Maine Voters Approve Medicaid Expansion, a Rebuke of Gov. LePage
by Abby Goodnough - NYT - November 7, 2017
Voters in Maine approved a ballot measure on Tuesday to allow many more low-income residents to qualify for Medicaid coverage under the Affordable Care Act, The Associated Press said. The vote was a rebuke of Gov. Paul LePage, a Republican who has repeatedly vetoed legislation to expand Medicaid.
At least 80,000 additional Maine residents will become eligible for Medicaid as a result of the referendum. Maine will be the 32nd state to expand the program under the health law, but the first where voters, not governors or legislators, decided the issue. Other states whose leaders have resisted expanding the program were closely watching the campaign, particularly Utah and Idaho, where newly formed committees are working to get Medicaid expansion on next year’s ballots.
Supporters, including advocacy groups that collected enough signatures to get the question on the ballot, said the measure would help financially fragile rural hospitals, create jobs and provide care for vulnerable people who have long gone without.
Mr. LePage and other opponents, including several Republicans in the state Legislature, said Medicaid expansion would burden the taxpayers and the state budget, and described it as a form of welfare.
“The truth is that Medicaid expansion will just give able-bodied adults free health care,” Mr. LePage said in a recent radio address. “We don’t mind helping people get health care, but it should not be free. ‘Free’ is very expensive to somebody.”
The pro-expansion side may have benefited from energized public support for government health programs in a year when President Trump and Republicans in Congress tried repeatedly to repeal the Affordable Care Act and cut spending on Medicaid, which covers one in five Americans. Senator Susan Collins of Maine, one of the few Republicans who firmly opposed the repeal efforts, has been an outspoken defender of Medicaid, although she did not take a position on the ballot question.
The health law gives states the option of allowing any citizen with income up to 138 percent of the poverty level — $16,642 for an individual, $24,600 for a family of four — to qualify for Medicaid, which states and the federal government both pitch in to pay for.
Under the Affordable Care Act, the federal government picked up the cost of new enrollees under Medicaid expansion for the first three years and will continue to pay at least 90 percent. States cover a significantly larger portion of the expenses for the rest of their Medicaid population.
Maine’s Legislature, which is controlled by Democrats in the House and Republicans, by one vote, in the Senate, could try to block the referendum, but since it voted for Medicaid expansion five times already, supporters and opponents alike believe it is unlikely to meddle. And the governor has no authority to veto the outcome, although he could may try to delay putting it in place during his remaining year in office. And if Congress eventually succeeds in repealing the Affordable Care Act, states with expanded Medicaid will likely have to scale back their programs.
Maine voters approve measure to expand Medicaid
by Patrick Whittle - AP/ PBS - November 8, 2017
PORTLAND, Maine — Maine voters on Tuesday approved a measure allowing them to join 31 other states in expanding Medicaid under the Affordable Care Act, the signature health bill of former President Barack Obama.
The referendum represented the first time since the law took effect that the question of expansion had been put in front of U.S. voters.
Some 11 million people in the country have gotten coverage through the expansion of Medicaid, a health insurance program for low income people.
The vote in Maine was a rebuke of Republican Gov. Paul LePage, who vetoed five different attempts by the state Legislature to expand the program. It follows repeated failures by President Donald Trump and his fellow Republicans in Congress to repeal Obama’s law.
“This is an exciting night in Maine, but also an exciting night for the country,” said David Farmer, spokesman for pro-expansion Mainers For Health Care. “Voters have made it clear they want more health care, not less.”
For supporters and opponents of “Obamacare,” Maine’s question took on the form of a referendum on one of the most important pieces of the Affordable Care Act. And it was taking place in a politically charged atmosphere with GOP efforts to undermine, or repeal, the health overhaul.
Here in the nation’s Northeast corner, the issue was personal to many in a rural state that has the nation’s oldest population and the region’s lowest wages.
Passage of the proposal would mean an estimated 70,000 people in Maine would gain health coverage. About 268,000 people currently receive Medicaid in the state.
Maine’s governor blamed an earlier Medicaid expansion for increasing state hospital debt, and he opposes giving able-bodied people more access to Medicaid.
LePage often summarizes his argument by saying: “Free is expensive to somebody.” He also warned that he would have to divert $54 million from other programs — for the elderly, disabled and children — to pay for the state’s share of the expansion once it’s fully implemented.
LePage’s office didn’t immediately respond to a request for comment.
Mainers For Health Care touted the proposal as a “common sense move” to ensure health care coverage for more people. Maine’s hospitals also supported the Medicaid expansion and say charity care costs them over $100 million annually.
The initiative’s supporters have reported spending about $2 million on their campaign, with hundreds of thousands of dollars coming from out-of-state groups. By comparison, the lead political action committee established to oppose the measure has spent a bit less than $300,000.
This may not be the last state vote.
Backers of Medicaid expansion in Idaho and Utah have started similar efforts to get the question on the 2018 ballots in their own states. If it passes in Maine, some 70,000 people would gain health coverage.
Maine just resoundingly became the first state to expand Medicaid by ballot initiative
by Amber Phillips - The Washington Post - November 8, 2017
Less than two months after Republicans' latest effort to repeal the Affordable Care Act imploded, a purple state just made a decidedly blue-state move to essentially expand Obamacare.
On Tuesday, Maine became the first state to expand Medicaid with a ballot initiative. And it passed overwhelmingly: Maine voters agreed to grant health care to an estimated 70,000 low-income residents by a nearly 20-percentage point margin by the time the measure was called by election watchers. In other words, a sizable number of voters in Maine just voted to do the exact opposite of what the state's Republican governor and Republicans in Washington have been trying to do.
Maine Gov. Paul LePage vetoed a bipartisan legislative deal to expand Medicaid under the Affordable Care Act at least five times. Since Republicans took control of Washington in January, they've spent more than half the year trying to repeal Obamacare with proposals that would have drastically cut Medicaid. But Maine's Sen. Susan Collins (R) was one of the defining “no” votes that ultimately ended the GOP efforts, saying the plans would pull the rug out from too many in her state.
What happened in Maine could provide momentum for progressives to get voters in other states to expand Medicaid, such as Alaska and Idaho, where groups have already started similar Medicaid expansion ballot initiatives next year.
“This will send a clear signal to where the rest of the country is on health care,” said Jonathan Schleifer, executive director of the Fairness Project, which helped put together the ballot initiative. As Republicans have tried to roll back Obamacare, public support for an active government role in health care has spiked.
Schleifer said his group has spent the past year in Maine — and some $2 million — laying the groundwork for this. After Trump won the election and Republicans held on to Congress, they went to their tried-and-true method of ballot initiatives to try to fight back.
“Looking at what progressives were able to accomplish by ballot initiatives in 2016, we asked ourselves what do we do for biggest challenge out there, which is the threat to Affordable Care Act,” Schleifer said. “We asked ourselves: What can we do to not just hold the line but to advance things?”
Schleifer is right. The left has had spectacular success over the past four years going around Republican legislatures to change state policy on everything from guns and minimum wage with ballot initiatives. In fact, when put to the voters over the past 20 years, minimum wage increases have rarely lost.
Last November was no different. Voters in four out of four states resoundingly approved minimum wage hikes in 2016. (The last time Congress approved a minimum wage hike, George W. Bush was president.) In Arizona, the vote for a high minimum wage outperformed Trump by 10 percentage points. Voters in eight of nine states also voted to ease restrictions on marijuana, and three of four states voted to put in place gun restrictions.
Ballot initiatives are an important tool for progressives in the Trump era, just like how conservatives used them in the '90s when Democrats dominated government. Other national groups descended on Maine to help this pass. Planned Parenthood's Maine political group said they knocked on over 8,600 doors in Portland over the last week of the election.
Not all progressive ballot advocates are as bullish on Maine's ballot initiative to change the health-care landscape.
Kellie Dupree with the Ballot Initiative Strategy Center, which helps progressive groups strategize ballot initiatives, said expanding Medicaid can be a tough sell as it requires taxpayer money.
“We'll wait to see how these policies shape up,” she said.
Most of Democrats' reasons to celebrate this past year has been the absence of legislation. So at the very least, expanding Medicaid in a state like Maine is a notable change of pace for a party largely locked out of power.
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by Margot Sanger-Katz - NYT - November 2, 2017
TORONTO — As he tells it, Senator Bernie Sanders of Vermont fell in love with the Canadian health system 20 years ago when he brought a busload of his constituents across the border to buy cheaper prescription drugs. Now he wants to make Americans fall in love with his proposal to make the United States system a lot more like Canada’s.
That’s one reason he took the equivalent of a busload of staffers, American health care providers and journalists to Toronto last weekend, in a two-day trip that was part immersion, part publicity tour. Canadian government officials and hospital executives showed him high-tech care, compassionate providers and satisfied patients, all as videographers recorded.
He ended the trip with a speech at the University of Toronto titled, “What the U.S. Can Learn From Canadian Health Care.”
But our question is this: What did Bernie Sanders learn from his weekend in Canada?
Lesson 1: He’s a ‘rock star’
Mr. Sanders — after wedging himself into Row 21 and taking extensive notes on a legal pad during the flight — had barely gotten off the plane in Toronto when an airport security guard chased him down the hallway, telling him, “You’re like a hero to me.”
A team of cardiac nurses at Toronto General Hospital asked to take pictures after he toured their unit. At a full 1,600-seat university auditorium on Sunday, he received repeated and sustained standing ovations. College students waited for hours to get into the auditorium and see him speak.
Mr. Sanders, who drew huge crowds as a presidential candidate in the United States last year, learned firsthand that he is also a household name in Toronto. His policy vision, decidedly from the left in the United States, matches mainstream Canadian views.
“You received the welcome here that is normally reserved for celebrity rock stars,” said Greg Marchildon, the director of the North American Observatory on Health Systems and Policies at the University of Toronto.
Ed Broadbent, the chairman of the progressive Broadbent Institute, called Mr. Sanders the most important social democrat in North America — even though Mr. Sanders is not a Canadian social democrat, and is not even a particularly powerful member of the Senate.
Lesson 2: Doctors like the system as much as patients do
Many developed countries have achieved universal health coverage, but Canada is relatively distinct in its insistence that individuals should not have to pay any money at the point of care. When Canadians go to the doctor or hospital, they just show their Canadian “Medicare” card.
At Women’s College Hospital, executives showed Mr. Sanders an empty billing window. The hospital, they told him, has one employee who manages bills. “For the entire hospital?” Mr. Sanders said, in mock disbelief.
Several patients told him about the comfort that comes from not having to pay for their care directly. And doctors, too, said they felt more comfortable recommending their patients get an operation or see a specialist than they might if those treatments weren’t free.
“I didn’t have to fill out any forms; I didn’t have to worry about how I was going to pay for the simple job of staying alive,” said Lilac Chow, a kidney transplant patient at Toronto General Hospital, who had been brought in to share her experience with the senator.
Whenever Mr. Sanders was asked what he learned about the Canadian system, the value of free care came up.
“What I think stuck out to me was from both the patients and the physicians, the importance of not having to worry about money in terms of the doctor-patient relationship,” he said in an interview after his trip on Tuesday.
His Medicare-for-All bill includes free care as a central feature. If the legislation became law, no American would pay directly for a doctor, dentist or hospital visit, and co-payments for prescription drugs would be limited. (Taxpayers would, of course, finance the system.)
Lesson 3: Sometimes, you have to wait
At a round-table discussion at Women’s College Hospital, the chief of surgery noted that Canadian patients can’t always get all the care they want right away. “Wait times, you could argue are a problem for certain procedures,” said Dr. David Urbach, before discussing the ways the province and hospital were working to shorten the lines. Mr. Sanders quickly turned to the glass-half-full interpretation. “What you are arguing — correct me if I’m wrong — is that waiting times are not a problem, and it’s an issue you are dealing with,” he said.
In Canada, where government finances health insurance and the private sector delivers a lot of the care, patients with life-threatening emergencies are treated right away. But patients with cataracts or arthritis often have to wait for operations the Canadian system considers elective. A governmental review of the Ontario system recently found that wait times were getting worse in some cases, like knee replacements.
The Canadian system puts hospitals on a budget and limits the number of specialists it trains, both factors that can lead to lines for complex care that’s not life-threatening. The system also limits access to services, like M.R.I. scans, that are much more abundant south of the border.
On his weekend tour, Mr. Sanders didn’t see the places where patients might wait. Hospital executives instead showed him a refugee primary care clinic, a neonatal intensive care unit and a cardiac surgery unit.
But he points out that many Americans who are uninsured — or who have limited savings and insurance with high deductibles — may wait even longer than Canadians for elective, or even urgent, care.
“If you’re very, very rich, you’ll get the highest-quality care immediately in the United States,” Mr. Sanders said, in the interview. “If you’re working class, if you’re middle class, it is a very, very different story.”
The Commonwealth Fund, a health research group, ranked the United States health system at the bottom of its most recent 11-country rankings, published in July. But Canada did only a little better, at No. 9. Of all the measures in the study, Canada ranked the worst on the “timeliness” of care. (A team of Upshot experts eliminated Canada in the first round in an eight-country virtual bracket tournament of international health system performance.)
Any single-payer system will need to grapple with how much it should spend over all, and where it will save money. Mr. Sanders’s Medicare-for-All bill currently includes few details about how the government would set budgets and allocate resources once all Americans were brought into the government system.
Lesson 4: Even Canada’s system has holes
Mr. Sanders wants to bring big, sweeping change to the American health care system. Unlike the Affordable Care Act, which filled in holes in an existing system, his Medicare-for-All plan would take away the health coverage that most Americans hold now, replacing it with a single, very generous government system. It would do away with the premiums, deductibles and co-payments that individuals and businesses pay for health care, and instead impose large tax increases.
That is not the kind of change that would be politically trivial. In his speech, he noted that the creation of a single-payer system in Canada and Britain followed grass-roots movements, and political landslides by the parties that favored the change. “Real change always happens from the bottom up,” he said, to big applause. “You’ve got to struggle for it. You’ve got to fight for it. You’ve got to take it. And that is the history of all real change in this world.”
Yet even in Canada, he learned, changes to the health care system have been difficult. The Canadian system, with insurance run at the province level, covers doctors and hospitals. But decades after the 1984 Canada Health Act, many Canadians pay for supplemental private insurance through their jobs for prescription drugs, dentistry and optometry — despite a growing recognition that medications are essential to care.
“Any one of us around the table is just a job loss away from having access to prescription medications, and that’s a problem,” said Danielle Martin, a vice president at Women’s College Hospital and policy researcher, who helped organize the trip, at a round-table discussion.
“I’m on my own going to the dentist,” said Naomi Duguid, a patient, sitting across the table. “It’s the only time I get to experience what it must be like to be an uninsured American.”
Ontario has recently started a program that will provide coverage for medications to residents under 25. And there is a patchwork of drug coverage programs for older people, the poor and those who get insurance from work. But even in Canada, it’s tough to find the resources to expand coverage.
“We have to find the money to fund the program up front,” said Kathleen Wynne, the premier of Ontario, who helped establish the youth drug coverage program.
Lesson 5: Canadians seem to value fairness more than Americans do
Equity. Fairness. Throughout the weekend, Mr. Sanders kept asking Canadians what they thought about the higher taxes they’d paid to finance their system. Every one among the patients and doctors selected to meet him said the trade-off was worth it because it made the system fair.
“I think it’s a really fair way to do it,” said Frederick Brownridge, 67, of Etobicoke, Ontario, as he sat by the window in his Toronto General Hospital room, with IV lines in his arms. Mr. Brownridge had had two heart valves repaired and a double bypass three days earlier. “It also means if you’re in a lower economic status or higher economic status, you’ll get the treatment you need.”
On Tuesday, Mr. Sanders said the uniformity of this message really stuck out to him: “There really is, I think, a deep-seated belief in Canada that health care is a right, and whether you’re rich or whether you’re poor or whether you’re middle class, you are entitled to health care.”
In the United States, though, Republicans control the presidency and the Congress, and many candidates last year ran on a promise to roll back government support for health care coverage.
Several recent public opinion surveys show majority support for a government guarantee of health coverage, but support declines substantially when pollsters mention that government coverage would mean higher taxes.
Mr. Sanders said he knows his bill isn’t going to become law anytime soon, but he thinks discussing the idea will help make its underlying values more broadly acceptable.
“When you talk about health care, you’re not just talking about health care,” he said in his Toronto speech. “You’re talking about values, because how a society deals with health care is more than medicine. It’s more than technology. It is about the values that those societies hold dear.”
https://www.nytimes.com/2017/11/02/upshot/bernie-sanders-went-to-canada-and-learned-a-few-things.html
Bernie Sanders, and Health Care
by Ian Austen - NYT - November 4, 2017
When Bernie Sanders made his way to Toronto last weekend, Margot Sanger-Katz, a health policy reporter in The Times’s Washington bureau, tagged along. Her resulting article in The Upshot is both a nicely drawn portrait of Mr. Sanders’ excursion and a thorough comparison of Canada’s health care system with that of the United States. Ms. Sanger had some additional thoughts about the trip for Canada Letter readers:
Bernie Sanders, and Health Care
by Ian Austen - NYT - November 4, 2017
When Bernie Sanders made his way to Toronto last weekend, Margot Sanger-Katz, a health policy reporter in The Times’s Washington bureau, tagged along. Her resulting article in The Upshot is both a nicely drawn portrait of Mr. Sanders’ excursion and a thorough comparison of Canada’s health care system with that of the United States. Ms. Sanger had some additional thoughts about the trip for Canada Letter readers:
| It was probably about the 10th time that a patient or doctor in Canada used the word “fair” that I started to realize how important the value was to Canadians. | ||||||||||||||||
| Mr. Sanders was making what his staff called a “cross-border learning tour,” though it was clear from the start that he already knew quite a lot about the Canadian system, and had found much to like about it. | ||||||||||||||||
| He is pushing hard for the Democratic Party in the United States to embrace the notion of a single-payer health care system like Canada’s. His legislative proposal shares many Canadian particulars — government-financed insurance, no direct payment at the point of care, private doctors and hospitals, global budgets. | ||||||||||||||||
| But Mr. Sanders also clearly admires and envies the values that lie beneath the Canadian system — a commitment to equity and a right to health care that is less commonly heard when Americans talk about what they want from their system. In many ways, he was in Canada to learn about how to achieve that change of heart. | ||||||||||||||||
| At a public event, he was asked how to make this change by Dr. Danielle Martin, a physician, hospital executive and advocate. “The journey is not easy,” Mr. Sanders said. “The journey never has been easy for human rights and human dignity.” | ||||||||||||||||
| Afterward, I asked Dr. Martin whether she thought the sentiment or the policy had come first in Canada. Did Canadians embrace a government health care system because they believed in equity? Or did they come to value equity because they’d been exposed to a health care system that promoted it? Some of both, she said, but “the system itself creates a language.” | ||||||||||||||||
| “We’re not genetically different people here on the other side of the border,” she said. “There is no reason why we would have different values, except there was a movement here.” | ||||||||||||||||
And I have two related questions for you: Is public health care a defining feature of Canada? If so, how is that reflected in the nation? Please email your thoughts to nytcanada@nytimes.com so that I can share some of them with other newsletter readers
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