House Republicans Unveil Long-Awaited Replacement for Health Law
by Robert Pear - NYT
WASHINGTON — After six years of vague talk about a conservative alternative to the Affordable Care Act, House Republicans on Tuesday finally laid out the replacement for a repealed health law — a package of proposals that they said would slow the growth of health spending and relax federal rules for health insurance.
Opponents began the “repeal and replace” mantra almost as soon as the Affordable Care Act was signed in 2010, and while they have voted dozens of times to repeal the health law, the replacement has been elusive.
In finally presenting one, Speaker Paul D. Ryan of Wisconsin and his Republican team did not provide a cost estimate or legislative language. But they did issue a 20,000-word plan that provides the most extensive description of their health care alternative to date.
Many of the ideas — for “health savings accounts,” “high-risk pools” and sales of insurance across state lines — are familiar. Democrats in and out of Congress have for weeks been rehearsing their lines of attack.
Others are sure to be contentious. House Republicans would gradually increase the eligibility age for Medicare, which is now 65. Starting in 2020, the Medicare age would rise along with the eligibility age for full Social Security benefits, eventually reaching 67.
Following Mr. Ryan’s budget plans of recent years, the health proposal would transform Medicare into “a fully competitive market-based model known as premium support.” The traditional fee-for-service Medicare program would compete directly with private plans offered by companies like UnitedHealth, Aetna and Humana.
In their blueprint, to be formally unveiled on Wednesday, House Republicans say they would eliminate the requirement that most Americans carry health insurance. They would offer a flat tax credit to each person or family in the individual insurance market, regardless of income or the premium for a particular insurance policy.
House Republicans also said they would roll back the Affordable Care Act’s expansion of Medicaid and give each state a fixed amount of money for each beneficiary or a lump sum of federal money for all of a state’s Medicaid program.
In addition, House Republicans would allow states to establish work requirements for able-bodied adults on Medicaid, requirements that the Obama administration has refused to permit. Under the House Republican plan, states could also “charge reasonable enforceable premiums or offer a limited benefit package” and use “waiting lists and enrollment caps” for certain groups of Medicaid beneficiaries.
Using these options and others proposed by House Republicans, states could profoundly reshape the Medicaid program, which provides health insurance to more than 70 million people at a federal cost of more than $350 billion a year.
“Reforming Medicaid’s financing with a per-capita allotment certainly will reduce federal spending, but just as importantly” will give states more control over the program and more incentives to manage care and costs, the blueprint says.
Still no Obamacare alternative from House Republicans, five years on
by Noam Levey - LA Times
re than five years after taking the majority on a promise to replace the 2010 Affordable Care Act, House Republicans have elected again not to advance a comprehensive alternative.
Instead, lawmakers are putting forward a general outline Wednesday that combines a series of familiar conservative healthcare ideas, including overhauling the government’s Medicare and Medicaid programs and eliminating federal regulations that require insurance plans to cover a basic set of benefits.
The 37-page plan, promised since Rep. Paul D. Ryan (R-Wis.) became House speaker last year, was originally billed as part of a comprehensive governing blueprint that would show voters the GOP was ready to advance real alternatives to President Obama’s agenda.
"This isn’t a return to the pre-Obamacare status quo,” the new healthcare outline says. “And it isn’t just an attempt to replace Obamacare and leave it at that. This is a new approach. It’s a step-by-step plan to give every American access to quality, affordable health care."
But like many previous Republican healthcare proposals -- including those put forward by presumptive GOP presidential nominee Donald Trump -- Ryan’s latest blueprint is missing key details and legislative language that would allow independent analysts such as the Congressional Budget Office to assess its cost and impact.
Rather than showcasing the party’s seriousness about policy, Ryan’s plan may reinforce widespread skepticism about the GOP’s interest in tackling complex healthcare policy.
Indeed, the new plan falls well short of what House Republicans themselves resolved to do more than five years ago, after they retook control of the House during the 2010 midterm election.
In January 2011, just days after the new Congress convened, GOP lawmakers unanimously backed a 12-point resolution that directed House committees to develop “legislation proposing changes to the existing law.”
Among the things the legislation was supposed to do were lower health insurance premiums, preserve patients’ ability to keep their doctors, provide access to affordable coverage for people with preexisting medical conditions and “increase the number of insured Americans.”
No such bills were ever advanced out of a congressional committee.
In the new plan, House Republicans are again proposing to replace the current government-run Medicare benefit with a system of vouchers that seniors could use to offset at least part of the cost of premiums for private health plans. Ryan has called the vouchers “premium support.”
The outline would also transform the current Medicaid program for the poor by eliminating federal rules that establish who should be covered, such as poor children and pregnant women, and which benefits should be offered. Each state would be allowed to decide who would get coverage.
Americans who don't get coverage through an employer or through Medicare or Medicaid would qualify for a tax subsidy that they could use to help offset the cost of a commercial insurance plan.
That system of subsidies to help people buy insurance is broadly similar to the current marketplace system created by the Affordable Care Act. But the House GOP plan would not link the tax credit to people's incomes, as the current law does, potentially leaving lower-income consumers with less help to purchase insurance.
The plan does not specify how generous the subsidy would be, but a senior House GOP official told reporters that the goal would be to at least allow people to buy a plan that would cover catastrophic health problems – something considerably less comprehensive than what the current law does.
The missing details make it impossible to gauge how many people could lose or gain health coverage and how much more some Americans might have to pay for coverage.
The new House GOP plan's architects argue that the reduced federal regulations and requirements will make coverage more affordable for everyone.
Repealing the current law, however, which House Republicans say needs to be the starting point for future reforms, would leave 24 million more Americans without health coverage, according to one recent estimate from the Washington-based Urban Institute.
Independent analysts of previous GOP plans have noted that scaling back federal oversight of state Medicaid programs, while giving states more flexibility, could prompt some states to roll back their healthcare safety nets. Converting Medicare to a voucher-based system would probably leave many seniors with bigger healthcare bills, those analyses have found.
“The current standards are designed to ensure that very vulnerable populations have access to needed care so coverage is affordable to low-income people,” said Edwin Park, vice president for health policy at the left-leaning Center on Budget and Policy Priorities in Washington. “Those protections are in place for a reason.”
Senior House Republican officials said details could be worked out by House committees.
It is not clear when that might happen.
Republicans have a plan to replace Obamacare, and its costs are unclear
by Mike Debones - Washington Post
GOP leadership in the House of Representatives are introducing a plan to replace the Affordable Care Act. Here's what the proposal wants to change. (Jenny Starrs/The Washington Post)
House Republicans are set Wednesday to unveil their latest plan to replace President Obama’s signature health care reform law — a plan that would discard the mandates and penalties that have made “Obamacare” a perennial target for GOP lawmakers but one that comes with uncertain costs and an unknown impact on the number of insured Americans.
The health-care plan is perhaps the most anticipated piece of the six-part policy agenda now being rolled out by House Speaker Paul D. Ryan (R-Wis.) and his fellow GOP lawmakers as they move to establish a campaign platform apart from presumptive Republican presidential nominee Donald Trump. Coming six years after the Patient Protection and Affordable Care Act passed Congress, it represents the first replacement proposal to carry the endorsement of House GOP leadership.
Republicans have attacked the health law vigorously since its passage, citing its costs, its effects on the health-insurance market and its effects on the economy at large. The opposition culminated in the two-week federal government shutdown in 2013, and repealing and replacing Obamacare remains at the center of GOP campaigns across the geographic and ideological spectrum.
“Obamacare simply does not work,” the new proposal reads, according to a copy distributed to reporters ahead of Wednesday’s launch. “It cannot be amended or fixed through incremental changes. Obamacare must be repealed so that Congress can move forward with the kinds of reforms that will give Americans the care they deserve.”
But developing those reforms has been a tricky proposition. While various Republican lawmakers and conservative policy thinkers have proposed pieces of an Obamacare replacement, the GOP-controlled House has had more success rallying around the “repeal” part than the “replace.”
Developing a comprehensive alternative to the Obama health-care law requires engaging in difficult trade-offs to balance the Republican goals of decreasing costs and deregulating the insurance market against a potential decline in coverage rates and the demise of popular Obamacare provisions like ending insurer denials for “preexisting conditions.” It would also require submitting any proposals for a nonpartisan fiscal scoring from the Congressional Budget Office, potentially exposing significant long-term costs.
The new House Republican plan does not include any price tags or fiscal estimates but rather is an assemblage of ideas that have already coursed through Republican policy circles. A senior House GOP leadership aide who briefed reporters on the proposal Tuesday compared the document to the “white paper” issued by then-Sen. Max Baucus (D-Mont.) days after Obama won the 2008 election that formed the blueprint for what became the Affordable Care Act.
“It’s a framework,” the aide said, explaining that the nitty-gritty of a GOP health-care plan would be hashed out by the relevant committees. “It is laying the groundwork for what the Congress and House Republicans can do next year through the committee work.”
Where the Affordable Care Act was predicated on expanding coverage, the aide said, the Republican plan is focused on lowering health-care costs and expanding choices for individuals and employers. It discards the central elements of Obamacare: the mandate for individuals to secure coverage and employers to provide it, the tax subsidies for low-income Americans to help pay for coverage, the expansion of Medicaid, national coverage standards for health plans, and the federal health insurance exchange.
In its place, the GOP plan floats a variety of proposals:
The new GOP plan to replace Obamacare has the same flaw as Bernie Sanders’s
by Max Ehrendfreund - Washington Post
On Wednesday morning, Republicans in Congress added a proposal of their own to the long list of big health care promises that politicians have made to voters during this campaign.
The document is part of a broader effort by Paul Ryan to show that the Republican majority is committed to sound governance and to a substantive debate about public policy amid what has been a chaotic presidential cycle. Yet, the House speaker and GOP lawmakers who wrote the proposal do not offer a clear plan for financing the major new expenditures they put forward.
It seems unlikely that the GOP plan would leave the government short $17 trillion over a decade, as the health-care proposal from Democratic presidential candidate Bernie Sanders might. Yet, the Republican proposal to replace the Affordable Care Act, President Obama's major health-care overhaul, raises more questions than it answers, particularly about cost.
"There have been very few detailed proposals to replace the ACA," said Larry Levitt, a health-care expert at the nonpartisan Kaiser Family Foundation. "It doesn’t mean it’s not technically possible, but it’s politically very difficult -- and I think this is part of why we may not see details in the plan this week."
In repealing the law commonly known as Obamacare, the GOP legislators would eliminate expenses associated with the law, such as the subsidies that help many middle-class policyholders pay for insurance in the individual market.
At the same time, the authors propose repealing all of the new taxes that the reform imposed, including an increase of 0.9 percent in the payroll tax and a 3.8 percent surcharge on capital gains and other income from investments for wealthy taxpayers.
Some of the new taxes still haven't been implemented, but assuming that they are, Obamacare should bring in more than enough new revenue to cover the additional costs, according to the Congressional Budget Office. The nonpartisan agency forecasts that repealing the law would increase the deficit by $137 billion over a decade, which means that the Republican plan for repeal is starting from behind.
Eliminating taxes and reducing federal spending have long been a goal for Republicans. While the new proposal would eliminate taxes, the authors would also replace much of the outlay under Obamacare with new spending of their own.
To replace the subsidies under the current law in the individual market, the proposal calls for a monthly tax credit that households could use toward insurance. The value would be adjusted for age, and households that paid less than the value of the credit in taxes would still receive the full benefit. Subscribers could spend any remainder from the credit that they do not use toward health insurance on incidental expenses such as dental care or over-the-counter drugs.
The proposal does not specify how much this credit would be worth to individual families or how much the authors think it would cost on the whole, but it is clear the credit would be a substantial grant made to a large number of people.
The authors write that the credit "would be large enough to purchase the typical pre-Obamacare health insurance plan," and that it would be universally available to anyone without employer-sponsored insurance, Medicare or Medicaid. By contrast, the Affordable Care Act only make subsidies available to households of modest means.
Additionally, the GOP lawmakers propose dedicating new federal funds to help states insure the most ill and most expensive patients. Currently, Obamacare requires insurance companies to cover these patients. The law is designed to defray the cost of doing so for the private sector by creating new customers with the requirement that most Americans, even if they are relatively healthy, buy insurance.
The Republican proposal would repeal that individual mandate and instead help pay for the sickest patients' care with federal subsidies. The document calls for $25 billion over 10 years to help underwrite special markets for these patients.
Yet past estimates of cost of such markets, known as "high-risk pools," suggest that amount might not be nearly adequate.
"That's not enough money," said Tom Miller, a health-care expert at the conservative American Enterprise Institute, who estimates that the cost of a robust system of high-risk pools would likely be between $70 billion and $100 billion over a decade.
"If you want to be credible about his, you do have to have sufficient funding," he added. "That number seems to be a good bit lower than it needs to be."
The GOP proposal rejects enforcing waiting lists for especially unwell patients hoping to participate in the high-risk pools to limit the costs. The document also rules out charging participants exorbitant premiums to make up the expense, so the states would presumably have to come up with the missing funds to cover their sickest citizens.
The proposal does include some provisions that would help pay for these new programs. For example, the authors want to limit the amount of employer-sponsored health-care benefits that are exempt from taxation -- firms and their employees would have to pay taxes on benefits paid above that limit.
The proposal does not specify what the limit would be or how much revenue it would create. The authors write that the limit would be high enough that "the vast majority" of companies would not pay new taxes. "Most Americans' plans would not be affected," they write. A limit that imposes new taxes on only a few, very generous plans would bring in less
The GOP document suggests there is some bipartisan agreement on health care. Democrats have also endorsed the basic aims laid out in the new Republican proposal -- reducing costs overall while ensuring that more Americans have coverage, including those who need it most.
Republicans might well have ideas for achieving those aims more cheaply, but their plan won't be free either, and so far, Ryan and his colleagues haven't put the money on the table.
U.S. will spend $2.6 trillion less on health care than expected before Obamacare, study projects
by Carolyn Y. Johnson - Washington Post
Expanding health insurance coverage to millions of Americans was bound to increase overall spending. After the Affordable Care Act was passed in 2010, the actuaries for the Centers for Medicare and Medicaid Services projected that, as the economy recovered, the historically low growth in health spending would return to higher levels, reaching $4.6 trillion by 2019. But in the intervening years, the annual expenditure increases have been more modest than expected, and the new estimate from the Urban Institute suggests national health spending is on to track reach $4 trillion by 2019.
"When CMS originally made those projections, they really thought the slowdown in health-care spending [growth] was mostly due to the recession, and afterward we'd see a return to the higher rates of spending growth — and that didn't really happen," said Katherine Hempstead, a senior adviser at the Robert Wood Johnson Foundation, which funded the new study by the Urban Institute.
What's inside the House Republicans' plan to replace Obamacare
GOP leadership in the House of Representatives are introducing a plan to replace the Affordable Care Act. Here's what the proposal wants to change. (Jenny Starrs/The Washington Post)
Looking forward, the study's authors also point to recent evidence that a 2014 uptick in health spending that had seemed to signal a return to higher growth may have been temporary. If slower growth persists, they argue that it will become harder to argue that it is just the economy and not the cost containment policies enabled by the Affordable Care Act that are tempering spending.
Hempstead said it's becoming increasingly plausible that the federal policies included in the Affordable Care Act — and its ripple effects as programs implemented within Medicare influence the private market — are having a tempering effect.
It's incredibly tricky to dissociate the cause of any particular policy on the effect of health-care spending. In addition to the Great Recession, reimbursement cuts because of sequestration would have had an effect on spending and the Supreme Court decision to make the expansion of Medicaid optional also reduced spending compared with the original projection.
A Kaiser Family Foundation analysis from 2013 found that about three-quarters of the slowdown could be traced to the sluggish economy, and attributed the rest of it to various other factors.
"The hangover from the Great Recession has had significant effects on consumer spending in general, and health spending specifically," Larry Levitt, a vice president at Kaiser, said in an email. But, he added, the Affordable Care Act "has clearly had a large and direct effect on slowing down health spending in Medicare. Its effect on the rest of the health system is somewhat more speculative, but I believe it’s real."
by Trudy Lieberman - Columbia UniversityAs candidates talk past each other, real debate over health reform goes missing
http://www.centerforhealthjournalism.org/2016/02/29/candidates-talk-past-each-other-real-debate-over-health-reform-goes-missing?utm_source=Newsletter+03%2F09%2F16&utm_campaign=Newsletter150708&utm_medium=emailNo one expected health care to be AWOL on the campaign trail, and it hasn’t been. In January the Kaiser Family Foundation Tracking Poll found that the cost of health care and health insurance ranked only third in importance for all registered voters, behind terrorism and jobs, while the Affordable Care Act came in eighth. The problem is not lack of interest, I’d wager. It’s that campaign talk has been way too sketchy and uninformative, leaving voters with precious little to chew on. They’ve tuned out. So it’s fair to ask: What exactly are the candidates saying about their positions on this most contentious of issues?
To explore this, I turned to Theodore Marmor, Yale professor emeritus whose specialty is health politics. “Most American debates about health care reform have been dominated by ideological slogans, misleading claims about financing, and mystifying labels,” he argues, and this year is no different. “The result,” Marmor says, “is a dialogue of the deaf, with each side talking past the other and little or no engagement with realistic description of either worthy reform increments or longer-term reform aspirations.” That translates into an empty discussion about Obamacare’s shortcomings and how to fix them, the shape of the insurance system, and the high price of care, especially for prescription drugs, which shuts out the public from understanding and ultimately from having a say in what’s to be done.
Marmor is talking about the Democratic side of the ledger, and so far, he says the Dems’ debate has been both confusing and misleading, with Clinton’s discussion of short-term reforms largely ignoring the question of what the country’s long-term future should look like, and Sanders emphasizing policy prescriptions, in particular his vision of Medicare-for-all social insurance, without discussing incremental steps that might be needed to achieve his objective. What would each do to make health care less costly, less complex and more accessible to achieve their goal of universal coverage which both say they share? Instead, Clinton is telling voters what’s wrong with Sanders’ ideas, Marmor says, but not what’s right about her own. Sanders omits the political tactics needed to get from A to B on the road to “Medicare for all.”
Health expert Marilyn Moon, who now directs the Center for Aging at the American Institutes for Research, explained the missing element in Sanders’ stump talk. “While I have a lot of sympathy for single-payer, the way Sanders is selling it makes me grind my teeth,” she told me, noting that having single-payer doesn’t instantly translate into lower costs. “You have to do things to save money. He’s selling people a bill of goods and making them believe change will be painless.” That observation gets to the heart of the U.S. health care dilemma. To save money, bring down costs, and give everyone coverage, the country has to control payments to doctors, hospitals, and other providers, and limit the availability of services that don’t work and sometimes waste hundreds of thousands of dollars. That’s been the issue every time the country has grappled with health reform, including Obamacare. “This would require a lot of painful adjustments and Americans aren’t ready for that,” Moon believes."Most American debates about health care reform have been dominated by ideological slogans, misleading claims about financing, and mystifying labels. The result is a dialogue of the deaf, with each side talking past the other and little or no engagement with realistic description of either worthy reform increments or longer-term reform aspirations." — Theodore Marmor, Yale
Perhaps that’s why no candidate is showing leadership on that fundamental problem and helping to bring Americans along. In other words, they are not changing the discourse — the way we think about limitless health care and the consequences of paying whatever the market will bear, and whatever taxes are needed to cover everyone. It’s easier and safer to let the misleading claims, mystifying labels, and ideological slogans fly through the media and above that very real dilemma, which allows the public to pick and choose the claim, label, or slogan they are predisposed to accept.
The mid-February debate with Sanders and Clinton is a good example of what Marmor and Moon are talking about. Clinton told viewers that every progressive economist who has analyzed Sanders’ numbers says they “don’t add up and that’s a promise that cannot be kept. We should level with the American people about what we can do to make sure they get quality, affordable health care.” Clinton said she had “very specific plans about how to get costs down,” especially for prescription drugs, but instead of defining those plans, she again attacked Sanders’ “Medicare-for-all” program. “If it’s ‘Medicare for all,’ then you no longer have the Affordable Care Act, because the Affordable Care Act, as you know very well, is based on the insurance system, based on exchanges, based on a subsidy system,” implying that people would not longer get help paying Obamacare’s high premiums. “Many people will actually be worse off than they are now,” she said. Sanders didn’t explain how subsidies for low-income people would not be necessary under his plan, simply brushing off Clinton’s charge as “inaccurate.” Instead he used his time to talk about lower costs in France, Canada, and the UK. “We can guarantee health care to all people in a much more cost-effective way,” he concluded. No word on how he’d achieve this except to say that we can do it if we have the courage to take on the health care industry.
Clinton and Sanders do discuss their proposals more fully on their websites, though details are still sketchy — more blah-blah campaign talk. Sanders’ website gives few specifics about lowering costs, but he does say moving to an “integrated system” will give the government the “ability to stand up to drug companies and negotiate fair prices” and “track access to providers” and “make smart investments to avoid provider shortages.” To make premiums more affordable, Clinton says she wants to “enhance” subsidies for those now eligible to buy exchange policies. Regulating premiums, however, is not one of her remedies. Why not? Why are enhanced tax credits better and for whom?
Website visitors also learn that “Hillary believes we need to demand lower drug costs for hardworking families and seniors.” How will that work? Both Sanders and Clinton favor some Medicare negotiation for drugs, but as Julie Rovner points out in an insightful piece for Kaiser Health News, “The only way Medicare negotiation would save money is if the program decided to cover some drugs and not others,” which is what the Veterans Administration does. (Otherwise, Medicare is unlikely to be more successful in negotiating lower prices than private payers have been.) That, of course, gets into the dangerous territory of leadership and changing the health care conversation.
The Republican side of the ledger is easier to parse, but it, too, is filled with misleading claims, ideological slogans and mystifying labels. Donald Trump, Ted Cruz, and Marco Rubio have all declared Obamacare dead if they win the presidency. In his victory speech after the New Hampshire primary, Trump yelled to his cheering fans, “ We’re going to repeal and replace Obamacare. It’s a total disaster. It’s gone.” On his website Rubio says, “Obamacare has revealed the painful consequences of placing our faith in big government.” Cruz asserts on his that Obamacare “is the most unpopular law in the country.”
The GOP’s menu of fixes after burying Obamacare is old hat, with scrutiny and questions as scarce as they are on the Democratic side. There’s been little or no serious discussion of whether those with low incomes can actually save with a health savings account. Nearly 90 percent of Obamacare policyholders last year needed subsidies in order to buy insurance. There’s been little discussion from the GOP of potential remedies to bring costs down, such as letting insurers sell across state lines. Insurers can do that now if a state allows them in and most do. Will tax credits to help people buy coverage really help the 29 million Americans who don’t have it now, as the GOP suggests?
If the public is looking for leadership to change the country’s health insurance arrangements and cover everyone at a lower cost, so far they haven’t gotten it. But can the discussion really happen given how dumbed-down the media discourse has become? Says Moon of the Center for Aging, “It’s a sad commentary on what the candidates have to do to sell reform in the U.S.”
Veteran health care journalist Trudy Lieberman is Contributing Editor of the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care blog.
How Not to Debate Health Care Reform
Ted Marmor
I: Introduction
Presidential campaigns in the United States are not typically fought over competing manifestos, with policy details set out in reasonably clear language. Rather they are disputes among candidates about the state of the country and what values—or aspirational visions—they endorse. And, for at least a century, most American debates about health care reform have been dominated by ideological slogans, misleading claims about financing, and mystifying labels.
More recently, Republicans have exemplified the mystification, repeatedly mislabeling Obamacare as socialized medicine and falsely claiming it a “takeover of American medicine.” Their presidential candidates have repeatedly called for the program’s repeal even though it relied upon traditional Republican preferences for private health insurance and Medicaid expansion.
In fairness, the Democratic primaries have generated their own version of mystification. The Clinton campaign has emphasized incremental reform possibilities and politically criticized Senator Sanders’ proposal of Medicare for All as unrealistic. Sanders, by contrast, has offered a compelling conception of a fairer and less expensive version of what Americans want, but no incremental steps to get to it. The result is a dialogue of the deaf, with each side talking past the other; this produces all too little engagement with realistic description of either worthy reform increments or longer-term reform aspirations.
Notice too that while the Clinton campaign does take credit for Obamacare’s undeniable and desirable expansion of health insurance coverage, it pays little attention to the millions of Americans uninsured—or under-insured—and what candidate Clinton thinks should be the first incremental reform steps. Nor has Clinton and her defenders addressed seriously the reliance on deductibles and co-insurance that not only makes access to care difficult for many, but threatens the economic security of those with health insurance. In short, there is considerable cheerleading about the ‘signature’ health reform program of the Obama Presidency, but little clear engagement with what further reform is needed.
The Sanders campaign, by contrast, has repeatedly emphasized what is appealing about expanding Medicare to all, taking for granted that celebrating this popular program would be enough, a vision without an incremental map of any kind. The result has been an utterly confusing clash between Sanders and Clinton about health care reform.
A recent article in the American Prospect illustrates why in its treatment of “The False Lure of the Sanders Single Payer Plan.” The critique is a model of how not to clarify a health reform proposal. The central contention is this: Sanders proposes is to shift the costs of all private health care to Medicare, in one fell swoop. This would substantially expand the federal budget, requiring increased taxes taxes that seem impossible in contemporary American politics. But this so-called “false lure” confuses Sanders vision of what the future could be like with a tax plan for 2017 he does not offer. To claim Sanders ignores the practical impossibility of his reform expansion is misleading. But it is also true that Sanders is not admitting to his supporters that his plan, given the current partisan deadlock, is infeasible. Clinton’s support for building incrementally on Obamacare lacks the emotional resonance of Sanders call for Medicare’s expansion and Sanders responds with reaffirmation of his principles. The result is bewildering.
II: The Democratic debate
The two candidates do agree on the goal of universal health insurance. But clarity ends there. Clinton’s discussion of short-term reforms largely ignores the question of what America’s long-term future should be like. The emphasis is on what’s wrong politically with Sanders’ ideas, not what right about Clinton’s. By contrast, the Sanders campaign emphasizes policy, not political tactics. It celebrates a substantive, long-term for universal health insurance, but does not provide the short-term incremental steps that could take the country in that direction.
Each candidate has answered only one of two key questions. How, asks the Sanders campaign, can American medical care arrangements more equitable, less costly overall, less complex and yet more financially accessible? What pragmatically, the Clinton team asks, would be the next incremental steps to take in 2017 were the Democrats to win the presidency?
A number of economists with ties to the Clinton campaign have offered the fiscal grounds for the ridicule, concentrating on the political impossibility of the tax increases the Sanders plan would require. According to Kenneth Thorpe, an economist at Emory University, Medicare for All would, would cost the federal government $1.1 trillion a year. Such fiscal criticism can easily distort rather than illuminate what Sanders was proposing. It ignores—or downplays the foregone private expenditures a Medicare for All program would replace.
The most obvious point is that the likely politics of 2017 and beyond are incompatible with a major reform of any American public policy—whether it is federal aid to higher education, climate change policy, or Medicare for All. That should frame the discussion of Sanders’ proposal around the aspirational values it reveals. Such a debate framing would provide Clinton the opportunity to outline a competing long-term vision that builds on her initial incrementalism.
III: Implications of the piece - could be deleted for space
A sensible debate in 2016 must necessarily address incremental possibilities. The debate could turn to state experimentation. It might lead to considerations discussion of moving the eligibility for Medicare down by a decade to 55. Or it could awaken interest in making Medicare less complex, which it has become, as have private health insurance policies.
Most fundamentally, it would recall the long struggle over Medicare itself, starting with a plan to initially cover Social Security retirees with what amounted to a Blue Cross plan for hospitalization only. Those reformers—Wilbur Cohen, Robert Ball, Oscar Ewing, and Nelson Cruikshank—first sketched this idea in 1951 and some of them were there to implement that program’s first step in 1965-66. That’s evidence of incrementalism with purpose and vision, not the opposite. If this were to be applied to the fight over Medicare in the first place, the program might well never have been enacted.
Online Tools to Shop for Doctors Snag on Health Care’s Complexity
by Reed Abelson - NYT
Need a dermatologist? Today, online tools can show you which doctors are in your plan’s network as well as rank them by the likely cost of a visit.
Still not sure which one to pick? The tools also show whether you have already met your plan’s deductible and offer Yelp-like reviews of the doctors.
The idea behind these web tools, which have been available from health insurers and start-ups for several years, is to harness the power of so-called big data. The companies cull medical claims and other sources of information to help people become sophisticated shoppers for medical care — and they promise to curb the overall cost of health care in the process. By some estimates, the savings from this newfound transparency could run in the billions of dollars a year.
Yet the limits of this data are becoming increasingly clear. Even when people have access to the newly available information, they may not use it. And when they do, they may not rely on the insight. It is impossible to know, for example, whether a dermatologist who costs twice as much as another can more successfully diagnose skin cancer.
“Price transparency tools are not likely the panacea that many have hoped for with respect to controlling health care costs,” Dr. Kevin Volpp, the director of the Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute, wrote in an editorial for The Journal of the American Medical Association. The editorial ran with a study of two large employers that found no decrease in outpatient spending as a result of workers’ use of online transparency tools.
This data’s limits are exemplified by Castlight Health, a San Francisco technology company and an early proponent of price transparency.
Castlight, which started eight years ago, ignored the resistance from health insurancecompanies, hospitals and doctors to make the prices they negotiated available. Castlight told employers it would help their workers make better medical decisions by giving them better information.
When it went public in 2014, it earned a valuation of about $3 billion. Today, Castlight’s stock has fallen nearly 90 percent as it has found that changing how people pick doctors and hospitals is much harder than expected. Obtaining prices and other crucial information has proved difficult, and trying to engage employees when they are deciding where to go and what care they need has been daunting for everyone in the industry. And many fewer people are shopping than employers had hoped.
Castlight executives insist is it still very early. “We overestimated the speed here,” said Dr. Giovanni Colella, the company’s chief executive and one of its founders.
“Transparency hasn’t even started,” he said.
Castlight says its tools continue to evolve, and some of its customers say their employees are using the tools to save money on labs or to steer them to certain providers.
Closest Thing to a Wonder Drug? Try Exercise
by Aaron Carroll
Last year, I wrote a column arguing that evidence shows that diet, not exercise, is the key to weight loss. Since then, I have been troubled at how some readers have taken this to mean that exercise therefore has no value.
Nothing could be further from the truth. Of all the things we as physicians can recommend for health, few provide as much benefit as physical activity.
In 2015, the Academy of Medical Royal Colleges put out a report calling exercise a “miracle cure.” This isn’t one of those things with just some cohort or case-control studies behind it, either. There are many, many randomized controlled trials. A huge meta-analysis examined the effect of exercise therapy on outcomes in people with chronic diseases.
Let’s start with musculoskeletal diseases. Researchers found 32 trials looking specifically at the effect of exercise on pain and function of patients with osteoarthritis of the knee alone. That’s incredibly specific, and it’s impressive so much research has focused on this one topic. Exercise improved those outcomes. Ten more studies showed, over all, that exercise therapy increases aerobic capacity and muscle strength in patients with rheumatoid arthritis. Other studies proved its benefits in other musculoskeletal conditions, like ankylosing spondylitis, and even some types of back pain.
For people (mostly middle-aged men) who had had a heart attack, exercise therapy reduced all causes of mortality by 27 percent and cardiac mortality by 31 percent. Fourteen additional controlled trials showed physiological benefits in those with heart failure. Exercise also has been shown to lower blood pressure in patients with hypertension, and improve cholesterol and triglyceride levels.
People with diabetes who exercise have lower Hba1c values, which is the marker of blood sugar control, low enough to probably reduce the risk of complications from the disease. Twenty randomized controlled trials have showed that patients with chronic obstructive pulmonary disease can walk farther and function better if they exercise.
Multiple studies have found that exercise improves physical function and health-related quality of life in people who have Parkinson’s disease. Six more studies showed that exercise improves muscle power and mobility-related activities in people with multiple sclerosis. It even appeared to improve those patients’ moods.
Seven-day nurses strike starts at five Twin Cities hospitably
by Jeremy Olson and Christopher Snowbeck - Minneapolis Star Tribune
More than 4,000 nurses went on strike at five Twin Cities Allina hospitals Sunday — some in tears as they left their shifts early in the morning and their patients in the hands of replacements recruited from across the country to cover the seven-day walkout.
Nurse Leah Otterness said goodbye to an orthopedic patient who was crying at Unity Hospital in Fridley.
"They will do their best to take care of you," said Otterness, who like most striking nurses was shuffled out of her hospital before the replacements arrived.
Whether the transition to 1,400 replacement nurses was smooth depends on who you ask. The Minnesota Nurses Association (MNA) reported problems at Allina's flagship, Abbott Northwestern in Minneapolis, such as replacements showing up for duty in intensive care with their licenses to practice in the state still pending.
Allina officials said doctors, nursing supervisors, respiratory therapists and nursing assistants pitched in to help the new nurses acclimate. Abbott had overstaffed for the day and compensated for the nurses whose licenses weren't finalized or whose skills were mismatched to their initial assignments.
"I don't know how you could make a complete changeover of all your nurses without having some challenges," said Dr. Ben Bache-Wiig, Abbott's president. He commended nurses and staff for their handling of critical cases Sunday morning, including a cardiac arrest that occurred an hour before the 7 a.m. shift change.
Leaders of the union-represented nurses and Allina expressed eagerness to renew negotiations, but no movement on the key issue: health insurance.
Conflicting Concerns at a Boston Hospital: Crowding, Costs and a Placid Garden
by Abby Goodnough - NYT
BOSTON — At a public hearing this year, a nursing director from Boston Children’s Hospital made a painfully detailed case for why the hospital needs to expand.
In the crowded neonatal intensive care unit, she said, doctors sometimes have to perform emergency surgery at an infant’s bedside, “within feet of other critically ill children and their anxious parents.” The open layout means that only a curtain separates a family preparing to take its baby home from parents who just took theirs off life support, she added, their sobbing heard by all.
“Time is of the essence,” said the director, Cheryl Toole, pleading for the Massachusetts Department of Public Health to approve a $1.068 billion expansion plan, the largest proposed by a hospital here in recent memory.
But what might seem an undeniable need for Boston Children’s — a new 11-story building that would house a bigger N.I.C.U. and heart surgery center, and private patient rooms instead of doubles — is instead bogged down in controversy.
To make room for the expansion, the hospital wants to bulldoze Prouty Garden, a serene half-acre green space at the center of its campus. A group of doctors and patients’ families are campaigning fiercely to save the 60-year-old garden, saying its value to sick and dying children and their families is irreplaceable.
“In a building full of monitors and beeping and probing staff, it’s a place you can go to just get away from all of it,” said Gus Murby, who took his 17-year-old son to the garden to die after a second bone marrow transplant for leukemia failed. “And that’s huge.”
More than 16,000 people have signed a petition supporting the campaign, including the biologist E .O. Wilson and the pediatrician T. Berry Brazelton, who worked at the hospital for decades.
The group behind it, Friends of Prouty Garden, has received enough donations to hire a lawyer and a public relations firm.
But while the garden has a powerful emotional tug, the group has also raised a practical question: Will a bigger, higher-tech hospital thwart state and national efforts to get spiraling medical costs under control?
Steffie Woolhandler, M.D., M.P.H., Briefs Democratic Platform Committee on Single Payer
Testimony in support of single-payer national health insurance
By Steffie Woolhandler M.D., M.P.H., M.A.I am a primary care doctor and professor of medicine and health policy. In 1986, I co-founded the non-partisan organization Physicians for a National Health Program, whose 20,000 members advocate for single payer reform.
Our proposals for single payer reform have appeared in the New England Journal of Medicine, The Journal of the American Medical Association, and most recently in the American Journal of Public Health. That proposal and references for my statements appear in my written testimony.
1. The ACA has not solved the health care crisis. About 30 million Americans are uninsured today. And 25 million would remain uninsured even if all states were to accept the Medicaid expansion.
2. Millions more have such hollowed-out coverage that they can’t afford care. Deductibles on employer-sponsored plans increased 255% between 2006 and 2015. Deductibles in the ACA’s exchange Silver plans average $3,064.
My research with Elizabeth Warren, when we were both professors at Harvard, found that medical problems were a cause of 62% of all personal bankruptcies. The majority of the medically bankrupt had private insurance that failed to protect them. This year, the Consumer Financial Protection Bureau reported that unpaid medical bills are by far the most common debts sent to collection agencies.
3. Many Americans have been forced into insurance that limits their choice of doctors and hospitals, often excluding leading cancer centers and teaching hospitals. Medicare for All would assure everyone a free choice of doctor and hospital.
4. Health inequality is on the rise. Today, the wealthiest American men live, on average, 15 years longer than the poorest. Meanwhile, the life expectancy gap has fallen in Canada. Overall, Canadians and Europeans now live 2 to 3 years longer than Americans.
5. Single payer systems in these nations provide first dollar coverage, while spending about half as much per person as we do.
6. The economic numbers on single payer add up. At the outset, government health spending would rise, but would be fully offset by reductions in premiums and out-of-pocket costs. Over the longer term, single payer reform would be less inflationary than our current market-based system. (Markets are designed to expand, and they do, especially when they're heavily subsidized.)
Single payer would save about $3.3 trillion on insurance overhead over the next decade by replacing private health insurers, whose overhead averages 12%, with a single public insurer with overhead of 2-3%, as in the traditional Medicare program or Canada’s single payer.
Single payer reform would also slash the paperwork that insurers inflict on doctors and hospitals, saving another $2.75 trillion over 10 years. Doctors would send all bills to one place using a simple billing form, and hospitals would stop sending bills. Instead, they’d be paid negotiated lump-sum budgets – much as we pay fire departments. Administration consumes 25% of hospital budgets in the U.S., vs. 12%, in Canada and Scotland.
Overall, a single payer reform would save more than $6 trillion on paperwork over the next decade, enough money to cover all of the uninsured, and to upgrade coverage for those of us with insurance.
7. A single payer reform could save an additional $2 trillion over ten years by using its leverage as a monopsony buyer to drive down drug prices. This strategy has allowed Europeans and Canadians (as well as the VA) to get drugs at half–price.
8. A Medicare buy-in or public option will not work. It would improve choices for some Americans but fail to garner most of the administrative or drug savings available through single payer. Moreover, as in the Medicare Advantage program, overall costs would go up because private insurers would cherry pick the healthiest patients, shunting expensive and unprofitable patients to the public option. We have already seen this dynamic at work in the collapse of the non-profit insurance coops under the ACA. In insurance competition, good guys finish last.
9. Single payer is popular. Most doctors, like other Americans, now favor national health insurance, and according a recent Gallup survey, the public now greatly prefers it to Obamacare.
10. In summary, single payer reform is the only route to affordable and sustainable universal coverage. The Democratic Party cannot pretend that minor tweaks to our failing health care system will fix it.
Additional Written Testimony and Documentation for the Democratic Party Platform Committee
By Steffie Woolhandler, M.D., M.P.H.1. The full text of the recent physicians’ proposal for single payer health care reform is available at http://www.pnhp.org/nhi.
http://www.pnhp.org/print/news/2016/june/steffie-woolhandler-md-mph-briefs-democratic-platform-committee-on-single-payer
Some Democrats Aren’t Giving Up on Universal Health Care
By Mary Ellen McIntire
Morning Consult, June 20, 2016
Democrats should push for universal health coverage ahead of the November election, several health care advocates urged the committee drafting the Democratic National Committee’s platform at a recent session focused on health policy.
Their liberal health care proposals echo a similar theme from an environment-themed session the same day, in which activists criticized DNC members for not pushing harder on climate change.
The hearing was part of a series of regional events held by the Democratic Platform Drafting Committee “designed to engage every voice in the party.”
Too many people are still uninsured six years after the passage of the Affordable Care Act, said many of the advocates who spoke before the committee in Phoenix on Friday. Still more are underinsured, they said, and people are struggling to pay for rising premiums and to afford prescription drugs.
While most of the witnesses speaking to the platform committee acknowledged the Affordable Care Act as a step forward toward ensuring health coverage for more people, some fault lines appeared among the party. Supporters of Sen. Bernie Sanders (I-Vt.) pointed out the shortfalls of the law, suggesting that it gets in the way of a single-payer system. Sanders hasn’t yet officially conceded the presidential primary race in his pursuit of influencing the party’s platform.
“It’s a national disgrace that we don’t provide health care for everyone,” said RoseAnn DeMoro, director of National Nurses United, which endorsed Sanders.
The Department of Health and Human Services says the ACA expanded health coverage to roughly 20 million Americans. The uninsurance rate fell to 9.1 percent last year, according to the National Health Interview Survey, though millions are still without coverage.
More than 50 percent of Americans now favor a single-payer health care system, DeMoro said. A Kaiser Family Foundation poll in December put that figure at 58 percent.
The current system, as an industry, isn’t fixable, she argued. “It’s very difficult to take a system that has profit in it, and this is what we find in the ACA, where so much money is taken out of the system and then think that we’re going to be able to resolve that piecemeal,” she said.
Rep. Barbara Lee (D-Calif.), a member of the drafting committee, said Democrats in Congress fought hard for a single payer or public option system while crafting the health law. They lost that fight because of Republican and industry pushback. States now have the option of adopting their own single-payer system if they choose. Coloradans will vote on such a ballot initiative in November.
Single-payer health care is the most effective route to universal coverage, argued Stephanie Woolhandler, co-founder of Physicians for a National Health Program. Government spending on health programs would initially rise, but it would later be offset by a reduction in premiums and out-of-pocket costs, she said. A Medicare buy-in or public option wouldn’t work as effectively because the system would not realize the same administrative and drug-cost savings available through a single-payer system.
“I think we, like the nurses, feel you just can’t pretend we’ve solved the problem here with the Affordable Care Act,” Woolhandler said. “What we have now is not a solution. We still have people dying. We still have people not getting care.”
Drug costs, which have come under significant political pressure in this election cycle, were another focus of the witnesses speaking to the drafting committee. Patients need relief from rising drug costs more quickly than the ACA is allowing, said Daniel Martinez, president of AARP Arizona. He wants to require drugmakers to explain how they are pricing products and create a new tax credit for people that are providing health care to relatives.
Kitty Kennedy, of the Arizona Alliance for Retired Americans, suggested that allowing safe importation of drugs from abroad could make it easier for Americans to afford prescription drugs. Hillary Clinton, the presumptive Democratic nominee, supports that idea. Oddly enough, that idea has also been floated by presumptive GOP nominee, Donald Trump.
http://www.pnhp.org/print/news/2016/june/some-democrats-aren’t-giving-up-on-universal-health-care
Morning Consult, June 20, 2016
Democrats should push for universal health coverage ahead of the November election, several health care advocates urged the committee drafting the Democratic National Committee’s platform at a recent session focused on health policy.
Their liberal health care proposals echo a similar theme from an environment-themed session the same day, in which activists criticized DNC members for not pushing harder on climate change.
The hearing was part of a series of regional events held by the Democratic Platform Drafting Committee “designed to engage every voice in the party.”
Too many people are still uninsured six years after the passage of the Affordable Care Act, said many of the advocates who spoke before the committee in Phoenix on Friday. Still more are underinsured, they said, and people are struggling to pay for rising premiums and to afford prescription drugs.
While most of the witnesses speaking to the platform committee acknowledged the Affordable Care Act as a step forward toward ensuring health coverage for more people, some fault lines appeared among the party. Supporters of Sen. Bernie Sanders (I-Vt.) pointed out the shortfalls of the law, suggesting that it gets in the way of a single-payer system. Sanders hasn’t yet officially conceded the presidential primary race in his pursuit of influencing the party’s platform.
“It’s a national disgrace that we don’t provide health care for everyone,” said RoseAnn DeMoro, director of National Nurses United, which endorsed Sanders.
The Department of Health and Human Services says the ACA expanded health coverage to roughly 20 million Americans. The uninsurance rate fell to 9.1 percent last year, according to the National Health Interview Survey, though millions are still without coverage.
More than 50 percent of Americans now favor a single-payer health care system, DeMoro said. A Kaiser Family Foundation poll in December put that figure at 58 percent.
The current system, as an industry, isn’t fixable, she argued. “It’s very difficult to take a system that has profit in it, and this is what we find in the ACA, where so much money is taken out of the system and then think that we’re going to be able to resolve that piecemeal,” she said.
Rep. Barbara Lee (D-Calif.), a member of the drafting committee, said Democrats in Congress fought hard for a single payer or public option system while crafting the health law. They lost that fight because of Republican and industry pushback. States now have the option of adopting their own single-payer system if they choose. Coloradans will vote on such a ballot initiative in November.
Single-payer health care is the most effective route to universal coverage, argued Stephanie Woolhandler, co-founder of Physicians for a National Health Program. Government spending on health programs would initially rise, but it would later be offset by a reduction in premiums and out-of-pocket costs, she said. A Medicare buy-in or public option wouldn’t work as effectively because the system would not realize the same administrative and drug-cost savings available through a single-payer system.
“I think we, like the nurses, feel you just can’t pretend we’ve solved the problem here with the Affordable Care Act,” Woolhandler said. “What we have now is not a solution. We still have people dying. We still have people not getting care.”
Drug costs, which have come under significant political pressure in this election cycle, were another focus of the witnesses speaking to the drafting committee. Patients need relief from rising drug costs more quickly than the ACA is allowing, said Daniel Martinez, president of AARP Arizona. He wants to require drugmakers to explain how they are pricing products and create a new tax credit for people that are providing health care to relatives.
Kitty Kennedy, of the Arizona Alliance for Retired Americans, suggested that allowing safe importation of drugs from abroad could make it easier for Americans to afford prescription drugs. Hillary Clinton, the presumptive Democratic nominee, supports that idea. Oddly enough, that idea has also been floated by presumptive GOP nominee, Donald Trump.
http://www.pnhp.org/print/news/2016/june/some-democrats-aren’t-giving-up-on-universal-health-care
Medicare and Social Security Trustees Warn of Shortfalls
by Robert Pear - NYT
WASHINGTON — The Obama administration said Wednesday that the financial outlook for Medicare’s hospital insurance trust fund had deteriorated slightly in the last year and that Social Security still faced serious long-term financial problems.
The report, from the trustees of the two programs, could inject a note of fiscal reality into a presidential campaign that has given scant attention to the government’s fiscal challenges as the population ages. Hillary Clinton, the presumptive Democratic presidential nominee, has proposed increasing Social Security benefits and allowing people age 55 to 64 to “buy into” Medicare, while Donald J. Trump, the presumptive Republican nominee, has repeatedly said he would not cut either program.
Under existing law, the trustees said Wednesday, Medicare’s hospital trust fund would be depleted in 2028, two years earlier than projected in last year’s report.
In addition, they said, the Social Security trust funds for old-age benefits and disability insurance, taken together, could be depleted in 2034, the same year projected in last year’s report. Tax collections would then be sufficient to pay about three-fourths of promised benefits through 2090, they said.
Social Security and Medicare account for about 40 percent of all federal spending.
Obama administration officials often say the Affordable Care Act has slowed the growth of health spending, compared with estimates made just before the law was adopted in 2010.
But the trustees said Wednesday that the short-term financial outlook for Medicare had worsened in the last year because of changes in their assumptions and expectations. Medicare actuaries now expect higher use of inpatient hospital services, as well as lower projected improvements in workers’ productivity and lower payroll tax revenue, as a result of slower growth in wages in the next few years.
In their report, the trustees — four administration officials — said that the costs of Medicare and Social Security would grow faster than the economy through the mid-2030s because of the aging of the baby boom generation. As for Medicare, they said, “growth in expenditures per beneficiary exceeds growth in per capita gross domestic product over this time period.”
The projected growth in Medicare spending will not immediately set off automatic cuts in the program under a controversial provision of the Affordable Care Act that generally requires such cuts when spending is expected to exceed certain benchmarks. However, such cuts could be required in a few years under the trustees’ forecast.
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