U.S. life expectancy declines for the first time since 1993
In all, death rates in 2015 rose for eight of the top 10 leading causes of death.
In all, death rates in 2015 rose for eight of the top 10 leading causes of death.
A wave of revulsion rolls around the world. Approval ratings for incumbent leaders are everywhere collapsing. Symbols, slogans and sensation trump facts and nuanced argument. One in six Americans now believe that military rule would be a good idea. From all this I draw the following, peculiar conclusion: no country with a McDonald’s can remain a democracy.
Twenty years ago, the New York Times columnist Thomas Friedman proposed his “golden arches theory of conflict prevention”. This holds that “no two countries that both have McDonald’s have ever fought a war against each other since they each got their McDonald’s”.
Friedman’s was one of several end-of-history narratives suggesting that global capitalism would lead to permanent peace. He claimed that it might create “a tip-over point at which a country, by integrating with the global economy, opening itself up to foreign investment and empowering its consumers, permanently restricts its capacity for troublemaking and promotes gradual democratisation and widening peace”. He didn’t mean that McDonald’s ends war, but that its arrival in a nation symbolised the transition.
In using McDonald’s as shorthand for the forces tearing democracy apart, I am, like him, writing figuratively. I do not mean that the presence of the burger chain itself is the cause of the decline of open, democratic societies (though it has played its part in Britain, using our defamation laws against its critics). Nor do I mean that countries hosting McDonald’s will necessarily mutate into dictatorships.
What I mean is that, under the onslaught of the placeless, transnational capital that McDonald’s exemplifies, democracy as a living system withers and dies. The old forms and forums still exist – parliaments and congresses remain standing – but the power they once contained seeps away, re-emerging where we can no longer reach it.
The political power that should belong to us has flitted into confidential meetings with the lobbyists and donors who establish the limits of debate and action. It has slipped into the diktats of the IMF and the European Central Bank, which respond not to the people but to the financial sector. It has been transported, under armed guard, into the icy fastness of Davos, where Friedman finds so warm a welcome (even when he’s talking cobblers).
Above all, the power that should belong to the people is being crushed by international treaty. Contracts such as Nafta, Ceta the proposed TransPacific Partnership and Trade in Services Agreement and the failed Transatlantic Trade and Investment Partnership are crafted behind closed doors in discussions dominated by corporate lobbyists. And those lobbyists are able to slip in clauses no informed electorate would ever approve of, such as the establishment of opaque offshore tribunals, through which corporations can bypass national courts, challenge national laws and demand compensation for the results of democratic decisions.
These treaties limit the scope of politics, prevent states changing social outcomes and drive down labour rights, consumer protection, financial regulation and the quality of neighbourhoods. They make a mockery of sovereignty. Anyone who forgets that striking them down was one of Donald Trump’s main promises will fail to understand why people were prepared to risk so much in electing him.
At the national level too, the McDonald’s model destroys meaningful democracy. Democracy depends on reciprocal belief, trust and belonging: the conviction that you belong to the nation and the nation belongs to you. The McDonald’s model, by rooting out attachment, could not have been better designed to erase that perception.
As Tom Wolfe observes in his novel A Man in Full, “the only way you could tell you were leaving one community and entering another was when the franchise chains started repeating and you spotted another 7-Eleven, another Wendy’s, another Costco, another Home Depot”. The alienation and anomie this destruction of place promotes are enhanced by the casualisation of labour and a spirit-crushing regime of monitoring, quantification and assessment (at which McDonald’s excels). Public health disasters contribute to the sense of rupture. After falling for decades, for instance, death rates among middle-aged white Americans are now rising. Among the likely causes are obesity and diabetes, opioid addiction and liver failure, diseases whose carriers are corporations.
Corporations, released from democratic constraints, drive us towards climate breakdown, an urgent threat to global peace. McDonald’s has done more than its fair share: beef production is among the most powerful causes of climate change.
In his book The Globalisation Paradox, the Harvard economist Dani Rodrik describes a political trilemma. Democracy, national sovereignty and hyperglobalisation, he argues, are incompatible. You cannot have all three at once. McDonaldisation crowds out domestic politics. Incoherent and dangerous as it often is, the global backlash against mainstream politicians is at heart an attempt to reassert national sovereignty against the forces of undemocratic globalisation.
An article about the history of the Democratic party by Matt Stoller in the Atlantic reminds us that a similar choice was articulated by the great US jurist Louis Brandeis. “We may have democracy, or we may have wealth concentrated in the hands of a few, but we can’t have both,” he said. In 1936 the congressman Wright Patman managed to pass a bill against the concentration of corporate power. Among his targets was A&P, the giant chainstore of his day, which was hollowing out towns, destroying local retailers and turning “independent tradesmen into clerks”.
In 1938 President Roosevelt warned that “the liberty of a democracy is not safe if the people tolerate the growth of private power to a point where it becomes stronger than their democratic state itself. That, in its essence, is fascism.” The Democrats saw concentrated corporate power as a form of dictatorship. They broke up giant banks and businesses and chained the chainstores. What Roosevelt, Brandeis and Patman knew has been forgotten by those in power, including powerful journalists. But not by the victims of this system.
One of the answers to Trump, Putin, Orbán, Erdoğan, Salvini, Duterte, Le Pen, Farage and the politics they represent is to rescue democracy from transnational corporations. It is to defend the crucial political unit that is under assault by banks, monopolies and chainstores: community. It is to recognise that there is no greater hazard to peace between nations than a corporate model that crushes democratic choice.
Twitter: @GeorgeMonbiot. A fully linked version of this column will be published at monbiot.com
Our View: There is no easy fix for health care reform law
'Repeal and delay' would cause much worse havoc than anything now in the Affordable Care Act.
Editorial - Portland Press Herald
Health care, with its interlocking systems of public and private insurers and providers, is complex, so health care reform is never easy.
But for the last four election cycles we have heard Republican office seekers say that it’s really simple. All you have to do is repeal “Obamacare,” they said, and replace it with something better.
But replace it with what? Anyone who can remember back before 2010, when you could be denied insurance because of a pre-existing condition, lose your insurance for getting too sick or find your medication unaffordable because you fell into a “doughnut hole,” knows that some things are worse than Obamacare.
Now some Republicans in Congress are saying that the solution should be “repeal and delay,” cutting out the legs from the health reform law and spend the next three years designing an alternative. As if what America really needs is three years of uncertainty and upheaval in the health care economy.
A recent study by the Urban Institute puts some of what’s at stake into perspective. If congressional Republicans pass a partial repeal of the Affordable Care Act through budget reconciliation (a process that requires only a majority vote in the Senate), they could eliminate Medicaid expansion, and tax credits for people who buy insurance on the exchanges, as well as individual and employer mandates.
While we wait for the new plan to take shape, this is what we could expect to see:
n 22.5 million would drop insurance they can’t afford without a subsidy.
n The individual market would collapse, driving insurance companies out, leaving millions more Americans without options.
n Hospital costs for uncompensated care would skyrocket.
There is a better way, even if it won’t match the hot rhetoric of the campaign trail.
While Republicans have talked about replacing the Affordable Care Act, Democrats have said that it should be fixed. There might be enough improvements that both parties could agree on that would satisfy the Republican promises in the short run, while the new administration takes on a more thorough reform.
Negotiating prescription drugs and expanding payment reform trials that reward wellness are among the small changes that could make a big difference.
Maine Sen. Susan Collins said that until she sees a bill, she’s not sure how she would vote on a plan to dismantle the ACA without replacing it right away.
But she did express her concern about the order of the steps that some of her colleagues are proposing. “I think what we need to focus on first is what would we replace it with and what are the steps to do that,” she told the Press Herald last week.
Collins is a longtime critic of the ACA, and would be a good source for recommendations on how it could be changed. We urge her to offer those ideas and fight an irresponsible repeal and delay strategy.
Incremental reforms are not the easy fix that some members of Congress are promising, but they’re a much better way to approach a problem for which no fix is easy.
New push to replace Obamacare reignites old GOP tensions
by Mike Debones and Kelsey Snell - Washington Post
Republicans on Capitol Hill are already laying the groundwork for a rapid repeal of President Obama’s signature health-care law beginning on the first day of the new Congress, before President-elect Donald Trump is even sworn in.
But the urgent efforts to make good on a Republican campaign promise six years in the making obscure major GOP divisions over what exactly to replace Obamacare with and how to go about it, and how long a transition period to allow before the law’s insurance would go away.
Hard-liners are pushing to move as fast as possible, bolstered by a GOP base eager to see lawmakers follow through on years of promises. But key congressional leaders are keenly concerned about potentially throwing millions off their insurance plans and repeating what they have long decried as Democratic missteps eight years ago, sparking a fierce political backlash by moving too far, too fast.
While Trump could sign legislation gutting the Affordable Care Act before the spring bloom, a full replacement could take months, if not years.
“I’d like to do it tomorrow, but reality is another matter sometimes,” said Sen. Orrin G. Hatch (R-Utah), chairman of the Senate Finance Committee that will help lead the “repeal and replace” efforts. “We have to live with the real world. And the real world right now is that the Democrats won’t help with anything.”
Trump has vowed to 'repeal and replace' Obamacare. Here's why it won't be so easy.
Play Video1:52
Donald Trump has campaigned to repeal and replace the Affordable Care Act, otherwise known as Obamacare, once he gets into office. Now that he's won the presidency with a majority Republican House and Senate, that feat might not prove to be too easy. Wonkblog's Max Ehrenfreund explains. (Daron Taylor/The Washington Post)
Hatch and other high-ranking Republican senators are pushing for an extended transition period that could keep large portions of Obamacare in effect until 2019 or beyond, allowing time to carefully craft a replacement and push the final debate past the midterm elections.
Many of them, like Sen. Susan Collins (R-Maine), have been chastened by conversations with insurers and state regulators who are warning of chaos in the market for individual insurance if Congress moves rashly.
“I don’t want to leave the 84,000 people in Maine who are buying insurance on the exchange uninsured because, all of a sudden, two-thirds of them who have subsidies have lost that subsidy,” Collins said.
But those Republicans are clashing with GOP colleagues — many of them sent to Congress in the midterm, anti-Obama waves of 2010 and 2014 — who see little reason to dawdle.
“The history of this place is, the longer it takes, the more exponentially the probability grows that it’ll never get done,” said Rep. Mark Meadows (R-N.C.), elected recently as the new chairman of the hard-right House Freedom Caucus. “Republicans have been saying they have a replacement plan for over two years, so why do we need three years?”
Part of the problem is that Republicans have never been able to agree on a replacement plan, despite railing against Obamacare for nearly eight years now. Their foot-dragging is a function of internal divisions and the political peril of floating a detailed alternative that would be closely evaluated for costs and benefits. Trump has also been vague, promising a “terrific” replacement that will provide “great health care at a fraction of the cost.”
The current battle centers on when exactly to schedule Obamacare’s sunset. But other fights loom — over what precisely a replacement plan should look like, whether Obamacare’s Medicaid expansion will continue, whether lawmakers should also now tackle the future of Medicare, and how Congress should assist insurers during the transition.
The battle lines, however, are familiar, with “establishment” Republicans on one side and conservative insurgents, mainly in the House, on the other. Those dynamics pushed GOP leaders into increasingly dramatic confrontations with President Obama and last year helped force House Speaker John A. Boehner (R-Ohio) to retire.
Come Jan. 20, Obama will no longer serve as a foil for Republicans, and while Senate Democrats could block parts of a health-care overhaul, the real fight will occur inside the GOP.
Senate Majority Leader Mitch McConnell (R-Ky.) has announced plans to put an Obamacare repeal on the Senate floor come Jan. 3. But that will only set the stage for a future repeal bill that will have to tackle major decisions such as a sunset date and interim measures to stabilize insurance markets.
So far, Trump and key GOP leaders on Capitol Hill have shied away from taking firm positions on repeal and replace, but they have done little to tamp down the expectations of conservatives expecting a swift and wholesale substitute.
“We’re going to repeal Obamacare lock, stock and barrel,” Vice President-elect Mike Pence told donors to the conservative Heritage Foundation recently. “The number one priority of this administration is to keep that promise to the American people.”
Hard-liners on Capitol Hill see Pence and Rep. Tom Price (R-Ga.), Trump’s pick for health and human services secretary, as allies in their push for quick and decisive action. Pence called on Congress to pass a repeal bill “with all deliberate speed” but pledged only to then “set into motion a process to replace it.”
House Speaker Paul D. Ryan (R-Wis.) said Thursday that Republicans would move “as well and as fast as we can but make sure that the transition does not pull the rug out from under people.”
Transition spokesman Sean Spicer said Friday that Obamacare replacement strategy has been part of discussions Trump and Pence are having with top congressional leaders and that the talks are ongoing.
“The idea is to really figure out the sequencing on both the repeal and the replace,” he said.
Conservative activists who pushed a take-no-prisoners approach toward the Obama administration say their patience is limited.
“When Republicans have the House, the Senate and the White House, you don’t wait,” said Adam Brandon, president and chief executive of FreedomWorks, a conservative advocacy group. “I’m a Cleveland Indians fan. I only get a shot at a World Series every couple decades. When you have a shot to do it, you do it. That’s it.”
Democrats and many health-care experts are warning that a swift repeal could lead insurers to stop selling policies to individuals on federally mandated exchanges. More than 12 million Americans are covered under those policies.
Health and Human Services Secretary Sylvia Mathews Burwell briefed Senate Democrats on Thursday on the expected unraveling of Obamacare’s insurance exchanges, according to people familiar with her remarks inside the closed-door meeting.
“Delayed replacement is a situation where it is basically repeal and chaos in terms of what will ensue, because of the uncertainty that will get presented to insurers, providers, consumers and states,” Burwell told reporters after the meeting.
Republicans want to end Obamacare’s system of penalties and subsidies. But many — including Trump — want to continue to ban insurers from denying coverage or sharply increasing rates for the sick.
Experts warn that “repeal and delay” under those conditions would prompt insurers to flee the individual market. Linda J. Blumberg, a senior fellow at the Urban Institute, said insurers could face as much as $3 billion in losses if healthy individuals leave the market once the subsidies and penalties are eliminated.
“That $3 billion is the tip of the iceberg,” Blumberg said. “With all of these changes and the uncertainty, it is hard to predict how bad the risk is going to get.”
Keeping insurers in the market during the transition could require Congress to step in with bailout payments, something that would be deeply unpopular among conservative lawmakers.
“The insurance industry should understand that there’s a new sheriff in town,” said Rep. Ken Buck (R-Colo.), a Freedom Caucus member. “They signed up for Obamacare, and if they want to make a profit, they’re going to have to figure out how to make a profit in a free-market insurance industry.”
The strategy of repealing Obamacare without first replacing it reflects not only the wishes of the GOP base, but also Senate arithmetic.
There will be a slim 52-to-48 Republican majority come January, and while Republicans can gut Obamacare with a simple majority using arcane budget rules, passing a complete replacement will require 60 votes.
Only by dismantling Obamacare first, Republicans say, will they have a chance to persuade enough Democrats to support a replacement plan — and Democrats have already signaled that they will not do so.
“We all know we have to repeal it to get them to even settle down and work with us at all,” Hatch said.
Incoming Senate Democratic leader Charles E. Schumer (D-N.Y.), however, has rejected that strategy. “We’re not going to do a replacement. If they repeal without a replacement, they will own it,” he told The Washington Post recently.
But the Republican base, prodded by conservative media outlets and well-organized activist groups, has been loath to accept Democratic obstruction as an excuse for inaction.
One prominent activist, Jenny Beth Martin, co-founder of the Tea Party Patriots, suggested that Trump could goose the repeal-and-replace efforts by reversing an administrative ruling that gave financial assistance to 11,000 congressional members and staff who were forced onto the Obamacare exchanges under a compromise included in the original law.
“I don’t think anyone thinks that you’re going to flip a switch . . . but the replacement for it needs to happen quickly,” she said. “We want it done as quickly as it possibly can be done.”
Brandon was even blunter: “This is going to be a hard thing for Republicans, but tough [cookies],” he said. “They’re going to have to push this through using parliamentary maneuvers, and guess what? It’s hard.
“The political risk in doing nothing is why you got Donald Trump in the first place,” he added. “The old excuses of having divided government, they’re gone.”
A few strident Obamacare critics are urging activists to soften a bit. “They have to look at the complexity of the problem here, and hopefully they’ll recognize that it’s not quite so simple,” said Sen. Ron Johnson (R-Wis.), who was first elected in the 2010 tea party wave.
But many others are not.
“Literally every Republican member has made this part of their platform in running for Congress,” said Rep. Mark Walker (R-N.C.), a first-termer who will chair the conservative Republican Study Committee next year. “We’ve got to act on it.”
Republicans can’t repeal, replace Obamacare without causing chaos
Editorial Board - Bangor Daily News
With the election of Donald Trump, Republican congressional leaders are eagerly formulating their strategy for repealing the Affordable Care Act. Under their latest plan, “repeal and replace,” Republican leaders would quickly hold a vote to repeal the ACA, or at least portions of it, but set the effective date of the repeal for sometime in the future to give themselves time to come up with a replacement.
This is not workable.
The House has voted more than 60 times to repeal the health insurance law that was a cornerstone of the Obama administration. However, it was easy to vote for a repeal when they knew it had no chance of becoming a reality because President Barack Obama would veto such legislation.
With that brake in the White House soon to be gone, a repeal vote could actually have consequences, such as depriving 20 million people of health care. That alone should give lawmakers pause in their rush to keep a campaign promise.
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Realizing this, Republicans have been soft pedaling their approach to the ACA. A plan under consideration would involve lawmakers repealing Obamacare soon after they return to Washington in January. They can do this with only 51 votes — and, therefore, no participation from Democrats — in the Senate through the budget reconciliation process.
Republicans wouldn’t have a replacement ready for votes for perhaps three years, so the ACA wouldn’t actually be repealed until then. A further complication is that a replacement would have to go through the typical Senate process, where Democrats could filibuster options they do not like.
Under their “repeal and replace” scenario, Republican leaders pretend that somehow people covered by the ACA will continue to have health insurance until they have a replacement figured out, even if it takes years.
But this isn’t how it would work.
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Once they knew the ACA was headed for repeal or significant change, with no idea of what would replace it, insurance companies would have no incentive to continue to develop new policies or to bring new customers into the system build around the 2010 law. That system would slowly collapse, well before the GOP has developed a replacement.
“The idea that you can repeal the Affordable Care Act with a two- or three-year transition period and not create market chaos is a total fantasy,” Sabrina Corlette, a professor at the Health Policy Institute of Georgetown University, told The New York Times. “Insurers need to know the rules of the road in order to develop plans and set premiums.”
Lawmakers also can’t repeal just the unpopular parts of the law, especially the individual mandate, and pretend the system will continue to work. The individual mandate was meant to bring younger, healthier people in the ACA market. Without them, the ACA pool is older and less healthy — and more expensive to insure.
U.S. Sens. Susan Collins and Angus King will be important bulwarks against this wrong-headed approach. King is opposed to repealing the ACA but open to changing parts of the law, if people currently covered do not lose their insurance.
“In addition to the direct human costs, the idea being floated of ‘repeal now, replace later’ injects a high level of uncertainty into the entire health care system, which currently constitutes one-sixth of our national economy. This is as dangerous as it is unnecessary,” King said in a statement to the Bangor Daily News.
“Those so intent on repealing the law have had seven years to come up with a credible replacement but have never done so,” he added. “My position is simple: Let’s see the replace before we start talking about the repeal.”
Collins has long advocated changes to the ACA but she believes a replacement plan must accompany any repeal effort to prevent people, including 84,000 in Maine, from losing their insurance coverage. As for fixes, Collins would target the rapid rise in premium costs and the decrease in insurers participating in the ACA marketplaces in many states, including Maine.
“We have an opportunity to develop solutions that are affordable and ensure that Americans have access to diverse insurance plans that meet their needs,” she said in a statement to the BDN. “I look forward to evaluating all legislative reform proposals introduced in the new Congress to increase the availability of affordable, quality healthcare for millions of Americans.”
The best way for Congress to proceed is to develop workable fixes to the ACA instead of voting to repeal it.
http://bangordailynews.com/2016/12/10/opinion/editorials/republicans-cant-repeal-replace-obamacare-without-causing-chaos/
New Coalition Will Push Back on Repeal of Obama Health Law
by The Associated Press - December 9, 2016
WASHINGTON — Supporters of the 2010 health care law will launch a political coalition Friday to block its repeal. They're targeting Republican lawmakers whose constituents may now be at risk of losing health insurance.
The initial goal is to stop Congress from repealing the law without simultaneously passing a replacement for some 20 million people covered through subsidized private health insurance and expanded Medicaid.
Called "Protect Our Care," the group brings together organizations that helped pass the Affordable Care Act, also known as "Obamacare."
On the list are the NAACP, liberal advocacy groups like Families USA and the Center on Budget and Policy Priorities, the Service Employees International Union, which represents many health care workers, and the Center for American Progress, a think tank closely aligned with the Obama White House.
Coordinating the group's activities will be Leslie Dach, a former Wal-Mart executive responsible for public policy and government affairs who also was a top adviser to Health and Human Services Secretary Sylvia Burwell in the Obama administration.
"Repeal and Delay is no better than repeal. American families deserve to know what will happen to them before Congress acts," the coalition said in a statement.
Republicans, who are considering first voting on repeal and then passing a replacement later, say their goal is a smooth transition to a system that will provide access for all Americans with fewer government requirements. The effective date of the repeal legislation would be delayed by months or years to give lawmakers time to figure out a replacement. But after six years trying to undo President Barack Obama's signature law, Republicans have not reached consensus on what their replacement would look like.
"It is highly irresponsible to move forward with repeal alone," said Ron Pollack, head of Families USA, and an organizer of the coalition.
A recent poll found that only about 1 in 4 people want President-elect Donald Trump to entirely repeal the health law. The post-election survey by the nonpartisan Kaiser Family Foundation underscored the nation's deep political divisions over health care. Thirty percent want to expand what the law does, 26 percent want it completely repealed, 19 percent say it should be implemented as is, and 17 percent say it should be scaled back.
The poll found some skepticism about repealing the law first and replacing it later. Forty-two percent of those who want the law repealed said lawmakers should wait until they figure out the details of a replacement plan before doing so.
A study earlier this week estimated up to 30 million people would be at risk of losing coverage, because a repeal-only approach could destabilize the entire health insurance market for people who don't have job-based coverage, not just those who buy their policies through HealthCare.gov.
Republicans say there's no turning back for them.
"Obamacare isn't fixable," House Ways and Means Chairman Kevin Brady of Texas said in a recent interview. But he added that Republicans want a replacement that provides affordable health care, and will allow an appropriate transition period.
Editors' Note:
Here is the response to the above AP article by Don McCanne of Physicians For A National Health Program
-SPC:
Comment by Don McCanne
The conservatives want to repeal much of the Affordable Care Act (ACA) and replace it with something similar. The centrists want to preserve ACA pretty much as it is. Although the specifics are important since many people could lose their coverage and the effectiveness of health plans could diminish further, in the global perspective we’ll still be left with a highly dysfunctional health care financing system that will not cover everyone while perpetuating inadequate coverage for many of those who are insured.
The national dialogue leading up to ACA early on was a debate between making modest adjustments in the financing system we had or replacing it with a much more effective and equitable system that would truly cover everyone while making health care affordable for all.
But very soon the Democratic Party leadership along with representatives of a multitude of supposedly liberal organizations (many through HCAN) coalesced around reform that would greatly benefit insurers, the pharmaceutical industry, and other vested interests. Those supporting comprehensive reform through a single payer national health program were quickly booted out of the process, and the media became silent on single payer. That ended the debate, and we moved on to providing some beneficial tweaks to the existing dysfunctional system, when instead we should have had an honest dialogue over the weak, inadequate policies of what became ACA and the profound, sweeping benefits that characterize the single payer model.
Here we go again. Our health care financing system is still in shambles with tens of millions remaining uninsured and the insured having increasing difficulties in obtaining care in the narrow provider networks while facing financial hardship because of the insurers shifting ever more risk onto the patients. And the “Protect Our Care“ coalition of centrists wants to make this a debate between protecting the shambles versus making them even worse through “replace” policies that would further weaken health care coverage.
No!! The debate needs to be between accepting or tweaking a system in shambles or moving on to a well-designed single payer system - an improved Medicare for all - affordable, accessible health care for everyone.
The same people who took control last time and led us down the wrong path are now regrouping as the “Protect Our Care” coalition with a mission to protect a program in shambles. We cannot let them get away with it this time. We need to form a large coalition of activist healers to lead us to the high-performance system we desperately need. And, yes, we need to be sure that members of the media understand the difference.
Obamacare's Demise Could Be Quicker Than Republicans Intend
By ALISON KODJAK • 3 HOURS AGO
Republicans in Congress say they'll vote to repeal much of the Affordable Care Act early next year — even though they don't yet have a plan to replace it.
But they also insist that they don't want to harm any of the millions of people who got their health insurance under the law.
The lawmakers' strategy? Vote to repeal, and fulfill their top campaign pledge. But delay the changes, and keep running Obamacare for as long as two years while they figure out how to fill the hole they'll create in the insurance market.
"We will move right after the first of the year on an Obamacare replacement resolution," Senate Majority Leader Mitch McConnell told reporters Monday, using terminology that refers to the type of vote lawmakers will take to defund the health care law.
"Then we will work expeditiously to come up with a better proposal," he added.
House Speaker Paul Ryan has said the plan will protect patients.
"There needs to be a reasonable transition period so that people don't have the rug pulled out from under them," he told reporters at a news briefing at the U.S. Capitol last week.
But repealing the law that essentially created an entire market for health insurance that didn't exist before — and then expecting that insurance market to remain healthy — may be fantasy, according to health insurance consultants.
"I don't think the Republicans have come to grips yet that it's going to be their responsibility to keep the wheels on Obamacare," Robert Laszewski, president of Health Policy and Strategy Associates, told Shots.
Republicans keep saying the Obamacare exchanges are collapsing, Laszewski said. But by voting to kill the law, they may actually speed up that process.
"They're arguing that the thing is in death throes, that the insurance companies are losing tons of money and it's not sustainable," Laszewski said. "Why do they think the insurance companies are going to provide the insurance policies in that scenario?"
An estimated 20 million people have obtained health insurance over the last three years via provisions in the Affordable Care Act. Some get coverage through the insurance exchanges, but millions are covered because of the expansion of Medicaid in most states, and because the law allows young adults to stay on their parents' insurance policies up to age 26.
Laszewski isn't the only one who's skeptical of the "repeal but delay replacement" strategy.
Last week America's Health Insurance Plans — the trade group that represents health insurance companies — circulated a memo on Capitol Hill warning that a sudden repeal of Obamacare could threaten the expanded health coverage for those millions.
"Making sudden, significant changes now, or mid-year, will jeopardize the coverage they depend on," the letter said.
AHIP asked lawmakers to keep in place many of the financial incentives that are central to the law — including the provision of subsidies for people to buy insurance and cover copayments, and the elimination of some taxes on insurers.
The American Academy of Actuaries also weighed in, warning in its own letter that a repeal of the ACA without replacing it would be dangerous to the long-term health of the insurance market.
"Insurers are in a situation right now where they're trying to determine whether or not they're going to participate in 2018," said Cori Uccello, a senior fellow at the American Academy of Actuaries. "And part of that depends on whether, in the long run, it makes sense for them to participate in the market. And that long run depends on what's going to happen, not just in 2018, but in the years after 2018."
The big problem is that through Obamacare, the government plays a huge role in helping people pay for insurance on the individual market. Many insurance companies are already losing money on those policies, so if they think the government won't keep offering subsidies, insurers may just stop selling individual policies altogether.
They won't necessarily wait to find out what Congress is hoping to do at some point in the future.
Insurers "will have to see more than the repeal element," Shubham Singhal, head of the health care practice at McKinsey, who consults with health insurance companies, told Shots. "They'll have to see, if it's delayed, then what's the transition plan? That's going to be quite important for them, to understand whether it creates a stable marketplace or not."
Another complication is that Republicans won't be able to repeal the law outrightbecause — in order to pass a regular piece of legislation in the Senate — they would need the support of Democrats to overcome a filibuster.
So they will have to use a special legislative maneuver that allows them to pass any bill related to taxes or the budget with a simple majority. That means lawmakers can defund Obamacare but leave some provisions in place, including a requirement that insurers cover people who have pre-existing medical conditions.
Most experts believe having that requirement in place with no mandate for healthy people to buy insurance will lead companies to quit writing individual insurance policies altogether.
So, even people who had insurance before the Affordable Care Act became law, and who pay for it without subsidies, could lose their coverage.
"I don't think the Republicans are taking this anywhere seriously enough," Laszewski says. "They could get themselves into a real hole."
Advocates Say Despite National Trend, Mainers Still Struggle to Pay Medical Bills
By PATTY WIGHT • NOV 30, 2016
Fewer American families are struggling to pay their medical bills, according to a report from the Centers for Disease Control.
Though the number has been in steady decline for the past five years, health advocates in Maine say there are still too many who can’t afford health care. And the problem of paying medical bills may affect more families in Maine than those in other states.
Five years ago, there were nearly 57 million people under the age of 65 who were in families that had a hard time paying medical bills, according to the CDC. This year, that number had dropped about 5 percent to nearly 44 million.
That dip, says Morgan Hynd of the Maine Health Access Foundation, is not surprising, because of the Affordable Care Act.
“The reduction in people and families who are having trouble with that is directly related to the fact that 20 million people now have coverage that didn’t five years ago,” she says.
Uninsured rates are at historic lows, says Emily Brostek of Consumers for Affordable Health Care, so it follows that more people can afford their medical costs.
“What we’ve wanted to achieve through national health reform has worked, to a great extent,” she says.
But, Brostek says, there is room for improvement.
“I would say there are still too many people struggling with their medical bills,” she says. “We hear from people on our help line who literally lose their house because they can’t pay their medical bills.”
Some of these bills were racked up before the Affordable Care Act was in place, says Brostek.
Other calls to the help line come from people who currently have insurance, but struggle to pay ever-increasing deductibles. And then there are people who don’t have any health insurance.
“We still have a number of people who don’t have affordable health coverage options because we haven’t accepted funding available to cover them through our state Medicaid program,” Brostek says.
Which, she says, means the number of Maine families struggling with medical bills likely skews higher than the national average.
The Maine Health Access Foundation released a report last year that found in 2013 and 2014, Mainers across all income levels had more difficulty paying their medical bills compared to the rest of the nation. Whether that gap narrows in the future and more families can afford health care depends on the policies that will be put forth by President-elect Donald Trump.
Trump has said he plans to repeal and replace the ACA. But Hynd says she hopes some elements will be preserved, including the individual mandate to buy insurance.
“Because you really need everyone in the insurance pool to make all the other pieces fit together properly. You need to have the good parts, and the not-so-good parts together,” she says.
In other words, healthier people need to be a part of the insurance pool to help offset the costs of those who are not as healthy.
There’s one other aspect of the ACA that Hynd says is worth preserving to increase health care affordability: Medicaid expansion.
“It’s also something that hasn’t happened in Maine yet, but I hope that Maine will still have the opportunity in 2017 to expand Medicaid,” she says.
This fall, a number of Maine organizations launched a petition to put Medicaid expansion on the ballot.
The Obama Years: Tepid Palliation for America’s Health Scourges
Steffie Woolhandler, MD, MPH, and David U. Himmelstein, MD
The ACA reduced the number of uninsured by 42% to 29 million, about as many as were uninsured in the early 1980s (Figure 1); even if all states expanded Medicaid, about 24 million would remain uninsured. The poor, near-poor, and minorities saw the largest gains, yet 25.8% of poor, nonelderly adults remained uninsured in 2015.
The Medicaid expansion that accounted for much of the new coverage was compromised by some states opting out entirely and by federal waivers allowing others to impose onerous out-of-pocket costs on impoverished enrollees. The ACA also expanded private coverage, but the skimpy plans endorsed by the law and sold on the exchanges (Bronze policies cover just 60% of medical costs) have encouraged the hollowing out of insurance across the board. By 2015, 51% of employer-based individual plans carried deductibles of $1000 or more, up from 27% in 2010.2 In addition, Americans are increasingly constrained by insurers’ narrow provider networks that often exclude leading referral centers, and by restrictive formularies that can make vital medications (e.g., antiretrovirals for HIV) unaffordable. On a more positive note, the ACA mandated first-dollar coverage for contraception and other preventive services and (nominal) parity for mental health and addiction treatment in exchange plans.
Access to care has improved, but remains abysmal, in part because many who gained coverage cannot afford to use it. In 2014, 66 million working-age adults skipped doctor visits, tests, or prescriptions because of costs—down from 80 million in 2012—while collection agencies dunned 37 million for medical debts, a reduction of 4 million.3 Post-ACA, the Consumer Financial Protection Bureau reported that medical debts still account for 52% of all bills sent to collection agencies.
It is disturbing that the ACA has abetted corporate dominance in health care. The law funneled most of its trillion dollars in new federal spending through private insurers as payments for exchange coverage and Medicaid managed care plans, fortifying insurers’ bottom line and political clout. Meanwhile, insurers have skirted the law’s caps on overhead; Aetna’s overhead actually rose from an average of 17.0% in 2008 to 2010, to 19.5% in early 2016. Taken together, insurers’ added overhead and that of the new exchanges will consume 22.5% of the new federal spending.4
The ACA’s promise to cut overpayments to Medicare Advantage plans (estimated at $1000 or more per enrollee) was also undermined, as the Centers for Medicare and Medicaid Services handed out “quality bonuses” to almost all of these private plans. In both the Medicare Advantage program and the exchanges, insurers are abandoning unprofitable local markets while continuing to reap large profits from federal payments in others, essentially cherry-picking by county. The insurance giants, awash in cash, have gone on a shopping and merger spree that will shrink the number of major insurers from five to three, unless two pending mergers are blocked on antitrust grounds.
The ACA’s mandate that Medicare pay for “value not volume” through health maintenance organization–like entities called accountable care organizations has driven a wave of corporate takeovers. The move from fee-for-service to quasi-capitation has not garnered the promised savings5 (and its health impacts remain unknown) but is driving small-scale providers from the market. They lack the financial reserves to bear risk for high-cost patients or to invest in the information technology and administrative systems needed to manage that risk or game the complex new payment incentives, as well as the market clout to bargain with suppliers and private payers. Giant systems have been snapping up practices and hospitals, despite compelling evidence that such takeovers raise costs (particularly when they create regionally dominant systems) and scant evidence that they improve care. The Medicare Access and CHIP Reauthorization Act of 2015 physician payment reform, which disproportionately penalizes small practices, promises to accelerate this trend.
Although some credit the ACA with slowing health care cost growth, the slowdown began in 2005, well before the law was passed, and ended in 2014 when it was fully implemented. It is disturbing that the slowdown was only seen among low- and middle-income Americans; health spending for the wealthiest 20% soared.6
In 2015, there was an almost unprecedented increase in overall US death rates, while the poorest 20% of Americans and middle-aged, non-Hispanic Whites have suffered rising mortality over the longer term. Some of this deterioration represents increasing rates of self-harm and fatal substance use, complex problems that cannot be blamed entirely on politicians. But politicians bear responsibility for the underfunding of mental health and addictions care, and for shrinking public health resources.
Congress and the president have also failed to pull policy levers—regulation, taxation, and social spending—that could ameliorate the market forces deepening the income divide and working-class despair. Between 2009 and 2015, the wealthiest 1% of Americans captured 52% of total income growth—continuing a decades-long trend—pushing the Gini index of income inequality up by 2.4%. Although median family income rose sharply in 2015 (with the poor enjoying the largest percentage gains), it remains 1.6% below the 2007 level.
In sum, inequalities in income and longevity are growing with no apparent inflection during the Obama years.
Could Obama have done better? Not by waging policy battles largely inside the Washington, DC, Beltway. Even during Obama’s first two years in office, when the Democrats controlled Congress, the lobbying clout of insurers and pharma (generous donors to Democrats as well as Republicans) made fundamental reform unwinnable in an inside game. The compromised ACA legislation, crafted to appease these corporate interests, offered nothing to the majority of Americans dissatisfied with the health care status quo, precluding grass roots mobilization and allowing Republicans to rally opposition. It is striking that, in a 2016 Gallup poll, 51% of Americans wanted to repeal the ACA, but 58% (including 41% of Republicans) would replace it with single-payer reform7 (findings that accord with a recent Kaiser survey).
The Sanders and Trump campaigns (and, indeed, Obama’s historic 2008 victory) demonstrated the electorate’s hunger for new directions. America has taken bold and difficult steps in the past: the abolition of slavery, women’s suffrage, Social Security, civil rights, and marriage equality, to name a few. All were gained through powerful, persistent social movements that eventually got their message through to Washington.
Our health and health care deficits are man-made scourges, not products of nature. Curing them will require broad popular mobilizations, not just a well-intentioned president
Partners posts $108m operating loss, its largest
By Priyanka Dayal McCluskey GLOBE STAFF
Partners HealthCare posted the biggest annual operating loss in its 22-year history, driven by red ink at Neighborhood Health Plan, a Medicaid insurer whose finances have deteriorated since Partners acquired it in 2012.
The state’s largest health network said Friday that it lost $108 million on operations in the year that ended Sept. 30, reversing a profit of $106 million a year earlier. Revenue at the parent company of Massachusetts General and Brigham and Women’s hospitals rose 7 percent to $12.5 billion, but expenses grew at a faster clip.
Partners said almost all of the losses — $104 million — came from Neighborhood Health, the largest insurer for low-income families and individuals on the state’s Medicaid program, called MassHealth. The insurer has increased its MassHealth membership by 80 percent in the past three years, but Partners said many of the people were sicker than expected, and that government payments don’t cover the full costs of care.
Partners acquired Neighborhood four years ago to gain a foothold in the insurance business and reach a broader population of patients. It argued that with a health plan in its portfolio, it could develop better ways of delivering care to patients with complex illnesses. But after $322 million in losses over the past three years, Partners is now under pressure to put the insurer on solid footing.
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In October, Neighborhood Healthstopped accepting new MassHealth members while it tries to negotiate new contracts with some hospitals. It is diversifying by bringing in a growing number of business customers. As Neighborhood’s losses mounted, Partners executives even considered selling off the insurance company, but they are now focused on fixing it.
“You can’t bleed red ink forever, but we’ve invested in the management there, brought some new people in,” Partners’ chief financial officer, Peter K. Markell, said in an interview. “We have reorganized to create a commercial division and MassHealth division. We’re pretty committed to trying to make it work.”
Partners’ hospital network also posted a $4 million loss during the year, a rare deficit that Markell attributed to growing competition for patients.
Although Partners has been criticized for using its market power to extract higher payments from insurers, Markell said the payments simply aren’t enough.
“At the end of the day, the biggest issue is the rate of payment we get from commercial payers and Medicare and Medicaid,” he said. “Those payments are not keeping up with wage increases and pharmaceutical costs.”
The financial challenges for the year also included continuing costs of implementing Partners’ new $1.2 billion electronic health record software .
Partners, like many health systems, has money invested in financial markets. When those investments are included, Partners lost $249 million in 2016, compared with a $92 million loss in 2015.
Neighborhood Health is one of six insurers that the state pays to manage care for people on MassHealth. All of those plans face similar challenges: Their members, often struggling with poverty, are more likely to have complex medical needs, and insurers say the state’s reimbursements through the MassHealth program don’t keep pace with their costs.
But Neighborhood Health’s losses have mounted as its MassHealth business has grown. MassHealth accounts for two-thirds of its 454,000 members, and the company is implementing a “corrective action plan.”
“Neighborhood Health Plan struggled financially for some time even prior to Partners’ acquisition of them,” said John Freedman, a health care consultant.
But Neighborhood faces an additional challenge, according to Partners officials and health experts. It is the only insurer available on the state Health Connector and the only MassHealth insurer that offers full access to Partners’ prestigious hospitals, so it tends to attract a mix of patients who are sicker than those who join other health plans.
Mark Shepard, an assistant professor at Harvard’s John F. Kennedy School of Government, has studied Neighborhood Health’s enrollment patterns. “The types of people that select into the only plan covering Partners would tend to be high cost, more likely to use Partners, which is an expensive health care provider, and therefore less profitable to the insurance company,” he said.
There is uncertainty ahead for Neighborhood as the state prepares to roll out a major restructuring of the MassHealth program, moving from the traditional fee-for-service payment model to one that gives providers a fixed amount to take care of patients. Partners also reported that its doctors and hospitals, which account for the bulk of its business, logged weaker financial performances this year. Two community hospitals, North Shore Medical Center and Newton-Wellesley Hospital, saw fewer patients than expected. Partners competes with Lahey Health, Steward Health Care System, Beth Israel Deaconess Medical Center, and other health systems.
“People are being lured away,” Markell said. “It’s just very competitive.”
Even while they advocate for higher payments from insurers, Partners executives have hired consultants to help them find efficiencies and reduce costs.
Partners’ financial challenges are being felt, to some degree, across the health care industry, said Robert S. Huckman, professor at Harvard Business School. “It is a tougher environment for providers and for insurers,” he said. “[There is] pressure to keep costs down, but health care requires labor and equipment and technology, all of which have costs that are increasing.”
Cures Act Gains Bipartisan Support That Eluded Obama Health Law
by Robert Pear - NYT
WASHINGTON — With self-congratulatory zeal and smiles all around, huge bipartisan majorities in Congress have just passed legislation to speed the discovery of cures for killer diseases. At the same time, Republican leaders have been devising a strategy to undo the Affordable Care Act, which has done more than any law in a generation to treat people with those diseases.
“It is a real contradiction,” said Dr. Otis W. Brawley, the chief medical officer at the American Cancer Society.
In recent years, few major bills have commanded as much support as the 21st Century Cures Act, which sailed to passage by votes of 392 to 26 in the House on Nov. 30, and 94 to 5 in the Senate a week later. Once it is signed by President Obama on Tuesday, as the White House has said it will be, the law will allow for money to be pumped into biomedical research and speed the approval of new drugs and medical devices. It also includes provisions to improve mental health care and combat opioid abuse.
“This is the most significant legislation passed by this Congress,” the Senate majority leader, Mitch McConnell of Kentucky, said on Thursday. By contrast, he once referred to the 2010 health law as “the single worst piece of legislation that has been passed in the last half-century.”
Ellen V. Sigal, the chairwoman of Friends of Cancer Research, an advocacy group, said “there’s a disconnect” between efforts to pass the Cures Act and to repeal the Affordable Care Act.
“Most people voting and lobbying on Capitol Hill have health insurance,” Ms. Sigal said. “Intellectually, they may know that some people are suffering without insurance. But do they have empathy? Those who are insured may not emotionally understand what it is like for those who are not insured. We live in our own bubble.”
Lawmakers have their own explanations.
For one thing, the two health care efforts vastly differ in size. At a cost of $6.3 billion, the Cures Act is not small, but the Affordable Care Act cost hundreds of billions of dollars and affected every facet of medicine — from insurance coverage to delivery of care. It was bound to be more difficult to enact.
The Republican authors of the Cures Act — Representative Fred Upton of Michigan and Senator Lamar Alexander of Tennessee — went to great lengths to work closely with Democrats, led by Representative Diana DeGette of Colorado and Senator Patty Murray of Washington. The cooperation paid off.
“We had bipartisan buy-in from Day 1,” Ms. DeGette said.
By contrast, the Affordable Care Act was adopted in 2010 without a single Republican vote — either because, as Democrats have said, Republicans refused to cooperate; or, as Republicans have said, because it was jammed down their throats.
“We have been like the Hatfields and McCoys ever since, shooting each other,” Mr. Alexander said.
Mr. Alexander, deeply frustrated by his dealings with the Obama White House in 2010, learned from that experience. “The next administration or the next Congress will not be repealing the Cures Act,” he said, “because we have taken the time to work out our differences, and create a consensus of support.”
The American Cancer Society supported both the Affordable Care Act and the current biomedical research bill, and sees the two efforts as intertwined.
“The Cures bill includes incredibly important reforms to get treatments to people faster,” said Dr. Brawley, the top medical officer at the society. But he added, “We need to get those treatments to all people faster,” and he emphasized the word “all.”
The surge in spending on medical research will almost surely lead to new treatments, which could include some extraordinarily expensive drug therapies. To get such treatments, patients would need to have not just insurance, but good insurance coverage. (Some drug companies offer prescription assistance programs to help defray the costs.) A repeal of the Affordable Care Act could leave millions without access to the benefits of the biomedical research bill, Democrats have said.
Another factor in passage of the Cures Act was the relentless advocacy of Dr. Francis S. Collins, director of the National Institutes of Health, who helped lawmakers appreciate the possibility of a golden age of medicine — with an artificial pancreas for diabetics, a vaccine for AIDS and the use of stem cells to repair damaged heart tissue.
Representative Steve Cohen, Democrat of Tennessee, said: “My secretary of defense is Francis Collins, because the true enemy of each and every one of us isn’t somebody in South Korea or somebody in Iran or ISIS. It’s cancer, it’s Alzheimer’s, it’s AIDS, it’s diabetes, it’s heart disease — all those dreadful, awful diseases that N.I.H. is looking for cures for.”
Even as Congress wrapped up approval of the Cures Act this week, Republicans were having serious discussions about how to repeal and replace the Affordable Care Act without interrupting coverage for the newly insured. Republicans say they feel an obligation to move fast, because the law is crushing many families and small businesses with high costs.
Democrats say some Republicans want to repeal the president’s signature legislative achievement just because it is called Obamacare. It would be “a poke in his eye politically,” said Senator Tim Kaine, Democrat of Virginia, who warned that a repeal could be “catastrophic to tens of millions of Americans.”
The Cures Act would also increase access to mental health care, which has been a bipartisan goal since the fatal shootings in 2012 of 20 children and six adults at Sandy Hook Elementary School in Newtown, Conn.
But Representative Frank Pallone Jr., Democrat of New Jersey, said the benefits of the mental health provisions “will be far outweighed by the catastrophic harm caused by individuals with mental illness if the Republicans move forward with their radical plans to repeal the Affordable Care Act.”
Sponsors of the Cures Act toured the country, visited clinics, held hearings and listened to patients who recounted their struggles with cancer, Alzheimer’s and dozens of other diseases. Patients and their well-organized advocacy groups proved to be more effective than the uninsured in lobbying Congress.
In debates on the Affordable Care Act, lawmakers have continually fought over the proper role of the federal government.
Republicans see the need for a federal role in conducting research and regulating drugs, but not in regulating the details of health insurance. Under the 2010 law, they have said, the Obama administration has issued so many regulations, bulletins, official policy statements and informal “guidance documents” that not even federal officials can keep track of them all.
Democrats have said the federal standards are needed to guarantee universal access to “essential health benefits,” and to prevent insurers from discriminating against those who are sick.
Bait and Switch: No One Voted to Destroy Medicare
by Nancy Altman - Common Dreams
Donald Trump did not campaign on a promise to destroy Medicare. In fact, he promised not to touch Social Security, Medicare, and Medicaid. But now that the Republicans are in charge of the White House, the Senate, and the House of Representatives, destroying Medicare appears to be on the top of their agenda.
This is classic bait and switch. Trump and his fellow Republicans promised to repeal Obamacare. Now, with the election in the rear-view mirror, House Speaker Paul Ryan has wasted no time in announcing his plan to end Medicare.
"Hostility to Social Security, Medicare, and Medicaid is the Republican establishment’s orthodoxy."
In order to get away with this bait and switch tactic, Ryan falsely claims that Obamacare hurt Medicare. WRONG! The Affordable Care Act left Medicare largely untouched. The Medicare provisions it did include expanded benefits and strengthened the program’s financing. Ryan further claims that they can’t repeal the ACA without dealing with Medicare. WRONG AGAIN! The Medicare provisions can simply be left unchanged. And, finally, and most untruthfully, Ryan claims that he wants to save Medicare. But Medicare does not need saving. It works extremely well.
The truth is not hard to discern. Hostility to Social Security, Medicare, and Medicaid is the Republican establishment’s orthodoxy. Consistent with that orthodoxy, Ryan has been proposing to end Medicare as we know it for years. As Chair of the House Budget Committee, his annual budgets included a plan to turn Medicare into a voucher system – replacing the program’s guaranteed benefits with a fixed, and inadequate, payment to beneficiaries.
Under the Ryan scheme, seniors and people with disabilities would be forced to fend for themselves against private insurance companies. They would have to bear whatever the insurance companies chose to charge, or go without insurance if they couldn’t afford it. And, if Republicans succeed in repealing the ACA with its protection of people with pre-existing conditions, many seniors and people with disabilities now covered by Medicare would be unable to get any coverage whatsoever at any price. Ironically, after railing against Obamacare for years, Ryan and his fellow Republicans want to transform Medicare into Obamacare. The Affordable Care Act is much better than what existed before, but it is much inferior to Medicare.
Not surprisingly, Ryan’s plan to end Medicare has one big problem. The American people – Democrats, Republicans, and Independents – overwhelmingly support Medicare. Not only is the Ryan plan extremely poor policy, it is also incredibly unpopular. Consistent with the unpopularity of the Ryan plan, Republican primary voters rejected the candidates who embraced it – Jeb Bush, Ted Cruz, and Chris Christie, to name the most prominent of the primary’s losers.
Instead, Republican primary voters picked Donald Trump, who made a solemn promise to voters, differentiating himself from the others by declaring loudly and often that he would not cut Social Security, Medicare, or Medicaid. He specifically called out Ryan, saying “You know, Paul wants to knock Medicare way down. I’m not going to cut it, and I’m not going to raise ages, and I’m not going to do all of the things that they want to do.”
Trump’s Medicare promise helped carry him to victory in the GOP primary, and again in November. Many advocates, including me, didn’t trust the promise - particularly after Trump picked as his running mate Mike Pence, a close Ryan ally who has pushed for Social Security and Medicare privatization for years. But despite that, Trump’s promise not to cut Social Security and Medicare (and the media’s willingness to believe it) kept them from being major issues in the campaign.
Now that Trump is President, however, all signs are that he is planning to to betray his supporters and let Ryan and Pence run the show. Less than a week after the election, Ryan announced that Medicare was “part of our plan” going forward – clear code for implementing his privatization plan. To this disturbing announcement, Trump was uncharacteristically quiet. Not a single tweet.
"Today, the Republican target is Medicare, Medicaid and Obamacare. Tomorrow it will be Social Security."
Even more recently, Trump spoke volumes about his view of Medicare and Medicaid when he announced that his nominee to head the Department of Health and Human Services was Representative Tom Price (R-Ga), another Ryan lieutenant and the current House Budget Committee Chair.
Just a few days before his nomination, Price announced that the Republicans planned to “address” Medicare in the first seven or eight months of the Trump administration. Trump’s action makes Price even more powerful in the upcoming battle over Social Security. There’s no question that if Price is confirmed, he will be the fox in charge of the Medicare hen house.
Nobody voted to destroy Medicare, but Paul Ryan, Mike Pence, and Tom Price are determined to make it happen anyway. Thus far, Trump seems entirely willing to be their Medicare cutting puppet or perhaps their quiet ally.
But supporters of Social Security, Medicare, and Medicaid are not going to surrender without a fight. In record time, over a million Americans have signed petitions demanding that the Republicans keep their hands off our Medicare. On Wednesday, boxes containing the more than a million petition signatures were on display at a press conference where
Democratic leaders Chuck Schumer, Nancy Pelosi and Bernie Sanders, together with Representatives Jan Schakowsky (D-IL), Ted Deutch (D-FL), and Tony Cardenas (D-CA), in the best tradition of the Democratic party, pledged to fight tooth and nail this Republican effort. Their message was that we should be expanding, not cutting, Social Security, Medicare, and Medicaid.
After the press conference, a group of seniors, nurses and other concerned citizens, led by Dr. Sanjeev Sriram (stage name, Dr. America), and Jon Bauman (Sha Na Na’s Bowzer) delivered the petitions to Senate Majority Leader Mitch McConnell and House Speaker Paul Ryan.
This is just the first step. Medicare and Medicaid are over a half century old. Having worked on them for over four of those five decades, I know that this is the greatest threat they have ever faced. This is a time when all Americans who care about these vital programs must pay attention.
Today, the Republican target is Medicare, Medicaid and Obamacare. Tomorrow it will be Social Security. For the economic security of all Americans, we must beat back this outrageous attack by the Republican establishment.
Lives and Profits in the Balance: The High Stakes of Medical Patents
by Clyde Habermas - NYT
“The West Wing,” Aaron Sorkin’s television series about a fictional White House, had a knack for crisply summarizing complex real-life issues. In an episode from 2000, pharmaceutical executives and leaders of an AIDS-plagued African country are summoned to the White House. The purpose is to see if reluctant businessmen can be persuaded to sell the Africans desperately needed drugs at a modest price.
“The pills cost ’em 4 cents a unit,” a presidential aide grouses about the companies.
“You know that’s not true,” a colleague says. “The second pill cost ’em 4 cents. The first pill cost ’em $400 million.”
The other man replies, “They also enjoy unprecedented tax breaks, foreign tax credits, research and experimentation exemptions, and expensing of research expenditures.” He might have added that many prescription drugs — antidepressants, arthritis medications, anticancer pills and more — result from research largely financed by taxpayers, not by private companies that reap the profits.
Tensions inherent to drug pricing — that 4-cent second pill versus the $400 million first one — underpin this final installment in the current series of Retro Reportvideos, which examine major news stories of the past and their lasting consequences. To highlight how the ground has shifted in the pharmaceutical world, the video recalls Dr. Jonas Salk, the creator of the first successful vaccine against polio in the 1950s. Dr. Salk’s conquest of this crippling and often deadly disease made him revered even beyond his death in 1995. One poll at the close of the 20th century showed that he was deemed, far and away, the greatest person in medicine over the last thousand years, ahead of Louis Pasteur, Marie Curie and Alexander Fleming.
In a 1955 interview with Edward R. Murrow, Dr. Salk was asked who owned the patent for his vaccine.
“Well, the people, I would say,” he said. “There is no patent.” After a pause, he added with a laugh, “Could you patent the sun?” That attitude was common among men and women of science. The physicist Enrico Fermi said scientists possessed “no proprietary rights” to their creations.
Times change. While the sun remains off limits, patents have become the norm in the drug industry. By the 1980s, even Dr. Salk could not resist them; he obtained patents for a potential AIDS vaccine. Such protections are now the lifeblood of drug companies, a reality raised with Retro Report by Lori M. Reilly of the Pharmaceutical Research and Manufacturers of America, an industry group. “Without patents,” she said, “companies wouldn’t have the incentive to bring a medicine to market.”
But at what cost to consumers? That question is at the heart of public policy decisions that can mean life or death for millions. On average, vital medicines cost appreciably more in the United States than in other developed nations. Annual spending on prescription drugs in this country averages nearly $1,000 a person — a total exceeding $300 billion, or about 10 percent of an overall health care bill of $3 trillion.
Some drug makers have belatedly concluded that their prices are indeed uncomfortably high, and they pledge to limit future increases. During the presidential campaign, their industry was criticized by the candidates of both major parties, and in an interview with Time magazine published last week, President-elect Donald J. Trump said, “I don’t like what’s happened with drug prices.” But how tough with manufacturers Mr. Trump intends to get is far from clear.
Price tags on some medications have been eye-popping. Gilead Sciences charged $1,000 a pill for Solvadi, a drug for hepatitis C. Eli Lilly priced a lung cancer drug, Portrazza, at about $11,430 a month. Pfizer’s list price for Ibrance, a medication for advanced breast cancer, was $9,850 a month.
Then there is Gleevec, which figures prominently in the video. It is a lifesaver for people with chronic myeloid leukemia, a relatively uncommon blood cancer that afflicts an estimated 5,000 Americans every year. Produced by the Swiss company Novartis, Gleevec has been called a miracle drug, and with reason. Unlike many other forms of chemotherapy, it directly attacks the cancer instead of poisoning every cell in the body. It thus gets the job done with few, if any, side effects. But a Gleevec regimen can run to more than $100,000 a year, and it is an expense for life.
Staggering prices lead some health professionals to conclude that profit making has at times turned into profiteering, at the expense of people who could not be more vulnerable.
Pharmaceutical companies, however, respond that in certain cases, a high price for that 4-cent drug is essential if the first $400 million pill is ever to be produced. Clinical trials are expensive, and failure is routine. Many drugs never make it to market.
Also, the companies say, many patients pay nowhere near the full price because of discounts and insurance benefits. Then, too, patents are not forever. Often, a manufacturer has maybe eight to 10 years to turn a profit before its patent expires and the drug may be produced in generic form at a significantly lower price. And profits, the industry adds, are what pay for the costly experimentation that may yield the next miracle.
Does all that money truly go to research and development? Not according to studies that show that the industry spends more on advertising and other marketing mechanisms — twice as much in some instances — than on laboratory work. Kantar Media, a consulting firm that tracks the industry’s spending, put the total devoted to marketing last year at $5.4 billion.
The emphasis on sales would not surprise anyone who watches the evening news. On the major broadcast networks, viewers are typically 60 and older. Accordingly, advertising amounts to a litany of age-related indignities. Kantar Media’s list of the most-advertised prescription drugs is led by Humira, to treat rheumatoid arthritis; Lyrica, for nerve pain; Eliquis, an anti-clotting medication; Cialis, for erectile dysfunction; and Xeljanz, also for rheumatoid arthritis.
A year ago, the American Medical Association urged a ban on these sorts of direct pitches to consumers, but congressional action seems unlikely. Even so, the government’s stake in the drug industry is considerable. A good deal of basic research is financed by American taxpayers, through institutions like the National Institutes of Health.
Under the Bayh-Dole Act of 1980, named for Senators Birch Bayh and Bob Dole, private companies are authorized to obtain patents for a variety of products developed with public money, pharmaceuticals among them. The assumption is that these firms are better positioned than the government to bring innovations to market.
But officialdom has a right under the law to withdraw patents from companies that put drugs out of reach because of high prices. It has yet to intervene despite petitions calling on it to do so. The pharmaceutical lobby, a dependable source of campaign contributions, is not readily defied in Washington. Politicians have resisted appeals to let Americans buy drugs lawfully in other countries and to allow Medicare, the nation’s biggest drug purchaser, to negotiate lower prices with pharmaceutical companies. That Americans want cheaper medicines seems incontestable. In a September poll by the Kaiser Family Foundation, 77 percent of those surveyed described prescription drug costs as “unreasonable.”
The industry’s reputation is hardly enhanced when someone like Martin Shkrelicomes along. The founder of Turing Pharmaceuticals, the smirking Mr. Shkreli seized upon a generic drug for treating a parasitic infection and summarily raised its price to $750 a pill from $13.50. The industry’s image suffered another blow when Mylan sharply raised, to $600, the list price for EpiPen, which is vital to treat severe allergy attacks.
Mr. Shkreli, who faces criminal charges on a separate matter, defended his actions at a health forum last year. “It’s a business,” he said. “We’re supposed to make as much money as possible.” But not everyone regards lifesaving drugs as just another product ripe for exploitation.
In 2013, some 120 doctors and researchers from around the world, all specialists in chronic myeloid leukemia, banded together to denounce the high prices being demanded for drugs like Gleevec. Leading them was Dr. Hagop M. Kantarjian of the MD Anderson Cancer Center in Houston. With prices at “unsustainable” levels, Dr. Kantarjian said, “pharmaceutical companies have lost their moral sense.”
The Power of Simple Life Changes to Prevent Heart Disease
by Aaron Carroll - NYT
Billions of dollars are spent every year on medications that reduce the risk of heart disease — the No. 1 killer in the United States.
But some people feel powerless to prevent it: Many of the risk factors seem baked into the cake at birth. Genetic factors can have a huge impact on people’s chances of dying of heart disease, and it has long been thought that those factors are almost always outside of one’s control.
Recent research contradicts this, though, and that should give us all renewed hope.
Since the 1930s, we’ve recognized that heart disease runs in families. For the last decade, we’ve been able to identify specific genes that are linked to coronary artery disease. In fact, these genes seem to have a cumulative effect. People who have more of them are at greater risk.
Familial factors are some of the strongest arguments for using drugs like statins widely. After all, there’s only so much you can do about your cholesterol through diet and exercise changes. Some people can see reductions in cholesterol only through pharmacological intervention.
Still, we tend to treat those at low risk with lifestyle changes, while those at high risk get more intensive therapy. A new study in The New England Journal of Medicine argues that thinking may be wrong.
Researchers gathered data from four large prospective cohort studies that followed thousands of people for years, looking at the relationships between various risk factors and heart disease. The first began enrolling patients in 1987 and the last in 2008. Even though specific genes of interest weren’t known when these studies began, data were available that allowed scientists to evaluate genetic risk decades later. Using about 50 different variations — single-nucleotide polymorphisms (otherwise known as SNPs) — researchers created a risk score.
They also looked at how lifestyle factors were associated with outcomes. These included not smoking cigarettes, not being obese (having a B.M.I. less than 30), performing physical activity at least once a week and having a healthful diet pattern.
That last criterion was defined as doing at least half of the following recommendations: eating more fruits, nuts, vegetables, whole grains, fish and dairy products and eating less refined grains, processed meats, unprocessed red meats, sugar-sweetened beverages, trans fats and sodium. Every one of the four lifestyle factors was associated with a decreased risk of coronary events.
That’s the first bit of good news. Doing any one of these things makes a difference.
But the effect is cumulative. The researchers divided people into three groups based on these factors. “Favorable” required at least three of the four factors, “intermediate” required two of them, and “unfavorable” required one or none. Across all studies, those with an unfavorable lifestyle had a risk that was 71 percent to 121 percent higher than those with a favorable lifestyle.
More impressive was the reduction in coronary events — heart attacks, bypass procedures and death from cardiovascular causes — at every level of risk. Those with a favorable lifestyle, compared with those with an unfavorable lifestyle, had a 45 percent reduction in coronary events among those at low genetic risk, a 47 percent reduction among those with intermediate genetic risk, and a 46 percent reduction among those at high genetic risk.
What does this mean in real-world numbers? Among those at high genetic risk in the oldest cohort study, 10.7 percent could expect to have a coronary event over a 10-year period if they had an unfavorable lifestyle. That number was reduced to 5.1 percent if they had a favorable lifestyle. Among those at low genetic risk, the 10-year event rate was 5.8 percent with an unfavorable lifestyle and 3.1 percent with a favorable lifestyle. In the other cohort studies, similar relative reductions were seen.
These differences aren’t small. The risk of a coronary event in 10 years was halved. The absolute reduction, more than 5 percentage points in the genetic group at high risk, means that lifestyle changes are as powerful as, if not more powerful than, many drugs we recommend and pay billions of dollars for all the time.
There are caveats, of course. All of the participants in these analyses were white, because there are few well-validated genetic studies in black populations. But the researchers also saw similar findings in the black population of the oldest cohort. These aren’t randomized controlled trials, and there could be other factors at play that we aren’t measuring. But the results were consistent over a number of studies, and the effect size is large.
There are important lessons to be learned. These results should encourage us that genetics do not determine everything about our health. Changes in lifestyle can overcome much of the risk our DNA imposes.
Lifestyle changes are hugely important not only for those at low risk, but for those at high risk. The relative reductions in events were similar at all levels of genetic risk.
Moreover, given how changes in lifestyle will also reduce your risk of other diseases like cancer (the No. 2 killer), it’s clear that a healthier lifestyle could have huge implications for many, many more people.
It’s important to acknowledge that these lifestyle recommendations are even less constrictive than those I’ve discussed in the past. You need only be a current nonsmoker; past smoking doesn’t exclude you. You can also be overweight, just not obese. And in contrast with most physical activity recommendations, it requires only once-a-week exercise, not the 30 minutes for five days that most professional organizations like the American Heart Association endorse.
Maine’s Largest Health Network Looks to Consolidate Spending
An emerging proposal by Maine’s largest health network is asking its hospitals in 10 Maine communities to consider relinquishing oversight of their budgets to the parent organization, a move that could affect health care for hundreds of thousands of Maine residents.
MaineHealth, based in Portland, seeks to combine its member hospitals into a single, $2 billion organization overseen by one governing board. Currently, member hospitals determine their spending priorities on the local level first, with a subsequent review by the network board.
MaineHealth calls its proposal part of a necessary evolution in the face of growing economic pressures. But the idea, although still in the early stages, is already fueling concern about how much control local communities would maintain over the hospitals that anchor their regions.
The proposal would affect patients throughout southern and western Maine at the flagship Maine Medical Center in Portland, Spring Harbor Hospital in Westbrook, Franklin Memorial Hospital in Farmington, LincolnHealth in Boothbay and Damariscotta, Pen Bay Medical Center in Rockport, Southern Maine Health Care in Biddeford and Sanford, Waldo County General Hospital in Belfast, and Stephens Memorial Hospital in Norway.
MaineHealth is a not-for-profit, but measured by revenue, this reorganization would create the largest business headquartered in Maine, exceeding L.L. Bean. MaineHealth is already Maine’s largest employer, with about 18,000 employees who work throughout the system.
“The rapidly changing industry landscape is forcing the conversation about governance and operating model unification across MaineHealth sooner than many of us had anticipated,” states a MaineHealth white paper about the proposal provided to the Bangor Daily News. “These trends are proving highly disruptive for our members and threaten to undermine our efforts to provide excellent, patient-centered care.”
Yet the proposal could prove a tough sell in some of MaineHealth’s communities, particularly where the system has already asked local boards to cut services or undergo difficult mergers with neighboring hospitals.
“The concern about loss of autonomy, which they acknowledge, is very real,” said Andy Coburn, a rural health expert at the University of Southern Maine’s Muskie School of Public Service. “People don’t want to give up their ability to govern themselves.”
New role for local boards
While MaineHealth’s hospitals are its most recognized members, the proposal also would affect a number of health organizations connected to them. The hospitals are run by legally separate corporations that oversee a broad range of related services, such as primary care practices, specialty physician groups, home health care providers, nursing homes and mental health care.
Those corporations fall under the MaineHealth umbrella, but they operate with some independence, choosing their own boards that weigh in on budgeting, which health services to offer, and how to improve the quality of care they provide, among other responsibilities.
The local residents who serve on those boards often help decide, for example, whether to invest in a new MRI scanner, hire a new CEO or undertake an expensive construction project.
That structure ensures a measure of local control, though MaineHealth still must approve their spending plans. The parent system also handles back-office functions such as billing, human resources and implementing a shared electronic medical records system.
But the configuration makes it hard for MaineHealth to channel its considerable financial and clinical resources toward struggling hospitals in more rural regions, according to officials. The burdens on hospitals, particularly smaller ones, are only increasing, including shrinking payments by government health insurers even as hospitals take on more responsibility for keeping their communities healthy.
As a result, some are forced to cut services that both the hospitals and MaineHealth agree their communities need, according to Bill Caron, president of MaineHealth.
“As our smaller hospitals get into financial difficulties, they’re making decisions that are inconsistent with those care models,” Caron said. “They can’t afford to fund the activities that we all believe are appropriate locally.”
Under the proposal, MaineHealth could more easily shift money, physicians and other resources to the hospitals that need them most, system officials say.
“You’ll have a rural health system that’s doing OK financially, then you’ll have another one that’s really struggling, having to cut essential services. You’ll have one that’s able to attract physicians and providers, and another one can’t. … Those legal separations make it very hard to take the resources and easily deliver them,” said Susannah Swihart, chair of MaineHealth’s board of trustees.
The proposal, which MaineHealth officials describe as a “unification,” would require its communities to think more broadly about their role in the system, Caron said. Pen Bay Medical Center would have to consider patients in Farmington, for example. Doctors in Biddeford would need to consider their counterparts in Norway, and so on.
“We’re saying to our local communities and our local boards, ‘We want you to play a different role than you’ve played in the past,’” Caron said.
How budgeting works now
Member hospitals already work with MaineHealth to set their operating budgets each year. Local CEOs work with the system on an outline, then hammer out details with their local boards. Once approved, the budgets go to MaineHealth’s board for approval. All of the member budgets then get added together to form an operating budget for the entire system, Caron said.
Under the proposal, those corporate boards would consolidate into one entity. The unified board would then decide how best to spend the unified pool of money across the system, rather than each of the 10 members making decisions for their local community.
“The bottom line here is we’re trying to take $2.2 billion of assets and operating revenues each year and say that we need to protect the care that we believe belongs in each one of our communities with that full asset base,” Caron said.
That arrangement could potentially benefit its member hospitals, say MaineHealth officials. The consolidation would give the system a way to offset disadvantages that smaller hospitals suffer from the way Maine, and the rest of the country, pays for health care.
Hospitals make the most money on the types of services that have become concentrated at bigger hospitals such as Maine Medical Center, such as hip and knee replacements, and heart and brain surgeries.
Smaller hospitals that used to perform those services now send those patients to Maine Medical Center and lose out on potential profits. They’re left providing more basic, but important, primary and preventive care for which health insurers often don’t fully reimburse.
“We don’t want a hospital to feel like they’re going to hurt their bottom line by doing the right thing for the patient,” said Bill Burke, chair of Maine Medical Center’s board of trustees and a member of the MaineHealth board.
Maine Medical Center, with all those patients flowing to its operating rooms from elsewhere in the system, is profitable, while at least three other hospitals in the system — Franklin, Pen Bay and Southern Maine Health Care — are losing money. The proposal would give MaineHealth a way to more fairly allocate that money throughout the system, officials say.
The proposal aims to also make it easier for medical staff to work throughout the system and allow the rural hospitals to benefit from Maine Medical Center programs, such as clinical trials and recruiting medical students through Maine Medical Center’s partnership with the Tufts University School of Medicine.
MaineHealth is discussing the proposal with its members and plans to do so for the next six months, Caron said. In the spring, the organization will decide whether to move forward, and estimates unification would take another year to 18 months.
MaineHealth officials do not believe they need state or federal antitrust approval, but will meet with the Maine attorney general’s office this week about regulatory requirements, Caron said.
“Most people believe we’ll be unified at some point,” he said. “The question is, is now the right time, or is it five years from now, 10 years from now?”
Early concerns
Some members are already voicing concern about a corporate board in Portland making health care decisions for their communities. The medical staff at Waldo County General Hospital in Belfast has said it doesn’t support the plan as currently known.
“We fear that further loss of the independence of our hospital will lead to decisions by others who are not a part of, nor equally concerned about our community as those of us
who live and work here,” the staff wrote in a Nov. 22 letter to their board.
The medical staff went on to raise questions about how the proposal would affect staffing, health care services, finances and community involvement, among other areas.
“There are many other very important questions, about which we don’t even know enough to ask, for we have so little knowledge of the details of the proposed agreement,” they wrote.
The Belfast hospital’s board merged with Pen Bay’s board in 2015 at MaineHealth’s urging, a challenging process that led to more sharing of physicians and services. This proposal would bring even more change.
Greg Dufour, who sits on both the board that oversees Waldo and Pen Bay, and the MaineHealth board, said, “We want the med staff to weigh in. There has to be more information coming out, because while we have the concept of unification, we have a lot of details to work out.”
MaineHealth officials acknowledge those questions need answers. They’re just beginning to reach out to local boards, and plan to seek out community feedback after their local boards and medical staffs weigh in, Caron said.
“We don’t know if this is the right answer yet. … If it doesn’t make sense for the majority of our communities, we’re not going to do something,” he said.
Under the proposal, member hospitals would still offer advice and make recommendations to the larger board, Caron said. But, he said, no decisions have been made about what kind of representation member hospitals would have on a unified corporate board.
He also declined to speculate about how the proposal might proceed if some MaineHealth members oppose any final plan, if one is reached.
But he did say that officials envision some specific areas remaining in local hands, such as ensuring the quality of the health care that’s delivered in each region and the process to credential and issue privileges to medical staff.
Whether a local board makes those decision is secondary to a larger question — whether the voices of the communities and physicians will be heard, said Gordon Smith, executive vice president of the Maine Medical Association.
“The issue is are people listening?” he told the Sun Journal. “Are the people that are actually providing the care, do they feel they’re being respected and their opinions valued and that they have a voice? And if you have all those things, I don’t think it matters if you have an advisory committee or a board or no board. Those are the things that, day-to-day, physicians tell me make a difference.”
MaineHealth also must overcome lingering resentments in certain communities, such as Boothbay, where its handling of the closure of the only emergency room on the peninsula in 2013 spurred backlash. Caron said MaineHealth relationship with the community has since improved, and officials learned important lessons about community involvement in such decisions.
“They understand that these are difficult community processes,” said Coburn of the University of Southern Maine. “They also know that they can’t just dictate anything.”
Sun Journal staff writer Lindsay Tice contributed to this report.
MaineHealth, based in Portland, seeks to combine its member hospitals into a single, $2 billion organization overseen by one governing board. Currently, member hospitals determine their spending priorities on the local level first, with a subsequent review by the network board.
MaineHealth calls its proposal part of a necessary evolution in the face of growing economic pressures. But the idea, although still in the early stages, is already fueling concern about how much control local communities would maintain over the hospitals that anchor their regions.
The proposal would affect patients throughout southern and western Maine at the flagship Maine Medical Center in Portland, Spring Harbor Hospital in Westbrook, Franklin Memorial Hospital in Farmington, LincolnHealth in Boothbay and Damariscotta, Pen Bay Medical Center in Rockport, Southern Maine Health Care in Biddeford and Sanford, Waldo County General Hospital in Belfast, and Stephens Memorial Hospital in Norway.
MaineHealth is a not-for-profit, but measured by revenue, this reorganization would create the largest business headquartered in Maine, exceeding L.L. Bean. MaineHealth is already Maine’s largest employer, with about 18,000 employees who work throughout the system.
“The rapidly changing industry landscape is forcing the conversation about governance and operating model unification across MaineHealth sooner than many of us had anticipated,” states a MaineHealth white paper about the proposal provided to the Bangor Daily News. “These trends are proving highly disruptive for our members and threaten to undermine our efforts to provide excellent, patient-centered care.”
Yet the proposal could prove a tough sell in some of MaineHealth’s communities, particularly where the system has already asked local boards to cut services or undergo difficult mergers with neighboring hospitals.
“The concern about loss of autonomy, which they acknowledge, is very real,” said Andy Coburn, a rural health expert at the University of Southern Maine’s Muskie School of Public Service. “People don’t want to give up their ability to govern themselves.”
New role for local boards
While MaineHealth’s hospitals are its most recognized members, the proposal also would affect a number of health organizations connected to them. The hospitals are run by legally separate corporations that oversee a broad range of related services, such as primary care practices, specialty physician groups, home health care providers, nursing homes and mental health care.
Those corporations fall under the MaineHealth umbrella, but they operate with some independence, choosing their own boards that weigh in on budgeting, which health services to offer, and how to improve the quality of care they provide, among other responsibilities.
The local residents who serve on those boards often help decide, for example, whether to invest in a new MRI scanner, hire a new CEO or undertake an expensive construction project.
That structure ensures a measure of local control, though MaineHealth still must approve their spending plans. The parent system also handles back-office functions such as billing, human resources and implementing a shared electronic medical records system.
But the configuration makes it hard for MaineHealth to channel its considerable financial and clinical resources toward struggling hospitals in more rural regions, according to officials. The burdens on hospitals, particularly smaller ones, are only increasing, including shrinking payments by government health insurers even as hospitals take on more responsibility for keeping their communities healthy.
As a result, some are forced to cut services that both the hospitals and MaineHealth agree their communities need, according to Bill Caron, president of MaineHealth.
“As our smaller hospitals get into financial difficulties, they’re making decisions that are inconsistent with those care models,” Caron said. “They can’t afford to fund the activities that we all believe are appropriate locally.”
Under the proposal, MaineHealth could more easily shift money, physicians and other resources to the hospitals that need them most, system officials say.
“You’ll have a rural health system that’s doing OK financially, then you’ll have another one that’s really struggling, having to cut essential services. You’ll have one that’s able to attract physicians and providers, and another one can’t. … Those legal separations make it very hard to take the resources and easily deliver them,” said Susannah Swihart, chair of MaineHealth’s board of trustees.
The proposal, which MaineHealth officials describe as a “unification,” would require its communities to think more broadly about their role in the system, Caron said. Pen Bay Medical Center would have to consider patients in Farmington, for example. Doctors in Biddeford would need to consider their counterparts in Norway, and so on.
“We’re saying to our local communities and our local boards, ‘We want you to play a different role than you’ve played in the past,’” Caron said.
How budgeting works now
Member hospitals already work with MaineHealth to set their operating budgets each year. Local CEOs work with the system on an outline, then hammer out details with their local boards. Once approved, the budgets go to MaineHealth’s board for approval. All of the member budgets then get added together to form an operating budget for the entire system, Caron said.
Under the proposal, those corporate boards would consolidate into one entity. The unified board would then decide how best to spend the unified pool of money across the system, rather than each of the 10 members making decisions for their local community.
“The bottom line here is we’re trying to take $2.2 billion of assets and operating revenues each year and say that we need to protect the care that we believe belongs in each one of our communities with that full asset base,” Caron said.
That arrangement could potentially benefit its member hospitals, say MaineHealth officials. The consolidation would give the system a way to offset disadvantages that smaller hospitals suffer from the way Maine, and the rest of the country, pays for health care.
Hospitals make the most money on the types of services that have become concentrated at bigger hospitals such as Maine Medical Center, such as hip and knee replacements, and heart and brain surgeries.
Smaller hospitals that used to perform those services now send those patients to Maine Medical Center and lose out on potential profits. They’re left providing more basic, but important, primary and preventive care for which health insurers often don’t fully reimburse.
“We don’t want a hospital to feel like they’re going to hurt their bottom line by doing the right thing for the patient,” said Bill Burke, chair of Maine Medical Center’s board of trustees and a member of the MaineHealth board.
Maine Medical Center, with all those patients flowing to its operating rooms from elsewhere in the system, is profitable, while at least three other hospitals in the system — Franklin, Pen Bay and Southern Maine Health Care — are losing money. The proposal would give MaineHealth a way to more fairly allocate that money throughout the system, officials say.
The proposal aims to also make it easier for medical staff to work throughout the system and allow the rural hospitals to benefit from Maine Medical Center programs, such as clinical trials and recruiting medical students through Maine Medical Center’s partnership with the Tufts University School of Medicine.
MaineHealth is discussing the proposal with its members and plans to do so for the next six months, Caron said. In the spring, the organization will decide whether to move forward, and estimates unification would take another year to 18 months.
MaineHealth officials do not believe they need state or federal antitrust approval, but will meet with the Maine attorney general’s office this week about regulatory requirements, Caron said.
“Most people believe we’ll be unified at some point,” he said. “The question is, is now the right time, or is it five years from now, 10 years from now?”
Early concerns
Some members are already voicing concern about a corporate board in Portland making health care decisions for their communities. The medical staff at Waldo County General Hospital in Belfast has said it doesn’t support the plan as currently known.
“We fear that further loss of the independence of our hospital will lead to decisions by others who are not a part of, nor equally concerned about our community as those of us
who live and work here,” the staff wrote in a Nov. 22 letter to their board.
The medical staff went on to raise questions about how the proposal would affect staffing, health care services, finances and community involvement, among other areas.
“There are many other very important questions, about which we don’t even know enough to ask, for we have so little knowledge of the details of the proposed agreement,” they wrote.
The Belfast hospital’s board merged with Pen Bay’s board in 2015 at MaineHealth’s urging, a challenging process that led to more sharing of physicians and services. This proposal would bring even more change.
Greg Dufour, who sits on both the board that oversees Waldo and Pen Bay, and the MaineHealth board, said, “We want the med staff to weigh in. There has to be more information coming out, because while we have the concept of unification, we have a lot of details to work out.”
MaineHealth officials acknowledge those questions need answers. They’re just beginning to reach out to local boards, and plan to seek out community feedback after their local boards and medical staffs weigh in, Caron said.
“We don’t know if this is the right answer yet. … If it doesn’t make sense for the majority of our communities, we’re not going to do something,” he said.
Under the proposal, member hospitals would still offer advice and make recommendations to the larger board, Caron said. But, he said, no decisions have been made about what kind of representation member hospitals would have on a unified corporate board.
He also declined to speculate about how the proposal might proceed if some MaineHealth members oppose any final plan, if one is reached.
But he did say that officials envision some specific areas remaining in local hands, such as ensuring the quality of the health care that’s delivered in each region and the process to credential and issue privileges to medical staff.
Whether a local board makes those decision is secondary to a larger question — whether the voices of the communities and physicians will be heard, said Gordon Smith, executive vice president of the Maine Medical Association.
“The issue is are people listening?” he told the Sun Journal. “Are the people that are actually providing the care, do they feel they’re being respected and their opinions valued and that they have a voice? And if you have all those things, I don’t think it matters if you have an advisory committee or a board or no board. Those are the things that, day-to-day, physicians tell me make a difference.”
MaineHealth also must overcome lingering resentments in certain communities, such as Boothbay, where its handling of the closure of the only emergency room on the peninsula in 2013 spurred backlash. Caron said MaineHealth relationship with the community has since improved, and officials learned important lessons about community involvement in such decisions.
“They understand that these are difficult community processes,” said Coburn of the University of Southern Maine. “They also know that they can’t just dictate anything.”
Sun Journal staff writer Lindsay Tice contributed to this report.
MaineHealth’s consolidation plan would eliminate local control for hospitals
by Joe Lawlor - Portland Press Herald
MaineHealth’s tentative plan to consolidate and streamline operations within the state’s largest health care network is running into opposition from health care organizations operating under its umbrella.
The proposal would merge a dozen affiliated health systems into one nonprofit MaineHealth entity. MaineHealth officials say it would be a fairer and more efficient way to manage the health systems, but critics liken it to a power grab.
The proposal – to be rolled out over the next several months – would unify 12 separate nonprofits into one 18,000-employee nonprofit organization, with one board that would make final decisions for the entire system.
“It is extremely difficult to see how something that is high-performing and operating in the black like LincolnHealth (in Boothbay Harbor) would benefit from consolidating,” said Les Fossel, a board member at LincolnHealth, part of the MaineHealth system. Fossel said losing local control of health systems could lead to poor decisions coming out of Portland.
“The culture in Portland is simply different than it is in other parts of Maine,” he said.
MaineHealth, located on Free Street in downtown Portland, is the parent company of Maine Medical Center and 11 other hospitals and health care networks, including Franklin Community Health Network, Western Maine Health, Maine Behavioral Healthcare, Memorial Hospital in New Hampshire and Southern Maine Health Care.
A group representing 42 doctors in Waldo County also expressed strong reservations in a letter released last week, according to a Dec. 1 story in The Republican Journal in Belfast.
“We are concerned that a geographically remote and diverse board cannot make the same well-informed decisions about staffing, services, finances and appointments for our hospital and community that our current local board can,” the letter said.
But Bill Caron, president of MaineHealth, said the local boards would still exist and their recommendations would be important. “We’ve always valued local input,” Caron said.
He said many health systems across the country operate with systems more centralized than what MaineHealth currently has.
To consolidate into one nonprofit would require the approval of the local health boards, and MaineHealth executives will be working over the next few months to explain the benefits of unification to board members.
“We really want everyone to come on board,” said Susannah Swihart, chair of the MaineHealth board of trustees.
Dr. Benjamin Mailloux, president of the Waldo County physicians group, said the group met with Caron recently, that the doctors still have many questions, and that MaineHealth has a lot of convincing to do.
“They need to show us they can do it as well or better than we can do,” Mailloux said. “Waldo (County General Hospital) has been in the black for 38 years, so it’s hard for us to say, ‘Oh yeah, you can do this better.’ ”
MaineHealth’s footprint stretches from Sanford to Belfast, into western Maine and Carroll County, New Hampshire. It was formed in 1997 as a decentralized system – the board overseeing each hospital or health network has much autonomy and manages separate budgets. Operating funds from one hospital cannot be transferred to another.
Each is its own nonprofit organization, despite being part of MaineHealth. If the plan becomes a reality, MaineHealth would become one nonprofit, and the boards that currently oversee outlying hospitals would recommend changes rather than have the power to make their own decisions.
The budgets would be consolidated into one $2.3 billion spending plan.
Caron said the flexibility of having one budget and being able to allocate resources where needed is crucial. He said, for instance, that it’s unfair for one hospital to undergo layoffs and wage freezes while employees at the more well-off hospitals enjoy raises.
“It doesn’t feel good to have those kinds of disparities across the system,” Caron said.
Three of the systems – Pen Bay Medical Center, Franklin Community Health Network and Southern Maine Health Care – are operating in the red, Caron said, and as it stands now it’s difficult for the parent company to help them out.
The disparity in finances has more to do with demographics and changes in the health care industry as opposed to how efficiently each hospital is run, Caron said.
For instance, patients that used to have surgeries done at outlying hospitals are instead being transferred to specialists at Maine Med – a nationwide trend of funneling patients to larger, urban hospitals for procedures that used to be done at local hospitals.
When that happens, it’s like the rural hospital is “taking money out of their hospital and transferring it to Portland,” said Bill Burke, chair of the Maine Medical Center board.
Also, as rural areas of Maine age faster than southern Maine, the patient mix is hurting the bottom line of health systems that rely on older and poorer patients. For instance, Maine Med has a higher percentage of privately insured patients than Medicare, Medicaid and free-care patients than other Maine hospitals. Private insurance reimburses hospitals at higher rates than patients with government insurance or no insurance.
MaineHealth already has consolidated some of its functions – such as human resources, IT and finance. Physicians are also being shared among some health systems, such as between Waldo County General Hospital and Pen Bay Medical Center.
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