Consulo Indicium - 3/19/19

Information for your Consideration…

The President’s Budget – As Presidential Budgets go, it is like all of the others that have been submitted in recent years.  Whether the President is Democrat or Republican, the characterization is the same: “Dead On Arrival”.  So, I wasn’t surprised when the Trump Administration recently laid out their FY2020 Budget to hear the same clarion call that Republicans gave to the Obama Administration.  A couple of key points and items of interest should be noted in the President’s Budget; however, including the following:

  • The discretionary portion for the Department of Health & Human Services funding was reduced to $87B (↓12% from FY2019).  That’s a fairly sizeable chunk of change and cuts deeply into the innovation side of DHHS spending.
  • National Institutes of Health (NIH) was proposed at $34.4B or, a reduction of $5B (↓12% from FY2019.
  • National Cancer Institute (NCI) was slotted at $5.2B, a reduction of $900M (↓15%)
  • National Institute of Arthritis & Musculoskeletal & Skin Diseases (NIAMS) – $521M, a reduction of $84M (↓20%).
  • Food and Drug Administration (FDA) – $6.1B or, a $643M Increase (↑12%) 
  • Mandatory Spending for Medicare & Medicaid is project to result in savings or reductions (depending on how you count it) of $1.25 Trillion over the next 10 years.  Now, that will be accomplished primarily through:
  • Modifying payments to hospitals for uncompensated care = $98B in savings over the next 10 years;
  • Consolidating and block granting graduate medical education payments = ($47.9B);
  • Reducing Medicare coverage of bad debts = ($38.5B);
  • Paying on-campus hospital outpatient departments at the physician office rate instead for certain services = ($131.4B); and,
  • Paying all hospital-owned physician offices located off-campus at the physician office rate = ($28.7B).
  • Not to be excluded were Prescription Drug Costs which were slotted for reductions or savings over the next decade with the following proposals:
  • Eliminating cost-sharing on generic drugs and biosimilars for low-income subsidy (LIS) enrollees = ($930M) over 10 years;
  • Excluding manufacturer discounts from calculation of out-of-pocket costs in the Medicare Part D coverage gap to correct misaligned incentive and treat brand and generic drugs the same when calculating out-of-pocket costs = ($74.7B) over 10 years;
  • Eliminating pass-through payments for drugs to lower out-of-pocket costs by making them eligible for the reduced 340B payment level= ($4.3B) over 10 years;
  • Reform exclusivity for first generics to spur competition = ($1.2B over 10 years; and,
  • Establishing a beneficiary out-of-pocket maximum in the Medicare Part D or, a cost of $14B over 10 years.
  • Other items of interest included the elimination of funding for the Agency for Healthcare Research & Quality (AHRQ) where the functions would be moved into a new National Institute for Research in Safety & Quality.

New Interoperability Rules Proposed by CMS – In a move that has been advocated by many of us for some time now, HHS finally proposed new interoperability rules requiring insurers of Medicare Advantage, Medicaid, Children's Health Insurance Program and Affordable Care Act plans to provide electronic health data in a standard format at no cost by 2020.  Kudos to the Office of the National Coordinator (ONC) for Health Information Technology who pushed the requirements forward at the various agencies including CMS. The information included in the rule stipulates that diagnoses, procedures, tests and providers that the patient has seen, and provides insights into a "beneficiary's health and healthcare utilization," according to a summary on the CMS proposed rule. The requirements would be accomplished through the use standard APIs or Application Programming Interfaces which allow disparate software products communication through standard interfaces on selected data. The new rule also stipulates that insurance providers who block the information will be publicly identified with the intent of ending the practice. It will be interesting to see if anyone objects to this portion of the rule.  Now, a final cautionary note.  With the CMS notice running at 251 pages and the ONC notice, at 724 pages – be prepared for a long week of review.  I’ve only glanced at the surface.  The new rules deserved your review, consideration and response. 

Baby Boomers Drive Higher Health Spending Costs in USA – In news that didn’t rock my day – in large measure because it is so obvious – CME came out with a new report citing that the US health spending rate is projected to grow from a current state of $3.6 trillion in 2018 to about $6 trillion by 2027 – or, within the next decade.  That represents about a 5.5% annual growth rate due to primarily Boomers getting older but also the rising costs of medical goods and services.  The growth also means that the percent of GDP devoted to health care is projected to grow from 17.9% (2018) to 19.4% (2027).  The good part – if you can say that increasing our proportion of GDP health care is good – is that the growth rate is far below the 1990-2007 period which experienced an average of annual 7.3% growth rate.  Regardless, the growth does continue and for every point of a percent that we take out of the GDP for health care, there is a reduction in expenditures someplace else.  I won’t go into the litany of reductions but my two favorites are education and infrastructure.  For a complete review of the findings, you should review the recent Health Affairs article which provides an overview of the findings from the US Office of the Actuary. It’s clear to me that a change in our nation’s payment model is moving into rapid focus along with cost management.  Without such change, I keep arguing that we – The Boomers – will bankrupt the nation.  And, I really don’t see that the Millennials and beyond are going to let that happen :-)

But, It’s Not Just The Boomers – One of the more disturbing news items in recent weeks has been the number of outbreaks from measles and other very controllable infectious diseases.  Facts matter here.  The fact is that immunizations save lives.  If there are real, documentable reasons why children (or adults) should not receive immunizations, it should be considered.  But, simply because you read junk information on the web and come to the conclusion that it’s true when it is not – is NOT a good reason to allow parents or others to simply skip out on required immunizations.  Perhaps we should let people forget about stop signs because someone wants to get to their destination quicker or how about just ignoring solid lines on the highway when we are going over a hill.  Perhaps we should do away with hand washing in public restaurants for those that don’t feel it is necessary.  There is a litany of half-baked ideas out there that could support any one of these ideas.  And, they are not facts.  They are not true.  Let’s get serious.  

Reconfiguring Primary Care – The leader of Medicare's innovation center, Adam Boehler, recently unveiled his thinking for a new model for primary care physician payments where he intends to "blow up" how primary care is reimbursed. One of the primary objectives is to adopt telehealth and online consultations.  You can check out the full report at STAT.

The Continuing Disintermediation –While I am an ardent supporter of technology, I’m increasingly concerned with the ongoing disintermediation of health care services.  The splintering is becoming a problem as more and more organizations enter the market by offering up solutions that provide “immediate” care.  The problem is not the solutions.  It is; however, the fact that the solutions are most often totally disconnected from the ongoing “care” of an individual.  It is not only the call-from-anywhere health clinics (e.g. AmericanWell, MDLive, etc.).  The newest one on the block is OnMed which are standalone kiosks where you can get immediate care 24x7 from online physicians.  In addition, you can also get your prescriptions filled right in the kiosk.  Does this mean that CVS and Rite Aid are next in the disintermediation play or will they simply deploy these devices?  While it is absolutely true that about ¾ of primary care can be provided on a virtual basis, the remaining 25% is crucial and requires face-to-face time.  The problem on the horizon is the dropped information, the disconnected virtual care, the miscommunication and other problems that will no doubt arise as more and more players enter the 75% without considering the 25%.  We may be creating more problems than we are solving. What are your thoughts?

In Case You Have Not Heard About Xcertia – On the possibility that you may not have heard about Xcertia, I thought I might include a short piece on it for the blog.  Xcertia is a joint initiative sponsored by the American Medical Association (AMA), American Heart Association (AHA), DHX Group and, the Healthcare Information and Management Systems Society (HIMSS) to focus on mHealth App standards and guidelines. The collaboration is bringing together the independent efforts of each organization to foster safe, effective, and reputable health technologies. Late last year, the organization released its Privacy and Security Guidelines as part of a multi-staged, annual approach toward defining guidelines for mHealth Apps.  The organization has tapped the expertise of members from the AMA, AHA, Partners HealthCare, PCHAlliance, HIMSS, Consumer Technology Association and others.  Check it out.  They are providing a very valuable service to the public and the health care community.  Here are some other issues that have been highlighted of late that need to be considered:

 

Consulo Indicium - 1/24/19

Information for your Consideration…

The State of International Medical Graduate Education – According to the National Resident Matching Program (NRMP), international medical graduates (IMGs) who sought residency positions in the US applied in smaller numbers than in prior years but had greater success in actually finding a postgraduate year 1 position in 2018.  57% of US citizen IMGs matched versus 56% for non-US citizen IMGs.  Both of those rates are the highest since 1993.  In addition, the most IMG-friendly specialties for the 2018 match were Pathology (45%), Internal Medicine (43%), Neurology (35%); and, Family Medicine (30%). 

Consulo Indicium - 12/31/18

Information for your Consideration…

The Disintermediation Is ComingDisintermediation is the process of taking apart and putting back together in new, more consumer-centric ways.  It is the process of giving the user or the consumer direct access to information that otherwise would require a mediator, such as a salesperson, a librarian, a lawyer – or, even a doctor. Whereas in the past “intermediaries” were required for interpreting the information – like priests reading the Bible - through the use of technology users hold direct access to medical, legal information, travel, or comparative data and information directly.  The “disintermediation” comes by way of removing the doctor, lawyer, salesperson or other individual from the process.  Before the coming together there is the tearing apart.  Some examples include:

  • Walgreens (LabCorp) and CVS (Aetna) are building clinics and mobile apps to provide immediate, 24x7 access to their services – and, that does not include the efforts by Walmart and others.  Sears should have listened to me 30 years ago when I suggested that they tear out the carpet section and install clinics instead.
  • At last count over 900 Direct Primary Care or Concierge Medicine practices have been established or, a 230+% increase from 2015.
  • Amazon, Berkshire Hathaway & JPMorgan Chase have teamed up to form an independent healthcare company and hired Atul Gwande, MD – an innovator and thought leader of the first order – as their new CEO.
  • And, not to be left behind – Google, Apple, Microsoft, Express Scripts Holding or, GAME, among others – are eyeing the healthcare industry for opportunities to participate in the disintermediation party.  Their insights and analysis into how and where “health” happens and is delivered will change the way we think about “health care” on into the future. 

Actually, the disintermediation is not coming – it has arrived!

Trump Administration Recommends More Consumer Responsibility – The Congressional Quarterly recently noted that the Trump Administration in a report on how to increase competition in health care recommended that Congress and the states could take steps to decrease health care spending by lowering “…spending is to expose consumers to more costs and allow them to ‘pay directly’ for health care.” The posit that consumers are in a better position to avoid unnecessary and expensive care rather than the insurance companies which they argue are incentivized to prioritize more expensive services. Hmmm.  One of the ways to foster such consumer attentiveness is through expansion of health savings accounts.  With more than 50 other recommendations, the Administration’s plan entitled “Reforming America’s Healthcare System Through Choice and Competition” provides a lens on the thinking of the leaders currently occupying the HHS offices.  At 120 pages, the full report is worthy of a download if you’re into the nits and nats of where US health policy might be headed.  No doubt, implementation of the recommendations will be yet another story.

But, on the telehealth front, we have not seen the type of adoption that could truly reduce costs and drive efficiency (my perspective).  According to the Centers for Medicare and Medicaid Services (CMS), only one quarter of one percent (0.0025%) of the Medicare beneficiaries took advantage of telehealth services in 2016.  To bring it back full circle to the Trump Administration’s report; however, their recommendations were woefully weak.  Of the entire 120 pages, only four short recommendations were noted and they are mini-steps forward.  They include

  1. States should consider adopting licensure compacts or model laws that improve license portability by allowing healthcare providers to more easily practice in multiple states, thereby creating additional opportunities for telehealth practice. Interstate licensure compacts and model laws should foster the harmonization of state licensure standards and approaches to telehealth.
  2. States and the federal government should explore legislative and administrative proposals modifying reimbursement policies that prohibit or impede alternatives to in-person services, including covering telehealth services when they are an appropriate form of care delivery [emphasis added]. In particular, Congress should consider proposals modifying geographic location and originating site requirements in Medicare fee-for-service that restrict the availability of telehealth services to Medicare beneficiaries in their homes and in most geographic areas.
  3. States generally should consider allowing individual healthcare providers and payers to mutually determine whether and when it is safe and appropriate to provide telehealth services, including when there has not been a prior in-person visit.
  4. Congress and other policymakers should increase opportunities for license portability through policies that maintain accountability and disciplinary mechanisms, including permitting.

These are obvious minor steps.  To solve the problem requires a much more aggressive – if not assertive – approach toward solving the problem.  The technology is available.  The resources can be mobilized.  The impediments remain.  Relatively empty recommendations won’t get us there although hope is on the horizon.  The Bipartisan Budget Act of 2018 will allow MA plans, starting in 2020, to provide additional telehealth benefits. The proposed rule would allow for telehealth services from a patient's home for Medicare Advantage patients only.  So, at least we are moving in the right direction – if ever so slowly…

Consulo Indicium - 11/5/18

Information for your Consideration…

Factoid – By 2020, the total volume of medical information will double every 73 days. So, the question becomes – how do we teach our young physicians, nurses and other health care providers to stay abreast of the latest and best approaches in care delivery?  It’s not just automating information.  It’s not just “augmented intelligence”.  The issue demands our immediate attention…

Factoid 02 – Medical researchers are actively studying the retina as an early-warning system for onset of not only diabetes – which is well known – but, also dementia, multiple sclerosis, Parkinson’s disease, Alzheimer’s, schizophrenia and more. I think I’ll invent a mirror that can be used for this purpose.  Darn.  I bet someone is already working on it… 

Exercise: An Old Idea Giving Shape to Better Outcomes – As we all know, falling is the bane of growing older.  Balance and proprioception become more difficult as we age.  In one of my JAMA articles that was lying on the floor waiting for me to read it – when I picked it up – I learned that an old form of aerobic training has become the new model.  In the September 10, 2018 issue of JAMA Internal Medicine, tai chi was found to be more effective than balance and strengthening exercises in preventing falls among adults.  The study came from Oregon with a randomized selection of older adults (primarily white women, average age = 78) who engaged in a twice weekly program of tai chi for 60 minutes.  After 6 months of training, the tai chi group was found to have significantly fewer falls than the traditional exercise and the control groups.  The end result: move slow, keep focused and do tai chi!!  Now, about that yoga exercise for cleansing the mind…

On The Upside-01: Healthcare Groups Oppose Rule Penalizing Use of Public Benefits by Immigrants – The Trump Administration via the Department of Homeland Security proposed a rule last month that would penalize legal immigrants for using government benefits like Medicaid.  It’s a rule that rang the alarm bells among a wide range of healthcare and public health organizations. Stepping up to the plate in opposition to the rule were the American Hospital Association, America's Essential Hospitals, the American Academy of Family Physicians and the American Academy of Pediatrics. Beyond the medical groups, there was a broad coalition of advocacy groups seeking to block the rule. According to experts in the field, literally hundreds of thousands of children and other members of low-income legal immigrant families would be forced out of participating in public programs that provide nutrition, housing and healthcare services. The opposing medical groups cited the ensuing public health dangers as a major consideration in why the rule was ill-advised.  Kudos to the health care leaders and advocates for drawing the line!!!

…And, for those who think I’m not a middle-of-the-roader…

On The Upside-02: CMS Proposes Telehealth Expansion for Medicare Advantage Plans – The Trump Administration via the Centers for Medicare and Medicaid Services made a 362-page proposal to eliminate geographical restrictions on telehealth access in Medicare Advantage (MA) plans by 2020. The change would enable those plans located in urban areas to use connected health technology services as a core component of their approach. Furthermore, the proposal would allow members access to telecare services in the home as well as through medical service locations.  The proposal was posted by CMS last week and will be available for comments through December 31st.  The proposal emanates from language in the Bipartisan Budget Act of 2018 signed into law by President Donald Trump earlier this year, which included provisions to increase the use of telehealth and telemedicine by MA plans. In issuing the proposal, CMS stated that it believes the change “…will increase access to patient-centered care by giving enrollees more control to determine when, where, and how they access benefits.” One of the benefits will be cost savings in care delivery to the tune of about $4.5 billion dollars over the next decade once implementation begins.  In other news, the Department of Agriculture announced over $39M in learning grants related to telehealth and telemedicine.  Kudos to the Trump Administration leaders at CMS!!

Rural Hospital Closures Spike – The General Accounting Office (GAO) noted recently in a late September report that a total of 64 rural hospitals closed between 2013 and 2017 which is more than twice as many closures as the previous five-year period.  The number did not include the eight that closed and then reopened.  Emily Rappleye, the Managing Editor of Becker’s Hospital Review, wrote a very concise list of “10 things” to remember about these closures.  Rather than synthesize her thoughts, I’m quoting her in the following excerpt from her article in early October.  Here are the “10 things”:

  1. “This has happened before.Between 1985 and 1988, 140 rural hospitals closed, accounting for about 5 percent of the rural hospitals in existence in 1985. These closures are credited to the then-new financial pressures of the Medicare Inpatient Prospective Payment System created in 1983.
  2. “Comparatively fewer urban hospitals closed. Forty-nine urban hospitals closed between 2013 and 2017, accounting for about 2 percent of all urban hospitals in 2013. The 64 rural closures accounted for 3 percent of rural hospitals in 2013.
  3. “Most closures – 77 percent – occurred in the South. Texas accounted for 22 percent of the closures between 2013 and 2017, more than the entire Midwest (11 percent) combined.
  4. “The hospitals that closed were predominantly for-profit. Thirty-six percent of the hospitals that closed between 2013-17 were for-profit, though for-profit hospitals accounted for just 11 percent of rural hospitals in 2013.
  5. “The hospitals that closed were also predominately designated Medicare Dependent. Of the 64 hospitals that closed between 2013-17, 25 percent were designated Medicare Dependent hospitals, though just 9 percent of rural hospitals were Medicare Dependent in 2013.
  6. “Financial issues were the root cause of most closures. The GAO notes rural hospital closures typically occurred when hospitals had negative margins and were unable to cover fixed costs.
  7. “Declining levels of inpatient care often aggravated the hospitals' financial standing. These declines stemmed from increased competition from federally qualified health systems and other larger health systems, as well as a declining rural population overall. The report notes 2010-16 was the first period of rural population decline in American history.
  8. “Medicare payment reductions were also a major factor in the closures. The GAO notes the average rural hospital in 2016 counted on Medicare for 46 percent of gross patient revenue. Medicare payment reductions across the board contribute to negative margins for rural hospitals, while reductions in Medicare bad debt payments also add financial pressure.
  9. “Medicaid payments are a boon to rural hospitals. Supporting past research, the GAO found rural hospitals in Medicaid expansion states were far less likely to close than those in states that had not expanded Medicaid as of April 2018.
  10. “More than half of the closed hospitals converted into another type of healthcare facility,such as urgent care, primary care or emergency services. Forty-seven percent ceased all services.” 

Hmmm – Social Media Use by Physicians – When I was going to medical school, we didn’t have to worry about things like social media.  Facebook, Instagram, Twitter, Snapchat and all the rest didn’t exist because there was no access to the Internet.  It’s didn’t exist, yet!  So, if you haven’t read the AMA Code of Medical Ethics  you may want to consider a closer read in lieu of yet another endless evening of “working the web”.  The Code recognizes that there is real value in the use of social media and – at the same time – a special need for caution among the physician community in how it is used. It’s becoming more and more of an issue.  The AMA is also now offering a credit-eligible CME course, Boundaries for Physicians: The Code of Medical Ethics, which provides guidance to physicians for identifying and understanding how to maintain proper boundaries with their patients and to articulate and understand the underlying importance of those boundaries to the practice of medicine. The module is not only available for CME credit but is also free to members or $20 for non-members.  It’s worth it.

Consulo Indicium - 10/11/18

Information for your Consideration…

Combatting the Opioid Menace – The US Department of Health and Human Services (DHHS) recently announced that the agency has “awarded more than $1 billion in grants to states, communities and organizations fighting the opioid crisis.” The bulk of the money ($930 million) has been allocated to support state efforts related to providing treatment and prevention services in combating the opioid problem.  DHHS also has allocated more than $350 million to community health centers throughout the nation to increase access for substance use disorder and mental health services.  The efforts are to be applauded but, we need to go beyond ex post facto treatment.  Prevention is the key and a broad strategy for engaging in prevention has yet to be put forward in an effective way.  So, let’s give the Administration credit for what’s been done but push them to do more.  The opioid problem cuts across all societal sectors.  More effort needs to be put into solving the problem…    

Health Care Leaders Group Speak Out on Top Concerns – The HealthCare Executive Group (HCEG) recently released its Top 10 list of concerns.  The group consists of provider, payor, technology and other related industry leaders who engage in a multiple day discussion before determining their consensus list of issues. The results of their list which presents challenges, issues and opportunities were as follows:

1.       Data & Analytics: Rising to the top of the list, the issue was all about leveraging the data – especially the clinical data – to manage health care more effectively and to support decision-making.

2.       Total Consumer Health: The consensus was focused on improving the overall medical, social, financial, and environmental well-being of individuals seeking health care services.

3.       Population Health Services:  There has been lots of talk about population health but not as much action.  The discussions centered on operationalizing community-based health strategies that support chronic care management, drive clinical integration, and address barriers by integrating the social determinants of health as action points.

4.       Value-based Payments: Again, another area that has gotten lots of talk and less action.  The need for systems to support the targeting of specific medical conditions to improve quality of care and manage costs rose to the top of the discussion points.

5.       The Digital Healthcare Organization: Health care is becoming a digital enterprise so literally all elements of the health care network including: portals, patient literacy, cost transparency, digital payments, mobile wearables and devices, other patient-generated data, remote monitoring, and omni-channel access/distribution of data were all issues that percolated to the top of the agenda.

6.       Rising Pharmacy Costs: Strategies to address the continuing escalation of pharma costs along with the best approaches for measuring benefits to quality of care and total healthcare costs were highlighted

7.       External Market Disruption: Suffice it to say, there was lots of discussion about the plethora of announcements emanating from new players in health care like Amazon, Chase, Apple, Walmart, Google – and, others...

8.       Operational Effectiveness: The spectrum of opportunities for creating efficiencies was discussed including: implementing lean quality programs, process efficiency (with new core business models), robotics automation, revenue cycle management, and real-/near-time point of sales transactions.

9.       Opioid Management: The struggle continues despite investments at the state and federal level for developing strategies to identify and support individuals and populations who struggle with substance abuse/addiction or are at-risk of addiction.

10.   Cybersecurity: Finally, for the fourth year in a row, cybersecurity was listed in the Top 10 list.  The protection of data by maintaining the privacy and security of consumer information and trust in sharing data were top concerns.

The Source of Academic Leadership – For the last century at least and probably longer, the USA has been a leader in academic circles.  Our research, our universities, our academicians have been the points of discovery for this little wonder we call, Earth.  It’s been the Golden Age in America.  But, we are seeing the glimmer of change on the horizon and, the challenge is coming from the East.  I remember my first visit to China in 1978 as a member of one of the very first delegations of health care professionals to visit China since before the Revolution.  We were impressed with the many public health measures that had been implemented to improve the health of the people.  It was remarkable!  But, it was also obvious that China was well behind the USA in research, acute care and much of the rest of health care.  Now, 40 years later (yes, 40 – argh), China is coming of age as a leader in the scholarly community.  In recent years, the Chinese government has shifted its focus from investments that improve agriculture and manufacturing toward more scientific efforts.  Witness the growth of investment in the technology sector as well as the fact that 11 of the top 100 universities globally are Chinese. During the ensuing period, Chinese academics have also moved to the pole position in the academic publications for math, the physical sciences and engineering where the number of academic publications has quadrupled since 2000.  For example, in Nature and Science, 20% of the publications emanate from Chinese authors based at Chinese universities. Research in health care is not far behind.  While the quality of their output is not up to par with the US, it’s not far behind either…

So, what’s the US response?  Rather than embracing the change, the US government under the Trump Administration has started tightening the rules for obtaining study or work visas for Chinese academics – which now represent 1/3 of foreign students studying in America.  The clamp down is being done on the notion that these academicians are gaining too much information and knowledge by studying in the US.  However, our US scientific community has reacted with alarm. Knowledge is porous. The good part about the Chinese studying in the US is that they get to know our culture, the way we live, the way we think and – while there are many good elements about Chinese culture – they learn the US is not some evil empire.  Scientific process absolutely requires an open collaboration. If, in fact, there are documented episodes of espionage or unsuitable behavior we have other avenues for managing such situations like criminal prosecution or academic expulsion. But, simply building a wall against academic collaboration will result in exactly the wrong result – the slow decline of research leadership in America.  Rather than closing our doors, we should open them wide and serve as the source of collaboration and collegial exchange.  At the end of the day, such an approach will yield far greater results than hiding behind our borders.

Paying It Forward – Yet another survey is out noting that workers are shouldering an ever-growing share of their medical costs because employers are simply passing along the additional health insurance costs in the form of deductibles. The non-profit Kaiser Family Foundation conducted a survey showing that health insurance premiums and deductibles for American workers continued to escalate in 2018.  But, it wasn’t just the escalation, it was also the fact that cost increases are outpacing wage growth and inflation. For example, the average cost of a family health plan is now $19,616 a year, with workers contributing $5,547, or about a quarter of the cost.  Employers pick up the balance of health plan costs for the workers as a benefit. But, the number of workers with large deductibles is increasing.  In 2009, only 7% of workers had a deductible of $2000 for single coverage.  Today, it is 26% (See Table). deductible What we’ve seen in the market place is that health insurance premium increases have moderated, increasing by about 5%.  However, deductibles have marched forward as employers adopt strategies which shift the cost burden to the workers.  With the Republican efforts in play to undo the Accountable Care Act (ACA), access to affordable insurance has become increasingly problematic.  I’ve said this before BUT – rather than undoing, we need to amend the ACA.  After all, even though neither political party seems to believe it, solutions do come to the middle.  They are not at the extremes of political agendas.  Perhaps the focus should shift toward doing something right for the American people as a whole.  The next revolution that we will see in the streets are marches about access to health care.  Mark my word – they are coming.  In 2000, 68% of the employers offered health insurance.  That dropped to just over one-half by 2017 although it has increased to 57% for 2018.  This is the one issue I get more emails on than any other – except, of course, those related to restaurants and where to eat…

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