The inadequate, shoddy debate over health care reform
by John Geyman, M.D. - The Hill
What does the recent election cycle portend for health care in America? Not good, if we go by the recent debate over further reform of our dysfunctional system. The non-debate has been shallow, barely covered by the mainstream media, and uninformative at this important juncture in deciding where to go next in U.S. health care.
In reality, we have three basic alternatives in how we finance health care: (1) continuation of the Affordable Care Act with changes as needed; (2) repeal of the ACA and replacement by a GOP “plan”; and (3) enactment of a single-payer Medicare-for-All system of national health insurance (NHI). But you would never know that from the debate, which is sketchy on the first two options and remains silent on the third.
Now that “conservatives” run the government in a new Trump administration, what can we anticipate? We are already seeing alarming evidence of racism, misogyny, bigotry, and authoritarianism at the highest levels of appointments in the White House and among some members of Congress.
In health care, we can expect efforts to dismantle the ACA, leaving more millions uninsured; to cut Medicaid through block grants to states; and to further the privatization of Medicare and Medicaid. We can also expect the easing of regulations on – and the protection of profits of – the big insurers, drug companies and other corporate stakeholders in our medical-industrial complex.
The GOP’s claims that “competition will work” have been repeatedly discredited over the last two-plus decades. Under its plan or the status quo, health care costs will continue to soar as health care becomes even less affordable, choice more restricted, coverage more skimpy, and as medical outcomes continue to worsen.
What we all want and need now is an honest and substantial debate over our three major options to reform U.S. health care. Debate over these alternatives should be nonpartisan, not a left-right or top-down issue.
For example, in the aftermath of the 2016 elections, conservatives now largely run the government at both the federal and state levels. If we were to base our future health policies on conservative principles, what would they be?
Donald Light, professor of comparative health care at the University of Medicine and Dentistry of New Jersey and researcher at Harvard’s Edmond J. Safra Center for Ethics, offers one answer. He notes that conservatives and business interests in every other industrialized country have endorsed these four conservative moral principles: anti-free-riding, personal integrity, equal opportunity, and just sharing. He proposes these 10 guidelines for conservatives to stay true to these principles in health care today:
1. Everyone is covered, and everyone contributes in proportion to his or her income.
2. Decisions about all matters are open and publicly debated. Accountability for costs, quality and value of providers, suppliers, and administrators is public.
3. Contributions do not discriminate by type of illness or ability to pay.
4. Coverage does not discriminate by type of illness or ability to pay.
5. Coverage responds first to medical need and suffering.
6. Nonfinancial barriers by class, language, education and geography are to be minimized.
7. Providers are paid fairly and equitably, taking into account their local circumstances.
8. Clinical waste is minimized through public health, self-care, strong primary care, and identification of unnecessary procedures.
9. Financial waste is minimized through simplified administrative arrangements and strong bargaining for good value.
10. Choice is maximized in a common playing field where 90-95 percent of payments go toward necessary and efficient health services and only 5-10 percent to administration.
Surprisingly, perhaps, if we were to reform health care financing along the lines of these conservative principles and hold so-called conservative lawmakers to them, our third option, single-payer NHI, would be the only alternative to meet these criteria.
Let’s have a thorough-going debate in the name of democracy and fairness, working toward the common good.
A just-completed Reuters poll puts health care at the top of what Americans want the new administration to address in its first 100 days, above the economy and immigration. Let’s demand more transparency and accountability for factual media coverage during and beyond this critical period.
John Geyman, M.D., is professor emeritus of family medicine at the University of Washington, Seattle, and author of “The Human Face of ObamaCare: Promises vs. Reality and What Comes Next.” He is past president of Physicians for a National Health Program.
The views expressed by authors are their own and not the views of The Hill.
Trump spurs fears, hopes among Americans insured by the Affordable Care Act
by Amy Goldstein - Washington Post
A 30-year-old cancer survivor in a small West Virginia town worries how she would pay for treatment if a tumor returned. A Chicago doctor wonders whether her hospital would cut back on care for ill or premature infants. In Northern Virginia, the head of a small nonprofit clinic lies awake at night fearing a surge of uninsured patients she couldn’t afford to take in.
Two weeks after the unexpected election of Donald Trump, the incoming administration and the Republicans who control Congress have defined few specifics for how they will carry out their promise to eliminate the Affordable Care Act. Yet the shift in Washington’s political geometry already is stoking anxiety among many of the 11 million people who have gained private insurance under the law, as well as among those who help care for them.
At the same time, some Trump voters with ACA health plans relish the idea of shedding the law. “How could it be worse?” asked Carl Galloni, who sells and installs garage doors in North Carolina. “My man won, so I’m not frightened [of] what he’s going to do.”
Such clashing perspectives offer a ground-level view of the two Americas exposed by a singularly polarizing presidential campaign — a campaign driven by profound disagreements over basic values, including the role of government.
On few matters is the political divide as pure as it is on health care. Early this fall, nearly 9 in 10 Democrats said in a survey for Harvard University and Politico that they thought the government has a major role in improving the health system, and 80 percent said the ACA is working well. Among Republicans, only about a quarter said the government has a major role, while an equal share said the government has none. Nearly 90 percent said the ACA is working poorly.
These beliefs “correlate perfectly with the [Hillary] Clinton versus Trump vote,” said Robert J. Blendon, a Harvard professor who specializes in public opinion on health issues.
In Fairmont, W.Va., Mina Schultz voted for Clinton. As she works at a community health center there, helping patients sign up for ACA coverage and her state’s expanded version of Medicaid, she sees firsthand how political health care has become. Some of her clients are now asking if it all is going to go away.
For Schultz, the fate of the law also is intensely personal. In 2011, when she was 25, she assumed she’d go uninsured for several months between graduate school and joining the Peace Corps. But her parents had heard that the fledgling ACA let them include her on their insurance policy through age 26, and they did.
That May, three weeks after getting her master’s degree in French, a recent pain in her right knee was diagnosed as bone cancer. So she happened to be insured when, instead of going overseas, she spent the next year in and out of the hospital for nine rounds of chemotherapy and a total knee replacement.
She moved back home to Fairmont when she was 27, first taking a crummy job that came with insurance, and then, because she’d become intrigued by the health-care system, finding the enrollment-counseling position at the Monongahela Valley Association of health centers. Her job, created through a federal grant, does not provide health benefits. Schultz signed herself up for an ACA Blue Cross-Blue Shield plan.
These days, in addition to work, she is pursuing a second master’s degree — in health policy. She still needs follow-up tests and medicine, including for the chronic kidney disease that is a remnant of her treatment. She also deals with anxiety and, since the election, a new fear: the future of her insurance and that of the people she has helped to choose health plans.
The impact of reversing the Affordable Care Act
Play Video1:08
Post reporter Amy Goldstein walks us through what changes health care will face under a Trump presidency. President-elect Donald Trump campaigned on his promise to repeal and replace the Affordable Care Act. (The Washington Post)
The president-elect, she knows, has been saying that the government should continue to forbid insurers to refuse people with preexisting medical problems — problems like her bone cancer. She also knows that, if the ACA ends, insurers may be able to revert to setting annual or lifetime limits on customers’ coverage.
“There’s not a day that goes by that I don’t think, ‘What if my cancer comes back?’ ” Schultz said. The prospect of capped insurance during a second bout of such expensive treatment “is terrifying. . . . I’m somewhat panicked.”
But in Jamestown, N.C., a suburb of 3,000 between Greensboro and High Point, Galloni, 61, is hopeful. He has never changed his party affiliation since registering as a Democrat at 18, but he often crosses party lines and this month was enthusiastic in his vote for Trump.
A small-business man, whose company consists of his wife and four employees, he is fed up with the ACA marketplace — the bureaucracy, the diminishing choice and the spiking price. Until now, Galloni has gotten federal subsidies because he wasn’t taking a salary from his company for several years. But he’s decided to draw some income again, so the subsidies are going away. The monthly premiums to cover him and his wife will leap from about $400 this year to $2,000 in January if he keeps his Blue Cross plan. He isn’t sure yet whether he will.
What gives him hope is the talk he’s heard from Trump about letting insurers sell health plans across state lines. “Why can’t I go three miles into Virginia and get my health insurance there if it’s cheaper?” he said. “Competition just makes the world go around.”
Among health-care professionals, the possibility that the ACA could soon be dismantled is setting off jitters, especially in places where many patients are poor.
At the University of Chicago’s children’s hospital, three-fourths of the babies in the neonatal intensive care unit have mothers on Medicaid. Illinois is one of 31 states that expanded Medicaid under the law. Bree Andrews, a pediatrician and neonatologist there who runs a center for healthy families, worries that a loss of extra Medicaid money the ACA has funneled into the hospital might mean fewer social workers or lactation specialists.
“I think it’s going to throw us into free fall,” Andrews said. “Neonatal care is expensive, and there is a lot of it. If hospitals don’t know how they will get paid . . . I wonder what will have to go.”
Hundreds of miles away in a Virginia suburb of Washington, Nancy White fears what will happen at the Arlington Free Clinic, where she became director a year ago. The clinic relies on donations and volunteers and can accept only about 2,000 patients at a time. It knows of about 200 patients who have gotten subsidized ACA plans and shifted to private doctors. Many more never arrived at the clinic’s doors because of coverage they found through the law.
If the new president and the Congress end the subsidies or the marketplaces, the clinic would not have the capacity to take back newly uninsured patients, White said. “It’s what’s been what’s been keeping me up at night.”
A Battle to Change Medicare Is Brewing, Whether Trump Wants It or Not
by Robert Pear - NYT
WASHINGTON — Donald J. Trump once declared that campaigning for “substantial” changes to Medicare would be a political death wish.
But with Election Day behind them, emboldened House Republicans say they will move forward on a years-old effort to shift Medicare away from its open-ended commitment to pay for medical services and toward a fixed government contribution for each beneficiary.
The idea rarely came up during Mr. Trump’s march toward the White House, but a battle over the future of Medicare could roil Washington during his first year in office, whether he wants it or not.
“Let me say unequivocally to you now: I have fought to protect Medicare for this generation and for future generations,” Senator Joe Donnelly of Indiana, a Democrat running for re-election in 2018, said this week in a video message to constituents. “I have opposed efforts to privatize Medicare in the past, and I will oppose any effort to privatize Medicare or turn it into a voucher program in the future.”
For nearly six years, Speaker Paul D. Ryan has championed the new approach, denounced by Democrats as “voucherizing” Medicare. Representative Tom Price of Georgia, the House Budget Committee chairman and a leading candidate to be Mr. Trump’s secretary of health and human services, has also embraced the idea, known as premium support.
And Democrats are relishing the fight and preparing to defend the program, which was created in 1965 as part of Lyndon B. Johnson’s Great Society. They believe that if Mr. Trump chooses to do battle over Medicare, he would squander political capital, as President George W. Bush did with an effort to add private investment accounts to Social Security after his re-election in 2004.
Democrats will “stand firmly and unified” against Mr. Ryan if he tries to “shatter the sacred guarantee that has protected generations of seniors,” said Representative Nancy Pelosi of California, the Democratic leader.
Republicans have pressed for premium support since Mr. Ryan first included it in a budget blueprint in 2011. As he envisions it, Medicare beneficiaries would buy health insurance from one of a number of competing plans. The traditional fee-for-service Medicare program would compete directly with plans offered by private insurers like Humana, UnitedHealth Group and Blue Cross Blue Shield.
The federal government would contribute the same basic amount toward coverage of each beneficiary in a region. Those who choose more costly options would generally have to pay higher premiums; those who choose plans that cost less than the federal contribution could receive rebates or extra benefits.
Supporters say this approach could save money by stimulating greater price competition among insurers, who would offer plans with lower premiums to attract customers.
Democrats say that premium support would privatize Medicare, replacing the current government guarantee with skimpy vouchers — “coupon care for seniors.” The fear is that the healthiest seniors would choose private insurance, lured by offers of free health club memberships and other wellness programs, leaving traditional Medicare with sicker, more expensive patients and higher premiums.
“Beneficiaries would have to pay much more to stay in traditional fee-for-service Medicare,” said John K. Gorman, a former Medicare official who is now a consultant to many insurers. “Regular Medicare would become the province of affluent beneficiaries who can buy their way out of” private plans.
Republicans say their proposal would apply to future beneficiaries, not to those in or near retirement. But the mere possibility of big changes is causing trepidation among some older Americans.
“I am terrified of vouchers,” said Kim Ebb, 92, who lives in a retirement community in Bethesda, Md., and has diabetes, atrial fibrillation and irritable bowel syndrome. “You get a fixed amount of money to draw on for your expenses. Then you are on your own.”
Charles R. Drapeau, 64, of East Waterboro, Me., said he was rattled by the Republican plans.
“I’m scared to death,” said Mr. Drapeau, who has multiple myeloma, a type of blood cancer, and takes a drug that costs more than $10,000 a month. “We don’t know exactly how it will work, but just the fact that they are talking about messing with Medicare, it’s frightening to me.”
Senator Richard M. Burr, Republican of North Carolina, has proposed a version of premium support, and other Republican senators have expressed interest, but the idea has not gained as much traction in the Senate as in the House.
The impact of premium support on Medicare beneficiaries depends on details of the plan to be specified by Congress. A crucial question is how the federal payment would be set. The effects would almost surely vary from one market to another, depending on whether private plans cost more or less than the traditional fee-for-service Medicare program.
Mr. Gorman said that premium support would be “a seismic change” in Medicare and could increase costs for many people in the traditional fee-for-service program, fueling a big increase in enrollment in private Medicare Advantage plans.
Enrollment in private plans is already on the rise, having increased more than 55 percent since adoption of the Affordable Care Act in 2010.
It is not just Republicans who have expressed interest in the idea. Alice M. Rivlin, who was the director of the White House Office of Management and Budget under President Bill Clinton, told Congress in 2012 that she favored a bipartisan proposal for premium support because health plans and providers would then “seek every possible way to provide higher-quality care at a lower cost.”
The nonpartisan Medicare Payment Advisory Commission, which advises Congress, has explored the idea of premium support and endorsed the principle that Medicare payments should be financially neutral — “that is, equal for fee-for-service and Medicare Advantage in each market.”
The Congressional Budget Office analyzed two of the leading options and found that “most beneficiaries who wished to remain in the fee-for-service program would pay much higher premiums, on average, under either alternative.” At the same time, the budget office said the proposal could slow the growth of Medicare spending if more beneficiaries enrolled in lower-cost private plans.
Nearly a third of the 57 million Medicare beneficiaries are already in private Medicare Advantage plans, and the government pays a monthly rate for each of those beneficiaries.
But, the budget office notes, several features of current law limit the degree of competition among insurers, and the traditional Medicare program does not bid against the private plans.
In a premium support system, each insurer would submit a bid showing the amount of money it was willing to accept to provide care for a typical Medicare beneficiary. Congress would need to define the bid for traditional Medicare. It could, for example, be the expected cost of providing care for a typical beneficiary in the fee-for-service program.
Medicare would pay the same basic amount on behalf of all beneficiaries in a region, regardless of whether they chose a private plan or traditional Medicare.
Nationwide, on average, Medicare spends about 2 percent more for a beneficiary in a private plan than it would for the same person in the fee-for-service program, according to the Medicare Payment Advisory Commission. But in some large urban areas with many competing private plans, those are less expensive than traditional Medicare.
Consumer advocates express several concerns about premium support. Private plans, under pressure to rein in costs, could respond by creating smaller networks of doctors and hospitals. Such plans would then be less attractive to sicker patients who need more health care services.
“What happens if the voucher doesn’t grow with the cost of health care?” asked Leslie B. Fried, a health lawyer at the National Council on Aging, a service and advocacy group. “Will people have more and more out-of-pocket costs?”
Ms. Fried said that having a healthy fee-for-service Medicare program was important not just for the 38 million people who have such coverage but also for people with private plans. Sometimes, she said, people switch from private plans to traditional Medicare when they develop serious illnesses and want a broader array of doctors.
For their part, insurers say the government would have an unfair advantage in any system of premium support because it would be regulating health plans and competing with them at the same time. Medicare officials set detailed standards for private plans and can fine them or suspend their marketing and enrollment activities if they violate the rules.
http://www.nytimes.com/2016/11/24/us/politics/donald-trump-medicare-republicans.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=b-lede-package-region®ion=top-news&WT.nav=top-news
The G.O.P. and Health Care Chaos
by The Editorial Board - NYT
What will happen if President-elect Donald Trump and Republicans in Congress carry out their pledge to repeal the Affordable Care Act, the 2010 health reform law? By most estimates, up to 22 million people, many of them poor or older Americans, will lose their health insurance.
Mr. Trump seems to recognize this would be disastrous — to an extent. Since the election, he has said that he wants to keep the part of the law that prohibits insurance companies from discriminating against people with pre-existing conditions. Without this provision, insurers can deny those customers coverage, charge them exorbitant rates or refuse to cover treatment for those conditions.
But Mr. Trump and other Republicans are delusional if they think that they can preserve that provision while scrapping the rest of the health care law. Insurers are able to offer policies to people with pre-existing conditions because the law greatly expands the number of people who are insured, thus spreading the costs of treating people with chronic conditions over a larger number of paying customers.
The law provides subsidies to help individuals and families buy policies on government-run online health exchanges (those who do not buy insurance are required to pay a tax penalty). Take away or greatly reduce that benefit and millions won’t be able to afford the plans, and many insurers will simply stop selling policies or will charge individuals and families much higher rates. The law also expanded Medicaid by financing state programs with federal money. Take away that money, and many states will no longer be able to provide care to millions of poor families.
Republicans have said that Congress could vote early next year to repeal the Affordable Care Act but delay the actual end of the law for a year or two. In theory, that would allow lawmakers to come up with a workable replacement while putting off the consequences of repeal.
But any vote to repeal the law would almost certainly cause insurers — which know they won’t be able to depend on the federal government in the future — to start pulling their plans from the online marketplaces for 2018 coverage, kicking millions off coverage. State and local governments will have to start planning to increase spending on public hospitals and charity medical care. Consider this: Uncompensated care at hospitals declined by $7.4 billion in 2014 after most major provisions of the law kicked in, according to the Department of Health and Human Services. Those costs would most likely go right back up.
The House speaker, Paul Ryan, and Republican policy experts have sketched out a variety of replacements for the law, but have not coalesced around one plan. All of them would reduce government spending and slash coverage.
One idea backed by Mr. Ryan would create a government-run high-risk pool to help pay for the medical care of people with major health problems who don’t have insurance. But previous state and federal high-risk pools did not cover most of the people with pre-existing conditions and suffered large losses, according to the Kaiser Family Foundation. Other Republican ideas include expanding the use of health savings accounts, which would primarily benefit wealthy families that can afford to sock away substantial amounts for future health problems.
Those complexities explain why Senator Lamar Alexander, the Tennessee Republican who leads the Health, Education, Labor and Pensions Committee, recently said it would “take several years” to fully replace the Affordable Care Act. Though the law is not perfect, it has greatly increased access to medical care and has made some parts of the health system more efficient by, for example, increasing the use of preventive services.
In discussing the repeal of the law during the campaign, Mr. Trump said, “There will be a certain number of people who will be on the street dying, and as a Republican, I don’t want that to happen.” He might start by following the maxim to “first, do no harm.”
http://www.nytimes.com/2016/11/28/opinion/the-gop-and-health-care-chaos.html?action=click&contentCollection=opinion&module=NextInCollection®ion=Footer&pgtype=article&version=series&rref=collection%2Fseries%2Fdonald-trump-whats-at-stake
Tom Price's radically conservative vision for American health care
Trump's choice for HHS secretary sends the clearest signal yet that Medicaid and Medicare may also be on the table.
A Trump Pick, and Why Indiana’s Strict Medicaid Rules Could Spread
by Margot Sanger-Katz - NYT
In most of the United States, anyone poor enough to qualify for Medicaid simply receives whatever care doctors recommend at minimal cost. But many Medicaid enrollees in Indiana can’t get full benefits unless they pay monthly premiums, and some who fail to pay can be shut out of coverage entirely for six months. If they go to the emergency room too often, they have to pay a fee.
These provisions were unprecedented departures for the program last year, and they were negotiated with federal health officials by Seema Verma, a consultant, on behalf of Gov. Mike Pence, now the vice president-elect. This week Donald J. Trump chose Ms. Verma to lead the Centers for Medicare and Medicaid Services, the influential agency inside the Department of Health and Human Services that oversees Medicare, Medicaid and the Obamacare insurance markets.
It is not clear what Ms. Verma may have planned for Medicare, a fully federal program that covers millions of older Americans and that usually makes up most of the administrator’s job. Administrators of the agency typically come with some Medicare experience, and Ms. Verma appears to have little.
Her policy priorities for Medicaid are much clearer. Mr. Trump and congressional Republicans have vowed to repeal the Affordable Care Act, and to create new systems for providing health insurance to low and middle-income Americans. But even without legislation, the executive branch can do a lot to reshape existing programs by giving states more power. Ms. Verma’s nomination suggests that the administration will become much more enthusiastic about approving novel Medicaid policies like those adopted in Indiana.
The Healthy Indiana Plan, as it’s known, “has been successful in meeting its policy objectives, but it also continues to demonstrate the potential for consumer-driven health care as an alternative to the traditional Medicaid model,” Ms. Verma wrote in an article in the journal Health Affairs this summer, arguing that other states should adopt its provisions. (An employee of her consulting firm said Ms. Verma was not doing interviews or answering questions.)
The Medicaid statute allows states to throw out many, but not all, program rules to test whether they can deliver better care to Medicaid patients at a similar cost. The bright lines about which rules can be waived are often decided in court.
The Obama administration has been open to new ideas in Medicaid, in part because it has wanted to encourage Republican-led states to expand coverage to more of their residents. It has allowed major policy experiments in Arkansas and Iowa, but the Indiana plan pushed the furthest in requiring beneficiaries to spend their own money and follow complex rules to continue receiving full benefits.
Other changes to Medicaid long favored by Republican state officials, like requirements that applicants work to obtain benefits, could also be approved. The Obama administration has argued that such requirements violate the Medicaid statute.
Republican state officials argue that such rules help beneficiaries take a greater stake in their own health and help them learn the value of their benefits.
“When things aren’t completely free, people begin to make more careful decisions about how and how much to consume,” said Mitch Daniels, the former Indiana governor, who worked with Ms. Verma on an early version of the plan. Mr. Daniels, now the president of Purdue University, praised her as an “indispensible technician” for her efforts in devising the proposal.
Analysts have criticized the Indiana program, saying that there hasn’t been good evidence that beneficiaries understood the incentive structure or changed their behavior because of it. They have also raised concerns that the program is complex and hard to manage — that the cost of collecting small premiums exceeds the revenue the state receives. Judith Solomon, the vice president for health policy at the left-leaning Center on Budget and Policy Priorities, said the state had not cooperated with efforts to independently evaluate the program.
At the Centers for Medicare and Medicaid Services, Ms. Verma could also encourage large changes in middle-class coverage. A provision in the Affordable Care Act allows states to replace traditional Medicaid and the Obamacare insurance marketplaces with a different system if it can be demonstrated that the plan would cover a similar number of people at a similar cost. The provision was envisioned as a way to allow liberal states to pursue single-payer systems. But health policy experts believe it could also be used to reshape many of the Affordable Care Act’s insurance market rules.
“The Affordable Care Act really federalized the health insurance market, so now we can decentralize that again, bring that authority back to the states in determining what benefits are,” said Dennis Smith, a former federal director of Medicaid in the Bush administration, who has also run the Wisconsin Medicaid program. He is now working for the Medicaid agency in Arkansas.
Other Medicaid experts worry about new barriers to health care, if the Trump administration approves plans that Obama administration officials have blocked.
“We can expect to see far-reaching changes contemplated for Medicaid that will erect many more barriers to coverage — and very punitive barriers,” said Joan Alker, the executive director of the Center for Children and Families at Georgetown University, in an email. “For example, forcing people to remain uninsured for up to year if they miss a paperwork deadline or a premium payment, even though we know that conditions like mental illness or homelessness — or something more simple like a notice getting lost in the mail — may explain the missed deadline.”
But experts across the political spectrum agree: Ms. Verma’s appointment will probably usher in a new era of state flexibility in health care.
Seduced and Betrayed by Donald Trump
by Paul Krugman - NYT
Donald Trump won the Electoral College (though not the popular vote) on the strength of overwhelming support from working-class whites, who feel left behind by a changing economy and society. And they’re about to get their reward — the same reward that, throughout Mr. Trump’s career, has come to everyone who trusted his good intentions. Think Trump University.
Yes, the white working class is about to be betrayed.
The evidence of that coming betrayal is obvious in the choice of an array of pro-corporate, anti-labor figures for key positions. In particular, the most important story of the week — seriously, people, stop focusing on Trump Twitter — was the selection of Tom Price, an ardent opponent of Obamacare and advocate of Medicare privatization, as secretary of health and human services. This choice probably means that the Affordable Care Act is doomed — and Mr. Trump’s most enthusiastic supporters will be among the biggest losers.
The first thing you need to understand here is that Republican talk of “repeal and replace” has always been a fraud. The G.O.P. has spent six years claiming that it will come up with a replacement for Obamacare any day now; the reason it hasn’t delivered is that it can’t.
Obamacare looks the way it does because it has to: You can’t cover Americans with pre-existing conditions without requiring healthy people to sign up, and you can’t do that without subsidies to make insurance affordable.
Any replacement will either look a lot like Obamacare, or take insurance away from millions who desperately need it.
What the choice of Mr. Price suggests is that the Trump administration is, in fact, ready to see millions lose insurance. And many of those losers will be Trump supporters.
You can see why by looking at Census data from 2013 to 2015, which show the impact of the full implementation of Obamacare. Over that period, the number of uninsured Americans dropped by 13 million; whites without a college degree, who voted Trump by around two to one, accounted for about eight million of that decline. So we’re probably looking at more than five million Trump supporters, many of whom have chronic health problems and recently got health insurance for the first time, who just voted to make their lives nastier, more brutish, and shorter.
Why did they do it? They may not have realized that their coverage was at stake — over the course of the campaign, the news media barely covered policy at all. Or they may have believed Mr. Trump’s assurances that he would replace Obamacare with something great.
Either way, they’re about to receive a rude awakening, which will get even worse once Republicans push ahead with their plans to end Medicare as we know it, which seem to be on even though the president-elect had promised specifically that he would do no such thing.
And just in case you’re wondering, no, Mr. Trump can’t bring back the manufacturing jobs that have been lost over the past few decades. Those jobs were lost mainly to technological change, not imports, and they aren’t coming back.
There will be nothing to offset the harm workers suffer when Republicans rip up the safety net.
Will there be a political backlash, a surge of buyer’s remorse? Maybe. Certainly Democrats will be well advised to hammer Mr. Trump’s betrayal of the working class nonstop. But we do need to consider the tactics that he will use to obscure the scope of his betrayal.
One tactic, which we’ve already seen with this week’s ostentatious announcement of a deal to keep some Carrier jobs in America, will be to distract the nation with bright, shiny, trivial objects. True, this tactic will work only if news coverage is both gullible and innumerate.
No, Mr. Trump didn’t “stand up” to Carrier — he seems to have offered it a bribe. And we’re talking about a thousand jobs in a huge economy; at the rate of one Carrier-size deal a week, it would take Mr. Trump 30 years to save as many jobs as President Obama did with the auto bailout; it would take him a century to make up for the overall loss of manufacturing jobs just since 2000.
But judging from the coverage of the deal so far, assuming that the news media will be gullible and innumerate seems like a good bet.
And if and when the reality that workers are losing ground starts to sink in, I worry that the Trumpists will do what authoritarian governments often do to change the subject away from poor performance: go find an enemy.
Remember what I said about Trump Twitter. Even as he took a big step toward taking health insurance away from millions, Mr. Trump started ranting about taking citizenship away from flag-burners. This was not a coincidence.
The point is to keep your eye on what’s important. Millions of Americans have just been sucker-punched. They just don’t know it yet.
Many Medicare cancer patients hit by high out-of-pocket costs
by Laurie McGinley - Washington Post
A doctor monitors a patient's heart rate. A new study found that cancer patients who have only Medicare coverage have high out-of-pocket costs. (Bigstock)
Cancer patients with only Medicare coverage face steep out-of-pocket costs, spending on average almost a quarter of their household incomes on treatment, according to a study published Wednesday.
The study by researchers at Johns Hopkins University found that Medicare beneficiaries without additional health coverage paid an average of $8,115 a year, or 23.7 percent of their incomes, on out-of-pocket costs after a cancer diagnosis. Some paid up to 63 percent of their incomes. Hospitalizations were the major factor for their high expenses, the researchers said.
Medicare beneficiaries with the lowest out-of-pocket costs also had coverage through Medicaid or the Veterans Health Administration. Their expenses were $2,116 and $2,367 a year, respectively. Seniors with additional coverage through employers had costs of almost $5,500, while those with private "Medigap” policies, which cover copays and deductibles not picked up by Medicare, had expenses of $5,670.
Beneficiaries in private Medicare plans — part of Medicare Advantage, which one-third of beneficiaries now choose — had costs of almost $6,000.
"The primary take-home message is that even in a population in which everyone has some health insurance, many people end up paying a significant share of their incomes in out-of-pocket expenses, and it might not be something they were planning for,” said study co-author Lauren Hersch Nicholas, a health economist at the Johns Hopkins Bloomberg School of Public Health.
The study, published in JAMA Oncology, is the latest look at "financial toxicity” — a term for the onerous burdens of escalating cancer-treatment costs. Its findings coincide with the intensifying post-election debate over the future not only of the Affordable Care Act but of big entitlement programs, such as Medicare, the federal health program for older or disabled Americans, and Medicaid, the federal-state program for poor Americans.
Some leading Republicans, including House Speaker Paul D. Ryan (R-Wis.), want to restructure both programs to slow their growth in spending and, they say, to ensure their long-term survival. Ryan has proposed providing fixed-dollar subsides to let seniors buy private insurance or coverage through regular Medicare. Critics, such as AARP, have warned that doing so could result in even higher costs for many individuals — a concern that Nicholas shares.
For the study on out-of-pocket costs, she and Amol Narang, a co-author and Hopkins instructor in radiation oncology, examined data for more than 18,000 Medicare beneficiaries who participated in a federally backed survey between 2002 and 2012. About 1,400 people were diagnosed with cancer during that period. About 15 percent had only traditional Medicare coverage.
The program has significant coverage gaps, including a deductible of almost $1,300 for hospital stays during a certain time frame. Nicholas said that she was surprised that out-of-pocket costs for Medicare Advantage plans were so high, given that they are often marketed as an economical alternative.
Oncologists need to be more aware of treatment costs and discuss the financial impact of treatment with their patients, Nicholas said. And Medicare should cap how much out-of-pocket costs a patient can be charged each year, she and Narang suggested. Many private health plans have such limits.
In an accompanying editorial, Jonas de Souza and Rena Conti of the University of Chicago said financial burdens can lead patients to delay or abandon treatment, which, in a worst-case scenario, can hasten death.
Scott Ramsey, a health economist at Fred Hutchinson Cancer Research Center in Seattle who was not involved in the study, noted that it "provides more evidence that older Americans are not very well protected from potentially severe financial stress when serious illnesses like cancer strikes. We could do more to protect this vulnerable population.”
The authors said that their research had important limitations. For one thing, it was based on self reporting by participants, which isn't always accurate. In addition, some of the high costs attributed to hospitalizations might have been because of inpatient administration of intravenous chemotherapy.
https://www.washingtonpost.com/news/to-your-health/wp/2016/11/23/many-medicare-cancer-patients-hit-by-high-out-of-pocket-costs/?hpid=hp_hp-top-table-main_acaworries-855pm%3Ahomepage%2Fstory
House Overwhelmingly Approves Sweeping Health Measure
By Jennifer Steinhauer and Sabrina Tavernise - NYT
WASHINGTON — The House overwhelmingly passed a far-reaching measure on Wednesday to increase funding for research into cancer and other diseases, address weaknesses in the nation’s mental health systems and help combat the prescription drug addictions that have bedeviled nearly every state.
The bill, known as the 21st Century Cures Act, also makes regulatory changes for drugs and medical devices, which critics argue lower standards to potentially perilous levels.
Passage of the bill in the Senate next week appears likely, even though Senator Elizabeth Warren, Democrat of Massachusetts, has taken to the floor twice to criticize the bill as a windfall for drug companies, with too few safety provisions. “The American people are not clamoring for the Cures bill,” Ms. Warren said on Wednesday, calling it the sort of measure that explains “why people hate Washington.”
The bill, which passed 392 to 26, was the product of three years of work, largely in the House, with former and current officials from the Food and Drug Administration and National Institutes of Health — two of the biggest beneficiaries of new funding in the bill — as well as scientists, health care advocates and others. It aims to streamline the federal drug regulatory structure to keep up with advances in biotechnology and other forms of medical research.
“We have listened to every group out there,” said Representative Fred Upton, Republican of Michigan and the chairman of the House Energy and Commerce Committee, which shepherded the bill. “I think we have a pretty good bipartisan bill that’s going to meet everyone’s test of how legislation should be done.”
The bill authorizes billions of dollars in new funding for N.I.H. research, much of it directed for Alzheimer’s disease and cancer, including money for the cancer “moonshot” sought by Vice President Joseph R. Biden Jr., whose son died from complications of a brain tumor last year. The F.D.A. is expected to receive a half-billion dollars, in part to help expand its staff to speed up processes at that agency. States could tap into roughly $1 billion over two years to fight the opioid epidemic.
It also folds in another large piece of legislation designed to improve the nation’s mental health services.
Language that would have exempted some speaker fees from a requirement compelling doctors to report payments received from the pharmaceutical industry was excised at the last minute.
Democrats are unhappy with the way the bill is funded. It authorizes $6.3 billion in money taken from a preventive health care fund and other sources, but funding must be appropriated annually. Democrats wanted the funding to be automatic each year.
“We have assurances from Republicans that they want to spend this money,” said Representative Diana DeGette, Democrat of Colorado, who traveled around the country with Mr. Upton to build support for the bill. “I actually feel confident that the money will be spent on that because this is a goal that is shared by both parties.”
Critics of the bill say it lowers standards for drug and device approvals at the Food and Drug Administration, in exchange for a badly needed funding increase for the National Institutes of Health.
“I think this takes us backward,” said Susan Wood, an associate professor of health policy at George Washington University and a former assistant commissioner for women’s health at the F.D.A. “It was a trade-off that was never worth doing.”
Others argue that the bill falls short because it elevates measures of a drug’s success called surrogate end points that can be misleading — for example, if a drug shrinks a tumor but does not ultimately prolong life. “This legislation pressures the F.D.A. to rely more on surrogate end points instead of results that matter to patients, living longer or feeling better,” said Diana Zuckerman, president of the National Center for Health Research in Washington.
Ms. DeGette said that although the bill contained provisions she did not like, “there is nothing in this bill that the F.D.A. says would undermine safety or efficacy of drugs.” She and other Democrats said they would get no better a deal next year under President Donald J. Trump and a Republican-controlled Congress.
In talks among House Republicans, Mr. Upton said, “someone said, ‘Why don’t we let Trump have this victory?’
“But we can’t delay it for political reasons,” he continued. “Who knows what would have happened if we had to start from scratch next year?”
http://mainepublic.org/post/advocates-say-despite-national-trend-mainers-still-struggle-pay-medical-billsAdvocates Say Despite National Trend, Mainers Still Struggle to Pay Medical Bills
Advocates Say Despite National Trend, Mainers Still Struggle to Pay Medical BillsFewer American families are struggling to pay their medical bills, according to a report from the Centers for Disease Control.Though the number has been in steady decline for the past five years, health advocates in Maine say there are still too many who can’t afford health care. And the problem of paying medical bills may affect more families in Maine than those in other states.Five years ago, there were nearly 57 million people under the age of 65 who were in families that had a hard time paying medical bills, according to the CDC. This year, that number had dropped about 5 percent to nearly 44 million.That dip, says Morgan Hynd of the Maine Health Access Foundation, is not surprising, because of the Affordable Care Act.“The reduction in people and families who are having trouble with that is directly related to the fact that 20 million people now have coverage that didn’t five years ago,” she says.Uninsured rates are at historic lows, says Emily Brostek of Consumers for Affordable Health Care, so it follows that more people can afford their medical costs.“What we’ve wanted to achieve through national health reform has worked, to a great extent,” she says.But, Brostek says, there is room for improvement.“I would say there are still too many people struggling with their medical bills,” she says. “We hear from people on our help line who literally lose their house because they can’t pay their medical bills.”Some of these bills were racked up before the Affordable Care Act was in place, says Brostek.Other calls to the help line come from people who currently have insurance, but struggle to pay ever-increasing deductibles. And then there are people who don’t have any health insurance.“We still have a number of people who don’t have affordable health coverage options because we haven’t accepted funding available to cover them through our state Medicaid program,” Brostek says.Which, she says, means the number of Maine families struggling with medical bills likely skews higher than the national average.The Maine Health Access Foundation released a report last year that found in 2013 and 2014, Mainers across all income levels had more difficulty paying their medical bills compared to the rest of the nation. Whether that gap narrows in the future and more families can afford health care depends on the policies that will be put forth by President-elect Donald Trump.Trump has said he plans to repeal and replace the ACA. But Hynd says she hopes some elements will be preserved, including the individual mandate to buy insurance.
“Because you really need everyone in the insurance pool to make all the other pieces fit together properly. You need to have the good parts, and the not-so-good parts together,” she says.In other words, healthier people need to be a part of the insurance pool to help offset the costs of those who are not as healthy.There’s one other aspect of the ACA that Hynd says is worth preserving to increase health care affordability: Medicaid expansion.“It’s also something that hasn’t happened in Maine yet, but I hope that Maine will still have the opportunity in 2017 to expand Medicaid,” she says.This fall, a number of Maine organizations launched a petition to put Medicaid expansion on the ballot.
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