Monday, March 6, 2017

Health Care Reform Articles - March 6, 2017

Editor's Note:

The following quotation is from Daniel Fried's recent farewell speech after 40 years at the Department of State. The bold italics are mine. I think they pertain to any great struggle for justice.It is taken in part from a recent column by Roger Cohen in the NYT, that can be found at:


From Daniel Fried
"Fried had this to say in his parting remarks:My 40 years in the Foreign Service – and the careers of many of my friends – became associated with the fall of the Soviet Empire and the putting in order of what came after: the building of a Europe whole, free and at peace. It is hard to recall today how improbable victory in the Cold War appeared. For two generations, up through the mid-1980s, many thought we were losing the Cold War. Even in early 1989, few believed that Poland’s Solidarity movement could win, that the Iron Curtain would come down, that the Baltic states could be free, that the second of the Century’s great evils – Communism – could be vanquished without war. But it happened, and the West’s great institutions – NATO and the EU – grew to embrace 100 million liberated Europeans. It was my honor to have done what I could to help. I learned never to underestimate the possibility of change, that values have power, and that time and patience can pay off, especially if you’re serious about your objectives. Nothing can be taken for granted, and this great achievement is now under assault by Russia, but what we did in my time is no less honorable. It is for the present generation to defend and, when the time comes again, extend freedom in Europe.

‘Medicare for all’ in California?
Thanks to Trump, state single-payer healthcare could be more feasible
by David Lazarus - LA Times - March 3, 2017
Could California have its own single-payer health insurance system providing coverage for all residents? A bill has been introduced in the state Legislature that would do just that — and its chances of success could be vastly improved by President Trump and the Republican-controlled Congress.
Thanks, guys!
First, a little history lesson. Stick with me because this is important.
California flirted with a single-payer system when the Legislature signed off on the idea in 2006 and again in 2008. The bills were vetoed by former Gov. Arnold Schwarzenegger, who declared in 2006 that “socialized medicine is not the solution to our state’s healthcare problems.”
Those legislative efforts were spearheaded by Sheila Kuehl, who was then a state senator and is now a Los Angeles County supervisor. She and I spoke frequently during California’s flirtation with single payer and we caught up on the topic this week.
Her biggest mistake in 2008, Kuehl told me, was not effectively countering the “socialized medicine” line from Republicans and conservative critics.
“What we should have done from the very beginning was use the phrase ‘Medicare for all,’ ” she said. “People are familiar with how Medicare works. They would have understood that we weren’t taking over healthcare providers.”
Under the typical single-payer system, payroll taxes replace premiums, deductibles and co-pays as a funding mechanism for health insurance. This is how almost all other developed countries succeed in providing affordable coverage for everyone — and for about half as much as what Americans pay.
No one is proposing a government takeover of hospitals and doctors’ offices.
“Single-payer isn’t socialized medicine,” Kuehl said. “It has nothing to do with hospitals and doctors. It’s purely a form of insurance. But we didn’t communicate that as well as we could have.”
Messaging aside, she thinks the public has become more open to new ideas.
“With so much uncertainty from the Trump administration,” Kuehl said, “I’m more convinced than ever that single-payer is the way to go for California. It’s a very, very good idea.”
The idea is back in play thanks to state Sen. Ricardo Lara (D-Bell Gardens), who last week introduced a bill aimed at creating a Medicare-for-all system for Californians.
It doesn’t yet say how this would be accomplished. Instead, it declares the Legislature’s “intent” to pass a law that would “establish a comprehensive universal single-payer healthcare coverage program and a healthcare cost control system for the benefit of all residents of the state.”
Details, presumably, will come later.
“If Republicans abandon California and Congress moves to cut Medicaid, we will insist that the federal government treat us like any other state and give us the flexibility and freedom to address the health needs of our entire population through a universal healthcare system,” Lara told me.
Studies have shown that a single-payer system would result in lower out-of-pocket costs for most California residents.
But one big problem with Kuehl’s earlier bills was how the $100-billion Medi-Cal program — the state’s version of Medicaid — would integrate with a California single-payer system. Medi-Cal covers about a third of the state’s population. About $67 billion in funding comes from the federal government.
That state-federal partnership meant Washington would have needed to sign off on any move to incorporate Medi-Cal into a state single-payer plan, and Kuehl acknowledged at the time that this probably would have been hard to obtain.
Thanks to Trump and the Republican-controlled Congress, things are now very different.
“We should give our great state governors the resources and flexibility they need with Medicaid to make sure no one is left out,” Trump said in his speech to Congress this week.
What he and Republican leaders mean by that is giving states a fixed amount of Medicaid money in the form of block grants to cover low-income people. States currently are guaranteed at least $1 in federal funds for every $1 in state spending.
The Republicans’ goal is for the federal government to pay less for Medicaid annually. But what they’re also unintentionally doing is removing perhaps the biggest obstacle to California and other states establishing their own single-payer systems.
With block grants, states wouldn’t need congressional approval to use Medicaid money for a broader insurance program.
“Yes, that solves the problem,” said Gerald Kominski, director of the UCLA Center for Health Policy Research.
But he noted that block grants create a different issue in the form of program sustainability. Unless the annual grants grow with healthcare costs, states will find themselves increasingly underfunded in covering Medicaid populations.
“If the grants are linked to inflation, that won’t be sufficient,” Kominski said. “Healthcare spending always grows faster than the overall economy.”
The average cost of living for Americans rose about 2% last year. Healthcare spending, meanwhile, climbed 4.8%, and is expected by the Centers for Medicare and Medicaid Services to rise 5.4% this year.
“Block grants are a poison pill,” Kominski said. “They’re a slow-acting poison that cuts off your healthcare funds.”
That’s not an insurmountable problem. California could structure a single-payer system so that it’s sustained by a greater share of state tax revenue, with program efficiencies offsetting a gradual decline in federal dollars.
2005 study by the Lewin Group found that a single-payer insurance plan would save California nearly $344 billion over 10 years, primarily by streamlining bureaucratic overhead and relying more on bulk purchases of prescription drugs and medical equipment.
The study also predicted a significant economic boost for businesses because they’d no longer be responsible for employees’ health coverage. This, in turn, would probably spur job creation.
A single-payer system would be a clear improvement for California and would serve as a model for the rest of the nation. Don’t forget: Canada didn’t adopt a single-payer system overnight. It rolled out its universal-coverage program gradually, province by province. The same methodical approach would be prudent for the United States.
But now another question arises: What sort of single-payer system do we want? They’re not all created equal. On Tuesday, we’ll look at alternative approaches to covering everyone.

Patience Gone, Koch-Backed Groups Will Pressure G.O.P. on Health Repeal

by Jeremy Peters - NYT - March 5, 2017

The battle over the future of the Affordable Care Act (ACA) has clearly begun in earnest. A striking feature of this debate is the disconnect between commonly cited complaints about the ACA and prescriptions offered by Republican lawmakers. For example, the most common complaint about the ACA’s exchange-based insurance policies is that they are too “thin”—deductibles, co-pays, and other cost-sharing burdens are too high. This complaint is understandable. For people used to getting employer-sponsored insurance (ESI) who find themselves now buying in the exchange, it is true that these plans are thinner than most ESI plans. But we should remember that the pre-ACA individual market for insurance offered much less comprehensive plans that required much larger out-of-pocket costs. For example, fully half of the plans offered on the individual market before the ACA would not be allowed today precisely because they demanded too-costly out-of-pocket exposure.
Fixing the problem of too-high exposure to out-of-pocket costs is straightforward: the exchange subsidies for premiums and cost-sharing could be increased. There would be plenty of members of Congress—mostly (or exclusively) Democratic—who would sign onto this. The obvious objection to this is that it costs taxpayer money. This, in turn, begs the question of are there any policy changes that could both lower the cost of health care to consumers and also the tax bills of households?
Luckily, there are such policies. Senator Bernie Sanders and co-sponsors are introducing the Affordable and Safe Prescription Drug Importation Act. This would instruct the HHS Secretary to put forward regulations allowing the importation of qualifying prescription drugs from Canadian sellers. In two years, importation from other advanced countries would also be allowed. The bill sets high standards to insure that only safe and effective prescription drugs could be imported, and there would be strict controls following the drugs into the United States to insure their proper dispensing.
The theory behind this bill is simple: drug prices in our advanced peer countries are substantially cheaper than in the United States, so we should leverage the ability of free trade to lower prices in the United States. Our failure to allow this today is surely the most costly form of protectionism (in goods trade, anyhow) still plaguing our country today, and yet it is never addressed by those in charge of our trade policy.
Prescription drug prices in the United States are needlessly high, and the economic stakes are large: U.S. patients consume more than $300 billion worth of prescription drugs annually, with the government picking up more than a third of the tab. The beneficiaries of high drug prices are shareholders and corporate managers of pharmaceutical companies, some of the most profitable corporations in the world. The losers from these high drug prices are America’s working families. It is time to introduce some genuine economic competition into this highly protected industry.
Will this bill alone solve all of our health care cost and access problems? Of course not. There is no silver bullet here, and further progress will have to be made. One obvious next step would be legislation requiring the federal government to bargain aggressively with pharmaceutical providers for the tens of billions of dollars we spend as taxpayers through the Medicare prescription drug program. But the Affordable and Safe Prescription Drug Importation Act is an excellent start. It aims to find genuine efficiencies in our wildly dysfunctional health system, and it can lower costs for both patients and taxpayers.

Editors Note: The Koch brothers and others among the ultra-rich will have their way! After all, they paid good money for this Congress, and they want their money's worth.

Repeal of Health Law Faces a New Hurdle: Older Americans

by Robert Pear - NYT - March 5, 2017

WASHINGTON — Republican plans to repeal the Affordable Care Act have encountered a new obstacle: adamant opposition from many older Americans whose health insurance premiums would increase.
AARP and its allies are bombarding congressional offices with objections as two House committees plan to vote on the Republicans’ bill this week.
If the law is repealed, the groups say, people in their 50s and 60s could see premiums rise by $2,000 to $3,000 a year or more: increases of 20 percent to 25 percent or higher.
Under current rules, insurers cannot charge older adults more than three times what they charge young adults for the same coverage. House Republican leaders would allow a ratio of five to one — or more, if states choose.
Insurers support the change, saying it would help them attract larger numbers of young customers.
The current rating restrictions, they say, have increased premiums for young adults, discouraging them from enrolling.
But the Republican proposal would “increase the financial burden of older Americans, making coverage significantly less affordable,” says a letter to Congress from the Leadership Council of Aging Organizations, a coalition of nonprofit groups that represent the interests of older Americans.
The letter was addressed to Representative Greg Walden, Republican of Oregon and the chairman of the Energy and Commerce Committee, one of two House panels planning to vote this week on a bill that would roll back major provisions of President Barack Obama’s signature domestic accomplishment.
David M. Certner, the legislative policy director of AARP, said the proposal would have “a severe impact on Americans age 50 to 64 who have not yet become eligible for Medicare.”
At the same time, Mr. Certner said, the Republican proposal could reduce the financial assistance available to help people pay insurance premiums.
Republicans say their proposal would reduce insurance prices by stimulating competition and by allowing insurers to sell a leaner, less expensive package of benefits.
In Mr. Walden’s hometown, Hood River, Ore., for example, the average premium for a midlevel silver plan for a 60-year-old man is $10,500 a year, compared with $3,864 for a 21-year-old man, according to, the online federal insurance marketplace.
Many people who buy insurance through the exchanges qualify for subsidies to help defray the cost. But people who buy insurance outside the Affordable Care Act marketplace cannot obtain subsidies.
Republicans in the House and the Senate want to change that, so people can get subsidies in the free market outside the public exchange.
Before the Affordable Care Act took effect, about 40 states allowed insurers to charge older adults five times as much as young adults. This appears to be consistent with patterns of medical spending.
“Average spending among people who are 64 years old is about 4.8 times as high as average spending among people who are 21 years old,” the Congressional Budget Office said last year, citing research by actuaries.
Representative Larry Bucshon, Republican of Indiana and a heart surgeon, said the rating restrictions in the 2010 health law had “led to sicker insurance pools and driven younger, healthier patients away from the marketplace.”
“The argument that the three-to-one ratio saves seniors money may not be true,” Mr. Bucshon said. “In fact, I don’t think it is true. It has just increased costs for younger people.”
Republicans contend that benefit mandates in the health law have driven up insurance costs. The House Republican bill would allow states to define the “essential health benefits” that insurers must provide.
Jerry C. Fleming, a retired health insurance executive who worked at Kaiser Permanente for more than 35 years, said on Sunday that the House Republican plan could produce “breathtaking increases in premiums” for older people with low incomes.
Their share of the premium could, in some cases, more than double, he said.
Another provision of the bill drafted by House Republican leaders has come under fire in recent days.
The bill says that, in providing financial assistance to help people buy insurance, federal officials will verify eligibility using the same “methods and procedures” used by the Obama administration under the Affordable Care Act.
Republicans have repeatedly criticized those procedures as inadequate, saying they verify citizenship but not a person’s identity.
The Government Accountability Office, an investigative arm of Congress, has found the marketplaces “vulnerable to fraud” because they do not adequately check the identity of people applying for financial assistance.
In 2010, just before Congress gave final approval to the Affordable Care Act, the conservative House Republican Study Committee said the verification procedures in the bill were “insufficient and ineffective.”
The study committee was headed then by Representative Tom Price, Republican of Georgia, who was sworn in last month as President Trump’s secretary of health and human services.

Americans have lost faith in institutions. That’s not because of Trump or ‘fake news.’

by Bill Bishop - Washington Post - March 3, 2017

The easiest sell of President Trump’s life is that a “corrupt” media produces “fake news.” After all, fewer than 2 in 10 Americans have “a lot” of trust in news organizations, the Pew Research Center has found, and we live in a “Matrix”-infused “conspiracy culture,” according to social scientists, where one is thought to be impossibly simple to not understand that the world is ruled by collusion and machination.
Trump has helped make trust a big deal for media types, and they are now searching for ways to regain the faith of their readers. To combat the “fake news” charge, the New York Times, for example, is running full-page ads and even bought a television spot during the Oscars declaring that “the truth is more important now than ever.” For some, the problem is that journalists have allowed too much of their personalities to creep into their work. Pittsburgh Post-Gazette editor David Shribman prescribes “less analysis and more reporting, less personality and more facts.” For others, there’s a need to demonstrate that journalists are not faceless elites but real people. Washington Post opinion writer Dana Milbank wrote of his newsroom colleagues: “They hail from all corners of this country, from farms and small towns, the children of immigrants and factory workers, preachers and teachers.” But even local papers, the ones most closely connected to their readers, are struggling to defend their integrity. One editor of a rural California paper accepted an op-ed about the danger of “fake news” in an attempt to instill some faith among the anti-press crowd.
You can hear similarly fretful discussions in dozens of other professions. The president has maligned politicians, scientistsjudgesteacherslabor union leaders and intelligence officials, among others. “Donald Trump’s most damaging legacy may be a lower-trust America,” the Economist’s Lexington column predicted. Trust in American institutions, however, has been in decline for some time. Trump is merely feeding on that sentiment.
The leaders of once-powerful institutions are desperate to resurrect the faith of the people they serve. They act like they have misplaced a credit card and must find the number so that a replacement can be ordered and then FedEx-ed, if possible overnight.
But that delivery truck is never coming. The decline in trust isn’t because of what the press (or politicians or scientists) did or didn’t do. Americans didn’t lose their trust because of some particular event or scandal. And trust can’t be regained with a new app or even an outbreak of competence. To believe so is to misunderstand what was lost.
In 1964, 3 out of 4 Americans trusted their government to do the right thing most of the time. By 1976, that number had dropped to 33 percent. It was a decline that political scientist Walter Dean Burnham described as “among the largest ever recorded in opinion surveys.”
Of course, that intervening period brought a series of tumultuous events: the expansion of the war in Vietnam, the Watts riots of ’65, the civil rights movement and, then, assassinations and Watergate. These affairs have served as shorthand explanations for our decline in trust. After all, who could trust an incompetent government that brought us scandal, riots and an unpopular war?
There are at least two problems with this explanation. First, the decline in trust in government has been accompanied by falling trust in nearly every institution. Why should a riot in Watts lead to distrust of organized labor? Yes, the news of the day caused fluctuations in how Americans felt about their institutions. The Watergate scandal caused Americans to lose faith in their government. Conversely, after the country was attacked on 9/11, trust in government soared and people went back to church. After the impact of scandal and threat faded, however, the long-term trends returned.
Second, the erosion hasn’t been confined to the United States. “Declining trust in government has spread across almost all advanced industrial democracies since the 1960s/1970s,” writes political scientist Russell Dalton. “Regardless of political history, electoral system, or style of government, most contemporary publics are less trustful of government than they were in the era of their grandparents.”
We haven’t simply changed our attitudes. We’ve voted with our feet, walking away from the institutions we supported for generations.
For instance, historian Martin Marty describes a “seismic shift” in religion. “From the birth of the republic until around 1965, as is well known, the churches now called mainline Protestant tended to grow with every census or survey,” Marty wrote. And then, the pews started to empty. The six largest Protestant denominations together lost 5.6 million members — a fifth to a third of their membership — between 1965 and 1990.
And civic engagement has declined. Harvard’s Robert Putnam has counted the drop in members of the Lions, the League of Women Voters and, famously, bowling leagues beginning in the mid-’60s . The decline of these associations brought about a decrease in consistent social connections. Society began to fray.
The changes that seemed to erupt suddenly in the early 1960s actually began long before and moved slowly at first, as the globe shrank and societies modernized. As far back as the 1600s, travelers confronted by new cultures and novel deities began to question their own societies’ rules and institutions. “Not a tradition which escapes challenge, not an idea, however familiar, which is not assailed; not an authority that is allowed to stand,” historian Paul Hazard wrote. “Institutions of every kind are demolished, and negation is the order of the day.” This was the Enlightenment, a turning away from tradition and an anointing of reason, scientific inquiry and individualism.
Rising incomes and the welfare state brought Enlightenment individuality to the people. Political scientist Ron Inglehart proposed in the 1970s that as societies grow wealthier and less concerned about basic survival, we should expect a shift from communal to individual values: People express themselves more and trust authorities less.
Everything about modern life works against community and trust. Globalization and urbanization put people in touch with the different and the novel. Our economy rewards initiative over conformity, so that the weight of convention and tradition doesn’t squelch the latest gizmo from coming to the attention of the next Bill Gates. Whereas parents in the 1920s said it was most important for their children to be obedient, that quality has declined in importance, replaced by a desire for independence and autonomy. Widespread education gives people the tools to make up their own minds. And technology offers everyone the chance to be one’s own reporter, broadcaster and commentator.
We have become, in Polish sociologist Zygmunt Bauman’s description, “artists of our own lives,” ignoring authorities and booting traditions while turning power over to the self. The shift in outlook has been all-encompassing. It has changed the purpose of marriage (once a practical arrangement, now a means of personal fulfillment). It has altered the relationship between citizens and the state (an all-volunteer fighting force replacing the military draft). It has transformed the understanding of art (craftsmanship and assessment are out; free-range creativity and self-promotion are in). It has even inverted the orders of humanity and divinity (instead of obeying a god, now we choose one).
People enjoy their freedoms. There’s no clamoring for a return to gray flannel suits and deferential housewives. Constant social retooling and choice come with costs, however. Without the authority and guidance of institutions to help order their lives, many people feel overwhelmed and adrift. “Depression is truly our modern illness,” writes French sociologist Alain Ehrenberg, with rates 20 to 30 times what they were just two generations ago.
Sustained collective action has also become more difficult. Institutions are turning to behavioral “nudges,” hoping to move an increasingly suspicious public to do what once could be accomplished by command or law. As groups based on tradition and consistent association dwindle, they are being replaced by “event communities,” temporary gatherings that come and go without long-term commitment (think Burning Man). The protests spawned by Trump’s election are more about passion than organization and focus. Today’s demonstrations are sometimes compared to civil-rights-era marches, but they have more in common with L.A.’s Sunset Strip riots of 1966, when more than 1,000 young people gathered to object to a 10 p.m. curfew. “There’s something happening here,” goes the Buffalo Springfield song “For What It’s Worth,” commemorating the riots. “What it is ain’t exactly clear.” In our new politics, expression is a purpose itself.
A polarized and distrustful electorate may stymie the national government, but locally most communities are either overwhelmingly Republican or Democratic. In 2016, 8 out of 10 U.S. counties gave either Trump or Hillary Clinton a landslide victory. In these increasingly homogenous communities, nobody need bother about compromise and the trust it requires. From anti-abortion measures to laws governing factory farming, the policy action is taking place where majorities can do what they want without dealing with “those people” who live the next state over or a few miles down the road. At last count, 1 in 4 Americans supports the idea of their state seceding from the union.
Solutions and action shrink to the size of the individual. Increasing numbers of New York state parents have been holding their children out of end-of-year school tests in a kind of DIY education reform. In some Los Angeles schools, so many parents opt out of the vaccination regime that inoculation rates are on a par with South Sudan’s as people make their own scientific judgments. The “we medicine” of community health, writes Donna Dickenson, is replaced by the “me medicine” of individual genetic testing, tailored drug regimes and all manner of personal “enhancement” technologies. And where once antitrust laws were used to break up monopolies in food markets, Michael Pollan concludes that today, we must “vote with our fork.”
These are all penny-in-a-burned-out-fuse solutions that don’t touch the big issues, such as economic inequality and climate change. They also avoid the question that now demands an answer: How does an increasingly diverse society govern itself democratically?
Political scientists tell us that democracies require a little faith. To engage with others, you have to believe that if you lose a contest or a debate, the winner will treat you equitably; that if the other side wins, it will act within the law and not send its opponents off to jail. You have to assume that institutions will be fair and that leaders will act in the country’s best interest.
“Aren’t you concerned, Sir,” CNN’s Jim Acosta asked Trump at last month’s news conference, “that you are undermining the people’s faith in the First Amendment, freedom of the press, the press in [this] country, when you call stories you don’t like fake news?”
Trump responded: “The public doesn’t believe you people anymore. Now maybe I had something to do with that. I don’t know. But they don’t believe you. If you were straight and really told it like it is . . . I would be your biggest booster.”
The president is right that they don’t believe. But he’s wrong to take credit for it — and wrong to suggest that there’s much that can be done.

Nurses Warn Trump/GOP Health Ideas Would Accelerate Crisis

Recycled Schemes Would Deprive Care for Tens of Millions,  Expanding, Strengthening Medicare Only Solution Post-ACA
National Nurses United sharply criticized the health care proposals outlined by President Trump in his address to Congress Tuesday night, warning they would deprive care for tens of millions of Americans and increase the health and economic security of millions more.
“In his speech Tuesday night, President Trump broke his promise during the campaign and before his inauguration when he pledged that no Americans now covered as a result of the Affordable Care Act would lose that coverage,” said NNU Co-President Jean Ross, RN.
“Instead, the President adopted the cynical language embraced by (Health and Human Services Secretary) Tom Price in his confirmation hearing that people with pre-existing health conditions should ‘have access to coverage.’
“But access to buying expensive private insurance is worlds apart from getting the coverage and care you need when you need it,” said Ross. “As Sen. Bernie Sanders said to Price in that hearing, ‘Has access to’ does not mean that they are guaranteed health care. I have access to buying a $10 million home; I don’t have the money to do that’.”
“If the Republicans in control of Congress force through their obsession with repealing the Affordable Care Act, millions will lose the coverage they have gained, especially without any meaningful proposals from Congress or the administration to actually lower the escalating out-of-pocket costs.” Ross cited a recent Commonwealth Fund report that 30 percent of Americans already skip needed health treatment due to the extra costs of deductibles and co-pays even when already paying for their healthcare premiums.
“Only one replacement for the ACA would guarantee everyone can get health care, lower the skyrocketing costs to families and individuals, and assure real patient choice they can go to the doctor and hospital of their choice – strengthening and expanding Medicare to cover all Americans,” Ross said.
Ross also condemned other key legs of the President’s health care proposals Tuesdaynight.
*Use of tax credits and expanded Health Savings Accounts. “That would be a devastating replacement for the ACA subsidies, and merely reinforce an already broken system largely based on ability to pay. With no restrictions on the price gouging by insurance companies, hospitals, drug companies and other healthcare corporations, fewer and fewer people could afford the cost of quality coverage, and have to settle for skeletal health plans with little protection when you get sick.”
*Giving state governors “flexibility” on Medicaid. “This proposal, long floated by Price, House Speaker Paul Ryan, and other critics of Medicaid would result in a steady decline in federal funding of Medicaid, which would merely put pressure on states to slash the number of people covered or drastically cut care, by restricting eligibility, sharply cutting covered services, or making it much harder to enroll.”
*Selling insurance across state lines. “Another long time conservative talking point. It would encourage insurers to be based in states with the fewest public rules and protections for coverage, depriving people in states with stronger protections of the health security they need. The result would be an ugly race to the bottom.”
“As nurses know from the patients we care for every day, without health, there is no security. We cannot risk the reckless disregard for the health of our patients and our nation proposed by these heartless ideas. Nurses will continue to oppose these ideas, as we have already been doing in protests across the country, and continue to campaign for real reform, improved Medicare for all,” Ross concluded.
National Nurses United, with close to 185,000 members in every state, is the largest union and professional association of registered nurses in US history.

Republican Unity on Health Care Is Elusive, Despite Trump’s Support

by Thomas Kaplan and Robert Pear - NYT - March 1, 2017
WASHINGTON — President Trump’s address to Congress on Tuesday night buoyed House Republican leaders who were hopeful that his leadership would unite fractious lawmakers around a plan to replace the Affordable Care Act. But fundamental disagreements still divide Republicans on one of the central promises of their 2016 campaigns: repealing the health law.
While Mr. Trump appeared to back a health plan being drawn up by Republican leaders, it became clear Wednesday that lawmakers were continuing to argue over its details. Republican senators emerged from a closed-door meeting on health care tight-lipped.
Some have balked at a proposal to require workers to pay taxes on particularly generous employer-provided health benefits. Some are worried about the future of Medicaid.
But the central dividing line appears to be over how the federal government would help people purchase health insurance.
House Republican leaders would offer to help people buy insurance on the free market with a tax credit that, for some low-income households, could exceed the amount they owe in federal income taxes.
Some of the most conservative Republicans say the tax credit should not be more than the amount of taxes consumers owe. If the government makes payments to people with little or no tax liability, they say, that would amount to a new entitlement program, replacing one kind of government largess from President Barack Obama with another from Mr. Trump.
“Coming in as a Republican president with a new federal entitlement program?” asked Representative Dave Brat, a conservative Republican from Virginia. “That’s your first big move? You would have politicians bidding up the cost, adding to the financial problems of other entitlement programs like Medicare and Social Security.”
After the president’s speech, aides to the House speaker, Paul D. Ryan, crowed that they had the full backing of Mr. Trump for their health care plan.
But Mr. Trump was decidedly vague. He backed tax credits to buy insurance, but he did not clearly resolve the disagreement between Mr. Ryan and the most conservative Republicans.
“We should help Americans purchase their own coverage through the use of tax credits and expanded health savings accounts,” Mr. Trump told a joint session of Congress.
The details of the tax credit could make a substantial difference to consumers. If a family is eligible for a $3,000 tax credit to buy insurance and owes $1,000 in federal income taxes, should it get only $1,000? Or should it get the full $3,000?
Most tax breaks reduce the amount owed to the government. A refundable tax credit can also result in payments from the government: If the credit exceeds a person’s tax liability, the government pays him or her the excess.
“I think refundable tax credits are just another word for subsidies,” said Senator Rand Paul, Republican of Kentucky.
Defenders of refundable tax credits say they are needed to make insurance affordable to people who pay little or no taxes.
“Otherwise, they’re useless,” said Representative Chris Collins of New York, one of Mr. Trump’s top supporters in Congress. “What good’s a tax credit for folks who don’t pay taxes?”
In fact, for those who cannot pitch in much of their own income, even a refundable tax credit is not likely to be enough to pay for a health insurance policy, Democrats say. That is one reason the Republican alternative is not likely to cover as many people as the Affordable Care Act.
At the meeting on Wednesday, several Republican senators expressed concern that the tax credit proposed by House leaders would be available even to people with high incomes who did not need federal assistance.
Earlier, Representative Kevin Brady, Republican of Texas and head of the Ways and Means Committee, said the credit would be a way to provide more equity in the tax code by creating a tax break for people who buy insurance on their own, similar to the break already available to people who get insurance through the workplace.
He predicted that Republicans would overcome their divisions.
“Rather than using his speech to divide Republicans,” Mr. Brady said, “it’s really an opportunity for us to sit down and work through what remaining differences there are, and I’m confident we can.”
Mr. Brady and another architect of the House plan, Representative Greg Walden of Oregon, the chairman of the Energy and Commerce Committee, huddled with Republican senators on Wednesday. But lawmakers left the meeting with many unanswered questions and were not ready to endorse the House plan.
The fractures among Republicans have been on display in the past few days. On Monday night, three senators — Mr. Paul, Mike Lee of Utah and Ted Cruz of Texas — posted on Twitter in support of what they called #FullRepeal.
“If we fail to honor our commitment to repeal Obamacare, I believe the consequences would be, quite rightly, catastrophic,” Mr. Cruz said on Wednesday.
The leaders of two groups of House conservatives, the Republican Study Committee and the House Freedom Caucus, also came out against a draft of the health care legislation that became public during last week’s congressional recess. The groups have more than enough members to thwart House leaders’ plan if they are determined to do so.
Senator James Lankford, Republican of Oklahoma, likened the leadership’s tax-credit proposal to the earned-income tax credit, which supplements the wages of low-income workers. There has been “a tremendous amount of improper payments” in that program, he said.
Other Republican skeptics include Senators Thom Tillis of North Carolina and Lindsey Graham of South Carolina. “There are other ways you can address that segment of the population,” Mr. Tillis said of the working poor with little or no income tax liability.
Some Republicans are also concerned about the possibility of requiring workers to pay taxes on the value of employer-sponsored coverage exceeding certain thresholds. Employers and labor unions strenuously oppose such a move, which would affect people in the most expensive health plans and is similar in purpose to a provision of the existing law. Both measures are designed to curb overuse of health care and to help pay for the broader measures.
“I don’t think it’d go over very good in the Senate,” Senator Charles E. Grassley, Republican of Iowa, said last week.
Then there is the issue of Medicaid. Lawmakers from states that expanded Medicaid under the Affordable Care Act face pressure back home — in some cases, from Republican governors — to oppose sharp cuts to the generous federal funding that those states are receiving.
Senator Lisa Murkowski, Republican of Alaska, which has expanded eligibility for Medicaid under the health care law, said she wanted to be sure that her state could retain the expansion if its legislature wanted to do so.
“Alaska should have that option,” she said.

Here’s why Republicans are finding it so hard to come up with a replacement for Obamacare
by Jared Bernstein - Washington Post - March 6, 2017

In the beginning, God created a health-care system. But she quickly found it to be a thankless and terribly complex endeavor, so she decided to create the heavens and the Earth. The Earth was covered in darkness, so she said, “Let there be light,” and there was light. “That was easy,” she thought, so she decided to go back to health care.
“Let there be coverage,” she declared. And from the void came the questions: “You mean single-payer coverage? Universal coverage, or separate programs for the poor and the elderly? How high should we set the deductibles? Should we provide tax credits? If so, should they be refundable? What about guaranteed issue? Community rating? You’re gonna want to cover preexisting conditions, right, God?”
So she went back to creating the land and seas.
Okay, I may be making the health-care challenge sound harder than it is, but clearly Republicans have been struggling with it, and I think I know why. First, Obamacare has set a new baseline, and President Trump has promised that their replacement won’t just hit the baseline, it will surpass it. Second, the fundamental logic of affordable coverage for all goes against their basic brand such that they’ve set up an impossible goal: better, cheaper coverage than Obamacare that reduces the government’s footprint in the sector.
The baseline: What’s so great about the Affordable Care Act?
Though the ACA has some clear flaws, its benefits to millions of people are very real, and once people start getting a benefit, it’s very hard to take it away. It has also helped to generate some real cost savings.
With north of 20 million people getting coverage through either the Medicaid expansion or the health-care exchanges, the ACA has led to a sharp decline in the rate of the uninsured, from about 15 to about 9 percent, the largest such decline since Medicare/Medicaid came online in the 1960s.
The ACA’s effect on costs is harder to tease out, but it appears to be accomplishing one of its important goals of “bending the health-care cost curve.” Paul Van de Water highlights a remarkable finding in this regard. He shows that the Congressional Budget Office projection of how much it expects the federal government to spend on health care has come down by about $600 billion since 2010. That is, its 2017 spending projection is lower than the one it made seven years earlier.
But here’s the kicker: Unlike the higher 2010 estimate, that 2017 estimate includes the costs of the ACA, which we know is covering 20 million more people! And it’s still lower.
Some of these cost savings derive from the ACA’s improvements in the way health care is delivered. These include a tighter fit between what medical services actually cost and what public programs such as Medicare pay out; nudging the system away from the often expensive and wasteful fee-for-service approach toward bundled payments (a single payment for the treatment of a disease or clinical “episode”) and “accountable care” (wherein a group of providers coordinate to oversee the broad needs of their patients); incentives to reduce hospital readmissions; and trying to move these efficiency enhancers from the public to the private side of the market.

Pelosi says GOP is hiding health-care plan 'in the basement'

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At a news conference, March 2, House Minority Leader Nancy Pelosi (D-Calif.) spoke about Republican lawmakers' plan to repeal and replace the Affordable Care Act.(Reuters)
What about costs to individuals? Various indexes of health-care prices show relatively slow growth in recent years (some of which is because of the recession/slow recovery): The health price deflator rose at an average rate of 1.5 percent since 2010, compared with 3.2 percent in the 2000s. Analysis by the Obama administration’s Council of Economic Advisers shows lower cost growth for Medicare, for Medicaid and in employer coverage in the post-ACA years (2010-2016).
Of course, there’s the infamous, headline-generating 2017 premium increases in the non-group market. After growing 2 and 7 percent in 2015 and 2016, insurers in the state-based exchanges raised the cost of the benchmark plan by an average of 25 percent. To Obamacare critics, this was proof of the program’s unsustainability. But because 85 percent of participants in this market (state exchanges) receive premium tax credits to offset the cost of coverage, they do not face the full shock. With the subsidies, Obama administration officials pointed out, about three-quarters of those in the exchanges could find a plan for $75/month or less. Second, if the ACA survives, time will tell whether this 2017 jump was the one-time correction many analysts believe it to be. Marketplace insurers appear to have initially underpriced premiums, in part because they may have initially overestimated the wellness of those buying coverage in the exchanges (and, thus, underpriced their premiums). In fact, even with the big 2017 increase, premiums are about where nonpartisan analysts thought they would be at this point.
Still, stable markets don’t typically generate price shocks of that magnitude, and while the non-group market — the part of the ACA served by the exchanges — provides less than 10 percent of coverage in the United States, there are many stories of thin networks and premium price shocks. Solutions to this problem include more generous subsidies and a public option in each exchange (to ensure a reasonable offer in markets with too few insurers), but such ideas are, of course, inconsistent with conservatives’ repeal efforts.
While the ACA hasn’t been in place long enough to observe its long-term effects on health outcomes, it is already generating some positive indicators:
— The share of persons reporting that they could not access needed care rose by half in the decade before the ACA became law. Since then, it has fallen by more than a third.
— The above finding appears to be clearly related to the ACA. We know that the ACA played a role in the decline in state’s uninsured rates, and states with greater declines in the uninsured also had greater declines in people reporting they could not access care because of cost.
— Both the Medicaid expansion and allowing young adults to remain on their parents’ plans have generated significant increases in self-reported health status, mental health and financial stability.
— Most of the ACA’s coverage gains have come through the Medicaid expansion, and Medicaid has been shown to have both near- and long-term positive health impacts. Studies find that Medicaid is particularly helpful in stabilizing patients with chronic diseases such as heart disease, diabetes and asthma. Medicaid patients are more likely to use preventive care and far less likely to experience catastrophic out-of-pocket medical expenses. Medicaid eligibility during early childhood was found to reduce mortality rates among African Americans in their later teenage years by 13 to 20 percent. Longitudinal studies that track children into adulthood find that children on Medicaid for more of their childhood earn more as adults and are more likely to attend and complete college. Such benefits pose a challenge to replacers who want to repeal the Medicaid expansion and significantly cut what’s left of the program.
— Though the ACA is too new to measure longer-term health outcomes, research on health-care reform in Massachusetts, where a similar program was implemented years earlier, finds that for every 830 people who gained coverage, one death was avoided. Though I wouldn’t extrapolate that precise estimate to the ACA (which would imply 24,000 lives saved), it is likely that the program is having a similar effect, though we cannot yet know its magnitude.
Other positive outcomes include the fact that hospitals have seen a significant reduction in uncompensated care, but that reduction has occurred almost exclusively in the 32 states that opted for Medicaid expansion (including D.C.), which makes sense as low-income, uninsured people are those most responsible for uncompensated hospital care and are most likely to be covered by the expansion.
So, that’s the baseline that the replacement plan either has to hit, or Republicans have to explain why we should be fine about losing these gains. Good luck with that.
Another reason for the Republicans’ muddled state is that once you take health care at least partially out of the market, as is the case in every advanced economy, you’ve set off on a path that has a fairly predictable set of branches or decision points posing questions like the voices from the void to the deity in my allegory. Dealing with these questions comes much more naturally to Democrats or moderate Republicans than it does to tea partyers and others who just want to get the government out of the health-care business and give the stream of tax revenue that funds the ACA back to the wealthy.
What do I mean by “we’ve taken health care out of the market?” Simply put, you show up to the supermarket hungry, and they don’t have to feed you. You show up to the ER sick, and they have to treat you. Unless we’re willing to punt on that commitment, and all evidence shows we’re not, the government will be a significant player in health care, though how significant is, of course, what we’re arguing about.
The logic of insurance thus dictates that you’ll need to pool risk so that the healthy can subsidize the sick. Since some of the healthy won’t go for that deal, there needs to be a mandate to avoid an unbalanced risk pool leading to adverse selection, or the death spiral that health wonks warn about (with too many sick people in the risk pool, premiums must rise, pushing out the least ill, exacerbating the problem). But if you have a mandate, there will be those whose income is insufficient to comply, and they’ll need subsidies to afford coverage.
And that’s pretty much it. If you want to cover everyone, you need to pool risk. To do that, you need a mandate, and the mandate implies a subsidy.
Where does this leave those who would repeal and replace Obamacare?
That leaves the replacers in a fairly tight box. Weirdly, the Republicans seem to have somehow convinced themselves that people want to pay more out-of-pocket for health care — that’s certainly the philosophy behind their high-deductible plans and getting rid of the Medicaid expansion. I think they’re misreading the public.
Here are the replacement ideas they’ve been coalescing around.
Capping Medicaid: Instead of the current federal-state match that finances Medicaid, Republicans propose to save money by shifting costs to the states in a way that will cut the program relative to its current trajectory. A per capita cap fixes the level of federal Medicaid funding per beneficiary, which it then adjusts by a formula. Any costs above the cap would fall on the state.
In practice, block-granted programs (of which the per capita cap is a variant) rarely get adequate plus-ups when need increases because of, for example, the aging of their populations or unexpected spikes from epidemics or costly technical advances. Since 2000, funding for block-granted programs that serve low-income people fell by almost 40 percent once accounting for inflation and population growth.
Thus, eventually, the money supporting Medicaid would diminish and coverage losses would follow as millions of low-income families, people with disabilities and seniors would lose access to the program. Edwin Park estimates that over the next decade, the health plan being considered by the Republicans would shift over $500 billion in Medicaid costs to states. Park’s estimate implies ending the ACA’s Medicaid expansion, a stated goal of the repealers, leaving 11 million people without coverage, while also risking the coverage of the kids, seniors and disabled people who have long depended on Medicaid.
Creating state high-risk pools: This idea challenges what I think of as a fundamental truth of health policy design: the essential role of balanced risk pools. A pool comprising mostly sicker people will, of course, face relatively expensive coverage, and vice versa: If they had their druthers, healthy people would prefer their own, cheaper risk pool. Mandates forbid such segmentation, and those who oppose them argue this is unfair, as it raises the relative costs of coverage to healthier people. High-risk pools — insurance markets for those with expensive preexisting conditions — are offered as a solution, wherein healthy people get reduced costs and sicker people still get coverage.
Unfortunately, the logic of risk pooling still prevails. Experience with state risk pools shows that even expensive premiums fail to cover costs, and medical loss ratios (paid claims/premium revenue) always exceed 100 percent, with the difference made up by state revenue, fees on insurers, or employers.
States often found these pools unsustainable and, thus, restricted enrollment, raised premiums, cut back on coverage and benefits, raised deductibles and cost sharing, imposed waiting periods for coverage of preexisting conditions, and established lifetime limits on benefits.
In other words, in the interest of providing low premiums to healthy persons, high-risk pools avoid the cross-subsidization that is basic to insurance. The only way that can work, however, is either if some other entity makes up the difference between spending and premium revenue, or those with preexisting conditions get a lot less care.
Health Savings Accounts: Actually, these accounts are not just part of current law, they are also widely used. One recent study found there were 20 million such accounts with assets of $37 billion. HSAs allow people in a high-deductible plans to shelter savings (including the growth of those savings) from taxes. Unlike a traditional IRA, even the withdrawal of the savings goes untaxed as long as the money’s used for health-related spending.
There are at least four problems with HSAs. First, if you can’t afford to save, HSAs can’t help you. Some proposals offer subsidized savings through tax deductions or credits, which can help, but depending on how it’s set up, that, too, can be problematic, as I’ll discuss below. Second, this whole high-deductible, HSAs play is based on the skin-in-the-game theory of cost control, i.e., the view that the more costs are directly shared with patients, the less unnecessary care patients will seek. But the problem here is that since few of us are doctors, we don’t always know what’s important and what’s wasteful. And so, numerous studies have shown that skin-in-the-game policies end up dis-incentivizing necessary care. Rather than dip into the HSA to meet their high deductible, patients will go without needed care.
Third, we’re talking a major tax shelter here, as HSAs shelter savings, accruals and even withdrawals (when spent on medical costs). That’s why 70 percent of the total value of HSA contributions comes from households with incomes above $100,000.
Finally, some proposed plans allow tax-deductible contributions to HSAs that can be used to offset premium costs and meet the costs of high deductibles. But that won’t provide much help to low- and moderate-income people. The vast majority of those uninsured before the ACA were in the 0, 10 or 15 percent tax bracket, meaning that at best, they’d get a tax benefit from HSA contributions that amounted to 15 cents on the dollar. Their lack of tax liability would translate into a loss of coverage.
Letting insurers sell across state lines: Conservatives argue that different insurance rules in different states limit competition, and because consumers should have more options and competition lowers price, insurers should be able to sell across state lines.
The problem here is again the segmentation problem, as states with cheap, weak coverage will attract healthier customers from across the country, leading to a sicker pool in states with better insurance. Thus, if what I would consider an enlightened state decided to keep all the coverage benefits of Obamacare — covering preexisting conditions; no price discrimination based on age, gender or health status; benefit requirements — that state’s healthier residents could get inferior, cheaper coverage elsewhere, making coverage more expensive for everyone else in the state. That is, because insurers would have to meet the requirements only of the state in which they were licensed, “high-road” states would be undermined and their sicker residents would face higher premium costs.
Implementing “continuous coverage provisions” for people with preexisting conditions: Conservatives who want to provide coverage to people but are hostile to mandates face the problem discussed above about the fundamental structure of health reform. Without a mandate, healthy people will leave the risk pool and come back in only when they need care, creating the classic adverse-selection problem that leads to unsustainable, spiraling costs. So, in a search for some incentive to prevent this problem, they require guaranteed access to a marketplace plan only for those with a history of uninterrupted coverage.
One problem is that people with preexisting conditions have a track record of coverage gaps. One report found that “about 23 percent of Americans with a preexisting condition (31 million people) experienced at least a one-month gap in coverage in 2014, and nearly one third (44 million) had at least a one-month gap of coverage during the two-year 2013 to 2014 period.” Such spells are more acute among those who’ve been uninsured at some point in the past: More than 90 percent of such people have experienced gaps in coverage lasting at least two months.
These plans rarely say what will happen when someone without continuous coverage shows up at the ER. Of course, they will get treated and, under the fair assumption that we’re not talking about a wealthy person (those with interrupted coverage tend to have lower incomes), the costs of that treatment will be borne by the rest of us. Even those with higher incomes who fall on hard times, say through a job loss, could easily have a break in coverage, making them ineligible for a subsidized plan and, thus, facing much higher premiums on the open market or denial of coverage. In essence, I think of this continuous-coverage provision as the “kick-’em-while-they’re down” approach.
New tax credits or a standard tax deduction: Right now, for those in the individual market who purchase insurance on the exchanges, the Affordable Care Act provides premium tax credits that vary based on individuals’ income, their age and the cost of premiums in a given area. Low-income people get bigger credits, as do those who live where insurance costs are greater. At incomes above 400 percent of poverty (just short of $100,000 for a family of four), the ACA credits go to zero. In place of these credits, some replacement plans establish either new, uniform credits that do not vary by income or a standard tax deduction for health care. What’s the point of such a switch? This part sounds a little like replacing Obamacare with the Affordable Care Act.
In fact, salient differences abound. The ACA credits are scaled to help those with low and moderate incomes pay for coverage in the non-group market where they live. That means the credits will adjust to incomes and geography, both of which are key determinants of affordability. The proposed changes, however, at least as we understand them thus far, are based neither on income nor geography (they make some adjustments for age), nor, most importantly, the actual cost of coverage.
This means that those currently receiving credits in the ACA exchanges would get smaller credits under the proposed changes, while families with incomes above 400 percent of poverty, who get no credits under the ACA, would get a credit under the proposals. Low-income families in high-price places would be hit especially hard. One recent study predicts that in five years, credits under the replacement plans will probably be about 40 percent to 55 percent less than those under the ACA. Plans that give greater subsidies to the wealthy and less to those with moderate incomes will lead to less coverage than under the ACA.
Those are the problems engendered by tax credits. The problem with the standard-deduction approach is the same as was discussed under HSAs: The vast majority of those who got ACA coverage have low or no tax liability, so deductions don’t help them. Conversely, deductions return the largest benefits to those at the top of the income scale, so again, this change tilts against coverage for low-income families.
To put it in its simplest terms, Republicans are finding health-care reform a challenge for two main reasons: 1) the ACA established a new coverage baseline that they realize they have to hit or they have to be ready for serious political blowback, and 2) the logic of high-coverage-oriented health care implies risk pools, mandates and subsidies, all of which are discomforting to Republicans who correctly view them as “stuff Obama did” (and, thus, verboten) or just more big government.
They appear to be coming up with a set of ideas for reform that, at least as I understand them, will fail to deliver what their constituents want in terms of their health coverage. Their ideas call for most cost-sharing, more out-of-pocket spending and, ultimately, significantly less coverage. My impression is that Americans want health care that is less complex and calls for less skin in the game, and yet Republicans appear to be teeing up the opposite.
Thus, to the extent that they really do try to repeal and replace Obamacare with something like the set of ideas they’re currently considering, I think they’re going to find out the hard way that not only is health reform a challenge, but it is one they haven’t met.

Obamacare Got Their Goat: An Illustrated Guide to Republicans’ Metaphors

by Margot Sanger-Katz - NYT - March 3, 2017

It’s a goat on a bridge eating a flaming rug pulled from a collapsing sand castle! Yes, of course, I’m talking about the Affordable Care Act, which you may also know as Obamacare.
Killing the health insurance law is a top priority of Republicans in the White House and Congress. As they try to achieve that, it has brought out some lively and figurative language. Many imagine the health law as a pioneer homestead. Others as a marauding farm animal. Still others direct their rhetoric to its complexity. Just this week, Kevin Brady, the House Ways and Means Committee chairman, described the G.O.P. challenge as akin to a Rubik’s Cube.
These metaphors can be clarifying or confusing, an occupational hazard of metaphors. Just why exactly is a rug the only metaphor that Republicans all seem to agree on? Here’s a summary of many memorable attempts to make health care reform seem familiar — and bizarrely unfamiliar.

James Sensenbrenner: Puzzle

The metaphor: “It’s kind of like, you know, getting a 30,000-piece jigsaw puzzle for Christmas,” Mr. Sensenbrenner, a congressman from Wisconsin, said in a town hall meeting. “And, you know, cleaning off the dining room table and seeing how long it takes to put all the 30,000 pieces together in the right place. It’s not going to be easy.”
Assessment: After years of campaigning against it, Republicans probably did see the opportunity to repeal Obamacare as a gift. But as President Trump recently discovered, health policy is “so complicated.” Interlocking parts kind of make sense.
But while lawmakers like to cite the view from 30,000 feet, few puzzles are sold in 30,000 pieces. Even if one could be bought, a puzzle of that size may overwhelm all but the most hardy of puzzle masters, with the largest dining-room tables.

Drew Ferguson: Goat

The metaphor: “The need for this process can best be explained by a story I’ve been telling my colleagues,” said Mr. Ferguson, a freshman congressman from Georgia, in a speech on the House floor. It must be relayed in its entirety: “A little over six years ago I lived in a pretty decent house. And one day I heard a knock on the door. Before I knew it, my colleagues from the other side of the aisle had let a goat loose in my house. Now for six years that goat has been messing in and destroying my house. I want to renovate my house, but before I can, I have to get the goat out of the house before it does any more damage. It makes no sense to start fixing up my house until we get the goat out. Voting for the fiscal year ’17 budget resolution gets this goat out of my house. Mr. Speaker, make no mistake, we must renovate our house.”
Assessment: Major points for vividness. Who wouldn’t want to expel a rampaging goat from a home before undertaking a renovation?
Republicans dislike Obamacare, but its record is more mixed and far less destructivethan that of a wanton farm animal with an appetite for garbage and a tendency to defecate in bedclothes. The key political challenge for Republicans is devising a new health policy that preserves portions of Obamacare that have been successful and popular.

Paul Ryan: Something on a sand castle?

Metaphor: “Obamacare is built on a house of sand that is quickly collapsing,” Mr. Ryan said to Charlie Rose in January.
Assessment: Mr. Ryan, the Speaker of the House, makes the task seem urgent. The health law may appear to be stable now, but it may fall along with its underlying house soon. This metaphor, probably a misquoting of Matthew 7:24, is confusing. Who builds something atop a sand castle? And Mr. Ryan’s image suggests that it is not Obamacare that’s in trouble, but the health care system that lies beneath it. His policy proposals don’t do much to change that system.

Lamar Alexander: Bus ticket

Metaphor: “Obamacare is a bus ticket in a town with no buses,” Mr. Alexander, the chairman of the Senate committee on health, education, labor and pensions, said in a confirmation hearing for Tom Price, the Secretary of Health and Human Services.
Assessment: The metaphor captures a key weakness of Obamacare’s new insurance markets: the limited choices some consumers face.
So far, however, everyone who wants an Obamacare plan can get one. Mr. Alexander leaves us to wonder about the destination the ticket holder hopes to reach. (Good health?)

Michael Enzi: Bridge

“The Obamacare bridge is collapsing, and we’re sending in a rescue team,” the Senate Budget Committee chairman Michael Enzi said the night he voted to begin the Obamacare repeal process. (Senator Alexander has also been known to evoke the Obamacare bridge.) “Then we’ll build new bridges to better health care, and finally, when those new bridges are finished, we’ll close the old bridge.”
Assessment: Mr. Enzi’s metaphor aims to explain Republicans’ complex strategy for replacing the health law: first, passing a budget bill to repeal major portions, then freezing current law in place for a time and finally establishing a new system. And he evokes infrastructure investment, something most members of Congress love.
But the metaphor highlights a central problem with the multi-step strategy. In this metaphorical world, the collapsing bridge will need to stay open for some time, even after the initial rescue.

Various: Rug, possibly burning

Metaphor: “Nobody’s interested in pulling the rug out from under anybody,” Secretary Price said in his confirmation hearing.
Assessment: This talking point, adopted by manymany members of the G.O.P. caucus, is intended to reassure those happy with Obamacare that any changes brought by repealing it won’t upset them. Still, this popular metaphor is a poor match for the larger context of inflammatory language used to describe the health care law. If the rug is on fire, why would anyone want to keep standing on it?

Patty Murray: Roof, possibly burning

Metaphor: “We can’t repair the roof while the Republicans are burning the house down,” Ms. Murray, the ranking member of the Senate committee on health, education, labor and pensions, told my colleague Robert Pear.
Assessment: Another home construction metaphor. Ms. Murray, a Democrat, reverses Mr. Ryan’s logic. In her formulation, Obamacare is the house in need of roof repairs. Ms. Murray, perhaps more than her rug-preserving colleagues across the aisle, seems to suggest the health law has already been ruined beyond repair.

Ted Cruz: More cowbell

Metaphor: “I’m reminded of an old ‘Saturday Night Live’ skit with Christopher Walken where they are playing in a band, and he keeps ringing the cowbell,” Mr. Cruz, the Texas senator and former presidential candidate, said in a televised health care debate with Senator Bernie Sanders of Vermont. “And every time they recorded, his solution is more cowbell, more cowbell. It was government control that messed this all up. And Bernie and the Democrats’ solution is more cowbell, more cowbell. Yes, it didn’t work when we said you wouldn’t get your plan canceled. Yes, it didn’t work when we said your premiums would be cut. But give government even more power.”
Assessment: Has Mr. Cruz seen the classic skit? Musical taste is, of course, subjective. But, to this reporter, the cowbell made the song. (And to be clear, Will Ferrell was the cowbell player.)

The Obamacare Sticking Points Behind Closed Doors

by Margot Sanger-Katz - NYT - March 6, 2013
The debate over the future of Obamacare is taking place in secret meetings among Republican lawmakers. President Trump and House Speaker Paul Ryan have promised to bring forward a bill to modify the law soon. But before they do, they have to work out disagreements among their colleagues on the best way to proceed.
There are, of course, many small issues that are likely to be discussed in committee hearings or in other open forums. But several disagreements are so fundamental that they probably need to be resolved behind closed doors before a bill can even be introduced. Here’s a guide to the major sticking points that are holding up Republicans’ quest to replace the Affordable Care Act.

What to do about Medicaid

Obamacare expanded this federal-state program to cover more adults below or just above the poverty line. That change has enabled some 10 million more low-income Americans to have health insurance. It has also brought infusions of federal cash to 31 states and the District of Columbia, which expanded their programs. Medicaid also covers millions of poor seniors, mothers and children, and Americans with disabilities.
But the expansion of Medicaid has been unpopular among Republican lawmakers. It is a costly and growing entitlement for the poor. And its coverage is seen as largely government-run, unlike the private coverage that higher earners buy in the individual insurance markets.
House leaders would like to restructure the program to drastically slow its long-term costs. They want to cut back the amount the federal government pays states that cover poor adults without disabilities, and they want to change the overall structure so that it awards states a flat fee each year for people who sign up, instead of the current system in which the federal government pays a share of every Medicaid patient’s bills.
The budget hawks in the Republican caucus don’t like this plan because it essentially leaves much of Obamacare’s costly Medicaid expansion in place. But more moderate Republicans, especially those who come from states that expanded their program under the health law, dislike the proposal because it would cut back funds to their states.
Getting unstuck: It’s hard to see how leadership could alter the proposal in a way that would please both factions. Leadership’s bet is that conservatives may be willing to embrace a larger program if its long-term structure is changed. But that solution may be a compromise that mollifies neither side.
For people who don’t get employer insurance and earn too much to qualify for Medicaid, Obamacare offers subsidies to buy insurance on a sliding scale according to income. Those subsidies have come under attack by Republicans as too expensive and too complicated to administer. (Figuring out subsidies involves verifying people’s income, and sharing data between several federal agencies.)
But Republican leaders acknowledge that many Americans would struggle to pay for insurance without government help. The committee plan would offer a different kind of refundable tax credit: a flat subsidy, depending on the age of the insurance purchaser. Some conservatives see such a system as too profligate — Senator Rand Paul of Kentucky has called it “Obamacare-lite” — because it still pays some people more in financial assistance than they would otherwise pay in taxes. Those lawmakers tend to support plans that would lower people’s tax bills if they bought insurance, but not award them additional financial aid if they don’t pay much in income tax.
President Trump appeared to weigh in on this debate during his address to Congress on Tuesday, by offering an endorsement of “tax credits” as the funding mechanism.
Getting unstuck: The fate of the tax credit approach may come down to money. The Congressional Budget Office is working with committees to estimate how much the plan would cost and how many people it would cover. If the cost is deemed large or the number of Americans covered shrinks by a lot, compromise gets even less likely. But if the tax credits turn out to be inexpensive, the fights over the subsidy structure might become less heated.

The role of employer plans

Congressional Republicans are largely united in wanting to sweep away the many new taxes created by the Affordable Care Act. The law taxed drugs, health plans, medical devices, tanning salons, expensive health plans — and raised Medicare taxes on high earners. The plan would do away with all those taxes.
But without them, even a stripped-down Medicaid program and smaller tax credits start to get expensive. And finding a source of funding for the bill’s benefits is tricky in a caucus that tends to oppose any sort of tax increase.
The committee plan would find some money by limiting the tax exclusion for employer health benefits. Currently, neither employers nor their workers pay any taxes on money that goes toward health insurance. Limiting the money that can go to employer benefits tax-free would help provide tax assistance for people who buy their own coverage. Health economists also think that limiting the exclusion could help drive down health spending. But the employer tax exclusion is widespread and popular — and capping it is seen by some as a tax increase. That means that some members of Congress are ideologically opposed to the idea.
Getting unstuck: The Republican lawmakers who care about the federal deficit will have to find money from somewhere to make the math work, and capping the employer exclusion is the only proposal on the table. Using this method would allow them to brag about sweeping away Obamacare’s other taxes. But they’ll have to be willing to stomach complaints from constituents and employer groups.


by Atul Gawande - The New Yorker - March 6, 2017

The pitchforks are changing hands. In 2009, it was Democratic members of Congress supporting health-care reform who were set upon by outraged constituents. When they passed the Affordable Care Act anyway, it cost their party control of Congress in the 2010 midterm elections. House Republicans subsequently voted more than fifty times to repeal or cripple the A.C.A. Nineteen Republican-led states spurned the offer of federal funds to expand Medicaid coverage. In January, Donald Trump’s first act as President was to order government agencies to avoid implementing, as much as is legally possible, what has become known as Obamacare.
But Obamacare, it turns out, has done a lot of good. It guarantees that people with preëxisting health conditions cannot be rejected by insurers or charged more than others. It has reduced the number of uninsured people by twenty million. It has increased access to primary care, specialty care, surgery, medicines, and treatment for chronic conditions. Patients are less likely to skip needed care because of the cost. As a result, according to studies conducted at Harvard, the A.C.A. is saving tens of thousands of lives each year.
Now Republicans in Congress are facing the wrath of constituents who don’t want to lose those gains. Conservatives have had to back off from their plan to repeal Obamacare now and worry about replacement later. Instead, they must grapple with what they have tried to ignore: the complexities of our health-care system, especially in the four vital areas of employer-sponsored coverage, Medicaid, the individual insurance market, and taxes.
Half of Americans get their health coverage through their employer. For them, the A.C.A. brought such popular changes as uncapped coverage, inclusion of children up to the age of twenty-six, and requirements that insurers cover not only primary care but also pediatric dental and vision care, mental-health care, and, with no co-payments, preventive care. The Republicans probably won’t risk eliminating these provisions—except for contraceptive coverage—but they dislike the measures that have kept employers providing health benefits: tax penalties for big companies that don’t; tax credits for small businesses that do.
It was Obamacare’s dramatic expansion of Medicaid, in participating states, to all Americans living near the official poverty line that produced the largest reductions in the uninsured. Many Republicans have vowed to cut back the program’s funding, and to send the money to states as a lump sum, or “block grant.” This approach, however, is apt to throw millions out of coverage and many states into fiscal crisis, and key Republican governors and senators are opposing it.
Republicans are also divided on what to do about the roughly ten per cent of Americans—freelancers, independent contractors, and the like—who aren’t covered by an employer, don’t qualify for Medicare or Medicaid, and must rely on the individual health-insurance market. Before the A.C.A., these people were the most vulnerable in the system; twenty-seven per cent of non-elderly adults have a preëxisting condition that makes them effectively uninsurable without the law’s protections. Now they can sign up through online exchanges for plans that are priced without regard to health history and are subsidized based on income.
Republicans claim that the program is in a death spiral. It isn’t; enrollment has held constant. But there is a need to draw in younger, healthier people to offset the costs of older, sicker people and keep the premiums steady. Doing so depends on promoting widely and enforcing the tax penalty for people who don’t sign up. The President, however, has issued a raft of contradictory directives that ultimately instruct the government to do neither. As a result, more and more insurers are saying that they will pull out of the exchanges, risking the collapse of the individual market.
Having promised to get rid of the insurance mandate, Republicans are considering alternatives, but so far they are all inadequate. A requirement for people to maintain “continuous coverage”—to take an example supported by the new Secretary of Health and Human Services, Tom Price, and Speaker of the House Paul Ryan—would mean that people who lose their insurance temporarily, because they, say, change jobs or suffer a financial setback, would also lose their preëxisting-condition protections. For these people and for others left behind, Price and Ryan advocate state-run “high-risk pools.” But, in the thirty-five states that offered high-risk pools to the uninsurable before the A.C.A., inadequate funding delivered terrible coverage, with extremely high premiums and deductibles, and annual limits as low as seventy-five thousand dollars. Hardly anyone signed up.
For orthodox Republicans, the central issue is, of course, taxes. Obamacare increased them, particularly for high-income individuals and for industries that profit from the expansion of coverage, to pay for the costs of reform. (The A.C.A. actually reduces the deficit.) Many Republicans have made cutting those taxes their top priority; others see preserving coverage as the imperative. Each side thinks the other is committing political suicide. But, with so many Americans beginning to recognize how much they stand to lose, the political equations are shifting.

Governance is forcing Republicans to confront the reality that repeal without replacement is untenable. In a stalemate, Congress would likely need to delay repeal and, to reassure skittish insurers, focus on small-scale repairs, such as affirming that subsidies will continue to be funded, and either enforcing the existing mandate or revising it so that more young and healthy people sign on. (For instance, healthy people could be charged an extra ten per cent on premiums if they forgo insurance for a year, the same as the penalty for elderly people who refuse Medicare Part B.) In addition, the states that sat out the Medicaid expansion in order to thwart President Obama would be free to join in under a Republican Administration, as many would like to. “Insurance for everybody,” Trump has vowed. A Trumpcare compromise could yet bring us a step closer to it.
But legislators have no time to waste. Insurers must decide by April whether to offer a plan for the exchanges in 2018, and at what price. That requires certainty about the future. Pitchforks have their uses, but crafting health-care policy calls for more delicate instruments. The basic functioning of the health-care system is at stake. So are American lives. 

The Cockroach Proposal––Selling Insurance Across State Lines

by Robert Laszewski - March 1, 2017

 call support for giving insurance companies the ability to sell insurance across state lines the cockroach proposal.

As bad as it is, you just can't kill the damn thing!

Last night, President Trump once again listed this idea in his address to Congress as one of his health care talking points.

Here is a post about the idea I published on this blog a year ago in the midst of the Republican presidential primary:

Any candidate that suggests such a scheme only shows how unsophisticated he and his advisers are when it comes to understanding how the insurance markets really work––or could work. 

I gave a speech to 750 health insurance brokers and consultants in DC last week.

When selling health insurance across state lines, something Trump and a number of other Republican presidential candidates have been pushing, was mentioned the audience literally laughed. That's what health insurance professionals who spend their days in the market think of it! 

This is about as dumb an insurance "reform" idea as has ever been proposed.

This is nothing more than an attempt to take the market back to the days of cherry picking risk––figuring out how to sell policies to only the healthy people. If this were ever enacted it would only serve to shuffle the healthy people into one set of health insurance policies and the sick into another thereby driving down costs for the healthy and in return just driving costs up for the sick––and accomplishing nothing toward fundamentally making insurance cheaper. 

People who promote the idea are targeting the many state benefit mandates that drive health insurance policy prices up. The idea is, after the federal Obamacare mandates are repealed, to allow the sale of cheaper policies from states with the fewest benefit mandates to be able to be sold in high mandate states––thereby encouraging the state with more mandates to curtail them.

But if their aim is to eliminate many of these "excessive" state benefit mandates with a federal law, why not just curtail these mandates in all of the states with a federal law? If they are going to stick their federal noses into some of the states that have traditionally regulated insurance, why not just go ahead and stick their noses in all of the states at once and create a level playing field while they are at it?

There are a number of basic problems with this idea:

If it did attract new carriers to a market, it would be a great way to blow up the existing health insurance market––for example, the high market share local legacy Blue Cross plan whose business is in compliance with all of the existing state benefit mandates. A new carrier could conceivably come into the market with much lower rates––because it is offering fewer benefits––and thereby attract the healthy people out of the old more regulated state pool leaving the local legacy carrier with a sicker pool still attracted to the richer benefits.

Stripping down a health plan is a great time tested way for a predatory insurance company to attract the healthiest consumers at the expense of the legacy carrier who is then left with the sickest––cherry picking.

Proponents might argue that creating more competition by allowing carriers with stripped down policies into a state would be a great catalyst to force all of the states to reduce their mandates––like creating market chaos is a great tool for reform. 

It's a 1990s idea that fails to recognize the business a health plan is now in. Health plans these days don't just cross a state line and set up their business like they did decades ago when the insurance license and an ability to pay claims was all a carrier needed to do business.

This idea was first suggested by the last of the insurance industry cherry pickers back in the 1990s, on the heels of the first generation of insurance underwriting reform (HIPAA), as a way to compete with the more sophisticated managed care companies––and it has long outlasted its relevance.

Today, building a new health plan in a single market can easily cost hundreds of millions of dollars over a plan's first few years of operation. The most important thing a health plan now offers is not an insurance contract but rather a comprehensively managed provider network. Just look at the capital costs for the new co-ops under Obamacare that often received $100 million or more to set up a new plan––and ended up grossly undercapitalized.

This scheme doesn't even solve the problem it identifies––too many state mandated benefits. So, solve that problem. Why do we even need to enact this convoluted and market obsolete idea? Why even encourage the return of predatory health insurance cherry pickers? Why create a two-tiered market? Why not fix the real problem and create a level playing field for everyone at the same time? I suggest the supporters of this idea first ask the leaders of the insurance industry if they would even do this under the best of circumstances (They will just laugh like they did in DC last Monday).

And, if it did work, we're talking about a one-time minor league savings of only a few percentage points. Hardly meaningful cost containment or sophisticated health care policy.

Back in the early 2000s when we had a Republican majority in both houses and a Republican President, the House did pass legislation that would have enabled carriers to sell across state lines. The bill went to the Senate where Republicans couldn't even get 50 votes for the idea. Largely because state insurance commissioners––Republican and Democratic––were overwhelmingly opposed to this from the beginning and made that clear to their Republican Senators.

The insurance commissioners were universally opposed because this is a dumb idea. 

Obamacare needs major fixing.

But not with simplistic sound bites that claim this would increase competition but in fact would only lead to the health insurance cherry picking schemes we got rid of back in the 1990s.

Obamacare has already proven that the Democrats who wrote it never understood the insurance markets.

Things like this just prove that some of these Republicans are no smarter.

Informed Patient? Don’t Bet On It

by Mikkael Sekeres and Timothy Gilligan - NYT - We want to let you in on a secret.
As your oncologists, we’d like to treat you with two, or three, or four different chemotherapy drugs, each of which has distinct side effects, some of which can kill you.
Or, if we were cardiothoracic surgeons, we might tell you that we need to crack your chest open to repair your damaged heart valve, and for that to happen you’ll need to undergo anesthesia from which you may never wake up.
As doctors, our goal is to help you, of course, and to do no harm. But we may actually hurt you, irreversibly. Not that this happens frequently, but it might.
How does that sound? Ready to take the plunge?
The secret is that informed consent in health care is commonly not-so-well informed. It might be a document we ask you to sign, at the behest of our lawyers, in case we end up in court if a bad outcome happens. Unfortunately, it’s often not really about informing you.
In schools, teachers determine what students know through tests and homework. The standard is not whether the teacher has explained how to add, but instead whether the student can add. If we were truly invested in whether you were informed, we’d give you a quiz, or at least ask you to repeat back to us what you heard so we could assess its accuracy. Instead, our script frequently looks more like this:
Us: Blah blah blah.
You, as the patient, nod, and look like you’re paying close attention.
Us: Did you understand everything we said?
You: Yes.
Us: Any questions?
You: No.
There’s a sort of collusion that takes place, and we’re all complicit. Over your lifetime of seeing us, we have trained you that we will look impatient and concerned if you say you didn’t understand something or if you have a lot of questions. After all, we’re busy and have other patients to see. Shame on us.
We’ve been on the receiving end of this, too. We have both undergone medical procedures ourselves for which a colleague asked us to acknowledge that we were properly informed. We said we were, fearing disappointing our doctor if we said otherwise.
Unfortunately the farce of informed consent only worsens in medical research. Before you can enroll in a clinical trial of a cancer drug, we’ll hand you a 25-page document that describes the trial’s purpose, its design, the medications you’ll receive, other standard treatments, and the complications you may suffer. Oh, and we’ll tell you that you are responsible for any medical costs not covered by insurance or the trial sponsor. That’s for the lawyers, again. We will then ask you to sign the final page, acknowledging your understanding and your agreement to participate in the trial.
When is the last time you read a 25-page document from beginning to end?
But maybe it’s O.K. if you don’t read it. Some people don’t want to hear about potential bad outcomes. Others trust their doctors to recommend what’s best for their health, and find comfort in handing decisions about interventions like chemotherapy or heart surgery over to another. We tell our patients that if it makes their cancer journeys any easier, we will do the worrying for them.
And we really do wring our hands about our decisions, and rend our garments over bad outcomes that result from our recommendations.
A fundamental challenge with this process is that it is often unrealistic to think that you actually could be fully informed of what you’re about to undergo. How can we explain to you the experience of having your chest cracked open, or what it feels like when you go through chemotherapy? Neither of us has undergone heart surgery, or treatment for cancer, and we don’t kid ourselves that any depiction of the experience we provide will be enough.
We’d love for you to help us do a better job of informing you, though. So here’s our request:
■ Ask us to use common words and terms. If your doctor says that you’ll end up with a “simple iliac ileal conduit” or a “urostomy,” feel free to say “I don’t understand those words. Can you explain what that means?”
■ Summarize back what you heard. “So I should split my birth control pills in half and take half myself and give the other half to my boyfriend?” That way, if you’ve misunderstood what we did a poor job of explaining, there will be a chance to straighten it out: “No, that’s not right. You should take the whole pill yourself.”
■ Request written materials, or even pictures or videos. We all learn in different ways and at different paces, and “hard copies” of information that you can take time to absorb at home may be more helpful than the few minutes in our offices.
■ Ask for best-case, worst-case, and most likely scenarios, along with the chance of each one occurring.
■ Ask if you can talk to someone who has undergone the surgery, or received the chemotherapy. That person will have a different kind of understanding of what the experience was like than we do.
■ Explore alternative treatment options, along with the advantages and disadvantages of each. “If I saw 10 different experts in my condition, how many would recommend the same treatment you are recommending?”
■ Take notes, and bring someone else to your appointments to be your advocate, ask the questions you may be reluctant to, and be your “accessory brain,” to help process the information we are trying to convey.
We’ve seen too many patients regret decisions that they made without fully understanding their options, or the possible outcome. We encourage our patients, and our colleagues, to be partners in what are often life-changing decisions about health care.

Our View: Anti-Obamacare fog still hovers over D.C.

Many Republicans agree that they hate the Affordable Care Act, but they can't agree why.
Portland Press Herald Editorial - March 5, 2017
You would have had to have been in a coma for the last six years if you didn’t know that many, many Americans hate the Affordable Care Act, especially when it goes by the name “Obamacare.”
But you can be excused if you didn’t realize that they all don’t have the same reasons for hating it.
This is what Republicans in Washington are discovering, which is what is making it so hard to repeal and replace the ACA, the signature policy achievement from the Democrats’ brief two-year stint of controlling both the White House and Congress, the same levers of power that Republicans now hold.
For instance, people say they don’t like the program because of the cost. But what cost are they talking about?
Some Republicans are complaining about the taxes it collects from high-income individuals and companies that gained demand for their services in a subsidized market. But other critics are talking about the high premiums and deductibles on plans offered through the health care exchanges.
You can’t please both sides: If you cut the taxes, the plans will get more expensive. If you increase the subsidies to make the plans less costly, you can’t afford to cut the taxes. And, by the way, the ACA actually reduces the deficit, so repealing it would cost everybody more even as millions of people lost their coverage.
As President Trump himself said last week, “Nobody knew that health care could be so complicated!”
That wasn’t the only thing the president said about health care. In his well-received speech to a joint session of Congress on Tuesday, Trump spoke in slightly more detail about the shape that an ACA replacement should take, and listed five principles for a replacement plan. Each reveals another level of complexity.
 “First, we should ensure that Americans with pre-existing conditions have access to coverage, and that we have a stable transition for Americans currently enrolled in the health care exchanges.”
Republicans will have to decide whether “should ensure … access” means the same thing as “should have coverage” and whether a “transition” means a transition to other coverage or to no coverage at all.
 “Secondly, we should help Americans purchase their own coverage, through the use of tax credits and expanded health savings accounts, but it must be the plan they want, not the plan forced on them by our government.”
Tax credits aren’t free, and the president appears to be siding with the people who complain that health insurance is too expensive to buy under the ACA. But finding the money to pay for the subsidies is apparently Congress’ problem
 “Thirdly, we should give our great state governors the resources and flexibility they need with Medicaid to make sure no one is left out.”
This sounds like a reference to Republican efforts to turn Medicaid into a block grant program, which analysts predict will leave many people out, especially if the federal government caps spending.
Medicaid rolls grow and shrink along with economic cycles. When a recession hits and people lose their jobs, they become eligible; when they get back to work, they go off Medicaid. A flat amount from Washington would create a financial crisis in Maine every time we hit a period of high unemployment.
 “Fourth, we should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance – and work to bring down the artificially high price of drugs and bring them down immediately.”
Medical malpractice reform is perennially popular during campaigns, but studies show it would have limited impact on health care costs. Prescription drugs, on the other hand, are a major driver of health care costs, putting coverage out of reach for millions of Americans. If Trump could get Republicans in Congress to give up their historical objection to regulating drug prices, he might indeed make coverage affordable without high subsidies.
• “And finally, the time has come to give Americans the freedom to purchase health insurance across state lines – which will create a truly competitive national marketplace that will bring cost way down and provide far better care.”
This has been part of Republican orthodoxy for decades, but there is no evidence that it would drive costs down. It’s not just state regulation that keeps insurance companies from setting up shop in Maine – it’s also the underlying cost of caring for people here, because our population is older and sicker than those in other parts of the country.
The most complicated problem Trump faces is political. Republicans have run for office for years claiming that repealing Obamacare would be easy: It’s not, and not just because 20 million more people have health insurance than had it before.
Even Republicans don’t agree on why it is that they hate the program, so they can’t agree on how to fix it.
Until they do, it would be irresponsible to go any further down the road to repeal.

More Than 80 Percent of Patient Groups Accept Drug Industry Funds, Study Shows

by Katie Thomas - NYT - March 1, 2017

The nation’s largest patient advocacy groups are on the front lines of some of the biggest health care debates, from the soaring costs of prescription drugs to whether new medicines are being approved quickly enough.
But while their voices carry weight because they represent the interests of sick patients, a new study has found that more than 80 percent of them accept funding from drug and medical-device companies. For some groups, the donations from industry accounted for more than half of their annual income, and in nearly 40 percent of cases, industry executives sit on governing boards, according to the study, which is published in The New England Journal of Medicine.
Nearly “nine out of every 10 are taking money,” said Dr. Ezekiel J. Emanuel, an oncologist and vice provost at the University of Pennsylvania. He is one of the authors of the study, which looked at the top 104 nonprofit patient advocacy groups that reported more than $7.5 million in annual revenues for 2014. “I think that is not well known — I think that is a shock.”
Dr. Emanuel, who previously advised President Obama on health care, said patient groups were far less transparent about conflicts of interest than medical researchers, who are now pushed to disclose ties to the drug and device industries when they write articles and make public appearances.
“Compared to what researchers are doing, this is pathetic,” he said. And yet “they wrap themselves in white as if they’re pure.”
Patient groups said they have taken steps in recent years to improve their financial disclosures and conflict-of-interest policies, and rejected the suggestion that they were influenced by their corporate donors.
“Patient advocacy organizations are driven by their missions — putting patients first,” said Marc M. Boutin, the chief executive of the National Health Council, an umbrella group for patient-advocacy groups. “To say otherwise negates the extraordinary work achieved by these organizations on behalf of their patients.” The health council had previously said that pharmaceutical companies accounted for 62 percent of the council’s $3.5 million budget in 2015.
The study also found a wide disparity in how the groups disclose the donations, making it difficult for members of the public to know how significant the industry funding is. The study authors gathered their data by examining the websites of the nonprofit groups, as well as their tax filings and annual reports from 2014.
The researchers pointed to the National Hemophilia Foundation as one group that is vague about its funding because, although it lists corporate donors, it only discloses donation ranges. Drug makers contributed a range from $8.5 million to $14 million of the group’s $16.8 million annual budget in 2014, the year researchers studied. Its top donors, Baxter, Biogen and Novo Nordisk, make products used by people with hemophilia; each donated between $2 million and $3 million, the researchers said.
The American Diabetes Association, by contrast, reported receiving more than $28 million in industry funding in 2014, or about 15 percent of its budget, but provided detailed disclosures of which companies donated, and how much, the study authors said.
In a statement, the hemophilia foundation said it never allows its corporate sponsors to influence its decision-making, and that it also does not endorse specific products or favor certain companies. It declined to provide precise dollar amounts of contributions from companies, saying that the foundation complied with “accepted financial reporting standards.”
The study’s authors said transparency could be improved by requiring the drug and device industries to report how much they donate to patient groups, much like they are already required to do with doctors.
That was applauded by other critics of the drug industry. “I think sunshine is an excellent disinfectant,” said David Mitchell, the founder of a new group, Patients for Affordable Drugs, that seeks to lower drug prices, and does not take funding from industry groups. He was not involved in the study.
Mr. Mitchell said patient groups often do not disclose that they take industry funds when they testify before Congress or government agencies, or when they disseminate educational information to patients.
Many have also been silent on the issue of rising drug prices, even as the issue has enraged patients, who have been increasingly exposed to the prices that pharmaceutical companies set as insurers have asked them to pay a greater share of their drug costs. Last summer, patients and their families loudly protested the skyrocketing price of EpiPens, though the movement gathered steam on social mediarather than through traditional patient-advocacy groups.
And a year ago, for example, a representative for the National Psoriasis Foundationdid not disclose that her group receives at least 40 percent of its annual revenues from drug companies when she testified before the North Carolina state legislature on an unsuccessful measure supported by the pharmaceutical industry that would have limited insurers’ ability to block coverage of certain drugs. Similarly, the hemophilia foundation did not disclose its pharmaceutical ties when it took the industry’s side in 2015 in a letter to the Food and Drug Administration over the issue of biosimilars, which are cheaper alternatives to complex biological drugs.
“In the absence of disclosure,” Mr. Mitchell said, “those policy makers or patients are unable to make informed judgments about the motives of the information being given, and the credibility of the information.”
Randy Beranek, president and chief executive of the psoriasis foundation, said he did not see a conflict of interest because both the foundation and pharmaceutical companies are seeking to help serve patients.
“Our interests all intersect at some point, and that’s at the patient,” he said.
In the case of the North Carolina proposal, Mr. Beranek acknowledged that his group sides with the drug industry on some issues but said, “it’s a coincidence that it’s an important policy issue to them, but to us, it’s in the patient interest.”
Holly Campbell, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, an industry trade organization, said its members did not expect patient groups to agree with them on every issue. “We work with many organizations with which we have disagreements on public policy issues, including on prescription medicine costs, but believe engagement and dialogue are critical,” she said.

Vital Signs: Does the U.S. have the right mindset for value-based care?

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