Health News from the Week, June 11-17

The ACA

The New York Times [06-11-17, Reed Abelson] reports how repeal of the ACA would negatively impact a particular group that benefited from the ACA—those between jobs, or who for whatever reason lose their employer-provided coverage.  As the Times notes, the ACA gave many individuals greater flexibility by allowing them to purchase subsidized health insurance plans when out of work; under the House GOP plan, however, these plans may be risk-rated based on pre-existing conditions, and might be prohibitively expensive.

The Washington Post [06-12-17, Amy Goldstein] reports how Iowa is seeking to radically restructure its ACA marketplace in the face of the possible departure of all insurers from the state.  The Post states that the proposed plan would involve the abolition of Iowa’s marketplace, and would allow individuals to use subsidies to buy plans off the exchanges. It notes that the legality of this change outside the context of a 1332 waiver is unclear.

USA Today [06-12-17, Eliza Collins] describes how the drafting process of the Senate’s Obamacare repeal bill is cloaked in secrecy, with rank-and-file Republicans unaware of its contents.  The bill, USA Today notes, will be handed over to the Congressional Budget Office for scoring before it is made publicly available; it may include a somewhat slower phase-out of the Medicaid expansion as compared to the House bill.

Axios [06-12-17, Caitlin Owens] reports that the Senate Republicans are not planning to make a draft of their healthcare bill publicly available.  “We aren’t stupid,” a senior Senate Republican aide told Axios.  The outlet notes that the bill will be sent to the CBO, with a possible vote prior to the July 4 recess.

 Vox [06-14-17, Jeff Stein] reports on the left-wing groups leading the resistance to the Senate GOP’s healthcare law.  The article describes how town hall protests and a barrage of phone calls to lawmakers may have helped derail the House GOP’s initial attempt to pass the American Health Care Act in March.  It also notes a split between Democratic Senators and activist groups on a tactical issue. By withholding “consent,” activists contend that Senate Democrats could stop all Senate business and slow down passage of the law, buying more time to defeat it; some Senators, however, argue that this would have no sustained beneficial impact.

 

Medicaid

The Wall Street Journal [06-11-17, Arian Campo-Flores] describes how Kentucky—a state that had especially benefited from the Affordable Care Act, in particular through a robust Medicaid expansion—is looking to now retreat from those reforms.  As the Journal notes, Governor Matt Bevin is seeking a waiver from the Centers for Medicare and Medicaid Services that would allow—among other things—the state to require premiums from Medicaid participants, one of a number of changes that are expected to substantially shrink the program (head of CMS Seema Verma helped design this proposal, and has recused herself from the decision on its approval).

Modern Healthcare [06-12-17, Virgil Dickson] describes how Indiana’s approach to adding a work requirement for Medicaid participants—a change also being pursued by Maine, Kentucky, Arizona, and other states—may have skirted legal requirements for public comment.  Indiana’s Medicaid expansion, dubbed HIP 2.0, was designed by now CMS head Seema Verma, and represented a major departure from traditional Medicaid, requiring premiums from participants and kicking some out of the program for failure to pay.

 

 

 

Pharma

The New York Times [06-11-17, Abby Goodnough and Kate Zernike] reports how the maker of a  long-acting injectable opioid antagonist (trade name Vivitrol) has aggressively marketed its product as superior to less expensive agents that are used to treat those with opioid dependence—suboxone and methadone—without evidence to back up these claims. The Times note that the maker of the drug has put money into influencing legislators, policy makers, and judges to expand its use in supervised drug treatment programs, where it may be the only allowed option.

Bloomberg [06-12-17, Suzanne Woolley] reports that high healthcare costs are translating into booming business for crowdfunding platforms like GoFundMe, which may stand to benefit from a Republican Obamacare repeal that increases the number of uninsured. It notes that for one crowdfunding company, some 70% of campaigns were for healthcare fundraising.

Kaiser Health News [06-16-17, Emily Kopp] described how President Donald Trump’s “Drug Pricing and Innovation Working Group” has been heavily influenced by individuals and ideas straight from the pharmaceutical industry (the group is led by a former lobbyist for drug giant Gilead, for instance).  KHN obtained documents that demonstrate that the group has been focusing on a number of “principles” that would be highly favorable to industry and would be unlikely to do much about drug costs, including stricter enforcement of drug patents overseas, lower standards of evidence in clinical trials, reducing drug discounts for safety-net hospitals, and allowing drug companies to give information on off-label use of drugs to insurers before drugs are approved by the FDA.

Health News Round Up, early June

Some recent notable healthcare news:

The New York Times [06-01-17, Robert Pear] reported that the Trump administration is moving to revise a federal rule that could result in the loss of contraceptive coverage for hundreds of thousands of women.  While the Supreme Court”s Hobby Lobby decision had given “closely held” corporations the option to not cover contraception on religious grounds, the Times describes that the Trump rule would extend this exemption to other sorts of for-profit corporations as well as not-for-profit organizations, and also to widen the grounds for the exemption beyond religious reasons alone.

The New York Times [06-06-17, Reed Abelson] reported that Anthem was abandoning the ACA marketplace in Ohio, a move that could leave up to 10,500 people in the state uninsured.  This comes on the heels of marketplace departures by a number of other carriers, which the Times notes is being used as evidence by Republicans that the ACA is in a death spiral.

The New York Times [06-08-17, Robert Pear] reported that the chairman of the House Ways and Means Committee Kevin Brady (R-TX) has now called for Congress to fund these cost-sharing subsidies.  The subsidies lower out-of-pocket spending for those who purchase ACA marketplace plans and earn less than 250% of the federal poverty level.  As noted by the Times, a Federal District Court found that governments payments to insurers to cover the cost-sharing reductions was illegal.  Payments have thus far continued while the decision is being appealed, but the Trump administration has threatened to end them, contributing to turmoil in the ACA marketplaces.

Politico [06-08-17, Adam Cancryn, Jennifer Haberkorn, Burgess Everett] describes difficulties facing Senate Republicans as they aim to forge a compromise ACA repeal bill that satisfies both their more conservative and more moderate members.  While, as Politico notes, the Senate bill is likely to slow the rate of Medicaid cuts (as compared to the House bill) and to increase marketplace subsidies for older enrollees, reaching consensus may be difficult if the Senate is to vote on the bill by July 4, as Majority Leader Mitch McConnell has promised.

Vox [06-09-17, Sarah Kliff] reported that some 38,000 individuals—spread among 47 counties in three states—who are now enrolled in ACA marketplace plans may have no health insurance options in 2018 as more insurers withdraw from ACA marketplaces, a development stemming in part from actions of the Trump administration’s, like its threat to end payments to insurers for ACA cost-sharing reductions.

Blog: A Brief Response to Dave Kamper’s “Taking Single Payer Seriously” in Jacobin

Yesterday in Jacobin, Labor organizer Dave Kamper had a good article arguing that single-payer supporters need to have a more robust plan ready to deal with the expected displacement of administrative and billing workers that would result from implementation of a Medicare-for-All system.  As he puts it:

Medicare for All wouldn’t just scrap Obamacare — it would uproot the entire industry. It would be a huge efficiency savings. But it would also be devastating in the short term for hundreds of thousands of working people whose only crime was getting a job at an insurance company, and the hundreds of thousands more who work as billing specialists for clinics and hospitals…

And Kamper is correct here.  The elimination of administratively inefficient private health insurers, the transition to global budgeting of hospitals, and simplified billing requirements for physicians’ practices would translate into huge efficiency savings, which is part of the very raison d’etre of single-payer.  The latest number on administrative savings from David Himmelstein and Steffie Woolhandler, published in the Annals of Internal Medicine, is $503.6 billion/year.

This clearly would result in job losses for billers, coders, and insurance workers on a significant scale, and so a concrete plan to deal with this displacement is necessary.  Now, as Kamper notes, Representative John Conyers’ HR 676 “Medicare-for-All” bill does have an explicit plan for this: it would provide these workers with salaries for two years as well as prioritized job training.  Perhaps that is not enough, as he contends.

But I would take slight issue with one aspect of Kamper’s argument, which seems to suggest that efficiency savings in single-payer would result in job losses beyond administrative workers to the larger healthcare workforce (he notes, as one example, that we may need fewer MRI machines).

This issue actually relates to the broader debate about the costs of single-payer healthcare that is currently ongoing.  I and others argue that in the short term, we should not expect major net savings from single payer.  Yes, there will be large savings on administration and on pharmaceutical expenditures, but at the same time, we are going to be providing more healthcare overall, not less.

Currently, 28.6 million people in America lack health insurance coverage.  The uninsured are going to use more care, more medications, and more services of every type (potentially including more MRIs!) once they are insured (although there are supply constraints that limit this on the system-wide level).  And the elimination of cost sharing for the rest of us—together with the inclusion of new benefits that today are often uncovered, like universal dental care and long term care—are also going to cost money and require a larger, not a smaller, clinical workforce (points made here and here and elsewhere).

The idea here is that efficiencies balance new costs, not that we suddenly slash overall US healthcare expenditures as a percent of GDP to Canadian levels (although moving forward, cost growth can certainly be better controlled on single-payer, which may be the most important issue, and does not have the sorts of workforce implications under discussion here).

In other words, while we need less billers and coders and clerks, we will most likely need more clinical workers.  Retraining non-clinical healthcare workers to be clinical healthcare workers may not always be possible, but it is not impossible either.  And with overall healthcare spending remaining roughly unchanged during the transition to single-payer, there would no reason to predict disruptive changes to the communities that are based around large healthcare delivery systems.

I agree with Kamper “that any attendant growth in federal employment would need to be funneled back into the same communities that shed jobs.”  However, the transition to single-payer will simply not be akin to the fall of manufacturing in the neoliberal era: think more of a deliberate, thoughtful transition from fossil fuels to green energy than the gutting of an entire industry.

Lancet series: “America: equity and equality in health”

Yesterday, the Lancet published a new series “America: equity and equality in health.”  It is available online for free (you need only to register on the site).  In addition to the five papers (below), there is an accompanying editorial as well as comments from Senator Bernie Sanders and Thomas Sequist.  I had the pleasure of co-writing the paper on the Affordable Care Act with colleague/mentor, Dr. Danny McCormack.  The papers are:

  • “Inequality and the health-care system in the USA”,  Samuel L Dickman, David U Himmelstein, Steffie Woolhandler
  • “The Affordable Care Act: implications for health-care equity,” Adam Gaffney, Danny McCormick
  • “Population health in an era of rising income inequality: USA, 1980–2015,” Jacob Bor, Gregory H Cohen, Sandro Galea
  • “Structural racism and health inequities in the USA: evidence and interventions,”   Zinzi D Bailey, Nancy Krieger, Madina Agénor, Jasmine Graves, Natalia Linos, Mary T Bassett
  • “Mass incarceration, public health, and widening inequality in the USA,” Christopher Wildeman, Emily A Wang

 

Blog: Canada’s single payer system produces better outcomes for CF patients than the US system

An important study was published this week in the Annals of Internal Medicine, “Survival Comparison of Patients With Cystic Fibrosis in Canada and the United States,” by Anne L. Stephenson and colleagues.1  The investigators used cystic fibrosis (CF) registries in the United States and Canada to compare outcomes for these patients between the two countries, and the bottom line made headlines in major media outlets: Canadian CF patients did better—much better—indeed they lived some 10 years longer than US CF patients.  The investigators found 34% lower mortality for Canadian CF patients even after controlling for a wide variety of patient and clinical characteristics, including genotype, an important marker of disease severity.  This difference was demonstrated in multiple subgroup analyses (for instance, when looking only at delta F508 homozygotes).    Moreover, over time, Canadian CF patients saw greater improvements in life expectancy.  Finally, they were also more likely to receive organ transplants.

Thus, despite the often-vaunted superiority of the American healthcare system, here is yet another piece of evidence that single payer public systems can deliver better results—indeed in this case the Canadian system even provided more high-technological care (i.e. transplants), which is supposed to be our specialty.

There is one additional finer point to make.  When examining US CF patients by insurance status, the investigators found that those with private insurance did not do significantly worse than Canadian CF patients, whereas the uninsured and those with Medicare/Medicaid (treated as one category) did.  Does this somehow provide evidence that private insurance is superior to public insurance, or does it weaken the overall point that the Canadian single payer system better served CF patients?  No, for a number of reasons.  First, Medicaid, as important as it is, does in fact sometimes provide a lower tier of access to medical care:  for instance, CF patients with Medicaid are less likely to be accepted for a lung transplantation in the US.2  Thus, even apart from the possibility of residual confounding given the association of Medicaid with lower socioeconomic status, it would not be surprising to find worse outcomes for those with Medicaid as compared to those with private insurance in the US.  Second, it is hard to use this study to say much about Medicare.  In part, this is because subjects with Medicaid and Medicare were combined into a single group, so it’s unclear which (or both) of these populations were driving the finding.  Additionally, those under 65 can only get Medicare if they are disabled.  Comparing this disabled CF population to a general Canadian CF population would leave the door open for residual confounding.

  1. Stephenson AL, Sykes J, Stanojevic S, et al. Survival comparison of patients with cystic fibrosis in canada and the united states: A population-based cohort study. Annals of internal medicine 2017.
  2. Quon BS, Psoter K, Mayer-Hamblett N, Aitken ML, Li CI, Goss CH. Disparities in Access to Lung Transplantation for Patients with Cystic Fibrosis by Socioeconomic Status. American Journal of Respiratory and Critical Care Medicine 2012;186:1008-13.