Health Reform: Diabetes and the Sum of Hopes and Fears

Nobly-intentioned health reform – affordable, accessible, effective care for all- sums up hopes and fears of all humankind.

Hopes that care is there for all, fears that care will not be there. But these hopes and fears are always dashed by the reality that only so much resources are available to satisfy these hopes and fears.  Demands always exceed supply.

Common Sense

Sooner or later, reality  and common sense generally kicks in.

Take the problem of the obesity –diabetes- and their chronic disease aftermaths, a prevalent chronic disease epidemic.  In America,  100 million of us are obese,  29 million have diabetes, and 86 million have pre-diabetes.   That’s 215 million,  one-third of our population of 320 million.

More Expensive Approaches

We are taking steps to address this problem – through a flurry of  weight-loss programs,  bariatric surgery programs, the fitness mania, and the development of a host of diabetic drugs.  All of these approaches are expensive.

Low Cost Low Carbohydrate Diet

But suddenly common sense is beginning to rear its head.    Various diabetic programs are showing you can treat your diabetes are simply changing to a low carbohydrate diet – by eating meat, fish, vegetables, fruit, nuts, high fat dairy products, and root plants – rather than sugar-laden foods, pasta,  bread,  processed foods, and all those carbohydrate-rich snacks.

Source:  Sarah Hallberg, MD, and Osama Hamda,  MD, Indiana University and Joslin Diabetes Center at Harvard,  “The Old-Fashioned Way to Treat Diabetes: It’s Cheaper thatn $26,000 Weight-Loss Surgery and Probably More Effective, “ New York Times, September 11, 2016

The Chicago Tribune:  Why ObamaCare Failed

It is newsworthy when the Chicago Tribune  uses the past tense to describe ObamaCare. The editorial board of the Tribune gives these reasons why ObamaCare “failed,” as if that was a foregone conclusion.

Here are reasons the Tribune offers.

·         It flunked Economics 101 and Human Nature 101.  It wasn’t flexible enough to let people buy as much or as little coverage as they wanted or could afford.

·         Its penalty for going uninsured ($695) were too low when stacked against skyrocketing premiums so people simpy skipped coverage.

·         It didn’t recognize the essence of insurance risk pools  - the lucky (the healthy) have to subsidize the unlucky (the sick).  The sick reap much greater benefits thatn the healthy,  yet insurers can’t exclude the sick, those with preconditions, or even ask them what ails them.

·         It allows Americans to sign up even after they got sick.  If you can buy insurance after you get sick, why buy it before you get sick.

·         It did not decrease health costs.   It increased demand for care while decreasing supply of physicians  and choices of plans.

·         It ignored the fact that too many carriers could not cover their expenses, or created condition that carriers could not even estimate those expenses in advance.  For every dollar earned,  insurers paid out $1.32  for services rendered.  Small wonder insurers, business beholden to stakeholders and shareholders,  abandon ObamaCare markets and raise premiums by double digits, sometimes by 45% to 60%, to offset losses.

The Tribune suggests federal authorities offer more flexible plans to let consumers buy what’s best for them, not coddle them by letting them duck in and out of the system,  when the need or don’t need care.   The new plan, says the Tribune, should kill the employer mandate, and instead offer tax credits for hiring and covering new employees.  And let insurers compete across state lines.   Competition is a wonderful antidote  for charging what the market will bear.

To these ObamaCare’s failings I would add this simple caveat.  Get over the notion that government can homogenize and standardize care through  centralized control.  Homogeneity and standardization violate two fundamental American values – pluralism and self-determination.   There is not simple, magical, structural,  managerial answer to universal, affordable, acceptable  universal coverage – no management  data-based “value’ evidence,  no quality control measures,  no compensation by performance,  and no amount of collaborative,  cooperative  synergistic  efforts  by federal authorities to enforce  ethical and elitist “truths” as perceived in Washington rather than on the frontlines of care.

 

Aging : The Problem of Health Reform

Milton Berle (1908-2002) and Dylan Thomas (1914-1953) on Aging, Cost of Care, and Resistance to Dying

However old we get, no matter how close we are to the end, we want to live another day, whatever it costs.

As comedian Milton Berle remarked  "When it comes to my health, money is no obstacle."

As poet Dylan Thomas observed,

"Do not go gentle into that good night.
Old age should burn and rage at the close of  day ;
Rage, rage against the dying of the light."

A Mercifully Brief History of Health Care Spending and Health Reform

Every reform, however necessary, will be carried to excess, that itself will need reforming

Samuel Coleridge (1772-1834)

U.S. health reform is evolution, not revolution, with no resolution in sight.

Personal Belief

·         1945 to 1950 – Public generously supports federal spending for NIH and academic medical research.

·         1950 – Government spending 5% of GDP.

 

·         1950 -1965 – Government spending spikes to 8.9%, leading to passage of Medicare and Medicaid to relieve cost pressures on seniors and the poor.

·         1966-1982 – Government spending soars to 13.0% of GDP,  causing HMO Act of 1973 and other federal actions to contain spending.

·         1983-1992 -   Spending continues at 9.9%.   Clinton administration  introduces comprehensive reform which fails.

·         1993-2016 -  Costs  climbs to 17.5%  of GDP by 2014 despite passage of ObamaCare’s  Patient Protection and Affordable Care Act passage in 2010.

·         2016 -2020 -  Costs still rising with critics predicting that costs may reach 20% of GDP by 2020.    California study indicates government pays for 70% of health costs in that state, versus 45% nationwide. 

·         1950-2020 – Health care industry becomes big business, with emergence of Medical Industrial Complex -  hospitals ,physicians,  drug companies,  high tech suppliers, and health plans working in concert to expand their piece of GDP pie.   

      Doctors enter specialties,  now comprising two-thirds of all  physicians. 

      Health care innovations -  open heart surgery,  organ transplants,  cataract surgeries,   hip and knee replacements,   MRI, CT, and Pet Scans,    and a variety of new drugs, such as statins,  to prevent and treat disease and relieve pain – introduced.   

      Population ages with 55 million on Medicare and 80 million on Medicaid.
   
      ObamaCare health exchanges enter scene in October 2013,  but soon falter, with half of expected enrollment,  more sick patients than expected,  and billions of dollars of losses for big insurers, who withdraw from most markets, and bankruptcy of three of four not-for-profit consumer plans.  

      By 2016,  talk of death spiral of ObamaCare becomes common,  and CMS moves fast to shore up health exchanges and save ObamaCare by changing rules of reimbursement , introducing Simple Care Plans,  compensating insurers more for sick patients,   creating incentives  for doctors to prescribe fewer drugs, and moving from fee-for-service to data-driven “value” payments and Accountable Care Organizations and other forms of risk-based  hospital-primary care- specialty collaborations.    

       Doctor shortages develop, with more doctors not accepting Medicare and Medicaid patients.  Physicians extenders – NPs and PAs- begin to replace doctors as first line of defense against   ill-health and disease.    More than half of doctors become employees, mostly of hospitals.
     
     Private practice declines.  Doctors become employees rather than independent practitioners.  As choices of doctors, hospitals, and health plans decline,  premiums predicted to rise by average of 23% in 2017.    Consumer and voter backlash begins and becomes campaign issue.   Hillary Clinton promises to “fix” ObamaCare, partly by introducing Public Option, the precursor to government-run care.  Donald Trump says he will keep hands off Medicare and Medicaid .  Says he will repeal ObamaCare but assure universal coverage.   He does not exactly how.
     
      The VA does not have enough primary care doctors, veterans die while waiting for care, and scandals develop within agency.   

     In summary,  over the last 70 years  SNAFU (Situation Normal All Funds Up) sets in.  Costs began to escalate after Medicare and Medicaid became law in 1965-1966, going from roughly 7% of GDP spending to 17.5% in 2015 and projected to approach 20% by 2020.  Medicare and Medicaid entitlements biggest drivers of national debt of $19 trillion. 

      In retrospect, this rise was inevitable with an aging population,  advances in technology,  more physicians becoming specialists,  evolution of the medical industrial complex,  comprehensive health plans  that made consumers insensitive to costs,    and a series of medical innovations - MRI and CT scans, ACE inhibitors, coronary stents, statins, mammography,  bypass surgery,  organ transplants, cataract extraction and lens implants, and hip and knee replacements.

      Public demand for these procedures and drugs,  and lack of tort reform contributed.   Also through the Internet, consumers became aware of what services were available.    Government programs - Medicare, Medicaid, CHIP,  renal dialysis - exploded in growth and were subject to  10% to 15% fraud and abuse. 

     ObamaCare, passed in 2010, has these features:  the good (20 million fewer uninsured), the bad (unfilled promises of keeping your physician, hospital, and health plan while lowering premiums),  the ugly (premium spikes, narrowing of networks),  and  possible death spiral of health law.  

     Only history will tell if government can simultaneously expand access while lowering rate of costs elevations  while making care fairer,  improving  quality, and satisfying  consumers.   

    History is not optimistic.

 

Health  Care Premium Spikes and the Political Home Stretch

As we enter the home stretch,  Hillary Clinton leads by 4% in average of polls,  and the odd makers give her a 75% chance of winning.

Unknown Factor

One unknown factor is the effect of predicted average spikes of 24% in health care premiums,  which vary widely from state to state.  This effect may determine the outcome of Senate races in  8 key states in which Democrats and Republicans are favored in 4 states each.      Democrats need to win in 5 states to seize control of the Senate.   The final premium increases will be announced in the week before the election.

ObamaCare in Trouble

ObamaCare is widely perceived to be deep trouble,  with major insurers withdrawing from the majority of states, and consumers left with narrowing choices or no choices at all of physicians,  hospitals, and health plans.   Enrollments are expected to drop to about half of what the Obama administration hoped for,  and critics say ObamaCare may be in a death spiral because not enough of the young and healthy are signing up to sustain a viable insurance market.

Simple Choice Plans to the Rescue

The Obama administration is trying to save ObamaCare health exchange markets through marketing its benefits and offering “Simple Choice Plans” in 2017.   The idea behind in these “Simple Choice Plans” is to simplify health exchange choices by standardizing  certain options for its bronze, silver, and gold plans.   

In a “Simple Choice” silver plan, for example, the deductible will be limited to $3500 and the out-of-pocket costs cannot exceed $7100.  For specific services, the amounts charged before the deductible kicks in will be $30 for a primary care visit,  $65 for a specialty visit,  $75 for an urgent care visit, and a generic drug prescription.

Not So Simple

Sounds simple, doesn’t it?   But, according to Sabrina Corlette, a professor in  health care policy at Georgetown University,  it isn’t.  Consumers will still need  to differentiate between plans, presumably through healthcare.gov, to weed through the options.  

Ending the Uncertainties

To end to the uncertainties,  Hillary Clinton, if elected, says she will  introduce a Public Option,  which, effect,  would give government control of insurance options.  Meanwhile, trend-setting California has just announced a study indicating government already pays for 70% of all health care costs in that state.    Can single-payer be far behind?