Category Archives: Insurance

Medicare for All, funding and ‘impossible promises’ deeply divide Democrats during 2020 debate; and How Many More Shootings of Innocent people Can Our Society Tolerate?

 

promise312What a horrible week it has been! The debates were an embarrassment for all, both Democrats as well as everyone else. Who among those twenty who were on stage, spouting impossible strategies, attacking each other and in general making fools of themselves.

But the worst was the mass shootings this past weekend. Why should anybody be allowed to own assault weapons? We all need to finally do something about this epidemic of mass shootings. How many more innocent people do we have to lose before the Republicans, as well as the Democrats and our President, work together to solve this problem.

As the President of the American Medical Association stated:

“The devastating gun violence tragedies in our nation this weekend are heartbreaking to physicians across America. We see the victims in our emergency departments and deliver trauma care to the injured, provide psychiatric care to the survivors, and console the families of the deceased. The frequency and scale of these mass shootings demand action.

“Everyone in America, including immigrants, aspires to the ideals of life, liberty, and pursuit of happiness. Those shared values – not hatred or division – are the guiding light for efforts to achieve a more perfect union.

“Common-sense steps, broadly supported by the American public, must be advanced by policymakers to prevent avoidable deaths and injuries caused by gun violence. We must also address the pathology of hatred that has too often fueled these mass murders and casualties.”

Brittany De Lea when reviewing the Democrat presidential hopefuls noted that Democratic contenders for the 2020 presidential election spent a sizable amount of time during the second round of debates detailing the divide over how the party plans to reform the U.S. health care system – while largely avoiding to address how they would pay for their individual proposals.

Massachusetts Sen. Elizabeth Warren dodged a point-blank question from moderators as to whether middle-class families would pay more in taxes in order to fund a transition to a Medicare for All system.

Instead, she said several times that “giant corporations” and “billionaires” would pay more. She noted that “total costs” for middle-class households would go down.

Independent Vermont Sen. Bernie Sanders said during the first round of Democratic debates in Miami that taxes on middle-class families would rise but added that those costs would be offset by lower overall health care costs. Warren seemed to refer to this plan of action also.

Sanders and Warren quickly became targets on the debate stage for his proposed plan, which she supports, to transition to a Medicare for All system where there is no role for private insurers.

Former Maryland Congressman John Delaney (and even though I am not a big fan of Mr. Delaney, he is the only one that makes any sense with regard to health care) said Sanders’ plan would lead to an “underfunded system,” where wealthy people would be able to access care at the expense of everyone else. He also said hospitals would be forced to close.

Delaney asked why the party had to be “so extreme,” adding that the Democrats’ health care debate may not be so much about health care as it was an “anti-private sector strategy.” In his opening statement, he appeared to throw jabs at Sanders and Warren for “impossible promises” that would get Trump reelected.

Former Texas lawmaker Beto O’Rourke said taxes would not rise on middle-class taxpayers, but he also does not believe in taking away people’s choice for the private insurance they have.

Minnesota Sen. Amy Klobuchar said there needed to be a public option, as did former Colorado Gov. John Hickenlooper.

South Bend, Indiana, Mayor Pete Buttigieg thought the availability of a public alternative would incentivize people to walk away from their workplace plans.

Earlier this week, California Sen. Kamala Harris unveiled her vision for a transition to a Medicare for All system over a 10-year phase-in period, which called for no tax increase on families earning less than $100,000. She instead said a Wall Street financial transaction tax would help fund the proposal.

Harris is scheduled to appear during Wednesday’s night debate in Detroit, alongside former Vice President Joe Biden whose campaign has already criticized her health care plan.

Health care comes in focus, this time as a risk for Democrats

Ricardo Alonso-Zaldivar reported that the Democratic presidential candidates are split over eliminating employer-provided health insurance under “Medicare for All.”

The risk is that history has shown voters are wary of disruptions to job-based insurance, the mainstay of coverage for Americans over three generations.

Those divisions were on display in the two Democratic debates this week, with Sens. Bernie Sanders and Elizabeth Warren calling for a complete switch to government-run health insurance for all. In rebuttal, former Vice President Joe Biden asserted, “Obamacare is working” and promised to add a public option. Sen. Kamala Harris was in the middle with a new Medicare for All concept that preserves private insurance plans employers could sponsor and phases in more gradually. Other candidates fall along that spectrum.

The debates had the feel of an old video clip for Jim McDermott, a former Democratic congressman from Washington state who spent most of his career trying to move a Sanders-style “single-payer” plan and now thinks Biden is onto something.

“There is a principle in society and in human beings that says the devil you know is better than the devil you don’t know,” said McDermott, a psychiatrist before becoming a politician. “I was a single-payer advocate since medical school. But I hit every rock in the road trying to get it done. This idea that you are going to take out what is known and replace it with a new government program — that’s dead on arrival.”

Warren, D-Mass., was having none of that talk Monday night on the debate stage. “Democrats win when we figure out what is right, and we get out there and fight for it,” she asserted.

Confronting former Rep. John Delaney, D-Md., a moderate, Warren said, “I don’t understand why anybody goes to all the trouble of running for president of the United States just to talk about what we really can’t do and shouldn’t fight for. … I don’t get it.”

Here’s a look at options put forward by Democrats and the employer-based system that progressives would replace:

MEDICARE FOR ALL

The Medicare for All plan advocated by Sanders and Warren would replace America’s hybrid system of employer, government and individual coverage with a single government plan paid for by taxes. Benefits would be comprehensive, and everybody would be covered, but the potential cost could range from $30 trillion to $40 trillion over 10 years. It would be unlawful for private insurers or employers to offer coverage for benefits provided under the government plan.

“If you want stability in the health care system, if you want a system which gives you freedom of choice with regard to doctor or hospital, which is a system which will not bankrupt you, the answer is to get rid of the profiteering of the drug companies and the insurance companies,” said Sanders, a Vermont senator.

BUILDING ON OBAMACARE

On the other end is the Biden plan, which would boost the Affordable Care Act and create a new public option enabling people to buy subsidized government coverage.

“The way to build this and get to it immediately is to build on Obamacare,” he said.

The plan wouldn’t cover everyone, but the Biden campaign says it would reach 97% of the population, up from about 90% currently. The campaign says it would cost $750 billion over 10 years. Biden would leave employer insurance largely untouched.

Other moderate candidates take similar approaches. For example, Colorado Sen. Michael Bennet’s plan is built on a Medicare buy-in initially available in areas that have a shortage of insurers or high costs.

THE NEW ENTRANT

The Harris plan is the new entrant, a version of Medicare for All that preserves a role for private plans closely regulated by the government and allows employers to sponsor such plans. The campaign says it would cover everybody. The total cost is uncertain, but Harris says she would not raise taxes on households making less than $100,000.

“It’s time that we separate employers from the kind of health care people get. And under my plan, we do that,” Harris said.

Harris’ plan might well reduce employer coverage, while Sanders’ plan would replace it. Either would be a momentous change.

Job-based coverage took hold during the World War II years, when the government encouraged employers and unions to settle on health care benefits instead of wage increases that could feed inflation. According to the Congressional Budget Office, employers currently cover about 160 million people under age 65 — or about half the population.

A poll this week from the nonpartisan Kaiser Family Foundation underscored the popularity of employer coverage. Among people 18-64 with workplace plans, 86% rated their coverage as good or excellent.

Republicans already have felt the backlash from trying to tamper with employer coverage.

As the GOP presidential nominee in 2008, the Arizona Sen. John McCain proposed replacing the long-standing tax-free status of employer health care with a tax credit that came with some limits. McCain’s goal was to cut spending and expand access. But Democrats slammed it as a tax on health insurance, and it contributed to McCain’s defeat by Barack Obama.

“The potential to change employer-sponsored insurance in any way was viewed extremely negatively by the public,” said economist Douglas Holtz-Eakin, who served as McCain’s policy director. “That is the Achilles’ heel of Medicare for All — no question about it.”

These Are the Health-Care Questions That Matter Most

Max Nisen then noted that Health care got headline billing at both of this week’s second round of Democratic presidential debates. Unfortunately for voters, neither was very illuminating.

The biggest culprit was the format. Jumping between 10 candidates every 30 seconds made any substantive debate and discussion impossible. The moderators also deserve blame; they asked myopic questions intended to provoke conflict instead of getting any new information. And the candidates didn’t exactly help; there was a lot of sniping and not a lot of clear explanation of what they wanted to do.

The next debates may well be an improvement, as a more stringent cutoff should help to narrow the field and give candidates added time to engage in thoughtful discourse. Regardless, here are the issues that matter, and should be at the heart of any discussion:

The issue of how candidates would propose paying for their various health-care plans has been framed in the debates by the question, “Will you raise middle-class taxes?” That’s a limited and unhelpful approach. Raising taxes shouldn’t be a yes or no question; it’s a trade-off. Americans already pay a lot for health care in the form of premiums, deductibles, co-payments, and doctor’s bills. Why is that regressive system, which rations care by income, different or better than a more progressive tax?  Insurer and drug maker profits, both of which got airtime at the debates, are only a part of the problem when it comes to America’s high health costs.  The disproportionately high prices Americans pay for care are a bigger issue. What we pay hospitals and doctors, and how we can bring those costs down, are crucial issues that the candidates have barely discussed. What’s their plan there? The first round of debates saw the moderators ask candidates to raise their hands if they would eliminate private health coverage. Round two did essentially the same thing without the roll call. The idea of wiping out private insurance seems to be a flashpoint, but there doesn’t seem to be as much interest in questioning the merits of the current, mostly employer-based system. It’s no utopia. Americans unwillingly lose or change employer coverage all the time, and our fragmented system does an awful job of keeping costs down. People who support eliminating or substantially reducing the role of private coverage deserve scrutiny, but so do those who want to retain it. What’s so great about the status quo?

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As the field narrows, voters need specifics. A chunk of the field has been remarkably vague. Answers to these questions could offer some clarity:

For Senator Elizabeth Warren: Are there any differences between your vision of “Medicare for All” and Senator Bernie Sanders’s? There’s wiggle room here; his plan is more expansive (and expensive) than single-payer systems in countries like Canada.  For Senator Kamala Harris: What will your plan cover and how much will it cost? The skeletal outline of Harris’s plan lacks details on premiums and what patients would have to pay for out of pocket. She didn’t clarify matters at the debate.  For former Vice President Joe Biden: Will people with access to employer insurance be eligible for subsidies in your public option plan? If the answer is no or restrictive, his public option could have a relatively limited impact. It the answer is yes, his $750 billion cost estimate should head to the dustbin.  For the morass of candidates who pay lip service to Medicare for All but want to keep private insurance but don’t have a specific plan: What exactly do you want?

Health care is the most important issue for Democrats, according to polling. We need to find a way to have a discussion that does it justice.

Democrats’ Health-Care Feud Eclipses Message That Won in 2018

So, what have we learned from these debates? John Tozl realizes that in the four evenings of Democratic presidential debates since June, one phrase appeared for the first time on Wednesday: “pre-existing conditions.”

New Jersey Senator Cory Booker uttered it in his remarks on health care, chiding fellow Democrats for their infighting as Republicans wage a legal battle to undo the Affordable Care Act, which prohibits insurers from charging people more for being sick.

“The person who is enjoying this debate the most tonight is Donald Trump,” he said. “There is a court case working through the system that’s going to gut the Affordable Care Act and actually gut protections on pre-existing conditions,” Booker said, citing litigation in which the Trump administration and Republican-controlled states seeking to strike down Obamacare.

Over two nights this week, the 20 candidates spent at least an hour fiercely arguing over health-care plans, most of which are significantly more expansive than what the party enacted a decade ago in the Affordable Care Act. It’s a sign of how important the issue will be in the bid to unseat Trump, and how the party’s position has shifted leftward.

In November, Democrats won control of the House on the strength of their message to protect people with pre-existing conditions. That provision, a fundamental change to America’s private insurance market, is central to the ACA, the party’s most significant domestic policy achievement in a generation.

Booker’s attempt to unify his fractious colleagues against their common opponent stood out, because most of the discussion of health care, which kicked off the debate as it did on Tuesday, but the party’s divisions into sharp focus.

Biden v. Harris

Senator Kamala Harris of California and former Vice President Joe Biden tried to discredit each other’s proposals. Biden says he wants to build on the Affordable Care Act while expanding access to health insurance through a public insurance option.

Harris, in a plan, unveiled this week, likewise favors a public option but wants to sever the link between employment and health insurance, allowing people instead to buy into public or private versions of Medicare, the federal health-care program for seniors.

Harris took Biden to task over a plan that fails to insure everyone, saying his plan would leave 10 million people without insurance.

“For a Democrat to be running for president in America with a plan that does not cover everyone, I think is without excuse,” she said.

Biden accused Harris of having had “several plans so far” and called her proposal a budget-buster that would kick people off health plans they like.

“You can’t beat President Trump with double-talk on this plan,” he said.

Other candidates split along similar lines, with Colorado Senator Michael Bennet saying Harris’s proposal “bans employer-based insurance and taxes the middle class to the tune of $30 trillion.”

New York Mayor Bill de Blasio argued for a more sweeping approach, like the Medicare for All policies embraced by Senators Bernie Sanders and Elizabeth Warren.

“I don’t understand why Democrats on this stage are fear-mongering about universal health care,” he said. “Why are we not going to be the party that does something bold, that says we don’t need to depend on private insurance?”

How Bold?

The question any candidate will eventually have to answer is how bold a plan they believe voters in a general election want.

In 2018, Democrats running for Congress attacked Republicans for trying to repeal the ACA and then, when that failed, asking courts to find it unconstitutional. Scrapping the law would mean about 20 million people lose health insurance.

About two-thirds of the public, including half of Republicans, say preserving protections for people with pre-existing conditions is important, according to polls by the Kaiser Family Foundation, a nonprofit health research group.

More than a quarter of adults under 65 have pre-existing conditions, Kaiser estimates.

But that message has been mostly absent from the primary debates, where health-care talk highlights the divisions between the party’s progressive left-wing and its more moderate center.

Warren and Sanders weren’t on stage Wednesday, but their presence was looming. They’re both leading candidates and have deeply embraced Medicare for All plans that replace private insurance with a government plan. Bernie is an idiot, especially in his come back that he knows about Medicare for All since he wrote the bill. He has no idea of the far-reaching effect of Medicare for all. Our practice just reviewed our payments from Medicare over the last few years as well as the continued discounts that are applied to our services and noted that if we had to count on Medicare as our only health care payer that we as well as many rural hospitals would go out of business.

I refer you all back to John Delaney’s responses to the Medicare for All discussion. In the middle of a vigorous argument over Medicare for All during the Democratic debate tonight, former Representative John Delaney pointed out the reason he doesn’t support moving all Americans onto Medicare: It generally pays doctors and hospitals less than private-insurance companies do.

Because of that, some have predicted that if private insurance ends, and Medicare for All becomes the law of the land, many hospitals will close, because they simply won’t be able to afford to stay open at Medicare’s rates. Fact-checkers have pointed out that while some hospitals would do worse under Medicare for All, some would do better. But Delaney insisted tonight that all the hospital administrators he’s spoken with have said they would close if they were paid at the Medicare rate for every bill.

Whichever candidate emerges from the primary will have to take their health plans not just to fervent Democrats, but to a general electorate as well.

More on Medicare

If you remember from last week I reviewed the inability of our federal designers to accurately estimate the cost of the Medicare program and the redesign expanding the Medicaid programs mandating the states expand their Medicaid programs to provide comprehensive coverage for all the medically needy by 1977.

The additional provision of the 1972 legislation was the establishment of the Professional Standards Review Organizations (PSROs), whose function it was to assume responsibility for monitoring the costs, degree of utilization, and quality of care of medical services offered under Medicare and Medicaid. It was hoped that these PSROs would compel hospitals to act more efficiently. In keeping with this set of goals, in 1974 a reimbursement cap was instituted that limited hospitals from charging more than 120 percent of the mean of routine costs in effect in similar facilities, a limit eventually reduced to 112 percent named as Section 223 limits. But despite these attempts at holding down costs, they continued to escalate inasmuch as hospitals were still reimbursed on the basis of their expenses and the caps that were instituted applied only to room and board and not to ancillary services, which remained unregulated.

Now think about the same happening on a bigger scale with the proposed Medicare for All. Those that are proposing this “Grand Plan” need to understand the complexities issues, which need to be considered before touting the superiority of such a plan. Otherwise, the plan will fail!! Stop your sputtering arrogance Bernie, Kamala, and Elizabeth, etc. Get real and do you research, your homework before you yell and scream!!!!!!

More to Come!

Governors Weigh Health Care Plans as They Await Court Ruling, the Future of the ACA and San Francisco Experience with Healthcare Insurance and, Yes, More on Medicare

Screen Shot 2019-07-07 at 8.29.30 PMBrady McCombs reported that as they gather at a conference in Utah, governors from around the U.S. are starting to think about what they will do if an appeals court upholds a lower court ruling overturning former President Barack Obama’s signature health care law, the Affordable Care Act or Obamacare.

More than 20 million Americans would be at risk of losing their health insurance if the 5th U.S. Circuit Court of Appeals agrees with a Texas-based federal judge who declared the Affordable Care Act unconstitutional last December because Congress had eliminated an unpopular tax is imposed on people who did not buy insurance.

The final word on striking down the law will almost certainly come from the Supreme Court, which has twice upheld the 2010 legislation.

Nevada Gov. Steve Sisolak, a Democrat, signed a bill earlier this year prohibiting health insurers from denying coverage to patients due to pre-existing conditions, a pre-emptive move in case the Affordable Care Act was struck down.

He said this week in Salt Lake City at the summer meeting of the National Governors Association that he would ask his recently created patient protection commission to come up with recommendations for how to ensure patients don’t lose coverage if the law is overturned, which would impact about 200,000 people enrolled in Medicaid expansion in Nevada.

“To rip that away from them would be devastating to a lot of families,” Sisolak said.

Nevada is among a coalition of 20 Democratic-leaning states led by California that appealed the lower court ruling and is urging the appeals court to keep the law intact.

At a news conference Thursday, Democrats touted the protections they’ve passed to prevent people from losing health coverage.

New Mexico Gov. Michelle Lujan Grisham signed laws this year that enshrine provisions of the Affordable Care Act into state law, including guarantees to insurance coverage for patients with pre-existing conditions and access to contraception without cost-sharing. She said half of the state’s residents use Medicaid, prompting New Mexico officials to research creating a state-based health care system.

California Gov. Gavin Newsom said his state is already deep in contingency planning because five million people could lose health insurance if the law is struck down and the state doesn’t have enough money to make up for the loss of federal funds. He said the decision this year to tax people who don’t have health insurance, a revival of the so-called individual mandate stripped from Obama’s model, was the first step. That tax will help pay for an expansion of the state’s Medicaid program, the joint state, and federal health insurance program for the poor and disabled.

Newsom said the state is looking at Massachusetts’ state-run health care program and investigating if a single-payer model would work as possible options if the law were spiked.

“The magnitude is jaw-dropping,” Newsom said. “You can’t sit back passively and react to it.”

Arkansas Gov. Asa Hutchinson, a Republican, said states need Congress to be ready to quickly pass a new health care plan if the court overturns Obama’s law since doing so would cut off federal funding for Medicaid expansion.

A court decision in March blocked Arkansas from enforcing work requirements for its Medicaid expansion program, which has generated seemingly annual debate in that state’s Legislature about whether to continue the program.

“Congress can’t just leave that out there hanging,” Hutchinson said.

The 2018 lawsuit that triggered the latest legal battle over the Affordable Care Act was filed by a coalition of 18 Republican-leaning states including Arkansas, Arizona, and Utah.

Arizona Gov. Doug Ducey, a Republican, said he wants to see how the court rules before he makes any decisions about how his state would deal with the loss of Medicaid funds but that Arizona has backup funds available.

“They’re going to rule how they’re going to rule and we’ll deal with the outcome,” Ducey said. “The best plans are to have dollars available.”

It is unknown when the three-judge panel will rule.

The government said in March that 11.4 million people signed up for health care via provisions of the Affordable Care Act during open enrollment season, a dip of about 300,000 from last year.

Utah Gov. Gary Herbert, a Republican, said if the law is overturned, it would provide a perfect opportunity for Congress to try to craft a better program with support from both political parties.

He said his state, which rolled out its partial Medicaid expansion in April, probably will not start working on a contingency plan for people who would lose coverage until the appeals court rules.

“It’s been talked about for so long, people are saying ‘Why to worry about it until it happens?'” Herbert said. “I think there’s a little bit more of a lackadaisical thought process going on.”

President Donald Trump, who never produced a health insurance plan to replace Obama’s health care plan, is now promising one after the elections.

Newsom warned Americans not to rely on that.

“God knows they have no capacity to deal with that,” Newsom said. “The consequences would be profound and pronounced.”

Appeals Court Judges Appear Skeptical About ACA’s Future

Alicia Ault noted that if its line of questioning serves as a barometer, a three-judge panel of the US Fifth Circuit Court of Appeals here seemed to be more favorably inclined toward the arguments of a group of 18 Republican states and two individuals seeking to invalidate the Affordable Care Act (ACA) than to those bent on defending the law.

“I think the plaintiffs had a better day than the defendants,” Josh Blackman, an associate professor of law at the South Texas College of Law, Houston, told Medscape Medical News.

“I think they found that the plaintiffs had standing,” said Blackman, who attended the arguments. The judges also seemed to believe the plaintiffs have been injured by the ACA, and that the individual mandate still demanded that people buy health insurance, even though Congress has eliminated the penalty, he said.

“Short news is it went very badly,” said Ian Millhiser, a senior fellow at the liberal-leaning Center for American Progress, on Twitter, after attending the hearing.

“The two Republican judges appear determined to strike Obamacare,” he said, adding, “There is a chance they will be too embarrassed to do so, but don’t bet on it.”

At the outset, Judge Jennifer Walker Elrod asked Samuel Siegel, a lawyer with the California Department of Justice representing the 20 states and Washington, DC, who are defending the ACA, “If you no longer have the tax, why isn’t [the ACA] unconstitutional?”

Only two of the three judges on the panel asked questions during the 1-hour-and-46-minute hearing — Elrod, appointed by President George W. Bush in 2007, and Kurt Engelhardt, appointed by President Donald J. Trump in 2018. Carolyn Dineen King, appointed by President Jimmy Carter in 1979, did not ask a single question.

The defendants — led by California — were first to argue. They were given 45 minutes to make their case that District Court Judge Reed O’Connor in Texas had erred in December when he ruled that the ACA should be struck down because Congress had eliminated the penalty associated with the requirement that individuals buy health insurance.

Essentially, said Judge O’Connor, the mandate could not be severed from the rest of the ACA. O’Connor did not grant the plaintiffs’ request that the ACA be halted while the case made its way through the courts.

The plaintiffs — led by Texas Solicitor General Kyle Hawkins — also had 45 minutes before the appellate court judges.

Is the ACA Now a “Three-Legged Stool?”

Both Judges Elrod and Engelhardt interrupted Siegel several times while arguing for the ACA to ask him to explain why California and the other states had the standing to defend the federal law. Siegel said that if the law were to be struck down it would cost the defendants hundreds of billions of dollars.

The two judges seemed intent on getting both sides to explain why Congress would have eliminated the penalty that went along with the individual mandate but left the rest of the law standing. The plaintiffs contend that the law could not be severed into parts, that it lived or died with the mandate and its penalty.

When asked to assess congressional intent, Hawkins said, “I’m not in the position to psychoanalyze Congress.” But he said the US Supreme Court had already settled the question, ruling in King v Burwell that the ACA was like a three-legged stool without the penalty. And, he said, even without the penalty, the individual mandate remained part of the law, which he called “a command to buy insurance.”

Douglas Letter, the general counsel to the US House of Representatives, arguing in defense of the ACA, said the opposite: that the Supreme Court had determined in NFIB v Sebelius that the ACA presented a choice of buying health insurance or facing a penalty. Without the penalty, “The choice is still there,” said Letter, adding that individuals could choose to maintain insurance or not.

“We know definitively that ‘shall’ in this provision does not mean must,” Letter said.

Engelhardt disagreed and said that Congress perhaps should have revised the ACA after the penalty was removed. He also asked Letter why the Senate was not also a party to the defense of the ACA. “They’re sort of the 800-pound gorilla not in the room,” Engelhardt said.

What’s Next?

The judges are not expected to rule for several months and will be addressing several issues, including whether the Democratic states and the House of Representatives have proper standing to defend the law and whether the plaintiffs have the standing to challenge the law.

They also will address whether the individual mandate is still constitutional, and if the mandate is ruled unconstitutional, whether it can be severed from the rest of the ACA, or, on the other hand, whether other provisions of the ACA also must be invalidated, according to the Kaiser Family Foundation.

The court could dismiss the appeal and vacate O’Connor’s judgment, “in which case there wouldn’t be any decision in the case at all,” Timothy S. Jost, professor emeritus at the Washington and Lee University School of Law in Lexington, Virginia, told Medscape Medical News ahead of today’s hearing.

At the hearing, Texas’ Hawkins said it was wrong to say the plaintiffs were trying to strike the law. “There’s an erasure fallacy,” he told the judges. “We’re not asking the court to erase anything.”

Still, O’Connor did say in his ruling that the ACA was unconstitutional. The Trump administration announced in March that it would not defend the law, but said it would continue to enforce the ACA. August E. Flentje, a US Department of Justice lawyer, reiterated that position at the Fifth District hearing today.

But, in a briefing before the hearing, the administration argued that, if ultimately the law is ruled unconstitutional, it should only be struck down in the states seeking to overturn the law. Any ultimate judgment “should not declare a provision unlawful if it doesn’t impact the plaintiff,” Flentje said.

Douglas Letter, for the defendants, was agog. “The DOJ position makes no sense,” he said, noting, for instance, that that would mean that the US Food and Drug Administration — which is required to speed biosimilar drugs to market under the ACA — would approve drugs in California, but not Arizona.

Elrod pressed the point by asking Flentje, “What is the government planning to do?” if the ACA is halted.

“A lot of this has to get sorted out — it’s complicated,” he said.

Despite the outcome of today’s hearings, the case is still ultimately expected to go before the Supreme Court again, according to multiple legal experts.

Advocates: The Stakes Are Astronomical

Shortly after the hearing ended, California Attorney General Xavier Becerra issued a statement predicting disaster for American healthcare if the appeals court agrees that the ACA is unconstitutional. If that happens, “Millions of Americans could be forced to delay, skip, or forego potentially life-saving healthcare,” he said.

“Our state coalition made it clear: on top of risking lives, gutting the law would sow chaos in our entire healthcare system,” Becerra said, vowing to “fight the Trump administration tooth and nail.”

Physicians, consumer and patient advocates, and healthcare groups have voiced their support of the law through friend-of-the-court briefs, starting in June 2018, when the American Medical Association, the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry joined together in a brief.

Other organizations have also voiced their support for the ACA through amicus briefs, including: the American Hospital Association, the Federation of American Hospitals, the Catholic Health Association of the United States, the Association of American Medical Colleges, Americas Health Insurance Plans, the Disability Rights Education and Defense Fund, the Blue Cross Blue Shield Association, Families USA, AARP, the Children’s Partnership, 483 federally recognized tribal nations, and 35 cities, counties, and towns.

A coalition led by the American Cancer Society, and including the American Diabetes Association, the American Heart Association, the American Lung Association, the Crohn’s & Colitis Foundation, the Cystic Fibrosis Foundation, the Epilepsy Foundation, the Hemophilia Federation of America, the Leukemia & Lymphoma Society, the March of Dimes, the National Alliance on Mental Illness, the National Coalition for Cancer Survivorship, the National Hemophilia Foundation, the National Multiple Sclerosis Society, and The Kennedy Forum also filed an amicus brief and issued a joint statement ahead of the hearing.

“If allowed to stand, the lower court’s ruling would once again mean people could be charged more or denied coverage based on their health history,” said the statement. “Insurance plans could impose arbitrary annual and lifetime limits on patients’ coverage and could exclude whole categories of care — like prescription drugs — from their plans,” they said, adding that striking the law from the books would jeopardize tax credits used by 8 million Americans to buy health insurance on the individual market.

Millions more could be dropped from Medicaid, the coalition stated. In total, the groups said that some 27 million people could lose health insurance — a figure they said was calculated by the Congressional Budget Office.

The Kaiser Family Foundation estimated that 19 million people could lose insurance. Also at stake: requiring private insurance, Medicare, and Medicaid expansion coverage of preventive services with no cost-sharing, and a phase-out of the Medicare prescription drug “doughnut hole” coverage gap.

“All of these provisions could be overturned if the trial court’s decision is upheld, and it would be enormously complex to disentangle them from the overall health care system,” Kaiser said.

The Urban Institute estimated that if the ACA were overturned, the number of uninsured would increase by 65% — 20 million people; state spending on Medicaid/Children’s Health Insurance Program (CHIP) would fall by $9.6 billion — and that uncompensated care would rise by $50.2 billion, an increase of 82%.

Health Insurance for All: Learning From San Francisco

This last article is an interview with Dr. George Lundberg and the San Francisco healthcare insurance. Hello and welcome. I’m Dr. George Lundberg and this is At Large at Medscape.

You can pay me now or you can pay me later. Perhaps best known as a commercial promoting automobile maintenance, this statement could also apply to healthcare.

Everybody gets sick. If left alone, most acute human maladies fix themselves (automobiles don’t), but people with chronic diseases do better if managed sensibly, including with professional help. Some serious illnesses are fully preventable. The effects of many potentially serious diseases can be ameliorated by early diagnosis and intervention.

Who pays? In whose best interest is it for payment to be assured?

Medical expense insurance in the United States began in Dallas, Texas, in 1929 and Sacramento, California, in 1932. Hospitals needed to be paid; surgeons were particularly motivated early on to assure not only that patients who needed surgery would get it, but also that the surgeons would get paid. Surgical fees often exceeded more typical fees for medical care, so out-of-pocket costs (the normal way doctors and hospitals were paid back then) were more difficult for many patients to afford. Usual medical care did not cost much, but then again, neither did it offer much.

Growing up in small-town, lower Alabama in the 1930s and ’40s, I did not know anyone who had medical expense insurance. Oddly, many people had burial insurance, which was aggressively marketed and sold.

Once medical (health) insurance became common, medical services (and costs) increased and then flourished—an early example of supply-induced demand. Of course, there were benefits for many.

The enactment of Medicare and Medicaid legislation poured gasoline on the already upward-spiraling healthcare cost fire. That is how we arrived at nearly 20% of the US annual gross domestic product going to healthcare.

Our American Medical Association actually warned the country about that risk.[1] The incipient medical-industrial complex developed an insatiable capacity to transfer money by greatly increasing costs, often to gain small, incremental improvements.

Yet, lifesaving medical and surgical interventions do occur, they are often expensive, and someone has to pay for them. Ergo, health insurance. Everyone should have it. Why not?

I live in Silicon Valley. Many of the key innovations that have revolutionized how the world functions day by day have been begun and are headquartered here. Think Google, Apple, Facebook, Airbnb, Uber, Twitter, YouTube, Salesforce, Oracle, Intel, Cisco, Netflix, etc.

So why would it not make sense for San Francisco to pioneer healthcare for all via innovation?

Residents of San Francisco are expected to have health insurance coverage via employment-based insurance, Medicare, the Affordable Care Act (ACA), and Medi-Cal, if eligible, just like all other Americans, with all the pluses and minuses of those programs. But if they don’t, Healthy San Francisco is available regardless of immigration status, employment status, or preexisting medical conditions.

The 2008 Health Care Security Ordinance created the authority that underpins the Healthy San Francisco program. It requires businesses to pay a minimum set amount of money on healthcare benefits for their employees.

Restaurant users learn of this expense of doing business by seeing the note, “In response to employer mandates, including the San Francisco Health Care Security Ordinance, a 4% surcharge will be added to all food and beverage sales.”

Healthy San Francisco is administered by the San Francisco Department of Public Health and delivered via designated Medical Homes. Eligible annual income is set at 500% of the federal poverty limit.

Health insurance is not, a panacea it is not. It is a safety net below the other safety nets. By July 2010, 50,000 people had enrolled, but by 2019, that number declined to about 14,000. The drop probably represents both low unemployment and the success of California’s robust implementation of the ACA via Covered California.

Any other city or county in the United States that would like to provide economic access to basic medical care for its people, without such care being forgone, termed charity, or simply written off as bad debt by providers, could do well by learning from San Francisco’s experience.

Read through the last few paragraphs, especially as we consider elimination, i.e. the uncertain future of the ACA and the possibility of Medicare for All. Also, as I have pointed out in the past few weeks as I have discussed the history of Medicare and Medicaid remember the inability of the administration to accurately predict the true costs. The following addition to the discussion on Medicare and Medicaid will further emphasize the huge costs and expenses of the programs. The next question would be how would the additional up-ward healthcare spiraling costs/expenses be paid for.

Back to our Medicare and Medicaid discussion:

Remember as I just mentioned, that last week I discussed the underestimation of the Medicare program and even more increases which occurred in the Medicaid program. Remember also that because of the wording of Title XIX where the federal government had an open-ended obligation to help underwrite the costs of medical care for the wide range of services to such a large number of recipients, which made it very difficult to accurately predict the ultimate cost.

Then in 1965, the House Ways and Means Committee had estimated that if all of the states were to take advantage of the Medicaid program, including all of the services, that the additional federal costs of medical assistance would amount to $238,000,000. However, in the fiscal year 1967, the total cost of Medicaid payments amounted to $1,944,000,000. Realize that half of these payments were federal funds and realize that the program was operating in only twenty-eight states. Also, interestingly even with the decline in usage and expenditures of other programs by the end of the year 1968 forty-one states had opted into the Medicaid program the total expenditures amounted to $3,783,000,000. Compare this to the total federal outlays for all medical assistance programs in the fiscal year 1965, prior to the introduction of Medicare and Medicaid, amounted to $1,239,000,000.

The goal of the House and Ways Committee when they met in 1971 discussed the need to contain the spiraling costs of Medicare and Medicaid. Members of the individuals testifying were members of the Nixon administration who suggested a whole series of cost-control measures, among them that the new legislation promote a system of capitation payments to health maintenance organizations (HMOs) and that Medicaid introduces cost-sharing while Medicare expands its own cost-sharing policies. Interestingly many of these cost-saving recommendations eventually found their way into the final bill to reform these programs, which became law in October1972.

So, among these changes to the Medicare program was:

  • The inclusion of the totally disabled as eligible for Medicare benefits. Workers of any age and widows and disabled dependent widowers over the age of fifty were eligible to receive Medicare benefits after having received APTD (Aid to Permanently and Totally Disabled) assistance for twenty-four months. This added approximately 1,700,000 beneficiaries to Medicare rolls and was the first instance of any group under the age of sixty-five being made eligible benefits;
  • Beneficiaries of Part B (Supplementary Medical Insurance) who otherwise were ineligible for Part A (Hospital Insurance) by virtue of not qualifying for Social Security coverage could now voluntarily enroll in Part A by paying a monthly premium;
  • Provision was made for capitation payments to HMOs and certain limits were placed on the items that a health care facility could include in calculating its cost.

However, the most significant change in the Medicare program contained in the 1972 amendments was the repeal of a provision contained in the original legislation that made it mandatory that each state expands its Medicaid program each year until it offered comprehensive coverage for all the medically needy by 1977. Remember that when Medicare and Medicaid were first introduced, Congress had hoped to establish a universal hospital and medical insurance scheme for the needy using Medicaid as its foundation but largely as a result of the swelling costs of the program this design was abandoned in1972.

So, let’s see how this week’s set of debates evolve as the candidates make more promises for the answer to the health care problem. How will Kamala Harris pay for her health care system and will private insurance be a thing of the past?

2020 Dems Grapple with How to Pay for ‘Medicare for All’ and the Biden and Sanders Argument, and Yes, More on Medicare

rights328I recently spoke with a friend in the political world of Washington and his comment was that “there is a war here in D.C.” After listening to whatever news reports that you and yes I, listen to I can certainly believe it!! I’m wondering who is really in charge!!

Reporter Elena Schor noticed that the Democratic presidential candidates trying to appeal to progressive voters with a call for “Medicare for All” are wrestling with the thorny question of how to pay for such a dramatic overhaul of the U.S. health care system.

Bernie Sanders, the chief proponent of Medicare for All, says such a remodel could cost up to $40 trillion over a decade. He’s been the most direct in talking about how he’d cover that eye-popping amount, including considering a tax hike on the middle class in exchange for healthcare without co-payments or deductibles — which, he contends, would ultimately cost Americans less than the current healthcare system.

His rivals who also support Medicare for All, however, have offered relatively few firm details so far about how they’d pay for a new government-run, a single-payer system beyond raising taxes on top earners. As the health care debate dominates the early days of the Democratic primary, some experts say candidates won’t be able to duck the question for long.

“It’s not just the rich” who would be hit with new cost burdens to help make single-payer health insurance a reality, said John Holahan, a health policy fellow at the nonpartisan Urban Institute think tank. Democratic candidates campaigning on Medicare for All should offer more specificity about how they would finance it, Holahan added.

Sanders himself has not thrown his weight behind a single strategy to pay for his plan, floating a list of options that include a 7.5% payroll tax on employers and higher taxes on the wealthy. But his list amounts to a more public explanation of how he would pay for Medicare for All than what other Democratic presidential candidates who also back his single-payer legislation have offered.

Kamala Harris, who has repeatedly tried to clarify her position on Medicare for All, vowed this week she wouldn’t raise middle-class taxes to pay for a shift to single-payer coverage. The California senator told CNN that “part of it is going to have to be about Wall Street paying more.”

Her contention prompted criticism that she wasn’t being realistic about what it would take to pay for Medicare for All. Colorado Sen. Michael Bennet, a rival Democratic presidential candidate, said Harris’ claim that Medicare for All would not involve higher taxes on the middle class was “impossible,” though he stopped short of calling her dishonest and said only that candidates “need to be clear” about their policies.

A Harris aide later said she had suggested a tax on Wall Street transactions as only one potential way to finance Medicare for All, and that other options were available. The aide insisted on anonymity in order to speak candidly about the issue.

Another Medicare for All supporter, New York Sen. Kirsten Gillibrand, would ask individuals to pay between 4% and 5% of their income toward the new system and ask their employers to match that level of spending. Gillibrand’s proposal, shared by an aide who requested anonymity to discuss the campaign’s thinking, could supplement the revenue generated by that change with options that hit wealthy individuals and businesses, including a new Wall Street tax.

Gillibrand is a cosponsor of Sanders’ legislation adding a small tax to financial transactions, while Harris is not.

New Jersey Sen. Cory Booker, who also has signed onto Medicare for All legislation but said on the campaign trail that he would pursue incremental steps as well, could seek to raise revenue for the proposal by raising some individual tax rates, changing capital gains taxes or expanding the estate tax, according to an aide who spoke candidly about the issue on condition of anonymity.

The campaign of Massachusetts Sen. Elizabeth Warren, who used last month’s debate to affirm her support for Sanders’ single-payer health care plan, did not respond to a request for more details on potential financing options for Medicare for All.

Meanwhile, Sanders argued during a high-profile Medicare for All speech this week that high private health insurance premiums, deductibles, and copayments, all of which would be eliminated by his proposal, amount to “nothing less than taxes on the middle class.”

Medicare for All opponents are also under pressure to explain how they’d pay for changes to the health insurance market. Former Vice President Joe Biden is advocating for a so-called “public option” that would allow people to decide between a government-financed plan or a private one. He would pay for his $750 billion proposals by repealing tax cuts for the wealthy that President Donald Trump and the GOP cut in 2017, and by raising capital gains taxes on the wealthy.

Inside Biden and Sanders’ Battle Over Health Care—and the Party’s Future

Sahil Kapur noted that Joe Biden and Bernie Sanders are engaged in open warfare over health care that could harden party divisions and play into the hands of President Donald Trump.

In the latest iteration of the battle, Biden’s communications director posted an article on Saturday, entitled “Let’s Get Real About Health Care,” that delved into the potential costs of the proposals favored by the Democratic party’s left flank.

The tension points to a broader power struggle in Washington and on the campaign trail that pits long-dominant moderates like Biden against an insurgent wing led by Sanders and Elizabeth Warren. But a prolonged battle risks entrenching bitterness between the factions that threatens party unity heading into the general election.

Many prominent Democrats fear that backing an end to private health insurance means defeat in the presidential race and the competitive districts that won the party a House majority in 2018. They prefer more modest legislation to expand government-run insurance options.

Biden favors that approach, calling for largely preserving the popular Obamacare while adding a “public option” that would compete with private insurers. Sanders, a Vermont senator and the chief architect of a Medicare for All plan that would cover everybody under a single government plan, wants to replace the 2010 law.

Aimee Allison, who runs She the People, an activist group that seeks to elevate women of color and recently hosted a Democratic presidential forum, said young voters and minorities are eager for change.

“The Democratic Party leadership is more concerned about moderate to conservative Democratic voters, who are a shrinking and less reliable part of the party base than they are about people of color, women of color, younger voters who are inspired by these kinds of ideas,” Allison said.

“That decision led to the loss in 2016,” she said. “There were plenty of black voters who could be inspired to vote and weren’t — and that’s why we lost.”

Climate Change

The split extends far beyond health care. Democrats also differ on how aggressively to tackle climate change and whether to support mass cancellation of student debt.

Dan Pfeiffer, a former senior adviser to President Barack Obama, said the differences among Democrats reflect meaningful policy disagreements rather than just political calculations.

“Bernie Sanders should be applauded for pushing the debate” about how bold to be, Pfeiffer said in an email. “But I do think some of the opposition among the candidates to Sanders’ version is about policy as much as politics.”

The health care debate grew heated earlier this week when Biden, who as vice president helped steer the Affordable Care Act, or Obamacare, through Congress, told voters that the “Medicare For All Act” authored by Sanders “means getting rid of Obamacare — and I’m not for that.” He said the bill would end private insurance and ensure that “Medicare goes away as you know it.”

Fear-Mongering’

Sanders responded by accusing Biden of “fear-mongering” and parroting the “lies” of Trump and the insurance industry. His campaign website posted a “who said it” quiz on health care mocking Biden as being aligned with Senate Majority Leader Mitch McConnell and Trump.

Biden argues that Medicare for All would cancel plans for the 150 million people on private insurance and that he’d give them the option to keep their plan. Sanders says adding a public option to Obamacare would be less effective at covering the 27 million uninsured Americans or cutting costs. While a tax increase would be required to pay for single-payer, eliminating premiums and out-of-pocket costs would offset it, he says.

Biden pressed his argument Thursday, insisting he wasn’t criticizing Sanders but rather conveying what his plan would do.

“Bernie’s completely honest about saying he’s going to raise taxes on the middle class and just straightforward about it,” the former vice president told reporters in Los Angeles.

The Biden campaign went after Sanders’ plan again on Saturday in a Medium.com post, saying that defending Obamacare is a way for Democrats to win in 2020.

“We all understand the appeal of Medicare for All, but before we go down that road we should take a clear-eyed and honest look at what the plan actually says and what it will cost,” wrote Biden communications director Kate Bedingfield. She suggested Biden’s view would prevail “once voters look beyond Twitter and catch-phrases.”

A similar power struggle is unfolding in the House of Representatives, where Speaker Nancy Pelosi and moderate Democrats have clashed with the “Squad” of newly elected progressive women – Representatives Ayanna Pressley, Alexandria Ocasio-Cortez, Ilhan Omar and Rashida Tlaib.

The new lawmakers have used their large social media followings to elevate far-reaching ideas while challenging party leaders to be more tactically aggressive with Trump on issues like immigration and impeachment.

“The Squad — they’re a proxy for the millions of us who want to see a bolder, more progressive set of policies and changes,” Allison said, arguing that limiting the Democratic Party’s vision based on what appears politically possible would prevent new voters from getting engaged and turning out.

Conditional Support

Polling on Medicare for All illustrates the party’s dilemma. Surveys indicate that a majority of Americans favor the idea. But support plummets when people are told the program would eliminate private insurance and rises again when they are told that switching to a government-run plan doesn’t necessarily mean losing their doctors and providers.

Pelosi and other Democratic leaders back Biden’s approach. 2020 rivals Warren, and Senators Kamala Harris, Cory Booker, and Kirsten Gillibrand cosponsor sanders’ single-payer plan. Harris says she prefers single-payer but has also cosponsored legislation for a public option as a route to extending coverage.

Ocasio-Cortez said Americans she talks to “like their health care, they like their doctor,” but that they aren’t “heartbroken” about the prospect of having to transition off an Aetna or Blue Cross Blue Shield plan.

Trump and his allies have sought to make the Squad the face of the Democratic Party, believing that they alienate moderate voters. House GOP campaign chairman Tom Emmer called the four women the “red army of socialists” at a Christian Science Monitor breakfast for reporters.

The four women are among the 114 cosponsors of the Medicare For All Act in the House, but the legislation has stalled out and is unlikely to be brought to a vote, which suggests that the moderate wing is winning the battle in Washington.

Andy Slavitt, a former acting head of the Centers for Medicare and Medicaid Services under Obama, said Democrats unanimously agree on the goal of universal coverage but differ on how best to get there.

“Primaries are about calling out differences in approach. There should be sufficient oxygen to say how would Joe Biden or Michael Bennet do it versus how would Bernie Sanders do it,” he said in an interview.

Slavitt warned that while a debate was healthy, Democrats shouldn’t lose sight of the ultimate goal.

“It’s important that we don’t get so overwhelmed with the distinctions around ‘how’ that we forget there is a massive gulf between what the visions are,” Slavitt said, “between Democrats and the president’s position to repeal the ACA, make coverage more expensive.”

Surprise! Here’s Proof That Medicare for All Is Doomed

Ramesh Ponnuru discovered that there’s a high-profile debate over health care playing out in the presidential race, and a lower-profile one taking place in Congress. Several Democratic presidential candidates are telling us that they are going to provide health care that is free at the point of service to all comers. In little-noticed congressional mark-ups, members of both parties are demonstrating why these promises will not be met.

The legislation under consideration is aimed at so-called surprise medical bills” – charges a patient assumes were covered by insurance but turn out not to have been. My family got one last year: The hospital where my wife delivered our son was in our insurer’s network, but an anesthesiologist outside the network-assisted. The bill had four digits.

Surprise bills seem to be something of a business model for some companies. A 2017 study showed how bills rose when EmCare Inc. took over hospitals’ emergency rooms, with the percentage of visits incurring out-of-network charges jumping “like a light switch was being flipped on.”

Policy experts from across the political spectrum have devised ways to prevent this sticker shock. Benedic Ippolito and David Hyman have a short paper for the American Enterprise Institute (where I am a fellow) that suggests providers of emergency medicine should have to contract with hospitals, reaching agreement on prices and folding them into the total bill, rather than sending separate bills to patients and their insurers. In incidents where the surprise bill is the result of an emergency involving treatment by an out-of-network hospital (or transportation by an out-of-network ambulance), their solution would be to cap payments at 50% above the level that in-network providers get paid on average. In both cases, prices would be determined by negotiation among parties that are informed and not in the middle of a medical emergency.

Senator Lamar Alexander, a Tennessee Republican, has introduced a bill that includes a version of that cap. But provider trade groups favor a different measure introduced by Representative Raul Ruiz, a Democrat from California, which would create a 60-day arbitration process to determine what insurers should pay out-of-network providers, and instructs arbiters to first consider the 80th percentile of list prices for a service in a given market. It is a generous approach that analysts with the USC-Brookings Schaeffer Initiative for Health Policy conclude “would likely result in large revenue increases for emergency and ancillary services, paid for by commercially-insured patients and taxpayers.” It would, therefore, mean higher premiums and federal deficits, while Alexander’s alternative has been estimated to reduce both. Ruiz has 52 co-sponsors who range from liberal Democrats to conservative Republicans.

Turn from this dispute, for a moment, to the Medicare for All proposal (which has some of the same co-sponsors as the Ruiz bill). It envisions sharp cuts in payments to providers – as high as 40%. Those cuts enable advocates to say they will cover the uninsured and provide added coverage to the insured while reducing national health spending.

Is this at all likely? The Alexander bill would try to rein in billing by one subset of providers in cases where the bills are especially unpopular. But the House Energy and Commerce Committee is watering down its surprise-billing legislation, accepting a provider-backed Ruiz amendment to add arbitration. It’s not as generous as Ruiz’s own bill, but its effect would be to keep payments at today’s rates.

The House is following a long line of precedents. For years, bipartisan majorities in Congress voted down planned cuts in provider-payment rates under Medicare; ultimately, they got rid of the planned cuts altogether. Now even modest measures like Alexander’s face determined and effective resistance.

There is, in short, very little appetite for cutting payments to providers. If medical-provider lobbies can force Congress to back off from addressing surprise bills – which are, in the grand scheme of our health-care system, a small kink – what are the odds lawmakers will force a much larger group of providers, including the powerful hospitals lobby, to accept the much larger reductions that Medicare for All would have to entail? Maybe the Democratic presidential hopefuls should be asked that question at the next debate so that we can judge whether Medicare for All is a fantasy or a fraud.

Those of us who are covered by Medicare, we realize the limitations of coverage as well as the discounted reimbursements paid to physicians, hospitals, nursing facilities, etc. Do we think that Medicare for All is going to make it any better for “All”?

Back to Medicare History

By 1972 the costs associated with Medicare had spiraled out of control to such a rate that even the administration and Congress were expressing concern as I pointed before. Then as a consequence, a number of studies were undertaken to examine what were the causes. The conclusions were that this rise was due to hospital service charges that rose much faster than the Consumer Price Index and especially the medical care component of the index as well as physicians’ charges over the first five years of Medicare ending in 1971. The charges rose 39 percent as compared with a 15 percent rise in the five years before the advent of Medicare. If you adjust for the increase in CPI, the Medicare physicians’ charges rose by 11 percent during that first five years of Medicare.

Also as important is that the proportion of total health care expenditures of the elderly that originated in public sources rose far more sharply than had been expected prior to Medicare’s passage. In fact in the fiscal year 1966, the government programs provided 31 percent of the total expended on health care for the elderly and just one year later this proportion had risen to 59 percent. Also, consider that Medicare alone accounted for thirty-five cents of every dollar spent on health services by or for those over the age of 65. There were even more dramatic increases occurred in the Medicaid program during its first few years.

The wording of Title XIX provided that the federal government had an open-ended obligation to help underwrite the costs of medical care for a wide range of services to a large number of possible recipients, depending on state legislation. Therefore, there was no accurate way of predicting the ultimate costs of the program and I will leave this discussion here. Why? Because age we have an older and older population we will have a bigger group in which Medicare will cover. Now if we enlarge the demographic to include “All” Americans the main question is how will we pay for that program?

 

Congress Finally Doing Something: Bundled Billing Won’t Solve Surprise Billing and More About Medicare, Is it Actually Lowering Costs?

57403779_2004991206297195_8128613615025520640_nI stated and I believe that the answer to our healthcare problem has to be a bipartisan solution. Last week Senate health committee Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Murray (D-Wash.) introduced S.1895, the Lower Health Care Costs Act of 2019 — bipartisan legislation to deliver better health care at a lower cost. Chairman Alexander and Ranking Member Murray announced that the committee would vote on the legislation on June 26, 2019.

“The single issue I hear most about from Tennesseans is, ‘What are you going to do about the health care costs I pay for out of my own pocket?’ Well, we’ve got an answer,” said Chairman Alexander. “This legislation will reduce what Americans pay out of their pockets for health care in three major ways: First, it ends surprise billing; second, it creates more transparency — you can’t lower your health care costs until you know what your health care actually costs. And third, it increases prescription drug competition to help bring lower cost generic and biosimilar drugs to patients. I look forward to working with my colleagues in the Senate health committee to mark up this legislation next week before sending it to the full Senate for consideration.”

“People across the country have been facing impossible decisions to afford the care they need and are counting on us to act. So I’m glad my Republican colleagues decided to listen to families and join Democrats at the negotiating table to work on these bipartisan steps to help lower health care costs, end surprise billing, respond to issues like the maternal mortality crisis, vaccine hesitancy, and obesity, and more,” said Senator Murray. “But this must be a first step, not a last one. I hope Republicans will build on this momentum by joining us at the table on bigger health care issues too—like repairing the damage from President Trump’s health care sabotage and protecting people with pre-existing conditions.”

Since last Congress, the Senate health committee has held five hearings on ways to reduce health care costs and four hearings on the cost of prescription drugs. In May, Alexander and Murray released a draft of this legislation for discussion, receiving over 400 comments. The Lower Health Care Costs Act of 2019 is composed of nearly three dozen specific provisions from at least 16 Republican senators and 14 Democrat senators.

Congress is fully engaged in trying to solve “surprise” medical bills and the conversation has exploded into a full-fledged debate on the best way to rein in bad actors while ensuring that physicians receive fair reimbursement for their services. The bipartisan U.S. Senate Working Group on Transparency dropped a new bill in 2019 that aims to address surprise billing. This Working Group, led by Sen. Bill Cassidy, MD (R-LA), has engaged in the most thoughtful discussion on the issue, meeting with stakeholders since summer 2018.

It is no surprise that in May the White House turned to Sen. Cassidy for advice on how to address this issue through legislation. During these discussions, a proposal emerged that would utilize hospital bundled billing to curb unanticipated medical bills. In a letter to the bipartisan Working Group, ASPS and other stakeholders urged the Working Group to consider the full scope of bundling and its ripple effect on patients. This practice would negatively affect patients in rural communities, as bundling could lead to further financial strains on rural and underserved hospitals. Patients may face reduced access to specialty care if hospitals and other facilities are forced to close. The letter highlighted that the use of hospital bundled billing to address this issue is untested and could be highly disruptive to the healthcare delivery system.

Medicare program aimed at lowering costs, improving care may not be working as well as thought

Kara Gavin reported that as the Medicare system seeks to improve the care of older adults while also keeping costs from growing too fast, a new University of Michigan study suggests that one major effort may not be having as much of an impact as hoped.

A new analysis of data from the Medicare Shared Savings Program finds that high-cost physicians and high-cost patients dropping out of the program accounted for much of the savings reported from 2008 to 2014.

After the effects of those departures were taken into account, the Accountable Care Organizations taking part in the MSSP had the same costs as physicians in their area who weren’t taking part in ACOs but also took care of other patients with traditional Medicare coverage.

The study also compares ACO and non-ACO providers on measures of health care quality, finding that patients in an MSSP ACO were not more likely to get four proven tests for common health problems than similar patients with the same kind of Medicare coverage who weren’t part of an ACO.

The study is published in the Annals of Internal Medicine. The authors note that the results have greater implications for providers who voluntarily join an ACO, rather than physicians employed by large group practices that have engaged in Medicare cost and quality efforts for many years—such as those at Michigan Medicine, U-M’s academic medical center.

The findings suggest that as the federal government continues its effort to “bend the cost curve” for Medicare through voluntary reforms, it should take into consideration year-to-year shifts in which providers and patients are taking part in ACOs. Otherwise, the researchers say, “selection bias” could skew the interpretation of the program’s effects.

ACOs can earn extra dollars from Medicare based on their overall costs and quality averaged across all their providers’ patients or can lose money if they don’t meet cost or quality goals. The Centers for Medicare and Medicaid Services has set a goal of increasing the disincentives or “risk” that ACOs face, so accurate measurement of actual cost and quality performance will increase in importance, the researchers say.

“Our results suggest that there is less reason for optimism about the MSSP’s effects to date that might have been suggested by other studies,” said Andy Ryan, senior author of the new study and a professor at the U-M School of Public Health. “We hope CMS will consider the implications as it moves forward with evaluating programs aimed at improving the long-term sustainability of the Medicare system.”

Ryan worked with Adam Markovitz, who led the analysis as part of his doctoral degree in public health and is now completing his medical degree at the U-M Medical School as part of the Medical Scientist Training Program.

“At the project’s outset, we hypothesized that early savings in this voluntary ACO program were driven by the disproportionate entry of high-performing “early adopter” clinicians into ACOs,” Markovitz said. “To our surprise, we found that ACO savings may be driven by the disproportionate exit of higher-spending clinicians out of ACOs.”

In all, the ACO providers whose overall costs were in the top 1% of all providers studied were more than twice as likely to leave an MSSP ACO as providers whose costs fell into the middle level of spending.

Whether these providers were encouraged to leave the ACO because of their costs, or whether they left voluntarily because they were unable or unwilling to reduce the growth in the cost of their patients’ care, can’t be determined through the current study.

MSSP ACO administrators are able to see the costs attributed to each of the providers taking part in their ACO, so “gaming” of which providers to include could be happening, say Ryan and Markovitz.

“We would hope that if a provider shows a trend toward low-value care, the ACO would work with them to remedy the situation,” Ryan said.

Markovitz, Ryan, and colleagues published a study in Health Affairs earlier this year, showing that high-cost patients were slightly more likely to leave ACOs than lower-cost ones. They noted in that study that the MSSP program does not adjust ACOs’ payments depending on how much more ill their participating patients have become over time—the payment is based on how sick each patient was when their provider first joined the ACO.

While this has apparently kept ACOs from “up-coding” patients to game the system, it also means that ACOs may have an incentive to drop providers whose patients become more severely ill—and therefore more costly.

That study and the new study have implications for the changes being proposed for MSSP and other value-based payment programs in Medicare.

“There need to be more safeguards against the selective attrition of patients and providers from ACOs that we’ve observed in our studies,” Ryan said. “As CMS encourages more provider risk-taking, it should design its systems to support what’s working best to improve care and efficiency.”

Markovitz also notes that CMS could design more future Medicare innovations as true experiments—for instance, with randomization (as in Medicare’s bundled payment plan for joint replacement surgery) or a phased roll-out that allows researchers to evaluate more readily whether a program truly saved money or improved quality.

CVS just laid out a big reason why health companies are worried about Amazon

Kyle Walsh of CNBC noted that when word spread that Amazon would move into health care in 2017, health-care executives had a ready answer: We are not afraid.

“I honestly don’t believe that Amazon will be interested in the near future in the next few years in this market,” Walgreens’ CEO Stefano Pessina told investors in an earnings call in July 2017.

“I think we have a lot of capabilities and a value proposition that can compete effectively in the market,” CVS CEO Larry Merlo said back in August.

But recent legal actions tell a different story.

In April, CVS filed a lawsuit against John Lavin, a former senior vice president in charge of CVS Caremark’s retail pharmacy network, after Lavin told the company he was leaving to take a job at Amazon’s pharmacy arm, PillPack. The judge this week ruled in CVS’ favor, preventing Lavin from taking immediate employment at PillPack.

That follows another case from January of this year, where insurance giant UnitedHealth sued one of its employees for attempting to join a different Amazon initiative. That was Haven, Amazon’s joint employer health venture with Berkshire Hathaway and J.P. Morgan.

These lawsuits suggest incumbents are more concerned than they’re letting on in public.

The underlying concern: Amazon going directly to insurers

Amazon has said almost nothing in public about its health-care strategy.

But Amazon could disrupt the space dramatically by negotiating directly with insurance companies on drug pricing, cutting out the existing pharmacy benefits managers, or PBMs. All of that could potentially lower health-care costs for consumers.

Among other functions, PBMs help insurance companies negotiate lower drug costs. Manufacturers arrange discounts, called rebates, with the benefits managers so they can fix a spot for their products on a PBM’s list of preferred drugs. It’s a huge business — CVS’ PBM business represented approximately 60% of its overall revenues in 2018, or around $116 billion, according to a person familiar with CVS’ business.

Amazon PillPack CEO TJ Parker, in a deposition in the Lavin case, admitted to the court that the company had “explored a number of different things.”

But he said the company had “no immediate plans” to compete with CVS Caremark’s core offering, its PBM.

CVS certainly seems to think differently, according to the lawsuit to prevent Lavin from working for PillPack.

“Given its robust infrastructure, operational capacity, and distribution reach, Amazon-PillPack is uniquely positioned to negotiate directly with payers (insurers) and displace CVS Caremark’s email-based services,” CVS argued in support of its motion for a preliminary injunction.

In other words, CVS worries that Amazon is hiring Lavin to approach its clients — insurance plans — for deals that could undercut its PBM.

In particular, CVS said PillPack is already approaching Blue Cross Blue Shield. (CNBC reported talks between PillPack and the insurance network in May.)

“Most recently, Amazon-PillPack engaged in direct discussions with Blue Cross Blue Shield, a federation of 36 health insurance plans that cover more than 100 million Americans, to provide its members with prescription home delivery,” CVS’ motion reads.

Lavin, who has an extensive background working with payers, would be well positioned if Amazon PillPack did decide to take that step toward direct contracting over time.

According to Jefferies’ analyst Brian Tanquilut, who also reviewed the legal documents, there’s a real threat that Amazon could chip away at CVS Caremark’s business over time by going directly to insurers. “The lawsuit shows that pharmacy benefits managers are now also at risk of being dis-intermediated,” he wrote.

To that assertion, a PillPack spokesperson responded: “It is important to keep in mind that what’s being reported here is another company’s speculation about our business strategy for a lawsuit to which neither Amazon nor PillPack is a party.”

However, other drug supply chain experts agree that the PBMs have reason to worry, especially as the health industry consolidates and policymakers are pushing PBMs to be more transparent about their practices.

“PBMs are going to be more protective of their mail pharmacy business than ever and less welcoming to outsiders like PillPack,” said Stephen Buck, a drug supply chain expert who previously worked at McKesson.

For his part, Lavin said in communications to his former employer that he would not be competing head-on with them but would be negotiating from the opposite side of the table.

“I’ll be … handling [PillPack’s] negotiations with PBMs … in other words, it’ll be the opposite of what I did for CVS,” he noted in an email to CVS’ human resources department that was disclosed during the case.

The judge disagreed and granted CVS’ motion to enforce the non-compete agreement and block Lavin from working for PillPack for 18 months.

In his ruling, Judge John J. McConnell wrote, “Mr. Lavin will also negotiate and build relationships with private Payers and public Payers, both of whom are current CVS clients.” McConnell wrote, “It also appears that PillPack will be looking to negotiate directly with the insurers and others on the Payer level.”

CVS, in a statement to CNBC, denied any claim that it is working to block competition and said that it will continue to work with new players.

“We remain focused on delivering innovative solutions to transform the health care experience, but there is always room for new players in health care, as competition can help lower overall costs for payers and patients,” said a spokesperson for CVS Caremark.

If you remember our discussion last week, last we noted was that Wilbur Mills the Chairman of the Ways and Means Committee hit upon the idea of combining the most ambitious components of three of the bills that all of the various groups arguing for a health care solution for the senior population. His idea was quickly embraced by the Administration because they all regarded it as insurance against any Republican attack. On Marci 23, 1965, the Ways and Means Committee voted to substitute the Mill’s bill for the King-Anderson bill and on the following day, it was introduced on the House floor. After only one day of floor debate, the Mill’s bill was passed without amendment by a vote of 313 to 115.

The features of the new bill was incorporated into two amendments to the Social Security Act, which provided in Title 18 for a universal hospital insurance program for the elderly and for optional coverage of physicians’ services while Title 19 (known as Medicaid) expanded the Kerr-Mills program of medical coverage for the needed.

When the Mills bill was referred to the Senate, months of debate and discussion proceeded and then was referred out of committee having been amended no less than seventy-five times.  The full Senate considered further 250 amendments, passed the bill as amended. It was then sent to a Senate-House conference committee with the task to resolve the over 500 differences between the two chambers.

In July the House passed the finally revised bill to be officially part of the Social Security Amendments of 1965 and the next day after the House passed it the Senate approved the measure. Finally, on July 30, 1965, President Johnson flew into Independence Missouri to sign the Medicare bill into law in the presence of former President Truman. Success finally!!

What were the provisions of the legislation?

Title XVIII, Part A: Hospital Insurance provided that all persons over the age of sixty-five otherwise entitled to benefit under the Social Security or Railroad Retirement Act were eligible and were automatically covered. The benefits were measured in sixty-day periods following discharge from a hospital or extended-care facility. During each benefit period, they were entitled to up to ninety days in a hospital, one hundred days in an extended care facility, and home-care benefits for up to one year after the most recent discharge from either a hospital or extended care facility.

Care in either a psychiatric or tuberculosis hospital was limited to a lifetime amount of 190 days, provided that a physician as being “reasonably expected to improve” certified the patient.  Subscribers were required to pay a “front-end deductible” for each hospital stay of up to ninety days. This deductible started at $40 but has risen to more than $760 for the first sixty days and an additional $190 for days 61-90. No front-end deductibles were imposed for the use of extended care facilities for the first twenty days but after that point, a daily copayment was levied.

The program was financed by earmarked payroll taxes levied on employers and employees and disbursements were made from the fund either directly to providers or through an intermediary insurance company who then reimbursed the providers based or what was and still is known as “reasonable costs.”

Because there is a lot more to the bill I will further breakdown the other provisions of the Medicare bill. But as seen in the eventual design and passing of the Medicare bill it took cooperation and bipartisanship to get the job done.

Listen up Congress, no matter which party you belong to!!

More to come.

Critical condition: The crisis of rural medical care, Guns and Knives and Medicare!

d day257[1467]I wanted to start with this article because our rural area of Maryland is going through the same scenario. We had 3 hospitals serving the mid and upper Delmarva Peninsula but 2 of the hospitals were barely making ends meet. In fact, one of the hospitals will be closed down replaced by an enlarged Urgent care type of facility. Another needs to be shut down and reconfigured as a stabilizing/urgent care center. This last hospital sometimes has an in-hospital census of 1 or 2 patients. You can’t pay the bills with that census and how do you pay your staff, keep the heat and air conditioning and electric running?

Tonopah, Nevada, is about as isolated a place as you can find – 200 miles south of Reno, 200 miles north of Las Vegas, with one road in or out. But to those who call it home, this scenic dot on the desert landscape once had everything they needed.

Emmy Merrow had no concerns about living in such a remote place: “It had a store and a gas station, and I was fine!” she laughed.

Merrow has lived here for four years. She has a two-and-a-half-year-old, Aleyna, and a newborn daughter, Kinzley.

They moved here when her husband got a great job offer from the sheriff’s department. But six weeks before she found out she was pregnant with Aleyna, she also found out Tonopah’s struggling hospital, its only hospital was shutting its doors for good.

“I’m frustrated, I’m mad, I cry, I’m upset about it because we would live less than a mile away from a hospital,” she said.

It was all the more worrisome when, shortly after she was born; Aleyna was diagnosed with Dravet Syndrome, a catastrophic form of epilepsy. “She’s just like any other typical kid, and our day is just like any other day, except for when she has seizures,” Merrow said.

“And how many does she have a day?” asked correspondent Lee Cowan.

“She’s at about 400 now.”

“So, is there anybody within a reasonable distance that can help?

“No.”

When the seizures are bad enough, which is about every six weeks or so, Merrow has to make a mad, desolate dash to the closest hospital, which is across the border in California, some 114 miles away.

She’ll never forget the first time she had to do it: “It was in the middle of the night, so it was dark and I couldn’t see her, so I did stop quite often to just check and make sure she was still breathing.”

“That must have been terrifying,” Cowan said.

“Yeah, I was sobbing the whole way. It is the worst feeling in the world.”

Elaine Minges lives in Tonopah, too. She came here with her husband, Curt, for a high-paying job at the nearby solar plant, and thought they’d retire here one day. “We knew that there was a hospital here and there were a few physicians, and we felt comfortable at the time,” Minges said.

But after the hospital closed, everything changed. “They shut the doors and that was it,” she said.

“And they didn’t give you any warning?”

There were rumors, she said, but “we thought no, that won’t happen. That doesn’t happen. Look, we’re out in the middle of nowhere!”

Curt, who had diabetes, tried not to think about it until one night he suddenly fell very ill. Minges recalled, “He woke up and I thought he was having a heart attack. He was gasping for air. He tried to get up, but he was just too sick.”

He was suffering a serious complication from diabetes. It’s a condition normally survivable with prompt medical attention, but in this case, prompt meant getting a helicopter. “That particular night, the helicopter was 45 minutes out before they could get to the airport, and in that time, he went into cardiac arrest.”

Cowan asked, “Had the hospital here been open, would that have saved your husband?”

“I would like to think so, yeah.”

It’s a grim tale repeating itself all across the country.

Since 2010, 99 rural hospitals like the one in Tonopah have closed; that’s almost one a month.

“Basically about half of the rural hospitals are losing money every year,” said Mark Holmes, a professor of health policy and management at the University of North Carolina, who has been studying the decline for more than a decade.

Cowan asked, “Is there an end in sight?”

“Every time that I’ve said, ‘I think we’re through the worst of it,’ we’ve been surprised,” Holmes replied. “You always have to wonder, who’s next?”

A whole cross-section of America is now facing the very real risk of having no local hospital to turn to. The causes are varied; the population in some of those towns has dwindled to a size that can’t support a hospital anymore.

In others, the hospitals are either mismanaged or they end up as table scraps in mega-mergers. Medicaid expansion would have helped some stay open, Holmes says, but not all, and even so reimbursement rates are often too low for hospitals to break even. Whatever the cause, the impact on the community is almost always the same:

“The hospital closes, the emergency room dries up, all the other services that went with that – home health, pharmacy, hospice, EMS – they leave town as well, and now you’re left with a medical desert,” said Holmes.

That’s exactly the fate residents of Pauls Valley, Oklahoma was worried about. The town, about 60 miles south of Oklahoma City, has only one hospital, but the previous management company had run it into bankruptcy.

The city brought in Frank Avignone to save it. When Cowan visited, Avignone was working the phones to find a generous donor to keep it open: “I’ve got 130 employees here that I’m going to have to tell they have no future,” he said.

“It’s literally day-by-day for this hospital,” Cowan asked.

“It’s minute-by-minute,” he replied.

“How much money do you have in the bank right now?”

“About $7,000.”

“Which gets you how far?”

“The next 15 minutes. I mean, it’s not enough to really make a difference.”

Townspeople rallied, especially those who had been treated here, like Susanne Blake. She and her husband pitched in half of their retirement savings – a gamble that to them, made some good-natured sense. “We got tickled about how much we should give, because he said, ‘Well, without a hospital, we don’t have to worry about as long a retirement!'” she laughed.

Employees were just as passionate. Linda Rutledge, who’s worked in the hospital’s cafeteria for nearly 20 years, baked over a thousand cookies – a bake sale with a lot riding on it.

Asked what will happen should the hospital close, Rutledge replied, “I’m going to cry. That’s just can’t happen.”

But it can happen. And last year, in response to the need for medical care, a massive free health clinic popped up at a fairground in Gray, Tennessee, set up by a non-profit called Remote Area Medical – originally founded to serve third-world countries.

But Chris Hall, the charity’s COO, says a rural hospital closure back in 1992 forced the organization to address the medical needs of the underserved here at home, too.

“Today alone, there’s seven states’ worth of patients that have come to this event,” Hall said. “People have gotten in their car and driven 200 miles to get here today just to be able to get a service that they couldn’t get in their local area, or [couldn’t] afford in their local area.”

Some who lined up overnight in the cold did, in fact, have a hospital; they just didn’t have the insurance to access it. But for others, like Leanna Steele, this is the closest thing they have to an emergency room. Her local hospital, which she used to go to when she got debilitating migraines, also closed.

Cowan asked, “So, what do you do now?”

“Mainly just sit and hope,” Steele said.

Usually, before a hospital closes entirely, administrators will try cutting back on non-emergency services, like maternity wards. That’s happened so often that more than half the rural communities in this country now no longer have labor and delivery units, leaving expectant mothers facing long drives at the worst of times.

  • But in Lakin, Kansas, population 2,200, they tried something different. The only hospital for miles decided to invest in obstetric care instead, the thinking being that babies can be a growth industry. They get patients in the door, and just as Kearny County Hospital’s young CEO Ben Anderson had hoped, they stay … and bring along the rest of the family, too.

“Moms came here and had a great experience, and they said, ‘You know, you’re gonna be my baby’s pediatrician, and you’re gonna be my women’s health physician, and you’re gonna take care of my husband as an internist. We’re all coming to you,'” said Anderson.

And that’s just what’s happened. Dr. Drew Miller has a bulletin board outside his office with pictures of the future patients he’s brought into this world – almost 500 in the last eight years, from all across the state.

“The most rewarding thing of what I get to do is to take care of families of multiple generations,” Dr. Miller said. “I could tell you stories of people I’ve delivered their babies, and taken care of their grandma or their great-grandma. That’s what I love about what I get to do here.”

And another thing: There are no high-priced specialists employed here, not even an OB-GYN. Instead, the hospital is staffed entirely by physicians trained in full-spectrum family medicine instead. “We determined we only have so many dollars to spend at a rural critical access hospital on medical care staff coverage, so it’s important that everybody is trained to do the same thing, and it’s important that everyone is willing to do it equally,” Anderson said.

A typical day for these rural doctors can include doing a colonoscopy in the OR in the morning and removing a skin lesion at a clinic in the afternoon. It’s a flexible, can-do approach to rural medicine that has kept these hospital doors open – at least for now.

“This last year we had the first profitable year in probably two or three decades,” said Anderson. “But we’re riding very, very close. We don’t have the margin for mistakes.”

It’s that razor’s edge that hospitals like the one back in Pauls Valley, Oklahoma, had ridden for too long. Cowan was there when CEO Frank Avignone brought the staff together to share some news: “You can only live on borrowed time so long,” he said. The hospital was closing, immediately.

“I’m not sure people really understand what’s going on,” Avignone told Cowan. “The story’s gotta get out. People have to see the faces of the folks in this community and the employees and what they’ve been through. People die because this hospital won’t be open.”

Back in Tonopah, Nevada, Emmy Merrow understands those risks firsthand after one excruciatingly long drive to a hospital with Aleyna that had irreversible consequences. “She fell into a seizure that lasted three hours long; it lasted the whole entire trip,” she said. “So, she has brain damage from that. She wasn’t breathing correctly, she lost oxygen.”

“I think people watching this are going to wonder if it’s that bad, and you’re so far away from a hospital, and you need help basically all the time, why not move?” asked Cowan.

“It would be great if we had the money to be able to move,” she replied. “We make enough to live, but not really enough to save up to be able to make that move.”

As for Elaine Minges, with her husband now gone, the rural life they loved so much is gone, too, and like so many who live in small-town America, she’s at a loss for what to do next.

Cowan asked, “Will you stay here knowing there’s not a hospital?”

“My home is here,” she said. “I feel my husband here.”

“What do you think he’d want you to do? Would he want you to stay?”

“No,” she said.

Right now, we all in our community are considering alternatives and more and more of our patients are going “across the bridge” to University or “better” hospitals. I suspect that this is going to be more of a problem in the future with more talk of Medicare for All.

These next two discussions are in response to a local senseless stabbing/murder in our small town. We were lucky that the murderer wasn’t carrying a gun or the deceased could have numbered in a much higher amount.

Angry young white men charged in America’s latest mass shootings

Annalisa Merelli noted that there have been 25 mass shootings in the US this year. Seventeen of the incidents were deadly and 11 killed three to five victims each—for a total of 45 fatalities.

Last week alone, 17 people (not including the shooters) lost their lives in four mass shootings. Three of the attacks were said to be carried out by 21-year-old white men:

  • Zephen Xaver allegedly shot and killed five women in the lobby of a SunTrust bank branch in Sebring, Florida on Jan. 23.
  • Jordan Witmer killed three in State College, Pennsylvania on Jan. 24.
  • Dakota Theriot has been charged with killing five: his girlfriend, her brother, her father, and both of his own parents in Livingston Parish and Baton Rouge, Louisiana on Jan. 25.

Investigators are still looking into motives yet it’s hard not to note some commonalities: All of these mass shooters were men, and they all targeted women. They had shown violent behavior and tendencies in the past or had been exposed to violence. None of this seemed to have stopped them from being able to acquire guns. It’s an all-too-familiar pattern in the US. The shooters’ identities are also consistent with the overall American trend: Mass shootings are nearly exclusively perpetrated by men, the vast majority of whom are white.

Xaver, ex-girlfriend Alex Gerlach told WSBT-TV, “for some reason always hated people and wanted everybody to die” and “got kicked out of school for having a dream that he killed everybody in his class, and he’s been threatening this for so long.” Gerlach said her warnings about Xaver were not taken seriously, even as he bought a gun it was not considered a warning sign. After the shooting, police chief Karl Hoglund described the targeting of five women a “random act.” Amongst Xaver’s interests were prominent right-wing figures such as Milo Yannopoulos and Alex Jones; when he was arrested, he was wearing a T-shirt with a print of the Four Horsemen of the Apocalypse, the New Testament figures of destruction.

Witmer, the Pennsylvania shooter, also took aim at a female victim. He was having drinks with Nicole Abrino, a woman identified a current or former girlfriend when the two argued. Dean Beachy, who was sitting across the bar, tried to break up the fight. Witmer shot him in the head, killing him, then fatally shot Beachy’s son. Witmer also shot Abrino, who survived. Witmer left the bar, later crashing his car and breaking into a home where he shot and killed a fourth person. He then killed himself. Witmer, who didn’t have a history of violent behavior, had recently returned from a three-year stint with the US Army. According to his family, he was planning to become a police officer.

Theriot, targeted his girlfriend of about two weeks, Summer Ernest, police said, and the murder in Louisiana seemed premeditated. The young man was living with Ernest and her family after he had been kicked out of his own home. He is said to have shot her dead, followed by her father and younger brother. Theriot then took the father’s truck, and drove to his parents’ home, police said, killing both of them. He was arrested as he tried to reach his grandmother, still carrying a gun. Theriot, his neighbors said, had a history of trouble with drugs and he had been arrested for minor drug possession. Though authorities say he didn’t have a history of violent behavior, some who knew him to seem to disagree. They say he had pulled a gun out on his mother, which was among the reasons he had been kicked out of the house.

ACCORDING TO THE FBI, KNIVES KILL FAR MORE PEOPLE THAN RIFLES IN AMERICA – IT’S NOT EVEN CLOSE

Columnist Benny Johnson noted that knives kill far more people in the United States than rifles do every year.

In the wake of the horrific school shooting in Florida last week, the debate over guns in America has surged again to the forefront of the political conversation. Seventeen students were killed when a deranged gunman rampaged through the Stoneman Douglas High School in Parkland Florida. Many are calling now for stricter gun laws in the wake of the shooting, specifically targeting the AR-15 rifle and promoting the reinstatement of the assault weapons ban.

However, recent statistics from 2016 show that knives actually kill nearly five times as many people as rifles that year.

According to the FBI, 1,604 people were killed by “knives and cutting instruments” and 374 were killed by “rifles” in 2016.

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The statistics match the trends seen in previous years, which show knife murders far outnumbering rifle statistics. In 2013, knives were used to kill 1,490 and rifles were used to kill 285. Handguns far outnumber both knives and rifles in American murders. There were 7,105 murders by handgun in America in 2016.

Handguns were not included in the assault weapons ban.

Writing on the issue of handgun violence, The Federalist makes this interesting point:

“But what about handgun murders?” you might ask. “They’re responsible for the majority of gun murders, so why don’t we just ban them and stop worrying about rifles?”

Easy: because gun bans and strict gun control don’t really prevent gun violence. Take, for example, Illinois and California. In 2013, there were 5,782 murders by handgun in the U.S. According to FBI data, 20 percent of those — 1,157 of the 5,782 handgun murders — happened in Illinois and California, which have two of the toughest state gun control regimes in the entire country. And even though California and Illinois contain about 16 percent of the nation’s population, those two states are responsible for over 20 percent of the nation’s handgun murders.

One of the difficulties in the FBI’s statistics is the pinpointing of the exact type of firearm used in the overall number of gun murders. In over 3,000 cases, the firearm is not “stated.” This means it could be a rifle, handgun or shotgun used in the crime.

Certainly, this could potentially add to the number of rifle deaths each year. However, if the ratios of weapons used in the uncategorized 3,000 number reflected the overall sample size, the number of rifle deaths would only rise by a small fraction, not nearly enough to surpass the number of knife deaths.

So, what next? Do we outlaw guns as well as knives? What do we use as cutting utensils……plastic knives????

And More About the Medicare Story!

For Medicare, the best progress was made thanks to Presidential candidate John F Kennedy. Kennedy along with Clinton P. Anderson of New Mexico, introduced a measure similar to the previous Forand bill in the Senate the summer of 1960. The measure was defeated in favor of the Kerr-Mills bill, but the Democratic platform contained a provision supporting an extensive hospital insurance strategy for the aged. Kennedy made this proposal a subject of his speeches during his stumping for the presidency and even before his administration took office a White House Conference on Aging again brought the issue of a government health insurance. They seemed to get more and more support, especially since Eisenhower’s Secretary of Health, Education, and Welfare was among several prominent Republicans who were in support of the enactment of a comprehensive measure.

Almost immediately following his inauguration, on February 9, 1961, President Kennedy sent a message to Congress calling for an extension of the social security benefits to cover hospital and nursing home costs. The bill would have covered 14 million recipients over the age of sixty-five was predicted to cost approximately a billion and a half dollars, but didn’t include the cost of medical or surgical treatment. It only covered for ninety days of hospital care, outpatient diagnostic services and a hundred and eighty days of nursing home care. Imagine the cost back then of adding on the medical and surgical treatment costs!

Because of Kennedy’s thin margin of victory in November, it was deemed expedient not to press for passage of the bill until the following year. But along comes the AMA creating the American Medical Political Action Committee, which was joined with the commercial health insurance carriers and Blue Cross-Blue Shield in opposing the bill and questioned the cost put forward by the administration. The opposition mounted a strong campaign against the King-Anderson using posters, pamphlets and radio, and TV extensively. The Association seemed to be angered by included fee schedule for hospitals, nursing homes, and nurses which could serve as a precedent should government insurance be expended to include.

There was a great deal of fighting as the Kennedy administration demonized the AMA, accusing the association of thwarting the public will with the interest of lining the pockets of its membership and of employing scare tactics against the government’s interest and only concern to extend to the aged and infirm needed medical benefits. The administration got support from organized labor and several new organizations which lobbied extensively in favor of the measure.

On and on went the supporters and the opposition until finally after Kennedy’s assassination when Congressional support for Kennedy’s legislation swelled, but that is for another day and next week.

And an impressive celebration of D-day. Thank you again Veterans who fought for us all!!

The Conversation We Refuse to Have About War and Our Veterans, Hospital Billing and More on the History of Medicare.

Screen Shot 2019-05-26 at 11.34.05 PMMemorial Day and the latest redeployment of soldiers and a carrier group to the Middle East is a perfect time to realize that Veterans bear the burden of war long after they leave the battlefield. It’s time for America to acknowledge it.

I went to the market

Where all the families shop

I pulled out my Ka-bar

And started to chop

Your left right left right left right kill

Your left right left right you know I will

-Military cadence

“You can shoot her…” the First Sergeant tells me. “Technically.”

Benjamin Sledge wrote reflecting, we’re standing on a rooftop watching black smoke pillars rise from a section of the city where two of my teammates are taking machine gun fire. Below, the small cluster of homes we’ve taken over is taking sporadic fire as well. He hands me his rifle with a high powered scope and says, “See for yourself.”

It’s the six-year-old girl who gives me flowers.

We call her the Flower Girl. She hangs around our combat outpost because we give her candy and hugs. She gives us flowers in return. What everyone else at the outpost knew (except for me, until that day) was that she also carried weapons for insurgents. Sometimes, in the midst of a firefight, she would carry ammunition across the street to unknown assailants.

According to the rules of engagement, we could shoot her. No one ever did. Not even when the First Sergeant morbidly reassured them on a rooftop in the middle of Iraq.

Other soldiers didn’t end up as lucky.

Sometimes they would find themselves paired off against a woman or teenager intent on killing them. So they’d pull the trigger. One of the sniper teams I worked with recounted an evening where he laid up a pile of people trying to plant an IED. It was a “turkey shoot,” he told me laughing. But then he got quiet and said, “Eventually they sent out a woman and this dumb kid.” I didn’t need to ask what happened. His voice said it all.

I often wonder what would have happened if the Flower Girl pointed a rifle at me, but I’m afraid I already know. The thought didn’t matter anyway. There was enough baggage from tours in Afghanistan and Iraq that coming home was full of uncertainty, anger, and confusion — and not, as I had been led to believe, warmth and safety.

“People only want to hear the Band of Brothers stories. The ones with guts and gusto! Not the one where you jam a gun in an old woman’s face or shoot a kid.” I pause, then add, “Look around the room for a second…”

Andy surveys the restaurant we’re in for a moment while I lean in with a sardonic half-smile.

“How many people can even relate to what we’ve been through? What would they rather hear about? How Starbucks is giving away free lattes and puppies this week? Or how a soldier feels guilty because he pulled a trigger, lost a friend, or did morally questionable things in war? Hell, I want to hear about the latte giveaway… especially if it’s pumpkin spice.”

This eases the tension and he smiles.

Andy and I feel like we don’t fit in. We met a few years ago at the church where he works, and where I volunteer. Of the thousands of people in the congregation, we are a handful of veterans. The veterans I meet are few and far between, and we typically end up running in the same circles.

How do you talk about morally reprehensible things that have left a bruise on your soul?

Years ago, Andy fought in the siege of Fallujah. We never readjusted to normal life after deployment. Instead, we found ourselves angry, depressed, violent and drinking a lot. We couldn’t talk to people about war or its cost because, well, how do you talk about morally reprehensible things that leave a bruise on your soul?

The guilt and moral tension many veterans feel is not necessarily post-traumatic stress disorder, but a moral injury — the emotional shame and psychological damage soldiers incur when we have to do things that violate our sense of right and wrong. Shooting a woman or child. Killing another human. Watching a friend die. Laughing about situations that would normally disgust us.

Because so few in America have served, those who have can no longer relate to their peers, friends, and family. We fear being viewed as monsters or lauded as heroes when we feel the things we’ve done were morally ambiguous or wrong.

The U.S. is currently engaged in the longest running war in the history of the United States. We are entering our 15th year in Afghanistan, and we still station troops in some Iraqi outposts. In World War II, 11.5% of U.S. citizens served in four years. In Vietnam, 4.3% served in 12 years. Since 2001, only 0.86% of our population has served in the Global War on Terror. Yet, during World War II, 10 million men were drafted, and over 2 million men were conscripted during Vietnam. Despite the length of the Iraq and Afghan Wars, there has been no draft, whereas, in times past, shorter wars cost us millions of young men. Instead, less than 1% of the population has borne this burden, with repeated tours continually deteriorating our troops’ mental health.

Screen Shot 2019-05-25 at 8.13.38 PM

The gap between citizens and soldiers is growing ever wider. During WWII, the entire nation’s focus was on purchasing war bonds and defeating the Nazis. Movie previews and radio shows gave updates on the war effort. Today’s citizens, however, are quickly amused by the latest Kardashian scandal on TV, which gives no reminder of the men and women dying overseas. Because people are more concerned about enjoying their freedoms and going about their day to day lives, veterans can feel like outcasts. As though nothing we did matter to a country that asked us to go.

This is part of the problem with a soldier’s alienation. People quickly point out that we weren’t forced to join the military and fight in a war. We could have stayed home. The counterpoint is that, because the U.S. has now transitioned to an all-volunteer force, those opposed to war should be thanking their lucky stars that volunteers bear the burden of combat.

Additionally, regardless of whether you’re Republican, Democrat, Libertarian, Communist, Liberal, Conservative, Conscientious Objector, or Pacifist, we all sent the soldier overseas. Because we live in a democracy, we vote to put men and women in charge of governing our affairs, and those elected representatives send troops overseas. We may have voted for someone else, but it does not change the fact that we’ve put ourselves under the governance of the United States. When you live in a country, you submit yourself to their governing body and laws — even if you don’t vote.

The citizen at home may not have pulled the trigger, but they asked the soldier to go in their place.

By shirking responsibility, civilians only alienate our soldiers more. The moral quagmire we face on the battlefield continues to dump shame and guilt onto our shoulders while they enjoy the benefits of passing the buck and asking, “Whose fault is it, really?”

On March 3, 1986, 11 years after the end of the Vietnam War, Metallica released their critically acclaimed album Master of Puppets. On the album, a song entitled “Disposable Heroes” tells the story of a young man used as cannon fodder in the midst of war and the terror that enveloped him on the battlefield. Three years later, Metallica released “One,” a song about a soldier who lost all his limbs and waits helplessly for death. The song won a Grammy for Best Metal Performance.

In an odd twist, both songs are amazingly popular among members of the United States military. During my time at the John F. Kennedy Special Warfare Center, we had an entire platoon that could practically sing every last lyric to “One.” In Afghanistan and Iraq, these songs were on playlists made to get soldiers amped before missions. We sang songs about dying on behalf of the people or coming home a vegetable. As crazy as that sounds, we sang those songs because they felt true. And they felt true because of the conversation we refuse to have as a country.

As Amy Amidon, a Navy psychologist stated in an interview regarding moral injury:

Civilians are lucky that we still have a sense of naiveté about what the world is like. The average American means well, but what they need to know is that these [military] men and women are seeing incredible evil, and coming home with that weighing on them and not knowing how to fit back into society.

Most of the time, like the conversation Andy and I had, people only want to hear the heroics. They don’t want to know what the war is costing our sons and daughters in regard to mental health, and this only makes the gap wider. In order for our soldiers to heal, society needs to own up to its part in sending us to war. The citizen at home may not have pulled the trigger, but they asked the soldier to go in their place. Citing a 2004 study, David Wood explains that the “grief over losing a combat buddy was comparable, more than 30 years later, to that of a bereaved spouse whose partner had died in the previous six months.” The soul wounds we experience are much greater. Society needs to come alongside us rather than pointing us to the VA.

Historically, many cultures performed purification rites for soldiers returning home from war. These rites purified a broad spectrum of warriors, from the Roman Centurion to the Navajo to the Medieval Knight. Perhaps most fascinating is that soldiers returning home from the Crusades were instructed to observe a period of purification that involved the Christian church and their community. Though the church had sanctioned the Crusades, they viewed taking another life as morally wrong and damaging to their knights’ souls.

No one in their right mind wants war. We want peace. And no one wants it more than the soldier.

Today, churches typically put veterans on stage to praise our heroics or speak of a great battle we’ve overcome while drawing spiritual parallels for their congregation. What they don’t do is talk about the moral weight we bear on their behalf.

Dr. Jonathan Shay, the clinical psychologist who coined the term moral injury, argues that in order for the soldier and society to find healing, we must come together and bear the moral responsibility of what soldiers have done in our name.

Whether you agree or disagree with the war, you must remember that these are our fellow brothers and sisters, sons and daughters, flesh and blood. As veterans, we are desperate to reconnect with a world we feel no longer understands us. As a country, we must try and find common ground. We’re not asking you to agree with our actions, but to help us bear the burden of carrying them on behalf of the country you live in. A staggering 22 veterans take their lives every day, and I can guarantee part of that is because of the citizen/soldier divide.

But what if it didn’t have to be this way? What if we could help our men and women in uniform bear the weight of this burden we carry? We should rethink exactly what war costs us and what we’ve asked of those who’ve fought on our behalf. In the end, no one in their right mind wants war. We want peace. And no one wants it more than the soldier. As General Douglas MacArthur eloquently put it:

“The soldier above all other people prays for peace, for he must suffer and bear the deepest wounds and scars of war.”

And what do we offer our Veterans for their healthcare when they come home? A truly horrid attempt at a government-run healthcare system, which now is pushing to get our Vets to private healthcare programs!!

Surprise! House, Senate Tackle Hospital Billing

Senate bill also addresses provider directories, drug maker competition

Our friend Joyce Frieden wrote that responses are generally positive so far regarding draft bipartisan legislation on surprise billing and high drug prices released Thursday by the Senate Health, Education, Labor, and Pensions (HELP) Committee.

“We commend this bipartisan effort to address several of the key factors associated with rising health care costs,” Richard Kovacs, MD, president of the American College of Cardiology, said in a statement.

“We agree with and support many of the principles outlined by the HELP Committee,” Matt Eyles, president, and CEO of America’s Health Insurance Plans, a trade group for health insurers, said in a statement. “We agree patients should be protected from surprise medical bills, and that policy solutions to this problem should ensure premiums and out-of-pocket costs do not go up for patients and consumers.”

The HELP Committee draft bill, known as the Lower Health Care Costs Act, would:

  •  Require that patients pay only in-network charges when they receive emergency treatment at out-of-network facilities, and when they are treated at an in-network facility by an out-of-network provider that they did not have a say in choosing/
  • Ban pharmacy benefit managers (PBMs) from “spread pricing” — charging employers, health insurance plans, and patients more for a drug than the PBM paid to acquire the drug.
  • Require insurance companies to keep provider directories up to date so patients can easily know if a provider is in-network.
  • Require healthcare facilities to provide a summary of services when a patient is discharged from a hospital to make it easier to track bills, and require hospitals to send all bills within 30 business days, to prevent unexpected bills many months aftercare.
  • Ensure that makers of branded drugs, including insulin products, are not gaming the system to prevent generics or biosimilars from coming to market
  • Eliminate a loophole that allows the first company to submit a generic drug in a particular class to enjoy a monopoly
  • Give patients full electronic access to their own health claims information.

Although the patient will only need to pay in-network charges when receiving service from an out-of-network provider, that in-network amount won’t pay for the entire out-of-network bill, so lawmakers still must decide how to deal with the rest of the out-of-network charge. The committee says it’s considering several options, including having insurance companies pay the out-of-network providers the median contracted rate for the same services provided in that geographic area, and, for bills over $750, allowing the insurer or the provider to initiate an independent dispute resolution process. The insurer and provider would each submit a best final offer and the arbiter would make a final, binding decision on the price to be paid.

The bill’s provisions “are common-sense steps we can take, and every single one of them has the objective of reducing the health care costs that you pay for out of your own pocket,” committee chairman Lamar Alexander (R-Tenn.) said in a statement. “We hope to move it through the health committee in June, put it on the Senate floor in July and make it law.” The bill is co-sponsored by Sen. Patty Murray (D-Wash.), the HELP Committee’s ranking member.

Over on the House side, legislators also released a bipartisan bill Thursday on surprise billing. This bill, known as the Protect People From Surprise Medical Bills Act, mirrors the Senate bill in prohibiting balance billing to patients receiving emergency care out of network or anticipated care at in-network facilities that use out-of-network providers without the patient’s knowledge or consent.

The patient would pay in-network rates in those situations, and then the health plan would have 30 days to pay the provider at a “commercially reasonable rate.” If either party is dissatisfied with that rate, the plan and doctor would settle on a payment amount; if that didn’t work, the parties could go to arbitration.

This legislation “will ban these bills and keep families out of the middle by using a fair, evidence-based, independent, and neutral arbitration system to resolve payment disputes between insurers and providers,” Rep. Raul Ruiz, MD (D-Calif.), the bill’s main sponsor, said in a statement. “As an emergency doctor, patients come first and must be protected.”

Co-sponsors of the bill include representatives Phil Roe, MD (R-Tenn.), Donna Shalala (D-Fla.), Joseph Morelle (D-N.Y.), Van Taylor (R-Texas), Ami Bera, MD (D-Calif.), Larry Bucshon, MD (R-Ind.), and Brad Wenstrup (R-Ohio). The group expects to introduce the final legislation in the next few weeks.

The American Society of Anesthesiology (ASA) praised the House bill. “The approach to addressing the problem of surprise medical bills outlined by Congressmen Ruiz and Roe is a fair proposal that puts patients first by holding them harmless from unanticipated bills,” ASA president Linda Mason, MD, said in a statement. “The proposal doesn’t pick winners or losers but instead places the dispute where it should be — between the health care provider and the insurance company.”

The American Medical Association (AMA) also liked the bill. “The outline released today represents a common-sense approach that protects patients from out-of-network bills that their insurance companies won’t pay while providing for a fair process to resolve disputes between physicians and hospitals and insurers,” AMA president Patrice Harris, MD, said in a statement.

Now, back to Medicare and the history of healthcare reform. Next, there was a convening of a National Health Conference, which had earlier approved a report of its Technical Committee on Medical Care, urging a huge extension of federal control over health matters. Sound familiar? Here we are in 2019 urging more control of the federal government over health care again in the form of a government-run health care system as either Obamacare or Medicare for All. The conference in 1938 opened with a statement by President Roosevelt describing the ultimate responsibility of the government for the health of its citizens.

The “technical committee” advised the Conference recommended that the federal government enact legislation in several areas:

  1. An expansion of the public health and maternal and child health programs including the original Social Security Act.
  2. A system of grants to the various states for direct medical care programs.
  3. Federal grants for hospital construction.
  4. A disability insurance program that would insure against loss of wages during illness.
  5. Grants to the states for the purpose of financing compulsory statewide health insurance programs.

The total costs of the program were about $850 million tax-funded and now compare this to the cost of Medicare for All at about $34 trillion. We should have adopted Medicare for All then. We would have saved a boatload of money.

It was interesting to learn that in order to placate the majority of medical practitioners the Committee urged the adoption of these programs on the state level. The reason why physicians opposed a program on the national level was the fear of becoming government salaried employees with not much to say in the administration of the program.

As predicted in 1943 when Senator Robert Wagner of New York, together with Senator James Murray of Montana and Representative John Dingle of Michigan, introduced a bill, which called for compulsory national health insurance/ mandatory health insurance as well as a federal system of unemployment insurance, broader coverage and extended benefits for old-age insurance, temporary and permanent disability payments underwritten by the federal government, unemployment benefits for veterans attempting to reenter civilian life, a federal employment service, and a restructuring of grants-in-aid to the states for public assistance.

Roosevelt wasn’t against the bill but he wasn’t prepared to endorse a bill quite so sweeping and so the bill dies in committee. But interestingly Roosevelt wanted to save the issue of national health care for the next presidential campaign in 1944. During the campaign he then called for an “Economic Bill of Rights,” which would include “the right to adequate medical care and the opportunity to achieve and enjoy good health” and the right to adequate protection from the economic fears of old age, sickness, accident, and unemployment” and in his budget message of January 1945 he announced his intention of extending social security to include medical care.

However, Roosevelt died in April 1945 and then Harry Truman took over the presidency committed to most of the same domestic policies as Roosevelt. But then came politics and party and the attempts to enact a health insurance bill during the Truman era came to a definite end with the election of 1950 where a number of the proponents of the mandatory national health insurance were defeated as well as a vigorous and costly campaign by the American Medical Association which was against compulsory health insurance associating the plan in the mind of the public with notions of socialism. Sound familiar?

More next week!

Let us all thank our veterans, our heroes, our real Avengers for all that they have done to assure us all of living in such a great free country. Happy Memorial Day!!

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Health Insurance Inflation Hits Highest Point in Five Years and More on Medicare; and What is this about Abortion and SATs?

57358059_1998437466952569_3700281945192660992_nFirst of all, I must yell and scream at the idiots in the States, you know who you are, that have or are in the process of passing the most restrictive abortion bills. This is especially Alabama where Governor Kay Ivey signed the strictest anti-abortion law. Legislation to restrict abortion rights has been introduced in 16 states this year. The Alabama Senate approved a measure on last week that would outlaw almost all abortions in the state, setting up a direct challenge to Roe v. Wade, the case that recognized a woman’s constitutional right to end a pregnancy. The legislation bans abortions at every stage of pregnancy and criminalizes the procedure for doctors, who could be charged with felonies and face up to 99 years in prison. It includes an exception for cases when the mother’s life is at serious risk, but not for cases of rape or incest — a subject of fierce debate among lawmakers in recent days. The House approved the measure — the most far-reaching effort in the nation this year to curb abortion rights and was just signed by the Governor.

What the heck are you thinking, not even for rape or incest? You are forgetting the women who bare the brunt of your idiot decisions. Do you think that the Supreme Court will overturn Roe versus Wade, passed in 1973? Get real and attend to the real multiple crises out there!

And diversity scores on the SAT exams??? Again, what are you all thinking? I know to correct the “crises of rich parents who got their “unfortunate” children into the best of colleges. Next, the strategy to get our children into good colleges will be to take courses to improve their test-taking abilities, but now they will have to figure out how to improve their adversity scores. Mom and Dad, we need to move into the ghettos of Scarsdale, get on food stamps, get fired from your high paying jobs and become homeless. I know this all sounds crazy, but that is where we are.

Shelby Livingston wrote that the health insurance inflation rate hit a five-year peak in April, possibly because managed care is rising.

The Consumer Price Index for health insurance in April spiked 10.7% over the previous 12 months—the largest increase since at least April 2014, according to a Modern Healthcare analysis of the U.S. Bureau of Labor Statistics’ unadjusted monthly Consumer Price Index data.

In contrast, the other categories that make up the medical care services index—professional services and hospital and related services—rose 0.4% and 1.4% in April, respectively. The CPI for medical care services in April rose 2.3%, while overall inflation increased 2% year over year.

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Because of the way the BLS calculates the health insurance index, the change year over year does not reflect premiums paid by customers, but “retained earnings” after paying out claims. These earnings are used to cover administrative costs or are kept as profit.

The BLS redistributes the benefits paid out a portion of the health insurance index to other non-insurance medical care categories, such as physician services.

The likely reason health insurance inflation is rising is because of growth in managed care, including Medicare Advantage, Medicaid managed care and commercial insurance, according to Paul Hughes-Cromwick, an economist at Altarum. He noted that added administrative costs increase insurance price growth.

Hughes-Cromwick said the increase in the health insurance index could also be driven by the fact that insurers’ medical loss ratios may be decreasing as high premiums, particular in the individual health insurance exchanges, exceeded anticipated claims.

The medical loss ratio reflects the percentage of every premium dollar spent on medical claims and quality improvement. Insurers must pay at least 80% of premiums on those things and if they don’t, they must issue rebates to plan members, as part of the Affordable Care Act.

In response to rising inflation, a spokeswoman for America’s Health Insurance Plans, the industry’s biggest lobbying group, commented that “consumers deserve the lowest possible total costs for their coverage and care.” She pointed out the medical loss ratio requirements and said health insurers spend 98 cents of every premium dollar on medical care, operating costs that include care management, and preventing fraud, waste, and abuse.

Affordable Care Act exchange insurers hiked premiums higher than necessary in 2018 and now expect to pay out $800 million in rebates to individual market customers this year because they did not meet the medical loss ratio threshold, according to a Kaiser Family Foundation analysis published this month. Because medical loss ratios are declining, health insurers in the individual, small group and large group markets expect to issue $1.4 billion in rebates based on their 2018 performance, the analysis stated.

Still, health insurance profits have been on the rise. The eight largest publicly traded insurers posted net income of $9.3 billion in the first quarter of 2019, an increase of 29.9%. They made a combined $21.9 billion in profits over the course of 2018.

Medicaid waiver loophole sparks transparency concerns

Robert King noted that the CMS is doing a poor job in ensuring the public knows about major changes to Medicaid, including the installation of work requirements, a federal watchdog said Friday.

The Government Accountability Office’s report found that the CMS has limited transparency for amendments to existing Section 1115 waivers. That has allowed some states to score approval for their work requirements while skirting some rules, such as projecting how the changes will impact Medicaid enrollment.

The government watchdog noted that two of the four states it studied did not seek public comment on changes that could significantly impact Medicaid beneficiaries.

The transparency requirements for an amendment are more relaxed than a new waiver application, the GAO said. Arkansas and New Hampshire both added work requirements to their Medicaid programs through amendments to their existing Section 1115 waivers.

Currently, new waivers or extension requests must include whether the state thinks that enrollment will decrease and any spending changes. While amendments must address the impact on beneficiaries and explain the changes, there are fewer requirements for what information must be disseminated to the public.

The GAO also found that the CMS had inconsistent transparency requirements for amendments.

For example, the CMS determined Massachusetts’ amendment to waive non-emergency medical transportation was incomplete because the application didn’t include a revised design plan. However, the CMS-approved Arkansas’ work requirement amendment even though it did not include a revised design plan.

The GAO recommended that the CMS develop standard transparency requirements for new waivers, extension requests, and significant Section 1115 amendments.

In response, HHS said it has already implemented policies to improve transparency. GAO said those changes “do not apply to amendments.”

The CMS also lacks policies for ensuring that major changes to a pending application are transparent.

The report comes as the Trump administration is appealing a federal judge’s decision to strike down Medicaid work requirement programs in Kentucky and Arkansas.

Seven other states have received CMS approval for work requirements. Those states are Arizona, Indiana, Michigan, New Hampshire, Ohio, Utah, and Wisconsin. Another six states—Alabama, Mississippi, Oklahoma, South Dakota, Tennessee, and Virginia—have applications pending federal approval.

Industry enters new battle phase over surprise billing

Susannah Luthi reported that the knives are out over legislation to end surprise medical bills and specifics haven’t even been unveiled yet. But will this solve the problems of the healthcare crisis?

The industry is pushing back hard against a particular principle laid out by President Donald Trump last week.

The administration wants all out-of-network charges from a doctor at an in-network hospital to be wrapped into a single bill from the hospital.

How this provision will technically play out in policy is yet to be seen, as the Senate health committee plans to release its legislative package on surprise medical bills this summer.

But the administration’s position has roiled hospital groups and specialty physicians like emergency doctors, radiologists, and anesthesiologists, who don’t always share the same insurance network as hospitals and have higher than average charges.

“Untested proposals such as bundling payments would create significant disruption to provider networks and contract without benefiting patients,” American Hospital Association CEO Rick Pollack said in a statement shortly after Trump made his remarks. He reiterated the AHA’s position that all Congress needs to do is enact a ban on balance billing and leave the rest to the industry to figure out.

Specialty physicians argue that a single bill will complicate all the billing processes on the back-end with hospitals and insurers.

Dr. Sherif Zaafran, a Texas anesthesiologist, said he doesn’t see room within the White House framework for a policy he could support. He sees it as undercutting specialty physicians’ independence from hospitals. “As a patient, I think a single hospital bill on the surface sounds really good, but in the reality of how most of us practice it’s probably not very practical,” Zaafran said. “A single bill would imply you’re marrying the system for how a physician gets paid with other components that bill completely separately.”

He expects a resulting policy would end up cutting pay for both hospitals and ancillary physicians—hospitals taking a hit as they try to collect the fee and reimburse the physician, and physicians taking a hit if hospitals need to negotiate with insurers on their behalf.

“There are downstream effects that folks haven’t thought through,” Zaafran said.

But the administration’s stance shows how thinking around policy has morphed during months of scrutiny of the issue. And analysts have been documenting the trajectory of high ancillary physician charges in part to lay out the argument for payment bundles.

Discussions started last fall with an initial legislative push from a bipartisan group led by Sens. Bill Cassidy (R-La.) and Michael Bennet (D-Colo.). Cassidy and his co-sponsors introduced a draft proposal to cap out-of-network charges at a regional average. Not long after, Sen. Maggie Hassan (D-N.H.) pitched arbitration to settle disputes between insurers and providers.

As the months passed, the debate transitioned into a look at the underlying contracts between hospitals and insurers—even as policy analysts note that the problem of surprise medical bills is limited to a small number of hospitals.

Experts and economists from think tanks like the Brookings Institution, American Enterprise Institute, and the Urban Institute have weighed in, aided by data from states that have tried to curb the practice in the individual insurance markets that fall under their regulating power.

Several have warned that if lawmakers don’t handle the policy carefully, they could end up inflating overall costs, leading to higher premiums and expenses in an already costly system.

Joyce Frieden pointed out the solutions proposed by the President and hopefully most of the GOP.  President Trump announced an initiative Thursday aimed at ending the problem of surprise medical billing, in which patients undergoing procedures at in-network hospitals receive unexpectedly high bills because one or more of their clinicians was out of network.

Trump called surprise billing as I just outlined, “one of the biggest concerns Americans have about healthcare” and added, “The Republican Party is very much becoming the party of healthcare. We’re determined to end surprise medical billing for American patients and that’s happening right now.” He thanked the mostly Republican group of lawmakers who came to the White House to discuss the initiative, including Senators Lamar Alexander (R-Tenn.), Maggie Hassan (D-N.H.), Bill Cassidy, MD (R-La.), and John Barrasso (R-Wyo.) and representatives Kevin Brady (R-Texas), Devin Nunes (R-Calif.), and Greg Walden (R- Ore.).

Trump then announced guidelines that the White House wants Congress to use in developing surprise billing legislation. They include:

  • In emergency care situations, patients should never have to bear the burden of out-of-network costs they didn’t agree to pay. “So-called ‘balance billing’ should be prohibited for emergency care. Pretty simple,” he said
  •  When patients receive scheduled non-emergency care, they should be given a clear and honest bill up front. “This means they must be given prices for all services and out-of-pocket payments for which they will be responsible,” Trump said. “This will not just protect Americans from surprise charges, it will [also] empower them to choose the best option at the lowest possible price”
  •  Patients should not receive surprise bills from out-of-network providers that they did not choose themselves. “Very unfair,” he commented
  •  Legislation should protect patients without increasing federal healthcare expenditures. “Additionally, any legislation should lead to greater competition, more choice, and more healthcare freedom. We want patients to be in charge and in total control,” the president said
  •  All types of health insurance — large groups, small groups, and patients on the individual market should be included in the legislation. “No one in America should be bankrupted unexpectedly by healthcare costs that are absolutely out of control,” said Trump

He noted that “we’re going to be announcing something over the next 2 weeks that’s going to bring transparency to all of it. I think in a way it’s going to be as important as a healthcare bill; it’s going to be something really special.”

Also at the announcement was Martin Makary, MD, MPH, a surgical oncologist at Johns Hopkins University in Baltimore. “When someone buys a car, they don’t pay for the steering wheel separately from the spark plugs,” he said. “Yet, in healthcare, surprise bills and overpriced bills are commonplace and are crushing everyday folks … People are getting hammered right now.”

Trump also introduced two families who had experienced high medical bills. Drew Calver, of Austin, Texas, said that after a heart attack 2 years ago, “although I had insurance, I was still billed $110,000 … I feel like I was exploited at the most vulnerable time in my life just having suffered a heart attack, so I hope Congress hears this call to take action, close loopholes, end surprise billing, and work toward transparency.”

Paul Davis, MD, of Findlay, Ohio, said that his daughter was billed nearly $18,000 for a urine drug screening test. “She had successful back surgery in Houston and at a post-op visit, because she was given a prescription for narcotic pain relief — which she used as directed — the doctor said, ‘Oh, by the way, I’d like to get a urine specimen.’ Fine; she did it. A year later, a bill showed up for $17,850.”

He noted that her insurance company’s Explanation of Benefits said that the insurer would have paid $100.92 for the test had it been done by an in-network provider. “This type of billing is all too common … The problem of improper billing affects most [of] those who can afford it least. We must put aside any differences we have to work together to solve this problem.”

“Today I’m asking Democrats and Republicans to work together; Democrats and Republicans can do this and I really think it’s something [that is] going to be acted on quickly,” Trump said.

Healthcare groups responded positively to the announcement, with one caveat. “The AHA commends the Administration and Congress for their work to find solutions to this problem,” Rick Pollack, president, and CEO of the American Hospital Association (AHA), said in a statement. “The AHA has urged Congress to enact legislation that would protect patients from surprise bills. We can achieve this by simply banning balance billing. … Untested proposals such as bundling payments would create significant disruption to provider networks and contracting without benefiting patients.”

“ACEP appreciates the White House weighing in on this important issue and welcomes congressional action to address surprise medical bills,” said Vidor Friedman, MD, president of the American College of Emergency Physicians (ACEP), in a statement. “Emergency physicians strongly support taking patients out of the middle of billing disputes between insurers and out-of-network medical providers.”

“ACEP is concerned about the administration’s call for a single hospital bill,” he continued. “Such a ‘bundled payment’ approach may seem simple in theory for voluntary medical procedures. But if applied to the unpredictable nature of emergency care, this untested idea opens the door to massive and costly disruption of the health care system that would shift greater costs to patients while failing to address the actual root cause of surprise bills — inadequate networks provided by insurers.”

The president also mentioned another one of his administration’s healthcare initiatives. “We may allow states to buy drugs in other countries … because the drug companies have treated us very, very unfairly and the rules and restrictions within our country have been absolutely atrocious,” he said. “So we’ll allow [states], with certain permission, to go to other countries if they can buy them for 40%, 50%, or 60% less. It’s pretty pathetic, but that’s the way it works.”

And now back to Medicare. As you all probably remember the reason that physicians decided not to support the national plan was the confusion regarding reimbursement or payment to physicians. But the insurance companies as well as organized labor who opposed the compulsory system on the grounds that its passage would deprive the labor movement of an extremely effective issue with which to organize workers.

Also, with the entry of America into the First World War the interest in the passage of a compulsory health care bill waned. Because of the anti-German hysteria, the AALL bill opposition became more organized with the biased thoughts that mandatory health insurance was the product of a German conspiracy to impose Prussian values on America.

Renewed interest in mandatory health insurance didn’t emerge until during the New Deal as a consequence of the report of the Committee on Economic Security, the committee appointed by President Roosevelt in 1934. As the Depression worsened the President and his advisors were eager to offer an alternative social welfare package. Roosevelt and his advisors particularly those of the Committee on Economic Security advised the passage of a comprehensive social security system to include unemployment insurance, old-age security, and government-administered-health-care insurance.

The final report by the Committee on the Costa of Medical Care was issued in 1932, by the Committee under the chairmanship of Dr. Ray Lyman Wilbur who was the former Secretary of the Interior and former President of the AMA. The Committee actually concluded that the infrastructure in medicine as well as the medical services in the United States were inadequate and made recommendations for changes. And, despite the favorable climate especially among labor leaders, politicians and social scientists the President’s Committee on Economic Security recommender unemployment insurance and social security but not the passage of a mandatory health insurance bill.

But Roosevelt wanted to keep the subject of health insurance and therefore established an Interdepartmental Committee to Coordinate Health and Welfare Activities immediately following the passage of the Social Security Act and ordered his staff to keep the subject out there before the public. Over the next few years it was the subject of many books and extensive studies by the federal government, but no bill yet.

More to come!!