Why Essential Medical Services need to be protected

Why Essential Medical Services need to be protected

Why Essential Medical Services need to be protected

Essential medical services is kind of important in my world. Because I may live a very miserable 48 to 72 hours without Insulin.

Essential medical services really means keeping the person alive. When I first found out I was on insulin for the rest of my life, the experience was pretty bad. I had a trip to the ER, a weekend thinking all was ok, then I went back to the ER and spent five days in the hospital. Day 1 and 2 was in ICU, intubated. All I remember about those five miserable days were a super nice male nurse saying he would take care of me, and my parents coming home from Europe only to jump in the car and drive to the hospital. Because some random virus smoked my pancreas and thyroid. Then learning to give myself shots. Good times.

And my issue with the HHS decision to cut essential medical services is not just about me and my Type 1 peers. It is about my friends who are having babies and who lose guaranteed coverage. Or my friends who have kids with asthma. Inhalers like insulin are really expensive. The ones that actually work are tier 2 or 3, or off formulary. Which means inhaler or pay the electric bill this month. In the current medical system, the cost of meds is too damn high.

I am blessed to have a job with good benefits and be able to connect the underserved with benefits. And I do not speak for my employer. Just wanted to put that out there. This is very personal. The American Diabetes Association issued a press release here.

Today, the American Diabetes Association (ADA) expresses disappointment with the Notice of Benefit and Payment Parameters for 2019, announced on April 9 by the U.S. Department of Health and Human Services (HHS), which moves forward with changes that weaken rules requiring certain health plans to cover a minimum set of “essential health benefits” (EHBs). The changes allow states and health insurers to scale back coverage of EHBs, which include prescription drugs, preventive services, chronic disease management, hospitalization, maternity, and newborn and pediatric care. This final rule allows states to redefine EHBs and/or give insurers flexibility to avoid covering benefits that are necessary for people with pre-existing conditions including diabetes.

In other words, insurance does not have to cover essential care. The stuff keeping us alive kind of care. Nice.

Five hundred dollars a month for the pump and supplies. Six thousand dollars a year. With insurance. The cash price is significantly higher. Not including doctor visits, labs done three or four times a year and more. And pumps are replaced about every 3-5 years. They cost between $6,000 and $10,000. Per device. This means living paycheck to paycheck. And hoping the pump is covered. Cash prices are out of control.

So here are my three reasons why essential medical services need to be left alone:

Reason number one: Sane people in both parties agree that medical costs are hellish. And this is not a partisan issue. It is also not the pharmacist at CVS or Kay’s Pharmacy or WalMart driving the prices up. It is manufacturers and a reimbursement system that is ironically one of the most regulated markets out there. Medicaid and Medicare don’t help.

Reason number two: Managing essential medical costs means making hard choices every day. I switch glucometers based on which one my insurance has cut a deal with. And same goes for insulin. If I was underinsured or uninsured, the cost would be something like my annual net income plus. For medication, supplies, lab visits and doctor visits. Just for me.

Earlier this year, drugmakers Eli Lilly and Novo Nordisk boosted their insulin list prices by almost 8 percent. The American Diabetes Association said the average price of insulin nearly tripled between 2002 and 2013.

And the price keeps going up and up for short acting and long acting insulin. Cash prices and prices with insurance are frankly too damn high. IF HHS Secretary Azar does do something to control prices, I will happily retract the ire towards the man. But for now, the fox appears to be running the chicken coop.

Reason number three: This is not Viagra. Or birth control. These are medications literally keeping us alive. Ask a parent with a nut allergic or bee allergic kid where the EpiPen is.

Without making changes to malpractice suits or drug price fixing, simply ending protections for essential medical services is a very bad idea. See, chronic medical conditions are life long and can be managed, but the cost of staying alive makes it harder to manage said condition. Because you are taking less pills or insulin. So the lights stay on and you have a roof over your head. Or you are not getting the inhaler that works best. Or the EpiPen.

“All people living with diabetes should have access to comprehensive health insurance that includes coverage for the care necessary to successfully manage their disease and avoid costly, and life-threatening, complications,” said ADA’s Senior Vice President of Government Affairs and Advocacy LaShawn McIver, MD, MPH. “The changes issued by HHS put Americans with diabetes at risk, and it is our mission to continue to advocate on their behalf. ADA is committed to continuing our advocacy work at the state level to maintain or improve, not reduce, coverage of essential health benefits for people with diabetes across the country.”

The key phrase is “have access to.” This is not single payer. This is not universal health care. It is as simple as being able to afford medication. Do I want the FDA to do their job and reign in insulin costs? You can bet your life (I am betting mine) on that. Do I want insurance reform? Absolutely, and I want to see something happen with cost of medications and supplies that actually works. And lasts more than a press conference. Both parties own this.

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  • GWB says:

    And my issue with the HHS decision to cut essential medical services
    When did the HHS offer that medical care? I don’t seem to recall that being authorized under legislation?

    Oh, what you mean is “the decision to no longer force an unconstitutional mandate on insurance providers to cover everything just because some people think it’s important.”

    Sorry, Gail, but I didn’t even bother to read further*, as you commit a gross fallacy there. While I am all for making our medical system the best in the world and doing our collective best to help people get what they need, I am adamantly against telling anyone they must provide you with free or cut-rate services or goods.

    Granted that our current system is entirely borked as a market. But I won’t support continued interference in the market as the answer. If you bought real insurance to cover sudden and unexpected expenses, you could expect your carrier to provide for this according to that policy. But expecting it based on gov’t mandates to “cover” an expense purely as a cost-sharing exercise on the part of all subscribers to that health plan? No.

    (* I did read a bit more. You do say that doing this without other reforms is the problem. Well, guess what? Congress won’t pass those other reforms. But this is within the purview of the executive branch [which is another required reform – it should NOT be].)

  • Nina says:

    Very true. The same with those dealing with Epilepsy. Many are on not only one but at least two medications in order to block seizures. Not having those medications puts the individual at major risk. And the meds aren’t cheap. For example. 10 days worth of one type of anti-seizure medication, if paying cash, is nearly $2500.

    That’s the thing that epilepsy patients or diabetics, among many others, need their meds EVERY SINGLE DAY. Covering EHB’s actually SAVES $$. Not covering EHB’s … healthcare costs will go up. Simple as that.

  • Gail Boer says:

    Insurance is absolutely the wrong term. More accurate terminology is group health plan or cost sharing plan. But whatever you call Blue Cross, it is one part of the problem. The rest is piss poor government oversight and drug company greed. Medical costs in general are insanely high. And since the chances of the free market ever going near this area are slim to none, the federal oversight needs to be better. There is no reason the same med costs anywhere from free to $1200 a month.

    • GWB says:

      The rest is piss poor government oversight and drug company greed.
      The rest is gov’t
      mandates that distort the market, followed by gov’t regulation (read monopoly protections/barriers to entry) that further distorts it.

      Medical costs in general are “insanely high” because they have to be plused up to account for every “insurance” contract giving a discount. If 85% of your market demands a discount, you have to adjust your prices so that the discounted amount covers your actual costs plus a profit margin. (The high medication costs also help support the $20 prescription plans at WalMart and such.)

      The only thing preventing the market from approaching this area is gov’t regulation. Right now, “insurance” companies have a great niche they can exploit, because entry to that niche requires insanely high amounts of money to comply with mandates and regulation. Drug companies are the same, along with the protectionism in the current patent/regulation scheme.

      A lot of people will get hurt in the initial crash if the gov’t were to pull apart its regulatory scheme (including mandates). However, everyone is hurt by continuing the mess we currently have.

      • GWB says:

        The first italics should end after “greed.”
        Then it should start again before “mandates”. Like so…

        The rest is piss poor government oversight and drug company greed.
        The rest is gov’t mandates that distort the market, followed by gov’t regulation (read monopoly protections/barriers to entry) that further distorts it.

  • Garland Twitty says:

    Herewith a different perspective: Christians like myself have a responsibility to help needy people. We are to feed the hungry, give drink to the thirsty, shelter the stranger, clothe the naked, tend the sick, and visit the imprisoned. We also know that those that lack adequate food, water, shelter, and clothing will die. As for health care, some is essential for life (insulin for diabetes), some not (viagra).

    To place the entire responsibility for caring on governments has disasterous consequences, as people in the U.K. and Venezuela can attest. Even in this country, we can document how recent Medicaid expansion has hurt more than helped. We would do much better if more citizens exercised their charitable responsibilities, and governments provided matching grants to the best charitable organizations.

    Insulin costs have increased? Perhaps not surprising since the incidence of diabetes has risen faster than population growth. What factors are holding back supplies? Econ 101: when demand increases faster than supplies, prices rise!)

    We hope that better quality, more affordable health care will be available in the future.

    • Gail Boer says:

      You are right but people as you know are not instinctively good. The government IS in every single solitary step of research and production but inexplicably steps back when it comes time to price the product. The factor is something called evergreening where insulin is tweaked just enough to keep it under patent. There is no generic fast acting or long acting Apidra, Lantus or the shot acting Humalog or Novalog. Same issue with certain inhalers.

      • Garland Twitty says:

        Thanks for taking time to reply.
        “People are not instinctively good” is one of my favorite topics. Yes, people will revert to the behaviors of our primate ancestors–self-centered and hierarchical. Yet, communities of people evolved to be caring and sharing, and it is that culture we should be persuading all to embrace today, despite the constant back-sliding.
        Evergreening: So, some (many?) politicians collude with businesses to promote self-interest at the expense of others. Might could we elect officials not so easily seduced by their Dark Side?

  • Nell says:

    The problem with the cost of insulin is that drug companies are allowed to hold onto their monopoly by insignificant changes to the formulation, thereby preventing generics from entering
    the market. This is what ought to be addressed by diabetics with the FDA. It is pure greed and is holding millions hostage.

  • Judy says:

    The best price for insulin is Wal Mart, $25/ bottle that’s with no insurance and no prescription needed

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