Trump’s Health Secretary Pick Leaves Nation’s Doctors Divided
by Robert Pear - NYT
WASHINGTON — When President-elect Donald J. Trump chose Representative Tom Price of Georgia to be his health and human services secretary, the American Medical Association swiftly endorsed the selection of one of its own, an orthopedic surgeon who has championed the role of physicians throughout his legislative career.
Then the larger world of doctors and nurses weighed in on the beliefs and record of Mr. Price, a suburban Atlanta Republican — and the split among caregivers, especially doctors, quickly grew sharp.
“The A.M.A. does not speak for us,” says a petition signed by more than 5,000 doctors.
Mr. Trump and a Republican-held Congress are considering some of the biggest changes to the American health care system in generations: not only the repeal of the Affordable Care Act, which is providing insurance to some 20 million people, but also the transformation of Medicare, for older Americans, and Medicaid, for low-income people. Mr. Price has favored those changes.
Seven years ago, the A.M.A.’s support helped lift President Obama’s health care proposals toward passage, and the group has backed the law, with some reservations, since its adoption in 2010. But as Republicans push for its dismantlement, deep disagreements within the A.M.A., which has long wielded tremendous power in Washington, could lessen its influence.
http://www.nytimes.com/2016/12/26/us/tom-price-hhs-donald-trump-cabinet.html?smprod=nytcore-ipad&smid=nytcore-ipad-share
Donald Trump's Cabinet Pick for Health and Human Services Made a Killing on Medical Stocks in the House
Rep. Tom Price also has big plans to kill Medicare.
by Joan McCarter - Daily Kos
Rep. Tom Price (R-GA), an orthopedic surgeon by trade and popular-vote-loser Donald Trump's pick to head Health and Human Services, traded more than $300,000 in shares in medical-related companies, all the while working and voting on legislation that could affect those companies’ stocks.
Rep. Tom Price, a Georgia Republican, bought and sold stock in about 40 health-care, pharmaceutical and biomedical companies since 2012, including a dozen in the current congressional session, according to a Wall Street Journal review of hundreds of pages of stock trades he filed with Congress.
In the same two-year period, he has sponsored nine and co-sponsored 35 health-related bills in the House.His largest single stock buy was an August 2016 purchase of between $50,000 and $100,000 of an Australian biomedical firm, Innate Immunotherapeutics Inc., whose largest shareholder is a GOP congressman on the Trump transition team, according to the filings, which list price ranges. The stock has since doubled in price. […]Mr. Price’s trading is likely to be a significant issue during his Senate confirmation hearings. Allegations of abusive trading by members of Congress in recent years led to a 2012 law—the Stop Trading on Congressional Knowledge (STOCK) Act—that bars members and employees of Congress from using “any nonpublic information derived from the individual’s position…or gained from performance of the individual’s duties, for personal benefit.” The law also requires members to report their trades within 45 days.
The law stops short of requiring members of Congress to put their investments into mutual funds or blind trusts, and what the law doesn't make them do, you can sure as hell bet that the likes of Price won't do. He'll have to sell them, if he's actually confirmed, or recuse himself from any decisions HHS would be making that has anything to do with these companies. But Price has been a very big player in health policy in the House, sitting on the Ways and Means Committee’s health panel, which oversees Medicare. He's also a member of the Republicans’ Congressional Health Care Caucus. While holding shares in a tobacco company. Because he cares so much about health. And he's been a big recipient of campaign cash from the industry, too. In this Congress, he received about $730,000 in campaign donations, and in his six terms in office, "he has raised about $15 million, and about $4.8 million came from the health sector."
But his stock trading is what should be raising questions in the Senate confirmation hearings. Like his major investment in Aetna stocks, and the fact that his own legislation to "replace" Obamacare, the Empowering Patients First Act, would give patients tax credits to go by health insurance, with the health insurance companies freed from the restrictions and requirements Obamacare places on them to actually provide worthwhile coverage.
Oh, and he wants to kill Medicare. Which should be a confirmation-killer in an of itself. But the conflict of interest thing? Yeah, they might want to talk with him about that.
Chaotic, dysfunctional system of health ‘insurance’ needs medical attention
by Keith Vallencourt - Portland Press Herald
Why can't we have one big bucket of money for health care that we all pay into – it would be so simple.
Why does any discussion of health care always revolve around “health insurance”? I question if there’s any such thing.
Why?
Insurance implies spreading risk. For catastrophes with low probabilities of occurrence, it works fine. Only about one in 300 houses will experience a serious fire, so instead of setting aside $300,000 to rebuild your house in the event of such an unlikely tragedy, you and 299 other homeowners can kick in $1,000 apiece and share the exposure. That’s fire insurance.
But what are the odds of us getting sick and requiring health care, especially later in life? Pretty much 100 percent, right? So there is no pooling of risk, which vitiates the whole notion of health insurance. Instead, we ought to be thinking in terms of health savings accounts, which in effect is what we have now, but with a diabolical twist or two. Consider …
This figure is hard to pin down, but averaging the estimates published by various sources, a typical American pays about $400,000 in lifetime health costs. (That number is way higher than it ought to be, but that’s a different column.)
Now assume that you have 40 years to save up that amount, and that health care costs will rise at an effective annual rate of 3 percent (by “effective rate,” I mean that health care costs will rise at a rate that’s 3 percent higher than the rate at which you can invest your money). That means you’ll have to set aside $1,432 per month to pay for your lifetime health care costs.
Now look at what you’re actually paying for health care.
First, figure out what your real health care premium is, not just what gets taken out of your paycheck. For an individual, $700 a month is a ballpark figure.
Add in your deductibles and co-pays: Does $2,400 a year – or $200 a month – sound about right? Then there’s your long-term care insurance premium – $150 a month or thereabouts.
Now consider your Medicare payroll taxes – typically about $400 a month. (To simplify things a bit, this number includes the amortized value of your post-retirement premiums and other payments.)
And don’t forget Medicaid – you may never need it, but you pay for it anyway. These vary from state to state, but $150 a month will do for now.
All told, that’s $1,600 a month, more than the savings rate we calculated, and even that increases sharply as we age. Ergo, we don’t buy “insurance” with our premiums; we just make deposits into a health savings account. Now here come the diabolical twists.
We don’t pay nearly enough for Medicare. Most of us incur two-thirds of our lifetime health expenses after we retire, after many of us have exchanged our former health insurance for Medicare. So that $700 a month we pay in insurance premiums only yields $233 in benefits; the insurance company keeps the rest – which is why Medicare is such a mess. On average we receive three times more in Medicare benefits than we pay because the money we put into health insurance isn’t available when we need it. Unless we agree to triple our Medicare contribution – not too likely, I’d say – our progeny will get stuck with the bill.
But the really diabolical twist is this: If suddenly we find ourselves out of work and unable to pay the full health insurance premiums under the COBRA law, we lose it all – possibly hundreds of thousands of dollars gone because of one missed payment. Until the Affordable Care Act came along, if you were old or sick, you probably never would be covered again. No, we don’t have health insurance; we have a health savings account, but in the name of an insurance company.
Is this insane, or what?
Instead of paying into all these different buckets that don’t overflow into each other – health insurance, long-term care insurance, Medicare, Medicaid and out-of-pocket – wouldn’t it make a lot more sense to just pay into a single bucket? And instead of insurance companies, to have health care brokers who, for a fee, bargain on our behalf for the best rates and provide gap insurance between what we’ve saved and what we might need?
Moreover, wouldn’t such a scheme be a boon to entrepreneurs and small businesses, who’d be out from under the disproportionately heavy burden of supplying health care to themselves and their employees?
The rest of the world seems to think so, but they’re not Americans, so what do they know?
After states legalized medical marijuana, traffic deaths fell
by Ronnie Cohen - Reuters
(Reuters Health) - Legalization of medical marijuana is not linked with increased traffic fatalities, a new study finds. In some states, in fact, the number of people killed in traffic accidents dropped after medical marijuana laws were enacted.
“Instead of seeing an increase in fatalities, we saw a reduction, which was totally unexpected,” said Julian Santaella-Tenorio, the study’s lead author and a doctoral student at Columbia University’s Mailman School of Public Health in New York City.
Since 1996, 28 states have legalized marijuana for medical use.
Deaths dropped 11 percent on average in states that legalized medical marijuana, researchers discovered after analyzing 1.2 million traffic fatalities nationwide from 1985 through 2014.
The decrease in traffic fatalities was particularly striking – 12 percent – in 25- to 44-year-olds, an age group with a large percentage of registered medical marijuana users, the authors report in the American Journal of Public Health.
Though Santaella-Tenorio was surprised by the drop in traffic deaths, the results mirror the findings of another study of data from 19 states published in 2013 in The Journal of Law and Economics. It showed an 8 to 11 percent decrease in traffic fatalities during the first full year after legalization of medical marijuana.
“Public safety doesn’t decrease with increased access to marijuana, rather it improves,” Benjamin Hansen, one of the authors of the previous study, said in an email. Hansen, an economics professor at the University of Oregon in Eugene, was not involved in the current study.
He cautioned that both marijuana and alcohol are drugs that can impair driving.
It’s not clear why traffic deaths might drop when medical marijuana becomes legal, and the study can only show an association; it can’t prove cause and effect.
The authors of both studies suggest that marijuana users might be more aware of their impairment as a result of the drug than drinkers. It’s also possible, they say, that patients with access to medical marijuana have substituted weed at home for booze in bars and have stayed off the roads.
Or, they suggest, the drop in traffic fatalities could stem from other factors, such as an increased police presence following enactment of medical marijuana laws.
Law-enforcement authorities have yet to devise a way to test drivers for marijuana intoxication, and have raised concerns about drivers high on cannabis.
Though traffic deaths dropped following legalization of medical marijuana laws in seven states, fatality rates rose in Rhode Island and Connecticut, the study found.
California immediately cut traffic deaths by 16 percent following medical marijuana legalization and then saw a gradual increase, the study found. Researchers saw a similar trend in New Mexico, with an immediate reduction of more than 17 percent followed by an increase.
The findings highlight differences in various states’ medical marijuana laws and indicate the need for research on the particularities of how localities have implemented them, Santaella-Tenorio said.
Voters in Denver, Colorado approved a November ballot measure to allow public consumption of marijuana, Hansen noted. But, he said, “We don’t know the public health consequences of those types of policy changes yet.”
Analysis: GOP united on repealing Obamacare, but disagree on how to replace it
by Ricardo Alonso-Zaldivar - Associated Press
WASHINGTON — Republicans are united on repealing President Barack Obama’s health care law, but ideologically and practically speaking, they’re in different camps over replacing it. Getting the factions together won’t be easy.
Some Republicans would revise and rebrand “Obamacare,” junking unpopular provisions like its requirement that most Americans carry health insurance, while preserving more popular provisions. Others would rip up the Affordable Care Act, or ACA, and not replace it.
President-elect Donald Trump and Republican congressional leaders will have to unite the groups on complicated changes affecting the financial and physical well-being of millions of people. For some constituents in fragile health, it’s literally a life-and-death debate.
Republicans have “a really narrow path,” says Grace-Marie Turner of the Galen Institute, a free-market health care research organization. “They’ve got to deal with the politics of this, they’ve got to make sure they come up with good policy, and they also have process challenges.”
Success is not guaranteed, and Republicans may come to regret that their party defined itself as totally opposed to “Obamacare.”
Yet House Ways and Means Chairman Kevin Brady seems unfazed by the challenge. “It’s like tax reform,” the Texas Republican says, explaining that many pieces will be pulled together. “Unlike Obamacare, which ripped up the individual market, this will be done deliberately, in an appropriate timetable.”
Republicans say they will move quickly to repeal the ACA, while suspending the effective date to allow them to craft a replacement. Here’s a look at the GOP camps and who’s in them:
REVISE & REBRAND
Many Republicans may quietly be in this contingent, but fear being accused of promoting “Obamacare-lite.”
They’d strip out some of the ACA’s taxes and requirements. The unpopular “individual mandate” to carry health insurance or risk fines could be replaced with other persuasion short of a government dictate. Rules on insurers would be loosened.
But popular provisions such as protecting those with pre-existing health conditions would be retained in some form, as well as financial assistance for low- and moderate-income people. The requirement that health plans cover adult children until age 26 would be fairly easy to preserve, since employers have accommodated it.
A rebranded version of Obama’s law may well cover fewer people. But its GOP advocates believe most Americans will find their goal of “universal access” politically acceptable when measured against the Democratic ideal of “universal coverage” underwritten by government.
Many GOP allies in the business community favor revising the ACA. That includes major players among hospitals, insurers and pharmaceuticals.
Trump may have given this group some cover by saying that he wants to keep parts of the law, but his bottom line remains unknown.
BUDGET HAWKS
For budget hawks, unwinding the Obama health law is a beginning. Next they could move on to much bigger objectives like restructuring Medicaid and Medicare, and placing a cost-conscious limit on tax breaks for employer coverage.
Budget hawks see health care as the main driver of government deficits, and they are loath to address that imbalance by raising taxes. Instead they want to rewrite the social compact so individuals accept more responsibility and risk for their health care.
House Speaker Paul Ryan is the most prominent member of this camp, and his “Better Way” agenda is its roadmap. Georgia Rep. Tom Price, Trump’s nominee to run the Department of Health and Human Services, is a budget hawk. Vice President-elect Mike Pence has been in the same orbit throughout his career.
The problem for budget hawks is that the 2016 political campaign did not give them a mandate. Issues like Medicare and Medicaid were scarcely discussed. Trump said he wouldn’t cut Medicare, and sent conflicting signals on Medicaid.
Many Democrats can’t wait for Republicans to follow the call of the budget hawks. Betting that will backfire, House Democratic Leader Nancy Pelosi is rallying her lawmakers against “attacks on the ACA and Medicare.”
THE RIP-IT-UP SOCIETY
The most conservative lawmakers want to “pull Obamacare up by the roots as if it never existed,” says Republican political consultant Frank Luntz. That sentiment is embodied by the 40 or so members of the House Freedom Caucus, and it’s probably broadly shared among conservatives.
Some do not believe the federal government should be involved in health care, and they couldn’t care less about replacing the ACA.
“They would say that Obama’s plan has failed,” said Luntz.
GOP leaders may need these lawmakers to advance on replacement legislation; coaxing them to a middle ground might not be possible.
Trump calls the ACA “a disaster,” and that’s pleasing to those farthest on the right. It’s unclear if he’d walk their walk.
PRAGMATISTS
At the core of this small group are legislative veterans who understand the excruciating difficulties of getting major bills to a president’s desk. GOP Sens. Lamar Alexander of Tennessee and Susan Collins of Maine are pragmatists.
They may find support from Republican governors who expanded Medicaid under the health law. GOP congressional leaders could gravitate to this camp.
The biggest challenge for pragmatists will be to win over some Democrats for replacement legislation. While repealing most of “Obamacare” is possible with a simple majority in the Senate, 60 votes would probably be needed for a replacement. There will only be 52 GOP senators in the coming congressional session.
“Republicans need a fancy Rose Garden repeal ceremony…and I expect them to have one,” said Dan Mendelson, CEO of the consulting firm Avalere Health. “On the other hand, there’s 20 million people with health insurance under the ACA, and they don’t want to dump them. There’s no clear path for how to square that conflict.”
Trump Has a Perfect Blueprint to Make the Poor Pay More for Medicaid: Mike Pence's Indiana
Participants call the program a "nightmare."
by Sarah K. Burris - Alternate
The architect of Indiana’s Medicaid expansion has been hired by the incoming Donald Trump administration. If what Seema Verma did to Mike Pence's state is any indication, Medicaid could soon become a more profitable enterprise on the backs of the poor and disabled.
Verma has been named to run the Centers for Medicare and Medicaid Services. According to an NPR report, she was previously hired by Indiana Gov. Pence to create a “Republican version” of Medicaid under the Affordable Care Act. For a $5 million fee, Verma devised a system that requires the poor and disabled to pay a monthly fee for Medicare. The program expanded Medicaid to an additional 246,000 people, who all pay from $1-$27 a month into individual health savings accounts.
If they don’t pay, they lose their health care. Those above the poverty level lose their health care for three months. Anyone below the poverty level who can’t pay has their plan taken down to a lower level of care. The plan hasn’t gone into effect yet, however. They asked for a waiver to work out the kinks.
“The Medicaid program has not kept pace with the modern health-care market,” Verma said during a 2013 congressional hearing. “Its rigid complex rules designed to protect enrollees have also created an intractable program that does not foster efficiency quality or personal responsibility.”
She wants to see the poor take responsibility. If people get vaccines or other preventative care, they earn discounts on their premiums the next year.
Amber Thayer, a mother of three who has been living in an Indiana shelter, calls the program a nightmare. She’s a recovering addict who has been clean for six months and is training to be a nursing assistant. Thayer has been giving $1 a month to her health care, but said that each month she gets a $1 invoice from a different company.
“It is only a dollar,” she says. “I could pay a dollar a month or I could pay $12 and that will cover me for the year. Unfortunately, at that time I only had I believe it was like $2.38 on my card.”
She paid her dollar, but somehow the state lost track, perhaps because it changed the companies. So her health insurance was cut off. Thayer had bank statements and receipts to prove she had paid, but it still took her six weeks on the phone to get her health care reinstated. That meant paying out of pocket for the medication helping with her sobriety.
She was also scared the insurance problem might prevent her from being able to take her nursing assistant exam. If she couldn’t take her exam she wouldn’t get the stipend she receives because she is in a job training program.
“If I don’t get my stipend, we’re not going to have our money to help us move into our home.”
Adam Mueller, a lawyer for Indiana Legal Services, explained that the idea of “personal responsibility” being attained by paying $1 a month for health care doesn’t exactly work out in the real world.
“They don’t feel like they have skin in the game,” Mueller says. “One guy told me that it feels like Indiana is trying to take his last $12.”
Arkansas had a similar program, but it was scrapped after a few years because it wasn’t worth it.
The state’s former surgeon general Joe Thompson explained that the GOP value of “personal responsibility” sounds great politically, but in practice, it doesn’t work.
“We had about a year and a half of experience there, and candidly the administrative cost and the operating aspects exceeded what the legislature subsequently perceived the benefit of that program was,” Thompson says. So they canceled the program.
“We lose too many folks along the way, and we may be causing more challenges than we’re solving,” he says.
President-elect Trump campaigned on repealing and replacing Obamacare “on day one,” but with Americans setting new records signing up for the program, it’s unclear what it will be replaced with.
Hospitals in Safety Net Brace for Health Care Law’s Repeal
by Abby Goodnough - NYT
PHILADELPHIA — Jason Colston Sr. went to the emergency room at Temple University Hospital last month with his calf swollen to twice its normal size. A bacterial infection had entered his bloodstream, requiring him to spend nine days at Temple, where patients are overwhelmingly poor.
Mr. Colston, 36, had no insurance through his job at a 7-Eleven, but it turned out he was eligible for Medicaid under the Affordable Care Act. Temple helped him enroll as soon as he was admitted, and Medicaid paid for his stay and continuing treatment.
Before the health law, the hospital had to absorb the cost of caring for many uninsured patients like Mr. Colston. Now, with President-elect Donald J. Trump and the Republican-controlled Congress vowing to dismantle the law, Temple and other hospitals serving the poor are bracing for harsh financial consequences that could have a serious effect on the care they provide.
Since the election, hospitals have been among the loudest voices against wholesale repeal of the health law. In a letter to Mr. Trump and congressional leaders this month, the two biggest hospital trade groups warned of “an unprecedented public health crisis” and said hospitals stood to lose $165 billion through 2026 if more than 20 million people lose the insurance they gained under the law. They predicted widespread layoffs, cuts in outpatient care and services for the mentally ill, and even hospital closings.
Here in Pennsylvania, where the health law has brightened the financial outlook of hospitals statewide, many are scrambling to assess how repeal would affect their bottom line and the patients they serve. The stakes are particularly high for safety-net hospitals like Temple, but even more prosperous hospitals face uncertainty after investing in new ways to deliver care under the law.
Temple executives estimate their system could lose as much as $45 million a year if the law were entirely repealed, which would return it to the losses it posted for years before the health law took effect.
“We are the de facto community hospital in one of the poorest neighborhoods in the country,” said Robert Lux, the senior vice president, treasurer and chief financial officer of Temple University Health System, which includes two general hospitals and a cancer center. “Any kind of change like this would not only push Temple University Hospital into financial extremis, it would do the same thing for our entire system.”
Not far from Temple, Main Line Health, a nonprofit hospital system in the affluent Philadelphia suburbs, is far better positioned to weather the financial impact of repeal. While Temple has one of the poorest patient populations in the state — about half of its patients are on Medicaid — Main Line, which has an outpatient clinic in an upscale mall and another with a fitness center outfitted with filtered saltwater pools, has few Medicaid patients.
Still, even hospitals serving affluent populations have reason to be nervous about a future without the health law. Main Line has invested substantially in response to the law’s push to base hospital pay on patient outcomes instead of the amount of medical services provided. Repealing the law would create uncertainty about the future of this new paradigm, which has forced hospitals to rethink how they deliver care.
“I’m dreading the unpredictability,” said John J. Lynch III, Main Line’s president and chief executive.
Over all, the health law has improved the financial outlook of Pennsylvania hospitals significantly, even though the state was a year late in expanding Medicaid. The former governor, Tom Corbett, a Republican, initially balked, and the program did not expand here until 2015. Still, hospital operating margins statewide increased to about 5.5 percent on average in 2015, from 4.25 percent in 2014, according to the Hospital and Healthsystem Association of Pennsylvania. The amount of care provided to patients who cannot pay dropped by 8.6 percent on average.
North Philadelphia, where Temple is based, is among the poorest neighborhoods in the nation. Many of its residents live in deep poverty, a census designation that means their income is less than half the federal poverty level of $24,300 for a family of four. That helps explain why Temple is so dependent on Medicaid revenue, and the high stakes of repeal here.
Under the health law, hospitals that served a large number of poor and uninsured patients agreed to a series of funding cuts in exchange for getting far more patients with insurance coverage. Temple has lost about $11 million so far in these federal funds, known as disproportionate share payments, Mr. Lux said.
But like other hospitals in the 31 states that expanded Medicaid under the law, it has made up that revenue in part through the Medicaid expansion. It recorded about 13,000 more visits from patients with Medicaid coverage in 2015, the first year Pennsylvania expanded Medicaid eligibility, and at least as many this year. Still, Temple is barely turning a profit: It had operating income of $3.6 million in the fiscal year that ended June 30, despite revenue of $1.7 billion.
“You still have a pretty fragile enterprise,” Mr. Lux said, noting that Medicaid pays hospitals and doctors far less than Medicare and private insurance. “Our current state of stability could be broken pretty quickly.”
So, too, could Temple’s efforts to connect its newly insured patients with preventive care instead of waiting until they show up in the emergency room with advanced, expensive illnesses. Dr. Robert McNamara, chairman of emergency medicine at the Lewis Katz School of Medicine at Temple University, said he had seen more than a few uninsured people arrive in the emergency room with kidney failure, needing costly dialysis for the rest of their lives because they had lived with high blood pressure for so long.
Main Line Health’s financial picture is much stronger, and will most likely remain so even if the health law is repealed and replaced with a program that leaves far fewer people insured. Main Line ended the 2016 fiscal year with $106.8 million in operating income and a 6.5 percent operating margin, compared with Temple’s margin of 0.2 percent.
Still, Main Line has invested substantially in efforts to improve the care it provides its patients while lowering the cost, as the Affordable Care Act encourages. As with many hospitals across the country, these efforts — like preventing readmissions and focusing more heavily on primary care, especially for patients with chronic diseases — have caused the system’s inpatient population to drop.
“As we decrease our volume, looking at providing care differently, that’s financially impacting us,” Mr. Lynch said.
He added that over time, the law’s slowing of Medicare payment increases added up to “real money.” The study commissioned by the hospital associations found that unless the annual increase in Medicare reimbursements is restored to what it was before the health law passed, hospitals will face additional losses of about $290 billion by 2026.
In the end, though, Main Line’s far more robust revenue, because of its large number of commercially insured patients, all but guarantee it will not have to worry — for now — about cutting programs or plans. It is installing a new electronic records system and has spent $700 million renovating its hospitals over the last few years.
“If you don’t have a strong payer mix or a healthy bottom line,” Mr. Lynch said, “it’s very difficult to do those things.”
One major question for Temple and other safety-net hospitals is whether states would restore supplemental funds or programs that defrayed the cost of caring for the uninsured before the health law took effect. Pennsylvania, for example, paid for emergency medical care for certain low-income people who did not qualify for Medicaid. This allowed Temple to be paid for their inpatient care, but often not for the care they needed after being discharged.
“We don’t know that that program would come back,” Mr. Lux said, adding that the program used to pay for about $23 million a year worth of care provided at Temple University Hospital.
Mr. Colston, who was still returning daily to Temple for intravenous antibiotics a month after his discharge, would have qualified to have most of his inpatient costs met under the old state-financed program. Paul Fabian, who received a double lung transplant at Temple last year after getting a subsidized private insurance policy from the Affordable Care Act marketplace, would not have qualified at all. Mr. Fabian, who suffered from emphysema and chronic lung failure, said he sold his truck to afford his $262 monthly premiums.
“If you walk into the E.R. they have to help you,” Mr. Fabian, 61, said. “But if you have a condition like I had, what’s the hospital’s obligation?”
Temple officials said that without insurance, Mr. Fabian would have had to endure a two-year waiting period to qualify for Medicare coverage for his disability.
“We were finally in a situation where for most of our patients there was a coverage option,” said Anita Colon, Temple’s director of patient financial services, already speaking about the health law in the past tense. “Now there’s just a total unknown about what will be left.”
These coal country voters backed Trump. Now they’re worried about losing Obamacare.
by Greg Sargent - Washington Post
Last night, CNN aired a terrific segment on people from coal country who voted for Donald Trump — but are now worried that his vow to repeal Obamacare will deprive them of crucial protections that enable them to stay afloat financially. This dovetails with other reporting that suggests a lot of Trump voters may be harmed by repeal of the law.
Which raises a question: Did voters such as these know they were voting for this? After all, Trump promised countless times throughout the campaign to repeal the Affordable Care Act, didn’t he? If they are complaining about this now, don’t they have only themselves to blame?
No. I’m going to argue that, while Trump did repeatedly vow repeal, these voters were absolutely right to conclude that he would not leave them without the sort of federal protections they enjoy under Obamacare. That’s because Trump did, in fact, clearly signal to them that this would not happen.
The CNN segment features people who live in Eastern Kentucky coal country and backed Trump because he promised to bring back coal jobs. Now, however, they worry that a provision in the ACA that makes it easier for longtime coal miners with black lung disease to get disability benefits could get eliminated along with the law. That provision shifted the burden of proving that the disability was directly caused by work in the mines away from the victim. Those benefits include financial and medical benefits. Some benefits now also extend to the widows of miners who had black lung disease — or pneumoconiosis, a lung illness associated with inhalation of coal dust — after their husbands die. Other reporting has also confirmed widespread coal country worries about losing these protections.
One man who worked in the mines for 35 years told CNN’s Miguel Marquez:
“When they eliminate the Obamacare, they may just eliminate all of the black lung program. It may all be gone. Don’t matter how many years you got.”
The widow of a deceased miner, who is now trying to get the benefits, said she doesn’t want to see Obamacare repealed, and even suggested Trump may be on the verge of betraying her and others in the region:
“If he don’t come across like he promised, he’s not gonna be there next time. Not if I can help it.”
But what did Trump actually “promise”?
These coal country residents are not quite in the same situation as many of the law’s other beneficiaries, who are currently gaining access to health coverage due to increased federal spending and regulation. But they are all benefiting from increased governmental intervention under the law designed to expand health care and support to lower-income or sick people who were unable to secure it for themselves under the old system. Many of them would lose these benefits if the law is repealed.
There is some evidence that many of those people voted for Trump. The Wall Street Journal recently demonstrated that rural, aging, and working class counties that went overwhelmingly for Trump also showed large drops in the uninsured rate. Similarly, Gallup-Healthways data shows that among non-college, lower income whites — a Trump demographic — the uninsured rate has dropped 10 percentage points.
Now, obviously, many Trump voters may still not like the flawed aspects of Obamacare, even if it did expand coverage to a lot of them. And many Trump voters may have backed him because of his promise of jobs — which they’d prefer over government as their means to gaining health care.
But these coal country voters in the CNN segment were very clear: They don’t want to lose the protections Obamacare grants them. Other reporting has found similar worries in Trump country. Still other reporting has turned up examples of Trump voters who don’t actually believe he’ll take away their Obamacare.
So what did Trump really tell these voters?
Yes, Trump said endlessly that he’d do away with the ACA instantly. Yes, his own replacement plan would leave millions without coverage. But here’s the rub: Trump also went to great lengths to portray himself as ideologically different from most other Republicans on fundamental questions about the proper role of governmental intervention to help poor and sick people without sufficient access to medical care.
In January of 2015, Trump said he wanted “to try and help” lower income people get health care, even if it cost him the GOP nomination — signaling a core differencewith the GOP on this moral imperative. During the primaries, Trump pointedly told fellow Republicans he would not allow people to “die on the street,” telegraphing that core difference once again. Trump also repeatedly vowed not to touch Medicare, explicitly holding this up as proof he is not ideologically aligned with Paul Ryan on the safety net. As David Leonhardt details, Trump repeatedly demonstrated an ideological willingness to embrace a role for government in expanding health care to, well, all Americans.
And so, if many Trump voters didn’t really believe they’d lose protections under President Trump, this was not a crazy calculation to make. Now, Trump and congressional Republicans may indeed end up rolling back protections for millions who voted for him. But if that happens, and these voters do end up feeling betrayed by Trump, they will be right to feel that way — they will, in fact, have been scammed by Trump.
Perhaps, like other scam victims, they should have looked more closely at the fine print. But the broad conclusion they reached was a perfectly reasonable one.
Donald Trump has campaigned to repeal and replace the Affordable Care Act, otherwise known as Obamacare, once he gets into office. Now that he's won the presidency with a majority Republican House and Senate, that feat might not prove to be too easy. Wonkblog's Max Ehrenfreund explains. (Daron Taylor/The Washington Post)
A Letter to Donald Trump About Health Care
by David Leonhardt - NYT
Dear Mr. President-elect:
Your position on universal health insurance has been admirably clear. You support it. You did before you ran for president and continued to do so in the campaign.
In 2000, you wrote, “We must have universal healthcare.” In a Fox News debate last year, you said, “We have to take care of the people that can’t take care of themselves.” On “60 Minutes,” you said, “Everybody’s got to be covered.”
I am writing to you now because I am concerned that Republicans in Congress do not share your goal and are not giving you good advice on this issue. I’m worried that they are not acting in the best interests of your presidency or the country. I encourage you to be skeptical of them.
It is entirely possible for you to sign a conservative health care bill that lives up to your belief in universal coverage. It’s a bill that you could celebrate as a replacement of Obamacare. But it would be quite different from the bills that congressional Republicans are pushing.
When they claim that their bills will not take health insurance away from millions of people, they’re engaging in magical thinking. They are trying to fool the media, voters and you.
They are focusing on a strategy of “repeal and delay,” in which major parts of Obamacare will remain for months or years. In the intervening time, they say, they will somehow keep people from losing insurance.
But they do not have a realistic plan, despite years of talk. Nor, to be blunt, does your choice for secretary of health and human services, who is one of those congressional Republicans. And a repeal is likely to undermine insurance markets long before its effective date.
Mr. President-elect, you are a businessman. You understand that savvy executives don’t simply live in the present. They look to the future. They’re fond of quotingWayne Gretzky: “Skate to where the puck is going, not where it has been.”
Insurance executives can see through the magical thinking of politicians. They know that a functioning insurance market must include both healthy and sick people. There are very few ways to guarantee this combination. Without Obamacare’s subsidies to help people buy coverage and its mandate (weak as it is) to require they have coverage, markets will break down. The healthy will leave, the sick will stay and costs will soar.
After a repeal is signed, the uncertainty will give insurers reason to exit quickly. As Nicholas Bagley, a leading expert at the University of Michigan, says, “If you’re an insurer, you’re likely to head for the hills.”
The chaos runs a high risk of leaving millions of people without insurance early in your presidency. Many of them will be members of the white working class who voted for you. Everyone who loses insurance will be grist for criticism of you.
As you know, the Republican leaders in Congress have never been your biggest fans. I think it’s fair to say that they care more about being able to brag that they got rid of Obamacare than about your political standing. The bills they are considering threaten your standing.
But you have alternatives.
The crucial first step is to avoid repealing the insurance expansion without simultaneously replacing it. The new Congress comes to Washington next week, and its members should know where you stand from the beginning. It won’t work to promise millions of people health insurance on spec.
If you avoid this trap, you can then push both parties toward a different version of universal health coverage.
“There is a ton of policy space for compromise,” as Bagley says. “There is room for a really interesting discussion and potentially a breakthrough that could rebrand Obamacare and replace some of the portions of it that most set Republican teeth on edge.” You will like this, Mr. President-elect: Bagley also says you are “the kind of politician who could cut a really interesting deal.”
That deal could give states more flexibility to meet the top-line coverage goals. It could rely more heavily on subsidies to bring healthy people into the market — and ultimately scrap the mandate. It could permit insurers to charge young people less (and older people more). It could create incentives for personal responsibility, allowing higher prices for people who have voluntarily gone without insurance.
I will be honest that I do not favor some of these ideas and worry that they would cause hardships. But I was not elected president, and you were. And all of these ideas are within the realm of serious debate about our health care system.
For your sake and the country’s, I hope you insist that Congress deals in reality. Magical thinking isn’t good for a presidency.
