Life Expectancy Drops First Time Since 1993

The Centers for Disease Control and Prevention (CDC), a federal agency, has reported the remarkable news that U.S. life expectancy has dropped for the first time since 1993. According to Mortality in the United States, 2015 (NCHS Data Brief No.  267, December 2016):

• Life expectancy for the U.S. population in 2015 was 78.8 years, a decrease of 0.1 year from 2014.
• The age-adjusted death rate increased 1.2% from 724.6 deaths per 100,000 standard population in 2014 to 733.1 in 2015.
• The 10 leading causes of death in 2015 remained the same as in 2014. Age-adjusted death rates increased for eight leading causes and decreased for one.

The one death rate which improved was for cancer. So, we are “winning” that war, at least relatively speaking. The entire decrease was for life expectancy at birth. Life expectancy at age 65 was unchanged from the previous year. In other words, children and working-age people are bearing the burden of this decline.

Obamacare Repeal Has Already Begun For Small Businesses

(A version of this column was published by Forbes.)

My previous column suggested the 21^st Century Cures Act, which President Obama signed on December 13, demonstrated Republicans can lead on health reform. Promoted as a pro-innovation bill, the new law will improve the Food and Drug Administration’s regulatory processes; as well as fund Vice-President Biden’s Cancer Moonshot, the National Institutes of Health, and steps to reduce the opioid epidemic.

However, the final version of the bill also included an important payment reform, which takes a small but significant bite out of Obamacare. Tacked onto the end of the bill, section 18001of the 21^st Century Cures Act expands the use of Health Reimbursement Arrangements (HRAs) by small businesses. This is a win for small businesses which were harmed by Obamacare. Indeed, given the overwhelming bipartisan support for the 21^st Century Cures Act, section 18001 could be defined as Democrat politicians’ first real step towards conceding Obamacare needs to be repealed and replaced.

GDP: Health Spending Almost Flat

For those (like me) concerned about how much health spending continues to increase after Obamacare, the third report of third quarter Gross Domestic Product confirmed good news. Although GDP growth was revised up $14.5 billion from the second report, spending on health services was revised downward. It is good to have a breather from the second quarter, which was dominated by growth in health services spending.

Overall, real GPD increased 3.5 percent on the quarter, while health services spending increased only 0.6 percent, and contributed only 2 percent of real GDP growth. Growth in health services spending was also significantly lower than other services spending and personal consumption expenditures (PCE). However, the annualized change in the health services price index increased by 1.8 percent, lower than the price increase of 2.8 percent in non-health services, slightly more than the 1.4 percent price increase in non-health PCE, and non-health GDP.

(See Table I below the fold.)

Obamacare’s Effect on Employers’ Health Costs

The Bureau of Labor Statistics has published a chart showing how health benefit costs among private employers have increased over the past decade. The chart shows health benefits increased from 6.9 percent of total compensation in September 2006 to 7.6 percent last September. The 0.7 percentage point absolute increase is a relative increase of ten percent.

21st Century Cures Act Shows Republicans Can Lead on Heath Reform

(A version of this column was published by Forbes.)

Since the election, there has been a lot of sturm und drang around what the alternative to Obamacare will look like. It looks like we can be highly confident the Republican-majority Congress will repeal Obamacare very quickly starting in January. However, there is some question about what exactly will be repealed.

Last year’s repeal bill, H.R. 3762 repealed Obamacare’s spending and taxes, but not its over regulation of health insurance. Further, Republican politicians have promised not only to repeal Obamacare, but replace it with a better payment system than existed previously. People’s primary concern about the previous system was that people in the individual market could be denied coverage for pre-existing conditions or charged higher premiums as a result of underwriting.

Zeke Emanuel, Obamacare Architect, Visits Trump To Urge One-Term Presidency

Last Wednesday, the Trump transition team disclosed the remarkable news that Ezekiel Emanuel, MD, an architect of Obamacare, was Mr. Trump’s first official guest of the morning. The spokesman demurred with respect to the details of the conversation, but I can guess: Dr. Emanuel was urging Mr. Trump to remain in office only one term, in accordance with Dr. Emanuel’s principle that people should be cut off at age 75.

CPI: Dramatic Drop in Prescription Prices

The Consumer Price Index rose 0.2 percent in November. Remarkably, medical prices were flat overall. This is the third month in a row we have enjoyed medical price relief. Prices of prescription drugs dropped by 0.6 percent. Even the prices of health insurance and hospitalization dropped a smidgeon!

Prices for physician services rose the most, by 0.6 percent, followed closely by other medical professionals (0.5 percent).  

Over the last 12 months, however, medical prices have increased 2.7 times faster than non-medical prices: 1.5 percent versus 4.0 percent. Price changes for medical care contributed 20 percent (one fifth) of the overall increase in CPI.

Many observers of medical prices decline to differentiate between nominal and real inflation. Because CPI is has been low until recently, even relatively moderate nominal price hikes for medical care are actually substantial real price hikes. More than six years after the Affordable Care Act was passed, consumers have not seen relief from high medical prices, which have increased over twice as much as the CPI less medical care since March 2010, the month President Obama signed the law.

(See Figure I and Table I below the fold.)

PPI: Health Prices Tame, Inflation Picks Up

November’s Producer Price Index rose 0.4 percent. However, prices for most health goods and services grew slowly, if at all. Nine of the 16 price indices for health goods and services grew slower than their benchmarks.* The major exceptions were prices for pharmaceutical preparations, which increased 0.4 percentage points more than prices for final demand goods less food and energy; and nursing homes, for which prices increased 0.3 percentage points more than prices for final demand services less trade, transportation, and warehousing.

Prices of health goods for intermediate demand, were lower than their benchmark. Perhaps slow price increases for medicinal and botanical chemicals, and biological products will flow through to prices of pharmaceutical preparations but that has not previously been the case.

Over the last twelve months, prices of nine of the 16 health goods and services have increased slower than their benchmarks. Three stand out as having increased significantly more than their benchmarks: Pharmaceutical preparations (7.0 percentage points), biological products (1.8 percentage points), and dental care (1.7 percentage points).**

(See Table I below the fold.)

Health Savings Accounts Continue To Grow

One of Donald Trump’s campaign promises is to make Health Savings Accounts more widely used. The purpose of HSAs is to give patients more directly control over health spending, and reducing the share of spending controlled by insurers. Unfortunately, the 2003 law which established HSAs requires they be linked with a highly regulated type of health insurance policy.

These policies, like all health insurance today, give insurers power to dictate prices instead of allowing prices to be formed through interactions between patients and providers (that is, a normal market process). So, these health insurance policies are not as popular as truly consumer-driven plans should be.

Nevertheless, HSAs (which are bank accounts, not health insurance policies) are growing like gangbusters, according to new research from the Employee Benefits Research Institute (EBRI). As I wrote previously, EBRI is a rock-solid member of the health-benefits establishment.

Puzder Pick A Second Win on Health Reform

Soon after announcing his intention to nominate Tom Price, MD as U.S. Secretary of Health & Human Services, Donald Trump announced his intention to nominate Andrew Puzder Secretary of Labor. This is yet another good sign for the repeal of Obamacare.

Since the election, the media have asserted repealing Obamacare will yank health insurance from over 20 million people. This refers to Obamacare’s having increased welfare dependency (via expanding Medicaid) and the expensive individual policies offered in its exchanges, subsidized by tax credits.

This has sucked oxygen out of another important part of the debate, which is Obamacare’s regulations on employment. The Congressional Budget Office projects Obamacare will shrink the workforce by 2 million full-time equivalent (FTE) jobs in 2025.

The CEO of CKE Restaurants, which owns the Carl’s Junior and Hardee’s brands, Mr. Puzder warned of the harm to jobs in chain restaurants from Obamacare’s mandate to offer employees overpriced health insurance as far back as July 2013:

Banning Organ Sales in Free Countries Enables Harvesting Prisoners’ Organs In Unfree Ones

Two new films, one a documentary and one a drama based on the same facts, expose one of the most horrific markets operating today: Communist China’s selling of organs harvested from prisoners of conscience.

Ten thousand “transplant tourists” travel annually to communist China, where they pay top dollar to get organs transplanted on demand. The Boston Globe’s Jeff Jacoby summarizes how China became the go-to destination for desperate patients on waiting lists:

Health Services Revenue Slides, Hospital Profits Drop in Q3

This morning’s Quarterly Services Survey (QSS), published by the Census Bureau, showed a decline in revenues for most health services. Overall, revenue shrank 1.5 percent in the third quarter. However, growth versus Q3 2015 was a strong 5.4 percent and YTD growth is up 5.7 percent.

Only outpatient care centers, home health services, other ambulatory services, and specialty hospitals reported growth. Revenue at psychiatric hospitals has grown 16.3 percent, Q3 2016 versus Q3 2015, a remarkable growth which I cannot explain. General hospitals’ revenues have finally begun to shrunk, suggesting they have maximized their Obamacare business opportunities.

See Table I below the fold.

Repealing Obamacare Demands Deliberate & Thoughtful Process

The next Congress is likely to repeal Obamacare by “reconciliation,” a parliamentary maneuver that allows a simple majority in the U.S. Senate to pass a bill. With fewer than 60 Republican Senators in the next Congress, reconciliation is the only way to move quickly to solve the problems Obamacare created. Otherwise, we could expect Democratic Senators to filibuster a repeal bill.

However, not every jot and tittle of Obamacare can be repealed through reconciliation, which sets up a challenging couple of years (at least) for those who wish to repeal Obamacare and replace it with patient-centered health care.

Read this entire op-ed in The Hill.

Castro's Death and Cuban Health Care

The recent death of Cuban dictator Fidel Castro brought forth a grotesque encomium from the Canadian Prime Minister, Justin Trudeau, who asserted “Mr. Castro made significant improvements to the education and healthcare of his island nation.”

Michael Moore, producer of propaganda dressed as documentaries, made a film in 2007 called Sicko, in which he also praised Cuban health care. The reality was different. According to a U.S. intelligence cable published by WikiLeaks, a local person employed by U.S. intelligence covertly observed:

• Many young cancer patients reportedly have become infected with Hepatitis C after their surgeries. Contracting Hepatitis C after surgery indicates a lack of proper blood screening prior to administering transfusions. All blood should be screened for Hepatitis B, C, HIV and Syphilis prior to use. Patients have no recourse and are not fully informed of the seriousness of such an inadvertent infection.

• Patients had to bring their own light bulbs if they wanted light in their rooms. The switch plates and knobs had been stolen from most of the rooms so one had to connect bare wires to get electricity. There was no A/C and few patients had floor fans. Patients had to bring their own sheets, towels, soap and supplemental foods. Hospital food service consisted of rice, fish, rice, eggs, and potatoes day after day. No fresh fruits, vegetables, or meat were available.

• The laboratory equipment is very rudimentary - a simple CBC (complete blood count) blood test is calculated manually by a laboratory technician looking through a microscope and counting the individual leucocytes, lymphocytes, monocytes, etc.

Health Jobs Grow 1.5 Times Faster Than Non-Health Jobs

This morning’s jobs report maintained the trend of high growth in health services, which grew 1.5 times faster than non-health jobs (0.18 percent versus 0.12 percent). With 28,000 jobs added, health services accounted for almost one in six of 178,000 new jobs.

The disproportionately high share of job growth in health services is a deliberate outcome of Obamacare. While this trend persists, it will become increasingly hard to carry out reforms that will improve productivity in the delivery of care.

Ambulatory sites added jobs at a much faster rate than hospitals. This was concentrated in offices of physicians and other practitioners, and outpatient care centers. Physicians' offices alone added seven thousand jobs, more than the six thousand added by hospitals. This is a good sign because hospitals are high-cost locations of care versus doctors’ offices and other ambulatory sites.

See Table I below the fold.

Significant Drop in Health Facilities Construction in October

Construction of health facilities slowed in October, while other construction increased a little. Overall, health facilities construction starts declined 3.1 percent, versus an increase of 0.7 percent for other construction. Health facilities construction accounted for almost 6 percent of non-residential construction starts. However, while both private and public health facilities construction both declined, there was divergence between private and public non-health construction.

(See Table I below the fold.)

Surprise Medical Bills A Growing Problem Requiring Price Transparency

(A version of this column was published by Forbes.)

Donald Trump’s health reform proposal during the presidential campaign promised to deliver price transparency to health care:

Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals. Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure.

Doctors and hospitals are infamously terrible at sharing price information with patients. It is a problem for both scheduled procedures and visits to emergency rooms. 

The root problem is not that providers are unwilling to share prices, but that prices are not formed through a normal market process. Instead they are administratively determined between government, insurers, and providers.

The Price is Right! Trump’s Choice Indicates Push to Repeal and Replace Obamacare

Donald Trump’s choice of Dr. Tom Price as his nominee for U.S. Secretary of Health & Human Services indicates the Trump Administration will make a serious effort to repeal and replace Obamacare with patient-centered health reform.

After some initial signs of hesitation at actually trying to achieve this six-year old campaign promise, Obamacare’s opponents can now be confident that skilled leadership will wage a sophisticated and likely successful effort to restart health reform. Here are four reasons why:

Tame Health Spending Confirmed in Strong Q3 GDP

For those (like me) concerned about how much health spending continues to increase after Obamacare, the second report of third quarter Gross Domestic Product confirmed good news. Although GDP growth was revised up $10 billion, only a scratch was due to health spending. It is good to have a breather from the second quarter, which was dominated by growth in health services spending.

Overall, real GPD increased 3.1 percent on the quarter, while health services spending increased only 2.3 percent, and contributed only 9 percent of real GDP growth. Growth in health services spending was also in line with other services spending and personal consumption expenditures (PCE). However, the annualized change in the health services price index increased by 1.7 percent, lower than the price increase of 1.3 percent in non-health GDP but less than the 2.8 percent price increase for non-health services.

(See Table I below the fold.)

Health Technology Forum: DC Third Speaker Announced December 5

Please join us in Washington, DC on December 5 at 6 p.m. for Crossing the Chasm from Analog to Digital Health.

There is a lot of digital technology being deployed, but is it actually succeeding in disrupting health care in a positive way, to increase quality and cut costs? Our speakers will discuss digital opportunities are succeeding in achieving this.

As usual, our format will present three speakers: Our third will be Mark A. Cochran, PhD, Executive Director, Johns Hopkins Healthcare Solutions. Professor Cochran will discuss Using Digital Health Tools to Manage Population Health.

The White Man's Burden: Drugs, Drinking, Suicides Up Since 2000

More nonsense has been written about white nationalism/supremacy in the wake of Donald Trump’s election than anyone should have to read. So, it is a pleasure to find some actual data analysis on the role of the non-college educated white citizen in the success of the Trump candidacy, especially versus Mitt Romney’s failed 2012 campaign.

The Economist has determined health status explains the Trump vote better than being a non-college educated white citizen does. The sicker you are, the more likely you are to have voted for Trump. Non-college educated whites are also likely to be sicker, so the two variables are not independent. Nevertheless:

Will Trump Really Kick 22 Million Off Health Insurance?

(A version of this article was published by Forbes.)

Now that repeal of Obamacare is within striking distance, Obamacare’s supporters and the media are aghast at over 20 million people potentially losing their overly expensive health insurance.

If Republican politicians cannot overcome this objection, they will never move forward with repealing and replacing Obamacare. U.S. Senator Lamar Alexander, Chairman of the Senate’s Health, Education, Labor, & Pensions (HELP) Committee anticipates it will take “several years” to transition out of Obamacare to a patient-centered health system.

Why would Republican politicians balk at fulfilling a promise on which they have campaigned successfully since 2010? The answer lies in the swamp which President-elect Trump promises to drain – Washington, DC. Remember every industry in the health sector acceded to Obamacare in 2010 because it would permanently divert funds from the rest of the economy into the health sector.

Widespread Government Failure in Health Care

The Commonwealth Fund has published yet another survey comparing health care in the United States to health care in other countries. The title emphasizes US Adults Still Struggle With Access To And Affordability Of Health Care.

Really? As I’ve previously written, I agree fully with the Commonwealth Fund scholars that health care in the U.S. is inefficiently delivered and over bureaucratized. 

Nevertheless, suggesting U.S. health care is the worst overall is not consistent with the data. The latest survey compares 11 developed democracies. The relationship between government control of health care and various measures of health status is not at all clear, despite other countries having so-called “universal” health systems.

When it comes to actual access to care, 35 percent of low-income Americans (with household incomes below one half the median income) had to wait six or more days to see a primary-care doctor or nurse the last time they needed care. However, so did 38 percent of low-income Germans and 32 percent of low-income Swedes.

Big Pharma and Access to Medicines

Having written critically about a decision made by a philanthropic organization to reject a donation of vaccines by Pfizer, Inc., I am grateful for a new report which ranks research-based pharmaceutical companies on a number of measurements of how they make medicines available to patients in low-income countries.

Jointly funded by the Bill and Melinda Gates Foundation and British and Dutch taxpayers, the Access to Medicine Index ranks 20 large drug makers: "The 2016 Index used a framework of 83 metrics to measure company performances relating to 51 high-burden diseases in 107 countries."

CPI: Flat Medical Prices Lower Than Inflation

The Consumer Price Index rose 0.4 percent in October. Remarkably, medical prices were flat overall. This is the second month in a row we have enjoyed medical price relief. Even prescription drugs rose by only 0.2 percent, half the rate of headline CPI, while prices of non-prescription drugs dropped significantly. Even the price of health insurance dropped a smidgeon!

Prices for inpatient hospital services rose the most, by 0.6 percent. As noted in my discussion of the Producer Price Index, this bears closer watching as President-elect Trump promises more spending on infrastructure, including hospitals.

Over the last 12 months, however, medical prices have increased three times faster than non-medical prices: 1.4 percent versus 4.3 percent. Price changes for medical care contributed 22 percent of the overall increase in CPI.

Many observers of medical prices decline to differentiate between nominal and real inflation. Because CPI is has been low until recently, even relatively moderate nominal price hikes for medical care are actually substantial real price hikes. More than six years after the Affordable Care Act was passed, consumers have not seen relief from high medical prices, which have increased over twice as much as the CPI less medical care since March 2010, the month President Obama signed the law.

(See Figure I and Table I below the fold.)

Health Coverage the Same As Ten Years Ago

The best measurement of people who lack health insurance, the National Health Interview Survey published by the Centers for Disease Control and Prevention (CDC), has released early estimates of health insurance for all fifty states and the District of Columbia in the first half of 2016. There are three things to note.

First: 69.2 percent of residents, age 18 to through 64, had “private health insurance” (at the time of the interview) in the first half of this year, which is which is the same rate as persisted until 2006 (page 1, Figure 1; and page A5, Table III). Obamacare has not achieved a breakthrough in coverage. It has just restored us to where we were a decade ago.

Health Technology Forum: DC Meetup December 5, 2016. All Welcome

I am happy to announce the second speaker for our Health Technology Forum: DC Meetup on December 5, 2016 will be Dieter Schuller of Radiant Logic, who will discuss how The Digital Experience Begins with Authentication and Authorization.

Please join us in Washington, DC. Learn more at RSVP at this link.

Bill Clinton Is Right: Obamacare Is Crazy For Workers

(A version of this column was published by The Hill.)

Bill Clinton’s pre-election criticism of Obamacare reflected a good understanding of labor economics. In October, he explained:

So you've got this crazy system where all of a sudden 25 million more people have health care and then the people who are out there busting it, sometimes 60 hours a week, wind up with their premiums doubled and their coverage cut in half. It's the craziest thing in the world.”

Clinton was referring to high marginal income tax rates that Obamacare imposes on workers through the design of its tax credits, which get clawed back in a very unfair way. The Administration recently confessed premiums for the benchmark Obamacare plans are going up 25 percent, on average. Trying to appease angry enrollees, the Administration feebly claims tax credits reduce net premiums people pay.

Nobody is satisfied by this excuse. However, even if Obamacare premiums were reasonable, they would still punish the people for whom Bill Clinton claims to speak. The more you work, the more you earn; and the more you earn, the higher net premium you pay. This is not a characteristic of the employer-based group market in which most of us participate.

PPI: Health Prices Tame, Inflation Flat

October’s Producer Price Index was flat. However, prices for most health goods and services grew slowly, if at all. Seven of the 15 price indices for health goods and services declined (Table I). The major exception was prices for dental care, which increased 1.5 percent. Dental care is dominated neither by government nor private insurance, so dental price increases are not explained by my usual theory of health inflation. I addressed dental price increases in a previous article.

Should Medicaid Pay Family Members to Care for Disabled Patients?

We now take a break from incessant discussion of the Trump transition, to bring up a very delicate subject: How to ensure severely disabled patients do not become victims.

What politician could ignore the pleas of families caring for disabled members, asking for some help with the burden they carry? Unfortunately, government funding this type of personal care cannot deter significant unintended consequences.

The Office of Management and Budget (OMB) has designated 16 programs as “high error” which means money goes offside due to fraud, waste, and abuse. Medicaid, the joint state-federal program that subsidizes medical services for low-income people, ranks highly on the list. $29.1 billion, or almost ten percent of the $297.7 billion federal contribution is considered by the U.S. government to be paid “improperly.”

The Department of Justice under President Obama has had significant success tracking down and charging those who bill Medicaid and Medicare falsely. However, there is an even worse type of abuse happening in Medicaid: Actual physical abuse of the most vulnerable patients in the system. This often goes hand-in-hand with financial fraud in the area of personal-care services.

Despite Six-Figure Starting Salaries, FDA Can't Hire Reviewers

Would a starting salary of over $160,000 turn you off? Well, maybe if you had a scientific PhD and had to wait four months before the employer could decide whether to hire you or not, you would find a spot elsewhere.

This is the situation the Food and Drug Administration finds itself in, according to the Washington Post:

The Food and Drug Administration has more than 700 job vacancies in its division that approves new drugs, and top officials say the agency is struggling to hire and retain staff because pharmaceutical companies lure them away.

“They can pay them roughly twice as much as we can,” Janet Woodcock, who directs the FDA’s Center for Drug Evaluation and Research (CDER), said at a rare-diseases summit recently in Arlington, Va.

(Sidney Lupkin & Sarah Jane Tribble, “Despite ramped-up hiring, FDA continues to grapple with hundreds of vacancies,” Washington Post, November 1, 2016.)

As I’ve discussed before, the FDA is not short of money. On the contrary, its budget for drug approvals has increased significantly over the years. However, one reason it cannot hire enough staff to review applications is that it is too slow to process hiring.

If it cannot hire regulatory staff efficiently, how will it ever process drug approvals efficiently?

The fundamental problem is that the FDA is a monopoly, protected by government. Its staff do not suffer if new medicines and devices are not approved in a timely manner. Rather, patients, investors, and innovators suffer. The FDA has lots of reason to complain, because that is how it increases its budget.

However, it has no incentive to become more productive or efficient in approving new therapies. A bigger budget just makes the FDA bigger, but not better. Patients need more freedom to use new therapies without having their access strangled by the FDA.

Health Technology Forum: DC Meetup December 5, 2016: Crossing the Chasm from Analog to Digital Health Care

Our next Health Technology Forum: DC Meetup will be December 5. All are welcome to join us in Penn Quarter, Washington, DC. Join the Meetup at this link.

There is a lot of digital technology being deployed, but is it actually succeeding in disrupting health care in a positive way, to increase quality and cut costs? Our speakers will discuss digital opportunities are succeeding in achieving this.

As usual, our format will present three speakers. Our first speaker will be Phil Newman, Co-Founder & CEO of Viimed.

Health Jobs Grew Twice As Fast As Non-Health Jobs in October

This morning’s jobs report maintained the trend of high growth in health services, with those jobs growing twice as fast as non-health jobs (0.21 percent versus 0.10 percent). With 31,000 jobs added, health services accounted for almost one fifth of 161,000 new jobs.

The disproportionately high share of job growth in health services is a deliberate outcome of Obamacare. While this trend persists, it will become increasingly hard to carry out reforms that will improve productivity in the delivery of care.

Obamacare Coverage 10 Percent Less Expensive Than Job-Based Benefits

Scholars at the Urban Institute have previously struggled to find ways to report Obamacare’s good news by pointing out “thereis no meaningful national average” of premium hikes. More recently, they have concluded that Obamacare coverage is 10 percent less expensive than employer-based coverage.

Comparing average employer-based premiums to the second-lowest cost Silver benchmark Obamacare plans, the Urban Institute scholars found lower Obamacare premiums in 38 states plus Washington, DC. These are the unsubsidized Obamacare premiums, adjusted for age, actuarial value, and utilization associated with actuarial value.

What to make of this finding?

Divided on Obamacare, Trump and Clinton Both Threaten Medical Innovation

(A version of this column was published by Forbes.)

The recently announced 25 percent rise in Obamacare health insurance premiums has brought renewed attention to health policy. As this is my last column before Election Day, it is time to review how the presidential candidates would address the continuing challenge of skyrocketing health costs.

We should not kid ourselves that Obamacare’s failure is enough to cause the next President or Congress to act energetically to fix the problems Obamacare exacerbated. The interest groups which brought us Obamacare have cut bait and moved on. The health care sector – interests for which the $3.35 trillion spent on health care counts as revenue rather than cost – has bigger fish to fry.

Although insurers are losing money in Obamacare’s exchanges, they are far more concerned with employer-based group benefits, Medicare Advantage, and Medicaid managed care than Obamacare exchanges. Obamacare exchanges cover fewer than 13 million people at any time during the year; and only about four million stick with Obamacare coverage throughout the year. Those poor souls comprise a powerless political constituency, unlike employers or seniors on Medicare.

Divergence in Private Versus Public Health Facilities Construction Continues in September

Construction of health facilities slowed in September, along with other construction. Overall, health facilities construction starts declined 0.3 percent in September, versus a drop of 0.4 percent for other construction. Health facilities construction accounted for 6 percent of non-residential construction starts. However, the divergence between private and public continued.

Construction of private health facilities dropped 1.0 percent, versus a drop of 0.2 percent for other private construction. Private health facilities construction starts accounted for almost 8 percent of private nonresidential construction starts.

Construction of public health facilities increased 2.4 percent, versus a drop of 1.0 percent for other public construction. Is this what they mean by “infrastructure” spending – broken bridges and roads, while more VA and county hospitals spring up?

(See Table I below the fold.)

Health Spending Tame in Strong Q3 GDP

For those (like me) concerned about how much health spending continues to increase after Obamacare, today’s flash report of third quarter Gross Domestic Product brings good news. Of course, the flash GDP report is subject to significant revision. Nevertheless, it is good to have a breather from the second quarter, which was dominated by growth in health services spending.

Overall, real GPD increased 2.9 percent on the quarter, while health services spending increased only 2.3 percent, and contributed only 9 percent of real GDP growth. Growth in health services spending was also in line with other services spending and personal consumption expenditures (PCE). Also, the annualized change in the health services price index increased by 1.6 percent, very close to overall GDP.

(See Table I below the fold.)

Obamacare 2017 Premium Hikes 25 Percent

The Administration has confessed the average 2017 Obamacare premium hike for the benchmark (second-lowest cost) Silver plan will be 25 percent. (Back in June, it looked like the hike would be 16 percent.)

Don’t worry, says the Administration, tax credits will ensure beneficiaries only pay a fraction of their premiums. It is true, very few people would buy Obamacare plans without the tax credits the Administration cheers. However, that is not a sign the plans are "affordable," but only that taxpayers are bearing more of the burden.

Nor do the tax credits actually prevent people from sticker shock. In fact, the design of the tax credits usually makes the net premium hike higher than the gross premium hike. For example, the average premium hike next year in California will be 13.2 percent, but a 56-year old woman in Los Angeles just learned her premium will jump 57 percent next year.

California's Public Option Would Not Rescue Obamacare

(A version of this Health Alert was published by the Orange County Register.)

Dave Jones, California’s Insurance Commissioner, has lifted a page from Hillary Clinton’s playbook for the rescue of Obamacare – the so-called “public option.” The public option would probably look at lot like Medicaid. Its proponents give it a less pejorative name to lull people into a false sense of confidence that the market for private health insurance would not be harmed more than it already has by Obamacare. 

However, the public option would surely lead to more of the same problems Medi-Cal (California’s Medicaid program) has experienced – poor access to care and exploding costs to taxpayers.

They Can't Even Give It Away: Global Charity Rejects Free Vaccines

Doctors Without Borders /Médecins Sans Frontières (MSF) has decided to reject a donation of one million doses of pneumonia vaccine from Pfizer, Inc. The global health charity’s convoluted reasoning goes like this:

There is No Such Thing as “Free” Vaccines

Pneumonia claims the lives of nearly one million kids each year, making it the world’s deadliest disease among children. Although there’s a vaccine to prevent this disease, it’s too expensive for many developing countries and humanitarian organizations, such as ours, to afford.

Free is not always better. Donations often involve numerous conditions and strings attached, including restrictions on which patient populations and what geographic areas are allowed to receive the benefits.

Critically, donation offers can disappear as quickly as they come. The donor has ultimate control over when and how they choose to give their products away, risking interruption of programs should the company decide it’s no longer to their advantage.

This remarkable document goes on to praise GSK, a competitor of Pfizer’s, for having declined to offer pneumonia vaccines for free, but instead offer them for $3.05 per dose to all humanitarian organizations. I don’t know about you, but I will take free over three bucks any day.

Everybody Gets A Medal: Performance “Incentives” In Medicare Reform

In April 2015, huge bipartisan majorities passed a milestone Medicare reform bill called MACRA, which imported all the worst elements of Obamacare into Medicare. At the time, I wrote an alternative proposal, and anticipated physicians would refuse to swallow the medicine MACRA prescribed.

The gist of MACRA is that Medicare will no longer pay for “volume” but “value” in a zero-sum game wherein physicians who do not satisfy the government’s requirements for “value” transfer income to those who do. Since the bill was signed, the details have percolated from the elite physician executives who run the medical societies which lobbied for the bill down to practicing physicians. There has been pushback.

Nervous that physicians will bail out of Medicare if the government squeezes them too hard, the Administration has backtracked on MACRA’s sticks and shifted towards carrots. Last April, the Administration published a proposed rule, 426 pages long. After a lengthy comment period, the final rule, which is 2,205 pages long (!), was published on October 14.

What Holds Back Consumer-Driven Health Plans?

A previous entry discussed new evidence that so-called consumer-driven health plans (CDHPs) reduce health spending one eighth among employer-sponsored group plans run by national health plans.

CHDPs are defined as High-Deductible Health Plans coupled with Health Savings Accounts or Health Reimbursement Arrangements). These plans became available in 2005. However, they only appear to cover a little over one quarter of employed people or their dependents who are enrolled in their benefits.

The case for CDHPs is that consumers (patients) will spend their health dollars more prudently than insurers or employers will. So: How can such a small proportion of people be enrolled in CDHPs after over a decade of evidence supporting the case that they cut the rate of growth of health spending?

California’s Surprise Medical Bill Law Papers Over A Systemic Problem

(A version of this column was published by Fox & Hounds.)

Insured patients who go into hospital for scheduled surgery are often shocked to find they owe bills well beyond what they expected to pay, especially if they understood the hospital and surgeon to be in their health plan’s network. The problem usually occurs when an anesthesiologist or other specialist involved in the procedure is not in the insurer’s network. Until now, when it came to the amount the out-of-network specialist could charge, the sky was the limit. A recent Consumers Union survey found nearly one third of Americans who had hospital visits or surgery in the past two years were charged an out-of-network fee when they thought all care was in-network.

Medical Care Prices Rose Less Than Non-Medical Prices in September

The Consumer Price Index rose 0.3 percent in September. Remarkably, medical prices rose a smidgen less, at 0.2 percent. This is a big breather from August, when increases in medical prices were dramatic. Nevertheless, both prescription and non-prescription drugs increased prices by 0.8 percent. Prices for medical equipment and supplies dropped by almost as much, shrinking 0.7 percent.

Over the last 12 months, however, medical prices have increased four times faster than non-medical prices: 1.2 percent versus 4.9 percent. Price changes for medical care comprise 27 percent of the overall increase in CPI.

Many observers of medical prices decline to differentiate between nominal and real inflation. Because CPI is flat, even relatively moderate nominal price hikes for medical care are actually substantial real price hikes. More than six years after the Affordable Care Act was passed, consumers are seeing no relief from high medical prices, which have increased over twice as much as the CPI less medical care since March 2010, the month President Obama signed the law.

(See Figure I and Table I below the fold).

Fifty Percent Increase in Share of Physicians Owned By Hospitals in Three Years

A new survey by the Physicians Advocacy Institute and Avalere Health, a consulting firm, shows a significant increase in the number of physicians leaving independent practice and joining hospital-based health systems:

·        From July 2012 to July 2015, the percent of hospital-employed physicians increased by almost 50 percent, with increases in each six-month period measured over these three years.

·        In 2012, one in four physicians was employed by a hospital.

·        By 2015, 38 percent of physicians were employed by hospitals.

Good or bad? Well, color me skeptical. This acquisition spree is driven by new payment models which seek to reward providers for “accountable” care (which I suppose is better than unaccountable care.) So far, the results of payment reform in Medicare have been trivial.

Mixed News on Generic Drug Approvals

A response to expensive patented medicines is generic competitors. The U.S. has struck a pretty good balance between innovation and low prices through the Hatch-Waxman (1984) Act, which specified patent terms for newly invented medicines, and a pathway for generic competitors to enter the market after a period.

One obstacle to generic entry in recent years was a very slow approval process at the Food and Drug Administration. This led to a backlog, which was unexpected because one important benefit of Hatch-Waxman was that generic competitors did not have to replicate the expensive clinical trials innovative drug-makers had to carry out to receive the FDA’s approval.

The FDA’s Office of Generic Drugs (OGD) considers approving generic copies of drugs upon receipt of an Abbreviated New Drug Application (ANDA) from the manufacturer. The system changed under a law passed in 2012, the Generic Drug User Fee Act (GDUFA). Recent data show improvement:

PPI: Health Prices (Except Pharmaceuticals) Stay Tame

September’s Producer Price Index rose 0.3 percent, a significant pick up. However, prices for most health goods and services grew slowly, if at all. Eleven of the 15 prices for health goods and services reported grew slower than the headline PPI. The major exception was prices for pharmaceutical preparations, which increased 1.2 percent, resuming a trend which I had hoped was breaking down. Further, prices of medicinal and botanical chemicals dropped 0.7 percent. So, price increases for pharmaceutical preparations are not coming from the ingredients.

However, over the last twelve months, prices of health goods and services have increased faster than overall PPI, which grew 0.7 percent. The tables are turned: 11 of 15 health categories experienced larger price increases than PPI did. Pharmaceutical preparations continue to stand out dramatically, having grown 8.1 percent. Nursing homes, for which prices rose 2.4 percent, might replace drug makers as the whipping boy for high health prices, but they have a long way to go.

See Table I below the fold:

The United Nations Report on Access to Medicines is a Public Health Hazard

(A version of this Health Alert was published by RealClearHealth.)

Almost one year ago, the Secretary-General of the United Nations convened a High-Level Panel on Access to Medicines, which is especially limited among the poor in parts of the developing world still suffering the burden of tropical diseases (such as river blindness, sleeping sickness, leprosy, and rabies.) According to World Health Organization, 1.7 billion people in 185 countries needed treatment for neglected tropical diseases in 2014.

In the 21st Century, such numbers are shocking. However, the panel’s recommendations would have many harmful effects on the development of new medicines that benefit patients in both the developing and developed world. Indeed, it identifies the wrong culprit in the ongoing health catastrophe in the developing world.

Rather than allow the current decentralized system of primarily private for-profit - supplemented by some government and philanthropic - funding for researching, developing, and distributing new medicines, the panel recommends governments take over this function. And not even governments acting independently, but a sort of supra-national cartel would dictate how the world’s R&D budget would be spent.

Specifically, the panel advocates that governments “negotiate global agreements on the coordination, funding, and development of health technologies.” The funding would come from “transaction taxes and other innovative financing mechanisms.” (Only a panel mostly comprised of public-sector veterans would describe tax hikes as “innovative financing.”)

The report estimates $240 billion was invested in medical R&D in 2009 and 2010, of which $144 billion was from the private sector, $72 billion from the public sector, and $24 billion from the non-profit sector. Ninety percent was from highly developed countries, especially the U.S., which the panel recognizes holds a “central position in health technology innovation.”

The purpose of a multi-lateral government cartel seizing control of this capital would be to cause a “delinkage” between R&D spending, prices and consumer costs. In other words, investors would no longer be allowed to execute business plans that channeled R&D funding to profitable therapies.