It should be easy for the Democrats to beat President Trump on healthcare. After all, he never followed through on his promise to “take care of everyone” or to unveil a “phenomenal” plan. Moreover, his sabotage of Obamacare, attacks on Planned Parenthood, and stress introduced by his tweets have caused additional damage.
However, leading Democrats including Bernie Sanders and Elizabeth Warren insist on shooting themselves in the foot by touting Medicare for All. The critics are right: it would be expensive, complex, disruptive and represent a government takeover of the healthcare system. A new Kaiser Family Foundation poll shows that most people don’t even believe their wages will rise if employers save a bundle on health care, as they would under Medicare for All.
Meanwhile, Trump has competent people in his administration in healthcare (unlike other areas) and they’ve worked hard on productive areas such as Medicare Advantage, kidney care, transparency, and vaping.
As a result, Trump can win on healthcare even without a signature TrumpCare program.
Democrats would be wise to nominate someone who espouses building on Obamacare, not replacing it with Medicare for All. Michael Bennet is my pick, but he isn’t getting traction. Joe Biden is the best of the current frontrunners and as Obama’s Vice President is best placed to cement the Obamacare legacy.
The air ambulance industry has grown steadily in the U.S. from about 1,100 aircraft in 2007 to more than 1,400 in 2018. During that same time, the fleet in Wyoming has grown from three aircraft to 14. [A]n oversupply of helicopters and planes is driving up prices because air bases have high fixed overhead costs. [C]ompanies must pay for aircraft, staffing and technology… before they fly a single patient.
But with the supply of aircraft outpacing demand, each air ambulance is flying fewer patients… So, companies have raised their prices to cover their fixed costs and to seek healthy returns for their investors.
Imagine if there were three gas stations in a town and then there were 14. Would prices go up or down? [Hint: Down.]
But healthcare doesn’t work like that, somehow. Ambulances in general and air ambulances in particular are great examples of why not. In particular, you can’t really refuse to be transported by ambulance and if you have private insurance the ambulance companies can stay out of network and stick you –the consumer– with the bill.
In this case, Wyoming is doing the right thing in trying to socialize the industry by pushing everything into Medicaid. The legislature would be wise to use this as an opportunity to reconsider its opposition to Medicaid expansion, which it has rejected in the past, even it added a hard hearted and counterproductive work requirement.
According to today’s Wall St. Journal, not only are air ambulances liable to crash (a crew member who worked 20 hours/week for 20 years would have a 40% chance of being killed), they are often slower than ground ambulances, and are used to transport patients who aren’t that sick.
Of course, there are situations where air ambulances make sense, such as in rural areas. On the other hand, even speedy air ambulances can’t do much about the 10-20 hours waits I mentioned in yesterday’s post on Mass General.
After 9-year-old Tyler Herman fell and broke his jaw in the wilds of Arizona, doctors at a community hospital decided the boy should fly to Phoenix to undergo plastic surgery for a gash on his face. During the flight he was well enough to sit up and remark on the scenery. Upon arriving in Phoenix, he waited nearly 20 hours to undergo surgery. “We could have driven him there in four hours,” says Sharon Herman, the boy’s mother. Her insurance didn’t cover air transport, leaving the Hermans with a bill for $25,000.
Wyoming is a rural state, and the picture that air ambulances conjure up is people being rescued from car crashes or heart attacks in remote areas. Of course that’s the story the owners of air ambulance services want you to believe. Here’s what the lobbyist in Wyoming says about it:
“How many of these 4,000 people a year [flown by air ambulance] are you willing to tell, ‘Sorry, we decided as a legislature you’re going to have to take ground ambulance?’” Mincer said during a June hearing on the proposal.
Sure enough, in Wyoming the situation now is like it was in Arizona a decade and a half ago. “On-scene trauma responses,” represent just a small portion of the flights. In this case, supply creates its own demand and in many cases a ground ambulance would be a better option.
It’s tempting –but too easy– to place all the blame on private equity investors for the problem. State and federal government, health plans, physicians and even consumers have the power to make it stop.
In this edition of #CareTalk, CareCentrix CEO John Driscoll and I have a little fun at the expense of our neighbors to the North. Will Canada build a wall along its Southern border to keep out US patients?
(0:43) Are Canadians right to worry that Americans are going to clean out their pharmacies, leaving nothing for the locals?
(1:43) What are “authorized generics” and are they a good idea?
(3:22) Are skilled nursing facilities a piggybank for accountable care organizations?
Looking through my news alerts today I saw a couple items that support the old adage, “there’s nothing new under the sun.”
Exhibit 1: Biosimilars
Two academics have been arguing for a few months that biosimilars aren’t like generics after all and that the US should regulate the prices of biotech drugs once they go off patent. They’ve been banging their heads against the wall and are getting tired of it. “Time to throw in the towel on biosimilars,” they write in the Wall Street Journal.
Maybe I shouldn’t be so cynical –I think I’ll write to the authors and see if I can lend them a hand!
Exhibit 2: Medical Tourism
In 2007 I got pretty excited about medical tourism (aka medical travel) as a way to reduce costs without cutting quality –at a time when we were throwing our hands up about costs and coverage in the US. I went so far as to travel to Singapore and South Korea to research the topic and set up a TripAdvisor-style website to facilitate the phenomenon. Here’s the transcript of my interview with the author of the first serious book on the topic.
It’s a great topic to write about, and there are some excellent anecdotes, but it didn’t catch on in a big way a decade ago and I’m skeptical it will do so now. Before the Affordable Care Act many middle class people were uninsured, so going abroad for orthopedic or heart surgery could mean the difference between losing one’s house/retirement savings or not. It was still a novel idea. But with the ACA there were many fewer people for whom it made great sense.
Most of what I saw was people going abroad for cosmetic treatments or dentistry. The other category was immigrants going back to their home country for treatment. (My sister-in-law went back to Canada for LASIK, for example.) Then as now, the US is the biggest destination country for medical “tourists.”
I really haven’t followed the field lately, but I’m seeing the same kinds of stories now (A prescription for a passport? Health plans covering medical tourism) that I saw then. This one says the industry is $439 billion growing at 15-25% per year. I haven’t reviewed the research but I promise you the market definition must be pretty broad!
Harvard Pilgrim and Tufts –the second and third largest health plans in Massachusetts– are merging. It deserves the front page treatment it’s receiving today (check out the comprehensive coverage in the Boston Globe) –and will have an impact on employees and members– but I predict that the long term impact on Massachusetts healthcare overall will be modest at best.
To boil it down, despite being ranked by NCQA as the top two health plans in the whole country for many years (here’s 2014 for example), it’s been a long time since either Harvard or Tufts had a major influence in the local market. That’s harsh but I don’t think I’m overstating things.
In 2001 when I was setting up my business and looking for health insurance, I asked around about which insurer to use. My doctors said they were indifferent, but a friend at Partners Health Care told me Blue Cross was the only plan they paid attention to.
The last time Tufts tried to seriously impact the market was about 20 years ago, when Partners HealthCare manhandled them in rate negotiations. And former Harvard Pilgrim CEO, Charlie Baker admitted publicly around the early aughts that when Harvard Pilgrim tried innovative reimbursement structures, hospitals just ignored them and converted everything into Medicare equivalents. And clearly the attempt to channel volume to community hospitals and away from Partners was a bust.
At least in Baker’s current job as Governor he has some influence.
I don’t mean to be cynical at all. I’ve followed both of these mission-driven companies for many years and would love the new combined entity to be an influential innovator –not just in holding down costs but in radically improving experience and quality as well.
But after so many years of banging their heads against the wall, will they give it another go? I kind of doubt it. As the number 2 player in an insurance market led by Blue Cross Blue Shield, and a healthcare market dominated at the Massachusetts level by Partners and BI/Lahey and overall by the federal and state governments, I see their role mainly around the margins. I’m not sure their leadership is ready to go all out to change the system either.
In the last several years, under CEO Andrew Dreyfus, Blue Cross has actually passed Harvard Pilgrim and Tufts in the NCQA ratings. It’s been more innovative as well, with the Alternative Quality Contract (AQC) in particular.
I looked back this morning at my blog coverage of these companies over the years and picked out some highlights.
I’ve interviewed the CEOs of all three:
Tom Croswell, who will head the combined entity and is currently CEO of Tufts (2018)
Eric Schultz, then CEO of Harvard Pilgrim in a four-part video series in 2011 and again in a podcast in 2013
Charlie Baker, when he was running for Governor in 2014. (I interviewed every candidate that year)