Republicans for Single-Payer Health Care
by David Leonhardt - NYT - March 28, 2017
Without a viable health care agenda of their own, Republicans now face a choice between two options: Obamacare and a gradual shift toward a single-payer system. The early signs suggest they will choose single payer.
That would be the height of political irony, of course. Donald Trump, Paul Ryan and Tom Price may succeed where left-wing dreamers have long failed and move the country toward socialized medicine. And they would do it unwittingly, by undermining the most conservative health care system that Americans are willing to accept.
You’ve no doubt heard of that conservative system. It’s called Obamacare.
Let me take a step back to explain how we got here and how the politics of health care will most likely play out after last week’s Republican crackup.
Passing major social legislation is fantastically difficult. It tends to involve taking something from influential interest groups — taxing the rich, for example (as Obamacare did), or reducing some companies’ profits or hurting professional guilds. Those groups can often persuade voters that the status quo is less scary than change.
But when big social legislation does pass, and improves lives, it becomes even harder to undo than it was to create. Americans are generally not willing to go backward on matters of basic economic decency. Child labor isn’t coming back, and the minimum wage, Social Security and Medicare aren’t going away. Add Obamacare to the list. “Americans now think government should help guarantee coverage for just about everyone,” as Jennifer Rubin, a conservative, wrote.
Trump seemed to understand this during the campaign and came out in favor of universal coverage. Once elected, though, he reversed himself. He turned over health care to Price, a surgeon and Georgia congressman with an amazing record, and not in a good way.
Price had spent years proposing bills to take away people’s insurance. He also had a habit of buying the stocks of drug companies that benefited from policies he was pushing. Preet Bharara, the federal prosecutor, was investigating Price when Trump fired Bharara this month, ProPublica reported.
Price and Ryan were the main architects of the Republican health bill. They tried to persuade the country to return to a more laissez-faire system in which if you didn’t have insurance, it was your problem. They failed, spectacularly. Again, Americans weren’t willing to abandon basic economic decency.
But Price may not be finished. This weekend, Trump tweeted that “ObamaCare will explode,” and Price, now Trump’s secretary of health and human services, has the authority to undermine parts of the law. Here’s where the irony begins: He can more easily hurt the conservative parts than the liberal parts.
Obamacare increased coverage in two main ways. The more liberal way expanded a government program, Medicaid, to cover the near-poor. The more conservative way created private insurance markets where middle-class and affluent people could buy subsidized coverage.
The Medicaid expansion isn’t completely protected from Price. He can give statessome flexibility to deny coverage. But Medicaid is mostly protected. On Friday, after the Republican bill failed, Andy Slavitt, who ran Medicaid and Medicare for Obama, was talking on the phone to a former colleague. “Virtually the only words either of us could say,” Slavitt relayed, “were ‘Medicaid is safe.’ ”
The private markets are less safe. They have already had more problems than the Medicaid expansion. Price could try to fix those problems, and I hope he does. Or he could set out to aggravate the problems, which he has taken initial steps to do. Above all, he could make changes that discourage healthy people from signing up, causing prices to rise and insurers to flee.
Now, think about the political message this would send to Democrats: It’s not worth expanding health coverage in a conservative-friendly way, because Republican leaders won’t support it anyway.
Politics aside, private markets in many areas of the economy have substantive advantages over a government program. They create competition, which leads to innovation and lower prices. But private markets in medical care tend to be more complicated and less successful.
And government health care programs turn out to be very popular, among both Democratic and Republican voters. Medicare is a huge success. Medicaid also works well, and some Republicans have defended it in recent weeks.
So if voters like government-provided health care and Republicans are going to undermine private markets, what should Democrats do? When they are next in charge, they should expand government health care.
They should expand Medicaid further into the working class. They should open Medicare to people in their early 60s. They should add a so-called public option to the private markets. They should push the United States closer to single-payer health insurance. It will take time and involve setbacks, but they are likely to succeed in the long run.
Until then, the future of socialized medicine is in the hands of Dr. Tom Price.
In Health Bill’s Defeat, Medicaid Comes of Age
by Kate Zernike, Abby Goodnough and Pam Bullock - NYT - March 27, 2017
When it was created more than a half century ago, Medicaid almost escaped notice.
Front-page stories hailed the bigger, more controversial part of the law that President Lyndon B. Johnson signed that July day in 1965 — health insurance for elderly people, or Medicare, which the American Medical Association had bitterly denounced as socialized medicine. The New York Times did not even mention Medicaid, conceived as a small program to cover poor people’s medical bills.
But over the past five decades, Medicaid has surpassed Medicare in the number of Americans it covers. It has grown gradually into a behemoth that provides for the medical needs of one in five Americans — 74 million people — starting for many in the womb, and for others, ending only when they go to their graves.
Medicaid, so central to the country’s health care system, also played a major, though far less appreciated, role in last week’s collapse of the Republican drive to repeal and replace the Affordable Care Act, also known as Obamacare. While President Trump and others largely blamed the conservative Freedom Caucus for that failure, the objections of moderate Republicans to the deep cuts in Medicaid also helped doom the Republican bill.
“I was not willing to gamble with the care of my constituents with this huge unknown,” said Representative Frank A. LoBiondo of New Jersey, a member of the centrist Tuesday Group caucus, noting that in three of the counties in his district in the state’s more conservative southern half, over 30 percent of all residents are covered by Medicaid.
In the Senate, many Republicans, echoing their states’ governors, had worried about jeopardizing the treatment of people addicted to opioids, depriving the working poor, children and people with disabilities of health care and in the long run reducing funding for the care of elderly people in nursing homes.
The Republican bill would have largely undone the expansion of Medicaid under the A.C.A., which added 11 million low-income adults to the program and guaranteed the federal government would cover almost all of their costs. It would have also ended the federal government’s open-ended commitment to pay a significant share of states’ Medicaid costs, no matter how much enrollment or spending rose. Instead, the bill would have given the states a choice between a fixed annual sum per recipient or a block grant, both of which would have almost certainly led to major cuts in coverage over time.
The nonpartisan Congressional Budget Office predicted that the Republican bill would have cumulatively cut projected spending on Medicaid by $839 billion and reduced the number of Medicaid beneficiaries by 14 million over the coming decade.
Many Republicans could not stomach those consequences. Even some conservatives — Christopher H. Smith of New Jersey, for example, and Daniel Webster of Florida — expressed concerns about the number of Medicaid recipients who could suffer.
The Trump administration will likely still seek to rewrite Medicaid rules and give states more leeway to limit benefits or eligibility, for example, allowing them to require certain adults in the program to have jobs or pay monthly premiums. And many Republican governors and members of Congress remain determined to curb Medicaid spending, including by methods proposed in the bill. In 2015, the nation spent more than $532 billion on Medicaid, of which about 63 percent was federal money and the rest from the states.
Still, last week’s defeat reflected how hard it is to take away an entitlement. It also showed the broad and deep reach of Medicaid, which covers about six times as many people as the private marketplaces created under the A.C.A. but, perhaps because the markets are more strongly associated with President Barack Obama and his law, got less attention in this month’s contentious debate.
Medicaid now provides medical care to four out of 10 American children. It covers the costs of nearly half of all births in the United States. It pays for the care for two-thirds of people in nursing homes. And it provides for 10 million children and adults with physical or mental disabilities. For states, it accounts for 60 percent of federal funding — meaning that cuts hurt not only poor and middle-class families caring for their children with autism or dying parents, but also bond ratings.
The program is so woven into the nation’s fabric that in 2015, almost two thirds of Americans in a poll by the Kaiser Family Foundation said they were either covered by Medicaid or had a family member or friend who was. The program not only pays for 16 percent of all personal health care spending nationwide, but also accounts for 9 percent of federal domestic spending.
Because it has always covered a patchwork of groups — and many of its beneficiaries are poor and relatively powerless — Medicaid lacks the unified, formidable political constituency that Social Security and Medicare have. States often have different names for the program, and many who rely on it don’t realize that MassHealth in Massachusetts or TennCare in Tennessee are just Medicaid by another name.
But in Kaiser’s polling since 2005, the percentage of people who support cutting Medicaid spending has never exceeded 13 percent. “The conventional wisdom that there’s a great deal of stigma attached to this program does not bear out in the public opinion data,” said Mollyann Brodie, who oversees polling for the foundation.
President Trump led the charge for the bill that would have slashed Medicaid, but he recognized the program’s political potency during his campaign, proclaiming when he announced his candidacy that Medicaid should be saved “without cuts” and repeatedly taking to Twitter to declare his support for it. “The Republicans who want to cut SS and Medicaid are wrong,” he wrote in July 2015.
The C.B.O. report made it clear that within a few years, the cuts to Medicaid in the Republican bill would have been felt by millions of Americans.
“It’s health care for a huge chunk of the country,” said James A. Morone, a political-science professor at Brown University, “and as Donald Trump discovered, it’s really, really complicated to mess around with.”
Facing Need Back Home
As he waited to see what would happen to the Republican proposal last week, Myrone Pickett said, “I’ve got a question mark hanging over my head.”
Mr. Pickett, of Bloomfield, N.J., got health insurance under the A.C.A.’s expansion of Medicaid, and has used it for monthly shots of Vivitrol, a drug that reduces cravings for opioids and alcohol. A heroin addict for 16 years, Mr. Pickett, 51, said the treatment had helped him stay clean for the past year, get medication for bipolar disorder and land a job at a grocery store.
The A.C.A. offered a tempting deal to states that agreed to expand Medicaid eligibility to everyone with incomes up to 138 percent of the poverty level — $16,400 for a single person — mostly low-wage workers like cooks, hairdressers and cashiers. The federal government would initially pay 100 percent of the costs of covering their medical care, and never less than 90 percent under the terms of the law. Over the past three years, 31 states and the District of Columbia took the deal.
The move was especially helpful to states overwhelmed by the opioid epidemic. It required Medicaid to cover addiction and mental health treatment for those newly eligible.
Announcing his vote against the G.O.P. proposal last week, Representative Brian Fitzpatrick, a Pennsylvania Republican who represents a politically moderate district north of Philadelphia, said his top concern was “the impact on the single most important issue plaguing Bucks and Montgomery Counties, and the issue that I have made my priority in Congress: opioid abuse prevention, treatment and recovery.”
The Republican bill would have allowed Medicaid payments to grow per person at an inflation rate that would have eroded their value over time. The C.B.O. estimated that states would have gradually had to devote more of their own money to Medicaid, cut payments to doctors, tighten eligibility or cut services covered.
In 2020, states would have started losing the 90 percent federal match for anyone who had gained Medicaid under the A.C.A. expansion but was dropped from the rolls, even briefly. And the bill required beneficiaries in the expansion population to re-enroll every six months, instead of annually, increasing the likelihood that many would be dropped.
As a result, the C.B.O. estimated that by 2026, less than 5 percent of Medicaid recipients enrolled under the A.C.A. would have been covered at the higher matching rate. But more broadly, the cuts would have almost inevitably affected every group covered by Medicaid, including the biggest block of recipients: 36 million children as of last year.
Representative Jaime Herrera Beutler, a Washington State Republican, announced her “no” vote on the bill Thursday, saying, “Protecting vulnerable children is a core purpose of the Medicaid program and when the program fails to do so, it fails entirely.”
The cuts would also likely have eventually hit poor, chronically ill mothers like Tracie Scott of Paulding, Ohio. She has multiple sclerosis and quit her job at a dollar store two years ago because of it. Medicaid covers her and her four children, including her 2-week-old daughter and an 8-year-old son with brittle-bone disease who has needed expensive medication and care for frequent fractures.
“I’d be afraid to see some of the bills for my son,” Ms. Scott, 30, said as she cradled her newborn, Izabella, in their hospital room recently. “It’s been a lifesaver.”
For more than six million Americans older than 64, Medicaid pays for nursing homes and other long-term care that they would never otherwise be able to afford, while Medicare covers their medical care.
The threat to such care propelled Representative Webster, whose Central Florida district includes The Villages, a retirement community with more than 150,000 residents, to lean “no” on the bill.
“This uniquely impacted Florida and our growing senior population that’s only going to explode in years to come,” said Jaryn Emhof, his spokeswoman.
Representative Smith of New Jersey said he was voting no because of concerns about the impact on people with disabilities, who make up just 15 percent of all Medicaid recipients but account for 42 percent of spending, making them particularly vulnerable to cuts.
For millions of disabled people, Medicaid covers services provided at home or through local programs — aides who help them walk, eat and bathe, for example, and physical and speech therapy — that allow them to stay out of institutions, where care is often more expensive. But those services are optional for states, while the cost of institutional care is not. The law would have given states an incentive to place them in institutions.
Medicaid pays for Barbara Theus, 67, to attend a day program in Southfield, Mich., so that her son and caregiver, Royale Theus, can work. Ms. Theus sustained a serious head injury in a car accident 11 years ago and has not been able to care for herself since then. Medicaid also pays for home health aides who help Ms. Theus, a former nurse who did not have much savings at the time of her accident, get showered and fed.
Mr. Theus was relieved when the bill failed. Had his mother lost coverage, he said, he would have had to leave his job to care for her. “I was hopeful that the powers that be would make the best decisions for the people, and that’s what happened,” he said.
The Battle Against Medicaid
This was the third major effort by Republicans to end Medicaid as an open-ended entitlement. The first was under President Ronald Reagan, the second was in 1995, after President Bill Clinton’s unsuccessful attempt to expand health care coverage. But this was the first time Republicans tried it while they controlled the White House and both houses of Congress.
For all the battles over the years, Medicaid started as something of an afterthought.
By 1960, both parties were worried that the country’s growing reliance on employer-based insurance was leaving out elderly people, who were unable to pay the rapidly rising cost of health care.
The night of President John F. Kennedy’s assassination in November 1963, Lyndon Johnson returned to his home in Washington and, unable to sleep, summoned three aides. “That’s when he took out his pen and wrote down the priorities that he was going to pursue,” one of those aides, Bill Moyers, recalled in an interview. Among them was government health insurance.
President Harry S. Truman had sought to establish national health insurance — and failed. Democrats decided to take on a more limited goal: insurance for elderly people. They called it Medicare. Democrats pushed for it to cover hospital bills for the elderly; Republicans wanted it to pay for private doctor’s bills.
The American Medical Association had long lobbied against Medicare, hiring Reagan, then a Hollywood actor, to be the face of its campaign, producing a 1961 LPtitled “Ronald Reagan Speaks Out Against Socialized Medicine.”
And the doctors’ group had an ally in Wilbur Mills, a conservative Democrat who was chairman of the powerful House Ways and Means Committee, who like the doctors’ group did not think that well-off elderly people should have their bills covered. In 1960, Mr. Mills had co-sponsored a law that established a small programto help the states treat the needy, as a way to stave off proposals for Medicare. The doctors’ group suggested expanding this program, preferring it because it would be administered by states, not the federal government.
Mr. Mills had a change of heart after Johnson’s landslide victory in 1964. Johnson’s Republican opponent, Senator Barry Goldwater of Arizona, had denounced Medicare, and Mr. Mills, and many Republicans, were eager to distance themselves from him.
In early 1965, Mr. Mills proposed what became known as the three-layer cake: Medicare for hospital insurance, Medicare for doctor’s bills and a broadened version of the law that helped states pay for the care of the poor, the program that would become Medicaid.
“Hardly anybody talked about Medicaid,” said Paul Starr, a sociology professor at Princeton. “It just got added on.”
At first, Medicaid helped states provide medical care only for single parents and children on welfare.
Over the next 25 years, Democrats — sometimes working with Republicans — gradually pushed to expand benefits — to two-parent families, to children with speech and development delays, to home treatment for people who would otherwise be institutionalized, to children up to age 5, then to age 8 and later to age 18, and to pregnant women.
Ironically, some of the biggest expansions in Medicaid came in the 1980s under Reagan, the onetime A.M.A. mouthpiece.
After Republicans failed to turn Medicaid into a block grant, Democrats, who still controlled Congress, worked on compromises with the president and other Republicans, sometimes allowing cuts in programs like Medicare in exchange for expanding Medicaid, said former Representative Henry Waxman, a Democrat who shepherded many of those expansions.
Democrats carefully calibrated each expansion to fit within the annual budget, submitting plans to the Congressional Budget Office for “scoring,” to see how much each would cost. “We couldn’t do it all at once because we didn’t have enough money in the budgets,” Mr. Waxman said. But eventually, the goal to decouple Medicaid from the welfare system was achieved. “We broke the link to welfare,” he said.
By the 1980s and ’90s, health insurance was becoming prohibitively costly, and wages were starting to stagnate. Employer-based health insurance was eroding. States led by Republicans as well as Democrats began to expand their Medicaid programs.
“What people began to accept, including Republicans, was that the assumption that you could afford health insurance if you were an able-bodied adult was not true,” said Colleen M. Grogan, a professor at the School of Social Service Administration at the University of Chicago, who has written extensively on health care. “You could be working and still not afford health insurance.”
In 1996, Mr. Clinton expanded Medicaid to cover more working families as part of his welfare overhaul. Campaigning for re-election that year, he depicted Medicaid as a middle-class program, telling audiences it was helping their grandparents.
“He is the first Democrat to start calling Medicaid one of ‘our programs,’” said Professor Morone of Brown. “There was a sense that Medicaid had sort of grown up as an entitlement.”
The expansion of Medicaid in the Children’s Health Insurance Program, passed with Republican sponsorship in 1997, set the stage for the sweeping expansions of the Affordable Care Act 13 years later.
But politics during Mr. Obama’s presidency had become highly polarized. While earlier expansions of Medicaid had sometimes been bipartisan, the A.C.A. passed without a single Republican vote in Congress. The Tea Party had risen in opposition to the legislation, and later helped elect many of those who now form the conservative Freedom Caucus.
Gradually, though, Republican-led states have adopted the expansion. And now that the law known as Obamacare has survived the effort to repeal it, more states may choose to expand Medicaid. In Maine, voters will decide this fall whether to do so, and in Kansas, the Legislature has all but approved an expansion, although Gov. Sam Brownback could veto it.
Last week, despite their desire to repeal Mr. Obama’s biggest domestic legacy, some Republicans recognized that any bill that would lead to such drastic cuts in Medicaid would simply hurt too many of their constituents.
In Ashland, Va., Medicaid made it possible for Kim Goodloe and her husband, Tom, to start a small company making metal parts for semiconductors and medical devices after the birth of twin boys with tuberous sclerosis 27 years ago. The genetic disorder causes tumors in vital organs, leading to frequent seizures, and Mrs. Goodloe had quit her job to take care of the boys when they were 4 — Medicaid did not cover services for them back then. But now, Medicaid provides a home aide for Matthew, who is incontinent and nonverbal, suffers daily seizures and needs help walking.
For the other twin, Christopher, who is less severely developmentally disabled, Medicaid provided a job coach, helping him to work at their company and earn enough money that he now pays taxes.
The Goodloes have private insurance, but it is not required to pay for the twins’ services, she said. With Virginia facing such steep cuts to its federal Medicaid payments, Mrs. Goodloe worried about losing the home health aide. They would have had to downsize the business, which employs 30 people.
“Even within my own family, when you say ‘Medicaid’ it comes with some, ‘Those people don’t want to work.’ They believe there’s a lot of fraud, there’s people that don’t deserve it.”
“But then,” she said, “They’ll say, ‘How could they take it away from Matthew?’”
SAMUELSON: Transfer Medicaid’s long-term care to federal government
Robert Samuelson - The Washington Post - March 19, 2017
WASHINGTON - It’s time to take control of Medicaid before it takes control of us. Unless we act — and there is little evidence that we will — Medicaid increasingly becomes another mechanism by which government skews spending toward the old and away from the young. In the raging debate over the Affordable Care Act, this is a subject that neither Republicans nor Democrats dare touch. It’s an ominous omission.
Medicaid is the sleeping giant of U.S. health care. Created in 1965, it provides health insurance for the very poor. Here are some basic Medicaid facts:
- It is the nation’s largest health insurance program by beneficiaries, with 68 million recipients compared with Medicare’s 55 million (Medicare provides insurance for the 65 and over population).
- Medicaid’s costs are shared between the federal government (roughly 60 percent) and state governments (40 percent). In 2015, Medicaid spending totaled $545 billion compared with Medicare’s $646 billion, reports the Kaiser Family Foundation.
- Although the Obamacare debate has focused on private insurance subsidized through health exchanges, the expansion of Medicaid — adopting more liberal eligibility requirements — resulted in the largest gain of insurance coverage, about 11 million people.
But the most significant Medicaid fact is this: Although three-quarters of Medicaid recipients are either children or young adults, they account for only one-third of costs. The elderly and disabled constitute the other one-quarter of recipients, but they represent two-thirds of costs.
How could this be? Doesn’t Medicare — not Medicaid — cover the elderly and disabled? Well, yes, but there’s a giant omission: nursing home and other long-term care. Medicaid covers these for the poor elderly and disabled.
Here’s where the past and future collide. As the population ages, the people needing long-term care will soar. From 2015 to 2030, the number of Americans 85 and older will rise about 50 percent to 9 million, projects the Census Bureau. Many will end up in nursing homes, with high costs. The average health costs of Americans 85 and over are 2.5 times greater than for people 65 to 74, says the Center on Budget and Policy Priorities.
At the federal level, spending on the elderly — mainly for Social Security, Medicare and Medicaid — is already crowding out non-elderly spending, as the Trump administration’s new 2018 budget shows. Now pressures are tightening on states.
Because they pay 40 percent of Medicaid, its escalating costs compete directly with state and local services — schools, roads, police, parks, sanitation — and lower taxes. Medicaid’s “entitlement” nature means that anyone who qualifies for support must get it. By contrast, schools and other state services get what seems affordable.
Fortunately, there’s a sensible solution to this problem. It isn’t to gut care for the elderly. Instead, we should transfer Medicaid’s long-term care to the federal government, which would pay all costs, probably by merging with Medicare. In return, the states would assume all Medicaid’s costs for children and younger adults, give up some or all of their federal aid for K-12 schools and, if needed, trim other federal grants to ensure financial neutrality.
For states, spending would no longer be tied to demographic trends — an aging society — they can’t change. Controlling schools and a child-centered Medicaid, they would be in the best position to fight child poverty, which is arguably the nation’s most serious social problem. The rising costs of long-term care, a national problem, would not handcuff them.
As for the federal government, it would control all major programs for the elderly and disabled. If benefits for the elderly are to be cut (say, by raising eligibility ages), that job is best done if the federal government can choose from all programs for the old.
Unfortunately, national politicians seem uninterested. They prefer instead to bleed the states.
Trumpcare is dead. May it forever stay in its shallow grave
by Adam Gaffney - The Guardian - March 27, 2017
The American Health Care Act – a bill engineered to transform the healthcare of the poor into precious metal for the rich – has departed. Let us hope it stays in its admittedly shallow grave.
Its implosion on Friday – attributable to some combination of the intransigence of the House hard right, an extraordinary lack of popular support, and an impressive show of grassroots antagonism – will prove to be a pivotal moment in healthcare history, for at least two reasons.
First, it is tantamount to a societal rejection of the conservative healthcare ethos. Second, it may very well open the door to more progressive, fundamental healthcare change in the years to come.
Would-be Trumpcare had three main pillars: continue the Affordable Care Act’s (ACA) subsidization of private health plans (though recalibrated along highly regressive lines), shrink Medicaid by about 25% over a decade, and provide lavish tax breaks to the rich.
It was thus the evil cousin of Obamacare: it would have benefited the well-off at the expense of the working class and sick, it is true, yet it would also have conserved Obamacare’s overall organization, and left many of its insurance regulations intact.
This last fact played a major role in the bill’s fate, for it alienated hard-right true believers in the “House Freedom Caucus”. Conservatives contended that it would only be by eliminating Obamacare’s various insurance regulations – including the one that requires that plans cover “essential health benefits“ like hospitalizations, maternity care and medicines – that premiums would fall.
They are not entirely wrong on this point: skimpier plans are cheaper. Likewise, we could lower rent if landlords weren’t expected to provide heat, running water and a low risk of structural collapse.
And ideologically, for true believers in the conservative ideal of healthcare freedom, governments shouldn’t mandate that plans cover particular benefits any more than they should require that all pizzas be sold with some arbitrary assortment of toppings (which would admittedly not be to everyone’s tastes).
Why, for instance, should I be forced to pay for coverage of prenatal care, if I have no uterus? And no emphysema coverage for me, thank you very much! – as a pulmonologist I’m wise enough to have other vices than cigarettes. Of course, even putting aside old-fashioned notions like solidarity and basic decency, as policy such sentiments are puerile nonsense.
We cannot know what medical problems we will encounter: a system wherein we all select coverage tailored to our unique gonads, bad habits or unlucky genes would be as dysfunctional as it was cruel.
Yet to the dismay of many on the right, the Trumpcare bill did little, at least initially, to let a thousand health insurance plans bloom. These hard-right House Republicanswere unimpressed, seeing the bill as little more than Obamacare reincarnate.
In the 18 days between the introduction of his bill and its death, Speaker of the House Paul Ryan strove to mollify them: he offered modifications including a Victorian-era themed provision to encourage states to impose work requirements on Medicaid participants, an option for states to more radically degrade Medicaid through “block granting”, and – at the eleventh hour – a provision to shred Obamacare’s “essential health benefits” requirements.
All was to no avail. For Trumpcare had almost no popular support – a widely cited poll found that pathetically few Americans (a mere 17%) liked what they heard – and each slide to the right risked shedding more support from so-called “moderates”, who probably mostly feared for their own necks (electorally speaking) by lining up behind such a widely detested bill (which could have been a factor among hard-right lawmakers as well). With an excess of defectors on both sides, Ryan and Trump were forced to declare a humiliating defeat.
Trumpcare, it is clear, belongs in the dustbin of history. But with it should go the pernicious principle at the heart of conservative healthcare policy. The right promises “choice”, which is intrinsically appealing, for we all want choice in healthcare: the right to choose our doctor, and to receive care that comports to our unique needs and beliefs.
Yet what the right – and, for that matter, the center – promise is the mostly empty choice of insurance coverage. But coverage choice dictated by one’s wallet is frequently no choice at all. More importantly, the greatest choice in care is found in a universal system with a single tier of comprehensive coverage.
And so, it may be the second legacy of Trumpcare’s defeat – the opening of a window for progressive healthcare change – that will prove even more consequential. Trump lied – he was never going to deliver “insurance for everybody”, as he promised in an interview with the Washington Post – but that’s what people want.
The only feasible path to that goal – the one that would produce the savings needed to cover the new costs – remains a universal system with single-payer financing. The next move for progressives is therefore a no-brainer, both politically and morally: coalesce behind single-payer as the healthcare vision of tomorrow.
Maine Voices: The problem isn’t Obamacare; it’s the insurance companies
by Cathleen London - Portland Press Herald - November 28, 2016
Patients and primary care physicians are getting the raw end of the deal for the sake of corporate profits.
MILBRIDGE — With the recent news about increases in premiums for health plans sold through the Affordable Care Act marketplace, everyone wants to vilify the ACA. The ACA is but a symptom of the issue. Where are our policy dollars going?
As a primary care physician, I am on the front lines. Milbridge is remote. In good weather, we are 30 to 40 minutes from the nearest emergency room, so my office operates as an urgent care facility as well as a family medical practice.
It can take 20 minutes for an ambulance to get here (as it did one time when I had a patient in ventricular tachycardia — a fatal rhythm). I have to be stocked to stabilize and treat.
We are also about two hours from specialist care. Fortunately, I am trained to handle about 90 percent of medical problems, as my patients often do not want or do not have the resources to travel. I have to be prepared for much more than I did in Boston or New York City, where I had colleagues and other materials down the hall or nearby. No longer do I have a hospital blocks away.
One evening I was almost home after a full day’s work. Around 7:30, I got a call on the emergency line regarding an 82-year-old man who had fallen and split his head open. His wife wanted to know if I could see him, even though he was not a patient of mine.
Instead of sending them to the ER, I went back to the office. I spent 90 minutes evaluating him, suturing his wound and making sure that nothing more sinister had occurred than a loss of footing by a man who has mild dementia. When I was sure that the man would be safe, I let them go.
I billed a total of $789 for the visit, repair, after-hours and emergency care costs. Stating that the after-hours and emergency services had been billed incorrectly, Martin’s Point Health Care threw out the claims and reimbursed me $105, which does not even cover the suture and other materials I used.
I called them about their decision, said that it was not right and let them know they’d lose me if they reimbursed this as a routine patient visit. They replied, “Go ahead and send your termination letter” – which I did.
The same day, Anthem Blue Cross kept me on the phone for 45 minutes regarding a breast MRI recommended by radiologists on a woman whose mother and sister had died of breast cancer. She’d had five months of breast discharge that wasn’t traceable to anything benign (and it turns out the MRI is highly suspicious for cancer).
Anthem did not want to approve the MRI unless it was to localize a lesion for biopsy, even though the mammogram had been inconclusive! This should have been a slam-dunk fast track to approval; instead, dealing with Anthem wasted a good part of my day.
Then Aetna told me there is no way to negotiate fees in Maine. I was somewhat flabbergasted. I do more here than I did in either Brookline, Massachusetts, or New York. The rates should be higher given the level of care I am providing. I have chosen not to participate with them. This only hurts patients; however, I cannot keep losing money on visits.
I do lose money on MaineCare – their reimbursement is below what it costs me to see a patient. For now, that is a decision that I am living with.
I had thought those losses would be offset by private insurance companies, but their cost shifting to patients is obscene. I pay half of my employees’ health insurance, though I’m not required to by law – I just think it is the right thing to do.
My personal policy costs close to $900 a month for me and my sons (all healthy), and each of us has a $6,000 deductible. This means I am paying rack rate for a policy that provides only bare-bones coverage.
Something is wrong with the system. In one day, I encountered everything wrong with insurance. I am not trying to scam the system. I am literally trying to survive. I am trying to give care in an underserved area.
This is not the fault of Obamacare, which stopped the most egregious problems with insurance companies. Remember lifetime caps? Remember denials for pre-existing conditions? Remember the retroactive cancellation of insurance policies? Returning to that is not an option.
One answer is direct primary care: contracting straight with patients to provide their care, instead of going through insurance companies to get paid. I offer it (though I still accept Medicare, MaineCare and some private insurers). Many of my colleagues have also opted for direct primary care – they’ve experienced the same frustrations I have.
Something has to change if we are to attract up-and-coming medical students to primary care and retain practicing physicians. When both patients and physicians are frustrated, we know that only greed is winning, and the blame for that lies with corporations.
Pushing Obamacare Over the Cliff
by Steve Rattner - NYT - March 28, 2017
After Republicans pulled their legislation to repeal and replace the Affordable Care Act last Friday, President Trump told The Washington Post, “The best thing politically is to let Obamacare explode.”
Or he could light a match. Republicans may have conceded defeat in their legislative effort to get rid of Obamacare, but their guerrilla war to achieve its demise remains underway.
The stealth battle began on Inauguration Day, when Mr. Trump signed an executive order giving his agencies wide latitude to weaken the law.
Almost immediately, the Department of Health and Human Services scaled back advertising aimed at encouraging people to enroll in a health insurance plan by the Jan. 31 deadline for 2017.
No surprise, then, that sign-ups for this year came in a bit short of expectations.
Next, the Internal Revenue Service announced that it would continue to allow taxpayers to file their returns without indicating whether they had complied with the mandate to have insurance. Assertions to the contrary notwithstanding, this was quickly interpreted to mean that those failing to comply with the health care act’s insurance requirement would not be assessed penalties.
These may sound like small potatoes, but the requirement that all Americans have insurance is at the heart of Obamacare. Without maximum participation of healthy, young Americans in the insurance exchanges, insurers cannot afford the cost of covering older, less healthy individuals.
That’s the essence of why companies have been dropping out of the marketplace, creating the risk that counties in states like Tennessee and Arizona may have no insurers participating.
Much more seems on the horizon. This month, Tom Price, the secretary of the Health and Human Services Department, tweeted: “There are 1,442 citations in the #ACA where it says. ‘The secretary shall …’ or ‘The secretary may …’ @HHSGov, we’ll look at every single one.”
Through that pathway, the Trump administration can chip away at other parts of Obamacare, notably the expansion of Medicaid.
While Medicaid expansion can’t collapse the way that the exchanges could, Mr. Price could diminish it by taking steps like allowing states to impose a work requirement on enrollees or to limit lifetime benefits. He could also water down the 10 essential benefits required for all policies by the law, like maternity care and mental health coverage.
Even if my worries are misplaced, remember that Obamacare worked, in part, because it had the active support of the entire executive branch.
It’s no surprise that, like every huge new social program, the A.C.A. needs some tuneups.
For example, the well-intentioned decision to limit the size of the premiums that can be charged to older people to three times what can be charged to younger people has resulted in higher premiums for younger Americans, which has in turn discouraged sign-ups.
Raising that limit (as Republicans have proposed) would be a plus if coupled with higher subsidies for deserving older people, as would be increasing the penalties on those who opt out. At present, those fees are far less than the cost of insurance.
Conservatives say they want states to have more flexibility. One meritorious idea would be allowing states to create reinsurance pools that would cushion insurers against losses, thus lowering premiums.
To be fair, the administration’s actions to date have not been completely one-sided. In February, to provide more certainty to insurers, H.H.S. set stricter limits on sign-ups outside the defined enrollment periods. The Republicans even incorporated one good idea in their failed bill: a $100 billion pool that states could use to help cover the cost of insuring very sick people, thereby shoring up weak exchanges. There seems little chance of that happening now.
But the White House has been silent on a major issue: whether it will continue to fight a lawsuit by House Republicans intended to eliminate subsidies to low-income Americans to help cover their deductibles and co-payments.
If the effectiveness of the A.C.A. is diminished — whether by affirmative moves by the Trump administration or passive resistance to needed improvements — rest assured that the Republicans will try to blame Obamacare’s supporters. Mr. Trump may not know how to govern, but he’s proven his ability to conduct Twitter wars.
Supporters of the A.C.A. — perhaps the greatest single legislative achievement in many decades — need to counter that, informing Americans that any deterioration in their coverage will be the fault of the Trump administration.
2018 Dilemma for Republicans: Which Way Now on Obamacare?
by Jonathan Martin - NYT - March 28, 2017
WASHINGTON — As they come to terms with their humiliating failure to undo the Affordable Care Act, Republicans eyeing next year’s congressional campaign are grappling with a new dilemma: Do they risk depressing their conservative base by abandoning the repeal effort or anger a broader set of voters by reviving a deeply unpopular bill even closer to the midterm elections?
The question is particularly acute in the House, where the Republican majority could be at risk in 2018 if the party’s voters are demoralized, and Democratic activists, energized by the chance to send a message to President Trump, stream to the polls.
Sifting through the wreckage of a disastrous week, Republican strategists and elected officials were divided over the best way forward. Some House Republicans pressed to move on to other issues and notch some victories that could delight their own loyalists while not turning off swing voters.
“We’ve got a lot of time to do real things on infrastructure, to do real things on tax reform, on red tape reform, and really get the American economy moving,” said Representative Steve Stivers of Ohio, chairman of the National Republican Congressional Committee, the House campaign arm. “We do those things and we still have a lot of time to recover.”
“If you’re going to fumble the ball,” he added, “better to do so in the first quarter of a football game.”
Devising health care legislation that could appeal to both wings of the House Republican Conference — the hard-line conservatives and more moderate members — would require a nearly superhuman feat, added Representative Billy Long, Republican of Missouri.
“Not unless Harry Houdini wins a special election to help us,” Mr. Long said about the prospects of cobbling together a coalition that could agree on how to repeal and replace the health care law.
But other longtime Republicans warned that if the party did not address what they have derided as Obamacare, an issue that has been central to their campaigns for the last seven years, they would incur a heavy political price in the midterm elections.
Midterm campaigns have increasingly become akin to parliamentary elections — referendums on the party in power rather than on individual candidates, where turnout by dependable partisan voters is the deciding factor.
“If they fall on their sword on this, they’re going to get slaughtered,” said former Representative Thomas M. Davis III, a Virginia Republican who himself was once at the helm of the House campaign committee.
“Where parties get hurt in midterms is when their base collapses,” Mr. Davis said. “Democrats are going to show up regardless of what you do. If our voters don’t see us fulfilling what we said we were going to do, they’ll get dispirited.”
What troubles many Republican strategists is the specter of the party’s most reliable voters being bombarded by reminders of their leaders’ failure to address the health law. They fear a recurring story line sure to pop up every time insurance premiums increase, providers leave local networks, or, most worrisome, Republicans fund President Barack Obama’s signature achievement.
Conservatives, many of whom opposed the House repeal bill, now warn that it is untenable to stand pat on the issue — and that lawmakers will face retribution if they do not return to the repeal-and-replace effort.
“If people are looking at a situation where there’s no action on this, there are going to be conversations about primaries,” warned Michael A. Needham, the chief executive of Heritage Action for America, the Heritage Foundation’s political arm, which worked to scuttle the Republican health bill last week.
That Republicans even find themselves in such a quandary just over two months after Mr. Trump was sworn in is at once extraordinary and not altogether surprising. Republicans who were then in office opposed the Affordable Care Act when it was enacted in 2010, yet they were paralyzed in efforts to undo it.
The paradox is predictable for a party that has been at war with itself since the final years of President George W. Bush’s administration. Mr. Trump transcended those divisions last year in his campaign, but congressional Republicans remain riven between their hard-liners and mainstream conservatives.
Perhaps it was inevitable that these factions would clash over an issue as sensitive as remaking the American health care system. The purists — often from politically safe districts — believe the government should play almost no role in providing health insurance to its citizens. Placating them without endangering more pragmatic lawmakers worried about depriving constituents of their health coverage may be an impossible task.
“I think we need to start negotiating with Democrats instead of the Freedom Caucus,” said a frustrated Mr. Stivers, referring to the most conservative bloc of House Republicans. “They don’t know how to get to yes.”
Democrats, though, have no appetite for conciliation: They see the Republican disarray over health care, and the broader tensions on display in the clash over the health care law, as a path back to the House majority.
Seizing on the Republicans’ American Health Care Act, which according to a Quinnipiac University survey last week was supported by only 17 percent of Americans, Democrats have started digital advertising against the 14 potentially vulnerable House Republicans who supported the legislation in committee votes.
Some of these lawmakers represent districts that Hillary Clinton carried last year. They are as concerned about the consequences of casting a vote for the bill as they are about inviting a backlash from their bases for not addressing the issue at all.
Indeed, though much of the frustration from mainline Republicans has been directed at the Freedom Caucus, Republican lawmakers from pro-Clinton districts played just as big a role in torpedoing the American Health Care Act.
“I don’t want to vote for a bill that has no chance of passing the Senate,” explained Representative Leonard Lance of New Jersey, one such lawmaker who invoked the haunting tradition of House members’ casting risky and, in some cases, career-ending votes, only to see their Senate colleagues sit on the proposals.
Mr. Lance, whose district Mrs. Clinton carried, and other Republicans insisted after the bill’s collapse last week that they still wanted to wrestle with the Affordable Care Act in this Congress.
But former Representative Earl Pomeroy of North Dakota, a Democrat who lost his seat in 2010 in part because of his vote for the Affordable Care Act, said he thought Republicans like Mr. Lance were actually “breathing a sigh of relief” for averting a floor vote.
“It’s a very, very tough vote for somebody in a competitive race,” Mr. Pomeroy said. “They may alienate their base by voting against it, but if they support a bill resulting in people losing their coverage, there will be electoral hell to pay.”