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“Ideology Standing In The Way”: How To Get Sicker, Die Sooner, And Pay More For It

It is painful that five years after passage of the Affordable Care Act, 19 states still have not taken advantage of its option to expand Medicaid. It becomes more so with each new report on the deeply flawed U.S. health system.

The latest, from the National Academy of Sciences, finds that rich people live about 13 years longer than poor people. The researchers note that consequently, rich people end up getting the lion’s share of Social Security benefits. Such inequity should be attacked at its root. At the very least, we could use available tools to help low-income people get health insurance.

The NAS report is far from the first to highlight problems in our approach and results. The Commonwealth Fund last year examined health systems in 11 western industrialized nations. For the fourth time in a decade, the United States system placed first in cost and last in what it delivers. Our system is less fair, less efficient, makes us less healthy and gives us shorter lives. All that for an average of $8,508 per person, way more than second-place Norway at $5,669. In case you were wondering, Britain’s socialized National Health Service was No. 1 at less than half the U.S. cost.

That information landed just as Allan Detsky published a New Yorker analysis of two 2013 reports on global health systems by the Organization for Economic Cooperation and Development and the National Institutes of Health. The study of the 34 OECD countries found an alarming trend: The United States ranked 20th for life expectancy at birth in 1990 and fell to 27th in 2010. On a measure combining level of health and length of life, we plunged from 14th to 26th.

The NIH report by the federal Institute of Medicine found that Americans fared worse than people in 16 “peer” countries in nine areas: infant mortality, injuries and homicides, teen pregnancy, HIV and AIDS, drug-related deaths, obesity and diabetes, heart disease, chronic lung disease, and disability. Why? The authors cite a larger uninsured population than peer countries, worse health habits, more poverty, and more neighborhoods designed to require automobiles.

We have gained a few new tools since some of those studies were done. Some, such as Michelle Obama’s “Let’s Move” initiative and money for electronic medical records in the stimulus law, are nudging us slowly in a better direction. Among the most significant advances are the ACA’s new marketplaces (where individuals can buy insurance regardless of their health status) and the law’s expansion of Medicaid (even though the Supreme Court transformed it into an option that states could take or leave).

The Medicaid expansion is designed for people who make too much to qualify for traditional Medicaid but too little to afford even subsidized private insurance plans. In states that have rejected the expansion, nearly 4 million people are stuck in an absurd coverage gap. That’s even though the federal government is footing the entire bill for the additional enrollees until 2016 and will pay at least 90 percent for them after that.

If we’re already spending a huge amount on health care, why should we sink more into it? It’s a good question — yet we might not have to spend more if we were spending more wisely. We could start by slashing our astonishing medical pricing. It costs more than eight times as much for an MRI here as in Switzerland, a typical example from a study of nine countries released last year by the International Federation of Health Plans. Just this month, The New York Times reported on a 62-year-old drug that went from $13.50 to $750 per tablet overnight.

How can we get a grip on costs? In part by getting a grip on politics. Medicare, overcoming “death panels” alarmism, recently announced it will reimburse doctors for discussing end-of-life choices with patients. That may lead to a decline in expensive, painful and futile treatments. Next, we should lift bans on research into gun violence, the better to reduce shootings and their public health costs.

Ideology is standing in the way on guns, as it is in the 19 states refusing so far to expand Medicaid. The struggles of purple-state Virginia have been among the most epic. Democratic Gov. Terry McAuliffe has been repeatedly thwarted by Republican lawmakers in his push to expand Medicaid. Last year, a disloyal Democratic lawmaker resigned and threw the state Senate into GOP hands. This year Democrats are trying to win back the chamber and, along with it, the slim chance of a Medicaid deal. In the meantime, some 350,000 Virginians are stranded in the coverage gap.

And this, dear readers, is how you get to be last place in the developed world.

 

By: Jill Lawrence, The National Memo, September 24, 2015

September 25, 2015 Posted by | Affordable Care Act, Health Care Costs, Medicaid Expansion, Uninsured | , , , , , , , | 1 Comment

“The Medicare Miracle”: Everything The Usual Suspects Have Been Saying About Fiscal Responsibility Is Wrong

So, what do you think about those Medicare numbers? What, you haven’t heard about them? Well, they haven’t been front-page news. But something remarkable has been happening on the health-spending front, and it should (but probably won’t) transform a lot of our political debate.

The story so far: We’ve all seen projections of giant federal deficits over the next few decades, and there’s a whole industry devoted to issuing dire warnings about the budget and demanding cuts in Socialsecuritymedicareandmedicaid. Policy wonks have long known, however, that there’s no such program, and that health care, rather than retirement, was driving those scary projections. Why? Because, historically, health spending has grown much faster than G.D.P., and it was assumed that this trend would continue.

But a funny thing has happened: Health spending has slowed sharply, and it’s already well below projections made just a few years ago. The falloff has been especially pronounced in Medicare, which is spending $1,000 less per beneficiary than the Congressional Budget Office projected just four years ago.

This is a really big deal, in at least three ways.

First, our supposed fiscal crisis has been postponed, perhaps indefinitely. The federal government is still running deficits, but they’re way down. True, the red ink is still likely to swell again in a few years, if only because more baby boomers will retire and start collecting benefits; but, these days, projections of federal debt as a percentage of G.D.P. show it creeping up rather than soaring. We’ll probably have to raise more revenue eventually, but the long-term fiscal gap now looks much more manageable than the deficit scolds would have you believe.

Second, the slowdown in Medicare helps refute one common explanation of the health-cost slowdown: that it’s mainly the product of a depressed economy, and that spending will surge again once the economy recovers. That could explain low private spending, but Medicare is a government program, and shouldn’t be affected by the recession. In other words, the good news on health costs is for real.

But what accounts for this good news? The third big implication of the Medicare cost miracle is that everything the usual suspects have been saying about fiscal responsibility is wrong.

For years, pundits have accused President Obama of failing to take on entitlement spending. These accusations always involved magical thinking on the politics, assuming that Mr. Obama could somehow get Republicans to negotiate in good faith if only he really wanted to. But they also implicitly dismissed as worthless all the cost-control measures included in the Affordable Care Act. Inside the Beltway, cost control apparently isn’t considered real unless it involves slashing benefits. One pundit went so far as to say, after the Obama administration rejected proposals to raise the eligibility age for Medicare, “America gets the shaft.”

It turns out, however, that raising the Medicare age would hardly save any money. Meanwhile, Medicare is spending much less than expected, and those Obamacare cost-saving measures are at least part of the story. The conventional wisdom on what is and isn’t serious is completely wrong.

While we’re on the subject of health costs, there are two other stories you should know about.

One involves the supposed savings from running Medicare through for-profit insurance companies. That’s the way the drug benefit works, and conservatives love to point out that this benefit has ended up costing much less than projected, which they claim proves that privatization is the way to go. But the budget office has a new report on this issue, and it finds that privatization had nothing to do with it. Instead, Medicare Part D is costing less than expected partly because enrollment has been low and partly because an absence of new blockbuster drugs has led to an overall slowdown in pharmaceutical spending.

The other involves the “sticker shock” that opponents of health reform have been predicting for years. Bulletin: It’s still not happening. Over all, health insurance premiums seem likely to rise only modestly next year, and they are on track to be flat or even falling in several states, including Connecticut and Arkansas.

What’s the moral here? For years, pundits and politicians have insisted that guaranteed health care is an impossible dream, even though every other advanced country has it. Covering the uninsured was supposed to be unaffordable; Medicare as we know it was supposed to be unsustainable. But it turns out that incremental steps to improve incentives and reduce costs can achieve a lot, and covering the uninsured isn’t hard at all.

When it comes to ensuring that Americans have access to health care, the message of the data is simple: Yes, we can.

 

By: Paul Krugman, Op-Ed Columnist, The New York Times, August 31, 2014

September 2, 2014 Posted by | Affordable Care Act, Health Care Costs, Medicare | , , , , , , | Leave a comment

“Veterans And Zombies”: The Hype Behind The Health Care Scandal

You’ve surely heard about the scandal at the Department of Veterans Affairs. A number of veterans found themselves waiting a long time for care, some of them died before they were seen, and some of the agency’s employees falsified records to cover up the extent of the problem. It’s a real scandal; some heads have already rolled, but there’s surely more to clean up.

But the goings-on at Veterans Affairs shouldn’t cause us to lose sight of a much bigger scandal: the almost surreal inefficiency and injustice of the American health care system as a whole. And it’s important to understand that the Veterans Affairs scandal, while real, is being hyped out of proportion by people whose real goal is to block reform of the larger system.

The essential, undeniable fact about American health care is how incredibly expensive it is — twice as costly per capita as the French system, two-and-a-half times as expensive as the British system. You might expect all that money to buy results, but the United States actually ranks low on basic measures of performance; we have low life expectancy and high infant mortality, and despite all that spending many people can’t get health care when they need it. What’s more, Americans seem to realize that they’re getting a bad deal: Surveys show a much smaller percentage of the population satisfied with the health system in America than in other countries.

And, in America, medical costs often cause financial distress to an extent that doesn’t happen in any other advanced nation.

How and why does health care in the United States manage to perform so badly? There have been many studies of the issue, identifying factors that range from high administrative costs, to high drug prices, to excessive testing. The details are fairly complicated, but if you had to identify a common theme behind America’s poor performance, it would be that we suffer from an excess of money-driven medicine. Vast amounts of costly paperwork are generated by for-profit insurers always looking for ways to deny payment; high spending on procedures of dubious medical efficacy is driven by the efforts of for-profit hospitals and providers to generate more revenue; high drug costs are driven by pharmaceutical companies who spend more on advertising and marketing than they do on research.

Other advanced countries don’t suffer from comparable problems because private gain is less of an issue. Outside the U.S., the government generally provides health insurance directly, or ensures that it’s available from tightly regulated nonprofit insurers; often, many hospitals are publicly owned, and many doctors are public employees.

As you might guess, conservatives don’t like the observation that American health care performs worse than other countries’ systems because it relies too much on the private sector and the profit motive. So whenever someone points out the obvious, there is a chorus of denial, of attempts to claim that America does, too, offer better care. It turns out, however, that such claims invariably end up relying on zombie arguments — that is, arguments that have been proved wrong, should be dead, but keep shambling along because they serve a political purpose.

Which brings us to veterans’ care. The system run by the Department of Veterans Affairs is not like the rest of American health care. It is, if you like, an island of socialized medicine, a miniature version of Britain’s National Health Service, in a privatized sea. And until the scandal broke, all indications were that it worked very well, providing high-quality care at low cost.

No wonder, then, that right-wingers have seized on the scandal, viewing it as — to quote Dr. Ben Carson, a rising conservative star — “a gift from God.”

So here’s what you need to know: It’s still true that Veterans Affairs provides excellent care, at low cost. Those waiting lists arise partly because so many veterans want care, but Congress has provided neither clear guidelines on who is entitled to coverage, nor sufficient resources to cover all applicants. And, yes, some officials appear to have responded to incentives to reduce waiting times by falsifying data.

Yet, on average, veterans don’t appear to wait longer for care than other Americans. And does anyone doubt that many Americans have died while waiting for approval from private insurers?

A scandal is a scandal, and wrongdoing must be punished. But beware of people trying to use the veterans’ care scandal to derail health reform.

And here’s the thing: Health reform is working. Too many Americans still lack good insurance, and hence lack access to health care and protection from high medical costs — but not as many as last year, and next year should be better still. Health costs are still far too high, but their growth has slowed dramatically. We’re moving in the right direction, and we shouldn’t let the zombies get in our way.

 

By: Paul Krugman, Op-Ed Columnist, The New York Times, June 19, 2014

June 23, 2014 Posted by | Health Care Costs, Health Reform, Veterans Administration | , , , , , , | Leave a comment

“Almost Anything Would Be More Important”: Memo To Fiscal Hawks, The Long-Term Deficit Doesn’t Matter

Over the weekend I got in a long argument with some ally of the deficit hawk group Fix the Debt on Twitter, and while most of the conversation turned on who should be blamed for mass unemployment, it did reach an interesting place in one respect. This person took as a given that long-term deficit reduction is a policy priority of the first rank — a belief that is very common among America’s elite.

This priority is misguided both in detail and in general. Here’s why.

There are two points to make here: First, long-term deficits are entirely about the rising cost of health care. Centrist elites insist that this is a reason to make our social insurance programs less generous, but the reality is that America’s high prices are driven by inefficient service provision, not by excessively generous programs. American health care is unfair, monopolistic, and captured by specialist doctors, and our policies are designed poorly, which is why we pay about half again as much as the next-most-expensive developed nation for what is in fact a pretty threadbare safety net.

This point is crucial. What it means is that making our social insurance more stingy, by raising the Medicare eligibility age for example, will accomplish almost nothing. Unless you tackle the skyrocketing cost problem, the budgetary headroom created by benefit cuts will be eaten almost immediately by rising prices. In other words, no matter how many grannies you put into the poorhouse, on predicted trends eventually a single ibuprofen will cost the entire federal budget. (Unless, of course, you just repeal all social insurance altogether and let sick, poor, and old people go bankrupt and die in the hundreds of thousands per year.)

Fortunately, we just passed a gigantic health care reform package. You might have heard of it: It’s called ObamaCare, and it seems to be helping slow health care inflation.

Second, even if we set that issue aside and talk about the Platonic ideal of long-term deficits, there again the case for action is weak at best. The political problem is that America does not actually have the consensus necessary to reduce deficits on a long-term basis, despite the constant whining about it one hears all the time on cable news. One of our two political parties is composed of total hypocrites on this issue — just look at Paul Ryan. It is a near-certainty that any long-term work on the deficit would be immediately squandered on tax cuts for the rich the moment Republicans got a chance — it’s what happened in 2001.

But even on the merits, if you actually run through the economic reasoning (PDF), the case for worrying about the long-term deficit is weak at best. The U.S. is indebted in its own sovereign currency and cannot go bankrupt. Inflation could be a worry, but given current mass unemployment it’s a hypothetical concern at best.

So don’t worry about the deficit in 2050 or whatever. People ain’t got no jobs. People ain’t got no money. That’s what matters.

 

By: Ryan Cooper, The Week, March 3, 2014

March 5, 2014 Posted by | Deficits, Health Care Costs | , , , , , , , | Leave a comment

“Let’s Not Forget Medicare Advantage”: Selective Outrage Over Federal Health Care Costs

Knowing I’ve been both a critic of insurance company practices and a supporter of efforts to reform the industry, a FOX news producer reached out last week to get my take on accusations by conservatives that Obamacare will actually result in a bailout of big insurance companies.

Under the headline, “Bailing Out Health Insurers and Helping Obamacare,” The Weekly Standard on Monday urged Republicans to insist that future debt ceiling increases contain a no-bailout provision. The magazine also cited Sen. Marco Rubio’s, R-Fla., bill to repeal a provision of the Affordable Care Act designed to limit potential initial losses of insurers selling policies on the new health insurance exchanges.

I reminded the FOX producer that Republicans have been supporting — and vigorously defending — a much more expensive transfer of taxpayer dollars to private insurers than the one Obamacare foes are now concerned about.

Here’s the issue:

Lawmakers who drafted the Affordable Care Act knew that insurers would be reluctant to participate in the new health insurance exchanges — also called marketplaces — if the government didn’t create a temporary program to protect them against what’s known in the insurance world as adverse selection.

Insurers were concerned, for good reason, that the first people to sign up for coverage through the exchanges would be folks previously shut out of the insurance market — people who were older and sicker than the population at large. Those people couldn’t afford to buy coverage previously because insurers were able to charge them far more than younger, healthier people.

In many cases, insurers refused to sell coverage at any price to prospective customers with preexisting conditions. That’s a big reason why the number of uninsured Americans had reached nearly 50 million when Congress passed the reform law.

So it wasn’t the least bit surprising that the first few million who have signed up for coverage since the exchanges opened on Oct. 1 skew older than many expected. People who have been denied coverage for years are far more motivated to get insurance — and fast — than anyone else. There is not the same pent up demand among the young and healthy.

In anticipation of this, drafters of the reform law established a $25 billion risk fund to insulate insurers from big losses during the first three years. Although the risk fund has always been in the law, conservative pundits apparently just became aware of it.

Yes, $25 billion is a lot of money, but it is pocket change compared to the enormous amount of taxpayer dollars that have been flowing to private insurance companies for nearly three decades to keep them in the Medicare Advantage program, which has had the unwavering support of Republicans.

Republicans have long supported efforts to privatize Medicare, and the Medicare Advantage program is one of the ways they’ve tried to do it. Medicare Advantage is billed as a private alternative to traditional Medicare. When Americans reach 65, they can enroll in traditional Medicare or in a private plan operated by an insurer. If they opt for a private plan, the federal government still picks up the tab and transfers money to the private insurer every month.

As the U.S. Government Accountability Office explains it, the Centers for Medicare and Medicaid Services (CMS) adjusts the monthly payments it sends to private insurers to account for each beneficiary’s health status. As part of this risk adjustment process, CMS assigns each Medicare Advantage beneficiary a risk score — “a relative measure of expected health care costs,” as the GAO puts it.

We’re talking a lot of money here. In 2012 alone, the GAO calculated that the federal government spent about $135 billion on the Medicare Advantage program. The problem for taxpayers is that, according to the GAO, the government has been more than generous over the years to private insurers, having paid them way more than it should have because of shortcomings in how the risk scores are developed.

Interestingly, but not surprisingly, there was no mention of that, or any reference at all to the Medicare Advantage program, the biggest champion of which are Republicans, in The Weekly Standard’s “bail-out” story last week. If they are sincere in their alarm that Obamacare might reward private insurers with an extra $25 billion between now and the end of 2016, they should be apoplectic about the ongoing bailout known as the Medicare Advantage program.

 

By: Wendell Potter, The Center for Public Integrity, January 20, 2014

January 21, 2014 Posted by | Affordable Care Act, Conservatives, Health Care Costs | , , , , , , | 6 Comments

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