‘Medicare for all’ could be cheaper than you think
Public support for single-payer health care has been rising in recent months amid failed Republican efforts to repeal and replace the Affordable Care Act.
That’s perhaps why Sen. Bernie Sanders on September 13 introduced a new versionof his single-payer plan with the support of 16 Democratic colleagues, a sharp rise from 2013 when none signed on to a similar proposal. It would not only expand Medicare to all Americans but make it more comprehensive by covering more services like mental health, dental care and vision, all without copayments or deductibles.
But Sanders’s plan would come at a steep price: likely more than US$14 trillion over the first decade, based on an estimate I did of a previous version.
There is, however, a simpler and less costly path toward single-payer, and it may have a better chance of success: Simply strike the words “who are age 65 or over” from the 1965 amendments to the Social Security Act that created Medicare and, voila, everyone (who wants) would be covered by the existing Medicare program.
While this wouldn’t be single-payer – in which the government covers all health care costs – and private insurers would continue to operate alongside Medicare, it would be a substantial improvement over the current system.
I have been researching the economics of health care for four decades. While I prefer a more comprehensive universal health care plan that covers all Americans, a simpler version would be much more affordable – and maybe even politically possible.
Still Getting It Wrong: How Media Pundits Keep Steering Democrats into the Shoals
by John Atcheson - Common Dreams - September 19, 2017
In his Monday column at the New York Times, Paul Krugman said:
These days, America starts from a baseline of extreme tribalism: 47 or 48 percent of the electorate will vote for any Republican, no matter how terrible, and against any Democrat, no matter how good. This means, in turn, that small things — journalists acting like mean kids in high school, ganging up on candidates they consider uncool, events that suggest fresh scandal even when there’s nothing there — can tip the balance in favor of even the worst candidate imaginable.
He’s not alone. This is the explanation most elite media types will give for Trump’s victory, and it’s the one the neoliberal’s in the Democratic Party cling to. It’s also the reason the Democrats are unlikely to get the House or Senate back unless Trump, McConnell, Ryan and the rest of the Republicans do something so crazy that they sabotage themselves. With their latest health “care” gambit they may be in the process of doing just that.
But even if they do, and Democrats get one or both of the Houses back, it’s not the same as getting a mandate for reform. Getting elected because the other guy or gal is so abhorrent that even the crazies couldn’t bring themselves to vote for them is not the same as getting elected because you managed to sell your agenda.
And therein lies the problem. Democrats have no agenda, and they have no agenda because they believe the myth that the Party’s neoliberals, Krugman, Fareed Zakara, and many others of the elite media are spewing: that America is a closely divided nation that is center-right politically.
Let’s unpack Krugman’s statement.
We can start with his contention that “47 or 48 percent of the electorate will vote for any Republican …” no matter how terrible and against any Democrat no matter how good. Well, this is flat out wrong. First of all, less than 25 percent of Americans identify as Republican. Second of all, Trump won with only 26.1 percent of eligible voters. Third of all, total turnout has been in the 50 to 55 percent range for four decades now (with one exception – 2008, when a little over 58 percent turned out).
This means that 45 to 50 percent of eligible voters don’t turn out. The majority of these no-shows—43 percent of eligible voters—are independents. And these independents may lean Republican or Democrat, but they are not die-hards who give their vote to one Party or another automatically. In fact, a poll by Pew found that they are motivated not by loyalty to the Party they lean toward so much as hostility to the other Party’s ideas, and the majority of independents lean Democrat. Finally, the majority of Americans lean liberal on an issue-by-issue basis.
So, Krugman’s hardcore crazies who will vote for a Republican “no matter how terrible” and against a Democrat do not make up 47 to 48 percent of the electorate, they make up a small minority of potential voters of about 25 percent. Again, Krugman is not alone in seeing the political landscape as a closely divided world in which the scales can be tipped by small things like “… journalists acting like mean kids in high school … even when there’s nothing there.”
Here’s the problem with that view. It allows neoliberal Democrats to ignore the fact that it is their policies that have caused them to lose. They believe that little things can tip the balance, so Hillary’s loss, or the loss of the Senate, the House, and the vast majority of state governorships and legislatures is not a result of their failure to actually represent the voters’ interests over their donors, or their backing of Wall Street over Main Street, or their refusal to embrace progressive policies supported by the majority of potential voters—rather it is just little things that tipped the balance.
And as long as that scapegoat is allowed to exist, then the neoliberals will not change. Oh, they’ll try to create the appearance of change with gimmicks like their “Better Deal,” campaign. But at the end of the day, money will still talk, the voters will still walk, and too many crazies will still get elected.
Republican Leaders Defy Bipartisan Opposition to Health Law Repeal
by Robert Pear and Thomas Kaplan - September 19, 2017
WASHINGTON — Eleven governors, including five Republicans and a pivotal Alaskan independent, urged the Senate on Tuesday to reject a last-ditch push to dismantle the Affordable Care Act.
But Republican leaders pressed toward a showdown vote. And they choked off separate bipartisan efforts to shore up health insurance markets under the Affordable Care Act, hoping to give Republican senators no alternative but to vote for repeal.
The latest repeal bill, drafted by Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, would undo much of the Affordable Care Act and send tens of billions of federal dollars to the states with vast discretion over how to spend the money.
This is the choice for America, Mr. Graham said on Tuesday: “Socialism or federalism when it comes to your health care.”
Yet some governors, the supposed beneficiaries of that federalism, were decidedly cool to the proposal. New Hampshire’s Republican governor, Chris Sununu, had criticized the proposal on Monday. But it was the opposition of Alaska’s governor, Bill Walker, that might prove most important. He increased pressure on Senator Lisa Murkowski, Republican of Alaska, to cast what could be a deciding vote to kill the repeal effort, just as she voted against the last repeal bill in July.
Republican leaders appeared determined to thwart any alternative ahead of a possible showdown vote next week. Senator Lamar Alexander, Republican of Tennessee, announced Tuesday that he and Senator Patty Murray, Democrat of Washington, would not come forward with the “limited, bipartisan plan to stabilize 2018 premiums” in the individual health insurance market that they had been working toward.
Their bipartisan efforts, which grew out of four days of committee hearings, were overtaken by the resumption of partisan warfare on health care.
“We have worked hard and in good faith,” said Mr. Alexander, the chairman of the Senate health committee, “but have not found the necessary consensus among Republicans and Democrats.”
Ms. Murray was more blunt: “Republican leaders have decided to freeze this bipartisan approach and are trying to jam through a partisan Trumpcare bill.”
The Senate Democratic leader, Chuck Schumer of New York, accused Republicans of crushing “very, very hopeful sprouts of bipartisanship.”
But the latest repeal legislation was facing significant opposition. The American Medical Association, the American Hospital Association and AARP, the lobby for older Americans, all urged the Senate to reject the bill. And 10 of the 12 governors opposing the measure signed a letter urging Senate leaders to scrap it.
The Graham-Cassidy bill “would result in millions of Americans losing their health insurance coverage, destabilize health insurance markets, and decrease access to affordable coverage and care,” Dr. James L. Madara, the chief executive of the A.M.A., said in a letter to Senate leaders.
Richard J. Pollack, the president of the hospital association, said the bill “would erode key protections for patients and consumers.”
While the two main insurance associations remained silent on Tuesday as they pondered how they planned to respond to the legislation, Centene, one of the few insurers that has aggressively expanded its presence in the individual market for next year, voiced misgivings.
“From a public policy standpoint, it is not a good piece of legislation,” Centene’s chief executive, Michael F. Neidorff, said in an interview. He urged lawmakers from both parties to work together to avoid passing a law before understanding its full impact. States may not be able to plan, given the uncertainty over their funding, he said. “You could end up with 50 different plans,” he said.
“This is unlike anything I have ever seen,” Mr. Neidorff said. “They have to sit back and think through what they are doing.”
Within hours after the bipartisan group of governors sent their letter opposing the repeal bill, Senator Cassidy provided a letter from 15 Republican governors supporting the concept of “adequately funded block grants to the states.”
By Tuesday evening, Ms. Murkowski appeared to be the key vote.
At least two other Republican senators, Rand Paul of Kentucky and Susan Collins of Maine, are likely no votes. With Democrats united in opposition, Republican leaders cannot afford to lose any other votes.
Vice President Mike Pence met with Senate Republicans at lunch in the Capitol on Tuesday and told them the Trump administration was fully behind the repeal bill, which would send more than $1 trillion to states from 2020 to 2026.
After the lunch, Mr. Graham said, “I’ve never felt better about where we’re at.”
Mr. Graham said he had spoken to President Trump about the bill five times in the last two days, and said Mr. Trump was “focused like a laser” on it. Mr. Graham quoted Speaker Paul D. Ryan as saying that the House would pass the bill if the Senate approved it.
The Graham-Cassidy bill would blow up the architecture of the Affordable Care Act, a striking departure from the Alexander-Murray effort to draft a modest bipartisan bill to provide federal funds to insurance companies to reimburse them for reducing out-of-pocket costs for low-income consumers.
Some conservatives argued that the bipartisan bill would just prop up the health law.
It “doesn’t have a chance in the House,” said Senator Ron Johnson, Republican of Wisconsin, who helped write the Graham-Cassidy bill.
Mr. Alexander said the resistance to his bill was formidable. “I know how to get bipartisan results, but I’m not a magician,” he said.
The battle over the Affordable Care Act — adopted in 2010 without any Republican votes — has once again become an all-consuming political drama on Capitol Hill.
The chairman of the Senate Finance Committee and the top Democrat on the panel announced last week that they had reached agreement on a plan to prevent the imminent exhaustion of federal funds for the Children’s Health Insurance Program. But efforts to translate that agreement into legislation have been at least temporarily derailed by the Republican push for repeal of the Affordable Care Act.
Republicans were trying desperately to round up votes for the Graham-Cassidy bill before the end of next week, when the measure will lose the procedural protection that allows it to pass with a simple majority, rather than the 60 votes that would otherwise be required.
While Republicans like the idea of federalism and block grants, many wanted to know how their states would be affected. Under the legislation, states with high health care costs — especially if they expanded Medicaid under the Affordable Care Act — would generally lose money, while low-cost states that did not expand Medicaid would gain.
“The idea of giving the states more flexibility and authority is a good idea,” said Senator Rob Portman of Ohio. “As a Republican, I join my colleagues in thinking that states are the place where many health care decisions are already being made, and can be made more efficiently to cover more people and to lower costs.”
But he added, “I want to see what the impact is on Ohio.’’
Ohio did expand Medicaid, and roughly 700,000 people have gained coverage as a result.
The Republican governors who signed the letter opposing the latest Republican repeal plan were John R. Kasich of Ohio, Brian Sandoval of Nevada, Charlie Baker of Massachusetts and Phil Scott of Vermont.
Two other Republican governors, Mr. Sununu and Larry Hogan of Maryland, expressed similar concerns in separate statements.
“The Graham-Cassidy bill is not a solution that works for Maryland,” Mr. Hogan said. “It will cost our state over $2 billion annually while directly jeopardizing the health care of our citizens.”
Mr. Graham and Mr. Cassidy have cited Maryland as a state that, in their view, has been receiving more than its fair share of money under the Affordable Care Act.
Mr. Sununu said he could not support the Graham-Cassidy proposal because “New Hampshire could possibly lose over $1 billion in Medicaid funding between 2020 and 2026.” He said such a cost shift would be a particular problem for his state because “New Hampshire is proud of its tradition of not having an income tax or sales tax.”
Members of the Senate health committee, who celebrated its bipartisan efforts to stabilize insurance markets in the past two weeks, said they were disappointed.
Senator Collins said she hoped the panel would continue its work on a bipartisan measure, which she said had gone “extremely well” under the leadership of Mr. Alexander and Ms. Murray.
Senator Bob Casey, Democrat of Pennsylvania, said the Graham-Cassidy bill had been moving quietly through Washington, “like a snake in the grass,” while senators on the health committee were trying to work together across party lines.
“If we allow that snake in the grass to inject its venom into people — my analogy for losing your health care coverage — then we’re not the Senate we should be,” Mr. Casey said. “We’re not the government that we should be.”
Besides creating block grants, the Graham-Cassidy bill would make deep cuts in Medicaid. It would end the expansion of eligibility under the Affordable Care Act, which has provided Medicaid coverage to 13 million people. And it would put the entire program, which serves more than 70 million people, on a budget, ending the open-ended entitlement that exists. States would instead receive a per-beneficiary allotment of federal money.
Blue States Face Biggest Cuts Under
New Republican Health Care Plan
by Haeyoun Park - NYT - September 19, 2017
Biggest funding cuts and gains per person
A new Republican plan to repeal the Affordable Care Act would give each state a federal block grant for health care using a complex formula that cuts funding for some states — including many that were won by Hillary Clinton in 2016 — according to a New York Times analysis of estimates from the Center on Budget and Policy Priorities, a left-leaning think tank.
The grants would replace federal money currently being spent on Medicaid expansion and on subsidies to help people afford insurance. The bill, introduced by Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana last week, would cause 36 states to face funding cuts in 2026.
Blue States Lose Biggest
The biggest losers of federal funding are states that voted for Hillary Clinton in the 2016 presidential election.
The Times calculated the funding impact per person by totaling the number of people receiving Medicaid benefits, those who purchased insurance in the Affordable Care Act marketplaces and those who are uninsured.
Funding loss per person
Nineteen states and the District of Columbia voted for Mrs. Clinton and face funding cuts. Many of them face cuts of more than $1,000 per person in 2026.
G.O.P. Leaders Need Votes From
States That Would Lose Funding
Thirteen Republican senators from 12 states voted against one of the recent Senate repeal bills in July. Eight of those senators are from states that would lose funding, making it politically tricky to get this bill passed.
Funding loss per person
Two senators — Lisa Murkowski of Alaska and Susan Collins of Maine — voted no on all three of the Republican bills. Senators John McCain of Arizona and Dean Heller of Nevada voted no twice. All four are from states that would lose funding.
All States That Expanded
Medicaid Would Lose
The bill shifts money from states that expanded Medicaid to those that did not.
Funding loss per person
Under the Affordable Care Act, 31 states and the District of Columbia expanded Medicaid to cover adults whose income was at or below 138 percent of the poverty line.
Most of the states that did not expand Medicaid coverage under the Affordable Care Act would see an increase in federal funding.
Obamacare Repeal Bill Offers Both Enormous Flexibility and Uncertainty
by Reed Abelson and Margot Sanger-Katz - NYT - September 20, 2017
The latest Republican proposal to undo the Affordable Care Act would grant states much greater flexibility and all but guarantee much greater uncertainty for tens of millions of people.
The legislation, proposed by two Senate Republicans, Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, would not only reduce the amount of federal funding for coverage over the next decade, but would also give states wide leeway to determine whom to cover and how. The result is a law that would be as disruptive as many of the Republicans’ previous proposals, but whose precise impact is the hardest to predict.
The bill would initially preserve nearly all the funding currently provided to Americans through Obamacare’s state insurance marketplace subsidies and expansion of Medicaid. But starting in 2020, that funding would be reallocated to state governments as block grants. Over time, the division of money would shift among the states based on a complex formula, and the total pot would grow according to a set rate, not based on the number of people nationwide who sign up for coverage.
States could use the money to replicate Obamacare’s programs, or to pursue completely different health policy strategies. The bill lays out some standards for program goals, but gives states broad discretion to use the funds in a variety of ways. “There will be clear differences between states about how they implement,” said Deep Banerjee, an analyst with Standard & Poor’s. “It will create quite a bit of uncertainty over the next few years.”
The bill is structured as a sort of slow-motion repeal of Obamacare’s main coverage programs. Though the bill establishes the new state block grant program for a decade, all of the program’s money expires after 2026. That makes it different from the Obamacare overhaul bill passed by the House and a previous bill considered by the Senate, which would have made modifications and cuts to those programs, but preserved them in perpetuity. The expiration of the Obamacare programs alone would probably mean that about 23 million fewer Americans would have health coverage, if compared with current law, according to an estimate the Congressional Budget Office made in regard to a previous repeal bill.
In the meantime, analysts say, the individual insurance markets could face enormous changes. The legislation rolls back popular consumer protections in Obamacare, leaving each state to decide what minimum benefits must be covered or if customers with pre-existing illnesses should be protected from higher prices. Not every state would drop these provisions, but several might. One of the few Obamacare requirements that would remain is to allow children to stay on their parents’ insurance policies until age 26.
The budget office has said it does not have time to analyze the full effects of the bill before the Senate hopes to consider it, though it will provide some overall estimates of its effects on the federal deficit. While a floor vote is not certain yet, Republicans are racing against the clock. They are considering the bill under special budget rulesthat allow them to pass it with a simple majority of votes in the Senate. That opportunity expires when the fiscal year ends at the end of next Saturday (Sept. 30).
The legislation also does little to stabilize the individual market from now until when the states would have to administer new health programs in 2020. Insurers are sharply raising their prices for 2018 because lawmakers have not committed to funding the so-called cost-sharing subsidies that help insurers lower deductibles and co-payments for low-income customers. The bill does not fix this problem.
The legislation also eliminates the tax penalty that people who refuse coverage face — the individual mandate — which could discourage insurance enrollment among healthier people, who are critical to making the program work. Insurance companies, some of whom are only reluctantly staying in the market, may think twice about whether they need to remain while the alternatives are being worked out.
This mix of policies during the two-year transition period is similar to that imagined in earlier Republican bills. The budget office said that such an environment would cause insurance prices to spike by 20 percent, and about 15 million fewer Americans to have health coverage in 2019.
The block-grant formula would affect who gets covered, by shifting money to states with the greatest number of low-income residents and away from states that have tried to provide more of their middle-income citizens with insurance.
A recent analysis from the left-leaning Center on Budget and Policy Priorities found that, by 2026, blue states with low numbers of uninsured residents, including New York and Massachusetts, would experience substantial reductions in federal funding. Poorer states with high uninsured rates, like Texas and Mississippi, would see increases. Many of the states that make out better, financially, could have obtained more Obamacare funding if they had chosen to expand their Medicaid programs to cover more low-income residents.
The bill’s formula shifts around the current pot of money based on how many residents in each state are close to the poverty line, and also seeks to equalize payments, regardless of differences in the price of medical care in different regions. “It redistributes from higher income to lowest income,” said Caroline Pearson, a senior vice president at Avalere Health. “It also redistributes among the states.”
Like several earlier Republican health bills, this one would also change the structureof the 52-year-old Medicaid program, which even before Obamacare’s expansion to poor adults in many states, covered tens of millions of vulnerable Americans, including poor children, older Americans in nursing homes, adults with disabilities, and many pregnant women. The program currently pays for 49 percent of all births and 64 percent of all nursing home residents’ bills.
The Graham-Cassidy bill moves funding for the Medicaid expansion population into the state block grant. It would also convert the rest of the program from an open-ended commitment of paying a share of those people’s medical bills to a capped allotment for each person every year, set to grow by a fixed amount. Independent analysts have said that the change would cause substantial shifts in financial responsibility to states, ultimately leading to reductions in benefits or in the number of Americans covered by Medicaid over time.
Most Americans receive insurance through their employers, and they, too, would probably see changes under this bill. The legislation would eliminate Obamacare’s penalties for employers that decline to offer their workers affordable coverage. The changes to benefit rules in some states could, through a complicated interplay of law and regulation, allow insurers to impose annual or lifetime limits on coverage for some people covered under employer plans. More than half of plans had such limits before they were barred by Obamacare.
With all these changes in the Cassidy-Graham bill, the states might have considerable difficulty coming up with plans of their own by 2020, when the current system of covering their residents under Medicaid and the A.C.A. insurance market would end. “You’ve only got two years to figure all of this out,” said Robert Laszewski, an industry consultant in Alexandria, Va. “You need a comprehensive plan to phase Obamacare out to something that replaces it.”
Insurers Come Out Swinging Against New Republican Health Care Bill
by Robert Pear - NYT - September 20, 2017
WASHINGTON — The health insurance industry, after cautiously watching Republican health care efforts for months, came out forcefully on Wednesday against the Senate’s latest bill to repeal the Affordable Care Act, suggesting that its state-by-state block grants could create health care chaos in the short term and a Balkanized, uncertain insurance market.
In the face of the industry opposition, Senate Republican leaders nevertheless said they would push for a showdown vote next week on the legislation, drafted by Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana.
That puts Republican senators in a squeeze, especially those whose states would lose money under a complicated formula in the bill. Generally, it would shift federal funds away from states that have been successful in expanding coverage to states where Republican leaders refused to expand Medicaid or encourage enrollment.
Republican senators from Alaska, Arizona, Arkansas, Colorado, Ohio and West Virginia will all have to decide whether to heed the pleas of consumers who like the current health law — or yield to the will of Republican leaders, donors and voters who demand an end to the Affordable Care Act.
That has put the spotlight not only on the three Republicans who killed the repeal drive in July — Lisa Murkowski of Alaska, John McCain of Arizona and Susan Collins of Maine — but also on those who have been reluctantly supportive, such as Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Rob Portman of Ohio.
Senate Republicans are already under pressure from 11 governors — including five fellow Republicans and a pivotal Alaskan independent — who this week urged the Senate to reject the last-ditch repeal effort.
The two major trade groups for insurers, the Blue Cross Blue Shield Association and America’s Health Insurance Plans, announced their opposition on Wednesday to the Graham-Cassidy bill. They joined other groups fighting the bill, such as the American Medical Association, the American Hospital Association, AARP and the lobbying arm of the American Cancer Society.
“The bill contains provisions that would allow states to waive key consumer protections, as well as undermine safeguards for those with pre-existing medical conditions,’’ said Scott P. Serota, the president and chief executive of the Blue Cross Blue Shield Association. “The legislation reduces funding for many states significantly and would increase uncertainty in the marketplace, making coverage more expensive and jeopardizing Americans’ choice of health plans.”
America’s Health Insurance Plans was even more pointed. The legislation could hurt patients by “further destabilizing the individual market” and could potentially allow “government-controlled single payer health care to grow,” said Marilyn B. Tavenner, the president and chief executive of the association. Without controls, some states could simply eliminate private insurance, she warned.
Insurers had been reluctant to speak out against the Republicans’ previous proposals in hopes that the White House and Congress would agree to stabilize insurance markets by providing critical funding for subsidies aimed at low-income Americans. But with hopes of securing that money before they finalize their rates virtually extinguished, insurers have less to lose by coming out against the proposal.
And many within the industry are worried that the next two years will be chaotic, with little support for the current market while states scramble to come up with a new way for individuals to buy policies.
“It’s just basically injecting chaos in 50 state capitals for the next two years,” said Sabrina Corlette, a research professor at Georgetown University.
At this point, Republicans have not secured the 50 votes they would need to pass the bill, with help from Vice President Mike Pence to break a tie. But President Trump, in New York for meetings with world leaders at the United Nations, said he thought the health care bill had “a very good chance’’ of passing.
It has “tremendous support from Republicans — certainly we’re at 47 or 48 already,’’ he said, and “a lot of others are looking at it very positively.’’
“A great Bill,” Mr. Trump concluded on Twitter later Wednesday.
The latest Republican drive to repeal the Affordable Care Act has created painful choices for Republican senators from states that stand to lose money under the legislation.
The bill would eliminate penalties for people who go without insurance, and it would funnel federal funds to states in the form of block grants for health care or coverage. States could decide how to spend the money, which is now being used for the expansion of Medicaid and for subsidies to help low- and middle-income people buy private insurance.
State officials were racing to try to figure out the impact, looking to experts to help them do the calculations.
“States such as Alaska, Connecticut, Delaware, New Hampshire, New Mexico, New York, Oregon, Vermont and Washington would see reductions of 25 percent or more over the 2020 to 2026 period,” compared with what they would receive under current law, said a monograph issued on Wednesday by Manatt Health, a unit of Manatt, Phelps & Phillips, a national law firm that advises many states on health care issues.
Among the Republicans agonizing over how to vote is Ms. Murkowski, who has said the bill’s effect on her state will be her paramount consideration.
Becky Hultberg, the president and chief executive of the Alaska State Hospital and Nursing Home Association, said on Wednesday that the cuts in the bill could have a “huge impact” on Alaska.
“The cuts could be devastating to our health care system, including rural and frontier hospitals that operate on razor-thin margins,” Ms. Hultberg said in an interview. “These hospitals are often accessible only by airplane or ferry, so the loss of a hospital means an expensive and disruptive medical evacuation out of the community.”
“Ultimately,” Ms. Hultberg said, “patients will bear the consequences, through reduced access to health care and lost insurance coverage.”
The authors of the new repeal bill, Mr. Graham and Mr. Cassidy, say decisions about health care are best made at the local level.
Mr. McCain is a close friend of Mr. Graham, but is still studying the bill and has not said how he would vote.
The other Republican senator from Arizona, Jeff Flake, had no such hesitation. “Given the choice between Arizona or Washington deciding how federal health care dollars are spent in the state,’’ he said, “I’ll take Arizona every day of the week.’’
The Manatt study said Arizona would lose money under the bill, and a study by Avalere, a health policy consulting company, reached a similar conclusion. Both studies indicated that Tennessee would gain money.
Senator Bob Corker, Republican of Tennessee, said he liked the latest repeal bill. “I’d be ecstatic if we could finally make something happen on health care’’ by passing it, he said, adding: “I’m a states’ rights kind of guy. Our state has been well run for a long time. To know that our state would have the flexibility to carry out the program with more money than it now has could be a real win for us.’’
The studies by Manatt and Avalere suggest that West Virginia would lose money under the bill. Ms. Capito “is still evaluating the proposal,” said her spokeswoman, Ashley Berrang.
But the state’s senior senator, Joe Manchin III, a Democrat, said, “The numbers do not work at all for West Virginia, with an older, sicker population and an opioid addiction problem.”
“As a former governor, I like the concept of block grants because they give you flexibility,” Mr. Manchin said. “But the cuts are deeper than the needs we have, and our needs are greater than the money we would have under the bill.”
While Premiums Soar Under Obamacare, Costs of Employer-Based Plans Are Stable
by Reed Abelson - NYT - September 19, 2017
In sharp contrast to the soaring health insurance premiums in many Affordable Care Act marketplaces, the cost of coverage for the vast numbers of people who get insurance through their jobs rose relatively little this year, continuing a period of remarkable stability in the employer market, according to a national survey released Tuesday.
The annual premium for family coverage rose an average of 3 percent to $18,764 this year, according the Kaiser Family Foundation, a nonprofit group, which conducted the annual survey of employers. That is the sixth straight year that employer-provided policies have increased by well under 5 percent, according to the survey. Employers paid the bulk of the costs, the survey found, with workers shouldering an average of $5,714, a year for a family policy.
About 151 million people are covered through an employer, and the insurance environment for many of those companies is characterized by “a remarkable stubborn stability,” said Craig Garthwaite, a health economist at the Kellogg School of Management at Northwestern University.
The exception is the smallest companies, which are still finding it challenging to afford insurance for their workers. In recent years, a growing number of smaller companies have stopped providing health benefits, according to the Kaiser data. Over the last five years, the percentage of businesses with under 50 workers offering coverage has fallen from 59 percent to 50 percent. In 2001, two thirds of those employers offered benefits.
Health costs remain an issue even for families with stable employer coverage. This year’s modest rise still outpaces both overall inflation and the increase in workers’ earnings. “The sticker shock for people is still very real,” said Drew Altman, the Kaiser foundation’s chief executive.
But it is a calm environment compared to the marketplaces where individuals shop for coverage under the Affordable Care Act. While fewer than 20 million Americans buy their own insurance, the tribulations of the individual market have captured most of the public’s attention. The average cost of a benchmark plan in the individual market rose 20 percent this year, according to Kaiser, as insurers tried to stem their losses.
The combination of political uncertainty over the future of the health law and insurer unrest may result in a similar jump in individual premiums for 2018. Insurers must make their final decisions where to sell and what to charge in the Affordable Care Act marketplaces by the end of the month.
Early results from another employer survey, conducted by Mercer, a benefits consultant, indicate that businesses expected to see health benefit costs increase 4.3 percent for 2018 after making changes like switching insurers or raising plan deductibles. “Our take away from this is that the trend for employers remains stable, and it remains low,” said Tracy Watts, a senior partner at Mercer.
As a result, employers may not feel the need to make any drastic changes. “What I see in our renewals is very predictable and very steady,” said Lisa Trombley, benefits manager for Kelly Services, the Troy, Mich., staffing company.
Overall, health care costs have increased at historically low rates in recent years, said Matthew Fiedler, a health economist at the Brookings Institution. “We’ve got lots of indicators, across a constellation, that the health care trend is pretty low,” he said.
While employers credit their efforts to slow down costs, others, including Mr. Fiedler, say some of the changes enacted under the Affordable Care Act have also contributed. The federal law reduced what Medicare pays for care, which allows private payers to strike better bargains, he said, and the government has been encouraging experiments in how to pay doctors and hospitals in new ways that may reduce spending.
Even the deductibles people pay toward their own medical bills, which have gone up steadily in recent years, seem to be holding steady. Deductibles rose only slightly this year, averaging $1,505 for a single person, according to Kaiser.
While employers have relied on steeper deductibles to lower their own costs, companies are recognizing that they have reached the limits of what they can ask their workers to pay, said Michael Thompson, the chief executive of the National Alliance of Healthcare Purchaser Coalitions, which represents employers. “We’re running out of runway to keep cost-shifting to employees,” he said.
But people remain confused about how the turmoil in the individual market affects them, even when they get their coverage through an employer, Mr. Altman said. In a recent Kaiser poll, six out of 10 Americans worried that the higher rates being charged in the A.C.A. markets would negatively affect them, he said.
The two markets are distinct, and the groups of people being covered are “like night and day,” Mr. Altman said. The individual market has a large portion of people who need expensive medical care, which has led to sharply higher prices some areas. The large employer market can spread the costs of expensive care more easily over the greater numbers of people that work for large companies.
Small businesses, however, can’t spread their medical costs over a large work force. Premiums “have gone up double digits up here,” said Martin Dole, the controller for Gateway Motors, a car dealership in White River Junction, Vt., which covers 28 people.
The family plan Gateway offers costs more than $700 a month and comes with a deductible of $9,500, which workers “hate,” he said. Health care is one of the dealership’s largest expenses, Mr. Dole said, and he is concerned that the dealership may not be able to afford to offer coverage in coming years.
Larger companies tend to view health benefits as a key component of compensation and essential to attracting employees. Companies and their workers also enjoy a generous tax subsidy for employer-sponsored coverage. While there has been some discussion about reducing or eliminating that subsidy, including as part of the push for a single-payer Medicare-for-all plan that would replace the current system with the one now providing coverage to people 65 and older, there seems to be significant support for maintaining the current system.
“It’s pretty much business as usual,” said Larry Boress, the chief executive of the Midwest Business Group on Health, a regional group of employers. Companies are holding down costs through a variety of efforts, like offering workplace clinics or more telehealth services so employees do not have to go to the doctor or show up in the emergency room.
Employers will continue to look for ways to reduce what they pay toward their workers’ health care costs, he said. “Whether the A.C.A. exists or not, they will clearly do that,” he said.
Republicans tweak Sanders over health care, but Cassidy-Graham could open a path for his bill
by David Weigel - The Washington Post - September 20, 2017
One short week ago, 16 Senate Democrats and dozens of progressive groups rallied with Sen. Bernie Sanders (I-Vt.) to celebrate the release of his Universal Medicare for All bill — a moonshot that they hoped would reset the national conversation on health care.
Sen. Lindsey O. Graham (R-S.C.) sounded downright giddy. His own legislation to curtail the Affordable Care Act, and block grant Medicaid, was released just a few hours before Sanders’s, to a smaller but just as skeptical group of reporters.
“You’re skipping Bernie for this?” he joked. Before he got to the substance of the Cassidy-Graham bill, the senator framed it as an alternative to the Sanders bill, a way to stop an inevitable lurch toward European-style universal coverage: “Hell no to Berniecare!”
Play Video 1:38
Graham positions his health-care plan as a choice between 'socialism or federalism'
Sen. Lindsey Graham (R-S.C.) painted a dark picture of health care in the U.S. if the Graham-Cassidy plan doesn't pass. "I'm trying to take the money and power in Washington and send it back closer to the patient," he said on Sept. 19. (The Washington Post)
The momentum for Graham’s bill, and the surprise reanimation of a repeal effortthat has been declared dead twice before, has sparked one of the Capitol’s most cherished traditions: panicky Democrats taking shots at each other. Egged on by Graham, and by a snarky Republican National Committee, a few liberal analysts and Democratic pols have asked whether Sanders bears some responsibility for the 11th hour repeal fight.
“I thought that anyone who believed that you should take your eye off the ball before Sept. 30 wasn’t being smart,” Sen. Heidi Heitkamp (D-N.D.), one of 30 Democrats who did not endorse the Sanders bill, told Politico.
Sanders, who since his presidential bid has become judicious about talking to reporters in Senate hallways, was particularly tight-lipped at Tuesday’s lunches, saying only that single-payer was “where the American people want to go.” He had, after all, delayed the release of his bill several times, partially to get more input from Democrats, but largely to avoid confusing the Democratic caucus’s united stance against repeal.
But did he crack the door open for Republicans this time? Most of his colleagues say no; those who don’t reject the idea outright acknowledge that the GOP was never going to let the Sept. 30 reconciliation deadline pass without another run at health care. One pointed out that the Sept. 30 deadline itself came after Sanders, the ranking member of the Senate Budget committee, got the Senate parliamentarian to clarify that Republicans could not drag the issue out forever — a development that Democrats considered to be a win.
“As soon as the parliamentarian’s ruling came down, they were going to do something,” said Sen. Chris Murphy (D-Conn.).
Sen. Bill Cassidy (R-La.), the bill’s co-sponsor, had been talking up Medicaid reform since the 2016 election; Graham himself had been workshopping the bill since before the collapse of the Better Care Reconciliation Act, the first Senate vehicle for repeal, and had pledged to release it in September before Sanders set a date for his Medicare for All launch.
More baffling to Democrats was Graham’s Sanders-focused selling point: That if his bill passed, a federal Medicare for All program would become impossible. By block-granting Medicaid, Republicans would prevent Democrats from going back to the well when they next controlled Congress, because states would have set up their own insurance systems.
“Bernie, this ends your dream,” Graham said last week.
Senate Republicans are trying to revive the momentum to overhaul the Affordable Care Act with the Cassidy-Graham proposal. Here's a rundown of the plan, and the rush to pass it.
That, say Democrats and policy analysts, made sense to Republican senators but almost no one else. The block-grant proposal at the center of Cassidy-Graham is astoundingly unpopular, with just 26 percent of all voters and 48 percent of Republicans telling pollsters that they favor it. In an essay for Slate, the conservative writer Reihan Salam warned that Republicans, if they passed the bill, would be shifting voter blame for rising health-care costs or lost coverage onto state legislatures, at a moment when Republicans enjoy historic control of the states.
[T]he complaints they could once deflect to Congress would land firmly on their doorsteps. Every single person employed in the health care sector and every single person who depends on subsidized medical care, whether directly or indirectly, would have a vested interest in ensuring that local health systems are generously funded and that funding grows robustly from year to year. They would soon learn that their livelihoods depend on the outcome of state legislative races, and they would vote accordingly. All of this is perfectly consistent with the conservative commitment to decentralizing health care policy. It is also perfectly consistent with Republicans losing elections.
If Cassidy-Graham became law, and became unpopular, Graham’s push would have enabled Sanders in a more effective way. The two senators, joined by 48 Republicans and the vice president, will have dramatically altered a major entitlement in a two-week sprint, with no serious CBO score, no bipartisan input, and one hasty hearing. To describe why that mattered, one Democratic aide pointed to an analysis from New York magazine’s Jonathan Chait, a liberal columnist who had ridiculed the Sanders bill.
It would make it easier for the left to argue that the program’s compromise structure is a failure, that its markets are inherently susceptible to sabotage by Republican administrations, and that the risk of political capital is worthwhile. And the method used to pass repeal — a hastily assembled reconciliation bill devoid of serious analysis — would make fools of the party’s Senate institutionalists. Democrats would be incentivized to pass a sweeping 50-vote Medicare expansion, with the goal of creating as many beneficiaries as possible, as quickly as possible.
With support growing for universal health coverage, just what does "single-payer" mean? Here's a deep-dive into what a single-payer health-care system would look like, and the arguments for and against it. (Jenny Starrs, Danielle Kunitz/The Washington Post)
After the near-passage of BCRA, some progressive policy analysts began daydreaming about how the 50-vote threshold could advance their goals — goals that had been stymied when the Democrats of 2009-2010 passed most of the ACA through the normal legislative process. Mike Konczal, an analyst at the Roosevelt Institute, posited a way to pass outright Medicare for All, and a fallback plan of Medicare for More. The key, in both cases, was that progressives’ simplest ask — a public option — could pass easily.
The CBO will analyze the proposal and basically say “Congratulations, you have $16 billion a year from your savings to spend, for free. What would you like to spend it on?” The CBO has scored an aggressive public option as savings money and done so consistently, on the order of $158 billion over ten years. It does this by lowering premiums overall, which means the ACA spends less on subsidies. But it also means more employers take advantage of it and pay people less through tax-free benefits, which increases the amount taxes collected. Combine it with some other easy budgetary reforms to pass through reconciliation, like having Medicare negotiate lower drug prices, which alone would save about $11 billion a year, and we can picture an overall savings of $30 billion a year.
At the time, Konczal, like most of Washington, assumed that the GOP had made its final, failed lunge at repeal. (One Democratic aide pointed out, ruefully, that the Sunday talk shows after the release of both Cassidy-Graham and Medicare for All asked no questions to legislators about the Republican bill.) Some observers, making the point that the 50-vote standard would actually make progressive health-care reform dramatically easier, have been chastised for sounding glib about how block-granting and the rest of Cassidy-Graham would affect health care in the years before Democrats could reverse it.
If they sounded that way, it was because the thought of beating back repeal in March, May, and July, and losing in the final hours before the deadline, was unthinkable to Democrats. In an interview last week, shortly before his rollout event, Sanders shook his head when asked if Republicans could take a final, successful run at repeal.
“It is like a zombie,” he said.https://www.washingtonpost.com/news/powerpost/wp/2017/09/20/republicans-tweak-sanders-over-health-care-but-cassidy-graham-could-open-a-path-for-his-bill/?
Single Payer Myths: Redundant Health Administration Workers
by Matt Bruening - People's Policy Report - September 19, 2017
One of the reasons why the current US health care system is so bloated is that it wastes a lot of labor on health insurance administration. Health care providers have to employ many people to make agreements with health insurers and to bill health insurers. Health insurance companies also have to employ many people to make agreements with health care providers and to pay the bills those providers send them. By streamlining billing and payments under a single national insurer, a single payer system would eliminate much of this work, which is one of its many charms.
Critics argue that the elimination of this work would strike an intolerable blow to employment in the country. In reality, the loss of employment would be relatively small compared to the overall economy, should only be temporary, and can be cushioned through unemployment benefits and active labor market policies that help reallocate redundant workers into new jobs.
Existing Labor Turnover
One of the reasons for the pervasiveness of this myth is a lack of understanding of just how many people get separated from their job already every year.
One of the reasons for the pervasiveness of this myth is a lack of understanding of just how many people get separated from their job already every year.
In 2016, 60 million people separated from their job at some point during the year. That is equal to 42 percent of the American workforce.
Of course, there is a difference between quitting a job (often for another job already in waiting) and being fired from a job. But if you look only at layoffs and discharges (grouped in the above graph as “dismissals”), you see that, in 2016, 20 million people were fired from their job, representing around 14 percent of the total US workforce.
Being fired from a job without having another job waiting can be a very bad experience, but it is also a very common experience that does not generally have long-term negative economic consequences.
Vulnerable Health Care Employment
Figuring out how many people work “in health care” can be a little tricky.
Figuring out how many people work “in health care” can be a little tricky.
One way to do it is to look directly at health care professions as defined by the Occupational Employment Statistics (OES) codes. The Kaiser Family Foundation does this in their analysis saying that health care currently employs around 12.7 million people, or 9 percent of the workforce.
The problem with this figure for our purposes here is that it defines health care workers by the work that they do rather than by the establishments they work for. This means it excludes occupation groups like Office and Administrative Supportthat are the most likely to be made redundant in a single payer transition. Actual health care workers, defined as those providing frontline health care services like doctors, nurses, medical technicians, and so on are the least likely to be made redundant by such a transition.
Another approach is to isolate the relevant establishments in the North American Industry Classification System (NAICS) and then add up the number of people employed by those establishments in the types of professions threatened by bureaucratic streamlining. There are around 2.6 million jobs in Office and Administrative Support within health care provider establishments. This includes every establishment under NAICS 62 excepting social assistance establishments. There are also around 0.4 million total jobs under Direct Health and Medical Insurance Carriers (NAICS 524114). So, under this most liberal of possible interpretations, we are talking about a universe of 3 million jobs.
If you were to lay off all 3 million of those workers, it would be equal to how many workers are already lay off in this country every 54 days.
Of course, you would not lay off anywhere near that many people. Office and Administrative Support jobs include everything from HR jobs, payroll specialists, and people who answer the phone. Only a minority of those 2.6 million jobs are actually involved in the kinds of insurance intermediary work that is threatened by the switch, and even then some of those jobs will still remain in order to bill the national insurer. All 0.4 million medical insurance jobs are threatened, but at least some of those workers will be able to move into the smaller number of similar jobs created by the expansion of the public insurer (e.g. Medicare).
Although it is hard to come up with a precise estimate, the likely number of jobs made redundant by the switch is a few hundred thousand over the course of a few years, this in a country where 1.6 million people are dismissed from their jobs every single month.
Transitional Assistance
Given the small numbers we are talking about in the context of the entire economy and given the fact that office and administrative skills are fairly portable to other sectors (non-health care establishments employ over 19 million people in such jobs), it is not at all clear that there needs to be any special program for reallocating those made redundant by this change. But even if there does not need to be such a program, single payer proposals generally contain one.
Given the small numbers we are talking about in the context of the entire economy and given the fact that office and administrative skills are fairly portable to other sectors (non-health care establishments employ over 19 million people in such jobs), it is not at all clear that there needs to be any special program for reallocating those made redundant by this change. But even if there does not need to be such a program, single payer proposals generally contain one.
For instance, here is how the issue is handled in Conyer’s HR 676:
(e) First Priority In Retraining And Job Placement; 2 Years Of Salary Parity Benefits.—The Program shall provide that clerical, administrative, and billing personnel in insurance companies, doctors offices, hospitals, nursing facilities, and other facilities whose jobs are eliminated due to reduced administration—(1) should have first priority in retraining and job placement in the new system; and(2) shall be eligible to receive two years of Medicare For All employment transition benefits with each year’s benefit equal to salary earned during the last 12 months of employment, but shall not exceed $100,000 per year.
How Economic Growth Works
As a closing note, it is worth emphasizing that reallocating workers away from unnecessary tasks and towards new tasks is how economic growth works. Such a reallocation can be painful to those directly affected by it in the short-term, which is why humane societies create systems of unemployment benefits and institutions capable of helping people dislocated by economic changes get into new jobs. But the basic mechanics of finding ways to be more productive with the same amount of labor is fundamentally good.
As a closing note, it is worth emphasizing that reallocating workers away from unnecessary tasks and towards new tasks is how economic growth works. Such a reallocation can be painful to those directly affected by it in the short-term, which is why humane societies create systems of unemployment benefits and institutions capable of helping people dislocated by economic changes get into new jobs. But the basic mechanics of finding ways to be more productive with the same amount of labor is fundamentally good.
When people talk about single payer making some health administration workers redundant, they often characterize it as a purely negative thing. It is the “con” of single payer that is nonetheless outweighed by so many countervailing “pros.” But this is not quite right. Making the workers redundant is also a pro insofar as it creates a more prosperous society through greater economic efficiency.
This is the first post in our Single Payer Myths series. The series tackles common arguments against a single payer system one at a time.
To the Editor:
Re “In Outline of ‘Medicare for All,’ a More Modest Starting Point” (The Upshot, Sept. 16):
We support proposals that look to the Medicare program as a starting point for expanding coverage. Before doing so, however, Congress should improve Medicare for its current and future beneficiaries. Drawing on our expertise from serving people with Medicare, these improvements are critical:
Fill in coverage gaps, including vision, hearing and dental coverage; include a cap on out-of-pocket expenses and a prescription drug benefit in the traditional Medicare program; strengthen assistance for low-income people; ensure the right to buy supplemental Medigap insurance for all Medicare beneficiaries, including those under 65; and ease transitions into Medicare from other types of insurance.
The Medicare program is a national treasure. We should preserve and enhance it as we work toward the goal of comprehensive universal coverage. Then Medicare can truly help reduce the national uninsured rate to zero.
JUDITH STEIN, JOE BAKER
WASHINGTON
WASHINGTON
The writers are, respectively, executive director of the Center for Medicare Advocacy and president of the Medicare Rights Center.
Jimmy Kimmel gets heated about health-care bill, says Sen. Bill Cassidy ‘lied right to my face’
by Emily Yahr - The Washington Post - September 20, 2017
Sen. Bill Cassidy (R-La.) praised the proposed Senate health-care bill, saying it “begins to address the Jimmy Kimmel test,” on June 22 at the Capitol. (Alice Li, Libby Casey/The Washington Post)
Fast forward to this month, and there’s a new proposal as the Senate continues in its quest to repeal Obamacare: It’s called the Cassidy-Graham bill, spearheaded by Cassidy and Sen. Lindsey Graham (R-S.C.). People have already pointed out it would fail the “Jimmy Kimmel test.” On his show Tuesday night, the late-night host eviscerated Cassidy and the bill.
“I know you guys are going to find this hard to believe. But a few months ago, after my son had open heart surgery … a senator named Bill Cassidy from Louisiana, was on my show and he wasn’t very honest,” Kimmel said, kicking things off. Here’s a transcript of most of Kimmel’s remarks, which got heated, especially toward Cassidy — and he had a few choice words for people who will criticize him for politicizing his son’s health problems.
It seemed like [Cassidy] was being honest. He got a lot of credit and attention for coming off like a rare, reasonable voice in the Republican Party when it came to health care for coming up with something he called — and I didn’t name it this, he named it this — the Jimmy Kimmel test, which was in a nutshell: No family should be denied medical care, emergency of otherwise, because they can’t afford it. He agreed to that. He said he would only support a health-care bill that made sure a child like mine would get the health coverage he needs no matter how much money his parents make.
And that did not have annual or lifetime caps. These insurance companies, they want caps, to limit how much they can pay out. So for instance, if your son has to have three open heart surgeries, it can cost hundreds of thousands of dollars apiece. If he hits his lifetime cap of, let’s say, a million dollars, the rest of his life, he’s on his own.
Our current plan protects Americans from these caps and prevents insurance providers from jacking up the rates for people who have preexisting conditions of all types. And Sen. Cassidy said his plan would do that, too. He said all of this on television many times.
(Clip of Sen. Cassidy on CNN saying, “I ask, does it pass the Jimmy Kimmel test? Would the child born with a congenital heart disease be able to get everything she or he would need in the first year of life? I want it to pass the Jimmy Kimmel test.”)
So last week, Bill Cassidy and Sen. Lindsey Graham proposed a new bill, the Graham-Cassidy bill. And this new bill actually does pass the Jimmy Kimmel test, but a different Jimmy Kimmel test. With this one, your child with a preexisting condition will get the care he needs — if, and only if, his father is Jimmy Kimmel. Otherwise, you might be screwed.
Now, I don’t know what happened to Bill Cassidy. But when he was on this publicity tour, he listed his demands for a health-care bill very clearly. These were his words. He said he wants coverage for all; no discrimination based on preexisting conditions; lower premiums for middle-class families; and no lifetime caps. And guess what? The new bill? Does none of those things.
Coverage for all? No. Fact, it will kick about 30 million Americans off insurance. Preexisting conditions? Nope. If the bill passes, individual states can let insurance companies charge you more if you have a preexisting condition. You’ll find that little loophole later in the document after it says they can’t. They can, and they will.
But will it lower premiums? Well, in fact, for lots of people, the bill will result in higher premiums. And as far as no lifetime caps go, the states can decide on that, too, which means there will be lifetime caps in many states. So not only did Bill Cassidy fail the Jimmy Kimmel test, he failed the Bill Cassidy test. He failed his own test. And you don’t see that happen very much.
This bill that he came up with is actually worse than the one that, thank God, Republicans like Susan Collins and Lisa Murkowski and John McCain torpedoed over the summer. And I hope they have the courage and good sense to do that again with this one, because these other guys who claim they want Americans to have better health care — even though eight years ago they didn’t want anyone to have health care at all — they’re trying to sneak this scam of a bill they cooked up in without an analysis from the bipartisan Congressional Budget Office.
They don’t even want you to see it. They’re having one hearing. I read the hearing’s being held in the Homeland Security Committee, which has nothing to do with health care. And the chairman agreed to allow two witnesses, Bill Cassidy and Lindsey Graham, to speak.
So, listen, health care is complicated. It’s boring. I don’t want to talk about it. The details are confusing, and that’s what these guys are relying on. They’re counting on you to be so overwhelmed with all the information you just trust them to take care of you, but they’re not taking care of you. They’re taking care of the people who give them money, like insurance companies. And we’re all just looking at our Instagram accounts and liking things while they’re voting on whether people can afford to keep their children alive or not.
Most of the congresspeople who vote on this bill probably won’t even read it. And they want us to do the same thing, they want us to treat it like an iTunes service agreement. And this guy, Bill Cassidy, just lied right to my face.
(Clip of Kimmel and Cassidy’s interview from May — Kimmel: “Do you believe every American regardless of income should be able to get regular checkups, maternity care, etc., all of those things, that people who have health care get and need?” Cassidy: “Yep.”)
So “yep” is Washington for “nope,” I guess. And I never imagined I would get involved in something like this, this is not my area of expertise. My area of expertise is eating pizza, and that’s really about it. But we can’t let them do this to our children, and our senior citizens, and our veterans, or to any of us.
And by the way, before you post a nasty Facebook message saying I’m politicizing my son’s health problems, I want you to know: I am politicizing my son’s health problems because I have to. My family has health insurance, we don’t have to worry about this. But other people do, so you can shove your disgusting comments where your doctor won’t be giving you a prostate exam once they take your health-care benefits away.
Kimmel went on to list the myriad health organizations that oppose this “bad bill,” and urged viewers to call their members of Congress and let them know that “this bill doesn’t pass your test.” And he delivered one final message to Cassidy:
https://www.washingtonpost.com/news/arts-and-entertainment/wp/2017/09/19/jimmy-kimmel-gets-heated-about-health-care-bill-says-bill-cassidy-lied-right-to-my-face/?Sen. Cassidy, you were on my show, you seem like you’re a decent guy. But here’s the thing: Nobody outside of your buddies in Congress wants this bill. Only 12 percent of American supported the last one, and this one is worse. Right now, there’s a bipartisan group of senators working to improve the health-care system we have. We want quality, affordable health care. Dozens of other countries figured it out.So instead of jamming this horrible bill down our throats, go pitch in and be a part of that, I’m sure they could use a guy with your medical background. And if not? Stop using my name. Okay? Cause I don’t want my name on it. There’s a new Jimmy Kimmel test for you, it’s called the lie detector test. You’re welcome to stop by the studio and take it anytime.
Health care revolution within reach (minus the revolution part)
by David Farmer - Bangor Daily News - September 20, 2017
Maine is so close.
Despite the best efforts of Gov. Paul LePage, his Department of Health and Human Services and his acolytes in the Maine House of Representatives, a major achievement is within reach.
While all political eyes last week were focused on the rollout of Medicare for All by Sen. Bernie Sanders, there was other health care news.
According to the US Census Bureau, Maine’s uninsured rate is stuck stubbornly at about 8 percent. That means 106,000 people in Maine lack health insurance.
It’s a number that’s way too high.
The number of people without insurance has dropped across the country since the implementation of the Affordable Care Act, and it’s dropped faster and farther in the 31 states that have expanded Medicaid. The uninsured rate in states that have expanded is down to 6.5 percent, compared to 11.7 percent for states that didn’t expand.
This November, Question 2 will ask Mainer voters if they want to expand Medicaid to cover 70,000 people in the state. I’m working on that campaign and am a longtime supporter of Medicaid expansion.
If the Census estimates are correct, Question 2 could bring Maine within 36,000 people of a major health care accomplishment: universal coverage.
Universal coverage is often conflated with the idea of a single-payer health care system, such as Medicare for All. But the two things aren’t the same.
Universal coverage is the goal of making sure that everyone has access to affordable health care coverage. Single-payer is one way that the health care system can be structured to achieve universal coverage.
With new leadership in Augusta just a year away, Medicaid expansion puts us within striking distance of universal coverage and would position Maine to innovate around health care coverage to achieve the goal.
No doubt that the remaining 36,000 people without health insurance coverage are some of the most challenging people to reach, and there are real problems with some elements of the Affordable Care Act, which have kept insurance premiums too expensive for some families.
Medicare for All or other single-payer options are a worthwhile goal, particularly on the national level. So far, they have been impractical on the state level. Both Vermontand California have tried, without much success so far.
The biggest hurdle to overcome for the single-payer is real. In addition to reordering about one-sixth of the country’s economy and overcoming the initial sticker shockfor the cost, more than 155 million Americans under the age of 65 receive their health care coverage through their employer.
Medicare for All would upend that system. For those families, Medicare for All would require a huge leap of faith.
In addition, the change in health care delivery would have real consequences. While jobs would surely be created inside the Medicare program, Medicare for All would be extremely disruptive for private insurance companies.
That’s not a reason to oppose the idea, but any serious discussion of this type of single-payer reform has to account for the thousands of jobs that would be lost or re-ordered.
Maine has seen this before with the downsizing of our forest products industry. While there are real frustrations with the insurance industry and the way it makes its profits, there’s no question that there are real people – our friends and neighbors – who work for those companies and who would face an uncertain employment future.
Medicare for All makes sense, particularly if you were able to go back in time and remake our health care system from scratch. But supporters of the idea should not underestimate the legitimate concerns of the switch, and the real fears it will create for millions of Americans.
In the meantime, we shouldn’t forestall real progress. (And we should continue to oppose the efforts in Washington to undermine the Affordable Care Act and take insurance away from millions of people.)
We have the chance to lower the uninsured rate to less than 3 percent in Maine. And with a new administration in Augusta determined to improve health care coverage instead of stand in its way, we could work on solutions to close that gap and make coverage more affordable for people who buy coverage on the private market.
Voters last year showed an appetite for big, bold ideas. Medicare for All certainly fits that bill.
But we have a real chance to make progress right now – to make our health care system more fair and our economy stronger – and to put universal coverage at the tip of our fingers.
Big and bold may be beautiful. But I have a soft spot in my heart for raging incrementalism – and universal coverage.
Groups that guide Mainers to ACA insurance plans avoid drastic cutbacks
by Joe Lawlor - Portland Press Herald - September 19, 2017
Maine’s health insurance navigator organizations, which help people sign up for health care under the Affordable Care Act, have avoided the drastic cutbacks seen in other states for ACA outreach, and one group is even seeing an increase in funding.
Navigators connect with people most likely to need ACA insurance, also known as Obamacare, such as self-employed and part-time workers. They help people understand how insurance works, qualify for subsidies and make their choices among the maze of plans available for purchase.
Western Maine Community Action, which operates most of the navigator programs in Maine, is seeing its federal grant reduced from $521,000 per year to $452,000. The Maine Lobstermen’s Association, with a goal of signing up self-employed workers in the fishing industry, will get a boost in funding, from $79,000 to $100,000.
Ashley McCarthy, Western Maine’s navigator, said the nonprofit is relieved to receive about 86 percent of the funding that it was awarded in 2016. Agencies were bracing for a 40 percent reduction, and in some states, the cutbacks were even more drastic.
The Trump administration has also slashed its ACA advertising budget by 90 percent, from $100 million to $10 million.
“It’s not as bad as what we feared it would be,” said McCarthy, who found out the size of the funding cuts last week. “We’re still able to fund navigator programs. We’re just chugging along and trying to help as many people as we can.”
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Western Maine funds 10 nonprofit agencies across the state, including Opportunity Alliance in Cumberland County, York County Community Action Agency and Midcoast Maine Community Action. McCarthy said it’s up to the agencies to determine how best to use the money for ACA outreach with a mix of full-time and part-time employees and volunteers helping people sign up for ACA insurance.
About 80,000 Mainers have health plans through the ACA, and most receive a subsidy to help them purchase insurance. About 20 million Americans have ACA insurance, either through Medicaid expansion or by purchasing individual plans in the health insurance marketplace. Western Maine’s navigators helped more than 2,000 sign up for ACA insurance last year.
The Centers for Medicare and Medicaid Services based its award on how closely navigators met enrollment goals in 2016.
“Navigator grantees will receive funding based on their ability to meet their enrollment goals during the previous year. For example, a grantee that achieved 100 percent of its enrollment goal for plan year 2017 will receive the same level of funding as last year, while a grantee that enrolled only 70 percent of its enrollment goal would receive 70 percent of its previous year funding level, a reduction of 30 percent. The new funding formula will ensure accountability within the navigator program,” according to a CMS news release.
The formula has triggered severe cutbacks in some states, with some navigators losing 50 to 90 percent of federal funding, including programs in Michigan, Nebraska, South Carolina, Georgia and Ohio, according to The Washington Post.
Nationally, the cuts were 40 percent, going from $63 million to $36 million. The Trump administration has argued that many of the navigators were not effective in signing up people, so that’s why it based grants on how close navigators came to reaching their 2016 enrollment goals. Critics have argued that the Trump administration is attempting to sabotage the ACA because President Trump wants to see the ACA repealed.
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A last-ditch Republican effort to repeal and replace Obamacare that health analysts say would result in millions of people without health insurance is still pending in Congress.
While the law is still in place, open enrollment will last from Nov. 1 to Dec. 15, a shorter period than the first four years.
The Maine Lobstermen’s Association exceeded its goal of 260 sign-ups by enrolling 312 in 2016, according to the association, which is why it received extra funding.
“The MLA has an excellent track record in providing lobstermen and others throughout Maine in learning more about their health insurance options and assisting them in getting enrolled in ACA plans,” said MLA executive director Patrice McCarron in an email response to questions. “Our operations will not be impacted and we look forward to continuing to provide health insurance assistance to Maine lobstermen and our coastal communities.”
Also, the Maine Health Access Foundation, in response to the uncertainty in the future of the ACA, decided to spend $200,000 on “outreach and marketing” this year to help boost enrollment, after initially deciding to end its outreach efforts. The foundation had launched the enroll207.com website as a way to help people sign up.
“This will primarily be focused on social media, as well as likely on some transit advertising and radio, as well as bringing back the enroll207 website,” said Barbara Leonard, the foundation’s president and CEO.
Steve Butterfield, public policy director for Consumers for Affordable Health Care, a Maine-based health advocacy group, said even though Maine’s navigators will be OK this year for funding, the overall message of the Trump administration and the truncated enrollment period will curtail sign-ups.
“People think it’s closing down, and by the time they hear that it’s not, it may be too late to sign up,” Butterfield said. “We used to get a lot of enrollments in January, after the holiday season.”
Sen. Collins teams up with Florida Democrat on bill to shore up ACA
by Joe Lawlor - Portland Press Herald - September 19, 2017
Even as the Senate is yet again considering a bill to repeal the Affordable Care Act, Maine Sen. Susan Collins is teaming up with a Florida Democrat in a potential across-the-aisle compromise that aims to shore up the existing ACA insurance markets.
Collins and Sen. Bill Nelson, D-Florida, introduced the Reinsurance Act of 2017 on Tuesday in an attempt to stabilize the health insurance marketplace. Reinsurance are programs designed to reduce risk for insurance companies by providing funds to insurers for high-risk enrollees. When they work, reinsurance programs help keep premiums in check. The bill would provide $2.25 billion per year in federal funding for state-run reinsurance programs.
Collins held out the olive branch in a Senate floor speech Tuesday, beseeching her colleagues for a bipartisan compromise. Her speech came at the same time Republican leadership is heading toward a potential vote to repeal the ACA. Collins was one of three Republican senators to buck the party and vote “no” in a dramatic late night vote on July 27 that seemingly sank efforts to repeal the ACA. Collins, known as a moderate, is one of the few Republicans touting fixes to the health care law as opposed to repealing it.
“I personally remain ever hopeful that a bipartisan agreement on a targeted consensus approach to stabilizing the markets and reducing premiums can still be reached,” Collins said in the floor speech.
Collins has been lobbying for a bipartisan compromise on health care since January. Early this month, the Senate’s Health, Education, Labor and Pensions committee, of which Collins is a member, held hearings on how to fix the ACA, and reinsurance was a solution that Republicans and Democrats agreed on.
“Insurance commissioners from Alaska, Pennsylvania, South Carolina, Tennessee, and Washington state all spoke positively of its benefits as did the five governors who testified before the committee, three Republicans and two Democrats,” Collins said. “They were in broad agreement that reinsurance funding would help to stabilize the markets and lower premiums.”
Collins, while not yet taking an official position on the latest repeal effort, Graham-Cassidy, has expressed strong reservations, and many political experts are counting her in the “no” column.
Appearing on CNN Tuesday, Collins said Graham-Cassidy contains “many of the same flaws of the bill we rejected previously and in fact, it has some additional flaws.”
Collins has said that previous Republican bills to repeal the ACA would have been a “disaster” for the United States.
Graham-Cassidy would remove all subsidies to help moderate and low-income people afford insurance, slash Medicaid, undermine protections for pre-existing conditions and eliminate funding for Planned Parenthood. There would be 32 million fewer Americans with insurance, according to a Washington think tank, the Center on Budget and Policy Priorities.
“I am very concerned by projections cited by the Maine Hospital Association, which show that the bill would cut Medicaid and other federal health care spending in Maine by more than $1 billion in the next 10 years,” Collins said Monday in a statement about Graham-Cassidy,
Collins said that while the Senate is “deeply divided on what to do on health care policy,” politicians should be able to “come together” on a solution to fix the ACA.
The Sickness of American Healthcare
Media fixation on small fraction of patients distorts system's real problems
Mike Casey and John Canham Clyne - FAIR - September 8, 2017
The recent collapse of Republican efforts to repeal and replace the Affordable Care Act demonstrated that the GOP’s tireless obsessions—free market platitudes and tax cuts for the wealthy—contribute absolutely nothing to fixing the American healthcare system.
Unfortunately, that was the only thing made clear by media coverage of the healthcare debate.
Looking back, we are struck by the degree to which the media’s fixation on a narrative that mocks a small slice of American voters—pro-Trump voters who had new ACA coverage—deflected attention from the frustration of millions of American workers who have struggled with healthcare problems the ACA either failed to address or exacerbated.
The truth is our healthcare system is sick, and the Affordable Care Act has been little more than a bandage on a compound fracture. The ACA cut the rate of the uninsured to an all-time low, and limited the health insurance industry’s most outrageous consumer abuses, both important steps forward. At the same time, 29 million people remain uninsured, most of the non-elderly population who have employer-paid coverage are increasingly underinsured, and costs continue to soar at 200–400 percent of inflation.
Instead of taking a serious look at the flaws in the ACA, and the deep impact they have on the lives of working-class Americans, reporters covering the healthcare repeal saga spent untold hours and column inches seeking out a tiny slice of the electorate for “reporting” that amounted to little more than mockery. Less than 2 percent of the American people both got new coverage under the ACA and voted for Donald Trump. Yet major media outlets obsessively sought out this sliver of the electorate, to ask, in the words of the Atlantic’s Olga Khazan (2/23/17),
a question that’s baffled health reporters in the months since the election: Why would people who benefit from Obamacare in general—and its Medicaid expansion specifically—vote for a man who vowed to destroy it?
Vox’s Sarah Kliff found these voters in Kentucky, more than once. Abby Goodnough and Reed Abelson did too in North Carolina for a front-page Sunday feature in theNew York Times (3/7/17). Jessica Contrera found them in West Virginia for the Washington Post (3/11/17). The LA Times’ Noam Levy (2/24/17) found them in Florida. The Kaiser Family Foundation held monthly focus groups with them in Pennsylvania, Ohio and Michigan, allowing KFF president Drew Altman to opine on the Times’ op-ed page (1/5/17). Like Kliff, ABC (2/27/17) found them in Kentucky, and CNN’s Dr. Sanjay Gupta (1/6/17) went to Florida. Reporting stimulated comment from the Post’s Dana Milbank (12/20/16) to the Times’ Paul Krugman (3/14/17) to influential liberal sites like Daily Kos (1/28/17), Salon (12/15/16) and Digby’s Hullabaloo (3/13/17).
Khazan’s “baffling” question has a simple answer. Trump did not promise to “destroy” Obamacare, he promised to give people better health plans (a promise broken, obviously). Many people can’t afford ACA exchange coverage, made clear in the Kaiser focus groups:
They spoke anxiously about rising premiums, deductibles, co-pays and drug costs. They were especially upset by surprise bills for services they believed were covered. They said their coverage was hopelessly complex. Those with marketplace insurance—for which they were eligible for subsidies—saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it. They expressed animosity for drug and insurance companies, and sounded as much like Bernie Sanders supporters as Trump voters.
The most damaging effect of singling out this minuscule fraction of the electorate and questioning their motives was the license it gave media to ignore the realities faced by the rest of American working families and to distort the politics of the Affordable Care Act.
Here’s who the media failed to cover: the 177 million Americans who get their insurance through job-based coverage. They are Clinton voters, Sanders voters, Johnson voters, Stein voters and, yes, Trump voters. Media generally overlook the crushing impact the ACA has had on their health insurance. To the extent people with employer-provided insurance are interviewed on healthcare, they are often wrapped in the wrong frame—that their concerns about the ACA are irrational, because the ACA didn’t impact people who were already covered.
This is just a little of what has actually happened across political, racial, economic and gender divisions to the millions of Americans with employer-sponsored health insurance since the ACA was implemented in 2010:
- The ACA imposed an excise tax on their benefits, the simple threat of which caused 73 percent of employers to cut benefits, raise out-of-pocket costs or make plans to do so.
- Their premiums went up more than 3 times faster than inflation. (See sidebar.)
- Their deductibles increased 89 percent, while their compensation went up just 14 percent.
- When they can afford to get care, they see a stranger: 15 percent of Americans lost access to one of their doctors because their insurance network changed in just the last year.
- Even though the US has the lowest rate of un-insurance in our lifetimes, 31 percent of Americans told Gallup they either skipped or delayed necessary medical care last year because of costs, the majority for serious conditions.
- The Census Bureau reports that 11.2 million Americans live in poverty due to out-of-pocket medical expenses.
In short, the majority of Americans who get their insurance through work are facing an escalating crisis of underinsurance, brewing under the ACA and not addressed in the GOP’s proposed replacements. With more than a third of workers carrying deductibles of $1,000 or more, and 20 percent now in plans linked to Health Savings Accounts, few Americans’ benefits look much like 2010.
Shifting costs to patients
The deepest flaws in the ACA are the fruition of President Obama and congressional Democrats creating a law that counted on controlling costs by forcing employers to make American workers pay more so they would use less healthcare, instead of having millionaires pay their fair share. In particular, the misleadingly named “Cadillac Tax” is putting enormous pressure on workers’ out-of-pocket costs, based on the false notion that Americans use too much healthcare and that giving employers and workers more “skin in the game” will shrink overall costs—as if shifting costs to the least-powerful players in the system weren’t a recipe for boostingrather than curbing healthcare inflation.
In reality, we already pay more out of pocket than almost anyone else, but go to the hospital and see the doctor less often than the average for wealthy nations. American costs aren’t out of control because we use too much healthcare, they’re out of control because our healthcare system allows corporations to charge too much:
- Hospitals have been on a 20-year merger spree. Now they’re buying up doctors’ practices and charging monopoly prices for both hospital and physician care.
- Drug companies are gaming patent law and charging monopoly prices, refusing to reveal any justification for their larcenous prices.
- Insurance companies are passing provider and drug prices to their ratepayers and skimming billions of dollars off the top of an ever-growing pie.
These trends are covered, but only episodically compared to the avalanche of coverage of the ACA marketplaces and Medicaid expansion. The New York Times(12/15/15) and others covered a groundbreaking study of 3 billion insurance claims that showed that hospital market power and prices, not utilization, are the primary drivers of private-sector costs. Steven Brill (Time, 3/4/13) has relentlessly exposed extreme hospital prices, and pharmaceutical price-gouging is a national story (e.g., New York Times, 4/26/16). But overall, the media allows Washington politicians to frame the “reform” debate as a false choice between a status quo and Republican reaction—in other words, between a system that punishes working-class Americans and even more punitive proposals.
There are plenty of policy tools to combat healthcare corporate monopolies—from Nevada’s first-in-the-nation law curbing Big Pharma’s price-gouging on insulin, to Maryland’s successful hospital rate-setting system, to Hawaii’s employer mandate—or, of course, creating a universal Medicare-for-All (“single-payer”) system. However, all of these require politicians to put working-class Americans before Pharma, hospital and insurance industry profits. Unfortunately, few in Washington, DC, have a taste for any change that isn’t paid for by poor and middle-class families, and corporate media allow politicians to get away with it.
Republicans’ simplistic market nostrums and fixation on tax cuts for millionaires have already run smack into the brick wall of reality. The Democrats’ turn is coming. Standing back and watching GOP infighting may be satisfying, but until Democrats acknowledge the direct harm that their healthcare reforms have inflicted on American families, and the even greater harm that failing to include any restraint on the industry in the original bill has caused, Democrats will continue to suffer apparently mystifying failures at the ballot box.
The media’s myopic focus on a tiny slice of Trump voters, singled out for mockery and disdain, has enabled Democrats’ denial of the true practical and political consequences of a flawed law under whose purview the family fortunes of the majority of Americans have continued to decline.
Mike Casey is chair of the Healthcare Initiatives Task Force of UNITE HERE, a union of 270,000 North American hospitality workers. John Canham-Clyne is deputy director of research for UNITE HERE.
Seven doctors resign from small Maine hospital
by Patty Wight - Maine Public - September 20, 2017
Seven physicians — including four in the emergency department — are resigning from Maine Coast Memorial Hospital in Ellsworth.
Hospital officials say the departures are due to changes the hospital is making to improve quality. But other physicians who have left in recent years say the turnover stems from the administration’s increasingly caustic relationship with providers.
Speaking on condition of anonymity, one hospital physician said that doctors who are leaving are reluctant to be interviewed for fear that hospital administration will retaliate as they seek other jobs. But one doctor who resigned from the hospital two years ago agreed to go on the record.
“Until about five years ago, I would have told anybody that this was the place to go, the place to work, the place to be a patient,” said Craig Williamson, an orthopedic surgeon who resigned from Maine Coast Memorial in 2015 after being on staff for eight years.
Williamson said a change in administration a few years ago ushered in a new culture that affected the relationship with staff.
“The medical staff has not felt for a long time that the administration has any respect for the medical staff or the nursing staff,” he said.
Williamson said the dysfunctional dynamic has effectively forced many medical staff out. By his count, 30 have left the hospital over the past five years. He said some positions haven’t been filled, leaving the hospital understaffed.
But the president of Maine Coast Memorial, John Ronan, who has been leading the hospital for about a year, said the turnover among the hospital’s 55 providers is typical of hospitals.
“I attribute a lot of it to change and a different way of looking at how we provide services here,” he said.
Maine Coast Memorial was acquired by Eastern Maine Healthcare Systems in 2015. Since then, Ronan said, the hospital has made changes to improve quality, such as establishing a collaborative that allows doctors within the system to fill shifts at various emergency departments depending on need.
Some doctors, he said, may not find these new strategies palatable.
“We want to reassure the community that while there has been some turnover with providers, it’s still great care here and we’re still working through plans to make it better care than it has ever been,” Ronan said.
As health care changes and hospitals face decreasing revenues, Gordon Smith of the Maine Medical Association said the situation at Maine Coast Memorial is playing out at other hospitals.
“When the system is strained, particularly for dollars, it’s going to make it more difficult to have positive relationships with staff,” he said.
But a woman who identified herself as a former patient of Maine Coast Memorial said the changes at the hospital have translated into a poor patient experience. Nadine Lewis of Ellsworth, who contacted Maine Public after seeing news coverage of the recent resignations, says she stopped using the hospital last year.
“At first it was wonderful. I felt the doctors were competent, kind people who were very committed to the community and their patients. And then something happened a few years back, and everything started to change. Doctors started to leave. You were rushed through appointments,” she said.
Lewis says she now travels to Bangor for her health care.
“I’m very afraid and very sad, because this community had a really strong medical team here, and now I don’t know what’s going to happen,” she said.
The leader of the board at Maine Coast Memorial, meanwhile, is expressing confidence in hospital leadership. In a written statement, Debra Ehrlenbach says the plans that have been developed in partnership with EMHS will “position us for long-term success in a changing health care world.”
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