Tuesday, January 14, 2020

Health Care Reform Articles - January 14, 2020

 Editor's Note -

The following essay is one I wrote as an op-ed or (long) LTE for the Bangor Daily News in response to an article they wrote in December. They have chosen not to publish it, citing a plethora of submissions and limited space. I think the article is self-explanatory.


The ACA’s Family Glitch Can Be Fixed- and Mainers Could Save over a Billion Dollars a year on Healthcare

by Philip Caper, M.D. - Maine AllCare

On December 22 the BDN published an article titled “This Maine man lost his ACA insurance because he got married. He’s not alone.”  The man, Owen Marshall, unwittingly lost his ACA subsidy when he got married. That was due to the well known “family glitch” in the Affordable Care Act. It’s unclear whether the family glitch was inserted into the ACA by Congress to save money, or was simply an unintentional error.

It doesn’t really matter. If the glitch was intentionally inserted into the law it’s unlikely the current Congress would have any interest in changing it. If it was an error, as many believe, it would have been routinely corrected by Congress long ago through the passage of non-controversial technical and conforming amendments. But in today’s hyper-polarized political climate Congress has been unreceptive to re-opening”ObamaCare” to any amendments, no matter how harmless they may seem.

Quoting Kate Ende of Consumers for Affordable Health Care, the article concluded that Owen’s only quick and “practical” solution to his dilemma would be to divorce his wife! Ende also opined that “there’s currently no good solution to the problem, no workaround and no national legislation in the works to fix it.” 

That opinion is not accurate. There are at least two bills in Congress and one now under consideration in the Maine Legislature that would definitely fix the family glitch, and many other of the deficiencies in the ACA - for good. What Ende should have said is that there is no bill aimed solely and specifically at fixing the family glitch. That is true. But that’s not what was reported.

Advocates of fundamental reform of our badly broken healthcare system, (such as me) have become accustomed to being routinely ignored, discounted or marginalized by politicians, the media and “practical" experts on both sides of the aisle for being unrealistically radical. We truly are the skunks at the healthcare lawn party.

Many of those who are so dismissive of our “radical” proposals are the same political savants who not so long ago predicted that Donald Trump and Bernie Sanders could never be serious candidates for the US presidency. As late as October of 2016 they were also confidently predicting that Hillary Clinton was going to be POTUS starting in 2017.

It’s never too late to learn. Anybody who believes they can predict the course of today’s politics in the US simply hasn’t been paying attention.

In fact, there are at least two serious “Medicare for All” style bills in Congress: the Sanders bill in the Senate and the Jayapal bill in the House.  But there is no reason to have to wait for action by the Congress.  A bill pending in the Maine legislature - LD 1611, introduced by Representative Heidi Brooks, would provide the people of Maine many of the benefits of those federal bills.

At a pubic hearing On December 16, a study by the Maine Center for Economic Policy, funded by Maine AllCare, was presented to the Health Care, Insurance and Financial Services Committee of the legislature. In it MECEP presented an economic model that could be created under a bill such as LD 1611. They concluded that universal heath care for the people of Maine was not only feasible, but would be a vast improvement over Maine’s current system.

By adopting the MECEP model, healthcare total spending overall in Maine would be reduced by about $1.5 billion and 80% of Mainers would pay less for healthcare than they do now. Expanded coverage would be paid for by eliminating some of the tremendous waste in our present healthcare system. Under the MECEP model, Every Mainer would be covered. Co-pays and deductibles would be greatly reduced or eliminated and the scope of benefits expanded for all Mainers including those covered by Medicare, Medicaid and private insurance.

The focus of healthcare providers would return to treating patients, not fighting over medical bills. Health coverage would be permanent for everybody, and could not be taken away. No major changes in federal law would be necessary as existing federal programs would be retained pretty much intact, and supplemented by the new Maine program.

The MECEP study has demonstrated that there are plenty of excuses, but no insurmountable economic or technical barriers to moving ahead with such a transformation - only politics. 

Now it’s up to the legislature and the people of Maine.

Trump’s Plot Against Health Care Continues

by Paul Krugman - NYT - January 13, 2020

Make no mistake: Health care will be on the ballot this November. But not in the way ardent progressives imagine.
Democrats running for president have spent a lot of time debating so-called Medicare for all, with some supporters of Bernie Sanders claiming that any politician who doesn’t demand immediate implementation of single-payer health care is a corporate tool, or something. But the reality is that whatever its merits, universal, government-provided health insurance isn’t going to happen anytime soon.
I say this because even if Democrats take the Senate in addition to the White House, the votes for eliminating private health insurance won’t be there; nor will the kind of overwhelming public support that might change that calculus. In practice, any of the Democratic candidates — even Sanders — will, if victorious, end up building on and improving Obamacare.
On the other hand, if Donald Trump wins, he will probably find a way to kill Obamacare, and tens of millions of Americans will lose health coverage.
Let’s talk for a minute about Obamacare. There’s a sort of perverse alliance between Republicans and some progressives, both of whom are determined, albeit for different reasons, to see the Affordable Care Act as a failure.
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These downbeat assessments are made easier by the fact that the A.C.A. left much of its implementation up to the states, and that national performance has been held down by states that have done their best to sabotage health reform.
But look at states that have tried to make the law work, and what you see is a huge if incomplete policy success. Take the case of California. In 2010, before the A.C.A. went into effect, 21 percent of nonelderly Californians were uninsured, above the national average. By 2016 the uninsurance rate had dropped to 8 percent. And Californians with pre-existing medical conditions saw an enormous improvement in their health and financial security.
Now, 8 percent uninsured is still too many, and even those with insurance often face high out-of-pocket costs. But relatively minor improvements in the law, especially a modest increase in the generosity of insurance subsidies, could substantially improve both the quality and the quantity of coverage.
Does pointing out the possibility of incremental progress mean giving up on a truly universal system? No. By all means let’s make something more ambitious, such as Medicare for all, a long-term goal. But this goal shouldn’t stand in the way of policies that would immediately benefit millions of Americans, and save thousands of lives.
And while we debate the ideal health system, we mustn’t forget that Trump and his allies are as determined as ever to undo the progress we’ve made.
It’s true that so far repeated Republican attempts to destroy the Affordable Care Act have failed. In 2012 the Supreme Court rejected claims that the whole law was unconstitutional. In 2017 a Republican-controlled Congress narrowly failed to repeal Obamacare. And a variety of narrower efforts to undermine health reform and send insurance markets into a “death spiral” have fallen short: Markets seem to have stabilized, and one by one, states that initially rejected Medicaid expansion have been relenting.
But the people who want to take away your health care haven’t given up.
The latest attempt is a lawsuit claiming that the 2017 tax cut, which reduced the penalty for not having insurance to $0, somehow made the entire Affordable Care Act unconstitutional. It’s a ludicrous claim, both in terms of substance — would the law suddenly become constitutional if the penalty were a penny? — and because it’s clear that this was not legislators’ intention.
But the Trump administration has joined the suit and a partisan Republican judge has indeed ruled that the A.C.A. as a whole should be struck down.
Clearly, this case is headed for the Supreme Court. But Trump doesn’t want it heard until after the election.
Why does Trump want to leave this court case hanging? Partly because his side would probably lose. As I said, the lawsuit is ludicrous, although, given the partisanship of Republican-appointed judges, it might prevail anyway.
Beyond that, however, Trump’s political health care strategy is to flat-out lie about what he has done and is trying to do. On Monday he made the breathtakingly dishonest claim that he is “the person who saved pre-existing conditions” — breathtaking because he has tried at every stage to remove the protections for Americans with pre-existing conditions created by the Affordable Care Act.
And while Trump, who lies constantly, often seems to pay little penalty for those lies, this one — which touches the lives of millions of voters — would be thrown into sharp relief if the case were heard by the Supreme Court. He wants to take away your health care, but he doesn’t want you to see him doing it until the election is behind him.
So that’s the real health care issue this year. Will it be expanded coverage under a Democrat — it probably doesn’t matter much which one — or will it be tens of millions of newly uninsured Americans under Trump?

Labor Take My Benefits—Please!

Employment-based Health Care Has Become an Anchor Around the Neck of the U.S. Working Class

‘I Honestly Don’t Trust Many People at Boeing’: A Broken Culture Exposed

A trove of internal employee communications shows that the aviation giant’s troubles go beyond one poorly designed plane. 

by David Gelles - NYT - January 10, 2020

Boeing’s troubles run deep. The 737 Max, its newest and most important jet, has been grounded since March after two deadly crashes killed 346 people. The cascading crisis has disrupted the global aviation industry, cost the company billions of dollars and led to the ouster of its chief executive.
Yet the steady drip of bad news and embarrassing revelations — culminating in Thursday’s release of 117 pages of damning internal communications — has revealed something more disturbing than one poorly designed plane. The very culture at Boeing appears to be broken, with some senior employees having little regard for regulators, customers and even co-workers.
Perhaps most tellingly, the documents show Boeing employees repeatedly questioning the competence of their own colleagues, and the quality of the company’s engineering.
“This is a joke,” a Boeing employee, referring to the 737 Max, said to a colleague in 2016. “This airplane is ridiculous.”
Another employee wrote: “I honestly don’t trust many people at Boeing.”
Boeing is the largest manufacturing exporter in the United States, and its fate can sway the national economy. It employs more than 130,000 people, in all 50 states, and supports a network of thousands of suppliers. And the dysfunction at the heart of one of America’s most important companies, as illustrated by the new messages, still has the power to shock.
“We’ve all seen this movie before, in places like Enron,” Chesley B. Sullenberger III, the pilot who safely landed a plane on the Hudson River in 2009, said in an interview. “It’s not surprising that before a crisis, there are indications of real deep problems that have their roots in leadership.”
Sara Nelson, the president of the Association of Flight Attendants union, said the messages revealed a “sick” culture at Boeing, noting that “the trust level was already in the toilet.”
The internal communications, which were provided to congressional investigators and cover a five-year period before the crashes in late 2018 and early 2019, show Boeing employees cavalierly dismissing the Federal Aviation Administration, which certified the Max as safe to fly. Ahead of a 2016 meeting to discuss training requirements for the plane, a Boeing employee described regulators as “dogs watching TV.” Another time, a Boeing employee wrote: “There is no confidence that the F.A.A. is understanding what they are accepting (or rejecting).”

117 pages, 23.73 MB

Airlines, which pay about $100 million apiece for the Max, were derided as incompetent, their questions unreasonable. When discussing whether pilots at an Indonesian airline connected to Lion Air, which operated the first Max that crashed, might need simulator training before flying the Max, a Boeing employee said it was “because of their own stupidity” and called the airline “idiots.”
“This is confirmation that the problems go beyond Muilenburg,” said Michael Stumo, whose daughter Samya was killed in the second Max crash, referring to Dennis A. Muilenburg, the chief executive who was dismissed last month. “This is deeply flawed, long-term cultural erosion.”
On Friday morning, Greg Smith, Boeing’s interim chief executive, wrote an email to employees expressing contrition for the messages and imploring the company to change.
“These documents do not represent the best of Boeing,” Mr. Smith said in the email, which was obtained by The New York Times. “The tone and language of the messages are inappropriate, particularly when used in discussion of such important matters, and they do not reflect who we are as a company or the culture we’ve created.”
Mr. Smith noted that the messages involved a relatively small number of employees, and said the company had confidence in the Max. The company declined to comment on Friday beyond Mr. Smith’s email.
For generations, Boeing represented the pinnacle of American engineering. It helped win World War II, land men on the moon, build Air Force One and make commercial air travel ubiquitous, even glamorous. But the newly released messages portray a company that appears to have lost its way.
Once relentlessly focused on safety and engineering, Boeing employees are shown obsessing over the bottom line. Though Boeing is one of the American government’s biggest contractors, the F.A.A. was viewed as a roadblock to commercial goals that would “impede progress” when it tried to “get in the way.”
At times, Boeing employees expressed reservations about the safety of their planes.
“Would you put your family on a Max simulator trained aircraft? I wouldn’t,” one said to a colleague in 2018, before the first crash.
While the most insensitive comments appear to have been made by a few employees, the messages reveal a coordinated effort among Boeing employees to persuade the F.A.A. that the Max did not need simulator training, a significant financial boon for the company.
Boeing employees congratulated one another for using “Jedi mind tricks” to convince regulators that minimal training was needed on the Max. In an email from 2016 celebrating the agency’s preliminary decision not to require simulator training on the Max, the plane’s chief technical pilot, Mark Forkner, said the news “culminates more than three years of tireless and collaborative efforts across many business units.” Last year, other damaging internal communications involving Mr. Forkner were released.
In an exchange with Mr. Forkner in 2014, an employee who was developing the computer-based training for the Max suggested providing more guidance in the pilot manual for how to handle certain emergencies. (The plane featured a new software system later found to have played a role in both crashes.)
Mr. Forkner told the employee that the company couldn’t add that information because it might lead regulators to require more extensive training for pilots. “We need to sell this as a very intuitive basic pilot skill,” Mr. Forkner wrote.
“I fear that skill is not very intuitive any more with the younger pilots and those who have become too reliant on automation,” the employee responded.
“Probably true, but it’s the box we’re painted into,” Mr. Forkner said, citing the desire to keep training to a minimum. “A bad excuse, but what I’m being pressured into complying with.”
After fighting so hard to avoid simulator training, Boeing reversed itself this week and recommended that all pilots have the training before flying the Max. Bloomberg Intelligence estimated that it would cost the company $5 billion, though Boeing said it was too soon to know the true figure.
“Had they done the right thing upfront, they might have had slightly higher costs upfront, but they would have saved billions in the long term,” Mr. Sullenberger said. “But that’s hard to do in this world run by Wall Street.”
Stan Sorscher, a former Boeing engineer who then worked with a union representing company engineers, said priorities had shifted over the past two decades, with profits mattering more than quality.
“Engineers normally just don’t talk that way,” Mr. Sorscher said of the messages. “It’s not the company I knew.”
Boeing and the F.A.A. said on Thursday that the new messages, damning as they are, did not reveal any new safety concerns about the Max. Regulators may approve the Max to return to service in the coming months, and the plane could be flying commercially by the summer.
Yet Boeing’s problems are hardly over. The messages are likely to further undermine public confidence in the company and the Max. Today, according to Boeing’s own research, 40 percent of travelers are unwilling to fly on the plane. There is no timetable for the return of the Max, costs are mounting, and shares in the company have fallen 22 percent since the second crash, including a 2 percent drop on Friday.
After last month’s announcement that Boeing would temporarily shut down production of the Max, suppliers are hurting, too. On Friday, Spirit AeroSystems, which makes the fuselage for the plane, said it would lay off around 2,800 employees.
With a new chief executive, David Calhoun, taking over on Monday, Boeing is trying to turn a corner. The company promoted its transparency in releasing the messages and its decision to recommend simulator training as examples of a new culture. On Friday, Boeing said Mr. Calhoun would receive a $7 million bonus if he got the Max safely flying again. (Mr. Muilenburg is leaving with $62.2 million in stock and pension awards.)
But in the words of Boeing’s own employees, the culture is entrenched. As recently as mid-2018, colleagues were lamenting the state of their company in pained emails to one another.
“I don’t know how to fix these things … it’s systemic,” one employee wrote to another in an email about the 737 Max. “Sometimes you have to let big things fail so that everyone can identify a problem … maybe that’s what needs to happen rather than continuing to scrape by.”

The View From Here: A moderate case for Bernie Sanders

The Vermont left-winger might be best positioned to deliver the policies that moderates say they prefer. 
by Greg Kesich - Portland Press Herald - January 12, 2020

Let’s say that you’re a moderate Democrat trying to decide who to vote for in the 2020 presidential primary.
Your top concern is picking a candidate who can beat Donald Trump in November. You also want a humane immigration policy, health care that’s affordable to everyone and action on climate change.
It’s not asking a lot, but you’re a moderate and have moderate dreams.
Your candidate should be Sen. Bernie Sanders.
I know. He’s the most radical member of the 12-candidate field. But you may have to learn to love a 77-year-old, Sandinista-supporting, democratic socialist from the electorally irrelevant state of Vermont.
That’s because Joe Biden, the logical safe choice for risk-averse voters, is not seeming like a very safe bet right now.
The former vice president is still leading in most polls, but not by much. His debate performances have been unsteady, and that’s being generous. If you wonder how he’ll hold up to six months of questions about what his son Hunter was doing in a Ukrainian corporate boardroom while his dad was vice president, check out Biden’s answer to  a retired farmer in Iowa last month. Biden called the guy a liar and challenged him to a pushup contest.
This could go very badly.
But there are so many other candidates in the race – why Sanders?
It has to do with your top concern: beating Trump. Sanders’ advantage is that he talks to people who don’t always vote.
If you had been watching the Democratic debates last year, you would see candidates struggling to boil their 12-point plans into digestible sound bites.
Sanders doesn’t get dragged down into the details. He makes his case with a few blunt assertions illustrated with hand gestures, which you don’t need a college diploma and a subscription to The Atlantic to understand.
Health care for all would be funded by taxes, like they do in every other country in the developed world.  The same goes for free tuition in public colleges and universities. Workers deserve a minimum wage that you could live on. Simple.
Sanders isn’t the only candidate who is talking about major changes that would help millions of people stuck in an economy that works best for the wealthy. But he does it without apology, leaving little room to wonder what he’s really up to.
But you’re a moderate. You are comfortable with nuance.
You may have to leave your comfort zone if you want to beat Trump.
Biden has strong support from older voters, the kind of people you can count on to show up on Election Day, but that’s the point. Those people will be showing up anyway. It’s the less-reliable voters you need on board, and they may not turn out for Joe.
Biden also has strong support from African-American voters, according to the polls. But so did Hillary Clinton.
Sanders is especially strong with young voters (of all races), exactly the kind of people who stay home or vote for a third-party candidate when they don’t like the nominee. The danger of going too safe would be alienating them.
Is Sanders’ program too radical for moderates? Not if they are paying attention.
You have to remember that the legislative process is basically broken. A President Sanders would not be able to pass his “Medicare for All” bill as written, even if the Democrats retook the Senate this year. Sanders can say he wants to tear the system down, but the only kind of change that we are likely to see in the near term is the incremental kind that moderates say they want. The political revolution Sanders says would be needed to achieve his ultimate goals would take a series of election victories, not just one.
In the meantime, a president committed to humane immigration policy, universal health care and an adequate response to climate change could achieve a lot. He could also keep us out of a war.
The theory of Sanders’ electability will be put to the test soon. If infrequent voters don’t show up to support him in the early state primaries, he can’t claim he has the ability to motivate them.
But if they do turn out for Sanders, center-left Democrats may have to do what they told progressives to do four years ago: Swallow hard and fall in behind a candidate well outside their comfort zone.

The health-care industry is letting surgeons behave like muggers 


Commentary: Cancer isn’t the only thing that’s killing Americans

Big drops in cancer mortality rates are worth celebrating, but they stand in sharp contrast with many persistent and worrisome health trends.