Archive for the ‘health care’ Category

A Few Items To Ponder, Two Of Them Important

Wednesday, November 30th, 2022

Type 1 Diabetics get good news

As I have written before, Type 1 diabetes (T1D) is a horrific disease. It is a leading cause of stroke, heart disease, blindness, kidney disease and non-traumatic amputations. It also costs a lot to manage. The media has been full of stories of unfortunate people who have had to choose between taking insulin or food. The Inflation Reduction Act, passed in August, caps the cost of a vial of insulin at $35 for Medicare beneficiaries, but does nothing for diabetics not on Medicare. About 70% of the nation’s 1.9 million Type 1 diabetics are on Medicare.

Research has proven Type 1 diabetics contract the disease in three stages over time. According to a 2015 study on the presymptomatic stages of Type 1 diabetes:

Insights from prospective, longitudinal studies of individuals at risk for developing type 1 diabetes have demonstrated that the disease is a continuum that progresses sequentially at variable but predictable rates through distinct identifiable stages prior to the onset of symptoms. Stage 1 is defined as the presence of β-cell autoimmunity as evidenced by the presence of two or more islet autoantibodies with normoglycemia and is presymptomatic, stage 2 as the presence of β-cell autoimmunity with dysglycemia and is presymptomatic, and stage 3 as onset of symptomatic disease.

Type 1 diabetics go through two stages of disease development before full-blown diabetes appears in Stage 3. Imagine a platform diver. Stage 1 is climbing to the platform and standing at the edge. Stage 2 is lifting off and moving through the air. Stage 3 is hitting the water and getting very wet. Diabetics don’t know they have the disease until they hit the water. But what if they did, and what if the time in the air between the platform to the water could be extended, say by 25 months?

On 17 November, the FDA approved a biologic therapy that delays the onset of Stage 3 by about that much.

The monoclonal antibody teplizumab, which will be marketed under the brand name Tzield, from ProventionBio and Sanofi is given daily through intravenous infusion over two weeks. And it works. Patients who take it extend Stage 2 by a little more than two years.

But there’s a catch, two, in fact. First, PreventionBio announced last week it is pricing Tzield at $193,900, which is considerably higher than insurers anticipated. Second, how does a person know they’re in Stage 2 and, therefore, should be taking the drug? The answer is screening for autoantibodes that are markers for diabetes. This will also incur a cost. More about that below.

The question to be answered is will insurers cover the considerable cost for screening and drug infusion?

In 2014, the FDA approved Harvoni as treatment for Hepatitis C, which is the leading cause of liver failure. Hep C is a life-threatening disease. Harvoni cured it. Completely. Its maker, Gilead, priced the pill at $95,000 for a twelve-week course of treatment. At the time, I was a Director at a Boston HMO. We wrestled with the cost issue. In the end, because Harvoni cured what was a horrific and terrifically costly disease, we gladly decided to provide it for our members.

Tzieild is different. It does not cure diabetes. Rather, it delays its onset. The American Diabetes Association and the Juvenile Diabetes Research Foundation (JDRF) are ecstatic about the arrival of Tzield. They point out this is the first time a successful treatment for diabetes has appeared on the scene, although it’s not really a treatment. However, they’re concerned about the screening issue.

Aaron Kowalski, CEO of JDRF, says the main challenge in prescribing Tzield will be finding people who need it. The drug is approved for people who don’t have any symptoms of the disease and may not know they’re on the road to getting it.

“Screening becomes a really big issue, because what we know is, about 85% of type 1 diagnoses today are in families that don’t have a known family history,” Kowalski said. “Our goal is to do general population screening” with blood tests to look for markers of the disease.

It will be interesting to learn how insurers and health plans react to Tzield. According to the JDRF, 64,000 people a year are diagnosed with Type 1 diabetes. If every one of them received the drug the total cost would be about $12.5 billion. But if you were one of the 64,000, my guess is you’d happily stand in line for it. So would I.

Donald Trump and the Mar-A-Lago fiasco

By now, every sentient person in America knows ex-president Donald Trump dined last week with Nick Fuentes, the poster child for anti-Semitic white nationalism, and Kanye West, who now calls himself Ye and has also spouted anti-Semitic whinge. Afterwards, when social media lit up like the Rockefeller Center Christmas tree, Trump claimed he didn’t know Fuentes was going to be there; West just brought him along.

Putting aside the fact that Trump’s Secret Service detail would never in a month of Sundays allow just anyone to drop in to break bread with the big cheese without getting clearance from the big cheese himself, I’m more concerned with the response of the Republican Party’s leadership to this. Republicans who are likely to run for President, notably Mike Pence and Chris Christie, criticized their former leader, although it took them two or three days to do it. It took more than a week for anyone in Republican leadership to put their wet finger in the air and decide to say he shouldn’t have done it.

The stench wafting from the halls of Congress is remarkable, indeed.

A personal note

Starting tomorrow I shall be away from this, and any other, keyboard for a little bit.

Since I was eight years old, I have been an avid, competitive, pretty good, tennis player. I’ve calculated that in the intervening years I have hit somewhere around just under a million overhead smashes. That’s a lot of serves and put-aways. And they have taken their toll. So, at 7:00 AM tomorrow morning, a very good doctor (I hope) will be concentrating deeply (I hope) on the job of giving me a new shoulder. I’m told it will be a little painful for a while, but on the other side lies bliss, and more overheads.

I look forward to being back at the keyboard.

Paid Sick Leave: Public Policy That Makes Ethical And Economic Sense

Tuesday, August 23rd, 2022

On Health, History And The Fine Art Of Fudging Data

Wednesday, August 10th, 2022

The cost of insulin, or, half a loaf is better than none

The Inflation Reduction Act (IRA), passed this past Sunday in the Senate and now sitting for certain passage in the House this week, will cap the cost of an insulin vial at $35 for Medicare beneficiaries with diabetes. However, for those not on Medicare, insulin costs will remain unchanged.

Of the 30 million Americans who have diabetes, more than 7 million of them require daily insulin. A Kaiser Family Foundation study released in July, 2022, found 3.3 million of the 7 million are Medicare beneficiaries  and documented the rise in insulin’s cost since 2007.

Aggregate out-of-pocket spending by people with Medicare Part D for insulin products quadrupled between 2007 to 2020, increasing from $236 million to $1.03 billion. The number of Medicare Part D enrollees using insulin doubled over these years, from 1.6 million to 3.3 million beneficiaries, which indicates that the increase in aggregate out-of-pocket spending was not solely a function of more Medicare beneficiaries using insulin.

The IRA is great news for the Medicare beneficiaries who make up nearly half of the population needing daily injections of insulin to live, but a provision in the original bill that would have capped the cost at $35 for all diabetics, not just those on Medicare, never made it to the final bill. Left out in the cold are the 3.7 million diabetics requiring insulin to keep living who are privately insured or not insured at all. That was an expense bridge too far for Republicans.

Will you permit a bit of cynicism here? Needing 60 votes to pass, 57 senators voted in favor of capping insulin at $35 per vial for all diabetics, 50 Democrats, seven Republicans.  Americans overwhelmingly support this as is shown in this Kaiser Family Foundation poll taken recently:

Eighty-nine percent consider this a priority, 53% a top priority. I suggest Republican leadership, never intending to allow this to pass, permitted those seven, standing for reelection this fall, to vote for the bill to give them cover in the upcoming election. Is that too cynical?

If that’s not bad enough, a study by Yale University researchers, published in Health Affairs, also in July, concluded that “Among Americans who use insulin, 14.1 percent reached catastrophic spending over the course of one year, representing almost 1.2 million people.” The researchers defined “catastrophic spending” as spending more than 40 percent of postsubsistence family income on insulin alone. Postsubsistence income is what’s left over after the cost of housing and food.

Nearly two-thirds of patients who experience catastrophic spending on insulin, about 792 thousand people, are Medicare beneficiaries. The IRA will help these people immensely. However, as it stands now it will do nothing to assist the non-Medicare diabetics who annually face catastrophic spending due to the cost of insulin. This group numbers about 408 thousand who need insulin just to go on living, and, yes, these are poor people with few resources.

Not to put too fine a point on it, but we should not forget that insulin isn’t the only medical resource diabetics use and need. There are also the syringes used to inject the stuff, not to mention the testing strips and glucose monitors that analyze the levels of blood glucose, which diabetics have to track religiously. Diabetes is an expensive disease, and insulin is only one part of the expense.

Every time I and others write about the cost and quality of health care in the US, it almost seems as if we’re all standing on the shore throwing strawberries at a battleship expecting some sort of damage. The Inflation Reduction Act contains the first significant health care move forward since the Affordable Care Act of 12 years ago. It’s progress at last, but so much more is needed.

A great historian and better American is now history himself

David McCullough has died. We have lost a giant.

McCullough had that special gift of telling stories of our past in ways that made us think we were there when they happened. He put us solidly in the shoes of the people he was writing about. For him, history is not about a was; it is about the is of the time. Like us, his subjects lived in a present, not a past. He never judged the choices made in the past; he just told the truth through stories meticulously researched and empathically written. That’s how he could win two Pulitzer Prizes, two National Book Awards and a Presidential Medal of Freedom.

I first met McCullough in the 1980s through his first book, The Johnstown Flood, published in 1968. I could not put it down. Read it through in one sitting. It was the start of his brilliant career, and its success gave him  hope he could actually devote himself to history and do well at it. But he never wrote for the money. What drove him was his love for and curiosity about understanding from whence we came.

In a 2018 interview for Boston Magazine with Thomas Stackpole, he was discussing his latest, and last, historical work, The Pioneers, about a group of New Englanders in the 19th century who picked themselves up, headed west,  settled Ohio, and courageously kept it an anti-slavery state. During the interview, he said:

There are an infinite number of benefits to history. It isn’t just that we learn about what happened and it isn’t just about politics and war. History is human. It’s about people. They have their problems and the shadow sides of their lives, just as we do, and they made mistakes, as we do. But they also have a different outlook that we need to understand. One of the most important qualities that history generates is empathy—to have the capacity to put yourself in the other person’s place, to put yourself, for example, in the place of these people who accomplished what they did despite sudden setbacks, deaths, blizzards, floods, earthquakes, epidemic disease. The second important thing is gratitude. Every day, we’re all enjoying freedoms and aspects of life that we never would have had if it weren’t for those who figure importantly in history.

Today’s Americans seem to think history begins about ten years ago. It is a modern day tragedy, and we own it.  Consequently, humanity keeps making the same mistakes over and over again, never learning from those who showed us where the land mines were lying, hidden underfoot. McCullough did that for 50 years. He leaves a large hole in our American universe.

Fudging data with style

Heading back to diabetes for a moment. You may recall the old adage, “Figures lie, and liars figure.” Well, this is not about that. The fudging I’m going to show has not a lie in it. What it does have is deception on a grand scale, and it comes from our CDC, which, usually, I greatly admire. But not this time.

As we’ve all learned throughout the COVID pandemic, the CDC tracks and reports data — a lot of it.

One of the things the CDC  reports about is Diabetes Mortality By State. It’s been doing it since 2005, and it’s in the last six years that we see, if we look, deception.

Here is how the CDC reported this data in 2015:

The redder things are, the worse they are, so this looks bad, and it is.  The scale above shows the distribution of the colors for the states, starting at 13.4 in Colorado and Nevada and ending at 32.4 in West Virginia. Those are deaths per 100,000 people.

Now, here is how the CDC reported diabetic mortality six years later in 2020:

In 2015 there were three dark red states, eight almost dark red states, and 20 almost almost dark red. But now we have only two dark red, three almost dark red, and those 20 semi dark states have turned to light tan. Wow! What an improvement.

One could be forgiven for going away happy….if one did not look at the actual numbers.

In 2015, Mississippi and West Virginia were the highest mortality states, 32.4 and 31.7 deaths per 100,000 people, respectively. Their numbers in 2020 soared about 30% to 41.0 and 43.1. The states with the lowest mortality in 2015, Nevada and Colorado (13.4 and 15.9), in 2020 are 18.0 and 24.2 deaths per 100,000. Wyoming now comes in with the second lowest mortality at 20.7.

But things look so much better. The distribution scale is different, but who looks at that?

The CDC has done something shameful; it has moved the goalposts and didn’t tell anyone. In reality, diabetic mortality has gotten much worse over the last six years, but unless you dug deep, not only would you not know that, you’d think there was an actual big improvement.

This is another reason why the insulin provision in the Inflation Reduction Act is a big deal.

 

 

An Indiana Power Grab Shows Politics At Its Worst

Thursday, July 21st, 2022

Fifty-two-year-old Theodore Edward Rokita, known as Todd, not Ted, is Indiana’s 44th Attorney General.

A dedicated far-right Republican, his political life is a thirsty search for one powerful political office after another. Elected Indiana’s Secretary of State at age 32 in 2002, he was the youngest Secretary of State in America at the time. He went on to capture Indiana’s 4th Congressional District seat in 2011 and served in the U.S. House until 2019.

In 2015, during his time in the House, Indiana created the Healthy Indiana Plan and expanded its Medicaid Program to take advantage of the Affordable Care Act. Rokita’s reaction to this was to say the ACA was “one of the most insidious laws ever created by man.”

He ran against Eric Holcomb for Governor in 2016 to replace Mike Pence, who had resigned to become Donald Trump’s running mate. Holcomb won convincingly, and, as I hope to prove below, Rokita never forgave him for the drubbing.

In 2017, Rokita resigned his House seat and sought the Republican nomination for U.S. Senator. He failed again.

But in 2020, in a political comeback of sorts, Todd, not Ted, Rokita defeated incumbent Curtis Hill for the Republican nomination for Indiana Attorney General, and in November 2020, he won the general election.

If that were all we ever learned of Todd Rokita, we could chalk him up as just another political hack of the Republican persuasion.

But the story doesn’t end there. It begins there. And it begins with a 10-year-old girl from Ohio.

In May 2022, a man from Columbus, Ohio, Gerson Fuentes, 27, allegedly raped that 10-year-old girl not once, but twice, and she became pregnant by him. On 27 June, a child abuse doctor treated her, but could not refer her for an abortion in Ohio, because, following the Supreme Court’s Roe reversal earlier in June, Ohio’s trigger law fired and outlawed abortions after six weeks of insemination. He determined the girl was six weeks and three days pregnant. So, he called a colleague in neighboring Indiana, where abortions were still legal in the first 22 weeks. Dr. Caitlin Bernard, an obstetrician-gynecologist, agreed to help, and the 10-year-old was quickly on her way to Indiana.

On 30 June, Dr. Bernard performed the abortion. The 10-year-old, who will bear the horrid psychological scars of this for the rest of her life, was spared the further horror of giving birth to her rapist’s child.

Among all the bureaucratic red tape government can create, Indiana has created what are called Termination of Pregnancy Reports, TPRs, and these must be completed by physicians who terminate pregnancies in the state. In the case of a pre-teen abortion, the law calls for TPR completion within three days of the abortion. Dr. Bernard completed and submitted her TPR for the 10-year-old within two days, on 2 July, thereby complying with the law.

On the first of July, one day after the abortion and one day before Dr. Bernard submitted her TPR, the Indianapolis Star ran a story about pregnant women from Ohio and Kentucky who were heading to Indiana for abortions because of the restrictive laws in their states. The story began:

On Monday, three days after the Supreme Court issued its groundbreaking decision to overturn Roe v. Wade, Dr. Caitlin Bernard, an Indianapolis obstetrician-gynecologist, took a call from a colleague, a child abuse doctor in Ohio.

Hours after the Supreme Court action, the Buckeye state had outlawed any abortion after six weeks. Now this doctor had a 10-year-old patient in the office who was six weeks and three days pregnant.

Could Bernard help?

The story later said Dr. Bernard had agreed to help. It did not say she had performed the abortion, just that she had agreed to help.

This story caught the nation’s attention, mostly for the wrong reasons. It was ridiculed. The Wall Street Journal called it “fanciful.” Republican Ohio Attorney General Dave Yost was among those who questioned the validity of the story.  Ohio Republican Representative Jim Jordan called the story “another lie” in a now-deleted tweet. Some of Fox’s most high-profile hosts — Tucker Carlson, Jesse Watters, Laura Ingraham — suggested the account of the 10-year-old rape victim was a “hoax” and “politically timed disinformation,” and claimed that the Biden administration was “lying” about the case after the Supreme Court overturned Roe v. Wade.

All this happened between the Indy Star’s story and the arrest—and confession—of Mr. Fuentes, which is when the backtracking happened. Jordan deleted his tweet, the WSJ issued a “correction,” Fox News actually took credit for “justice being served,” and Indiana Attorney General Todd Rokita, with all the empathy of an empty paper cup, saw an opportunity and took the stage.

Was he devastated that a 10-year-old had suffered such a horrific experience? If he was, he never said. What he did say, during a press conference he hurriedly called on the subject, complete with TV, Radio and Print media, was that he would be investigating Dr. Bernard for failing to provide the Termination of Pregnancy Report within the time required by law (She had).

On 13 July, twelve days after the abortion, he wrote a letter to Governor Holcomb, the same Eric Holcomb who had trounced him in the race for Governor, advising, “If  Doctor Bernard has failed to file the required reports on time, she has committed an offense, the consequences of which could include criminal prosecution and licensure repercussions.” Rokita went on to say “key” people on his staff had been trying to get the Indiana Department of Health to forward the TPR for two days, without success. Two days.

Rokita’s letter lectures the Governor, saying, “As state officeholders, we bear an important responsibility to get to the bottom of this matter immediately….” He admonishes the man who beat him in the election of 2016 by saying Holcomb should “direct the state agencies under your purview to produce immediately to my office the requested TPRs…so we can confirm Dr. Bernard’s compliance with the law.”*

Not one drop of the Balm of Gilead does Todd, not Ted, Rokita offer the 10-year-old whose life has been so tragically scarred. Nope. He can’t be bothered. He has other things on his mind. He is 100% focused on scoring whatever rancid political points he can.

No wonder people hate politicians.

 

*On 14 July, one day after Rokita’s letter to the Governor, Indianapolis TV station Fox 59 published the TPR, submitted by Dr. Bernard within two days of the procedure, which it had secured by a Freedom of Information request. Maybe Todd should have tried that.

Gavin Newsome And Insulin: An Example Of What Leadership Looks Like

Monday, July 11th, 2022

Having just returned from a wonderful and pretty much off the grid trip to America’s southwest, I discover some pennies have dropped.

Roe is now in Wooly Mammoth land; New Yorkers, and soon many others, will now find it easier to pack a bit of heat; the EPA (and, presumably a lot of other governmental agencies) is no longer going to be able to regulate what its been regulating for the last 50 years; the January 6 Select Committee continues to unearth the sewer-living sludge of the Trump Big Lie; another mass shooting happened, the 309th of 2022, at a July 4th parade no less (only in America); the charlatan Boris Johnson is officially on the way out; and, this past Friday morning, a 41-year-old Shinzo Abe hater, assassinated the former prime minister of Japan at a campaign stop.  Abe’s killer made the gun himself, because it’s nearly impossible to procure a gun in Japan—Japan, the country with the lowest rate of handgun violence in the developed world.

With all of that, I’m thinking Chicken Little was right, and the sky is about to fall any minute now and land on my bucolic, Berkshire back deck.

Nonetheless, today’s Letter is not about any of that sky is falling stuff. We’ll get to all of it later. No, today’s Letter is about a momentous, and non-COVID, medical development that happened while I was gone, when California’s Governor Gavin Newsome announced the state would commit $100 million to making its own insulin for California’s diabetics.

Diabetes kills one American every three minutes. It affects children and adults, both genders, every race and ethnic group and leaves a vicious imprint on those who suffer from it and on those who love them. It is a leading cause of blindness, heart disease, stroke, kidney failure and non-traumatic amputations.

According to a nationwide survey by the Juvenile Diabetes Foundation International, 75 percent of Americans do not know how deadly the disease is, and 38 percent believe that either insulin cures diabetes, makes it harmless, or they don’t know what effect it has.

In 2017, the nation’s total direct medical cost due to diabetes was $237 billion. Average medical expenses for diabetics were 2.3 times higher than for non-diabetics.

Based on information found on death certificates, diabetes was the 7th leading cause of death in the United States in 2015, with 79,535 death certificates listing it as the underlying cause of death, and 252,806 listing diabetes as an underlying or contributing cause of death. However, diabetes is underreported as a cause of death; studies have found that only about 35% to 40% of people with diabetes who died had diabetes listed anywhere on their death certificates and only 10% to 15% had it listed as the underlying cause of death. An example of best practice would be, “Death caused by infection contracted from hemodialysis due to kidney failure, a complication of the patient’s diabetes.”

At 10.2%, California ranks 31st among US states in the percent of adults with diabetes*. There are more than 3.2 million of them in California, the great preponderance being Type 2 diabetics.

There are close to 35 million Type 2 diabetics in the nation. T2Ds still make some insulin, just not enough. For most, lifestyle changes will improve their health, sometimes to the point where they will no longer have to inject insulin. Some will become insulin dependent, and without it, those people will face life-changing complications.

There is a rarer, but much worse, kind of diabetes. That would be Type 1, also known as Juvenile Diabetes. There are 1.6 million T1Ds in the country. According to the CDC, of all the states, California has the lowest rate of juvenile, Type 1 diabetes. T1Ds make no insulin and will die quickly if they don’t get it. Type 1 diabetes can happen at any time in life, but is vastly more prevalent in young people. My daughter came down with Type 1 diabetes at 21 years of age; my late wife Marilyn, at 12. You wouldn’t be wrong to think I’m invested in this topic.

I have argued strenuously in the past (here and here) that the country should guarantee insulin to T1Ds, regardless of their ability to pay for it. It is quite literally a matter of life and death. I can think of no other disease in which, if a patient is deprived of their medicine, death will result within a couple of weeks. But that’s the world T1Ds inhabit.

Government has been kicking the diabetes can down the road for generations. It’s been playing patty-cake with it since then Speaker of the House Newt Gingrich made it a core cause of his 25 years ago, in 1997. This has resulted in two things: government investing more money in looking for a cure—unsuccessfully, and skyrocketing insulin costs for patients. As President Biden noted correctly in his State of the Union address, insulin costs its manufacturers less than $10 per vial to make. Yet, depending on their circumstances, patients are paying anywhere from $300 to $800 for that same vial.  Reprehensible doesn’t begin to describe this situation.

While it is true that most of the ~50% of Americans who have employer sponsored insurance (ESI) only pay co-pays of $30 to $50 for a month’s supply of insulin, nearly all of them pay the full, painful cost until they meet their pharmacy deductible requirements. And one thing more to keep in mind: before Congress Passed the Affordable Care Act in 2010, the 1.9 million diabetics without ESI found their diabetes treated as a pre-existing condition. They paid full freight every time. Fast forwarding to now, some T1Ds are dying, because they either ration, or even go without, their insulin. Why? Because they can’t afford the price.

In my 2018 series on this topic, What Price Life?, I concluded:

So, here’s a question: Should anyone in the United States who requires a daily drug just to stay alive be forced to come up with the money to pay for it? Or, should that be a government-sponsored, health care right, as in the Declaration Of Independence’s “self-evident…unalienable right…to life.”

Gavin Newsome has answered that question. He has had enough. In taking matters into his own hands, he is extending a lifeline to California’s diabetics who struggle with the cost of staying alive. His move will both help those diabetics and provide good paying jobs to the people hired to build the manufacturing process and supply chain. He promises to provide California’s insulin to its diabetic citizens at “a little above cost.”

I don’t know what you think of Gavin Newsome. He certainly has his critics. But on this critical, life and death issue, he is showing a brand of leadership seldom, if ever, seen in that bought-and-paid-for vacuum of mediocrity we call the United States Senate.

_______________________

*It may not surprise you to learn the states with the highest incidence of diabetes, primarily Type 2, are the states whose citizens have the worst health care problems in the country. They are Red states, and are led by Senator Joe Manchin’s West Virginia at 15.7%, followed by Louisiana, Mississippi and Alabama. Mississippi. Always Mississippi. Pounded so low it has to look up to tie its shoes.

Rick Scott Is Going To Rescue America!

Friday, April 1st, 2022

Rick Scott is the junior U.S. Senator from Florida. Elected in 2018, Scott has now served in Congress for 39 months. In November, 2020, his Senate GOP colleagues elected him Chairman of the National Republican Senatorial Committee (NRSC). His job is to get Republicans elected and reelected to the Senate.

Prior to the Senate, Scott was a two-term governor of Florida, succeeded by Republican Ron DeSantis. Before that, he was a businessman. We’ll get back to that later.

You would think the Chairman of the NRSC would be lock-step with Republican leadership in the strategy to take the Senate from the tenuous hold of the Democrats in the upcoming mid-terms. But this does not appear to be the case. Senator Scott is marching to his own drummer.

On Thursday, after no consultation with or cooperation from Senate GOP elites, Scott officially unveiled and launched the Rick Scott, 31 page, 11 Point Plan to Rescue America. The Rescue Plan has 117 agenda items.

This is not a surprise to GOP Senate Leader Mitch McConnell. Scott’s Plan has been discussed for more than a month, and as far back as 1 March McConnell publicly rebuked Scott for it. McConnell is fixated on making the mid-terms a referendum on President Biden, not on laying out a Republican plan he and the GOP establishment would have to spend the entire mid-term campaign defending. He wants Biden playing defense. Scott, on the other hand, wants America to know what Republicans will do if given control of the Senate. Right at the beginning of his Rescue Plan he says, “Americans deserve to know what we will do if given the chance to govern.” If Scott gets his way, now they will. And you have to hand it to him; he certainly doesn’t tap dance around the many issues facing the country.

Before diving into his 11 point, 117 agenda item plan, Scott lays out what the future will look like if nothing changes:

The militant left now controls the entire federal government…Among the things they plan to change or destroy are: American history, patriotism, border security, the nuclear family, gender, traditional morality, capitalism, fiscal responsibility, opportunity, rugged individualism, Judeo-Christian values, dissent, free speech, color blindness, law enforcement, religious liberty, parental involvement in public schools, and private ownership of firearms.

Wow! We need a plan to stop all that!

A few of Senator Scott’s 117 agenda items, guaranteed to be saliva-producing red meat for the trumpiest of trumpsters caught my eye.  For instance,

We will secure our border, finish building the wall, and name it after President Donald Trump.

Kids in public schools will say the Pledge of Allegiance, stand for the National Anthem, and honor the American Flag. We must foster national unity.

Teacher tenure at public schools must be eliminated

We will not allow political or social indoctrination in our schools. Teachers who refuse to comply will need to find new jobs.

We will close the federal Department of Education. Education is a state function.

Government will not ask American citizens to disclose their race, ethnicity, or skin color on any government form.

Our military will engage in ZERO diversity training, teachings on critical race theory, or any woke ideological indoctrination that divides our troops.

We will force prosecutors to prosecute. At present, many prosecutors in big cities are allowing criminals to go free with no justice, and they are doing it on purpose.

Immigrants will not be eligible to collect unemployment benefits or welfare for the first 7 years after arriving in the US.

No government assistance unless you are disabled or aggressively seeking work.

If Congress does not pass a budget, the members of Congress do not get paid. Full stop.

Other than disaster relief, the federal government must stop spending money on non-essential state and local projects until the budget is balanced.

All Americans should pay some income tax to have skin in the game, even if a small amount. Currently over half of Americans pay no income tax.

Enact term limits for the Washington ruling class – 12-year limits for Congress and government bureaucrats.

All federal legislation sunsets in 5 years. If a law is worth keeping, Congress can pass it again.

We will immediately cut the IRS funding and workforce by 50%.

Humans are born male and female, there are two genders, and to deny that is to deny science. No government forms will include questions about “gender identity” or “sexual preference.”

We will protect women’s sports by banning biological males from competing.

No tax dollars will be used to pay for any diversity training or other woke indoctrination that is hostile to faith.

We will not pay any dues to the United Nations or any international organization that undermines the national interests of the USA.

The weather is always changing. We take climate change seriously, but not hysterically. We will not adopt nutty policies that harm our economy or our jobs.

There are a few difficulties with a number of these policy tectonic changes. Ending Social Security, Medicare and Medicaid in five years being among the biggest. Also, Scott’s colleagues in Congress might have something to say about going without pay and getting sent home after 12 years. Increasing taxes on 50% of Americans may prove challenging for Republicans on the campaign trail. Pulling billions of dollars from the states until we have a balanced budget might irritate a few Republican governors. And reducing the IRS’s funding and currently understaffed workforce by 50% would have brought tears to the eyes of mobster Al Capone.*

Although Senator Scott’s plan is dead on arrival, the problem is it arrived in the first place. It’s not about getting Republican senators elected; it’s about Rick Scott.

And what about Rick Scott? As I mentioned above, before getting into government, Scott was a “businessman.” He co-founded Columbia Hospital Corporation in 1987. Columbia later merged with another corporation to form Columbia/HCA, which eventually became the nation’s largest private for-profit health care company with Scott as Chief Executive. According to The New York Times, “[in] less than a decade, Mr. Scott had built a company he founded with two small hospitals in El Paso into the world’s largest health care company – a $20 billion giant with about 350 hospitals, 550 home health care offices and scores of other medical businesses in 38 states.”

Sounds good, right? Quite the businessman.

But there were problems. In March of 1997, the FBI, the IRS, and the Department of Health and Human Services arrived with search warrants. Four months later, Scott was forced to resign by his Board. He didn’t leave willingly, but when he did, he left with a settlement $9.88 million and 10 million shares of stock worth $350 million. Columbia/HCA pleaded guilty to 14 felonies and agreed to a $600+ million fine in what was at the time the largest health care fraud settlement in U.S. history.

The company admitted to systematically overcharging the government by claiming marketing costs as reimbursable, by striking illegal deals with home care agencies, and by filing false data about use of hospital space. It also admitted to fraudulently billing Medicare and other health programs by inflating the seriousness of diagnoses and to giving doctors partnerships in company hospitals as a kickback for the doctors referring patients to HCA. It filed false cost reports, fraudulently billing Medicare for home health care workers, and paid kickbacks in the sale of home health agencies and to doctors to refer patients. In addition, it gave doctors “loans” never intending to be repaid, free rent, free office furniture, and free drugs from hospital pharmacies.

And that’s not all. In 2002, HCA agreed to pay the government an additional $631 million, plus interest, and $17.5 million to state Medicaid agencies, in addition to $250 million paid up to that point to resolve outstanding Medicare expense claims. The entire fiasco cost the company $1.7 billion.

All on Senator Scott’s watch.

There’s one last twist. In a civil suit deposition connected to the case (there were a lot of civil lawsuits), Senator Scott invoked his 5th Amendment rights 75 times.

Somehow, all of that has been forgotten, and Scott has managed to be a governor, a Senator, and, I’m guessing, a man, a businessman, who has his eyes on the biggest prize of all, the one up for grabs in 2024.

Rescue Plan, indeed.

*Capone was a nationally famous, Chicago-based killer and crime boss who went to prison in 1931 for tax evasion.

 

Stories I Was Planning To Address. They’ll Have To Wait.

Thursday, March 3rd, 2022

The life and death stories coming out of Ukraine, as its people continue to exhibit fierce and inspirational resistance to Vlad the Invader’s barbaric onslaught, tend to suck the air out of any room. Somehow, Joe Biden’s approval ratings, or America’s vitriolic partisan divide, or who will prevail in the midterms or the desperate state of our infrastructure, or the future of our newest Supreme Court nominee, while important at any other time, just cannot compete with Putin’s intentional and indiscriminate killing of anyone, man, woman, child, beloved pet, anyone in the way of his rapacious army. This is causing the most momentous change on the European continent and throughout the geopolitical world in nearly 80 years. And it’s taken only a week.

So, here are some quick takes of the things I would have written about, and maybe will in the future in more depth, were it not for the blackhole-like gravity of what’s happening in Ukraine.

Tuesday night’s State of the Union

Joe Biden’s speech to the Congress and the nation came in two chapters. Chapter One: Ukraine. Chapter Two: His domestic agenda.

Chapter One was riveting, and it appeared nearly everyone sitting on the floor and in the gallery of the House of Representatives was united in support of the West’s monumental pushback to  Vlad the Villain. I thought it ironic they were all sitting in a sacred building where, just 14 months ago fellow citizens tried to steal American democracy, and nearly did. Ironic, indeed, when one considers so many who were sitting on the R side of the aisle now want to look the other way and pretend it never happened.

Chapter Two was pretty much what you’d expect from any State of the Union speech — until the heckling. Representatives Lauren Boebert, R-Colo., and Marjorie Taylor Greene, R-Ga, put on a disgusting display of crass and boorish incivility. These two ladies have never demonstrated having had an original idea in their lives. Why should they? They’re both travelling on borrowed gas, and inferior gas, at that. Boebert, especially, raised poor taste to a new level when she screamed out accusing Biden of killing 13 soldiers during the evacuation of Afghanistan as he was describing the death of his beloved son, Beau, from cancer attributable to burn pits in wartime. These two, both of whom have about as much empathy as a New Jersey loan shark, would be rejected from Dante’s Inferno for giving the place a bad name. (Pity the poor fellow sitting between them  wishing he were anywhere else on earth — except maybe Ukraine)

Why can’t Medicare negotiate drug prices?

When you insure more than 61.2 million beneficiaries you’d think you’d have tremendous leverage to negotiate the lowest drug prices on earth. But that is not the case in the USA.

The Medicare Modernization Act (MMA) of 2003, the one that created the unfunded Part D drug program along with the infamous “doughnut hole,” specifically forbids Medicare from negotiating prices with drug companies, giving that responsibility, instead, to for-profit insurers and Pharmacy Benefit Managers. Health policy Guru John C. Goodman calls the MMA, “arguably the worst domestic policy decision in the history of the country.” At the time of enactment, the Social Security and Medicare Trustees estimated the long-term (75 years) unfunded liability of the MMA’s Part D program to be $17 trillion. The Trustees project that cost growth over the next 5 years will average 7.3 percent for Part D, significantly faster than the projected average annual GDP growth rate of 4.3 percent over the period.

And, still, Medicare cannot negotiate prices.  Result? High drug prices for Medicare and its beneficiaries.

By contrast, the VA is able to negotiate for its nine million veterans enrolled in its health care program, yours truly being one of them. Result? Low cost drugs.

Since passage of the MMA, there have been repeated attempts to introduce and pass legislation that would allow Medicare to bring the full weight of its considerable power to the price of pharmaceuticals. Two things have prevented any success in these endeavors. First, the bottomless well of pharmaceutical industry cash, and, second, members of congress who are the beneficiaries of that bottomless well of cash.

To quote that eminent American philosopher, Mark Twain, “We have the best government that money can buy.”

Federally Qualified Health Centers. Now there’s a well kept secret!

Federally Qualified Health Centers (FQHC) are community-based health care providers that receive funds from the Health Center Program of the Health Resources and Services Administration (HRSA) to provide primary care services in underserved areas. They must meet stringent requirements, including providing care on a sliding fee scale based on a patient’s ability to pay and operating under a governing board that includes patients. Specifically, at least 51% of their Boards must be patients.

By law, FQHCs must treat anyone, regardless of the ability to pay.

There are 1,368 FQHCs in the country. Most have a number of locations, called Service Sites, bringing the total health care locations to 14,200. They welcome people with insurance, but their main targets are poor people who could otherwise not afford health care.

In addition to FQHCs, the Health Center Program also funds Rural Health Centers (RHCs), whose mission is to increase access to primary care services for patients in rural communities.

FQHCs and RHCs are funded annually by congressional approval. Additionally, Section 330 of the Public Health Service Act provides grant awards to eligible health centers and outlines the requirements the centers must meet to be eligible .

Taken together, FQHCs and RHCs are Community Health Centers. They are ubiquitous throughout the country. For example, in my home state of Massachusetts, there are 52 community health center organizations providing high quality health care to some one million state residents through more than 300 sites statewide. For perspective, there are 351 cities and towns in Massachusetts.

Given the woeful state of our nation’s public health system, as was amply demonstrated by our response to COVID-19, it might not be a bad idea to consider the Community Health Center model as we attempt to re-engineer how we deliver health care to all of us.

Just a thought.

 

 

 

News You Might Have Missed To End Your Week

Friday, February 4th, 2022

Interesting weather today, here in the heart of the Berkshire mountains. A little rain, a little sleet, a little freezing rain, a little snow and a lot of ice. The very definition of my newly coined word, quinaryfecta (I toyed with pentafecta).

Governor Baker has asked everyone to stay off the roads, so, here I sit putting together a few stories that might have slipped under your radar.

The cost of health care continues it ever-upward trajectory

In November, the Kaiser Family Foundation published the results of its annual Employer Health Benefits Survey, and 2021 continued what appears to be an unstoppable trend.

More than 155 million Americans get their health care from Employer Sponsored Insurance (ESI). That’s 55% of the working population. There are two facts about this year’s survey I would like to highlight:

First, the annual cost of health insurance for a family is rising faster than both wages and inflation.

To their credit, employers have been absorbing most of the rise in premium costs, but this prevents them from using those funds now going to health care insurance for other worthwhile endeavors, like growing their companies, enhancing their risk management programs, or raising wages.

Second, annual premium costs in 2021 rose 4% over 2020 to a record high $22,221. That’s $1,852 per month. Workers are paying an average of 28% of the cost, or about $500 per month. But that’s before a 2021 average deductible of $1,669, which is 92% higher than ten years ago. In 2021, 85% of workers in ESI plans were subject to a deductible.

As these costs continue their stratospheric rise it’s like employers and employees are side by side trying to outswim a Navy Destroyer ―  with every stroke they fall farther behind.

Speaking of upward trends, let’s consider traffic deaths in 2021

The Department of Transportation just released a statistical projection of traffic fatalities for the first 9 months of 2021 showing an estimated 31,720 people died in motor vehicle traffic crashes nationwide. This represents an increase of about 12% as compared to 28,325 fatalities that were projected in the first nine months of 2020. This is the highest percentage increase over a nine-month period since the Department began recording fatal crash data in 1975. The numbers in 2021 are 32.5% higher than they were a decade ago.

Something weird is happening on our roads. Over the last 45 years, traffic safety engineers and automakers have made remarkable progress in improving the safety of our roads and cars. But they haven’t been able to change the human element, about which we wrote a week ago.

Don’t go by raw numbers, however. The important statistic is the rate of traffic fatalities per million miles driven. From 2011 through 2019, the rate didn’t waffle much, going from 1.09 to 1.10, with a blip up to 1.17 in 2016.

All that changed in 2020, when the rate jumped to 1.35. In 2021, it inched up to 1.36 to prove 2020 wasn’t a momentary aberration.

Secretary of Transportation Pete Buttigieg announced the Department will dedicate significant resources to attack these daily tragedies. We will be paying close attention to this.

Another example of our fragmented health care

The Biden Administration has made it easier for people to get free at home rapid tests. Here at our home, we applied on Day One of the program, and four days later our tests arrived. And the Administration has distributed millions of tests to pharmacies and states. People can go to CVS or Walmart or any other participating entity, buy tests, and get reimbursed by their insurance company. That’s not how other countries are doing it, and they’ve been doing it longer. They’ve cut out the insurer middleman, and have just gone directly to their people with the tests. In the the UK, for example, testing has become a way of life.

The insurer reimbursement issue has become a Medicaid problem for the states. The rules of Medicaid do not allow for it, and, because each state administers the program in its own way, they’re all approaching the problem differently.

Some states have made it easier for the safety net program to reimburse pharmacies for providing the tests at no cost. Others are experiencing what CMS described in an 11 January call with the states as “operational considerations and challenges.” Here’s one such challenge: Some states require a prescription for Medicaid enrollees to get anything from a pharmacy. To deal with this, states are making what they are calling “standing orders” to allow enrollees to get free tests at pharmacies without a prescription.

Another challenge for the states: How to get tests to homebound enrollees. Some states are attacking this by setting up temporary mail order programs.

My point here is that each state has to create its own solution. That is counterproductive. All the states are facing the same COVID problems, but each is attacking those problems differently. Throughout, one thing has become clear to the various Medicaid State Directors: the more they communicate with each other, the better off they are.

It is becoming more and more evident that the absence of one cohesive system to guide everyone wastes time and money, and jeopardizes the health of Medicaid enrollees all over the nation.

Have a nice weekend.

 

Medicaid Expansion: An Addendum To My Two-Part Series

Thursday, February 3rd, 2022

Long ago in 2009, I wrote about  a PBS special hosted by Journalist T. R. Reid, in which Reid analyzed the health care systems in five other countries: The UK, Japan, Germany, Taiwan and Switzerland. Reid had spent a full year in those five countries trying to figure out how they provided universal health care at much lower cost than the U.S. with better results. He later published a book about it, The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care (available on Amazon).

The good news is Reid did a wonderful job, both in his book and on his PBS special. The bad news is things in the U.S. have only gotten worse since then. Health care costs as a percent of GDP have increased three percentage points since 2009 to about 20% (the Opioid epidemic and COVID haven’t helped), and our health care outcomes have remained sub-par to the rest of the Organization for Economic Co-operation and Development (OECD), the 38 country organization of which the United States was a founding member 60 years ago.

I was reminded of Reid’s work while preparing my two-part Medicaid expansion series published over the last two days, and I couldn’t help thinking the ACA’s Medicaid expansion provision, for all the good it has done, only aims to put a band-aid on a mortally wounded patient.

In America, health care has become a commodity, a market-driven enterprise. Throughout the rest of the developed world, it is an essential human right; something governments were created to provide and protect. In America, 55% of us have earned the right to health care by working for an employer who provides it. Another 18% of us have earned health care by reaching the age of 65. A further 3.7% have earned it by serving in the military. The remaining 23.3% are on their own, which is where Medicaid comes in. Sadly, it appears many powerful people resent that final group and our inclination to provide them what the rest of the world views as a moral duty.

In America, legend, myth and vulnerable gullibility influence many of our citizens, who have been led to believe any government intrusion into health care will lead to draconian tactics typical of a fascist state (remember Sarah Palin’s death panels?). They don’t seem to realize that health care provided by our Veterans Administration, treating millions of our veterans every year (including this one), is a direct copy of Britain’s. Or that Medicare, our largest insurer with more than 62 million members who, in poll after poll, report high satisfaction with their health care, is modeled on the health care system of Canada.

Maybe American health care is just too big to be redesigned into something that would make us all proud. Too many vested interests, each making boatloads of cash. Each saying they support creating a better system ―  just as long as we don’t touch their sacred slice of the profitable pie.

But when I’m tempted to say, “A plague on their houses,” I think of the Taiwanese, who went from nothing to one of the most technologically advanced, yet inexpensive, health care systems in the world in just fourteen years. And I think of the Swiss, the bureaucratic, economically driven, bankers-of-the-world Swiss, who took off their stuffed shirts and came to see high-quality, affordable health care as the absolute right of every Swiss citizen.

The health care systems in Taiwan and Switzerland have flaws, but, even so, they are light years ahead of the U.S. in terms of quality, cost and universal coverage. If these two totally different countries can do that, I ask you, why can’t we?

Eventually, America is going to have to decide if good quality health care is a basic human right, or a privilege to be earned.

ACA Medicaid Expansion — Part 2: The Opposition

Wednesday, February 2nd, 2022

Yesterday, I wrote about the proven benefits of the Affordable Care Act’s expansion of Medicaid to provide health insurance to millions of our previously uninsured fellow citizens. By way of background, I began yesterday’s column with the following:

According to the Department of Health and Human Services (HHS), there were 48 million uninsured in 2010 when the Affordable Care Act (ACA) became law. Over the next nine years, 38 states, using ACA funding, expanded their Medicaid programs. During that time, the numbers of uninsured fell to 28 million before rising to 30 million in the first half of 2020 due to policy changes to the ACA by the Trump Administration that made it harder to qualify for coverage.

There are now twelve states left that have refused to take advantage of the ACA’s provisions to expand Medicaid, a move that would significantly lower the number of uninsured people within their borders.

The states in orange are the states that have refused to accept Medicaid expansion and the significant federal dollars that go with it. The orange states are all “red” states.

Today, we’ll examine the reasons governors and legislatures in those 12 states give for not accepting the massive federal funding coming with ACA expansion. Tomorrow, I’ll offer an opinion and a plea for building a better system.

But first, we’ll need to set the stage.

The rate of uninsurance in non-expansion states is nearly double that of expansion states.

A word about the uninsured in non-expansion states. As the above chart shows, nearly 22% of them live in rural areas. The majority of these Rurals are registered Republican voters. They are also white/non-Hispanic and less educated than their urban counterparts. Medicaid expansion would be of great benefit to them. But their governors and legislators refuse to expand Medicaid to help these people and the rest of their uninsured populations. Why?

What is even more perplexing is why the rural uninsured continue to vote for people who refuse to help them improve their health care lot in life.

There is another darker result of not expanding Medicaid, and it concerns people of color. People of color, especially the uninsured, have faced longstanding disparities in health coverage that contribute to disparities in health. The states that expanded Medicaid following passage of the ACA saw significant decreases in these disparities from 2010 through 2016; the non-expansion states did not. Beginning in 2017, the Trump administration implemented policy changes that made it harder to qualify for Medicaid. The result was a reversal of progress made during the prior six years; the number of uninsured began growing again, and, once again, people of color were the hardest hit.

Just another example of the cultural and moral divide in America.

Governors and legislators opposing expansion offer 3 primary arguments:

The state cannot afford it.

This is political theatre. The federal government pays 90% of the cost of expansion, the state the remaining 10%. States that have expanded coverage have demonstrated affordability by moving  funds from other areas that, because of expansion, will not need as much money. In Michigan, for example, the state budget realized substantial savings in correctional health care and community mental health when some of the expenses of these programs were shifted to Medicaid. Taking into account other economic effects of expansion, such as increased tax revenues from increased economic activity, Medicaid expansion was a net benefit to the state’s budget. Moreover, the Families First Coronavirus Response Act, which was signed into law on 18 March 2020, included a provision for the federal government to assume a larger share of existing Medicaid obligations in every state, freeing up state Medicaid funds for other uses — like expanding coverage. The “We can’t afford it” line does not hold water.

Allowing people to access Medicaid will discourage them from working.

Multiple studies have found no evidence that expanding Medicaid is a disincentive to working. A typical finding is, “We find that although the expansion increased Medicaid coverage by 3.0 percentage points among childless adults, there was no significant impact on employment.”*

Expanding Medicaid will only add more people to a broken system.

Opponents of expanding coverage often deride Medicaid as a low-quality program. Yet a majority of people in the U.S. — Democrats, Republicans, and independents alike—believe that the program is working well. In states that have not expanded Medicaid, a clear majority favor doing so. Most Medicaid enrollees are quite happy with their coverage, reporting higher rates of satisfaction than people with private insurance.

The arguments listed above are the three reasons most often cited by leaders in the 12 non-expansion states for their opposition. There is one argument that goes unexpressed, but is often present: People who are uninsured are uninsured because they lack the money to become insured. They lack that money because they never worked hard enough to get it. They are irresponsible. Consequently, society does not owe them a free health care lunch.

Over the last two days, I’ve tried to counter that “thinking” with clear, hard, proven, factual data. None of it has been opinion (if you ignore my comment yesterday about Senator Ron Johnson, that is). I’ve tried to demonstrate that all the arguments in opposition are nothing more than groundless opinion.

I end with these questions: Is health care a basic human right? Does society owe its poorest decent health care, or must they earn the privilege? How do we answer the murderer Cain’s question in Genesis 4:1-13, “Am I my brother’s keeper?”

We need answers to those questions.

*Leung and Mas, Employment Effects of the Affordable Care Act Medicaid Expansions, 25 March 2018, in Industrial Relations, A Journal of Economy And Society.