Only in America

The phrase “only in America” was one I heard frequently as a child. It was often said in a light-hearted manner, sometimes with a faux Eastern European accent, but always with a deep reverence for what my parents believed to be it’s central truth: that the United States was a special place. Its unique blend of opportunity, freedom and compassion had allowed our family to go from poor immigrants to prosperous professionals in 2 generations. What a country!

I thought of that phrase this morning in a darker, ironic sense, as I read about a middle-aged couple in Tennessee who were struggling to figure out how to afford health insurance. The husband is retired, and the wife makes a solid salary at a small company. Yet they found that they were trapped by their circumstances: they were too young for Medicare, earning too much for Medicaid, not offered health insurance by the wife’s employer, and not able to afford the market rate for an individual policy on the ACA exchange. After considerable study they decided that they had two options – they could get a divorce, which would allow the husband to qualify on the basis of his lower income for an insurance subsidy, or the wife could take a substantial pay-cut, which would make them eligible for an exchange subsidy. They chose the latter, and actually appear to have come out ahead, since the subsidy was greater than the after-tax difference in her pay before and after.

What is wrong with this picture? Here are a few things that come to mind:

  • The health insurance “system” is clearly broken if it creates incentives, no matter unintended, to dissolve marriages and earn less
  • There is a huge “complexity tax” that we are all paying to prop up the Rube Goldberg arrangements of the current health insurance marketplace. How much time, effort and anxiety were spent by this couple to figure this out? For those of you fortunate enough to have employer-provided benefits, how much time did it take you to do your benefits enrollment? Did you get it right?
  • All this is playing out while Congress cut taxes on the most fortunate in our society

Only in America.

Looking in the Wrong Place?

It is no secret that there is a lot of waste in healthcare. Even if one leaves aside the most egregious examples such as duplication of tests and patient harm that necessitates more care, we still collectively do a lot of stuff that does not improve health. A recent report in Health Affairs changed my assumptions about what that stuff looks like.

The authors analyzed claims data from an all payer database in Virginia for services provided in 2014. They prospectively defined 44 services that were of “low value” defined as providing no net health benefit in specific clinical circumstances. Their assessments were based on nationally recognized standards, including the “Choose Wisely” campaign of the ABIM, the US Preventive Services Task Force, CMS criteria, and others. They then scoured the database to see how frequently these services were provided, and calculated the aggregate costs associated with them.

Continue reading Looking in the Wrong Place?

Holy (Sacred) Cow!

The headline in the New York Times summarized the initial reaction of the cardiology community – “unbelievable” – but still seemed to understate the ground-shaking implications of a recent study of coronary stenting.

The report of The Objective Randomised Blinded Investigation with Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA)Trial was published last week in the Lancet. In brief, investigators in the UK (hence “randomised”) enrolled about 200 patients with angina, objective evidence of inducible myocardial ischemia and angiographic and hemodynamic evidence of significant single vessel coronary artery disease. Half the group received a drug eluting stent, with excellent technical results. The other half got a sham angioplasty. Both groups were treated medically. The key finding: “real” stenting produced no measurable benefit in exercise time increment (the primary endpoint) compared with a “placebo procedure.” The study was well done, with true blinding of patients and evaluating physicians, careful selection of endpoints, and sufficient power to support the conclusion. Whoa.

Continue reading Holy (Sacred) Cow!

Happy Birthday Emily

A couple of my recent blog posts have advocated for single-payer financing for health care in the United States as the most effective path to universal coverage and lower cost. This one is more personal, but also ends with the same conclusion.

My daughter Emily is an actor and singer. Like many artists, she gets by with a part-time job (without benefits) and professional gigs. And, until her recent 26th birthday, she had health insurance coverage as my dependent. She now faces the challenge of finding affordable coverage that will not disrupt her established patterns of medical care.

In many ways, she is fortunate. Until the ACA, she would have been booted off my insurance coverage after she graduated college, and would probably have found it impossible to get private insurance because of pre-existing medical conditions. And even now, I can extend her coverage through COBRA for up to 3 years (and can afford to do so) or she can buy insurance (with some help) on the NY State Health Insurance Exchange. So this is not a crisis for us, but it points out another fundamental flaw of how health insurance generally works in the United States – it is, uniquely among other developed countries, tied to employment.

Continue reading Happy Birthday Emily

Growing Sentiment

A couple of months ago, I wrote that I favored transforming our complex hodge-podge of health care financing to a national single-payer system. It now seems as though a majority of physicians in the US  feel the same way, with 42% strongly supporting the idea. This is a remarkable evolution from the days when the American Medical Association vociferously opposed the creation of Medicare and Medicaid in the early 1960s. Why the shift?

The folks who commissioned the poll cite 4 major reasons:

  1. Complexity fatigue. Back in the day, Medicare was seen as a threat to the simple and straightforward fee for service relationship that physicians had with their patients. Doctors resisted the intrusion of the “government into the exam room.” Now, the exam room is crowded with so many players, each with its own rules and demands, that having only the government to deal with would seem like a relief. This certainly rings true to me.
  2. Many feel as if the handwriting is on the wall about movement toward a single payer, so they grudgingly agree that we might as well do it sooner than later. I would say that another way to look at this is that few can articulate another alternative that reduces administrative complexity and expands coverage.
  3. Shifting demographics. Merritt and Hawkins cite a generational shift, with younger physicians more inclined to support a single payer. I don’t have the data they cite to judge the validity of the explanation, but I suspect it is not just about age, but about the changing nature of physician employment. As more and more physicians are employed by health systems or other large organizations, I believe they feel more financially secure, and more insulated from the details of reimbursement which makes them more open to single payer.
  4. Changing assumptions. One of the most remarkable aspects of the recent debacle in Congress over attempts to repeal the ACA is that public opinion has changed in a fundamental way. It now seems that there is a widespread belief that the government does have a legitimate role in guaranteeing access to health care, and physicians agree.

Another sign that physicians’ attitudes are changing: record membership in Physicians for a National Health Program.

I think the time has come. What do you think?

It’s Still a Dog

Back in March, I made some observations about the AHCA, the bill to “repeal and replace” the Affordable Care Act that was ultimately passed by the House of Representatives and both hailed and disparaged by the President. Some of the naked political calculus that facilitated the passage of such a truly despicable bit of legislation was the belief that the Senate would somehow rescue the Republican Party from itself and restore something “beautiful.” Well, it is now pretty clear that the Senate bill – cynically dubbed the “Better Care Reconciliation Act of 2017” – is no better than what the House threw over the fence.

The bill retains essential “features” of the House version: less funding for Medicaid, fewer constraints on bad behavior of insurers, leaner subsidies for the uninsured to buy insurance, and repeal of the mandate to buy insurance for those with neither employer provided insurance or eligibility for Medicaid or Medicare.

I think Paul Krugman explained pretty well why the current plans to dismantle parts of the ACA don’t work. The ACA is based on a few interdependent ideas:

  1. For insurance to be useful, it has to have certain features, like broad benefits and inclusion of people with pre-existing conditions
  2. To avoid the insurance “death spiral,” everybody has to be in the risk pool. Otherwise, only sick people would buy insurance, thereby pushing up the price and making those who are relatively healthier drop coverage, driving up the price further and driving more healthy people away, worsening the problem
  3. To facilitate getting everyone in the risk pool, subsidies are provided to those who can’t afford the premium

Remove any one of these and the system collapses. We are likely to end up with fewer people insured and worse coverage for those who buy insurance. As is true of the House bill, the Senate bill does nothing to address the real challenges facing our healthcare system today – access, quality, and affordability. As the President might say: “sad.”

What do you think?

Structure and Function

Providers of medical care in the United States are consolidating. Hospitals are merging into “systems” and physicians are joining large physician groups, many of which are part of “vertically integrated” delivery networks that include hospitals.

Many forces are driving this consolidation, including the high capital requirements technologically advanced care, the challenge of meeting government regulations, the “arms race” consolidation of the commercial insurance industry, and the drive toward accountable care, in which providers take on some or all of the financial risk associated with the health outcomes of a population, and therefore need to work closely together to manage care delivery.

A recent paper in Health Affairs points out that structural integration does not necessarily translate into functional integration from the perspective of those who ought to matter the most – patients.
Continue reading Structure and Function

Back to Health Care

While Washington now seems consumed with the mess swirling around the White House that was triggered by the abrupt firing of the FBI director, I want to get back to the mess swirling around the latest effort to “repeal and replace” the Affordable Care Act.

Although the President stated that nobody knew that health care could be so complicated, his apparent surprise is surely based on his own profound, willful ignorance. Anyone who has paid even the most cursory attention to American health care delivery and financing knows that our “system” is uniquely complicated (actually, it is complex). The complexity has been driven by many forces including, among others, the historical accident of employer-based health insurance, a mythic belief in “the market” to improve everything it touches, a corresponding skepticism that government can do anything effectively, and a lack of national consensus about what we, as citizens, owe each other to “promote the general welfare.”

The net result has been well documented. Health care in America is characterized by huge disparities in access to care, major failures of quality and safety, and unsustainable costs. It is, of course, also characterized by amazing life-saving and life-sustaining technology and millions of dedicated, compassionate people who struggle daily to overcome the dysfunction to deliver great care. So how to fix the bad without destroying the good?

Continue reading Back to Health Care

Workforce Predictions and Horse Manure

The Association of American Medical Colleges (AAMC) recently released a new report detailing their predictions for the physician workforce of the future. The accompanying press release highlighted the key finding of the report: by 2030, the US “physician shortage” will be between 40,000 and roughly 105,000 physicians. The projection is based on a few assumptions, including that the 2015 physician workforce was “in balance” (enough doctors to meet demand); the aging of the population; retirement trends among physicians; and improvements in access to care for traditionally underserved populations.

Mostly the report made me think of horse manure. Specifically, it reminded me of frequently quoted predictions, made in the late 19th century, that cities such as New York and London would, by the early 20th century, be buried in mountains of it. This has been dubbed “The Great Horse Manure Crisis of 1894” which, of course, never came to pass.

In retrospect, it is easy to see that the 19th-century alarmists missed the technological revolution that was about to replace horses with vehicles powered by internal combustion engines, which averted the “crisis.”

Continue reading Workforce Predictions and Horse Manure

Worse Than Making Sausage

Everybody knows the old saw about how the legislative process resembles a sausage factory: even if you like the product, it may turn your stomach to see how it is made. I have been thinking about that metaphor a lot lately as I have watched the Republican caucus in the US House of Representatives slap together their plan to “repeal and replace Obamacare.”

As the House lurches toward a critical vote today, I offer a few personal observations:

  • The Republicans have long complained bitterly about how the Democrats “rammed through” the ACA in 2009. This, despite the fact that there were months of negotiations and the bill incorporated many previously mainstream Republican principles (including the individual mandate, which now seems anathema), and the Republicans deliberately walked away as part of their obstructionist strategy to deny President Obama a legislative victory of any sort. It is therefore particularly disturbing to see them scramble to bring this dog of a bill to a vote on some arbitrary self-imposed deadline. What is the rush?
  • Speaking of a dog of a bill (with apologies to dogs everywhere), the only “principle” or “goal” that it advances is checking a box that says “repeal Obamacare.” The challenges facing our health care system are pretty easy to categorize. We need to assure access to care, we need to improve care, and we need to control costs. This bill does none of those things and stands to reverse the progress made by the ACA in providing coverage for millions of Americans.
  • Don’t be fooled by claims of “lower costs.” The only thing this bill would lower is coverage, mostly by throwing millions off of Medicaid, and by stripping covered services from ACA plans. Any accrued “savings” are achieved by just providing less care for those who are in need.
  • The targeting of Planned Parenthood and of reproductive health services, in general, is a shameful demonstration of the deep hypocrisy in the Republican party that has stood for individual choice and limited government (well, at least back when the party stood for anything at all) until it comes to dictating women’s health choices.
  • The proposal is demonstrably, clearly, unambiguously and completely at odds with the President’s stated goal of “repealing Obamacare and replacing it with something beautiful” that “covers everybody.”
  • Mostly, I am saddened by this rush to do harm, driven by political expediency, facilitated by ignorance, and leavened by a callous disregard for the health and wellbeing of our fellow citizens

What do you think?