Monday, March 13, 2017

Health Care Reform Articles - March 13, 2017

No Politico Wants to Know: We Are Patients

by Donna Smith - Common Dreams - March 11, 2017

It is hell out here for patients right now in America.  There may be a swampy, dirty-flash flood going on in D.C. right now, but there are precious few elected officials who see patients as patients.  We are health industry consumers.  We are political props for both sides of another ridiculous, costly and futile battle over who will please the industry and its political champions enough — who will grow profits across the board.  Patients are on the losing end of this upheaval. 
Patients haven’t had access to our doctors without the elephant in the room for a very long time now, and that elephant is greed, plain and simple.  Until we decide that healthcare access through the expansion of Medicare is the best way to finally re-engage around healthcare for patients who need it, we will fail. Until we move away from greed-driven, winner-takes-all motivation for measuring health system success, we will not break the cycle of going from one dysfunctional model to another.
Greed in the systems — health and political — is nothing new.  But in 2017, that greed has reached epic levels.  Republicans are smirking and smiling their collective way toward making sure the wealthy are happy and the health industry dollars keep flowing into their coffers.  Democrats must stop simply pushing back against the repeal of the ACA/Obamacare as a strategy to make the Republicans look bad leading into yet another campaign cycle for 2018.  Patients are not stupid people.  Patients know when they are being worked.  Patients are angry and worried and even scared in some cases.  Taking advantage of that anger, worry and fear for political gain is among the greediest things going on in this period.  
The greed that is harming patients in the U.S. healthcare system is growing exponentially.  Greedy insurance companies.  Greedy providers — including greedy doctors (say it isn’t true), dentists, hospital systems, etc.  Greedy pharmaceutical companies.  Patients are never allowed to forget the greedy demands — premiums, co-pays and deductibles are calculated and collected from us before any healthcare is delivered.  Most patients take that into account before submitting to the embarrassment and sadness of not being able to pay and the disgust about paying so much and in advance of any services actually rendered.  Patients are so reviled by the entire system that the system works to protect itself from us.  Patients ought never to forget our current place in the U.S. healthcare industry.  Widgets.  Patients are widgets.  Broken widgets, damaged widgets and imperfect widgets interrupt profit flow.   
The greed that is harming patients in the U.S. political system is at least as insidious as that shown by industry behavior.  Our politicians calculate their own political outcomes first and foremost over anything patients may need.  Political greed is driving even those politicians and political advocacy groups who espouse a position of caring about health and patients to first calculate if they will prosper under any given course of action — will their latest campaign, photo op, town hall meeting, event/rally, or other carefully scripted plan benefit their own positions?  This political greed is at work on both sides of the aisle.  Patients are useful, sometimes, and patients sometimes allow ourselves to be used if we believe telling our stories will make a difference.  As a patient who has spent the past decade watching the political maneuverings around healthcare reform, I know the good and the bad parts about being a patient who speaks the truth openly.  It still boggles my mind that so many people in so many ways just do not want to be bothered hearing from patients.  If the current moves by the Democrats to hear how fearful many of us are about losing our coverage prove genuine, those Democrats will swiftly offer up not just a defense of a few provisions of the ACA/Obamacare but a real healthcare transformation.  I heard former Michigan Governor Jennifer Granholm ponder this week why we wouldn’t move to expand Medicare to cover more people.  Why not, indeed?  
Just in case anyone wonders any more how this turmoil is playing in living rooms across America, let me tell you how the post election period has gone in my home.  Almost immediately after November 8, 2016, I knew I would be in trouble.  As a 62 year-old cancer survivor who was seriously harmed by a 2015 hospital-acquired MRSA infection that caused sepsis and pulmonary embolisms and also required surgery to remove an infected vein from my wrist to my chest wall, I must use supplemental oxygen and multiple medications just to stay functional and working to pay our bills.  We live in a modest, two-bedroom, 950 sq. ft. apartment in a working class area of Denver.  I purchase my health insurance coverage on the Connect for Health Colorado ACA exchange.  I work three jobs.  My husband is retired and relies on his Medicare coverage and a supplemental plan for his healthcare access.  His sole source of income is Social Security.  Try as we might, we cannot figure out any other way to do this.  We have talked divorce to find a way to affordable coverage.  But to stay afloat, I can never allow us to have so little income that we would qualify for Medicaid benefits.  We are, like so many working class people, caught between the rock and the hard place that was designed for us by those in the greedy class.
Unless we move to a Medicare For All system, millions of Americans will face more intense greed and higher costs.  Hospitals and doctors with fewer “customers” will need to charge more to continue making big profits, and insurance companies will really watch what is a covered benefit once they lose millions of people who once sought coverage.  Costs will not go down.  So, what will happen to patients under the “Deplorable Healthcare Act” that the Trump-Ryan-McConnell cabal loves so much?  And what will happen to patients should the Dems prevail and retain parts of the ACA/Obamacare without the ability to pass any improvements to that law?  The organization for which I work, Progressive Democrats of America, is calling on all who call themselves progressives to support a real solution and not just a push back on the ACA.  We are asking one of our progressive champions, Sen. Elizabeth Warren, to stand with us.  
Well, in the interest of honesty, some patients are already planning for the eventuality of various scenarios.  Some patients are writing and calling their governors and their Congressional members and showing up to express outrage and worry.  I sent the message below to my doctor last evening, to Colorado Governor John Hickenlooper and Congresswoman Diana DeGette, D-CO1, this morning, and now through this piece, to a broader audience.  I believe the only way we will make it through any of this is giving one another the gift of being honest about it.  It is too critical to do otherwise.  
Good evening,
1. I am due to get a B12 blood test when I drop by the lab, and I wondered if you might be willing for me to have a CBC as well. I have swollen glands or something along my jawline on the left, and I feel a bit puny. I’m guessing it is some sort of virus thing but the gland hurts a bit and it is not changing in size one way or the other over the 10 days I have noticed it there and felt a bit “off.”
2. This is a longer term, more difficult question. I would like to know what Kaiser’s policy (and yours) is around Colorado’s “right to die” law. Because I am a cancer survivor and because this darned COPD/chronic bronchitis and asthma stuff combined with the back/hip/wrist issues and pain are my baseline in my health world, and because there is a possibility I will lose access to any health coverage or care under the political conditions, I am deeply worried about suffering without access to care or alternatively burdening my family with costs that will be overwhelming. If at some point I were to face diminished health that will likely become life-threatening without meds/inhalers/oxygen or other needed care and the inability to afford further care without coverage, would Kaiser allow prescribing of the drugs that would allow me to die? I am really sorry to even ask this, but it is weighing on my mind, and I want to know I have options. I understand that so long as I have coverage and access to my medication and oxygen this is unnecessary to consider, but things may not stay this way for me. I worry about it and my husband gets angry if I even mention the subject. 
In any case, thank you for reading this.
Peace, your patient,

Editor's Note:

Whether or not you agree with the points Donna Smith makes in the above essay, there is no denying that her view is becoming increasingly common among the general public - a fact that should be deeply troubling to every health professional. We should do everything possible , through words and actions, to counter that perception.


G.O.P. Health Law Insures Fewer People, Nonpartisan Review Shows

by Thomas Kaplan - NYT - March 13, 2017

WASHINGTON — The House Republican plan to repeal and replace the Affordable Care Act would cause 24 million people to lose health insurance within a decade, the nonpartisan Congressional Budget Office said on Monday.
Republicans had been bracing for what was almost certain to be a bleak accounting of the legislation’s projected effects. The American Health Care Act, as Republicans call their bill, was already facing widespread criticism from providers of health care, some conservatives, and a united Democratic Party. The numbers released Monday will only make it more difficult for Republicans to explain why their legislation would bring positive change to the country’s health care system.
In recent days, Democrats had criticized Republicans for pushing the health care bill through two House committees last week before the Congressional Budget Office had weighed in, saying it was irresponsible to begin considering legislation without a firm grip on its potential costs and ramifications.
“Republicans are racing their disastrous health bill forward before the C.B.O. can expose its consequences to the American people, but they can’t hide from the facts forever,” the House Democratic leader, Representative Nancy Pelosi of California, said last week.
The C.B.O. produces a variety of budget and economic analyses, including deficit projections, legislative options for lawmakers confronting the nation’s most vexing problems, and cost estimates for legislation. Its director, Keith Hall, was appointed in 2015 by congressional Republicans, and it has maintained respect for its objective analysis.
But with an unfavorable analysis expected, Republicans from the White House to Capitol Hill began to undermine the credibility of the budget office’s numbers last week and kept it up through the weekend.
“If the C.B.O. was right about Obamacare to begin with, there’d be 8 million more people on Obamacare today than there actually are,” President Trump’s budget director, Mick Mulvaney, said Sunday on ABC’s “This Week.” He added, “Sometimes we ask them to do stuff they’re not capable of doing.”
The number of people who have signed up for insurance through the health law’s exchanges is lower than expected, in part because employers did not drop coverage to the extent that had been anticipated. In addition, the Supreme Court ruled that states could not be compelled to expand Medicaid — and many Republican-led states opted not to do so.
The House Republican legislation, which was released last week, would repeal major parts of President Barack Obama’s health care law. It would scrap the income-based tax credits that helped people pay for coverage, end the penalty for people who do not have health insurance and phase out the expansion of Medicaid that has brought coverage to millions of people.
Republicans would provide a new tax credit based on age that would help people buy insurance on the individual market. While people would not face a penalty for not buying insurance, Republicans would put in place a new provision to encourage continuous coverage: People would face a 30 percent surcharge in their premiums if they signed up for insurance after having gone without it for about two months or more.
But the bill would save the government $337 billion over 10 years, a big win for conservatives that could ease pressure on the legislation from the right. Under budgeting rules that Republicans are using to rush through a bill to repeal the health care law, the measure was supposed to trim the deficit at least $2 billion over 10 years. Otherwise, Democrats in the Senate could move to filibuster it.
In an interview last week with the radio host Hugh Hewitt, the House speaker, Paul D. Ryan, played down the significance of the forthcoming coverage estimate. He said the goal of Republicans was not “to win some coverage beauty contest” or “to show a pretty piece of paper that says we’re mandating great things for Americans” with their health bill.
“If the government says, ‘Thou shall buy our health insurance,’ the government estimates are going to say people will comply and it will happen,” Mr. Ryan said. “And when you replace that with, ‘We’re going to have a free market and you buy what you want to buy,’ they’re going to say not nearly as many people are going to do that.”
Before the C.B.O. assessment was released, Mr. Trump lauded the Republican health plan Monday at the beginning of a discussion with people the White House described as “victims” of the Affordable Care Act.
The president said the Republican plan would provide “more choices, far more choices, at lower cost.”
“Americans should pick the plan they want,” he said. “Now they’ll be able to pick the plan they want. They’ll be able to pick the doctor they want.”
Mr. Trump predicted that if the Republican plan gets enacted, “you’ll see rates go down, down, down, and you’ll see plans go up, up, up.” He said it would be “a thing of beauty.”

Nobel economist takes aim at rent-seeking banking and healthcare industries

by Greg Robb - Market Watch - March 6, 2017

Income inequality is not killing capitalism in the United States, but rent-seekers like the banking and the health-care sectors just might, said Nobel-winning economist Angus Deaton on Monday.
If an entrepreneur invents something on the order of another Facebook, Deaton said he has no problem with that person becoming wealthy.
“What is not OK is for rent-seekers to get rich,” Deaton said in a luncheon speech to the National Association for Business Economics.
Rent seekers lobby and persuade governments to give them special favors. 
Bankers during the financial crisis, and much of the health-care system, are two prime examples, Deaton said.
Rent-seeking is not only does not generate new product, it actually slows down economic growth, Deaton said.
“All that talent is devoted to stealing things, instead of making things,” he said.
Another prime example of rent-seeking is that the Medicaid is funding opioid prescriptions for low-income workers, Deaton said. The results are workers who are becoming addicted and overdosing while profits are going to the Sacker family which owns Purdue Pharma that makes OxyContin.
Deaton said he favors a single-payer health system only because our current part-private and part-public system is exquisitely designed to give opportunities for rent-seeking.
“So I, who do not believe in socialized health-care, would advocate a single-payment system...because it will get this monster that we’ve created out of the economy and allow the rest of capitalism to flourish without the awful things that healthcare is doing to us,” he said.
Raising taxes on the wealthy is not a good way to combat rent-seeking because it taxes the legitimate profits of entrepreneurs along with rent-seekers.
“The key is to somehow find a way of tackling rent-seeking, crony capitalism, and corruption legal and illegal and build fairer, more equal society without compromising innovation or entrepreneurship,” he said.

Follow the Health Care Money

by David Leonhardt - NYT - March 6, 2017
Many Americans over the age of 60 would have to pay more for health insurance under the Republican health care plan. Many low-income families would lose their insurance. Many disabled people, hepatitis patients and opioid addicts, among others, would no longer receive treatments that they do now.
Care to guess where the billions of dollars in savings from these cuts would go instead?
They would go largely to the richest 1 percent of households, those earning at least $700,000 a year, according to the Tax Policy Center. A disproportionate amount of the savings would go to the richest of the rich — those earning in the millions.
The Republican health care bill is, in no small measure, a tax cut for the wealthy.
If you’re wondering how Republican leaders can defend cutting benefits for older, sicker and poorer Americans to pay for a top-end tax cut, House Speaker Paul Ryan offered a revealing non-answer, as Jonathan Chait noted in New York Magazine.
At a news conference, a reporter asked Ryan why the bill cuts taxes for the rich. Ryan laughed, waved the question away, told the reporter to read the bill and then moved on to another question. Evidently, he can’t defend the tax cut.
In related news, the list of groups opposing the bill now includes AARP, the American Medical Association, the American Hospital Association, the Association of American Medical Colleges, the Catholic Health Association of the United States and the Children’s Hospital Association.

Bernie Sanders: Trump Should Avoid a Bad Zika Deal

by Bernie Sanders - NYT - March 11, 2017

Donald J. Trump told the American people during his presidential campaign, “This country is being drained of its jobs and its money because we have stupid people making bad deals.” He promised to make better deals, ones in which we would win so much we “may even get tired of winning.”
Now his administration, through the Army, is on the brink of making a bad deal, giving a French pharmaceutical company, Sanofi, the exclusive license to patents and thus a monopoly to sell a vaccine against the Zika virus. If Mr. Trump allows this deal, Sanofi will be able to charge whatever astronomical price it wants for its vaccine. Millions of people in the United States and around the world will not be able to afford it even though American taxpayers have already spent more than $1 billionon Zika research and prevention efforts, including millions to develop this vaccine.
The Department of Health and Human Services gave Sanofi $43 million to develop the Zika vaccine with the United States Army. And the company is expected to receive at least $130 million more in federal funding.
Sanofi is not a nonprofit or a tiny start-up struggling to bring medicine to market. Its chief executive, Olivier Brandicourt, earns about $4.5 million a year. Even the government of France criticized this salary, calling it “incomprehensible,” yet the American government is perfectly happy to enrich Mr. Brandicourt even more.
Before President Trump makes this deal, he must guarantee that Sanofi will not turn around and gouge American consumers, Medicare and Medicaid or our military when it sells the vaccine.
Unfortunately, the likelihood is that Sanofi will engage in exactly this predatory behavior — because it’s happened before.
Here is one recent example: The critical prostate cancer drug Xtandi was developed at U.C.L.A. with taxpayer-backed research grants and support from the Army and the National Institutes of Health. The patents, which were assigned to U.C.L.A. by the United States government, were transferred ultimately to a pharmaceutical company that is charging Americans $129,000 a year. Across the border in Canada, the same drug costs just $30,000 because, unlike the United States, Canada regulates drug prices.
Under this insane system, Americans pay twice. First we pay to create these lifesaving drugs, then we pay high prices to buy those drugs. And at the same time, we subsidize consumers in the rest of the world, including in advanced nations, by financing the research behind the medications they buy.
A Zika vaccine would be a tremendous scientific advancement and could prevent birth defects, including severe congenital brain damage, in countless children around the world. American soldiers serving in Zika-prone areas need it.
American consumers should not be forced to pay the highest price in the world for a vaccine we paid to help develop.
A failure by the government to demand fair prices from Sanofi in exchange for giving the company a monopoly would be only one more example of the broader insanity around American drug prices. A decision by the Army on Sanofi’s application is expected later this year.
Our government must stop being pushovers for the pharmaceutical industry and its 1,400 lobbyists. We must not hand this gift to a French drug company without making it pledge not to overcharge American consumers.
Will the president negotiate a better deal for the taxpayers of this country and our soldiers? Or was the president lying when he claimed he would make only the best deals on behalf of the American people?
We will soon find out.

Obamacare revision clears first hurdle in House committee early Thursday
by Juliet Eilperin, Mike De Bonis and Elise Viebeck - Washington Post - March 8, 2017

A key committee in the House approved a Republican proposal to replace the Affordable Care Act before dawn Thursday morning after roughly 18 hours of debate, awarding the bill its first procedural victory even as opposition mounted from conservatives, Democrats and health-care industry groups. 
The House Ways and Means Committee voted 23 to 16 to advance the American Health Care Act shortly before 4:30 a.m. Committee Chairman Kevin Brady (R-Tex.) called the move historic and praised President Trump, who has vowed to counter resistance to the bill with his own campaign-style effort. 
“Ways and Means Republicans just passed legislation that will help Americans finally have access to affordable health care,” Brady said in a statement following the vote. 
“This legislation reflects President Trump’s strong commitment to improving health care for all Americans. I sincerely thank my colleagues for their hard work and commitment to delivering on the President’s promise,” he said. 
Ways and Means was one of two House committees that began to consider the embattled health-care plan on Wednesday morning. The other, Energy and Commerce, was still working at 7:30 a.m. Thursday. 
The passage of the bill through Ways and Means prompted furious responses from Democrats, who said Republicans failed to accept a single amendment from the minority party. 
“We won’t back down from a fight to protect Americans’ health care,” committee Democrats wrote early Thursday on Twitter. 
Major associations representing physicians, hospitals, insurers and seniors had leveled sharp attacks against the House GOP’s plan on Wednesday, as some Republicans publicly questioned whether the measure can clear the House of Representatives.
The flurry of activity — including an evening meeting between President Trump and leaders from five skeptical conservative groups — created new uncertainty about the viability of Republicans’ signature promise to repeal and replace Obamacare.
Wednesday’s events also showed the uneasy predicament facing House Speaker Paul D. Ryan (R-Wis.), the proposal’s chief booster, who described the plan as a “conservative wish list” that would deliver on years of GOP campaign promises to change the nation’s health-care system.
After House Republicans released a proposal to transform the Affordable Care Act, members of their own party offered a mixture of support and suggestions for changes to the plan. (Sarah Parnass/The Washington Post)
“Right now I feel confident saying there aren’t 218 votes for this,” said Rep. Scott Perry (R-Pa.), a member of the conservative Freedom Caucus, who was referring to the number of votes needed to pass the measure out of the House. Perry opposes the proposal.
Thursday’s early vote showed that Ryan and other Republican House leaders are resolved to press ahead. Yet the proposal met a new round of GOP resistance in the Senate on Thursday morning when Sen. Tom Cotton (R-Ark.) wrote on Twitter that the House should “start over.”
“House health-care bill can’t pass Senate w/o major changes. To my friends in House: pause, start over,” Cotton wrote from his political account, rather than his official one. “Get it right, don’t get it fast.”
Cotton has been an outspoken critic of the swift pace at which House Republicans are moving ahead with their legislation. He also held a town hall recently that grew heated amid impassioned questions by constituents deeply concerned about changes to the ACA. 
The uninsured rate in Arkansas has dropped more dramatically than in any state other than Kentucky from 2013 to 2016 according to Gallup. 
“GOP shouldn’t act like Dems did in O’care,” Cotton wrote in a second tweet. “No excuse to release bill Mon night, start voting Wed. With no budget estimate!”
In another tweet, he wrote: “What matters in long run is better, more affordable health care for Americans, NOT House leaders’ arbitrary legislative calendar.”
Cotton’s tweet adds new uncertainty to the bill’s fate in the Senate should it pass the House. A quartet of other GOP senators in states that accepted Medicaid expansion under the ACA have already expressed concerns about the changes the bill would make to the way the program is administered. 
Meanwhile, the bill is taking fire on the right from Sens. Ted Cruz (R-Tex.), Rand Paul (R-Ky.) and Mike Lee (R-Utah), who say they want a more complete repeal. 
The barrage of criticism shows how fraught the terrain of health-care policy is. It also reflects a backlash prompted at least partly by the breakneck speed with which House Republicans are trying to push through their proposal — with little upfront effort to work with interest groups or political factions.
“What we’re seeing now is that the political prospects for repealing the Affordable Care Act are as daunting as the effort to pass national health reform,” Larry Jacobs, a political science professor at the University of Minnesota’s Hubert H. Humphrey School of Public Affairs, said in an interview.
House Republican leaders have given little indication that they will make anything but marginal changes to their plan, which would eliminate the requirements that all Americans obtain coverage or pay a tax penalty and that businesses with at least 50 employees provide insurance. The American Health Care Act would replace income-based subsidies with refundable tax credits based on age and income, charge individuals a 30 percent surcharge if they buy a plan after allowing their coverage to lapse and phase out the law’s more generous Medicaid funding over time.
White House spokesperson Sean Spicer said the administration is in "full court press" to promote the GOP health-care plan as calls of concern about the bill build from both Democrats and Republicans. (The Washington Post)
While conservatives complained that these changes don’t go far enough, they have sparked criticism not just from Democrats but from moderate Republicans, AARP, the American Medical Association and the American Hospital Association. 
“We cannot support the AHCA as drafted because of the expected decline in health insurance coverage and the potential harm it would cause to vulnerable patient populations,” James L. Madara, chief executive of the American Medical Association and a doctor, wrote in a letter to committee leaders overseeing work on the bill.
Richard Pollack, CEO of the American Hospital Association, voiced similar fears, saying efforts to “restructure the Medicaid program” by shifting it from an entitlement program to one based on a per capita allocation “will have the effect of making significant reductions in a program that provides services for our most vulnerable populations and already pays providers significantly less than the cost of providing care.”
America’s Health Insurance Plans, the insurance industry’s largest trade association, sent a letter Wednesday saying that while it appreciated several of the proposed changes, the changes to Medicaid “could result in unnecessary disruptions in the coverage and care beneficiaries depend on.”
House Energy and Commerce Committee Chairman Greg Walden (R-Ore.) told reporters Wednesday that critics were exaggerating the proposal’s potential repercussions.
“It’s tough to do entitlement reform, it’s tough to make these changes, but I think at the end of day, seniors are going to be fine,” Walden said. “If you’re on Medicaid today, you’ll be on Medicaid tomorrow. States can intercede here and help out. So there’s more to this story.”
Walden said it was “sort of shocking” that hospital groups were strongly opposing the plan, because the GOP legislation restores the ACA’s cuts to “disproportionate share” payments to hospitals that serve large numbers of uninsured patients. 
“There’s a pretty big medical-industrial complex in America,” he added. “And when you touch it, I’ve discovered, it touches back.”
House Republicans’ determination to deliver on their promise to undo the ACA — Ryan said Wednesday that it is “the covenant we made with the American people when we ran on a repeal-and-replace plan in 2016” — has spurred a legislative drive that is happening at warp speed.
A cadre of lawmakers and staffers worked behind closed doors for several weeks to draft the pair of bills, which were designed to move through the annual budget process in order to clear the Senate with a simple majority vote.
But that process, which did not involve an extended period of negotiation with interest groups or consultation with Democrats, has produced a furious backlash. 
Some insurers, including Molina Healthcare and the Alliance of Community Health Plans, said they did not get to offer any input into the House proposal.
“It doesn’t seem like the industry got any heads up or was involved. We definitely were not,” Sunny Yu, spokeswoman for Molina Healthcare, which has about a million members in the Affordable Care Act exchanges, said in an email.
Democrats threw up procedural obstacles Wednesday in the committee meetings and on the House floor, complaining that it was irresponsible to consider the bills before the Congressional Budget Office offered an analysis that showed the legislation’s impact on the budget and Americans’ overall health care coverage.
“We need to know, what this is going to cost?” asked Rep. Anna G. Eshoo (D-Calif.), a member of the Energy and Commerce Committee. “We need to know, what kind of health insurance is going to be feasible?”
Both House Republicans and White House budget director Mick Mulvaney have predicted that they will have a CBO “score” ready by early next week, before the bills are combined and brought before the House Budget Committee. GOP staffers noted that other health-care bills, including the 21st Century Cures Act and the 2015 reauthorization bill for Medicare and the Children’s Health Insurance Program, began their journeys through congressional committees without a CBO score.
Democrats on the Energy and Commerce Committee moved to delay the bill’s consideration for 30 days, while those on Ways and Means moved to delay it for one week to allow for further hearings and to examine the CBO report. Both motions were voted down on a straight party-line vote, and the panels continued working into the evening. 
Still, the most imminent threat GOP leaders must contend with comes from the far right. The speaker can lose only 21 Republican votes if the American Health Care Act is to pass, and opponents are promising to use that leverage to force changes to the bill. 
Rep. Thomas Garrett (R-Va.), a freshman member of the conservative House Freedom Caucus, said he was confident that his camp could help reshape the legislation. While Trump had endorsed it already, Garrett said, he would probably be willing to accept something else if it were changed in a way conservatives could support.
“This is a guy who said he wasn’t sure that NATO, in its classic role, is necessary — and then two months later we saw countries like Germany vow to increase their defense spending to 2 percent of GDP,” said Garrett. “Why’d they do that? Because Donald Trump wasn’t going to accept the status quo. They made a counteroffer. Right now, there’s an offer, and he’s saying he likes to get people to make counteroffers.”
Vice President Pence met with two House Freedom Caucus leaders Tuesday, and that same day Mulvaney — a former caucus member — spent more than an hour at a meeting of the group. Its members have been invited to visit the White House next Tuesday.
Wednesday night, Trump met with leaders from Americans for Prosperity, the Club for Growth, FreedomWorks, the Heritage Foundation and its political arm, Heritage Action, and the Tea Party Patriots.
But the hard reality for Republicans is that any changes made to appease House conservatives could threaten the bill’s support among moderates.
“My fear is that the bill will go backwards,” said Rep. Tom MacArthur (R-N.J.), a co-chairman of the centrist Tuesday Group who has gotten White House attention of his own: He met Tuesday with Health and Human Services Secretary Tom Price. “If the bill starts going in the reverse direction in order to satisfy certain members of my party, then I’m going to have a problem. I think the federal government has a role to play here, and I’m not looking to just see the federal government undermine the health-care needs of the American people.”
Sen. Susan Collins of Maine, a pivotal Republican moderate, said in an interview Wednesday with Yahoo News’s Katie Couric that the current House measure would “not be well received in the Senate” and stood no chance of passing as is. “I want us to slow down to take more time to be sure we get this right.”

Republicans wave a white flag on health care

by Charles Lane - Washington Post - March 8, 2017

Democrats denouncing the new House GOP health-care bill should actually be dancing in the streets. Perhaps, in the privacy of their own homes, the savvier ones are popping the champagne corks. The true meaning of the proposed legislation is that, after eight years of all-out political and ideological struggle against Obamacare, Republicans have surrendered — pretty much on all fronts.
House Speaker Paul D. Ryan (R-Wis.) should have written the bill on a large white tablecloth and run it up the nearest flagpole.
Yes, yes, the plan is labeled “repeal and replace.” And, true, it does away with many of the Obamacare provisions that conservatives most reviled, including the individual mandate to buy insurance and a bevy of taxes. If enacted and fully implemented, the plan probably would insure fewer people and shift more of the cost down the income distribution scale, in part by restricting the flow of Medicaid funds to the states.
Democrats and their allies in the liberal policy community are not wrong to fret about that. However, when they look up from their spreadsheets, what they’ll notice is that much of Obamacare’s architecture remains: The GOP bill relies on regulated and subsidized individual insurance, plus a Medicaid program that would be smaller than it has been since Obamacare began, but still larger than it was before, to fill coverage gaps left by the mainstays of U.S. health care: Medicare and employer-paid plans.
After vilifying that set of interlocking policy compromises as a budget-busting, freedom-destroying ticket to second-rate medical care, the leaders of the GOP House have now declared, in writing, that they don’t have a fundamentally different idea, much less a better one. Even the individual mandate, and the “tax penalty” that enforced it, isn’t really gone. It is recast as a requirement to maintain continous coverage, enforced by a surcharge payable to insurance companies. 
Heretofore, the health-care debate was a contest between Republicans, who were bent on repealing “every word of Obamacare,” and Democrats, who defended it. 
Now it’s an argument about whose subsidized-regulated-individual-market-plus-some-Medicaid thingy works better. 
And it’s far from clear that the Republican mousetrap would win this contest. What would it do to the federal deficit? The bill didn’t come with the usual Congressional Budget Office fiscal projection, but it’s hard to believe there’s a fiscally responsible way to maintain so many of Obamacare’s popular benefits, such as coverage for preexisting conditions, as the bill does, while abolishing or postponing the taxes that would help pay for them, as the bill also does. 
Who knows if this bill would actually stabilize individual insurance markets, as the GOP claims? Again, by purporting to fix them, the Republicans have assumed the burden of showing that their incentives are better calibrated to draw young, healthy people into the risk pool than President Barack Obama’s were. One conservative health-care expert, Avik Roy, has crunched the numbers and calls the plan “a recipe for . . . death spirals” in the individual market.
To be sure, the bill attempts to evade, or postpone, political fallout by waiting until after the 2018 elections for its most controversial provisions to take effect: Medicaid expansion, for example, wouldn’t end until 2020 — plenty of time for a state or two that balked under Obama to change their minds! — after which skimpier federal funding kicks in. Maybe this gambit will work. Or maybe it just hands the Democrats a campaign issue: Vote for us and we’ll stop the GOP cuts.
Conservative true believers certainly aren’t impressed. “Many Americans seeking health insurance on the individual market will notice no significant difference between the Affordable Care Act (i.e., Obamacare) and the American Health Care Act,” wrote Michael A. Needham of Heritage Action for America. “That is bad politics and, more importantly, bad policy.” 
Needham has a point. However, there’s little evidence that Americans are clamoring for the free-market alternatives that Heritage Action and other Obamacare critics have been pushing — and which the House leadership accordingly eschewed.
Donald Trump got elected president by promising to repeal Obamacare — except for all the good stuff such as preexisting-condition coverage and up-to-26-year-olds staying on their parents’ plans — as well as to protect Medicare.
A not-unfair summary of the typical American voter’s view on health care might go like this: “Give me a plan with abundant covered services and choice, and shift as much of the cost as possible onto someone else, while protecting the poor, but for heaven’s sake don’t make it ‘government-run.’ ”
That inconsistent set of demands pretty much defined public opinion back in 2009, too, which is partly why Obamacare came out as it did. It represented the maximum politically feasible distance Democrats could move toward their top goal, universal coverage.
The GOP bill conversely — and revealingly — represents the maximum progress House Republicans think they can make toward free-market health care without committing political suicide. They sure didn’t get very far.

The Republican Health Care Crackup

The Republican health care bill could represent the moment when the old order of American politics completely cracks up, the end of a certain era in American politics.
That era began around 1974, when Ted Kennedy introduced a bill to supplement America’s employer-based insurance system with a government program. The Democratic dream of universal coverage continued through Hillary Clinton’s time as first lady and reached a partial culmination with the passage of Obamacare.
Combating government health care was a central Republican preoccupation through all that time, and the passage of Obamacare provoked the Tea Party reaction and final arrival of Goldwaterite populist conservatism.
By 2010, however, both the Obama administration and the Tea Party opposition were out of step with the times. They both still thought the big political issues in American life were universal health care and the size of government.
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In fact, another set of problems had magnified and come to overshadow the old set. This new set included:
First, the crisis of opportunity. People with fewer skills were seeing their wages stagnate, the labor markets evaporate. Second, the crisis of solidarity. The social fabric, especially for those without a college degree, was disintegrating — marriage rates plummeting, opiate abuse rates rising. Third, the crisis of authority. Distrust in major institutions crossed some sort of threshold. People had so lost trust in government, the media, the leadership class in general, that they were willing to abandon truth and decorum and embrace authoritarian thuggery to blow it all up.
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If President Obama had made these crises the center of his administration, instead of the A.C.A., Democrats wouldn’t have lost Congress and the White House. If the Tea Party had understood the first two of these crises, there would have been no opening for Donald Trump.
Trump came along and exploited these crises. But if his administration’s health care approach teaches us anything, it is that he has no positive agenda for addressing them. He can tap into working class anxiety negatively, by harnessing hostility toward immigrants, foreigners and the poor. But he can’t come up with a positive agenda to make working class life more secure.
So we have a group of Freedom Caucus Republicans who still think the major problems in the country today can be cured with tax and spending cuts. We have a Trump administration that has populist impulses but no actual populist safety net policies. And we’ve got a Republican leadership in Congress mired in Reagan-era thinking and trying to pay lip service to every obsolete prejudice in the various wings of the party.
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You end up with this hodgepodge legislation that pleases nobody and takes the big crises afflicting our country and makes them all worse.
The Republican health plan would make America’s economic chasm worse. It would cut health subsidies that go to the poor while eliminating the net investment income tax, which benefits only the top 1 percent.
The Republican plan would further destabilize the social fabric for those at the bottom. Throwing perhaps 10 million people off the insurance rolls will increase fear, isolation, social tension, chronic illness, suicide and bankruptcy.
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The Republican plan will fuel cynicism. It’s being pushed through in an elitist, anti-democratic, middle of the night rush. It seems purposely designed to fail. The penalties for those who don’t purchase insurance are so low they seem sure to guarantee Republican-caused death spirals in the weaker markets.
This thing probably won’t pass, but even if it passes it will probably lead to immense pain and disruption. That will discredit market-based social reform, cost the Republicans their congressional majorities and end what’s left of the Reagan-era party.
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It will also point the way to a new era.
The central debate in the old era was big government versus small government, the market versus the state. But now you’ve got millions of people growing up in social and cultural chaos and not getting the skills they need to thrive in a technological society. This is not a problem you can solve with tax cuts.
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And if you don’t solve this problem, voters around the world have demonstrated that they’re quite willing to destroy market mechanisms to get the security they crave. They will trash free trade, cut legal skilled immigration, attack modern finance and choose state-run corporatism over dynamic free market capitalism.
The core of the new era is this: If you want to preserve the market, you have to have a strong state that enables people to thrive in it. If you are pro-market, you have to be pro-state. You can come up with innovative ways to deliver state services, like affordable health care, but you can’t just leave people on their own. The social fabric, the safety net and the human capital sources just aren’t strong enough.
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New social crises transform party philosophies. We’re in the middle of a transformation. But to get there we’ve got to live through this final health care debacle first.

Wealthy Would Get Billions in Tax Cuts Under Obamacare Repeal Plan

by Jesse Drucker - NYT - March 10. 2017

Two of the biggest tax cuts in Republican proposals to repeal the Affordable Care Act would deliver roughly $157 billion over the coming decade to those with incomes of $1 million or more, according to a congressional analysis.
The assessment was made by the Joint Committee on Taxation, a nonpartisan panel that provides research on tax issues.
It is not unusual for tax cuts to benefit mostly the wealthiest, but still save some money for a majority of Americans. But the benefits of these reductions would be aimed squarely at the top.
The provisions would repeal two tax increases on high earners enacted in 2010 to help pay for the Affordable Care Act: an increase in capital gains taxes and other investment-related income, and a surcharge on Medicare taxes.
People making $200,000 to $999,999 a year would also get sizable tax cuts. In total, the two provisions would cut taxes by about $274 billion during the coming decade, virtually all of it for people making at least $200,000, according to a separate assessment by the committee.
“Repeal-and-replace is a gigantic transfer of wealth from the lowest-income Americans to the highest-income Americas,” said Edward D. Kleinbard, a professor at the University of Southern California law school and former chief of staff for the Joint Committee on Taxation.
Tax economists point out that even tax cuts for the wealthy can have indirect benefits for others. For example, the additional cash can prompt extra spending and extra hiring.
That said, “most of the benefit of getting rid of those two taxes would go to wealthy people,” said Joel Slemrod, a professor at the University of Michigan Ross School of Business and former senior staff economist for President Ronald Reagan’s Council of Economic Advisers. “It’s not significant for me to add a caveat.”
One of the taxes targeted in the repeal bill is a 3.8 percent tax on investment income, like capital gains. The other is a 0.9 percent surcharge on the Medicare taxes imposed on high-income earners — individuals making more than $200,000 a year and married couples filing joint returns who earn more than $250,000 a year. That brings the Medicare tax levied on that income up to 3.8 percent as well.
The tax repeal would solely benefit wealthy Americans because the taxes were imposed only on the wealthiest. The increases were passed in 2010, when capital gains rates were near historical lows. During the George W. Bush administration, Congress cut the rates to 15 percent from 20 percent. With the 3.8 percent tax imposed by the Affordable Care Act, the top capital gains rate stands at 23.8 percent for the wealthiest Americans. That still makes the rate lower it was for most of the 1970s, 1980s and 1990s.
The panel’s analysis was provided to members of the House Ways and Means Committee on Wednesday but has not been published on the committee’s website. A copy was reviewed by The New York Times.
The analysis found that by 2020, the repeal of the two tax provisions would save about $15.9 billion a year for those with incomes of $1 million or more. By 2026, the final year of the analysis, they would combine to save that group a little more than $20 billion a year.
For all the taxpayers who would benefit, the tax cuts would save nearly $37 billion in a single year by 2026.
On Monday, the Congressional Budget Office is expected to issue its analysis of the total cost of the Republican plan to replace the Affordable Care Act, including how much, if anything, it would add to the federal deficit in the coming decade.

A state single-payer healthcare system? Nice idea, but it's just California dreaming
by George Skelton - LA Times - March 9, 2017

Voters want politicians to be bold. They disrespect timidity. And trying to push every Californian into a government-run healthcare system is certifiably bold.
The voters’ desire for boldness has a caveat, of course: They’ve got to like what the politician is being bold about.
We really don’t know how Californians feel about government-run universal healthcare. People haven’t been asked for a while.
The Public Policy Institute of California surveyed voters in January, however, and found that 54% opposed congressional repeal of the Affordable Care Act, or Obamacare.
But for generations, it has been the dream of many — mostly Democrats — to enact whatever you want to call it: “single-payer,” “Medicare-for-all” or “socialized medicine.”
Now, with congressional Republicans and President Trump trying to repeal and replace Obamacare, some Sacramento Democrats think they see an opening to finally adopt a California version of single-payer.
Under single-payer, healthcare costs are paid for by the government, rather than by private insurance. The healthcare itself is still delivered by private physicians.
Some version that would allow people to buy supplemental private insurance — call it “Medicare-for-all” — presumably could fit into the system these Democrats envision.
We really don’t know because they haven’t actually proposed anything. They’re promising details in two weeks. So far, they’ve just tucked the concept of single-payer into an essentially hollow bill, SB 562, by Sens. Ricardo Lara (D-Bell Gardens) and Toni Atkins (D-San Diego).
The bill merely declares: “It is the intent of the Legislature to enact legislation that would establish a comprehensive universal single-payer healthcare coverage program and a healthcare cost control system for the benefit of all residents of the state.”
Yes, that means “all” — whether they’re in the country legally or not.
Medi-Cal, the state’s enhanced version of federal Medicaid for poor people, already covers children here illegally. But not their parents.
Lara told me that he mentioned to one kid that the Legislature had extended Medi-Cal to undocumented children.
“He said, ‘Thank you senator, but what about my mom?’” Lara recalled. “What about my dad? How do we get to healthcare for everyone?’”
With great difficulty, I’d say. And the same for enacting any single-payer system.
Dreams can be good. But this dream — especially with Trump and conservative Republicans controlling the national agenda — seems like wishful fantasy, even in deep blue California.
The envisioned policy long has made sense. Cut out the insurance industry profiteering and reduce healthcare costs. Perhaps eliminate co-pays and deductibles, as Lara wants to do.
Even Medicare-for-all would be better than what most people have today. Ever hear a senior seriously complain about Medicare? I haven’t.
Most industrialized nations have some sort of government-run healthcare coverage — either single-payer or a hybrid public-private system.
But good policy aside, there are two huge obstacles to a state going solo: financing and politics.
In California, it would cost the state tens of billions of dollars. Who’d pay for that? Business, which presumably would no longer need to provide employees with health insurance? Wage earners through payroll withholding? Medical providers? How much would the federal government kick in? Anything?
That presumably will be in the bill’s details. Good luck.
And how would this legislation ever get passed? The politics are daunting. The insurance industry would fight with all it has — meaning campaign money. So would many healthcare providers that historically have feared “socialized medicine.”
On the other side, the California Nurses Assn. is the bill’s chief sponsor. And that labor union has influence among liberals.
But nothing of this magnitude and controversy can pass the Legislature without a committed governor pushing strongly. And Gov. Jerry Brown hasn’t said a peep about single-payer healthcare since he was elected in 2010. Moreover, the normally cautious skinflint is not likely to commit the state to such a financial gamble.
No other state has a single-payer plan. Vermont did briefly, but scrubbed it in 2014 because of high costs and unpopular taxes.
The California Legislature passed a single-payer bill — sort of — when Arnold Schwarzenegger was governor, but he vetoed it.
Actually, it wasn’t a real single-payer plan anyway. It didn’t include any financing. That was to be passed later and required a two-thirds supermajority vote. No way.
Democrats currently hold a supermajority in each house. But you can bet not all are inclined to vote for a tax increase. Possibly for highway repairs, but not for an untested, radical change in healthcare coverage.
“The time is right, the time is now,” insists Lara, who’s thinking about running for state insurance commissioner next year. “California can be the national laboratory for our country.”
“What everyone agrees on,” he adds, “is we need to have an alternative” to threatened Obamacare.
But many Democrats believe their best hope is congressional gridlock and the blockage of repeal.
“Perhaps I’m like Alice in Wonderland, but I really am hopeful,” says state Sen. Holly Mitchell (D-Los Angeles), the Budget Committee chairwoman. “There’s an amazing groundswell of people showing up all over the country fighting to retain the Affordable Care Act.”
What about single-payer? “I honestly don’t know.”
Not a lot of enthusiasm there.
She sounds like other Democrats who privately believe the focus should be on preserving what they can of Obamacare, which has pumped nearly $24 billion annually into California healthcare and halved the number of uninsured.

Our View: Republican health care proposal would hit rural Maine hard

Maine's 2nd District U.S. Rep. Bruce Poliquin is applauding the plan, even though it would put medical insurance out of the reach of thousands of his constituents.
Editorial - Portland Press Herald - March 9, 2017
If you were going to design a health care plan that would punish Maine’s 2nd Congressional District, you couldn’t do much better than the House Republicans’ proposal to replace the Affordable Care Act.
Their idea is to help younger, healthier and well-off Americans buy insurance by pulling back help from their older, sicker and poorer neighbors. That’s a shot at Maine’s 2nd District, which has a much higher median age than the nation as a whole (44.6 to 37.9) and a much lower median annual income ($44,560 as opposed to $51,939).
In addition, the Republican plan would stop adjusting the size of health insurance tax credits by region, so people who live in places where health coverage is expensive – like rural Maine – would take the biggest hit. The plan has taken heat from those on the left, right and center, but it has one surprising cheerleader: 2nd District U.S. Rep. Bruce Poliquin.
Poliquin, who has had nothing to say on other matters of national importance, has stepped forward as an early and enthusiastic proponent of a bill that looks like it was drawn up to hurt the people he represents.
“This legislation will bring much-needed health insurance relief to the American people while keeping the promises made to them,” Poliquin said in a prepared statement. The congressman applauded the new plan for keeping some popular features of Obamacare – namely, coverage for people with pre-existing conditions and the inclusion of young adults on their parents’ plan.
Then he said the bill would “make sure insurance companies sell health insurance to everyone who wants it.”
But Poliquin did not address the main reason someone might not “want” health insurance – because they can’t afford it.
The reason health insurance is so expensive is that health care is so expensive, and the plan cooked up by House Republicans would do nothing to change that. President Trump campaigned on promises to bring down the cost of health insurance premiums by negotiating lower prices for prescription drugs, but there is no such language in the bill that Poliquin backs now.
Instead, it cuts taxes on incomes over $200,000 for an individual and $250,000 for a family, and makes up for the loss of revenue by cutting the subsidies that help low- and moderate-income people pay for their coverage.
Sen. Angus King told his colleagues that a 60-year-old in Aroostook County who earns $30,000 a year would see his or her benefit slashed by 70 percent. It is a game, the senator said, of “shift and shaft: shift the cost and shaft the people who need coverage.”
The plan also would shift Medicaid costs onto states over time, which would likely result in higher taxes and fewer services for low-income people and those with disabilities. And it would defund Planned Parenthood, which would further reduce access to affordable health care for women.
It’s clear now why Poliquin did not bother to have a town hall meeting in his district last month. He’s listening to Republican leaders in Washington, not the people of his district.
If he had been listening to them, he might have had something more to say about a plan designed to put the cost of health insurance out of reach for thousands of his constituents than calling it “much-needed relief.”

Sen. King says Republican health plan ‘will hammer Maine’

In a speech on the floor of the Senate, the independent says the plan would cost Mainers more and deliver less.
Portland Press Herald Staff - March 9, 2017
Sen. Angus King criticized the proposal to replace the Affordable Care Act during a speech on the Senate floor Wednesday, saying the plan by House Republicans would hurt Maine seniors, give tax breaks to the wealthy at the expense of middle-class Mainers, and end up costing people across the state more money while delivering less.
Maine’s independent senator called on the House of Representatives to instead work to improve the existing law, also known as Obamacare.
“I don’t think there is much question that this proposal will hammer Maine and my people, and I can’t stand for that,” King said.
He cited estimates that, under the replacement proposal, a 60-year-old person in Aroostook County with an income of $30,000 a year would lose about 70 percent of the federal support for his or her health insurance plan.
“The pattern is shift and shaft: shift the cost and shaft the people who need coverage,” King said.
King also has expressed concern about the effects of repeal on hospitals in rural Maine.
House Republicans’ plan to replace the Affordable Care Act was attacked from all sides Tuesday, including criticism by conservative Maine Gov. Paul LePage and U.S. Sen. Susan Collins of Maine, a moderate Republican.

Dana Milbank: Obamacare replacement not selling like iPhones, even to Republicans

Who knew that reforming health care could be so hard and complex, except for everyone else?
President Trump, long at the forefront of intellectual discovery, last week came up with a major finding: Health care reform is hard. “Unbelievably complex,” in fact.
“Nobody knew that health care could be so complicated,” the president said.
Actually, we all knew. That’s why Republicans’ successor plan to Obamacare, “repeal and replace,” became repeal and delay.
That’s why House Republicans kept their draft legislation under guard in a secret, Republican-only “reading room” in the Capitol, so copies wouldn’t leak. That’s why they decided to push the legislation through committees this week only a couple of days after introducing it – and before waiting for the Congressional Budget Office to say how much the legislation would cost taxpayers and how many people would lose health insurance.
Apparently they have to pass the bill so we can find out what’s in it.
And now that Republican leaders in the House have finally revealed their plan, the magic formula turns out to be … a cheap knockoff of Obamacare: covering fewer people, charging them more and giving a tax cut to the rich.
Democrats, predictably, panned it because it’s a cheap knockoff of Obamacare, and they prefer the original over imitators.
The bigger problem for Republican leaders is that conservatives also panned it because, well, it’s a cheap knockoff of Obamacare.
Outside the Capitol Tuesday afternoon, conservative legislators lined up to denounce the bill.
“A step in the wrong direction,” said Sen. Mike Lee, R-Utah.
Rep. Louie Gohmert, R-Texas, likened the “flawed bill” to “horse excrement.”
“Let’s not lower the bar on what we believe simply because a Republican is in the White House,” said Rep. Mark Sanford, R-S.C.
“Obviously,” deduced Rep. Mark Meadows, R-N.C., “we have some serious concerns.”
The sales effort so far has been wanting. Rep. Jason Chaffetz, R-Utah, defending the legislation on CNN on Tuesday, suggested that Americans, “rather than getting that new iPhone that they just love and they want to spend hundreds of dollars on that, maybe they should invest in their own health care.”
The authors of the legislation, Ways and Means Committee Chairman Kevin Brady, R-Texas, and Energy and Commerce Committee Chairman Greg Walden, R-Ore., didn’t do much better. They paraded their 123-page bill before the cameras Tuesday morning with a sign pasted on it: “Read the Bill.”
They came armed with a letter from Trump’s health and human services secretary, Tom Price, backing the legislation (Trump himself calls it “wonderful”), but they had no direct answers for how much the bill would cost, how many fewer would be covered and what sort of tax break the wealthy would see.
CBS’ Nancy Cordes pointed out that Republicans complained for years about Democrats ramming through Obamacare. “So aren’t you doing the exact same thing?”
“No, not at all,” replied Walden – who then admitted he was indeed following the procedure the Democrats did when, in passing Obamacare, “they didn’t have a CBO score before it went up to the Budget Committee.”
The Republican legislation also includes many of the “gimmicks” they decried in Obamacare: delaying implementation of costly provisions to out years to make the bill appear cheaper than it is.
The bill, which Rep. Justin Amash, R-Mich., called “Obamacare 2.0,” uses the structure of Obamacare, sustains Obamacare’s Medicaid expansion at least through 2020 and keeps the “Cadillac tax” on generous health care plans.
Democrats say the Republican plan would cause at least 11 million to lose health coverage, drive up premium, co-pay and deductible costs, deplete the Medicare trust fund and amount to a huge transfer of wealth to the richest.
They are getting a bit of support from a group of four relatively moderate Senate Republicans who have already demanded protections for those covered by Obamacare’s Medicaid expansion.
Powerful conservative groups such as Heritage Action, FreedomWorks and Club for Growth have all denounced the Republican legislation. Sen. Rand Paul, R-Ky., called the bill “Obamacare lite,” and he and Rep. Jim Jordan, R-Ohio, said they would reintroduce legislation calling for an outright repeal of Obamacare.
Brady, one of the authors of Obamacare lite, warned Republicans: “We can act now or we can keep fiddling around and squander this opportunity to repeal Obamacare.”
Apparently, that argument hasn’t prevailed.
As Brady and Walden finished their news conference, an email arrived from the office of House Speaker Paul Ryan, R-Wis., announcing a do-over: Brady and Walden would have another health care news conference later in the day, this time joined by Ryan.
Who knew it would be so hard?

LePage: ‘You can’t go from Obamacare to RINOcare’

by Michael Shepard - Bangor Daily News - March 9, 2017
Republican Gov. Paul LePage on Thursday amplified his criticism of the health care reform effort being mulled in Congress, saying it would be devastating to Maine’s budget because the state has the oldest per-capita population in the country.
LePage said during a radio interview on WGAN that he was leaving for Capitol Hill at 10 a.m. for meetings today and Friday with lawmakers, White House staff and Health and Human Services Secretary Tom Price.
“The big issue right now that I’m trying to work on is this repeal, replace and reform,” said LePage. “You can’t go from Obamacare to RINOcare.”
RINO, which you probably understand, is an acronym for “Republican in Name Only.”
As he has said before, LePage argued that Congress and President Donald Trump should immediately eliminate the option for states to expand health coverage through Medicaid, which the current Republican plan would preserve until 2020. 
“It’s almost like a bait and switch,” he said. “I’m saying ‘wait a minute, let’s fix it now.’ … You can’t just put it on the taxpayers and that’s what I’m objecting to.” 
LePage said putting a per-capita cap on health coverage would be financially damaging to Maine because of our high number of senior citizens.  
“We are disproportionate to the rest of the country because of our demographics,” said LePage. “It’s going to be an absolute disaster.” 
LePage continued to tout a private-market approach to providing health insurance. He told the radio hosts on Thursday that thousands of Mainers gave up employer-sponsored health insurance because they could get free coverage through Medicaid. The radio hosts did not ask him for a source to support that claim. 
Maine’s Republican governor said that states would face crippling new costs if a final version of the House Republicans’ plan keeps expanded Medicaid eligibility guidelines in place through 2020, suggesting that it would trigger a return to massive state health care spending shortfalls that his administration had to deal with in 2009 and 2010.
LePage, who has taken a more assertive role as a conservative voice in the national debate over the Affordable Care Act, said he is not confident Congress will do the right thing.
“I look at Congress like I look at the Legislature,” he said. “Backbone is not their strongest asset.”

A Plan Set Up To Fail

by Paul Krugman - NYT - March 7, 2017

So now we know what Republicans have to offer as an Obamacare replacement. Let me try to avoid value judgments for a few minutes, and describe what seems to have happened here.
The structure of the Affordable Care Act comes out of a straightforward analysis of the logic of coverage. If you want to make health insurance available and affordable for almost everyone, regardless of income or health status, and you want to do this through private insurers rather than simply have single-payer, you have to do three things. 
1.Regulate insurers so they can’t refuse or charge high premiums to people with preexisting conditions
2.Impose some penalty on people who don’t buy insurance, to induce healthy people to sign up and provide a workable risk pool
3.Subsidize premiums so that lower-income households can afford insurance
So that’s Obamacare (and Romneycare before that): regulation, mandates, and subsidies. And the result has been a sharp decline in the number of uninsured, with costs coming in well below expectations. Roughly speaking, 20 million Americans gained coverage at a cost of around 0.6 percent of GDP. 
Republicans have nonetheless denounced the law as a monstrosity, and promised to replace it with something totally different and far better. Which makes what they’ve actually come up … interesting.
For the GOP proposal basically accepts the logic of Obamacare. It retains insurer regulation to prevent exclusion of people with preexisting conditions. It imposes a penalty on those who don’t buy insurance while healthy. And it offers tax credits to help people buy insurance. Conservatives calling the plan Obamacare 2.0 definitely have a point.
But a better designation would be Obamacare 0.5, because it’s really about replacing relatively solid pillars with half-measures, severely and probably fatally weakening the whole structure. 
First, the individual mandate – already too weak, so that too many healthy people opt out – is replaced by a penalty imposed if and only if the uninsured decide to enter the market later. This wouldn’t do much.
Second, the ACA subsidies, which are linked both to income and to the cost of insurance, are replaced by flat tax credits which would be worth much less to lower-income Americans, the very people most likely to need help buying insurance.
Taken together, these moves would almost surely lead to a death spiral. Healthy individuals, especially low-income households no longer receiving adequate aid, would opt out, worsening the risk pool. Premiums would soar – without the cushion created by the current, price-linked subsidy formula — leading more healthy people to exit. In much of the country, the individual markets would probably collapse.
The House leadership seems to realize all of this; that’s why it reportedly plans to rush the bill through committee before CBO even gets a chance to score it.
It’s an amazing spectacle. Obviously, Republicans backed themselves into a corner: after all those years denouncing Obamacare, they felt they had to do something, but in fact had no good ideas about what to offer as a replacement. So they went with really bad ideas instead.

After Halting Start, Trump Plunges Into Effort to Repeal Health Law

by Maggie Habermas and Robert Pear - NYT - March 9, 2017

WASHINGTON — President Trump, after a halting start, is now marshaling the full power of his office to win over holdout conservatives and waffling senators to support the House Republicans’ replacement for the Affordable Care Act.
There are East Room meetings, evening dinners and sumptuous lunches — even a White House bowling soiree. Mr. Trump is deploying the salesman tactics he sharpened over several decades in New York real estate. His pitch: He is fully behind the bill to scotch President Barack Obama’s signature domestic achievement, but he is open to negotiations on the details.
In so doing, Mr. Trump is plunging personally into his first major legislative fight, getting behind a bill that has been denounced by many health care providers and scorned by his base on the right. If it fails, Mr. Trump will find it difficult not to shoulder some of the blame.
“He understands the power he has as president to drive the legislative process,” said Representative Patrick T. McHenry, Republican of North Carolina and a top House vote counter, who was part of a meeting with Mr. Trump in the East Room on Tuesday.
“He made it clear that this is his priority, that it has to get done, and he made clear that he has to get it through before he moves on tax reform,” Mr. McHenry added.
The bill represents an opening for an administration that has been mired in infighting and controversy over an early executive action on immigration. And it will allow Mr. Trump to make good on a pledge he made in rally after rally in 2016 to replace Mr. Obama’s law, which he called a “disaster.”
And it has momentum. On Thursday, two key House committees approved the legislation, which would undo the Affordable Care Act and replace it with a more modest system of tax credits and a rollback of Mr. Obama’s Medicaid expansion. Party-line votes by the House Energy and Commerce and Ways and Means Committees sent the measure to the House Budget Committee for consideration next week before a final House vote that Speaker Paul D. Ryan plans for later this month.
“Today marks the beginning of the end of Obamacare,” Representative Steve Scalise of Louisiana, the majority whip, declared after the votes.
The risks for Mr. Trump are high. His initial foray into the debate was a declaration that nobody should lose insurance coverage with a replacement bill — a standard that is likely to be impossible to meet. When House Republicans finally unveiled the legislation Monday night, he declared on Twitter, “Our wonderful new Healthcare Bill is now out for review and negotiation” — hardly a hard line.
Already, debate on the measure is taking far longer than Mr. Trump had hoped, delaying his push to cut taxes, rewrite the tax code and secure a sizable new infrastructure program. If his health care push fails, the reverberations will affect those other measures.
For all of Mr. Trump’s characteristic bluster, the self-described king of the deal is treading gingerly on the actual policies in the bill. Since members of the hard-line House Freedom Caucus complained that they were not being listened to by the House Republican leadership, Mr. Trump has sought to bring them along by listening to their concerns before dictating his desires, his advisers say.
For now, those advisers say, Mr. Trump is in listening mode. He had dinner on Wednesday with Senator Ted Cruz of Texas, who is leery of the House bill. He got an earful from conservative opponents of the bill when he met at the White House with representatives of the Heritage Foundation and Americans for Prosperity on Wednesday night.
On Thursday afternoon, the White House director of social media, Dan Scavino Jr., posted a photo on Twitter of the president sitting around a table at a meeting that Mr. Scavino said was budget-related. But among those at the table with the president were Representative Mark Meadows of North Carolina, the chairman of the Freedom Caucus, and Representative Jim Jordan of Ohio, two of the biggest obstacles to any health care bill deemed insufficiently thorough in obliterating the Affordable Care Act.
The president has not spent enormous time negotiating specific aspects of the bill, people who have spoken with him say. But some of his advisers have been critical of the House Republican Conference, led by Mr. Ryan, for not doing more to bring along conservative members. The meeting at the White House with leaders of conservative groups was an effort to remedy that, Mr. Trump’s aides said.
And in a sign of the White House still grappling with how tightly it wants to embrace the current bill, Vice President Mike Pence will appear instead of Mr. Trump on a trip to Louisville, Ky., this weekend. On Wednesday, Mr. Trump will hold a campaign rally in Nashville, where he is also expected to barnstorm for the repeal of the Affordable Care Act.
“The president will be visiting several cities over the next coming weeks to engage the American people on the need to repeal and replace,” Sean Spicer, the White House press secretary, said on Thursday.
Last week, Mr. Trump’s aides grew frustrated when the House Republican leadership bluntly told them that the president would need to use his political capital to bring people along. The tensions fall squarely in the purview of Reince Priebus, Mr. Trump’s chief of staff, who is close to Mr. Ryan and who some of the president’s advisers fear has divided loyalties. Mr. Trump vented his frustrations with Mr. Priebus last Friday over how much work remained toward preparing for the health bill rollout.
Mr. Trump’s advisers mostly welcomed the discussion of the bill as a reprieve from the controversy over Mr. Trump’s post on Twitter saying, without evidence, that he had information that Mr. Obama had “tapped” Mr. Trump’s phones at Trump Tower during the campaign.
Those advisers are also aware that the rollout of the plan has been bumpy, with only deeply limited spade work done by the House Republican Conference to shore up outside support beforehand. Nudged by frustrations from the West Wing, Mr. Ryan on Thursday conducted a PowerPoint presentation with members of the news media to explain the three phases planned for repealing and replacing the A.C.A.
But White House advisers are well aware that they are saddled with the bill now. At the same time, they describe Mr. Trump as walking lightly — by his standards, at least.
The vice president’s trip to Kentucky will bring Mr. Pence to a state that is being treated as ground zero in the repeal fight. Kentucky’s junior senator, Rand Paul, is the bill’s most prominent Republican critic. Its former governor, Steve Beshear, became a Democratic hero for successfully implementing the health care law in the deep red state, but Republicans took full control of its statehouse in elections last year despite the Democrats’ strong support for the Affordable Care Act.
There is some daylight between the House Republican leaders and the White House on how much change the bill can absorb. Representative Joe L. Barton, Republican of Texas, offered an amendment on Thursday that would have moved the health care bill in a conservative direction, reducing federal funds for the Affordable Care Act’s expansion of Medicaid at the end of 2017, two years earlier than under the legislation drafted by House Republican leaders.
Mr. Barton withdrew the amendment but hinted that it could reappear when the bill hits the House floor. The proposal was supported by two influential conservative groups, the Republican Study Committee and the House Freedom Caucus — and, he said, “the Trump administration is open to it.” Indeed, the White House has begun pushing for a 2017 end to the Medicaid expansion, a senior Trump adviser confirmed — a move that risks pushing away moderates across Congress.
Mr. Trump also wants the Republicans’ health care bill to inject more consumer choice into the process of selecting plans, said someone familiar with the president’s thinking, as well as the elimination of state-by-state insurance options. Such changes are impossible under the budget rules that Republicans are using to avoid a Democratic filibuster in the Senate.
Representative McHenry said Mr. Trump talked in the meeting this week about how he had performed in the districts of lawmakers whose votes will be necessary.
The criticism of the bill from conservative groups grew so hostile so quickly that it surprised even Mr. Trump. So Mr. Trump moved to use the trappings of the presidency to woo them.
Initially, the group was told it would see the president in the Roosevelt Room. But after the group’s members waited there for a short while, an aide entered and said, “The president would like to see you in the Oval Office.”
Even so, it quickly became evident that the objections the activists had with the bill could not be washed away with the awe of the Oval Office. The president told them he did not appreciate the attacks on the proposal as “Obamacare lite” or something that fell short of a repeal. That kind of talk, he warned them, could be detrimental to their shared cause of gutting the Affordable Care Act.

Is ObamaCare unkillable?
By Jeff Sprosser - The Week - March 10, 2017

With each passing day, Republican infighting over replacing ObamaCare steadily worsens. Moderates in the party fear it will screw their constituents. Hardcore conservatives deride the replacement as "ObamaCare lite." And any changes made to placate one side will just further alienate the other.
Watching it all play out, a remarkable possibility is emerging: ObamaCare just might survive.
After promising for six years to nuke the Democrats' health-care reform, could the Republicans actually chicken out? It wouldn't be the first time. Back in 2005, the GOP tried to push a privatization of Social Security long beloved by conservative ideologues. But it fizzled despite the Republicans' control of the House, Senate, and White House because they never could cobble together a majority from within their own ranks. Sound familiar?
There's a political science theory that certain welfare programs are so big, so universal, and help so many people that they effectively become politically untouchable. Neither party can find majorities to cut them. Social Security and Medicare are the two classic examples. But plenty of observers (including yours truly) assumed ObamaCare was too targeted, too complex, and too accommodating of market forces to cross that threshold.
Maybe we were wrong.
According to Politico, President Trump is having similar thoughts. If the GOP can't conjure the political will to repeal and replace ObamaCare, Trump's plan is reportedly to let ObamaCare collapse under its own weight. The Democrats, he assumes, will take the blame, and then the GOP can take another stab at replacement in two years.
But will ObamaCare actually collapse?
The Republicans all seem genuinely convinced. "If we did nothing, the law would collapse and leave everybody without affordable health care," Speaker of the House Paul Ryan said on Tuesday. "If we waited two years, it's going to explode like you've never seen an explosion," Trump said earlier this year. "The Dems would come begging to do something because '17 is going to be catastrophic price increases, your deductibles are through the roof, you can't use them, and they will come to us."
Premiums throughout ObamaCare's insurance exchanges are indeed anticipated to spike 22 percent this year. Several insurance providers pulled out of the exchanges because they couldn't find enough customers to make their business models work.
Is this the start of the dreaded "death spiral"? To function financially, insurers need lots of healthy customers paying premiums. Without them, insurers can't cover their sick customers, whose costs of care vastly exceed their premiums. But ObamaCare's penalties for not buying insurance were never that strong, and its subsidies to encourage people to buy insurance were never that generous. If insurers can't get enough healthy customers, they have to raise premiums. That discourages even more healthy people from signing up, so the sick people grow as a portion of insurers' customer base, and premiums rise again. The spiral goes on until the insurers collapse or abandon the market.
So it's not crazy to assume ObamaCare's death spiral has commenced.
But there's another possibility. ObamaCare's insurance exchanges are still young, and providing health insurance to a new population is a learning process. You have to guess how many people will sign up, how many will be sick, and what their costs will be. Then you set your premiums accordingly, and find out if you guessed right. If not, you adjust your premiums. In a new market, there's also a lot of jockeying for position and market share — so you get insurers trying to undercut each other with unusually low initial premiums.
In that case, ObamaCare's problems aren't the beginning of a death spiral. They're just a one-time course correction. That won't mean the reform is "okay," since the premiums and deductibles will still be painfully high. But they'll also be low enoughfor ObamaCare's exchanges to function sustainably.
As for which description is actually right? Who knows. But we'll find out in a few months if the Republicans actually have the stomach to kill ObamaCare. If they don't, we'll probably know in two or three years if the health reform's exchanges can stand on their own two feet.
The Republicans' only other option would be to deliberately sabotage ObamaCare, but in such a way that the public doesn't blame them for it.
For example, one of Trump's recent executive orders pushed the Internal Revenue Service (IRS) to enforce the penalty for ObamaCare's individual mandate in a more lax fashion. That could also spark a death spiral. Trump's political calculus is presumably that if the GOP actually passes a law altering ObamaCare, the public will blame it for any subsequent bad turn of events. But the party won't be blamed over an executive order that few people notice.
That's possible. But it seems risky to assume the public won't automatically blame the Republicans for a health insurance collapse that occurs on their watch.
More practically, Trump's executive order didn't change the way the IRS was already enforcing the mandate. It prevented the IRS from beginning to enforce it more strictly. From the start, ObamaCare's individual mandate has been lax and its penalties low. If even that state of affairs was enough for ObamaCare to eek out a sustainable equilibrium, then Trump's executive order won't matter. And the GOP won't have any other sabotage option that direct.
So if the GOP can't bring itself to repeal ObamaCare, if they can't sabotage it, and if it doesn't destroy itself, the Democrats' health-care reform really will join the ranks of politically unkillable entitlement programs. The Republicans could still conceivably take ObamaCare out with a constitutional challenge, but they already tried that onceand it didn't work.
From then on, the only politically viable options would be improvements to ObamaCare: A more user-friendly setupmore generous subsidies, a public option, etc. Wouldn't that just be a remarkable turn of events?

Republicans should blow up the entire health-care system
by Pascal Emmanuel Gabry - The Week - March 10, 2017

Pretty much everyone hates the House GOP's new health-care plan. And they're right to. As my colleague Michael Brendan Dougherty explains, the plan is unworkable: It doesn't get at the deepest problem with American health care, namely that it is an absurd ballet between third-party cartels.
Republicans have been talking for decades about health reform that would put choice back in patients' hands, and thereby unleash the forces of competition that would deliver innovation and relentless cost decreases, as they have in every other non-government-run high-tech sector, like automobiles, computers, and phones.
Pop quiz: What's the only high-tech sector that sees rampant price increases with mediocre increases in quality, besides health care? Fighter jets. And what does that industry have in common with health care? That's right, the government.
The way American health care works is insane. Imagine if car insurance worked like health insurance, and didn't just cover low-probability, high-cost events (you know, the textbook definition of "insurance") but also recurring, low-cost events like getting gas and changing your oil, and you had to go through your insurance to fill up your tank. I guarantee that you would have miles-long lines for gas, you could only fill up at stations that are part of your insurance company's network because of some byzantine business deal, a tank of gas would be billed at $2,000, and half the time instead of gas you would get sesame oil in your tank.
That system would be absolutely insane. No one in their right mind would live with it — that is, unless the government made it the law that that's how car insurance worked.
Now imagine that the system had worked this way for so many decades that nobody could even conceptualize a world without it. Imagine a parallel universe where this has been the way forever, and you find yourself trying to explain normal car insurance to people in that parallel universe. Car insurance that only covers wrecks? But I could never afford $2,000 a week for a tank of gas!
After a while, the denizens of this absurd land would almost certainly trot out sophisticated "car economists" (because that would totally be an academic specialty) who would pull out charts to explain why your idea is nice and fine in theory but cars are such a special sector of the economy that they could never work the way you want. At this point, you might break down and cry.
Welcome to how conservatives see the health-care debate in the U.S.
This is why ObamaCare was so frustrating. Progressives looked at America's insane system, and instead of doing anything to truly change it, said, hey, let's just spend some government money buying insurance for more people. This is why RyanCare is equally frustrating, because it also does nothing to truly fix the system. It just spends less money doing it, which, without altering the underlying system, really is cruel because, within the system, those who don't have insurance really are up a creek without a paddle.
As Dougherty points out, the reason why the insane system is so resilient is, in part, because people just can't imagine the common-sense alternatives anymore, but also because the upper-middle class, America's most powerful constituency, benefits from the status quo. Because they have the best insurance in the country, they object to any truly meaningful change in the system; even though they also would benefit in the long run, status quo bias means they won't give an inch.
But in that dreadful status quo, there lies an opportunity. As Dougherty points out, the GOP's health reform is doomed to be radioactive no matter what. So if you're going to push something radioactive, you might as well make it good.
If there was one virtue you might have expected out of the election of Donald Trump as president, it is that for better or worse, he has expanded the field of what was previously thought politically possible. Trump is non-ideological. He doesn't care what health care looks like, he just cares that it be "winning."
So if Republicans are going to go for broke anyway, if they're going to piss off everyone (mission accomplished!), they should at least piss them off with a truly conservative and radical health-care solution.
Republicans should make a law mandating that every American enrolled in an employer-sponsored health-care plan receive the premiums their employer pays into a personal health savings account. Those Americans would be automatically auto-enrolled back into their employer-sponsored plan; for those who don't want anything to change, nothing would change; but for those who want to shop for a better option, they'd be able to. This would be the most radical thing you could do for health care. Everyone else also gets a health savings account, and those who are poor get it filled up by the government with a sliding scale.
And what about catastrophic expenses? Well, this is the radicality and potential political viability of the plan. If you have to spend more than 20 percent of your yearly income on health care, the government picks up the bill. That's right: Medicare-for-all! As a conservative I don't like it, but even I have to admit that it can't be that much worse than the status quo, especially if I get all the other things I like.
Something like this has been proposed by a number of pragmatic progressives, like the economist Brad De Long and the business executive David Goldhill, but also conservative heroes like Milton Friedman. Do non-catastrophic health care through health savings accounts to introduce consumer dynamics in the health-care system and get rid of the worst aspects of the status quo. And for catastrophic expenses, have the government cover everyone. Politically, instead of some awful centrist compromise, it would combine the best idea of the radical right (total decentralization) and the best idea of the radical left (government as final backstop). That's the best kind of bipartisanship, i.e. the kind that never happens in Washington.
Is it crazy? Probably. Is it political suicide? Probably. But the GOP's current approach is definitely crazy and definitely politically suicidal.

Fact check: how many lottery winners could lose access to Medicaid?

by Mona Chalbi - The Guardian - March 9, 2017

The Republican healthcare plan wants to crack down on ‘high dollar lottery winners’ – how many of those are there?

Powerball probabilities.
Powerball probabilities. Photograph: Mona Chalabi

Hi there, how are you doing? If you live in the US and you’re concerned about your health insurance, I assume you’ve spent the past few days reading the news nervously.
When the Republican healthcare plan was unveiled this week, those who looked at it were less than impressed. Asked if the much-anticipated bill was on the right track, Republican senator Pat Roberts said “it’s on some track”, while Democratic senator Chris Murphy was a little more direct, saying: “This is a dumpster fire of a bill that was written on the back of a napkin.” 
One of the main goals of the Affordable Care Act, also known as Obamacare, was to improve healthcare for America’s poorest citizens. And it’s those Americans who are most likely to lose out under a new policy. Of virtually no importance whatsoever is the effect of this policy on America’s millionaires.
So, why focus this week’s fact check on the wealthy? Well, for two reasons. 
One, the provision in the draft law that relates to “high dollar lottery winners” seems like a strange way to spill ink (almost six of the draft law’s 66 pages are spent on these Americans). Two, it’s a great way to get to grips with probabilities, a statistical concept you can apply to everything from “Will my health condition still be covered?” to “What are my chances of getting hit by a car?”
Let’s start fact-checking this together – how many lottery winners could lose their access to Medicaid?
Step 1: Find out how many people in the US are covered right now. Do an internet search for this question but use the term Affordable Care Act rather than Obamacare so that you can focus on academic and governmental studies. You can add “filetype:pdf” to your search in Google if you want to try to limit the results to published reports. I also filter so I can only see results published in the past year – I need recent numbers.
I end up clicking on this report by the Centers for Disease Control and Prevention, this country’s public health institute. In terms of national health statistics, it doesn’t get more accurate. Their latest numbers, from 2015, estimate that 18.9% of people aged 18 to 64 have public health insurance (I’m looking at Table 1.2a of this link).
Step 2: Check that number. Below 18.9, the report says “(18.23-19.65)”, which means they’re not really sure it’s exactly 18.9% of Americans in that age group – it could be as low as 18.23% or as high as 19.65%. I’m OK with that margin of error. More importantly, the footnote says that the CDC defines public health insurance as including “Medicare (disability), Medicaid, Children’s Health Insurance Program (CHIP), state-sponsored or other government sponsored health plan, and military plans”. So keep in mind that we’re throwing lots of different types of healthcare into this basket, not all of which would be affected by the new policy. 
Step 3Find out how many people are lottery winners. I search for things such as “lottery winners US statistics” and end up at sites such as this one. They are rubbish. No sources for your numbers? You’re dead to me. 

I try to find out how many Americans play the lottery. About 49% of people played the lottery in the past year, according to this study published in 2011 in the Journal of Gambling Studies. The study also found that the share who have played the lottery rises to 61% for the poorest Americans and falls to 42% for the richest.1
OK, that’s a lot of people. Let’s find out what their chances are of winning. Well, there again I hit a bit of a dead end. Strangely enough, most lotteries don’t tell players their chances of winning. But I can tell you about the odds of one type of win – the Powerball jackpot. Because, using some pretty simple math, I can calculate those odds for myself. They’re low. Really low.
The odds of winning the Powerball jackpot are about 1 in 292,201,338. Only 192 people in the US have ever won that jackpot since 2003, according to Powerball’s site. Those 192 people, as a share of the 249 million adults who live in the US, is 0.0008%.
Are you still with me here? You’re a trooper.
Step 4: Find out how many people are lottery winners and have benefited from ACA. Let me use an analogy here. Let’s say you wanted to find the chances of a coin toss landing on heads and a second coin toss on heads too. You simply multiply the chance of throwing a head (which is one in two or 0.5) with the chance of throwing another head (again, 0.5) to get one in four, or 0.25. 
Let’s do the same thing here. The chances of an American having public health insurance are, very roughly speaking, 18.9 in 100, or 0.189. The chances of winning the Powerball jackpot are (again, very roughly speaking), 8 in 1,000,0000 or 0.000008. To find out the chances of having public health insurance and being a jackpot winner is roughly 0.189 multiplied by 0.000008. That gives you odds of 0.000001512.
Which means that about 377 American adults meet both criteria.2
But the analogy with a coin toss isn’t quite right. See, the chances of getting heads on your second coin toss aren’t in any way affected by whether you got heads on your first toss (statisticians call these “independent” events). The chances of winning the lottery and having public health insurance aren’t quite like that. 
On the one hand, we know that the ACA was supposed to reach the poorest Americans and we know those are also the people most likely to play the lottery. So maybe the odds of falling into both groups are higher than it first seems. On the other hand, people who win huge sums of money might want to spend some of it on private healthcare. That would mean that the odds of being a lottery winner andreceiving insurance through ACA are even lower than these numbers suggest.
Whatever the case, though, we know that there aren’t that many people at all that fall into both groups. So, spending six pages of a draft bill that could affect the nation’s health by focusing on a couple hundred Americans? Well, that seems strange to say the least. 
1 I’m trying footnotes! While we’re on the subject of the poor, it might be worth mentioning this Google result I bumped into – a study by three economists that used 10 years of data from 39 states and found a “strong and positive” correlation between lottery ticket sales and poverty rates.
2 Weeell, maybe. The probabilities I’m using here are about slightly different groups. There’s the population that the CDC uses (everyone age 18 to 64) and there are those who play the lottery (in most states you have to be 18 or over but there’s no upper age limit). And don’t forget, I’m only talking about the Powerball here. The chances of winning are much higher if you include state lotteries too.

How Healthy Are You? G.O.P. Bill Would Help Employers Find Out

by Reed Abelson - NYT - March 11, 2017

A bill in Congress could make it harder for workers to keep employers from getting access to their personal medical and genetic information and raise the financial penalties for those who opt out of workplace wellness programs.
House Republicans are proposing legislation aimed at making it easier for companies to gather genetic data from workers and their families, including their children, when they collect it as part of a voluntary wellness program.
The bill, the Preserving Employee Wellness Programs Act, introduced by Representative Virginia Foxx, a Republican from North Carolina and the chairwoman of the House Committee on Education and the Workforce, would also significantly increase the financial costs faced by someone who does not join a company wellness program.
The bill, which is under review by other House committees and has yet to be considered by the Senate, has already provoked fierce opposition from a wide range of consumer, health and privacy advocacy groups, as well as by House Democrats. Critics claim it undermines existing laws aimed at protecting an individual’s personal medical information from use by employer and others.
“We strongly oppose any legislation that would allow employers to inquire about employees’ private genetic information or medical information unrelated to their ability to do their jobs, and to impose draconian penalties on employees who choose to keep that information private,” a group of advocates, including AARP, the American Diabetes Association, the American Academy of Pediatrics, the EpilepsyFoundation, the March of Dimes and others wrote in a letter this week to Ms. Foxx.
As wellness programs proliferate across the corporate landscape, workers are increasingly being asked by their companies to undergo health screenings and medical assessments. Employees can opt out of these programs, and personal information specific to a worker is not supposed to be shared directly with the company. The prohibition is aimed at preventing someone from being fired or otherwise discriminated against because of a serious medical condition.
The federal Equal Employment Opportunity Commission has vigorously pursued legal action against some employers it claimed went too far and used these programs inappropriately, but the courts have largely been sympathetic to the employers’ arguments. Companies also complained that the regulations were confusing, and the commission issued final rules in May aimed at addressing some of their concerns.
Companies defend the wellness programs, saying they keep workers healthier and help reduce insurance costs. But some studies have questioned the effectiveness of these initiatives.
Critics argue that workers are essentially being coerced into giving up private medical information, such as their weight, their blood pressure and whether they are at particular risk for cancer. Under the Affordable Care Act, employers can entice a worker by offering as much as a 30 percent reduction in insurance payments. Although the financial incentives offered have typically been lower, an employee who refused to participate could lose as much as thousands of dollars in savings.
The bill would also weaken the role of the E.E.O.C. in overseeing wellness programs and its ability to prevent violations of antidiscrimination laws established under the Genetic Information Nondiscrimination Act and the Americans With Disabilities Act. Employers would be generally governed by rules established by different agencies. The bill “is trying to streamline the regulatory scheme,” said Kathryn Wilber, a senior official at the American Benefits Council, which represents employers’ interests.
She said that companies remain committed to protecting the privacy of this information and that employers take this responsibility “very, very seriously.”
Bethany Aronhalt, a spokeswoman for the House committee, said the goal was to address employers’ concerns rather than to drastically change the laws protecting workers. “We want to ensure working families can continue to benefit from these voluntary programs, and so did the Obama administration,” Ms. Aronhalt said. “This legislation will reaffirm existing law and provide regulatory clarity so that employers can have the certainty they need to help lower health care costs for their employees.”
Opponents contend that the bill would leave workers much more vulnerable because the rules under the antidiscrimination laws would not apply if someone volunteered personal health information under a wellness program. “It just takes away the workplace protection,” said Jennifer Mathis, the director of policy and legal advocacy of the Bazelon Center for Mental Health Law.
The E.E.O.C. does not comment on pending legislation, a spokeswoman said.
The bill would significantly increase the amount of money at stake by allowing an employer to offer higher incentives, up to 30 percent of the cost to cover the whole family, as opposed to 30 percent of an individual’s coverage cost.

Republican Health Plan Could End Insurance Coverage of Abortion

by Kate Zernike - March 10, 2017

The Republican proposal to replace the Affordable Care Act would bar people from using federal tax credits to buy health insurance plans that cover abortion.
If the measure is passed, abortion rights advocates fear it could compel insurers to stop offering abortion coverage at all.
“There’s no reason insurers would sell any plans that cover abortion because everyone would be wanting to use these tax credits,” said Adam Sonfield, a senior policy manager for the Guttmacher Institute, a research center that works to promote access to abortion.
For now, the proposal would create a big problem for two of the largest and most liberal states: California, where state law requires insurers to cover abortion, and New York, which has long encouraged coverage by including it in its model plan of what insurers have to cover. Massachusetts, too, has long indicated that insurers should cover abortion as “medically necessary.”
The law, if passed, would all but make it impossible for Californians to use the new tax credits to buy health insurance.
“States would be faced with this choice: Do we get rid of our abortion coverage requirement, or deny state residents all the tax credits?” said Gretchen Borchelt, the vice president for reproductive rights and health at the National Women’s Law Center. “It’s putting states in a really terrible position.”
She and other advocates for abortion rights said they expected legal challenges from California and other states if the law passed. They argued it goes against Republican promises of increased options in health insurance, and their embrace of states’ rights.
The proposal continues a move away from abortion coverage in recent years. Until the Affordable Care Act was passed in 2010, insurers in most states offered plans covering abortion. The A.C.A. allowed states to bar insurers from offering plans through the A.C.A. marketplaces that cover abortion and 25 states did so (except for coverage of abortions in cases of rape or incest, or where the woman’s life is in danger). Ten of those extended that ban to prevent insurers from providing abortion coverage in any private insurance plan in the state.
Since 1977, the federal Hyde Amendment has prohibited federal money from going to abortions. Under the Affordable Care Act, state officials had to separate out the federal subsidies used to buy health insurance into separate funds so that no federal money would go toward abortions.
Representative Kevin McCarthy of California, the leader of the Republican majority in the House, has asked Tom Price, the new secretary of Health and Human Services, to examine whether California’s law violates laws protecting the religious freedom of health care providers who object to abortion.
Ms. Borchelt said other language in the proposal also moved to stop insurance companies from covering abortion. Under that language, health insurance plans could not be considered “qualified,” and therefore eligible to be sold on the individual market, if they covered abortion. Because insurance companies tend to set a lot of the same benefits in plans across their various markets, she said, “the language is disincentive and meant to discourage plans from covering abortions.”
Republicans have argued that women can buy an additional rider on their insurance to cover abortion.
But, Ms. Borchelt said: “No such plans exist. All those provisions work as a de facto ban on insurance coverage in every state with no real option to get it elsewhere.”
Most abortions are performed in the first trimester of pregnancy. The Kaiser Family Foundation estimates that an abortion at 10 weeks costs between $400 and $550.
The proposed replacement for the Affordable Care Act would mostly affect insurers offering plans in the individual market. But it would also affect employer-sponsored insurance plans in two ways. It would prevent tax credits used by small businesses to buy health insurance, as well as those used by people who have left their jobs to extend employer-sponsored insurance coverage, from being used to buy plans that cover abortion.
Employers might decide not to offer abortion coverage, knowing that their employees, if they left, could not use their tax credits to continue that policy.
Given the various restrictions across the country, Elizabeth Nash, a state policy analyst at Guttmacher, asked whether insurers might simply reach a point where it is standard not to cover abortion. “Have we reached the tipping point where it’s so complicated and cumbersome to provide it that insurers will simply stop?” she asked. “You can imagine insurers saying it isn’t worth the hassle.”

The Moral Failing of Obamacare Repeal

by Theresa Brown - NYT - March 11, 2017

PITTSBURGH — Imagine a car crash. There’s twisted metal, broken glass and the low moaning of an injured human being. An ambulance arrives, and two emergency medical technicians get out.
Now imagine this: One E.M.T. moves to the wreck, sees the wounded driver — a man, the one who’s moaning — and before doing anything else, flips down the driver’s seat visor, looking for an insurance card that isn’t there. Then he stands back up, frowns and shakes his head.
“No insurance?” his partner calls out. The E.M.T. shakes his head again.
“We could try,” the partner offers. “We could —”
“I tried last time,” the E.M.T. interrupts, cutting through air with a blunt slice of his hand. “It didn’t help,” he whispers, almost to himself.
Could this be America, some day? Maybe nothing this extreme would ever happen. But contrary to what some congressional Republicans say, a world in which it could is the logical conclusion of their efforts to repeal the Affordable Care Act and set per capita caps on Medicaid — and the all-but-explicit desire among dozens of hard-liners.
The House leadership is making gestures toward covering the uninsured by retaining popular portions of the A.C.A. and offering a suite of “market-based” programs like health savings accounts and tax credits. In some ways, that’s their problem; if the Republican bill designed to replace the A.C.A. fails, it could well be because of pressure from the far right, which is insisting on repeal, full stop. For a large number of Congressional Republicans, any effort to cover the costs of care for the poor and uninsured smacks of socialism and unwelcome government interference in the market.
It’s easy, politically, to make that case against the A.C.A., since the Republicans have spent the better part of a decade demonizing it. And it’s easy to forget how bad things were for tens of millions of Americans before Obamacare.
To begin with, consider the numbers. A percentage of the 20 million Americans who gained insurance under the A.C.A. will very likely lose it if the law is repealed. Even with the provisions in the proposed American Health Care Act, the “replace” part of the Republican approach, an estimated 10 million people would fall off the rolls.
Some of them will be glad to be free of the law’s yoke; many others, probably a vast majority, will be terrified by the idea of living without health insurance. As was the case before the passage of the A.C.A., many of the uninsured — the terrified and relieved alike — will end up using hospital emergency departments for their health care needs, even if they cannot afford it.
After all, the opposite of the A.C.A. is not a free market. The Emergency Medical Treatment and Labor Act, a 1985 law, requires that hospital emergency departments treat all comers. So, while some uninsured patients will forgo care after repeal of the A.C.A., others, especially the seriously injured and mortally ill, will secure the care they need even if they can’t pay for it, even if they know they will never be able to pay for it. And in the end, all of us pay for that care through higher insurance premiums, increased hospital costs and overtreatment of the (paying) insured.
This is important, because Republicans are championing a free-market health care system unencumbered by strong government interference. As we know from decades of debate leading up to the A.C.A., the only way to rein in health care costs in a system without some form of universal public health insurance is to place limits on care for those without insurance or the ability to pay for it outright.
I remember a recent case, here in Pittsburgh. A woman, young and fit, moved to the city to be with her boyfriend. She didn’t have health insurance because she was new in town and hadn’t yet found a job. But she wasn’t worried; her youth, she thought, guaranteed her health.
But it turned out she had A.M.L. — acute myelogenous leukemia — a killer disease, the medical version of a high-speed collision. The first round of curative treatment required a six-week hospital stay, multiple infusions of chemotherapy and intensive round-the-clock nursing. And that was just the start.
I was this patient’s nurse at the end of her six-week stay, after we’d successfully put a brake on her disease. She was eager to return home, and her pale face radiated a diffuse hope. Her main preoccupation was not whether her cancer would return, but how to sufficiently thank the hospital staff who had saved her life. A registered nurse care coordinator had signed the patient up for Medicaid immediately after she received the diagnosis, so she didn’t pay for her care. In fact, she couldn’t have. Treating A.M.L. can cost upward of $100,000. Neither she nor her boyfriend had that kind of money.
If the A.C.A. is scrapped and Medicaid is converted to per capita caps, partly to ensure that everyone who gets care pays her fair share, I worry about what will happen to patients like this young woman. Abandoning this patient to her terrible disease simply because she couldn’t pay for the cure feels sad and wrong. Just as sad and wrong as abandoning an injured patient at a crash site.
House Speaker Paul Ryan and others would take mock offense at the idea that they’re willing to let people go without care, but it’s the unavoidable logic of their drive to undo Obamacare — the part that Republicans would rather not talk about, even as it drives them to ram through the legislation without debate.
People without insurance and little money are still going to need care, some of it very expensive. To deny these people care by restricting their access at the source — ambulances, emergency departments, hospitals — would reflect equity in a you-get-what-you-pay-for model. But the human cost of limiting health care to those who can pay would be higher than any of us should be willing to bear.

Why Appalachia (and the Whole Nation) Needs a Single Payer Healthcare System

by Katie Lee - Common Dreams - March 10, 2017

During a rural medical outreach visit in East Tennessee, I met a woman who had become concerned after she found a lump in her breast. She was 44 years old, only a year younger than her mother was when she died of breast cancer at 45. The patient had not seen a physician in many years because she could not afford the copay and she had to drive 45 minutes to reach her appointment that day. She was working as a waitress and had no health insurance, which further delayed her seeking care. She had a history COPD and methamphetamine abuse, but had been clean for five years. During my exam, I felt a mass in her left breast. My alarm bells were sounding.
Unfortunately, stories like this patient abound in Appalachia and reveal the need for rethinking our healthcare system.
The recent presidential election is likely to bring change in the healthcare system of this nation, but we have a choice to make. During these tumultuous times in policy, the way forward is not to strip 20 million Americans of their healthcare by repealing the Affordable Care Act (ACA) without a replacement. The Republican alternative presented this week is also woefully inadequate in terms of coverage. Instead, we should pursue the most equitable and just option – a single payer healthcare system. No, this is not “socialized medicine,” which would mean both the financing and delivery of care are government funded. We already have a form of this system for our veterans, and it leaves much to be desired. What I, and 20,000 other medical students and physicians, propose is a Medicare for All system.
The ACA has taken necessary steps toward a universal system, but it has fallen short. Approximately 27 million people remained uninsured after the landmark legislation was passed and an acceptable reduction in cost was not truly achieved. Supporters of the ACA aimed to bend the curve on ever-increasing healthcare expenditures and while this was accomplished, they still accounted for 18% of GDP last year.
The United States remains the only developed country with a system based on for-profit insurance companies. We are spending the largest amount per capita ($8,000+) on healthcare expenditures of any nation in the world, but without the best outcomes. The leading cause of bankruptcy in the United States is medical bills, and an estimated 45,000 deaths annually can be attributed to lack of health insurance. Over 100 million Americans forgo professionally recommended medical care due to cost each year. Clearly, we have work to do. A single payer system by way of a Medicare for All structure would allow coverage for all Americans and would actually reduce spending.
Not all states chose to expand Medicaid, including approximately half of those traditionally included in Appalachia, leaving lower income earning adults like my patient with the breast mass in a gap between Medicaid and Marketplace subsidies. Americans were left with artificial lines between states that create headaches for Tri-Cities area patients on a daily basis, when the nearest hospital to rural dwellers may be across state lines. Social workers in our local hospitals work tirelessly to coordinate care for patients leaving Tennessee hospitals, but needing follow-up in West Virginia, Virginia, or Kentucky where their health insurance coverage and state law differs. Paying employees to navigate these complexities is currently unavoidable, but it is my hope that a more streamlined, simple system could render these duties unnecessary.
Today we spend about a third of our healthcare dollars to overhead, administrative costs, and insurance profits. Physicians cite administrative burden as one of the leading causes of burn out, leading to decreased quality of care. With a single payer system for all Americans, we reduce this waste and instead direct these funds toward medical care. There is an additional benefit of freeing up physicians to spend longer appointments with patients as needed or increase patient volume.
Moreover, Americans living in rural areas face a physical access to care issue in addition to cost barriers. This makes seeking appropriate preventive care visits and screening tests even more important. It is a well-known fact that it is cheaper to prevent a chronic illness than to treat it long-term. Consequently, removing the cost barrier to preventive services in Appalachia while we work to improve the number of physicians and hospitals in rural areas is morally imperative but also cost effective.
Uninsured Americans cited lack of affordability and unemployment as their top two reasons for their insurance status. While the national unemployment rate in 2014 was around 6%, in the more economically depressed parts of Appalachia that figure reached as high as 14%. Increased levels of unemployment in the region together with state policies declining Medicaid expansion contribute to higher uninsured rates, and consequently poorer health outcomes. Our mixed system including employer-based health coverage is a relic of a time when most employees remained in the same job for decades and is inappropriate for the more dynamic, shifting workforce of today. Transition away from employer-based care would prevent workers from fearing a job change lest they lose their insurance, freeing workers to pursue innovative, entrepreneurial positions they might otherwise have foregone.
President Trump has praised the concept of universal healthcare multiple times in the past, citing the improved mortality rates and reduced costs per capita in countries with this structure. More than a decade ago, Trump preached the sensibility of covering all Americans in his book, The America We Deserve. “We must have universal healthcare,” Trump wrote. “I’m a conservative on most issues but liberal on this one.” In order to capitalize on his promise to take care of “the forgotten” in the United States, including those living in the impoverished communities of coal country, I urge the president to reconsider a Medicare for All system. Not only will it help make this country “great,” it is the right thing to do.

Surgery or Drugs? Doctors’ Pay May Influence Choice

by Nicholas Bacalar - March 8, 2017

Sometimes doctors choose to do surgery not because it is absolutely preferable to other treatments but because they get reimbursed for it, a new study suggests.
Researchers looked at patients with a narrowed artery in the neck, a condition called carotid artery stenosis that can be treated with surgery or managed with medicine and lifestyle changes. The choice is often a judgment call.
Some were treated in a fee-for-service system, which pays doctors for every procedure they do. Others were treated by doctors on salary at a military hospital. After adjusting for health, behavioral and socioeconomic variables, they found that over all, patients in the fee-for-service system were 63 percent more likely to have surgery than those in the salary system. Patients with symptoms were especially likely to receive surgery, though those without symptoms also contributed to the difference. The study is in JAMA Surgery.
“Fee-for-service doctors are incentivized to do more because they are paid by the procedure,” said the lead author, Dr. Louis L. Nguyen, an associate professor of surgery at Harvard. “And salaried physicians are incentivized to do less. That’s human behavior. What we need is a system that incentivizes doctors to be aggressive in treating patients in a timely fashion, but not to create procedures for reimbursement.”

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