Friday, March 15, 2019

Health Care Reform Articles - March 15, 2019


Editor's Note: 

This blog posting is unusual in that it will feature one original essay in place of a curated collection of articles from newspapers and journals. 

Henry Broeska is a medical researcher who has spent most of his life in Canada and who, during the course of his career, has dealt with both the Canadian single-payer Medicare system as well as the infinitely more complex American system of medical billing and coding. The stark contrast in the complexity of the two systems has stimulated in him a passion for health policy. 

To quote Henry "Little did I know ........ I would be in the thick of a fight that would be to get rid of all the deliberately-contrived administrative waste in US healthcare through reforming healthcare policy. I suppose you could say I went from helping to tie the Gordian Knot of US healthcare administration to slicing it in half to destroy it." 

He has written an essay about the elephant in the room we too often ignore in comparing the Canadian and American systems - the significant differences in cultural values and history between Canada and the US, that exert such a powerful effect on the healthcare politics of the two countries.  So I've decided to distribute his essay via this blog.

I'm not doing this to complicate our discussions of healthcare reform in the US, but because I believe we need to be acutely aware of and acknowledge those differences in our advocacy work.




Canadian vs. American Healthcare

by Henry Broeska - March 13, 2019

We often use Canada’s Medicare system in contrast to ours to show folks here in the US that there is a better way to do things. The Canadian healthcare system is just a few miles away from the US but it is light-years away as far as what each system values. If I can put this difference in one sentence, the US healthcare system is focused mainly on profiting on the treatment of patients, while the Canadian healthcare system’s objectives are directed toward best patient outcomes.
As this essay by Henry Broeska, a Canadian now living in the US and someone who has worked in both systems points out, Canadians believe that their healthcare system underlies their social contract with the country of Canada; that basic healthcare is an inalienable right, and that they have a guarantee of equity, access, and high standards of quality. But what Canadians seem to have understood better than Americans from the outset of their Medicare system, was that anyone who put profits ahead of what is best for patients is in conflict with those values. The thing that the American healthcare industry prizes above all else became illegal in Canada. Now in 2019, which country is better off for the values they hold?

Five Words to Remember
As a Canadian ex-pat now living in California, I have been mystified by the resistance to universal healthcare in the US. As long as I lived in Canada, the care I received under ‘Medicare’ served me and my family very well. I’m not alone. Surveys confirm that Canadians are passionately proud of their healthcare system. With the power and wealth of the United States, it’s impossible to believe that healthcare couldn’t be organized along the same lines here too. The main problem for Americans seems to be that unlike other industrialized countries, healthcare is not a public service to which Americans have a right. It’s not guaranteed under the constitution as it is in other industrialized countries. In the US, the provision of healthcare is positioned instead as a commodity. More and more Americans don’t agree with this market-based approach. As healthcare horror stories abound, there is no doubt that running healthcare the way we’ve been doing it is devastating the country. Unfortunately, The Affordable Care Act was woefully inadequate as a comprehensive solution—an ugly patch on an ugly system as Uwe Reinhardt described it.
Everywhere the indicators are flashing red: Americans are dying four years sooner than people in comparable countries; personal bankruptcies for reasons due to medical debt affects a population the size of Phoenix, AZ each year; in 2017, 276,000 more American children were added to the astounding total of 3.9 million uninsured children nationwide; key health indicators like maternal mortality and infant mortality put the US at the very bottom of the ranking of the 34 OECD countries. It goes on and on.
That’s why healthcare was the number one issue in the 2018 mid-term election and it will be the number one issue in the 2020 presidential election. Now consistently in opinion polls, over 70% of Americans want tax-funded ‘Medicare-for-all.’ Less and less a liberal or conservative issue, this demonstration of broad support indicates that the issue of healthcare cuts across party lines.
For the short number of years I’ve been involved with health policy reform advocacy in the US, the universal healthcare system ideal that everyone here is trying to achieve is one of a single payer. Canada seems to be held up as the prime example. But does that goal align to the current reality given the legislation and infrastructure that is already entrenched here in the US?
To institute single payer healthcare (also called ‘Medicare’), Canadians had to agree to a trade-off. New taxes replaced the premiums, deductibles, out-of-pocket expenses and shared costs (co-pays) that everyone was used to paying. But as each province and territory came onboard back in the early 1970s, all personal costs for basic healthcare disappeared overnight. In return, every Canadian gained access to a public healthcare system that rationalized services at a much lower cost since all of the negotiating power was in the hands of the single payer. That lower cost and equitable access to healthcare has represented Canadians’ social contract with their country ever since. Canadians went from physicians’ strikes and riots in the streets (YES…that actually happened) instigated by AMA fear-mongering, to broad consensus and unwavering popularity for their Medicare within just 2 years and ever since. Doctors said that they were better off financially under Medicare. And that, I believe, is why and where we want to go here.
The Canadian healthcare system is really 13 provincial and territorial systems governed by the federally legislated Canada Health Act of 1984. Interesting that the Act was put in place long after Medicare was already up and running. In fact the CHA strengthened and replaced legislation that was already enacted. The CHA itself was based on the over-arching premise that conditions of human need should be socialized. It finally established that healthcare would be a non-profit enterprise with service guarantees—and it’s withstood 35 years of vigorous court challenges, mostly from private companies who want to get their own piece of what is essentially the biggest business in Canada. The insurance plans administered by each province and territory must adhere to the terms and conditions of the Act in order to receive federal transfer payments under the Canada Health Transfer. This is the hammer that the federal government holds over individual provinces that are tempted to cheat by allowing extra billing or opening the door to private providers, no matter how well-intentioned their motives to shorten wait lists and expand diagnostics and therapies. So far it’s a strategy that has worked to keep the rate of healthcare inflation on par with other OECD countries. (Q: Could similar legislation in the US withstand endless court challenges given our right-leaning, 5-4 decision-making Supreme Court?)
If the US followed the Canadian model precisely, it’s possible that $1.3 trillion in wasted costs could be saved each year. But even if the administrative savings only offset the added costs at first, Americans would all do better—much better. Without coverage disruptions caused by profit-obsessed insurers or care interruptions caused by unaffordable prescription medications, Americans would be happier and healthier. The other benefits that Canadians enjoy because of their healthcare system would accrue to all Americans over time. For example, personal medical debt would be immediately eliminated just as it was in Canada. There would be lower national and state deficits, hundreds of thousands of lives saved, lower mortality rates across the board, better health outcomes for everyone, higher national life expectancies, and higher economic growth nationally (Just as an aside, I frequently knock around the idea with others that we should advocate for the concept of healthcare-for-all on the basis that it’s perhaps the most conservative of positions to take on national health policy. In Canada, even the most right-wing, conservative people I know are strongly behind Medicare for the reason that it saves money and makes Canadian industry more competitive globally).
There are two inviolable conditions that are essential for the system to work. On these this can be no equivocation or compromise. Firstly, all basic healthcare must be delivered on a non-profit basis and services provided by doctors and hospitals for basic medical care must be fully covered. To accomplish this, the single payer must assume all risks. The entire point of engaging a single payer is to avoid all intermediaries by having the payer perform adjudication and reimbursement of providers directly. Secondly, the single payer must set common rates for all medical goods and services. A true single payer plan fixes limitations or caps on what all third-party providers, pharmaceutical companies, device manufacturers, etc. can charge. Following Canada’s example, an American single payer plan must also conform to the other conditions of portability, universality, comprehensiveness, accessibility, and public administration by writing them into federal legislation. These are the tenets that were established by Tommy Douglas for Canada’s Medicare plan. The ‘public administration’ feature is particularly relevant to this discussion.
Unlike a private system in search of profits, a single payer system like Canada’s is focused on patient outcomes. The Canadian model is an important example for Americans because it symmetrically solves the three main problems inherent in the American system. Firstly, it solves the problem of universal access; there are no uninsured Canadians. Secondly, it solves the problem of runaway healthcare costs, which in the US consistently run well beyond the rate of inflation; global budgets and the ability to hold a hammer over providers in price negotiations are its main ‘under-the-hood’ features. Thirdly, it solves the problem of degraded quality, including under-insurance, now recently measured at 87 million Americans. I’ve noticed that all of the various ‘Medicare-for-all’ healthcare bills now before congress aspire to these qualities but most fall short for either ideological reasons, or for the reason that lawmakers’ opinions are corrupted by the financial influence of private companies (ie: these companies fund politicians’ re-election campaigns). Therefore the question of whether legislators can agree to establish such a system is not one of policy preferences but of politics.
The current debate in the US continues with respect to the features that define ‘Medicare-for-all.’ We are a long way from consensus. Most lawmakers assume that certain incentives will be needed so that third-party costs won’t get out of control. From the Canadian example we see that full financial control over hospitals and urgent care facilities is essential. And that full control is also enough to avoid other artificial cost-control mechanisms such as HMOs and ACOs. In the US, discussion is focused on those mechanisms that allow other third-parties to assume risks. Here’s where we get into trouble. There are no social controls over things like executive salaries, executive incentive packages and stock options paid to the CEO class, engagement with third-party suppliers, and contractors. They spend and pay themselves as they please. Nor is there a control on hospital systems that continue their ‘merger madness’ pursuits in a restriction-free financial environment. That’s a night and day difference from Canada where all hospitals are under the strict management control of the provincial health agencies and must live within their annual budget allocations (even the highest paid CEOs only make around $400k per year).
There have indeed been many recent consolidations and integrations of hospitals in Canada. But the only consideration for hospital consolidation in Canada is to enhance service distribution and prevent expensive duplications of specialized services for the benefit of taxpayers and patients alike. For example, instead of many hospitals in one region offering cardiac or orthopedic care, just one or two hospitals in any Canadian city now usually provide services in these areas. Other hospitals within that region discretely specialize in emergency care, maternity care, mental health, and so on. All residents in that region have access to any care including the specialists they need at any one of those hospitals without restriction. This consolidation/integration of services not only saves money but creates centers of excellence in those areas of care practice. The sickest and poorest patients are therefore protected by making the system both accessible and affordable. In such a scenario, American-style ‘value-based payment’ incentives through HMO or ACO middlemen are irrelevant and totally unnecessary. The answer to whether a ‘fee-for-service’ type incentive structure for physicians and hospitals is that it works very well if all of the other conditions are in place.
Unfortunately, we’re not dealing with anything close to a healthcare infrastructure that looks like Canada, nor the years of evolution it took Canada to get to what their healthcare system is now. Where once both healthcare systems were identical in almost every respect, 50 years of maturation in opposite directions has created differences between Canada and the US that can’t be easily bridged. Most of us can’t even imagine how we might get to the level of cooperative integration I’ve described. Here in the US we haven’t even agreed that conditions of human need should be socialized as part of our social contract with our country. Constitutionally-speaking, protecting our guns is far more important. Whether single or multipayer, we will end up getting resistance from every private third-party stakeholder. So let’s go through the multi-payer discussion where we’ll discover that Germany is fraught with two-tier coverage problems and not panacea by any stretch. Even they are talking about going to a more equitable system that “looks more like the Canadian healthcare system.” But whatever consensus we reach with respect to the Medicare-for-all bill we end up supporting, the alternative of not achieving universality is so much worse. Just remember the conditions that will allow the system to work; portability, universality, comprehensiveness, accessibility, and public administration. Anything less was a deal-breaker for the founder of Canadian Medicare, Tommy Douglas and these words must become our mantra too.
But whatever consensus we reach here in this working group, the alternative of not achieving universality is so much worse and that is why we do this.

Thursday, March 14, 2019

Health Care Reform Articles - March 14, 2019

Maine Voices: We’ve tried everything else – it’s time for universal health care

by Les Fossel - Portland Press Herald - March 11, 2019

ALNA — Interesting things are happening in rural Maine:
People with software jobs elsewhere are moving to Maine – but only where high-speed internet exists.
Artists, photographers, actors, musicians from away have created a sophisticated cultural economy.
A bumper crop of young farmers is moving in – the number of farmers, the acres under cultivation and the value of their product are all increasing. Farmers are now growing, processing and marketing specialty products – 30 Acre Farm and Singing Prairie Farm are good examples. This is part of the foodie revolution – note how craft breweries have gone statewide, as is increasingly true of high-quality restaurants.
Retirees are attracted to our world-class health care, cultural amenities and low living costs. Our economy benefits since they have middle-class incomes and volunteer in the community but do not strain the tax base.
These four legs can be the economic foundation for rural Maine. However, health care is facing daunting challenges:
Maine’s per capita health care costs are among the nation’s highest, but our per capita income is in the middle range. Maine’s per capita wage income is among the lowest and all the other states with the highest health care costs also have the highest incomes. That’s not us. A large portion of our population cannot afford to use our health care system. This is creating a severe financial crisis in health care.
While we like to think that quality is the same among health care providers in Maine, it is not true. The Leapfrog Group is the organization whose annual ratings are the recognized standard for comparing health care quality across America. Only seven hospitals in Maine got the award – all were small rural hospitals with higher costs. Every one of these same rural hospitals also is either in the red, or close to it.
My hospital, LincolnHealth (I’m on the board), has won the Leapfrog Award almost every year. Three years ago Consumer Reports named our hospital the safest in America. This high quality does nothing for our bottom line. Rural hospitals are merging with larger health care groups because we have no alternative. Medicare and Maine-Care reimbursements (which represent most of our revenues) don’t cover costs. We were not bought out – we joined MaineHealth in order to continue to provide world-class care.
Though most Mainers have health insurance, they don’t use it since they can’t pay the deductibles. This is why LincolnHealth’s uncompensated and charity care is so high. Further, the unaffordability crisis in Maine gets worse every year, since health care cost increases always outstrip economic growth – much like a cancer. Health care is now over 20 percent of our economy, but it should be half that. Imagine if Maine could devote those wasted health care dollars to address our real needs.
I served in the Maine Legislature on the Health and Human Services Committee. I authored some good health care legislation, but I could not address our underlying problems. I have been an employer for over 40 years. I have seen solution after solution attempted – but none has worked.
Now I am treasurer of Maine AllCare – our largest universal health care education group – because it is the only way left to control health care costs. Exporting patients to Portland or Boston just treats the symptoms of the crisis, not the underlying problems. To cut health care costs and live longer, we must root our health care in our local communities – the approach that has worked for all other First World countries.
We must pay attention to what works. Universal health care works. It is less costly and more effective. Winston Churchill once said that Americans always do the right thing – but only after they’ve tried everything else.
Well, we have tried everything else – and it doesn’t work. Isn’t it finally time we do the right thing in health care?

Medicare-for-all v. Medicare-for-less: Trump’s proposed cuts put health care at center of 2020 race

by Toluse Olorunnipa and Sean Sullivan - Washington Post - March 11, 2019

A new proposal by President Trump to slash Medicare spending puts Republicans in a political bind ahead of the 2020 election as Democrats are pitching an expansion of the popular health-care program for all Americans.
Trump’s 10-year budget unveiled Monday calls for more than $845 billion in reductions for Medicare, aiming to cut “waste, fraud and abuse” in the federal program that gives insurance to older Americans. It’s part of a broader proposed belt-tightening effort after deficits soared during the president’s first two years in office in part due to massive tax cuts for the wealthy.
The move immediately tees up a potential messaging battle between Democratic proposals for Medicare-for-all — castigated by Republicans as a socialist boondoggle — and a kind of Medicare-for-less approach. focused on cutting back on spending, from the GOP.
Democrats, including some seeking to challenge Trump in 2020, seized on the proposed Medicare cuts Monday as an example of the GOP seeking to balance the budget on the backs of the elderly and the poor after giving broad tax breaks to the wealthy.
“Make no mistake about it: Trump’s budget is a massive transfer of wealth from the working class to the wealthiest people and most profitable corporations in America,” Sen. Bernie Sanders (I-Vt.), a Democratic presidential candidate, said in a Monday tweet that highlighted Medicare cuts.
During his 2016 campaign, Trump broke from Republican orthodoxy by promising not to cut Medicare, Medicaid or Social Security. His budget, by contrast, calls for scaling back all three programs.
In states with large senior populations, such as Florida, political attacks over Medicare cuts have proved so effective that both parties have used them. Sen. Rick Scott (R-Fla.) won his seat after running ads last year accusing Democrat Bill Nelson of voting to cut Medicare.
Trump probably needs to win Florida, Arizona, Pennsylvania and other states with large numbers of seniors to secure reelection in 2020. Older Americans consistently vote at higher rates than younger Americans.
Since taking office, Trump has largely left untouched Medicare and other programs heavily used by seniors. Republicans have followed his lead, ditching previous proposals to raise the retirement age or impose other restrictions to save costs and reduce the $22 trillion national debt.
While announcing his presidential bid in June 2015, Trump said he would “save Medicare, Medicaid and Social Security without cuts.” He added that it was “not fair” to make cuts to a program that people had been paying into for many years, and that he would save it “by making us rich again” and cutting waste, fraud and abuse.
The White House said Monday that Trump’s budget, which calls for changing hospital reimbursement rates and finding savings on drug prices, does not amount to cuts for Medicare or change the program structurally.

Sen. Kamala Harris (D-Calif.), a 2020 presidential candidate, speaks during an event Saturday in St. George, S.C. She said Monday that President Trump’s proposed Medicare cuts would “hurt seniors.” (Meg Kinnard/AP)
“He’s not cutting Medicare in this budget,” Russell Vought, the acting director of the Office of Management and Budget, told reporters Monday at the White House. “Medicare spending will go up every single year by healthy margins, and there are no structural changes for Medicare beneficiaries.”
But Trump’s proposed Medicare savings are more than three times as large as those in his previous budget, and industry lobbying groups said the reductions would hurt hospitals and seniors.
“The impact on care for seniors would be devastating,” Chip Kahn, president and CEO of the Federation of American Hospitals, said in a statement. “Hospitals are less and less able to cover the cost of care for Medicare patients, it is no time to gut Medicare.”
Many prominent Democratic presidential candidates have embraced some version of a Medicare-for-all system, which would allow most Americans to be covered under the federal program.
Trump and his Republican allies had been on the offensive on health care in recent months, after several Democratic candidates struggled to answer questions about how they would pay for universal coverage and whether they would allow Americans to keep their private insurance.
“Just this week, more than 100 Democrats in Congress signed up for a socialist takeover of American health care,” Trump said earlier this month at the Conservative Political Action Conference, claiming that a Medicare-for-all plan would “take away private coverage from over 180 million Americans.”
Democratic strategists and officials argued Monday that Trump’s budget proposal exposed how little credibility Republicans have in debating health care, and showed signs of confidence that it would sharpen the contrast Democrats are seeking to make in the run-up to the 2020 election.
“It totally eviscerates any integrity to their already pretty flimsy attack,” Sen. Richard Blumenthal (D-Conn.) said. “This assault on Medicare lays bare the real Republican agenda, which is to destroy the health-care safety net. They have no shred of intellectual underpinning or integrity to their attack on Democrats if they make this kind of proposal.”
Republicans and fiscal conservatives offered tepid praise for the president’s proposal, which would not balance the federal budget until 2034. Republicans have long called for more significant changes to Medicare and other mandatory spending programs that are the biggest drivers of the national debt.
“President Trump has the right mind-set regarding his proposed budget,” said Adam Brandon, president of FreedomWorks, a conservative group. “Congress, however, needs to make entitlement reform a priority if we are to address the nation’s burgeoning national debt in the long term.”
In last year’s midterm elections, Democrats campaigned aggressively on health care, attacking Republicans over their failed effort to repeal and replace the Affordable Care Act. The dynamic marked a shift from the two previous midterm elections, during which the GOP was the party mainly going on offense on health care, slamming Democrats over the creation of the ACA, also known as Obamacare.
“On one hand, you don’t like handing the other side a potential campaign message at any point, and Democrats will inevitably try to make this into a ‘Trump wants to cut your Medicare’ argument,” Republican pollster Chris Wilson said. But Wilson argued that the plan probably would not reverberate as the ACA repeal push did. “A proposed cut to entitlements in a budget proposal that has no chance of passing the House just isn’t going to enter the public consciousness in the same way,” he added.
The latest discussions about Medicare mark a new chapter in the partisan debate. Many Democrats are eager to continue putting health care at the forefront of the national conversation. Democratic presidential candidates “should be raising this issue morning, noon and night,” said Blumenthal, who co-sponsored a Medicare-for-all proposal in the last Congress.
Democratic presidential candidates seized on Trump’s budget framework Monday, singling out the Medicare cuts.
“This budget says a lot about the President’s priorities: cut $845 billion from Medicare, while spending billions on his vanity project, the wall,” Sen. Kamala D. Harris (D-Calif.) tweeted, referring to Trump’s request for border wall funding. “This would hurt our seniors and is yet another piece of evidence for why we need a new president.”
Trump’s proposed Medicare cuts amounted to a “huge gift for Democrats,” said Dan Pfeiffer, who served as White House communications director under President Obama.
“It’s a political fumble on the Republican part in the sense that this budget is going nowhere,” he said. “The argument prior to this was the Democrats’ plan versus the status quo. And now it’s the Democrats’ plan versus the Republican plan to cut Medicare.”
Sen. Brian Schatz (D-Hawaii) said on Twitter: “One party wants to expand Medicare and Medicaid and the other wants to cut them. That’s the end of my tweet.”

Why Medicare for some is the wrong idea

by Diane Archer - The Hill - March 11, 2019

If you’re following the health care debate, you’ve already heard quite a bit about “Medicare for all,” the proposal to improve and expand Medicare, the government health insurance program for older adults and people with disabilities, to all Americans. As proposed by Sen. Bernie SandersBernard (Bernie) SandersSenate set to rebuke Trump on support for Saudi Arabia Sanders announces first staff hires in Iowa, New Hampshire Will Washington finally do something about high drug prices? MORE (I-Vt.) and others, Medicare for all provides all Americans the right to use physicians and hospitals of their choice anywhere in the country, eliminates premiums, deductibles and co-payments, and is projected to drive down national health care spending by $2 trillion to $5 trillion over the next 10 years.

For most Americans, this sounds like a pretty good idea. And it looks even better when compared against the failures of our commercial health insurance system. Commercial insurance forces Americans to spend nearly twice as much on health care as our peers in Europe and Japan for significantly worse health care outcomes. Commercial insurance creates an estimated $500 billion a year in administrative waste, enables excessive and irrational provider rates, and forces one in four Americans under 65 to forgo necessary health care because they cannot afford their out-of-pocket costs.
Nonetheless, a number of thoughtful commentators and well-intentioned politicians are telling us that Medicare for All is not a practical approach to health care reform – that it’s just not doable given the political context and the country’s long history with employer-based health insurance. These self-described “pragmatists” would offer Medicare as an additional option alongside commercial insurance, proposing a Medicare buy-in or Medicare for some.
By any measure, Medicare for some would deliver very little for the American people.  At best, it would capture a fraction of the health care savings created under Medicare for all. It would not address the unaffordable premiums, deductibles and coinsurance that keep millions of Americans from getting needed health care. And it would leave tens of millions of Americans uninsured or underinsured.
So, too, Medicare for some does not address the most basic questions about our health care system: Why do we trust health insurers to determine the doctors and hospitals we can see? Why should a knee replacement cost anywhere between $16,000 and $61,000?  Why should Americans pay twice as much for prescription drugs as our peers in Europe and Japan?  And, why should our health coverage depend on where we work?
The “pragmatists” argue that we have to live with this crazy system because Americans want “choices” in health care, and most are not willing to give up their current insurance. As a result, they say, the best we can do today is to support Medicare for some and hope for real reform in the future. However sincere or politically fashionable, this view makes no sense.
Let’s get real: Commercial insurance is the biggest threat to health care choices and our freedom to receive the health care we need. Employers choose our insurers, and the insurers restrict the providers we can use, the treatments we can receive, and the prescription drugs we can take. Every year, we can be forced to change provider networks, benefits, out-of-pocket costs and, often, insurers. If we change jobs, every aspect of our health insurance changes. And, we are left to fend for ourselves if we leave the job market.
No one loves Aetna, Anthem or any other insurance company. What we love – and what we need – is the freedom to get care from the doctors we want to see at a price we can afford. Medicare for all guarantees all Americans access to health care, with freedom to see the doctors we want, throughout our lives, wherever we live, wherever we work and whenever we are out of work. That’s about as pragmatic as it gets.
Maybe the “pragmatists” are concerned that we lack the votes in Congress to pass Medicare for all or that the commercial interests with a stake in maintaining the status quo are too powerful to overcome. That might be right. The health care industry is flush with cash, and insurers use campaign contributions to wield substantial influence in Congress. As we learned in 2009 and 2010, the health insurance industry will fight hard to retain its place in the health care system.
But fixing our broken commercial health insurance system is too important to leave to the politicians or to the insurance industry. The American people deserve a frank conversation about how we can guarantee access to health care as a right in this country. That conversation does not begin with Medicare for some.  It begins – and ends – with Medicare for all.


In Democrats’ ‘Medicare for All’ battle cry, Republicans see 2020 weapon

by Alan Fram - Portland Press Herald - March 11, 2019

WASHINGTON — “Medicare for All” has become catnip for Democratic presidential candidates and many lawmakers, yet Republicans prepping for next year’s congressional races are also flocking to it – for entirely different reasons.
Republican strategists say they’ll use proposals to expand government-run health insurance to pummel Democrats for plotting to eliminate job-provided coverage, raise taxes and make doctors’ office visits resemble trips to the dreaded Department of Motor Vehicles. If Republicans can define the health care issue on their terms – and they face significant obstacles – that would be a stunning turnabout.
“Democrats have opened the door,” Republican consultant Glen Bolger said.
Democrats made health care their defining 2018 issue as they captured the House and limited losses in a difficult set of Senate races. They denounced Republicans, who tried repealing President Obama’s health care law, for seeking to end coverage for patients with pre-existing conditions. In one monthlong stretch last fall, 6-in-10 ads backing Democratic House candidates focused on health care, according to the nonpartisan Wesleyan Media Project.
Rep. Tom Emmer, R-Minn., chairman of the House Republicans’ campaign committee, says thanks to Medicare for All, times have changed.
“We are going to associate every Democrat running with socialized medicine,” he said. “By the end of this cycle, that is going to be, to them, their pre-existing condition Waterloo.”
Republicans intend to tie the proposal to other currents in Democratic politics, including the Green New Deal for fighting climate change and talk of President Trump’s impeachment and reparations to slaves’ descendants. The goal: A narrative that Democrats are marching toward socialism and beholden to extremists.
Yet it’s unclear that Medicare for All will be the tonic Republican tacticians envision.
Elections are 21 months off and will be dominated by Trump and his Democratic presidential rivals, whatever congressional candidates emphasize. And Republicans start with a disadvantage: A November poll by the Pew Research Center found most people preferred Democrats’ to Trump’s handling of health care.
Looking to woo moderate voters, Democrats led by now-Speaker Nancy Pelosi, D-Calif., campaigned last year on an agenda that included curbing prescription drug and other medical costs. A total health care overhaul wasn’t featured.
“Nobody has to advise Nancy on the political implications of any policy,” said House Budget Committee Chairman John Yarmuth, D-Ky.
While Pelosi said in a brief interview that there will “probably” be votes on some type of Medicare for All, few expect a full-blown version to reach the House floor. Instead, committees will hold hearings while work proceeds on other measures, like curbing prescription drug prices.
“We will deliver on our promise of passing legislation to lower the costs of health care,” said Rep. Cheri Bustos, D-Ill., who heads House Democrats’ campaign organization. Medicare for All is “just one idea,” she said.
Democrats worry that Medicare for All would put candidates on the defensive in suburban swing districts, where moderate voters abound. Those districts were crucial to House Democrats’ 40-seat gain last November and will be 2020 battlegrounds.
“Do what you can to help people now, and don’t get yourself in a box on Medicare for All, which can’t pass Congress” soon anyway, advises Democratic consultant John Anzalone.
There are several Medicare for All variants. The most sweeping would replace today’s blend of private and federal health care like Medicare and Medicaid with a federally run system for everyone, likely financed by higher taxes or astronomical boosts in federal deficits.
One was introduced by Sen. Bernie Sanders, I-Vt., a Democratic presidential candidate, and co-sponsored by fellow presidential contenders Sens. Cory Booker of New Jersey, New York’s Kirsten Gillibrand, Kamala Harris of California and Massachusetts’ Elizabeth Warren. A similar House measure by Reps. Pramila Jayapal, D-Wash., and Debbie Dingell, D-Mich., has over 100 Democratic co-sponsors.
Government coverage would replace private policies and patients would pay no premiums or deductibles. The 10-year cost would be an enormous $25 trillion to $35 trillion, private estimates say, though supporters say it would cost less.
While Medicare for All polls well, the details face skepticism. A January survey by the nonpartisan Kaiser Family Foundation showed that 56 percent back the overall idea, but majorities turned against it when told it could boost taxes and eliminate private health insurance companies.
“Once you get past the bumper sticker, it doesn’t do that well. It’s got a glass jaw” when details are explained, said Jim Kessler, executive vice president of center-left research group Third Way.
Because Medicare for All is deeply popular with Democrats’ presidential contenders and galvanized liberal wing, it should remain a prominent campaign theme. That invites Republicans to wield it against Democrats whether they’re supporters or not.
“It’s hard to imagine that Medicare for All doesn’t become the banner which Democrats have to defend up and down the ticket,” said Steven Law, president of the Senate Leadership Fund, a super political action committee whose purpose is to help Republicans win more Senate seats.
In 2018, Republicans had little success accusing Democrats of backing Medicare for All. Democrats won House seats in Maine, Texas and elsewhere despite such attacks.
But in one open seat in eastern Kansas, Democrat Paul Davis lost by 1 percentage point after ads linked him to Pelosi. One spot accused them of backing “a government takeover of health care” that “could double your income taxes.”
Those ads tried tying him “to national Democrats and policies that were not going to have a great deal of acceptance,” Davis said last week.
The proposals could also fuel Democratic primary challenges, particularly in urban districts loaded with liberal voters. Activist groups like Justice Democrats, which last year backed Rep. Alexandria Ocasio-Cortez’s successful ouster of a longtime Democratic incumbent from New York City, say Medicare for All will be one test as they seek targets.
“We need Democrats fighting for big ideas and big solutions,” said Waleed Shahid, spokesman for the group.

     In New Survey Of Eleven Countries, US Adults Still Struggle With Access To And Affordability Of Health Care.

by Osborn R1, Squires D2, Doty MM3, Sarnak DO4, Schneider EC5 - Health Affairs - December 2016


Surveys of patients' experiences with health care services can reveal how well a country's health system is meeting the needs of its population. Using data from a 2016 survey conducted in eleven countries-Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States-we found that US adults reported poor health and well-being and were the most likely to experience material hardship. The United States trailed other countries in making health care affordable and ranked poorly on providing timely access to medical care (except specialist care). In all countries, shortfalls in patient engagement and chronic care management were reported, and at least one in five adults experienced a care coordination problem. Problems were often particularly acute for low-income adults. Overall, the Netherlands performed at the top of the eleven-country range on most measures of access, engagement, and coordination.

California Man Learns He's Dying From Doctor on Robot Video

by Associated Press - NYT - March 8, 2019

Wilharm figured the visit was routine. She was astonished by what the doctor started saying.
"This guy cannot breathe, and he's got this robot trying to talk to him," she said. "Meanwhile, this guy is telling him, 'So we've got your results back, and there's no lung left. There's no lung to work with.'"
Wilharm said she had to repeat what the doctor said to her grandfather, because he was hard of hearing in his right ear and the machine couldn't get to the other side of the bed.
"So he's saying that maybe your next step is going to hospice at home," Wilharm is heard saying in a video she recorded of the visit. "Right?"
"You know, I don't know if he's going to get home," the doctor says.
Steve Pantilat, chief of the palliative medicine division at University of California, San Francisco, said he doesn't know the details in the case but that the robot technology has done wonders for patients and their families, some of whom are too far away for in-person visits.
The video meetings are warm and intimate, he said, adding that not all in-person discussions have empathy and compassion.
"No matter how well we deliver very difficult news, it's sad and it's hard to hear," he said.
Wilharm said her grandfather, a family man who kept every childhood drawing he ever gave her, deserved better. She said that after the visit, he gave her instructions on who should get what and made her promise to look after her grandmother.
"He was such a sweet guy," she said.

Trump Administration Targets ‘Secretive Nature’ of Health Care Pricing

by Robert Pear - NYT - March 8, 2019

WASHINGTON — Attacking “the secretive nature of pricing in the health care market,” the Trump administration said this week that it wanted to require public disclosure of the rates that doctors and hospitals negotiate with health insurance companies.
“Patients have a right to price information” before they receive care, the administration said.
Disclosure of the wildly different prices paid by insurers for the same services in the same market would probably incite competition and “drive down health care prices,” the administration said in soliciting comment on its idea.
The concept, set forth Monday in the Federal Register and reported by The Wall Street Journal, is not a formal proposal, but rather a first step toward a possible proposal, clearly signaling the direction in which President Trump wants to go.
Price transparency has been a hallmark of health policy under Mr. Trump. In a country that spends more than $3.5 trillion a year on health care, administration officials say, it is absurd that consumers cannot shop for medical goods and services as they shop for airline tickets and electronic gear.
“There is no more powerful force than an informed consumer,” Alex M. Azar II, the secretary of health and human services, has often said, exhorting health care providers and insurers to “become more transparent about their pricing.”
It was not immediately clear whether the price disclosures contemplated by the White House would directly benefit consumers shopping for a knee replacement operation or the delivery of a baby at a hospital.
“Price transparency is desirable,” Robert Weissman, the president of Public Citizen, a consumer group, said on Friday. But, he said, the disclosure requirement described by the Trump administration “won’t make any difference in the experience of individual patients or for the health care system over all.”
What consumers want to know is what they will have to pay, and that is not the same as the reimbursement rates negotiated by doctors, hospitals and insurers, Mr. Weissman said.
In a similar vein, the administration has proposed requiring pharmaceutical companies to disclose the list prices of prescription drugs they advertise on television, even though consumers often pay less. And the administration has required hospitals to post the list prices for all of their services. Consumers say the data, posted online in spreadsheets for thousands of procedures, is often incomprehensible — a hodgepodge of numbers and technical medical terms.
In its latest proposal, the administration asked if health care providers could be required to disclose the “negotiated rates” for all of the insurance plans with which they do business.
Thomas P. Nickels, an executive vice president of the American Hospital Association, said this was “a radical idea, requiring the disclosure of privately negotiated rates between two parties in a contract.”
Moreover, Mr. Nickels said, it would be impractical because a hospital may have contracts with a dozen insurers, and each insurer may have four or five different health plans with different terms.
The new initiative to require disclosure of price information came in an unusual way, slipped into the preamble to a proposed rule promoting the exchange of information stored in electronic health records. In 2009, Congress provided money to foster the adoption of electronic records, but health care providers cannot always communicate with one another when they use technology made by different vendors.
Economists say health care markets are opaque and frustrate consumers who want to shop for the best value.
Martin Gaynor, a professor of economics and health policy at Carnegie Mellon University in Pittsburgh, said it was possible shining sunlight on the rates paid to doctors and hospitals could put pressure on the industry to lower prices. But in some places, hospitals have market power and can raise prices without losing customers to competitors.
“If you are the only hospital in town, any insurer will have to have you in its network,” Mr. Gaynor said. “The fact that prices are public will not change that.”
The Trump administration said that its plan could reduce huge, inexplicable differences in prices.
In Minnesota, it said, insurers pay as much as $47,000 and as little as $6,200 for a total knee replacement operation. For a total hip replacement, payments have ranged from $6,700 to $44,000.
Reimbursement for a typical vaginal delivery of a baby ranged from $2,900 to $12,300 in one study of Minnesota markets, while C-section deliveries ranged from $4,700 to $22,800.
The American Medical Association and America’s Health Insurance Plans, a lobby for insurers, said they needed more information about the administration’s plan before they could formulate a response.
A research report by securities analysts at Jefferies L.L.C. said the plan faced legal hurdles. “Contract details between managed care organizations and health care providers are covered by confidentiality clauses, so forcing hospitals to post negotiated prices will require hard-to-achieve legislative action,” they wrote.

Drug Costs, in the U.S. and Abroad

A reader points to lower prices in Europe and Mexico.
LTE by Anne Marie O'Connor - NYT - March 13, 2019

To the Editor:
Viewed from abroad, the kind of markup described in “How High Prices Inflate C.E.O.s’ Pay,” by William Lazonick and Oner Tulum (Op-Ed,, Feb. 26), seems like inhumane gouging at the expense of the vulnerable ill.
My generic asthma bronchodilator inhaler, which could save my life, cost me more than $100 at American pharmacies. I moved to Mexico, and the same inhaler cost me $4. In London, it costs me just over $9, and in Spain — where it is manufactured — about $2.60.
What accounts for the American markup? Greed and profit. Who loses? The low-income American children and adults whose asthma could be an easily managed condition, if medication prices did not make it a huge burden.
We are witnessing a large transfer of wealth to already rich Americans, and our inhumane for-profit medical system is playing a shameful role in it. Drug companies still make big profits in Europe, even in countries where prescription drug prices are collectively negotiated by national health systems to benefit their citizens.
Anne-Marie O’Connor

Friday, March 8, 2019


Health Care Reform Articles - March 8, 2019

Medicare For All Can Begin In 2021: Here’s How

by Billy Wynne and Alyssa Llamas - Health Affairs - February 28, 2019

While Democratic presidential candidates and the newspaper headlines hash out the ideological nuances of a Medicare-based single payer coverage scheme, work is underway to consider how coverage can be expanded to those in need within a realistic timeframe at minimal cost or disruption to the existing system.

Even if we stretch to assume that Democrats, much less the broader public and any Republicans, can coalesce around a unified vision of what “true” Medicare for All would look like, history and political demands suggest that other priorities will capture their attention and expenditure of political capital should the party gain control of the White House and Senate in 2021. After all, they spent the first year and a half of President Obama’s first term drafting and passing the Affordable Care Act (ACA), and eight years hence paying the political price for it.
Instead, through use of existing authority under section 1332 of the ACA and the Center for Medicare and Medicaid Innovation (CMMI), states could begin opting in to a Medicare fallback option that will help expand coverage and stabilize existing markets. If deemed necessary and viable, modest statutory changes could be included in a reconciliation package (oh yes, it’s coming…) to strengthen and broaden the long-term horizon for such a plan. More importantly, legislation has already been introduced that points to how the program could be designed and implemented under current law.
Bills introduced by Senators Michael Bennet (D-CO) and Tim Kaine (D-VA) as well as Senator Debbie Stabenow (D-MI) provide a roadmap to how a Medicare fallback plan could be implemented.
In the Medicare-X Choice Act of 2017, Senators Bennet and Kaine propose allowing individuals to purchase a Medicare-like plan through the ACA Exchanges if their county has one or less plan options currently available in that marketplace. A Medicare-X plan would be available in all Exchange markets, including for small businesses, shortly after that.
They recognize that some mechanical changes would be necessary to institute such a program. For example, benefits offered would need to be expanded to cover essential health benefits required by the respective participating states. Premiums would need to be set by CMS using local market factors and ensuring that the actuarial value of the plan and administrative costs are covered. They would also include enrollees in the Medicare-X plan in their respective Exchange risk pools to ensure costs and benefits for existing Medicare beneficiaries are not impacted.
Senators Bennet and Kaine include some policy changes for Medicare-X however that we believe are unnecessary and, because they will create new bureaucratic and political burdens, are probably ill-advised at this point. (Editor's Note 1)
For example, requiring CMS to negotiate drug prices and adopt new payment models (beyond the numerous approaches already being implemented) will likely expand the playing field of opposition and complexity that could jeopardize enactment.
Senator Stabenow’s Medicare at 50 Act also provides some framework for how a Medicare fallback option could be implemented. While her bill limits coverage expansion to those between 50-64 and does not require enrollment via the Exchanges, it specifically applies premium and cost-sharing subsidies available via the Exchanges to Medicare buy-in enrollees and allows for enrollment in Medicare Advantage (MA) plans that include prescription drug coverage.
Here, as elsewhere, to facilitate adoption of this ambitious but limited program, it will be vital to maintain existing policies whenever possible. We undermine ourselves when we get jazzed about designing wholly new coverage systems (and bureaucracies).
So, in sum, we propose the following core components of the plan:
  • Enrollees in Exchange markets with one or no plans currently available would be allowed to purchase a traditional Medicare or MA plan with drug coverage currently available in those areas, with wrap-around coverage included to ensure compliance with state essential health benefit requirements. Additional Exchange markets could be added after initial testing on this more limited basis, a la the Bennet-Kaine bill.
  • Medicare providers participating in Medicare or in applicable MA plan networks would be included and paid at existing Medicare or relevant MA rates.
  • Premiums would be based on a combination of the actuarial value of the plan and the local Exchange market, as other Exchange plans are. Premium and cost-sharing subsidies would be identical to those offered in the Exchanges today.
That’s about it folks. No fancy bells or whistles, just offering the current Medicare program in uncompetitive Exchange markets. Pencils down.
Now the admittedly trickier part: demonstrating that the program can be implemented via a combination of existing ACA section 1332 waiver and CMMI authority.
Under the ACA, section 1332 waivers allow states to test innovative approaches to coverage so long as they insure as many people as the ACA regime would with the same or more generous coverage and at the same or less cost (in a nutshell). One way to leverage this authority could be to suggest that most individuals who elect the Medicare fallback option would have otherwise enrolled in an Exchange plan and that, by leveraging Medicare provider rates and reduced administrative costs, their premiums would be lower, thereby reducing Federal subsidy expenditures. The Congressional Budget Office took this view in its 2013 analysis of a potential public plan in the Exchange markets.
Luckily, however, Mr. Trump and his Administration have set such a strong precedent for “creative” reinterpretation of these waivers that such economic gymnastics won’t be necessary. In this age of tit-for-tat politics, we are happy to take their ball and run with it to expand quality coverage at relatively low cost.
Naturally, the Trump Administration’s interpretation of section 1332 waivers flexes them in the opposite direction of what we’re suggesting here, i.e., they are allowing states to reduce coverage and limit benefits. For example, under their guidelines, states need only make available coverage options that are as comprehensive as those under the ACA and need not demonstrate that those comparable plans will actually be purchased.
The essential health benefits requirements for such waivers don’t even have to be the actual requirements already elected by that state. They just need to be any benefit package the state could theoretically design. States are then free to offer alongside that token coverage other options that do not meet ACA standards for benefits, preexisting condition protections, etc. Swell deal.
In assessing cost, the new 1332 wavier standard looks at the “aggregate effects of the waiver” and that deficit neutrality take into account “all changes in income, payroll, or excise tax revenue” as a result of the plan. Waivers that include access to noncompliant ACA plans like association health plans and short-term limited duration plans will be viewed “favorably.”
We think you get the point. Section 1332 waivers today are a long way from home. By applying a lesser degree of deviation from the underlying law than the current Administration, new Medicare fallback option waivers could comfortably be approved in 2021.
While less pivotal, ACA authority afforded to CMMI would permit CMS staff to expend the time and energy necessary to facilitate modification of existing Medicare and MA plan options to meet the new fallback plan requirements. Federal regulation of these plan options would be loosely comparable to those applied to employer group waiver plans (EGWPs), which are essentially MA plans with modest modifications to meet the needs of that market.
CMMI authority allows for pilot programs that maintain or reduce expenditures under the applicable program while maintaining or enhancing the quality of care delivered. It is focused primarily on Medicare, though participation by other payors is encouraged. The Medicare fallback option is consistent with this goal by improving the quality of care delivered to the un- and underinsured, and progress toward that end would be assessed via the same metrics currently deployed for Medicare and MA plans. Deficit neutrality requirements would be met by accurately embedding administrative costs into the fallback plan premiums. No other Medicare-related costs would be incurred because the fallback option would be funded by a combination of premiums and Exchange subsidies.
CMMI also has the authority to extend permanently and expand the geographic area encompassed by such pilot programs if they prove effective in meeting their quality and cost goals. Section 1332 waivers assume the programs would be permanent.
To demonstrate how this plan could work immediately, we suggest examining the market in Colorado, which happens to be home to one of us as well as one of the Medicare-X plan’s lead sponsors, Senator Michael Bennet. It also has a newly elected governor, former Congressman Jared Polis, who won handily on a platform that included implementing Medicare for All in the state. Both chambers of the legislature are controlled, with some room to spare, by Democrats.
According to the Colorado Department of Regulatory Agencies, for 2019, consumers in 14 of the state’s 64 counties only have access to a single insurer. Essential health benefits the state has adopted that are not currently covered by Medicare include routine eye exams, vision care, maternity care, well baby visits, dental care, and a few other services. It is not hard to see how this program could be implemented in Colorado with relatively streamlined administrative burden, so long as the state and federal government stay disciplined in adhering to the core, necessary components.
In addition to the traditional Medicare benefit being offered statewide, 51 MA plans are available from ten insurers in Colorado, with 95 percent of Medicare beneficiaries in the state having access to MA. On average, a beneficiary can choose from 19 plans offered by five insurers. In other words, there is ample competition in the vast majority of areas. In 2018, 36 percent of Medicare beneficiaries in Colorado were enrolled in an MA plan, a portion and trend that reflects the programs rising popularity nationwide.
Consistent with Billy Wynne’s five-part series, we believe it is a serious mistake, from coverage expansion, consumer satisfaction, and political viability perspectives, for Democrats to deny the full range of Medicare coverage options to any new program claiming the Medicare for All mantle, as the single payer bill recently introduced by Congresswoman Pramila Jayapal (D-WA) and over 100 other House Democrats would do. We want to actually get this done, right?
While it’s imperative to be honest about legal and regulatory requirements, not to mention political and other practical barriers, it’s also necessary to be aggressive and perhaps a bit shameless in utilizing all existing pathways to expanding coverage and bringing down health care costs. Enough is enough and, in this case, it starts with Democrats.
Let’s not cannibalize each other over relatively minor ideological differences that won’t actually have much impact on coverage, quality, or cost. Let’s look at the policy and political reality before us, such as it is in this relatively conservative of developed nations, and initiate a Medicare fallback option that will bring coverage and cost relief to millions immediately without sabotaging equally important efforts to address the manifold challenges we face.

Editor's Note:

Here is a link to an "interview" of PNHP President Adam Gaffney by a gang of five Fox Business "News" talking heads. Apparently they thought it would take five of them to take on Dr. Gaffney.

Very informative:

US should transition to single-payer health care system: Dr. Adam Gaffney

by Fox Business News - March 1, 2019


The following clipping from Don McCanne's "Quote of the Day" is a worthwhile and thought provoking essay. The authors, from the Hasting Center (a bioethics research center) points out the differences between "patients" and "consumers", and the misguided efforts to conflate the two, part of the concerted effort to portray a professionally managed public service as a business.

Well worth the time it will take to read it.


Patient-Centered Care, Yes; Patients As Consumers, No 

1Michael K. Gusmano, Karen J. Maschke and Mildred Z. Soloman - Health Affairs - March, 2019


There are numerous calls for building health care delivery systems that are more patient centered. The focus on patient-centered care has increasingly begun to rely upon, and even merge with, the concept of patients as consumers. Early references to patients as consumers were made by patient advocates who were attempting to challenge professional and corporate dominance in health care. Today, “consumer-driven” health care has become associated with neoliberal efforts to emphasize market factors in health reform and deemphasize government regulation and financing. In our view, a narrow focus on consumerism is conceptually confused and potentially harmful. The consumer metaphor wrongly assumes that health care is a market in the usual understanding of that term, that the high cost of US health care is a function of excessive consumer demand, and that price transparency and competition can deliver on the promise of reducing costs or ensuring quality. Furthermore, a consumer metaphor places disproportionate burdens on patients to reduce health care costs, and it could erode professional obligations to provide appropriate and effective care.


Building a health care delivery system that is more patient centered has a lengthy history, including powerful grassroots efforts beginning in the 1960s. These initiatives see patient-centered care as an important means of improving health outcomes and a morally worthy good in itself. As a means to an end, patient-centered care includes efforts to make the care delivery system more efficient and easier for patients to navigate. Patient engagement—a particular form of patient-centered care—yields better, well-documented outcomes by stimulating patients to take on more active roles in promoting and maintaining their health. As a moral end in itself, patient-centered care emphasizes the importance of honoring patients’ values and preferences, and it is less paternalistic and more respectful. Although there are concerns about how the concept might be misapplied, there is broad support for it, evidenced by federal investment in studying how best to ensure patient-centered outcomes and patient-centered outcomes research.

Increasingly, however, the focus on patient-centered care has begun to rely upon, and even merge with, the concept of patients as consumers. In this article we call for greater vigilance in distinguishing patient-centered care from the concept of consumer-driven health care. Too often consumer-driven health care is used as if it were a synonym for patient-centered care. We argue that consumer-driven care is based on critical myths about what creates, and what can rein in, high-cost care. Moreover, the consumer-driven concept can easily place the burden for systemwide cost containment on the shoulders of individual patients. In this article we offer a brief history of the patient-centered care movement, demonstrate how the language of patient-centeredness is becoming appropriated by those advocating market reforms, and then articulate why the consumer metaphor is misguided and potentially harmful.

Origins of the Patient-Centered Care Movement

In contrast to the early use of these terms to connote ways of empowering patients, consumer driven and consumerism are now associated with market-oriented health reforms that place a burden on patients to solve cost and quality problems. These consumer terms function as metaphors that represent conceptual confusion and are potentially harmful. The terms wrongly assume that health care is a competitive market and that the high cost of US health care is a function of excessive consumer demand. Because these requisite assumptions are not met, the metaphor’s remedy—price transparency and competition—cannot deliver on the promise of reducing costs or ensuring quality. Moreover, it is misleading to use consumer driven, defined in this narrow sense, as a synonym for patient centered. A consumer metaphor could also erode obligations by policy makers and health care systems to build a truly patient-centered care system.

Health Care Is Not a Market

Patients can be construed as consumers only if they are operating within a market. But health care is not a market in the usual way that markets are defined, and thus patients do not have the power that consumers have to shape that market. Patients are not as well informed as physicians are about medical care. Often patients do not have well-formed preferences, and they seek care under circumstances in which they do not have the time or emotional stamina to shop around on the basis of quality and price. And if policy makers treat health care like any other market, there will likely be very limited cost savings, if any, and huge inequities will continue and likely increase. As Nancy Tomes puts it, “this linguistic transformation has come to represent the worst consequences of American medicine’s growing market orientation.

The High Cost of US Health Care Is Not Due To Excessive Consumer Demand

Policy makers in the US frequently act as if the main problem is excess volume, which in turn arises from excess patient demand. Because most patients in the US have some form of health insurance, they are insulated from the full cost of health care. Some commentators are concerned that there is a potential moral hazard, because insurance provides patients with an incentive to consume health care beyond the point at which marginal benefit equals marginal cost.

More than just a technical term, moral hazard is a concept that is normatively loaded. It suggests that health care spending is the result of policies that offer an incentive for bad behavior.

Moral hazard concerns suggest that the use of expensive hospitalizations, surgeries, and other interventions are shaped primarily by ability to pay. This perspective fails to recognize that most people consume such services only reluctantly. The use of these services is often driven by providers, not by patients. Indeed, academics and policy makers have expressed concern for decades about the reliance of the health insurance system on fee-for-service payments to physicians, hospitals, and other health care providers. Fee-for-service provides an incentive for physicians to deliver additional and more complex services than patients need (or more care than economists would view as efficient) because health care providers receive an additional payment for every additional service—and services that are viewed as more technically complex generate higher fees. In most countries outside the US, however, “provider-driven” demand is not countered by shifting costs to individual patients and asking them to control costs by acting as informed consumers in a marketplace. Instead, most countries rely on a combination of overall budget targets for health care services and systems of all-payer rate regulation in which national health insurance funds negotiate rates for hospital, physician, and other services with representatives from those professions. Because the US does not use the negotiating power of government to confront the power of providers, it pays higher prices for all medical goods and services than other countries do.

Not only is the use of market competition limited when it comes to asking patients to make efficient decisions about health care services and providers, but it also does not work well when it comes to making decisions about health insurance plans. Competition among health plans in the Medicare program was promoted as a method for reducing the costs of the program, but Medicare Advantage has not produced the intended savings. In fact, there has been some examination of choices made in Medicare Part D, suggesting that consumers do not necessarily make choices in their own best interests: Beneficiaries fail to select plans that provide better risk protection at lower cost. These findings are consistent with earlier work on choice overload and Medicare beneficiaries’ selection of health plans. The findings led economist Paul Krugman to exclaim that “‘consumer-based’ medicine has been a bust everywhere it has been tried.

While it is wise to help patients make more informed decisions about the costs of care and to grow in their ability to make quality comparisons across health systems, the main driver of health care costs is not consumer demand, but rather the introduction of new technologies and unwillingness on the part of US political leaders to regulate prices—or at least use government bargaining power as leverage to negotiate lower prices. The US relies on a system of uncoordinated payment by thousands of payers, many of which do not have the bargaining power necessary to drive down prices. This has resulted in high prices for medical services. Technological improvements in health care have driven increases in cost all over the world, but extraordinarily high prices and a refusal by government to regulate them or bargain them lower differentiate the US from other countries.

The Consumer Metaphor Could Erode Health Care Professionalism

Medical professionalism requires independent, discretionary judgment. Professionals do not simply do as they are told or requested but must act on the basis of knowledge, skill, and fiduciary obligations to patients’ well-being.

Hospitals must judge each case to find the right balance between patient and family preference and physician integrity. It seems reasonable to anticipate that as the consumer metaphor grows, physicians’ authority in these kinds of cases could erode to the point where they may become technicians doing what they are asked to do, but doing so against their own consciences.

Professionalism may also erode if physicians are more inclined to offer unproven treatments simply because patients demand them. If the customer is always right, self-restraint on the part of providers could erode. 


After four decades of organized patient advocacy, US patients are still struggling to influence the health care decisions and policies that shape their lives. Conflating consumer approaches with authentically patient-centered approaches will exacerbate this gap. In health care delivery and health policy, a patient-centered approach affirms the ethical principles of respect for persons and justice while striving to make the health system more responsive to patients’ values and preferences. There are some patient-centered approaches, such as patient engagement and activation, that yield substantial improvements in health outcomes. Pursuing the sensible goal of creating a patient-centered health system will be undermined if consumer metaphors prevail. It is important for policy makers and health system leaders to be vigilant in distinguishing between these seemingly similar, but different, approaches. Patient-centered approaches aim to ensure clinical care that can meet patients’ preferences and needs. That is different from a consumer orientation calling on patients to be prudent purchasers of medical care services. The former approach empowers patients. The latter expects patients to solve society’s cost-containment challenges.

At least 25% of diabetes patients rationing insulin as drug costs continue to skyrocket

by Walter Einenkel - Daily Kos - February 28, 2019

One of the many hopes of a Medicare-for-all program is that in giving our government a larger share of the medical “market” (for lack of a better term), Americans—collectively—will be able to negotiate down the skyrocketing costs of medicine. Every day brings tragic stories of Americans young and old, of all racial backgrounds, dying after rationing their insulin—the result of explosive increases in the costs of the drug. While some people’s diabetes treatments have risen from $24 to $80 per vial over the past decade, others face much more prohibitive prices. As diabetes patient Alec Raeshawn Smith’s mother told NPR in September, her son’s monthly bill for insulin and related supplies was around $1,300 without insurance—something he and his family could not afford. He died, having most likely been rationing a lifesaving medication he could not afford.
These aren’t outliers. According to a study by Yale University researchers, 1 in 4 people with diabetes are rationing their prescriptions. This is not a new phenomenon, but one that is getting worse with the continuing rise in drug costs.
The most severe cost of insulin deprivation is death, but people who survive with diabetes have to deal with the stresses brought about by rising and falling blood sugar levels. These can include passing out, losing one’s ability to control their temper, nausea, and dizziness. A woman recounted to the New Yorker’s Amanda Schaffer how she and her sister, who both have Type 1 diabetes, have shared and rationed their insulin due to its rising costs. It’s something that has driven her life, leading to her dropping out of college her first year: “I lost a lot of weight that year, about twenty pounds. When you don’t have insulin, you can’t eat much because you can’t correct your blood sugar. So I was barely eating. I was supposed to take four to five shots of insulin a day, and I was only taking two to three. I was lethargic all the time. I was rationing just so I could live. I knew if I ran out I wouldn’t survive more than a few days. That took a mental toll.”
The solution is cheaper insulin. The problem, as Audrey Farley writes in the Washington Post, is that many people are hoping that older types of cheaper insulin are the solution—they just need to go to Walmart! The problem with using older forms of insulin is that the level of planning for adults and children can be unrealistic, as the older, slower-acting forms must be taken well in advance of eating meals. The costs of older, slow-acting insulins may be less, but the possibility of error on the part of patients is much higher. When Trump breaks his campaign promises about lowering drug prices, he’s not simply being a corrupt liar—he’s complicit in our growing public health crises.

Drugmaker will offer half-price insulin in wake of debate over rising drug costs

by Thomas Mulier - Bloomberg - March 4, 2019

Eli Lilly's move is one of the first by a major drugmaker to offer a cut-price version of a major product, and could put pressure on other pharmaceutical companies to do the same.
Drugmaker Eli Lilly & Co. will offer a half-priced version of its blockbuster insulin, becoming one of the first companies to effectively cut the price of a top-selling drug amid the ongoing U.S. debate over pharmaceutical costs.
While it will continue selling its brand-name version at the existing price, Indianapolis-based Lilly will also sell a half-cost “authorized generic” for $137.35 a vial, or $265.20 for a five-pack of injectable pens. That will give a better deal to customers who pay cash, or who are in insurance plans that make them pay a percentage of a drug’s list price.
Insurers and PBMs don’t typically pay the listed prices for drugs, and instead negotiate discounts and rebates that can help lower premiums as a whole, but that can result in large out-of-pocket costs for some patients on costly medicine or who have chronic conditions that force them to take treatments year-round.
“The significant rebates we pay on insulins do not directly benefit all patients. This needs to change,” Lilly Chief Executive Officer David Ricks said in a statement announcing the move. “We hope our announcement is a catalyst for positive change across the U.S. health-care system.”
Lilly’s move is one of the first by a major drugmaker to offer a cut-price version of a major product, and could put pressure on other pharmaceutical companies to do the same. Mylan faced a similar outcry over the price of its EpiPen allergy shot, and in 2016 announced a lower-cost authorized generic. But such moves have been rare, even as drug CEOs have been called before Congress and faced frequent criticism from both political parties.
There are millions of people with diabetes in the U.S., and insulin has become a particular flashpoint for the debate over the cost of drugs. Lilly, Novo Nordisk A/S and Sanofi last month were sent letters by a Senate committee asking how they set insulin prices, and Sanofi CEO Olivier Brandicourt was among the pharma bosses who headed to Washington last month to testify on drug costs.
Shares of Novo Nordisk, the world’s biggest maker of insulin, fell as much as 2.8 percent after Lilly’s announcement.
Lilly, Novo and Sanofi all heavily discount the price of many of their diabetes medications, and there is typically a wide difference in the list and net prices.
Sanofi’s CEO said in his testimony that the average net price of Lantus, the company’s most prescribed insulin, has fallen by more than 30 percent since 2012, yet out-of-pocket costs for patients with commercial insurance and Medicare have increased about 60 percent. In an emailed statement, Sanofi said it has a competing version of Humalog, called a biosimilar, that it sells under the name Admelog. The company said it also offers a variety of discount programs for patients.

Sorry, ER patients. People with elective procedures get the hospital beds first.