Reforming the U.S. health care system

The benefits pharmacy benefit managers manage are usually not for consumers

Middlemen Who Save $$ On Medicines — But Maybe Not For You ( Francis Ying, Julie Appleby, Stephanie Stapleton, Kaiser Health News, 8-2-17) Pharmacy benefit managers — companies that are often unnoticed and even less understood by most consumers — hold an important place in the prescription drug-pricing pipeline. In this video, Kaiser Health News examines the role of PBMs in the drug pricing pipeline -- detailing the emergence of these multimillion-dollar corporations and the impact they have on medication costs and patients’ access to these treatments. The big three PBMs are: CVS Caremark, Optum RX, and Express Scripts. They make money and get rebates, may favor the meds with the biggest rebates (for them, not us), and apparently do not pass savings on to consumers.
The opioid epidemic: It’s time to place blame where it belongs (Ronald Hirsch, Kevin MD, 4-6-16) "I call on Congress to hold hearings and compel the top executives from Purdue Pharmaceutical, the Joint Commission, Press Ganey, and CMS and hospital administrators to appear and testify as to their role in this national epidemic." (Charles Ornstein, ProPublica, 9-26-17) The move follows a story by ProPublica and The New York Times detailing how insurance companies and pharmacy benefit managers have made it easier to get opioid painkillers than less risky alternatives. "Only one-third of the people covered, for example, had any access to Butrans. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval from the insurer for them. Moreover, we found that many plans make it easier to get opioids than medications to treat addiction, such as Suboxone."
Bernie Sanders calls for federal investigation of insulin makers for price collusion (Ed Silverman, STAT, 11-3-16) In his latest attack on the pharmaceutical industry, Senator Bernie Sanders has asked the Department of Justice and the Federal Trade Commission to investigate three insulin makers for price collusion. The practice known as shadow pricing was first reported by Bloomberg News. “The original insulin patent expired 75 years ago. Instead of falling prices, as one might expect after decades of competition, three drug makers who make different versions of insulin have continuously raised prices on this life-saving medication,” the lawmakers wrote. “In numerous instances, price increases have reportedly mirrored one another precisely.” Drug makers in general argue that they have to raise prices in order to give substantial rebates to pharmacy benefit managers, which are the middleman that negotiate with health plans.

United Healthcare To Buy Pharmacy Benefit Manager Amid Growing Concerns About Cutting-Edge Drug Costs The nation's largest insurer will acquire Catamaran Corp. for about $12.8 billion. Pharmacy benefit managers are viewed as a key element in efforts to negotiate the prescription drug prices paid by customers.
UnitedHealth to acquire pharmacy benefits firm Catamaran in $12-billion deal (Stuart Pfeifer, Los Angeles Times, 3-30-15) UnitedHealth Group Inc., the largest health insurer in the United States, agreed to spend more than $12 billion to buy an Illinois pharmacy benefits management firm, saying it is seeking to control the rising costs of prescription drugs. Whether the acquisition will benefit consumers may be an issue in the months ahead. Some experts suggest that the deal may weaken competition and prompt opposition from the Federal Trade Commission. Pharmacy benefit managers help negotiate with drug companies the prices of prescription drugs on behalf of employers, insurers and government agencies. The largest players in the industry include Express Scripts and CVS/​Caremark..;Unconvinced is David Balto, a Washington antitrust lawyer and former policy director for the Federal Trade Commission. He said the acquisition could reduce competition and lead to higher prices for consumers. "I think this merger will face very stiff head winds at the FTC," Balto said. "A dominant insurance company is going to extinguish one of the paltry sources of competition in the market."
PBM Express Scripts Did Not Pass Along Rebates to New York’s Employee Health Program, Lawsuit Alleges (Kaiser Health News, 6-11-09) New York Attorney General Eliot Spitzer (D) on Wednesday filed suit against pharmacy benefit manager Express Scripts -- which manages drug benefits for New York state employees - alleging the company defrauded the state of up to $100 million over five years, USA Today reports (Appleby, USA Today, 8/​5). Spitzer and state Civil Service Commissioner Daniel Wall allege Express Scripts violated its $600,000 contract to negotiate lower drug prices for state workers and pass the rebates on to the state (AP/​Long Island Newsday, 8/​5). Spitzer said that Express Scripts officials were using their "role as an intermediary not to live up to their fiduciary duty to their clients but to line their own pockets.
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Repeal, replace, and various proposed alternatives to Obamacare (ACA)

Koch Groups Move On From Health-Care Fight (Julie Bykowicz, WSJ, 1-28-18) The billionaire Koch brothers’ political organization spent more than $200 million in the past decade on what official Tim Phillips calls “without question our biggest policy defeat,” the quest to kill the Affordable Care Act. Now, the network of donors is turning its attention to the more urgent matter of protecting Republican majorities in both chambers of Congress this fall. “You can’t pout; you have to move on,” said Mr. Phillips, the longtime president of Americans for Prosperity, the Kochs’ primary vehicle for advocating on health care and other state and federal policies. “We won’t hold the majority forever, and we have many more policy goals.”
Doctors: No (James Hamblin, The Atlantic, 9-21-17) Physicians rarely agree on anything as strongly as they do that the Graham-Cassidy health-care bill would do harm to the country and should be defeated. This is a call for the entire profession to clarify its fundamental principles. The American Medical Association 'this week asks only that Congress “work in a bipartisan, bicameral manner to increase the number of Americans with access to quality, affordable health insurance.”
Lawmakers Hunt the Capitol for an Obamacare Bill Moved Between Secret Locations (Paul McLeod, BuzzFeed, 3-2-17) Speaker Paul Ryan says Republicans are unified behind the secret Obamacare replacement plan, but lawmakers were searching in vain for the bill on Thursday. The committee working on the bill says it is still a work in progress.
Where things stand on repeal-and-replace – or stabilize-and-repair (Joanne Kenen, Covering Health, 10-23-17) If you've been trying to figure out where President Trump stands on repairing the Affordable Care Act - good luck. He literally has changed positions in as little as 11 minutes - reporters have clocked it. And fact-checking does not support his assertions.
Trump Administration Guiding Health Shoppers to Agents Paid by Insurers (Robert Pear, NY Times, 11-11-17) "After cutting funds for nonprofit groups that help people obtain health insurance under the Affordable Care Act, the Trump administration is encouraging the use of insurance agents and brokers who are often paid by insurers when they help people sign up. The administration said in a recent bulletin that it was “increasing partnerships” with insurance agents and viewed them as “important stakeholders” in the federal marketplace, where consumers are now shopping for insurance. But some health policy experts warned that a shift from nonprofit groups, which are supposed to provide impartial information, to brokers and agents, who may receive commissions for the plans they recommend, carries risks for consumers....Consumers can get contact information for agents and brokers, as well as nonprofit groups known as navigators, by clicking on “Find Local Help” on
U.S. Judge Questions Trump Administration On Birth Control Rules (Dan Levine, Reuters, NYTimes, 12-12-17) New rules from the Department of Health and Human Services announced in October let businesses or non-profit organizations lodge religious or moral objections to obtain an exemption from the Obamacare law's mandate that most employers provide contraceptives coverage in health insurance with no co-payment. The move from President Donald Trump's administration kept a campaign pledge that pleased the Republican's conservative Christian supporters. California and several other states with Democratic attorneys general promptly sued and asked for the policy to be blocked while its legality is decided. In its reasoning for the move, the administration said among other things that mandating birth control coverage could foster "risky sexual behavior" among teens and young adults. It overturned the Obama administration's view that the birth control requirement was necessary to meet the government's "compelling interest" to protect women's health.
Donald Trump's Obamacare Whiplash (Russell Berman, The Atlantic, 10-18-17) Does the president want Congress to strike a bipartisan deal on health care? As with so many other issues, it depends on the hour.
Chris Murphy's brief and brilliant summary of the Republican's disaster of a health care proposal (YouTube, 6-23-17)
Jimmy Kimmel: new Obamacare repeal bill flunks the Jimmy Kimmel Test (Dylan Scott, Vox, 9-19-17) Jimmy Kimmel became an unlikely figure in the Republican health care debate a few months ago when he reached an accord of sorts with Sen. Bill Cassidy (R-LA), setting standards that any bill to repeal and replace Obamacare should meet. The late-night host had been outspoken about his newborn son’s open-heart surgery. He and Cassidy discussed what became called the “Jimmy Kimmel test.” Cassidy has used that term repeatedly throughout the past few months of the health care debate. Kimmel defined it like this: “No family should be denied medical care, emergency or otherwise, because they can't afford it.” The host ticked through related requirements that he said Cassidy had set for his own health care plan:
Provide health coverage for everyone
Prevent discrimination against people with preexisting conditions
Lower premiums for middle-class Americans
Prohibit lifetime caps on insurance benefits
“The new bill does none of those things,” Kimmel said on Tuesday night. “Not only did Bill Cassidy fail the Jimmy Kimmel test, he failed the Bill Cassidy test.”
5 Ways the Graham-Cassidy Proposal Puts Medicaid Coverage At Risk (Kaiser Family Foundation, 9-18-17)
Compare Proposals to Replace the Affordable Care Act (of the six proposals made so far, you can compare three at a time. Analysis provided, side-by-side columns.
State-by-State Estimates of Reductions in Federal Medicaid Funding Under Repeal of the ACA Medicaid Expansion (Rachel Garfield and Robin Rudowitz, KFF, 7-19-17)
August 2017: The Politics of ACA Repeal and Replace Efforts (Kaiser Health Tracking Poll, August 2017) The August Kaiser Health Tracking Poll finds that the majority of the public (60 percent) say it is a “good thing” that the Senate did not pass the bill that would have repealed and replaced the ACA. Since then, President Trump has suggested Congress not take on other issues, like tax reform, until it passes a replacement plan for the ACA, but six in ten Americans (62 percent) disagree with this approach, while one-third (34 percent) agree with it.
The Most Important Health Officials You’ve Never Heard Of: State Insurers In Hot Seat (Julie Appleby, KHN, 9-6-17) With insurance premiums rising and national efforts at health reform in turmoil, a group of 50 state bureaucrats whom many voters probably can’t name have considerable power over consumers’ health plans: state insurance commissioners. Most commissioners have the authority to reject premiums or modify rates they deem excessive. They also have the power of their bully pulpit. But critics worry that in some states the position is a revolving door with industry, moving them to do less than they could. Commissioners’ regulatory powers vary by state, depending on the rules state legislators have put in place for them to enforce.
What happens when you treat health care like a soap opera (Vox, 6-7-17, on YouTube) Carlos Maza of Vox talks about how cable news treats health care policy like a soap opera rather than explain the issues and how it affects their viewers. Why don't the journalists talk to actual experts on health policy? When you treat big Congressional votes like soap operas, you train audiences to think about politics, not policies. Note how on CNN Town Hall segment the people in the audience ask question after question about the things that matter to them, questions that journalists (notably Wolf Blitzer) aren't asking.
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Schumer: Republicans have been in touch about health care (Jimmy Vielkind, Politico, 7-31-17) “No one thought Obamacare was perfect — it needs a lot of improvements,” Schumer (D-N.Y.) said after an unrelated news conference at Albany Medical Center. “We’re willing to work in a bipartisan way to do it. What we objected to was just pulling the rug out from it and taking away the good things that it did: Medicaid coverage for people with parents in nursing homes, for opioid treatment, for kids with disabilities, pre-existing conditions.”
Don’t Assume That Private Insurance Is Better Than Medicaid (Aaron E. Carroll and Austin Frakt, The Upshot, 7-12-17) It’s far from proven that Medicaid is worse than private insurance. A lot depends on what kind of insurance is compared with Medicaid, and how they are compared. A RAND study randomly assigned 2,750 families to one of four health plans. One had no cost-sharing whatsoever — kind of like Medicaid. The other three had cost-sharing (money people had to pay out-of-pocket for care) at levels of 25, 50 or 95 percent — capped at $1,000 at the time, which is about an inflation-adjusted $6,000 today. This level of personal liability acts like a deductible, making the plan with a 95 percent level of cost-sharing comparable to a “Bronze” plan on the Affordable Care Act’s exchanges today. The RAND study found that the more cost-sharing was imposed on people, the less health care they used — and therefore the less was spent on their care. The study also found that, over all, people’s health didn’t suffer from lower health care use and spending. But even if most people are healthy, some are not (and particularly those on Medicaid). In the RAND study, poorer and sicker people — exactly the kind more likely to be on Medicaid — were slightly more likely to die with cost-sharing. The best recent evidence we have is that giving free care to poorer and sicker people improves health and saves lives. It is reasonable to conclude that switching them to a plan with high cost-sharing (even a private plan) would do the opposite.
Report on Cruz amendment shows how one option would affect insurance market (Joseph Burns, Covering Health, Association of Health Care Journalists, 8-4-17) "As Robert King explained in The Washington Examiner, the amendment would allow insurers to sell cheap, bare bones plans on the individual market, including the ACA’s Marketplace, as long as they sold at least one plan that met Obamacare’s more-stringent requirements. Plans offered outside of the exchanges would be exempt from some of the ACA’s more-stringent rules, such as those regarding guaranteed issue, the prohibition against excluding individuals with pre-existing conditions, and the requirement to offer essential health benefits, Avalere said. Sicker Americans who have subsidized health insurance likely would remain in ACA-compliant plans, the Avalere analysis predicted. At the same time, younger, healthier Americans who do not have subsidized insurance would shift to non-ACA-compliant plans. Such market segmentation would undermine one of the goals of the ACA, which is to have younger, healthier people in the risk pool to help cover the costs of older, sicker individuals."
Health reporters: Secrecy, speed, and Twitter changed coverage of GOP bill (Trudy Lieberman, CJR, 7-10-17) "What we’re seeing is a whole other magnitude of deception. It’s an attempt to portray the bill as the opposite of what it is....The volume of information coming in is so enormous and often contradictory that it’s hard to synthesize into a story, and to keep track of what’s being said. “In 2009 [with Obamacare] the goals were very clear—cover more people and reduce costs,” she says. “When you talk to Republicans and ask what’s the point of their bill, they say, ‘We need a bill that can get 51 votes.’”
Candidate for Md. governor shares son’s health story, slams Congress (Josh Hicks, WaPo, 7-26-17) Ross accused “privileged members of Congress” of trying to trade other people's access to health care for tax cuts that would benefit the wealthy--a sign of a damaged America.
In Clash Over Health Bill, a Growing Fear of ‘Junk Insurance’ (Reed Abelson, NY Times, 7-15-17) "Plans with much lower premiums are certain to be attractive to many people. But Elizabeth Imholz, a health policy expert for Consumers Union, warned, “The reality for consumers is that they can be stuck with huge, unexpected out-of-pocket costs.”...“These plans lacked the necessary transparency that would give consumers an idea of what they were actually purchasing,” said Ashley Blackburn, a senior policy analyst with Community Catalyst, a consumer advocacy group.
GOP Failure to Replace the Health Law Was Years in the Making (Julie Rovner, NY Times, 7-18-17) " Republicans’ inability to overhaul the health law should not come as much of a surprise. Here are some of the reasons: 1. It’s hard to take things away from people. 2. Republicans have long been divided on health care. 3. Presidential leadership on hard issues is important. 4. Health care is complicated. Really. 5. Some parts of the ACA really are popular, even among Republicans. "In fact, in recent months, the Affordable Care Act has been growing in popularity. Most polls show it more than twice as popular as GOP efforts to overhaul it."
How the Senate Health Care Bill Failed: G.O.P. Divisions and a Fed-Up President (Jennifer Steinhauer, Glenn Thrush, andRobert Pear, NY Times, 7-18-17) "The Senate bill, which faced a near-impossible path forward after the House passed its version of the legislation in May, was ultimately defeated by deep divisions within the party, a lack of a viable health care alternative and a president who, one staff member said, was growing bored in selling the bill and often undermined the best-laid plans of his aides with a quip or a tweet."
Follow The Money: Drugmakers Deploy Political Cash As Prices And Anger Mount (Jay Hancock, Elizabeth Lucas, and Sydney Lupkin, Kaiser Health News, 7-24-17) Two federal investigations — one examining opioid sales, another about a multiple sclerosis drug whose price had soared to $34,000 a vial — were only part of the troubles Mallinckrodt faced as the year began. Wall Street worried that Medicare might reduce the half-billion dollars it was spending yearly on a Mallinckrodt drug with limited evidence of effectiveness. This year, a critical and risky one for drug companies, the industry as a whole is ratcheting up campaign donations and its presence on Capitol Hill. Chart shows Rep. Paul Ryan collecting $82,750 in such donations in first quarter.
• How do drug firms respond? Martin Shkreli declines to answer house panels questions. As the New York Times reports, "The hearing, about drug prices, focused on the actions of Turing and another company, Valeant Pharmaceuticals International, which acquired the rights to decades-old drugs and increased their prices by huge amounts overnight."...'Little of substance was discussed on what to do about the increases. Instead, lawmakers from both parties took turns berating Mr. Shkreli, Turing and Valeant with words like “scandal,” “disgusting” and “disgraceful.”
A Simple Guide to the GOP Health Care Bills (Alissa Scheller, Jeffrey Young, NY Times, 6-22-17. Here's a simple guide to how they would change Obamacare.
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My Life With a Pre-Existing Condition (Nomi Kane, The Nib, 7-9-17) In the high-risk health insurance pool that Republicans say will be available to Americans with pre-existing conditions, the cost of coverage is way higher than coverage for others. Under that system, states can opt-out of Community Rating rules, allowing insurance companies to inflate premiums for patients with pre-existing conditions. While they can't technically deny coverage to such patients, they can price coverage so high people can't afford it. The Kaiser Family Foundation estimates that 23% of Americans under the age of 65 live with a declinable pre-existing condition.
“There will be deaths”: Atul Gawande on the GOP plan to replace Obamacare (Julia Belluz, Vox, 6-23-17) Gawande and experts Benjamin Sommers and Katherine Baicker reviewed the research on what taking health insurance away means for Americans. “The bottom line,” Gawande told Vox, “is that if you’re passing a bill that cuts $1.2 trillion in taxes that have paid for health care coverage, there’s almost no way that does not end up terminating insurance for large numbers of people....If you are doing that, then there’s clear evidence that you will be harming people. You will be hurting their access to care. You will be harming their health — their physical health and mental health. There will be deaths."
Susan Collins won’t back down on health care (Victoria McGrane, Boston Globe, 6-19-17) Senator Susan Collins and several other key moderates are exerting outsized influence on the debate — and they show little sign of backing down. They worry that the House Republican plan would strip insurance from millions of Americans with preexisting conditions and inflict unacceptably deep cuts on Medicaid. On the opposite end of the spectrum, Paul and other Senate conservatives want to eradicate all vestiges of Obama’s Affordable Care Act, including its insurance market interventions and costly Medicaid expansion. They’ve spent seven years promising voters this opportunity would come.Another key disagreement is how generous the tax credits for low-income people should be, with another stark moderate-conservative divide.
Senate Unveils Bill to Repeal and Replace ACA (Robert Lowes, Medscape, 6-22-17) "A Senate Republican bill to repeal and replace the Affordable Care Act (ACA) that debuted today is a gentler version of what the House passed last month in many respects and a harsher version in others. Both bills would end funding for Medicaid expansion in 31 states and Washington, DC, but while the House bill cuts it off entirely in 2020, the Senate bill would phase it out over 3 years, beginning in 2021. That's meant to ease the financial pain for states and beneficiaries. When it comes to premium subsidies for individual and family health plans sold on the ACA marketplaces, or exchanges, the Senate bill would base them on income and age, as the ACA does. The House bill, which links the subsidies solely to age, translates into far less assistance for older, low-income Americans than what they now receive under the ACA." And more. "Republicans designed the bill under Senate rules to be filibuster-proof, meaning that it requires only a simple majority to pass (60 votes are needed to overcome a filibuster). Republicans control 52 seats in the Senate, but they need only 50 of them to pass the ACA repeal-and-replace legislation because Vice President Mike Pence would break the tie in their favor."
• “Our lives and liberty shouldn’t be stolen to give a tax break to the wealthy. That’s truly un-American,” said one disability advocate demonstrating outside Senate Majority Leader Mitch McConnell's office (Disability advocates arrested during health care protest at McConnell’s office by Perry Stein, WaPo, 6-22-17)
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The Republicans’ Jekyll-and-Hyde Health Care Plan (Drew Altman, NY Times, 6-22-17) "The Senate Republicans’ health bill that was made public today is a Jekyll-and-Hyde plan: in some ways kinder than the House Republican plan, and in some ways meaner, to use President Donald Trump’s yardstick. Overall the plan will benefit the wealthy and young adults, but hurt larger numbers of people who are old or poor....And both plans will cause more Americans to go without coverage and struggle with health care bills. Both bills are likely to increase the number of Americans having problems paying medical bills — about a quarter of the public today. For voters, that is the single most important barometer of the performance of the health care system."
Deciphering CBO’s Estimates On The GOP Health Bill (Julie Rovner, Kaiser Health News, 3-13-17) The federal government’s budget experts estimate that the Republican plan would reduce the deficit but dramatically drive up the number of uninsured. To keep up with this excellent coverage, go to Repeal and Replace Watch (Kaiser Health News)
How ACA Repeal and Replace Proposals Could Affect Coverage and Premiums for Older Adults and Have Spillover Effects for Medicare (Tricia Neuman, Karen Pollitz, and Larry Levitt, Kaiser Health News, 6-5-17) The House-passed American Health Care Act (AHCA) would make a number of changes to current law that would result in a 5.1 million increase in the number of uninsured 50-64-year-olds in 2026, according to CBO’s updated analysis.
The most devastating paragraph in the CBO report (Sarah Kliff, Vox, 5-24-17). This is it: "People who are less healthy (including those with preexisting or newly acquired medical conditions) would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law, if they could purchase it at all — despite the additional funding that would be available under H.R. 1628 to help reduce premiums. As a result, the nongroup markets in those states would become unstable for people with higher-than-average expected health care costs."
And let's be clear: "The Republican plan achieves lower premiums by breaking the promise to protect preexisting conditions. Premiums drop because sick people who need coverage more would drop out of the marketplace. This plan does not deliver on that promise in any way, shape, or form."
Affordable Care Act Gains Majority Approval for First Time (Jim Norman, Gallup, 4-4-17) A majority of Americans approve of the Affordable Care Act for the first time since it was enacted in 2010. Still, 40% want significant changes.
G.O.P. Bill Would Make Medical Malpractice Suits Harder to Win (Robert Pear, NY Times, 4-15-17) Low-income people and older Americans would find it more difficult to win lawsuits for injuries caused by medical malpractice or defective drugs or medical devices under a bill drafted by House Republicans. The bill would impose new limits on lawsuits involving care covered by Medicare, Medicaid, or private health insurance subsidized by the ACA. The limits would apply to some product liability claims, as well as to medical malpractice lawsuits involving doctors, hospitals and nursing homes. It would limit frivolous lawsuits, but it would also take rights away from people served by federal health programs, including patients harmed by horrific medical mistakes. It would apply even in cases of “egregious medical error,” such as when a foreign object is left inside a patient’s body or surgery is performed on the wrong body part.
This is what dying without health insurance looks like (Pamela Rafalow Grossman, Garnet News, 5-5-17) GOP wants to take us back to the days when the law favored industry profits over patients
Why deductibles would rise under the GOP health care plan (Drew Altman, Kaiser Family Foundation, Axios, 3-22-17)
Republican Health Proposal Would Undermine Coverage for Pre-existing Conditions (Margot Sanger-Katz, NY Times, 4-4-17) Proposed changes from conservative lawmakers known as the Freedom Caucus, after failure to pass of first Republican alternative to ACA, would effectively cast aside the Affordable Care Act’s pre-existing conditions provision. States could also opt out of required minimum coverage and "do away with a rule that requires insurance companies to charge the same price to everyone who is the same age, a provision called community rating." "The result could be a world where people with pre-existing conditions would struggle to buy comprehensive health insurance — just like before Obamacare."
Don't expect Medicaid work requirements to make a big difference (Drew Altman, KFF, Axios, 3-3-17) Liberals and conservatives have irreconcilable differences of policy and principle over the issue of Medicaid "work requirements." But their impact depends on how they are implemented and is likely to be very small — because most people on Medicaid who can work already are working.
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Latest repeal bid may gut one of Obamacare’s most popular provisions (Jennifer Habercorn, Politico, 4-4-17) Conservative Republicans make sneak attack on safeguards for people with pre-existing conditions. They "argue they are protecting people with pre-existing conditions while creating a framework that enables state officials to gut those very protections. White House officials and members of the House Freedom Caucus are discussing giving states the option of a waiver from a key Obamacare protection — called community rating — as part of their last-ditch effort to revive the repeal effort. Community rating is a wonky term for barring insurers from charging sick people more than healthy individuals for the same insurance policy. Without community rating, for instance, insurers could theoretically charge a healthy person $100 per month for a health plan and a sick person $10,000 per month for the same coverage."
US Public Opinion on Health Care Reform, 2017 (Visualizing Health Policy infographic, 3-29-17) As of March 2017:
---"The largest percentage of Democrats and Republicans give top priority to lowering out-of-pocket costs for health care."
---63% of Republicans vs 21% of Democrats view Affordable Care Act (ACA) repeal as a top priority
---67% of Democrats vs 55% of Republicans view lowering the cost of prescription drugs as a top priority
---49% of the public view the ACA favorably and 44% view it unfavorably
---The majority of individuals in both political parties feel positively about many ACA provisions, including allowing states to expand Medicaid and prohibiting denial of insurance coverage due to preexisting conditions.
---Only 21% of Republicans and 30% of independents favor the individual mandate that requires paying a fine in the absence of health insurance.
---The public is divided on what should happen to the ACA: just more than half say they don’t want lawmakers to repeal the law, about a quarter want a repeal only after replacement plan details are announced, and only 19% favor an immediate repeal in advance of a replacement plan
---64 percent of the public supports guaranteeing a certain level of health coverage for seniors and low-income people, even if the federal government’s spending and role in health care increases.
Inside the GOP’s Health Care Debacle (Tim Alberta, Politico, 3-24-17) Eighteen days that shook the Republican Party—and humbled a president. By and large, Trump’s first attempt to corral the GOP Congress failed miserably and threatens to paralyze his first-year policy agenda. All this obscures an uncomfortable question for Republicans as they ponder how it is that they control both houses of Congress and the presidency, and yet were unable to get rid of a hated law they spent seven years attempting to destroy. Obamacare, that great white whale Republicans had long hunted—and hoped to harpoon on its seven-year anniversary Thursday—would remain “the law of the land” due to the GOP's inability to function as a “governing body,” the speaker of the House announced.

Trump’s colossal failure (Jennifer Rubin, WaPo, 3-24-17) "While Ryan loses stature, Trump does not necessarily gain any. Previously he claimed victory merely by decimating the opposition (GOP challengers, Hillary Clinton, a reporter, etc.). Now Ryan’s loss is not Trump’s gain. (It might be Stephen K. Bannon’s gain, but not Trump, who needs to show results.)"
In Trump country, voters know who’s to blame for the health bill debacle. And it’s not their president (Max Siegelbaum and David Steen Martin, STAT, 3-24-17) Yet a day of talking to Trump voters across the country underscored just how tough it will be to ever work out details that appeal to all the fractious elements of his coalition.
We Fact-Checked Lawmakers' Letters to Constituents on Health Care (co-published by ProPublica, Kaiser Health News, Stat, and Vox, 3-22-17) An important clarification of which praise and criticism is factually wrong or misleading, and which true. Letters citizens are getting from their legislators from both parties often don't stand up to fact-checking. Similar points made here: 9 health reform lies Congress members are telling their constituents (Charles Ornstein and Julia Belluz, Vox, 3-22-17)
Fewer Americans Would Be Insured With G.O.P. Plan Than With Simple Repeal (Margot Sanger-Katz, NY Times, 3-21-17) "Getting rid of the major coverage provisions and regulations of Obamacare would cost 23 million Americans their health insurance, according to another recent C.B.O. report. In other words, one million more Americans would have health insurance with a clean repeal than with the Republican replacement plan, according to C.B.O. estimates....The people who would end up without health insurance are slightly different in the two cases. The current bill would cause more people to lose employer insurance, while a straight repeal bill would most likely cause more people who buy their own coverage to become uninsured. A simple repeal would be worse for Americans with pre-existing conditions, but the current bill would be worse for older Americans who are relatively healthy. Both approaches would lead to major reductions in the number of Americans covered by Medicaid."
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The fundamental problem with the American Health Care Act (Marshal Chin, MD, MPH, Kevin MD, 3-15-17) The AHCA tolerates significant health disparities and would make them worse. "The most vulnerable Americans are at highest risk for not being able to afford health insurance and losing access to care. Older persons not yet eligible for Medicare, the poor, and people with multiple chronic medical conditions are at highest risk of losing insurance. The proposed tax credits are insufficient to make health insurance affordable for many of the poor, premiums for the chronically ill on the health exchanges would likely rise significantly, and per capita Medicaid block grants to states would probably result in major cuts to health care funding for the underserved and cannibalization of funds for non-health purposes such as closing state budgetary deficits. Many people would be harmed and would suffer. The Congressional Budget Office estimates that 24 million more Americans would be uninsured by 2026."
The Parts of Obamacare House Republicans Will Keep, Change or Discard (Haeyoun Park and Margot Sanger-Katz, NY Times, 3-6-17) Excellent chart showing which parts of the Affordable Care Act House Republicans would keep, repeal, or change (compared with how things are at end of Obama's term of office). It fundamentally changes how health care is financed for people who do not have insurance through work, and it eliminates the mandate requiring most Americans to have health insurance, a centerpiece of the Affordable Care Act (considered essential to spread out risk for most unhealthy citizens).
Ryan Clings to Core of GOP Health Bill as Opposition Mounts (Billy House, Anna Edgerton, and Sahil Kapur, Bloomberg, 3-16-17) With a steady trickle of Republicans coming out against the bill, Ryan is sending the message he won’t drop any of its four main elements -- refundable tax credits, health savings accounts, the phaseout of Medicaid expansion and the ban on insurers denying coverage over pre-existing conditions -- according to a senior Republican aide.
How Republicans and Democrats can both keep their promises on health care (Darius Lakdawalla and Anup Malani, The Conversation, 3-2-17) Republicans who want to repeal the Affordable Care Act (ACA) emphasize the importance of patient choice and market efficiency. Democrats opposing repeal focus on the need to protect the most vulnerable. President Trump asked for a plan that would “expand choice, increase access, lower costs, and at the same time, provide better health care.” Here's a four-step market-based proposal consistent with those aims: (1) Clear the deck. (2) Stop insurance price regulation. (3) 3. Subsidize insurance premiums for the poor and especially poor households burdened by illness. (4) 4. Switch to long-term insurance contracts. Needless to say, best to read the whole piece.
No Magic in How G.O.P. Plan Lowers Premiums: It Pushes Out Older People (Margot Sanger-Katz, NY Times, 3-14-17) On premiums alone, prices would rise by more than 20 percent for the oldest group of customers. By 2026, the budget office projected, “premiums in the nongroup market would be 20 percent to 25 percent lower for a 21-year-old and 8 percent to 10 percent lower for a 40-year-old — but 20 percent to 25 percent higher for a 64-year-old.”

"But the change in tax credits matters more. The combined difference in how much extra the older customer would have to pay for health insurance is enormous. The C.B.O. estimates that the price an average 64-year-old earning $26,500 would need to pay after using a subsidy would increase from $1,700 under Obamacare to $14,600 under the Republican plan.""By 2026, the uninsured rate for those 50 to 64 earning less than about $30,000 would more than double, from around 12 percent to around 30 percent. Those older customers who would lose out on insurance coverage are more likely than the young customers who would buy it to need help paying big medical bills."
Say What? Fact-Checking The Chatter Around The GOP Health Bill (Julie Rovner, Kaiser Health News, 3-13-17) Five items commonly confused (and DO go to the article for a full explanation):
1) The GOP bill would replace the health law’s subsidies with tax credits. (Not really. It would replace the Affordable Care Act’s tax credits with different tax credits.)
2) 2. Republicans have left popular provisions of the ACA in their bill because they are popular. (Not necessarily. They're keeping the parts that allow adult children to stay on their parents’ health plans until they turn 26 and that prohibit insurers from rejecting or charging more to people with preexisting health conditions because the budget rules Congress is using to avert a filibuster in the Senate forbid them from repealing much of the ACA that does not affect government spending.
3) 3. This bill is one part of a three-part effort to remake the health law. (True, and the second and third parts will be more difficult to get passed, requiring considerable time and many legal proceedings.
4) The bill’s Medicaid provisions just scale back the program’s expansion. ("In truth, the Medicaid portions of the GOP bill would fundamentally restructure the Medicaid program. The Republican bill would, for the first time ever, limit the amount the federal government provides to states for Medicaid spending. The left-leaning Center on Budget and Policy Priorities estimates that states could be on the hook for an additional $370 billion over 10 years if the bill becomes law.
5) 5. The GOP bill is a huge tax break for the wealthy. (Technically true, because they are repealing nearly all the taxes that helped pay for the health law’s benefits, and the Democrats had targeted many of those to higher-income people.)
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How the Republican Health Plan Could Affect You (Haeyoun Park, Margot Sanger-Katz, and Sergio Pecanha, NY Times, 3-12-17) Excellent scenarios, showing when you might benefit (and how) and when not (and how not).
Rep. Joe Kennedy III forces Paul Ryan to admit that the Republican House plan excludes coverage for mental illness (Daily Kos, 3-9-17)
Congressional Budget Office: 24 million more uninsured under GOP bill over a decade (Peter Sullivan and Jessie Hellmann, The Hill, 3-13-17) The CBO report finds that the 24 million people would become uninsured by 2026, largely due to the proposed changes in Medicaid. The bill both ends the extra federal funds for the expansion of Medicaid and caps overall federal spending for the program, both of which CBO says would lead to people losing coverage. The report finds 7 million fewer people would be insured through their employers by 2026, both because some people would choose not to get coverage and some employers would decline to offer it. CBO finds that people's out-of-pocket costs, including deductibles, "would tend to be higher" because of a loosening of requirements on insurers. Deductibles would be higher and financial assistance for low-income people available under ObamaCare to help them pay their deductibles would be repealed. "n positive news for Republicans, the CBO finds the legislation would decrease the federal deficit by $337 billion over the 2017-2026 period, mostly through the elimination of ObamaCare’s Medicaid expansion and the law’s subsidies to help people buy insurance."
The American Health Care Act: the Republicans’ bill to replace Obamacare, explained (Sarah Kliff, Vox, 3-6-17) Under legislation proposed by the House, the GOP health care plan takes from poor Americans, to give to richer ones. Some of Obamacare’s signature features are gone immediately, such as the tax on people who don’t purchase health care. The replacement plan benefits people who are healthy and high-income, and disadvantages those who are sicker and lower-income. The bill looks a lot more like Obamacare than previous drafts. AHCA would end Medicaid expansion in 2020. The AHCA bans discrimination against those with preexisting conditions — but charges more to people who have a break in coverage. (Buy insurance later and you pay a surcharge. This might end up having unintended consequences, because only the people who really need insurance — and who have high medical costs — may want to pay the surcharge. That could drive up premiums for everybody. The AHCA would let insurers charge older enrollees up to five times more than young enrollees.
Examining The House Republican ACA Repeal And Replace Legislation (Timothy Jost, Health Affairs blog, 3-7-17)
No Wonder the Republicans Hid the Health Bill (NY Times Editorial, 3-7-17) The bill they released on Monday would kick millions of people off the coverage they currently have. So much for President Trump’s big campaign promise: “We’re going to have insurance for everybody” Read the details!
Who benefits from Health Savings Accounts (HSAs)?
G.O.P. Health Bill Faces Revolt From Conservative Forces (Jennifer Steinhauer, NY Times, 3-7-17) "...many of the factions that provided financial and political support to back Republicans who vowed to wipe out the Affordable Care Act are nowhere near satisfied with the option rolled out on Monday....Some conservatives have labeled the House plan “Obamacare lite,” saying it is nearly as intrusive in the insurance market as the law it would replace.In particular, they dislike the delay in getting rid of the law’s Medicaid expansion. They also dislike the tax credits in the Republican plan, which can exceed the amount a consumer actually owes in federal income taxes, meaning that the Internal Revenue Service would be issuing checks to cover insurance premiums. The House plan also maintains many of the demands on insurers that the Affordable Care Act has, including a defined suite of “essential benefits” that all insurers must offer."
Repeal of Health Law Faces a New Hurdle: Older Americans (Robert Pear, NY Times, 3-5-17) Under current rules, insurers cannot charge older adults more than three times what they charge young adults for the same coverage. House Republican leaders would allow a ratio of five to one — or more, if states choose. Before the Affordable Care Act took effect, about 40 states allowed insurers to charge older adults five times as much as young adults. This appears to be consistent with patterns of medical spending. At the same time, the Republican proposal could reduce the financial assistance available to help people pay insurance premiums. The Government Accountability Office, an investigative arm of Congress, has found the marketplaces “vulnerable to fraud” because they do not adequately check the identity of people applying for financial assistance.
How Affordable Care Act Repeal and Replace Plans Might Shift Health Insurance Tax Credits (Cynthia Cox, Gary Claxton, and Larry Levitt, Kaiser Health News, 3-1-17) What is a Tax Credit, and how is it different from a Deduction? Also explained: the difference between a refundable tax credit, an advanceable tax credit, etc. The underlying details of health reform proposals, such as the size and structure of health insurance tax credits, matter crucially in determining who benefits and who is disadvantaged.
Points to consider from the Kaiser Family Foundation. A roundup of key points to consider, and documents to study.
Major Considerations for Repealing and Replacing the Affordable Care Act (Kaiser Family Foundation, or, and the Committee for a Responsible Federal Budget). Video of a public forum to discuss the process and implications of repealing and replacing the Affordable Care Act. The discussion covered the implications of using the budget reconciliation process to repeal the ACA, and what an ACA replacement could mean for health insurance coverage and costs.
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• Nate Beeler's cartoon ‘Past Prologue?’ captures the heart of the Republic dilemma. Looking at a tome called Obamacare in 2010, the Democrat says, "We need to pass it to find out what's in it." Looking at the same tome in 2017, the Republicans say, "We need to repeal it to find out what to replace it with." Having promised to repeal the Affordable Care Act, the Republicans had better come up with something that, if not better, at least won't be worse.
Patience Gone, Koch-Backed Groups Will Pressure G.O.P. on Health Repeal (Jeremy W. Peters, NY Times, 3-5-17) "Saying their patience is at an end, conservative activist groups backed by the billionaire Koch brothers and other powerful interests on the right are mobilizing to pressure Republicans to fulfill their promise to swiftly repeal the Affordable Care Act. Their message is blunt and unforgiving, with the goal of reawakening some of the most extensive conservative grass-roots networks in the country. It is a reminder that even as Republicans control both the White House and Congress for the first time in a decade, the party’s activist wing remains restless and will not go along passively for the sake of party unity. With angry constituents storming town hall-style meetings across the country and demanding that Congress not repeal the law, these new campaigns are a sign of a growing concern on the right that lawmakers might buckle to the pressure." Tim Phillips, the president of Americans for Prosperity, which is coordinating the push with other groups across the Kochs’ political network, says “Our network has spent more money, more time and more years fighting Obamacare than anything else. And now with the finish line in sight, we cannot allow some folks to pull up and give up.”
Six Quick Observations On The Leaked Draft Republican Repeal And Replace Plan (Seth Chandler, Forbes, 2-25-17)
The Health Care Plan Trump Voters Really Want (Drew Altman, NY Times, 1-5-17) "Those voters have been disappointed by Obamacare, but they could be even more disappointed by Republican alternatives to replace it. They have no strong ideological views about repealing and replacing the Affordable Care Act, or future directions for health policy. What they want are pragmatic solutions to their insurance problems. The very last thing they want is higher out-of-pocket costs."
In Red-State Utah, a Surge Toward Obamacare (Abby Goodnough, NY Times, 3-3-17) "From the moment the Affordable Care Act passed in 2010, most elected officials in this sturdily Republican state have been eager to squash it. But something surprising is happening here. Despite deep uncertainty about the law’s future, Utah recorded one of the biggest increases of any state in residents who signed up for coverage under the act this year. Now, the state is seeing a surprising burst of activism against repealing the law — including from Republicans."
The Health Care Plan Trump Voters Really Want (Drew Altman, New York Times, 1-5-17) Altman draws on observations from focus groups in rust belt states of people in the Affordable Care Act (ACA) marketplaces who voted for President-elect Trump and say they may not like their coverage under the ACA but could like Republican replacement plans even less. “The Washington debate is disconnected from the concerns of working people,” he says.
What reporters need to keep in mind as they cover the Obamacare repeal story (Kellie Schmitt, Remaking Health Care, 1-26-17) In a Center for Health Journalism webinar this , leading health policy experts discussed possible replacement proposals and their flaws, and offered suggestions on how journalists can best navigate this huge, fast-moving story. Speakers included MIT’s Jonathan Gruber, an architect of the ACA; American Enterprise Institute's Joseph Antos; and Jennifer Haberkorn, senior health care reporter for Politico. Schmitt reports what panelists said.
Piling on the Affordable Care Act while giving private insurers a free pass (Gary Schwitzer, Center for Health Journalism, 11-3-16) The ACA has become a scapegoat in the media for all kinds of health care woes. "Somebody needs to be the referee on some of the cheap shots flying around on an uneven playing field," says Health News Review's Gary Schwitzer.
With Obamacare in limbo, the transition toward value-based care faces big challenges (David Lansky, Remaking Health Care, 1-24-17) Amid talk of ACA repeal, the signs suggest that the new Congress and president will diminish the emphasis on value-based health care. Here's what reporters should keep in mind.
Remaking Health Care (?Center for Health Journalism) This thoughtful blog explores how health reform is changing the ways in which we pay for and deliver health care in the U.S. On any given week, that could mean a look at how Republican plans to repeal Obamacare could reshape the individual insurance market, how the safety net system is adapting to new financial pressures, or whether Trumpcare will affect the trend of doctors and hospitals merging into ever-larger entities. It also explores health care costs and whether Obamacare or its successor plans can live up the promise to rein them in.
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In growing fight over Medicare, honest language takes a beating (Trudy Lieberman, Remaking Health Care, Center for Health Journalism, 2-9-17) "We are now in another war of words over health care," writes Trudy Lieberman, "and the first casualty, as in any war, is always truth." Look no further than Medicare. Republicans, in a drive to privatize Medicare, are coached to talk about "saving Medicare." GOP spinmeister Frank Luntz warns Republicans "not to talk about 'improving' Medicare because seniors immediately think of new benefits like eyeglasses, hearing aids, lower deductibles, and free prescription drugs, which the GOP had no intention of providing. (In 2003 Congress did pass legislation authorizing a prescription drug benefit, but as part of the deal the law also took a big step toward privatizing the program.)...their real intent to transform Medicare from a social insurance program to a privatized system using commercial insurers to provide all the coverage, much like Obamacare does. The underlying goal: shift more of the responsibility for paying seniors’ health care bills from the federal government to seniors themselves."
Why Obamacare’s promise of an affordable health system is dead (Trudy Lieberman, Center for Health Journalism, 11-21-16 ) Republicans, with their relentless insistence on repealing and replacing the ACA, have reframed the discussion of what’s politically possible to achieve in America at the moment.
How to Repeal Obamacare: A road map for the GOP (Paul Winfree and Brian Blasé, Politico, 11-11-16)
Introduction to Budget “Reconciliation” (David Reich and Richard Kogan, Center on Budget and Policy Priorities, or CBPP, 11-9-16)
Compare Proposals to Replace The Affordable Care Act (Kaiser Health News) President Donald Trump and Republicans in Congress have committed to repealing and replacing the Affordable Care Act (ACA). How do their replacement proposals compare to the ACA? How do they compare to each other?
A Bipartisan Reason to Save Obamacare (Tina Rosenberg, Opinion, NY Times, 1-4-17) "The A.C.A. is more than insurance. As the Times reported Monday, the law is leading a transformation of America’s health care system. It’s a change that nearly everyone, Republicans and Democrats, agrees is desperately needed — and for it to happen, the relevant parts of the A.C.A. must be preserved. The transformation moves health care away from a fee-for-service model, which pays doctors and hospitals according to the number of procedures they do, toward value-based care, which pays based on what helps patients get better." The author then explores various experiments in this new approach that have paid off and should continue to be encouraged.
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Interactive Maps: Estimates of Enrollment in ACA Marketplaces and Medicaid Expansion (Kaiser Health News, 1-10-17)
GOP Rebrands Obamacare Strategy From ‘Repeal’ to ‘Repair (Anna Edney, , Billy House, , and Zachary Tracer,, 2-1-17) Lawmakers advised to shift to friendlier Obamacare messaging. Some try out ‘repair’ as others stick with stronger words. Republicans are grappling with their party’s desire -- and President Donald Trump’s promise -- to dismantle Obamacare, as well as the political disaster that could ensue if millions of Americans lose coverage as a result of legislation. A Jan. 6 Kaiser Family Foundation poll found that 75 percent of Americans either are opposed to Congress repealing Obamacare or want lawmakers to wait until they have a replacement ready before repealing it. Lately, Trump has pivoted to pledging insurance for everyone. Conservatives have voiced frustrations about the slow pace of repeal, aiming to get rid of the law as soon as possible and figure out a replacement later, if at all.
Employers Fret Job-Based Coverage Vulnerable To Fallout From GOP Health Overhaul (Jay Hancock, KHN, 2-3-17) Through years of acrimony over Obamacare coverage for the poor and other individuals lacking health policies, one kind of insurance has remained steady, widespread and relatively affordable. Employer-sponsored medical plans still cover more Americans than any other type, typically with greater benefits and lower out-of-pocket expense. Now, as President Donald Trump promises a replacement for the Affordable Care Act that will provide “insurance for everybody,” employers worry Republican attempts to redo other parts of the insurance market could harm their much larger one. Business dislikes many parts of the ACA, including its substantial paperwork, the mandate to offer coverage and the “Cadillac tax” on high-benefit plans that takes effect in 2020. But large companies in particular — those that have always offered job-based insurance — say a poorly thought-out replacement might turn out to be worse for them and their workers.
About That Cadillac Tax (Jeff Lemieux and Chad Moutray, Health Affairs blog, 4-25-16). In December 2015 Congress passed and the President signed a two-year delay of a 40 percent excise tax on high-cost employer-sponsored health plans, also known as the “Cadillac Tax.” This delay, part of a year-end government funding package, changed the effective date from 2018 to 2020. Economists are generally keen to reduce or cap “tax expenditures,” like the current tax exclusion, to help prevent overuse of tax-favored items. They also tend to worry about the relative inefficiency of the health sector in particular, and the adverse impact of ever-higher health costs on federal and state budgets. Political leaders oppose it. The indexing problem and the adaptation question are issues that warrant caution before implementing the Cadillac tax. Although health plans administering employer benefits would pay the tax, the cost would be passed through to the health plan enrollees. Read fuller explanation in this article.
Ryan plans to steamroll Democrats with budget tool (Ben Weyl, Politico, 10-06-16) While GOP leaders have made threats in the past to use reconciliation to repeal Obamacare, Ryan is making it clear he plans to use it when it counts.
GOP eyes new ObamaCare strategy: Repeal and delay (Peter Sullivan, The Hill, 11-17-16) A Republican plan to quickly repeal most of ObamaCare but delay the effects for up to two years is gaining steam on Capitol Hill.

Marketplace Enrollment Still Importan

Who benefits (and how) from health savings accounts

Who Benefits From Health Savings Accounts? ( Julie Rovner (@​jrovner) of Kaiser Health News, on Here and Now, NPR, 3-13-17) Listen or read summary of main points. ""It's one of the most tax-advantaged accounts you can find. The money is tax-free going in. It is tax-free as it grows over the years if you don't use it. And it is tax-free coming back out, as long as you use it for qualified medical expenses." but..."they benefit most people who are healthy — so they don't use a lot of money for health care — and people who are wealthy, so they have enough money sitting around that they can put into these accounts. As I mentioned, employers can put money in, but the average employer contribution is under $1,000. So if you really want to get it, you know, funded all the way up to where you would be protected in case of a serious health problem, you would have to have, if you're a family, $13,000 to put away."..." savings accounts are intended, in fact can only be used, in conjunction with a high-deductible health insurance plan. So there is a catastrophic plan underneath all of this. The question is whether you can afford to put as much into this health savings account as you would need to reach that deductible."
Health Savings Accounts (HSAs): ‘Tax-Break Trifecta’ Or Insurance Gimmick Benefiting The Wealthy? (Julie Appleby, Kaiser Health News, 2-3-17) Republicans hope to expand the use of health savings accounts to encourage consumers to be more judicious in using their coverage. The theory behind HSAs is that making consumers bear a bigger up-front share of medical care — while making it easier to save money tax-free for those costs — will result in more judicious use of the health system that could ultimately slow rising costs. HSAs all generally seek to allow larger tax-free contributions to the accounts and greater flexibility on the types of medical services for which those funds can be used. Supporters say premiums for the insurance linked to an HSA are lower, and they like HSAs’ trifecta of tax savings — no taxes on contributions, the growth of the funds in the account or on their withdrawal if spent on medical care. But skeptics note the tax break benefits wealthy people more than those with lower incomes. Critics also point out that older or sicker consumers could blow through their entire fund every year and never accumulate any savings.This article explains what you need to know about HSAs, including what they cannot be used for.
Health Savings Accounts Are Back In The Policy Spotlight--FAQs (Julie Appleby, Shots: Health News, NPR, 2-2-17) A good Q&A: How do HSAs work? How would they change under GOP proposals? What services can HSA funds cover? How common are HSAs? How much do they cost and what are the advantages? What are the disadvantages?
The Perplexing Psychology Of Saving For Health Care (April Fulton, Shots: Health News, NPR, 2-15-17) Even many people eligible for a health savings account who have extra cash to contribute to one don't do it. Therapists say that's partly because nobody wants to admit they will get old or sick. "Then there's the issue of figuring out how much you, as an individual or a family, would need to save for health care — it's not easy to find out the average price for a medical test or procedure in your town, let alone how much that price varies from doctor to doctor or hospital to hospital."
Health Savings Accounts and Other Tax-Favored Health Plans IRS Publication 969 (2016) Explains Health savings accounts (HSAs), Medical savings accounts (Archer MSAs and Medicare Advantage MSAs), Health flexible spending arrangements (FSAs), Health reimbursement arrangements (HRAs).
Your Guide to the Health Savings Account (Selena Maranjian, Motley Fool, 10-1-15) Surprisingly powerful, a Health Savings Account might serve you very well -- either now or in retirement. And you don't even have to use it for your health expenses, though it's especially effective in that regard.
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Understanding the issues health care reform should address

More evidence expanding Medicaid increases emergency room visits (Carolyn Y. Johnson, Wash Post, 10-19-16) A provocative study showed in 2014 that "expanding Medicaid increased trips to the emergency room," "challenging the key assumption that low-income people who gained insurance coverage would go to primary care doctors instead of relying on emergency rooms" (where care is far more expensive). “Why has this become such a widespread notion — that we can sort of coordinate our way out of the cost problem?" says J. Michael McWilliams, a professor of health-care policy at Harvard Medical School. “One reason is that it’s a much easier conversation to have: We can all subscribe to this notion of prevention saves money and care coordination saves money — and we don’t have to talk about regulating prices, or breaking up monopolies....Changing payment systems, argues Ezekiel Emanuel, can incentivize doctors and patients to act differently. Right now, those incentives don't exist and the system is built so that the path of least resistance may be the emergency room for many patients."
Times obit for Uwe Reinhardt (Sam Roberts, NY Times, 11-15-17) 'Professor Reinhardt argued that what drove up the singularly high cost of health care in the United States was not the country’s aging population or a surplus of physicians or even Americans’ self-indulgent visits to doctors and hospitals. Then he would succinctly answer the cost question by quoting the title of an article he wrote with several colleagues in 2003 for the journal Health Affairs: “It’s the Prices, Stupid.” What propelled those prices most, he said, was a chaotic market that operates “behind a veil of secrecy.” That market, he said, is one in which employers “become the sloppiest purchasers of health care anywhere in the world,” as he wrote in the Economix blog in The New York Times in 2013. It is also defined by the high cost of prescription drugs, he said, and the astronomical amounts that hospitals spend in dealing with a maze of insurers and health maintenance organizations. “Our hospitals spend twice as much on administration as any hospital anywhere in the world because of all of this complexity,” he told Managed Care magazine in 2013. If the nation cut the cost of health care administration in half, he said, the savings would be enough to insure everyone.' See It’s The Prices, Stupid: Why The United States Is So Different From Other Countries (Gerard F. Anderson, Uwe E. Reinhardt, Peter S. Hussey, and Varduhi Petrosyan, Health Affairs, May/​June 2003)
Dead Man Walking (Michael Stillman and Monalisa Tailor, NEJM, 11-14-13). For many of our patients, poverty alone limits access to care...."We sometimes pay for our patients' medications because they are unable to cover even a $4 copayment. But a fair number of our patients — the medical “have-nots” — are denied basic services simply because they lack insurance, and our country's response to this problem has, at times, seemed toothless....A 2009 study revealed a direct correlation between lack of insurance and increased mortality and suggested that nearly 45,000 American adults die each year because they have no medical coverage...formerly uninsured adults given access to Oregon Medicaid were more likely than those who remained uninsured to have a usual place of care and a personal physician, to attend outpatient medical visits, and to receive recommended preventive care....Elected officials bear a great deal of blame for the appalling vulnerability of the 22% of American adults who currently lack insurance. The Affordable Care Act (ACA) — the only legitimate legislative attempt to provide near-universal health coverage — remains under attack from some members of Congress, and our own two senators argue that enhancing marketplace competition and enacting tort reform will provide security enough for our nation's poor." "During our appointment with Mr. Davis, he worried aloud that under the ACA, 'the government would tax him for not having insurance.' He was unaware (as many of our poor and uninsured patients may be) that under that law's final rule, he and his family would meet the eligibility criteria for Medicaid and hence have access to comprehensive and affordable care....The American College of Physicians, the American Medical Association, and the Society of General Internal Medicine have endorsed the principle of universal health care coverage yet have generally remained silent during years of political debate. Lack of insurance can be lethal, and we believe our professional community should treat inaccessible coverage as a public health catastrophe and stand behind people who are at risk....A recent study showed that underinsured patients have higher mortality rates after myocardial infarction,4 and it is well documented that our country's uninsured present with later-stage cancers and more poorly controlled chronic diseases than do patients with insurance.5 We find it terribly and tragically inhumane that Mr. Davis and tens of thousands of other citizens of this wealthy country will die this year for lack of insurance."
Depending on where you live, it can be really difficult to get a rape kit (Vanessa Nason, Muckrock, 12-12-17) A lack of sexual assault forensic examiners, particularity in rural areas, denies women access to treatment guaranteed by law
The US maternal death rate is unacceptably high. It doesn't have to be. (Byrd Pinkerton, Sarah Kliff, Jillian Weinberger, Amy Drozdowska, and Julia Belluz, Vox, 12-4-17) Compared to its peer countries, the United States has a surprisingly high maternal death rate. Mothers are three times more likely to die of childbirth here than in the UK, and eight time more likely to die of childbirth here than in Norway or Sweden. But in California, a group of doctors came together just over a decade ago to build “toolkits” that would help doctors manage the most prevalent causes of maternal death, including preeclampsia, blood clots, and hemorrhage. They brought California's maternal death rate way down.
In Health Care, A Good Price (Or Any Price) Is Hard To Find (Jenny Gold, Reporter's Notebook, KHN, 9-14-17)A recent story about why Northern California is the most expensive place in the country to have a baby began as a tip from an obstetrician. Dr. Sarah Azad told me that insurers were paying her just a third of what they pay doctors employed by large hospital systems in her town of Mountain View, Calif. "As it turns out, the vast majority of contracts between doctors or hospitals and insurance companies are subject to a gag clause, which prohibits either party from disclosing negotiated rates. That means it’s almost impossible for consumers, researchers or journalists to find actual, accurate numbers, despite the fact that cost differentials among doctors can be so stark.... I have long understood that the lack of price transparency is one reason our system stays so expensive. It was a surprise, though, to find out that this opacity is cemented by legally binding contracts....It’s no accident that data on physician costs are so hard to find. Its inaccessibility allows hospitals to keep raising their prices. It’s simply not in their interest for the public to know how much they’re charging. And insurers don’t want other doctors or hospitals to see the high prices they’ve agreed to pay, for fear they would demand the same....In the end, all of us — through our insurance premiums and our taxes — pay a price for non-transparency."

Health Giant Sutter Destroys Evidence In Crucial Antitrust Case Over High Prices (Chad Terhune, Kaiser Health News, 11-17-17) Sutter Health intentionally destroyed 192 boxes of documents that employers and labor unions were seeking in a lawsuit that accuses the giant Northern California health system of abusing its market power and charging inflated prices, according to a state judge....In April 2014, a grocery workers’ health plan sued Sutter and alleged it was violating antitrust and unfair competition laws. The plaintiffs began requesting documents related to contracting practices, such as “gag clauses” that prevent patients from seeing negotiated rates and choosing a cheaper provider and “all-or-nothing” terms that require every facility in a health system to be included in insurance networks....The Federal Trade Commission (FTC) enforces antitrust laws in health care to prevent hospitals, drugmakers and other industry players from engaging in anti-competitive behavior that could harm consumers....The plaintiffs are seeking to recover hundreds of millions of dollars from Sutter from what it claims are illegally inflated prices. The lawsuit alleges that an overnight hospital stay at Sutter hospitals in San Francisco or Sacramento costs at least 38 percent more than a comparable stay in the more competitive Los Angeles market....“This was groundbreaking in the industry,” Grossman said. “Until we address the anti-competitive behavior of entities like Sutter, we will not solve the problem of high costs in health care.”
Mental illness: Families cut out of care (Liz Szabo, USA Today, 3-7-16) 'Although a federal law on patient privacy was written to protect patients’ rights, the Angells and a growing number of mental health advocates say the law has harmed the care of adults with serious mental illness, who often depend on their families for care, but don’t always recognize that they’re sick or that they need help. The federal law, called the Health Insurance Portability and Accountability Act, or HIPAA, forbids health providers from disclosing a patient’s medical information without consent. Unlike patients with physical conditions, people with serious mental illness often need help making decisions and taking care of themselves, because their illness impairs their judgement, says Jeffrey Lieberman.... In some cases, patients may not even realize they’re sick....Many health providers don’t understand what HIPAA actually allows them to say....Three members of Congress — Rep. Doris Matsui, D-Calif., Sen. Chris Murphy, D-Conn. and Rep. Tim Murphy, R-Pa. — have introduced legislation to educate health care providers about what HIPAA does and doesn’t permit....Family involvement is “extraordinarily important” for people with serious mental illness.'
Mental Illness, Human Rights, and US Prisons (Human Rights Watch Statement for the Record to the Senate Judiciary Committee Subcommittee on Human Rights and the Law) "Prisons were never designed as facilities for the mentally ill, yet that is one of their primary roles today. Many of the men and women who cannot get mental health treatment in the community are swept into the criminal justice system after they commit a crime. According to the Bureau of Justice Statistics, 56 percent of state prisoners and 45 percent of federal prisoners have symptoms or a recent history of mental health problems....Unfortunately, prisons are ill-equipped to respond appropriately to the needs of prisoners with mental illness." Read what prison is like for a person with mental illness.
Flight risk (Mark Johnson and McKenna Oxenden, Milwaukee Journal Sentinel, 11-24-17) There is no national plan to deal with contagious disease in our busy skies. There is no consistent way to notify towers of incoming problems. And sometimes airplane cleanup crews ignore even basic hygiene.
Hospitals and PhRMA face off over drug prices and 340B program (David Pittman, Political, 11-9-17) President Donald Trump promised to crack down on drug companies “getting away with murder,” but it turns out that it’s hospitals taking it on the chin over the cost of medicine. There’s a big, expensive fight brewing between the two powerful lobbies around a somewhat obscure drug discount program called 340B. PhRMA’s ongoing fight with hospitals might be the result of where drug company’s most expensive new drugs are — cancer treatments delivered in hospitals. “As more cancer drugs fall under the 340B discount, manufacturers have increased their attention to the scope of the 340B program in the oncology space,” said Allan Coukell, senior director for health programs at The Pew Charitable Trusts. Created in 1992 to help rural and charity hospitals and clinics, the 340B program is supposed to offset the cost of medicines for providers that serve a lot of low-income people with discounted drugs. But it’s grown exponentially, and now $16 billion worth of medications dispensed in hospitals go through the program each year. The "pharmaceutical industry has crafted a message that hospitals are taking nearly $6 billion in drug discounts and using it to enrich themselves rather than help poor patients. They say the 340B cash has even played a role in hospitals buying up doctors’ offices, causing a rise in health care costs that more than cancels out any benefit of the drug discounts."
How U.S. Health Care Became Big Business (Terry Gross, Fresh Air, NPR, 4-10-17) Terry Gross interviews Elisabeth Rosenthal, author of An American Sickness: How Healthcare Became Big Business and How You Can Take It Back by Elisabeth Rosenthal. ("An authoritative account of the distorted financial incentives that drive medical care in the United States . . . Every lawmaker and administration official should pick up a copy of An American Sickness. Then, at last, the serious debate could begin.” -The Washington Post) She "explains how health care became big business and how the pricing and billing of medical services, devices and prescription drugs became so complicated even a lot of doctors don't understand it." Among points made: "More competition doesn't mean better prices. In fact, it can drive prices up" "...if you look at drug prices, for example, there was a miraculous drug called Gleevec which really changed cancer patient's lives when it came out maybe 10, 15 years ago. Now there are many, many kind of copycat versions of Gleevec. We call them in the profession sons of Gleevec. And they're all four or five times more expensive than Gleevec was when it came out....So if you were looking at a world where an economic market worked, you would think, wow, there are 10 of these now so the price should have come down - it hasn't...because the standard in health care has been usual and customary...the ultimate lesson of much of American health care is that prices rise to whatever the market will bear. And another concept that I think is unique to medicine is what economists call sticky pricing...and you see this over and over again in the drug sphere and also in the hospital chargemaster sphere - once one drug maker, one hospital, one doctor says hey, we could charge 10,000 for that procedure or that medicine. Maybe it was 5,000 two months ago, but once everyone sees that someone's getting away with charging 10,000, the prices all go up to that sticky ceiling....What you see often now is when generic drugs come out, so there's lots of competition, the price doesn't go down to 20 percent of the branded price, it maybe goes down to 90 percent of the branded price. So we're not getting what we should get from a really competitive market where we, the consumers, are making those choices." But to comparison shop you need to know the prices available. "No one's going to tell me the price. They're all going to say it depends on your insurance or we don't know."

Another rule: "A lifetime of treatment is preferable to a cure." You've got to look at every medical problem from two sides - what's right for health care and what's good for business. Which is more likely: that a drug manufacturer would invent a pill that would cure diabetes, would make the disease go away overnight, or that it would keep going with the current multi-billion dollar business market. They want a treatment that would go on for life. Then there's hospital consolidation: "what we see in research over and over again is that the cities that have the most hospital consolidation tend to have the highest prices for health care without any benefit for patient results." A lot of procedures that used to be done in hospitals began being done outpatient (in a clinic in a shopping mall, for example). "So the hospitals as a whole don't like it. But in the latest twist of this ongoing consolidation of financial power, many of the hospitals have decided to end this trade war with the outpatient surgery centers and are just buying them up."
"if Americans really want something that's more market-based, other countries have used market-based solutions or more market-based solutions and have gotten really good health care, too. If you look at Switzerland, they have a largely market-based system. But - and this is a really important but - all the countries that have working marketplace-based systems have some form of control over pricing. It's not kind of the Wild West open market. They'll say this is the ceiling you can charge for that procedure. They'll say this is a bandwidth in which you can charge. And you can compete all you want below that ceiling or within that band. But you can't just drive up prices to whatever the market will bear because - I think one of the legitimate analogies is if water or electricity was a totally free market, imagine what prices would be like."
A nation of McHospitals? (Dan Diamond, Politico, 11-8-17) "For years, the nation's hospital chains worked to get bigger, bigger, bigger. In the 1980s and 1990s, for-profit companies like HCA and Tenet emerged as juggernauts, snapping up local hospitals and opening clinics in one town after another. Their ambitious not-for-profit cousins, the big academic medical centers like Harvard-affiliated Partners Healthcare, scooped up smaller rivals in response. Just four years ago, the Tennessee-based Community Health Systems spent $7.6 billion to buy a competitor and become the nation's largest for-profit hospital company, with more than 200 hospitals in 29 states....Providers' growing market power has "been the leading reason for the [rise] in health care spending" for decades, Bob Berenson, a former Carter and Clinton administration official said in 2015. (“And in conventional political circles,” he added, “it’s still being overlooked.”)...Charlie Martin, a legendary health care investor who founded two hospital companies, said the old model is doomed as new technologies allow care to be delivered outside of the hospital — leaving behind large, costly facilities that are better suited to 1990 than 2020." No simple diagnosis here. Read the whole story!
Sickle Cell Patients Suffer Discrimination, Poor Care — And Shorter Lives (Jenny Gold, KHN, 11-6-17) About 100,000 people in the United States have sickle cell disease, and most of them are African-American. In 1994, life expectancy for sickle cell patients was 42 for men and 48 for women. By 2005, life expectancy had dipped to 38 for men and 42 for women. Sickle cell disease is “a microcosm of how issues of race, ethnicity and identity come into conflict with issues of health care,” said Keith Wailoo, a professor at Princeton University, and auithor of Sickle Cell Disease — A History of Progress and Peril (Keith Wailoo, New England Journal of Medicine, 3-2-17) Studies have found that sickle cell patients have to wait up to 50 percent longer for help in the emergency department than other pain patients. The opioid crisis has made things even worse, Vichinsky added, as patients in terrible pain are likely to be seen as drug seekers with addiction problems rather than patients in need.
Rapid flurry of new drug pricing leaves no room for public debate (Dr. Kevin A. Schulman, The Hill, 10-26-17) The Food and Drug Administration (FDA) has approved breakthrough products for pediatric cancer, a rare form of blindness, and now adult non-Hodgkin's lymphoma. "The price of Novartis's CAR-therapy — a form of treatment primarily for blood cancers like leukemia and lymphoma — was $475,000 per patient based (although they may offer a refund for patients who do not benefit from the therapy). Kite Pharmaceutical has a CAR therapy lymphoma product for adults priced at almost $400,000. Speculation in the trade press on the price of Spark Therapeutics gene therapy for blindness suggest prices of up to $1,000,000.... This rapid flurry of unprecedented pricing benchmarks for new drugs has not given us time for public debate about the appropriateness of these pricing strategies, nor their impact on the health insurance premiums we all pay. All of these technologies are based on science funded by the National Institutes of Health....In these cases, pharmaceutical manufacturers are packaging publicly funded science, and being paid handsomely for their efforts....What is unique in the pharmaceutical market is the lack of outcry from hospitals and physicians over these unprecedented prices. Unfortunately, in health care, the federal government has developed a pricing program that make many hospitals a beneficiary of this aggressive pricing strategy on the part of pharmaceutical manufacturers. You see, hospitals buy drugs at a significant discount from the list prices under a program called 340B, and then are able to sell them at above the list price to Medicare and private health insurance plans. This markup on drug costs is now the largest profit center of many of these hospitals....We cannot allow this lack of any reasonable pricing strategy to be the new standard in healthcare and expect anything but a significant escalation of this price war....Politicians on both sides of the aisle should be concerned about this overt exploitation of both public science and public health insurance. We need to quickly develop a consensus approach to responding to this crisis. In this discussion, we will need to consider radical approaches, including price negotiation and regulation, and maybe even a windfall profits tax on NIH-funded products."
The Drug Industry's Triumph Over the DEA )Scott Higham and Lenny Bernstein, Washington Post, 10-15-17) Amid a targeted lobbying effort, Congress weakened the DEA’s ability to go after drug distributors, even as opioid-related deaths continue to rise, a Washington Post and ‘60 Minutes’ investigation finds. A handful of members of Congress, allied with the nation’s major drug distributors, prevailed upon the DEA and the Justice Department to agree to a more industry-friendly law, undermining efforts to stanch the flow of pain pills. The DEA had opposed the effort for years. The law was the crowning achievement of a multifaceted campaign by the drug industry to weaken aggressive DEA enforcement efforts against drug distribution companies that were supplying corrupt doctors and pharmacists who peddled narcotics to the black market. The industry worked behind the scenes with lobbyists and key members of Congress, pouring more than a million dollars into their election campaigns. The chief advocate of the law that hobbled the DEA was Rep. Tom Marino, a Pennsylvania Republican who is now President Trump’s nominee to become the nation’s next drug czar."
McKesson, Cardinal and AmerisourceBergen scrutinized over opioid arm-twisting (Eric Sagonowsky, FiercePharma, 10-16-17) "Following a bombshell investigation that exposed how drug distribution companies lobbied in Congress to weaken government drug enforcement powers, investors are demanding major changes—including a housecleaning in the management ranks. The reports ... put top drug distributors McKesson, Cardinal Health and AmerisourceBergen in the hot seat. With the help of a DEA whistleblower, the investigation at CBS' 60 Minutes and the Washington Post detailed a lack of controls at the companies to stop illicit painkiller sales. Then, as the opioid epidemic worsened, the companies undermined enforcement efforts by using their influence in Congress and Washington, D.C., to get the rules changed, the outlets reported. Following a bombshell investigation that exposed how drug distribution companies lobbied in Congress to weaken government drug enforcement powers, investors are demanding major changes—including a housecleaning in the management ranks. "While these drug companies were promising to strengthen their anti-diversion programs and compliance practices, they were diverting resources to rig the system in their favor," Hall said in a statement. "No responsible shareholder can see this corporate behavior as justified, even under the mantra of shareholder value."
Dr. Vinay Prasad, OHSU's iconoclastic oncologist, calls out shoddy medicine (Lynne Terry, The Oregonian, 9-7-17) "At 34, the Oregon Health & University oncologist identifies bad therapies and practices in medicine. He's taken aim at the high cost of cancer drugs, panned cancer screenings for doing more harm than good and pointed out peers who profit from drug company money. He's also criticized federal regulators for approving drugs on flimsy evidence and derided the media for hyping weak research. Prasad is part of a small but influential group of researchers who are creating ripples in the medical establishment by taking a hard look at their profession, often to the dismay of fellow doctors." You can read about much of this in Ending Medical Reversal: Improving Outcomes, Saving Lives by Vinayak K. Prasad and Adam S. Cifu.
Dangerous doctors: Despite malpractice charges, Florida lets them keep treating patients (Stephen Hobbs, SunSentinel, 10-28-17) Florida settles, doctors dodge blame. It has been more than nine years since Florida health regulators concluded that Dr. Barry Jack Kaplan botched a woman’s breast implants and shouldn’t practice cosmetic surgery. In the time since, he’s been accused of injuring two other women, one so seriously she had to have her nipples removed. Florida regularly allows doctors to continue to see, treat, and operate on people for years after accusing them of endangering patients, a South Florida Sun Sentinel investigation found. The health department currently has nearly 400 doctor cases that have been pending for a year or more, state data shows. They include at least 19 doctors who racked up new charges while their initial cases languished. The willingness of Florida’s medical boards to settle cases with doctors enables doctors to keep their licenses even after repeated accusations of wrongdoing.While state boards can strip the licenses of doctors they have found to have committed medical malpractice, cases that end in settlements don’t count. In most settlements, doctors don’t admit or deny the allegations against them and there is no finding of malpractice.
How to Repair the Health Law (It’s Tricky but Not Impossible) (Reed Abelson, Abby Goodnough, and Katie Thomas, NY Times, 7-29-17) Stabilizing the market ("calm jittery insurance markets"), lowering drug prices and expanding access to coverage would go a long way to easing millions of Americans’ concerns. Democratic proposals, such as allowing Medicare to directly negotiate drug prices with pharmaceutical companies and allowing cheaper drugs to be imported from overseas, are fiercely opposed by the drug industry — a potent lobbying power in Washington — as well as Republicans in Congress. (See A Better Deal: Lowering the Cost of Prescription Drugs.)
Chomsky: How the U.S. Developed Such a Scandalous Health System (C.J. Polychroniou, Truthout, Alternet, 8-3-17) It all started after World War II, but now public support for universal health care is higher than ever. Article 25 of the UN Universal Declaration on Human Rights (UDHR) states that the right to health care is indeed a human right. Yet close to 30 million Americans remain uninsured even with the 2010 Patient Protection and Affordable Care Act (ACA) in place. The "US does not accept the Universal Declaration of Human Rights -- though in fact the UDHR was largely the initiative of Eleanor Roosevelt....The UDHR has three components, which are of equal status: civil-political, socioeconomic and cultural rights. The US formally accepts the first of the three, though it has often violated its provisions. The US pretty much disregards the third. And to the point here, the US has officially and strongly condemned the second component, socioeconomic rights, including Article 25." And so on. " To an unusual extent, the US health care system is privatized and unregulated. Insurance companies are in the business of making money, not providing health care, and when they undertake the latter, it is likely not to be in the best interests of patients or to be efficient. Administrative costs are far greater in the private component of the health care system than in Medicare, which itself suffers by having to work through the private system." Do read this one.
How U.S. Health Care Became Big Business (on Fresh Air, 4-10-17, Terry Gross interviews Elisabeth Rosenthal, author of An American Sickness: How Healthcare Became Big Business and How You Can Take It Back). "Health care is a trillion-dollar industry in America, but are we getting what we pay for? Dr. Elisabeth Rosenthal, a medical journalist who formerly worked as a medical doctor, warns that the existing system too often focuses on financial incentives over health or science. "We've trusted a lot of our health care to for-profit businesses and it's their job, frankly, to make profit," Rosenthal says. Rosenthal's new book, An American Sickness, examines the deeply rooted problems of the existing health-care system and also offers suggestions for a way forward. She notes that under the current system, it's far more lucrative to provide a lifetime of treatments than a cure." She talks about what consolidation of hospitals is doing to the price of care, about the ways the health-care industry stands to profit more from lifetime treatment than it does from curing disease, about how prices will rise to whatever the market will bear, about how to decipher coded medical bills, and about why we must learn to initiate conversations early on with doctors about fees and medical bills. She also talks about getting charged for "drive-by doctors" brought in by the hospital or primary doctor.
Price Transparency In Medicine Faces Stiff Opposition — From Hospitals And Doctors (Rachel Bluth, Kaiser Health News, 7-25-17)
When Health Law Isn’t Enough, the Desperate Line Up at Tents (Trip Gabriel, NY Times, 7-23-17) The Remote Area Medical Expedition, held at a county fairground in Appalachia over three days, draws patients from states like Virginia that did not expand Medicaid to childless adults among the working poor, as the law allowed--drawing especially from the 29 million Americans who still lack health insurance. The group, staffed by medical volunteers, has treated more than 700,000 people at free clinics around the country and overseas since 1985. One man gets disability benefits for mental health issues, but the plan does not cover a dentist. "Only 16 percent of the patients who visited the clinic were employed full time, according to data collected by Remote Area Medical, known as RAM. Twenty-five percent were disabled. Ninety-two percent were white." “We’re sicker here than in Central America,” said Dr. Smiddy, who has volunteered on charity health trips there. “In Central America, they’re eating beans and rice and walking everywhere. They’re not drinking Mountain Dew and eating candy. They’re not having an epidemic of obesity and diabetes and lung cancer.” "... if the Republican-controlled General Assembly in Richmond would expand Medicaid, 400,000 low-income Virginians would be helped. Republicans, who hold all seats in southwest Virginia, say the Affordable Care Act is a failure."
Health Insurance: How Does It Work? (Yonatan Zunger, Health Care in America, Medium, 2-15-17) Four Questions to Ask About Health Care Reform. Three different things get bundled under the misleading name “health insurance:” (1) Ordinary health insurance , which splits up the cost of your expected lifetime medical bills over time; (2) Catastrophic health insurance , which splits up the cost of rare expenses so big that people couldn’t pay them across everyone; and (3) Access to the health care system itself . How does a proposal handle those three? And any health care proposal that involves any spreading out of costs faces the same question as a tax proposal: how do we spread out that cost? "What mechanism do we use to collect that — insurance premiums and fines, an overall tax payment, something else? If not, what do we do with people at risk for cancer?"
Scripps CEO Chris Van Gorder: 'Good' healthcare law 'will not come out of back room deals' (Tamara Rosin, Becker's Hospital Review, 3-24-17) "If we hope to get this legislation right for the country, we should be working together across party lines and truly involving the experts — healthcare providers. At some point for all of us, healthcare will become the most important thing in our life. That's why good legislation will not come out of back room deals and forcing a vote in a short period of time. Let's develop something sustainable that's good for Americans and not just special interests."
Pharmaceutical Marketing for Rare Diseases: Regulating Drug Company Promotion in an Era of Unprecedented Advertisement (Sham Mailankody and Vinay Prasad, JAMA Network, 5-18-17) Highlighting and quoting points made in the article: The US Food and Drug Administration (FDA) draws a distinction between direct-to-consumer advertising of specific drug products, which it regulates, and advertisements intended to create disease awareness, which it does not. This year, General Hospital, the longest running US soap opera, advanced a plotline whereby a star character was diagnosed as having polycythemia vera (PV) and a blood clot. Highlighting this specific cancer represents the culmination of a partnership between the Incyte Corporation and the producers of General Hospital to raise awareness for MPNs as part of the rare disease month. First, is disease awareness marketing in disguise? Second, do disease awareness campaigns promote specific drug sales? Third, does disease awareness have benefits? Fourth, could this campaign lead to overdiagnosis? "The challenge that faces the medical profession is balancing the need to regulate truthful but perhaps misleading medical communication with the strong constitutional interpretation of free speech. See also Collusion between Hollywood script writers and pharmaceutical companies isn’t new. Nor is the call to regulate it. (Mary Chris Jaklevic,, 6-1-17)
Insurers Battle Families Over Costly Drug for Fatal Disease (Katie Thomas, NY Times, 6-22-17) Duchenne muscular dystrophy overwhelmingly affects boys and causes muscles to deteriorate, killing many of them by the end of their 20s. Nolan and Jack Willis are twins who took part in a clinical trial that led to the approval last fall of the very first drug to treat their rare, deadly muscle disease, Exondys 51, manufactured and sold by Sarepta Therapeutics. The drug can cost more than $1 million a year even though it’s still unclear if it works. "While insurers once covered drugs for rare diseases as a matter of course, that may be changing now that a wave of expensive drugs have reached the market. The pharmaceutical industry has been in hot pursuit of an increasingly enticing demographic target: An estimated 30 million people in the United States — about 10 percent of the population — are living with one of roughly 7,000 rare diseases. The agency’s approval of Exondys 51, though, prompted a rebellion among some insurers, who are refusing to play along and saying they are concerned about the cumulative impact of such breathtakingly expensive drugs on health care costs."
Where Both the ACA and AHCA Fall Short, and What the Health Insurance Market Really Needs (David Blumenthal and Sara Collins, Harvard Business Review, 3-21-17) "First, these insurance markets were distressed before the enactment of the Affordable Care Act. Second, the ACA improved their functioning but was not sufficient as passed and implemented to stabilize all of them. Neither, however, is the American Health Care Act (AHCA), the repeal and replacement legislation proposed by House Republicans and embraced by President Trump. Third, the reforms that will improve individual markets, which we discuss below, are known. They include greater balance between premium subsidies and penalties for not taking up coverage, using proven mechanisms for stabilizing risks such as reinsurance, and accelerating efforts to control the costs of health care services. To date, the United States has just lacked the political will to adopt them."
What’s Past Is Prologue: CBO’s Score for the House-Passed AHCA Reminds Us Why Insurance Markets Need Regulation (Sara R. Collins, Commonwealth Fund, 6-2-17)
Poll: U.S. unready for future long-term care needs (Liz Seegert, Covering Health, AHCJ, 6-20-17) Medicare does not cover many long-term care expenses such as nursing homes or home health aides. Medicaid pays for most nursing home care and community-based long-term services and supports (LTSS) in the United States. Nearly 75 percent of respondents could not accurately estimate the costs of long-term care, either in a nursing home, assisted living, or hiring a part-time home care aide.
Stopping surprise medical bills: Federal action is needed ( Loren Adler, Mark Hall, Caitlin Brandt, Paul B. Ginsburg, and Steven M. Lieberman, Brookings, 2-1-17) Surprise balance billing is widespread. "Even when patients are diligent in seeking an in-network hospital or lead physician, their care often involves consulting specialists – such as radiologists, anesthesiologists, pathologists, neonatologists, or assistant surgeons – who are out-of-network and whom the patient has no role in selecting. Legally, patients might be able to challenge such surprise bills in court, but existing law is not clear on what billing is permissible, and patients seldom are able or willing to undertake expensive and stressful litigation in such situations." Federal action is needed to protect all consumers and assure a “level playing field,” particularly as narrow networks grow increasingly common for employer-sponsored as well as individual insurance." States play an important part in the regulation of insurance markets...but states cannot protect more than half of commercially-insured consumers due to an arcane federal law, known as the Employee Retirement Income Security Act of 1974 (ERISA), which exempts almost 100 million people in private insurance plans from state regulation because their plans are self-funded by employers. And based on existing evidence, there is no reason to believe that surprise balance billing is substantially less prevalent under self-funded employer plans than under other, commercially insured private plans."
Health policy issues (Association of Health Care Journalists, or AHCJ)
A Regulation That Protects Big-Hospital Monopolies (Hal Scherz, Wall Street Journal, 6-13-17) By restricting construction of new medical facilities, certificate-of-need laws drive up health-care costs. In Cartersville, Ga., two highly regarded obstetricians, Hugo Ribot and Malcolm Barfield, hoped to add a second room to their one-room surgery center. But the plan hit a snag. They needed to obtain a “certificate of need” from Georgia’s Department of Community Health. Three large hospitals in the area—which provide similar services at far higher cost—blocked their application. Dr. Ribot and Dr. Barfield are now suing the state for restraint of trade.
Health Reform reading list (Joanne Kenen, AHCJ, resources for journalists) ****
Diagnosing Health of the Healthcare System (animated video, Peterson-Kaiser Health System Tracker, measuring the performance of the U.S. health system). See more Peterson-Kaiser charts, tracking health care trends.
Who benefits from Health Savings Accounts (HSAs)?
Many Parents With Job-Based Coverage Still Turn To Medicaid, CHIP To Insure Kids (Michelle Andrews, Kaiser Health News, 12-9-16)
12 steps to make America’s health care great again (Michael F. Weisberg, MD, KevinMD, 2-23-17) This is an agenda the Trump administration is likely to reject wholesale.
The Tooth Divide: Beauty, Class and the Story of Dentistry (Sarah Jaffe, NY Times, 3-23-17), a review of Mary Otto's book Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. "If the idea of death from tooth decay is shocking, it might be because we so rarely talk about the condition of our teeth as a serious health issue....Otto’s book begins and ends with the story of Deamonte Driver, a 12-year-old Maryland boy who died of an infection caused by one decaying tooth, and the system that failed him. In pointing out the flaws in that system, Otto takes us back through the history of dentistry and shows us how the dental profession evolved, separately from the rest of health care, into a mostly private industry that revolves almost entirely around one’s ability to pay. In other words, all of the problems with health care in America exist in the dental system, but exponentially more so....A dentist tells Otto that members of his profession “once exclusively focused upon fillings and extractions, are nowadays considered providers of beauty.” And thanks to decades of deregulation, allowing medical advertising and then medical credit cards...dentists make more per hour than doctors." BUT "One-third of white children go without dental care, Otto notes; that number is closer to one-half for black and Latino children. Forty-nine million people live in “dental professional shortage areas,” and even for those who do have benefits under public programs like Medicaid, which ostensibly covered Deamonte Driver and his siblings, it can be difficult to find a provider....Yet in a country where the party in power fights tooth and nail against expanding regular health care benefits, what chance do we have of publicly funded dental care? ...Though more women are dentists these days, the job of hygienist grew from men’s expectations of women’s appropriate work, and it has always, Otto notes, made dentists nervous when hygienists move to be more independent. Plans to put dental hygienists in public schools, for instance, have been squashed by dentists’ associations....In addition to the fear of competition from hygienists, Otto details dentistry’s fear of socialized medicine and how that fear kept the profession largely privatized." Otto's book explores "a two-tiered system — it is a call for sweeping, radical change."
I remember a pre-NHS Britain. I don't want to see a post-NHS one (Shirley Murgraff, The Guardian, 10-7-11) "If our leaders won't protect the jewel in the crown of civilised society, it's time to act. Join me on the UK Uncut protest."
A Chance to Talk About Drug Prices is Slipping Away (Richard Young MD, American Health Scare, 7-9-16) The new hepatitis C drug Harvoni costs $1000 per pill for a total of $84000 for treatment. Initially, state Medicaid plans did not cover the drug except in very narrow circumstances, but under reports of the threat of a lawsuit many Medicaid plans are expanding coverage. "According to a study by the AARP, the average retail price of 115 specialty drugs for diseases ranging from cancer to multiple sclerosis to rheumatoid arthritis cost more per year than the median household income." "Other countries have the maturity and courage to have conversations about the best use of collective resources that always include restrictions on expensive treatments to only those patients who will likely experience significant benefit."
Medical Whistleblower Advocacy Network
Curing Medicare: One doctor's view of how our health care system is failing the elderly and how to fix it by Andy Lazris. Don't have the book yet? Read the blog: An Inside Look at Health Care for the Elderly and Medicare
Actuaries’ analysis of ACA alternatives can inform news coverage (Joanne Kenen, Covering Health: Monitoring the Pulse of Health Care Journalism, 2-24-17) The American Academy of Actuaries has released three papers analyzing long-time conservative ideas about health reform. These alternatives – high-risk pools, selling insurance across state lines, and association health plans (AHPs) – are playing a high-profile role in the debate over ACA “repeal and replace.” (AHPs allow an organization or group to pool together to buy insurance, likely without the current regulatory framework over required benefits and consumer protections.) The three actuary briefs:
---Using High-Risk Pools to Cover High-Risk Enrollees.
---Association Health Plans
---Selling Insurance Across State Lines

What we know about how health insurance affects health (Carolyn Y. Johnson, Washington Post, 9-8-15) "The real question now may not be how big the effect of insurance is on health, but how to structure insurance so that it gives people the best chance of staying healthy. There is also growing interest in comparing insurance coverage to other ways that money could be spent to improve health, for example by reducing poverty, which is associated with poor health outcomes, spending on food stamps, or structuring insurance plans differently. 'We know we improve health care coverage, but .... what are some of the other strategies to improve health?' Long said."
Study: Medicaid Expansion Encourages More Poor Adults To Get Health Care (Phil Galewitz, Kaiser Health News, 4-18-16) In states that expanded Medicaid under the Affordable Care Act, low-income adults were more likely to see a doctor, stay overnight in a hospital and receive their first diagnoses of diabetes and high cholesterol.
The most important thing you’re not discussing with your doctor (Melissa Armstrong, The Conversation, 2-15-17) "The Institute of Medicine (IOM) released the landmark publication Crossing the Quality Chasm 15 years ago. The report proposed six aims for improvement in the U.S. health system, identifying that health care should be patient-centered, safe, effective, timely, efficient and equitable." That means shared decision-making, honoring the patient's goals and values,
Why U.S. medical costs are so high and where the system needs fixing . Links to important series and articles on this problem.
What being overwhelmed by rules and regulations looks like (Fred N. Pelzman, KevinMD, 8-31-14)
Concierge Care (Deborah Pierce, Pulse, 12-20-13) "...very often the efficient, patient-centered care [my cat] Humphrey received is not available to human patients who face similar illnesses. Most people's medical insurance will not reimburse medical providers for two visits on a single day; nor can you obtain ultrasounds or CT scans on the same day as a consultation. Delay is often the norm, not the exception....And I wonder: what if we could set up the human healthcare system so that the communication, competence and kindness that made Humphrey's care so special--that made it so humane--were not only valued but also reimbursed?"
Confessions of a 75-Year-Old Drug Addict (Arlene Silverman, Pulse, 1-22-10) "There's sort of a war going on in the field of pain management, he continues. One camp worries about opiate addiction; the other is more concerned about the effects of long-term pain. It seems that, given my pain's severity, my doctors opted for opiates.

A Generation X physician embraces the millennial doctor perspective (Sherwin Gallardo, MD, Physician, posted on Kevin MD, 2-21-16) "And in the students and residents I teach, I see in their faces, with each repetitive click of the mouse and keyboard EMR shortcut, their passion for medicine slowly fade. Many of them match in our residency program with their wellness accounts already in negative balance, or precariously close to empty — the product of an obsolete, hierarchical medical education system that still often relies on overwork and humiliation as a sort of rite of passage with no formal teaching on how to deal with emotions, time management, financial or business competence, or self-care.
What little they have left to give often evaporates in the face of endless utilization measurements, and required documentation for meeting regulatory mandates and Medicare coding. In the name of efficiency, my residents’ progress notes on the inpatient medicine service all begin to look frighteningly similar and generic. Often at the expense of learning why and how an ACE-inhibitor helps their heart failure patient, they are consumed in exercises of futile box-checking and the metrics game of whether or not they documented that the ACE-inhibitor was ordered upon discharge."
We are not taking care of nurses. Who will heal the healers? (Michael Kirsch, Kevin MD, 10-3-16) Nurses are routinely required to care for more patients than they should because there is a nursing shortage on a particular day. Why do hospital administrators allow this to happen? Don’t administrators fear the risk of medical errors from overworked nurses? Nurses have confided for years how demoralized they are that no one speaks for them.

What do we do when antibiotics don’t work any more? Public health journalist Maryn McKenna's excellent TED talk, recounting the often terrifying stories behind emerging drug-resistant diseases that medical science is barely keeping at bay. "We've squandered the advantages of penicillin and the antibiotics that followed. New, drug-resistant bacteria mean we're entering a post-antibiotic world -- and it won't be pretty. There are, however, things we can do ... if we start right now."
Where Does Rationing Fit Into Healthcare Reform? (Trisha Torrey, About Health, 11-24-14) Rationing is not new, nor will it be any better or worse under healthcare reform. Private insurers too often deny care based on cost -- a form of rationing. Care is also rationed denial of coverage and care for people with pre-existing conditions. See What Is Healthcare Rationing?
In a State of Denial (Norman Bauman, New Scientist, 10-7-95). Thousands of Americans will die of AIDS because politicians refuse to believe scientists who say needle exchanges make good sense
Politicians need to get over their squeamishness about needle exchange programs (Christopher Ingraham, Wash Post, 3-24-15) There's widespread evidence going back decades that needle exchange programs are effective at preventing the spread of HIV and other blood-borne diseases, that they encourage drug users to seek treatment for their addictions, and that they do not promote or encourage drug use overall.
Older people risk losing access to health information if services move online and to the phone (UK) (press release, International Longevity Centre, UK, 2-12-15)
Controversies in Hospital Infection Prevention (
Finding the full story behind hospital mergers, consolidations (Joanne Kenen, Health Journalism blog, 3-10-15) "Across the country, health systems are getting larger, gobbling up community hospitals or smaller chains. Some of this has to do with payment incentives in Obamacare, but just as much has to do with changes to Medicare, Medicaid and providers’ desire for leverage as they negotiate payments with insurance companies." See New York’s leading health systems differ on growth strategy (Dan Goldberg, Capital Magazine, 3-10-15). Goldberg explains how the old model (fee for service, which meant chronically ill patients were good for business), differs from the new model (paying a set amount per patient or per service, encouraged by ACA, state Medicaid reforms, shifting demographics, and Medicare's ACO models and payment penalties), which provides an incentive to treat more patients but also provide less in-patient service. These five NY systems represent two camps: one "believes in aggressive upsizing"; the other, wary of affiliation with other hospitals, "made strategic investments and focused on ambulatory care and their traditional role as teaching hospitals. They have steered well clear of the insurance business." Excellent explanations.
How to destroy a great ER: A step by step guide (Thomas Paine, MD, Kevin MD, 4-19-16) Take a small independent, locally administered hospital in the suburbs, make it part of a large regional health care system (in a merger), and follow his steps for creating an ER department in which emergency clinicians no longer feel valued, respected, and supported.
The time a 28-year-old MBA told a physician where to round first (Sundeel Dhand, Kevin MD, 5-11-16) "The last couple of decades have seen a dramatic shift of power and clout away from individual physicians and towards administrators and the business side of health care....we’ve seen the relentless push towards consolidation and mass employment of physicians, a rise in mandates and bureaucratic requirements, and a general explosion in the number of administrative folks while the number of physicians appears to be shrinking!" and the subtle changes: calling them providers instead of doctors. How did the medical profession surrender so much to the business of medicine? Is there any way that physicians can wrestle back a bit of control over their own profession?
Unnatural inequality making us sick? (an important PBS series).
---In Sickness and in WealthWhat connections exist between healthy bodies, healthy bank accounts, and skin color? Four individuals from different walks of life demonstrate how one’s position in society – shaped by social policies and public priorities – affects health. Read transcript here
---When the Bough Breaks (“When the Bough Breaks” examines the mystery of the Black-white infant mortality gap, while “Becoming American” sheds light on the shifting health status of newly arrived Latino immigrants. Read the transcript here.
---Bad Sugar explores the causes and effects of diabetes within two Native American communities. “Place Matters” connects the dots between health, wealth and zip code. Read the transcript here.
---Collateral Damage traces the health challenges of Marshall Islanders from the South Pacific to Springdale, Arkansas, while “Not Just a Paycheck” explores the toll taken by layoffs and job insecurity in western Michigan. Read the transcript here.
Bill Moyer Journal (12-18-09) Amidst fading hopes for real reform on issues ranging from high finance to health care, economist Robert Kuttner and journalist Matt Taibbi join Bill Moyers to discuss Wall Street's power over the federal government. You can read transcript here.
Reform by the Numbers (Robert Wood Johnson Foundation, RWJF)), a source for timely and unique data about the impact of health reform. For example:

Doctors' incentives to prescribe expensive drugs

The Cost of Cancer Drugs (Leslie Stahl, 60 Minutes, CBS, 10-5-14--you can listen or read transcript.) Dr. Leonard Saltz: "We're in a situation where a cancer diagnosis is one of the leading causes of personal bankruptcy." "... we as a society have been unwilling to discuss this topic and, as a result, the only people that are setting the line are the people that are selling the drugs." Dr. Peter Bach: "Medicare has to pay exactly what the drug company charges. Whatever that number is." "The challenge, Dr. Saltz at Sloan Kettering says, is knowing where to draw the line between how long a drug extends life and how much it costs." "High cancer drug prices are harming patients because either you come up with the money, or you die." Gleevec as a life-saving drug that makes patients a slave to it and its high cost. Dr. Leonard Saltz: " I don't know where that line is, but we as a society have been unwilling to discuss this topic and, as a result, the only people that are setting the line are the people that are selling the drugs." "Dr. Kantarjian says one thing that has to change is the law that prevents Medicare from negotiating for lower prices."
Dollars for Docs search tool (Pro Publica). Use this to see if your doctors receive money from drug or device companies (which might influence which drugs and devices they prescribe)
Rapid flurry of new drug pricing leaves no room for public debate (Dr. Kevin A. Schulman, The Hill, 10-16-17) In August, Novartis announced the price of their CAR-therapy — a form of treatment primarily for blood cancers like leukemia and lymphoma — was $475,000 per patient based (although they may offer a refund for patients who do not benefit from the therapy).
What is the unique in the pharmaceutical market is the lack of outcry from hospitals and physicians over these unprecedented prices. In any other industry, if the cost of your core technology faced astronomical price increases, you’d quickly see a backlash. Unfortunately, in health care, the federal government has developed a pricing program that make many hospitals a beneficiary of this aggressive pricing strategy on the part of pharmaceutical manufacturers. You see, hospitals buy drugs at a significant discount from the list prices under a program called 340B, and then are able to sell them at above the list price to Medicare and private health insurance plans. This markup on drug costs is now the largest profit center of many of these hospitals.
TransUnion, Equifax and Experian Agree to Overhaul Credit Reporting Practices (Tara Siegel Bernard, NY Times, 3-9-15) "The three companies will also establish a six-month waiting period before reporting medical debts on consumers’ credit reports, providing more time for consumers to resolve issues that might amount only to a delayed insurance payment or another dispute. The credit agencies will also remove medical debts from an individual’s report after the debt is paid by insurance." "“Too many people are surprised to learn of medical billing problems only after having a bill sent to collection and being forced to deal with damaged credit,” said Mark Rukavina, a longtime consumer advocate and principal of Community Health Advisors, a consultancy that works with nonprofit hospitals on billing and collection issues. “Having the agencies finally agree to remove medical debts that were reported and subsequently paid by insurers is long overdue.”
Drugs, Big Pharma, conflicts of interest, and why U.S. patients pay too much for medication. A roundup of articles and analysis on the subject. For example: (a) It doesn't matter if a cheaper (often generic) version may be available if doctors don't pay attention to costs and consumers believe the more expensive drug is probably more effective. Moreover, doctors who do pay attention to costs have an incentive to prescribe the more expensive version of a drug, not the generic version. (b) Step therapy ("fail first" protocols insist that a patient start with a traditional lower-cost drug and advance to a newer, more expensive drug only if the first drug fails to produce the desired results. For new drugs that are clearly more effective, this means doctors and patients have to jump through hoops to get patient to the more effective drug, in order to get insurance coverage." (c) Why do drug companies charge so much? Because they can. (d) The United States does set medical prices for the 50 million elderly Americans who rely on Medicare. The Republican plans put the burden of high prices more squarely on patients. (e) 'It’s sort of embedded in the health care system that the price is never the price, unless you’re a cash-paying customer,' Mr. Fein said. 'And in that case, we soak the poor.'”' And so on.
Want to see how problematic Medicare pricing is? Look to ophthalmology (Max Ehrenfreund, Washington Post, 4-9-14) "...doctors also receive commissions of 6 percent to cover their own expenses. The commission a doctor collects on each dose of Avastin would be only about $3, as opposed to $120 on each dose of Lucentis. Congress and the courts have refused to allow Medicare to save money by scrutinizing doctors' decisions."
Doctors Often Receive Payments From Drug Companies (Neal Conan, Talk of the Nation, NPR, 9-13-11) A Pro Publica investigation shows that many doctors are being paid by the same drug companies whose medicines they prescribe. By 2013, all doctors must report any payments from pharmaceutical companies to the federal government, and those records will be available to the public.
• Prescriptions. No room to negotiate. The Soaring Cost of a Simple Breath (Elisabeth Rosenthal, NY Times, 10-12-13) Part 4 of Paying Till It Hurts In her series on the cost of health care, Elisabeth Rosenthal interviews patients, physicians, economists, hospital and industry officials to examine the high price of health care. Her book: An American Sickness: How Healthcare Became Big Business and How You Can Take It Back . And read the series here--including the readers' comments (from both patients and doctors).

Pay to Prescribe? Two Dozen Doctors Named in Novartis Kickback Case (Theodoric Meyer, ProPublica, 5-3-13)
Dollars for Docs How Industry Dollars Reach Your Doctors (Eric Sagara, Charles Ornstein, Tracy Weber, Ryann Grochowski Jones and Jeremy B. Merrill, for ProPublica, Updated 3-3-14). See if Your Health Professional Has Received Drug Company Money.
As Full Disclosure Nears, Doctors’ Pay for Drug Talks Plummets (Charles Ornstein, Eric Sagara and Ryann Grochowski Jones, ProPublica, 3-3-14) As transparency increases and blockbuster drugs lose patent protection, drug companies have dramatically scaled back payments to doctors for promotional talks. This fall, all drug and medical device companies will be required to report payments to doctors.
Medicare Drugs Turn Doctors into Millionaires (Walter Russell Mead & Staff, The American Interest, 4-10-14)
Prescribing Under the Influence (E. Haavi Morreim, Markkula Center of Applied Ethics, Santa Clara University)
\• Why do drug companies charge so much? Because they can. (Marcia Angell, Washington Post, 9-25-15) "Unlike every other advanced country, the United States permits drug companies to charge patients whatever they choose. ...Drug companies say high prices are necessary to cover their research and development costs" but most drugs "are invented not by the companies that sell them now but by someone else. Then, like big fish swallowing little fish, larger companies either buy small firms outright or license promising drugs from them. Very often, the original discovery occurs in a university lab with public funding from the National Institutes of Health (NIH), then licensed to a start-up company partly owned by the university and then to a large company. There is very little innovation at the big drug firms. Instead, their major creative output is trivial variations of top-selling medications that are already on the market (called “me-too drugs”), to cash in with treatments just different enough to justify new patents." Pharmaceutical companies are among the most profitable and "they spend more on marketing and administration than on R&D." ... "Congress has blocked Medicare from negotiating the price of drugs or creating a formulary for patients. It’s time that we, too, move to stop price-gouging by the pharmaceutical industry — even when no one notices."
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Can markets cure health care?

Does competition lead to better health care? Does it really give consumers choices?

Why markets can’t cure healthcare (Paul Krugman, The Conscience of a Liberal, NY Times, 7-25-09)
Hearing Amazon’s Footsteps, the Health Care Industry Shudders (Nick Wingfield and Katie Thomas, NY Times, 10-27-17) "The latest category alarmed by the specter of competition from Amazon is the pharmacy market. With huge amounts of consumer spending and frustrating inefficiencies, it is the type of business that invariably attracts Amazon’s attention. CVS Health is now in talks to acquire Aetna, one of the nation’s largest health insurance providers, a move considered to be partly a reaction to the footsteps of Amazon. The likelihood of Amazon’s eventually getting into the pharmacy business is high, several analysts and a former employee said....'The pharmacy business was always a topic of interest when I was with Amazon, and there was a sincere desire on the part of Amazon to create a better customer experience across pharmacy and health care as a whole,' [said one former Amazon employee]....If Amazon wanted to go bigger, Ms. Gupte and others said, it could sell to insured customers and even serve as a pharmacy-benefit manager, overseeing drug coverage for people on behalf of insurers and large employers. This would be far more complex. It would likely require Amazon to either acquire a pharmacy-benefit manager or enter into a partnership with an existing one. Expanding the pharmacy business without the aid of a major pharmacy-benefit manager would be tough, because the benefit managers serve as gatekeepers to insured patients, deciding which pharmacies they can and cannot use. The benefit managers also operate their own mail-order pharmacies, which might make them less willing to accommodate Amazon."
Uncertainty and the Welfare Economics of Medical Care (Kenneth J. Arrow, The American Economic Review, Dec. 1963) Health care can’t be marketed like bread or TVs. As Avik Roy points out in the following article, which I lean on here, Arrow identified five principle distortions in the market for health care services and products: 1. Unpredictability of need. (And yet often urgently needed.) 2.Barriers to entry. (There are medical-school driven restraints on the number of medical professionals, and not everyone can practice.) 3. The importance of trust. (Trust is a key component of the doctor-patient relationship, and patient's can test-drive a surgeon etc.) 4. Asymmetrical information. (Patients know less than doctors about what's needed and are thus subject to exploitation.) 5. Idiosyncrasies of payment. (Patients usually pay for services after they're received and rarely directly.)

A physician tells a health insurance CEO what she really thinks (Cathleen London, Kevin MD, 8-24-16) A doctor serving in an underserved area of rural Maine, who believes in a single-payer health care system, is troubled by a health insurance company saying she would get a fee schedule only after she signs a "provider" agreement. She explained that at this point in her career anything under 150 percent of Medicare rates would be unacceptable. They could not meet that. She is starting a direct primary care (DPC) model to avoid headaches of dealing with insurance companies more concerned about company and stockholder profits than about helping patients.

Liberals Are Wrong: Free Market Health Care Is Possible (Avik S. A. Roy, The Atlantic, 3-18-12) Roy explains that Kenneth Arrow endorsed the view that "the laissez-faire solution for medicine is intolerable," that the delivery of health care deviates in fundamental ways from a classical free market, and therefore, that government must intervene to correct these deviations. Roy explains the five market distortions for health care Arrow cited, but says, "No, you can't shop for health care when you're unconscious, or when you're in acute or emergent situations. Does this justify nationalizing the health care system? No." "So, it seems to me, those who strongly believe in the shopping argument for socialized medicine should adopt a hybrid approach. Let's have a free market for the 70-plus percent of health care where market forces can most directly apply, and let's have universal catastrophic insurance for those situations where market forces work less well. This way, we might get the best of both worlds: an efficient, affordable, high-quality market for chronic and routine health care, and a universal system for those who get hit by a bus, or have a stroke, or get cancer. Such a system would leave no one behind. But it would also allow our health-care system to benefit, as much as possible, from the forces of choice, competition, and innovation."
Consumers’ Interest In Provider Ratings Grows, And Improved Report Cards And Other Steps Could Accelerate Their Use (Steven D. Findlay, Health Affairs, April 2016). "In addition to new technology, recent laws and changes in society and the delivery of care are laying the foundation for greater use by consumers of provider performance report cards. Such use could be accelerated if the shortcomings of current report card efforts were addressed. Recommendations include making online report cards easier to use and more understandable, engaging, substantive, and relevant to consumers’ health and medical concerns and choices. "
Ratings for hospitals, doctors, surgeons, home health agencies, nursing homes

What journalists should know about hospital ratings (Liz Seegert, Covering Health, Association of Health Care Journalists, 6-24-16) "Journalists should take hospital ratings with a healthy dose of skepticism, according to experts at a recent AHCJ New York chapter event. Simply looking at an institution’s overall rating is just the start. Reporting that without understanding what’s being rated and how ';success' is measured does a disservice to your audience."

What quality measures can tell us about nursing home ratings (Liz Seegert, Covering Health, AHCJ, 7-27-16). "Nursing home star ratings are misleading and disingenuous, according to a recent analysis comparing ratings with quality measures alone. More than a thousand nursing homes nationally with high overall ratings had only one or two stars in quality measures, which could point to some serious health implications for residents."

Donabedian’s Lasting Framework for Health Care Quality (John Z. Ayanian, M.D., M.P.P., and Howard Markel, M.D., Ph.D. N Engl J Med 2016; 375:205-207July 21, 2016DOI: 10.1056/​NEJMp1605101) In a landmark article published 50 years ago, Avedis Donabedian proposed using the triad of structure, process, and outcome to evaluate the quality of health care. That triad, along with his eventual seven pillars of quality, continues to inform efforts to improve care. "Health care is a sacred mission . . . a moral enterprise and a scientific enterprise but not fundamentally a commercial one. We are not selling a product. We don't have a consumer who understands everything and makes rational choices -- and I include myself here. Doctors and nurses are stewards of something precious . . . " With thanks, as so often, to Norman Bauman for links and references.
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Improving health care practices

ECRI Institute Announces Top 10 Health Technology Hazards for 2015 . Alarm hazards, electronic health record data integrity issues, and infusion line mix-ups top the list, available now for free download.) Topics on the 2015 list include:
1. Alarm hazards: Inadequate alarm configuration policies and practices
2. Data integrity: Incorrect or missing data in electronic health records and other health IT systems
3. Mix-up of IV lines leading to misadministration of drugs and solutions
4. Inadequate reprocessing of endoscopes and surgical instruments
5. Ventilator disconnections not caught because of mis-set or missed alarms
6. Patient-handling device use errors and device failures
7. “Dose creep”: Unnoticed variations in diagnostic radiation exposures
8. Robotic surgery: Complications due to insufficient training
9. Cybersecurity: Insufficient protections for medical devices and systems
10. Overwhelmed recall and safety alert management programs

Further to point 2, read the brief 3 reasons why health care IT will always be terrible (Suneel Dhand, MD, Kevin MD, 2-15-17) IT caters to hospital administration, not to doctors. It's a monopoly once installed. And doctors have allowed themselves to be turned into data-entry clerks without demanding major change.

50 Ways to Leave a Refill Request (Fred N. Pelzman, MD, Building the Patient-Centered Medical Home, MedPageToday, 5-18-17) Imagine a system in which, when your medication is running low, you ask the pharmacist to ping the doctor, and the pharmacist fills the order -- instead of dozens of phone calls, voicemails, emails, faxes, electronic messages, and walk-ins eating up time and man-hours inefficiently. We "have to keep trying, streamlining the way we do things, hopefully eliminating the excess baggage of dealing with all of these multiple systems, to get us to a place where we can much more easily take care of our patients, and our patients can much more easily get the care they need."
Genetic testing fumbles, revealing ‘dark side’ of precision medicine (Sharon Begley, STAT: Reporting from the frontiers of health and medicine, 10-31-16) 'Enthusiasm for precision medicine, from the White House down to everyday physicians, is at an all-time high. But serious problems with the databases used to interpret patients’ genetic profiles can lead to “inappropriate treatment” with “devastating consequences,” researchers at the Mayo Clinic warned on Monday....“This is the proverbial dark side of genetic testing and precision medicine,” said Ackerman. Because databases that companies use to interpret DNA tests are riddled with errors, “we’re starting to see a lot of fumbles,” with patients told that a DNA misspelling is disease-causing when it actually isn’t....That raises the very real concern that some people treated with “precision” approaches will be misdiagnosed and given useless or even harmful treatment.'
Genetic test costs taxpayers $500 million a year, with little to show for it (Casey Ross, STAT, 11-2-16). Unnecessary medical care is estimated to cost the United States between $750 billion and $1 trillion dollars a year, accounting for nearly a third of its overall spending on health care. Wasteful testing is one of the primary drivers of those costs. In the case of inherited thrombophilia, said Dr. Christopher Petrilli (a University of Michigan hospitalist who coauthored the study cited), doctors appeared to be complicit in the waste — possibly due to fear of litigation or simply a shared desire to get the answers for their patients. “You can explain to them that getting a test is not going to change therapy and that it’s just going to lead to more anxiety, unclear results, and more testing,” said Dr. Nitin Damle, president of the American College of Physicians.
One Hospital Tells Bronx's Sick: You Call Us, We’ll Call You (Amanda Aronczyk, WNYC, ) A patient's "accountable care manager" helps him coordinate his complex health care procedures and visits.

Choosing Wisely (aimed at teaching physicians to think more carefully about default screening options--at eliminating unnecessary or overused procedures)

• Community paramedicine. Beyond 911: State and Community Strategies for Expanding the Primary Care Role of First Responders
Development of Community Paramedic Programs (Discussion paper for Joint Committee on Rural Emergency Care (JCREC), National Association of State Emergency Medical Services Officials, National Organization of State Offices of Rural Health. Rural EMS systems should be able to respond in a timely, appropriate manner whenever serious injury or illness strikes someone in need. The concept of community paramedicine represents one of the most progressive and historically based evolutions available to community-based healthcare and to the Emergency Medical Services arena. By utilizing Emergency Medical Service providers in an expanded role, community paramedicine increases patient access to primary and preventative care, provides wellness interventions within the medical home model, decreases emergency department utilization, saves healthcare dollars and improves patient outcomes. Planning for a system in which the role of EMS providers is expanded role as part of a community-based team of health services and providers.

The Essential (Before I Kick the) Bucket List (Amy Berman, Health AGEnda, John A. Hartford Foundation, 8-30-12) Diagnosed with Stage IV inflammatory breast cancer in October 2010, Berman decided instead of making a personal bucket list of things to do before she dies to make a health care bucket list (for the system). Read about the five things she listed:
1) Care centers on the patient;
2) Care addresses the needs of the family;
3) Care is better coordinated;
4) Care focuses on quality of life and patient goals;
5) End of life care is more compassionate and driven by preferences.
The Doctor Who Championed Hand-Washing and Briefly Saved Lives (Rebecca Davis, Morning Edition, NPR, 1-12-15) It's not enough to discover an important way to improve health care--one has to convey it in an acceptable manner, suggests this story of a Hungarian doctor named Ignaz Semmelweis.

N.C. Program A Model For Health Overhaul? (Rose Hoban, North Carolina Public Radio, Morning Edition, NPR, 10-15-09). The state Medicaid program in North Carolina is helping people stay healthier--and saving the state money. Medicaid (not the clinics) pays nurses and social workers to do case management. They're placed in clinics and sites that see lots of patients and their priorities are those of the state, not the clinic managers (who might be interested in churning to create revenue). See also this policy profile of Community Care of North Carolina (Kaiser Commission on Medicaid and the Uninsured, 2009).CCNC's website has links to more stories and information.
The Checklist Manifesto: How to Get Things Right by Atul Gawande, who argues persuasively that medicine has become so complex that without a checklist for medical teams to work by, medical professionals will inevitably make fatal errors or omissions.

The Simple Idea That Is Transforming Health Care (Laura Landro, WSJ, 4-16-12). A focus on quality of life helps medical providers see the big picture—and makes for healthier, happier patients. Focusing on well-being might seem like a basic idea, but it is a departure from the traditional approach, especially with chronic-disease sufferers.

The Radical Rethinking of Primary Care Starts Now (Dan Diamond, The Health Care Blog, 3-7-13)

Safety-net clinics adopt medical home model (Mike Sherry, Health Care Foundation of Greater Kansas City, 1-10-13). Health care reform advocates cite patient-centered medical homes as a best-practice in providing comprehensive primary care while reducing the need for costly treatments.
And the federal Department of Health and Human Services has set a goal of having 25 percent of the nation’s community health centers certified as medical homes in fiscal year 2013, which ends Sept. 30. Proponents say certification ‘more than just paperwork,’ it’s a better model for practicing medicine.

Sharing Psychiatric Records Helps Care (Nicholas Bakalar, Well column, NY Times, 1-7-13)

A doctor's touch (Abraham Verghese's TED Talk, July 2011). Verghese describes our strange new world where patients are merely data points, and calls for a return to the traditional one-on-one physical exam.

Checking Boxes (Regina Harrell, Pulse, 10-18-13). A primary-care doctor who makes house calls in and around Tuscaloosa, Alabama, could spend more time caring for frail elders in their home if she didn't waste so much time filling in irrelevant boxes on computer forms so that she'll get paid.

U.S. Preventive Services Task Force (recommendations for, against, and for a specific number of various screening procedures).
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The costs of neglecting the mentally ill

Cost of not caring: Nowhere to go (Liz Szabo, in excellent series in USA TODAY, ). The financial and human toll for neglecting the mentally ill. First story: A man-made disaster: A mental health system drowning from neglect. “We have replaced the hospital bed with the jail cell, the homeless shelter and the coffin” (Rep. Tim Murphy, R-Pa.) States have been reducing hospital beds for decades, because of insurance pressures as well as a desire to provide more care outside institutions. Tight budgets during the recession forced some of the most devastating cuts in recent memory, says Robert Glover, executive director of the National Association of State Mental Health Program
Mental illness cases swamp criminal justice system (Kevin Johnson, USA Today) On America's streets, police encounters with people with mental illnesses increasingly direct resources away from traditional public safety roles. Chapter 1: Hordes of inmates are ill. Fractured system plagued by problems. “They end up here (the criminal justice system), because we are the only system that can't say no.” ~Cook County sheriff Tom Dart. Chapter 2: Taken away in cuffs. Exhausted cops transport those needing help all over the state. Chapter 3: A gunshot, and a teen dies. Not all officers are trained to deal with mental patients. Chapter 4: Lessons from a fatal shooting. A call goes out for special officer training. Chapter 5: A call for help, then Navy Yard. Aaron Alexis and the 'vibrations' in his body
Cost of not caring: Stigma set in stone (Liz Szabo, USA TODAY) Mentally ill suffer in sick health system. Chapter 1: A separate and unequal system. People with mental illness face legal discrimination. “'There is no other area of medicine where the government is the source of the stigma.' ” Rep. Tim Murphy, Rep. PA. Chapter 2: Lost in darkness. Many wait nearly a decade for treatment. "“'If someone had listened to me the way that psychiatrist listened to me in jail. I think maybe my illness wouldn't have gotten that far.'” Chapter 3: Working for change. Advocates chip away at discriminatory policies. “'Every parent I know has to fight for treatment for their child.'” Chapter 4: Overcoming the shame: Speaking up heals old wounds. “'Where we are at is where the cancer community and HIV community were 25 years ago.'” NFL player Brandon Marshall
The Fortunate Mother: Caring for a son with schizophrenia (Rick Hampson, USA TODAY) The lucky one: Despite hardships, a mother knows it could be worse. For the mentally ill, relatives are the last to leave.
Early intervention could change nature of schizophrenia (Liz Szabo, USA Today) Programs aim to prevent psychosis or halt a patient's decline.
Solutions to woes of mentally ill exist but aren't used (Liz Szabo, USA TODAY) Millions could be helped if programs were put into place.
Substance abuse treatment often impossible to find (Larry Copeland, USA Today) Promising strategies gather dust: 'It's hard to get anyone to pay attention until it happens again.' Joan Ayala now works as a mental health clinician trying to help others avoid her decades-long ordeal.
Mental disorders keep thousands of homeless on streets (Rick Jervis, USA Today) Thousands with mental illness end up homeless, but there are approaches that can help out. Dorothy Edwards hugs her 8-year-old dog, a shepherd-pit bull mix that helped protect her when she lived on the streets.
40,000 suicides annually, yet America simply shrugs (Gregg Zoroya, USA Today) There's a suicide in the USA every 13 minutes.

Navy SEAL Loses Battle with PTSD (Here and Now, WBUR, 1-14-13). For a Navy Seal, getting help for PTSD disqualifies you for security clearance, and in this case, Rob Guzzo, who served in Iraq, went for help too late. "For a SEAL, if you don’t have a security clearance, you don’t go on secret classified missions, therefore you’re not a Navy SEAL.”
• You can watch Michael Moore's documentary, Sicko online. You can hear on Bill Moyers' interview with Wendell Potter how the insurance industry planned to defuse reactions to Moore's documentary. As Potter states: "The industry has always tried to make Americans think that government-run systems are the worst thing that could possibly happen to them, that if you even consider that, you're heading down on the slippery slope towards socialism. So they have used scare tactics for years and years and years, to keep that from happening. If there were a broader program like our Medicare program, it could potentially reduce the profits of these big companies. So that is their biggest concern." Potter himself says of the documentary, "I thought that he hit the nail on the head with his movie. But the industry, from the moment that the industry learned that Michael Moore was taking on the health care industry, it was really concerned."
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Organizations serious about improving U.S. health care

Alliance for Health Policy (until recently Alliance for Health Care Reform) provides tools for journalists to cover health reform, which are equally useful to ordinary citizens. See this invaluable resource: The Sourcebook: Essentials of Health Policy, which links to resources.
Agency for Healthcare Research and Quality, including Center for Outcomes and Effectiveness and Centers for Education and Research on Therapeutics
Association of Health Care Journalists (AHCJ) , an invaluable organization for journalists covering health care and health care reform. Core topics at September 2013 conference include health reform, aging, oral health, and medical studies. Topics to be covered in future include insurance, health insurance, health professionals, and health information technology. Many of the resources listed here I learned of from AHCJ, which also provides special informal toolkits for members. The annual conference is excellent and very helpful at keeping members up to date on what's happening in the health care field. See Health Reform resource links and Topic overview. Any journalist covering health care reform should belong to this organization.
CDC's National Center for Chronic Disease Prevention and Health Promotion
CDC's Center for Emergency Preparedness and Response
Cochrane Database of Systematic Reviews (CDSR--systematic reviews of primary research in human health care and health policy -- the highest standard in evidence-based health care). See, for example, the top 50 reviews (The Cochran Collaboration).
Commonwealth Fund's health reform resource center , including a timeline for an overview of the Affordable Care Act's major provisions and a "Find Health Reform Provisions" tool to search for specific provisions by year, category, and/​or stakeholder group. Also see related Commonwealth Fund content and links to regulations as they become available. (because health professionals can't do it alone). See particularly e-Patient Dave on BMJ's evaluation of online symptom checkers: Evaluation of symptom checkers for self diagnosis and triage: audit study ( BMJ 2015;351:h3480)
Find Help (SAMHSA's links for substance abuse and mental health services)
Get Health Care (HRSA links to free and inexpensive care)
Health Affairs, including its blogs and health policy briefs. Official site of Affordable Care Act., U.S. government database/​encyclopedia of information and interactive tools. See Health Topics A to Z, find services near you, and check out the gazillion other helpful topics.
Medicare Rights Center, national nonprofit consumer service organization, National Helpline: 1-800-333-4114. Counselors are available Monday through Friday, and are happy to answer your questions about insurance choices, Medicare rights and protections, payment denials and appeals, complaints about care or treatment, and Medicare bills.
Medicine (Science Blogs)
Medline Plus makes available information from the National Library of Medicine (NLM), the National Institutes of Health (NIH), and other government agencies and health-related organizations. Provides access to medical journals and extensive information about drugs, an illustrated medical encyclopedia, patient tutorials, and health news.
NAIRO (National Association of Independent Review Organizations, dedicated to protecting the integrity of the medical review process)
Physicians for a National Health Program (supports single-payer national health insurance)
Reporting on Health (USC Annenberg)
Reports from the Institute of Medicine (National Academies)
Rural Health Information hub (RHIhub) (formerly the Rural Assistance Center, U.S. Dept. of Health and Human Services) 1-800-270-1898. See online library. Helps rural communities and stakeholders gain access to wide range of programs, funding, and research. , links to resources for people who want to quit smoking.
Society for Participatory Medicine (a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners) (Consumers' Checkbook's new website lists surgeons Checkbook has identified as having better–than–average outcomes -- covers 15 types of surgery, but only lists surgeons significantly above average on 90-day mortality, readmissions, and same-stay complications_
Surgeon Scorecard. ProPublica's website shows death and complication rates in eight types of surgery, showing results on all surgeons, good or bad. with 20 or more surgeries in a category. See USA Today story 'Surgeon scorecard' measures docs by complications.
Paul Burke compared methods for the Checkbook and ProPublica rating systems (Globe1234). provides all kinds of data a patient might/​should want to have
SurveyUSA News Poll on Health Care Data (showing public opinion on various aspects of the health care debate, by gender, race, party affiliation, ideology, level of college education, income,region, and age)
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The politics and policy issues of health care (insurance) reform and the ACA

C-Span is a good place to find various town hall discussions, hearings, wonderful links. For example: Supreme Court Determining the Constitutionality of Health Care Act and Supreme Court Hears Argument on Individual Mandate Provision
How Trump May End Up Expanding Medicaid, Whether He Means To or Not (Jeff Stein, WashPost, 1-28-18) Republican lawmakers in a half-dozen states are launching fresh efforts to expand Medicaid, the nation’s health insurance program for the poor, as party holdouts who had blocked the expansion say they’re now open to it because of Trump administration guidelines allowing states to impose new requirements that program recipients work to get benefits. In Utah, a Republican legislator working with the GOP governor says he hopes to pass a Medicaid expansion plan with work requirements within the year. In Idaho, a conservative lawmaker who steadfastly opposed Medicaid expansion in the past says the new requirements make him more open to the idea. And in Wyoming, a Republican senator who previously opposed expansion — a key part of President Barack Obama’s health-care law — says he’s ready to take another look at fellow Republicans’ expansion efforts in his state.
Why Do People Hate Obamacare, Anyway? (Julie Rovner, Kaiser Health News, 12-13-17) The Affordable Care Act, aka “Obamacare,” has roiled America since the day it was signed into law in 2010. From the start, the public was almost evenly divided between those who supported it and those who opposed it. They still are. The November monthly tracking poll from the Kaiser Family Foundation found that 50 percent of those polled had a favorable view of the health law, while 46 percent viewed it unfavorably. Partisan politics drives the split. Eighty percent of Democrats were supportive in November, while 81 percent of Republicans were strongly negative. (Illustrations shows banners saying "Keep the IRS out of my healthcare" and "Obamacare's IRS MANDATE is illegal")
Why American doctors keep doing expensive procedures that don’t work (Eric Patashnik, Vox, 12-28-17) The " coalition in favor of evidence-based medicine is weak. It includes too few doctors, commands too little attention and energy from elected officials and advocates, and it’s shot through with partisanship....While virtually all doctors support evidence-based medicine in the abstract, clinicians and medical societies seek to maintain their professional and clinical autonomy....Politicians, who recognize that the public holds them in much lower regard than physicians, are hesitant to challenge the belief of many Americans that “doctor always knows best.” The American faith in markets leads to a cultural discomfort with government-imposed limits on the supply or consumption of medical technology. Meanwhile, other advanced democracies use such limits (along with price controls) as part of the toolkit to control medical spending and promote “value for money.” ...Other countries, including the UK, may require a favorable cost effectiveness ratio before a treatment is placed on the national formulary — meaning that some treatments, such as some cancer drugs, won’t be recommended for routine funding if they are too expensive relative to their clinical benefits. Many Americans would bridle at that kind of explicit rationing....In the US, even modest reforms to use taxpayer money to fund research to learn what treatments work best, for which patients, have engendered controversy. Republicans famously charged that the establishment of the Patient-Centered Outcomes Research Institute (PCORI) through the Affordable Care Act, would lead to the creation of “death panels.” Patashnik is co-author, with Alan S. Gerber and Conor M. Dowling, of the book Unhealthy Politics: The Battle over Evidence-Based Medicine.
Medicare Payment Plan on Cancer Drugs Sparks Furious Battle (Ricardo Alonso-Zaldivar, ABC News, 4-10-16) A Medicare proposal to test new ways of paying for chemotherapy and other drugs given in a doctor's office has sparked a furious battle, and cancer doctors are demanding that the Obama administration scrap the experiment. At issue are some of the most expensive drugs for treating life-changing diseases. The question isn't whether those drugs are fairly priced, but whether Medicare's current payment policy encourages doctors to prescribe the costliest medications so they can make more money. Injected and infused drugs for such conditions as macular degeneration, rheumatoid arthritis and Crohn's disease are also affected.
"The new formula announced last month combines a 2.5 percent add-on (as opposed to 6 percent) with a flat fee for each day the drug is administered. A control group of doctors and hospitals would continue to be paid under the current system. "A second wave of experimentation would try to link what Medicare pays for a given drug to how well it works." "Specialist doctors, drugmakers and some patient advocacy groups are trying to compel Medicare to drop the plan. Primary care doctors, consumer groups representing older people, and some economic experts want the experiment to move ahead."
Double-Booked: When Surgeons Operate On Two Patients At Once (Sandra G. Boodman, KHN, 7-12-17) The controversial practice of overlapping surgery — in which a doctor operates on two patients in different rooms during the same time period —has been standard in many teaching hospitals for decades, its safety and ethics largely unquestioned and its existence unknown to those most affected: people undergoing surgery. But it has ignited an impassioned debate in the medical community, attracted scrutiny by the powerful Senate Finance Committee that oversees Medicare and Medicaid, and prompted some hospitals, including the University of Virginia’s, to circumscribe the practice. Known as “running two rooms” — or double-booked, simultaneous or concurrent surgery — the practice occurs in teaching hospitals where senior attending surgeons delegate trainees — usually residents or fellows — to perform parts of one surgery while the attending surgeon works on a second patient in another operating room. Critics of the practice, who include some surgeons and patient-safety advocates, say that double-booking adds unnecessary risk, erodes trust and primarily enriches specialists.
UnitedHealth Warns Of Marketplace Exit – Start Of A Trend Or Push For White House Action? (Julie Appleby, Kaiser Health News, 11-20-15) UnitedHealthGroup laid out a litany of reasons Thursday why it might stop selling individual health insurance through federal and state markets in 2017 — a move some see as an effort to compel the Obama administration to ease regulations and make good on promised payments. “Disproportionately, the sick are signing up and the healthy are dropping out,” said former insurance executive and consultant Robert Laszewski, adding that alternative plans with fewer benefits but lower costs should be made available.
Core topic: Insurance (invaluable resource page, Association of Health Care Journalists). See, for example, Glossary; key concepts; resource links; multimedia archive.
Safety net programs for the poor.
Repairing Medicare (Wash Post, 1-6-13) "There are two major reasons for Medicare’s rising costs. The first is the program’s design, often tweaked but left fundamentally intact since its creation in 1965, which basically pays doctors and hospitals fixed fees for whatever they do. The ultimate solution is structural: to limit growth in expenditures per beneficiary. Easier said than done. he current Medicare program includes a hodgepodge of cost-sharing requirements that neither give participants clear incentives to limit consumption of services nor shield them from catastrophic expenses. "
How does health spending in the U.S. compare to other countries? (Bradley Sawyer and Cynthia Cox Kaiser Family Foundation, Health System Tracker, 5-22-17) Helpful chart.
Medicine’s Top Earners Are Not the M.D.s (Elisabeth Rosenthal, Sunday Review, NY Times 5-12-14) The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries. (There are more doctors than administrators, so she's talking about individual, not total, salaries for a group.)
Remembering What Matters About the Affordable Care Act (Paul Waldman, American Prospect, 1-30-14) On the Affordable Care Act front today, there's very good practical news, and not-so-good political news. That gives us an excellent opportunity to remind ourselves to keep in mind what's really important when we talk about health care.
GOP Views of Medicaid Expansion Differ From Conventional Wisdom (Drew Altman, WSJ blog, 11-4-15) Many Republicans in states that have not expanded Medicaid are favorable toward expansion. "That even a slim majority of Republicans favor expansion is notable given the tone of debate on this issue on the campaign trail, where expansion has become like a third rail for GOP candidates. ...But Medicaid may not be as unpopular with Republicans overall as the conventional wisdom suggests, and other issues may be more salient for Republican voters in primary and general elections across the country than opposition to Medicaid expansion."
Bernie Sanders, Hillary Clinton, and Medicare for All (Drew Altman, WSJ blog, 12-20-15) A skirmish broke out recently between Hillary Clinton and Bernie Sanders about the merits of single-payer health care, an idea that Mr. Sanders has long advocated. Most Democrats either strongly favor (52%) or somewhat favor (24%) the general idea of Medicare for all. Meanwhile, 62% of Republicans either strongly or somewhat oppose the idea. In his advocacy of Medicare for all, a policy that he recognizes cannot be achieved any time soon, Mr. Sanders is signaling his outside-the-box approach to policy and politics, while in opposing the idea Mrs. Clinton may have been signaling her more practical and incremental approach to achieving policy change.
Health Insurance Is Not a Favor Your Boss Does For You (Paul Waldman, American Prospect, 7-9-14) Everyone seems to have forgotten that insurance is a form of compensation, no less than your salary. Click here for more Waldman stories on health care and insurance.
The Tennessean pushes for better healthcare (Trudy Lieberman, Columbia Journalism Review, 12-1-14) on how one reporter's (Tom Wilemon's) stories show readers the effect of state government policy on real people. For example, Twin babies' $200K hospital bill illustrates TennCare flaws (10-4-14), Thousands caught in TennCare limbo await hearings (11-14-14), TennCare patients on ventilators face cuts in home care (11-9-14), and TennCare point system leaves some seniors fending for themselves (video and print story on TennCare's scoring system, under which those who have difficulty walking and eating still may not qualify for nursing home care) 2-16-14).
Behind the Scenes on Those Enormous Medicare Billing Numbers (Kevin Jones, Mother Jones, 4-10-14)
A British Woman Spent Three Days in a U.S. Hospital. Here's What She Learned About Obamacare. (Eleanor Margolis, New Republic, 10-18-13. First appeared in New Statesman) "I begin to wonder how the Republicans have managed to convince even those in the very midst of a system that punishes the poor, that the slightest implementation of state-funded healthcare is an evil, communist conspiracy. ...As a foreigner with travel insurance, I’m lucky enough to observe American healthcare from a safe distance. But to someone fully enmeshed, like Carmen, Obamacare is a tiny drop in the murkiest of quagmires."
What's in a name? Lots when it comes to Obamacare/​ACA (Steve Leisman, CNBC, 9-26-13) In CNBC's third-quarter All-America Economic Survey, we asked half of the 812 poll respondents if they support Obamacare and the other half if they support the Affordable Care Act. And 30% of those polled don't know what ACA is, vs. only 12% when asked about Obamacare; 29% support Obamacare compared with 22% who support ACA; and 46% oppose Obamacare and 37% oppose ACA. "So putting Obama in the name raises the positives and the negatives." Republicans coined the term Obamacare as a pejorative, but not everyone perceives it that way.
Understanding the Right’s Obamacare Obsession (Joshua Holland, What Matters Today,, 9-2-13) Excellent overview.
Why Republicans can't come up with an Obamacare replacement (Ezra Klein, Vox, 1-16-15) Making "sure poor people have health insurance is politically popular, at least in the abstract. But the plans that achieve it tend to be in tension with both broad tenets of conservatism — it raises taxes, it redistributes wealth, and it grows the government — and with key factions of the conservative coalition....It is ironic that the law Republicans loathe most is actually based on ideas they developed, and that their most recent presidential nominee actually implemented."
Supreme Court Case May Be A Wake-Up Call For Republicans (Julie Rovner, KHN, 2-23-15) About Obamacare: "“Republicans are united around repeal. And they’re united around replace. But obviously they’re not united around ‘replace with what...’”
Obamacare: The Rest of the Story (Bill Keller, Opinion Page, NY Times, 10-13-13) "You realize those computer failures that have hampered sign-ups in the early days — to the smug delight of the critics — confirm that there is enormous popular demand. You have probably figured out that the real mission of the Republican extortionists and their big-money backers was to scuttle the law before most Americans recognized it as a godsend and rendered it politically untouchable. What you may not know is that the Affordable Care Act is also beginning, with little fanfare, to accomplish its second great goal: to promote reforms to our overpriced, underperforming health care system. " An interesting account of "accountable care organizations" (ACOs), which are springing up all around the country.
Americans' Top Health-Care Priorities for the President and Congress (Drew Altman, WSJ, 5-4-15) Surprising results of the Kaiser Family Foundation’s April 2015 Health Tracking Poll. #1 priority: Making sure that high-cost drugs for chronic conditions are available at affordable costs.
Medicaid Expansion in Red States (Drew Altman, WSJ's Think Tank, 12-18-14) "In the struggle between pragmatism and ideology over Medicaid expansion in red states, pragmatism may slowly be winning."
Majority Favors the Affordable Care Act’s Employer Mandate, But Opinion Can Shift When Presented With Pros and Cons (Kaiser Family Foundation, 12-18-14) Recent news stories on the health law did not attract most Americans’ attention, and many are unaware of details and implications of the developments.
Three Words and the Future of the Affordable Care Act (PDF, Nicholas Bagley, draft accepted for publication in Journal of Health Politics, Policy and Law, 2014, open access)
The Piecemeal Assault on Health Care(NY Times editorial, 11-22-14) "Now that they will dominate both houses of Congress, Republicans are planning to dismantle the Affordable Care Act piece by piece instead of trying to repeal it entirely....All of the provisions they are targeting should be retained — they were put in the reform law for good reasons."
Hospitals and health law (Opinion, NY Times, 12-7-14) "The American people aren’t the only ones who will suffer from the systematic dismantling of the Affordable Care Act. It’s also bad news for America’s hospitals."
The Affordable Care Act Will Work (Sen. Jay Rockefeller, Reader Supported News, 10-3-13)
Where Poor and Uninsured Americans Live (interactive map, NY Times, 10-2-13). The 26 Republican-dominated states not participating in an expansion of Medicaid are home to a disproportionate share of the nation’s poorest uninsured residents. Eight million will be stranded without insurance.
Church Insurance Improvements To Obamacare Threatened By Partisan Fighting (Sarah Pulliam Bailey, Religion News Service, 8-9-13)
Little Evidence Obamacare Is Costing Full-Time Jobs (Kaiser Health News' Daily Report, 10-23-13) Roundup of stories from WSJ, NYTimes, Reuters, Wash Post, Politico and others.
States Are Focus of Effort to Foil Health Care Law (Sheryl Gay Stolberg, NY Times, Politics, 10-18-13) In Virginia, conservative activists are pursuing a hardball campaign as they chart an alternative path to undoing “Obamacare” — through the states.
The Republican party's 'defund Obamacare' disorder (Michael Cohen, The Guardian, 8-25-13) In denial of political reality thanks to its Tea Party fringe, the GOP is revving up for a debt ceiling showdown it can only lose.
How the ObamaCare defunding fight became a political showdown (Sam Baker, HealthWatch, 8-29-13)
as part of a whole section on
Health Care Reform, Medical Error, and the Affordable Care Act, including one section on What you need to know about long-term care insurance.
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Health insurance, ACA, and the marriage glitch

What Happens When Marriage Makes Health Insurance Unaffordable (Sammy Mack, Health News Florida, 12-2-15) The “family glitch”: when you get married and lose your subsidy to buy insurance in the individual marketplace. "Under the Affordable Care Act, if one person in a family has a job that offers health insurance to the rest of the family then nobody can get subsidies on the federally run exchanges. A recent study from the Kaiser Family Foundation estimates that more than 400,000 Floridians went without health coverage—even when they could have gotten it through work....Big employers have to offer “affordable” health insurance options to employees to avoid federal tax penalties. An affordable plan for the employee can’t cost more than 9.5 percent of her household income. But the rules don’t apply to family members of the employee....As health insurance costs keep rising, the family benefit is one of the places employers can shift costs without getting fined. And, says Ullmann, there’s reason to believe more families will find themselves in this situation."
When the partner over 65 picks up Medicare (and a secondary insurer), the under-65 person is left out in the cold, says one member of Association of Health Care Journalists, through whom I learn much of what you find here).

The Hidden Marriage Penalty in Obamacare (Garance Franke-Ruta, The Atlantic, 11-5-13) Childless couples and empty nesters pay more. Much more. The Obamacare subsidies "are more generous to single people and one- or two-parent families with children in the house than to couples who lack children. They were designed to help single moms and struggling middle-class families with children, not married creative-class millennials in pricey cities who have not yet settled into well-paid work, or barring that, work for a single employer."
"Any married couple that earns more than 400 percent of the federal poverty level—that is $62,040—for a family of two earns too much for subsidies under Obamacare. "If you're over 400 percent of poverty, you're never eligible for premium" support, explains Gary Claxton, director of the Health Care Marketplace Project at the Kaiser Family Foundation."

Some Face Marriage Penalty In Obamacare Subsidies (Robert Calandra, The Philadelphia Inquirer and Kaiser Health News, 12-4-13) Some couples are complaining that "the law has a hidden marriage penalty. Here’s why: Say a couple has a household income of $70,000 with one spouse making $30,000 and the other $40,000. Combined, they are ineligible for a subsidy. But if they were just living together, each would be eligible for a subsidy." “We’ve known all along that some people will do better in this market and some people will do worse,” said one expert. "The ACA, like the tax code, is complicated, and it sometimes provides a marriage subsidy and a penalty, said Mark Duggan, a health economist at the University of Pennsylvania’s Wharton School." Changing "the way health insurance is delivered in America is a huge undertaking.... the country will have to break a few eggs to make this omelet."

Resources for Agents and Brokers in the Health Insurance Marketplaces (The Center for Consumer Information & Insurance Oversight, CCIIO, CMS)

Why The GOP’s ‘Marriage Penalty’ Is A Myth (Igor Volsky, ThinkProgress, 10-27-11) Issue one: "since the majority of the uninsured are not married and marrying lowers uninsurance rates, providing more subsidies to individuals is a better way of targeting affordability credits to those who need them expand the affordability definition and allow more people to take advantage of the tax credits within the exchanges would cost the government “an extra $50 billion a year” — spending Republicans would surely oppose....Republican health care prescriptions — look to the Boehner alternative introduced in the House for an example — don’t provide subsidies to anyone — married or unmarried and it’s actually their efforts to repeal the ACA and do little to nothing for health care spending that would significantly strain families and their economic well being."
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