Medicaid – R&R – Reachout and Rebuild

Social Security Under Attack

David Posnett — Fri, 18 Sep 2020 02:04:18 +0000

https://www.americanprogress.org/issues/economy/news/2020/08/12/489401/trumps-plan-defund-social-security/

The Social Security Act was signed into law by President Franklin Delano Roosevelt, a Democrat, on August 14, 1935, to function as a “federal safety net for elderly, unemployed and disadvantaged Americans,” while legislating that it cannot spend more than it receives through payroll taxes.

More than just a retirement program, it provides important life insurance and disability insurance protection as well. Over 64 million people, more than 1 in every 6 U.S. residents, collected Social Security benefits in June 2020.

One-third of all retirees are dependent on Social Security for 90 percent or more of their income, and over 60 percent depend on it for more than half of their income. About 61 million people are enrolled in Medicare.

Social Security and Medicare are both funded entirely through payroll taxes paid into “The Social Security Trust Funds” Every penny paid out must be paid with money coming in now and in the future from payroll taxes. There are no other funding sources.

We know the Republican Party, in its chronic itch to defund entitlement programs, has sought to cut Social Security, even though it operates at a very efficient administrative cost of around 2 percent.

Last month, due to his administration’s disastrous response to COVID-19, Trump signed an executive order delaying some payroll taxes until next year — but would then require payroll taxes to be doubled from January through April 2021 to restore losses.

However, within this executive order, Trump also asks his treasury secretary to “explore avenues, including legislation, to eliminate the obligation to pay the taxes deferred.” He was sounding an early call to scratch the itch and de-fund Social Security, along with Medicare.

And then, out campaigning more recently after his payroll tax delay order, Trump said: “If I win, I may extend and terminate. In other words, I’ll extend it beyond the end of the year and terminate the tax.”

If he were, in fact, to “terminate” the payroll tax, Trump would effectively leave the Social Security system with no ongoing funding at all. That means no Social Security and no Medicare benefits, since all funding of the system will have been terminated.

The Social Security Administration’s chief analyst, Stephen Goss, recently stated that if Trump’s (Republican) plan goes into effect, “we estimate that [the Disability Insurance] Trust Fund asset reserves would become permanently depleted in about the middle of calendar year 2021,” and that “the Social Security Trust Fund would become permanently depleted by the middle of calendar year 2023 with no ability to pay [Old-Age and Survivors Insurance] benefits thereafter.”

What does this mean for us if Trump, with his Republican majority, win?

What else does it mean?

James Ewing

Published as a letter to the editor in the Southampton Press this week.

Changing her mind on Medicare for All

David Posnett — Wed, 22 Jul 2020 17:42:42 +0000

https://thehill.com/opinion/healthcare/507348-how-i-changed-my-mind-on-medicare-for-all

Dr. Li Tso, opinion contributor July 14, 2020

I know most of the arguments against “Medicare for All.” I’ve been making them for most of my professional life as a physician:

1) We don’t need it; our current mix bag of public and private insurance coverage is adequate

2) Disrupting the private insurance industry would result in too many job losses

3) The government cannot be trusted to run a program of this size

4) We don’t have buy-in from a majority of constituents

5) We simply can’t afford it.

I’ve said all of these for 30 years. I now know that I am wrong.

Health care policy can be simplified to answering the basic question of who gets covered and at what cost. Universal coverage was once championed only by the most progressive. Then came COVID-19.

COVID has taught us that every member of our society needs adequate health care. This is not just a progressive talking point, it is the reality of infectious disease: those without proper care run the risk of acquiring and transmitting the disease to the rest of us.

The most marginalized segments of our population such as the homeless, undocumented workers, and the incarcerated still have contact with clerks in coffee shops, police officers, and staff in our emergency rooms. This was made evident when a homeless patient came to my practice’s office for wound care seven times over a two weeks period at the beginning of the pandemic before strict safety protocols were instituted. This patient subsequently tested positive for COVID-19. Fortunately, none of the staff in my practice contracted COVID from this patient. This scenario is just a microcosm of what can go wrong if we do not care for everyone.

Universal coverage is no longer charity or a luxury, it’s now medically necessary as protection for us all.

COVID has also taught us that tying insurance to employers no longer makes sense. It’s a historical accident that we even have this system: The Stabilization Act of 1942 was passed to limit war-time inflation and limited employers’ ability to raise wages, but there was an exemption for “insurance and pension benefits” which could grow “in a reasonable amount” during the freeze.

Suddenly, employers were in the health insurance business as health benefits could be considered compensation but did not count as taxable income.

When Congress rewrote the tax code in 1954, it preserved the tax subsidies for third-party insurance, and by 1964, almost 80 percent of the population had some form of employer-sponsored health insurance.

This system sort of worked until the cost of health coverage became too expensive and companies, especially small companies, reduced or eliminated coverage. Today, Kaiser Permanente estimates that only about 49 percent of Americans get their coverage this way.

COVID made it clear what a weak link this is as sudden massive unemployment can quickly result in public health catastrophe. More than 30 million people lost their jobs — and for many, their health insurance–in just a few months of lockdown. Many of these people run the risk of being suddenly uninsured.

Yes, Medicare for All will cost a lot, and it will cause huge disruptions. But disruption is part of free enterprise and innovation. Why should health care companies be exempt? It makes little sense and is almost un-American. Think electricity replacing whale oil, combustible engine replacing horse and buggy, the invention of the computer, the internet, smartphones, fax machines. Each innovation caused massive job restructuring but they also made our lives better and easier. By some estimates, Amazon has resulted in the elimination of 1.5 million retail jobs. Are health insurance jobs more vital than retail jobs? In the case of Medicare for All, displaced private insurance workers are the very ones the government would need to hire and help implement the new program.

For many years I didn’t trust the government to run a system as large as Medicare for All — not when the DMV can barely handle your license renewal. Consider our newest department, the Department of Homeland Security, which was created in 2002. DHS now has over 240,000 employees and a budget of nearly $50 billion. Bureaucracy exists within any large organization. We now readily accepted this new department after the terrorist attacks of 9/11. Aside from the extremists, no one is calling for the dismantling of major departments due to bureaucracy.

Medicare for All will certainly be expensive. Projections range from 13-47 trillion dollars over 10 years.

Critics claim that this enormous amount would bankrupt our treasury and unfairly pass down this debt to our children and grandchildren. However, other than for a short duration in the 1990s, the U.S. government has run a budget deficit every year since 1970. Our national debt is now over 25 trillion dollars and will surely grow in the future. Economists continue to debate about the meaning and consequence of this large debt.

The United States government has spent more than six trillion dollars to help support the economy during the pandemic with widespread support from both politicians and the public and very muted dissent from the traditional deficit hawks. That’s because it’s clear to politicians that the stimulus is preventing a broader crisis. Deficit spending is considered not only reasonable but a wise use of resources when it provides benefit to a large segment of our population.

The sizable cost of 1 to 4 trillion per year for universal health coverage is justifiable and may even appear to be a bargain considering the amount we have already spent on COVID, and the amount people will continue to spend on the most expensive health care system in the world. We currently are already spending nearly $4 trillion per year on U.S. healthcare. Despite this enormous amount, we still have gaps in coverage and we rank poorly as measured by healthcare access and quality index compared with other developed countries.

COVID has made clear that we need to reframe the way we think about universal health coverage. It would be naïve to think that COVID will be our last novel pathogen or last economic shock. The disruption and cost of permanent universal coverage is indeed high but the cost of not pursuing this policy will likely be much higher.

Li Tso, M.D. is a primary care physician at Mass General Hospital, assistant professor of medicine at Harvard Medical School.

Lee Zeldin’s Record

David Posnett — Thu, 11 Jun 2020 17:00:39 +0000

No matter where you live — Montauk or Manorville, Smithtown or Shirley, Patchogue or Port Jefferson — we all want our communities to thrive. To do that, we need a representative who puts our needs first: safe drinking water and well-paying jobs. Affordable healthcare and prescription drugs. A tax plan that works for working families. And decisions based on science, not donations. Although Zeldin says he’s fighting for us, his voting record says otherwise. Zeldin serves the needs of big business and the powerful few, not the working families in his district.

Check out the issues here. For example healthcare.

NY-01 deserves a representative who puts us first.

Photo Courtesy of Sean P. Mills Photography

VOTES DON’T LIE. FOLLOW US ON SOCIAL.

Facebook: @LeeZeldinRecord | Twitter: @ZeldinRecord

Website: https://www.leezeldinrecord.com/

COVID-19 is here!

David Posnett — Mon, 09 Mar 2020 20:21:29 +0000

We now have a confirmed case admitted at Southampton Hospital. It is time to reassess. Although there is but a single patient confirmed on the South Fork of Long Island, suspicion is running high. (update 3/11: 6 cases in Suffolk county including one in the retirement home PECONIC LANDING). A local physician tells me that patients with potential COVID-19 symptoms are examined in the parking lot, in their cars, by the physician (wearing protective gear). This is in order to avoid transmission to critical medical staff in the office. Healthcare professionals are a known risk group for contacting COVID-19. But physicians on the South Fork are still struggling to get testing for their patients.

Delays in testing

A few days ago I called the Suffolk County Department of Health to inquire about getting COVID-19 tests done on people that had recently returned from international travel to countries with now well-documented outbreaks. These persons also had flu-like symptoms. The county officials thought this did not meet CDC criteria for testing (no high fever and no acute respiratory distress) and they recommended self-isolation. I know first hand how unreliable self-isolation can be! A recent news report confirmed my suspicions when a Missouri patient’s family broke quarantine to attend a school dance!

The problems seem to have been threefold — the Centers for Disease Control did not move quickly enough to manufacture test kits at scale (either because of lack of funding or political will) nor did it open up testing options to other institutions that could have worked to develop tests — and because of the limited availability of tests, the CDC rationed how many tests were performed. Those issues were compounded by the initial release of faulty tests by the CDC in early February.

As former U.S. Food and Drug Administration official Scott Gottlieb wrote on Twitter in early February, “Since CDC and FDA haven’t authorized public health or hospital labs to run the tests, right now #CDC is the only place that can.

Also, the CDC has somewhat arbitrary criteria (?) for placing countries on the list of places that will increase your risk of having contracted COVID-19. Here is a list of countries with documented cases as a percentage of the population size. Level 3 Travel Health Advisory (CDC) applies only to the top 4 on the list. Note that Bahrain with 5.42 documented cases/100,000 inhabitants does not make the list while China with 5.79 does! Neither does Switzerland with 3.96 cases, where many cases have been tourists from its southern neighbor, Italy.

The above graph comes from a local Swiss Newspaper (NZZ) – test your German skills!

By January there was a test available. It was offered worldwide by Roche, Inc. FOR FREE and to any country in the world! The US declined the offer. Read more about these early missteps here.

The above report is from a Zurich Newspaper: note the date on the sample is Jan 29th 2020.

Note also, patients that took the test were billed about $200 (SFR 180) for labor of administering the test. That was their entire cost.

At the time an astute observer commented: “It’s very difficult to understand that countries like the US didn’t seize the opportunity to get the test for free. Perhaps some US companies wanted to make money by developing their own tests?”

Thermo Fisher Scientific corporation provides the COVID-19 test in the US currently. According to the Associated Press, Donald Trump, has listed investments in Thermo Fisher Scientific Corporation (TMO), which moved jobs out of the U.S. in high profile outsourcing deals. Apparently, Donald Trump stands to profit from medical testing of coronavirus that will now take place in the United States.

The response by the administration

The reason that COVID-19 cases are low in the USA is most likely because it has been difficult to get patients tested.

For instance, a recent CDC conference gave us a glimpse into Trump’s view of the coronavirus as a political rather than health issue. Trump said he would rather have the passengers of the Grand Princess, a cruise ship docked in San Francisco with 21 confirmed cases on board, stay on the ship than move to land — all because doing so would raise the number of total Covid-19 cases in the US:

“I would rather because I like the numbers being where they are,” Trump said. “I don’t need to have the numbers double because of one ship that wasn’t our fault.”

It is unclear how many people have been infected by the virus due simply to a delay in testing, but it has become increasingly clear in recent days that there are Americans infected with the virus across the country. It is naive to think that one can suppress the numbers.

Trump fears the fall out on the economy and indirectly on his political chances in November. But his actions are likely to make things worse for himself.

The coronavirus outbreak has U.S. companies starting to shutter offices and send workers home through layoffs, furloughs or directives to telecommute until health risks from the spreading virus recede. Even if that’s helpful to guard against further spread of the disease, it’s triggering widespread uncertainty and the biggest threat to the labor market since the financial crisis almost a dozen years ago.

The evidence is expected to show up through lost consumer spending.
“If workers can’t work … production and income go down,” Georgetown University economist Harry Holzer said. “That becomes a demand problem if workers lose income and stop spending.” When that happens, “odds of recession can go way up.”

Eleven states, including California, Massachusetts and New York, require employers to offer workers paid leave, as does the District of Columbia. But none of these jurisdictions explicitly guarantee the benefit to healthy workers on leave because a virus outbreak sent everybody home.

Fourteen Democratic senators last week wrote to leaders of the Business Roundtable, the Chamber of Commerce and the National Association of Manufacturers to urge their member companies not to penalize workers for going home during the outbreak.
Paid sick days are particularly rare for low-income workers. Ninety-three percent of workers in the top tenth of the income distribution get paid sick leave, compared with only 30 percent of those in the bottom tenth, according to the Economic Policy Institute, a left-leaning think tank.

Our Healthcare system can not handle a pandemic efficiently

Finally, let’s consider our health care system and how it is ill-suited to handle a pandemic: America’s Health System Will Likely Make the Coronavirus Outbreak Worse
Out-of-network costs, high deductibles, and confusing coverage options may keep people from getting tested or receiving care (Abigail Abrams)

Deductibles, networks, and a complicated insurance bureaucracy—that already make it tough for many Americans to afford medical care under normal conditions will likely make the outbreak worse.

First, people must actually choose to get tested—a potentially expensive prospect for millions of Americans. While the government will cover the cost of testing for Medicaid and Medicare patients, and for tests administered at federal, state and local public health labs, it’s unclear how much patients will be charged for testing at academic or commercial facilities, or whether those facilities must be in patients’ insurance networks. Just recently, a Miami man received a $3,270.75 bill after going to the hospital feeling sick following a work trip to China. (He tested positive for the seasonal flu, so did not have the new coronavirus, and was sent home to recover.)

Those who test positive for COVID-19 possibly face an even more financially harrowing path forward. Seeking out appropriate medical care or submitting to quarantines—critical in preventing the virus from spreading further—both come with potentially astronomical price tags in the U.S. Last month, a Pennsylvania man received $3,918 in bills after being released from a mandatory U.S. government quarantine after he and his daughter were evacuated from China. (Both the Miami and Pennsylvania patients saw their bills decrease after journalists reported on them, but they still owe thousands.)

In 2019, 82% of workers with health insurance through their employer had an annual deductible, up from 63% a decade ago, according to a report from the Kaiser Family Foundation. The average deductible for a single person with employer insurance has increased from $533 in 2009 to $1,396 last year. The timing of the new coronavirus at the beginning of the year makes the outlook even worse: because most deductibles reset each January, millions of Americans will be paying thousands out of pocket before their insurance companies pay a cent.

Many patients may simply decide not to go to the doctor, which is “exactly the opposite of what we want to happen in this type of situation.”

Public health experts and Democrats have also criticized the Trump administration’s decision to allow people to sidestep the Affordable Care Act’s rules and buy limited, short-term health insurance coverage. Such “junk plans,” are not required to cover diagnostic tests or vaccines.

A large group of health, law and other experts released a letter this week urging policymakers to “ensure comprehensive and affordable access to testing, including for the uninsured.”

The Trump Administration is considering using a national disaster recovery program to reimburse hospitals and doctors for treating uninsured COVID-19 patients. And even Republicans, who have traditionally opposed health care paid for by the government, are warming to the idea. “You can look at it as socialized medicine,” Florida Rep. Ted Yoho, who has vocally opposed the Affordable Care Act, told HuffPost this week. “But in the face of an outbreak, a pandemic, what’s your options?”

Sanders’ Vaporware

David Posnett — Sun, 08 Mar 2020 00:49:18 +0000

Published as an LTE in the East Hampton Star.

Vaporware
Springs, February 24, 2020

Why doesn’t Bernie Sanders level with voters as to how he plans to pay for his flagship “Medicare for All” plan? The answer is simple: He can’t.

Take a look at Sanders’s official campaign website and take a look at his program for Medicare for All. If as Senator Warren says Pete Buttigieg’s plan is nothing more than a “Post-it,” the Sanders plan is more like a postage stamp. Nowhere does his campaign site include a plan for paying for his pie-in-the-sky program. After spending seven-plus years of foisting this plan on voters, one would think he would be able to explain it to us. He can’t, because it is unworkably expensive.

In short, it is nothing but political vaporware. What is vaporware? When the term was in vogue it described efforts by software companies to promise a non-existent product to deceptively discourage customers from buying an existing competitive product (or discourage competitors from developing one). So what Sanders is doing is deceptively attracting voters to a Medicare for All plan that promises everything but will deliver nothing.

And what’s even worse is that there is proof of his plan’s nonviability from an actual attempt to launch a similar plan. And guess where that plan was tried? Vermont (Bernie’s home state)! In 2011, then-Governor Pete Shumlin euphorically promised a single-payer plan, dubbed Green Mountain Care. Backed by advocates bordering on the “theological,” Green Mountain Care (encouraged by Senator Sanders) promised a system of health care for all that would save money, even though no one knew what it would cost when it passed in 2014.

That belief proved hopelessly naïve. As the Green Mountain plan moved into implementation, it became clear that the plan would double Vermont’s budget, would require raising state income taxes by up to 9.5 percent, and imposing an 11.5-percent payroll tax on employers.

The Green Mountain Plan crashed in flames in 2014, after the governor realized that the only economically viable plan would offer Vermonters less protection than they already had.

So there is every reason for Senator Sanders to avoid discussing how his Medicare for All plan would be financed (other than in the broadest of generalities, like “taxes would go up.” (Yes, but how much?) There is an equally obvious reason why he fails to even mention the failed Vermont plan, and a mysterious absence of any explanation of how his plan would correct the deficiencies of the Vermont plan he touted at the time.

Given Senator Sanders’s evasions, it is incumbent upon voters (and his competitors) to put his feet to the fire and force him to explain in detail, with data, how his plan would be paid for and why it would behoove 150 million Americans to vote for a candidate who would deprive them of their existing health care for an unknown product. Until he comes clean, it’s vaporware, and voters should beware of being duped. Taking him on faith could not be more dangerous.

Sincerely, BRUCE COLBATH

Exposing Lee Zeldin’s Record on Healthcare

David Posnett — Thu, 05 Mar 2020 17:15:21 +0000

Remember the Graham Cassidy bill?

By Perry Gershon

Representative Lee Zeldin (R-NY1) is a master at telling half-truths. He goes to great lengths to tell his constituents that he supports healthcare coverage for people with pre-existing conditions and lowering prescription drug prices, but his voting record says differently. Zeldin voted against coverage for pre-existing conditions, and just recently shot down a bill for prescription drug coverage reform and prescription drug coverage reform. He even has the audacity to take credit for programs he voted against. A quick look at his record, however, is quite revealing.

Lee Zeldin voted to repeal the Affordable Care Act (ACA). He has cast several such votes in his three terms in office, most recently May 2017 (and he openly urges the courts to overturn the ACA now). The federal requirement to provide coverage for people with pre-existing conditions comes directly from the ACA, so Zeldin’s opposition to coverage for pre-existing conditions is right there in his votes! Zeldin and Trump claim to offer ACA-replacement legislation that provides for pre-existing condition coverage, but these bills do not protect consumers, especially those with pre-existing conditions. They provide no requirement that these individuals will not be penalized in pricing and availability of coverage.

When Congress, in December 2019, passed its bill to make prescription drugs more affordable, Lee Zeldin voted against the bill (HR-3). His position on this critical issue is again demonstrated by his vote. The only effective way to control the cost of prescription drugs is to let Medicare, the largest consumer, negotiate drug prices directly with the manufacturers. It’s no surprise that Zeldin continues to prohibit Medicare from negotiating because much of his campaign contributions come from drug makers and their affiliates. This isn’t me saying this, it’s right there in his campaign finance reports that he is legally obligated to file with the Federal Election Commission. Given Zeldin’s benefactors, it’s no wonder he opposes true prescription price reforms.

Zeldin takes credit for funding medical research at Stony Brook. His most recent February “newsletter” stated that he secured $3 million of new NIH grants to Stony Brook for medical research, and he cites a bi-partisan letter he signed requesting a budget increase specifically for NIH research. What Zeldin does not tell you is that when the actual budget came to a vote on July 25, 2019, he voted against it. His own voting record proves that Zeldin did not vote to increase NIH appropriations or increased funding for Stony Brook.

But Zeldin’s biggest deception of all is that he is has listened and knows what his constituents need for their healthcare. Again, the facts belie that. Zeldin’s last public town hall was in April 2017, before his vote to repeal the ACA. He has not held one since then. He has no idea what his constituents want or need!

Town halls are meant to be open to ALL constituents who want to attend. There should be no prescreening of questions or questioners (to exclude critics) or else it is not really a true town hall. I know this from first-hand experience.

I have held five open town halls since last September and I will hold five more before the end of June. I take questions from Democrats, Republicans – whoever attends and wants to ask a question. As a matter of fact, I take each and every question asked of me and I give truthful fact-based answers. There is no pre-screening and no spin at my town halls.

People on Long Island deserve a representative who will listen to them when they speak out about healthcare. I want to see universal healthcare for everyone – and I believe we can do it with the ACA supercharged with a public option. We need to allow Medicare to negotiate drug prices to achieve true pricing reforms. This November, we have a chance to give NY-1 a representative who will fight for us in Washington and tell us the truth here at home.

Originally published in the Village Times Herald

Curb Drug Costs: Makes Sense For All

David Posnett — Thu, 23 Jan 2020 15:31:21 +0000

By Mike Anthony, on page A10 of the Southampton Press:

http://digital.olivesoftware.com/Olive/ODN/SouthamptonEast/

Makes Sense For All

Dr. David Posnett’s informative letter about House of Representative bill HR3 [“Choosing Sides,” Letters, January 9], see prior post herein, details key elements of Congress’s promise to establish a consumer- and patient-friendly drug price negotiation system. Dr. Posnett aptly captures the gist of the matter in several paragraphs.

My prime takeaway: If the Veterans Administration can negotiate drug prices, why not the Centers for Medicare and Medicaid Services? High-quality and lower-cost drugs makes sense for all of us.

As Dr. Posnett points out, Congressman Lee Zeldin repeats the canard that “these policies would siphon $1 trillion from biopharmaceutical innovators over the next 10 years.” A cynic might ask: Why don’t the drug companies use some of their robust advertising budget and redirect it to research?

The thing is, you don’t have to be a cynic to think that way. Dr. Marcia Angell reveals how drug companies have strayed from their mission in “The Truth About the Drug Companies: How They Deceive Us and What to Do About It.” Here’s an excerpt from the publisher:

“As Dr. Angell powerfully demonstrates, claims that high drug prices are necessary to fund research and development are unfounded. The truth is that drug companies funnel the bulk of their resources into the marketing of products of dubious benefit.”

Any doubt about that? Just ask Purdue Pharma, the company that pleaded guilty to criminal charges of misbranding Oxycontin by claiming that it was less addictive compared to other opioids. Purdue was fined $634 million.

Yes, drug efficacy and safety are as important as pricing — and HR3 covers that as well.

NPR reports that several overseas generic drug manufacturers abuse safety protocols. In India, about 25 percent of inspected drug manufacturing plants violated drug integrity rules; in China, 32 percent of their plants violated these rules.

To guarantee the safe manufacture of drugs, HR 3 provides $920 million to improve regulatory oversight of medical products and to protect public health. And, most important to the East End community, HR3 provides $7.5 billion in funding for states, counties, cities and towns to fight the opioid epidemic.

Contact Congressman Zeldin and ask him to reconsider his opposition to HR3: https://zeldin.house.gov/contact/offices

Mike Anthony

Westhampton

Trump: I will “Negotiate Like Crazy”

David Posnett — Tue, 14 Jan 2020 15:29:19 +0000

https://www.27east.com/east-hampton-press/choosing-sides-1666846/

Choosing Sides

Donald Trump has repeatedly proposed to allow Medicare to “negotiate like crazy” on prescription drugs. Now, he is backtracking. Was this all showmanship? He probably realizes that skyrocketing drug prices will be an issue in 2020.

Here is where we stand.

HR3 is the House bill that recently passed, 230-192, with unanimous Democratic support. This bill requires the Centers for Medicare & Medicaid Services (CMS) to negotiate prices for certain drugs; current law prohibits the CMS from doing so. CMS must negotiate maximum prices for insulin products and expensive brand-name drugs that do not have generic competition.

In addition, the negotiated maximum price may not exceed 120 percent of the average price in Australia, Canada, France, Germany, Japan and the United Kingdom. This is meant to stop drug companies from ripping off Americans, while charging other countries less for the same drugs. Drug manufacturers that fail to comply are subject to penalties.

The bill also reduces annual out-of-pocket costs for patients to $2,000. Also, the Congressional Budget Office claims that HR3 would lower health insurance costs for employers and increase federal revenue by about $45 billion a year, because employer insurance premiums would decline, and those savings would manifest in increased taxable wages.

Sounds reasonable, right? Of course, pharma disapproves, and its arguments have become the Republican rallying cry: HR3 would stifle innovation and new drug development.

It’s exactly the ageless claim I have been hearing for over 40 years from the pharma industry — a claim meant to stifle price controls. I say this having worked with pharma companies in drug development as an outside collaborator and consultant: Note that every other first-world country has price controls, and their pharma industries do quite well. Note also that much of the “innovation” in this country comes from government-funded research grants (tax dollars). Pharma often gets a freebee when they pick up a promising project and help carry it to fruition (I’m thinking of anti-HIV drugs, for example).

U.S. Representative Lee Zeldin voted against HR3 and is one of the standard-bearers of the pharma party line. He’s covering himself politically by expressing support for a watered-down Senate bill, which has little chance of passage, even in the Senate.

Although one HR3 opposition group calls itself Voters for Cures, it is clear who they really are: They complain that “these drastic policies would siphon $1 trillion from biopharmaceutical innovators over the next 10 years.” And Lee Zeldin is on board, writing: “House Democrats’ legislation stifles medical innovation.”

One trillion dollars for big pharma? That’s your money.

By opposing HR3, Lee Zeldin has voted for the drug companies, against drug price controls and against the interest of his constituents.

David N. Posnett, M.D., East Hampton

Medical Debt Collectors Decide Who Gets Arrested

David Posnett — Thu, 24 Oct 2019 01:54:45 +0000

From ProPublica comes a shocking story. While things aren’t quite as bad where I live, I think the story is telling about what to expect in the future unless we somehow reform our healthcare system. (D. Posnett)

Ambulance > Judge > Jail

Welcome to Coffeyville, Kansas, where the judge has no law degree, debt collectors get a cut of the bail and Americans are watching their lives — and liberty — disappear in the pursuit of medical debt collection.

On the last Tuesday of July, Tres Biggs stepped into the courthouse in Coffeyville, Kansas, for medical debt collection day, a monthly ritual in this quiet city of 9,000, just over the Oklahoma border. He was one of 90 people who had been summoned, sued by the local hospital, or doctors, or an ambulance service over unpaid bills. Some wore eye patches and bandages; others limped to their seats by the wood-paneled walls. Biggs, who is 41, had to take a day off from work to be there. He knew from experience that if he didn’t show up, he could be put in jail.

…

Biggs, who is tall and broad-shouldered, with sun-scorched skin and bright hazel eyes, looked up as defendants talked, but he was embarrassed to say much. His court dates had begun after his son developed leukemia, and they’d picked up when his wife started having seizures. He, too, had been arrested because of medical debt. It had happened more than once.

Judge David Casement entered the courtroom, a black robe swaying over his cowboy boots and silversmithed belt buckle. He is a cattle rancher who was appointed a magistrate judge, though he’d never taken a course in law. Judges don’t need a law degree in Kansas, or many other states, to preside over cases like these. Casement asked the defendants to take an oath and confirmed that the newcomers confessed to their debt. A key purpose of the hearing, though, was for patients to face debt collectors. “They want to talk to you about trying to set up a payment plan, and after you talk with them, you are free to go,” he told the debtors. Then, he left the room.

The first collector of the day was also the most notorious: Michael Hassenplug, a private attorney representing doctors and ambulance services. Every three months, Hassenplug called the same nonpaying defendants to court to list what they earned and what they owned — to testify, quite often, to their poverty. It gave him a sense of his options: to set up a payment plan, to garnish wages or bank accounts, to put a lien on a property. It was called a “debtor’s exam.”

If a debtor missed an exam, the judge typically issued a citation of contempt, a charge for disobeying an order of the court, which in this case was to appear. If the debtor missed a hearing on contempt, Hassenplug would ask the judge for a bench warrant. As long as the defendant had been properly served, the judge’s answer was always yes. In practice, this system has made Hassenplug and other collectors the real arbiters of who gets arrested and who is shown mercy. If debtors can post bail, the judge almost always applies the money to the debt. Hassenplug, like any collector working on commission, gets a cut of the cash he brings in.

Across the country, thousands of people are jailed each year for failing to appear in court for unpaid bills, in arrangements set up much like this one. The practice spread in the wake of the recession as collectors found judges willing to use their broad powers of contempt to wield the threat of arrest. Judges have issued warrants for people who owe money to landlords and payday lenders, who never paid off furniture, or day care fees, or federal student loans. Some debtors who have been arrested owed as little as $28.

More than half of the debt in collections stems from medical care, which, unlike most other debt, is often taken on without a choice or an understanding of the costs. Since the Affordable Care Act of 2010, prices for medical services have ballooned; insurers have nearly tripled deductibles — the amount a person pays before their coverage kicks in — and raised premiums and copays, as well. As a result, tens of millions of people without adequate coverage are expected to pay larger portions of their rising bills.

The sickest patients are often the most indebted, and they’re not exempt from arrest. In Indiana, a cancer patient was hauled away from home in her pajamas in front of her three children; too weak to climb the stairs to the women’s area of the jail, she spent the night in a men’s mental health unit where an inmate smeared feces on the wall. In Utah, a man who had ignored orders to appear over an unpaid ambulance bill told friends he would rather die than go to jail; the day he was arrested, he snuck poison into the cell and ended his life.

In jurisdictions with lax laws and willing judges, jail is the logical endpoint of a system that has automated the steps from high bills to debt to court, and that has given collectors power that is often unchecked. I spent several weeks this summer in Coffeyville, reviewing court files, talking to dozens of patients and interviewing those who had sued them. Though the district does not track how many of these cases end in arrest, I found more than 30 warrants issued against medical debt defendants. At least 11 people were jailed in the past year alone.

With hardly any oversight, even by the presiding judge, collection attorneys have turned this courtroom into a government-sanctioned shakedown of the uninsured and underinsured, where the leverage is the debtors’ liberty.

Seated at the front of the courtroom, Hassenplug zipped open his leather binder and uncapped his fountain pen. He is stout, with a pinkish nose and a helmet of salt and pepper hair. His opening case this Tuesday involved 28-year-old Kenneth Maggard, who owed more than $2,000, including interest and court fees, for a 40-mile ambulance ride last year. Maggard had downed most of a bottle of Purple Power Industrial Strength Cleaner, along with some 3M Super Duty Rubbing Compound, “to end it all.” His sister had called 911.

Maggard took his seat. He had cropped red hair, pouchy cheeks and mud-caked sneakers. “The welfare patients are the most demanding, difficult patients on God’s earth,” Hassenplug told me, with Maggard listening, before launching into his interrogation: Are you working? No. Are you on disability? He was diagnosed with schizoaffective disorder, bipolar type, and anxiety. Do you have a car? No. Anyone owe you money you can collect? I wish.

They had been here before, and they both knew Maggard’s disability checks were protected from collections. Hassenplug set down his pen. “Between you and me,” he asked, “you’re never going to pay this bill, are you?”

“No, never,” Maggard said. “If I had the money, I’d pay it.”

Hassenplug replied, “Well, this will end when one of us dies.”

Though debt collection filings are soaring in parts of America, Hassenplug speaks with pride about how he discovered their full potential in Coffeyville long before. A transplant from Kansas City, he was a self-dubbed “four-star fuck-up” who worked his way through law school. He moved to Coffeyville to practice in 1980 and soon earned a reputation as a hard ass. He saw that his firm, Becker, Hildreth, Eastman & Gossard, hadn’t capitalized on its collections cases. The lawyers didn’t demand sufficient payments, and they rarely followed up on litigation, he said. Where other attorneys saw petty work, Hassenplug saw opportunity.

Hassenplug started collecting for doctors, dentists and veterinarians, but also banks and lumber yards and cities. He recognized that medical providers weren’t being compensated for their services, and he was maddened by a “welfare mentality,” as he called it, that allowed patients to dodge bills. “Their attitude a lot of times is, ‘I’m a single mom and … I’m disabled and,’ and the ‘and’ means ‘the rules don’t apply to me.’ I think the rules apply to everybody,” he told me.

He logged his cases in a computer to track them. First with the firm and later in his own practice, he took debtors to court, and he won nearly every time; in about 90% of cases nationally, collectors automatically win when defendants don’t appear or contest the case. Hassenplug didn’t need to accept $10 monthly payments; he could ask for more, or, in some cases, even garnish a quarter of a debtor’s wages. His fee was, and often still is, one-third of what he collects. He asked the court to summon defendants, over and over again. It was the judge’s contempt authority that backed him, he said. “It’s the only way you can get them into court.”

The power of contempt was originally the power of kings. Under early English rule, monarchs were considered vicars of God, and disobeying them was equivalent to committing a sin. Over time, that contempt authority spread to English courts, and ultimately to American courts, which use it to encourage compliance with the judicial system. There is no law requiring that a court use civil contempt when an order isn’t followed, but judges in the U.S. can choose to, whether it’s to force a defendant to pay child support, for example, or show up at a hearing. A person jailed for defying a court order is generally released when they comply.

When Casement took the bench in 1987, after passing a self-study exam, he didn’t know much legalese — he had never been in a courtroom. But attorneys taught him early on that the power of contempt was available to him to punish people who ignored his orders. At first, Casement could see himself in the defendants. “I was a much more pro-debtor aligned judge, much more sympathetic, much less inclined to do anything that I thought would burden them,” he told me. “And over the years, I’ve gradually moved to the other side of the fulcrum. I still consider myself very much in the middle, and I don’t know if I am or not.”

Once a bustling industrial hub, Coffeyville has a poverty rate that is double the national average, and its county ranks among the least healthy in Kansas. Its red-bricked downtown is lined with empty storefronts — former department stores, restaurants and shops. Its signature hotel is now used for low-income housing. “The two growth industries in Coffeyville,” Hassenplug likes to say, “are health care and funerals.”

Coffeyville Regional Medical Center is the only hospital within a 40-mile radius, and it reported $1.5 million in uncollectible patient debt in 2017. A nonprofit run in a city-owned building, the hospital accounts for the vast majority of medical debt lawsuits in the county — about 2,000 in the past five years. It also accounts for the majority of related warrants. Account Recovery Specialists Inc. handles its collections, and it does so for hospitals in most Kansas counties. Though the hospitals can direct ARSI and its contracted attorneys to tell judges not to issue warrants, hardly any have. The Coffeyville hospital’s attorney, Doug Bell, said that its only motivation is to continue to serve the area, and that Kansas’ decision to not expand Medicaid under the Affordable Care Act has had a “dramatic effect on the economic liability of small rural hospitals.”

Three nearby hospitals in this rural region have closed in the past several years, meaning ambulances make more trips. A half-hour from Coffeyville, Independence runs its ambulance service at about a $300,000 annual loss. Its bills were at the root of four arrests this year alone. Derek Dustman, who is 36 and works odd jobs, had been driving a four-wheeler when he was hit by a car and rushed to the hospital. Though he was sued for not paying his $818 ambulance bill, he didn’t have a license to drive to the courthouse. This spring, he spent two nights in jail. “I never in a million years thought that this would end with jail time,” he told me.

For years, Hassenplug has requested that the judge issue warrants on the ambulance service’s behalf. When I asked Lacey Lies, the city’s director of finance, if she ever considered telling him not to resort to bench warrants, she was puzzled. “You’re saying an attorney with no teeth?”

The first time Tres Biggs was arrested, in 2008, he was dove hunting in a grove outside Coffeyville. It had been just a year since his 6-year-old son Lane was diagnosed with leukemia, and Biggs watched him breathe in the fresh air, seated on a haybale under an orange sky. When a game warden came through to check hunting permits, Biggs’ friends scattered and hid. He wasn’t the running type, and he took Lane by the hand. The warden ran Biggs’ license. There was a warrant out for his arrest. Biggs asked a friend to take Lane home and crouched into the warden’s truck, scouring his memory for some misstep.

The last few years had been a blur. His wife, Heather, had quit her job as a babysitter to care for their son. Then, she got sick. Some days, she passed out or felt so dizzy she couldn’t leave her bed. Her doctors didn’t know if the attacks were linked to her heart condition, in which blood flowed backward through a valve. To provide for his wife, son and two other kids, Biggs worked two jobs, at a lumber yard and on construction sites. He didn’t know when he would have had time to commit a crime. He’d never been to jail. As he stared out the window at the rolling hills, his face began to sweat. He felt his skin tighten around him and wondered if he would be sick.

The warrant, he learned at the jailhouse, was for failure to appear in court for an unpaid hospital bill. Coffeyville Regional Medical Center had sued him in 2006 for $2,146, after one of Heather’s emergency visits; neither of his jobs offered health insurance. In the shuffle of 70-hour workweeks and Lane’s chemotherapy, he had missed two consecutive court dates. He was fingerprinted, photographed, made to strip and told to brace himself for a tub of delousing liquid. His bail was set at $500 cash; he had about $50 to his name.

His friend bailed him out the next morning, but at the bond hearing, the judge granted the $500, minus court fees, to the hospital. Biggs compensated his friend with a motorboat that a client had given him in exchange for a hunting dog. But it wasn’t long before the family received a new summons. In 2009, a radiologist represented by Hassenplug sued them for $380.

Some court hearings fell on days when Lane had treatment, at a hospital in Tulsa, an hour south. Heather refused to postpone his care. Lane’s condition was improving — in a year, he would be cancer-free — and his dirty blond hair was sprouting again. Her health, though, had taken a turn. She began having weekly seizures, waking up on the floor, confused about where their Christmas tree had gone or why a red Catahoula puppy was skidding around their ranch house. Her doctors concluded she had Lyme disease, which was affecting her nervous system and wiping her short-term memory. Each time she woke up, she repeated: “Don’t take me to the hospital.”

Biggs was still on the hook for the bill that had landed him in jail; bail had covered only part of it, and the rest was growing with 12% annual interest. The hospital had garnished his wages, and the radiologist had garnished his bank account, seizing contributions that his family had raised for Lane’s care. Living on $25,000 a year, Biggs couldn’t afford to buy insurance. His family was on food stamps but didn’t qualify for Medicaid, a federal insurance program for people in poverty. Other states were about to expand it to cover the working poor, but not Kansas, which limited it, for families of his size, to those who earned under $12,000. Like millions of others across America, he and Heather fell into a coverage gap.

By 2012, the Biggs family had accrued more than $70,000 in medical debt, which it owed to Coffeyville Regional Medical Center and other hospitals, pediatricians and neurologists. Some forgave it; others set up lenient payment plans. Coffeyville’s was the only hospital that sued. The doctors who took them to court were represented by Hassenplug.

Biggs began to panic around police, haunted by the fear that at any moment, he might be locked up. That spring, outside the Woodshed gas station, he spotted a sheriff’s deputy who was also an old friend. To shake off his dread, he asked the friend to run his license. The deputy found another warrant, signed by Casement, involving the $380 radiologist’s bill. “You’re not really going to take me in, right?” Biggs remembers asking. The deputy said he had no choice. Bail, as usual, was set at $500.

The family filed for bankruptcy, a short-term fix that erased their debt but burdened them with legal fees. They lost their home and started renting. Biggs ultimately got a job that offered insurance, as a rancher, covered by Blue Cross Blue Shield. But it required Biggs to pay the first $5,000 before it covered medical expenses. When chest pain hit him as he worked cattle in the heat, and he began vomiting, the only nearby hospital was Coffeyville’s. In 2017, the hospital sued again. It was the family’s sixth lawsuit for medical debt.

Sitting in Casement’s courtroom this July, Biggs calculated that he was losing about $120 by taking time off from work to attend this hearing. “I haven’t received a bill,” he told me, slouched over his turquoise shorts. “The only thing I received was this summons.” Around noon, he finally sat down with an ARSI representative, who explained that the underlying bill had been garnished from his wages, but he still owed $328 in interest and court fees. He had another couple thousand dollars in collections for separate bills he hadn’t paid, for which he hadn’t yet been sued. He said the most he could afford to pay, every two weeks, was $12.50.

Before the end of the Tuesday docket, Casement returned to the courtroom to read off the names of the hospital’s defendants. Five had failed to show up for contempt citations, to give their reasons for missing their debtor’s exams. Casement saw that two of the no-shows hadn’t been properly notified of the hearing, so attorneys would need to try to reach them again. The judge read the names of the other three defendants and told the hospital’s collections lawyer, “That would be a bench warrant if you want it.”

The following morning, I was reading court files in the clerks’ office when Christa Strickland arrived at 10:20 in flip-flops and black leggings, her caramel hair wrapped in a bun atop her head. She ran her finger down a docket on the bulletin board and asked why her case wasn’t listed. When the clerk pulled up her file, she told Strickland that her contempt hearing had been on Tuesday and she was one day late. “You need to call the law office of Amber Brehm,” the clerk insisted, referring to ARSI’s contracted lawyer, who represents the hospital. She handed over the phone number.

Strickland sat on a hard bench and took out her cellphone. She had saved the hearing in the wrong day on her calendar, but she had taken the day off from work and wanted to clear up the misunderstanding. “I had a court date,” she said when a man answered at the law office. “I thought it was today but apparently it was yesterday. I’m just needing to see if I can set something up?”

“By not appearing at that, the court would be in the process of issuing a bench warrant,” he said.

“What does that mean?” Strickland asked, shaking her head.

“You don’t know what a bench warrant means?” he asked. “That means you will be arrested and taken to jail and ordered to post bond.”

“Oh my God.” Strickland squeezed her eyes shut, wetness smudging her mascara. She poked at her cheek with her index finger. Her father was a preacher. She’d never been in trouble with the law. She had made a mistake, she tried to explain. She wanted to make an arrangement to pay.

The man on the phone told her that it might take a couple weeks before the court processed her warrant paperwork, which the law office had not yet submitted. Once the judge issued the warrant, she could turn herself in. Strickland wanted to scream, I’ll pay the bill, don’t make me go to jail! but she didn’t have the money. Instead, she looked at the ceiling and asked: “Turn myself into the court? The police station?”

“The Sheriff’s Department,” he responded.

“They’re here in the same building,” she said. “I won’t leave here until I get this figured out. Thank you!”

She hung up. Prick, she muttered to herself. You’re going to talk to me like I’m a freaking idiot? That’s not okay. Educate me. The court has to process it? Her mind kept moving in circles. She herself worked in debt collection, for an auto title lending company. She understood that everyone was doing their job. Still, she couldn’t grasp how this bill had gotten this far.

Before she had taken this position, during her second pregnancy, her right breast had developed a chronic infection. In 2008, she was uninsured, needed surgery to remove the swollen abscess and ran up a $2,514 bill. More than a decade later, she was still chipping away at a balance that, because of interest and court fees, had more than doubled to $5,736. She had fallen behind on her monthly payment plan and now worried that her booking photo would be on Mugshot Monday, a Facebook album run by the Police Department. She imagined what she would tell her boss: I went to jail … because I missed a court date … for medical bills. It sounded absurd.

She spotted a sheriff’s deputy in a bulletproof vest with a name tag that said Bishop and a pistol on his hip. “Hey!” she called out, explaining her phone call and how the man said something about a warrant and turning herself in. Bishop radioed into dispatch and smiled with an update: “There’s no warrant in the system yet,” he told her.

“Yet!” Strickland replied, deflating his look of reassurance. “That’s what I’m worrying about.”

“You better give Amber a call back,” Bishop said.

When I asked ARSI about how attorneys decide to request warrants, Joshua Shea, who is general counsel, told me that they don’t. The judge can choose to issue one if court orders are not followed, he said. But Casement said the opposite, telling me that he gave the choice to the attorneys. “I’m not ordering a bench warrant. My decision is to give them that option,” Casement told me. “Whether they exercise it is up to them, but they have my blessing if that’s what they want to do.”

Shea sent me an eight-page email to make clear, in large part, that ARSI, as a collection agency, has no involvement in the courts, and that Brehm is a lawyer whom the agency contractually employs and who represents the hospital directly. Her email address, though, has an ARSI domain, and her resume lists her as ARSI’s director of legal. Brehm said that court hearings aren’t the only option for debtors, who can call her instead and answer questions under oath. Shea said nobody — not the hospital, ARSI, Brehm or the court — uses the threat of jail to “extract payment.”

Strickland reached Brehm after several days, and the attorney agreed to a new hearing. On Aug. 13, when they met in court, Brehm sat at the front of the room.

“We’re giving you a second chance on that citation; just to try to take care of this without there having to be any sort of bench warrant,” the lawyer said. “I want to make sure that we’re all on the same page about the consequences of not coming into court when the order has been issued.”

Strickland nodded.

“Again, if you set a payment plan and keep it,” Brehm said, “we won’t have to worry about that.”

In some courthouses, like Coffeyville’s, collection attorneys are not only invited to decide when warrants are issued, but they can also shape how law is applied. Recently, Hassenplug came to believe that debtors were only attending every other hearing in a scheme to avoid jail, and he raised his concern with the judge. He suggested that the judge could fix this by charging extra legal fees; Casement wrote a new policy explaining that anyone who missed two debtor’s exam hearings without a good reason would be ordered to pay an extra $50 to cover the plaintiff’s attorney fees. If they didn’t pay, they would be given a two-day jail sentence; for each additional hearing that they missed, they would be charged a higher attorney fee and get a longer sentence.

Most states don’t allow contempt charges to be used for nonpayment, and some, like Indiana and Florida, have concluded that it is unconstitutional. Michael Crowell, a retired law professor at the University of North Carolina and an expert in judicial authority, reviewed Casement’s policy. “You can’t lock people up for contempt for failing to pay unless you have gone to the trouble to determine that they really have the ability to pay,” he said. Casement told me he hadn’t made findings on ability to pay before ordering defendants to foot attorney’s fees, “but I know that’s something the court should consider,” he said. He also made plain why he wrote the policy: “Mr. Hassenplug and Brehm’s outfit have asked me to.” (Brehm denied she requested this.)

Casement has not done everything the debt collection lawyers have suggested. At first, he agreed to their requests to set bail at the amount of the debt, but he eventually settled on $500. “Most people can come up with $500,” he said. “It may not be their money, but they know someone who will pay.” He made sure no one was arrested unless they’d been reached by personal service or certified mail.

Kansas law allows courts to order debtors in “from time to time,” leaving discretion to judges. Casement limited the frequency of Hassenplug’s debtor’s exams to once every three months. He came to the decision by his own logic around what seemed like a reasonable burden for defendants, and it remains his personal policy today. The law also states that anyone found to be disabled and unable to pay can only be ordered to appear once a year. Without an attorney, debtors like Kenneth Maggard don’t know to assert this right.

Allowing bail money to count toward collections raises some of the most critical legal questions. Hassenplug told me that he thinks it’s great that cash bail is applied to the debt. “A lot of times, that’s the only time we get paid, is if they go to jail,” he said. Peter Holland, the former director of the Consumer Protection Clinic at the University of Maryland Law School, explained that this practice reveals that the jailing is not about contempt, but about collection. “Most judges will tell you, ‘I’m working for the rule of law, and if you don’t show up and you were summoned, there have to be consequences,’” he explained. “But the proof is in the pudding: If the judge is upholding the rule of law, he would give the bail money back to you when you appear in court. Instead, he is using his power to take money from you and hand it to the debt collector. It raises constitutional questions.”

Congress has not acted on advocates’ calls to amend the Fair Debt Collection Practices Act to prohibit collectors from requesting warrants. There are also no current efforts to bar nonprofit hospitals or medical providers that receive funds through Medicare or Medicaid from seeking warrants. Some states have reformed their laws, to make sure defendants are properly served or to prohibit wage garnishments for debt. But legal experts on collections say that more remains to be done, like taking jail out of the equation and instead requiring debtors to sign a financial affidavit or a promise to appear.

Shea, from ARSI, said that using the legal process is time-consuming and costly — a last resort; arrests are “the least desirable stage for any case to reach for all involved.” Even after lawsuits are filed, they try to connect eligible debtors with the Coffeyville hospital to apply for financial assistance, he said. Last year, the hospital wrote off $1.7 million in charity care, said Bell, the hospital lawyer. “That is evidence of a hospital that cares.”

Casement said he did not consider the legality of his policies a problem. He placed some blame on the health care system. “What we have isn’t working,” he said. “As a lifelong Republican, I would probably be hung, but I think we need health care for everybody with some limits on what it’s going to cost us.”

The way he saw it, he had wide latitude to enforce compliance with a court order, though he acknowledged that creditors used bail money to their advantage. “I don’t know whether the Legislature intended it to be used that way or not,” he told me. “I have not had enough pushback from the defendants’ side to give me the impression that I’m really abusing this badly.”

Before I left Coffeyville, I sat down with Hassenplug in the low-ceilinged courtroom. I asked him whether he thought that the system in Coffeyville was effectively imprisonment for debt, in a country that has outlawed debtors’ prisons. “The only thing they’re in jail for is not appearing,” he replied. “I do my job, I follow the law. You just have to show up in court.”

Debt collection is an $11 billion industry, involving nearly 8,000 firms across the country. Medical debt makes up almost half of what’s collected each year. Today, millions of debt collection suits are overwhelming state courts. The practice is considered a “race of the diligent,” where every creditor is rushing to the courthouse, hustling to get the first judgment, in order to be the first to collect on a debtor’s assets. In Hassenplug’s view, though, this work is not the rich taking from the poor. He laughed at how locals spread rumors, saying that he seized wheelchairs or Christmas trees. Once, he confessed, he took a man’s Rolex, only to find out it was a fake. Some months, he said, even his law office could not make ends meet.

After a couple of hours, a clerk poked her head into the courtroom and told us it was time to leave. Hassenplug and I began to walk out, and on the terrazzo steps, he asked if I wanted to see his buildings. He owned five of them on a shuttered stretch of town. He wondered out loud if he was making a mistake by inviting me, but he was pleased when I accepted. “There ain’t any place on earth quieter than downtown Coffeyville,” he said, leading me into the silent streets.

He walked me through the alleys under a cloudless sky, and when he arrived at one of his buildings, he tapped a code to his garage. The door lifted, and inside, five perfectly maintained motorcycles, Yamahas and Suzukis, were propped in a line. To their left, nine pristine, candy-colored cars were arranged – a Camaro SS with orange stripes, a Pontiac Trans Am, a vintage Silverado pickup with velvet seats. He toured me around the show cars, peering into their windows, and mused about what his hard work had gotten him.

By Lizzie Presser, Photography by Edmund D. Fountain October 16, 2019. Doris Burke contributed research.

Correction, Oct. 16, 2019: This story originally misstated the type of cancer Tres Biggs’ son, Lane, had. It was leukemia, not lymphoma.

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica’s Big Story newsletter to receive stories like this one in your inbox as soon as they are published.

The emphases are mine (D. Posnett)

Wendell Potter on ‘Medicare For All’

David Posnett — Fri, 12 Apr 2019 21:50:39 +0000

Medicare For All: A Conversation with Wendell Potter

by Francesca Rheannon

The campaign against Medicare For All is being fueled by health insurance cash to politicians.

The health insurance industry is mounting a full court press against Medicare For All. Former health insurance industry executive and whistleblower Wendell Potter says one big way they’re doing that is by making sure their talking points are repeated by politicians who have taken big donations from them.

Potter had an inside seat to the process when he was a health insurance executive for Cigna. He blew the whistle on the industry with his books, Deadly Spin and Nation On the Take. He went on to found the website Tarbell.org, which does investigative journalism on the healthcare industry.

I spoke with Wendell Potter for my radio show Writer’s Voice about the health industry’s talking points against Medicare For All and how he counters them. What follows is part of that interview, lightly edited for reading. I started out by asking Potter who were the different players in the health care industry that are involved in the campaign against Medicare For All.

Wendell Potter: There’s this front group that was formed last year by health insurance companies, pharmaceutical companies, and big hospital chains through their trade associations, the American Hospital Association and the Federation of American Hospitals, which is the for-profit hospital organization and they’re pooling their money–-all these parts of healthcare–-to finance collectively this campaign against Medicare for All.

Francesca Rheannon: Why are the hospitals against Medicare For All?

WP: The hospitals are against it because they’ve got a good thing going. One of the things I often tell people is that it’s not really accurate to think that health insurance companies are really all that much in the game to control healthcare costs. They’re not. They can’t, for one reason or another, nor do they have an interest in doing it, because the more healthcare costs go up, the more money they are able to demand from us in terms of premiums.

Hospitals are in on the game, in that, because health insurance companies cannot really control health care costs, the hospitals can pretty much have their way with them. So they like the system as it is. They get more money from private insurers than they do from the current Medicare program or from the Medicaid program, and it’s because of the weakness and the smallness of individual private insurance companies.

FR: So, what are the industry talking points that politicians, including some Democrats, are using?

WP: Some of the talking points are that this country can’t afford Medicare For All, that it would cost too much money and that so many Americans get their coverage through their workplace.

Those are talking points directly from the insurance industry and this partnership that I mentioned, to scare people, to make them think that this is really not something that we should strive for, that we shouldn’t even give it any consideration.

It is true, most Americans who are not enrolled in Medicare or Medicaid or some other public program do get their coverage through private insurers. That’s the way it’s been for in this country for many, many decades. But it doesn’t mean it always has to be that way. And the reality also is that many people who are enrolled—in fact probably a majority—of people enrolled in private insurance plans through their workplace, are finding that their coverage is increasingly less valuable, even though they’re paying more for it every single year.

So, I know that in reality a lot of people are very dissatisfied with what they’re getting for the high premiums they are paying and they’re having to pay more and more out of their own pockets these days for coverage, even if they have insurance. But that’s one of those talking points. It is to try to make policymakers and the public believe that for some reason our employer based system is sacred, that we can’t touch it.

FR: Yes. I remember the last time I got health insurance through an employer, they instituted a new program called Value Plus and I used to joke that it was more like Value Minus, because I was paying a lot more for a lot less.

WP: Right. In fact, my last CEO in the health insurance business, at Cigna, was asked by someone what kept him up at night and he said it is the worry that employers and individuals will wake up and question the value proposition of health insurers and I think employers and individuals are waking up to question-–and rightfully so: what value do the private insurers actually bring to this country? One of the things I used to have to do for a living was was to try to make people believe that we had a reason to exist, but increasingly employers in particular are questioning the reason why we have this middleman in the equation in the first place.

FR: Let’s go to some of the other talking points. Cheryl Bustos, the new head of the DCCC, has said that a $33 trillion price tag for Medicare For All is just too much.

WP: Well, that actually is only part of the number that this think tank–-actually a conservative think tank–-came up with. So she’s quoting that. But even that think tank said that is at least $2 trillion less over ten years than what it would be if we continue with the current system. So in other words, even that—yes, that’s a big number—but it’s over ten years, first of all. And what she did not say was that that would represent less money than the country would spend on healthcare if we go to Medicare For All than if we don’t.

The reality is that this year, we’ll spend three and a half trillion dollars on healthcare as a country. So if you multiply that by ten, you’ve already gotten over $30 trillion. And that is just based on the assumption that there will be no medical inflation, which of course you have to factor in. So if we stick with what we’ve got, we will be spending a lot more than $33 trillion over the course of the next ten years.

FR: Now, the third talking point is “think of all the jobs that are going to be lost for people who are processing all those claims—or denying all those claims.

WP: Right. And I think it’s a talking point to obscure the reality that the work that they do makes it, in many cases, impossible for the rest of us, the many millions of us, to get the care that we need. A lot of these folks, as you pointed out, are employed to try to avoid their companies paying claims. Because we have a multi-payer system, which is unique in the world, insurance companies not only have armies of employees who are in the business of determining whether or not someone should get coverage for whatever it is a doctor recommends, but you also, on the provider side, have to have armies of people who do nothing more than deal with insurance company bureaucrats day in and day out. So you’ve got these tens, if not hundreds of thousands of people who are employed in our healthcare system who do not do anything to make us better or to help us with our health. In fact, in many cases it keeps us from getting the care that we need.

Insurance companies have employed literally tens of thousands of nurses who are not providing care, but they are working for these big insurance companies, in many cases standing in the way of the care that we need, And medical doctors as well. So in my view, those folks have been trained as caregivers; they should be back at the bedside or providing care in offices, rather than making it more difficult for us to get care.

The other thing is that most of these big insurance companies have diversified over the years. They have other lines of business that are really quite profitable and are growing. So it’s a fallacy to say that they would go out of business if we move tomorrow to a Medicare For All plan. Some people would need to be retrained and some, like doctors and nurses, could go straight away to work at a better place, in my opinion.

FR: Some of the 2020 Democratic candidates are saying that instead of Medicare For All, which is too hard to get, we should just go for universal coverage and that we can do it with the kinds of plans that, let’s say, Switzerland has or Germany or Holland, where there are private nonprofit insurance companies that the government pays and bargains with.” So what is the best way to do health care for all?

WP: I’ve heard that too. Obviously my response is, why in the world would you not want to do the best job? Why would you want to emulate another country that, yes, they have achieved universal coverage, but they’re kind of runners up with us in terms of how much they spend on healthcare. We spend almost $10,000 per person per year on health care, which is twice the average of other developed countries and we have worse outcomes than most of those countries, so we have very little to show for all that we’re spending. But Switzerland comes in second in terms of the amount of money that the country spends on healthcare. Germany’s not too far behind.

The thing that is distinctive about those countries is that the insurance companies or sickness funds, as they may be called, are heavily price regulated. They’re all nonprofit entities. And we moved far away from that kind of structure many decades ago. So insurance companies would be just as resistant to a proposal that would force them into nonprofit status as they are to Medicare for All.

Why do we want to do a half measure? Why do we want to postpone what is inevitable, which is moving to a single payer healthcare system? And it is the one system of those that are proposed that not only would get us to universal coverage but would save us the most money.

In fact, when the Affordable Care Act was being debated, policy makers knew that we needed to try to do something about healthcare costs, while also trying to achieve the goal of universal coverage. They decided during the Obama administration to go first for universal coverage and deal with healthcare costs later. We see now where we wound up. We wound up with a bill that does a great deal of good in terms of bringing a lot of us into coverage, but there’s still about 30 million of us who are uninsured.

And the other problem is that a fast growing percentage of us are under-insured, because of the way that law is structured, and the insurance industry has been going in the direction of moving every last one of us into high deductible plans. And increasingly, those of us who are low and moderate income have trouble meeting our deductible. So we go without care. That’s the definition of underinsurance. So why don’t we just do something that really gets us to where we need to be rather than just continuing to tinker with the system that has failed us for many years?

FR: And the other thing that I’ve heard coming out with some of the candidates are proposals to decrease the Medicare eligibility age to 55 or 50. In other words, an incremental approach. The other one is make it possible for businesses and people to buy into Medicare. What are your thoughts on those proposals?

WP: Well, you know, it would be better than not doing anything, I guess. But again, why do you want to settle for something that is not as good as you can try to get?

FR: Well, the reason is politics.

WP: The reason is politics. But as I said, you can expect as much resistance to that as you would to going boldly. In fact, an American historian was interviewed on TV not too long ago saying, if you look at American history or history broadly, you’ll see that sometimes it’s easier to achieve sweeping change by bold views than by incremental change. Incremental change can be incredibly tough to pull off. Sometimes bold measures are more successful.

But back to that specific proposal, instead of simplifying the system, it just adds greater complexity. And you would keep the insurance industry in place maybe indefinitely. It is our multi payer system and the complexity of our system that is at the heart of our problem with costs being out of control.

It also does nothing to curb the practice of the health insurance industry to limit the choice of doctors and hospitals we have in these so called limited or narrow networks that are in vogue among the companies. Almost all of them have limitations to the doctors and hospitals you can see. And they’re forcing you to pay more and more for prescription medications by putting more and more drugs in tiers that require that you pay more out of your own pocket. Why do we want to keep a system in place that makes us pay more for care out of our own pockets, even if we have insurance, and to pay more and more every year in premiums? That doesn’t make sense to me. And I can’t imagine why policy makers would propose that we keep a system like that in place just because it might be easier politically.

FR: This is affecting cancer drugs too, isn’t it?

WP: Yes. In fact, I draw your attention to a piece that is on Tarbell now written by a leading oncologist from MD Anderson in Houston about the cost of oncology drugs. And it’s just extraordinary what has happened to the price of pharmaceuticals broadly, but in particular for cancer drugs. And insurance companies are just largely on the sidelines because they are not large enough. None of them, even the biggest, have enough clout to really do anything to control drug prices. All they are able to do is require that we take one drug as opposed to another that our doctor might have recommended, or again, shift those medications into tiers that make us pay more. So they’re not controlling costs, they’re shifting more of the cost to us. And in many cases, as this doctor who wrote that piece pointed out to me, he has seen patients die for economic reasons. They just simply can’t figure out the resources to get the medications or the treatments that they need.

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Francesca Rheannon, Journalist

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