PNHP

Recent Articles of Interest

Dunn County voters turn out to pass health care referendum

Posted

By Audrey Korte
La Crosse (Wisc.) Tribune, November 9, 2022

In July, the legislative committee of Dunn County approved a referendum question that is unprecedented in rural America. The question asked Congress and the U.S. president to nationalize health care.

Generally, attempts such as these come from large, urban areas. They might come with a left-leaning agenda. But the Dunn County Board of Supervisors voted unanimously to add this question to the November ballot despite the fact that many of them are conservative.

The referendum passed on Tuesday with 9,049 voting yes — 51% of county voters; 8,564 people, or 49%, voted against it.

“My first reaction when they came in at 51% to 49% was initially, a little bit disappointed that it wasn’t more (favorable) but when I started digging into the numbers more specifically, I understood how big of a win this actually is,” said Monica Berrier, a Dunn County supervisor.

“This was the most important issue on the ballot. When you look at the total number of votes that were cast in this race, the referendum issue had more votes cast, total, than any other race (in the county),” she said.

The referendum had about 34% more votes cast in Dunn County than the governor’s race and Senate race, Berrier said. That means that people showed up to vote on the health care issue alone.

John Calabrese, who’s spent months working to support the effort in the hopes that the referendum would pass, said he finds the numbers from yesterday’s race “fascinating.”

Voting for national health care fared better than voting for Democratic candidates, numbers show.

“When you consider that the referendum got 51.4% approval, and Governor Evers got 39% in Dunn County, and Mandela Barnes got 36% — it just says to me that this is not a partisan issue, which is the main point of why we were pushing it. Because we don’t think it’s a partisan issue,” Calabrese said.

The results were encouraging, Berrier said. They demonstrate that the issue of national health insurance is not a single-party issue.

“It wasn’t the case that the left-leaning city of Menomonie carried this. There was significant support in the rural areas as well,” Berrier said.

“When you compare the number of votes that we got for the referendum compared to the votes that we got for Tony Evers, the referendum had more yes votes than Evers by 12% points. So that suggests that there are quite a few conservatives who voted for (Tim) Michels who also voted for this referendum. That was really encouraging.”

Results of this referendum could make waves in Wisconsin. Other counties are considering putting the same question to voters in the spring.

“What I hope is that this discussion in Dunn County will inspire other counties to do the same. And I think that if other counties across Wisconsin, and even into other states start doing that, I think that the federal legislators are really going to have to start to pay attention,” Berrier said.

There also are people in Minnesota, California, Texas, Massachusetts and Kentucky that are paying close attention to this referendum. They hope to be able to replicate what’s happening in Dunn County in their states.

For now, Berrier and Calabrese want to make sure this referendum has meaning, that it can be replicated across the state.

“I think we need to continue to take it to other counties and try to replicate the formula and remember what works,” Calabrese said. “There’s a tendency among people who are involved to want to, you know, reach out to county board supervisors and other counties and I think that’s important, but a key part of why this was put on the ballot was the input from actual citizens of Dunn County, imploring their county board to put it on the ballot. So there needs to be a groundswell localized in each county.”

Passing the referendum won’t immediately affect national policy. However, it does tell the state and federal governments that residents of Dunn County want new national health care options.

“I think it’s really exciting that Dunn County is breaking ground here and being the first county in the state to do this,” said Berrier. “And I think it’s really important for us, and the local government, to give the people a voice on national issues as much as we can.”

https://lacrossetribune.com…

Secret rules, denials & fraud: The dark side of Medicare Advantage

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By Brenda Gazzar
Code Wack Podcast, November 7, 2022

What are the major differences between Original Medicare and Medicare Advantage? How do the two programs compare when it comes to accessing care?

To get the facts, join host Brenda Gazzar and Ed Weisbart, M.D., a retired family physician, former chief medical officer of Express Scripts and a national board member of Physicians for a National Health Program.

From narrow provider networks to pre-authorizations and claims denials, Dr. Weisbart shares the nitty-gritty on Medicare Advantage. What is the Medicare Advantage business model? Why are so many Medicare Advantage insurers being accused of fraud?

Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

(ambulance siren)

Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar. This time on Code WACK! What are some of the possible dangers and pitfalls of Medicare Advantage plans and how do they respond to patients’ needs differently compared to traditional Medicare? To find out, we spoke to Dr. Ed Weisbart, a retired family physician, former chief medical officer of Express Scripts and a national board member of Physicians for a National Health Program.

(5-second music stinger)

Welcome to Code WACK!, Dr. Weisbart.

Weisbart: Well, thank you Brenda.

Q: It’s open enrollment time for those signing up or renewing their insurance and a critical time for Medicare recipients who face a major choice between traditional Medicare and Medicare Advantage. One key difference between traditional Medicare and Medicare Advantage is who pays the claims. Can you talk about why this difference is so important?

Weisbart: Yeah, thanks. It’s a really important distinction. So when Medicare pays your claims as it does in original or traditional Medicare parts A and B, when they pay your claims, that’s their only job is to pay your claims. They don’t get in the way, they’re not not trying to make money off of you. You have Medicare as your health insurance. You go to the doctor or hospital that you want and Medicare pays your claims and it’s that simple almost.

But if you have opted into Medicare Advantage, Medicare itself is no longer paying your claims at all. Instead, Medicare is paying an insurance company to pay your claims and the insurance company as we all learned from having employer-based insurance and other things is really not out to just pay your claims. They’re out to make money off of this and so the more often they can avoid paying your claims or deny paying your claims or delay paying your claims or make it complicated for anybody to get a claim paid, the more they can do that, the more money they can make <laugh>. So they’re no longer really focused on you. They’re now focused on their own profits and that’s completely different than having the government just pay your claims and having Medicare pay your claims.

Q: Wow, and so how do the two programs differ when it comes to provider networks and access to specialists?

Weisbart: Same kind of difference. So provider networks in traditional or original Medicare, 89% of adult medicine physicians accept traditional Medicare as a payment model, 89% of adult medicine physicians and actually 96% of surgeons accept traditional Medicare and you can go to any of them that you want frankly with traditional Medicare. There isn’t a number like that for Medicare Advantage, but it’s significantly smaller. <Laugh> You know, there is no place where that data is collected for Medicare Advantage. So we don’t know what that is, but we know that their business model is to direct you towards the doctors and hospitals that they prefer. That may not seem important when you’re relatively younger and healthier. Certainly before your Medicare age or when you turn Medicare age, you may not really care. You think, ‘Oh well you know, I’ve had to change doctors before. My employer has done that to me, I’ve had to do that.

I don’t like it, but you know, I’m healthy, relatively.’ But as you get older, as your health becomes more vulnerable and you have more health issues, you become if anything more determined to want to see the doctor and hospital that you want and so Medicare Advantage, you may be willing to make that trade off when you first join Medicare and think, ‘Oh, they’ll tell me and I’ll deal with that.’ You need your health insurance when you are sick. The older you get having Medicare Advantage restrict which doctors you can go to or even change, You know, Medicare Advantage networks can change any time. You can have the Medicare Advantage program that you bought during open enrollment this year that you picked because it included your doctor and Medicare Advantage programs have the right to get rid of that doctor from your network at any time during the year.

So you’re out of control. You know, if you have Medicare Advantage, you no longer have the ability to pick which doctors and hospitals up to a point. You know, it usually only becomes an issue when you’re really sick near the end of life, when you need something complicated or you know, highly specialized, that’s when the money really matters and that’s when the Medicare Advantage networks really become intrusive and you may not run into that for a while. So, you know, and look outside of your state. What if you’re traveling somewhere else? What if you’re someone who spends a couple of months for the winter or the summer or somewhere else? Your insurance in Medicare advantage may not cover anything but the most dire of emergencies, if you’re not in your so-called service area. That may not matter when you’re younger and healthier, but the more medical conditions you acquire, the more important that becomes to you.

Q: Mm, wow. So do you know how the Medicare Advantage plans pick which doctors that they want to work with?

Weisbart: It’s a trade off between what they can contract them for and how important that is for selling their product. So sometimes a large hospital in a community may be able to command a high rate and from the insurance company and they’ll work it out cuz the insurance company feels that they have to have that hospital. But the trade off to that for the insurance company is if that hospital focuses on some very expensive condition, if it’s a cancer network for example, the Medicare Advantage plan may actually decide, ‘well yeah, we’re not going to get as many members to sign up for Medicare Advantage if we don’t include this high powered, you know, specialty cancer center. But those are primarily the really sick, expensive patients who we didn’t want to begin with.’ So sometimes the Medicare Advantage plans actually decide not to cover the top end hospital in your community or elsewhere in the country because they don’t want to attract the people that really want those top-end hospitals.

And we’ve seen this over and over again. I mean, there’s a ton of data that shows that … I was just reading this morning actually about nursing homes that people in Medicare Advantage in general are forced to use the lower quality nursing homes compared to people in traditional Medicare that have more flexibility and can go to the nursing homes or home health – that Medicare Advantage patients are more likely to be connected up with a lower quality home health agency than are people in traditional Medicare. But let me quickly say that that’s not everybody that’s just on the average. If you look across the board, there are still of course some splendid care, you know, and home health and hospitals being delivered within Medicare Advantage. I’m just saying, you know, playing your odds, your odds are worse for getting really the best if you’re in Medicare Advantage.

Q: Wow. I’m glad you pointed that out. I mean, my guess is not a lot of people know that about Medicare Advantage plans.

Weisbart: I know. There’s an awful lot of people don’t know about it and they just see Joe Namath on TV or some other, you know, ad which we can talk about on TV and Medicare Advantage offers lots of perks to convince you to join and you don’t realize what you’re trading off for a number of reasons.

Q: Right, right. What about pre-authorizations. In 2021, Kaiser Family Foundation found that 99% of Medicare Advantage enrollees are in plans that require prior authorizations. How does this affect doctors and patients?

Weisbart: Yeah, a prior authorization is as you know, before you can get something that your physician, you and your physician think is medically necessary and appropriate. Prior authorization means that for the insurer to pay for it, the doctor typically has to call the insurance company and get permission, get prior authorized to do the thing. That’s something that’s almost unheard of in original or traditional Medicare. It’s, you know, pretty much if you and your doctor want you to go get something in original traditional Medicare, that’s the end of the story. You go get it. You have to deal with the copays and deductibles for which there’s a strategy that we need to talk about, but there’s nobody asking you to get approval or prior authorization.

Whereas Medicare Advantage, it’s the exact opposite. There’s an awful lot of things that you just simply can’t go get, even if you and your doctor think it’s important and medically necessary and appropriate. There’s this, you know, set of bureaucrats in a Medicare Advantage company, an insurance company that knows if it’s expensive, that’s less profit for them and so they require the physician to get it prior authorized.

And even if the answer is yes at the end of that prior authorization, we as physicians, we buckle down and we do it most of the time, but we’re loathe to do it. It makes us, you know, really think twice because it’s expensive. I have to take time out of my day or I have to hire someone on my staff to take time out of their day to spend hours and hours jumping through these hoops and calling for approval and then the insurance company says, ‘Well, but we don’t really approve that much of it and so call back again and we’ve seen stories of people fighting the denial, getting an approval in a nursing home. I saw this once in a rehab center. They were denied extent more care. It was clearly appropriate.

And so the patient pursued getting an exception. They went through the exception process. The insurance company ultimately gave them the exception. Only three days later they were in the same situation. And the insurance company said, ‘well, we gave you those two or three days but not the next two or three days’ and there are people who go through that cycle, six, eight even. Well I heard a story of somebody who did it 10 times before she reached the end of her rehab course that her physician and physical therapists and the facility and indeed the patient and the family, all thought was valuable. So it’s really onerous. It makes us not always do the things that we think our patient would benefit from. The patient is really aggravated by that process cuz it’s aggravating just to talk about it right now. But often when you’re sick, you know, you have brain fog, you know, we talk about that with COVID and it’s true, that’s a whole thing, but in lots of illnesses it’s just overwhelming to be dealing with a life-threatening major chronic, you know illness and then on top of that, in that scenario, to have to deal with this third party, this insurance company, the Medicare Advantage folks who were only looking out for their bottom line and for their Wall Street traded profits, they make money the less care you get and that’s a fundamentally flawed problem as compared to, you know, (traditional) Medicare where it’s not like that.

Q: Right. It seems like patients might just give up too.

Weisbart: They do and that’s what the insurance company counts on and, and the insurance company counts on. So what are you gonna do, complain, What are you going to do? Switch to a different insurance company, Victory <laugh>, we’re happy if we didn’t want you here to begin with, you’re too sick. So, you know, your leverage over the insurance company, over theMedicare Advantage company is pretty limited. So yeah, patients do give up, doctors give up and you know, well, we’ll muddle along and it’s, you know, a lot of those things shouldn’t happen.

Q: Wow. Thank you Dr. Weisbart. Overall, how do Medicare Advantage plans respond to patients’ medical needs versus traditional Medicare with Medigap?

Weisbart: Yeah, so they get to decide, you know, the Medicare Advantage company gets to decide and there’s double digit numbers of percentages of cases where the Medicare Advantage company applies their own proprietary rules about what’s medically necessary and what’s not. You could really legitimately call them secret rules about what they think is medically appropriate or not. And they were just fined for this. There was just a huge discussion of this by the (U.S. Department of Health and Human Services’) Office of the Inspector General a few months ago saying that Medicare Advantage companies frequently deny things based on their own secret proprietary rules that are still within the guidelines of what traditional, original Medicare says should be covered and, you know, they’ll keep talking about that, but as long as nobody forces them to change that in a fundamental way, they get to decide and they often decide much more narrowly than is decided in traditional Medicare.

And this was an OIG report, this was the Office of Inspector General report on the broad population so I don’t think that particular report resulted in any fines. It resulted in a recommendation to Medicare that you guys should tighten up your language on that so that they can’t get away with this and Medicare responded saying, you know, you’re right, we should tighten up our language. Well that’s, you know, okay, great – necessary but not sufficient. You know, you need to do a lot more than that and basically it’s not going to change cuz the business model of the Medicare Advantage plan is to get in the way of health care and so I don’t care how many roadblocks you put for them to act egregiously, they’re going to continue to do it. We’ve looked at Medicare Advantage plans and found more than 10 of them that have been convicted of fraud or settled for fraud to Medicare.

And those are the large ones. More than half of people in Medicare are in one that’s done that. You know we just saw it again Centene here where I live in St. Louis, Centene just last week settled for I think more than a million dollars for one of their subsidiaries that was getting in the way of people having necessary pharmaceutical care. They’re all doing that cuz that’s the fundamental business model, get in the way of healthcare as much as they can until the penalties are so big that it’s no longer their business model and that’s, that’s just not going to happen. Noneof this happens in traditional original Medicare and people need to know, and they’re opting to go into the Medicare Advantage plan because of a number of reasons we can talk about. These are the kinds of hazards to which they’re exposing themselves that they may not be able to escape once they’ve locked into.

Q: Could a patient’s health status affect whether they would be better off with traditional Medicare or with Medicare Advantage? Is there any case where they might be better off with Medicare Advantage in your opinion?

Weisbart: No, the only reason to pick Medicare Advantage is that the upfront short term costs, if you’re healthy, can be lower – the upfront short term costs if you’re healthy in Medicare Advantage than they would be in traditional Medicare, particularly if you have to buy a supplement, which you should. So the upfront short term costs are lower. But once you get even a little bit sick, the personal financial advantage of being in Medicare Advantage disappears. And I am unaware of any evidence of better health outcomes or a subpopulation that Medicare Advantage does a splendid job at. So you also have to, I also need to point out that this is, again, looking at all Medicare Advantage plans and there are probably some that do better and some that do worse, and we don’t have any data about that. Medicare doesn’t release, you know, meaningful data about which Medicare Advantage plans do better and worse. Medicare releases a star rating, they supposedly rate the quality of Medicare Advantage plans and they give them 1, 2, 3, 4, 5 stars based on how well the Medicare Advantage plan meets certain quality metrics. But those are really limited and almost all the Medicare Advantage plans do pretty well on those because they play to, you know, they know what the metric is, they perform well on that specific narrow thing but on a broad population, there’s no reason to think broadly they do any better at all.

Thank you Dr. Ed Weisbart from Physicians for a National Health Program or PNHP.

Do you have a personal story you’d like to share about our ‘wack’ healthcare system? Contact us through our website at heal-ca.org.

Find more Code WACK! episodes on ProgressiveVoices.com and on Nurse Talk Media. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.

https://heal-ca.org…

I’m A Doctor. Here’s Why We Need Universal Healthcare

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By Belinda McIntosh, M.D.
Common Dreams, November 1, 2022

On September 19th, Atlanta became one of the latest municipalities to pass a resolution endorsing national universal health coverage. This important local action is aspirational in its urging of the United States Congress to pass the Medicare for All Act of 2021 – 2022 (H.R. 1976). However, the need for the affordable insurance this legislation would provide for every American is huge and pressing.

Luckily, the momentum behind Medicare for All is growing as Americans increasingly see that access to adequate, affordable, and equitable healthcare is an urgent need. The passage of this resolution comes just weeks after the Georgia State Democratic Convention adopted a similar resolution in support of an improved Medicare for All national health insurance program. Since 2018, over 100 cities and counties across the country have passed resolutions in support of Medicare for All. Last October, the American Public Health Association issued a policy statement declaring that healthcare is a human right and calling for the adoption of a single-payer health system to provide universal coverage in the best, most efficient, and equitable way.

Here is why national universal health coverage is so important to me. I am a private practice physician, a mother, and a cancer survivor. As a physician, I spend countless hours fighting with insurance companies to help my patients get the care they need. I watch them struggle to pay their medical bills. And I see the negative outcomes when they decline recommended treatments because they simply cannot afford to pay. As a physician who trained and worked in private and public healthcare systems for twenty years, I regularly see the encroachment of health management corporations into medical decision-making. As a private practice physician and a small business owner with a pre-existing health condition, I struggle to find appropriate health coverage for myself and my family.

From each vantage point—as a patient, a provider, and a small business owner—I see everyday how for-profit corporations fail to provide adequate access and coverage for vital health care services. I had to do something different. So I joined Physicians for a National Health Program and began advocating for change.

On September 27th, the same day that I addressed the Atlanta City Council’s Community Development/Human Services Committee and thanked them for passing the resolution in support of Medicare for All, I attended a rally on the steps of Grady Hospital, Atlanta’s largest public hospital. Doctors were gathered there to protest Governor Brian Kemp’s disastrous and stubborn refusal to expand Medicaid in Georgia, a policy that prevents access to care, results in negative health outcomes, and exacerbates a concerning trend of rural hospital closures. Georgia is one of only twelve states that has not expanded Medicaid, a provision in the Affordable Care Act that extends Medicaid coverage to almost all adults earning up to 138% of the federal poverty level. Georgia also ranks 41st in healthcare access and 43rd in healthcare outcomes.

The action taken by Atlanta City Council in passing a resolution endorsing Medicare for All comes at a critical time when Atlanta is experiencing a monumental casualty due to the failed policy of the Georgia’s Governor and its state legislature—the closure of a large city hospital.

In early September, Wellstar Health Systems, which owns and operates the Atlanta Medical Center (AMC), announced that the hospital will be closing its doors on November 1. AMC is one of two hospitals that the city of Atlanta relies on to care for the uninsured and most economically disadvantaged residents of Fulton and Dekalb Counties. Besides Grady, AMC is also the only other Level 1 trauma center in the city, providing treatment for the most severely injured. In the shadow of the impending crisis of AMC’s closure, doctors from Grady addressed the public about the importance of expanding Medicaid in Georgia, a move that would insure hundreds of thousands of Georgians who live in poverty, bring revenue to the hospitals who serve them, and potentially avert more disastrous hospital closures. In the past ten years, eight rural hospitals in Georgia have closed, with deadly consequences. Now similar impacts will be felt on a large city scale within a ten-minute walk of City Hall and a short drive from the state Capitol.

Expanding Medicaid in Georgia is one part of the solution to our healthcare dilemma. But it is not enough. We must guarantee adequate and equitable health coverage for all Americans regardless of their socioeconomic status, their zip code, or whether or not they are employed.

The Atlanta City Council, in passing a resolution in support of Medicare for All, inspires those in other cities and counties to take similar stands for affordable healthcare. Such actions amplify the voices of Americans who lack health insurance or are dissatisfied with their health care coverage. A recent AP-NORC pollshowed that 56% of Americans are dissatisfied with America’s healthcare system and only 10% of respondents said that our health care is handled well or very well.

Perhaps the radical idea was thinking that corporations could be relied upon to provide reasonable coverage at a reasonable cost for the majority of Americans. As it turns out, that is simply not what corporations are about. Corporations are about profits. We need a national single payer health insurance program. It is time to join the growing wave of support for passage of the Medicare for All Act of 2021.

Dr. Belinda McIntosh is a psychiatrist residing in Atlanta.

https://www.commondreams.org…

Recent Members in the news

Dr. Susan Rogers on “Healthcare-NOW”

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This article includes video

PNHP president Dr. Susan Rogers appeared on the “Healthcare-NOW” podcast on October 12, 2022. Dr. Rogers discussed the  lure of privately administered Medicare Advantage plans, which offer lower premiums to seniors, but can prove costly in the long-run when it comes to copays and outright denial of care.

“I’m not an MBA, but I know that if I spend more money than I bring in, [then] I have to change something,” said Dr. Rogers in reference to the high administrative costs that are another hallmark of Medicare Advantage. “What they’ve changed is not providing care.”

Dr. Ana Malinow on “Rising Up With Sonali”

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This article includes video

PNHP past president Dr. Ana Malinow appeared on “Rising Up With Sonali” on Free Speech TV and Pacifica radio stations on May 25, 2022. Dr. Malinow described the dangers of Medicare Direct Contracting and REACH, which allow third-party (often corporate) middlemen to “mange” the care of Traditional Medicare beneficiaries.

Dr. Malinow was especially critical of the claim that these programs would do anything to advance equity: “We cannot possibly trust corporations, which created inequality in the first place, to achieve health equity.”

Dr. Adam Gaffney on “The Jacobin Show”

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This article includes video

PNHP immediate past president Dr. Adam Gaffney appeared on “The Jacobin Show” on May 18, 2022. Dr. Gaffney discussed the recent U.S. Senate hearing, “Medicare for All: Protecting Health, Saving Lives, Saving Money,” where he testified along with Dr. Abdul El-Sayed and National Nurses United executive director Bonnie Castillo, and why now is an especially crucial time for a resurgence in single-payer activism.

Recent Quote of the Day

John Geyman: The Medical-Industrial Complex…plus exciting changes at qotd

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“America’s Mighty Medical-Industrial Complex: Negative Impacts and Positive Solutions”

By John Geyman

This book has three goals: (1) to bring an historical perspective to how medicine and health care have evolved over the last 100 years, including the transformation of their original ethic of service with a moral purpose and how that ethic has been compromised by corporate greed; (2) to describe where an engulfing medical-industrial complex has brought us in terms of decreasing access to affordable health care, unacceptable quality of care, profiteering and fraud; and (3) to consider whether and how our unsustainable health care system can be brought into line against this deepening crisis in serving the needs of our people.

Copernicus Healthcare: http://www.copernicus-healthcare.org

Amazon: https://www.amazon.com…

Comment:

By Don McCanne, M.D.

Most of us want a health care system that has a mission to maintain and improve our health, yet we have a system that has lost its way in that its mission places a priority on advancing the interests of the medical-industrial complex at the cost of compromising our health care. John Geyman explains how we got there and how detrimental the impact has been. Although the political barriers to reform seem almost insurmountable, he does show us that there is a path to the essential reform that we need to bring health care justice to all. By understanding the source and nature of the dysfunctions, we can find our way out.

Exciting changes at qotd

As some of you may have heard, the interruption in the Quote of the Day messages was due to a TIA/stroke suffered by the author. Fortunately, the recovery has been dramatic, though incomplete. As a result, after two decades of daily commentaries in his retirement years, it is time for a change.

Future messages will be from noted health policy experts within and outside of PNHP. We will be receiving the latest from the best. With this change in format, we will also be changing the name to “Health Justice Monitor.” Launch is planned for next week.

I hope that you are as excited as I am as I become a consumer rather than a producer of the latest in health policy science. The more we understand, the sooner we will have health care justice for all.

Peace,
Don McCanne

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

Quote of the Day interlude

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By Don McCanne, M.D.

Quote of the Day will take a brief interlude. We are refining our approach to communicating information to educate and advocate for single payer and health care justice for all.

See you soon.

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

More trouble: Drug industry consolidation

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Over 30 years, dramatic consolidation has meant higher prices, fewer treatment options and less incentive to innovate

By Robin Feldman
The Washington Post, April 6, 2021

In the past few decades, three waves of mergers have substantially increased concentration in the pharmaceutical industry.

All told, between 1995 and 2015, the 60 leading pharmaceutical companies merged to only 10.

As a result, now only a handful of manufacturers are responsible for sourcing the vast majority of prescription drugs: Just four companies, for example, produced more than 50 percent of all generic drugs in 2017.

Drug companies were drawn to merging because of the lure of increased market power, improved synergies, larger economies of scale and more diverse product portfolios.

In the period following merger waves one and two, the industry generated fewer new molecular entities each year compared to pre-merger levels. Merged drug companies also spent proportionally less on research than their non-merged competitors.

Consolidation also enabled drugmakers to directly quell competition through what were known as “killer acquisitions,” in which they acquired innovative peers solely to stop potential competition.

In short, consumers were the losers from the two waves of drug company mergers. They confronted higher prices and fewer choices — and saw companies exploring fewer paths that might produce breakthroughs. To make matters worse, around 2010, another wave of mergers began.

As with the earlier waves, giant drug companies have merged. But in a new twist, in recent years, most consolidation has featured bigger players acquiring smaller start-ups. The difference reflects a dramatic shift in the structure of the pharmaceutical industry. Faced with stagnating research productivity, large drugmakers now rely on outsourcing their new drug research to start-ups and other small pharmaceutical firms.

Increasingly, these smaller players specialize in high-risk research and early drug development, with larger firms then gobbling them up and navigating the FDA’s regulatory process. For example, 63 percent of all new molecular entities in 2018 came from smaller biopharma firms, compared with just 31 percent in 2009.

The end result of now three waves of pharmaceutical consolidation is decreased or diverted new drug innovation, fewer treatment options and higher prices. Consumers have lost as firms fuse together to bolster the bottom line.

Robin Feldman is director of the UC Hastings Center for Innovation.

https://www.washingtonpost.com…

Comment:

By Don McCanne, M.D.

Yesterday we discussed consolidation of UnitedHealth/Optum and how it has become a mega-corporation of the medical-industrial complex. Today’s selection discusses consolidation within the pharmaceutical industry. The article describes how we can expect decreased or diverted drug innovation, fewer treatment options, and above all, higher prices. Works for the industry, but not so well for the people.

We’re just trying to introduce single payer Medicare for All. How much impact can that have on these mega-corporations? Where is our government in all of this? Aren’t they supposed to protect us? Maybe we’re aiming too low by advocating for a social insurance program. Maybe we should be taking over the industry so that we can gear it up to better serve us, the people. International comparisons do rate national health services very high in performance. Maybe if we talk about it a little more we can convince them that Medicare for All is a compromise that they can live with. We think we can too.

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

Recent State Single Payer News

N.Y. Assembly passes universal health care bill

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By Dan Goldberg
Capital New York, May 27, 2015

The state Assembly on Wednesday voted for a single-payer health bill, the first time in more than two decades the chamber has taken up the measure.

The vote was 89-47, an overwhelming but largely symbolic step toward universal health insurance. The bill now heads to the Republican-controlled Senate where it is not expected to pass.

Assemblyman Richard Gottfried, chair of the health committee, gave an impassioned speech on the floor in support of the New York Health Act, arguing that it was long past time for New Yorkers to rid themselves of the intrusive insurance companies whose goal is to deny claims rather than provide care.

“You do not have to be an Einstein to understand New York Health is the right choice for New York,” Gottfried said.

Gottfried, a Democrat from Manhattan, spent the legislative session barnstorming the state, trying to gain support for his bill, which would be funded through a progressive income tax and payroll assessments. There would be a net savings of $45 billion in health spending by 2019, Gottfried said, based on an analysis from Dr. Gerald Friedman, a professor at the University of Massachusetts at Amherst, though that figure was attacked by Republicans.

The bill, Gottfried said, would lower costs by getting rid of insurance companies. It would lower administrative costs and allow doctors to focus their time on treating patients instead of fighting for reimbursements.

“What will bring down health care costs is taking out of the equation the more than 20 percent we now spend on administrators whose job it is to fight with insurance companies,” he said.

The plan’s benefits, Gottfried said, would be more generous than any plan on the current market, and there would be no co-pays or deductibles. The bill would also require a care coordinator for every member, though that coordinator is not empowered to choose the type of care a patient receives.

For some Republicans, it was all too good to be true.

“This bill promises remarkable things for New York State residents,” said Assemblyman Andy Goodell, a Republican from Chautauqua. “It says providers, ‘you’ll be paid a lot more money,’ and it says to the employees ‘you’ll contribute a lot less money,’ and it says to the patients ‘you’ll have much broader access,’ and to the employers ‘you’ll pay $45 billion less.’ My background is in math and economics and I haven’t been able to figure out how this all works. … There is no free lunch, there is no free health care.”

Leslie Moran, spokeswoman for the New York Health Plan Association, which represents insurers, said the bill “represents an unrealistic, utopian view of a universal health care system where everyone would be covered, everything would be covered and the system would magically pay for it all.”

One problem, pointed out by Republicans, is that the offering, while generous, is the opposite of what public health officials are pushing, including those in the Cuomo administration, who have professed that insurance systems, and high deductibles and co-pays help ensure people use the health system judiciously instead of opting for more, often unnecessary, care.

“There is a role for insurance companies,” state health commissioner Dr. Howard Zucker said Wednesday before the debate.

The last time a universal health care bill was on the Assembly floor was 1992. It passed but the debate was sidelined because of federal efforts to reform health care, which ultimately failed under the Clinton administration.

The passing of the Affordable Care Act, which subsidizes private insurance for people below a certain income level, was a valid effort, Gottfried said, but ultimately served to highlight why the system needs to be entirely scrapped.

“I think the A.C.A. has made it clear to people … there are profound problems in our health care system that cannot be addressed by incremental change in that system,” Gottfried said.

Wiping out an industry — even the insurance industry — was not seen as popular by many Republicans who worried about the loss of jobs and what might happen should this plan fail.

Goodell asked why the state should go down this road when when Medicaid — a government run insurance program for lower-income residents — is expensive, burdensome and not well liked.

“Why would we want to expand that type of approach,” he asked.

Gottfried responded that his bill would improve Medicaid by putting everyone into one pot. He would, he said, eliminate the two-tiered system. There’d be no greater risk of fraud under this law than in the current Medicaid program.

Republicans also pointed out how much was left to be done. The income tax rates have yet to be decided, but would likely cost the highest earners more than they currently pay for health insurance, while subsidizing lower income residents.

The analysis provided by Gottfried estimates no income tax on the first $25,000, an income tax of 9 percent on income between $25,0001 and $50,000, graduating to 16 percent tax for income over $200,000.

The legislation is also not specific on how to deal with residents of New York State who retire to another state.

That would have to be resolved at a later date, Gottfried said.

“Though we have numerous pages on this legislation, we have numerous holes also,” said Al Graf, a Republican from Holbrook. “There is no way I can go back to my constituents and tell them you may have coverage in the future. … This is an exercise in insanity.”

Moran said there is no certainty that providers would accept government set reimbursement, though Gottfried said almost all would receive more for their services than they are currently being paid.

The bill also “completely disregards the economic contribution of health plans — both to the state and to local communities,” Moran said.

Joseph Borelli, a Republican from Staten Island, cited Vermont, which tried and failed to enact a single-payer health system.

Vermont’s collapse has been a cautionary tale for even the most enthusiastic supporters of government sponsored health insurance, but Gottfried was having none of it.

“New York … bears no resemblance to Vermont,” Gottfried said. “The bill bears very little resemblance to Vermont. Their financing system is different. The two have absolutely nothing to do with one another, nothing! Why don’t you ask me whether New York will flood Just like Texas flooded if we enact this plan. The weather in Texas has as much to do with this as Vermont does.”

Read the bill here: http://bit.ly/1JVUg1I

http://www.capitalnewyork.com/article/albany/2015/05/8568890/assembly-pa…

N.Y. Assembly votes for universal health coverage

By Michael Virtanen, Associated Press
Democrat & Chronicle (Rochester, N.Y.), May 27, 2015

ALBANY – The New York Assembly voted 89-47 on Wednesday for legislation to establish publicly funded universal health coverage in a so-called single payer system.

All New Yorkers could enroll. Backers said it would extend coverage to the uninsured and reduce rising costs by taking insurance companies and their costs out of the mix.

With no patient premiums, deductibles or co-payments for hospital and doctor visits, testing, drugs or other care, New York Health would pay providers through collectively negotiated rates. It would be funded through a progressive payroll tax paid 80 percent by employers and 20 percent by employees.

Also, waivers would be sought so federal funds now received for New Yorkers in Medicare, Medicaid and Child Health Plus would apply.

“Employers are shifting more and more health care costs to workers or are dropping it entirely,” said Assemblyman Richard Gottfried, chief sponsor. “The only ones who benefit are the insurance companies.”

The Manhattan Democrat estimated universal care would save New Yorkers more than $45 billion annually, cutting the statewide total cost for health care to about $255 billion in 2019.

Assembly Republicans doubted Gottfried’s estimate and questioned what would happen to everyone now employed by insurance companies.

“All I can say right now I think this is the last think New York state needs as far as an additional cost,” said Assemblywoman Jane Corwin, an Erie County Republican. She said they’re still trying to grapple now with the cost of the federal Affordable Care Act. That extended health care coverage to about 1 million New Yorkers, more than half in Medicaid and the others in private insurance with possible tax subsidies to offset costs.

An identical bill hasn’t advanced in the state Senate and isn’t expected to before the legislative session ends in June. Senate Health Committee Chairman Kemp Hannon said Wednesday that Gottfried’s bill faces two major hurdles, resistance from senior citizens to giving up Medicare for a new state program and obtaining federal waivers to apply Medicaid and Medicare funding to support it.

http://www.democratandchronicle.com/story/news/local/2015/05/27/assembly…

Single-Payer Health-Care Bill to be Introduced in Pa.

Posted

Berks Community Television (Reading, Pa.), Oct. 25, 2015

HARRISBURG, Pa. – A bill to create a single-payer health-care system in Pennsylvania will be introduced in the state Legislature by the end of the month.

The legislation is being introduced by Representative Pamela DeLissio of Philadelphia and was crafted with the assistance of HealthCare 4 ALL PA, a not-for-profit advocacy group. David Steil, past president of that organization, says the bill is simply called the Pennsylvania Health Care Plan.

“What it does is create a health-care system that includes every resident of Pennsylvania, that is publicly funded and privately delivered,” says Steil.

The cost of the program would be covered by increased taxes, which Steil acknowledges may present a significant obstacle to passage by the state Legislature.

The plan would increase the state personal income tax by an additional three percent, substantially less than most pay for private insurance. It would also add a 10 percent payroll tax on businesses which, as Steil points out, is much less than what businesses spend on health insurance now.

“The average cost for health care benefits for companies that provide health care is about 17 percent of payroll,” he says. “So at 10 percent of payroll, the saving is significant.”

Similar legislation has been introduced in each legislative session since 2007.

Most recently it was introduced as Senate Bill S-400. None of the earlier versions have not gotten very far. Raising taxes is a hard sell, especially to conservative lawmakers. But Steil insists they’re asking the wrong question.

“The question each one has to ask is not just ‘look at the taxes’ because there are taxes to it, it’s not free,” he says. “The question is, ‘How much less than you’re currently paying is this plan to you?'”

Steil says the bill would also eliminate health-insurance costs on pension plans and vehicle insurance, making the potential savings even larger.

http://www.bctv.org/special_reports/health/pa-legislature-introduces-sin…

Single-Payer Health-Care Bill to be Introduced in Pa.

Posted

Berks Community Television (Reading, Pa.), Oct. 25, 2015

HARRISBURG, Pa. – A bill to create a single-payer health-care system in Pennsylvania will be introduced in the state Legislature by the end of the month.

The legislation is being introduced by Representative Pamela DeLissio of Philadelphia and was crafted with the assistance of HealthCare 4 ALL PA, a not-for-profit advocacy group. David Steil, past president of that organization, says the bill is simply called the Pennsylvania Health Care Plan.

“What it does is create a health-care system that includes every resident of Pennsylvania, that is publicly funded and privately delivered,” says Steil.

The cost of the program would be covered by increased taxes, which Steil acknowledges may present a significant obstacle to passage by the state Legislature.

The plan would increase the state personal income tax by an additional three percent, substantially less than most pay for private insurance. It would also add a 10 percent payroll tax on businesses which, as Steil points out, is much less than what businesses spend on health insurance now.

“The average cost for health care benefits for companies that provide health care is about 17 percent of payroll,” he says. “So at 10 percent of payroll, the saving is significant.”

Similar legislation has been introduced in each legislative session since 2007.

Most recently it was introduced as Senate Bill S-400. None of the earlier versions have not gotten very far. Raising taxes is a hard sell, especially to conservative lawmakers. But Steil insists they’re asking the wrong question.

“The question each one has to ask is not just ‘look at the taxes’ because there are taxes to it, it’s not free,” he says. “The question is, ‘How much less than you’re currently paying is this plan to you?'”

Steil says the bill would also eliminate health-insurance costs on pension plans and vehicle insurance, making the potential savings even larger.

http://www.bctv.org/special_reports/health/pa-legislature-introduces-single-payer-health-care-bill/article_a41a6da0-7996-11e5-b8a4-2ba3ba19b536.html