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The Elephant in the Room

By Carole R. Myers

July 13, 2017

Photocredit: Andrew Griggith

 

What’s next? The Affordable Care Act (ACA) has not remedied the cost problem in the United States.  Americans balked at Congressional plans to save the federal government money by raising consumer costs while dramatically cutting coverage and imposing unsustainable funding reductions on the states.   We need a better plan!  Have we reached a breaking point where Congressional leaders will actually work across party lines, put aside self-interests, and look for long-term, sustainable changes?  The verdict is still out.   The next few weeks will be critical.

 

Meaningful change requires dealing with the metaphorical elephant in the room.   The term elephant in the room connotes a big problem or issue that is avoided or minimized and for which there is little real dialogue, discussion, or debate.  The big problem that Congress and all Americans need to address with inclusive and deep dialogue is unsustainable healthcare costs in the United States.

 

It is hard to separate what we call the big three: cost, quality, and access.  We have learned that you cannot address access problems, as the ACA did, without addressing cost problems.  Years of research have shown that you can increase value in healthcare, which means that healthcare is concurrently cost-effective, appropriate, and efficiently delivered.  Simply said: better healthcare does not have to cost the exorbitant prices we currently pay.  A quick look at the Commonwealth Fund’s comparison of international health systems reveals a sad tale about the United States.  In the report, eleven democratic countries with advanced economies are compared to one another on a complement of measures related to health system performance.  The U.S. has the highest per capital cost, 51% more than the second most expensive country, Switzerland, and 169% more expensive than the country with the lowest per capital costs, New Zealand.  Paying more does not get you more.  The U.S. ranks last on a measures related to Healthy Lives.   The U.S. scores last on Access: Cost-Related Problems.   According to the Kaiser Family Foundation, the U.S. has the lowest life expectancy at birth when compared to similar countries.   In 1980 life expectancy in the U.S. was similar to comparator countries.   However in the ensuing time the U.S.  has gained five years while other countries have gained seven.

 

Why is the cost of healthcare so high in the United States?  One reason is distorted supply, demand, and pricing.  Competition does not reduce prices in healthcare.  Pricing of healthcare services is illogical.  Prices are not based on material and labor cost and prices varies depending on who is paying.  Medicare prices tend to be lower because the purchaser, the federal government, has exercised their bargaining power, with the exception of Medicare Part D.  With private insurers we sometimes see just the opposite.  Provider consolidation tips the balance of power in providers’ favor in negotiations with private insurers.  The biggest losers are the uninsured who have no one bargaining on their behalf and are at the mercy of hospitals, physicians, and other healthcare providers.

 

Prices in healthcare will rise to whatever the market will bear.  The cost of drugs is in a class of its own.  The U.S. spends more on drugs than any other country.  U.S. per capita spending on drugs exceeds that of other countries.  The U.S. spends $858 per person while the average for 19 other industrialized countries is $400.  One way to change this is to do what other countries do and allow the federal government to negotiate with the pharmaceutical companies.   Currently the provisions of Medicare Part D prohibit this.

 

The U.S. has a market-based economy.   This works well for most consumer goods and services, but not healthcare.  Market-based solutions in healthcare are harmful to Americans.  At best healthcare is an imperfect market.  A major concern is that the ACA repeal and replace strategies currently being considered by the Congress are based on market principles.

 

Buying a car is much different than receiving open heart surgery.   When you were buying a car you make the decision.  However in healthcare, the services you need are generally determined by the person and/or institution that provides the service.   This can set-up perverse incentives.  If you are facing open heart surgery, you are generally ill-equipped and often restricted in your decision to buy the service.  This is because the supply and demand dynamics we see when purchasing a car are distorted.  The healthcare market does not offer free, unrestricted competition based on price and quality.  Patients usually do not have the time or information needed about the appropriateness or value of the surgery.  In general, patients are unable to amass the most important information and determine how it applies to them to ascertain if they truly need the surgery, what the options are, where to have the surgery, and who should perform the surgery.  Another complicating factor is that is a patient you are shielded from the full cost of the service if you have insurance and because it is near impossible to compare prices.

 

The second reason healthcare costs are so high is because the mix of services that Americans receive.  More care is not better care.  By some estimates, a third of what the U.S. spends on healthcare may be wasteful.   More treatments may benefit providers’ bottom line but not necessarily patients.  In the United States we love high-tech care and too many resources are expended on tertiary and futile care to the detriment of prevention and primary care.  This makes no sense when investments and prevention in primary care pay much greater dividends and result in better outcomes.

 

Another reason that healthcare costs are too high is because of system costs and profits.  The use of multiple payers and providers of care and lack of standardization and inter-operability, as well as the profit motive that has come to characterize U.S. healthcare delivery, results in excessive administrative costs.  Healthcare administrative costs in the United States (25.3%) are double Canada and Scotland (12%).  Furthermore, there is no link between higher administrative costs and better quality.

 

Since 2010 when the ACA became law, profits for managed care giants United Healthcare. Aetna, Anthem, Cigna, Humana, and Centene have risen at a rate far greater than the Standard and Poor’s Stock Index.  The index return was 135.6% while stocks for the named managed care companies returned in excess of 300% plus dividends.

 

Does competition have a role in healthcare? I think it can.  However strategic regulation and government oversight is needed to address the problems we currently face.  There are other options but the gap between where we are and the other options is far greater than what it will take to work with in the basic structure of the ACA.

 

For insurance to work, the risk pool must be large and diverse.  The individual mandate is a necessity if our goals are to extend healthcare coverage to all Americans and assure access to needed services at a cost we can sustain.  As we have seen, uncertainty is destabilizing.  We need to take the time as a country to debate ACA reform but in the meantime the federal government and state insurance commissioners need to support the ACA.

 

The federal government needs a larger role in negotiating and managing prices for healthcare.   We can start with the federal government negotiating prices for the Medicare Part D program.  As a country we should consider the reform approach Switzerland took in 1999 when they determined that insurance companies could not be for-profit entities.  The United States is alone in the dominance of largely unregulated, for-profit health insurance companies.

 

As a country, we need to pivot towards prevention and primary care.  Reimbursement is the best lever for changing behavior.  Reimbursement needs to be structured to reward value, including keeping people well, maximizing the functioning of individuals regardless of their health status, and paying only for needed services based on available evidence and in a system with price transparency and consistency.  We cannot cost-shift our way around the problem.  We must deal with the elephant in the room and address costs head-on.

 

Carole R. Myers, PhD, RN is an Associate Professor at the University of Tennessee with a joint appointment in the College of Nursing and the Department of Public Health.  She has recently been appointed as Senior Fellow for the George Washington University Center for Health Policy and Media Engagement.

 

Carole R. Myers

Trumpcare and Community Health Centers

By Eve Adler

March 16, 2017

The World Health Organization refers to health policy as the “decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. An explicit health policy can achieve several things: it defines a vision for the future which in turn helps to establish targets and points of reference for the short and medium term. It outlines priorities and the expected roles of different groups; and it builds consensus and informs people” (http://www.who.int/topics/health_policy/en/).

 

During the current shift in the political administration of the United States, questions arise about the continuity of existing health policies and how changes may impact the healthcare of a nation.  What changes have been seen in the delivery of healthcare among the uninsured and underinsured under the Affordable Care Act?  What impact could changes in the Affordable Care Act have on individuals, and the healthcare institutions that serve them? How can we advocate and become more informed about the health policies that influence the quality of our lives? These questions will be explored on HealthCetera.

 

On today’s HealthCetera, Eve Adler will be speaking with Sion Roy (http://www.harbor-ucla.org/cardiology/faculty/), a cardiologist at Harbor UCLA Medical Center in California, member of the Board of Trustees for both the California Medical Association (CMA) and LA County Medical Association (LACMA), and college faculty member who teaches about Health Policy and Education.

 

This program was to have aired on March 9th but was postponed. So tune in on Thursday, March 16th at 1:00pm to HealthCetera Radio on WBAI 99.5FM in New York City, or streaming online at www.wbai.org; or you can listen to the interview anytime by clicking here:

 

Eve Adler
Eve Adler MA RN RYT-500 is a Registered Nurse, Health Educator, and Yoga Teacher with experience in the areas of clinical practice, academic planning, cultural competency training, integrative healing modalities, and professional development. She is currently a professor in the Health Sciences Department at Santa Monica College.

Luna’s Story: How one health center cares for the transgender community

By Liz Seegert

March 16, 2017

 

The American Health Care Act, the proposed Republican health plan, would deal a major blow to Medicaid funding for the states. The Congressional Budget Office projects that if it passes, Medicaid cuts will total about $800 billion over the next decade, and leave 24 million more people uninsured—including many in the LGBT community.

 

Under the ACA, health plans cannot refuse coverage based on pre-existing conditions, such as HIV, substance abuse, or a transgender medical history. There are non-discrimination protections based on sex, which  include gender identity and sex stereotypes, in any health program receiving federal funds (including Medicaid and in state marketplaces). This also includes sexual orientation.

 

The Center for American Progress found that among lower income LGBT individuals (making between $15,000 and $22,000 annually), the uninsured rate dropped 18 points since the ACA’s Medicaid expansion.

 

Luna Hernandez is among those benefitting from enhanced Medicaid coverage. She is a transgender woman who receives care through Community Health Center, Inc. in Middletown, Conn. Thanks to the Center’s Project ECHO program, an education program for safety-net providers, Luna’s care team is knows more about prevalent health issues among the transgender community and understands how to best interact with their patients.

 

On this week’s HealthCetera, Luna discusses her struggles and triumphs, her focus on staying healthy and the importance of the care CHC provides. I also speak with Wanda Montalvo, PhD, an advance practice nurse at the Weitzman Institute the policy arm of CHC that oversees Project ECHO, about what the real-world ramifications of Medicaid funding cuts mean to vulnerable populations.

 

This segment airs on HealthCetera on Thursday, March 16 at 1:00 PM to 2:00 PM on WBAI 99.5 FM, New York, and is streamed live at wbai.org.

 

You can also listen to the interview here, or on on iTunes.

 

Liz Seegert
Liz Seegert is a health care journalist and directs the media fellows program at the Center. She serves as topic editor on aging for the Association of Healthcare Journalists, writes for a variety of print and online publications and coproduces HealthCetera Radio on WBAI-FM. She tweets @lseegert.