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Health care gets heated on Night 2 of the Democratic presidential debate
Just as on Wednesday night, moderators asked candidates who would support abolishing private insurance under a single-payer system. Again, only two candidates — this time Sen. Sanders and Sen. Kamala Harris of California— raised their hands.
Former Vice President Joe Biden also jumped on health care, saying Americans “need to have insurance that is covered, and that they can afford.”
But he offered a different view of how to achieve the goal, saying the fastest way would be to “build on Obamacare. To build on what we did.” He also drew a line in the sand, promising to oppose any Democrat or Republican who tried to take down Obamacare.
Candidates including South Bend, Ind., Mayor Pete Buttigieg, New York Sen. Kristen Gillibrand and Colorado Sen. Michael Bennet offered their takes on universal coverage, each underscoring the importance of a transition from the current system and suggesting that a public option approach, something that would allow people to buy into a program like Medicare, would offer a “glide path” to the ultimate goal of universal coverage. Sen. Gillibrand noted that she ran on such a proposal in 2005. (This is true.)
Meanwhile, former Colorado Gov. John Hickenlooper used the issue of Medicare for All to say that it is important to not allow Republicans to paint the Democratic Party as socialist but also to claim his own successes in implementing coverage expansions to reach “near universal coverage” Colorado. PolitiFact examined this claim and found it Mostly True.“You don’t need big government to do big things. I know that because I’m the one person up here who’s actually done the big progressive things everyone else is talking about,” he said.
But still, while candidates were quick to make their differences clear, not all of their claims fully stood up to scrutiny.
We fact-checked some of those remarks.
Sen. Sanders: “President Trump, you’re not standing up for working families when you try to throw 32 million people off the health care that they have.”
This is one of Sanders’ favorite lines, but it falls short of giving the full story of the Republican effort to repeal and replace Obamacare. We rated a similar claim Half True.
Scrapping the Affordable Care Act was a key campaign promise for President Donald Trump. In 2017, as the Republican-led Congress struggled to deliver, Trump tweeted “Republicans should just REPEAL failing Obamacare now and work on a new health care plan that will start from a clean slate.”
The Congressional Budget Office estimated that would lead to 32 million more people without insurance by 2026. But some portion of that 32 million would have chosen not to buy insurance due to the end of the individual mandate, which would happen under repeal. (It happened anyway, when the 2017 tax law repealed the fine for the individual mandate.)
In the end, full repeal didn’t happen. Instead, Trump was only able to zero out the fines for people who didn’t have insurance. Coverage has eroded. The latest survey shows about 1.3 million people have lost insurance since Trump took office.
Sen. Bennet, meanwhile, used his time to attack Medicare for All on a feasibility standpoint.
Sen. Bennet: “Bernie mentioned that the taxes that we would have to pay — because of those taxes, Vermont rejected Medicare for All.”
This is true, although it could use some context.
Vermont’s effort to pass a state-based single-payer health plan — which the state legislature approved in 2011 — officially fell flat in December 2014. Financing the plan ultimately would have required an 11.5% payroll tax on all employers, plus raising the income tax by as much as 9.5%. The governor at the time, Democrat Peter Shumlin, declared this politically untenable.
That said, some analysts suggest other political factors may have played a role, too — for instance, fallout after the state launched its Affordable Care Act health insurance website, which faced technical difficulties.
Nationally, when voters are told Medicare for All could result in higher taxes, support declines.
And a point was made by author Marianne Williamson about the nation’s high burden of chronic disease.
Ms. Williamson: “So many Americans have unnecessary chronic illnesses — so many more compared to other countries.”
There is evidence for this, at least for older Americans.
A November 2014 study by the Commonwealth Fund found that 68% of Americans 65 and older had two or more chronic conditions, and an additional 20% had one chronic condition.
No other country studied — the United Kingdom, New Zealand, Sweden, Norway, France, Switzerland, the Netherlands, Germany, Austria, or Canada — had a higher rate of older residents with at least two chronic conditions. The percentages ranged from 33 percent in the United Kingdom to 56 percent in Canada.
An earlier study published in the journal Health Affairs in 2007 found that “for many of the most costly chronic conditions, diagnosed disease prevalence and treatment rates were higher in the United States than in a sample of European countries in 2004.”
PolitiFact’s Jon Greenberg and Louis Jacobson contributed to this story. Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. Politifact is owned by the nonprofit Poynter Institute for Media Studies.
Just as on Wednesday night, moderators asked candidates who would support abolishing private insurance under a single-payer system. Again, only two candidates — this time Sen. Sanders and Sen. Kamala Harris of California— raised their hands.
Former Vice President Joe Biden also jumped on health care, saying Americans “need to have insurance that is covered, and that they can afford.”
But he offered a different view of how to achieve the goal, saying the fastest way would be to “build on Obamacare. To build on what we did.” He also drew a line in the sand, promising to oppose any Democrat or Republican who tried to take down Obamacare.
Candidates including South Bend, Ind., Mayor Pete Buttigieg, New York Sen. Kristen Gillibrand and Colorado Sen. Michael Bennet offered their takes on universal coverage, each underscoring the importance of a transition from the current system and suggesting that a public option approach, something that would allow people to buy into a program like Medicare, would offer a “glide path” to the ultimate goal of universal coverage. Sen. Gillibrand noted that she ran on such a proposal in 2005. (This is true.)
Meanwhile, former Colorado Gov. John Hickenlooper used the issue of Medicare for All to say that it is important to not allow Republicans to paint the Democratic Party as socialist but also to claim his own successes in implementing coverage expansions to reach “near universal coverage” Colorado. PolitiFact examined this claim and found it Mostly True.“You don’t need big government to do big things. I know that because I’m the one person up here who’s actually done the big progressive things everyone else is talking about,” he said.
But still, while candidates were quick to make their differences clear, not all of their claims fully stood up to scrutiny.
We fact-checked some of those remarks.
Sen. Sanders: “President Trump, you’re not standing up for working families when you try to throw 32 million people off the health care that they have.”
This is one of Sanders’ favorite lines, but it falls short of giving the full story of the Republican effort to repeal and replace Obamacare. We rated a similar claim Half True.
Scrapping the Affordable Care Act was a key campaign promise for President Donald Trump. In 2017, as the Republican-led Congress struggled to deliver, Trump tweeted “Republicans should just REPEAL failing Obamacare now and work on a new health care plan that will start from a clean slate.”
The Congressional Budget Office estimated that would lead to 32 million more people without insurance by 2026. But some portion of that 32 million would have chosen not to buy insurance due to the end of the individual mandate, which would happen under repeal. (It happened anyway, when the 2017 tax law repealed the fine for the individual mandate.)
In the end, full repeal didn’t happen. Instead, Trump was only able to zero out the fines for people who didn’t have insurance. Coverage has eroded. The latest survey shows about 1.3 million people have lost insurance since Trump took office.
Sen. Bennet, meanwhile, used his time to attack Medicare for All on a feasibility standpoint.
Sen. Bennet: “Bernie mentioned that the taxes that we would have to pay — because of those taxes, Vermont rejected Medicare for All.”
This is true, although it could use some context.
Vermont’s effort to pass a state-based single-payer health plan — which the state legislature approved in 2011 — officially fell flat in December 2014. Financing the plan ultimately would have required an 11.5% payroll tax on all employers, plus raising the income tax by as much as 9.5%. The governor at the time, Democrat Peter Shumlin, declared this politically untenable.
That said, some analysts suggest other political factors may have played a role, too — for instance, fallout after the state launched its Affordable Care Act health insurance website, which faced technical difficulties.
Nationally, when voters are told Medicare for All could result in higher taxes, support declines.
And a point was made by author Marianne Williamson about the nation’s high burden of chronic disease.
Ms. Williamson: “So many Americans have unnecessary chronic illnesses — so many more compared to other countries.”
There is evidence for this, at least for older Americans.
A November 2014 study by the Commonwealth Fund found that 68% of Americans 65 and older had two or more chronic conditions, and an additional 20% had one chronic condition.
No other country studied — the United Kingdom, New Zealand, Sweden, Norway, France, Switzerland, the Netherlands, Germany, Austria, or Canada — had a higher rate of older residents with at least two chronic conditions. The percentages ranged from 33 percent in the United Kingdom to 56 percent in Canada.
An earlier study published in the journal Health Affairs in 2007 found that “for many of the most costly chronic conditions, diagnosed disease prevalence and treatment rates were higher in the United States than in a sample of European countries in 2004.”
PolitiFact’s Jon Greenberg and Louis Jacobson contributed to this story. Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. Politifact is owned by the nonprofit Poynter Institute for Media Studies.
Just as on Wednesday night, moderators asked candidates who would support abolishing private insurance under a single-payer system. Again, only two candidates — this time Sen. Sanders and Sen. Kamala Harris of California— raised their hands.
Former Vice President Joe Biden also jumped on health care, saying Americans “need to have insurance that is covered, and that they can afford.”
But he offered a different view of how to achieve the goal, saying the fastest way would be to “build on Obamacare. To build on what we did.” He also drew a line in the sand, promising to oppose any Democrat or Republican who tried to take down Obamacare.
Candidates including South Bend, Ind., Mayor Pete Buttigieg, New York Sen. Kristen Gillibrand and Colorado Sen. Michael Bennet offered their takes on universal coverage, each underscoring the importance of a transition from the current system and suggesting that a public option approach, something that would allow people to buy into a program like Medicare, would offer a “glide path” to the ultimate goal of universal coverage. Sen. Gillibrand noted that she ran on such a proposal in 2005. (This is true.)
Meanwhile, former Colorado Gov. John Hickenlooper used the issue of Medicare for All to say that it is important to not allow Republicans to paint the Democratic Party as socialist but also to claim his own successes in implementing coverage expansions to reach “near universal coverage” Colorado. PolitiFact examined this claim and found it Mostly True.“You don’t need big government to do big things. I know that because I’m the one person up here who’s actually done the big progressive things everyone else is talking about,” he said.
But still, while candidates were quick to make their differences clear, not all of their claims fully stood up to scrutiny.
We fact-checked some of those remarks.
Sen. Sanders: “President Trump, you’re not standing up for working families when you try to throw 32 million people off the health care that they have.”
This is one of Sanders’ favorite lines, but it falls short of giving the full story of the Republican effort to repeal and replace Obamacare. We rated a similar claim Half True.
Scrapping the Affordable Care Act was a key campaign promise for President Donald Trump. In 2017, as the Republican-led Congress struggled to deliver, Trump tweeted “Republicans should just REPEAL failing Obamacare now and work on a new health care plan that will start from a clean slate.”
The Congressional Budget Office estimated that would lead to 32 million more people without insurance by 2026. But some portion of that 32 million would have chosen not to buy insurance due to the end of the individual mandate, which would happen under repeal. (It happened anyway, when the 2017 tax law repealed the fine for the individual mandate.)
In the end, full repeal didn’t happen. Instead, Trump was only able to zero out the fines for people who didn’t have insurance. Coverage has eroded. The latest survey shows about 1.3 million people have lost insurance since Trump took office.
Sen. Bennet, meanwhile, used his time to attack Medicare for All on a feasibility standpoint.
Sen. Bennet: “Bernie mentioned that the taxes that we would have to pay — because of those taxes, Vermont rejected Medicare for All.”
This is true, although it could use some context.
Vermont’s effort to pass a state-based single-payer health plan — which the state legislature approved in 2011 — officially fell flat in December 2014. Financing the plan ultimately would have required an 11.5% payroll tax on all employers, plus raising the income tax by as much as 9.5%. The governor at the time, Democrat Peter Shumlin, declared this politically untenable.
That said, some analysts suggest other political factors may have played a role, too — for instance, fallout after the state launched its Affordable Care Act health insurance website, which faced technical difficulties.
Nationally, when voters are told Medicare for All could result in higher taxes, support declines.
And a point was made by author Marianne Williamson about the nation’s high burden of chronic disease.
Ms. Williamson: “So many Americans have unnecessary chronic illnesses — so many more compared to other countries.”
There is evidence for this, at least for older Americans.
A November 2014 study by the Commonwealth Fund found that 68% of Americans 65 and older had two or more chronic conditions, and an additional 20% had one chronic condition.
No other country studied — the United Kingdom, New Zealand, Sweden, Norway, France, Switzerland, the Netherlands, Germany, Austria, or Canada — had a higher rate of older residents with at least two chronic conditions. The percentages ranged from 33 percent in the United Kingdom to 56 percent in Canada.
An earlier study published in the journal Health Affairs in 2007 found that “for many of the most costly chronic conditions, diagnosed disease prevalence and treatment rates were higher in the United States than in a sample of European countries in 2004.”
PolitiFact’s Jon Greenberg and Louis Jacobson contributed to this story. Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. Politifact is owned by the nonprofit Poynter Institute for Media Studies.
‘Medicare for All’ emerges as early divide in first Democratic debate
Health care dominated early on June 26, with Sens. Elizabeth Warren (Mass.) and Cory Booker (N.J.) using questions about the economy to take aim at pharmaceutical and insurance companies. Sen. Amy Klobuchar (Minn.) emphasized the difficulties many Americans face in paying premiums.
But the candidates broke ranks on the details and not all of their claims stayed strictly within the lines.
Only two candidates — New York City Mayor Bill de Blasio and Sen. Warren — raised their hands in favor of banishing private insurance to install a government-sponsored Medicare for All approach.
Sen. Klobuchar, a single-payer skeptic, expressed concern about “kicking half of America off their health insurance in 4 years.” (That’s correct: In 2017, a majority of Americans had private coverage, with 49% getting that insurance through work, according to the Kaiser Family Foundation.)
Former Texas Rep. Beto O’Rourke, who also supports maintaining a private insurance system, outlined his own universal health care plan, based on a “Medicare for America” bill in Congress.
The single-payer talk set off other discussions about the role of health insurance and the cost of care. We fact-checked some of the biggest claims.
Sen. Warren: “The insurance companies last year alone sucked $23 billion in profits out of the health care system. $23 billion. And that doesn’t count the money that was paid to executives, the money that was spent lobbying Washington.”
We contacted Warren’s campaign, who directed us to a report from the National Association of Insurance Commissioners, a nonpartisan group of industry regulators. It supports her assessment.
The report says that in 2018, health insurers posted $23.4 billion in net earnings, or profits, compared with $16.1 billion a year prior.
This came up in the context of Warren’s support for eliminating private insurance under a Medicare for All system. However, the financing and price tag of such a system is unclear.
Sen. Booker: “The overhead for insurers that they charge is 15%, while Medicare’s overhead is only at 2%.”
This is a flawed comparison. Booker said administrative overhead eats up much more for private carriers than it does for Medicare, the government insurance program for seniors and the disabled. But Medicare piggybacks off the Social Security Administration, which covers costs of enrollment, payments, and keeping track of patients.
Also, Medicare relies on private providers for some of its programs, and overhead charges there are higher. Medicare’s overhead is less than that of private carriers, but exact figures are elusive.
The insurance companies’ trade group, America’s Health Insurance Plans (AHIP), reported in 2018 that 18.1% of private health care premiums went to non–health care services. That includes taxes of 4.7% and profits of 2.3%. The Medicare trustees reported that in 2018, total expenses were $740.6 billion, with administrative expenses of $9.9 billion. That comes to 1.3%, less than Booker said.
Sen. Warren: “I spent a big chunk of my life studying why families go broke, and one of the No. 1 reasons is the cost of health care, medical bills. And that’s not just for people who don’t have insurance. It’s for people who have insurance.”
Is the No. 1 reason people go broke the cost of health care? We’ve rated similar statements Half True — partially accurate but lacking important context.
A 2005 study Warren coauthored and a 2009 paper both found that health care expenses were a leading cause of personal bankruptcy. But these claims have come under dispute, in particular from academics who suggest that people may overstate the role medical bills play in their financial problems. Other research suggests a far narrower impact, though that, in turn, has been criticized for focusing only on adult hospitalizations.
That said, research from the Consumer Financial Protection Bureau found that medical bills are a leading cause of personal debt — in 2014, the CFPB found that nearly 20% of credit reports included a medical debt tradeline.
But Rep. Tulsi Gabbard (Hawaii) drew on examples of universal health coverage in other countries to explain why she still supported some private insurance options.
Rep. Gabbard: “If you look at other countries in the world who have universal health care, every one of them has some form of a role of private insurance.”
This is correct. Virtually every country with universal health care includes a role for private insurance. Some allow it to cover services not addressed by the national plan. Others allow it as a means to get care faster. Others heavily regulate it as a principal source of coverage.
For instance, Canada, the model for the principal Medicare for All bill, allows private insurance to address prescription drug coverage, private rooms in hospitals, and vision and dental care. (It is not allowed to compete with the government plan.) In England, about 10% of people — mostly wealthier people — elect for private coverage, which can yield faster access to care. Countries such as the Netherlands and Switzerland heavily regulate private coverage.
Beyond Medicare for All, candidates touched on strategies to bring down drug prices as well as other issues.
Sen. Klobuchar: “2,500 drug prices have gone up in double digits since [Donald Trump] took office.”
This is accurate, according to a report from Pharmacy Benefits Consultants, an industry group, which listed a number of pharmaceutical products experiencing price increases as high as 1,468%.
And the numbers are even less flattering than Sen. Klobuchar suggested.
An analysis by the Associated Press found that, between January and July 2018, more than 4,400 branded prescription drugs experienced price increases. Meanwhile, data compiled by Rx Savings Solutions found that the list price of more than 3,000 drugs went up this year.
Rep. O’Rourke: “In Texas, the single largest provider of mental health care is the county jail system.”
This is correct. Texas jails are the largest mental health care systems in the state, according to a report from the University of Texas at Austin. The Harris County jail, which includes a 108-bed unit, identifies itself as the largest mental health care facility in Texas.
This is not a Texas-specific issue. According to a 2011 NPR report, it is more common to see Americans getting mental health care in jails and prisons than in hospitals or other dedicated treatment facilities.
Election Day is 495 days away.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. Politifact is owned by the nonprofit Poynter Institute for Media Studies.
Health care dominated early on June 26, with Sens. Elizabeth Warren (Mass.) and Cory Booker (N.J.) using questions about the economy to take aim at pharmaceutical and insurance companies. Sen. Amy Klobuchar (Minn.) emphasized the difficulties many Americans face in paying premiums.
But the candidates broke ranks on the details and not all of their claims stayed strictly within the lines.
Only two candidates — New York City Mayor Bill de Blasio and Sen. Warren — raised their hands in favor of banishing private insurance to install a government-sponsored Medicare for All approach.
Sen. Klobuchar, a single-payer skeptic, expressed concern about “kicking half of America off their health insurance in 4 years.” (That’s correct: In 2017, a majority of Americans had private coverage, with 49% getting that insurance through work, according to the Kaiser Family Foundation.)
Former Texas Rep. Beto O’Rourke, who also supports maintaining a private insurance system, outlined his own universal health care plan, based on a “Medicare for America” bill in Congress.
The single-payer talk set off other discussions about the role of health insurance and the cost of care. We fact-checked some of the biggest claims.
Sen. Warren: “The insurance companies last year alone sucked $23 billion in profits out of the health care system. $23 billion. And that doesn’t count the money that was paid to executives, the money that was spent lobbying Washington.”
We contacted Warren’s campaign, who directed us to a report from the National Association of Insurance Commissioners, a nonpartisan group of industry regulators. It supports her assessment.
The report says that in 2018, health insurers posted $23.4 billion in net earnings, or profits, compared with $16.1 billion a year prior.
This came up in the context of Warren’s support for eliminating private insurance under a Medicare for All system. However, the financing and price tag of such a system is unclear.
Sen. Booker: “The overhead for insurers that they charge is 15%, while Medicare’s overhead is only at 2%.”
This is a flawed comparison. Booker said administrative overhead eats up much more for private carriers than it does for Medicare, the government insurance program for seniors and the disabled. But Medicare piggybacks off the Social Security Administration, which covers costs of enrollment, payments, and keeping track of patients.
Also, Medicare relies on private providers for some of its programs, and overhead charges there are higher. Medicare’s overhead is less than that of private carriers, but exact figures are elusive.
The insurance companies’ trade group, America’s Health Insurance Plans (AHIP), reported in 2018 that 18.1% of private health care premiums went to non–health care services. That includes taxes of 4.7% and profits of 2.3%. The Medicare trustees reported that in 2018, total expenses were $740.6 billion, with administrative expenses of $9.9 billion. That comes to 1.3%, less than Booker said.
Sen. Warren: “I spent a big chunk of my life studying why families go broke, and one of the No. 1 reasons is the cost of health care, medical bills. And that’s not just for people who don’t have insurance. It’s for people who have insurance.”
Is the No. 1 reason people go broke the cost of health care? We’ve rated similar statements Half True — partially accurate but lacking important context.
A 2005 study Warren coauthored and a 2009 paper both found that health care expenses were a leading cause of personal bankruptcy. But these claims have come under dispute, in particular from academics who suggest that people may overstate the role medical bills play in their financial problems. Other research suggests a far narrower impact, though that, in turn, has been criticized for focusing only on adult hospitalizations.
That said, research from the Consumer Financial Protection Bureau found that medical bills are a leading cause of personal debt — in 2014, the CFPB found that nearly 20% of credit reports included a medical debt tradeline.
But Rep. Tulsi Gabbard (Hawaii) drew on examples of universal health coverage in other countries to explain why she still supported some private insurance options.
Rep. Gabbard: “If you look at other countries in the world who have universal health care, every one of them has some form of a role of private insurance.”
This is correct. Virtually every country with universal health care includes a role for private insurance. Some allow it to cover services not addressed by the national plan. Others allow it as a means to get care faster. Others heavily regulate it as a principal source of coverage.
For instance, Canada, the model for the principal Medicare for All bill, allows private insurance to address prescription drug coverage, private rooms in hospitals, and vision and dental care. (It is not allowed to compete with the government plan.) In England, about 10% of people — mostly wealthier people — elect for private coverage, which can yield faster access to care. Countries such as the Netherlands and Switzerland heavily regulate private coverage.
Beyond Medicare for All, candidates touched on strategies to bring down drug prices as well as other issues.
Sen. Klobuchar: “2,500 drug prices have gone up in double digits since [Donald Trump] took office.”
This is accurate, according to a report from Pharmacy Benefits Consultants, an industry group, which listed a number of pharmaceutical products experiencing price increases as high as 1,468%.
And the numbers are even less flattering than Sen. Klobuchar suggested.
An analysis by the Associated Press found that, between January and July 2018, more than 4,400 branded prescription drugs experienced price increases. Meanwhile, data compiled by Rx Savings Solutions found that the list price of more than 3,000 drugs went up this year.
Rep. O’Rourke: “In Texas, the single largest provider of mental health care is the county jail system.”
This is correct. Texas jails are the largest mental health care systems in the state, according to a report from the University of Texas at Austin. The Harris County jail, which includes a 108-bed unit, identifies itself as the largest mental health care facility in Texas.
This is not a Texas-specific issue. According to a 2011 NPR report, it is more common to see Americans getting mental health care in jails and prisons than in hospitals or other dedicated treatment facilities.
Election Day is 495 days away.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. Politifact is owned by the nonprofit Poynter Institute for Media Studies.
Health care dominated early on June 26, with Sens. Elizabeth Warren (Mass.) and Cory Booker (N.J.) using questions about the economy to take aim at pharmaceutical and insurance companies. Sen. Amy Klobuchar (Minn.) emphasized the difficulties many Americans face in paying premiums.
But the candidates broke ranks on the details and not all of their claims stayed strictly within the lines.
Only two candidates — New York City Mayor Bill de Blasio and Sen. Warren — raised their hands in favor of banishing private insurance to install a government-sponsored Medicare for All approach.
Sen. Klobuchar, a single-payer skeptic, expressed concern about “kicking half of America off their health insurance in 4 years.” (That’s correct: In 2017, a majority of Americans had private coverage, with 49% getting that insurance through work, according to the Kaiser Family Foundation.)
Former Texas Rep. Beto O’Rourke, who also supports maintaining a private insurance system, outlined his own universal health care plan, based on a “Medicare for America” bill in Congress.
The single-payer talk set off other discussions about the role of health insurance and the cost of care. We fact-checked some of the biggest claims.
Sen. Warren: “The insurance companies last year alone sucked $23 billion in profits out of the health care system. $23 billion. And that doesn’t count the money that was paid to executives, the money that was spent lobbying Washington.”
We contacted Warren’s campaign, who directed us to a report from the National Association of Insurance Commissioners, a nonpartisan group of industry regulators. It supports her assessment.
The report says that in 2018, health insurers posted $23.4 billion in net earnings, or profits, compared with $16.1 billion a year prior.
This came up in the context of Warren’s support for eliminating private insurance under a Medicare for All system. However, the financing and price tag of such a system is unclear.
Sen. Booker: “The overhead for insurers that they charge is 15%, while Medicare’s overhead is only at 2%.”
This is a flawed comparison. Booker said administrative overhead eats up much more for private carriers than it does for Medicare, the government insurance program for seniors and the disabled. But Medicare piggybacks off the Social Security Administration, which covers costs of enrollment, payments, and keeping track of patients.
Also, Medicare relies on private providers for some of its programs, and overhead charges there are higher. Medicare’s overhead is less than that of private carriers, but exact figures are elusive.
The insurance companies’ trade group, America’s Health Insurance Plans (AHIP), reported in 2018 that 18.1% of private health care premiums went to non–health care services. That includes taxes of 4.7% and profits of 2.3%. The Medicare trustees reported that in 2018, total expenses were $740.6 billion, with administrative expenses of $9.9 billion. That comes to 1.3%, less than Booker said.
Sen. Warren: “I spent a big chunk of my life studying why families go broke, and one of the No. 1 reasons is the cost of health care, medical bills. And that’s not just for people who don’t have insurance. It’s for people who have insurance.”
Is the No. 1 reason people go broke the cost of health care? We’ve rated similar statements Half True — partially accurate but lacking important context.
A 2005 study Warren coauthored and a 2009 paper both found that health care expenses were a leading cause of personal bankruptcy. But these claims have come under dispute, in particular from academics who suggest that people may overstate the role medical bills play in their financial problems. Other research suggests a far narrower impact, though that, in turn, has been criticized for focusing only on adult hospitalizations.
That said, research from the Consumer Financial Protection Bureau found that medical bills are a leading cause of personal debt — in 2014, the CFPB found that nearly 20% of credit reports included a medical debt tradeline.
But Rep. Tulsi Gabbard (Hawaii) drew on examples of universal health coverage in other countries to explain why she still supported some private insurance options.
Rep. Gabbard: “If you look at other countries in the world who have universal health care, every one of them has some form of a role of private insurance.”
This is correct. Virtually every country with universal health care includes a role for private insurance. Some allow it to cover services not addressed by the national plan. Others allow it as a means to get care faster. Others heavily regulate it as a principal source of coverage.
For instance, Canada, the model for the principal Medicare for All bill, allows private insurance to address prescription drug coverage, private rooms in hospitals, and vision and dental care. (It is not allowed to compete with the government plan.) In England, about 10% of people — mostly wealthier people — elect for private coverage, which can yield faster access to care. Countries such as the Netherlands and Switzerland heavily regulate private coverage.
Beyond Medicare for All, candidates touched on strategies to bring down drug prices as well as other issues.
Sen. Klobuchar: “2,500 drug prices have gone up in double digits since [Donald Trump] took office.”
This is accurate, according to a report from Pharmacy Benefits Consultants, an industry group, which listed a number of pharmaceutical products experiencing price increases as high as 1,468%.
And the numbers are even less flattering than Sen. Klobuchar suggested.
An analysis by the Associated Press found that, between January and July 2018, more than 4,400 branded prescription drugs experienced price increases. Meanwhile, data compiled by Rx Savings Solutions found that the list price of more than 3,000 drugs went up this year.
Rep. O’Rourke: “In Texas, the single largest provider of mental health care is the county jail system.”
This is correct. Texas jails are the largest mental health care systems in the state, according to a report from the University of Texas at Austin. The Harris County jail, which includes a 108-bed unit, identifies itself as the largest mental health care facility in Texas.
This is not a Texas-specific issue. According to a 2011 NPR report, it is more common to see Americans getting mental health care in jails and prisons than in hospitals or other dedicated treatment facilities.
Election Day is 495 days away.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. Politifact is owned by the nonprofit Poynter Institute for Media Studies.
CBO’s report on single-payer health care holds more questions than answers
Progressive Democrats have rallied around “Medicare-for-all,” a single-payer health plan popularized by Sen. Bernie Sanders (I-Vt.). Now, some of Washington’s official bean counters are trying to add a new framework around what it might look like. The picture they offer highlights just how complicated that shift might be.
A report released May 1 by the nonpartisan Congressional Budget Office outlined a laundry list of options and technicalities lawmakers would need to consider if they are serious about such a proposal.
“The conversation about single-payer is getting more in the weeds, more detailed, which is a good thing because it’s such a complicated issue,” said Jodi Liu, an associate policy researcher at the Rand Corp. who studies single-payer proposals.
The takeaway: There’s a lot left to be answered about the concepts of Medicare-for-all specifically and the category of single-payer more broadly before policymakers and voters can come close to understanding what it would mean in practice. The term “single-payer” generally refers to a system in which health care is paid for by a single public authority.
“Even single-payer systems around the globe vary from each other in many, many ways,” said John McDonough, a Harvard health policy professor who helped draft the Affordable Care Act. “There’s just so many aspects of it that differ from a Canada to a Sweden to a Taiwan – and those are all intensely consequential.”
The report comes as this once-lefty pipe dream becomes officially mainstream.
Medicare-for-all has been name-checked by Democrats running for president. On April 30, Democrats and Republicans alike put the proposal under the microscope at a House Rules Committee hearing. And that won’t be the last time that happens. House Ways and Means Committee Chairman Richard Neal (D-Mass.) said he, too, intends to hold a hearing on the issue this session. Meanwhile, Sanders’ latest Medicare-for-all bill, reintroduced in the Senate in April, and a similar House bill, have 14 and 108 cosponsors, respectively.
Let’s break down the most crucial issues raised by the CBO report – what single-payer might cover, why “what it would cost” isn’t easy to determine, and what it could mean for how Americans get their health care.
Medicare-for-all backers say the program would cover all medically necessary services. But what does that truly mean?
What may seem obvious – the notion of medical necessity – isn’t so easy to distill into policy rules. And different single-payer systems around the world handle the benefits question differently, the CBO noted.
For instance, Canada doesn’t cover prescription drugs, but the United Kingdom and Sweden do. Of those three, only Sweden fully covers long-term support services, according to the report.
There are two questions at the heart of it, said Robert Berenson, a health policy analyst at the Urban Institute, a left-leaning think tank.
What benefits would be covered? Would it include dental care or prescription drugs or vision, as Sanders’ bill would? And, how does one determine the discrete services included within those benefits categories?
Single-payer architects could look at existing standards, such as the so-called essential health benefits that govern Obamacare health plans, to determine what’s covered. They could be more generous by including long-term care, which isn’t currently covered by Medicare or most private insurance plans.
Even the two “Medicare-for-all” bills in Congress have slightly different takes. Though both provide for long-term support and services, they diverge on how to pay for it. Sanders’ bill covers only at-home long-term care and keeps Medicaid intact for services provided in institutions. The House bill by Rep. Pramila Jayapal (D-Wash.) covers both.
And there are questions about new medical treatments, and how to determine whether they provide added value. The CBO report suggested some kind of “cost-effectiveness criterion” could determine what the government is willing to cover. In practice, though, that standard could be difficult to develop and could fall victim to political lobbying or trigger contentious debate.
Separately from the CBO report, Mr. McDonough noted, controversial medical services could bring up different kinds of political baggage – whether this plan would cover abortion, for instance, likely would change the single-payer debate.
Next: Single-payer health care would probably require new taxes. Just what level of taxes, though, and who they would hit hardest remain open questions.
Notably, the CBO report avoids a question that critics frequently surface: How much would this cost? How would you pay for it?
That’s because there’s no uniform cost estimate for single-payer and no easy formula to apply.
For one thing, the price tag depends on what services are covered – something like long-term care would make the idea much more expensive.
There’s also the question of cost sharing. In some single-payer systems, people must pay a copay, meet a deductible, or pay a premium as part of the health plan. That would alleviate some need for new taxes.
“I don’t think you can put numbers on it until someone defines a benefit package and defines cost sharing,” Mr. Berenson said.
The current Medicare-for-all bills eschew cost sharing. Other health reform proposals would keep premiums intact to help foot some of the bill.
The CBO report suggests that new taxes would likely play a role in financing a new single-payer plan. But what kind of taxes – a payroll tax, an income tax, or a sales tax, for instance – has not yet been stipulated. And each would have different consequences.
The single-payer approach could bring down health expenses, or at least increase value. But how effectively it would do so – and its larger economic impact – would depend on other design choices.
Single-payer backers dismiss the “pay-for” questions because, the reasoning goes, this approach would save lots of money in other ways, ultimately making it a good deal.
Yet again, though, the CBO said, whether that actually happens depends on the system’s design.
By eliminating most private insurers, a single-payer system would likely slash hospitals’ administrative overhead. The government could then pay a rate that better reflects reduced hospital costs, according to the CBO report.
But, ultimately, the single-payer bottom line depends on what the system pays hospitals, doctors, and drug companies for different services and products. That answer also would inform other economic assessments – ascertaining, for instance, how single-payer affects a small town where the hospital is the main employer.
Even without clear answers, outlining those questions moves the ball, Liu said.
“This area is moving really fast,” she said. “To me, it seems like this is the beginning of a longer conversation.”
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
Progressive Democrats have rallied around “Medicare-for-all,” a single-payer health plan popularized by Sen. Bernie Sanders (I-Vt.). Now, some of Washington’s official bean counters are trying to add a new framework around what it might look like. The picture they offer highlights just how complicated that shift might be.
A report released May 1 by the nonpartisan Congressional Budget Office outlined a laundry list of options and technicalities lawmakers would need to consider if they are serious about such a proposal.
“The conversation about single-payer is getting more in the weeds, more detailed, which is a good thing because it’s such a complicated issue,” said Jodi Liu, an associate policy researcher at the Rand Corp. who studies single-payer proposals.
The takeaway: There’s a lot left to be answered about the concepts of Medicare-for-all specifically and the category of single-payer more broadly before policymakers and voters can come close to understanding what it would mean in practice. The term “single-payer” generally refers to a system in which health care is paid for by a single public authority.
“Even single-payer systems around the globe vary from each other in many, many ways,” said John McDonough, a Harvard health policy professor who helped draft the Affordable Care Act. “There’s just so many aspects of it that differ from a Canada to a Sweden to a Taiwan – and those are all intensely consequential.”
The report comes as this once-lefty pipe dream becomes officially mainstream.
Medicare-for-all has been name-checked by Democrats running for president. On April 30, Democrats and Republicans alike put the proposal under the microscope at a House Rules Committee hearing. And that won’t be the last time that happens. House Ways and Means Committee Chairman Richard Neal (D-Mass.) said he, too, intends to hold a hearing on the issue this session. Meanwhile, Sanders’ latest Medicare-for-all bill, reintroduced in the Senate in April, and a similar House bill, have 14 and 108 cosponsors, respectively.
Let’s break down the most crucial issues raised by the CBO report – what single-payer might cover, why “what it would cost” isn’t easy to determine, and what it could mean for how Americans get their health care.
Medicare-for-all backers say the program would cover all medically necessary services. But what does that truly mean?
What may seem obvious – the notion of medical necessity – isn’t so easy to distill into policy rules. And different single-payer systems around the world handle the benefits question differently, the CBO noted.
For instance, Canada doesn’t cover prescription drugs, but the United Kingdom and Sweden do. Of those three, only Sweden fully covers long-term support services, according to the report.
There are two questions at the heart of it, said Robert Berenson, a health policy analyst at the Urban Institute, a left-leaning think tank.
What benefits would be covered? Would it include dental care or prescription drugs or vision, as Sanders’ bill would? And, how does one determine the discrete services included within those benefits categories?
Single-payer architects could look at existing standards, such as the so-called essential health benefits that govern Obamacare health plans, to determine what’s covered. They could be more generous by including long-term care, which isn’t currently covered by Medicare or most private insurance plans.
Even the two “Medicare-for-all” bills in Congress have slightly different takes. Though both provide for long-term support and services, they diverge on how to pay for it. Sanders’ bill covers only at-home long-term care and keeps Medicaid intact for services provided in institutions. The House bill by Rep. Pramila Jayapal (D-Wash.) covers both.
And there are questions about new medical treatments, and how to determine whether they provide added value. The CBO report suggested some kind of “cost-effectiveness criterion” could determine what the government is willing to cover. In practice, though, that standard could be difficult to develop and could fall victim to political lobbying or trigger contentious debate.
Separately from the CBO report, Mr. McDonough noted, controversial medical services could bring up different kinds of political baggage – whether this plan would cover abortion, for instance, likely would change the single-payer debate.
Next: Single-payer health care would probably require new taxes. Just what level of taxes, though, and who they would hit hardest remain open questions.
Notably, the CBO report avoids a question that critics frequently surface: How much would this cost? How would you pay for it?
That’s because there’s no uniform cost estimate for single-payer and no easy formula to apply.
For one thing, the price tag depends on what services are covered – something like long-term care would make the idea much more expensive.
There’s also the question of cost sharing. In some single-payer systems, people must pay a copay, meet a deductible, or pay a premium as part of the health plan. That would alleviate some need for new taxes.
“I don’t think you can put numbers on it until someone defines a benefit package and defines cost sharing,” Mr. Berenson said.
The current Medicare-for-all bills eschew cost sharing. Other health reform proposals would keep premiums intact to help foot some of the bill.
The CBO report suggests that new taxes would likely play a role in financing a new single-payer plan. But what kind of taxes – a payroll tax, an income tax, or a sales tax, for instance – has not yet been stipulated. And each would have different consequences.
The single-payer approach could bring down health expenses, or at least increase value. But how effectively it would do so – and its larger economic impact – would depend on other design choices.
Single-payer backers dismiss the “pay-for” questions because, the reasoning goes, this approach would save lots of money in other ways, ultimately making it a good deal.
Yet again, though, the CBO said, whether that actually happens depends on the system’s design.
By eliminating most private insurers, a single-payer system would likely slash hospitals’ administrative overhead. The government could then pay a rate that better reflects reduced hospital costs, according to the CBO report.
But, ultimately, the single-payer bottom line depends on what the system pays hospitals, doctors, and drug companies for different services and products. That answer also would inform other economic assessments – ascertaining, for instance, how single-payer affects a small town where the hospital is the main employer.
Even without clear answers, outlining those questions moves the ball, Liu said.
“This area is moving really fast,” she said. “To me, it seems like this is the beginning of a longer conversation.”
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
Progressive Democrats have rallied around “Medicare-for-all,” a single-payer health plan popularized by Sen. Bernie Sanders (I-Vt.). Now, some of Washington’s official bean counters are trying to add a new framework around what it might look like. The picture they offer highlights just how complicated that shift might be.
A report released May 1 by the nonpartisan Congressional Budget Office outlined a laundry list of options and technicalities lawmakers would need to consider if they are serious about such a proposal.
“The conversation about single-payer is getting more in the weeds, more detailed, which is a good thing because it’s such a complicated issue,” said Jodi Liu, an associate policy researcher at the Rand Corp. who studies single-payer proposals.
The takeaway: There’s a lot left to be answered about the concepts of Medicare-for-all specifically and the category of single-payer more broadly before policymakers and voters can come close to understanding what it would mean in practice. The term “single-payer” generally refers to a system in which health care is paid for by a single public authority.
“Even single-payer systems around the globe vary from each other in many, many ways,” said John McDonough, a Harvard health policy professor who helped draft the Affordable Care Act. “There’s just so many aspects of it that differ from a Canada to a Sweden to a Taiwan – and those are all intensely consequential.”
The report comes as this once-lefty pipe dream becomes officially mainstream.
Medicare-for-all has been name-checked by Democrats running for president. On April 30, Democrats and Republicans alike put the proposal under the microscope at a House Rules Committee hearing. And that won’t be the last time that happens. House Ways and Means Committee Chairman Richard Neal (D-Mass.) said he, too, intends to hold a hearing on the issue this session. Meanwhile, Sanders’ latest Medicare-for-all bill, reintroduced in the Senate in April, and a similar House bill, have 14 and 108 cosponsors, respectively.
Let’s break down the most crucial issues raised by the CBO report – what single-payer might cover, why “what it would cost” isn’t easy to determine, and what it could mean for how Americans get their health care.
Medicare-for-all backers say the program would cover all medically necessary services. But what does that truly mean?
What may seem obvious – the notion of medical necessity – isn’t so easy to distill into policy rules. And different single-payer systems around the world handle the benefits question differently, the CBO noted.
For instance, Canada doesn’t cover prescription drugs, but the United Kingdom and Sweden do. Of those three, only Sweden fully covers long-term support services, according to the report.
There are two questions at the heart of it, said Robert Berenson, a health policy analyst at the Urban Institute, a left-leaning think tank.
What benefits would be covered? Would it include dental care or prescription drugs or vision, as Sanders’ bill would? And, how does one determine the discrete services included within those benefits categories?
Single-payer architects could look at existing standards, such as the so-called essential health benefits that govern Obamacare health plans, to determine what’s covered. They could be more generous by including long-term care, which isn’t currently covered by Medicare or most private insurance plans.
Even the two “Medicare-for-all” bills in Congress have slightly different takes. Though both provide for long-term support and services, they diverge on how to pay for it. Sanders’ bill covers only at-home long-term care and keeps Medicaid intact for services provided in institutions. The House bill by Rep. Pramila Jayapal (D-Wash.) covers both.
And there are questions about new medical treatments, and how to determine whether they provide added value. The CBO report suggested some kind of “cost-effectiveness criterion” could determine what the government is willing to cover. In practice, though, that standard could be difficult to develop and could fall victim to political lobbying or trigger contentious debate.
Separately from the CBO report, Mr. McDonough noted, controversial medical services could bring up different kinds of political baggage – whether this plan would cover abortion, for instance, likely would change the single-payer debate.
Next: Single-payer health care would probably require new taxes. Just what level of taxes, though, and who they would hit hardest remain open questions.
Notably, the CBO report avoids a question that critics frequently surface: How much would this cost? How would you pay for it?
That’s because there’s no uniform cost estimate for single-payer and no easy formula to apply.
For one thing, the price tag depends on what services are covered – something like long-term care would make the idea much more expensive.
There’s also the question of cost sharing. In some single-payer systems, people must pay a copay, meet a deductible, or pay a premium as part of the health plan. That would alleviate some need for new taxes.
“I don’t think you can put numbers on it until someone defines a benefit package and defines cost sharing,” Mr. Berenson said.
The current Medicare-for-all bills eschew cost sharing. Other health reform proposals would keep premiums intact to help foot some of the bill.
The CBO report suggests that new taxes would likely play a role in financing a new single-payer plan. But what kind of taxes – a payroll tax, an income tax, or a sales tax, for instance – has not yet been stipulated. And each would have different consequences.
The single-payer approach could bring down health expenses, or at least increase value. But how effectively it would do so – and its larger economic impact – would depend on other design choices.
Single-payer backers dismiss the “pay-for” questions because, the reasoning goes, this approach would save lots of money in other ways, ultimately making it a good deal.
Yet again, though, the CBO said, whether that actually happens depends on the system’s design.
By eliminating most private insurers, a single-payer system would likely slash hospitals’ administrative overhead. The government could then pay a rate that better reflects reduced hospital costs, according to the CBO report.
But, ultimately, the single-payer bottom line depends on what the system pays hospitals, doctors, and drug companies for different services and products. That answer also would inform other economic assessments – ascertaining, for instance, how single-payer affects a small town where the hospital is the main employer.
Even without clear answers, outlining those questions moves the ball, Liu said.
“This area is moving really fast,” she said. “To me, it seems like this is the beginning of a longer conversation.”
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
As Sanders officially revives Medicare-for-all, Plan B for Democrats gains traction
On April 10, Sen. Bernie Sanders (I-Vt.) reaffirmed his stance by reintroducing a Medicare-for-all bill, the idea that fueled his 2016 presidential run.
As with its previous iterations, Sen. Sanders’s latest bill would establish a national single-payer Medicare system with vastly expanded benefits, prohibit private plans from competing with Medicare, and eliminate cost sharing. New in this version is a universal provision for long-term care in home and community settings (but Medicaid would continue to cover institutional care).
Already, it has an impressive list of Senate cosponsors – including Sen. Sanders’s rivals for the Democratic presidential nomination, Cory Booker (D-N.J.), Kirsten Gillibrand (D-N.Y.), Kamala Harris (D-Calif.), and Elizabeth Warren (D-Mass.).
But many of the candidates – even official Medicare-for-all cosponsors – are at the same time edging toward a more incremental approach, called “Medicare for America.” Proponents argue it could deliver better health care to Americans while avoiding political, budgetary, and legal objections.
It comes as politicians tread carefully over the political land mines a Medicare-for-all endorsement could unleash, while seeking to capitalize on a growing appetite for health reform.
During the 2018 midterm election campaigns, some congressional candidates talked about allowing people older than 55 years to join Medicare, or allowing people younger than 65 years to buy into it if they choose (the “public option”). Many aren’t eager to face the industry opposition that a full-on Medicare expansion would surely trigger.
From the consumer perspective, sweeping reform poses a risk. Despite Medicare’s popularity with its beneficiaries, the majority of Americans express satisfaction with their health care, and many are nervous about giving up private options. Also, many analysts are worried that a generous Medicare-for-all plan that promises everything would break the bank without any patient payments.
That tension is pushing a number of candidates toward the emerging Medicare for America option. The bill was introduced last December to little fanfare by two Democrats, Rep. Rosa DeLauro of Connecticut and Rep. Jan Schakowsky of Illinois. It hasn’t been reintroduced in the new Congress.
This proposed system would guarantee universal coverage, but leaves job-based insurance available for those who want it. Unlike Medicare-for-all, though, it preserves premiums and deductibles, so beneficiaries would still have to pay some out-of-pocket costs. It allows private insurers to operate Medicare plans as well, a system called Medicare Advantage that covers about a third of the program’s beneficiaries currently, and which would be outlawed under Medicare-for-all.
“Before policies get defined, what you see is people endorsing a plan that is a little, perhaps, less subject to early attack,” said Celinda Lake, a Democratic pollster. “A lot of candidates feel if they endorse a plan that leaves some private insurance, they get more time to say what their ideas are about.”
Medicare for America got its first high-profile endorsement from former Texas Rep. Beto O’Rourke, who launched his own 2020 bid in mid-March. Other candidates – including Sen. Warren, Sen. Gillibrand, and Pete Buttigieg, the mayor of South Bend, Ind. – have tiptoed toward it without making any endorsements, suggesting they back Medicare-for-all in theory but also support a system that retains private insurance, at least temporarily.
Such an approach is perhaps unsurprising. Polling indicates voters want strong health reform. Candidates, election experts say, need something powerful to deliver.
Improving the Affordable Care Act, an idea backed by Sen. Amy Klobuchar (D-Minn.) who is running in the presidential primary’s moderate lane, may not suffice.
“The ACA is popular at the 50% level, but it’s not energetic. It doesn’t get people who really like it,” said Bob Blendon, a political analyst at the Harvard T.H. Chan School of Public Health. “What they’re looking for is something that is exciting but isn’t threatening.”
Both Medicare-for-all and Medicare for America, experts noted, offer something that presidential candidates can campaign on and a health alternative that at first blush sounds appealing to many. But the latter could skirt some potential obstacles.
Approval for Medicare-for-all drops when people learn that, under such a program, they would likely lose their current health plan (even if the government-offered plan could theoretically provide more generous coverage).
The cost-sharing element of Medicare for America, meanwhile, would ostensibly quiet some of the concerns about paying for Medicare’s expansion, though critics on the left worry it would mean some people would still be unable to afford care.
This also tracks with recent polling suggesting that, while Medicare-for-all support can be swayed, voters of all political stripes favor some sort of way to extend optional Medicare coverage, without necessarily eliminating the private industry altogether.
Employers would have to offer plans that were at least as generous as the government program, or direct employees to Medicare. Employers who stop offering health benefits would have to pay a Medicare payroll tax.
For now, most candidates are still avoiding a concrete stance on Medicare for America. Despite signs of interest, the campaigns of Mr. Buttigieg, Sen. Gillibrand, and Sen. Warren all declined to directly answer questions about whether they endorse Medicare for America. The campaigns of other Democratic candidates in the race – Sen. Harris, Sen. Klobuchar, Sen. Booker, and former Housing and Urban Development Secretary Julian Castro and Washington Gov. Jay Inslee – similarly declined to comment.
Reading between the lines, though, their promises to achieve universal health care by expanding Medicare – while retaining private insurance – leaves them few options besides something like Medicare for America, argued one of its main architects.
“There are variations besides this particular plan, but once you start to actually dig into this, if you want universal coverage you’re going to have to do the kinds of things” spelled out in Medicare for America, argued Jacob Hacker, a political scientist at Yale University, who played a lead role in devising this proposal.
Still, though, it has prompted objections from both the left and the right.
On the far left, the cost sharing is a dominant concern. (Under Medicare for America, an individual would have a $3,500 out-of-pocket limit; a family would have a $5,000 limit. Premiums would be capped at almost 10% of a household’s income.) Those critics also say the plan’s accommodations to private insurance limit the government’s ability to negotiate lower prices.
Conservatives repeat many of the arguments levied against Medicare-for-all – too expensive and too disruptive.
Hospitals, insurance, drugmakers, and doctors, who have already mobilized against Medicare-for-all, also can be expected to make just as strong a showing against Medicare for America, political analysts said. More Medicare means less revenue for the medical industry.
Said David Blumenthal of the Commonwealth Fund: “The fact of expanded Medicare will be the focus of attacks.”
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
On April 10, Sen. Bernie Sanders (I-Vt.) reaffirmed his stance by reintroducing a Medicare-for-all bill, the idea that fueled his 2016 presidential run.
As with its previous iterations, Sen. Sanders’s latest bill would establish a national single-payer Medicare system with vastly expanded benefits, prohibit private plans from competing with Medicare, and eliminate cost sharing. New in this version is a universal provision for long-term care in home and community settings (but Medicaid would continue to cover institutional care).
Already, it has an impressive list of Senate cosponsors – including Sen. Sanders’s rivals for the Democratic presidential nomination, Cory Booker (D-N.J.), Kirsten Gillibrand (D-N.Y.), Kamala Harris (D-Calif.), and Elizabeth Warren (D-Mass.).
But many of the candidates – even official Medicare-for-all cosponsors – are at the same time edging toward a more incremental approach, called “Medicare for America.” Proponents argue it could deliver better health care to Americans while avoiding political, budgetary, and legal objections.
It comes as politicians tread carefully over the political land mines a Medicare-for-all endorsement could unleash, while seeking to capitalize on a growing appetite for health reform.
During the 2018 midterm election campaigns, some congressional candidates talked about allowing people older than 55 years to join Medicare, or allowing people younger than 65 years to buy into it if they choose (the “public option”). Many aren’t eager to face the industry opposition that a full-on Medicare expansion would surely trigger.
From the consumer perspective, sweeping reform poses a risk. Despite Medicare’s popularity with its beneficiaries, the majority of Americans express satisfaction with their health care, and many are nervous about giving up private options. Also, many analysts are worried that a generous Medicare-for-all plan that promises everything would break the bank without any patient payments.
That tension is pushing a number of candidates toward the emerging Medicare for America option. The bill was introduced last December to little fanfare by two Democrats, Rep. Rosa DeLauro of Connecticut and Rep. Jan Schakowsky of Illinois. It hasn’t been reintroduced in the new Congress.
This proposed system would guarantee universal coverage, but leaves job-based insurance available for those who want it. Unlike Medicare-for-all, though, it preserves premiums and deductibles, so beneficiaries would still have to pay some out-of-pocket costs. It allows private insurers to operate Medicare plans as well, a system called Medicare Advantage that covers about a third of the program’s beneficiaries currently, and which would be outlawed under Medicare-for-all.
“Before policies get defined, what you see is people endorsing a plan that is a little, perhaps, less subject to early attack,” said Celinda Lake, a Democratic pollster. “A lot of candidates feel if they endorse a plan that leaves some private insurance, they get more time to say what their ideas are about.”
Medicare for America got its first high-profile endorsement from former Texas Rep. Beto O’Rourke, who launched his own 2020 bid in mid-March. Other candidates – including Sen. Warren, Sen. Gillibrand, and Pete Buttigieg, the mayor of South Bend, Ind. – have tiptoed toward it without making any endorsements, suggesting they back Medicare-for-all in theory but also support a system that retains private insurance, at least temporarily.
Such an approach is perhaps unsurprising. Polling indicates voters want strong health reform. Candidates, election experts say, need something powerful to deliver.
Improving the Affordable Care Act, an idea backed by Sen. Amy Klobuchar (D-Minn.) who is running in the presidential primary’s moderate lane, may not suffice.
“The ACA is popular at the 50% level, but it’s not energetic. It doesn’t get people who really like it,” said Bob Blendon, a political analyst at the Harvard T.H. Chan School of Public Health. “What they’re looking for is something that is exciting but isn’t threatening.”
Both Medicare-for-all and Medicare for America, experts noted, offer something that presidential candidates can campaign on and a health alternative that at first blush sounds appealing to many. But the latter could skirt some potential obstacles.
Approval for Medicare-for-all drops when people learn that, under such a program, they would likely lose their current health plan (even if the government-offered plan could theoretically provide more generous coverage).
The cost-sharing element of Medicare for America, meanwhile, would ostensibly quiet some of the concerns about paying for Medicare’s expansion, though critics on the left worry it would mean some people would still be unable to afford care.
This also tracks with recent polling suggesting that, while Medicare-for-all support can be swayed, voters of all political stripes favor some sort of way to extend optional Medicare coverage, without necessarily eliminating the private industry altogether.
Employers would have to offer plans that were at least as generous as the government program, or direct employees to Medicare. Employers who stop offering health benefits would have to pay a Medicare payroll tax.
For now, most candidates are still avoiding a concrete stance on Medicare for America. Despite signs of interest, the campaigns of Mr. Buttigieg, Sen. Gillibrand, and Sen. Warren all declined to directly answer questions about whether they endorse Medicare for America. The campaigns of other Democratic candidates in the race – Sen. Harris, Sen. Klobuchar, Sen. Booker, and former Housing and Urban Development Secretary Julian Castro and Washington Gov. Jay Inslee – similarly declined to comment.
Reading between the lines, though, their promises to achieve universal health care by expanding Medicare – while retaining private insurance – leaves them few options besides something like Medicare for America, argued one of its main architects.
“There are variations besides this particular plan, but once you start to actually dig into this, if you want universal coverage you’re going to have to do the kinds of things” spelled out in Medicare for America, argued Jacob Hacker, a political scientist at Yale University, who played a lead role in devising this proposal.
Still, though, it has prompted objections from both the left and the right.
On the far left, the cost sharing is a dominant concern. (Under Medicare for America, an individual would have a $3,500 out-of-pocket limit; a family would have a $5,000 limit. Premiums would be capped at almost 10% of a household’s income.) Those critics also say the plan’s accommodations to private insurance limit the government’s ability to negotiate lower prices.
Conservatives repeat many of the arguments levied against Medicare-for-all – too expensive and too disruptive.
Hospitals, insurance, drugmakers, and doctors, who have already mobilized against Medicare-for-all, also can be expected to make just as strong a showing against Medicare for America, political analysts said. More Medicare means less revenue for the medical industry.
Said David Blumenthal of the Commonwealth Fund: “The fact of expanded Medicare will be the focus of attacks.”
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
On April 10, Sen. Bernie Sanders (I-Vt.) reaffirmed his stance by reintroducing a Medicare-for-all bill, the idea that fueled his 2016 presidential run.
As with its previous iterations, Sen. Sanders’s latest bill would establish a national single-payer Medicare system with vastly expanded benefits, prohibit private plans from competing with Medicare, and eliminate cost sharing. New in this version is a universal provision for long-term care in home and community settings (but Medicaid would continue to cover institutional care).
Already, it has an impressive list of Senate cosponsors – including Sen. Sanders’s rivals for the Democratic presidential nomination, Cory Booker (D-N.J.), Kirsten Gillibrand (D-N.Y.), Kamala Harris (D-Calif.), and Elizabeth Warren (D-Mass.).
But many of the candidates – even official Medicare-for-all cosponsors – are at the same time edging toward a more incremental approach, called “Medicare for America.” Proponents argue it could deliver better health care to Americans while avoiding political, budgetary, and legal objections.
It comes as politicians tread carefully over the political land mines a Medicare-for-all endorsement could unleash, while seeking to capitalize on a growing appetite for health reform.
During the 2018 midterm election campaigns, some congressional candidates talked about allowing people older than 55 years to join Medicare, or allowing people younger than 65 years to buy into it if they choose (the “public option”). Many aren’t eager to face the industry opposition that a full-on Medicare expansion would surely trigger.
From the consumer perspective, sweeping reform poses a risk. Despite Medicare’s popularity with its beneficiaries, the majority of Americans express satisfaction with their health care, and many are nervous about giving up private options. Also, many analysts are worried that a generous Medicare-for-all plan that promises everything would break the bank without any patient payments.
That tension is pushing a number of candidates toward the emerging Medicare for America option. The bill was introduced last December to little fanfare by two Democrats, Rep. Rosa DeLauro of Connecticut and Rep. Jan Schakowsky of Illinois. It hasn’t been reintroduced in the new Congress.
This proposed system would guarantee universal coverage, but leaves job-based insurance available for those who want it. Unlike Medicare-for-all, though, it preserves premiums and deductibles, so beneficiaries would still have to pay some out-of-pocket costs. It allows private insurers to operate Medicare plans as well, a system called Medicare Advantage that covers about a third of the program’s beneficiaries currently, and which would be outlawed under Medicare-for-all.
“Before policies get defined, what you see is people endorsing a plan that is a little, perhaps, less subject to early attack,” said Celinda Lake, a Democratic pollster. “A lot of candidates feel if they endorse a plan that leaves some private insurance, they get more time to say what their ideas are about.”
Medicare for America got its first high-profile endorsement from former Texas Rep. Beto O’Rourke, who launched his own 2020 bid in mid-March. Other candidates – including Sen. Warren, Sen. Gillibrand, and Pete Buttigieg, the mayor of South Bend, Ind. – have tiptoed toward it without making any endorsements, suggesting they back Medicare-for-all in theory but also support a system that retains private insurance, at least temporarily.
Such an approach is perhaps unsurprising. Polling indicates voters want strong health reform. Candidates, election experts say, need something powerful to deliver.
Improving the Affordable Care Act, an idea backed by Sen. Amy Klobuchar (D-Minn.) who is running in the presidential primary’s moderate lane, may not suffice.
“The ACA is popular at the 50% level, but it’s not energetic. It doesn’t get people who really like it,” said Bob Blendon, a political analyst at the Harvard T.H. Chan School of Public Health. “What they’re looking for is something that is exciting but isn’t threatening.”
Both Medicare-for-all and Medicare for America, experts noted, offer something that presidential candidates can campaign on and a health alternative that at first blush sounds appealing to many. But the latter could skirt some potential obstacles.
Approval for Medicare-for-all drops when people learn that, under such a program, they would likely lose their current health plan (even if the government-offered plan could theoretically provide more generous coverage).
The cost-sharing element of Medicare for America, meanwhile, would ostensibly quiet some of the concerns about paying for Medicare’s expansion, though critics on the left worry it would mean some people would still be unable to afford care.
This also tracks with recent polling suggesting that, while Medicare-for-all support can be swayed, voters of all political stripes favor some sort of way to extend optional Medicare coverage, without necessarily eliminating the private industry altogether.
Employers would have to offer plans that were at least as generous as the government program, or direct employees to Medicare. Employers who stop offering health benefits would have to pay a Medicare payroll tax.
For now, most candidates are still avoiding a concrete stance on Medicare for America. Despite signs of interest, the campaigns of Mr. Buttigieg, Sen. Gillibrand, and Sen. Warren all declined to directly answer questions about whether they endorse Medicare for America. The campaigns of other Democratic candidates in the race – Sen. Harris, Sen. Klobuchar, Sen. Booker, and former Housing and Urban Development Secretary Julian Castro and Washington Gov. Jay Inslee – similarly declined to comment.
Reading between the lines, though, their promises to achieve universal health care by expanding Medicare – while retaining private insurance – leaves them few options besides something like Medicare for America, argued one of its main architects.
“There are variations besides this particular plan, but once you start to actually dig into this, if you want universal coverage you’re going to have to do the kinds of things” spelled out in Medicare for America, argued Jacob Hacker, a political scientist at Yale University, who played a lead role in devising this proposal.
Still, though, it has prompted objections from both the left and the right.
On the far left, the cost sharing is a dominant concern. (Under Medicare for America, an individual would have a $3,500 out-of-pocket limit; a family would have a $5,000 limit. Premiums would be capped at almost 10% of a household’s income.) Those critics also say the plan’s accommodations to private insurance limit the government’s ability to negotiate lower prices.
Conservatives repeat many of the arguments levied against Medicare-for-all – too expensive and too disruptive.
Hospitals, insurance, drugmakers, and doctors, who have already mobilized against Medicare-for-all, also can be expected to make just as strong a showing against Medicare for America, political analysts said. More Medicare means less revenue for the medical industry.
Said David Blumenthal of the Commonwealth Fund: “The fact of expanded Medicare will be the focus of attacks.”
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
Drug-pricing policies find new momentum as ‘a 2020 thing’
The next presidential primary contests are more than a year away.
“This is a 2020 thing,” said Peter B. Bach, MD, who directs the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center in New York and tracks drug-pricing policy.
Spurred on by midterm election results that showed health care to be a deciding issue, lawmakers – some of whom have already launched presidential-run exploratory committees – are pushing a bevy of new proposals and approaches.
Few if any of those ideas will likely make it to the president’s desk. Nevertheless, Senate Democrats eyeing higher office and seeking street cred in the debate are devising more innovative and aggressive strategies to take on Big Pharma.
“Democrats feel as if they’re really able to experiment,” said Rachel Sachs, an associate law professor at Washington University, St. Louis, who tracks drug-pricing laws.
Some Republicans are also proposing drug-pricing reform, although experts say their approaches are generally less dramatic.
Here are some of the ideas either introduced in legislation or that senators’ offices confirmed they are considering:
- Make a public option for generic drugs. The government could manufacture generics (directly or through a private contractor) if there is a shortage or aren’t enough competitors to keep prices down. This comes from a bill put forth by Sen. Elizabeth Warren (D-Mass.) and Rep. Jan Schakowsky (D-Ill.).
- Let Medicare negotiate drug prices. This idea has many backers – what differs is the method of enforcement. Sen. Sherrod Brown (D-Ohio) has suggested that if the company and the government can’t reach an agreement, the government could take away the company’s patent rights. A proposal from Sen. Bernie Sanders (I-Vt.) and Rep. Elijah Cummings (D-Md.) would address stalled negotiations by letting Medicare pay the lowest amount among: Medicaid’s best price, the highest price a single federal purchaser pays or the median price paid for a specific drug in Canada, France, Germany, Japan, and the United Kingdom.
- Pay what they do abroad. Legislation from Mr. Sanders and Rep. Ro Khanna (D-Calif.) would require companies to price their drugs no higher than the median of what’s charged in Canada, France, Germany, Japan, and the United Kingdom. If manufacturers fail to comply, other companies could get the rights to make those drugs, too.
- Penalize price gouging. This would target manufacturers who raise drug prices more than 30% in 5 years. Punishments could include requiring the company to reimburse those who paid the elevated price, forcing the drug maker to lower its price, or charging a penalty up to three times what a company received from boosting the price. Backers include senators Richard Blumenthal (D-Conn.), Kamala Harris (D-Calif.), Jeff Merkley (D-Ore.), and Amy Klobuchar (D-Minn.).
- Import drugs. A Sanders-Cummings bill would let patients, wholesalers, and pharmacies import drugs from abroad – starting with Canada, and leaving the door open for some other countries. Sen. Chuck Grassley (R-Iowa) and Ms. Klobuchar have a separate bill that is specific to patients getting medicine from Canada alone.
- Abolish “pay for delay.” From Mr. Grassley and Ms. Klobuchar, this legislation would tackle deals in which a branded drugmaker pays off a generic one to keep a competing product from coming to market.
This flurry of proposed lawmaking could add momentum to one of the few policy areas in which conventional Washington wisdom suggests House Democrats, Senate Republicans, and the White House may be able to find common ground.
“Everything is up in the air and anything is possible,” said Walid Gellad, MD, codirector of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh. “There are things that can happen that maybe weren’t going to happen before.”
And there’s political pressure. Polls consistently suggest voters have a strong appetite for action. As a candidate, President Trump vowed to make drug prices a top priority. In recent months, the administration has taken steps in this direction, like testing changes to Medicare that might reduce out-of-pocket drug costs. But Congress has been relatively quiet, especially when it comes to challenging the pharmaceutical industry, which remains one of Capitol Hill’s most potent lobbying forces.
One aspect of prescription drug pricing that could see bipartisan action is insulin prices, which have skyrocketed, stoking widespread outcry, and could be a target for bipartisan work. Ms. Warren’s legislation singles out the drug as one the government could produce, and Mr. Cummings has already called in major insulin manufacturers for a drug-pricing hearing later this month. In addition, Rep. Diana DeGette (D-Colo.), the new chair of the House Energy and Commerce Oversight and Investigations Subcommittee, has listed prescription drug pricing as a high priority for her panel. As cochair of the Congressional Diabetes Caucus, Ms. DeGette worked with Rep. Tom Reed (R-N.Y.) to produce a report on the high cost of insulin.
To be sure, some of the concepts, such as drug importation and bolstering development of generic drugs, have been around a long time. But some of the legislation at hand suggests a new kind of thinking.
House Speaker Nancy Pelosi (D-Calif.) has labeled drug pricing a top priority, and the pharmaceutical industry has been bracing for a fight with the new Democratic majority.
Meanwhile, in the GOP-controlled Senate, two powerful lawmakers – Sen. Lamar Alexander (R-Tenn.) and Mr. Grassley – have indicated they want to use their influence to tackle the issue. Mr. Alexander, who chairs the Health, Education, Labor and Pensions Committee, has said cutting health care costs, including drug prices, will be high on his panel’s to-do list this Congress. Mr. Grassley runs the Finance Committee, which oversees pricing issues for Medicare and Medicaid.
“The solution to high drug prices is not just having the government spending more money. ... You need to look at prices,” Dr. Gellad said. “These proposals deal with price. They all directly affect price.”
Given the drug industry’s full-throated opposition to virtually any pricing legislation, Ms. Sachs said, “it is not at all surprising to me to see the Democrats start exploring some of these more radical proposals.”
Still, though, Senate staffers almost uniformly argued that the drug-pricing issue requires more than one single piece of legislation.
For instance, the price-gouging penalty spearheaded by Mr. Blumenthal doesn’t stop drugs from having high initial list prices. Letting Medicare negotiate doesn’t mean people covered by other plans will necessarily see the same savings. Empowering the government to produce competing drugs doesn’t promise to keep prices down long term and doesn’t guarantee that patients will see those savings.
“We need to use every tool available to bring down drug prices and improve competition,” said an aide in Ms. Warren’s office.
KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation. Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
The next presidential primary contests are more than a year away.
“This is a 2020 thing,” said Peter B. Bach, MD, who directs the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center in New York and tracks drug-pricing policy.
Spurred on by midterm election results that showed health care to be a deciding issue, lawmakers – some of whom have already launched presidential-run exploratory committees – are pushing a bevy of new proposals and approaches.
Few if any of those ideas will likely make it to the president’s desk. Nevertheless, Senate Democrats eyeing higher office and seeking street cred in the debate are devising more innovative and aggressive strategies to take on Big Pharma.
“Democrats feel as if they’re really able to experiment,” said Rachel Sachs, an associate law professor at Washington University, St. Louis, who tracks drug-pricing laws.
Some Republicans are also proposing drug-pricing reform, although experts say their approaches are generally less dramatic.
Here are some of the ideas either introduced in legislation or that senators’ offices confirmed they are considering:
- Make a public option for generic drugs. The government could manufacture generics (directly or through a private contractor) if there is a shortage or aren’t enough competitors to keep prices down. This comes from a bill put forth by Sen. Elizabeth Warren (D-Mass.) and Rep. Jan Schakowsky (D-Ill.).
- Let Medicare negotiate drug prices. This idea has many backers – what differs is the method of enforcement. Sen. Sherrod Brown (D-Ohio) has suggested that if the company and the government can’t reach an agreement, the government could take away the company’s patent rights. A proposal from Sen. Bernie Sanders (I-Vt.) and Rep. Elijah Cummings (D-Md.) would address stalled negotiations by letting Medicare pay the lowest amount among: Medicaid’s best price, the highest price a single federal purchaser pays or the median price paid for a specific drug in Canada, France, Germany, Japan, and the United Kingdom.
- Pay what they do abroad. Legislation from Mr. Sanders and Rep. Ro Khanna (D-Calif.) would require companies to price their drugs no higher than the median of what’s charged in Canada, France, Germany, Japan, and the United Kingdom. If manufacturers fail to comply, other companies could get the rights to make those drugs, too.
- Penalize price gouging. This would target manufacturers who raise drug prices more than 30% in 5 years. Punishments could include requiring the company to reimburse those who paid the elevated price, forcing the drug maker to lower its price, or charging a penalty up to three times what a company received from boosting the price. Backers include senators Richard Blumenthal (D-Conn.), Kamala Harris (D-Calif.), Jeff Merkley (D-Ore.), and Amy Klobuchar (D-Minn.).
- Import drugs. A Sanders-Cummings bill would let patients, wholesalers, and pharmacies import drugs from abroad – starting with Canada, and leaving the door open for some other countries. Sen. Chuck Grassley (R-Iowa) and Ms. Klobuchar have a separate bill that is specific to patients getting medicine from Canada alone.
- Abolish “pay for delay.” From Mr. Grassley and Ms. Klobuchar, this legislation would tackle deals in which a branded drugmaker pays off a generic one to keep a competing product from coming to market.
This flurry of proposed lawmaking could add momentum to one of the few policy areas in which conventional Washington wisdom suggests House Democrats, Senate Republicans, and the White House may be able to find common ground.
“Everything is up in the air and anything is possible,” said Walid Gellad, MD, codirector of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh. “There are things that can happen that maybe weren’t going to happen before.”
And there’s political pressure. Polls consistently suggest voters have a strong appetite for action. As a candidate, President Trump vowed to make drug prices a top priority. In recent months, the administration has taken steps in this direction, like testing changes to Medicare that might reduce out-of-pocket drug costs. But Congress has been relatively quiet, especially when it comes to challenging the pharmaceutical industry, which remains one of Capitol Hill’s most potent lobbying forces.
One aspect of prescription drug pricing that could see bipartisan action is insulin prices, which have skyrocketed, stoking widespread outcry, and could be a target for bipartisan work. Ms. Warren’s legislation singles out the drug as one the government could produce, and Mr. Cummings has already called in major insulin manufacturers for a drug-pricing hearing later this month. In addition, Rep. Diana DeGette (D-Colo.), the new chair of the House Energy and Commerce Oversight and Investigations Subcommittee, has listed prescription drug pricing as a high priority for her panel. As cochair of the Congressional Diabetes Caucus, Ms. DeGette worked with Rep. Tom Reed (R-N.Y.) to produce a report on the high cost of insulin.
To be sure, some of the concepts, such as drug importation and bolstering development of generic drugs, have been around a long time. But some of the legislation at hand suggests a new kind of thinking.
House Speaker Nancy Pelosi (D-Calif.) has labeled drug pricing a top priority, and the pharmaceutical industry has been bracing for a fight with the new Democratic majority.
Meanwhile, in the GOP-controlled Senate, two powerful lawmakers – Sen. Lamar Alexander (R-Tenn.) and Mr. Grassley – have indicated they want to use their influence to tackle the issue. Mr. Alexander, who chairs the Health, Education, Labor and Pensions Committee, has said cutting health care costs, including drug prices, will be high on his panel’s to-do list this Congress. Mr. Grassley runs the Finance Committee, which oversees pricing issues for Medicare and Medicaid.
“The solution to high drug prices is not just having the government spending more money. ... You need to look at prices,” Dr. Gellad said. “These proposals deal with price. They all directly affect price.”
Given the drug industry’s full-throated opposition to virtually any pricing legislation, Ms. Sachs said, “it is not at all surprising to me to see the Democrats start exploring some of these more radical proposals.”
Still, though, Senate staffers almost uniformly argued that the drug-pricing issue requires more than one single piece of legislation.
For instance, the price-gouging penalty spearheaded by Mr. Blumenthal doesn’t stop drugs from having high initial list prices. Letting Medicare negotiate doesn’t mean people covered by other plans will necessarily see the same savings. Empowering the government to produce competing drugs doesn’t promise to keep prices down long term and doesn’t guarantee that patients will see those savings.
“We need to use every tool available to bring down drug prices and improve competition,” said an aide in Ms. Warren’s office.
KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation. Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
The next presidential primary contests are more than a year away.
“This is a 2020 thing,” said Peter B. Bach, MD, who directs the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center in New York and tracks drug-pricing policy.
Spurred on by midterm election results that showed health care to be a deciding issue, lawmakers – some of whom have already launched presidential-run exploratory committees – are pushing a bevy of new proposals and approaches.
Few if any of those ideas will likely make it to the president’s desk. Nevertheless, Senate Democrats eyeing higher office and seeking street cred in the debate are devising more innovative and aggressive strategies to take on Big Pharma.
“Democrats feel as if they’re really able to experiment,” said Rachel Sachs, an associate law professor at Washington University, St. Louis, who tracks drug-pricing laws.
Some Republicans are also proposing drug-pricing reform, although experts say their approaches are generally less dramatic.
Here are some of the ideas either introduced in legislation or that senators’ offices confirmed they are considering:
- Make a public option for generic drugs. The government could manufacture generics (directly or through a private contractor) if there is a shortage or aren’t enough competitors to keep prices down. This comes from a bill put forth by Sen. Elizabeth Warren (D-Mass.) and Rep. Jan Schakowsky (D-Ill.).
- Let Medicare negotiate drug prices. This idea has many backers – what differs is the method of enforcement. Sen. Sherrod Brown (D-Ohio) has suggested that if the company and the government can’t reach an agreement, the government could take away the company’s patent rights. A proposal from Sen. Bernie Sanders (I-Vt.) and Rep. Elijah Cummings (D-Md.) would address stalled negotiations by letting Medicare pay the lowest amount among: Medicaid’s best price, the highest price a single federal purchaser pays or the median price paid for a specific drug in Canada, France, Germany, Japan, and the United Kingdom.
- Pay what they do abroad. Legislation from Mr. Sanders and Rep. Ro Khanna (D-Calif.) would require companies to price their drugs no higher than the median of what’s charged in Canada, France, Germany, Japan, and the United Kingdom. If manufacturers fail to comply, other companies could get the rights to make those drugs, too.
- Penalize price gouging. This would target manufacturers who raise drug prices more than 30% in 5 years. Punishments could include requiring the company to reimburse those who paid the elevated price, forcing the drug maker to lower its price, or charging a penalty up to three times what a company received from boosting the price. Backers include senators Richard Blumenthal (D-Conn.), Kamala Harris (D-Calif.), Jeff Merkley (D-Ore.), and Amy Klobuchar (D-Minn.).
- Import drugs. A Sanders-Cummings bill would let patients, wholesalers, and pharmacies import drugs from abroad – starting with Canada, and leaving the door open for some other countries. Sen. Chuck Grassley (R-Iowa) and Ms. Klobuchar have a separate bill that is specific to patients getting medicine from Canada alone.
- Abolish “pay for delay.” From Mr. Grassley and Ms. Klobuchar, this legislation would tackle deals in which a branded drugmaker pays off a generic one to keep a competing product from coming to market.
This flurry of proposed lawmaking could add momentum to one of the few policy areas in which conventional Washington wisdom suggests House Democrats, Senate Republicans, and the White House may be able to find common ground.
“Everything is up in the air and anything is possible,” said Walid Gellad, MD, codirector of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh. “There are things that can happen that maybe weren’t going to happen before.”
And there’s political pressure. Polls consistently suggest voters have a strong appetite for action. As a candidate, President Trump vowed to make drug prices a top priority. In recent months, the administration has taken steps in this direction, like testing changes to Medicare that might reduce out-of-pocket drug costs. But Congress has been relatively quiet, especially when it comes to challenging the pharmaceutical industry, which remains one of Capitol Hill’s most potent lobbying forces.
One aspect of prescription drug pricing that could see bipartisan action is insulin prices, which have skyrocketed, stoking widespread outcry, and could be a target for bipartisan work. Ms. Warren’s legislation singles out the drug as one the government could produce, and Mr. Cummings has already called in major insulin manufacturers for a drug-pricing hearing later this month. In addition, Rep. Diana DeGette (D-Colo.), the new chair of the House Energy and Commerce Oversight and Investigations Subcommittee, has listed prescription drug pricing as a high priority for her panel. As cochair of the Congressional Diabetes Caucus, Ms. DeGette worked with Rep. Tom Reed (R-N.Y.) to produce a report on the high cost of insulin.
To be sure, some of the concepts, such as drug importation and bolstering development of generic drugs, have been around a long time. But some of the legislation at hand suggests a new kind of thinking.
House Speaker Nancy Pelosi (D-Calif.) has labeled drug pricing a top priority, and the pharmaceutical industry has been bracing for a fight with the new Democratic majority.
Meanwhile, in the GOP-controlled Senate, two powerful lawmakers – Sen. Lamar Alexander (R-Tenn.) and Mr. Grassley – have indicated they want to use their influence to tackle the issue. Mr. Alexander, who chairs the Health, Education, Labor and Pensions Committee, has said cutting health care costs, including drug prices, will be high on his panel’s to-do list this Congress. Mr. Grassley runs the Finance Committee, which oversees pricing issues for Medicare and Medicaid.
“The solution to high drug prices is not just having the government spending more money. ... You need to look at prices,” Dr. Gellad said. “These proposals deal with price. They all directly affect price.”
Given the drug industry’s full-throated opposition to virtually any pricing legislation, Ms. Sachs said, “it is not at all surprising to me to see the Democrats start exploring some of these more radical proposals.”
Still, though, Senate staffers almost uniformly argued that the drug-pricing issue requires more than one single piece of legislation.
For instance, the price-gouging penalty spearheaded by Mr. Blumenthal doesn’t stop drugs from having high initial list prices. Letting Medicare negotiate doesn’t mean people covered by other plans will necessarily see the same savings. Empowering the government to produce competing drugs doesn’t promise to keep prices down long term and doesn’t guarantee that patients will see those savings.
“We need to use every tool available to bring down drug prices and improve competition,” said an aide in Ms. Warren’s office.
KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation. Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
Too high to drive: States grapple with setting limits on weed use behind wheel
It used to be the stuff of stoner comedies and “Just Say No” campaigns. Today, marijuana is becoming mainstream as voters across the country approve ballot questions for legalization or medical use.
In response, state governments are testing ways to ensure that the integration of this once-illicit substance into everyday life doesn’t create new public health risks. These efforts are sparking a difficult question: At what point is someone too high to get behind the wheel?
The answer is complicated. Brain scientists and pharmacologists don’t know how to measure if and to what extent marijuana causes impairment.
The reason: Existing blood and urine tests can detect marijuana use, but, because traces of the drug stay in the human body for a long time, those tests can’t specify whether the use occurred earlier that day or that month. They also don’t indicate the level at which a driver would be considered “under the influence.”
“It’s a really hard problem,” said Keith Humphreys, a psychiatry professor and drug policy expert at Stanford University (Calif.), the first state to legalize medical marijuana and where recreational pot use among adults became legal in 2016. “We don’t really have good evidence – even if we know someone has been using – [to gauge] what their level of impairment is.”
Marijuana is now legal for recreational use in 10 states and the District of Columbia – including Michigan, where a ballot initiative passed in November 2018 took effect Dec. 6. In New York, the governor said Dec. 17 that legalization would be a top priority for 2019. And nearly three dozen states have cleared the use of medical cannabis.
For alcohol, there is a clear, national standard. If your blood alcohol content is 0.08% or higher, you’re considered cognitively impaired at a level that is unsafe to drive. Extensive research supports this determination, and the clarity makes enforcement of drunken-driving laws easier.
Setting a marijuana-related impairment level is a much murkier proposition. But states that have legalized pot have to figure it out, experts said.
“You can’t legalize a substance and not have a coherent policy for controlling driving under the influence of that substance,” said Steven Davenport, an assistant policy researcher at the nonprofit Rand Corporation, who specializes in marijuana research.
Marijuana, after all, weakens a driver’s ability to maintain focus, and it slows reflexes. But regulators are “playing catch-up,” suggested Thomas Marcotte, a psychiatry professor at the University of California, San Diego, and one of a number of academics around the country who is researching driving while high.
States have put forth a bevy of approaches. At least five have what’s called a “per se” law, which outlaws driving if someone’s blood level of tetrahydrocannabinol, or THC, exceeds a set amount. THC is marijuana’s main intoxicant.
Colorado, where voters approved legalization of recreational marijuana in 2012, has this type of driving law on the books. It took 3 years to pass amid fiery debate and deems “intoxicated” any driver who tests higher than 5 ng of THC per milliliter of blood.
Indiana, Pennsylvania and Rhode Island are among states that forbid driving at any THC level. Still others say drivers should be penalized only if they are impaired by the chemical – a standard that sounds reasonable but quickly gets difficult to measure or even define.
None of these approaches offers an ideal solution, experts said.
“We’re still definitely evaluating which policies are the most effective,” said Ann Kitch, who tracks the marijuana and driving issue for the National Conference of State Legislatures.
States that set a THC-level standard confront weak technology and limited science. THC testing is imprecise at best, since the chemical can stay in someone’s bloodstream for weeks after it was ingested. Someone could legally smoke a joint and still have THC appear in blood or urine samples long after the high passes.
There’s general agreement that driving while high is bad, but there’s no linear relationship between THC levels and degree of impairment. States that have picked a number to reflect when THC in the bloodstream becomes a hazard have “made it up,” argued Dr. Humphreys.
“The ones who wrote [a number] into legislation felt they had to say something,” he said. But “we don’t know what would be the analogy. Is the legal amount [of THC] equal to a beer? Is that how impaired you are? Is it a six-pack?”
Roadside testing for THC is also logistically difficult. Blood, for instance, needs to be analyzed in a lab, and collecting urine gets ... complicated.
In Canada, which legalized recreational pot just this year, law enforcement will test drivers with a saliva test called the Dräger DrugTest 5000, but that isn’t perfect, either.
Some private companies are trying to develop a sort of breathalyzer for marijuana. But Jonathan Caulkins, a drug policy researcher at Carnegie Mellon University, Pittsburgh, said, “There are fundamental issues with the chemistry and pharmacokinetics. It’s really hard to have an objective, easy-to-administer roadside test.”
Some states rely on law enforcement to assess whether someone’s driving appears impaired and ascertain after the fact if marijuana was involved.
In California, every highway patrol member learns to administer “field sobriety tests” – undergoing an extra 16 hours of training to recognize the influence of different drugs, including marijuana. Because medical marijuana has been legal there since 1996, officers are “very used” to recognizing its influence, said Glenn Glazer, the state’s coordinator for its drug recognition expert training program.
That kind of training is taking off in other states, too, Ms. Kitch said. Lobbying groups such as Mothers Against Drunk Driving are pushing to bump up law enforcement training and rely on officers to assess whether a driver is impaired.
These tests, though, risk their own kind of error.
“They are subjective,” Mr. Davenport warned.
For one thing, officer-administered tests can be influenced by racial bias. Someone who has previously had poor experiences with law enforcement may also perform worse, not because of greater impairment but because of nervousness.
Indeed, relying on more subjective testing is in some ways the direct opposite of conventional wisdom.
“A general pattern of the last ... 40 years is to try to take human judgment out of decision making processes when possible. Because we fear exactly these issues,” Mr. Caulkins said. “The idea that you could come up with a completely objective test of performance ... is ambitious.”
Researchers like Dr. Marcotte are trying to devise some kind of test that can, in fact, gauge whether someone is showing signs of marijuana impairment. But that could take years.
In the meantime, the public health threat is real. States with legalized pot do appear to experience more car crashes, though the relationship is muddled. “This is going to be a headache of an issue for a decade,” Mr. Caulkins said.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
It used to be the stuff of stoner comedies and “Just Say No” campaigns. Today, marijuana is becoming mainstream as voters across the country approve ballot questions for legalization or medical use.
In response, state governments are testing ways to ensure that the integration of this once-illicit substance into everyday life doesn’t create new public health risks. These efforts are sparking a difficult question: At what point is someone too high to get behind the wheel?
The answer is complicated. Brain scientists and pharmacologists don’t know how to measure if and to what extent marijuana causes impairment.
The reason: Existing blood and urine tests can detect marijuana use, but, because traces of the drug stay in the human body for a long time, those tests can’t specify whether the use occurred earlier that day or that month. They also don’t indicate the level at which a driver would be considered “under the influence.”
“It’s a really hard problem,” said Keith Humphreys, a psychiatry professor and drug policy expert at Stanford University (Calif.), the first state to legalize medical marijuana and where recreational pot use among adults became legal in 2016. “We don’t really have good evidence – even if we know someone has been using – [to gauge] what their level of impairment is.”
Marijuana is now legal for recreational use in 10 states and the District of Columbia – including Michigan, where a ballot initiative passed in November 2018 took effect Dec. 6. In New York, the governor said Dec. 17 that legalization would be a top priority for 2019. And nearly three dozen states have cleared the use of medical cannabis.
For alcohol, there is a clear, national standard. If your blood alcohol content is 0.08% or higher, you’re considered cognitively impaired at a level that is unsafe to drive. Extensive research supports this determination, and the clarity makes enforcement of drunken-driving laws easier.
Setting a marijuana-related impairment level is a much murkier proposition. But states that have legalized pot have to figure it out, experts said.
“You can’t legalize a substance and not have a coherent policy for controlling driving under the influence of that substance,” said Steven Davenport, an assistant policy researcher at the nonprofit Rand Corporation, who specializes in marijuana research.
Marijuana, after all, weakens a driver’s ability to maintain focus, and it slows reflexes. But regulators are “playing catch-up,” suggested Thomas Marcotte, a psychiatry professor at the University of California, San Diego, and one of a number of academics around the country who is researching driving while high.
States have put forth a bevy of approaches. At least five have what’s called a “per se” law, which outlaws driving if someone’s blood level of tetrahydrocannabinol, or THC, exceeds a set amount. THC is marijuana’s main intoxicant.
Colorado, where voters approved legalization of recreational marijuana in 2012, has this type of driving law on the books. It took 3 years to pass amid fiery debate and deems “intoxicated” any driver who tests higher than 5 ng of THC per milliliter of blood.
Indiana, Pennsylvania and Rhode Island are among states that forbid driving at any THC level. Still others say drivers should be penalized only if they are impaired by the chemical – a standard that sounds reasonable but quickly gets difficult to measure or even define.
None of these approaches offers an ideal solution, experts said.
“We’re still definitely evaluating which policies are the most effective,” said Ann Kitch, who tracks the marijuana and driving issue for the National Conference of State Legislatures.
States that set a THC-level standard confront weak technology and limited science. THC testing is imprecise at best, since the chemical can stay in someone’s bloodstream for weeks after it was ingested. Someone could legally smoke a joint and still have THC appear in blood or urine samples long after the high passes.
There’s general agreement that driving while high is bad, but there’s no linear relationship between THC levels and degree of impairment. States that have picked a number to reflect when THC in the bloodstream becomes a hazard have “made it up,” argued Dr. Humphreys.
“The ones who wrote [a number] into legislation felt they had to say something,” he said. But “we don’t know what would be the analogy. Is the legal amount [of THC] equal to a beer? Is that how impaired you are? Is it a six-pack?”
Roadside testing for THC is also logistically difficult. Blood, for instance, needs to be analyzed in a lab, and collecting urine gets ... complicated.
In Canada, which legalized recreational pot just this year, law enforcement will test drivers with a saliva test called the Dräger DrugTest 5000, but that isn’t perfect, either.
Some private companies are trying to develop a sort of breathalyzer for marijuana. But Jonathan Caulkins, a drug policy researcher at Carnegie Mellon University, Pittsburgh, said, “There are fundamental issues with the chemistry and pharmacokinetics. It’s really hard to have an objective, easy-to-administer roadside test.”
Some states rely on law enforcement to assess whether someone’s driving appears impaired and ascertain after the fact if marijuana was involved.
In California, every highway patrol member learns to administer “field sobriety tests” – undergoing an extra 16 hours of training to recognize the influence of different drugs, including marijuana. Because medical marijuana has been legal there since 1996, officers are “very used” to recognizing its influence, said Glenn Glazer, the state’s coordinator for its drug recognition expert training program.
That kind of training is taking off in other states, too, Ms. Kitch said. Lobbying groups such as Mothers Against Drunk Driving are pushing to bump up law enforcement training and rely on officers to assess whether a driver is impaired.
These tests, though, risk their own kind of error.
“They are subjective,” Mr. Davenport warned.
For one thing, officer-administered tests can be influenced by racial bias. Someone who has previously had poor experiences with law enforcement may also perform worse, not because of greater impairment but because of nervousness.
Indeed, relying on more subjective testing is in some ways the direct opposite of conventional wisdom.
“A general pattern of the last ... 40 years is to try to take human judgment out of decision making processes when possible. Because we fear exactly these issues,” Mr. Caulkins said. “The idea that you could come up with a completely objective test of performance ... is ambitious.”
Researchers like Dr. Marcotte are trying to devise some kind of test that can, in fact, gauge whether someone is showing signs of marijuana impairment. But that could take years.
In the meantime, the public health threat is real. States with legalized pot do appear to experience more car crashes, though the relationship is muddled. “This is going to be a headache of an issue for a decade,” Mr. Caulkins said.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
It used to be the stuff of stoner comedies and “Just Say No” campaigns. Today, marijuana is becoming mainstream as voters across the country approve ballot questions for legalization or medical use.
In response, state governments are testing ways to ensure that the integration of this once-illicit substance into everyday life doesn’t create new public health risks. These efforts are sparking a difficult question: At what point is someone too high to get behind the wheel?
The answer is complicated. Brain scientists and pharmacologists don’t know how to measure if and to what extent marijuana causes impairment.
The reason: Existing blood and urine tests can detect marijuana use, but, because traces of the drug stay in the human body for a long time, those tests can’t specify whether the use occurred earlier that day or that month. They also don’t indicate the level at which a driver would be considered “under the influence.”
“It’s a really hard problem,” said Keith Humphreys, a psychiatry professor and drug policy expert at Stanford University (Calif.), the first state to legalize medical marijuana and where recreational pot use among adults became legal in 2016. “We don’t really have good evidence – even if we know someone has been using – [to gauge] what their level of impairment is.”
Marijuana is now legal for recreational use in 10 states and the District of Columbia – including Michigan, where a ballot initiative passed in November 2018 took effect Dec. 6. In New York, the governor said Dec. 17 that legalization would be a top priority for 2019. And nearly three dozen states have cleared the use of medical cannabis.
For alcohol, there is a clear, national standard. If your blood alcohol content is 0.08% or higher, you’re considered cognitively impaired at a level that is unsafe to drive. Extensive research supports this determination, and the clarity makes enforcement of drunken-driving laws easier.
Setting a marijuana-related impairment level is a much murkier proposition. But states that have legalized pot have to figure it out, experts said.
“You can’t legalize a substance and not have a coherent policy for controlling driving under the influence of that substance,” said Steven Davenport, an assistant policy researcher at the nonprofit Rand Corporation, who specializes in marijuana research.
Marijuana, after all, weakens a driver’s ability to maintain focus, and it slows reflexes. But regulators are “playing catch-up,” suggested Thomas Marcotte, a psychiatry professor at the University of California, San Diego, and one of a number of academics around the country who is researching driving while high.
States have put forth a bevy of approaches. At least five have what’s called a “per se” law, which outlaws driving if someone’s blood level of tetrahydrocannabinol, or THC, exceeds a set amount. THC is marijuana’s main intoxicant.
Colorado, where voters approved legalization of recreational marijuana in 2012, has this type of driving law on the books. It took 3 years to pass amid fiery debate and deems “intoxicated” any driver who tests higher than 5 ng of THC per milliliter of blood.
Indiana, Pennsylvania and Rhode Island are among states that forbid driving at any THC level. Still others say drivers should be penalized only if they are impaired by the chemical – a standard that sounds reasonable but quickly gets difficult to measure or even define.
None of these approaches offers an ideal solution, experts said.
“We’re still definitely evaluating which policies are the most effective,” said Ann Kitch, who tracks the marijuana and driving issue for the National Conference of State Legislatures.
States that set a THC-level standard confront weak technology and limited science. THC testing is imprecise at best, since the chemical can stay in someone’s bloodstream for weeks after it was ingested. Someone could legally smoke a joint and still have THC appear in blood or urine samples long after the high passes.
There’s general agreement that driving while high is bad, but there’s no linear relationship between THC levels and degree of impairment. States that have picked a number to reflect when THC in the bloodstream becomes a hazard have “made it up,” argued Dr. Humphreys.
“The ones who wrote [a number] into legislation felt they had to say something,” he said. But “we don’t know what would be the analogy. Is the legal amount [of THC] equal to a beer? Is that how impaired you are? Is it a six-pack?”
Roadside testing for THC is also logistically difficult. Blood, for instance, needs to be analyzed in a lab, and collecting urine gets ... complicated.
In Canada, which legalized recreational pot just this year, law enforcement will test drivers with a saliva test called the Dräger DrugTest 5000, but that isn’t perfect, either.
Some private companies are trying to develop a sort of breathalyzer for marijuana. But Jonathan Caulkins, a drug policy researcher at Carnegie Mellon University, Pittsburgh, said, “There are fundamental issues with the chemistry and pharmacokinetics. It’s really hard to have an objective, easy-to-administer roadside test.”
Some states rely on law enforcement to assess whether someone’s driving appears impaired and ascertain after the fact if marijuana was involved.
In California, every highway patrol member learns to administer “field sobriety tests” – undergoing an extra 16 hours of training to recognize the influence of different drugs, including marijuana. Because medical marijuana has been legal there since 1996, officers are “very used” to recognizing its influence, said Glenn Glazer, the state’s coordinator for its drug recognition expert training program.
That kind of training is taking off in other states, too, Ms. Kitch said. Lobbying groups such as Mothers Against Drunk Driving are pushing to bump up law enforcement training and rely on officers to assess whether a driver is impaired.
These tests, though, risk their own kind of error.
“They are subjective,” Mr. Davenport warned.
For one thing, officer-administered tests can be influenced by racial bias. Someone who has previously had poor experiences with law enforcement may also perform worse, not because of greater impairment but because of nervousness.
Indeed, relying on more subjective testing is in some ways the direct opposite of conventional wisdom.
“A general pattern of the last ... 40 years is to try to take human judgment out of decision making processes when possible. Because we fear exactly these issues,” Mr. Caulkins said. “The idea that you could come up with a completely objective test of performance ... is ambitious.”
Researchers like Dr. Marcotte are trying to devise some kind of test that can, in fact, gauge whether someone is showing signs of marijuana impairment. But that could take years.
In the meantime, the public health threat is real. States with legalized pot do appear to experience more car crashes, though the relationship is muddled. “This is going to be a headache of an issue for a decade,” Mr. Caulkins said.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
5 things to know about Trump’s new ‘public charge’ immigration proposal
A proposed rule from the White House would make it harder for legal immigrants to get green cards if they have received certain kinds of public assistance – including Medicaid, food stamps, and housing subsidies. Green cards allow them to live and work permanently in the United States.
“Those seeking to immigrate to the United States must show they can support themselves financially,” Homeland Security Secretary Kirstjen Nielsen said in a statement.
The proposal, announced Sept. 22, marks a new frontier in the administration’s long-term effort to curb immigration, both legal and illegal. It already has spurred intense criticism from Democrats, anti-poverty activists, health care organizations, and immigrants’ rights advocates, who call its restrictions unprecedented.
“We are operating in an overall climate of tremendous fear and anxiety as a result of the administration’s overall approach to immigration enforcement and immigration policy,” said Mark Greenberg, a senior fellow at the Migration Policy Institute, which studies migration and refugee policies at local, national, and international levels. He is also a former Obama administration official.
But what effect would this proposal have?
It’s a complicated question, touching upon vast government programs, with billions of dollars at stake. While the implications aren’t all immediately clear, Kaiser Health News breaks down some of the key elements.
1. First thing first: What is the White House proposing?
The Trump administration wants to redefine a status known as “public charge” – a category used to determine whether someone seeking permanent resident status is “likely to become primarily dependent on the government for subsistence.”
In the past, people have been at risk of being defined a “public charge” if they took cash welfare – known as Temporary Assistance for Needy Families, or Supplemental Security Income – or federal help paying for long-term care. (Immigrants must be in the country legally for 5 years before being eligible for TANF or SSI.)
And that “public charge” designation could undermine their applications for permanent residence.
The new rule would expand the list to include some health insurance, food, and housing programs. Specifically, it would penalize green-card applicants for using Medicaid, a federal-state health plan for low-income people. (Penalties would not apply for using Medicaid in certain emergencies or for some Medicaid services provided through schools and disability programs.)
Using food stamps, Section 8 rental assistance, and federal housing vouchers also would count against applicants. Enrollment in a Medicare Part D program subsidy to help low-income people buy prescription drugs would work against them, too.
The proposal “is definitely a dramatic change from how public charge works today,” said Kelly Whitener, an associate professor at Georgetown University’s Center for Children and Families who specializes in pediatric health benefits and managed-care systems.
A leaked version of the rule from March suggested officials then were also considering penalizing those who receive subsidies to buy health insurance on the Affordable Care Act marketplaces. But that idea was not in the proposal. The marketplace subsidies are aimed at people at a generally higher income bracket than the beneficiaries targeted in the Trump plan, Whitener noted.
“They’re really homing in on low-income immigrants,” she added.
Nielsen said the proposed rule is “intended to promote immigrant self-sufficiency and protect finite resources.”
2. Is this as unprecedented as critics say?
Yes.
Public charge is an old idea. In the 1990s, lawmakers expanded it to consider explicitly whether people had received cash-based welfare.
But including programs like Medicaid and food stamps, which are much wider in scope, is a significant change. It would more likely hit working people – the majority of people on Medicaid are themselves employed, and almost 80% live in families with at least one working member, according to data compiled by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
Children who are American citizens but whose parents are immigrants could be more likely to suffer repercussions, said some experts. When parents opt out of public assistance for fear of their own legal status, their kids are less likely to be enrolled in programs such as the Children’s Health Insurance Program, or CHIP, for which they would qualify.
To be clear, receiving public aid wouldn’t necessarily stop people from getting a green card. But it would tilt the odds against them.
“Another piece is the enormous discretion the administration will have under its proposal in making judgments about who gets admitted to the country and who gets a green card,” said the Migration Policy Institute’s Greenberg.
3. When will the policy shift take effect?
This is an early step in the complex federal rule-making process. And a lot could still change.
Once the proposed rule appears in the Federal Register, a 60-day countdown starts, during which anyone can weigh in with comments.
A final rule likely wouldn’t take effect until 2019.
And DHS is still seeking input on some details. For instance, it hasn’t decided whether CHIP would be counted as one of the “public charge” eligible programs.
In the interim, people who had received public benefits before the rule took effect would not be penalized for doing so.
4. Already, though, the proposal is having effects
DHS estimates that 2.5% of eligible immigrants would drop out of public benefits programs because of this change – which would tally about $1.5 billion worth of federal money per year. But others expect a much larger impact.
“The chilling effects will be vastly greater than the individuals directly affected,” Greenberg said. “There’s considerable reason to believe that [the White House estimate] may be a significant understatement.”
In the proposed rule, DHS notes that the changes could result in “worse health outcomes,” “increased use of emergency rooms,” “increased prevalence of communicable diseases,” “increased rates of poverty,” and other concerns.
Given the complexity of these programs and the proposed rule – and the high stakes at play – low-income immigrants would be much more likely to avoid public benefits altogether, immigration experts said. Millions of immigrants are likely to be affected directly or indirectly, according to the Center for Law and Social Policy, a D.C.-based nonprofit organization.
That could have stark health implications.
Take free vaccines, for which children are often eligible and which would not be subject to the public charge rule. Families afraid of jeopardizing a green card could still be more likely to opt out of that service, Whitener said.
Already, she added, there are reports of people declining federal assistance – even though nothing has yet happened.
“The fear factor cannot be underestimated,” she said.
5. Will people sue?
Legal action is likely.
Officials such as California Attorney General Xavier Becerra, who has frequently clashed with the White House, are weighing challenges to the rule.
“The Trump Administration’s proposal punishes hard-working immigrant families – even targeting children who are citizens – for utilizing programs that provide basic nutrition and healthcare. This is an assault on our families and our communities,” Becerra said in a statement.
But these actions depend on the final shape of the regulation, which could change through the rule-making process.
“They are likely to receive a very large number of sharply critical comments, and there is no way to know what changes they might make as a result,” Greenberg said.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.
A proposed rule from the White House would make it harder for legal immigrants to get green cards if they have received certain kinds of public assistance – including Medicaid, food stamps, and housing subsidies. Green cards allow them to live and work permanently in the United States.
“Those seeking to immigrate to the United States must show they can support themselves financially,” Homeland Security Secretary Kirstjen Nielsen said in a statement.
The proposal, announced Sept. 22, marks a new frontier in the administration’s long-term effort to curb immigration, both legal and illegal. It already has spurred intense criticism from Democrats, anti-poverty activists, health care organizations, and immigrants’ rights advocates, who call its restrictions unprecedented.
“We are operating in an overall climate of tremendous fear and anxiety as a result of the administration’s overall approach to immigration enforcement and immigration policy,” said Mark Greenberg, a senior fellow at the Migration Policy Institute, which studies migration and refugee policies at local, national, and international levels. He is also a former Obama administration official.
But what effect would this proposal have?
It’s a complicated question, touching upon vast government programs, with billions of dollars at stake. While the implications aren’t all immediately clear, Kaiser Health News breaks down some of the key elements.
1. First thing first: What is the White House proposing?
The Trump administration wants to redefine a status known as “public charge” – a category used to determine whether someone seeking permanent resident status is “likely to become primarily dependent on the government for subsistence.”
In the past, people have been at risk of being defined a “public charge” if they took cash welfare – known as Temporary Assistance for Needy Families, or Supplemental Security Income – or federal help paying for long-term care. (Immigrants must be in the country legally for 5 years before being eligible for TANF or SSI.)
And that “public charge” designation could undermine their applications for permanent residence.
The new rule would expand the list to include some health insurance, food, and housing programs. Specifically, it would penalize green-card applicants for using Medicaid, a federal-state health plan for low-income people. (Penalties would not apply for using Medicaid in certain emergencies or for some Medicaid services provided through schools and disability programs.)
Using food stamps, Section 8 rental assistance, and federal housing vouchers also would count against applicants. Enrollment in a Medicare Part D program subsidy to help low-income people buy prescription drugs would work against them, too.
The proposal “is definitely a dramatic change from how public charge works today,” said Kelly Whitener, an associate professor at Georgetown University’s Center for Children and Families who specializes in pediatric health benefits and managed-care systems.
A leaked version of the rule from March suggested officials then were also considering penalizing those who receive subsidies to buy health insurance on the Affordable Care Act marketplaces. But that idea was not in the proposal. The marketplace subsidies are aimed at people at a generally higher income bracket than the beneficiaries targeted in the Trump plan, Whitener noted.
“They’re really homing in on low-income immigrants,” she added.
Nielsen said the proposed rule is “intended to promote immigrant self-sufficiency and protect finite resources.”
2. Is this as unprecedented as critics say?
Yes.
Public charge is an old idea. In the 1990s, lawmakers expanded it to consider explicitly whether people had received cash-based welfare.
But including programs like Medicaid and food stamps, which are much wider in scope, is a significant change. It would more likely hit working people – the majority of people on Medicaid are themselves employed, and almost 80% live in families with at least one working member, according to data compiled by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
Children who are American citizens but whose parents are immigrants could be more likely to suffer repercussions, said some experts. When parents opt out of public assistance for fear of their own legal status, their kids are less likely to be enrolled in programs such as the Children’s Health Insurance Program, or CHIP, for which they would qualify.
To be clear, receiving public aid wouldn’t necessarily stop people from getting a green card. But it would tilt the odds against them.
“Another piece is the enormous discretion the administration will have under its proposal in making judgments about who gets admitted to the country and who gets a green card,” said the Migration Policy Institute’s Greenberg.
3. When will the policy shift take effect?
This is an early step in the complex federal rule-making process. And a lot could still change.
Once the proposed rule appears in the Federal Register, a 60-day countdown starts, during which anyone can weigh in with comments.
A final rule likely wouldn’t take effect until 2019.
And DHS is still seeking input on some details. For instance, it hasn’t decided whether CHIP would be counted as one of the “public charge” eligible programs.
In the interim, people who had received public benefits before the rule took effect would not be penalized for doing so.
4. Already, though, the proposal is having effects
DHS estimates that 2.5% of eligible immigrants would drop out of public benefits programs because of this change – which would tally about $1.5 billion worth of federal money per year. But others expect a much larger impact.
“The chilling effects will be vastly greater than the individuals directly affected,” Greenberg said. “There’s considerable reason to believe that [the White House estimate] may be a significant understatement.”
In the proposed rule, DHS notes that the changes could result in “worse health outcomes,” “increased use of emergency rooms,” “increased prevalence of communicable diseases,” “increased rates of poverty,” and other concerns.
Given the complexity of these programs and the proposed rule – and the high stakes at play – low-income immigrants would be much more likely to avoid public benefits altogether, immigration experts said. Millions of immigrants are likely to be affected directly or indirectly, according to the Center for Law and Social Policy, a D.C.-based nonprofit organization.
That could have stark health implications.
Take free vaccines, for which children are often eligible and which would not be subject to the public charge rule. Families afraid of jeopardizing a green card could still be more likely to opt out of that service, Whitener said.
Already, she added, there are reports of people declining federal assistance – even though nothing has yet happened.
“The fear factor cannot be underestimated,” she said.
5. Will people sue?
Legal action is likely.
Officials such as California Attorney General Xavier Becerra, who has frequently clashed with the White House, are weighing challenges to the rule.
“The Trump Administration’s proposal punishes hard-working immigrant families – even targeting children who are citizens – for utilizing programs that provide basic nutrition and healthcare. This is an assault on our families and our communities,” Becerra said in a statement.
But these actions depend on the final shape of the regulation, which could change through the rule-making process.
“They are likely to receive a very large number of sharply critical comments, and there is no way to know what changes they might make as a result,” Greenberg said.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.
A proposed rule from the White House would make it harder for legal immigrants to get green cards if they have received certain kinds of public assistance – including Medicaid, food stamps, and housing subsidies. Green cards allow them to live and work permanently in the United States.
“Those seeking to immigrate to the United States must show they can support themselves financially,” Homeland Security Secretary Kirstjen Nielsen said in a statement.
The proposal, announced Sept. 22, marks a new frontier in the administration’s long-term effort to curb immigration, both legal and illegal. It already has spurred intense criticism from Democrats, anti-poverty activists, health care organizations, and immigrants’ rights advocates, who call its restrictions unprecedented.
“We are operating in an overall climate of tremendous fear and anxiety as a result of the administration’s overall approach to immigration enforcement and immigration policy,” said Mark Greenberg, a senior fellow at the Migration Policy Institute, which studies migration and refugee policies at local, national, and international levels. He is also a former Obama administration official.
But what effect would this proposal have?
It’s a complicated question, touching upon vast government programs, with billions of dollars at stake. While the implications aren’t all immediately clear, Kaiser Health News breaks down some of the key elements.
1. First thing first: What is the White House proposing?
The Trump administration wants to redefine a status known as “public charge” – a category used to determine whether someone seeking permanent resident status is “likely to become primarily dependent on the government for subsistence.”
In the past, people have been at risk of being defined a “public charge” if they took cash welfare – known as Temporary Assistance for Needy Families, or Supplemental Security Income – or federal help paying for long-term care. (Immigrants must be in the country legally for 5 years before being eligible for TANF or SSI.)
And that “public charge” designation could undermine their applications for permanent residence.
The new rule would expand the list to include some health insurance, food, and housing programs. Specifically, it would penalize green-card applicants for using Medicaid, a federal-state health plan for low-income people. (Penalties would not apply for using Medicaid in certain emergencies or for some Medicaid services provided through schools and disability programs.)
Using food stamps, Section 8 rental assistance, and federal housing vouchers also would count against applicants. Enrollment in a Medicare Part D program subsidy to help low-income people buy prescription drugs would work against them, too.
The proposal “is definitely a dramatic change from how public charge works today,” said Kelly Whitener, an associate professor at Georgetown University’s Center for Children and Families who specializes in pediatric health benefits and managed-care systems.
A leaked version of the rule from March suggested officials then were also considering penalizing those who receive subsidies to buy health insurance on the Affordable Care Act marketplaces. But that idea was not in the proposal. The marketplace subsidies are aimed at people at a generally higher income bracket than the beneficiaries targeted in the Trump plan, Whitener noted.
“They’re really homing in on low-income immigrants,” she added.
Nielsen said the proposed rule is “intended to promote immigrant self-sufficiency and protect finite resources.”
2. Is this as unprecedented as critics say?
Yes.
Public charge is an old idea. In the 1990s, lawmakers expanded it to consider explicitly whether people had received cash-based welfare.
But including programs like Medicaid and food stamps, which are much wider in scope, is a significant change. It would more likely hit working people – the majority of people on Medicaid are themselves employed, and almost 80% live in families with at least one working member, according to data compiled by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
Children who are American citizens but whose parents are immigrants could be more likely to suffer repercussions, said some experts. When parents opt out of public assistance for fear of their own legal status, their kids are less likely to be enrolled in programs such as the Children’s Health Insurance Program, or CHIP, for which they would qualify.
To be clear, receiving public aid wouldn’t necessarily stop people from getting a green card. But it would tilt the odds against them.
“Another piece is the enormous discretion the administration will have under its proposal in making judgments about who gets admitted to the country and who gets a green card,” said the Migration Policy Institute’s Greenberg.
3. When will the policy shift take effect?
This is an early step in the complex federal rule-making process. And a lot could still change.
Once the proposed rule appears in the Federal Register, a 60-day countdown starts, during which anyone can weigh in with comments.
A final rule likely wouldn’t take effect until 2019.
And DHS is still seeking input on some details. For instance, it hasn’t decided whether CHIP would be counted as one of the “public charge” eligible programs.
In the interim, people who had received public benefits before the rule took effect would not be penalized for doing so.
4. Already, though, the proposal is having effects
DHS estimates that 2.5% of eligible immigrants would drop out of public benefits programs because of this change – which would tally about $1.5 billion worth of federal money per year. But others expect a much larger impact.
“The chilling effects will be vastly greater than the individuals directly affected,” Greenberg said. “There’s considerable reason to believe that [the White House estimate] may be a significant understatement.”
In the proposed rule, DHS notes that the changes could result in “worse health outcomes,” “increased use of emergency rooms,” “increased prevalence of communicable diseases,” “increased rates of poverty,” and other concerns.
Given the complexity of these programs and the proposed rule – and the high stakes at play – low-income immigrants would be much more likely to avoid public benefits altogether, immigration experts said. Millions of immigrants are likely to be affected directly or indirectly, according to the Center for Law and Social Policy, a D.C.-based nonprofit organization.
That could have stark health implications.
Take free vaccines, for which children are often eligible and which would not be subject to the public charge rule. Families afraid of jeopardizing a green card could still be more likely to opt out of that service, Whitener said.
Already, she added, there are reports of people declining federal assistance – even though nothing has yet happened.
“The fear factor cannot be underestimated,” she said.
5. Will people sue?
Legal action is likely.
Officials such as California Attorney General Xavier Becerra, who has frequently clashed with the White House, are weighing challenges to the rule.
“The Trump Administration’s proposal punishes hard-working immigrant families – even targeting children who are citizens – for utilizing programs that provide basic nutrition and healthcare. This is an assault on our families and our communities,” Becerra said in a statement.
But these actions depend on the final shape of the regulation, which could change through the rule-making process.
“They are likely to receive a very large number of sharply critical comments, and there is no way to know what changes they might make as a result,” Greenberg said.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente. KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.
Some doctors are warming to single-payer medicine
When the American Medical Association – one of the nation’s most powerful health care groups – met in Chicago this June, its medical student caucus seized an opportunity for change.
Though they had tried for years to advance a resolution calling on the organization to drop its decades-long opposition to single-payer health care, this was the first time it got a full hearing. The debate grew heated – older physicians warned their pay would decrease, calling younger advocates naive to single-payer’s consequences. But this time, by the meeting’s end, the AMA’s older members had agreed to at least study the possibility of changing its stance.
“We believe health care is a human right, maybe more so than past generations,” said Brad Zehr, MD, a pathology resident at Ohio State University, who was part of the debate. “There’s a generational shift happening, where we see universal health care as a requirement.”
The ins and outs of the AMA’s policymaking may sound like inside baseball. But this year’s youth uprising at the nexus of the medical establishment speaks to a cultural shift in the medical profession, and one with big political implications.
Amid Republican attacks on the Affordable Care Act, an increasing number of Democrats – both candidates and Congress members – are putting forth proposals that would vastly increase the government’s role in running the health system. These include single-payer, Medicare-for-all, or an option for anyone to buy in to the Medicare program. At least 70 House Democrats have signed on to the new “Medicare-for-all” caucus.
Organized medicine, and previous generations of doctors, had for the most part staunchly opposed any such plan. The AMA has thwarted public health insurance proposals since the 1930s and long been considered one of the policy’s most powerful opponents.
But the battle lines are shifting as younger doctors flip their views, a change that will likely assume greater significance as the next generation of physicians takes on leadership roles. The AMA did not make anyone available for comment.
Many younger physicians are “accepting of single-payer,” said Christian Pean, MD, a third-year orthopedic surgery resident at New York University.
In prior generations, “intelligent, motivated, quantitative” students pursued medicine, both for the income and because of the workplace independence – running practices with minimal government interference, said Steven Schroeder, MD, professor of medicine at the University of California, San Francisco.
In his 50 years of teaching, students’ attitudes have changed, he said. “The ‘Oh, keep government out of my work’ feeling is not as strong as it was with maybe older cohorts,” said Dr. Schroeder. “Students come in saying, ‘We want to make a difference through social justice. That’s why we’re here.’ ”
Though single-payer health care long has been dismissed as a left-wing pipe dream, polling suggests a slim majority of Americans now support the idea – though it is not clear people know what the term means.
A full single-payer system means everyone gets coverage from the same insurance plan, usually sponsored by the government. “Medicare for all,” a phrase that gained currency with the presidential campaign of Sen. Bernie Sanders (I-Vt.), means everyone gets Medicare, but, depending on the proposal, it may or may not allow private insurers to offer Medicare as well. (Sen. Sanders’ plan, which eliminates deductibles and expands benefits, would get rid of private insurers.)
Meanwhile, lots of countries achieve universal health care – everyone is covered somehow – but the method can vary. For example, France requires all citizens purchase coverage, which is sold through nonprofits. In Germany, most people get insurance from a government-run “public option,” while others purchase private plans. In England, health care is provided through the tax-funded National Health System.
American skeptics often use the phrase “socialized medicine” pejoratively to describe all of these models.
“Few really understand what you mean when you say single-payer,” said Frank Opelka, MD, medical director of quality and health policy for the American College of Surgeons, which opposes such a policy. “What they mean is, ‘I don’t think the current system is working.’ ”
But the willingness to explore previously unthinkable ideas is evident in young doctors’ ranks.
Recent surveys through LinkedIn, Merritt Hawkins, and NEJM Catalyst indicate growing support. In the March NEJM Catalyst survey, 61% of 607 respondents said single-payer would make it easier to deliver cost-effective, quality health care.
Delving further, that survey shows support is stronger among younger physicians, said Namita Mohta, MD, a hospitalist at Brigham and Women’s Hospital, Boston, and clinical editor at NEJM Catalyst.
But it’s unclear whether these findings reflect young doctors’ feelings about the policy or whether they are tapping in to broader frustrations with the American health system.
Much like the general public, doctors often use terms like single-payer, Medicare for all, and universal health care interchangeably.
“Our younger generation is less afraid to come out and say we want universal health care,” said Anna Yap, MD, an emergency medicine resident at UCLA, who served as a medical student delegate to the AMA until this past June. “But how? It’s different in what forms we see.”
Younger doctors also pointed to growing concern about how best to keep patients healthy. They cited research that broadly suggests having health insurance tracks with better health outcomes.
“Medical students, I would say, are very interested in public health and improving social determinants of health – one of them being access to health insurance,” said Jerome Jeevarajan, MD, a neurology resident at the University of Texas–Houston, referring to nonmedical factors that improve health, such as food or housing.
Some of the shift in opinion has to do with the changing realities of medical practice. Doctors now are more likely to end up working for large health systems or hospitals, rather than starting a practice. Combined with the increasing complexity of billing private insurance, many said, that means contracting with the government may feel like less of an intrusion.
The debate is, at this point, still theoretical. Republicans – who control the White House and both houses of Congress – sharply oppose single-payer. Meanwhile, single-state efforts in California, Colorado, and New York have fallen flat.
Also, doctors represent only one part of the sprawling health care industrial complex. Other health care interests – including private insurance, the drug industry, and hospital trade groups – have been slower to warm to catchphrases like single-payer or universal health care, all of which would likely mean a drop in income.
But increasingly physicians seem to be switching sides in the debate, and young physicians want to be part of the discussion.
“There’s tremendous potential ... to be at the table if single-payer becomes a significant part of the political discourse, and create a system that is more equitable,” Dr. Pean said.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
When the American Medical Association – one of the nation’s most powerful health care groups – met in Chicago this June, its medical student caucus seized an opportunity for change.
Though they had tried for years to advance a resolution calling on the organization to drop its decades-long opposition to single-payer health care, this was the first time it got a full hearing. The debate grew heated – older physicians warned their pay would decrease, calling younger advocates naive to single-payer’s consequences. But this time, by the meeting’s end, the AMA’s older members had agreed to at least study the possibility of changing its stance.
“We believe health care is a human right, maybe more so than past generations,” said Brad Zehr, MD, a pathology resident at Ohio State University, who was part of the debate. “There’s a generational shift happening, where we see universal health care as a requirement.”
The ins and outs of the AMA’s policymaking may sound like inside baseball. But this year’s youth uprising at the nexus of the medical establishment speaks to a cultural shift in the medical profession, and one with big political implications.
Amid Republican attacks on the Affordable Care Act, an increasing number of Democrats – both candidates and Congress members – are putting forth proposals that would vastly increase the government’s role in running the health system. These include single-payer, Medicare-for-all, or an option for anyone to buy in to the Medicare program. At least 70 House Democrats have signed on to the new “Medicare-for-all” caucus.
Organized medicine, and previous generations of doctors, had for the most part staunchly opposed any such plan. The AMA has thwarted public health insurance proposals since the 1930s and long been considered one of the policy’s most powerful opponents.
But the battle lines are shifting as younger doctors flip their views, a change that will likely assume greater significance as the next generation of physicians takes on leadership roles. The AMA did not make anyone available for comment.
Many younger physicians are “accepting of single-payer,” said Christian Pean, MD, a third-year orthopedic surgery resident at New York University.
In prior generations, “intelligent, motivated, quantitative” students pursued medicine, both for the income and because of the workplace independence – running practices with minimal government interference, said Steven Schroeder, MD, professor of medicine at the University of California, San Francisco.
In his 50 years of teaching, students’ attitudes have changed, he said. “The ‘Oh, keep government out of my work’ feeling is not as strong as it was with maybe older cohorts,” said Dr. Schroeder. “Students come in saying, ‘We want to make a difference through social justice. That’s why we’re here.’ ”
Though single-payer health care long has been dismissed as a left-wing pipe dream, polling suggests a slim majority of Americans now support the idea – though it is not clear people know what the term means.
A full single-payer system means everyone gets coverage from the same insurance plan, usually sponsored by the government. “Medicare for all,” a phrase that gained currency with the presidential campaign of Sen. Bernie Sanders (I-Vt.), means everyone gets Medicare, but, depending on the proposal, it may or may not allow private insurers to offer Medicare as well. (Sen. Sanders’ plan, which eliminates deductibles and expands benefits, would get rid of private insurers.)
Meanwhile, lots of countries achieve universal health care – everyone is covered somehow – but the method can vary. For example, France requires all citizens purchase coverage, which is sold through nonprofits. In Germany, most people get insurance from a government-run “public option,” while others purchase private plans. In England, health care is provided through the tax-funded National Health System.
American skeptics often use the phrase “socialized medicine” pejoratively to describe all of these models.
“Few really understand what you mean when you say single-payer,” said Frank Opelka, MD, medical director of quality and health policy for the American College of Surgeons, which opposes such a policy. “What they mean is, ‘I don’t think the current system is working.’ ”
But the willingness to explore previously unthinkable ideas is evident in young doctors’ ranks.
Recent surveys through LinkedIn, Merritt Hawkins, and NEJM Catalyst indicate growing support. In the March NEJM Catalyst survey, 61% of 607 respondents said single-payer would make it easier to deliver cost-effective, quality health care.
Delving further, that survey shows support is stronger among younger physicians, said Namita Mohta, MD, a hospitalist at Brigham and Women’s Hospital, Boston, and clinical editor at NEJM Catalyst.
But it’s unclear whether these findings reflect young doctors’ feelings about the policy or whether they are tapping in to broader frustrations with the American health system.
Much like the general public, doctors often use terms like single-payer, Medicare for all, and universal health care interchangeably.
“Our younger generation is less afraid to come out and say we want universal health care,” said Anna Yap, MD, an emergency medicine resident at UCLA, who served as a medical student delegate to the AMA until this past June. “But how? It’s different in what forms we see.”
Younger doctors also pointed to growing concern about how best to keep patients healthy. They cited research that broadly suggests having health insurance tracks with better health outcomes.
“Medical students, I would say, are very interested in public health and improving social determinants of health – one of them being access to health insurance,” said Jerome Jeevarajan, MD, a neurology resident at the University of Texas–Houston, referring to nonmedical factors that improve health, such as food or housing.
Some of the shift in opinion has to do with the changing realities of medical practice. Doctors now are more likely to end up working for large health systems or hospitals, rather than starting a practice. Combined with the increasing complexity of billing private insurance, many said, that means contracting with the government may feel like less of an intrusion.
The debate is, at this point, still theoretical. Republicans – who control the White House and both houses of Congress – sharply oppose single-payer. Meanwhile, single-state efforts in California, Colorado, and New York have fallen flat.
Also, doctors represent only one part of the sprawling health care industrial complex. Other health care interests – including private insurance, the drug industry, and hospital trade groups – have been slower to warm to catchphrases like single-payer or universal health care, all of which would likely mean a drop in income.
But increasingly physicians seem to be switching sides in the debate, and young physicians want to be part of the discussion.
“There’s tremendous potential ... to be at the table if single-payer becomes a significant part of the political discourse, and create a system that is more equitable,” Dr. Pean said.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
When the American Medical Association – one of the nation’s most powerful health care groups – met in Chicago this June, its medical student caucus seized an opportunity for change.
Though they had tried for years to advance a resolution calling on the organization to drop its decades-long opposition to single-payer health care, this was the first time it got a full hearing. The debate grew heated – older physicians warned their pay would decrease, calling younger advocates naive to single-payer’s consequences. But this time, by the meeting’s end, the AMA’s older members had agreed to at least study the possibility of changing its stance.
“We believe health care is a human right, maybe more so than past generations,” said Brad Zehr, MD, a pathology resident at Ohio State University, who was part of the debate. “There’s a generational shift happening, where we see universal health care as a requirement.”
The ins and outs of the AMA’s policymaking may sound like inside baseball. But this year’s youth uprising at the nexus of the medical establishment speaks to a cultural shift in the medical profession, and one with big political implications.
Amid Republican attacks on the Affordable Care Act, an increasing number of Democrats – both candidates and Congress members – are putting forth proposals that would vastly increase the government’s role in running the health system. These include single-payer, Medicare-for-all, or an option for anyone to buy in to the Medicare program. At least 70 House Democrats have signed on to the new “Medicare-for-all” caucus.
Organized medicine, and previous generations of doctors, had for the most part staunchly opposed any such plan. The AMA has thwarted public health insurance proposals since the 1930s and long been considered one of the policy’s most powerful opponents.
But the battle lines are shifting as younger doctors flip their views, a change that will likely assume greater significance as the next generation of physicians takes on leadership roles. The AMA did not make anyone available for comment.
Many younger physicians are “accepting of single-payer,” said Christian Pean, MD, a third-year orthopedic surgery resident at New York University.
In prior generations, “intelligent, motivated, quantitative” students pursued medicine, both for the income and because of the workplace independence – running practices with minimal government interference, said Steven Schroeder, MD, professor of medicine at the University of California, San Francisco.
In his 50 years of teaching, students’ attitudes have changed, he said. “The ‘Oh, keep government out of my work’ feeling is not as strong as it was with maybe older cohorts,” said Dr. Schroeder. “Students come in saying, ‘We want to make a difference through social justice. That’s why we’re here.’ ”
Though single-payer health care long has been dismissed as a left-wing pipe dream, polling suggests a slim majority of Americans now support the idea – though it is not clear people know what the term means.
A full single-payer system means everyone gets coverage from the same insurance plan, usually sponsored by the government. “Medicare for all,” a phrase that gained currency with the presidential campaign of Sen. Bernie Sanders (I-Vt.), means everyone gets Medicare, but, depending on the proposal, it may or may not allow private insurers to offer Medicare as well. (Sen. Sanders’ plan, which eliminates deductibles and expands benefits, would get rid of private insurers.)
Meanwhile, lots of countries achieve universal health care – everyone is covered somehow – but the method can vary. For example, France requires all citizens purchase coverage, which is sold through nonprofits. In Germany, most people get insurance from a government-run “public option,” while others purchase private plans. In England, health care is provided through the tax-funded National Health System.
American skeptics often use the phrase “socialized medicine” pejoratively to describe all of these models.
“Few really understand what you mean when you say single-payer,” said Frank Opelka, MD, medical director of quality and health policy for the American College of Surgeons, which opposes such a policy. “What they mean is, ‘I don’t think the current system is working.’ ”
But the willingness to explore previously unthinkable ideas is evident in young doctors’ ranks.
Recent surveys through LinkedIn, Merritt Hawkins, and NEJM Catalyst indicate growing support. In the March NEJM Catalyst survey, 61% of 607 respondents said single-payer would make it easier to deliver cost-effective, quality health care.
Delving further, that survey shows support is stronger among younger physicians, said Namita Mohta, MD, a hospitalist at Brigham and Women’s Hospital, Boston, and clinical editor at NEJM Catalyst.
But it’s unclear whether these findings reflect young doctors’ feelings about the policy or whether they are tapping in to broader frustrations with the American health system.
Much like the general public, doctors often use terms like single-payer, Medicare for all, and universal health care interchangeably.
“Our younger generation is less afraid to come out and say we want universal health care,” said Anna Yap, MD, an emergency medicine resident at UCLA, who served as a medical student delegate to the AMA until this past June. “But how? It’s different in what forms we see.”
Younger doctors also pointed to growing concern about how best to keep patients healthy. They cited research that broadly suggests having health insurance tracks with better health outcomes.
“Medical students, I would say, are very interested in public health and improving social determinants of health – one of them being access to health insurance,” said Jerome Jeevarajan, MD, a neurology resident at the University of Texas–Houston, referring to nonmedical factors that improve health, such as food or housing.
Some of the shift in opinion has to do with the changing realities of medical practice. Doctors now are more likely to end up working for large health systems or hospitals, rather than starting a practice. Combined with the increasing complexity of billing private insurance, many said, that means contracting with the government may feel like less of an intrusion.
The debate is, at this point, still theoretical. Republicans – who control the White House and both houses of Congress – sharply oppose single-payer. Meanwhile, single-state efforts in California, Colorado, and New York have fallen flat.
Also, doctors represent only one part of the sprawling health care industrial complex. Other health care interests – including private insurance, the drug industry, and hospital trade groups – have been slower to warm to catchphrases like single-payer or universal health care, all of which would likely mean a drop in income.
But increasingly physicians seem to be switching sides in the debate, and young physicians want to be part of the discussion.
“There’s tremendous potential ... to be at the table if single-payer becomes a significant part of the political discourse, and create a system that is more equitable,” Dr. Pean said.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
Nation’s Top Doc Wants The Overdose Antidote Widely On Hand. Is That Feasible?
When Surgeon General Jerome Adams issued an advisory calling for more people to carry naloxone — not just people at overdose risk, but also friends and family — experts and advocates were almost giddy.
This is an “unequivocally positive” step forward, said Leo Beletsky, an associate professor of law and health sciences at Northeastern University.
And not necessarily a surprise. Adams, who previously was Indiana’s health commissioner, was recruited to be the nation’s top doctor in part because of his work with then-Gov. Mike Pence, now the vice president. In Indiana, Adams pushed for harm-reduction approaches, which included expanded access to naloxone and the implementation of a needle exchange to combat the state’s much-publicized HIV outbreak, which began in 2015 and was linked to injection drug use.
Others cautioned, though, that his have-naloxone-will-carry recommendation is at best limited in what it can achieve, in part because the drug is relatively expensive.
Kaiser Health News breaks down what the advisory means, experts’ concerns and what policy approaches may be in the pipeline.
Many public health advocates applaud the surgeon general’s position.
Naloxone, which is a drug that can keep drug users alive by reversing opioid overdoses, is viewed by many as the cornerstone of the harm-reduction approach to the epidemic. Experts say people with addiction problems should carry it, and so should their family, friends and acquaintances.
“We want to put it more in reach,” said Traci Green, an associate professor of emergency medicine and community health sciences at Boston University, who has extensively researched the opioid abuse crisis. “It could not have been a better endorsement.”
Others, including Diane Goodman, who penned a recent Medscape commentary reflecting on the advisory, wonder whether this is a “rational” response to the scourge, since opioid addiction is one of many health problems people might encounter in everyday life and for which treatment options are still limited.
“I’m not sure it makes much more sense than any of us carrying a bottle of nitroglycerin to treat patients with end-stage angina,” wrote Goodman, an acute-care nurse practitioner, referring to chest pain.
“What, exactly, are we offering to addicts once their condition has been reversed?” she asked, noting that without treatment and therapy programs that help wean people from addiction “the odds of survival for any length of time remain low, no matter how much reversal medication is kept nearby.”
Results would likely be limited by naloxone’s price tag.
Take Baltimore, which has been hit particularly hard by the opioid epidemic. Its health department already has pushed for more people to carry naloxone.
But the drug’s price is an issue, said Dr. Leana Wen, the city’s health commissioner, and an emergency physician. She suggested that the federal government negotiate directly for a lower price, or give more money to organizations and agencies like hers so they can afford to maintain an adequate supply.
“Every day, people are calling us at the Baltimore City Health Department and requesting naloxone, and I have to tell them I can’t afford for them to have it,” Wen said.
The drug is available in generic form, which can be stored in a vial and injected via a needle, as well as in patented products, such as the nasal spray Narcan, sold by ADAPT Pharmaceuticals, and Kaleo’s Evzio, a talking auto-injector.
Generic naloxone costs $20 to $40 per dose. Narcan, the nasal spray, costs $125 for a two-dose carton, according to ADAPT’s website. A two-pack of Evzio costs close to $4,000, according to GoodRx.
Health departments and first responders qualify for a discounted rate of $75 per carton of Narcan. Kaleo has made Evzio coupons available to consumers, so that some will not have a copay, and it advertises a discount for federal and state agencies.
Skeptics point out that similar methods have been used to build brand loyalty and potentially make a particular product a household name. That’s how Epi-Pen became synonymous with epinephrine for the treatment of anaphylactic shock.
“There’s clearly some overlap” here between the pricing strategies used by naloxone manufacturers and Epi-Pen distributor Mylan, said Richard Evans, co-founder of SSR Health, which tracks the pharmaceutical industry.
But it’s not a perfect comparison. The presence of low-cost generics changes the calculus, he said, as does the different level of demand.
Nonprofit organizations and health care providers keenly feel the pressures of increasing demand and cost.
Experts say price breaks on naloxone are not sufficient to cover the costs on the ground.
“Sixty-four thousand people lost their lives [nationally in 2016] — that’s someone every 12 minutes,” said Justin Phillips, executive director of Overdose Lifeline, an Indianapolis-based nonprofit. “Ten free kits is not going to be enough.”
Phillips said her organization relies on generic naloxone, which is the least expensive formulation. It’s the only feasible option, using dedicated grant money the group received from the state attorney general’s office as part of a program funded by a settlement with pharmaceutical companies.
But that money is almost dried up. “We need to be able to access naloxone — which I’m told is pennies to make — for the pennies it cost to make it,” Phillips said.
Phillips, who worked with Adams when he ran Indiana’s health department, said she has discussed the need for naloxone funding with the surgeon general, but never its price.
Pharmacies assess the hurdles of distribution.
Local pharmacies are key in this chain, but the overdose antidote is new territory for many pharmacists, said Randy Hitchens, the executive vice president of the Indiana Pharmacists Alliance. He said in 2015, when Adams began his push to get naloxone into the hands of drug users and their families, only one or two retail pharmacies carried it.
“This has always been an emergency room drug. Retail pharmacists typically were not used to dealing with [it],” Hitchens said. “A lot were probably saying, ‘What in the devil is naloxone?’”
Today, he estimates 60 to 70 percent of Indiana’s more than 1,100 retail pharmacies carry the drug. Walgreens, the pharmacy chain, has committed to stocking Narcan.
Access, though, is always subject to retail pressures.
“If pharmacies are not seeing a steady stream coming in asking for it, they won’t be incentivized to carry it on their shelves,” said Daniel Raymond, the deputy director of policy and planning for the Harm Reduction Coalition.
A patchwork of other decentralized sources for naloxone exist: syringe-exchange vans, county and state health departments, churches and community centers, all trying to find ways to get overdose medication into the hands of people who need it.
That supply stream “meets people where they are,” Raymond said, but those little programs don’t have the muscle to negotiate discounted prices.
“Individual health programs are trying to navigate the crisis on their own, but when you see … growing demand and limited supply, it’s a role for federal intervention,” Raymond said.
He’d like to see the federal government step in to negotiate prices where smaller programs can’t.
The surgeon general’s message is one part of Washington’s broader response to the epidemic. But even as Congress crafts an opioid epidemic response package, it’s not clear it will tackle these concerns.
In the House of Representatives’ Energy and Commerce Committee, one bill being discussed would require all state Medicaid programs to cover at least one form of naloxone. Currently, not all state Medicaid programs do so.
A Senate bill would authorize $300 million annually to equip first responders with naloxone.
But critics say those approaches still don’t address the underlying problems: cost and funding.
“You can either make naloxone available, at a much discounted price, or we need to have a lot more resources in order to purchase it,” Wen said. “I don’t care which one. My only concern is the health and well-being of our residents.”
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
When Surgeon General Jerome Adams issued an advisory calling for more people to carry naloxone — not just people at overdose risk, but also friends and family — experts and advocates were almost giddy.
This is an “unequivocally positive” step forward, said Leo Beletsky, an associate professor of law and health sciences at Northeastern University.
And not necessarily a surprise. Adams, who previously was Indiana’s health commissioner, was recruited to be the nation’s top doctor in part because of his work with then-Gov. Mike Pence, now the vice president. In Indiana, Adams pushed for harm-reduction approaches, which included expanded access to naloxone and the implementation of a needle exchange to combat the state’s much-publicized HIV outbreak, which began in 2015 and was linked to injection drug use.
Others cautioned, though, that his have-naloxone-will-carry recommendation is at best limited in what it can achieve, in part because the drug is relatively expensive.
Kaiser Health News breaks down what the advisory means, experts’ concerns and what policy approaches may be in the pipeline.
Many public health advocates applaud the surgeon general’s position.
Naloxone, which is a drug that can keep drug users alive by reversing opioid overdoses, is viewed by many as the cornerstone of the harm-reduction approach to the epidemic. Experts say people with addiction problems should carry it, and so should their family, friends and acquaintances.
“We want to put it more in reach,” said Traci Green, an associate professor of emergency medicine and community health sciences at Boston University, who has extensively researched the opioid abuse crisis. “It could not have been a better endorsement.”
Others, including Diane Goodman, who penned a recent Medscape commentary reflecting on the advisory, wonder whether this is a “rational” response to the scourge, since opioid addiction is one of many health problems people might encounter in everyday life and for which treatment options are still limited.
“I’m not sure it makes much more sense than any of us carrying a bottle of nitroglycerin to treat patients with end-stage angina,” wrote Goodman, an acute-care nurse practitioner, referring to chest pain.
“What, exactly, are we offering to addicts once their condition has been reversed?” she asked, noting that without treatment and therapy programs that help wean people from addiction “the odds of survival for any length of time remain low, no matter how much reversal medication is kept nearby.”
Results would likely be limited by naloxone’s price tag.
Take Baltimore, which has been hit particularly hard by the opioid epidemic. Its health department already has pushed for more people to carry naloxone.
But the drug’s price is an issue, said Dr. Leana Wen, the city’s health commissioner, and an emergency physician. She suggested that the federal government negotiate directly for a lower price, or give more money to organizations and agencies like hers so they can afford to maintain an adequate supply.
“Every day, people are calling us at the Baltimore City Health Department and requesting naloxone, and I have to tell them I can’t afford for them to have it,” Wen said.
The drug is available in generic form, which can be stored in a vial and injected via a needle, as well as in patented products, such as the nasal spray Narcan, sold by ADAPT Pharmaceuticals, and Kaleo’s Evzio, a talking auto-injector.
Generic naloxone costs $20 to $40 per dose. Narcan, the nasal spray, costs $125 for a two-dose carton, according to ADAPT’s website. A two-pack of Evzio costs close to $4,000, according to GoodRx.
Health departments and first responders qualify for a discounted rate of $75 per carton of Narcan. Kaleo has made Evzio coupons available to consumers, so that some will not have a copay, and it advertises a discount for federal and state agencies.
Skeptics point out that similar methods have been used to build brand loyalty and potentially make a particular product a household name. That’s how Epi-Pen became synonymous with epinephrine for the treatment of anaphylactic shock.
“There’s clearly some overlap” here between the pricing strategies used by naloxone manufacturers and Epi-Pen distributor Mylan, said Richard Evans, co-founder of SSR Health, which tracks the pharmaceutical industry.
But it’s not a perfect comparison. The presence of low-cost generics changes the calculus, he said, as does the different level of demand.
Nonprofit organizations and health care providers keenly feel the pressures of increasing demand and cost.
Experts say price breaks on naloxone are not sufficient to cover the costs on the ground.
“Sixty-four thousand people lost their lives [nationally in 2016] — that’s someone every 12 minutes,” said Justin Phillips, executive director of Overdose Lifeline, an Indianapolis-based nonprofit. “Ten free kits is not going to be enough.”
Phillips said her organization relies on generic naloxone, which is the least expensive formulation. It’s the only feasible option, using dedicated grant money the group received from the state attorney general’s office as part of a program funded by a settlement with pharmaceutical companies.
But that money is almost dried up. “We need to be able to access naloxone — which I’m told is pennies to make — for the pennies it cost to make it,” Phillips said.
Phillips, who worked with Adams when he ran Indiana’s health department, said she has discussed the need for naloxone funding with the surgeon general, but never its price.
Pharmacies assess the hurdles of distribution.
Local pharmacies are key in this chain, but the overdose antidote is new territory for many pharmacists, said Randy Hitchens, the executive vice president of the Indiana Pharmacists Alliance. He said in 2015, when Adams began his push to get naloxone into the hands of drug users and their families, only one or two retail pharmacies carried it.
“This has always been an emergency room drug. Retail pharmacists typically were not used to dealing with [it],” Hitchens said. “A lot were probably saying, ‘What in the devil is naloxone?’”
Today, he estimates 60 to 70 percent of Indiana’s more than 1,100 retail pharmacies carry the drug. Walgreens, the pharmacy chain, has committed to stocking Narcan.
Access, though, is always subject to retail pressures.
“If pharmacies are not seeing a steady stream coming in asking for it, they won’t be incentivized to carry it on their shelves,” said Daniel Raymond, the deputy director of policy and planning for the Harm Reduction Coalition.
A patchwork of other decentralized sources for naloxone exist: syringe-exchange vans, county and state health departments, churches and community centers, all trying to find ways to get overdose medication into the hands of people who need it.
That supply stream “meets people where they are,” Raymond said, but those little programs don’t have the muscle to negotiate discounted prices.
“Individual health programs are trying to navigate the crisis on their own, but when you see … growing demand and limited supply, it’s a role for federal intervention,” Raymond said.
He’d like to see the federal government step in to negotiate prices where smaller programs can’t.
The surgeon general’s message is one part of Washington’s broader response to the epidemic. But even as Congress crafts an opioid epidemic response package, it’s not clear it will tackle these concerns.
In the House of Representatives’ Energy and Commerce Committee, one bill being discussed would require all state Medicaid programs to cover at least one form of naloxone. Currently, not all state Medicaid programs do so.
A Senate bill would authorize $300 million annually to equip first responders with naloxone.
But critics say those approaches still don’t address the underlying problems: cost and funding.
“You can either make naloxone available, at a much discounted price, or we need to have a lot more resources in order to purchase it,” Wen said. “I don’t care which one. My only concern is the health and well-being of our residents.”
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
When Surgeon General Jerome Adams issued an advisory calling for more people to carry naloxone — not just people at overdose risk, but also friends and family — experts and advocates were almost giddy.
This is an “unequivocally positive” step forward, said Leo Beletsky, an associate professor of law and health sciences at Northeastern University.
And not necessarily a surprise. Adams, who previously was Indiana’s health commissioner, was recruited to be the nation’s top doctor in part because of his work with then-Gov. Mike Pence, now the vice president. In Indiana, Adams pushed for harm-reduction approaches, which included expanded access to naloxone and the implementation of a needle exchange to combat the state’s much-publicized HIV outbreak, which began in 2015 and was linked to injection drug use.
Others cautioned, though, that his have-naloxone-will-carry recommendation is at best limited in what it can achieve, in part because the drug is relatively expensive.
Kaiser Health News breaks down what the advisory means, experts’ concerns and what policy approaches may be in the pipeline.
Many public health advocates applaud the surgeon general’s position.
Naloxone, which is a drug that can keep drug users alive by reversing opioid overdoses, is viewed by many as the cornerstone of the harm-reduction approach to the epidemic. Experts say people with addiction problems should carry it, and so should their family, friends and acquaintances.
“We want to put it more in reach,” said Traci Green, an associate professor of emergency medicine and community health sciences at Boston University, who has extensively researched the opioid abuse crisis. “It could not have been a better endorsement.”
Others, including Diane Goodman, who penned a recent Medscape commentary reflecting on the advisory, wonder whether this is a “rational” response to the scourge, since opioid addiction is one of many health problems people might encounter in everyday life and for which treatment options are still limited.
“I’m not sure it makes much more sense than any of us carrying a bottle of nitroglycerin to treat patients with end-stage angina,” wrote Goodman, an acute-care nurse practitioner, referring to chest pain.
“What, exactly, are we offering to addicts once their condition has been reversed?” she asked, noting that without treatment and therapy programs that help wean people from addiction “the odds of survival for any length of time remain low, no matter how much reversal medication is kept nearby.”
Results would likely be limited by naloxone’s price tag.
Take Baltimore, which has been hit particularly hard by the opioid epidemic. Its health department already has pushed for more people to carry naloxone.
But the drug’s price is an issue, said Dr. Leana Wen, the city’s health commissioner, and an emergency physician. She suggested that the federal government negotiate directly for a lower price, or give more money to organizations and agencies like hers so they can afford to maintain an adequate supply.
“Every day, people are calling us at the Baltimore City Health Department and requesting naloxone, and I have to tell them I can’t afford for them to have it,” Wen said.
The drug is available in generic form, which can be stored in a vial and injected via a needle, as well as in patented products, such as the nasal spray Narcan, sold by ADAPT Pharmaceuticals, and Kaleo’s Evzio, a talking auto-injector.
Generic naloxone costs $20 to $40 per dose. Narcan, the nasal spray, costs $125 for a two-dose carton, according to ADAPT’s website. A two-pack of Evzio costs close to $4,000, according to GoodRx.
Health departments and first responders qualify for a discounted rate of $75 per carton of Narcan. Kaleo has made Evzio coupons available to consumers, so that some will not have a copay, and it advertises a discount for federal and state agencies.
Skeptics point out that similar methods have been used to build brand loyalty and potentially make a particular product a household name. That’s how Epi-Pen became synonymous with epinephrine for the treatment of anaphylactic shock.
“There’s clearly some overlap” here between the pricing strategies used by naloxone manufacturers and Epi-Pen distributor Mylan, said Richard Evans, co-founder of SSR Health, which tracks the pharmaceutical industry.
But it’s not a perfect comparison. The presence of low-cost generics changes the calculus, he said, as does the different level of demand.
Nonprofit organizations and health care providers keenly feel the pressures of increasing demand and cost.
Experts say price breaks on naloxone are not sufficient to cover the costs on the ground.
“Sixty-four thousand people lost their lives [nationally in 2016] — that’s someone every 12 minutes,” said Justin Phillips, executive director of Overdose Lifeline, an Indianapolis-based nonprofit. “Ten free kits is not going to be enough.”
Phillips said her organization relies on generic naloxone, which is the least expensive formulation. It’s the only feasible option, using dedicated grant money the group received from the state attorney general’s office as part of a program funded by a settlement with pharmaceutical companies.
But that money is almost dried up. “We need to be able to access naloxone — which I’m told is pennies to make — for the pennies it cost to make it,” Phillips said.
Phillips, who worked with Adams when he ran Indiana’s health department, said she has discussed the need for naloxone funding with the surgeon general, but never its price.
Pharmacies assess the hurdles of distribution.
Local pharmacies are key in this chain, but the overdose antidote is new territory for many pharmacists, said Randy Hitchens, the executive vice president of the Indiana Pharmacists Alliance. He said in 2015, when Adams began his push to get naloxone into the hands of drug users and their families, only one or two retail pharmacies carried it.
“This has always been an emergency room drug. Retail pharmacists typically were not used to dealing with [it],” Hitchens said. “A lot were probably saying, ‘What in the devil is naloxone?’”
Today, he estimates 60 to 70 percent of Indiana’s more than 1,100 retail pharmacies carry the drug. Walgreens, the pharmacy chain, has committed to stocking Narcan.
Access, though, is always subject to retail pressures.
“If pharmacies are not seeing a steady stream coming in asking for it, they won’t be incentivized to carry it on their shelves,” said Daniel Raymond, the deputy director of policy and planning for the Harm Reduction Coalition.
A patchwork of other decentralized sources for naloxone exist: syringe-exchange vans, county and state health departments, churches and community centers, all trying to find ways to get overdose medication into the hands of people who need it.
That supply stream “meets people where they are,” Raymond said, but those little programs don’t have the muscle to negotiate discounted prices.
“Individual health programs are trying to navigate the crisis on their own, but when you see … growing demand and limited supply, it’s a role for federal intervention,” Raymond said.
He’d like to see the federal government step in to negotiate prices where smaller programs can’t.
The surgeon general’s message is one part of Washington’s broader response to the epidemic. But even as Congress crafts an opioid epidemic response package, it’s not clear it will tackle these concerns.
In the House of Representatives’ Energy and Commerce Committee, one bill being discussed would require all state Medicaid programs to cover at least one form of naloxone. Currently, not all state Medicaid programs do so.
A Senate bill would authorize $300 million annually to equip first responders with naloxone.
But critics say those approaches still don’t address the underlying problems: cost and funding.
“You can either make naloxone available, at a much discounted price, or we need to have a lot more resources in order to purchase it,” Wen said. “I don’t care which one. My only concern is the health and well-being of our residents.”
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
Federal court puts chill on Maryland drug price-gouging law
The 2-to-1 ruling April 13 by the U.S. 4th Circuit Court of Appeals invalidated a Maryland law meant to limit “price-gouging” by makers of generic drugs. The measure was inspired by cases such as that of former Turing Pharmaceutical CEO Martin Shkreli, who raised one generic’s price 5,000% after buying the company.
If dissatisfied with the company’s justification, the attorney general could have filed suit in state court. Manufacturers would have faced a fine of up to $10,000 and potentially have to reverse the price hike. The generics industry was fiercely critical of the law.
“We are evaluating all options with regard to next steps,” said Maryland Attorney General Brian Frosh in a statement. His office would not elaborate further.
The state could appeal to have the case heard “en banc,” meaning by the full 4th Circuit, with jurisdiction over five states.
Such appeals aren’t commonly granted, but this law could be a strong candidate, suggested Aaron S. Kesselheim, MD, an associate professor at Harvard Medical School, Boston, who researches drug-price regulation.
The April 13 ruling looms large as other state legislatures grapple with ever-climbing drug prices.
Similar price-gouging legislation has been introduced in at least 13 states this year, though none of those measures became law, according to the National Conference of State Legislatures (NCSL). Three other bills failed to gain passage.
The NCSL also cited the law in a March advisory for states seeking new approaches to regulating drug prices.
The court’s finding could have a chilling effect on such efforts, especially as more state legislatures wrap up business for 2018.
“A negative court ruling will put a damper or a pause on state activities,” said Richard Cauchi, NCSL’s health program director. “Unless this topic is your No. 1 priority of the year, your legislators are juggling multiple bills, multiple strategies. When bill three gets in trouble, they move to bill four.”
The appeals court held that Maryland’s law overstepped limits on how states can regulate commerce – specifically, a constitutional ban on states controlling business that takes place outside their borders. The majority ruling argues that, since most generics manufacturers and drug wholesalers engage in trade outside Maryland, the state cannot control what prices they charge.
In a dissenting opinion, the panel’s third judge argued Maryland can regulate the drug prices charged within the state since the law is meant to affect only medications being sold to its own residents.
Dr. Kesselheim argued similarly in a JAMA viewpoint (2018;319[9]:865-866).
Regardless, striking down a law on constitutional grounds can be particularly discouraging, suggested Rachel Sachs, an associate law professor at Washington University in St. Louis who researches drug regulations.
“If it had been a rejection on vagueness grounds, that’s something you can cure with a more specific statute,” she said. “But the fact that they said this is unconstitutional poses real concern for other states.”
That’s important. While the federal government has talked a big game on bringing down drug prices, it has done little. Instead, states have taken the lead – spurred by the budget squeeze pricey prescriptions impose on their Medicaid programs and on state employee benefits packages.
But states have far fewer tools at their disposal than does Congress. Most state laws so far tackle only pieces of the problem – targeting a specific drug or particular practice, experts said.
“We’ll get more broad and better evolution on this issue if the federal government decides to take it seriously – which it hasn’t so far,” Dr. Kesselheim said.
To be fair, Maryland’s law is only one of a bevy of approaches.
Other states have focused on price transparency laws. In California, drug companies must disclose in advance if a price might increase by more than a set percent and that they justify the increase. Industry has sued to block the California law.
New York has limited what the state will pay for drugs, establishing a process to review if expensive drugs are priced out of step with their medical value.
A number of states have since 2017 passed laws regulating pharmacy benefit managers – the contractors who negotiate discounted drug coverage for insurance plans, but who rarely reveal what level of discount they actually pass on to consumers.
Experts expect that activity to continue, especially as escalating drug prices show little sign of letting up.
“The states are going to keep trying and experimenting,” Ms. Sachs added. “This is a problem that isn’t going away.”
Even efforts such as Maryland’s – which targeted price-gouging – will likely remain at the forefront.
“I don’t think this is the end of states trying to do something on price gouging,” said Ellen Albritton, a senior policy analyst at the left-leaning advocacy group Families USA who consults with states on drug-pricing policy. “It’s such an issue that offends people’s sensibilities. It’s crazy people can do this.”
KHN’s coverage of prescription drug development, costs, and pricing is supported by the Laura and John Arnold Foundation. Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
The 2-to-1 ruling April 13 by the U.S. 4th Circuit Court of Appeals invalidated a Maryland law meant to limit “price-gouging” by makers of generic drugs. The measure was inspired by cases such as that of former Turing Pharmaceutical CEO Martin Shkreli, who raised one generic’s price 5,000% after buying the company.
If dissatisfied with the company’s justification, the attorney general could have filed suit in state court. Manufacturers would have faced a fine of up to $10,000 and potentially have to reverse the price hike. The generics industry was fiercely critical of the law.
“We are evaluating all options with regard to next steps,” said Maryland Attorney General Brian Frosh in a statement. His office would not elaborate further.
The state could appeal to have the case heard “en banc,” meaning by the full 4th Circuit, with jurisdiction over five states.
Such appeals aren’t commonly granted, but this law could be a strong candidate, suggested Aaron S. Kesselheim, MD, an associate professor at Harvard Medical School, Boston, who researches drug-price regulation.
The April 13 ruling looms large as other state legislatures grapple with ever-climbing drug prices.
Similar price-gouging legislation has been introduced in at least 13 states this year, though none of those measures became law, according to the National Conference of State Legislatures (NCSL). Three other bills failed to gain passage.
The NCSL also cited the law in a March advisory for states seeking new approaches to regulating drug prices.
The court’s finding could have a chilling effect on such efforts, especially as more state legislatures wrap up business for 2018.
“A negative court ruling will put a damper or a pause on state activities,” said Richard Cauchi, NCSL’s health program director. “Unless this topic is your No. 1 priority of the year, your legislators are juggling multiple bills, multiple strategies. When bill three gets in trouble, they move to bill four.”
The appeals court held that Maryland’s law overstepped limits on how states can regulate commerce – specifically, a constitutional ban on states controlling business that takes place outside their borders. The majority ruling argues that, since most generics manufacturers and drug wholesalers engage in trade outside Maryland, the state cannot control what prices they charge.
In a dissenting opinion, the panel’s third judge argued Maryland can regulate the drug prices charged within the state since the law is meant to affect only medications being sold to its own residents.
Dr. Kesselheim argued similarly in a JAMA viewpoint (2018;319[9]:865-866).
Regardless, striking down a law on constitutional grounds can be particularly discouraging, suggested Rachel Sachs, an associate law professor at Washington University in St. Louis who researches drug regulations.
“If it had been a rejection on vagueness grounds, that’s something you can cure with a more specific statute,” she said. “But the fact that they said this is unconstitutional poses real concern for other states.”
That’s important. While the federal government has talked a big game on bringing down drug prices, it has done little. Instead, states have taken the lead – spurred by the budget squeeze pricey prescriptions impose on their Medicaid programs and on state employee benefits packages.
But states have far fewer tools at their disposal than does Congress. Most state laws so far tackle only pieces of the problem – targeting a specific drug or particular practice, experts said.
“We’ll get more broad and better evolution on this issue if the federal government decides to take it seriously – which it hasn’t so far,” Dr. Kesselheim said.
To be fair, Maryland’s law is only one of a bevy of approaches.
Other states have focused on price transparency laws. In California, drug companies must disclose in advance if a price might increase by more than a set percent and that they justify the increase. Industry has sued to block the California law.
New York has limited what the state will pay for drugs, establishing a process to review if expensive drugs are priced out of step with their medical value.
A number of states have since 2017 passed laws regulating pharmacy benefit managers – the contractors who negotiate discounted drug coverage for insurance plans, but who rarely reveal what level of discount they actually pass on to consumers.
Experts expect that activity to continue, especially as escalating drug prices show little sign of letting up.
“The states are going to keep trying and experimenting,” Ms. Sachs added. “This is a problem that isn’t going away.”
Even efforts such as Maryland’s – which targeted price-gouging – will likely remain at the forefront.
“I don’t think this is the end of states trying to do something on price gouging,” said Ellen Albritton, a senior policy analyst at the left-leaning advocacy group Families USA who consults with states on drug-pricing policy. “It’s such an issue that offends people’s sensibilities. It’s crazy people can do this.”
KHN’s coverage of prescription drug development, costs, and pricing is supported by the Laura and John Arnold Foundation. Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
The 2-to-1 ruling April 13 by the U.S. 4th Circuit Court of Appeals invalidated a Maryland law meant to limit “price-gouging” by makers of generic drugs. The measure was inspired by cases such as that of former Turing Pharmaceutical CEO Martin Shkreli, who raised one generic’s price 5,000% after buying the company.
If dissatisfied with the company’s justification, the attorney general could have filed suit in state court. Manufacturers would have faced a fine of up to $10,000 and potentially have to reverse the price hike. The generics industry was fiercely critical of the law.
“We are evaluating all options with regard to next steps,” said Maryland Attorney General Brian Frosh in a statement. His office would not elaborate further.
The state could appeal to have the case heard “en banc,” meaning by the full 4th Circuit, with jurisdiction over five states.
Such appeals aren’t commonly granted, but this law could be a strong candidate, suggested Aaron S. Kesselheim, MD, an associate professor at Harvard Medical School, Boston, who researches drug-price regulation.
The April 13 ruling looms large as other state legislatures grapple with ever-climbing drug prices.
Similar price-gouging legislation has been introduced in at least 13 states this year, though none of those measures became law, according to the National Conference of State Legislatures (NCSL). Three other bills failed to gain passage.
The NCSL also cited the law in a March advisory for states seeking new approaches to regulating drug prices.
The court’s finding could have a chilling effect on such efforts, especially as more state legislatures wrap up business for 2018.
“A negative court ruling will put a damper or a pause on state activities,” said Richard Cauchi, NCSL’s health program director. “Unless this topic is your No. 1 priority of the year, your legislators are juggling multiple bills, multiple strategies. When bill three gets in trouble, they move to bill four.”
The appeals court held that Maryland’s law overstepped limits on how states can regulate commerce – specifically, a constitutional ban on states controlling business that takes place outside their borders. The majority ruling argues that, since most generics manufacturers and drug wholesalers engage in trade outside Maryland, the state cannot control what prices they charge.
In a dissenting opinion, the panel’s third judge argued Maryland can regulate the drug prices charged within the state since the law is meant to affect only medications being sold to its own residents.
Dr. Kesselheim argued similarly in a JAMA viewpoint (2018;319[9]:865-866).
Regardless, striking down a law on constitutional grounds can be particularly discouraging, suggested Rachel Sachs, an associate law professor at Washington University in St. Louis who researches drug regulations.
“If it had been a rejection on vagueness grounds, that’s something you can cure with a more specific statute,” she said. “But the fact that they said this is unconstitutional poses real concern for other states.”
That’s important. While the federal government has talked a big game on bringing down drug prices, it has done little. Instead, states have taken the lead – spurred by the budget squeeze pricey prescriptions impose on their Medicaid programs and on state employee benefits packages.
But states have far fewer tools at their disposal than does Congress. Most state laws so far tackle only pieces of the problem – targeting a specific drug or particular practice, experts said.
“We’ll get more broad and better evolution on this issue if the federal government decides to take it seriously – which it hasn’t so far,” Dr. Kesselheim said.
To be fair, Maryland’s law is only one of a bevy of approaches.
Other states have focused on price transparency laws. In California, drug companies must disclose in advance if a price might increase by more than a set percent and that they justify the increase. Industry has sued to block the California law.
New York has limited what the state will pay for drugs, establishing a process to review if expensive drugs are priced out of step with their medical value.
A number of states have since 2017 passed laws regulating pharmacy benefit managers – the contractors who negotiate discounted drug coverage for insurance plans, but who rarely reveal what level of discount they actually pass on to consumers.
Experts expect that activity to continue, especially as escalating drug prices show little sign of letting up.
“The states are going to keep trying and experimenting,” Ms. Sachs added. “This is a problem that isn’t going away.”
Even efforts such as Maryland’s – which targeted price-gouging – will likely remain at the forefront.
“I don’t think this is the end of states trying to do something on price gouging,” said Ellen Albritton, a senior policy analyst at the left-leaning advocacy group Families USA who consults with states on drug-pricing policy. “It’s such an issue that offends people’s sensibilities. It’s crazy people can do this.”
KHN’s coverage of prescription drug development, costs, and pricing is supported by the Laura and John Arnold Foundation. Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.