Wednesday, January 25, 2017

Health Care Reform Articles - January 25, 2017

Help us, GOP. You’re our only hope.

by Garrison Keillor - Washington Post
On Jan. 20, 2017, President Trump took the oath of office, pledging in his inaugural address to embark on a strategy of "America first." Here are key moments from that speech. (Sarah Parnass/The Washington Post)
What we know so far is that the man is who he is. There is no larger, finer man inside him trying to get out. Everyone who is paying attention knows this. Flags flying at the Capitol, the U.S. Marine Band, gray eminences in black coats, and He Who Is Smarter Than Those With Intelligence delivers 16 minutes of hooey and horse hockey about corrupt politicians betraying the people, and American carnage, and patriotism healing our division, though the division is mainly about Himself and though love of country does not necessarily make people stupid.
There might as well have been a 14-year-old boy at the lectern saying that he is in possession of the Golden Goblet that will drive the Gimlets from Fredonia and preserve the Sacred Marmite of Lord Numbskull and his Nimrods.
The next day he motored out to the CIA and stood before the memorial wall honoring heroes who gave their lives in anonymity and he bitched about his newspaper coverage. The next day he boasted that his inauguration’s TV ratings were higher than those in 2013. The day after that, he told the congressional leadership that he lost the popular vote because millions of illegal votes were cast, which everyone in the room knew was a bald-faced lie, except perhaps Himself. The man is clueless, tightly locked inside his own small bubble. A sizable minority of Americans, longing for greatness or wanting to smack down an ambitious woman and to show those people in the hellhole coastal cities what the real America is all about, has elected him. To him, this minority is a mass movement such as the world has never seen. God have mercy.
“American carnage,” my Aunt Sally: The correct term is “American capitalism.” Jobs are lost to automation, innovation, obsolescence, the moving finger of fate. The carriage industry was devastated by the automobile, and the men who made surreys and broughams and hansoms had to learn something new; the Pullman porter union was hit hard by the advent of air travel, and the porters sent their sons to college; the newspaper business was hit hard by Craigslist. Too bad for us. I know gifted men who were successful graphic designers until computers came along and younger people with computer skills took their place and those gifted men had to do something else. T-shirts are made in Asian countries because Americans don’t want to pay $20 for one. Coal yields to natural gas as renewable energy marches forward. Who doesn’t get this? The idea that the government is obligated to create a good living for you is one the Republican Party has fought since Adam was in the third grade. It’s the party of personal responsibility. But there he is, promising to make the bluebirds sing. As if.
Everyone knows that the man is a fabulator, oblivious, trapped in his own terrible needs. Republican, Democrat, libertarian, socialist, white supremacist or sebaceous cyst — everyone knows it. It is up to Republicans to save the country from this man. They elected him, and it is their duty to tie a rope around his ankle. They formed a solid bloc against President Obama and held their ranks, and now, for revenge, they will go after health insurance subsidies for people of limited means, which is one of the cruelest things they can possibly do. Dishwashers and cleaning ladies need heart surgery, too — hospital emergency rooms already see streams of sick people, uninsured, poor or unable to deal with the paperwork, coming in for ordinary care, and when upward of 30 million are left high and dry, people will suffer horribly. “Nobody is going to be dying on the streets,” Trump said. No, they’re going to die at home in their bedrooms. 
The question is: How cynical are we willing to be and for how long? How long will Senate Republicans wait until a few of them stand up to the man? Greatness is in the eye of the beholder. American self-respect is what is at stake here, ladies and gentlemen. The only good things to come out of that inauguration were the marches all over the country the day after, millions of people taking to the streets of their own free will, most of them women, packed in tight, lots of pink hats, lots of signage, earnest, vulgar, witty, a few brilliant (“Take your broken heart and make it art”), and all of it rather civil and good-humored. That’s the great America I grew up in. It’s still here.

A 10-point plan to stop Trump and make gains in justice and equality

by George Lakey

I was among the 100,000 who marched in San Francisco’s Women’s March the day after Donald Trump’s inauguration. While enthusiasm for the struggle seemed high, an important question was looming: What’s the strategic plan, as we head into the Trump era? Although there’s no simple answer, I offer this 10-point plan — fully open for discussion and debate.
1. Recognize that we represent the majority, not Trump. 

Three times more people participated in the Women’s March in Washington, D.C., than were present at the inauguration the day before. He lost the popular vote in the election. Many of his own voters admitted in exit polls that they consider him unqualified to be president. Furthermore, Trump plans to target progressive policies that polls find to be supported by solid majorities of Americans.
Trump does have strengths in addition to his brilliance in manipulating mainstream media. Key parts of the economic elite have decided that they can use him for their own goals. So, they will support him — as long as he can deliver acceleration of school privatization, for example, or the fossil fuel pipelining of America. His core voting base (the minority of a minority) may support him for a period, until his failure to deliver unrealistic promises becomes apparent.
Even before the inauguration, he alienated significant parts of the security state that he needs to depend on. He needs a vast professional bureaucracy to carry out his will, but it has many subtle ways of thwarting him. Harry Truman famously admitted, publicly, his frustration after he was repeatedly stymied by an uncooperative bureaucracy.
Trump’s bullying is both a strength and a weakness. His style alienates many, including among his own voters, and stirs opposition.
Stopping Trump is not a slam dunk, but it is possible when he is given his due as a cagey opponent. It also helps when we decide to be strategic rather than led by fear and moral outrage, jumping from whichever tactic feels good in the moment, but has little impact. Now is the time when we can identify his pillars of support and lay plans to undermine them.
2. Strengthen civic institutions and their connections with targeted populations.
Trump will continue to turn to the age-old weapon of scapegoating to shore up his working-class base, and he’ll feel more pressure to do that as his own programs for “making America great again” fail to deliver the goods to that base — even while enriching the economic elite.
Some sanctuary cities have already made a good start by declaring their resistance to anti-immigrant moves by the federal government. Activists can reinforce these initiatives with a range of civic and religious institutions, urging them to strengthen their connections with scapegoated groups like Jews, immigrants and African Americans. The civics may not by themselves always think of this, so it may take activists within or near them to alert them to their responsibility of solidarity.
Because we are the majority, we can make full use of Bill Moyer’s four roles of social change. Consider: How can advocates, helpers, organizers and rebels strengthen their solidarity impact? Training for Change organizer Daniel Hunter brainstormed some possible moves: Advocates persuade cities and states to give drivers licenses to undocumented people. Organizers create circles of solidarity in which citizens could physically intervene — when immigrants are in danger —and surround the vulnerable ones. (The New Sanctuary Movement in Philadelphia calls this “sanctuary in the streets.”) Helpers could insist that they provide food and healthcare to people in deportation centers, and if entry is refused, collaborate with rebels to break in with food and risk arrest.
3. Play offense, not defense.  
The last time progressives in the United States faced this degree of danger was when Ronald Reagan became president. One of Reagan’s first acts was to fire the air traffic controllers when they went on strike, putting into question national air safety. Strategically, he chose “shock and awe,” and it worked – most of the U.S. movements for change went on the defensive.
Gandhi and military generals agree: No one wins anything of consequence on the defensive. I define “defensive” as trying to maintain previous gains. U.S. movements in 1980 made many gains in the previous two decades. Understandably, they tried to defend them. As Gandhi and generals would predict, the movements instead lost ground to the “Reagan Revolution” and, for the most part, have lost ground ever since.
One exception stands out: the LGBT movement. Instead of defending, for example, local gains in city human relations commissions, LGBT people escalated in the 1980s with ACT-UP leading the way. They followed up with the campaign for equal marriage and escalated again with the demand for equality in the military.
LBGT people proved that Gandhi and the generals are right: The best defense is an offense.
I hear many American progressives unconsciously talking about Trump defensively, preparing to make precisely the same mistake as an older generation did with Reagan. The LGBT’s lesson is obvious: heighten nonviolent direct action campaigns and start new ones. Instead of defending Obamacare, let’s push for an even more comprehensive health solution, like Medicare for all.
direct action campaign is defined by a pressing issue, a clear demand, and a target that can yield that demand. Powerful social movements, even those that overthrew military dictatorships, have often been built in exactly this way.
These days, campaign design needs to take account of the recent impact of social media. Because many people have allowed social media to draw them into an isolating bubble, activists need to design campaigns that deliberately increase their base through building relationships “beyond the choir.” Increased use of training may be necessary to maximize impact.
4. Link campaigns to build movements.
Standing Rock is a current example of the synergistic and expanding effect of linking campaigns. Pipeline fights, indigenous rights, and even the role of Veterans for Peace — in raising questions about the U.S. empire — were all amplified through linking to the ongoing campaign in North Dakota.
The classic American example of campaign linkage grew from the simple act of four college students in North Carolina on Feb. 1, 1960, starting their campaign to desegregate a lunch counter. Students in other towns followed the example, and the wave of sit-ins became a movement. The movement helped grow existing organizations — for example, the Congress of Racial Equality, or CORE, which then started a new kind of campaign, the Freedom Rides. Multiple freedom rides were linked and further built the strength of the civil rights movement.
These campaigns did not have the American majority on their side, nor did they win all their demands, but their cumulative value forced major changes and eventually changed public opinion as well. The civil rights movement illustrates the crucial difference in mode of operation between direct action campaigns and political parties’ campaigns.
Democrats, for example, are hugely about polls and focus groups. Their power rests on current public opinion and its manipulation through electioneering and political maneuver. Even for progressive-inclined Democrats, the ability to act is tightly limited by the narrow range of current opinion (not to mention by what the economic elite is willing to allow).
Social movements, by contrast, can take stands that go beyond current opinion and wage campaigns that have transformative impact, such as women’s right to vote, gay rights and stopping pipelines. This difference helps explain why progressive Democrats habitually fight defensively, while movements are free to stay on the offensive and win. Bernie Sanders, for example, is now defensively fighting to save Medicare. By contrast, a social movement is free to launch a fight for single-payer health care. Such a struggle could threaten to split off part of Trump’s working class base and — even if it failed to fully achieve its goal – save more of Medicare.
5. Link movements to create a movement of movements.
When times are out of joint, a successful movement around one issue inspires campaigns on other issues to link and become new movements. That’s what happened the last time the U.S. took major steps toward justice. The civil rights movement begat the Berkeley Free Speech campaign and the national student movement for university reform, the draft resistance campaign and the anti-Vietnam war movement, and so on — energizing seniors, people with disabilities, mental health consumers, women, Chicanos, Puerto Ricans, auto workers and many more.
With so many movements developing, A. Philip Randolph and Bayard Rustin catalyzed the 1963 March on Washington for Jobs and Freedom, hoping to start linking movements into a movement of movements. They glimpsed an opportunity to amass so much power independent of the major parties that the United States could develop a counter-force to the economic elite and bring about democratic socialism. Creating an independent movement of movements was the successful path taken by the Scandinavians, and both Randolph and Rustin wanted it for the United States.
Substantial linkage, however, was not available at that time. For one thing, the U.S. economy was booming, and there wasn’t enough discontent in the white working class — let alone the burgeoning middle class — to create an opening. What’s more, racism was still too intense, although the United Auto Workers had successfully found a way forward by uniting black and white workers to fight employers in the auto industry. In the past half century, much has changed on both those dimensions.
My point is that multiple campaigns on the same or similar issues generates a movement, and that multiple movements provide the opportunity for a movement of movements. The closer we come to that point, the more pressure there is on the Democrats to co-opt us. The Republicans’ historic role is usually repression, while the Democrats’ job is to limit and control grassroots movements by pulling them into the party.
We saw that happen to the later stage of the civil rights movement and again with the Democrat-embraced health reform movement of 2007-9, when the single-payer option — and even the public option — was dropped to pass the medical industrial complex-friendly Affordable Care Act.
When a social movement is independent, it can force the Democrats to become allies instead of controllers. The civil rights movement did exactly that before 1965; we see what it can look like in the excellent film “Selma.” On a more micro level, Daniel Hunter — in his book “Strategy and Soul” — reveals how a neighborhood-based movement forced politicians to come to the campaigners, instead of the campaigners seeking help from the politicians.
Whatever our partisan sympathies, a quick look at political trends in the United States shows why movement independence is more crucial now than at any time in the last half-century.
Public alienation from the major parties – Republican or Democratic – has gone off the charts. Voters stay away from the polls, as if afraid of catching germs. The Tea Party gains more cred when it trashes the Republican Party. Donald Trump reassures his voter base by verbally attacking Congress – both parties, no less — in his inaugural address. Much of his voter base had long since left the Democratic Party because of its own betrayal of working-class interests. Black working-class voters also signaled their alienation by failing to give full support to Hillary Clinton, despite Barack and Michelle Obama’s entreaties.
Such a period of alienation is just the time for direct action campaigns that fight for progressive demands — like $15 per hour and Medicare for all — to signal independence from the politicians who bear so much responsibility for U.S. decline. Such independence appeals to the vast majority, including many Trump voters. A self-respecting movement of movements knows that the Democrats will then come to them and offer to be allies.
6. Avoid one-off demonstrations.
This political moment adds force to the sizable advantage of direct action campaigns over single demonstrations, however large. Protests are by their nature reactive. In these next years, predictably, Trump will act and progressives will react, then Trump will act again and progressives will react again. Trump, an accomplished fighter, knows that staying on the offensive is what enables him to win. Progressives, often led by people with a track record of loss, take the bait and react, over and over.
Simple protests, no matter what the issue, essentially signal to Trump that he is winning — he has manipulated us into reacting.
I realize that reactivity is a habit among many activists, and may take heroic self-discipline to avoid. An alternative is to organize a campaign, or join a campaign near you, even if the issue is not your favorite, and plunge in with full talent and energy.
7. Heighten the contrast in confrontations between the campaigners’ behavior and our right-wing opponents.
Many have noted Trump’s signals to his white supremacist and other allies that violence is an acceptable means to use against us.
This is an old story in the United States, and there’s no reason to let it throw us. Through clear nonviolent policy, like that of the Women’s March that urged against bringing anything that could be considered a weapon, we remain centered and able to attract large numbers. Some movements have made grave mistakes by responding to violent attacks in kind, losing ground on their goals as a result. Others have performed brilliantly, as did the civil rights campaigns that faced down the largest sustained terrorist organization in U.S. history, the KKK, often without protection from local law enforcement and even federal authorities.
The Global Nonviolent Action Database presents campaigns in almost 200 countries, including many nations where repressive violence was far worse than it has been in the United States. The database makes it possible to search for campaigns that faced repressive violence and to learn how they handled it. It is easy to find out, therefore, what worked and what didn’t, and to reinforce the lessons through training.
8. Aim to unite around a vision for justice, equality and freedom.
Individuals, campaigns, and movements all gain greater power and credibility through projecting a vision of what they want, as well as what they don’t want. They grow more easily, withstand attacks more easily, and have an easier time maintaining their boldness and creativity. “Protest movements” like Occupy are notoriously fragile and precarious; sustainable movements like the struggle for LGBT rights and equality have a liberating vision. The homophobes were right: We did have a “homosexual agenda!”
The good news is that on August 1, 2016, the Movement for Black Lives offered a vision that can be a draft for dialogue for many campaigns and movements. Many groups have already endorsed it. The vision is bold, substantive and so different from the present that it is even in alignment with the best practices of the Nordic countries. In that sense, it is highly practical and backed by a half-century track record. Compared with the ever volatile and shifting Donald Trump act, a rough agreement on vision by a movement of movements could enhance our credibility and divide his base.
9. Make the vision more real by extending new economy institutions and coops.
These often fly under the radar in our highly politicized discourse, so two things need to happen. People who are active in campaigns and movement development need to honor the development of economic infrastructure that reflects the values of our united vision.
Second, the new economy institutions need to brand themselves as part of the justice movement, giving up the advantages of modesty. They may find new advantages and surprising opportunities for growth. After all, a majority of Americans polled have already said they like the concept of employee-owned companies.
10. See U.S. polarization as opportunity.
Donald Trump frames U.S. polarization in ways that benefit him, trying to increase the loyalty of his base. Many progressives decry the polarization, as if their upset at its ugly manifestations will make it go away. The reality is that the polarization is fundamentally linked to economic inequality and was growing for years before Trump came forward. It is not going away. The question is how to manage our fears and learn to navigate the stormy waters.
The good news is that the greatest polarization in Scandinavian history — Nazis vs. Communists in the 1920s and ‘30s — was also the time when broad people’s movements made their breakthrough, pushed the domination of their economic elites aside and invented a new model of economic justice. The polarization did not stop them — if anything, the movements used the opportunity.
Yes, polarization is dangerous. Germany and Italy polarized when Sweden and Norway did, but went fascist. Their movements made huge mistakes, mistakes avoided by the Swedes and Norwegians. Our most recent period of great polarization in the United States was also dangerous, but the 1960s and ‘70s was our period of greatest progress since the polarized 1930s.
In short, there’s good reason to see the Trump era as an opportunity not only to stop him, but to make major gains in justice and equality. It will help to learn to turn our fear into power. We’ll also need strategy, and the humility to learn from successes of other movements that have come out ahead during hard times. It is not rocket science. If we’re willing to shift personal habits and priorities, support each other through hardship, and come together on a plan, we can win. That is our opportunity.

Repealing the Affordable Care Act will kill more than 43,000 people annually
by David Himmelstein and Steffie Woolhandler

Now that President Trump is in the Oval Office, thousands of American lives that were previously protected by provisions of the Affordable Care Act are in danger. For more than 30 years, we have studied how death rates are affected by changes in health-care coverage, and we’re convinced that an ACA repeal could cause tens of thousands of deaths annually.
The story is in the data: The biggest and most definitive study of what happens to death rates when Medicaid coverage is expanded, published in the New England Journal of Medicine, found that for every 455 people who gained coverage across several states, one life was saved per year. Applying that figure to even a conservative estimate of 20 million losing coverage in the event of an ACA repeal yields an estimate of 43,956 deaths annually.
With Republicans’ efforts to destroy the ACA now underway, several commentators have expressed something akin to cautious optimism about the effect of a potential repeal. The Washington Post’s Glenn Kessler awarded Sen. Bernie Sanders (I-Vt.) four Pinocchios for claiming that 36,000 people a year will die if the ACA is repealed; Brookings Institution fellow Henry Aaron, meanwhile, predicted that Republicans probably will salvage much of the ACA’s gains, and conservative writer Grover Norquist argued that the tax cuts associated with repeal would be a massive boon for the middle class.
But such optimism is overblown.
The first problem is that Republicans don’t have a clear replacement plan. Kessler, for instance, chides Sanders for assuming that repeal would leave many millions uninsured, because Kessler presumes that the Republicans would replace the ACA with reforms that preserve coverage. But while repeal seems highly likely (indeed, it’s already underway using a legislative vehicle that requires only 50 Senate votes), replacement (which would require 60 votes) is much less certain.

Moreover, even if a Republican replacement plan comes together, it’s likely to take a big backward step from the gains made by the ACA, covering fewer people with much skimpier plans.

Although Aaron has a rosy view of a likely Republican plan, much of what they — notably House Speaker Paul D. Ryan (R-Wis.) and Rep. Tom Price (R-Ga.), who is Trump’s nominee to head the Department of Heath and Human Services, which will be in charge of dismantling the ACA — have advocated in place of the ACA would hollow out the coverage of many who were unaffected by the law, harming them and probably raising their death rates. Abolishing minimum coverage standards for insurance policies would leave insurers and employers free to cut coverage for preventive and reproduction-related care. Allowing interstate insurance sales probably would cause a race to the bottom, with skimpy plans that emanate from lightly regulated states becoming the norm. Block granting Medicaid would leave poor patients at the mercy of state officials, many of whom have shown little concern for the health of the poor. A Medicare voucher program (with the value of the voucher tied to overall inflation rather than more rapid medical inflation) would worsen the coverage of millions of seniors, a problem that would be exacerbated by the proposed ban on full coverage under Medicare supplement policies. In other words, even if Republicans replace the ACA, the plans they’ve put on the table would have devastating consequences.
The frightening fact is that Sanders’s estimate that about 36,000 people will die if the ACA is repealed is consistent with well-respected studies. The Urban Institute’s estimate, for instance, predicts that 29.8 million (not just 20 million) will lose coverage if Republicans repeal the law using the budget reconciliation process. And that’s exactly what they’ve already begun to do, with no replacement plan in sight.
No one knows with any certainty what the Republicans will do, or how many will die as a result. But Sanders’s suggestion that 36,000 would die is certainly well within the ballpark of scientific consensus on the likely impact of repeal of the ACA, and the notion of certain replacement — and the hope that a GOP replacement would be a serviceable remedy — are each far from certain, and looking worse every day.

Senators Propose Giving States Option to Keep Affordable Care Act

by Robert Pear - NYT

WASHINGTON — Several Republican senators on Monday proposed a partial replacement for the Affordable Care Act that would allow states to continue operating under the law if they choose, a proposal meant to appeal to critics and supporters of former President Barack Obama’s signature health law.
But the plan was attacked by Democrats as a step back from the Affordable Care Act’s protections, and it was unlikely to win acceptance from conservative Republicans who want to get rid of the law and its tax increases as soon as possible. If anything, the proposal — by Senators Bill Cassidy of Louisiana, a medical doctor, and Susan Collins of Maine, a moderate Republican — may show how difficult it will be for Republicans to enact a replacement for the Affordable Care Act.
Legislation that can pass muster in the more conservative House may not win enough support in the Senate. A bill with broad appeal in the Senate may fail in the House.
Under the proposal, states could stay with the Affordable Care Act, or they could receive a similar amount of federal money, which consumers could use to pay for medical care and health insurance. “We are moving the locus of repeal to state government,” Mr. Cassidy said. “States should have the right to choose.”
The proposal shares some features with House Republican proposals: It would encourage greater use of health savings accounts and eliminate the requirement for most Americans to have insurance or pay a tax penalty. But the option for states to keep the Affordable Care Act alive will rankle the most conservative Republicans who have been trying for nearly seven years to blow it up.
“Obamacare is flawed, failing and not fixable, and it needs to be fully repealed,” said Representative Mark Meadows of North Carolina, the chairman of the House Freedom Caucus.
A stalemate between the House and Senate would leave in place Mr. Obama’s health law, but efforts by President Trump and Congress to undermine it could send health insurance markets into a tailspin. On Friday, as one of his first official acts as president, Mr. Trump signed an executive order that could allow officials to ease up on enforcement of the mandate requiring most Americans to have insurance.
Supporters of the Affordable Care Act panned the Cassidy-Collins proposal. “Millions of Americans would be kicked off their plans, out-of-pocket costs and deductibles for consumers would skyrocket, and protections for people with pre-existing conditions, such as cancer, would be gutted,” said the Senate Democratic leader, Chuck Schumer of New York.
Ronald F. Pollack, the executive director of Families USA, a liberal-leaning consumer group, said the bill “falls way short of providing the protections and coverage people have under the Affordable Care Act.”
Ms. Collins said the bill would allow states to “keep the Affordable Care Act if it is working for their residents.” But she predicted that most states would choose something different.
Under the Cassidy-Collins bill, states could enroll people who would otherwise be uninsured in health plans providing basic coverage. These high-deductible health plans are intended to protect consumers against catastrophic medical expenses. They would cover generic versions of prescription drugs, and they would also have to cover recommended childhood immunizations without co-payments. States would contract with one or more insurers to offer this coverage.
Consumers could buy “more robust coverage” if they want, Mr. Cassidy said, but they could be automatically enrolled, by default, in the high-deductible health plans providing basic coverage. “A state could say, ‘All those eligible are enrolled unless they choose not to be,’” he explained.
This “passive enrollment” would provide insurers with a large pool of customers, including many healthy people, without the coercion of an “individual mandate,” Mr. Cassidy said.
“We think that we could cover more people than Obamacare,” Mr. Cassidy said, although he acknowledged that the effects of his bill had not been analyzed by the Congressional Budget Office, which serves as Capitol Hill’s official scorekeeper.
If a state opts out of the Affordable Care Act, many of the federal insurance standards established under the law would no longer apply. The bill would repeal federal benefit mandates that “often force Americans to pay for coverage they don’t need and can’t afford,” Mr. Cassidy said.
But some protections would remain in place. Parents would still be allowed to keep children on their insurance until the age of 26, and insurers could not impose annual or lifetime limits on benefits.
The Cassidy-Collins bill, called the Patient Freedom Act, would eliminate not only the unpopular individual mandate, but also the federal requirement for larger employers to offer coverage to full-time employees.
Mr. Cassidy said that Senators Shelley Moore Capito of West Virginia and Johnny Isakson of Georgia, both Republicans, were also sponsors of the bill.
The Senate majority leader, Mitch McConnell, Republican of Kentucky, and the No. 2 Senate Republican, John Cornyn of Texas, were sponsors of a similar bill that Mr. Cassidy introduced in 2015. But the legislative landscape is different now. Republicans in Congress can repeal the Affordable Care Act, with support from Mr. Trump. In the Senate, they will need help from Democrats to adopt a replacement because Republicans are eight votes shy of the 60 needed to stop a filibuster.

Here’s the nitty gritty on Collins’ Obamacare replacement plan

by Jackie Farwell - Bangor Daily News

Republican U.S. Sen. Susan Collins joined a Louisiana senator Monday to unveil new legislation aimed at replacing the Affordable Care Act.
The Patient Freedom Act of 2017announced last week, would increase Americans’ access to affordable health care by giving states more flexibility in regulating health insurance, according to Collins and co-sponsor U.S. Sen. Bill Cassidy, a Republican from Louisiana.
The bill presents states with three options:
Door #1: The ACA is here to stay. If a state likes the ACA, it can keep it. (Anyone else hearing echoes of President Barack Obama’s oft-repeated and oft-maligned, “If you like your plan, you can keep your plan”comments about the health reform law?) This includes the provisions people like, such as subsidies that help consumers afford their coverage, as well as the less popular requirements, such as the mandates that large companies provide insurance and that everyone has coverage. The bill actually repeals the section of the ACA that imposes the mandates but allows states to reinstate it.In places such as Maine, where the governor and legislative Republicans have resisted the ACA, this option might more accurately be described as, “If you like your plan and your state government decides to play along, you can keep it, as long as your insurer continues to participate,” Mitchell Stein, a Maine health policy consultant, said.
It also may not give states a way to fix any known problems with the ACA, he said.
For the sake of simplicity, we’ll skip ahead to:
Door #3: No thanks, Uncle Sam. States can decline all federal funding set aside through the ACA and devise their own programs. But they have to keep some consumer protections required under the ACA.
Collins and Cassidy don’t expect many states to jump on these two options, though. They see the most potential in:
Door #2: Keep the money, cut the cord. States receive 95 percent of the federal money they were due under the ACA. Those funds are now used to pay for the subsidies and for Medicaid expansion. States could receive the money in one of two ways — either as a grant based on the number of beneficiaries or in the form of tax credits consumers use to help pay for insurance. In both cases, the money is deposited into a Roth health savings account, “meaning the money will go directly to the patient.”
The financial assistance would benefit about the same population that now relies on Obamacare insurance — people who buy their own plans rather than getting it through work or government programs, such as Medicaid and Medicare. In Maine, that’s about 75,000 people. But the bill aims to serve more people, including the 30 million Americans who remain uninsured under the ACA.
Collins and Cassidy are calling this the “default option,” because states could automatically enroll uninsured individuals in “basic health care coverage” unless the person opts out. That’s designed to ensure that enough healthy people enroll to offset higher costs for sicker ones but stops short of mandating it.
That coverage would be a high-deductible health plan with additional coverage for prescription medications. People who can afford it could choose to buy a more generous plan.
States choosing this option would get extra funding to use for “population health initiatives.”
The senators propose that states would pick one of these options in 2018 and implement them in 2019, so no one loses coverage during the transition.
The bill would keep some of the ACA’s consumer protections:
— Prohibiting insurers from setting annual and lifetime limits.
— Prohibiting insurers from excluding people with pre-existing conditions.
— Young adults could stay on their parents’ plan until age 26.
— Coverage for mental health and substance abuse would stay.
It also establishes several new protections:
— Limiting out-of-network fees for emergency medical care paid for with the HSA.
— Health providers must publish “cash prices” for services paid for with an HSA or with cash.
As they say, the devil is in the details. The proposal is sparking plenty of questions and criticism, including doubts about its chance of passing. Democrats attacked it as falling short of the ACA’s protections and conservative Republicans who want to repeal the law are unlikely to support it, according to the New York Times. It leaves ACA taxes in place to fund its provisions, which supporters of the law like but many Republicans oppose.
Collins said she sees the bill as a “good faith effort” that remains open to refinements.
Here are some of the major questions and sticking points:
How much money goes into the HSAs? With Option 2, states would get that pile of ACA money, then divide it up as tax credits among residents who earn too much to qualify for Medicaid but less than $90,000 per year for an individual or $150,000 for married couples. The credits would gradually reduce from that income level up to $190,000/$250,000.
But it’s hard to say how much money you’d get if you fall into that group. No one has done the math yet, as far as I’ve seen. All we know is that older people who live in areas where medical costs are higher would get more.
Individuals also could contribute their own money into the HSAs, as well as their employers. The maximum amount would be $5,000 for an individual and $10,000 for a married couple — plus another $1,000 for anyone older than 55. That limit doesn’t include the federal tax credits, so for people who get them, more than $5,000 or $10,000 could be contributed each year.
Consumers could use the HSA money to pay for medical care and out-of-pocket costs, such as deductibles, co-pays and monthly premiums.
Whether the HSAs would be adequate to cover those costs is a huge question. Say you need one surgical procedure that’s not covered by your plan — $10,000 could disappear in a blink.
The senators contend that premiums will be lower under this plan, but the bill sets no limits on premiums, co-insurance or deductibles.
Unlike the ACA subsidies, this financial leg up isn’t as closely tied to income. That’s got health advocates worried that many people won’t be able to afford decent coverage. The bill aims to take a smaller pot of money — because of the 5 percent cut to ACA funds — and distribute it evenly to more people than the ACA currently serves. That will necessarily mean lower subsidies for people who earn just a little too much to qualify for Medicaid, Loren Adler, associate director of the Center for Health Policy at the Brookings Institution, noted on Twitter.
He projects that states with the highest premiums, and therefore subsidies, would get the most money.
What counts as “basic” health coverage? The bill eliminates “essential health benefits” the ACA requires insurers to offer as part of all plans they sell. Those are non-negotiables, such as paying for hospitalization, outpatient care and pregnancy and maternity care. Critics of the ACA say this requirement forces Americans to pay for coverage they don’t need and can’t afford. But supporters of the law are worried that without this requirement, insurers will sell barebones plans. Stein points out that even though the bill still prevents insurers from imposing lifetime caps, the loss of essential health benefits renders that protection meaningless, because the caps would apply only to covered services.
We also don’t know exactly how high the deductibles would be for that basic health plan.
What about people with pre-existing conditions? Collins and Cassidy said the bill would protect people with pre-existing health issues, but not in the same way the ACA protects them.
Insurers would still have to offer those people insurance, though they could charge them higher premiums if those individuals have any interruption in coverage.
The first time around, anyone could enroll in any type of plan without medical underwriting, or that delightful process in which insurers quiz you about your health and charge you more if you have certain ailments.
After that, consumers could pick only the basic plan without underwriting. But if they drop their insurance and then decide they need more generous coverage, they open themselves up to both medical underwriting and paying a penalty.
Critics argue that the bill punts major decisions about ACA repeal to the states, and this is a major one. People with pre-existing conditions tend to be the sickest and most expensive to insure, and states, including Maine, have wrestled with how to cover them for years.
What does this mean for states like Maine that didn’t expand Medicaid? Those states would apparently receive the 95 percent of the money they were due under the ACA for the tax subsidies plus 95 percent of the money they would have received if they’d expanded.
What if you have health insurance through work? Low-income residents with health insurance through their jobs could receive partial tax credits, which would vary based on how much their employer kicks in towards the premium. Employer plans would have to keep the ACA limits on out-of-pocket costs and lifetime limits, plus cover preventive services

Meet The Republican Governors Who Don't Want To Repeal All Of Obamacare

by NPR

As Congressional Republicans begin work on repealing the Affordable Care Act, many of the nation's governors want to make sure that their state budgets don't take a hit during the dismantling process.
They're most concerned about Medicaid, the health insurance program for the poor that's run jointly by the states and federal government. As a result of a Supreme Court decision, states were allowed to decide whether they would expand Medicaid under the ACA. 14 million people have gained health insurance coverage through Medicaid since eligibility for the program was expanded.
While 19 states declined the expansion, primarily due to the opposition of Republican governors and lawmakers, several Republican governors did choose to expand the program. Now they're lobbying to keep their citizens covered and billions of dollars of federal Medicaid money flowing.
Among them is Ohio Gov. John Kasich who, along with several other Republican governors, met with GOP members of the Senate Finance Committee last week for a closed-door discussion about the healthcare law.
Kasich has been anything but quiet on the subject.
In a letter to Congressional leaders, Kasich recommended that Medicaid expansion not be repealed, while indicating he's open to some changes, such as in income eligibility. Kasich urged Congress in an op-ed on to pass an Obamacare replacement at the same time as a repeal.
"For the millions of Americans who have gained health coverage since 2010, it's safe to assume that their idea of fixing Obamacare does not involve ripping away their own health care coverage without a responsible alternative in place," wrote Kasich.
'If I had to pay for my medical costs, I wouldn't be taking no medicine'
Evelyn Johnson is among those who would be affected were the ACA repeal to also roll back the Medicaid. She sat in the back of the cafeteria at a social services drop-in center in Cleveland last week as a pair of healthcare navigators made calls to help people sign up for Medicaid.
"So far I've got a pair of glasses. They're going to do my teeth," she said of the benefits she's received since getting health insurance.
Johnson, who lives with a friend, does not have children and works as a babysitter, would not have been eligible for state-backed insurance before the Medicaid expansion, when it was limited largely to low-income children, parents and people with disabilities.
Now, anyone whose income is at or below 138 percent of the federal poverty line, about $16,000 a year for a single person, is eligible.
Without insurance, Johnson said she would not able to afford the prescription drugs she needs.
"If I had to pay for my medical costs, I wouldn't be taking no medicine," she said. "There's no way. I take too many pills."
Around 700,000 Ohioans have signed up for expanded Medicaid since January 2014. Since the Affordable Care Act came into effect, Ohio's uninsured rate has fallen to 6.5 percent from 15 percent in 2012.
Unpopular position with Republicans
Kasich's decision to expand Medicaid was unpopular with Republicans. He fought his own party and sidestepped the state legislature to get the expansion done.
At an event with business leaders earlier this month, Kasich argued it's been a good deal for the state.
"If they don't get coverage, they end up in the emergency room, they end up sicker, more expensive. I mean, we pay one way or the other," Kasich said. "And so this has been a good thing for Ohio."
Also defending their decisions to expand Medicaid are such Republican governors as Rick Snyder of Michigan, Brian Sandoval of Nevada and Gary Herbert of Utah.
"So if all of a sudden, that goes away, what do we tell these 700,000 people? We're closed? Can't do that," Kasich said at the business event.
Medicaid covers about one in four people here in Ohio. If the expansion is rolled back, it will mean fewer payments to doctors and hospitals.
"You pull on one thread, you topple the whole tower," said John Corlett, who ran the Medicaid program in Ohio under the previous Democratic governor.
"There's nothing to say that the program can't be improved, that it can't be made better," Corlett, who now runs a think tank in Cleveland called the Center for Community Solutions said. "But just to say we're going to get rid of all of it, and then we'll figure out how to make it better, I think would be really disruptive. It'd be disruptive to healthcare providers, to patients, to insurance companies."
Even if the Medicaid expansion remains, the new Trump administration may make major changes to it in the future.
Last year, Ohio asked the federal government to require beneficiaries to pay into health savings accounts, a request the federal government denied.
"I think that with the constellation in Washington the way that it is, that there's going to be an awful lot of opportunities," said Greg Lawson, a senior policy analyst with the Buckeye Institute, a conservative think tank in Ohio that opposed expansion.
Lawson would like to see limits on federal spending per state, and hopes Ohio will be able to add a work requirement for some beneficiaries.
"I don't think you're going to see the light switch probably just get turned, and one day it's all going to just disappear," he said. "I think what you're more likely to see is major structural changes to the program that over time that will have budgetary impacts."
But it's not clear yet what shape those changes will take—or whether the governor who expanded Medicaid here will support them.

Changes to ACA could devastate hospitals

by Steve Michaud - Maine Hospital Association

Maine hospitals would stand to lose more than $3 billion over 10 years, according to our estimate that envisions a nightmare scenario where the Affordable Care Act cuts to hospitals remain but benefits to hospitals are repealed.
For this reason, Maine hospitals strongly urge Congress that there should be no ACA repeal unless there is an adequate and simultaneous replacement of its provisions.
The ACA contained both positives and negatives for hospitals. That was by design.
Hospitals were poised to benefit from three primary provisions in the ACA. The first was expanded health insurance coverage via the health insurance exchanges. The system of subsidies for people who do not receive health insurance through the workplace and instead have to rely on the “individual market” has successfully enabled more than 70,000 Mainers to gain affordable coverage.
The second positive feature of the ACA was the federal offer to cover the vast majority of costs associated with expanding eligibility for Medicaid coverage for low-income individuals. The Supreme Court blocked the implementation of Medicaid expansion as originally envisioned in the ACA. Subsequently, Gov. Paul LePage has blocked attempts to implement expansion in Maine.
The third positive feature of the ACA for hospitals was the expansion of the discounted pharmaceutical purchasing program for small, rural hospitals. The program is known as “340b” and it has been a vital lifeline for hospitals during the past four years. Pharmaceutical drug costs are the single largest driver of hospital cost increases in the Medicaid program — by a very wide margin.
These benefits to hospitals were, in part, offset by a series of cuts to hospital reimbursement. The mechanics of those cuts are a bit more difficult to explain in a sentence or two. The cuts were made to several of the Medicare reimbursement programs for hospitals.
The ACA also contains provisions to encourage higher quality in hospitals. Maine hospitals support change in this area to both reward high quality hospitals, and not just penalizing hospitals for failing to meet benchmarks. We believe in both carrots and sticks.
Hospitals understand that elections have consequences and that no federal law is written in stone. In fact, as we said, we welcome the opportunity to help improve some of the obvious shortcomings in the ACA. We also understand that while the ACA has improved affordability of health care for individuals, there is a financial strain on the federal government. And of course, that in turn is pressure on the taxpayers.
However, we do feel strongly that changes should be done fairly and responsibly.
Obviously, none of us knows what the replacement legislation for the ACA will include.
The Maine Hospital Association's primary concern is what happens to the benefits, specifically the Exchange subsidies that account for $200 million a year in reimbursement to hospitals, and the 340b drug pricing program for Critical Access Hospitals, which saves our smallest hospitals $15 million a year.
While we’re hopeful that the nightmare doesn’t materialize, the public needs to know that hospitals simply can’t afford to lose anything close to $200 or $300 million per year. The hospital system in Maine would be crushed if the hospital cuts were to remain and the replacement was inadequate. Make no mistake, some hospitals would close and the rest would be strained to their limits. Health care workers would lose their jobs. A person's ability to see a doctor, any doctor, could be severely limited.
Ultimately, though, the scope of the financial impact on hospitals is merely a proxy to help the public understand the benefits to Maine people. We’re talking about programs that have provided the opportunity for thousands of Mainers to see a doctor, fill a prescription or simply sleep at night knowing that they and their families are covered by health insurance.
Changes to the ACA, even good ones, must be done thoughtfully and with care. The physician adage: “First, do no harm” has never been more instructive.

Tackling Patients’ Social Problems Can Cut Health Costs

by Sarah Varney - Kaiser Health News

HOUSTON — Donning a protective gown, rubber gloves and a face mask, Dayna Gurley looks like she’s heading into surgery. But Gurley is a medical social worker charged with figuring out why her client, a man who uses more health care services than almost anyone else in Houston, has been in three different hospitals in the last month.
The patient, who asked not to be identified, has chronic massive ulcers, AIDS and auditory hallucinations. He rents a cot in another person’s home but is more often homeless, with no family to help him.
“It’s almost like self-sabotage,” Gurley said about her many attempts to steady her client’s life. “We get really close to an important doctor’s appointment or getting him connected with stable housing, and his impulsiveness gets in the way of that.”
Patients like the Houston man are health care’s so-called “super-utilizers”— people with complex problems who frequent emergency rooms for ailments more aptly handled by primary care doctors and social workers. They cost public and private insurers dearly — making up just five percent of the U.S. population, but accounting for 50 percent of health care spending.
As health care costs continue to rise, hospitals and doctors are trying to figure out how to find these patients and get to the root of their problems.
An effort to do just that started in New Jersey’s poorest city, Camden, more than a decade ago. Inspired by the way police departments mapped crime data to detect “hot spots,” family physician Dr. Jeffrey Brenner dug into ambulance records and emergency department data to show how high-cost patients were shuttling between city hospitals.
“In America, we’re medicalizing social problems and we’re criminalizing social problems, and we’re wasting huge amounts of public resources,” Brenner said. “We have the wrong tools to solve the wrong problem.”
To steer patients away from expensive emergency care and push health systems to change the way they do business, the Affordable Care Act funds programs called Accountable Care Organizations. These are networks of hospitals, physicians and others who team up to improve care, lower costs and reap the savings.
Brenner’s team at the Camden Coalition includes Latonya Oliver and Bill Nice, social workers who seek out patients like Peter Bowser in local neighborhoods. Bowser was once homeless and went to the emergency department nearly 30 times in one year.
But after Oliver and Nice helped get a permanent roof over his head, Bowser’s trips to the ER all but stopped.
“I think you’d prefer to spend your time here than in the hospital any day of the week,” Nice said to Bowser on a recent afternoon, gathered at the kitchen table in his tidy apartment.
This high touch, data-driven approach has yielded big savings. ER visits for the first group of patients dropped by 40 percent, cutting monthly hospital bills from $1.2 million dollars to $500,000.
Since then, Brenner has sought to spread the model around the country. One example is the Patient Care Intervention Center in Houston, a sprawling city desperate to aid its sickest and most isolated patients.

While the more than 100 hospitals here typically know their own super-utilizers, they had no way of knowing the top users across the entire city.
Tackling that problem took unprecedented planning among typically disjointed city and county agencies, hospitals and nonprofits. Now, many of the hospitals in Houston and the fire department pool their data and send it to Kallol Mahata, a former oil industry IT engineer with the patient care intervention center who combines it into one database.
Mahata and Dr. David Buck, the group’s founder, help to identify patients at the top of the list—the outliers of the outliers.
Teams are dispatched to parks and neighborhoods to find the patients.
Firefighters and paramedics like Thomas Pierrel often know these residents from 911 calls. But this time, their mission is different: to encourage them to enroll in the volunteer program.
Inside one super-utilizer’s threadbare home, Pierrel makes his pitch. “We go with you to your doctors, we make appointments, we find specialists. We try to maximize the resources that you have,” he tells the prospective client.
The results of these intensive interventions can be stunning.
Timmy Williams was dying when Dayna Gurley found him.
He was holed up at home and reeling from untreated HIV that had progressed to AIDS. He couldn’t take care of his young son and cycled through Houston’s hospitals.
“When we first met Timmy, he was very hard to engage,” Gurley recalled. “We knew that he probably was not taking any of his medication, and he was very skinny.”
She arranged for a home aide to care for Williams seven days a week, got his apartment cleaned and the lights turned back on.
Now, Williams’ HIV is undetectable and his health — and life — have been steadied.
In the two years since Houston’s Patient Care Intervention Center has been up and running, costs for those in the program have gone down 83 percent and hospital visits by 70 percent.
But it can be difficult to keep these programs moving. Often insurance companies and government payers reap those savings, rather than hospitals. Buck and Dayna Gurley were once banned from a Houston hospital whose executives feared losing money if their high-cost patients stopped showing up.
“Nobody wants to take ownership of any of it,” said Buck, his voice bristling with frustration. “The people just want ownership of what they have authority over, and that’s really the issue: each of these areas are little fiefdoms.”
Back in Camden, even Brenner is less optimistic than he once was. His office now overflows with pillows and kitchenware for clients the Camden Coalition is trying to place in housing. And he thinks homelessness and entrenched financial interests in health care are the biggest barriers.
“I think this is going to take a lot longer than I ever imagined,” he said. “I think we’re in a 20-year arc of recalibrating and rethinking what is health and what’s health care? What’s the purpose of our health care system? What are we trying to accomplish?”
But Brenner still believes these intensive efforts are the best way to help patients like Timmy Williams. He’s now healthy enough to make his way around the city on his own, says Gurley, and her super-utilizer team did more than rescue him from his darkest days.
“I had to put it in my head that no one is going do it for me,” he said. “I have to do it for myself. I have to step out and do it myself.”
At home now with his son, his illness no longer gets in the way of being the father he wants to be.
But it’s unclear how these efforts will be affected by a Trump administration, which along with congressional Republicans

Association of State and Territorial Health Officials
2231 Crystal Drive, Suite 450, Arlington, Virginia 22202  •  Phone: 202-371-9090  •  Fax: 571-527-3189  •  Web:


TO:                      ASTHO Alumni Society Members
FROM:                Chris Gould, Chief, Government Affairs and Public Relations
DATE:                  Jan. 23, 2017
RE:                       ACA Repeal and Replace and its Impact on State and Territorial Public Health Agencies

Last week, the Senate Budget Committee began Senate floor consideration of the vehicle that will include the repeal of the Affordable Care Act (ACA). The budget resolution introduced will likely clear the Senate (being a budget resolution, only a simple majority is needed to pass), and will then go to the House of Representatives for consideration. Committees with authority and jurisdiction over the ACA in the House and Senate have also received instructions to send the budget committees information on what to include in the budget resolution by Jan. 29. 

Prevention and Public Health Fund
Of major concern, we are hearing from multiple sources that the Prevention and Public Health Fund (PPHF) will be repealed as part of the overall ACA repeal and replace effort. This will have a tremendous impact on state public health. For example, in FY 16, CDC received almost $900 million from the PPHF that offset cuts to CDC’s specific program funding lines. Should Congress rescind the PPHF, the loss would leave a gaping hole at CDC for FY 17. We have heard directly from the budget and appropriations office at CDC that there is no way they could shift those kinds of dollars around inside the agency to protect states and restore the funding. 

Some of the scenarios we are hearing from sources in Congress are:  
1)      The fund is repealed whenever reconciliation passes—in or around February – with the caveat that PPHF dollars could possibly be rescinded in FY 17.
2)      At that time, appropriations for FY 17 are still outstanding and will not be completed until April 28 (we are on a continuing resolution for FY 17 until April 28).
3)      Should the Congress rescind any unobligated funds from the PPHF, a continuing resolution at current levels leaves no opportunity to backfill the loss of those dollars. This leaves programs such as ELC crippled for the remainder of the year, and the Prevent Block grant will disappear as this is wholly funded through PPHF. This also includes other programs that are essential to state and territorial public health agencies (see list below).

ASTHO Strategy for FY 17
It is no surprise that PPHF was vulnerable and will likely be repealed under a republican Congress and administration due to its inclusion in the ACA, however, we did not expect that Congress would move to rescind the fund in FY 17 given funding was already allocated in the continuing resolution. In a mid-year elimination scenario, any PPHF funding could entirely disappear.

ASTHO staff are recommending that Congress consider delaying repeal of the fund until a replace “fix” is identified. Delaying would provide a safety net for states, and would allow the CDC a transition period so they can get through FY 17 and then work with appropriators on how to responsibly fund the specific funding lines at CDC lost by the elimination of the fund. While not an ideal situation, this is likely the only path forward at this time given the intel we have heard about the fund’s immediate demise.

ASTHO’s strategy consists of the following:
·       We are going to ask Congress, specifically the authorizing committees (i.e. Energy and Commerce in the House, and Health, Education, Labor, and Pensions in the Senate) to delay the rescinding of the fund until the full repeal takes place in FY 18. Doing so would keep funding levels in place for FY 17, and would not “pull the rug” out from underneath state public health mid-year.
·       Should the fund be rescinded in FY 17, there is no opportunity to backfill those dollars, as there will also likely be a cut in the next iteration of a spending bill that takes us through FY 17 (until Sept. 30, 2017). This would mean large gaps in public health funding for the remainder of 2017, including zeroing out the Prevent Block grant. 
As ASTHO alumni, you serve a key role in helping share the impact of these cuts on state and territorial public health programs from your experience as a state health official. If you have the ability to speak with your members of Congress about the impact of the cuts to public health, ASTHO urges you to contact them in the next few weeks as decisions about the fund and funding for public health are being made in Washington, D.C. If you would like additional information or have specific questions, please contact me at your convenience (

Talking Points to Share with your Members of Congress:
·       When you move to repeal ACA, you will also be repealing the Prevention and Public Health Fund, which supplies our state with ($X million -- see state by state charts and TFAH resource link below). 
·       If funding for the Prevention and Public Health Fund is rescinded in FY 17, ($X million) would be removed from the health agency’s budget essentially overnight, jeopardizing the health of our state’s population.
·       Eliminating and rescinding the Prevention and Public Health Fund will also eliminate the Preventive Health and Health Services Block Grant (Prevent Block), which was created through an initiative by President Reagan in 1982. 
·       The programs that are funded by the Prevention and Public Health Fund were not authorized by ACA, and many of these public health programs have existed decades before the passage of ACA.
·       The public health programs funded through the Prevention and Public Health Fund were either entirely or partially moved from the CDC’s budget authority and were supplanted by the fund.  This was not something the public health community asked to have happen. 

·       Congress is currently moving the vehicle that would repeal ACA. 
·       Relevant Congressional committees have until Jan. 27 to send their replace legislation to the House and Senate Budget Committees for inclusion in the budget resolution.
·       It is expected that the final passage of repeal will occur within the first two weeks of February.
·       The current continuing resolution expires on April 28, and a large spending package or another long-term continuing resolution will have to be passed – likely with spending cuts (and with hopefully the Prevention and Public Health Fund intact).

Trust for America’s Health Information
The Trust for America’s Health (TFAH), under the new leadership of John Auerbach, has compiled state specific summaries of programs funded in PPHF. These are helpful summaries that show the real cost of cuts for every state. You can find them at

Since its inception in FY 10, funding appropriated to CDC from PPHF has become integral to CDC program operations.
·       In FY 16, PPHF accounted for over 12 percent of CDC’s total program funding.
·       This growth in PPHF at CDC was accompanied by a $119 million reduction in budget authority (BA) and the elimination of PHS Evaluation Transfers (-$352 million).

Starting in FY 14, Congress began directing the allocation of PPHF, as part of the Appropriation bill.

Over the last six years, the PPHF has improved the health of Americans and slowed the growth of public and private healthcare costs. Below are examples of programs that save lives and money and were paid for by PPHF. Most of these were previously supported in whole or in part through regular budget authority.

Protecting children and adults through immunization
CDC’s immunization program is vital to achieving the goal of protecting Americans from infectious diseases. In FY 16, PPHF funding of $324.4 million accounted for over 40 percent of total program funding. Losing this funding would cripple CDC’s ability to detect, prevent, and respond to vaccine-preventable respiratory and related infectious disease threats including pandemic influenza.

Supporting local solutions through the Preventive Health & Health Services Block Grant
The Preventive Health & Health Services (PHHS) Block Grant provides all 50 states, Washington, D.C., two American Indian tribes, and eight U.S. territories with funding to address their unique public health needs in innovative and locally defined ways. Since FY 14, the PHHS Block Grant –$160 million each year–has been entirely funded by the PPHF.

Strengthening capacity to respond to domestic infectious disease threats
The PPHF allows CDC to support states in strengthening their ability to detect and respond to infectious disease and other public health threats, including increasing the use of electronic laboratory reporting and improving their information technology infrastructure through the Epidemiology and Laboratory Capacity (ELC) program. This capability has been critical in recent outbreaks including those related to multi-state foodborne illness, influenza, and fungal meningitis, and provides a foundation for the antibiotic resistance program that can avert $7.7 billion in healthcare spending over the next five years. In FY 16, PPHF investments in ELC totaled $40 million.

Preventing childhood lead poisoning
As was illustrated by the recent crisis in Flint, Michigan, lead exposure remains a major concern in the United States. Today, at least 535,000 children still have blood lead levels high enough to damage their health. Medical and special education expenses alone can equal $5,600 for each child with serious lead poisoning in just three years after diagnosis, and CDC estimates that lead exposure will result in more than $59 billion in lost lifetime productivity costs. CDC has received PPHF funds for childhood lead poisoning prevention since 2014, including $17 million in FY 16. With these funds, CDC supports 29 states, Washington, D.C., and five local health departments to conduct blood-lead surveillance and to reduce or eliminate lead sources for children at highest risk for exposure.

In 2015, CDC’s grantees tested 2,415,604 children in the United States and identified nearly 80,000 children with elevated blood lead levels (at or above 5 micrograms per deciliter). CDC’s efforts have contributed to reduced blood lead levels in children 5 years and under with elevated blood lead levels (between 5-9 micrograms per deciliter) from over 256,000 children (6%) in 2010 to under 80,000 children (3%) in 2015.

Protecting patients by preventing healthcare-associated infections
Reducing healthcare-associated infection (HAI) can save lives and substantially reduce healthcare expenditures. CDC estimates that at any given time, one in 25 hospitalized patients has an HAI. With PPHF funds, CDC supports health departments in all states, Washington, D.C., and Puerto Rico to enhance their capacity to detect, respond, prevent and control healthcare-associated infections. In FY 16, PPHF investments in HAI totaled $12 million.

Examples from just two states show the power of public health interventions to reduce HAI. Facilities in Michigan’s Carbapenem-resistant Enterobacteriaceae (CRE) Surveillance and Prevention Initiative have prevented at least 153 CRE infections and reported a 33 percent reduction in CRE-positive cultures, among participating facilities. In one long-term acute care facility, the prevalence of CRE decreased from 37 percent to 7 percent. This was achieved by initiating admission surveillance, patient isolation, contact precautions, and conducted cultures every 30 days. Connecticut’s Antimicrobial Stewardship Collaborative improves stewardship practices in select acute care hospitals and long-term care facilities. Preliminary results show 13 percent fewer Clostridium difficile infections and 17 percent fewer Methicillin-resistant Staphylococcus aureus infections that non-collaborative facilities.

Repeal and Compete

by Ross Dothan - NYT

Modern conservatism, at least in its pre-Donald Trump incarnation, evolved to believe in a marriage of Edmund Burke and Milton Friedman, in which the wisdom of tradition and the wisdom of free markets were complementary ideas. Both, in their different ways, delivered a kind of bottom-up democratic wisdom — the first through the cumulative experiments of the human past, the second through the contemporary experiments enabled by choice and competition.
In health care policy, however, conservatives tend to simply favor Friedman over Burke. That is, the right’s best health care minds believe that markets and competition can deliver lower costs and better care, and they believe it even though there is no clear example of a modern health care system built along the lines that they desire.
The dominant systems in the developed world, whether government-run or single-payer or Obamacare-esque, are generally statist to degrees that conservatives deplore. A few of them — notably Singapore’s, the beau ideal of right-wing health care wonks — do have distinctive elements that conservatives favor. But mostly they tend to be much more heavily regulated and subsidized than the system that conservative health policy wonks and policy-literate Republicans would like to see take over from Obamacare.
Which is not to say that the conservative health policy vision lacks empirical grounding. There is compelling evidence that markets in health care can do more to lower costs and prices than liberals allow, and good reasons to think that free-market competition produces more medical innovation than more socialized systems.
But still — there is no existing system on a national scale that looks like the health care system that Paul Ryan or Tom Price would design, no wisdom of developed-economy experience that proves that such a system would actually keep overall costs low and prevent too many people from being shut out of insurance markets. So embracing even the smartest conservative Obamacare alternative requires a not-precisely-Burkean leap of faith.
And this, in a nutshell, is why Republicans should give serious consideration to the proposal that Senator Bill Cassidy of Louisiana and Senator Susan Collins of Maine have just put forward as a possible health care reform alternative.
The essence of Cassidy-Collins, and the reason that many Republicans don’t like it, is that it isn’t actually a full Obamacare replacement. Instead, it’s a federalist compromise. It lets individual state governments decide whether they want to stick with Obamacare or not, which would mean that the law would remain intact in most blue states for the time being, while redder states would have the opportunity to turn roughly the same amount of money (95 percent) to a different end.
That end would look like one of the more plausible conservative alternatives to Obamacare: a subsidy to cover the cost of a catastrophic health insurance plan, plus a directly funded health savings account to cover primary care.
This system could be layered on top of the existing Medicaid expansion, replacing only the Obamacare subsidies and exchanges, or it could replace the Medicaid expansion as well, offering the poor and near poor the same “catastrophic insurance plus a subsidy” as everyone else in the individual market. Either way the individual mandate would disappear, but people would be auto-enrolled in a catastrophic plan (with the option to opt out), meaning that coverage would be nearly universal (thus fulfilling one of President Trump’s various promises) even though its benefits would be less comprehensive than Obamacare’s.
Taken as a whole, this approach distills both the promise and the peril of conservative health care policy. The promise is that by having people pay for more of their health care in cash and by giving them more freedom in what plans they’re allowed to buy, you would end up with less spending, lower prices and less cost inflation. (And you wouldn’t need the heavy, innovation-squashing price controls that single-payer systems use to get there.)
The peril is that there would be too wide a gap between what the money in your health savings account covers and what you need before your catastrophic coverage kicks in. In which case many people with consistent health care costs for chronic problems would rack up impossible medical bills in short order.
Conservatives who want this model to replace Obamacare nationwide believe that the promise outweighs the risk — and this is, again, a reasonable belief. But it’s also a belief that hasn’t been tested on any kind of sweeping, economywide scale. And this is the advantage of Cassidy-Collins: It encourages governors and legislators to actually put the conservative theory of health care to the test without simply reversing the ideological colors of the great Obamacare experiment and immediately turning the entire United States health care system over to the right’s technocratic vision.
Of course this would mean that Obamacare’s existing problems would persist in the states where it continues. But those problems — the rise in premiums, the fleeing insurers, the risk of a death spiral downstream — are not equally problematic in every state, and they are not fiscally dangerous, as yet, on the scale that many conservatives initially feared.
As the conservative policy thinker Yuval Levin wrote late last year, the striking thing about Obamacare to date is how much smaller than expected its effect on the overall health care system has been. Fewer people are being insured on the exchanges than liberals hoped, fewer employers are dumping high-cost employees onto the exchanges than conservatives feared, and as a result, he writes:
The extremely serious problems we are seeing now are within the one system that Obamacare created from scratch, the exchange system. That system may not survive, and its condition has a lot to teach us about the problems with liberal health economics. But it is a much smaller system than anyone thought it would be at this point, about half the size that C.B.O. projected, so that the effects of any failure it suffers are likely to be more contained than anyone might have expected.
This containment means that conservatives have room and time to be more patient, cautious and experimental than were the Obama Democrats before them. If the Obamacare exchanges aren’t ultimately going to work out, then allowing them to persist in liberal states while an alternative system gets set up in red states is a reasonable way to gradually transition from the liberal model toward the conservative one. If the right’s wonks are right about health policy, the Cassidy-Collins approach should — gradually — enable conservatives to prove it.
And if the right is wrong, if its model doesn’t match reality, if people are simply miserable as health care consumers because the system has too much of Friedman and not enough of Burke — well, in that case both the country and conservatism will be better off if we learn that via a voter rebellion in 10 right-leaning states, rather than through a much more widespread backlash against a nationwide health-insurance failure. (Which is something a president with a high self-regard and poor approval ratings might have a particular reason to avoid.)
Between this reasonable case and legislative reality, of course, falls a variety of shadows. But more than for the various repeal-and-replace alternatives? I’m not so sure.
Right now the Cassidy-Collins compromise has few enthusiastic backers. In a few months, however, it might turn into conservative health care reform’s best hope.

Editor's Note:

It's worth clicking on the hotlink above, and having a look at the readers' comments on the Douthat article.


Judge says Aetna dropped out of some Obamacare markets to help win its merger fight
by Carolyn Y. Johnson - Washington Post

Aetna announced it would pull out of most of the state exchanges where it sold health insurance under the Affordable Care Act last August, citing financial losses. But a U.S. District Court judge who rejected the company's proposed merger with Humana on Monday revealed in his opinion that profitability wasn't the only concern driving the company's decision -- Aetna also exited several markets as part of an effort to "improve its litigation position."
U.S. District Court Judge John D. Bates wrote that Aetna, pushing for a $37 billion merger with Humana since summer of 2015, decided to leave 17 counties in three states in order to improve the likelihood that the deal would be approved -- including one where the business was doing well. Florida was the company's third most-profitable exchange market in 2015 and the beginning of 2016.
“I just can’t make sense out of the Florida decision," Christopher Ciano, Aetna’s Florida market president wrote in an email quoted in the opinion. "Never thought we would pull the plug all together. [sic] Based on the latest run rate data ... we are making money from the on-exchange business."
The federal court decision hinged largely on an argument that the proposed merger between Aetna and Humana would substantially decrease competition in the Medicare Advantage market in 364 counties, where private insurers provide Medicare benefits. But it also included the politically tempestuous issue of competition on the exchanges, which are a linchpin of the Affordable Care Act, also known as Obamacare. The exchanges are state and federally run marketplaces where insurers sell plans to people who do not have employer-based insurance.
When Aetna announced last summer that it was losing money in the health insurance exchanges and would exit most of them for 2017, the announcement helped spark a national debate about the sustainability of the Affordable Care Act's exchanges. The opinion provides a rare glimpse into the politics behind Aetna's participation in the exchanges, revealing what executives said in e-mails and in depositions. It also shows that competition with Humana appeared to be working in Florida to lower prices for consumers.

'I would appreciate a good word for all that we've done with you'

Aetna was losing money in the exchanges, nationally, from day one -- and faster than it expected. The company projected losses of $70 million in 2014, but lost $100 million. The next year, it expected a $100 million profit, but instead lost $131 million. The company remained committed to the exchanges in early 2016 and, the opinion reveals, tried to remind the Obama Administration of its dedication as its proposed merger was being evaluated by antitrust officials.
A month before the Justice Department blocked the merger, Aetna chief executive Mark Bertolini talked with Secretary of Health and Human Services Sylvia Burwell by phone.
“If, by chance, you get a reach-out from the DOJ about us as a candidate for this merger, I would appreciate a good word for all that we’ve done with you," he said, according to the opinion.
When the merger was blocked in July, Bertolini said in an email to former Aetna chief executive Ron Williams that "the administration has a very short memory, absolutely no loyalty and a very thin skin," according to the opinion. He was frustrated that his company had endured major losses on the exchanges and yet were "doing good things for the administration and the administration is suing us," according to a later deposition.
In early July, Bertolini learned that there were big losses in Aetna's exchange business for the second quarter of 2016 and began to re-evaluate its participation. Shortly after, the Justice Department blocked the merger. According to the opinion, after learning that Humana was staying in the 17 counties that had been highlighted by antitrust officials in their case, the company decided to withdraw from those counties -- "to avoid antitrust scrutiny," the judge wrote.
"Other documents and testimony also indicate that the team of executives did not evaluate the profitability of the 17 counties in the same manner as it did for the other states from which Aetna was considering withdrawing," Bates wrote in his opinion.
The judge ultimately decided that Aetna would be likely to continue to offer exchange plans in one of the states, Florida, because the business was profitable, even though the company said it was a business decision. Thus, the proposed merger would have had anticompetitive effects in that state's three counties.

Competition in action

The opinion also illustrates how competition works between insurers to help consumers -- at a time when five states and nearly a third of counties have only one insurer offering plans on their exchanges, according to the Kaiser Family Foundation.
Ciano, the Florida market president, expressed concern in an email that Aetna was falling behind Humana in enrollment and recommended lowering "rates" by 4 percent for 2016 to "maintain #1 in Broward" County, according to the opinion.
A Humana executive, according to the opinion, was doing similar research on its competitor, requesting information on Aetna's pricing and plan design and where it offered plans in the exchanges.
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Bates was unpersuaded by the companies' arguments that the merger would not hurt consumers in Florida.
"The Court concludes that the merger is likely to substantially lessen competition on the exchanges in the three counties in Florida where Aetna is likely to compete in the future," Bates wrote. "The Court’s conclusion is again based on the level of market concentration and the evidence of substantial head-to-head competition between Aetna and Humana that would be lost."
It is unclear what action the companies will take next. A spokesman for Aetna said on Monday that the company was considering an appeal. A joint statement released Tuesday added little clarity.
“After putting forward a compelling case that addressed each of the Department of Justice concerns, we are disappointed with the court’s decision and will carefully consider all available options,” Bertolini and Humana chief executive Bruce Broussard said in a joint statement. They stressed that health plan members would be unaffected as the companies worked through next steps.

Compromise doesn't work with our political opponents. When will we learn?

by Chelsea Manning - The Guardian

Barack Obama left behind hints of a progressive legacy. Unfortunately, despite his faith in our system and his positive track record on many issues over the last eight years, there have been very few permanent accomplishments.
This vulnerable legacy should remind us that what we really need is a strong and unapologetic progressive to lead us. What we need as well is a relentless grassroots movement to hold that leadership accountable. 
On the night of 4 November 2008, Barack Obama was elected on a platform of “hope” and “change”. He was hailed as a “uniter” in an age of “dividers”. I experienced a political awakening that night. I watched as the hope that President Obama represented was tempered by the shocking passage of Proposition 8 by a majority of voters in California. This reversed a major marriage equality court victory from earlier that year.
Throughout his two terms in office, these types of contradictions would persist. Optimism and hope would be met with backlash and hate. He faced unparalleled resistance from his opponents, many of whom wanted him to fail.
I remember during his first inauguration, on an icy January morning in 2009. I sat on the floor of a military headquarters office in Fort Drum, New York. With a dusty overhead television showing the ceremony, I sat, working in support of a half dozen military officers. We had our weapons ready, and our rucksacks heavily packed. Selected as the active duty army unit to deploy to Washington DC in case of an emergency, we were prepared for rapid deployment. 
Ironically, many of the officers and enlisted personnel that were selected for this security detail openly despised President Obama. The seething vitriol and hatred simmered quietly in that room. In retrospect, it was an ominous foreshadowing of things to come. 
On domestic issues, his instinct, as former First Lady Michelle Obama explained at the Democratic national convention this past summer, was to “go high” when his opponents would “go low”. Unfortunately, no matter how “high” the former president aimed to be, his opponents aimed to undermine him anyway. There was absolutely no “low” that was too low to go.
Even when they agreed with him on policy, they resisted. For example, when it came to healthcare reform, Obama opened the debate starting with a compromise. His opponents balked. They refused to move an inch. When he would push for the concessions they asked for, they only dug in deeper in opposition. Even when he tried proposing a bill that had been proposed by opponents years earlier. 
When it came to foreign policy, even though he was only carrying out the expanding national security policies of the previous administration, they would ceaselessly criticize him for being too weak, or too soft or too sympathetic. After months of comprise on his end, they never cooperated a single time.
In December 2009, I sat in a hot and stuffy plywood room outside Baghdad, Iraq, as President Obama made speeches. He argued that military action was necessary. An unusual statement to present while receiving the world’s most prestigious peace prize. Yet, the people around me still spoke about him quietly, with a strong criticism, and even sometimes, pure disgust. 
In November 2012, when President Obama was re-elected, I sat in a civilian jail cell in suburban Baltimore, awaiting a court martial hearing. Surrounded by a different crowd of people, the excitement and elation of his re-election was genuine. Even among those being penalized merely for being disadvantaged or a minority. Even in those unbearably unfair circumstances, there was genuine hope, faith and trust in the president. 
For eight years, it did not matter how balanced President Obama was. It did not matter how educated he was, or how intelligent he was. Nothing was ever good enough for his opponents. It was clear that he could not win. It was clear that, no matter what he did, in their eyes, he could not win.
In the aftermath of the deadly shooting at the Pulse nightclub in Orlando that took the lives of nearly 50 queer and brown people, it took Obama over 300 words of his speech to acknowledge the queer community, and even then, as an abstract acronym. 
Never did he acknowledge the particularly painful toll on the Puerto Rican and wider community that was also navigating through this horrific tragedy. Even in the midst of a shocking and horrific tragedy, he attempted to comprise with opponents who were uninterested and unwilling to meet him halfway. 
Now, after eight years of attempted compromise and relentless disrespect in return, we are moving into darker times. Healthcare will change for the worse, especially for those of us in need. Criminalization will expand, with bigger prisons filled with penalized bodies – poor, black, brown, queer and trans people. People will probably be targeted because of their religion. Queer and trans people expect to have their rights infringed upon.
The one simple lesson to draw from President Obama’s legacy: do not start off with a compromise. They won’t meet you in the middle. Instead, what we need is an unapologetic progressive leader. 
We need someone who is unafraid to be criticized, since you will inevitably be criticized. We need someone willing to face all of the vitriol, hatred and dogged determination of those opposed to us. Our opponents will not support us nor will they stop thwarting the march toward a just system that gives people a fighting chance to live. Our lives are at risk – especially for immigrants, Muslim people and black people. 
We need to stop asking them to give us our rights. We need to stop hoping that our systems will right themselves. We need to actually take the reins of government and fix our institutions. We need to save lives by making change at every level.