Posts Tagged 'Physicians for a National Health Plan'

Why Organized Labor Is Organizing Against Obamacare

This significant article shows a potential new source of support for winning Single-Payer healthcare: organized labor. Unions which had held back from embracing Single-Payer because they had their own health plans are now realizing that Obamacare does not just encourage employers to cut back full-time jobs to un-benefited part-time jobs. Obamacare also damages hard-won union-based health plans.

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Click to enlarge image.

The Fiscal Times, August 30, 2013

Why Organized Labor Is Organizing Against Obamacare
(Read this article on-line at http://tinyurl.com/pchnggr )

By ERIC PIANIN, The Fiscal Times

Now look who’s making a fuss about Obamacare.

President Obama has had his hands full fending off Republican assaults against Obamacare. Sen. Ted Cruz of Texas and a handful of other GOP lawmakers even favor shutting down the government, if necessary, to prevent the new law from fully taking effect.

But Obama is also getting blasted these days from an unexpected quarter: Major labor groups instrumental in helping the president win a critical second term are charging that Obamacare is undercutting existing union-sponsored health insurance programs and even encouraging employers to cut workers’ hours.

This is the latest bizarre wrinkle in the unfolding political drama over Obama’s signature program for extending health insurance coverage to millions of uninsured Americans.

Last month, leaders of three of the largest labor unions sent a scathing letter to Senate Majority Leader Harry Reid (D-NV) and House Minority Leader Nancy Pelosi (D-CA), warning that if the problems with the insurance program are not addressed, the new health care law will “shatter not only our hard-earned health benefits, but destroy the foundation of the 40-hour work week that is the backbone of the American middle class.”

The letter was written by James Hoffa, president of the International Brotherhood of Teamsters, Joseph Hansen, president of the United Food and Commercial Workers International Union, and Donald Taylor, president of UNITE-HERE, a union that represents hotel, airport and food service workers. It stressed the unions’ displeasure with a law they all had previously supported and helped to pass.

“When you and the president sought our support for the Affordable Care Act, you pledged that if we liked the health plans we have now, we could keep them. Sadly, that promise is under threat,” said the letter. “We have been strong supporters of you. In campaign after campaign we have put boots on the ground, gone door-to-door to get out the vote, run phone banks and raised money to secure this vision. Now this vision has come back to haunt us.”

AFL-CIO president Richard Trumka echoed those concerns Thursday, telling reporters during a breakfast event that the administration and Congress made some serious blunders in drafting the legislation that must be fixed to quiet the growing union discontent.

“We’ve been working with the administration to find solutions to what I think are inad-vertent holes in the act,” said Trumka. “When the act was put together, it wasn’t thought completely through. So we work on a daily basis. I’m hopeful we get something done in the very near future.”

PERVERSE INCENTIVE?

From labor’s perspective, arguably the biggest problem is that the law – when fully implemented – will create an incentive for employers to keep their workers’ hours below 30 hours a week.

The Affordable Care Act will eventually penalize firms employing 50 or more people that don’t offer health insurance – or that offer coverage below minimum standards. This is the so-called “employer mandate.” The White House this summer put that provision on hold until 2015 to give medium and large employers the opportunity to better prepare and plan for the changes and reporting requirements. But once that provision finally takes hold, union leaders say that companies will cut the hours of workers below 30 hours per week to get under the 50-worker threshold for providing health care coverage.

With salaries remaining relatively static during this tepid economic recovery, a cutback in hours would be tantamount to a substantial pay cut for many union and other workers who are struggling to make ends meet.

“Employers are trying to plan their future by creating a work force that gets 29-and-a-half hours or less a week, so that they don’t have to pay health care,” Trumka said yesterday. “That is obviously something that no one intended….Is that an issue? Yeah, that’s an issue.”

Labor leaders also fear that Obamacare may end up “destroying” the union’s multi-employer health plans unless it is changed.

At issue are “Taft-Hartley plans” – the non-profit health care plans long used by union-ized workers in the building trades and service industries and jointly administered by participating companies and unions. Those plans have traditionally allowed workers in transient industries to move between employers while still preserving the same quality of health care. Because union leaders have helped negotiate those plans, they typically offer strong coverage at a low out-of-pocket cost to workers.

Under the Affordable Care Act as currently interpreted by the administration, union members with this form of health insurance coverage would not be entitled to federal tax subsidies available to others who purchase policies from private companies in the new insurance exchange, according to labor leaders. Moreover, many union members who hold these “non-profit” policies may get hit with federal taxes to help offset the cost of the subsidies offered in the new state exchanges.

“Taken together, these restrictions will make non-profit plans like ours unsustainable, and will undermine the health-care market of viable alternatives to the big health insurance companies,” according to the letter sent to Reid and Pelosi by the labor chiefs.

The Treasury Department has signaled it views the Taft-Hartley plans as equivalent to other employer-based plans, which aren’t eligible for subsidies. And the Congressional Research Service, a nonprofit legislative analysis group, published a paper saying Taft-Hartley plans likely wouldn’t be eligible for subsidies based on the way the law is written.

The health care law is likely to be a prime topic of conversation when Obama addresses the AFL-CIO’s Quadrennial Convention next month in Los Angeles. Obama’s relations with labor have been rocky at times, for sure. Yet while he’ll talk about his plans to create jobs, provide better pay and strengthen workplace protections, the president’s speech on Sept. 9 may not include every reassuring word that labor leaders are right now longing to hear.

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Bipartisan plan to gut Medicare: Vouchers, Premium Support, and Competition

Bipartisan plan to gut Medicare: Vouchers, Premium Support, and Competition

Democrat Ron Weiden and Republican Paul Ryan are pushing a plan to send the Medicare we know into a death spiral.  Medicare would become voucher system, with recipients receiving checks based on the premiums of the second-cheapest Medicare-HMO in an area.  Annual voucher increases would be limited to Gross National Product  growth plus one percent, far less than the historical growth rates of Medicare costs.  Medicare’s premiums would be higher than HMOs premiums, because Medicare would be forced to accept sicker, more expensive patients, who would not survive under HMOs managed care.  Medicare recipients would have to pay the difference between Medicare’s higher premiums and the vouchers based on the 2nd-cheapest-HMO plan, out of their own pockets, which would steadily drive healthier patients out of Medicare.  Medicare would fall into a death spiral of higher premiums, fewer, sicker patients, and less funding.  This plan was also promoted in the 2003 Medicare Modernization Act.  See http://tinyurl.com/7enm8eo .

New York Times, December 14, 2011

Lawmakers Offer Bipartisan Plan to Overhaul Medicare

By ROBERT PEAR

WASHINGTON — A Democratic senator, Ron Wyden of Oregon, and a Republican member of the House, Paul D. Ryan of Wisconsin, unveiled a bipartisan plan on Wednesday to revamp Medicare and make a fixed federal contribution to the cost of coverage for each beneficiary.

The lawmakers aim to reshape the debate over the giant health insurance program by addressing concerns that have provoked fierce opposition to similar ideas in the past.

Just as important as the details of their proposal was the fact that the two were working together on an issue that both parties have exploited for political advantage.

In 2010, many Republicans won House seats — and the support of older voters — by arguing that President Obama’s health care law would damage Medicare. Democrats are hoping to retake the House by arguing that Mr. Ryan and other House Republicans are pushing for the privatization of Medicare, which they say could greatly increase costs for beneficiaries.

The new Wyden-Ryan proposal, by blurring the contrast between the parties on this issue, could make it more difficult for Democrats to win the argument.

The proposal would make major structural changes in Medicare and limit the government’s open-ended financial commitment to the program.

Under the proposal, known as premium support, Medicare would subsidize premiums charged by private insurers that care for beneficiaries under contract with the government.

Congress would establish an insurance exchange for Medicare beneficiaries. Private plans would compete with the traditional Medicare program and would have to provide benefits of the same or greater value. The federal contribution in each region would be based on the cost of the second-cheapest option, whether that was a private plan or traditional Medicare.

In addition, the growth of Medicare would be capped. In general, spending would not be allowed to increase more than the growth of the economy, plus one percentage point — a slower rate of increase than Medicare has historically experienced.

To stay under the limit, Congress could cut payments to providers and suppliers responsible for the overspending and could increase Medicare premiums for high-income beneficiaries, the lawmakers said.

The proposal is sure to come under fire from beneficiaries and Democratic lawmakers who see themselves as the pre-eminent defenders of Medicare.

For his part, Mr. Wyden said: “Medicare is the most important fiber in the social safety net. I would never do anything to shred it, weaken it or harm it in any way. Our proposal places traditional Medicare, long supported by progressives, alongside a menu of private alternatives that provide the choice and competition long supported by conservatives.”

Unlike the Ryan budget blueprint approved by the House in April, Mr. Ryan said, the new proposal would preserve the traditional fee-for-service Medicare program as an option for all beneficiaries. “Our proposal harnesses the power of competition to address the root cause of medical inflation,” said Mr. Ryan, the chairman of the House Budget Committee.

Democrats expressed concerns about the proposal based on policy and politics. A senior Democratic Congressional aide said, “This plan gives bipartisan political cover to Ryan and other Republicans against whom we have been waging a very successful political offensive.”

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“Everybody In! Nobody out!” Means No Exclusion of Undocumented Immigrants

Since its inception, Single-Payer healthcare’s most enduring rallying theme has been “Everybody In!  Nobody Out!”  This vision, which resonates with our most basic striving for equality, is being challenged now, as progressives and sections of labor rally behind Bernie Sanders’ new single-payer law, S.915, which contains the fatal flaw of excluding undocumented immigrants.  (Section 102, Universal Entitlement)  Single Payer has always been about EQUAL, comprehensive, accessible, affordable, economical healthcare for EVERYONE.  The damage the working class would suffer from passing this bill as is, and splitting us into “legal” and “not legal” groupings, would negate any advances that would be made by getting rid of  insurance companies.

I would like to present a resolution that was submitted to the American Public Health Association in response to the Obama Health Plan’s exclusion of undocumented immigrants.  In the year before the American Public Health Association (APHA) had its 2010 annual meeting on the theme of “Social Justice,” a massive health reform law had passed which totally excluded some 12 million undocumented immigrants. And while immigrants had been hoping for far-reaching reforms and a measure of long-delayed justice, harassment and deportation of undocumented immigrants had markedly increased.  In response, members of the Health-Not-War group at APHA proposed the following resolution to send an unequivocal message that this is intolerable to us as human beings and as public health workers.

Opposing the Exclusion of Undocumented Immigrants from Health Care Reform

November 5, 2010

The American Public Health Association,

Noting that this March, 2010, Congress passed and the President signed a massive Patient Protection and Affordable Care Act (PPACA), which not only leaves at least 23 million uninsured1, but explicitly excludes ALL undocumented immigrants,1 and,

Noting that the PPACA even forbids undocumented immigrants from using their own money to buy health insurance at discounted prices through the exchanges,2 and,

Noting that, of all groups, undocumented immigrants have arguably the greatest need of having healthcare expanded to them because:

FIRST: Undocumented immigrants are twice as likely to be uninsured as documented immigrants,3 and,

SECOND: Undocumented immigrants are generally excluded from Medicaid and SCHIP by federal law, and state-funded exceptions to this pattern will become rarer as state budgets languish. Moreover, most undocumented immigrants must wait five years after gaining legal residency to apply for Medicaid and SCHIP.4

THIRD: Undocumented immigrants’ future access to healthcare will be more challenging because  (1) increasing raids5 and deportations6, Arizona’s SB 10707, and the Secure Communities Initiative8 are likely to make undocumented immigrants more fearful of registering at health facilities and traveling to them, (2) State and County budget cuts are eliminating health services for  undocumented immigrants9, (3) Anti-immigrant groups are pressing jurisdictions to withdraw health services from undocumented immigrants10, and (4) Legislators are considering withdrawing citizenship from US-born children of undocumented immigrants, compromising their children’s access to healthcare as well as overturning a 150-year old constitutional right,11 and,

FOURTH:  Many of the factors contributing to poor access to healthcare for immigrants in general are worse for undocumented immigrants, such as immigrants’ fears of presenting at health institutions, immigrants’ increasing unemployment rates combined with the higher cost of buying individual insurance, and health institutions’ fear of losing funding for treating immigrants.   Even among the insured, immigrants’ and their children’s access to ambulatory and emergency care is worse than that of citizens,12 and,

FIFTH: Future funds for hospitalization of the uninsured, including undocumented immigrants, will be reduced, as PPACA reduces Medicare and Medicaid Disproportionate Share Hospital payments to hospitals serving the uninsured. Though these hospitals’ burden of uninsured will drop over time, PPACA specifies DSH payments must drop faster13, and Center for Medicare & Medicaid Services Chief Actuary estimated that the combined reductions at $64 billion over ten years.14

SIXTH: Reducing undocumented immigrants’ already poor access to healthcare is particularly dangerous and morally indefensible in light of their increased rates of injury, illness15, and death16 from hazardous  occupations17 and housing18, compounded with their vulnerability to deportation if they report dangerous conditions or seek treatment.

Noting that measures taken to deny healthcare to undocumented immigrants often result in citizens losing healthcare also, as exemplified by the 2004 cancellation of Colorado’s Presumptive (Medicaid) Eligibility program, which had allowed pregnant women to receive prenatal care while their Medicaid applications were being processed. The entire program was eliminated because about half of the women were found to be ineligible by immigration status. Citizen and immigrant women alike were put at risk, as well as their unborn children.19

Noting that  APHA has taken a clear positions against withholding medical care from undocumented immigrants in its resolution 2001-23, which “Urges the President and the Congress to oppose denial of eligibility for programs providing nutritional, prenatal, public health, medical care, and behavioral health benefits and services to any person residing in the United States on the basis of her or his immigration status”;20  its resolution 9501, which “Opposes any mandates and initiatives that would limit access to public health interventions and health services for undocumented and documented immigrants and their children;”21 and its resolution LB04-07, which “Deplores and warns against measures curtailing, eliminating, or disrupting health care to undocumented immigrants.”22

And finally, noting that the recent passage of this massive Health Reform law that explicitly and categorically excludes the grossly underserved undocumented immigrant population presents public health advocates with a grave challenge,

Therefore, the American Public Health Association

1.  Calls on the President, and Congress to end the exclusion of healthcare for undocumented immigrants from Health Reform, and

2.  Calls on the President and Congress to support health reform that provides equal, comprehensive, affordable, accessible healthcare for every person, regardless of their status of health, employment, income, or legalization,  and

3.  Calls on the President and Congress to assure that community health centers receiving $11 billion of dollars of federal aid over the next five years through the PPACA23 continue to give undocumented immigrants comprehensive health care, and

4.  Encourages public health advocates to attend future events on immigration reform (public rallies, demonstrations, press conferences and the like) with the demand of comprehensive, affordable, accessible medical care for all immigrants, regardless of legalization status.

References:

1.  Kaiser Health News. Some Will Remain Uninsured After Reform. Available at: http://www.kaiserhealthnews.org/Stories/2010/March/24/Some-Will-Remain-Uninsured.aspx.   Accessed October 3, 2010.

2.  Lewin Group.  Patient Protection and Affordable Care Act (PPACA): Long Term Costs for Governments, Employers, Families and Providers.   Available at: http://www.lewin.com/content/publications/LewinGroupAnalysis-PatientProtectionandAffordableCareAct2010.pdf.  p. 22.  Accessed October 3, 2010.

3.    Pew Hispanic Center.  Hispanics, Health Insurance and Health Care Access.   Available at: http://pewresearch.org/pubs/1356/hispanics-health-insurance-health-care-access.  Accessed October 3, 2010.

Working Immigrants.  Health uninsured rates among immigrants: far higher.  Available at: http://www.workingimmigrants.com/2009/08/health_uninsured_rates_among_i.html.  Accessed October 3, 2010.

4.   Kaiser Commission on Medicaid and the Uninsured,  Summary: Five Basic Facts on Immigrants and Their Health Care.   Available at: http://www.kff.org/medicaid/upload/7761.pdf.  Accessed October 3, 2010.

5.   Coalicion de Derechos Humanos.  Massive ICE sweep terrorizes Arizona communities following state passage of anti-immigrant profiling law.   Available at: http://www.derechoshumanosaz.net/index.php?option=com_content&task=view&id=166&Itemid=1.  Accessed October 3, 2010.

6.   Common Dreams.  Obama Administration Immigration Deportations Exceed Bush’s Record.   Available at: http://www.commondreams.org/print/56327.  Accessed October 3, 2010.

7.   Arizona Daily Star, National Physician Groups Condemn Arizona SB 1070.  Available at: http://azstarnet.com/news/blogs/health/article_ca3a8c46-62c6-11df-9a0a-001cc4c002e0.html.  Accessed November 3, 2010.

8.   San Francisco Immigrant Legal and Education Network.   San Francisco Immigrant Legal And Education Network Opposes The Implementation Of The Dangerous Secure Communities Program In San Francisco.   Available at: http://www.sfimmigrantnetwork.org/comments/sfilen_opposes_implementation_of_secure_communities_program_in_san_francisc, Accessed October 3, 2010.

9.   New York Times.  Reprieve Eases Medical Crisis for Illegal Immigrants.   Available at: http://www.nytimes.com/2010/01/06/us/06grady.html.  Accessed October 3, 2010.

Kaiser Daily Health Policy Report.  Economic Recession Forcing Local Health Departments To Reduce Services to Undocumented Immigrants.   Available at: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=57497.  Accessed October 3, 2010.

New York Times,   Immigrants Facing Deportation by U.S. Hospitals.   Available at: http://www.nytimes.com/2008/08/03/us/03deport.html?_r=1&hp=&pagewanted=all.  Accessed October 3, 2010.

10.   Washington Independent.   Anti-Immigration Activists See Opportunity in Health Care Debate.  Available at: http://washingtonindependent.com/55044/anti-immigration-activists-see-opportunity-in-health-care-debate.   Accessed October 3, 2010.

11.   Newsweek Magazine.  The Next Front on Immigration.   Available at: http://www.newsweek.com/2010/08/01/the-next-front-on-immigration.html.  Accessed October 3, 2010.

Politico.  John McCain backs citizenship hearings.  Available at: http://www.politico.com/news/stories/0810/40589.html.  Accessed October 3, 2010.

12.   Health Affairs.  Left Out: Immigrants’ Access to Health Care and Insurance January/February 2001.   Available at: http://www.projectshine.org/files/shared_images/Left_Out.pdf ,   Accessed October 20, 2010.

13.   The Hospital & Healthcare Association of Pennsylvania.  The Patient Protection and Affordable Care Act

(PPACA) of 2010 and the Health Care and Education Affordability Reconciliation Act (HCEARA) of 2010. Available at: http://www.haponline.org/downloads/HAP_Summary_2010_PPACA_HCEARA_April2010.pdf.  Accessed November 4, 2010.

14.  Centers for Medicare & Medicaid Services. Estimated Financial Effects of the “Patient Protection and Affordable Care Act,” as Amended.  Available at https://www.cms.gov/ActuarialStudies/Downloads/PPACA_2010-04-22.pdf.  Accessed November 4, 2010.

15.  Moure-Eraso R,  Friedman-Jimenez G.  (2004) Occupational health among Latino workers: a needs assessment and recommended interventions.  New Solutions. 14/4:319-47.  Available at: http://www.nap.edu/openbook.php?record_id=10641&page=129.  Accessed November 4, 2010.

16.   Richardson, S. Fatal work injuries among foreign-born Hispanic Workers. Monthly Labor Review, October, 2005.   Available at:  http://www.bls.gov/opub/mlr/2005/10/ressum.pdf.   Accessed on November 4, 2010.

17.   APHA Policy Statement 2005-4: Occupational Health and Safety Protections for Immigrant Workers.  December 14, 2005.  Especially see Richardson S, Ruser J, Suarez P. Hispanic Workers in the United States: An Analysis of Employment Distributions, Fatal Occupational Injuries, and Non-fatal Occupational Injuries and Illnesses in National Research Council: Safety is Seguridad. Washington, D.C., National Academies Press, 2003.  Available at: http://www.nap.edu/openbook.php?record_id=10641&page=48  and http://www.nap.edu/openbook.php?record_id=10641&page=57.  Accessed November 4, 2010.

18.   Robert Wood Johnson Foundation.  Living in America: Challenges Facing New Immigrants and Refugees.  Available at: http://www.rwjf.org/files/publications/other/Immigration_Report.pdf.  Accessed November 4, 2010.

19.   Wall Street Journal.   Prenatal Care Is Latest State Cut In Services for Illegal Immigrants.   Available at: http://www.uniset.ca/naty/maternity/wsj_imm_med.htm.  Accessed October 3, 2010.

20.   APHA Policy Statement 2001-23: Protection of the Health of Resident Immigrants in the United States.  Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=262.   Accessed October 3, 2010.

21.   APHA Policy Statement 9501: Opposition To Anti-Immigrant Statutes.   Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=96.   Accessed October3, 2010.

22.   APHA Policy Statement LB04-07: Responding to Threats to Health Care for Immigrants.  November 9, 2004.

23.   PPACA Health Care Reform Timeline.   Available at: http://stabenow.senate.gov/healthcare/Health_Care_Timeline.pdf.  Accessed October 3, 2010.

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Obama shields states cutting Medicaid doctor payments

Bipartisan attack on Medicaid, healthcare for low-income children, seniors and workers.
  • The GOP’s justly-hated Ryan Plan puts states’ Medicaid programs on an ice floe, because it caps federal payments to states regardless of states’ needs (“block-granting”), and also gives states the rights to cut their Medicaid programs in defiance of federal standards of of who must be eligible and what services must be covered. 
  • But Democrats have also attacked Medicaid, beginning with the Clinton administration, which granted states huge numbers of waivers to the federal requirements.  Now the Obama administration is shielding states that are cutting their Medicaid programs by saying Medicaid patients and doctors cannot sue states for reducing doctor payments, even if such cuts cause a reduction in the number of doctors serving Medicaid patients to the point where patients cannot access care.
  • California has among the lowest Medicaid payments to doctors and pharmacies in the nation, and among lowest Medicaid doctor-to-patient ratios in the country.  Doctors, pharmacies, and patient advocates, including San Francisco and Sacramento Gray Panthers, sued California in response to Schwarzenegger’s 10% cuts to Medi-Cal.  Brown’s budget includes and additional 10% cut.  The suit has worked its way up to the Supreme Court, and it is this context that the Obama administration has submitted a brief saying states cannot be sued for cutting their Medicaid programs.
  • Democrats and Republicans are unified in their determination to cut our programs.  Medicare and Medicaid were won in the in the streets in the 1960s, and that is where they must be defended now.

By Robert Pear

WASHINGTON — Medicaid recipients and health care providers cannot sue state officials to challenge cuts in Medicaid payments, even if such cuts compromise access to health care for poor people, the Obama administration has told the Supreme Court.

States around the country, faced with severe budget problems, have been reducing Medicaid rates for doctors, dentists, hospitals, pharmacies, nursing homes and other providers.

Federal law says Medicaid rates must be “sufficient to enlist enough providers” so that Medicaid recipients have access to care to the same extent as the general population in an area.

In a friend-of-the court brief filed Thursday in the Supreme Court, the Justice Department said that no federal law allowed private individuals to sue states to enforce this standard.

Such lawsuits “would not be compatible” with the means of enforcement envisioned by Congress, which relies on the secretary of health and human services to make sure states comply, the administration said in the brief, by the acting solicitor general, Neal K. Katyal.

In many parts of the country, payment rates are so low that Medicaid recipients have difficulty finding doctors to take them.

But, the Justice Department said, the Medicaid law’s promise of equal access to care is “broad and nonspecific,” and federal health officials are better equipped than judges to balance that goal with other policy objectives, like holding down costs.

The administration expressed its views in a set of cases consolidated under the name Douglas v. Independent Living Center of Southern California, No. 09-958.

In 2008 and 2009, the California Legislature passed several laws reducing Medicaid payment rates. Recipients and providers challenged the cuts in court, arguing that the California plan violated — and was pre-empted by — the federal Medicaid statute.

The law does not explicitly allow such lawsuits. But the United States Court of Appeals for the Ninth Circuit, in San Francisco, said beneficiaries and providers could sue under the supremacy clause of the Constitution, which makes federal law “the supreme law of the land.” In reducing payment rates, the appeals court said, California violated the requirements of federal Medicaid law and threatened access to “much-needed medical care.”

California appealed to the Supreme Court, which is likely to hear oral arguments in the fall, with a decision by next spring.

Consumer advocates were dismayed by the administration’s position, which they said undermined Medicaid recipients’ rights and access to the courts.

“I find it appalling that the solicitor general in a Democratic administration would assert in a Supreme Court brief that businesses can challenge state regulation under the supremacy clause, but that poor recipients of Medicaid cannot challenge state violations of federal law,” said Prof. Timothy S. Jost, an expert on health law at Washington and Lee University, who is usually sympathetic to the administration.

Representative Henry A. Waxman of California, the senior Democrat on the Energy and Commerce Committee and an architect of Medicaid, said the administration’s brief was “wrong on the law and bad policy.”

“I am bitterly disappointed that President Obama would accept the position of the acting solicitor general to file a brief that is contrary to the decades-long practice of giving Medicaid beneficiaries and providers the ability to turn to the courts to enforce their rights under federal law,” Mr. Waxman said. He said that he and other Democratic lawmakers planned to file a brief opposing the administration’s view.

By contrast, many state officials agree with California and the Obama administration.

The National Governors Association and the National Conference of State Legislatures filed a friend-of-the-court brief endorsing California’s position that Medicaid recipients and providers could not sue.

In a separate friend-of-the-court brief, Michigan and 30 other states went further. “Allowing ‘supremacy clause lawsuits’ to enforce federal Medicaid laws will be a financial catastrophe for states,” they said.

Medicaid is financed jointly by the federal government and the states. The number of recipients and the costs increased sharply in the recent recession and will increase further with the expected addition of 16 million people to the rolls under the new federal health care law.

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Shortages of key drugs endanger patients. Free market to blame.

“Doctors, hospitals and federal regulators are struggling to cope with an unprecedented surge in drug shortages in the United States that is endangering cancer patients, heart attack victims, accident survivors and a host of other ill people.”  … The causes vary from drug to drug, but experts cite a confluence of factors: Consolidation in the pharmaceutical industry has left only a few manufacturers for many older, less profitable products, meaning that when raw material runs short, equipment breaks down or government regulators crack down, the snags can quickly spiral into shortages.”

This is a perfect illustration of why the research, development, ownership and production of medicines must not be left in the hands of private businesses.  Drugs must be researched and produced according to our needs, not profit opportunities. Private companies must not be allowed to own patents on drugs. Despite spectacular advances in research techniques, companies’ profit-driven research has produced few significant advances.  It is virtually impossible to oversee private manufacture of medicines, and companies regard fines in response to tragic “accidents” as a cost of doing business.

Washington Post, Sunday, May 1, 2011

Shortages of key drugs endanger patients

By Rob Stein

Doctors, hospitals and federal regulators are struggling to cope with an unprecedented surge in drug shortages in the United States that is endangering cancer patients, heart attack victims, accident survivors and a host of other ill people.

A record 211 medications became scarce in 2010 — triple the number in 2006 — and at least 89 new shortages have been recorded through the end of March, putting the nation on track for far more scarcities.

The paucities are forcing some medical centers to ration drugs — including one urgently needed by leukemia patients — postpone surgeries and other care, and scramble for substitutes, often resorting to alternatives that may be less effective, have more side effects and boost the risk for overdoses and other sometimes-fatal errors.

“It’s a crisis,” said Erin R. Fox, manager of the drug information service at the University of Utah, who monitors drug shortages for the American Society of Health-System Pharmacists. “Patients are at risk.”

The causes vary from drug to drug, but experts cite a confluence of factors: Consolidation in the pharmaceutical industry has left only a few manufacturers for many older, less profitable products, meaning that when raw material runs short, equipment breaks down or government regulators crack down, the snags can quickly spiral into shortages.

“It seems like there were a lot of things happening with consolidations and quality issues and more things coming from overseas,” said Allen J. Vaida, executive director of the Institute for Safe Medicine Practices, a nonprofit group that helped organize a conference last fall to examine the issue. “It just reached a point where the number of shortages was slowly going up and up, and now we have a national crisis with this huge shortage of critical medications.”

While the dearth that has garnered the most public attention is — ironically — for a barbiturate that is hindering prisons trying to execute inmates, the scarcities are having a much broader impact on keeping people alive, especially in emergency rooms, oncology wards and intensive care units.

No one is systematically tracking the toll of the shortages, but reports are emerging of delayed treatments, anxious searches for desperately needed drugs, devastating injuries from mistakes and less-adequate drugs, and even possible deaths.

Federal regulators have been rushing to alleviate the shortages, sometimes helping firms resume production more quickly or approving emergency imports of supplies from overseas.

The Food and Drug Administration eased a shortage of the anesthetic propofol last year by allowing foreign importation, for example, and this year approved bringing in several other medications, including two cancer drugs.

“The types of products we’re seeing shortages of are really concerning,” said Valerie Jensen, who heads the FDA’s Drug Shortages Program. “This is affecting oncology drugs, critical-care drugs, emergency medicine drugs. We’re doing everything we can under our current authority to try to deal with this situation.”

In Congress, legislation has been introduced to address the problem. For example, a bill would require companies to notify the FDA in advance about anything that might cause a shortage and give the agency new powers to try to assuage them.

“We can’t put patients’ lives at risk simply because there’s some snafus in a process or a manufacturer decides it’s less profitable to make a certain drug,” said Sen. Amy Klobuchar (D-Minn.). “Patients deserve better than that.”

‘Very global supply chain’

Many of the shortages involve older, cheaper generic medications that are less profitable, causing many firms to stop producing them and leaving fewer sources. Most involve “sterile injectable” medications that are more complicated to produce and therefore are more prone to manufacturing problems.

In addition, drug companies increasingly rely on raw materials from other countries.

“We’ve certainly reached a very global supply chain for drug products, with the active ingredients typically made outside of the United States,” said Gordon Johnston, vice president for regulatory sciences at the Generic Pharmaceutical Association. “It could be Europe, India — some cases China. If there’s a problem at a facility in Italy or India, it leads to disruption of the drug supply in the United States.”

Some industry representatives blame part of the problem on increased oversight by the FDA, which has made drug safety a higher priority after coming under intense criticism for being too lax.

“As you know right now, FDA has taken a heightened approach towards drug safety,” said Maya Bermingham, senior assistant general counsel at the Pharmaceutical Research and Manufacturers of America. “FDA has stepped up inspections. The more you look, the more you may discover problems.”

While acknowledging that the industry needs to do a better job of coordination, some company officials said the agency should coordinate enforcement actions and drug shortage issues more closely to avoid administrative requirements that cause interruptions.

“We’re not sure how much of that is going on recently because we’ve seen more and more shortages in the industry. We think that maybe some of those coordination issues can be worked on,” said Joshua Gordon, vice president and general manager of specialty pharmaceuticals at Hospira, the largest producer of specialty generic sterile injectables.

Shortages of pre-loaded epinephrine syringes and propofol, for example, occurred when suppliers dropped out just as the FDA was demanding additional documentation, he said.

“They are very focused on taking quick and and aggressive action,” Gordon said. “We applaud the agency’s role in assuring quality, but it can slow things down significantly.”

FDA officials dispute that greater government oversight is a major factor, saying manufacturing problems were the cause of most shortages.

“There has not been a significant increase in domestic enforcement actions (seizure or injunction) for this class of products in recent years,” Jensen wrote in an e-mail.

‘Too many . . . will die’

Whatever the causes, many of the affected drugs are mainstays of medical care, such as the potent painkiller morphine, norepinephrine, which is commonly used in emergency rooms, and electrolytes, which are often given to patients in intensive care.

But shortages have been reported in many categories of drugs, including antibiotics, and drugs central to the treatment of many cancers, forcing oncologists to delay or alter carefully timed chemotherapy regimens.

“We have heard some horror stories where patients are really begging to get the drugs from other sources and where practices or institutions are forced to kind of triage patients and save the drugs for those — quote — most curable, where they have the best prognosis and using substitutes where there isn’t a cure possibility,” Michael Link, president-elect of the American Society of Clinical Oncology.

The drug cytarabine has caused the most concern and gotten the most attention because it is highly effective for treating several forms of leukemia and lymphoma but must be administered as quickly as possible, especially to patients with acute myeloid leukemia.

“With this drug they can be cured and without this drug too many of them will certainly die. That’s the simplest way to put it,” said Deborah Banker, vice president for research communication at the Leukemia & Lymphoma Society. “The disease progresses so rapidly that untreated patients can sadly die within days. There is no time for delay and no certainty of a good outcome if you can’t get a full dose.”

Many hospitals are running low, and some have run out completely. That has required many facilities to ration the drug, giving priority to those who need it most urgently.

“It’s so unbelievable,” said Mary Collins, 57, of La Crosse, Wis., whose husband, Michael, 66, had problems obtaining cytarabine to fight lymphoma. “A cancer diagnosis is a long, very, very stressful circumstance. And then to learn that a particular drug is no longer available to you and that there seems to be no formalized mechanism in place to correct it just makes it worse.”

Cytarabine’s scarcity was caused by hitches that two out of the three manufacturers hit in obtaining raw materials, as well as the discovery of crystals in some shipments.

The third manufacturer was unable to make up for the shortfall. Some of the problems have been resolved, however, and the FDA is working on importing the drug.

The shortages are forcing hospital pharmacists to juggle supplies and hunt for new sources. Many hospitals, including several contacted in the Washington area, say they are usually able to patch together solutions.

But some resort to paying inflated prices or buying from unfamiliar suppliers, increasing the risk they may be getting counterfeits.

“When it becomes clear that some drug may be in short supply or going into a shortage, what happens is sometimes there are unsavory folks — small distributors — who buy up whatever is left and sell it back at exorbitant prices,” said Roslyne Shulman, director of policy development for the American Hospital Association.

‘Panic in the pharmacy’

When shortages occur, physicians turn to less optimal alternatives or find out too late that the drug they need is unavailable. Mark Warner, president of the American Society of Anesthesiologists, described two calamities that occurred in the past year because of shortages. In one, a 16-year-old boy suffered brain damage because doctors did not have one muscle relaxer needed to treat a complication from jaw surgery.

In another, a middle-aged woman was left in a permanent vegetative state because doctors did not have the drug epinephrine after she experienced complications from heart surgery.

“These are tragic cases,” Warner said. “It’s one of those things most anesthesiologists in the country think about when they are driving to work every day. We don’t know where the shortages are and they come on very quickly. ”

Nurses and doctors responding to emergencies, meanwhile, are losing precious minutes when they must work with unfamiliar substitutes or recalculate dosages, increasing the chances of overdosing or under-dosing patients. One of the biggest problems is a shortage of syringes pre-filled with precisely measured doses.

“Grabbing the right medication out of a crash cart that’s already in a syringe is a big advantage over having to get out the syringe, get out the needle, get the medication and get the measurement right,” said Angela Gardner, an emergency medicine physician at the University of Texas Southwestern Medical Center in Dallas and immediate past president of the American College of Emergency Physicians. “Those minutes are lives.”

Many hospitals are recalibrating electronic medication delivery systems or preparing the correct doses ahead of time, especially for the emergency room, to minimize mistakes.

“We’ve been extremely fortunate using strategies in cooperation with our medical staff,” said Jay Barbaccia, head pharmacist at the Washington Hospital Center. “We’ve had a lot of panic and inconvenience but minimal, if any, impact on our ability to provide care. It makes my life miserable — the panic is in the pharmacy when we’re scrambling around to find alternatives.”

Nevertheless, a long list of errors and near-misses have been reported, including incidents in which patients required emergency care to save them.

At least two patients reportedly died from overdoses of hydromorphone they received because of a morphine shortage.

At least 19 patients were sickened and nine died in Alabama this year after being infused with a solution through their feeding tubes that was apparently contaminated with bacteria by a pharmacy using an unfamiliar ingredient because of a shortage.

The shortage occurred because the manufacturer had trouble getting the product’s packaging.

“It’s horrible. It’s something that shouldn’t have happened,” said Donald J. Mottern of Alabaster, Ala., whose 71-year-old mother was one of the victims. “We lost the matriarch of our family. The loss to our family has left each of us very hollow.”

© 2011 The Washington Post Company

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Health Reform may not be able to cover the uninsurables

The Hill, July 1, 2010

Health law risks turning away sick
By Julian Pecquet – 07/01/10 07:13 PM ET

The Obama administration has not ruled out turning sick people away from an insurance program created by the new healthcare law to provide coverage for the uninsured.

Critics of the $5 billion high-risk pool program insist it will run out of money before Jan. 1, 2014. That’s when the program sunsets and health plans can no longer discriminate against people with pre-existing conditions.

Administration officials insist they can make changes to the program to ensure it lasts until 2014, and that it may not have to turn away sick people. Officials said the administration could also consider reducing benefits under the program, or redistributing funds between state pools. But they acknowledged turning some people away was also a possibility.

“There’s a certain amount of money authorized in the statute, and we will do our best to make sure that that amount of money insures as many people as possible and does as much good as possible,” said Jay Angoff, director of the Office of Consumer Information and Insurance Oversight at the Department of Health and Human Services (HHS). “I think it’s premature to say [what happens] when it’s gone.”

The administration has not discussed asking Congress for more money down the line if the $5 billion runs out before Jan. 1, 2014. Uninsured sick people could start applying for participation in the high-risk insurance pools on Thursday.

Healthcare experts of all stripes warned during the healthcare debate that $5 billion would likely not last until 2014. Millions of Americans cannot find affordable healthcare because of their pre-existing conditions, and that amount would only cover a couple hundred thousand people, according to a recent study by the chief Medicare actuary.

Republicans continued to hammer that point on Thursday, asking HHS officials to brief them about the program.

We are “deeply concerned that these pools may not provide quality coverage or will limit enrollment,” Reps. Joe Barton (R-Texas), John Shimkus (R-Ill.) and Michael Burgess (R-Texas), the ranking members on the Energy and Commerce panel and its health and oversight subcommittees, wrote in a letter to HHS Secretary Kathleen Sebelius.

The letter requests a briefing on high-risk pools by July 15, particularly on three topics: protections and services in place “to make sure that access is efficient and unimpeded; whether HHS believes the program is financially sustainable through 2013; and details about how each state’s pool will be administered and what options they’ll have available.”

Leading health reform advocate Ron Pollack, founding executive director of Families USA, said the pools were a “very imperfect tool that could be implemented quickly” but were the best option available for the interim period before 2014.

“The pools are going to be helpful for a significant number of people,” he told The Hill, “but nobody thought they’re the ultimate answer for helping people with pre-existing conditions.”

Still, he didn’t rule out that Families USA could press lawmakers to allocate more money in a few years if it looks like the program needs it.

Each state has a certain budget allocation for its pool, and the first step to stay under budget would be to shift money around between states that don’t see a lot of applicants and those that do, said Richard Popper, deputy director of the Office of Consumer Information and Insurance Oversight at HHS.

“If we have that situation where we have strong demand in one state and not as strong demand in another state, the secretary of HHS after a year or two has the authority to reallocate the funding,” said Popper, who used to run Maryland’s high-risk pool.

“Along with that, we can work with the states to adjust their benefit structure, the deductibles, the co-pays, the overall plan structure to address some of those cost drivers, again to help the plan make it to 2014, when it will no longer be needed.”

In addition, Popper said, many people won’t be able to afford to participate in the program since premiums will range between about $140 and $900 a month, depending on applicants’ age and where they live. HHS estimates that at least 200,000 people will be in the program at any one time. To be eligible, applicants have to be citizens or nationals of the United States or be lawfully present; have a pre-existing medical condition; and have been uninsured for at least six months before applying for the high-risk pool plan.

“There are going to be meaningful premiums that are going to be required to stay in this plan — premiums in the hundreds of dollars every month,” Popper said. “There are a significant number of people out there with pre-existing conditions who are uninsured, but a significant number of those people … also have limited income. And some of them, while they may need this plan, the premiums may not be something they can afford.

“We have that to think about as well,” he added. “But for those who can afford it, this is going to be a great, great plan.”

If it looks like too many people are signing up — states will get monthly updates on how many people they can cover with the money they have left — there’s always the option of turning people down.

The bill “does give the secretary authority to limit enrollment in the plan … nationally or on a state-by-state basis,” Popper said. “So that is present, but at this point, we’re starting with no one in the plan as of today … so we don’t see that happening anytime soon.”

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British Medical Journal: ‘Obama’s reform: no cure for what ails us’

British Medical Journal, March 30, 2010

Obama’s reform: no cure for what ails us

By David U. Himmelstein and Steffie Woolhandler

British Medical Journal, March 30, 2010

As the applause fades for President Obama’s health reform, David Himmelstein and Steffie Woolhandler fear that the new law will simply pump funds into a dysfunctional, market driven system

It was a stirring scene: President Obama signing the new health reform law before a cheering crowd, and a beaming vice president whispering in his ear, “This is a big f*cking deal.” As doctors who have labored for universal health care we’d like to join the celebration, but we can’t. Morphine has been dispensed for the treatment of cancer – the reform may offer a bit of temporary relief, but it is certainly no cure.

The new law will pump additional funds into the currently dysfunctional, market driven system, pushing up health costs that are already twice those in most other wealthy nations. The Medicaid public insurance program for poor people will expand to cover an additional 16 million poor Americans, while a similar number of uninsured people with higher incomes will be forced to buy private policies. For the “near poor” the government will pay part of these private premiums, channeling $447 billion in taxpayer funds to private insurers over the next decade.

Unfortunately, private insurers win in the marketplace not through efficiency or quality but by maximizing revenues from premiums while minimizing outlays. They pursue this goal by avoiding the sick and forcing doctors and patients to navigate a byzantine payment bureaucracy that currently consumes 31 percent of total health spending. The health reform bill’s requirement that uninsured people buy insurers’ defective products will fortify these firms financially and politically.

Meanwhile insurers will exploit loopholes to dodge the law’s restrictions on their misbehaviors. For instance, the limit on administrative overheads will predictably elicit accounting gimmickry, for example by relabeling some insurance personnel as “clinical care managers.” While insurers are prohibited from “cherry picking” – selectively enrolling healthy, profitable patients – they’ve circumvented similar prohibitions in the Medicare health maintenance organizations (HMOs). The ban on revoking policies after an individual falls ill similarly replicates existing but ineffective state bans.

Sadly, even if the reform works as planned, 23 million people will remain uninsured in 2019. Meanwhile the public and other safety net hospitals that uninsured people rely on will have to endure a $36 billion cut in federal government funding.

Moreover, many Americans will be left with coverage so skimpy that a serious illness could lead to financial ruin. At present, illness and medical bills contribute to 62 percent of all bankruptcies, with three-quarters of the medically bankrupt being insured. The reform does little to upgrade this inadequate coverage; it mandates that private policies need cover only 70 percent of expected medical costs. The president has often promised that “if you like your current coverage you can keep it.” Yet Americans who now get job based insurance will be required to keep it – whether they like it or not. And many who receive full coverage from an employer will face a steep tax on their health benefits from 2018.

Soaring costs and rising financial strains seem inevitable, despite claims that the reform will “bend the cost curve.” Computer vendors have trumpeted imminent cost savings for half a century (see, for instance, a video made by IBM in the 1960s, available at http://bit.ly/cckdtB). Prevention, though laudable, does not generally reduce costs. Windfalls from prosecuting fraud and abuse have been promised before. The new Medicare advisory board merely tweaks an existing panel. Without an enforcement mechanism, stepping up comparative effectiveness research cannot overcome drug and equipment makers’ promotion of profligate care. Existing insurance exchanges where patients can compare and shop among private plans haven’t slowed growth in costs for public workers nationally or in California. And the mandated experiments with capitated payment systems are warmed-over versions of President Nixon’s pro-HMO policies and subsequent failed initiatives to fix America’s health cost crisis through managed care.

Experience with reforms in Massachusetts in 2006 – the template for the national bill – is is instructive. Our state’s costs, already the highest of any state, grew by 15 percent in the first two years after reform, twice the national rate. Moreover, capitated physician groups had costs at least as high as those who were paid on a fee for service basis. Meanwhile, after initial improvements in the state, access to care has begun to deteriorate, and the state has begun to cut back coverage.

Overall, President Obama’s is a conservative bill, drafted in close consultation with the drug and insurance industries. Its modest salutary provisions – such as an extra $1 billion a year for community health centers and the expansion of Medicaid – mirror measures that have been passed even under Republican regimes. Its central tenet, that the government should force citizens to buy coverage from a for-profit firm, was first proposed by Richard Nixon when faced with the seeming inevitability of national health insurance in 1972. Similarly, Mitt Romney, a favorite of conservatives, embraced the Nixon approach as Massachusetts governor in 2006, a stance he has now abandoned. Democrats, having retreated from their traditional push for national health insurance, freed Republicans to move still further to the right.

Throughout the reform debate we, and the 17 000 others who’ve joined Physicians for a National Health Program, advocated for a far more thoroughgoing reform: a non-profit, single payer national health insurance program. We will continue to do so. Our health care system has not been cured or even stabilized. For now, we will continue to practice under a financing system that obstructs good patient care and squanders vast resources on profit and bureaucracy.

Passage of the health reform law was a major political event. But for most doctors and patients it’s no “big f*cking deal.”

David U. Himmelstein, M.D., is associate professor of medicine at Harvard Medical School and Steffie Woolhandler, M.D., M.P.H., is professor of medicine at Harvard Medical School. They are also co-founders of Physicians for a National Health Program.

Cite this as: BMJ 2010;340:c1778

http://www.bmj.com/cgi/content/full/bmj.c1778?ijkey=qLFfFBwLmfvN8vo&keytype=ref

Physicians for a National Health Program

29 E Madison Suite 602, Chicago, IL 60602

Phone (312) 782-6006 | Fax: (312) 782-6007

www.pnhp.org | info@pnhp.org

PNHP 2010

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