Health Care Reform Articles - June 20,2015

Destructive Health Care Proposals

By THE EDITORIAL BOARDJUNE 18, 2015

Frustrated by their inability to repeal the Affordable Care Act and unable to produce a conservative alternative to replace it, House Republicans are moving two bills to repeal small but important provisions of the law — a tax on medical device manufacturers and an independent board to clamp down on out-of-control Medicare spending. The two bills would harm the federal budget and do nothing to help consumers, but were approved by the House Ways and Means Committee and are expected to pass the House on Thursday.

The Affordable Care Act imposes a modest 2.3 percent tax on revenues from sale of medical devices in this country, to be paid by the manufacturers or importers. The tax applies to big-ticket devices like M.R.I. scanners, X-ray machines, artificial joints and pacemakers, but not to consumer items like eyeglasses, contact lenses or hearing aids. Repealing the tax would reduce revenues, and thus increase federal deficits, by an estimated $24.4 billion over the next 10 years. The bill provides no way to replace the lost revenue.

http://www.nytimes.com/2015/06/18/opinion/destructive-health-care-proposals.html?_r=0

Top Plaintiff in Health Subsidies Case Awaits Edict Unperturbed

By ROBERT PEARJUNE 17, 2015

FREDERICKSBURG, Va. — Millions of people are waiting anxiously for the Supreme Court to decide the fate of President Obama’s health care law with a ruling this month on health insurance subsidies. But David M. King, a plaintiff in the case, is not among them.

Mr. King, 64, said recently that he was reasonably confident he would prevail in his challenge to the subsidies, a central element of the Affordable Care Act.

“We have a good chance of winning,” he said in an interview at his home here.

Mr. King and three other Virginia residents are challenging the payment of subsidies in states like Virginia that depend on the federal insurance marketplace. They contend that the 2010 health care lawallows subsidies only in states that establish their own marketplaces.

But Mr. King said that he was not really worried about the outcome of the case, King v. Burwell, because as a Vietnam veteran, he has access to medical care through the Department of Veterans Affairs.

If he wins, Mr. King said, “the left will blow it out of proportion and claim that eight million people will lose their health insurance.” But he said lawyers had assured him that “things are in play to take care of the problem.”

Mr. King did not provide details, and supporters of the health care law have said that there are no quick or easy solutions if the Supreme Courtrules against it. The president could not simply give out subsidies if the court stripped them away, so the critical decisions about how to respond “would sit with Congress and the states,” said Sylvia Mathews Burwell, the secretary of health and human services.

http://www.nytimes.com/2015/06/18/us/david-king-obamacare-supreme-court.html?hpw&rref=politics&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well

Two deals boosting healthcare to immigrants illegally in U.S. are OKd in Sacramento

By SOUMYA KARLAMANGLA

As Gov. Jerry Brown struck a budget deal Tuesday that would offer healthcare to children in the country illegally, Sacramento County supervisors — sitting less than a mile away — also agreed to provide medical care for county residents who lack papers.

Speaking of a statewide campaign for universal health coverage, Anthony Wright, executive director of the advocacy group Health Access California, said, "It was a big day for Health for All, in Sacramento and in Sacramento," referring to Capitol Hill and the county.

California law has long required county governments to provide healthcare to their poorest residents, but only 11 of the state's 58 counties interpret that mandate to include those who have entered the country illegally.

Advocates hope Sacramento's decision to become the 12th county to do so will be a catalyst for others to follow suit.

"The whole state of California is watching very closely," Sacramento County Board of Supervisors Chairman Phil Serna said before the vote.

The supervisors unanimously approved a plan that includes $5.2 million to pay for primary care and some specialty care for undocumented adults. Officials estimate it will fund care for up to 3,000 of the county's 50,000 immigrants.

Sherri Heller, director of the county's Health and Human Services Department, said that the program — likely to begin later this year — would give officials a sense of how to manage a system like this. "It's a solid first step," she said.

HTTP://WWW.LATIMES.COM/LOCAL/POLITICS/LA-ME-SACRAMENTO-VOTE-20150618-STORY.HTML

Legal arguments that could sway Supreme Court on Affordable Care Act

By DAVID G. SAVAGE AND NOAM N. LEVEY

The Supreme Court will decide a seemingly simple question this month in the latest challenge to the Affordable Care Act: Does the law limit subsidies for low- and moderate-income consumers to insurance purchased through an exchange “established by the state.”

The phrase at issue is found in a section of the law that outlines how subsidies should be calculated. It has taken on enormous importance because only 13 states and the District of Columbia operate their own exchange, or marketplace. Three more states established marketplaces, but rely on the federal HealthCare.gov online market. The remaining 34 states declined to establish a marketplace, leaving the job to the federal government, an option provided by the law.

The challengers argue that the four words mean that no one in these 34 states should get assistance.

The Obama administration, which points to other parts of the law that make clear subsidies are meant to be available everywhere, has been providing aid in all 50 states for the last two years.

Today, an estimated 6.3 million people have subsidized health insurance in states that did not “establish” their own marketplaces.

Here are three ways the justices may answer the question posed in King vs. Burwell and the potential impact of what they decide:

http://www.latimes.com/nation/la-na-supreme-court-health-law-decision-20150617-story.html

'Death-with-Dignity' Bill Fails in the Maine Legislature 

By THE ASSOCIATED PRESS • 21 HOURS AGO

AUGUSTA, Maine - Maine lawmakers have defeated a bill that would have allowed doctors to provide lethal doses of medication to terminally ill patients.

Republican Sen. Roger Katz's bill died Tuesday because the Senate and House failed to agree on the bill.

The Republican-controlled Senate narrowly rejected the bill with an 18-17 vote earlier this week. The Democratic-led House supported it with a 76-70 vote.

Katz and other supporters said that people who don't have much time left to live should be free to end their life when they are ready. But opponents said lawmakers should focus on expanding access to palliative care. They said they feared it would send the message that the state of Maine condones suicide.

Five states currently allow dying patients to end their lives under a doctor's care. 

HTTP://NEWS.MPBN.NET/POST/DEATH-DIGNITY-BILL-FAILS-MAINE-LEGISLATURE

THE U.S. HEALTH CARE SYSTEM: REALLY THE BEST?

By Samuel Metz, M.D.
Anesthesiology News, June 2015

In his opinion piece (Anesthesiology News 2015;41[February]:44), Dr. S.J. Slavin takes the proverbial ax to the tree of American health care reform. And he wields it with gusto. Two assumptions animate his swing and both deserve careful attention: 1) Despite its flaws, our U.S. health care system is better than any other, and 2) foreign nations have nothing to teach us.

Such patriotic vigor is understandable. After all, America gave the world Elvis Presley, footprints on the moon and the oil depletion allowance. With such achievements, why shouldn’t we think of ourselves as world leaders in health care?

Unhappily, our success in rock ’n’ roll, technology and finance does not translate to health care. Americans pay twice as much as citizens in the average industrialized nation — our health care is the most expensive on earth. Yet our public health is a disgrace. There are 60 other countries where a pregnant woman and her baby have better chances of surviving the pregnancy.¹ American diabetics are more likely to suffer a foot amputation from an untreated ulcer than are diabetics living anywhere else where you can drink the tap water.²

Our infant mortality rates are the highest in the civilized world, as Dr. Slavin noted, even when compared only with other nations that, as Dr. Slavin wrote, do not throw out premature babies and label them “miscarriages.” Our life expectancy ranks 30 to 35 in the world, even after correcting for trauma, traffic accidents, racial disparity and smoking.³ And each year, 44,000 Americans die of treatable diseases because they lack money for treatment.⁴ Patients in other countries might wait for elective treatment, but Americans might very well die before they get essential treatment. There’s no wait time longer than the rest of your life.

Adding insult to the injury of expensive care and dismal outcomes is that medical debt is the leading cause of personal bankruptcy in the United States. Most of those bankrupt families owned an insurance policy when the medical crisis began — so much for insurance policies protecting access to health care.⁵ A further insult is that “medical bankruptcy” is an exclusively American disease. In no other country will you lose your home, your foot or your life if you can’t pay for health care.

Our results look bad even when compared only with foreign nations that don’t impose government control on health care (most of them don’t). Socialized medicine or not, every other industrialized nation provides better care to more people for less money than we do. In spite of Dr. Slavin’s caution to turn our backs on these alien, socialist, non-American solutions, we should still pay attention.

Universal Health Care?

The common characteristic of nations with better results at less cost is a universal health care plan. Regardless of how it’s implemented, the administrative efficiency of universal care more than compensates for the added costs of more benefits to more people.

Example: UnitedHealthcare provides private insurance to 24 million Americans, most of them healthy enough to hold steady jobs and wealthy enough to afford high-end policies. The company spends almost 20%⁶ of its premium dollars paying for 37,000 administrators.⁷ In contrast, Taiwan’s national health care service, which also cares for 24 million people (employed and unemployed, sick and healthy, rich and poor), spends 1% of its premium dollars paying for 2,900 administrators⁸ — a 90% reduction in administration, enabling the health service to provide comprehensive coverage to 100% of the population.

In fact, no nation on earth spends more money than we do on health care administration, nor requires as many administrators, nor loses as much money filtering its premium dollars through insurance companies as we do.

This administrative loss doesn’t include the administrative losses of we physicians who spend $82,000 a year — each — desperately attempting to collect our payment from an insurance industry that denies 30% of all first claims.⁹

Parenthetically, Dr. Slavin mentions Danny Williams, the wealthy premier of Labrador, who flew to Miami for his mitral valve repair rather than stay in Canada. This story is instructive. Mr. Williams’ first option included Canadian hospitals in Ottawa and Toronto that specialize in the operation. He could then have his operation performed at public expense immediately by surgeons who enjoy international reputations.

However, Mr. Williams consulted a college friend in New Jersey who recommended a surgeon in Miami. Miami had the advantage of being close to Mr. Williams’ vacation condominium in Sarasota. Mr. Williams opted to have his operation performed by a less experienced surgeon in another country at his own expense. The operation took twice as long as expected, but Mr. Williams did just fine. He recovered uneventfully at his nearby condo.

This story may or may not reflect quality of health care in the two countries. But it certainly illustrates, as Dr. Slavin might agree, that wealthy people sometimes make medical decisions based on convenience, word-of-mouth and other nonmedical factors, just like the rest of us.

We all share Dr. Slavin’s frustration at the hideous complexity and injustice of our country’s health care system. Yet our despair should not blind us to the single most important lesson that other industrialized nations with better systems (i.e., all of them) can teach us: Start with a universal care plan, and build on that.

Health care reform does not need to be the terrifying specter that Dr. Slavin warns against. It can be the first step toward better care to more people for less money.

A tree bearing that kind of fruit deserves nurturing, not the ax.

HTTP://WWW.PNHP.ORG/PRINT/NEWS/2015/JUNE/THE-US-HEALTH-CARE-SYSTEM-REALLY-THE-BEST

When Doctors Don’t Talk to Doctors

By ALLISON BOND

 JUNE 18, 2015

I could tell my patient was dying. In the final stage of liver failure, she lay listlessly in her hospital bed, her skin ashen and her eyes dull. Intractable intestinal bleeding, likely related to her underlying disease, had landed her in the intensive care unit. Although all patients in intensive care are tenuous, it was clear she was worse off than most.

Her daughter and granddaughter hovered worriedly near her bedside. “What is going to happen to her?” her daughter asked me, her voice wavering.

I proposed a family meeting in a small room nearby to discuss the next steps in her care. As her loved ones and I sat around the table, I explained that our team and the consultants had concluded that one option was to insert a tube to briefly stop the bleeding. The tube was merely a temporary fix, however; for a number of reasons, there was no way to permanently stanch the flow of blood. Alternatively, we could focus on making her as comfortable as possible. Given her underlying liver disease, even if the bleeding stopped, she would live a few days at most. 

“She would never want any of this,” her daughter said softly, dabbing her wet eyes with a tissue. “She’s been saying for months that she knew her time was coming. She was at peace with it.”

Her mother would not want to undergo the procedure – her daughter was sure of that. She would want simply to die peacefully, without pain and surrounded by family.

Yet when we returned to her room, we found that another team had already inserted the tube. I was shocked and livid. Such a critical miscommunication between doctors taking care of the same patient horrified me. 

I apologized profusely and, surprisingly, the family was not upset; the procedure had not been painful, and she died peacefully that night. When her family left the hospital, they expressed gratitude for her care and did not mention the tube. 

Yet I felt disturbed, and I couldn’t stop thinking about it. What if the tube placement had ended up being very painful or had caused physical harm? 

Poor communication between doctors and patients, and between doctors and nurses, is discussed relatively frequently. But what about confusion between the teams of doctors who share patients in the hospital or clinic? 

HTTP://WELL.BLOGS.NYTIMES.COM/2015/06/18/WHEN-DOCTORS-DONT-TALK-TO-DOCTORS/?HPW&RREF=HEALTH&ACTION=CLICK&PGTYPE=HOMEPAGE&MODULE=WELL-REGION&REGION=BOTTOM-WELL&WT.NAV=BOTTOM-WELL

Republican Proposals To Extend Obamacare Subsidies Would Create Big Problems

BY ROBERT LASZEWSKI

While both the Republican House and Senate plans would create a means for people to continue to be covered in the wake of any Supreme Court finding that ended the Obamacare subsidies in the federally run states, what we so far know about these proposals is clearly unworkable in the market and would lead to very big and unfortunate unintended consequences.

Both Senate and House Republicans are now openly discussing what they would do if the Supreme Court strikes down the Obamacare subsidies in at least 34 states.

Senator Ron Johnson (R-WI) has offered a plan to extend the Obamacare subsidies if the Supreme Court strikes them down. His plan is supported by at least 31 Republican senators including the Republican Senate Majority Leader, Mitch McConnell (R-KY).

Johnson’s plan would continue subsidies only for people already getting their health insurance coverage on Obamacare and only through September 2017.

Most importantly, no new people would be able to enroll in Obamacare subsidized coverage during this period. Presumably, Republicans would offer a more permanent fix in 2017 when we have a new President and Congress.

This proposal would be an underwriting nightmare for the insurance companies leading to much higher prices and fewer options for consumers during the transition period.

According to the Obama administration, during the most recent 2015 Obamacare open enrollment, 8.84 million people signed up for coverage in the 37 states that used the federal enrollment platform through February 15^th. More than half––4.6 million––were new customers.

Having such a high percentage of an individual health insurance program’s enrollment recently enrolled is not new. That is pretty much how the individual market has always worked. We have always referred to the individual market as a “high churn” market as people transition away from individual health insurance—often because they start a new job where employer coverage is offered, or qualify for Medicare or Medicaid, or simply decide to opt out of the health insurance market.

http://www.forbes.com/sites/robertlaszewski2/2015/06/18/republican-proposals-to-extend-obamacare-subsidies-would-create-big-problems/

Researchers find prescription drug benefit did not save money for Medicare

June 16, 2015 by Joe O'ConnellFor years, the Medicare pre­scrip­tion drug ben­efit Part D has been cred­ited with pos­i­tively impacting national trends in health out­comes and med­ical ser­vices. But a recent study led by North­eastern asso­ciate pro­fessor Becky Briesacher chal­lenges that assump­tion and sug­gests that the U.S. Con­gres­sional Budget Office’s adopted a new costing method based on assumed cost-​​savings may be “premature.”

ince its imple­men­ta­tion in 2006, Part D has sub­stan­tially increased access to pre­scrip­tion drugs for the nearly 50 mil­lion Medicare sub­scribers. That increased access, though, has not led to a clear decrease in emer­gency room visits, hos­pital stays, inpa­tient costs, or mor­tality, according to the research by Briesacher and her team, which included col­leagues from Har­vard Med­ical School.

“We are con­cluding that Medicare Part D did not save the (Medicare) pro­gram any money overall,” said Briesacher, a health ser­vices researcher in the School of Phar­macywith nationally-​​recognized exper­tise in drug policy and med­ica­tion use in older adults. “You have to be real­istic about the fact that giving people access to med­ica­tion is impor­tant, but it’s not going to sub­stan­tially save money in other parts of the health care system or keep a sig­nif­i­cant number of people out of the hospital.”

The team pre­sented its results in a paper pub­lished Monday in Annals of Internal Med­i­cine.

http://www.northeastern.edu/news/2015/06/researchers-find-prescription-drug-benefit-did-not-save-money-for-medicare/

The latest legal challenge to Canada's healthcare system

A primer on the legal dispute between Dr. Brian Day and British Columbia – and how it may affect Canada's healthcare system

By Karen S. Palmer, M.P.H., M.S.
EvidenceNetwork.ca, June, 18, 2015

In British Columbia, as in the rest of Canada, the health care system, “Medicare,” provides public funding for all medically necessary hospital and physician services.

The Canada Health Act (federal legislation enacted in 1984) strongly discourages private payment, such as extra billing and user charges, for hospital and physician services covered under Medicare. If provinces (except Quebec) allow private payment for such services, the federal government is mandated to withhold an equivalent amount from federal cash transfers. With rare exceptions, this financial penalty for failing to comply with the legislation has been effective in restricting extra billing and other user fees.

The CHA is silent on care delivery, taking no position on whether health care should be delivered in private, not-for-profit or private, for-profit facilities.

When are doctors legally permitted to charge patients?

Under BC legislation, physicians enrolled in (and thus being paid by) the BC Medical Services Plan (MSP) must work entirely within the publicly-funded system when providing medically necessary care, whether that care is provided in hospitals or privately-owned facilities. As long as physicians are enrolled in MSP, they are prohibited from charging BC residents any fee for, or in relation to, the delivery of medically necessary hospital and physician services.

Physicians are, however, permitted to completely un-enroll from MSP. Non-enrolled physicians in BC may charge patients whatever amounts they want for providing medically necessary services, so long as those services are not provided in a “hospital” or a “community care facility” (as defined by the Hospital Act).

Patients are permitted to pay a non-enrolled physician out-of-pocket, but not with private “duplicative” insurance (such insurance — covering the same patients and services as the public insurance — does not currently exist in BC). Very few BC physicians are non-enrolled in MSP.

What’s the court case about?

Dr. Brian Day, the President and CEO of two private for-profit investor-owned facilities (Cambie Surgery Centre and their partner, Specialist Referral Clinic, neither of which is designated as a “hospital”) is challenging the prohibition on private billing by enrolled physicians.

Dr. Day alleges that the limits on charging patients privately, enshrined in the Canada Health Act (CHA, and its equivalent provincial legislation in BC), infringe patients’ rights to life, liberty and security of the person under Section 7 of the Canadian Charter of Rights and Freedoms.

The essence of Dr. Day’s claim is that, because the publicly-funded system compels some patients to wait for the delivery of some medically necessary services (in particular, elective surgery), patients should have the right to obtain such services more quickly by paying privately, either out-of-pocket or through private insurance.

Dr. Day supports a system of “dual practice” in which physicians can be paid from both public and private purses, including through private health insurance covering medically necessary hospital and physician care.

Beyond this, Dr. Day also argues that even physicians still enrolled in MSP should be allowed to “extra bill” patients — through out-of-pocket payment and private insurance — who do not wish to wait their turn for publicly-funded care. His rationale is that since BC physicians not enrolled in MSP are already permitted to collect out-of-pocket payments for care delivered outside of hospitals or community care facilities, then private duplicative insurance should also be for sale to BC patients who do not wish to wait for publicly-funded care, even when they are treated by physicians still enrolled in MSP.

Why is the province of BC opposing Day’s position?

The Attorney General (AG) of BC will argue against these changes to Medicare, based on evidence affirming that allowing a parallel private payment system, and physician dual practice, in an otherwise publicly-funded health care system, negatively affects these systems.

The AG will argue that there is no causal connection between BC’s limits on private payment and the alleged deprivation of life, liberty or security of the person.

Instead of care being delivered on the basis of need, as is the case now, overturning the limitations on private payment would result in care being provided first to those who can afford to pay. This means that if the law impeding extra-billing is over-turned, then all physicians would be able to charge patients whatever fees they wished, on top of what physicians are already paid by the government.

The AG will argue that care should be delivered on the basis of need, not ability to pay. If the same physicians are delivering both publicly-funded and privately-funded care, evidence from other countries shows that patients who can afford to pay out-of-pocket or through private insurance are likely to get care faster, regardless of their need. When physicians preferentially treat private pay patients, the probable result of a parallel public-private pay system is increased wait times for those unable to pay.

The AG will also bring evidence to show that allowing a multi-payer health care system will lure physicians from the public-pay sector to the private-pay sector, potentially reducing the availability, quality and timeliness of care in the publicly-funded system.  It will also argue that a multi-payer health care system that includes private health insurance will drive up costs, forcing public funders to pay higher prices to “compete” with private insurers.

The trial is expected to commence in the British Columbia Supreme Court in November 2015.

http://www.pnhp.org/print/news/2015/june/the-latest-legal-challenge-to-canadas-healthcare-system

From Exchange to Egalité

However the Supreme Court rules, Obamacare isn’t enough. We need a more fundamentally egalitarian health care system

By A.W. Gaffney, M.D.
Jacobin magazine, June 18, 2015

Though admittedly not its most emblematic feature, one rather remarkable aspect of the French Revolution was its ambitious orientation towards the provision of social welfare, including medical care. Following a period of great deprivation, the French revolutionaries “endeavored to set up a national system of social assistance, inclusive of health care,” as the great historian of medicine George Rosen wrote; they furthermore “called attention to the need for assistance, inclusive of medical care, in neglected areas and for neglected groups in the population.”

Alas, as Rosen and others have noted, they also violently undercut the inadequate but at least functional system of church-based charitable care — before their own sweeping projects ever came close to fruition. Good intentions were insufficient, and it was the poor and ill who suffered the consequences.

With both Bastille Day and a decision in King v. Burwell — the case now before the Supreme Court that may threaten the viability of the Affordable Care Act (ACA) — soon to be upon us, this episode seems reasonably relevant. The Affordable Care Act isn’t — and is never going to be — adequate for delivering health care justice. At the same time, the sudden withdrawal of private health insurance from millions of Americans would be a human travesty that no sensible left should countenance, much less celebrate.

Yet such an acknowledgement must not mean turning a blind eye to the deep structural inadequacies of our health care system, which will persevere — whatever the decision of the Supreme Court — until more fundamental change is won.

A Vulnerable System

There are many roads to what is called, often problematically, “universal health care.” Some nations — for instance, Canada — have systems of national health insurance in which a governmental “payer” insures everyone (though the provision of care may remain predominantly private). Other nations have “national health services” — e.g., Britain — where the provision of care is a direct public service.

The health care reforms embodied in the ACA are neither of these: the law instead contains a number of intricate, interlocking provisions designed to lower the number of uninsured while preserving the role of private insurers (and also accommodating, not infrequently, the for-profit provision of care).

Understanding the complicated interdependency of the ACA’s insurance reforms is crucial to appreciating its fundamental vulnerability to legal challenges. This interdependency is frequently conceived as a precarious “three-legged stool”: a well-aimed kick delivered to any single leg, it is argued, would topple the law in its entirety.

The first “leg” is the ACA’s provision preventing insurance companies from discriminating against those with “pre-existing” conditions (for instance, through the imposition of punishingly high premiums). This particularly popular provision most easily accords with a sense of common decency.

The second leg of the stool is the “individual mandate,” a concept with its genesis, as is frequently noted, in the conservative Heritage Foundation. The mandate requires that the uninsured buy private health insurance or pay a penalty, so as to prevent “free riders” from taking advantage of the protections afforded by the first leg (for example, by postponing the purchase of insurance until one is in the throes of a terrible illness). In 2012, this leg came close to being severed in the Supreme Court case National Federation of Independent Business v. Sebelius, but emerged with its constitutionality intact by a single vote.

And third, given that it would be rather cruel to mandate the purchase of health insurance for people who cannot physically afford it, the law provides income-adjusted subsidies for those who buy plans on the ACA’s “exchanges.” It is this leg that is now under threat in King v. Burwell.

The legal basis for the suit revolves around what seems to be sloppy wording in one provision of the law. Sarah Kliff of Vox traces the origins of the case back to a 2010 presentation at a conference hosted by the conservative American Enterprise Institute and “aimed at finding new ways to challenge the healthcare law.”

The presentation, Kliff writes, pointed out one eyebrow-raising finding: a single provision of the ACA referred to subsidies being available to those who purchased insurance in exchanges “established by the state.” However, most states — thirty-four at present — have elected not to set up their own exchanges, and to instead rely on the federal government’s exchange (which the law permits).

If the Court finds that residents of those thirty-four states are not eligible for federal subsidies, it could deliver a potentially fatal blow to Obamacare: those who purchased plans in these states would quickly lose the subsidies that made buying health insurance affordable.

However, many legal scholars, interpreting the provision more contextually, are highly suspicious of the merits of this case. For instance, though the law professor Timothy Jost, writing in theNew England Journal of Medicine, acknowledges that the provision is “awkwardly worded,” he opines that nonetheless:

The purpose of the statute is clear, however, and there is no evidence, other than the four words on which these cases turn, that Congress meant to deny millions of Americans health insurance simply because their states elected not to operate exchanges.

Though that may be true, the health care access of these millions now very much hinges on the Supreme Court’s interpretation of the clause.

As things stand, individuals and families earning up to 400% of the federal poverty level are eligible for premium subsidies; in the thirty-four states using the federal exchange, about 6.4 million people (or 87% of those buying insurance on the exchange) would be at risk of losing these subsidies.

According to the Kaiser Family Foundation, the loss of these subsidies would translate into an average premium increase for these individuals and families of 287% (ranging from a 132% increase in Arizona to a whopping 650% increase in Mississippi).

Furthermore, those who were sick would try harder and sacrifice more to stay in the exchanges than those who were well, which would further destabilize the actuarial basis for the marketplace. According to modeling by the RAND Corporation, this would result in an overall decline in enrollment in the individual market by 9.6 million.

And Congress isn’t likely to deliver to Obama the simple “one sentence” fix needed to resolve this snafu, while a variety of substantial political and legal barriers would preclude or at least hinder an effective, expeditious remedy at the state level.

Though there may be some debate about the precise effects of uninsurance on mortality, the consequences of such an abrupt change should not be underestimated. Simply put, pulling the rug — or the hospital bed — out from under millions of people cannot be accomplished without substantial bloodshed. By one estimate, some 9,800 “additional deaths” a year may result from such a surge in the ranks of the uninsured.

Towards a Better World

And yet, a careful look at the very health insurance plans now under threat in King v. Burwell (the “non-group” plans purchased through the ACA exchanges) demonstrates why the heath care reform law, and the US health care system as a whole, will remain grossly unjust regardless of the Supreme Court’s ruling.

First, the combination of the individual mandate, the expansion of Medicaid, and the subsidy-supported health insurance plans (assuming a positive outcome in King) will still leave some 27 million people in America uninsured.

Second, the exchange plans themselves reflect a type of health insurance entirely at odds with a more expansively defined “universal health care,” in which health care access is not only universal, but also equitable, and where covered services are free at the point of care. Many of those who receive subsidies to purchase plans on the exchanges, for instance, still have serious financial exposure to medical bills.

Average deductibles — i.e. money paid out of pocket before insurance kicks in — for the standard “silver” family plans in 2015 are estimated to be $6,010. Out-of-pocket costs for copayments and deductibles — after premium payments — can be as high as $13,200 for a family making as little as 250% of the federal poverty level (or $60,625 for a family of four). Such out-of-pocket health care costs satisfy the dogmatists of “consumer-driven medicine” while further squeezing the working class.

Third, equality of access is not assured. Insurers gain negotiating power with providers by issuing plans that limit access to particular hospitals and physician groups. For instance, Anthem Blue Cross and Blue Shield in New Hampshire excluded ten out of the twenty-six hospitals in the state from its plans. These so-called “narrow networks” have caused understandabledissatisfaction, as individuals and families are unable to be seen by the physicians or in the facilities of their choosing; they then can get stuck with astronomical bills when, whether by choice, necessity, or accident, they are seen “out-of-network.”

Given such limitations, is it inconsistent to denounce an outcome in King that strips many of health care access? Certainly not: our friends, family members, partners, and patients currently rely on such plans. This is the awkward position that the Left always straddles when flawed social welfare programs come under attack.

Yet the vision of a more just health care system must not, in the process, be lost. In particular, it is an emphasis on the revolutionary notion of égalité that is absent from the health care discourse. A health care system based on the principle of equality would not feature the overlapping, interconnected disparities endemic to the American health care system: persistent uninsurance, “metallic tiers” of coverage, uneven and inequitable “networks,” non-financial barriers to care for the poor, and continued financial hurdles for those who aren’t wealthy. (Such divisions can be exploited by populists on the Right, and may explain — in part — the persistent divisiveness of the law among Americans.)

The meaning of equality has changed. Today, as the French historian Pierre Rosanvallon put it in his recent book The Society of Equals, equality is used as “a sort of negative incantation — ‘reduce inequalities’ — without a corresponding positive image of a better world.” This is even more true in health care. Moving forward must mean going beyond a discussion of increasing “health care access,” and working towards a vision of health care equality founded upon a single-payer national health program.

http://www.pnhp.org/print/news/2015/june/from-exchange-to-egalité

Mixed Effects Are Seen on an Affordable Care Act Repeal

By ROBERT PEARJUNE 19, 2015

WASHINGTON — The nonpartisan Congressional Budget Office said Friday that repealing the Affordable Care Act would significantly increase federal budgetdeficits and the number of people who are uninsured.

But, it said, repealing the law would also raise economic output because it would create incentives for some people to work more.

The estimates came in the first major study issued by the new director of the budget office, Keith Hall. It was also the first report to use new methods of fiscal analysis, according to instructions from the Republican majority in both houses of Congress.

Repealing the law would increase federal budget deficits by $137 billion in the decade from 2016 to 2025, Mr. Hall said in the report. In addition, he said, the number of uninsured people, estimated at 35 million under current law, would increase by 24 million if the law was repealed.

Mr. Hall itemized the likely changes: Fourteen million fewer people would be enrolled in Medicaid, and 18 million fewer people would have private insurance purchased on the open market or on public exchanges established under the health law. But eight million more would have coverage through employers.

The report came as consumers, lawmakers and politicians wait anxiously for a Supreme Court ruling on health insurance subsidies paid under the health care lawto millions of people in more than 30 states.

President Obama has repeatedly threatened to veto legislation repealing the health care law, his biggest legislative accomplishment as president, but Republicans keep trying and stepped up their efforts this year after taking control of both houses of Congress.

Proposals to repeal the law are included in legislation being prepared by Republicans to respond to the Supreme Court decision, which is expected within days.

The report by the budget office is sure to be cited by members of both parties as they continue fighting over health care through the 2016 elections. Democrats, defending the law they passed five years ago, can use the report to argue that repealing the law would be a bad move because it would increase the deficit. Republicans can use it to argue that the law itself is bad.

http://www.nytimes.com/2015/06/20/us/politics/mixed-effects-are-seen-on-an-affordable-care-act-repeal.html?&hp&action=click&pgtype=Homepage&module=first-column-region&region=top-news&WT.nav=top-news&_r=0

At Home, Many Seniors Are Imprisoned by Their Independence

JUNE 19, 2015

by Paula Span

What she mourns most, says Solange DeLaPaz, are the mundane pleasures and rituals of her once-active life. A weekly manicure at the corner nail salon. Saturday excursions to Macy’s shoe department.

“I miss going to Sunday brunch on Second Avenue with my friends,” she said. “I miss going to church.”

Though only 67, Ms. DeLaPaz retired early with chronic obstructive pulmonary disease and now struggles to leave her Manhattan apartment. She needs constant oxygen, and carrying even a portable oxygen unit troubles her breathing.

Climbing or descending the few steps from the elevators into her building’s lobby presents another obstacle. “I wouldn’t dare do that on my own,” she said.

About every three weeks, therefore, the home care aide who provides 12 hours of city-subsidized weekly assistance accompanies Ms. DeLaPaz outdoors. They walk to the corner and back, perhaps a six-minute expedition. Other outings are largely limited to medical appointments, with an escort from the social service agency Dorot.

Unlike some homebound older people, Ms. DeLaPaz doesn’t feel isolated, she said. Friends and relatives stop by; between a son’s and a grandson’s visits from Texas and California, she stays in touch online and by phone. A hairdresser and a priest make house calls. A volunteer helps with grocery shopping; a pharmacy delivers prescriptions.

Being homebound in rural areas can be harder and lonelier. Even for Ms. DeLaPaz, however, “being inside the house all the time is stifling. I’m confined.”

Almost two million people over age 65, or nearly 6 percent of those Americans (excluding nursing home residents), rarely or never leave their homes, researchers recently reported in JAMA Internal Medicine. The homebound far outnumber the 1.4 million residents of nursing homes.

Using data from the 2011 National Health and Aging Trends Study, the study authors defined as homebound those who in the past month had not left their homes at all or had gone out no more than once a week. The researchers categorized another six million people as “semi-homebound,” able to leave home only with difficulty or with another’s assistance.

http://www.nytimes.com/2015/06/23/health/at-home-many-seniors-are-imprisoned-by-their-independence.html?hpw&rref=health&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well