TrumpCare vs. ObamaCare

I posted quite a few articles on D2L related to possible changed to the Affordable Care Act.  There are more after President Trump's State of the Union.  I read a transcript with sidebars to offer a fact check and more detailed explanation.

I think the recent New Yorker article on Donald Trump learning that healthcare is "complicated" offers some very good links, include the Kaiser News Health Tracking Poll, which I also posted on D2L.  The "complicated" article is telling.  "I have to tell you, it’s an unbelievably complex subject,” President Donald Trump told a group of governors at the White House yesterday. “Nobody knew that health care could be so complicated."

Posted on 2/28, Ryan Lizza deciphers it for us:

“Nobody knew” is Trumpspeak for “I just found out.” Large-scale reform of the American health-care system is one of the most complicated policy issues the government faces, as all of Trump’s modern predecessors learned.

“The health care reform story illuminates almost every aspect of the presidency,” David Blumenthal and James Morone write in The Heart of Power: Health and Politics in the Oval Office, a 2009 examination of how eleven Presidents, from to Franklin Roosevelt to George W. Bush, grappled with the issue. “Because health reform is excruciatingly difficult to win, it tests presidents’ ideas, heart, luck, allies, and their skill at running the most complicated government machinery in the world.” (The book is on Amazon, and you can Read Inside.)

Lizza discussed the dived in the Republican party and ends noting that in their history of health-care reform, Blumenthal and Morone conclude with eight conditions necessary for passing major reform. The first, and perhaps most important, is “passion.”

“Major health care reform is virtually impossible, difficult to understand, swarming with interests, powered by money, and resonating with popular anxiety,” they write. “The first key to success is a president who cares about it deeply.” Any President who is just learning the basic fact that health care is “complicated” has failed the passion test. And without that, little else matters. 

The title of the post is based on another New Yorker article in the March 6 issue by Atul Gwande on
TrumpCare vs. ObamaCare. In his commentary, Gwande points out that Republicans in Congress are facing the wrath of constituents who don’t want to lose those gains they now have with Obamacare.
But even if there is a stalemate in Congress, insurers must decide by April whether to offer a plan for the exchanges in 2018, and at what price. That requires certainty about the future. Pitchforks have their uses, but crafting health-care policy calls for more delicate instruments. The basic functioning of the health-care system and American lives are at stake.

Also today, 2/28, I read an NPR Health Shots article about the portability of health insurance.  In that article, it asks,

Why should a health plan be tied to where you work or live? The answer, of course, is "it's complicated." As Republicans debate ideas for repealing and replacing the Affordable Care Act, portability might play a central role in their plan. So how would that work?

The problem is that portability Is hard to define.   The notion of "portability" means that consumers can stick with the same insurer, the same benefits and the same coverage limits, even if they move or change jobs. In the current policy discussion, though, portability is more likely to be viewed as a means for consumers to get access — possibly with the help of a tax credit — to a variety of health plans.   But, the author (who is with KNN) says that "if keeping the same plan is the goal, that would be very tricky. The health care system is just not built that way."  Read more to find out why.

I thought I would post this on the blog for you to comment, as well as add articles here for you to read.  I did not pick these articles just to be critical of President Trump, but, as you know, when it comes to healthcare, it takes passion, careful consideration, and thoughtful policy discussions.  Feel free to add your own thoughts, or your own readings.

Proposal Draft

I asked you to submit your proposal on D2L.  In addition, you should update your personal blog (or shared blog), so we can all follow your work.  Alternatively, you can post a comment here about what research questions you want to pursue as a way to focus the objective for your research, either as a group or individual.  If you have ideas for data, let me know.  I will also post data links on the blog.  Comment here about specific data you would prefer, or like to have for your project.

Same But Different

Subtitle:  How epigenetics can blur the line between nature and nurture.

We briefly discussed the nature vs nuture phenomenon with genes, and as I mentioned Siddartha Mukherjee, author of The Gene: An Intimate History, had a mother and aunt who were identical twins.  The article points out that in the late 1970s a team of scientists in Minnesota set out to determine why identical twins are similar, i.e., how much these similarities arose from genes, rather than environments—from “nature,” rather than “nurture.”  The question Mukherjee pursues is this:

Why are identical twins different? Because, you might answer, fate impinges differently on their bodies. One twin falls down the crumbling stairs of her Calcutta house and breaks her ankle; the other scalds her thigh on a tipped cup of coffee in a European station. Each acquires the wounds, calluses, and memories of chance and fate. But how are these changes recorded, so that they persist over the years? We know that the genome can manufacture identity; the trickier question is how it gives rise to difference.

The genome is not a passive blueprint.  When one twin breaks an ankle and acquires a gash in the skin, wound-healing and bone-repairing genes are turned on, thereby recording a scar in one body but not the other.  This article goes into some fascinating detail about how David Allis and many other scientists, figured out over decades that  protein systems, overlaying information on the genome, generated the bewildering intricacy necessary for a cell to build a constellation of other cells out of the same genes, and for the cells to add “memories” to their genomes and transmit these memories to their progeny. “There’s an epigenetic code, just like there’s a genetic code,” Allis said. “There are codes to make parts of the genome more active, and codes to make them inactive.”

So, why are twins different? Well, because if you sequence the genomes of a pair of identical twins every decade for fifty years, you get the same sequence over and over. But if you sequence the epigenomes of a pair of twins you find substantial differences: the pattern of epigenetic marks on the genomes of their various cells, virtually identical at the start of the experiment, diverges over time.

I know this is a long New Yorker article, but the science is fascinating for those interested in reading further, or get his book, or read a review about the book.

The beginning of the Personal Genome Project (PGP)

I found the original video from George Church in 2007.  His initial vision moved the dial on understanding and engineering years later.   It is fascinating to look back on the beginnings.  Take a look.



Also, here is the link to the video. The other two videos following this one (Webisode 2 & 3) tell the stories of two people who decided to share why they chose to post their personal genome with the public.

Tending the Body’s Microbial Garden

Here is an excellent overview of the microbiome, we briefly mentioned in class.

For a century, doctors have waged war against bacteria, using antibiotics as their weapons. But that relationship is changing as scientists become more familiar with the 100 trillion microbes that call us home — collectively known as the microbiome.

No one wants to abandon antibiotics outright. But by nurturing the invisible ecosystem in and on our bodies, doctors may be able to find other ways to fight infectious diseases, and with less harmful side effects. Tending the microbiome may also help in the treatment of disorders that may not seem to have anything to do with bacteria, including obesity and diabetes.

These links are worth investigating to learn more about the Human Microbiome Project (HMP).   Judging from a flood of recent findings about our inner ecosystem, that appears to be happening. Last week, Dr. Segre and about 200 other scientists published the most ambitious survey of the human microbiome yet. The Human Microbiome Project is based on examinations of 242 healthy people tracked over two years. The scientists sequenced the genetic material of bacteria recovered from 15 or more sites on their subjects’ bodies, recovering more than five million genes.   This project and other studies like it are revealing some of the ways in which our invisible residents shape our lives, from birth to death.   Here are some NIH  demonstration projects at the HMP.   

In this article, one interesting study (of many mentioned) is that a baby’s microbiome continues to grow during breast-feeding. In a study of 16 lactating women published last year, Katherine M. Hunt of the University of Idaho and her colleagues reported that the women’s milk had up to 600 species of bacteria, as well as sugars called oligosaccharides that babies cannot digest. The sugars serve to nourish certain beneficial gut bacteria in the infants, the scientists said. The more the good bacteria thrive, the harder it is for harmful species to gain a foothold.   

As the child grows and the microbiome becomes more ecologically complex, it also tutors the immune system, however ecological disruptions can halt this education.  Read more on how experiments on mice reveal how this happens.

Antibiotics kill off harmful bacteria, but broad-spectrum forms [of antibiotics] can kill off many desirable species, too. Antibiotics are likened to herbicides sprayed on a garden. The herbicide kills the unwanted plants, but also kills off the tomatoes and the roses. The gardener assumes that the tomatoes and roses will grow back on their own.   In fact, there’s no guarantee the microbial ecosystem will automatically return to normal.

Please read this article and the links attached to the article (under Related Coverage).   As you do so, let me know what you think.

Obese patients and smokers banned from routine surgery

So you not I'm not kidding about this. Hospital leaders in some cities in the UK, including London, said that patients with a body mass index (BMI) of 30 or above – as well as smokers – will be barred from most surgery for up to a year amid increasingly desperate measures to plug a funding black hole. The restrictions will apply to standard hip and knee operations.

A bit of background on this first.  The National Health Service (NHS) was launched in 1948 as a combined payer and delivery system to replace a longstanding mix of private, municipal, and charity insurance. When introducing the bill which was written by the economist William Beveridge (hence the Beveridge Model in T.R. Reid' chapter), to the House of Commons in July 1948 - almost 60 years ago! - the newly appointed Secretary of State for Health, Aneurin "Nye" Bevan argued that the NHS would “divorce the ability to get the best health and treatment from the ability to pay.”  Here is what T.R. Reid said about the NHS (pp. 104-105):

The NHS is dedicated to the proposition that nobody should ever have to pay a medical bill. In the NHS, there is no insurance premium to pay, no co-payment, no fee at all, whether you drop by the GP's office with a cold or receive a quadruple bypass from the nation's top cardiac surgeon.  The doctor's bill is paid by the government, and the patient never thinks about it.

The Brits do pay for medical care, of course.  They pay through a network of taxes that would make Americans cringe; the sales tax in the UK is 17.5% on anything you buy, while income and social security taxes are higher than America's in every income bracket.  The Brits pay by foregoing treatments and medications that the NHS won't provide.

Now you might see where this is leading.  The NHS controls its budget by controlling the range of medications, tests, and procedures it will pay for.  Should a 49-year old patient get a hip replacement?    Combining insurance and delivery of care in the NHS fostered a rational approach through the formal evaluation of therapeutic benefits against treatment costs. Yet because the NHS budget covers everybody, the money saved on one patient can be used to treat another.

Moreover, as the NHS secured annual increases averaging 6.3% during the 2000s, it grew to 20% of the government budget by 2009.  As British government debt rose from below 40% of GDP in 2007 to 72% in 2010, worries emerged that above-inflation spending had saddled the country with unsustainable commitments.

Now when you read the The Telegraph's article, it should make more sense why there is rationing - and to expect more. 

Post URL and First Blog

Please comment below with your URL.  Post your first blog when you are ready to do so.

Surprise Medical Bills (an update)

Juwen Zhang reported on this for the NYTimes case, but thought I would update this article with recent events.  First, a quick definition:

“Surprise medical bill” is a term commonly used to describe charges arising when an insured individual inadvertently receives care from an out-of-network provider. This situation could arise in an emergency when the patient has no ability to select the emergency room, treating physicians, or ambulance providers. Surprise medical bills might also arise when a patient receives planned care from an in-network provider (often, a hospital or ambulatory care facility), but other treating providers brought in to participate in the patient’s care are not in the same network.  These can include anesthesiologists, radiologists, pathologists, surgical assistants, and others.  In some cases, entire departments within an in-network facility may be operated by subcontractors who don’t participate in the same network.

In this March 17, 2016 article from the Kaiser Family Foundation, they conducted a survey among insured, non-elderly adults struggling with medical bill problems and found that charges from out-of-network providers were a contributing factor about one-third of the time.  Further, nearly 7 in 10 of individuals with unaffordable out-of-network medical bills did not know the health care provider was not in their plan’s network at the time they received care [my emphasis].

Data on the prevalence of surprise medical bills and costs to consumers are limited.  The Affordable Care Act (ACA) requires health plans in and out of the Marketplace to report data on out-of-network costs to enrollees, though this provision has not yet been implemented (see footnote in the article).  However, research studies offer some clues as to the prevalence and cost to patients due to surprise medical bills.  The list is worth reading.  New York has been investigating this since 2011. 

What is new are the Federal and State protections against surprise medical bills

Policymakers at the federal and state level have expressed concern that surprise medical bills can pose significant financial burdens and are beyond the control of patients to prevent since, by definition, they cannot choose the treating provider.  Various policy proposals have been advanced, and some implemented, to address the problem.  These include hold harmless provisions that protect consumers from the added cost of surprise medical bills, including limits or prohibitions on balance billing.  Others include disclosure requirements that require health plans and/or providers to notify patients in advance that surprise balance billing may occur, potentially giving them an opportunity to choose other providers.  Read the article for more on the federal response and other links.

Collaboration with a robotic scrub nurse

Some of you are interested in AI or robots in healthcare.  I was going to share this with certain students, but then thought you might all might find it interesting.  I found this in the ACM (Association of Computing Machinery - an excellent resource on all things technology) UA library database.   The article* is how surgeons use hand gestures and/or voice commands to the robot without interrupting the natural flow of a procedure.

* requires that you are on UAWiFi to access or look up.
by Mithun George Jacob, Yu-Ting Li, George A. Akingba, Juan P. Wachs (2013).
Communications of the ACM, Vol. 56 No. 5, Pages 68-75

The Soaring Cost of a Simple Breath

In the article, “The Soaring Cost of a Simple Breath”, readers are presented with the high-costs of asthma inhalers. Asthma is the most common chronic disease that affects around 40 million Americans and it is common knowledge that asthma is very controllable with drugs. In the United States, obtaining these drugs at fair costs is nearly impossible and requires the best insurance or tons of disposable income. Author Elizabeth Rosenthal meets with an upper-middle class family to understand the financial impact of these easy-to-make drugs. Pulmicort is a steroid inhaler that retails for over $175 dollars in the United States, it retails for $20 dollars in the Britain and is also dispensed to asthma patients free of charge. Even simple inhalers such as nasal sprays are $250 in the U.S. while the cost for Europeans is around $7.

Even with the insane costs of on-brand medicines, the United States is also dealing with rising costs of generic medicines. Generic Augmentin, a very common antibiotic, retails up to $120 for a 10-day prescription and the generic version of Adderall costs up to $150 per month. It’s also important to note that generics don't’ even exist for some medical conditions, including asthma. Generics increased in price at an average of 5.3% with brand-name medicines skyrocketing over 25% in 2012.

Every developed nation in the world has either direct or indirect government influence on the price of national wholesale price for each drug, while the United States leaves all of the prices up to competition in the free market. “Competition in the free market” is complete coded language in today’s health care arena. An incredible amount of lifesaving drugs is made by only one manufacturer and businesses can only slightly blunt market forces. The patent system in the United States allows for pharmaceutical companies to reign over the prices of their drugs. The repatening of older drugs (birth control, insulin and colchicine) is a way to charge exorbitant prices for drugs that once cost pennies. Besides repatening, pharmaceutical companies also gouge patients by choosing to sell drugs via prescription rather than over the counter, so that the insurers are forced to cover a price tag that would be considered unacceptable for customers to cover on their own. This article sheds light on the complete necessity of government intervention in the healthcare “industry.” It won’t be an easy battle considering that over $250 million was spent on pharmaceutical and healthcare lobbying in 2012.

A Funeral May Cost You Thousands Less Just By Crossing The Street

I read this article and thought about the costs that occur by one large funeral conglomerate over the prices by others.

In a months-long investigation into pricing and marketing in the funeral business, also known as the death care industry, NPR spoke with funeral directors, consumers and regulators. They collected price information from around the country and visited providers. They found a confusing, unhelpful system that seems designed to be impenetrable by average consumers, who must make costly decisions at a time of grief and financial stress [my emphasis].

Funeral homes often aren't forthcoming about how much things cost, or embed the information in elaborate package deals that can drive up the price of saying goodbye to loved ones.

 Read more....  and comment below.

In Need of a New Hip, but Priced Out of the U.S.

Link: http://www.nytimes.com/2013/08/04/health/for-medical-tourists-simple-math.html

A man by the name of Michael Shopenn was in need of getting a hip replacement. His artificial hip was made by a company based out of Europe that had to be installed at their manufacturing center. Michael had to fly all the way to Europe to get his hip replaced. The reason for his need of hip replacement was because he had arthritis and could barely stand long enough to make coffee. He had health insurance, but his health care did not cover his joint replacement because it was caused by a pre-existing condition. He became desperate to find a solution to his problem that was affordable and convenient for him. The surgery would be over $65,000 which was about a third of Michaels savings at the time so he had to look elsewhere. He compared prices from all over the world and found that they were mostly the same price but cheaper anywhere outside the United States.

The reason for implant list prices being so high as well as them rising by more than 5 percent a year is due to a cartel. All hip and knee implants are made by only 5 companies that simply tweak old models and patent the changes as new products and continue to bump up the price. This is a commonality throughout the healthcare world, this existence of cartels or monopolies that are able to charge ridiculously high prices simply because they can. They do not have enough competition to make them charge anything lower nor is there a reason to in their eyes.

In my opinion this is why medical costs are so high is because manufacturers are more focused on how much money they can make by charging the highest possible price people are willing to pay. They manufacture implants to help people live a better life but are not making it affordable. They should be wanting to help as many people as they can, not focus on the money. Its all about helping others and making sure they are happy and healthy. That is my biggest take away from this article.

As Hospital Prices Soar, a Stitch Tops $500

In the article, As Hospital Prices Soar, a Stitch Tops $500, author Elizabeth Rosenthal explains the the high costs involved with trips to the Emergency Room, and the reasoning behind why hospitals charge that much. Rosenthal sums up why hospitals are able to charge exorbitant prices for things such as gauze, IV bags, and pills quite simply: because they can. Rosenthal mentions "Economists note that hospitals can bill for emergency room care with relative impunity, since injured patients generally rush to the nearest treatment facility", an idea that we have discussed in class about how hospitals are able to use peoples fear to set prices well above market value.

Another big reasoning behind costs going up is attributed to mergers and consolidation of hospitals. Rosenthal points to Sutter in northern California, as the author writes "Sutter operates the only hospital in some California cities." providing them with the market power to raise prices without worrying about fear of decreased demand. She also notes how these major healthcare providers like Sutter or Banner are able to use their size and market power to dictate terms and pricing in contracts, as well as including gag orders that prevent patients from knowing what rate their insurers negotiated on their behalf.

One of the more interesting parts of the article was the interactive map of the cost of the medical care to treat a cut finger, highlighting the differences by regions. Next to the map was a bar graph of each of the regions and the amount that was paid to both the hospitals and doctors. Although there was a slight difference across the country in the amount paid to doctors (the biggest gap being $200 between Texas and New England), there is a huge discrepancy in the amount paid to hospitals with west coast hospitals collecting almost twice as much compared to those on the east coast. Again as we have discussed in class, is there any justification for massive difference in prices? The article points to the arbitrarily set prices on the "chargemaster".

There are many questions to think about going forward, such as what are we able to do about this? What alternatives do we, the consumer, have when it comes to receiving treatment with out being forced to pay the high prices?

 

Patients' Costs Skyrocket; Specialists' Incomes Soar

We've been introduced to the rise of health care costs in our past lectures, and in the movie Escape Fire. In a New York Times article, Patients Costs Skyrocket;Specialists' Incomes Soar, the author focuses on the astronomical increase of the cost of specialists in comparison to their primary care physician counterparts. There are certain specialists that are the top earners of any other physician in the field, these include orthopedics, cardiology, anesthesiology, radiology, dermatology, plastic surgery, urology, gastroenterology, and ophthalmology. These physicians earn more than $350,000 annually, according to American Medical Group Association. In some cases, certain specialists incomes have risen more than 10% since 2011 (Medscape). For dermatologists, gastroenterologists and oncologists, their incomes have risen 50% or more between 1995 and 2012. These prices are protected by the more than 750 lobbyists in Washington, as they push back on any efforts to limit the doctors' incomes. Primary care doctors on the other hand have only about 5 representatives who are often struggling to make ends meet without the extra cash from side surgeries/x-rays/etc. The incomes for primary care doctors only rose 10% in that same 17 year period.

The article talks of Ms. Little from Arkansas who felt she was bullied into seeing 3 different specialists for the removal of a small white mole on her cheek using the Mohs surgery (an effective way of removing carcinogenic moles but not needed more several cases). She started in with the dermatologist who removed the mole. Then, he sent her across the street to see the plastic surgeon who would close the wound with a "couple of stitches". Yet when she arrived, she was greeting by nurses who prepared her to see an anesthesiologist to sedate her as well. According to the article, "the vast majority of Mohs procedure are sewed up by the dermatologist or just bandages and left to heal." Her bills totaled more than $25,000.

It's alarming to me that many patients out there don't feel as if they can get in a say in what kind of treatments they receive. We are taught to trust doctors because of their extensive training in the medical field, and we think to trust specialists even more for their dedication to a specific trade. However, reading Ms. Little's story makes me think otherwise. My mom actually had Mohs surgery a few years ago for a spot on her nose, and she informed me that she only saw the dermatologist who diagnosed the spot and then was sent to just one Mohs specialist who did everything else. No plastic surgeon, and no anesthesiologist. This just shows the varying types of treatment people face all over the country. Now I don't know how much my mom paid before insurance because she also worked for the hospital at the time so her rates I believe were a bit discounted. Unfortunately, as the article mentioned, incomes are only going to increase over the years. So I wonder what we really can do to stop these inflated prices for certain treatments?

Preventive Vaccines - Costing more than just dollars!

“The Price of Prevention: Vaccine Costs Are Soaring” presents an interesting coverage on the pain of needle prick felt by the providers, policy makers, parents and of course neonatal alike. For few it is a pinprick pain of losing money on every single shot they give - providers; for few it is a pinprick pain brought by the frustration of their kids are being left deprived of life-saving vaccination - parents, and lastly for few other it is a pinprick pain felt by policy makers once their well-thought plans don’t produce effective results - the vaccine advisory committee.

In the USA, the cost of essential vaccination has increased steeply in last few years. Many clinicians have stopped providing the vaccination shots as they incur a loss for each shot they provide. In the article, a situation is illustrated for San Antonio, Texas where providers are facing an ethical dilemma associated with this peculiar issue. Providers know that it is absolutely imperative to provide the life-saving vaccination to the infants but it is a question of how much loss they can incur. Approximately 40% providers have stopped vaccinations as they are not profitable anymore which has certainly worsened the situations for consumers.

Many states recommend (if not mandate) vaccination like Prevnar before children can enter daycare or preschool. This recommendation has created a strong demand for vaccination in the market; and have allowed pharmaceutical companies to increase the costs. In a few cases, pharmaceutical companies patents a drug and hence monopolize the market. A specific example quoted in the article is of Prevnar 13 - a vaccination sold by Pfizer accounting to their $4 billion sales every year. Prevnar has no real competitor in US markets and courtesy to this fact, the price of Prevnar 13 has gone up 6% each year since its inception in 2010.

Even policy makers have failed to steady the ship. Ironically, their policies are promoting the price increase of vaccinations. For example, CDC(Centers for Disease Control) is contemplating on a recommendation of Prevnar 13 to people over 65. If this recommendation comes into the force, it will further monopolize the drug maker and increase the revenues by $1 billion.Moreover, there is no policy by CDC to sustain the profitability of solo practices who have smaller purchasing power.

I would like to conclude by pointing out that it’s unfortunate that high cost is a deterrent to the life-saving vaccination in a developed nation like the USA. Below mention policy changes would probably have a positive impact on this grim situation:

1.   Vaccination patenting should be discouraged. If this is not possible(in order to give a fair return on investments made on R&D by companies), the length of the patent should be reduced so that monopoly could be countered after certain years.
2.   The purchasing power of solo and small practices should be protected and they should be encouraged to participate in the vaccination program.
3.   Mandatory vaccination should be provided free by the government (much like what happens in developing nation like India under Universal Immunization Plan).

Trump’s new vaccination safety committee may be a ray of hope? Maybe!