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Sunday, June 28, 2015

Health Care Reform Articles - June 28, 2015

America’s health care system is still broken: Why single-payer is the only thing that will ever fix it

The final triumph of Obamacare was great news for Americans depending on it -- but it still isn't enough

BY A.W. GAFFNEY, M.D.
ON THURSDAY, THE SUPREME COURT SPLINTERED YET ANOTHER SPEAR HEAVED BY CONSERVATIVES TRYING TO DESTROY, BY WHATEVER MEANS NECESSARY, THE AFFORDABLE CARE ACT. THOSE LIVING IN THE 34 STATES THAT RELY ON THE FEDERAL “EXCHANGE,” WHO PURCHASE HEALTH INSURANCE USING SUBSIDIES PROVIDED BY HEALTHCARE REFORM, ARE UNDERSTANDABLY RELIEVED.
“WITHOUT THE SUBSIDY, I AM NOT SURE WHAT I WAS GOING TO DO,” SAID ONE MAN, A HAIRDRESSER WHO WAS DIAGNOSED LAST YEAR WITH KIDNEY CANCER, TO KAISER HEALTH NEWS. “I WAS THINKING OF MOVING OUT OF MY APARTMENT AND GO LIVE IN MY CAR TO AFFORD COVERAGE.” ANOTHER MAN, SUFFERING FROM A FORM OF BLOOD CANCER, TOLD THE NEW YORK TIMES: “I AM NERVOUS ABOUT THE SUPREME COURT DECISION, VERY NERVOUS,” HE SAID. “IF I DON’T TAKE THAT PILL, THE CANCER WILL COME BACK.” THE PILL, THE TIMES REPORTED, WOULD OTHERWISE HAVE COST HIM MORE THAN $10,000 A MONTH.
THIS IS WHAT MATTERS MOST ABOUT YESTERDAY’S SUPREME COURT DECISION ON OBAMACARE: MANY AMERICANS – SOME 8.2 MILLION, ACCORDING TO AN ESTIMATE FROM THE URBAN INSTITUTE – NO LONGER NEED TO WORRY ABOUT BEING UNCEREMONIOUSLY DUMPED INTO THE RANKS OF THE UNINSURED. IT HAS BEEN ESTIMATED THAT A RULING IN FAVOR OF THE PLAINTIFFS COULD HAVE COST BETWEEN 8,000 AND 9,800 LIVES A YEAR. HOW THE CASE PLAYS OUT WITH RESPECT TO ONGOING DEMOCRATIC AND REPUBLICAN POLITICAL GAMESMANSHIP SEEMS, IN COMPARISON, A PIDDLING MATTER.
NOW, IN OTHER NEWS YESTERDAY, HEALTH CARE STOCKS WERE SPIKING ON WALL STREET: INSURERS (UNITEDHEALTH AND AETNA) AND CORPORATE HOSPITAL NETWORKS (HOSPITAL CORPORATION OF AMERICA) WERE SEEING STRONG GAINS. THE LINK BETWEEN THESE EVENTS IS, OF COURSE, OBVIOUS: THE AFFORDABLE CARE ACT’S PREMIUM SUBSIDIES ARE FUNNELED THROUGH PRIVATE HEALTH INSURANCE COMPANIES, WHO TAKE A CUT. CORPORATE HOSPITAL CHAINS, MEANWHILE, PREFER A WELL-PAYING CUSTOMER.
TOGETHER, THIS MIGHT BE A BIT PUZZLING FOR THOSE WHO’VE ADOPTED THAT AGE-OLD MANTRA, “WHAT’S GOOD FOR THE HEALTH INSURANCE INDUSTRY IS BAD FOR AMERICA.” YET THIS CORPORATE COMPROMISE WAS FUNDAMENTAL TO THE PASSAGE OF OBAMACARE, AS STEPHEN BRILL DOCUMENTS IN HIS BOOK ”AMERICA’S BITTER PILL.” AS A RESULT, OBAMACARE IS, BY AND LARGE, GOOD FOR THE HEALTH CARE BUSINESS. A FEW YEARS BACK, AS DESCRIBED IN A NEW YORK TIMES STORY HEADLINED, “THE PRESIDENT WANTS YOU TO GET RICH ON OBAMACARE,” THOMAS SCULLY – WHO COMFORTABLY ALTERNATES BETWEEN WORKING AS A GOVERNMENT ADMINISTRATOR AND A GOVERNMENT LOBBYIST – TRIED TO ALLEVIATE THE CONCERNS OF A ROOM OF INVESTORS ABOUT OBAMACARE AT THE “21” CLUB IN NEW YORK.
“IT’S NOT A GOVERNMENT TAKEOVER OF MEDICINE,” HE WAS QUOTED BY THE TIMES AS SAYING, “IT’S THE PRIVATIZATION OF HEALTH CARE.” AS THE TIMES PUT IT, “BILLIONS COULD FLOW FROM WASHINGTON TO WALL STREET, INDEED.”
NEXT QUESTION: WHY SHOULD WE CARE, IF THE INSURED ARE BEING COVERED IN THE PROCESS? WELL, WE SHOULD CARE BECAUSE OUR CORPORATE HEALTH CARE COMPROMISE COMES AT A SERIOUS COST.
FIRST, IT’S A WASTE OF GOOD MONEY. PRIVATE INSURERS HAVE NOTORIOUSLY HIGH OVERHEAD: THEY SPEND PERHAPS 12 PERCENT OF YOUR PREMIUM ON ADMINISTRATION AND PROFITS. TRADITIONAL MEDICARE, IN CONTRAST, SPENDS ABOUT 2 PERCENT ON OVERHEAD. A RECENT ANALYSIS FOUND THAT THE INSURANCE EXPANSION UNDER THE ACA HAS BEEN PARTICULARLY COSTLY FROM THIS PERSPECTIVE, WITH ABOUT $1,375 SPENT ON OVERHEAD FOR EACH NEWLY INSURED PERSON.
SECOND, THE MANDATE MODEL OF HEALTH CARE REFORM WAS NEVER INTENDED TO RESULT IN UNIVERSAL COVERAGE. “IF YOU TOOK GEORGE H. W. BUSH’S HEALTH PLAN,” SCULLY TOLD THE INVESTORS AT THE “21” CLUB WITH SOME FAIRNESS (AGAIN AS QUOTED IN THE TIMES), “AND REMOVED THE LABEL, YOU’D THINK IT WAS OBAMACARE.” THE PROBLEM WITH A MANDATE MODEL – WHICH USED TO BE THE CONSERVATIVE APPROACH TO HEALTH CARE REFORM – IS THAT SOME PEOPLE WILL INVARIABLY FALL BETWEEN THE CRACKS: INDEED, SOME 27 MILLION WILL REMAIN UNINSURED IN THE LONG TERM UNDER THE ACA. SOME OF THESE PEOPLE ARE UNDOCUMENTED IMMIGRANTS, WHILE OTHERS ARE WORKING- OR MIDDLE-CLASS PEOPLE, FOR WHOM THE PURCHASE OF HEALTH INSURANCE IS SIMPLY TOO COSTLY.
THIRD, THE PROBLEM OF UNDERINSURANCE — WHICH IS, ROUGHLY SPEAKING, HAVING INSURANCE, BUT NOT BEING ABLE TO AFFORD TO USE IT BECAUSE OF COPAYMENTS OR DEDUCTIBLES — IS GOING NOWHERE QUICKLY. THE PERCENTAGE OF NON-ELDERLY AMERICANS WITH PRIVATE INSURANCE WHO HAVE A “HIGH-DEDUCTIBLE HEALTH PLAN” ROSE FROM 22.5 PERCENT IN 2009 TO 36.9 PERCENT IN 2014. UNDERINSURANCE DOUBLED BETWEEN 2003 AND 2014, SUCH THAT BY ONE MEASURE, 31 MILLION AMERICANS ARE NOW “UNDERINSURED.”
FOURTH, THE DELIVERY OF HEALTH CARE BY FOR-PROFIT CORPORATE ENTERPRISES HAS BECOME AN ENTRENCHED COMPONENT OF THE POLITICAL ECONOMY OF AMERICAN HEALTH CARE. FOR A PARTICULARLY UNSEEMLY EXAMPLE, CONSIDER THE EXPLOSION OF THE CORPORATE HOSPICE INDUSTRY. THERE WAS A TIME NOT LONG AGO WHEN THE HOSPICE WAS A CHARITABLE, RELIGIOUS OR NOT-FOR-PROFIT ENTERPRISE. IN THE NEOLIBERAL ERA, HOWEVER, IT WAS ALL BUT INEVITABLE THAT VENTURE CAPITAL WOULD TRY TO GET IN ON THE MARKET FOR DYING: BY 2013, 66 PERCENT OF MEDICARE-CERTIFIED HOSPICES WERE FOR-PROFIT BUSINESSES. QUALITY ISSUES WITH SUCH FOR-PROFIT PROVIDERS ARE A PERENNIAL CONCERN: AN INVESTIGATION BY THE WASHINGTON POST LAST YEAR, FOR INSTANCE, FOUND THAT “ON SEVERAL KEY MEASURES, FOR-PROFIT HOSPICES AS A GROUP FALL SHORT OF THOSE RUN BY NONPROFIT ORGANIZATIONS,” LIKE THE AMOUNT SPENT ON NURSING EACH POINT.
WHICH BRINGS US TO THE FINAL QUESTION: WHAT’S THE ALTERNATIVE? IS REAL UNIVERSAL HEALTH CARE – E.G. A SINGLE-PAYER NATIONAL HEALTH PROGRAM – AT THIS POINT FEASIBLE?
BASED ON NATIONAL POLLING, THE ANSWER IS YES, ABSOLUTELY, OF COURSE. A MAJORITY OR NEAR MAJORITY GENERALLY VOICE SUPPORT FOR A SINGLE-PAYER SYSTEM, INCLUDING IN ONE RECENT SURVEY.
NOW, I KNOW, “WILL OF THE POPULACE,” YADA YADA. BUT ON THE OTHER HAND, THERE DOES SEEM TO BE A GROUNDSWELL OF OUTRAGE AT RISING INEQUALITY IN OUR SOCIETY THAT MAY NOT BE SO EASILY SWEPT AWAY. ELECTORAL POLITICS, TO SOME EXTENT, SEEM TO BE REFLECTING THAT. BERNIE SANDERS, FOR INSTANCE – NOW IN SECOND PLACE BEHIND HILARY CLINTON IN THE DEMOCRATIC PRESIDENTIAL PRIMARY – HAS MADE ECONOMIC JUSTICE THE CENTER POINT OF HIS CAMPAIGN. HE’S ALSO A STRONG SINGLE-PAYER SUPPORTER: “WHAT THE UNITED STATES SHOULD DO,” HE PUT IT IN A STATEMENT ABOUT KING V. BURWELL YESTERDAY, “IS JOIN EVERY OTHER MAJOR NATION AND RECOGNIZE THAT HEALTH CARE IS A RIGHT OF CITIZENSHIP. A MEDICARE-FOR-ALL, SINGLE-PAYER SYSTEM WOULD PROVIDE BETTER CARE AT LESS COST FOR MORE AMERICANS.” WELL SAID, BERNIE.
FOR THOSE WHO WANT TO OPEN A BOTTLE – OR EVEN A CASE – OF CHAMPAGNE TO CELEBRATE YESTERDAY’S RULING, I’D SAY: ENJOY. BUT TOMORROW, ONCE THE HANGOVER HAS CLEARED, THE WORK TO TRANSFORM OUR CORPORATIZED, FRAGMENTED, AND INEQUITABLE HEALTH CARE SYSTEM REMAINS BEFORE US.
A.W. GAFFNEY IS A RESEARCH FELLOW IN PULMONARY AND CRITICAL CARE MEDICINE AT HARVARD MEDICAL SCHOOL AND MASSACHUSETTS GENERAL HOSPITAL. HE RECEIVED HIS MEDICAL DEGREE FROM THE NEW YORK UNIVERSITY SCHOOL OF MEDICINE AND COMPLETED RESIDENCY TRAINING AT COLUMBIA UNIVERSITY MEDICAL CENTER, WHERE HE SERVED AS CHIEF RESIDENT. HE IS A FREQUENT WRITER ON HEALTH POLICY, BLOGGING AT THEPROGRESSIVEPHYSICIAN.ORG.


 Medicare at 50: Strengths to Build On

By John Geyman, M.D.
The Huffington Post, June 22, 2015
Traditional, or Original, Medicare turns 50 on July 30, having had many challenges and achievements from the days of its passage to today. It is time to celebrate its many successes, note some of its current challenges and threats to its future, and briefly discuss how it gives us a strong foundation upon which to build still-needed health care reform.
When it was enacted in 1965, about one-half of seniors in the U.S. lacked health insurance, and many could not afford necessary health care. When it was passed with strong bipartisan support (313-116 in the House, and 70-24 in the Senate), 20 million Americans age 65 and older gained health insurance.1
From the start, Medicare was a political football raising strong arguments for and against any kind of universal health insurance, quite similar to those we hear today, including from the American Medical Association, hospitals, and the health insurance industry. But a "corporate compromise" was struck in 1965 whereby private insurers were relieved of their worse health risks, hospitals could expect assured payments for their costs of serving a previously disadvantaged population, and physicians gained a permissive "usual, customary, and reasonable" reimbursement policy.2 Claims processing and bill auditing were contracted out by the government to private fiscal intermediaries, especially Blue Cross and Blue Shield plans.3
From the beginning, Medicare has provided a broad set of benefits, defined by law, protecting all seniors, many of whom could not afford health insurance in the private market. Part A provides hospital insurance, while Part B provides supplementary medical insurance for 80 percent of physician services (initially with a $50 deductible and 20 percent coinsurance), X-ray and laboratory tests, and some home health and outpatient and mental health services. Some additional benefits were added in later years to this basic program, including coverage for the disabled and patients with end-stage renal disease in 1972 and partial coverage for prescription drugs in 2003 (Part D). Medicare's benefits have always been considered an earned right, not an entitlement, since all beneficiaries pay into the program through mandatory contributions from individuals and/or employers.4
Today, Medicare is a very large program, covering more than 55 million Americans, including all seniors and 9 million people with permanent disabilities under age 65. It accounted for 14 percent of the federal budget in 2014 and about 20 percent of total personal health expenditures in 2013.5 Since the 1990s, we have seen an increasing trend toward privatized Medicare plans (Part C), starting with Medicare + Choice HMOs in the 1990s and their sequel, Medicare Advantage (MA) since 2003. These plans have been promoted by conservative policymakers and think tanks with a goal to replace Medicare as an "entitlement program" with private market plans, health savings accounts and vouchers. Almost one-third of seniors are now enrolled in MA plans.
The Many Strengths of Traditional Medicare over 50 Years
Traditional Medicare has performed much better over the years than any of these private plans, which operate with the goal of profits more than service. Table 1 summarizes the major differences between traditional Medicare and privatized plans.6

Source: Adapted from Geyman, JP. Shredding the Social Contract: The Privatization of Medicare. Monroe, ME. Common Courage Press, 2006, p. 206.
These comparisons are supported by many studies over the years. As just four examples:
A literature review by the Kaiser Family Foundation of 40 studies since 2000 found that beneficiaries rated access and quality of care better in traditional Medicare than in Medicare Advantage, especially by those who were sick.7
An analysis by the Urban Institute over three decades found that private Medicare plans cost the government more than fee-for-service traditional Medicare, which contained costs better than private plans over those years.8
Traditional Medicare operates with an administrative overhead of 2 percent, compared to overhead of Medicare Advantage about seven times higher.9
The Centers for Medicare and Medicaid Services (CMS) took 35 enforcement actions against Medicare Advantage plans and Medicare Part D plans in 2014, particularly for inappropriate denials of care and requiring unnecessary preauthorization of services and medications that resulted in more cost shifting to beneficiaries.10
Some Major Challenges Facing Medicare Today
As in 1965, Medicare remains a lightning rod for intense political debates over its future. Despite its proven track record for efficiency, reliability, and responsible service over these last 50 years and widespread public support, Republicans are united in their attempts to dismember it, convert it to a voucher program, and shift patients to the private marketplace, all under the guise of reining in federal spending and austerity. Some Democrats are amenable to raising the eligibility age for Medicare and increasing cost sharing. These ideas are a complete disconnect with the needs of our aging society in a time of increasing inequality of incomes. More than 25 million seniors and people with disabilities live on annual incomes of $23,500 or less, many of whom cannot afford premiums and cost-sharing in either traditional or privatized Medicare. And as our population ages, pensions that in the past assured defined benefits are shifting to defined benefit pensions, without such assurances.11 There are still many gaps in coverage, even within traditional Medicare, including for long-term care and dental care.
Future funding for Medicare is seriously threatened and murky at best. The Obama administration has told us that the Affordable Care Act (ACA) will be financed in part by $716 billion in Medicare cuts over 10 years, with the unbelievable claim that these cuts will not result in reduction of services. The recently passed H. R. 2, the "doc fix" bill, has provisions in it that will require new deductibles in first-dollar supplemental Medigap plans (held by 40 percent of Medicare beneficiaries) and expand means-testing for Medicare Part D, both of which will increase costs for seniors and further undermine traditional Medicare.
Just as the future of Medicare is unclear, so is that of our entire health care system. The U. S. Supreme Court is expected to rule in coming days on the legality of subsidies under the ACA. A negative ruling will be a serious blow to the ACA and call into question where we should go next. Republicans in Congress will push for repeal or defunding parts of the ACA. As the debate heats up, the leading alternatives will likely be: (1) continuation of the ACA as it unravels, (2) some GOP "plan" based on patients having "more skin in the game" that further threatens access and affordability of care; (3) revival of the "public option" idea, hardly an effective fix as merely adding one more payer to our dysfunctional multi-payer financing system; and (4) long-overdue consideration of single-payer national health insurance that would cover all Americans in a large risk pool with more benefits, less cost, more reliability and equity in a sustainable way, as described in my recent book, How Obamacare Is Unsustainable: Why We Need a Single-Payer Solution for All Americans.11
Traditional Medicare has proven its superiority over any private, market-based alternatives for the last 50 years. It is time to build on this social insurance model as the health care debate continues.
http://www.pnhp.org/print/news/2015/june/medicare-at-50-strengths-to-build-on

Obamacare and Reagan

By DAVID LEONHARDT
JUNE 26, 2015
It is “socialized medicine,” and it forces “all citizens, regardless of need, into a compulsory government program.” From this program, “it’s a short step to all the rest of socialism.”
If you know your health care history, you know the person who leveled these charges was Ronald Reagan, and you know that he leveled them against Medicare. His opposition to the program – which he predicted would force Americans “to spend our sunset years telling our children and our children’s children what it once was like in America when men were free” – helped turn him from an actor into a conservative star in the early 1960s.
I thought of Reagan and Medicare last week, after the instant political analysis of Supreme Court decision in King v. Burwell. Pundits, both conservative and liberal, quickly pronounced the 6-to-3 ruling that upheld a central part of President Obama’s health law to be a political gift not only to Mr. Obama but to Republicans, too.
“Phew,” one anonymous Republican told NBC’s Luke Russert. Rick Wilson, a party strategist, told The Washington Post that he was “relieved,” noting the decision would keep the Republicans in the 2016 elections from having to endure advertisements “where a weeping Hispanic woman looks at the camera and says ‘They took away my son’s health care. Now he’s dead.’ ”
This political analysis isn’t wrong, as far as it goes. A ruling undoing parts of the health law could indeed have hurt Republicans in 2016. But the analysis is still a bit strange when you think about it.
Republicans, after all, have made undoing the law known as Obamacare their central domestic priority over the past five years. The House of Representatives has voted to repeal part or all of the program more than 50 times. Conservative groups have devoted thousands of hours and millions of dollars to the legal cases that the Supreme Court has now cast aside.
Yet now most experts believe that Obamacare is here to stay. Even if Republicans win back the White House in 2016, they are unlikely to have as good an opportunity to damage the law as the Supreme Court had. They would face the same problem that Mr. Wilson bluntly described. The Republicans can still win the electoral battle in 2016, but they appear to have lost the policy war over health care.
How, then, can the court’s ruling in favor of the health law – a ruling whose details were even more favorable to the law’s long-term standing than many court watchers expected – be good for Republicans?
The short answer is that it isn’t, not if you believe politics exists as a lever to affect government. The longer answer is that Republicans had already lost the war, well before the court ruled on Thursday.
They lost it in 2014, when the law began providing real benefits to millions of people – health insurance to a combination of middle-class, poor and sick Americans who could not have afforded it otherwise. Modern American history makes clear that once the social safety net expands in a major way, it’s almost impossible for anyone to reverse it.
Politicians and entire parties often oppose expansions before they happen, warning, as happened with Social Security, Medicare and the Affordable Care Act, that they would cause grave harm. In the 1930s, the Supreme Court blocked parts of the New Deal from taking effect. But when a program begins preventing elderly people from sliding into poverty or allowing cancer patients to receive treatment – when the beneficiaries morph from hypothetical to real – the politics are transformed.
Earlier this year, I asked historians for the closest analogy to a Supreme Court decision undoing a large part of the health law, and the best answer anyone had was the backlash to Reconstruction. Of course, that happened almost 150 years ago, and it could happen only because African-Americans were not yet considered full citizens. Since then, any large government program that improved millions of lives, once underway and functioning well, has endured.
http://mobile.nytimes.com/2015/06/28/upshot/why-undoing-social-safety-net-expansions-is-so-hard.html?em_pos=large&emc=edit_up_20150626&nl=upshot&nlid=1311158&ref=img&_r=1&referrer=

Legal Challenges Remain for Health Law 

By 
WASHINGTON — The Affordable Care Act survived another major test at the Supreme Court this week, all but assuring its place in the social safety net, but the legal challenges to the law are far from over.
One of the more significant tests is a lawsuit filed by Speaker John A. Boehner and other House Republicans who contend that the Obama administration is spending billions of dollars without the necessary appropriations from Congress.
The government is also trying to fend off dozens of lawsuits challenging rules that require health plans to offer women coverage for contraceptives without co-payments or deductibles.
The suit filed by Mr. Boehner, in the name of the House of Representatives, is not just a bookkeeping dispute. It involves fundamental questions of executive power and Congress’s power of the purse.
At issue is a provision of the health care law that requires insurance companies to reduce co-payments, deductibles and other out-of-pocket costs for certain low-income people. The federal government reimburses insurers for the “cost-sharing reductions.”
In their lawsuit, House Republicans say the Obama administration needed, but never received, an appropriation to make these payments to insurance companies. As a result, they contend, the spending violates the Constitution, which says, “No money shall be drawn from the Treasury, but in consequence of appropriations made by law.”
President Obama requested the money as part of the budget he sent to Congress in April 2013, but Congress did not act on the request. Seeing the issue as an urgent priority, the administration began making the payments in early 2014, using money from a separate account established for tax refunds and tax credits.
More than seven million people have insurance purchased through the federal marketplace. About 60 percent of them receive cost-sharing reductions, which lower their out-of-pocket costs for doctors’ services, hospital care and prescription drugs.
The discounts are available to people with incomes from 100 percent to 250 percent of the poverty level (roughly $11,700 to $29,300 a year for an individual).
This type of assistance is different from the subsidies upheld by the Supreme Court on Thursday. The subsidies, in the form of tax credits, help people pay insurance premiums.
The Congressional Budget Office estimates that the government will provide $599 billion worth of premium tax credits and $136 billion in cost-sharing payments to insurance companies in the coming decade.
In their lawsuit, House Republicans say, “Congress has not, and never has, appropriated any funds” for the cost-sharing reductions.
The Obama administration contends that the House does not have standing to sue because its members have not suffered a concrete injury or specific harm. The case is “a generalized institutional dispute between the executive branch and one chamber of the legislative branch,” the Justice Department said.


35 California counties grant healthcare to immigrants in U.S. illegally
In the latest wave of such decisions, a group of 35 mostly rural counties in California agreed this week to grant healthcare to immigrants in the country illegally.
For several years, just 11 of the state's 58 countiesprovided some form of low-cost medical care to these uninsured immigrants. But as of this month, 47 of the state's counties have promised to do so.
Healthcare services in 35 of the smallest counties are managed by a state outfit known as the County Medical Services Program. Mostly clustered in the northern part of the state, these counties include Sonoma, Solano and Marin, but also Imperial, at the Mexico border.
For the first time in its more than 30-year history, the panel that governs the program voted Thursday to offer primary medical care to people who have entered the country illegally.
"Even if these are not the most populated counties, for this to be available in nearly half of the geography of California is an important step," said Anthony Wright, executive director of Health Access California. Officials say a few thousand people could enroll in the program across the member counties.
Don Saylor, a supervisor in Yolo County — which participates in the program — said that offering health coverage will stop people from turning to costly emergency rooms for routine care. He also said that it is vital for preventing the spread of communicable diseases.
"Frankly, it's just the right thing to do," Saylor said in an interview Friday. "For us to have an underclass that is left out is unconscionable."



How to provide healthcare to the state's 2.7-million immigrants here illegally has been a recurring policy debate across the state this year. The population is barred from signing up for insurance under the Affordable Care Act and now makes up the single biggest group of Californians without insurance.


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Friday, June 26, 2015

Health Care Reform Articles - June 26, 2015

Supreme Court upholds Obamacare tax subsidies


By Lawrence Hurley,  Reuters

WASHINGTON — The U.S. Supreme Court handed President Barack Obama a major victory on Thursday by upholding tax subsidies crucial to his signature health care law, with Chief Justice John Roberts saying Congress clearly intended for them to be available in all 50 states.
The court ruled on a 6-3 vote that the 2010 Affordable Care Act, widely known as Obamacare, did not restrict the subsidies to states that establish their own online health care exchanges. It marked the second time in three years the high court ruled against a major challenge to the law brought by conservatives seeking to gut it.
“Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them,” Roberts wrote in the court’s decision, adding that nationwide availability of the credits is required to “avoid the type of calamitous result that Congress plainly meant to avoid.”
Roberts was joined by fellow conservative Justice Anthony Kennedy and the court’s four liberal members in the majority.
Shares of hospital operators, health services providers and insurers rallied broadly following the court’s decision to uphold the subsidies. Top gainers included hospital companies Tenet Healthcare Corp., up 8.8 percent, and Community Health Systems Inc., up 8.5 percent.
The decision means the subsidies will remain not just in the 13 states that have set up their own exchanges and the three states that have state-federal hybrid exchanges, but also in the 34 states, including Maine, that use the exchange run by the federal government.
The case centered on the tax subsidies offered under the law, passed by Obama’s fellow Democrats in Congress in 2010 over unified Republican opposition, that help low- and moderate-income people buy private health insurance. The exchanges are online marketplaces that allow consumers to shop among competing insurance plans.
In Maine, nearly 90 percent of the 68,000 residents who enrolled in health insurance under the law received subsidies to help them afford their monthly premiums. Without the financial leg up, the average premium would have shot up nearly 400 percent, from $88 to $425 per month, according to an analysis by the Kaiser Family Foundation.
“This is a tremendous victory for all of us. We are thrilled that Mainers will continue to have access to subsidies to make health insurance more affordable and accessible” Emily Brostek, executive director of the advocacy group Consumers for Affordable Health Care, said in a statement. “Tens of thousands of hard working Mainers will be helped by this decision. Without the subsidies, monthly insurance premiums are just too expensive for many people.”

Supreme Court Allows Nationwide Health Care Subsidies 

By 
WASHINGTON — The Supreme Court ruled on Thursday that President Obama’s health care law may provide nationwide tax subsidies to help poor and middle-class people buy health insurance.
Chief Justice John G. Roberts Jr. wrote the majority opinion in the 6-to-3 decision. The court’s three most conservative members — Justices Antonin Scalia, Clarence Thomas and Samuel A. Alito Jr. — dissented.
The case concerned a central part of the Affordable Care Act, Mr. Obama’s signature legislative achievement. The law created marketplaces, known as exchanges, to allow people who lack insurance to shop for individual health plans.
Some states set up their own exchanges, but about three dozen allowed the federal government to step in to run them. Across the nation, about 85 percent of customers using the exchanges qualify for subsidies to help pay for coverage, based on their income.
The question in the case, King v. Burwell, No. 14-114, was what to make of a phrase in the law that seems to say the subsidies are available only to people buying insurance on “an exchange established by the state.”
Four plaintiffs, all from Virginia, sued the Obama administration, saying the phrase meant that the law forbids the federal government to provide subsidies in states that do not have their own exchanges. Congress made the distinction, they said, to encourage states to create their own exchanges.
The plaintiffs challenged an Internal Revenue Serviceregulation that said subsidies were allowed whether the exchange was run by a state or by the federal government. They said the regulation was at odds with the Affordable Care Act.
Lawyers for the administration said the balance of the law demonstrated that Congress could not have intended to limit the subsidies. Accepting the plaintiffs’ position, the lawyers said, would affect more than six million people and create havoc in the insurance markets.
They added that the phrase, noticed by almost no one until long after the law was enacted, was a curious way to encourage states to establish exchanges.

The Supreme Court Saves Obamacare, Again

By 
On Thursday morning, for the second time in three years, a majority of the Supreme Court rightly rejected a blatantly political effort to destroy the Affordable Care Act. The case challenging the law, King v. Burwell, was always an ideological farce dressed in a specious legal argument, and the court should never have taken review of it to begin with.
Its core claim — that an ambiguous four-word phraseburied deep in the 900-page law eliminates health insurance for millions of lower-income Americans — was preposterous. The entire point of the law, as embodied in the title of its first chapter, is “Quality, affordable health care for all Americans.”
Writing for a six-member majority, Chief Justice John Roberts Jr. agreed that this clear, overriding purpose was the guiding principle. “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”
In all the years leading up to the law’s passage, no one questioned that purpose. Not a single person involved in passing or interpreting the law — including members of Congress, health-care journalists, and Supreme Court justices themselves — ever expressed a belief that subsidies would not be available on federally-operated exchanges. But the current challenge, brought to you by some of the same tireless conservative and libertarian activists who tried and failed to kill the health reform law in 2012, fabricated an alternate history out of thin air.
Their argument, based on an intentional misreading of four words, was that the tax-credit subsidies that make the law work are available only in the 13 states that fully run their own health care exchanges. Because a sub-sub-subsection of the law dealing with the calculation of those tax credits refers to an exchange “established by the state,” the challengers argued, no subsidies are available to the millions of Americans who live in the 34 states where the federal government runs the exchange.
It was a grandly orchestrated charade sold to people who were already furious about the law and just needed a legal rationale, however far-fetched, to try to gut it.

Obama Gains Vindication and Secures Legacy With Health Care Ruling

By 
WASHINGTON — For years, President Obama has faced the sneers of political adversaries who called his health care law Obamacare and assailed his effort to build a legacy that has been the aspiration of every Democratic president since Harry S. Truman.
But on Thursday, Mr. Obama walked into the Rose Garden to accept vindication as the Supreme Court, for a second time, affirmed the legality of a part of the Affordable Care Act. Mr. Obama said the law “is working exactly as it’s supposed to” and called for an end to the vitriolic politics that have threatened it.
“The point is, this is not an abstract thing anymore,” Mr. Obama told reporters, with Vice President Joseph R. Biden Jr. smiling broadly beside him. “This is not a set of political talking points. For all the misinformation campaigns, all the doomsday predictions, all the talk of death panels and job destruction, for all the repeal attempts — this law is now helping tens of millions of Americans.”
Mr. Obama’s plea to stop “refighting battles that have been settled again and again and again” met on Thursday with immediate resistance. House Speaker John A. Boehner, Republican of Ohio, promised to “do everything we can” to undermine the law. Jeb Bush, a Republican candidate for president, vowed “to repeal and replace this flawed law” if he succeeds Mr. Obama in the Oval Office.
Mr. Boehner said he will continue to move forward with a lawsuit against the president that argues that Mr. Obama overstepped his legal authority in carrying out the health care act, although the case is in its early stages at the district court level and could take years to come before the Supreme Court. Other Republicans mused on Thursday about using parliamentary maneuvers to chip away at the law.
But for Mr. Obama, the ruling was a personal affirmation of the wisdom of engaging in a costly political fight that began almost as soon as he took office. The court’s ruling, Mr. Obama said Thursday, cements the Affordable Care Act in American history as the logical extension of Social Security and Medicare.

Obamacare Ruling May Have Just Killed State-Based Exchanges

by Margot Sanger-Katz

Now that the Supreme Court has ruled that health insurance consumers can receive federal subsidies regardless of their state’s role in running their insurance market, fewer states may stay in the game.
When the Affordable Care Act passed in 2010, most people expected that each state would want to run its own health insurance marketplace. That never really happened, as many states opted to let the federal system, HealthCare.gov, do the work for them. Many of those states that did try running their own marketplaces are starting to think twice.
Now, with the Supreme Court ensuring that every state’s consumers will have equal access to federal subsidies, it is becoming clear that more of those states will revert to a federal system for enrolling people in health insurance.
“There may be a little bit of buyers’ remorse going on in some state capitals right now,” said Sabrina Corlette, the director of the Center on Health Insurance Reforms at Georgetown University. She said states underestimated the difficulty and expense of building and maintaining state marketplaces. Now, she said, many officials are asking: “What did we get ourselves into?”

Hooray for Obamacare


by Paul Krugman

Was I on the edge of my seat, waiting for the Supreme Court decision on Obamacare subsidies? No — I was pacing the room, too nervous to sit, worried that the court would use one sloppily worded sentence to deprive millions of health insurance, condemn tens of thousands to financial ruin, and send thousands to premature death.
It didn’t. And that means that the big distractions — the teething problems of the website, the objectively ludicrous but nonetheless menacing attempts at legal sabotage — are behind us, and we can focus on the reality of health reform. The Affordable Care Act is now in its second year of full operation; how’s it doing?
The answer is, better than even many supporters realize.
Start with the act’s most basic purpose, to cover the previously uninsured. Opponents of the law insisted that it would actually reduce coverage; in reality, around 15 million Americans have gained insurance.
But isn’t that a very partial success, with millions still uncovered? Well, many of those still uninsured are in that position because their state governments have refused to let the federal government enroll them in Medicaid.
Beyond that, you need to realize that the law was never intended or expected to cover everyone. Undocumented immigrants aren’t eligible, and any system that doesn’t enroll people automatically will see some of the population fall through the cracks. Massachusetts has had guaranteed health coverage for almost a decade, but 5 percent of its nonelderly adult population remains uninsured.
Suppose we use 5 percent uninsured as a benchmark. How much progress have we made toward getting there? In states that have implemented the act in full and expanded Medicaid, data from the Urban Institute show the uninsured falling from more than 16 percent to just 7.5 percent — that is, in year two we’re already around 80 percent of the way there. Most of the way with the A.C.A.!
But how good is that coverage? Cheaper plans under the law do have relatively large deductibles and impose significant out-of-pocket costs. Still, the plans are vastly better than no coverage at all, or the bare-bones plans that the act made illegal. The newly insured have seen a sharp drop in health-related financial distress, and report a high degree of satisfaction with their coverage.
What about costs? In 2013 there were dire warnings about a looming “rate shock”; instead, premiums came in well below expectations. In 2014 the usual suspects declared that huge premium increases were looming for 2015; the actual rise was just 2 percent. There was another flurry of scare stories about rate hikes earlier this year, but as more information comes in it looks as if premium increases for 2016 will be bigger than for this year but still modest by historical standards — which means that premiums remain much lower than expected.
And there has also been a sharp slowdown in the growth of overall health spending, which is probably due in part to the cost-control measures, largely aimed at Medicare, that were also an important part of health reform.
What about economic side effects? One of the many, many Republican votes against Obamacare involved passing something called the Repealing the Job-KillingHealth Care Law Act, and opponents have consistently warned that helping Americans afford health care would lead to economic doom. But there’s no job-killing in the data: The U.S. economy has added more than 240,000 jobs a month on average since Obamacare went into effect, its biggest gains since the 1990s.
Finally, what about claims that health reform would cause the budget deficit to explode? In reality, the deficit has continued to decline, and the Congressional Budget Office recently reaffirmed its conclusion that repealing Obamacare would increase, not reduce, the deficit.
Put all these things together, and what you have is a portrait of policy triumph — a law that, despite everything its opponents have done to undermine it, is achieving its goals, costing less than expected, and making the lives of millions of Americans better and more secure.

The Roberts Court’s Reality Check


by Linda Greenhouse
Sometimes the Supreme Court moves in mysterious ways. The health care decision was not one of those times.
A case that six months ago seemed to offer the court’s conservatives a low-risk opportunity to accomplish what they almost did in 2012 — kill the Affordable Care Act — became suffused with danger, for the millions of newly insured Americans, of course, but also for the Supreme Court itself. Ideology came face to face with reality, and reality prevailed.
The 6-to-3 vote to reject the latest challenge means that one or perhaps two of the justices who grabbed this case back in November had to have jumped ship. Here’s why: It takes at least four votes to add a case to the court’s docket. Given that the decision to hear this case, King v. Burwell, was entirely gratuitous — the Obama administration had won in the lower court, and an adverse decision in a different appeals court had been vacated — we can assume the votes came from the four justices who nearly managed to strangle the law three years ago in National Federation of Independent Business v. Sebelius.
These four were Justices Anthony M. Kennedy, Antonin Scalia, Clarence Thomas and Samuel A. Alito Jr. Maybe Chief Justice John G. Roberts Jr., excoriated in right-wing circles for having saved the statute with a late vote switch last time, also agreed to hear the new case. Or maybe his four erstwhile allies were trying to put the heat on him. It’s a delicious question without, at least for now, an answer.
When I think of this case on its trajectory toward the court, the image that comes to mind is of the great white shark in “Jaws,” swimming silently under the water, its lethal teeth bearing down on the statutory language freshly discovered by the administration’s enemies: “Exchange established by the State.”
Do “words no longer have meaning,” as Justice Scalia put it in his angry dissenting opinion? What, after all, could be clearer? The state, not the federal government. The two are not the same. They are different! So poor and middle-class people in the 34 (mostly red) states that refused to set up their own insurance exchanges, defaulting that task to the federal government, are just out of luck. They aren’t eligible for tax subsidies to help them buy insurance, subsidies that are critical to making the law work. End of story, end of case, end of the Affordable Care Act (or Scotuscare, as Justice Scalia said the law should be re-named).
The chief justice’s masterful opinion showed that line of argument for the simplistic and agenda-driven construct that it was. Parsing the 1,000-plus-page statute in a succinct 21-page opinion, he deftly wove in quotations from recent Supreme Court opinions.

A Turning Point for Health Care — and Its G.O.P. Opponents

By THEDA SKOCPOL and LAWRENCE R. JACOBS

FOR the second June in four years, the Supreme Court, led by its conservative chief justice, John G. Roberts Jr., has affirmed the legal framework of the Affordable Care Act of 2010 — the signature achievement of the Obama-era Democratic Party and a national social policy landmark. In so doing, the Roberts court assured the permanent expansion of social protections in America, and also saved the Republican Party from a no-win explosion its own extreme right-wingers tried to ignite.
For health reform, it is now steady as it goes, with wind at its back. The court’s June 2012 ruling that the Affordable Care Act was constitutional came at the price of a detour, because that ruling said states could choose whether or not to take federal money to expand their Medicaid programs to cover the near-poor.
However, this new Supreme Court decision, rejecting an ultraright challenge to the nationwide subsidies that allow lower-middle-income Americans to buy affordable private health insurance on state-level exchanges established by the federal government, will speed the already remarkable implementation of health reform. And that progress has been truly rapid by historical standards.
After Social Security was enacted in 1935, it faced a major revamp in 1939. Its taxes were stalled throughout World War II. Social Security remained politically vulnerable until the 1950s and did not become broadly popular or embedded in economic life until reforms under President Richard M. Nixon raised benefits for the poor and the middle class. In contrast, since full implementation of President Obama’s health law started in 2014, some 16 million additional Americans have gained health insurance coverage, and the national “uninsurance rate” has dropped to under 12 percent from 18 percent.
The Affordable Care Act would have survived even if the Supreme Court had decided King v. Burwell the other way, but insurance markets would have trembled in dozens of states. And millions would have faced threats to new coverage that most consumers report liking. Now sign-ups on the exchanges will continue and many more Republican-led states will decide to take federal money to pay for Medicaid expansion. By the time President Obama leaves the White House in January 2017, as many as 34 million will be covered by the exchanges and Medicaid, and the uninsurance rate could drop below 10 percent.

Health Law Ruling Elicits Sighs of Relief and Vows to Continue Fighting

By  and 
WASHINGTON — Democrats said it was finally time to accept that the Affordable Care Act was here to stay. Republicans vowed to keep trying to get rid of the law, but conceded that at this point, their best chance would be by winning back the White House next year.
And people like Margaret McElwain, who has breast cancer and a part-time job at Target, exulted over the Supreme Court’s decision to allow health insurance subsidies to keep flowing to more than six million Americans in the 34 states that did not establish their own online insurance marketplaces under the law.
“Thank God,” said Ms. McElwain, 64, of Mooresville, N.C., who was on her way to a chemotherapy appointment when she heard about the ruling. She said she pays $96 a month for the Blue Cross Blue Shield plan that she bought through the federal insurance marketplace, and receives a subsidy of more than $700 to cover the rest. “I really did not know how it was going to turn out, and you cannot imagine my relief.”
Hospitals and health centers across the country were breathing a sigh of relief.
“A catastrophe just got stopped,” said Dr. Gary Wiltz, an internist who runs a network of community health centers in rural Louisiana. He said his clinics have been able to increase diagnosis and treatment of diabetes and hypertension, two chronic illnesses that hit particularly hard among low-income Americans. “We have people in the middle of cancer treatments, some being worked up for heart disease. If that insurance would have gone away, it would literally have been a path to early death.”
In Congress, the court’s decision left Republicans badly divided on their next move. If the court had sided with the plaintiffs, they had hoped to force President Obama to negotiate a new set of health care reforms more to their liking. Now, any significant legislation will simply be vetoed, they conceded. That leaves them with a decision: Try to do something modest that could overcome a veto, or press forward with an attempt to truly replace the Affordable Care Act?



What to Take Away from the Supreme
Court Decision on Health Care


By CHARLIE SAVAGE

he Bottom Line

Chief Justice John G. Roberts Jr. explained why he and five other justices turned back this challenge to the Affordable Care Act.
FROM PAGE 26 OF THE DOCUMENT
In a democracy, the power to make the law rests with those chosen by the people. Our role is more confined— “to say what the law is.” Marbury v. Madison, 1 Cranch 137, 177 (1803). That is easier in some cases than in others. But in every case we must respect the role of the Legislature, and take care not to undo what it has done. A fair reading of legislation demands a fair understanding of the legislative plan. Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter. Section 36B can fairly be read consistent with what we see as Congress’s plan, and that is the reading we adopt.

Majority Opinion

The Key Phrase Open to Interpretation

The six justices in the majority concluded that the disputed phrase in the Affordable Care Act – “an exchange established by the state” – is ambiguous when read in context, and therefore can be interpreted in different ways. It does not have to be interpreted literally, as meaning that no subsidies are available to people in states that have not set up their own exchanges.
FROM PAGE 20 OF THE DOCUMENT
Anyway, we “must do our best, bearing in mind the fundamental canon of statutory construction that the words of a statute must be read in their context and with a view to their place in the overall statutory scheme.” Utility Air Regulatory Group, 573 U. S., at ___ (slip op., at 15) (internal quotation marks omitted). After reading Section 36B along with other related provisions in the Act, we cannot conclude that the phrase “an Exchange established by the State under [Section 18031]” is unambiguous.

Ruling to Avert an Insurance ‘Death Spiral’

The majority chose to interpret the ambiguous phrase in a way that allows the law to work, rather than cause an upheaval.
FROM PAGE 20 OF THE DOCUMENT
Given that the text is ambiguous, we must turn to the broader structure of the Act to determine the meaning of Section 36B. “A provision that may seem ambiguous in isolation is often clarified by the remainder of the statutory scheme … because only one of the permissible meanings produces a substantive effect that is compatible with the rest of the law.” United Sav. Assn. of Tex. v. Timbers of Inwood Forest Associates, Ltd., 484 U. S. 365, 371 (1988). Here, the statutory scheme compels us to reject petitioners’ interpretation because it would destabilize the individual insurance market in any State with a Federal Exchange, and likely create the very “death spirals” that Congress designed the Act to avoid. See New York State Dept. of Social Servs. v. Dublino, 413 U. S. 405, 419–420 (1973) (“We cannot interpret federal statutes to negate their own stated purposes.”).

Roberts Says Court Has Final Word on Interpreting Phrase



Supreme Court's Obamacare ruling boosts hospitals, health insurers

Health insurers and hospitals welcomed Thursday's Supreme Court decision upholding billions of dollars in Obamacare subsidies for U.S. consumers.
Many employers also applauded the 6-3 ruling, fearing the chaos that might have ensued in the health insurance markets from a ruling striking down the subsidies.
In wake of the decision, employers and other healthcare industry officials urged political leaders to tackle the unfinished business of taming the country's runaway medical spending.
"If we do not do more to control healthcare costs, the entire thing will collapse under its own weight regardless of what the Supreme Court or any other political body says," said Micah Weinberg, president of the Bay Area Council Economic Institute, an employer-backed group in San Francisco.
On Wall Street, hospital and health insurance company stocks rallied on news of the court decision.
Shares of hospital chain Tenet Healthcare Corp. shot up $6.13, or 12%, to $56.21 in trading Thursday.
UnitedHealth Group Inc., the nation's largest health insurer, saw its shares jump $3.16, or 3%, to $122.33 after the decision was announced.
"Today is a sigh of relief for the healthcare industry," said Megan Neuburger, a managing director and industry analyst at Fitch Ratings.
“The court’s decision to side with the administration in King vs. Burwell is ultimately positive for hospitals and health insurers as it keeps the status quo, which has been beneficial to them," she said.
Aetna Inc., the nation's third-largest health insurer, said subsidies played a significant role in attracting 6.4 million customers to federally run exchanges, and that an adverse ruling would have posed a major disruption.
"We believe that reform of the Affordable Care Act is still needed," Aetna said in a statement. "We urge Congress to focus on solutions that improve quality, transition our payment system to value-based care and broaden consumer choice."
Employer groups said they hope the court decision allows Congress and the Obama administration to address numerous issues related to the quality and cost of U.S. medical care.
"Now that the legal questions have been answered, the administration and Congress need to focus on real health reform -- rationalizing the way we pay for and deliver healthcare in this country," said Steve Wojcik, vice president of public policy at the National Business Group on Health.


Humana Said to Pursue Sale as Supreme Court Ruling Gives Insurers a Lift

By 
A new round of consolidation in the health insurance industry appeared closer as companies seek to grow larger, driven in part by cost-cutting and opportunities that are part of the Affordable Care Act.
In the latest jockeying, Humana, the smallest of the big five insurers, is pursuing a deal to sell itself and could reach an agreement by next week, according to a person briefed on the matter, who spoke on the condition of anonymity. Among those in the running to buy it are two bigger competitors, Aetna and Cigna.
The machinations of Humana — set against a backdrop of frenzied merger discussions within the insurance industry — received an extra jolt from the Supreme Court’s ruling on Thursday that the government could furnish tax subsidies for poor and middle-class Americans to buy health insurance.
The long-awaited ruling, in the case King v. Burwell, was a major victory for the Obama administration that will greatly benefit large parts of the American health care system. Insurers, especially, had been counting on those billions of dollars in tax subsidies to draw in new customers, particularly as Medicare and Medicaid turn to private health plans to offer coverage. Many insurers, including Humana, issued statements in support of the court’s decision.
Investors, too, were heartened by the ruling as shares in the major health insurers jumped on Thursday after the Supreme Court announced its decision. Trading in Humana’s stock was briefly halted and its price gained more momentum after Bloomberg News reported that it was near a deal to sell itself.
Still, it remains to be seen whether government regulators will bless too many consolidations, because of antitrust concerns. And it is unclear what effect more mergers will have on the prices consumers pay for insurance.
Other parts of the American health care sector were also bolstered by the ruling, particularly hospitals, which are expected to benefit from an increase in paying customers who now are covered by Medicaid or subsidized private insurance. Shares in HCA Holdings, the huge hospital operator, rose nearly 9 percent, while those of Tenet Healthcare jumped 12 percent.


The Supreme Court’s Obamacare ruling disappoints the conspiracy theorists

by The Washington Post Editorial Board.

IN ADVANCE of the Supreme Court taking its third crack at Obamacare, there was feverish speculation. The justices would vote according to their preferred policy outcomes, some said, striking down the subsidies that underpin the policy. Or the court’s conservatives would act to help Republican presidential candidates, preserving the subsidies to prevent a policy disaster for which the GOP would be blamed. Or maybe Chief Justice John G. Roberts Jr. would do whatever he thought was in the best interests of the institution of the Supreme Court.
No such untoward motivations were evident in the cogent ruling the court issued Thursday, which maintains government health-care subsidies for needy Americans in every state. Chief Justice Roberts and Justice Anthony M. Kennedy both joined the court’s liberal wing in endorsing the most reasonable reading of the statute, knowing they will face an angry backlash from the Obamacare-hating right. Perhaps the next time the court delivers a ruling that disappoints the left, the default position should not be to question its good faith.
The case decided Thursday, King v. Burwell, arose from a line in the Affordable Care Act that is, in fact, ambiguous. The law says that subsidies are available to those who buy coverage in a marketplace “established by the State.” Does that really mean, as the Obama administration’s opponents alleged, that the law denies subsidies to people in the majority of states that refused to establish a marketplace? The law, after all, also tells the federal government to establish “such” marketplaces in states that don’t do it on their own. That, among other things, suggests there should be no practical distinction between marketplaces established by states and that established by the federal government.
“Given that the text is ambiguous,” the chief justice wrote, “the Court must look to the broader structure of the Act.” Federal subsidies for insurance buyers are central to the policy, making the Affordable Care Act affordable. Without them, insurance markets would crumble. “It is implausible that Congress meant the Act to operate in this manner,” the opinion states. The court, therefore, wisely and modestly declined to rip apart the policy.
The practical impact of the ruling is unambiguously positive. Subsidies will not be suddenly revoked from people who rely on them to purchase health insurance. Insurance markets just beginning to find their footing in states across the country will continue to grow. A reasonable health-care policy has at least another year and a half to phase in under the supervision of a president who is committed to making it work, not undermining it. The law has not solved every problem in U.S. health care. But it already has done a lot of good, starting with the recent, dramatic drop in the uninsured rate.
It’s easy when disagreeing with a Supreme Court ruling, whether King v. Burwell orCitizens United, to dismiss it as the product of bad faith. Thursday’s ruling should encourage the court’s more strident critics to wonder who the real cynics are.

Republicans secretly cheer Supreme Court Obamacare decision

By 

Everybody has come out a winner with the Supreme Court’s ruling in favor of Obamacare — at least politically.
For President Obama, the 6-to-3 decision maintains the federally managed health plans in 34 states that do not have their own systems, thus preventing the collapse of the signature domestic achievement of his presidency. That is an obvious win and, in his White House Rose Garden speech on Thursday, Obama looked like a guy ready to run a victory lap with high-fives for everyone.
As happy as the president is with the result, though, Republicans may be even happier. If the court’s decision had gone the other way, the governors in those 34 states -- most of them Republicans -- would have had a crisis on their hands, and the GOP-led Congress would have been expected to come up with a very quick remedy or risk facing the wrath of millions of voters suddenly dumped from the healthcare system.
Now, Republicans in the House and Senate can continue to rail against Obamacare, hone their talking points and make vague assertions that they have a better idea without having to do anything — and congressional Republicans have proved pretty convincingly that doing nothing is what they do best.

The ruling is especially fortunate for the army of Republican presidential aspirants. Rather than offer detailed schemes to revamp American healthcare — plans that could be nitpicked by rival campaigns, the media and skeptical voters — they can continue to whip up the party’s angry and fearful base by making broad attacks on Obamacare while offering nothing more specific than platitudinous pledges to replace it with a pleasant-sounding “market-based” system that, they insist, will be a million times better.http://www.latimes.com/opinion/topoftheticket/la-na-tt-republicans-cheer-court-20150625-story.html

With Supreme Court’s Obamacare ruling, 61,000 Mainers to keep health insurance subsidies

By Lawrence Hurley, Reuters
WASHINGTON — The U.S. Supreme Court handed President Barack Obama a major victory Thursday by upholding tax subsidies crucial to his signature health care law, with Chief Justice John Roberts saying Congress clearly intended for them to be available in all 50 states.
The court ruled on a 6-3 vote that the 2010 Affordable Care Act, widely known as Obamacare, did not restrict the subsidies to states that establish their own online health care exchanges. It marked the second time in three years the high court ruled against a major challenge to the law brought by conservatives seeking to gut it.
“Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them,” Roberts wrote in the court’s decision, adding that nationwide availability of the credits is required to “avoid the type of calamitous result that Congress plainly meant to avoid.”
Roberts was joined by fellow conservative Justice Anthony Kennedy and the court’s four liberal members in the majority.
The decision means the subsidies will remain not just in the 13 states that have set up their own exchanges and the three states that have state-federal hybrid exchanges, but also in the 34 states, including Maine, that use the exchange run by the federal government.
The exchanges are geared toward people who buy “individual” health insurance, instead of get coverage through work or the government.
The case centered on the tax subsidies offered under the law, passed by Obama’s fellow Democrats in Congress in 2010 over unified Republican opposition, that help low- and moderate-income people buy private health insurance. The exchanges are online marketplaces that allow consumers to shop among competing insurance plans.
In Maine, the ruling will leave subsidies in the hands of nearly 61,000 people. Almost 90 percent of the 68,000 residents who enrolled in health insurance under the law received subsidies to help them afford their monthly premiums. Without the financial leg up, the average premium would have shot up nearly 400 percent, from $88 to $425 per month, according to an analysis by the Kaiser Family Foundation.
“This is a tremendous victory for all of us. We are thrilled that Mainers will continue to have access to subsidies to make health insurance more affordable and accessible,” Emily Brostek, executive director of the advocacy group Consumers for Affordable Health Care, said in a statement. “Tens of thousands of hardworking Mainers will be helped by this decision. Without the subsidies, monthly insurance premiums are just too expensive for many people.”
The Maine Health Access Foundation, which coordinated enrollment outreach in Maine, applauded the court’s decision, saying “in some cases these subsidies have made health insurance affordable for the first time in people’s lives.” 
People who can’t get affordable health insurance through their jobs and earn between 100 percent and 400 percent of the federal poverty level — between $23,850 and $95,400 per year for a family of four — are eligible for the subsidies.
The question before the justices was whether a four-word phrase in the expansive law saying subsidies are available to those buying insurance on exchanges “established by the state” has been correctly interpreted by the administration to allow subsidies to be available nationwide.
Roberts wrote that although the conservative challengers’ arguments about the plain meaning of the statute were “strong,” the “context and structure of the act compel us to depart from what would otherwise be the most natural reading of the pertinent statutory phrase.”
U.S. Sen. Angus King released a statement Thursday cheering the Supreme Court’s decision.
“Today, more than 60,000 people in Maine and millions more across the country can breathe a sigh of relief that they still have access to the high-quality, affordable health insurance plans provided through the Affordable Care Act,” King said. “I applaud the Supreme Court’s decision and hope that we can finally put discussions about dismantling the law behind us, and instead, dedicate ourselves to making this law better for the millions of Americans who it helps every day.” 
U.S. Rep. Chellie Pingree also weighed in on the Affordable Care Act ruling.
“I’m glad the Supreme Court did the right thing and protected health care coverage for millions of Americans,” Pingree said. “This is a case they should never have taken up. Opponents were trying to take a few words out of context to undermine the entire law. When the ACA was being written and passed, everybody — Republicans, Democrats, and the Congressional Budget Office alike — agreed that the subsidies would be available in all states. Only later did opponents change their mind.”
In light of the ruling, Congress must work together to fix some of the ACA’s “flaws” that have hurt low- and middle-income workers and employees of small businesses, U.S. Sen. Susan Collins said.
“These flaws include the harsh penalties under Obamacare for middle-income workers who earn extra money or get a raise in a given year and the disincentives for small businesses to hire additional employees,” she said in a statement. “These provisions need to be corrected — they discourage struggling workers from trying to earn more money and discourage small businesses from creating jobs.”
U.S. Rep. Bruce Poliquin said he would “continue to push for free market fixes to Obamacare that increase competition among health insurance companies, expand health care plan choices, lower costs, grow the economy, cover pre-existing conditions, and protect the vulnerable.” 

Scalia dissents

Justice Antonin Scalia took the relatively rare step of reading a summary of his dissenting opinion from the bench.
In his reading of the statute, “it is hard to come up with a reason to use these words other than the purpose of limiting credits to state exchanges,” Scalia said.
“We really should start calling the law SCOTUScare,” he added, referencing the court’s earlier decision upholding the constitutionality of the law. SCOTUS is the acronym for the Supreme Court of the United States.
Conservative Justices Clarence Thomas and Samuel Alito joined Scalia’s dissent.
The ruling will come as a major relief to Obama as he seeks to ensure his legacy legislative achievement is implemented effectively and survives political and legal attacks before he leaves office in early 2017.
The current system will remain in place, with subsidies available in all 50 states. If the challengers had won, at least 6.4 million people in at least 34 states would have lost the subsidies, whose average value is $272 per month.
“The subsidies upheld today help patients afford health insurance so they can see a doctor when they need one and not have to wait until a small health problem becomes a crisis,” Dr. Steven Stack, president of the American Medical Association, said.

Measuring the Success of Health Insurance Subsidies

By  and 
WASHINGTON — The Supreme Court will decide within days whether federal health insurance subsidies for people in more than 30 states are allowed by law. A broader question is, To what extent are the subsidies responsible for the expansion of health care coverage to millions of Americans under the Affordable Care Act?
In short, Have the subsidies succeeded?
By many measures, the answer is yes. More than seven million people are enrolled in the federal health insurance marketplaces, and a majority of them — 87 percent — receive subsidies in the form of tax credits to help pay their premiums, the government says. Without subsidies, many would be unable to buy insurance.
The subsidies also appear to have drawn substantial numbers of younger, healthier Americans into the new insurance markets, stabilizing premiums, even for people who pay the full cost themselves.
The subsidies average $272 a month, or $3,264 a year, and cover nearly three-fourths of the average premium for people receiving assistance, the government says. Beneficiaries are clustered in the lower income brackets, where the need has been greatest.
Two-thirds of federal marketplace customers have incomes less than twice the poverty level (less than about $23,500 a year for a single person), the Department of Health and Human Services says. More than 40 percent have incomes less than 150 percent of the poverty level.
Lower-income people have long been more likely than higher-income people to be uninsured.
Lizzie Perez Jimenez, 22, of Tampa, Fla., is studying to become a nurse and works part-time at a retail store in a shopping mall. She earns $1,300 a month and is not offered insurance. Her premium is $200 a month. She pays $50 and receives a tax credit of $150.
“Without the tax credit, I probably would not have insurance,” said Ms. Jimenez, who has asthma. “It’s way too expensive for me.”
The effectiveness of the subsidies is separate from the question of whether they are legal. In the Supreme Courtcase, King v. Burwell, the plaintiffs contend that the 2010 health care law allows subsidies only in states that established their own marketplaces, not in states that use the federal exchange.


Bad Neighborhoods May Be Bad for Your DNA

by Nicholas Bakalar - NYT - June 24, 2015

It has long been known that people who live in unsafe neighborhoods suffer poorer health and increased risk for death. Now researchers have found that living in these areas is associated with shorter telomere length, a marker of aging cells.
Telomeres, which lie at the ends of chromosomes, are structures involved in the replication of DNA molecules. Each time a cell divides, telomeres becomes shorter, a process associated with aging, illness and death.
Researchers studied 2,981 Dutch people aged 18 to 65, measuring telomere lengths in their white blood cells. They assessed neighborhood quality by asking residents about high noise levels, vandalism in the neighborhood, and feeling unsafe walking alone. The study is in PLOS One.
After controlling for a range of socioeconomic, health and lifestyle characteristics, they found that the greater the residents’ degree of unfavorable perceptions about their neighborhoods, the shorter the average telomere length in their cells.
The lead author, Mijung Park, an assistant professor of nursing at the University of Pittsburgh, said that the results should be interpreted cautiously — it is an observational study, and does not prove cause and effect.
Still, she said, “When we look at two people of the same age and gender and other characteristics, we find that those who live in bad neighborhoods are biologically older than those who do not by about 12 years.”

Why Don’t the Poor Rise Up?


Why are today’s working poor so quiescent? I’m not the only one posing this question.
“Why aren’t the poor storming the barricades?” asks The Economist. “Why don’t voters demand more redistribution?” wonders David Samuels, a political scientist at the University of Minnesota. The headline on an April 7 National Catholic Reporter article reads: “Why aren’t Americans doing more to protest inequality?”
There are legitimate grounds for grievance. For those in the bottom quintile, household income in inflation-adjusted dollars has dropped sharply, from $13,787 in 2000 to $11,651 in 2013. According to the Census Bureau, 64 million Americans currently live in the bottom quintile.
Still, it’s possible that poverty is less grueling than in the past, for several reasons. First, although incomes have declined, the cost of many goods – televisions, computers, air-conditioners, household appliances, cellphones – has fallen, leaving the bottom quintile less deprived than simple income figures might reflect. Second, people nowadays marry and have children later in life than in the past, postponing some financial demands to better earning years. Third, some economistscontend that commonly used inflation measures result in excessively high estimates of the real-world cost of goods for consumers, thus making living conditions less dire than they might otherwise be.
But there is another reason that there has not been broad public insurrection.
Society has drastically changed since the high-water mark of the 1930s and 1960s when collective movements captured the public imagination. Now, there is an inexorable pressure on individuals to, in effect, fly solo. There is very little social support for class-based protest – what used to be called solidarity.
Describing a process that sociologists have termed “individualization,” Christopher Ray, a researcher at the University of Newcastle in England, makes the point that individualization is, on one hand,
a positive, enabling and democratic phenomenon. On the other hand, the same dynamic generates the conditions of omnipresent and ever-changing risk, perceived as new obligations or burdens, and new forces bearing down on the individual and on local life.
People today, Ray continues, “are not only able to make choices in an ever-expanding range of situations, but they are also compelled to do so.”
In effect, individualization is a double-edged sword. In exchange for new personal freedoms and rights, beneficiaries are agreeing to, if not being forced to, assume new risks and responsibilities.




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