Category Archives: health policy

The next chapter in our unfinished novel


From: Mike KingMike King headshot 2

With the election of Donald J. Trump and Republicans firmly still in control of the House and Senate, we are, whether we like it or not, starting all over again on our tortured and very unfinished journey toward a health care system that is available and affordable for all our citizens.

This has been going on for more than 100 years. While other developed nations created more equitable and less costly (and, I would argue, equal in quality) health care systems we have steadfastly resisted the truth that our medical industrial complex works well for some, not at all for others, and costs way more than it reasonably should. So, after the Affordable Care Act’s noble effort to provide better access to care through a subsidized commercial insurance marketplace, we seem on the verge of blowing it up. I don’t think that will happen as quickly as promised. It’s a big, complicated law and it will take a complicated series of maneuvers to actually “repeal and replace” it. The new President doesn’t really have a replacement in mind. And his fellow Republicans in Congress have all sorts of proposals, most of them recycled free-market talking points about health insurance that have been tried – not all that successfully – at the state level. Expect to hear a lot more about those in the weeks to come.

Some of these ideas are worthy of consideration, if for no other reason, than we need to acknowledge we have tried a lot of things to bend the cost curve in recent years and they barely have budged it. (We got 20 million more Americans a health care plan, sure. But not enough has changed in terms of helping control costs. Perhaps nothing will. But we should be willing to consider all proposals.) You’ll be reading more about them on this blog in the weeks and months to come, if you are interested in exploring them further.

But it boils down to this (it always has): Are we capable of sustaining a thriving, for-profit commercial health insurance industry, a thriving for-profit pharmaceutical industry and a thriving health-care delivery system for a population that has equitable access to all three so that it too may thrive? All the proposals on the table, new ideas as well as the “good parts” of the ACA, should be considered.

One component that bears intense scrutiny and thoughtful reconsideration is Medicaid, the 50 year old program designed to get poor people access to health care. Medicaid, like it or not, has become a whipping boy that some states in recent years have purposely underfunded and undermined. This will be a major component of whatever comes next and it will — as it always has — be the key to the survival of our nation’s public, safety-net hospitals.

We should be open to a whole new approach on Medicaid. (Yes, even block grants, assuming – and this is a big assumption – that they aren’t being offered strictly for cost-saving reasons.) Perhaps there are some worthy experiments to conduct with the states along these lines. Among other things to consider: Why is Medicaid the payer for long-term care for the nation’s elderly and disabled? Shouldn’t there be a separate program for how to pay for nursing home care for those who can’t afford it? Why put these patients in competition for the same dollars with uninsured pregnant women and their children, or the day-laborer who can’t manage his diabetes and relies on the public hospital emergency room because the state says it can’t afford to put him on Medicaid?

Okay, everything back on the table. Except…..

There is one inviolable pact on which those of us who have pledged to equal access will not budge. We should muster all our energy and whatever political clout we have remaining to thwart, obstruct and litigate any plan at the federal or state level, where working people and their families living below the poverty level are purposely ignored and forced to go without the care they need.

That’s non-negotiable.

Better health, fewer deaths linked to Medicaid expansion


The theory guiding the Affordable Care Act’s call for expanding Medicaid to more low income and working-poor Americans is pretty simple: Getting them access to basic medical care will improve their lives and, in the long, run help control the overall cost of health care for millions of previously uninsured people.Mike King headshot 2

But measuring whether that theory works — beyond the anecdotal stories we’ve all heard — is exceedingly difficult, especially since the law is only a couple of years since being implemented.

The statistical evidence is beginning to come in, as illustrated here by this New York Times report about a study in the latest edition of JAMA Internal Medicine.

Looking at health surveys of people in neighboring states — one that expanded Medicaid and one that didn’t — researchers found that, in general, people who qualified for Medicaid in places where enrollment expanded reported better health than their demographically similar counterparts in states that have refused to expand the program. Moreover, those who got coverage reported two consecutive years of better health in follow up surveys.

Deeper dives into health care outcomes in years to come will be needed but this latest study is an indication that expanding Medicaid as the ACA envisioned it appears to be working. These same researchers using similar data points and surveys, two years ago calculated the predicted annual number of lives lost in states that refused to expand Medicaid.

In Georgia, that number is 1,170.

Let that sink in.

More than a thousand Georgians die every year because they don’t have insurance and can’t afford health care. If they lived in Ohio, or New Jersey or another state where Medicaid is available, they would be alive. Why is this not a public health priority?

By way of comparison, the Governor’s Office of Highway Safety wants Georgia to continue the note worthy trend of reducing the state’s annual death toll from traffic fatalities. The target for 2016 is 1,130. That’s a big challenge, given how crowded Georgia’s interstates and highways are.

It would be nice if we could get the number of Georgians who die because of lack of access to Medicaid down as well. That’s not so big a challenge. It’s pretty simple, actually.

Expand Medicaid. Save lives. Improve health.

Mike King is the Author of A Spirit of Charity: Restoring the Bond between America and Its Public Hospitals,” available through and the Seattle Book Co.

Read The New York Times review of the book:



By Arthur L. Caplan and Mike King

The first documented cases of local transmission of Zika infection in Florida illustrate the need for a coordinated and fully funded plan to deal with the public health threat Zika brings with it.

It’s one thing for the International Olympic Committee to ignore the clear and present danger of staging the Summer Games starting Friday in Rio. You can almost expect them to underplay the threat, given the financial investment of their member nations and the Brazilian government’s commitment to holding the games – Zika, raw sewage in the water, and bankruptcy be damned. But it is quite another for elected public officials in this country to walk away from their jobs with no funding and no real plan for what to do when – not if, but when – there is a Zika outbreak among pregnant women, threatening to deform and kill their babies.

It is too early for gloomy predictions of an epidemic in the mainland U.S. While Puerto Rico has been struck with a major outbreak it could be that other parts of the country will get lucky and dodge the Zika bullet.

But that’s the point. We already know enough about Zika to demand more action. We know that it can be spread by mosquitoes and is transmitted sexually by people who show no signs of illness or disease. We know it can get into the blood supply. We know that there is no vaccine or cure that mosquito control programs will help and that safe sex is a good idea. We know that all of us should take precautions while working or playing outdoors in areas where mosquitoes can breed.

And we also know this: That we need a sizeable infusion of federal and state dollars to carry all this out. Unfortunately, when Washington and the states can’t agree on how to engage a potential epidemic, history shows that that the burden of dealing with infectious disease outbreaks falls heavily on public hospitals, public health departments and local safety-net providers as it did 30 years ago with HIV/AIDS. Many of these providers are already overwhelmed dealing with poor and uninsured people with chronic conditions, like cancer, hypertension, heart disease and diabetes. Will the funding for programs these people depend on be set aside to deal with the more imminent threat of Zika? Should it be?

Florida officials have now confirmed more than a dozen cases of local transmission are located just north of downtown Miami. But weeks before that public health departments in South Florida had to scramble epidemiologists to investigate hundreds of potential cases, set up testing protocols to make sure no one is missed and gone door-to-door asking for urine samples. They have stepped up efforts at mosquito control in the region’s wetland-rich breeding vectors. Those efforts will be more important than ever – and more costly – now that it appears Zika-carrying mosquitoes have made their way into Florida’s tropical climate.

And if a locally widespread outbreak happens it will be South Florida’s largest public hospital, financially stressed Jackson Memorial in Miami, which will once again have to muster the expertise and financing to deal with a major public health threat.

Lest we calm our fears by wishful thinking that perhaps the transmissions will be contained to Miami, remember how wrong we were to think in the early 1980s that the first widespread cases of HIV among Haitian immigrants was mostly a South Florida problem. Keep in mind too that Miami is one of the biggest ports of entry into the U.S. from South American countries where Zika is widely circulating already. This includes returning visitors from Rio de Janeiro, which is expecting a half million tourists for the summer games. Brazilian health authorities have acknowledged more than 30,000 cases of Zika in the region around Rio.

The IOC ignored a plea by scientists and public health experts to postpone or move the games with what amounted to a claim that the event was too big to fail. But Congress lacks even that flimsy excuse for its failure to take timely action in this country. Despite President Barack Obama’s request for $1.9 billion in funding for Zika prevention and detection programs, Congress adjourned in July for seven weeks with no plan for how much the federal government is willing to spend.

Once again Republicans in Congress balked at more public funding for a public health emergency, preferring that the total appropriation be much less than what Obama sought. They insisted that whatever money was to be approved be offset by reductions elsewhere in the budget. This line of reasoning about zero-sum budgeting has gained popularity in recent years among the most zealous conservatives in Congress, even extending to special disaster assistance money going the Federal Emergency Management Agency after natural disasters. This crowd wants to hold the public health response from the Centers for Disease Control and Prevention and other federal health agencies to the same standard despite the fact that in outbreaks like Zika ands Ebola, speed matters and delays cost lives.

Even worse, when it appeared that a compromise on the funding level might be reached, conservative House Republicans attached deal-breakers to the measure – inserting language abolishing public funds for Planned Parenthood and some Obamacare programs – which Democrats correctly would not tolerate.

Unfortunately, holding important public health initiatives like Zika prevention hostage has become a standard tactic in a Congress that places a higher priority on ideological obstruction and zero-sum budgeting for anything but military spending. Zika unfortunately does not care about politics. Your children and grandchildren will pay the price for inaction.



Mike King headshot 2

Arthur L. Caplan is director of the division of medical ethics at the NYU Langone Medical Center. Mike King is a journalist and author of the recently released book, A Spirit of Charity: Restoring the Bond between America and Its Public Hospitals.


The Coming Cave-In on Medicaid


Mike King headshot 2This blog is hosted by the author of “A Spirit of Charity: Restoring the Bond between America and Its Public Hospitals,” available on Amazon. com and Seattle Books.

From Mike King

If you want to handicap what kind of Medicaid expansion Georgia and other Southern states that have thus far obstructed Obamacare’s efforts to reach more of the poor and uninsured will eventually embrace, Kentucky is a good place to watch.

The Bluegrass state was, until this year, the very model of how Obamacare and the Medicaid expansion contained within it has significantly reduced the number of people without insurance. Yet last November, voters elected  new Republican governor who campaigned to end the expansion and the state’s highly successful health insurance exchange. Not surprisingly, upon taking office, he began to reconsider both promises, realizing the amount of money the state would lose.  Moreover, it could have dawned on him that his promise put 400,000 or so Kentuckians back into the ranks of the uninsured, jeopardizing their health and turning their care over almost exclusively to the state’s public hospitals who will have no recourse other than to try to recoup their losses by raising local taxes or their charges to privately-insured patients.

So the new governor, Matt Bevin, has spent the first six months in office trying to fashion an alternative to the Medicaid plan now in place in Kentucky. He wants to seek a waiver from the federal government that creates a new set of rules for who qualifies for Medicaid and what is expected of them. Those new provisions are straight out of the Medicaid-is-a-Welfare-Program playbook, popular among Republican office holders in the South. It would, among other things, require new Medicaid enrollees to work, or be seeking jobs, or volunteer opportunities in order to qualify for coverage. It would also charge them premiums and deny coverage for six months, and require re-enrollment, if they fell behind on their premium payments.

Sound familiar? Republicans in the South have over the years conditioned many social welfare programs — from unemployment to food stamps to temporary assistance for needy families — on such moral hazard principles. It’s not a new thing. It goes back decades. As A Spirit of Charity details, in the post-New Deal era, Southern politicians looking to roll back some of FDR’s most successful programs, lobbied long and hard for allowing the states to set the rules for who gets government assistance and when. In those days, race played a significant role in the decision making. (A good argument could be made that it still does in some places.) But the basic premise — that able bodied Americans should work and save money and provide for themselves and not be dependent on the government — still holds for many political leaders in the South. When Medicaid was created as a health care program for the poor in 1965, the states were given considerable leeway in deciding who qualified for it and how much they would pay doctors and hospitals who provided care to them. The 2012 Supreme Court decision that made Obamacare’s Medicaid expansion an option for the states reinforced that when it comes to care for the poor the states still have a lot of say.

But the prospect of losing billions of dollars in federal funding for Medicaid expansion is simply too much to ignore, especially now as the Obama administration draws to a close and the political value of mindless bashing of anything connected to Obamacare is fading fast. Even in Georgia, where obstruction of Obamacare has been an organization principle of Republican politics, the tide is turning.

So be on the lookout for workfare/healthcare demands on new enrollees if Georgia and other southern states start creating new Medicaid expansion plans. Look, as well, for premium-sharing plans so that the poor will have to pay something to get coverage. (And yes, it’s not a stretch in this region of the country for our political leaders to demand drug testing for adult Medicaid enrollees.)

The question then becomes, will these requirements pass muster with the Obama administration, or a Democrat in the Oval Office in January of 2017?

The answer, more than likely, is hell-to-the-no.

Medicaid is not a welfare program. Placing work and earnings requirements on enrollees destroys the purpose for its existence. Decades of trying to do just that have demonstrably resulted in millions of Americans unable to afford health care access. There is no science to show that demanding such requirements will succeed in moving the poor from Medicaid to private insurance. Recent history has proven quite the opposite. As more and more employers ditch coverage, especially to part-time workers like those who make too much now for Medicaid, the need to be covered by a government plan has become more acute, not less.

This is not to say that a take-it-or-leave-it approach to Medicaid as we know it now is good public policy either. The program has its flaws and needs serious reconsideration. States that want to seek waivers trying to find better systems of health care delivery — the use of medical homes, telemedicine, nurse practitioners, physician assistants and other allied health professionals where there are shortages of primary care doctors — should (and have been) encouraged. Put those ideas and others in a waiver application and they will get a fair hearing.

No one disagrees that there is a huge need to make Medicaid a better, more effective program. Doing so will bring this country closer to the goal of joining the rest of the economically developed world when it comes to guaranteeing health care for all its citizens. But if your state’s waiver plan is premised on the notion that the poor are the problem and they should be paying more for their care, then you are about 50 years too late to the debate. You’ll need a better plan than that.



Blowing up the system

One of the most interesting aspects of the 2016 Presidential race thus far is that the discussion over the Affordable Care Act — what little discussion there is — has involved, essentially, blowing up the system and starting over.

Democratic candidate Sen. Bernie Sanders has gained significant traction with his call of “Medicare for all” — another way of talking about a single-payer system like the one in Canada (which is actually called “medicare”). The buzz stirred by Sanders and his supporters for a single-payer plan, with the government being the player, can be directly traced to the complicated and not-so-consumer friendly Affordable Care Act. The 2010 law has gone a long way toward getting millions of Americans coverage, but falls short of being all that affordable for too many and is still out of reach — thanks to backwards-thinking states like Georgia — for millions of low income people who should be, but aren’t covered by Medicaid. Why not simplify it? Enact payroll and income taxes to support it and make health insurance available to everyone — young, old, affluent and poor — the way Medicare is available to everyone over the age of 65.

The discussion on the Republican side has had a less-than-lofty tone, with presumptive nominee Donald Trump promising to repeal Obamacare and replace it with something or another that someone or another will present him when he becomes the greatest president of all time. Trump has also declared that he wouldn’t let people die in the streets, which has been — for more than a century now — the default health care policy of the United States since public hospitals, like Atlanta’s Grady Memorial, serve everyone regardless of ability to pay. (In this way, America doesn’t let our poor die on the streets. They can get sick on the streets, but they die in public hospitals because we don’t have a mechanism to ensure their health to keep them out of the hospital.)

On a more serious note, Republicans in Congress, including Georgia’s Tom Price, have offered boilerplate GOP proposals for repealing Obamacare and making insurance more affordable by instituting high-risk health pools, selling cheap policies across state lines, enacting more limits on malpractice lawsuits and other fixes that have demonstrably failed in the past at controlling costs or getting more Americans coverage. Interestingly, none of the talked-about plans have had a serious airing in the Republican-controlled House or Senate.

Now comes two more Republicans, Rep. Pete Session of California and Sen. Bill Cassidy of Louisiana — states with some of the highest rates of uninsured Americans — to offer another GOP plan. They want to change the tax code so as to provide every American adult with $2,500 to purchase coverage. They would do away with the tax credits provided to American employers for covering their workers on the job and essentially throw open the health insurance market to buy health insurance the way we now buy auto or home insurance.

Not gonna happen.

Just like Bernie’s single-payer plan, to do either of these things would require the current health insurance system to be torched and rebuilt from the ashes. For better or worse, the employer-based system we have now has been in effect for seven or so decades. It’s not going away, not very easily anyway.

It is no surprise that neither plan outlines in any detail how we get from here to there — from the current system of Medicare, Medicaid, private commercial insurance purchased on the Obamacare exchanges or elsewhere, or insurance provided and paid for by employers and their employees. How, under what time frame, do we go from this to a single payer, or a $2,500 stipend for everyone to go buy a plan on their own?

These are important questions that need be answered. Vox has a good piece up today about what would be needed to get to what Bernie is taking about.

My own best guess is that the Sessions-Cassidy plan is mostly just election year talk, whereas the single-payer option will continue to have resonance if a Democrat retains the White House in November. But we are still a long way from either. Meanwhile, we have Obamacare and in all likelihood we’ll tinker with that first. Incrementally, and with no small amount of blood, sweat, tears and another round of misrepresentation and outright lies about the impact — we’ll eventually adopt a universal plan that, in the end, looks a lot like Medicare-for-all.

Mike King headshot 2


Mike King is the author of “A Spirit of Charity: Restoring the Bond between America and Its Public Hospitals,” on sale now through Amazon.com


Doomsday for Obamacare: Again?



IMG_1864News that UnitedHealth Group, the nation’s largest commercial insurer, is withdrawing from the Affordable Care Act’s state exchanges because it can’t make enough money on them, has set off the latest round of gloom-and-doom predictions for Obamacare. Predictably, this rendering of failure, like all the others, is coming from opponents of the 2010 law that has made health insurance available to millions of Americans who otherwise may never have had an opportunity to purchase it.

This was the message in the Washington Post Tuesday from a fellow at the American Enterprise Institute.

It’s worth noting that the big insurance firm’s decision to get out of the ACA marketplace is not good news for Americans living in rural areas who rely on the insurance exchanges to get individual coverage. Indeed, in those sparsely populated areas of the South and West UH’s withdrawal will likely lead to fewer choices for many residents who can only afford what’s available on the government-subsidized exchanges.

But a little perspective about the company’s decision is needed as well. And when examined more closely, the Obamacare-is-destined-to-fail scenario of opponents is once again shown to be wishful-but-unhelpful thinking.

Here’s one of the better analyses I’ve seen of it — offered by a columnist and blogger for The Los Angeles Times.

Digging deeper into these developments as Obamacare evolves is extremely important because most Americans have little understanding how the health insurance marketplace works. As such they can be easily misled — and, as recently shown, lied to — about what’s happening and why.

I’m certain that many readers reacted with alarm when they heard the news last week that UnitedHealth was going to ditch its ACA exchange plans,. I’m willing to bet that most didn’t know that the company’s decisions does not impact the plans it offers to consumers through coverage they get on the job, or through an employee retirement plan or its large and profitable Medicare Advantage plans. Nor were critics quick to point this out because in their world any tremor in the health insurance force is ALWAYS a direct result of Obamacare, even when it isn’t.

In reality, the decision is limited to those plans the company was offering through the individual market exchanges, an arena UnitedHealth reluctantly joined in the first place, And even then, it declined to create low-cost premium/high deductible coverage plans in many markets. That one decision clearly put the company in competitive disadvantage with companies that were more than willing to jump into that part of the individual market, which we know now is the most popular with consumers. (Whether that tier of coverage is a good thing — it may be affordable, but is it really helpful? — is a much different topic and remains one of the most important policy questions remaining to be answered in the first years of the ACA.)

Indeed, the evolution of the insurance market after the ACA seems to be shaking out pretty much as the experts who promoted it in 2010 said it would. Millions of Americans who were screened out of the market before the ACA because of pre-existing medical conditions can now get insurance. Others, thanks to the individual mandate and subsidies, can afford coverage for the first time. And yes, some who had individual coverage in the past that they paid out of their own pockets have had to purchase new policies on the exchanges, a disruptive process that critics unconvincingly exploited as the beginning of the end of Obamacare. In reality, many of these consumers also qualify for subsidies now to help them afford better plans than they had in the first place.

And lastly, the American-revered concept of for-profit, commercial health insurance survives, even as the government plays an important role in helping make insurance more affordable and comprehensive. UnitedHealth is still a hugely profitable enterprise. It still offers employers and retirees and others in large-group markets a range of coverage options. It has simply decided to get out of the individual market because it wasn’t making enough money in it.

Too bad for them. Buh-bye.


Mike King headshot 2

Mike King is the author of “A Spirit of Charity: Restoring the Bond between America and Its Public Hospitals.” Advance ebook sales are available online through Amazon. The book will be available for full release May 31, 2016

The insurance market, Georgia style



By Mike King, author of A Spirit of Charity


So, another session of the Georgia General Assembly has drawn, gloriously, to an end. We should all breathe a sigh of relief. The inmates are finally out of the asylum again. (Okay, I know that’s counterintuitive, but if you’ve ever spent any time around the Georgia legislature, you know what I mean.)


For public health advocates, there was little to cheer in this session. But then again with this bunch of solons,  just keeping stupid stuff from happening can be counted as progress.


Case in point: While other states are re-examining their knee-jerk opposition to expanding Medicaid under Obamacare, Georgia remains consistently obstinate – to the point of turning away about $9 million a day in federal funding that would allow hundreds of thousands of the state’s low-income adults and families to qualify for coverage.


At least this year there was no effort to claw back any more provisions of the law that would make it easier for people to sign up on the Obamacare exchanges. It wasn’t that long ago that the Legislature and Insurance Commissioner  threatened state employees (at UGA, in public health departments and other state government agencies) with repercussions if they agreed to become unpaid, volunteer navigators that the new health law encouraged in order to help people understand their rights and benefits.


But  this year something even more ironic happened. Had it not been for the vigilance of The Atlanta Journal-Constitution in shining a spotlight on the usual shenanigans at the Gold Dome in the last weeks of the session, the state’s poor, put-upon insurance brokers would have had a guaranteed commission for any policies they sold on the Obamacare marketplace.

Yes, you read that correctly. The Legislature seriously considered a law that would have guaranteed insurance brokers a minimum commission.

These free-market-loving legislators were complaining, bitterly it turns out, that the health insurance companies were hosing their friends in the brokerage business. They contended the insurance firms were shortchanging the agents because the big companies were only being allowed to get a 20 percent return on premiums under Obamacare rules governing  profits, marketing and administrative expenses of the companies selling plans on the exchanges. That’s just plain unfair, or so the legislators – many of whom sell insurance in their day jobs – seemed to think. The dirty little secret, of course, is that individuals don’t need an agent to go on the exchange to help them find a policy – no more than you need an airline reservation clerk to book you a ticket, or a paid advisor to help you sign up for natural gas service or digital television. Perhaps an agent would be helpful in finding group policies for small businesses, but compensation for that role is usually negotiated between the agent and the company he or she is touting. If they don’t like the deal, the brokers could walk away. But, no, they wanted the Legislature to guarantee them a piece of the action.

In the end this heaping helping of special-interest guano was too much for the legislative leadership to swallow, especially once the newspaper was on the story, so the insurance-broker-full-employment-bill died a much-deserved death.


Meanwhile, as Andy Miller at Georgia Health News reports, the impact of the state’s resistance to Medicaid expansion can now be quantified in an area where Georgia has a pretty shameful history to begin with.

The hits just keep coming.

I suspect the guaranteed commission bill will be back next year, as will the advocates of hundreds of thousands of Georgians who just want a little help finding affordable insurance. It is, and always has been, a matter of priority.


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Spirit Cover

Why we don’t let people “die in the streets”

Spirit CoverA Spirit of Charity: Restoring the Bond Between America and  Its Public Hospitals will be available in print from Secant Publishing in May 2016. This column is drawn from the author’s research.

You’re forgiven if you can’t quite make out the Republican front runner’s health care reform policy positions. Donald Trump is not one for articulating details. Yes, he brings up the usual talking points his party’s leaders have offered over the years — Medicaid block grants to the states, more tax breaks for health savings accounts. You’ve heard those many times. But his overall vision of what the post-Obamacare-Donald Trump policy would look life can be summed up with this oft-repeated assurance:

“I will not let people die in the streets.”

Why doesn’t make you feel better?

Well, for starters this country decided a long, long time ago (during Colonial times) that not letting people die in the streets was a worthy goal. In fact, this is why large public hospitals like Bellevue in New York City and Charity in New Orleans were created in 1736. It’s also why places like Grady Memorial in Atlanta and County Hospital in Chicago opened a century or so later while European nations embarked on a path toward tax-supported health care for their populations. In our country the Bellevues, the Gradys and the Countys  and a few dozen others like them are more than safety net hospitals, they are the safety valves for a $3.2 trillion health care system that still hasn’t figured out how to care for the poor and uninsured.


When you really examine it, it’s more that a little embarrassing that of all the other comparable nations in the developed world, the U.S system remains so profoundly warped. Only here do we seem satisfied that when poor people develop chronic, treatable medical conditions they can at least get rescued by a public hospital when they finally get sick enough to need one.

Even now, even after the Affordable Care Act — the law Trump and his Republican colleagues want to repeal and replace (with what, no one seems to know for sure) — the continued existence of large, urban, public hospitals with charity missions make the unfinished business of health care reform so much easier to put off by voicing such platitudes that we won’t let people die in the streets.

You may have heard other versions of Trump’s not-to-worry health care position before. President George W. Bush, in justification of his veto of expansion of the Children’s Health Insurance Program for low-income families that Democrats tried to foist upon him in 2007, famously declared that it wasn’t needed because Americans already have access to health care, regardless of their ability to pay. They need only go to a hospital emergency room, Bush said.

True, that. But also truly inadequate. Then and now.

Indeed, the law that requires most American hospital ERs to take in people without ability to pay stems from evidence compiled by the medical residency staff at Chicago’s Cook County Hospital in the 1980s. County physicians documented that competing private hospitals were routinely turning away indigent patients — including pregnant women about to deliver — and sending them instead to County. When they published their findings in a prestigious medical journal, public hospital physicians around the country reported the same thing was happening in their communities.

The resulting 1986 law, known as EMTALA (Emergency Medical Treatment and Active Labor Act), forbids the practice that became known as “patient dumping.” It’s a good law and it has no doubt stopped some of the worst abuses. But the reality is that it only applies to patients deemed to be presenting with an “emergency medical condition.” If they aren’t considered in danger of death, the hospital can legally turn them away.

Still, most American hospitals are pretty good about treating indigent patients who show up in a emergency room with a chronic conditions like  diabetes, hypertension, even cancer. They write off millions of dollars of ER charges every year. But their responsibility ends once the patient is out the door — with or without a prescription or a follow-up appointment with a physician to manage the condition that sent him or her there in the first place.

This helps explain why life expectancy among Americans remains below 80 years and lags badly behind Japan, Italy, France, Canada, the United Kingdom, and 43 other nations. And why, as well, that we spend on average nearly $8,000 per year per person on health care while France spends, on average, half of that

Life expectancy by race within our own country raises even more troubling questions. Consider that there is an astounding 25-year difference between the life expectancy of Asian-American women and African-American men living in the United States. The former can expect to live, on average, 86.7 years, while the latter live just 61.7.

This is where public hospitals must shoulder the burden of a health care system that has no real program to assist the millions of Americans who remain uninsured. Yet the mission of the nation’s largest public hospitals over the years has expanded to go beyond the emergency room and attempt — often without the public financing they need — to provide primary care services to the poor and uninsured to keep them well and out of the hospital.

Public hospitals in urban areas, like Grady Memorial in Atlanta and others with large African-American populations suffering from hypertension, offer some of the best stroke and stroke recovery care in the nation. But they often go beyond just being there for stroke victims. They have vigorous outpatient and in-the-community programs aimed at preventing and controlling hypertension in populations at-risk for stroke. Cook County Hospital  has a highly coordinated program with Chicago’s federally-funded primary health care clinics to manage the chronic conditions of the city’s large Medicaid enrollees so that they can stay well. By doing so they not only keep the patients healthier, they help control Medicaid’s costs.

But public hospitals often fight these public health battles without the help they need from local, state and federal officials who look for marketplace miracles to minimize public spending on health care instead of examining how to do it better. The ACA has gone a long way toward extending health insurance to millions of Americans who couldn’t afford it before the law was enacted. But there are still about 30 million without it — many of them in states where political opposition to the law’s Medicaid expansion trumps (forgive the pun) the wisdom of receiving billions in federal financing. This desperately needed money that is being sent back to the federal treasury would go a long way toward insuring more low-income workers and their families, not to mention help public hospitals keep them healthy.

No matter who moves into the White House in January 2017, we still have a lot of work to do when it comes to health care reform. Perhaps the first place to start is to challenge the role of the states in setting Medicaid enrollment and reimbursement policies. There is a reason that Texas, Florida and Georgia have the most uninsured residents in the country after Obamacare was fully implemented. By refusing to expand Medicaid those states and about 15 others have purposely left millions of working poor people behind in the arrogant confidence that public hospitals won’t let people die in the streets.

Because of a dysfunctional health care system many of these Americans will die instead inside a hospital. Isn’t it time to find a way to take care of them before they need to go there?

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The author, a former editor, writer and columnist at The Courier-Journal in Louisville, Ky. and The Atlanta Journal-Constituton, blogs about health policy issues.

AMA jeopardizes Jeopardy ad base


Mike King headshot 2If you are one one of those geezers like me who still watches the network nightly news and then stays tuned for Jeopardy, you know about the proliferation of drug advertisements that dominate these shows. Ads for erectile dysfunction, benign prostate hyperplasia (together and separately), constipation, inflammatory bowel disease (rarely together, mostly separately), arthritis, fibromyalgia, type 2 diabetes — the list goes on — have become the advertising base for these programs. They are aimed at an audience demographic of people who pay attention to what’s out there for chronic medical conditions facing many of us. (Let me just stop right here to say that getting old is not for sissies.)

The question now is whether the $4.5 to $5 billion a year spent to promote these products is a good thing, given how expensive pharmaceuticals — even generics — for many chronic conditions have become? It’s also worth asking, how are they impacting consumer spending and could the these promotions for certain drugs cause more harm than good?

The American Medical Association meeting in Atlanta yesterday thinks they may not be worth it. It is considering asking for a ban on such ads.

I’ve been following direct-to-consumer (DTC) drug advertising for years, since commercials for prescriptions in the highly competitive lipid-lowering (cholesterol control) market started showing up in the 1990s. The same misgivings about the wisdom of these ads now were voiced then: Will they push patients to demand their physicians write scripts for drugs that won’t work, or could be harmful? Are they even necessary? Many doctors at the time said it’s their job to keep up with the latest treatment protocols and they routinely stay up to date on how new drugs on the market perform and whether they might be good for their patients.

The drug manufacturers countered that the ads serve a very useful purpose in making consumers aware of the conditions they treat. From a broader perspective, the ads could actually help people suffering from depression, anxiety and other rarely-discussed conditions seek treatment, the manufacturers said, noting that all of their voice-overs include “talk with your doctor” language.

This line of thinking prevailed and, for the most part, the government’s regulatory apparatus allowed them to proceed. (Aside from the litany of potential side effects the manufacturers are required to note in each commercial for their product.)

Then Viagra hit the market and direct-to-consumer advertising exploded. Indeed, after those ads started appearing, as well as ads for competitors Cialis and Levitra (whatever happened to the Levitra ads?) middle-aged men flocked to their physicians to ask for the magic pills. The ads did a little more than raise awareness, if you know what I mean. They clearly drove demand for the product.

More recently, I have been intrigued by DTC advertising for two classes of drugs that, at least to me anyway, seem to have a much more limited market. You may have seen them as well and wondered the same thing.

One is for a condition called opioid induced constipation. (Lovely topic, thanks Mike for raising it.) If you have ever taken Percocet or hydrocodone after surgery to control pain, you may have learned that constipation is a side effect to those potent meds. But that’s usually a temporary condition, isn’t it? Once off the drugs, your body seems to return to normal function. Even while on them there are plenty of over-the-counter remedies that could be employed.

Is there really a need for a prescription-strength medication to deal with this issue? I suppose so if you must take these powerful meds over a longer period of time, but long term use of opioids poses much more serious risks (addiction, being the most obvious). Will marketing a drug to deal with this one side effect drive pain-management patients to physicians asking for more Percocet? I honestly don’t know the answer. Maybe it’s not a major issue. But then again, do we really need a television advertisement to suggest pain management patients discuss this with their doctors? Wouldn’t any doctor who prescribes opioids be discussing the risks of the drugs, including constipation?

The other newly advertised drug I have seen recently is for late-stage lung cancer. This one is intriguing for lots of reasons, not the least of which would be the small market of patients it seems to be targeted to — a patient market that by definition should be intensely monitored by cancer specialists and other experts. The new drug is being pushed as a medication that “could extend your life,” meaning that it isn’t a potential cure for the disease but might give you a few more months to live when you are in the end stages of the disease.

There are dozens of clinical trials for these important drugs that may one day be routinely prescribed for end-stage cancer patients. Some of them have very encouraging initial results. But so far, most of them provide a life-extending measurement of months, not years. (In the fine print in the commercial for this one drug you’ll see that this is disclosed. But you might miss it against the backdrop of images of healthy-looking people enjoying life with their grandkids and pets.) And, we have to note here as well, they are very expensive and not always covered by insurance the way conventional chemotherapy is.

My concern is this: End stage cancer patients are a particularly vulnerable group. So are their families. They see an ad like this and will be at their physicians door the next day wanting that drug.  I suppose if the physician has neglected to discuss all the treatment alternatives available and the risks and benefits and costs of each, that’s not a bad thing. But will that very effective advertisement drive the decision more than physician judgment?

I honestly don’t know the answer. At a time when drug costs are driving up the overall price of health care in this country, the subject of direct-to-consumer advertising bears more examination.







What You Should Know About Open Enrollment Season


It isn’t fuMike King headshot 2n, but it really is important this time of year to look closely at your health insurance options, especially if you are on an individual plan through the Obamacare exchanges. It’s also true within the menu of options available to you through an employer.  Working around the edges, insurance companies change benefits, premium charges and out-of-pocket costs almost every year. They do this to maximize profits. That’s why they are in the business. So it is best to look closely at what you have now and what you can afford next year.

I like to make the analogy to signing up for residential natural gas service. Most of us only do that once even though the contracts we sign with marketers can adjust the per-therm rate, service fees and other costs once the contract expires and we fail to take note. Or think about your cable bill. How much has that monthly charge for your cable box/DVR set increased over the years? When did the “Premium Package” get so expensive?

It ain’t always easy, which is why many of us just sign up to renew our existing health insurance plans. And, by the way, when your friends start complaining about Obamacare being the cause of health insurance costs going up, ask them if they have shopped around for a potentially better plan at a better cost. They should. That’s how the health insurance system is designed to work in this country.

Here’s an excellent Washington Post piece on the subject.