Health insurance can literally be a life-or-death issue

Health insurance is not health care (and just because health insurance premiums rise does not necessarily mean health care is more expensive), but health insurance is a crucial mechanism that we use to finance and access health care.

And, in some cases, not having health insurance can be the difference between life and death. Just take a look at the results of two studies  published in the August issue of the journal Cancer comparing survival rates for men with two forms of cancer based on insurance status.

From the first study, regarding glioblastoma multiforme, an aggressive type of brain cancer:

Among the 13,665 adult patients in the study cohort, 558 (4.1%) were uninsured, 1516 (11.1%) had Medicaid coverage, and 11,591 (84.8%) had non-Medicaid insurance. Compared with patients who were uninsured, insured patients were more likely to be older, female, white, married, and with a smaller tumor size at diagnosis. Accelerated failure time analysis demonstrated that older age (hazard ratio [HR], 1.04; P<.001), male sex (HR, 1.08; P<.001), large tumor size at the time of diagnosis (HR, 1.26; P<.001), uninsured status (HR, 1.14; P =.018), and Medicaid insurance (HR, 1.10; P =.006) were independent risk factors for shorter survival among patients with GBM, whereas radiotherapy (HR, 0.40; P<.001) and married status (HR, 0.86; P<.001) indicated a better outcome. The authors discovered an overall yearly progressive improvement in survival in patients with non-Medicaid insurance who were diagnosed from 2007 through 2011 (P =.015), but not in uninsured or Medicaid-insured patients.

Rong, X., Yang, W., Garzon-Muvdi, T., Caplan, J. M., Hui, X., Lim, M. and Huang, J. (2016), Influence of insurance status on survival of adults with glioblastoma multiforme: A population-based study. Cancer. doi:10.1002/cncr.30160

Translation: patients with private insurance lived the longest with this form of brain cancer. In terms of surviving glioblastoma multiforme, Medicaid did not seem to make a difference compared to being uninsured.

And the second study, regarding germ cell testicular cancer:

Uninsured patients had an increased risk of metastatic disease at diagnosis (relative risk [RR], 1.26; 95% confidence interval [CI], 1.15-1.38) in comparison with insured patients, as did Medicaid patients (RR, 1.62; 95% CI, 1.51-1.74). Among men with metastatic disease, uninsured and Medicaid patients were more likely to be diagnosed with intermediate/poor-risk disease (RR for uninsured patients, 1.22; 95% CI, 1.04-1.44; RR for Medicaid patients, 1.39; 95% CI, 1.23-1.57) and were less likely to undergo lymph node dissection (RR for uninsured patients, 0.74; 95% CI, 0.57-0.94; RR for Medicaid patients, 0.76; 95% CI, 0.63-0.92) in comparison with insured patients. Men without insurance were more likely to die of their disease (hazard ratio [HR], 1.88; 95% CI, 1.29-2.75) in comparison with insured men, as were those with Medicaid (HR, 1.58; 95% CI, 1.16-2.15).

Markt, S. C., Lago-Hernandez, C. A., Miller, R. E., Mahal, B. A., Bernard, B., Albiges, L., Frazier, L. A., Beard, C. J., Wright, A. A. and Sweeney, C. J. (2016), Insurance status and disparities in disease presentation, treatment, and outcomes for men with germ cell tumors. Cancer. doi:10.1002/cncr.30159

Translation: men who had private insurance were 88 percent more likely to survive germ cell testicular cancer than those who were uninsured, and the men who had Medicaid were 58 percent more likely to survive than those who were uninsured.

In both studies, patients with private insurance tended to be diagnosed earlier on the disease progression than uninsured and Medicaid patients, and this was shown to be important to a patient’s survival.

Arguments for the left and right

There is fodder here for both sides of the political aisle. On the one hand, liberals can point to the 58 percent increase in survival rates among Medicaid patients compared to those who were uninsured. And they can also point to the researchers’ acknowledgement that many of the Medicaid patients were likely to have been uninsured until just after being diagnosed with cancer. Clearly having Medicaid was better for these patients than having no insurance at all.

And yet, on the other side of the aisle, conservatives can point to the results of the first study that, despite all the tax dollars spent on Medicaid, it did not seem to make a difference in survival rates compared to having no insurance at all. Even with the second study, the right can point to the far superior outcomes of patients with private insurance compared to those with Medicaid, even while acknowledging that Medicaid was better for those patients than being uninsured.

Underlying issues

So, what’s an objective observer concerned about health policy supposed to make of these results? I have a few suggestions.

  • Private insurance probably improves access to care because reimbursement rates for physicians and hospitals are much higher than Medicaid. Many physicians will not accept Medicaid patients due to the very low reimbursement rates. Medicaid can also have issues with the timeliness of reimbursement, depending how much funding is left in a given state’s Medicaid budget. Even the physicians who do accept Medicaid might be less inclined to proceed with aggressive cancer treatments for their Medicaid patients than they would be for their patients with private insurance. The germ cell study found that Medicaid and uninsured patients did have a different treatment path from patients with private insurance, but this might be because they were also diagnosed later.
  • Medicaid isn’t as good as private insurance, but it’s better than nothing. Particularly for the germ cell cancers, Medicaid patients had much better outcomes than uninsured patients even though they did not fare as well as the patients with private insurance. Medicaid certainly has its administrative and funding/reimbursement challenges as a government bureaucracy reliant in part on state government sources, but does anyone seriously believe this is causing the cancer patients in their population to die in such large numbers? I’m all for innovations to make Medicaid as efficient as possible so that it can serve these populations as effectively and cost effectively as possible, but the idea that is it a hindrance to care for people who can’t afford private insurance is simply not borne out by the evidence. One learning point from these studies for Medicaid plans is to do more to encourage their populations to get cancer screenings so that these cancers can be caught earlier, but that doesn’t fully explain the insurance disparities.
  • These comparisons don’t represent realistic policy choices. I don’t know of anyone on either side of the aisle who has proposed putting the Medicaid population on private health insurance plans like the ones employers offer to their employees. Republicans would balk at the high cost to taxpayers, and Democrats would balk at the high levels of cost sharing for poor people who can’t afford it as well as the involvement of private insurance companies in general. Sure, some private health insurers have contracts with state governments to administer managed Medicaid plans, but those plans still don’t reimburse physicians and hospitals the way private plans do. They’re not equivalent. Even the private health insurance plans that are available on the exchanges for people a little higher up the economic ladder than Medicaid patients tend to have lower physician and hospital reimbursement rates than most employer-sponsored or individual plans outside of the exchanges. Considering how many Medicaid patients are covered by managed Medicaid plans operated by private insurance companies, one would think these private insurers would be able to close the gap between their regular insured and their Medicaid patients. Given the very real policy implications being debated in state legislatures today, it would be interesting to learn if there are real disparities between managed Medicaid and traditional Medicaid patients, but so far that research is lacking.
  • Medicaid is not Medicare, and it’s especially not single payer. Some on the left, like Senator and former presidential candidate Bernie Sanders, have been calling for a single-payer system that would essentially be “Medicare for all.” Medicare’s reimbursement rates are lower than private insurance but higher than Medicaid, and Medicare have the same payment timeliness issues that Medicaid does because it’s funded entirely by the federal government without involvement of state governments. Unlike Medicaid, physician participation in Medicare is already nearly universal (although I don’t know of too many pediatricians who take Medicare patients today because most Medicare beneficiaries are over 65). Eliminating private health insurance and moving to a “Medicare for all” system regardless of age would bring those pediatricians and the few outliers from other specialties into the Medicare fold because there would literally be no other source of income for them if they intended to continue practicing medicine at all.
  • Achieving equally bad outcomes would be a pyrrhic victory. I’ve seen bumper stickers from conservatives that read, “Liberals want misery spread equally.” It’s a concern worth addressing. If we address these disparities by merely reducing the survival rates of people who currently have private insurance, things will be equal, but no one will be better off. For germ cell testicular cancer, the research tells us that taxpayer dollars spent on Medicaid are quite literally saving lives for people who would otherwise be uninsured. But it’s very important that we understand the complex reasons why the Medicaid population is experiencing these disparities compared to the population with private insurance and address them. My health economics professor from graduate school would say that we need to build a better model.

Republicans choose poison pills over Zika virus prevention

The Zika virus is a very scary thing indeed, and it is on the march here in America.

As of June 22, 820 cases have been reported in U.S. states and the District of Columbia, and another 1,860 cases have been reported in U.S. territories.

In February, President Obama requested $1.9 billion from Congress to fund Zika virus prevention. Congressional Republicans have responded with a bill that provides $1.1 billion in funding plus $622 million in reallocated funds.

It’s not everything President Obama asked for, but under ordinary circumstances he’d probably be eager to sign it. But he can’t sign this bill.

Why? Because Republicans have loaded the bill with a GOP wish list of exemptions from the Clean Water Act. Emergency pesticide use in cases like stopping the Zika virus is already exempt from these Clean Water Act regulations, but Republicans are counting on voters not to make such a fine distinction and just deregulate pesticide use in general. This bill also includes language prohibiting taxpayer funding for abortion (because the Zika virus causes birth defects), but the Hyde Amendment already prohibits that to begin with.

Republicans want to force President Obama to veto the bill so it looks like he doesn’t care about stopping the Zika virus — even though he asked for this funding back in February. It’s a poison pill: burying deal-breaker language in a piece of seemingly uncontroversial legislation just to embarrass your political opponents when they can’t support it, and it’s a tactic that both sides use all the time.

Since both sides agree that the funding is necessary, the games that politicians on Capitol Hill are playing with this legislation are wasting valuable time in the eyes of the people whose job it is to actually prevent the disease.

This is no way to fight an epidemic…Three months is an eternity for control of an outbreak. There is a narrow window of opportunity here, and it’s closing. Every day that passes makes it harder to stop Zika.”

Dr. Thomas Frieden, CDC director, May 2016

John Oliver buys – and forgives – $15 million in medical debt

John Oliver, host of Last Week Tonight on HBO, did something truly incredible recently. He purchased nearly $15 million in medical debt…and then forgave it all.

As wonderful as that act of generosity was, it was barely a drop in the bucket for the gigantic problem of medical debt in the USA.

Disclaimer: It only cost John Oliver $60,000 to buy this debt, but that’s still hugely generous.

Are medical marijuana laws just a gateway drug?

Marijuana will never be legalized because pot smokers cannot remember when to go to the polls. “Darn, I thought that was Super Thursday.” Drew Carey

Call me a nerd if you like, but if there’s one thing that I find the most frustrating about the debate over marijuana legalization, it’s the lack of good, reliable data for public health. The biggest reason for that is how difficult it is for public health researchers to collect data about people’s use of an illegal substance. People tend to be reluctant to talk openly about their participation in activities that could get them arrested.

Is it legal anywhere?

Of course, even the legality question is not a straightforward one. Despite laws allowing marijuana use for medical and even recreational purposes in 23 states and the District of Columbia, the federal government still has the authority to raid dispensaries and homes if it sees fit to.

Map of marijuana laws by state

Although cannabis is still illegal as a Schedule I drug under the federal Controlled Substances Act, many 23 states and the District of Columbia have passed their own laws allowing marijuana for medical or even recreational use. Source: Governing, 2015.

In 2002, the Drug Enforcement Agency raided the homes of California residents Angel Raich and Diane Monson and destroyed their marijuana plants. What Raich and Monson were doing was legal under a 1996 California state law, but not under federal law. Raich, Monson and two anonymous caregivers sued the federal government, and the case made it all the way to the U.S. Supreme Court in Gonzales v. Raich. In 2005, the Supreme Court decided 6-3 in favor of the federal government.

In spite of the ruling in favor of the Bush administration (the Gonzales in Gonzales v. Raich was Attorney General Alberto Gonzales), the Obama administration decided to leave marijuana users in these states alone. But another change in presidential administrations in 2017 could lead to a change in enforcement, as Chris Christie suggested when he was on the campaign trail.

Does medical marijuana need tighter regulations?

For people like me who live in states where marijuana is illegal under all circumstances, it may be difficult to picture exactly how things work in a state that permits medical marijuana. So I’ll let Drew Carey explain what it’s like in California, where marijuana is legal for medical purposes.

What Carey left out was how gray and unregulated the medical marijuana marketplace is in California.

It’s very easy to get a medical marijuana card in California. And, if you ask the right doctor, you can get one for virtually any medical condition you can think of. And the right doctor is pretty easy to find.

Doc 420 billboard

This “trusted and experienced” California medical marijuana doctor, advertises with billboards. She also has a website at www.doc420.com.

I don’t know about you, but all this strikes me as very bad medicine.

Before Colorado decided to legalize cannabis for recreational purposes beginning in 2015, it allowed medical marijuana. And, just like in California, the unregulated market (especially after 2009) led to some alarming medical practices. Here’s how one Colorado physician explained it.

Suppliers of pot to medical marijuana card holders are designated as primary care givers (yes, appallingly close to the term primary care providers). Additionally, the bulk of medical marijuana recommendations are written by a small number of doctors who make huge incomes without practicing within accepted standards that the rest of us must follow (performing diagnostic work-ups, counseling on the risks and benefits of possible treatments, and following up on effectiveness and side effects of treatment). Laurie D. Berdahl, MD, Medical Economics, 2012.

This might seem harmless to you, but there have been some negative public health outcomes as a result of lax medical marijuana regulations. And, fortunately, there is some credible data available on this.

Hospital discharges coded as marijuana-dependent increased 1% per month (95% CI=0.8, 1.1, p<0.001) from 2007 to 2013. A change in trend was detected in poison center calls mentioning marijuana (p<0.01). After 2009, poison center calls increased 0.8% per month (95% CI=0.2, 1.4, p<0.01). Poison center calls also increased 56% (95% CI=49%, 63%, p<0.001) in the period following the policy change. Further, there was one hospital discharge coded as dependent for every 3,159 (95% CI=2465, 3853, p<0.001) medical marijuana registrant applications. Davis, et al. Am J Prev Med. 2016 Mar;50(3):373-9

The American Public Health Association agrees.

APHA urges federal, state, and local governments to regulate commercially legalized marijuana in partnership with state and local health departments, including the provision of resources to local and state public health agencies for the purpose of reducing and preventing marijuana’s use, misuse, and abuse. American Public Health Association

Come on, (this is because you want to) get higher

Of course, there are lots of credible studies that demonstrate the positive effects of marijuana for treating certain serious medical conditions. But is that really what is going on with most people who use medical marijuana? Probably not.

Many voters believed this arrangement would help people who couldn’t get relief from cancer or from serious, debilitating illness any other way. In reality, however, only 2% of users in our state report having cancer, and only 1% each report glaucoma, cachexia, HIV, and seizures. In Colorado, most users request marijuana for nonspecific complaints, use unregulated doses, and have used pot recreationally in the past. It’s fortunate for the marijuana industry that no test can confirm that someone has severe pain, because that is the reason given by 94% of our state’s applicants…

Our children in Colorado grow up now thinking that marijuana is a medicine. I think this has led kids to believe pot has low risk, so they self-prescribe it for anxiety, headaches, or whatever ails them.

But what I find most shocking is when prenatal patients use marijuana. They’ve often heard that it’s good for nausea and pain and ask me, “Isn’t it a legal medicine now?” Then I have the task of trying to convince them to stop because marijuana is a developmental neurotoxin, potentially changing the fetal brain permanently.

Laurie D. Berdahl, MD, Medical Economics, 2012.

Colorado residents ultimately decided to stop the charade that medical marijuana laws were primarily about healing the sick and allowed people to use pot recreationally. At least that’s an honest approach. (Interestingly, much of the promised tax revenue that was supposed to be generated from full marijuana legalization in Colorado hasn’t materialized.)

California is taking a different approach. In 2015, California Gov. Jerry Brown signaled a major policy shift on medical marijuana by signing the California Medical Marijuana Regulation and Safety Act. This was partly driven by the U.S. Department of Justice’s insistence on “robust regulations” at the state level as a condition of DOJ and DEA leaving them alone. Voters will need to approve these new regulations by way of a ballot initiative in 2016.

I’m not (cough-cough) holding my breath for that to happen.

 

The elephant (or donkey) in the room: Part 3 on the fiscal crisis facing Medicare and Medicaid

I have previously written about the fiscal crisis facing Medicare and Medicaid. In Part 1, I wrote about the extent of the trouble that the United States finds itself in when it comes to financing Medicare and the “dual eligibles” who also receive Medicaid benefits for the future. In Part 2, I wrote about the origins of the problems that these programs face as well as the inaccurate forecasts of just how much these programs would cost.

Now I’ll finish up this series by talking about where we need to go from here.

But, first, a little news to set the stage.

A marriage made in red tape

Right now, two of the nation’s largest private health insurance companies – Anthem and Cigna – are trying to merge and become the very largest private health insurance company in the nation. The merger is pending, which is akin to an engagement prior to a wedding.

As a former Anthem employee, I’m totally rooting against for this despicable lovely couple. They most certainly deserve each other. But if these two companies are getting married soon, they may want to see a counselor to talk about their issues.

Akin to learning that your fiancée has a criminal history just before the wedding, Cigna just got busted by the Centers for Medicare and Medicaid Services (CMS) for its handling of Medicare Advantage (MA) and Medicare Part D prescription drug plans for doing all the things that private insurance companies are infamous for doing: denying health care services and prescription drugs to patients who needed and should have received them and mishandling the grievance and appeal process.

Cigna has had a longstanding history of non-compliance with CMS requirements. Cigna has received numerous notices of non-compliance, warning letters, and corrective action plans from CMS over the past several years. A number of these notices were for the same violations discovered during the audit, demonstrating that Cigna has not corrected issues of non-compliance.
Centers for Medicare and Medicaid Services

As a result of this bad behavior, Cigna informed the Securities and Exchange Commission (which would be akin to the wedding officiant, I suppose) that it couldn’t sell new MA or Medicare Part D policies.

But wouldn’t it be hypocritical for Anthem to break off the wedding? After all, Anthem (which was known as WellPoint at the time) got into the exact same predicament with CMS in 2009 due to similar bad behavior. Eventually those sanctions were lifted, but there was some lost revenue in the meantime.

Considering how lucrative managing these plans has been for private insurance companies, the new restrictions on Cigna could, at the very least, put a damper on the couple’s honeymoon plans.

Private insurers worsen fiscal crisis

For all of the problems that MA and Medicare Part D enrollees have experienced due to bad behavior on the part of the private insurers who operate the plans, you would think that Medicare Advantage would be saving taxpayer dollars in the Medicare Trust Fund.

You would be wrong.

Our findings indicate that the inclusion of private plans in the Medicare program has cost taxpayers $282.6 billion, or 24.4 percent of the total amount Medicare has paid private plans since 1985. Our findings likely underestimate the magnitude of the overpayments…

…In 2012 alone, we estimate that private insurers are being overpaid $34.1 billion, or $2,526 per MA enrollee…

..Advocates of market-based Medicare reforms suggest that competition among private plans will induce greater efficiency and result in cost savings. Our findings indicate that the opposite is true. Private plans have drained more than $280 billion from Medicare since 1985, most of it in the last eight years. Increasing private enrollment through voucher-type Medicare reform (as suggested by Republicans) or through quality bonuses and financial incentives to plans to enroll dual-eligible beneficiaries (as enacted by President Barack Obama’s administration) will almost certainly raise Medicare’s costs, not lower them.

Funds wasted on overpayments to private MA plans could instead have been used to improve benefits for seniors, extend the life of the Medicare Trust Fund by more than a decade, or reduce the federal deficit. Private insurers have enriched themselves at the expense of the taxpayers.

Hellander, et al. Medicare overpayments to private plans, 1985-2012: Shifting seniors to private plans has already cost Medicare US$282.6 billion. International Journal of Health Services 2013; 43(2): 305-319. 

Just to be clear, that means overpayments have amounted to about one fourth of all the payments made from taxpayers to private health plans to cover Medicare beneficiaries. And this is estimating conservatively.

The entire health system is sick, and the Doc Fix was no cure

As I’ve written before, the entire U.S. health system is burdened by an inordinate amount of wasteful spending that doesn’t improve anyone’s health. It’s impacting all health payers, not just Medicare and Medicaid.

Whereas private insurers have responded to increased health spending by increasing premiums — which they must do in order to turn a profit, stay afloat or even maintain the cash reserves required by insurance law — the Medicare Trust Fund doesn’t even remotely work that way.

Changing any Medicare or Medicaid formula, from taxes to provider reimbursement to benefits, requires an act of Congress and a debate that most politicians of all stripes would prefer to avoid.

When it comes to Congress’s action on provider reimbursement in Medicare, it’s a good news/bad news/good news scenario.

The good news: In 1997, Congress and President Bill Clinton enacted a Sustainable Growth Rate formula that indexed physician reimbursement in Medicare based on the rise (or fall) of the nation’s gross domestic product. If physician spending grew more slowly than the GDP did, physicians got a raise. If physician spending grew faster than the GDP did, physicians had to take a pay cut.

The bad news: This seemed reasonable in 1997 when GDP was growing rapidly and provided some cost control incentives to counterbalance the perverse incentives of the fee-for-service model. But, after the 9/11 attacks, the economy stagnated, and physicians felt a considerable pinch. After all, the broader economy was largely outside of each physician’s control, as were the actions of other physicians. The financial crisis of 2008 and the resulting recession would have really made things uncomfortable for physicians under the SGR…including a potential 21 percent pay cut in 2010.

So, from 2003 to 2015, the American Medical Association successfully lobbied Congress each year to bypass the SGR and give physicians a raise regardless of what happened with GDP. This was known as the “Doc Fix,” and it had to be renewed each year. As you might imagine, when you ignore the Sustainable Growth Rate formula for years, you end up with a growth rate that is not sustainable. And that’s indeed what happened – at a cost to taxpayers of $150 billion.

The good news: Just about everyone realized that this cut-and-paste formula of passing a new Doc Fix bill every year just to bypass the SGR was inefficient, expensive, and absurd.

So, in 2015, Congress and President Obama struck a deal to permanently eliminate the SGR and create a new reimbursement formula tied to quality of care and efficient use of resources. This was considered to be a permanent Doc Fix.

Without digging too far down into the weeds, suffice it to say that it sounds like we’re finally getting somewhere for reforming Medicare and reducing waste in the health care system. But I’ll believe it when I see it.