Sometimes I groan after I complete a piece of research, knowing that the results may be seized and simplified by either end of the political spectrum .

Nevertheless, I went ahead and decided to compare premiums and out-of-pocket limits of nonprofit vs. for-profit health plans. This task is easier said than done. First, health plans vary with respect to their benefits and premium comparisons aren’t especially meaningful if there are significant disparities in covered medical services among plans. Consequently, I had to define a minimum set of benefits in order to get a decent representation of both nonprofit and for-profit plans that were similar to one another. Plans that didn’t meet the criteria weren’t included in the study.

 Another problematic issue for premium comparisons is that there is a relationship between deductible amounts and monthly premiums: higher premiums often mean lower deductibles.. Comparing premiums between plans with wildly different deductible amounts isn’t fair. This issue led me to establish deductible ranges; comparisons between the plan types were performed only within those ranges.

 Finally, there was the issue of location. Health insurance premiums are strongly influenced by region. This influence exerts itself on several fronts: state-specific insurance regulations that have to be satisfied;  local level of competition in the market; and the medical claim trend for people living in the region. Accordingly, the premium comparisons were performed inside selected metropolitan regions and never between differing regions. Six cities were chosen as regions for premium comparisons, two from the east coast, two from the west, and two from the center of the country.

                                              Results of the Study

 The results? I found that in 47% of the comparisons a city’s nonprofit plans had the lowest average premium within a particular deductible range. For-profit health plans had the lowest premium in 39% of comparisons with the remaining 14% classified as ties since the differences between the nonprofit and for-profit averages were less than 3%.

An examination of out-of-pocket limits for these nonprofit and for-profit plans yielded similar results: Nonprofits had the lowest average limits on out-of-pocket costs in 56% of the comparisons. For-profit plans had the lowest average limits in just 28% of the comparisons.

What should we conclude based on these results? If you have strong political convictions, I can see several ways the data could be spun,  particularly given the thorny issue of tax advantages that some nonprofit plans enjoy. For myself, I satisfy myself with a modest set of conclusions and let the politicos fight about the rest:

 1) Nonprofit health plans are more likely to offer a lower premium than for-profit health plans

2) Removing a profit incentive from health plans as a means to make premiums more affordable cannot be supported by my study’s results since in over half the comparisons nonprofit health plans did not have the lowest premium

3) Nonprofit plans are more likely to have superior out-of-pocket cost protections than for-profit plans

 It will be interesting to revisit the nonprofit/for-profit premium comparisons once the new Affordable Care Act plans are released. The Essential Health Benefits will effectively commoditize plans and health status will no longer be a factor in availability or price of coverage. As a result, so premium differences and provider networks could assume greater importance to consumers shopping for health insurance.

 One of the issues not addressed in this study is the question of health plan quality (e.g. clinical outcomes, customer satisfaction, adherence to best practices, etc.). Health plans are more than premiums and the lowest cost plan might not be the wisest consumer choice if quality scores are unacceptably low. I plan on analyzing the same plans used in this study from the perspective of their quality scores to shed some light on the relationship of quality to the premium differences discovered.

Note from MM: — I am glad that Coleman  ends by emphasizing that consumers need to consider quality as well as price. If insurance doesn’t protect you, it’s not worth the money, no matter how low the premiums.

As it happens, I began comparing the quality of non-profit vs. for-profit insurance plans a  couple of weeks ago, and will be publishing a post on the topic in a few days.  I’ll invite Coleman to come back and report on his results as well.

Last week the House voted—for the 37^th time—to repeal the Affordable Care Act. Everyone knows that repeal will never pass the Senate.  Some suggest that legislators might better spend their time (and our tax dollars) figuring out how to create jobs.

Even the Congressional Budget Office (CBO) couldn’t take this 37^th vote seriously. When preparing for this latest showdown, Republican Paul Ryan requested an update to CBO’s July 2012 estimate that repealing the ACA would cost more than it would save, increasing the deficit by some $109 billion over the coming decade (2013-2022.)

CBO replied to his request: “Preparing a new estimate of the budgetary impact of repealing the Affordable Care Act would take considerable time – probably several weeks – for CBO and the staff of the Joint Committee on Taxation, because there are hundreds of provisions in the ACA and those provisions are already in various stages of implementation. . .   We have just finished the time-consuming task of updating our baseline budget projections and need to finish our analysis of the President’s budgetary proposals.”

I like economist Jared Bernstein’s paraphrase of CBO’s response: “You guys go ahead and keep gettin’ your crazy on … over here we’re kinda busy doin’ actual work, so can’t help you right now.”

CBO added that when it does have time to do an update, it expects similar results. Repealing health care reform would add to the deficit.

                              Are Republicans Crazy . . .  Or Cunning?

You might think that by continuing to obsess over a bill that will never succeed, Republicans are once again exhibiting their self-destructive tendencies. But I would argue that House Republican leaders are not crazy, at least not in a way that is easy to understand. They’re cunning.

Ask yourself this: How many people skimmed or half-heard the news stories telling them that the House had passed a bill to repeal Obamacare?

This helps to explain why 12 percent of all Americans believe that the ACA already has been scrubbed. Every time a commentator mentions “health care reform” and “repeal” in the same sentence, the words will sink into that morass of half-truths and fictions that we call “the conventional wisdom.”

Even if people realize that the ACA  is now the law of the land, many take the repeated efforts to kill reform as a sign that there is something very wrong with the legislation.

After all, they think: “why would Republicans spend so much time trying to overturn a law if there wasn’t something terribly wrong with it?”

Of course House Republicans also voted against re-authorizing the Violence Against Women Act.  (Until it became crystal clear that they were once again tossing the women’s vote under the bus.)  Then there was the time when they voted unanimously to support an anti-abortion bill that redefines rape as “coercive” (as opposed to voluntary rape?)  GOP solidarity is not necessarily a sign of clear thinking.

 (I would provide more detail about the newest edition of HWR, but my lap-top rolled over and died two days ago. As a result, I  don’t have the time to give newest edition of HWR the attention it deserves.)

I hope you will.

But under the Affordable Care Act everything changes. Beginning in January, you will be able to purchase a policy in your state’s Exchange—a one-stop marketplace where you can shop for plans. They will be easy to compare because all policies sold in the Exchanges must cover “10 essential benefits”  including pre-natal care, maternity, dental and vision care for children, rehab and mental health care.  There will be no no co-pays for preventive care and the deductible does not apply.No matter how much care you or your family need, there will be a cap on your out-of-pocket expenses of roughly $6,000 for a single individual or $12,000 for a family. (These rules apply to anyone buying their own insurance in the Individual Exchange, whether they are self-employed, unemployed, or work for an employer who doesn’t offer affordable, comprehensive health benefits.)

                                 Lower Premiums, Subsidies

In the Exchange, you will automatically become part of a large group, and as a result, premiums will be lower than the premiums you would papy today for similar coverage.

 Moreover, depending on your income, you may be eligible for a subsidy. For example, a 30-year-old couple with joint income of $45,000 would receive a subsidy of roughly $2700 and wind up paying $4,000 a year for comprehensive coverage that includes free preventive care. (This is a national average)  

 What You May Not Know about Health Insurance and Tax Deductions

You probably are aware that if you are self-employed and buy your own medical, dental or long-term care insurance, you can deduct premiums for an individual or a family plan on your income tax.

But did you know that if:  

You Have Children under 27, you also can deduct premiums you pay for  them–even if they are no longer your dependents?  

 You or  Your Spouse Receive Medicare, the IRS has now ruled that you can deduct Medicare premiums for Parts A, B, C and D?  This is in addition to the deduction for insurance that you or your spouse buy in an  Exchange.

                              How Much Can You Deduct?

To calculate your allowable health insurance deduction, take your self-employment income, and subtract the 50% deduction for self-employment taxes. Then subtract any retirement contributions made to SEP-IRA, SIMPLE-IRA, or Keogh plan. The remainder is how much you can deduct for health insurance expenses.

There, host Joe Paduda calls attention to an eye-opening post by The Health Business Group’s David E. Williams. 

Williams reports on what oncologists say about cancer drugs in “The Price of Drugs for Chronic Myeloid Leukemia (CML); A Reflection of the Unsustainable Prices of Cancer Drug.” The article, which was published in the journal, blood, includes candid comments from more than 100 experts  They tell us  that:.

• Many costly treatments aren’t worth the money
• New treatments with tiny orno benefits often cost a multiple of existing therapies
• Despite their reputation for penny-pinching, health plans are often not aggressive in negotiating price
• Patients are already suffering mightily from high costs –and it impacts quality of life and survival as well as financial health
• Society as a whole cannot afford to pay the high prices charged for so many of the new therapies

 (I’m reminded of “A Very Open Letter from an Oncologist published on HealthBeat in 2009.)  It’s encouraging to see more oncologist stepping forward to telll the truth about cancer drugs..)

.As Williams observes these insights “come from people who know what they’re talking about and who have traditionally been sympathetic to drug makers and unperturbed about costs.”  

But now, the companies that make these drugs have taken greed too far.

 Paduda also highlights Health Affairs just-released research indicating that the decline in inflation could result in a reduction of $770 billion (yup, that’s “billion” with a B) in public program health care costs over ten years. “

But is the trend sustainable? John Holahan and Stacy McMorrow of the Urban Institute are “cautiously optimistic.” Paduda agrees: “there’s no question there are fundamental changes occurring that are affecting care delivery, pricing, and reimbursement.”

Posting on Health Affairs Blog, John Roehring is less optimistic. His in-depth analysis of health care spending and economic cycles is rigorous. But is it relevant?
Something extraordinary has happened in the past few years: The U.S. finally has passed health reform legislation that aims to provide universal access to high quality care. The legislation recognizes that in order to do this, we Must bring down costs.
Passage of the legislation was all but inevitable. 

After years of over-spending, we were heading for a wall. Healthcare spending cannot swallow 25% of GDP. And what can’t happen, won’t. We must become more efficient. 

Thus, the past may not tell us much how health care spending will respond to an economic recovery this time around. The Affordable Care Act marks a turning point—and there is no going back. We are in a truly different era.

Roehring is not as hopeful as I am, but he acknowledges that “Some portion of the slowdown is permanent but some will be given back during a recovery”.

Over at The Hospital Leader, Dr. Brad Flansbum writes a provocative post about “Successful Home Management and the Hospital Bottom Line”:

“Care management done right and transitions executed properly keep folks out of hospitals and reduce profits,” he observes. ”If HQP gives a glimpse of the future, the exponential growth of our field will flatten, if not fall.”

In other words: “We receive our salary from the beast we wish to slay. Sucks for us and I cannot help but think of Upton Sinclair’s quote:
‘It is difficult to get a man to understand something, when his salary depends upon his not understanding it!’”

That may be, but these days, more and more physicians are deciding that in the battle over healthcare they would rather be Knights than Knaves or Pawns. (Hat tip to the National Physicians’ Alliance for coming up with these categories.

Signs of the times: Oncologists are telling us that many of our priciest cancer drugs aren’t worth the money. Urologists are no longer recommending PSA testing.
Increasingly, these physicians are looking past their salaries, and asking: “What would be best—not for the hospitals, not for the doctors– but for the patients?”

“Being in a hospital” clearly is not the answer.

This brings us to the question of reducing readmissions.  Paduda notes that in response to “a recent WSJ opinion piece assaulting Medicare’s new hospital re-admissions reimbursement policy; the John Hartford Foundations’ Chris Langston presents a clear-eyed, point-by-point rebuttal that shows why the program is a necessary and important step to improving health for older adults.”  I would add that, as Langston points out, hospitals will not be penalized for readmitting some patients.  The penalty applies only if Medicare sees a pattern showing an unusual number of patients bouncing back into hospital beds. .

Over at Health News Review, Gary Schwitzer highlights an innovative way to market a product to doctors that involves Hooters. I don’t spoil the surprise—just go to Paduda’s Health Wonk Review, and click on the link to Schwitzer’s story.

Will there be a “train wreck” in Colorado when the state opens its Exchanges? Louise Norris of Colorado Health Insurance says “No.” They’re ready—and they’re not alone.\
Will there be enough insurance products available in the Exchanges to give consumers choices ? Writing on HealthInsurance.org. Wendell Potter says there will be plenty. In a few months, we’re likely to be complaining about how hard it is to compare so many plans. Moreover, the notion that you need a dozen companies competing to keep prices down is a myth. In Vermont, he points out, just two companies vying for Exchange business, and premiums are not going up.

How much do you think UnitedHealth’s CEO earns? On Health Care Renewal, Roy Poses will tell you. Brace yourself.
Recently, the state of Oregon compared the the health of citizens who made the cut for the state’s Medicaid program, to those who didn’t. (They qualified, but there were not enough spaces.)
The comparison revealed that, after two years on Medicaid, patients in the program had not made much progress in lowering blood pressure or cholesterol. Diagnosis of diabetes went way up, and the use of medicine to control diabetes also went up, but, again, there wasn’t much difference on the relevant blood tests

.
John Goodman sees this as damning indictment of Obamacare; “a new study finds that (as far as physical health is concerned) there is no difference between being in Medicaid and being uninsured.”

By contrast,Health Wonk’s  Ezra Klein points out that depression rates for patients on Medicaid fell by 30%. This is huge. If you think about the damage that depression does to our bodies and our minds—as well as the links between depression, smoking, drug abuse and alcoholism—these patients were clearly better off. My guess is that they no longer felt as isolated as they had in the past. They had someone to talk to. (To learn more about the connection between poverty, loneliness and poor health, see this briliant PBS documentary, “Unnatural Causes.”

At the very least, their diabetes had been diagnosed, making it much less likely that they would go blind, or face amputations down the road. (If this isn’t good enough for Goodman . . .)

Finally, here’s my take on what the study showed:

1) People on Medicaid are poor.

2)There is a limit to what healthcare can do for people who have been born into poverty and have been poor for most of their lives.

The stresses and deprivations of poverty take an enormous toll. As Dr. Steven Schroeder pointed out in a landmark Shattuck lecture in 2007: “When compared to poverty, medical care plays “a relatively minor role” in premature deaths.” Scroll down to the pie chart in his article, and you’ll see what he is talking about.

I’m not at all surprised that after two years on Medicaid, complicated problems like hypertension and high cholesterol had not been resolved. They still may die sooner than many of us, but clearly the quality of their lives has improved.

Note– This was a rich edition of Health Wonk Review, and these are just highlights. I would urge you to read the whole post.

No. IPAB was, from the beginning, only meant to serve as a backstop. The law says that the board will be asked to recommend places where we could pare Medicare spending if—and only if—Medicare inflation begins to outstrip inflation in the rest of the consumer economy.

But over the past three years Medicare spending has decelerated; it is no longer growing faster than the economy as a whole. This is why Medicare’s chief actuary has decided to put IPAB on hold.

Some observers argue that as the economy recovers from the Great Recession, the nation’s health care bill is bound to climb. I disagree. Particularly in the case of Medicare, I don’t think that the economic downturn explains most of the slowdown. 

 I believe that reform is already having  an effect on health care inflation:  Four years of debate over the Affordable Care Act has made us more aware of the waste in our health care system. Patients are asking more questions, and providers know that they are going to be held accountable for that waste.

                                 We Still Need IPAB as a Backstop

That said, in the future, spending could pick up–and we may need IPAB. This is why President Obama has made it clear that he will veto any attempt to eliminate the Board.

It is important to know that IPAB exists, as a reminder to drug companies, device makers, nursing homes and others that, one way or another, we can no longer afford a system that is wasting $1 out of $3 of our health care dollars on over-priced, unnecessary tests and treatments that, too often, put patients at risk without benefits.

If, and when, IPAB is asked to recommend cuts it will use medical evidence to decide where to trim. IPAB is likely to recommend lower payments for certain services and products that medical research tells us are now “overvalued”–based, not on cost-benefit analysis, but on patient outcomes. If patients who fit a particular medical profile are not helped, Medicare should not cover the treatment for those patients.

As I have explained in the past, IPAB is not the panel of bean counting bureaucrats that Obamacare’s opponents suggest.  IPAB will not “ration” care; it is charged with making care more rational by letting Science–rather than lobbyists– decide what Medicare should cover.  Moreover, Congress can veto IPAB’s recommendations, if legislators can agree on  ways to achieve equal savings– without rationing care, or shifting costs to seniors.

                                                      Why We Don’t Need IPAB Now. 

Medicare spending is no longer “out of control.”  In fiscal year 2012 spending per Medicare beneficiary increased by only 0.4%. This followed slow growth in 2010, when spending rose by just 1.8% per beneficiary, and in 2011 when outlays increased by 3.6%.  We cannot be absolutely certain that the trend will continue. But I see signs of changes in our medical culture that suggest we have reached a turning point in how we think about healthcare.  

                           Why Has Medicare Spending Slowed?  New Research       

Some argue that the Great Recession has led seniors to consume less health care. But I’m not convinced.

It’s easy to see how high unemployment would cause Americans under 65 to use less health care. Even if you didn’t lose your job, your neighbor did, and virtually everyone has become more cautious. But it is much harder to argue that the economy explains slower growth for Medicare. 

Most seniors have not been hit by a sudden job loss. They still have health insurance.  Their income—much of which comes from Social Security—has remained relatively stable. In addition, the vast majority of seniors have supplemental insurance (Medicare Advantage or Medigap) that covers out of pocket costs. So why would they cancel a doctor’s visit, or postpone elective surgery?

Meanwhile new research published in this month’s Health Affairs looks at why total health care spending (including both the private sector and Medicare) grew at a record-slow pace of 3.9% in 2009, 2010 and 2011. According to the investigators, hard times, accounted for only about 1/3 (37 percent) of slower growth in the nation’s health care bill.  My guess is that most of the effect was felt in the private sector.

A second paper published in the same issue of Health Affairs  analyzes spending by 150 large employers from 2007 through 2011. They report that larger deductibles, more co-insurance and higher copayments accounted for about 20% of the slowdown.

 But Michael Chernew, a Harvard health policy professor and co-author of the paper, told Modern Healthcare that slower growth was due to more than the weak economy or increases in out-of-pocket spending as employers shifted costs to employees. Instead, “the results appear to underscore a shift in culture among hospital officials and physicians who have grown more focused on greater efficiency in the last five years.”  

 If Chernew is right we are looking at more than a cyclical change that is tied economic cycles. Though as he stresses, we if we want to support a  long-term structural change in our health care system “we need to build a system with the right incentives and information flow.”

                                                      Looking Ahead

Medicare’s currrent chief actuary, Paul Spitalnic, sees the recent past as prologue– at least to the near future. On April 30, he sent a letter to Marilyn Tavenner, acting Medicare administrator, saying that based on the most recent numbers, the projected 5-year average growth in Medicare per capita spending is 1.15 percent, and the 5-year average growth target is 3.03 percent.” As a result, he advised Tavenner that we won’t need the IPAB until 2016—at the earliest. 

 If Spitalnic’s projections prove true, over the next few years, Medicare won’t be growing faster than GDP. This means that it won’t be adding to the deficit. If the trend continues, over time, we won’t have to worry about Medicare “crowding out” spending on education, infrastructure or the environment.

                                    Looking Ahead 30 Years

Nevertheless over the next three decades, as baby-boomers join the ranks of Medicare recipients, we will have to find new ways to squeeze the waste out of the system. Reining in spending “per beneficiary” will not be enough. There will be so many more beneficiaries.

But the boomers will not turn 65 all at once.  We will have time to make the thoughtful adjustments needed to improve care while simultaneously  reducing costs.  This is something conservatives don’t seem to understand about healthcare: lower bills and better care go hand in hand.  Inefficient care is expensive.  We don’t have to inflict pain—or demand that seniors pay more – in order to make Medicare sustainable.  There is plenty of waste in the system.

I am hopeful—not “confident,” but hopeful—that we can do this. First, some cuts already are  baked into the ACA cake. Over the next decade, the Affordable Care Act restrains the rate of growth of payments to Medicare Advantage plans, shaves the rate of growth in unit payments to hospitals and nursing homes, cuts their annual updates by 1% a year for ten years, and  promotes value-based payment systems  while making major investments to reduce fraud and abuse. The Congressional Budget Office estimates that these provisions will reduce Medicare spending by 1 percent a year over the 10-year budget window.  Rather than rising by 2% to 3% a year, Medicare’s outlays would inch up by 1% to 2%.

                                             A Cultural Change

Moreover, like Chernew, I believe that we are beginning to see changes in our medical culture that could reap far greater savings. As we discuss reform, doctors, patients and hospitals  have begun to look at healthcare in a new way.

For example, in the post below I describe how urologists have done an about-face on the question of PSA testing for prostate cancer. Rather that recommending widespread routine testing of asymptomatic patients, they are cautioning patients that they should ask their doctors about risks as well as benefits.

Urologists are leading the way in putting patients’ interests ahead of not just their own financial interests, but their understandable desire to believe that a test they have relied on for many years was indeed savings lives. Now they are taking a hard look at the medical evidence which suggests that potential benefits may not justify risking life-changing side effects. In other words, the urologists are doing just what IPAB is supposed to do—letting Science rather than custom shape their recommendations. (In 2010,the National Physicians’ Allilance asked a question: “Are Doctors Knights, Knaves or Pawns?”  Urologists, at least, have stood up and identified themselves: they are knights.)

If fewer men are tested, fewer men will be diagnosed with “early-stage prostate cancer”—a slow-moving disease that may well never cause them problems. As a result, fewer will undergo treatments that can cost anywhere from $7,500 to $22,500 while savings few if any lives.

                                                            Mammograms

Patients, too, are becoming more aware that “more care is not always better care.” I was struck by the generally positive response to last week’s New York Times Magazine about mammograms.  When I scanned “readers’ comments,” I fully expected to find dozens of outraged readers attacking the writer for questioning whether this annual ritual is best for all women at all ages. Instead, many thanked her for analyzing such a fraught issue in a thoughtful way.

 Reformers have been trying get the message out for year:. We have two problems in this country: while many uninsured and underinsured Americans are undertreated, others, who are well-insured, are over-treated. Today, it seems that more patients are becoming wary. They understand that medicine is shot through with uncertainties, and that they need to be fully informed about side effects and risks when they make  a medical decision.

                             Hospitals Adopt Better Systems

Even though the final phase of health care reform has not yet kicked in, hospitals have been anticipating the effect the ACA will have on them .They know that they will be held accountable for delivering better care at a lower price  They are keenly aware, for example, that in the future, they will face financial penalties if too many Medicare patients bounce back into a hospital bed less than 30 days after discharge.

As a result, today, many hospitals are doing a better job of making sure that patients understand their medications before they leave. At Einstein Medical Center in Philadelphia, for instance, hospital pharmacists meet with patients in their room to discuss doses. Patients  receive a 30 day supply of medications when they leave; and providers call patients to follow-up within three days of discharge and at the end of the month to answer questions about the drugs.  Einstein has reduced readmissions for heart patients by 50%

 Nationwide,hundreds of  hospitals are experimenting with new systems designed not just to cut readmissions, but to reduce the preventable errors that haunt both providers and patients.  For years, hospital CEOs have  focused on growing revenues. Now, the ACA is sending a new message: the hospital’s mission should be to cut costs while delivering safer, more effective patient-centered care.

The organization added that “men ages 55 to 69 who are considering the PSA test” for prostate cancer “should consult their doctors about the test’s benefits and risks.”

The potential “benefit of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade” should be weighed  “against the known potential harms associated with screening and treatment [which include side effects such as incontinence and impotence }  For this reason, “ shared decision-making is recommended for men age 55 to 69 years that are considering PSA screening,”  The AUA stressed that “ patients’ values and preferences” should direct a final decision.

.In addition,  the AUA announced that “to reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening.

I wrote about “shared decison-making” and how it could help patients considering a PSA test make an informed choice  here on HealthBeat back in 2007.(Readers interested in why this protocol is so important to patient-centered medicine may be interested in this story that I wrote for Dartmouth Medicine: “Making Choice An Option.” )  Congratuations to the AUA for having the courage to take this giant step forward into the future of medicine.

“The new guideline is significantly different than previous guidance,” the organization acknowledged, noting that it “was developed using evidence from a systematic literature review rather than consensus opinion.” In other words, urologists didn’t take a vote; they looked at the Science.

Authors of the new guidelines have “learned very quickly that there really was no high-level evidence supporting the use of screening with PSA,” said urologist H. Ballentine Carter, who chaired the panel that wrote the new guidelines.”                         

When I last wrote about PSA testing, in July of 2012, such a radical shift in the AUAs positions would have been unthinkable.  At the time, the U.S. Preventive Services Task Force (USPSTF) had given PSA testing a grade of “D”—suggesting that benefits did not outweigh risks. 

 In response, urologists joined forces with Republicans to threaten the autonomy of the USPSTF by supporting  a House bill (H.R. 5998)  that proposed to mandate “greater role for specialists and advocacy groups” in developing guidelines”  while ”eliminating the Department of Health and Human Services’ secretarial discretion to withhold Medicare funding for interventions that lack convincing evidence for benefit.”      

What a difference a year makes.

No. In the end, most smokers should be able to get health insurance without paying a stiff penalty.

For one, it’s up to individual states as to whether they want to let insurers charge smokers more. By early April of 2013, Rhode Island, Vermont, Massachusetts and D.C. had voted to eliminate smoking premiums in their health care exchanges:  The American Cancer Society, which is opposed to the surcharge, is working to persuade other states to ban it. (The ACS explains: “We’re anti-smoking, not anti-smoker.”)

I agree with the ACS that the penalty is counter-productive.  If it makes insurance unaffordable for some smokers, this means that they won’t have access to smoking cessation programs, nicotine patches and other drugs that could help them quit.  Keep in mind that most smokers want to quit, and these programs have proved extremely successful.

The good news is that many Americans who are addicted to nicotine will be eligible for Medicaid. In the U.S. 39 percent of adult smokers live below the poverty level. . Many more live below 133 percent of the poverty level. As states expand Medicaid, they, too, will become eligible for the program. Since Medicaid charges no premiums, they will not pay a premium surcharge.

Meanwhile, new research by the George Washington University School of Public Health and Health Services indicates that including comprehensive tobacco cessation benefits in Medicaid insurance coverage can result in substantial savings for Medicaid. The study found that every dollar spent on tobacco cessation program costs resulted in an average program savings of $3.12, which represents a $2.12 return on investment. 

Under the Affordable Care Act all state Medicaid programs are required to cover tobacco cessation medications, beginning in 2014.

Finally smokers who receive health benefits from their employer are likely to find that they don’t have to pay the premium if they join a smoking cessation program.

At that age few of us are ready to come face-to-face with our own mortality.  In last Sunday’s New York Times Magazine, she writes: “Recalling the fear, confusion anger and grief of that time is still painful.”

But sixteen years after her diagnosis we have learned more about breast cancer, and Orenstein is willing to look the truth in the eye:  “As study after study revealed the limits of screening — and the dangers of overtreatment — a thought niggled at my consciousness. How much had my mammogram really mattered? Would the outcome have been the same had I bumped into the cancer on my own years later?”

Regret is a tough one. After making a major decision that has life-changing consequences, few of us want to consider that we might have made the wrong call.  Instead, most women in Orenstein’s position say: “I’m so glad I had that mammogram. It saved my life!”

 Orenstein herself confesses, “that is what I used to say. I even wrote that in the pages of this magazine.

But if she hadn’t had the mammogram, and the cancer wasn’t discovered until she felt a lump, wouldn’t it have spread? Wouldn’t she be dead?

No. As Orenstein point out, “Breast cancer in your breast doesn’t kill you; the disease becomes deadly when it metastasizes, spreading to other organs or the bones.  Early detection is based on the theory, dating back to the late 19th century that the disease progresses consistently, beginning with a single rogue cell, growing sequentially and at some invariable point making a lethal leap.”

But science has advanced since the late 19th century, and we now know that just isn’t true. Sometimes breast cancer invades other parts of the body. Sometimes it doesn’t. The problem is that mammograms can’t tell us which cancers will spread.

                                  The Likelihood Of Over-Treatment               

What many women don’t realize is how commonplace the harmless cancers are. When someone is told she has breast cancer, she is likely to imagine a large, ugly lump, buried somewhere in her breast. Yet as Dr. David H. Gorski,  a surgical oncologist at the Barbara Ann Karmanos Cancer Institute who specializes in breast cancer explains: today approximately 30% to 40% of breast cancer diagnosis”  are examples of “ductal carcinoma in situ (DCI)”—cancers that begin in the milk ducts and “stay in place” (in situ). If they don’t spread, they are not life-threatening.  Some researchers call DCIs “Stage Zero” cancer. 

A recent study found that DCIS incidence rose from 1.87 per 100,000 in the mid-1970s to 32.5 in 2004,” he adds. “That’s a more than 16-fold increase over 30 years, and it’s pretty much all due to the introduction of mammographic screening.” (Mammograms are especially good at spotting DCIs. Unfortunately, they are not as good at finding the very aggressive cancers that are most likely to kill us.) )

“When it comes to DCIS, we don’t have a good handle on what percentage of DCIS will progress to invasive cancer, but we do know that a significant percentage will not.” For that reason, some argue that we should not tell patients that DCIS are “pre-cancerous.”  Labeling them “Stage Zero” would be more accurate.

Nevertheless, precisely because we don’t know, “oncologists tend to treat them all the same,” says Gorski.  “In other words, over diagnosis leads to overtreatment.”

Following diagnosis of DCIS, the most common scenario is for the oncologist to recommend lumpectomy, followed by radiation and hormone suppressive therapies such as Arimidex and Tamoxifen.  “The problem here is that women are not being educated about the nature of DCIS or the concept of ‘non-progressive’ breast cancers. There is still the black and white perception out there that you either have cancer, or do not have cancer,” writes Sayer Ji. http://www.greenmedinfo.com/blog/mammograms-linked-epidemic-misdiagnosed-cancers

As a result 1/3 of women diagnosed with DCI’s choose to have a mastectomy– sacrificing a breast, rather than asking for a less invasive lumpectomy. http://link.springer.com/article/10.1007/s10549-011-1430-5#page-1

                   Breast Cancer “Awareness” –the Problem with Pink

Fifty years ago, mammograms seemed to promise so much.  Trials that began in 1963 suggested that screening healthy women along with giving them clinical exams reduced breast-cancer death rates by about 25 percent. “Although the decrease was almost entirely among women in their 50s, it seemed only logical that, eventually, screening younger women (that is, finding cancer earlier) would yield even more impressive results,” Orenstein explains.  “Cancer might even be cured”

The solution seemed so clear. We just needed to persuade more women to go for annual mammograms.  In 1982, Nancy Brinker, who had lost a sister to breast cancer, founded the Susan G. Komen foundation, the organization that would create the Race for the Cure to raise funds for breast cancer research. Three years later, AstraZeneca, the giant international pharmaceutical company that makes the breast cancer drugs tamoxifen and Arimidex, invented “National Breast Cancer Awareness Month.” At the 1991 Race for the Cure in New York City, “Komen Greater NYC” distributed pink ribbons to every breast cancer survivor and Race participant.  (Pink was the color Komen National designated to promote awareness.)

 By 1993 Avon and Estee Lauder had begun to use the pink ribbon as a marketing tool, slapping it on their products, while giving a portion of their profits to the Foundation.  Companies that followed their example saw their sales rises, along with their image, and soon discovered that they could even raise their prices.   Pink ribbons created warm feelings.

 Soon we were awash in pink—pink lids on our yogurt, pink sneakers, pink dog leashes. We even have a “Breast Cancer Barbie” resplendent in a pink gown. Thus, Breast Cancer Awareness spread.

 The message was always the same, Orenstein explains:  “breast cancer was a fearsome fate, but the good news for woman was that through vigilance and early detection, surviving was within their control.”

“Control”—that was the goal.  From childhood, girls are trained to be good, to do the right thing. Going for annual mammograms is what we should do—not just for ourselves, but for our loved ones.  If you just found the tumor early, and your surgeon cut it out, you would be safe.  

While “there has been about a 25 percent drop in breast-cancer death rates since 1990 some researchers argue that treatment,” — not mammograms — “may be chiefly responsible for that decline,” Orenstein observes. “They point to a study of three pairs of European countries with similar health care services and levels of risk: In each pair, mammograms were introduced in one country 10 to 15 years earlier than in the other. Yet the mortality data are virtually identical. Mammography didn’t seem to affect outcomes. In the United States, some researchers credit screening with a death-rate reduction of 15 percent — which holds steady even when screening is reduced to every other year.

“Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and co-author of a New England Journal of Medicine survey of screening published in November estimates that only 3 to 13 percent of women whose cancer was detected by mammograms actually benefited from the test.

Meanwhile, many were harmed because the diagnosis led to unnecessary surgery, hospital acquired infections, depression—and even divorce.

                  Over-Selling Mammograms and Magical Thinking

After years of being bombarded with the message that early detection saves lives—some women began to engage in magical thinking. At some subconscious level, they began to think that mammograms don’t just discover cancer, they prevent it.

Today, almost all of  us understand that mammograms don’t ward off cancer. But what many women still don’t understand is that “early detection” won’t necessarily save you. “I’ve watched friends whose cancers were detected ‘early” die anyway” Orenstein recalls.

Is this because their doctor didn’t do the right thing? 

No.  It’s because the most pernicious tumors move quickly and can metastasize in between mammograms. “Mammograms, it turns out, are not so great at detecting the most lethal forms of disease — like triple negative — at a treatable phase,” she points out..  “Even catching them ‘early’ while they are still small, can be too late: they have already metastasized. That may explain why there has been no decrease in the incidence of metastatic cancer since the introduction of screening.”

 That last sentence stopped me in my tracks. I double-checked, and discovered that, yes, the recent survey of mammography in the NEJM titled “”Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence,” reveals that when it comes to “metastatic breast cancer, the kind that has by far the worst survival rate,” mammograms “appeared to have had no benefit at all.” http://www.pbs.org/newshour/rundown/2012/12/commentary-why-yearly-mammograms-can-be-harmful.html

                                                Marketing Fear

“And yet, mammography remains an unquestioned pillar of the pink-ribbon awareness movement,” Orenstein writes.  “Just about everywhere I go. . .  I see posters proclaiming that “early detection is the best protection.” . . . But how many lives, exactly, are being ‘saved,’ under what circumstances and at what cost? “

Here, Orenstein is not talking about the financial cost, but the emotional cost of “cancer awareness.”  Our fear of breast cancer has become so great that among women diagnosed with “stage zero” (DCIS) in one breast, the share choosing a double mastectomy rose from 6.5% in 1998 to 18.4%  in 2005.

This is not the case in other developed countries.  No one is as good at marketing fear as we are.

 “Our fear of cancer is legitimate “ Orenstein writes,” but how we manage that fear,”  she now realizes –“our responses to it, our emotions around it—can be manipulated, packaged, marketed and sold, sometimes by the very forces that claim to support us.”

As a result women who once asked for lumpectomies are choosing to have their entire breast removed.  Now young women are saying: “Just take them both off. I want to get it over with.” (Research shows that women who elect to have a lumpectomy are just as likely to survive as women who choose a mastectomy. But those who have a lumpectomy run the risk of having to go back for a second surgery.)

According to Dr. Todd Tuttle, chief of the division of surgical oncology at the University of Minnesota and lead author of a study on prophylactic mastectomy published in The Journal of Clinical Oncology, most of women diagnosed with “Zero Stage Cancer” who chose to have a double mastectomy did not have a genetic predisposition to cancer. They were not at a high risk of dying of cancer. Why, then did they make such a drastic decision?

 “Tuttle speculates they were basing their decisions not on medical advice but on an exaggerated sense of their risk of getting a new cancer in the other breast,” Orenstein explains. “Women, according to another study, believed that risk to be more than 30 percent over 10 years when it was actually closer to 5 percent” that they will have ) to go back for a second, more aggressive operation.

Tuttle suggests that breast cancer awareness has become “over-awareness.”

 “You could attribute the rise in mastectomies to a better understanding of genetics or better reconstruction techniques,” Tuttle says, “but those are available in Europe, and you don’t see that mastectomy craze there. There is so much ‘awareness’ about breast cancer in the U.S. I’ve called it breast-cancer overawareness. It’s everywhere. There are pink garbage trucks. Women are petrified.”  

Part two of this post will begin with a list: “Ten Things Every Woman Should Know about Breast Cancer,”  including that fact that, whether or not you go for annual mammograms, your chances of dying of breast cancer are very, very slim.

I part two, I also will discuss:

– the importance of “shared decision-making”– which insures that patients are fully aware of the risks as well as the benefits of any test or treatment;

–whether “watchful waiting” might be an appropriate strategy when a medium–risk asymptomatic woman is diagnosed with breast cancer;

–how much the Komen Foundation is spending on “awareness” vs. research;  

– why the awareness rallies always feature “survivors” (many of whom are blissfully unaware that they never had invasive breast cancer in the first place), and rarely focus on the women facing the last stage of breast cancer—often with great grace and courage.

When it comes to health care stories, the media prefers “Feel Good News.” No one wants to read about the cures that didn’t work. Few really want to know that mammograms can hurt women. These stories don’t draw eyeballs. 

Thus, women diagnosed with breast cancer too often find themselves on a conveyer belt headed for the OR. .

The Preventive Services Task Force’s (PSTF’s) recommendations on mammograms were met with rage. This is what happens when health care policy is driven, not by Science, but by public opinion polls, the media and self-perpetuating PR machines.

We need experts—doctors and medical researchers—shaping health policy.  But polls show that many Americans are wary of “experts.”

Finally, in part 2, I will talk about what happened the last time Peggy Orenstein went for a mammogram.

– Who Will Become Navigators?

–  Can Insurance Agents and Brokers Apply to Be Navigators? (Wouldn’t that create a conflict of interest?)

–  Just How Will Navigators Help People Sort Out Their Options in the Exchanges?

–  How Much Training Will They Receive?

–Finally, many people worry that the “navigators” just won’t be able to handle the heavy traffic. Giving the American public the information it will need about Obamacare is an enormous task. Will these navigators be up to it?

The answer to that last question is that the navigators will have help.  Patient advocacy groups, the states, and county health agencies will pitch in.  The federal government  also is launching a marketing program, “Enroll America” that will urge mothers to nag their uninsured 20-something and 30-something sons. (Seriously– and I expect that in many cases, this will be effective.)

Meanwhile insurers will be eager to draw young, healthy customers into the Exchanges. This means that they will invest in marketing campaigns designed to let 20-somethings and 30-somethings know that the vast majority will be eligible for generous government subsidies.

Just one example: Blue Cross and Blue Shield of Illinois already has launched a “Be Covered Illinois” campaign. The campaign is being funded by the insurer, and carried out by various community groups:  

Keep in mind that if insurers mislead customers about their offerings, those customers will have an opportunity to pick a different plan a year later. And under the ACA, they will have “navigators” to help them make a better choice.

Insurers know this. They  also are well aware  that under the new ACA rules that regulate them, a health insurance company will have to draw—and keep—a large share of the market’s customers in order to survive financially. For that reason, I suspect that savvy insurers will make a major effort to provide information about specific plans that will attract customers who will want to stick with those plans.

For my answers to the first four questions above, go to Health Insurance.org, click on the question and the answer will pop up.