Spoiler: It isn’t working. Charles Gaba at ACA Signups had this up.

In an excellent scoop by Dan Diamond and Adam Cancryn this morning, Politico reports CMS Administrator Seema Verma, the person in charge of Medicare/Medicaid and who takes great joy in trashing Medicare and Medicaid, has spent millions of dollars on partisan consulting firms to boost her image.

The Trump appointee who oversees Medicare, Medicaid and Obamacare quietly directed millions of taxpayer dollars in contracts to Republican communications consultants during her tenure atop the agency and including hiring one well-connected GOP media adviser to bolster her public profile.

The communications subcontracts approved by CMS Administrator Seema Verma was routed through a larger federal contract and described to POLITICO by three individuals with firsthand knowledge of the agreements. The move by the CMS Administrator represents a break from precedent at the agency. Managed by Verma’s deputies, the deals came over the objections of some CMS staffers who raised concerns about her push to use federal funds to pay GOP consultants to amplify coverage of her own work. CMS has a capable communications shop which includes about two dozen people who handle the press.

The good news is that Congress is finally on the case now that the Democrats have the reins.

On Friday, House Energy and Commerce Chairman Frank Pallone called for an HHS inspector general probe into CMS’ use of CMS funding for communications consultants, calling it a “highly questionable use of taxpayer dollars.”

IN a statement, the New Jersey Democrat said; I intend to ask the HHS OIG to immediately begin an investigation into how these contracts were approved, whether all regulations and ethical guidelines were followed, and why taxpayers are stuck paying for these unnecessary services.”

For the record, Seema Verma is also the one who slashed the HealthCare.Gov marketing and navigator program budgets by 90% and 80% respectively over the past year and a half, allegedly in the interest of . . . “providing more efficient, targeted outreach” (via one of her press releases from last year).

Charles; I’m not sure exactly what sort of “bolstering of her public profile” these taxpayer-funded GOP image consultants are doing, but I would imagine, it is crap and similar to sending out promotional mailers like this one which showed up in my in box yesterday . . . sent from the official CMS Press Office:

Click on image to enlarge it.

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Brad DeLong got a huge amount of attention by saying it was time for neoliberals such as Brad DeLong to pass the baton to those to their left. Alarmingly, he seems to have written this first on twitter.

Zach Beuchamp rescued it from tawdry twitter to now very respectable blogosphere with an interview.

One interesting aspect is that Brad has very little criticism of 90s era Brad’s policy proposals. Basically, the argument is that Democrats must stick together, because Republicans are purely partisan and no compromise with them is possible. I absolutely agree with Brad on this.

But I also want to look at criticisms of Clinton/Obama center left policy as policy.

Brad tries to come up with 2 examples

I could be confident in 2005 that [recession] stabilization should be the responsibility of the Federal Reserve. That you look at something like laser-eye surgery or rapid technological progress in hearing aids, you can kind of think that keeping a market in the most innovative parts of health care would be a good thing. So something like an insurance-plus-exchange system would be a good thing to have in America as a whole.

It’s much harder to believe in those things now. That’s one part of it. The world appears to be more like what lefties thought it was than what I thought it was for the last 10 or 15 years.

Now monetary vs fiscal policy is only considered right vs left because of the prominence and fanaticism of Milton Friedman. Is see no connection between laser eye surgery, hearing aids, and private health insurance. Medicare for all is not a National Health Service (note I am not conceding that a national health service would be bad for medical innovation). Brad did not advocate insurance/plus/exchange system in 1993. He (and Bentson, Summers and Rubin) advocated a payroll tax financed system not the Clinton-Clinton and Magaziner mess. I think he is stretching to get a second example.

I think the first isn’t really left vs right and the second is and always was a bad political calculation. IIRC Obama certainly said that he thought single payer was better policy but politically impossible. That was the general line on the center left wonkosphere. I think the case for insurance-plus-exchange was at most a bad political argument disguised as a bad policy argument.

In another twitter thread (no not the one where he says twitter is a horrible medium for serious discussion) Paul Krugman comments

I want to focus on two of his tweets

Last point: wages. Here’s where research has convinced me and others that wages are much less determined by supply and demand, much more determined by market power, than we used to believe. This implies a much bigger role for “predistribution” policies like minimum wage hikes 10/

Pro-union policies, and more than we used to think. “Let the market do its thing, but spend more on education/training and a bigger EITC” no longer sounds like wisdom 11/

I listed this as the one economist’s mea culpa based on empirical evidence which came to my mind. A lot of center left economists used to oppose minimum wage increases and were convinced by empirical evidence (mostly by Card and Krueger) that this is actually good policy. But I don’t see any problem with the EITC. Rather, economics 101 based arguments against the minimum wage and unions have been undermined by evidence*.

I think Krugman’s problem with “a bigger EITC” is political. It appears on the Federal budget so deficit hawks won’t allow a really huge increase. In contrast, people can think firms pay the minimum wage, so increasing it sounds like a cheap way to help the working poor.

More generally, I don’t see any reason to abandone redistribution (like the EITC). In fact, I think that is both excellent policy and political dynamite. I note that Bill Clinton and Barack Obama campaigned promising to raise taxes on the rich and cut taxes on everyone else. Also they won. Other Democrats didn’t promise that and they lost. A more progressive income tax is a relatively market respecting policy long supported by left of center economists. Oh and also Alexandria Ocasio Cortez. I don’t think there is any evidence against the Clinton 1993 tax increase combined with EITC increase.

The fact that it is totally obvious that it is good politics (rejected absolutely by the Republican party and supported by most self identified Republicans) doesn’t mean that it is too obvious to stress. It means debating redistribution vs predistribution is a distraction (which one here is not like the others)?

I personally have criticisms of Bill Clinton type neoliberalism after the jump

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In parts of Livingston and Oakland counties, the people have been warned not to eat the fish from the Huron River and Kent, Strawberry, Zukey, Gallagher, Loon, Whitewood, Base Line and Portage lakes as well as Hubbell Pond due to the fish being contaminated with PFAS and similar chemicals coming from industries. In 2016, Michigan started to tell people about the impact of PFAS and how dangerous the PFAS and PFOAs are.

PFAS/PFOA are part of a class of man-made chemicals used in many industrial and consumer products to make the products resist heat, stains, water, and grease. Product Examples include: Teflon® cookware, waterproofing fabric and coating on fast food wrappers.

Former Army reservist Spc. Mark Favors, his relatives, and family have lived around Fort Carson and Peterson Air Force Base for years drinking and bathing-in base and off-base water for years. The level of PFAS and PFOA on base around Peterson Air Force Base has been established at 79 to 88,400 parts per trillion on-base wells and 79 to 7,910 parts per trillion in public and private drinking wells off base.

It was not until the EPA published its 70 parts per trillion guidelines did the DOD claim it began to understand how harmful exposure could be and voluntarily took action. Spc. Mark Favors does not buy the excuse. The issue has been explored in-depth by the Colorado Springs Gazette, which produced a timeline dating back to the first concerns about the foam used to fight fires in 1962. Fort Carson stopped using the firefighting foam in 1991 stating, “Firefighting operations that use AFFF must be replaced with nonhazardous substitutes.”

In Michigan, it will take a Flint-sized emergency before it begins to take aggressive action with businesses dumping contaminated water in company drainage pipes going to water reclamation plants. Then too, Livingston County is the richest in income in the state and is also 96% white, an advantage the county has over the City of Flint.

Fifty year old Mark Favors can count at least 16 relatives from around the area who have been diagnosed with cancer; 10 have died. Six of those relatives have died since 2012, including his father at age 69 and two cousins, ages 38 and 54.

“In my family alone, we have had five kidney cancer deaths,” Favors said. “And those people only lived in the contaminated area.”

Many of Favors’ relatives lived near Peterson Air Force Base, where scores of both on-base and off-base water sources have tested significantly above the Environmental Protection Agency’s recommended exposure of 70 parts per trillion of perfluorooctane sulfonate (PFAS) or perfluorooctanoic acid (PFOA). The compounds were part of the military’s firefighting foam until just last year. The same compounds in the foam have been linked to cancers and also developmental delays for fetuses and infants.

In a recent March 6, 2019 House subcommittee hearing, Mark Favors was among those in attendance as the subcommittee was questioning the actions of the Environmental Protection Agency and Department of Defense representatives over the decades long use of PFAS, the failure to regulate it’s usage, provide adequate protection from its usage, and monitor the safe disposal to prevent contamination of ground water and the environment. Knowing its dangers, a reasonable person would have found an alternative to its usage as demonstrated by Fort Carson in 1991. Obvious, some elements of the military were not of that mind.

With a large degree of politeness, House Oversight and Reform subcommittee on the environment chairman Rep. Harley Rouda, D-CA commented:

“To put it charitably, it is unclear why DoD feels justified in passing the buck to the EPA, particularly in light of the evidence suggesting DoD’s awareness of the toxicity of the chemicals since the early 1980s.”

If stationed at a military bases (and who has not been for some period of time?), this is a big issue as many of us were using the water supplied to us at places such as Camp Lejeune where we were drinking and showering in water contaminated with chemicals such as benzene. For those who were at Camp Lejeune for at least 30 days, there is now a list of disorders which the VHA will accept as being attributed to exposure to base water. Some of us have disorders on that list and some of us do not. There are many other military sites where former military and civilian personnel have complained of disorders and illness which they believe is attributed to the bases they were stationed during their enlistment or working as civilians.

In Michigan, there is a site where you can get an idea of how bad the issue is in and around your community. All known PFAS sites in Michigan and check your own area (at the bottom you scroll to find your county and township/community).

Many knowledgeable sources believe the 70 parts per trillion is still too high.

by run75441 (Bill H)

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“The Pentagon is planning to tap $1 billion in leftover funds from military pay and pension accounts to help President Donald Trump pay for his long-sought border wall, a top Senate Democrat said Thursday.

Sen. Dick Durbin, D-IL ‘It’s coming out of military pay and pensions. $1 billion. That’s the plan.

The funds are available because Army recruitment is down and a voluntary early military retirement program is being underutilized.’

The development comes as Pentagon officials are seeking to minimize the amount of wall money that would come from military construction projects that are so cherished by lawmakers.

‘Imagine the Democrats making that proposal — that for whatever our project is, we’re going to cut military pay and pensions.'”

Gee, did anyone ever think of tossing this into the VHA funding since the VA now has to pay for the Choice program which Trump said he will not fund.

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This should come as no surprise as I have written on the topic of Healthcare Costs and Its Drivers before. In particular, the overriding statistic from an earlier post was 50% of the increase in healthcare costs was due solely to price increases between 1996 and 2013 (JAMA, Factors Associated With . . . . Adjusting for inflation, “annual health care spending on inpatient, ambulatory, retail pharmaceutical, nursing facility, emergency department, and dental care increased from $1.2 trillion to $2.1 trillion or $933.5 billion between 1996 and 2013.” This was broken down into 5 fundamental factors contributing to rising healthcare costs.

– Increased US population size was associated with a 23.1% increase or $269.5 billion
– An aging population was associated with an 11.6% increase or $135.7 billion
– Changes in disease prevalence or incidence (inpatient, outpatient, ED) resulted in spending reductions of 2.4% or $28.2 billion
– Changes in service utilization (inpatient, dental) were not associated with a statistically significant change in spending
– Changes in service price and intensity were associated with a 50.0% increase or $583.5 billion.

Five fundamental factors (Population size, Population aging, Disease prevalence or incidence, Service Utilization, and Service Pricing) were collectively associated with a $933.5 billion increase in annual US health care spending between 1996 through 2013. Represented pictorially, stated objectively, and categorized numerically, I can not make it any more obvious.

Some Explanation

The change in disease prevalence or incidence was associated with a spending reduction of 2.4%, or $28.2 billion while the change in service utilization did not result in a statistically significant change in spending. Said another way, these two factors had little or no impact on the rising cost of healthcare.

The increased healthcare costs from 1996 to 2013 were largely related to Healthcare Service Price and Intensity and secondarily impacted by Population Growth and Population Aging in order of impact. The bar chart reflects all of the impact in changes.

So the aging tsunami of baby boomers has not hit yet and population growth has not greatly impacted the results of this study. In patient stays at hospitals are down as well as out patient use of facilities. The big issue is the change in pricing for inpatient hospital stays and pharmaceuticals. Hospital/clinic consolidations leads to the former even though insurance has been fighting for a reduction in stays. Pharmaceutical has instituted new pricing strategies which we have all read about in the news. Old drugs such as Humalog, Viovo, and the infamous Epipens as well as others are now more expensive. This study points to pricing for pharma and service as the issues.

An example?

There is a tendency to challenge the lifestyle practices of people who indulge in too much. One factor did come out in the increased cost of healthcare. The increase in annual diabetes spending between 1996 and 2013 was $64.4 billion of which $44.4 billion of this increase was pharmaceutical spending. Said another way, two-thirds of the increase in treating diabetes was due simply to the increased pricing of pharmaceutical companies.

And yes, there should be time spent on changing habits where it can be changed and providing the means to do so. However, in 1996 Eli Lilly’s Humalog was $21 per vial. By 2017, the price increased to $275 (700%) for a vial which equates to a one-month supply.

Why has the cost of Humalog increased? “The truth is the improvements in new formularies of old versions which are marginally different, and the clinical benefits of them over the older drugs have been zero.” Just like slapping “new and improved” on the labels of food products with a change of ingredients (which qualifies under USDA and FDA labeling regs)., pharmaceuticals can play the same game and they do.

As the article (“Eli Lilly Raised U.S. Prices Of Diabetes Drug 700 Percent Over 20 Years”) explains, “most patients do not pay the full cost/price of a drug up front and absorb their portion of the cost via an increase in monthly healthcare premiums.” This leads to pharmaceutical companies charging as much as the U.S. insurance companies will let them. Both parties profiting from increased prices. Perhaps Alex Azar the Secretary of Healthcare can explain it better as he was an officer of Eli Lilly when Humalog began its ascend?

Another Study via Health Affairs

A shorter time period extending one year longer than the Jama study, the Health Affairs study supports what is being said in the JAMA study. According to data from the Henry J. Kaiser Family Foundation, total health spending on the privately insured in the United States increased in real terms by nearly 20 percent from 2007 to 2014.

A more recent study funded by the Commonwealth Fund and published by Health Affairs examined other costs impacting healthcare. Commonwealth Fund supported researchers recently analyzed hospital and physician prices for inpatient and hospital-based outpatient services as well as for four high-volume services: cesarean section, vaginal delivery, hospital-based outpatient colonoscopy, and knee replacement. Its findings were as follows:

– From 2007 to 2014, hospital-prices for inpatient care grew 42 percent compared to 18 percent for physician-prices for inpatient hospital care
– For hospital-based outpatient care, hospital-prices rose 25 percent compared to 6 percent for physician-prices
– There was no difference in results between hospitals directly employing physicians and indirectly employing physicians
– Hospital prices accounted for over 60 percent of the total price of hospital-based care.
– Hospital prices accounted for most of the cost of the four high-volume services included in the study. The hospital component ranged from 61 percent for vaginal deliveries to 84 percent for knee replacements.

Sound familiar? The JAMA study looked at both in and out patient costs/prices associated with hospital services and said they were up. The Health Affairs study looks at in patient services for four high volume inpatient services stating they have increased significantly from 2007 to 2014.

What the Health Affairs study Showed

The Health Affairs study also presents a comparison of hospital pricing growth rates as compared to physician pricing growth rates. The study is only a few weeks old and I am surprised I am able to access as much information as I have. While Health Affairs admits the study is a start and more work differentiating other aspects must be done, the study suggests there are significant growth in the bargaining leverage of hospitals as compared to physicians.

If you recall Rusty “Tom” and I engaged in a number of different conversations on healthcare with one of them being hospital consolidations (2013). It is a power grab, as Rusty pointed out, for more market segment and pricing control with those having name-recognition gaining the most. Maggie Mahar also referenced the same issue.

In my own commentary On the Horizon After Obamacare (2014): As it stands and even with its faults, the ACA is a viable solution to many of the issues faced by the uninsured and under-insured; but in itself, it only addresses the delivery-half of the healthcare problem. The other half of the problem rests with the industry delivering the healthcare and the control of pricing through the inherent monopolistic power coming and pushing the industry into greater integration of delivery. As Longman and Hewitt posit,

“the message from Department of Health and Human Services stresses the vast savings possible through a less ‘fragmented and integrated’ health care delivery system. With this vision in mind, HHS officials have been encouraging health care providers to merge into so-called accountable care organizations, or ACOs”; “while on the other side of the Mall, ‘pronouncements from the FTC are about the need to counter the record numbers of hospitals and doctors’ practices merging and using their resulting monopoly power to drive up prices.”

Two different messages from government, greater efficiencies in healthcare through consolidations as ACOs versus monopolistic pricing control in healthcare by large hospital and pharmaceutical corporations an unintended result. There is large amounts of inefficiencies, waste, and rent-taking in healthcare as well as in Medicare which is touted as the go-to by politicians and advocates of it. Lets not make a similar mistake, the creation of any forthcoming healthcare system must first address the costs of healthcare and then the delivery of it not ignoring the quality of the product and its outcome after treatment. Again Maggie Mahar was big on promoting this result emanating from any new system.

While Physician fees grew at a compounded annual rate of 6% for baby deliveries and 1% for office visits between 2003 and 2010, hospitals fees during a similar period grew at 17%.

A measurement of the competitiveness of a hospital within a certain area of the country is done utilizing the Herfindahl-Hirschman Index (HHI). It has been used to measure competition in and around cities. The results of the HHI revealed an increase in the concentration of hospitals from mergers and acquisitions, going from moderately concentrated in 1990 with an HHI numeric of 1570, to more concentrated in 2009 with a HHI of 2500, and with some cities purely monopolistic at 10,000.

Rigorous action by the FTC would certainly go a long way in improving compositeness; however, the FTC has been purposely understaffed by cutting its funding. In place at the FTC is a staff 22 lawyers and economists to monitor a $3 trillion healthcare industry. It is too understaffed to take on such a large industry which would overwhelm it with legalese and paper. Maybe in the next election will bring forth the right person to take on healthcare.

Resources

Hospital Prices Grew Substantially Faster Than Physician Prices For Hospital-Based Care In 2007–14, Zack Cooper, Stuart Craig, Martin Gaynor, Nir J. Harish, Harlan M. Krumholz, and John Van Reenen, HealthAffairs, February 2019

Hospital Care Prices Rose Faster Than the Cost of Physician Services, Zack Cooper, February, 2019

After Obamacare Phillip Longman and Paul S. Hewitt, Washington Monthly, January – February 2014

by run75441 (Bill H)

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(Dan here…lifted from Robert’s Stochastic Thoughts)

The Ethics of Clinical Trials

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Massachusetts ACA Enrollment Exceeds Last Year, Charles Gaba, ACA Signups Blog

Massachusetts: (January 14, 2018) saw an increased 285,000 signups for healthcare for 2019 which is up 6.6% YOY and with 9 days left until the ACA signup deadline. This comes even though Republicans and Trump have been sabotaging the ACA. Even more impressive, 97.2% (90% National Average) of enrollees have paid their 1st month fees.

Republicans and Trump Implement the CSR again, Ban Silver Loading, and then Kill the CSR in 2021, Andrew Sprung, xpostfactoid blog

The Trump administration has called for an appropriation to fund CSR the old way — by reimbursing insurers directly for providing it. This comes after President Trump revoked the CSR subsidy used to help pay for deductibles, copayments, and coinsurance. When the CSR was revoked, ACA companies loaded the costs solely into the Silver plans in which they were used and resulted in Bronze and Gold plans to become less costly. Income-based ACA premium subsidies are based on a silver benchmark and silver loading generated major discounts in bronze and gold plans.

“For the first half of 2018: 16% percent of enrollees were enrolled in a plan with zero premiums after application of advance payments of the premium tax credit, 19 percent of enrollees paid a premium of less than 5 percent of the total plan premium.” This is largely the result of Silver plan loading, which created $0 premium bronze plans widely available and less costly gold plans which doubled in enrollments in 2018. There was also an increased enrollment of approximately 300,000 enrollees in 2018 with the likelihood of a 2-3 million boost in subsequent years.

So what is the issue? CMS released the annual Notice of Benefit and Payment Parameters (NBPP) January 17th. In its efforts to kill the ACA, CMS is calling for an elimination of Silver loading in 2021. Given the lowered cost of various plans resulting from Silver loading, Democrats should not be willing to sacrifice the silver loading windfall without trading it for a less haphazard boost to marketplace funding.

As xpostfactoid blog suggests, perhaps a cap on premiums as a percentage of income for all enrollees up to 600% FPL and improved subsidies for the 200 – 400%FPL.

Healthcare Job Growth Outpaces Nearly Every Sector in 2018, MedPage Today, John Commins

For 2018, healthcare created a total of 346,000 jobs or nearly 29,000 new jobs each month which is up from 284,000 jobs created in 2017. The 2018 figure includes 219,000 new jobs in ambulatory services and 107,000 new hospital jobs.
Healthcare job growth outpaced nearly every other major sector of the economy in 2018, including food services (261,000), construction (280,000), manufacturing (284,000), and retail sales (92,000).

The new data is in line with Bureau of Labor Statistics projections that healthcare sector employment will grow 18% from 2016 to 2026, much faster than the average for all occupations, adding about 2.4 million new jobs.

The VA’s Choice Program Meant to Eventually Replace the VA Gave Companies Billions and Vets Longer Waits, Isaac Arnsdorf & Jon Greenberg, Politifact

As a short-term response to a crisis, the VA paid contractors at least $295 every time it authorized private care for a veteran. The fee was high because the VA hurriedly launched the Choice Program to meet a ninety-day deadline from Congress in response to an Arizona VA facility not responding quick enough to veteran’s needs for healthcare and resulting in deaths.

Four years later, the fee never subsided — it went up to as much as $318 per referral.

Since 2014, 1.9 million former service members have received private medical care through Choice. It was supposed to give veterans a way around long wait times in the VA or travel long distances to be seen. But their average waits using the Choice Program were still longer than allowed by law, according to examinations by the VA inspector general and the Government Accountability Office. The watchdogs also found widespread blunders, such as booking a veteran in Idaho with a doctor in New York and telling a Florida veteran to see a specialist in California. Once, the VA referred a veteran to the Choice Program to see a urologist, but instead he got an appointment with a neurologist.

While it was true officials at the Phoenix VA were covering up long wait times, the inspector general eventually concluded that no deaths were attributable to the delays. However, critics seized on this scandal to demand that veterans get access to private medical care. As a safety valve for veterans, the Choice program is an alternative provided the quality of outcomes is there. My own experience with the VA has not been bad nor did my appointments take months. On the other hand, there are times I end up at clinics or the ED when I can not see my PCD.

An IG of the Choice program found the VA overpaid by $140 million besides other issues with the program.

Access to VA Health Services Now Better Than Private Hospitals? Nicole Lou, MedPage Today

Researchers find some wait times generally improved since 2014.

In 2014, the average wait for a new VA appointment in primary care, dermatology, cardiology, or orthopedics was 22.5 days, compared with 18.7 days in private sector facilities (P=0.20). Although these wait times were statistically no different in general, there was a longer wait for an orthopedics appointment in the VA that year (23.9 days vs 9.9 days for private sector.

The study, published in JAMA Network Open, found that wait times in 2017 favored VA medical centers (17.7 days vs 29.8 days for private sector facilities). This was observed for primary care, dermatology, and cardiology appointments — but not orthopedics, which continued to produce appointment lags in the VA system (20.9 days vs 12.4 days), the authors stated.

As resources in the VA are increasingly diverted to purchase care in the community, it remains to be seen if access to healthcare services can be maintained while access in the private sector continues to deteriorate, adding that virtual care may be one way to improve access given the non-infinite supply of face-to-face appointments.”

Fee-for-Service Must Go Says Ex-Vermont Governor Howard Dean, Joyce Frieden, MedPage Today

Dean, an internist and former Democratic governor of Vermont: “Under the current system, you only make money if people get really sick. Every financial incentive we have in American healthcare is to spend as much as we possibly can.

“We’re not getting paid for keeping people healthy in our system. I don’t believe that doctors think it’s a wonderful idea to have people get sick. But incentives work in every system … and monetary incentives always work in human beings. If you keep the incentive system the way it is, you have a distorted system that works against good health.”

As for universal care in the U.S., I’m not necessarily opposed to Medicare for All, but the problem is it’s a fee-for-service system so we’d have to fix that. The only way you can really save money is with capitated care.”

by run75441 (Bill H)

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In a clinical trial the therapy is decided by a pseudo random number generator. How can this be ethical ? People are treated differently for no reason related to different interests different values and priorities or even different merit (assuming merit can differ).

There is a utilitarian rational for clinical trials. Through such trials doctors learn, and that knowledge is useful to future patients. But this rationale is utterly rejected as ethically unacceptable, because it was used to justify depraved experiments.

I think the current discussion of the ethics of clinical trials is based on a mixture which is partly consequentialist and partly deontological, and that it is incoherent, because people feel the need to claim it is totally both, while the two are inevitably in conflict.

So it is asserted that physicians must act in the interest of the patient – each and every patient. It is also argued that clinical trials are morally acceptable. This does not make sense.

It is only possible if the expected welfare of the patients is identical under the two treatments over which one randomizes. Any difference, no matter how tiny, in expected welfare would compel the use of only the current standard therapy, or of only the new experimental therapy.

I think the failed effort to avoid this is to reject the concept of expected welfare. It is argued that it is OK to do one or the other because one does not know which is better for the patient.

It would be OK if one were to say all probabilities must be rounded to 0, 1 or 0.5 so we don’t know means each is exactly equally likely. However, this approach would make life strange and brief. In particular it would rule out general anesthesia for any procedure not necessary to save a life. The chance of death is very low but demonstrably not zero. Don’t operate unless you would operate with a 50% chance of killing the patient would rule out almost all surgery. We must make choices under uncertainty and can’t pretend that all uncertainty is the same and survive for long.

Consider 2 examples:

1. There are 2 treatments, and, with best estimates, with treatment A the probability that the patient lives is 50% and with treatment B the probability is 30%.

2. There are 2 treatments, and, with best estimates, with treatment C the probability that the patient lives is 50% and with treatment D the probability is 30%.

According to current medical ethics, one must provide treatment A not treatment B but one may chose treatment D or treatment C. This always is based on the assertion that the interests of the patient is all that matters. Yet I have assumed that, for the patient, the two pairs of choices are identical. This can’t make sense.

In the first case there is an unobservable difference between patients of type 1 or type 2 where if they are type 2, then treatment A kills them on the spot. 10% of people are of type 2 (as learned from decades of painful experience). If someone is of type 1, their chance of surviving with treatment A is 5/9. In contrast with treatment B all have a 30% chance of living. With decades of painful experience it is known with essentially complete certainty that the probabilities are 50% and 30%.

In the second case, there aren’t two types, but the evidence on treatment C is preliminary based on a small (phase II) trial. The fraction who survived in the trial was 50% but the 95% confidence interval is 20% to 80%. The null that the true chance is 30% is not rejected at standard confidence intervals. By standard reasoning it is time for a phase III trial with randomization.

In each case, we know that giving A not B might cause a patient to die who would otherwise live and our best estimate of the probabilities of survival are higher with A than with B and higher with C than with D.

I think the difference is that one learns something by randomizing and giving half of the patients D and that this outweighs the expected deaths due to the randomization.

I think it is possible to believe people have a right to care, and also conduct randomized trials, if one says there must be a standard of care, and all people have right to that. That one may deviate if the weight of evidence suggests that an experimental therapy is better, but that such deviation is a matter of utilitarian total expected welfare maximization not individual rights which trump average interests.

But it is not easy or comfortable to believe this, so I think that doctors have decided to rely on statistics but reject the very concept of probability. The logical inconsistency might cause some discomfort. It would cause more if the concept of probability weren’t so utterly alien to normal human thought. But in any case the tension between believing in rights and believing those rights don’t always trump utilitarian calculations clearly causes more discomfort.

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In The New York Times Abby Goodnough wrote
” she got a Vivitrol (naltrexone) shot but it was so expensive — her co-payment was $600 — that she never got another” !!!

This is insane. Naltrexone is an opioid antagonist. It prevents opioids from causing a high (and relieving pain and suppressing coughing and breathing). In no way is it conceivably a drug of abuse. But opioid addicts who wish to cut off all effects of opioids have to pay for their Naltrexone.

Also (as explained in the excellent article) some of the same people who oppose the use of methadone and buprenorphine oppose naltrexone too. I have never understood their logic. I am sure it is based on a moralistic belief that there are no simple easy solutions. It isn’t even “no pain no gain” as cold turkey withdrawal while using naltexone is just as horrible as any other cold turkey withdrawal. Pointless speculation after the jummp.

But for now two practical proposals. Everyone who wants naltrexone for any reason should be given naltrexone (given no co-pay). I think this is obvious. Now somehow a drug which has been around practically forever is expensive, but the cost of paying off the pharmaceutical company whatever they demand for such a program (which will be great for them) is trivial compared to the costs of the opioid epidemic.

I should have provided a link to the Wiki on Naltrexone. Note the cost (retail) of oral Naltrexone is $0.74 a day — providing one a day to every addict and anyone who wanted to pretend to be an addict would cost hundreds of millions a year. This is a completely insignificant sum for the US government, so it should be done immediately. Delayed release Naltrexone is expensive (prescribing it with a $600 copay is bad practice of medicine). Here a technological improvement has made it possible for doctors to give the patients a better, but expensive option, which they don’t take.

I also have an impractical proposal that Naltrexone should be available over the counter — it can’t be abused and the reported side effects are the reported symptoms of being a person. However, I know this proposal is impractical.

My second practical proposal is phased drug assisted therapy. I think it should be
1) whatever you want for a week provided you don’t want a lethal dose (you want heroin — here’s your heorin)
2) second week whatever you want provided you take your methadone under our supervision. All the heroin you want will be none (it doesn’t do anything for someone full of methadone).
3) third week, 50% methadone 50% buprenorphine.
4) fourth week buprenorhine
5) fifth week 50% buprenorphine 50% naltrexone
6) 6th week through death do us part naltrexone.

Why not ?

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To add to Robert Waldman’s post on ACA enrollment, here is the chart as taken from Andrew Sprung’s Blog (Expostfactoid) on the ACA. This is data Charles Gaba had gathered and Andrew rearranged. Note non-expansion Medicaid states did better than expansion states in enrollment.

Why is that true? The states marked in yellow on the left are expansion states.

Without getting into the data and explaining Andrew’s findings, it is interesting the difference in each state experienced from application of carrots (generously subsidized health plans) and sticks (the individual mandate) on ACA marketplace enrollment.

1. The relative enrollment resilience in non-expansion states points toward the power of really affordable comprehensive insurance.
2. The steep enrollment drop in expansion states perhaps shows the impact of mandate repeal.
3. The superior performance of SBEs (State Based Exchanges) indicates that active insurance market oversight, investment in outreach and enrollment assistance, and a governmental will to make the marketplace work has a significant impact.

Findings:

Twelve states running their own exchanges have all expanded Medicaid. Enrollment in those states is likely to remain flat this year and will outperform the HealthCare.gov states the same as in 2017 and 2018. Impressive given the lack of the 100-138% FPL income strata. Idaho just expanded its plan and has underperformed to date. The enrollment gap between State and Federal Exchanges (SBE vs. FFE) points to the importance of enrollment assistance and outreach. CMS decreased time and funding FFE states. State Based Exchanges have advertising, outreach budgets, and mostly continued the effort. They were not blindsided by Trump and the CMS,

As I read some more, I will expand this farther. Just back from Christmas holiday and catching up.

by run75441 (Bill H)

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