Monday, June 26, 2017

Health Care Reform Articles - June 26, 2017

Senate Leaders Try to Appease Members as Support for Health Bill Slips

by Robert Pear and Thomas Kaplan - NYT - June 25, 2017

WASHINGTON — Senate Republican leaders scrambled Sunday to rally support for their health care bill as opposition continued to build inside and outside Congress, and as several Republican senators questioned whether it would be approved this week.
President Trump expressed confidence that the bill to repeal the guts of the Affordable Care Act would pass.
“Health care is a very, very tough thing to get,” Mr. Trump said in an interview shown Sunday on Fox News. “But I think we’re going to get it. We don’t have too much of a choice because the alternative is the dead carcass of Obamacare.”
With Democrats solidly opposed to the legislation, Senate Republicans must find the votes from within. They can afford to lose only two votes, but five Republican senators have announced that they cannot support the health care bill as drafted, and others have expressed concerns.
Senate leaders have been trying to lock down Republican votes by funneling money to red states, engineering a special deal for Alaska and arguing that they could insure more people at a lower cost than the House, which passed a repeal bill last month.
But as more analysis of the bill reached state officials, especially in places that expanded Medicaid access under the Affordable Care Act, misgivings grew. Senator Bill Cassidy, a Louisiana Republican and doctor who is considered a critical vote, said he remained undecided. Louisiana, with its high levels of poverty, recently expanded Medicaid.
“There are things in this bill which adversely affect my state, that are peculiar to my state,” Mr. Cassidy said on CBS’s “Face the Nation.”
The bill was drafted in secret, mainly by the Senate majority leader, Mitch McConnell of Kentucky, who unveiled it on Thursday. Mr. McConnell wants a vote this week, before lawmakers take a break for the Fourth of July holiday.
Senator Jerry Moran of Kansas, usually a reliable vote for Senate Republican leaders, said on Fox News, “I just don’t know whether the votes will be there by the end of the week.”
Over the weekend, senators and their aides were poring over the bill, drafting possible amendments, preparing speeches and compiling personal stories from constituents whom they portrayed as either beneficiaries or victims of the Affordable Care Act.
But the bill’s supporters were battling an internal threat: reluctant Republicans. Senator Ron Johnson of Wisconsin said Sunday that “there’s no way we should be voting” on the legislation this week. “No way.”
“I have a hard time believing Wisconsin constituents or even myself will have enough time to properly evaluate this for me to vote for a motion to proceed,” Mr. Johnson said on NBC’s “Meet the Press.”
And Senator Susan Collins, Republican of Maine, said on ABC’s “This Week”: “It’s hard for me to see the bill passing this week, but that’s up to the majority leader. We could well be in all night a couple of nights.”

The reporter Margot Sanger-Katz examines how the Republican health plan aims to roll back a program that insures one in five Americans.
By MARGOT SANGER-KATZ, ROBIN STEIN and SARAH STEIN KERR on  June 22, 2017. Photo by Doug Mills/The New York Times. Watch in Times Video »

The U.S. Chamber of Commerce, the National Federation of Independent Business and the National Retail Federation have all said they support the bill. Thomas J. Donohue, the president of the Chamber of Commerce, said it would “help stabilize crumbling insurance markets” and eliminate “ill-conceived Washington mandates and taxes.”
But much of the nation’s $3 trillion health care industry opposes the bill. And Mr. McConnell has done little to woo the health care stakeholders whom Mr. Obama courted assiduously from his first months in office.
The concerns expressed by outside groups also appear to be growing. Top lieutenants in Charles G. and David H. Koch’s political network sharply criticized the legislation over the weekend, saying it was insufficiently conservative and did not do enough to rein in the growth of Medicaid. And a number of Republican governors have joined doctors, hospitals and patient advocacy groups in opposing the bill, in part because of its cuts to Medicaid.
Mr. McConnell has only a few days to wheel, deal and cajole reluctant senators to get behind legislation that has grown less popular with more exposure. He has considerable firepower to win votes by guaranteeing amendments that would address the concerns of individual Republican senators, and by playing on their loyalty to him and to conservative voters still demanding an end to the Affordable Care Act. At the same time, Democrats say, he has striking liabilities. Mr. Trump has endorsed the bill, and Democrats say they will take every opportunity to link the legislation to an unpopular president.
And the Democratic wall of opposition is backed by less partisan voices. Senators are being flooded with appeals like this from the advocacy arm of the American Cancer Society: “Cancer is scary enough. Don’t take away our coverage.”
The American Childhood Cancer Organization, a charitable group formed by parents, is mobilizing a small army of grass-roots lobbyists with the message that the bill, with its deep cuts to Medicaid, “will threaten the lives of children battling cancer.”
The United States Conference of Catholic Bishops said the Senate bill was “unacceptable as written” and would “wreak havoc on low-income families.” At the same time, the bishops said they liked two sections that seek to “prohibit the use of taxpayer funds to pay for abortion or plans that cover it.”
Republicans are finding allies to be few and inconstant. Mr. Trump has said he is “very supportive” of the Senate bill. But that support will be of limited help to Mr. McConnell. Few senators feel loyal to Mr. Trump, whose erratic message has often weakened his influence on Capitol Hill.
After pushing for passage of the House repeal bill, he criticized it as “mean” several weeks later. A spokeswoman, Sarah Huckabee Sanders, said last week that Mr. Trump did not necessarily support cuts to Medicaid, even though his budget and the Senate bill would make such cuts.
Kellyanne Conway, a top adviser to Mr. Trump, claimed on Sunday that the Senate bill did not actually cut Medicaid. Ms. Collins said, “I respectfully disagree with her analysis.”
So far, five Republican senators have announced that they cannot support the bill as drafted: Dean Heller of Nevada, who says it cuts coverage too deeply, and four conservatives — Rand Paul of Kentucky, Ted Cruz of Texas, Mike Lee of Utah and Mr. Johnson — who say it does not do enough to lower health costs. Other Republicans, like Ms. Collins and Senator Lisa Murkowski of Alaska, have expressed misgivings, and Senator Ben Sasse of Nebraska declined to say Sunday how he would vote.
Senate leaders, trying to muster support, are looking for ways to address a conspicuous omission: The bill requires insurers to accept anyone who applies, but repeals the mandate for people to have coverage and does not replace it with anything. So people could wait and buy insurance only when they need it. Insurers say they need large numbers of healthy people to help pay for those who are sick.
Republicans said they might revise their bill to establish a six-month waiting period for people who go without insurance and then want to sign up, in the belief that this would encourage consumers to maintain continuous coverage.
The House bill has an incentive, imposing a 30 percent surcharge on premiums for people who have gone without insurance. But the Congressional Budget Office said this provision could backfire. As a result of the surcharge, it said, two million fewer people would enroll, and the people most likely to be deterred are those who are healthy.
The Senate’s answer also has potential problems. For someone with cancer, a six-month waiting period could be a death sentence.
The Senate fight is happening amid a striking shift in public opinion. Fifty-one percent of Americans now have favorable views of the Affordable Care Act, according to a monthly tracking poll by the Kaiser Family Foundation. “That’s the first time in our 79 tracking polls over seven years that this share has topped 50 percent,” said Craig Palosky, a spokesman for the foundation.
Medicaid is by far the largest program of federal grants to the states, and state officials are always trying to tweak the formula for distributing that money to their advantage.
The House and Senate bills would convert Medicaid from an open-ended entitlement program to a system of per-capita payments for beneficiaries. A novel feature of the Senate bill would redistribute federal Medicaid money from higher-spending states like New York to lower-spending states like Alabama.
One noteworthy exception to this provision is tailor-made for Alaska. “This paragraph shall not apply to any state that has a population density of less than 15 individuals per square mile,” it says.
Only five states — Alaska, Montana, North Dakota, South Dakota and Wyoming — meet that criterion, and Alaska’s two Republican senators have expressed concern about the bill’s potential effects on their state, where medical costs are exceptionally high.
Ms. Murkowski said federal legislation must recognize Alaska’s high costs. Premiums on the insurance exchange there average about $1,000 a month for an individual, according to federal data. But the special provision may not be enough to win Ms. Murkowski’s vote. She is also concerned about two other sections of the bill: one that would cut federal funds for the expansion of Medicaid under the Affordable Care Act and one that would block federal Medicaid payments to Planned Parenthood.

Medicare for All: A Prescription for What Ails Us

by Amy Goodman - Common Dreams - June 4, 2017

President Donald Trump’s long-promised repeal of Obamacare, or the Affordable Care Act, edges closer to reality, as the Senate releases its secretly written version of the House’s American Health Care Act—the very bill that Trump first championed, then recently reportedly called “mean.” The Republican majority in the Senate is intent on passing the bill before the July Fourth holiday. Obamacare has led to tens of millions of Americans getting at least some health insurance, but it has problems of its own. Since health care represents one-sixth of the U.S. economy, the political debate between the very bad Republican bill and the less bad Obamacare may create an opening for the sensible solution enjoyed in just about every developed nation outside the US: single-payer health care.

Single-payer is already in practice in the U.S., and is immensely popular. It’s called Medicare, the taxpayer-funded program that guarantees health care for seniors and people with permanent disabilities. Public polling soon after World War II showed widespread support for the proposal; Medicare became law in 1965. Trump, in his notorious June 2015 campaign announcement in which he attacked Mexicans as “rapists,” also promised: “Save Medicare, Medicaid and Social Security without cuts. Have to do it.”

If the current bill continues on its trajectory and gets passed, Donald Trump will have to decide if he is going to break that promise. While the bill has to first pass the Senate and then go through a process in which the Senate and House bills are reconciled, it will, at the very least, massively cut Medicaid.

The reason why many opponents call Trumpcare “wealth care not health care” is the elimination of an Obamacare tax on the wealthiest Americans. They’ll get a tax cut, while tens of millions will lose insurance. Others will remain unable to afford it, or will be forced to buy hollow plans that offer minimal coverage, or plans with enormous deductibles and copays. People with so-called pre-existing conditions will find themselves virtually uninsurable in most states. A recent study by the Kaiser Family Foundation estimates that there are over 52 million non-elderly people with pre-existing conditions. Kaiser specifies “non-elderly,” as the elderly, covered by Medicare, can’t be excluded because of pre-existing conditions.
Currently, 57 million seniors and people with disabilities are on Medicare, out of a U.S. population of 320 million. There is no rational reason why Medicare couldn’t be expanded to cover all Americans, regardless of age, from birth to death. This is what single-payer health care advocates call “Medicare for All.”

Medicare for All would maintain the current system of private and nonprofit hospitals, doctor offices and all the other familiar aspects of the U.S. health system. The single most important difference is that health insurance companies as we know them would cease to exist. Insurance companies don’t actually deliver health care. They act as administrators, processing bills, making unconscionable profits off people’s pain and paying enormous executive salaries. The savings would be extraordinary, and the system would most likely be as popular as Medicare is today.

There are hopeful signs for single-payer. Representative John Conyers, the longest-serving member of Congress (he’s been in office since 1965, the year Medicare launched), has put forth H.R. 676, the Expanded & Improved Medicare for All Act. It currently has a remarkable 112 co-sponsors (all Democrats). Since the Republican majorities in both houses are unlikely to support this bill, activists are taking the fight to the states. The Healthy California Act, SB 562, would cover all residents of California, and has already passed the state Senate there. The Democratic-controlled Assembly is considering it now. In New York state, a similar bill has passed the Assembly and will be debated in the state Senate, where Republicans control the chamber by one vote.

Behind all the legislation is a diverse and growing grass-roots movement. National groups have been working on it for years, including Healthcare-NOW!, Physicians for a National Health Program and unions like National Nurses United. Statewide coalitions educate, organize, lobby and pressure lawmakers, and prominent politicians like Bernie Sanders rally the troops, building momentum.

Canada’s Medicare system, which covers all residents, started in the rural province of Saskatchewan and then went national. As Trumpcare versus Obamacare dominates the cable news channels, the unreported movement for single-payer health care grows. As with all great shifts in history, when the people lead, the leaders follow.

Editor's Note -

The following statement came at the end of an email sent by Nicholas Kristof, columnist for The New York Times. It speaks for itself.


"Finally, a comment on health care. The G.O.P. Senate and House bills are fairly similar, and I’m afraid the discussion has gotten into the weeds about the differences. The bottom line is that both bills would finance a huge tax cut to the wealthiest Americans (almost half to people with incomes of more than $1 million) by slashing health care for the most vulnerable Americans. Whether or not it would kill Obamacare, the G.O.P. plan would gut Medicaid, which provides insurance for 40 percent of American children.
The U.S. already has poor health statistics, with infant mortality and maternal mortality more than twice as high as in many other developed countries. Meanwhile, we pay much more per person for health care. The entire health care debate for many years has been about how to tweak an ineffective and expensive system, when ultimately we would be better off with a single-payer system resembling Medicare for all. It won’t happen soon, but that should be our aspiration."

The Health Debate Shows What Both Parties Care About Most

by Neil Irwin - NYT - June 23, 2017

Economists believe what people do more than what they say. It’s called revealed preference: People’s actions are the best indication of what they actually want, not their words.
The same applies to political parties. This is plain to see in the Senate health care bill, which would eliminate large parts of President Barack Obama’s health care overhaul.
More so than speeches and slogans ever could, the content of the Affordable Care Act and the Better Care Reconciliation Act, or Obamacare and Trumpcare, reveal the different values of the two parties. It’s hard to imagine a clearer statement of priorities than the competing approaches to health care in the United States.
In short, Democrats are focused on trying to maximize the number of people who have decent health insurance, and are willing to accept whatever tax increases and arrangements with health insurers and other private interests are needed to make that happen. They seek the broadest possible availability of health care, whatever the cost and political trade-offs it takes to achieve it.
Republicans are focused on trying to minimize taxes, especially on investment income, and keeping federal subsidies for health care to a minimum. They are willing to accept the wrenching consequences that attaining those goals might have for Americans’ insurance coverage, betting that lower taxes and smaller government will fuel a more vibrant economy.
This contrast is evident in both the content of the two bills and some of the choices the parties’ leaders have taken in pursuing them.
The Republican bill, which the Senate intends to vote on next week, has been cast as the Obamacare repeal bill. But it leaves some significant parts of the Affordable Care Act intact and has some provisions that change health policy that aren’t really about the 2010 law. Those details shed light on the underlying goals of Republican leaders apart from simply being able to tell their supporters that they repealed Obamacare.
The bill, for example, eventually eliminates the expansion of Medicaid that was a major part of the Affordable Care Act. But it also goes further than that, imposing caps on Medicaid’s spending per recipient. This shrinks the entire program, significantly reducing the federal government role.
In other words, it’s as much about changing the very nature of the Medicaid program — away from an open-ended promise from the federal government and toward a narrowly constrained program — as it is about undoing provisions of the Affordable Care Act.
It’s also telling which parts of Obamacare are being tweaked, and which are being fully repealed. Tax subsidies to help the middle class pay for health insurance under the Affordable Care Act are being reduced, not eliminated. But the tax increases for high-income Americans that Democrats used to help pay for the Affordable Care Act are being scrapped entirely.
A 3.8 percent tax on investment income over $250,000 for a couple would be history, as would an 0.9 percent surcharge on payroll tax above that same level. The Tax Policy Center estimates that would amount to an average tax cut of $54,000 for households making over $1 million.
Finally, in parsing what Republicans really value most in health policy, there is what they didn’t do. The Congressional Budget Office estimated that the House’s version of this legislation would reduce the number of people with health insurance by 23 million; similar estimates of the Senate legislation are expected next week.
But there’s not much evidence that congressional Republicans see those estimates as a reason to devise a new plan that would keep more people insured. Rather, they are barreling ahead — the House voted on its version of the plan before the C.B.O. numbers on the latest version had even been finished.
Then there are the Democrats.
Republicans have shown willingness to do whatever it takes to achieve goals of less federal spending on health care and lower taxes; Democrats have, conversely, displayed a similar approach to get to the goal of more widely available insurance.
In 2009, the Obama administration was focused on cobbling together the votes for a program to expand the availability of insurance, through any path it could find.
That meant negotiating with the health insurance industry to keep its central role in the United States health care system, even as some on the left wing of the Democratic Party would have preferred shifting to a single-payer system in which the government would supplant private insurers.
It meant including the tax increases that Republicans now seek to repeal in order to keep the proposal from blowing out the budget deficit, soothing deficit hawks.
The Affordable Care Act included other provisions that angered some on the left, such as a so-called Cadillac tax (disliked by labor unions) on expensive health insurance plans, and a powerful board focused on reducing the growth of Medicarecosts over time.
Congress and the Obama administration did extensive back-and-forth with health policy experts and the C.B.O. to figure out which tweaks to the various subsidies in the bill would do the most to expand coverage.
Essentially, in the Affordable Care Act debate the Obama administration and Congress rejected a major overhaul that some liberals would have preferred in favor of a gradualist approach that didn’t disrupt existing industries but did result in a large expansion of health insurance availability and federal subsidies.
One hope was that this strategy it would not only help the Affordable Care Act pass in the first place, but would also make it more resilient no matter which direction the political winds might shift. Sure enough, the health insurance industry, hospital and doctors’ groups, and other major interests oppose the Republican plan.
But what happens on the floor of the Senate in the days ahead will determine whether Mr. Obama’s bet was correct. And the nation will, or will not, get to experience a very different philosophy of government’s role in health care.

Planned Parenthood Battle Could Sway Fortunes of G.O.P. Health Bill

by Avantike Chilkoti - NYT - June 23, 2017

WASHINGTON — As the Senate barrels toward a vote next week to sever all federal support for Planned Parenthood, the 100-year-old organization is mobilizing furiously to bring down the Republicans’ broader legislation to repeal the Affordable Care Act before it reaches President Trump’s desk.
The fight over one provision — to cut off funding to Planned Parenthood for a single year — may be tangential to the wider war over the American health care system. But with the Senate so narrowly divided, Mr. Trump’s vow to repeal President Barack Obama’s signature domestic achievement could rest on the hot-button issue of abortion.
Republicans can afford to lose only two votes when the final tally comes as soon as Thursday. Moderate Republican senators such as Susan Collins of Maine and Lisa Murkowski of Alaska have expressed deep misgivings over the Planned Parenthood provision, which would deprive the organization of more than 40 percent of its funding, jeopardizing health care for women in states like theirs. But restoring Medicaid reimbursements to the health organization could cost just as many votes on the right.
“The expectations of the pro-life movement have been very clear: The health care bill must not indefinitely subsidize abortion and must redirect abortion giant Planned Parenthood’s taxpayer funding to community health centers,” Marjorie Dannenfelser, president of the anti-abortion Susan B. Anthony List, and Tony Perkins, president of the socially conservative Family Research Council, said in a joint statement Friday.
The proposed health care bill is bringing a decades-old debate over abortion to something of a climax, pitting powerful abortion rights groups, women’s organizations and medical associations against the wealthy religious organizations and anti-abortion groups that most Republicans lean on. Funding for Planned Parenthood has been a perennial issue since Republicans won control of the House in 2010, and each time, Republican leaders have finessed it by saying the matter would be settled in a broader health care bill.
That broader bill is now here. The single-year funding cutoff has obscure roots. The Congressional Budget Office has ruled that cutting off money to Planned Parenthood would actually increase federal spending — by depriving women of birth control and increasing the number of births covered by Medicaid. Republicans are trying to maximize the deficit reduction in their health care bill.
But even if the defunding provision is for a single year, anti-abortion activists see a beachhead they must defend, then fight from.
“That one-year mark is not going to pass quietly,” said John Seago, legislative director at Texas Right to Life.
Groups on both sides of the debate have lobbying operations in place and millions of dollars at their disposal for the final sprint.
Planned Parenthood’s political wing invested $30 million to encourage voters to turn out in last year’s elections alone. That effort fell short, but it will introduce a blitz ahead of the Senate vote, using a surge of donations since Mr. Trump’s election to press supporters to call their senators. Protests are also planned in Washington.
“Sometimes you have this phenomenon where everyone freaks out in the moment, signs a petition and then goes back to their everyday life,” says Ilyse Hogue, president of Naral Pro-Choice America. “But that’s not what we’re seeing. We’re seeing really high levels of retention and engagement.”
Anti-abortion groups are also gearing up for the Senate vote. Ms. Collins plans to amend the health care bill to restore Planned Parenthood funding, giving Democrats a conundrum: They may strongly favor supporting Planned Parenthood, but Democratic aides say senators must decide whether the bill has a better chance of passing with or without the defunding provision. If they think the Collins amendment would help final passage, they are likely to vote against it, ensuring its defeat.
That would be fine for the anti-abortion forces.
“As the Republicans start negotiating with the Democrats or with more moderate members, this is one of the hot-button topics that comes up that they try to negotiate away,” Mr. Seago said. “We will keep pressure on the Texans in D.C. to ensure this isn’t a bargaining chip to make sure this bill goes across the finishing line.”
Kristan Hawkins, the president of Students for Life of America, an anti-abortion group, toured 80 college campuses this spring, preparing for this moment.
“We can’t afford to wait around. We can’t afford to rest on our laurels,” Ms. Hawkins said.
The proposed legislation, which Planned Parenthood labels “the worst bill for women’s health in a generation,” would strip the organization of federal funding for one year and bar any federal tax credits from being used to help buy private health plans that cover abortions.
With over 600 affiliate health centers across the country, Planned Parenthood serves 2.4 million people a year, three-quarters of whom have incomes at or below 150 percent of the federal poverty level.
The election of Mr. Trump has in some ways helped the group’s financial footing. Since November, contributions have poured in from big-name patrons such as Facebook’s chief operating officer, Sheryl Sandberg, and smaller donors alike.
But those new funds do not come close to compensating for the money that the bill would strip away. The national office and affiliates of Planned Parenthood together rely on reimbursements and grants from the government for more than 41 percent of their total $1.35 billion in revenue, according to the group’s latest annual report.
The showdown is hardly a surprise. Republicans threatened to shut down the government over continued Planned Parenthood funding two summers agoAbortion dominated the budget fights of 2011, right after the Tea Party influx to the House. With a Republican in the White House, Planned Parenthood can no longer count on a veto as it did with Mr. Obama. The group has held over 2,200 events as diverse as marches and phone banks. It has delivered almost a million petitions and made over 157,400 calls to Congress as its volunteer base has ballooned.
“We basically have a pink army that we’re able to deploy,” said Paul Dillon, a spokesman at Planned Parenthood of Greater Washington and North Idaho.
This activism has been teamed with contingency planning at some affiliates in the event that the legislative battle is lost.
“A lot of us across the country are doing that, shoring up of our business, being more efficient and looking for alternative funding,” says Vicki Cowart, chief executive of Planned Parenthood of the Rocky Mountains, which serves about 100,000 patients a year across Colorado, southern Nevada, New Mexico and Wyoming.
Affiliates, and even individual clinics, face a different threat level based on geography and politics.
A Planned Parenthood center near Aspen, Colo., for example, receives generous funding from the affluent residents of the skiing community, Ms. Cowart explained. Two centers in Las Vegas just got part of a $1 million donation by the casino magnate Elaine Wynn.
Planned Parenthood of Orange and San Bernardino Counties in California sends both money and staff to other states in need of extra resources. And Planned Parenthood Southeast, which serves several Southern states, is now providing advice to teams elsewhere in the country on how to operate in an environment without generous government funding and local support.
“So much of this threat is something that we’ve been living with for decades already in the south,” said Staci Fox, head of Planned Parenthood Southeast, which has seven health centers in Georgia, Alabama and Mississippi.
But without federal assistance, such planning can go only so far. Remote centers serving poor patients without alternative health care providers have no fallback.
After last year’s election, Planned Parenthood of the Rocky Mountains decided to close six of its 29 health centers.

Senate Health Plan Falls Short of Promise for Cheaper Care, Experts Say

by Reed Abelson - NYT - June 23, 2017

President Trump and the Republicans have promised that their plan to overhaul the federal health care law will make medical coverage much more affordable.
Premiums and deductibles will be “much lower,” Mr. Trump tweeted in April. He also assured Americans that the plan to replace the Affordable Care Act would protect people with potentially expensive medical conditions.
As Senate Republicans unveiled their draft legislation this week, they reiterated the goal of making it easier and cheaper for consumers buy coverage than under the current law.
“This plan will improve the affordability of health insurance,” the Senate majority leader, Mitch McConnell of Kentucky, wrote in an opinion piece on Friday.
But millions of Americans will pay more for an insurance policy that comes with a much steeper deductible under the new Senate plan, according to some health economists and insurance experts. It could also make it much harder to find a comprehensive plan covering various conditions ranging from heart disease to depression that would not be prohibitively expensive.
“This is going to be a very unstable market” where only the very sickest people resort to buying coverage on the federal exchanges at much higher prices, said Paul B. Ginsburg, a health economist and the director of the Center for Health Policy at the Brookings Institution.
Those likely to suffer the most under the Senate plan are people who would not be eligible for any remaining subsidies, he said, because they could be priced out of the market. Most worrisome to those opposing the Senate bill is that states could give insurers leeway to offer skimpy plans that cover a lot less and exclude people with certain illnesses.
Insurers have been largely quiet since the Senate Republicans released their versionof the bill on Thursday morning. But some did criticize the legislation for not doing more to help people pay for insurance.
“The draft bill does not expand coverage; it does not do enough to protect people in need of care; nor does it provide enough assistance to those who need help in paying for health care and coverage,” said Bernard J. Tyson, the chief executive of Kaiser Permanente, a California insurer that offers plans on the exchanges in eight states and in Washington.
If the Senate version becomes law, insurers could increase premiums for individual coverage by at least 20 percent more than the double-digit increases already under consideration. By 2020, other changes are likely to result in plans with much higher deductibles. People now getting tax credits that allow them to purchase a policy with a deductible of $3,500 would get subsidies for a plan where the deductible would nearly double, without any funding to pay their out-of-pocket costs.
Many people will face a Hobson’s choice, said Craig Garthwaite, a health economist at Northwestern’s Kellogg School of Management. They will have to choose between a plan with a premium they cannot afford or a plan with a deductible they cannot afford.
While lower premiums touted by Republicans could attract healthier people to buy coverage on the exchanges, other changes could still drive up prices, said Mr. Garthwaite, who is a registered Republican. “It could turn out to be higher premiums and higher deductibles,” he said.
One stark difference between the Senate bill and the Affordable Care Act is the decision to drop the mandate requiring insurance. That could inadvertently discourage the youngest and healthiest people from buying insurance, leaving a higher percentage of sicker people with expensive treatments on the exchanges, driving up insurers’ costs.
When Congress debated the Affordable Care Act under President Barack Obama, a major objective was to tackle soaring premiums and steep deductibles that Americans faced in their employer-based plans and when they bought coverage on their own.
On Thursday, Health Secretary Tom Price argued that Republicans needed to pass a replacement for the same reasons. “We’ve got prices going up, we’ve got deductibles going up, premiums going up,” he said in a television interview on Thursday. “We’ve got people that have an insurance card but they don’t have any care because they can’t afford the deductible.”
Some Republican policy experts are not convinced that this bill’s provisions would solve those problems. “Republicans are taking it and going in the opposite direction,” said Rodney L. Whitlock, a former aide to Senator Charles E. Grassley, Republican of Iowa. Mr. Whitlock thinks the bill’s changes in 2020 to allow insurers to offer plans with less generous coverage could lead to policies with “almost assuredly five digit” deductibles — $10,000 or more.
Insurers are assuaged that the bill provides temporary funding for the so-called cost-sharing reductions, federal money they receive to sell plans that cover out-of-pocket costs for people earning low incomes.
But those subsidies end after 2019, meaning that when people buy plans with much higher deductibles, they would be exposed to paying thousands of dollars in medical bills. It is difficult to see how someone making $40,000 a year will pay for health insurance that forces them to come up with $10,000, Mr. Whitlock said, meaning only the very sickest may be willing to try to pay for a plan to offset some medical expenses. “This is where Republicans are in a direction they are going to regret,” he said.
There are provisions aimed at reducing premiums, including federal funding to states to stabilize the market. High-deductible plans tend to carry lower premiums. Younger individuals would also pay much lower prices under the proposed bill; people over 40 could be charged a lot more.
Without a requirement to buy insurance, the Senate bill provides no reason to sign up for insurance before coverage is needed.
“There needs to be provisions to discourage people from waiting until they get sick to buy insurance,” said Karen Ignagni, the chief executive of EmblemHealth and the former head of America’s Health Insurance Plans, a trade group. The absence of any penalty for not having insurance could cause some markets to fall into a death spiral as prices rise and drive out the healthy.
“We don’t have to speculate about it,” Ms. Ignagni said, pointing to a number of states, like New York, where insurance was virtually unavailable because of the high costs before the Affordable Care Act.
In Pennsylvania, the state insurance regulator, Teresa D. Miller, warned that insurance rates could be at least 23 percent higher without the individual mandate. While the proposed bill could lower rates by funding the cost-sharing reductions for the next year or so, other provisions have the opposite effect. “With everything else going on in this bill, I don’t think it’s going to be that stabilizing force people might want it to be,” she said.
The changes are likely to result in fewer people being covered, and those people could be much sicker, said Dr. Stephen Ondra, a former insurance executive who worked under the Obama administration. “The insurance company has no choice but to set rates based on the risk pool they have, not the one they like,” he said.
Insurers were beginning to get a handle on the market, he said, but the uncertainty and the changes under the Senate bill could lead to more companies deciding to leave. “This is a crisis that has been created by uncertainty and proposed legislation, not a failure of the A.C.A. markets,” Dr. Ondra said.

How Medicaid Works, and Who It Covers

by Abby Goodnough and Kate Zernike - NYT - June 23, 2017

One of the biggest flash points in the debate over Republican legislation to repeal and replace the Affordable Care Act is the future of Medicaid. Here are some basic facts about the 52-year-old program.

What is Medicaid? 

It’s a public health insurance program largely for low-income people, though some middle-class disabled and elderly people also qualify. States and the federal government share the cost.

Whom does Medicaid cover? 

■ Nearly one in five Americans, 74 million people, are on Medicaid.
■ Federal law guarantees Medicaid coverage to pregnant women, children, elderly and disabled people under certain income levels.
■ It covers more than a third of the nation’s children and pays for half of all births.
■ It also covers almost two-thirds of nursing home residents, including many who are middle class and spent of all their savings on care before becoming eligible.
■ States also have the option of covering other groups, like children and pregnant women whose household incomes are higher than the federal thresholds, or young adults up to age 26 who were once in foster care.
■ The Affordable Care Act allowed a new optional group: any adults with income up to 138 percent of the poverty level, which would be $16,643 for an individual this year. Thirty-one states now offer Medicaid to this group.

When was it created?

■ In 1965, as part of President Lyndon B. Johnson’s “Great Society.”
■ There was little political debate; the bigger fight was over creating Medicare, the program to cover the elderly, which Medicaid is often confused with.

Is Medicaid an entitlement 

Yes. Anyone who meets the eligibility rules has a right to Medicaid coverage, and for now, states are guaranteed open-ended financial support from the federal government.

How much does it cost? 

■ Medicaid cost $553 billion in fiscal year 2016. Of that amount, $348.9 billion came from the federal government; the states paid $204.5 billion.
■ Medicaid accounts for 9 percent of federal domestic spending. For states, it is the biggest source of federal funding and the second-largest budget item, behind education.
■ The biggest costs in Medicaid are for the elderly and the disabled, often because of long-term care in nursing homes.
■ Washington pays 50 to 75 percent of Medicaid costs for most eligible groups, with poor states receiving more money.
■ Under the Affordable Care Act, the federal government initially covered all of the costs for the roughly 11 million people insured under the law’s expansion of Medicaid, who are largely adults without disabilities.
■ Under the law, Washington picks up 95 percent of state costs for the expansion of Medicaid this year, whittling down to 90 percent in 2020.

What changes are in store? 

■ Both the House and Senate health bills would fundamentally change the way the federal government pays its share of Medicaid costs, setting a per-person limit on spending that would adjust annually for inflation.
■ The bills would also effectively end the Medicaid expansion, by sharply reducing how much the federal government pays for that population starting in 2020.
■ The result of these changes, according to independent analyses, would be major reductions in federal Medicaid spending over time.
■ Enrollment would drop, too, according to the nonpartisan Congressional Budget Office, with states making it harder to qualify for the program and getting rid of certain benefits to make up for tightened federal spending.

Taking Single-Payer Seriously

by Dave Kamper - Jacobin - May 28, 2017

Has the time for Medicare for All finally arrived? Many on the Left certainly think so.
“Various half-measures are not worth it,” physician and activist Adam Gaffney wrotea few weeks ago. “Single-payer is the alternative to the health care status quo.”
This is not just idle chitchat. A January Pew Research survey found that 60 percent of Americans think the government “has a responsibility to make sure all Americans have health care coverage.” And a recent Morning Consult poll showed 44 percent of Americans backed a single-payer plan, much more than those who opposed it.
Those are real numbers, and the Left has every reason to be excited that our arguments are gaining traction.
But if we want to make Medicare for All a reality, we have an obligation to think through the consequences of effectively euthanizing an industry that many have come to rely on for employment.

A Spending Machine

The private health insurance industry is, as many have observed, one of the primary drivers of health care costs. We spend far more on health care than any other advanced capitalist country and end up with inferior health outcomes.
The Affordable Care Act (ACA) kept that basic system in place. For all the talk of mandates and cost curves and exchanges, Obamacare massively increased spending in the health care system. When more people get health insurance, more people use health care.
The Medicaid expansion and the subsidies for coverage on the individual market funnel tens of billions of additional dollars into insurance companies and health care providers every year. In 2014, the first year that the ACA was more or less in full force, net expenditures on health care rose 4.6 percent. In 2015, they jumped 5.6 percent. The same year, the federal government estimated that outlays would expand “1.2 percentage points faster than Gross Domestic Product” over the next decade. By 2025, it projected, health care would no longer make up one-sixth of the American economy. It would make up one-fifth.
Much of this spending results in new jobs. From 2011 to 2016, overall job growth in the US sat at 8.3 percent, but the number of health care practitioners rose 15.8 percent. Nurse practitioner jobs increased 76 percent. Speech-language pathologist positions expanded by 29.6 percent. “Medical records and health information technicians” went up 58.6 percent. In the health insurance industry, “insurance claims and policy processing clerks” went up 11 percent.
As long as the ACA fire hose keeps spraying money at the health care industry, jobs will balloon accordingly. If the water pressure drops, the consequences will be real and drastic, even if the overall result is more equitable and more affordable health care.
Medicare for All wouldn’t just scrap Obamacare — it would uproot the entire industry. It would be a huge efficiency savings. But it would also be devastating in the short term for hundreds of thousands of working people whose only crime was getting a job at an insurance company, and the hundreds of thousands more who work as billing specialists for clinics and hospitals (the number of medical assistants shot up 44 percent between 2011 and 2016). Yes, the CEO of United Health Group made $101 million in 2011. But few of the 230,000 other people working for the company saw money like that.
Bernie Sanders’s recently announced Medicare for All plan asserts that we “need a health care system that significantly reduces overhead, administrative costs, and complexity,” and projects that his plan would save $6 trillion over ten years.
Those trillions — currently being sucked up by a bloated, profit-hungry industry — could do amazing things. Infrastructure. Education. Housing. Insurance for all, in and of itself, would be remarkable.
But you don’t save $6 trillion just by getting rid of the insurance industry. The US has 35.5 MRI machines per million people. The UK, with its National Health Service, has 6.1. Single-payer Canada has 8.5. We don’t need as many as we have. We can deliver complete patient care with many fewer machines. But fewer machines means fewer manufacturing jobs, fewer technician jobs, less need for new construction for new facilities, and so on.
And MRIs are just one facet of a huge health care system that will see efficiencies across the board in a single-payer system. The benefits of those efficiencies will be felt by all, the harms by few, but they will feel them hard.
The effects of these changes would be highly local. Some of the campuses of large health insurance companies employ thousands. Shuttering them would be like shuttering a steel mill or auto factory — the shockwaves would reverberate through the whole community. Like laid-off autoworkers, employees of insurance companies would be pushed onto the job market with a set of skills and experiences unsuited to most other occupations. The color of their collar wouldn’t change that.
And that disruption would have serious political effects.
The 2016 election hinged on the Rust Belt, states like Michigan, Ohio, and Pennsylvania that used to be home to huge numbers of unionized, high-wage blue-collar jobs. As those industrial jobs disappeared, cities across the Midwest sustained hits from which they still haven’t recovered.
The Democratic Party’s prescriptions — like trying to encourage fifty-year-old autoworkers to go back to community college to study IT — were both condescending and impractical. Many saw no reason to back a party that hadn’t done anything for them, and that left them exposed to the nativist economic nationalism of Trump.
We can’t risk the same thing happening because of single-payer.

The Senate GOP hid the meanest things very deeply in its Obamacare repeal bill. We found them
by Michael Hiltzik - LA Times - June 23, 2017

The Affordable Care Act repeal bill unveiled Thursday by Senate Republicans has aptly drawn universal scorn from healthcare experts, hospital and physician groups and advocates for patients and the needy. That’s because the bill is a poorly-disguised massive tax cut for the wealthy, paid for by cutting Medicaid — which serves the middle class and the poor — to the bone.
Yet some of the measure’s most egregious, harshest provisions are well-disguised. They’re hidden deep in its underbrush or in the maze of legislative verbiage. We’ve ferreted out some of them and present them here in all their malevolent glory. In this effort we’ve built on ace detective work by Adrianna McIntyreNicholas Bagley of the University of Michigan, David Anderson of Duke University and, Andy Slavitt, the former head of Medicare and Medicaid in the Obama administration, and others.
Some of these provisions match those in the House Republicans’ repeal bill passed May 4, and some are even harsher — more “mean,” to use a term President Trump himself applied to the House bill. That bill, according to the Congressional Budget Office, would cost some 23 million Americans their health coverage by 2026. The Senate bill wouldn’t do much better, and might do worse.
—States will have more authority to reimpose lifetime and annual benefit caps and eliminate essential health benefits. This may be the most insidious provision of the repeal bill, and certainly is the most deeply hidden.
It’s buried in changes made to the ACA’s so-called Section 1332 waivers, which are designed to allow states to try innovative approaches to healthcare, especially through their Medicaid programs. Under the ACA, states can only seek waivers under certain conditions. The “innovative” changes can’t lead to fewer people insured, or subject them to higher out-of-pocket expenses.
The Senate bill repeals those limitations — and removes the flexibility of the Secretary of Health and Human Services to approve them. Under the measure, the secretary “must” approve a waiver request as long as it won’t increase the federal deficit. As a result, states would be able to eliminate the essential health benefits that all health plans must provide under the ACA — including hospitalization, prescription coverage, maternity care and substance abuse and mental health treatment. Since only essential health benefits are subject to the ban on lifetime and annual benefit limits, high-cost patients such as cancer victims and sufferers from chronic diseases could permanently lose their benefits in the course of their treatment.

Would states roll back these protections? By some reckonings, they’d have no choice. The overall impact of the Senate bill would be to shrink the individual health insurance market and leave sicker customers in the insurance pool, says Jeanne Lambrew of the Century Foundation, in part because the measure eliminates the individual mandate that keeps younger and healthier buyers in the market. As a result, she says, insurers will put enormous pressure on state governments to loosen their regulations to lower the insurance companies’ risk.
States would also be authorized to waive rules requiring that almost all customers be charged the same premium. That’s an invitation to preferential pricing that would effectively remove protections for people with preexisting conditions — they could be priced out of the individual market in a return to the dysfunctional system that denied them insurance in the pre-ACA era.
Under the repeal bill, waivers would be in place at least for eight years, compared with five under the ACA. That means that the rollbacks of consumer protections would be inoculated against repeals by new state or federal administrations.
—Protection for people with preexisting conditions is destroyed. Senate Republicans claim in their talking points that the measure protects people with preexisting conditions from being denied coverage or priced out of the market. Don’t believe them. As Gene Sperling, a former economist for the Clinton and Obama administrations, and Michael Shapiro observe, “the Republican plan may not allow insurers to discriminate … through the front door, but they’ve created a backdoor way in.”

The key is that same Secton 1332 waiver provision. If state’s allow insurers to offer plans without those essential health benefits, they’ll offer “skinny” plans that don’t serve the needs of those with serious conditions. Plans that don’t cover cancer drugs or hospitalization, perhaps. Those patients will have no choice but to opt for more comprehensive plans, which will end up with an overabundance of expensive enrollees and therefore much higher premiums.
“The Senate bill will open the door to states forcing people with preexisting conditions into segregated markets that will lead them to pay far, far higher costs than everyone else,” Sperling and Shapiro say. “This bill will bring the country back to a system in which insurance only works for the healthy, and the sick can’t afford the coverage they need.”
—Older Americans would get socked with much higher premiums and costs. The Senate bill changes the ACA’s premium subsidies in ways that severely hurt older customers. The bill expands the permissible range of premiums for older buyers compared to younger from a ratio of 3 to 1 in the ACA to 5 to 1. In other words, older buyers could be charged much more. It reduces subsidies for older buyers in other ways. The ACA’s subsidies are based entirely on income, and are provided to households with income up to 400% of the federal poverty line. That ceiling is $48,240 for an individual.

The Senate bill cuts the maximum income to be eligible for subsidies to 350% of the poverty line — $42,210 for an individual. The measure also pegs subsidies partially to age, with older buyers entitled to smaller subsidies. Under existing law, the most that anyone within 400% of the poverty line can pay for a qualified health plan is 9.5% of their income. Under the Senate bill, buyers age 60 or older within 350% of the poverty line would pay as much as 16.2% of income — and those over 350% of poverty would get no help at all.

In other words, an insurance buyer today earning $48,240 would pay a maximum premium of $4,583; anything over that would be paid by the government. Under the Senate plan, a 60-year-old earning up to $42,210 would pay a maximum premium of $6,838. And anyone earning more than $42,210 would have to pay whatever the insurer charged, with no subsidy.
—The biggest tax cut for the rich is retroactive. As we’ve reported before, the repeal measure delivers an estimated $346 billion in tax cuts over 10 years, all of it going to households with income over $250,000. But the biggest component of the cut — repeal of a 3.8% surcharge on capital gains and dividends for those taxpayers — would be retroactive to the beginning of this year. That turns it into more of a free handout for wealthy people who already had sold securities or collected dividends since Jan. 1.
Even the Wall Street Journal is aghast. “Retroactive tax cuts like this don’t create an incentive and can yield windfall gains for people who already made decisions,” the paper observed. A millionaire who already had booked a $1-million gain on a stock sale, for example, would collect a $38,000 benefit.
This provision in particular is heavily loaded toward the richest of the rich. According to the Tax Policy Center, 90% of the cut goes to the top 1% (those with income of $699,000 or more); they’d get an average tax benefit of about $25,000. And almost two-thirds goes to the top 0.1% (with income exceeding $3.8 million); they’d get an average $165,000.

In fact, all the measure’s tax cuts taken together, valued at about $700 billion over 10 years, would be almost entirely paid for by the bill’s elimination of Medicaid expansion in the 30 states and the District of Columbia that accepted it—that’s similar to the House version. Medicaid expansion, which covers households earning 138% of the federal poverty line or less, will cost about $702 billion in that period. There’s no clearer illustration of how the Republican repeal bills transfer wealth from the poor to the rich.
—The fight against opioid addiction is crippled. Opioid addiction has emerged as perhaps the worst public health crisis in America. But as much as 40% of the cost of treatment of addicts has been paid by Medicaid. The harsh cuts in that program imposed by the Senate bill would force more of that expense onto states that simply can’t afford it. Meanwhile, the projected loss of medical coverage by as many as 23 million Americans under repeal will keep many victims of the epidemic from finding treatment.
The Senate measure substitutes a frayed Band-Aid to cover that loss. Despite estimates of as much as $183 billion over 10 years to fight the epidemic and treat its victims — and a request from GOP Sens. Rob Portman of Ohio and Shelley Moore Capito of West Virginia that $45 billion be added to the Senate measure for the purpose — the bill offers only a risible one-year appropriation of $2 billion.
—Salaries for health insurance chief executives can go through the roof. This provision matches one that was buried in the House bill, and is similarly obscured in the Senate version. It removes a limit on the deductibility of CEO pay in the health insurance industry written into the ACA.
Most public companies can’t deduct more than $1 million in pay for their top executives, but there’s a big loophole: “Performance-based” compensation, such as stock options or restricted stock grants, is exempt from the limit. The Affordable Care Act cut the limit on the deductibility for health insurers to $500,000 in pay per executive and eliminated the performance-pay loophole for them entirely. The Senate would repeal that provision, restoring the higher deductibility and the loophole for health insurers.
As we reported earlier this year, according to calculations by the progressive Institute for Policy Studies based on the pay of top executives at the five biggest publicly traded insurers in 2015, the deduction constraint saved taxpayers about $92 million that year. The figure would undoubtedly be higher now: The CEOs alone of the top five health insurers (Aetna, Anthem, Cigna, Humana, and United Health) collected nearly $88 million in compensation last year.

The GOP says its healthcare bill will protect those with preexisting conditions. Um, no it won't
by Jon Healey - LA Times - June 23, 2017

Here’s the opening quote from a press release Thursday from Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Health, Education, Labor and Pensions Committee, about the Senate GOP leadership’s healthcare bill:
“To begin with, the draft Senate healthcare bill makes no change in the law protecting people with preexisting conditions, no change in Medicare benefits, and increases Medicaid funding — that’s TennCare — at the rate of inflation.”
The second and third of those points are blatant head fakes, given that Medicare has not been an issue in this debate and that the changes Republicans are proposing for Medicaid would slash the program by hundreds of billions of dollars. But the first point is just as misleading, albeit in a more subtle and pernicious way.
Considering how strongly Americans support the Affordable Care Act’s protections for people with preexisting conditions, this is no small issue. People need to penetrate the spin and understand exactly what this bill would do on that score.
Under the ACA, a.k.a. Obamacare, insurers are required to sell a comprehensive insurance policy to anyone who wants it, and their premiums have to be based on the expected needs of an entire community, not each individual applicant. Those three elements — “guaranteed issue,” mandatory coverage of “essential health benefits” and “community rating,” in the parlance of the insurance industry — are collectively the shield that protects people with preexisting conditions who aren’t covered by a large employer’s insurance plan.
The Senate’s “Better Care Reconciliation Act” wouldn’t repeal that part of the ACA — Senate rules don’t allow that sort of legislating on a budget reconciliation bill. But it does include a provision giving states carte blanche to waive the essential health benefits, as long as they don’t increase the federal deficit.
Wait, what?
Under current law, states can apply to waive the essential health benefits requirements as well as the federal rules for premium and out-of-pocket subsidies, insurance exchanges, the “individual mandate” that requires adult Americans to obtain insurance, and the “employer mandate” that requires businesses with 50 or more full-time employees to offer health benefits. To earn a waiver, however, they have to show that their approach will provide insurance coverage that’s just as comprehensive to at least as many people and be at least as affordable as it would be without a waiver.
In other words, the ACA invited states to be creative in achieving the law’s goals.
The Senate bill would eliminate those requirements for obtaining a waiver (and would end the individual and employer mandates for everyone, retroactively). States would merely have to describe how they plan to increase access to comprehensive coverage, reduce average premiums and increase enrollment. The only mandate is that they not add to the feds’ red ink.
So, under the Senate bill, it would be perfectly fine for a state to let insurers offer cheap policies that exclude coverage for potentially costly risks and preexisting conditions (for example, by omitting maternity care and cancer drugs) as well as extremely expensive comprehensive policies that any resident can access — but not necessarily afford. Or a state could offer the comprehensive policies itself through a high-risk pool, an approach that’s been tried and failed repeatedly because of its high costs. Either way, average premiums would drop, which the state could argue would be expected to boost enrollment.
At least two governors have already indicated an interest in waiving the essential benefits. They could do so under the Senate bill with only the assent of their state insurance commissioner, with no need for state lawmakers to approve.
Even if just one state opts for a more limited set of “essential” benefits, the effects could spill over onto Americans covered by large employer plans across the country. That’s because the law bars employers from setting annual or lifetime benefit caps only on benefits that are essential — and lets them use any state’s list of those benefits. So a single state that excludes maternity care or prescription drugs would open the door to any U.S. employer’s health plan to slap a cap on those benefits.
So, while it’s technically true that the Better Care Reconciliation Act wouldn’t amend the ACA’s protections for people with preexisting conditions directly, it would leave them open to indirect attack by state officials eager to cut insurance premiums the easy way: by allowing insurers to cater to the customers they really want to serve, which are the ones who don’t need healthcare.
Republicans aren't just repealing Obamacare, they are gutting a guarantee of healthcare for the poor
by Henry Waxman - LA Times - June 22, 2017
Three million and $1.6 trillion. The first number represents an estimate of the children who would lose healthcare coverage under the bill Republican senators worked on in secret and finally unveiled on Thursday. The second number reflects the total amount of Medicaid cuts — in the form of the elimination of the Medicaid expansion for working families that was part of the Affordable Care Act, capped federal spending for Medicaid and additional cuts proposed in the president’s budget — that would go to pay for tax breaks for billionaires.
As with the House version of the American Health Care Act — also written in secret and passed in reckless haste — the Senate revision would end Medicaid as we know it. In essence, Trumpcare would abandon the federal government’s 52-year responsibility to guarantee healthcare for those unable to afford it on their own.
If Republicans succeed in passing this legislation, millions of parents who work hard but struggle to make ends meet will find it prohibitively expensive to get their children the care they need. Millions of earaches will go untreated, leading to hearing loss. Those who can’t see the blackboard in school won’t receive eyeglasses. Treatable illnesses will turn into hospitalizations. Some will die; one study found that in-hospital mortality rates are 60% higher for uninsured than insured children.
And suffering most of all will be the 60% of children with disabilities — and their families — who currently receive Medicaid coverage. Insurance companies will not be eager to step in to cover them
I’m thinking of children such as Spencer, who lives in Indianapolis, an 11-year-old who experienced a stroke in utero. Multiple surgeries were required to correct problems with his arms and legs and left him with autism, behavioral problems, seizures and a blood-clotting disorder.
Thanks to Medicaid, Spencer has access to what’s called applied development analysis therapy, the most effective autism treatment available. Some of it is covered by the Indianapolis school system, but most is paid for by Medicaid.
Because Spencer’s health often requires his mother, Erica, to take time off work, she has struggled to keep a full-time job. Today, she is covered through Medicaid, too, which allows her to take care of herself while she cares for Spencer.
Erica says the legislation moving through Congress has left her “stressed to the max.” Sadly, she has good reason to feel that way. If it becomes law, she and Spencer could be kicked off Medicaid — Indiana may take an option available under the American Health Care Act to stop covering the therapy so essential to his health, or it simply may not be able to pick up the additional costs if the law is passed and Medicaid cuts become reality.

We have a moral responsibility to protect the well-being of children. That’s why when I was chair of the House health subcommittee, I authored several bills in the 1980s and ‘90s expanding Medicaid coverage for children and strengthening their benefits.
These vital gains will be reversed if Congress shifts the financial responsibility for Medicaid from the federal government to the states through a per capita cap. Such a proposal would not merely repeal the Affordable Care Act, it would also fundamentally change the much longer-standing, successful program for working families, children, people with disabilities and the low-income elderly. And the effects will be felt beyond the individual loss of health coverage.
The cuts to Medicaid funding are so steep that many safety-net hospitals and clinics would be forced to close. This would be an unmitigated disaster for rural communities, where healthcare options are few and far between, leaving residents with less access to care where and when they need it.
For states to deal with the large budget shortfall that would result from caps on federal Medicaid dollars — which will increase each year under the current proposal — they would have to raise taxes, or make cuts in other areas such as education or infrastructure or, most likely, keep cutting Medicaid benefits, eligibility or payments to providers.
In the Senate’s discussion draft, the working group attempts to protect children with special healthcare needs from Medicaid caps by maintaining the current match rate that applies to them. But to shield children with special healthcare needs while also balancing its budget, a state would have to make much deeper cuts in care for other children, parents and working adults on Medicaid.
Legislation needs to pass sufficient public scrutiny or it’s unworthy of becoming law. If monumental, transformative legislation can be written in the dark and enacted in a rush— and children’s lives are compromised or ruined so that billionaires can get tax cuts they don’t need — it would rank among the worst scandals in U.S. history. Americans of conscience must mobilize now to stop this from happening.
Henry A. Waxman, past chairman of the House Energy and Commerce and the House Oversight and Government Reform committees, represented California’s 33rd Congressional District from 1975 to 2015. He’s currently chairman of the public affairs firm Waxman Strategies.

What If Jon Ossoff Campaigned On Message For Medicare For All?

by Kevin Gosztola - Common Dreams - June 23, 2017
When Jon Ossoff launched his campaign for the Georgia congressional seat formerly held by Health and Human Services Secretary Tom Price, Democrats mobilized to bolster his candidacy because they believed he could win. Yet, Ossoff’s failure to beat Republican Karen Handel has not produced the kind of reflection that should follow the outcome that occurred in one of the most expensive congressional races in history.
Amy Goodman, host of “Democracy Now!”, asked Reverend Dr. Raphael Warnock of the Ebenezer Baptist Church in Atlanta and Democratic state senator Nan Orrock a basic question: “Is this not just a battle between Republicans and Democrats but [also] the heart of the Democratic Party?”
“Right now, [a] massive issue in the country is the issue of healthcare. He was opposed to single-payer healthcare. Many felt he was running away from a progressive Democratic platform, as he ran against the Republican candidate. Do you think this is a message to the Democratic Party, almost like the Hillary-Bernie Sanders divide, that they’re going in the wrong direction?”
Each gave telling answers, which are representative of the reaction of Democrats to Ossoff’s loss.
Warnock answered, “I’ll let the politicians get into the mix of how to, you know, win an election,” unwilling to critique Ossoff’s campaign.
“I am not going to Monday morning quarterback on Jon Ossoff’s race, which was a remarkable race, an incredible gain from where the last Republican that ran was 22 points up, and we were two points lower than 50 percent, in a race that was not supposed to ever even be feasible,” Orrock declared.
This is the common refrain from Democrats. Georgia’s sixth congressional district is a Republican district so that is why Ossoff lost. But it is disingenuous because President Donald Trump only beat Hillary Clinton by 1.5 points in the district.
Democrats did not put an exorbitant amount of money and resources into Ossoff to pull off a moral victory. They invested this amount because the party establishment thought they could peel off “reluctant Trump voters” and show they had a strong chance of flipping districts in the 2018 midterm election. So, what effect refusing to support single-payer healthcare and other progressive agenda items had is a question those involved in boosting his campaign should confront.
The congressional district was supposedly one, where Democrats could capitalize on “reluctant Trump voters.”
Ossoff made appeals to respect, civility, kindness, and decency that were directed at Trump. He focused on partisanship in Washington, D.C., like previous Democratic candidates, who lost their races.
Focusing on the major character defects of Trump and the politics he practices is not a winning strategy for recruiting “reluctant Trump voters.” They are still, as an Atlanta Journal Constitution survey showed, tremendously loyal to the Republican Party.
At minimum, their common sense on issues have to be challenged directly in ways that incentivize them to go from being opposed to Democrats to being open to voting for them.
It is pretentious to say they will never support Democrats because they are Republicans. That is insular thinking that ensures the Democrats continue to hemorrhage seats at all levels of power.
Let’s consider the issue of health care, a supposedly high-ranking concern for “reluctant Trump voters.”
What would have happened if Ossoff came out for a national Medicare For All program?
In a suburban red district, what if he appealed to Republicans who dislike the Affordable Care Act? What if he adopted a message like Senator Bernie Sanders and National Nurses United that addressed the very real defects in the ACA?What if he made the case that beating back the GOP’s cold-hearted health insurance bill—which not one state supports—was only possible with Medicare For All?Instead, Ossoff ran with a health care message Clinton pushed. Ossoff said he would fight for “quality, affordable health care.” But what do these buzzwords mean in terms of policy?Is it any wonder Republican voters tuned this out? It was a vapid message. On the other hand, a message about workers saving thousands of dollars on premiums and employers saving more than $10,000 a year might have intrigued voters.Several Democrats point to the extensive voter suppression, which likely occurred in the election. The disenfranchisement of voters is a very serious issue. And yet, one cannot help but think Ossoff did not quite capitalize on this enough in the race.
Handel has quite a history of supporting voter suppression as Georgia’s secretary of state. She incorporated a “voter verification” system that disproportionately prevented people of color from voting in the 2008 presidential election. Ossoff could have made a much bigger deal about the right to vote as an issue, where Handel was on the wrong side.Finally, it is simply not true that Democratic candidates cannot win in Republican strongholds. Christine Pellegrino, a former Sanders delegate, won the New York State Assembly District 9 seat in a special election and pulled off a huge upset, where Trump garnered 60 percent of the vote.Natalie Vowell, who was also a Sanders delegate, won a school board seat in St. Louis. Chokwe Lumumba was elected mayor of Jackson, Mississippi.There are down-ballot campaigns in the United States, where strong candidates who come out of movements or have strong relationships with movements, are winning. Their strategy contrasts with the failed strategy of the Democratic Party establishment, which is to simply appeal to red state voters to support them as smarter, better, and leaner Republicans.Even though millions were pouring in from progressives and left of center Democrats, who undoubtedly support key groups doing work for social and economic justice, those groups never really left a mark on the message of his campaign. That may be what truly undermined Ossoff’s potential to win.

Health insurance co-op shutting down in New Hampshire

by Holly Ramer - AP - June 24, 2017

CONCORD, N.H. — A health insurance cooperative with 37,000 customers in Massachusetts and New Hampshire is shutting down but hopes to reopen as a for-profit company in January.
Minuteman Health and 22 other small nonprofit insurers were created by the Affordable Care Act to stimulate competition and lower prices, but nearly all of them have since folded. In an announcement Friday, Minuteman blamed a provision of the law that requires insurers with healthier customers to make payments to insurers with sicker customers.
“The risk adjustment program has been highly volatile. It hasn’t worked as intended,” CEO Tom Policelli said in an interview.
In a federal lawsuit filed last year, the company argued that it has been punished for offering lower-cost products because the risk adjustment payments are based in part on how a company’s premiums compare to statewide averages. It said its premiums were substantially lower than average not because its customers were healthier but because its business model focused on keeping costs low and because its members were more likely to purchase less-expensive plans.
Policelli said the company has had to spend about a third of the amount it collects in premiums on risk adjustment payments, and for 2018, was seeking to increase premiums by 30 percent. Further, as a cooperative, the company was not allowed to expand beyond the individual and small-group market.
“We’re forced to be in the penalty box, basically,” he said.
Minuteman started in Massachusetts and later expanded to New Hampshire, where it has about 27,000 customers and has the second-largest share of the individual market among four companies offering such plans under the Affordable Care Act. In Massachusetts, Minuteman is one of the smaller players among 11 companies, said insurance division spokesman Chris Goetcheus.
Minuteman is the second co-op to stop offering plans in New Hampshire. Maine’s Community Health Options pulled out for 2017 to focus on Maine, and recently announced it had achieved a surplus after two years of losses.
Nationally, competition in many markets has dwindled to one insurer, or in some cases, none. Insurers are retreating from some markets or charging a lot more to stay in others. And Republicans in Washington are hoping to get their bill scuttling much of former President Barack Obama’s health care overhaul through the Senate next week.
“Today’s announcement by Minuteman Health is more clear evidence that Obamacare has failed and that our nation’s health care system demands reform,” said New Hampshire’s Republican Gov. Chris Sununu. “This environment of instability was created by Obamacare’s costly regulations and taxes that are causing premiums to skyrocket. Washington must work together to end the partisan gridlock and move reform forward; otherwise more Granite Staters are likely to be negatively impacted.
Policelli said the new company, Minuteman Insurance, is committed to staying in the exchanges in Massachusetts and New Hampshire and to continuing its model of partnering with low-cost, high-quality providers.
He declined to respond to Sununu’s comments but said there’s no question the risk adjustment program has created instability and increased premiums. Beyond that, the company considers itself “purple” when it comes to politics, he said.
“There were some good ideas and some bad ideas in the ACA, and I think there are good ideas and bad ideas in the new Republican version being kicked around,” he said. “I don’t think anyone has a monopoly on genius.”

Medicaid Cuts May Force Retirees Out of Nursing Homes

by Jordan Rau - NYT - June 24, 2017

ORANGE, Va. — Alice Jacobs, 90, once owned a factory and horses. She has raised four children and buried two husbands.
But years in an assisted living center drained her savings, and now she relies on Medicaid to pay for her care at Dogwood Village, a nonprofit, county-owned nursing home here.
“You think you’ve got enough money to last all your life, and here I am,” Ms. Jacobs said.
Medicaid pays for most of the 1.4 million people in nursing homes, like Ms. Jacobs. It covers 20 percent of all Americans and 40 percent of poor adults.
On Thursday, Senate Republicans joined their House colleagues in proposing steep cuts to Medicaid, part of the effort to repeal the Affordable Care Act. Conservatives hope to roll back what they see as an expanding and costly entitlement. But little has been said about what would happen to older Americans in nursing homes if the cuts took effect.
Under federal law, state Medicaid programs are required to cover nursing home care. But state officials decide how much to pay facilities, and states under budgetary pressure could decrease the amount they are willing to pay or restrict eligibility for coverage.
“The states are going to make it harder to qualify medically for needing nursing home care,” predicted Toby S. Edelman, a senior policy attorney at the Center for Medicare Advocacy. “They’d have to be more disabled before they qualify for Medicaid assistance.”
States might allow nursing homes to require residents’ families to pay for a portion of their care, she added. Officials could also limit the types of services and days of nursing home care they pay for, as Medicare already does.
The 150 residents of Dogwood Village include former teachers, farmers, doctors, lawyers, stay-at-home parents and health aides — a cross section of this rural county a half-hour northeast of Charlottesville. Many entered old age solidly middle class but turned to Medicaid, which was once thought of as a government program exclusively for the poor, after exhausting their insurance and assets.
A combination of longer life spans and spiraling health care costs has left an estimated 64 percent of the Americans in nursing homes dependent on Medicaid. In Alaska, Mississippi and West Virginia, Medicaid was the primary payer for three-quarters or more of nursing home residents in 2015, according to the Kaiser Family Foundation.
“People are simply outliving their relatives and their resources, and fortunately, Medicaid has been there,” said Mark Parkinson, the president of the American Health Care Association, a national nursing home industry group.
With more than 70 million people enrolled in Medicaid, the program certainly faces long-term financial challenges. Federal Medicaid spending is projected to grow 6 percent a year on average, rising to $650 billion in 2027 from $389 billion this year, according to the Congressional Budget Office.
Even if Congress does not repeal the Affordable Care Act, Medicaid will remain a target for cuts, experts say.
“The Medicaid pieces of the House bill could be incorporated into other pieces of legislation that are moving this year,” said Edwin Park, a vice president at the Center on Budget and Policy Priorities, a Washington nonprofit that focuses on how government budgets affect low-income people. “Certainly, nursing homes would be part of those cuts, not only in reimbursement rates but in reductions in eligibility for nursing home care.”
While most Medicaid enrollees are children, pregnant women and nonelderly adults, long-term services such as nursing homes account for 42 percent of all Medicaid spending — even though only 6 percent of Medicaid enrollees use them.
“Moms and kids aren’t where the money is,” said Damon Terzaghi, a senior director at the National Association of States United for Aging and Disabilities, a group representing state agencies that manage programs for these populations or advocate on their behalf. “If you’re going to cut that much money out, it’s going to be coming from older people and people with disabilities.”
The House health care bill targets nursing home coverage directly by requiring every state to count home equity above $560,000 in determining Medicaid eligibility. That would make eligibility rules tougher in 10 states — mostly ones with expensive real estate markets, including California, Massachusetts and New York — as well as in the District of Columbia, according to an analysis by the Center for Budget and Policy Priorities.
Dogwood Village receives about half of its $13 million annual operating costs from Medicaid, with rates from $168 to $170 a day. Some residents who come to the nursing home after a hospital stay are initially covered by Medicare, but if they stay longer than 100 days, that benefit ends, and those without savings move to Medicaid.
“You have patients who have spent their life savings, and they come here,” said Kristen Smith, the admissions coordinator. Ms. Smith said patients now are older and sicker than they used to be, frequently arriving directly from a hospital.
“It used to be hips and knee” surgeries, she said. “And now a lot of those patients are going home. What we’re seeing is more complex, sicker patients.”
With cinder-block walls brightened by pictures of horses that evoke this equestrian county, the nursing home offers crafts, bingo and other activities.
Mary Ann Mohrmann is 85, the average age of Dogwood Village residents. An elementary schoolteacher for 25 years, she has Charcot-Marie-Tooth disease, a neurological disorder that has weakened her legs, feet and thumbs and compromised her fine motor skills.
Two of her children have it, too, she said. None of them can take care of her at home. “I’ve been here years,” she said. “I don’t know how many.”
Medicaid helps pay for care for people with disabilities, like Nancy Huffstickler, 65, who has been here for four years and regards herself as “a medical disaster.”
She listed her ailments: spinal cancer in remission, restless leg syndromehigh blood pressure and multiple ulcers. She has had spinal reconstructive surgery and a hip replacement. She is undergoing physical therapy with the hope that one day she will be able to leave her wheelchair and use a walker.
Ms. Huffstickler is fearful of Republicans’ health care changes. “It may save the federal government money, but what about us?” she asked.
Major Medicaid cuts would compel Dogwood Village to cut staff, supplies and amenities — changes that would affect the quality of care for all residents, not just those on Medicaid.
If that does not save enough money, the nursing home might have to reduce the number of Medicaid residents, said Vernon Baker, who resigned as administrator in April. “It’s not like our toilet paper or paper towels are like the Ritz-Carlton’s,” he said.
Some residents do not even know they are on government insurance; administrators often complete the paperwork to start Medicaid once other insurance expires. Others are embarrassed that they are dependent on a program that still carries stigma.
They should not be, said Jennifer Harper, the assistant director of nursing. Relying on Medicaid for nursing home care has become the new normal.
“These folks have worked their whole lives, some with pretty strenuous jobs, and paid into the system,” she said. But with changes looming, she said, “it may be a system that fails them.”

Insulin is too expensive for many of my patients. It doesn’t have to be.
by David Tridgell - The Washington Post - June 22, 2017
At age 15, I suddenly felt an unquenchable thirst and began urinating frequently. I lost 20 pounds. I had developed Type 1 diabetes, an autoimmune disease that destroyed my body’s ability to produce insulin. Without insulin, I would have eventually developed a condition called diabetic ketoacidosis, which is lethal without (and even sometimes with) treatment. 
Years later, I’m a practicing endocrinologist. I could never have imagined back when I first started taking insulin that one day I would have so many patients who could not afford the medication because of skyrocketing prices. When the drug was discovered in 1921, the original patent was sold to the University of Toronto for $1 so that no one else could patent it and “secure a profitable monopoly.” 
Numerous improvements later, insulin is produced by a three-company oligopoly. When the first of the newer insulin “analogs,” Humalog, hit the market in 1996, it sold for $21 a vial. Today, vials of analog insulins, including Humalog, sell for about $300 . Patients with Type 1 diabetes typically require two or three vials of insulin per month, but patients who are more resistant to insulin, such as those with Type 2 diabetes, may require six or more.  
A recent paper in the Journal of the American Medical Association found that insulin nearly tripled in cost from 2002 to 2013. A lawsuit filed in January accuses pharmaceutical companies of price collusion for allegedly raising insulin prices repeatedly and in lockstep to match their competitors. Prices have gotten so bad that the American Diabetes Association recently launched an online petition at, which has been signed by more than 250,000  people. 
Because insulin is so expensive, some people take less than their prescribed dose, causing higher blood sugars, which may lead to preventable, very expensive complications such as kidney failure, blindness, amputation, heart attacks or even death. 
Unfortunately, the American Health Care Act (AHCA) passed by the House last month would let states allow insurance companies to charge people more for preexisting conditions such as diabetes, as would the version under consideration in the Senate. This may leave more people unable to afford insurance and make it even more difficult for patients with already high premiums and deductibles to pay for insulin. 
While current law protects patients with preexisting conditions better than the AHCA would, too many people with diabetes are still going without proper medical care. One of my patients, whom I’ll call “Joe” to protect his identity, lost his insurance, then developed ketoacidosis, a buildup of acid in his blood, because he couldn’t afford to pay $600 monthly for two vials of insulin. He didn’t die, but he required a costly stay in an intensive-care unit. 
Pressure on drugmakers has started to bring small changes. But they’re not enough. In response to rising costs, Novo Nordisk will limit future price increases to single-digit hikes per year. Eli Lilly will provide insulin at up to 40 percent off for patients on high-deductible plans. (The downside is that it may not count toward their deductibles.)
Drug companies also offer savings cards that lower patients’ co-pays. However, these cards steer patients toward newer, more expensive insulins. And most cards may not help if the insulin a patient takes isn’t on their insurance provider’s formulary. Plus, such programs may save patients money, but the insurance companies don’t save anything, so the costs are likely to be shifted back to patients through higher premiums, deductibles or co-pays. 
Endocrinologists like me spend far too much time deciding what patients can afford instead of making sound medical decisions. I deal with these issues nearly every day. Some doctors are uncomfortable discussing costs with patients; many patients are embarrassed to admit they can’t afford medication, and some won’t acknowledge they aren’t taking their full dosages. The physician may then increase the dose, or with Type 2 diabetes may add another drug, when the real issue is that the patient isn’t taking the right amount. Since it is so common that patients cannot afford insulin, I’ve posted the American Diabetes Association petition in each of my practice’s exam rooms, and if patients don’t bring up cost as an issue, I will frequently point to the petition as an icebreaker. I ask if they have difficulty affording their insulin and medications, and I let them know they aren’t alone.
Like some other doctors, I have transitioned many patients with Type 2 diabetes onto older, less costly insulins. I try not to do that for patients with Type 1 diabetes, because these older insulins cause more dangerous low blood sugars. But sometimes I have no choice: It’s either cheaper insulin or no insulin.
Our system has additional issues that may heap more straw onto patients’ already strained backs — such as insurers’ “quantity limits.” My patient “Mike” uses 40 units of insulin per day. A box of five insulin pens contains 1,500 units and should last Mike 37 days. Since that is more than a 30-day supply, his insurer charges him a 60-day co-pay. The cutoff depends on the policy: For some, a 31-day supply will trigger a 60-day co-pay. Sometimes this problem manifests itself in reverse: “Mary” needs three vials of insulin to last at least one month. But three vials lasts her 33 days, so when she refills her prescription for a month of insulin, she is dispensed only two vials — a 22-day supply — for which her insurer charges a 30-day co-pay. Sometimes patients are allowed “up to” a 90-day supply, so they are dispensed five vials (which might work out to a 77-day supply) instead of the six vials they were prescribed (a 92-day supply). From the patient’s perspective, this “co-pay overcharging” or “under-dispensing” feels like getting one dozen golden eggs for the price of two dozen.
Why do we pay so much more for insulin and other medications in the United States than people do in the rest of the world? Many factors drive prices up. Half a dozen companies may be involved with a drug before it reaches the patient, and each may mark up the cost. Unlike in many countries, there are no government-set limits on what companies can charge. These include manufacturers, wholesalers, pharmacies and pharmacy benefit managers (PBMs), which serve as the middlemen between insurers and drugmakers. PBMs negotiate which drugs are on an insurance company’s formulary; they can receive a “rebate” from pharmaceutical companies when drugs make it to formularies. These “rebates” result in inflated list prices that the insurer never pays. (In other countries with nationalized health care, there’s no such middleman.) When people pay a co-pay, they don’t pay the list price, either. The only people who do are patients who haven’t meet their deductible, are in the Medicare “donut hole” or are uninsured — and these people are the hardest hit.
We also live in one of the only two countries in the world (New Zealand is the other) that allow direct-to-consumer advertising for prescription medications. Pharmaceutical companies spend billions on advertising, and those expenses become juicy tax deductions. Finally, while many countries with single-payer systems negotiate drug prices, our Medicare system by law is barred from doing so.  
All that complexity — and all the opportunities for profit — leaves patients to be squeezed by the weight of the system when they go to fill their prescriptions. 
And it gets even worse. “Tim” ran out of insulin for the first time in his life last year because his insurance provider allowed him to pick up only one vial at a time, and he didn’t realize he’d used it up until it was too late. “Brian,” a Medicaid patient, requires six vials of insulin per month, three vials each of short-acting and long-acting varieties. Yet he, too, is not allowed to pick up more than one vial of each at a time. Medicaid won’t dispense a 90-day supply, because many patients frequently change insurance, and many Medicaid providers don’t want to give away a month or two of free insulin. That’s understandable — insurers have a bottom line.
But properly managing diabetes requires a lot of work and can be a tremendous burden. These sorts of limitations and frequent pharmacy trips make it that much harder, and they magnify patients’ anxiety about running out of insulin and getting seriously ill. Vials can fall and shatter. Insulin exposed to high or low temperatures becomes ineffective. Mail-order shipments may arrive late.
Anyone who’s taking insulin should always have at least two vials on hand for emergency backup. Having only one vial is simply not safe — it creates anxiety, and can mean preventable hospital admissions or even death in some cases. It feels like driving on an eighth of a tank of gasoline in the middle of nowhere.
My experience is limited to Minnesota, and I can find no published peer-reviewed data on these practices. Internet forums discuss them often, though, and I have spoken with academic endocrinologists from both coasts who tell me my experience with patients is common in their states as well.
All of these problems could be fixed. We should require pharmacies and insurers to dispense a minimum 30-day supply and make sure patients have a second vial on hand for emergencies. Let’s prorate co-pays for patients who are dispensed more than a 30- or 90-day supply, rather than rounding their co-pays up. Insurance companies could decide to do this themselves, but since they’re unlikely to do so, it should be legislated at the state or federal level. We should also eliminate co-pay savings cards and require insurers to charge the lowest co-pay for insulin to encourage good blood sugars and reduce hospitalizations.
 If Congress were truly serious about addressing access to lifesaving medication, it would overhaul the whole system and eliminate tax write-offs for drug advertising to consumers (or better yet, eliminate this advertising altogether), force more transparency into the pharmaceutical market and PBM rebate system, investigate those rebates and how and why PBMs and manufacturers raise prices, and allow Medicare to negotiate drug prices. 
Insulin is a necessity. It’s time we return to the spirit of that original $1 patent, put people before profits, and rein in these greedy and unjust cost increases.

New Report: House and Senate Bills Would Be as Damaging as a Recession, Destroy 10,000 Jobs, Cost 111,000 Mainers Their Health Insurance
by The Maine Center for Economic Policy - June 26, 2017

(Augusta, Maine) A new report from the Maine Center for Economic Policy (MECEP) finds that the health care bills currently pending in the House and Senate would cost more than 111,000 Mainers their health insurance while damaging the state's economy.
"The efforts to repeal the Affordable Care Act (ACA)- in both the House earlier this year and this week in the Senate -would have a dramatic impact on Maine people and Maine's economy," said James Myall, a MECEP policy analyst and primary author of the report. "Not only would this legislation take health insurance away from tens of thousands of people, it would shrink our economy by $1.6 billion and destroy an estimated 10,000 jobs. The promised improvements from a Senate bill do not pan out," he said.
MECEP will hold a briefing call and media availability at 10:30 a.m. today to discuss this new data and answer questions.
Key findings of the report on the impacts of the bills:
  • About 111,000 more Mainers would lack health insurance, including 11,000 children, by 2026.
  • Most areas of the state would see a double-digit increase in the number of uninsured, with rural areas suffering the greatest impact.
  • By 2026, almost one in five non-elderly adults in Maine would be without health insurance.
  • Health insurance premiums for older Mainers would skyrocket, increasing as much as 18 times more than current costs.
  • Medicaid, which provides health insurance for 263,000 Mainers (including thousands in nursing home care), would face drastic cuts, shifting more than $2.4 billion in costs to Maine.
  • The House and Senate efforts to repeal the ACA would cripple the health care sector, which employs about one in five Mainers, and destroy an estimated 10,000 jobs.
  • Business output would decline by $1.6 billion and the gross state product would be $1 billion smaller, a 2 percent decline that's larger in real terms than the decline from the recession of 2008-2009.
For a copy of the full report, click here.

Maine Voices: Priceless benefits would come from single-payer health care system

It's part of the same moral responsibility that Americans share for public safety and education.
Letter to the Editor - Portland Press Herald - June 26, 2017

YORK — As a piece of legislation intended to provide affordable, quality health care to the greatest number of Americans, the Affordable Care Act has failed miserably. Twenty million Americans remain uninsured and tens of millions more with insurance have trouble affording their co-pays or deductibles. Half a million Americans with health insurance coverage declare bankruptcy every year as a result of medical expenses.
The ACA has been a disaster for providing affordable coverage, but soon our health care system will be in worse shape. Far worse. The “death spiral” of health care coverage, stimulated by a Republican Party hell-bent on undermining any legislation promoted by Barack Obama, has accelerated.
Both the House and Senate versions of the American Health Care Act attempt to stall that death spiral, but the trade-off they offer is less coverage and a certain increase in pain, suffering and premature death to older Americans as well as those who struggle the most to pay their bills. The beneficiaries of the AHCA through tax cuts and subsidies are the super wealthy, the health insurance industry and Big Pharma.
Only weeks after championing the House version and then celebrating its passage in the Rose Garden, President Trump recognized that what House Speaker Paul Ryan, et al., had crafted was “mean” – a remarkable admission for a man who has a profound aversion for the truth.
The Senate version, crafted in secret by 13 hand-picked older white men, was finally offered up four days ago, giving the other 87 members less than a week to critique, discuss and amend before being asked to pass it. Any reasonable person would agree that this is not only unprecedented but also a dangerous way to legislate.
Though their version in many ways is even more “mean” than the House version, those 13 senators may have managed to make it more palatable by extending time lines and shuffling numbers. So it may well pass.
Regardless of how this plays out, whether we continue with the ACA or get some version of the AHCA, America in general and the poor, the elderly and the middle class in particular, will not do well in regard to having their health care needs met over the next several years.
It’s important to recognize that the United States pays nearly two times more in health care costs than any other industrialized country while having far worse outcomes on most measures of care, and still we leave over 10 percent of our citizens without access to care because of lack of insurance.
Being uninsured means being unable to treat chronic conditions such as diabetes, hypertension, chronic obstructive pulmonary disease, schizophrenia, addictions, Crohn’s disease – and the list goes on and on. Failure to treat these chronic conditions results in pain, suffering, expensive trips to the emergency room and premature death. The financial costs are huge to the taxpayers, but they pale in comparison to the emotional costs paid by individuals and families of those with pre-existing conditions.
Call it what you will, but “single-payer” or “Medicare for all” or “socialized medicine” would guarantee quality health care for every American, and it would provide it for a fraction of the cost we pay for health care today. Why? Because a single-payer system would not be burdened by financially supporting insurance or pharmaceutical industries that take advantage of our campaign finance and lobbying laws and in doing so manage to generate enormous profits through limiting patients’ access to care or life-saving treatment.
Our elected officials, on both sides of the aisle, have become intoxicated by the money poured into their campaigns and have become dependent on that money to get re-elected. Their primary focus is to stay employed, i.e., to get re-elected, and access to quality health care by their constituents can be damned.
We guarantee our children access to a quality education through high school for good reason: It makes for a better society and a more robust economy.
And you would not deprive your neighbors a quick response from the local fire department if their house were on fire. If you did, lives could be destroyed or lost and businesses and communities decimated.
Is it any less cruel or ill-advised to deprive those same neighbors access to health care?
Our country needs an affordable, effective health care system. Plans that are not single-payer, quite simply, are motivated by greed and fueled by ignorance. And they are cruel.
There is no question that the ACA needs to be repealed and replaced. It needs to be replaced with comprehensive, universal coverage that is affordable and compassionate. Single-payer.

Putting Profits Ahead of Patients

by Jerome Groopman and Pamela Hartzband - The New York Review of Books - June 15, 2017

Not long ago, a relative called us for advice about a hospital bill. A public interest lawyer in New York, he had developed chest pain when exercising and consulted his internist, who ordered a stress test with an echocardiogram. To his relief, no abnormalities were found. Distress came later, when he saw that the hospital had charged some $8,000 for this test. Despite having excellent insurance, he was informed that he was responsible for $2,000 of the total.
The bill seemed exorbitant to us, and we suggested that he contact other medical centers in the city to find out what they would charge for the same examination. To his surprise, he discovered that prices ranged from about $1,200 to $6,000. When he called the billing office at the hospital where his test was performed and asked why the echocardiogram was priced at such a high level, he did not receive a clear answer. Frustrated, he informed the hospital that he declined to pay. This resulted in several veiled threats, but he countered that he would contact the attorney general of New York about what he believed was abusive pricing without justification. After much back-and-forth, his internist intervened on his behalf, and the hospital dropped the demand for the $2,000 difference.
This story points to the extraordinary predicament of our current health care system. Since the implementation of President Obama’s Affordable Care Act (ACA)—and the mandatory coverage it brought—most patients needing a procedure such as an echocardiogram can count on some form of insurance. But Obamacare put no controls on the pricing of drugs or clinical care, leaving the profit-driven health industry mostly intact.1 As a result, patients are too often required to pay large out-of-pocket costs while insurance premiums have continued to rise. Most patients navigating the financial shoals of our health care system do not have relatives who are doctors to advise them, nor are they lawyers; and many do not have insurance policies as generous as our relative’s.
Now, if the Trump administration and a Republican-led Congress are successful in their efforts to replace the ACA with “a free market solution,” largely stripped of regulatory restraints, the situation could get much worse. In May, the House of Representatives passed its version of a bill (called the American Health Care Act or “Trumpcare”) aimed at dismantling Obamacare, and the Senate has been crafting its own bill. The Congressional Budget Office has estimated that the House bill, if enacted, would leave 14 million people uninsured as soon as next year, and 23 million by 2026. Furthermore, this plan would make it even more costly for the neediest patients to access care.
At the center of both our flawed current system and its disastrous proposed replacement is a more fundamental reality: health care in the United States is enormously costly, often in ways that are baffling not only to patients but to doctors themselves. In An American Sickness, Elisabeth Rosenthal, a physician turned journalist, first at The New York Times and now at Kaiser Health News, sets out to explain how we got here. The book takes its structure from the way doctors record clinical notes, delineating a “chief complaint,” the “history of the present illness,” then a diagnosis, and finally a treatment. But here the sick patient is our health care system. With health care reform becoming one of the main issues of the current administration, An American Sickness could not be more timely or alarming.
Rosenthal identifies the “chief complaint” as an American medical system that “has stopped focusing on health or even science. Instead it attends more or less single-mindedly to its own profits.”
Who among us hasn’t opened a medical bill or an explanation of benefits statement and stared in disbelief at terrifying numbers? Who hasn’t puzzled over an insurance policy’s rules of copayments, deductibles, “in-network” and “out-of-network” payments—only to surrender in frustration and write a check, perhaps under threat of collection?
Rosenthal contends that the behavior of the health care market does not match that of other commodities. Instead, she points out, it defies economic logic:
More competitors vying for business doesn’t mean better prices; it can drive prices up, not down…. Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more…. Prices will rise to whatever the market will bear.
The American system was not always like this. Rosenthal gives a lucid and revealing history of American health care beginning with religious institutions ministering to the sick and dying in the nineteenth century. Absent effective treatments like antibiotics and anesthetics, therapy was not very costly, and recovery largely depended upon the body’s natural systems of resistance and repair. In the early 1900s, as clinical knowledge and treatment advanced, medications and surgeries were developed, and costs increased.
The question for hospitals at the time was how to cover expenses, not how to make money. The archetype for today’s insurance plans, developed at the Baylor University Medical Center in Dallas in the 1920s, was never intended to generate profit. It began when the hospital accumulated large numbers of unpaid bills for its services and decided to offer the local teachers’ union a deal: for six dollars a year, members “who subscribed were entitled to a twenty-one-day stay in the hospital, all costs included.” But there was a deductible: the insurance took effect only after a week of hospital costs pegged at $5 daily.
Baylor’s plan spread across the country and was given the name “Blue Cross.” The aim of this insurance was to protect patients from bankruptcy and to sustain hospitals and the charitable religious groups that supported them. Employer-based health insurance arose as a “quirk of history.” The federal government ruled in 1943 that no taxes would be levied on the money paid for employee health benefits. “When the National War Labor Board froze salaries during and after World War II,” Rosenthal writes, “companies facing severe labor shortages discovered that they could attract workers by offering health insurance.” After the war, in many other countries, a national health care system came to be regarded as a public good. But in the US, many viewed government-based health insurance as a form of socialism, and despite several attempts, proposals for such a system never could pass Congress.
As more Americans gained coverage, for-profit insurance companies sprang up to compete with the nonprofits Blue Cross and Blue Shield. The “Blues”—which coordinated their efforts starting in the 1940s and formally merged in 1982—accepted everyone, and all members paid the same rate no matter how old or how sick they were. (By the 1960s, more than fifty million Americans had hospital coverage from Blue Cross.) “Unencumbered by the Blues’ charitable mission,” Rosenthal writes, the private insurers “accepted only younger, healthier patients on whom they could make a profit.”
In the 1970s and 1980s, the rise of for-profit insurance companies like Aetna and Cigna made it difficult for the Blues to compete. In 1994, “hemorrhaging money,” Blue Cross and Blue Shield became for-profit as well. “This was the final nail in the coffin of old-fashioned noble-minded health insurance,” Rosenthal writes. The for-profit California Blues “gobbl[ed] up” their fellows in a dozen other states and, renamed WellPoint, emerged as the second-largest insurer in the country. Premiums rose rapidly. “WellPoint’s first priority appeared no longer to be its patient/members or even the companies and unions that used it as an insurer, but instead its shareholders and investors,” Rosenthal writes. This truth is often obscured; insurance companies market themselves in the media as caregivers, confusing the public, but they are not. The companies are fundamentally investment vehicles, maximizing profits to boost shareholder value.
Before the Blues turned into for-profit companies, they spent 95 percent of premiums on medical care. To increase profits, the Blues, along with other insurers, now spend as much as 20 percent of their premiums on marketing, lobbying, and administration. In contrast, Medicare, the federal program for seniors that enjoys widespread popularity, devotes nearly all of its funding to health care and only 1 to 2 percent to administration.2
Rosenthal’s indictment extends well beyond insurance companies. She looks carefully at hospitals, and the reader learns how they have been transformed by marketing consultants and administrators with business degrees to generate large profits, though many still enjoy a tax-exempt status as “nonprofit institutions”—meaning that they pay “almost no US property or payroll taxes.” Instead of profit, tax-exempt hospitals call it “operating surplus.” In 2011, the US government calculated that hospitals were getting an annual tax advantage of $24.6 billion. Steven Brill, who highlighted the predatory pricing that occurs in calculating costs of care in America’s Bitter Pill (2015), recently listed the yearly pay of the CEOs of large hospital systems, which often amounts to many millions of dollars. Rosenthal points out that “total cash compensation for hospital CEOs grew an average of 24 percent from 2011 to 2012 alone.”
Rosenthal’s case study is Providence Portland Medical Center in Portland, Oregon, founded by nuns in the 1850s. A century later, Providence, as other hospitals did, began charging patients for each service rendered. The hospitals hired administrators to “up-code” physician examinations and diagnoses in such a way as to maximize revenue. Providence then decided to stop paying salaries to physicians and treated them instead as independent contractors, turning each doctor into a “business.” A series of mergers and acquisitions followed, creating a giant hospital-based network that dominated geographic regions and had revenues in the billions. Rosenthal notes that Providence still presents itself as a “not-for-profit Catholic health care ministry,” invoking the tradition of its founding nuns. But it
comprises a weird mix of Mother Teresa and Goldman Sachs: one day it is donating $250,000 to help build a new teaching hospital in Haiti to replace one destroyed by the 2010 earthquake, and the next its new offshoot, Providence Ventures, is announcing the launch of a $150 million venture capital fund, led by a former Amazon executive.
As Rosenthal highlights, when doctors are turned primarily into businessmen, there can be egregious abuses of the system. Medicare tightly regulates reimbursement for cataract surgery, and in 2013 it reduced payments to ophthalmologists by 13 percent for simple procedures and 23 percent for complex operations as the technique became more efficient and required less time:
Many eye surgeons made up for Medicare’s increasingly stingy cataract payments by charging commercially insured patients more, leading to some staggering prices. Wendy Brezin, a Web designer in Jacksonville, Florida, had cataract surgery billed at $17,406. John Aravosis, a political blogger, was stunned to be billed over $10,000 for each eye.
Rosenthal also writes of a plastic surgeon who closed a cut on a girl’s face with three stitches and sent a bill to the family for $50,000. This kind of abuse is a betrayal of the profession and should not be tolerated.
But Rosenthal detracts from her story by repeatedly invoking unfounded stereotypes of physicians. She describes pathologists as “quiet, antisocial types.” The training of anesthesiologists is “not terribly difficult.” Rosenthal quotes a remark from an anonymous source regarding anesthesiologists overseeing the care of multiple patients and billing for this work “while sitting in the lounge monitoring their portfolios.” She asserts:
When I left medicine in the 1990s doctors commonly complained that they made less per hour than plumbers. Today, they seem more inclined to compare (negatively) their compensation to that of sports stars like LeBron James or titans of commerce like Lloyd Blankfein, the CEO of Goldman Sachs.
In an otherwise serious and well-researched work, these hyperbolic characterizations are gratuitous and disappointing.
Some of Rosenthal’s medical advice is inaccurate. She incorrectly claims that “neurosurgery to remove a brain tumor is never an emergency.” Tumors can press on the brain (sometimes due to bleeding) and cause a herniation, a life-threatening event in which the brain is squeezed on top of the spinal cord. This is an emergency that necessitates urgent neurosurgical intervention.
In the prescriptive section of the book, Rosenthal offers some useful pointers on contesting medical bills. As we suggested to our relative, she recommends contacting the hospital armed with comparable test charges and alerting a medical society or state agencies to possible abuse. (A surgical specialty society got the plastic surgeon to reduce his bill from $50,000 to $5,000 for the three stitches.)
However, she stumbles in the advice she gives on interacting with your physician. In a section called “In Your Doctor’s Office,” Rosenthal writes:
Here are some questions every doctor or healthcare provider should be able to answer for you at a doctor’s appointment:
1. How much will this test/surgery/exam cost? “I don’t know” or “It depends on your insurance” is not an answer. The doctor should give you a ballpark range with the cash price at the center where he or she refers.
When a patient seeks medical care, the doctor must listen and examine to formulate a diagnosis and recommend treatment options. In many clinics, appointments have been shaved down to some twenty minutes. Time is precious and should be spent on clinical care, rather than searching and quoting price lists. To be sure, information on cost is important, but accurate estimates can be difficult for both patients and doctors to obtain. The “cash price” often bears little relationship to what the patient’s actual cost will be because of the wide variation in deductibles and other specifics of each insurance plan. However, an administrator in the clinic, or a website, could appropriately provide assistance.
Importantly, there may also be unintended consequences of focusing the doctor–patient interaction on money. As Paul Krugman, the Nobel economist, has emphasized, patients should not be understood as “customers.” Doctoring, he avers, is not the same as selling cars. Indeed, we value our health differently than objects we purchase for utilitarian or luxury reasons.3 Research in cognitive psychology indicates that repeatedly cueing the physician to view patient care as a market exchange risks promoting selfish behavior and eroding essential aspects of our profession that contribute to high-quality health care, including pride in work, sense of duty, altruism, and collegiality.4
A recent national survey from the Mayo Clinic of some 6,800 physicians revealed that more than half, many of whom are salaried, reported feeling “burned out.”5Commenting on this finding, a leading cognitive psychologist, Dan Arielly, and his coauthor, Dr. William Lanier, point out that this feeling is largely attributed to the transformation of the health system into “a sort of ‘fixing-people production line.’” This industrial approach has caused loss of physicians’ autonomy as well as micromanagement of their use of time and how they make decisions. The result is a change in the nature of the relationship of doctors and their patients, veering toward a “market” transaction rather than a communal relationship. The time to discuss not only the patient’s physical malady but its effects on other important aspects of his life—time that allows doctors and patients to forge personal bonds—has been all but eliminated.
In his book Getting Risk Right, Geoffrey Kabat offers insight into why the health care debate is so fraught and why it is so difficult to reach consensus:
Different groups—scientists (who themselves fall into different disciplines with different points of view), regulators, health officials, lay advocates, journalists, businessmen, lawyers—are shaped by different backgrounds and motivated by different beliefs and agendas. Depending on the issue at hand, the interests of these parties may conflict or may align and reinforce one another.
In the case of the Affordable Care Act, each group forcefully lobbied Congress and the Obama White House to protect its own share of the pie. In order to craft a bill that would pass Congress in the face of such potent lobbying, the Obama administration caved in to the pharmaceutical industry, omitting provisions that would constrain drug prices. Similarly, the insurance industry was given considerable leeway in setting premiums and deductibles in exchange for agreeing to offer policies that required essential benefits like maternity and preventative care, and that did not discriminate against patients with preexisting medical conditions. And to satisfy lawyers the administration did not pursue any serious tort reform in malpractice cases.
A painful compromise narrowly passed by a Democratic Congress, Obamacare achieved several laudable goals: providing coverage for tens of millions of previously uninsured Americans; ensuring care of preexisting conditions; allowing young adults to stay on their families’ policies until age twenty-six; subsidizing premiums for those of moderate incomes; and expanding Medicaid coverage for the poor, disabled, and elderly in many states. But it failed in one crucial respect, as Rosenthal observes: “The ACA did little…to control runaway spending.”
In the final section of her book, Rosenthal sets out a series of possible reforms to reduce the cost and chaos we now encounter. She rightly argues for greater transparency in the pricing of tests, like the echocardiogram our relative received. Patients should have easy access to websites that show comparative charges among different hospitals.
Rosenthal also proposes creating a national body of experts to assess the “cost effectiveness” and “value” of tests and treatments, like that in the United Kingdom, which sets access to these elements of care. We find this idea misguided. Paul Dolan and Daniel Kahneman have observed that the methodology used to calculate cost effectiveness is deeply flawed. And as Ashish Jha, a widely respected health policy researcher, recently noted, empirical data largely fail to support the notion that paying for “value” improves outcomes for patients.6
Further, much of the practice of medicine exists in a gray zone where there is no one right answer for everyone. Instead, there is continued disagreement among different groups of experts about what is best. Kabat explains in Getting Risk Right that experts have their own biases, often ideological rather than financial. He debunks
the simplistic notion that the “consensus among scientists” is always correct. This is a widely invoked criterion or shortcut for determining who is “right” in a scientific controversy. However, the results of a scientific study should not be expected to line up on one side or the other of a neat yes/no dichotomy. Unfortunately, the science is not always clear-cut, and the consensus on a particular question at any given moment may not be correct.
The American Health Care Act (Trumpcare) has been framed as “freedom of choice,” with minimally regulated competition in the health care market. As a result, patients of limited financial means will be at the mercy of unshackled insurance companies. Some people with preexisting medical conditions may be unable to get affordable insurance, while an estimated 14 million low-income Americans who now depend on Medicaid for health insurance will no longer qualify. Perhaps unsurprisingly, recent polls have consistently shown that, however dissatisfied they are with the current system, a wide majority of Americans are against repeal of Obamacare.
Republican senators have been working behind closed doors on their version of Trumpcare and may try to rush it to a vote as soon as the CBO can analyze its effects on health care costs and coverage. In early June, Senator Claire McCaskill, Democrat of Missouri, decried the lack of open debate about “a bill that impacts one-sixth of the economy.” Even if it doesn’t pass the Senate, the Trump health reform has led to new uncertainty in the health insurance market, with some insurers withdrawing from the exchanges set up under Obamacare.
What is a feasible step to begin to remedy our costly and chaotic health care system? Many industrialized nations, including Germany, Japan, Belgium, and others, have uniform negotiated national fee schedules for hospital admissions and clinical encounters with doctors. Medicare also does this. Furthermore, Medicare markedly decreases administrative costs for both doctors and hospitals, compared to private insurance.
A public option like Medicare that provides vital services and devotes nearly all of its funds to patient care, actively competing in the marketplace with private insurance, would be a welcome step in the right direction.7 This could achieve a goal unmet by either Obamacare or the Trumpcare plan: to remove money as the centerpiece of our health care system and restore the essential communal relationship that sustains patients and physicians alike.

Big Pharma gets $28 billion tax break in GOP health plan

by Will Rice - Nation of Change - There will be a lot of losers if the House GOP’s disastrous plan to repeal and replace the Affordable Care Act ever becomes law: people with preexisting medical conditions, working families, older folks, kids.
One of the few winners would be the nation’s pharmaceutical industry: $28 billion richer thanks to a big tax cut. The Senate is likely to keep this tax break in its version of the legislation.
Do America’s drug makers deserve a $28 billion tax cut over 10 years, when the profits of the top 10 companies topped $83 billion last year alone, with the top 5 pocketing nearly $58 billion?
Hardly. In fact, they need to start paying their fair share.
Profits of Top 10 U.S. Pharmaceutical Corporations
Company                                                                              2016 Profits (in U.S. Billions)
Johnson & Johnson$19.8
Gilead Sciences$17.1
Subtotal Top 5$57.8
Eli Lilly$3.4
Bristol-Myers Squibb$5.9
Top 10 Total$83.6
The Republican plan passed by the House and endorsed by President Trump this spring would cost 23 million Americans their health care while handing out $660 billion in tax cuts, mostly to wealthy individuals and big health-care companies.
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Drug companies already avoid paying their fair share of taxes, even as they pump up their profits by price-gouging public health systems and individual patients. And let’s not forget about the massive subsidies they get for federally-funded research that leads to new and lucrative drug discoveries.
Pharmaceutical companies are among the biggest offshore tax dodgers. Three drug firms – Pfizer, Johnson & Johnson, and Merck – are among the top 10 American corporations stashing earnings offshore to avoid U.S. taxes. Pfizer (maker of Celebrex, Lipitor, and Viagra) alone has some $200 billion in profits parked offshore, much of it presumably in tax havens.
Gilead Sciences and Amgen each has around $37 billion offshore, apparently all of it in tiny nations where little or no tax is due. (American corporations owe U.S. taxes on all their worldwide profits each year, but a giant loophole lets multinationals indefinitely delay paying on profits booked offshore.)
A big chunk of Gilead’s stashed profits came from hepatitis cures priced so high that hundreds of thousands of patients went untreated even as the federal government was laying out billions of dollars a year for Gilead’s drugs.
Last year, Pfizer tried to renounce its American identity in order to dodge $35 billion in U.S. taxes, even though it’s prospered here for over 150 years and gets about a billion dollars annually in federal contracts.
Big Pharma has been getting fat off American consumers and public health systems for years. Prescription drug prices have surged eight times faster than the general rate of inflation over the past decade.
The expansion of health-care coverage to 20 million people by the Affordable Care Act has been paid for in part through taxes on health care companies, including drug firms, which have benefitted from millions of new customers. The GOP plan would eliminate those taxes, in the process stripping care away from millions of Americans.
That’s not a prescription for a healthy society. Seniors, children, people with disabilities, and working-class families need the affordable, quality coverage offered by the ACA. And America’s profit-laden drug companies need to help pay for it.

Senate Health Bill Gets a Wary Reception, From Coast to Coast

by Campbell Robertson - NYT - June 26, 2017

The health care bill unveiled Thursday by Senate Republicans has been out in the open for less than a week, and there are many obstacles to clear before it can become law: an uncertain Senate vote, a return to the House for final approval, a presidential signature.
But in newspapers and on radios and TV stations from Anchorage to Miami, the effects of the bill are already being contemplated. These could vary considerably from region to region, state to state, even family to family. Thirty-one states expanded Medicaid under the Affordable Care Act, though the design of these programs are not the same, and the states that did not choose to expand would still be significantly affected. Clinics in Pennsylvania desperately need funding to battle the opioid epidemic; rural hospitals in Maine rely on Medicaid for survival; Nebraskans struggle to cover rising premiums; and Floridians fear the loss of money to fight the Zika virus.
Yet while context varies, the reception to the bill described in these local news reports is almost uniformly unhappy, a sentiment reflected in the polling numbers for the health care bill approved by House Republicans and in many of the interviews.
“All of them are supposed to be there for us,” said JoAnn Johnson, 80, in an article on the front page of Sunday’s Argus Leader in Sioux Falls, S.D., “and we are lost in this.”

Alabama: Longer Waits

The loss of federal money would require the Alabama Legislature to raise taxes to replace the lost funds, or reduce services. The Republican-controlled bodies have never shown any willingness to increase taxes. That would likely mean cuts to the program, which could extend waiting times for patients, even those with private insurance, and lead to closures of hospitals and primary care practices, particularly in rural areas that count on Medicaid. — Montgomery Advertiser

California: Undoing Medi-Cal Expansion

Now anyone in California can sign up for Medi-Cal if their annual income is low enough: $16,395 or less for a single person or $22,108 or less for a couple. Medi-Cal is free for participants.
The Senate bill recommends slowly undoing the Medi-Cal expansion starting in three years, which could ultimately leave 3.9 million Californians without insurance. — The Los Angeles Times

Pennsylvania: Cuts to Drug Programs

Eliminating the Medicaid expansion would impact drug and alcohol treatment. About 124,000 people covered by the expansion have accessed such treatment. The cut would be especially damaging given the opioid addiction crisis, which is presently killing 13 Pennsylvania residents per day, according to Jennifer Smith, the acting secretary of drug and programs. — Penn Live

South Dakota: ‘You Never Know What’s Going to Happen’

“You work so hard for years, taking care of yourself and whatever, but you never know what’s going to happen,” said [Sharon] Rueschhoff, who voted for President Donald Trump. “What happens when it comes to the worst and you’ve burned through it all? What are they going to do? Throw us in the gutter somewhere?” — Argus Leader

Nebraska: ‘It Was a Big Rip-Off’

One family said this will impact their household.
“My younger brother has autism and before Obamacare we’d tried to keep that a secret, that way it could not prevent us from health care.”
But others saying they just want a replacement for our current healthcare plan.
“We should really repeal Obamacare, it was a big rip off from the get-go,” James Leibhart said. — Nebraska.TV

Delaware: ‘People Will Die’

The effects of the Affordable Care Act rollback will be deadly, especially for those struggling with addiction, according to Delaware law enforcement and elected officials.
Treatment is already hard to come by in Delaware, even for those with insurance, but new health care proposals discussed earlier this week in the United States Senateindicate an even harder hit to those with chronic illness, addiction and mental healthdiagnoses.
“The bills under consideration by Congress are simply inhumane,” said Dr. Karyl Rattay, director of the state Division of Public Health. “People will die.” —

Alaska: Effects on the Poor

The Better Care Reconciliation Act would start cutting Medicaid by the year 2021 if passed. For Alaska, the effects could be enormous as 10.3% of the population is in poverty and 26.4% have no health insurance, according to “Talk poverty”. The Medicaid cut also includes disability services.
Paid Medicare coverage would be cut to 100 days of skilled nursing care. The population of Alaskans 65+ is expected to reach 110,000 people by 2021. —

Montana: A Medicaid Gap

More than 79,000 Montanans are covered under expansion, which was previously estimated to largely vanish by 2024 under the House version of the bill. Health care analysts say the Senate version of the bill just pushes back this date and could result in even greater cuts to Medicaid over time, compared to the House version, by resetting the inflationary adjustment in 2026.
Medicaid represents 38 percent of federal funds coming into Montana. The state’s share of Medicaid cost makes up 10 percent of state spending. Previous estimates from the state Department of Health and Human Services show Montana would need an extra $251 million a year to maintain present coverage under reduced federal funding. — Missoulian

New Hampshire: Rising Costs

For families like hers with severely ill members, the Senate proposal has many things not to like - yet last week’s announcement of another health insurer exiting the Obamacare exchange market points to the rising costs many middle class families face getting coverage under that Affordable Care Act. — Union Leader

Michigan: Care for Women

Planned Parenthood has 19 health centers in Michigan. In fiscal 2015, the centers served 63,805 patients for services that includes breast exams, pap tests, prenatal visits, testing for pregnancy and sexually transmitted disease and providing birth control and abortion—

Maine: Cuts in Rural Areas

Rural Maine would be hit especially hard, as the outlying areas of the state are more reliant on Medicaid funding for health services. Rural hospitals would be under more financial stress if the Senate bill were to be approved. —

Ohio: ‘What Are We Saying?’

She says if this bill passes, it will bring a tremendous burden on her family, not to mention other families supporting elderly loved ones and those who depend on government assistance.
“What are we saying to these people in this country? ‘You don’t matter.’ And I’m sorry, I think it’s sinful, I really do,” [Jeanetta] Russell said. —

Virginia: Calls to Slow Down

Virginia legislative budget leaders had a quick response to a new health care plan proposed by Republicans in the U.S. Senate — please don’t do what you just did.
The Republican co-chairmen of the Joint Subcommittee for Health and Human Resources Oversight said Thursday that the Senate’s current proposal “fails to address the inequities in the federal funding allocation between states” for the Medicaid program that Virginia has operated in partnership with the federal government for a half-century. — Richmond News

Ohio: Hidden Extra Costs

Senate Republicans say through their healthcare bill that they want states to take more responsibility for Medicaid, and their bill says it will give them that flexibility.
Yet the bill to dramatically alter Obamacare may actually tie the hands of Ohio in a little-noticed way, costing the state hundreds of millions a year. —

The Senate’s three big lies about health Care

by E.J. Dionne - The Washington Post - June 26, 2017

To succeed in gutting health coverage for millions of Americans, Senate Republican leaders need to get a series of lies accepted as truth. Journalists and other neutral arbiters must resist the temptation to report these lies as just a point of view. A lie is a lie.
Lie One: Democrats and progressives are unwilling to work with Republicans and conservatives on this issue. “If we went and got the single greatest health-care plan in the history of the world, we would not get one Democrat vote,” President Trump told an Iowa crowd last Wednesday. 
In fact, Democrats, including President Barack Obama when he was in office, have said repeatedly that they would like to work with Republicans to improve the Affordable Care Act. Senate Democratic leader Charles E. Schumer’s office put out a list of such offers, including a June 15 letter from Schumer to Senate Majority Leader Mitch McConnell calling for a cross-party meeting to “find a way to make health care more affordable and accessible.”
But Democrats can never be complicit in a wholesale repeal of Obamacare that would take health coverage away from millions of Americans.
This first lie is important because it rationalizes the Republican claim that the bill has to be draconian because it can’t pass without support from the party’s most right-wing legislators. “This is not the best possible bill,” said Sen. Pat Roberts (R-Kan.). “It is the best bill possible under very difficult circumstances.”
But those “circumstances” have been created by the GOP itself. A completely different coalition is available, but Republicans don’t want to activate it because they are hellbent on repealing Obamacare. Why? 
This brings us to Lie Two: This bill is primarily about improving health care for American families. No, this effort is primarily about cutting taxes. When it comes to health care, the main thing the bill does is take money away from providing it to pay for the tax reductions it contains and for future bonanzas the Republicans have promised.
The tax cuts in this legislation alone would amount to some $700 billion over a decade, according to the Center on Budget and Policy Priorities. About $33 billion of this would go to tax cuts conservatively averaging $7 million every year to each of the 400 highest-income families in the country. What could $33 billion buy? The CBPP reports it would be enough to pay for the expansion of Medicaid in Nevada, West Virginia, Arkansas and Alaska. Talk about income redistribution.
A telltale: One of the main Republican complaints about Obamacare has been that the deductibles and co-pays under ACA policies are too high. But the Republican bill only makes this problem worse. 
As the New York Times’ Margot Sanger-Katz wrote: “Many middle-income Americans would be expected to pay a larger share of their income to purchase health insurance that covers a smaller share of their care.” 
If this bill were truly about health care, Republicans would take all the tax cuts out and use that money to ease the pain their bill would cause. But they won’t, because the tax cuts are the thing that matters to them.
Lie Three: The Senate bill is a “compromise.” Really? Between whom? The House wants to destroy Obamacare quickly, the Senate a bit more slowly while also cutting Medicaid more steeply over time. This is only a “compromise” between two very right-wing policies.
What's in the Senate health-care bill?
Senate Majority Leader Mitch McConnell (R-Ky.) unveiled the legislation that would reshape a big piece of the U.S. health-care system on Thursday, June 22. Here's what we know about the bill. (Monica Akhtar/The Washington Post)
Imagine you are negotiating with two creditors who say you owe them $1,000 and you insist you owe nothing. The first creditor wants the money quickly. The second says you can take a bit little longer, but you have to pay $1,200 — and he has the nerve to call this a “compromise.” Nowhere in this deal is your position taken into account. Welcome to the logic of the Senate health-care bill.
I hope I never have to write about Lie Four, which would be Republican senators who surely know better — including Susan Collins, Dean Heller, Lisa Murkowski, Jeff Flake, Shelley Moore Capito and Rob Portman — justifying their votes for this monstrosity by claiming that it’s the best they could do.
Heller signaled doubts about the proposal on Friday, which is a step in the right direction. But only by killing this bill would these senators open the way for reasonable fixes to the ACA. Do they really want to say someday that one of their most important votes in the Senate involved taking health care away from millions of Americans? I would like to believe they are too decent for that. I hope I’m not lying to myself.