Category Archives: Health Policy

Trump’s health care focus puts GOP on edge

Posted on by • Posted in 2020 Election Issues, ACA, Health Policy, Transparency • Leave a comment

Trump’s health care focus puts GOP on edge

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President Trump has put the issue of health care back on the political front burner, providing ammunition to Democrats and worrying Republicans who think a new battle over ObamaCare will hurt their party in next year’s elections.

Senate Republicans, defending 22 seats next year, thought they had put ObamaCare repeal behind them when they told Trump earlier this year that they have no intention of acting on a health care overhaul before the election.

But Trump threw the issue back at them in an interview with ABC News that aired Sunday, saying his administration will unveil “something terrific” to overhaul the nation’s health care system “in a month.” He argued that action is needed because “ObamaCare has been a disaster.”

Republican lawmakers have little idea of what to expect and say there hasn’t been communication from the administration on the issue.

“All the members of Congress thought it had subsided and hope that it continues to be subsided,” one senior GOP aide said.

“We don’t actually agree with each other on what replacement should be, which means we don’t have a replacement that Republicans can unite around,” added the aide, who called Trump’s remarks a “political gift for Democrats.”

Speaker Nancy Pelosi (D-Calif.), signaling she likely agrees with the GOP aide, released a statement Monday denouncing Trump’s plan and saying Democrats would “fight relentlessly” against it.

“The American people already know exactly what the president’s health care plans mean in their lives: higher costs, worse coverage and the end of lifesaving protections for people with pre-existing conditions,” she said.

Senate Majority Leader Mitch McConnell (R-Ky.) offered a cautious take, stating of Trump in an interview with Fox News that “we’re looking forward to seeing what he’s going to recommend.”

McConnell added that there’s no chance Congress will act on anything Trump proposes until after next year’s election.

“The problem in the Senate and the House is the Democrats control the House. Se we can’t pass what we would like to do,” he said in an interview on “Fox & Friends.”

McConnell has told colleagues he wants to play offense by making the 2020 health care debate about Democrats’ calls for a single payer “Medicare for All” system. Trump’s move makes that more difficult.

“Democrats would much rather say, ‘Republicans are trying to take away ObamaCare and are trying to repeal the law on preexisting conditions’ and not make it about Medicare for All,” the GOP aide said.

Senate Minority Leader Charles Schumer (D-N.Y.) also took a shot at the president, saying Trump had repeatedly promised but failed to provide a “magic health care plan.”

“It never comes out,” Schumer tweeted. “Instead they just keep trying to sabotage your health care and suing to end protections for pre-existing conditions.”

The administration filed a legal brief in May calling for an appeals court to strike down all of ObamaCare. This represented a switch, first revealed in March, days after special counsel Robert Mueller’s report was filed with the Department of Justice, from the administration’s earlier position that only portions of the law should be struck down.

Many Republicans were caught off guard by the administration’s legal brief, which was widely seen in GOP circles as a mistake.

Republicans in the Senate, rather than focusing upon repealing the health care law, have sought to work on bipartisan legislation to lower health care costs.

Senate Health, Education, Labor and Pensions Committee Chairman Lamar Alexander (R-Tenn.) last month introduced a bill with Sen. Patty Murray (Wash.), the ranking Democrat on his committee, to address surprise medical billing and improve transparency for drug pricing.

In a statement last week, he emphasized the bipartisan nature of the proposal.

Separately, Senate Finance Committee Chairman Chuck Grassley (R-Iowa) is working with Sen. Ron Wyden (Ore.), the top-ranking Democrat on his panel, on legislation to cap seniors’ prescription drug expenses under Medicare.

Polls show why Republicans are nervous about ObamaCare.

A Wall Street Journal-NBC News poll published earlier this month showed that 24 percent of respondents nationwide think health care should be the federal government’s top priority, and Democrats lead Republicans on the issue by 8 points.

Democrats also won back the House majority last fall largely by talking about health care and the GOP’s failed effort to repeal ObamaCare.

“It’s been a loser of an issue for them,” said John Weaver, a GOP strategist who previously worked for former Ohio Gov. John Kasich (R) and the late Sen. John McCain (R-Ariz.). “In the last cycle it was one of the main causes for them losing the House.”

Some Republicans on Capitol Hill are skeptical about whether the White House will come out with a detailed health care plan and suspect that Trump’s latest comments may be more motivated by the desire to signal to his conservative base that he hasn’t given up on repealing ObamaCare.  

“The president and congressional Republicans have two fundamentally different political views on health care — not substantive views but political views. The president thinks any health care reform, repeal and replace, is a win and goes into his column and helps him and the Republicans,” said Vin Weber, a Republican strategist.

Weber said the GOP’s best strategy going into 2020 is “attacking the Democrats for being too far to the left, and the Democrats are giving them ammunition.”

McConnell in April said the key to GOP success in 2020 is to make the election “a referendum on socialism,” while Weaver on Monday said Republicans would like Trump to simply focus on the economy.

“You think he would be focused on the economy,” Weaver said. “Republicans have no credibility when it comes to health care.”

He called Trump’s renewed health care push “politically irresponsible.”

 

Efforts to save new moms clash with GOP’s Medicaid cuts

Posted on by • Posted in 2020 Election Issues, Block Grants, Health Policy, Maternal Mortality, Medicaid, Safety-Net Providers, Underinsured, Uninsured, Vulnerable Populations, Womens Health • Leave a comment

https://www.politico.com/story/2019/06/14/new-moms-clash-gop-medicaid-cuts-1364564

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The push to address the soaring U.S. maternal morality rate is colliding with a broader, more ideological public health imperative: Republican-led efforts to scale back Medicaid.

The safety net program pays for half of all births in the nation. Democrats and many public health experts see it as a natural vessel for slowing the death toll of pregnant women and new mothers, by extending care in the crucial year following childbirth.

But concern over the potentially staggering cost has already quashed efforts in states such as Texas and left liberals in Congress glum over the prospects for a nationwide legislative fix.

“Medicaid represents the best of America and the administration’s effort to gut it would be a massive step backwards on confronting America’s maternal mortality crisis,” Sen. Elizabeth Warren (D-Mass.) wrote in an email.

The dynamic mirrors the federal response to the opioid epidemic, in which Republicans and the Trump administration support making addiction services more available while simultaneously working to shrink Medicaid, the largest single payer of behavioral and maternal health care.

Research has shown the risk of death after childbirth persists for a full year, from such factors as heart disease, stroke, infections and severe bleeding. Black and Native American women are about three times more likely to die from a pregnancy-related cause as white women, according to the Centers for Disease Control and Prevention.

Warren, along with fellow 2020 Democratic presidential contenders Sens. Bernie Sanders, Cory Booker and Amy Klobuchar, back extending Medicaid’s current requirement to cover new mothers from 60 days to one year after childbirth. Democratic proposals in the Senate from Dick Durbin of Illinois, and in the House, from Reps. Robin Kelly of Illinois and Ayanna Pressley of Massachusetts would do that along with provide states grants to improve hospital deliver practices, among other things.

But the efforts aren’t yielding GOP buy-in across the country, as conservative lawmakers keen on shrinking the program press for narrower fixes, such as increased data collection on deaths and a national standard of best medical practices. Proposals to enhance Medicaid coverage to address maternal mortality haven’t attracted a single Republican co-sponsor in Congress, with both sides at loggerheads on whether to grow or shrink the entitlement program.

“All mothers must have access to adequate care before and after delivery, and we should provide states with the tools and flexibility they need to ensure coverage of their most vulnerable populations,” Sen. John Cornyn (R-Texas) told POLITICO.

A Republican aide said GOP lawmakers are focused on getting a better picture of how many pregnant and postpartum women actually need coverage before exploring how to expand access to care. “That is a laborious process to undertake as we have to talk to both the states, stakeholders, and CMS to discern what coverage gaps exist. And we need to know the role other sources of coverage play as well,” the aide said.

Democrats say the prospect of expanding Medicaid benefits scares Republicans in an era of pitched partisan battles over health policy.

“Following the ACA and repeal Obamacare debates, health care, especially Medicaid experience, has become a hot issue — not quite a third rail but definitely hot and our GOP counterparts are a little squeamish,” a Democratic aide working on the issue said.

President Donald Trump last year signed a maternal care measure that directed millions of dollars in new spending to help states collect data on maternal mortality, but has been mum on extending Medicaid coverage to new mothers. His administration will weigh whether to allow Missouri to use its Medicaid programs to offer extended coverage to mothers struggling with addiction — but not the broader Medicaid population.

Meanwhile, the administration is aggressively pursuing an overhaul of Medicaid, finalizing proposals to allow states to apply for block grants that cap program spending and approving requests to condition benefits on work. The administration’s separate efforts to overturn Obamacare would also jeopardize federal subsidies that low-income mothers use to purchase coverage.

The focus on maternal mortality is driven by rising trend lines showing about 700 women die each year due to pregnancy related conditions a rate that’s more than doubled over the last three decades. About a third of the fatalities occur between one week and one year postpartum, according to a recent CDC report, putting the U.S. behind other developed countries for maternal health. And 60 percent of maternal deaths are preventable, with African American women and other minorities disproportionately affected.

Researchers studying the pattern say that extending Medicaid coverage would provide comprehensive benefits for chronic health conditions like heart disease, which accounts for a quarter of maternal deaths.

“The postpartum period is such a period of vulnerability,” said Houston physician Lisa Hollier, immediate past president of American College of Obstetricians and Gynecologists and chair of Texas’s Maternal Mortality and Morbidity task force. “The transition time [from pregnancy to full recovery] is one when we see unmet health needs.”

Obamacare helped boost coverage for new mothers. The uninsured rate for women who reported giving birth in the past year fell to 11.3 percent in 2016 from 19.2 percent in 2013 according to a study in Health Affairs.

The gains in states that expanded their Medicaid programs under Obamacare were especially pronounced, with the uninsured rate among new mothers falling 56 percent compared with 29 percent in non-expansion states.

But the Republican-led push to dial back Medicaid expansion has put a spotlight on controlling spending across the entire program.

Some states are exploring alternatives. Missouri’s Department of Social Services this month intends to ask the Trump administration for a waiver that would allow it to offer Medicaid coverage to postpartum women struggling with substance abuse for one year after they give birth. The move would cover about 1,500 of the 24,000 women in the state whose benefits lapse 60 days after childbirth.

The state’s Republican-controlled legislature endorsed the idea last year after killing a broader expansion of Medicaid benefits to postpartum women.

In Texas, where 382 women died within a year of giving birth between 2012 and 2015, Republican Gov. Greg Abbott this week downplayed the state’s maternal mortality rate on Twitter and said that the state was already doing enough to deal with the issue.

Last month, legislators opted to develop postpartum care services within an existing state program geared towards family planning, which will cost about $56 million over five years, instead of extending Medicaid for 12 months, which carried a five-year price tag of nearly $1 billion in state and federal funds.

Kay Ghahremani, the state’s Medicaid director disputes the cost analysis, saying it would actually save money in the long run by promoting wellness and averting potential emergencies.

“It’s the most important thing we can do for maternal health in this state,” said Ghahremani, now president of the Texas Association of Community Health Plans. “We don’t want to see a single mom die from things that are avoidable.”

 

The drug pricing debate is stuck in the past

Posted on by • Posted in 2020 Election Issues, ACA, Biologics, Biosimilars, Competition, Food and Drug Administration (FDA), Gene Therapy, Generic Drugs, Generic Entry, Health Policy, High Drug Prices, High Prices, Highly Specialized Drugs, Limited Competition, Out of Pocket Expenses, Patent Protections, Precision Medicine, Preexisting Conditions • Leave a comment

https://www.axios.com/drug-pricing-debate-stuck-in-past-10ba315e-0ddf-4013-8c5a-f8ee89c2f530.html

Illustration of falling pills and coins

There’s a scientific and economic revolution happening in medicine, and the political debate over drug prices isn’t keeping up. Not only are policymakers struggling to agree on solutions, they’re mostly talking about yesterday’s problems.

Why it matters: Medical innovation is already hurtling toward a new era of highly specialized drugs — some are even tailor-made for each individual patient. They may be more effective than anything we’ve seen before, and also more expensive. But the drug-pricing debate is more focused on decades-old parts of the system.

The big picture: “We haven’t really contemplated how we’re going to absorb some of these things,” Food and Drug Administration Scott Gottlieb said. “These are good problems to have…but they are policy challenges.”

Where it stands: Congress is mainly squabbling over proposals to reduce prices by boosting competition — by making it easier to start developing generics, or by changing patent protections that help pharmaceutical companies keep their rivals at bay.

Yes, but: Those regulatory tools were designed for a world in which pharmaceutical companies develop relatively simple drugs and try to market them to a big group of people. But science is rapidly moving away from that world.

  • Gene therapy, for example, is the new wave in cancer treatment. It helps patients’ own immune systems fight off cancer — which means each dose is custom-made for each patient. It’s a highly promising approach, but treatment can come with a price tag north of $1 million once all is said and done.
  • The old dichotomy of a brand-name pill followed by a generic version of that pill doesn’t really hold up for custom-made drugs.
  • So tools that try to promote competition simply may not work as well. “I don’t think they’re solutions for gene therapies because I think you’re ultimately going to have to figure out ways to capitalize those costs,” Gottlieb said.

Even without being custom-made, many new drugs are still trying to treat smaller groups of patients — like people with the same specific genetic mutation.

  • “Generic entry might not prove to be as successful for addressing this problem as it has historically been, and I think it’s because we fundamentally have shifted into these other types of products where competition is just more challenging,” Vanderbilt’s Stacie Dusetzina said.

Most of these new drugs belong to a class known as biologics. They’re more complex than the drugs we’re used to, and therefore have the potential to be more precise in the way they interact with your body.

  • “The way drugs are produced and made now is quite different from the way they were produced and made in the early ‘80s, and that’s both because…you have a lot of these drugs being made for small populations, and for biologics the science is so much more complicated,” said Rachel Sachs, a professor at Washington University.
  • Biologics don’t have traditional generic versions; the equivalent are products known as “biosimilars.”
  • The Affordable Care Act created a pathway for the FDA to approve biosimilars, but that market has been slow to take off, and at least in the early going, biosimilars often don’t offer the same steep discounts as traditional generics.

Promoting competition isn’t the only idea in the world, but more muscular price controls are much more controversial.

  • Most of these new, complex drugs are administered at a doctor’s office, not picked up from a pharmacy. The Trump administration has proposed tying Medicare’s payments for that class of drugs to the lower prices that other countries pay, and Democrats support direct Medicare price negotiations.

The bottom line: “One version of ten years from now will have very limited competition in certain types of markets, either because the market has eroded it to be that way or because the drugs that are coming out will by definition have limited competition,” said Rena Conti, a professor at Boston University.

 

 

 

On the Doorstep With a Plea: Will You Support Medicare for All?

Posted on by • Posted in 2020 Election Issues, Employer-Based Health Insurance, Grass Roots Support, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, High Deductible Health Plans, High Premiums, Human Rights, Labor Union, Out of Pocket Expenses, Preexisting Conditions, Public Option, Single Payer Health System • Leave a comment

Art Miller listened patiently as the stranger on his doorstep tried to sell him on the Medicare for All Act of 2019, the single-payer health care bill that has sharply divided Democrats in Congress and on the presidential campaign trail.

The visitor, Steven Meier, was a volunteer canvasser who wanted Mr. Miller to call his congresswoman, Abby Finkenauer, the young Democrat who took a Republican’s seat last year in this closely divided district — and press her to embrace Medicare for all. Beyond congressional politics, there was the familiar role that Iowa plays as the first state to weigh in on the fight for the Democratic presidential nomination.

“I want to know how my grandkids are going to pay for it, O.K.?” Mr. Miller, 71, mused, peering at the flier that Mr. Meier had handed him.

It was a fairly typical encounter for Mr. Meier, 39, who with hundreds of volunteers around the country is working with National Nurses United, the country’s largest nurses’ union, to build grass-roots support for the single-payer bill, a long shot on Capitol Hill and a disruptive force in the party. House Democrats have declared this Saturday and Sunday to be “a weekend of action on health care” — but they are split over whether to embrace extreme change or something closer to the status quo.

A single-payer health care system would more or less scrap private health insurance, including employer-sponsored coverage, for a system like Canada’s in which the government pays for everyone’s health care with tax dollars. Democrats not ready for that big a step are falling back on a “public option,” an alternative in which anyone could buy into Medicare or another public program, or stick with private insurance — a position once a considered firmly on the party’s left wing.

Lawmakers like Ms. Finkenauer, mindful of the delicate political balance in their districts, fear the “socialism” epithet that President Trump and his party are attaching to Medicare for all. On Friday, Mr. Trump called the House bill “socialist health care” that would “crush American workers with higher taxes, long wait times and far worse care.” But even Ms. Finkenauer, who beat the incumbent Republican in November by 16,900 votes, has been pulled left by the debate, embracing the public option, which could not get through Congress when the Affordable Care Act passed in 2010.

“In a divided Congress, I’m focused on what we can do to bring immediate relief to Iowans,” she said in an email.

The nurses’ union and a number of other progressive groups want nothing less than a government system that pays for everyone’s health care, seizing on the issue’s prominence and a round of Medicare for all hearings in the House with canvassing in the districts of many of the 123 House Democrats who have not thrown their support behind a single-payer system.

“Hearings are a moment for us to have a national stage for this campaign,” Jasmine Ruddy, the lead organizer for the nurse union’s Medicare for all campaign, told several dozen new volunteers on a training call last month. “It’s up to us to take advantage of the momentum we already see happening and turn it into political power.”

But building support for a single-payer health care system has been slow going. On Wednesday, the chairman of the Ways and Means Committee, Representative Richard E. Neal of Massachusetts, convening the House’s third Medicare for all hearing, said it was about “exploring ideas.”

Republicans warned darkly of sky-high tax increases, doctor shortages and long waits for care. Representative Kevin Brady of Texas, the senior Republican on the committee, said his constituents were “frightened” about their private coverage being “ripped out from under them.”

The nurses’ union campaign began just after Democrats won the House in November, when the union and several other groups held a strategy call with Representative Pramila Jayapal, Democrat of Washington, the chief author of the Medicare for All Act, and Senator Bernie Sanders of Vermont, who pushed Medicare for all into the mainstream during his 2016 presidential campaign.

“Rather than try to convince people it’s the right system,” Ms. Ruddy said, “our strategy is to reach the people who are already convinced that health care is a human right, to bring them in and actually make them feel the action they are taking matters.”

In Dubuque, Mr. Meier and his partner, Briana Moss, have knocked on 250 doors and gathered about 50 signatures over the past few months. About 20 volunteers, including a retired nurse and several college students, are also involved. Nationwide, canvassers have knocked on 20,000 doors and collected 14,000 signatures since February.

On a Saturday afternoon, Mr. Miller, a Vietnam veteran, told Mr. Meier about his positive experience with government health care through the Department of Veterans Affairs, saying, “I’ve seen how it can work.”

A few houses down, a woman who owns a cleaning service and would give only her first name, Sharon, and her party affiliation, Republican, said that if the bill covered abortions, “I won’t go for that.”

She added that she would be happy to stop paying $170 a month for supplemental insurance to cover what Medicare does not, but she did not want to see people who do not work receive free care. From the garage, her husband hollered that he agreed. Conceding defeat, Mr. Meier and Ms. Moss moved along.

Both Sanders supporters, they took on the cause in part because Ms. Moss has Type 1 diabetes and has struggled on and off to stay insured, though now she has Medicaid under the Affordable Care Act’s expansion of the program. Ms. Moss, 30, went to see Ms. Finkenauer in her district office this year and asked if she supported a government system that eliminated insurance. Ms. Finkenauer, she said, stated her preference for a public option.

“That’s simply a compromise that leaves the insurance companies still in the game,” said Mr. Meier, who recently started working at John Deere building backhoes and will soon have employer-based coverage after being uninsured for his entire adult life.

The Jayapal and Sanders bills would both expand traditional Medicare to cover all Americans, and change the structure of the program to cover more services and eliminate most deductibles and co-payments. There would effectively be no private health insurance, because the new system would cover almost everything; Mr. Sanders has said private coverage could be sold for extras like cosmetic surgery.

While polling does show that Medicare for all has broad public support, that drops once people learn it would involve raising taxes or eliminating private insurance. That finding bewilders Mr. Meier, given many of the conversations he has on people’s front steps.

Those conversations keep coming. Rick Plowman 66, complained bitterly about how despite having Medicare, he had to pay nearly $500 for inhalers to treat his chronic obstructive pulmonary disease. Still, he was skeptical.

“I just don’t know what it’s going to look like down the road,” Mr. Plowman said. “Even Social Security for kids, you know? Even for you guys?”

“I’m willing to start making that sacrifice right now,” Mr. Meier pushed back. Mr. Plowman signed the petition.

At a white bungalow around the corner, Mr. Meier found — finally — that he was preaching to the choir with Bobby Daniels, 50, and his wife, Andrea, 46. Mr. Daniels, a forklift operator from Waterloo, said their coverage came with a $3,000 deductible and he would “most definitely” support Medicare for all. Ray Edwards, 36, an uninsured barber, also heartily signed on.

At the final stop of the day, Mr. Meier and Ms. Moss encountered Jeremy Shade, 36, a registered Republican who promptly told them his sister lived in Canada and had spent “hours and hours in the hospital, waiting for care” under that country’s single-payer system.

“I get that concern, and it’s something I’m worried about, too,” Mr. Meier said as Mr. Shade’s dog barked. “Would you be interested in maybe just calling Abby Finkenauer and saying, ‘Hey, what are we doing about the health care problem in this country?’”

“My wife would,” Mr. Shade said, explaining that she was a Democrat. “I’m real wary about it.”

Two hours of hot canvassing amid swarms of gnats had yielded six petition signatures and a few pledges to call Ms. Finkenauer. Mr. Meier was determined to end on a positive note. “I really think health care could be the issue that could get people to stop being so on one side or the other,” he said, a point that Mr. Shade accepted, shaking his hand before retreating inside.

 

 

 

Healthcare consolidation goes beyond usual players

Posted on by • Posted in 2020 Election Issues, Antitrust, Barriors to Entry, Competition, Federal Trade Commission (FTC), Health Policy, Market Consolidation, Market Power, Monopoly, Monopoly Behavior • Leave a comment

https://www.modernhealthcare.com/mergers-acquisitions/healthcare-consolidation-goes-beyond-usual-players?utm_source=modern-healthcare-daily-finance&utm_medium=email&utm_campaign=20190610&utm_content=article1-readmore

Consolidation in the health system and health insurance industries has been a focus for years. But a new report sheds light on how the “bigger is better” mantra has taken hold in companies that make syringes, X-ray machines or other healthcare products.

The report, prepared by the Open Markets Institute using data from IBISWorld, shows a small handful of companies dominate their respective markets in certain healthcare sectors that tend to get less of a spotlight than their payer and provider counterparts. The largest three pharmacy and drugstore companies represent 67% of market share and the largest two ambulance manufacturers represent 83% of market share. Just two dialysis providers dominate 76% of market share.

Open Markets has released data on monopolization in other sectors of the economy, and Phil Longman, the group’s policy director, said with healthcare approaching 20% of the U.S. gross domestic product, it’s important to direct attention there, too.

“Pretty much anywhere you go in this economy, whether it’s eyeglasses or beer or automobiles or airplanes, if you ask the right questions, you’ll find it’s much more concentrated than it was before,” he said. “That’s true in healthcare, including all of its component parts.”

Pharmacy benefit management draws $453.4 billion in revenue, according to the report, and just four companies hold three-quarters of its market share: CVS, Express Scripts, UnitedHealth and Humana. The four largest healthcare consulting firms represent 76% of their sector, which draws $6 billion in revenue.

Two companies, LabCorp and Quest, have 37% of diagnostic and medical laboratory market share, a $52.6 billion industry, the report said. And three of the largest medical patient financing companies, Synchrony, Citigroup and Wells Fargo, make up 77% of that market, which draws $4.1 billion in revenue.

The report highlighted consolidation across several different healthcare manufacturers, including those that produce hospital beds, surgical apparel, PET imaging, pacemakers and wheelchairs. Three firms own 88% of the $10.6 billion orthopedic products manufacturing sector: Stryker Corp., Zimmer Holdings and Johnson & Johnson.

Healthcare in the U.S. costs more than in other countries because the prices are higher, Longman said. That’s almost always because there is a barrier to entry that thwarts competition. Longman noted that health systems typically purchase the supplies they need, from bed sheets to bandages, from group purchasing organizations.

“That adds up to serious money,” he said.

One of the factors driving consolidation across these subsectors of healthcare is the continued decline in government and commercial health insurance reimbursement for medical products and services, which puts the squeeze on the associated costs like equipment and doctor’s fees, said Beth Everett, managing director of healthcare banking and head of middle-market healthcare with MUFG in New York. Consolidation may help achieve healthcare cost reduction by creating economies of scale, she said. Whether this ultimately happens is “the million-dollar question,” Everett said.

Greater consolidation and integration in the healthcare system is widely recognized as necessary for improving patient care, Longman said. But it should come with some means of regulation to ensure the benefits of the resulting efficiencies go to the consumer. In this case, that hasn’t happened, and monopolistic corporations are holding the benefits of greater scale, efficiencies and coordination of care rather than passing them along.

“We’ve just really mismanaged competition policy in healthcare,” Longman said.

 

Drivers of Health, a New Project

Posted on by • Posted in Health Policy, Social Determinants of Health • Leave a comment

Drivers of Health, a New Project

Image result for social determinants of health

There is broad consensus that the U.S. spends too much on health care. Some feel that we would be better served by investing more on factors outside of the health system that affect health — so-called social determinants of health.

However, we lack reliable evidence to indicate where and how much to invest. Should we spend more on education or on the environment? Housing or nutrition? While there have been attempts to quantify the contribution of various factors to health, most have significant methodological limitations and do not incorporate more recent evidence.

As part of a Robert Wood Johnson Foundation-funded project, my team and I have organized a series of workshops to consider these questions. The first meeting “Refining the Question, ‘What Affects Health?” will be held on Monday, June 17, 1-5:15pm at the Weston Princeton in Princeton, NJ. David Cutler and Paula Braveman will speak about the wide range of factors that influence health and engage with the project’s committee — led by Ashish Jha and Sherry Glied — and others in attendance who wish to contribute. Details and registration on the DriversOfHealth.org website. Please RSVP and attend!

I would greatly appreciate it if you would share this invitation and project with anyone you think may be interested — your department, students, and other colleagues, friends, family, neighbors, etc.

Also, please explore, share, and revisit our project website, which includes an interactive (and more interactives to come), ways to engage on the project’s topics, and a blog that we will add to every week.

The Drivers of Health: What makes us healthy?

Posted on by • Posted in Access & Quality of Healthcare, Causation, Centers for Disease Control & Prevention (CDC), Correlations, Education, Environment, Gender Identity, Genetics, Health Behaviors, Health Policy, Household Structure, Income/Wealth, Interventions, Marginal Effects, Occupation, Outcomes, Racial Indentity, Social Circumstances, Social Determinants of Health, Social Support & Isolation, Timespan • Leave a comment

The Drivers

 

What makes us healthy?

We have an intuitive sense that things like what we eat, how much we exercise, the quality of our water and air, and getting appropriate health care when sick all help us stay healthy, but how much do each of these factors matter?

Studies have also shown that our incomes, education, even racial identity are associated with health — so-called “social determinants of health.”

How much do social determinants matter? How much does the health system improve our health?

In the 1970s the Centers for Disease Control and Prevention tried to answer these questions but had little rigorous science to guide it. Though we know a great deal more today, they still have not been fully answered. This is no mere curiosity — knowing what makes us healthy will help us direct investments into the right programs.

Over the years, many frameworks have been developed to illuminate what affects health. The relationships are so complex that no single framework captures everything. To get us started on this research project — and our broader conversation about what drives health — we created a model that allows us to explore some of the dimensions of these drivers, and their relationships to each other.

The Framework

We developed our framework by reviewing research on factors that influence health and surveying similar projects and tools from prominent organizations . It is not meant to be complete, but a starting point that allows us to think about what drives health and how.

Indirect vs. Direct Factors
Many things affect health, some directly and others indirectly. Government/policy, income/wealth, education, and racial identity don’t necessarily affect health in an immediate way. They are indirect factors that tend to affect health through complex pathways. Those pathways usually involve other factors that more immediately affect health. These are the direct factors such as occupation, health care access, and health behaviors.

Why these Outcomes?
There are many possible health outcomes. The framework includes four examples—age-adjusted mortality, life expectancy, quality of life/well-being, and functional status. These outcomes are commonly studied, prevalent in the literature, and reflect the kinds of things people care most about.

The Drivers

Government/Policy
A wide range of government policies can affect health. For example, in 2007, Australia became the first country to introduce a government-funded human papillomavirus (HPV) vaccination program. For years later, significantly lower levels of HPV were present in the population. As another example, studies show that Medicaid expansion in the US facilitates access to care and improves self-reported health outcomes. Policies outside the health system can affect health too. Those pertaining to deportation of undocumented immigrants and same-sex marriage have been linked to health outcomes, for example.

Income/Wealth
Income and wealth are associated with health, but through complex pathways. While income and wealth facilitate access to health care, food, and housing, it’s also true that good health facilitates labor force participation, potentially leading to higher income. Several studies suggest that income and resources have profound effects in early life and development, but a much smaller effect on adults.

Education
Evidence suggests that education has a causal effect in reducing mortality. Among all age groups, every additional year of school is associated with increased self-reported health status.

Racial Identity
Racial Identity is closely associated with health outcomes in the US. For example, African-American adults experience much higher levels of mortality than white adults, from all causes. Racial Identity also plays a role in the accumulated stress from discrimination and in the quality of health care received.

Gender Identity
Evidence suggests that gender identity plays a role in health and health care. For example, one study found that women with angina pectoris and low socioeconomic status were referred to cardiologists less frequently than men.

Genetics
Genetics play a role in the development of certain disease. For example, while cancer is not caused by genetics, most cancers have some genetic determinants. The BRCA1 and BRCA2 genes play a role in tumor suppression, and, when mutated, increase the risk of female breast, ovarian, and other cancers.

Environment
Environmental factors — natural and built — have profound effects on our health. Of course, factors like air quality affect our health, evidenced by a study that demonstrated an association between higher levels of air pollutants O3 and PM2.5 and pediatric pneumonia. Environmental conditions even before birth (present during fetal development) can affect health and well-being into adulthood.

Medical Care
Medical care is designed to facilitate good health, so both the quality of medical care and access to it influence our health outcomes. One study found that the medically uninsured receive 20% less care after auto accidents and have significantly higher mortality rates than people who are insured.

Health Behaviors
Health behaviors encompass a wide range of human behaviors that affect health including: physical activity; diet; sleep; and tobacco, alcohol, and other substance use. Just as one example, reducing exposure to tobacco has been identified as the single biggest way to prevent morbidity, disability, and early death.

Social Circumstances
Social relationships can affect mental and physical health as well as behaviors and mortality risk. The people we are surrounded by (at an early age, parents, and later in life, peers and romantic partners) strongly influence health through mechanisms of stress, social support, and pressure to engage in or avoid risky behaviors.

Occupation
Occupation is linked to health outcomes, and may both cause health due to the conditions of the job, and be caused by health due to the limitations particular to certain conditions.

Let’s Dig Deeper

Historical vs. Current, Marginal Effects
When attempting to quantify the impact of direct health-related factors, it is important to make a distinction between how much of our current health is related to these factors versus how much of our current health can be improved by interventions that target particular factors. Grasping this distinction is critical so that we know where our dollars are best spent to maximize health improvement. In other words, how much have each of these factors affected our health in the past through today versus how much could they affect health in the future if policy was immediately changed? For example, a disease like smallpox has a huge direct effect on health outcomes, but it has essentially been eradicated, so an additional investment in eradicating smallpox has virtually no marginal gains, even though the disease is closely linked to health.

Timespan
It is also relevant to consider the timespan on which we see certain effects taking place, especially when considering policy intervention. For example, with an environmental change such as improving the air quality, it would take a significant amount of time for all measurable changes in health outcomes to manifest; other interventions, such as dramatically increasing flu vaccination rates, could have significant health outcomes that would be observable on a much shorter timescale.

Correlations vs. Causation
Considering the available literature on social determinants of health and the links between these factors and measurable health outcomes, it is critical to clarify whether what we are observing or seeking is a correlation or causation. Correlations can guide hypothesis generation, but only causation is actionable in terms of policy.

Interventions
Finally, it is worth considering how a framework like this relates to policy intervention. The specific interventions that might be effective within a category (e.g., health behaviors) could change over time. For example, promotion of wearing motor vehicle seat belts was an important area for policy interventions in the 1970s and 1980s, but is less so now because doing so has become commonplace. Though health behaviors remain relevant to health today, the class of interventions that would have the largest impact are different.

 

 

 

 

Health system cost-effectiveness

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Health system cost-effectiveness

How much value do we obtain per dollar spent on the health system? How has that changed over time? How does it compare across countries? These are tough but important questions.

To explore them, this chart is worth close study. It’s an updated version of one that appears in this 2017 Lancet article by Reinhard Busse, Miriam Blümel, Franz Knieps, and Till Bärnighausen. It represents how much health systems reduce mortality per dollar spent.

Let’s unpack it. Seven countries are represented: US (red, labeled “USA”), Denmark (yellow), France (dark green), Germany (light green, labeled), United Kingdom (red), Switzerland (blue, labeled), Canada (grey). For each country, about a dozen points are plotted, roughly 2006 – 2016 (some start in 2005 and some end in 2015).

Each plotted point represents a year — earlier years are toward the upper left, later ones toward the lower right. And each point, for each country, conveys how many lives were lost that could have been saved by the health system and how much is spent by the health system.

Specifically, the horizontal axis is per capita health spending, in US dollars and adjusted for purchasing power (meaning a dollar equivalent of another currency buys the same amount of goods and services as a US dollar does in the US). All else held constant, one would prefer to spend less on health care, so movement to the left along the axis is preferred.

The vertical axis is amenable mortality per 100,000 people, for those under 75 years old. That is, it’s the number of 0-74 year olds that die per 100,000 due to factors that they health system can address with accessible, timely, and effective health care. All else held constant, one would prefer fewer deaths, so movement downward along the axis is preferred.

With that in mind, points more to the left and further downward are to be preferred than points upward and to the right. That’s because they imply fewer deaths for less money. I don’t care what your values are, you should always prefer less death at lower cost. I’ll let you conclude from that what to make of US health care spending relative to that of any other country represented.

There’s another way to look at this chart, though. Just focus on one specific country— let’s take Germany. As the years passed, Germany (and every other country) spent more on health care. How much reduction in death did it achieve as it did so? The spending is more efficient the greater decrease per dollar. In other words, the steeper the downward slope of a country’s line, the more efficiently it is investing in health care.

Relative to other countries depicted, Germany has a moderately steep downward slope. From about 2010-2015, Denmark’s slope is the steepest shown—vast improvements in mortality per dollar spent. Switzerland’s really flattens out in recent years, indicating very little gain for a lot more spending.

Now look at the US. Recently, it’s line has sloped a tad bit upward. More spending and more death. That’s the worst deal of all.

 

 

 

 

 

Wonky Supreme Court Ruling on Medicare DSH Formula to Affect More Than Money

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Moving forward, the government will have to complete notice-and-comment rulemaking for a broader set of its decisions.

KEY TAKEAWAYS

Monday’s decision by the Supreme Court kicks the dispute back to the District Court level. What happens next is unclear.

Beyond the money at stake, this case increases the rulemaking burden on HHS and CMS, though the extent of that burden is disputed.

Hospitals that treat high numbers of low-income patients secured a big win this week at the U.S. Supreme Court.

Seven of the justices agreed that officials in the U.S. Department of Health and Human Services stepped out of line when they rejiggered a Medicare reimbursement formula for disproportionate share hospitals (DSH) five years ago without a formal notice-and-comment process.

The decision carries implications well beyond the money hospitals say they are owed.

“It’s a big deal for the hospitals, obviously,” says Helen R. Pfister, JD, a New York–based partner with Manatt Health.

By the government’s estimates, the dispute implicates $3-4 billion in payments over nine years. That’s how much more the Centers for Medicare & Medicaid Services would have paid in DSH reimbursements, had the formula not been changed, according to court records.

“But I think it’s also a big deal in terms of the fact that the Supreme Court has clearly indicated that, going forward, CMS is going to have to do notice-and-comment rulemaking for a much more expansive set of agency decisions than they thought and argued in this case that they would need to do,” Pfister adds.

Precisely how much of the routine work completed by HHS and CMS will be affected by this broader take on notice-and-comment rulemaking remains to be seen. While some stakeholders have raised concerns the added burden could stifle the government’s work, others contend any inconvenience imposed will be both manageable and beneficial.

In any case, the impact of Monday’s decision will flow along two distinct paths, affecting not only hospital finances but also, for better or worse, the way HHS and CMS operate.

What’s Next, Procedurally?

In 2016, nine hospitals led by Allina Health Services lost their case against HHS at the U.S. District Court in D.C., where a judge ruled that notice-and-comment rulemaking wasn’t required. In 2017, however, three judges at the D.C. Circuit Court of Appeals reversed the lower court’s decision and sent the dispute back for further proceedings.

In 2018, attorneys for HHS asked the Supreme Court to review the appellate decision. Now that the justices have affirmed the Circuit Court’s decision, the parties have up to seven days to file a status report at the District Court level on where the case stands, according to court records. That filing, expected by early next week, could shed light on where things are headed procedurally.

Pfister says she doesn’t think anyone knows for the time being whether the government will automatically revise DSH payments for the affected fiscal years, pursue another round of notice-and-comment rulemaking, or take some other course of action in response to the Supreme Court ruling.

And the parties themselves aren’t saying much. When asked about the agency’s plans, a CMS spokesperson told HealthLeaders on Wednesday that the agency is still reviewing the decision. Allina referred questions to its law firm, which declined to comment.

Beyond the nine plaintiff hospitals involved in this week’s Supreme Court decision, there are hundreds of plaintiffs suing HHS on similar grounds. Dozens of follow-on lawsuits have been consolidated into a single docket pending before U.S. District Judge Amy Berman Jackson. Parties to that proceeding have up to 14 days to file a status report in light of the Supreme Court’s decision, according to court records.

An Overly Burdensome Decision?

The government’s attorneys had issued dire warnings about the potential consequences of the decision the Supreme Court ultimately reached.

The notion that CMS must go through a notice-and-comment process for the sort of routine process at issue in this case could “substantially undermine effective administration of the Medicare program” because it would apply not just to DSH formula calculations but to “nearly every instruction” the agency gives to its contractors as well, U.S. Solicitor General Noel J. Francisco argued on HHS’ behalf.

Pfister largely rejects the government’s dire take on the decision’s impact.

“I think that might have been a little bit hyperbolic,” she says.

But other stakeholders outside the government have taken the Supreme Court’s ruling as a troubling sign of uncertainty to come.

“This is a frightening decision, that throws a lot of doubt on the validity of thousands of pages of Medicare sub-regulatory guidance,” Adam Finkelstein, JD, MPH, counsel with Manatt Health and a former health insurance specialist with the CMS Innovation Center, wrote in a tweet.

Stephanie A. Kennan, senior vice president of federal public affairs for McGuire Woods Consulting in Washington, D.C., tells HealthLeaders that she thinks the government’s argument “is somewhat overblown.” Officials should be able to manage any added burden from this ruling, even if it slows them down a bit, she says.

“I think it may mean they cannot move as quickly on some policies as they would like to,” Kennan says.

A Boon to Public Input?

The benefits of a more-transparent process justify any added hassle that may stem from having to go through a mandatory comment process more often as a result of this decision, Kennan says.

“In this case, they have to do 60-day comment periods, which can seem like an eternity if you want to keep the process moving, regardless of whether you’re the agency or a stakeholder,” she says. “The transparency is probably worth the 60 days.”

But others reject the notion that this decision should be seen as balancing effective governance with transparency.

“Allina isn’t a vindication of the importance of public participation in agency decision-making. It’s a testimonial to the heedlessness of lawyers who impose silly procedural rules on an administrative state they only dimly understand,” Nicholas Bagley, JD, a law professor at the University of Michigan who teaches on administrative law and health law, wrote in a series of tweets.

“Bear in mind,” he added, “that CMS is a tiny, beleaguered agency … To further encumber it will make Medicare more capricious, not less, as staffers tend to senseless procedures instead of doing their jobs.”

Moving forward, HHS and CMS will continue to have discretion to determine whether to go through notice-and-comment with a given action, Pfister says. The difference now, she says, is that there’s a stronger incentive for government officials to cover themselves; otherwise, another case like Allina’s could pull them into another round of prolonged litigation.

 

 

A Large Employer ‘Frames’ The ‘Medicare For All’ Debate

Posted on by • Posted in 2020 Election Issues, Business Case, Competition, Economic Case, Employer-Based Health Insurance, Health Insurance Industry, Health Policy, Labor Union, Medicare, Medicare for All, Single Payer Health System • Leave a comment

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As health costs continue to grow, straining employer budgets and slowing wage growth, the business community is beginning to take the option more seriously.

KEY TAKEAWAYS

More than 156 million Americans get employer-paid healthcare, making it by far the single-largest form of coverage.

Medicare-for-all supports say the health system overall would see savings from a coordinated effort to lower prices and administrative costs and eliminate insurance company profits.

While large business lobbying groups strongly oppose Medicare for all, the resolve of many in the business community — especially among smaller firms — may be shifting.

Walk into a big-box retailer such as Walmart or Michaels and you’re likely to see MCS Industries’ picture frames, decorative mirrors or kitschy wall décor.

Adjacent to a dairy farm a few miles west of downtown Easton, MCS is the nation’s largest maker of such household products. But MCS doesn’t actually make anything here anymore. It has moved its manufacturing operations to Mexico and China, with the last manufacturing jobs departing this city along the Delaware River in 2005. MCS now has about 175 U.S. employees and 600 people overseas.

“We were going to lose the business because we were no longer competitive,” CEO Richard Master explained. And one of the biggest impediments to keeping labor costs in line, he said, has been the increasing expense of health coverage in the United States.

Today, he’s at the vanguard of a small but growing group of business executives who are lining up to support a “Medicare for All” national health program. He argues not that healthcare is a human right, but that covering everyone with a government plan and decoupling healthcare coverage from the workplace would benefit entrepreneurship.

In February, Master stood with Rep. Pramila Jayapal (D-Wash.) outside the Capitol after she introduced her Medicare for All bill. “This bill removes an albatross from the neck of American business, puts more money in consumer products and will boost our economy,” he said.

As health costs continue to grow, straining employer budgets and slowing wage growth, others in the business community are beginning to take the option more seriously.

While the influential U.S. Chamber of Commerce and other large business lobbying groups strongly oppose increased government involvement in healthcare, the resolve of many in the business community — especially among smaller firms — may be shifting.

“There is growing momentum among employers supporting single-payer,” said Dan Geiger, co-director of the Business Alliance for a Healthy California, which has sought to generate business support for a universal healthcare program in California. About 300 mostly small employers have signed on.

“Businesses are really angry about the system, and there is a lot of frustration with its rising costs and dysfunction,” he said.

Geiger acknowledged the effort still lacks support from any Fortune 500 company CEOs. He said large businesses are hesitant to get involved in this political debate and many don’t want to lose the ability to attract workers with generous health benefits. “There is also a lingering distrust of the government, and they think they can offer coverage better than the government,” he said.

In addition, some in the business community are hesitant to sign on to Medicare for All with many details missing, such as how much it would increase taxes, said Ellen Kelsay, chief strategy officer for the National Business Group on Health, a leading business group focused on health benefits.

Democrats Propel the Debate

For decades, a government-run health plan was considered too radical an idea for serious consideration. But Medicare for All has been garnering more political support in recent months, especially after a progressive wave helped Democrats take control of the House this year. Several 2020 Democratic presidential candidates, including Sens. Bernie Sanders and Elizabeth Warren, strongly back it.

The labor unions and consumer groups that have long endorsed a single-payer health system hope that the embrace of it by employers such as Master marks another turning point for the movement.

Supporters of the concept say the health system overall would see savings from a coordinated effort to bring down prices and the elimination of many administrative costs or insurance company profits.

“It’s critical for our success to engage employers, particularly because our current system is hurting employers almost as much as it is patients,” said Melinda St. Louis, campaign director of Medicare for All at Public Citizen, a consumer-rights group based in Washington.

Master, a former Washington lawyer, worked on Democratic Sen. George McGovern’s presidential campaign before returning to Pennsylvania in 1973 to take over his father’s company, which made rigid paper boxes. In 1980, he founded MCS, which pioneered the popular front-loading picture frame and steamless fog-free mirrors for bathrooms. The company has grown into a $250 million corporation.

Master frequently travels to Washington and around the country to talk to business leaders as he seeks to build political support for a single-payer health system.

In the past four years, he has produced several documentary videos on the topic. In 2018, he formed the Business Initiative for Health Policy, a nonprofit group of business leaders, economists and health policy experts trying to explain the financial benefits of a single-payer system.

Dan Wolf, CEO of Cape Air, a Hyannis, Mass.-based regional airline that employs 800 people calls himself “a free market guy.” But he also supports Medicare for All. He said Master helps turn the political argument over single-payer into a practical one.

“It’s about good business sense and about caring for his employees and their well-being,” he said, adding that employers should no longer be straddled with the cost and complexity of healthcare.

“It makes no more sense for an airline to understand health policy for the bulk of its workers than for a health facility to have to supply all the air transportation for its employees,” he said.

Employers are also an important voice in the debate because 156 million Americans get employer-paid healthcare, making it by far the single-largest form of coverage.

Master said his company has tried various methods to control costs with little success, including high deductibles, narrow networks of providers and wellness plans that emphasize preventive medicine.

Insurers who are supposed to negotiate lower rates from hospitals and doctors have failed, he added, and too many premium dollars go to covering administrative costs. Only by having the federal government set rates can the United States control costs of drugs, hospitals and other health services, he said.

“Insurance companies are not watching the store and don’t have incentives to hold down costs in the current system,” he said.

Glad The Boss Is Trying To Make A Difference

What’s left of MCS in Pennsylvania is a spacious corporate office building housing administrative staff, designers and a giant distribution center piled high with carton boxes from floor to ceiling.

MCS pays an average of $1,260 per month for each employee’s healthcare, up from $716 in 2009, the company said. In recent years, the company has reduced out-of-pocket costs for employees by covering most of their deductibles.

Medicare for All would require several new taxes to raise money, but Master said such a plan would mean savings for his company and employees.

MCS employees largely support Master’s attempt to fix the health system even if they are not all on board with a Medicare for All approach, according to interviews with several workers in Easton.

“I think it’s a good idea,” said Faith Wildrick, a shipper at MCS who has worked for the company 26 years. “If the other countries are doing it and it is working for them, why can’t it work for us?”

Wildrick said that even with insurance her family struggles with health costs as her husband, Bill, a former MCS employee, deals with liver disease and needs many diagnostic tests and prescription medications. Their annual deductible has swung from $4,000 several years ago to $500 this year as the company has worked to lower employees’ out-of-pocket costs.

“I’m really glad someone is fighting for this and trying to make a difference,” said Wildrick.

Jessica Ehrhardt, the human resources manager at MCS, said the effort to reduce employees’ out-of-pocket health costs means the company must pay higher health costs. That results in less money for salary increases and other benefits, she added.

Asked about Medicare for All, Ehrhardt said, “It’s a drastic solution, but something needs to happen.”

For too long, Master said, the push for a single-payer health system has been about ideology.

“The movement has been about making healthcare a human right and that we have a right to universal healthcare,” he said. “What I am saying is this is prudent for our economy and am trying to make the business and economic case.”

 

“This is prudent for our economy and am trying to make the business and economic case.”