A New Plan To Rescue The ACA: Medicare-At-55
by Thomas Bodenheimer - Health Affairs - October 16, 2017
On October 12, 2017, the Trump Administration announced that it would end subsidies that reduce out-of-pocket payments for low-income individuals. This action might drive insurers out of the exchanges and might encourage younger people to drop their individual insurance plans — thereby destabilizing the individual insurance market.
Extending Medicare to the 55-64 age group—who have relatively high health care costs—is a potential fix that could insure the near-elderly and provide stability to the marketplaces. It would remove expensive individuals and families from coverage by private insurance companies, who could in turn reduce premiums for individuals and families below the age of 55.
Under this proposal, Medicare-at-55 would be universal for people in the 55-64 age group and they would leave their current private insurance. It would require an increase in the Medicare payroll tax contribution which has not increased proportionately to increases in Medicare spending; other countries sustain their health insurance programs by gradually increasing their payroll tax contributions. To make this plan fiscally sustainable, the United States would need to do the same.
The Problem With Making Medicare-At-55 Optional
Medicare-at-55 is quite different from proposals suggested by Democrats in 2009 and 2017, which allowed people aged 55-64 to voluntarily buy into Medicare as an alternative to private insurance. The problem with the idea of Medicare buy-in is that relatively few of the near-elderly would choose it. Medicare premiums for this age group—about $8,200 per year for an individual—would be significantly higher than what they currently pay with employer-sponsored insurance and with individual insurance subsidized under the Affordable Care Act (ACA).
In addition, under an optional buy-in there would be confusion among potential enrollees on whether to use the buy-in and person-by-person enrollment would be administratively complex. Moreover, the buy-in would raise vexing legislative questions around premium levels, Medigap and Medicare Advantage policies, and whether people could buy-in to Parts A, B, and D separately.
Automatic Enrollment, Just Ten Years Earlier
The better approach would be to implement a Medicare-at-55 concept in which everyone would be automatically enrolled in Medicare — just like the current system does for those 65 and above. Upon reaching the age of 55, eligible individuals (almost everyone in the 55-64 age group) would simply receive their red-white-and-blue Medicare card. Private insurers and employers would no longer be responsible for this age group, which would allow private insurers to reduce premiums on younger families because they would have a younger, and typically healthier, pool of people to cover. In 2015, per capita health care costs for people between 55 and 64 years of age were $9,707 compared with $6,637 for the 45-54 age group, $4,442 for the 26-44 cohort, and $2,915 for those between 19 and 25.
Once on Medicare at the age of 55, people could choose to get a Medicare supplement through their previous insurer or join a Medicare Advantage plan. While the 55-64 age group has higher health care costs than younger people, they have lower costs than current Medicare beneficiaries, which in 2015 incurred per capita spending of $11,904.
Keep in mind that this is not small group to be adding to Medicare’s risk pool. In 2015, there were 41.1 million people in the 55-64 age group. 24 million have access to employer-sponsored insurance, 3 million have subsidized individual insurance under the ACA, 2 million purchase unsubsidized individual insurance, and 3.4 million are uninsured. This leaves an estimated 8 to 9 million already on Medicare and/or Medicaid.
How Would We Pay For Medicare-At-55?
First, it is noteworthy that from 2010 to 2016, per capita Medicare spending growthwas 1.3% compared with 3.5% for private insurance. Second, it would be impossible for most people in the 55-64 age group to pay for their Medicare plan and—given the high per capita costs of this age group—it would be very expensive for the federal government to subsidize their plan. The costs of Medicare-at-55 would have to be borne by the younger population, who would benefit greatly as they reached 55.
The best revenue source for Medicare-at-55 is the current Medicare financing model: payroll tax for Medicare Part A, individual premiums and general federal revenues for Medicare Part B, and Part D through general federal revenues and out-of-pocket costs. The same model could be extended to the 55-64 age group, with an increase in the payroll tax, for example, from 2.9% (half from employers and half from employees) to 3.9% and an increase in the higher-income payroll tax from 2.35% to 3.35%. The precise increases would have to be calculated by federal actuaries and these increases could also be used to extend Medicare’s life from the current date of 2029.
To add to these Medicare revenues, which are distributed throughout the entire population, the new 55-64 beneficiaries would still pay their Part B premiums ($134 per month for incomes of $85,000 or less, more for higher incomes) and Part D (prescription drugs) premiums. Their out-of-pocket costs would depend on whether they have a Medicare supplement or Medicare Advantage plan. The 55-64 population would be subject to the same Medicare rules as the over 65 Medicare population.
To pay for the 55-64 age group to be folded into Medicare, not only the payroll tax, but the portion of Medicare financing provided by general federal revenues, needs to increase. Employers that insure their employees would be required to contribute through Medicare-earmarked payments. Otherwise these employers would receive a windfall since they would no longer be responsible for the health care costs of their 55-64 year-old employees.
Medicare-at-55 is a reasonable proposal to stabilize the ACA while providing reliable health insurance for the 55-64 age group. As the most expensive group insured through the ACA marketplaces moves to Medicare, insurers could reduce premiums for the remaining younger and healthier age groups. The transfer of the 55-64 cohort from employer-sponsored insurance to Medicare would allow insurers to also moderate their premiums in the employer market.
Many questions have yet to be answered in developing the concept of Medicare-at-55, but the idea deserves to be added to the mix of proposals designed to extend our nation’s insurance coverage and repair the ACA marketplaces.
2 Senators Strike Deal on Health Subsidies That Trump Cut Off
by Thomas Kaplan and Robert Pear - NYT - October 17, 2017
WASHINGTON — Two leading senators, hoping to stabilize teetering health insurance markets under the Affordable Care Act, reached a bipartisan deal on Tuesday to fund critical subsidies to insurers that President Trump moved just days ago to cut off.
At the White House, virtually as the deal was being announced, Mr. Trump voiced support for it while insisting that he would try again to repeal President Barack Obama’s signature health law.
The plan by the senators, Lamar Alexander, Republican of Tennessee, and Patty Murray, Democrat of Washington, would fund the subsidies for two years, a step that would provide at least short-term certainty to insurers. The subsidies, known as cost-sharing reduction payments, reimburse insurance companies for lowering deductibles, co-payments and other out-of-pocket costs for low-income customers.
Without them, insurance companies said, premiums for many customers purchasing plans under the Affordable Care Act would shoot up, and with profits squeezed, some of the companies would probably leave the market.
“In my view, this agreement avoids chaos,” Mr. Alexander said, “and I don’t know a Democrat or a Republican who benefits from chaos.”
Mr. Trump appeared to back the deal, even as he berated insurance companies, declared the Affordable Care Act “virtually dead” and promised the demise of the health law in due time.
“It’ll get us over this intermediate hump,” the president said at a Rose Garden news conference, describing it as “a short-term solution so that we don’t have this very dangerous little period.”
Passage of the deal negotiated by Mr. Alexander and Ms. Murray is still far from assured. If approved, the agreement could provide a reprieve for the Affordable Care Act that would prevent 2018 premiums from increasing as much as they might otherwise have gone up. But consumers in many states will still face double-digit rate increases, and in many counties, health plans will be available from only one insurance company.
Moreover, Mr. Trump and other Republicans are still intent on repealing much of the Affordable Care Act, and an executive order issued last week by Mr. Trump could destabilize markets in 2019 and later years by encouraging sales of health plans that skirt the coverage requirements of the health care law.
“For a period of one year, two years, we will have a very good solution,” Mr. Trump said. “But we’re going to have a great solution, ultimately, for health care.”
Mr. Alexander, the chairman of the Senate health committee, said that in addition to funding the payments to insurers, the deal would also give states “more flexibility in the variety of choices they can give to consumers” — a change that should appeal to Republicans eager to give states more say over health care.
“This takes care of the next two years,” Mr. Alexander said. “After that, we can have a full-fledged debate on where we go long-term on health care.”
The agreement bears the hallmarks of bipartisanship. For Republicans, state governments would find it easier to obtain waivers from certain requirements of the Affordable Care Act. But there would be explicit protections for low-income people and people with serious illnesses.
Consumers of any age would be allowed to obtain catastrophic insurance plans that typically have low monthly premiums but high deductibles and other out-of-pocket costs. Catastrophic plans provide protection against serious illnesses and injuries, but consumers must pay most routine medical expenses themselves.
Under current law, catastrophic plans are available only to people who are under the age of 30 or have received an exemption from the federal coverage requirement because they cannot afford other insurance.
For Democrats, not only would the cost-sharing reductions be brought back, but millions of dollars would be restored for advertising and outreach activities that publicize insurance options available in the health law’s open enrollment period, which starts next month. The Trump administration had slashed that funding.
“We will spend about twice as much or more than President Trump wanted to expend,” Mr. Alexander promised.
Accusing Mr. Trump of taking steps to “sabotage health care in our country,” Ms. Murray said, “I’m really glad that Democrats and Republicans agree it’s unacceptable, and that the uncertainty and dysfunction cannot continue.”
Senator Chuck Schumer of New York, the Democratic leader, hailed the agreement as a model for how the two parties could work together on other issues, such as taxes.
“I don’t expect the Republicans to give up their goal of repealing A.C.A.,” Mr. Schumer said. “But in the meantime, stabilizing the system, preventing chaos and stopping the sabotage is in everybody’s interest.”
The fate of the cost-sharing subsidies has been in doubt since a federal district judge ruled in 2016 that the payments to insurers were unconstitutional, because Congress had never appropriated money for them. Mr. Trump, whose administration has been taking steps to undermine operation of the health law, declared last week that he would stop the payments.
If the cost-sharing payments were cut off and premiums increased, many low-income people would receive more financial assistance, in the form of larger tax credits, to help pay the higher premiums. But many middle-income people who do not receive such assistance would have to bear the additional cost on their own.
A coalition of state attorneys general filed suit on Friday, and Congress immediately came under pressure to take action to ensure that the payments would continue. Doctors, hospitals and insurers, as well as the National Governors Association and the U.S. Chamber of Commerce, urged lawmakers to provide the funding.
Mr. Alexander said that he spoke with Mr. Trump over the weekend, and that the president encouraged his efforts with Ms. Murray, the top Democrat on the Senate health committee. But it remains to be seen whether conservative-leaning Republicans will get on board with the agreement, and whether the House will accept it.
It is not clear how the agreement might move through Congress. Supporters of funding the subsidies could push to have the deal included in a measure to keep the government open past Dec. 8. Democratic votes will be needed to fund the government, and the health care deal could come to fruition when Democratic leverage is particularly strong.
Some Republicans have already said they do not wish to provide what they describe as a bailout to insurers.
“I think it would be a mistake for Congress to provide billions in bailouts to insurance companies without providing meaningful relief to the millions of Americans who have been hurt by Obamacare,” Senator Ted Cruz of Texas said Tuesday before the deal was announced.
Mr. Alexander said the agreement would include “the strongest possible language” to guarantee that money provided for cost-sharing payments goes to the benefit of consumers, not insurance companies. “I want that, Senator Murray wants that, the president wants that,” he said.
The Senate majority leader, Mitch McConnell of Kentucky, gave no indication on Tuesday about when — or whether — the chamber might move ahead with the plan drawn up by Mr. Alexander and Ms. Murray.
Senator John Thune of South Dakota, a member of the Senate Republican leadership, said there would be “a sense of urgency to move a bill,” since Mr. Trump intended to stop the payments right away.
The House is away for a weeklong recess, and a spokesman for Speaker Paul D. Ryan of Wisconsin declined to comment.
A leading conservative in the House, Representative Mark Walker of North Carolina, the chairman of the Republican Study Committee, immediately declared the deal to be “unacceptable.”
“Obamacare is in a ‘death spiral,’ ” Mr. Walker said. “Anything propping it up is only saving what Republicans promised to dismantle.”
Another leading conservative, Representative Mark Meadows of North Carolina, the chairman of the hard-line House Freedom Caucus, described the agreement as a “good start,” but said “much more work needs to be done.”
“Most importantly,” he added, “it bears repeating: Republicans cannot allow short-term solutions to become a distraction to repealing and replacing Obamacare — something we’ve promised to do for seven years.”
https://www.nytimes.com/2017/10/17/us/politics/alexander-murray-deal-obamacare-subsidies.html?
Will Mitch McConnell Help His Friend Get a Health Care Deal?
By Carl Hulse - NYT - October 19, 2017
WASHINGTON — Mitch McConnell and Lamar Alexander go way back.
The two Southern Republicans met in Washington in 1969 when Mr. Alexander was a promising young aide at the Nixon White House and Mr. McConnell an up-and-coming legislative assistant to Senator Marlow W. Cook of Kentucky.
The story goes that Senator Howard H. Baker Jr. suggested to Mr. Alexander, his fellow Tennessean, that he should look up Mr. McConnell, that he was a “smart young man and I think you’d like him.” A nearly 50-year friendship and political alliance was born.
In his book “The Long Game,” Mr. McConnell, now the Senate majority leader, says of Mr. Alexander: “Lamar would go on to become one of my closest confidantes and a very good friend.” Not many people are considered a close, let alone the closest, confidant of the notoriously reticent leader.
But deep friendship aside, Mr. McConnell will be extremely cautious in moving ahead with the health care compromise that Mr. Alexander struck with Senator Patty Murray, a Washington Democrat, in an effort to stabilize the insurance exchanges for those buying coverage under the Affordable Care Act. And considering that President Trump is giving mixed signals on the proposal and that many Republicans in both the Senate and House are already opposed to it, the outlook for the rare bipartisan deal is murky at best.
With Mr. McConnell’s blessing, Mr. Alexander engaged in a concerted effort to find a compromise with Ms. Murray, the senior Democrat on the health committee that Mr. Alexander leads. The goal was for Congress to officially appropriate the subsidies paid to make insurance more affordable for lower-income Americans while giving states more freedom in regulating insurance — an approach favored by Republicans.
The subsidies, estimated at $7 billion this year, were challenged in federal court by the House in 2014 and found unconstitutional because Congress had not approved them. Mr. Trump announced last week that he was cutting them off and Mr. Alexander said he feared millions of people could now find insurance out of their financial reach.
espite the serious negotiations, there was no firm commitment that a compromise would reach the Senate floor if one could be struck. In fact, Mr. Alexander deferred to Mr. McConnell last month when Mr. McConnell wanted to take one last shot at overturning the health care law. He broke off his talks with Ms. Murray, resuming them only when the repeal effort faltered once again.
All sides agree that Mr. Trump — in conversations with Mr. Alexander and Senator Chuck Schumer of New York, the Democratic leader — strongly encouraged the bipartisan talks and initially seemed to embrace the agreement to restore the subsidies as a way to buy time for another repeal push. So backers of the plan were blindsided when the president said on Twitter on Wednesday that he could not back what he considered an insurance industry bailout.
Mr. Schumer said the president was undercutting himself by wavering on deals he had helped set in motion, not just on health care but also on issues like immigration. Mr. Schumer suggested that Mr. Trump caved to conservative opposition to the health care compromise.
“This president cannot govern if whenever the hard right frightens him and says, ‘Jump,’ he says, ‘How high?’” Mr. Schumer said.
Backers of the compromise face a tough task in selling the idea to many Republicans who would now be voting not to repeal the health care law, but to temporarily prop it up to avoid a breakdown in the marketplace. In addition, many on Capitol Hill say the compromise could be an important first step toward stabilizing the overall program, making future attempts to repeal it even more difficult.
Mr. Trump’s view will be crucial. His endorsement could provide important political cover for those nervous about voting to bolster the health care law while his opposition could cause Republicans to flee, fearing they will come under attack from the president and his allies.
Mr. Alexander is not retreating. Trying to build momentum, he and Ms. Murray introduced the legislation on Thursday along with two dozen leading Republican and Democratic co-sponsors — an almost unheard-of event on a major bill in this highly polarized environment.
Among Republicans backing the measure were Senators Charles E. Grassley of Iowa, long active in health policy; Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, the authors of the most recent repeal plan; Bob Corker, Mr. Alexander’s Tennessee colleague who has been feuding with the president; and the group who thwarted Republican repeal efforts, John McCain of Arizona, Susan Collins of Maine and Lisa Murkowski of Alaska.
“I don’t believe Congress will want to fail to deal with a problem that will hurt millions of Americans if we allow it to continue,” Mr. Alexander said.
He and Ms. Murray said that they had built in protections to make sure the money went to consumers and that it was a mischaracterization to call it an industry bailout. They said both sides gave substantial ground in the talks. Ms. Murray told fellow Democrats this week that it was the toughest bargaining she had been involved in as a senator.
“It sends a powerful message that when members of Congress decide to get past our talking points and take a few steps out of our partisan corners, there is a lot we can agree on and a lot we can get done,” Ms. Murray said of the negotiation.
But to a large degree, the ultimate success of the talks depends on Mr. McConnell. He has been quiet so far about the bill and whether he would push it forward. The Senate would no doubt have to give it a strong vote for the plan to have any chance of moving through the House.
The support from a growing list of Republican co-sponsors is no guarantee that the Senate will consider the bill if Mr. McConnell views it as too politically risky. He refused to bring to the floor last year a bipartisan criminal justice overhaul that had broad support because of political considerations — despite the fact that Senator John Cornyn of Texas, the No. 2 Senate Republican, was a chief author.
Mr. Alexander has repeatedly predicted that some version of his new legislation will become law by the end of the year. For him to be proved right, he is going to need some help from his good friend Mitch McConnell.
Trump’s health subsidy shutdown could lead to free insurance
by Ricardo Alonzo Salvador - Associated Press - October 19, 2017
If President Donald Trump prevails in shutting down a major “Obamacare” health insurance subsidy, it would have the unintended consequence of making free basic coverage available to more people, and making upper-tier plans more affordable.
The unexpected assessment comes from consultants, policy experts, and state officials trying to discern the potential fallout from a Washington health care debate that’s becoming harder to follow.
What’s driving the predictions? It’s because another of the health law’s subsidies would go up for people with low-to-moderate incomes, offsetting Trump’s move.
“It’s a kind of counterintuitive result,” Kurt Giesa, a health insurance expert with the Oliver Wyman consulting firm, said.
According to one estimate, more consumers would sign up for coverage next year even though Trump says the Affordable Care Act is “virtually dead.”
On Wednesday, the fate of the health law’s subsidy for copays and deductibles remained unclear as a bipartisan congressional deal to continue payments ran into political roadblocks. Separately, state attorneys general asked a federal court to order the administration to keep the money flowing.
But if Trump succeeds, it may be like pushing down on one end of a see-saw only to see the other end go up.
His attempt to shut off the subsidy for copays and deductibles would cause a different subsidy to jump up, the one for premiums.
The Obama-era health care law actually has two major subsidies that benefit consumers with low-to-moderate incomes. The subsidy Trump targeted reimburses insurers for reducing copays and deductibles, and is under a legal cloud. The other subsidy is a tax credit that reduces the premiums people pay, and it is not in jeopardy.
If the subsidy for copays and deductibles gets erased, insurers would raise premiums to recoup the money, since by law they have to keep offering reduced copays and deductibles to consumers with modest incomes.
The subsidy for premiums is designed to increase with the rising price of insurance. So government spending to subsidize premiums would jump.
“This is where the counting gets sort of weird,” Matthew Buettgens, a senior research analyst with the Urban Institute, said.
The nonpartisan policy research group has estimated that richer premium subsidies could entice up to 600,000 more people to sign up for health law coverage, depending on how insurers and state regulators adjust.
The group also found that the federal government would end up spending more overall on health insurance through higher premium subsidies.
That hasn’t been lost on officials at the state level.
“It means many more Californians and people across the country will get a zero-premium bronze plan,” said Peter Lee, executive director of Covered California, the health insurance marketplace in the nation’s most populous state.
“Bronze” is the health law’s basic coverage level. “Silver” is the mid-range standard plan and the most popular. “Gold” is close to employer health insurance in value.
In addition to free bronze plans, many consumers would be able to buy a gold plan for about the same monthly premium as silver coverage, Wyman and the Urban Institute concluded.
Other states where consumers could see zero-premium bronze plans include Florida, Georgia, Illinois, Mississippi, Pennsylvania, Utah and Wyoming, according to an industry estimate.
It’s complicated, but here’s why:
— First, the subsidy for copays and deductibles is provided only if you have a silver plan.
— Next, the other subsidy, the one for premiums, is pegged to the cost of a lower priced silver plan.
In California, regulators instructed insurers to increase premiums for silver plans sold on the public marketplace to account for the loss of the subsidy for copays and deductibles.
Premiums for bronze plans and gold plans were shielded from that increase.
But because the federal subsidy for premiums is tied to the cost of a silver plan, that subsidy will be higher for everybody whose income qualifies them for financial assistance.
So consumers can use their richer premium subsidy to get a bronze plan for no monthly cost or very little or a gold plan for much less than they would pay now.
Lee, the California official, said he believes regulators in close to half the states have taken a similar approach.
Final premiums for 2018 have not been officially unveiled yet, and some states are still making adjustments. Sign-up season starts Nov. 1.
‘Drug Dealers in Lab Coats’
by Nicholas Kristof - NYT - October 19, 2017
For decades, America has waged an ineffective war on drug pushers and drug lords, from Bronx street corners to Medellin, Colombia, regarding them as among the most contemptible specimens of humanity.
One reason our efforts have failed is we ignored the biggest drug pushers of all: American pharmaceutical companies.
Our policy was: You get 15 people hooked on opioids, and you’re a thug who deserves to rot in hell; you get 150,000 people hooked, and you’re a marketing genius who deserves a huge bonus.
Big Pharma should be writhing in embarrassment this week after The Washington Post and “60 Minutes” reported that pharmaceutical lobbyists had manipulated Congress to hamstring the Drug Enforcement Administration. But the abuse goes far beyond that: The industry systematically manipulated the entire country for 25 years, and its executives are responsible for many of the 64,000 deaths of Americanslast year from drugs — more than the number of Americans who died in the Vietnam and Iraq wars combined.
The opioid crisis unfolded because greedy people — Latin drug lords and American pharma executives alike — lost their humanity when they saw the astounding profits that could be made.
It used to be in America that people became addicted to opioids through illegal drugs. In the 1960s, for example, 80 percent of Americans hooked on opioids began with heroin.
That has completely changed. Today, 75 percent of people with opioid addictions began with prescription painkillers. The slide starts not on a street corner, but in a doctor’s office.
That’s because pharmaceutical companies in the 1990s sought to promote opioid painkillers as new blockbuster drugs. Company executives accused doctors of often undertreating pain (there was something to this, but pharma executives contrived to turn it into a crisis that they could monetize). The companies backed front organizations like the American Pain Foundation, which purported to speak on behalf of suffering patients.
These front organizations, as well as professionals sometimes funded by the pharmaceutical industry, heralded pain as the “fifth vital sign,” along with pulse, temperature, respiratory rate and blood pressure. The opioid promoters hailed opioids as “safe and effective,” and they particularly encouraged opioids for returning veterans — one reason so many veterans have suffered addictions.
Pharma companies spent heavily advertising opioids — $14 million in medical journals in 2011 alone, almost triple what they had spent in 2001 and pitched them for a wide range of chronic pains, such as arthritis and back pain.
Companies even argued that signs of addiction were a reason to prescribe more opioids. Endo Pharmaceuticals distributed a book suggesting that when a patient showed strange behavior, “the clinician’s first response” should be to increase the dose of opioids.
Several of these examples come from a lawsuit by Ohio against major pharmaceutical companies, including Purdue, Teva, Cephalon, Johnson & Johnson and Janssen. A company affiliated with Purdue pleaded guilty of felony fraud in connection with its marketing of OxyContin, but none of its executives went to prison.
Drug companies employed roughly the same strategy as street-corner pushers: Get somebody hooked and business will take care of itself. So last year, Americans received 236 million opioid prescriptions — that’s about one bottle for every adult.
A Senate investigation found that one company, Insys Therapeutics, successfully redirected a powerful opioid called Subsys, meant for cancer pain, to patients without cancer. Sarah Fuller, a woman with neck and back pain, was prescribed Subsys by her doctor, who received payments from Insys.
Fuller died of an overdose of Subsys.
Meanwhile, Insys had the best-performing initial public offering in 2013, and revenue tripled in the next two years, the Senate report said. Likewise, the Sackler family, owner of the company that makes OxyContin, joined Forbes’s list of richest American families in 2015, with $14 billion.
It’s maddening that the public narrative is still often about an opioid crisis fueled by the personal weakness and irresponsibility of users. No, it’s fueled primarily by the greed and irresponsibility of drug lords — including the kind who inhabit executive suites. The Washington Post quoted a former D.E.A. official as referring to pharmaceutical company representatives as “drug dealers in lab coats.”
I was invited the other day to a gala honoring the C.E.O. of one of these pharma companies for his moral leadership. I wanted to throw up. Since 2000, more than 200,000 Americans have died from overdoses of prescription opioids — the consequence of a deliberate strategy to make money by ignoring public welfare.
Our pattern of opioid addiction points to a tragedy, driven by the greed of some of America’s leading companies and business executives, systematically manipulating doctors and patients and killing people on a scale that terrorists could never dream of.
There’s a lot of talk in the Trump administration about lifting regulations to free up the dynamism of corporations. Really? You want to see the consequences of unfettered pharma? Go visit a cemetery.
Warnings of 'Big Pharma Coup' as Trump Considers Drug Exec. for Health Secretary
"Trump has decided to cut out the middleman, and let a pharmaceutical executive literally run the health department."
by Jake Johnson - Common Dreams - October 18, 2017
"Just days after denouncing 'out-of-control' drug prices, President Donald Trump appears set to show he doesn't mean it by naming a former pharmaceutical company executive to run the U.S. Department of Health and Human Services," said Public Citizen president Robert Weissman. "In his public statements, Alex Azar has made clear that he is opposed to measures to restrain drug company profiteering and limit improper marketing and favors weaker drug safety approval standards."
Azar spent a decade as an executive with the pharma giant Eli Lilly, where he directed the company's sales operations. Before joining Eli Lilly, Azar served as deputy secretary of the HHS under George W. Bush.
As Politico reports, Azar also happens to be "one of the many drug industry executives" who contributed to Trump's presidential campaign—a fact that runs counter to the president's frequent criticism of elected officials who take cash from pharma executives.
If nominated, Azar would be filling the role left vacant by Tom Price, who resigned last month amid growing outrage over his use of private jets to travel across the U.S. on government business.
Weissman argued on Wednesday that while Price was a supporter of the pharmaceutical industry, Azar would take Big Pharma's influence on American healthcare to the next level.
"The swamp only gets worse," Weisman said. "Trump has decided to cut out the middleman, and let a pharmaceutical executive literally run the health department."
Weissman concluded that Azar's nomination would effectively foreclose the possibility of any substantive steps toward tackling high drug prices or pharma monopolies.
"Americans understand, passionately, that drug company price gouging leads to rationing of care. It is unethical and must end," Weissman said. "But it is highly unlikely that a pharmaceutical company executive who has made passionate arguments against price restraints is going to advance real reform."
The Outlook for Stabilizing Obamacare in 2018 and the President Who Can't Shoot Straight
by Robert Laszewski - Health Care Policy and Marketplace Review - October 19, 2017
The Alexander-Murray bipartisan effort to stabilize the Obamacare individual insurance markets will not pass the Congress on its own.
The only chance it now has is to be added to a must-pass legislative deal, such as the one needed to fund the government by the December 8 deadline in order to avoid a government shutdown.
Also sitting in the queue, and certain to pass at some time, is the Children's Health Insurance Program (CHIP) reauthorization bill. The Congress is currently struggling over the pay-fors for this reauthorization but there is wide bipartisan agreement that it must be funded before the states start running out of money, which will begin in a few weeks. CHIP now covers nine million kids.
Conservative Republicans are adamant that they do not want to pass an “insurance company bailout” bill like Alexander-Murray. Particularly in the House, where Republicans were able to pass a "repeal and replace" bill, these members have already taken a controversial vote to cut Medicaid and insurance subsidy support and after that tough vote don't now want to have to explain why they have backtracked to "bail out" Obamacare with the Alexander-Murray short-term patch bill.
Tuesday, Trump pulled his initial support for the bill. That he would first support it and then abandon it just speaks to how little he understands the health issue and how essentially worthless his presidential leadership is toward getting a solution for Obamacare. This Trump flip-flopping just proves that there is only one place health care gets decided—in the Congress and a very divided Congress at that.
Tuesday, Trump pulled his initial support for the bill. That he would first support it and then abandon it just speaks to how little he understands the health issue and how essentially worthless his presidential leadership is toward getting a solution for Obamacare. This Trump flip-flopping just proves that there is only one place health care gets decided—in the Congress and a very divided Congress at that.
On health care, if leading conservative organizations told Trump to sign a ham sandwich he would do it and declare it, “A Marvelous victory, really a very marvelous victory.”
If you want a description of a President who can't shoot straight, look at Trump’s citing the stock price gains among the big managed care companies as justification for his killing the cost sharing subsidies (CSRs) for low-income people in the insurance exchanges.
Hasn’t anyone told Trump that almost all of those big publicly traded health insurers he's been railing against for their big stock price appreciation since Obamacare launched––Aetna, United, Humana, and Anthem–– have bailed, or are in the process of bailing, on all or most of their insurance exchange business and won’t be hurt by his action? It’s the not-for-profits that have largely stayed in the exchanges, not his intended targets!
If you want a description of a President who can't shoot straight, look at Trump’s citing the stock price gains among the big managed care companies as justification for his killing the cost sharing subsidies (CSRs) for low-income people in the insurance exchanges.
Hasn’t anyone told Trump that almost all of those big publicly traded health insurers he's been railing against for their big stock price appreciation since Obamacare launched––Aetna, United, Humana, and Anthem–– have bailed, or are in the process of bailing, on all or most of their insurance exchange business and won’t be hurt by his action? It’s the not-for-profits that have largely stayed in the exchanges, not his intended targets!
There is no hope of the Republican caucus in either the House or the Senate advancing anything in the coming months—repeal and replace or a short-term patch––on their own. We saw them exhaust all of their policy ideas over the past four months. They claim they will again try to advance a Graham-Cassidy-like bill focusing on state block grants but until they can reconcile the cuts to Medicaid and the insurance subsidies the conservatives want with the cuts the moderates don’t want, they aren't going to pass anything.
That leaves us with the Democrats. The Dems don’t have a majority in either house. But there are must-pass bills on the table—such as funding the government by December 8 to avoid a shutdown and the reauthorization of CHIP before the states run out of money to continue health insurance for nine million kids. The most likely vehicle for them to exert their leverage will be on the shutdown bill. It will take 60 Senate votes to avert a government shutdown just before the Congressional holiday break (never underestimate an ideologues desire to get his holiday vacation). Look for the Dems to try to take the December 8th funding bill hostage toward getting something like Alexander-Murray.
Of course, it they are successful, any short-term help for the insurance exchanges will be too late for 2018 since next year's open enrollment is scheduled to end on December 15th.
Congress, End the Health Care Chaos. You Have 9 Million Kids to Protect.
The Editorial Board - NYT - October 18, 2017
President Trump and Republicans in Congress have brought chaos to the American health care system by trying to destroy the Affordable Care Act and failing to reauthorize the Children’s Health Insurance Program, which, with bipartisan support for the past 20 years, has provided care for millions of children. Over the next few weeks they can choose to set things right or to destroy them.
Senators Lamar Alexander and Patty Murray on Tuesday announced a bipartisan deal that could help stabilize the A.C.A.’s insurance markets and undo some of the damage Mr. Trump has done through administrative actions. In an ideal world, Congress would quickly pass that bill, which includes several Republican priorities, and, at the same time, reauthorize CHIP, which now covers nearly nine million children. But with Mr. Trump in the White House and feckless Republicans leading Congress, it’s possible that none of this will get done, health care costs will be driven up and millions of children will be left without health insurance.
First up, the Alexander-Murray deal represents real progress. These two no-nonsense lawmakers — the leading Republican and Democrat on the Senate health committee — have done yeoman’s work trying to fix a mess created largely by Mr. Trump. Their bill would appropriate money for payments to insurance companies that the president said he was stopping last week. He said they amounted to an illegal corporate bailout — a blatant lie. These payments, authorized by the A.C.A., or Obamacare, compensate insurers for lowering the deductibles and co-payments for low-income families. Further, Mr. Alexander and Ms. Murray would require the administration to spend $106 million on advertising and on people to help people sign up for insurance when open enrollment begins on Nov. 1. Mr. Trump’s minions at the Department of Health and Human Services slashed spending on outreach efforts in recent months.
The deal also advances two Republican health care ideas: giving states more flexibility to make changes to the A.C.A. and letting more people sign up for high-deductible health care policies. Thankfully, Mr. Alexander and Ms. Murray have made sure that neither of these changes undermines Obamacare’s protections for people with pre-existing conditions and the requirement that insurers cover essential health services like maternity care and cancer treatment. These changes could make the law function better by allowing sparsely populated states to attract more insurers by, for example, making it easier for them to set up reinsurance programs that protect companies from losses from a few customers. And the proposed high-deductible plans could work well for a small subset of people who buy A.C.A. policies but do not receive subsidies because they earn too much money.
While these compromises provide some hope for the A.C.A., CHIP’s fate, and health care for nine million children, is being held hostage by Republican extremists in the House. The Republican and Democratic leaders of the Senate Finance Committee — Orrin Hatch and Ron Wyden — have worked together to extend the program, which expired on Sept. 30. But Republican House members such as Greg Walden of Oregon and Fred Upton of Michigan are demanding that spending on CHIP be offset by cuts to A.C.A. costs and unnecessary changes to Medicare and Medicaid. Of course, these same lawmakers who are so tightfisted with children’s medical care want to slash taxes on wealthy families with no effort to offset that loss of revenue.
State governments, which run CHIP, are continuing to cover children with money left over from earlier appropriations and with emergency infusions from the federal government. But 11 states are expected to run out of federal funds by the end of December and 20 states and the District of Columbia will get to that point in the first three months of next year, according to the Kaiser Family Foundation. CHIP, created in 1997 to cover lower-income families who could not get Medicaid, helped lower the uninsured rate for children to 5 percent, from 14 percent. Most children in CHIP are from families with incomes below twice the poverty level, or $49,200 for a family of four.
So far, neither Mr. Trump nor Republican leaders in Congress have taken these vital matters very seriously. Mr. Trump has made several contradictory statements about the Alexander-Murray proposal and he has not said much of anything about children’s health insurance.
That only makes it more crucial for members of Congress to heed Mr. Alexander, who said on Tuesday, “I don’t know a Democrat or a Republican who benefits from chaos.”
The Collapse of Trumpcare and the Rise of Single Payer
by Zachary Berger and Adam Gaffney - Common Dreams - October 18, 2017
Two major developments in September upended US healthcare politics. The month’s end saw the failure of a last-ditch blitz by Senate Republicans to dispatch the Affordable Care Act (ACA) via the Graham-Cassidy bill, a painful defeat for opponents of Obamacare, including President Trump. And on 13 September, Senator Bernie Sanders’ single-payer “Medicare-for-All” bill was released, galvanizing proponents of progressive healthcare reform.
Among the notable aspects of Sanders’ bill was its co-sponsorship by 16 Senators (as opposed to zero for Sanders’ last bill), among whom were most of the potential Democratic 2020 presidential contenders. Rising support for single-payer in the Senate follows a similar shift in the House of Representatives, where a majority of Democratic lawmakers now support Representative John Conyers’ single-payer bill.
The immediate impact of these single-payer bills—given that neither will pass in the current Congress—may seem modest. Yet in conjunction with the collapse of Republicans’ ACA repeal efforts, they could signal a new era in American healthcare politics.
Firstly, on the political level, Democrats’ growing embrace of single-payer is tantamount—as many have noted—to a historic shift in the so-called “Overton window,” or the boundaries of the politically possible. Indeed, it now seems likely that single-payer healthcare reform proposals will figure prominently not only in the 2020 Democratic presidential primaries, but in the general election as well.
Secondly, the bills—or something like them—could serve as a framework for legislation under a new government. Sanders’ bill (like Conyers’) would achieve the long-sought goal of universal coverage for US residents through a single public programme. It would eliminate most “cost-sharing”—e.g. copayments and deductibles— a radical departure from trends towards high patient exposure to healthcare costs. Indeed, the bill would cover comprehensive medical benefits without any fees at point of use; the only copayments are for prescription drugs (to incentivize the use of generics), and even these are capped and would not apply to “preventive” medications.
Such fundamental reform could do much good; given that lack of healthcare coverage (28 million remain uninsured at present, despite Obamacare) has been associated with premature deaths, it could be lifesaving. [1] The shift away from cost-sharing could also bring dramatic improvements in the financial and physical well-being of American patients. “Underinsurance” appears to be rising: one recent survey of insured patients seeking cancer treatment found that more than one in three had an unexpectedly high financial burden from care, and about one in six had “high or overwhelming financial distress.” For the latter group of cancer patients, out-of-pocket healthcare spending consumed nearly a third of income despite insurance coverage. [2,3]
Still, even supporters of single-payer reform recognize that Sanders’ bill is merely the first step. First, unlike the House counterpart, the Senate bill excludes long-term care from the new universal programme; it would continue to be provided through the current federal-state Medicaid programme and so would still be a means-tested, rather than a universal, benefit. Advocates also stress other areas for improvement in Sanders’ bill, including shifting hospitals to global budgets (to reduce hospital administrative spending); planned capital expenditures (to control long-term cost growth); and the exclusion of investor-owned health facilities (given concerns about the quality and inefficiency of corporate healthcare). [4]
No one claims, however, that this version of the bill will constitute final legislative text. It also lacks a funding mechanism. Most importantly, its passage will require a shift in the power balance in Washington, as well as greater familiarity and understanding among the electorate, given that new taxes will be needed to replace current spending private healthcare spending. Nonetheless, in addition to providing a potential model for future legislation, the bill serves a number of useful functions now: it has already spurred discussion of the inadequacies of the healthcare status quo (including unsustainable costs), and it provides a vision of the future that contrasts with the bleak plans of both the Republican Party and insurance company lobbyists.
Lawmakers from across the political spectrum are taking notice. “To my friends to the Left,” Senator Lindsey Graham (R-SC), sponsor of Republicans’ Graham-Cassidy bill, said, “I will do everything I can to stop and put a stake into the heart of single-payer healthcare.” [5]
Yet there is a reason why Graham’s bill crashed and burned, and why single-payer may one day succeed despite such threats of impalement. 52% of Americans disapproved of Graham’s bill; even among Republicans, only 46% were in favour, with 21% opposed and a third uncertain. [6] Single-payer, by contrast, is favoured by 53% of Americans, including 64% of Democrats, 55% of Independents, and even 28% of Republicans. [7]
Such poll numbers portend a grim prognosis for the conservative healthcare project. By contrast, as the notion of healthcare as a right—and not a commodity—increasingly becomes part of the national ethos, the prospects for single-payer reform continue to sweeten.
A different take on Medicaid expansion
By David Jolly - Ellsworth American - October 19, 2017
In her Oct. 5 op-ed opposing Medicaid expansion in Maine, Sen. Kimberley Rosen includes a number of statistics about expansion in other states running over budget, with a fairly clear implication that the citizens of those states have ended up footing the bill (e.g. “West Virginia, a state very similar to Maine, ran 46 percent over budget in the first year alone, costing it an additional $198 million.”) I found these figures confusing and misleading given that the federal government paid 100 percent of a state’s Medicaid expansion costs from 2014 through 2016. Thus the cost of any budget overruns in those years was borne by the federal government, not by the state.
It is true that in 2017, states expanding Medicaid began bearing 5 percent of the costs, and from 2020 on, they will pay 10 percent. Still, this is considerably less than states’ share for those who qualify for Medicaid under the eligibility criteria in place prior to expansion. In Maine, this share is 37.2 percent. This means that if Maine expands Medicaid, it will pay 27 percent less of the cost of care for Medicaid recipients newly qualified under expanded Medicaid than it is and will be paying for traditional Medicaid enrollees.
Sen. Rosen also overlooks other important economic points about what Medicaid expansion would mean for Maine: There would be what economists call a multiplier effect associated with the 525 million federal dollars that came to Maine annually under expansion. Most of those dollars would support direct medical care. The largest part of the cost of that care is labor, and those health care workers paid with Medicaid expansion dollars will be spending much of that money in ways that support their local economy — in grocery stores, restaurants and movie theaters. The nonpartisan health policy journal Health Affairs estimates that the 90 cents that Maine would receive from the federal government for each dollar spent on Medicaid expansion would yield between $1.35 and $1.80 in state economic activity.
The state also would reap the benefit of the income taxes paid by those employed because of Medicaid expansion and the sales taxes on the economic activity expansion generates.
Right now, through their federal income taxes, the citizens of Maine are subsidizing the health care that 31 states with expanded Medicaid are providing their low-income citizens newly qualified for coverage under the expanded eligibility criteria. Shouldn’t taxpayers in other states be helping to pay for health coverage for low-income persons in Maine? This will only happen if and when Maine expands Medicaid.
Just days ago the Kaiser Family Foundation issued a report based on its review of 153 studies of the effects of expanding Medicaid (https://www.kff.org/medicaid/issue-brief/ the-effects-of-medicaid-expansion-underthe- aca-updated-findings-from-a-literature- review-september-2017/). Here are a few of its conclusions about the economic impacts of Medicaid expansion: Multiple studies found that states expanding Medicaid realized budget savings, revenue gains and overall economic growth.
New national research found that from 2010 to 2015, there were no significant increases in spending from state funds as a result of Medicaid expansion and no signifi cant reductions in state spending on education, transportation or other state programs as a result of expansion.
Medicaid expansions led to reductions in uninsured hospital visits and uncompensated care costs. (This is a particularly important result for financially strapped and struggling hospitals in rural Maine.) Economics aside, Sen. Rosen fails to note the primary reason for and benefit of Medicaid expansion — the health coverage it would provide to an additional 64,000 of Maine’s lowest-income citizens. How low? Those whose incomes are at or below 138 percent of the federal poverty level ($16,643 for a single person and $22,412 for a family of two). For these Mainers, health insurance is currently beyond their financial reach, but having it could be both life-enhancing and life-saving. In fact, a 2012 Harvard School of Public Health study found that expanding Medicaid to low-income adults improved health care outcomes and reduced mortality in three states. One of these states was Maine, which first expanded its Medicaid program back in 2003 under Dirigo Health.
Sen. Rosen concludes that “Medicaid expansion isn’t the answer we’re looking for.” Apparently the many Republican governors who expanded Medicaid in their states disagreed. These included governors in New Jersey, Michigan, Ohio, Indiana, Kentucky, Iowa, North Dakota, Nevada, Arizona and New Mexico. They recognized the economic benefit of accepting federal funds for Medicaid expansion, and they saw wisdom in extending health coverage to more low-income citizens under financial terms so favorable to their states. Perhaps some governors even saw this as an ethical obligation.
Sen. Rosen offers an incomplete and misleading economic analysis of Medicaid expansion, and she overlooks the very human and most important argument in its favor.
David Jolly is a resident of Penobscot and a retired associate professor of public health education at North Carolina Central University, where he taught public health policy with a focus on access to health care.
