Recently, Gloria Mazza wrote, (and other Iowa Republicans signed), an essay in The Des Moines Register that urged President Trump and Iowa’s Republican Senators to oppose recent proposals by the Centers for Medicare and Medicaid Serivces (CMS) that would have taken reasonable steps to reign in increasing drug cost under Medicare Part D. It has now been reported that CMS and the Trump administration have backed off of important parts of the proposed changes.
Currently, Medicare Part D regulations require patient access to “all or substantially all” medications within “six protected classes” of drugs regardless of price. (Protected classes include drugs for HIV, mental illness, cancer, epilepsy, and organ transplants.)
Among other things, the proposed new rule would have allowed Medicare Part D plans to exclude a drug from coverage, 1) for an existing drug if the price increased more than the rate of inflation, or 2) for a new drug if it was simply a reformulation of an existing drug. Apparently, lobbying efforts were successful in getting these two provisions removed from the final new rule.
We don’t have a free market for prescription drugs under Medicare Part D. We should not allow drug makers to set their own price and still require coverage. It is unfortunate that the Trump administration caved-in to the lobbying pressure.
The Iowa Legislature made the correct decision when they passed the bill that prohibited Medicaid from covering gender transition surgery. One the one hand, it is morally correct and good public policy that our government not discriminate against a people based on their gender identity. On the other hand, that does not mean Medicaid or any other insurance should be required by law to cover gender transition surgery. Proponents of requiring such coverage say that it is medically necessary because of the mental distress that gender dysphoria may cause. But, cosmetic surgery of any type has not been required to be covered just because a person feels bad about the way they look physically.
I’m sure some people feel great mental distress over their teeth being crooked, or their nose being too big, or many other aspects of their body, but that does not mean Medicaid (taxpayers) or other health insurance plans should be required to cover procedures to make people feel better about their appearance. Requiring health insurance plans to cover almost everything makes the makes the cost unaffordable to almost everyone. There is nothing inherently wrong with expecting people to pay their own way for cosmetic procedures.
As reported in the Des Moines Register, a jury recently found the State of Iowa guilty of illegal discrimination against a transgender man. He had not been allowed to use the men’s bathroom or locker room, and he had been denied health insurance coverage for gender re-assignment surgery. (See link below to Register article.)
It is morally correct and good public policy that our government not discriminate against a people based on their gender identity. But refusal by government or private employers to cover gender reassignment surgery under their health insurance plans should not be considered wrongful discrimination, unless the plans cover other types of cosmetic procedures for people who feel similar dysphoria. People may feel mental distress over their teeth being crooked, or their nose being too big, or many other aspects of their body, but that does not mean health insurance plans should be required to cover procedures to make people feel better about their appearance. We have already seen that requiring health insurance plans to cover almost everything makes the premiums unaffordable for many people. There is nothing inherently wrong with expecting people to pay their own way for cosmetic procedures.
Thanks to Susan Voss for her thoughtful essay about the complexities of our health care system, and how difficult it is to reduce costs. (See link to Register essay below.) I don’t claim to have “the answer”, but I do suggest that the following cost saving ideas be given serious consideration.
Medicare, Medicaid and private insurance should not be required to cover every new drug, product, or procedure that is approved by the FDA. Some are very high cost but provide only marginal improvement over alternatives that cost much less. Also, at least some covered products and procedures would likely be considered not medically necessary by most people.
Consider shortening the amount of time that government grants a monopoly for patents. Patents are not natural property: humans have copied one another since the beginning of time. Our U.S. Constitution allows patents to be granted to encourage inventiveness, but there is no objective reason why a patent must be granted for 20 years. Why won’t five or ten years work? Maybe the length of the patent should be based on the cost to develop the patented item and whether or not government funds were used to help develop the item.
Don’t require limits on out-of-pocket payments such as co-payments, especially for very high cost items. A person should have “skin-in-the-game” if they expect their insurance to cover very high cost items. Today, we see the opposite: drug companies offer to help pay people’s out-of-pocket costs so there won’t be so much political pressure on them to lower their prices.
Allow both pharmacies and individuals to purchase drugs from sellers in other countries that are “deemed” to have sufficient safety procedures in place. If drug companies are free to charge lower prices in other countries, then pharmacies and individuals should be free to purchase the drugs from those other countries.
Allow Medicare and Medicaid to negotiate with drug companies on prices they pay for the drugs that are covered by the programs. Right along with that, Medicare and Medicaid should be allowed to develop formularies (lists of drugs that are preferred over other therapeutically similar drugs), that give beneficiaries a financial incentive to use the preferred drugs and a penalty for using higher cost drugs.
Our health care wants are unlimited. Our ability to pay is not. We, as citizens, should not expect private insurance or our government health care programs to cover everything, regardless of cost. We should expect our government to NOT do things that increase costs, or reduce our choices.
The Des Moines Register recently reported that Wellmark Blue Cross Blue Shield has been accused of violating federal HIPAA privacy regulations in the case of a patient with severe hemophilia. (See link to Register article below.) As reported, a representative of Wellmark was discussing the high cost of health insurance at a Rotary Club meeting last March. She gave an example of an extreme case that was costing $1 million per month. (ACA – Obamacare – prohibits insurance companies from placing any limit on the amount it will pay for patients.) She did not identify the patient by name, but described him as a 17 year old male with hemophilia. Maybe she should not have mentioned the age or sex of the patient, but that information alone did not identify who the specific patient was, and should not be considered a violation of federal privacy regulations.
Wellmark and other insurance companies must be able to cite specific high cost cases that are causing health insurance premiums to rise to unaffordable amounts. How can we openly debate ways to contain health care costs if we don’t know what is causing the high costs? Can we really afford to require insurance companies to pay out unlimited amounts for any patient? I recently heard that the last remaining company to offer individual health insurance policies in Iowa may charge more than $30,000 per year next year for a couple who are 55 years old. Health care wants are unlimited. Our ability to pay is not. We need to debate whether or not government should prohibit health insurance policies from having limits on how much they pay out for individual patients.
In The Des Moines Regiser’s report about Wellmark getting out of the health insurance market for individual policies under the Affordable Care Act (ACA), they reported, “Forsythe (CEO of Wellmark) cited a single Wellmark customer who has a rare genetic disease that is costing more than $1 million per month to treat.” One person – A million dollars a month. (See link to article below.)
One of the fatal provision of the ACA is the requirement that there be no limit in health insurance policies on how much can be paid for any individual’s care. No limit. Should we really expect others (society) to pay a million dollars a month for the care of ourselves or our family members? If you help to pay that much for someone else, then won’t you expect the same to be paid for you if you have the need? How can that be sustainable? Who gets to makes decisions regarding who we pay for and who we don’t? Unfortunate as it may be, it is a reality of life that we cannot afford, even as a society, to pay for everything we want. To the extent that those decisions, including limits on health insurance policies, can be made privately and voluntarily, we will have a more just, civil, and sustainable society.
The Register recently criticized our fee-for-service health care payment system for causing over-utilization and for driving up health care costs. (2/12/2015 – “Florida, home of medical scans — and scams” – see link below) They gave examples of doctors ordering unnecessary test because they get paid more for every additional service that they provide. They advocated paying physicians a salary like Mayo Clinic does, so that doctors, “…have no personal, financial incentive to provide unneeded care.” They urged the Obama administration to, “…continue to work toward reimbursing providers based on quality instead of quantity while fairly reimbursing them.” I agree with the Register that, “Ultimately, reducing the overuse and misuse of health care falls to patients.” They urge patients to not rush to the doctor for every ache, ask questions when doctors order tests, resist clinic staff who want to schedule tests and procedures.
One thing the Register failed to mention is the importance of patients being required to pay out-of-pocket for some portion of their health care costs. To the extent that patients are not required to pay for some portion of their costs, they will not question the recommendations of doctors and other providers and they will tend to over-utilize health care. Requiring patients to make some out-of-pocket payment will also help reduce fraud, since patients won’t want to pay part of any fraudulent charges that billed to their insurance. Many insurance policies under Obamacare do seem to have significant deductibles and co-payments. That will go a long way to help keep down health care costs.
Link to Register article: http://www.desmoinesregister.com/story/opinion/2015/02/12/florida-home-medical-scans-scams/23278965/