Category: Health Policy

Nov
15

The most important thing you aren’t paying attention to

Posted by Joe Paduda on Friday, November 15th, 2019 | Comments

Is the ACA case in Texas.

Briefly, Republican Attorneys General have sued to overturn the ACA.  The AGs’ claim the entire law must be thrown out because the individual mandate — a penalty imposed on people who chose to remain uninsured – was killed by Congress in 2017.

You may recall that, in addition to the mandate, the ACA:

  • expanded Medicaid to more low-income families and individuals
  • reduced seniors’ drug costs by closing the “Donut Hole” in Part D plans
  • reduced insurance costs for older Americans
  • increased funding to fight healthcare fraud
  • increased funding for rural healthcare
  • increased tax credits for small businesses providing health insurance
  • provided insurance subsidies for families making less than $88,000
  • required insurers to offer complete insurance coverage to all without discriminating by medical condition, age, or sex

If the Republican Attorneys General prevail, the ACA will be overturned, and health insurers will be allowed to:

  • stop covering pre-existing conditions; 
  • stop covering your adult kids;
  • limit your maximum dollar benefit;
  • exclude different types of medical care
  • medically underwrite small groups; and 
  • subsidies for folks buying health insurance go away.

Meanwhile, there is NO alternative plan if the judge rules in favor of the AGs. While HHS Secretary Seema Verna says there will be a replacement plan, there are no details about this “plan“, and no information whatsoever from the President or Congress.

photo credit Leslie Boorhem-Stephenson for the Texas Tribute,

I don’t understand how the entire law can be overturned because one part of it is no longer in effect – but I’m no attorney and will leave that to those readers who are.

From a political perspective, this doesn’t seem too smart on the part of Republicans.  People hate losing things they already have – much more than they don’t like not getting things they wish they had. And if the ACA is overturned, millions of voters – including millions of seniors – will be really mad.

What does this mean for you?

If you’re a Medicare recipient, parent, make less than $88,000 a year, are a small business owner, have pre-existing condition, and/or need comprehensive insurance coverage…

nothing good.

Sep
24

Guns and public health

Posted by Joe Paduda on Tuesday, September 24th, 2019 | Comments

Guns are a major public health and safety problem. Guns are associated with tens of thousands of deaths every year, most preventable.

And we Americans are among the world leaders in death via firearm.

Before you make any assumptions – I own guns. I hunt – although I’m a pretty poor hunter.

My dad taught me to shoot, and handle firearms, and gun safety. Among the guns I own are his service rifle – a 1903 Springfield – from WW2 and the revolver he carried while flying in B-17s over Europe. They mean a lot to me, and one day I’ll pass them down to my kids.

A couple key factoids that are worth considering.

  1.  Most Americans – and most Republicans – want background checks and “red flag” laws.  And most Americans want stricter control of gun sales in general.

2. Firearms are used to commit far more suicides than homicides.

3.  People who attempt suicide with a gun are much more likely to die than those who use other means.

4. There’s a strong correlation between higher rates of gun ownership and higher suicide rates.

5.  Lastly, every day 65 people use guns to kill themselves.

Guns are a major public health concern, yet no other public health menace gets the same public support.  As a gun owner, I’m deeply troubled by the willingness of some to advocate positions that will get more guns into more hands – which will lead to more unnecessary tragedies.

What does this mean for you?

The data is clear – people want stricter gun laws – and for very good reason.

Sep
3

If other services were like healthcare…

Posted by Joe Paduda on Tuesday, September 3rd, 2019 | Comments

There’s this ongoing debate/discussion about healthcare as an economic good.  Fact is, unlike flat panel TVs or cars, healthcare is quite different for a whole bunch of reasons;;

  • we often don’t know what services we need,
  • even experts are often unable to make informed decisions,
  • we don’t know what the cost will be, and
  • even if we’re given an estimate up front, that’s just an estimate,
  • once you’ve paid your out-of-pocket maximum you don’t care about cost, and
  • in many circumstances the emotion involved makes rational decision making impossible

To further explain how healthcare is different, I offer Sarah Mirk’s take on what would happen if other services were like healthcare…

How the health insurance marketplace works – School!

How emergency healthcare works – Fire departments!

More of Sarah’s work – and a lot of other cool stuff – is at The Nib.

Aug
22

Three reasons we’ll have major healthcare reform by 2025

Posted by Joe Paduda on Thursday, August 22nd, 2019 | Comments

Middle class voters can’t afford healthcare.

Total health insurance cost for the average family with employer-sponsored coverage is over $22,000 annually.

Even families that have coverage are being crushed by costs not covered by insurance.

lawsuits keep the “Debt and Collections” courtroom in Poplar Bluff busy. (Michael S. Williamson/The Washington Post)

Hospitals and health systems are going out of business, leaving towns and rural areas with reduced access healthcare.

Health systems and hospitals have a Hobbesian choice – force families into bankruptcy or go bankrupt themselves.

Tennessee and Texas lead the nation in hospital closures, with one-fifth of the Lone Star State’s rural hospitals already closed or close to it. Just north, a grassroots movement in Oklahoma driven by closure of a half-dozen rural hospitals, is gaining traction.

While Becker’s reports all but one of the hospitals going belly up are in states that didn’t expand Medicaid.   While there’s no question the problem is much worse in non-expansion states, facilities’ fiscal problems aren’t all solvable by Medicaid. Hospitals from Philadelphia to Chicago are facing bankruptcy, leaving behind massive unpaid bills and huge gaps in the provider landscape.

Improved access to care has big economic benefits.

Growing evidence indicates Medicaid expansion has been a big positive for expansion states:

Medicaid expansion was associated with improved hospital financial performance and significant reductions in the probability of hospital closure, especially in rural areas and areas with higher pre-ACA uninsured rates.

A study in Louisiana found that the injection of federal expansion funds created and supported 19,195 jobs (while creating and supporting personal earnings of $1.12 billion) in sectors throughout the economy and across the state as of SFY 2017. A study in Colorado found that the state supported 31,074 additional jobs due to Medicaid expansion as of FY 2015-2016

Another Louisiana study found that as a result of the federal infusion of Medicaid expansion dollars into the state’s economy, Louisiana derived an additional $103.2 million in overall state tax receipts (which exceeded the state dollars budgeted for the Medicaid expansion program by close to $50 million) and local governments derived an additional $74.6 million in local tax receipts. A study in Montana found positive financial effects for businesses due to infusion of federal dollars to fund health coverage for workers

The net is this – People want their kids to be covered, to be protected from medical cost bankruptcy, to have access to care.

Politicians who offer solutions to these problems are finding receptive audiences, even in red states and states where Medicaid expansion was turned down. Louisiana, Kansas and Maine are three states where healthcare was a significant factor in gubernatorial elections – all have expanded, or working to expand Medicaid.

Voters will drive healthcare reform, and politicians will follow. More coverage = a healthier economy.

What does this mean for you?

It’s going to happen.

Aug
19

Are health insurers’ profits and costs the problem?

Posted by Joe Paduda on Monday, August 19th, 2019 | Comments

There’s a lot of bleating about the huge profits made by health insurers, with some – including too many who should know better – complaining loud and long. [Insurers and pharma netted about $97 billion last year.]

While some would argue the billions raked in by insurers is far too much, let’s take a step back and look at the big picture.

First, insurers’ profits are a tiny fraction of our $3.6 trillion healthcare spend – as in >1 percent.

Second, healthplan, insurers, and other payers’ total administrative expenses amount to 8.3% of that $3.6 trillion – roughly $300 billion.

Oh, and a big chunk of most health insurers’ business comes from servicing governmental programs.  Example – 58% of United Healthcare’s revenue is from Medicare, Medicaid, and other governmental programs.

Frankly, given commercial insurers’ demonstrated inability to control costs and improve quality, that $30 billion may be too generous by far. But it’s clear the big problem with healthcare costs is not insurer profits or administrative expense.

It’s the underlying prices of healthcare.

What does this mean for you?

It’s not insurer profits.

Jul
1

Key takeaways from what happened last week

Posted by Joe Paduda on Monday, July 1st, 2019 | Comments

Here’s what else was happening last week while we were tracking One Call’s financial troubles…

Who’s for Medicare For All? Who wants to “abolish private health insurance in favor of a public run plan?”

That was the question asked of the 20 (!) Democratic candidates for President at last week’s debate with the request that those in favor raise their hands.

While it was great to see politicians put on the spot, forced to give a “yes or no” answer, the reality is it’s not that simple: There are multiple and quite different versions of “MFA”, ranging from Sanders’ version which is the “no cost to consumers, covers everyone, administered by the Feds, paid for with a big tax increase” to others’ “you can buy into Medicare if you want or keep your employer-based coverage.”

When someone tells you Candidate X wants to do away with your health insurance, make sure that someone knows what they are talking about. Ask them to define exactly what Candidate X’s platform is, then fact check with Google.

Here’s a great side-by-side analysis of all the health reform bills now under consideration. Lots of nuance here…

Provider consolidation – costs and benefits

The California Health Care Foundation published a solid analysis of the implications costs and possible benefits of provider consolidation.

The net – costs go up, quality of care doesn’t.

Key takeaways include:

  • A study of US hospitals by Stanford University researchers found that “hospital ownership of physician practices leads to higher prices and higher levels of hospital spending.”
  • vertical integration increases hospitals’ bargaining power with insurers.
  • Physician groups owned by large hospital systems were more than 50% more expensive than those owned exclusively by physicians, and
  •  “Physician-hospital integration did not improve the quality of care for the overwhelming majority of [quality] measures,”

Drug pricing

Thanks to WCRI for sharing their Flash Report on Drug Trends. The researchers looked at very recent data from 27 states; key takeaways include:

  • compound utilization has fallen off a cliff
  • opioid spend dropped in every one of the 27 states
  • Louisiana’s opioid spend topped all study states at $100 per claim per quarter
  • total drug spend also decreased in 25 of the 27 states.

A brief video intro is available here.  And, the findings parallel what I’m hearing from respondents to our latest PBM in WC Survey.

Next up, another excellent piece from Adam Fein on spread pricing and rebates.

Dr Fein opines that spread pricing – the PBM makes its money on the difference between what it pays the pharmacy and what it charges the payer – isn’t necessarily a bad thing. He also discusses how some manufacturers use rebate payments as a way to force buyers to use their drugs.

head’s up – I’m about halfway thru the 16th (or is it 17th?) “Annual survey of pharmacy benefit management in workers’ comp”; pricing is a hot topic, but the respondents’ views are not what I expected. More on this next week…

Worker mis-classification

Excellent piece in WorkCompCentral about the ongoing effort to combat the real fraud in comp – sleazy employers, employee leasing companies, and labor brokers that lie to avoid paying workers’ comp premiums.

The piece reviews research by Harvard University’s Law School; the research was triggered by:

the USDOL [Department of Labor]…rolling back worker protections in a variety of ways, initially withdrawing a WHD Administrative Interpretation on misclassification, and piloting an amnesty program for wage and hour violators, called the PAID program. As a result of this retreat at the federal level, state enforcement has become more critical than ever.

The entire report is here; the takeaway [emphasis added] is:

“Misclassification and payroll fraud harm workers, depriving them of rights and protections to which they are legally entitled. Law abiding businesses also suffer, as they struggle to compete with companies that unlawfully lower their costs”

Have a great holiday week, enjoy friends and family, and get out and away from work.

I am!

May
2

The CBO’s Single Payer Report and worker’s comp

Posted by Joe Paduda on Thursday, May 2nd, 2019 | Comments

The CBO’s 34-page analysis of Single Payer is out, and there are no references to workers’ comp or occupational injuries/illnesses. 

That doesn’t mean there aren’t plenty of ways Single Payer would affect work comp.

Briefly, Single Payer is a very broad term that over-generalizes a bunch of very different approaches to universal health insurance coverage. As defined in the CBO report, in Single Payer programs “people enroll in a health plan operated by the government, and the receipts and expenditures associated with the plan appear in the government’s budget.”

When you recall that work comp accounts for about 1% of total US medical spend, it’s no wonder the CBO report ignores us. But, how Single Payer would affect comp depends on two core issues:

  • whether care for occupational injuries/illnesses is covered by Single Payer, and
  • whether there is a universal fee schedule.

If WC care is included under Single Payer, it is likely work comp would evolve to an indemnity-only system. This currently exists in several other countries, and seems to work pretty well.

If WC medical care is NOT included in Single Payer, the impact would be driven largely by the presence – or absence – of a universal fee schedule. 

Without that universal fee schedule, providers would likely continue to do their revenue maximization thing, although they’d supercharge those efforts. Why? Because reimbursement from all other payers would drop significantly, and providers would look to comp to replace as much of that lost income as possible.

What does this mean for you?

The healthcare system is the elephant, and workers’ comp is the mouse.

Apr
17

Where single payer works – part 1

Posted by Joe Paduda on Wednesday, April 17th, 2019 | Comments

I’m reading Uwe Reinhardt’s last book, Priced Out. Reinhardt, a universally respected and admired economist with a strong focus on healthcare, died in late 2017. He left a legacy of curiosity and compassion – and practical results.

Reinhardt was instrumental in convincing the government of Taiwan to implement a simple and very effective single payer healthcare system.

Besides an 80% patient approval rating, Taiwan’s system:

  • allows people to see any provider they wish
  • is funded by a payroll tax, with some contributions from other government funds as well as patient copays (which are quite inexpensive)
  • has the lowest administrative expense in the world – 2% of total cost
  • every member has a smart card with their medical records and other key data encrypted. This enables any provider to quickly access key information.
  • costs about a third of the US system.

It is by no means perfect; global budgets and a perceived lack of doctors and nurses are frequently noted as problems.

Yet it has addressed many of the problems we have with our system – medical record transferability, patient costs, paperwork, overall expense, and administrative expense.

What does this mean for you?

The more you know, the better it is.

 

 

Apr
10

On the one hand…

Posted by Joe Paduda on Wednesday, April 10th, 2019 | Comments

We have a healthplan you’ll absolutely love.  Covers EVERYTHING – glasses, hearing aids, nursing home care, doctor visits, hospital care, surgery, drugs – all FREE!

It’s the about-to-be-announced BernieCare 2.0, aka the “Whole Enchilada Plan”. You can go to  any doctor, hospital, acupuncturist, yoga instructor, therapist, or nursing home your heart – or other internal organ – desires. And did I say, it’s all for FREE!

On the other hand, there’s the SkimpyPlan – and as the Brits say, it’s “on offer” today. Well, it was until a Federal Judge ruled it isn’t.

SkimpyPlans cover, well, not much. Especially if you had one of those pre-existing condition things. You know, migraines, high blood pressure, the “C” word, bad knees, anxiety or pretty much anything else. Oh, and the list of doctors and hospitals is, well, “limited”… and they don’t cover drugs, or pregnancy, or, well, lots of things.

But hey! they’re cheap! Affordable even!

Ok, enough with the sarcasm, here’s where this is headed.

For some unfathomable reason Mitch McConnell and the current Administration think these SkimpyPlans are a great response to the not-hated-any-more ACA.  SkimpyPlans are pretty much the only plan offered by the GOP, and they are awful. They are getting hammered in the press as patients find themselves without coverage for needed care, facing tens of thousands in medical bills, stuck fighting faceless bureaucrats in some distant “insurance company” via voice mail.

Sure many are covered by their employers, even that is getting unaffordable for many AND sticking families with big bills. 

Then there’s the While Enchilada Plan – an end to paperwork, doctor shopping, copays and deductibles, and all FREE.

Do you see where this is going?

Nov
14

Capitalism will never solve our healthcare problem – because capitalism is the problem

Posted by Joe Paduda on Wednesday, November 14th, 2018 | Comments

Some ill-informed but perhaps well-intentioned people opine that all we need to do to solve the healthcare cost problem is unleash the free market.

Their thinking seems to be that creative approaches and Adam Smith’s “invisible hand” will conquer the cost:quality:access conundrum.

That is wrong for several reasons.

First, no for-profit insurance company wants to “insure” a person with cancer, depression, heart disease, asthma. Nor do they want to keep insuring someone who gets sick.

That would be irrational and stupid, a bad business decision indeed.

Second, there has been ample time and much experimentation with various types of “free market” solutions – yet here we are. Family insurance premiums are close to $20,000 and come with sky-high deductibles, medical trend continues to climb, and big insurers are not jumping into markets.

The free marketers will argue that allowing people to buy skinny healthplans like those pushed by the Trump Administration that don’t cover stuff like drugs or pregnancy is the solution, that this keeps insurance costs down by eliminating coverage that’s “not needed”.

Funny thing about health insurance – no one can predict when they’ll find out they have Hepatitis C, have a motorcycle accident, or have an aneurism.

There’s another problem with the skinny plan idea – insurance requires the many subsidize the few. If healthy people aren’t in the regular insurance pool, costs for sick folks will go up a lot – and inevitably lead to insurance market death spirals where only the wealthiest people can afford insurance.

To be fair, free marketers will assert that this is exactly the problem – a big part of healthcare costs (e.g. maintenance drugs, child health, care for chronic conditions) shouldn’t be insured as they are not a classic “insurable risk”; somewhat unpredictable and random. That’s true. But it begs the question – most Americans can’t afford to pay for needed medical care without support from an insurer or third party.

Which leads us to the real problem – healthcare in this country is very much a profit driven business, and the companies and individuals making gazillions on healthcare are going to fight to the death to keep it that way.

As evidence, see California’s attempt to limit the profits of the dialysis industry. The big dialysis companies spent $111 million dollars to prevent this – which makes perfect sense. However, one needs to understand that almost all dialysis treatment is paid for by you, the taxpayer. And a big chunk of Californians’ tax dollars going to fatten up corporate profits – 3 billion dollars to be precise.

It’s not just dialysis.

Investment firms are buying up dermatology practices, and, according to some reports, encouraging providers to order lots of expensive and potentially unnecessary treatments.

I’m not blaming private equity firms – they are doing what they are supposed to do, generate big returns for their investors. (to be fair, I know several PE firms that are NOT like this – they believe in doing well by doing good.)

And they are very, very good at it.

Finally, Invisible Hand fans will argue that dialysis is the issue – if we get government out of the mix, then the consumer will force down the price.

Ha.

What does this mean for you?

Can you afford dialysis? Is it right for those who can’t afford it to die? Because that’s what the invisible hand would do – push many of us right into a long and painful death.

Note – friend and colleague Tom Lynch must’ve been thinking the same thoughts I have been, as his post is a data-rich, elegant and thoughtful discussion of single payer, and government’s role in healthcare.