Beware the Consequences of Government Setting Health Prices

Prescription drug spending in 2019 was less than 10 percent of the nation’s $3.8 trillion health-care spending. But high drug prices clearly are low-hanging fruit when it comes to eye-dropping examples of how health-care companies exploit U.S. consumers.

The latest exhibit was last week’s report by the Congressional Budget Office (CBO) looking at drug prices paid by different federal programs. Millions of older and disabled Americans using the private drug plans offered under Medicare’s Part D drug program, it turns out, paid a whole lot more for their meds than did people using Medicaid and federal programs for current (Department of Defenses and Tricare) and former (Veterans Administration) military service members.

The CBO looked at spending on major brand-name drugs in 2017 across different federal programs. (I’d love to see results for a more recent year but timeliness and detailed health data are often incompatible concepts.) The Federal Supply Schedule, which is included in the chart below, reflects drug prices in other U.S. programs that take advantage of its volume-based purchase agreements. (Apologies for the lo-res file.)

Part D prices are much higher than those in other federal programs, including nearly double Tricare and VA prices. The prime reason is that Medicare is legally prohibited from using its massive market clout to negotiate for lower drug prices, while the military programs are not. The story with Medicaid is less straightforward. It’s relatively low retail prices reflect reduced consumer choices and more controls on consumer access to medication. State program oversight and budget pressures also make apples-to-apples comparisons misleading.

Congress did not accidentally forget to give Medicare the power to use its market muscle when it approved creation of the Part D program in 2003. Republicans controlled the White House and both houses of Congress, and used the strong consumer appeal of lower drug prices to overcome resistance from within their ranks. Democrats didn’t much like the bill but most did not want to miss a chance to broaden Medicare protections.

In exchange, the drug companies were able to open up a new vein of federal red ink. Consumers are protected from some of those higher Part D drug costs by the law’s open-ended federal subsidies. In 2019, Part D premiums paid by Medicare enrollees were about $15 billion, with Uncle Sam and state governments picking up nearly 85 percent of the program’s annual price tag of nearly $100 billion.

(Shameless commercial plug: My new health care book provides details on the success of private health care companies in getting Uncle Sam to subsidize consumer health costs. This permits continued health care inflation and hides the true costs of that care from the people who receive it.)

Trying to give Medicare the power to lower Part D prices is a perennial Congressional non-starter. However, always the optimist, it would not be surprising to see movement this year as part of a broader health bill. Republicans have usually supported the interests of private Part D insurers, but may wilt after being on the anti-consumer side of domestic spending initiatives of the new Biden administration that are popular even among Republican voters.

The likelihood of unintended and unappealing consequences is high here. Lowering Part D drug prices, however, would not necessarily cut billions from drug-company revenues. They would adopt new strategies to change pricing to other customers, including perhaps seeking higher prices from private employer insurance programs.

Never underestimate the ability of regulated entities to outwit regulators’ intentions. The CBO report included a diagram of how Part D drug prices are determined. Beyond its complexity, keep in mind that every interaction looks like a henhouse to people looking to make a buck off the program.

Want Health Insurance? Biden Has Deals for You!

If you have no health insurance and are not yet eligible for Medicare, the federal government is doing three things to make your life more secure when it comes to getting affordable health care.

One: From February 15 through May 15, people have a special enrollment period, ordered by President Biden, to sign up for new Affordable Care Act plans. Millions of uninsured people, including those who’ve recently lost jobs, qualify for coverage under existing ACA rules.

Two: ACA rules are likely to be made much more attractive, They are contained in the health care provisions of the president’s $1.9 trillion rescue program, which is tied to the pandemic and the extensive economic damage it’s caused.

Three: Medicaid may become easier to get and states no longer can require people to seek work before being eligible.

Assuming Democrats in the U.S. Senate can approve the rescue program via a budget resolution that does not require Republican support, the ACA will be expanded for at least the next two years. Unless, of course, the U.S. Supreme Count strikes down the law, which it may do in a case now before the court.

If the law survives, as most pundits expect, consumers can look forward to expanded tax credits that will make ACA plans more attractive to both low- and middle-income individuals and households.

The ACA is complex, featuring different tiers of coverage (bronze, silver, gold, and platinum) and income-based rates and tax credits. A program to help people navigate these rules and sign up for coverage was gutted by former president Trump but would receive added funding in the Biden rescue program. The timing of that boost is not known but until then, there are solid help websites operated by the Kaiser Family Foundation and the Georgetown Center on Health Reforms.

The Center on Budget and Policy Priorities (CBPP), a liberal Washington think tank, assessed Democrats proposals developed in the House of Representatives. Here are examples of how the changes would affect people at different income levels:

Affordable Care Act Monthly Premiums
National Averages
Current House Savings
45-year-old individual
$18,000 (141% FPL) $54 $0 $54
$30,000 (235% FPL) $195 $85 $110
$45,000 (352% FPL) $369 $274 $95
$60,000 (470% FPL) $511 $425 $86
60-year-old couple
$30,000 (174% FPL) $132 $24 $108
$45,000 (261% FPL) $325 $167 $158
$60,000 (348% FPL) $492 $360 $132
$75,000 (435% FPL) $1,920 $531 $1,389
Family of four*
$45,000 (171% FPL) $193 $32 $161
$60,000 (229% FPL) $379 $158 $221
$90,000 (343% FPL) $737 $531 $206
$120,000 (458% FPL) $1,445 $850 $595
*Two adults age 40, children age 10 and 5


The CBPP’s projected impacts of the changes include:

  • If the remaining states expanded Medicaid nearly 4 million uninsured low-income adults could gain coverage.
  • More than two million other low-income people are now in the so-called coverage gap and could get coverage. They have incomes below the poverty line and thus are ineligible for premium tax credits for ACA coverage and also ineligible for Medicaid under their state’s rules.
  • Premium tax credits for 2021 and 2022 would lower to 8.5 percent from 9.83 percent the ceiling on how much of a person or family’s income can be spent on ACA plans, “eliminating or reducing premiums for millions of current marketplace enrollees.” This applies to people with income of 300 to 400 percent of the federal poverty level. Premium caps for higher earners also are proposed.

Medicaid is also on the president’s to-do list. Late last week, the Centers for Medicare & Medicaid Services (CMS) reversed Trump’s requirement that states could require people to seek work before they were eligible for Medicaid. That effort has been at least temporarily halted by the courts, and presumably won’t be pursued by any states now.

In a potentially more important action, the rescue bill offers more funds to entice Medicaid participation in ACA plans by the 14 states that did not expand Medicaid following enactment of the ACA – Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota. Tennessee, Texas, Wisconsin, and Wyoming.



Our Enduring Health Tragedy Is Its Cost

It is no exaggeration to say that health care has never occupied such a central place in our minds. COVID-19 is taking record numbers of lives in the U.S. even as remarkable progress is being achieved on promising vaccines that could provide herd immunity, assuming enough people take them.

Beyond trying to control this devastating disease, the future of the Affordable Care Act – and continued health insurance for 20 million people – is now before the U.S. Supreme Court. Health reform is also back on the front burner. President Biden is expanding access to care and insurance through executive orders, most notably boosting the Affordable Care Act.

Lost in this flurry of Defcon 1 health emergencies is the ongoing damage being done to our economy and wallets by health costs that are twice as large in the U.S. per person as in other developed nations.

Even as the economy tanked earlier this year, health spending soldiered on. Total spending for the year may dip because of drops in routine care, preventive screenings, and elective surgeries. But the decline could be as little as half a percent.

“We have never seen a year in which health spending actually goes down,” commented Drew Altman, head of the Kaiser Family Foundation. “It may be a long time before we see a reduction in health spending like this again.”

Once the pandemic is under control, we will still be saddled with a national health care bill of more than $3.8 trillion. Imagine what we could do with half of that money — an extra $1.9 trillion each and every year — either keeping it in our own pockets or using it to address climate change, aging infrastructure needs, or a host of other needs.

Wishing we could save health dollars won’t make it happen, of course. Enacting even the most comprehensive single-payer health reform proposal would lower per-capita costs but the national price tag for universal insurance could be staggering. Not that it has a glimmer of being approved by Congress.

Beyond policy issues, a lot of those $3.8 trillion dollars wind up as the salaries of nurses, doctors, and other health care workers. Who would want to reduce their paychecks these days, if ever? They are the heroic human faces of health care. But they also are part of an entrenched network of highly profitable and often uncompetitive health care giants – insurance, drug, equipment, hospital, and physician companies.

Teamed with powerful Washington lobbyists, they have mastered the art of picking our pockets. They have been far more effective at this, it should be noted, than in providing broader public access to quality health care. Analyses by the Organisation for Economic Co-operation and Development (OECD) regularly place the U.S. in the bottom third of important health outcomes among developed nations.

The beauty of the health industry’s work is that it has left very few fingerprints. In 1970, consumers directly paid 34 percent of national health expenses out of their own pockets, according to an analysis from the Peterson-KFF Health System Tracker.

By 2018, people were paying only 10 percent of health expenses directly. Over the same period, the share of national spending shifted to private and public health insurance plans rose to 75 percent from 43 percent.

Shifting health spending away from consumers has had multiple and mostly bad consequences. Consumers no longer pay their own health bills and have little if any idea what providers charge for health services or whether such charges bear any resemblance to underlying costs. Why should they even care, given that these costs have little bearing on their own out-of-pocket spending?

This disconnect also causes people to use more health care than they need, often stimulated by commercial health advertising unique to the planet. Private enterprise is supposed to bring competition, lower prices, and improved quality. It fails on all three counts in health care.

With insurers and Uncle Sam legally responsible for paying covered services, health care companies have little reason to favor quality of care over quantity. More care, whether clinically appropriate or not, translates into higher profits for shareholders.

Health reform proposals, which will face high hurdles in Washington, largely deal with expanding coverage and not lowering prices. Even aggressive proposals to cut drug prices would barely move the needle on total health costs.

If the excesses wrought by our health oligopolies are one facet of how capitalism works, these inefficiencies also are giving rise to another: disruptive new health companies. There is so much money and waste in U.S. health care that new entrants are drawn to the industry like bees to honey, seeing the chance to deliver better and lower-cost health solutions and still make enormous profits.

Walmart, CVS, Amazon, Apple, Google, and others are building large, consumer-facing health businesses that provide convenience and lower prices, often accompanied by publicly posted price lists. Over time, demand for health care will shift to these lower-cost providers.

But make no mistake. We’ve lost the larger war on health costs and are settling instead for endless skirmishes seeking only cost containment. Victory will be declared when health inflation is comparable to overall price increases in the economy. Huzzah.

Affordable Care Act Access to be Expanded

President Biden issued an executive order today that will expand access to the Affordable Care Act (ACA) and create a special enrollment period for ACA sign-ups from February 15 to May 15.

The non-profit Kaiser Family Foundation said earlier this week that nearly 15 million uninsured persons would be eligible to get ACA plans based on current rules. That’s roughly half of Americans without health insurance, although this number is rising because of pandemic-related job losses.

The order’s language, quoted below, is likely to lead to eased ACA access rules and reduced consumer out-of-pocket expenses. It directs federal health agencies to re-examine:

Policies that undermine protections for people with pre-existing conditions, including complications related to COVID-19;

Demonstrations and waivers under Medicaid and the ACA that may reduce coverage or undermine the programs, including work requirements;

Policies that undermine the Health Insurance Marketplace or other markets for health insurance;

Policies that make it more difficult to enroll in Medicaid and the ACA; and

Policies that reduce affordability of coverage or financial assistance, including for dependents. 

As part of their reviews, agencies will consider whether to take additional actions to strengthen and protect access to health care. 

Kaiser said its estimates excluded those already eligible for Medicare and Medicaid as well as impoverished people who make too little money under current rules to afford ACA marketplace plans.

Kaiser, as quoted below, said three groups would be affected:

4.0 million uninsured people could get a free bronze plan (with a $0 premium payment, after accounting for subsidies). . . . People in this group would clearly benefit from getting Marketplace coverage rather than continuing to go without coverage.

4.9 million uninsured people could purchase Marketplace coverage for a reduced premium, partially covered by a subsidy. Although subsidies for this group do not cover the full premium, they may significantly lower the premium and/or out-of-pocket liability. Even so, some people in this group may still find Marketplace coverage unaffordable or unattractive due to high deductibles.

6.0 million uninsured people are eligible to buy Marketplace plans but are ineligible for financial assistance. Of this group, 2.6 million (43 percent) have incomes that would qualify them for a subsidy, but their unsubsidized premium is not high enough to merit financial assistance under the current ACA subsidy structure. The remaining 3.4 million (57 percent) people in this group are ineligible for subsidies because their income exceeds 400 percent of poverty. People in this final group are often priced out of coverage under the ACA’s current subsidy structure.

Joe Versus the Health Care Volcano

Listing President Joe Biden’s health care challenges would be like reading to the end of the Internet – impossible and, after a point, unproductive. Like much else in health care, however, there is no shortcut to understanding them and how difficult meeting them will be. Major health reforms get most of the ink, but incremental progress is a worthy goal here.

If you closely follow these issues in the national press, you will come across excellent reporting on specific things we can do to tackle health care access, affordability, equity, and quality. But these are individual pieces of a Rubik’s Cube. To understand what we face in health care, you need to see all the pieces, and begin learning how they may fit together. This is not the stuff of four-minute online reads with a few links to other studies.

If you’re serious about the topic, a recent piece in the journal Health Affairs is an excellent place to start. “Health Costs And Financing: Challenges And Strategies For A New Administration” was co-authored by seven prominent health experts (see details at the end of today’s post).

Don’t get your hopes up for sweeping changes anytime soon. “Any effort at reform will occur amidst the COVID-19 pandemic, which has placed unprecedented strain on policy makers and public institutions,” the article says. “There will simply not be the same capacity or appetite for sweeping regulatory changes that would have been present in other circumstances.”

The article does stress five sets of more immediate objectives. Its issues and recommendations are direct quotes from the piece. If some points are obscure, Google them for more details. It’s noteworthy that many do not require Congressional approval.

1 – Expand Insurance Coverage

There remains political resistance to expanding coverage through mechanisms set forth in the ACA. Twelve states have not expanded Medicaid, several coverage-related provisions in the ACA have been repealed, and support of the Marketplaces for individual coverage has been uneven. Bipartisan approaches and public-private partnerships are needed.

Sustainable financing presents another challenge. Mechanisms for publicly financing coverage expansion—through deficit spending, new revenue sources, or revenue transfers—come with inherent trade-offs and will require bipartisan compromise. We believe that reallocating the substantial resources spent on care that does not improve health represents an opportunity to expand coverage without sacrificing affordability or quality, but the impact of associated revenue reductions on providers needs to be closely considered.


The HHS [Health and Human Services) secretary should develop alternative pathways to insurance coverage, including strengthening and better supporting the individual insurance Marketplaces and working with Congress to decrease the age of Medicare eligibility to fifty-five.

Governors should also create opportunities for expanded coverage in their states. Optimal use of the Medicaid program offers the greatest opportunity to expand coverage and promote health equity.

2 – Accelerate Transition to Value-Based Care

A central action priority identified in the original Vital Directions initiative was to “pay for value”—specifically, to “drive health care payment innovation providing incentives for outcomes and value.” Since that time, value-based payment has grown notably. According to the Health Care Payment Learning and Action Network, the share of health care payments administered via alternative payment models increased from 23 percent in 2015 to 36 percent in 2018. Although selected models have generated significant savings, the overall impact of new payment models on cost and quality has been mixed.


The CMS [Centers for Medicare & Medicaid Services] administrator should increase the adoption of advanced value-based payment models.

It will also be important for CMS to help stabilize independent primary care providers. COVID-19 has placed significant financial strain on independent primary care providers. This is especially troubling, as these clinicians provide critical access to health care for much of the US population and have been uniquely successful at delivering value-based care.

In addition, Medicare Advantage should be strengthened. More than a third of Medicare beneficiaries are now enrolled in Medicare Advantage plans. The program benefits from strong bipartisan support and has catalyzed the adoption of advanced value-based payment models. Strengthening the program could position it to serve as a chassis for coverage expansion. To achieve this goal, the administrator should continue to increase flexibility for Medicare Advantage plans to design new benefit packages, incentivize healthy choices, and redistribute funding to reduce disparities and improve equity.

3 – Advance Home-Based Care

Improvements in internet, video, and remote monitoring capabilities increasingly allow for the delivery of health care services in more cost-effective, patient-centered settings. Patients now can receive home-based acute care, primary care, and behavioral health services of equal or better quality compared with facility-based delivery, and at a lower cost.


To advance home-based care, the CMS administrator should formalize changes to telehealth reimbursement. Working with Congress where needed, the administrator should make permanent some of the changes to telehealth reimbursement that were instituted under the COVID-19 public health emergency.

The CMS administrator should also develop reimbursement models for home-based care. . . .   and test new payment models for home-based acute, post-acute, and long-term care.

4 – Improve The Affordability of Drugs and Other Therapeutics

Highly effective therapeutics may lower aggregate spending by reducing the need for costly interventions or hospitalizations, but many of these novel medicines command high prices. More challenging is the fact that high prices are not always aligned with value. Prices on existing, branded drugs have increased substantially during the past decade, limiting affordability and access. And even in circumstances where the benefits are unclear or modest, many new therapeutics are still reimbursed at high rates.

With continued innovation on the horizon—including gene therapy—these challenges will become more acute. Broadening the pool of Americans who can obtain and afford high-value therapeutics will require reimbursement structures that align payment with value and balance affordability with the continued need for innovation.


The FDA [Food and Drug Administration] commissioner should expand on recent efforts to reduce barriers to generic and biosimilar development and market entry with the goal of increasing competition, improving access, and reducing prices.

The FDA commissioner also should accelerate efforts to build a robust real-world evidence program and develop rigorous, science-based criteria for how real-world evidence can be used to inform decisions about the safety and effectiveness of new therapeutics. . . . This infrastructure is a prerequisite for any effort at value-based pricing for therapeutics.

The CMS administrator can also play a key role in improving the affordability of drugs by developing value-based reimbursement models for high-value therapeutics.

5 – Develop a High-Value Workforce

The U.S. benefits from a highly skilled health care workforce and is home to premier training institutions. But there are significant and growing workforce shortages in the areas of primary care, behavioral health, and dental care. A coordinated strategy to train, deploy, and support a diverse health care workforce is an essential enabler of access, quality, and value, particularly in under-resourced communities.


Through a partnership with state governments and private payers, the HHS secretary should facilitate the development and deployment of a national workforce of community health workers.

Governors could promote the development of a high-value health care workforce by removing barriers to affordable telehealth access. They should, in collaboration with state licensing bodies, formalize changes to state licensure laws made during the COVID-19 pandemic that reduce or eliminate the barriers facing out-of-state providers who wish to provide telehealth services and coordinate care across state lines.


Dr. William Shrank, Humana Chief Medical Officer. More: The Check Up: Dr. William Shrank of Humana.

Nancy-Ann Min DeParle, a leading architect of the Affordable Care Act and of CVS Health and HCA Healthcare. More: Present At The Creation: Launching The ACA—2010 To 2014.

Scott Gottlieb, commissioner of the Food and Drug Administration from 2017 until April 2019; director of Pfizer; affiliated with CVS Health. More: Scott Gottlieb discusses coronavirus on “Face the Nation,” January 17, 2021.

Sachin H. Jain, president and CEO of SCAN Group and Health Plan, with 220,000 members and revenues exceeding $3.4 billion. More: Top 10 Healthcare Industry Predictions For 2021.

Peter R. Orszag, CEO of Financial Advisory at Lazard Freres & Co LLC, and former head of the Office of Management and Budget and the Congressional Budget Office. More: Fiscal resiliency in a deeply uncertain world: The role of semiautonomous discretion.

Brian W. Powers, Deputy Chief Medical Officer at Humana.

Gail R. Wilensky, an economist and senior fellow at Project HOPE, and former director of the Medicare and Medicaid programs; a director of UnitedHealth Group and Quest Diagnostics. More: The Next Step In Medicare Reform.

Biden’s Shopping List of Administrative Health Actions

Joe Biden is set to take office tomorrow. His incoming administration faces enormous challenges to help get the country back on something resembling a normal footing. Nowhere is this truer than in health care.

Immediate attention will and should be focused on his plans to greatly expand support for COVID-19 care, testing, and vaccinations. The challenge here will be to secure quick Congressional action on his broader, $1.9 trillion package to send more money to consumers, speed the reopening of in-person K-12 schooling, and help people get back to work.

There is overwhelming support for the COVID portions of this package but enough opposition to the entire measure to threaten quick approval by our bitterly divided houses of Congress. Toss in a second impeachment trial of our soon-to-be former president, and damaging delays become that much more likely, even if House Speaker Nancy Pelosi creates breathing room to consider Biden’s plan by deferring delivery of her chamber’s articles of impeachment to the Senate.

Broader changes in health care are also on the agenda. Attention has been directed at expanding Medicare to younger ages and also responding to the continuing wish from progressive Democrats for a new single-payer system that would provide cheaper health insurance to every citizen, largely at the expense of private insurance and health care companies. Few people expect such changes to become law anytime soon.

Because Congress is so sharply divided, the most imminent health care changes are those that the incoming president has the power to implement without Congressional approval. The Kaiser Family Foundation has worked up a useful list of such administrative items. The summary list below includes short-hand references that are fully explained in the Kaiser review.



Renew Declaration that COVID-19 is a National Emergency

Renew Declaration that COVID-19 is a Public Health Emergency

Restore U.S. Membership in the World Health Organization


Restore Directorate for Global Health Security and Biodefense

Convene Daily White House COVID-19 briefings

Launch National COVID-19 Vaccine Campaign

Establish Pandemic Testing Board

Issue Strong National Social Distancing Guidance to States and Localities

Expand Use of the Defense Production Act (DPA)

Establish COVID-19 Racial and Ethnic Disparities Task Force

Create National COVID-19 Data Dashboard

Review Entry and Detention policies based on public health criteria



Restore federal spending on navigators and on marketing and outreach and restore navigator standards

Ensure availability of and strengthen standards for web brokers and brokers selling marketplace plans

Reverse guidance for Section 1332 state waivers

Increase Marketplace enrollment by extending open and special enrollment opportunities

Restore federal marketplace user fees

Increase Marketplace subsidies

Reverse expansion of short-term health insurance

Reverse association health plan regulation

Strengthen Essential Health Benefits



Revise Section 1115 state demonstration waiver policy to focus on increasing and expanding coverage

Ensure eligible people can enroll in and maintain Medicaid coverage

Reinstate beneficiary protections and provide certainty on state financing mechanisms

Maintain Medicaid coverage and beneficiary protections

Expand support for states to respond to COVID-19 pandemic

Strengthen and expand long-term care services and supports



Restore Title X Family Planning Program regulations to require pregnancy options counseling to include abortion and allow clinics to provide abortions with non-federal funds

Prohibit state Title X grantees from banning family planning providers that also provide abortions from participating in the program

Simplify payment for abortion coverage in Marketplace plans

Revise ACA contraceptive coverage regulations to guarantee coverage for more women

Restore guidance to affirm the Medicaid “free choice of provider” provision

Rescind Mexico City Policy

Affirm reproductive health rights, including abortion, globally

Allow NIH funding of research involving fetal tissue

Restore ACA non-discrimination regulations to protect patients who have had an abortion or are seeking an abortion

Reverse policies that promote and expand religious conscience protections for medical providers over civil rights

Improve health care access for incarcerated women

Protect and prioritize survivors of sexual assault



Improve mental health services for veterans

Address suicide among LGBTQ youth

Increase school-based mental health services

Enforce Mental Health Parity

Fight the Opioid Crisis



Reinstate Deferred Action for Childhood Arrivals (DACA) program and review Temporary Protected Status (TPS) designations

Reverse policies that limited pathways to lawfully enter the United States

Reprioritize enforcement policies to protect immigrant families and children

Revise policies on immigrant detention for families

Reverse changes to public charge policies



Restore mandatory penalties for nursing facility violations of federal requirements when residents were in “immediate jeopardy” but did not suffer harm

Revise recent or pending nursing home regulations to restore resident protections and strengthen oversight

Improve nursing home staffing and oversight

Support nursing homes’ response to COVID-19 pandemic

Advance policies that strengthen home and community-based services



Reinstate White House Office of National AIDS Policy

Release a new comprehensive National HIV/AIDS Strategy

Revise regulation implementing Section 1557 of the ACA

Reverse expansion of short-term limited duration (STLD) plans, non-ACA compliant plans

Update FDA blood donation policy

Rescind “Deploy or Get Out” Policy

Rescind Mexico City Policy



Revise regulation implementing Section 1557 of the ACA

Reverse policies that promote and expand religious conscience protections for medical providers over civil rights

Expand data collection related to gender identity and sexual orientation


Find details about how you can reform your own health care right now, in my new book, Get What’s Yours for Health Care: How to Get the Best Care at the Right Price.

How to Find High-Quality Health Care

Trying to find a health care provider who meets your needs and fits your budget can feel overwhelming. In the old days, you’d depend on a personal recommendation or referral from a trusted friend—now, in modern times, you can rely on the aggregated experiences of many other patients via ratings sites for doctors, hospitals, and nursing homes.

Not all ratings and reviews are created equal. Rating the quality of health care providers requires attention to the procedures used by ratings providers. Read the reviews to make sure that the ratings you’re seeing apply to the qualities that are most important to you. It’s also a good idea to use multiple ratings tools and not rely on just one.

Whether you’re looking for a physician, a hospital, a nursing home, or home health, here are some rating sites to help you choose the right health provider for you. I’ve linked to each rating site below — click through to find details on review requirements and ratings methodologies.




Nursing Homes

Medicare’s Family of “Compare” Tools

Find further details in my new book, Get What’s Yours for Health Care: How to Get the Best Care at the Right Price.

Health Care is a Team Sport

Consider health care a team sport—your health and care may impact you the most, but there are people out there who can help and advocate for you. Everyone needs help, especially when facing a serious disease or medical crisis. For this reason, you should establish a health posse: a few people in your life who can act on your behalf should you need assistance.

Whether it’s a spouse, a friend, or a neighbor down the street, here are the things members of your health posse should be prepared to do:

  • Make legally binding health decisions for you if for any reason you are not able to make these decisions yourself.
  • Become an expert on your medical condition, including recommended treatments, finding the highest-quality care, and connecting with other patients who have gone through the same condition.
  • Deal with the medical folks and institutions who wind up providing your care. This can include the care being provided, who is providing it, what they charge for the services, and advocating for your rights.
  • Understand how your health insurance works, including what it covers, how to appeal claims denials, and how to wrangle over bills.
  • Worry on your behalf about how you’ll pay for treatment, including what it costs, what it should cost, and how to negotiate effectively to pay as little as possible.
  • Coordinate with other people in your life to help handle your obligations, including grocery shopping and meal preparation, handling home maintenance appointments and repair visits, helping your kids and other family members.
  • Keep posse members up to date on how you’re doing.
  • Listen to you, rants and all, and provide the emotional support you need.
  • Do whatever else it takes so that you can focus on your treatment and recovery need.

If someone is in your health posse, you are likely in theirs. Take the time to educate and involve yourself in their health care so you can support them when they need it most.

Find further details in my new book, Get What’s Yours for Health Care: How to Get the Best Care at the Right Price.


Haven Failure a Reminder of Health Reform Pitfalls

Lost amid last week’s existential threat to democracy was the announcement that Haven, the heavily hyped 2018 health care startup, would be ceasing operations.

Nearly three years ago, Amazon, Berkshire Hathaway and JPMorgan Chase announced they would build an independent health company to explore better and cheaper ways of delivering health care, at first to their more than one million employees and perhaps later to other health providers and consumers. Health insurance stocks shuddered at the prospect of a well-funded new entrant that might introduce reforms that would hurt that industry.

Health stocks took another hit in June 2018 when the new venture selected Atul Gawande as its chief executive. A gifted surgeon, Harvard faculty member, and widely followed New Yorker writer and author, Gawande was expected to walk on water and perform miracles at the new venture, which was later named Haven.

It was, in hindsight, an impossibly high bar for anyone to leap, and neither Gawande nor Haven wound up leaping much of anything. During its three years of existence, the company did not publicly announce a single new health initiative. Gawande stepped down from the CEO role last year, leading to speculation that the venture had run its course.

“Haven’s demise demonstrates that it will take more than big names and buzz to create meaningful change,” said Kate Brown, health innovation leader at the Mercer employee benefits firm. “For the U.S. healthcare system, there’s no single solution or entity that will deliver transform our system to deliver higher quality care at lower cost.”

Given Haven’s visibility, its failure to make much of a dent in health care will foster a new cottage industry of post mortems and B-school case studies. I don’t claim any special insights but do think the venture’s fate should be a powerful reminder of how hard it is to make significant changes in the U.S. health care system.

These difficulties are laid out in my new book, and in fact were the reason I decided to do the book in the first place. Reforming health care is a process, not the act of any single legislative or corporate effort. When the Affordable Care Act (ACA) was passed in 2010, it only cleared the finish line due to big Democrat majorities in the Senate and House.

Even then, the law contained major compromises, especially the absence of a public option that would have let any consumer buy a policy from the government that covered ACA-mandated benefits. That would have been a game changer. But it didn’t happen.

Even with a more modest set of coverage innovations, it took four years to implement the ACA, and it still generated enormous turmoil in insurance markets and public confusion. Keep in mind the ACA involves 20 million persons – a big number but only about one in fourteen (7 percent) of those in the U.S. with health insurance.

Imagine what it would take to reform health care for the other 93 percent and you’ll have some idea of the enormous mountain that needs to be scaled to cover more people, lower health costs, and improve quality.

Extended Medicare to those aged 60 to 64 isn’t even a steep hill in comparison. Medicare for All would get closer but there is scant evidence it would make much of a dent in U.S. health costs, which were $3.8 trillion in 2019 – twice as high per person as in any other country that is comparable to the U.S.

Smart and powerful health care interests – insurers, pharmaceutical and medical equipment companies, and hospitals and doctor firms and lobbies — will block the way to even modest reforms.

Faced with such daunting opposition, waiting for health reform is even more exhausting than Waiting for Godot. The good news, explained in only 355 pages in my book, is that consumers do not need to wait. We can reform our own health care right now, using new tools and mountains of research that can improve our access to care that is better and cheaper than what many of us can now find.

This consumer-led revolution will not be easy or quick. But it has the potential to help us achieve our health care goals more quickly than relying on government reforms. Or on Godot.

Pandemic Changes the Game for Aging in Place

Older people, especially those at highest risk for infection by COVID-19, have pretty much stayed in their homes if they could for the past nine months. The friendly phrase for this is sheltering in place. The reality for many, however, is that our homes can also become prisons.

This is especially true for people living on fixed and tight budgets and those who are frail and usually suffer from multiple chronic health problems. This describes tens of millions of older citizens, 90 percent of whom depend on Social Security for nearly all their income. With monthly benefits averaging $1,400 – less than $17,000 a year – the idea of remodeling bedrooms, bathrooms, and kitchens to enjoy that extra time at home is a pipe dream.

Living alone has always been challenging for older people. Isolation and depression are not uncommon. Maintaining a home can be hard when even getting up on a ladder to change a light bulb can be hazardous. Going to the grocery and out to even routine appointments at the doctor or beauty salon can become major issues for those who no longer can drive and don’t live near accessible public transportation.

The pandemic has raised the stakes for all of these activities, turning the idea of aging in place from an appealing idea, and attractive marketing phrase, into a mandatory way of living that can eliminate the choices and mobility that permitted older people to enjoy the social and cultural activities in their communities.

One solution, and it’s hardly a panacea, is to use technology to create virtual support groups and social spaces for people who are spending nearly all their time in the walls of their home. This is happening all over but it’s less likely an option for people without the economic means to afford expanded Internet services and subscriptions to online entertainment and information services.

Aging in place began becoming “a thing” nearly 20 years ago. Older people had always aged in place, of course, usually staying in their homes as long as possible and then initiating a common cycle of downsizing, moving in with family, and making what usually was their last stop in a nursing home.

Today, nursing homes may be the last place an aging person wants to be. Even well-run homes can become coronavirus hot spots. And we’ve learned that many homes are not particularly well-run.

One clear message from the pandemic is that the incoming Biden administration needs to provide more oversight and funding of nursing homes. Most government spending on nursing homes comes via Medicaid, so the solution must involve a lot more funding for state Medicaid programs.

Another message that is perhaps not so generally clear but nonetheless essential is that there must be a stronger government role to make aging in a place a more successful strategy, not only for residents but also for the landlords who own most of the housing that lower-income seniors occupy. I prefer the carrot to the stick here and would offer attractive tax incentives for property owners who upgrade apartments and homes with aging-in-place safety and living improvements that meet government quality thresholds.

Another boost to aging in place can come from a relatively new set of Medicare insurance benefits that cover non-medical services strongly associated with improved health and well-being.

These are identified under the label of social determinants of health (SDOH). They include things like grab bars in bathrooms, removal of steps and raised doorway thresholds, wider corridors that accommodate wheelchairs and walkers, elevated electrical outlets, and the like. They also include transportation to doctors appointments and grocery stores, and home-delivered meals for those recovering from major surgeries and illnesses.

Medicare Advantage plans offered by private insurers began covering these items a couple of years ago, but the uptake has been slow. I would provide Pandemic-related inducements for broader SDOH insurance benefits. They also should be extended to the nearly two-thirds of Medicare enrollees who use original Medicare and do not have Medicare Advantage plans.