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A Free-Market Intrusion into Health Care

» Washington Post: The drug that’s forcing America’s most important – and uncomfortable – health-care debate

Months before Gilead Sciences’ breakthrough hepatitis C treatment hit the market, Oregon Medicaid official Tom Burns started worrying about how the state could afford to cover every enrollee infected with the disease. He figured the cost might even reach $36,000 per patient.

Then the price for the drug was released last December: $84,000 for a 12-week treatment course.

At that price, the state would have to spend $360 million to provide its Medicaid beneficiaries with the drug called Sovaldi, just slightly less than the $377 million the Oregon Medicaid program spent on all prescription drugs for about 600,000 members in 2013. It potentially would be a backbreaker.

It's not just Oregon. Having watched many of the interim hearings going on with the Texas Lege, we're seeing references to the drug's impact on costs all over the place. The Employee Retirement System highlighted the impact on their health care coverage costs by noting that their costs for all "compound drugs" rose from $660k in 2009 to $31.3 million in 2014. UTMB-Galveston, in pointing out how their pharmacy costs were similarly impacted, noted that while Hepatitis C prevalence is somewhere around 1-1.5% in the free world, it turns up in about 30% of the prison inmates that it sees.

The response by the Health and Human Services Commission was to ask Medicaid to cover the costs (alas - EXPANSION!). That was without luck, as it was suggested by the Medicaid board that Texas do what "other reputable groups were recommending." Which is what agencies like ERS have chosen to do: limit drugs like Sovaldi by requiring approval on a patient-by-patient basis.

I think its safe to say we'll be hearing more about the drug and others like it during the next legislative session. But the cost factors that are pushing state-level health care costs into the red are greater than just one drug. Still, it's always good sporting fun to see states that deny Medicaid expansion under 'evil Obamacare' turn to Medicaid to cover costs associated with drugs like Sovaldi. But it's also an interesting case study anytime you have a hyper-expensive drug that's incredibly effective in a field full of low- and reasonably-priced drugs that haven't proven effective. The current bet to resolve this seems to be over whether newer drugs will enter the market and drive costs down, or whether they'll engage in "shadow pricing" - setting their price point at a premium on a similar basis to Sovaldi. I don't think those two options are exclusive of one another (say, if a new entrant sets their cost at $40-50,000). But even more worth watching is to see the so-called conservative reaction to a drug being priced at something that at least mimics free-market pricing practices.

» Wonkblog: Why Sovaldi took off: Previous treatments were terrible
» NY Times: Gilead’s Hepatitis C Drug, Sovaldi, Is on Pace to Become a Blockbuster
» Forbes: Politicizing Gilead's Research And Development Costs For Sovaldi Is A Reckless And Dangerous Misadventure


Aggreblogging in the Raw

Just pure, raw linkage this time. A few of these, I may come back to at some point during the week. But for now ... read 'em yourself. Committee hearings are picking up here in Austin, so there's much fear and loathing to contend with. Reminds me: why is it that Hunter S. Thompson never thought to cover the Texas Legislature?

» Huffington Post: University Of Texas, Rick Perry Clash Over Future Of Public Higher Education

» NY Times: Fears of the Future Haunt a Budding Generation of Afghan Strivers

» NY Times: Slower Growth of Health Costs Eases U.S. Deficit

» TNR: Original Sin: Why the GOP is and will continue to be the party of white people

» Inside Higher Ed: Questions on Debit Cards

» Atlanta Journal-Constitution: The “Me” Curriculum at the DOE: Why we need to stop telling students “Narrative writing is all about me.”

» Washington Post: Why introverts shouldn’t be forced to talk in class

» EducationNext: Solving America’s Math Problem
» EducationNext: A Double Dose of Algebra

» Chron: School district, others owe Valero nearly $5 million

» Atlas Project: Changing demographics in Georgia could give Democrats a chance in the deep south

» NY Times: Voting Rights Act Is Challenged as Cure the South Has Outgrown

» Politico: Lone Star Rising

» The Atlantic: Obama's LBJ Moment: The War on Inequality Is the New 'War on Poverty'

» NY Times Magazine: Can the Republicans Be Saved From Obsolescence? (Robert Draper)


Election-Eve Aggreposting …

One final sampling before the votes start trickling in tomorrow ...

» Washington Post: Let’s shatter the myth on Glass-Steagall
I'm glad to see a bit of provocative thinking on this topic. Of course, I'm old enough to remember that it was the late Sen. William Proxmire who led the charge to get Glass-Steagall undone. Proxmire wasn't exactly a Phil Gramm carbon copy, so it bears some attention that there was a liberal critique of the law, as well. Whether the final, passed version of the law was something Proxmire still found merit with or whether there were any issues that came up afterward that might make him change his mind, I don't know. But I'm not certain that just putting Glass-Steagall back in place is much of a solution.

» NY Times: Genetic Data and Fossil Evidence Tell Differing Tales of Human Origins
If science and whatnot isn't your bag, just think of this as pre-historic multiculturalism and diversity.

» NY Times: Political Fortunetelling
Fanciful fiction, to be sure. But I don't think every one of the names mentioned will be absent enough political ambition on the top job. Cuomo should be a certainty. But even after that, I'd expect a few of the rest. As far as the sponsorship element to the tale, I'm more doubtful. But the two strands of the story do weave in with the over-celebritization of politics.

» Dan Froomkin: You Know What the ‘Voter ID’ Push Is All About, So Say So
What? ... and tell the truth?

On the Wednesday-through-Friday reading pile:

» NY Times: What Can Mississippi Learn From Iran?
» New Yorker: We Are Alive - Bruce Springsteen at sixty-two.
» New Yorker: Fussbudget - How Paul Ryan captured the G.O.P. (Ryan Lizza)

Highly coincidental that today's batch includes two writers who I think are very much missed from their previous employers: Froomkin from the Washington Post and Lizza from The New Republic.

In other news, I've got a quick one-day getaway "vacation-let" planned for San Antonio at the end of the week. If the heat doesn't kill me while I'm there, I hope to see enough of the outdoors to do a bit of blogging about some beautiful sights, scenes, and sounds from another little dot on the map.


Obamacare Goes to Court: Day Two

» NY Times: Hard Questions From Justices Over Insurance Mandate

Doesn't sound like the individual mandate had a good day in court yesterday. Says Ezra ...

The quick read is that today went very badly for supporters of the individual mandate. As one of the experienced Supreme Court watchers who runs SCOTUSblog tweeted, “Paul Clement” — the attorney arguing against the health-care law — “gave the best argument I’ve ever heard. No real hard questions from the right. Mandate is in trouble.”

... and Toobin is more blunt in his assessment:

"This was a train wreck for the Obama administration .... This law looks like it's going to be struck down. I'm telling you, all of the predictions including mine that the justices would not have a problem with this law were wrong... if I had to bet today I would bet that this court is going to strike down the individual mandate."

So it looks like the only question left is whether the scope of the opinion will be narrowly tailored to nix the individual mandate, or if the majority in the court will strike for bigger gold in limiting the commerce clause.

The Washington Post interviews Randy Barnett of Georgetown Law and captures his take on the issue at hand ...

... the duty to pay taxes is part of your duty to support the government in return for the protections the government gives you. What the government is claiming here is this power — and this ought to disturb people on the left — to make people do business with private companies when Congress thinks it’s convenient.

That's a fair encapsulation of why I've consistently found the individual mandate troubling. The argument that we're all engaged in the health care market, hence we should pay for it by some means, is problematic on logical grounds. First, the only reason it's offered is because of a Hippocratic Oath that doesn't exactly bind any doctor to see any patient on any grounds whatsoever. At least not in any legally codified manner that I'm familiar with. Secondly, the assumption is that the entirety of the uninsured do not manage to cover the health care costs that they end up incurring. I'm sure that the net effect is a loss of dollars, but I've not seen anything that outlines the scope of the problem (ie - what percentage of uninsured contribute to the problem). I'm uninsured since I don't know when (minus some time during 2010). I have incurred zero health care expenses in the past decade. The last time I did, I paid my bill in full. So why do I need to be forced into the insurance market against my will to fix a problem that I don't contribute to?

In sum, the so-called "health care reform" bill signed into law is, in effect, nothing more than a health insurance reform in this regard. And that brings me to the final problem I have with the mandate: why are we sanctifying the insurance market? Is that really the highlight of liberal thought, these days? ... forcing people to deal with the insurance industry? That seems a far cry even from Al Gore's trope of "the people vs the powerful."


Pondering Mandates

» Politico: Can there be life after mandate?

Who could have guessed?

Nearly 90 percent of Republicans and 69 percent of independents want to repeal it, according to a February poll from the Kaiser Family Foundation. Even Democrats aren’t crazy about it — 51 percent want to repeal it, according to the same poll.

The most plausible alternative to the mandate could be a package of provisions designed to encourage people to buy insurance. But no alternative has emerged that would cover nearly as many people as the Congressional Budget Office says the Affordable Care Act would cover.

There could be penalties for buying coverage outside a certain month of the year, a disincentive against buying coverage only when a patient is sick. Other ideas include subsidies for buying coverage (as in the reform law) and government assistance for plans that take on sicker customers.

Of course, I'm not opposed to the idea simply because a lot of other people don't like it. I think it's just too expansive of a government mandate, especially when it's questionable as to whether it will solve the problem it's designed to address. Add to that, the fact that it can be argued that it's already taken a political party down from its majority status in one body - and likely another in the next election - and I'd humbly suggest that there were better ways to address health care coverage and/or costs.


The Still-Impending GOP Death Panels

The NYT's David Leonhardt has a good reset on health care matters, this one covering rationing in light of the current budget decisions throughout the states that are limiting options for patients. He also post a link to his June '09 column on ways that we ration health care in America. None of these, of course, have anything to do with the Affordable Care Act or the oft-parroted talking points from failed VP candidates' facebook or twitter accounts. Leonhardt also references Norm Ornstein's op-ed from the weekend (below).

As the Texas Lege convenes on the 11th, with a budget gap in excess of $20B being pinched by population growth that exacerbates demand for public services like education and health care, it's useful to note the all-but-certain contradiction that we're about to see. Democratic pols advocating living wills and the sort ... evil; Republicans actually cutting life-saving services ... not so much. The logic failure is a big part of the reason why it's impossible for me to accept any "pro-life" claims by the GOP with a straight face. Not that it'll be hard for rightwing bloggers to explain it away with one.

» Washington Post: 'Death panels' are real -- brought on by budget pressures (Norm Ornstein)

In Arizona, the government headed by Gov. Jan Brewer summarily stopped approving Medicaid payments for many organ transplants in October; one man had a liver virtually snatched away while he waited to go into the operating room. He couldn't get it unless he came up with $200,000 to pay for the procedure.

In Indiana, the state Medicaid program denied a lifesaving operation last year to a 6-month-old boy who lacked a thymus gland, which generates cells that the body uses to fight infection. The Indiana Family Social Services Administration said the procedure was "experimental" - even though it had been successful in 43 of the 60 cases in which it had been applied. The state twice denied the family's appeals, but fortunately the publicity caused by this case prodded two health-care companies to pay for the $500,000 operation.

These are real death panels. They are far from the Affordable Care Act's provision for end-of-life counseling for families to enable them to make rational decisions about their loved ones outside of the awful stress in a hospital or hospice. But these decisions are not being made by evil people reveling in the anguish of patients on Medicaid; they are the result of painful choices made by state governments struggling with a sluggish economy, balanced budget requirements and soaring Medicaid costs. States have to react, and one solution to their constraints is rationing care.

In other words, the nightmares of conservatives bitterly opposed to health reform are coming true on two fronts, but with zero relation to the reform bill they opposed.


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