Federal Involvement in Medical Care is Not the American Way
Obesity: America’s Self-inflicted Preexisting Condition
Consuming too many potato latkes and Christmas cookies has left its mark on our waistlines. Unfortunately for Americans and their medical care, the seasonal overeating seems to last all year. Indeed, the American Medical Association has declared that obesity is a disease.
It may be more accurate to describe obesity as a contributor to certain diseases. Obesity raises the risk of premature death, heart disease, high blood pressure, stroke, type 2 diabetes, gallbladder disease, breathing problems, certain cancers, and osteoarthritis. Certainly, obesity can result from certain uncommon diseases and hereditary factors, but most people become obese simply because they eat too many unhealthy foods and do not exercise.
At its last count, the Centers for Disease Control and Prevention (CDC) estimated that 40 percent of U.S. adults age 20 and over, 21 percent of teens, and 14 percent of preschoolers are obese. A December 2019 study that analyzed 26 years of body mass index (BMI [the relation of weight to height]) data concluded that half of U.S. adults will be obese (BMI>25) by 2030. Some 25 percent will be severely obese (BMI>35). Moreover, less than 5 percent of adults get the recommended 30 minutes a day of physical activity. And even when people living in “food deserts” were presented with healthy options, only 10 percent changed their evil eating ways.
According to the CDC’s last comprehensive analysis, the annual medical cost of obesity in the United States to Medicare, Medicaid, and private insurers was $147 billion in 2008. And the medical costs for obese people were $1,429 higher than those of healthier weights.
The saddest development is the cultural normalization of obesity with lingerie models, singers, and television shows celebrating fatness. Do we high-five people with other lifestyle related conditions such as alcoholism, emphysema, or coronary artery disease? Of course not.
The obese are easy targets for drug company peddlers of quick fixes or “providers” who want to extract money from third-party payors. U.S. pharmaceutical companies spent $6.1 billion on direct-to-consumer prescription drug advertising in 2017. Many ads feature chunky type 2 diabetics happily frolicking about, thanks to the drug company’s magic pill. The ads might as well say, “pass the chocolate cupcakes with statin sprinkles drizzled with insulin.” We all know the prescription of eating less and exercising more is free of charge.
Alas, we are losing the battle of the bulge. A recent study found that participants failed to lose weight despite reporting that they were exercising and watching their diet. The authors concluded that “many of [the participants] might not have actually implemented weight loss strategies or applied a minimal level of effort, which yielded unsatisfactory results.”
While politicians debate the merits of spending trillions of dollars on government-sponsored medical care, a correctable source of high medical costs is hiding in plain sight. Irrespective of who pays for medical care, rational economic decisions must be made. The Affordable Care Act (ACA) waved a magic wand and removed preexisting conditions from the underwriting equation when calculating premiums. A sick person and a healthy person of the same age could purchase insurance at the same price. Consequently, the ACA doubled the costs for people who made the effort to take care of themselves.
The ACA did allow a “tobacco surcharge” of up to 50 percent more for premiums. Why not an obesity surcharge? This would provide an incentive for consumers to take obesity seriously. Additionally, health-conscious persons would not have to pay for the bad habits of others through taxes to fund government health insurance programs or through higher private insurance premiums.
Those who are stricken with illnesses through no fault of their own need a path to affordable medical care. A good start for lowering costs would be eliminating costly middlemen by encouraging consumers to pay directly for day-to-day medical expenses. Expanding contribution limits and eligible uses of Health Savings Accounts would help pay for the more reasonably priced direct-pay surgery and other alternatives to insurance like direct primary care.
With regard to insurance, we need a revival of competition in the insurance market with multiple products and carriers. Once again, single men could opt to decline pregnancy coverage. We need to restore the pre-ACA availability of low-cost catastrophic (major medical) insurance policies to all ages. Even before mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the large majority of insurers offered guaranteed renewable policies. Here, assuming timely payment of premiums, at the end of the policy period the insurer must renew coverage regardless of the health of the insured. Naturally, this valuable feature costs more but provides consumers with a strong incentive not let the insurance lapse.
Let’s confront the elephant in the room. Healthcare policy should promote personal responsibility, rather than encourage free riders. In America we are free to overeat and under-exercise but we have no right to make innocent bystanders pay for the consequences.
Don’t Buy What They Are Selling
By Marilyn M. Singleton, MD, JD
Buying and selling is in the news lately with President “at some point you’ve made enough money,” “climate change is urgent and growing” Obama’s well-publicized imminent purchase of a 7,000 square foot, $14.85 million estate in Edgartown, Martha’s Vineyard, the playground of the rich and famous, guaranteed to survive the rising seas. Our current politicians are also on the hunt for buyers.
Sales Pitch Number One: A medical care crisis is afoot and only the government can save you. Yes, there is a crisis of rising prices and premiums after the government started meddling in the medical care market. Once health insurance became popular, by 1963 906 insurance companies wrote health and accident insurance, with 42 offering exclusively health insurance. Now we have five companies that have cornered the health insurance market. Additionally, politically powerful hospitals continue to merge and gobble up physicians’ practices leading to up to 70 percent higher prices in geographic areas with minimal competition.
Premiums and out-of-pocket costs steeply rose after the passage of the Affordable Care Act and show no sign of going back down. In 2018, according to eHealth, the average cost of health insurance premiums was $440 for individuals and $1,168 for families – almost double the cost in 2014. The deductibles (the amount of money that you have to pay out-of-pocket before health insurance starts paying for your covered benefits) similarly rose to $4,328 for individuals and $8,352 for families.
Sales Pitch Number Two: The government-to-the rescue plan is fair and free. Now that we have had debates and the Iowa State Fair, we’ve heard enough to know that Medicare-for-All is neither free nor fair. There is a good political reason the House and Senate Medicare-for-All bills fail to provide a financing mechanism. We would have a collective national heart attack after seeing the price tag.
In 2016, the federal government spent more than $1.2 trillion on Medicare, Medicaid, and Children’s Health Insurance Program (CHIP). Total national health expenditures by all government levels and private entities were $3.3 trillion. A 2018 Mercatus Center analysis concluded that Medicare-for-All conservatively would add $32.6 to $38.8 trillion to federal expenditures during its first 10 years. The government predicts that in 2026 the Medicare Hospital Insurance Trust fund will be depleted and total national health expenditures will be $5.7 trillion. The federal government collected about $100 billion in Medicare premiums and a total of $3.32 trillion in taxes last year. Given the projected expenditures and no cost-sharing or premiums, new ways to perform mass wallet biopsies on the populace will emerge. The simplest tool, as Senator Sanders has suggested, is to raise payroll taxes on everyone.
Moreover, with the elimination of private insurance, when the money runs out and care is rationed, only the wealthy will be able to pay for care outside of the government system. Is that fair?
Upping the ante, Senator Sanders wants to pay off some Americans’ current medical debt by taxing Americans with no medical debt. Under his proposal, only people unable to pay their medical debt would be granted relief. Those keeping up with their payments would have to continue to pay. What does “unable” mean? If they are living below the poverty level, they have Medicaid. Is it the working poor? Or is it people who failed to prioritize their medical bills over Starbucks and take-out food? Hardly fair.
Sales Pitch Number Three: If you like your doctor you can keep your doctor, Politifact’s lie of the year. Essentially, the promise was that government would not interfere in the practice of medicine. But both state and federal government wants the final say-so in our medical care. For example, the California assembly passed a bill requiring the state Department of Public Health to review and potentially reject medical vaccine exemptions written by doctors who have granted five or more in a year. No exceptions for doctors specializing in neurological or immunological diseases. In order for Medicare to pay claims, physicians will be required to complete a computerized algorithm and certify that they have done so before ordering certain imaging like MRIs and CT scans. A computer will now determine whether the order is “appropriate.” Medical care by government robots will supplant individualized care – the heart of the patient-physician relationship. Who cares if the patient has a missed or delayed diagnosis?
As the government tries to trap physicians and patients in its restrictive bubble, independent physicians are pursuing avenues for increased choice in medical care and insurance products. Above all, we will never put the needs of the state ahead of the needs of the patient.
Bio: Dr. Singleton is a board-certified anesthesiologist. She is a Past President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.
Hoaxes, Scams, and Your Medical Care
By Marilyn M. Singleton, MD, JD
Hoaxes and scams have been dominating the news lately. We have a marginally known actor faking a hate crime supposedly to raise his Hollywood profile. His attempt to claw his way to the middle could have resulted in race riots, injury, and death. His punishment? All charges dropped.
The scandal about Hollywood and other elites buying their children’s way into top-rated universities really hit home. I remember when I had tutored some recent Vietnamese immigrants for a debate contest to win a scholarship for college. I could only hope that their hard work was rewarded and not wiped away by special favors bestowed on the “haves.”
Now we continue to have a slew of healthcare hoaxes: corporate stakeholders, legislators, and government agencies promise everything and have no accountability for their failure to keep their promises.
Take the large health systems’ claim that hospital consolidation and buying up physician practices would benefit consumers with cheaper prices from coordinated services and other unspecified savings. A major study of California hospital mergers found just the opposite. The analysis showed that the price of an average hospital admission went up as much as 54 percent. When the large hospital systems bought doctors’ groups, the prices rose even more. There was as much as a 70 percent increase in prices of medical services in geographic areas with minimal competition. This finding seems obvious to any of us who has the choice of shopping at Walmart or Target or Costco.
Logic aside, some legislators believe that having the government take over medical care would solve our access and cost problems. Single payer means no competition whatsoever. The single payer plans (H.R. 1384 and S. 1804) that abolish private insurance leave patients with an empty choice. Patients can contract with a physician to pay cash for government medical services covered by the government. But if the physician contracts for such services he cannot be part of the government program for any patient for 2 years. Realistically, these single payer bills make it financially unfeasible for physicians to privately contract with patients. Thus, only well-heeled patients, along with independently wealthy doctors, can buy their way out of the system.
There are variations on the theme of government involvement that allow buy-ins to Medicare, Medicaid, or iterations of the Affordable Care Act marketplaces. All of these all have the same defect: expanding the government healthcare monopoly.
The opioid crisis is an example of the unintended consequences of intervention by oversight agencies not directly involved in patient care. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), now the Joint Commission, a nonprofit organization that accredits more than 20,000 healthcare organizations and programs in the U.S, is for all practical purposes a government surrogate. In 2001, JCAHO declared that pain was the “5th vital sign” that had to be addressed or face consequences. The Federation of American Medical Boards told physicians that “in the course of treatment,” large doses of opioids were just fine. Moreover, Medicare has a hospital payment formula that relies on patient satisfaction surveys. If the patients are satisfied, including being so zoned out on opiates that they can’t taste the bad food, the hospital is paid more. The hospital is penalized for a bad rating.
And now to deal with the opiate issue, the government has issued guidelines that have been found to be harmful to some patients. One-size-fits-all restrictions have caused physicians to fear being flagged as over-prescribers by the medical board. Consequently, some physicians are tapering patients off opioids more quickly than they would ideally like. And in the public eye patients have been transformed from objects of compassion to criminal drug addicts.
Individualized medical care must not be reserved for the chosen few. Patients need physicians who are empathetic, thorough, and not married to a medical cookbook written by disinterested third parties. Perhaps this is why Mick Jagger of the Rolling Stones chose to have his heart surgery in the U.S. and not with his British homeland’s National Health Service.
Central control is not a good idea. Period. Do not believe the hoax perpetrated by the ruling class who will never have to live by their own rules. It is highly unlikely that Venezuela’s President Maduro is starving along with his people.
BDr. Singleton is a board-certified anesthesiologist. She is President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers. She lives in Oakland, Ca.
Expanded and Improved Medicare for All: Beware of Greeks Bearing Broccoli
By Marilyn M. Singleton, MD, JD
During the Supreme Court oral arguments in the challenge to the Affordable Care Act’s mandate to purchase health insurance, people laughed when the late Justice Scalia asked whether the government could make you buy broccoli. Never happen? The laughable has become reality. A California bill awaiting the governor’s signature forbids restaurants from serving any beverage other than water or unflavored milk with kiddie meals. As of yet, the meal’s purchasers, unlike the restaurant, won’t be fined for ordering another beverage for their child.
Shrugging off assertions that the ACA was about control, not care, President Obama quipped that his opponents acted like the ACA “was a Bolshevik plot.” That supposedly ludicrous plot is embodied in a too-good-to-be-true congressional bill, H.R. 676, the “Expanded & Improved Medicare For All”. With no dollar amounts in sight, the bill gives the government a blank check to exert total control over our medical care.
H.R. 676 provides that all individuals residing in the United States showing up at the doctor’s office are “presumed to be eligible” for benefits. The federal government will pay for unlimited “medically necessary” health expenses, including pharmaceuticals, mental health, substance abuse, vision, dental, hearing, and long-term care — with no deductibles or other cost-sharing. Unless a patient opts out, all interactions will be memorialized in a “standardized, confidential electronic patient record system.” Yes, those same electronic records that have been hacked and are contributing to physician burnout.
Overseen by regional offices and the Presidentially appointed 15-member National Board of Universal Quality and Access, participating institutions will receive separate monthly fixed sums for capital expenses (e.g., buildings, improvements) and for operating expenses (including physician salaries). Non-salaried physicians can be paid based on a national fee schedule that is “fair and optimal” as decided by the government. Finally, each geographic region would receive a single allotment to cover long-term care.
There are some restrictions. Only public or not-for profit institutions may participate. Private physicians and clinics can exist but cannot be investor-owned. And to keep the patients on the reservation, private health insurers are prohibited from selling health insurance coverage that duplicates the government-sponsored benefits.
Ever magnanimous, the government will pay for “reasonable financial losses” resulting from the conversion from for-profit to nonprofit status through the sale of U.S. Treasury bonds, assuming we choose to buy them. Additionally, the government will compensate insurance and other relevant clerical, administrative, and billing personnel up to $200,000 per person for losing their jobs.
Patients would have “free choice of participating physicians and other clinicians, hospitals, and inpatient care facilities.” But under the business restrictions and capped payments, the better institutions and clinicians may choose not to participate, thus decreasing access.
There is a big bad wolf in this fairy tale. In 2016, the feds spent more than $1.2 trillion on Medicare, Medicaid, and Children’s Health Insurance Program (CHIP). Total national health expenditures by all government levels and private entities were $3.3 trillion.
H.R. 676 provides funding from appropriations for federal public health care programs, including Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP); an unspecified increase on personal income taxes on the top 5 percent of income earners; a “modest and progressive” excise tax on payroll and self-employment income; a “modest” tax on unearned income, and a “small” tax on stock and bond transactions.
Fast forward to 2026, when the government predicts that the Medicare Hospital Insurance Trust fund will be depleted and total national health expenditures will be $5.7 trillion. The federal government collected about $100 billion in Medicare premiums and a total of $3.32 trillion in taxes last year. Given the projected costs, no cost-sharing, and the $2.4 trillion shortfall, the bill’s “modest” tax increases will soon be obscene.
Not only will the benefits decrease as the money runs out, patients will see real world consequences of total control. For example, Oregon’s Medicaid program wants to limit coverage for opiates for some chronic pain conditions and taper off patients who have been taking opioids long-term — even if they have no signs of addiction. Long-term care will be an easy target; the ACA’s long-term care program was scuttled due to cost concerns. With current nursing home costs averaging $7,500 per month, inevitably when the monthly allotment is depleted, hospice care becomes the medically necessary treatment.
Tell the sponsors of H.R. 676 that it’s your money, your health, your privacy, your life. The government is neither our parent nor our benefactor. The government is not the middleman you want between you and your doctor. At a time when the movement toward innovative and personalized care is moving forward, care via government control is taking us backwards.
Dr. Singleton is a board-certified anesthesiologist. She is also a Board-of-Directors member and President-elect of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.
The Courage to Trust Medical Care to Patients and Physicians
by Marilyn M. Singleton, MD, JD
The days of trusting your legislators to have your best interests at heart are in the rear view mirror. Apparently, their main interest is parroting the buzzwords of the moment to get elected and then being too busy banking lobbying money to listen to the voters. Our legislators have become spectators who wait for the perfect moment to pounce on their political “enemy” and then go on cable news shows to boast about it.
The “us against them” attitude, punctuated by hyperbolic, apocalyptic rhetoric closes the door to finding solutions. Our interests would be better served by having town hall meetings where voters could state their concerns, air their differences, and learn what legislators are doing about their issues. Caution: meetings at 9 a.m. on Wednesday when paid activists are guaranteed to outflank the working general public are prohibited.
There are strong differences of opinion on how to attain a healthy citizenry. Educating potential patients about what drives up medical care expenditures can start the conversation. Well-informed patients would demand solutions based not on corporate interests or government or political agendas, but on a fair, competitive market that maximizes choices and achieves lower costs.
Eight years of the Affordable Care Act have borne out Congressional Budget Office predictions that abandoning basic principles of insurance—which compensates only for events beyond the insured’s control and is priced according to the degree of risk—would lead to higher and higher premiums, fewer participating insurers, and unsustainable government expenditures to subsidize insurance premiums. The data in three recent Centers for Medicare and Medicaid reports on ACA exchanges show “individual market erosion and increasing taxpayer liability.” The average monthly premium for coverage purchased through the exchanges rose 27 percent in 2018, and federal premium subsidies increased 39 percent from 2017 to 2018.
A less frequently discussed cost driver is the disturbing trend of private doctors’ offices being scooped up by hospitals, health insurance companies, and venture capital groups. Prices tend to rise when health systems merge, because of decreased competition. And not only do hospitals and health systems generally charge more than private physicians’ offices, the government compounds this problem by paying more to hospitals than independent offices for the same service. A review of 2015 Medicare payments showed that Medicare paid $1.6 billion more for basic visits at hospital outpatient clinics than for visits to private offices. Patients are the biggest losers: they paid $400 million more out of pocket and had their tax dollars wasted. The study also found hospital-employed physicians’ practice patterns in cardiology, orthopedic, and gastroenterology services led to a 27 percent increase in Medicare costs. This translated to a 21 percent increase in out-of-pocket costs for patients.
Similarly, a U.C. Berkeley School of Public Health study of consolidation of California’s hospital, physician, and insurance markets from 2010 to 2016 concluded “highly concentrated markets are associated with higher prices for a number of hospital and physician services and Affordable Care Act (ACA) premiums.” In consolidated markets (defined by the Federal Trade Commission’s Horizontal Merger Guidelines), prices for inpatient procedures were 79 percent higher and outpatient physician prices ranged from 35 percent to 63 percent higher (depending on the physician specialty) than less concentrated markets.
Big medicine and third-party financing are taking the cost curve in the wrong direction. This speaks to the urgency of encouraging cash friendly practices that bypass insurance and direct primary care (DPC) practices. With DPC, all primary care services and access to low-priced commonly used medications are included in an affordable upfront price. Importantly, DPC’s time-intensive and individualized management of chronic diseases decreases hospital admissions, paring down Medicare’s $17 billion spent on avoidable readmissions.
Why corporations want to marginalize private practice seems clear; the government’s motive is open to debate. Surveys consistently find that patients overwhelmingly want “personalized provider interactions.” Thus, herding patients into government-directed programs is not the solution. One core problem with government systems is their reliance on the goodwill of politicians. As President Ford said, “a government big enough to give you everything you want is a government big enough to take everything you have.”
It’s time for Congress to scrutinize anti-competitive health system mergers. It’s time to bring to the floor over a dozen bills to expand and improve Health Savings Accounts (HSAs) to give patients more control over all facets of their medical care.
Congress, the clock is ticking on this legislative session. Stand up for patients. Or did the dog eat your courage?
Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).
Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.
While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.
Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.
Legislative Update, June 13, 2018: Special Opiate Edition
In this special edition of Legislative Update, Marilyn Singleton, MD, JD breaks down the surge of opiate-related legislation under consideration on Capitol Hill.
In response to the opiate abuse epidemic, Congress has put forth almost 60 bills, many of which are receiving votes by the full House this week (the week of June 11th). In addition, the Senate Finance Committee, on June 12, “unanimously approved its big bill to address the opioid crisis,” reports Politico.
Here is a peek inside the provisions under consideration:
Privacy
H.R. 3331, a bill to amend title XI of the Social Security Act to promote testing of incentive payments for behavioral health providers for adoption and use of certified electronic health record technology. This bill amends title XI (General Provisions) of the Social Security Act to specify that the Center for Medicare and Medicaid Innovation may test models to provide incentive payments to behavioral health providers for: (1) adopting electronic health records technology, and (2) using that technology to improve the quality and coordination of care. Rep. Lynn Jenkins (R-KS); https://www.govtrack.us/congress/bills/115/hr3331/text.
While not specifically an opioid bill, urging mental health professionals to use EMR is one more assault on privacy.
H.R. 5009, Jessie’s Law, would require HHS with outside experts to develop best practices for displaying information about opioid use disorder in a patient’s medical record. HHS would be required to develop and disseminate written materials annually to health care providers about what disclosure could be made while still complying with federal laws governing health care privacy. Rep. Tim Wahlberg (R-WI); https://www.govtrack.us/congress/bills/115/hr5009/text.
H.R. 5795, the Overdose Prevention and Patient Safety Act, would amend the Public Health Service Act so that requirements pertaining to the confidentiality and disclosure of medical records relating to substance abuse disorders align with the provisions of HIPAA. The bill would require HHS to issue regulations prohibiting discrimination based on data disclosed from such medical records, to issue regulations requiring covered entities to provide written notice of privacy practices. Rep. Earl Blumenauer (D-CT); https://www.govtrack.us/congress/bills/115/hr5795/text.
Legislation Affecting Medicaid, CHIP
H.R. 3192, CHIP Mental Health Parity Act, would require all Children’s Health Insurance Program plans to cover mental health and substance abuse treatment. States would not be allowed to impose financial or utilization limits on mental health treatment that are lower than limits placed on physical health treatment. Rep. Joseph Kennedy III (D-MA); https://www.govtrack.us/congress/bills/115/hr3192/text.
H.R. 4005, Medicaid Reentry Act, would amend Title XIX (Medicaid) of the Social Security Act to allow Medicaid payment for medical services furnished to an incarcerated individual during the 30-day period preceding the individual’s release. Rep. Paul Tonko (D-NY); https://www.govtrack.us/congress/bills/115/hr4005/text.
H.R. 5477, the Rural Development of Opioid Capacity Services Act (DOCS Act), would require the Centers for Medicare & Medicaid Services (CMS) to to conduct a 5-year demonstration project to increase the number of providers participating in Medicaid to provide treatment for substance abuse disorders. The CMS must select 10 states for inclusion under the demonstration project, giving preference to states that have a prevalence of substance-use disorders (in particular, opioid-use disorders) comparable to or higher than the national average. Rep. Tom Halloran (D-AZ); https://www.govtrack.us/congress/bills/115/hr5477/text.
H.R. 5789, a bill to amend title XIX of the Social Security Act to provide for Medicaid coverage protections for pregnant and post-partum women while receiving inpatient treatment for a substance use disorder, would direct HHS to issue guidance to states on best practices under Medicaid and CHIP for treating infants with neonatal abstinence syndrome. The bill would also direct the Government Accountability Office to study Medicaid coverage for pregnant and postpartum women with substance abuse disorders. Rep. Bill Foster (D-IL); https://www.govtrack.us/congress/bills/115/hr5789/text.
H.R. 5797, the IMD Care Act, would expand Medicaid coverage for people with opioid use disorder who are in institutions for mental disease (IMDs) for up to 30 days per year. Under a current polity called IMD exclusion, the federal government generally does not make matching payments to state Medicaid programs for most services provided to IMDs to adults between the ages of 21 to 64. Rep. Mimi Walters (R-CA); https://www.govtrack.us/congress/bills/115/hr5797/text.
H.R. 5799, the Medicaid Drug Review, Utilization, Good Governance Improvement Act the (Medicaid DRUG Improvement Act), would require Medicaid programs to implement additional review of opioid prescriptions, monitor concurrent prescribing of opioids and certain other drugs, and monitor the use of antipsychotic drugs by children. Rep. Marsha Blackburn (R-TN); https://www.govtrack.us/congress/bills/115/hr5799/text.
H.R. 5800, the Medicaid Institutes for Mental Disease Are Decisive in Delivering Inpatient Treatment for Individuals but Opportunities for Needed Access are Limited without Information Needed about Facility Obligations Act (Medicaid IMD ADDITIONAL INFO Act), would direct the Medicaid and CHIP Payment and Access Commission to study institutions for mental diseases in a representative sample of states. Rep. Fred Upton (R-MI); https://www.govtrack.us/congress/bills/115/hr5800/text.
H.R. 5801, the Medicaid Providers Are Required To Note Experiences in Record Systems to Help In-Need Patients (PARTNERSHIP Act), would require providers who are permitted to prescribe controlled substances and who participate in Medicare to query prescription drug monitoring programs (PDMPs) before prescribing controlled substances to Medicaid patients. The bill would also require PDMPs to comply with certain data and system criteria, and PDMPs would receive additional federal funds to help cover administrative costs. Rep. Morgan Griffin (R-VA); https://www.govtrack.us/congress/bills/115/hr5801/text.
H.R. 5808, the Medicaid Pharmaceutical Home Act of 2018, would require Medicaid programs to operate pharmacy programs that would identify people at high risk of abusing controlled substances and require those patients to use a limited number of providers and pharmacies. Rep. Gus Bilirakis (R-FL); https://www.govtrack.us/congress/bills/115/hr5808/text.
H.R. 5810, the Medicaid Health Homes for Opioid-Use-Disorder Medicaid Enrollees Encouraged Act (the “Medicaid Health HOME Act), would allow states to receive 6 months of enhanced federal Medicaid funding for programs that coordinate care for people with substance use disorders. The bill would require states to cover all FDA-approved drugs used in medication-assisted treatment for five years, but states could seek a waiver from the requirement. Currently a few states exclude methadone. Rep. Leonard Lance (R-NJ); https://www.govtrack.us/congress/bills/115/hr5810/text.
Legislation Affecting Medicare
H.R. 3331 amends title XI (General Provisions) of the Social Security Act to specify that the Center for Medicare and Medicaid Innovation may test models to provide incentive payments to behavioral health providers for: (1) adopting electronic health records technology, and (2) using that technology to improve the quality and coordination of care. Rep. Lynn Jenkins (R-KS); https://www.govtrack.us/congress/bills/115/hr3331.
H.R. 3528, the Every Prescription Conveyed Securely Act, would require prescriptions for controlled substances covered under Medicare Part D to be transmitted electronically starting January 1, 2021. Rep. Katherine Clark (D-MA); https://www.govtrack.us/congress/bills/115/hr3528/text.
H.R. 4284, the Indexing Narcotics, Fentanyl, and Opioids Act of 2017 (INFO Act), would require HHS to appoint a Federal Coordinator for the Department of Health and Human Services to coordinate programs within the Department of Health and Human Services that relate to opioid abuse reduction. Rep. Robert Latta (R-OH); https://www.govtrack.us/congress/bills/115/hr4284/text.
H.R. 4841, Standardizing Electronic Prior Authorization for Safe Prescribing Act of 2018, would require health care professionals to submit prior authorization requests electronically starting January 1, 2021, for drugs covered under Medicare Part D. Rep. David Schweikert (R-AZ); https://www.govtrack.us/congress/bills/115/hr4841/text.
H.R. 5582, the Abuse Deterrent Access Act of 2018, would require the Centers for Medicare & Medicaid Services to report to Congress on the adequacy of access to abuse-deterrent opioid formulations for individuals with chronic pain enrolled in a prescription drug plan under Medicare or Medicare Advantage (MA). The report must account for any barriers preventing enrollees from accessing such formulations under Medicare or MA. Rep. Buddy Carter (R-GA); https://www.govtrack.us/congress/bills/115/hr5582/text.
H.R. 5590, the Opioid Addiction Action Plan Act, would require the Centers for Medicare & Medicaid Services (CMS) to develop an action plan to provide recommendations on changes to the Medicare and Medicaid programs to enhance: (1) the treatment and prevention of opioid addiction, and (2) the coverage and reimbursement of medication-assisted treatment for opioid addiction. The CMS must convene a stakeholder meeting to solicit public comment on the action plan. Rep. Adam Kinzinger (R-IL); https://www.govtrack.us/congress/bills/115/hr5590/text.
H.R. 5603, Access to Telehealth Services for Opioid Use Disorders Act, would permit HHS to lift current geographic and other restrictions on coverage of telehealth services under Medicare for treatment of substance abuse disorders or co-occurring mental health disorders. HHS would be directed to encourage other payers to coordinate payments for opioid use disorder treatments and to evaluate the extent to which the demonstration project reduces hospitalizations, increases the use of medication-assisted treatments, and improves health outcomes. Rep. Doris Matsui (D-CA); https://www.govtrack.us/congress/bills/115/hr5603/text.
H.R. 5605, the Advancing High Quality Treatment for Opioid Use Disorders in Medicare Act, would require the Centers for Medicare & Medicaid Services (CMS) to carry out a demonstration program to: (1) increase access of opioid use disorder treatment services for Medicare beneficiaries, (2) improve physical and mental health outcomes for such beneficiaries, and (3) reduce Medicare expenditures. Opioid use disorder care teams of practitioners may apply for participation in the demonstration project. The CMS must establish a performance-based incentive payment for participating teams. The CMS must adopt or develop program quality standards and performance methods. Rep. Raul Ruiz (D-CA); https://www.govtrack.us/congress/bills/115/hr5605/text.
H.R. 5675. This bill would require Medicare prescription drug plan (PDP) sponsors, for plan years beginning on or after January 1, 2021, to establish drug management programs for at-risk beneficiaries. Current law authorizes, but does not require, PDP sponsors to establish such programs. Rep. Gus Bilirakis (R-FL); https://www.govtrack.us/congress/bills/115/hr5675/text.
H.R. 5684, Protecting Seniors From Opioid Abuse Act, would establish individuals who are identified as at-risk beneficiaries for prescription drug abuse as qualifying participants in medication therapy management programs under the Medicare prescription drug benefit. Rep. Mike Kelly (R-PA); https://www.govtrack.us/congress/bills/115/hr5684/text.
H.R. 5685, Medicare Opioid Safety Education Act of 2018, would require the Centers for Medicare & Medicaid Services to provide Medicare beneficiaries with educational resources regarding opioid use and pain management, as well as descriptions of covered alternative (non-opioid) pain-management treatments. Rep. John Faso (R-NY); https://www.govtrack.us/congress/bills/115/hr5685/text.
H.R. 5686, Medicare Clear Health Options in Care for Enrollees Act of 2018 or the Medicare CHOICE Act of 2018, would require Medicare and Medicare Advantage prescription drug plan (PDP) sponsors to annually disclose information to enrollees about: (1) the adverse effects of prolonged opioid use; and (2) the plan’s coverage of nonpharmacological therapies, devices, and non-opioid medications. PDP sponsors may limit disclosure to a subset of enrollees (such as those who were prescribed an opioid in the previous two-year period). Rep. Erik Paulsen (R-MN); https://www.govtrack.us/congress/bills/115/hr5686/text.
H.R. 5715, the Strengthening Partnerships to Prevent Opioid Abuse Act, would require the Centers for Medicare & Medicaid Services (CMS) to establish a secure online portal to allow: (1) data sharing among the CMS, Medicare prescription drug benefit plans, and Medicare Advantage (MA) plans; and (2) referrals by such plans of substantiated fraud, waste, or abuse in order to initiate or assist investigations by contracted entities under the Medicare Integrity Program. The CMS must disseminate and report certain collected information to such plans, including information regarding providers that were referred through the portal and trends in identifying suspicious activity. Additionally, for plan years beginning on or after January 1, 2021, MA organizations must submit information to the CMS regarding investigations or other actions taken by MA plans against providers that prescribe high volumes of opioids (as determined by the CMS). Rep. James Renacci (R-PH); https://www.govtrack.us/congress/bills/115/hr5715/text.
H.R. 5716, the Commit to Opioid Medical Prescriber Accountability and Safety for Seniors Act (the COMPASS Act) would require the Centers for Medicare & Medicaid Services (CMS) to identify outlier prescribers of opioids under the Medicare prescription drug benefit and Medicare Advantage prescription drug plans. Specifically, the CMS must: (1) establish an opioid-prescription threshold for determining whether a prescriber is an outlier compared to other prescribers, based on specialty and geographic area; (2) use National Provider Identifiers (unique provider identification numbers currently included on claims for covered drugs) to identify outlier prescribers; and (3) annually notify identified outlier prescribers of their status and provide them with resources on proper prescribing methods. The CMS may also identify and notify outlier prescribers based on co-prescriptions of covered drugs that have adverse effects when used in combination with opioids. Rep. Peter Roskam (R-IL); https://www.govtrack.us/congress/bills/115/hr5716/text.
H.R. 5796, Responsible Education Achieves Care and Healthy Outcomes for Users’ Treatment Act of 2018 (REACH OUT Act of 2018), would allow HHS to award grants to certain organizations that provide technical assistance and education to high-volume prescribers of opioids. The bill would appropriate $100 million for fiscal year 2019. Rep. Brian Fitzpatrick (R-PA); https://www.govtrack.us/congress/bills/115/hr5796/text.
H.R. 5798, the Opioid Screening and Chronic Pain Management Alternatives for Seniors Act, would add an assessment of current opioid prescriptions and screening for opioid use disorder to the Welcome to Medical Initial Preventive Physical Examination. Rep. Larry Bucshon, MD (R-IN); https://www.govtrack.us/congress/bills/115/hr5798/text.
H.R. 5804, Post-Surgical Injections as an Opioid Alternative Act, would freeze Medicare payment rate for certain analgesic injections provided in ambulatory surgical centers. Rep. John Shimkus (R-IL); https://www.govtrack.us/congress/bills/115/hr5804/text.
H.R. 5809, the Postoperative Opioid Prevention Act of 2018, would create an additional payment under Medicare for nonopioid analgesics. Under current law, certain new drugs and devices may receive an additional payment – separate from the bundled payment for a surgical procedure – in outpatient hospital departments and ambulatory surgical centers The bill would allow nonopioid analgesics to qualify for a five-year period of additional payments. Rep. Scott Peters (D-CA); https://www.govtrack.us/congress/bills/115/hr5809/text.
Legislation affecting the FDA
H.R. 5333, the Over-the-Counter Monograph Safety, Innovation, and Reform Act of 2018, would change the Food and Drug Administration’s (FDA) procedures for regulatory activities for over-the-counter medications. The bill would require the Government Accountability Office to study exclusive market protections for certain qualifying OTC drugs. Rep. Robert Latta (R-OH); https://www.govtrack.us/congress/bills/115/hr5333/text.
H.R. 5473, Better Pain Management Through Better Data Act of 2018, would require the FDA to conduct a public meeting and issue guidance to the industry addressing data collection and labeling for medical products that reduce pain while enabling the reduction, replacement, or avoidance of oral opioids. Barbara Comstock (R-VA); https://www.govtrack.us/congress/bills/115/hr5473/text.
H.R.5752, Stop Illicit Drug Importation Act of 2018, would amend the federal Food, Drug, and Cosmetic Act (FDCA) to strengthen FDA’s seizure powers and enhance its authority to detain, refuse, seize, or destroy illegal products offered for import. The legislation would subject more people to debarment under the FDCA and thus increase the potential for violations, and subsequently, the assessment of civil penalties. Rep. Marsha Blackburn (R-TN); https://www.govtrack.us/congress/bills/115/hr5752/text.
H.R. 5687, the Securing Opioids and Unused Narcotics with Deliberate Disposal and Packaging Act of 2018 (the SOUND Disposal and Packaging Act) would permit the FDA to require certain packaging and disposal technologies, controls, or measures to mitigate the risk of abuse and misuse of drugs. This bill would also require that the Government Accountability Office study the effectiveness and use of packaging technologies for controlled substances. H.R. 5687 would permit the Secretary of Health and Human Services to require drug developers and manufacturers to implement new packaging and disposal technology for certain drugs. Rep. Richard Hudson (R-NC); https://www.govtrack.us/congress/bills/115/hr5687/text.
H.R. 5806, the 21st Century Tools for Pain and Addiction Treatment Act, would require the HHS acting through the Commissioner of Food and Drugs, to hold at least one public meeting to address the challenges and barriers of developing non-addictive medical products intended to treat pain or addiction and to issue one or more final guidance documents, or update existing guidance documents, to help address challenges to developing non-addictive medical products to treat pain or addiction. Rep. Michael Burgess, MD (R-TX); https://www.govtrack.us/congress/bills/115/hr5806/text.
H.R. 5811, the Long-Term Opioid Efficacy Act of 2018, would allow the FDA to require that pharmaceutical manufacturers study certain drugs after they are approved to assess any potential reduction in those drugs’ effectiveness for the conditions of use prescribed, recommended, or suggested in labeling.
H.R. 5811 would expand an existing mandate that requires drug developers to conduct post-approval studies or clinical trials for certain drugs. Under current law, in certain instances, the FDA can require studies or clinical trials after a drug has been approved. H.R. 5811 would permit the FDA to use that authority if the reduction in a drug’s effectiveness meant that its benefits no longer outweighed its costs. Rep. Jerry McNerney (D-CA); https://www.govtrack.us/congress/bills/115/hr5811/text.
Miscellaneous
H.R. 449, Synthetic Drug Awareness Act of 2017, would require the Surgeon General to report to Congress on the public health effects of the increased use since January 2010 by individuals who are 12 to 18 years old of drugs developed and manufactured to avoid control under the Controlled Substances Act (e.g., synthetic marijuana, also known as “spice,” and synthetic amphetamines, also known as “bath salts”). Rep. Hakeem Jeffries (D-NY); https://www.govtrack.us/congress/bills/115/hr449/text.
H.R. 4275, Empowering Pharmacists in the Fight Against Opioid Abuse Act, would require the Drug Enforcement Administration (DEA) to develop and disseminate training programs and materials on: (1) the circumstances under which a pharmacist may refuse to fill a controlled substance prescription suspected to be fraudulent, forged, or indicative of abuse or diversion; and (2) federal requirements related to such refusal.
The DEA must seek input from relevant stakeholders. Rep. Mark DeSaulnier (D-CA); https://www.govtrack.us/congress/bills/115/hr4275/text.
H.R. 4684, Ensuring Access to Quality Sober Living Act of 2017, would require the Substance Abuse and Mental Health Services Administration to publish best practices for operating recovery housing, to distribute such publication to the states, and to provide technical assistance to states seeking to adopt such practices. “Recovery housing” means a shared living environment free from alcohol and illegal drug use and centered on peer support and connection to services to promote recovery from substance use disorders. Rep. Judy Chu (D-CA); https://www.govtrack.us/congress/bills/115/hr4684/text.
H.R. 5041, Safe Disposal of Unused Medication Act, would require hospice programs to have written policies and procedures for the disposal of controlled substances after a patient’s death. Rep. Tim Wahlberg (R-WI); https://www.govtrack.us/congress/bills/115/hr5041/text.
H.R. 5102, the Substance Use Disorder Workforce Loan Repayment Act of 2018, would amend the Public Health Service Act to create a loan repayment program for individuals who complete a period of service in a substance use disorder treatment job in a mental health professional shortage area or a county where the drug overdose death rate is higher than the national average.
The substance use disorder treatment job must be a full-time position where the primary intent and function is the direct care of patients with or in recovery from a substance use disorder.
Individuals must enter into an agreement of service of up to six years with the Health Resources and Services Administration. The repayment program would pay one-sixth of the principal and interest on any eligible loan for each year of service; the maximum total amount of repayment by the program is $250,000 per individual. Rep. Katherine Clark (D-MA); https://www.govtrack.us/congress/bills/115/hr5102/text.
H.R. 5176, the Preventing Overdoses While in Emergency Rooms Act of 2018, would authorize $50 million in 2019 and require HHS to develop protocols and grant a program for health care providers to address the needs of people who survive a drug overdose. Rep. David McKinley (R-WV); https://www.govtrack.us/congress/bills/115/hr5176/text.
H.R. 5197, Alternatives to Opioids (ALTO) in the Emergency Department Act, would direct HHS to carry out a demonstration program for hospitals and emergency departments to develop alternative protocols in pain management that limit the use of opioids. Rep. Bill Pascrell, Jr. (D-NJ); https://www.govtrack.us/congress/bills/115/hr5197/text.
HR 5202, Ensuring Patient Access to Substance Use Disorder Treatments Act of 2018, would clarify permission for pharmacists to deliver controlled substances to providers under certain circumstances, i.e., delivered to the location listed on the practitioner’s certificate of DEA registration, for substance abuse treatment, or for intrathecal injection, and not for general dispensing by the practitioner. Rep. Ryan Costello (R-PA); https://www.govtrack.us/congress/bills/115/hr5202/text.
H.R. 5228, the Stop Counterfeit Drugs by Regulating and Enhancing Enforcement Now Act (the SCREEN Act), would require drug distributors to cease distributing any drug that HHS determines might present an imminent or substantial hazard to public health. CBO cannot determine what drugs could be subject to such an order nor can it determine how private entities would respond. Consequently, CBO cannot determine whether the aggregate cost of the mandate would exceed the annual threshold for private-sector mandates. Rep. Frank Pallone, Jr. (D-NJ); https://www.govtrack.us/congress/bills/115/hr5228/text.
H.R. 5261, Treatment, Education, and Community Help to Combat Addiction Act of 2018 (the TEACH to Combat Addiction Act of 2018), would direct HHS to designate regional centers of excellence to improve the training of health professionals who treat substance abuse disorders. Rep. Bill Johnson (R-OH); https://www.govtrack.us/congress/bills/115/hr5261/text.
H.R. 5272, Reinforcing Evidence-Based Standards Under Law in Treating Substance Abuse Act of 2018 (the RESULTS Act of 2018), would require the National Mental Health and Substance Use Laboratory to issue guidance to applicants for SAMHSA grants that support evidence-based practices. Steve Stivers (R-OH); https://www.govtrack.us/congress/bills/115/hr5272/text.
H.R. 5327, Comprehensive Opioid Recovery Centers Act of 2018, would direct HHS to award grants to at least 10 providers that offer treatment for people with opioid use disorder, and would authorize $10 million a year from 2019 – 2023. Rep. Brett Guthrie (R-KY); https://www.govtrack.us/congress/bills/115/hr5327/text.
H.R. 5353, the Eliminating Opioid Related Infectious Diseases Act of 2018, would amend the Public Health Service Act by broadening the surveillance and education about Hepatitis C prevention and treatment of infections associated with injected drug use. Rep. Leonard Lance (R-NJ); https://www.govtrack.us/congress/bills/115/hr5353/text.
H.R. 5483, Special Registration for Telemedicine Clarification Act of 2018, would amend the Controlled Substances Act to establish a deadline for the Drug Enforcement Administration to promulgate regulations for the special registration of practitioners to practice to telemedicine. Rep. Buddy Carter (R-GA); https://www.govtrack.us/congress/bills/115/hr5483/text.
H.R. 5580, the Surveillance and Testing of Opioids to Prevent Fentanyl Deaths Act of 2018 (STOP Fentanyl Deaths Act of 2018), would establish a grant program for public health laboratories that conduct testing for fentanyl and other synthetic opioids. It would direct the CDC to expand its drug surveillance program with a focus on collecting data for fentanyl. Rep. Ann Huster (D-NH); https://www.govtrack.us/congress/bills/115/hr5580/text.
H.R. 5587, Peer Support Communities of Recovery Act, would direct HHS to award grants to nonprofit organizations that support community-based, peer-delivered support, including technical support for the establishment of recovery community organizations, independent, nonprofit groups led by people in recovery and their families. The bill would authorize $15 million per year for the 2019-2023 period. Based on historical spending patterns for similar activities, CBO estimates that implementing H.R. 5587 would cost $62 million over the 2019-2023 period; the remaining amounts would be spent in years after 2023.
Rep. Ben Lujan (D-NM); https://www.govtrack.us/congress/bills/115/hr5587/text.
H.R. 5788, the Securing the International Mail Against Opioids Act of 2018, would provide for the processing by U.S. Customs and Border Protection of certain international mail shipments and to require the provision of advance electronic information on international mail shipments of mail.
Rep. Mike Bishop (R-MI); https://www.govtrack.us/congress/bills/115/hr5788/text.
H.R. 5812, the Creating Opportunities that Necessitate New and Enhanced Connections That Improve Opioid Navigation Strategies Act of 2018 (the CONNECTIONS Act), gives the Director of the Centers for Disease Control and Prevention authorization to carry out any evidence-based prevention activity and provide training and technical assistance to States, localities, and Indian tribes. Rep. Morgan Griffith (R-VA); https://www.govtrack.us/congress/bills/115/hr5812/text.
Disrupt This: Jettison Medicare and Medicaid
By Marilyn M. Singleton, MD, JD, @MSingletonMDJD
“Disruptive innovation” is all the buzz. Repealing the Affordable Care Act (ACA) is so last year. Well, disrupt this: repeal Medicare and Medicaid and get the government out of the medical care business.
The federal government appropriately began its involvement in health care in 1798 when Congress established the U.S. Marine Hospital Service. It should have ended with taking care of our soldiers and sailors.
This is America, and the private sector knew what to do. The mid-1800s brought “sickness funds,” financed by small wage deductions. In the late 1800s, mining, lumber, and railroad companies created industrial clinic plans that prepaid physicians a fixed monthly fee to provide medical care to employees. Workers were so satisfied with these that they rejected the idea of state-sponsored compulsory insurance.
To guarantee payment in the midst of the Depression, pre-paid group plans were established. Hospital and surgical insurance featuring physician choice and fee-for-service payment was introduced in the 1930s. Government policies in the 1940s influenced the growth of employer-sponsored health insurance. Favorable tax treatment and World War II’s wage and price controls led employers to offer health insurance in lieu of higher wages.
The poor were not forgotten. Charity hospitals developed from almshouses that cared for the poor. Public hospitals grew from community efforts to care for those who could not afford to care for themselves.
By 1964 some 80 percent of Americans were privately insured with 821 companies offering individual plans. Health insurance was an affordable safety net because most people are healthy most of the time and people took care of their simple medical needs out of pocket. The challenge was insuring the poor-risk top 5 percent of health consumers who spend half of the medical dollars. The government could have — but did not — use the opportunity to encourage the private sector to innovate practical, cost-effective insurance products and launch public education campaigns to invigorate community public hospitals.
Unfortunately, the Sixties brought us far more than flower power. After an uphill battle fighting images of wizened widows without medical care, the Kerr-Mills Act of 1960 giving federal funding to the states to help low-income seniors with their medical bills was passed. This opened the door to a bureaucratic monster that took on a life of its own.
The Great Society’s social engineers would not be satisfied until the government burrowed deeper into medical care. Thus Medicaid for all the “medically indigent” and Medicare for all seniors (aka middle class welfare) were born.
And since money grows on third-party and government trees, medical costs were ignored, and expenditures dramatically increased from 5.0 percent of GDP in 1960 to 17.9 percent in 2016. And at 28 percent, healthcare expenditures are the single largest piece of the federal budget pie.
The ACA’s justification for commandeering the remainder of the health insurance market was to rid our nation of the uninsured. Yet six years later, the nation’s uninsured dropped a mere 3.8 percent, and premiums have more than doubled. The number one reason the current uninsured did not buy insurance was because the cost was too high. Of course it was. The ACA’s mandated “free” benefits had to be paid for somehow. Worse yet, it now takes a Herculean effort to find individual health insurance; nationally, there are only 3.5 issuers in the ACA marketplace.
Medicare and Medicaid began the upending of the health insurance business. These programs became the siren call, enticing us to cede control over our health to disinterested third parties and middlemen. Government largesse led us to accept blind pricing as the norm. Where else do you buy something before you know what it costs? Freebies lured us into relinquishing our privacy to government data banks and now leave us longing for the comfort and simplicity of a computer-free doctor visit.
Medicare and Medicaid started us down the road to dependency and government control. The nightmare has become a reality: when government controls your medical care it controls your life and death through treatment denials and Medicare’s ever-expanding direct-to-hospice pathway.
In the 50s drama, The High and the Mighty airplane passengers were forced to throw all their baggage into the Pacific Ocean to save themselves from certain doom. Likewise it’s time to shed our government healthcare baggage and move forward.
Dr. Singleton is a board-certified anesthesiologist. She is also a Board-of-Directors member and President-elect of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.
A Health Savings Account Could Save Your Life
By Marilyn M. Singleton, M.D., J.D
Some pundits blamed algorithmic trading for the stock market’s recent wild ride. “Algo-trading” relies on computers programmed to follow defined instructions for placing trades. For example, the computer buys 50 shares of stock when its 50-day moving average goes above the 200-day moving average. Period. Algo-trading was popularized as a systematic approach that removes human emotion, intuition, or instinct from the transaction.
Advanced medical algorithms are becoming the next best thing. Their intended purpose is to improve and standardize decisions made in the delivery of medical care, enabling multiple levels of health care practitioners to use the same “thought” process.
A medical algorithm can be a list of risk factors for various conditions, such as heart disease, or a simple calculation such as BMI (body mass index) utilizing height and weight to determine ideal numbers. Many algorithms are flowcharts with a binary decision tree: if BMI is greater than 25, do this; if not, do that. Newer algorithms based on machine learning, a form of artificial intelligence that simulates how humans learn, can analyze and diagnose radiology images or pathology slides or predict the actual risk of developing certain conditions.
Some of these advances are extraordinary and will likely add to our medical armamentarium. But they do not exist in a vacuum. Concomitant with the flow chart revolution, patients complain that when barely a nanosecond has passed since the physician’s first “hello,” they are handed a DNR form.
Yes, it is a good thing for a physician to know about a patient’s desires at what could be the end of his life. But it is unsettling when the 35 year-old “provider” cheerfully encourages a patient to fill out the form, crowing that she signed her DNR form. The patient is thinking, “you’ll feel a lot different about it at 65 than you do now.” Unfortunately in today’s healthcare delivery factories, when illness strikes “your” doctor may be a previously unknown-to-your hospitalist whose sole knowledge about you, the human being, is lab tests, x-rays, findings on physical exam, and a form you signed 10 years ago. Your family relationships, religious views, and the like are not his purview. When death is actually walking down your street you want to know and trust those in charge of your life.
In a recent case, a toddler was declared brain dead by one hospital, but apparently showed signs of life. His mother sought but failed to stop the removal of her child from life support. After the plug was pulled, she challenged the constitutionality of California’s Determination of Death Act which effectively takes away life-and-death decisions from parents. The Act provides that a person is dead when, in accordance with accepted medical standards, either the body or the brain has irreversible cessation of all function. A federal court dismissed the case, reasoning that the State cannot be held responsible for its determination-of-death laws, because doctors have “broad and legitimate discretion” to end patients’ life support.
Less obvious but nonetheless devastating, is the power Medicare, Medicaid, and insurers exercise over life and death through pre-authorizations and denials of claims. In a lawsuit against Aetna for denial of benefits which the patient alleges “almost killed him,” Aetna’s medical director admitted under oath that he never looked at patients’ medical records when deciding whether to approve or deny care.
If physicians have the power over life and death, “if you like your doctor, you can keep your doctor” takes on added significance as more states adopt physician-assisted suicide laws. Even in Belgium where euthanasia is legal, its proponents are increasingly uncomfortable with the speedy approval of psychiatric patients’ requests to die. Discomfort turned to outrage when a dementia patient was euthanized when there was no evidence that the patient had asked to die.
As independent physicians we want to use the best advances to help our patients but we do not want medicine to devolve into paint-by-the-numbers. We dread the day when “algo-medicine” devoid of human emotion, intuition, or instinct will say Sell! (to the mortician) when the patient hits 70? Buy! if the baby has no problems discerned on prenatal ultrasound?
If you want to ensure that your doctor has your back, run – don’t walk to a direct primary care practice (DPC). Tell your congresspersons to add the 1-page Primary Care Enhancement Act (HR 365 / S 1358) to upcoming “must pass” legislation. This will allow patients to use Health Savings Accounts (HSAs) to pay for DPC. Your life could depend on it.
Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).
Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.
While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.
Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.
Medical Care in 2018: Ring Out the Broken Promises and Bring In Solutions
By Marilyn M. Singleton, M.D., J.D.
The U.S. “health care system” continues to be a costly behemoth. Health care costs were the number one financial concern for 17 percent of families in 2017—the same level as it was in 2007 pre-Affordable Care Act era. And only 18 percent of those polled said the Affordable Care Act helped their family.
The ACA did not work as promised.
“If you like your health care plan, you can keep it.” Unfortunately, health insurance companies canceled plans for 4.7 million people. Many insureds chose to have inexpensive, limited plans to cover major expenses. These plans however were not ACA-compliant as they did not contain the mandated 10 “essential health benefits” with no copays or deductibles. While many of these required “benefits” are medically useful, many (e.g., pediatric vision and oral care, maternity care, breast cancer genetic screening, mammograms, and female contraception) are superfluous for childless unmarried men.
“I’ll also bring Democrats and Republicans together to provide every single American with affordable, available health care that reduces health care costs by $2,500 per family.” Kumbaya? The ACA was passed in the dark of night with only Democrat votes. Affordable? Overall costs to the consumer have risen dramatically.
In 2008, the cost of the average employer-sponsored family plan was $12,680, with an employee share of $3,354. The 2016 cost topped out at $18,142 with a $5,277 employee cost. In the individual market, the biggest losers are those who earn a little too much to qualify for federal premium subsidies, particularly the self-employed in their 50s and 60s. For a bronze-level plan with a health savings account, a three-person family can pay $15,000 a year in premiums and paid out-of-pocket for the first $6,550 of medical expenses for each family member.
Moreover, many insurers have requested—and will likely receive—double-digit premium increases for 2018. Nationally, the increases between 2017 and 2018 for unsubsidized premiums for the lowest-cost bronze plan averaged 17 percent, the lowest-cost silver plan averaged 32 percent, and the lowest-cost gold plan averaged18 percent.
“We’ll start by increasing competition in the insurance industry.” That was a colossal failure. Overall, the number of insurers in the individual market has decreased since 2014. In 2017 UnitedHealth Group eliminated ACA Exchange plans in 31 of 34 states and Aetna remains in only four states. Humana and Aetna plan to exit all ACA Exchanges in 2018.
Agreed, some Americans gained health coverage. Medicaid and the Children’s Health Insurance Program (CHIP) accounted for 14.5 million of the 20 million of newly covered. The 2014 cost per non-disabled adult and child enrollee was $3,955 and $2,602, respectively. Some 27.5 million people remain uninsured with cost cited as the main problem.
Further, being “covered” was meant to keep emergency departments (EDs) from being used as an alternative to primary care. But according to the federal Agency for Healthcare Research and Quality (AHRQ), the number of emergency department visits covered by Medicaid increased by 66.4 percent between 2006 and 2014, outpacing population growth by a factor of two, making Medicaid the leading payer for ED visits.
These data tell us we must have a serious conversation, not intellectually lazy political slogans, like “Repeal and Replace!” Instead of ruminating about how to modify the government’s involvement in medical care, Congress and policymakers should ask how can we take better care of more patients and be open to all suggestions.
One successful model is direct primary care (DPC) mainly seen in solo and small medical practices. Here, patients pay a monthly fee (generally ranging $75 to $150) directly to the physician’s office for 24/7 access, and in many cases, basic labs and medications, and steep discounts on radiology and pathology services. Also growing are direct pay specialty and surgical practices where the fees for the operating room, surgeon, and anesthesiologist are included in one low price. And yes, many of these practices (even in California) offer sliding scales and charity care without running afoul of rigid federal regulations.
With DPC, patients spend more quality time with their doctors and physicians can shed the administrative burdens of government programs and insurance companies and treat patients according to their best judgment. A testament to the success of this model is the University of Michigan offering such a program this spring. Hopefully, the big boys won’t ruin a good thing.
ObamaCare’s individual mandate is dead. It’s time to use our healthcare dollars wisely and pay for the medical care, not the middlemen.
Dr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).
Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.
While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.
Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.