Health Care Reform Articles - December 5, 2016

National Health Spending: Faster Growth In 2015 As Coverage Expands And Utilization Increases

1. Anne B. Martin1,*, 
2. Micah Hartman2, 
3. Benjamin Washington3, 
4. Aaron Catlin4, 
5. the National Health Expenditure Accounts Team5 - Health Affairs

Abstract

Total nominal US health care spending increased 5.8 percent and reached $3.2 trillion in 2015. On a per person basis, spending on health care increased 5.0 percent, reaching $9,990. The share of gross domestic product devoted to health care spending was 17.8 percent in 2015, up from 17.4 percent in 2014. Coverage expansions that began in 2014 as a result of the Affordable Care Act continued to affect health spending growth in 2015. In that year, the faster growth in total health care spending was primarily due to accelerated growth in spending for private health insurance (growth of 7.2 percent), hospital care (5.6 percent), and physician and clinical services (6.3 percent). Continued strong growth in Medicaid (9.7 percent) and retail prescription drug spending (9.0 percent), albeit at a slower rate than in 2014, contributed to overall health care spending growth in 2015.

http://content.healthaffairs.org/content/early/2016/11/22/hlthaff.2016.1330.abstract

Tom Price, a Radical Choice for Health Secretary

by The Editorial Board - NYT

In picking Representative Tom Price, President-elect Donald Trump has chosen as his secretary of health and human services a man intent on systematically weakening, if not demolishing, the nation’s health care safety net.

Mr. Price, a Republican from Georgia, is a fierce opponent of the Affordable Care Act, the 2010 health reform law, and beyond that, supports plans to slash Medicare and Medicaid, which cover tens of millions of elderly, disabled and low-income Americans. He is against a woman’s right to choose and has backed legislation to strip Planned Parenthood of federal funding.

Mr. Trump and many Republicans have talked vaguely about plans to repeal the health reform law but suggest they might keep some popular parts of the law. Mr. Price makes no such noises. The detailed legislation he introduced most recently in 2015 would destroy the reform law and is a good indication of his philosophy in managing the nation’s largest health programs: cut benefits and leave millions with no health care at all.

His bill would, among other things, roll back the federally financed expansion of Medicaid in 31 states and the District of Columbia, taking coverage away from 14 million poor people. It would severely cut federal subsidies that help individuals and families buy policies on government-run health exchanges. The reduced subsidies would make it hard, if not impossible, for millions to afford the coverage they have gotten since the Affordable Care Act went into effect. And the bill would no longer require insurers to cover addiction treatment, birth control, maternity care, prescription drugs and other essential medical services.

As for coverage of pre-existing medical conditions — a key element of the current law, requiring insurers to sell plans to those with health problems — Mr. Price’s bill has that protection only for those who maintained continuous health coverage with any insurer for the previous 18 months. This means that insurers would not be required to sell an affordable plan to anyone who did not have coverage for, say, a month while he or she was between jobs.

Beyond his commitment to tearing apart the health care law, Mr. Price, who leads the House Budget Committee, published a budget proposal last year that would convert Medicaid into a block grant to state governments. This would reduce federal spending on the program by 34 percent by 2025, according to the Center on Budget and Policy Priorities. Such a cut would inevitably cause states to offer fewer benefits and reduce the number of people covered, far beyond the 14 million who would lose their coverage if Medicaid expansion is rolled back.

Mr. Price also supports big changes to Medicare that could hurt older Americans by increasing their health care costs. A plan backed by Mr. Price and the House speaker, Paul Ryan, would turn Medicare, which covers the cost of medical care for people over 65, into a program in which people would buy private insurance through what is known as premium support. The idea is to turn Medicare into a voucher program, designed to limit federal spending while forcing seniors to bear more of the cost. Given that most American families have little or no retirement savings, this would be disastrous. It also stands in stark contrast to Mr. Trump’s campaign promise not to “cut” Medicare and Social Security.

It is impossible to know which parts of Mr. Price’s agenda will become priorities for the new administration. But we do know that he will now have a very powerful perch from which to advocate his radical positions.

http://www.nytimes.com/2016/11/30/opinion/tom-price-a-radical-choice-for-health-secretary.html?mabReward=CTM&recp=2&action=click&pgtype=Homepage&region=CColumn&module=Recommendation&src=rechp&WT.nav=RecEngine

Tom Price Is Eager to Lead H.H.S., and Reduce Its Clout

by Robert Pear - NYT

WASHINGTON — During his 12 years in Congress, Representative Tom Price has made clear what role he thinks the government should play in health care. It can be summed up in one word: less.

Throughout his career, Mr. Price — who has been picked by President-elect Donald J. Trump to be secretary of health and human services — has argued that the government should get out of the way of doctors and give patients more control over their health care.

This position is rooted in Mr. Price’s experience as an orthopedic surgeon for more than 20 years. “As a physician,” he said in the House in 2007, “I know oh so well how the intervention of the state and federal government into the practice of medicine destroys the ability to take care of people. It makes it so you can’t provide quality health care for children and moms and dads.”

Though he has worked for years to shrink the government’s role, Mr. Price, a Georgia Republican, could soon lead a government agency whose expansive mission is to ensure care for more than 100 million Americans. As chairman of the House Budget Committee, he has tried to put a lid on federal spending. As secretary, he would be responsible for more than $1 trillion in spending, a number that will surge as the population ages.

The health secretary has immense discretion to impose, revoke and modify rules. A review of Mr. Price’s record in Congress, including his speeches and legislative proposals, suggests that he would try to reduce the burden of federal regulations on health care providers, especially doctors.

As secretary, he would be responsible for the popular Children’s Health Insurance Program, which insures eight million children at some point each year. In 2007, he opposed expansion of that program because, he said on the House floor, some children with private insurance would become eligible for “government-run socialized medicine.”

Two years later, as the House debated a huge bill to jolt the economy out of a severe recession, Mr. Price jumped to his feet after spotting an item that provided $1.1 billion for research comparing the effectiveness of different drugs and medical treatments. He denounced it, saying he feared that the findings would be used to decide which items and services would be covered by insurance.

“This is indeed the foundation of rationing of American health care for each and every American,” he said — a step toward Democrats’ dream of “nationalized health care.”

And in 2010, when Congress approved the Affordable Care Act, Mr. Price called it “a dark day for America,” saying that “our founders are weeping” over a bill that was “an affront to federalism, an affront to individual liberty.”

Senate Democrats are sure to challenge many of his positions at his confirmation hearings. Just as they distrust him on health care, he distrusts them.

“The true desire of those on the left,” Mr. Price said on the House floor in 2007, “is to gradually and enticingly move all Americans to Washington-controlled bureaucratic health care.” The bureaucracy, he said, is “not nimble like the private sector.”

Mr. Price, whose father and paternal grandfather were also physicians, is a fierce advocate for doctors. But he says his primary concern is for patients. A desire to “empower consumers” has been a theme of his work in Washington.

In 2010, he said on the House floor that he had discovered that “there were more folks in Washington who affected what I could do for and with my patients than anybody I ever met in residency or in medical school.” That, he said, “was wrong.”

Mr. Price often reminds colleagues of a sentence in the original Medicare law, passed in 1965: “Nothing in this title shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine.”

“We violate this law all the time,” Mr. Price said in 2005, referring to the government, especially “the bureaucrats, nonmedical individuals,” who have written reams of rules defining the quality of care.

Mr. Price has opposed the Obama administration’s effort to require employers and insurers to provide free coverage of birth control for women, saying it threatens religious freedom. The government should not “define and control what constitutes health care,” he said in 2012, voicing a concern he has long expressed.

Women’s rights advocates say Mr. Price’s position on birth control is at odds with his antipathy to government interference in health care. Decisions about contraception, they say, should be left to women, in consultation with their doctors.

Soon after becoming a House member in 2005, Mr. Price introduced a resolution stating that Congress should move the nation toward a new model of health insurance, in which employers would give employees a certain amount of cash so they could buy insurance on their own, rather than enrolling in a health plan chosen by the employer.

“Moving from a defined-benefit system to a defined-contribution system,” he said, would have a big advantage for consumers: They would “own and control” their insurance policies.

“That is a sea change,” Mr. Price said. It means that “patients can vote with their feet” and go to a different insurer, regardless of whether the cost is paid by Medicare, Medicaid or an employer.

“Unleashing the power of choice and competition is the best way to lower health care costs and improve quality,” he said.

House Republicans, led by Speaker Paul D. Ryan, embraced this idea in their “Better Way” policy agenda, issued in June. Under their proposal, Medicare would offer a fixed amount of money for coverage of each beneficiary. The money could be used to buy private insurance or to pay for the traditional Medicare program.

Democrats have assailed this approach, saying it leaves older Americans to fend for themselves if they need care that costs more than the federal contribution.

Many of Mr. Price’s legislative proposals would affect the department he now hopes to lead. The stated purpose of one bill is “to restore to states the freedom and flexibility to regulate health insurance markets.”

The bill would roll back insurance standards prescribed in the Affordable Care Act. Women could again be charged more than men of the same age for similar insurance policies, unless states banned such practices. Some people with pre-existing conditions who allow their insurance to lapse could have difficulty obtaining affordable coverage in the future.

Under another one of his bills, consumers could receive tax credits to help pay for insurance, but for many lower-income people, the amount of assistance would be less than what they receive under the Affordable Care Act.

Residents of one state might be able to buy insurance more easily from companies in other states. For consumers willing to take more responsibility for the cost of their medical care, it would be easier to set aside money in tax-favored health savings accounts.

But people with high-cost employer-sponsored health coverage could face new taxes. And patients who believe they have been injured by negligent doctors could find it more difficult to win damages in court.

If confirmed, Mr. Price will have a chance to practice what he has preached for decades. He could try to overhaul what he calls the “predatory trial lawyer litigation system.” He could try to stop what he calls “regulatory oppression” by the federal government. And he could eliminate some of the mandates that he calls a “death knell for quality health care.”

http://www.nytimes.com/2016/12/04/us/politics/tom-price-is-eager-to-lead-hhs-and-reduce-its-clout.html?_r=0

We Condemn the AMA and AAMC Endorsements of Tom Price for HHS Secretary

By Janine Petito, Andrew Hyatt, and Michael Zingman
Common Dreams, December 1, 2016

Early Tuesday morning, President-elect Donald Trump announced his selection of Representative Tom Price (R-Ga.) for Secretary of Health and Human Services (HHS), to succeed Secretary Sylvia Mathews Burwell. Almost immediately, the American Medical Association (AMA) and Association of American Medical Colleges (AAMC) expressed strong support for this nomination.

As students and future health care professionals, we are deeply troubled by the AMA and AAMC endorsements of Rep. Price. The policies he has endorsed not only stand in stark contrast to our ideals, but also threaten the wellbeing of our patients. We question why these organizations—established to protect the interests of all physicians, students, patients, and communities—would ignore the priorities of those they represent. As HHS secretary, Dr. Price will endanger medical institutions and policies, as well as jeopardize our medical education and the very practice of evidence-based medicine. 

Though Price, an orthopedic surgeon, claims to prioritize patient, family, and physician needs, his track record suggests decidedly otherwise. In 2015, as leader of the House Budget Committee, he proposed repealing the Affordable Care Act (ACA) in its entirety, privatizing Medicare, making enormous cuts to federal Medicaid funding, and abolishing the mandate that states use Medicaid dollars for patient care. These proposals would guarantee an immediate loss of health insurance for 22 million Americans; increase health care costs for the aged and disabled; and reverse recently-gained protections for vulnerable members of our society, abolishing protections of women’s health, addiction, LGBTQ+, and other necessary medical services.

Despite evidence of the substantial harm his policies would inflict upon patients, Rep. Price continues to advocate for them in his fiscal plan for 2017, promising to destroy the systems already in place to protect the neediest among us and placing the health of millions of Americans at risk.

The AMA’s support of Price lies in direct conflict with the organization’s purported values and its mission “to promote the art and science of medicine and the betterment of public health.” If the AMA is truly committed to promoting the science of medicine, it must recognize that this country cannot afford to place power in the hands of a man who opposes promising scientific breakthroughs like embryonic stem cell research. Similarly, it must ensure that the nation’s HHS secretary values the truth. On the contrary, Rep. Price has demonstrated a severe lack of respect for facts, exemplified by his false claims that women have always been able to afford birth control, and that “not one” has benefitted from the ACA’s contraceptive mandate.

If the AMA is truly concerned about the betterment of public health, it is frankly irresponsible to endorse a nominee who wants to decimate Medicaid—which serves more than 70 million Americans who cannot otherwise afford care—and privatize Medicare, creating narrow networks for enrollees, making seniors increasingly responsible for their health expenses, and decreasing access to needed care.

We find the AMA’s paradoxical endorsement objectionable, but unsurprising. This would not be the first time the organization has acted in the interest of profits over patients; it supported the ACA only begrudgingly, and has historically blocked every effort for universal health care reform, despite evidence of the innumerable benefits that a Medicare-for-All system would afford patients and providers alike. While the AMA has failed to represent the priorities and values of its member physicians for decades, the situation at hand poses too great a danger to our nation’s health for the medical community to remain silent.

The AAMC’s endorsement of Price is equally, if not more disturbing, given its role in molding future physicians and its mission to “serve and lead the academic medicine community to improve the health of all.” In its endorsement, the AAMC claims that Price “has long been a proponent of academic medicine.” This blatantly ignores the fact that the financial solvency of most academic medical centers depends directly on Medicare and Medicaid payments, given that individuals covered by these programs comprise a large percentage of those receiving care at these institutions. Without these programs, academic medicine as we know it would cease to exist.

If the AAMC truly wishes to “improve the health of all,” it cannot reasonably justify endorsing the nomination of a man who would strip 22 million people of health insurance, who has vocally opposed expanding health benefits for children, who believes our government has no responsibility to provide coverage to transgender individuals, and who ignores substantial evidence that access to preventative screenings, contraception, and abortion services have overwhelmingly positive impacts on women’s health.

As medical students and physicians, we condemn the AMA and AAMC endorsements of Price for HHS secretary, and are disheartened by professional organizations like the American Academy of Family Physicians (AAFP) and others choosing to follow suit. Price’s stances are incompatible with the values of the medical profession and with the stated missions of the above organizations. Their support reveals a warped set of priorities, with the short-term professional and financial interests of hospitals and physicians superseding the health and wellbeing of patients. We staunchly reject these endorsements and urge their immediate withdrawal.

In endorsing Price’s nomination and contravening their founding principles, the AMA and AAMC have failed to represent us, the future health care providers of this country. As members and supporters of Students for a National Health Program (SNaHP), we will combat every attempt to deny Americans the health care they deserve, and will fight to create a single-payer health care system that covers every person living in this country without discrimination. If the AMA and AAMC truly believe in their own missions, we urge them to join us in this fight.

Please consider adding your name to our statement to show your support in our condemnation of the AMA, AAMC, and others who endorse the nomination of Rep. Price for Secretary of Health and Human Services.

Janine Petito is a fourth-year medical student at Boston University School of Medicine, who plans to complete residency in internal medicine and pursue a career in adult primary care. She is co-chair of the Students for a National Health Program (SNaHP) Political Advocacy Team and a Physicians for a National Health Program (PNHP) student board member.

Andrew Hyatt is a third-year medical student at Boston University School of Medicine, an active member of Students for a National Health Program (SNaHP), and co-chair of the SNaHP Political Advocacy Team.

Michael Zingman is a first-year student at Columbia College of Physicians & Surgeons and active member of Students for a National Health Program (SNaHP).

http://www.commondreams.org/views/2016/12/01/we-condemn-ama-and-aamc-endorsements-tom-price-hhs-secretary

Future Physicians’ Demands For National Health Insurance

by John Geyman, M.D. - Huffington Post

Medical students are becoming strong advocates all over the country for expanded and improved Medicare for All. Spurred on by their increasing awareness of the restricted access, unaffordability, and inequities keeping many Americans from necessary health care, they are organizing and making their voices heard about the urgency of real health care reform.

With the co-sponsorship of the American Medical Student Association (AMSA), the Latino Medical Student Association (LMSA), White Coats for Black Lives, and many regional and local groups, a good example of their activism was the Halloween Day event in Boston a few days ago, which they dubbed #TreatNotTrick. Donning their white coats, often with Halloween costumes, they staged a public demonstration and call-in asking Rep.Mike Capuano to co-sponsor the single-payer bill in the House, H. R. 676. Their message is that private health insurance is a trick, and that they just want to treat patients in a fair system of universal coverage of health care for all Americans. (Kirchner, E. Let’s treat our patients, not trick them with private insurance. Common Dreams, October 27, 2016)

The Boston event was part of the Second Annual Medicare-for-All National Day of Action put on by Students for a National Health Program (SNaHP), the student arm of Physicians for a National Health Program (PNHP). Similar events were held from California to Minnesota to Tennessee on no fewer than 33 medical campuses. In Ohio, medical students visited Sen. Sherrod Brown’s office urging him to sponsor a single-payer bill in the Senate. In Philadelphia, they rallied to memorialize the lives lost because of being uninsured or underinsured. Their message is clear—private health insurance is a trick that erects barriers to care. (Ibid)

Today’s medical students, altruistic as so many are, see a medical profession caught up in a medical-industrial complex controlled by large corporations ranging from the insurance industry to the pharmaceutical and medical device industries. The business model prevails—profits and revenue for corporate CEOs and their shareholders call the tune. Medical students are seeing that almost two-thirds of physicians are now employed by big organizations, mostly expanding hospital systems. They see the decline of small group practice and the professional autonomy of earlier years diminished. They see an increasingly fragmented system with erosion of continuity of care amidst frequent changes of insurance coverage, narrowed and changing networks, and patients losing choice of physicians and hospitals. And they hear about earlier retirements and increasing burnout of physicians trying to keep up with the paperwork and bureaucracy of today’s multi-payer, largely for-profit system.

Medical students and their colleagues in other health professions are looking for a simplified system with universal access for all Americans to necessary care based on the principle that health care is a human right. That approach has been adopted for many years, in one way or another, by almost all advanced countries, while the U. S. remains by far the most expensive system with worse access and quality of care than most of these countries. 

A sizable majority of Americans have favored national health insurance for many years, usually including about three of five respondents to national surveys. A 2008 survey of more than 2,200 U. S. physicians in 13 specialties also favored NHI. (Carroll, AE, Ackermann, RT. Support for national health insurance among U. S. physicians: five years later. Ann Intern Med 1481: 566-6-567, 2008). Activist positions for single-payer NHI have been taken in recent years by a growing number of leaders of professional organizations, including prominent members of the American College of Physicians, the American Society of Clinical Oncology, the American Psychiatric Association, the American Women’s Medical Association, the American Public Health Association, the American Nurses Association, and National Nurses United. Jean Ross, co-president of National Nurses United, recently had this to say about the rapidly increasing insurance premiums in 2017 under the Affordable Care Act: 

The [just announced] premium increases are outrageous and just the
most recent sign of a broken, dysfunctional healthcare system. (2)

Medical students and other young health professionals are right in calling single-payer national health insurance (NHI), or Medicare for All, an urgent need. They are the future of health care in this country. Those of us in older generations welcome their empathy and caring in leading toward health care reform. NHI, as soon as it is enacted, will deliver a better system for both patients and health professionals—one based on a service ethic that will transition over 15 years to a not-for-profit system. It would have simplified administration allowing physicians and other health professionals more time for direct patient care, the essential purpose of the medical profession. 

John Geyman, M.D. is the author of The Human Face of ObamaCare: Promises vs. Reality and What Comes Next and How Obamacare is Unsustainable: Why We Need a Single-Payer Solution For All Americans

http://www.huffingtonpost.com/john-geyman/future-physicians-demands_b_12786706.html

G.O.P. Plans Immediate Repeal of Health Law, Then a Delay

by Robert Pear, Jennifer Stenhauer and Thomas Kaplan - NYT

WASHINGTON — Republicans in Congress plan to move almost immediately next month to repeal the Affordable Care Act, as President-elect Donald J. Trump promised. But they also are likely to delay the effective date so that they have several years to phase out President Obama’s signature achievement.

This emerging “repeal and delay” strategy, which Speaker Paul D. Ryan discussed this week with Vice President-elect Mike Pence, underscores a growing recognition that replacing the health care law will be technically complicated and could be politically explosive.

Since the law was signed by Mr. Obama in March 2010, 20 million uninsured people have gained coverage, and the law has become deeply embedded in the nation’s health care system, accepted with varying degrees of enthusiasm by consumers, doctors, hospitals, insurance companies and state and local governments.

Unwinding it could be as difficult for Republicans as it was for Democrats to pass it in the first place and could lead Republicans into a dangerous cul-de-sac, where the existing law is in shambles but no replacement can pass the narrowly divided Senate. Democrats would face political pressure in that case as well.

It is not sheer coincidence that at least one idea envisions putting the effective date well beyond the midterm congressional elections in 2018.

“We are not going to rip health care away from Americans,” said Representative Kevin Brady, Republican of Texas and chairman of the Ways and Means Committee, which shares jurisdiction over health care. “We will have a transition period so Congress can develop the right policies and the American people can have time to look for better health care options.”

Senator Lamar Alexander, Republican of Tennessee and chairman of the Senate health committee, said: “I imagine this will take several years to completely make that sort of transition — to make sure we do no harm, create a good health care system that everyone has access to, and that we repeal the parts of Obamacare that need to be repealed.”

But health policy experts suggest “repeal and delay” would be extremely damaging to a health care system already on edge.

OPEN Graphic 

“The idea that you can repeal the Affordable Care Act with a two- or three-year transition period and not create market chaos is a total fantasy,” said Sabrina Corlette, a professor at the Health Policy Institute of Georgetown 

Details of the strategy are in flux, and there are disagreements among Republicans about how to proceed. In the House, the emerging plan, tightly coordinated between Mr. Ryan and Mr. Pence, is meant to give Mr. Trump’s supporters the repeal of the health law that he repeatedly promised at rallies. It would also give Republicans time to try to assure consumers and the health industry that they will not instantly upend the health insurance market, and to pressure some Democrats to support a Republican alternative.

“I don’t think you have to wait,” Representative Kevin McCarthy of California, the majority leader, told reporters this week. “I would move through and repeal and then go to work on replacing. I think once it’s repealed, you will have hopefully fewer people playing politics, and everybody coming to the table to find the best policy.”

Under the plan discussed this week, Republicans said, repeal will be on a fast track. They hope to move forward in January or February with a budget blueprint using so-called reconciliation instructions, which would allow parts of the health care law to be dismembered with a simple majority vote, denying Senate Democrats the chance to filibuster. They would follow up with legislation similar to a bill vetoed in January, which would have repealed the tax penalties for people who go without insurance and the penalties for larger employers who fail to offer coverage.

That bill would also have eliminated federal insurance subsidies, ended federal spending for the expansion of Medicaid, and barred federal payments to Planned Parenthood clinics.

But in the Senate, Republicans would need support from some Democrats if they are to replace the Affordable Care Act.

The budget reconciliation rules that would allow Republicans to dismantle the Affordable Care Act have strict limits. The rules are primarily intended to protect legislation that affects spending or revenues. The health law includes insurance market standards and other policies that do not directly affect the budget, and Senate Republicans would, in many cases, need 60 votes to change such provisions.

Repealing the funding mechanisms but leaving in place the regulations risks a meltdown of the individual insurance market. Insurers could not deny coverage, but they would not get as many healthy new customers as they were expecting. Hospitals would again face many uninsured patients in their emergency rooms, without the extra Medicaid money they have been expecting.

Even a delay of two to three years could be damaging. Health policy experts said the uncertainty could destabilize markets, unnerving insurers that have already lost hundreds of millions of dollars on policies sold in insurance exchanges under the Affordable Care Act.

“Insurers would like clarity on the shape of the replacement plan to continue participating on exchanges if Obamacare is repealed,” Ana Gupte, an analyst at Leerink Partners who follows the insurance industry, said Friday.

Republicans are hoping that Mr. Trump will be able to use his bully pulpit to lean on vulnerable Democrats up for re-election in states Mr. Trump won, such as Senators Joe Manchin III of West Virginia and Jon Tester of Montana.

“When that date came and you did nothing, if you want to play politics, I think the blame would go to people who didn’t want to do anything,” Mr. McCarthy said.

But Democrats may not be so quick to break.

“If they are looking at fixing what’s there, I’ve been wanting to work with Republicans for years now,” said Mr. Tester, whose state cast just 36 percent of its vote for Hillary Clinton. “But if they are going to take away provisions like pre-existing conditions, lifetime caps, 26-year-olds, I think they are barking up the wrong tree.”

And some moderate Republicans see peril in repealing first and replacing later, favoring instead a simultaneous replacement to ensure a smooth transition.

“We are firing live rounds this time,” Representative Charlie Dent, Republican of Pennsylvania, said. “If we repeal under reconciliation, we have to replace it under normal processes, and does anyone believe that the Senate Democrats, with their gentle tender mercies will help us?”

Republicans said they would work with the Trump administration on replacement legislation that would draw on comprehensive plans drafted by Mr. Ryan and Representative Tom Price, the Georgia Republican picked by Mr. Trump to be his secretary of health and human services.

Any legislation is likely to include elements on which Republicans generally agree: tax credits for health insurance; new incentives for health savings accounts; subsidies for state high-risk pools, to help people who could not otherwise obtain insurance; authority for sales of insurance across state lines; and some protection for people with pre-existing conditions who have maintained continuous coverage.

Republicans said they hoped that the certainty of repeal would increase pressure on Democrats to sign on to some of these ideas.

Democratic leaders, for now, feel no such pressure. Republicans “are going to have an awfully hard time” if they try to repeal the health law without proposing a replacement, said Senator Chuck Schumer of New York, the next Democratic leader. “There would be consequences for so many millions of people.”

http://www.nytimes.com/2016/12/02/us/politics/obamacare-repeal.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=b-lede-package-region&region=top-news&WT.nav=top-news

U.S. Health Spending in 2015 Averaged Nearly $10,000 Per Person

by Robert Pear - NYT

WASHINGTON — Total spending on health care in the United States increased last year at the fastest rate since the 2008 recession, reaching $3.2 trillion, or an average of nearly $10,000 a person, the Department of Health and Human Services reported on Friday.

The growth coincided with continuing increases in the number of Americans with insurance coverage, through private health plans or Medicaid.

Federal spending on health care has increased by 21 percent over the past two years, as millions of Americans gained coverage through the Affordable Care Act, the department said in its annual report on health spending.

The increase in federal spending was driven mainly by the expansion of Medicaid eligibility and enrollment, according to the report, published online in the journal Health Affairs.

Under the Affordable Care Act, the federal government has been paying the full cost of Medicaid coverage for newly eligible beneficiaries. Thirty-one states have chosen to expand eligibility.

Over all, the government said, health spending accounted for 17.8 percent of the nation’s economy in 2015, up from 17.4 percent in 2014.

Total health spending rose 5.8 percent last year, and spending per person increased 5 percent. The Obama administration said this growth was “below the rates of most years prior to passage of the Affordable Care Act.”

Anne B. Martin, an economist who was the principal author of the report, said the federal government became the largest source of health spending last year, accounting for 29 percent of the total — more than households, private businesses or state and local governments. That stems not only from rising coverage through the health law but also an aging population, which is expanding Medicare.

The health law was always expected to fuel an increase in health spending, but the law has cost less than originally projected by the Congressional Budget Office, in part because the number of people signing up for subsidized coverage through online insurance exchanges was lower than expected.

Growth in total national health spending was exceptionally low for five years, from 2009 through 2013, in part because of lingering effects of the recession, officials said. The White House also asserted that the health law had slowed health spending, by cutting the growth of Medicare payments to many health care providers and by encouraging them to become more efficient.

“Over the last 55 years, the largest increases in health spending’s share of the economy have typically occurred around periods of economic recession,” Ms. Martin said. “The 2014 and 2015 increases occurred more than five years after the last recession ended. But they coincided with 9.7 million individuals gaining private health insurance coverage and 10.3 million more people enrolling in Medicaid.”

Rapid increases in retail spending on prescription drugs also contributed to the growth of national health spending, officials said.

The report noted “strong growth in new specialty medications such as those used to treat hepatitis C, cancer, autoimmune diseases and multiple sclerosis, as well as in more traditional brand-name medications such as those used to treat diabetes.”

In 2015, the report said, prices for existing brand-name drugs increased at a double-digit rate for the fourth consecutive year. An increase in the number of new drugs approved for use was also a factor.

“In 2015,” the government said, “45 new drugs were approved, more than in any one year over the past decade.”

Retail sending on prescription drugs grew 9 percent last year — more than any other category of health care goods and services — and reached $324.6 billion, representing 10 percent of all health spending, the government said.

Those figures understate drug spending, officials said, because they generally do not include spending on drugs administered in doctor’s offices, hospitals and nursing homes.

In the past two years, the report said, 20 million people either gained private health insurance coverage or enrolled in Medicaid, primarily as a result of the Affordable Care Act. The share of the population with health coverage increased to 90.9 percent in 2015, from 86 percent in 2013, before the law’s major coverage provisions took effect.

http://www.nytimes.com/2016/12/02/us/politics/us-health-care-spending.html?action=click&contentCollection=Politics&module=RelatedCoverage&region=Marginalia&pgtype=article

Sen. Collins has ‘reservations’ about privatizing Medicare, repealing health care law without replacement

Those positions would put Maine's Republican senator at odds with party leaders, who are expected to pursue both initiatives in the new year.

by Joe Lawlor - Portland Press Herald

Sen. Susan Collins of Maine said Friday that she’s unlikely to support efforts to privatize Medicare and might not vote to repeal the Affordable Care Act, positions that would put her at odds with Republican party leaders.

Though Collins opposed the Affordable Care Act and says it needs many fixes, she might not support repealing the law if a suitable, detailed replacement is not identified. However, Collins stressed in a brief interview Friday that she’s not sure how she would vote on the issue.

Plans to abolish the ACA and privatize Medicare have accelerated since voters elected businessman Donald Trump to the presidency on Nov. 8. Rep. Tom Price, a Georgia Republican nominated by Trump to lead Health and Human Services, has proposed gutting the ACA and privatizing Medicare.

Collins is a moderate Republican and her vote could be crucial if those initiatives are taken up by the Senate, where Republicans will hold a slim majority come January.

Sen. Angus King of Maine, an independent who caucuses with the Democrats, said he is opposed to efforts to repeal the ACA or privatize Medicare.

Collins said plans to privatize Medicare – which have been proposed by Price and House Speaker Paul Ryan – have many problems, and she’s voted against similar ideas. Privatizing Medicare would provide skimpier benefits and be more costly to seniors, critics say.

“Suffice it to say I have a number of reservations,” Collins said Friday during an interview by phone. “A complete upending of a program (Medicare) that by and large serves seniors well is not something that appeals to me.”

President Obama has vetoed several previous efforts by Republicans to eliminate the ACA, rebuffing numerous attempts since it became law in 2010.

But once Trump becomes president in January, it’s much more likely that he will sign an ACA repeal into law.

Pending the outcome of a runoff in Louisiana this month, Republicans probably will control the Senate by a 52-48 majority. If that’s the case, it would take only three Republican defections to derail efforts to repeal the ACA or privatize Medicare.

Collins said her “number one” goal for any ACA repeal effort would be to protect people who have purchased Affordable Care Act marketplace insurance. That group includes about 10 million people, while Medicaid expansion covers an additional 15-18 million. Maine is one of 19 states that has not expanded Medicaid. The uninsured rate has plummeted in the U.S. since the ACA took effect.

“You can’t just drop insurance for 84,000 people,” Collins said, referring to people who have signed up for ACA insurance in Maine.

Collins said she’s interested in an approach advocated by Sen. Lamar Alexander, R-Tenn., who recently told reporters that an ACA replacement should be the “first” focus of Congress.

“I think what we need to focus on first is what would we replace it with and what are the steps that it would take to do that?” Alexander said, according to a report in Slate magazine.

Collins said her first impression is to agree with Alexander.

“It strikes me as a more cautious approach,” she said.

Rep. Kevin McCarthy, R-California, the Republican House majority leader, has advocated for the opposite approach, eliminating the ACA and giving Congress two to three years to come up with a replacement.

But Collins also said that without a specific bill in front of her, she can’t commit to voting one way or the other.

“I’m hesitant to speculate on something that doesn’t exist,” she said.

Collins said there are many components of the ACA that she would like to change,such as allowing insurers to sell catastrophic plans, easing requirements on small businesses and reducing the narrow networks that some insurers offer.

Emily Brostek, executive director of Consumers for Affordable Health Care, an Augusta-based health advocacy group and supporter of the ACA, was encouraged to hear that Collins is taking a thorough look at repealing the ACA and seems opposed to privatizing Medicare.

“That’s the kind of leadership that Mainers have come to expect and appreciate,” Brostek said.

Brostek said if plans to partially repeal the ACA move forward – such as eliminating the individual mandate to purchase insurance and axing subsidies to help people purchase insurance – the entire system could collapse and insurers could flee the marketplace during the uncertainty. The ACA was devised as a series of interlocking components, and removing one could cause the others to fall apart in a chain reaction.

King said if the individual mandate is revoked, people would wait to purchase insurance until they were extremely sick, perhaps “on the ambulance ride to the hospital.” That would drive up the cost of insurance, he said.

“I’ll be the first to say the ACA is not perfect,” King said. “But I’ve heard a lot about repealing, but I haven’t heard much about how it would be replaced.”

King said the proposal to privatize Medicare is “an awful idea.”

“I can’t understand why people want to change a Medicare system that has worked well for 50 years,” he said. “If it ain’t broke, don’t fix it is an old Maine motto and it should apply in this situation.”

Both King and Collins said they don’t know yet whether they would vote to approve Price for Health and Human Services. King said Price “has a tall mountain to climb” to get his vote, considering Price’s stance on the ACA and Medicare.

http://www.pressherald.com/2016/12/02/collins-has-reservations-about-privatizing-medicare-repealing-affordable-care-act/

Not many Republicans spoiling for a fight over Medicare

House Speaker Paul Ryan's plan to remake the government's flagship health care program is getting a lukewarm reception, especially in the Senate, from members of his own party.

by Andrew Taylor - Associated Press

WASHINGTON — Congressional Democrats are warning that Speaker Paul Ryan and President-elect Donald Trump are gunning for Medicare – and they are rubbing their hands with glee at the prospect of an epic political battle over the government’s flagship health program that covers 57 million Americans.

It turns out that Republicans, especially in the Senate, are not spoiling for a fight.

“We are not inclined to lead with our chin,” said No. 2 Senate Republican John Cornyn of Texas. “And right now, we’ve got a lot on our plate.”

Ryan, R-Wis., is the most powerful advocate in Washington for a premium-support approach that would, over time, remake Medicare into a voucher-like program that could force some seniors entering the program to buy health insurance on the open market instead of getting coverage through the traditional open-ended program. Critics say such coverage would take away a Medicare guarantee and give seniors subsidies whose value won’t keep up with inflation.

Medicare covers 48 million seniors and nine million disabled people.

Ryan, just days after the election, said any legislation to replace President Obama’s signature Affordable Care Act law would necessarily include cuts to Medicare and Medicaid.

“Obamacare rewrote Medicare, rewrote Medicaid, so if you’re going to repeal and replace Obamacare, you have to address those issues as well,” Ryan told Fox News. “Those things are part of our plan to replace Obamacare.”

Ryan’s comments set off alarms, as did recent remarks by Rep. Tom Price, R-Ga. – made before becoming Trump’s nominee to head the Department of Health and Human Services – suggesting that House Republicans are eyeing major Medicare cuts as early as next summer.

“Speaker Ryan has pushed to privatize Medicare for years and the president-elect has nominated a champion of that effort,” said incoming Senate Democratic leader Charles Schumer of New York. “The people who are genuinely and rightly scared are millions of American seniors who don’t believe privatization of Medicare will be in their interest.”

Schumer on Friday announced a news conference next week with liberal groups to deliver more than 1 million signatures demanding that Republicans “keep their hands off” Medicare.

http://www.pressherald.com/2016/12/02/not-many-republicans-spoiling-for-a-fight-over-medicare/

The Art of the Scam

by Paul Krugman - NYT

Remember Donald Trump’s tax returns? It was unheard-of for a presidential candidate to refuse to release returns, since doing so strongly suggests that he has something to hide. And at first the Trump campaign offered excuses, claiming that the returns would eventually be made available once an I.R.S. audit was done, or something. But at this point it’s apparent that Mr. Trump believed, correctly, that he could violate all the norms, stonewall on even the most basic disclosure, and pay no political price.

Indeed, it’s clear that Hillary Clinton was in effect punished for her financial transparency, while Mr. Trump was rewarded for his practice of revealing nothing about how he makes money.

And as a result, we can expect radical lack of transparency to be standard operating procedure in the new administration. In fact, it has already started.

Take, for example, the budget process. Normally, an incoming administration issues a fiscal plan conveying its priorities soon after taking office. But as the budget expert Stan Collender notes, there are strong indications that the Trump administration will ignore this precedent (and, possibly, the law) and simply refuse to offer any explanation of how its proposals are supposed to add up. All we’ll get, probably, are assurances that it’s going to be great, believe me.

True, we don’t yet know for sure that there will be no budget. But it’s already clear that bait-and-switch — big but empty promises, completely lacking in detail — will be central to Republican strategy on one key issue: the future of health coverage for millions of Americans.

The background: Back in 2010 President Obama and the short-lived Democratic majority in Congress passed the Affordable Care Act with zero G.O.P. support. Ever since, Republicans have promised to repeal the law as soon as they had a chance, replacing it with something much better. Strange to say, however, they have never described what their replacement would look like.

And I don’t mean that they haven’t spelled out all the details. Almost seven years after Obamacare was enacted, Republicans haven’t offered even the broad outline of a health reform plan. Why not?

Actually, there’s no mystery here. While many Americans say they disapprove of Obamacare, large majorities approve of the things the Affordable Care Act does, notably ensuring that people with pre-existing medical conditions can still buy insurance. And there’s no way to achieve these things without either a major expansion of government health programs — hardly a Republican priority — or something very much like the law Democrats passed.

Worse yet, from the Republican point of view, Obamacare has worked. It’s not perfect, by a long shot, but the number of uninsured Americans has plummeted to its lowest level in history. And Americans newly insured thanks to Obamacare are highly satisfied with their coverage.

So what can the G.O.P. offer as an alternative? We know what Republicans want: a free-for-all in which insurance companies can discriminate as they like, with minimal regulation and drastic cuts in government aid. Going there would, however, cause millions of Americans — many of them people who voted for Trump, believing that their recent gains were safe — to lose coverage. The political blowback would be terrible.

Yet failing to repeal Obamacare would also bring heavy political costs. So the emerging Republican health care strategy, according to news reports, is “repeal and delay” — vote to kill Obamacare, but with the effective date pushed back until after the 2018 midterm elections. By then, G.O.P. leaders promise, they’ll have come up with the replacement they haven’t been able to devise over the past seven years.

There will, of course, be no replacement. And there’s likely to be chaos in health care markets well before Obamacare’s official expiration date, as insurance companies exit markets they know will soon collapse. But the political thinking seems to be that they can find a way to blame Democrats for the debacle.

It’s all very Trumpian, if you think about it. An honest memoir of the president-elect’s business career would be titled “The art of the scam.” After all, his hallmark has been turning a profit on failed business projects, because he finds a way to leave other people holding the bag.

In this case, the effort to replace Obamacare will clearly fail miserably in terms of serving the American people, perhaps especially the white working-class voters who backed Mr. Trump. But it could nonetheless be a political success if the public can be convinced to blame the wrong people.

You might think that this would be impossible, given the obviousness of the ploy. But given what we’ve seen so far, you have to take seriously the possibility that they’ll get away with it.

http://www.nytimes.com/2016/12/05/opinion/the-art-of-the-scam.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-left-region&region=opinion-c-col-left-region&WT.nav=opinion-c-col-left-region

The Problem With One-Size-Fits-All Health Insurance

by Nicholas Bagley and Austin Frat - NYT

A co-worker struggling to make ends meet comes to you with a problem. The price of admission to a dear colleague’s retirement party at an upscale establishment is beyond her means, though not yours.

You both feel obliged to attend. She’d rather bring some refreshments to a conference room than spend what she cannot afford on a lavish event. You like the idea of a grand send-off for your retiring colleague. There can be only one party.

A similar, underrecognized conundrum arises in health insurance. Both you and your less fortunate co-worker are obliged under the law to obtain coverage (which you both want anyway).

But you differ in what you’d prefer to pay for. A high-level manager who makes, say, $200,000 per year is probably willing and able to pay more for health care than someone who makes $50,000.

Unfortunately, neither person really has a choice because the plans all cover “medically necessary” care, meaning any care that offers a clinical benefit. That includes lots of expensive and technologically sophisticated care that is no better, or only slightly better, than cheaper alternatives. You may be just fine paying for high-tech care of marginal value. For your colleague of more modest means, it’s a stretch.

Consider, for example, treating prostate cancer with proton-beam therapy. It’s more expensive than alternatives like intensity-modulated radiation therapy, but isn’t proven to be any better. If given the choice, many people — especially those with lower incomes — might rather buy health insurance plans that exclude high-cost, low-value treatments.

The trouble is that insurers rarely sell those sorts of plans. Even insurers that try to exclude a particularly expensive and unproven technology from coverage are often rebuffed by legislatures and the courts.

This one-size-fits-all approach to insurance coverage disproportionately hurts low-income people, many of whom might reasonably prefer to devote their scarce dollars to housing or their children’s education. To some extent, subsidies and other monetary adjustments can mitigate this problem. Medicare and Medicaid, for example, are financed in large part out of federal income taxes. And within the Affordable Care Act marketplaces, lower-income people receive subsidies that cover some of their costs.

People who receive coverage through their employers, however, don’t get that kind of help. Perversely, employer-sponsored health insurance is more highly subsidized for the rich than the poor. The subsidy comes in the form of an exclusion of health-insurance premiums from taxation. Since income tax rates are progressive — that is, the rich pay a higher rate of income tax than the poor — lower-income families get less of a benefit.

But both high-wage and low-wage workers at the same company are effectively forced into the same plans. To qualify for the tax exclusion, federal law requires that companies offer the same plans to all or most of their employees, with no consideration for the variable demand for health care. Employees then pay for their fringe benefits by taking home lower wages — and a flat, across-the-board cut in wages burdens low-wage workers disproportionately.

In theory, the labor market could adjust in ways that might lessen the problem: Low-income workers, for example, could demand higher wages for being forced into plans that are more expensive than they’d prefer. These would have to be made up by reducing the wages of high-income workers, something it’s not clear they would accept. There’s no evidence that labor markets actually work this way.

“The notion that labor markets perfectly offset the varying preferences for health insurance among workers by giving higher wages to those who value health insurance less is a comforting but crazy idea,” said Amitabh Chandra, a Harvard economist.

The problems with one-size-fits-all insurance run deeper. In some insurance markets, like those for small businesses in Massachusetts, employees across companies are pooled together and pay the same premium. A recent report from the Massachusetts attorney general showed that workers in companies that receive health care at less expensive hospitals effectively subsidize those at comparable companies who receive care at more expensive ones.

The uniformity of insurance plans also affects the pace and composition of technological innovation. To extend our party metaphor, if everyone — even those who preferred simpler events — were effectively forced to pay for any retirement party, regardless of how lavish, we’d see, and pay for, retirement parties of ever-escalating extravagance.

In much the same way, medical innovators respond to the size of the market for new technologies. The fact that health plans routinely cover all medically necessary care sends an “if you build it, we will pay for it” signal. Innovators are not getting the right signals, the right incentives, to develop high-value or cost-saving treatments. It’s more lucrative, instead, to develop pricey new therapies, even if they offer only marginal clinical benefits. The result is lots of new treatments that don’t provide much bang for the buck.

Those new treatments pose a continuing challenge to efforts to bend the cost curve. Economists have long known that technology is the primary driver of escalating health expenditures. Indeed, in 2012 medical technologies that were not offered a decade earlier accounted for almost a third of Medicare spending delivered by physicians and outpatient hospital departments.

What’s to be done? Managing technological innovation would require us to consider policy changes that would have been unthinkable a generation ago. “The tax code could be restructured to make extravagant health insurance less appealing,” Mr. Chandra suggested. Employers might then offer health plans that appealed more to low-income workers.

The Cadillac tax on expensive health plans, which is scheduled to go into effect in 2020, is a step in that direction, but according to Mr. Chandra doesn’t go far enough. And it is unpopular across the political spectrum. Other ideas — like incorporating cost-effectiveness criteria into Medicare and private plan coverage criteria — are sure to prompt disagreement.

Contentious solutions they may be. But as the cost of health care and health insurance rises, it won’t be a party for politicians feeling more pressure from consumers.

http://www.nytimes.com/2016/12/05/upshot/the-problem-with-one-size-fits-all-health-insurance.html?emc=edit_tnt_20161205&nlid=1311158&tntemail0=y