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Opinion and Commentary from TMA

Where Do We Go From Here With Our Health Care System?

(Legislature, Public Health, U.S. Congress) Permanent link

APM_Options
  This post was originally published on Rob Tenery, MD’s blog

When the Affordable Care Act (Obamacare) was first introduced, the public was told that they could keep the doctor of their choice and their premiums would not escalate. Quickly, it became obvious that was not possible. Many doctors failed to become participants and the costs for coverage in 2017 ranged anywhere from 20 to 60 percent higher since the ACA’s inception. Additionally, not every uninsured individual chose to participate. Thus, almost 20 million remained without coverage.

“If you have a law that makes it explicit healthy people pay in and sick people get the money, it wouldn’t have passed,” said the often-called architect of the ACA, MIT Professor Jonathan Gruber. “Lack of transparency is a huge political advantage, and basically call it the stupidity of the American voter or whatever, but basically that was really critical to getting the thing to pass.”

                                                                ~~~

There are several social and economic realities that doomed the ACA from the start:

1.) The patient was taken out of the decision-making process, with no incentive or effective disincentive for financial responsibility.

2.) There was a failure to develop an affordable basic benefits package of health care services that would be available to all, through expansion of the state-run Medicaid programs, medical savings accounts, vouchers, and allowing the private health insurance carriers to compete for patients across state lines.

3.) Similar to automobile liability insurance, the ACA is mandated personal coverage with punitive penalties that weren’t persuasive enough to force compliance under an individual mandate regulation.

                                                                     ~~~

To make the ACA work, the more healthy individuals would have to sign up or face a fine if they didn’t. The fine would be levied under the Individual Mandate (IM) stipulation dictated under the ACA. The problem with the IM was that the penalty was relatively minimal and only recoverable by a withholding part of any tax rebate for which they might be eligible.

When Justice Roberts joined the other liberal justices on the Supreme Court in ruling the ACA constitutional, he ruled on the basis that the ACA was not a mandate, but a tax, which the Congress could lawfully create. The other part of his ruling was that Congress could not lawfully issue mandates.

The Republicans were not able to pass their version to repeal and replace the ACA. When President Trump issued an Executive Order to do away with the very unpopular IM, a George W. Bush appointee Federal District Judge Reed O'Connor in Ft. Worth ruled that without the IM, the ACA was no longer constitutional, since that was the only tax in the original ACA.

This ruling, once again, brings up options: Reinstate the IM, but make it more punitive, so as to force more of the uncovered into obtaining coverage. Another, create a mandatory catastrophic coverage plan that would be a variant of the IM. A third, 'Medicare for All', as proposed by Bernie Sanders and reportedly to be introduced as a bill in the US House of Representatives. Unfortunately, this option will lead to a single payer system and would cost added trillions of dollars in additional costs.

To say that Medicare works well, denies the fact that in many patients are no longer able to go to the doctor of their choice. In fact, even finding a doctor is difficult. Additionally, many doctors no longer participate in the Medicare program.

This program is only one step away from a single payer health care system, which was once referred to as socialized medicine. Under this system, the government, controlled by federal dictates and paid for by taxes or raising the federal debt, provides all medical and hospital services, and determines all reimbursement levels.

Under a single payer, all people are guaranteed health care services, but that care is dependent on the availability of the services and the providers who would render that care. One just has to look at the Canadian system where examinations, tests and procedures are often put off for weeks to months, while patients’ morbidities drag on.

The complexities of reimbursement may be reduced under a single payer system. But added billing and coding time requirements, often take doctors away from direct patient care. Although escalation of overall costs of care is easier to control, the reimbursement levels usually decrease to the doctors and institutions, resulting in potential compromise of the time that is devoted to that care.

The questions for any new plan or revision of what is left are two: What to do with pre-existing conditions as pointed out in the recent New York Times article and how to bring money back into health care to offset the losses from including pre-existing conditions. The latter is most easily resolved by going back to the healthy individuals who are not eligible for a government program and have decided to go ‘bare’. Reintroducing the Individual Mandate again, but make it much more punitive than before if they don’t choose that option. Or create a catastrophic coverage plan that is mandated to protect the patients that have unexpected, catastrophic medical or surgical events, the public from bearing those added costs through taxes or accepting these losses by the health care providers and hospital systems. 

Community rating alone makes others’ premiums too high. Continuing high-risk pools, as we have, is another option. The current Democratic answer seems to be 'Medicare for All', which is much more expensive in the long run. Then there is the ’single payer’ option. This should be the LAST choice, because then the government makes all the choices, which is close to what we already have now.

Is moving into a single payer the answer? Just because the coverage questions are addressed, the skyrocketing costs and access for these added patients are not. Simply put, this country’s delivery system is second to none. Why would we want to give that up?

Robert Tenery Jr., MD, is an ophthalmologist in Dallas. He is a TMA past president and Distinguished Service Award winner.

Beyond the Slogan “Medicare for All”

(Legislature, Public Health, U.S. Congress) Permanent link

US capitol
 This is an excerpt of a post originally published on Sarah Fontenot’s website. The opinions expressed are Ms. Fontenot’s. Texas Medicine Today is sharing them to further the conversation on the future of health care reform.

Medicare For All has become a rallying cry for many (if not most) Democrats, but it was independent Sen. Bernie Sanders of Vermont who started the movement in the 2016 presidential election.

Senator Sanders introduced his Medicare for All Bill in September 2017 with 13 Senate co-sponsors, including five who have announced their candidacy for president in 2020.

The public is embracing the concept as well. Polling is mixed, but as high as 70 percent of Americans now support Medicare for All, including 85 percent of Democrats and 52 percent of Republicans, according to a recent Reuters survey.

However, as popular as the concept is, the details are lost in the simple slogan of “Medicare for All.”

To further confuse the issue, the specifics of any Medicare for All plan may differ between advocates, with “Single-Payer,” “Public Option,” and “Universal Health Care” all added into the mix to further confuse what any politician or pundit believes.

“Voters have become casualties as candidates toss around these catchphrases – sometimes vaguely and inaccurately,” Kaiser Health News wrote in November.

Health care was the top issue in the midterm elections, and is expected to be a dominant issue in 2020 as well. The potential of an overhaul of our health care delivery system is far too complicated (and weighty) to capture in a jingle.

I will take four options all affiliated with Medicare for All and provide a bit of detail on each.

Option No. 1: Senator Sanders’ plan

The most common interpretation of Medicare for All is the option espoused by Senator Sanders. Although he did not invent the idea of a single-payer health care system, he made the concept a trend.*

Senator Sanders’ plan dispenses with private insurance and creates a government-run health coverage plan (like Medicare) for everyone. There would be no copays or deductibles, and everyone would have access to inpatient and outpatient care for needs as diverse as substance-abuse treatment and long-term care. Prescription drugs, diagnostic tests, and vision care will be obtainable to all.

Unlike a socialist health care system (for example the United Kingdom), in this plan doctors, hospitals and other health care providers will remain independent – the government will pay for care but not provide it.

Paying for this version of Medicare For All is controversial and has incited debate. It will at least be paid for partially by multiple new taxes in the bill, such as a tax on households earning more than $28,800 (escalating for those with annual earnings over $250,000), as well as taxes on capital gains and dividends, and a new “Responsible Estate Tax” on Americans inheriting more than $3.5 million. The tax on employers under Senator Sanders’ bill is 6.2 percent of their employees’ incomes.

As helpful as those revenues may be, the biggest argument against Senator Sanders’ plan is the predicted cost. Senator Sanders estimates a $1.38 trillion per year expenditure; other calculations range from $2.4 trillion to $2.8 trillion – and a report last July by the Mercatus Center at George Mason University placed the cost at a staggering $3.26 trillion annually.

Cost is a significant barrier, but there are other reasons not everyone is endorsing Senator Sanders’ plan. A federal government takeover of health care raises questions about federalism, and there are a lot of people that like the insurance they currently have – such as people with generous employment benefits. The eradication of the health insurance industry would hit small-town insurance brokers on “Main Street, Everywhere” and devastate insurance centers like Hartford, Conn. Finally, this plan would destroy much of the structure created by the Affordable Care Act (ACA), when support for the law is at an all-time high.

*Although I am focusing on the Bernie Sanders’ Bill, in March an even more ambitious plan for Medicare For All – HR 676 – was introduced by 124 progressive Democratic representatives in the House. The bill makes health insurance illegal as well as any for-profit health institution.

Option No. 2: The Public Option

Other lawmakers who endorse Medicare for All want the return of the Public Option. (Some of these people are arguing for both plans simultaneously.)

I wrote about the Public Option in detail in Fontenotes No. 25. This version of “Medicare for All” would not extend government-backed health care coverage to everyone but would make a Medicare-like product available for purchase on the ACA (also called “Exchanges”). Presumably, this would help to control costs within the pool of available policies and could help bring insurance costs down across the industry.

This idea – individuals choosing to buy in to Medicare – was born (and died) in California in 2001. Presidential candidate John Edwards revived the idea in 2008; candidates Barack Obama and Hilary Clinton adopted similar proposals in their campaigns that year.

As President Obama and Congress moved forward writing the ACA, the Public Option remained part of the design, but increasingly it became controversial as private insurance companies argued they could not compete in the market with a government-backed alternative. Democrats ultimately killed the public option, with Sen. Joe Lieberman (D-Conn.) delivering the final blow. (Why? Hint: Where is the Insurance Capital of America?).

Hillary Clinton raised the public option from the ashes as part of her 2016 Presidential Platform.

Now, as we face the presidential election cycle of 2020 the public option has resurfaced again, but under the rubric Medicare for All.

The persistence of this idea was predicted in 2010; that tenacity may point to its value.

The Public Option does not require destroying the private insurance industry, people can keep the insurance they like, and the structure of our providers (profit and not-for-profit) remain the same – there is no immediate government takeover of health care.

The only downfall may be the threat the Public Option poses to the private insurance industry, but that would seem to prove the point. Could the Public Option ultimately lead to a single-payer government-run health care system? Yes, but over time and only if the insurance industry fails to adapt.

Option No. 3: Expanding Medicare eligibility

There are some in Washington with a much smaller expansion of Medicare in mind – simply lowering the age of eligibility to 50 (or 55). Private insurance companies charge more to cover those who fall in the 50 to 64 age range (known as the “age tax”).

Arguments for allowing people as young as 50 into Medicare include the prevention of health conditions that could cost the government more in the long run if untreated until 65, and the business opportunity for private insurance companies offering Medicare Advantage plans to this segment of the population.

The reason to not expand Medicare is, of course, the cost to American taxpayers.

Option No. 4: Leave it to the states

And as another wrinkle, some Democrats want Medicare for All to be a choice each state makes – state-run single-payer plans.

How do any of these options compare with what voters envision?

It is possible that none of the options I described match the expectation of Americans marching under the Medicare for All banner.

Based on promises from politicians, talking heads, and 30-second sound-bites, the vision of many Americans appears to be a health care system even more glorious than any under consideration in Washington. The prospect of obtaining all the care they need, from any provider, without permission from an insurance company, and at no cost is a clarion call for voters.

Democratic politicians, particularly those with their eyes on the presidency, continue to stoke those dreams without addressing the realities: the costs, payoffs, and pitfalls of their plans. One progressive leader described the “pleasant ambiguity” of Medicare for All, which creates “a broad umbrella where any candidate can embrace some version of it.”

American voters deserve better. We need to demand facts, numbers, and clarity as we head into this heated political season. The first question we should ask is “What do you mean by Medicare for All?”

A Dozen Ways the Shutdown is Affecting Health Care

(Legislature, Public Health, U.S. Congress) Permanent link

Fontenotes_Shutdown

This is an exceprt of a post originally published on Sarah Fontenot’s website.  

As other industries are struggling through the partial government shutdown, it would be easy to feel positive about health care. Funding for both Health and Human Services (HHS) and the Department of Veteran Affairs (VA) are secure due to appropriation bills that predate the current crisis. VA benefits, Medicare, Medicaid and the Affordable Care Act (also known as Obamacare) are — at least at face value — protected. 

The Centers for Disease Control and Prevention (CDC) is up and running, the National Institutes of Health (NIH) continues to oversee biomedical research, and Food and Drug Administration (FDA) responsibility for drug approval is not affected.

But that is not the whole story.

The shutdown is impacting — even risking — the health of countless Americans. Protections and processes all of us rely on are on hold. Innovations and developments in science, policy, and the law are being delayed or subverted.

Starting with the most important examples — people who are directly affected — here are 12 ways this shutdown is doing damage in the realm of health care.

1. Some Federal Workers are Losing Their Health Benefits  

The 800,000 employees at shut down federal agencies who fall under the Federal Employees Health Benefits (FEHB) program are not at risk of losing their health care insurance. But they could start to receive bills for their dental, vision, and long-term care coverage if the crisis continues. 

The federal employees most in jeopardy are those working under contracts not eligible for the FEHB program. Not only are contract workers potentially not going to get paid when the shutdown ends, they lost their health care benefits at midnight on Dec. 22. A poignant story highlighted by NBC News and the New York Post covers a young woman from the Interior Department now rationing her insulin because she cannot afford the cost.

2. Many Native Americans are Going Without Health Services  

The Indian Health Service — run by HHS but funded through the Department of the Interior — is directly affected by the shutdown. Native American tribes have already missed millions of dollars in essential services; only health care that meets the "immediate needs of the patients, medical staff, and medical facilities" are included in the department’s shutdown plan. Some clinics serving Native Americans have closed already; others are expected to cease services by the end of this week. 

3. Some People Eligible for ACA Subsidies May Have Their Applications Delayed  

Many (if not most) people who purchase insurance on the Affordable Care Act (ACA) Exchanges (or “Marketplaces”) receive a subsidy from the government to help them afford health care coverage. Applications for subsidies may require an Internal Revenue Service (IRS) review in some circumstances, such as when applicants lose their job, a baby has been born, or the person involved filed for an extension on paying income taxes or signed up for insurance outside of the open enrollment window.

With 90 percent of IRS workers out of the office, these applications are now delayed — and the patients involved could lose their insurance entirely if they can’t pay the full premium while they are waiting. (As a bonus, the IRS Call Center is closed so these people can’t get information on what they should do.). Democratic senators andrepresentatives sent a letter Monday to HHS and Treasury asking for protection from unexpected premium costs due to the shutdown.

4. People Who Receive SNAP Benefits (Food Stamps) Have Another Month of Coverage  

The United States Department of Agriculture, Food and Nutrition Service (FNS) released funds to each state to provide February Supplemental Nutrition Assistance Program (SNAP) benefits two days before the shutdown. This means people who receive SNAP (food stamps) must ration their benefits to last two months; it is unclear if there will be any further assistance if the shutdown continues into March.

People who were in the process of applying for food stamps when the shutdown began may have to go without until the reopening of the government. Although the SNAP program is administered through the states, “FNS does not guarantee eligible applicants will receive food stamp benefits while the partial federal shutdown is in effect,” St. Louis Public Radio wrote.

5. Food Safety Issues May Affect Public Health  

Food safety is a basic component of public health, and it is now threatened by the interruption of routine food safety inspections. However, the day after FDA Commissioner Scott Gottlieb confirmed the cessation of food control efforts, the FDA announced that “high-risk” inspections, including infant formula, shellfish, and prepared salads and sandwiches, will resume with the return of 150 furloughed (but still unpaid) people next week.

6. Industry Developments Are Affected by Government Regulators’ Lack of Funding  

The Antitrust Division of the Justice Department asked the U.S. District Court in Washington, D.C., last week to suspend review of the $70 billion CVS-Aetna merger due to lack of resources. The judge told them to keep working.

This “mega-merger” is a highly publicized case — and the judge’s opinion presumably reflects that. Undoubtedly there are lesser-known business dealings and corporate plans that cannot come to fruition while the necessary federal agencies are unavailable to serve their role.

7. The Safety of Drinking Water is Threatened  

After what is happening in Flint, Mich., water safety is top-of-mind for all health care providers, but with more than 13,000 workers furloughed, the Environmental Protection Agency does not have enough staffing to inspect drinking water adequately.

8. State 1332 Waivers for Innovations in Marketplaces are on Hold  

IRS evaluation of the financial impact of proposed innovations is a central component in a state’s process to obtain a 1332 waiver, but because the IRS is currently crippled (see above) that agency can’t work with HHS to evaluate state initiatives to revamp their ACA marketplaces, a chief focus of conservative efforts to alter the ACA.

9. The Appeal of the Texas Decision Striking Down the ACA is on Pause  

The federal court system has survived the shutdown by conserving resources as best as possible (although a closure could happen as early as next week), but the shutdown has still impacted the most prominent court case in health care today: the Texas lawsuit decided in December declaring the entire ACA invalid. On Jan. 11, the 5th Circuit Court of Appeals in New Orleans issued a stay in the appeal of that decision until the government reopens.

10. The FDA is Open — but New Drug Treatments may be Delayed  

The FDA, as a branch of HHS, is up and running, but even so, some pending new drug treatments (including those for multiple sclerosis, depression, and diabetes) may be delayed if the shutdown continues, as the agency cannot process the application fees paid by drug manufacturers during the shutdown. Funds available at FDA are expected to be exhausted before March. 

11. It is Increasingly Difficult to Hire Researchers at the FDA  

In 2016, the passage of the 21st Century Cures Law (Pub. L. 114-255) was “designed to help accelerate medical product development and bring innovations and advances to patients who need them faster and more efficiently.” Part of that directive was to accelerate hiring scientists (and increase their pay) at the FDA. However, as recently reported by Bloomberg, the shutdown is making it difficult to entice the best minds away from the private market — to reinforce the argument that the government is “a good place to work.”

 

12. Activities of Homeland Security Related to Health are at Peril  

The division of the Department of Homeland Security that monitors threats related to infectious diseases, pandemics, and biological and chemical attacks (the Office of Health Affairs) is scaled back throughout the shutdown. Of the 204 people who typically address these threats as well as others in the Countering Weapons of Mass Destruction Office, only 65 remain active.

Other Homeland Security employees who will continue to work without pay include border health inspectors and members of the border patrol.

This shutdown is a world of pain for all of us. But for many, it is an actual threat to life (such as living without insulin).

2019 will be a year of political battles over the future of the American health care system on both a federal and state level. The Trump Administration will (presumably) continue to erode protections provided in the ACA, and the December case ruling the entire ACA unconstitutional will continue to wind its way toward a newly constituted conservative U.S. Supreme Court. The ying and yang of “Medicare for All” and “Free Market Health Care” will be the debate of the year. All of that, and much more, will be the subject of future Fontenotes.

But until our government fully reopens — those debates all seem irrelevant — if not irreverent.