The U.S. Chamber of Cancer

I recall sitting in my office in the U.S. Senate’s Hart Office Building in DC between 2008 and 2010 with my desk TV always turned onto one of the cable news channels when the Senate was not in session.  Incessantly, I saw TV ads from the U.S. Chamber of Commerce speaking as the “voice of small business” attacking Democratic efforts to achieve national health reform and universal coverage because of the harm it would cause small business.

Only later, in 2011, did we learn that the entire tab for that endless advertising campaign was paid for by major U.S. health insurance companies and their trade association, America’s Health Insurance Plans (AHIP) to the tune of more than $100 million in direct donations.  Later, I had the chance to ask AHIP President Karen Ignagni (who recently stepped down) why these donations had never been disclosed.  “Because no one ever asked us,” she replied.

Today, the New York Times reports a devastating story about the role the U.S. Chamber of Commerce is playing in advancing the interests of the global tobacco industry in thwarting tobacco regulation and smoking prevention efforts in nations all around the globe:

“From Ukraine to Uruguay, Moldova to the Philippines, the U.S. Chamber of Commerce and its foreign affiliates have become the hammer for the tobacco industry, engaging in a worldwide effort to fight antismoking laws of all kinds, according to interviews with government ministers, lobbyists, lawmakers and public health groups in Asia, Europe, Latin America and the United States.”

Continue reading “The U.S. Chamber of Cancer”

The Supreme Court’s Surprise that Wasn’t

Those watching the U.S. Supreme Court process on the King v. Burwell suit that almost upended insurance subsidies for about 6.4 million Americans knew that three outcomes were possible – 5-4 for the plaintiffs, and 5-4 or 6-3 for the government. That indicated to me a two-thirds probability of a pro-Affordable Care Act ruling.

carygrantIntellectually, that’s what I expected. Too many long-standing and widely-shared judicial precedents would have been trampled by a ruling for the Libertarian/Cato Institute’s lawsuit – including the core Chevron principle that “context matters,” and the Pennhurst principle that federal laws shall not “surprise states,” among others. With a ruling the plaintiffs, the Court’s only way out would be to repeat the 2000 scandalous ruling in Bush v. Gore that the Court’s decision installing George W. Bush as President would represent no precedent for any future case.

Still, it would have been foolhardy to assume any certain result from this Supreme Court. Happily, the decision was not close. The window of opportunity for using the Supreme Court to disassemble the ACA is now all but ended, even as a baker’s dozen of cases are still in circulation. Continue reading “The Supreme Court’s Surprise that Wasn’t”

CBO Says ACA Repeal Will Increase Uninsured and Federal Deficits (by a lot)

My favored definition of “health policy wonk” is someone who reads health reports from the Congressional Budget Office AND enjoys it.  Guilty as charged.  Last Friday’s new report, “Budgetary and Economic Effects of Repealing the Affordable Care Act,” was enlightening and fascinating.  It will be a benchmark document during the coming two years of debates over the ACA’s future — and required reading for my students this fall.  Lucky them!

This report is already a fountain of numbers thrown around by both parties — and it reflects the changing politics at CBO under Republican control of the U.S. House of Representatives and the Senate.  What are the key numbers?

  • Repeal on 1/1/2016 would increase the federal deficit by $353 billion between 2016-2025, or by $137B using the CBO’s new “voodoo” macroeconomic analysis;
  • Repeal would cause “federal budget deficits to increase by growing amounts after 2025, whether or not the budgetary effects of macroeconomic feedback are included.”
  • Repeal would increase the number of uninsured Americans by 19 million in 2016 and by 24 million in 2020;
  • Repeal would increase the US gross domestic product (GDP) by 0.7% between 2021-25, with “substantial uncertainty” regarding this estimate in both directions.cbo 2015 2

So there you have it.  Repealing the ACA, the premiere policy goal of just about every Republican House and Senate member, will dramatically increase both federal deficits and the numbers of uninsured Americans in a report signed, sealed, and delivered to Capitol Hill by Republicans’ newly appointed CBO Director Keith Hall. Hall replaced the prior highly respected CBO Director Doug Elmendorf (who was just announced as the new Dean of the Kennedy School of Government at Harvard beginning next January). Continue reading “CBO Says ACA Repeal Will Increase Uninsured and Federal Deficits (by a lot)”

Of Secrets and Share Responsibility

One proposal to change the Affordable Care Act would repeal the law’s 2.3 percent tax on sales of medical devices.  On June 2, the Ways and Means Committee of the House of Representatives voted, once again, to rescind the tax and a vote in the full House is expected soon. Even progressive Democrats such as Sens. Elizabeth Warren (D-MA) and Al Franken (D-MN), who hail from states where the medical device industry is strong, support repeal. But repeal is a bad idea on principle and impact. If Congress insists on repeal, they should at least demand something in return for the public, namely, an end to the medical device industry’s secrecy clauses and gag rules.medical-device-tax

The medical device tax is one of many revenue increases included in the ACA so that the law does not increase the federal deficit.  Pegged at $29 billion in new revenues over ten years, it embodies a principle called “shared responsibility.” To achieve comprehensive health reform, every system stakeholder contributes something to make reform succeed, and nobody gets off the hook.  Who else pays?  Insurance companies, hospitals, home health agencies, drug companies, businesses, labor unions, hospices, consumers, tanning salons(!) – just about every constituency connected to health care pays something to achieve the coverage and system improvements in the law.

The medical device tax has been in effect since January 2013 with no disastrous effects.  More than 75 percent of it is paid by the largest 1 percent of firms such as Johnson & Johnson and Medtronic.  (J&J actually opposes repeal.)  But the medical device lobby has focused on repeal like a laser beam gaining support among Members of Congress to accompany their tens of millions of dollars in campaign donations.

If Congress is determined repeal this tax, Members should demand something from the medical device industry to improve the health care system as an alternative form of shared responsibility.  It’s this – Congress should ban the practice common among medical device makers requiring that hospitals never disclose to anyone how much they pay for the devices they purchase, especially implantable medical devices such as hip and knee implants, coronary drug eluting stents, and pacemakers. The price secrecy clauses written into contracts forbid hospitals even telling their own surgeons the costs they incur and pass onto patients. Continue reading “Of Secrets and Share Responsibility”

President Obama on the ACA at the Catholic Health Association

Today, President Obama spoke to the Catholic Health Association, the nation’s organization of Catholic Hospitals, about the progress and success of the Affordable Care Act.  It’s just under 29 minutes and, in my humble opinion, it’s really worth your time to view, especially in the stories he tells of individual citizens whose lives have been rescued by this law.

Please give it a look and I don’t think you will regret it.  President Obama takes his lumps every day, and I’m proud to have him as our President.

Republicans’ New Bridge to Nowhere

It’s been nearly 5 and 1/4 years (63 months for those counting) since President Obama signed the Affordable Care Act into law.  Since then, Republican Congressional leaders have continually declared their intentions to advance their own plan to repeal the law and replace it with something else.  This took on new urgency this year because of the U.S. Supreme Court’s (SCOTUS) decision to hear the King v. Burwell lawsuit that would eliminate all insurance subsidies to ACA private coverage enrollees in the 34 states with federal — as opposed to state — run exchanges/marketplaces.

New federal data show that 6.4 million would lose their insurance subsidies if the Court rules for the plaintiffs (King) and against the government (Burwell).

All this year, Republican lawmakers in the Senate and House have been insisting they would have a replacement plan out and even scored by the Congressional Budget Office before a SCOTUS decision in late June (an assurance made by House Ways and Means Chairman Paul Ryan (R-WI).

1 McCarthy Rep
US House Majority Leader Rep. Kevin McCarthy (R-CA).

Now, House Majority Leader Kevin McCarthy (R-CA) has announced the Republicans will have no replacement plan to unveil until after a Supreme Court decision is released, expected late this month, and Senate Republicans are stating the same.  As Jon Cohn notes in the Huffington Post, not only is there no plan, Republicans have not even held a hearing on the matter — though they repeatedly berated Obama Administration officials, notably Health & Human Services Secretary Sylvia Burwell, for having no contingency plan in the event of an adverse ruling in the King case.

What about Congress? [asked Supreme Court Justice Antonin Scalia]  You really think Congress is just going to sit there while – while all of these disastrous consequences ensue?”  The Solicitor General responded “well, this Congress, I ….,” a response which generated laughter.

Some may quibble and point to a number of ACA replacement bills filed by various members.  None of them have even received a committee hearing, much less a committee markup, or a vote in either chamber.  The most prominent replacement proposal, the Patient CARE Act, from Sen. Richard Burr (R-NC) and Orrin Hatch (R-UT) and Rep. Fred Upton (R-MI), which has had two public unveilings since 2013, has yet to be translated into legislative language and sits as a well-trumpeted narrative description of a non-existent bill.

I believe it’s pretty plain what is happening here.  Republicans are quite capable of uniting around what they all oppose and quite incapable of uniting behind what they would propose as an alternative.  With firm control of the House and Senate, the GOP has a golden opportunity to advance a comprehensive and clear alternative to the ACA.  They just can’t do it — short, medium, or long term — it’s a bridge way too far for them.  A bridge to nowhere.

Is the “Triple Aim” a Part of the Problem?

If you care about transforming the delivery of medical care in the U.S., then you should should read a blog post from last week by Paul Levy, former CEO of Beth Israel Deaconess Hospital in Boston and conductor of “Not Running a Hospital.”  It’s titled: “The Triple Aimers Have Missed the Mark.”

For those who don’t know, the “Triple Aim” was the 2008 invention of Dr. Donald Berwick and colleagues from the Institute of Health Care Improvement (IHI) which Berwick triple-aim-graphic1-300x225created in the last 1980s when he also developed the now-essential medical care construct of “continuous quality improvement“.  As Berwick and colleagues articulated in a 2008 article in the journal Health Affairs:

“Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an “integrator”) that accepts responsibility for all three aims for that population.  The integrator’s role includes at least five components: partnership with individuals and families, redesign of primary care, population health management, financial management, and macro system integration.”

One can look at the Affordable Care Act and see the Triple Aim model at work in numerous places.  The key notion behind the Triple Aim is to ask: what are we trying to accomplish in the U.S. medical care system and where are we trying to go?  A quick Google search will give some indication of how far and wide the concept has traveled over the past 7 years, including well beyond U.S. borders.  It is a global phenomenon.

Now comes Paul Levy with a bucket of cold water: Continue reading “Is the “Triple Aim” a Part of the Problem?”

King v. Burwell — The Actuaries Explain All

In the late 1980s, Dr. William Hsiao, a colleague of mine at the Harvard Chan School of Public Health, my former professor, and a globally renowned health economist, explained to me the difference between an accountant and an actuary.  “An actuary is an accountant with a sense of humor,” said he.  Since then, I’ve carried large respect for the professionals who call themselves actuaries.

Their association, the American Academy of Actuaries, has published an issue brief that demands attention: “Implications of Proposed Changes to the ACA in Response to King v. Burwell.  King v. Burwell, if you don’t know, is the case currently before the U.S. Supreme Court that challenges the legality of insurance subsidies being provided to eligible health care consumers in states with federal as opposed to state health insurance exchanges.  A decision is expected in late June.

Straight shooters, they are.  Here are excerpts from their conclusions:

“If federal premium tax credits become no longer available in FFM (federally facilitated marketplaces) states, enrollment in the individual market would decline precipitously among those previously eligible for premium assistance.  Moreover, individuals with high-cost health care needs would be more likely to remain enrolled, while individuals with low-cost health care needs would be more likely to exit the market.  Such adverse selection would cause average health costs, and therefore premiums, to rise…”

“Potentially millions of people would drop coverage, and the average costs of those remaining insured would soar.  Insurers could face solvency concerns, especially those for whom exchange business is a relatively large share of their book of business…”

“…extending the premium subsidies through the 2016 plan year (or longer) could help mitigate these concerns for the short term. … However, if subsidies are made available only to those already receiving them, individuals who would be newly eligible for subsidies, due for instance to a change in income or loss of employer-sponsored coverage, would not benefit from the temporary premium subsidy extension.  This would lead to lower overall enrollment in the individual market, as some individuals would transition out of coverage, but few would transition in…”

“Even if a temporary extension of premium subsidies would help avoid disruption in the short term, it is likely that the disruption would only be delayed, not avoided altogether.  If the subsidies are ultimately eliminated, potentially millions of individuals will drop coverage and premiums will increase substantially…”

“Weakening or eliminating the individual mandate could result in adverse selection that would raise premiums and threaten the viability of the market … although such voluntary incentives would provide incentives for healthy individuals to obtain coverage when first eligible, they would likely not be as effective as a strong individual mandate.”

A lot of damage would be done.  Anyone who suggests they know how the Court will decide is deluded.  No one, no one, predicted the outcome of the 2012 SCOTUS decision on the constitutionality of the individual mandate.  No one knows the outcome of this case either.  But, thanks to the Actuaries, we do know the results of a decision against the government.

The New Conversation on Affordability and Underinsurance

Just like spring, a new public conversation is busting out across the nation and the topic is health insurance and health care affordability for patients and consumers. The conversation is taking different forms and is beginning to trigger policy proposals. More will come – and when it does, this conversation may well become a charged debate.

Here are two important streams in this conversation:

Cost Sharing: The first stream involves the growth of deductibles, copayments, and coinsurance, especially deductibles, aimed at consumers. This past week, the Commonwealth Fund released a new Issue Brief showing that 23% of adults with health insurance, 31 million, had “such high out-of-pocket costs or deductibles relative to their incomes that they were underinsured.” About 11% of privately insured adults have policy deductibles of $3,000 or more, up from 1% in 2003. Half of these underinsured (51%) “reported problems with medical bills or debt and more than two of five (44%) reported not getting needed care because of cost.” Fully 41% of adults with high deductibles had debt loads of $4,000 or more.  Fully 75% of all consumers now have deductibles on their policies — so if you’re part of the remaining 25%, be grateful! Continue reading “The New Conversation on Affordability and Underinsurance”

A Most Important Demo You’ve Never Heard of… “One Care”

A new report from the Kaiser Family Foundation puts a welcome spotlight on a most important U.S. health reform demonstration — called One Care — going on first and right now in Massachusetts.   How wonky is this?  The report title says it all: Early Insights from One Care: Massachusetts’ Demonstration to Integrate Care and Align Financing for Dual Eligible BeneficiariesWhat’s it all about?

1-care-banner-headerA population of Americans known as the “dual eligibles” is among the nation’s most needy and expensive groups.  They are 9.6 million elderly and disabled low-income Americans who are dually enrolled in both Medicare and Medicaid.  For most of the 50 year history of the two programs, the “duals” fell between the cracks, getting poorly coordinated or no care.  Twelve years ago, with federal support, Massachusetts’ Medicaid program, called MassHealth, started a “Senior Care Options” (SCO) program for coordinated/managed care for duals over age 65. Continue reading “A Most Important Demo You’ve Never Heard of… “One Care””