Part 2 discusses why we must have the government issue payments to hospitals, clinics, etc. and also set the budgets for hospitals and this is how they are paid rather than billing multiple insurers and also patients. There is also only one payer. The later part is what I have been pounding on repeatedly. Forget prices and work with cost data. It is then we have a much clearer picture of the costs of healthcare and we can begin to control prices.

Rep Jayapal and Sen Sanders Have Introduced Medicare For All Bills: One Is a Lot Better Than the Other, Healthcare for All Minnesota, Kip Sullivan, May 8, 2019

What is an ACO and why is it a defect?

Congress included in the Affordable Care Act of 2010 (aka Obamacare) a section (Section 3022) requiring CMS to establish an ACO program within the traditional FFS Medicare program. It is not clear why Congress chose to use ACOs. Congress was warned in 2008 by the Congressional Budget Office (CBO) that ACOs would not save money for Medicare. The simplest way to describe ACOs is to say they are HMOs in training. Like HMOs, they are corporations that own or contract with chains of hospitals and clinics; they have the equivalent of enrollees; they attempt to keep their “enrollees” from seeking care outside their networks; they bear insurance risk (that is, they are paid on a per-enrollee basis and in exchange are obligated to provide medically necessary services to their enrollees); and because they are risk-bearing organizations, they generate overhead costs similar to those created by traditional insurance companies.

More on ACOs and the absence of Single Payer budgets past the leap

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I have exchanged emails with Kip Sullivan several times and believe he has the clearest explanation on Single Payer. I have found him to be a good source for the two Single Payer bills in Congress today. Unfortunately, it is a long explanation and it can not be summed up on one page or in the amount of time you would spend watching the news at 10 PM. To compensate for the length of the presentation, I have broken it down into two parts. I hope you take some time and read it.

“ Rep Jayapal and Sen Sanders Have Introduced Medicare For All Bills: One Is a Lot Better Than the Other,” Healthcare for All Minnesota, Kip Sullivan, May 8, 2019

Two bills that are called “Medicare for all” bills by their supporters have just been introduced in Congress. On February 27, Representative Pramila Jayapal introduced the Medicare For All Act of 2019, HR 1384, in the House of Representatives. On April 10, Senator Bernie Sanders introduced a bill bearing the same name in the Senate, S 1129. The cost-containment section in Representative Jayapal’s bill will cut health care costs substantially without slashing the incomes of doctors and hospitals. Senator Sanders’ bill cannot do that.

In this article, I explain the differences in the cost containment sections of the two bills and call upon Senator Sanders to correct two defects in his bill that minimize its ability to reduce costs. Defect number one: S 1129 authorizes a new form of insurance company called the “accountable care organization” (ACO). Defect number two: S 1129 fails to authorize budgets for hospitals. Representative Jayapal’s bill, on the other hand, explicitly repeals the federal law authorizing ACOs, and it authorizes budgets for individual hospitals.

I write this essay as both a long-time organizer, writer and speaker for a single-payer (the older name for “Medicare for all” system) and a strong supporter of Senator Sanders. Bernie’s enthusiastic support for a “single payer” solution to the American health care crisis has added millions of new supporters to the single-payer movement. But precisely because he is now the most recognizable face of the single-payer movement, it is extremely important that all of us, whether we’re already in the single-payer movement or we just long for a sane and humane health care system, encourage Bernie to fix the defects in his bill.

To explain the two defects in S 1129, I must first explain why a single-payer bill like Representative Jayapal’s will be effective at cutting the high cost of American health care. I begin by explaining the origin and meaning of the “single payer” label. I will then describe the two defects in S 1129 in more detail.

Past the leap, the origin of Single Payer

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“Teacher of the Year‘ kneels during college football championship attended by Trump,”ABC News, January 16, 2020

During a ceremony honoring the 2019 “Teachers of the Year,” one in particular stood out.

The honoree from Minnesota, Kelly Holstine, chose to kneel during the national anthem at the NCAA football championship game on Monday, where the ceremony took place, “to stand up for marginalized and oppressed people,” according to a tweet she wrote, which included a photograph of her kneeling.

“Like many before, I respectfully kneeled during Nat’l Anthem because, ‘No one is free until we are all free,'” she wrote, referencing former San Francisco 49ers quarterback Colin Kaepernick and citing a quote from Dr. Martin Luther King, Jr.

“Virginia school board refuses to ban Confederate flag” from the dress code, Today, Alyssa Newcomb, January 16, 2020

A Virginia school board is refusing a dress code ban on clothing showing the Confederate flag, despite the appeals of the board’s only black member.

The Franklin County School Board in Rocky Mount, Virginia, voted 7-1 on Monday against formally writing a ban on the Confederate flag into the dress code. The board cited Tinker vs. Des Moines, a 1969 case that ruled students were allowed to wear black armbands to protest the Vietnam War and did not lose their right to free expression, even while attending school.

“In Franklin County, we do not have any documented cases of a substantial disruption caused by the Confederate flag

“The Miseducation of the American Boy,” The Atlantic, Peggy Orenstein, January 15, 2020

I knew nothing about Cole before meeting him; he was just a name on a list of boys at a private school outside Boston who had volunteered to talk with me (or perhaps had had their arm twisted a bit by a counselor). The afternoon of our first interview, I was running late. As I rushed down a hallway at the school, I noticed a boy sitting outside the library, waiting—it had to be him. He was staring impassively ahead, both feet planted on the floor, hands resting loosely on his thighs.

My first reaction was Oh no.

It was totally unfair, a scarlet letter of personal bias. Cole would later describe himself to me as a “typical tall white athlete” guy, and that is exactly what I saw. At 18, he stood more than 6 feet tall, with broad shoulders and short-clipped hair.

Additional after the Leap

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Adapted from; “Trump’s Plot Against Health Care Continues, He is still coming for your coverage and lying about it.,NYT Opinion, Paul Krugman, January 13, 2019.

Trump in a tweet: “Mini Mike Bloomberg is spending a lot of money on False Advertising. I was the person who saved Pre-Existing Conditions in your Healthcare, you have it now, while at the same time winning the fight to rid you of the expensive, unfair and very unpopular Individual Mandate…..”

As one reporter noted, President Trump was not in office when the PPACA established a unpenalized right to healthcare even if you had pre-existing conditions. Much of Trump’s efforts since taking office has been to wipe away President Barack Obama’s legacy of which the PPACA was a major accomplishment in spite of the well known resistance to his even being in office coming from Republicans “even” before he took office. Due to President Trump’s efforts, key parts of the PPACA have been removed and legislation pushed through a majority Republican Congress attempting to repeal the PPACA. The DOJ is now attempting to have the PPACA repealed before . . . nope, now after the election so the blame can not impact it.

Prior to this latest lie by Trump, an earlier lie in 2019 had the Administration work through the CMS to take action against protections for people with pre-existing conditions by allowing states to let individual market insurers vary premiums and cost sharing based on “health outcomes.” A new CMS project allowed up to ten states to apply and then establish “health-continent wellness programs.” The state programs would let insurers vary premiums and cost sharing by as much as 30 percent based on upon an enrollee’s meeting designated health outcomes, a return to charging sick people more than healthy people.

So there has been an unending stream of efforts to repeal or stymie. (More Krugman after the leap)

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I have been beating the drum for transparency of cost information before granting exclusivity for drugs via patents. With a patent, companies can charge what the market  will bear and have demonstrated they will do so on particular drugs such as insulin, Vimovo, EpiPens, etc. as well as other drugs identified in recent papers on Drug Pricing also. The following chart depicts cancer drug Sales Income as it relates to R & D Costs. It is an example of how quickly R & D costs can be recouped for Cancer drugs with the median being 2 to 5 years.

To get to the point quickly,  of the 156 US FDA-approved cancer medicines identified, 99 had data for more than half of the years since approval and were included in the WHO (Page 23) analysis. Total sales from this set of medicines (US$ 106.9 billion) represent 80.4% of the estimated global revenue of cancer medicines in 2017 (US$ 133 billion). At the end of 2017, forty-nine (49.5%) of the cancer drugs had cumulative sales of over US$ 5.0 billion and at the end of 2017, five drugs had accrued sales incomes of greater than US$ 50 billion for the originator companies: rituximab (US$93.7 billion), trastuzumab (US$ 88.2 billion), bevacizumab (US$ 83.4 billion), pegfilgrastim (US$ 64.0 billion), imatinib (US$ 63.8 billion) (Fig. 3.5, p.26). Pricing of Cancer Medicines and Its Impacts Technical Report.

The median time to generate revenue to fully cover risk-adjusted R&D cost of US $794 million was 3 years (range: 2 years; 5 years, n=73). For the maximum estimated risk-adjusted cost of R&D (US$ 2.827 Bn), the time to cost recovery was 5 years (range: 2 years; 10 years, n=56).  A threshold analysis found that 99% of the 45 cancer medicines with sales data for 10 years from their first year of launch had generated incomes sufficient to at least offset the risk-adjusted R&D costs irrespective of the assumed threshold values for R&D costs (Fig. 3.4). (page 24 25)

Past the Leap, Trends in Prices of Popular Brand-Name Prescription Drugs and why You can not Negotiate Blind Folded

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The idea I have is not to be surprised. I am a careful patient who asks a lot of questions and also advocate for myself. I have refused treatment when they use drugs which may threaten my health further (Heparin). I am also not well liked by the bloodsuckers who come in to draw blood and stab me through the vein for two weeks and destroyed my left arm in the process. Ask them questions and do not be so willing to accept treatment (if cognizant) until they answer your questions and then get their name. Take names and dates. It is ok to be a forceful advocate for yourself. When all is said and done, the bill will come to you alone.

If you are on Medicare, do not stay for observation unless you have a Plan G or Plan F. If you are on Plan N Supplemental to Medicare or lower, the plan will NOT pay 100% for Observation. You have to be admitted. You can go anywhere with Medicare for treatment.

Medicare Advantage? You had better be in network or have some type of alternative program within your plan.

There are good points to this article which is why I “C and P-ed” it here per their request.

As taken from Preventing Debt from Surprise Medical Bills, Bankrate, Madison Blancaflor. July 19, 2019

The cost of healthcare has become a hot topic in American politics in recent years, and with good reason. A recent survey found that 22 percent of Americans are losing sleep over healthcare or insurance costs, up from 13 percent just one year ago.

One aspect in particular has even gained attention from both Congress and the President within the past two months: surprise medical bills.

Congress has proposed bi-partisan legislation that sets up consumer protections against surprise billing in certain situations. President Trump also issued an executive order in June that calls for hospitals to be more transparent upfront about prices for common tests and procedures, a measure that should go into effect later this year. (While the House took out the 10 year exclusivities for Biologic drugs in the NAFTA Bill, similar  ended up in the Budget bill giving exclusivity for 12 years on new biologics. As I have pointed out repeatedly, risk adjusted R & D costs are recouped in a median period of 3- 5 years. It is another give-away to  pharma which adds to costs.)

Past the leap, causes and prevention of Surprise Billing.

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As reported by Market Watch and Axios, drug prices are on the rise the beginning of 2020. The increases exceed the 2% inflation the nation has been incurring and the 3.4% growth in wages recently incurred by nonsupervisory labor. According to Market Watch, overall drug pricing will rise 5.8% at the start of 2020 due to price increases. This is about the same as Medical CPI.

Fortune Magazine; “The price hikes are almost all below 10%, with the median price increase hovering around 5%, though more price increases could come in the following weeks.

The increases are lower than the 2019 average price increase at 6.3% and it is within the 10% annual limit many Big Pharma companies have pledged to honor while politicians zero in on drug pricing as a key talking point in the 2020 election.”

What is an issue is what the end consumer pays in price and how those prices play back into the cost of the drug, the cost of healthcare, and the rising cost of healthcare insurance. Bob Herman at Axios points out; brand name drugs start out with high sticker prices such as Humira’s $58,000 per year (Elsevier’s Gold Standard Drug Database). Healthcare insurance plans negotiate discounts off of the list price which are kept secret and the negotiators (PBMs) keep some of the savings for themselves which is also kept secret. The drug is awarded a Tier status within each insurance company plan at a price preserving the discounts as profit for the healthcare plan and the PBM. The balance goes back to the manufacturer.

The pricing system for brand name drugs administered by a doctor and yet another system for certain hospitals are different from the one for healthcare insurance companies.

For a generic drug which costs $3 to make and sells for $15; the resulting split of the remaining $12 could be a manufacturer receiving an approximate $3, the pharmacy $1.50, a wholesaler $2 and the largest share going to the healthcare insurance company managing your insurance plan’s drug benefits of approximately $5.50.

Past the leap, why is it difficult to negotiate prices.

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Of the 16.7 million uninsured people who could be shopping on the Marketplace whether or not they are eligible for a subsidy; a Kaiser Family Foundation analysis estimates 4.7 million of the uninsured Americans are eligible for free ($0 premiums) Bronze plans in the ACA marketplace. The 4.7 million is also a bit less than half of the uninsured who are eligible for marketplace subsidies, according to a 2017 Kaiser estimate.

Bronze plans have an average deductible of $6,506, and many people eligible for a $0 bronze premium would also be eligible for significant cost-sharing assistance by instead purchasing a silver plan. Single individuals with incomes below 250% of the poverty level can purchase benchmark silver plans with cost-sharing reductions (CSR) for $20 to $215 per month after subsidies in 2020, on average, depending on an enrollees’ income. Silver CSR plans have average annual deductibles ranging from $209 to $3,268 in 2020, also depending on income, and have reduced copays and coinsurance. It is therefore important for potential enrollees, particularly those with significant health needs, to not only consider the premium, but also the significant cost-sharing assistance that is only available if they enroll in a silver plan.

Trump and Republicans  stifling ACA advertising has made it impossible for people to gain the knowledge. They support the healthcare industry which can be legitimately blamed for the rising cost of healthcare premiums and deductibles.

How Many of the Uninsured Can Purchase a Marketplace Plan for Free in 2020?, KFF; Rachel Fehr, Cynthia Cox, and Matthew Rae; December 10, 2019

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As I pointed out in a public meeting, Republicans have had control of the Michigan Senate since 1992, the House two-thirds of the time, and the governorship two of 3 times up till Gretchen Whitmer came to office. Yet under the control of Republicans, the state’s infrastructure is crumbling, its economy has decreased when compared to other nearby competitive states, and employment Participation Rate still has not returned to what it was pre-2008 when the Republicans left a nation’s economy in shambles and a large deficit.

The one thing Republicans are good at is attacking the rights of everyday citizens,  a woman’s right to birth control and information, the rights of minorities to societal equality, and the rights of those living homeless and in poverty. In Michigan, the majority Republican legislature mostly sponsored by creative districting will pass a veto – proof bill based upon petitions from those who wish to deny women the right to decide rather than put the decision on a ballot initiative in Michigan.

From Bloomberg Law:

“Anti-abortion group Right to Life Michigan said it handed in more than enough valid signatures Dec. 23 to put its proposed ban of dilation-and-evacuation abortion procedures before the Legislature in 2020. The procedure, which dismembers the fetus, is the most common second-trimester abortion operation.

The vote would be held under a divisive process that allows the Michigan House and Senate to adopt citizen referendums headed to the ballot on a majority vote not subject to veto. Right to Life of Michigan has used the referendum-to-adoption process four times in the past when a governor opposing abortion restrictions proved a barrier in Lansing, and the group says it already has assurances from GOP leaders in the House and Senate that the ban will be adopted.

‘The 379,418 people who signed their names on this life-saving dismemberment ban should be confident that our prolife majorities in the Michigan Legislature will pass the bill again, just like they did back in May,’ Right to Life of Michigan President Barbara Listing said in a Dec. 23 statement.’”

Michigan Edges Toward Ban on Common Abortion Procedure, Bloomberg Law, December 23, 2019

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Sigh . . .

If the general public has not caught it, there are some of us who watch the political mechanizations by commercial healthcare to improve their lot in Congress. I know the public has not caught this switcheroo in Congress causing them to look good (and boast of it) in removing new drug exclusivity from NAFTA. What we have missed is it was granted in H.R. 1865 instead and for a longer period of time to boot. Read on to see how this was accomplished.

Addressed to Congresswoman Elissa Slotkin:

The Good:

Yes with the revision of NAFTA, Democrats “removed a provision giving the makers of ultra-expensive biologic drugs 10 years of protection from less expensive knockoffs. This is up from 5 years.

Democrats opposed what they called a giveaway to the industry locking in inflated prices by stifling competition. Top examples of the injected drugs made from living cells include medications to fight cancer and immune disorders such as rheumatoid arthritis. This legislation impacted drugs such as Rituxan, Humira, and Enbrel. Humira and Rituxan being two of the more expensive drugs on the market which have incurred pricing increases exceeding twice Medical CPI. From January 2012 to December 2017, Humira experienced price increases of 124%. Rituxan which I use from time to time is right behind Humira in cost.

The Bad:

Recently finished up an article on the prices/costs of healthcare and the resulting increases in Healthcare Insurance and deductibles whether it be Employer, ACA, or Medicare/Medicaid. House Bill H.R. 1865 was passed in the Senate and one of the few to make it through the Senate. It was the 2020  budget bill coming out of the House, altered by the Senate and altered by the House and finally passed by the Senate.

Besides repealing the Cadillac tax and the Medical Device tax which were never implemented and the Healthcare Insurance tax which was implemented; the bill also included (page 1503) a phrase to include “chemically synthesized polypeptides,” medicines such as Novo Nordisk’s Victoza. While it is only for new drugs and not drugs newly deemed to be Biologics such as Humulin and Humira, it is similar to what was removed from the NAFTA bill, is 12 years long for exclusivity, and it is still a huge and similar give away to Pharmaceutical companies the same as what was in the NAFTA revisionary bill.

And The Ugly:

The reasoning for the designation is to give companies a chance to bring new and cheaper bio-similar drugs to market. Ok fine bringing a drug to market, risk adjusted costs can be recouped in 5 years for the most expensive drug such as Humira and Rituxan as detailed by the recent World Healthcare Organization Technical Report on Cancer Drugs. With anywhere from 50% increases to a doubling of prices over a two year period (JAMA Network Open), Pharma does not need legislative incentives through extended exclusivity to be creative and profitable.

References:

Generic Drug Groups See Giveaway to Brand Names in Spending Bill, Bloomberg Law, Alex Ruoff and Jaquie Lee, December 19, 2019

THE HOUSE AMENDMENT TO THE SENATE AMENDMENT TO H.R. 1865, Appropriations Act, 2020, Page 1503, December 16, 2019

TECHNICAL REPORT Pricing of cancer medicines and its impacts, World Health Organization

run75441 (Bill H)

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