Health care reform: It’s complicated

By Ken Frederic | Feb 13, 2020

"It's complicated." That often means “I don’t know,” or “It’s none of your business.” But nothing significant is ever simple or easy and that is particularly true of health costs in America. We are again immersed in a quadrennial flood of promises to make health care and medications at once less costly and more accessible.

Most propose simplistic solutions backed by assertion that the problem is “greedy doctors, hospitals, and pharmaceutical companies,” “greedy insurance companies” or “incompetent government meddling.” It doesn’t take great insight to understand that none of these is the problem but all of them are.

One advertisement featuring Republican Sen. Susan Collins highlights the devastating increases in the cost of insulin over the past decade. A bill she sponsors (S 2199) will prohibit “pharmacy benefit managers and insurers from receiving rebates for insulin products” when the manufacturer has reduced the list price to the 2006 price. That is quite a word salad and the words mostly do not mean what one would think. It takes knowing a good bit about that market to decode what is being done.

Few, if any of us knew there was such a thing as a pharmacy benefit manager or PBM. These “middleman” companies negotiate rebates on mostly brand name drugs and pass on (some of) the savings to insurance companies, not to pharmacies or consumers.

President Trump proposed changing the rules to eliminate PBM kickbacks for Medicare and Medicaid but withdrew that proposal in the face of strong resistance and an assessment by the Congressional Budget Office that blocking the kickback regime would result in higher prices paid by Medicare and Medicaid and higher insurance premiums for everyone.

It’s rather murky who really benefits from the rebate scheme, but it is certain that the consumer does not. The uninsured and those buying their medications with “deductible” dollars pay the fully inflated price.

A federal judge sustained a challenge to another administration proposal that would have required drug manufacturers to advertise their actual list prices. Curiously, the opposition came not from drug manufacturers but from PBMs and insurance companies (Kaiser Health News, July 12, 2019). Even more curious is that search engines return nothing regarding the decision rationale or even a specific citation.

As would be expected, the usual culprits published hit pieces last summer shrieking that Trump had abandoned the vulnerable and caved to special interests. But it is complicated, and the truth is that we, through past legislation permitting and protecting this kickback scheme, created a mess that cannot easily be dismantled without unforeseen consequences.

Worse yet, in this election year, legislators are unlikely to risk making changes with unpredictable consequences and the administration is fighting a push by Democrats for an expedited Supreme Court decision they hope will overturn the lower court ruling that the Obamacare individual mandate is unconstitutional.

The patient price for insulin is just one manifestation of the hideous web of rules and practices created by providers and insurance companies to escape scrutiny, frustrate regulation, avoid competition, and ensure profitability.

Undoubtedly the complexity is deliberate, but that the PBMs and insurance companies (some of whom own PBMs) are at the forefront of opposing price transparency is telling. Lobbying groups may spend as much effort and money to prevent any action as to promote one.

Keeping the public and the media focused on assigning fault extends the status quo, precisely the goal of PBMs and their client insurance companies.

While some argue that insulin is a 100-year-old “product,” the fact is that the product today is nothing like what was discovered in 1921. The often cited 10 to 1 markup may be real or it may ignore the very real costs of researching new formulations and developing modern production facilities. None of those costs are published and audited.

There is no true competition among producers or PBMs and insurance providers. Most of all, nobody has anything to gain by representing the consumer but everyone other than the consumer has potential losses if the status quo is disrupted and much to gain from blame shifting.

President Trump has promised and acted to dismantle the kickback scheme. His efforts thus far have been resisted and frustrated: The status quo remains for another year. That is no less true of care provided in hospitals, clinics and other facilities. It’s complicated: Disruption may come quickly but meaningful change will take time and unprecedented cooperation and deliberation.

If ever there was a case for voters to be careful what they wish for, this is one. Few will take the time to do the reading to be even minimally informed. All will hear specious, disingenuous promises and vicious blame shifting.

In the end, even the most informed and deliberative voter will be left to decide who they trust and hopefully that will be based more on what the candidate has done than on what he or she has said. Sen. Collins is not seen on talk shows shifting blame. She gathers information and then decides based on facts and instinct. We could do much worse than elect those who follow her approach.

Another View is a Maine Press Association award-winning column written by Midcoast conservative citizens/writers Jan Dolcater, Ken Frederic, Paul Ackerman, Doc Wallace and Dale Landrith Sr.


Comments (12)
Posted by: Richard Ferguson | Feb 16, 2020 16:59

Mary, my Canadian friend had cancer and serious heart issues. Multiple hospitalizations prevented him from working any longer as an auto mechanic. In the US, he would be bankrupt and dead. In Canada he is alive and well.  The myth of Canadian health care being 'not very good' is just that, a myth.

Posted by: Kevin Riley | Feb 16, 2020 14:52


Canadians are sick and damn sick and tired of the persistent and utter lie.

I have friends in Canada and they laugh at the perpetrators of that lie and invite them to come up and check it out. Of course they never do.

As a side note I have family in Norway, another whipping boy for conservatives, and they are agast at the lies that are told about there system.

I have friends in the UK, both England and Scotland, the reaction is about the same, "what the hell are they taking about?"

You are being lied to.

Take a look at this congressional testimony by a Canadian Doctor.

Posted by: Ronald Horvath | Feb 16, 2020 14:07

That's a myth, Mary, pushed by conservatives like Mr. Frederic.  I lie, in other words.  Here's better information:



“In Canada, life expectancy at birth is about two years higher than in the United States. And this advantage is not gained by spending more. Medical costs as a percent of G.D.P. (combining public and private costs) are 15 percent in the United States and 10 percent in Canada.” –Letters,


"In fact, neither Canada’s single-payer system nor the Medicare system disrupted things. Neither of them broke the bank financially. In fact, there’s been almost no increase in Medicare costs over the last ten years, while private health insurance costs have continued to go up. In Canada, they’re spending about 40 percent less than we are. The doctors make plenty of money, the hospitals are doing just fine, and they have universal coverage. Their taxes are not much higher than what we pay in this country, and the higher taxes are more than offset by the fact that Canadian taxpayers don’t have to pay any premiums or out-of-pocket costs for most services.


So the facts on the ground, experience in both Canada and the United States, say that a single-payer system is imminently doable from an economic point of view, and that it is not overly expensive. In fact, it’s significantly cheaper than what we have in this country." -Steffie Woolhandler, co-founder of Physicians for a National Health Program and professor at the CUNY School of Public Health.


“One Canadian lesson — the movement toward universal health care in Canada started in 1916 (depending on when you start counting), and took until 1962 for passage of both hospital and doctor care in a single province. It took another decade for the rest of the country to catch on. That is about 50 years all together. It wasn’t like we sat down over afternoon tea and crumpets and said please pass the health care bill so we can sign it and get on with the day. We fought, we threatened, the doctors went on strike, refused patients, people held rallies and signed petitions for and against it, burned effigies of government leaders, hissed, jeered, and booed at the doctors or the Premier depending on whose side they were on. In a nutshell, we weren’t the sterotypical nice polite Canadians. Although there was plenty of resistance, now you could more easily take away Christmas than health care, despite the rhetoric that you may hear to the contrary.” -Karen S. Palmer MPH, MS



"A "caravan" of Americans living with Type 1 diabetes made its way across the U.S. border into Canada over the weekend in search of affordable medical care in a country where they can get the "exact same" life-saving drugs for a dramatically lower price.


"We're on a #CaravanToCanada because the USA charges astronomical prices for insulin that most people can't afford," tweeted caravan member Quinn Nystrom as she shared updates on the journey.


Nystrom was among a group of Minnesotans who piled into cars on Friday to make the 600-mile journey from the Twin Cities to Fort Frances, Ontario, where she said insulin, the hormone patients with Type 1 Diabetes rely on to regulate their blood glucose levels, can be bought for a tenth of what it costs in the U.S.


The caravan was organized as part of a campaign launched under the banner "#insulin4all" to call on the U.S. government to regulate the cost of life-saving drugs, including insulin, and make medication affordable for anyone who needs it.


Calling the cost of insulin in the U.S. a "price crisis," the #Insulin4All group noted on its website that since the mid-1990s, the price tag on insulin in America has skyrocketed more than 1,100 percent, according to data from Truven Health Analytics, despite the cost of production for a vial of analog insulin costing less than $10.


A recently released report ordered by Representative Elijah Cummings, a Maryland Democrat who chairs the House Oversight Committee, found that millions of Americans who rely on insulin were paying up to 92 percent more for the lifesaving medication than patients in other countries.


Posting a photo of a Walgreens pharmacy store on the caravan's journey to Canada, Nystrom wrote that the group "could've ended our #CaravanToCanada in 5 minutes, but unfortunately, they charge $300 for insulin. So, we will travel another 5 hours north so we will only have to pay $30 for a vial of insulin."

Posted by: Mary A McKeever | Feb 16, 2020 13:15

As I understand it Universal Health Care did not work well in Canada. Canadians came to the US for health care

. I remember!

Posted by: MARY JEAN CROWE | Feb 15, 2020 09:22

Thank you Kevin Riley and Ron Horvath for your researched rebuttals.  Why is it that every week those who share this column, Another View, respond AGAIN and MORE to folks who comment online to this shameful weekly biased, unfiltered blathering. Ken Fredric and Jan Dolcateur, you have an entire weekly column to make your point.  Why isn't that enough for you.

VIVA Mitt Romney.

Posted by: Kevin Riley | Feb 15, 2020 08:47


"Do you ever consider attempting to be pleasant or is it your nature to exhibit hostility on a consistent basis"

Pot meet kettle.

For the most part, the vast majority of hostility I've seen here comes from the conservative side of the argument.

I realty Ron is correct. You exhibit a holier than thou attitude that is so thick one can cut it with a knife.  You are incapable of reasoned debate. Anyone the disagrees with you is a blind idiot.

As Ron states, links and copy and paste (not cut and paste) are how it's done in the real world. If you make an assertion it is incumbent upon you to provide information to bake that up. Just believing something is true does NOT make it so.

We are talking about demonstrable, verifiable sources with references to materials that support your claim. You don't do that.

You might want to read this article to get some insight into the conservative mind. And as it should be there is a link in the article too one of the papers used to write the piece.

Here comes the dreaded copy and paste you fear so much!

Posted by: Ronald Horvath | Feb 14, 2020 18:40

Perhaps, Jan, I've experienced your "pleasantries" in debate here too often to be fooled by this pose of pious pseudo-indignation.  Years of experience arguing with self-righteous conservatism have taught me to see the smug superiority of Mr. Frederic behind his simpering prose just as I can see your down-the-nose expression of disgust that anyone should express an opposing viewpoint.  I'm sorry that you're feeling overwhelmed but that's part of the price of free debate.  Maybe you should drop down to an easier level.  And if I seem infatuated with my own thoughts than at least I have my own with no need to regurgitate Fox News propaganda.  As I've always said my "cut and pastes" are factual references -part of the actual process of reasoning- in contrast to your cabal's habit of pulling "alternate facts" out of their butts.

Oh, and I'm feeling just great.  How about you?

Posted by: JUNE DOLCATER | Feb 14, 2020 17:50


Do you ever consider attempting to be pleasant or is it your nature to exhibit hostility on a consistent basis? Instead of attempting to develop reasonable discussion it appears that you attempt to overwhelm everyone with a display of voluminous rhetoric which really proves nothing more than that you are a single minded creature infatuated by your own thoughts and lack the ability to reason.  Hope you feel better as you recover.

Jan Dolcater Rockland

Posted by: Ronald Horvath | Feb 13, 2020 18:06

What you mean, Ralph, is a simpering, partisan, description of a world that doesn't exist in reality, met with a factual, referenced response that proves it all beyond a doubt.  "Cut and paste" is a substantive answer to Mr. Frederic's made-up nonsense.


“The party told you to reject the evidence of your eyes and ear.  It was their final, most essential command.” -George Orwell, “1984“



Posted by: RALPH WALLACE | Feb 13, 2020 14:47

As usual, a well-reasoned, in-depth, unemotional commentary met with sad, TDS, hyperbolic, cut-and-paste nonsense.

Posted by: Ronald Horvath | Feb 13, 2020 14:21

More double talk from the right and, of course, in defense of more lies from trump.  Remember when he promised "something great" in health care since day one?  Where is it?  Where is the Republican health care "plan?"  I think we've learned too well that what trump says -and what his defenders say as well- and what he does are wildly different.  Such as:


"Because the drug companies have an unbelievable lobby. And these guys that run for office, that are on my left and right and plenty of others, they're all taken care of by the drug companies. And they're never going to put out competitive bidding."  -Donald Trump, 2016


But then he does this:


"Donald Trump’s pick for health secretary, Alex Azar, was previously an executive at a pharmaceutical company that repeatedly raised the prices of its drugs and tripled the cost of its top-selling insulin over the five years he served as a company president...  "

Sounds like trump either gave up trying to make a deal to never intended to, except to side with the exploiters.



"By a 230-192 vote, H.R.3, the Elijah E. Cummings Lower Drug Costs Now Act, passed on a largely party line vote. Every Democrat supported the legislation, joined by only 2 Republicans."


According to NPR, the legislation would allow the federal government to negotiate the cost of prescription drugs for Medicare, limit out-of-pocket costs for Medicare participants, and prevent drug price hikes. The Trump administration vowed to veto the legislation if it ever comes to his desk."


Sounds like trump made a deal with big Pharmco but the American health care consumer got left out.



"The US spent $817 billion on healthcare administrative costs in 2017, $600 billion more than Canada, which has a smaller population than the US but also has much lower per capita healthcare costs: For example, the US spends an average of $2,479 per patient on admin costs, compared with $551 per capita under Canada's single-payer system, according to a new study published in the Annals of Internal Medicine.


...  An increase in overhead from private insurers caused spending as a percentage of total US healthcare costs to surge from 31% in 1999 to over 34% in 2017, which equates to an added $100 billion burden each year over that same period.


The US' sky-high healthcare costs are driven in no small part by the oversized admin spending burden private insurance places on hospitals and other providers — and these costs could have negative implications on patient health.


"...  the cost burdens associated with private insurance are being passed along to US consumers, making treatment an unmanageable expense. Patients are coughing up large portions of their budget on health, with the average nonelderly US family spending $8,200 per year on healthcare — or 11% of their income.


And when we consider that 67% of all US bankruptcies are due to exorbitant healthcare costs...  it's critical to recognize that the admin burden from private insurers is at least partially to blame for why health costs have become so unmanageable for so many people.


And anxieties around the possibility of medically induced poverty are driving poor health habits among US consumers. In a recent Gallup poll, 25% of US consumers said they or a family member had delayed treatment for a serious illness because of the high cost of care.


...  patients with otherwise treatable conditions develop worse, more complicated ailments simply due to a lack of financial resources — the fact of the matter is that the cost of care in the US is out of control right now — driving families into poverty and no doubt exacerbating underlying health issues.


...  the US' private insurance system may no longer be sustainable: CEO of insurtech Bind Tony Miller said on a 2019 Health 2.0 panel that, "They see disruption coming, and I think that 'Medicare for All' is evidence that, as a society, we're at a point where this has got to get better or we need a reset."


Such consumer frustration with the cost and complexity of the US health insurance system is evident in the early polling and fundraising success of Vermont senator and Democratic presidential frontrunner, Bernie Sanders, who counts Medicare For All as a central pillar of his campaign platform."


The idea that trump is "acting" to counter all this is laughable.  When would he get the time between watching Fox News, playing golf, or stuffing his face.  And poor Susan Collins is always presented as "working" toward a solution.  Always working but never quite achieving anything.  I guess if you look like you're "working" no one will ask you why nothing as been done.  

And that's the whole point, isn't it.

Posted by: Kendall Merriam | Feb 13, 2020 10:30

America is the only developed country without universal health care. Why can't USA figure this out? Its because the pharma lobby and health insurance lobby pay congress to continue the poor health care we have and which Trump is promising to gut even further. Sen. Collins is no moderate or friend of those in need of affordable health care.

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