http://www.pnhp.org/news/2011/march/the-health-law-at-one-year-should-we-celebrate

On March 23, a year after President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), “the most expansive social legislation enacted in decades,” according to the New York Times, it’s worth taking a look at Massachusetts.

After all, PPACA was inspired in the Massachusetts health plan, which sought universal coverage through Medicaid expansions for individuals living under 150 percent of the federal poverty level (FPL), partial subsidies for those between 151 and 300 percent of the FPL, a state-based exchange to act as a one-stop-shopping place of private insurance plans, and a mandate to purchase one of those plans under penalty of a fine.

And yet, four years after implementation, health reform Massachusetts-style has failed a critical test. As a recent study in the American Journal of Medicine showed, the percentage of personal bankruptcies linked to medical bills and illness, at 52.9 percent, has not decreased significantly, and the absolute number of medical bankruptcies has increased, from 7,504 in 2007 to 10,093 in 2009. How so?

Well, it’s not hard to understand why. Health insurance is a means to an end. The end is health care. And skimpy policies with significant, and increasing, out-of-pocket costs are useless when people need care.

And in Massachusetts, skimpy policies are not even cheap. For example, as study authors pointed out, the least expensive individual coverage available to a 56-year-old Bostonian carries a premium of $5,616 and a deductible of $2,000, and covers only 80 percent of the next $15,000 in costs of covered services (uncovered services fall 100 percent on you).

This is not small change if your annual income is around $32,000, or 300 percent of the FPL, so you’re not entitled to subsidies (which, mind you, come from taxpayers’ pockets).

But what about at least slowing the increase in health care costs? Fail again. Double-digit increases in premiums have become routine in Massachusetts, and insurers have warned this will continue next year, even as “consumer-driven” policies that shift more costs to individuals multiply.

But won’t PPACA, a federal program, control costs in U.S. health care? No, at least if you go by its effect on California, where, maybe to celebrate PPACA’s first year anniversary, Blue Shield recently announced its third premium hike since October 2010. An outside consultant found, unsurprisingly, that the planned hike was “reasonable.” (PPACA does not forbid insurers to raise their prices; it only demands that they show that increases are deemed “reasonable” by authorities that have little power to enforce their standards of reasonableness anyway.)

And what about the promise that kids with “pre-existing conditions” would not be charged more than other kids? Good luck with that one. This past October HHS Secretary Kathleen Sebelius already backed down on that promise, allowing insurers to charge more to cover sick kids to, according to the New York Times, “persuade companies to offer child-only policies.”

And Medicaid expansions, which would enroll at least 16 million individuals? Not a chance, especially after governors throughout the nation begin to implement the creative ideas offered by Sebelius explaining how, as state budgets collapse and nobody bails them out, Medicaid costs can be reduced “by cutting benefits,” as noted in California Healthlines.

Wait a minute, you might say. Whatever problems it may have, the law offers (near) universal coverage, no? Out of luck again. The law will leave around 23 million uninsured close to 10 years out from its implementation (and over 50 million annually over the next three years). Many of these will be undocumented immigrants, whom the law forbids to buy coverage from the insurance exchanges, even with their own money.

On the bright side, as the failure of the attempt to further strengthen the worst of the U.S. health care system — for-profit insurance for medically necessary care, and trading uninsurance for underinsurance — becomes increasingly apparent, a space will open up for Americans to demand real health care reform: a publicly financed, privately delivered health care system that provides comprehensive and equitable health care to everybody in the United States: an expanded and improved Medicare for All.

Claudia Chaufan, M.D., Ph.D., is assistant professor at the Institute for Health and Aging at the University of California, San Francisco. She teaches sociology of health and medicine, sociology of power, public health, comparative health care comparative health care systems and sociological theory. Dr. Chaufan is also vice president of Physicians for a National Health Program-California (http://pnhpcalifornia.org/).

Among the many fascinating documents is a list of physicians that Merck sought to “neutralize/discredit” because they were not favorable enough to Vioxx.  Some of these names come with an ominous all-caps and bolded “NEUTRALIZED” under their names.  Each physician has noted down their contact information, affiliations, a detailed description of why they are problematic, and a recommended plan of action.

Dr. John J. Condemi, a speaker for Searle (a Merck competitor) was someone targeted for neutralization. According to the documents Dr. Condemi had the following background: “Thought leader in the community and Upstate NY; speaking on behalf of Searle as an advocate and investigator; recently enrolled him in a clinical trial (RA) after many months of promises and hard effort; not entirely certain this wasn’t too little, too late; speaking to community physicians at programs sponsored by Rochester Blue Cross Blue Shield (80% market share in a 90% managed care market); have not been in attendance at these meetings, but can imagine that VIOXX has not been mentioned nearly as often as Celebrex; has trained many of the RHU in the Upstate area and is considered the expert by many (thus, the reason BC/BS has used him as a speaker); has done studies on FOSAMAX and SINGULAIR but for some reason was slighted by us for VIOXX; wants to be involved with VIOXX.” As this document shows one of the ways to win physicians is to enroll them in “clinical trials.”

The plan for Dr. Condemi is as follows: “Provide scientific information; research; interested in NSAID-induced asthma; provide investigator slides to balance presentations; personal visit by a “heavyweight” from MRL or CDP (Greg Bell or Greg Geba) to discuss where we want to go with VIOXX; could work with him to develop a clinical pathway for COX-2 inhibitors in a managed care setting; panel with Dr. Singh of Stanford and some others to focus on pharmacoeconomic studies which verify reductions in PPI or H2 blocker use.  – He is in a clinical trial; – He is attending a program given by Dr. Geba  – Speaker – doing a good job”

Dr. Max Hamburger, President of a large, private Rheumatology practice in Long Island (New York) is listed as having become an ADVOCATE. Here the hook was not a clinical trial but rather financial support.  Hamburger’s practice was important to Merck because it included “high volume prescribers” who were users of Celebrex (an anti-inflammatory drug that competed with Vioxx).  Here is how Merck characterized the situation presented by the practice: “companies that provide funding will receive preferred status with its members and those that do not will have trouble accessing the IPA members; first endeavor is to put together a “Standards of Care” retreat meeting to develop a document that will serve as their manifesto (to include a drug formulary and how the members will treat certain diseases, preferred medications); price tag is $25,000 to support this meeting and to have access during it.” In its recommendation the document concludes: “Financial support of private practice rheumatology IPA – (has taken place). Has been turned around.” Such horse-trading is worthy of a grade B movie.  It is important to remember that we are talking about highly expensive and dangerous medicines.  And patients who trusted their physicians to provide the best-possible clinical advice, not suggestions based on which drug company was willing to finance their practice.

This types of relationships form part of the context for a recent JAMA article recommending that professional medical associations sharply curtail their reliance on drug companies for financing (Rothman et. al. Professional Medical Associations and Their Relationships With Industry: A Proposal for Controlling Conflict of Interest, JAMA 2009;301:1367).  The document offers a number of specific recommendations and concludes: “PMAs should work toward a goal of $0 contributions from industry; they should not collaborate in or profit from industry marketing activities; PMA leaders and executive staff should be free of conflict of interest and, in time, so should the entirety of the board and the members of the practice guideline committees.“  Since so many of the “leaders” in organized and academic medicine have close financial ties to industry, this is essentially a call for revolution.

How much such a revolution come about?  It would seem to us that the only way would be in the context of a universal, publicly funded and administered health care system which is measured by its ability of efficiently protect and promote the health of the populace.   Is that a revolutionary idea?

posted by Matt Anderson, MD