have increased for the top insurers and their CEOs.

The problem is that this is the nature of private health insurance. Plans are designed to be successful business products. To improve markets they shift risk and costs to patients and they impair patient access to health care through network restrictions and the financial barriers of high deductibles.

Does anybody believe it will get better? Are insurers going to lower their premiums, lower their deductibles, and expand their networks while covering all essential health care benefits? No, they are going to continue to squeeze to enhance their margins. We can anticipate even higher deductibles, higher coinsurance instead of copays, greater tiering of health care services and products, more restrictive access, especially to specialized services, and the new thing will be the introduction of plans with sharply curtailed benefits such as the association health plans that the Trump administration will be pushing.

Yet the politicians have been saying that we need to protect our current system but add the option of being able to purchase a public plan. Some are now latching on to the Medicare for all rhetoric but when pressed they say, “yes, Medicare for all by allowing a buy-in to the Medicare program” – merely a public option with a new but misleading label. Merely adding a public option to our highly dysfunctional, fragmented financing system will have virtually no impact on resolving the problems inherent in our system.

If we want true universality, comprehensiveness, equity, assured access, and affordability for every one us, we are going to have to dump the current system and enact and implement a well designed, single payer, expanded and improved Medicare for all. Nothing else will do, that is unless we are ready to nationalize our entire health care delivery system and convert it into a national health service. Shall we do a poll?

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‘Medicare Advantage Premium Support For All’ – a terrible proposal

Creating Medicare Advantage Premium Support For All, Part 4: Financing

By Billy Wynne
Health Affairs Blog, July 9, 2018

In this post, I will illustrate how current spending by the federal government, states, and employers could be repurposed to fund universal Medicare coverage that emphasizes competition among private, Medicare Advantage plans and the traditional fee-for-service option, deployed via a premium support benefit model.

As pundits, commentators, and industry stakeholders begin to converge on the wisdom of “Medicare Advantage for All,” let’s take another step down the path of specifying exactly what that means and why it is both economically and politically viable.

The Tally

Starting with the current Medicare per capita spending of $12,139, age-adjusting that by 44 percent, then taking a 4 percent haircut for premium support-induced competition yields an average cost of providing the existing Medicare benefit to a non-Medicare enrollee of $5,127. That is more than 10 percent less than the per capita funding available from current non-Medicare health care programs ($5,721).

(Here I pause for rabid, health policy wonk golf clapping.)

I’m not here to fool anyone or advance a political agenda. I just think our current approach is radically, audaciously absurd. It’s like we’re investing every last morsel of our industriousness and ingenuity into getting it wrong. I posit that, with about the same amount of effort, we can get it right.

(For a full understanding of the proposal by Billy Wynne you should read all four of his posts. Links to the previous three posts are available in Part 4.)

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Posted Comment:

By Don McCanne, M.D.

Premium support is supposedly dependent on competition between private plans, but we’ve had competing private plans for well over half a century, and yet our costs are highest of all nations. This also neglects the profound administrative waste that is uniquely characteristic of our fragmented, dysfunctional health care financing system.

Besides high prices and administrative waste, the premium support model would also perpetuate the loss of choice of health care professionals and institutions because of the dependence on provider networks. Perhaps even worse, the perpetuation of high deductibles and other cost sharing would continue to impair access because of lack of affordability, not to mention creating financial hardship, especially for America’s working families.

A model that would correct these defects without increasing spending would be a single payer, improved Medicare for all. The efficiency of such a system would save a few hundred billion dollars in administrative costs, and administered (negotiated) prices would become sustainable over time. Planning and separate budgeting of capital improvements would improve allocation of our health care resources. That wouldn’t reduce spending much, but it would redistribute it to better serve the currently uninsured and underinsured. Everyone would have free choice of actual health care, not the artificial choice of health plan intermediaries. And the system would be funded equitably though progressive tax policies without the necessity of erecting cost-sharing financial barriers to care.

Considering the money that’s already being wasted in private Medicare Advantage plans, a “Medicare Advantage for All” seems to only perpetuate the high costs and impaired choices in our current health care financing system. It is no wonder that AHIP finds it attractive, but instead we should be supporting reform that would be attractive to patients.

https://www.healthaffairs.org…

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Financing Medicare Into The Future: Premium Support Fails The Risk-Bearing Test

By Sherry A. Glied
Health Affairs, July 2018

Abstract

One often-discussed option for controlling Medicare spending is to switch to a premium-support design. This would shift part of the risk of future health care cost increases from the federal treasury to Medicare beneficiaries. The economics of risk bearing suggests that this would be a mistake for three reasons. First, political decisions, not beneficiary choices, are the critical determinants of future health care costs. Second, only Congress can take into account the consequences of cost-containment decisions for both current and future generations. Third, the federal government is best able to diversify against the risk of future cost growth. Tying Medicare spending to the government’s budget so that Congress sees the benefits of tough cost containment choices is the only way to force the program to make those politically difficult decisions. Economic efficiency is served by retaining the program’s current structure instead of shifting risk to beneficiaries.

From the Introduction

Some members of Congress see entitlement reform—namely, a restructured Medicare program—as the best strategy for bringing federal expenditures in line with newly reduced revenues, particularly as the baby-boom generation swells Medicare rolls.

One frequently touted option is to shift the program to a premium-support structure. Under this structure, the federal government would provide each Medicare beneficiary with a specified allotment (sometimes called a voucher or defined contribution) that the beneficiary could use to purchase health insurance. Beneficiaries would be responsible for all additional premium costs if they chose insurance costing more than the allotted amount.

In some respects, premium support resembles the current Medicare Advantage program, under which many beneficiaries opt in to private health plans. If beneficiaries choose a plan that costs less than the Medicare Advantage benchmark, which is based on the local per capita cost of traditional fee-for-service Medicare, they gain extra benefits and save money on premiums and cost sharing. But premium support would change that model in one very significant respect.

The current Medicare Advantage benchmark rises over time as Medicare utilization and congressionally mandated provider payment levels rise. The savings from premium-support plans, however, are realized by changing that benchmark so that it rises more slowly over time.

Advocates of premium support argue that it would control Medicare expenditures by harnessing competition among health plans and by giving beneficiaries strong incentives to make wise health plan choices. That can be debated. But what is clear is that premium support would transform the federal government’s current open-ended obligation, or entitlement, by making the government’s liability more fixed and predictable and shifting much of the risk and burden of unanticipated future health care cost increases to Medicare beneficiaries. Such a reallocation is bad policy because it leads to inefficient risk bearing. It is inconsistent with the clear guidance that economics provides about how to most efficiently allocate risk.

Who should bear the uncertainty of cost projections?

Legislators see the uncertainty of Medicare spending forecasts and the challenges of designing and implementing legislation to slow the growth of Medicare spending as reasons to shift more of the risk of future Medicare spending growth to beneficiaries through a move to premium support. This intuition is backward. Political decisions, not beneficiary choices, are the critical determinants of future health care costs.

Leaving beneficiaries with the responsibility for cost increases also doesn’t make sense. Beneficiaries cannot plausibly forecast their future health care costs, so they cannot effectively save to protect themselves against these costs. They also cannot turn to private insurance for protection. No private market does or can exist against risks that are highly correlated across everyone in a society, and the costs associated with political decisions and unforeseen health care technologies are exemplars of such correlated costs.

The federal government is best situated to bear the risks associated with unanticipated changes in future health care costs, the federal government is best able to shape the future costs of the program, and only the federal government can appropriately trade off current costs and future technological advances against each other. The economic case is clear: The federal government, not individual beneficiaries, should bear the risk of future increases in the cost of Medicare. Premium support is bad economics.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

You can access on the PNHP website (www.pnhp.org) a multitude of articles on why competing private Medicare Advantage plans and the financing of them through premium support are terrible ideas. The quirk covered today has to do with the extreme to which others are going in order to latch onto the popular “Medicare for All” rhetoric to advance their inadequate or detrimental schemes for reform.

“Medicare Advantage Premium Support For All” is a real head-shaker, representing policies that are just about the opposite of what we mean by a “single payer, improved Medicare for all” (my posted comment on the HA Blog, reproduced above, clarifies this).

Sherry Glied, dean of the Robert F. Wagner Graduate School of Public Service at New York University, explains why premium support is bad economics. She concludes, “The federal government, not individual beneficiaries, should bear the risk of future increases in the cost of Medicare.” That should apply to all of us, and that is why we need an improved Medicare for all.

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Corporate medicine is about money – duh!

Is private equity helping or hurting healthcare?

By Harry Gamble
Modern Healthcare, July 10, 2018

Some view third-party investment in physician practices as a vital trend that offers economies of scale that make healthcare more efficient. Others believe it fosters monopoly control while driving up prices. But nearly everyone agrees that further consolidation within the U.S. healthcare market is coming.

“The days of Marcus Welby are behind us,” said Anthony LoSasso, professor of health policy and administration at the University of Illinois at Chicago’s School of Public Health. “The uncertainty over healthcare policy in Washington is probably driving the integrated healthcare delivery systems and large hospitals to bulk up almost as a counterweight to the uncertainty they face. They know that if you are bigger, you are in a better position to survive whatever may come your way.”

“I think the jury is still out on whether those larger systems can translate that scale into quality improvements,” he said. “What I do know is they can translate that scale into price increases. That means insurers are going to have to pay more, which translates on the consumer side into higher premiums.”

But the jury is in for Marni James-Carey, executive director of the Association of Independent Doctors.

“We know that when corporate medicine takes over the practice of independent medicine, costs go up, quality goes down, and patients and doctors lose,” she said. “We don’t need a study for any of this. We just need common sense to prevail.

“This is all about capturing market share so you can have more bargaining power with payers, and get more money in reimbursement for the same procedure. That’s what causes costs to go up,” she said.

Craig Garthwaite, director of the Health Enterprise Management Program at Northwestern’s Kellogg School of Management, said recent pricing controversies in the pharmaceutical industry (think Martin Shkreli) have left some consumers fearing a repeat performance by large-scale physician practices.

“Some see private equity firms as really for-profit for-profits, for lack of a better term,” Garthwaite said. “These are firms that are often not involved in the medical field, but move in because they see an attractive investment opportunity.”

“To date, we see this more in pharmaceuticals rather than in providers,” he continued. “Outside companies realized a glaring market imperfection in pharmaceuticals, and found that if they were willing to price to the limit of their monopoly power, they could make an exceptional amount of money. So people might be worried that the same thing could happen with providers.”

http://www.modernhealthcare.com…

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The real driver of health care spending

By Edward M Murphy
CommonWealth, July 9, 2018

The revenue and profitability of these corporations support the proposition that high pharmaceutical prices and insurance-related administrative costs account for much of the extraordinary expense of our system. US health policy, or the absence thereof, has enabled these businesses annually to drive costs up for the benefit of their bottom line. That effect will continue. Not surprisingly, the big health care companies are developing new strategies to enhance their businesses and drive their profits going forward.

The term now heard often among health care giants is “vertical integration,” which means combining upstream suppliers with downstream buyers to control the flow of business. If this strategy persists, health care delivery will evolve significantly although it is unlikely to become less expensive. The most prominent current example of vertical integration is the planned $68 billion acquisition of Aetna by CVS.

How would these companies work together? A Wall Street analyst recently described the vision as a way to “identify high risk patients and preemptively get them into a Minute Clinic.” Thus, your health insurer could send you to a local store for diagnosis, treatment, drugs, and anything else you might need from the shelves. This will keep even more of the health care dollar under their control.

Similarly, Cigna is in the process of acquiring Express Scripts, a huge pharmacy benefits manager, for $54 billion, another attempt to bring more services under one roof. United Health, a leader of vertical integration, previously bought a pharmacy benefit manager but co-pays and deductibles for its patients have continued to climb.

If this course continues, the health care system will evolve quickly, giving fewer and larger companies even more market leverage. Integration of this kind benefits the large corporations that initiate it but there is no evidence it will lead to lower costs, improved access, or enhanced quality. These changes are driven by highly focused corporate financial interests and are occurring without reference to public policy. That’s because there is no coherent public policy to guide these changes.

It is not in the interest of huge profit-making corporations to restrain the overall cost of the US health care system. In fact, their interest is served by driving health care expenditures higher. Any progress will require driving down pharmaceutical pricing and reducing administrative costs imposed by middlemen. We are not doing that yet but, ultimately, we must.

https://commonwealthmagazine.org…

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Comment:

By Don McCanne, M.D.

Three quotes from these two articles say it all:

“Outside companies realized a glaring market imperfection in pharmaceuticals, and found that if they were willing to price to the limit of their monopoly power, they could make an exceptional amount of money. So people might be worried that the same thing could happen with providers.”

“It is not in the interest of huge profit-making corporations to restrain the overall cost of the US health care system. In fact, their interest is served by driving health care expenditures higher.”

“These changes are driven by highly focused corporate financial interests and are occurring without reference to public policy. That’s because there is no coherent public policy to guide these changes.”

Ouch.

No coherent public policy? How about enacting and implementing a publicly financed, publicly administered, single payer, improved Medicare for all? Now!

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

Interruptions in private health insurance are routine, but hazardous

Interruptions In Private Health Insurance And Outcomes In Adults With Type 1 Diabetes: A Longitudinal Study

By Mary A. M. Rogers, Joyce M. Lee, Renuka Tipirneni, Tanima Banerjee, and Catherine Kim
Health Affairs, July 2018

Abstract

Type 1 diabetes mellitus, which often originates during childhood, is a lifelong disease that requires intensive daily medical management. Because health care services are critical to patients with this disease, we investigated the frequency of interruptions in private health insurance, and the outcomes associated with them, for working-age adults with type 1 diabetes in the United States in the period 2001–15. We designed a longitudinal study with a nested self-controlled case series, using the Clinformatics Data Mart Database. The study sample consisted of 168,612 adults ages 19–64 with type 1 diabetes who had 2.6 mean years of insurance coverage overall. Of these adults, 24.3 percent experienced an interruption in coverage. For each interruption, there was a 3.6 percent relative increase in glycated hemoglobin. The use of acute care services was fivefold greater after an interruption in health insurance compared to before the interruption and remained elevated when stratified by age, sex, or diabetic complications. An interruption was associated with lower perceived health status and lower satisfaction with life. We conclude that interruptions in private health insurance are common among adults with type 1 diabetes and have serious consequences for their well-being.

From the Introduction

The Bureau of Labor Statistics estimates that between the ages of 18 and 50, Americans hold an average of twelve different jobs. Particularly for younger workers, the jobs tend to be of short duration: 69 percent of jobs held by people ages 18–24 last for less than one year, as do 36 percent of jobs held by people ages 35–44. This has health consequences because, for the majority of working adults in the United States, health insurance coverage has traditionally been tied to employment. For working adults without employer-sponsored insurance, the Affordable Care Act (ACA) Marketplaces provide an opportunity for coverage. However, there remain challenges regarding affordability with self-funded plans and disparities in premiums across different areas of the country.

Interruptions in health insurance affect access to health care services, particularly for patients with chronic conditions. Type 1 diabetes mellitus is one such lifelong chronic disease, often originating in childhood, and requires intensive daily medical management. People with type 1 diabetes are at exceptional risk because of their requirement for insulin and the supplies necessary for insulin delivery.

From the Discussion

Interruptions in private health insurance are common among working-age adults with type 1 diabetes in the United States. Overall, one in four experienced at least one interruption in coverage, over an average period of 2.6 years. There were considerable consequences associated with the interruptions. Use of acute care services increased greatly after an interruption in coverage—with differences ranging from fourfold to sevenfold, depending upon the length of the interruption. As the number of interruptions increased, so did HbA1c levels, in a dose-response manner. For each additional break in coverage, there was a 3.6 percent relative increase in HbA1c. Satisfaction with life and perceived health status were lower among adults with interruptions in insurance, compared to those with continuous coverage.

Patients with type 1 diabetes face particular challenges in the management of their disease. Interruptions in health insurance are common in the United States, and such interruptions increase the use of costly acute care services such as ED visits and hospitalizations. We do not anticipate that these challenges will diminish in the near future, because of the instability of health insurance markets and the increase in temporary employment and contract work without employer-sponsored insurance. In the US, 50.1 percent of private-sector establishments offered health insurance to their employees in 2012, a share that declined to 45.3 percent in 2016.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

One of the most serious policy defects of the U.S. health care financing system is that it is uniquely characterized by interruptions in health care coverage, yet we seem to take that for granted. This study of type 1 diabetics who have a continual need for health care brings into focus the seriousness of gaps in health care coverage, but these gaps can affect all of us because of the unpredictability of future health care needs.

Our health care coverage is heavily dependent on employer-sponsored plans, yet job stability is no longer the norm; it is the exception. Almost everyone can anticipate some interruptions in their health care coverage.

For the type 1 diabetics in this study, interruptions in private insurance coverage resulted in poorer control of their diabetes as measured by their glycated hemoglobin levels; they required a fivefold increase in health care services, and the interruptions were associated with lower perceived health status and lower satisfaction with life. Imagine the difficulties that other individuals with interruptions in coverage would have if they suddenly experienced severe traumatic events or the onset of a major illnesses.

Yet we accept this, even praising our employer-sponsored plans as the part of our health care financing system that is working very well and that we want to protect. Nonsense. As the authors state, “We do not anticipate that these challenges will diminish in the near future, because of the instability of health insurance markets and the increase in temporary employment and contract work without employer-sponsored insurance.”

By design, a single payer national health program – an improved Medicare for all – never has any interruptions in coverage, throughout life. And this is only one of a great multitude of advantages of a well designed, single, publicly financed and publicly administered health care financing program that covers absolutely everyone and would cost no more than our current, highly dysfunctional system. What are we waiting for?

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U.S. opposes WHO breast feeding resolution

U.S. Opposition to Breast-Feeding Resolution Stuns World Health Officials

By Andrew Jacobs
The New York Times, July 8, 2018

A resolution to encourage breast-feeding was expected to be approved quickly and easily by the hundreds of government delegates who gathered this spring in Geneva for the United Nations-affiliated World Health Assembly.

A 2016 Lancet study found that universal breast-feeding would prevent 800,000 child deaths a year across the globe and yield $300 billion in  savings from reduced health care costs and improved economic outcomes for those reared on breast milk.

Based on decades of research, the resolution says that mother’s milk is healthiest for children and countries should strive to limit the inaccurate or misleading marketing of breast milk substitutes.

Then the United States delegation, embracing the interests of infant formula manufacturers, upended the deliberations.

American officials sought to water down the resolution by removing language that called on governments to “protect, promote and support breast-feeding” and another passage that called on policymakers to restrict the promotion of food products that many experts say can have deleterious effects on young children.

When that failed, they turned to threats, according to diplomats and government officials who took part in the discussions. Ecuador, which had planned to introduce the measure, was the first to find itself in the cross hairs.

The Americans were blunt: If Ecuador refused to drop the resolution, Washington would unleash punishing trade measures and withdraw crucial military aid. The Ecuadorean government quickly acquiesced.

Health advocates scrambled to find another sponsor for the resolution, but at least a dozen countries, most of them poor nations in Africa and Latin America, backed off, citing fears of retaliation, according to officials from Uruguay, Mexico and the United States.

In the end, the Americans’ efforts were mostly unsuccessful. It was the Russians who ultimately stepped in to introduce the measure — and the Americans did not threaten them.

A Russian delegate said the decision to introduce the breast-feeding resolution was a matter of principle.

“We’re not trying to be a hero here, but we feel that it is wrong when a big country tries to push around some very small countries, especially on an issue that is really important for the rest of the world,” said the delegate, who asked not to be identified because he was not authorized to speak to the media.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

It is almost beyond belief that United States delegates at the World Health Assembly of WHO opposed a resolution to “protect, promote and support breast-feeding.” It is difficult to imagine any other reason than that the Trump administration representatives place a much higher priority on protecting, promoting and supporting the baby formula business than they do on protecting and nurturing the health of the world’s infants.

Even the Russians, who stepped in to introduce the resolution, said it was a matter of principle. By extrapolation, it seems that the Trump administration is unprincipled. Threatening retaliation against poorer nations if they supported breast feeding? “Unprincipled” is too mild of a word. Considering that they are placing corporate interests above the people, perhaps “corrupt” is a more accurate term.

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The conservative case for universal health care

Why in five years, the American right will embrace socialized medicine.

By Chase Madar
The American Conservative, July 25, 2017

Don’t tell anyone, but American conservatives will soon be embracing single-payer healthcare, or some other form of socialized healthcare.

Yes, that’s a bold claim given that a GOP-controlled Congress and President are poised to un-socialize a great deal of healthcare, and may even pull it off. But within five years, plenty of Republicans will be loudly supporting or quietly assenting to universal Medicare.

And that’s a good thing, because socializing healthcare is the only demonstrably effective way to control costs and cover everyone. It results in a healthier country and it saves a ton of money.

In fact, in every first-world nation that has socialized medicine–whether it be  a heavily regulated multi-insurer system like Germany, single-payer like Canada, or a purely socialized system like the United Kingdom–-it costs less. A lot, lot less, in fact: While healthcare eats up nearly 18 percent of U.S. GDP, for other nations, from Australia and Canada to Germany and Japan, the figure hovers around 11 percent. (It’s no wonder that smarter capitalists like Charlie Munger of Berkshire Hathaway are bemoaning the drag on U.S. firm competitiveness from high healthcare costs.) Nor are healthcare results in America anything to brag about: lower life expectancy, higher infant mortality and poor scores on a wide range of important public health indicators.

The barrier to universal healthcare is not economic but political. Is profligate spending on health care really a conservative value?

The objections to socialized healthcare crumble upon impact with the reality. One beloved piece of folklore is that once people are given free healthcare they’ll abuse it by going on weird medical joyrides, just because they can, or simply let themselves go because they’ll have free doctor visits. I hate to ruin this gloating fantasy of lumpenproletariat irresponsibility, but people need take an honest look at the various health crises in the United States compared to other OECD (Organisation for Economic Cooperation and Development) countries.

If socialized medicine could be in conformity with conservative principles, what about Republican principles? This may seem a nonstarter given the pious market Calvinism of Paul Ryan and Congressmen like Reps. Scott Perry (R-Pa.) and Mo Brooks (R-Ala.), who seem opposed to the very idea of health insurance of any kind at all. But their fanaticism is surprisingly unpopular in the U.S. According to recent polling, less than 25 percent of Americans approve of the recent GOP healthcare bills. Other polls show even lower numbers. These Republicans are also profoundly out of step with conservative parties in the rest of the world.

Strange as it may seem to American Right, $600 EpiPens are not the sought-after goal of conservatives in other countries. In Canada, the single-payer healthcare system is such a part of national identity that even hard-right insurgents like Stockwell Day have enthusiastically pledged to maintain it. None of these systems are perfect, and all are subject to constant adjustment, but they do offer a better set of problems–the most any mature nation can ask for–than what we have in the U.S.

And virtually no one looks at our expensive American mess as a model.

Even in the GOP, this is where the votes are: Trump’s move to the center on questions of social insurance–Medicare, Medicaid, Social Security–was a big part of his appeal in the primaries. The rising alt-Right, not to hold them up as any moral authority, don’t seem to have any problem with universal Medicare either.

It will fall on “reform conservatives” to convince themselves and others that single-payer or some kind of universal care is perfectly keeping with conservative principles, and, for the reasons outlined above, it’s really not much of a stretch. Lest this sound outlandish, consider how fully liberals have convinced themselves that the Affordable Care Act–a plan hatched at the Heritage Foundation for heaven’s sake, and first implemented by a Republican governor–is the every essence of liberal progressivism.

The real obstacle may be the Democrats. As Max Fine, last surviving member of John F. Kennedy’s Medicare task force, recently told the Intercept, “Single payer is the only real answer and some day I believe the Republicans will leap ahead of the Democrats and lead in its enactment,” he speculated, “just as did Bismarck in Germany and David Lloyd George and Churchill in the UK.” For now, an invigorating civil war is raging within the Democrats with the National Nurses Union, the savvy practitioner-wonks of the Physicians for a National Health Program, and thousands of everyday Americans shouting at their congressional reps at town hall meetings are clamoring for single-payer against the party’s donor base of horrified Big Pharma executives and affluent doctors. In a few years there might even be a left-right pincers movement against the neolib/neocon middle, whose unlovable professional-class technocrats are the main source of resistance to single payer.

I don’t want to oversell the friction-free smoothness of the GOP’s conversion to socialized healthcare. Our funny country will always have a cohort of InfoWars ooga-boogas, embittered anesthesiologists and Hayekian fundies for whom universal healthcare is a totalitarian jackboot. (But, and not to be a jerk, it’s worth remembering that Hayek himself supported the socialized healthcare of Western Europe in one of his most reasonable passages from the Road to Serfdom.)

So even if there is some banshee GOP resistance at first, universal Medicare will swiftly become about as controversial as our government-run fire departments. Such, after all, was the trajectory of Medicare half a century ago.

http://www.theamericanconservative.com…

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Comment:

By Don McCanne, M.D.

Although this article was published a year ago it is even more pertinent today considering the ever-deteriorating political milieu. Not only are the left and right divided, the left is divided amongst itself over support for a market-based versus a public service approach to financing health care, and the right is divided amongst itself over a Trumpian-style market-based versus a nihilistic drown-Medicare-in-a-bathtub approach.

Liberals or progressives – whatever you want to call them – have long been supportive of a national health program along the line of Medicare. However, their concept of political pragmatism has stifled their open support of such an approach, though that is now changing as we see how popular advocacy for Medicare for all has become.

Conservatives or libertarians have fixated on anti-government rhetoric, though views such as those of Friedrich Hayek, and those of the conservative leaders of European nations have long supported a prominent government role in ensuring health care for everyone. So it is not surprising that a conservative publication – The American Conservative – publishes an article on anticipated conservative support of “socialized medicine.”

Though we may have continued political turmoil, it is agreed that health care costs must be contained, waste reduced, and that everyone should have health care when needed. Those are concepts shared by conservatives and liberals. It’s about time that we adopted policies that would make them a reality, i.e., an improved Medicare for all.

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

By Helaine Olen
The Washington Post, July 5, 2018

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

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

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

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

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

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

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

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

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

https://www.washingtonpost.com…

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

Radical Democrats Are Pretty Reasonable

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

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

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

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

https://www.nytimes.com…

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

By Dylan Scott
Vox, July 2, 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

https://www.vox.com…

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Comment:

By Don McCanne, M.D.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

That’s the good news.

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

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

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

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

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

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

Or maybe it won’t.

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

https://www.statnews.com…

Tallinn Charter: Health systems for prosperity and solidarity

Health systems for prosperity and solidarity: Tallinn 2018

The Lancet, Editorial, June 23, 2018

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

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

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

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

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

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

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

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

https://www.thelancet.com…

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Comment:

By Don McCanne, M.D.

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

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

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

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

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Health care spending in late life is usually appropriate

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

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

Abstract

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

From the article

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

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

http://science.sciencemag.org…

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

By Carey Goldberg
WBUR, June 28, 2018

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

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

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

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

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

Question: So what are the policy implications?

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

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

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

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

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

http://www.wbur.org…

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Comment:

By Don McCanne, M.D.

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

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

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

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

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

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

Background Information

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

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

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

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

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Lawsuit will hurt health of Hoosiers

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

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

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

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

https://www.heraldtimesonline.com…

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

https://www.heraldtimesonline.com…

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

https://www.change.org…

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Comment:

By Don McCanne, M.D.

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

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

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

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

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