Will End of Obamacare Hurt the Chronically Sick?

By Barby Ingle, Columnist

When a pebble is thrown into a pond, it creates a ripple effect that is noticeable, but no long-term damage occurs.

But if an asteroid were to land in the ocean, it could be catastrophic to all life on earth. We are simply not prepared for such a disaster.

The chronic pain community was hit by an asteroid of sorts last year with the release of the CDC’s opioid prescribing guidelines. The tsunamis are still hitting patients in its aftermath. To make any change to the healthcare system without having something to replace it is never a good idea.

Now we are anxiously waiting for details on what President-Elect Donald Trump and the Republican-led Congress will offer to replace Obamacare.

Although things won’t change overnight, the early signs are that “Trumpcare” could affect the already limited healthcare that the poor, elderly and chronically ill receive.

Some of you who are not chronically ill may feel like I am saying the sky is falling. But many of us are already unable to afford proper and timely treatment with the coverage we have now, because the system is set up to give priority to acute care, not chronic care.

Republican lawmakers can’t wait until Obamacare is repealed and replaced. But they need to take the time to develop a system that is effective for patients, providers, educational institutions, insurance companies, pharmaceutical companies and government agencies. Patients and providers are far too often left out of the discussion about treating the chronically ill and appropriate compensation for those providing their care.

In the first few days of 2017, GOP leaders such as House Speaker Paul Ryan and Health and Human Services Secretary-nominee Dr. Tom Price announced that they will target the Medicare system with major restructuring. They have not yet offered any details on their plans, but say they will lower healthcare costs for taxpayers. 

Medicare is an east target. With the number of elderly increasing as baby boomers move into retirement age, it’s inevitable that health care costs are going to increase. In 2015, Medicare spending grew 4.5% to $646 billion, and Medicaid grew twice as fast, by 9.7% to $545 billion.

"Value-Based" Medicine

Based on their recent announcement, congressional leaders are likely to try to convert Medicaid from an entitlement program for low-income, elderly and disabled Americans to one that is “value based” with fixed federal contributions to the states. They have not yet offered details on how those payments would be calculated or whether they would keep pace with inflation. 

Measuring a providers’ pay using a value based system is not going to work with chronic illness. There is not enough incentive in the current system that gives providers the compensation they need. We have already seen many providers across the country choose to stop treating people with chronic pain diseases. 

Every patient is also different. There is no one-size-fits-all cure for any disease. Two people can be given the same medication for cancer, and while it may work for one patient, the other one may have to try other treatments. This is the same for every single chronic disease. 

A person who breaks a bone can go to the emergency room, get the bone set, and wear a cast while it heals. They don’t have to think about how they are going to keep living with an incurable disease and the roadblocks they have to face in getting treatment.

Now we have people who don’t understand the complexity of treatment for chronic care patients deciding what additional roadblocks they can put up to keep costs down. 

Can we start by paying Congress with a value based system, like they want to do with our providers? Can we punish lawmakers with fines for needing extra hearings to get a bill passed or blocked? I don’t think so. Yet the current leadership wants states to provide better healthcare at a lower cost by giving them greater flexibility in setting eligibility and benefits. I see it as taking away even more of the limited coverage we currently have. 

Without federal guidelines, states will push poor people out of programs, eliminate important benefits, and cut already-low payment rates to providers to save money.

I remember a time in Arizona when poor men and women qualified for state assistance for health and food. Now, you must have children to qualify for many of our assistance programs. 

Every state is different in what its Medicaid program covers and the eligibility requirement. Giving additional incentives states to “cut costs” instead of putting the focus on patient care is a big mistake and will cost society more in the long run. 

It reminds me of something I have seen in the insurance industry. Insurers want to lower emergency room costs, so they put payment practices in place to discourage chronic care patients from seeking the care they need. 

I have personally been in the position of not wanting to go to the ER because I knew they wouldn’t do anything to help me. As soon as the attending doctor sees my complicated medical history, they don’t want to treat me for the acute issue that I am having due to the extra precautions they need to take due to my chronic disease. They spend more time trying to find another hospital to transfer me to than they spend working on me! 

This past September, I had two hospital doctors fight in front of me because one didn’t want to be my attending provider. I am a complicated case, and he knew he was not going to be compensated properly for taking care of me. The outcome was leaving me in the emergency room for over 12 hours before getting me a room. This gave him enough time to pressure me to check myself out and head to another hospital, which was suggested more than once. 

The emergency room provider knew I needed to be in the hospital, so she loudly spoke up to keep me there and worked hard to help me as best she could. The delays in getting me treatment only wound up increasing the insurance bill.

New congressional proposals would phase out enhanced federal payments to the states to cover low-income adults. States need to save money as well, so what will they do to offset these costs? They will either raise taxes or cut what is covered to those in need. Long-term care coverage items seem to get cut first, as they are the most costly. 

President-elect Trump campaigned on not touching Medicare and promised to make sure everyone has access to healthcare. But we don’t know whether he will go along with the healthcare agendas of top congressional leaders. We do know that the Trump administration is receptive to the states' Medicaid waiver proposals. This would impose more patient-responsibility requirements. Chronic care patients already have trouble paying insurance premiums, sustaining employment, and dealing with illnesses that last a lifetime. Putting time limits on benefits for a chronically ill person is ridiculous.

Congressional leaders are now saying they are working to turn Medicare into a program that would pay private plans and the traditional fee-for-service program a fixed amount per beneficiary by 2024. If traditional Medicare competes with private plans on equal terms, there will be a loss in coverage of long-term care needs for the chronically ill. 

We are not equal to a healthy working individual and our coverage needs are critically different. It is also important to remember those who are disabled and qualify for Medicare have earned it by paying into the system when they could work. Demanding someone to be engaged in meaningful work to receive Medicare benefits when they are disabled is ridiculous.  

Let’s not wait to move until the asteroid hits. Let us unite and voice our needs so we are not overlooked as these new policies are developed. Let’s demand that our congressional leaders give chronically ill patients a seat at the table, and take the time to create a health system that is right for all Americans. Don’t let them forsake the chronically ill to save money. 

Barby Ingle suffers from Reflex Sympathetic Dystrophy (RSD) and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the Power of Pain Foundation. She is also a motivational speaker and best-selling author on pain topics.

More information about Barby can be found at her website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Can Trump Make Healthcare Great Again?

By Barby Ingle, Columnist

As a chronic pain patient, I know that the Affordable Care Act (ACA) has not been so affordable for some people. Here in Arizona, monthly insurance premiums are going up 75 percent and the national average is seeing a double digit increase.

Running a foundation for the past decade, I have heard many stories of patients unable to afford proper and timely healthcare. Since the enactment of Obamacare in 2010, I've heard even more stories of regret, loss of care and rising costs. Premiums have gone up so much that many would rather pay the penalty for not having insurance, instead of getting it.

I am not sure if President-elect Donald Trump can "repeal and replace" the ACA in a timely manner. It will take an act of Congress to completely repeal ACA and eliminate the individual mandate.

We need to broaden healthcare access for all Americans, especially those of us living with chronic illnesses. Let’s look at the 7 steps proposed by Trump during the presidential campaign.

1. Completely repeal Obamacare and eliminate the individual mandate. No person should be required to buy insurance unless he or she wants to.

I agree with not mandating the purchase of insurance, but I also see why it was put into the plan. It was thought if we force everyone to pay into the system, it will be easier to bear the costs of caring for the elderly and disabled. 

Current enrollment for Obamacare shows that less than 12.7 million of the 40 million without insurance are now covered. That's progress, but even with subsidies, many people in pain (not on disability) are unable to afford coverage. Also, many with insurance were cut from their long-time providers as their plans were no longer accepted by the provider.

2. Modify existing law that prohibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in the market, insurance costs will go down and consumer satisfaction will go up.

This is one provision I would like to see. I travel currently for my pain management care. I would like to see the sale of health insurance across state lines, as I believe it will offer me better in-plan coverage. Paying out of network is very costly for patients like myself.

As we allow the free market to play a bigger role, we must also make sure that no one slips through the cracks simply because they cannot afford insurance. We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it. I don’t believe that basic Medicaid covers enough treatments for chronic pain patients.

I would also want multiple patient representatives and caregivers to play a role on boards and advisory committees that make these decisions. There is no plan in place for the involvement of the patient voice that I am aware of.

3. Allow individuals to fully deduct health insurance premium payments on their tax returns.

I would like the ability to fully deduct my health insurance premiums. Businesses are allowed to take these deductions, so why wouldn’t Congress allow individuals the same exemptions?

4.  Allow more individuals to use Health Savings Accounts (HSAs). Contributions to HSAs should be tax-free and should be allowed to accumulate from year to year. These accounts could become part of the estate of the individual and could be passed on to heirs. HSA funds could then be used by any member of a family without penalty. 

As someone who has participated in an HSA in past years, I found that they were not a benefit for me as a chronic pain patient. I spent everything in my HSA account as fast as it went in from my husband’s paychecks.

But for others who don't have to worry about paying for long-term chronic care needs, I have seen the HSA system work and help spread out costs throughout the year. HSA accounts would be particularly attractive to healthy young people with high-deductible insurance plans.  

5. Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals. Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure.

I believe in 100% price transparency from all providers, insurance companies, pharmacies and hospitals. We should be able to easily see the costs of our care.

6. Give Medicaid block grants directly to the states. Nearly every state already offers benefits beyond what is required in the current Medicaid structure. The state governments know their people best and can manage the administration of Medicaid far better without federal oversight. States will have the incentives to seek out and eliminate fraud, waste and abuse.

I like this as well. Giving each state the ability to fund and provide their own Medicaid benefits will be beneficial. We have to cut down on fraud and get proper and timely access of care to those who need it most.

7. Remove barriers that prevent foreign drug makers from offering safe, reliable and cheaper products. Congress will need the courage to step away from the special interests and do what is right for America. Allowing consumers access to imported and cheaper drugs will save money.

We need more abuse resistant medications, along with drugs that are more affordable. I agree that allowing consumers access to imported drugs will give us more options and help cut prices.

These seven steps are just the start of what we need to make the system work better. The process will take years to figure out. Let’s keep our voices loud as patients and advocates, so that we keep the good parts of our healthcare system and increase access for those who need it by lowering costs and opening access to alternative treatments. We also need to address the abuse of opioid medication, while maintaining access for those that truly need it. 

Barby Ingle suffers from Reflex Sympathetic Dystrophy (RSD) and endometriosis. Barby is a chronic pain educator, patient advocate, and president of the International Pain Foundation. She is also a motivational speaker and best-selling author on pain topics.

More information about Barby can be found at her website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

What Will Trump Election Mean for Pain Care?

By Pat Anson, Editor

The day after one of the biggest political upsets in American history, millions of chronic pain patients are wondering what a Donald Trump administration will mean for them.

President-elect Trump has repeatedly vowed to “immediately repeal and replace Obamacare,” but has not clearly defined what he would replace the Affordable Care Act with. Trump has also supported reductions in the supply of oxycodone, hydrocodone and other Schedule II opioids.

But perhaps the biggest change will be in leadership positions at federal agencies that set health care policies. That happens whenever a new administration takes office, but the changing of the guard this time will almost certainly mean the departure of several politically appointed administrators who played key roles in setting policies that many pain sufferers consider anti-patient.   

Health and Human Services (HHS) Secretary Sylvia Burwell – who presided over key policy decisions such as the CDC’s opioid prescribing guidelines and Medicare’s decision to drop pain questions from patient surveys – will be replaced.

Also likely to depart are CDC director Dr. Thomas Frieden, FDA commissioner Dr. Robert Califf, acting DEA administrator Chuck Rosenberg, and Surgeon General Dr. Vivek Murthy. All have endorsed policies harmful to pain patients.  

Murthy recently sent letters to over 2 million physicians urging them “not to prescribe opioids as a first-line treatment for chronic pain.”

Rosenberg has called medical marijuana "a joke" and recently tried to criminalize kratom as a Schedule I controlled substance, a move the DEA withdrew after widespread opposition from the public and some members of Congress.

In his short time as FDA commissioner, Califf has overruled some of the FDA’s own experts in endorsing the CDC guidelines and has instituted a series of policies at FDA aimed at reducing opioid prescribing.

Frieden’s departure from the CDC will likely lessen the influence of Physicians for Responsible Opioid Prescribing (PROP) at the agency. PROP founder Dr. Andrew Kolodny has a long association with Frieden, having worked for him when Frieden was commissioner of New York City’s Health Department. PROP President Dr. Jane Ballantyne continues to serve as a consultant to CDC, despite complaints that she has a conflict of interest.

The new heads of the CDC and DEA will be appointed by president-elected Trump, while the HHS Secretary, FDA commissioner, and the Surgeon General are nominated by the president and confirmed by the Senate.

According to Politico, one of the front runners to be nominated by Trump as HHS Secretary is Dr. Ben Carson, a former Republican presidential candidate and retired brain surgeon, who Trump has called a “brilliant” physician.

"I hope that he will be very much involved in my administration in the coming years," Trump said at a campaign rally.

Other names being mentioned for HHS Secretary are Florida Gov. Rick Scott, former House Speaker Newt Gingrich, and Rich Bagger, a pharmaceutical executive on leave from Calgene who is the executive director of Trump's transition team.

None of this means that a Trump administration will reverse any of the pain care policies at CDC, FDA and other federal agencies. Like most Republicans, Trump wants to reduce government regulations, not increase them. But as PNN reported last month, the president-elect has already indicated he supports measures to limit the supply of opioids.

“DEA should reduce the amount of Schedule II opioids -- drugs like oxycodone, methadone and fentanyl -- that can be made and sold in the U.S. We have 5 percent of the world’s population, but use 80 percent of the prescription opioids,” Trump said in prepared remarks at a campaign rally in New Hampshire. “I would also restore accountability to our Veterans Administration. Too many of our brave veterans have been prescribed these dangerous and addictive drugs by a VA that should have been paying them better attention.”

Trump wants the FDA to speed up the approval of opioid pain medication with abuse deterrent formulas. And he wants to increase the number of patients that a doctor can treat with addiction treatment drugs like buprenorphine (Suboxone).

"The FDA has been far too slow to approve abuse-deterring drugs. And when the FDA has approved these medications, the rules have been far too restrictive, severely limiting the number of authorized prescribers as well as the number of patients each doctor can treat," he said.

The president-elect has also pledged to stop the flow of fentanyl and other illegal drugs into the country.

“We will close the shipping loopholes that China and others are exploiting to send dangerous drugs across our borders in the hands of our own postal service. These traffickers use loopholes in the Postal Service to mail fentanyl and other drugs to users and dealers in the U.S.” Trump said.

“When I won the New Hampshire primary, I promised the people of New Hampshire that I would stop drugs from pouring into your communities. I am now doubling-down on that promise, and can guarantee you – we will not only stop the drugs from pouring in, but we will help all of those people so seriously addicted get the assistance they need to unchain themselves.”

Trump has personal dealings with addiction, having lost a brother to alcoholism at age 43. Watching the long downward spiral of his older brother Fred led Trump to a life-long aversion to alcohol, drugs and tobacco.

Trump and Clinton Pursue Same Policies in Pain Care

By Pat Anson, Editor

Chronic pain patients hoping for a dramatic change in federal pain care policies as a result of the presidential election are likely to be disappointed.

Both Donald Trump and Hillary Clinton favor more restrictions on opioid prescribing, as well as expanded access to addiction treatment programs, which are essentially the same policies being pursued by the Obama administration.

At a rally in New Hampshire this weekend, Trump outlined for the first time his strategy to combat the nation’s so-called opioid epidemic.

“DEA should reduce the amount of Schedule II opioids -- drugs like oxycodone, methadone and fentanyl -- that can be made and sold in the U.S. We have 5 percent of the world’s population, but use 80 percent of the prescription opioids,” Trump said in prepared remarks.

“I would also restore accountability to our Veterans Administration. Too many of our brave veterans have been prescribed these dangerous and addictive drugs by a VA that should have been paying them better attention.”

Trump said the Food and Drug Administration has been “too slow” in approving opioid pain medication with abuse deterrent formulas. And he said he would “lift the cap” on the number of patients that a doctor can treat with addiction treatment drugs.

donald trump

donald trump

But the Republican nominee seemed confused about the difference between abuse deterrent formulas and addiction treatment drugs like buprenorphine (Suboxone).

"The FDA has been far too slow to approve abuse-deterring drugs. And when the FDA has approved these medications, the rules have been far too restrictive, severely limiting the number of authorized prescribers as well as the number of patients each doctor can treat," he said.

There are no limits on doctors for prescribing abuse deterrent drugs, but there are for the buprenorphine. In August, the Obama administration nearly tripled the number of patients that a doctor can treat with buprenorphine.

Trump also seemed unaware that the DEA recently said it would reduce the production quota for many opioids by 25 percent or more.

Trump claimed the Obama administration has worsened the nation’s drug problem by commuting the sentences of drug traffickers and by releasing “tens of thousands” of drug dealers early from prison. He also pledged to stop the flow of illegal drugs into the country.

“We will close the shipping loopholes that China and others are exploiting to send dangerous drugs across our borders in the hands of our own postal service. These traffickers use loopholes in the Postal Service to mail fentanyl and other drugs to users and dealers in the U.S.” said Trump.

“When I won the New Hampshire primary, I promised the people of New Hampshire that I would stop drugs from pouring into your communities. I am now doubling-down on that promise, and can guarantee you – we will not only stop the drugs from pouring in, but we will help all of those people so seriously addicted get the assistance they need to unchain themselves.”

Like Trump, Hillary Clinton has also promised to expand access to addiction treatment, but in more detail. Her Initiative to Combat America's Deadly Epidemic of Drug and Alcohol Addiction would allocate $10 billion in block grants to states to help fund substance abuse programs.  

Clinton also wants doctors to undergo training in opioid prescribing before they are licensed to practice and to require that they consult prescription drug databases before writing prescriptions for controlled substances.

One area where Clinton differs with Trump is that she puts less emphasis on law enforcement. Saying she wants to “end the era of mass incarceration,” Clinton has called for low-level drug offenders to get treatment and not just be locked up.

“For those who commit low-level, nonviolent drug offenses, I will reorient our federal criminal justice resources away from more incarceration and toward treatment and rehabilitation. Many states are already charting this course — I will challenge the rest to do the same,” Clinton wrote in an op/ed published in the New Hampshire Union Leader.

hillary clinton

hillary clinton

In their public statements, neither Trump or Clinton have given any indication that they believe that  federal policies affecting pain care, such as the CDC’s opioid prescribing guidelines, have gone too far. If anything, they want to go further.

Clinton has endorsed a proposed tax on opioid pain medication sponsored by West Virginia Sen. Joe Manchin (D). If approved, the so-called Lifeboat Act would raise $2 billion annually to fund addiction treatment programs. The tax would be the first federal tax on a prescription drug ever levied on consumers.  

During a roundtable discussion about opioid overdoses in West Virginia, Clinton called the tax “a great idea” and said it was “one of the reasons why I am such an admirer of Sen. Manchin.”

Pain News Network has asked the Trump campaign where the Republican nominee stood on the opioid tax. We have yet to get a response.