Editor's Note: Since November 2010, I have been distributing this blog consisting of articles about health care reform from a variety of sources to a growing list of interested parties. I include articles I think are factual, well written and relevant to the contentious national struggle about what our health care system should be like.
The blog has never been and never will be behind a paywall, . My motive for curating and distributing it is simple - the education of readers about a highly politicized, complicated, confusing and emotional topic of great importance to our well-being as individuals and as a society.
I spend between two and four hours most days researching, curating, composing and distributing the blog, and receive no compensation other than the satisfaction that the blog will, in some small way, lead to a more rational, fact-based (not alternative facts) and productive discussion about improving our badly dysfunctional and increasingly expensive health care system.
Much of the rest of my time is devoted to my responsibilities as a founding member of the board of Maine AllCare, a non-profit chapter of Physicians For A National Health Program, devoted to advocacy and public education toward the goal of a universal, publicly funded and politically sustainable health care system for all of the residents of Maine and the United States. We have made significant progress during the past year, and now have ten chapters throughout Maine (with three more being formed), up from three at the beginning of 2017. We have also identified over 25,000 supporters in Maine.
Until this year, we have been sustained by purely volunteer efforts from our board and other active supporters. But we have now reached the point where we are increasingly in need of professional staff, for organizing, developing educational materials (including our new website at www.maineallcare.ogg) and database management.
We are now conducting our year-end fundraising campaign. So, if you find this blog useful and wish to support our efforts that, if partially or wholly successful, will certainly have ramifications nationwide, please consider making a contribution to our efforts.
You can do so online at
Thanks - on behalf of all of us!
And Happy Holidays!
And Happy Holidays!
-SPC
Congress Refuses to Do Right by Children’s Health Care
by The Editorial Board - NYT - December 20, 2017
As Republican lawmakers celebrate the passage of a tax bill that will make the wealthiest Americans richer, many lower-income families are faced with the real possibility that their children will soon lose their health insurance because Congress didn’t care enough to renew funding for it.
The Children’s Health Insurance Program has enjoyed bipartisan support since its creation in 1997. It covers about nine million kids from families who are not affluent by any stretch of the imagination but happen to earn too much to qualify for Medicaid. In the past, the program was typically reauthorized for five years with little controversy. Not this time. Republican leaders in Congress have been unwilling or unable to make CHIP, as the program is known, a priority since funding lapsed nearly three months ago. The situation has gotten so bad that families with young children who benefit from the program visited Capitol Hill this week to beg lawmakers to fund CHIP.
This has forced state governments, which run the program, to scramble. This week, officials in Alabama said they would drop the coverage of 7,000 children and freeze the program to new enrollees on New Year’s Day. That state would have to end its program, which serves 84,000 kids in total, on Feb. 1. Virginia told parents of 68,000 children that its program could end on Jan. 31. Connecticut, Colorado and other states have issued similar warnings. All told, 16 states will run out of CHIP funds by the end of January, and another 21 will run out of money by the end of March, according to the Kaiser Family Foundation.
Republican lawmakers say they will eventually get around to reauthorizing CHIP. First, though, they insist that Democrats must agree to cut other spending to offset some of the cost of the program. For example, they have proposed raising Medicare premiums on affluent retirees and cutting spending on public health programs created by the Affordable Care Act. Democrats have rightly balked at such demands, especially since Republicans just passed a tax bill that will mostly benefit corporations and the wealthiest families in the country while adding more than $1.4 trillion to the federal deficit over the next 10 years. By contrast, CHIP costs just $14 billion a year, or $140 billion or more over a decade.
In dismissing concerns about the program, Senator Orrin Hatch of Utah epitomized the degradation of so much of the Republican Party this year. Mr. Hatch, who helped create this program with Senator Edward Kennedy, said on the floor of the Senate, almost sneering sanctimoniously, “the reason CHIP’s having trouble is because we don’t have money anymore.” Mr. Hatch and his Republican colleagues had no trouble finding boatloads of money to cut taxes on real estate developers, hedge fund managers and corporate chief executives.
This much is clear: Many children stand to lose access to health care if Congress does not act soon. States do not have the wherewithal to bear the full cost of CHIP. While some families who rely on the program might be able to get insurance for their kids through an employer or from the insurance marketplaces created by the A.C.A., many kids will end up losing coverage. CHIP is free or costs much less than private insurance depending on family income and state.
Two Republican lawmakers, Senators Lamar Alexander and Susan Collins, on Wednesday signaled that Congress would not fund CHIP until early next year. Lawmakers are now expected to head out of town after they pass yet another short-term extension of the larger spending bill needed to avoid a government shutdown.
President Trump and his fellow Republicans were desperate to pass a tax bill by Christmas but seem unconcerned about the more urgent and important work of making sure children can get the health care they need. That will be quite a legacy.
Trump just told the truth
by Dana Milbank - The Washington Post - December 20, 2017
On Wednesday, the 335th day of his presidency, Donald J. Trump did something most extraordinary and uncharacteristic. He told the truth.
The president, celebrating his $1.5 trillion tax cut with fellow Republicans at the South Portico of the White House, was midway through his remarks when he veered sharply off message.
“I shouldn’t say this,” Trump said, “but we essentially repealed Obamacare.”
No, he probably shouldn’t have said it. But it’s true. Republicans, in rushing the tax bill to passage, kept fairly quiet about the fact that they were killing the “individual mandate” and thereby removing the engine that made the Affordable Care Act work. In doing so, they threw the health-care system into chaos without offering any remedy. And Trump just claimed paternity of the destruction.
Trump, in a Cabinet meeting earlier Wednesday, let his fleeting encounter with honesty get the better of him when he read aloud the stage directions that called for Republicans not to advertise that they were killing Obamacare. “Obamacare has been repealed in this bill. We didn’t want to bring it up,” he said. “I told people specifically, ‘Be quiet with the fake-news media because I don’t want them talking too much about it.’ Because I didn’t know how people would —.” Trump didn’t finish that thought, but he said he could admit what had been done “now that it’s approved.”
Opinion | The tax bill is the worst domestic policy legislation in a lifetime
Deputy editorial page editor and columnist Ruth Marcus counts the reasons why she thinks the GOP tax bill is awful. (Gillian Brockell, Kate Woodsome/The Washington Post)
With those admissions now on tape, Trump has officially claimed full ownership of the health-care system for himself and fellow Republicans. Whatever it is now — or isn’t — is Trumpcare. Here are some of its features:
●Premiums for the most popular health insurance on the individual market exchanges are estimated to rise 34 percent on average next year, according to the consulting firm Avalere Health, because of previous sabotage done by the Trump administration. Premiums in Iowa would be up 69 percent, Wyoming 65 percent and Utah 64 percent.
●Employer-based health insurance costs are forecast to rise in 2018 by the most since 2011, at 4.3 percent, according to the human resources consulting firm Mercer, and overall medical costs will be up 6.5 percent, the first increase in the rate in three years, according to the consulting firm PwC. Assuming those increases are passed along to workers, they would eat up half of the $910 tax cut received next year by households with income between $55,000 and $93,000 and all of the tax cut received by households earning $27,000 to $54,000.
The more Trump claims to have done away with Obamacare, “the more he owns problems in the health system of his making or not,” says Drew Altman, head of the Kaiser Family Foundation and an authority on health care and public opinion. Altman tells me Trump will “certainly own” responsibility for premium increases on the former Obamacare exchanges and for the up to 13 million who will no longer have coverage under the new tax plan.
The new system also belongs to Republicans such as Sen. Susan Collins (R-Maine), who, in exchange for her vote for the tax bill, was hornswoggled into believing Congress will take action before year end on subsidies to stabilize the former Obamacare exchanges. That has now been put off until next year, and it will meet stiff resistance from Collins’s fellow Republicans.
This will be but one source of division among Republicans now that they have secured the tax cut, which was a rare source of unity within the party — and the main reason many GOP lawmakers who find Trump distasteful have stuck with him until now.
Trump and congressional leaders, walking along the White House driveway Wednesday afternoon to “Hail to the Chief,” applauded GOP lawmakers around the South Portico, and the lawmakers applauded back. But soon they will be fighting about immigration, funding the government, cutting Medicare and attacking special counsel Robert Mueller. The divisions will only worsen if Trump continues to have bouts of unaccustomed honesty, as he did Wednesday.
In addition to his confession about Obamacare, he also acknowledged that “the tax cuts supersede” reform in the tax bill and that “the biggest factor in this plan” is the cut in the corporate tax rate from 35 percent to 21 percent. Republican lawmakers had taken pains to describe their work as tax “reform” and asserted that it was primarily for the middle class, but Trump was correct: The legislation does little to simplify the tax code, and it is primarily a windfall for corporations.
Trump did not trespass long in the land of truth. He also renewed his claim that the tax bill is “the largest tax cut in the history of our country.” It isn’t that, by a long shot. But it is many other things, including a huge shock to the health-care system, with no remedy in sight.
Editor's Note:
Although the following LTE published in the Ellsworth American is not directly related to health care, I think it is relevant to the ongoing effort in Washington to shrink government, including health care programs, so it can be, in the words of anti-government activist Grover Norquist, be "drowned in a bathtub"
-SPC
Herbert Hoover’s “dangers” list is a poor measure of “greatness”
Dear Editor: I am stunned that you quote a speech by Herbert Hoover in support of your views on what is ailing our country.
Let’s look at the items on the list of “dangers” Hoover decried:
• An ever-increasing federal debt. Do you mean the debt incurred by wars in Iraq and Afghanistan that U.S. taxpayers were not asked to pay for? Do you mean the debt caused by the collapse of our financial system due to an SEC that wasn’t paying attention and a chairman of the Federal Reserve Bank who was blinded by his ideological commitment to the worldview of Ayn Rand? Do you mean the debt that Republicans in Congress want to dramatically and irresponsibly increase with passage of their tax bill?
• Expanding government oversight and overregulation of commerce and individuals. Do you mean the government oversight that ended Jim Crow in the South? That gave us the Clean Air Act and other environmental and occupational protections? Was Enron overregulated? Wells Fargo? Is our price-gouging pharmaceutical industry overregulated? Are firearms overregulated?
• The growth of dependency on government support. I assume you mean agricultural subsidies and the numerous tax breaks given to large corporations. I assume you don’t mean the support given to people who have been downsized or have seen their jobs go overseas or their pensions taken away or simply can’t find a job due to lack of public transportation or affordable child care or decent public education. Or maybe you mean the appalling growth in America’s government-dependent prison population due to our broken criminal justice system.
• Increasing federal taxes and the impact on all citizens’ savings and income. The conundrum here is that these so-called “increasing” federal taxes have not prevented the frightening growth of our national debt that you point out every week on your front page. Perhaps we haven’t been taxed enough. Or perhaps we’ve made it too easy for people to avoid paying taxes.
• Government overpromising services and benefits. Do you mean the promise that Iraq would become a democracy instantaneously after we liberated it from Saddam Hussein? Do you mean the promise of trickle-down economics, a promise that will never be kept but will never die? Or maybe you mean Herbert Hoover’s promise of “a chicken in every pot.” Or maybe you just mean the impossible-to-fulfill promise made by our current President to “make America great again.” Great how? Great when? I wish I knew what is meant by this promise.
You seem to think that America was great when Herbert Hoover was our president. I guess we can only hope that we don’t achieve similar “greatness” under our current regime.
Michael Fisher
Sullivan, ME
Editor's Note: Yesterday the Maine Legislature's newly appointed Taskforce on Health System Reform" met for the first time. The link below is a local news segment about the Task Force and the meeting. Maine AllCare was instrumental in getting the legislation mandating the task force formed, and in generating private donations to fund it.
Deja-Vu all over again!!
-SPC
Obamacare Sign-ups at High Levels Despite Trump Saying It’s ‘Imploding’
by Robert Pear - NYT - December 21, 2017
WASHINGTON — The Trump administration said Thursday that 8.8 million people had signed up for health insurance through the Affordable Care Act’s federal marketplace, a surprisingly large number only slightly lower than the total in the last open enrollment period, which was twice as long and heavily advertised.
The numbers essentially defied President Trump’s assertion that “Obamacare is imploding.” They suggested that consumers want and need the coverage and subsidies available under the Affordable Care Act, even though political battles over the law, President Barack Obama’s signature domestic achievement, are sure to continue in Congress and in next year’s midterm election campaigns.
Seema Verma, the administrator of the federal Centers for Medicare and Medicaid Services, reported the total in a Twitter post on Thursday. She said her agency had done a great job to “make this the smoothest experience for consumers to date.”
The number of people who signed up this year was 96 percent of the 9.2 million who selected health plans or were automatically re-enrolled through the federal marketplace in the last sign-up season.
“It’s a very, very strong number,” said Joshua Peck, who was the chief marketing officer for HealthCare.gov in the Obama administration. “It implies that the final week of open enrollment this year was very big.”
Republican efforts to dismantle the Affordable Care Act this year had an unintended effect: They heightened public awareness of the law and, according to opinion polls, galvanized support for it among consumers who feared that it might be taken away.
“It’s incredible how many people signed up for coverage this year,” said Lori Lodes, an Obama administration official and a founder of Get America Covered, a nonprofit group.
But the strong demand for insurance through the Affordable Care Act could set off new efforts to dismantle the law.
The tax cut that Mr. Trump will soon sign repeals the Affordable Care Act’s tax penalties for most Americans who go without insurance, starting in 2019. The president said Wednesday that with elimination of the individual mandate, the health law is being effectively repealed, a statement that is untrue given the law’s expansion of Medicaid, the continued guarantee of coverage for people with pre-existing conditions and the subsidies still available to millions of people with low or moderate income.
And some Republicans signaled they have not given up. “By eliminating the individual mandate in the tax bill,” Senator Lindsey Graham, Republican of South Carolina, said Thursday on Twitter, “we have pulled one of the pillars of Obamacare out. But by no means has Obamacare been repealed or replaced.”
Mr. Graham said that Republican leaders were “sadly mistaken” if they thought there would not be another effort to repeal and replace Obamacare in 2018.
But his leadership might not be with him, especially in an election year when the Republicans are facing a stiff headwind.
guarantee of coverage for people with pre-existing conditions and the subsidies still available to millions of people with low or moderate income.
And some Republicans signaled they have not given up. “By eliminating the individual mandate in the tax bill,” Senator Lindsey Graham, Republican of South Carolina, said Thursday on Twitter, “we have pulled one of the pillars of Obamacare out. But by no means has Obamacare been repealed or replaced.”
Mr. Graham said that Republican leaders were “sadly mistaken” if they thought there would not be another effort to repeal and replace Obamacare in 2018.
But his leadership might not be with him, especially in an election year when the Republicans are facing a stiff headwind.
Healthcare.gov Enrollment
This year’s enrollment in Affordable Care Act marketplaces was not far below last year, even as the Trump administration cut the advertising budget and shortened the sign-up period.
Last year
9.2 million
This year
8.8 million
This year’s signup period was only 45 days. Last year’s was about twice as long.
“I think we’ll probably move on to other issues,” Senator Mitch McConnell, Republican of Kentucky and the majority leader, told National Public Radio when asked about Affordable Care Act repeal.
The sign-up numbers seemed to indicate that despite all the politics, millions need the insurance. Nearly half of all plan selections this year — 4.1 million of the 8.8 million — occurred in the last week of open enrollment. More than one-fourth of the people who signed up this year — 2.4 million — were new customers, and 6.4 million people returned to HealthCare.gov to select plans or were automatically re-enrolled.
Those large numbers came in the face of big challenges. Before the enrollment period, which ran from Nov. 1 to Dec. 15, many insurers announced big rate increases for 2018. The Trump administration cut the budget for advertising to promote enrollment and greatly reduced grants to insurance counselors, known as navigators, who help people sign up for coverage.
In the first nine months of this year, Republicans tried repeatedly to repeal the Affordable Care Act, continually criticized it and asserted that health insurance markets were collapsing. Mr. Trump highlighted huge increases in premiums without noting that many consumers were eligible for federal subsidies that help cover the extra cost.
For weeks, consumers have been confused about whether they would be subject to penalties for going without insurance.
The report Thursday shows sign-ups by people in 39 states that use HealthCare.gov. It does not include activity in 11 states that operate their own insurance exchanges and are also reporting strong enrollment. In some of those states, consumers have more time to sign up. The deadline is Jan. 14 in Minnesota, Jan. 15 in Washington State and Jan. 31 in California and New York.
In addition, people losing coverage because their insurer withdrew from the marketplace may qualify for a special enrollment period providing 60 additional days to sign up for a health plan.
More than 80 percent of people buying insurance through the marketplace qualify for subsidies to help pay premiums. The Trump administration said in October that the average subsidy in states using the federal marketplace would be $555 a month next year, up 45 percent from this year.
Among states using the federal exchange, the largest numbers of sign-ups this year were in Florida (1.7 million), Texas (1.1 million), North Carolina (524,000), Georgia (483,000), Virginia (403,000), Pennsylvania (397,000) and Illinois (340,000).
Federal officials reported a huge surge of activity near the end of open enrollment. In Florida, more than 700,000 people selected plans or were automatically enrolled in the final week, and in Texas, the number was more than 550,000.
Ms. Verma tried over the summer to persuade Congress to repeal the Affordable Care Act, but on Thursday, she boasted about how well the law’s insurance marketplace — under new management — was meeting the needs of consumers.
The Trump administration, she said, spent only $10 million on marketing and outreach to consumers, or just over $1 for each person who signed up. By contrast, she said, the Obama administration spent a total of $100 million last year, or nearly $11 for each person who signed up.
Moreover, Ms. Verma said, the Trump administration “took a more cost-effective approach” that emphasized the use of digital advertising and email to reach consumers.
While cutting the budget for navigator groups, the Trump administration encouraged the use of insurance agents and brokers, saying it wanted to “shift away from the government selling a private product.”
Requiem for the Individual Mandate
by Margot Sanger-Katz - NYT - December 21, 2017
Born a conservative idea, maturing as a bipartisan one, then tagged a Democratic invention, it survived many attacks but fell victim to the G.O.P. tax plan.
The individual mandate, an idea inspired by conservative intellectuals but ultimately embraced by Democratic lawmakers as an essential part of the Affordable Care Act, will soon be dead. The provision would be eliminated under the tax bill passed on Wednesday.
Left behind would be a policy structure that relied on the mandate to push the young and healthy to buy health insurance and thus strengthen the marketplace for millions of Americans. The Affordable Care Act, which adopted the mandate as a central provision, will remain the law, and President Trump far overstated matters when he said that “we have essentially repealed Obamacare.” But the loss of the mandate — the best-known and least liked part of the health care law — will cause substantial changes.
The magnitude of the consequences is uncertain, but most experts believe the mandate’s elimination will usher in an era of higher insurance prices and lower health coverage rates. The economists at the Congressional Budget Office estimatethat as many as 13 million more Americans could become uninsured in 10 years and that insurance premiums will rise by an additional 10 percent each year. The impact won’t start to become clear until 2019, when the provision’s penalties for remaining uninsured officially expire.
The mandate was devised by conservative health care experts at the Heritage Foundation in the late 1980s, who conceived it as a necessary part of a market-based system for providing health insurance in America. The mandate was intended to encourage individual responsibility: More families should be able to choose their own health plans in a market, but they would be expected to have some sort of coverage so they wouldn’t burden their neighbors if they became sick or injured.
“Society does feel a moral obligation to insure that its citizens do not suffer from the unavailability of health care,” Stuart Butler, then Heritage’s director of domestic policy studies, said in a 1989 lecture that was published in a book. “But on the other hand, each household has the obligation, to the extent it is able, to avoid placing demands on society by protecting itself.”
It attracted interest across the political spectrum, becoming a favored policy prescription of some Republicans opposed to President Bill Clinton’s health care overhaul plan in the early 1990s. It was discussed in economics and policy journals. And it later became the basis for a bipartisan health care bill that attracted co-sponsors from both parties but never made it to a vote.
The mandate’s first big moment in the spotlight came in 2006, when it became part of a Massachusetts health care law passed by a Democratic state legislature and championed by a Republican governor, Mitt Romney. Mr. Romney was persuaded to include it in the health plan after seeing estimates that without it the health plan would cost nearly as much but cover far fewer people. Both the liberal icon senator Ted Kennedy and Robert Moffit, a senior Heritage official, attended the elaborate Faneuil Hall signing ceremony and praised the legislation.
The mandate became branded as a Democratic policy shortly afterward. Hillary Clinton, who had rejected the idea in the early 1990s, adopted it as part of her presidential platform in the 2008 primaries. Barack Obama, running against her, took some convincing. But as president he ultimately embraced the mandate. It became a central plank of the 2010 health law.
The Affordable Care Act bars insurers from discriminating against customers with a history of previous illness, so a 40-year-old woman with a history of multiple sclerosis must be charged the same price for coverage as a 40-year-old man with a clean bill of health.
The mandate was devised to nudge healthier, less expensive people into the market, lowering the average price of insurance. People who could afford to buy insurance but didn’t would face a tax penalty, and increased participation in the market would help cover the bills of sick people who were nearly guaranteed to sign up, the thinking went.
Once the mandate was attached to the Democratic plan, it became a target of Republican attacks. It was described as un-American, unfair and unconstitutional. The Heritage Foundation disavowed its own idea. A Supreme Court case attacking the provision came close to wiping the whole health law off the books. The mandate became a sort of unloved mascot for a complex, broad law touching many parts of the health care system.
But despite many attempts over the years, Republicans failed to repeal it and to retool large sections of the health law. Instead, the mandate fell victim to an indirect blow — leveled when tax writers realized its repeal would, on paper at least, deliver savings that could be used to lower tax rates.
In practice, the precise effect of the provision has been unclear. The Obama administration had made the mandate somewhat porous, with a long list of life circumstances that would exempt people from having to pay a penalty. Some economists have argued that the penalties are too small to encourage the truly reluctant to enroll. The C.B.O. said it was re-evaluating its own assumption but thought it had probably overestimated the provision’s impact on premiums and insurance enrollment. Still, some mandate enthusiasts continue to argue that the provision’s disappearance will lead to a death spiral of ever-escalating insurance premiums and eventual market collapses.
Those questions, once largely academic, will get real-life answers in coming months and years. The end of the mandate will establish a sort of natural experiment, in which its influence will become much more clear. Some states may not wait to find out. Policymakers in several blue states are weighing state-level insurance mandates. Those policy descendants may help settle the question of the importance of the mandate to the design of Obamacare, with its market-based system for expanding insurance coverage.
“For better or for worse, we’re going to find out what the answer is,” said Benedic Ippolito, a research fellow at the American Enterprise Institute, who recently wroteabout the question. He wished the mandate well: “We hardly knew ye.”
Congress just broke the health care system, now Mainers will feel the pain
by Steve Butterfield - Portland Press Herald - December 22, 2017
AUGUSTA — Sen. Susan Collins cast a courageous vote this summer to preserve the Affordable Care Act. This was an act of political leadership, and a vote for preserving affordable health care for Mainers. The amount of pressure she endured from her Republican colleagues, I can only imagine.
Which is why we were disappointed by her vote in favor of the Republican tax package this week. Even with the concessions she received, we feel that the package does far more harm than good.
There’s a reason that this bill is so dramatically unpopular: It repeals health care in order to pay for tax cuts for corporations and the wealthiest 1 percent. It will hit low-income, disabled, elderly and middle-class Mainers hard. Up to 50,000 Mainers are expected to lose coverage as a result of this bill, and thousands more will see premiums rise by over $2,000. Older Mainers will be hit with an age tax climbing as high as $1,748. The bill will set in motion a devastating $120 million cut to Maine Medicare funds.
In fairness to the senator, she did what she could to make sure that other bills she supported would mitigate the fallout from gutting the health care markets. The reality is that these patchwork solutions will only soften the blow, not stop it. Repealing the individual mandate will still destabilize the health care market, causing tens of thousands of Mainers to lose their coverage and even more to see their premiums increase.
Of course, this won’t occur in one fell swoop. It takes time to destabilize a market. But the fact still remains that, even if the “fix” bills she is supporting work as well as she hopes, they will only begin to contain the damage that Congress willingly chose to inflict. These patchwork policy Band-Aids will not make anybody better off: At best, they’ll make sure you’re only somewhat worse off in 2018 because of what Congress has done. The timeline to pass these fixes continues to grow, and leadership has backed away from promises to move them.
And now, the additional support for the health care system that Sen. Collins has worked hard to secure won’t be considered until next year. Should congressional leaders stay true to their word and bring the additional health care reform to a vote next year, there is serious doubt whether or not the updates can pass both chambers of Congress. I’ll say it again: These Band-Aids are only a patchwork and serve only to soften the outcome of passing the tax package, rather than substantively improve health care for Mainers and Americans.
Mainers have repeatedly made clear what their priorities are, evidenced by the most recent and resounding referendum to expand Medicaid. Hart Research pollsters have found that a dismal 22 percent of the state approves of this tax bill.
Voting for health care repeal is a setup to do even greater harm to Mainers. Congressional leaders have already signaled that Social Security, Medicare and Medicaid are next on the chopping block, something that Mainers certainly will not tolerate. Conservative estimates say that this tax bill will increase the deficit by $1.5 trillion. The next step will be for congressional leadership to claim the deficit is out of control and point to the programs Mainers rely on – Social Security, Medicare and Medicaid – as the reason. It’s already happening.
But let’s be clear: The enormous deficit the Republicans just created is because of their giveaways to corporations and the wealthy, not because of Mainers’ Social Security and Medicare. Being the oldest state in the nation, Maine will be hit hard if they follow through on their plans to gut these programs next.
We applaud the senator for doing her best to convince her colleagues that they must now pass other bills to contain the damage that’s already been done. We only wish that she, and the rest of Congress, had chosen the far easier fix: not to break our health care system in the first place.
Maine has spoken on Medicaid expansion. It’s time to honor the result.
by Steve Bien - Bangor Daily News - December 20, 2017
The people of Maine have clearly spoken on Medicaid expansion. The question now is whether the Legislature will act in our behalf or play politics with the result.
Medicaid expansion passed by an overwhelming 60-40 margin, but already the governor and his followers in the Legislature are working hard to throw sand in the works. They are trying to convince us that getting $500 million in federal money annually is not worth the state chipping in $50 million. Much as he was willing to stiff job training centers because it did not sit well with his ideology, the governor seems committed again to put political dogma over public benefit.
The immediate beneficiaries of Medicaid expansion will be the approximately 70,000 Mainers with incomes between 101 percent to 138 percent of the federal poverty level. Those winners are not hard to identify, but the rest of us also have serious skin in this game. An inconvenient truth is that Maine’s health care system has been in a state of decline over the past several years.
Serious warning signs are not hard to find: First and foremost is the dire financial straits of Maine’s hospitals, especially smaller, rural hospitals on which many rural communities depend. Maine hospitals are in trouble because they are footing the bill for so much uncompensated care. Five of seven of the state’s health care systems lost money last year; 19 of our 36 hospitals are in the red; and our 23 rural hospitals are in serious financial trouble.
To stanch the red ink, many of those hospitals have cut services like obstetrics, pediatrics, or emergency room and intensive care unit staffing. Others, like Franklin Memorial Hospital in Farmington, have given up their independence to become part of larger health systems. Faced with rising costs and declining populations, Calais Regional Hospital closed its obstetrics unit in May, Penobscot Valley Hospital in Lincoln closed its unit in 2014, and Blue Hill Memorial in 2009.
Cutbacks in services like these are severe enough, but if this situation continues, some hospitals in the state will close, and the closure of a hospital can be a death knell for a town. All of these forces combine to drive the next concern: the rising infant mortality rate.
The infant mortality rate is widely regarded as one of the most important measures of a community’s health. This is because it reflects so many community features such as insurance coverage and availability of care, quality of care, maternal nutrition, general maternal health, and child health in the first year. In the early 1990s, Maine had the lowest infant mortality rate in the U.S.; now we have fallen to 31st. Many factors contribute here, including maternal health and nutrition, child and family poverty, and general adult health.
Not all of this improves with health insurance, but some of it certainly does. If the health of the adult population is in decline, as it has been in the rural counties like mine, the infant mortality rate goes up, and it has.
Finally, there is the the tidal wave of Maine’s opioid epidemic. With more than one Mainer dying a day from an opioid overdose, there are few treatment resources, and the number needing but unable to get treatment continues to rise.
In Maine, about 8 percent of babies are born with a drug withdrawal syndrome, and nearly 10 percent of our 18- to 25-year-olds are in need of addiction treatment. While 15,000 Mainers are in treatment for substance-use disorder, the number in need of treatment is probably much higher.
Opioid-related problems are an increasing percentage of emergency room visits and hospital admissions, yet hospitals are forced to eat these costs, draining vital resources from other areas. We have no hope of catching up to this problem without expanding access to health insurance and treatment.
The governor and some in the Legislature are throwing up roadblocks to implementation of Medicaid expansion as fast as they can think of them. But they have no answers to these problems. Implementation will not solve all of these problems, but expanding access to those 70,000 Mainers would be a major and essential first step.
Having vetoed five bills to expand Medicaid, it is no surprise the governor, who consistently puts ideology over public need and health, promises to do all he can to stop this, too. Will the Legislature carry his water or ours?
Steve Bien is a family physician in Farmington.
Friday, Dec. 22, 2017: Tax bill posed moral questions, safety net cuts coming, tax benefits modest
Sen. Susan Collins drank the Trump Kool-Aid. Passage of the tax bill she just embraced could lead to cuts to Medicare for more than 300,000 Maine seniors. Medicaid benefit cuts to over a quarter million Maine’s least well off could happen, too, as Congress looks to cut spending. And very likely Social Security recipients will also feel pain. How else will the Republicans pay for their $1.5 trillion debt their “tax reform” brings about?
Our state will be less productive, less healthy, with greater poverty and inequality because this tax disproportionately favors the rich. People like President Donald Trump whose family stands to gain a lot in tax relief.
Here in Maine far too many families already go hungry at least one day a week, facing what is euphemistically referred to as “food insecurity.” Some families can’t afford milk for their school-age children. The U.S. Department of Agriculture estimates that 16.4 percent of Maine households, or over 200,000 individuals, are in this predicament.
Our government, both federal and state, need more tax revenue, not less. We have an infrastructure problem — roads, bridges, power plants, airports, schools, communications — that need rebuilding right now. Moving ahead in these areas would immediately accomplish a number of things: provide good-paying jobs to people, thereby reducing hunger, poverty and inequality, begin to rebuild our deteriorating and dangerous infrastructure, give a great boost to our economy and increase flow of capital along with tax revenues. All constructive, positive results.
Joe Lendvai
Brooklin
Taking Health Care From Kids
by David Leonhardt - NYT - December 21, 2017
At the White House yesterday, Republicans celebrated their passage of a big tax cut. Somehow, though, they still haven’t found the time or the money to protect health insurance for millions of low-income children.
In September, Congress allowed funding for the Children’s Health Insurance Program (known as CHIP) to expire. By the end of next month, 25 states are likely to run out of their remaining CHIP money, according to a new report by Georgetown University’s Center for Children and Families. That could put health coverage for 1.9 million children at risk. Eventually, if CHIP isn’t extended, almost nine million children — or about one out of every eight children in America — could lose coverage.
CHIP isn’t supposed to be controversial. It enjoys bipartisan support, at least rhetorically. Senator Orrin Hatch, the Utah Republican who helped create the program in the 1990s, said yesterday that Congress should remain in session until its funding is restored.
But the program has become a casualty of congressional leaders’ failure to agree on a plan to fund the federal government, largely because of an insistence on budget cuts from conservative Republican members. Congress seems likely to push an overall funding bill into January, creating uncertainty and anxiety for many families.
Congress’s decision to put tax cuts ahead of health care, writes The Washington Post’s Catherine Rampell, “has left millions of children, including some in the middle of lifesaving care such as cancer treatment, in limbo.” She adds: “When so many dire priorities abound, it’s hard to fathom how tax cuts got to the front of the queue.”
As The Times’s Robert Pear reported this week, CHIP has become a bargaining chip, a noncontroversial measure that Republicans can use to force Democrats to vote for other provisions they might otherwise oppose.
”In the meantime,” writes Vox’s Dylan Scott, “we are 11 days away from a state like Alabama freezing enrollment and Congress’s inaction having a real effect on some number of American children’s ability to access health care.”
As V. Ram Krishnamoorthi and Philip Verhoef, both doctors at the University of Chicago, put it in Crain’s Chicago Business: “Our fear is that, if legislators continue to politicize CHIP funding, they will destabilize the entire program. Without a stable foundation of federal money, states are unable to budget for, much less cover, the current needs of their most vulnerable people.”
Congressional leaders keep talking as if they regret the uncertainty over CHIP. But they’re the only ones who can end it. They should cut back on the platitudes and make sure children get to keep their health insurance.
Trump-friendly media on tax cuts. Breitbart covered the passage of the G.O.P. tax plan in glowing terms. It played up members’ praise for the president’s leadership as well as early reports that some companies plan to offer employee bonuses because of the bill.
But the coverage also included some obvious spin. In a Wednesday post, Breitbart’s John Carney tried to explain the bill’s consistent unpopularity in public-opinion polls. He blamed Americans’ negative perception of the bill partly on “journalists and politically motivated opponents of tax cuts who have spread falsehoods about the tax bill.” He also tried to discredit the Tax Policy Center, which did several objective analyses of the bill that were consistent with other independent analysis of the bill.
“Americans are not really opposed to the Republican tax bill,” Carney wrote. “They are opposed to an imaginary bill that hikes taxes on many people and lowers taxes for a very small segment of American households. That is just about the photographic negative of the actual tax bill.”
Carney is correct that most households initially receive a tax cut from the bill. But he’s also engaging in the common diversionary tactics of the bill’s supporters. They wave away the temporary nature of the middle-class tax cuts, essentially arguing that people should ignore Congress’s decision to let those cuts disappear in the bill’s final years. And the bill’s supporters pretend that its deficit increases bill won’t eventually lead to budget cuts that hurt the middle class, as Bryce Covert explains in The Times.
The American public gets it. People saw the rushed, secretive way that Congress passed the bill. They understand that this bill is a bad deal for most families.
People Don’t Take Their Pills. Only One Thing Seems to Help.
by Austin Frakt - NYT - December 11, 2017
High-tech approaches and “reminder” packaging don’t work well. Reducing prices does.
For all that Americans spend on prescription drugs — $425 billion last year — you’d think we’d actually take our medicine.
But one of the frustrating truths about American health care is that half or more of prescribed medication is never taken.
It’s called medication nonadherence, and it’s a well-documented and longstandingproblem, particularly for patients with chronic conditions. The drugs they’re prescribed are intended to prevent costly complications, reduce hospitalization, even keep them alive. But even when the stakes are high, many patients don’t take their meds.
This seems like a problem we ought to be able to solve. It motivates high tech approaches, like digital pills that can automatically communicate to doctors that they’ve been taken.
Maybe people forget to take their meds — about 60 percent of people say as much — so we just need to remind them. Maybe people don’t understand the value of what they’re prescribed, so we just need to educate them. Maybe drug regimens are too complex, so we just need to simplify dosing.
All these methods have been tried. It’s not so clear any of them work very well.
Only one approach has repeatedly been shown to be effective: reducing the cost of medications.
First, let’s look at the research on the other methods. So-called reminder packaging — pill packaging or containers that organize drugs by single dose or day of the week — is a relatively simple idea intended to help people remember to take their prescribed dose.
A systematic review by the Cochrane Collaboration found that it was helpful in doing so, but only modestly. Surveying 12 randomized controlled trials, the authors concluded that reminder packaging increased the number of pills taken by patients by 11 percentage points. But they also found that most of the studies had significant methodological flaws, casting doubt on the findings. Other systematic reviews of reminder packaging studies also found problems with the research, like small sample sizes and short follow-up periods.
Perhaps reminder packaging is too passive, and patients need something like an alarm to alert them when they’ve missed a dose. Electronic pill monitors can do that. Some just remind patients to take their medication. More sophisticated ones alert doctors when they don’t. In 2014, a team of researchers from the Brigham and Women’s Hospital and Harvard Medical School published a systematic review of such devices in the Journal of the American Medical Association. Here, too, the results are disappointing. Most studies of such devices do not detect improvement in adherence.
A recent randomized trial not included in these systematic reviews tested three dose reminder approaches for people with a chronic health condition or depression: a pill bottle with toggles for each day of the week that can be changed after each daily dose; a pill bottle cap with a digital timer displaying the time elapsed since the medication was last taken; and a pill organizer with a compartment for every day of the week. Over 50,000 subjects were assigned randomly to one of these approaches or to none, as a control.
None of the devices performed better than the control in getting patients to take their medications. One possible explanation is that forgetfulness may not be whypatients don’t take their medications as prescribed. Drug costs, a wish to avoid side effects, and a desire to be less reliant on drugs are some of the other reasons patients don’t take them.
“It is also possible that for reminder devices to be effective, they need to be coupled with other adherence-improvement strategies,” said Niteesh Choudhry, lead author of the study and a physician with Brigham and Women’s Hospital and Harvard Medical School.
That’s why augmenting electronic monitoring with other information or assistance delivered to patients may be more successful, if more expensive. For example, one study found that the adherence of hypertensive patients increased when digitaldisplay containers were combined with a blood pressure cuff and a card for recording blood pressure. This suggests that when patients receive feedback that signals how well they are controlling their condition, they may be more willing to take their medication.
Still, it isn’t hard to find studies that show that even with considerable support, getting patients to take medications can be challenging. A Cochrane review examined randomized controlled trials of interventions — across many dimensions — to increase medication adherence. Reminder packaging and alarms were just some of the methods assessed, with approaches including patient and family education about the value of medication, and mail or telephone follow-up.
Of the 182 randomized trials reviewed, four stood out as the most methodologically sound. Among those, two increased adherence but two did not. Over all, the authors concluded that there was a lack of convincing evidence that even complex and costly interventions significantly increased patients’ compliance with drug regimens.
“A cure for nonadherence is nowhere to be seen,” they wrote. A more recent studynot included in the Cochrane review found that not even providing patients with financial incentives and social support, along with pill bottles that signal when a dose should be taken, was enough to boost adherence among heart attack survivors.
So why is price so important?
When drugs cost them less, patients are more likely to fill prescriptions. Even if people have already purchased drugs, they may skip doses — or split the pills — because of concerns that they won’t be able to afford future refills. Free drugs don’t get everyone to take them, but many more do so than if they have to pay for them.
For those with certain chronic conditions, extra help in affording medications can reduce adverse events and hospitalizations — a big increase in quality of life, as well as a potential benefit to the wider health care system and the economy.
Lowering prescription drug costs has been a longstanding pursuit for many politicians, and Medicare Part D and the Affordable Care Act helped (although most Americans still say costs are too high). President Trump said drug companies “have been getting away with murder,” but lower drug costs have not yet been a top priority of this White House.
Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health. He blogs at The Incidental Economist, and you can follow him on Twitter. @afrakt
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