Friday, March 24, 2017

Health Care Reform Articles - March 24, 2017

The Trump Elite. Like the Old Elite, but Worse!

by David Brooks - NYT - March 24, 2017

Legislation can be crafted bottom up or top down. In bottom up you ask, What problems do voters have and how can they be addressed. In top down, you ask, What problems do elite politicians have and how can they be addressed?
The House Republican health care bill is a pure top-down document. It was not molded to the actual health care needs of regular voters. It does not have support from actual American voters or much interest in those voters. It was written by elites to serve the needs of elites. Donald Trump vowed to drain the swamp, but this bill is pure swamp.
First, the new Republican establishment leaders needed something they could call Obamacare repeal — anything that they could call Obamacare repeal.
It became clear as the legislative process rushed forward that there was no overarching vision in this legislation on how to reform health care or even an organizing thought about how to improve the lives of voters. There was no core health care priority that Republicans identified and were trying to solve.
There were just some politicians who wanted a press release called Repeal.
Second, Donald Trump needed a win. The national effects of that win seemed immaterial to him.
His lobbying efforts for the legislation were substance-free. It was all about Donald Trump — providing Trump with a pelt, polishing a credential for Trump. His lobbying revealed the vapidity of his narcissism. He didn’t mind caving to the Freedom Caucus Wednesday night on policy because he doesn’t care about policy, just the publicity win.
Third, the bill was crafted by people who were insular and nearsighted, who could see only a Washington logic and couldn’t see any national or real-life logic.
They could have drafted a bill that addressed the perverse fee-for-service incentives that drive up health costs, or a bill that began to phase out our silly employment-based system, or one that increased health security for the working and middle class.
But any large vision was beyond the drafters of this legislation. They were more concerned with bending, distorting and folding the bill to meet the Byrd rule, an arbitrary congressional peculiarity of no real purpose to the outside world. They were more concerned with what this internal faction, or that internal faction, might want. The result was a pedantic hodgepodge that made no one happy.
In 24 hours of ugly machinations, the Trump administration was willing to rip out big elements of the bill and insert big new ones, without regard to substance or ramification.
House members were rushed to commit to legislation even while major pieces of it were still in flux, when nobody had time to read it, when the Congressional Budget Office had no time to score it, when the effect on health outcomes of actual Americans was an absolute mystery.
As the negotiating process has gone on you’ve seen rank-and-file House Republicans caught between the inside game and the outside game. The logic of the inside game says vote for the bill. Support Speaker Ryan. Don’t defeat a Republican president. But the outside game screams: Oppose This Bill. It’s bad for most voters, especially Republican voters. And nobody likes it.
I opposed Obamacare. I like health savings accounts, tax credits and competitive health care markets to drive down costs. But these free-market reforms have to be funded in a way to serve the least among us, not the most. This House Republican plan would increase suffering, morbidity and death among the middle class and poor in order to provide tax cuts to the rich.
It would cut Medicaid benefits by $880 billion between now and 2026. It would boost the after-tax income for those making more than $1 million a year by 14 percent, according to the Tax Policy Center. This bill takes the most vicious progressive stereotypes about conservatives and validates them.
It’s no wonder that according to the latest Quinnipiac poll this bill has just a 17 percent approval rating. It’s no wonder that this bill is already massively more unpopular that Hillarycare and Obamacare, two bills that ended up gutting congressional majorities.
If we’re going to have the rough edges of a populist revolt, you’d think that at least somebody would be interested in listening to the people. But with this bill the Republican leadership sets an all-time new land speed record for forgetting where you came from.
The core Republican problem is this: The Republicans can’t run policy-making from the White House because they have a marketing guy in charge of the factory. But they can’t run policy from Capitol Hill because it’s visionless and internally divided. So the Republicans have the politics driving the substance, not the other way around. The new elite is worse than the old elite — and certainly more vapid.

The Scammers, the Scammed and America’s Fate

by Paul Krugman - NYT - March 24, 2017

Many people are horrified, and rightly so, by what passes for leadership in today’s Washington. And it’s important to keep the horror of our political situation up front, to keep highlighting the lies, the cruelty, the bad judgment. We must never normalize the state we’re in.
At the same time, however, we should be asking ourselves how the people running our government came to wield such power. How, in particular, did a man whose fraudulence, lack of concern for those he claims to care about and lack of policy coherence should have been obvious to everyone nonetheless manage to win over so many gullible souls?
No, this isn’t a column about whatshisname, the guy on Twitter, who’s getting plenty of attention. It’s about Paul Ryan, the speaker of the House.
I’m writing this column without knowing the legislative fate of the American Health Care Act, Mr. Ryan’s proposed Obamacare replacement. Whatever happens in the House and the Senate, however, there’s no question that the A.H.C.A. is one of the worst bills ever presented to Congress.
It would deprive tens of millions of health insurance — the decline in the number of insured Americans would be larger than what would result from simple repeal of Obamacare! — while sharply raising expenses for many of those who remain. It would be especially punitive for lower-income, older, rural voters.
In return, we would get a small reduction in the budget deficit. Oh, and a tax cut, perhaps as much as $1 trillion, for the wealthy.
This is terrible stuff. It’s made worse by the lies Mr. Ryan has been telling about his plan.
He claims that it would lower premiums; it would actually increase them. He claims that it would end the Obamacare death spiral; there isn’t a death spiral, and his plan would be more, not less, vulnerable to a vicious circle of rising premiums and falling enrollment. He claims that it would lead to “patient-centered care”; whatever that is supposed to mean, it would actually do nothing to increase choice.
Some people seem startled both by the awfulness of Mr. Ryan’s plan and by the raw dishonesty of his sales pitch. But why? Everything we’ve seen from Mr. Ryan amid the health care debacle — everything, that is, except the press coverage — has been completely consistent with his previous career. That is, he’s still the same guy I wrote about back in 2010, in a column titled “The Flimflam Man.”
I wrote that column in response to what turned out to be the first of a series of high-profile Ryan budget proposals. While differing in detail, all of these proposals share a family resemblance: Like his health plan, each involved savage cuts in benefits for the poor and working class, with the money released by these cuts used to offset large tax cuts for the rich. All were, however, sold on false pretenses as plans for deficit reduction.
Worse, the alleged deficit reduction came entirely from “magic asterisks”: claims about huge savings to be achieved by cutting unspecified government spending, huge revenue increases to be achieved by closing unspecified tax loopholes. It was a con job all the way.
So how did Mr. Ryan reach a position where his actions may reshape the lives of so many of his fellow citizens, in most cases very much for the worse? The answer lies in the impenetrable gullibility of his base. No, not his constituents: the news media, who made him what he is.
You see, until very recently both news coverage and political punditry were dominated by the convention of “balance.” This meant, in particular, that when it came to policy debates one was always supposed to present both sides as having equally well-founded arguments. And this in turn meant that it was necessary to point to serious, honest, knowledgeable proponents of conservative positions.
Enter Mr. Ryan, who isn’t actually a serious, honest policy expert, but plays one on TV. He rolls up his sleeves! He uses PowerPoint! He must be the real deal! So that became the media’s narrative. And media adulation, more than anything else, propelled him to his current position.
Now, however, the flimflam has hit a wall. Mr. Ryan used to be able to game the Congressional Budget Office, getting it to produce reports that looked to the unwary like proper scores of his plans, but weren’t. This time, however, he couldn’t pull it off: The C.B.O. told the devastating truth about his plan, and his evasions and lies were too obvious to ignore.
There’s an important lesson here, and it’s not just about health care or Mr. Ryan; it’s about the destructive effects of false symmetry in reporting at a time of vast asymmetry in reality.
This false symmetry — downplaying the awfulness of some candidates, vastly exaggerating the flaws of their opponents — isn’t the only reason America is in the mess it’s in. But it’s an important part of the story. And now we’re all about to pay the price.

Your guide to the most contentious parts of the GOP health-care plan
by Robert Gebelhoff - Washington Post - March 24, 2017

The American Health Care Act falls far short of repealing and replacing the Affordable Care Act, but there are some big potential changes. (Daron Taylor/The Washington Post)
Is the Republican health-care plan a return to freedom or a watered-down version of Obamacare? Will Republicans placate their base with a major legislative achievement, or will this be the party’s undoing for a generation of voters?
We’ve published the most incisive arguments from health experts and our columnists in the two weeks since Republicans unveiled this bill. As the debate reaches a climax, we’re giving you a guide to that commentary — pro and con, divided by subject matter:
  1. Eliminating health insurance mandates
  2. Age-adjusted tax credits
  3. Medicaid
  4. Tax cuts
  5. The essential benefits package
  6. What’s the GOP’s end-game?

Eliminating health insurance mandates:
Conservatives have long argued that the Affordable Care Act’s requirement to buy health insurance is an affront to freedom — both for individuals and employers. They plan to replace these mandates with a penalty — paid to insurance companies, not the government — for people who buy insurance after a lapse in coverage of more than 63 days.
Here’s Douglas Holtz-Eakin, president of the American Action Forum and former director of the Congressional Budget Office: “The [GOP bill] places trust in the decisions of individuals and families by making greater use of health savings accounts (which hone the market incentives for higher-value care) and respecting their ability to follow incentives to be continuously insured.”
Critics are not convinced. The mandates exist to encourage healthy and younger people to buy into the insurance system. Without them, people would only buy insurance as soon as they are sick, and no one would pay the premiums that keep insurance profitable — causing an insurance market “death spiral.”
Here’s Timothy Jost of Washington and Lee University School of Law: “Paradoxically, this [insurance] penalty may discourage a healthy uninsured person from applying after a coverage lapse, but not someone in ill health who really needs insurance — and who will cost the system more.”
Age-adjusted tax credits:
To attract young people into insurance markets, the Republicans scrap subsidies and tax credits targeted toward low- and middle-income people. Instead, they want age-based systems that give older people larger tax credits than younger people. But the bill also lets insurance companies charge older people at a higher rate (five times more than younger enrollees, up from three times more under the ACA).
The CBO projects that this change would attract a sufficient number of younger, healthy people into individual health-care markets to lower premiums in the long run. But it does so by “substantially raising premiums for older people.”
Conservatives, like Charles Krauthammer, say this is fair:
Premiums better reflecting risk constitute a major restoration of rationality. Under Obamacare, the young were unwilling to be swindled and refused to sign up. Without their support, the whole system is thus headed into a death spiral of looming insolvency. Rationality, however, has a price. … GOP hard-liners must accept that Americans have become accustomed to some new health-care benefits.
Opponents worry this puts low-income elderly people at risk. There are also concerns whether the tax credits that are available would be enough to offset costs in places where care is expensive — particularly rural areas.
Andy Slavitt, former acting administrator of the Centers for Medicare and Medicaid Services, argued that this structure would inherently destabilize markets:
The ACA pegs tax credits to income levels and, when premiums rise, those tax credits rise along with them, protecting consumers against regional differences and sudden increases in medical costs. But take those protections away, as the new bill would, and something perverse but entirely predictable happens: Sicker people keep paying (if they can), healthy people do not, and costs go up. That’s not partisanship but simple math.
Conservative critics worry that placing so much of a burden on the elderly would become toxic for Republicans, given older Americans’ voting power. Hugh Hewitt suggests fixing this by tying tax credits to both income and age:
Think of a square divided into four boxes: People are either poor or not poor, old or not old. Under the current bill, the credits are weighted too much toward the “young and not poor.” Instead, the tax credits should be disproportionately aimed at the “poor and old” box and after that the “poor and young” box. Then perhaps some small slice of the credits can be for “the old and not poor” with none for “the young and not poor.”
This is perhaps the most important part of the GOP plan for conservatives. Overall, the CBO projects that the bill would cut Medicaid spending by $880 billion over 10 years, resulting in 14 million fewer enrollees.
This is why supporters of the bill regularly characterize it as the first major repudiation of a government entitlement program in history. Avik Roy, president of the Foundation for Research on Equal Opportunity, describes the plan as “akin to the 1996 welfare reform bill times 10.”
Other supporters see this as a chance to keep Medicaid spending from growing out of control. The program has long been seen as a looming budgetary disaster, especially for states. Robert Samuelson covers this issue:
Slowly, Medicaid is usurping state priorities. Medicaid now claims nearly one-fifth of states’ general revenues, reports Robin Rudowitz of the Kaiser Family Foundation. Under present law, the squeeze will worsen.
Medicaid costs are split between federal and state governments — with the federal government agreeing to pay a certain percentage of the cost (varying by state). Republicans propose changing that structure by capping the amount of federal spending based on the number of people in the state. This, they hope, will prevent states from expanding the program.
Opponents of the bills say this would be a disaster. Here’s Andy Slavitt on that point:
In my time overseeing the government agency that runs [Medicaid], we dealt with many unexpected shocks — Zika, high-cost drugs and the national opioid epidemic, to name a few. Under the changes sought by Republicans, states would no longer have the resources to manage these crises.
Republicans often argue that the bill would only prevent Medicaid from growing further, protecting coverage for people who gained coverage under the ACA’s Medicaid expansion, so long as they have no lapse in coverage greater than 63 days.
But Benjamin Sommers explains that the legislation is designed to silently undo the Medicaid expansion:
People frequently move in and out of coverage, a phenomenon often called “churning.” Eligibility for Medicaid fluctuates with job losses or new employment, seasonal work or overtime, changes in family circumstances such as marriage or divorce and other factors.
So, for better or worse, this is where the rubber hits the road ideologically. Do we support government intervention in the market for low-income Americans, or not?
Freedom Caucus Republicans already shepherded an amendment allowing states to implement work requirements for Medicaid benefits. They would also give states the option to accept a lump sum of federal funds instead of the per-capita payments. This might be the closest they get to block grants for Medicaid.
Tax cuts:
Some of the fiercest criticism highlights how much high-income earners benefit from the bill. The GOP plan would repeal taxes on the wealthy imposed by the ACA to fund increased coverage, including a 3.8 percent tax on investment income and a 0.9 percent tax on people in the highest income brackets.
According to the CBO, the bill takes $1.2 trillion out of helping people get health care (including $880 billion from Medicaid) and then hands out about $600 billion of that in tax cuts, mostly for the well-to-do and various interest groups, the beleaguered tanning industry being my favorite. This could also be called the Make Inequality Worse Act of 2017.
And here’s Catherine Rampell on why these tax cuts are essential to the Republican’s plan:
The presence of expensive tax cuts in a bill purportedly about health-care reform is not a side effect; it’s the entire point. They make it easier for Republicans’ (much bigger) individual and corporate tax cuts to sail through the Senate with minimal Democratic obstruction in a few months’ time. Why? … Republicans can take the filibuster option away by using the “reconciliation” process, which is an option if, and only if, the tax bill doesn’t increase government deficits in the long term, relative to existing law.
Of course, these tax cuts are funded primarily by cutting Medicaid spending, so it’s an easy target for liberals to make the case that Republicans are filling the coffers of the rich off the backs of the poor (a.k.a., a reverse Robin Hood tax).
The GOP plan does preserve one particular tax that mostly affects the wealthy, and that’s the one on so-called Cadillac insurance plans — or expensive plans often available to high-income employees. The ACA was originally supposed to tax these plans at 40 percent starting in 2018 but delayed implementation until 2020. The GOP plan pushes that date back again to 2025.
Still, preserving the “Cadillac tax” attracted criticism from Republicans such as Sen. Rand Paul (Ky.), who characterizes the bill as “Obamacare Lite.” Avik Roy defends the GOP bill:
Rhetorically, GOP hard-liners such as Paul claim that they are implacably opposed to federal subsidies for health insurance, that they’re taking a brave stand against big government. Operationally, however, they support subsidies for the rich, and only oppose subsidies for the poor and the sick. That comes across not as a principled stand against statism, but as a political stand against Americans whose votes they don’t need.
The essential benefits package:
This is a policy item that got some last-minute attention to woo votes from conservatives opposing the bill. When the ACA was passed, it required insurers to provide “essential benefits” in 10 areas — such as mental health, dental and vision care for kids and maternity care.
For procedural reasons, the original bill preserved these requirements — Greg Sargent explains in depth here — but that didn’t sit well with Freedom Caucus members. So GOP leadership changed its view.
What would stripping out these benefits mean? Free market-minded people say that it would remove “paternalistic” government overreach. But others are concerned that health insurance wouldn’t do any good if it doesn’t cover basic needs.
What’s the GOP’s end game?
The goal of this bill is clearly to reduce the footprint of the federal government in health — pulling back Medicaid and adding market-based reforms.
But it’s hard to identify a fully formed Republican strategy since so many people within the party’s own ranks dislike the bill, as Dana Milbank notes. Plenty of critics argue that this entire episode illustrates how the Republicans never had a fully formed replacement plan in mind. Here’s Charles Lane:
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.
Of course, Republicans aren’t able to draft their ideal plan because they’re trying to pass this plan through reconciliation — which means that this is technically a budget bill and can avoid a filibuster. That severely limits what they can put in the bill, such as a provision allowing consumers to buy insurance across state lines.
But more cynical critics believe that hard-line Republicans opposing the bill simply want the ACA to fail on its own without repealing it, even if that means actively taking steps to weaken President Barack Obama’s signature achievement. Here’s Greg Sargent’s analysis:
[It’s] not crazy to imagine that conservatives might prefer for the current repeal effort to fail, at least in its current form. … And needless to say, if it does fail, and the ACA lives on, conservatives can continue to say it’s a horrific failure — no matter what actually happens — thus proving them right about the folly of government efforts to expand coverage.
Conservative pundits such as Hugh Hewitt warn that such a failure to pass a health-care bill would mean the death of Republican majorities. But others, such as Jennifer Rubin, argue that it would be more disastrous for the GOP to put out a bill that would ultimately damage health-care coverage gains. Who is right is anyone’s guess.

If Health Bill Is Killed in the House, Ideology

by Nate Cohn - NYT - March 22, 2017

The bill to replace Obamacare is struggling to gain support from House Republicans, but not necessarily because of how the plan would affect their constituents.
Millions could lose insurance coverage under the Republican plan, particularly people in the states that expanded Medicaid under Obamacare, or the older, rural and low-income Americans who would receive fewer tax credits. Those issues have driven much of the Republican opposition in the Senate, where the bill is thought to have limited support.
But so far, the House Republicans who oppose the plan aren’t from the places most dependent on Medicaid or the Obamacare tax credits. They’re not even among the most vulnerable Republicans when considering the 2018 elections.
Instead, the health care debate is splitting House Republicans along ideological lines, with few signs that members are being pulled off familiar terrain by the effect of the law on their states or districts.
This could change before the Republicans bring their plan to a vote on Thursday. A disproportionate share of undecided Republicans are from Medicaid expansion states or relatively moderate districts.
But by Wednesday morning, 27 Republicans had publicly indicated that they would vote against the plan, according to NBC News — more than the 21 defectors that House Speaker Paul Ryan can afford to lose. It’s clear that ideological considerations, not whether their constituents are more or less vulnerable to the Republican plan, is driving the opposition to the bill.
Take Medicaid expansion. So far, 12 percent of Republicans from Medicaid expansion states are poised to vote “no.” For the states that haven’t expanded Medicaid? Also 12 percent.
What about rural districts, or states where the Republican plan offers far fewer tax credits than the Affordable Care Act, like Alaska? Same story.
Electoral vulnerability doesn’t seem to be a major factor either. So far, there are just three apparent “no” votes out of the 24 Republicans who represent districts carried by Hillary Clinton. By that measure, endangered Republicans are slightly more likely to oppose the plan, but most of the opposition still comes from Republicans who don’t have to worry about the general election.
Over all, 15 percent of Republicans who have less than an 80 percent chance of winning re-election (by our estimates) oppose the bill. In comparison, 12 percent of those with a greater than 95 percent chance of winning are opposed.
What do the opponents of the House bill seem to have in common? They represent competing ideological factions with predictable reservations about the Republican plan, regardless of whether their districts or constituents are posed to be disproportionately affected.
The members of the House Freedom Caucus, a group of conservative lawmakers that helped expel John Boehner as Speaker, are by far the likeliest to oppose the Republican bill. So far, more than half of Freedom Caucus members have announced their opposition, preferring a full repeal of Obamacare. They represent half of the current opposition to the bill, and more could follow.
Just 4 percent of Republicans who aren’t members of the Freedom Caucus oppose the bill. Those members tend to be ideologically moderate by most measures — although there is a small number of conservative, non-Freedom Caucus members who oppose the bill.
There’s a lot of overlap between relatively moderate Republicans and those who might consider themselves vulnerable to re-election. And it’s more than just overlap: The Republicans who would be likeliest to vote differently as a result of their electoral vulnerabilities would also be likeliest to have already amassed a moderate voting record. So far, both electoral vulnerability and past vote record seem to matter, but whether members have been moderate in the past has been a more powerful predictor of opposition.
These patterns could change by the time voting starts. Right now, vulnerable Republicans or those who represent Medicaid expansion states are much less likely to have publicly committed to vote for the bill, even though they’re not much more likely to oppose the bill.
Just 27 percent of representatives who have less than an 80 percent chance of winning re-election in 2018 (by our estimates) have publicly committed to vote for the law, compared with 48 percent of those who have greater than a 95 percent chance of winning. Similarly, 40 percent of representatives from Medicaid expansion states have said they support the bill, compared with 47 percent of those from non-expansion states.
As for the members that Mr. Ryan is counting on, to get over the top, he’ll need to break through among the representatives driven by ideology.

ACA's repeal would cause tens of thousands of deaths, while single payer would save 20,000 more lives than ACA: AJPH editorial

Researchers: Peer-reviewed evidence points to deadly consequences of being uninsured

Contact: Clare Fauke, PNHP communications specialist, 312-782-6006,  
Repealing the Affordable Care Act without replacing it, as some conservative hardliners are demanding, would cost a minimum of 37,127 lives over the next two years (14,528 in 2018 and 22,599 in 2019), and perhaps as many as four times that number, according to scientific studies summarized in an editorial in this week’s American Journal of Public Health.
The new analysis of the effect of widespread insurance loss is particularly relevant in light of the report issued March 13 by the Congressional Budget Office. The CBO estimates that the American Health Care Act, the Republican plan to replace the ACA, would cause 14 million people to lose insurance in the first year alone. By 2026, 24 million would lose coverage, leading to a total of 52 million uninsured in that year.
In contrast, the editorial’s authors estimate the impact of replacing the ACA with a universal, single-payer health system, along the lines of the Expanded and Improved Medicare for All Act, H.R. 676, would provide immediate coverage to the 26 million Americans who are currently uninsured, saving at least 20,984 lives in year one.
Longtime health system researchers Drs. David U. Himmelstein and Steffie Woolhandler analyzed all of the peer-reviewed studies of mortality associated with losing or gaining insurance. Using the CBO estimates of how many people currently lack insurance and how many more would lose coverage if the ACA were repealed without replacement, they provide a range of estimates of the excess deaths or lives saved under different health reform options (see table below). The evidence indicates that one American dies for every 300 to 1,239 who go without health insurance.

(See full Himmelstein and Woolhandler editorial for details on methods and sources.)
“The ACA extended coverage to 20 million Americans. But it offered little help to 90 percent of the population, including the 26 million who remain uninsured and millions more with unaffordable copayments and deductibles,” said study co-author Dr. Woolhandler, an internist, professor of public health at the City University of New York at Hunter College (CUNY), lecturer in medicine at Harvard Medical School. “Clear evidence tells us that fixing these defects would save thousands of lives. But Republicans’ plans would move us backwards.”
Dr. Himmelstein, the lead author of the editorial, a primary care doctor and, like Woolhander, a professor at CUNY’s Hunter College and lecturer at Harvard Medical School, added, “The Republican plan to replace the ACA would leave 52 million people uninsured in 2026. We know that will lead to many deaths – at least 41,969 and perhaps many times that number.”
Drs. Woolhandler and Himmelstein authored one of the early studies of the lethal effects of lacking health insurance, which President Obama cited in his push for the ACA. They, together with then-Harvard law professor Elizabeth Warren, led widely cited studies of medical bankruptcy.

The only way to end inequality in American health care is universal coverage

by Timothy Burns - Bangor Daily News - March 23, 2017

I know numbers. I am a radiation oncology physicist, so I use math and science to help physicians and the rest of our team treat cancer patients with X-rays. I’m used to large numbers and complex systems, but hearing the nonpartisan Congressional Budget Office’s estimates about the Republican replacement for the Affordable Care Act left me numb.
There are a lot of numbers we can discuss in respect to this bill: $880 billion, the cut to Medicaid; $600 billion, the tax cut; 43 percent, the percent of births in Maine to mothers on Medicaid; $7,260, the estimated increase in out-of-pocket costs to a 60-year-old making $20,000 per year in Penobscot County.
As bad as those numbers are, the more important number is 24 million, which is really all you need to know about House Speaker Paul Ryan and President Donald Trump’s health care plan. That’s how many Americans the Congressional Budget Office predicts will lose their insurance by 2026 if this plan becomes law. That is a big number. If you remember it, great, but you can leave those numbers to the policy experts for a minute. There is a much smaller number I want to talk about: one.
We are privileged to live in America. Our industries, ingenuity and ideals serve as inspiration to the world. While we excel on so many levels, we fall woefully short when it comes to health care. The American medical community should be the envy of our peers, but there is one glaring hole. If we get sick, we expect the exams, blood tests, diagnostic imaging, genetic testing, consultations, surgery, chemotherapy, long-term care or whatever medical intervention is called for, but we can get it only if we have the right insurance or the means to pay.
In America, arbitrary personal factors often determine if you can get health care at a cost you can afford. You may be eligible for Medicare, VA coverage or Medicaid. Your employer may offer you coverage. This system leaves massive gaps, and that is what puts us in a category of one globally. One neighbor can feel a dreaded lump and get the best care money can buy. Another could feel the same lump and know she can’t afford to pay the doctor’s bill and the grocery bill. She puts off the doctor so her kids can eat. The lump grows, and the cancer spreads. Instead of seeing her children graduate, get married and have kids of their own as her neighbor does, without insurance she dies needlessly and much too young.
This, some would argue, is the American dream. Both neighbors have access to the same insurance and care. They had the freedom to choose their care. That’s personal liberty, they say.
This is nothing new. As Dr. Martin Luther King Jr. said, “Of all the forms of inequality, injustice in health is the most shocking and inhumane.”
The evidence is overwhelming and clear: People are more likely to die prematurely when they lack insurance, and the Republican plan will drastically decrease the number of people with insurance. We need our political leaders to know it’s not acceptable in the richest country on Earth to pass laws that could result in thousands of preventable deaths each year. No law is perfect, especially in health care. But the American Health Care Act is not even a good faith effort to insure more people. So, let’s revisit our lonely number, one.
We can improve our health care system by allowing everyone to enroll in a plan with a single payer. Another bill, HR 676, is before Congress that would expand Medicare to provide health coverage for all Americans. If you are that one who loses insurance or are priced out of the market before you feel the lump, your lawmakers have failed you. What tax cuts are worth that?
One is easier to remember than 24 million. Take it from a physicist.
Timothy Burns is the chief radiation physicist at the Lafayette Family Cancer Center in Brewer, where he ensures patients get safe and effective radiation treatments. He is also active in the newly formed Bangor chapter of Maine AllCare.

House Republicans, Deeply Divided, Face Painful Choice on Health Vote

by Jennifer Steinhauer - NYT - March 22, 2017

WASHINGTON — For the House Republicans who have never served under a Republican president — roughly two-thirds of them — the vote scheduled for Thursday on a measure to replace President Barack Obama’s health care law is a legislative fantasia, the culmination of seven years of campaign promises impeded by Mr. Obama’s veto pen.
But weeks of back-room machinations to bring a disparate group of lawmakers on board have left many Republicans with an excruciating choice: Pass a bill with an extremely limited constituency that could well wreak havoc with their own voters, and with Republicans’ re-election prospects, or vote it down, undermining President Trump’s agenda.
Speaker Paul D. Ryan said Wednesday that he was confident the House would pass the bill. But as of late Wednesday, roughly 30 Republicans had said they either would vote against the measure or had not made up their minds. That left the bill’s sponsors short of the 216 votes needed, and on Wednesday night Mr. Ryan scheduled a meeting in the Capitol to try to win over skeptics.
If House Republicans reject the measure, the working relationship between the White House and Republican leaders in Congress, still in its infancy, will suffer a powerful blow. In Washington, failure often begets more failure, as opposition forces strengthen, alliances fragment and the thin foam of bipartisanship evaporates.
“How do we have any momentum to do anything else?” asked Representative Richard Hudson, Republican of North Carolina. “Without this bill, I don’t know how you do tax reform,” he said. If the bill fails, “it’s going to have negative repercussions for all of us.”
Mr. Trump, a man who rushes to hang his name in gold anywhere he can, has rejected the nickname that some have given the House bill: Trumpcare.
But he has begun a last-minute campaign to both sweet talk and vaguely threaten fellow Republicans into supporting the leadership’s hastily written bill, though the measure, which would replace the Affordable Care Act’s health insurance mandate and generous subsidies with tax credits to buy insurance, has been criticized by the right and the left.
Mr. Trump met with a group of the most conservative House members at the White House on Wednesday, and Republican leaders are depending on him to finish the job. Indeed, this week many Republicans have begun to acquiesce to his and the House leadership’s desires, accepting that the bill, however flawed, is the best they are going to get.
At least for now, though, too many have not.
“The bill maintains Obamacare’s overall structure and approach, an approach that cements the federal government’s role in health insurance,” said Representative Rick Crawford, Republican of Arkansas, an opponent of the bill who represents the concerns of the conservatives.
Other more moderate members expressed opposite objections. “Under the current proposal, many South Jersey residents would be left with financial hardship or without the coverage they now receive,” said Representative Frank A. LoBiondo, Republican of New Jersey. “Our seniors on Medicare already struggle to make each dollar stretch.”
Some Republican leaders and those charged with drumming up votes suspect that some of the more conservative members are simply trying to force Mr. Ryan to cancel a vote on the bill so they do not have to go on record against Mr. Trump. But moderates may feel the pressure of voters: Large protests against the bill are planned for Thursday.
Further hampering them, House Republicans failed to do the grueling work of building a coalition outside Washington as Democrats did with the Affordable Care Act in 2009. While anti-abortion groups have warmly embraced the bill, which could restrict coverage of the procedure, it lacks other advocates. Doctors, nurses and hospitals have come out strongly against the measure, and insurance companies have been largely skeptical.Even if Mr. Ryan manages to secure the bare minimum of votes required, the bill that would pass the House would not become law. The Senate expects to make significant changes in the legislation, dragging out the process deep into the spring, if it can pass any version at all.
Senate Republicans, largely those from states that chose to expand their Medicaidprograms under the Affordable Care Act, so far have not seemed susceptible to pressure from leaders and Mr. Trump, listening instead to governors and constituents concerned about significant reductions in benefits.
Part of the bill’s problem is time itself. Much has changed in the years since the Affordable Care Act passed, with millions of Americans, many in red states, now getting health insurance as a result of the law, as well as treatment for the prescription drug addictions that have plagued scores of communities.
“My goal for this whole process was to help the people the law harmed and not harm the people it helps,” said Representative Dan Donovan, Republican of New York. At the same time, a fair number of conservatives would like to see those benefits greatly reduced, the central tension of the Republican debate.
As a result, it remains difficult to imagine a bill that could find its way out of the Capitol to Mr. Trump’s desk, given the broad disparities in what Republicans now seek.
Even if they can come together, House Republicans risk making the same mistakes Democrats made in the beginning of Mr. Obama’s term, when they pushed through what came to be known as Obamacare. That achievement, monumental at the time, ended up dragging down a once formidable Democratic majority and reducing the ability of Democrats to pass more legislation during his presidency.
Yet if the bill fails, Republicans in the House could end up like House Democrats under President Bill Clinton, who passed a controversial energy tax that was reduced to rubble in the Senate, but remained an albatross for Democrats in the 1994 elections.
The Democratic majority repeated that error in the early years of the Obama administration when the House passed a highly unpopular bill to cap the carbon emissions that cause climate change, only to see it go nowhere in the Senate, bringing down some House Democrats in the process.
Republican leaders are privately telling members that they do not want to be tarred as Republicans who voted with Democrats to maintain the Affordable Care Act. It’s a message they expect to resonate once the bill reaches the Senate.
“We remain committed to the repeal and replacement of Obamacare with policies that actually work,” Senator Mitch McConnell of Kentucky, the Republican leader, said on the Senate floor Wednesday as he urged members to get on board. “Americans are ready for a better way forward after the failure of Obamacare.”
But the flaw in that theory is that plenty of groups that usually support Republicans have already expressed distaste for the repeal-and-replace measure and are urging members to reject it.
“In 2018, members are going to have to campaign for re-election and say, ‘Look we repealed Obamacare,’ and voters are going to look at their premiums and say, ‘Oh no you didn’t,’ ” said Dan Holler, a spokesman for Heritage Action for America, a conservative group. “In the long term, it is not in the best interest of the Republican Party to pass this bill.”
House Republicans could console themselves in thinking that the vote on Thursday could be more like the excruciating vote in 2003 for President George W. Bush’s Medicare prescription drug benefit.
Then, House Republican leaders had to keep the vote open for hours as they twisted arms, finally securing passage, 216-215, over the opposition of the party’s most conservative members, including the current vice president, Mike Pence, an Indiana congressman at the time.
But that measure, which did become law, has proved popular and durable, and the vote — which led to ethics charges against some of the arm-twisters — has largely receded into the history books.

How the Rich Gain and the Poor Lose Under the Republican Health Care Plan

The Republican Health-Care Unraveling

Speaker of the House Paul Ryan and House Majority Leader Kevin McCarthy discuss the House Republican's new health-care plan to repeal and replace the Affordable Care Act. 
This is the first part of a two-part article. The full version appears in the Spring 2017 issue of The American Prospect under the title: “The Republican Health-Care Unraveling: Resist Now, Rebound Later.” This is the “resist” part. Subscribe hereto the magazine.
Imagine if Donald Trump had been a genuine populist and followed through on his repeated promises to provide health insurance to everybody and take on the pharmaceutical and insurance industries. Populists in other countries have done similar things, and Trump might have consolidated support by emulating them.
Of course, Trump’s promises about health care weren’t any more genuine than his promises about Trump University. But even if he had been in earnest, he would have still faced a problem. Unlike right-wing populists elsewhere, Trump did not come to power with a party of his own or well-developed policies. He came tethered to the congressional Republicans, entirely dependent on them to formulate and pass legislation. That dependence will likely complicate Trump’s ambitions in such areas as trade policy. But nothing so far has made more of a mockery of Trump’s populism than the health-care legislation introduced in early March by Paul Ryan and the House Republican leadership and fully backed by Trump.
The Ryan bill is abhorrent for many reasons. It calls for a massive tax cut for people with high incomes, while costing millions of other Americans—24 million by 2026, according to the Congressional Budget Office—their health coverage. It would turn Medicaid from a right of beneficiaries into a limited grant of funds to the states, and it pays for the tax cuts for the rich with cuts in health care for the poor. The bill’s reduced tax credits for insurance make no adjustment for low income, while some credits would go to people with incomes over $200,000.
But what is most amazing about the bill is how badly it treats constituencies and states that voted for Trump and the GOP. The changes it calls for in the individual insurance market would hammer older people (those between the ages of 50 and 64) and residents of red states and rural areas. Republicans appear to be so determined to cut taxes on top incomes that they are willing to sacrifice the interests not only of the poor—we knew that—but of many of their own voters. The same pattern is evident in the federal budget that Trump has proposed.
While the whole effort to “repeal and replace Obamacare” poses an enormous political risk for Republicans, it presents an equally significant political opportunity for liberal and progressive Democrats. I am not talking only about short-term resistance to the Republican rollback of the Affordable Care Act. Now that Republicans have shown their true hand on health care, they are creating new possibilities for long-term progressive organizing and policy alternatives.
The struggles to achieve health insurance for all in the United States have long suffered from one fundamental political handicap. The uninsured and underinsured (people enrolled in plans riddled with exclusions and limits) have been an inchoate population without any organization or voice of their own. The combination of measures America adopted in the mid-20th century produced a large, protected public: employees with good fringe benefits, seniors and the disabled with Medicare, veterans, and the low-income groups that qualified for Medicaid. The people who were left out—mainly low-wage workers, people in part-time work, the unemployed, and individuals with pre-existing conditions—did not share a common identity or cohere politically.
It is one thing to go without health insurance; it is another thing to have that insurance threatened or taken away. 
But the Republican effort to undo the ACA could provide the long-missing organizational impetus. It is one thing to go without health insurance; it is another thing to have that insurance threatened or taken away. It also matters who would be losing coverage. Overall, according to the CBO, the Ryan bill would raise the number of uninsured in 2026 to 52 million, or 19 percent of the nonelderly population (compared with a projected 10 percent under the ACA). But the uninsured under Ryan’s legislation would be concentrated among 50- to 64-year-olds. That’s primarily because the bill would allow insurers to charge 60-year-olds five times as much as 20-year-olds, instead of the 3-to-1 ratio in the ACA. (The adjustments for age in the bill’s tax credits do not come close to offsetting the higher premiums; a last-minute amendment, allowing increased tax deductions for medical expenses, provides little or no benefit to low-income people but may be changed in the Senate.) When twenty-somethings don’t have insurance, many give it little thought because they may not expect to need medical care. But older people aren’t so oblivious. Take away their health insurance, and they are going to be angry.
Besides pushing a lot of older people out of coverage, the Ryan bill is brutal on states with high health costs because it would provide a flat tax credit that doesn’t vary according to geography (unlike the ACA, which provides greater subsidies in high-cost states to make coverage affordable). The Ryan bill’s tax credits are substantially smaller on average than those in the ACA, but people in high-cost states would face especially sharp increases in premiums because of the way the bill structures its tax credits.
According to an analysis by the Center on Budget and Policy Priorities, Ryan’s bill would reduce premium tax credits by more than half in Alaska, North Carolina, Oklahoma, Alabama, Nebraska, Wyoming, West Virginia, Tennessee, Arizona, South Dakota, and Montana. The net cost of insurance would rise dramatically as a result. Notice something about those states? They elect a lot of Republicans—or at least they did.
Within states, rural areas generally have higher premiums than urban areas. So the flat tax credits provide less help in affording insurance there, too. The big Medicaid cuts that Republicans are calling for will also have a severe impact in rural areas. The resulting declines in coverage will force some rural hospitals and clinics to close, with spillover effects on middle-class people who depend on the same facilities and services.
Ryan and other House Republicans have touted one CBO finding: After initially increasing insurance premiums, their bill would reduce premiums after 2020 compared with the ACA. But that’s because their measure would force so many older people to drop coverage that the average age of the insured population would drop. It’s nothing to be proud of. Trump and the Republicans promised more coverage and lower costs when they replaced Obamacare. It is now transparently obvious that they can’t deliver on that promise and that they are willing to deny health insurance even to millions of people who voted for them.

Blocking Trump’s Chaos Option

If Trump and the Republican Congress cannot pass legislation this year, they do have a fallback option. They can claim that the ACA is collapsing and make sure that it does. Then they can return to health-care legislation later and say they have no choice except to repeal Obamacare. This is the option Trump at times has seemed to prefer. “Let it be a disaster, because we can blame that on the Dems,” he told the National Governors Association on February 27. “Let it implode, then let it implode in 2018 even worse. … Politically, I think it would be a great solution.”
When Trump talks about Obamacare imploding, he is talking not about the entire program (although he seems to think so), but rather one specific part: the insurance exchanges in the individual market. The danger he and other Republicans invoke is a “death spiral”—a situation where rising premiums drive the healthy out of the market, forcing premiums up and more healthy people out, until the market fails. The exchanges are nowhere near that point. Although rates in the exchanges did rise sharply in 2016, they rose to the level originally projected by the CBO (premiums had come in lower than expected earlier). Moreover, the vast majority of individuals who buy insurance in the exchanges receive subsidies that cap the cost of their premiums; many of them also receive subsidies covering a share of deductibles and co-pays. Consequently, as the CBO and other studies have found, the exchanges have some protection against a death spiral—as long as the subsidies are fully funded and the individual mandate is enforced.
But the insurance exchanges could soon face a dire crisis because the Trump administration has created uncertainty for both insurers and enrollees about the survival of the program and enforcement of the mandate. If the administration doesn’t enforce the mandate—or if Congress eliminates the penalty for failing to insure, as the House bill would do for this year—the incentive for healthy people to pay for coverage will fall, threatening the viability of the market.
Some damage has already been done. 
Some damage has already been done. As soon as the Trump administration came into office, it canceled outreach efforts in the final phase of the open-enrollment period for 2017. Since individuals who enroll early tend to be those who know they will have high medical costs, while late enrollees are a healthier group, the cutoff of late outreach not only reduced total enrollment but also led to a higher-cost pool. The Trump administration is also proposing to shorten the open-enrollment period for 2018.
Other measures the administration favors could encourage insurers to stay in the market, albeit with mixed effects on enrollees. The administration wants to tighten up special enrollment outside of the open-enrollment period, which may well be justified; it also proposes requiring people to pay any unpaid premiums before enrolling for the next year. In a step that would help keep premiums down, the administration has encouraged states to seek waivers to develop reinsurance programs for the individual market, as Alaska has already done. (Reinsurance spreads the cost of high-cost cases across the entire market.) Alaskans buying insurance individually faced a possible 40 percent rate increase because of 37 very high-cost cases, accounting for one-quarter of claims. The reinsurance measure adopted by the state, using funds from an existing premium tax, kept premium increases by Premera Blue Cross, the sole insurer in Alaska’s exchange, to 9.8 percent.
Insurance companies need to indicate by June whether they will offer coverage in the exchanges for 2018. Uncertainty about the rules is a recipe for chaos. If they believe the mandate will not be enforced, they are likely to jack up premiums or withdraw entirely from the market. About a third of the exchanges, mainly in rural areas, have only one carrier offering coverage this year; additional withdrawals for 2018 could create just the kind of crisis that Trump and the Republicans need as a pretext to undo the ACA.
This problem has a ready solution. If Republicans in Congress do not replace the ACA for the coming year, the Trump administration needs to make clear that it will enforce the law as it stands for 2018 and fully fund the program (including cost-sharing subsidies). Moreover, Republicans cannot plead there is no way to strengthen the individual market. The Ryan bill contains a Patient and State Stability Fund of $100 billion over ten years that the CBO believes states would use largely to cover high-cost enrollees in the individual market and thereby prevent a death spiral. In the absence of comprehensive new legislation, Congress should provide those funds in a separate measure to stabilize the market for 2018. The Republicans cannot blame a collapse on Democrats when they have it in their power to maintain coverage for the millions of people who depend on the market now.

The Next Progressive Health Agenda

Even as they resist the Republican rollback of the ACA and Medicaid, Democrats should be thinking about new initiatives in health care. No doubt the next steps will depend in part on what Trump and the Republicans end up doing. In the wake of federal legislation, many of the critical decisions in the short run may move to the states. But Democrats cannot limit themselves to defensive efforts to salvage the ACA at either the federal or the state level. They need to think about a more attractive national agenda in health care that reflects the lessons of the ACA and new political realities.
The coming national Democratic debate is going to focus on extending Medicare—to whom, how quickly, and under what rules will be the questions. The strategy for universal coverage in the ACA relied on the extension of Medicaid for the poor, but the limitations of that approach should now be clear. In its 2012 health-care ruling, the Supreme Court effectively made it impossible to use Medicaid as a foundation for universal coverage. As a mixed federal-state program, Medicaid affords states the opportunity to limit coverage, and the ACA experience has shown how far red states will go in doing that. Republicans may also succeed in eliminating Medicaid’s status as an entitlement, which will be hard to restore.
As a national program with deeper public support as an entitlement and no role for the states, Medicare does not suffer from these problems. When Medicare was enacted in 1965, its backers hoped to use it to cover other groups besides seniors, and in 1972 Congress did extend it to the disabled and patients with end-stage renal disease. (The disabled become eligible for Medicare two years after they qualify for federal disability insurance, a delay that leaves many people with high costs in the individual market.) But the expansion of Medicare then stopped, and in the 1980s Democrats in Congress obtained Republican support for incremental expansions of Medicaid to cover low-income pregnant women and young children. This was the path that led to the ACA’s further Medicaid expansion, a strategy that the Supreme Court and Republicans have now brought to an end.
Many people will equate an expansion of Medicare with a “single-payer” plan. But even Medicare-for-all would not be a single-payer system since about one-third of current Medicare beneficiaries use the program to buy coverage in a private Medicare plan. Medicare today is a marketplace—but a marketplace with a dominant public plan and not just a “public option,” which might turn out, if badly designed and established separately from Medicare, to be a relatively small and weak player in the market.
Medicare-for-all faces two enormous obstacles. Moving everyone under age 65 into Medicare would require a huge increase in taxes; employees who now receive health care as a fringe benefit would inevitably look at those taxes as an additional burden, even if reformers try to assure them that their wages would rise once health care was financed by taxes.
Moreover, many seniors insist that Medicare is their program, and they fear—or can be made to fear—that extending the program to others will jeopardize their coverage. They also see Medicare as an earned benefit, and many of them resist extending it to people who they believe haven’t earned it.
But there is a way forward: create a new part of Medicare for the older population below age 65—the older population who have also earned Medicare coverage by paying taxes and who are directly threatened by current Republican legislation. My name for this new program is “Midlife Medicare,” which would be open to people age 50 to 64 not otherwise insured (for example, by an employer). Seniors would be more likely to accept this extension than any other; for one thing, AARP welcomes as members all Americans 50 years of age and older. Earlier versions of this idea have been referred to as a “Medicare buy-in”; I have in mind a program that would be partly financed by taxes and that would automatically provide a basic level of coverage (no mandate needed), which those in midlife could increase by paying income-related premiums (as seniors do now).
Midlife Medicare would have advantages for both its beneficiaries and those age 49 and below remaining in the individual insurance market. The enrollees in Midlife Medicare would benefit from the countervailing power that Medicare exercises. Medicare pays provider rates that are substantially below those paid by private insurers in the non-Medicare market, yet providers accept Medicare patients, who consequently do not face the “narrow networks” in most plans in the individual and small-group markets. Americans who continue to have employer coverage will have the assurance that if they need to retire early, they will have health insurance as good as they would now get at age 65. Midlife Medicare is also a response to the rising death rates and declining health that economists Anne Case and Angus Deaton have demonstrated among non-Hispanic whites in midlife.
Moreover, by pulling the 50- to 64-year-olds out of the individual insurance pool covering people 49 years of age and under, Midlife Medicare would make coverage for the younger population substantially cheaper. The younger enrollees in the individual market would, in effect, no longer be shouldering part of the cost of the more expensive 50- and 60-year-olds. This is a much better way to reduce rates for 20-year-olds than the Republicans’ proposal to let insurers charge 60-year-olds five times as much as young adults.
An additional step to relieve the burden on the individual market would be to eliminate the two-year delay in the eligibility of the disabled for the existing Medicare program. Combining this step with Midlife Medicare and a strong reinsurance program would stabilize and make coverage in the individual insurance market significantly less expensive. With these measures in place, the system could be more or less workable even if Republicans eliminate the individual mandate in favor of a 30 percent premium surcharge on individuals who fail to maintain continuous coverage (as the Ryan bill would do). Although I don’t think that would be a good thing to do, I also don’t think Democrats want to focus their next health agenda on restoring the individual mandate.
Formulating a new health-care agenda requires acknowledging that although the ACA has done much good, it has not worked out as well as its supporters originally hoped. The Supreme Court and the red states have limited how far the strategy could go in achieving health care for all. High deductibles and narrow networks have meant that many people are unhappy with the coverage they are receiving. Trump and the Republicans cynically played on public dissatisfactions, suggesting they would provide something better when, in fact, their alternatives would intensify the problems Americans face. We need to move in a more promising direction that takes into account the difficulties that progressive reform has long faced in health care. Midlife Medicare could be a big next step toward a system that works better for everyone.

Health care 'access' is not the same as 'coverage'
By Clarence Page - Chicago Tribune - March 23, 2017

Watching top Republicans explain their proposed Affordable Care Act replacement can make you wonder who hijacked the English language.
For example, if you're like me, you might have been shocked by the news that 24 million fewer Americans will have health insurance by 2026 if the Republican-proposed alternative passes, according to the nonpartisan Congressional Budget Office — including 14 million fewer people in the next year alone.
But that's OK, say Republican congressional leaders. House Speaker Paul Ryan, a Wisconsin Republican, already had declared such gloomy outlooks to be a "bogus" metric. It's not "coverage" that counts, he said; it's "access."
"What matters is that we're lowering costs of health care and giving people access to affordable health care plans," Ryan said in a news conference. Ryan, a self-described "policy wonk," was excited.
He loves the mere sound of words like "freedom," "choice" and "access" even when the reality of "access" amounts to having the freedom to be offered decent health insurance but also being too poor to buy it.
And he's not alone. "Insurance is not really the end goal here," Mick Mulvaney, director of the Office of Budget and Management, later told NBC. "We're choosing instead to look at what we think is more important to ordinary people: Can they afford to go to the doctor?"
OK, call me old-fashioned but I thought being able to afford to go to the doctor is why we have insurance.
But, no, said White House chief economic adviser Gary Cohn to host Chris Wallace on "Fox News Sunday" about the prospect of millions losing their health insurance: "It's not just about coverage, it's about access to care. It's about access to be able to see your doctors."
So where did I get the idea that the goal was coverage? Maybe President Donald Trump had something to do with that when he promised a Republican plan that would provide "insurance for everybody."
ut he also said in a White House meeting with House Republicans after the Grand Old Party's proposed legislation was unveiled that it "will lower costs, expand choices, increase competition and ensure health care access for all Americans."
There's that word "access" again. By now, I suppose, we should know from experience that only the president's most recent version of the truth should be believed, if that.
What gives? Is promising "access" a nice-sounding squishy doublespeak way to say, "We're not giving you any more money to help you buy insurance"?
That's the biggest reason why the CBO and other analysts expect to see millions lose coverage under the Republican plan. Yet Speaker Ryan and other GOP leaders are more excited by the $337 billion that the CBO says the federal government will save over the next decade by shifting most of the ACA's health care burden back to the states and to individuals.
The Republican plan would remove mandates that require everyone to buy insurance, which have enabled the ACA to bar insurance companies from denying coverage because of pre-existing conditions. It would replace subsidies with tax credits to help low-income people buy insurance, and it would expand health savings accounts so more people could save more of their own money to pay for their own health care.
But market-driven incentives work best for people who can afford them. I like HSAs, for example, but households that are living paycheck-to-paycheck often find they simply can't afford to salt away much savings. One health crisis can eat up your health savings overnight. And there goes your "access."
All of which makes it all the more poignant — or sad, as President Trump might tweet — that the biggest losers in what's being called "Trumpcare" probably would be the core supporters of Trump's election campaign.
The same lower-income, older voters who voted for him in rural red-state America stand to lose more in federal insurance subsidies than any other demographic, according to an analysis of country voting and tax credit data by Noam Levey of the Los Angeles Times.
That's the political base that Trump in his inaugural address lauded as the forgotten men and women to whom he had given a political voice. Now the burden is on Trump to show whether "access" to health insurance is as good as the real thing.

Why Big Insurance Adores the American Health Care Act

By Wendell Potter - Huffington Post - March 23, 2017

There’s been a lot of talk about just who was hurt and helped by Obamacare and who will profit or be imperiled by the next phase of health care legislation. Yet health insurance executives have been curiously silent about the House GOP plan to repeal and replace Obamacare. While the American Medical Association and the American Hospital Association, among many others, have come out against it, insurers have clearly made a strategic decision not to show their hand.
Their fingerprints are all over what the Republicans are calling the American Health Care Act.
But know this: They love it. Their fingerprints are all over what the Republicans are calling the American Health Care Act. Arguably the only thing they don’t like about House Speaker Paul Ryan’s Ayn Randish creation is the way the plan would slash funding for the Medicaid program. That’s not because insurance executives are more compassionate for the poor than they’ve been in the past; it’s because a growing percentage of their profits now comes from Medicaid. In fact, more than half of the big insurers’ revenues is now coming from the government, not the private sector. And they’re fine with that.
Make no mistake, health insurance lobbyists also helped shape the Affordable Care Act. Most notably, they were able to get a provision stripped from the bill that would have created a government-run insurance plan (the “public option”) to compete with private insurers. But they didn’t get everything they wanted.
It gets rid of those pesky new rules on consumer protection
Over insurers’ objections, the ACA was enacted with important consumer protections. Thanks to the ACA, insurers can no longer charge older people more than three times as much as younger people for the same policy, and they can’t allocate more than 20 percent of what we pay in premiums to profits and administrative activities like sales and marketing. It’s also now illegal for insurers to deny people coverage because of a pre-existing condition. And policies sold now must cover several “essential benefits,” a provision that outlawed junk insurance.
Now that the insurance executives have more friends in Washington than during the Obama years, they smell an opportunity to get rid of most of  those pesky new rules. Don’t think for a minute that the ACA’s regulations have been a big drag on profits. Even with those consumer protections, most insurance companies have reported record profitsduring the Obamacare years, and their investors are considerably richer.
The ACA was really the Health Insurance Profit Protection and Enhancement Act
I saw that coming. When I testified before a House committee during the health care reform debate in 2009, I warned that if Congress passed a reform law that did not create a public insurance plan, they might as well rename their bill the Health Insurance Profit Protection and Enhancement Act.
And boy, have those profits been protected and enhanced. Here’s just one example: The share price of the biggest health insurer, UnitedHealth Group, has increased more than 1,000 percent since the early days of the Obama administration.
Obama himself had said that a public option was needed “to keep health insurers honest.” He was right. Insurance company executives cannot be trusted to put the interests of their customers first. The evidence before Obamacare was abundant, especially in the individual market, where people who can’t get health insurance through an employer must go to buy coverage.
In another appearance before Congress, I told the Senate Commerce Committee that during the 20 years I worked for insurance companies, “I saw how they confuse their customers and dump the sick — all so they can satisfy their Wall Street investors.”
Not only were they able to dump the sick through a previously common practice of rescinding coverage when a policyholder was diagnosed with a disease like breast cancer, they did all they could through their extensive underwriting practices to avoid selling coverage in the first place to anyone who might need expensive care.
It was because insurers could declare a significant percentage of the population “uninsurable” and cancel policies when they thought they might have to pay for costly treatments that the individual market pre-Obamacare was quite profitable.
“Enhance shareholder value”
It is a myth that the big for-profit insurers like the ones I worked for have an interest in providing all of us with access to affordable care. That would conflict with their top priority, which, as I quickly learned in my corporate job, is to “enhance shareholder value.” That is why several of the big insurers started bailing from the Obamacare exchange markets last year after congressional Republicans eliminated the additional payments the ACA had set aside for insurers while the individual market was becoming more stable, predictable and fair. Never mind those same insurers were reaping big profits from the government’s Medicaid and Medicare programs, thanks in large part to the ACA’s expansion of Medicaid.
It is also a myth that the for-profits are even still in the insurance business in a significant way. Over the past several years, employers and the government have assumed the risk of insuring most of us. While you might see the name Cigna on your insurance card, if your coverage is through your job, chances are your employer is technically your insurer and Cigna just administers your benefits (for a hefty fee, of course). It’s not unusual for more than 80 percent of a big for-profit’s revenues to come from these “administrative services only” contracts with employers.
These companies had relatively little interest in the individual market pre-Obamacare because they — not an employer or government — would have to assume the risk of paying medical expenses for individual market customers. To reduce the risk of having to pay medical claims, insurers went to great lengths to avoid selling coverage to people who might need it. In my home state of Tennessee, even the big nonprofit BlueCross BlueShield of Tennessee refused to sell policies to more than a third of applicants before the Obamacare rule prohibiting that practice went into effect. And once you were turned down by one insurer, the chances of getting coverage from another company were slim to none. If you had a pre-existing condition pre-Obamacare, the insurance industry could declare you “uninsurable.” They might as well have said, “You’re dead to me.”
Insurers also reduced their risk by charging older people five to 10 times as much as younger people for the same policy. Some states allowed them to charge even more. As a consequence, the “pool” of people in the individual market pre-Obamacare had more young people than today for one simple reason: people in their 40s, 50s and early 60s simply couldn’t afford the premiums.
Goodbye individual mandate, hello insurance gap
It is clear House Republicans delegated the drafting of big chunks of their American Health Care Act to insurance industry lobbyists. Yes, their bill gets rid of the much-vilified individual mandate (which insurers insisted be included in Obamacare), but it replaces it with something more profitable to insurers. Under the GOP plan, if there is a gap in your coverage of 63 days or longer, insurers can charge you 30 percent more when you reapply.  This is the GOP/insurance industry stick to discourage people from going without insurance. The problem is that many people will go 63 days or longer without coverage because of a job loss. When you’re unemployed, being able to pay health insurance premiums can quickly become a financial hardship, if not an impossibility. The tax credits the Republican bill would provide wouldn’t be enough to help a lot of people. It’s a devious way of eliminating undesirables from the risk pool over time.
The bill would also allow insurers to once again discriminate against older people by allowing them to charge five times more than younger people. And it would give them more “benefit design flexibility” — an industry euphemism for allowing insurers to once again sell policies with sky-high deductibles and skimpier benefits.
The bill would also allow insurers to spend a smaller percentage of our premium dollars on medical care, freeing up more for profits. And to put a bow around the whole package, the bill would repeal a provision of the ACA that limits to $500,000 the amount of executive pay insurance companies can deduct on their federal taxes.
Now you know why insurers haven’t joined doctors and hospitals and many others in condemning the American Health Care Act. Overall, it would be a big win for health insurance companies, the big for-profits in particular. And, of course, their top executives and shareholders.

Trump Tells G.O.P. It’s Now or Never, Demanding House Vote on Health Bill

by Julie Hirschfield Davis, Robert Pear and Thomas Kaplan - NYT - March 23, 2017

WASHINGTON — President Trump issued an ultimatum on Thursday to recalcitrant Republicans to fall in line behind a broad health insurance overhaul or see their opportunity to repeal the Affordable Care Act vanish, demanding a Friday vote on a bill that appeared to lack a majority to pass.
The demand, issued by his budget director, Mick Mulvaney, in an evening meeting with House Republicans, came after a marathon day of negotiating at the White House and in the Capitol in which Mr. Trump — who has boasted of his deal-making prowess — fell short of selling members of his own party on the health plan.
House Speaker Paul D. Ryan emerged from the session and announced curtly that Mr. Trump would get his wish for a vote on Friday. Mr. Ryan refused to answer reporters’ questions about whether he expected the measure to pass.
Although the House Republicans’ closed-door meeting became a cheerleading session for the bill, their leaders braced for a showdown on the floor, knowing they were likely to be at least a handful of votes short of a majority for the health insurance bill and would need to muscle their colleagues to the last to prevail.
Some conservatives were still concerned that the bill was too costly and did not do enough to roll back federal health insurance mandates. Moderates and others, meanwhile, were grappling with worries of their states’ governors and fretted that the loss of benefits would be too much for their constituents to bear.
Mr. Ryan had earlier postponed the initial House vote that was scheduled for Thursday to coincide with the seventh anniversary of the Affordable Care Act’s signing. Mr. Trump confronted the possibility of a humiliating loss on the first significant legislative push of his presidency.
At a White House meeting with members of the hard-line Freedom Caucus earlier on Thursday, Mr. Trump had agreed to the conservatives’ demands to strip federal health insurance requirements for basic benefits such as maternity care, emergency services, mental health and wellness visits from the bill. But that was not enough to placate the faction, part of the reason that Thursday’s vote was placed on hold.
As House leaders struggled to negotiate with holdouts in the hopes of rescheduling the vote, Mr. Trump sent senior officials to the Capitol with a blunt message: He would agree to no additional changes, and Republicans must either support the bill or resign themselves to leaving President Barack Obama’s signature domestic achievement in place.
“We have a great bill, and I think we have a good chance, but it’s only politics,” Mr. Trump said earlier Thursday, as it was becoming clear that his negotiating efforts had failed to persuade enough members of his party to back the plan — which was years in the making — to repeal and replace the health law.
Privately, White House officials conceded that competing Republican factions were each demanding changes that could doom the effort, placing the measure in peril and Mr. Trump’s chances of succeeding at a high-stakes legislative deal in jeopardy. With some of its demands in place, the Freedom Caucus ratcheted up its requests, insisting on a repeal of all regulatory mandates in the Affordable Care Act, including the prohibition on excluding coverage for pre-existing medical conditions and lifetime coverage caps.
Mr. Trump, who has touted his negotiating skills and invited the label “the closer” as the vote approached, was receiving a painful reality check about the difficulty of governing, even with his own party in power on Capitol Hill.
“Guys, we’ve got one shot here,” he told members of the Freedom Caucus at a meeting in the Cabinet Room, according to a person present in the room who spoke on the condition of anonymity because the meeting was private. “This is it — we’re voting now.”
“The choice is yes or no,” Representative Joe Barton, Republican of Texas and a member of the Freedom Caucus, said on Thursday night. “I’m not going to vote no to keep Obamacare. That’d be a stupid damn vote.”
Others were unconvinced.
Having secured Mr. Trump’s acquiescence to eliminate the requirement that insurers offer “essential health benefits,” members of the Freedom Caucus pressed their advantage. While they did not specify precisely which regulations they wanted to eliminate, the section they wanted to gut requires coverage for pre-existing health conditions, allows individuals to remain on their parents’ health care plans up to age 26, bars insurers from setting different rates for men and women, prohibits annual or lifetime limits on benefits, and requires insurers to spend at least 80 percent of premium revenue on medical care.
“We’re committed to stay here until we get it done,” said Representative Mark Meadows, Republican of North Carolina and the chairman of the Freedom Caucus. “So whether the vote is tonight, tomorrow or five days from here, the president will get a victory.”
He said 30 to 40 Republicans planned to vote “no”; House leaders can afford to lose only 22 in order to pass the bill.
But for every concession Mr. Trump made to appease critics on the right, he lost potential rank-and-file supporters in the middle, including members of the centrist Tuesday Group who had balked at the bill’s Medicaidcuts and slashed insurance benefits. Moderate Republicans in that group went to the White House on Thursday but emerged unmoved in their opposition.
“There’s a little bit of a balancing act,” conceded Sean Spicer, the White House press secretary.
Representative Leonard Lance, Republican of New Jersey, said he still opposed the bill because he did not believe it would give people “complete and affordable access” to health insurance.
At the same time, a new estimate of the bill’s cost and its impact on health coverage further soured the picture for wavering lawmakers. The nonpartisan Congressional Budget Office on Thursday issued a report on the revised version of the health care bill showing that it would cost more than the original version but would not cover more people. The report said the bill, like the original version, would result in 24 million fewer Americans having health insurance in 2026 than under current law.
But recent changes to the bill, made through a series of amendments introduced on Monday, would cut its deficit savings in half. Instead of reducing the deficit by $337 billion, the new version of the bill would save only $150 billion over the decade.
The budget office did not consider the effects of various additional changes that remain under negotiation, including eliminating benefit requirements and other health insurance regulations.
Quinnipiac University national pollfound that voters disapproved of the Republican plan by lopsided margins, with 56 percent opposed, 17 percent supportive and 26 percent undecided. The measure did not even draw support among a majority of Republicans; 41 percent approved, while 24 percent were opposed.
President Trump appealed to supporters to weigh in, assuring them in a video on Twitter, “Go with our plan. It’s going to be terrific.”
The chaotic process that unfolded on Thursday exposed Republicans to criticism that they were moving recklessly in a desperate bid to get their plan passed. Representative Raúl Labrador, Republican of Idaho and a Freedom Caucus member, said the party’s leaders had tried to ram through the measure over their members’ objections. He panned what he described as a “brute force” strategy that resembled the approach of former Speaker John A. Boehner, Republican of Ohio.
“It’s better to get it right than to get it fast,” Mr. Labrador said.
It was not clear that the changes that Mr. Trump has agreed to and those being demanded could survive. Under the strict budget rules being used to advance the bill, changes to the Affordable Care Act must affect federal spending or revenues. Regulatory measures that affect private health policies, not government programs like Medicaid, are highly likely to be challenged by Senate Democrats. If the Senate parliamentarian rules in the Democrats’ favor, those changes in the House would be stripped from the bill.
The emerging power of the Freedom Caucus, a group that has been historically marginalized in policy making but a thorn in the side of leadership, is one of the surprises of the rushed health care debate. The group has been empowered by the addition of Mr. Mulvaney to the senior White House staff, and Mr. Trump’s disengagement from policy details, coupled with his intense desire to score a win after a rocky start to his presidency.
Mr. Obama stepped into the fray on Thursday with a lengthy defense of his law on the seventh anniversary of its signing, and a call for bipartisan improvements.
Treatment for addiction grew with the Medicaid expansion under Obama’s health care act, but millions may lose coverage if the House approves a measure to repeal the Affordable Care Act.
By NILO TABRIZY and AINARA TIEFENTHÄLER on  March 23, 2017. Photo by Nilo Tabrizy. Watch in Times Video »
“I’ve always said we should build on this law, just as Americans of both parties worked to improve Social SecurityMedicare, and Medicaid over the years,” he wrote in a mass email to followers. “So if Republicans are serious about lowering costs while expanding coverage to those who need it, and if they’re prepared to work with Democrats and objective evaluators in finding solutions that accomplish those goals — that’s something we all should welcome.”
The Affordable Care Act requires insurers to provide “essential health benefits” in 10 broad categories, including maternity care, mental health care, addiction treatment, preventive services, emergency services and rehabilitative services.
Mr. Spicer defended the removal of the “essential health benefits” regulations, saying that it would accomplish Mr. Trump’s stated goal of reducing health care costs. “Part of the reason that premiums have spiked out of control is because under Obamacare there were these mandated services that had to be included,” Mr. Spicer said.
Family planning groups and advocates for women’s rights criticized Republican plans to roll back these requirements.
“Paul Ryan and his House members are willing to sell out the moms of America to pass this bill,” said Dawn Laguens, an executive vice president of the Planned Parenthood Federation of America.
Conservatives say the mandates, as interpreted in rules issued by the Obama administration, add to the costs of health insurance and make it difficult for insurers to offer lower-cost options to meet consumers’ needs.
Democrats say that the purpose of insurance is to share risk, and that without federal requirements, insurers would once again offer bare-bones policies. Before the Affordable Care Act took effect, maternity coverage was frequently offered as an optional benefit, or rider, for a hefty additional premium.

C.B.O. Update: Health Bill Amendments Will Cost More But Not Insure More

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