Structural Racism and Supporting Black Lives — The Role of Health Professionals

By Rachel R. Hardeman, Ph.D., M.P.H., Eduardo M. Medina, M.D., M.P.H., and Katy B. Kozhimannil, Ph.D., M.P.A.
The New England Journal of Medicine, October 12, 2016

On July 7, 2016, in our Minneapolis community, Philando Castile was shot and killed by a police officer in the presence of his girlfriend and her 4-year-old daughter. Acknowledging the role of racism in Castile’s death, Minnesota Governor Mark Dayton asked rhetorically, “Would this have happened if those passengers [and] the driver were white? I don’t think it would have.”

Disproportionate use of lethal force by law-enforcement officers against communities of color is not new, but now we increasingly have video evidence of the traumatizing and violent experiences of black Americans. Structural racism — a confluence of institutions, culture, history, ideology, and codified practices that generate and perpetuate inequity among racial and ethnic groups — is the common denominator of the violence that is cutting lives short in the United States.

The term “racism” is rarely used in the medical literature. Most physicians are not explicitly racist and are committed to treating all patients equally. However, they operate in an inherently racist system. Structural racism is insidious, and a large and growing body of literature documents disparate outcomes for different races despite the best efforts of individual health care professionals. If we aim to curtail systematic violence and premature death, clinicians and researchers will have to take an active role in addressing the root cause.

Structural racism, the systems-level factors related to, yet distinct from, interpersonal racism, leads to increased rates of premature death and reduced levels of overall health and well-being. Like other epidemics, structural racism is causing widespread suffering, not only for black people and other communities of color but for our society as a whole. It is a threat to the physical, emotional, and social well-being of every person in a society that allocates privilege on the basis of race. We believe that as clinicians and researchers, we wield power, privilege, and responsibility for dismantling structural racism — and we have a few recommendations for clinicians and researchers who wish to do so.

First, learn about, understand, and accept the United States’ racist roots.

Second, understand how racism has shaped our narrative about disparities.

Third, define and name racism.

Finally, to provide clinical care and conduct research that contributes to equity, we believe it’s crucial to “center at the margins” — that is, to shift our viewpoint from a majority group’s perspective to that of the marginalized group or groups.

Addressing violence against black communities can start with antiracist practices in clinical care and research. Do we have the courage and conviction to fight to ensure that black lives do indeed matter?

http://www.nejm.org…

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Comment:

By Don McCanne, M.D.

The authors note that “most physicians are not explicitly racist and are committed to treating all patients equally,” but, importantly, “they operate in an inherently racist system.” Further, “structural racism is insidious, and a large and growing body of literature documents disparate outcomes for different races despite the best efforts of individual health care professionals.”

They state, “If we aim to curtail systematic violence and premature death, clinicians and researchers will have to take an active role in addressing the root cause.” They then offer some useful suggestions on how we might approach structural racism.

But we should go further. In an internal communication, David Himmelstein and Steffie Woolhandler suggest developing “a list of health financing demands related to fighting racism.”

One of the more obvious places to start would be the enactment of a single payer national health program in which financing of health facilities and health care would be equitable.

But reading the comments published by NEJM in response to this article suggest that we have more to do than simply address structural racism. One physician commented, “The NEJM, a formerly highly respected medical journal, has lowered itself to the level of  a political journal that supports people who advocate the murder of policemen… This journal is now a ‘throwaway’.”

Another commenter from Georgia wrote, “K-12 schools need to teach students how to comply with police orders.”

Sadly, the problems are deeper than just structural racism. That will make our task much more difficult. But as health professionals, it is imperative that we join in leading the way toward improving the health of the nation by implementing structural reform that would improve the health of each and everyone of us. These efforts should be disproportionately directed to the greatest problems until we can achieve a truly egalitarian equilibrium.

For more on this very important topic, see the article below:

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Single-Payer Health Reform: A Step Toward Reducing Structural Racism in Health Care

By Dominic F. Caruso, MD/MPH Candidate, David U. Himmelstein, MD, and Steffie Woolhandler, MD
Harvard Public Health Review, July 20, 2015

https://www.pnhp.org…

How Narrow Is It? Gov’t Begins Test Of Comparison Tool For Health Plan Networks

By Michelle Andrews
Kaiser Health News, October 14, 2016

The incredible shrinking provider network is nothing new in marketplace plans. One way insurers have kept premiums in check on the individual market is by reducing the number of providers available in a plan’s network. Earlier this year, the federal government said that it would introduce a tool this fall to help consumers who are shopping on HealthCare.gov gauge how narrow a plan’s provider network is compared with others in the area.

But most consumers who want that information will have to wait at least another year. The Department of Health and Human Services recently announced that the pilot project to test the network breadth tool just got a little, well, narrower.

Consumers can already check whether specific doctors or hospitals are included in a marketplace plan’s provider network on HealthCare.gov. But there’s currently no way to easily measure the breadth of a plan’s provider network. This can be an important factor for some consumers, especially given the growing number of plans with no out-of-network benefits.

The new tool will designate marketplace health plan networks as “basic,” “standard” or “broad” based on how they compare with other health plan networks in a county. The label will reflect the availability of three types of providers: primary care, pediatricians and hospitals.

Originally, network-breadth information was going to be available for the 35 states on HealthCare.gov, the federally facilitated marketplace. But in August HHS announced it would make the tool available in just six unnamed states.

In September, HHS said it would shrink the pilot still further, to four states — Maine, Ohio, Tennessee and Texas.

Although the tool will let people compare networks in their area, still, “it’s all relative,” (Georgetown Professor Sabrina) Corlette said. “If you’ve got a market where every single network is narrow, this network breadth rating is less useful.”

http://khn.org…

CMS update on the network breadth pilot program:
https://www.cms.gov…

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Comment:

By Don McCanne, M.D.

One of the major concerns with the implementation of the Affordable Care Act is that many of the exchange plans have narrow to ultra-narrow provider networks. Since it is difficult to determine the breadth of providers included, CMS is providing a network rating system to provide more transparency, as if the problem of narrow networks wasn’t much more serious than simply lack of adequate information.

The fact that the pilot program was pared back suggests that this will not be a simple process. It will be difficult to match a fluctuating provider list with the medical needs of the plan enrollees. Further, since each enrollee has different medical needs, it will be even more difficult to be certain that the needs of each enrollee will be met, even if the enrollees’ preferences are ignored.

Although a recent report suggests that plans with narrow networks have premiums that are about 7 percent lower than plans with broad networks, once most insurers switch to narrow networks, that differential will go away.

But this is typical of CMS. When the problem is that insurers are limiting patients’ choices in their health care, CMS decides that the solution should be to merely tweak the system with more transparency while keeping it intact. The solution needed is to eliminate the restrictive provider list, allowing patient access to the entire health care delivery system.

Patients often choose their plans based primarily on the lowest premium prices. Secondarily they may sometimes check to be certain that their primary care physician is on the list, if they have one. But both of these are flawed policies. Choice of physicians and hospitals should be unlimited (except for providers expelled for reason). Also the entire health care system should be funded automatically through progressive taxes – a much more equitable system with much less wasteful administrative complexity than assigning varying individual premiums for a market of private plans.

Today CMS released the final rule on MIPS and APMs – a major administrative boondoggle if there ever was one. They just don’t get it. When we need real reform, they simply serve us more “garbage salad” (but not the one Trump serves).

PNHP note: Physicians for a National Health Program is a nonpartisan educational organization. It neither supports nor opposes any candidate for public office.

Customers sue UnitedHealth over prescription drug co-pay costs

By Brendan Pierson
Reuters, October 5, 2016

UnitedHealth Group Inc has been sued by three customers who accused the largest U.S. health insurer of charging co-payments for prescription drugs that were higher than their actual cost and pocketing the difference.

For example, the lawsuit claims, one class member paid a $50 co-payment for Sprintec, a contraceptive, while UnitedHealth paid the pharmacy only $11.65. The pharmacy was then required to hand the extra $38.85 over to UnitedHealth under its agreement with the insurer, the lawsuit said.

The lawsuit claims that such a co-payment “is not a ‘co-‘ payment for a prescription drug because the insurer is paying nothing,” but is instead “a hidden additional premium.”

The lawsuit says UnitedHealth has hidden this practice from its customers, forcing them to overpay for a wide variety of common, low-cost drugs.

The lawsuit claims UnitedHealth’s co-payments violate the Racketeer Influenced and Corrupt Organizations Act (RICO), a federal law used to target illegal conspiracies, and in some cases also violate a federal law governing employee benefit plans.

http://www.reuters.com…

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Comment:

By Don McCanne, M.D.

Yesterday’s message described how insurers were using the deductibles to avoid paying anything for covered drugs while collecting a significant proportion of the patient’s payment for the prescription. Today’s shows how UnitedHealth is establishing co-payments much larger than the retail value of many of its authorized prescriptions, then requiring a kickback of the balance of the co-payment. In both instances, the insurer’s net payment for the prescriptions is zero whereas the patient is unknowingly making a generous payment to the insurer. The insurer is collecting additional patient funds in exchange for providing…nothing!

These two examples are not a mere coincidence. They are written into the contracts. They are proof of the ongoing conspiracy of the insurers to cheat their own clients – the patients.

A racketeering lawsuit has now been filed. But that is not enough. We need to expel these rip-off artists from our health care system. We need to replace these leeches with our own dedicated public stewards serving us in a financing system that works for patients instead: Single payer.

Secret Rebates: Why Patients Pay $600 for Drugs That Cost $300

By Robert Langreth
Bloomberg, October 5, 2016

Behind the scenes, drugmakers gave insurers and benefit managers more than $100 billion a year in rebates and other discounts to reduce the skyrocketing cost of drugs.

No one balks when insurers get rebate checks after they actually paid for a drug. But, increasingly, Americans are forced to pay for medication out of their own pockets — at least for part of the year.

That’s because more are enrolling in insurance plans with deductibles as high as $4,000 for a family. In such cases, insurers receive the rebates even though they haven’t paid a dime.

Eight pharmaceutical companies contacted by Bloomberg, including Novo Nordisk A/S, which makes NovoLog; Merck & Co., Pfizer Inc. and EpiPen maker Mylan NV, said their contracts with benefit managers and insurers generally require rebates be paid to them on all prescriptions, even when the patients pay the full cost because of high deductibles.

On a $600 prescription, “if the patient has a high-deductible plan, then the insurer could pocket the $300 rebate and not share it with the patient,” says Adam Fein, president of Pembroke Consulting, which advises drugmakers on sales and distribution.

But why not break up the rebate checks and send the cash back to the patients who paid for the drugs? Representatives of corporate health plans say it would be impractical to do so because they get the money months after employees bought the drugs.

Says Laurel Pickering, chief executive of the Northeast Business Group on Health, a coalition of large employers: “It would be very difficult to figure out how to administer that.”

http://www.bloomberg.com…

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Comment:

By Don McCanne, M.D.

Drug rebates go to insurers. How does this work? Well, let’s go through this step by step.

1. The patient buys a health insurance plan with a high deductible – a plan that provides drug benefits.

2. The patient is prescribed a $600 medication before having met the deductible.

3. The patient purchases the drug at the pharmacy for the retail price of $600.

4. The insurance company (or pharmacy benefit manager) has previously made a confidential deal with the drug manufacturer that a 50% rebate will be paid to the insurer in exchange for including that drug in the formulary of drugs that are approved for coverage under the plan.

5. The 50% rebate – $300 – is paid to the insurer who keeps it.

6. None of the $600 is refunded to the patient.

7. The pharmaceutical firms jack up the retail prices of their drugs to pay for the rebates and to increase profits.

8. Net result:

• The insurance provided no benefit to the patient.
• The insurer paid out nothing.
• The patient paid $600 for a drug that had a negotiated price of $300.
• The insurer pocketed $300 which rightfully belonged to the patient.
• We all pay more for drugs because of these secret deals.

The insurers may argue that they should be rewarded for negotiating the drug discount for the patient. But scooping up the entire discount and running away with it?

Will somebody please explain why our policymakers continue to demand that we maintain the middleman role for the private insurers in our health care financing system? It’s a great deal for the insurer, but wasn’t reform supposed to be about the patient?

What Would A Public Insurance Option Look Like In California?

By Pauline Bartolone
California Healthline, October 11, 2016

The “public option,” which stoked fierce debate in the run-up to the Affordable Care Act, is making a comeback — at least among Democratic politicians.

The proposal to create a government-funded health plan, one that might look like Medicare or Medicaid but would be open to everyone, is being reconsidered at both the federal and state levels.

Amid news that two major insurers were pulling out of Affordable Care Act exchanges, 33 U.S. Senators recently renewed the call for a public option. The idea was first floated, then rejected, during the drafting of the federal health reform law, which took effect in 2010.

Democratic presidential candidate Hillary Clinton includes a public option in her campaign platform, and President Barack Obama urged Congress to revisit the idea in a JAMA article published in August.

Dave Jones, the elected regulator of California’s private insurance industry, endorsed the idea of a state-specific public option in an interview last month with California Healthline, though he did not specify how it might work.

California may be uniquely poised for a public plan — but the state may not need one, according to Gerald Kominski, Director of the UCLA Center for Health Policy Research.

“It would look just like an insurance plan,” except that the state would pay for medical care, potentially set up the network of doctors and hospitals, and make rules about paying providers, Kominski said. Private industry could be involved in these or other aspects of running the health plan, much as they do in Medicare Advantage and managed care Medi-Cal.

Creating a public option in California may not be necessary at present, since the state currently has sufficient competition in the private insurance market, Kominski said. But he said policymakers could choose to implement a public option now as a backstop against a potential future scenario in which private insurers scaled back their California plan offerings.

California Healthline interviewed Kominski to better understand how a public option could work in California and on a national level. The interview was edited for length and clarity.

Q: When we talk about a public option, do we mean a health plan for which the government takes the risk, sets the coverage rules and pays out the claims — and enrollees pay premiums just as they would to an insurance company?

That is what the public option would be. But that still leaves out the answer to a lot of questions about how actually that would occur. How would a government agency essentially become the insurer? So we have two examples. We have the Medicare program and we have the Medicaid program.

Medicare establishes the rules. It contracts with insurance companies to pay the bills. And that’s the way that Medicare has operated for over 50 years.

Now we have Medicare Advantage plans, where the contracting is not to pay bills but is basically contracting with insurers to bundle the services. And rather than pay the doctors and hospitals, the government pays the insurer and puts the insurer at risk.

Q: Insurers have opposed this idea in the past, and they’re opposing it again now that it’s being raised by members of Congress.

Private insurers could participate as administrators or providers on behalf of the state. But here’s one concern that I have with that model: California has four large insurance companies in the exchange that account for about 90 percent of the market.

Let’s say the state of California wanted to create a public option and hire an insurance company to administer that product for it. What would be the reason or the incentive for any of those companies to agree to be the plan administrator for the public option when the public option would be competing with the product that they’re already offering? They would be competing with themselves.

Q: Some provider groups may be opposed to a public option because they say that government programs like Medi-Cal pay very little and they believe a public option plan would also pay little. Is this necessarily the case that a government program would pay low rates?

It’s not necessarily the case, but it is in fact what we observe in the Medicare and the Medicaid/Medi-Cal programs.

Q: Do you think a publicly subsidized or operated program would run the risk of having narrower provider networks because of lower payments to providers?

I don’t want to pre-judge that. If the anecdotal evidence that I’ve been told over the last couple years is indicative of what’s going on statewide, then Covered California plans are already paying somewhere around Medicare rates.

Q: Do you think a public plan would help bring down costs in the health care system by negotiating for lower payments to hospitals and doctors?

I think that is possible in other areas of the country, where there are markets with one or two health insurance plans in the exchange. I think California has one of the most competitive ACA marketplaces. And so would the public option in California dramatically reduce premiums? I think the answer is no. It would have little or no effect.

For some people, the advantage is that we think that the public option’s going to be around because the state’s not going to back out of its commitment, whereas private insurers come and go in the marketplace.

Q: Do you think we need a public option in California for any other reason?

In my opinion, a public option isn’t necessary in California, but it might nevertheless be worth exploring as a longer-term mechanism for guaranteeing access and an alternative to relying solely on the private insurance market.

Q: Is there something about California’s health care system that uniquely primes the state for a public option?

I think so. One of the things that’s unique about California is the high percentage of managed care enrollment. The public option in California would probably include or be based on a managed care model and Californians are pretty receptive to that model.

Q: So if the public option could include private insurance, why are the insurers so opposed?

Well, the simple answer is they don’t want more competition. And again it goes back to, why was this battle so intense during the development and enactment of the ACA back in 2009 and 2010? The insurance industry said we cannot compete with a plan, a government plan, that pays doctors and hospitals using Medicare fees or fee schedules.

You remember the fundamental rule of business is you don’t want more competition. You want the market to yourself.

Q: Do you think it would be more effective or easier to implement a public option at a state or national level?

Well that’s where you can’t ignore the political environment. And so the short answer is in the current political environment, doing something at the national level is extremely difficult. Even though there might be arguments to develop a public option at the national level, it’s very challenging in the current political environment to get the agreement.

Q: Is there something that’s more efficient about a national public option?

Potentially. It’s economies of scale. You know, the larger your potential market nationally, the lower the potential costs per person. You just get administrative savings and efficiency. But it’s not easy to create a national program. One issue that’s challenging is how to put together a national network of doctors and hospitals that would participate. That’s a lot of work.

Q: Do you think the idea of a public option is more viable now than it was when it was debated before and ultimately stripped from the Affordable Care Act?

Well, I think that what makes it more attractive right now is the fact that we’ve got two large insurance companies that are pulling out of the exchange marketplaces. And because of that…the idea of a public option to provide stability and protection for people in the exchanges has resurfaced. And I think with good reason.

http://californiahealthline.org…

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Comment:

By Don McCanne, M.D.

Many public option supporters have this concept that the government would create a public insurance plan that would successfully compete with private insurance plans, eventually displacing them and becoming a single payer national health program. Is this realistic?

Gerald Kominski describes for us precisely what a public option really would look like. Clearly it would be nothing more than one more player in our inefficient, fragmented multi-payer system, only adding further to the administrative excesses that have created a tremendous financial burden for our health care system.

For those who usually skip the source in these messages and only read the comment, you should make an exception this time. It is important to understand that the public option would be crafted to resemble private plans with provider networks. It would not be a free standing public program, like Medicare, if for no other reason than the fact that you could not get the majority of physicians and hospitals to agree to participate unless you promised higher payment rates which then would make the premiums even less affordable. Further, the private insurance industry would be there to ensure that the design of the government insurance product would place it at a competitive disadvantage, just as they did with the co-ops.

Besides, competition is a feature of private markets. A public program is a model based on service. A public insurance model designed for competition in private markets, as Gerald Kominski has described, would be very different than a public model designed to remove financial barriers to care, such as a single payer national health program.

Really. Try to imagine a public option designed to become a single payer. It would have its own separate risk pool, funded with premiums instead of progressive taxes, subject to adverse selection, with pressure to reduce provider payment rates to keep the premiums affordable, with consequent difficulties in ensuring access to an adequate numbers of providers, and greatly burdened with administrative complexity. When you try to design such a system, you keep tweaking it until you end up with the model Gerald Kominski has described – just another private-style plan, public in name only.

It is no wonder that Professor Kominski said to his UCLA health policy students (in a recent Quote of the Day), “I believe that there are people in this room who will one day see a single payer system in this country.”

So you think Obamacare is a disaster? Here’s how California is proving you wrong

By Noam N. Levey
Los Angeles Times, October 7, 2016

Even as turmoil in insurance markets nationwide fuels renewed election-year attacks on the Affordable Care Act, California is emerging as a clear illustration of what the law can achieve.

The state has recorded some of the nation’s most dramatic gains in health coverage since 2013 while building a competitive insurance marketplace that offers consumers enhanced protections from high medical bills.

California and its Obamacare marketplace, Covered California, still face challenges, including rising costs. Like consumers elsewhere, some Californians, particularly those who make too much money to qualify for government subsidies, are seeing substantial premium increases and narrowing networks.

But while health coverage has faltered in other states where politicians worked to undermine the law, California highlights what can be accomplished if government officials and industry leaders work together to expand insurance, control costs and protect consumers.

More than three-quarters of newly insured Californians said their health needs are now being met, a recent survey by the nonprofit Kaiser Family Foundation found.

At the same time, Californians who gained coverage reported fewer worries about paying for not just healthcare, but also housing, transportation, even food.

Much of the insurance expansion in California has been fueled by the state’s decision to take advantage of federal funding in the health law to expand Medicaid eligibility to poor, childless adults, a population traditionally excluded from most states’ safety nets.

But Covered California has also played a critical role, with about 1.3 million direct customers and nearly 1 million more who get health plans that must meet Covered California standards even though consumers don’t use the marketplace to purchase them.

In 2017, Covered California rates are increasing an average of 13.2%, driven in part by rising medical costs and the end of a federal program that helped hold down rates.

Premiums for several insurers, including Blue Shield of California and Anthem Inc., are increasing even more dramatically.

Preventing large rate hikes in the future will require adjustments to the marketplaces in California and elsewhere, many experts say.

http://www.latimes.com…

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Comment:

By Don McCanne, M.D.

California’s aggressive implementation of the Affordable Care Act has made it one of the more successful states in expanding the numbers of individuals with insurance coverage while reducing, for the previously uninsured, the financial burden of health care. As the title of this article indicates, California has proved that Obamacare is not a disaster. But what if California had had a better designed health care financing system with which to work? Say, a single payer system.

* The 3.8 million California residents who remain uninsured would be covered.

* Patients would not be faced with unaffordable deductibles.

* Exchange enrollees would not be facing an average of 13.2% increase in premiums.

* Patients would not be locked into narrow networks, limiting their choice of providers.

* Patients’ health would not be negatively impacted by constant churning of health plans and programs.

* The need to shop premium prices, which increases churning, would go away.

* Patient dollars would no longer be wasted on our profound administrative excesses.

* Employers would be relieved of the burden of administering employee health benefit  programs.

* Since lifetime, comprehensive, public coverage would be initiated at birth automatically, health insurance plans and their exchanges would go away.

California is to be commended for accomplishing what they have within the limitations of our multi-payer system as modified by the Affordable Care Act. But is this the best we could have done?

California bears responsibility for not leading the nation in demanding enactment of a single payer national health program – an improved Medicare for all. All that work for a comparatively small gain, when we could have had a much simpler, more equitable, more effective, more efficient and more affordable health care financing system.

The disaster is that we didn’t move forward with single payer. In this case, disaster relief is only a matter of political will.

Insurance Churning Rates For Low-Income Adults Under Health Reform: Lower Than Expected But Still Harmful For Many

By Benjamin D. Sommers, Rebecca Gourevitch, Bethany Maylone, Robert J. Blendon and Arnold M. Epstein
Health Affairs, October 2016

Abstract

Changes in insurance coverage over time, or “churning,” may have adverse consequences, but there has been little evidence on churning since implementation of the major coverage expansions in the Affordable Care Act (ACA) in 2014. We explored the frequency and implications of churning through surveying 3,011 low-income adults in Kentucky, which used a traditional expansion of Medicaid; Arkansas, which chose a “private option” expansion that enrolled beneficiaries in private Marketplace plans; and Texas, which opted not to expand. We also compared 2015 churning rates in these states to survey data from 2013, before the coverage expansions. Nearly 25 percent of respondents in 2015 changed coverage during the previous twelve months—a rate lower than some previous predictions. We did not find significantly different churning rates in the three states over time. Common causes of churning were job-related changes and loss of eligibility for Medicaid or Marketplace subsidies. Churning was associated with disruptions in physician care and medication adherence, increased emergency department use, and worsening self-reported quality of care and health status. Even churning without gaps in coverage had negative effects. Churning remains a challenge for many Americans, and policies are needed to reduce its frequency and mitigate its negative impacts.

http://content.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Churning – moving in and out of health plans, whether or not there are gaps in coverage – is clearly bad for the patient’s health.

In this study, the rate of churning did not differ between states with different approaches to implementing the Affordable Care Act. In a multi-payer system, churning automatically occurs due to factors such as changes in employment, changes in income and program eligibility, changes in residency, changes in plan availability, and changes because of administrative disruptions.

Regardless of the reason, churning resulted in “disruptions in physician care and medication adherence, increased emergency department use, and worsening self-reported quality of care and health status.” Negative effects occurred even without gaps in coverage.

Need it be said? A single payer national health program would totally eliminate churning and thus would improve the health of Americans caught up in the churning trap. If this were the only reason for enacting a single payer system, it would certainly be worth doing.