Vol. 169 April 15, 2017 “Free-market Health Care Doesn’t Work”

April 17, 2017

“Nobody knew health care could be so complicated.”
-Donald Trump 2/27/17

Stephen Colbert responded with: “There was at least one person who knew that it was complicated, that tall, thin, greying guy who used to be in your office, Donald.”

Of course, there are lots of people who know how complicated it is. One of them is my old boss, Jim Lyons, founder and past-CEO of Cape Cod Healthcare, Inc. He is retired now and hasn’t lost his knack of making sense of the morass. He did just that in a recent Op Ed piece in the Cape Cod Times, and I’m shamelessly plagiarizing parts of it (in bold) for today’s blog.

“The fallacy [of the health care debate] is that necessary healthcare services is a free-market choice, as with buying a car, a house, or a kitchen table. If you have a stroke, break your hip or have an automobile accident [you don’t make] the same free-market choice for service”.

You could argue that if you want an elective procedure like a new knee, a new hip, or cancer treatment there is the opportunity for more choice, and that is true. Just take a look at the burgeoning advertising budgets of competing medical centers. The say they are competing on “quality”, and they are competing for your dollar, or more nearly correct the insurance company’s and the federal Medicare dollar. So far, in no U.S. health care market region has this “competition” led to lower costs. We recently wrote about the growing “lower-cost” market of medical tourism.

The two biggest reasons that health care costs keep rising are 1) we are all living longer and 2) better medical technology (both electronic and “better living through chemistry”).

 “New technology in health care almost always results in increased costs. In industry, new technology often lowers the cost of production. This is not the case for health care innovations.”

In fact, The Hastings Center estimates that 50% of our increasing health care costs is due to new technology. MRI exams have replaced  CT scans and other x-ray procedures in many instances, even in mammography; coronary surgery is being replaced in some instances by “simpler” medical devices inserted through a blood vessel; newer drugs with marginally better effects for heart disease and cancer are selling at much higher prices; PET scans are becoming the standard of care in certain cancer treatment protocols, etc.

Many years ago I remember the responses of a delegation of physicians and administrators from Great Britain who were touring American medical centers looking at our health care facilities. They were impressed, of course, with the MRIs and cardiac surgery units in Boston, but they “were just like what we had in London.” But, then they saw the same facilities in Worcester, Springfield, even Winchester and Burlington, and impossibly, Cape Cod, and they were impressed.

Efforts to control health care costs continue to be futile. “Republicare” was a political disaster and only attained a 17% approval rate in public polls. “Medicare For All” which calls for an incremental extension of Medicare coverage to those below 65 years of age has been in the House of Representatives (HR 676) since 2015. In Massachusetts there are now no less than four separate bills in the legislature calling for a single-payer Medicare For All in Massachusetts.

“One reason that it’s probably not politically possible to make a change to a single-payer system at this time is the more than 1,000 great buildings for servicing health insurance companies all over the country, full of many workers, many executives, and billions of forms.”

“Whether health care is a privilege or a right, we have made such great progress in the past 50 years that I don’t want to see any new health care plan that slows or reverses our progress. Please remember, health care is not a free-market choice like many of our other important decisions.”


Vol. 168 April 1, 2017 Trump Tweets About Medical Tourism

April 1, 2017


“Medical Tourism is where people who live in one country travel to
another country to receive medical, dental and surgical care.”

Medical Tourism Association


We believe the market size is  $45 – 72 Billion based on approximately 14 million cross-border patients worldwide spending an average of $3,800-6,000 per visit.  We estimate some 1,400,000 Americans will travel outside the US for medical care this year (2016).”
 – Patients Beyond Borders


@realDonaldTrump
 
 People will do ANYTHING to escape Obamacare. TRUE fact! #obamacareimploding


“Using US costs across a variety of specialties and procedures as a benchmark, average range of savings for the most-traveled destinations:
Brazil: 20-30%
Costa Rica: 45-65%
India: 65-90%
Malaysia: 65-80%
Mexico: 40-65%”

@realDonaldTrump 
TREMENDOUS deals, and I love a deal. Except maybe for that Mexican country. I want them making big profits to pay for the wall. #BEAUTIFULwallfrombladders/gall

“Igor Lanskoi, Advisor to the Russian Health Minister, says the number of medical travelers coming to Russia is increasing, with four times as many foreign patients entering the country in 2015 than in 2014.  Last year, foreign patients brought in nearly 10 billion rubles, or $154 million, in revenue for Russia. More and more Americans are traveling to Russia to improve their health. “

@realDonaldTrump
                             Just watched the totally biased and fake news reports of my partnership with the Putin Institute of Plastic                                 Surgery and Tanning in Moscow on NBC and ABC. Such dishonesty! #palesbycomparisonwithTRUTH!

@realDonaldTrump
                              How would they know? More FAKE news! I don’t even know where my money is. All my businesses are                                      with my kids now. #note2IRS#4getCaymanIslands  

When someone wants to undergo treatment in his own country but his insurance doesn’t cover it, he gets angry and chooses to come to Russia since here he can receive the same medical services at a much lower price,” said Yakov Margolin, General Director of the Clinical Hospital in Yauza.  – Rise of Medical Tourism in Russia
 
@realDonaldTrump
I usually don’t agree with the Russians, but America hates Obamacare! SAD but TRUE.
  Suck it up liberal                                  
Democrats… and Freedom Caucus.  #PaulRyan/wimp

Cosmetic and dental surgery are the most frequent treatments sought by medical tourists. Plastic surgery is a close third.

@realDonaldTrump
                              I don’t care. NOT interested. Ivanka needs none of that anymore! #URbeautifulbabe#hairtransplant

Medical travel to Israel has shown significant growth over the years and was recently ranked as the world’s third most popular medical travel destination by VISA and Oxford Economics. – Medical Tourism Magazine 

@realDonaldTrump
                              NO new hospital buildings on the West Bank! Jared says we have an agreement. BETTER BE                                                          TRUE! #gojewishsoninlaw

@realDonaldTrump
                             I love Jews. I have made lots of H-Y-UGE deals with Jews. The Palestinians? Not so much.                                                                     
#go4thejewishvote  

“Some insurers and large employers have formed alliances with overseas hospitals to control health care costs, and several major medical schools in the United States have developed joint initiatives with overseas providers, such as the Harvard Medical School Dubai Center, the Johns Hopkins Singapore International Medical Center, and the Duke-National University of Singapore.” – CDC Yellowbook on Medical Tourism

@realDonaldTrump
                             Like Ghandi – a great friend of mine – said last week, “Just follow the money”. #greatquote

The administration’s reduction and delay in issuing H-1B visas will drastically reduce the number of International Medical Graduates allowed to enter the U.S.  Since 25% of U.S. working physicians are IMGs this will exacerbate our physician shortage, particularly in underserved rural areas.  – New England Journal of Medicine

@realDonaldTrump
                             If you can’t find a doc here, just go to THEIR country. SIMPLE! #betterthanOcare

Funds withdrawn from Health Savings Accounts (HSAs) can be used for medical treatments outside the country.

@realDonaldTrump
                              But come to Florida for your tan.#tanningboothtax/gone

HAPPY APRIL FOOLS DAY
(but only the tweets are made up)


Vol. 167 March 15, 2017 AHCA (RepubliCare) Revealed

March 15, 2017

WINNERS: Young, Wealthy, Healthy, “Blue States” (urban millennials)
LOSERS: Older, Poor, Sick, “Red States” (rural working poor)

The American Health Care Act (AHCA) was developed by Paul Ryan (R) who has been publicly promising a Republican health care act since 2009!  He apparently does not want his name attached to this one. Neither does Trump. So I choose to call it “RepubliCare”.

The Congressional Budget Office’s “quick and dirty” analysis of the American Health Care Act (actually two bills still in committee) estimates that 14 million people will lose their health insurance in 2018 if it “replaces” the Affordable Care Act (Obamacare). Of all the projections, this one is probably the most crucial, since it will be a factor in the mid-term elections.

The CBO is a non-partisan, independent body created by President Richard Nixon in his last act before resigning in 1974. The CBO aids Congress in developing their own budget proposals, in objectively costing out their proposed bills, and in analyzing budgets developed by the Executive branch. The Commonwealth Fund (a liberal think tank) has determined that all financial projections of ACA costs were inaccurate, but that the CBO was closest to the actual. This current CBO report was done in association with the Congressional Joint Committee on Taxation. It is “quick and dirty” because the sudden appearance of the two bills surprised them. The CBO states it had insufficient time to project the cost effects on states and other “macroeconomic” effects, as required by the House of Representative rules for any “major legislation”.  The published projections actually represent the mid-point between low and high estimates, neither of which have been made public.

RepubliCare is projected to trim $337 Billion off the federal deficit over 10 years. According to the CBO most of the increase in the uninsured and the cost savings (federal only) would result from repealing the individual mandate, lowering the federal subsidies for low-income non-group policies, decreasing the federal subsidy to Medicaid by going to “block grants” to states, and stopping any expansion of Medicaid coverage after 2020.

CBO had three weeks to analyze the ACA. They had 5 days with RepubliCare. CBO 2010 projections of the ACA costs were lower than actual because 1) more people opted for Medicaid coverage than expected, 2) actual Medicaid costs per enrollee were higher than expected,  3) the individual mandate (currently a $695 yearly penalty for not buying health insurance) proved too weak an incentive for young people to buy insurance, 4) health insurance exchanges (the private insurers market place) attracted only about half of the projected number of people, and 5) the general economy improved slower than estimated (“did not match the Ronald Reagan Recovery curve.”)

Rather than boring you with repeats of the number of “millions losing health insurance per year” under RepubliCare, here are some “fun facts” about it you can use to punctuate chats with your friends and colleagues:

  • It is 66 pages long. (That calculates out to about 8.25 pages per year for the writing pace of Paul Ryan (R).
  • 6 pages are devoted to changes in Medicaid eligibility rules, including the interesting item prohibiting any Lottery winner from being eligible for Medicaid.
  • replaces the individual mandate ($695 penalty tax) with tax credits worth about 1/12th of the average yearly insurance premium (for anyone, of course, who has a taxable income).
  • eliminates the 2.3% tax on medical devices. (The Advanced Medical Technology Association is the only Massachusetts medical organization that has expressed support of RepubliCare so far)
  • eliminates the 10% tax on tanning stores (Probably a blatant try for support from Trump and ex-senator John Boehner (R). Actually, pale Paul Ryan (R) could use a visit or two, though universities and colleges across the country are limiting student access to tanning stores because of the increased risk of melanoma).
  • removes coverage for substance abuse and mental health services by 2020.
  • eliminates tax surcharge on insurance executives “earning” more than $500,000 a year.
  • eliminates tax on big pharma-manufacturing companies
  • delays implementation of 40% tax on “Cadillac” health insurance policies for high income people until 2025.
  • prohibits Medicaid reimbursement to Planned Parenthood for any of their services. (a major source of revenue for the 97% of preventative and non-abortion treatment services PP provides)
  • retains prohibition against denying pre-existing conditions (but imposes a 30% surcharge for such for 1 year).
  • retains coverage of children under 26 on parents’ policy.
  • retains coverage for contraceptive and maternity benefits.
  • retains prohibition of any surcharges on women’s policies (“gender equivalence”)
  • allows elders to be charged 5 times the premium of younger people. (AARP is all over this one as age discrimination) ACA allowed a 3:1 premium ratio.
  • increases maximum contributions to Health Savings Account (HSA) from $3,400 to $6,500. ( Great , if you are making enough money to save.)

Liberals, Democrats, many Republicans, many governors, hospitals, physicians, the AARP, and even conservatives don’t like the bill.

“The AHCA does what it was intended to do; it lowers federal spending and reduces the number of people with health insurance.” (Michael Chernew, MD, Harvard University)

“ It would repeal far less of ObamaCare than the bill Republicans sent to President Obama one year ago. The House Republican leadership bill does not replace ObamaCare. It merely applies a new coat of paint to a building that Republicans themselves have already condemned.” Cato Institute 

Republicans in Congress are claiming that the CBO did not cover the “whole” plan. “What was not covered was what else we are going to do in terms of ‘regulation reforms’, state Medicaid rules, and future bills.”

I believe we are being asked to buy a hastily produced “pig in a poke”, an even bigger pig in a bigger poke than Obamacare.


Vol. 166 March 1, 2017 Who’s Stupid??

March 5, 2017

alfred_e_neumanI can’t believe I SKIPPED FEBRUARY.
I also can’t believe that only one reader called me on it.
Maybe I only have one reader.
I dated my last blog, “Can Pregnancy Make You Stupid”,  with March 15 and the one before with March 1, but they were both published in February!
My only explanation is that I was looking forward so much to my March vacation in the Caribbean that I fast forwarded to that month.
Today is March 1, … and I am on vacation.  So, this is today’s blog.
I guess I needed a vacation.
March 15 blog will be on time and correctly dated.


Vol. 165 March 15, 2017 Can Pregnancy Make You Stupid?

February 15, 2017

Hub thumbnail 2015

“Most pregnant women will admit to bouts of “pregnancy brain” or “mommy brain” — whether it’s forgetting doctor’s appointments or forgetting their own phone number. This pregnancy-induced mental fog is part of the neurological changes at the start of pregnancy that continue throughout postpartum. ”

 

I am not at all sure that this phenomenon really exists, but scientists at Barcelona University recently published results from their study of 25 first-time pregnant women, the 25 fathers responsible for the pregnancies, and 20 non-pregnant childless women.  By comparing “before conception” and “postpartum” MRIs in the pregnant women the researchers documented a definite reduction in the pregnant women’s gray matter. The volume loss of gray matter occurred in three specific areas of the brain associated with social cognition and emotional feelings.  The differences of volume in the pregnant women was so apparent that the researchers could accurately pick which women were pregnant just by looking at the MRIs. Similar MRI imaging of the fathers and non-pregnant women showed no reduction of gray matter.

Gray matter is the part of the brain cortex that is mostly neuronal cells. White matter consists mostly of connections between the neuronal cells, axons (“wires”) coated with white myelin. The reduction of gray matter in the pregnant women was in brain areas associated with “being able to think about how other people feel and perceive things.” and persisted for 2 years after delivery.

Using fMRI (functional MRI – measures brain activity not just structure) these reduced gray matter areas would “light up”, show higher metabolic activity, when the mother gazed upon a picture of her own baby rather than a picture of someone else’s baby. The researchers speculated that this was a measure of quality “mother-infant attachment”.

The implication of this gray matter reduction is not clear. Many past studies in all kinds of people suggest strongly that people with larger volume of gray matter have better memory and are happier.

A study of ultra-marathoners (ran 2,788 miles in 64 days without a rest day) showed a reduction of gray matter of 6%, but it was reversed in 6 months and was not associated with any brain lesions. In comparison to the less than 0.2% per year gray matter reduction in the elderly this 6% is H-Y-U-G-E. Pre- and post-run Cognitive tests would have been help in this study of ultra-marathoners, but I am not sure you could detect any increase in stupidity in them. Presumably the reversible reduction in brain volume was due to dehydration.

Studies of chronic marijuana users show reduction in gray matter, but increased “connections”, and no loss of cognitive skills (if not high at the time of testing). This and similar findings in adolescent brains have been explained as either a bad thing about marijuana use or as a “maturation” of the brain as it gets “better organized” for specialized tasks. A similar explanation of an “organizing process”, “a pruning toward a more efficient brain” is offered by the researchers of these pregnant women.

So where does this leave us regarding permanent gray matter reduction in pregnant women? We, of course, don’t really know at this point. fMRI studies are still in their infancy, and there is some controversy about what they really mean. But, cognitive tests of both these pregnant and non-pregnant women showed no difference, and no change in cognitive functions after delivery, so we can confidently say that pregnancy does NOT make you “stupid”… or even “stupider”.


Vol. 164 March 1, 2017 The Exercise Paradox

January 31, 2017

Hub thumbnail 2015

“You can’t outrun a bad diet”

It appears that an African native chasing a wounded giraffe through the bush and over the plains for 12 hours in order to get food for himself and his family burns the SAME NUMBER OF CALORIES per day as the modern couch potato. Researchers measuring the urine excretion of two radioactive isotopes of water ingested by the subjects (the “gold standard” of measuring energy expenditure) have confirmed this fact as postulated previously by several studies. These African hunter-gatherers burned about 2,600 calories a day, about the same as average adults in present day U.S. and Europe.

The researchers were looking to measure the size of the “energy shortfall” in Westerners to explain the global rise of obesity. They found none. In fact, another review of almost a hundred (98) world-wide studies of energy expenditure (calories burned per day) revealed that “the persons with all the modern conveniences have similar energy expenditures to those with more physically demanding lives in less developed countries.”  Therefore, “obesity is a disease of gluttony, not sloth.”

Physical activity does NOT cause weight loss, but exercise can help prevent weight gain.  A JAMA 2010 study of 34,000 middle-aged U.S. women showed that 60 minutes a day of moderate exercise (walking) prevented weight gain in those on a normal diet who had previously lost weight through dieting.

As someone who collected articles about  bad things happening to joggers to justify my ignoring Society’s “persistent call to go running”, this is music to my ears. The evidence that exercise, including just walking, is good for you is absolutely true and well accepted. It just doesn’t help you lose weight. Again, as someone who has made a resolution every January to lose weight by going to the gym only to peter out by the end of every March, this made me feel less inadequate, or at least less guilty.

Humans have a fixed rate of energy expenditure which is independent of their physical activity. A subsequent study of 300 people wearing Fit-bits showed that those doing moderate activity  (some exercise and always taking the stairs) burned only 200 more calories than couch potatoes. People doing intense physical activity did NOT burn more calories than the moderately active people. Again, the African bushman burns the SAME number of calories walking a mile as does the Westerner.

Studies of energy expenditure in zoo animals compared to animals in the wild reveal the same constancy. How can this be? No one really knows, but the authors speculate that since human energy expenditure is quite constant (and constrained), we modern adults who are not chasing wounded giraffes over the veld have evolved metabolic adaptations that spend our calories on supporting brain functions (the oxygen you take in with every fourth breath is needed just to feed your brain) , running our inflammatory processes (exercise may prevent inflammation by diverting energy from it), producing more and bigger babies, and living longer. But, I am not sure that I am any smarter than the African bushman who lives to 70 in his world, and many of them do.

Humans have learned to cook which increases the caloric value of many foods and makes them more efficiently digested.
We also have evolved to be fat. Our tendency to store fat is probably an adaptation for surviving lean times.
During lean times our survival is enhanced by us sharing what food there is.
Apes do not share.

“Exercise to stay healthy and vital;
focus on diet to look after your weight.”

References:
1. The Exercise Paradox, Herman Pontzer, Scientific American, Feb. 2017, 28-31


Vol. 163 January 16, 2017 From Zero to $7,500: One Consequence of Obamacare Repeal.

January 16, 2017

Hub thumbnail 2015

“As a doctor, I will take it and make it my mission
to heal the nation, reverse the course of Obamacare,
and repeal every last bit of it. ”
-Rand Paul

What exactly could happen if Obamacare was taken away? My daughter’s recent landing of a second part-time job offered an opportunity for me to understand the possible result in one case.

As a singer-songwriter, energy healer, and part-time retail clerk my daughter shares a common situation with many on Cape Cod; an annual income of less than $16,000, which is the current federal definition of poverty.  She is therefore eligible for Medicaid in Massachusetts. She pays no premium, has no deductible, and except for some named prescription medicines she has no co-pays. Preventative, pre-natal, and behavioral health services are covered. Her out-of-pocket cost per year is essentially zero. Some Obamacare repealers want to roll back the extension of Medicaid eligibility financed by federal subsidies. In many states that would strip this kind of  coverage from many of those newly covered under the ACA, but that is not a possibility in Massachusetts.

In my daughter’s case her new, second part-time job may push her annual income over $16,000. If so, she will no longer be eligible for Medicaid. As a part-time worker she is not be eligible for an employer-sponsored (and partially paid for) health plan. Her employer’s HR department told her she could buy a basic policy with a $2700 annual deductible for $226 a month through the school. “Co-pays varied and are difficult to predict.”  For her that is a new potential cost of $5400 out-of-pocket per year.

She got married last year and her spouse is in the same “low-income” bracket, so she inquired about a family policy (“for 2”). The answer: $400 a month at the same $2700 deductible amount for a $7,500 potential out-of-pocket cost. A $7,500 out-of-pocket cost “exposure” per year is a big nut for a family earning less than $22,000 a year.

Her other choice (besides going uninsured and paying a fine of $300-$2,085 in 2017 depending on income level) is buying an individual policy through an ACA Health Insurance Exchange. Under Obamacare any individual that is making less than 138% of the federal poverty level (about $22,000) can shop for a policy via a state or federal health insurance marketplace (also called health insurance exchange).  The exchanges can offer federally-financed subsidies of up to 60% of premium for eligible “working poor”. After lengthy website surfing, face-to-face help from the Health Connecter facilitator at a local hospital, and several phone calls with prolonged holding periods, she discovered that she could buy about the same basic policy of $2700 deductible for $226 a month through the health insurance exchange. BUT, despite providing all sorts of financial info they could not tell her…”yet” … what the premium would be and whether she was eligible for a premium subsidy. She was told that “things were in flux”, and that she could get a “call back in a week or two about that”. The enrollment deadline for signing up is January 31.

Just “for the fun of it” and to satisfy my curiosity I masqueraded online as my daughter to experience the health insurance application process via the Mass Health Connector. Over three different days I persisted on the internet and on the telephone to try to get the answer to : ”What would it cost to buy a basic individual health insurance policy?”  After reviewing and clicking on 5 to 7 different logos with unfamiliar company names, after entering the same information on multiple screens, after holding for more than 20 minutes on three separate phone calls, after being passed on to three different “responders” on one phone call, and after twice being hung up on after saying that “I was currently on Medicaid, but was looking for insurance to start February 1 when I would become ineligible”, I GAVE UP THE QUEST WITHOUT AN ANSWER.

Different sites had different definitions of “basic” and most had three or more different levels of benefits (coverage). Descriptions of benefits were quite lengthy and often complex.  For instance, the Bronze (basic) Level of “Access Blue Saver II“ (from Blue Cross; the easiest comparison charts to read) offered a 9 page policy offering no preventative or prenatal care with a $3,350 deductible and $60 co-pay for office visit and $1000 co-pay for an ER visit. Silver, Gold, and Platinum “Access” policies had different benefits. I could not get any information about actual premiums without further phone calls to “licensed brokers.”

Why is this so convoluted and confusing in contrast to the simpler processes of Medicaid and Medicare? One answer is that individual insurance policies are a gamble. For instance, a life insurance policy is really a bet between you and the insurance company. If you lose (die), you win (receive all the premiums back). If you win (out live the term), you lose and the company wins (keeps all the premiums). Another answer is that 400,000 people more than 2015  are flocking to sign up through health insurance exchanges.(1)

Obamacare has not changed the basic premise of individual health insurance policies, and the insurance companies are trying to make their  “best bets”. The betting odds are not as clear as the 1:6 of Russian Roulette, though we know that lack of health insurance can be lethal. The betting odds are more like those of Black Jack. The dealer (health insurance company) is using multiple decks, other players (consumers) at the table can affect your odds, the best odds are not always intuitively obvious, and the dealer (health insurance company) can change the betting rules every year.

Medicaid and Medicare are insurance programs based on large populations and therefore need less of the gambling “tricks of the trade” of writing individual polices. Hence my support for a health insurance program based on a large population, sometimes called a single-payor system. If not “Medicare For All”, then how about state-based programs of “Medicaid For All.” (2)

References:
1. Boston Globe, pg.2, December 22, 2016, from the NY Times.
2. NEJM, 375;26, December 29, 2016, “Maintaining Insurance Access Under Trump – A Strategy”


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