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eridani's Journal
eridani's Journal
December 20, 2015

Representative Jan Schakowsky Introduces Medicare Fair Drug Pricing Act

This month, the Honorable Jan Schakowsky introduced the Medicare Fair Drug Pricing Act (H.R. 4207), which would give the Secretary of Health and Human Services (HHS) tools to bring down the price of prescription drugs in the Medicare program.

In a statement, Representative Schakowsky said, "Over the past few years, many breakthrough drugs have come to market, providing hope to many Americans living with diseases that currently have little or no treatment or cure. Yet, little has been done to ensure that patients can actually afford those life-saving treatments. That is why, I introduced the Medicare Fair Drug Pricing Act, which would ensure that Medicare beneficiaries have access to breakthrough, life-saving drugs. Under my legislation the Secretary of Health and Human Services would negotiate directly with drug manufacturers of sole source drugs and biologics covered under Medicare Part D to ensure that these medicines are affordable and accessible for beneficiaries."

Endorsed by the Medicare Rights Center, the legislation would require the HHS Secretary to negotiate prices for prescription drugs covered by Medicare Part D that are the only prescription drug of their kind and are not produced by more than two manufacturers. The law would give the Secretary and the drug manufacturer 90 days to negotiate the prescription drug price, and the set price would remain in effect until more than two manufacturers enter the market with competing medicines, as long as one of the prescription drugs is a generic.

Read Representative Schakowsky's announcement.

December 17, 2015

Act Blue and the Democratic Party small donor advantage

Small Donors Are Clicking More With Democrats Than Republicans


In an office here with the trappings of a Silicon Valley tech firm, a band of politically engaged twentysomethings has built a formidable Democratic fund-raising machine that is fueling the insurgent presidential campaign of Senator Bernie Sanders against Hillary Rodham Clinton and leaving even Republican rivals envious.

The success of the Boston-area outfit, a nonprofit called ActBlue, can be seen most starkly in the latest fund-raising report filed by Mr. Sanders, its most prominent political client at the moment. A whopping 74 percent of the $26 million that Mr. Sanders raised came through ActBlue, an online platform that lets people donate a few dollars at a time to Democrats — and Democrats only — with just a few clicks. Eighty-eight percent of contributions to Mr. Sanders came from donations of $200 or less.

“They’ve obviously found a successful formula that works with their base,” Benjamin Ginsberg, a prominent Republican campaign lawyer in Washington, said. “We don’t have something like ActBlue. We wish we did.”

Inside the PAC Republicans Fear Most


Republicans generally scoff at Tom Steyer and other big-money Democrats’ efforts to swing elec­tions against them. When it comes, however, to one group—a group that marshals millions of small-dollar donors against their candidates—they don’t hide their concern.

“The power that Act­Blue has is very real, and that is something that is quickly coming to the realization of not just us but members of Congress,” Tom Newhouse, the National Republican Congressional Committee’s digital director, said at a recent panel. “When we talk to large gatherings of some of our most hotly contested seat, these members get up and say, ‘My opponent raised $800,000 from Act­Blue. What are we doing about this?”

Three-quar­ters of Demo­crat­ic Sen­ate cam­paigns, more than half of Demo­crat­ic House cam­paigns, and both caucuses’ of­fi­cial cam­paign com­mit­tees use Act­Blue, a non­profit vendor, to pro­cess their on­line dona­tions. And the data Act­Blue gen­er­ates in the pro­cess has helped form an ever-grow­ing, di­git­al fun­drais­ing feed­back loop push­ing Demo­crats’ on­line money-gath­er­ing to new heights—and spur­ring Re­pub­lic­an ef­forts to catch up or be swamped.

ActBlue’s One-Click Donations Are Transforming the 2016 Race


There’s a long list of tech giants that are helping drive the presidential race this election season: Facebook, Twitter, Reddit, Snapchat, Instagram, Periscope, even Yik Yak.

Amazon, on the other hand, is not at the top of the list, but that doesn’t mean it hasn’t made difference, at least indirectly. By taking a page from the e-commerce giant’s playbook, a non-profit called ActBlue is driving small donor dollars to Democrats, especially Hillary Clinton and Bernie Sanders, with a single click.

The tool, called ActBlue Express, has been around since 2008, but it’s having an outsized impact this election season, now accounting for nearly 70 percent of the millions of donations ActBlue has processed this election season alone.

“Small dollar donors are a strategic advantage for us on the left,” says Erin Hill, ActBlue’s executive director. “Being able to provide tools that we all work on and share together helps increase participation, which we think is better for the Democratic party, makes for stronger campaigns, makes for more lucrative campaigns, but also makes for better democracy.”

It’s true that small donors are, quite literally, giving billionaire-backed Super PACs a run for their money this election season, boosting candidates like Ben Carson on the right and Sanders on the left. Since it was founded in 2004, ActBlue has been working to bring more of these donors into the Democratic fold. In that time, the non-profit, which is backed by donations and gives its software tools to campaigns for free, has processed more than $850 million in donations for 11,000 Democratic candidates and committees.

But ActBlue’s impact has ballooned this year, thanks, in large part, to ActBlue Express. It’s not that it’s the only political donation tool on the market. There are plenty. But more often than not, they’re either dedicated to a single candidate or cost campaigns a lot of money. The key to ActBlue Express’s popularity—and its success—is the fact that aside from the fees credit cards companies charge, it’s free for campaigns and has been used for everything from the presidential elections to local school board races.
December 9, 2015

Insurance companies don't like gold and platinum plans


What we know is if [a patient is] asthmatic and more actively managed, the health outcomes and therefore the affordability can be quite different. This is a case where if you have a chronic illness, you need to be in a management program.”

Question: What is Cigna’s concern with gold products?

“Adverse selection. [It’s not that policyholders] are necessarily older or sicker. The whole way the benefits are configured and the way marketplace is working — the performance of those plans — is much less reasonable than all the other plans. Either there will be more flexibility to configure them in a way to make them sustainable or there won’t be gold plans.”

Comment by Don McCanne of PNHP: Skimming through the comments of Cigna CEO David Cordani, it comes as no surprise that, with the Anthem/Cigna merger (approved by the shareholders last week), plans are being laid to enhance the business advantages of the corporation to the detriment of the plan participants.

Squeezing enrollment (favoring the healthy), reconfiguring provider networks (impairing access for the sick), reducing spending on Medi/Medi dual-eligibles, selling more patient management programs, and using benefit design to fragment risk pools are the types of policies that we have come to expect from the private insurers. Works well for them.

In this interview, there are a couple of points that demonstrate the problem described in yesterday’s Quote of the Day on information frictions and how they impact adverse selection (concentrating high-risk individuals in a single plan). The more information the purchaser of an insurance plan has, the much greater is the possibility that it will lead to adverse selection.

Cordani says that the market must have a focus on transparency for consumers. With greater transparency, patients with high health care needs will select plans that have the greatest actuarial value - plans that pay the highest percentage of the health care costs. In the exchanges, those are the gold plans. They pay 80 percent of the costs, as opposed to 60 or 70 percent for the bronze and silver plans respectively.

As we learned yesterday, it is essential to have effective risk-adjustment transfers to correct for adverse selection that results from patients understanding the benefits of the plans that they purchase. Well informed, high-risk patients will be concentrated in the gold plans, but since we do not have tools that adjust risk adequately, the insurers will be exposed to the greater risk of adverse selection impacting the gold plans.

So what is Cordani’s solution? Either provide “more flexibility to configure them in a way to make them sustainable,” or eliminate them. Configuring them to make them sustainable is, of course, code language for screwing up the benefits so they it becomes more difficult for patients to access the care that they need. If they can’t screw them up enough, then just get rid of them.

Yesterday’s message on information frictions was a challenging read, but it does show that academics with a heart, such as Benjamin Handel and his colleagues, do have something to offer the policy community. Those who might be interested but passed over yesterday’s message because of its complexity may want to take another stab at reading it. It’s an important concept to understand. It is posted at:

December 5, 2015

Work ‘Till We Die (Social Security video)


The loudest calls for cutting Social Security come from wealthy CEOs who will never have to worry about their own retirement security.

The roughly 200 CEOs who collectively make up Business Roundtable — a business lobbying group that often pushes conservative views, including Social Security cuts — have average retirement savings of $14.5 million, according to the Institute for Policy Studies and the Center for Effective Government.

That’s about 1,200 times more than what the median American worker has saved for retirement a decade before the end of his or her career, according to the study. (That paltry amount is just $12,000, by the way, according to a separate report.)

But by simply requiring upper-income taxpayers to pay the same tax rate as middle-class families, Social Security’s benefits could be expanded — AND its funding would remain in balance for decades beyond the longest projections.
December 4, 2015

Wyden-Grassley Sovaldi Investigation Finds Revenue-Driven Pricing Strategy Behind $84,000 Hepatitis

-- Drug


Senate Finance Committee Ranking Member Ron Wyden, D-Ore., and senior committee member Chuck Grassley, R-Iowa, today released the results of an 18-month investigation into the pricing and marketing of Gilead Sciences’ Hepatitis C drug Sovaldi and its second-wave successor, Harvoni. Drawing from 20,000 pages of internal company documents, dozens of interviews with health care experts, and a trove of data from Medicaid programs in 50 states and the District of Columbia, the investigation found that the company pursued a marketing strategy and final wholesale price of Sovaldi – $1,000 per pill, or $84,000 for a single course of treatment – that it believed would maximize revenue. Building on that price, Harvoni was later introduced at $94,500. Fostering broad, affordable access was not a key consideration in the process of setting the wholesale prices.

“Gilead pursued a calculated scheme for pricing and marketing its Hepatitis C drug based on one primary goal, maximizing revenue, regardless of the human consequences. There was no concrete evidence in emails, meeting minutes or presentations that basic financial matters such as R&D costs or the multi-billion dollar acquisition of Pharmasset, the drug’s first developer, factored into how Gilead set the price. Gilead knew these prices would put treatment out of the reach of millions and cause extraordinary problems for Medicare and Medicaid, but still the company went ahead. If Gilead’s approach to pricing is the future of how blockbuster drugs are launched, it will cost billions and billions of dollars to treat just a fraction of patients,” Senator Wyden said.


Comment by Don McCanne of PNHP
: Gilead’s heartless strategy in deciding to price their hepatitis C drugs well above what any reasonable market would tolerate demonstrates yet another detrimental consequence of our health care financing model, perpetuated and expanded by the Affordable Care Act. Gilead assumed that they could get away with it since they figured that most of the costs would be covered by the drug plans in the various public and private insurance programs. Well, they pushed too hard.

The extensive investigation by the staffs of the Senator Ron Wyden and Senator Charles Grassley confirmed that the pricing of Sovaldi and Harvoni was based on pure greed, ignoring completely the human consequences.

The other report released today by the Kaiser Family Foundation demonstrates the consequences that these egregious pricing behaviors have on Medicare beneficiaries enrolled in the Part D drug program - a program supposedly designed to improve value by leveraging market forces. Even when the preferred drug - Harvoni - is included in the Part D formulary, the median out-of-pocket cost for the Medicare beneficiary is $7,153! There goes the food and the rent and a whole lot more.

The Kaiser Foundation report is particularly helpful in demonstrating how deficient the Medicare Part D program is. They suggest shopping, but who knows what outrageously priced drugs will be prescribed next year? How can you shop drug formularies for drugs you have not yet been prescribed?

Single payer advocates understand that none of this would be tolerated in a well designed national health program. You would simply receive the drugs you need, when you needed them. Gilead would be compensated fairly for their products. It’s just too bad that their current executives will not end up in jail, where they belong.
December 2, 2015

Dismayed by drug prices, public supports Democrats’ ideas


Most Americans believe that the prices of brand-name prescription drugs have become unreasonable, and their dismay is leading to wide support for government action to keep costs down, including letting Medicare negotiate prices with drug companies, according to a new poll by STAT and the Harvard T.H. Chan School of Public Health.

About 7 out of 10 Americans, including two-thirds of Republicans, said Medicare, the federal health insurance program for older and disabled Americans, should be able to negotiate lower prices for all prescription drugs.

The poll found that the pharmaceutical industry’s reputation has suffered substantial damage. Barely half of all Americans now say drug companies are doing a good job for their customers, compared with the nearly 8 out of 10 who expressed that kind of confidence in a 1997 Harris Poll.

And they soundly rejected the industry’s argument that government action against rising drug costs would slow the development of new drugs. Sixty-four percent said they did not believe that would happen if Medicare negotiated lower prices, while 26 percent said they believed it could.

Poll results:

Comment by Don McCanne of PNHP: There is an important lesson here for single payer advocates. The public now wants the government to do something about the large increases in drug prices. It is not because of personal experience with these high prices but rather it is due to the OUTRAGE over the injustice of patients in need unnecessarily facing egregiously high drug pricing.

Much worse than the drug pricing crisis is the financial hardship, outrageous physical suffering and even loss of life that is due to our highly dysfunctional method of financing health care, even though we are spending about twice as much per capita as the average of other wealthy nations

Our nation needs to understand that merely switching to a single payer system would correct the injustices of the financing system that the Affordable Care Act failed to rectify. With a well designed single payer system we would not only get the pricing of pharmaceuticals right, we would price correctly the rest of the system as well while improving access and free choice of health care - all without spending any more than we do already, yet spending it more equitably so as to eliminate for everyone the prospect of financial hardship due to health care.

If it takes outrage to create a demand for government action, then let’s work on our framing so that people understand that they should be outraged by the profound but remediable injustices that characterize our health care financing system. Start with intensified efforts to educate the media, since it has been the media that aroused the nation on outrageous drug pricing.

December 1, 2015

Instability in Marketplaces Draws Concern on Both Sides of Health Law


In applying for rate increases in 2016, many insurers filed data showing that they had lost money on their exchange business in 2014. To stop the losses and control costs, many have increased premiums and deductibles and other out-of-pocket costs, while reducing the number of doctors and hospitals available to consumers through their provider networks.

Conservatives want to let consumers buy policies with fewer mandated benefits, on the theory that such coverage would be more affordable. Some lawmakers say that insurers should be allowed to sell cheaper “copper” plans alongside the bronze, silver, gold and platinum plans available in the marketplaces.

Harvey J. Rosenfield, the founder of Consumer Watchdog, an advocacy group based in California, suggested that “maybe the government should step in and run the system as Medicare for all.”

“People are sticking their heads in the sand if they say there are not serious problems with the Affordable Care Act,” Mr. Rosenfield said, adding: “People who were previously uninsured are indisputably better off, but many people in the middle class are struggling. They are entitled to buy health insurance, but that is an empty promise if the number of doctors and hospitals in your network has shrunk and deductibles have soared.

Comment by Don McCanne of PNHP: Instability. Shrinking networks. Soaring deductibles. These are characteristics of plans offered in the Obamacare insurance exchanges - features that are now contaminating employer-sponsored health benefit programs. What can be done?

We can stabilize choice in physicians and hospitals by eliminating the networks, providing patients with free choice of their health care professionals and institutions. We can eliminate instability in access caused by financial barriers to care by eliminating deductibles, copays and coinsurance. We can stabilize insurance coverage by mandating it while making premiums truly affordable for everyone.

The problem is that under the current model of financing care, the insurers cannot offer plans with affordable premiums without reducing patient access to care - precisely what networks and deductibles are designed to do.

As it turns out, even with these perverse measures most insurers are still losing money. Mounting losses only perpetuate and intensify instability since the insurers must make additional changes to ensure the success of their business model. Quite clearly, additional changes based on business decisions will benefit only the insurers while serving to the further detriment of patients.

Suppose we did reverse course and eliminated networks, excessive cost sharing, tiering of benefits, and other detrimental features of today’s health plans. The variable that would have to give is affordability of the insurance premiums. They would skyrocket. If we really want people to have affordable access to decent health care by correcting these problems, that means that the government subsidies would have to be greatly expanded - both in the amount and in the size of the population that would be eligible. Basically, the government would be covering much of our care, except for the wealthy.

If we were to spend that much in taxes to support such a system, why would we perpetuate this very wasteful and dysfunctional model that we have? If we had any sense, we would demand an efficient, effective system that would ensure access for everyone - a single payer national health program (an improved Medicare for all). Until we do, learn to enjoy the torment of increasing instability in our health care.
November 20, 2015

UnitedHealth May Quit Obamacare in Blow to Health Law


The biggest U.S. health insurer is considering pulling out of Obamacare as it loses hundreds of millions of dollars on the program, casting a pall over President Barack Obama’s signature domestic policy achievement.

UnitedHealth Group Inc. has scaled back marketing efforts for plans sold to individuals this year and may quit the business entirely in 2017.

While millions of Americans have gained coverage under Obamacare since new government-run marketplaces for the plans opened in late 2013, in UnitedHealth’s case they haven’t been the most profitable. Customers the company has added have tended to use more medical care. UnitedHealth also said today that some people are signing up for coverage, getting care and then dropping their policies.

“We cannot sustain these losses,” Chief Executive Officer Stephen Hemsley told analysts on a conference call. “We can’t really subsidize a marketplace that doesn’t appear at the moment to be sustaining itself.”

UnitedHealth said it expects as much as $500 million in losses on the Obamacare plans in 2016.

Comment by Don McCanne of PNHP: The Affordable Care Act was designed by the nation’s largest insurers to serve the interests of the nation’s largest insurers. It was almost as if the patients were not much more than a necessary nuisance, required only because an insurance market requires patients to purchase their plans. How is it working out for the insurers?

The largest insurer in the nation - UnitedHealth - has scaled back their marketing of ACA exchange plans and is considering totally exiting the exchanges by the end of next year. Two of the other largest insurers - Anthem and Aetna - have yet to profit from the exchanges and are waiting to see if the exchange business will improve before they decide about the future.

It is no secret what happened. The insurers had to agree to crucial reforms in the insurance market. They had to accept higher cost individuals with preexisting disorders; they had to cover ten categories of health care benefits; they had to limit excess administrative costs and profits by agreeing to minimum medical loss ratios, and they had to submit higher premium increases to insurance regulators for greater public scrutiny.

In other words, they had to agree to market basic insurance products to anyone who was eligible for them. With these requirements, premiums would be unaffordable for all but the wealthy. Thus ACA was crafted to keep premiums down by making lower actuarial value plans the standard - requiring greater cost sharing by patients, though with government subsidies for lower-income individuals. ACA also was crafted to provide government subsidies for the premiums to assist lower-income individuals with the purchase of these plans. That still was not enough so they used the leverage of narrow provider networks to contract for cheaper medical services, and they increased the deductibles, shifting more of their costs to patients.

Guess what. It isn’t working - for the insurers or the patients. Congress dumped on us an administratively complex system that has made it almost impossible for the insurers to offer a product with affordable premiums that still meets the basic plan elements required by the legislation. For the patients, the premiums and deductibles are not affordable for the average family, and they have had to give up their health care choices because of the narrow networks selected by the insurers.

Congress and the Obama administration did this one for the insurers. Yet the insurers are beginning to back out now. That’s just fine because it will allow us to replace them with a financing plan that is designed for patients instead. A well designed single payer national health program would make health care affordable for everyone while returning to them their choices in health care delivery.

November 17, 2015

Many Say High Deductibles Make Their Health Law Insurance All but Useless


But for many consumers, the sticker shock is coming not on the front end, when they purchase the plans, but on the back end when they get sick: sky-high deductibles that are leaving some newly insured feeling nearly as vulnerable as they were before they had coverage.

Sara Rosenbaum, a professor of health law and policy at George Washington University who supports the health law, said the rising deductibles were part of a trend that she described as the “degradation of health insurance.”

Insurers, she said, “designed plans with a hefty use of deductibles and cost-sharing in order to hold down premiums” for low- and moderate-income consumers shopping in the public marketplaces.

Comment by Don McCanne of PNHP: The deductibles are out of control. The anecdotes in the full article (link above) demonstrate that many people find that their insurance is “all but useless” simply because they cannot afford to pay the deductibles. Anecdotes do not constitute a scientifically valid study, but they certainly do tell us what is happening to individuals out in the real world.

Insurers needed to keep premiums affordable in order to maintain a viable market of private plans. They do that by shifting costs to patients through ever higher deductibles. This was inevitable through the reform model selected for the misnamed Patent Protection and Affordable Care Act. Because of the large deductibles, actual health care is not affordable for individuals with modest incomes and thus patients do not have the protection that they need.

The three trillion dollars that we are already spending on health care is enough to provide all essential health care services for everyone. With a properly designed financing system there is no need to erect financial barriers to care since cost containment can be achieved through patient-friendly policies such as those of a single payer national health program.

Without proper reform, “degradation of health insurance” will progress. People will face greater financial hardship because of medical bills. People will suffer more because of forgone health care. People will die.

This isn’t right. We need an improved Medicare that includes everyone.

November 14, 2015

Medicaid coverage improves access to health care and chronic disease control:

American Journal of Public Health study


Low-income Americans with Medicaid insurance have more awareness and better treatment of chronic diseases, such as high blood pressure, than their uninsured counterparts, a group of Harvard researchers said today. People with Medicaid are also five times more likely to see a doctor than those with no health insurance.

These are among the chief findings of a new study by a team of researchers led by Dr. Andrea Christopher, a fellow at Harvard Medical School, published today in the American Journal of Public Health. The study is based on data gathered from 4,460 poor Americans in national surveys conducted by the Centers for Disease Control and Prevention.


From the Discussion

Our findings suggest that, nationally, Medicaid was associated with improved access to outpatient medical care, as well as awareness and control of important chronic conditions. Medicaid recipients visited health care providers much more frequently than comparable uninsured individuals, and were more likely to be aware of their hypertension and overweight. In addition, Medicaid recipients were more likely to have their blood pressure controlled, a clinical goal known to reduce all-cause mortality by as much as 17%. However, we found no differences in the diagnosis or control of diabetes, and only nonsignificant differences among those with hypercholesterolemia. We theorize that the lack of findings for diabetes may be because control requires more significant diet and lifestyle changes compared with other chronic conditions, and these changes may not be easily remedied through access to medical care.

Comment by Don McCanne of PNHP: Opponents of the Affordable Care Act have been using the Oregon Health Insurance Experiment (OHIE) to supposedly show that Medicaid does not improve health outcomes even though the study was not powered to demonstrate such. Thus this new study is important because it does show that Medicaid improves access, improves awareness of important chronic conditions, and improves control of hypertension. The OHIE trial did show that “Medicaid coverage increased health care use, improved patients’ financial security and self-reported health, lowered depression rates, and raised diabetes diagnosis rates.”

Clearly Medicaid is of benefit. However, as a chronically underfunded welfare program, Medicaid does have significant deficiencies. Last week, a UC Davis study reported that cancer care is worse for Medicaid patients than for other insured patients. The question is, what should we do about it?

Some conservatives would convert Medicaid into a block grant to the states, limiting federal contributions, likely compounding the problem of underfunding. Other conservatives would eliminate Medicaid and place everyone in high-deductible private plans, perhaps with some federal contributions to health savings accounts for low-income individuals. Narrow networks and cost sharing would surely limit access for this population.

A much better solution would be to replace our fragmented health care financing system with a single payer national health program, eliminating cost sharing and network barriers. Since the program would cover all of us, chronic underfunding for a sector of us would not be tolerated.

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About eridani

Major policy wonk interests: health care, Social Security/Medicare/Medicaid, election integrity
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