Americans worry a lot about how to get and pay for good health care, but the 2020 presidential candidates are barely talking about what’s at the root of these problems: Almost every incentive in the U.S. health care system is broken.
Why it matters: President Trump and most of the Democratic field are minimizing the hard conversations with voters about why health care eats up so much of each paycheck and what it would really take to change things.
Two courts have so far ruled against the landmark health law, finding that the individual mandate is unconstitutional because Congress stripped away the financial penalty for forgoing insurance coverage.
Without the financial penalty attached, the so-called individual mandate can no longer be considered a tax and is therefore unconstitutional, according to the courts. A lower court went even further than the appellate court and found that the entire law must fall because the mandate cannot be severed from the remainder of the ACA.
The appellate court avoided answering this key question regarding severability and sent it back to the lower court for additional analysis. The appellate court ruling generated outcry from industry, which argues the case will take years to wind its way through the courts leaving a cloud of uncertainty in its wake.
The ACA fundamentally reshaped the nation’s healthcare system and is credited with lowering the ranks of the uninsured by millions.
A coalition of blue states that stepped in to defend the law petitioned the Supreme Court to hear the case and asked for an expedited review. Meanwhile, a group of red states looking to overturn the law has argued the case does not merit intervention from the high court.
After failed attempts by Republicans in Congress to kill the law entirely, in 2017 Congress cut the penalty for not having insurance coverage to zero in a unrelated tax bill. The red states and two individual plaintiffs from Texas have argued the move renders the law unconstitutional.
AHIP argues that the ACA can stand without the penalty (and has) since Congress’ changes in 2017.
“Congress has unmistakably indicated through its actions: that the ACA should continue in operation even in the absence of the individual mandate,” AHIP said in its brief, arguing a repeal of the law would “wreak havoc” on the nation’s healthcare system.
Other advocacy groups, including AARP, American Cancer Society and Small Business Majority filed separate briefs urging the Supreme Court to take on the case. A group of bipartisan economic scholars also submitted a brief in support of the Supreme Court taking on the case.
It was always misleading. Now Democrats are repeating it.
There’s a dangerous talking point being repeated in the Democratic primary for president that could affect the survival of millions of people, and the finances of even more. This is partly my fault.
When the candidates discuss health care, you’re bound to hear some of them talk about consumer “choice.” If the nation adopts systemic health reform, this idea goes, it would restrict the ability of Americans to choose their plans or doctors, or have a say in their care.
It’s a good little talking point, in that it makes the idea of changing the current system sound scary and limiting. The problem? It’s a P.R. concoction. And right now, somewhere in their plush corporate offices, some health care industry executives are probably beside themselves with glee, drinking a toast to their public relations triumph.
I should know: I was one of them.
To my everlasting regret, I played a hand in devising this deceptive talking point about choice when I worked in various communications roles for a leading health insurer between 1993 and 2008, ultimately serving as vice president for corporate communications. Now I want to come clean by explaining its origin story, and why it’s both factually inaccurate and a political ploy.
Those of us in the insurance industry constantly hustled to prevent significant reforms because changes threatened to eat into our companies’ enormous profits. We were told by our opinion research firms and messaging consultants that when we promoted the purported benefits of the status quo that we should talk about the concept of “choice”: It polled well in focus groups of average Americans (and was encouraged by the work of Frank Luntz, the P.R. guru who literally wrote the book on how the Republican Party should communicate with Americans). As instructed, I used the word “choice” frequently when drafting talking points.
But those of us who held senior positions for the big insurers knew that one of the huge vulnerabilities of the system is its lack of choice. In the current system, Americans cannot, in fact, pick their own doctors, specialists or hospitals — at least, not without incurring huge “out of network” bills.
Not only does the current health care system deny you choice within the details of your plans, it also fails to provide many options for the plan itself. Most working Americans must select from a limited list made by their company’s chosen insurance provider (usually a high-deductible plan or a higher-deductible plan). What’s more, once that choice is made, there are many restrictions around keeping it. You can lose coverage if your company changes its plan, or if you change jobs, or if you turn 26 and leave your parents’ plan, among other scenarios.
This presented a real problem for us in the industry. Well aware that we were losing the “choice” argument, my industry colleagues spent millions on lobbying, advertising and spin doctors — all intended to muddy the issue so Americans might believe that reform would somehow provide “less choice.” Recently, the industry launched a campaign called “My Care, My Choice” aimed in part at convincing Americans that they have choice now — and that government reform would restrict their freedom. That group has been spending large sums on advertising in Iowa during this presidential race.
This isn’t the first time the industry has made “choice” a big talking point as it fights health reform. Soon after the Affordable Care Act was passed a decade ago, insurers formed the Choice and Competition Coalition and pushed states not to create insurance exchanges with better plans.
What’s different now is that it’s the Democrats parroting the misleading “choice” talking point — and even using it as a weapon against one another. Back in my days working in insurance P.R., this would have stunned me. It’s why I believe my former colleagues are celebrating today.
The truth, of course, is that Americans now have little “choice” when it comes to managing their health care. Most can’t choose their own plan or how long they retain it, or even use it to select the doctor or hospital they prefer. But some reforms being discussed this election, such as “Medicare for all,” would provide these basic freedoms to users. In other words, the proposed reforms offer more choice than the status quo, not less.
My advice to voters is that if politicians tell you they oppose reforming the health care system because they want to preserve your “choice” as a consumer, they don’t know what they’re talking about or they’re willfully ignoring the truth. Either way, the insurance industry is delighted.
I would know.
In the late 19th century, English polymath Sir Francis Galton noted that tall parents often had kids shorter than they were, while short parents often ended up with taller kids. He dubbed this regression to the mean — when something measured as extreme in a first instance is likely to be measured as less extreme later on.
That concept has important implications for health care policy today, one of which is that more health policymakers and health care researchers should use randomized evaluations to avoid problems of regression to the mean in estimating the effects of policies.
In the U.S. health care system, the very highest-cost patients — known as super-utilizers — have been a focus of attention. That is because this 1% of patients account for almost 25% of all U.S. health care spending. A spate of high-profile studies have reported dramatic reductions in health care spending from programs designed to keep super-utilizers out of the hospital through various means, such as coordinating their outpatient care and coaching them on managing their conditions and medications.
This work raises an important question: Does hospital use decline because of the programs or, due to regression to the mean, because high-use patients are likely to use care less in the future?
Several colleagues and I set out to answer that question in partnership with the Camden Coalition of Healthcare Providers. It had created a comprehensive health care delivery model that aims to meet the medical and social services needs of very high-use patients who have had at least two hospital admissions in the last six months and two or more chronic conditions, among other criteria. The coalition has been widely heralded as a promising approach for reducing costs and improving health. Dr. Atul Gawande profiled the program in the New Yorker and the coalition’s founder won a MacArthur “genius grant.”
As a data-driven, learning organization, the coalition did not want to rest on its considerable laurels. To learn what its program was doing — and innovate based on the findings — it partnered with our research team to conduct a randomized controlled trial (RCT).
We randomly assigned patients who were eligible and who consented to participate to receive either the coalition’s program or status quo care. Randomization ensured that, at the start of the program, these two groups were similar. That way, the outcomes observed in the control group would tell us what would have happened over time in the intervention group in the absence of the program.
When we looked at patients in the intervention group, the results of the Camden Coalition’s program looked very encouraging: Participants in this group visited the hospital about 40% less in the six months after the intervention. But as we report in this week’s New England Journal of Medicine, we saw the same decline in hospital use among those in the control group. These results tell us that the improvements we saw in the intervention group were the result of regression to the mean, not the coalition’s program.
These results offer an important lesson: We wouldn’t have accurately measured the intervention’s impact if we hadn’t done a randomized controlled trial.
Since we learn more from RCTs than just the impact of an intervention on a single outcome, finding no effect doesn’t mean the end of the road. In the Camden Coalition trial, our results suggest that existing systems poorly serve the complex needs of the coalition’s patients. The Camden group (and others) are now exploring models involving more complete designs for providing care.
Regression to the mean isn’t unique to health care, but it is a particularly salient concern for studies of health care programs that are often (and understandably) implemented in response to extreme signals like advanced disease, high expenditures, or excessive prescribing. Fortunately, when randomized controlled trials are feasible and ethical, they provide a way to determine the effect of a program free from concerns about regression to the mean and other biases.
Concern about excessive prescribing presents another example where regression to the mean may lead to spurious findings but where an RCT can provide clear results. The Centers for Medicare and Medicaid Services recently partnered with researchers to conduct randomized evaluations of interventions designed to curb overprescribing of Seroquel, an antipsychotic drug. The researchers found that sending strongly worded letters that compared high prescribers’ behavior to their peers’ reduced overprescribing by 11%.
We can be confident that the letters are what caused the reduction in prescribing — rather than just regression to the mean (today’s extreme prescribers are less likely to be as extreme tomorrow) — because the trial included as a randomized control group prescribers who only received standard CMS outreach.
That study also shows how we can build on and learn from any finding, whether it is positive, negative, or null. The CMS overprescribing study built on a prior randomized controlled trial which found that the original peer comparison letters CMS had been regularly sending did not reduce prescribing of controlled substances. As a result, the researchers and CMS used psychological and other research to innovate and devise a different kind of letter to be sent to a different set of providers, which then did reduce prescribing behavior.
Randomized controlled trials can be used to study programs and policies across the health care industry. In my experience leading J-PAL North America’s U.S. Health Care Delivery Initiative, which funds and conducts randomized controlled trials of health care delivery interventions, RCTs have shed light on issues such as the effectiveness of clinical decision support alerts on ordering inappropriate medical imaging and nudges to improve consumers’ choices of health insurance. And there are ongoing RCTs of many more interventions, including food as medicine, home visits by nurses, and opioid buyback programs.
J-PAL North America is part of a growing movement of health systems, payers, providers, and more that are using randomized controlled trials to test and learn, whether through evaluations of whole programs or quick process improvements. Researchers at NYU Langone Health use rapid-cycle, randomized tests aimed at quickly evaluating simple process improvements to encourage best practices. This one medical center launched 10 trials in the first year alone and hopes to launch dozens more.
Finding solutions to address the complex medical and social needs of patients is a pressing issue. Yet all too often we don’t rigorously evaluate these solutions, which hurts patients we could be helping. Randomized clinical trials are essential tools for helping us learn, adapt, and move forward on innovative solutions that make peoples’ lives better.
It looks like Kansas will become the 37th state to expand Medicaid through the Affordable Care Act, the latest breakthrough in more conservative territory for the health care law.
Democratic Gov. Laura Kelly, a moderate elected in 2018 in the anti-Trump wave driven largely by health care, and Sen. Jim Denning, the Republican leader of the state Senate announced Thursday that they had reached a deal on Medicaid expansion.
Under Obamacare, states can expand coverage to anybody with an income 138 percent of the federal poverty level or less (about $17,000 for an individual or $29,000 for a family of three) and receive a generous federal funding match.
Between 130,000 and 150,000 people are expected to be covered by Medicaid expansion in Kansas, mostly adults without children or parents currently ineligible for benefits despite living in or near poverty. Roughly 9 percent of Kansans are uninsured.
According to the AP, the agreement between Kelly and Denning includes a provision for state support to reduce private insurance premiums, to prevent people eligible for Medicaid expansion from leaving their current private plan (if they have one) to join the public program:
Denning had proposed financing his new program by increasing tobacco taxes, including a $1-per-pack increase in the state’s cigarette tax, to $2.29. His compromise with Kelly gives the state a year to develop the premium-reduction program and drops the tax increase, which Kelly and many lawmakers thought wasn’t likely to pass anyway.
It’s a relatively small concession for Republican support. An estimated 50,000 people would be expected to make the switch. The compromise notably does not include work requirements, which some other GOP-led states have sought (though they are on hold in the courts) as a condition of expansion. There will also be small premiums (about $25 a month), a provision approved in other Republican-leaning states looking to expand.
In some ways, Medicaid expansion has proven the most important part of Obamacare, covering 20 million or so people, but it has yet to reach its full potential. That’s because the Supreme Court ruled in 2012 that states must have the option to refuse to expand the program, and many Republican-led states have. About 2.5 million people, half of them in Texas and Florida, don’t have health coverage because their state has blocked Medicaid expansion.
But the number of non-expanding states has shrunk over the years, with a number of Republican states unable to refuse the ACA’s deal of more federal funding and more people with insurance. Even Vice President Mike Pence had cut a deal as governor with President Obama to expand Medicaid in Indiana. Voters in Idaho, Nebraska, and Utah have approved Medicaid expansion at the ballot box in the last few years.
Now Kansas looks like it will join the expansion ranks. Previous attempts to expand Medicaid ran up against the veto pen of a GOP governor. But Kelly’s election changed the situation.
Its decision is also a small act of defiance: Even as 20 red states and the Trump administration fight to overturn Obamacare in the courts, government leaders in Kansas are pushing to expand the law’s reach in their state to cover more people. Though the ideological battle over the law isn’t totally over, in practice, its reach is only growing.
Subpoenas have been issued to a company that solicits memberships for a health insurance alternative that offers no guarantees for covering medical bills.
New York State officials are investigating a business representing a major Christian group offering an alternative to health insurance, joining several states scrutinizing these cost-sharing programs that provide limited coverage.
On Wednesday, New York state insurance regulators issued a subpoena to Aliera, which markets the Christian ministry run by Trinity Healthshare, according to people who have seen the subpoena.
More than one million Americans have joined such groups, attracted by prices that are far lower than the cost of traditional insurance policies that must meet strict requirements established by the Affordable Care Act, like guaranteed coverage for pre-existing conditions.
These Christian nonprofit groups offer low rates because they are not classified as insurance and are under no legal obligation to pay medical claims. But state regulators are questioning some of the ministries’ aggressive marketing tactics, saying some consumers were misled or did not grasp the lack of comprehensive coverage in the case of a catastrophic illness.
Some members have paid hundreds of dollars a month, and then have been left with hundreds of thousands in unpaid medical bills in several states where the ministries, which are not subject to regulation as insurers, failed to follow through on pooling members’ expenses.
Numerous states are taking action against Aliera Healthcare, the for-profit company based in Georgia that was been the subject of an investigation by The Houston Chronicle. The Texas attorney general sued Aliera last summer to stop it from offering “unregulated insurance products to the public,” while Connecticut, Washington and New Hampshire are trying to stop Trinity and Aliera from doing business in those states.
Regulators say they are concerned that the ministry is, in fact, operating as an insurer. In New York, which has not previously investigated any ministries, there have been 15 to 20 complaints, including accusations that Aliera misrepresented the coverage being offered. It’s not clear how many customers Aliera has in New York.
“It’s deeply disappointing to see state regulators working to deny their residents access to more affordable alternatives offered by health care sharing ministries,” said Aliera in an emailed statement.
“We’re proud of the work we do to help ministries provide a more flexible method for securing affordable high-quality health care, and we will continue to vigorously defend against the false claims about our company, just as we expect the health care sharing ministries we serve to vigorously defend their members’ right to exercise their religious convictions in making health care choices,” it said.
Trinity, which was not subject to the subpoena, has said its website makes clear that the ministry does not offer health insurance.