Vol. 174 July 15, 2017 Dumb Government and Smart Guns

July 15, 2017

Gun violence injuries and deaths in the U.S. is a public health crisis.”   – AMA

Gun violence kills roughly 30,000 Americans each year, about as many people as car accidents. The federal government has been restricted in gathering and analyzing gun violence data since 1996 when a CDC study linked the presence of a gun in the house with an increased risk of homicide. The NRA responded with a successful lobbying effort to pass the restriction that the CDC may not use any money allocated to it for “activities that advocate or promote gun control.” It stripped $2.6 million from the CDC budget for firearm injury research. After the Newton School shooting in 2012 Obama issued an Executive Order (one of his relatively few) commanding the CDC to renew their research into gun violence and requested Congress to allocate $10 million for that. Congress never did, and research never resumed.

The NRA has also successfully limited the federal government’s ability to trace guns involved in crimes, “crime gun-tracing”. Some states have developed data bases of crime-gun tracing to identify sources of and reduce illegal gun trafficking. Massachusetts established crime-gun tracing in 2014, but has not published a meaningful analysis of the data which might lead to some action. The 2017 Massachusetts legislature has inserted into their budget proposal a request that the governor produce such an analytical report.

Doctors, particularly pediatricians, are keenly aware of the dangers of having guns in the  house. 90% of accidental gun injuries to children happen in a home with a gun. The American Academy of Pediatrics has explicitly recommended that pediatricians routinely ask gun-safety questions during health and wellness visits. But in 2011, Florida passed a “Privacy of Firearm Owners” law levying $10,000 fines and loss of medical license to any pediatrician that inquired about the presence of firearms in the house. The law was upheld by a Florida state court in 2014 based on “2nd Amendment infringement”. The law was just struck down this year by a Federal Appeals Court that ruled that “there was no evidence that the law infringed on the Second Amendment.” By the way, the Affordable Care Act (aka Obamacare… remember Obamacare?) specifically prohibits physicians from keeping records on gun ownership. an assurance to any paranoid, conspiracy-theory-believing gun owner that docs were now not in league with big government. (see “Docs vs. Glocks”, Scientific American, August 2015. pg. 10)

The solutions to gun violence deaths are mostly focussed on mass shootings including either/or/and:
1. eliminate mental illness,
2. eliminate terrorists,
3. eliminate humane treatment (put water boarding video of terrorists on You Tube),
4. eliminate Muslims,
5. eliminate political correctness  (utter the words “Radical Islam Terrorists” which Obama refused to say (sic.) (1)

The truth is that “mass shootings”, though a big part of media attention, are a small part of the  30,000 annual gun death toll. 62% of  gun deaths are due to suicides committed with guns that DO NOT BELONG to the victim (particularly among the young). Criminals steal about 250,000 guns per year. 1.7 million children live in homes with unlocked, loaded firearms. (2)

The NRA consistently raises the spectrum of the need for the home owner to have a means of self-defense, but a gun is 22 times more likely to be used in a criminal assault, an accidental death or injury, a suicide attempt, or a homicide than it is for self-defense. 61% of gun homicides are by people who know each other.(3)

Making a gun as smart as an iPhone is one way to prevent to a large portion of gun injuries and deaths. Previous attempts to develop such a smart gun have been fraught with problems, have been actively boycotted by gun manufacturers, and have been opposed by gun advocates and the NRA. Kai Kloepfer, a 15-year-old high school student in Colorado, in response to the Aurora theater shooting near his home, started a science project in 2015  to design a pistol that will only fire when a sensor in the grip recognizes the fingerprint of the owner. His project won awards, and Kloepfer delayed his entrance to MIT for a year when he got a grant to develop a working model of such a smart gun. By 2017 he successfully built and demonstrated a smart pistol. The gun takes 1 second to unlock, its battery lasts a year, a light indicates the battery status, and a second light indicates it is unlocked and ready to fire. Neither a child nor a thief can fire the gun. The owner may store up to 10 “authorized user” fingerprints (like for a spouse or domestic partner ). The smart gun is smart enough to NOT  connect with the internet, so it can not be hacked or hijacked.

The NRA response has been predictable: “NRA does not oppose new technological developments in firearms; however, we are opposed to government mandates that require the use of expensive, unreliable features, such as grips that would read your fingerprints before the gun will fire.”(2)

Hey, at least the NRA didn’t evoke the 2nd Amendment argument. That is progress!  Technology can deal with “expensive” and “unreliable”. Technology is far faster to upgrade than the Constitution.

References:
1. “A Nation Captive To The Gun”, Garry Wills, Boston Globe 6/15/2016
2. “The Future of Everything”, Wall Street Journal, 2017, Geoffrey Fowler
3. Journal of Trauma and Acute Care Surgery, 1998

 

 


Vol. 172 June 1, 2017 Why Republicans Dislike Obamacare (simplified)

June 2, 2017

“You pays yer money,
and you takes yer choice.”

 

 

The #1 reason is that the Affordable Care Act (ACA) expanded health insurance to at least 23 million voters in the name of Obama, a Democrat.

The #2 reason is that Obamacare is costing the federal government more than the Congressional Budget Office (CBO) predicted.

That is because more of the uninsured enrolled in Medicaid than predicted and less than predicted bought policies through the health insurance exchanges. I am sure that there are all sorts of complex economic reasons for that, but to my mind it seems pretty simple.  If Medicare is the Gold Card of health insurance, Medicaid is at least the Silver Card.  The Medicaid card is accepted by all hospitals and ERs (by law) and many physician specialists. Even some behavioral health services can be paid for with the card. Medicaid insurance is always state-funded, and each state develops their own program.”If you know one Medicaid program, you know just one Medicaid program.”

Obamacare increased federal subsidies to states that expanded people’s eligibility ( i.e.; by raising eligible income levels) for Medicaid insurance. Federal subsidies existed for the first few years, but Medicaid costs would eventually be borne by the individual states’ taxpayers. If you are the Republican governor of a state running for reelection every four years you’re probably not enthusiastic about that. However, one Republican Governor ( Romney of Massachusetts) had already expanded that state’s Medicaid eligibility to achieve nearly 100% insured. The present Republican Governor (Baker of Massachusetts) will be very unhappy if he loses the federal subsidies to Medicaid under Trumpcare.

Health insurance exchanges were supposed to recruit into the health insurance risk pool a lot of healthy young people not covered by employer-based plans. These healthy young people would need less health care than their elders, so their premiums would be a “net plus revenue” to the insurance companies. When that “net revenue” did not appear as large as expected several companies withdrew from the exchanges with much media attention. The “individual mandate” tax which was supposed to “incentivize” the uninsured to buy policies through the exchanges was apparently too low to work.

So, the essential elements of the Republican “replacement” of Obamacare are to:
1) roll back federally subsidized Medicaid expansion and
2) do away with the health insurance exchanges with their federal subsidy of premiums and the associated “individual mandate”.

Of course, Republicans propose to keep the more popular benefits like required coverage for pre-existing conditions and coverage for children up to age 26 living at home. Obamacare also established a new standard definition of “essential benefits” such as pregnancy and other maternal benefits and put a maximum cap on premiums for the elderly. One Republican proposal would define pregnancy as a “preexisting condition” and deny coverage. Watch for further developments in evolving Senate proposals.

The predictions of the CBO in the past (since Nixon created it on the way out the Oval Office door) have been more nearly correct than those of most other agencies and organizations. It’s reputation as bipartisan and objective remains intact. The publication of Republican “replacements” before the CBO’s analysis could be carried out clearly hurt the credibility of their proposals.

Multiple evidence-based studies and the experience of all other developed countries with government-based health insurance (does NOT have to be a “single payer”) have shown that providing universal health insurance in the long run saves money;
-by providing access to medical care for all citizens,
-by enhancing the cost-effective introduction of new technology,
-and by rationalizing the resource allocation of a defined budget.

We have a history of difficulty in taking the long view. For example, the initial enthusiasm for preventative/wellness programs exhibited by the early HMOs eroded considerably when they realized that the policy holder might not be with the same insurance company when the time came years later to reap the benefits of good health (less medical care expenses).  Certainly Governors, congressmen, and other public officials with short 2, 4, or 8-year terms have little incentive to always appreciate the long-term cost benefits down the road. (“No regulations to fight against climate change” comes to mind)

So as “they”say, being either the British magazine Punch in 1846 or Mark Twain in 1884 in “Huckleberry Finn”,
“You pays yer money, and you takes yer choice.” 


Vol. 171 May 15, 2017 Medical Updates (Real News)

May 15, 2017

 

“The Only Thing That Is Constant Is Change -”― Heraclitus

 

 


Those TV ads work … for the drug companies.
A study of the effectiveness of TV ads (Direct-to-Consumer Advertising or DTCA) for prescribed testosterone supplements (no effectiveness in men without endocrine disease) in 75 regional markets from 2009 to 2013 showed that the addition of ONE TV ad per household per month for 4 years was associated with an increase in new blood tests of testosterone level, new prescriptions with blood level testing, and new prescriptions without any blood level testing. About 2% of the middle-aged men in this study of 17 million men received a testosterone prescription. (JAMA,Mar 21, 2017)

In other news, the British Medical Journal published a study of over 900,000 men which showed that those taking testosterone were 63% more likely to develop potentially fatal blood clots in the legs or lungs during the first six months of taking it. (BMJ, Nov. 13, 2016)

Vitamin D gets an “F”.
Vitamin D supplements became very much in vogue when some studies suggested that people with low blood levels had a higher risk of cardiovascular disease. BUT, in New Zealand 2500 adults were given 1000 units of vitamin D once a month and a matched group of 2500 were given placebo. The vitamin D blood level doubled in the supplemented adults, but at the end of 3 years both groups had identical rates of adverse cardiovascular events (12%). (JAMA Cardiol Apr 5, 2017)

PSA testing -“D” or “C”? It depends.
In 2012 the U.S. Preventative Services Task Force (USPSTF) gave the PSA blood test screening for prostate cancer a “D” – (not recommended) because of false positives leading to unnecessary procedures and treatment, and the fact that PSA screening prevented less than 1 prostate cancer-related death per 1000 men screened.

In 2017 the USPSTF is upgrading that “D” to a “C” (maybe a small benefit) but only for men aged 55-69. (Dare we call it a “gentlemen’s C” ?) The “D” remains for those over 70. This upgrade for the younger men is based mostly on the emergence of the “active surveillance” option to immediate surgery or radiation for positive PSA tests and biopsy. The USPSTF strongly recommends that physicians 1) explain all the risks and benefits of PSA testing to men from 55-69, 2) be aware of the patient’s “values and preferences”, and 3) practice effective “joint decision-making” with the patient. (J Watch General Medicine May 15, 2017)

In other news, a Michigan study of 431 men with localized prostate cancer discovered by PSA testing and confirmed by biopsy who opted for “active surveillance” rather than immediate surgery or radiation showed that only 31% actually followed the complete “active surveillance” protocol. (PSA testing every 6 months and annual repeat biopsy.) Another 31% complied with just the PSA test repeats, but not the biopsy. 22% did neither repeat PSA tests nor biopsy. Outcomes were not measured in this study, (J Urol Mar 2017)

Aspirin may get a third “A”
Aspirin is well-known to relieve pain, reduce inflammation, reduce fever, and reduce blood clotting. It does that by inhibiting the production of prostaglandins, a hormone-like substance in play in all those conditions. In 2000 scientists discovered that aspirin also increases our production of resolvins which also reduce our inflammatory response. We make resolvins from Omega-3 fatty acid precursors (hence the contemporary popularity of fish oil).

Investigators are very interested in a newly defined, third effect of aspirin which is unrelated to its role in anti-inflammation – aspirin’s interference in the ability of cancer cells to metastasize. Cancer cells apparently need to be coated with clumps of platelets in order to survive their trip through the blood stream to distal sites. In mice, aspirin’s anti-platelet action (the “reducing blood clots” function) has been found to interfere with platelet clumping around the cancer cell and successful migration of the cancer cells through blood vessels is inhibited. (Scientific American May 2017)

Trying to avoid sugary beverages? Don’t jump to diet soda.
A 10 year study monitoring 4000 people without diabetes for strokes and cognitive decline found that people who drank diet soda every day were three times more likely to develop strokes and dementia. In a separate study people who drank more juices and more sugar-sweetened soda than others were more likely to have poorer memory and smaller brains on MRI imaging than the other people. The researchers state clearly that this is not a cause and effect situation, just an “association”. (Stroke April 24, 2017)
“More research is needed.” Of course.
“Water is best.”

Bilingual brains remember their first language, even when they can’t speak it!
Korean-born adults who were adopted by Dutch families before the age of six and who did not speak nor understand Korean were better at distinguishing between the sound contrasts of the Korean language and could pronounce the Korean sounds much better than those Dutch adults who had no exposure to the Korean language as children. This better discrimination of sounds is not genetically based because numerous studies have shown that all infants are capable of reproducing all the sounds of all languages. “Remarkably, what we learn before we can even speak stays with us for decades.” (Duh!) (Royal Society Open Science, Mar 2017)

No federal money to study pistols or pot.
According to David Hemenway, Professor of Health Policy, Harvard School of Public Health, an average of 300 people get shot in the U.S. each day. One-third of them die. Twenty years ago the CDC funded about $2.6 million a year (“a small amount”) for firearms research. Now that funding is ZERO. Since 2006 Congress has pprohibited the CDC from gathering any gun-related statistics and developing a gun-related data base, but there is apparently no formal, official prohibition for funding gun-issue research,; just the CDC’s desire to “stay out of congressional crosshairs”.

NIH apparently has the same reticence. In the past 40 years over 486 NIH grants have been awarded in the areas of cholera, diphtheria, polio, and rabies which have caused 2000 deaths in the U.S. Over the same 40 years while 4 million people were shot in the U.S. , NIH has awarded 3 gun-issue research awards. (Note: this period of time is during the relatively scientific-friendly Clinton, Bush, and Obama administrations .)

Marijuana is still classified by the FDA and the DEA as a Schedule I substance which prevents any clinical trial or study of its medicinal benefits. Medicinal marijuana must have FDA required “drug development” studies to get off Schedule I, and those studies are virtually impossible while it is on Schedule I. (Note: current Attorney General Jeff Sessions said in April 2016: “Good people don’t smoke marijuana”) (Scientific American May 2017)


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. 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. 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”


Vol. 160 December 15, 2016 ACA or Not ACA, That Is The Question.

December 15, 2016

Hub thumbnail 2015

As Trump continues to form his cabinet and Obama counts the days left while Hillary remains hidden in the woods, speculation about what will happen to the Affordable Care Act (ACA) is wide-ranging. Will it be repealed? CAN it be repealed? What will replace it? What if nothing replaces it?

It may help to remember that the vast majority of citizens who had health insurance before ACA were already heavily subsidized by government funds via Medicare, Medicaid, and tax subsidies for employer-sponsored insurance ($300 billion for the employer-sponsored policies alone). Studies have shown that 5% of the population accounts for 50% of health expenditures. The least costly half of our population accounts for 3% of the expenditures. (This is, of course, the essential element of risk spreading that makes insurance of anything “work”.)

ACA accomplishments since 2010

23 million citizens have gained health insurance coverage
-coverage that is not denied due to pre-existing conditions
-coverage of children up to 26 yo. on parents’ policy
-more than half of those (13.7 million) gained coverage under expanded Medicaid (by increasing the eligible income levels)
-all but 19 states took the federal subsidy to expand Medicaid coverage

Uninsured citizens dropped from 16% in 2010 to 9% in 2016
91% of U.S. citizens now have health insurance coverage (Spoiler Alert: in our big, or should I say “Hu-u-y-ge”, country that 9% translates into 29 million citizens still un- or underinsured.)

All this without additional net cost over the cost of medical services that was predicted in the U.S. without the ACA, i.e “no net increased cost due to the ACA.” (The largest single source of spending increase since 2013 was “retail pharmaceuticals”.)

Reduced “gender bias” by mandating maternal health benefits (coverage of contraception) as part of essential benefits package.

Mandated some mental health service coverage.

Mandated some coverage of substance abuse services.

What about repeal?

Unlikely, but possible. Outright repeal could immediately create another 23 million people without health insurance which would dump all that cost burden back on the states, the insurance companies, and the health care providers.

Repeal would require 60 votes in the Senate, and the Republicans are 8 short. There is speculation that some Democrats running for reelection in 2018 might join a repeal vote knowing that some of their Democratic colleagues that supported Obamacare lost reelection in 2016. The Gallup poll currently puts the public attitudes toward Obamacare at 50/50 “favorable/unfavorable”.

“Replacement” of selected provisions is more likely since it could be done as part of the “budget reconciliation process” which requires only a simple majority of 51 votes.

Replacement?

Coverage to age 26 on your parent’s policy and ban on denying coverage of pre-existing conditions are so popular that they are here to stay.
What parts might Republicans target to replace?
(An “ACA repeal bill” passed by the Senate in 2015 and vetoed by Obama gives us some clues).

Individual mandate – Even though this was proposed by Republican Mitt Romney and successfully passed the Supreme Court test as a tax, this penalty for not getting health insurance rankles the Republicans, and a sizable portion of the public. Proponents argue that it is essential to incentivize “healthy people” to buy insurance, a fundamental principle of spreading the risk over a large group.

Block grants to the states and/or vouchers for Medicare – Block grants would change this federal standard “entitlement” program into a state-controlled one with variable benefits and premiums. Vouchers, touted as making consumers more “powerful in the marketplace”, really shift the obligations (“unpaid bills”) to the states and health care providers

Reduce income level eligibility for Medicaid from the ACA level of 138% of federal poverty level (about $22,000 for a couple) back down to about $16,000 a year for a couple.

Middle-class subsidies via insurance marketplaces to be replaced by Health Savings Accounts (HSA), tax credits, across-state line insurance policies, and reestablishment of high-risk pools. All of these are advantages to people who have income, often sizable incomes.
-70% of HSAs are currently held by people with over $100,000 annual income.
-Many insurance companies already sell across state lines, but this provision would free companies from state mandated benefits and other state regulations.
-Reestablishment of high risk pools could provide higher premium policies for those with chronic diseases without unduly penalizing healthy individuals. This reflects a trend back toward indemnity or catastrophic insurance policies with few preventative benefits.

Rescind the new taxes to fund the ACA – details on how to pay for replacement provisions TBD.

Maternal health benefits– Trump suggests making contraception available over-the-counter without a prescription, thus avoiding the problem of exempting churches from this mandated benefit. Planned Parenthood would, of course, be defunded.

Medical liability reform – Though a cherished symbol of support of and a psychologically warm and fuzzy concept to physicians, all studies show that no significant cost reductions occur from tort reform because the actual cost of “defensive medicine” is very small compared to the total.

What about ACOs?

Remember them? Accountable Care Organizations are physician groups and hospitals organized together to reduce costs without degrading quality. The first ACOs, so-called “Pioneer” ACOs, could keep a share of any savings if they delivered care to a defined population at a cost below a “target cost” without missing any of the “quality targets.” If they overshot the “target cost”, they would owe money to the federal government at the end of the year.

This is the last year for the original 32 Pioneer ACOs, and only 16 remain in the program. Half have withdrawn from their contracts because of losing money, continuous wrangling over targets, and lack of flexibility in defining risks and benefits. The “Next Generation” ACOs are due to sign up in January 2017, and most will opt for sharing savings without taking financial risk for losses.

Bottom Line:

The vetoed 2015 Senate “ACA repeal bill” had a two-year transition period embedded in it, so even if a repeal bill is passed and Trump signs it the loss of health insurance will not be immediate. Many political experts, if we can still use that label for them after this election, suggest that even “replacement” of ACA provisions will be politically difficult and will take at least two years to pass. A new study by the Urban Institute shows that Paul Ryan’s proposed Republican replacement plan would result in more uninsured citizens than existed before ACA. 80% of those losing insurance would be part of a working family.

How high are the stakes? A 2009 study by Harvard Medical School and the Cambridge Health Alliance estimated that the lack of health insurance led to almost 45,000 unnecessary deaths. “Lack of health insurance can be fatal.”

So, for a variety of reasons, the next two years will be “vel-l-ly in-ter-esting” In the meantime if you have health insurance through a ACA-based insurance marketplace make sure you re-enroll by January 31 to continue coverage.


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