Monday, September 28, 2020

Health Care Reform Articles - September 28, 2020

Editor's Note -

Some may wonder why I've included the following short article by Jeffrey Toobin in a health care blog.  It's because the problem of health care reform and the resistance to meaningful reform of a system so badly in need of it is only the poster child for a much more widespread problem - one that Toobin clearly describes very well.  Read on!


 There Should Be No Doubt Why Trump Nominated Amy Coney Barrett

by Jeffrey Toobin - The New Yorker - September 26, 2020

Amy Coney Barrett, whom President Trump has nominated to replace Ruth Bader Ginsburg on the Supreme Court, was born in 1972, so she can expect to spend several decades shaping both American law and American life. As it happens, a year before Barrett’s birth, Lewis F. Powell, Jr., then a prominent lawyer in Richmond, Virginia, and later a Supreme Court Justice himself, wrote a now famous memorandum to the United States Chamber of Commerce, arguing that businesses needed to take a more aggressive hand in shaping public policy. “The American economic system is under broad attack,” he wrote, from, specifically, the consumer, environmental, and labor movements. He added that “the campus is the single most dynamic source” of that attack. To counter it, Powell suggested that business interests should make a major financial commitment to shaping universities, so that the “bright young men” of tomorrow would hear messages of support for the free-enterprise system. A little less than a decade later, a pair of law professors named Robert Bork and Antonin Scalia signed on as the first faculty advisers to a fledgling organization for conservative law students called the Federalist Society for Law and Public Policy Studies. The efforts of the Federalist Society were lavishly funded by the business interests invoked by Powell, and it has trained a generation or two of future leaders. Not all of them have been “bright young men.” Some are women, including Barrett, and her confirmation would vindicate Powell’s plan and transform the Supreme Court.

Barrett made an appealing first impression in 2017, during her confirmation hearings to the federal bench. She and her husband are the parents of seven children. For many years, she was a popular professor at Notre Dame Law School, which she also attended and from which she graduated summa cum laude. She clerked on the Supreme Court for Justice Scalia. As a judge on the Seventh Circuit, she has been a reliable conservative voice. Even liberal peers in the academy find her personable. She will probably do well in providing the artful non-answers that are the currency of Supreme Court confirmation hearings before the Senate Judiciary Committee, just as she did in 2017.

But there should be no doubt about why Barrett has been chosen. Much of the commentary about her selection will focus on the issue of abortion, and her likely role in overturning Roe v. Wade. During the 2016 campaign, Trump repeatedly promised to appoint Justices who would vote to overrule that landmark, and with his three selections, including Neil Gorsuch and Brett Kavanaugh, he appears to have delivered. Barrett is not only a member of a conservative organization within the Catholic Church; her legal writings, and the views of some who know her, suggest that she would overturn Roe.

Still, it’s worth remembering the real priorities of Trump and Mitch McConnell, the Senate Majority Leader, in this nomination. They’re happy to accommodate the anti-abortion base of the Republican Party, but an animating passion of McConnell’s career has been the deregulation of political campaigns. The Supreme Court’s Citizens United decision brought the issue to wide public attention, but McConnell has been crusading about it for decades. He wants the money spigot kept open, so that he can protect his Senate majority and the causes for which it stands. This, too, is why the Federalist Society has been so lavishly funded over the years, and why it has expanded from a mere campus organization into a national behemoth for lawyers and students. Under Republican Presidents, Federalist Society events have come to operate as auditions for judicial appointments. The corporate interests funding the growth of the Federalist Society probably weren’t especially interested in abortion, but they were almost certainly committed to crippling the regulatory state.

Barrett is a product of this movement, and not just because she clerked for Scalia. Her writings and early rulings reflect it. Her financial-disclosure form shows that, in recent years, she has received about seven thousand dollars in honoraria from the Federalist Society and went on ten trips funded by it. But it’s not as if Barrett was bought; she was already sold. The judge has described herself as a “textualist” and an “originalist”—the same words of legal jargon that were associated with Scalia. (She believes in relying on the specific meaning of the words in statutes, not on legislators’ intent. She interprets the Constitution according to her belief in what the words meant when the document was ratified, not what the words mean now.) But these words are abstractions. In the real world, they operate as an agenda to crush labor unions, curtail environmental regulation, constrain the voting rights of minorities, limit government support for health care, and free the wealthy to buy political influence.

It should go without saying that the nomination and the expected confirmation of Barrett in the final days before a Presidential election represent a paramount act of hypocrisy for McConnell and the other Republicans who denied even a hearing to Merrick Garland, President Barack Obama’s choice for the Supreme Court, in 2016. But the fact that these Republicans are willing to risk that charge shows how important the Supreme Court is to them. Far more than a senator, a Supreme Court Justice can deliver on the agenda. The war on abortion is just the start.

Editor's Note -

I have sometimes been criticized for comparing the American healthcare system to a large and very successful extortion racket. Let me know whether or not you agree with that comparison after reading the following article from today's NYT.



Some Workers Face Looming Cutoffs in Health Insurance

by Reed Abelson - NYT - September 28, 2020

Jeremy Fritz stopped working as an assistant manager for a fitness center in Carlsbad, Calif., during the pandemic lockdown in the spring when gyms were first closed.

By the end of April, the company operating the fitness center, Active Wellness, eliminated his health insurance. And in July, he was laid off when it became clear the center where he worked would be closed through 2020. Most of the small company’s gyms are still shuttered.

Losing coverage in the middle of the coronavirus crisis, as millions of other Americans have, was like “going into this thunderstorm without an umbrella,” Mr. Fritz recalled. Active Wellness put him in touch with an insurance broker, which helped him and his husband sign up for a plan under the Affordable Care Act.

For people like Mr. Fritz, as well as those who qualify for Medicaid under the law, “there is still a safety net that wasn’t there 10 years ago,” said Sara R. Collins, a vice president at the Commonwealth Fund.

But that net is already fraying, with thousands of small businesses that had always expressed difficulty in providing employee health insurance under Obamacare now in far worse trouble because of the pandemic.

Hopes have also dimmed for another federal aid package before the presidential election.

Not only are businesses shedding workers, with the nation’s unemployed numbering roughly 13.6 million, but employers are also cutting expenses like health coverage, and projections of rising numbers of uninsured have grown bleak.

Tens of millions of people could lose their job-based insurance by the end of the year, said Stan Dorn, the director of the National Center for Coverage Innovation at Families USA, the Washington, D.C., consumer group. “The odds are we are on track to have the largest coverage losses in our history,” he said.

While estimates vary, a recent Urban Institute analysis of census data says at least three million Americans have already lost job-based coverage, and a separate analysis from Avalere Health predicts some 12 million will lose it by the end of this year. Both studies highlight the disproportionate effect on Black and Hispanic workers.

“There is this expectation that we are going to see big losses in employer-based coverage,” Ms. Collins said.

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Many businesses have tried to keep their workers insured during the pandemic. Employers relied on government aid, including the Paycheck Protection Program authorized by Congress to ease the economic fallout, to pay for premiums through the spring and summer.

Government funding appears to have “prevented the economic crisis from becoming a coverage crisis right away,” said Leemore S. Dafny, a professor at Harvard Business School and one of the authors of a report last month looking at the pandemic’s effect on small business.

Describing those employers as “the proverbial canary in the coal mine,” the researchers say there could be significant coverage losses if insurers and lawmakers fail to act in the coming months. Nearly a third of small businesses surveyed in late June said they were not sure they could keep paying premiums beyond August, according to the report.

“We will probably really start to see it during renewal time, November and December,” said Mark Hall, the director of health law and policy at Wake Forest University. “That will be when the money really dries up.”

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For many of these companies, insuring their workers has become increasingly difficult.

Aaron Seyedian closed his housecleaning business, Well-Paid Maids in Washington, D.C., for four and a half months before reopening in early August. Even when his employees weren’t working, he paid $5,000 a month toward their health insurance, including vision and dental. “I didn’t think the right thing to do was to kick my employees off the plan during a pandemic,” he said.

He used some federal aid to cover those expenses, but he still owes nearly $14,000 in back premiums to the company’s insurer, CareFirst. He had been given a small discount off one month’s premiums.

The District of Columbia’s insurance department, and some states, have provided some relief to businesses in situations like Mr. Seyedian’s. It permits them to defer missed payments for up to a year during the coronavirus public health emergency. “I don’t know how we’re going to pay them next summer,” he said of back premiums.

Health insurers, whose profits have soared as people stayed away from hospitals and doctors, have been stingy in offering businesses much in the way of breaks, according to the Harvard report. Just 14 percent of the companies said they received premium credits or a longer grace period.

The insurance companies insist they are providing refunds to their customers, but some business owners say they have had more luck with their landlords or the electric company than their health insurer. “When I contacted our insurance agencies, you can negotiate a lot, but you really can’t negotiate health insurance,” said Gary Novotny, who owns Gary Michaels Clothiers in Lincoln, Neb., a small retailer whose sales are down by about half. “No matter what it costs, you have to have it.”

The first check Neil Abramson wrote after receiving his federal loan was to his local Blue Cross plan. Although he furloughed the people working at his group of consignment stores in Leominster, Mass., he continued their insurance.

“You don’t need not to have your health insurance in the middle of the pandemic,” he said, describing his employees as like family. “Are you going to tell your sister that you are going to cancel your insurance because you don’t have the money?”

Small businesses are traditionally the least able to afford health benefits for their employees. While nearly all large companies offer insurance to their employees, only 56 percent of firms with fewer than 200 employees provide coverage, according to the most recent survey by the Kaiser Family Foundation.

“Health insurance is an enormous cost for small businesses,” said Amanda Ballantyne, the executive director of the Main Street Alliance, an advocacy group for small businesses. “It continues to be even after the passage of the Affordable Care Act.”

Many businesses say they need Congress to provide more money, and health insurers say they support federal efforts to help employers continue their coverage. “We believe Congress should provide temporary subsidies or direct financial assistance for employers to protect the health and financial stability of hard-working Americans,” said Justine Handelman, a senior vice president at the Blue Cross Blue Shield Association, which represents the nation’s Blue Cross plans.

Under the Affordable Care Act, insurers must return the excess profits if they do not spend at least 80 or 85 cents out of every dollar in premiums on customers’ health care. But even that provision strikes some as inadequate, given the current circumstances and the timing of the potential rebates.

“We are in the middle of a once-in-a-century health and economic crisis, and it will take everyone stepping up to do their part to get us past it — including health insurance companies,” said Representative Lauren Underwood, a Democrat from Illinois.

Dave Piersall, the owner of Lake Marine & RV, a boating business in Woodstock, Ill., used some of his federal aid on the $7,400-a-month insurance bill to cover his employees. “We came within inches of being canceled,” he said.

Although his business has rebounded as people have bought boats to help them cope with staying home, he worries about the coming cold weather. “I would be lying if I didn’t say winter is a scary time for the boat business,” Mr. Piersall said. “The health care is the biggest concern.”

And as hard as he is trying to maintain insurance for everyone, he is also concerned about efforts to do away with Obamacare. He was uninsured for a year and a half after leaving a corporate job to start the business before he could enroll in an A.C.A. plan that covered his Crohn’s disease.

“They’re fighting to go back in time,” he said, adding that he and his wife could lose coverage if companies were no longer required to cover pre-existing conditions. “It’s a great fear,” he said.

Without Ginsburg, Supreme Court Could Rule Three Ways on Obamacare

Why the Affordable Care Act may still be safe.

By Sarah Kliff and - NYT -  September 22, 2020

The death of Justice Ruth Bader Ginsburg means the Supreme Court will have a smaller liberal wing when it hears the latest Obamacare challenge in November.

That case, California v. Texas, could unwind Obamacare completely if the Supreme Court rules in favor of 20 Republican-led states and the Trump administration’s Justice Department. The Democratic nominee for president, Joseph R. Biden Jr., has already begun linking the court vacancy to Obamacare’s future, telling a crowd in Philadelphia this weekend that “health care hangs in the balance” with this year’s election. A more conservative court may invite further litigation against the health law, which has faced multiple Supreme Court challenges in its decade-long existence.

Those who have followed the case for years, however, do not expect the Affordable Care Act to be overturned with this case. “Replacing Ginsburg could have big effects in lots of areas,” said Jonathan Adler, a law professor at Case Western Reserve University. “I’m just not sure this case is one of them.”

The case centers on changes that Congress made to the health law as part of its 2017 tax bill. That law eliminated financial penalties associated with Obamacare’s mandate that Americans obtain health insurance.

The plaintiffs argue that the mandate becomes unconstitutional without those fines and that, if the court agrees, the rest of the law must come down with it. In legal terms, they make the case that the mandate is “inseverable” — so crucial to Obamacare that the law, including a provision banning insurers from rejecting patients with pre-existing conditions, cannot stand without it.

When experts make their best guesses on California v. Texas, they see three possible outcomes: a ruling in the law’s favor, a deadlocked vote or a decision that takes down Obamacare. The first two generally seem more likely than the third.

Just because many Republican-led states and the Republican White House have brought this case does not mean that Republican-appointed justices on the court will take their side. A majority of the court may still uphold the A.C.A.

That’s because many scholars see the case as legally weak. Unlike the two previous cases involving the health law — when the court’s liberal and conservative justices tended to disagree on major legal issues — this case centers on areas of law that are less disputed and less ideological.

A majority of the justices could rule that the mandate, now lacking a penalty, is unconstitutional. But, alone, such a finding would have no practical effects. What matters more is what happens to the rest of the law if the mandate is overturned.

Chief Justice John Roberts and Justice Samuel Alito have ruled in several recent cases that courts should try to preserve existing laws as much as possible when eliminating problematic provisions. And Justice Brett Kavanaugh wrote a majority opinion this term — while the Texas case was pending — agreeing with such reasoning.

“The court presumes that an unconstitutional provision in a law is severable from the remainder of the law or statute,” Justice Kavanaugh wrote in the majority opinion upholding a congressional ban on robocalls. (He was joined by Justice Alito and Chief Justice Roberts.)

His opinion says the court’s duty should be “to salvage rather than destroy the rest of the law passed by Congress and signed by the president.”

Mr. Adler is one of many legal scholars who supported earlier legal efforts to overturn the Affordable Care Act but who have sided with the law’s defenders on this case. In considering possible outcomes, he said he would not rule out a unanimous decision upholding the law.

The Supreme Court is scheduled to hear oral arguments in California v. Texas on Nov. 10. If a new justice is not confirmed and seated by then, the case will be decided by the remaining eight members. A ninth justice who joined the court after oral arguments but before a decision would still not cast a vote.

An eight-member court raises the possibility that California v. Texas could end in a tie at the Supreme Court. When that happens, the appellate court’s decision typically stands. But in this instance, the appellate court did not rule on the key issues in the case; it ruled instead to send the case back to the original trial judge in Texas for more analysis.

The group of Democratic states defending the health law rushed it to the Supreme Court anyway, arguing that the court could end the “uncertainty already caused by this litigation.” That means that a tie could lead to years of litigation as the case is re-argued, potentially resulting in another Supreme Court hearing years from now. The health care law would be left standing in the meantime, with the justices skirting a political controversy in the short term.

“The advantage is there is no opinion, just a one-sentence ruling saying the lower court is affirmed,” said Josh Blackman, a law professor at South Texas College of Law who has submitted an amicus brief on behalf of the challengers. “They don’t weigh the issues. You don’t know why they ruled the way that they ruled.”

Such a tie would most likely occur if Chief Justice Roberts sides with the court’s three Democratic appointees, and the other Republican-appointed justices vote the other way. Barring a recusal, a tie would not occur if a new justice were seated before November, bringing the number of justices back to nine. But there is a chance a majority of the justices simply affirm the appellate court’s ruling, sending the case back through the process again in the same way.

Though many legal observers predict Chief Justice Roberts will find against the Republican states, the Supreme Court was controlled by five Republican-appointed justices even before Justice Ginsburg’s death. That is why advocates for the Affordable Care Act and Democratic politicians have been concerned about this case all along.

“It is still unlikely to prevail, but the small chance of a very bad thing happening is worth worrying about,” said Nicholas Bagley, a law professor at the University of Michigan, who supports Obamacare.

There are a few different ways such a decision might work. Texas and the Trump administration have asked the court to overturn the entire Affordable Care Act. The Supreme Court could make such a ruling. But it’s also possible the court will rule to overturn some parts of the health law while leaving others untouched. Early in the litigation, the Trump administration’s lawyers suggested leaving most of Obamacare intact, but eliminating the provisions providing protections for Americans with pre-existing health conditions, for example.

Any such ruling would have major practical and political effects. The Affordable Care Act is a complex law with tentacles across nearly every area of health policy — including state Medicaid funding; Medicare beneficiaries’ drug costs; and F.D.A. approvals for generic-like copies of biologic drugs.

But even a ruling that only touched pre-existing conditions would have huge effects, especially during a pandemic when so many Americans have lost their job-based insurance.

That resulting chaos may also weigh on the justices. Amy Howe, a co-founder of Scotusblog, said a group of justices that includes Chief Justice Roberts and Justice Kavanaugh are concerned about the reputation of the Supreme Court as an institution.

“This is happening in such a fraught time, right after Election Day,” she said. “I do think the politics of the moment are not even at the back of their minds, but in the middle of their minds.”

If the court did amend Obamacare, the government could pass new legislation to restore coverage options, and any new policy would most likely take different forms depending on who controls the White House and Congress. Mr. Biden supports creating a public option — more people could get government insurance, but only if they want it — while the Trump administration has repeatedly promoted a “wonderful plan” for health care while releasing no details.

A less ambitious Congress interested in preserving the health law could also resurrect it by restoring a penalty for people who don’t buy insurance — even one as low as $1. 


If the Supreme Court Ends Obamacare, Here’s What It Would Mean

The Affordable Care Act touches the lives of most Americans, and its abolition could have a significant effect on many millions more people than those who get their health coverage through it.

By Reed Abelson and - NYT - September 21, 2020

What would happen if the Supreme Court struck down the Affordable Care Act?

The fate of the sprawling, decade-old health law known as Obamacare was already in question, with the high court expected to hear arguments a week after the presidential election in the latest case seeking to overturn it. But now, the death of Justice Ruth Bader Ginsburg increases the possibility that the court could abolish it, even as millions of people are losing job-based health coverage during the coronavirus pandemic.

A federal judge in Texas invalidated the entire law in 2018. The Trump administration, which had initially supported eliminating only some parts of the law, then changed its position and agreed with the judge’s ruling. Earlier this year the Supreme Court agreed to take the case.

Mr. Trump has vowed to replace Justice Ginsburg, a stalwart defender of the law, before the election. If he is successful in placing a sixth conservative on the court, its new composition could provide the necessary five votes to uphold the Texas decision.

Many millions more people would be affected by such a ruling than those who rely on the law for health insurance. Its many provisions touch the lives of most Americans, from nursing mothers to people who eat at chain restaurants.

Here are some potential consequences, based on estimates by various groups.

As many as 133 million Americans — roughly half the population under the age of 65 have pre-existing medical conditions that could disqualify them from buying a health insurance policy or cause them to pay significantly higher premiums if the health law were overturned, according to a government analysis done in 2017. An existing medical condition includes such common ailments as high blood pressure or asthma, any of which could require those buying insurance on their own to pay much more for a policy, if they could get one at all.

The coronavirus, which has infected nearly seven million Americans to date and may have long-term health implications for many of those who become ill, could also become one of the many medical histories that would make it challenging for someone to find insurance.

Under the A.C.A., no one can be denied coverage under any circumstance, and insurance companies cannot retroactively cancel a policy unless they find evidence of fraud. The Kaiser Family Foundation estimated that 54 million people have conditions serious enough that insurers would outright deny them coverage if the A.C.A. were not in effect, according to an analysis it did in 2019. Its estimates are based on the guidelines insurers had in place about whom to cover before the law was enacted.

Most Americans would still be able to get coverage under a plan provided by an employer or under a federal program, as they did before the law was passed, but protections for pre-existing conditions are particularly important during an economic downturn or to those who want to start their own businesses or retire early. Before the A.C.A., employers would sometimes refuse to cover certain conditions. If the law went away, companies would have to decide if they would drop any of the conditions they are now required to cover.

The need to protect people with existing medical conditions from discrimination by insurers was a central theme in the 2018 midterm elections, and Democrats attributed much of their success in reclaiming control of the House of Representatives to voters’ desire to safeguard those protections. Mr. Trump and many Republicans promise to keep this provision of the law, but have not said how they would do that. Before the law, some individuals were sent to high-risk pools operated by states, but even that coverage was often inadequate.

Of the 23 million people who either buy health insurance through the marketplaces set up by the law (roughly 11 million) or receive coverage through the expansion of Medicaid (12 million), about 21 million are at serious risk of becoming uninsured if Obamacare is struck down. That includes more than nine million who receive federal subsidies.

On average, the subsidies cover $492 of a $576 monthly premium this year, according to a report from the Department of Health and Human Services. If the marketplaces and subsidies go away, a comprehensive health plan would become unaffordable for most of those people and many of them would become uninsured.

States could not possibly replace the full amount of federal subsidies with state funds.

Medicaid, the government insurance program for the poor that is jointly funded by the federal government and the states, has been the workhorse of Obamacare. If the health law were struck down, more than 12 million low-income adults who have gained Medicaid coverage through the law’s expansion of the program could lose it.

In all, according to the Urban Institute, enrollment in the program would drop by more than 15 million, including roughly three million children who got Medicaid or the Children’s Health Insurance Program when their parents signed up for coverage.

The law ensures that states will never have to pay more than 10 percent of costs for their expanded Medicaid population; few if any states would be able to pick up the remaining 90 percent to keep their programs going. Over all, the federal government’s tab was $66 billion last year, according to the Congressional Budget Office.

Losing free health insurance would, of course, also mean worse access to care and, quite possibly, worse health for the millions who would be affected. Among other things, studies have found that Medicaid expansion has led to better access to preventive screenings, medications and mental health services.

The health law took effect just as the opioid epidemic was spreading to all corners of the country, and health officials in many states say that one of its biggest benefits has been providing access to addiction treatment. It requires insurance companies to cover substance abuse treatment, and they could stop if the law were struck down.

The biggest group able to get access to addiction treatment under the law is adults who have gained Medicaid coverage. The Kaiser Family Foundation estimated that 40 percent of people from 18 to 65 with opioid addiction — roughly 800,000 — are on Medicaid, many or most of whom became eligible for it through the health law. Kaiser also found that in 2016, Americans with Medicaid coverage were twice as likely as those with no insurance to receive any treatment for addiction.

States with expanded Medicaid are spending much more on medications that treat opioid addiction than they used to. From 2013 through 2017, Medicaid spending on prescriptions for two medications that treat opioid addiction more than doubled: It reached $887 million, up from nearly $358 million in 2013, according to the Urban Institute.

The growing insured population in many states has also drawn more treatment providers, including methadone clinics, inpatient programs and primary care doctors who prescribe two other anti-craving medications, buprenorphine and naltrexone. These significant expansions of addiction care could shrink if the law were struck down, leaving a handful of federal grant programs as the main sources of funds.

The law protects many Americans from caps that insurers and employers once used to limit how much they had to pay out in coverage each year or over a lifetime. Among them are those who get coverage through an employer — more than 150 million before the pandemic caused widespread job loss — as well as roughly 15 million enrolled in Obamacare and other plans in the individual insurance market.

Before the A.C.A., people with conditions like cancer or hemophilia that were very expensive to treat often faced enormous out-of-pocket costs once their medical bills reached these caps.

While not all health coverage was capped, most companies had some sort of limit in place in 2009. A 2017 Brookings analysis estimated that 109 million people would face lifetime limits on their coverage without the health law, with some companies saying they would cover no more than $1 million in medical bills per employee. The vast majority of people never hit those limits, but some who did were forced into bankruptcy or went without treatment.

About 60 million people are covered under Medicare, the federal health insurance program for people 65 and older and people of all ages with disabilities. Even though the main aim of the A.C.A. was to overhaul the health insurance markets, the law “touches virtually every part of Medicare,” said Tricia Neuman, a senior vice president for the Kaiser Family Foundation, which did an analysis of the law’s repeal. Overturning the law would be “very disruptive,” she said.

If the A.C.A. is struck down, Medicare beneficiaries would have to pay more for preventive care, like a wellness visit or diabetes check, which are now free. They would also have to pay more toward their prescription drugs. About five million people faced the so-called Medicare doughnut hole, or coverage gap, in 2016, which the A.C.A. sought to eliminate. If the law were overturned, that coverage gap would widen again.

The law also made other changes, like cutting the amount the federal government paid hospitals and other providers as well as private Medicare Advantage plans. Undoing the cuts could increase the program’s overall costs by hundreds of millions of dollars, according to Ms. Neuman. Premiums under the program could go up as a result.

The A.C.A. was also responsible for promoting experiments into new ways of paying hospitals and doctors, creating vehicles like accountable care organizations to help hospitals, doctors and others to better coordinate patients’ care.

If the groups save Medicare money on the care they provide, they get to keep some of those savings. About 11 million people are now enrolled in these Medicare groups, and it is unclear what would happen to these experiments if the law were deemed unconstitutional. Some of Mr. Trump’s initiatives, like the efforts to lower drug prices, would also be hindered without the federal authority established under the A.C.A.

Repealing the law would also eliminate a 0.9 percent increase in the payroll tax for high earners, which would mean less money coming into the Medicare trust fund. The fund is already heading toward insolvency — partly because other taxes created by the law that had provided revenue for the fund have already been repealed — by 2024.

The A.C.A. required employers to cover their employees’ children under the age of 26, and it is one of the law’s most popular provisions. Roughly two million young adults are covered under a parent’s insurance plan, according to a 2016 government estimate. If the law were struck down, employers would have to decide if they would continue to offer the coverage. Dorian Smith, a partner at Mercer, a benefits consulting firm, predicted that many companies would most likely continue.

Doctors and hospitals could lose a crucial source of revenue, as more people lose insurance during an economic downturn. The Urban Institute estimated that nationwide, without the A.C.A., the cost of care for people who cannot pay for it could increase as much as $50.2 billion.

Hospitals and other medical providers, many of whom are already struggling financially because of the pandemic, would incur losses, as many now have higher revenues and reduced costs for uncompensated care in states that expanded Medicaid. A study in 2017 by the Commonwealth Fund found that for every dollar of uncompensated care costs those states had in 2013, the health law had erased 40 cents by 2015, or a total of $6.2 billion.

The health insurance industry would be upended by the elimination of A.C.A. requirements. Insurers in many markets could again deny coverage or charge higher premiums to people with pre-existing medical conditions, and they could charge women higher rates. States could still regulate insurance, but consumers would see more variation from state to state. Insurers would also probably see lower revenues and fewer members in the plans they operate in the individual market and for state Medicaid programs at a time when millions of people are losing their job-based coverage.

The A.C.A. requires nutrition labeling and calorie counts on menu items at chain restaurants.

It requires many employers to provide “reasonable break time” and a private space for nursing mothers to pump breast milk.

It created a pathway for federal approval of biosimilars, which are near-copies of biologic drugs, made from living cells.

These and other measures would have no legal mandate to continue if the A.C.A. is eliminated.


Beyond the Medicare Advantage Scam

by Kay Tillow - Daily Kos - September 20, 2020

In a television ad repeated incessantly, 60’s quarterback star Joe Namath reads his lines to promote the Medicare Coverage Helpline.  “Are you getting all the benefits you deserve?”  He ticks off the new benefits.  You may be able to lower your out of pocket costs and get extra benefit now, he says.

The ad announces that the Center for Medicare and Medicaid Services has officially authorized new benefits that Medicare Advantage Plans may include.  “One simple call gives you free, professional assistance to help you get more benefits and save money,” says Namath.  It sounds like a public service announcement from Medicare.  

But it isn’t.  It’s a pitch to sign up in the privatized, for-profit Medicare Advantage plans—and it’s a scam.  It is true that a person may be able to lower monthly costs by enrolling in one of these plans.  That’s a powerful incentive in a time when the majority of seniors live on tight budgets, many just an inch from disaster.  The laws and regulations allow these insurance companies to lure seniors away from traditional Medicare, and Congresspersons of both parties should be held responsible.

Namath continues:   “And like you I’m at home staying safe, but I wanted to get this message out.  To make these uncertain times easier and safer while at home, Medicare Advantage plans have added new benefits including telephone appointments with your doctors, in home aides, home delivered meals, home delivered prescriptions, and so much more.”

He makes it seem to be a new opportunity provided by Medicare because of the corona virus that is keeping us homebound.

“But you don’t get all the benefits automatically, you need to enroll.  The easiest way to enroll is to call the Medicare Coverage Helpline.  It’s now more important than ever to make sure that your Medicare coverage is up to date,” says Namath.

It mimics a public service announcement—there are new benefits to help out in the pandemic but the benefits aren’t automatic, you have to enroll.  That doesn’t sound like you are abandoning your traditional Medicare plan and allowing Medicare to give an annual sum to the for-profit insurance company that has now taken you into its scheme.  But once you sign up, you’ve been had.  

You may be okay for a time and save money monthly – as long as you don’t get sick.  Once you need to use the plan, you will discover the problems that come from being in a for-profit plan that makes more when it denies you care.  Your choice of physicians will be restricted to a list.  The specialist you need may not be anywhere near where you live.  The hospitals and rehabs centers will be limited.   The post-hospitalization facility available to you is likely to be the one with the worst reputation.  The drugs you need may now cost a fortune.  

Tom Mills of San Diego  was in one of these Medicare Advantage plans.  Following a mitral valve repair and a mild stroke, his plan began to charge him hundreds of dollars in monthly copays for drugs and other services.  He had to pay $295 a night for a hospital stay.

Then he learned the even worse news.  If he tries to escape these exorbitant costs by returning to traditional Medicare and a prescription plan, he will need a supplemental Medigap plan to handle the 20% copays and deductibles.   But he now has a pre-existing condition.  A broker for health insurance told Mills that no supplemental plan would cover him and that applying would be a waste of time.

Namath didn’t mention that in the ad.  

When seniors first sign up for a Medicare plan, they are protected by law against discrimination for pre-existing conditions in the purchase of a Medigap plan.  But when a person tries to change back to traditional Medicare later, that protection is gone.   Only four states have regulations to prohibit such practices.

Mr. Mills no longer saves that monthly sum on his Medicare Advantage plan;  he pays extra.

The Medicare Advantage Plans are smiling all the way to the bank.  In 2019 each Medicare Advantage beneficiary cost taxpayers $11,822 while those in original Medicare cost $10,813 each—that’s over $1,000 more and over 9% more per person for the for-profit insurers! 

The Center for Medicare and Medicaid Services estimates that the Medicare Advantage insurers will be overpaid by $200 billion over the next decade.  

Despite the problems of purchasing a Medigap plan, the negative experiences that Medicare Advantage patients encounter once they get sick induce many to return to traditional Medicare.  It all works so well for the insurance companies!  While the patient is healthy with few expenses, the company rakes in the money.  Once the patient becomes ill and needs more care, many patients, facing massive expenses, will return to original Medicare.  Now the extra expenses of a sicker patient will fall on the public once again.

That’s the way this for-profit system functions.  The poor, the disabled, the sick and the elderly are covered under the public programs, Medicaid and Medicare, leaving the healthy, vibrant families to the private insurers who profit from the lower costs of care for the healthy.

Not only do these Medicare Advantage Insurance companies profit at the public trough, they use the seniors who are signed up in their plans to lobby Congress to continue with these rip-offs.  America’s Health Insurance Plans (AHIP), the organization of health insurance companies, keeps the deceptions going by telling seniors to let their Congressperson know that their Medicare plan is in jeopardy.  All legislative efforts to reduce the massive ill-gotten gains of these companies are defeated by AHIP’s shrewd use of the popular “protect Medicare” sentiment to ward off any reform of the Medicare Advantage plans.

In 2019 368 members of Congress, a solid majority, signed the letter in favor of Medicare Advantage plans. AHIP thanked Congress for the overwhelming support. 

The Senate letter includes 66 signatures and the House letter over 300, including many who ought to know better.

The insurance industry manipulates our democracy.

That’s just the beginning of the shameful marketing of Medicare Advantage plans.  The Joe Namath ad for the Medicare Coverage Helpline includes some tiny print that no one could possibly read on the television.  The fine print of the ad says “The Medicare Coverage Helpline is a private for-profit lead generation campaign and does not offer insurance and is not an insurance agency or broker.  Your call is sold to a licensed insurance agent….”

The ad also states that Medicare Coverage Helpline…(and others) are all service marks or trademarks owned by TogetherHealth PAP, LLC.”  In June of 2019, TogetherHealth was acquired by Health Insurance Innovations, a company that is facing at least two class-action lawsuits over its alleged role in a health insurance scam that bilked millions of dollars from consumers and that the FTC shut down last fall, reported Truth in Advertising.

Now the Medicare Payment Advisory Commission (MedPAC) announces that Medicare is spending more than planned during the pandemic and that funds will run short by 2024.  There is a solution to all of this.  A well-designed national single payer plan, an Improved Medicare for All, would boot the Medicare Advantage cheats, solve Medicare’s funding future, and cover everyone, not just the elderly, for all medically necessary care.  

Such a plan has been set forth by Physicians for a National Health Program.

The plan removes the profits from the system, allowing our wealth to instead expand care to all, ending forever the for-profit scams and the denial of care because of inability to pay.

Voting G.O.P. Means Voting Against Health Care

The death of Ruth Bader Ginsburg has only raised the stakes.

by paul Krugman - NYT - September 21, 2020

If you or someone you care about is among the more than 50 million Americans suffering from pre-existing medical conditions, you should be aware that the stakes in this year’s election go beyond abstract things like, say, the survival of American democracy. They’re also personal. If Donald Trump is re-elected, you will lose the protection you’ve had since the Affordable Care Act went into effect almost seven years ago.

The death of Ruth Bader Ginsburg has made this even more obvious. In fact, it’s now possible that coverage of pre-existing conditions will be stripped away even if Trump loses to Joe Biden, unless Democrats also take the Senate and are prepared to play serious hardball. But health care was always on the line.

Now, Trump denies this; like almost every other politician in his party, he keeps insisting that he has a plan to protect Americans with pre-existing conditions. But he and they are lying. And no, that’s not too strong a term.

On Trump: In early August he promised that he would soon release a great health care plan to replace Obamacare, probably by the end of the month. We’ve heard nothing since, which isn’t surprising, since he has made and broken similar promises many times.

It’s safe to assume that there was never any basis for these promises; there is not now and has never been a secret skunk works in the executive branch devising a brilliant new health plan.

Paul Krugman’s Newsletter: Get a better understanding of the economy — and an even deeper look at what’s on Paul’s mind.

Among other things, Trump administration officials have been too busy botching their response to the coronavirus. Did I mention that, as we pass the 200,000 deaths mark, cases appear to be rising again?

But we would know that Republicans are lying about pre-existing conditions even if Trump hadn’t established such a remarkable record of serial dishonesty. For the fundamental logic of health policy says that if you want to protect pre-existing conditions, you either have to have the government provide health insurance directly, as it does with Medicare and Medicaid, or use a combination of strict regulation and subsidies to induce private insurers to offer coverage.

And if you do try to rely on private insurers, the necessary system of regulation and subsidies will, inevitably, look a lot like Obamacare.

To protect people with pre-existing conditions, you must prevent insurers from discriminating based on medical history — which includes imposing minimum standards, so that they can’t offer cheap, minimalist plans that appeal only to the healthy while charging exorbitant premiums on plans that help those who really need care.

You also need to induce healthy people to sign up for coverage, which means providing financial incentives to do so — especially generous subsidies to working-class adults.

In other words, you need a system very similar to the one America has had since 2014, when the Affordable Care Act went fully into effect. That system can and should be made better, but this would require spending more, not less — which is, in fact, what Biden is proposing.

None of this is news. The G.O.P.’s inability to come up with a superior alternative to Obamacare was put on stark display in 2017, when Republicans came very close to enacting their own health care plan.

At the time, the Congressional Budget Office estimated that the legislation would cause 32 million Americans to lose health insurance — and even that number understated the likely damage, because those still buying insurance would have faced sharply higher premiums.

How does Ginsburg’s death affect the health care outlook? The Trump administration is backing a lawsuit, now before the Supreme Court, claiming that a fairly minor provision in the 2017 tax cut somehow rendered the whole Affordable Care Act unconstitutional. It’s a ludicrous argument — but Republican judges in lower courts have backed it anyway, and a court without Ginsburg is more likely to let partisanship override any pretense of respect for logic.

The odds that the court will destroy Obamacare, and with it protection for pre-existing conditions, will obviously go up if Trump is able to install a right-wing partisan to replace Ginsburg. And even if this particular attempt to take away health insurance from millions falls short, it’s a safe bet that a court with a 6-3 conservative majority will find some excuse to undermine the protections Americans have come to count on.

Indeed, such a court might well try to strike down Obamacare even if Trump loses.

So are Americans with pre-existing conditions doomed? Not if Democrats take the Senate as well as the White House. If they do that, they’ll be in a position to quickly reinstate an improved version of Obamacare soon after Biden is sworn in.

And yes, adding seats to the court will have to be on the table. Spare me talk about norms. Between Trump’s lawlessness and Mitch McConnell’s naked power plays, Republicans have forfeited any right to complain if Democrats legally act to protect the well-being of millions of Americans.

So once again, if you or someone you care about has a pre-existing condition, be aware that your fate is very much on the ballot this year.


Trump Says He Will ‘Always’ Protect Those With Pre-Existing Conditions. He Hasn’t.

The president’s promises on health care stand in stark contrast with his legislative, regulatory and legal record.

by Margot Sanger-Katz - NYT - September 24, 2020

In speeches, in tweets, in media interviews, President Trump keeps promising that he will preserve protections for Americans with pre-existing health conditions. It’s a crowd-pleaser of a policy, but one entirely at odds with his administration’s legislative, regulatory and legal record to date.

In the final weeks of the election season, expect to see the words “pre-existing conditions” again and again. Mr. Trump makes the promise so consistently that it is likely to appear in television ads, the presidential debates and possibly in an oft-teased, ever forthcoming executive order on the subject. Vice President Pence said Tuesday that the president would “take action” in the days ahead.

But rather than enshrine the ability of Americans with health problems to buy insurance, the Trump administration has, at every turn, pursued policies that have tended to do the opposite.

Some of the efforts to weaken protections have been successful — like an expansion of cheap, lightly regulated health plans that insurers are not required to offer when customers are sick. Others, like multiple attempts to “repeal and replace Obamacare” in 2017, failed to attract enough Republican votes in Congress to pass. The Justice Department’s quest to overturn the Affordable Care Act, while no replacement is being offered, is still underway, with oral arguments scheduled at the Supreme Court in November.

“We will always and very strongly protect patients with pre-existing conditions,” Mr. Trump said in his speech at the Republican National Convention. “We will protect your pre-existing conditions,” he said at a recent campaign rally in Las Vegas. In January, he went as far as to say he “saved pre-existing conditions.”

Yet despite a record to the contrary, these repeated statements seem to be having an impact. A recent survey from the Kaiser Family Foundation found that 84 percent of Republicans believe President Trump has a better approach for “maintaining protections for people with pre-existing conditions.” (Over all, 38 percent of American adults said they thought Mr. Trump had the better approach.)

Before Obamacare, Americans with a history of both serious and trivial diseases had trouble buying health insurance. Health plans could omit coverage for addiction, could charge customers higher prices because of a history of acne, or could simply decline to sell insurance altogether to someone who’d had a cancer diagnosis. All of those practices were eliminated as part of Obamacare, which requires insurance companies to offer the same, comprehensive health plans to everyone in a geographic area, varying the prices based only on the customer’s age.

This provision has long been one of the Affordable Care Act’s most popular features. Even when a majority of Americans disliked the law over all, most supported this part of it. Over time, as Obamacare has become more popular and more embattled, pre-existing-condition protections have become so popular that any politician who declines to support them is likely to pay a political price. In 2018, Democrats retook control of the House of Representatives, after campaigning heavily on pre-existing conditions as an issue.

“I think it’s gotten to the point where every politician has to say they’re for protecting people with pre-existing conditions,” said Larry Levitt, the executive vice president for health policy at the Kaiser Family Foundation. “And then the question is: How far are they wiling to go in providing those protections?”

That popularity probably explains why President Trump keeps repeating the words “pre-existing conditions.” But saying that he will support these rules doesn’t make it true. His policies to date have slightly weakened the Obamacare framework, providing some escape hatches where healthier customers can buy unregulated, cheaper insurance. Because Obamacare is also on the books, people with pre-existing conditions can buy plans, too. But President Trump has repeatedly pressed to eliminate the Affordable Care Act. The Justice Department filed a brief asking for the wholesale erasure of the law as recently as June.

“If there’s any merit in the president’s record on pre-existing conditions, it is purely by accident,” said Michael Cannon, the director of health care policy studies at the libertarian Cato Institution. Mr. Cannon, who favors a less regulated health insurance market, is no fan of Obamacare, but says that Mr. Trump has little to support his claims.

Defenders of the president’s health policies point to the ways he has worked to lower the cost of care and expand consumer choice. The skimpier plans his policy expanded did lower prices for Americans who are fortunate enough to qualify and want coverage with limited benefits, and they did expand the ability of people who bought them to keep them longer. His expansion of health reimbursement accounts may pave the way for people who currently get work-based coverage to select their own plans. His new rules expanding the transparency of hospital prices may come to lower those prices over time. Recent executive orders may lead the way to new policies regulating prescription drug prices.

But none of the president’s health policies have offered new consumer protections for the sick who seek health insurance.

Recent reports that the president will release an executive order to protect pre-existing conditions are puzzling, since such protections are already the law. If Obamacare were overturned, such an order would be toothless. Major new regulations of the health insurance industry would require legislation, which is why the Trump administration pursued Obamacare replacement in Congress in the first place.

The structure of the Affordable Care Act, of course, is not the only way to protect people with pre-existing conditions. Obamacare sets up one system with highly regulated private insurance markets and a system of federal tax credits to help low- and middle-income Americans buy insurance.

But other systems could also offer some level of protection for the sick. A single-payer system, like the “Medicare for all” plans championed by Senator Bernie Sanders and other progressives in Congress, would provide standardized government health insurance to Americans of all health histories. And there are other possible approaches that may appeal more to conservatives, such as well-funded high-risk pools, which would offer special coverage to the sick while keeping it affordable.

President Trump may have some other policy idea in mind to protect Americans with pre-existing health conditions. But there is no evidence from his record. Nearing four years into his presidential term, he has repeatedly promised to release a comprehensive health plan, then declined to do so. He and his staff are often asked about how he will fulfill this promise, and have offered no specific reply. If protecting pre-existing conditions is a priority of the president, it’s not clear why his strategy is still a secret.


Urban Hospitals of Last Resort Cling to Life in Time of COVID

Victor Coronado felt lightheaded one morning last month when he stood up to grab an iced tea. The right side of his body suddenly felt heavy. He heard himself slur his words. “That’s when I knew I was going to have a stroke,” he said.

Coronado was rushed to Mercy Hospital & Medical Center, the hospital nearest his home on Chicago’s South Side. Doctors there pumped medicine into his veins to break up the clot that had traveled to his brain.

Coronado may outlive the hospital that saved him. Founded 168 years ago as the city’s first hospital, Mercy survived the Great Chicago Fire of 1871 but is succumbing to modern economics, which have underfinanced the hospitals serving the poor. In July, the 412-bed hospital informed state regulators it planned to shutter all inpatient services as soon as February.

“If something else happens, who is to say if the responders can get my husband to the nearest hospital?” said Coronado’s wife, Sallie.

While rural hospitals have been closing at a quickening pace over the past two decades, a number of inner-city hospitals now face a similar fate. And experts fear that the economic damage inflicted by the COVID-19 pandemic on safety-net hospitals and the ailing finances of the cities and states that subsidize them are helping push some urban hospitals over the edge.

By the nature of their mission, safety-net hospitals, wherever they are, struggle because they treat a large share of patients who are uninsured — and can’t pay bills — or are covered by Medicaid, whose payments don’t cover costs. But metropolitan hospitals confront additional threats beyond what rural hospitals do. State-of-the-art hospitals in affluent city neighborhoods are luring more of the safety-net hospitals’ best-insured patients.

These combined financial pressures have been exacerbated by the pandemic at a time their role has become more important: Their core patients — the poor and people of color — have been disproportionately stricken by COVID-19 in metropolitan regions like Chicago.

“We’ve had three hospital closures in the last year or so, all of them Black neighborhoods,” said Dr. David Ansell, senior vice president for community health equity at Rush University Medical Center, a teaching hospital on Chicago’s West Side. He said the decision to close Mercy “is really criminal in my mind, because people will die as a result.”

Mercy is following the same lethal path as did two other hospitals with largely lower-income patient bases that shuttered last year: Hahnemann University Hospital in Philadelphia, and Providence Hospital in Washington, D.C., which ended its inpatient services. Washington’s only public hospital, United Medical Center — in the city’s poorest ward — is slated to close in 2023 as well, and some services are already curtailed.

Slow Death of Urban Safety Nets

So far, urban hospital closures have remained infrequent compared with the cascading disappearance of their rural counterparts. But the closing of a few could portend problems at others. Even some of those that remain open may cut back crucial specialties like labor and delivery services or trauma care, forcing patients to travel farther for help when minutes can matter.

Nancy Kane, an adjunct professor at Harvard T.H. Chan School of Public Health who has studied urban safety-net hospital changes since 2010, said that “some close, but most of them have tried to get into a bigger system and hang on for a few more years until management closes them.”

For much of the 20th century, most cities ran their own hospitals to care for the indigent. But after the creation of Medicare and Medicaid, and as the rising cost of health care became a burden for local budgets, many jurisdictions turned away from that model. Today only 498 of 5,230 general hospitals in the country are owned by governments or a public hospital district.

Instead, many hospitals in low-income urban neighborhoods are run by nonprofits — often faith-based — and in some cases, for-profit corporations. In recent years owners have unloaded safety-net hospitals to entities with limited patience for keeping them alive.

In 2018, the for-profit hospital chain Tenet Healthcare Corp. sold Hahnemann to Joel Freedman, a California private equity investor, for $170 million. A year later, Freedman filed for bankruptcy on the hospital, saying its losses were insurmountable, while separating its real estate, including the physical building, into another corporation, which could ease its sale to developers.

In 2018, Tenet sold another safety-net hospital, Westlake Hospital in Melrose Park, Illinois, a suburb west of Chicago, to a private investment company. Two weeks after the sale, the firm announced it would close the hospital, which ultimately led the owners to pay Melrose Park $1.5 million to settle a lawsuit alleging they had misled local officials by claiming before the sale they would keep it open.

Some government-run hospitals are also struggling to stay open. Hoping to stem losses, the District of Columbia outsourced management of United Medical Center to private consulting firms. But far from turning the hospital around, one firm was accused of misusing taxpayer funds, and it oversaw a string of serious patient safety incidents, including violations in its obstetrics ward so egregious that the district was forced to shut the ward down in 2017.

Earlier this year, the district struck a deal with Universal Health Services, a Fortune 500 company with 400 hospitals and $11 billion in revenues, to run a new hospital that would replace United, albeit with a third fewer beds. Universal also operates George Washington University Hospital in the city in partnership with George Washington University. That relationship has been contentious: Last year the university accused the company of diverting $100 million that should have stayed in the medical system. In June, a judge dismissed most of the university’s complaint.

No Saviors for Mercy

Chicago has three publicly owned hospitals, but much of the care for low-income patients falls on private safety-net hospitals like Mercy that are near their homes and have strong reputations. These hospitals have been sources of civic pride as well as major providers of jobs in neighborhoods that have few.

Fifty-five percent of Chicagoans living in poverty and 62% of its African American residents live within Mercy’s service area, according to Mercy’s 2019 community needs assessment, a federally mandated report. The neighborhoods served by Mercy are distinguished by higher rates of death from diabetes, cancer and stroke. Babies are more likely to be born early and at low weight or die in infancy. The nearest hospitals from Mercy can be 15 minutes or more away by car, and many residents don’t have cars.

“You’re going to have this big gap of about 7 miles where there’s no hospital,” Ansell said. “It creates a health care desert on the South Side.”

Dr. Maya Rolfe, who was a resident at Mercy until July, said the loss of the hospital’s labor and delivery department would cause substantial harm, especially since African American women suffer from a higher rate of maternal mortality than do white women. “Mercy serves a lot of high-risk women,” she said.

Mercy, a nonprofit, has been in financial trouble for a while. In 2012, it joined Trinity Health, a giant nonprofit Roman Catholic health system headquartered in Michigan with operations in 22 states. In the next seven years, Trinity invested $124 million in infrastructure improvements and $112 million in financial support.

During that time, the hospital continued to be battered by headwinds facing hospitals everywhere, including the migration of well-reimbursed surgeries and procedures to outpatient settings. Likewise, patients with private insurance, which provides higher reimbursements than government programs do, departed to Chicago’s better-capitalized university hospitals, including Rush, the University of Chicago Medical Center and Northwestern Memorial Hospital. Seventy-five percent of Mercy’s revenues come from government insurance programs Medicare and Medicaid.

Only 42% of its beds were occupied on average, according to the most recent state data, from 2018. Mercy told state regulators it is losing $4 million a month and required at least $100 million in additional building upgrades to operate safely.

Trinity said it spent more than a year shopping for a buyer. After that yielded no success, Mercy joined forces with three other struggling South Side hospitals to consolidate into a single health system planning to build one hospital and a handful of outpatient facilities to replace their antiquated buildings. They sought state financial help.

The plan would have cost $1.1 billion over a decade. At the close of the legislative session, Illinois lawmakers — already strapped for funding because of the economic effects of the pandemic — balked at the hospitals’ request for the state to cover half the cost. Lamont Robinson, a Democratic state representative whose district includes Mercy Hospital, said that was because the group did not declare where the new hospital would be built.

“We were all supportive of the merger but not with the lack of information,” Robinson said.

Mercy said in an email that the location would have been chosen after the hospital organizations combined and chose new leaders. Trinity said in a statement: “We are committed to continuing to serve the Mercy Chicago community through investment in additional ambulatory and community-based services that are driven by high-priority community needs.”

Blame for Mercy’s closure has been spread widely to include the city and state governments as well as Mercy’s owner. Trinity Health had $8.8 billion in cash and liquid investments at the end of March and until the pandemic hit had been running a slight profit. Earlier this year in Philadelphia, Trinity Health announced it would phase out inpatient services at another of its safety-net hospitals, Mercy Catholic Medical Center-Mercy Philadelphia Campus, a 157-bed hospital that has been around since 1918.

“People put their money where they want to,” said Rolfe, the former medical resident at Mercy in Chicago. Noting that the city has no qualms about spending large sums to beautify its downtown while other neighborhoods are in danger of losing a major institution, she said: “It shows to me that those patients are not that important as patients that exist in other communities.” 


After years of promising his own health care plan, Trump settles for rebranding rather than repealing Obamacare

By - Toluse Olorunnipa - Washington Post - September 24, 2020

President Trump capped his fruitless four-year journey to abolish and replace the Affordable Care Act by signing an executive order Thursday that aims to enshrine the law’s most popular feature while pivoting away from a broader effort to overhaul the nation’s health insurance system.

The order declares it is the policy of the United States for people with preexisting health conditions to be protected, avoiding the thorny details of how to ensure such protections without either leaving the ACA, or Obamacare, in place or crafting new comprehensive legislation.

Trump announced the move during a trip to North Carolina, outlining his “vision” for revamping parts of the nation’s health care. During the speech, which came shortly before a campaign swing to Florida, Trump barely veiled the political nature of his intent.

“The historic action I’m taking today includes the first-ever executive order to affirm it is the official policy of the United States government to protect patients with preexisting conditions,” Trump said, despite the fact such protections are already enshrined in law. “We’re making that official. We’re putting it down in a stamp, because our opponents, the Democrats, like to constantly talk about it.”

The speech and executive order stood as a tacit admission that Trump had failed to keep his 2016 promise to replace his predecessor’s signature achievement with a conservative alternative. For a president who campaigned in 2016 pledging to “repeal and replace” the ACA, Trump’s 2020 signature health-care speech instead expressed a willingness to keep the law largely in place. Unable to repeal the law, Trump appeared open to simply rebranding it.

“Obamacare is no longer Obamacare, as we worked on it and managed it very well,” Trump said of the law that continues to provide coverage for more than 20 million Americans. “What we have now is a much better plan. It is no longer Obamacare because we got rid of the worse part of it — the individual mandate.”

While Trump’s 2017 tax law did eliminate the requirement that virtually all Americans maintain insurance, the ACA remains in place with its expansion of Medicaid and insurance markets covering millions.

The failure to repeal and replace the ACA has not stopped Trump from repeatedly promising a soon-to-come health-care plan in a repetitive cycle of boastful pledges and missed deadlines that intensified in recent weeks ahead of the November election.

Trump’s speech and executive action Thursday constituted his most concrete effort yet to make good on those pledges by spelling out his health-care principles and criticizing his opponents.

“We’ve really become the health-care party — the Republican Party,” Trump said before reading a list of his accomplishments that pointedly did not include replacing the Affordable Care Act.

But even as other Republicans have tried to avoid the issue of health care — with some appearing to defend components of the ACA in political ads — Trump has continued to raise the subject and promise a soon-to-come comprehensive proposal.

Health care, long a top issue for voters, has taken on fresh urgency with less than five weeks to go before the November election.

The ongoing coronavirus pandemic has killed more than 200,000 Americans and caused millions to lose their jobs and health insurance. A pending Supreme Court case over the constitutionality of the ACA is set to be heard in November, and the death of justice Ruth Bader Ginsburg last week has raised the prospect that the law could be invalidated.

Trump said he supported the lawsuit but also claimed he would be fine maintaining the core of Obamacare “if we lose,” the first time he has openly expressed a willingness to abandon his original promise to “completely repeal” President Barack Obama’s most significant domestic achievement.

Democrats have been talking about health care constantly, while Republicans have largely steered clear of the issue, a phenomenon that tracks with public polling showing Americans trust the party responsible for passing the last major health-care legislation over the party that has tried to repeal it without offering an alternative.

Trump has sought to cut into that advantage ahead of the vote, touting his record and signing executive actions just days before he is set to face Democratic presidential nominee Joe Biden in a debate next week.

But the vision Trump laid out Thursday was a far cry from the “full and complete” plan he has promised repeatedly in recent months — each time failing to meet his self-imposed deadlines.

In addition to the executive action on preexisting conditions, Trump also promised millions of older Americans would receive $200 toward the cost of prescription drugs and signed executive orders he said would somehow prevent unexpected medical bills and protect insurance coverage for preexisting medical problems. The White House released no details of how the $200 program would work, how it would be funded and whether this was a long-term plan or one-time payment to seniors ahead of the election.

Both actions fall short of a comprehensive health-care overhaul. By comparison, the Affordable Care Act revamped much of the nation’s health-care and insurance systems for the first time in decades.

After entering office determined to undo the law and quickly replace it with a conservative alternative, Trump swiftly ran into obstacles.

In 2017, Republicans were repeatedly forced to abandon their proposals to repeal the ACA when they failed to reach a consensus on a replacement despite holding majorities in the House and Senate. Trump has expressed frustration at the late senator John McCain (R-Ariz.) for torpedoing the last GOP attempt to replace the law, but the lack of consensus was widespread in the party.

In the years since, Trump has taken some action on health care using his executive authority, including symbolic executive orders intended to lower drug prices and changes to Medicare billing practices.

In June 2018, Trump said he would unveil a health-care plan “in a very short period of time.”

A year later, he said such a plan would be out “over the next four weeks.” A month after that, he said a “phenomenal” plan would arrive “in about two months.”

While no such plan arrived, the pandemic and the upcoming election have only increased the frequency with which Trump has reiterated his promises.

In July, Trump told “Fox News Sunday” anchor Chris Wallace that he would be “signing a health-care plan within two weeks, a full and complete health-care plan.”

Two weeks came and went with no plan. During a town hall that aired on ABC on Sept. 15, Trump was confronted by a voter who told him that she would die if the ACA’s protections for preexisting conditions were eliminated

Again, Trump said his own plan preserving those protections would be out soon.

“We’re going to be doing a health-care plan very strongly and protect people with preexisting conditions,” Trump said.

Pressed by ABC News anchor George Stephanopoulos about the ever-shifting deadline for the plan, Trump claimed to have already formulated it.

“I have it all ready. I have it all ready,” he said.

Democrats and the Biden campaign have seized on health care, highlighting the Trump administration’s decision to back a lawsuit from a group of Republican attorneys general to have the entire ACA declared unconstitutional by the Supreme Court while offering no alternative.

In a memo released Thursday, party leaders including Democratic National Committee Chairman Tom Perez highlighted the wave of Democratic victories in 2018, noting that health care was an animating issue across the country.

The pandemic and the prospect of the ACA’s demise have revived similar sentiments, allowing the party to go on offense even as Republicans struggle to find a unified message, the memo said.

Biden’s campaign criticized Trump on Thursday for so far failing to put forward a full health-care plan just weeks before the election, saying his administration’s attempt to repeal the ACA could leave millions of Americans without coverage during a global pandemic.

In the aftermath of Ginsburg’s death, Biden has opted to avoid questions about potential Democratic court-packing plans and instead focus on how a more solidly conservative court might undermine the ACA.

“I think we should focus on what this is going to mean for health care, what it’s going to mean to once again have to say if you’re pregnant it’s a preexisting condition, to be able to charge women more for the same procedure as men,” Biden told reporters Wednesday when asked about Trump’s potential Supreme Court nominee. Biden has pledged to build on the ACA if elected.

Some of Trump’s allies have been dismissive of health care as a motivating factor in an upcoming election they believe will be determined by the state of the economy and the spread of unrest in communities.

“Health care is way, way, way down on the list,” said one official at a Trump-aligned super PAC, speaking on the condition of anonymity to discuss internal strategy. “It is right up there for Democrats, but we’re not looking at Democrats to take us to 270” electoral votes. 


Plan To Allow States To Import Drugs From Canada Doesn't Go Far Enough, Says Maine Senate Leader

- Maine Public - September 26, 2020

The Trump administration's announcement this week that it will allow states to import drugs from Canada is getting a tepid reception in Maine from Senate President Troy Jackson.

Jackson is behind a law enacted last year to establish a drug importation program in the state.  He says the green light from Trump administration is a step forward, but nowhere near the goal line.

"My problem with it at this point is it looks very onerous and very prescriptive," Jackson says.

Jackson says the Trump administration's rule still gives too much power to pharmaceutical companies and could stymie efforts to bring in cheaper drugs.

"We just need to keep hammering away, saying this is not what importation should look like."

The new rule takes effect in 60 days, and states must apply for approval for their importation program.