by Paul Waldman - Washington Post
For six years, Republicans in Congress have promised that very, very soon they’d release their plan to “repeal and replace” the Affordable Care Act. Just you wait, they said back in 2010, when we put out our plan America will see how terrific our health care ideas are. They also said that in 2011 — the plan was coming, hold on! They said that in 2012 — any day now, here it comes! They said that in 2013, and 2014 and 2015 — just give us a few more weeks, and you’ll have it! Well, now it’s 2016, and House Speaker Paul Ryan, R-Wisconsin, Wednesday released something that sort of looks like a “plan” if you just focus on the middle distance and take it in through your peripheral vision.
If you want to read Ryan’s plan, here’s an executive summary, and here’s the somewhat longer version. It’s light on details — such as how much it would cost and how many people would lose their coverage because of it — which isn’t all that surprising, given that the more specific you get, the more problematic things become. But it still illustrates the dilemmas Republicans face on this issue and their inability to solve them.
We’ll get to the potentially catastrophic effects of this plan (and I don’t say that lightly) in a moment. But first, let’s briefly look at what it contains. The starting point is the assertion that the ACA is a complete and utter disaster from top to bottom and therefore can’t be changed, altered or reformed, so it must be completely repealed: “This law cannot be fixed. Its knot of regulations, taxes and mandates cannot be untangled. We need a clean start in order to pursue the patient-centered reforms the American people deserve.” But after saying this, Ryan proposes to put back all the things about the ACA he thinks are popular. No denials for pre-existing conditions? Don’t worry, we won’t take that away! Young people up to age 26 being allowed to stay on their parents’ insurance? We’ll give you that, too! The ban on “recission,” where your insurer cancels your plan if you get sick? It’s in there!
So here’s what else is in the plan: Ryan would eliminate the individual and employer mandates; shut down the insurance exchanges; cancel the ACA’s expansion of Medicaid and then cut the program and convert it to block grants so that states could kick people off; move Medicare to a “premium support” model, which essentially means privatizing it and cutting it back; eliminate the ACA’s subsidies for low- and middle-income people, which would be replaced by a refundable tax-credit; promote health savings accounts and “mini-med” plans that cover virtually nothing; cap the tax exclusion for employer plans, which he presents as a friendlier alternative to the ACA’s “Cadillac tax” but which in effect is pretty much the same thing; and limit the amount victims of medical malpractice can sue for, along with a few other things.
One important note: Despite what Ryan says, the plan doesn’t actually maintain the prohibition on denials of coverage for pre-existing conditions, which may be the single most popular element of the ACA. It does so only if you maintain continuous coverage, beginning with a special one-time open enrollment. If you don’t, you’ll find that insurers can once again deny you because of your medical history, just like in the bad old days. And his answer for people with costly medical conditions is high-risk pools, which are just about the worst way possible to provide insurance (they segregate the costliest patients together, making coverage impossibly expensive).
So what would happen to this plan if Donald Trump actually became president and Republicans retained control of Congress? Trump himself couldn’t care less about the details of health-care policy — he’d probably sign whatever Congress put in front of him (don’t forget that his central health care promise was to repeal the ACA and replace it with “something terrific”). But would they actually fill out the details and pass Ryan’s plan? There are strong reasons to think the answer is no.
That’s because this plan, like almost any repeal-and-replace idea Republicans have, would cause absolutely cataclysmic upheaval in Americans’ health care. I cannot stress this strongly enough. Even if you accept the Republicans’ argument that it would eventually bring us to health care nirvana (which I obviously don’t), in the short and medium term it would be a nightmare. It would be much more disruptive than the implementation of the ACA was in the first place. One of the ironies of Republican rhetoric on this topic is that on one hand they complain that the ACA is so complex and made so many changes, touching every part of the American health care system, yet on the other hand, they claim they can undo it all with the stroke of a pen, and it’ll be no problem.
But they’re right on the first part. If you repeal the ACA, that means not only what we’ve already talked about, but also things like reopening the “doughnut hole” in Medicare prescription drug coverage, and moving Medicare back to the fee-for-service model the ACA has successfully begun a move away from, and taking away subsidies from small businesses, and taking away funding for community health centers, and bringing back cost-sharing (i.e. you paying money) for preventive care, and shutting down all the pilot programs the law created to test out new ways of delivering and paying for care, and a hundred other things that are going to cause enormous problems for hospitals, doctors and patients.
But that’s just the stuff that won’t get all that much attention. What will? The fact that when you repeal the ACA, you’ll be tossing tens of millions of Americans off their health coverage. The nonpartisan Congressional Budget Office estimates that in the first year after repeal, there would be 20 million more people without insurance.
Just imagine that: 20 million Americans losing their coverage all at once. Consider the parade of horror stories in the news about people being destroyed financially, and more than a few dying, because they can’t afford health care. Think that would pose a bit of a political problem for Republicans?
Which is why Ryan’s “reform” is not going to happen. It would be political suicide, and Republicans know it. If they do get the chance, they’ll pass something much, much more modest. They’ll call it “repeal and replace,” but it won’t be anything of the sort.
Paul Waldman is a contributor to The Washington Post’s Plum Line blog, and a senior writer at The American Prospect.
Paul Ryan’s flimsy health plan
IT HAS been more than six years since the Affordable Care Act passed and nearly three years since its major provisions began phasing in. During that time, the rate of uninsured Americans has plummeted to a historic low. Also during that time, Republicans have blamed the law for practically every problem with the health-care system, the economy and more. But they have infamously not united behind a credible alternative.
House Speaker Paul D. Ryan (R-Wis.) seemed to promise better when he announced that he would roll out an ambitious policy agenda this summer. Instead, last week he released an Obamacare alternative that is less detailed in a variety of crucial ways than previous conservative health reform proposals. The outlines that the speaker did provide suggest that it would be hard on the poor, old and sick.
Mr. Ryan’s plan would replace Obamacare with a tax credit available to people buying insurance plans in markets regulated by the states, not the federal government. The proposal does not say how valuable the credit would be, nor the rate at which it would increase. The document also does not predict how many people it would cover, nor how much the plan would cost. The latter is a major question in part because the plan would waste money offering tax credits to everyone, regardless of income. Republican staffers argue that the proposal is just a starting point for discussion. Yet other Obamacare-replacement proposals have included such numbers. The fact that Mr. Ryan’s does not renders the plan difficult to evaluate or take seriously. This many years on, the GOP has no excuse for blank spaces.
The proposal hints that the credit would be sufficient to cover the cost of plans that existed before the ACA. This is not reassuring: Pre-ACA, individual-market insurance plans were often thin, with limited benefits, extensive cost-sharing and other elements designed to deter anyone who might actually need care. Without strong coverage requirements, insurers would have limited incentive to offer plans that appealed to people who may be — or may become — sick. States would be hampered in responding to these issues: The proposal would allow insurers to sell plans across state lines, so the state with the skimpiest regulations would likely set the national standard.
People with money to put into health savings accounts (which the proposal would expand), could cover gaps in thin insurance coverage with tax-advantaged out-of-pocket spending — but this would not be a realistic option for low-income people. As for the old, the plan would scale up the tax credits with age, but it would also permit insurers to raise premiums with age much more than the ACA currently allows. The proposal gives no sense that the two will come close to matching up; as in other conservative plans, those in late middle age could face much higher costs. For the sick, meanwhile, Mr. Ryan’s plan would offer an ultimate backstop by funding high-risk insurance pools. But health-care experts caution that this approach would cost a massive amount of federal money — a fact that has caused Republican lawmakers to balk at policies like it when fleshed out.
At least, Republicans might argue, Mr. Ryan’s proposal would eliminate the hated individual mandate requiring people to buy insurance. Yet it would replace it with an even more coercive system. Protections for those with preexisting conditions would only apply for those who kept continuous health-care coverage. Under the current system, if you fail to obtain health insurance in a year, you might have to pay a penalty of few hundred dollars. Under Mr. Ryan’s plan, the Urban Institute’s Linda Blumberg explains, “If you slip through the cracks, your penalty is you may never be able to get health-insurance coverage again.”
Cutting healthcare costs shouldn't be this painful
by David Lazarus - LA Times
When my son was circumcised, Sade’s “Love Is Stronger Than Pride” was playing on a radio at the hospital. The pediatrician glanced over at me and said, “Some day, he’ll hear that song and won’t know why it makes him uncomfortable.”
Snip.
I recalled this experience while speaking the other day with Matt Williamson about his own son’s quiet storm of foreskin loss. The issue wasn’t the procedure, which I know some people question. The issue was the cost.
Williamson, 43, wanted to know why Kaiser Permanente’s South Bay medical center apparently charged him more than $3,000 when a nearby private clinic charges as little as $175.
“They never told us beforehand how much it would cost,” the Manhattan Beach resident told me. “They just gave us a piece of paper with mainly religious stuff and some health studies. If they had said it would cost $3,000, I would have immediately said, ‘No, thank you.’ I think most people would.”
This is yet another example of the lack of transparency in medical pricing, and the fact that hospital charges for routine tests and procedures can be orders of magnitude more expensive than those of specialized clinics – although patients typically will find that out only after they’ve paid their bill and realize they’ve been fleeced.
“These such huge price disparities show how uncompetitive the healthcare market is,” said Mireille Jacobson, director of the Center for Health Care Management and Policy at UC Irvine’s Merage School of Business.
“All these high-deductible health plans give patients an incentive to find the best price,” she said. “But the reality is that it’s very hard to shop around.”
When You Dial 911 and Wall Street Answers
by The NYT
A Tennessee woman slipped into a coma and died after an ambulance company took so long to assemble a crew that one worker had time for a cigarette break.
Paramedics in New York had to covertly swipe medical supplies from a hospital to restock their depleted ambulances after emergency runs.
A man in the suburban South watched a chimney fire burn his house to the ground as he waited for the fire department, which billed him anyway and then sued him for $15,000 when he did not pay.
In each of these cases, someone dialed 911 and Wall Street answered.
The business of driving ambulances and operating fire brigades represents just one facet of a profound shift on Wall Street and Main Street alike, a New York Times investigation has found. Since the 2008 financial crisis, private equity firms, the “corporate raiders” of an earlier era, have increasingly taken over a wide array of civic and financial services that are central to American life.
Today, people interact with private equity when they dial 911, pay their mortgage, play a round of golf or turn on the kitchen tap for a glass of water.
Continue reading the main story
Private equity put a unique stamp on these businesses. Unlike other for-profit companies, which often have years of experience making a product or offering a service, private equity is primarily skilled in making money. And in many of these businesses, The Times found, private equity firms applied a sophisticated moneymaking playbook: a mix of cost cuts, price increases, lobbying and litigation.
In emergency care and firefighting, this approach creates a fundamental tension: the push to turn a profit while caring for people in their most vulnerable moments.
For governments and their citizens, the effects have often been dire. Under private equity ownership, some ambulance response times worsened, heart monitors failed and companies slid into bankruptcy, according to a Times examination of thousands of pages of internal documents and government records, as well as interviews with dozens of former employees. In at least two cases, lawsuits contend, poor service led to patient deaths.
Private equity gained new power and responsibility as a direct result of the 2008 crisis. As cities and towns nationwide struggled to pay for basics like public infrastructure and ambulance services, private equity stepped in. At the same time, as banks scaled back their mortgage operations after the crisis, private equity firms — which face lighter regulation than banks, and none of their rainy-day capital requirements — moved in there as well.
The power shift has happened with relatively little scrutiny, even as federal authorities have tightened rules for banks. Unlike banks, which take deposits and borrow from the government, private equity firms invest money from wealthy individuals and pension funds desperate for returns at a time of historically low interest rates.
Since the 2008 financial crisis, private equity firms have gone from managing $1 trillion to managing $4.3 trillion — more than the value of Germany’s gross domestic product — according to the advisory firm Triago. Retirement nest eggs are fueling the growth and sharing in private equity’s risks and returns: Nearly half of private equity’s invested assets come from pensions.
“There is private equity — a lot of it — and it’s happening everywhere,” said Vikram Pandit, a former Citigroup chief executive who is now head of the Orogen Group, which invests in financial businesses. Across the financial landscape, he said, “New champions will emerge.”
Tense talks led to Brigham, nurses deal
Late Saturday, after months of tense negotiations and with a strike looming, it wasn’t disagreement on wages or benefits that kept Brigham and Women’s Hospital and its nurses union from nailing down a new contract. The final sticking point was a new patient-monitoring device that the Boston hospital wanted to deploy, and nurses wanted a say in how it would be used.
With help from Mayor Martin J. Walsh, who played the role of unofficial mediator throughout the weekend even though he was out of town, Brigham and the Massachusetts Nurses Association found a late-night compromise that averted what would have been the largest nurses strike ever in the state on Monday.
“I am certain that the mayor’s intervention turned the tide of this negotiation,” said Dr. Ron M. Walls, the Brigham’s chief operating officer. “He helped both sides understand how important reaching an agreement was, how important it was to the city.”
At 12:30 a.m. Sunday, the hospital and the union representing 3,300 nurses announced they had arrived at contract terms they each could live with. The hospital will get three years of labor peace, which officials said would provide needed stability. Nurses won wage concessions that were less than what they initially sought, but more than the Brigham had previously offered.
It was the culmination of almost 10 months of often contentious talks, including some 27 hours over Friday and Saturday, when Governor Charlie Baker, Senator Elizabeth Warren, state Attorney General Maura Healey, and businessman Jack Connors also worked to help prevent a potentially disruptive job action.
“We’re very relieved,” said Kelly Morgan, a nurse and vice chairwoman of the bargaining committee. “We’re feeling very satisfied with the agreement we reached. It benefits our patients tremendously. It benefits our nurses tremendously.”
The contract talks — with many highs and lows that had officials from both sides thinking they were close to a deal, only to see it fall apart — had grown more acrimonious in recent weeks. The union authorized a 24-hour strike, accusing the Brigham and Partners of disrespecting nurses. The hospital said it would lock out the union nurses for an additional four days.
Medicare, an effective program that needs expansion
by Jack Bernard
I have been amazed at the number of negative Medicare-for-all attack pieces printed in various respected papers over the last few months, making me wonder why primarily liberal economists would be attacking a program that progressives have been trying to enact since Truman.
The underlying implication is that the current private system is more effective than a federal government run single-payer model. As a Republican former elected official with a very conservative spending record, I too believe in eliminating governmental waste and in utilizing the private sector when it is more effective.
Therefore, my record makes some citizens surprised when I advocate for Medicare for all. Objectively, the U.S. healthcare system is and has been severely broken. Despite our spending far more per capita, our country is far behind all developed democracies, which scoff when our politicians make the false claim that we have the best healthcare in the world.
For example, the National Research Council and Institute of Medicine recently commissioned a panel of experts to compare our health with that of 16 other developed nations. We ranked poorly, on the bottom in several key areas! The NRC/IM report stated that our health care is “inaccessible or unaffordable” with “lapses in the quality and safety of care”.
The nations with the lowest cost and best outcomes have comprehensive universal health insurance, either: A.) the government provides direct care (like England or the “socialist” VA here); B.) there is a public utility model (like Denmark and France); or C.) there is single-payer (like Canada, with Medicare covering everyone).
Despite the demagoguery, options “B” and “C” do not represent a government takeover of health care delivery. These options eliminate private-sector insurance company marketing and administrative costs, and big pharma price gouging, directing that money into patient care rather than paying for bureaucracy and multimillion-dollar CEO salaries.
Medicare, the U.S.’s national health care insurance for the disabled and those over 65, has under 3 percent overhead costs (Canada is under 2 percent). Private insurance companies complained because the Affordable Care Act (ACA) required them to get down to 20 percent, or pay a fine.
You will notice that the list of options used by other nations does not include an “Obamacare” model, with dozens of private insurance companies offering a multitude of confusing, expensive plans. In fact, the ACA is a direct descendant of the private insurance plan model derived by the conservative Heritage Foundation as an alternative to “Clinton Care” in the 1990s. That overly complex model became “Dolecare,” which then became “Romneycare.” Oddly, the ACA was then passed by Democrats.
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