Thursday, April 27, 2017

Health Care Reform Articles - April 27, 2017

Hard-Line Republican Caucus Backs Revised Bill to Repeal Obamacare

by Jennifer Steinhauer and Robert Pear - April 26, 2017
WASHINGTON — The House Freedom Caucus, a group of hard-line conservatives who were instrumental in blocking President Trump’s plan to repeal the Affordable Care Act last month, gave its approval Wednesday to a new, more conservative version, breathing new life into Republican efforts to replace President Barack Obama’s health law.
Senior White House officials, led by Reince Priebus, the chief of staff, have relentlessly pressed Republicans to revive the health care push before Mr. Trump’s hundred-day mark on Saturday, and with conservatives falling into line, the bill has a chance to get through the House, possibly as early as Friday.
It was not clear whether conservative support for the revised legislation would be matched by losses in the center, especially among Republicans representing districts won by Hillary Clinton. But the rest of the House Republican Conference was left with a stark choice: Reject the measure and take the blame previously left at the feet of conservatives for undermining a central goal of the administration, or give it the nod, please voters who want a repeal, and risk taking a potentially fatal hit in the next election for approving a measure expected to leave tens of millions of Americans without insurance.
“Members went home and got an earful,” said Representative Tom Cole, Republican of Oklahoma, saying that voters were wondering, “Why can’t you get something done?” Mr. Cole said he was now “cautiously optimistic” that the measure could pass on the floor.
The latest proposal, drafted by Representative Tom MacArthur, a moderate Republican of New Jersey, would allow states to obtain waivers from federal mandates that insurers cover certain “essential health benefits,” like emergency services, maternity care, and mental health and substance abuse services, which many Republicans argue have driven up premiums.
It would also permit states to get waivers allowing insurers to charge higher premiums based on a person’s “health status,” if a state had a program to help pay the largest claims or had a high-risk pool where sick people could purchase health insurance.
To qualify for a waiver, a state would have to explain how it would advance at least one of five purposes: reducing average premiums for consumers; increasing the number of people with coverage; stabilizing the insurance market; increasing the choice of health plans; or stabilizing premiums for people with pre-existing conditions.
The House Freedom Caucus members, acutely aware that the White House and Republican colleagues blamed them for the failure of the earlier bill, were eager to shift the blame to more moderate members who may now reject the measure. And the biggest conservative pressure groups off Capitol Hill — Heritage Action, Club for Growth and Freedom Partners — dropped their opposition to the measure, known as the American Health Care Act.
“Over the past couple of months, House conservatives have worked tirelessly to improve the American Health Care Act to make it better for the American people,” Alyssa Farah, a spokeswoman for the House Freedom Caucus, said in a prepared statement. Because of those changes, she added, “the House Freedom Caucus has taken an official position in support of the current proposal.”
The group agrees to take an official position when 80 percent of its roughly three dozen members agree.
But what is good for the most conservative corners of the House is not necessarily going to please their colleagues, including the dozens who had already rejected a less-conservative version of the bill. Republican senators had been equally wary. “I think a better approach is to stabilize the insurance pool,” said Senator Bill Cassidy, Republican of Louisiana.
In effect, the more that the bill changes to get through the House, the less chance it has of surviving in the Senate, both because of Senate rules and because the provisions that conservatives have excised are popular.
A recent ABC News/Washington Post poll found that 62 percent of respondents supported nationwide minimum insurance coverage standards and just 33 percent would leave such standards up to the states. Among Republicans, 54 percent supported a nationwide standard for coverage of pre-existing conditions.
Republican senators from states that have expanded Medicaid under the Affordable Care Act said the new House bill did nothing to ease their concerns about the deep cuts to Medicaid that remain in the legislation.
“There’s still going to be some of us here in the Senate who would like to weigh in, particularly on Medicaid expansion, which is not part of the bill,” said Senator Rob Portman, Republican of Ohio.
Democrats assailed the latest proposal, saying it did nothing to help those who would be left without coverage under the repeal bill. By 2026, the number of uninsured people would be 24 million higher than under the current law, according to the nonpartisan Congressional Budget Office.
Democrats denounced one part of the new proposal that, they said, would protect health insurance for members of Congress. This provision, they said, guarantees that lawmakers would not lose “essential health benefits” and could not be charged higher premiums because of their health status. The group that helps elect House Democrats immediately unleashed internet ads in 30 Republican-held districts railing against the carve-out.
“The monstrous immorality of Trumpcare is perfectly encapsulated in House Republicans’ plan to exempt their own health coverage from the damage it will do to everyone else,” said the House Democratic leader, Nancy Pelosi of California.
Mr. MacArthur backed away from this part of his proposal on Wednesday. “Congressman MacArthur does not believe members of Congress or their staff should receive special treatment and is working with House leadership to make absolutely clear that members of Congress and staff are subject to the same rules, provisions and protections as all other Americans,” a spokeswoman said.
Mr. Trump, seeking a major legislative victory in his first 100 days in office, has been pressing hard to get a floor vote on a measure to repeal Mr. Obama’s signature health care law and to fulfill a campaign promise of most Republicans for the better part of a decade.
Vice President Mike Pence and other White House staff have been feverishly trying to get the most conservative members to support a bill, even one that is not viable in the Senate, and without the input of many moderate members.
But the effort may be creating momentum.
“The key is, all of us recognize we and the president made campaign promises to repeal and replace Obamacare,” said Representative Chris Collins, Republican of New York and a top Trump ally. “We, as a team, all recognize we need to get to yes.” He added, “I am guardedly optimistic.”
Speaker Paul D. Ryan said Wednesday that a new bill could come to the floor at some point if sufficient support surfaced. “We’ll vote on it when we get the votes,” he said.
As Republican leaders maneuvered toward a vote to repeal the Affordable Care Act, they were working to assure Democrats that the government would continue to subsidize out-of-pocket expenses for people buying insurance through the law’s online marketplaces. Democrats have threatened to hold up legislation to keep the government funded past Friday unless they get guarantees that the so-called cost-sharing reductions would continue.
House Republicans had successfully sued the Obama administration to stop the payments, arguing that the administration was illegally spending money that Congress had not explicitly appropriated. By Wednesday afternoon, Democrats appeared convinced that the money would keep flowing, a significant promise that should help reassure insurance companies as they decide whether to offer policies on the marketplaces in 2018.
Ms. Pelosi neared a declaration of victory on that front, and on efforts to block funding this year for Mr. Trump’s promised wall on the Mexican border.
“Our major concerns in these negotiations have been about funding for the wall and uncertainty about the CSR payments crucial to the stability of the marketplaces under the Affordable Care Act,” she said. “We’ve now made progress on both of these fronts.”

Donald Trump Threatens to Sabotage Obamacare

by The Editorial Board - NYT - April 19, 2017

After Republican leaders in Congress failed to destroy the Affordable Care Act last month, President Trump tweeted that the law would “explode.” Now he seems determined to deliver on that prediction through presidential sabotage.
Mr. Trump is threatening to kill a program in the A.C.A. that pays health insurers to offer plans with lower deductibles and out-of-pocket expenses to about seven million lower-income and middle-class people. The president thinks that this will get Democrats to negotiate changes to the 2010 health law. This is cruel and incredibly shortsighted. Without these subsidies, health care would be unaffordable for many Americans, including people who voted for Mr. Trump because they were frustrated by high medical costs.
These subsidies lower the cost of medical care for people who earn between 100 percent and 250 percent of the federal poverty level. For a family of four, that income is $24,600 to $61,500 a year. For example, the deductible on qualifying Obamacare policies for families living at the poverty line in Charlotte, N.C., would be $1,000, compared with $10,000 for a standard policy, according to government data. In Philadelphia a similar family would have no deductible, compared with a $5,000 deductible for policies without subsidies. The government is expected to spend $7 billion on subsidies in 2017, and nearly 60 percent of the 12.2 million people who bought Obamacare policies for 2017 benefit from them.
Conservatives have been trying for years to end these subsidies in an effort to destabilize the A.C.A. House Republicans filed a lawsuit in 2014 to prevent the Obama administration from making these payments to insurers without appropriations from Congress. A Federal District Court ruled in the Republicans’ favor, but President Barack Obama appealed the case and the payments have continued — so far, at least. Mr. Trump has to decide how to proceed.
It is not surprising that Mr. Trump would see the subsidies as a bargaining chip. Governing, to him, is a matter of quick-hit deals, and he shows no concern about gambling with the health of millions of people.
Even if Mr. Trump does not end the subsidies, experts say, many insurers are already skittish about the administration’s animosity toward the A.C.A. They could stop selling Obamacare policies if the payments went away. Some counties in red states like Arizona, Oklahoma and Tennessee could be left with no insurers for individuals and families that do not get coverage through employers. Companies that remain would increase premiums by an average of 19 percent to make up for the loss of government money, according to the Kaiser Family Foundation.
Many insurance companies and health experts are also worried that the government will stop enforcing the A.C.A. provision that requires people to buy coverage or pay a penalty. That would encourage healthy people to forgo insurance, leaving companies to cover a smaller, sicker population. The administration has suggested that it might look the other way if individuals don’t buy insurance.
There would be a huge political cost for disrupting the health insurance market. A recent Kaiser poll found that 61 percent of Americans say that Mr. Trump and Republicans in Congress would be responsible for any future problems with the A.C.A. Lawmakers need look no further than recent town hall meetings where voters lashed out at Republicans for trying to take health care away from 24 million people. Referring to the subsidies, Mr. Trump recently told The Wall Street Journal: “Obamacare is dead next month if it doesn’t get that money. I haven’t made my viewpoint clear yet. I don’t want people to get hurt.”
This isn’t Mr. Trump’s promised “insurance for everybody.” It sounds more like a two-bit Hollywood villain promising carnage if he doesn’t get his way.

Anthem Threatens to Leave Health Exchanges if Subsidies Are Halted

by Reed Abelson - NYT - April 26, 2017

Even as Anthem, one of the nation’s largest insurers, reported an improved financial picture for the last year, the company warned on Wednesday that it would consider leaving some federal health care marketplaces or raising its rates sharply if the government does not continue subsidies to help low-income people.
Joseph R. Swedish, the company’s chief executive, set a deadline of early June for a decision on the subsidies, saying Anthem would weigh increasing rates by at least 20 percent next year.
These subsidies, called cost-sharing reductions because they reduce the amount people must pay out of pocket when they go to the doctor, have become a political football as President Trump and House Republicans try to repeal the federal health care law and negotiate a spending bill with a deadline looming this week.
While Republicans successfully sued the Obama administration to discontinue funding the payments, the decision is on appeal, and Mr. Trump has recently indicated that he wants to use the subsidies as a bargaining chip with Democrats.
On Wednesday, Republican leaders were seeking to assure Democrats that the subsidies would continued to be funded, although there was no guarantee.
If the subsidies ended in 2018, the lack of funding “would cause further market instability,” Mr. Swedish said, which would make the company’s participation in the federal market “even more challenging.”
While the Republican-controlled Congress and President Trump insist that the markets under the Affordable Care Act have been “imploding,” Anthem’s earnings report on Wednesday offered another sign that some markets were stabilizing.
By adding new customers and raising prices, Anthem said its overall profits reached $1 billion on higher revenue of about $22 billion, beating Wall Street expectations and sending its stock higher on Wednesday. Its shares closed at $179.03, an increase of 3.8 percent.
Anthem, which operates for-profit Blue Cross plans in 14 states, is the latest insurer to say its performance has improved over the past year in the individual markets created under the Affordable Care Act. The company said it now covered 1.1 million people through the state marketplaces or exchanges, with an additional 500,000 customers buying individual policies under the law.
The company is deciding where to sell policies and what to charge for 2018, and it is telling state insurance regulators that it will need to make significant adjustments to its offerings if the government funding remains unclear by early June.
While Mr. Swedish praised some of the steps that have been taken to stabilize the markets, he also urged the Trump administration and Congress to eliminate the tax on health insurance as a way of keeping premiums lower and to create a reinsurance program or high-risk pool to help insurance companies pay claims for people with very high medical expenses.
Another for-profit insurer that has a major presence in the market, Centene, announced its results on Tuesday. The company expressed confidence that there was support from both Republicans and Democrats for the subsidies and said it expected to remain in the market.
Like many other insurers, Anthem has struggled to make money in the marketplaces, but it said it expected to break even or do better this year.
Two independent analyses, from the Kaiser Family Foundation and Standard & Poor’s, suggested that the markets over all were stabilizing despite the claims from Mr. Trump and congressional Republicans that they were collapsing. But there have been recent exits by high-profile insurers like Aetna and Humana, and there is concern that some places could be without an insurer to sell individual policies under the law. Other markets may have only a single insurer offering coverage.
Anthem’s results seemed to bolster the view that the remaining insurers were turning the corner, although significant uncertainty remained, said Gary Claxton, a Kaiser vice president who was one of the authors of the recent report.
Anthem also addressed questions about its pharmacy benefit manager, the company that handles the drug claims for its customers. This week, that company, Express Scripts, said it would most likely lose Anthem, its largest customer, beginning in 2020, a significant blow. Anthem accounted for more than $17 billion of Express Scripts’ annual revenue. In the first quarter of this year, Anthem accounted for 18 percent of Express Scripts’ business.
Last year, the two companies engaged in a bitter legal battle in which Anthem sued Express Scripts for $15 billion and claimed the company had been overcharging it for drugs.
In comments this week on CNBC, Express Scripts’ chief executive, Timothy C. Wentworth, said he would like to keep Anthem’s business, adding, “We’ve given them terrific service.”
In its call with investors, Anthem seemed to suggest that it had not decided which company it would pick to handle its drug business. “We’ve not made a final decision with respect to any vendor,” Mr. Swedish said. “We’ve not ruled anyone in or out.”
The company said it would evaluate its options and make a decision by the end of the year. Mr. Swedish said he hoped that the two companies would reach an amicable resolution on Anthem’s lawsuit.
Mr. Swedish also discussed Anthem’s proposed $48 billion merger with Cigna, another large health insurer. In February, a federal judge blocked the merger after the Justice Department challenged the combination as being harmful to consumers, one of two mergers of insurance giants that it successfully challenged. Anthem and Cigna have had a fraught relationship, but Anthem is appealing the decision and said it expected a ruling soon on whether the merger could proceed.

How to Stop Drug Price Gouging

by Tim Wu - NYT - April 20, 2017

One of Donald Trump’s few universally welcomed campaign promises was to do something about the prices of pharmaceutical drugs. Most Americans recognize that prices are too high, and are bothered by the rise of pharmaceutical price gouging: the giant price increase for decades-old drugs and devices by the likes of Martin Shkreli with Daraprim or Mylan with the EpiPen. But what few people realize is that the president already has the power to do something about drug prices if he really wants to. If Mr. Trump wishes to show he’s serious about his populist promise, the place to start is by declaring war on the price gougers.
The key power is found in the “import relief” law — an important yet unused provision of the Medicare Modernization Act of 2003 that empowers the Food and Drug Administration to allow drug imports whenever they are deemed safe and capable of saving Americans money. The savings in the price-gouging cases would be significant. Daraprim, the antiparasitic drug whose price was raised by Mr. Shkreli to nearly $750 per pill, sells for a little more than $2 overseas. The cancer drug Cosmegen is priced at $1,400 or more per injection here, as opposed to about $20 to $30 overseas.
The remedy is simple: The government can create a means for pharmacies to get supplies from trusted nations overseas at much lower prices. Doing this would not only save Americans a lot of money but also deflate the incentive to engage in abusive pricing in the first place.
Why hasn’t the law been used? Over the years, the industry has tried to describe the statute as a nuclear option, repeatedly warning of the catastrophic danger of relying on the drugs used by those reckless Canadians. More legalistically, the industry has insisted that the Department of Health and Human Services (which oversees the F.D.A.) cannot reliably certify that imports would “pose no additional risks to public health and safety” as the statute requires. But Health and Human Services is an executive agency, bound to obey the president, and the needed cost and safety determinations are well within its capacity.
The safety fears, if not purely imaginary, are wildly exaggerated. Twenty-five percent or more of drugs labeled American-made are actually manufactured in other countries, in plants inspected by the F.D.A. (So are 80 percent of the active ingredients used in the production of drugs in American factories.) The “imports” that the industry refers to are the same pills as those “American-made” drugs, produced by the same F.D.A.-inspected plants overseas. The only difference is that some of those drugs are shipped to countries like Canada, while others are sent directly to the United States, where they are sold for 10 or sometimes hundreds of times the Canadian price.
The F.D.A., in other words, is already regulating imported drugs. It might as well use those powers to fight price gouging. Indeed, over the past six years the F.D.A. has been allowing imports of drugs to deal with shortages in accordance with a 2011 executive order. For example, when facing shortages of the cancer drug Doxil, the F.D.A. authorized imports of a substitute, Lipodox, manufactured at an F.D.A.-inspected plant in India. Lives have been saved, not lost, and the practice confirms that this country already knows how to ensure that importing drugs from trusted nations can be safe. The industry’s “safety” warnings are more politics than reality.
President Trump can do serious damage to the pharmaceutical price-gougers if he wants to, and will be cheered on by everyone who is not on the payroll of the pharmaceutical industry, and even some of them as well. A suitably aggressive beginning would be to select the 10 most outrageous instances of excessive pricing (I would define that as an unjustified price increase of more than 1,000 percent for a drug that is no longer protected by a patent). Go after the worst offenders first: the owners of drugs like Daraprim, Cosmegen, Thiola, Mustargen and Indocin, all of which have had price increases of 1,000 percent to 5,000 percent. Let companies like Ovation, Turing, Valeant, Mylar and other abusers of the system become a warning to others who might want to make price-gouging their business model.
Obviously, waging war on pharmaceutical pricing abuses would not represent a full solution to the broader problems in drug pricing. Congressional proposals, including a new Senate bill introduced by Bernie Sanders, independent of Vermont, Amy Klobuchar and Al Franken, Democrats of Minnesota, and others, would go further. But it would be the beginning of imposing discipline on an industry accustomed to its absence and a signal that this administration is serious about using the powers it has to make drugs affordable.
President Trump ran as an economic populist who would take on industry on behalf of the people. Here, the people clearly want something done. All it really takes is a chief executive who has the courage that he claims.

A New G.O.P. Health Proposal Evokes the Old Days

by Margot Sanger-Katz - NT - April 20, 2017

In the days before Obamacare, applying for health insurance meant filling out dozens of pages of forms and submitting medical records. It was almost impossible to compare prices. Your premium might be set higher for a large number of reasons, including if your child was overweight. This could be the future in some states under the latest Republican proposal to overhaul the health law.
The proposal, offered by leaders of libertarian and centrist groups within the House Republican caucus, would allow states to waive key insurance rules imposed by the Affordable Care Act if they believe the changes could lower premiums or advance other state goals. The proposal retains the health law’s promise that people with pre-existing health conditions can still buy insurance. But the protection would be largely technical.
States could waive a closely related rule that requires insurers to charge the same prices to healthy and sick customers of the same age. States could also exempt insurers from offering the “essential health benefits” currently required. To compensate, states would have to set up special insurance markets for sick customers called high risk pools.
To get an idea of what such a world might look like, please join me in my time machine as we travel back to 2011.
At that time, the Affordable Care Act had been passed, but most of its key provisions hadn’t kicked in. Insurers could charge different prices to customers, depending on their health history. And patients who were shut out of the traditional market had access to a high-risk pool.
Researchers at the Kaiser Family Foundation studied an “underwriting guide” that the insurance company Anthem used back then to sell health plans in Indiana, Kentucky and Ohio. The guide explained how people could apply for health insurance, and how their prices might change, depending on their answers to questions.
There were a lot of questions. In addition to a multi-page form, asking about prior diagnoses, prescriptions, height, weight, occupation and other details, many customers were asked to fill out supplementary questionnaires about their health problems. Anyone who answered “yes” to a question about a history of allergies, for example, would get follow-up questions — and sometimes be asked for more medical records or a doctor’s note.
Customers were slotted into different categories, depending on their answers. The most healthy were called “Super Preferred,” and could get a 7 percent discount on the standard premium. The least healthy were called “Modified 5,” and were charged three times the standard rate. (This was at a time when anyone receiving treatment for, say, acne or osteoarthritis, or with blood cholesterol above 260, could be denied coverage altogether, so least healthy was relative.)
Height and weight calculations also affected premium prices, and not just for adults. If your child was 3 feet 2 inches tall and weighed more than 62 pounds, the price of insurance would rise.
Some plans would make you get a physical if you hadn’t been to the doctor in a while.
The only way to find out the price of a given plan was to fill out all the forms, and wait for an answer. Other insurers had different questions and different cutoffs for price changes. And the various plans, freed from standard benefit requirements, often covered substantially different health services.
This system was tedious for everyone, but ended up being a pretty good deal for the super-preferred customers of the world. If you were fortunate enough to have required little medical care in the past, and you didn’t smoke, or you didn’t weigh too much or didn’t work a dangerous job, you could buy insurance that was less expensive than what you can find today in many markets.
People with health problems, even relatively minor ones, often paid much higher prices. And insurance tended not to cover services not required by states — like addiction treatment or pregnancy care.
For the patients with conditions that typically knocked them out of the standard market — those with H.I.V., cancer or M.S. — there was the state-run high-risk pool. But those insurance plans, designed for very sick and very costly patients, often included high costs, waiting periods and exclusions. As my colleague Reed Abelson wrote recently, many states ran out of money before they could accommodate all the sick patients.
The latest House health plan looks very much like a proposal that the more libertarian Freedom Caucus discussed with the White House a few weeks ago, which spooked many moderates. The key differences are the requirement that waiver-obtaining states maintain high risk pools and a rule that men and women be charged the same prices, assuming, of course, that their health histories are identical.
In states with waivers, the health insurance market of the future might look substantially like the market of the past, where buying health insurance meant jumping through various hoops and where sicker patients struggled to find affordable coverage.
The changes in the newly proposed amendment would be layered atop the existing Republican bill, the American Health Care Act, which the Congressional Budget Office has estimated would cause 24 million fewer Americans to have health insurance within a decade.
The bill would also substantially reduce federal funding for state Medicaid programs, and revamp the federal subsidy system used to make insurance affordable for middle-income Americans who buy their own coverage. The bill would make insurance more expensive for Americans who are poorer and older, but more affordable for people who are younger and richer.
With the newly proposed changes, the shifts would not just be from old to young and poor to rich, but also from sick to healthy. Tom MacArthur, an author of the proposal and a co-chairman of the centrist House Tuesday Group, wrote on Facebook that the proposal “protects pre-existing conditions.” It would do so only in a very limited sense.

White House Officials, Craving Progress, Push Revised Health Bill

by Matt Flegenheimer and Reed Abelson - NYT - April 20, 2017
WASHINGTON — White House officials, desperate to demonstrate progress on President Trump’s promise to repeal the Affordable Care Act, are pushing to resurrect a Republican health care bill before his 100th day in office next week.
Some members of the president’s team have grown consumed by that deadline, worrying that appraisals of the president’s tenure will be brutal and hoping that a last push on health care might bring a measure of salvation.
But Congress usually cannot take on two big things at once. At the same moment Mr. Trump hits his 100th day on Saturday, April 29, Republican congressional leaders face a far more urgent deadline: Much of the federal government will run out of money.
Reaching agreement to keep the government open past midnight that Friday will be the first priority of Republican leaders when Congress returns Monday from a two-week recess.
“I believe that when we first go back, that’s going to be the thing we’ll address immediately and have to get done by Friday,” said Representative Dan Donovan, Republican of New York.
The president himself has not laid down a hard deadline on the health care bill. “We have a good chance of getting it soon,” Mr. Trump said in a news conference Thursday. “I’d like to say next week, but it will be — I believe we will get it. And whether it’s next week or shortly thereafter.”
Republican leaders and the White House have been searching for a health care agreement that could placate enough moderates and hard-line conservatives to win passage in the House.
The latest version of the proposal, published Thursday morning by Politico, would maintain popular benefits in President Barack Obama’s signature domestic achievement, like guaranteed coverage for emergency services and maternity care. It would also preserve the health law’s ban on insurers rejecting customers with pre-existing medical conditions.
But under this Affordable Care Act replacement, states could seek waivers from many of those mandates if they demonstrate that premiums would be lowered, the number of insured people would increase, or “the public interest of the state” would be advanced.
States could request an exemption from the rule intended to ensure that people with pre-existing conditions could not be charged prohibitive premiums — but only if those states establish a high-risk insurance pool.
“The plan gets better and better and better, and it’s gotten really, really good, and a lot of people are liking it a lot,” Mr. Trump said. Asked if a health bill could pass as Congress tries to avert a government shutdown, the president said, “I think we’ll get both.”
The complications that remain in the bill are likely to be far too difficult to finesse at the same time the House and Senate press to pass a giant spending bill. Tussles over the spending deadline — including possible debates over top administration priorities like a border wall and money for immigration enforcement officers — are expected to consume the Capitol.
And Democrats — whose votes will be needed to keep the government open — will have their own demands, most importantly billions of dollars to lower out-of-pocket spending for low-income Americans purchasing health coverage on the Affordable Care Act’s online marketplaces.
Senior Republicans appear unconvinced that a revised health care bill would ensure passage in the House. Mr. Donovan, an opponent of the original Republican health care bill, said the proposed amendment “really doesn’t address the concerns that I had.”
Representative Charlie Dent, Republican of Pennsylvania and a leader of the moderate House Tuesday Group, said it “does nothing to change my views.” He lamented any focus “on an arbitrary 100-day deadline.”
The changes — proposed by Representative Tom MacArthur, Republican of New Jersey and co-chairman of the Tuesday Group — come as Republicans face anger from supporters over their failure to act on longstanding campaign pledges, as well as from defenders of the Affordable Care Act.
“We’re in the midst of negotiating sort of finishing touches,” Speaker Paul D. Ryan said this week in London while leading a congressional delegation.
He added: “It’s difficult to do. We’re very close.”
But the legislation’s future is unclear. For now, the proposal exists only in vague talking points. West Wing advisers to Mr. Trump are decidedly mixed in their views of how aggressively to raise expectations. The aide feeling perhaps the most pressure, according to people close to the discussions, is the chief of staff, Reince Priebus, who was blamed internally for the botched vote count around the first repeal effort and is closest to Mr. Ryan within Mr. Trump’s circle.
The initial bill’s failure has left lawmakers wary of artificial deadlines. And even a triumph in the House would not guarantee final passage, given the skepticism of several Republicans in the Senate.
“We want to make sure we replace it with something that will stand the test of time,” Senator Bob Corker, Republican of Tennessee, said in a brief interview Thursday after speaking at a Rotary Club meeting in Crossville, Tenn. “Now we’re taking our time. We realize that this is real — that it’s going to affect people in a real way.”
The House bill’s inability to garner enough support last month to be brought for a floor vote was an embarrassing setback for Mr. Trump, Mr. Ryan and the Republican conference.
This month, Vice President Mike Pence and other Trump administration officials sought a new agreement with the conservative House Freedom Caucus, whose opposition helped fell the first bill. The measure, which gained little traction, earned a nickname on Capitol Hill: Zombie Trumpcare.
Regardless of the bill’s fate, lawmakers are approaching a critical moment on health care. Insurers and business groups are pressing hard for Republicans and Mr. Trump to maintain health insurance subsidies ahead of insurers’ decisions in the coming weeks on whether to keep offerings on the Affordable Care Act’s marketplaces and how much to charge for them.
Without those “cost-sharing reductions,” insurers warn that they will have to sharply raise the prices of their plans on the state marketplaces or leave the markets altogether.
About seven million people now qualify for the subsidies, which reduce the amount someone has to pay in deductibles and co-payments when they buy a plan. At stake is roughly $10 billion in payments expected to be made to the insurers next year. Some House Republicans oppose how the Obama administration funded them, and they won a court case potentially blocking the funding that is now on appeal. The next court date is May 22.
This week, insurance executives met with Medicare officials to plead their case. They left that meeting with Seema Verma, the new Medicare head, with no promises. Mr. Trump has publicly toyed with the idea of withholding the subsidies as a way to force Democrats to negotiate over the House proposal, and Ms. Verma told the insurers they should look to Congress to appropriate the money.
State insurance regulators with the National Association of Insurance Commissioners sent a letter to Congress on Wednesday, pleading, “Your action is critical to the viability and stability of the individual health insurance markets in a significant number of states across the country.”
Insurers must begin the process of filing rates in the coming weeks, and many are looking at various scenarios, said David M. Dillon, a fellow at the Society of Actuaries, who has been working with state regulators and insurers about how to price plans in the marketplace. Insurers say their rates could rise as much as 30 percent, high enough to destabilize the markets.
Insurers remained largely silent on the proposed amendment, which seemed to revive a discussion of how to handle the sickest and most costly individuals by allowing states to set up high-risk pools. The insurers have previously indicated that they would be open to ideas that helped pay for people with very expensive conditions.
Separating off these individuals causes the cost of coverage for everyone else to go down, making it a potentially popular idea, said Stephen Zuckerman, a co-director of the Health Policy Center at the Urban Institute. But these pools have traditionally been poorly funded, leaving many people with potentially expensive pre-existing medical conditions without affordable coverage, if they can buy a plan at all. 
“Why would these high-risk pools work better now than they have historically?” Mr. Zuckerman asked.

Health Insurers Make Case for Subsidies, but Get Little Assurance From Administration

by Reed Abelson - NYT - April 18, 2017

Health insurers pressed Trump administration officials on Tuesday to continue billions of dollars in subsidies for low-income people buying plans under the federal health care law, but left with nothing that would dissipate the fog of uncertainty hanging over the industry.
The insurers have been closely watching as President Trump and congressional Republicans and Democrats debate the future of those subsidies, known as cost-sharing reductions paid by the Obama administration that now go to the companies covering about seven million individuals to help lower deductibles and co-payments.
Insurers who attended Tuesday’s meeting with Seema Verma, the new Medicareadministrator, “reiterated our most pressing concern: the instability in the individual market created by the uncertainty of funding,” according to a statement from America’s Health Insurance Plans, one of the main industry trade groups.
But Ms. Verma made no promises, according to accounts of the meeting, and indicated to the insurance executives that Congress would have to decide whether to appropriate the money.
Many insurers have already been anxiously pressuring lawmakers and the administration as deadlines loom in the coming weeks for setting next year’s rates and as they weigh leaving the federal marketplace altogether.
Congress returns next week to Washington, to immediately begin negotiating a spending bill or face a government shutdown.
The subsidies have become a sticking point in Congress, with some House Republicans steadfastly opposing how the Obama administration funded them, especially after winning a court case that is now on appeal.
White House officials said Tuesday that Mr. Trump had not made a final decision about whether the administration should withhold the subsidies from insurance companies next year. One White House official said this week that the president was leaning toward ending the subsidies, but was waiting to see how Democrats would respond when they return to Washington.
In an interview last week with The Wall Street Journal, Mr. Trump raised the possibility of holding up the payments as a way of forcing Democrats to negotiate with him about the future of the law.
America’s Health Insurance Plans’s chief executive, Marilyn Tavenner, had warned late last week that discontinuing the subsidies would have far-ranging effects.
“Without funding, millions of Americans who buy their own plan will be harmed. Many plans will likely drop out of the market. Premiums will go up sharply — nearly 20 percent — across the market,” said Ms. Tavenner, who preceded Ms. Verma as the administrator of the Centers for Medicare and Medicaid Services under President Barack Obama, and had requested the meeting.
Unlike Mr. Trump’s meeting with major insurers in February, Tuesday’s session did not include the chief executives from some of the biggest companies, including Anthem, Aetna and UnitedHealth Group. Both Aetna and UnitedHealth Group have largely exited the market, but Anthem, which operates for-profit Blue Cross plans, is still a major player. Its chief executive has repeatedly warned that it will withdraw from some markets if the market appears unstable.
With such uncertainty four months into the year — amid the continuing efforts by Republicans to overturn Mr. Obama’s Affordable Care Act — some insurers say they are preparing two scenarios on prices that could soar to 30 percent rate increases.
While the Obama administration paid the subsidies that amounted last year to more than $7 billion, House Republicans successfully argued that payments made by the executive branch were unconstitutional. The decision has not taken effect while the case is being appealed, and the next court date is May 22.
Ms. Verma’s office would not elaborate on her meeting with the insurers, but said in a statement that “all parties came to the table committed to maintaining an active dialogue to improve care for patients and focus on long-term solutions that will fix the problems created by the Affordable Care Act.”
Aside from the subsidies, insurers raised other unresolved issues. Some have been particularly worried about whether the administration would decide not to impose the tax penalties people face if they refuse to sign up for coverage.
Without enforcing the mandate, healthier people might consider going without insurance, possibly resulting in a costlier pool of sicker patients. The Internal Revenue Service has said the current mandate essentially stays in effect, but it remains unclear how widely any fees have been collected.
Some insurers said they had struggled to make money selling policies under the law, and many companies dropped out of the state marketplaces.
This year, Humana announced it would stop selling policies in 2018, and Iowa’s Blue Cross plan and Aetna announced they would leave the state marketplace next year, leaving one insurer in most of the state’s counties.
But many of the remaining insurers say they are starting to turn the corner, and a Standard & Poor’s analysis released this month contradicted administration claims that the market was in a “death spiral.”

Affordable Care Act: A
Tale of Two Red States

by Abby Goodnough and Reed Abelson - NYT - April 21, 2017

BARTLESVILLE, Okla. — When President Trump describes the Affordable Care Act as “imploding,” Lori Roll, an insurance agent here, does not consider it hyperbole.
Only one health insurer in Oklahoma is left selling coverage through the federal marketplace, and the hospital in this city of 36,000 is not in the network. Premiums are among the highest in the country, and while most marketplace customers qualify for the Affordable Care Act’s income-based subsidies that lower the cost, many of Ms. Roll’s middle-class clients do not.
“A lot of them are friends,” she said, “and I’m having to tell them: ‘My God, your premium just doubled. I’m so sorry.’”
In neighboring New Mexico, also under Republican leadership, the Affordable Care Act marketplace is in far better shape. Marketplace customers can still choose among four insurers, and the state has one of the lowest average premium costs.
Nearly four years after they opened, the Affordable Care Act’s insurance marketplaces, also known as exchanges, are not uniformly failing, as Mr. Trump claims. Instead, they have risen or fallen in no small part because of political and policy decisions by each state. New Mexico embraced the law, and its marketplace has been healthy, while Oklahoma resisted at every step, and its marketplace is foundering.
But now both states are worried that political maneuvering at the federal level may deeply destabilize the marketplaces. In an effort to get Democrats to negotiate, Mr. Trump has threatened to stop paying more than $7 billion in subsidies to insurers that don’t charge deductibles and co-payments to millions of poor people. Uncertainty about the subsidies, which are a critical financial underpinning of the law, may drive more insurers out of the market — leaving Oklahoma with no health plans in the marketplace — and raise premiums significantly higher for those that stay.
Politics at both the state and federal levels have been critical to shaping the success and failure of the Affordable Care Act. Oklahoma and New Mexico offer a case study of how that has played out.
New Mexico expanded Medicaid as soon as the law allowed, oversees its marketplace and conducts vigorous outreach to draw in potential customers, moves that have most likely helped attract healthier customers.
Oklahoma has raged against the law since its passage, challenging its subsidies in a lawsuit and refusing to expand Medicaid or set up its own state-run insurance exchange. Instead, the federal government runs the state’s marketplace through, an option taken by more than two dozen mostly Republican states.
“I was never for Obamacare from the beginning,” John D. Doak, the Oklahoma insurance commissioner, said in an interview at his office, where a red trucker hat that says “Make Health Insurance Great Again” sits on his desk.
The uninsured populations in both New Mexico and Oklahoma have fallen since the law took effect. But New Mexico’s progress has been stronger, even though it started with a higher rate of uninsured.
Oklahoma’s uninsured rate was the third highest in the country in 2015, the most recent year available: 13.9 percent, according to the Census Bureau, compared with 17.7 percent in 2013, just before the Affordable Care Act’s coverage provisions took effect. New Mexico’s uninsured rate fell to 10.9 percent in 2015 from 18.6 percent in 2013.
Here in Bartlesville, an oil town that has felt the economic impact of the drop in oil prices, the anger that Ms. Roll and many of her clients feel is directed more at the health law — and its champion, former President Barack Obama — than at the state’s unyielding resistance to it.
“You don’t get on the Titanic when you know it’s going to sink,” said David Moore, 51, who owns a fishing tackle business.
Mr. Moore, a self-described “libertarian guy” who voted for Mr. Trump, avoided a doubling of his premiums this year by switching to a small group health plan with his wife, an audiologist, and one of her employees. But Mr. Moore, who earns too much to qualify for premium subsidies under the Affordable Care Act, still had his monthly premiums increase sharply for his plan covering his family of four, to $1,100 from $700, with a $12,000 deductible.
“My biggest problem with this is our government picking winners and losers,” Mr. Moore said, referring to the fact that lower-income people get large subsidies under the law and higher-income people do not. “I’m a loser. And it should not be this way.”
Cameron Jarrett, 31, is equally disappointed with his insurance options, even though his employer gives him money toward his premium and he gets a subsidy, too. He pays the rest: $303 a month for a Blue Cross plan that covers his family of three, with a $12,000 deductible.
Still, Mr. Jarrett, another Trump voter who wants the Affordable Care Act repealed, does not entirely blame the law.
“States like Oklahoma that sit on their hands and do nothing — that’s not helping,” he said. “If we’re going to do this, let’s give it every opportunity to work, even if it’s not a policy I agree with over all.”
Mr. Trump and Republicans in Congress have repeatedly pointed to markets like Oklahoma’s, with just a single insurer, as a sign that the Affordable Care Act exchanges are deeply troubled. But Oklahoma’s individual market has never been very competitive. In New Mexico, several local insurers have long competed on the individual market, but Blue Cross has been the dominant player in Oklahoma for years, and is now the only insurer offering plans on the exchange. Even when other insurers offered plans through the Affordable Care Act marketplace during its first few years, Blue Cross scooped up by far the most customers.
In addition to big decisions, like whether to expand Medicaid, some seemingly minor ones may have influenced the marketplaces’ health. Oklahoma has continued to allow about 45,000 people to keep old policies that do not meet Affordable Care Act standards. People with this type of “transitional” policy tend to be healthy, and may have helped the risk pool if they had been required to buy insurance through the exchange. Oklahoma is also one of three states that do not review insurers’ proposed rates from year to year, ceding the job to the federal government instead.
In New Mexico, on the other hand, insurance regulators did not allow people to keep their old plans and required any insurer that sold plans through the Affordable Care Act marketplace to offer them in every county. John G. Franchini, the state’s superintendent of insurance, has also negotiated rates with insurers, even denying a 52 percent increase requested by Blue Cross and Blue Shield of New Mexico for 2016.
Now, seven years after Mr. Obama signed the Affordable Care Act into law, Oklahoma is changing its stance and seeking a more active role. The state is preparing to ask the federal government’s permission to change how the law works here through waivers allowed under the law. One of its proposals is to help very poor people afford private plans by giving them subsidies.
The state may also ask for permission to “re-evaluate” and perhaps reduce the package of essential benefits that the Affordable Care Act requires every insurance plan to have. And it wants plans under the law to be sold not through the federal marketplace, but through a program called Insure Oklahoma, which has provided subsidized coverage to a subset of low-income residents here since before the health law took effect.
The changes, which the state hopes would make insurance more affordable and provide more choices, would have to be approved by the Trump administration and in some cases by the Legislature. Most would not go into effect until 2019 at the earliest.
Meanwhile, Oklahoma, which has faced a series of budget crises because of the oil industry downturn, does not have the money to help pay insurers’ costs next year, as Alaska and Minnesota are doing. So Oklahoma is looking to the Trump administration and Congress to help stabilize its marketplace in time for next year and persuade Blue Cross to stay.
Mr. Doak raised alarms last month when he wrote in a letter to Gov. Mary Fallin, a fellow Republican critic of the health law, that Blue Cross was “making preparations to withdraw” from the marketplace. Blue Cross, which is operated as a nonprofit insurance company, said it had not made a final decision about next year.
“We certainly want to continue to offer products in 2018,” said Kurt Kossen, an executive at Health Care Service Corporation, Blue Cross’s parent company.
Mr. Doak said that without any stabilization funds or other federal efforts to stabilize the individual insurance market, another round of steep premium increases was inevitable here.
But Blue Cross plans have been doing better in the marketplaces, and Health Care Service Corporation, which offers plans in Oklahoma, New Mexico and three other states, is losing less money. It aggressively raised prices last year, with a 75 percent average rate increase in Oklahoma.
A major factor in the insurers’ losses was the decision by Congress not to fully fund a program aimed at protecting insurers during the early years of the Affordable Care Act, when the companies did not know what to charge. Mike Rhoads, the deputy insurance commissioner, said Blue Cross “started too low,” with some of the lowest prices in the country in 2014.
Regulators in both states say that now, the fate of the marketplaces depends very much on the actions of Congress and the Trump administration.
“We’re just a little boat in this ocean,” said Mr. Franchini, the New Mexico superintendent. “If there’s a tidal wave from Washington, it could scuttle us.”

Our Costly Addiction to Health Care Jobs

by Chad Terhune - NYT - April 22, 2017

The health care industry has been a great friend to the United States economy. Its plentiful jobs helped lift the country out of the Great Recession, and thanks in part to the Affordable Care Act, it now employs one in nine Americans — up from one in 12 in 2000.
As President Trump seeks to fulfill his campaign pledge to create millions more jobs, the industry would seem a promising place to turn. But the billionaire businessman also campaigned to repeal Obamacare and lower health care costs — a potentially serious job killer. With Mr. Trump renewing his push to replace Obamacare, he faces a dilemma.
“The goal of increasing jobs in health care is incompatible with the goal of keeping health care affordable,” said Katherine Baicker, a Harvard University health economist who sees advantages in trimming the industry’s growth. “There’s a lot of evidence we can get more bang for our buck in health care. We should be aiming for a health care system that operates more efficiently and effectively. That might mean better outcomes for patients and fewer jobs.”
But the country has grown increasingly dependent on the health sector to power the economy, and it will be a tough habit to break. Thirty-five percent of the nation’s job growth has come from health care since the recession hit in late 2007, the single biggest sector for job creation.
Hiring rose even more as coverage expanded in 2014 under the health care law and new federal dollars flowed in. The law gave hospitals, universities and companies even more reason to invest in new facilities and staff. Training programs sprang up to fill the growing job pool. Cities welcomed the development — and the revenue. Simply put, rising health spending has been good for some economically distressed parts of the country, many of which voted for Mr. Trump last year.
The West Virginia University health system, for example, recently opened a 10-story medical tower in Morgantown and hired more than 2,000 employees last year. In Danville, Pa., the Geisinger Health System has added some 2,200 workers since July, and it’s trying to fill 2,000 more jobs across its 12 hospital campuses and insurance company. Out west, UCHealth in Colorado expanded its Fort Collins hospital and is building three new hospitals in the state.
In cities such as Pittsburgh, Cleveland and St. Louis, health care has replaced dying industries like coal mining and heavy manufacturing as a primary source of jobs. “The industry accounts for a lot of good middle-class jobs and, in many communities, it’s the single-largest employer,” said Sam Glick, a partner in the San Francisco office of Oliver Wyman, a consulting firm. “One of the hardest decisions for the new Trump administration is how far do they push on health care costs at the expense of jobs in health care.”
House Republicans, with backing from Mr. Trump, took the first swipe. Their American Health Care Act sought to roll back the current health law’s Medicaid expansion and cut federal subsidies for private health insurance. The plan faltered in the House, but Republican lawmakers and the Trump administration say they are again trying to draft a replacement for Obamacare.
Neither the Affordable Care Act nor the latest Republican bill tackles what some industry experts and economists see as a serious underlying reason for high health care costs: a system bloated by redundancy, inefficiency and a growing number of jobs far removed from patient care.
Labor accounts for more than half of the $3.4 trillion spent on American health care, and medical professionals like health aides and nurse practitioners are in high demand. But the sheer complexity of the system has also spawned jobs for legions of data-entry clerks, revenue-cycle analysts and medical billing coders who must decipher arcane rules to mine money from human ills.
For every doctor, there are 16 other health care workers. And half of those 16 are in administrative and other nonclinical roles, according to Bob Kocher, a former Obama administration official who worked on the Affordable Care Act and is now a partner in the venture capital firm Venrock.
“I find super-expensive drugs annoying, and hospital market power is a big problem,” Mr. Kocher said. “But what’s driving our health insurance premiums is that we are paying the wages of a whole bunch of people who aren’t involved in the delivery of care. Hospitals keep raising their rates to pay for all of this labor.”
Take medical coders. Membership in the American Academy of Professional Coders has swelled to more than 165,000, up 10,000 in the past year alone. The average salary has risen to nearly $50,000, offering a path to the American dream.
“The coding profession is a great opportunity for individuals seeking their first joband it’s attractive to a lot of medical professionals burned out on patient care,” said Raemarie Jimenez, a vice president at the medical coding group. “There is a lot of opportunity once you’ve got a foot in the door.”
Some of these back-office workers wage battle every day in clinics and hospitals against an army of claims administrators filling up cubicles inside insurance companies. Overseeing it all are hundreds of corporate vice presidents drawing six-figure salaries.
Administrative costs for the American health care system are the highest in the developed world, according to a January report from the Organization for Economic Cooperation and Development. More than 8 percent of domestic health spending is tied up in administration, while the average globally is about 3 percent. America spent $631 for every man, woman and child on health insurance administration for 2012, compared with $54 in Japan.
America’s huge investment in health care and related jobs hasn’t always led to better results for patients, data show. But it has provided good-paying jobs, which is why the talk of deep cuts in federal health spending has many people concerned.
Linda Gonzalez, a 31-year-old mother of two, was among the thousands of enrollment counselors hired to help sign up Americans for health insurance as Obamacare rolled out in 2014. Ms. Gonzalez, a college graduate, makes more than $40,000 a year working at an AltaMed enrollment center, tucked between a Verizon Wireless store and a nail salon on a busy street in Los Angeles.
In her cramped cubicle, families pull up chairs and sort through pay stubs and tax returns, often relying on her to sort out enrollment glitches with Medicaid. As the sole breadwinner for her two children, ages 9 and 10, she counts on this job but isn’t sure how long it will last.
“A lot of people depend on this,” she said recently. “It’s something I do worry about.”

This one unbelievably expensive Iowa patient makes the case for single-payer healthcare

by Michael Hiltzik - LA Times - April 24, 2017

Back in mid-2016, Iowa customers of Wellmark Blue Cross Blue Shield, the dominant company in the state’s individual insurance market, got a shock: Premium increases of 38% to 43% were in store for many of them for this year.
Three weeks ago they got a bigger shock: Wellmark was pulling out of Iowa’s individual market entirely, leaving the state with one company selling individual policies. Wellmark placed some of the blame on congressional Republicans’ failure to come up with a coherent repeal plan for the Affordable Care Act, leaving plans for 2018 in legislative limbo. With Wellmark’s departure, Iowa’s individual market may be down to a single insurer next year.
But Iowa has another problem that appears to be unique for a state its size: one single state resident whose care costs $1 million a month. That’s enough to all but destroy an individual insurance market that comprises about 30,000 customers. Indeed, that one patient’s care, according to Wellmark, was responsible for 10 percentage points of the 43% premium increase this year.

The patient has not been identified; nor has his or her medical condition, beyond a statement by Wellmark that he or she suffers from a complicated and severe genetic disorder. Speculation in the healthcare industry about the reasons for the expense focuses on the cost of the patient’s medications.
The important aspect of the Iowa case is what it tells us about the importance of spreading risk in the healthcare market, and the limitations of the Republican nostrum of segregating seriously ill patients into high-risk pools. The idea is to keep their costs from driving up everyone else’s premiums.
The case also points directly to the benefits of a single-payer healthcare system. “The idea of single-payer is that there’s just one risk pool,” says Steffie Woolhandler, a New York physician who is co-founder of Physicians for a National Health Program, the nation’s leading advocacy group for single-payer healthcare. “That’s what makes the care of very high-cost patients affordable.”
Before the Affordable Care Act, obviously, patients like our unnamed Iowan would be in mortal trouble. He or she would likely have been rendered uninsurable either by outright rejection or by surcharges that would make insurance unaffordable. Even if he or she had obtained coverage, the usual pre-ACA lifetime benefit limits of $1 million-$5 million would have kicked in early in the first policy year.
“Most likely the patient would quickly run through their private insurance,” conjectures health insurance expert David Anderson of Duke. “At that point, s/he would most likely either qualify for Medicaid, put on charity care or left to die.” (How the patient received treatment before the ACA isn’t known.)
Anderson calls this “fundamentally an uninsurable scenario” in which “a high cost risk pool or invisible reinsurance or a prospective re-assignment system would make sense.” These are all elements of a Republican Obamacare repeal plan put forth earlier this month and based, if haphazardly, on a program Maine created before the ACA. Any of these options would spread the patient’s cost to a pool larger than the one consisting of Wellmark’s roughly 30,000 Iowa customers.
But there are three limitations to these ideas even if the pool encompasses an entire state, Anderson observes. One is that some states are so small that even one such patient will break the bank. California could manage it, Wyoming could not, Iowa will struggle.
The other is that high-cost patients don’t always appear randomly, but sometimes in clusters. Zika cases, for example, will show up heavily in Southeastern states with inadequate Medicaid funding, he argues. And genetic diseases of the sort suffered by the Iowa patient may be geographically concentrated in part because “most people live near their families rather than being randomly distributed.”
The third problem is that high-risk pools and reinsurance funds tend to be hopelessly underfunded. This was the case in most of the 35 states with high-risk pools prior to the Affordable Care Act, including California. Without sufficient public funding to cover all their high-cost residents adequately, most imposed waiting lists for coverage, time limits on eligibility, and premiums so high that many patients couldn’t afford them at all. The proposals for high-risk pools coming from congressional Republicans are similarly stingy.
“What high-risk pool could tolerate a patient costing a million dollars a month?” asks Woolhandler. “It would have to be a huge pool.”
The only fair and effective way to manage such patients, especially the few with truly stratospheric medical costs, is to make them part of a nationwide pool. A risk pool on that scale would represent the functional equivalent of single-payer healthcare. And that’s leaving aside some of the other virtues single-payer advocates cite, including the ability to negotiate prices on pharmaceuticals with the bargaining power of the entire country, and the virtual elimination of insurance company and provider billing office overhead.
As unusual as the Iowa patient may be, extremely high-cost treatments may not be extreme outliers for much longer. Drug treatments for “orphan” diseases with a few hundred or thousand cases are becoming more expensive, but so are drugs for more common conditions such as cancer or high-cholesterol disease. State budgets are going to be increasingly hard-pressed to cover these costs. The healthcare cost crisis is spreading nationwide, which makes it a national problem demanding a national — meaning a federal — solution.

Letter to the editor: Personal experiences show Medicare-for-all is the way to go

Letter to the Editor - Portland Press Herald - April 13, 2017

Cathleen London (Maine Voices, April 5) makes a strong case, from a physician’s point of view, for adopting single-payer health insurance (Medicare for all). I would like to add a few personal observations.
Ever since I enrolled in Medicare five years ago, I have liked its simplicity and its benefits to the patient, including a much broader choice of providers than is available from private insurers, who restrict you to providers in their networks. I have wondered why there couldn’t be a similar plan for all of our citizens.
In discussions of this topic, the term “socialized medicine” is often used and referred to as something to be feared. It is incorrect to use this term in this context. We are only talking about socializing health insurance.
Nobody is proposing that the government run the hospitals or that the doctors become government employees. Single-payer would simply be a change in how the bills are paid, not in how medical services are delivered. (Whether there should be changes in the latter to reduce costs is a separate, though important, issue.)
From my experience with Medicare, I can say with confidence that the government does no harm to the doctor-patient relationship. Decisions about my care are made solely by me in consultation with my doctor. Medicare is patient-centered.
A study published in 2016 in The Lancet, a British medical journal, ranked the healthiest countries in the world. The U.S. ranks 28th. We should aspire to be first. Politicians who disagree should explain why.
Medicare-for-all would move us decisively toward the goal and would ensure that all of our citizens – whether lucky or unlucky, healthy or unhealthy, more successful or less successful in our highly competitive economy – are fully insured. It would be an accomplishment we could all be proud of. It would make America greater – and healthier.
Michael P. Bacon