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Reforming the U.S. health care system

Taking the mystery out of health care prices
Improving health care practices
Understanding the issues health care reform should address
The costs of neglecting the mentally ill
Doctors' incentives to prescribe expensive drugs
Does competition lead to better health care? How much choice do consumers have?
Drugs, Big Pharma, conflicts of interest, and why U.S. patients pay too much for medication (updated blog post)
Generic drugs: overpricing, shortages, market manipulation, and other issues
Health savings accounts: Who benefits from them?)
Organizations serious about improving U.S. health care
Pharmacy benefit managers: The benefits they manage do not benefit consumers
Ratings for hospitals, doctors, surgeons, home health agencies, nursing homes (helpful blog post)
Why U.S. medical costs are so high and where the system needs fixing (updated blog post)

The Affordable Care Act (ACA, aka Obamacare)
Health care reform and the Affordable Care Act (ACA)
Health insurance, ACA, and the marriage glitch
Repeal, replace, and Republican efforts to get rid of Obamacare ("Inside the Sausage Factory")
The politics and policy issues of health care (insurance) reform and the ACA
The truth about health care reform and health care policy


Single payer and other models for health care financing
Pros and cons of a single-payer system
Lessons from health insurance systems in other countries
Gradual and modified approaches to single payer system
      (including Direct primary care)
Dealing with physician (and other healthcare professional) shortages 

     (greater during the pandemic)

"If you think you're too small to have an impact,
try going to bed with a mosquito."

Understanding the issues health care reform should address

Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare by Niran Al-Agba and Rebekah Bernard. These authors expose "a vast conspiracy of political maneuvering and corporate greed that has led to the replacement of qualified medical professionals by lesser trained practitioners. As corporations seek to save money and government agencies aim to increase constituent access, minimum qualifications for the guardians of our nation’s healthcare continue to decline—with deadly consequences. This is a story that has not yet been told, and one that has dangerous repercussions for all Americans.With the rate of nurse practitioner and physician assistant graduates exceeding that of physician graduates, if you are not already being treated by a non-physician, chances are, you soon will be.

     Written by two physicians, "this data-driven book interweaves heart-rending true patient stories with hard data, showing how patients have been sacrificed for profit by the substitution of non-physician practitioners."
A Look Inside the Exorbitant Costs of Applying to Residency (Andrea Zhang, Second Opinions, MedPage Today, 5-2-24) Many factors lead to a low percentage of low-income students in medical schools, such as limited resources for academic preparation, financial barriers to pursuing higher education, and disparities in opportunities for extracurricular activities and experiences that strengthen medical school applications.

     The cost of applying to medical school alone rules out many potential applicants. One result: About 50% of medical students belong to the top quintile of households (≥$130,000 in 2019), and about 24% of medical students belong to the top 5% (≥$248,728 in 2019). The U.S. median household income in 2019 was $68,703. Only about 5% of medical students were in the lowest household income quintile ($25,600 or below in 2019), and these students disproportionately identify as Black or Hispanic.
Hospitals’ Trauma Care Prices Differed Wildly In 2023: Study (KFF Health News) A new study found prices were so unpredictable between hospitals that some insured patients needing trauma care even ended up with more bills than uninsured people did. Stat, meanwhile, covers tech startups who are making money out of hospital price transparency rules.
Cancer Patients Face Frightening Delays in Treatment Approvals (Lauren Sausser, KFF Health News, 12-22-23) Delaying cancer treatment can be deadly — which makes the roadblock-riddled process that health insurers use to approve or deny care particularly daunting for oncology patients.
Dear Congress, Here's How to Fix the Clinician Shortage (N. Adam Brown, MedPage Today, 3-26-23) The U.S. faces a predicted shortfall of between 37,800 and 124,000 doctors over the next 10 years. While physician shortages will affect nearly every specialty, primary care, pediatrics, and psychiatry will suffer the most. The shortages will make it even more challenging to provide care to a growing population, particularly in underserved areas. Don't believe me? The country's nursing shortage is just as bad as its doctor deficit and patient safety is already at risk as a result.
Healing the Damaged Nurse-Physician Dynamic (Angel J. Mena and Ali Morin, KevinMD, Medpage Today, 3-25-23) This relationship is critical during the current tumultuous landscape of medicine. Multiple factors are damaging the nurse-physician dynamic. Staffing shortages, which have only been exacerbated by the pandemic, continue to plague health systems across the country. Within the next 2 years, it is estimated that there will be a shortage of more than 120,000 doctors and a need for 450,000 more nurses. Additionally, we're seeing increased burnout and attrition rates. In 2021, nurse turnover increased by a staggering 8.4%, resulting in a national average of 27.1%. In the past 5 years alone, the average hospital has turned over 95.7% of its RN workforce.

     Moving forward, the healthcare ecosystem needs to work on tackling staffing shortages and improving retention through a combination of increased support, more institutional training between nurses and physicians, and implementing technology solutions to help improve communication and collaboration.
Monkeypox: Another Lesson in Global Health Neglect (Zain Rizvi and Aly Bancroft, MedPage Today, 8-9-22) We ignore the health of poorer nations at our peril. The U.S. spends hundreds of billions to shore up military defenses, but a small fraction to bolster global health defense -- grants and loans totaling less than a couple of hundred million to support global vaccine manufacturing. We cannot rely on vaccines from private companies for each new disease that goes global. "The solutions need to be global in nature," said the director of the Africa CDC, describing the stakes for monkeypox: "If we're not safe, the rest of the world is not safe." The global community can help contain this outbreak and build toward a more resilient future, but only if it works together.
Racial disparities in opioid addiction treatment: a primer and research roundup (Naseem S. Miller, Journalist's Resource, 5-17-21) The story of how systemic racism took root in policy and addiction treatment dates back to the 1800s. Disparities persist today in the prescription of methadone and buprenorphine. Here's what history and research reveal.
Trans Teens in Texas Worry About Losing Access to Health Care: 'I'm Just as Human as Everyone Else' (Sandy West, People, 5-11-22) After Texas limited transgender medical care for young people, patients are trying to figure out what’s next.
Emergency Care Can't Stop at the Insurance Denials (Andrew Fenton, MedPage Today, 9-6-22) Many have called emergency physicians "heroes" during this pandemic, but some insurance companies don't see us that way. Higher volumes of denied claims harm doctors and patients alike. In the last year alone, Anthem has refused to reimburse physicians in California for the care of thousands of patients, including treatment for those with worrisome chest pain, excruciating abdominal pain, multiple fractured ribs, and other severe emergencies.
ProPublica on Health Care Invaluable investigative reporting from many angles on problems in health care.

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How Big Pharma Grew Addicted to Big Profits (Natasha Singer, New York Times, 3-12-2020) A once-over-lightly review of how Big Pharma got started with Bayer, Merck and Pfizer peddling then-legal heroin and cocaine as a treatment for "colds, coughs, asthma, epilepsy, multiple sclerosis, stomach cancer, schizophrenia"--and as "safe for children". It moves on to their "outrageous marketing of addictive medicines like opioids" and to the "mass production of penicillin during World War II [which] helped pharmaceutical companies throw off their reputations as addictive drug pushers and rebrand themselves as producers of innovative, lifesaving products." They went on to push broad-spectrum antibiotics “prescribed unnecessarily more than 90 percent of the time.” The book: Pharma: Greed, Lies, and the Poisoning of America by Gerald Posner. Posner traces the heroes and villains of the trillion-dollar-a-year pharmaceutical industry and uncovers how those once entrusted with improving life have often betrayed that ideal to corruption and reckless profiteering—with deadly consequences.
How Hospitals Make Enormous Profits from Botched Surgeries (Michael Allen, Opposing Views, 3-1-18) A study published in The Journal of the American Medical Association said that botched surgeries bring in more money for hospitals than successful surgeries. The study found that hospitals bill insurance companies for more money to cover surgical complications, reports Sarah Kliff in the Washington Post (4-16-13)
Three Ways to Fix the Drug Industry's Rampant Dysfunction (Michele Cohen Marill, Wired, 9-10-19) Big Pharma has come under fire for mislabeled drugs, price spikes, and life-threatening shortages. Now a handful of startups hope to clean up the industry. Adam Clark-Joseph and David Light are cofounders of "Valisure, a mail-order pharmacy that tests each batch of drugs it receives from wholesalers or distributors (generic, brand name, and even some over-the-counter items) for dose, dissolution (an indicator of how quickly it is absorbed), and impurities. Customers only receive medicine that is free of contaminants and meets federal standards for dose and dissolution.... Dysfunction in the drug industry has triggered outrage over contaminated generics, massive price increases, and life-threatening shortages of cheap but vital products. Outrage is a catalyst of entrepreneurship, and now Valisure is one of several startups seeking to solve some of the industry’s most glaring problems. Among them are Civica Rx, which aims to eliminate the frequent shortages of dozens of medicines, and Capital Rx, which wants to make drug pricing less opaque....'I think the entire pharmaceutical industry, branded and generic, is ready for major disruption,' says Martin VanTrieste, CEO of Civica Rx.
New study finds 45,000 deaths annually linked to lack of health coverage (David Cecere Cambridge Health Alliance, Harvard Gazette, 9-17-09) Uninsured, working-age Americans have 40 percent higher death risk than their privately insured counterparts. Deaths associated with lack of health insurance now exceed those caused by many common killers such as kidney disease....An increase in the number of uninsured and an eroding medical safety net for the disadvantaged likely explain the substantial increase in the number of deaths, as the uninsured are more likely to go without needed care. Another factor contributing to the widening gap in the risk of death between those who have insurance and those who do not is the improved quality of care for those who can get it."

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How Your Beloved Hospital Helps To Drive Up Health Care Costs (Elisabeth Rosenthal, KHN, 9-5-19) Politicians have been targeting pharmaceutical companies, whose prices have risen more than inflation, and insurers, who pay their executives millions in salaries while raising premiums and deductibles. Why have they given a total pass to arguably a primary culprit behind runaway medical inflation: America’s hospitals. Spending on hospitals represents 44% of personal expenses for the privately insured, and hospital prices increased a whopping 42% from 2007 to 2014 for inpatient care and 25% for outpatient care, compared with 18% and 6% for physicians. So why have politicians on both the left and right let hospitals off scot-free? Because virtually every congressman and every mayor of every large city has a powerful hospital system in his or her district. And those hospitals are as politically untouchable as soybean growers in Iowa or oil producers in Texas. As hospitals and hospital systems have consolidated, they have become the biggest employers in numerous cities and states. Beyond that, hospitals are often beloved by constituents. When members of Congress voted for a Medicare provision that allowed hospitals to apply to have their government payments increased, jospitals in districts of members who voted “yea” got more money than hospitals whose representatives voted “nay,” to the collective tune of $100 million. While on paper many hospitals operate on the thinnest of margins, that is in part a choice, resulting from extravagance. Some rural hospitals are genuinely struggling. But many American hospitals have been spending capital “like water,” said Kevin Schulman a physician-economist at Stanford. The high cost of hospitals today, he said, is often a function of the cost of new infrastructure or poor management decisions. Compared with their European counterparts, some American hospitals resemble seven-star hotels. And yet, on average, the United States doesn’t have better outcomes than other wealthy nations. By some measures — such as life expectancy and infant mortality — it scores worse than average. Our elected officials need to address the elephant in the room and tell us how they plan to rein in hospital excesses.

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Self-insured companies do no better on cost control (Drew Altman, Kaiser Family Foundation, Axios, 1-24-2020) Self-insured firms would seem to have an advantage because they cut out the middleman. But most large insured firms buy insurance from the same companies that administer self-insured plans.The bottom line: Even large, self-insured companies with all the advantages still have a poor track record on cost control.
Profiting from the Poor: Inside Memphis’ Debt Machine (Lylla Younes, Doris Burke, Beena Raghavendran, Maya Miller, ProPublica and Wendi C. Thomas and Deborah Douglas, MLK50, 2018) An investigation into what keeps poor people poor in a city where wages are low. Methodist Le Bonheur Healthcare filed 8,300 lawsuits in the past five years, some of them against its own employees. Across the country, low-income patients are overcoming stigmas surrounding poverty to speak out about nonprofit hospitals that sue them. Stories about aggressive debt collection are leading to real change.
Sarah Kliff (of Vox) answers 7 key questions about why American health care is so screwed up (Lauren Katz, Vox, 1-24-19) 1) The key information that hospitals have is the prices they get paid. Policymakers don’t have access to that information. Insurance plans have only partial access. 2) Out-of-network providers should be required to disclose their status to patients after they have been stabilized. 3) There seems to be more momentum right now behind plans to reduce prescription drug pricing (likely an issue that affects more patients), than there is around balance billing. Senators Maggie Hassan and Bill Cassidy are working on the issue. 5) Payment reform: We need figure out the best ways to provide health care, and pay for it in a way that helps patients. 7) "Some of the biggest bills I see are from patients who went to in-network ERs but were seen there by an out-of-network doctor" — and "people going to the emergency room often have little say over the care being provided to them — especially if they’re dealing with a life-threatening, traumatic situation."
Why An ER Visit Can Cost So Much — Even For Those With Health Insurance (Fresh Air, 3-3-19) Terry Gross interviews Vox reporter Sarah Kliff, who spent over a year reading thousands of ER bills and investigating the reasons behind the costs, including hidden fees, overpriced supplies and out-of-network doctors. "One of the things that's really, really unique about the United States, compared to our peer countries, is that we don't regulate health care prices. Nearly every other country in the developed world - they see health care something as, you know, akin to a utility that everyone needs, like electricity or water. It's so important that the government is going to step in and regulate the prices. That doesn't happen in the United States."
You Snooze, You Lose: Insurers Make The Old Adage Literally True (Marshall Allen, NPR and ProPublica, part of the Health Insurance Hustle series, 11-21-18) Millions of sleep apnea patients rely on CPAP breathing machines to get a good night’s rest. Health insurers use a variety of tactics, including surveillance, to make patients bear the costs. Experts say it’s part of the insurance industry playbook. As many CPAP users discover, the life-altering device comes with caveats: Health insurance companies are often tracking whether patients use them. If they aren’t, the insurers might not cover the machines or the supplies that go with them. Patients have been required to rent CPAPs at rates that total much more than the retail price of the devices, or they’ve discovered that the supplies would be substantially cheaper if they didn’t have insurance at all.

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How an insurance company auditor tried to destroy a physician’s career (Niran S. Al-Agba, MD, KevinMD, 2-6-19) "Only when I got caught in the crosshairs of an insurance company auditor with a bone to pick that I fully appreciated their power to also destroy physicians’ careers....The 18 months of excruciating stress that followed my altercation with the auditor made it patently clear that insurance companies wield far too much power. Bureaucrats are making life-and-death medical decisions without a single minute of medical training, and their auditors are terrorizing physicians, by coercing state medical boards to act as their henchman. Unfettered by any consequences for enforcing policies that fly in the face of rules protecting patient safety, insurance companies will continue to harm doctors and patients alike if no one can stop them."
US health care is an ongoing miserable failure (Anders Åslund, Opinion, The Hill, 1-5-19) The state of U.S. health care is catastrophic. In no other area is the U.S. lagging so far behind the European Union. Average U.S. life expectancy is 78.7 years to compare with 81 in the 28 countries of the European Union. U.S. life expectancy has fallen for the last three years, while it rises all around the world. U.S. infant mortality is 5.6 per 1,000 life births, but only 3.6 on average in the EU. American maternal mortality is 14 per 100,000 births and rising. Compare that with a mere 3 deaths per 100,000 births each in Finland, Greece and Poland. As if to add insult to injury, U.S. health-care costs 18 percent of GDP while the cost is limited to barely 9 percent of GDP in Europe. There are five main reasons for the failure of U.S. health care. They have been well analyzed and all of them benefit major lobbies:
---expensive, dysfunctional health insurance,
---a non-transparent and discriminatory pricing system,
---a monopolistic pharmaceutical complex,
---a highly-profitable tort industry, and
---high incomes of physicians. Worth a read.
Health Insurers Make It Easy for Scammers to Steal Millions. Who Pays? You. ((Marshall Allen, ProPublica and Vox, 7-19-19) Health insurers are regarded as fierce defenders of health care dollars. But the case of David Williams shows one reason America’s health care costs continue to rise. The personal trainer spent years posing as a doctor and billing the nation’s top insurers, making off with millions.
What Can Be Done Right Now to Stop a Basic Source of Health Care Fraud (Marshall Allen, ProPublica, 7-19-19) Fraud is one reason we all pay so much for health care. But there are simple fixes that would make it more difficult for scammers to operate: Check to see whether people getting federal ID numbers that allow them to bill insurers have valid licenses. Require insurance companies to verify that the people they are paying are licensed medical providers. Require insurance companies to report cases of suspected fraud to state and federal regulators. Audits and the potential for fines may be needed to spur the insurers to file the reports.

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McCain’s Complicated Health Care Legacy: He Hated the ACA. He Also Saved It. (Emmarie Huetteman, Kaiser Health News, 8-25-18) The six-term Arizona senator, who died Saturday, took on some of health care’s goliaths, such as the tobacco industry and insurance companies, in addition to the health law. While McCain was instrumental in the passage of the Americans with Disabilities Act in 1990 ("the country’s first comprehensive civil rights law that addressed the needs of those with disabilities"), most of the health initiatives he undertook failed after running afoul of traditional Republican priorities--often involving more government regulation and increased taxes. He fought the Affordable Care Act (Obamacare) because " extended insurance coverage to millions of Americans but did not solve the system’s ballooning costs." But his "late-night thumbs-down vote halted his party’s most promising effort to overturn" the ACA, for which Trump treated him as an enemy.

       "While he agreed that the health care system was broken, he did not think more government involvement would fix it. Like most Republicans, he campaigned in his last Senate race on a promise to repeal and replace" Obamacare with something better. What bothered McCain more, though, was "his party’s strategy to pass their so-called skinny repeal measure, skipping committee consideration and delivering it straight to the floor. They also rejected any input from the opposing party, a tactic for which he had slammed Democrats when the ACA passed in 2010 without a single GOP vote. He lamented that Republican leaders had cast aside compromise-nurturing Senate procedures in pursuit of political victory." “I was thanked for my vote by Democratic friends more profusely than I should have been for helping save Obamacare,” McCain wrote. “That had not been my goal.”
       Huetteman's summary of McCain's other efforts at health care legislation reads like a to-do list for Congress to consider should it ever go back to considering the "little guy" above all--to being willing to "work across the aisle," across parties. "McCain also joined an effort with two Democratic senators, Kennedy of Massachusetts and John Edwards of North Carolina, to pass a patients’ bill of rights in 2001. He resisted at first, concerned in particular about the right it gave patients to sue health care companies....The legislation would have granted patients with private insurance the right to emergency and specialist care in addition to the right to seek redress for being wrongly denied care. But President George W. Bush threatened to veto the measure, claiming it would fuel frivolous lawsuits. The bill failed."
       One plan he supported "would eliminate the tax break employers get for providing health benefits to workers, known as the employer exclusion, and replace it with refundable tax credits to help people — not just those working in firms that supplied coverage — buy insurance individually. He argued [that] employer-provided plans were driving up costs, as well as keeping salaries lower." That triggered “a total freakout." "McCain’s health care efforts bolstered his reputation as a lawmaker willing to work across the aisle. Sen. Chuck Schumer of New York, now the Senate’s Democratic leader, sought his help on legislation in 2001 to expand access to generic drugs. In 2015, McCain led a bipartisan coalition to pass a law that would strengthen mental health and suicide prevention programs for veterans, among other veterans’ care measures he undertook."

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I started collecting ER bills. The American Hospital Association started warning its members. (Sarah Kliff, Vox, 10-26-17) These prices are often kept secret. Vox is trying to change that. Links here to the many stories in this series, including case studies.
GoFundMe CEO: ‘Gigantic Gaps’ in Health System Showing Up in Crowdfunding (Rachel Bluth, KHN, 1-16-19) Scrolling through the GoFundMe website reveals seemingly an endless number of people who need help or community support. A common theme: the cost of health care. It didn’t start out this way. Back in 2010, when the crowdfunding website began, it suggested fundraisers for “ideas and dreams,” “wedding donations and honeymoon registry” or “special occasions.” A spokeswoman said the bulk of collection efforts from the first year were “related to charities and foundations.” A category for medical needs existed, but it was farther down the list. In the nine years since, campaigns to pay for health care have reaped the most cash. Of the $5 billion the company says it has raised, about a third has been for medical expenses from more than 250,000 medical campaigns conducted annually....The prominence of the medical category is the symptom of a broken system, according to CEO Rob Solomon...He said he never realized how hard it was for some people to pay their bills: “I needed to understand the gigantic gaps in the system.” The health care system in the United States is really broken. Way too many people fall through the cracks. Many people have rare diseases a drug company can't make money from, so they’re left with nothing. "The system is terrible. It needs to be rethought and retooled. Politicians are failing us. Health care companies are failing us....We firmly believe that access to comprehensive health care is a right and things have to be fixed at the local, state and federal levels of government to make this a reality."
Kansans drank contaminated water for years. The state didn’t tell them. (Katherine Burgess, Wichita Eagle, 8-26-18) In 2011, while investigating the possible expansion of a Kwik Shop, the state discovered dry cleaning chemicals had contaminated groundwater at 412 W. Grand in Haysville. The Kansas Department of Health and Environment didn’t act for more than six years. It didn’t test private wells less than a mile away. Nor did it notify residents that their drinking wells could be contaminated with dry cleaning chemicals, known as perchloroethylene, so they could test the water themselves.
The crusade for ‘religious liberty’ will reverberate badly in health care (Haider Warraich, STAT, 9-10-18) "Patients should not have to worry that their physicians’ or nurses’ religious beliefs supersede their duty to provide unbiased care. In fact, patients’ right to receive care congruent with their religious or spiritual beliefs is recognized by governing bodies like the World Health Organization. If anything, doctors are undertrained in being able to address the need for many patients to discuss religious and spiritual issues, especially when they are dealing with serious illness....Sometimes it means making choices on behalf of patients one wouldn’t necessarily make for themselves or their own family members. Sometimes it might mean working outside the confines of a belief they hold dearly. In such moments, I silently recite one of the laws of medicine made famous in “The House of God,” a satirical 1978 novel: “the patient is the one with the disease.”
"Doctors’ religiosity certainly affects how they go about managing patients: doctors who are more religious are more likely to be opposed to withdrawing life support from their patients. Patients who are taken care of by more religious doctors tend to die sooner after being withdrawn from life support, suggesting that the decision to remove supports such as mechanical ventilation had been delayed until the patient was very close to dying."

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Pain & Profit (August 2018) A Dallas News series. Your tax money may not help poor, sick Texans get well, but it definitely helps health care companies get rich
---Part 1. The preventable tragedy of D’ashon MorrisDoctors described him as “happy and playful” and told his foster mother he would be healthy by the time he went to kindergarten. That was before a giant health care company made a decision that saved it as much as $500 a day — and cost D’ashon everything.
---2. As patients suffer, companies profit (Imagine being trapped in a bed for more than a year because you can't get the medical equipment you need. Years of poor oversight by the state have allowed health care companies to skimp on essential care for sick kids and disabled adults.
---3. Texas pays companies billions for ‘sham networks’ of doctors The state tells foster parents that hundreds of psychiatrists will see their kids. We found only 34. Managed-care companies overstate the number of physicians available to treat the state’s sickest patients.
---4. ‘Glossover of the horror’ A whistleblower says taxpayers are not getting their money’s worth and sick people are not getting the care they need. Texas fails to act when health care companies put patients in peril.
---5. Parents vs. the Austin machine “You can tell that he’s crying or screaming, but nothing comes out.” Texas families take fight for medically fragile children to the Legislature.
---6. 'Recipe for Disaster' (Part 6. J. David McSwane and Andrew Chavez, Dallas News, 8-26-18) A company’s refusals to cover medical costs, from inexpensive diapers to costly treatments, have made some Texas foster parents’ jobs nearly impossible.
Four Things That Almost Nobody Is Talking About That Need Fixing In Medicine (Rob McMillin, Scareduck blog, 12-24-14). In brief: 1) End low-deductible insurance. 2) Break the American Medical Association's cartel. The AMA's ability to limit medical school slots and internships must end. 3) Limit patents to 17 years, period. 4) Remove anticompetitive Certificate of Need state laws. By creating a moat around existing hospitals and other medical facilities, governments retard actual competition and thus raise prices.
How American Health Care Killed My Father (David Goldhill, The Atlantic, Sept 09) Perhaps the greatest problem posed by our health-insurance-driven regime is the sense it creates that someone else is actually paying for most of our health care—and that the costs of new benefits can also be borne by someone else. Unfortunately, there is no one else. Worth a read.
U.S. Health Care Ranked Worst in the Developed World (Melissa Hellmann, Time, 6-17-14) The U.S. health care system has been ranked as the worst among industrialized nations for the fifth time, according to the 2014 Commonwealth Fund survey 2014. The U.K. ranked best with Switzerland following a close second. Although the U.S. has the most expensive health care system in the world, the nation ranks lowest in terms of “efficiency, equity and outcomes,” according to the report. One of the most piercing revelations is that the high rate of expenditure for insurance is not commensurate to the satisfaction of patients or quality of service. “Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home,” it said.
Ad Check: What Happens If California Limits Dialysis Center Profits? (Harriet Rowan, KHN, 11-2-18) Here’s what both sides had to say and what they base it on.
Republicans are struggling to fix America’s dysfunctional health-care system (The Economist, 5-22-19) America "spends about twice as much on health care as other rich countries but has the highest infant-mortality rate and the lowest life expectancy (see chart). Some 30m people, including 6m non-citizens, remain uninsured. And yet, though costs remain a major concern—out-of-pocket spending on insurance continues to rise—Americans say they are generally satisfied with their own health care. Eight in ten rate the quality of their care as “good” or “excellent”. Few are in favour of dramatic reform."The Burnout Crisis in American Medicine (Rena Xu, The Atlantic, 5-11-18) "Doctors become doctors because they want to take care of patients. Their decade-long training focuses almost entirely on the substance of medicine—on diagnosing and treating illness. In practice, though, many of their challenges relate to the operations of medicine—managing a growing number of patients, coordinating care across multiple providers, documenting it all. Regulations governing the use of electronic medical records (EMRs), first introduced in the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, have gotten more and more demanding, while expanded insurance coverage from the Affordable Care Act may have contributed to an uptrend in patient volume at many health centers. These changes are taking a toll on physicians: There’s some evidence that the administrative burden of medicine—and with it, the proportion of burned-out doctors—is on the rise."
ProPublica (Journalism in the Public Interest) has run several excellent investigative series:
---Dollars for Doctors: How Industry Money Reaches Physicians
---Lost Mothers: Maternal Care and Preventable Deaths
---Patient Safety: Exploring Quality of Care in the U.S.
---The Prescribers: What Doctors Are Prescribing (large quantities of drugs known to be potentially harmful, disorienting or addictive for their patients)
---Wasted Medicine: Squandered Health Care Dollars
---When Caregivers Harm: America's Unwatched Nurses
Electronic Health Record Logs Indicate That Physicians Split Time Evenly Between Seeing Patients And Desktop Medicine (Ming Tai-Seale, Health Affairs, April 2017) Over time, log records from physicians showed a decline in the time allocated to face-to-face visits, accompanied by an increase in time allocated to desktop medicine.

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Goldman Sachs asks in biotech research report: 'Is curing patients a sustainable business model?' (Tae Kim, Investing, CNBC, 4-11-18, on "profit-driven health care") "The potential to deliver 'one shot cures' is one of the most attractive aspects of gene therapy, genetically-engineered cell therapy and gene editing. However, such treatments offer a very different outlook with regard to recurring revenue versus chronic therapies," analyst Salveen Richter wrote in the note to clients Tuesday. "While this proposition carries tremendous value for patients and society, it could represent a challenge for genome medicine developers looking for sustained cash flow."
Why I'm Giving Up on Preventative Care (Barbara Ehrenreich, Literary Hub, 4-9-18) "In the last few years I have given up on the many medical measures—cancer screenings, annual exams, Pap smears, for example—expected of a responsible person with health insurance....I gradually came to realize that I was old enough to die, by which I am not suggesting that each of us bears an expiration date....A cynic might conclude that preventive medicine exists to transform people into raw material for a profit-hungry medical-industrial complex." As one commenter on Facebook posted: " Prevention has been confused with early detection. A mammography does not "prevent" breast cancer, just detects abnormalities. Whereas real prevention, such as exercise, improving diet, removing environmental toxins, etc, will help prevent disease in the first place. But there is no money in that, plus it steps on the toes of mega industries. For instance, a pharma company that makes chemo agents and also pesticides--first create the cancer and then the treatment. But this distortion is intentional, to confuse real primary prevention with procedures that detect what is there."
Overdiagnosed: Making People Sick in the Pursuit of Health by H. Gilbert Welch, Lisa Schwartz, and Steve Woloshin. As S Golden noted, "excellent for relieving anxiety when you have a CT scan or some other procedure that detects "abnormalities which then lead to further testing....The authors have impeccable medical credentials and the book is really well written."
How We Spend $3,400,000,000,000 (T.R. Reid, The Atlantic, 6-15-17) Why more than half of America's healthcare spending goes to five percent of patients. The biggest medical costs are concentrated on a fairly small segment of the population—people with one or more chronic illnesses, plus victims of accidents or violent crime. The cost is so concentrated, in fact, that an estimated five percent of the population accounts for 50 percent of total medical costs....For most people, the vast majority of all the health care they’ll ever get comes near the hour of death. Hundreds of billions of dollars each year are spent treating Americans who are in the last weeks, or days, of life....About one-third of Americans undergo operations in the last month of life." “No country...can afford to pay for every advanced surgical procedure and every costly drug that modern medicine knows how to provide....So Britain created an organization to make rules for how its healthcare money is spent....Should a 94-year-old get a hip replacement? Should a terminal cancer patient be given a course of medication that costs $40,000 and extends life an average of four months? (In Britain, the answers are, generally, 'No.')" Worth reading.
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."

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Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care (The Commonwealth Fund) "Key findings: The U.S. ranked last on performance overall, and ranked last or near last on the Access, Administrative Efficiency, Equity, and Health Care Outcomes domains. The top-ranked countries overall were the U.K., Australia, and the Netherlands. Based on a broad range of indicators, the U.S. health system is an outlier, spending far more but falling short of the performance achieved by other high-income countries. The results suggest the U.S. health care system should look at other countries’ approaches if it wants to achieve an affordable high-performing health care system that serves all Americans."
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."

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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.'

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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."

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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."

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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.

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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."

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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, HealthNewsReview.org, 6-1-17)

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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.

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Problems with dental care
Often lost in health care debate, lack of dental insurance impacts millions (Yesenia Amaro and Nicole A Hayden, USC Center for Health Journalism News Collaborative, 6-20-19) Efforts to expand dental insurance rarely receive the same level of attention in the state as battles over universal medical care, but untreated dental problems can lead to other health complications and higher medical costs. A 2014 study showed that when adult Medicaid recipients had preventive dental care, medical costs for seven chronic health conditions, such as diabetes and coronary heart disease, were lower by 31% to 67%. The connection between oral and overall health seems to stem largely from bacteria and germs located in the mouth that can spread to other parts of the body and cause diseases, according to the Mayo Clinic.
Dental patients face years of debt, inflated bills with ‘out-of-pocket’ credit cards (Manuela Tobias, Sacramento Bee, 12-9-19) Legal aid organizations report that low-income Californians are particularly at risk of falling into debt traps with medical credit cards because of ongoing struggles with the state insurance system. Advocates say the terms of medical credit cards are too complicated for most people to understand. They are particularly confusing in high-pressure situations, like the moments of excruciating pain leading up to important dental procedures. If consumers do not fully understand the terms or fall behind on payments, they can end up facing inflated bills and crippling dental debts.
Painful Mistakes (Arthur Kane Las Vegas Review-Journal, 10-28-19) Six-part series. (1) Injured Patients Claim Botched Dental Work. Why didn’t the board revoke licenses? (2) Patients reveal the impact of failed dental work. (3) Dental board benefiting itself, not patients, records show. (4) Longtime dental feud sparks state investigation. (5) This patient complained. The dental board filed a restraining order against him. (6) Two videos: How to check your dentist’s background. How to file a complaint against a Nevada dentist.
Nevada is not the only state with dental oversight problems (William Heisel, Investigating Health, 1-2-2020) Problems in your state? Check out your state dental board.
How Dental Inequality Hurts Americans (Austin Frakt, The Upshot, NY Times, 2-19-18) Lack of dental care through Medicaid not only harms people’s health, but has negative economic implications as well. Not being able to see a dentist is related to a range of health problems. It’s an accident of history that oral care has been divided from care for the rest of our bodies. But it seems less of an accident that the current system hurts those who need it most.  For more on problems with dental care, see Dental care and oral health  What you should and probably don't know.

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The facts about health care reform and health care policy

and problems being addressed, or not

Health Care Reform: One (Percent) Step At A Time (Zack Cooper and Fiona Scott Morton. Health Affairs, 2-10-21) From 2000 to 2019, health spending in the US increased 87 percent while median household income increased by only 10 percent. Today, average annual health insurance premiums for a family of four are $21,342. The sheer scale of the US health care system is what makes reform so difficult. Rather than speaking about health spending via abstractions, we should view high US health care costs as the result of a series of discrete problems that each incrementally raises health spending by a percent or two – so-called “one percent problems.” While each problem is unremarkable in isolation, the collective impact of a series of one percent problems can help explain why the US spends more than other nations. Surprise medical bills are a good example of a discrete problem that raises health care costs, has zero benefit to the public, and can be addressed. Other examples:
---Decreasing cost barriers for living kidney donations
---Expanding kidney exchanges
---Addressing orphan drugs
---Expanding preferred pharmacy networks
---Reforming how Medicare reimburses biosimilars
---Eliminating prescription co-pay coupons
---Reducing fraud in home health
---Reforming the payments for long term care hospitals
---Addressing hospital consolidation
---Addressing vertical integration of hospitals and physicians
---Improving health insurance plan choice
---Increasing the efficiency of claims adjudication
---Introducing smart provider networks
---Improving plan auto-assignment in Medicaid managed care
---Regulating health care provider prices
Advancing Healthcare Reform: The American Heart Association’s 2020 Statement of Principles for Adequate, Accessible, and Affordable Health Care (2-3-20) A Presidential Advisory From the American Heart Association
Health and Social Care Reforms 'Fail to Address Staffing Shortages' (Peter Russell, Medscape, 11-24-21) Almost a third of care workers reported that staffing levels were dangerously low, deteriorating, and harming standards of patient care.
Health Insurance Reform (HHS.gov)
Health reform: How to improve U.S. health care in 2020 and beyond (American Medical Association)
Current Awareness in Aging Research (CAAR) Up-to-date information about news and internet resources on aging. Sign up for their e-clippings (not an archive, but a snap shot of the latest news in the field) or visit their blog.
Congress wants these 7 drug company CEOs to testify about prices (Lev Facher, STAT, 2-4-19) AbbVie, AstraZeneca, Bristol-Myers Squibb, Johnson & Johnson, Merck & Co., Pfizer, and Sanofi. Of the seven companies invited, five are already the subject of a separate investigation being conducted by the House Committee on Oversight and Reform.      

• T.R. Reid's conclusion in 5 Myths About Health Care Around the World:
"In many ways, foreign health-care models are not really 'foreign' to America, because our crazy-quilt health-care system uses elements of all of them. For Native Americans or veterans, we're Britain: The government provides health care, funding it through general taxes, and patients get no bills. For people who get insurance through their jobs, we're Germany: Premiums are split between workers and employers, and private insurance plans pay private doctors and hospitals. For people over 65, we're Canada: Everyone pays premiums for an insurance plan run by the government, and the public plan pays private doctors and hospitals according to a set fee schedule. And for the tens of millions without insurance coverage, we're Burundi or Burma: In the world's poor nations, sick people pay out of pocket for medical care; those who can't pay stay sick or die."
Lies, Damned Lies, and Medical Science by David H. Freedman (The Atlantic, Nov. 2010). "Much of what medical researchers conclude in their studies is misleading, exaggerated, or flat-out wrong. So why are doctors--to a striking extent--still drawing upon misinformation in their everyday practice? Dr. John Ioannidis has spent his career challenging his peers by exposing their bad science." On PLoS Medicine you can read Ioannidis's article, Why Most Published Research Findings Are False.
Whitehouse.gov (This was under Obama.) The eight basic consumer protections the White House wants health care reform to cover:

(1) No discrimination for pre-existing conditions,

(2) No exorbitant out-of-pocket expenses, deductibles or co-pays,

(3) No cost-sharing for preventive care,

(4) No dropping of coverage if you become seriously ill,

(5) No gender discrimination,

(6) No annual or lifetime caps on coverage,

(7) Extended coverage for young adults,

(8) Guaranteed insurance renewal so long as premiums are paid.

History of Employer-Based Health Insurance in the U.S. (Ramtin Arablouei and Rund Abdelfatah, podcast Throughline, National Public Radio, 10-7-20) Listen or read.
Accidents Of History Created U.S. Health System (Alex Blumberg and Adam Davidson, All Things Considered, NPR, 10-22-09)
The Everlasting Problem (Ramtin Arablouei and Rund Abdelfatah, podcast Throughline, National Public Radio, 10-1-2020) Hospitals used to be places people went to die.Things changed over time. But the United States has by far the most expensive health care system in the world. Hospitals and specialists that get very high payments from private health insurance are not eager to have that go away.
Excluded Voices. Trudy Lieberman's penetrating series of interviews on health care reform, in Columbia Journalism Review. Start with her interview with Wendell Potter, who "didn’t want to be part of another health insurance industry effort to shape reform that would benefit the industry at the expense of the public." You can also listen to Bill Moyers interview Potter or read the transcript and Potter's testimony before Congress.
Alliance for Health Care Reform (this nonpartisan organization has excellent resource guides for reporters).
Choosing to not have health insurance (J. Duncan Moore Jr., L.A.Times,9-21-09), though he may not have intended it, this is an argument for reform
Mental health: why journalists don’t get help in the workplace (Megan Jones, Ryerson Review of Journalism Spring 2014). "Reporters are finally telling empathetic stories about depression, anxiety and other mental illnesses, but newsroom culture keeps journalists’ own struggles in the dark." Find links to good articles about Suicide, suicide prevention, and suicide reporting here.
C-Span's Health Care Hub is a good place to find various town hall discussions, hearings, wonderful links. C-Span, you're wonderful!
The Cost Conundrum: What a Texas town can teach us about health care (Atul Gawande, The New Yorker, 6-1-09)
A consumer guide to handling disputes with your employer or private health plan, 2005 update, Kaiser Family Foundation
C-Span's Health Care Hub is a good place to find various town hall discussions, hearings, wonderful links. C-Span, you're wonderful!
DrSteveB's blogroll (helpful Daily Kos blogger--and check his blogroll for other resources)
Find Help (HRSA links to free and inexpensive care)
5 Myths About Health Care Around the World by T.R. Reid (Washington Post, 8-23-09).
Guaranteed Health Care (National Nurses Organizing Committee, California Nurses Association)
The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care by T.R. Reid
Health Affairs (the policy journal of the health sphere)
HELP Is on the Way (Paul Krugman on why universal health coverage is affordable)
Health Insurance Consumer Information (news you can use), with blogs that follow the health care debate and discuss news of health insurance coverage around the country, and a Consumer Guide for Getting and Keeping Health Insurance for each state and the District of Columbia. The American Cancer Society and the Robert Wood Johnson Foundation and other organizations provide support for this research by The Georgetown University Health Policy Institute. Worth checking out.
Health Insurance Woes: My $22,000 Bill for Having a Baby (And I had coverage for maternity care! Sarah Wildman, DoubleX, 8-3-09). "Our insurer, CareFirst BlueCross BlueShield, sold us exactly the type of flawed policy—riddled with holes and exceptions—that the health care reform bills in Congress should try to do away with. The “maternity” coverage we purchased didn’t cover my labor, delivery, or hospital stay. It was a sham."..."The individual insurance market is like that old joke about the food being terrible and the portions too small; it’s expensive, shoddy, and deeply unsatisfying. Those of us who buy into it are not protected by the federal and state laws that govern employer-based health care. In fact, there’s no one looking out for us at all."
Insurers explore savings in overseas care: Major health firms offer doctor networks at lower rates in foreign countries. AP/MSNBC story. ("more insurers are offering networks of surgeons and dentists in places like India and Costa Rica." "The four largest commercial U.S. health insurers — with enrollments totaling nearly 100 million people — have either launched pilot programs offering overseas travel or explored it....Growth has been slow in part because some patients and employers have concerns about care quality and legal responsibility if something goes wrong. Plus, patients who have traditional plans with low deductibles may have little incentive to take a trip.") This is the health insurance industry's approach to health care reform?
Journalists, Left Out of The Debate: Few Americans Seem to Hear Health Care Facts. "For once, mainstream journalists did not retreat to the studied neutrality of quoting dueling antagonists," writes Howard Kurtz (Washington Post 8-24-09). "They tried to perform last rites on the ludicrous claim about President Obama's death panels, telling Sarah Palin, in effect, you've got to quit making things up. But it didn't matter. The story refused to die." As always, Kurtz provides an intelligent analysis of the situation, stating that "the healthy dose of coverage has largely failed to dispel many of the half-truths and exaggerations surrounding the debate. Even so, news organizations were slow to diagnose the depth of public unease about the unwieldy legislation. For the moment, the story, like the process itself, remains a muddle."
Medical Science and Practice in Conflict (Kevin Sack, NYTimes, 11-20-09, on how the consumer public may see evidence-based medicine as a step toward rationing)
Myths and Falsehoods on budget reconciliation (Media Matters, fighting conservative misinformation)
The Pharmaceutical Industry: Angels or Demons? (Policy and Medicine reports a plea for less demonizing of the pharmaceutical industry)
Physicians for a National Health Program (supports single-payer national health insurance)
President's Question Time (Obama, Republicans spar in Q&A (Video of debate 1-29-10, plus Andrew Sullivan's commentary, Daily Dish)
The Real Death Panels: Insurers Deny 22% of Claims (National Nurses Movement on Daily Kos, 9-3-09)
Reach of Subsidies Is Critical Issue for Health Plan (Robert Pear, NY Times, 7-26-09—on another important issue: where the money comes from to cover the costs of the formerly uninsured)
Science Blogs (Health)
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)
•• Twenty-six Lies About H.R. 3200 (FactCheck.Org, 8-28-09). A notorious analysis of the House health care bill contains 48 claims. Twenty-six of them are false and the rest mostly misleading. Only four are true.
Why markets can’t cure healthcare by Paul Krugman (The Conscience of a Liberal, NY Times, 7-25-09).
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."

Godwin's Law: "As a Usenet discussion grows longer, the probability of a comparison involving Nazis or Hitler approaches"
~ Mike Godwin, creator of Godwin's Rule of Nazi Analogies, fearing glib use of the term will dilute the meaning of "Never Again"

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The benefits 'pharmacy benefit managers' manage do not usually benefit consumers

"Pharmacy benefit managers—the companies that operate prescription drug insurance programs—are supposed to operate on behalf of patients to get lower prices. But instead they insist on negotiating secret deals so we can’t see how much they are keeping and how much savings are reaching patients and consumers. We need complete transparency from pharmacy benefit managers."

     ~Patients for Affordable Drugs

How the FTC Protects Patients in Healthcare (MedPage Today, 5-7-24, Part 1.) Challenging "bogus" patents that stifle competition and inflate costs is one way, says Lina Khan. Listen to this fairly short recording. "The FTC oversees consumer protections, competition, and drug pricing -- recently challenging -- hundreds of what Khan called "bogus" patents on 20 brand name drugs for weight loss, diabetes, asthma, and chronic obstructive pulmonary disease.

      "...last year the FTC sued to stop Sanofi from getting exclusive access to Maze's drugs for Pompe disease. Pompe disease is a really awful disease that affects a whole set of Americans that end up being dependent on a particular drug. Right now, Sanofi has had a monopoly on these Pompe disease drugs. Americans are routinely charged hundreds of thousands of dollars for a course of treatment.

      "Maze was a company that has had in development a drug that people would be able to take orally, rather than having to hook up to an IV twice a week, and could dramatically bring down both the cost and make it just more convenient and manageable for patients that are living with this awful disease.

      "We wanted to make sure that Maze is able to actually bring its products and its drugs to market. We worried that if, instead, the existing monopolist was allowed to get exclusive access to these drugs, that monopolists would have an incentive to not have this new drug cannibalize its existing, very lucrative sales. So that's why we blocked that merger, to make sure that Maze is still able to come to market and make sure the patients are ultimately able to benefit from that.

      "...so, again, even if the patent system is working so that you're getting generics ultimately onto the market, if Americans can ultimately not access those generics because the PBM is getting a bigger rebate on a branded drug, that's a problem. 

---FTC Puts Pharmacy Benefit Managers, Private Equity in the Crosshairs (Jeremy Faust and Emily Hutto, MedPage Today, 5-10-24, Part 2) Part 2: Lina Khan, JD, chair of the Federal Trade Commission (FTC): MUST READ AND LISTEN (at the same time):  This is just a snippet from an important discussion:

     "The FTC has been scrutinizing the pharmacy benefit managers. We're aware that this is a pretty opaque set of players in the supply chain, but they can have a pretty significant role in effectively determining which drugs Americans can or cannot access when they go to the pharmacy.
      "We've heard primarily two sets of concerns about these PBMs. One is a concern [regarding] the rebate system between the PBMs and the drug manufacturers, where the drug manufacturers have to pay rebates to the PBMs to get access to certain formularies. There's a concern that those rebates could be effectively incentivizing the PBMs to put on the formulary the drugs that are most lucrative, which may be high-cost, branded drugs rather than generics.
       "And so, again, even if the patent system is working so that you're getting generics ultimately onto the market, if Americans can ultimately not access those generics because the PBM is getting a bigger rebate on a branded drug, that's a problem. So we're scrutinizing those sets of practices.
       "We've also heard concerns that independent pharmacies that are oftentimes having to do business with these PBMs may be subject to all sorts of fees and potentially arbitrary practices that are squeezing them and potentially contributing to their going out of business.

       "We've also seen over the last couple of decades that the PBMs both horizontally concentrate and vertically integrate. So some of these PBMs have, for example, their own mail-order pharmacy. We hear concerns from independent pharmacists that there may be some steering or some conflicts of interest embedded in this vertically-integrated structure." [A small part of a longer piece. Read the whole thing!]


FTC plans inquiry into pharmacy benefit manager practices (Tom Murphy, AP News, 6-7-22)

FTC Chair Lina M. Khan said in a statement that PBMs have “enormous influence” over the country’s prescription drug system.
    “This study will shine a light on these companies’ practices and their impact on pharmacies, payers, doctors, and patients,” Khan said.
    The FTC said it will seek to learn more from PBMs about drug manufacturer rebates and how they affect formulary design and the cost of drugs.
    The agency said it also will look at “complicated and opaque methods to determine pharmacy reimbursement” and how patients are steered toward PBM-owned pharmacies.
Centene agrees to pay $33 million to resolve another state probe into its pharmacy benefits business (Ed Silverman, STAT, 8-25-22) Centene’s pharmacy benefits management (PBM) subsidiary greatly overcharged Washington state's Medicaid program. That's part of "a larger trend in which PBMs are under scrutiny nationwide." When PBMs establish drug formularies (lists of the medications insurers will cover), they collect rebates from drug makers, but the amounts are kept confidential. “This is a controversial tactic because the deals are blamed for rising drug prices.” As a result of such practices, legislators in more than 30 states have introduced more than 130 bills to regulate how PBMs operate. The 27-page settlement agreement includes details on the allegations state officials leveled against Centene and its former PBM, Envolve. Source: Joseph Burns, Useful sources to aid reporting on pharmacy benefit managers (Joseph Burns, Covering Health, AHCJ, 9-2-22) See also 5 things to know about Centene's new PBM (Nona Tepper, Modern Healthcare, 10-27-21)
Side Effects: An ongoing investigation on the rising costs of prescription drugs (Major USA Today investigative series) The Dispatch spent a year uncovering how PBMs operate in Ohio and the rest of the country. Read this excellent series. Highlights:
"1. Pharmacy benefit managers (PBMs)—little-known middlemen in the supply chain that gets prescription drugs from manufacturers to consumers—receive hundreds of millions from Ohio taxpayers via the state’s Medicaid program.
2. A state-sponsored study conducted after several weeks of Dispatch stories found the PBMs are charging Ohioans 3 to 6 times the normal rate—costing taxpayers an extra $150 million to $186 million a year.
3. The PBMs use “spread pricing,” meaning they get about $225 million more a year from the state than they reimburse pharmacies for drugs used by Ohio’s poor and disabled.
4. PBMs cut the reimbursement rate so much for Suboxone that many pharmacies were forced to stop stocking the drug used by numerous Ohio addicts in recovery."  And much more. Well worth reading.
FTC Launches Inquiry Into Prescription Drug Middlemen Industry (FTC, 6-7-22) Agency to Scrutinize the Impact of Vertically Integrated Pharmacy Benefit Managers on the Access and Affordability of Medicine
Provider groups closely monitor Supreme Court case on pharmacy benefit managers (Joseph Burns, Covering Health, Association of Health Care Journalists, 10-26-2020) At issue in a case before the Supreme Court (Rutledge v. Pharmaceutical Care Management Association) is the right of states to regulate pharmacy benefit management (PBMs) companies, which employers and health plans hire as middlemen to manage their prescription benefit programs for workers and other plan members. This case involves more than state efforts to regulate drug prices. “In the brief, community oncology strongly supports the need for states to be able to stop PBM abuses, especially those that are hurting patients with cancer,” the COA said in a statement. “In recent years, PBMs have increasingly inserted themselves between oncologists and their patients, adversely impacting the delivery of cancer care.”
       "Under most insurers’ step-therapy protocols, the patient must take the lower-priced drug for a certain length of time and must fail on the insurer’s lower-cost drug before the physician would be allowed to prescribe the medication requested originally. Or, if the patients fails on the lower-cost drug, the physician may be required to try another medication and the patient would need to fail on that treatment before getting the original drug the doctor prescribed."
CVS accused of using Medicaid rolls in Ohio to push out competition (Catherine Candisky and Marty Schladen, Columbus Dispatch, 3-12-18) 'Not only does CVS operate Ohio’s second-largest retail pharmacy chain, but CVS Caremark is the pharmacy-benefit manager for four of Ohio Medicaid’s five managed-care companies. Like Medicaid managed-care companies, PBMs are supposed to save taxpayers money. But the public doesn’t know exactly how much of the more than $3 billion spent on pharmaceuticals goes to pharmacies and how much simply fattens PBMs’ bottom lines....Ciaccia said he suspects that CVS Caremark is engaged in “spread pricing” — using one list with a low price to reimburse the pharmacist, and another list with a high price to bill the managed-care program, and pocketing the difference. It’s impossible to know exactly what’s happening because the creation and use of such “maximum allowable cost” lists happens behind a veil of secrecy, he said.'
PBMA Abuses: Hurting Patients Halting Progress The Community Oncology Alliance's collection of cancer patient horror stories.
CVS accused of using Medicaid rolls in Ohio to push out competition (Cathy Candisky and Marty Schladen, Columbus Dispatch, 3-12-18) "Pharmacy giant CVS stands accused of overcharging Ohio taxpayers millions in an attempt to drive out retail competition — a charge that CVS flatly denies. Bottom line: The company allegedly boosts its profits by overcharging insurers for medications while often reimbursing pharmacists less than the cost of the drug, critics say. As a result, retail pharmacies in the Buckeye State have been dropping like flies, and state regulators are looking at ways to bring more transparency to a Medicaid benefits-management system that CVS dominates.
State probing whether pharmacy benefit managers are overcharging taxpayers (Cathy Candisky, Columbus Dispatch, 4-4-18) Ohio Medicaid officials pledged Wednesday to investigate claims that pharmacy benefit managers are paying pharmacists far less to fill prescriptions than they charge the state, allowing them to pocket the difference. Critics say the practice, known as spread pricing, is increasing costs in the tax-funded Medicaid program and driving many pharmacies out of business because some drug reimbursements are less than the cost to pharmacies of acquiring the medication. This is part of an award-winning series about pharmacy benefit managers. See links to other pieces on the site, which allowed me to view only three articles.
Ohio bans gag orders on cheaper cash prices for prescriptions (Columbus Dispatch, 4-4-18) State regulators ordered health insurers and their pharmacy benefits managers Wednesday to cease enforcement of gag orders preventing pharmacists from informing consumers of the lowest drug price available. In addition, the Ohio Department of Insurance prohibited charging consumers more for their prescription medication than it would cost if they paid without insurance, or out of pocket.
While pharmacy benefit managers are watching cable, patients are streaming Netflix (Keely McManamon, KevinMD, 8-14-19) Neither patients nor Big Pharma are happy with PBMs. Pharma argues that their payments to PBMs have done nothing to help rein in drug prices or stop PBM’s endorsement of expensive brand-name medicines. A subscription-based payment model--the “Netflix model"--has been introduced. CMS has just approved the Netflix model for hepatitis C therapy in Louisiana. the Netflix model also makes use of group purchasing but without a middle man. Instead, public and private payers enter into a global contract with a drug manufacturer to provide an unlimited amount of drug therapies at a fixed price for thousands of individuals, who can access the therapy as often as needed. The arrangement is akin to purchasing a Netflix subscription and accessing unlimited streaming over the duration of the purchasing agreement. (Read the article for details.)
• According to Nicholas Florko, of D.C. Diagnosis (STAT), Trump proposed "ending the rebates drug makers pay insurance companies in exchange for favorable placement on insurance formularies." The PBMs say that will give drugmakers free rein to charge high prices and argue that the rebate systems works well for negotiating down the price of drugs. PBMs are lobbying hard against this step. Pay to get STAT+ and you can read Will Trump’s new drug rebates proposal end PBMs? And 6 other burning questions about the idea (Nicholas Florko and Ike Swetlitz, STAT+, 2-1-19)
An economist’s change of heart: It’s time to regulate the prescription-drug middlemen (Geoffrey Joyce, MarketWatch, 8-20-18) While pharmacy benefit managers (PBMs), these giant middlemen in the supply chain, still drive hard bargains with manufacturers, they are increasingly finding ways to expand their profitability at the expense of employers and patients. PBM profit margins are much higher than other players in the supply chain who bear much of the public’s anger over rising drug prices. Federal regulators need to be empowered to restore order, and soon.
Rigged Drug Prices at Pharmacies and Hospitals (Randy Barrett, Tarbell, 5-29-18) Drug stores and hospitals make good money selling you medicines but prefer to lay low in the pricing debate. They do it by cloaking their charges in private contracts and convoluted billing. Retail pharmacies must first negotiate with pharmacy benefit managers, the powerful and profitable middlemen in the drug supply chain, that control which meds insurance companies will cover. What you might not know is that in the case of generics, the copay regularly covers more than the price of the drug. Many medicines will cost you less if you buy them outside your insurance for the cash price. That would be a nice thing to know at the drug store counter, but PBMs often require a “gag clause” that keeps pharmacists from informing you of the cheaper option; they regularly “claw back” a chunk of each copay from the drug store and keep it for themselves. What you can do: Check the cash price for your prescription at GoodRx.
Why a patient paid a $285 copay for a $40 drug (Megan Thompson, PBS, 8-19-18) "In recent years, the industry has taken a lot of heat from the media and elected officials over a controversial practice called “clawbacks.” This happens when a pharmacist collects a copay at the cash register that’s higher than the cost of the drug, and the pharmacy benefit manager takes most of the difference....Joyce said sometimes pharmacy benefit managers try to push customers to take another medication for which it had negotiated a bigger rebate....Insurance copays are higher than the cost of the drug about 25 percent of the time, according to a study published in March by the University of Southern California’s Schaeffer Center for Health Policy and Economics.... big retailers like Costco sometimes offer deep discounts on drugs through low-cost generics programs." And pharmacy benefit managers sometimes place some generic drugs on a more expensive "tier" than others, collecting a bigger rebate if a patient insists on a different-tier drug. "Websites like GoodRx and WellRx can help consumers find the best prices at local pharmacies." See also Buying drugs and procedures smartly, cheaply, safely
The Trump Administration Can't Decide Whether to Boost PBMs or Rein Them In (Ike Swetlitz, STAT, 8-22-18) Some days, President Trump vows to eliminate them. But then, there are days when his top health lieutenants promise to empower them. There are even days when they do both. The mixed and muddled signals from the administration are over the increasingly contentious role of the pharmacy benefit managers, or PBMs. Those discordant signals reflect a lack of clarity from Trump and his lieutenants over how best to address one of their top priorities: how to lower prescription drug prices.Why are drug prices so random? Meet Mr. PBM (An Arm and a Leg, Season 2, 6-26-19) I filled a prescription recently, and the drugstore said they wanted more than 700 bucks… for an old-line generic drug. My insurance ended up knocking that down, but it was WEIRD. And it meant a big homework assignment for me.
Washington is taking aim at drug industry middlemen. But can it break their grip on a captive market? (Casey Ross, STAT, 2-16-18) Ross clearly spells out the ways PBMs could be helpful in reducing drug costs and the ways in which instead of passing rebates along to patients they pocket them as part of a lucrative set of business practices that are a "black box" to everyone else.
Warren, Smith Raise Questions about Accuracy of Secretary Azar's Testimony Blaming PBMs for High Drug Prices (Letter from Senators Elizabeth Warren and Tina Smith, 8-17-18) Question Whether Secretary is Coordinating with Pharma to Deflect Responsibility for President Trump's Broken Promise to Reduce Drug Prices
Ohio firing pharmacy middlemen that cost taxpayers millions (Lucas Sullivan and Catherine Candisky, Columbus Dispatch, 8-14-18) Part of Side Effects: An ongoing investigation on the rising cost of prescription drugs. The Ohio Department of Medicaid is changing the way it pays for prescription drugs, giving the boot to all pharmacy middlemen because they are using "spread pricing," a practice that has cost taxpayers hundreds of millions. Medicaid officials directed the state's five managed care plans Tuesday to terminate contracts with pharmacy benefit managers using the secretive pricing method and move to a more transparent pass-through pricing model effective Jan. 1. "It will provide volumes of transparency," said Patrick Stephan, director of managed care for the Department of Medicaid. “The black box will effectively be eliminated.”...“(Tuesday's) decision to fire cheating big-PhRMA middlemen is proof positive of what many of us have been saying all along: big health-care corporations have been ripping off Ohio consumers by hundreds of millions of dollars to line their own pockets and boost their own bottom line,” West said.
States Question Costs Of Middlemen That Manage Medicaid Drug Benefits (Alison Kodjak, Shots, NPR, 8-8-18) "For example, Ohio paid the PBM $273.50 per unit for the generic version of Gleevec, a drug that treats leukemia and other cancers, while pharmacies reported the wholesale price of the drug was $83.69. In other words, the PBM charged the state more than the three times the price of the drug....If the analysis is released, it will offer an unprecedented look into the opaque world of pharmacy benefit managers and the mechanics of drug pricing....West Virginia last year stopped using pharmacy benefit managers altogether. And Kentucky is also doing an analysis of its costs while lawmakers consider legislation that would require pharmacy benefit managers that contract with Medicaid to report details of their costs to the state and ensure they pay independent pharmacies a fair price."
Report on MCP Pharmacy Benefit Manager Performance (PDF, Executive Summary, Ohio Department of Medicaid, 6-15-18)
When Copay Assistance Backfires on Patients (Julie Appleby, KFF Health News, 3-15-24) Drugmakers offer copay assistance programs to patients, but insurers are tapping into those funds, not counting the amounts toward patient deductibles. That leads to unexpected charges. But the practice is under growing scrutiny.
Patient Copay Clawbacks (National Community Pharmacists Association, "Under almost all health care plans, patients are responsible for a certain level of cost sharing usually in the form of a fixed Copayment or a percentage of the cost, known as co-insurance. The patient assumes they are paying a portion of the cost and their insurance company is paying the remainder. The practice known as "copay clawbacks," turns this premise upside down. Instead, the cost of the medication is lower than the patient's Copayment, but the insurer's PBM instructs the pharmacy to charge the patient an inflated Copay, and later the PBM "claws back" the excess from the pharmacy, keeping it for themselves." On this page you will find links to New Orleans investigative reporter Lee Zurik's series of stories exposing this practice, including Cigna faces class action suit amid 'Medical Waste' backlash (Fox 8, 10-14-16) "A spreadsheet given to FOX 8 News by a pharmacist in the Midwest shows Cigna Health Insurance overcharged at least 70 customers for prescription medication in one month, at just one community pharmacy. The spreadsheet details how the insurance company paid the pharmacist $25 for an acne cream. But Cigna instructed the pharmacist to collect a $187 copay, overcharging the customer $167. That money went right back to Cigna."
including "Zurik: Cigna faces class action suit amid 'Medical Waste":
Patients Overpay for Prescriptions 23% of the Time, Analysis Shows (Sydney, Lupkin, KHN, 3-13-18) Health economist Karen Van Nuys and her colleagues at the University of Southern California Schaeffer Center for Health Policy & Economics decided to launch a first-of-its-kind study to see how often it is cheaper to "pay cash at the pharmacy counter than to put down your insurance card and pay a copay....They found that customers overpaid for their prescriptions 23 percent of the time, with an average overpayment of $7.69 on those transactions....The practice of charging a copay that is higher than the full cost of a drug is called a “clawback” because the middlemen that handle drug claims for insurance companies essentially “claw back” the extra dollars from the pharmacy. (The middlemen, known as pharmacy benefit managers, include Express Scripts, CVS Caremark and OptumRx. Express Scripts and CVS Caremark say they don’t use clawbacks....)
Painful prescription: Pharmacy benefit managers make out better than their customers (Katherine Eban, Fortune Magazine, 10-23-13) "In this instance, the discount store bought the item for $3 before selling it for $20. In this analogy, the PBM makes $17 and the customer saves $2." Understand the "secret spread."
PillPack and Capsule expand their digital pharmacy toehold (Mark Brohan, Digital Commerce 360, 5-9-17) Online pharmacies such as PillPack Inc. in Manchester, N.H., and Capsule Corp. in New York are rolling out new digital services they contend will make filling prescriptions online quicker and easier.
"But," reports STAT Plus, "their ability to grow is largely controlled by existing competitors, including major pharmacy benefit managers who have been accused of twisting contract terms to block pharmacies’ access to their millions of U.S. customers." (Casey Ross, Feds broaden the definition of ‘pharmacy’ in a bid to level playing field for startups, STAT Plus, 4-6-18) See also Washington is taking aim at drug industry middlemen. But can it break their grip on a captive market? (Casey Ross, STAT Plus, 2-16-18) "Pharmacy benefit managers, or PBMs, are the middlemen who stand between manufacturers and consumers in the nation’s drug business. And they’ve been blamed by pharma companies for being the real profiteers in the current pricing system." STAT Plus is available online by subscription only.
Another Reporter Turns Up the Heat on PBMs (John Norton, The Dose (blog), National Community Pharmacists Association, NCPA, 3-17-17)
A video guide: How do prescription drug prices get set? (Katie Wedell, Dayton Daily News, 1-25-17) Text and video. Among points made: "5. Pharmacy benefit managers are companies that run prescription benefits for health plans. They use the millions of patients they represent as leverage, offering preferred coverage status to a drug in exchange for bigger rebates from the manufacturer. 6. The rebate the pharmacy benefit manager has negotiated with the manufacturer gets paid to them after the main drug transaction. The pharmacy benefit manager then passes all, some or none of that rebate amount along to the health plan sponsor depending on their contract. Critics argue that the rebates don’t actually lower drug prices because manufacturers build the cost into their pricing structure.
Who's really controlling your drug prices? 5 things to know (Katie Wiedell, Dayton Daily News, 1-26-17) Read and watch the full investigation into prescription drug prices. "These are very big companies. Three PBMs — Express Scripts, CVS Health and Optimum RX, a division of UnitedHealth Group — control about 70 percent of the market. The Fortune 500 list gives a sense of their enormous size....If a pharmacy charges $40 for a prescription and the patient’s share is already covered, the PBM might bill the health plan $40 plus 5 percent, and keep the difference." Critics "argue the door is open for price gouging without more transparency and if health plan sponsors aren’t savvy in negotiating those contracts....Some critics have accused PBMs of excluding certain medications, even when they’re effective, because the manufacturer didn’t offer a large enough rebate — a charge the PBM industry denies."
Aetna auditor accuses CVS of improperly reporting generic prices to Medicare (Ed Silverman, Pharmalot, STAT Plus, 4-9-18) "The CVS Caremark pharmacy benefit manager improperly reported generic drug prices to the federal government, causing Medicare and its beneficiaries to overpay for medicines, while pocketing a difference in pricing, according to a lawsuit filed by an actuary at the Aetna health insurer. The lawsuit revolves around complicated, behind-the-scenes contracts between pharmacy benefit managers and Medicare Part D plans, and the pricing that must be reported to the Centers for Medicare and Medicaid Services."
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."
Another Reporter Turns Up the Heat on PBMS (John Norton, The Dose:NCPA--The Voice of the Heat on PBMs, 5-17-17) "The success of pharmacy benefit managers (PBMs) comes from floating below the public's radar and framing a narrative about how much money they supposedly save the system. Independent community pharmacies' strategic efforts to rein in these drug middlemen occasionally get a welcome boost from investigative journalism.
The culprits behind high drug prices (Jim Maravelias, Daily Times, 5-15-18) Little-known middlemen called Pharmacy Benefit Managers, or PBMs, are benefiting from high drug prices. "For example, the list price on a medication is $100. The pharmacy first collects the patient’s co-pay of, say, $40 and then collects $60 from the insurance company. Here’s where the funny business comes in: The PBM retains part of the rebate for itself and then gives part of it to the insurer. It doesn’t give any to the patient, who still pays the $40 copay, regardless of the rebate. In the end, the patient ends up paying more than the insurer did. And the PBM makes a profit."
Klobuchar Wants To Stop ‘Pay-For-Delay’ Deals That Keep Drug Prices High (Emmarie Huetteman, KHN, 4-26-19) “We can stop this horrible practice where big pharmaceuticals pay off — they literally pay off — generics to keep the prices and the competition off the market.”

Berger Montague Files Antitrust Lawsuit Against Pharmacy Benefit Manager Express Scripts for Colluding with Rivals (PR Newswire)

Express Scripts offers new formulary for lower list-price drugs (Deena Beasley, Reuters, 11-13-18) The manager of prescription drug benefits for large corporate employers and government health plans said its new National Preferred Flex Formulary will be available as of Jan. 1 to all clients. Drug rebates have come under fire from the Trump Administration and consumer groups as patients find themselves paying much higher insurance co-payments and deductibles tied to a drug’s sticker price.
A video guide: How do prescription drug prices get set? (Katie Wedell has an excellent series in the Dayton Daily News, 1-25-17) Why are prescriptions so expensive?
It's Getting Harder for Rural Pharmacies to Stay Afloat (AP, MedPage Today, 6-8-24) These pharmacies fill a healthcare gap and can be a touchstone for their communities. Pharmacy benefit managers (PBMs) help employers and insurers decide which drugs are covered for millions of Americans. And the lack of transparency around fees and low reimbursements from PBMs is one of the biggest financial pressures for rural pharmacies.
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)


What is Trumpcare? (Larry Levitt, news@JAMA, 9-25-19)
Federal judge in Texas rules Obamacare unconstitutional; California vows to defend the law on appeal (Noam N. Levey, LA Times, 12-14-18) "A federal judge in Texas threw a dagger into the Affordable Care Act on Friday, ruling that the entire healthcare law is unconstitutional because of a recent change in federal tax law....The tax law eliminated the penalty on Americans who don’t have health insurance, although it preserved the technical requirement that people have coverage."... The judge did not issue an injunction ordering the government to stop carrying out the law, however, meaning that its provisions will remain in effect pending further action. The Trump administration had partially backed the suit by the conservative states, not endorsing their request to declare the entire law invalid. Instead, the administration had declined to defend the healthcare law and asked the judge to eliminate its guarantee of coverage for people with preexisting health conditions. A group of left-leaning states led by California that have stepped in to defend the healthcare law quickly said they would appeal O’Connor’s ruling....President Trump praised the judge's ruling...."
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.”
Federal Judge in Fort Worth Hears Latest Challenge to the Affordable Care Act (Ashley Lopez, All Things Considered, NPR, 9-5-18) Oral arguments got underway Wednesday in Texas v. United States, the lawsuit brought by 20 GOP state attorneys general versus the federal government. The Republican group The group argued that when Congress zeroed out the tax penalty for the individual mandate - that's the part of the law that requires people to buy health insurance - the whole law was invalidated. Stacey Pogue with the Center for Public Policy Priorities says there are a lot of problems with this argument. The first is that the individual mandate wasn't actually eliminated. The tax penalty that enforced it was. ASHLEY LOPEZ: But Henneke says this part of the case wasn't the biggest concern for the court. He says the judge had more questions about whether if one part of the law is found to be unconstitutional, that means the whole law is unconstitutional. And Henneke says the judge had questions about what happens if he does strike down the law.
Legal Case to Smash Obamacare Hands the Democrats a Hammer (Abby Goodnough, NY Times, 9-5-18) More than 1,000 miles from the caustic Supreme Court confirmation hearing of Brett M. Kavanaugh, a federal judge in Texas on Wednesday listened to arguments about whether to find part or all of the Affordable Care Act unconstitutional, in a case that may end up before a newly right-leaning set of justices. The case has become not simply a threat to the landmark legislation. Democrats have sought to make it both a flash point in the battle over whether to confirm Judge Kavanaugh and a crucial prong in their strategy to retake control of the House and Senate in the midterm elections.
The Affordable Care Act is under fire again in federal court
Understanding the issues health care reform should address (Amy Goldstein and Gayle Reaves, WaPo, 9-5-18) The nearly four hours of legal sparring at Wednesday’s hearing shone a light on the partisan acrimony surrounding the statute that, several years after it extended health coverage to millions of Americans, remains a favorite Republican whipping post and is serving as a convenient rallying cry for Democratic candidates in this year’s midterm elections. In an abnormal arrangement, attorneys for the federal government — the defendant in the case — sat on the same side of the courtroom as the plaintiff’s lawyers during Wednesday’s hearing. The odd seating pattern stems from the fact that the Trump administration is largely agreeing with the plaintiffs who are suing. In June, the Justice Department saying in a court filing it would not defend the law.
Drug Trade Group Quietly Spends ‘Dark Money’ to Sway Policy and Voters (Jay Hancock, KHN and New York Times, 7-30-18) "In 2010, before the Affordable Care Act was passed by Congress, the pharmaceutical industry’s top lobbying group was a very public supporter of the measure. It even helped fund a multimillion-dollar TV ad campaign backing passage of the law." Last year it ostensibly stayed out of the fray when Republicans mounted effort to repeal and replace the law. But it provided financial support of another group, the American Action Network (AAN), "which was heavily involved in that effort to put an end to the ACA, often referred to as Obamacare, spending an estimated $10 million on an ad campaign designed to build voter support for its elimination....PhRMA was one of AAN’s biggest donors the previous year, giving it $6.1 million, federal regulatory filings show. And PhRMA had a substantial interest in the outcome of the repeal efforts. Among other actions, the GOP-backed health bill would have eliminated a federal fee paid by pharmaceutical companies, one estimated at $28 billion over a decade....The conservative-leaning AAN has become one of the most prominent nonprofits for funneling “dark money” — difficult-to-trace funds behind TV ads, phone calls, grass-roots organizing and other investments used to influence politics. Such groups have thrived since the Supreme Court’s Citizens United decision in 2010, which loosened rules for corporate political spending, and amid what critics say is nonexistent policing of remaining rules by the IRS."
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 HealthCare.gov.
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 KFF.org, 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.

Who benefits (and how) from health savings accounts

Tax Secrets of Health Savings Accounts (Laura Saunders, WSJ, 9-30-22) Sure, HSAs can be used for medical expenses. But they can also be great rainy-day funds, retirement accounts that outstrip IRAs and 401(k)s, and tax-free accounts for twenty-somethings still on their parents’ health insurance.
HSA vs. FSA: What’s the Difference, and Should You Use Either? (Neal W. Fandek, GoodRX, 12-23-2020)  A health savings account (HSA) is yours: You contribute to it, it’s not tied to your employer, and it follows you from job to job and even into retirement. A health flexible spending account (FSA is your employer's. They sponsor your FSA, if it offers one. And you must spend almost all of what you decide to contribute to your FSA every year or you will lose your money. Both can save you money on a surprising number of health care expenses.
Another twist in the HSA debate – do they encourage more spending? Joanne Kenen, (@JoanneKenen) the health editor at Politico, on Covering Health, AHCJ, 6-13-19) Over time, as people build up more money in these accounts, they also tend to spend more, reports the Employee Benefit Research Institute (EBRI). There’s also a fair amount of data suggesting that the savings accounts are more beneficial to higher income people. “Over time, growing HSA balances may mitigate the impact of the deductible,” the authors noted. “We find that as individuals build up balances in HSAs, they use more health care services than they otherwise would."
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."..."...health 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.
Most Health Savings Account Owners Stick With Conservative Options (Michelle Andrews, Shots, NPR, 9-3-15) Only a tiny fraction of the growing number of people with health savings accounts invests the money in their accounts in the financial markets, a recent study finds. The vast majority leave their contributions in savings accounts instead where the money may earn lower returns.
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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Health care reform and the Affordable Care Act (ACA)

Often called Obamacare, originally by its opponents)

On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act, into law. The eight basic consumer protections the Obama White House wants health care reform to cover:
(1) No discrimination for pre-existing conditions,
(2) No exorbitant out-of-pocket expenses, deductibles or co-pays,
(3) No cost-sharing for preventive care,
(4) No dropping of coverage if you become seriously ill,
(5) No gender discrimination,
(6) No annual or lifetime caps on coverage,
(7) Extended coverage for young adults,
(8) Guaranteed insurance renewal so long as premiums are paid.
For more about the Obama White House plans for health care, see http://www.whitehouse.gov/healthreform .

Various sites, articles, judicial arguments (etc.) of interest and often helpful:
Repealing The Affordable Care Act Could Be More Complicated Than It Looks (Julie Rovner, Kaiser Health News, 11-9-16). President-elect Donald Trump has pledged to end the Affordable Care Act. But promising to make the law go away, and actually figuring out how to do it, are two very different things. Interesting analysis.
The Complex Mess of Health Insurance (David Leonhardt, OpEd, NY Times, 1-5-17) "A lot of Americans are deeply frustrated by the logistical headaches built into our health care system. Strikingly, some of the Trump voters told Kaiser that they resented lower-income people who were enrolled in Medicaid, which they viewed as a better deal. Medicaid has its own complexities (and its own problems), but government-run programs do tend to be simpler than private ones. It’s true of Medicare, and it’s true of single-payer systems in other countries....Wouldn’t that be ironic? The Republican passion for getting rid of Obamacare could ultimately lead to a bigger dose of Big Government."
Health Care Reform: What It Is, Why It's Necessary, How It Works by Jonathan Gruber (clear explanations in graphic novel format of the Affordable Care Act, by an MIT economist, and one of the architects of both RomneyCare and ObamaCare). Here's YouTube version, in short.
(Timothy Jost, Health Affairs, 12-11-15) Section 1332 of the Affordable Care Act provides for waivers for state innovation,. The idea behind this provision is that if individual states can find a better way of reaching the goals of the ACA, they should be allowed to try, so long as they delivered patient-centered, high-quality, cost-effective care. To be granted a waiver, states must demonstrate that their alternative proposal will stay within certain guardrails: as journalist Renee Despres has put it, 1) provide coverage that is "at least as comprehensive" as that mandated by the ACA; 2) limit out-of-pocket expenses to the same levels as required by the ACA; 3) cover at least as many people as the ACA; and 4) not increase the federal deficit. Other provisions of the ACA, including the prohibitions against imposing preexisting condition requirements or underwriting based on health status, cannot be waived. Some Republicans eager to do away with the ACA apparently want to use the waivers to avoid meeting ACA requirements.
State Innovation Waivers (Centers for Medicare & Medicaid Services) CMS explanation of little-known waivers that became newsworthy under Republican efforts to kill ACA.

The ACA’s Section 1332: Escape Hatch Or Straightjacket For Reform? (Jonathan Ingram, Nic Horton, and Josh Archambault, Health Affairs blog, 5-26-16) According to some proponents, the waivers in Section 1332 of the Affordable Care Act will “turbocharge state innovation” and will provide states with an “exit strategy” from the ACA. "State lawmakers on both sides of the aisle are coming to the realization that Section 1332 waivers will require more money and effort than they are worth. Policymakers should instead focus their time on proven, state-level reforms that drive costs down, agnostic to the ACA."
Ten Titles: Understanding the Affordable Care Act (pdf, John McDonough, Hunter College, October 2010)
Equitable Access to Care — How the United States Ranks Internationally (Karen Davis and Jeromie Ballreich, NEJM, 10-23-14) "The United States has been unusual among industrialized countries in lacking universal health coverage. Financial barriers to care — particularly for uninsured and low-income people — have also been notably higher in the United States than in other high-income countries. As more Americans become insured as a result of the Affordable Care Act (ACA), differences in access to care between the United States and other countries — as well as among income groups within the United States — may begin to narrow."
Obamacare’s trade-offs left too many Americans feeling like they got a raw deal (Trudy Lieberman, Center for Healthcare Journalism, 1-10-17) The failures of the national conversation during the run-up to Obamacare's passage are now hastening its demise, with too few Americans seeing firsthand benefits. The public discourse did not make it clear that all Americans did not have an equal stake in the outcome. Most already had insurance and wouldn’t be helped by the subsidies and other benefits bestowed on those who didn’t. The discourse must change if all Americans are to have health insurance someday. If the U.S. is ever to achieve real universal health coverage, then we’re going to have to all join the insurance pool together. Until our discourse embraces that concept of shared risk, we’ll continue to have large numbers of uninsured Americans.

Are More Americans Benefiting From Obamacare Than Realize It? (Drew Altman, Wall Street Journal, 5-20-15) The ACA guarantees coverage despite pre-existing conditions (previously denied coverage), requires a range of preventive services (without co-pays), eliminates lifetime caps on insurance coverage. Many Americans don't realize that that free flu shot is one benefit that resulted. "...gradually, more people may become aware of the popular benefits the ACA provides beyond expanding coverage for the uninsured."
• The Kaiser Family Foundation's summary of the law (pdf), and of changes made to the law by subsequent legislation, focuses on provisions to expand coverage, control health care costs, and improve health care delivery system. Kaiser also posts the implementation timeline for health reform , an interactive tool designed to explain how and when the provisions of the Affordable Care Act will be implemented over the next several years.
Frequently Asked Questions about Health Reform (Kaiser Family Foundation)
Medicare’s Rush To Risk: Confounding Theory And Practice, Leaving ACOs Vulnerable (David Introcaso and Clifton Gaus, Health Affairs blog, 6-19-15) It's hard to summarize this piece, which is well worth reading. While tying payment to value makes perfect sense, transforming the Medicare program without the evidence that explains how to do this does not.
HHS interactive state-by-state map.
Preventive Services Covered by Private Health Plans under the Affordable Care Act (Kaiser Foundation 10-28-14) A key provision of the ACA is the requirement that private insurance plans cover recommended preventive services without any patient cost-sharing. Full discussion.
The Great Cost Shift comes into focus (Trudy Lieberman, CJR, 12-24-14). "Consumers, even consumers who have insurance, are paying a larger share of their healthcare costs. This shift has been in the works for years, but provisions in the ACA have made it more visible."
The ‘unmitigated disaster’ of Obamacare in Mississippi (Trudy Lieberman, Columbia Journalism Review, 11-5-14). Sarah Varney and Jeffrey Hess report the heck out of a grim, ominous healthcare story. The story: Mississippi, Burned: How the poorest, sickest state got left behind by Obamacare. (Sarah Varney with Jeffrey Hess, Politico, Oct. 2014).
Obamacare’s Secret Success (Paul Krugman, NY Times Opinion page, 11-28-13) The law establishing Obamacare was officially titled the Patient Protection and Affordable Care Act. And the “affordable” bit wasn’t just about subsidizing premiums; t was also about “bending the curve” — slowing the seemingly inexorable rise in health costs. Follow the bending cost curve and you will find that the slowdown in health costs has been dramatic.
Feds Target Health Law Loophole That Allows Large Employers To Offer Plans That Don’t Cover Hospitalization (Kaiser Health News, 11-4-14) The administration intends to disallow plans that “fail to provide substantial coverage for in-patient hospitalization services or for physician services,
A death blow for Obamacare? (Laurence H. Tribe, Boston Globe, 7-18-14) "The moment the Affordable Care Act was enacted in 2010, it became a litigation magnet. The lawsuits threatening to derail it were initially dismissed as ridiculous but became deadly serious by the time Chief Justice John Roberts’s decisive fifth vote two years later barely upheld the law’s individual mandate, while the Court’s decisive 7-2 vote left the health law’s Medicaid expansion in tatters. Last month, the court struck a second blow to the ACA by allowing some for-profit corporations to opt out of offering contraceptive coverage they deemed religiously offensive. And even House Speaker John Boehner is joining in the litigation..."
Another Baseless Attack on Health Law (NY Times editorial, 12-12-14) A suit filed by the "Republican-dominated House aims to block another important subsidy: federal payments to insurance companies to keep deductibles, co-payments and other cost-sharing low for the poor. ... If the federal government cannot assist, a lot of other individual policyholders may have to pay more."

A closer look: Did the ACA result in more canceled plans? (Joanne Kenen, Covering Health, AHCJ, 4-29-14)
Warren: It's too soon to call Obamacare — or Obama — a failure (James Warren, Daily News, 12-1-13) There was a lot of melodrama over Saturday's 'sort-of deadline' for repairing HealthCare.gov. Though Obama's approval ratings are tanking and the Obamacare website had early missteps, the President and his health care plan shouldn't be written off so quickly.
Safety Leaders. Actor Dennis Quaid's family is joining forces with the Texas Medical Institute of Technology (TMIT) to raise public awareness about our broken medical system, to eliminate human error, and to make caregivers aware that patients have the right to know all information that could have an impact on their health and well-being, with major focus on increasing awareness of the dangers of medication errors. See also Preventable Medical Malpractice: Revisiting the Dennis Quaid Medication/Hospital Error Case (Rick Schapiro, The Legal Examiner 8-9-10).
Bringing local, national perspectives to report on ACA in rural Kentucky (Joanne Kenen, Covering Health, AHCJ, 6-17-14)
The AP downplays its Obamacare scoop (Trudy Lieberman, Columbia Journalism Review 4-11-14). AP calls "minor' a change in legislation that shifts costs to consumers by raising deductibles.
Rooting for Failure (Timothy Egan, NY Times Opinion page, 11-28-13) It's hard to remember a time when a major political party and its media arm were so actively hoping for fellow Americans to lose. Tim Egan's unvarnished take on the shamelessness of the anti-Obamacare creed.
Challenges For The New Health Insurance Exchanges (transcript for Diane Rehm show, with guests Susan Dentzer of The Robert Wood Johnson Foundation, Louise Radnofsky of The Wall Street Journal, Jon Kingsdale of the Wakely Consulting Group, who led the agency that implemented the Massachusetts health insurance exchange, and David Simas, speaking from the White House, 10-16-13).
Special Investigation: How Insurers Are Hiding Obamacare Benefits from Customers (Dylan Scott, Talking Points Memo, 11-4-13). "By warning customers that their health insurance plans are being canceled as a result of Obamacare and urging them to secure new insurance plans before the Obamacare launched on Oct. 1, these insurers put their customers at risk of enrolling in plans that were not as good or as affordable as what they could buy on the marketplaces."
Middle class families wary of higher premiums Carla K. Johnson, AP story in Portland Press Herald, 9-13-13). "The new Affordable Care Act health exchanges won't offer any bargains for higher-income families, who fear that their current health insurance policies may get more expensive under the new law's requirements. As many as nine in 10 Texans buying health insurance on the new federally run exchange will get a break on costs, according to federal health officials. Steve and Maegan Wolf won't be among them."
Medical Device Industry Fears Health Care Law’s Tax on Sales (Barry Meier, Tracking the Affordable Care Act, NY Times, 10-1-13)
Questionable design blamed for healthcare website woes (Carla K. Johnson and Ricardo Alonso-Zaldivar, AP, 10-8-13)
A decision by the Obama administration to require that consumers create online accounts before they can browse health overhaul insurance plans appears to have led to many of the glitches that have frustrated customers, independent experts say.
How Obamacare’s medical device tax became a top repeal target (Sarah Kliff, Wonkblog, WashPost, 9-28-13). See also:
In Need of a New Hip, but Priced Out of the U.S. (Elisabeth Rosenthal, NY Times, 8-3-13) Paying Till It Hurts: A Trip Abroad. Part of an excellent series on what's wrong with American health care.
How can I get an estimate of costs and savings on Marketplace health insurance? (Healthcare.gov)
Kaiser Family Foundation information site on the Affordable Care Act (extremely helpful)
LocalHelp.HealthCare.gov (for state-specific information)
ACA-Mandated Insurance Quick Tips (Bob Rosenblatt, Aging Today)
2015 Marketplace health insurance plans and prices right now (HHS, Assistant Secretary of Planning and Evaluation)
New York State of Health: The Official Health Place
Covered California, the new marketplace for affordable private health insurance
Millions of Poor Are Left Uncovered by Health Law ( Sabrina Tavernise and Robert Gebeloff, NY Times, 10-2-13)
A Nevada Health Plan -- Without The Insurance (Pauline Bartolone, Kaiser Health News, Capital Public Radio, NPR, 9-14-13) An unusual Nevada nonprofit that helps connect 12,000 uninsured residents to doctors and hospitals who are willing to accept a lower-cost, negotiated fee for their services. Giving care to the uninsured before they require urgent care helps lower costs by keeping their members out of the ER.

Health Reform D-Day? Or not for a few more months? (Joanne Kenen, Covering Health, AHCJ, 10-1-13). See also Tracking exchange activity.
Shutdown Din Obscures Health Exchange Flaws (Robert Pear, NY Times, 10-4-13)

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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.
Equifax, Experian, TransUnion to remove some medical debt from credit reports (Kerry Dooley Young and Joseph Burns , Covering Health, AHCJ, 4-6-22)  See also:
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)
Analysis of pharmaceutical R&D ranks Novo Nordisk and Johnson & Johnson above their peers ( Matthew Herper, STAT, 5-16-24) When it comes to bringing an experimental drug to market and selling it, Novo Nordisk, the maker of the weight loss drug Wegovy, is tops, according to a new analysis. But if you want to invent lots of potential drugs that could eventually reach the market, you’d be far better off with Johnson & Johnson, Merck, or AstraZeneca.
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

An Arm and a Leg Show A place where they do health care more cheaply and effectively. (And yes, it’s in the U.S.) Dan Weissmann's podcast series about the cost of health care.
Health System Dashboard How well is the U.S. health system performing? Explore a variety of indicators of health spending, quality of care, access, and health outcomes. See brief: State of the U.S. Health System: 2020 Update (Nisha Kurani, Rabah Kamal, Krutika Amin Twitter, Giorlando Ramirez, and Cynthia Cox, KFF) and archive of articles.
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.
What Level of Disparity in Health Care Are We Willing to Tolerate? (Michael Apkon, Boston Globe, 8-1-19) The United States leads the world in health care innovation, but we are tragically dead last compared with other high-income countries when it comes to keeping our citizens healthy. While those in other countries have access to regular physical exams and a wide range of preventive care regardless of their economic status, the only level of care we, the richest nation in the world, guarantee every resident is a trip to the local emergency room. I believe we can — and should — do better. We must agree on a minimum defined set of benefits for every member of society.
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.
More registered nurse staffing means fewer sepsis deaths (Tara Haelle, Covering Health, AHCJ, 7-22-22) Higher levels of registered nurse staffing are associated with a lower likelihood of Medicare patients' dying from sepsis in hospitals. Nurses can play a crucial role in the prevention and treatment of a wide range of conditions.

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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.
Choosing Wisely (aimed at teaching physicians to think more carefully about default screening options--at eliminating unnecessary or overused procedures)
U.S. Preventive Services Task Force (recommendations for, against, and for a specific number of various screening procedures).
This Indiana Clinic Has Patient-Care Stats Worth Bragging About (Dan Weissmann, An Arm and a Leg, KHN, 7-31-19) Maple City (in Goshen, Indiana) is a federally qualified health center — a designation for community-based clinics in underserved areas that take all patients regardless of ability to pay. They are outperforming all the other clinics.Federal goals say 80% of kids should be fully vaccinated by age 2. This clinic is at 84%. Next highest in the state is 63; the average is 27. Patients in financial trouble stopped coming in, so clinic developed a new plan: Patients who couldn’t pay in cash could volunteer for local nonprofits, for schools — anyplace they liked — and earn $10 an hour in credit toward their health care bills. And they started coming in again. The clinic looks at the whole family: a family comes in for a child's problem and the parent gets a preventive treatment also (knowing that time for the family is precious).
What One Man's Brush With Death Reveals About Access to Health Care (Kerry Klein, Valley Public Radio,NPR For Central California, 4-2-19) In early 2014, Jesus Gomez nearly lost his life to an autoimmune disease that attacked his skin cells. Without insurance or a dedicated primary care doctor, he struggled for a year within a disjointed healthcare system to find a diagnosis and treatment. He finally found care at the burn center at Community Regional Medical Center in downtown Fresno. Less than two-thirds of specialists in the area accept Medi-Cal patients or the uninsured—which together are estimated to make up more than half of the San Joaquin Valley.
Top 10 Health Technology Hazards for 2019 (PDF, a report on technology devices).

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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.
• 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.

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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 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)

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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
American Society on Aging (ASA)
American Telemedicine Association (ATA)
Advanced Research Projects Agency for Health (ARPA-H) NIH has funding for this new agency to develop breakthroughs – to prevent, detect, and treat diseases like Alzheimer’s, diabetes and cancer.
---ARPA-H website
---ARPA-H Fact Sheet (White House)
---The U.S. just created a big new biomedical research agency. But questions remain (Jocelyn Kaiser,Science, 3-15-22) Congress gave it a $1 billion startup investment--a fraction of the $6.5 billion Biden had proposed, but advocates say it’s plenty to launch ARPA-H. "Biden proposed ARPA-H in 2021 as a biomedical version of the military’s Defense Advanced Research Projects Agency (DARPA), famed for its nimbleness and for backing innovations like the internet. Like DARPA, ARPA-H is expected to hire program managers on short-term contracts who would have enormous freedom to solicit research ideas and swiftly fund them with milestone-driven contracts."
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
Center for Connected Health Policy (CCHP) develops and distributes telehealth policy solutions designed to promote improvements in health and healthcare systems; initially it focused on telemedicine in California. In 2012, the organization became the federally designated National Telehealth Policy Resource Center (NTRC-P) and today, has expanded its mission to include national health policy. CCHP monitors both state and federal legislation, identifies barriers to telehealth use, and provides policy technical assistance to the regional telehealth resource centers and state and federal policymakers.
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.
Globe1234.com provides all kinds of data a patient might/should want to have. Paul Burke compared methods for the Checkbook and ProPublica rating systems (Globe1234).
e-patients.net (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)
FDA (U.S. Food and Drug Administration. An interesting story: The FDA, but with guns: How far should a little-known office go to track down counterfeit drugs? (Nicholas Florko, STAT, 11-5-18) The FDA's criminal investigations team investigates counterfeit drugs with raids and search warrants, much like their counterpart agents at FBI and DEA. FDA's Office of Criminal Investigations was created by Congress in the early 1990s, as part of its response to an FDA corruption scandal, when a handful of FDA officials had been indicted for accepting bribes from generic drug makers attempting to get their drugs approved more quickly. Trained in law enforcement and knowledgeable about chemistry, OCI staff are sometimes expected to play a regulatory, not a law-enforcement role, and two years without a national leader has not helped clarify their important role.
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.
HealthCare.gov. Official site of Affordable Care Act.
HealthFinder.gov, 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.
Institute for Safe Medication Practices (ISMP)
ICN Telenursing Network (International Council of Nurses)
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)
National Institutes of Health (NIH)
---Research and training
---Building 10 at Fifty: 50 Years of Clinical Research at the NIH Clinical Center (Pat McNees)
---Articles about NIH and research
---McNees page on NIH
National Practitioner Data Bank (NPDB) contains selected variables from medical malpractice payment and adverse licensure, clinical privileges, professional society membership, and Drug Enforcement Administration (DEA) reports (adverse actions) received by the NPDB concerning physicians, dentists, and other licensed health care practitioners. It also includes reports of Medicare and Medicaid exclusion actions taken by the Department of HHS Office of Inspector General. But NPDB Records Often Ignored in Docs' Licensing (Matt Wynn, MedPage Today, and John Fauber, Reporter, Milwaukee Journal Sentinel, 3-7-18)
National Rural Health Association. See its history.
Physicians for a National Health Program (supports single-payer national health insurance)
Pro Publica (a nonprofit newsroom that produces investigative journalism in the public interest)
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.
Smokefree.gov , 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)
SurgeonRatings.org (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.
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

The Health System We’d Have if Economists Ran Things (Austin Frakt, NY Times, 2-17-2020) A survey of nearly 200 Ph.D. health economists finds them taking a few politically unpopular positions. They strongly rejected repeal of Obamacare (89% oppose the idea). They overwhelmingly (81% agreement) said the A.C.A.’s individual mandate — in which people paid a fine if they chose not to be insured — was essential for its success. 80% said premiums should not be higher for those with “genetic defects” (the poll’s wording). "But nearly 70 percent of health economists are comfortable charging people more if they engage in unhealthy behaviors that lead to higher health costs." And so on.
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")
High-Deductible Plans Jeopardize Financial Health of Patients and Rural Hospitals (Markian Hawryluk, KHN, 1-10-2020) Plans with annual deductibles of $3,000, $5,000 or even $10,000 have become commonplace since the implementation of the Affordable Care Act as insurers look for ways to keep monthly premiums to a minimum. But in rural areas, where high-deductible plans are even more prevalent and incomes tend to be lower than in urban areas, patients often struggle to pay those deductibles, and hospitals are left with uncollectible "bad debt."
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, Moyers.com, 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 most....to 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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