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Real Health Care Reform Requires A Price Reduction Conversation


After weeks of silence, followed by news of Obamacare sabotage, health care reform policy returns to center stage. Last week, Bernie Sanders revealed his Medicare for all plan, and Republican Senators renewed efforts to repeal and replace Obamacare with a plan (Graham-Cassidy-Heller-Johnson (GCHJ) plan) that will leave tens of millions without health insurance. If it seems like American health care reform continues on the road to nowhere, it's because it does.

The Sanders plan is long on moralizing (yes, health care should be a right) and short on concrete ideas to address health care costs. The plan includes all of the usual policy proposals to lower health care costs: administrative simplicity, enhanced negotiating power with prescription drug makers, federal subsidies for health care worker training, incentives for doctors to provide better care, and making rich people and employers pay more of the costs for national health care. The only thing new about the Sanders Medicare for all plan is that now it is official.

The Graham-Cassidy et al plan put out by Republican Senators Bill Cassidy (a doctor), and Lindsey Graham is a lot like other Republican health care reform proposals of late in that it looks to reduce federal funding of health care by replacing current subsidies with smaller block grants. The bill would also reduce the amount of money the federal government gives to states to fund their Medicaid programs. But mostly the bill, if passed, will unabashedly, take health care away from millions who currently have it with no pretense of offering them anything in return. There's more awfulness to read in Cassidy-Graham, but the overarching message is that Americans do not have a right to federally funded health care.

So here we are, again, with two opposing policies on American health care reform. Meanwhile, big pharmaceutical companies continue to introduce drugs approaching or surpassing the half a million-dollar cost mark. Employers persist in maintaining health plans whose costs they cannot manage. Workers' keep on watching health care premiums eat up their small wage increases. Politicians continue to move money around from one powerful health care interest group to another. And Americans continue to fall for the you-can't-put-a-value-on-your-health and the importance of American innovation cons to justify uniquely high-priced American health care.

No Shame In the Health Care Price Game

No one disputes that
America has the highest medical care prices in the world. But in typical American fashion, some of us like being at the top of even this list. Defenders of high-cost American health care claim the costs are high because we as a country can afford it, and that that's the price tag for medical and drug innovation. But neither of these claims is necessarily true or right. Tens of millions of Americans cannot afford to pay for health care, and the high price of medical innovation shouldn't go unchallenged.

Last week there was a report about a new cancer drug with a $475,000 price tag. And it seems like just last year we in awe about a new Hepatitis C drugs that cost about $80,000 per patient. Also, just two weeks ago,
Texas Medical Center was bragging about its $50 million worth of floodgates protecting it from Hurricane Harvey. Yes, America obviously has a lot of money to invest in medical care, but is it investing it wisely, is the greatest number of people helped by these investments and who gets to make these decisions. Continue Reading...

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Affordable Health Care Is No Where In Sight


Don't be fooled. After finally agreeing to pay the August Affordable Care Act (aka Obamacare) cost sharing reduction (CSR) payments to insurers, Trump and corrupt Secretary of Health & Human Services, Tom Price, remain committed to destroying Obamacare. Their goals are to pay less in subsidies that help people purchase individual health insurance plans and pay for medical care, and to scare health insurers away from the exchanges by injecting uncertainty about future subsidy payments.

Unfortunately, and despite the latest CSR payment, Trump and Price's sinister plot to undermine Obamacare is having the intended effect. Because health insurers cannot be certain that this Administration will not stall or stop future subsidy payments, they will increase rates by a higher percentage than they otherwise would have. And when health insurers feel uncertain and are afraid they won't meet their financial objectives, they take it out on everyone. That means health insurance premiums may be higher for everyone next year, even employer-sponsored group health plans.

But that is not all on Trump and Price. Their childish, mean-spirited antics only highlight a fundamental problem with a for-profit, private sector led health insurance industry. You see, American health insurers have always insisted that their profits be assured. Taking a loss in one line of business (selling to individuals) and making it up in another line (employer-sponsored and other group insurance), but still making an overall profit, is viewed as a loss for them. They want all of their lines of business to be profitable all of the time.

Even if Trump and Price admit that the Republican health care reform efforts have failed, that they will now honestly administer the Obamacare law as intended, and promise to make all future CSR payments on time, insurers will still raise rates higher than are needed until they feel comfortable that their profits will continue. How long will they wait until they are comfortable that their profits are not in imminent danger? They will wait as long as they want to, which is forever, and there is nothing we can do about it.

Health Insurers Will Always Inflate Premiums

It is so disingenuous for Obamacare critics to imply that the health insurance market was ok or even better before Obamacare. How they ignore or explain away that purchasing individual health insurance pre-Obamacare was hit or miss or that finding comprehensive and affordable coverage was impossible is beyond my comprehension.

Purchasing individual health insurance pre-Obamacare was a long and difficult experience. First, you had to find a reputable insurer that sold individual plans, and then you had to work with an insurance broker to apply and purchase the policy because you couldn't work directly with the insurer. And that describes the not too bad parts of that old way of purchasing insurance. The fact that tens of millions could not purchase individual health insurance, some because they didn't want to, but many because they were denied or couldn't afford it, tells you everything you need to know about why Obamacare or something like it was bound to happen.
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Tax-Free Health Insurance For All Is An Easy Obamacare Fix


As Donald Trump puts his limited energy into showing the world that this presidency thing is way beyond his limited abilities, the insufficient patches to the American health care system lumber into another year. More of the same high-cost but accessible health care is a better deal than what Republicans were offering with their American Health Care and Better Care Reconciliation Acts. But for the millions of people not eligible for subsidies and purchasing their health insurance in the non-group market, the failure of both parties to make health insurance more affordable is unacceptable.

Republicans lawmakers are not the only ones that waited seven (7) years to suggest changes to the Affordable Care Act (aka Obamacare), Democrats did too. And, to add insult to injury, they callously repeated that the number of non-subsidy receivers was so low and, if you thought about it, these people could technically afford high-cost insurance. They also promised to eventually come up with a solution to this
minor Obamacare problem. Well, after 7.5 years Democrats have yet to propose one suggestion to the non-subsidy problem for the millions stuck with paying 100% of high-cost health insurance. However, strangely, there is a law that was passed by both Republicans and Democrats that could help these individuals, including me, but by design, does not.

Say QSEHRA, QSEHRA

In December 2016, a nearly unanimous Congress passed the 21st Century Cures Act. This Act includes a provision that allows small employers to offer a flexible benefits plan, called a qualified small employer health reimbursement arrangement (
QSEHRA), to help their employees pay health insurance premiums and health care expenses with tax-free dollars. One way a QSEHRA works is an employee purchases an individual policy, pays the premium out of their pocket and submits proof of coverage to the employer who has set up the QSEHRA plan. The employer reimburses the employee for the premium, with tax-free dollars, up to a mandated amount. Or, if the employee has coverage through a spouse’s plan, the employee can receive tax-free reimbursement to cover medical expenses. The QSEHRA regulation changed the way health reimbursement accounts were treated under Obamacare as it was designed to help small employers provide premium and health care cost assistance to their workers when providing health insurance was not financially or administratively possible. Continue Reading...

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Talking About Highly Paid Doctors Does Not Devalue Their Work


Becoming a medical doctor in the U.S. is very hard. It takes years of study. We know this because doctors are great at reminding the rest of us of the costs they incur and sacrifices they make in pursuit of their medical degrees. Also, let’s not forget, because they won’t let us, that doctors help the sick and save lives. Don’t get me wrong; I’m not trying to undervalue the efforts and commitment of doctors. However, I’m also not willing to exclude doctors from criticism for the role they play in our overpriced American health care system.

American doctors have much higher salaries than their equally qualified international peers. At least one justification for the sometimes significant salary differentials is legitimate—medical school and training costs are greater in the U.S. than in other countries. Other justifications such as the U.S. is a wealthy country that can afford to pay its doctor more or that doctors could have chosen even higher paying jobs in other industries are even weaker. No one forces you to become a doctor. And, even if you think medicine is a noble profession, there is no such thing as “nobility pay” in the world of compensation management.

If Medicine Is Noble, Not Every Doctor Is

Medicine and money go hand in hand, and so does greed and self-importance. Some doctors enter the medical profession for noble reasons—they want to alleviate illness and save lives; for others, it is a pathway to wealth and prestige. And no one exemplifies the greedy, egoism of the medical profession like Health & Human Services (HHS) Secretary Tom Price. Now a politician, Price was once an orthopedic surgeon and director of an orthopedic surgery clinic in a wealthy area of Atlanta, GA. Orthopedic surgeons are the highest paid of all medical specialists, with an average salary of nearly half a million dollars a year.

Tom Price was never shy about wanting to become a wealthy doctor. It was his goal. And even after moving into politics as an elected Congressman and now head of HHS, he continues to invest in the health care industry and lies about his corrupt investments in the medical field. Another thing Price never lies he doesn’t lie about is his views that doctors should be left alone to make as much money as they can make. At HHS,
Price is looking out for doctors’ pocketbooks. In Price’s world, Medicare payments to doctors rise, quality standards and medical malpractice awards go down, and electronic health records disappear (because who wants to share data with other physicians and invite competition). And that’s not even the worst of Price’s financial activism on behalf of his fellow doctors that don’t want to change but want more money. Price wants to collaborate with doctors in letting them decide how much Medicare (taxpayers) pay for their services.

It Matters Who Becomes A Doctor Continue Reading...

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Medicaid For All Will Make Health Care Just Another Commodity. So What!


I finally agree with what health care policy writers have been saying for months—An American Medicaid or Medicare For All program may be imminent. I reach this conclusion not because of the recent failure by the Republican-majority Senate to repeal and replace the Affordable Care Act (aka Obamacare), but due to the comments of many doctors following this failure. Medical providers sense the change in attitudes away from a for-profit, insurance company driven health care system, and they want to make sure that their role is safe from public backlash and government changes.

And to make it clear on where they stand on this impending new health care world, they are reviving their
objections to the “provider” label. Although decades old, doctors hate the provider label now more than ever. They find the use of the term condescending because it links them with other medical care professionals like nurses and physician assistants—people not at their level of expertise. But the primary reason many doctors dislike being called “providers” is that they see it as a “commoditization of the doctor-patient relationship” and now you’re messing with their money.

Commoditization refers to the process by which goods become so similar that their only distinguishing characteristic becomes price. The development of tablets and smartphones are an example of commoditization. They all have the same or similar features like touch screen and syncing with other devices, etc. And even though I prefer Apple products and give the company credit for pioneering much of the technology now available on other devices, I know that I could accomplish pretty much the same tasks with a non-Apple tablet, phone or computer and at a much lower cost.

Apple is not afraid of commoditization; it expects and thrives in this type of environment. It sees the competition as good for customers because it pushes the company to innovate more. Doctors, on the other hand, hate the idea of commoditized health care. They don’t want to compete on service or price. In fact, the real reason doctors and hospitals don’t want electronic medical records or to publish their prices has nothing to do with costs but because they are afraid a competitor will “steal” their patients if they had access to this data. And, of course, doctors think that their product (health care services) is unique

To date, we have protected doctors and hospitals from real competition and allowed them to charge whatever they want for their services. A Medicaid or Medicare For All single payer health care system that includes electronic medical records and price transparency will force doctors and hospitals to compete on price. This type of system is good for the public because it’s one of the few ways, other than forced price reductions, to make health care affordable. Doctors and hospitals won’t like this more transparent health care system, but who cares; it’s coming, and they know it.
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America's Health Care Identity Crisis


About every July 4th or after a presidential election writers try to explain the American Identity. Some of them, especially of late, conclude that the American Identity is in crises. America does not know who she is. Others say America knows who she is—she is freedom of speech, religion, and opportunity. America is individualism. If there is an American Identity crisis, it is because we have replaced these freedoms with government interference.

There's no denying American democracy is under attack, but ironically our present debilitating state has crystallized our identity. As the famous quote by Carl Jung, "you are what you do, not what you say you'll do." America is and has always been what it does, not what it says.

America is a place where:

  • Slumlords rent substandard, barely habitable housing to the poor because people will pay to live there
  • Payday lenders, check-cashing centers and prepaid debit card providers keep the working poor in a cycle of debt offering services traditional banks will not
  • Children, under strict rules, receive summer meals from food trucks
  • Families wait days to receive free dental care at tent clinics where buckets of pulled teeth pile up
  • Hospitals charge the poor and uninsured full price for the same medical care the rich and insured receive at a steep discount
  • A cancer-stricken Senator who's been on the receiving but never the giving end of compassion, votes to put in motion a vote that will make health care more expensive for the poor, sick and elderly
And yes America is still a preferable place to live than just about any other country in the world. We still have a far superior economic and political system than most. But that is why conservative efforts to leave the poor at the mercy of health insurance companies and so-called free-market health care are so frustrating.

Avik Roy, Paul Ryan, Mike Pence, Tom Price and other conservatives talk about the freedom people will have to buy only the health insurance they can afford even if it's crappy coverage. That's the equivalent of saying that it is okay for families to pay rent at market rates for a house without a working toilet, broken windows and holes in the walls. These guys use the traditional definition of American Identity, freedom, to justify withholding legitimate government services and investment in its citizens.

Conclusion

Why doesn't America cringe at the thought of buckets full of rotten teeth and decide that's not what America is? Why doesn't America say that even though there is a market for a specific service, we won't let the lucky take advantage of the unlucky? Why isn't America ashamed that it believes more in the principle of freedom to die prematurely than providing basic health care to everyone?

America talks a good talk about democracy and freedom, but the world sees all the bad stuff too. They see the wretched conditions of America's poor communities. They see poverty, gun violence and a country unwilling to solve its health care access and cost problems. They see America for what it does, not what it says.
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The Health Care Reform Fight Is Just Beginning For Some Of Us


While the health care reform debate stalls in the Republican-majority Senate, individuals health insurance purchasers like me are left wondering what's next. Will Health and Human Services Secretary (HHS), Tom Price, miraculously develop a base level of professionalism and sense of duty to administer the Affordable Care Act (aka, Obamacare), the law of the land, for now, the way it was intended? Will Republicans restore the funds for the risk corridors so that insurers are certain that the government will cover losses they may incur? Will HHS role out a robust national open enrollment program for the exchanges and will they staff the effort appropriately? Or will the Senate, like the House, find a way to pass their awful health care bill, the Better Care Reconciliation Act (BCRA) before the 2018 Open Enrollment on the Exchanges?

We, I, need answers to these questions soon because the fall health plan open enrollment season is just a few months away. My current health insurer has already sent me a good luck because we won't be here for you next year letter. And health insurance companies need answers to these questions now to make decisions about what, if any, plans they will offer to individual health plan purchasers.

Reason To Be Afraid For The Future Of Individual Health Plans

It's so disheartening to witness long-term Republican lawmakers and the White House react so vindictively to their current legislative debacle. After seven years of ranting about the awfulness of Obamacare and promising a better replacement, they delivered bupkis. But don't expect these guys to hang their heads in shame, that's a completely unfamiliar emotion to them. In fact, they can't even call their failure a failure. This is
a line from the official statement put out by the Majority Leader's office on the Obamacare repeal vote.

" Regretfully, it is now apparent that the effort to repeal and replace the failure of Obamacare will not be successful."

In other words, Obamacare, which provided health insurance and health care to millions of people, is a failure but the seven-year long Republican effort that created the unpassable Trumpcare is not. The fact that McConnell refuses to acknowledge that Republicans do not have a better alternative to Obamacare that they are all willing to vote for makes me queasy.

And what's even scarier about the future of the individual health insurance market is that where McConnell leaves off in his hypocrisy and projection, Trump picks up with his mean, hateful, nastiness. Since being elected, (gag)
Trump has boasted about letting 'Obamacare explode,’ ‘die on its own,’ or ‘fail,’ as he and his fellow Republican liars and obstructionists do everything they can to undermine the law. He threatened explosion when the House wavered in passing their crappy health care reform bill, the American Health Care Act (AHCA); and now he's threatening the same thing now that the Senate's bill is down and out (for now). I think Trump is dumb enough to try this strategy, and with his devil's helper, HHS Secretary Tom Price, things could spiral out of control quickly for people like me. Continue Reading...

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If Only Conservatives Would Demonize Health Care Prices Instead Of The Poor


Republican Congressman Mo Brooks of Alabama wants us to "take into account our financial limitations" in providing health care to every American. Some people interpreted his remarks as meaning that we can't afford to provide health care to every American. I want to give Congressman Brooks the benefit of the doubt and assume he meant that not everyone could have unlimited medical care at any price paid for by the government. But I can understand how others would translate his words negatively. Brooks is the same guy who talked about "people who lead good lives" as part of the health care reform debate.

This healthy people lead good lives, sick people lead bad lives is just updated phraseology for the same old moralizing nonsense conservatives use to demonize the poor and revere the rich. This type of thinking is so stupid and inapplicable in the real world. There are millions of healthy people who lead good lives that get sick. My best friend in the world was one of those people. She was active, did yoga regularly, ate organic, had an active social life and had a sharp mind. But one day she was diagnosed with cancer, and I lost her. This is a story repeated many times every day yet we still have jerks like Brooks that would rather use hateful language against the poor than address the unnecessarily high prices charged by hospitals and medical care providers.

You see politicians and doctors want us to believe the problem of unaffordable health care is our fault. If we only lead good, healthy lives, no one would need expensive, government-paid health care, says the politician. If we engaged in healthy behaviors and avoided unhealthy behaviors, we wouldn't suffer from expensive chronic diseases, says the doctor. And these politicians and doctors may have valid points—health care would be less expensive if we all lead healthy lives. But what world do these politicians and doctors live in? Who are these perfect, healthy people who do everything right in life? So instead of promoting this myth of the good, healthy, righteous, never need health care super-human being that does not exist, I wish Congressman Brooks and others like him would join us in the real world. A world where real good people, rich and poor alike get sick, sometimes really sick, and need expensive medical care.

The Alabama Congressman could address the financial limitations of high-cost medical innovations. About how much is too much medical innovation for the nation's pocketbook to cover? He could bring up for conversation why we require American doctors to obtain a Bachelor's degree before starting their medical degree education when many other industrialized nations do not. The cost of a medical education in America is the main justification doctors use for their high salaries. Mr. Brooks could learn more about the impact of socioeconomic factors on a person's health and support public policies to address these issues. He could also say that Americans should not pay
hundreds of thousands of dollars for heart attack treatment. But he doesn't focus on any of these issues. Continue Reading...

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Now Is The Time To Start Talking About Health Care Rationing


We are right to mock the hypocrisy of elected Republican officials that criticize the Affordable Care Act (aka Obamacare) for leaving millions of individuals uninsured and doing little to address the high cost of health insurance. Instead of creating policies to address these two Obamacare shortcomings, Republicans decided to exacerbate them by withholding funding to insurance companies that all but ensure that premiums will rise even higher and fewer individuals will have health insurance. We are also right to sneer when conservative intellectuals and Libertarians extol the virtues of a so-called free-market health care system where people are free to buy or not to buy any level of health insurance, and from any location they want. When the reality is that health insurers aren't in the habit of offering a la carte health plans. There's also the issue of opaque pricing with “free market health care.” Another issue with conservative and Libertarian views on health care is that half of the purchasers can buy insurance at a significant discount because of the workplace health insurance premium tax exclusion and the other half have no such benefit.

But at some point, and I think the time is now, Obamacare supporters and proponents of single payer or universal health care will have to realistically and publicly address how their proposed policies will deal with the problems of health care costs and affordability. Unlimited health care at any cost paid for by the government is not a realistic option, and no such system exists anywhere in the world. There are and should be limits on the amount of medical care an individual receives if they are not paying for it or if doctors and hospitals determine additional care would have no meaningful impact.

Our current U.S. health care system already places limits on the amount and form of medical care individuals receive. Sometimes these decisions are based on ability to pay the cost of care, and at other times they are based on medical science. However, this approach of rationing medical care won't be sufficient in a Medicare For All style system. Rationing of medical care will have to be front, and center of any government paid health care system. But that is not to say that people will not have access to care the government won't pay for; they are free to purchase health insurance or health care individually.

Some people may believe that a government codified system of medical care rationing harms the poor and favors the rich. Not necessarily. First, the poor won't likely pay anything for their medical care, and they will have access to preventative and continuous care that should improve their health status. Second, the poor won't have to pay for costly medical innovations, one of the real drivers of outrageous U.S. health care costs, but they will benefit from them. And third, the stigma applied to government-provided health care is diminished and so is the incentive for doctors and hospitals to treat the poor differently.

Okay, But Not Now

Right now proponents of government-paid health care for all our engaged in a battle to keep the poor from losing access to medical care. They may feel that they have to accomplish this goal first before they can start the conversation about their ideal health care system. Meanwhile, opposers of government-based health care use the socialists, communists, and hippie-dippy, out-of-control spending argument to make universal coverage look less attractive than the status quo. And I fear they are winning this argument because of a weak counter-argument of a greedy, evil opposition.
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The Republican You Either Don't Need Or Want Health Insurance Reform Bill


We will never know what the private health insurance market would look like today regarding cost and affordability if the Affordable Care Act (aka Obamacare) never became law. However, there is every reason to believe that premiums would be as high if not higher than they are today and that coverage for many people with pre-existing medical conditions that purchase individual plans would be unaffordable or unavailable. But as we contemplate what would have been we should also dread what will be.

Very soon, Republican elected officials will likely pass a health care bill, or tax bill if you prefer, that will return us to the health insurance status quo, but with a twist. The Affordable Health Care Act (AHCA) passed by the House and the Better Care Reconciliation Act (BCRA) proposed by the Senate make the pre-Obamacare health care status quo look not so bad. The BCRA effectively makes individual health insurance plans worthless.

The Better Care Reconciliation Act allows health insurance companies to get away with paying barely half the cost of medical care while charging individual purchasers more than they currently pay in premiums, copays, deductibles, and coinsurance. These provisions in the bill are not just a case of more money for less coverage; they are an attempt to eliminate the individual market for all but the wealthy. Furthermore, these features of the bill are a way for the government to pay less in premium subsidies because people who can't afford these skimpy plans will drop out of the individual market altogether.

This Law (BCRA) Stinks

When
Bill Clinton called Obamacare, "the craziest thing in the world," he was referring to the fact that the law offered no financial help to purchase health insurance for millions of individuals. These are people like me that didn't qualify for Obamacare subsidies, Medicaid, Medicare or the employer health insurance tax exclusion. We have to pay 100% of the cost of our health insurance even though most of us are not wealthy. Meanwhile, Obamacare supporters, especially the ones responsible for administering the ACA, downplayed the size of this group or claimed that they would get around to helping us eventually.

After winning the majority of seats in the House and Senate and electing a Republican president, Republican officials seized on Bill Clinton's statement claiming their health care reform bill would eliminate the craziness.
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The Splintered Health Care Policy Goals of Conservatives Are All Bad For The Poor


Before the passage of the Affordable Care Act (aka Obamacare), America had not had a conversation about health care policy in decades. So it's understandable that many elected officials lacked knowledge about America's health care system and assumed it was performing as intended. From what they understood the health care status quo met the needs of the wealthy, professional and middle classes. And the poor, elderly and veterans had government-provided insurance.

But looks can be deceiving; individuals without any group-provided insurance were left to the mercy of the health insurance market. A market that left over 40 million of them uninsured. Obamacare came along and upset the peace of health care policy reform at the best and worst possible time.

It was the best time for an Obamacare-type law because
about 40 million Americans did not have health insurance and Obamacare provided coverage to almost 40% of them. And it was the worst time for an Obamacare-type law because the country was and is so divided on most major public policy issues. Major health care reform was introduced in a politically polarized era that became even more polarized when Trump won the presidential election, and the Republicans won a majority of Senate and House seats.

More Than A House Divided

The Republican/conservative health care policy stance is much more splintered than it is among Democrats/liberals. Democrats want Medicare or Medicaid for All, universal health care or single payer. Or maybe they just want more federal funding for the Obamacare exchanges. It depends on which group of Democrats you ask, but at least they all want a health care reform policy that expands coverage to all Americans, Republicans disagree with Democrats on the very definition of universal access to health care. Remember when the Republican Party stupidly referred to health insurance/care access as "freedom?"

But idiotic catchwords aside, Republicans and conservatives also disagree with each other on the policy goals of health care reform. First, there is Senate Majority Leader, Mitch McConnell's (a real life villain) view that replacing Obamacare is the ultimate policy goal. He couldn't care less about the contents of any health bill and its impact on the public. His only health care reform policy objective is to convince enough Republican senators to pass an Obamacare repeal bill quickly.
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Americans Never Really Wanted A Fairer Health Care System, And They're Not Going To Get One Anytime Soon


A recent New York Times article laments the "halfhearted opposition" to the pending passage of the American Health Care Act (AHCA, aka Trumpcare) by powerful groups such as doctors, nurses, hospitals and patient advocates. Health policy experts condemn the "fast-tracking" of the ACHA in the Senate. And the Jeff Sessions' hearings and other Russia collusion noise, crowd out national reporting on the AHCA as the Senate is weeks away from passing their health care reform bill.

The AHCA passed by Congress and currently undergoing revisions in the Senate, rewards the healthy and wealthy and punishes the sick and poor. Some people are appalled and baffled by the impending passage of legislation that brings more inequality into an already unequal system. Isn't it more sensible to provide the most financial assistance to people that need the most health care? Well this is America, where a near majority believes it's okay that the rich can afford better health care than the poor.

The Poor Cost Too Much

Many people think the sick are responsible for their illness(es) due to their engagement in "voluntary health risks" or "changeable behaviors." Never heard these terms before? Me neither. I guess using the term
unhealthy lifestyle didn't sufficiently make the point that sickness is a choice, and an expensive one at that.

By some estimates an unhealthy lifestyle cost hundreds of billions of dollars each year in medical care. A recent
study contracted by General Electric estimated the cost of cancer care due to an unhealthy lifestyle at around $34 billion per year. Other studies put the annual costs of treating alcohol abuse at an estimated $176 billion, smoking at $137 billion and obesity at $147 billion (2008 number for obesity). These issues—cancer, alcohol abuse, smoking and obesity—costs nearly a half trillion dollars in health care each year.

But cost concerns are not what allow the Republican Congress and Senate to easily take away health insurance from the sick and poor. The truth is that despite the passionate town halls, we don't want the poor to live as long as the wealthy. We would save money if they did not. According to the Congressional Budget Office (CBO) score of the AHCA,
that savings is about $3 billion, to start (represents reduction in Social Security payments due to early deaths). Continue Reading...

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Health Care Reform Sausage-Making Grinds On


Overpricing and overcharging minorities and the poor in hospital ERs; health care specialists are driving up the cost of care; Mylan is waiting out the outrage over its high-cost Epipen and continuing its price gouging, and major health insurance companies settling multi-million dollar Medicare and Medicaid fraud cases with the government. The American health care system is a disaster and a disgrace. Greed and self-interest are its fuel. It's opaque. It's irredeemable.

And, the Affordable Care Act (aka Obamacare) trying to work with and maintain the American health care system, only highlighted all its ills. But at least the Democrats engaged in a comprehensive and intensive effort to improve one of America's biggest problems. Unfortunately, you can't say the same about the Republicans. From the start, and I'll give them credit for not lying about how vile the process would be, Republicans engaged in health care reform sausage making. Their health care reform plan consists of a three-step sausage making process—gut as much of Obamacare (cut taxes) via reconciliation, eliminate health care reform regulations, pass general health care regulation through the normal legislative process.

And like most sausage making, the Republican health care reform work is occurring out of sight. There are no experts to advise on the combination and impact of different policy options. In fact, Republicans in the Senate decided not to send their reform proposals through committees and instead assigned 13 Senators to review the House bill for further tweaking. This not-at-all discriminating approach to health policy reform all but guarantees an unappetizing product for millions. There should be no expectation of a Senate health care reform bill that is much better than the bill signed by the House. In fact, the Senate bill may be even worse than the House bill.

Initially, House Republicans were transparent about their health care reform bill. They made it clear that the Obamacare repeal law, the American Health Care Act (AHCA) was step one of a 3-step process to replace Obamacare. They collaborated with the Health & Human Services Secretary, Tom Price, to sell the proposed law to the public. And, lastly, they waited for the CBO score before deciding not to vote on the legislation. In the end, transparency was political poison for the House, and they resorted to secret meetings and hiding drafts of the revised proposal. The result was a reform bill that was just as bad as the first one but easier to pass politically. Republican senators have no desire to repeat the mistakes of their House colleagues. There will be no false starts on voting and no or little sharing of policy details before the vote, and there will be a vote and the bill will pass.

A Senate version of the AHCA will look a lot like the House version, but with
a longer timeline to implement its awfulness. Expect, Continue Reading...

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Health Care Reform Protestors Continue To Ignore Employment-Based Coverage


Some people think the original sin of health care and health insurance is government regulation and "patches" like Medicare and Medicaid. Other people think the problem originated from a different government sin—the employer health care tax exclusion. This tax break translates into significant money saved for individuals enrolled in employer-provided health plans. Individuals not enrolled in these plans and who purchase health insurance, do not receive these savings.

So which sin should the country address first, health insurance regulations and patches or health insurance costs equity? The easiest issue to address—equalizing or eliminating the special tax treatment of employer-sponsored health insurance plan payments is a good place to start. But our time-strapped Republican-majority Congress decided to spend the majority of its limited attention tinkering with the political and policy challenges of health care regulations. The Congressional health care reform bill, the
American Health Care Act (AHCA), does not equalize or eliminate the employer health care tax exclusion but goes very far in changing health insurance regulations.

These proposed regulatory changes will take hundreds of millions of federal dollars out of the health insurance and health care system if they survive the Senate and reconciliation processes and are signed by the President. Potentially,
tens of millions may lose their health insurance coverage and access to health care. People opposed to the AHCA are focusing their energies on protesting at congressional town halls, emailing and writing their representatives and educating the public about its possible impact. It's an uphill battle for these protestors to change the course of legislation, which is why I think they may have more luck at addressing the unequal tax treatment of health insurance premiums that exists between employer-sponsored and individually paid private health insurance.

The AHCA, in a very limited way, does address the employer health care tax exclusion by providing tax credits to individuals that purchase health insurance. However, these credits may not equal the value of the exclusion and the health plans available in the individual market do not equal what employers offer. So, at a minimum, protesters should demand that the AHCA equalize the tax treatment of all health insurance plans. But they shouldn't stop there. AHCA opponents may have more success trying to convince employers to stop providing health insurance or provide only supplemental health insurance.
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Universal Health Care Opposition Research, Is It Worth Reading?


After spending years studying the Affordable Care Act (aka Obamacare) and related health care reform proposals, I am on a journey to explore the other side. While I've made a point over the years to read the health care reform opinions of Obamacare opponents, I never took seriously their prescriptions. But with the dreaded feeling that the country is on the path to indefinitely postpone the next level of health care reform, I decided to read and reread the writings of those who think our most recent health care reform efforts were a big mistake.

So this past weekend I read a lot of Michael Cannon
articles and blogs. Cannon is the Director of Health Policy Studies at the libertarian Cato Institute and an avowed Obamacare hater. Cannon is famous for his many attempts to sabotage the Obamacare law in its early stages by mounting a legal challenge of the subsidies provided to federal exchange enrollees. He also encouraged states not to create their own exchanges (this approach went hand-in-hand with his legal challenge as to whether the federal government could provide subsidies to non-state exchange enrollees). Of course Cannon does not view his fight against Obamacare as sabotage, and although I think it clearly was, I am setting this aside for now.

Today, I'm more interested in understanding the health care reform viewpoint of single payer and universal health care opponents. But not just any opponent, more specifically, I am interested in comprehending the beliefs of the policy wonks, the die hard free market crusaders that oppose government playing any role in providing or paying for health insurance and health care. Consequently, I am reading the works of Michael Cannon and Ron Paul. Free market conservatives draw many negative conclusions about universal health care, including:
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As GOP Looks To Drag Health Care Backwards, Health Insurers Look Forward


Recently, Congressman Steve Chabot of Cincinnati, Ohio wrote on his blog, "I haven’t seen so much misinformation and hysterics about a piece of legislation in a long, long time—maybe ever" about the passage by the House of the American Health Care Act (AHCA). I guess he was asleep during the passage of the Affordable Care Act (aka Obamacare). But all kidding aside, I strongly suspect that the Senate will continue the House's work to make American health care look more like it did pre-Obamacare. They never thought health care reform was necessary in the first place.

Republicans have the numbers to pass the health care bill they want; still, I can't help but think that a return to the status quo is not in the country's future, at least not long-term. You see, Republicans may think that they are about to accomplish something that's never happened before, taking away a huge federal entitlement program, but not even health insurers are prepared to return to the bad old days. Insurers know they passed the big-changes-are-coming-moment and are in the redefining-and-refining-our-purpose-moment, and if the GOP had consulted them during the health care reform debate, they would know this also.

What Health Insurers See As Their Future

Optimizing value by providing doctors with data analysis services.
Last week Humana's CEO, Roy Beveridge, described the country's third largest health insurer as
an IT company focused on data analytics to improve health care value. According to Beveridge, the future of health care may be using data to understand risk better and sharing this data with doctors to improve patient outcomes. Doctors can use this data to determine which patient populations need what care and how often to engage with them.

Focusing in on getting a bigger piece of the (new) pie.
Also, last week, health insurer Aetna, Inc.,
announced it would pull out of the Obamacare exchanges for next year. In addition, Aetna CEO, Mark Bertolini, reportedly said, the country needs to have a conversation about single-payer health care. However, instead of health insurers competing with the government to offer health insurance, Bertolini envisions health insurers managing the single-payer program for the government, as it does with Medicare and Medicaid.

Enhancing patient access to health care services.
The Blue Cross Blue Shield Association is looking to help the very population the AHCA would possibly harm, the poor and isolated. Recognizing that not everyone has access to reliable transportation to get to non-emergency medical appoints BCBSA is
piloting a program to partner with Lyft to provide free rides to its members. Continue Reading...

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Obamacare Supporters May Accomplish More By Focusing On Multiple Policy Issues To Reduce Health Care Costs


You chose the wrong job. You're the wrong gender. Your lifestyle choices suck. You should pay for your risks. You're a celebrity and should stay out of the health care debate; also that's not how preexisting condition provisions work. The anti-universal health care set has a rational, in their eyes, retort for every appeal for government-paid health care for all.

Mocking the emotions of Medicare For All supporters is so easy it's been pushed down to the level of millennial reporters. And the formula for attacking their opponents is always the same—a charge of too much emotion and not enough facts. The fact that they know little about how health insurance and risk management works, the history of health insurance plan design and access, and the conflict associated with insurers determining risk while seeking profit is unimportant to them.

There's a wall between supporters of government-sponsored health care and those that oppose it that won't come down with appeals to decency and empathy. Still, a change in public policy is the only solution to addressing health care access and affordability. And while it may appear that policy just tilted for anti-government assisted health care reform with the Republican-majority Congress's vote to make health care less affordable for millions, that may not be a bad thing for two reasons.

One, overall the Affordable Care Act (aka Obamacare) is popular among the majority of Americans despite a vicious sounding minority that demonizes people who need assistance paying for health insurance and health care. If Obamacare "supporters" see the nation returning to pre-Obamacare days when coverage could be denied outright or so expensive as to represent a denial, they may demand to return to the protections offered by Obamacare or even greater protections.

Two, Obamacare supporters should take this as a sign to expand their support for health care reform by supporting policies that may potentially reduce health care costs. Policies that focus on alleviating hunger, especially among children and the elderly, should be at the top of the list. Also, addressing homelessness and mental illness is essential to reducing health care costs. These are issues policy advocates, and elected Democrats should include in any federal budget and hold firm on their passage. Of course, there will be opposition, possibly as strong as is currently for Obamacare, but with proper messaging, voters may come start to realize who want to address their needs and concerns.

Not everyone engages with the health care sector every day or even every year, but hunger, homelessness, mental illness and drug addiction are issues most people encounter regularly. Obamacare proponents have nothing to lose by dissecting and addressing the individual drivers of health care costs; it may even be easier than focusing solely on health insurance, which is too complex for most people to understand. Continue Reading...

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America's Culture Wars Stand In The Way Of Real Health Care Reform


America has always been a nation divided. The country fought over its divisions in a gruesome war, one side lost, and the nation stitched itself together again. But the stitches never healed and America never adopted a unified identity. This lack of identity led to smaller wars, culture wars, including conservative values versus liberal values, and the role of government versus the responsibility of the individual.

And with the election of Donald Trump, America's culture wars has reached fever pitch. So much so that some people believe America is headed for a second Civil War; but if not war, towards defining a new national identity. But don't underestimate America's ability to make minor adjustments and put off making tough decisions. A second American civil war is unlikely, but so is adopting a national identity acceptable to all. More than likely, America will move in the direction of greater universality in some areas because political and social forces at the time pushed us there.

We are currently experiencing a grudging push by some toward universal health care because, despite Trump supporters' hatred of their cultural opposites, many of them need assistance paying for health care. Even conservative columnist, George Will, thinks single payer health care in America is inevitable. This is good news for single payer advocates like me because single payer would improve access to health care. On the other hand, single payer health care will not reduce the cost of health care because America is not ready or willing to address the issues that make American health care so expensive, especially the issue of poverty. Continue Reading...

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Tom Price Asked Doctors To Tell Him How They Want To Get Paid. That's Ridiculous.


The big health care story last week was Trump threatening, again, to let the Affordable Care Act (aka Obamacare) implode if Democrats did not work with him to pass his health care reform bill. It's a story worth reporting because it clearly shows that Trump just wants to tick health care reform off his to-do list. Something he can brazenly claim is better than Obamacare, even though it won't be, and that he accomplished quickly and through force.

Meanwhile, while Trump was undermining Obamacare with threats, Health & Human Services (HHS) Secretary, the greedy and corrupt, Tom Price, was actively weakening the law. After the Republican health care reform law debacle, Price wasted no time tweaking Obamacare administrative provisions that will most definitely result in fewer people enrolling on the federal exchange. He did this by greatly reducing the annual open enrollment period and placing restrictions on special enrollment periods and requiring documentation for life events such as marriage, birth, and losing workplace health insurance, etc. The new rules also force you to pay the full year's premiums unless you have a life event like new job-based coverage, eligibility for Medicare or Tricare, etc. With this new rule, you cannot stop paying premiums the last few months of the year, as you could under the old Obamacare rules, to save a few bucks. Price and HHS also gave insurers the green light to offer slightly skimpier health plans. Bonus!

But Price's week wasn't done. The former doctor who wants to get rid of Medicare and Medicaid because he believes the reimbursement rates are too low
asked doctors for ideas on how they should get paid. Specifically, Price was referring to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which replaced the old system of paying doctors for Medicare services. MACRA is an attempt to move away from paying physicians based on the number of patients they see (fee-for-service model) and towards a system based on value and quality of services. Therefore, MACRA also requires reports on quality and pays physicians extra for meeting quality standards.

Price portrays MACRAs quality standards as so burdensome to doctors that they could lead to burnout and more doctors leaving the profession. He doesn't support bundled payments and likely doesn’t support value-based health care at all. He uses his credentials as a former orthopedic surgeon to claim he knows better than anyone that value is hard to define and therefore, unfair to pay doctors according to value-based standards.
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Medicare For All Requires New Health Care Industry Players


It seems everyone working in the health insurance and health care industries feels entitled to large profits. And they will do or not do just about anything to get their share of the multi-trillion dollar a year health care "market." Doctors thumb their noses at "low" Medicare and Medicaid payments, limiting the number of patients in these programs that they will treat. Health insurers balk at insuring the very sick without government subsidies to reduce their financial risk. Pharmaceutical companies threaten to curb drug innovation unless they are allowed to impose astronomical markups on existing products and enjoy long patent periods. And hospitals do whatever the heck they want to make a buck--different prices for the same care with no transparency or explanation. And these are only four of the big players in the health care market; there are many others elbowing for their share.

Under these conditions, American health care reform that tries to lower costs is dead on arrival. The powerful groups benefitting from our overpriced health care system aren't going to accept a pay cut. Some may suggest incentives to get doctors to accept lower reimbursements, like subsidizing their student debt or even reducing the requirements and the number of years it takes to become a doctor. Others may suggest performance bonuses, like the ACA tried.

There are a lot of good sounding suggestions for lowering health care costs, including drug re-importation, universal use of electronic health records, value-based health care pricing, hospital consolidation, competitive bidding for supplies, focus on tertiary care, etc. You name a health care cost cutting idea, and great minds have already penned it.

One health care cost cutting idea receiving more attention is allowing future American doctors to enroll directly into medical school instead of first getting a 4-year undergraduate degree. Medical students and the country would save a lot of money, and their student loan excuse to demand high salaries falls away. Many countries with similar or better health care outcomes require 5-6 years of schooling to become a doctor versus 8 in the U.S. But American doctors won't easily give up the prestige of being a doctor and, therefore, will continue to demand higher salaries.
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Maybe "Low" Medicaid Rates Are What We Should Be Paying To Make Health Care Affordable For All


I recently read a comment on social media from a doctor equating accepting Medicare and Medicaid to (a doctor) signing her slavery agreement. And as insulting and inaccurate (slaves didn't sign agreements!) as this statement is, the sentiment is not too far off from what many doctors in America share. Doctors often refer to Medicaid as charity work.

The claim that Medicaid reimbursements do not cover the cost of care is near universal.
Some specialists claim they make about $8/hr. treating Medicaid enrollees. Others publish a sampling of their Medicaid reimbursement payments online to show Medicaid paying less than $5 for care billed at $400. Of course, they never share all of the information about a claim, just enough to "prove" their narrative of poverty inducing Medicaid rates.

Meanwhile,
physician complaints about Medicaid are the same as the ones they have about private insurance; they just hate Medicaid (and Medicare) more because of the lower reimbursement rates. For all payers, doctors complain about jumping through hoops to get paid, late payments, paperwork, and regulations. Some doctors have also complained about the behavior of Medicaid patients (don't exactly know what they mean by that).

Unfortunately, doctors and hospitals can get away with their Medicaid-rates-are-too-low claims because they are the ones setting the rates. And, as we know, they charge different rates for different groups of patients—Medicare, Medicaid, patients with private health insurance, patients without private health insurance, etc. But these rates aren't related to actual costs because a doctor's time and effort are never measured. So doctors cannot prove Medicaid rates don't cover the cost of their services. Still, that doesn't stop them from demonizing Medicaid, but the reality is that doctors don't like any program or law that controls the fees they can charge or requires them to meet certain standards.

Brief Primer On Medicaid Reimbursement Rates Continue Reading...

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The 'Triple Evils' Of Republican Health Care Reform—Ryan, Price, Mulvaney


Decades ago Dr. Martin Luther King, Jr., spoke about the triple evils in society—poverty, racism and militarism. These three things still exist and continue to feed off of one another, but this week three more evils emerged. Speaker of the House of Representatives, Paul Ryan; Secretary of Health And Human Services (HHS), Tom Price; and Director of the Office of Management And Budget (OMB), Mick Mulvaney recently embarked on a tour to spread Step One of their evil health care plan. Shameless lying about an Obamacare death spiral is to be expected from these three, but the callous response to their health care bill's impact on the elderly and poor is shocking.

With a little preparation, Ryan, Price and Mulvaney hit the media circuit and boy did their true colors shine through. Ryan continued in his persona of the cocky politician staying true to his conservative principles. Price adopted the role of the all-knowing physician giving the uniformed a hard dose of medicine on the evils of government "interference" in health care. And Mulvaney, serving as Trump's representative, is just hard to watch.

Paul Ryan, Champion Of Free-Markets

The one and only good thing about the introduction of the American Health Care Act (AHCA), is that it totally destroyed Paul Ryan's (fabricated) reputation as a brilliant policy wonk. Ryan's contribution to the AHCA is ideological and administrative. Ideologically, Ryan does not believe in taxing rich people and does not like entitlement programs. Consequently, questions about the tax cut for the wealthy and the gutting of Medicaid elicit smirks and God-awful responses from Ryan, including these gems from his interviews with radio host, Hugh Hewitt and Fox News' Tucker Carlson, respectively:

“But we always know, you’re never going to win a coverage beauty contest when it’s free market versus government mandates.” Ryan's response is reminiscent of remarks made by former Louisiana Governor, Bobby Jindal, when he rolled out his Obamacare repeal plan:

"whatever amounts of money conservatives were willing to allocate to address a problem, Democrats would always be willing to spend more, so conservatives cannot get into a bidding war." And, “I think it's a mistake if we measure health care reform in terms of how many people we give cards to.”

But Ryan wasn't done being a jerk,
this is what he said when called out by Carlson for eliminating an investment income tax on the richest Americans as part of his reform reconciliation bill, "I'm not that concerned about it because we said we were going to repeal all of the Obamacare taxes and this was one of the Obamacare taxes."

And concerning millions of people potentially losing Medicaid coverage, Ryan has expressed absolute giddiness about the billions of dollars in federal savings and the prospect of de-federalizing Medicaid once and for all.

With Paul Ryan, you get an ideology without a soul.

Tom Price, Preserver of the Doctor-Patient Relationship And Access Proponent Continue Reading...

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Step One Of The Cruel Republican Health Care Bill Could Actually Pass


How bad the American Health Care Act (AHCA), the Republican replacement for the Affordable Care Act (aka, Obamacare), will be for the mentally ill, women, poor people, children, older people, and people needing drug treatment is still unknown. However, everyone expects these groups to receive less financial support in purchasing health insurance and in accessing health care. Meanwhile, the young, healthy and the wealthy have something to smile about if the AHCA becomes law.

But According to Donald Trump, weakening Medicaid and providing skimpier subsidies than Obamacare is just the first step in the rollout of the Republicans' great health care reform plan. For step one of the bill making process, Republicans had to navigate a complicated legislative process called reconciliation, as Paul Ryan likes to remind everyone, including critic, Senator Tom Cotton. So Ryan took this opportunity to do something thoroughly Republican and eliminate the Obamacare-related taxes for the rich and warn the poor that their health care free ride was over.

Don’t Underestimate The Republicans Capacity For Cruelty

After rolling out step one of the American Health Care Act, Republicans in Congress proceeded to make some of the dumbest and most hypocritical remarks in political history. I'm being dramatic but I'm not the only one that attacked Congressman Jason Chaffetz's on Twitter for his dumb iPhone remark, or who was disgusted by Senator Tim Scott's dissing of the Congressional Budget Office (CBO) because he suspects it will reveal the bill as a huge takeaway for the millions who got insurance under Obamacare. And let's just try and forget Paul Ryan's misleading, inaccurate and amateurish PowerPoint presentation where he revealed that he doesn't know the definition of insurance, and his performance on Fox News where he coldly stated that he didn't care about the windfall his bill gives to the rich.
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Let's Hope The Republican Health Care Plan Stays In The Basement


Everyone wants to see the Paul Ryan/Tom Price Affordable Care Act (aka Obamacare) replacement bill, even most Republican lawmakers. But Ryan and Price would rather look like a putz than reveal who will be the primary losers under their new plan. They are also afraid that their fellow Republicans will join the media in ripping their plan apart. They have no desire to be once again the objects of a mocking press, Democrats and Obamacare supporters for their inability to present a Republican, majority-supported Obamacare alternative plan.

After embarrassing leaks describing their reform paralysis at the Republican retreat in Philadelphia earlier this year, and the leaked draft that revealed a proposal to base tax credits on age instead of income, Ryan and Price literally went underground (House basement) to reveal their latest proposal to a select group of lawmakers. There's plenty to mock about this childish approach to drafting legislation. But like all things related to Republican health care reform efforts, this latest hide and seek stunt is about politics and not providing affordable health care. Ryan can't keep putting out bad proposals that the rest of the GOP won't support. At least not publicly. He failed in his promise from years ago to lead the effort to draft an Obamacare replacement bill and is now just a mere figurehead of the process. Health care reform is now a Senate and White House effort with Ryan serving as secretary and spokesperson.

And with Senator Mitch McConnell and Secretary Tom Price leading the effort, we can expect more drastic cuts to federal subsidies and fewer people with insurance coverage than if Ryan had pushed through all of his lackluster reform ideas. McConnell has always wanted to push health care reform back to the states via high-risk pools and other disproved policies. But states have made it clear that they need federal government funds and they like the money Obamacare provided. Therefore, I expect the new Republican health care reform bill to grandfather Medicaid expansion for the states that adopted it. And based on past Ryan/Price proposals and the Trump Joint Congressional speech this week, we can easily assume that the crux of the law includes health savings accounts and tax credits that will mostly benefit the well-off, healthy and young Continue Reading...

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The Battle Between The "I Was Helped/Hurt By Obamacare" Snowflakes


Since the presidential election, Trump supporters and non-supporters have accused one another of being Snowflakes, or overly sensitive. However, recently the term Snowflake is used increasingly to describe Trump supporters. Countless articles in liberal and conservative media publications warn about the dangers of referring to all Trump supporters as racists, misogynists or uninformed. They claim that these negative characterizations are starting to backfire and result in Trump supporters clinging to him even more.

And many Trump voters admit that they are completely turned off by liberal attacks and hurtful characterizations. Not surprisingly, Trump non-supporters refuse to alter their depiction of Trump voters. They find their characterization of Trump voters accurate and their feelings not worth protecting given the potential harm a Trump Administration can cause. Add to this war of words the contentious issue of affordable health insurance and health care, and you get a mini battle between people that claim Obamacare helped them versus people who claim it hurt them. Both camps have its share of Snowflakes with the "Help" combatants referring to the "Hurt" combatants as selfish and heartless, and the "Hurt" section referring to the "Help" warriors as smug.

The "Hurt" group desperately wants to explain its objections to government-mandated health insurance. They don't like being forced to pay higher premiums than they otherwise would to subsidize health insurance for people who can't afford it. Some in this group don't want to subsidize anyone's insurance but most object to subsidizing people they characterize as able-bodied adults who made bad life decisions. A typical social media thread between the two groups has traces of the culture war happening between Republicans and Democrats.

(This is a real, abbreviated thread from a health care Facebook group. I purposefully exclude the name of the group and the contributors):
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Obamacare Supporters Divide Into Groups To Protect Their Interests, But Not Everyone Is Represented


There's a lot of speculation about which group of Americans will be hurt the most by impending Republican health care reform legislation. People with preexisting conditions may see these exclusions return in some form. People with life-threatening medical conditions requiring expensive medical care may see the return of annual/lifetime limits. Group health plans may see their tax-favored plans altered and made less attractive. And freelancers and entrepreneurs may be forced to return to traditional employment, if available.

Everyone that is not wealthy enough to pay for health insurance or fortunate enough to have someone else pay for it has a reason to be concerned about Republican changes to the Affordable Care Act (aka Obamacare). And that's because health care reform is just an unwanted political exercise to Republicans. Made necessary by a law, that despite its shortcomings had a larger goal of providing affordable, comprehensive health insurance to all Americans.

Things Are Different Now

Oddly, not repealing Obamacare is more popular than the law itself. A lot has changed since the law's inception in 2010. While Republican lawmakers waited and tried to hasten the law's collapse by ending funding for the risk corridor program, something else happened—lives were saved. Cancer diagnoses that would never have occurred did. People with life altering mental illnesses started receiving treatment that allowed them to be more productive. Various artists obtained insurance for the first time in decades. The Obamacare death spiral that House Speaker Paul Ryan was so hoping for and wrongly claims is upon us didn't happen soon enough.

There are just too many Obamacare success stories getting in the way of the GOP narrative that every single component of the law has been a total failure. Not that Republican lawmakers are not trying to continue to push the narrative of Obamacare as the dumbest law ever passed by the government. They've even gone so far as to claim paid protesters are behind the current, vocal swell of support for the law, and are giving shout-outs to their well-funded and well-organized protesters to counter this support. This Retweet from the Heritage Foundation says it all:


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Can Price And Ryan Con America Into Accepting Less Health Insurance Protection?


It is official, the corrupt and greedy former orthopedic surgeon, Tom Price is the new head of the Department of Health and Human Services (HHS). What changes he will make to the Affordable Care Act (aka Obamacare) weighs heavily on a lot of minds. Will it be a slow dismantling of the law or full replacement? Will he work with House Speaker, Paul Ryan who promises to have a House plan ready in 2017, possibly by the end of the first quarter of the year? At the moment, who knows what he'll do, but expect a lot of noise over the next month from the GOP about their Obamacare replacement plan.

In fact, the show of the Republican's impending replacement plan has already started, with Paul Ryan as its star. First, he hosted a televised town hall in January, trying to convince America that Obamacare was in a death spiral. His criticism of Obamacare continued on the Charlie Rose show, and every other time he is in front of a television camera or reporters microphone. And just this week the American Action Network (AAN), using footage of Paul Ryan and hinting at his BetterWay plan, ran a television ad claiming Republicans have a plan.

After leaks of a clueless GOP grappling with health care reform at the Republican retreat in Philadelphia last month, Paul Ryan is eager to change the narrative. He is building up his party's Obamacare replacement reveal the only way he knows how, by using his star power and telling a bucket full of lies.

Ryan is not as smart as he wants people to think but unfortunately, he has a reputation for being the smart guy that's not afraid of getting into the weeds of policy. He's hoping that his undeserved reputation as technical but empathetic, will allow Republicans to replace Obamacare with less health care coverage. He doesn't frame his proposal as less than Obamacare. Instead, it is referred to as patient-centered and freedom (from costly mandates for coverage you don't need). Continue Reading...

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Republicans Need Help "Fixing" Obamacare, We Should Offer Some


Last week's Republican House and Senate retreat in Philadelphia revealed what we already knew; they don't have a plan to replace the Affordable Care Act (aka Obamacare). This week there were reports that some Republicans have given up on repeal and replace and want to “fix” Obamacare instead. Also, this week, shady Congressman Tom Price came one step closer to becoming Secretary of Health & Human Services when the Senate Finance Committee approved his nomination without Democratic support.

It's been a frustrating week for Obamacare supporters concerned about the future of health insurance and health care in America. Every statement about health care reform, even if it is a repeat of what's been said before is scrutinized for new meaning. But for now, we are in limbo, and that is not a bad thing. Things could be worse. We should use this time to put forth some ideas on health care reforml.

Obamacare Could Be Better

Everyone agrees that Obamacare plans could be better—more affordable and there should be more of them. Also, there's majority agreement that some provisions of Obamacare are keepers, like no prohibitions on coverage for preexisting conditions, keeping dependent children on employer-provided plans up to age 26, and receiving subsidies to pay for coverage. But these goodies cost money and require trade-offs. So knowing that Republicans would prefer the government get out of the health insurance business, what suggestions would you give them if they were forced to stay in it. Keeping in mind that you can't get everything you want.

Protests are fine, but how can we improve Obamacare when we know universal coverage is out of the cards in this new Republican reality?

First, agree not to turn Medicaid over to the states via block grant or any other program. States may know their constituents better than the federal government, but equality often comes in a distant second to state budget priorities. We can't trust states to cover everyone who needs Medicaid. We also can't trust them to regulate the quality of care Medicaid recipients receive. Medicaid patients wait longer to see a doctor and get a lower quality of care than patients with private insurance.

Instead of Medicaid block grants or any other state-based Medicaid program, the federal government should run the Medicaid program just like it does with Medicare. Everyone gets the same benefits, and medical providers must meet predetermined quality standards in exchange for higher reimbursement levels.

There is no way for the government, federal or state, to get around paying for health care for the poor. States can assist in this effort by addressing the poverty in their communities, but they should stay out of the health care business for the poor.
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Republican Health Care Reform Plans Are Getting Less Comprehensive And Less Acceptable


To borrow a line from Hamilton, the musical, [Republicans are having their] "governing is harder moment" with health care reform. Just this week they added two more health care reform proposals (outlines) to the seven they conjured up since 2009. The latest health care proposals are near opposites of each other and include an Affordable Care Act (aka Obamacare) light plan and a worse than before Obamacare plan with no subsidies, or possibly, insurance for the sick and poor.

The Road To Still No Health Care Reform Bill

Whenever Obamacare opponents provide an Obamacare alternative plan, its contents are 90% Obamacare is an abject failure, and 10% (usually a bulleted list), here's my plan. Because the focus is not on reforming America's complex and pricey health care and health insurance sectors, their plans come up short in money, benefits covered and access, when compared to Obamacare. This opposition-focused exercise that Republicans are engaged in has produced nine proposals so far.

  • The Obamacare Replacement Act
  • Patient Freedom Act
  • The American Health Care Reform Act
  • The Patient Choice, Affordability, Responsibility, and Empowerment (CARE) Act
  • Health Care Choices Act
  • A Better Way, To Fix Health Care (Reform Plan)
  • The Patients' Choice Act
  • Health Care Freedom Act
  • Empowering Patients First Act
So, from 2009 to 2017, Republicans have been unable to agree on a unified health care reform plan. But this week they are meeting in my hometown of Philadelphia to map out their policy agenda. According to leaked photocopies of the retreat agenda, there was a Thursday morning session labeled Keeping Our Promise On Health Care. And unless some waiter recorded this session, we probably won't know for some time what Republicans plan to do with American health care. Will they agree on a unified reform proposal—there's no shortage of them, including the two announced just this week? Will they, as Trump mused, wait to see if Obamacare explodes and then "rush" to fix it in 2018, after the mid-term elections? Or will they propose a series of health care reforms stretched out over several years? And will these reforms be more health care or health insurance-centric?

More Words Don't Equal More Coverage

Republicans' Obamacare replacement plans are all over the map. Some focus on health care and health insurance reform together, others one or the other. At first glance, they seem to be growing further apart. But look closer at the latest alternative from Senator Rand Paul, the Obamacare Replacement Act, and you may find several similarities to the plan Congressman Tom Price, proposed in 2009. The Secretary of Health & Human Services nominee, Price, is credited with proposing one of the most comprehensive Obamacare alternative plans, the Empowering Patients First Act. Paul's plan is short on details, but he and Price have the same or similar philosophy about American health care policy. The Acts similarities are notable. For one, both authors are physicians, but the similarities don't stop there.
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Tom Price Wants Individual Health Insurance For All, That's Not Universal Health Insurance


Two days before the U.S. presidential inauguration, Senator Bernie Sanders asked Secretary of Health and Human Services (HHS) nominee, Tom Price, "do you believe that health care is a right of all Americans, whether they are rich or they're poor." Like any worthy opponent, Price would not give a "yes" or "no" answer. Instead, he said, "I look forward to working with you to make certain that every single American has access to the highest quality care that is possible.” Here's how I interpret Price's cold reply:

Americans that can afford to pay for the highest quality health care shall have access to it. Americans that cannot afford the highest quality care shall have access to the level of care what little money they have can provide. A doctor is advocating for levels of care based on ability to pay. Shocker. But not all doctors are like Tom.

The Greedy Dr. Price

Tom Price has an estimated net worth of over $13 million. His HHS nomination hearing is as much
about corruption as it is about policy. There are allegations that he purchased health care stocks based on insider information and introduced legislation favorable to a company whose stock he owned. Price claims his stock purchases were legal, and that may be true, but his lack of propriety in making these purchases and their timing, is unsettling but not surprising.

Price's careers as a doctor, State Senator and U.S. Congressman have a common theme—oppose any and all legislation that threatens the paychecks of doctors. He opposed single payer health insurance long before Obamacare when he mobilized other doctors to lobby against Hillarycare. And he has a history of trying to limit, sometimes drastically, the amount patients can receive in malpractice lawsuits. With so much time and effort devoted to pursuing and sustaining wealth for doctors, the confirmation hearing may be uncomfortable, but Tom's been doing this for a long time, and he has an answer for everything.

Tom Wants A Health Care System Made Up Of Individuals

As an entrepreneur with a medical degree whose main purpose in life is to stay rich, we can expect Tom Price to oppose legislation to limit what doctors, hospitals and pharmaceutical and medical device companies can charge for their services and products. For Tom, health care is a commodity, not a right of all Americans. Other things not to get your hopes up about with a Price-led HHS department:

  • meaningful health care price transparency
  • limits on out-of-pocket health care cost for patients
  • the prohibition against balance billing
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Without Universal Health Care, Adopting Electronic Health Records Becomes Harder


In his January 6, 2017, interview with Vox.com, President Obama said that one of the great disappointments for him regarding the Affordable Care Act (aka, Obmacare) was the difficulty in getting doctors and hospitals to go paperless. His interviewers, Ezra Klein and Sarah Kliff, expressed surprise that the President chose this as one of the great disappointments of such a controversial law. But I get it.

The U.S. is a world technology leader. Home to the world's largest and richest tech companies like Apple, Microsoft, Intel, Google and Facebook. But whether we are the best in tech is a matter of debate. Some believe Israel is tops in tech, claiming it has the brightest software engineers in the world, responsible for creating the best firewall software and other tech innovations. Still, others give a shout-out to Denmark, Finland, Sweden and Estonia, well known for extending tech to all of its citizens who use it in the everyday lives, even more than Americans.

But despite the great things that other countries are doing with tech, I think it is fair to say that that America has the resources and capability to lead the world in health information IT; if we wanted to. And maybe that is the primary reason that electronic health records (EHRs) are still a hope of Obama's.

What Are EHRs And What Are The Benefits and Challenges Of Using Them

Electronic health records are digital records created on a computing device by doctors and other medical care providers and staff about a patient's treatments and care. They have many potential benefits for patients and doctors, including:

  • Less paperwork—won't have to provide the same basic information to every new doctor
  • Fewer medical errors—doctors can receive warnings and alerts about allergies and prescribed drugs
  • Easier remote access that may also expand the use of telemedicine—patients can communicate with providers online and make appointments
  • Better diagnosis—doctors have a more complete and up-to-date picture of a patient's medical status
  • Less diagnostic testing—doctors can see previously ordered tests and won't duplicate unless necessary
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The Republican Alternative To Obamacare Always Has And Always Will Be, Personal Responsibility


Trump voters don't like the Obamacare subsidies or the Medicaid expansion because they help the undeserving. Consequently, they are okay with repealing and replacing Obamacare with something better, and they believe Trump can provide it because he is a businessman. Yeah, they believe that. And while I play around with the idea that Trump will surprise Republicans by proposing single payer health care so that he can brag about accomplishing something President Obama could not, the realist in me expects a plan similar to the alternative "plans" already offered up by Republicans. And the overarching theme of all of these plans is, personal responsibility and nothing says personal responsibility like putting aside your money to pay for your out-of-pocket health care expenses. You don't need subsidies. You just need a good tax deal to help you better use the money you should have. And that's why Republicans love health savings accounts (HSAs) so much.

Health savings accounts (HSAs) allow individuals to set aside money in tax-favored accounts to pay for medical care and prescription drug expenses. So, in addition to paying health insurance premiums, deductibles, coinsurance and copays, you can put some "extra" money in a tax-free HSA account. Think of HSAs as the health insurance version of the 401(k) retirement savings plan. Before 401(k) plans, employers provided pension plans to workers and their retirement benefits were pretty much guaranteed. Employers typically financed these plans but some plans required small employee contributions—it was an employer responsibility or a shared responsibility between the employer and employee. Then came the 401(k) plan with its risk of losing money, high finance fees, and employee-only or employee-mostly contributions. Responsibility shifted.

And how has the retirement income responsibility shift worked out? Well, just the other day, the Wall Street Journal reported that many supporters and early adopters of 401(k) plans acknowledge that they were mistaken in its benefits. Continue Reading...

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Thinking Of Health Insurance/Care As A Reward For Working Is An American Problem


As the year 2016 comes to an end, many Americans are worried about the future of the Affordable Care Act (aka, Obamacare). Those who want to see the Act survive the likely oncoming assault by Congress and the new Administration are mobilizing to make their repeal objections heard. They are creating or joining social media groups, attending rallies, organizing events and writing campaigns, supporting related non-profits and calling and writing their elected representatives to voice their opposition to repealing the law.

Even some non-supporters of Obamacare have concerns about a full repeal. Many have insurance because of Obamacare, and they like some of the Act's provisions such as prohibiting the denial of insurance or treatment due to a preexisting medical condition. But then there is the hardcore minority who want full repeal of the law even if it means losing their insurance coverage. And one of the main reasons for their discontent with the law is that it provides free or subsidized coverage to the non-working poor. A
recent article in The Atlantic captured these sentiments when it quoted two central Pennsylvania, Trump voters:

“but everybody's gotta get out there and get a job to help pay for it.”

“I’m worried about people being willing to work hard and stopping being dependent on the government,”
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America's Cruel Health Care System

blogEntryTopper

Most Americans may read British writer, Adrian Gill's last column before his death from cancer and label him a fool or a socialist out to get a last bit of attention. I read it and thought of a man that looked at his options and decided he'd rather die humanely than live a little longer chasing expensive health care services. This notion that people would do anything and pay any amount of money to access medical care is not universally held after all. Some people prefer universal health care even if it means they may wait longer to see a doctor or die a few weeks before their time.

Americans don't have to agree with Mr. Gill that universal health care with all its warts is better than the alternative—American-style health care. But we should have the option of accessing health care at the same base level, instead of the country club system we have now. We are fooling ourselves if we think that America's private system of health care is better than the national system in the United Kingdom. It's not. The system may not provide access to some prescriptions that are available in the U.S., but at least what they do offer is available to everyone. And besides, what's the point of having available prescriptions, if you cannot afford them.

We like to paint the national health insurance programs offered in other industrialized countries as lotteries or death panels, but they are neither, and we know it. They are egalitarian systems where access to health care is not dependent on social class, income, race or geography, and many Americans think it should be. We not only think it should be, but we also make sure that it is by placing poor people in one health care program and signaling to doctors that it's okay if these people get less care or no care at all.

As explained in a
recent article by Virgil Dickson, a survey by the Cancer Support Community concluded that "cancer patients with Medicaid coverage receive poorer quality and less healthcare than those with employer-sponsored, Medicare or other private insurance." Low reimbursement rates and required prior authorization make it hard for these patients to find a cancer doctor who will treat them in a timely fashion. How is this any different from having to wait weeks to see a doctor in the U.K. or Canada?

So, we go on pretending that we have the best health care system in the world. But that depends on how you define "best." By many accounts, it is one of the worst and least humane systems anywhere. As Gill said, there are treatments that allow you to
"stretch more life, a considerable bit of life. More life with your kids, more life with your friends, more life holding hands, more life shared, more life spent on earth—but only if you can pay."

But the cruelest thing about the American health care system is how it is forced upon us by well-funded and well-organized groups who have duped us all into paying for a system that most benefits the wealthy. Let them pay for unbridled health care innovation; the rest of us deserve the option of basic universal health care.

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Rx Drug Price Reform Is Not A Question Of Price Vs. Innovation, But One Of Public Vs. Private Innovation

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Last week, Sarah Kliff wrote an interesting piece about why prescription drug prices in America are so high compared to other industrialized countries. The international comparisons aren't new, but the conclusion that Americans have to choose between high drug prices and innovation is interesting. In a nutshell, Sarah reports that America subsidizes the world's prescription drug costs to incentivize investment in drug innovation by pharmaceutical companies and financial investors.

Sarah's article was a timely piece because also last week, the U.S. Congress passed the
21st Century Cures Act. This Act's been in the making for about two years and is the largest health care reform Act since Obamacare. It is nearly 1,000 pages, with a price tag of over $6 billion. And guess what, it includes lots of stuff about health care innovation as well as reducing approval standards for Big Pharma to bring their drugs to market. And just yesterday, the Senate, with a vote of 85-13, ended debate on the bill.

You can read the entire act
here (it's at least worth a quick review).

Most of the Act's provisions, which President Obama will sign in the next few days, are uncontroversial and good. The Act provides more money for drug therapy and cancer research, mental health research and care, state opioid abuse programs and more. But not everyone's happy with the Act, including prominent Democratic Senators, Elizabeth Warren and Bernie Sanders. Both see this bill as a handout to pharmaceutical companies because of the provisions that may allow them to bring products to the market quicker than they can currently and with less attention to drug safety and efficacy.

But even Senators like
Al Franken who approved the bill, lament that it does nothing to address high prescription drug prices. And the total elimination of anything to address prescription drug prices in such a relevant and related piece of legislation is more disheartening than Sarah Kliff's high cost or innovation conclusion.

The 21
st Century Cures Act could easily have been, The Pharmaceutical Innovation And Price Reduction Act. Continue Reading...

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Trump's Family And Friends May Decide The Fate Of Obamacare


Donald Trump is the U.S. President-elect, and everyone who writes and cares about health insurance and health care policy in America is eager to learn what he and his Republican colleagues in the House and Senate will do with the Affordable Care Act (aka, Obamacare). Will they repeal it? Replace it? Both? Neither? We can reasonably expect that over the next four years, Trump will sign off on some policy changes to Obamacare and millions may lose their health insurance.

Still, the larger Obamacare repeal and replace questions remain, will Speaker of the House, Paul Ryan, get to institute his
Better Way (to Fix Health Care) outline? Or will professional President Obama hater and Senate Majority Leader, Mitch McConnell, get to declare Obamacare a total failure with no need to replace? It's looking increasingly likely that they may both get what they want although not because of any powers of persuasion they have, but because repealing and replacing Obamacare will help some Trump family members and friends.

Before he won the election, Trump said he would repeal and replace Obamacare with "something much better for everybody." He also called Obamacare, "A complete disaster." But after he won the election, he said that there are parts of Obamacare that he likes and wants to keep: allowing children to stay on their parents' health plan up to age 26 and the one about people with preconditions (he meant pre-existing conditions, but he's careless and uninformed). Then last week it was reported that Trump has
family and friendship ties to a health insurance start-up, Oscar Insurance, that isn't doing so well. Continue Reading...

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So Much For Anti-Elitism, The Health Insurance Status Quo Survives

blogEntryTopper

The upper middle class benefits a lot from the current system of access to health insurance.  They are more likely to have jobs that provide health insurance that they can easily afford, and they benefit favorably from the tax treatment of these workplace benefits.  So, it is fair to assume that the majority of these individuals do not support changes to the health insurance and health care status quo.  But the question on many people's minds is whether the unveiled contempt for the professional elite will impact their health care status.

The election of Donald Trump as President of the United States and a majority Republican House and Senate all but ensures changes to health insurance and health care policy in America.  What those changes will be is anyone's guess. Does it mean a cap on pre-tax health insurance premiums that most benefit the upper middle class?  It could since there is bipartisan support for such a change.

But I'm betting it won't be for several reasons. One, Trump supporters have yet to articulate what health care reform should look like. Two, most Trump supporters don't understand health insurance or the health care industry well enough to suggest any meaningful changes to them. And, three, many middle class people rely as much on workplace health insurance and its favorable tax treatment as the elites they hate.

But what is the point of beating the elites in a national election, if you can't also make them suffer?

Will Hate Trump Logic? Continue Reading...

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A Fragmented Health Insurance System Needs The Same Cure As a Fragmented Health Care System—Integration



There is a lot written about the downsides of fragmented health care. Most stories start out with an example of an extremely ill person, whose condition gets worse as they go from one medical specialist to another and one facility to another, taking one drug after another. The result is usually that the person suffers for a very long time until someone mercifully steps in to help coordinate care or the patient dies. No one is to blame for the person's suffering or death because they did what they were supposed to do. It's only after the fact that we find out that things should have gone better.

The good news is that there are solutions to address the horrible consequences of fragmented health care. Before the production of these solutions, a very sick person had to rely on the kindness and fortitude of family and friends to navigate a system where no one person could or would answer all of their questions. Harvard Business Review has an article
here on how to improve fragmented health care. The Affordable Care Act (aka, Obamacare) also works to try and improve the delivery of health care through Accountable Care Organizations (ACOs).

What Is An Obamacare ACO?

According to Jenny Gold, writing in Kaiser Health News online, a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation, "An ACO is a network of doctors and hospitals that share financial and medical responsibility for providing coordinated care to patients in hopes of limiting unnecessary spending." Currently, Obamacare ACOs are Medicare-based only.

Addressing the physical and mental suffering and costs of fragmented health care is one of the best components of Obamacare, even if it only addresses a small percentage of the insured. But wouldn't it be great if Obamacare addressed the fragmentation of health insurance programs instead of maintaining or add to them?

A Fragmented Health Insurance System Is A Bad Thing.

I'm not claiming that America's fragmented health insurance programs are as bad as fragmented health care. It's not. Still, fragmented health insurance is a big problem in that it separates us into groups with different levels of coverage, at varying rates and ends up costing us all more than if we were in one group. Instead, we are left with at least six groups—Disabled, Old, Poor, Veterans, Traditionally Employed and Individually Employed—each expected to carry its own financial weight. A difficult and unnecessary standard to meet and maintain...
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Obamacare Critics Or Explainers Don't Care About People Without Subsidies



Open enrollment on the healthcare exchanges doesn't start until November 1 but news of projected premium increases of 22% to 25% hit the streets last week. Write ups about the rate increases can be divided into two camps—the beginning of the end of Obamacare and it’s not as bad as you think because... That “because” refers to the fact that the increase, although huge, does not apply to the vast majority of health insurance purchasers. It does not apply to the more the 50% of Americans who get health insurance from their employers or seniors, veterans, the disabled and poor. It also does not apply to about 85% of people who purchase individual policies on the exchanges. It does apply to the millions of people, like me, who do not receive a health insurance premium subsidy.

So one camp want to amplify the harshness of the Obamacare increases, with the
Wall Street Journal (WSJ) going as far as to express its condolences to people, like me, who are stuck paying the full premium increase. But with their condolences comes a healthy dose of we told that arrogant President Obama that Obamacare was destined for failure. They don’t really care about the individuals paying high health insurance premiums, just like they never cared about the people paying even more or being denied coverage for preexisting conditions pre-Obamacare.

And then there is the, it’s
not as bad as it looks camp. They want to stress how few people have to pay the full increase in premiums without subsidy support and how subsidies will increase in step with premiums for those eligible for them. Some go into the mathematical weeds to prove their point of just how nearly insignificant this non-subsidy group is, with estimates ranging from 1.5 million people to as high as 9 million people. And then there is a very small subset of this camp that unfortunately includes some in the Administration, that claim millions of non-subsidy people are probably eligible for subsidies but just don’t know it. Continue Reading...

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The Upper Middle Class Frustrates Health Care Reform

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The upper middle class is finally receiving the attention it deserves but probably doesn't want. The income inequality standoff between the 99% and the 1% that exploded after the 2008-09 Great Recession is moving downstream. About five years after the start of the recession, economists, social and public policy experts and intellectuals began to notice where the real growth in income was happening. Articles in the Wall Street Journal and Fortune both reference a study by Stephen Rose of the Urban Institute that claims that in 2014 the “upper middle class controls 52.1% of America’s income.”

But it’s not just rising income inequality between the upper middle class and the lower income classes that is getting attention, it’s their increasing political clout that is receiving bad reviews. Some public policy writers believe that the upper middle class is destroying America. Check out some of these headlines:

"The Upper Middle Class Is Ruining America And I want it to stop." written by Reihan Salam, 2015,
slate.com.

"The Dangerous Separation of the American Upper Middle Class," written by Richard V. Reeves, 2015, brookings.edu.

"Check Your Privilege, Upper Middle Class," written by Richard Reeves, 2016,
washingtonpost.com.

Personally, I never really thought about the status of the upper middle class until last month when I spent two weeks with about 100 of them on a cruise from Moscow to St. Petersburg, Russia. Now, I can't confirm that all of the people I met on the cruise were legitimately upper middle class, but I'm guessing many were.

Let me explain.
In his article in slate.com, Reihan Salam, said that “upper-middle-class is a state of mind. We’re talking about families that earn well into the six-figure range yet don’t feel rich, either because of their student loan debt or the enormous cost of the amenities they consider nonnegotiable: living in well-above-average school districts for those with children or living in “cool” neighborhoods for those without.”

So, if Reihan is correct that upper middle class is a state of mind, my cruise mates who casually compared the number of countries they visited, fit the bill. They also, according to every article I read about this group, and I’ve read a few dozen, possess all or most of the characteristics of the upper middle class: mostly white, educated, current or former professionals (doctors, lawyers, financial advisors, public-sector administrators, etc.) lifestyle-focused, with the ability to spend thousands of dollars on,
experiences, and segregated from the lower income classes.

Should We Care About The Upper Middle Class?

Why does a blogger dedicated to writing about health insurance and retirement saving public policy issues care about the upper middle class? Well, as a former workplace employee benefit professional, I know that workplace health insurance and retirement plans favor highly compensated workers. You know, those employees who make above the FICA tax limit and the ones who can afford to contribute the maximum amount to their 401(k) and whine that they are not able to contribute more, tax-free.
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Health Insurance Illiteracy Is An American Problem



The Onion, a news satire organization known for fooling many journalists with it’s made up stories, has a hilarious story in its October 5, 2016, edition about a man who woke from a coma and suddenly understood his health insurance policy. And like most of The Onion headlines and stories, it's really funny because there is some underlining truth to the satire.

According to about a dozen annually produced surveys, Americans don't understand their health insurance. A UnitedHealthcare “Consumer Sentiment Survey,"
cited by BenefitsPro revealed that "just 7 percent have a full understanding of all four basic insurance concepts: plan premium, deductible, coinsurance, and out-of-pocket maximum." Despite decades of employer and insurer-provided communications, the majority of Americans can't explain what a deductible is or how it works. Not understanding their health insurance policy is an American problem because insurance isn't as confusing in other countries.

We just returned from vacationing in Russia and Finland. In our travels from Moscow to Uglich to Yaroslavl to St. Petersburg to Helsinki we met a lot of people. And despite their economic status, level of education, or age, everyone we spoke to about health insurance understood their health insurance plan coverage. They understand their health insurance because it's simple. No deductibles or coinsurance or out-of-pocket maximums.

Many Americans do not want government-sponsored health insurance but they do want health insurance they can understand. But is easy-to-understand health insurance possible in America in the age of high-deductible health plans, referencing pricing and tax-saving accounts? As an employee benefits professional, it is easy to blame health insurance illiteracy on lazy employees who refuse to read plan information, but that would be ignoring the fact that these plans are often so complex that few people can claim to fully understand them.
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Health Insurance Subsidies Matter (To Everyone)



Americans have very confusing views about government spending on health insurance. For example, it is common to hear how unaffordable health insurance has become and the shame over receiving a government subsidy to help pay for it, from the same person. It's impossible for me to understand the logic of it is unaffordable but I wish I could afford to pay for it anyway mentality.

This kind of mentality may be okay when considering a smartphone purchase but is downright crazy when discussing health insurance and health care purchases. So when Bill Clinton said the other day,

'...the people that are getting killed in this deal are small-business people and individuals who make just a little too much to get any of these subsidies. Why? Because they're not organized, they don't have any bargaining power with insurance companies, and they're getting whacked. So you've got this crazy system where all of a sudden, 25 million more people have health care, and then the people that are out there busting it — sometimes 60 hours a week — wind up with their premiums doubled and their coverage cut in half. It's the craziest thing in the world."

he forgot to blame the
crazies that find receiving subsidies for individually purchased health insurance shameful.

Don't get me wrong, I completely agree with Clinton about how people like me have been mistreated by this law and continue to be ignored by this Administration. But let's also call out the subsidy receivers who could care less about the subsidy non-receivers. It may just be a classic case of I got mine, you get yours but for some, it's about equating subsidies with looking poor. CRAZY!

We All Need A Health Insurance Subsidy Continue Reading...

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Workplace Health Insurance Is An Exclusive Club That Has Outlived Its Usefulness



The Obamacare marketplace has a big problem—too many sick people and not enough healthy people. The problem is so bad that health insurance companies claim they lost billions of dollars and some are leaving the exchanges. Unless the federal marketplace can enroll more young and healthy people these insurers may never return. Another proposition outlined in a New York Times article by Margaret Sanger-Katz, is for the remaining states to expand Medicaid, which will bring down health insurance premiums for everyone.

In her article, Sanger-Katz refers to a study by the Dept. of Health and Human Services that concluded that marketplace premiums were lower (in the high single digits) in states that expanded Medicaid compared to those that did not. That is great news but it’s not enough to offset premium rate increases in the high double digits. For that we need exactly what the health insurance companies claim they want—a healthier risk pool. Moving employer-sponsored health insurance to the exchanges give us a healthier risk pool that will lower premiums, but there is strong opposition to this.

Employers want to hold onto their health insurance programs because they want to control how much they contribute to them. Health insurers want to maintain these plans because they can better predict their risk and set their rates to ensure they always make a profit. Employees want to keep their employer-sponsored coverage because they don’t want to assume the responsibility of choosing and paying for their own coverage. They also want to keep their employer and government subsidies.

Anyone who thinks that these strong powerful advocates for employer group health insurance are going to suddenly decide it is in the public interest to have one health insurance risk pool is mistaken.
Individuals covered by employer health plans make up about half of the insured population. They are over 150 million individuals strong and it will take the other 150 million plus individuals to force change in our health insurance and health care system. And the first thing we other 150 million plus have to do is stop acting like workplace health insurance is more virtuous than other types of health insurance. Continue Reading...

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Betterment-Uber Partnership—Bromance Or Gig Economy Revolution



Last week Betterment and Uber announced a partnership to offer Betterment individual retirement accounts (IRAs) to Uber drivers. The program is already available to drivers in four cities—Boston, Chicago, New Jersey and Seattle—via the Uber app.

Who Are These Guys?

Betterment is a robo-advisor. The technical definition of a robo-advisor (robo-adviser) according to investopedia.com is: “an online wealth management service that provides automated, algorithm-based portfolio management advice without the use of human financial planners.”

Basically, Betterment has an online platform and app that allows you to save for retirement or other goals by investing in exchange traded funds (ETFs). To get started you answer a few questions that Betterment’s computer system (aka, automated algorithm) analyzes and then chooses your investment options. You don’t have to, nor could you if you wanted to, choose your own investment funds. Its purpose is to automate the investment choosing and saving process for people who don’t want to or feel they cannot make these decisions alone.

And Uber (originally UberCab) is an app-based ride hailing service whose drivers are independent contractors. The app hit the market in 2010.

A Match Made In Tech Heaven

I’m not surprised by this new partnership—Betterment and Uber have a lot in common. They are both successful tech start-ups that went up against well-established industries—financial advisors and taxicabs, respectively. They both rely on technology to deliver their products in a way their traditional competitors never did. They both emerged during the Great Recession of 2008 but hit the ground running in 2010-2011. They enjoy a lot of media attention and support from venture capitalists. And, increasingly, they market their products to businesses as an employee benefit.

Betterment founded Betterment for Business to offer 401(k) plans to small businesses. Uber has several partnerships with businesses:

Uber for Business – Businesses can set up an account to provide rides for their employees

UberCENTRAL – Businesses can set up an account to pay for rides for their customers

UberPOOL – New York City employees enrolled in a WageWorks commuter flex program can use their commuter benefits account to pay for rides with pre-tax dollars Continue Reading...

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Medicaid For All May Be Practical, But Is It Acceptable?



Some free-market health care proponents think that universal health care supporters want free, unlimited health care no matter what the price. They are wrong. After reading about $600 EpiPens, $1,000 Hepatitis-C pills and $1 million cancer treatment bills, most people are willing to settle for less.

There are, however, some people that want unlimited health care, including former Democratic candidate for president, Bernie Sanders. Sanders advocates for comprehensive universal health care.
According to his website, his (Medicare For All) "plan will cover the entire continuum of health care, from inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing and oral health care; mental health and substance abuse services; as well as prescription medications, medical equipment, supplies, diagnostics and treatments. Patients will be able to choose a health care provider without worrying about whether that provider is in-network and will be able to get the care they need without having to read any fine print or trying to figure out how they can afford the out-of-pocket costs."

But things have changed since Sanders first shared his vision of comprehensive universal health care. One, he lost in the presidential primaries and his platform for comprehensive universal health care disappeared. Two, large, private insurer, Aetna, made a showy announcement of leaving the public exchanges causing some to question the future of health care reform. Three, reality started to sink in as the threat of large premium increases became fact. Cries of Medicare For All have changed to Medicaid For All.

Medicaid For All has all the advantages of Medicare For All. It is an established program often administered by private insurance companies and has lower reimbursement rates than exchange or private insurance plans. And, some think we have already moved in the direction of Medicaid like health plans on the public exchanges.
Margot Sanger-Katz of the New York Times recently characterized public exchange plans as Medicaid plans but with a high deductible. She may be right. The exchanges are chock full of HMO and narrow network plans. These plans are popular with exchange plan purchasers because they are often the only affordable option. But that doesn’t mean people like or want them (especially those of us paying full cost for these plans).

So, if Medicaid For All is the route to comprehensive universal health care, the price for all individual health plans will need to come down for everyone. And for comprehensive universal health care to happen employer health insurance needs to go away.
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Aetna Was Dumping Unprofitable Policyholders and Mismanaging Risks Long Before Obamacare



If the presidential candidacy of Donald Trump has taught us anything it is that the federal government is a good punching bag and scapegoat. Yesterday, Aetna Chief Executive Officer, Mark Bertolini, took some time on the bag. Bertolini announced that the company “decided to reduce our individual public exchange presence in 2017.” Aetna will pull out of 11 states on the public exchanges but continue to sell individual policies off of the exchanges. The reasons provided for the pull out, in insurance-speak, were an unbalanced risk pool and “inadequate risk adjustment mechanism.”

What Aetna means by “an unbalanced risk pool.” Put plainly, Aetna did not sell enough policies to healthy people with low to no health care expenses to cover the cost of care for the unhealthy people it sold policies to.

What Aetna means by “inadequate risk adjustment mechanism.” The Affordable Care Act risk adjustment programs are technical. There is a state-based risk adjustment and reinsurance program and a federal risk corridor program. Basically, these programs give money to, take it away from or share it among insurance companies to balance out their losses and gains.

Is It Really The Governments Fault…?

Aetna stated that, it might return to the exchanges in the future, “should there be meaningful exchange-related policy improvements.” This shameless blaming of a federal program to increase access to health insurance is a disguise to hide Aetna’s incompetence at predicting and managing risks.
Aetna has a history of not anticipating changes in the health care market and of dropping unprofitable policyholders. Continue Reading...

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It's Ridiculous How We Let Health Insurance Companies Bully Us



Health insurance companies have a reputation for being bullies. Policyholders feel bullied when their medical claims are denied or processed incorrectly. Hospitals and doctors feel bullied when the bills they submit are refused or amended, or when procedures are not covered. Employers feel bullied when their rates go up automatically. In fact, no one is exempt from the bullying tactics of the big bad health insurance company. Their latest victim(s)—all of us!

My Way Or The Highway

Four large health insurers (Aetna and Humana and Anthem and Cigna) are trying to merge into two and the federal government has filed lawsuits to prevent that from happening. Now, the two companies that will surface if the mergers go through (Aetna and Anthem) are threatening to withdraw their plans from the public health care exchanges. It’s hard to know if Aetna and Anthem are threatening to leave the health care exchanges because they are losing money or because of the government lawsuits. But does it really matter.

Aetna and Anthem are both making moves to increase their profits and shareholder wealth. Any savings they receive by increasing their size and bargaining power with hospitals and doctors will stay with them. There will be no premium savings for policyholders, just more money for shareholders. But if these mergers do not happen, their next target is likely to be the exchanges. Because if they can’t realize increased profits by extracting bigger discounts from health care providers and hospitals, they will do it by minimizing losses on the exchanges.

Profits Without Risks

Through the individual mandate we require healthier people who need little or no health care to purchase insurance to offset the costs of care needed by the sick. Healthier people lose money by subsidizing the sick. However, health insurance companies are not willing to subsidize losses they incur on the exchanges with profits they earn from their other lines of business, like Medicare Advantage and Medicaid.
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Obamacare Can Feel Like A Prison Sentence



I don't have a problem with the Affordable Care Act's (aka Obamacare) individual mandate. I am willing to pool my limited resources with others so that we all have health insurance coverage. But I have to admit that I am starting to feel the squeeze of my non-subsidized, high premium, high deductible health plan. So much so that I think I want out of Obamacare. Honestly, I'm not quite there yet but it may not take much more to get me there.

I already pay nearly $4,000 per year in premiums for a plan with a $6,500 deductible and 60% coinsurance and no out-of-network, non-emergency coverage. And yes, it is a Bronze level plan. I did the research and I used the latest decision support tools and based on my age and excellent health status, which includes never taking a prescription drug, this is the best plan for me. But the plan sucks in both terms of coverage and costs. My only other option—pay a penalty and pay any medical expenses I incur out-of-pocket—is an even worse option. I deserve better choices than this.

And to make my situation even more difficult, there is speculation that insurers will drop many of their Bronze-level plans in 2017, forcing me into a higher premium tier. But who cares about me? A $4,000/$6,500 Bronze plan is equivalent to a $5,500/$5,000 Silver plan, right? No. I don't have an additional $1,500 to pay in premiums that I will never get back. My spirit for the greater good has monetary limits and it ends at the Bronze level.
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One-Person, Self-Employed Retirement Savers Are Being Ignored



The retirement services industry claims it has a retirement savings product for everyone. That government-sponsored retirement savings plans targeting those without access to a workplace retirement plan are redundant. Technically, the industry may have a point. You don’t have to save for retirement in an employer-sponsored plan; there are individual retirement plans already available. But if you are a low-wage worker, you’re not likely to be aware of these plan options and would have no idea how to get started using one. So a state or federal government retirement savings program marketed to you is not a bad idea.

But what if you are a low- to middle-income, one-person, self-employed worker in need of saving for retirement? Who’s marketing retirement plan products to you? Basically, no one...

Who Are The One-Person, Self-Employed

So who are these often low-balance retirement savers? Many fall into the one-person, self-employed category.
According to a report from Emsi, the largest self-employed occupations that are also the lowest earning include:

  • Child Care Workers
  • Maids
  • Farmers
  • Landscape Workers
  • Hairdressers, Hairstylists and Cosmetologists
  • Automotive Service Technicians
There are millions of workers in these occupations. These workers have the option of participating in several different retirement plans created specifically for the self-employed. These plans include but are not limited to:

  • SEP IRA
  • SIMPLE IRA
  • Solo 401(k)
  • Defined Benefit Plan
  • Traditional and Roth IRA
  • Robo-Advisor (e.g., Betterment)
The problem is finding out about these plans and understanding how they work and how to enroll in one. Online articles glibly talk about how easy they are to set up via a brokerage firm and the many tax-advantages they provide. But what if you don’t know what a brokerage firm is or does or what “tax-advantage” means? You’re left with hoping someone in your life understands this stuff and is willing to help you out. Or, you’re left to the mercy of the very few retirement advisors and accountants that do seek your business, for a price. Continue Reading...
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Another Day, Another National Retirement Plan Acronym



Congressman Joe Crowley of New York is just the latest politician to formally rollout his legislative version of a national retirement plan. The Act is titled the “Secure, Accessible, Valuable, Efficient Universal Pension Accounts” (SAVE UP Accounts). Its target customers are workers whose employers do not currently offer a retirement savings plan. It has many of the same features as other federal and state retirement plan proposals:

  • Automatic enrollment in an IRA-like plan
  • Pre-tax employee contributions
  • Limited number of low-cost investment funds
  • Opt-out option
But it also has some features many of the other proposals do not:

  • Requires an employer contribution indexed for inflation and based on employee hours worked (waived if employer is contributing to an existing retirement account)
  • Provides a limited employer tax credit to offset the cost of employer contributions
  • Sets target benefit amounts
  • Creates a collective investment pool to protect against losses
What Crowley Gets Right

According to
an article in Plan Sponsor, a recent report by Natixis Global Asset Management ranked the United States tenth among wealthy nations for retirement security. Some of the reasons put forth in the report for the tenth place ranking are income inequality, lack of access to a workplace retirement plan and a low contribution rate. The report suggests that the U.S. “learn from the experiences of other countries around the world.”

But the people in the countries ranked one through nine have numerous advantages over U.S. citizens when it comes to saving. Chief among them is lower health care costs and less income inequality, not to mention the many social programs like paid leave and childcare benefits.
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Despite Resistance, We Are Getting Closer to a Public Option Health Plan


Politicians at all levels are too afraid to upend a health care system that does not work for all because of the impact that change will have on some. The fact that that "some" consists of about 16 million health care related jobs and 18% of the U.S. economy is reason to think before we act. But with nearly a century to think about and work out a better health care policy, it’s clear that there’s never been a real strategy for revolutionary change. Instead, politicians focus on incremental health care policy changes, like the President’s latest proposal for a limited public health plan option.

On Monday, July 11, 2016, President Obama became the first sitting U.S. President to write an article for publication in a scholarly or academic journal. Published by the Journal of the American Medical Association (JAMA),
the article titled, "United States Health Care Reform: Progress to Date and Next Steps," recounts the process of health care reform from 2008 to the present. The article outlines the many legislative actions the President and his administration took to:

  • expand health insurance coverage
  • provide financial support to health insurance buyers
  • improve health care technology and research and
  • reform health care payment models
The President makes a case for the need for more incremental health care reform, including a public option in geographical areas that have little or not health insurer competition. But some Democratic politicians fear even this modest proposal. According to an article in thehill.com, Democratic Senator Heidi Heitkamp said this in response to a limited public option: “I think it's critically important that we stop trying to complicate healthcare and we start taking a look at what needs to be fixed in ObamaCare.” Besides being one of the dumbest statements ever made about the already impossible to understand U.S. health care system, it shows a real fear of the inevitable.

If health insurers merge as planned or drop out of the exchanges leaving little or no health plan options to choose from, something has to fill the gap. The only thing that can is a public option. Those who think that reducing the number of health plan options on the exchanges is a way to undo Obamacare are being naïve. People still want and need health insurance, not to mention that they are required to have it. I don’t see any other option but to offer a public health plan where few or no health plan options exist.
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EpiPen--Price Gouging Made Easy


Fortunately, I do not need an EpiPen. However, I live with someone who does. Less than 10 years ago he paid about $25 for one EpiPen; Today, he pays $250. Also, he’s forced to purchase two EpiPens at a time because of new FDA guidelines and subsequent changes by the drug manufacturer. That doubles the price to $500.

So why is the price of the EpiPen increasing when a vial of hormone epinephrine cost just $1? Political connections and sophisticated, target marketing.

Bloomberg has an excellent article on how Mylan Pharmaceuticals purchased EpiPen when it was bringing in about $200 million a year, The CEO of Mylan, Heather Bresch (formerly, Heather Manchin), is a U.S. Senator’s daughter. Through lobbying of the federal government (my assessment, not Bloomberg’s) and extensive marketing by outside experts, she and Mylan turned EpiPen into a $1 billion a year product. A look at Bresch’s profile on the Mylan website basically confirms that more EpiPen price increases are in the future as Mylan aims to reach its 2012-2018 earnings goals. And then there’s this...

A Little More About Heather Bresch

Bresch claimed she had an MBA degree she did not have and used her connections and influence to perpetuate this falsehood. She later backed away from the claim but only after a drawn out, public scandal. This is relevant to the story of how the price of this drug increased so rapidly in the hands of someone with political connections and is not afraid to use them. Heather Bresch is politically brilliant and she knows as much about pharmaceutical laws, regulations and guidelines as anyone (mostly because she studies these laws, has access to the people who write them and helps draft some herself).

The point – Heather Bresch heading Mylan Pharmaceutical Company is like placing a pharmaceutical lobbyist at the head of a pharmaceutical company. Knowledgeable—check. Connected—check. Price gouging protector—check. Continue Reading...

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