Category Archives: HR 676 Analysis

Unguarding the Henhouse: HR 676, Part 9, Prescriptions

If you’ve been following along with me on HR 676, the Medicare for All bill, we are now at Section 205, Payment for Prescription Medications, Medical Supplies, and Medically Necessary Assistive Equipment.  Even more than payment of physician and hospital costs, the problem of medication and device coverage is incredibly complicated.  I could spend a year blogging just about that one topic and still not get to everything.  The more I think about it, the more amazed I am that this bill manages to cover the whole thing in four concise paragraphs.


Here’s the meat of it:  prices to be paid by our national insurance will be negotiated annually; there will be a prescription drug formulary to “encourage best-practices in prescribing and discourage the use of ineffective, dangerous, or excessively costly medications when better alternatives are available”; generics will be promoted but use of brand-name and off-formulary medications will be allowed; and both clinicians and patients can petition their regions or the Director to add or remove drugs.


I hope you all know what an error it was to prevent Medicare from negotiating drug prices.  A person unfamiliar with the deep grasp of corporate money on our political system could probably infer it from just this one flagrant dereliction of duty to citizens.  The result?  Needless waste of our Medicare money on overpriced products.  We know this, and even so, it is unlikely to change any time soon


That provision seems obvious.  The formulary, though, strikes me as fascinating and different from other plans I’ve seen.  Any of you who have insurance, public or private, have a formulary—a list of medications covered by your plan.  There are a variety of approaches to limiting the use of expensive treatments.  Many policies have “tiers” – a preferred list of drugs we can buy for cheaper co-pays, and one or two additional lists of drugs available at higher cost-sharing.  Sometimes the first tier drugs are actually better and cheaper generics, but often they are just the ones your particular insurer got a better deal on.  These negotiated deals are bundles—drug companies will offer packages to insurers where they give deep discounts on certain medications in order to get preferred treatment on the big ticket drugs.


Because the packages are all different between insurers, it means that patients switching from one employer to another often have to change their long-standing medications.  I’ve told you about one such case I had recently, when an insurer insisted it would only cover one asthma controller medication for my patient—to which my patient happened to have a life-threatening allergy. I was finally able to convince them otherwise but it took a lot of back and forth.  Usually there is a process to appeal these decisions, often with inordinate amounts of fax and telephone time, and there is nothing to say they have to give a final decision that makes sense.


There are also always medications the insurer just will not cover under any circumstances, and these vary from plan to plan.  This seems to have nothing to do with medical effectiveness and everything to do with what they can get away with—the target patients are often those less likely to stand up for themselves, such as addicted people or the mentally ill.


It has been the general consensus that without such restrictions, docs will just willy-nilly bust the bank—that we are so much in the hands of drug reps that we are no longer capable of wise prescribing.  Did you notice there is no restriction in HR 676?  There is just encouragement and discouragement.  Unless the Program chooses to add to that in the regulatory process, there would be no teeth here of the type we are accustomed to.  Because there is no cost-sharing, patients would not pay more for inappropriate or excessively costly drugs.  I suppose it is possible there would wind up being some of those ghastly “incentive” programs for physicians, but I hope not. 


Possibly the ability to negotiate prices would be all that is needed – we could just simply refuse to pay more than a drug is worth, so that drug companies would quit wasting our time and money.  Can we trust doctors enough to use good sense in prescribing—pick the more effective generic and leave the “me-too” brand-names alone?  Is there any additional provision that would help strengthen the “encouragement”?


I think there are a few.  Accurate public and physician information tools, feedback on prescribing habits, and inclusion of certain OTC medications in the formulary.


Carrots and sticks are not effective tools for higher-order decision making.  In my experience, many patients (and even some doctors) translate the higher prices for second tier medicine and the extra hoops into a belief that these hard to get products are better.  Anything that takes so much time and effort must be worth it, right?  So even though constructing some sort of barrier to overspending is quite tempting, I believe it ultimately costs us more.  What does help people make better decisions?  Honest feedback and trustworthy, unbiased information. 


Along with reforms of the FDA (a topic for another post), we need more effective patient and physician education resources untainted by sneaky drug company advertising.  It would be very possible to design such tools so that we could all know the best available information on what works and what doesn’t.   Doctors who have a pattern of prescribing outside the fold could be closely observed—and not just in a heckling sort of way, but with a curious, open approach.  Because maybe their patients are doing better—maybe they know something we need to know.   Or maybe they need to update their education. 


Instead of basing payments on various grading systems as some insurers now do, we could try simply providing feedback to physicians on their prescribing habits and cost-effectiveness compared to national benchmarks.  I get charts like that from a couple of insurers, and even though the data doesn’t change my salary I do pay attention.  Once I saw that Medicaid had to pay more for one brand name asthma medicine than for another with the exact same active ingredient (remember this varies per plan), and because I don’t like to waste our money, I quit using the higher priced product for that insurer.  Most of us don’t like to be extreme outliers and will adjust our practices accordingly.  But the information needs to be presented in a truly useful way—right now, I have one patient with a genetic disease whose single expensive prescription from the specialist skews my data so much that I have no idea where my numbers really are anymore.


Including certain OTC medications in the formulary, just as Alabama does for Medicaid, would be essential.  I’d like to see that provision specifically stated in the bill.  Many patients in my practice ask me to switch to a prescription drug when their previously effective treatment goes over the counter, because the co-pay is cheaper than the OTC price.  There is also a certain placebo boost that goes with that prescription signature.  Including OTC coverage for selected items would remove a fair amount of prescribing pressure.


I can imagine a scenario like this:  you have arthritis, and you visit your doctor to find out what to do about it.  Once you have the diagnosis, you check the patient information portal with our national health plan and learn that OTC drugs like ibuprofen are just as effective as some of the expensive newer prescriptions.  You learn that in your particular case, with no increased risk for stomach bleeding, there is no reason whatsoever to start with a brand name drug.  Your doctor knows that too and what’s more—she knows you know better than to go by the deceptive advertising.  She also knows that even if you are on a very limited income, you are able to get the ibuprofen covered. So she recommends a trial of ibuprofen along with diet changes and exercise, educates you on possible side effects, and lets you know there are other options if needed.


For my friends who worry that a single formulary would restrict their options excessively, I hope you are impressed by the wording in this bill.  It is more open-ended than any private insurance formulary you will ever see.  It is a leap of faith worth making.


What do you think?  I’d be interested in hearing your prescription stories and thoughts.


Filed under evidence based medicine, HR 676 Analysis

HR 676, Part 8: A Tribute to LS, on Memorial Day

It’s a beautiful (and hot!) Memorial Day, and even though I’m using it mostly to catch up on odds and ends and hang out with my family, I know it is important to remember the day’s original purpose—to honor the memory of those who have died in war.  What do you think of, when you think of war and warriors?  Do you think of the immediate injuries of battle?  Or do you remember the slower, more painful losses of those who return home?  Far too many of our veterans eventually succumb to their wounds of PTSD and related mental illnesses, years and even decades after the formal military hostility has ended.


Today, I think of a lovely man, once a family member by marriage.  He fought in the Vietnam War and came home wounded more deeply than anyone knew at the time.  He was an engineer, a father, and a marvelous carpenter.  We still have a wooden lamp he made us by hand, 20 years ago, in his own design.  We shared many family dinners and stories and watched our young children play together.  When his war injuries finally got the better of him, no one could stop it—he became estranged from the family, disabled, and finally, one day we got the call that he was gone.


I count his death as both a casualty of war and of the failure of our mental healthcare system.  Whatever the inadequacies we encounter in the US healthcare machinery, the situation for mental health is many times worse.  Some of this is just because no one in the world has found cures for the most serious of mental illnesses, but much of the problem is in our failure to deliver treatments than can and do help.  In honor of those who have returned home from a military war only to die as a consequence of mental illness, let’s review Section 204 of HR 676 on Mental Health Services. 


As you can see, it is short and sweet.  Part A says:  “The Program shall provide coverage for all medically necessary mental health care on the same basis as the coverage for other conditions.  Licensed mental health clinicians shall be paid in the same manner as specified for other health professionals.”


This is basically “parity”—saying mental health is part of health and can’t be treated differently seems to me a no-brainer, but it continues to be a root problem in our system.  Our main attempt at parity, despite SAMHSA’s very optimistic wording, continues to fall short.   The truth is that we have multiple separate and UN-equal systems of care.  For those with private insurance, panels are limited to certain providers.  Many policies under Alabama’s largest insurer do not cover therapy unless it is by a PhD, leaving out large groups of very qualified and effective therapists who have other professional licenses. 


Even when a family is fortunate enough to find a skilled therapist their loved one can relate to, the whole relationship can end if the employer insurance policy (and thus the provider panel) changes.  Many of the policies I see in our office have “carve-outs” for mental health—the insurers pay a set portion of everyone’s premium to another insurance organization, so that patients must deal with an entirely different agency for mental health.  Typically, these specialist insurances have been very hard to deal with.  They use their own criteria for hospitalization, for instance, which are different from the standard-of-care published criteria the doctors use.  We can usually get little help from the patient’s main insurer in dealing with the behavioral insurer.


When there is a carve-out, pediatricians and other primary care docs get left out of the loop in treating milder conditions like ADHD or uncomplicated depression and anxiety.  I’ve recently had several children who had been stable and thriving in my care for their ADHD—they had to switch to a psychiatrist for medication monitoring, because their insurance policies have changed and do not have primary care doctors on the behavioral panel.  It made so much more sense for me to care for these children as whole humans—the asthma, the growth and development, and the ADHD are not really such separate issues.  It was easier for the families too, but now they have to add extra appointments to their overloaded schedules. 


Many private providers require up-front cash payment and tell the families to file for reimbursement from the insurer.  This allows the providers to charge whatever they want to, leaving families to do battle for uncertain payment.  Many families who have private insurance cannot afford to plunk down $200 a week for therapy and wait months to get some of it back.  So they don’t go.  They come back in a few months with the same problem I tried to get them help for, except it is worse and now harder to treat.  Quick help for mental illnesses is critical—the longer the brain goes on in a dysfunctional state, the higher the chance of long term illness and disability.


For those who have public insurance through Medicaid, in Madison County the options are limited.  Alabama Medicaid wisely allows primary care doctors to be paid for mental healthcare, but when the patients’ problems are beyond our training in psychopharmacology or when they need real counseling, they must go to the county Mental Health Center, now overloaded and underfunded.  Waiting lists are long.  Even though our MHC here tries hard to manage on a shoestring and has a director who truly cares about clients and families, it has not been able to keep a board certified child/ adolescent psychiatrist on staff.  For adults, budget cuts have led to a move towards group therapy instead of individual therapy for most patients.


The split in private and public systems has had other consequences, on the provider end.  Most of the families I know through NAMI who have loved ones affected by the disabling mental illnesses like schizophrenia or other psychotic disorders have wound up using public insurance, when their loved ones could no longer work.  This means that many private psychiatrists and therapists today have much more experience and skill with the “worried well” than they do with full-blown psychosis.  Many of them no longer even see hospitalized patients.  Patients in public care often see therapists in training, who leave once they have finished that training.


There is little patient choice in either the private or public system.  Competition between insurers won’t help, because the insurers must satisfy their shareholders and bottom line—they will continue to find ways of limiting access as a form of cost-control.  The only kind of competition that matters in mental (and all) health has to do with quality of care, and the only way we will ever see the fruits of such competition is for all patients to have access to any licensed provider.  Any form of cost-sharing at the point of service (co-pays and deductibles) would be especially detrimental in mental health—it is the treatment families in my practice seem most likely to put off until they can afford it.  Needing mental health care is still embarrassing for many families, and having an excuse to wait is dangerous.   Payment needs to be in advance, as in the Medicare for All plan, where we all pre-pay through taxes.


Part B of this section says the program will favor “community-based care” and that “in all cases the highest quality and most effective care shall be delivered, and, for some individuals, this may mean institutional care.”  If you held your breath (or picketed with us) as Alabama considered closing almost all our state psychiatric hospitals this year, take note of those words!  We cannot continue to put our most vulnerable citizens at risk because of floundering state economies.


I do not know if my former family member would have lived—or lived well— had he been in a country with a more integrated and accessible mental health system.  Some problems will always be beyond our reach.  We should not put our young men and women in the armed forces into combat for frivolous reasons—we should all know the human price of our votes for those who will make these decisions. 


Honor the memory of those who have lost their personal battles with mental illness today by doing something for those who have yet to fight.  Do something concrete—share this post with friends, call or email your legislators, or talk with a neighbor.  Tell them why we need Medicare for All.



Filed under HR 676 Analysis, mental health

HR 676, Part 7: Women’s Reproductive Health Should NOT Be Managed By Chicken Farmers

Before I get to mental health, which I promise is really coming soon, I’m going to reflect on how the current uproar in Alabama and other states over women’s reproductive rights might call for some careful editing of HR 676, the Expanded and Improved Medicare for All Act.  I’ve reviewed the wonderfully long list of covered services previously.  Is it clear enough to stop a conservative administration from limiting reproductive care?  I fear not—I believe it needs to be substantially strengthened.


Contraception would likely be covered without explicit mention.  The bill covers “all medically necessary services”, and preventive care plus prescription drugs are clearly listed.  There is no way we are going to list every medically necessary service in the bill itself, but other services that have been historically limited by insurers are mentioned outright, such as dental care and mental health services.  To be on the safe side, we should go ahead and specify contraception coverage.  Just as for other medications, there would be no co-pay at the point of service—this health plan is pre-paid entirely.


What about abortion? HR 676 needs to specify coverage, very directly.  Single-payer advocates sometimes avoid mentioning abortion, even though NOW is a supporter of HR 676. It has been an uphill battle to try and get Medicare for All on the table—I am sure the thought is probably just “don’t go there.  Don’t make the job even harder than it is.  If it is legal, we can assume it will be ok.”  That is likely a mistake.


Maybe one day, contraception will be so excellent and free of side effects that abortion will become obsolete.  Maybe one day, an embryo or fetus can be painlessly removed and grown in some high-tech incubator, later to be adopted.  Until that time, we must clearly state that we are going to fund a medical procedure the courts have already said is legal.


The best prevention of abortion, a very sad procedure no woman wants to need, is contraception and an educated public.  The Dutch have the lowest abortion rates in the world— they got there by teaching everyone how to prevent unplanned pregnancy and making contraception easily available.  Sure, contraception isn’t perfect, but it really does help, as opposed to delusional attempts to prevent sex itself.  If those who call themselves “pro-life” would quit behaving so irrationally, teens in the US could be just as well-educated, and all women would have access to contraception.  Instead, these forces reveal themselves to be about not life but power.


In Alabama, if you’ve read my recent posts, we are being besieged with a flurry of bills written by out-of-state special interest groups trying to keep women from accessing both contraception and abortion.  At the same time, the State House may cut funding for a range of services to children, including healthcare, education, enforcement of child support, and foster care.  Pregnant women may be unable to get Medicaid if they test positive for drugs, and there are efforts to imprison them as well.  It is a truly bizarre double-bind.


Seeing this dismal script played out has made me re-visit the most common critique of single-payer healthcare—that it would be done poorly, because it is government.  I have said before that our main protection is the requirement for ALL of us to have the insurance, including legislators and administrators.  Will that be enough?  Maybe not.  As long as there are procedures special to women, we are at risk of male legislators attempting to practice medicine without a license.  


In Alabama, we have a chicken farmer—a chicken farmer!—who thinks he knows enough about medicine to tell doctors how to get informed consent for abortion.  I will not come to his farm and try to manage his chickens.  He needs to stay out of our exam rooms.  I mean nothing derogatory about farmers or their chickens.  I would say the same about a nuclear physicist.  These are just very different specialties.


We already have insurers who get away with poor coverage of women’s health needs.  We need to be careful that a national insurance program would not put us at risk for the same problem.  How to do it?  Perhaps we can strengthen the design of the National Board of Universal Quality and Access.  I will go over it again when I get to that section of the bill, but as written it includes a minimum of one health care professional.  This board has many tasks, some of which don’t require significant medical training.  I believe we need to separate out a Board to include both practicing physicians and patients that will oversee the determination of medical necessity.  This board should have a voting majority of physicians and half should be female.  Members should be elected by physicians and patient advocacy groups and should not be employed by potentially conflicting interest corporations (like pharmaceutical and device companies).  They should also not be government employees.


Our nation’s founders attempted to set a balance of powers in place.  I was taught in elementary school this means the legislative, executive and judicial branches.  I’m learning there’s a lot more to it!  There’s the balance of power between citizens and our elected representatives, between states and the federal government, and between private enterprise and the state.  There’s even a balance of power between physicians and patients, one that has evolved markedly for the better in recent decades.  Men and women, adults and children, workers and employers—on and on.  It’s mindless to argue over big and small government—the argument needs to be around the power balance.  Anyone who gets too big, whether that’s government, corporations or a mob, will throw it off.


Power balances can and will get off kilter.  Sometimes the problem can be solved by adding a little more weight to one side or the other.  Sometimes one of the weights must be removed and replaced.  We don’t always know to predict an imbalance until it happens—I doubt if our founders expected Citizens United.  Monarchy might have been just fine if it had always been benevolent.  If we were a different sort of country, ideologically, we might be ok letting a government board determine our health benefits.  I do not trust our current crowd with that job.


Our healthcare balance has been weighted much too heavily in favor of corporate insurers who put their profits ahead of both patients and physicians.   We probably can’t fix the problem without replacing them.  HR 676 replaces them with government—the other side of the scale needs to be firmly weighted with physicians free to practice quality, professional medicine and patients who demand to be treated with respect, as full participants in their medical care.


Filed under Alabama legislative session 2012, HR 676 Analysis, women's healthcare

HR 676, Part 6: Long Term Care


This week’s section of HR 676 (Improved and Expanded Medicare for All) is Section 203—Payment for Long Term Care.

For long-term care, which includes in-home, nursing home and community based care, each region will get a lump sum amount to cover everything—regions will distribute the money to care providers.  Instead of paying for each service provided, the nursing homes and other care providers will get a global budget based on their past expenditures, performance, utilization and expected changes in service.  There will be an effort to favor care in the home or community instead of in institutions.

How many of you are struggling to take care of aging or disabled family members right now, with or without long-term care insurance?  I’d love to hear some stories.  How many of you have long-term care insurance for yourselves?  Many of us try not to think about it—we don’t want to be a burden on our children one day, but the cost of insurance can be fairly high.

I have an adult disabled family member.  Between Medicaid and my work insurance, most regular medical care is covered.   Because my family member had no long-term care insurance before becoming ill as a minor, the many non-medical expenses aren’t covered at all.  I’m talking about things like assistants to help get to doctor appointments, buy groceries/help  plan one or two meals a day, help remember basic maintenance tasks like laundry and cleaning, help plan/ accomplish goals and provide some of the critical human companionship we all need to stay healthy.  Of course, when we are not at work, we also pitch in as a family and enjoy spending time with each other.

Because it would be hard for one person to manage (and because we wanted some backup in case one person needed time off), we cobbled together a plan of care with several part-time helpers who do a wonderful job.   

We are fortunate that we can afford it—we wish we could afford even more help.  Many families can’t even come close.  We worry about what will happen when we are gone, and we just signed a Special Needs Trust today—kind of eerie to realize we are worth more dead than alive.  Even with life insurance money, there is a limit to how many years of care we can cover.  We’re both hoping to live a long time and never retire!  No bungee jumping for us.  Without us, and without long-term care insurance, the little bit of disability money that barely covers rent will not be enough.

I think it is absolutely amazing to have this long-term care be part of the plan.  It literally makes me tear up to imagine.  Muscles relax that I didn’t even know were tense.   And I wonder if it will wind up saving money in other ways.  How many people, with proper care, could overcome disabilities and return to the community to work?  How many would be less afraid to work intermittently—afraid of losing Medicaid or Medicare attached to their disability, because the loss of coverage would most likely doom them to the return of illness?

The only part of this section I wonder about is that all long-term care has to be done by agencies because of the global budget.  There would not be a way for families to individually pay for assistance, the way we do now, so we would lose some personal control.  It may be that this is the only way to set up long-term care in a cost-effective manner.  If so, I’m not complaining. What do you think?





Filed under HR 676 Analysis

HR 676, Part 5: Budget Nuts and Bolts

Title II of HR 676 is “Finances”—let’s look at Subtitle A, Budgeting and Payments.  A little dry, but very relevant, considering Alabama’s current budget squeeze and the threat to the 40% of Alabama children covered under our Medicaid!

First, there will be an annual budget for our national healthcare program, to include funds to pay physicians and other providers, capital expenditures (such as building hospitals/ buying equipment), health professional education, and administration of the program itself.  There will be a strict separation of funds for capital expenditures and operating expenses—I would imagine this is to protect our patient care funds from being eaten up by building costs. 

After the total annual budget amount is determined by Congress (susceptible to voter pressure if they don’t put enough in the pot), the Director of the program will give Regional offices their funds.  The specific payment arrangements to doctors, hospitals and so on will be done at the regional/ state level but with approval by the national Director.

There are different ways to get paid under this plan—hospitals, nursing homes and similar centers will negotiate a global annual budget, based on their past expenses and projected changes.  Kind of like a salary for organizations.  Doctors and other providers have three different options.  They can submit their bills as usual (fee-for-service) through a standardized electronic billing system (or on paper), they can be salaried by an organization that gets a global budget, or they can be salaried in a group practice or non-profit HMO that gets capitated payments (a set amount per patient enrolled).

How much will the doctors and others get paid?  The bill says the amount would have to be negotiated between physician/ provider representative groups and the regional/ state directors.  The starting point would be the current payment for various services—I hope this reassures those who worry about sudden/ dramatic changes in payment.  The exact details of these physician representative groups will be isn’t laid out, but it seems this could be worked out by the physicians themselves.  Might be done through state medical societies and/or through specific professional groups like state chapters of the American Academy of Pediatrics.

That requirement for negotiated rates is critical.  Right now, under regular Medicare, there isn’t negotiation.  There is only lobbying and outright begging by docs to get fair treatment.  Under this system, we have a guaranteed seat at the table.  Now, if you know how these budget things work, you can read a lot more into the word “negotiation”!  I feel sure there will be a few cat, dog or mud fights between groups who think someone else is getting an unfairly big slice of the pie, but at least we are all in it. 

There are a few specific rules worth mentioning.  Providers have to be paid within 30 days, or they get paid with interest.  There is no “balance billing” allowed for covered services—the docs can’t charge the patients more than what they have negotiated to accept as fair payment, already the rule for most insurances.  Patients have to be enrolled without discrimination (standard Civil Rights).  HMO’s must pay physicians salaries and are specifically not allowed to give incentives based on utilization.  This means, no productivity bonuses—very important to prevent a nasty pressure on docs to see more and more patients in a shorter amount of time.  Having experienced that myself several years ago, I can tell you it isn’t good for either the patients or the docs.  Obviously if you are a real slacker, you will get fired.

I like this payment/ budget plan overall and don’t see any significant holes in it.  The word “reimbursement” instead of “payment” is used several times—I know at least one doc who gets really steamed up at that term, but it could be replaced without much trouble.  

I know some don’t think we should allow for any fee-for-service at all, but I see a positive to continuing it at least initially.  For one thing, I think a more drastic change of completely going to salaries at the same time as changing how we fund healthcare is just too much.  Second, it would give us a chance to see which arrangement works better for patient care quality and cost control, with more of the other variables removed.

I also like that the specific payment agreements will be worked out on a regional/ state level but funded nationally.  Our Alabama Medicaid program is a good example of why this matters.  The current office does an amazing job of managing limited funds with very low overhead—the administration understands our state and what services we need better than a remote national office would– but we are now facing a ruined system because we just don’t have enough overall money in the General Fund.  Assurance of sufficient funds at the Federal level would protect folks in states with budget crunches, while still allowing states some reasonable autonomy for expenditures.

What do you think? Any comments, questions or suggestions to revise this section of HR 676?  I hope to have more updates on our Medicaid crisis soon.  In the meantime, I advise Alabama folks to join Alabama Arise ASAP, and also to see about getting your community/ civic groups to join.  Then set up a house party (see instructions on their website) this month, early in our legislative session.   I think this organization may be the best positioned to help us preserve our state Medicaid—they are smart, dedicated and have a good track record.

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Filed under Children's Issues, HR 676 Analysis

HR 676, Part 4: Room for Negotiation in Medicare for All?

I’m hard at work trying to keep our state legislature from throwing our Medicaid money away, but I promised to do a breakdown on HR 676, Medicare for All.  This week let’s take up Section 104.

Here it is, short and sweet:


 (a) IN GENERAL.—It is unlawful for a private health

 insurer to sell health insurance coverage that duplicates

 the benefits provided under this Act.

 (b) CONSTRUCTION.—Nothing in this Act shall be

construed as prohibiting the sale of health insurance coverage for

any additional benefits not covered by this Act,

 such as for cosmetic surgery or other services and items

 that are not medically necessary.

First, notice the very specific wording that only a private insurer can’t duplicate benefits.  Does it leave room for a different form of public insurance?  For instance, could a state get a waiver and offer its own insurance plan? And if so, would that option appeal to folks in regions that love the 10th Amendment?  Although I prefer a national program for cost-saving reasons, we don’t need to marry that idea if it would prevent moving forward.  I am watching the progress in Vermont and California toward state single payer with great interest.

Sometimes progressives don’t see the good side of states’ rights.  It isn’t only about limiting centralized power—it also allows for simultaneous trials of 50 variations on a theme.  This is a much more efficient way to test options than one at a time for all of us, and we can learn from each other.  For instance, I can use Connecticut’s experience with corporate managed care Medicaid to help Alabama see it would be a mistake. 

What about the allowed sale of private insurance for non-covered services?  I think that’s a great example of an area where the market is the most appropriate venue.  These are luxury services—cosmetic surgery, cosmetic orthodontics, etc—not things necessary for life and basic health.  The kicker is that more conventionally attractive people do have an edge when it comes to jobs and status.  But trying to flatten the playing field completely is a total waste of time—rich folks will always find a way to get ahead.  I just don’t think we should let them do it by denying ordinary medical care to us and tanking our economy in the process.

So let the insurers get into business there.  They can offer group negotiated discounts for face lifts.  It might actually bring the price down, because people can afford to take time for shopping around on luxuries.  As opposed to doing so in the middle of a heart attack.

This section will be the one opponents will argue against the hardest.  I can imagine it as the target of legal challenges when the bill is eventually passed.  Like the universal mandate with the ACA, without this section the rest of the plan will fail.  There is no reason that a government program will work any better than what we have now, unless we all have a dog in the fight.  If any substantial percent of us doesn’t have to use our national health plan, we will not be able to generate enough political pressure to force it to run well.

Is there any workable way around that?  Probably not.  The only one I think is worth at least discussing is to consider allowing private insurance for doctors, hospitals and patients who agree to opt out of the public system 100%.  They would still have to pay taxes on the public system, just as people do who use public schools, but upon purchase of private insurance, they would forgo the right to use public services.

Doctors would have to choose which system to participate in. Anyone who receives public money in any form (obviously legislators) or contracts with a public agency would not be able to participate in private plans for themselves or their employees.  And there would be “prison rules” for those insurances, because we should not have to waste public money on regulation and oversight.

In my book, I suggested the option of patients using either system, since they had paid taxes.  But a similar set-up hasn’t worked well for England.  The difference with my idea would be that politicians and anyone who gets any form of public funds couldn’t be allowed to go private and would have to experience what they set up.   Would that be enough to make it safe for the rest of us?

Germany did a mandated choice between public and private, and the problem is that people find out they can’t afford their private plans but then can’t switch to the public system.  This would create preventable suffering and hurt the economy (sick people can’t work well).

So what if we said patients could make one switch back to public insurance when private plans failed them?  Kind of like Dirty Santa?  And after that, I guess they’d have to emigrate to another developed country without national insurance—oh, wait, there aren’t any. 


Filed under HR 676 Analysis

HR 676, Part 3: Who Gets to Play?

Hope everyone had a happy New Year celebration! Ready to jump right back in to reading HR 676, the Expanded and Improved Medicare for All Act?   In a couple of months, the Supreme Court will be hearing arguments about our current healthcare law—  let’s be ready with a thorough knowledge of our proposed replacement.

Section 103 of HR 676 is titled “Qualification of Participating Providers.” First, it says “no institution may be a participating provider unless it is a public or not-for-profit institution.  Private physicians, private clinics, and private healthcare providers shall continue to operate as private entities, but are prohibited from being investor owned.”

There’s an extra comma at the end of that sentence, but generally this bill is so much better written than the ACA.  The meaning is quite clear—HR 676 does NOT institute socialized medicine.  Your hospital, doctor, chiropractor, etc will remain in the private sector (unless already part of a public entity like the VA).

For-profit entities that want to be paid out of our national insurance fund will need to convert, and there is money in this section to reimburse their expenses over a 15 year period, through the sale of Treasury Bonds.  The exact amount isn’t specified—it is not for loss of business profits but for the expense of conversion only.

Facilities and physicians must meet applicable state quality and licensing guidelines to participate.  I’m not sure why this was necessary to specify, since it is already illegal to practice without a license. I guess it is just to make clear that the bill doesn’t replace state licensing with national licensing?  It goes on to say “no clinician whose license is under suspension or who is under disciplinary action in any State may be a participating provider.”

 That sentence might need to be tweaked, because some disciplinary actions require probationary status—the physician might practice under supervision for a period of time or get more training to correct a deficit.  I see notices like that in our state medical association newsletter.   How can the doc complete probation and regain full licensure status without being able to get paid?  Would you all rather just go ahead and cut loose any doc who shows a deficiency, correctable or not?   This might increase already strenuous efforts of doctors to cover up their own medical problems, etc, rather than getting appropriate help.

Disciplinary actions have also been used politically.  Dr. Sonnie Hereford talks about this in his book “Beside the Troubled Waters:  A Black Doctor Remembers Life, Medicine and Civil Rights in an Alabama Town.” Great read—I highly recommend it.

Health Maintenance Organizations that provide their own care (like Kaiser) could continue to do so as non-profits.  HMO’s that contract with non-employee physicians are basically just insurance plans—we’ll look at their fate next week.  I notice that a lot of Alabama folks aren’t as familiar with HMO’s as people in other parts of the country, but it really works fine just to think of them as insurers.

There’s a trend recently of large insurers setting up facilities with their own employed physicians, so that subscribers have to see those doctors  for full coverage.  I don’t think that has happened yet in Alabama, except sort of for mental health.  One large insurer here restricts coverage of mental health services to a single provider, Alabama Psychiatric Services, owned by a company called Managed Health Care Administration.  MHCA is a private company that subcontracts with the insurer to administer and provide mental health benefits, so it is “sort of” an insurer but not exactly.  It is owned by investors— the psychiatrists who work for APS.  The key is that the people who are treating you also administer the contract that determines what services you can get. They get a capitated (per insured person) fee to provide whatever services are needed.  What happens to the money not spent on your care?  They get to keep it.  Draw your own conclusions about whether that could be a problem.  I don’t know of anything specific that has happened, but my conflict of interest would prevent me from further comment if I did. 

Under HR 676, such arrangements wouldn’t be allowed, because the benefits covered would be determined by a separate agency accountable to voters.  It would also be prevented by the last, critical phrase in Section 103: “Patients shall have free choice of participating physicians and other clinicians, hospitals and inpatient care facilities.”  This is so radically different from our current arrangement that I’ll devote a separate blog post to it, next week.

Any comments on this section or changes you would make?  Let me hear from you and I’ll pass it on to the other board members of Physicians for a National Health Program.


Filed under HR 676 Analysis, Insurer tricks