TAKING ACTION IN NYC

WHAT: "Pharma Greed Kills" Protest
WHEN: Sun 3/3 at 11AM
WHERE: Outside Pfizer HQ at 235 E42nd St near 2nd Ave
FB EVENT: https://www.facebook.com/events/943019352755598/
DIRECTIONS: Take the 4,5,6,7 to 42nd St Grand Central

The 5 lines above encapsulate weeks and weeks of organizing and planning, much of it by ZOOM conference call. To anybody who is not comatose, the need for action fairly screams, for with its sky-rocketing prices, Big Pharma is getting away with MURDER. People are dying, and Pharma doesn't care, so long as the stockholders are happy. And no Pharmaceutical  maker epitomizes Big Pharma's ruthless greed as does Pfizer, so that's where we are going.

I say "we", because I am honored to play a very small part in it. Although there are many placards available, in last night's ZOOM call the need was expressed for more. Since I own a 13X19 printer,  I came up with a placard:

One of the participants in this action will be the Campaign for The New York Health Act  (NYHA) -- which will guarantee healthcare for everyone who lives in New York State. How will NYHA "de-fang" Big Pharma?  Right now, through its "PDP" program, New York State is able to get a 30 percent discount for  volume purchases for some 2 million people -- a subset of the state's Medicaid population. When NYHA is in place, this "PDP" law -- which can be applied generally -- will enable the state to have the additional bargaining muscle of ordering for 10 times that population -- some 20 million people, which should enable it to enjoy a discount far greater than 30%. So our State will deal with Big Pharma for us, thus keeping Big Pharma's fangs far from our necks, so to speak. 

Melodramatic? It may seem so to those who are so rich that they don't have to worry about drug costs. But most of us are haunted by fears of  contracting a chronic disease for which the medications might bankrupt us -- if we could afford them at all. 

By now, many of us have heard that 1 out of every four patients cannot afford their medications. So long as we are among the 3 who can, the statistic might disturb us -- fleetingly.

But for the 25% who cannot, the reality is dreadful. A few days ago in the New Yorker, there appeared an article giving a sense of what those people have to face.

Living With Type 1 Diabetes When You Can't Afford Insulin

The article tells the story of Sa’Ra Skipper, a young woman who was terrified when she learned, at college, that she had aged out of her mother's insurance:

"I didn’t know what was going to come next. I was so scared. When I was a baby, my mom’s sister passed away from Type 1 diabetes, and my whole life that has been in the back of my mind: I don’t want to end up like Aunt Joy. My sister was in Virginia during that time, so she would mail me insulin when she had some to spare, and when she ran low, my grandparents would have to pay cash for hers.

“I lost a lot of weight that year, about twenty pounds. When you don’t have insulin, you can’t eat much because you can’t correct your blood sugar. So I was barely eating. I was supposed to take four to five shots of insulin a day, and I was only taking two to three. I was lethargic all the time. I was rationing just so I could live. I knew if I ran out I wouldn’t survive more than a few days.

Now she works at a call center, and her job gives her Blue Cross/Blue Shield insurance, which enables her to see  her primary care doctor and her endocrinologist. But even with the insurance, she can't afford the $1000 per month it would cost her to fill her insulin prescriptions:

"I can’t tell you the last time I was able to fill a prescription. I get samples from my endocrinologist. My sister also gets free insulin through a health center, because her income is lower than mine. So we’ve been sharing that....Last summer, my sister and I were living at my mom’s house, and one night we got our wires crossed. She was out late, and I took my ration dose and put the rest of the vial on the nightstand so she would see it. When she came in, she only took part of what was left, because she didn’t realize I had gotten some already. In the morning she went into diabetic ketoacidosis. She turned green and was throwing up and her sugar was through the roof. I drove her to the hospital, straight to the E.R. She had to get a [P.I.C.C. line] in her neck. She almost went into a diabetic coma. She was in the hospital for four days, and all because we were sharing insulin....

"So many people are being hit by the same issue. People are choosing between their car notes, their rent, and getting their medicine or their children’s medicine. Drug companies are gouging people who have no choice. I honestly don’t understand how they can do that. If you have Type 1 diabetes, there’s no superfood or exercise that you can do to make up for your pancreas not working. Insulin is life-sustaining. And insulin hasn’t changed in about a hundred years

"1 out of 4" is a statistic -- easy to "fly over" and forget. But Sa’Ra Skipper doesn't feel like she's  a statistic -- for her it's all too real. But how to convey that reality in a demonstration? Can it be conveyed by depicting Big Pharma as blood-thirsty vampire?  Can it be conveyed by a chant such as: 

           Leader: Pharma's greedy gouging kills!

           Group:   Profits are their poison pills!

I wonder.

Recently, I viewed a video in which I saw discussed Pelosi's apparent  coolness to Single-Payer.

And one of the participants said, "Come on: We're not going to get it until we take to the streets."

That's the answer -- and the challenge. The answer is to show our real passion for this healthcare reform -- in the streets, and everywhere! And the challenge is to grow that passion, and grow the number of people who feel it until it becomes a movement -- unstoppable.

Dio

PS: If you'd like to leave a comment -- and I encourage you to do so -- simply click on the "number of comments" area, and share your thoughts in the "comment rectangle" that appears.


PPS: We know that there are plenty out there who have stories to tell -- stories of your trying to cope with our dysfunctional healthcare system. Trouble is, we don't know what these stories are! That's where you come in. If you have a story to tell, you can email me at indivisible12401@gmail.com. You can be as anonymous as you like. Thanks!

WHY, NANCY, WHY?!

is Pelosi a Master Tactician or Anti-Progressive?

On February 5th, 2019, The Intercept ran a piece by Ryan Grim entitled, TOP NANCY PELOSI AIDE PRIVATELY TELLS INSURANCE EXECUTIVES NOT TO WORRY ABOUT DEMOCRATS PUSHING “MEDICARE FOR ALL” 

Pelosi Aide Tells Insurance Execs Not To Worry

According to the Intercept,  the Aide -- Wendell Primus, well known as a staunch opponent of Big Pharma -- met with executives of Blue Cross/Blue Shield less than a month after the Democrats won the midterm elections, many of them campaigning on "Medicare for All." Primus, said Grim, told the executives that "the party leadership" had "strong reservations" about single-payer healthcare, and assured the Executives that the Democrats would be their allies in the fight against single-payer, because their chief focus was fighting against Big Pharma's high prices, and they wanted the insurance companies' assistance in that fight.

All this was conveyed in a presentation of slides which were obtained by The Intercept and "re-created" to protect their sources. One of them appears below:

Note that the 5 bullet points objecting to single-payer boil down to three:

1. It's too expensive.
2. It's controversial.
3. It would be hard to implement.

As for the first, national economics differs radically from kitchen-table economics. In the latter, you try not to spend what you don't have. But for the United States as a whole,  that kind of economics  went out when we went off the Gold Standard. The truth is that the government can fund whatever it wants to. As Alexandria Ocasio-Cortez points out, our government has no problem writing a check for trillions -- when it will benefit the super-rich. It's only when the money is for good, moral causes, like education, healthcare, or fighting global warming that our pockets are suddenly empty, and we become deficit hawks.

Unfortunately, Pelosi is herself a deficit hawk who seems really to believe that stuff. The Intercept notes:

When [Pete} Peterson, a billionaire who spent hundreds of millions of dollars to push Washington policymakers toward austerity, died in 2018, Pelosi delivered a floor speech that praised him and his vision effusively, speaking of the man as if he’d dedicated his life to eradicating child malnutrition or curing cancer, rather than as a Wall Street tycoon who spent millions pushing for major cuts to Social Security and Medicare. “Pete was a clarion voice for fiscal responsibility, and a strong moral conscience in Washington,” Pelosi said in her House floor eulogy of Peterson, who, by 2012, had already spent half a billion dollars targeting Social Security, Medicare, and other spending programs.

As for the second point. who are the "stakeholders against it" here? According to Grim's article, Primus (and his sponsor, Pelosi) seem to believe that the only stake holders are the insurance companies and Big Pharma.  But what about the American People, whose stake in this is their health, not to mention their money: Don't they have a stake in this, too?  And as for winners and losers, the THE WINNERS WOULD BE EVERYONE -- except Big Insurance and Big Insurance.  But if Big Pharma's profits were less grand, and if millionaire insurance CEOs went away, that wouldn't bother me. Some of the insurance employees would need help finding new jobs, but that is feasible. 

And as for the other implementation challenges -- sure there would be some. But in my experience, when a problem poses a dire threat, somehow the difficulties solving it seem well worth overcoming.

Now before we brand Pelosi as our enemy, let's give her the benefit of the doubt: She is a master tactician to be sure, and she may be feeling that instead of attacking healthcare's entire profit-making nexus at once, better to attack one at a time. And in attacking Big Pharma, she fixes on a problem not only for the American people at large, but also for the health insurance companies, who really don't benefit from high-priced pharmaceuticals.

Maybe Pelosi hopes to make the insurance companies into an ally -- albeit a temporary one.

Having said all that, I would be remiss if I didn't mention that, having been pressured by the progressives in her caucus to let single-payer be debated, she agreed to a debate -- but not in the Ways and Means Committee which has the power to frame legislation, but in the budget committee which has no such power.

So what is she -- master tactician, anti-progressive, or both?

You decide.

Dio

PS: If you'd like to leave a comment -- and I encourage you to do so -- simply click on the "number of comments" area, and share your thoughts in the "comment rectangle" that appears.


PPS: We know that there are plenty out there who have stories to tell -- stories of your trying to cope with our dysfunctional healthcare system. Trouble is, we don't know what these stories are! That's where you come in. If you have a story to tell, you can email me at indivisible12401@gmail.com. You can be as anonymous as you like. Thanks!

BUSINESS AS USUAL

Exposing Fraud in Medicare Advantage

In the February 4th issue of The New Yorker, there appeared an article by Sheelah Kolhatkar

The Personal Toll of Whistle-Blowing

It tells the story of a physician, Darren Sewell, who worked for Freedom Health, a Tampa health-insurance company, and of his decision to blow the whistle on what he said were its "brazen" floutings of the law. Though his personal  story is gripping and achingly human, I won't repeat it here, but will encourage you to click on the link above and read the entire piece -- Ms. Kolhatkar is a wonderful writer.

The reason I bring up this article is to focus on behavior of some health insurance companies whose behavior is worse than unethical: It's criminal. Kolhatkar writes:

Medicare Advantage, the program that Sewell believed Freedom was abusing, is at the center of a growing number of fraud cases, some of which involve the biggest names in the health-insurance industry. The regulations around the issue are complicated, however, and legal questions about what constitutes prosecutable fraud are still the subject of debate. In 2017, the Department of Justice joined a multimillion-dollar case against the nation’s largest insurer, UnitedHealth Group, alleging widespread fraud dating back to 2006. The Justice Department is also investigating several other health insurers, including Anthem, Humana, Cigna, Health Net, and Aetna. An analysis co-authored by Fred Schulte, at the Center for Public Integrity, estimated that insurance companies had received nearly seventy billion dollars in undeserved Medicare Advantage payments between 2008 and 2013.

Kolhatkar says that Peter Budetti, experienced in these matters, told her: 

“We’ve never been able to get a direct measure of exactly how much fraud there is, but one of the clearest indicators is that, the more money is spent on fighting fraud, the more money is recovered by the government,” he said. He now works as an attorney at Phillips & Cohen, a firm that specializes in whistle-blowing cases. Fraud perpetrated by companies in the health-care industry, he said, is especially pernicious. “On the one hand, they are stealing public money,” he told me. “And on the other hand that money is not going to where it’s supposed to go, which is to taking care of people. They aren’t stealing from people who are selling imported shoes. They are stealing from people who would otherwise be immunizing kids or delivering babies. That’s the heart of it.”

When Sewell joined Freedom Health, he began to sense that the top brass had a "general attitude of contempt toward the government." In addition, he began to notice that the company "was intentionally rooting out sicker, more expensive enrollees by having sales agents target them and then encourage them to leave Freedom, an illegal practice known as 'lemon-dropping.'"  The sales agents, he said, were offered "cash bonuses" for this illegal practice. In addition, he saw that "Freedom was engaging in service-area-expansion fraud—misrepresenting the number of health-care providers in its network in certain counties, so that it could expand the areas in which it offered Medicare Advantage." As further evidence of service-area-expansion fraud: 

Freedom was “renting” groups of doctors in various counties in order to gain C.M.S. approval to expand, and then dropping the doctors after receiving it. In one example that Sewell found, Freedom said that there would be six in-network oncologists in Duval County, a large county in Florida, but patients couldn’t find a single one. The company’s strategy seemed to be paying off: in 2009, Inc.named Freedom one of America’s fastest-growing companies.

By 2010, Sewell had secretly "blown the whistle," and an investigation began. Around then,

Sewell was moved to a different job at Freedom, in the Medicare-revenue-management department, where he reported to an executive named Mital Panara. In his new role, Sewell  ... quickly noticed many coding inaccuracies, almost all of which were in the company’s favor, resulting in higher government payments. Sewell believed that Freedom was committing risk-adjustment fraud—instructing its internal coding auditors to scour medical records for places where the codes could be amplified, a practice known as “capturing” codes .... Freedom hired a nurse and coding specialist to conduct a mock audit of its diagnosis data in order to prepare for a possible audit by the government. According to evidence that Sewell gathered, the specialist found that approximately eighty per cent of the diagnosis codes in the company’s records were unjustified—a shocking number. When the specialist reported the results to Panara, Sewell alleged, he asked her to assess the codes more “leniently.” (Panara denies this.) Medicare regulations dictate that Freedom should have reported the invalid codes to the government and reimbursed it for millions of dollars in overpayments, but, according to Sewell, the company never did so.

In 2017, about 7 years after Sewell brought his whistle-blowing law suit, Freedom decided to settle and agreed to pay the Government $31.7 million. The company admitted no guilt in the matter.

Medicare Advantage is the Government's attempt to privatize Medicare, on the theory that businessmen would be more efficient than the government, and deliver more care for the money. Instead of paying by procedure (the method used by traditional Medicare). the Medicare Advantage insurance companies are paid a fixed amount for each member enrolled. What it doesn't spend in caring for the member, the private insurance company can keep as profit.  In my view, what this scheme has ended up doing is giving to the private health insurance industry billions in profits gained not only by limiting patients' access to treatment -- by networks, pre-authorization requirements, etc. not to mention outright denials of care -- but also by the sort of shady and illegal business practices described above -- practices which have been euphemistically termed "aggressive."  While Freedom was perpetrating these shenanigans, its owner was the cardiologist Kiran C Patel. a hugely successful entrepreneur with a house that has been compared to the Taj Mahal. His philanthropies are legion, and fellow Floridians look up to him with enormous respect, and in the very year of the $31.7 million settlement a Florida publication named him "Floridian of the Year." According to Ms.Kolhatkar, "When asked about the Freedom fine, he responded, 'I decided to take it as a cost of doing business.'"

The prevalence of fraud among Medicare Advantage plans offers one more reason to adopt Single-Payer: According to an opinion piece the New York Times (2/16/2019),

A single federal payer ... may well eliminate the waste, inefficiency and corruption that make the current system so expensive and inaccessible; the experience of countries like Canada and Britain that rely heavily on one government payer suggests as much.

What we have now is a system so fragmented that it is virtually impossible to keep tabs on all the players, who treat the insurance landscape as a wild west of greed and exploitation. Single-payer would be the new sheriff in town bringing law and order. 

Until that new sheriff arrives, what we'll continue to suffer is the anarchy of every man for himself, where Patel's "cost of doing business" is business as usual.

Dio

PS: If you'd like to leave a comment -- and I encourage you to do so -- simply click on the "number of comments" area, and share your thoughts in the "comment rectangle" that appears.

PPS: We know that there are plenty out there who have stories to tell -- stories of your trying to cope with our dysfunctional healthcare system. Trouble is, we don't know what these stories are! That's where you come in. If you have a story to tell, you can email me at indivisible12401@gmail.com. You can be as anonymous as you like. Thanks!

                                                                                                                                                                                                                                                                                                                                                                           

 THIS SUMS IT UP LIKE NOTHING I'VE SEEN BEFORE

In 1961, The American Medical Association was so upset about the approach of Medicare, that, as part of "Operation Coffee Cup," it hired the young Ronald Reagan to record on a vinyl LP (remember those?)  an attack on this legislation as the harbinger of a "Socialist Dictatorship."  In those days, I saw the AMA as the essence of die-hard, rock-ribbed conservatism. 

Boy, have things changed!  On February 13 of this year, Howard Bauchner, MD, the Editor in Chief of the Journal of the American Medical Association, published an editorial titled

Rationing of Health Care in the United States -- An Inevitable Consequence of Increasing Health Care Costs

In this editorial, the good doctor surveys the history of healthcare in this country since the sixties. He shows that advances in science have come with concomitant increases in healthcare costs, with every indication that these advances, and these costs, will continue to increase way beyond the rate of inflation -- providing increasingly critical challenges to our society. 

Don McCanne MD,, who comments on this editorial, says that before reading his commentary, you should read Bauchner's last three paragraphs.  So I'm supplying these paragraphs here,  followed by all of McCanne's commentary -- for me, both Bauchner and McCanne sum up what's going on. 

Here's Dr. Bauchner:

The United States is mired in a great philosophical debate. Is health care a right or a privilege? In part this debate is embedded in the historical, underlying sociopolitical discourse in the United States — is this a nation that champions individual rights and achievement at the expense of the common good? This philosophical debate plays out in health care. Rationing of health care is likely always going to occur, but for those who maintain that health care is a privilege, attention to rationing and attempts to ensure that rationing is minimized may not be a priority. Yet, even for those who assert that health care is a right and that health care coverage should be provided to all individuals in a more just and fair way, unless the relentless increase in the cost of health care is addressed, rationing of health care is likely to become more common.

Identifying approaches to mitigate the increase in health care costs has been elusive. Debates about waste in health care, prices of drugs and devices, volume, fraud, defensive medicine, inappropriate testing, and misaligned incentives have been ongoing for more than a decade. Each of these potential areas of cost containment provides income for specific groups, making change difficult. However, there is one area — administrative costs — about which there is broad agreement that it adds needlessly to the cost of health care, frustrates physicians and other clinicians, provides little benefit beyond employment, and clearly is one area in which the United States leads the world. These costs involve, but are not limited to, billing, excessive documentation, and the need to obtain prior approval for certain medications, radiological procedures, and specialty referrals. Although there is uncertainty about what percentage of the $3.5 trillion in annual health care spending is accounted for by administrative costs, if that amount is 10%, and could be reduced to 5%, an estimated $175 billion could be saved or redirected to provide care to patients and avoid rationing of some health care services. Reducing administrative costs should be the major focus of national efforts to reduce waste in health care and help control increases in health care spending.

For the United States to prosper in the 21st century, controlling health care costs is critical — indeed, it is the single most important challenge facing health care. Greater rationing of care is inevitable if health care costs continue to increase. Controlling health care costs is the only way to ensure appropriate investment in other areas, such as education, the environment, and infrastructure, and to provide a more equitable, just, and fair distribution of the remarkable health care advances that have been achieved with even more on the horizon. It has been said many times that in the richest country in the world, in which many of the greatest scientific and medical advances are developed, it is a blight on the US soul that each of its residents does not fully benefit from available health care.

https://jamanetwork.com/journals/jama/fullarticle/2725150

And here's Dr. McCanne:

For those of you who skip the quoted text and go right to the comment (often a wise move as a time-saver), please pause here and read the last three paragraphs of Howard Bauchner's editorial, and then return here.

How many times have you heard the opponents of single payer Medicare for All say that if we adopt such a system here then we'll have rationing like the socialist health care systems of other nations? Yet the irony is that we already have a major problem with rationing, and it is perhaps the cruelest version of all since we ration by ability to pay in spite of spending far more on health care than any other nation.

So how did we end up with both high spending and rationing? Quite simply we have the most administratively complex health care financing system of all nations, which is very expensive to run, wasting funds that could be used on health care for those who are victims of rationing, not to mention that our financing system is profoundly inefficient. Remember that tens of millions of US residents remain uninsured, tens of millions more face excessive financial barriers to care due to excessive out-of-pocket spending, and personal bankruptcy due to medical debt has not declined with the implementation of the Affordable Care Act.

Bauchner has defined the problem: profound administrative excesses. We know the solution: administrative efficiency through a publicly-administered, equitably funded Single Payer Medicare for All program.

There has been a surge in support for a public option such as a Medicare buy-in, but that only adds one more player to our administratively complex, wasteful system. There is also support being expressed for our employer-sponsored plans and for other private approaches such as the Medicare Advantage plans, but these perpetuate our costly, dysfunctional, multi-payer approach to health care financing.

So what about rationing? With Single Payer Medicare for All we would essentially eliminate rationing by insurance design, rationing by restriction of benefits covered, rationing by prohibition of obtaining care outside of narrow provider lists, rationing by unaffordable out-of-pocket cost sharing, or rationing by administrative barriers such as prior authorization requirements. These forms of administered rationing are harmful and should be done away with. Inability to pay for care would no longer be a barrier since a Single Payer Medicare for All program finances care equitably such that it is affordable for everyone. Maldistribution of health care professionals and institutions would be corrected through central planning and equitable distribution of our health care resources. Although all nations, including ours, must deal with queues, other nations have shown that the delays can be minimized by improving distribution of health care resources and funds, and also by simply applying the science of queue management, though that requires that we select to run our government stewards who actually care.


Bauchner says, "it is a blight on the US soul that each of its residents does not fully benefit from available health care." But we can fix this, and the sooner the better.

Near the end his commentary McCanne stresses the importance of electing to our government stewards who actually care.  I added the emphasis, because I think that requirement is paramount. What we too often get are people who claim to be stewards, but whose chief concern is staying in power. But to get some who actually care? I know they're out there. We just have to find them.

In his final comment, McCanne returns to Bauchner's comment that our failure to ensure that each of our residents benefits from available health care is "a blight on the US soul."

To heal that blight is our cause -- and it's a noble one. It won't be easy: Arrayed against us are the vast power of our corporate culture and even some of our leaders. 

They are banking on their privilege.

We are fighting for our lives.

Dio

PS: If you'd like to leave a comment -- and we hope you will -- simply click on the number of comments area and share your thoughts in the "comment box" that appears.

PPS: We know that there are plenty out there who have stories to tell -- stories of your trying to cope with our dysfunctional healthcare system. Trouble is, we don't know what these stories are! That's where you come in. If you have a story to tell, you can email me at indivisible12401@gmail.com. You can be as anonymous as you like. Thanks!

ADVANTAGE? FOR WHOM?

A few days ago, I emailed the following to my local networks:

Hi Guys.

Way back in the day, Carol and I rejected Medicare Advantage basically because we didn't trust For-Profit interests -- namely the private insurance companies -- to look out for our interests. We wanted to feel that if -- God forbid -- we had a very serious medical condition, we would be able to go to a very big city like New York, or Boston, for the best doctors available, and not be restricted to the network offered by any Medicare Advantage Plan.

After all, we thought, unlike traditional Medicare, which pays by procedure, the government pays Medicare Advantage insurance companies a fixed amount per client, regardless of what is or isn't wrong with them.  So the less the insurance company spends on your care, the more money they make.

I then saw a release by AHIP -- the American Health Insurance Plan trade group -- which promotes the virtues of big insurance:

America’s Health Insurance Plans (AHIP)
February 7, 2019
AHIP Thanks Congress for the Overwhelming Support for Medicare Advantage


368 bipartisan leaders in Congress signed their support for the Medicare Advantage program. On behalf of the nearly 22 million Americans who depend on Medicare Advantage, America’s Health Insurance Plans (AHIP) thanks the 66 members of the United States Senate and the 302 members of the House of Representatives who signed bipartisan letters to express their strong support for the program.

There followed two links -- the first to a letter from the Senate, with 66 signatures,

Letter From the Senate

and the second to one from the House, with 302 Signatures

Letter From the House

I checked out the Senate letter and was relieved to see that neither New York Senator Gillibrand nor Schumer had signed it. I checked the House letter and was unsurprised to see that it had been signed by the newly elected Congressman from CD19 (our district) who, during the primary and general election campaigns, had made no secret of his coolness -- if not outright hostility -- to Single-Payer. I'm not including his name here because he is not the main issue -- which is welfare to Big Insurance.

I did, however, mention his name in the email I sent to my networks, including McCanne's admonition that

This is a clear rejection of single payer since most of the efficiencies and the egalitarianism of single payer are lost under a multi-payer system that includes private insurers...[It]  automatically eliminates any consideration of a bona fide Single Payer Medicare for All program.

What a brouhaha ensued! Many folks wrote me to say that they were going to seek clarification from our Congressman, who was shortly to appear at a local activist organization, which in turn asked me to inform "my people" that this was a benefit (for themselves, not the Congressman), so that coming to speak with him would cost them $19 each -- a fact which set off another round of emails. In the slew of emails was one from someone who said she had used Medicare Advantage for 10 years, and though she lives in Hunter, had never been prevented from seeing her doctors in New York City and on Long Island.  I saw that I needed to learn more about Medicare Advantage.

So I checked out an article by Austin Frakt in the New York Times, August 18, 2014: Medicare Advantage Is More Expensive, but it May be Worth It. 

Medicare Advantage Is More Expensive but it May be Worth It.

I urge you to read it, not only for the article itself, but also for the comments, which I found very revealing.  For one thing, apparently not all Medicare Advantage plans are the same, and some clients professed themselves satisfied with the service they receive. But the majority were critical of Frakt's article, claiming it was inaccurate at best and biased at worst. I urge you to confirm this for yourself. You'll see, among other critics of Medicare Advantage, the words of  a doctor from Albany, California, who wrote:

Can't we just be honest about this? The so-called "Advantage" plan is nothing but a poison pill to destroy a vital protection senior citizens of our nation now have. Dressing it up to make it appear to be slightly better in the short term does not alter the reality that without true Medicare to compete against we will be right back where we were before its inception. We really need to focus on quality, single-payer health care for all now, not down-spiral to another for-profit scheme that will continue to skim the cream from the middle working class.

Medicine is very hard work. Medical personnel require long, extensive and expensive training, supported by costly infrastructure. There is no "profit" for share holders and CEOs in good medical practice.

Darla Totten, MD

From Syracuse, NY, came these blunt words:

Medicare Advantage is corporate welfare, plain and simple. People who want to buy these plans should be able to do so, but the taxpayers should not have to subsidize insurance companies to make these plans feasible.

When the GOP kept criticizing Obama for "Medicare cuts," they were talking about cutting subsidies for Medicare Advantage. They are defenders of corporate welfare, not your health.

While I was writing this, I got a phone call from a volunteer from the activist group I mentioned above. She urged me to attend the benefit featuring the appearance of our new Representative. On the phone, I conveyed to her a summary of what I've been writing now, and she said, "I work in a doctor's office, so you don't have to tell me about Medicare Advantage: they're horrible, horrible! Sometimes they even deny needed care!" 

She urged me to attend the benefit and confront the Representative with my thoughts. I replied that I wouldn't mind embarrassing the man, but that I wouldn't want to embarrass the activist group, which has done good work around here. Indeed, the Representative himself may also do good work in the future -- it's just too early to tell, yet.

I've come away with the impression that so long as you don't need any serious medical interventions, Medicare Advantage might suit you. But, Heaven forbid, if you should need extensive, and expensive care, the wolf will remove his sheep's clothing and reveal himself as the bloodthirsty beast he is.  And if the enemies of traditional Medicare -- and there are many -- get their way so that a senior's only option becomes Medicare "Advantage,"  there'll be no more sheep's clothing -- only the wolves.

Dio

PS: If you'd like to leave a comment -- and we'd love it if you would -- simply click on the number of comments area and share your thoughts in the "comment box" that appears.

PPS: We know that there are plenty out there who have stories to tell -- stories of your trying to cope with our dysfunctional healthcare system. Trouble is, we don't know what these stories are! That's where you come in. If you have a story to tell, you can email me at indivisible12401@gmail.com. You can be as anonymous as you like. Thanks!

AN HISTORIC MOMENT

Yesterday, Mon Feb. 11th, Carol and I were in Albany to attend the Press Conference celebrating the reintroduction of the New York Health Act. Those who know us can spot us if they look carefully: I'm the one wearing my trademark orange goggles, and Carol, holding a red sign, is wearing her brown wool hat.

There were a lot of speeches, hopeful words, and testimonials, among them the most striking coming from a man in a motorized wheelchair. Though his eyes were able to move, his head seemed fixed in position, and he chose his words very carefully. He said that he made a little money teaching, but had to be very careful not to exceed the income to which Medicaid limited him. If he went beyond it by one penny, they would take away all his support, which he needed to live.

By removing that limit, the New York Health Act would empower him to teach to his heart's content.

Of course I was profoundly impressed by this man who refused to be daunted by physical limitations which would overwhelm so many of us. Instead, what seemed his most daunting disadvantage was not his paralysis, but the cruelty of our health system, which stipulates that if  you earn more than $16,753 per year, you're on your own. But thanks to the reintroduction of the New York Health Act, he had hope.

So did we all. It was inspiring to hear how the inclusion of Long Term Care coverage in NYHA would improve the lives of so many, and relieve so many women of the pressure to drop out of the work force to care for a loved one. When the Press Conference was over, a woman said to me, "This is an historic moment, no?"

I told her that Carol and I had been in the crowd to hear The Rev. Martin Luther King Jr. deliver his "I have a dream" speech, and, as far as I was concerned, the current occasion was similar to that one. But as soon as those words left my mouth, I silently wondered whether they were true. Eloquent and moving as some of the speakers were, none of their speeches measured up to King's matchless oratory -- how could they?!

But in other ways, the two situations were the same: Both then and now all the listeners had a fervent hope for the future -- despite what seemed almost impossible odds. Senator Rivera,  who, along with Richard Gottfried, is co-originator of the NYHA bill, repeatedly stressed what a difficult struggle lay ahead, but his words, to me at least, seemed to underscore not only the gravity of the current situation but also the beauty of our goal -- to get to where all our sick and vulnerable will be treated well -- not merely the rich.

Afterwards we lobbied a couple of our representatives -- Kevin Cahill (Assembly Member for both Carol and me, and for the two people with whom we traveled to Albany) and Jen Metzger (State Senator for our travel partners). Neither was available, being in Chambers. But in Cahill's office we met Kevin's Chief of Staff, who informed us that while discussions would begin in the Assembly, in the Senate negotiations were still underway, the chief issues being the treatment of union members whose current benefits might exceed the allowances under NYHA; another concern being what happens if the federal waivers needed are denied by the federal government -- a not unlikely occurrence in the current administration.  

We left in Cahill's office a personalized valentine stating that with a man like Kevin who continues to support the New York Health Act, every day is Valentine's Day. We left a similar valentine in Jen Metzger's office. These were very much appreciated -- at least by the staff in those offices, who told us that not too many valentines came into their offices, and that they go over very well -- which I totally believe: Politicians love to be loved. It's not too late to send your representative(s) a valentine, and you could always give their offices a phone call. I say again: Politicians love to be loved.

On the way out, we encountered one of the speakers, Rachel McCullough, co-director of the New York Caring Majority. I called out to her: "You did well!"

She called back, "we all did."

When I arrived home, I reflected that Carol and I participated in what hopefully would be the first of many historic moments as we march toward the goal of true single-payer healthcare. I feel strongly that when the general public signals its desire for change -- possibly by filling the streets the way it did in the March on Washington DC so many years ago -- that will be another historic moment.

Dio

PS: If you would like to share a comment -- which I encourage you to do -- simply click on the number of comments area and share your thoughts in the "comment rectangle" that appears.

PPS: If you or someone you know has had difficulty coping with our dysfunctional healthcare system, it's important to share that story, so that our legislators will be moved all the more to pass the New York Health Act, and the public will be all the more inclined to demand that the lawmakers do so.  You can have all the anonymity you like. Thanks!

DOING THE RIGHT THING

In my last post, I included a clip of Alexandria Ocasio-Cortez responding to Chris Cuomo's challenge: "How are you going to pay for all the stuff you want?" in a way that left him almost at a loss for words. 

She said, "We write unlimited blank checks for war. We just  wrote a 2 trillion dollar  check for that tax cut, and nobody asked those folks how are they going to pay for it. So my question is: Why is it that our pockets are only empty when it comes to education and health care for kids? Why are pockets only empty when we talk about 100% renewable energy that is going to save our planet and allow our children to thrive? We only have empty pockets when it comes to the morally right thing to do. But when it comes to tax cuts for billionaires, and when it comes to unlimited war, we seem to be able to invent that money very easily, and it [betrays] a lack of moral priorities right now, especially in the Republican party."

And I say, ABSOLUTELY -- RIGHT ON!  In my opinion, if ever there were an emblem of immorality, it would be our healthcare system, which renders a lot of people too poor to live.

But this moral argument -- which I happen to agree with passionately -- is a dangerous one to make. Why? It's subjective; you can't prove it.  If I say that Single-Payer will save money, that is a claim which I can buttress with careful calculations based upon observable fact. Indeed, three research groups have come to this favorable conclusion, including one -- the Koch-funded Mercatus Institute -- which was trying to prove the opposite!

But if I say, "it's the right thing to do," then will come the rejoinder: "right according to whom? Might is right. The survival of the fittest is right; not only is it right, it's the rule of life. If I have the wherewithal to build for myself and my family a luxurious life, I am right to do so -- regardless of whom it may hurt -- that's just the way it is!  If I have an advantage, it would be WRONG of me not to pursue it. And if people starve and go hungry, who cares? I have got mine, so let them get theirs! Anything else is just the B.S. they teach in Sunday School."

Ah yes ... Sunday School, where you read about the your responsibilities to visit the sick, clothe the naked, comfort the widow, and leave some  of your ripened grain standing in the field so that the poor may take it.  And where did these responsibilities come from? From God, of course.  

I can hear some hedge fund operator crying out: "From God? Give me a break!"

Morality can be a very fluid thing. Following AOC's video clip, there were all sorts of comments, including an irate attack on her: "In your district there was an M13 killing -- you murderer!"

In spite of the above, I hold it as an article of faith that it is wrong to let someone die when you can help her live; it is wrong  to raise drug prices simply because you can; and it is wrong to give profits priority over patients -- indeed it is wrong to have our healthcare system driven in any way by the profit motive. 

Recently I was researching the financial status of the Pharmaceutical giant, Pfizer.  In not one analysis of their profit prospects was there any intimation that there were real people who would be at the receiving end of the drug "pipeline" -- if they had money enough.

The poor -- though they are less likely to receive Pfizer's drugs -- seem to be more generous than rich ones.  It's not that the poor give more -- they obviously cannot -- but that they give a greater percentage of their substance than do the wealthy. I'm guessing that because they themselves know what it is to suffer economic privation, they have more empathy for suffering than do those better off. But those with money -- or their forbears -- have worked precisely to distance themselves from any stress whatever. And the greater the distance, the less real become the sufferings of the poor. Those with money love not to be reminded of them, and of their obligation to do the right thing.

I think in our culture, doing the right thing seems to be something delegated to the woman -- especially care-giving. Our stereotype seems to be that empathy is attractive in women, but a downright hindrance to a man climbing the ladder of success. To be "hard-nosed" is a most positive attribute in a businessman, who, at home, can be very solicitous for his family's well being, but in his office, knows that to be cut-throat can increase profits.  So when he increases the price of insulin, he must calculate whether the increase in profits is worth incurring the public revulsion from the deaths that result. All too often, from my point of view, he decides that doing the right thing is to raise those prices.  And if he does it enough, he is promoted possibly to a corner office, the path to which is strewn with dead bodies. Of course, the corporate execs don't see them there. 

It's our job to make them visible, so that the country can see the full cost of what big business deems is doing the right thing.

Dio

PS: If you'd like to leave a comment -- and I hope you will -- simply click on the number of comments area and share your thoughts in the "comment rectangle" that appears.

PPS: If you or someone you know has been struggling in any way with our healthcare system, please consider sharing it. You can  be as anonymous as you like, but having a file of those stories will help persuade our state legislators to vote for our benefit.  And if you'd like to tell me in person so I can make a video of your testimony -- from the rear, if you like, so that nobody will know who is sharing this experience -- that would be fabulous.  You can email me at indivisible12401@gmail.com. Thanks!

THE NEW YORK TIMES IS 

NOT ALWAYS GOSPEL

On February 2nd, Jonathan Martin and Amy Goodnough in the New York Times wrote an article that unsettled me. I provide a link to it below:

Medicare For All Emerges as Early Policy Test

Prior to reading it, I had managed to feel that somehow there might be hope in our country's finally adopting a genuine single-payer program. But the article left me feeling that there was no way our elected Democrat representatives would spring for it -- or anything like it. But then I read an email circulated by Maggie Veve, an activist in the New Paltz area. What she said made so much sense that, with her permission, I'm reprinting it here:

This is a conventional article, not a good one: it's misleading (cost) and therefore, biased. In addition, the content is expected. 

 I am sure you know that politicians test the waters and politicians run scared. They run scared with the Green New Deal (GND) too. We will see the same when the fuel industry really hits back hard against the GND. It's just easier to run from Medicare for All because the fight is on with heavy hitters of the for-profit health establishment. They know health care cost is a non-partisan issue and that hearings will occur in the House. So the industry is clearly afraid of losing profits and wants to scare the populace with "socialism", "bankrupting the economy", "no choice", "long waits" to distract from the radical / root causes of the true cost of the current system. We cannot afford NOT to do what every other developed nation provides for their citizens. I think we need to educate the populace and push for what we think is right ("imagine the best of what is possible"/Deray McKesson). I also believe the narrative can be turned around by fearless belief in the right thing to do.

For an example of this fearless belief in the right thing to do, Maggie  provides a link featuring AOC answering Chris Cuomo's challenge: "How are you going to pay for all this healthcare, this Green New Deal you want?" AOC answers him with words that are for the ages:

AOC Dumbfounds Chris Cuomo

Not satisfied with that, Maggie then forwards her letter to Elissa Krauss, in these parts the lead organizer and advocate for the NYHA and Single-Payer in general. And Ms. Krauss replies with an email that nails it:

Thanks for including me in the conversation. Some thoughts:

   1.The regular Dems oppose Medicare for All. The Dem Congressional Campaign Committee specifically forbade candidates from mentioning single payer. Antonio Delgado has made clear that he does NOT favor Medicare for All. He wants a public option. More on that later.

  2. It is true that the Mercatus Center projected cost of Medicare for $32 trillion WITH A SAVINGS OF $2 trillion over 10 years. In other words, even a right wing think tank had to acknowledge that Medicare for All would cost LESS than current costs for health care. 

  3. NYHA would save New Yorkers billions in health care costs. Instead of premiums, deductibles and co-pays New Yorkers would pay a progressive tax on payroll and non-payroll income, that tax can be less than what they are currently paying.

  4. Two studies agree that NYHA would save money for New York and for New Yorkers. The RAND study agrees that single payer would cost NY less than current costs. It mistakenly predicts that some low-income New Yorkers would pay more for health care than they do now.  That’s because RAND’s analysis is based on a hypothetical tax structure that is not truly progressive and assumes that all New Yorkers would have to pay a tax. The Friedman study presumes that no tax would be paid on incomes less than $25,000.

   5. Exactly how the NYHA tax would be calculated remains to be seen.  First the bill needs to pass. Then the very important details need to be worked out. But the bill specifies a progressive tax. Remember- current private health insurance is a regressive tax. Note – NYHA is improved Medicare for All. No premiums, deductibles or co-pays,

   6. For single payer advocates I think the message of this article has to be – we have to embrace taxes as a cost-effective way to provide care to all. The fiction that all taxes are bad has been promulgated by opponents of government who have taken over the national government at the same time as they are trying to dismantle it. We need taxes. Taxes pay for police, firefighters, roads, bridges, and schools among other things. These important basics of society are all suffering because of the successful myth that taxes are inherently bad. Remember in Europe those higher taxes pay for free public education from Pre-K through college, access to medical care for all, paid family leave, longer vacations, etc.

   7. Public option. PNHP [Physicians for a National Health Plan] opposes a public option for the simple reason that if private insurance companies were competing against the government then we would see an expansion of what we are seeing now. The government provides care for the sickest, oldest and poorest. With a public option private companies could go further in limiting who they would cover and focus on the younger, healthier and richer. We would end up with an even worse two-tier system than we have now.

      So those are some thoughts on the NYT opinion piece. It is true that some studies show that when people are told that Medicare for All would increase taxes or end their private insurance, some get scared. BUT those questions do not tell them that their costs would be lower and their access to care increased.

      Let’s continue this conversation. Henry Moss is better than I am at covering these issues. I’m sure he’d be glad to come back to New Paltz to do another presentation.

Elissa

Personally, I don't believe that anybody could be much better in covering these issues than Elissa.

What  more can I say? After 57 years of marriage, I've learned to listen to women smarter than I am.

Hurray for Maggie!

Hurray for Elissa!

Hurray for AOC!

With women like these -- and thank God there are plenty of 'em -- we're in good shape!

Dio

PS: If you want to leave a comment -- and I hope you will -- simply click on the number of comments area and share your thoughts in the "comment rectangle" that appears.

PPS: If you'd like to share your story, I'd like to help you. You can share it publicly -- if you're up to it -- or privately, with only your representative knowing it. Either way, you would be helping the cause. Our current medical system is hurting people.  If you are one of them, you deserve to be heard. You need to be heard.  Thanks!

THEY THOUGHT THEY COULD GET AWAY WITH IT

In the August 7, 2018 issue of the L.A. Times there appeared the following article by David Lazarus: 

Sorry about your Stage 3 cancer. Here's a bill for $21,000 in charges you thought were covered.

When Michele Brough was diagnosed with Stage 3 breast cancer in April, her oncologist wasted no time in reaching out to her insurer, Anthem Blue Cross and Blue Shield, to obtain pre-approval for a drug that would strengthen her immune system to better withstand chemotherapy.

The good news came shortly afterward. “We are pleased to authorize benefits for the service(s),” Anthem informed Brough, 56, by letter.

The chemo began in mid-May, with each session including an injection of the pre-approved drug Neulasta Onpro to stimulate production of white blood cells and help ward off infection.

It wasn’t until after the second round of treatment that Brough’s oncologist informed her Anthem wasn’t covering the injections, sticking her with the staggering cost of $7,000 for each shot.As if that weren’t devastating enough, Anthem’s reasoning was downright absurd.

Yes, the drug had been pre-approved, but only if Brough bought it herself through the online pharmacy Express Scripts, and only if she gave herself the shots.“It just made no sense,” Darrell Brough, Michele’s husband, told me. “They covered everything else, all the drugs, all the doctor’s visits. But not this?”

There was nothing in Anthem’s approval letter that said anything about buying it exclusively from Express Scripts or handling your own shots.

And even if Indianapolis resident Brough had bought the drug, her husband said the oncologist refused for legal and safety reasons to administer a drug she had acquired herself.

“They wouldn’t administer it because it wasn’t from their own pharmacy,” he said.

I’ve come across some strange insurance denials, often involving treatments that corporate bean counters say are experimental whereas actual medical professionals say otherwise. But Anthem took this up a level.

The company’s behavior seemed inconsiderate to the point of cruelty — at best an act of gross incompetence, at worst sheer meanness.

I mean, who does that, approving part of a cancer patient’s treatment but not the whole thing? And then sticking the patient mid-treatment with thousands of dollars in unexpected costs for some totally bogus reason?

To be sure, insurance companies are entitled to make money for managing people’s healthcare risk. But that doesn’t justify acts and decisions that demonstrate a near-total lack of empathy.

Michele Brough’s Stage 3 cancer is considered an advanced form of the disease, although the American Cancer Society places the five-year survival rate at 72% with appropriate treatment.

Her husband, who handled all the bills and the dealings with the insurer, said no reasonable person would anticipate a patient receiving chemotherapy treatments from doctors and nurses would be personally responsible for administering her own immune-system booster shots.

Moreover, once the chemo has begun, you’re committed. Even though Brough and his wife were $14,000 in the hole after the second session, they weren’t going to stop even when the oncologist made Michele sign a waiver before the third round promising that she’d be responsible for the cost.

Anthem denied that claim as well, placing the Broughs $21,000 in debt.

For the fourth and final round of chemo, the oncologist decided to skip the booster drug, hoping Michele’s immune system was by now strong enough to take the punishment.

I’m not second-guessing a doctor, but it seems to me that any time you forgo an established treatment solely for financial reasons, you’re placing yourself in danger. Happily, Brough said his wife has responded well to the chemo treatments.

But they weren’t in the clear. Brough said he was told by the oncologist that if Anthem wouldn’t cover the $14,000 for the first two shots, he and his wife would be held responsible and the case could be referred to debt collectors.

“It’s crazy,” he told me. “Any way you look at it, it makes no sense.”

Brough, 56, a project engineer for a computer consulting firm, appealed the charges to Anthem. Weeks later, he wasn’t getting anywhere. So he came to me.

Within days of my getting involved, Anthem acknowledged it had screwed up.

“When we were recently made aware of a concern pertaining to an oncology drug used by one of our consumers, our team began working to understand what happened and found the claims were processed incorrectly,” said Leslie Porras, a company spokeswoman.

I asked why it took a call from a reporter to figure that out. Why didn’t Anthem discover the mistake as soon as Brough lodged his appeal?

“Since the member first contacted us, we have been working with all parties involved to coordinate and resolve this matter,” Porras replied.

All appearances to the contrary notwithstanding.

Shortly afterward, Brough told me he’d heard from Anthem. “They are covering the three injections in full,” he said.

That’s great. It goes without saying, however, that no one should have to rely on the press to resolve an insurance matter — especially when the insurance company is at fault.

The Broughs did everything right. They sought pre-approval for coverage. They promptly appealed questionable charges. Yet they still got what they felt was the runaround.

The only other thing I’d advise in a situation like this is to bring in a professional patient advocate, a person who specializes in navigating the twists and turns of the healthcare system, including billing issues.

Many group insurance plans will cover the cost of a patient advocate — ask your employer. Otherwise, the advocate might charge on an hourly basis or receive up to a third of whatever savings can be secured.

You can search for a local advocate on the website of the National Assn. of Healthcare Advocacy Consultants or via the Alliance of Claims Assistance Professionals.

Another piece of advice: Don’t give up.

As the Broughs saw, insurers make mistakes.

They’re just not particularly good at admitting it.

There's something rotten in the state of our health delivery system, and this article typifies it. First of all, for an insurance company to cover a drug only if the patient purchases it from a specified source, and then administers it herself, is cock-eyed.  What -- did they suppose that any hospital would allow a patient to purchase the drug from a  source other than the hospital? No hospital I've ever heard of would allow such a thing.  Even if the medicine was perfectly safe, the hospital needs to issue the medicine itself for the obvious legal and safety reasons, and, incidentally, so it can make its own absurd profit on the transaction. And would they allow anyone but a licensed professional to administer it? Come on! Anthem Insurance might as well have said, "we'll cover it only if it comes in a plaid wrapper." It's a non-starter, absurd. And even if the above were not so, to inform the patient of all this after the fact, would be ludicrous if someone's life weren't at stake.

I'll tell you what I think: After the pre-approval was granted, somebody at Anthem took a second look at the procedure and thought: "$7,000 per shot is a lot of money! Let's deny it and cook up a reason why -- any reason." And this is  why repeated appeals to them failed: They were, after all, Anthem Insurance, one of the biggest in the nation; who was  going to cross-examine them? 

Which bring me to the most rotten thing of all: It took an appeal to the press to set things right -- after all, the L.A. Times is a very big paper, with a very big circulation.  Did Anthem want all that bad publicity? 

Louis Brandeis once said, "Sunlight is said to be the best of disinfectants; electric light the most efficient policeman." To me, this means that if something is wrong, we have to scream to high heaven, and MAKE IT PUBLIC! That's what this blog is trying to do.

Which brings me to a request: If you or someone you know wouldn't mind making known their struggles with our broken healthcare system please let me know. You can email me at indivisible12401@gmail.com. There are more than a few state politicians out there who got Brownie Points for voting for NYHA when they were confident the Republicans would bat it down. But now that Democrats have the Senate, these "wobbly" Democrats are not so confident, and they may come to remember the source of the money -- corporate -- that got them elected.  SO PLEASE  CONTACT ME ABOUT THIS. You'll be doing us all a favor.

Dio

PS: if you'd like to make a comment -- and I hope you will -- simply click on the number of  comments area and share your thoughts in the "comment box" below.