Shefali Luthra: How insurers sank plan for 'public option' in Connecticut

Headquarters of the huge insurance company Cigna in Bloomfield, Conn

From Kaiser Health News

Health-care costs were rising. People couldn’t afford coverage. So, in Connecticut, state lawmakers took action.

Their solution was to attempt to create a public health insurance option, managed by the state, which would ostensibly serve as a low-cost alternative for people who couldn’t afford private plans.

Immediately, an aggressive industry mobilized to kill the idea. Despite months of lobbying, debate and organizing, the proposal was dead on arrival.

“That bill was met with a steam train of opposition,” recalled state Rep. Sean Scanlon, who chairs the legislature’s insurance and real estate committee.

Through a string of presidential debates, the idea of a public option was championed by moderate Democrats ― such as former South Bend, Ind., Mayor Pete Buttigieg, Minnesota Sen. Amy Klobuchar and former Vice President Joe Biden ― as an alternative to a single-payer “Medicare for All” model. Those center-left candidates again touted the idea during the Feb. 25 Democratic debate in South Carolina, with Buttigieg arguing such an approach would deliver universal care without the political baggage. (Buttigieg and Klobuchar have since ended their presidential bids.)

The public option has a common-sense appeal for many Americans who list health-care costs as a top political concern: If the market doesn’t offer patients an affordable health care insurance they like, why not give them the option to buy into a government-run health plan?

But the stunning 2019 defeat of a plan to implement such a policy in Connecticut — a solidly blue, or liberal-leaning, state — shows how difficult it may be to enact even “moderate” solutions that threaten some of America’s most powerful and lucrative industries. The health-insurance industry’s fear: If the average American could weigh a public option — Medicare or Medicaid or some amalgam of the two — against commercial plans on the market, they might find the latter wanting.

That fear has long blocked political action, said Colleen Grogan, a professor at the University of Chicago’s School of Social Service Administration, because “insurance companies are at the table” when health care reform legislation gets proposed.

To be sure, the state calculus is different from what a federal one would be. In the statehouse, a single industry can have an outsize influence and legislators are more skittish about job loss. In Connecticut, that was an especially potent force. Cigna and Aetna are among the state’s top 10 employers.

“They became aware of the bill, and they moved immediately to kill it,” said Frances Padilla, who heads the Universal Health Care Foundation of Connecticut and worked to generate support for the public option.

And those strategies have been replicated at the national level as a national coalition of health industry players ramps up lobbying against Democratic proposals. Beyond insurance, health-care systems and hospitals have joined in mobilizing against both public option and single-payer proposals, for fear a government-backed plan would pay far less than the rates of commercial insurance.

Many states are exploring implementing a public option, and once one is successful, others may well follow, opening the door to a federal program.

“State action is always a precursor for federal action,” said Trish Riley, the executive director of the National Academy for State Health Policy. “There’s a long history of that.”

Virginia state delegate Ibraheem Samirah introduced a new public option bill this session. In Colorado, Gov. Jared Polis is spearheading an effort. And Washington state is the furthest along — it approved a public option last year, and the state-offered plan will be available next year.

But in 2019, Connecticut’s legislators were stuck between two diametrically opposed constituencies, both distinctly local.

Health costs had skyrocketed. Across the state, Scanlon said, small-business owners worried that the high price of insurance was squeezing their margins. A state-provided health plan, the logic went, would be highly regulated and offer lower premiums and stable benefits, providing a viable, affordable alternative to businesses and individuals. (It could also pressure private insurance to offer cheaper plans.)

A coalition of state legislators came together around a proposal: Let small businesses and individuals buy into the state employee health benefit plan. Insurers’ response was swift.

Lobbyists from the insurance industry swarmed the Capitol, recalled Kevin Lembo, the state comptroller. “There was a lot of pressure put on the legislature and governor’s office not to do this.”

State ethics filings make it impossible to tease out how much of Aetna and Cigna’s lobbying dollars were spent on the public option legislation specifically. In the 2019-20 period, Aetna spent almost $158,000 in total lobbying: $93,000 lobbying the Statehouse, and $65,000 on the governor’s office. Cigna spent about $157,000: $84,000 went to the legislature, and $73,000 to the executive.

Anthem, another large insurance company, spent almost $147,000 lobbying during that same period — $23,545 to the governor, and $123,045 to the legislature. Padilla recalled that Anthem also made its opposition clear, though it was less vocal than the other companies. (Anthem did not respond to requests for comment.)

A coalition of insurance companies and business trade groups rolled out an online campaign, commissioning reports and promoting op-eds that argued the state proposal would devastate the local economy.

Lawmakers also received scores of similarly worded emails from Cigna and Aetna employees, voicing concern that a public option would eliminate their jobs, according to documents shared with Kaiser Health News. Cigna declined to comment on those emails, and Aetna never responded to requests for comment.

Connecticut’s first public option bill — which would let people directly buy into the publicly run state employee health plan ― flamed out.

So lawmakers put forth a compromise proposal: The state would contract with private plans to administer the government health option, allowing insurance companies to participate in the system.

The night before voting, that too fell apart. Accounts of what happened vary.

Some say Cigna threatened to pull its business out of the state if a public option were implemented. Publicly, Cigna has said it never issued such a threat but made clear that a public option would harm its bottom line. The company would not elaborate when contacted by KHN.

Now, months later, both Scanlon and Lembo said another attempt is in the works, pegged to legislation resembling last year’s compromise bill. But state lawmakers work only from February through early May, which is not a lot of time for a major bill.

Meanwhile, other states are making similar pushes, fighting their own uphill battles.

“It really depends on whether there are other countervailing pressures in the state that allow politicians to be able to go for a public option,” Grogan said.

And, nationally, if a public option appears to gain national traction, Blendon said, insurance companies “are clearly going to battle.”

They’re going to go after every Republican, every moderate Democrat, to try to say that … it’s a backdoor way to have the government take over insurance,” he said.

Still, when President Barack first proposed the idea of a public option as part of the Affordable Care Act, it was put aside as too radical. Less than a decade later, support for the idea ― every Democratic candidate backs either an optional public health plan or Medicare for All ― is stronger than it ever has been.

So strong, Grogan said, that it is hard for people to understand “the true extent” of the resistance that must be overcome to realize such a plan.

But in Connecticut, politicians say they’re up for a new battle in 2020.

“We can’t accept the status quo. … People are literally dying and going bankrupt,” Scanlon said. “A public option at the state level is the leading fight we can be taking.”

Shefali Luthra is a Kaiser Health News reporter.

Refund for Vt. woman shows how 'really arbitrary' medical insurance is

From Kaiser Health News

Sarah Witter had to pay for a second surgery to repair her broken leg after a metal plate installed during the first surgery broke. On Friday, she got a more welcome break — a $6,358.26 refund from the hospital and her insurer.

Witter’s experience was the subject of December’s KHN-NPR “Bill of the Month” feature. She and her insurer, Aetna, had racked up $99,159 in bills from a Rutland, Vt., hospital and various medical providers after she fractured her leg in a skiing accident last February.

A surgeon at Rutland Regional Medical Center implanted two metal plates, attached to her leg bones to help them heal. Less than four months later, one of these plates broke, requiring her to have a second surgery to replace the plate. Witter, who is 63, ended up paying $18,442, mostly to the hospital, for her portion of the total cost for all her care from the hospital, doctors, emergency services and physical therapists.

After KHN contacted Aetna about these costs, the insurer noticed that Rutland Regional had billed Witter for the difference between what it charged for its services and what Aetna considered an appropriate price for the first surgery. Those additional charges are known as “balance bills” and occur when a medical provider is not in the insurer’s network and has no contract with the insurer. Rutland Regional is not in Aetna’s network. In our original story, KHN had calculated $7,410 in balance bills.

Aetna said it contacted the hospital and negotiated a compromise in which the insurer paid the hospital nearly $3,800 and the hospital waived the remainder of the charges to Witter that Aetna considered unreasonably high.

“As part of her benefits plan, Sarah’s claims in question went through a patient advocacy process that allows us to negotiate with the provider on the member’s behalf to resolve any balance billing issues,” a spokesman wrote.

Aetna said it will negotiate disputed bills for any of its customers who request assistance, and also help schedule appointments, get services authorized and deal with other non-medical complications. However, an Aetna spokesman wrote, “we weren’t fully aware of all of the bills that Sarah had received before we received them from you/her.”

Last week, Rutland Regional again declined to discuss Witter’s account. Witter said she learned of the refund during a meeting, at Rutland Regional’s invitation, with a hospital financial administrator.

“They went through all the costs and I guess treated it [the first surgery] more like it was a hospital service that was within my contract,” she said. The administrator told her they had “reprocessed” the charges from her second surgery, but that her portion of the bill did not change, she said.

“It’s good news — who doesn’t like getting money back? But I don’t quite understand,” she said. “If it’s that easy for them to reprocess this billing to get me this, then it’s obvious that everything is really arbitrary.”

One difference between the two surgeries was the first one was conducted during a crisis after Witter was admitted to the hospital through the emergency room. Balance bills in those circumstances are the most difficult to justify because patients with injuries that require immediate care, such as a heart attack or car accident, are usually taken to the closest medical facility. Patients are not in a position to figure out where the closest in-network alternative is.

Neither Witter’s hospital nor her insurer budged on her underlying complaint: that she shouldn’t have had to pay for second surgery, which cost $43,208, because one of the plates — known as a bone fixation device and manufactured by Johnson & Johnson’s DePuy Synthes — broke.

Device manufacturers generally do not offer warranties for hardware devices once they have been implanted, saying that device failure can be due to a variety of factors beyond the company’s control. Those include poor implantation by the surgeon; bones that fail to heal and subject the device to unremitting strain, causing metal fatigue; or patients who apply too much weight or movement on the bone despite instructions not to.

DePuy, which declined to comment for this story, earlier said that device failures occur in “rare circumstances.” In its instructions for surgeons, DePuy noted: “It is important to note that these implants may break at any time if they are subjected to sufficient stresses.”

Witter said her surgeon was present at her meeting at Rutland Regional and told her that “the fact the bone hadn’t completely healed yet was part of the problem.” She said she has not been able to find a contact for the device manufacturer so she can complain about it breaking.

Even after she receives her refund, Witter still will have paid $12,084 for her broken limb. Asked her advice for other patients dealing with bills they consider excessive, she said: “Don’t break your leg!’’

Jordan Rau: In Vermont, no break after big breaks

From Kaiser Health News

Sarah Witter couldn’t get a break even though her leg had gotten several.

As she lay on a ski trail in Vermont last February, Witter, now 63, knew she hadn’t suffered a regular fall because she could not get up. An X-ray showed she had fractured two major bones in her lower left leg.

A surgeon at Rutland Regional Medical Center screwed two gleaming metal plates onto the bones to stabilize them. “I was very pleased with how things came together,” the doctor wrote in his operation notes.

But as spring ended, the wound started to hurt more. In June, Witter returned to the doctor. “He X-rayed it and said it broke,” she said. “And I was thinking, what broke? And he said, the plate. He said they do sometimes.”

The doctor performed another operation, removing the cracked plate and replacing it with a larger one.

Witter said she had been dutifully following all the instructions for her recovery, including going to physical therapy and keeping weight off her leg.

“I was, of course, thinking, ‘What did I do?’” Witter said. “The doctor said right off the bat it was nothing I did.”

Then the bill came.

The two surgeries Sarah Witter had following her skiing accident last February led to almost $100,000 in bills. Witter paid more than $18,000 of that out-of-pocket.

Total bill: $99,159 for emergency services, therapy and hospital care, including $52,587 for the first surgery and $43,208 for the second surgery. Altogether, Witter’s insurer, Aetna, paid $76,783. Witter paid $18,442 — including $7,808 for the second surgery. About half of Witter’s total expenses were copayments; another $7,410 was the portion of hospital charges that Aetna considered unreasonably high and refused to pay.

Service provider: Rutland Regional Medical Center, the largest community hospital in Vermont, performed the surgeries. Emergency services, anesthesia and physical therapy were done by other providers.

Medical service: In February, two metal plates called bone fixation devices and manufactured by Johnson & Johnson’s DePuy Synthes division were surgically attached to two lower leg bones Witter had fractured in a skiing accident. These plates are long, narrow pieces of metal with holes drilled in them at regular intervals for screws to attach them to the bones. A crack had developed in one of the plates running from the side of one of those holes to the edge of the plate. A second surgery was required to remove the plate and replace it.

What gives: When devices or treatments fail and need to be replaced or redone, patients (and their insurers) are expected to foot the bill. That may be understandable if a first course of antibiotics doesn’t clear a bronchitis, requiring a second drug. But it is more problematic — and far more expensive — when a piece of surgical hardware fails, whether it’s a pacemaker, a hip that dislocates in the days after surgery or a fractured metal plate.

Warranties, standard features at an electronic store or a car dealership, are rare for surgeries and in the medical device industry.

Dr. James Rickert, an orthopedic surgeon in Indiana and president of the Society for Patient Centered Orthopedics, said a plate like the one implanted in Witter’s leg can fail if the surgeon does not line it up correctly with the bone, although usually that causes the screws to break or back out. A plate also can fail if the patient puts too much weight on it or doesn’t follow other recovery instructions.

“When the plate breaks, it’s usually from overworking it, or a defect in the plate itself,” Rickert said. “The vast majority of people follow their instructions and are honest about it. If a person comes in and tells you they’ve been following their instructions and the surgery’s done properly, to me that’s a hardware failure.”

Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, said sometimes hospitals will not charge for a second surgery “if they were aware that it was something they did that caused the patient to need follow-up care.”

Rutland Regional, Witter’s hospital, would not discuss Witter’s care or bills, even though she gave it permission to do so. “The organization is not comfortable in getting into the specifics of an individual patient’s case,” a spokeswoman wrote. The hospital also declined to discuss under what circumstances, if any, it would discount a second surgery’s cost because of the first’s failure.

Hospitals do not consider it their responsibility if a medical device failure is the problem, Foster said. But manufacturers are reluctant to take the blame for an unsuccessful surgery.

Patients are usually out of luck when a second surgery is needed because of the failure of a medical device, like Sarah Witter’s broken plate. “The biggest annoyance with this whole thing, even though it took eight months out of my life,” Witter says, “is I hate to pay for it again, and the doctor clearly said it wasn’t anything I did.”

AdvaMed, the trade group for medical device manufacturers, said some companies will provide replacement devices if theirs failed, but others do not, especially if the failure of a procedure cannot “easily be attributeDed” to the device, the group said in a written statement.

“There are numerous factors outside of a manufacturer’s control — and unrelated to the safety of the device as designed — that could result in a device not performing as intended,” AdvaMed said.

These devices aren’t cheap: Witter’s hospital billed $9,706 for the first set of plates. It billed $12,860 for the replacement and an extra piece of equipment to attach it.

DePuy Synthes, which manufactured Witter’s plates, said in a written response that “in rare circumstances” metal plates “may fracture under normal weight-bearing or load-bearing in the absence of complete bone healing.” Even then, the company said, that is a chance patients have to take.

AdvaMed said it does not keep statistics on device performance, and DePuy did not respond to questions about how often its plates fail.

Resolution: The second surgery delayed Witter’s recovery by four months and prevented her from gardening, golfing, hiking, biking and motorcycling through the summer and fall, as she usually does. “I was pretty much chair-bound for 20 weeks,” she said.

In November, she was not able to join her husband and son on a trip to Iceland. Instead of volunteering at a nearby ski resort, as she had done for six years — and which carries the benefit of a free season pass — Witter said she tried selling hand warmers and lip balm out of a small kiosk and watching the skiers through a window. She said she had to quit after six days because of the pain in her feet.

“The biggest annoyance with this whole thing, even though it took eight months out of my life, is I hate to pay for it again, and the doctor clearly said it wasn’t anything I did,” she said.

Aetna said that while it does not allow providers to charge for indisputably inept medical mistakes such as leaving a surgical sponge in a patient or operating on the wrong limb, a broken plate does not qualify for such protection.

After reviewing Witter’s records, Aetna said it concluded the hospital had billed Witter for the portion of charges Aetna had considered excessive —a practice known as “balance billing.” While Aetna cannot reject those charges because the hospital does not have a contract with it, the spokesman said Aetna would try to negotiate with the hospital on Witter’s behalf to reduce the bill.

Rutland Regional, however, indicated in its statement that the only reason it would discount a bill was for people who had inadequate insurance or were suffering financial hardship from the size of the bills. Witter said she does not meet the hospital’s criteria.

The hospital invited her to meet with her surgeon and its chief financial officer.

The Takeaway: Witter brought up the seeming unfairness of the double charges to the hospital’s billing department as well as to her doctor, who, she said, was “charming,” but told her “he had no wiggle room to do anything.”

Patients are usually out of luck when a second surgery is needed because of the failure of a medical device or a surgeon’s mistake. A few places, most prominently the Geisinger Health System in Pennsylvania, offer warranties for hip and knee, spine and coronary artery bypass surgeries, among other procedures.

AdvaMed says that if a company provides a replacement, the hospital or surgeon is not supposed to bill Medicare or the patient for the equipment — even if the operation incurs charges.

Patients should scrutinize their bills and question their doctor and hospital or surgical center about charges for replacement devices.

If the doctor or hospital is partially at fault for the failure of the first procedure, request that part or all of the costs of the second surgery be waived. Get it in writing so you can make sure the billing department follows through. Also, in a medical market where insurers want to pay only for value-based care, let your insurer or employer’s human resources department know that you are being charged twice for the same surgery. Let them fight the battle for you.

Do you have an exorbitant or baffling medical bill? Join the KHN and NPR Bill-of-the-Month Club and tell us about your experience.

Jordan Rau: jrau@kff.org, @JordanRau

Ski trail in Stowe, Vt.

CVS may be a leader in health-care transformation

Adapted from Robert Whitcomb’s “Digital Diary,’’ in GoLocal24.com

Woonsocket-based CVS’s purchase of Aetna, the huge insurance company, could at least start to make fragmented and exorbitantly expensive U.S. health care a bit more coherent as well as cutting costs for consumers, both in medical-visit bills and insurance premiums. (We’ll see if that happens in our profit-obsessed system.)

Of course, other pharmacy chains and insurers will also tie the knot.

By putting together the insurance function and the direct provision of care, the merger will help create better, more complete patient medical records, thus facilitating better, especially preventive, care. And by helping to make many CVS drugstores even more of the primary-care/preventive-care centers that they’ve been becoming the past few years, the merger should take the pressure off astronomically expensive hospital emergency rooms, whose overuse is one reason that America’s health-care system is so expensive and inefficient.

Much of the treatment in CVS’s Minute Clinics is provided by nurse practitioners and physician assistants, who are less expensive than U.S. physicians -- the world’s highest paid. The American Medical Association has opposed the merger in part because it fears that the competition will cut doctors’ pay.

Importantly, the merger will strengthen CVS in negotiating with drug makers, which, protected by massive lobbying operations in Washington, charge by far the highest prices in the world – indeed sometimes engage in price-gouging. Those prices are yet another reason why health-care costs threaten to bankrupt the country.

(Happily, Trump signed two bipartisan bills into law last week to ban so-called gag clauses at the pharmacy counter. The bills, the Patient Right to Know Act and the Know the Lowest Price Act, would let pharmacists tell patients that they could save money by paying cash for drugs or try a lower-cost alternative. The existence of gag clauses was an outrage.)

We won’t know for several years what the full effects of the CVS-Aetna merger will be but it’s obvious that this experiment could profoundly affect many millions of Americans.

Will consumers benefit, as well as CVS senior executives and other shareholders?

Aetna CEO touts return to community-based healthcare

Via Cambridge Management Group (cmg625.com)

FierceHealthcare reports that Aetna CEO Mark Bertolini “is pushing for a return to community-based healthcare even as the insurance company prepares to merge with retail pharmacy giant CVS.''

“Critics of the merger have said the deal will hurt competition and cut local services. But Bertolini said the $69 billion deal with CVS doesn’t change the fact that the healthcare industry is moving toward a renaissance of community-based care,” the news service reported.

“Everything is going back to community,” Bertolini said at a conference in California. “I think the best way to manage the kind of shift we’re in is to go back to community and build smaller and smaller governance models to help support the growth of this. What you’re in essence building is a marketplace in the community around health.” Aetna is based in Hartford and CVS in Woonsocket, R.I.

To read more, please hit this link.

Calif. to probe Aetna's coverage denials.

The Aetna headquarters building, in Hartford, designed by renowned architect James Gamble Rogers, is the world's largest Colonial Revival Building. It was finished in 1931.

By BARBARA FEDER  OSTROV

For Kaiser Health News

Both of California’s health insurance regulators said they will investigate how Aetna Inc. makes coverage decisions, as the lawsuit of a California man who is suing the nation’s third-largest insurer for improper denial of care heads for opening arguments on Wednesday. Woonsocket, R.I.-based CVS Health, the pharmacy giant, seeks to buy Aetna.

The Department of Managed Health Care, which regulates the vast majority of health plans in California, said Monday it will investigate Hartford, Conn.-based Aetna after CNN first reported Sunday that one of the company’s medical directors had testified in a deposition related to the lawsuit that he did not examine patients’ records before deciding whether to deny or approve care. Rather, he relied on information provided by nurses who reviewed the records — and that was how he was trained by the company, he said.

Insurance Commissioner Dave Jones had already told CNN his office would investigate Aetna, which he reconfirmed in a statement Monday.

“If a health insurer is making decisions to deny coverage without a physician ever reviewing medical records, that is a significant concern and could be a violation of the law,” Jones said.

It is unclear how widespread the review of patient claims by non-physicians is in the industry or whether other insurers will feel compelled to revisit their practices.

The California Department of Insurance, which Jones heads, regulates only a small fraction of the state’s health plans, but they include several Aetna policies. He has previously criticized Aetna for “excessive” health insurance rate hikes, though neither his agency nor the managed health care department has the power to stop the increases.

Jones’ investigation of Aetna will review denials of coverage or pre-authorizations during the tenure of the medical director who testified in the California lawsuit, Jay Ken Iinuma, who has since left the company. Insurance department investigators will also look into Aetna’s procedures for managing medical coverage decisions generally.

The dual investigations come as federal regulators are examining a planned $69 billion purchase of Aetna by pharmaceutical giant CVS — a deal that many experts believe could transform the health care industry.

It’s unclear how the investigations might affect Aetna’s future coverage decisions, or those of other insurers, said Shana Alex Charles, an insurance industry expert and assistant professor at California State University-Fullerton. But she praised the decision to investigate as exactly what insurance regulators should be doing. “Without that strict oversight, corners get cut,” Charles said.

Scott Glovsky, the lawyer representing the California plaintiff, Gillen Washington, said he and his client were “very pleased” by the news that Aetna will be investigated. Speaking Monday, before the managed care department said it would also investigate, Glovsky said his client brought the case “to stop these illegal practices, and we’re looking forward to the insurance commissioner’s investigation so we can make things safer for Aetna patients.”

Washington, of Huntington Beach, had been receiving expensive medication for years to treat a rare immune system disorder known as Common Variable Immune Deficiency.

But in 2014, Aetna denied the college student’s monthly dose of immunoglobulin replacement therapy, saying his bloodwork was outdated. During the appeal process, Washington developed pneumonia and was hospitalized for a collapsed lung.

In recent years, as California Healthline reported last June, patients with similar diseases have faced increasing difficulty getting their insurers to approve treatments, according to clinicians and patient advocates.

In an e-mailed statement on Monday, Aetna did not directly address the question of case reviews by non-physicians. It said its “medical directors review all necessary available medical information for cases that they are asked to evaluate. That is how they are trained, as physicians and as Aetna employees.” It added, “adherence to those guidelines, which are based on health outcomes and not financial considerations, is an integral part of their yearly review process.”

Aetna also noted that it has paid for all of Washington’s treatments since 2014 and continues to do so.

Aetna said in previous documents filed in the lawsuit that it is standard for people with Washington’s immunodeficiency disease to get regular blood tests and that Washington had failed to do so. But Washington’s attorney said his client clearly needed the medication and that Aetna’s action violated its contract with Washington.

Charles, the professor, said she was most surprised by the fact that Iinuma had admitted not only that he hadn’t reviewed Washington’s medical records personally, but that he had no experience treating his disease. The burden should be on insurers to demonstrate why treatment should be stopped, not on doctors and patients to show why it should be continued, Charles said.

“It’s easy to see the cases as just files and not people standing in front of you,” she said.

CVS-Aetna merger: Who would benefit besides top execs and other shareholders?

From Robert Whitcomb's "Digital Diary,'' in GoLocal24.com:

Besides senior executives and other Aetna shareholders, who would benefit most from CVS’s $69 billion acquisition of Aetna?

Well, the  new behemoth’s pharmacy benefit management operation might use its even greater bargaining power with drug makers to negotiate down the extreme, indeed extortive, cost of so  many prescription drugs in such a way as to benefit consumers. But I doubt it. It’s  more likely that they’ll keep the savings to benefit CVS-Aetna senior executives and other shareholders and consumers will see little if any benefit from that.

Indeed, if the merger drives competitors out of business, CVS might, in the fullness of time and pricing power, increase other prices for its captive customer base a lot. But with giant insurer UnitedHealth Group also getting into the big-time clinic business, too, maybe that might not happen.

Anyway, much good can come from this combination.

The merger is part of CVS’s plan to turn itself into a much-wider-service health-care provider, building on its rapidly expanding chain of Minute Clinics. There, nurse practitioners, physician assistants and regular nurses are joining with pharmacists to offer many services that you’d once have to go to a doctor’s office or hospital to get, at very high cost.  After all, U.S. physicians are highest paid in the world, co-payments are jumping, etc. A brief visit to a hospital emergency room shows that far too many patients go to that very expensive venue for problems that could better be addressed in a, well, Minute Clinic. The aging of the population, and thus a flood of sicker people, especially raises the potential of Minute Clinic-like health-care retailers to slow surging health-care costs, or some of them anyway.

Indeed, whatever happens with drug prices at the likes of CVS-Aetna, consumers can save time, and thus money, by using a facility that will offer many primary-care services beyond pills, such as  medical tests, physical exams and medical consultations, as well as food and other products. Life can be frantic. One-stop shopping is very attractive. At the least, these centers might help you cut down on transportation costs.

Getting your health insurance from the same organization where you get much of your health care may also make your life easier.  For one thing, the sharing of patient data between the insurance side and the provider (CVS) may facilitate better care, especially for those with such chronic ailments as heart disease. But, yes, it will also make your personal data more vulnerable to computer hacking from crooks domestic or foreign (especially the Russians and Chinese)….

But again, much depends on whether the merger ends up squashing CVS-Atena competitors so much that the behemoth can jack up prices, including for insurance. Many patients may find themselves trapped in expensive “health-care hubs.’’ Always remember that most companies care far more about their senior executives and other shareholders than anyone else.

And the CVS-Aetna deal is more bad news for hospitals and physician groups: The new entity will probably drain away many of their patients.

Unless executives of the new outfit decide they really want the glamour of a big city headquarters and move it to, say, New York or Boston (remember Fleet Financial Group leaving Providence for Boston?), the merger is good news for Rhode Island, both psychologically (having such an even bigger company based here) and in the new employees that CVS-Aetna would presumably need to hire here for additional administrative, marketing and other headquarters-related work.

But don’t bet the farm on CVS keeping its headquarters in Woonsocket. Increasingly, those working at corporate headquarters, especially younger up-and-coming employees,  and the executive suite, like to be in a dynamic city instead of some suburban-style office park.

So Providence’s Financial District, once an important banking center, might eventually host CVS-Aetna headquarters. Given that Aetna is a financial company that would be fitting. And the Rhode Island School of Design’s  army of graphic and other designers would be next door;  a few blocks away would be the Brown Medical School. Both very handy for a consumer health-care chain. There’s been chatter lately that toy-and-entertainment giant Hasbro might consider moving its headquarters to downtown Providence. Wouldn't it be nice if this old city once again became a major corporate headquarters town?

Llewellyn King: Be scared of whom you kiss, and other big changes in 2017

"The Mistletoe Seller,'' by Adrien Barrère

Some years are indelibly etched into history, like 1941, with the bombing of Pearl Harbor; 1964, with the Civil Rights Act; and 1968, with the anti-war demonstrations.

Such a year may be 2017, not only because of Donald Trump’s presidency but also because of revolutionary changes in the way we live and work that aren’t directly produced or ratified by politics.

Here are some of the takeaways:

The uprising of women against men in power who have harassed them, assaulted them and sometimes raped them. Nothing quite like this has happened since women got the vote. The victims have already wrought massive changes in cinema, journalism and Congress: Great men have fallen, and fallen hard. Can the titans of Wall Street and the ogres of the C-Suite be far behind?

This Christmas, more people will buy online than ever before. Delivery systems will be stretched, from the U.S. Postal Service to FedEx, which is why Amazon and others are looking at new ways of getting stuff to you. There will be bottlenecks: Goods don’t come by wire, yet. The old way is not geared for the new.

The sedan car — the basic automobile that has been with us since an engine was bolted in a carriage — is in retreat. Incredibly, the great top-end manufacturers, from Porsche to Rolls Royce and even Lamborghini, are offering SUVs. They win for rugged feel, headroom and, with all-wheel drive, they’ll plow through snow and mud. In the West, luxury pickups are claiming more drivers every year for the same reasons.

No longer are electric vehicles going to be for the gung-ho few environmentalists. Even as the big automakers are gearing up for more SUV production, they’re tooling up for electrification on a grand scale, although the pace of that is uncertain. Stung by the success of Tesla, the all-electric play, General Motors is hoping to get out in front: It is building on its all-electric Volt. Volvo is going all-electric and others want to hedge the SUV bet. The impediments: the speed of battery development and new user-friendly charging.

The money we have known may not be the money we are going to know going forward. In currency circles, there is revolution going on about a technology called “blockchain.” Its advocates, like Perianne Boring, founder and president of the Chamber of Digital Commerce, believe it will usher in a new kind of currency that is safe and transparent. A few are making fortunes out of bitcoin, which has risen 1,000 percent in value this year so far. A fistful of new currencies are offered — and even bankrupt Venezuela is trying to change its luck with cryptocurrency. For those in the know, blockchain is the new gold. Will it glitter?

The proposed merger between CVS, a drugstore chain, and Aetna, an insurance giant, may be one of the few mergers that might really benefit the consumer as well as the stockholders and managers. It will lower drug prices because both the drug retailer and the paymaster will be at the same counter. Expect this new kind of health provider to drive hospital charges toward standardization.

This holiday season, consider the changes in the way you live now. Watch out for whom and how you kiss under the mistletoe, and for how Internet purchases get to you. If a new car is in store for you in 2018, a difficult choice may be to venture electric, go SUV or stay with a sleek sedan. And will you pay for it with the old currency or the new-fangled cryptocurrency?

Happy holidays!

On Twitter: @llewellynking2
Llewellyn King (llewellynking1) is executive producer and host ofWhite House Chronicle,  on PBS.

The Tesla Model 3 first deliveries event took place on July 28, 2017.

Chris Powell: Conn. shouldn't get emotional about exit of GE and Aetna

The soon-to-be former headquarters of Aetna in Hartford. It looks like a hotel or part of a college.

Having spent the last several decades capitulating to its government and welfare classes and squandering its advantages over other states, Connecticut has a lot to apologize for and correct. But it shouldn't feel quite so bad about the departure of General Electric's headquarters from Fairfield to Boston and the departure of Aetna's headquarters from Hartford to New York.

People have thought of GE and Aetna as Connecticut companies when they really haven't been.

General Electric got started in Schenectady in upstate New York, consolidated in New York City, and acquired many related companies around America before moving its corporate headquarters to Fairfield and transforming itself into an international financial conglomerate.

While Aetna started in Hartford in 1853, as it grew it also opened offices throughout the country and the world and became a financial conglomerate much like GE. Aetna has 5,000 employees in Connecticut but 44,000 elsewhere.

The boards of both companies long have lacked members with roots in the state.

People here like to think of United Technologies Corp. as a Connecticut company as well. But while UTC began in Connecticut with Pratt & Whitney Aircraft and retains its headquarters here, like GE and Aetna the company used its earnings to acquire other businesses and became an international conglomerate. UTC's employment in the state has declined steadily as it has expanded its aircraft engine and other businesses elsewhere.

Since the businesses of these companies are so dependent on and/or or regulated by national governments, politics has required them to diversify their geography. It's not enough for them to have the support of Connecticut's delegation in Congress. They need support nationally.

Meanwhile other national and international companies have expanded into Connecticut for the same reason, perhaps causing emotional pangs and resentments in the places where they originated.

But that's the evolution of most big businesses -- from entities with local character and geographic loyalty to cold accumulations of mobile capital. They're not emotional about Connecticut and the state is silly to be emotional about them.:

Defending their ratification of the new state employee union contract, Democratic state legislators say that its 10-year term, criticized by Republican legislators as too long, is no big deal. The Democrats note that state employee union contracts have been reopened early before, as the one just extended was.

But that argument is weak, since reopening such contracts is possible only with the consent of the unions and there is no guarantee that the unions will give their consent. Indeed, if, as the Democratic legislators suggest, reopening contracts is a mere technicality, why should their length be specified at all? Why shouldn't the contracts be written so they can be terminated by either party at any time?

When union leaders urged their members to ratify the new contract, they did not argue, as Democratic legislators argue now, that the duration clause is meaningless. No, union leaders argued that the contract provides long-term protection of jobs and compensation. Union members might not have ratified the contract if its four-year guarantee of employment really meant that layoffs could begin at any time.

The essence of the contract issue remains that Democrats, the party of government employees, believe that government employees should have more power over the government than the voters do. It's nonsense but it is repaid well by government employees at election time.

Chris Powell is managing editor of the Journal Inquirer in Manchester, Conn.

Connecticut needs to fix its cities

Aetna's headquarters in Hartford, but not for long: The company is moving its home office to Manhattan.

Adapted from Robert Whitcomb's "Digital Diary,'' in GoLocal24.com:

Derek Thompson, writing in The Atlantic’s online service, has some interesting takes on Connecticut’s current fiscal problems. The state government has a huge deficit,  some cities are effectively bankrupt, taxes are amongst the highest in the nation and some big companies have fled. And yet the state remains the richest on a per-capita basis in America, albeit largely because of New York City-connected rich folks living in Fairfield County. (Massachusetts is the second-richest; New Jersey the third.)

He notes some remarkably little reported reasons for the state’s ills: One is that Connecticut, like America in general, has lost much of its high-valued manufacturing, a sector for which  Connecticut was once famed around the world.  (I lived near Waterbury for four years in the early and mid-‘60s, from when I well remember the busy factories up and down the colorfully polluted Naugatuck River.)

Very highly paid people in finance, many of  them commuting to Manhattan but many doing their thing in Stamford and Greenwich, have offset some of this loss. However, finance, which of course follows the ups and downs of Wall Street, is more cyclical than manufacturing. And the latter provided a wider range of well-paying jobs to many more people than does finance.

Another important change  that Mr. Thompson cited is that the big cities close to Connecticut --- especially New York and Boston – have become much safer and more attractive. Rich people and Millennials have been moving back into them, having grown bored with suburbs, even those as attractively sylvan as some on Connecticut’s strip of the Long Island Sound shoreline.

Conservatives who seem obsessed with high taxes above all else should note that some of the big companies pulling their headquarters from Connecticut are not exactly moving to low-tax venues. Consider that Aetna is leaving Hartford for Manhattan and General Electric has left Fairfield for Boston. They want the dynamism of those cities and are happy to pay for it.

The Nutmeg State has poor, high-crime and often badly run cities. If the state is to improve its long-term prospects, I and Mr. Thompson would agree, it needs to fix its cities. Hartford, which used to be a vibrant and mostly middle-class city before bad municipal government, ill-considered“ urban renewal’’ and other factors drove it into the ditch, is expected to go into official bankruptcy soon. That should let it start cleaning up its act and make it a place that people, especially young adults who might otherwise go to New York, would want to live and work in. That could help turn around the whole state. After all, Hartford is the state capital.

Chris Powell: A clearer view of Aetna's travel plans

Aetna's current headquarters, in Hartford.

Aetna's supposed departure from Hartford may be recorded as the signature humiliation of Gov. Dannel Malloy's administration, the capstone of the last decade of Connecticut's decline. At least the governor's political opponents will portray it that way.

But they will be wrong, for several reasons. First, the company really doesn't plan to leave Hartford but rather to relocate its top executives. Most of the company's nearly 6,000 employees in Hartford are expected to remain.

Second, the move seems mainly a matter of the personal preference of Aetna CEO Mark Bertolini, who has no particular affection for Connecticut.

Third, the assertion by some "experts" that Aetna wants to attract young workers by being based in a livelier city is nonsense. For the top executives Aetna will be relocating will not be hipsters. Young workers don't start at the top.

More likely Aetna's top executives would like to be big fish in a big pond rather than in a small one.

Fourth, even those who deplore the corporate welfare of the Malloy administration can't deny that the governor was ready to do nearly anything to induce Aetna to stay, starting with his promise to match any financial incentives offered to Aetna by any other state.

That the company declined to pursue the governor's offer suggests that its decision has little to do with business climate, taxes, workforce skills, or anything else under state government's control. Commenting on Aetna's plans, the governor said, "Hartford is not ever going to be New York or Boston. And that's fine." Fine? He might have said, "Thank God!"

Of course those cities have their virtues, but congestion, noise, pollution and being prime targets for terrorism aren't among them. Connecticut is close enough to those cities to use them any time but conveniently set apart enough so that there is space for the reflection and privacy without which life provides little comfort and sense.

"The Connecticut countryside," the historian and sometime politician Odell Shepard wrote in 1939, "seldom obviously picturesque, has been made by long collaboration between earth and man. It is saturated with humanity. Vermont has far more landscape to the square mile but we mix more people with the view.

"This little place of ours is homely, used, and worn, like a weather-beaten homespun coat that has often been patched and turned. Or it is like some wise old face written with character and wrinkled deep in time. 

"Jonathan Edwards it was, I think, who defined a certain sort of beauty as ‘the visible fitness of a thing to its use,' like the exact adjustment of a mortise to its tenon.

"That is what we have here -- a beauty homemade and blood-warm, moderate, honest, and utterly our own. There is no glozing and seductive glamour about it, no mirage of a fairer land than earth affords. It renders the sober truth of things, no more."

The sober truth of things today is that Connecticut indeed is in danger but not particularly because of Aetna's departure or anyone else's. Instead the state's decline is a consequence of the corruption brought about by its former prosperity, which caused elected officials to think that they could not just appease every selfish or unproductive special interest but also lock that appeasement into perpetuity by contract, nullifying democracy for all time. That's not a natural disaster but a political one, and it has a remedy: a revival of civic virtue.

 Chris Powell is managing editor of the Journal Inquirer ,in Manchester, Conn.

Jim Hightower: Aetna the big business apostate

Business schools preach a strict, anti-social doctrine of corporate management that comes down to this: CEO's must be idiots.

By that I mean the original Greek word idiotes, which applied to people who care only about themselves and the prosperity of their immediate family. They’re the ones who reject any responsibility to the larger society, civic affairs, and the common good.

That selfish ethos is what prevails in today’s corporate suites, where it’s claimed that the only responsibility of executives is to maximize profits for the “family” — that is, for themselves and their major shareholders.

If they have to stiff workers, sidestep environmental rules, and shaft consumers to do it, well, that’s the lot of idiotes.

But now comes an apostate to this doctrinal idiocy.

Mark Bertolini,  chief executive of the Hartford-based health-insurance giant Aetna, says CEO's should raise the minimum wage their companies pay to a level approaching minimal fairness. Rather than just calling for it, though, he actually did it. He lifted Aetna’s lowest wage to $16 an hour, plus improved health benefits.

Then Bertolini really gave up the game: He publicly revealed that these increases aren’t so financially painful after all.

The total cost to Aetna will be about $26 million a year. That’s nothing for a company with annual revenues of $62 billion.

The only pain that Bertolini might feel is loneliness when he enters the CEO Club and sees other insurance chieftains turn their backs and shun him over his leadership on the moral matter of shared prosperity.

Indeed, the CEO's of Humana, Anthem and other insurers say “no” to raises for their employees, sniffing that they pay “competitive wages” — which is just a dishonest way of saying “low wages.”

Whether those idiotes like it or not, Aetna just lifted the national standard for competitive wages.

Moreover, the insurer has thrown open the doors of the executive suites to an honest public conversation about the morality of the suits inside jacking up their compensation while holding down everyone else’s pay.

Jim Hightower is a columnist for otherwords.org, where this originated.