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Thursday, January 19, 2017

Health Care Reform Articles - January 19, 2017

Editor's Note:
I apologize for the length of today's blog, but I've been on the road for the past week, so there's a bit of catch-up in this posting. I've tried to put the articles in (roughly) chronological order.

First, what follows is a letter to the editor of the New York Times. Since they have evidently decided not to publish it, I'm including it in today's blog.

 -SPC

To the Editor - New York Times: 
I am becoming increasingly frustrated by Paul Krugman’s approach to health care reform. TheAffordable Care Act has accomplish a lot of good things. But Krugman's uncritical enthusiasm for it is troubling. He consistently ignores its necessary flaws, that make it so unpopular with so many people, and such an easy target for critics. These include it’s unnecessary complexity, the weakness of its cost controls, the unfairness of both the ways it is financed and its benefits and the individual mandate that requires people to buy a product they may think they don't need from companies they neither like or trust.
He most recently repeated his error during a Times Insider podcast featured on today’s (January 8) front page. He incorrectly states “We cannot do universal coverage without something that looks a lot like ObamaCare.” That statement is true only if one believes that our current public policy of putting the welfare of insurance companies above those of all other Americans is immutable.
We already have Medicare, one of the most popular and successful of federal programs. Universal coverage could be achieved by simply expanding it to cover everybody, as originally envisioned by it’s founders.
I hope Mr. Krugman enriches the upcoming debate about how to replace ObamaCare by soon acknowledging that simple fact without the usual caveat that “it can’t be done”. Sometimes the common wisdom is wrong.
Philip Caper, M.D.
Brooklin, Maine


Access to Buying Insurance Is Not Health Coverage

by Rose-Ann DeMoro - National Nurses United - Common Dreams

A signature exchange early in the first Senate hearing Wednesday for Rep. Tom Price in his nomination to be the next Health and Human Services Secretary illustrates a lot about our still damaged healthcare system, and how it could now get much worse.
Sen. Bernie Sanders, whose call to expand coverage through an improved Medicare for all was a centerpiece of his presidential campaign, forcefully challenged Price to commit to guaranteed healthcare for every American.
Sanders: The United States of America is the only major country on earth that does not guarantee healthcare to all people as a right. Do you believe that healthcare is a right of all Americans, whether they are rich or they’re poor? Should people, because they are Americans, be able to go to the doctor, be able to go into a hospital because they are Americans? In Canada, in other countries, all people have the right to get healthcare. Do you believe we should move in that direction?
Price: I believe that every single American has access to the highest quality care and coverage that is possible.  
Sanders. ‘Has access to’ does not mean that they are guaranteed health care. I have access to buying a $10 million home; I don’t have the money to do that.
Unpack the evasions and you have the Ayn Rand-Tea Party philosophy in a nutshell. You only deserve the healthcare you can buy, from private insurance companies that have a history of price gouging with multiple restrictions on the care you can receive even after paying your premiums.
"Access to care" in the mouths of those devoted to shredding every vestige of our healthcare safety net only serves as a pointed reminder of the elevation of double speak for an incoming administration whose press secretary, Sean Spicer, can praise the "totality of diversity" that is "second to none" for a Cabinet where 13 of 16 nominees are white men. Or perhaps Spicer just meant the "diversity" of both millionaires and billionaires.
Any notion that the private healthcare market, which has long prioritized its profiteering above any guarantees of access, cost, or quality, will somehow do a better job of assuring “every person the financial feasibility to purchase the coverage they want” requires a suspension of disbelief that is truly Orwellian.
Probably the best evidence of the failure of the market-driven system – which saw the U.S. fall to 37th in the world according to a World Health Organization ranking  early in this century – is the decades long push for major healthcare reform.
The Affordable Care Act was a step forward, especially in access, through the expansion of Medicaid for many low and moderate income adults, and a ban on some of the worst insurance abuses that permitted more people to buy insurance plans through the ACA market exchanges.
Significant holes in the ACA, especially the failure to adequately control out of pocket costs for millions of people, opened the door to much of the attacks, as hypocritical as the ideological resistance has been from those in Congress to a plan that was evolved from conservative think tanks and designed to meet the desires of the healthcare industry.
Now, with the rush to repeal the ACA, things are in danger of getting very ugly fast.
Incoming President Trump did throw a wrench into the feeding frenzy in a series of statements insisting that the Republican majorities in the Senate and House adopt a concurrent replacement plan with repeal of the ACA.
Further he set conditions, that no one lose coverage they’ve gained under the ACA, and that premiums and deductibles be lowered.
That has made it sticky for the repeal and replace crowd. Not one scheme they have talked about the past eight years comes close to meeting those barometers.
Not health savings accounts or tax credits to buy insurance without any controls on the predatory pricing practices of the industry.
Not “selling insurance across state lines” which is merely a race to the bottom, letting insurance giants decamp in the least regulated states so that other states, with stronger public protections, must accept those same lowered standards.
And not converting Medicaid to block grants, which Price, and now Trump as well, are proposing as a “solution” for expanded coverage.
The Medicaid block grant proposal is intended to sharply reduce federal funding for Medicaid, and then leave it to states, more than half now controlled by conservative budget hawks, to reduce their commitment to health coverage for low and moderate income people by restricting eligibility and cutting covered benefits.
Sanders also pressed Price on whether he would adhere to another Trump promise not to cut Medicare and Medicaid.
And then there was this exchange, where Sanders pointed out another Trump call for increased negotiations to reduce prescription drug prices, which would be a sharp u-turn for Congressional conservatives who have repeatedly blocked the ability of Medicare to negotiate discounts as most other countries do.
Sanders: Will you work with us so that Medicare negotiates prices with the pharmaceutical industry
Price: You have my commitment to work with you and others to make certain that the drug pricing is reasonable and that individuals have access to the medications that they need.
There he goes again. “Access” to medications may mean you can stand in a pharmacy and admire the drugs on the shelves, but it still does not mean you can afford the massive price gouging to get them.

Life Expectancy Lower for Trump Voters

by Dante chin - nbc news
Throughout the 2016 campaign President-elect Donald Trump reached out to voters who felt the system didn't work for them. They were crucial to his November victory. 
But the challenges those voters face is about more than just economics and government policy, it cuts all the way to the physical health of their communities. 
People who live in Trump's most supportive communities feel they are not as healthy as the nation as a whole and people in their communities are more likely to die from a drug or alcohol overdose, according to data from the Gallup and the Centers for Disease Control analyzed by the American Communities Project. 
Meet The Press merged data from three groups of counties that Trump won by more than 20 points - Graying America, Evangelical Hubs and Working Class Country. Those counties carry some common traits. They are more rural than the other places and tend to have lower incomes and lower college education rates. 
There are 1024 counties in that merged group. Trump won 986 of them. And they look very different from the country on some key health measures. 
More than 28% of the people in those counties said they have health problems that prevent them from doing things people their age normally can do. In some of those places that was much higher, well over 30%. That's compared to a national average figure of roughly 22%, according to Gallup surveys conducted in the 3rd quarter of 2016. 
Those are self-diagnoses, of course, and respondents could be referring to anything from hard knee or back pain to diabetes. But the "health problems" question is fairly consistent across the counties Trump won. The counties Clinton won tended to have fewer than average people citing "health problems" that affected their lives. 
Maybe more surprising, those 1024 Trump-heavy counties also scored well above the national average in death induced by drugs or alcohol, according to 1999-2014 data from the CDC. The rate for drug or alcohol induced death was 24.2 per 100,000 people compared to less than 20 per 100,000 nationally. 
In fact, contrary to what many might expect, the numbers for drug and alcohol induced deaths were higher in those rural counties than they were big cities (20.9 per 100,000 people) or dense urban suburbs (18.4). That's despite the fact that drug and alcohol abuse is often seen as a bigger problem in urban areas. 
In many ways these health numbers are more crucial to understanding the frustration that drove parts of the Trump coalition than other political or economic indicators. In a very real sense, these data are not revealing attitudes, they are reporting outcomes — the impact of what it means to live in some of the nation's more rural, less wealthy areas. 
The health numbers further expose the depth of the urban/rural divide running through the country. They suggest that divide is increasingly connected to politics. And they indicate Donald Trump is inheriting a very nation that may be very difficult to bring together.

Why Trump’s Obamacare Promise Will Be So Hard to Keep

by Margot Sanger-Katz - NYT
As a candidate back in July 2015, Donald J. Trump promised that he would repeal Obamacare and replace it with “something terrific.”
The Senate voted, 51 to 48, on Thursday morning for a measure setting Congress on the path toward repealing President Obama’s health care law, and Mr. Trump is now a few days from taking office. The public, however, knows little more about his proposal than it did in 2015.
In comments to The New York Times on Tuesday and in his news conference on Wednesday, Mr. Trump described when a Republican health reform bill would be released — “very quickly.” But he has yet to give details about the policies it would contain.
“We’re going to have a health care that is far less expensive and far better,” he said Wednesday.
Mr. Trump accurately describes problems with the current health care system for Americans under 65: “You have deductibles that are so high, that after people go broke paying their premiums which are going through the roof, the health care can’t even be used by them because their deductibles bills are so high.”
Mitch McConnell, the Senate majority leader, and House Speaker Paul Ryan have also spoken forcefully in recent days about how health care is too expensive.
Premiums for health insurance plans in the United States are high. And increasing deductibles can make needed coverage a financial stretch even for the insured. Recent polling from the nonpartisan Kaiser Family Foundation suggests that the public agrees with Mr. Trump’s assessment: High out-of-pocket spending on health care is Americans’ No. 1 health care concern. (Mr. Trump has promised that he will not make major changes to Medicare, the program for Americans 65 and older.)
But solving those problems is not as easy as identifying them. The real reason health care premiums and deductibles are so high is that medical care is very expensive in the United States — far more costly than it is anywhere else in the world. The United States pays very high prices to doctors and hospitals and drug and device makers, and Americans use a lot of that expensive medical care. That means that the country spent far more on health care than its peers even when tens of millions of Americans lacked health coverage.
Obamacare has been successful in getting health insurance to people who lacked it before. About 20 million more Americans had insurance last year than before the law passed, according to an Obama administration estimate. But the health law, largely focused on health insurance regulation, did not drive down the cost of medical treatments. Health care, and health insurance, continues to be expensive.
That means that a Republican health reform plan that is both cheaper and better than Obamacare will be hard to deliver.
Republicans in Congress and right-leaning think tanks have put together a number of possible Obamacare replacement plans. They are all slightly different, and it is unclear which one Mr. Trump and congressional leaders will choose. But none of them solve both sides of the “less expensive and far better” equation.
Most of the G.O.P. plans manage to be less expensive for the federal government — by offering stingier federal payments in helping people buy insurance and allowing the coverage people buy to be skimpier. But those proposals will tend to increase, not decrease, the amount many Americans spend on their health care.
Lower-income people will end up paying a larger share of their income to buy coverage than they do under Obamacare. Deductibles and other forms of out-of-pocket spending, capped under Obamacare, will tend to rise in many plans. Millions to tens of millions fewer Americans will have coverage under such plans, according to independent estimates.
Republicans also want to pare back the minimum package of benefits that plans must cover, which will drive up costs substantially for some patients, while reducing them for others. If the bill eliminates requirements to pay for maternity care or prescription drugs, for example, that could lower the sticker price of a health plan, but will make health care much more expensive for anyone who has a baby or takes medication.
There will be people who will be better off under a Republican plan. Higher-income, healthy people who buy their own insurance have been the most disadvantaged group under Obamacare, and their fortunes would improve. The Republican plans, with their skimpier benefits, and more generous tax assistance for the wealthy, would offer them a better deal.
The G.O.P. plans tend to be worse for people who need insurance and are poor or have major health problems. (Some sick people may be far worse off. Mr. Trump has promised that people with pre-existing health conditions will be covered under his plan, but not all the Republican plans offer them the kind of coverage that they can get under Obamacare.)
The Affordable Care Act is a case study in these trade-offs. Most of the things its creators did to try to make health insurance “far better,” like requiring minimum benefits or banning lifetime coverage limits, also made it more expensive. The things they did to make insurance “less expensive,” like encouraging higher deductibles or requiring all Americans to buy health insurance or pay a fine, are top anti-Obamacare talking points.
The consensus Democratic approach to making Obamacare “far better” has been to make it more expensive for the federal government, but less expensive for individuals. Proposals circulated by President Obama and Hillary Clinton would involve more federal spending on subsidies to help make insurance more affordable for more people, but at the expense of higher taxes.
So far, the Republican plans have tended to engage in the same trade-offs, but tilt in the opposite direction, emphasizing government savings over program generosity.
The recent statements from Mr. Trump suggest that the coming replacement plan — promised in the next few weeks — will be able to achieve both goals simultaneously. Mr. Trump has provided almost no detail about what will be in it.

How Large Employer Health Plans Could Be Affected By Obamacare Overhaul

by Michelle Andrews - Kaiser Health News

If you think that you wouldn't be touched by a Republican overhaul of Obamacare because you get health insurance through your job at a big company, think again.
Several of the law's provisions apply to plans offered by large employers, too (with some exceptions for plans that were in place before the law passed in March 2010).
It's not yet clear how President-elect Donald Trump and congressional Republicans plan to revamp the federal health law, known as the Affordable Care Act or Obamacare. They have not agreed on a plan, and they do not have enough votes in the Senate to fully repeal the current statute. So they are planning to use a budgeting rule to disassemble part of the law, which will limit what they can change. But they also may seek revisions in important regulations and guidance that have determined how the law is implemented.
Nonetheless, as tensions grow in Washington over the future of the health law, it is important to understand some of its effects on large-group plans.
No copays for preventive services
The health insurance offered by big companies is typically pretty comprehensive, the better to attract and keep good employees. But Obamacare broadened some coverage requirements. Under the law, insurers and employers have to cover many preventive services without charging people anything for them. The services that are required with no out-of-pocket payments include dozens of screenings and tests, including mammograms and colonoscopies that are recommended by the U.S. Preventive Services Task Force; routine immunizations endorsed by the federal Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices; and a range of services that are recommended specifically for children and for women by the federal Health Resources and Services Administration.
The change that affects the most people on an ongoing basis is likely the requirement that plans cover without cost sharing all methods of contraception approved by the Food and Drug Administration. (There are limited exceptions for religious employers.)
"In terms of sustained costs, birth control is probably the biggest," said Caroline Pearson, a senior vice president at Avalere Health.
No annual or lifetime limits on coverage
Even the most generous plans often had lifetime maximum coverage limits of a few million dollars before the health law passed, and some plans also imposed annual coverage limits. The health law eliminated those dollar coverage limits.
Annual cap on out-of-pocket payments for covered services
The health law set limits on how much people can be required to pay in deductibles, copayments or coinsurance every year for covered care they receive from providers in their network. In 2017, the limit is $7,150 for individuals and $14,300 for families.
"Many employers often had an out-of-pocket limit anyway, but this guarantees protection for people with high needs," said JoAnn Volk, a research professor at Georgetown University's Center on Health Insurance Reforms, who has written on this issue.
Adult kids' coverage expanded
The law allowed workers to keep their children on their plans until they reach age 26, even if they're married, financially independent and live in another state. Republicans have said they may keep this popular provision in place if they dismantle the law.
Guaranteed external appeal rights
Consumers who disagree with a health plan's decision to deny benefits or payment for services can appeal the decision to an independent review panel.
The provision applies to all new health plans including those offered by self-funded companies that pay their workers' claims directly and who were previously exempt from appeals requirements.
No waiting periods to join a plan 
Employers used to be able to make new employees wait indefinitely before they were eligible for coverage under the company plan. No more. Now the waiting time for coverage can be no more than 90 days.
No waiting periods for coverage of pre-existing conditions 
Prior to the ACA, employers could delay covering workers' chronic and other health conditions for up to a year after they became eligible for a plan. Under the ACA, that's no longer allowed. As a practical matter, though, coverage of pre-existing conditions was rarely an issue in large-group plans, say some health insurance analysts.
Repeal could reopen the door to that prohibited practice, however.
Standardized plan descriptions
The law requires all plans to provide a "summary of benefits and coverage" in a standard format that allows consumers to understand their coverage and make apples-to-apples plan comparisons.
Basic coverage standards for large-group plans
The health law isn't as prescriptive with large-group plans about the specific benefits that have to be offered. They aren't required to cover the 10 essential health benefits that individual and small-group plans have to include, for example. But the law does require that big companies offer plans that meet a "minimum-value" standard, paying at least 60 percent of the cost of covered services, on average. Those that don't could face a fine.
Initially, the online calculator that the federal Department of Health and Human Services provided to help large employers gauge compliance with the minimum value standard gave the green light to plans that didn't cover hospitalization services or more than a few doctor visits a year. Now plans must provide at least that coverage to meet federal standards.
The result: Large employers generally no longer offer so-called "mini-med" policies with very skimpy benefits.
If the health law is repealed, that could change. In some industries with lower-wage workers and smaller profit margins, "they might begin to offer them again, and employees might demand it" to help make the premiums more affordable, said Steve Wojcik, vice president of public policy at the National Business Group on Health, a membership organization representing large employers.
Although the law strengthened coverage for people in large-group plans in several ways, consumer advocates have complained about shortcomings. It aimed to ensure that coverage is affordable by requiring that individuals be responsible for paying no more than 9.69 percent of their household income for individual employer coverage, for example.
If their insurance costs more than that, workers can shop for coverage on the marketplaces set up by the health law and be eligible for premium tax credits — if their income is less than 400 percent of the federal poverty level (about $47,000). But the standard does not take into consideration any additional costs for family coverage.
Consumer advocates also point to the wellness regulations as a problematic area of the law. The health law increased the financial incentives that employers can offer workers for participating in workplace wellness programs to 30 percent of the cost of individual coverage, up from 20 percent.
Such incentives can effectively coerce people into participating and sharing private medical information, critics charge, and unfairly penalize sick people.
"It potentially allows [plans] to discriminate against people with medical conditions, which the ACA is supposed to eliminate," said Linda Blumberg, a senior fellow at the Urban Institute's Health Policy Center.
Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Follow Michelle Andrews on Twitter: @mandrews110.


Donald Trump’s Medical Delusions

by Paul Krugman - NYT

Thanks, Comey.
The Justice Department’s inspector general is now investigating the way the F.B.I. director conveyed the false impression of an emerging Clinton scandal just days before the election, even as he said nothing about ongoing investigations into Russian intervention and possible collusion with the Trump campaign. That action very probably installed Donald Trump in the White House. And it’s already obvious that the incoming commander in chief will be a walking, tweeting ethical disaster.
On the other hand, he’s also dangerously delusional about policy.
Some Republicans appear to be realizing that their long con on Obamacare has reached its limit. Chanting “repeal and replace” may have worked as a political strategy, but coming up with a conservative replacement for the Affordable Care Act — one that doesn’t take away coverage from tens of millions of Americans — isn’t easy. In fact, it’s impossible.
But it seems that nobody told Mr. Trump. In Wednesday’s news conference, he asserted that he would submit a replacement plan, “probably the same day” as Obamacare’s repeal — “could be the same hour” — that will be “far less expensive and far better”; also, with much lower deductibles.
This is crazy, on multiple levels.
The truth is that even if Republicans were settled on the broad outlines of a health care plan — the way Democrats were when President Obama took office — turning such an outline into real legislation is a time-consuming process.
In any case, however, the G.O.P. has spent seven years denouncing the Affordable Care Act without ever producing even the ghost of an alternative. That’s not going to change in the next few weeks, or ever. For the anti-Obamacare campaign has always been based on lies that can’t survive actual repeal.
A prime example is the pretense that health reform hasn’t helped anyone. “Things are only getting worse under Obamacare,” declared Paul Ryan, the speaker of the House, last week. Yet the reality is that there has been a dramatic reduction in the number of Americans without insurance since reform went into effect — and an overwhelming majority of those covered by the new health exchanges are satisfied with their coverage.
How have Republicans nonetheless been able to get away with this lie? Part of the answer is that many of the newly insured don’t know that they’re being covered via Obamacare, or at any rate don’t realize that they will lose coverage if it’s repealed.
But that will change if repeal proceeds. For example, the percentage of nonelderly white adults without insurance fell by almost half from 2010 to 2016, from 16.4 to 8.7, a gain surely concentrated in the Trump-supporting white working class. Repeal would send that number right back up, and there would be no hiding the damage.
Meanwhile, Republicans have made hay over this year’s increase in insurance premiums. But this looks very much like a one-time adjustment; and the broader picture is that health costs have actually gone up much more slowly since Obamacare was enacted than they did before, in part due to the law’s cost-control features, which have worked far better than most expected.
And if the Affordable Care Act is killed, myths about its costs will be replaced by the reality of soaring bills for millions of Americans who don’t realize how much the act has helped them.
But won’t Trumpcare solve all these problems, by offering something much better and cheaper? Not a chance.
Republicans don’t have a health care plan, but they do have a philosophy — and it’s all about less. Less regulation, so that insurers can turn you down if you have a pre-existing condition. Less government support, so if you can’t afford coverage, too bad. And less coverage in general: Republican ideas about cost control are all about “skin in the game,” requiring people to pay more out of pocket (which somehow doesn’t stop them from complaining about high deductibles).
Implementing this philosophy would deliver a big windfall to the wealthy, who would get a huge tax cut from Obamacare repeal, and it would mean lower premiums for a relatively small number of currently healthy individuals — especially if they’re rich enough that they don’t need to worry about high deductibles.
But the idea that it would lead to big cost savings over all is pure fantasy, and it would have a devastating effect on the millions who have gained coverage during the Obama years.
As I said, it looks as if some Republicans realize this. They may go ahead with repeal-but-don’t-replace anyway, but they’ll probably do it because they believe they can find some way to blame Democrats for the ensuing disaster.
Mr. Trump, on the other hand, gives every impression of having no idea whatsoever what the issues are. But then, is there any area of policy where he does?

Do Markets Work in Health Care?

by David Brooks - NYT

Believe it or not, we’re not really going to have to spend the next four years wading through wonky drudgery of Russian spy dossiers and hotel sex cameras. At some point we’re going to have a thrilling debate over the most scintillating question in health care policy.
The Republicans are going to try to replace Obamacare. They’re probably going to agree to cover everybody Obama covered, thus essentially granting the Democratic point that health care is a right. But they are going to try to do it using more market-friendly mechanisms.
As you know, the American health care system is not like a normal market. When you make most health care decisions you don’t get much information on comparative cost and quality; the personal bill you get is only vaguely related to the services; the expense is often determined by how many procedures are done, not whether the problem is fixed.
You wouldn’t buy a phone this way.
The Republicans are going to try to introduce more normal market incentives into the process. They are probably going to rely on refundable tax credits and health savings accounts so everybody can afford to shop for their own insurance and care.
This would still be nothing like a free-market system — it would still be a highly regulated, largely public benefit — but it would rely more on consumer incentives.
The crucial question is: Do market incentives work in health care?
This is really two questions. The economic one: Would market mechanisms improve quality and reduce costs? The psychological one: Do people want the extra cognitive burden of shopping for health care, or would they rather offload those decisions to someone else?
Most progressives say markets don’t work. They point back to a famous essay the economist Kenneth Arrow wrote in 1963, which is the same year the Beach Boys had a huge hit with “Surfer Girl.”
Arrow argued that there are several features that make health care unlike normal markets. People’s needs for health care are unpredictable, unlike food and clothing. The doctor-patient relationship is unique and demands a high level of trust, empathy and care. Providers know much more about medicine than patients do, so the information is hopelessly asymmetric. Patients on a gurney can’t really make normal choices, and payment comes after care, not before.
These are all solid points, especially the doctor-patient one. But health care has become less exceptional over time. The internet and other mechanisms help customers acquire a lot more information. Sophisticated modeling helps with unpredictability in a bunch of fields.
We put our lives in the hands of for-profit companies all the time. I spent part of my week learning from an aviation mechanic how hard manufacturers work to prevent pieces of metal from shredding through the cabin if an engine explodes. Airplanes are ridiculously safe.
Proponents of market-based health care rely less on theory and more on data. The most fair-minded review of the evidence I’ve read comes from a McKinsey reportwritten by Penelope Dash and David Meredith. They noted that sometimes market forces lead to worse outcomes, but “we have been most struck by health systems in which provider competition, managed effectively, has improved outcomes and patient choice significantly, while at the same time reducing system costs.”
There’s much research to suggest that people are able to behave like intelligent health care consumers. Work by Amitabh Chandra of Harvard and others found higher-performing hospitals do gain greater market share over time. People know quality and flock to it.
Furthermore, health care providers work hard to keep up with the competitors. When one provider becomes more productive, the neighboring ones tend to as well.
There are plenty of examples where market competition has improved health care delivery. The Medicare Part D program, passed under President George W. Bush, created competition around drug benefits. The program has provided coverage for millions while coming in at 57 percent under the cost of what the Congressional Budget Office initially projected. A study of Indiana’s health savings accounts found the state’s expenses were reduced by 11 percent.
Laser eye surgery produces more patient satisfaction than any other surgery. But it’s generally not covered by insurance, so it’s a free market. Twenty years ago it cost about $2,200 per eye. Now I see ads starting at $250 an eye.
There’s a big chunk of evidence that market incentives would work in health care, especially in non-acute care. The harder problem for Republicans may be political. This is a harried society. People may not want the added burdens of making health care decisions on top of all the others. This is a distrustful society. People may not trust themselves or others to make decisions. This is an insecure society. People may not want what they perceive as another risk factor in their lives.
The policy case for the Republican plans is solid. Will they persuade in this psychological environment? I doubt it.

Trump Promises ‘Insurance for Everybody’ as Health Law Replacement

by Michael D. Shear - NYT
WASHINGTON — President-elect Donald J. Trump said this weekend that he was nearly ready to unveil a plan to replace President Obama’s Affordable Care Act with “insurance for everybody.”
Mr. Trump, in an interview Saturday evening with The Washington Post, said that health care offered under his plan would come “in a much simplified form — much less expensive and much better.”
“We’re going to have insurance for everybody,” Mr. Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”
In the interview, Mr. Trump provided no details about how his plan would work or what it would cost. He spoke in the same generalities that he used to describe his health care goals during the campaign — that it would be “great health care” that left people “beautifully covered.”
He also offered no explanation of how he would persuade Congress to pass his plan, though he indicated that it would have the backing of the House speaker, Paul D. Ryan of Wisconsin, and the Senate majority leader, Mitch McConnell of Kentucky. Mr. Trump said only that “I won’t tell you how, but we will get approval.”
He seemed to refer to his recent Twitter posts that helped persuade House Republicans to back away from a proposal to gut an ethics office. “You see what’s happened in the House in recent weeks,” he said.
Top aides to Mr. Trump declined to provide more information about the president-elect’s plans. In an interview last week with The New York Times, Mr. Trump said he wanted Congress to repeal the Affordable Care Act and replace it “very quickly or simultaneously, very shortly thereafter.”
The president-elect told The Post that his plan would be unveiled soon after the Senate confirmed Representative Tom Price, Republican of Georgia, to be the secretary of health and human services.
Achieving the promise of “insurance for everybody” has been a goal of health care policy experts for decades, but the political and financial realities have proved problematic. Government-provided health insurance, known as a single-payer plan, has found little political support in Washington. And market-based solutions, like the Affordable Care Act, have proved difficult to carry out.
Providing health insurance to everyone in the country is likely to be very costly, a fact that could diminish support from fiscal conservatives. And liberals who support Mr. Obama’s health care plan — which provides coverage to 20 million people — may be wary of the fine print of a program that claims to cover everybody.
Mr. Trump said specifically on Saturday that “I don’t want single-payer.” He told The Post that he would force drug manufacturers to negotiate better prices with Medicaidand Medicare, the government-run health programs.
Asked how he would force the drug companies to do that, he noted the public pressure that he had exerted on other companies, mentioning his Twitter posts criticizing cost overruns for Lockheed Martin’s F-35 fighter jet.
Last week, the House and the Senate began the process of repealing Mr. Obama’s health care law by approving parliamentary language that allows them to proceed without the threat of a filibuster by Democrats.
But Republicans have expressed anxiety about the demands from Mr. Trump and others for a quick replacement of the law. Many believe that will require a very complex plan that could be tricky to develop and push through Congress.

Trump vows ‘insurance for everybody’ in Obamacare replacement plan
by Robert Costa and Amy Goldstein - Washington Post

President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of “insurance for everybody,” while also vowing to force drug companies to negotiate directly with the government on prices in Medicare and Medicaid.
Trump declined to reveal specifics in the telephone interview late Saturday with The Washington Post, but any proposals from the incoming president would almost certainly dominate the Republican effort to overhaul federal health policy as he prepares to work with his party’s congressional majorities.
Trump’s plan is likely to face questions from the right, after years of GOP opposition to further expansion of government involvement in the health-care system, and from those on the left, who see his ideas as disruptive to changes brought by the Affordable Care Act that have extended coverage to tens of millions of Americans.
In addition to his replacement plan for the ACA, also known as Obamacare, Trump said he will target pharmaceutical companies over drug prices.
“They’re politically protected, but not anymore,” he said of pharmaceutical companies.

Congress takes key step toward scrapping Obamacare

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A week before President-elect Trump's inauguration, lawmakers passed a preliminary budget measure that starts the process of repealing the Affordable Care Act. (Video: Sarah Parnass/Photo: Matt McClain/The Washington Post)
The objectives of broadening access to insurance and lowering health-care costs have always been in conflict, and it remains unclear how the plan that the incoming administration is designing — or ones that will emerge on Capitol Hill — would address that tension.
In general, congressional GOP plans to replace Obamacare have tended to try to constrain costs by reducing government requirements, such as the medical services that must be provided under health plans sold through the law’s marketplaces and through states’ Medicaid programs. House Speaker Paul D. Ryan (R-Wis.) and other Republicans have been talking lately about providing “universal access” to health insurance, instead of universal insurance coverage.
Trump said he expects Republicans in Congress to move quickly and in unison in the coming weeks on other priorities as well, including enacting sweeping tax cuts and beginning the building of a wall along the Mexican border.
Trump warned Republicans that if the party splinters or slows his agenda, he is ready to use the power of the presidency — and Twitter — to usher his legislation to passage.
“The Congress can’t get cold feet because the people will not let that happen,” Trump said during the interview with The Post.
Trump said his plan for replacing most aspects of Obama’s health-care law is all but finished. Although he was coy about its details — “lower numbers, much lower deductibles” — he said he is ready to unveil it alongside Ryan and Senate Majority Leader Mitch McConnell (R-Ky.).
“It’s very much formulated down to the final strokes. We haven’t put it in quite yet but we’re going to be doing it soon,” Trump said. He noted that he is waiting for his nominee for secretary of health and human services, Rep. Tom Price (R-Ga.), to be confirmed. That decision rests with the Senate Finance Committee, which hasn’t scheduled a hearing.

Two Americans: One saved by Obamacare, the other left behind

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As Republicans in Congress gear up to repeal the Affordable Care Act, two Pennsylvanians reflect on their different experiences under Obamacare. (Alice Li/The Washington Post)
Trump’s declaration that his replacement plan is ready comes after many Republicans — moderates and conservatives — expressed anxiety last week about the party’s lack of a formal proposal as they held votes on repealing the law. Once his plan is made public, Trump said, he is confident that it could get enough votes to pass in both chambers. He declined to discuss how he would court wary Democrats.
So far, Republicans have taken the first steps toward repealing the law through budget reconciliation, a process by which only a simple majority is needed in the Senate. The process would enable them to dismantle aspects of the law that involve federal spending.
The plan that Trump is preparing will come after the House has taken more than 60 votes in recent years to kill all or parts of the ACA to adopt more conservative health-care policies, which tend to rely more heavily on the private sector.
“I think we will get approval. I won’t tell you how, but we will get approval. You see what’s happened in the House in recent weeks,” Trump said, referencing his tweet during a House Republican move to gut their independent ethics office, which along with widespread constituent outrage was cited by some members as a reason the gambit failed.
As he has developed a replacement package, Trump said he has paid attention to critics who say that repealing Obamacare would put coverage at risk for more than 20 million Americans covered under the law’s insurance exchanges and Medicaid expansion.
“We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”
Republican leaders have said that they will not strand people who gained insurance under the ACA without coverage. But it remains unclear from either Trump’s comments in the interview or recent remarks by GOP leaders on Capitol Hill how they intend to accomplish that. 
For conservative Republicans dubious about his pledge to ensure coverage for millions, Trump pointed to several interviews he gave during the campaign in which he promised to “not have people dying on the street.”
“It’s not going to be their plan,” he said of people covered under the current law. “It’ll be another plan. But they’ll be beautifully covered. I don’t want single-payer. What I do want is to be able to take care of people,” he said Saturday.
Trump did not say how his program overlaps with the comprehensive plan authored by House Republicans. Earlier this year, Price suggested that a Trump presidency would advance the House GOP’s health-care agenda.
When asked in the interview whether he intends to cut benefits for Medicare as part of his plan, Trump said “no,” a position that was reiterated Sunday on ABC by Reince Priebus, Trump’s incoming chief of staff. He did not elaborate on that view or how it would affect his proposal. He expressed that view throughout the campaign.
Timing could be difficult as Trump puts an emphasis on speed. Obama’s law took more than 14 months of debate and hundreds of hearings. To urge lawmakers on, Trump plans to attend a congressional Republican retreat in Philadelphia this month.
Moving ahead, Trump said that lowering drug prices is central to reducing health-care costs nationally — and that he will make it a priority as he uses his bully pulpit to shape policy. When asked how exactly he would force drug manufacturers to comply, Trump said that part of his approach would be public pressure “just like on the airplane,” a nod to his tweets about Lockheed Martin’s F-35 fighter jet, which Trump said was too costly.
Trump waved away the suggestion that such activity could lead to market volatility on Wall Street. “Stock drops and America goes up,” he said. “I don’t care. I want to do it right or not at all.” He added that drug companies “should produce” more products in the United States. 
The question of whether the government should start negotiating how much it pays drugmakers for older Americans on Medicare has long been a partisan dispute, ever since the 2003 law that created Medicare drug benefits prohibited such negotiations.
Trump’s goal is uncertain, however, with respect to Medicaid, the insurance for low-income Americans run jointly by the federal government and states. Under what is known as a Medicaid “best price” rule, pharmaceutical companies already are required to sell drugs to Medicaid as the lowest price they negotiate with any other buyer.
On his plan for tax cuts, Trump said that “we’re getting very close” to putting together legislation. His advisers and Ryan met last week and have been working from his campaign’s plan and from congressional proposals to slash current rates. “It’ll probably be 15 to 20 percent for corporations. For individuals, probably lower. Great ­middle-class tax cuts,” Trump said.
On corporate tax rates, “We may negotiate a little, but we want to bring them down and get as close to 15 percent as we can so we can see a mushrooming of jobs moving back.”
Trump said he would not relent on his push for increasing taxes on U.S. companies that manufacture abroad — and insisted that the upcoming tax cuts should be enough reason for companies to produce within the United States.
“If companies think they’re going to make their cars or other products overseas and sell them back into the United States, they’re going to pay a 35 percent tax,” he said.
Briefly touching on immigration, Trump said that building a border wall and curbing illegal immigration remain at the top of his to-do list and that he is spending significant time looking at ways to begin projects, both with Congress and through executive action. He did not disclose what was to come on those fronts.

The GOP’s Strategy for Obamacare? Repeal and Run

by Elizabeth Warren
For eight years, Republicans in Congress have complained about health care in America, heaping most of the blame on President Obama. Meanwhile, they’ve hung out on the sidelines making doomsday predictions and cheering every stumble, but refusing to lift a finger to actually improve our health care system.
The GOP is about to control the White House, Senate, and House. So what’s the first thing on their agenda? Are they working to bring down premiums and deductibles? Are they making fixes to expand the network of doctors and the number of plans people can choose from? Nope. The number one priority for congressional Republicans is repealing the Affordable Care Act and breaking up our health care system while offering zero solutions.
Their strategy? Repeal and run.
Many Massachusetts families are watching this play out, worried about what will happen — including thousands from across the Commonwealth that I joined at Faneuil Hall on Sunday to rally in support of the ACA. Hospitals and insurers are watching too, concerned that repealing the ACA will create chaos in the health insurance market and send costs spiraling out of control.
They are right to worry. Massachusetts has worked for years to provide high-quality, affordable health care for everyone. But there’s no magic wand we can wave to simply snap back to our old system if congressional Republicans decide to rip up the Affordable Care Act and run away.
Health care reform in Massachusetts wasn’t partisan. Democrats, Republicans, business leaders, hospitals, insurers, doctors, and consumers all came together behind a commitment that every single person in our Commonwealth deserves access to affordable, high-quality care. When Republican Governor Mitt Romney signed Massachusetts health reform into law in 2006, our state took huge strides toward offering universal health care coverage and financial security to millions of Bay State residents.
That law was a major step forward. Today, more than 97 percent of Bay Staters are covered — the highest rate of any state in the country.
But Massachusetts still has a lot to lose if the ACA is repealed. One big reason for our state’s health care success is that we took advantage of the new opportunities offered under the ACA. In addition to making care more accessible and efficient, our state expanded Medicaid, using federal funds to help even more people. And we combined federal and state dollars to help reduce the cost of insurance on the Health Connector.
When the ACA passed, Massachusetts already had in place some of the best consumer protections in the nation. But the ACA still made a big difference. It strengthened protections for people in Massachusetts with pre-existing conditions, allowed for free preventive care visits, and — for the first time in our state — banned setting lifetime caps on benefits.
If the ACA is repealed, our health care system would hang in the balance. Half a million people in the Commonwealth would risk losing their coverage. People who now have an iron-clad guarantee that they can’t be turned away due to their pre-existing conditions or discriminated against because of their gender could lose that security. Preventive health care, community health centers, and rural hospitals could lose crucial support. In short, the Massachusetts health care law is a big achievement and a national model, but it also depends on the ACA and a strong partnership with the federal government.
If the cost-sharing subsidies provided by the ACA are slashed to zero, Massachusetts will have a tough time keeping down the cost of plans on the Health Connector. The state can’t make funds appear out of thin air to help families on the Medicaid expansion if Republicans yank away support. And our ability to address the opioid crisis will be severely hampered if people lose access to health insurance or if the federal funding provided through the Medicaid waiver disappears. Even in states with strong health care systems — states like Massachusetts — the ACA is critical.
The current system isn’t perfect — not by a long shot. There are important steps Congress could take to lower deductibles and premiums, to expand the network of doctors people can see on their plans, and to increase the stability and predictability of the market. We should be working together to make health care better all across the country, just like we’ve tried to do here in Massachusetts.
This doesn’t need to be a partisan fight. But if congressional Republicans continue to pursue repeal of the ACA with nothing more than vague assurances that they might — someday — think up a replacement plan, the millions of Americans who believe in guaranteeing people’s access to affordable health care will fight back every step of the way.
Repeal and run is for cowards.
Elizabeth Warren is US Senator representing Massachusetts.
http://www.commondreams.org/views/2017/01/16/gops-strategy-obamacare-repeal-and-run

The Biggest Changes Obamacare Made, and Those That May Disappear

by Margot Sanger-Katz

It looks like the beginning of the end for Obamacare as we know it.
After years of vowing to repeal the Affordable Care Act, as it is formally known, Republican lawmakers in both chambers of Congress have now passed a bill that will make it easier to gut the law.
Because they are using a special budget process, Republicans won’t be able to repeal all provisions of the health law. But it seems like a good time to look at the major changes Obamacare brought to health care, which of those changes may now disappear, and what might replace them.
An important note: We still don’t know the details of a repeal bill, and passage is not guaranteed. But Republicans passed a similar package in 2015, vetoed by President Obama, that provides a rough template. Republicans have also said they hope to make further changes through additional legislation. We’ll provide updates when new legislative language arrives, expected in several weeks.

1) Obamacare insured millions through new insurance markets.
The health law reduced the number of uninsured Americans by an estimated 20 million people from 2010 to 2016. One of the primary ways it did so was by creating online markets where people who didn’t get insurance through work or the government could shop for a health plan from a private insurer. The law offered subsidies for Americans with lower incomes to help pay their premiums and deductibles.
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What would happen? The Republican bill is expected to eliminate the subsidies. This would make insurance unaffordable for millions of Americans and sharply reduce the number who buy their own health coverage.
With many fewer people buying coverage, the insurance markets are likely to become increasingly unstable. Many insurers will stop offering policies, and the remaining customers are likely to be sicker than current Obamacare buyers, a reality that will drive up the cost of insurance for everyone who buys it, and force more people out of the markets. The Urban Institute estimates that the change would cause a total of 22.5 million people to lose their health insurance.
What might replace it? Separate legislation may include some new form of subsidy to help people afford insurance. Plans from House Speaker Paul Ryan and the budget committee chairman Tom Price, President-elect Donald J. Trump’s pick to lead the Department of Health and Human Services, would both offer a flat tax credit to help buy insurance that varies by age. A proposal from the House Republican Study Committee would give all Americans a standard tax deduction to buy insurance.

2) Obamacare insured millions more by expanding Medicaid.
The health law provided federal funds for states to offer Medicaid coverage to anyone earning less than about $16,000 for a single person or $33,000 for a family of four. Not every state chose to expand, but most did.
What would happen? The Republican plan is expected to eliminate federal funding for the expansion. An estimated 12.9 million people would lose Medicaid coverage, according to the Urban Institute’s projections.
What might replace it? Republican leaders have discussed reforming the remaining Medicaid program to give states more autonomy and to reduce future federal investment.

3) Obamacare established consumer protections for health insurance.
One of the law’s signature features prevents insurance companies from denying coverage or charging a higher price to someone with a pre-existing health problem. The law included a host of other protections for all health plans: a ban on setting a lifetime limit on how much an insurer has to pay to cover someone; a requirement that insurers offer a minimum package of benefits; a guarantee that preventive health services be covered without a co-payment; a cap on insurance company profits; and limits on how much more insurers can charge older people than younger people. The law also required insurance plans to allow adult children to stay on their parents’ policies until age 26.
What would happen? These rules can’t be changed using the special budget process, so they would stay in place for now. But eliminating some of the other provisions, like the subsidies, and leaving the insurance rules could create turmoil in the insurance markets, since sick customers would have a much stronger incentive to stay covered when premiums rise. .
What might replace it? Mr. Trump has said that he’d like to keep the law’s policies on pre-existing conditions and family coverage for young adults, but Senate Republicans recently voted against nonbinding resolutions to preserve those measures, suggesting they may be less committed. Some of the other provisions would probably be on the table if there were new legislation. Republicans in Congress would probably eliminate rules that require a minimum package of benefits for all insurance plans and allow states to determine what insurers would have to include. Mr. Trump has said he’d like to encourage the sale of insurance across state lines, a policy likely to make coverage more skimpy but less expensive for many customers. Republicans would also like to expand tax incentives for people to save money for health expenses.
Many of the Republican proposals would also establish so-called high-risk pools, which would provide subsidized insurance options for people with chronic health problems who wouldn’t be able to buy insurance without rules forcing insurers to sell them coverage.
4) Obamacare required individuals to have health insurance and companies to offer it to their workers.
To ensure that enough healthy people entered insurance markets, the law included mandates to encourage broader coverage. Large employers that failed to offer affordable coverage, or individuals who failed to obtain insurance, could be charged a tax penalty.
What would happen? The bill is expected to eliminate the mandates. Some experts think that eliminating the individual mandate, in particular, could destabilize insurance markets by reducing incentives for healthy people to buy coverage. The mandate had less of an impact on the employers, which had already been offering coverage.
What might replace it? Some Republican plans would allow insurers to charge much higher rates to customers who allow their coverage to lapse than to those who renew their policies every year. Such a system might provide a different financial incentive for healthy people to stay insured.
5) Obamacare raised taxes related to high incomes, prescription drugs, medical devices and health insurance.
To help pay for the law’s coverage expansion, it raised taxes on several players in the health industry and on high-income earners.
What would happen? The G.O.P. package may roll back those tax increases, though there is some disagreement among Republican lawmakers about the deficit impact of such changes.
What might replace it? Republicans have not discussed raising new taxes to replace those in the Affordable Care Act. But some of their plans would limit the tax benefits offered to people who get their health insurance through work. That change would increase tax revenues, but would increase the cost of health insurance for many people who get it through work.
6) Obamacare made major reforms to Medicare payments.
The law cut the annual pay raises Medicare gives hospitals and reduced the fees Medicare pays private insurance companies. It created new incentives for hospitals and doctors to improve quality. It also set up a special office to run experiments in how Medicare pays doctors and hospitals for health care services. Those experiments are now widespread and have begun changing the way medicine is practiced in some places.
What would happen? The new legislation is expected to leave these changes alone, even though many have come under criticism by Republicans in Congress over the years, including from Mr. Price, an orthopedic surgeon. Many of the experiments could be reshaped or eliminated through regulation or through a future budget process.
What might replace it? Republicans in Congress have long talked about even more ambitious changes to Medicare, intended to move more beneficiaries into private insurance coverage. Mr. Trump has said that he does not want to make major changes to Medicare, so it is unclear if such a proposal would move forward.
7) Obamacare made many smaller changes that will probably last.
Obamacare had a range of policies meant to improve health and health care, including requirements that drug companies report payments made to physicians, a provision written by the Iowa senator Chuck Grassley, a Republican; a requirement that chain restaurants publish calorie counts on their menus; and a rule that large employers must provide a space for women to express breast milk.
What would happen? When Republicans talk about repealing Obamacare, they tend to focus on the parts of the law that expanded insurance coverage and regulated health insurance products, not these ancillary parts. That means that portions of the Affordable Care Act that people don’t associate with the word “Obamacare” are likely to endure.


Trump Health Secretary Pick’s Longtime Foes: Big Government and Insurance Companies

by Abby Goodenough
ROSWELL, Ga. — It was 1 in the morning, and the orthopedic surgeon on call was preparing to operate on a woman whose foot had been shattered in a car wreck, after hours of tending to other patients. The woman’s husband, Jeff Anderson, asked him, “Are you too tired to do this?”
“He looked me straight in the eye — very quiet guy — and said, ‘I was born to do this,’” Mr. Anderson recalled.
The surgeon that night more than 20 years ago was Representative Tom Price of Georgia, President-elect Donald J. Trump’s nominee for secretary of health and human services, the cabinet official who will lead the new administration’s efforts to dismantle the Affordable Care Act.
Since then, the assuredness that defined Mr. Price as a surgeon has carried into his political career. He has always listened politely to other viewpoints but never swerved from his policy mission to protect his former profession from what he views as heavy-handed government intrusion.
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Many who knew Mr. Price as a doctor here in Atlanta’s affluent northern suburbs praise his commitment to his patients. But his legislative record shows that over eight years in the Georgia Senate and 12 years in Congress, he has advocated at least as much for physician groups and health care companies — seeking to limit damages in malpractice cases, for instance, and voting against legislation that would have required the government to negotiate lower drug prices for Medicare beneficiaries.
Mr. Price has routinely argued that patients are the driving force behind his efforts. Still, his positions have often coincided with the financial interests of groups whose donations have helped advance his political career.
Doctors themselves are sharply divided over his nomination, and some are particularly galled by Mr. Price’s enmity for the Affordable Care Act and opposition to abortion rights. Some of his positions even clash with those of Mr. Trump, who wants to pressure pharmaceutical companies on drug prices, for example, and has pledged to largely leave Medicare alone.
If confirmed, Mr. Price, 62, will soon have far more power to influence the nation’s vast health care system than he ever did as a lawmaker. One of his first tasks would be to help Mr. Trump and Republicans in Congress determine how to eviscerate and replace the health law, a goal he has held since the law’s passage in 2010. But as leader of the agency that oversees Medicare, Medicaid, the Food and Drug Administration and the Centers for Disease Control and Prevention, Mr. Price would also hold considerable regulatory power, with the ability to influence everything from how applications to market new drugs are reviewed to how doctors are compensated for treating elderly and poor patients.
As Mr. Price prepares for two confirmation hearings — the first of which is scheduled for Wednesday — his past efforts on behalf of health-related companies, which have donated generously to his campaigns, are under scrutiny. So, too, is Mr. Price’s history of trading in biomedical, pharmaceutical and health insurance stocks while serving on the health subcommittee of the House Ways and Means Committee. Democrats have called for investigations into whether he traded stock based on information he gleaned as a congressman.
Last year, Mr. Price bought stock in a company that makes orthopedic implants shortly before introducing legislation that could have protected the company, Zimmer Biomet, from financial losses due to a new federal regulation. The regulation sought to rein in spending on joint replacements for Medicare patients; Mr. Price’s legislation would have delayed its implementation. After he introduced it, Zimmer’s political action committee contributed to his re-election campaign; the string of events was first reported Monday by CNN.
Phillip J. Blando, a spokesman for the Trump transition team, said Mr. Price “had no knowledge or input into the purchase” of the Zimmer stock, which he said was made by a broker. Asked why Mr. Price had not directed his broker to avoid buying health-related stocks while he wrote and voted on health legislation, Mr. Blando said, “We know that other members of Congress, including Democrats, have holdings in health care stocks and vote on health-related legislation.”
In a letter to an ethics lawyer at the Department of Health and Human Services last week Mr. Price said he would divest himself of holdings in 43 health-related and other stocks to avoid conflicts of interest. Noting that the Office of Government Ethics had completed an “exhaustive review” of Mr. Price’s financial holdings, Mr. Blando said last week that Mr. Price “takes his obligation to uphold the public trust very seriously.”
Although not among the billionaires whom Mr. Trump has tapped for his cabinet, Mr. Price has profited from medicine, both as a doctor and as an active investor in health care-related companies including Aetna, Bristol-Myers Squibb and Zimmer Biomet, which makes artificial joints and other medical devices. He has an estimated net worth of $13.6 million, according to the Center for Responsive Politics, with assets that include real estate. He has also been an effective fund-raiser: Even in his first run for office in 1996, his war chest of $173,000, much of which came from doctors and medical companies, led his poorly financed Democratic opponent to call him “Dr. Dollar.”
A brisk, hyper-focused workaholic who relishes the granular details of legislative proposals and process, Mr. Price expressed concern last year about Mr. Trump’s grasp of the issues. Taking questions from a student group at Emory University, he said he had voted for Marco Rubio in the Republican primary and called Mr. Trump an “empty policy vessel” who was “dangerous for politics and the economy,” according to the student newspaper.
Mr. Price, who declined to be interviewed, was engaged in a number of pitched partisan battles even before coming to Washington in 2005. In the Georgia Legislature, he voted against a new state flag that minimized the Confederate battle cross and supported a constitutional amendment banning same-sex marriage. In Congress, he has taken stances seen as antithetical to public health, opposing regulating tobacco as a drug and favoring legislation that would make it easier to sell bullets that can pierce armor.
He has also written a fairly detailed plan for replacing the Affordable Care Act. It would repeal the law’s expansion of Medicaid and provide tax credits to help with the cost of coverage based on age instead of income, with older people getting higher credits.
Mr. Price grew up in Dearborn, Mich., the son and grandson of doctors who heavily influenced his career choice. He has publicly recalled making house calls with his grandfather, who practiced medicine into his 90s. After medical school at the University of Michigan, he moved to Georgia, completing his residency at Emory and setting up practice in Roswell, a relatively affluent, conservative suburb of Atlanta.
In the 1990s, his practice, Compass Orthopedics, was among seven in the Atlanta area that merged into a large group that became known as Resurgens Orthopaedics. It became the largest orthopedic practice in Georgia, and now has 100 doctors and 1,000 employees spread over 21 locations.
Dr. Steven B. Wertheim, another founding partner of Resurgens, said one goal of the consolidation was to gain bargaining power with insurance companies and to provide M.R.I.s, physical therapy and even certain outpatient operations in-house rather than referring patients to other providers or operating at hospitals. More leverage with insurers often allows doctors to extract higher rates.
“His overall gist was, ‘Look, if all we did was practice good medicine, we’d be broke by tomorrow,’” Dr. Wertheim said of Mr. Price. “He understood the need to run a business.”
As a physician, Mr. Price was constantly frustrated by having to seek insurance companies’ approval for his patients to get an expensive diagnostic test or physical therapy — a common complaint among specialists. Similarly, he resented when federal health regulators intervened in something he and his partners thought they were already doing well, like using electronic medical records.
“Those are the things that drove him crazy,” Dr. Wertheim said.
His resentment of government intervention in medicine drove Mr. Price to become involved in the Medical Association of Georgia early in his career, and his work there led him to run for office in 1995, when the House seat in his district opened up. But by 2002, as his legislative duties increased, he traded his suburban practice for a job at Grady Memorial Hospital, a vast, chaotic, aging complex, just a few blocks from the State Capitol.
For the next two years, Mr. Price was the medical director of Grady’s orthopedic clinic, seeing a vastly different population than the well-off, privately insured patients he was used to. Most of Grady’s patients are poor and black, and many lack any form of insurance. Long waits for care are the norm, and trauma, including gunshot wounds, is a big part of the caseload.
“He called me and asked if there was a position,” said Dr. James R. Roberson, the chairman of the orthopedics department at Emory University School of Medicine, whose residents train at Grady. “He needed some flexibility — that was most of his impetus to want to return to Grady, because he was really very interested in pursuing a political career.”
Dr. Roberson said that Mr. Price played a “unique role” at the clinic, training residents and overseeing patient care but also seeking to address inefficiencies — long wait times, for example — and representing the clinic at hospital administrative meetings. Although he saw patients, he did not perform surgery or need to be on call at night — an unusual arrangement, Dr. Roberson said.
In the Legislature, Mr. Price spent his first six years in the powerless minority, although he quickly rose to the position of minority whip.
His fortunes changed in 2003, after Sonny Perdue became the first Republican governor since Reconstruction and persuaded enough Democrats to switch parties to put the Senate into Republican hands.
As the majority leader, Mr. Price’s intimate knowledge of procedural rules and maneuvers, gleaned from assiduous research, helped advance his party’s agenda.
In the state Legislature, he was the leader who delivered bad news, the no-nonsense tactician to some of his Southern-born colleagues’ more backslapping style. His sense of humor, when he used it, was dry. Colleagues often wondered if he slept.
“He’s a machine,” said Russell K. Paul, a Republican who served in the State Senate with Mr. Price.
During his two years in the majority, Mr. Price’s top priority was curbing the rising cost of medical malpractice insurance, which he said was forcing hospitals and nursing homes to close and forcing doctors to limit which procedures they performed.
“He was very bright, articulate, and smart enough to be able to see the different sides,” said Tom Bordeaux, a former Democratic state lawmaker and trial lawyer who negotiated with Mr. Price over a package of bills Mr. Price introduced to limit doctors’ liability in malpractice cases. “But he was just totally unwilling. He was very gracious and he was completely inflexible.”
Ultimately, Mr. Price failed to persuade even his Republican colleagues to accept a provision that would have capped pain-and-suffering damages for malpractice victims at $250,000.
Mr. Paul, now the mayor of Sandy Springs, Ga., said Mr. Price had become more partisan during his last few years in the Legislature, when the Republicans saw an opportunity to tip the balance of power in their favor for the first time since Reconstruction.
“There was not a lot of bipartisan collegiality when it came to trying to control the government in Georgia,” Mr. Paul said, “and that environment was the crucible that began to turn Tom into a hardened political warrior.”
In Congress, Mr. Price has made frequent speeches to health industry and physician groups, and has occasionally introduced legislation on their behalf. Last year, for example, he sponsored a bill fighting new lower Medicare payment rates for “durable medical equipment” like wheelchairs and canes. A few months later, he spoke at a conference for companies that supply such equipment, which held a $100-a-head fund-raiser on his behalf that same day.
Mr. Price has also supported proposals to overhaul Medicare — potentially putting him at odds with his new boss, Mr. Trump, who has pledged not to “touch” the program. Speaking to a student group at the University of Michigan in 2015, Mr. Price expressed concern that Mr. Trump would not listen to others, including Congress, if elected.
“When I hear Trump saying things like, ‘I’ll just do XYZ,’ without seemingly any regard for the legislative branch,” Mr. Price told the group, “it gives me some thought.”

‘Repeal and Replace’: Words Still Hanging Over G.O.P.’s Health Care Strategy

by Carl Hulse - NYT

In March 2010, on the day before President Obama was to sign the Affordable Care Act into law, a group of senior Republican aides huddled in Senator Mitch McConnell’s Capitol suite to try to come up with a catchy slogan to use against it.
Many conservatives were simply advocating a vow to repeal the new law, but Republican strategists worried that pressing for repeal without an alternative could backfire. So they batted around a few ideas before Josh Holmes, then a top communications adviser to Mr. McConnell, tossed out the nicely alliterative phrase “repeal and replace.” That seemed to do the job, with its promise to get rid of the new law detested by Republicans while suggesting that something better would follow.
The phrase has shown real staying power: President-elect Donald J. Trump proudly invoked “repeal and replace” twice during his news conference on Wednesday.
“The goal was to come up with something that had durability and could be a rallying cry for Republicans basically to campaign against Obamacare,” said Mr. Holmes, now the president of Cavalry, a consulting and media firm. “This obviously had sort of a catchy ring to it. And it was consistent with what we were trying to accomplish.”
As it turns out, producing the slogan turned out to be far easier than producing an actual replacement. Almost seven years later, congressional Republicans are still struggling to settle on a consensus alternative to the health care law, endangering their push to quickly undo and then redo the signature Obama administration achievement, which turned out to be a springboard to a Republican political resurgence.
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The uncertainty has reignited the fight to define the health insurance program in the public mind, with Republicans and Mr. Trump painting it as a disaster, and Democrats portraying it as a success that provides security to millions of Americans, many of them Trump voters. Democrats have latched on to their own catchphrase, warning that repealing the law will “Make America Sick Again” — a twist on the Trump campaign’s “Make America Great Again” theme.
Republicans have derided the Democratic message — personally developed by Senator Chuck Schumer of New York, the new Democratic leader — as trite and ineffective. But Democrats like it and believe that it goaded Mr. Trump into a more direct and complicating role in the Republican deliberations over how quickly to propose a replacement for the health care program.
They say Republicans are still relying on Mr. Holmes’s years-old brainchild because they are groping for a replacement with their new unified government days away. Democrats see the confusion as a victory in their push to thwart repeal or slow it down while wringing all the political advantage they can from the attempt.
After a series of late-night Senate budget votes that laid the procedural groundwork for repeal with no certainty on what was to follow, one Democrat delivered a new punch line.
“This is called repeal and run,” Senator Claire McCaskill, Democrat of Missouri, said on Twitter as the Senate was voting. “Chaos is coming.”
Mr. Trump’s involvement has muddled the issue further as he and Republican leaders in Congress have offered differing timetables for when a Republican alternative might be unveiled, underscoring again how difficult it can be to push through an agenda even for a party that controls all the levers of government.
The origin story of the “repeal and replace” mantra is also a reminder of how pivotal strategic messaging has been throughout the health care debate. It has produced some of the more memorable political lines in recent years, from “death panels” to “If you like your health plan, you can keep your health plan” to “Obamacare” itself. After Republicans began throwing that term around as a pejorative, Mr. Obama embraced it.
Even before landing on “repeal and replace,” Republicans scorched Democrats with buzzy phrases. In his book “The Long Game,” Mr. McConnell recounted how he instructed his legislative experts to identify special provisions that had been added to the health bill to win over wavering Democrats.
His communications staff would then “brand” these legislative sweeteners with catchy but disparaging nicknames to build opposition and public distrust for the law. The result: the “Louisiana Purchase,” “Gator Aid” and the memorable “Cornhusker Kickback,” to tarnish provisions inserted to woo senators from Louisiana, Florida and Nebraska.
“In some ways, we were enjoying ourselves,” Mr. McConnell acknowledged in his book.
The same communication strategists who originated those terms were brainstorming on March 22, 2010, while Mr. Holmes jotted ideas on a notecard. When he hit on “repeal and replace,” the McConnell team decided it had what it needed. The big question was whether they could get lawmakers to embrace it. That answer would come quickly.
“I think the slogan will be ‘repeal and replace,’ ‘repeal and replace,’” Mr. McConnell told reporters the next day. “No one that I know in the Republican conference in the Senate believes that no action is appropriate.”
Mr. Holmes said a turning point came shortly after, when Representative Mike Pence of Indiana, who was then in charge of political messaging for House Republicans, and is now the vice president-elect, latched on to the phrase. That caused conservative resistance to the “replace” aspect of the debate to evaporate.
Mr. Holmes acknowledged that he had to create only the phrase, not the actual replacement.
“I don’t do policy,” he said with a laugh.
But Republican lawmakers and leaders of the new administration do have to do policy. And they may need to do it fast if they are going to assure Americans that they intend to fulfill their seven-year-old promise to not just repeal the law, but also replace it.


Choice for Health Secretary Is Vague on Replacing Affordable Care Act
by Robert Pear and Thomas Kaplan - NYT
WASHINGTON — Representative Tom Price, the man President-elect Donald J. Trump has chosen to lead the Department of Health and Human Services, promised on Wednesday to make sure people do not “fall through the cracks” if the Affordable Care Act is repealed, and set a goal to increase the number of people with health insurance.
But at a hearing before the Senate Health, Education, Labor and Pensions Committee, Mr. Price provided only vague reassurance to members of both parties who pressed him for specific policies.
Republicans concluded he was well qualified; Democrats were not satisfied.
“Just days ago, President-elect Trump promised, quote, ‘insurance for everybody,’” said Senator Patty Murray of Washington, the senior Democrat on the committee. “But Congressman Price, your own proposals would cause millions of people to lose coverage, force many people to pay more for their care, and leave people with pre-existing conditions vulnerable to insurance companies’ rejecting them or charging them more.”
In four hours of testimony, Mr. Price, an orthopedic surgeon from the affluent northern suburbs of Atlanta, set lofty goals for a plan to replace the Affordable Care Act, President Obama’s signature domestic achievement, but did not say how he would achieve them.
Mr. Price, 62, also denied impropriety in his trading of stocks in health care and pharmaceutical companies, saying he had left many details to his broker. The Wall Street Journal reported last month that he had traded more than $300,000 worth of shares while promoting legislation that could have affected the companies he owned stock in.
Senator Al Franken, Democrat of Minnesota, said one investment looked like a “sweetheart” deal. But Mr. Price said, “I had no access to nonpublic information.”
Like several other candidates for top jobs in the Trump administration, Mr. Price put a little distance between himself and the president-elect on several issues.
Mr. Trump said last week that drug companies were “getting away with murder” and that Medicare should negotiate with drugmakers to secure lower prices, a position long championed by Democrats and fiercely opposed by Republicans.
Asked if he would press Congress to authorize such negotiations, Mr. Price did not give a definitive answer. “I think we need to find solutions to the challenges of folks’ gaining access to needed medication,” he said.
He added that, if confirmed, he would try to give states more freedom and flexibility under Medicaid, the federal-state program that provides coverage for more than 70 million low-income people. In response to questions, he said states should be allowed to require certain able-bodied adults without children to work, seek work or participate in job training as a condition of receiving Medicaid. Some Republican governors want to impose such requirements, but the Obama administration has turned down their proposals.
Mr. Price praised Indiana’s program to expand Medicaid eligibility under the Affordable Care Act with conservative policies that state officials say promote “personal responsibility.”
“States know best” how to care for their Medicaid beneficiaries, he said, adding, “What Indiana has done is really a best practice, I think, for many other states to follow.”
Mr. Trump has not said much about the future of Medicaid in the 31 states that have expanded eligibility, with large amounts of federal money.
Democratic senators were often frustrated in their efforts to get Mr. Price to say whether he supported the coverage requirements and insurance mandates in the Affordable Care Act.
In a typical response, he said that patients should have “access to the kind of coverage that they want,” rather than having it dictated to them by the government.
Senator Christopher S. Murphy, Democrat of Connecticut, said that Mr. Price appeared to support the coverage and protections provided by the Affordable Care Act, but that “we don’t get any specifics as to how that’s going to occur” if the law is repealed.
Without mandating coverage of specific benefits, Mr. Price said, the Trump administration could “make certain that individuals had the care and the kind of coverage that they needed for whatever diagnosis would befall them.”
He said the administration could put in place “a different construct” that “would allow for every single person to gain access to the coverage that they want and have nobody fall through the cracks.”
He did not say how the Trump team would guarantee such protection.
Mr. Trump has expressed support for a provision of the 2010 health law under which insurers must allow children to stay on their parents’ policies until the age of 26. This is “baked into the insurance programs that are out there right now,” Mr. Price said.
“I think that the insurance industry has included individuals up to age 26 on their parents’ policies virtually across the board,” he said, “and I don’t see any reason that that would change.”
Democrats were skeptical. Senator Maggie Hassan of New Hampshire said there was no guarantee that such protections would continue in the absence of federal requirements. Insurance companies did not routinely cover drug abuse treatment in the past and might not do so in the future without a requirement, she said.
The Congressional Budget Office said Tuesday that the number of uninsured Americans could increase by 18 million in one year if Congress repealed major parts of the health care law while leaving others. Mr. Price tried on Wednesday to allay fears of disruption.
“I think there’s been a lot of talk about individuals losing health coverage,” Mr. Price said. “That is not our goal, nor is it our desire, nor is it our plan.”
“One of the important things that we need to convey to the American people is that nobody’s interested in pulling the rug out from under anybody,” he said. “We believe that it’s absolutely imperative that individuals that have health coverage be able to keep health coverage and move, hopefully, to greater choices and opportunities for them to gain the kind of coverage that they want for themselves and for their families.”
Mr. Price said he would “absolutely” consider administrative action to stabilize the market for insurers, which are supposed to submit proposals for 2018 coverage in April. Insurers say it will be nearly impossible to calculate premiums if they have no idea what will replace the health care law.
Mr. Price championed “medical innovation” as an essential ingredient of high-quality care but criticized the Center for Medicare and Medicaid Innovation, which was created by the health law to test new ways of paying doctors, hospitals and other providers.
He said that the agency had great promise, but that too often, its experiments were compulsory for doctors and nearly nationwide in scope. He said he “adamantly opposed the mandatory nature” of some payment models, like one for joint replacement surgery and one for expensive drugs administered in doctors’ offices.
Mr. Price said he would not object if Medicare tested payment methods with small pilot projects that could expand if successful.
The health committee will not vote on Mr. Price’s nomination. Another hearing has been scheduled for Tuesday by the Senate Finance Committee, which will vote on whether to recommend confirmation. The committees share authority over issues for which the Health and Human Services Department is responsible.

The Conversation Placebo

by Danielle Ofri - NYT
In my daily work as a primary care internist, I see no letup from pain. Every single patient, it seems, has an aching shoulder or a bum knee or a painful back. “Our bodies evolved to live about 40 years,” I always explain, “and then be finished off by a mammoth or a microbe.” Thanks to a century of staggering medical progress, we now live past 80, but evolution simply hasn’t caught up; the cartilage in our joints still wears down in our 40s, and we are more obese and more sedentary than we used to be, which doesn’t help.
So it’s no surprise that chronic arthritis and back pain are the second and third most common non-acute reasons that people go to the doctor and that pain costs America up to $635 billion annually. The pain remedies developed by the pharmaceutical industry are only modestly effective, and they have side effects that range from nausea and constipation to addiction and death.
What’s often overlooked is that the simple conversation between doctor and patient can be as potent an analgesic as many treatments we prescribe.
In 2014, researchers in Canada did an interesting study about the role of communication in the treatment of chronic back pain. Half the patients in the study received mild electrical stimulation from physical therapists, and half received sham stimulation (all the equipment is set up, but the electrical current is never activated). Sham treatment — placebo — worked reasonably well: These patients experienced a 25 percent reduction in their levels of pain. The patients who got the real stimulation did even better, though; their pain levels decreased by 46 percent. So the treatment itself does work.
Each of these groups was further divided in half. One half experienced only limited conversation from the physical therapist. With the other half, the therapists asked open-ended questions and listened attentively to the answers. They expressed empathy about the patients’ situation and offered words of encouragement about getting better.
Patients who underwent sham treatment but had therapists who actively communicated reported a 55 percent decrease in their pain. This is a finding that should give all medical professionals pause: Communication alone was more effective than treatment alone. The patients who got electrical stimulation from engaged physical therapists were the clear winners, with a 77 percent reduction in pain.
This type of study provides hard evidence for what shamans, witch doctors and assorted mystics have known for millenniums: A substantial portion of “healing” comes from the communication and connection with the patient.
Before we had treatments that could actually counteract the pathology of disease — antibiotics, chemotherapy, stents, organ transplants, transfusions — placebo was the mainstay of medical care, and in many cases it was remarkably effective.
A good example is patients suffering from vague diffuse pains with no discernible cause. Frequently my patients ask if a multivitamin will give them more energy. In the past I would say no, because there are no significant scientific studies to demonstrate this, and also because in the absence of a vitamin deficiency there’s not much for a basic multivitamin pill to do. Now I take a different approach. I say something along the lines of “Many of my patients find that they have more energy when they take a multivitamin.” I’m not lying, because many have indeed said so. Without fail, there are always a few patients who come back at the next visit and swear they feel much better.
There are some who argue that it is unethical to promote placebos to patients. But increasingly, many say it would be unethical not to give placebos a try in situations where patients are not getting relief from traditional means (and where it would not cause harm or replace a necessary treatment).
It’s clear that how doctors and nurses communicate their treatment can have profound effects on how patients experience the results of that treatment. Yet the conversation between doctors and patients is one of the least valued aspects of medical care. Insurance reimbursements for tests and medical procedures dwarf reimbursements for talking to patients or spending time thinking about what ails them. And the pharmaceutical industry, with its direct-to-consumer advertising, has promulgated the fallacy that every ailment must be met with a pill — brand name, of course.
As health care faces its latest overhaul, it’s crucial for the medical profession, as well as insurance companies and decision makers in government, to recognize the power of the doctor-patient conversation. It’s the most valuable diagnostic tool we have and can be remarkably effective as a treatment tool as well. Training for doctors and other medical professionals should emphasize communication skills with the same rigor that it does for other clinical skills.
Call conversation a placebo if you like, but if it helps without causing harm, then it’s legitimate medicine. Relieving suffering, after all, is what the Hippocratic oath is all about.

Who Will Care for the Caregivers?

by Dhruv Khular - NYT

I should have put his socks back on.
The thought kept nagging me as I finished my clinic notes, replaying the afternoon in my head. My final patient of the day — a man with dementia — was a late addition to the schedule, after his daughter, herself a patient of mine, called to report he hadn’t been himself lately. We scheduled him for the last appointment, so she could join after finishing work across town.
She recounted the subtle changes she’d noticed in her father. He’d been eating less, sleeping more. He was less steady on his feet and seemed uninterested in playing with his grandchildren — an activity that normally filled him with irrepressible joy.
From her purse, she pulled out no fewer than eight pill bottles — each with a dose, time and frequency meticulously labeled. She handed me a handwritten transcript of his other recent appointments: an ophthalmologist, a neurologist, a cardiologist. As I examined him, her phone rang.
“Grandpa isn’t feeling well, sweetie,” she said. “There’s macaroni in the fridge. We’ll be home soon.”
She hung up and apologized for the interruption. Then she leaned over to pull his socks over his bare feet — socks I’d removed moments before and left on the exam table.
I should have put his socks back on.
There are some 40 million Americans like my patient’s daughter. Every day, they help a parent, grandparent, relative or neighbor with basic needs: dressing, bathing, cooking, medications or transportation. Often, they do some or all of this while working, parenting, or both. And we — as doctors, employers, friends and extended family — aren’t doing enough to help them.
According to AARP and the National Alliance for Caregiving, the typical family caregiver is a 49-year-old woman caring for an older relative — but nearly a quarter of caregivers are now millennials and are equally likely to be male or female. About one-third of caregivers have a full-time job, and 25 percent work part time. A third provide more than 21 hours of care per week. Family caregivers are, of course, generally unpaid, but the economic value of their care is estimated at $470 billion a year — roughly the annual American spending on Medicaid.
A recent report from the National Academies of Sciences, Engineering and Medicine suggests that society’s reliance on this “work force” — largely taken for granted — is unsustainable. While the demand for caregivers is growing because of longer life expectancies and more complex medical care, the supply is shrinking, a result of declining marriage rates, smaller family sizes and greater geographic separation. In 2015, there were seven potential family caregivers for every person over 80. By 2030, this ratio is expected to be four-to-one, and by 2050, there will be fewer than three potential caregivers for every older American.
This volunteer army is put at great financial risk. Sixty percent of those caring for older family members report having to reduce the number of hours they work, take a leave of absence or make other career changes. Half say they’ve gotten into work late, or had to leave early. One in five report significant financial strain. Family caregivers over 50 who leave the work force lose, on average, more than $300,000 in wages and benefits over their lifetimes.
Even worse, perhaps, is the physical and emotional toll of extended caregiving. Family caregivers are more likely to experience negative health effects like anxiety, depression and chronic disease. One study found that those who experienced mental or emotional stress while caring for a disabled spouse were 63 percent more likely to die within four years than noncaregivers who were also tracked. Another study found that long-term caregivers have disrupted immune systems even three years after their caregiving roles have ended. And caregivers of patients with long I.C.U. stays have high levels of depressive symptoms that can last for more than a year.
As overworked and underappreciated as family caregivers are, health systems, under pressure to reduce costs, increasingly rely on them to manage illness at home.
There’s more we medical professionals can do to improve the way we engage, support and educate them. Family caregivers aren’t always clearly listed in the medical record, and even when they are, we often fail to include them in important decisions about a patient’s treatment plan — despite expecting them to carry out that plan at home. We assume they’re able to perform complex medical tasks — administering injections, changing catheters, dressing wounds, starting tube feeds — but fewer than half of family caregivers receive the training to perform them.
The Academies’ report highlights several measures that could help. First, simply identify caregivers, assess their abilities and anticipate challenges they’re likely to encounter. The United Hospital Fund has developed a tool to understand caregivers’ existing home or work duties, as well as what training they’ll need to perform new caregiving tasks and any concerns they have about the treatment plan.
Having counseling and support services available to caregivers, as well as respite programs to temporarily relieve them of their responsibilities, could also help. And clinicians could be trained in how best to educate family caregivers, and to better meet their emotional and physical needs. A nurse might demonstrate how to turn a patient in bed without risking back strain. Or the right way to deliver an insulin injection — how to pinch the skin, what angle to insert the needle — and what signs to look out for if blood sugar levels get too low.
Policy makers can help caregivers, too. More than 30 states have passed versions of the Caregiver Advise, Record, Enable (CARE) Act. The act requires hospitals to identify family caregivers, inform them when patients are being discharged, and provide them with basic education on the tasks they’ll be expected to perform. Other policy changes might strengthen financial support for caregivers by increasing the amount of available paid leave and encouraging employers to offer more flexible work hours.
Caregivers should also feel comfortable speaking up about their needs, and asking for information on services available in their area. Increasingly, there are support groups available to those caring for patients with Alzheimer’s disease, cancer and other serious illnesses. The government’s Eldercare Locator is an online tool that allows older people and their caregivers to identify community organizations that can help with meals, transportation, home care, peer support and caregiving education.
Similarly, local Area Agencies on Aging can help connect patients and caregivers to the services they need. Employers might consider “time-banking” programs to share leave among employees. And, of course, we can all call to check in on a caregiver, and volunteer our time to give them a break.
If it’s a certainty that all of us will experience illness, it’s a near-certainty that most of us will care for someone with an illness. But our current conception of patient and disease seems too narrow. It may help to recognize that while patients’ needs come first, illness is often a family affair.
For many, caring for a loved one provides tremendous purpose and fulfillment. It can deepen relationships and offer the time and space for connection where it otherwise might not exist. It seems that the goal, then, should not be to reduce family caregiving, but to reduce its burdens.

‘Repeal and Replace’: Words Still Hanging Over G.O.P.’s Health Care Strategy

by Carl Hulse
In March 2010, on the day before President Obama was to sign the Affordable Care Act into law, a group of senior Republican aides huddled in Senator Mitch McConnell’s Capitol suite to try to come up with a catchy slogan to use against it.
Many conservatives were simply advocating a vow to repeal the new law, but Republican strategists worried that pressing for repeal without an alternative could backfire. So they batted around a few ideas before Josh Holmes, then a top communications adviser to Mr. McConnell, tossed out the nicely alliterative phrase “repeal and replace.” That seemed to do the job, with its promise to get rid of the new law detested by Republicans while suggesting that something better would follow.
The phrase has shown real staying power: President-elect Donald J. Trump proudly invoked “repeal and replace” twice during his news conference on Wednesday.
“The goal was to come up with something that had durability and could be a rallying cry for Republicans basically to campaign against Obamacare,” said Mr. Holmes, now the president of Cavalry, a consulting and media firm. “This obviously had sort of a catchy ring to it. And it was consistent with what we were trying to accomplish.”
As it turns out, producing the slogan turned out to be far easier than producing an actual replacement. Almost seven years later, congressional Republicans are still struggling to settle on a consensus alternative to the health care law, endangering their push to quickly undo and then redo the signature Obama administration achievement, which turned out to be a springboard to a Republican political resurgence.
The uncertainty has reignited the fight to define the health insurance program in the public mind, with Republicans and Mr. Trump painting it as a disaster, and Democrats portraying it as a success that provides security to millions of Americans, many of them Trump voters. Democrats have latched on to their own catchphrase, warning that repealing the law will “Make America Sick Again” — a twist on the Trump campaign’s “Make America Great Again” theme.
Republicans have derided the Democratic message — personally developed by Senator Chuck Schumer of New York, the new Democratic leader — as trite and ineffective. But Democrats like it and believe that it goaded Mr. Trump into a more direct and complicating role in the Republican deliberations over how quickly to propose a replacement for the health care program.
They say Republicans are still relying on Mr. Holmes’s years-old brainchild because they are groping for a replacement with their new unified government days away. Democrats see the confusion as a victory in their push to thwart repeal or slow it down while wringing all the political advantage they can from the attempt.
After a series of late-night Senate budget votes that laid the procedural groundwork for repeal with no certainty on what was to follow, one Democrat delivered a new punch line.
“This is called repeal and run,” Senator Claire McCaskill, Democrat of Missouri, said on Twitter as the Senate was voting. “Chaos is coming.”
Mr. Trump’s involvement has muddled the issue further as he and Republican leaders in Congress have offered differing timetables for when a Republican alternative might be unveiled, underscoring again how difficult it can be to push through an agenda even for a party that controls all the levers of government.
The origin story of the “repeal and replace” mantra is also a reminder of how pivotal strategic messaging has been throughout the health care debate. It has produced some of the more memorable political lines in recent years, from “death panels” to “If you like your health plan, you can keep your health plan” to “Obamacare” itself. After Republicans began throwing that term around as a pejorative, Mr. Obama embraced it.
Even before landing on “repeal and replace,” Republicans scorched Democrats with buzzy phrases. In his book “The Long Game,” Mr. McConnell recounted how he instructed his legislative experts to identify special provisions that had been added to the health bill to win over wavering Democrats.
His communications staff would then “brand” these legislative sweeteners with catchy but disparaging nicknames to build opposition and public distrust for the law. The result: the “Louisiana Purchase,” “Gator Aid” and the memorable “Cornhusker Kickback,” to tarnish provisions inserted to woo senators from Louisiana, Florida and Nebraska.
“In some ways, we were enjoying ourselves,” Mr. McConnell acknowledged in his book.
The same communication strategists who originated those terms were brainstorming on March 22, 2010, while Mr. Holmes jotted ideas on a notecard. When he hit on “repeal and replace,” the McConnell team decided it had what it needed. The big question was whether they could get lawmakers to embrace it. That answer would come quickly.
“I think the slogan will be ‘repeal and replace,’ ‘repeal and replace,’” Mr. McConnell told reporters the next day. “No one that I know in the Republican conference in the Senate believes that no action is appropriate.”
Mr. Holmes said a turning point came shortly after, when Representative Mike Pence of Indiana, who was then in charge of political messaging for House Republicans, and is now the vice president-elect, latched on to the phrase. That caused conservative resistance to the “replace” aspect of the debate to evaporate.
Mr. Holmes acknowledged that he had to create only the phrase, not the actual replacement.
“I don’t do policy,” he said with a laugh.
But Republican lawmakers and leaders of the new administration do have to do policy. And they may need to do it fast if they are going to assure Americans that they intend to fulfill their seven-year-old promise to not just repeal the law, but also replace it.

Fear Spurs Support for Health Law as Republicans Work to Repeal It

by Robert Pear - NYT

WASHINGTON — President-elect Donald J. Trump and congressional Republicans appear to have accomplished a feat that President Obama, with all the power at his disposal, could not in the past seven years: They have galvanized outspoken support for the Affordable Care Act.
People who benefit from the law are flooding Congress with testimonials. Angry consumers are confronting Republican lawmakers. And Democrats who saw the law as a political liability in recent elections have suddenly found their voice, proudly defending the law now that it is in trouble.
Thousands of people across the country held rallies over the weekend to save the health care law, which Republicans moved last week to repeal with a first but crucial legislative step. A widely circulated video showed Representative Mike Coffman, Republican of Colorado, eluding constituents who had wanted to meet with him to express their concerns on Saturday at a community event in Aurora, Colo. Rallies on Sunday to save the health law drew robust crowds around the country.
“We are here today — thousands strong in Boston, and at more rallies all across this country — because we will make our voices heard,” Senator Elizabeth Warren, Democrat of Massachusetts, told a crowd outside Faneuil Hall in Boston. “If Republicans try to rip health care out of the hands of millions of Americans, we will fight them every step of the way.”
And progressive groups are planning a two-month cross-country bus tour to fight the repeal effort, starting Tuesday.
With their quick strike on the law in the first days of the new Congress, Republicans had hoped to begin the repeal process before a backlash could develop or opposition could be organized. But congressional Republicans are at risk of losing the message war, especially since they are fighting on two fronts.
On one side, the president-elect has repeatedly lobbed disruptive demands at them, such as his insistence that they prepare a replacement health bill almost immediately. To that, he added a new promise over the weekend: that the Republican version would provide “insurance for everybody.”
On the other front, Democratic lawmakers have taken to quoting grateful constituents to personalize what can be an arcane legislative fight: Bryce in Seattle; Randy in Rhinelander, Wis.; Nicole in Hockessin, Del.; and many more. The focus of public attention appears to be shifting from the well-documented defects of the health care law to the plaintive pleas of people terrified of losing insurance if the law is repealed.
“I want to thank President Obama from the bottom of my heart because I would be dead if it weren’t for him,” Jeff Jeans, a small-business man from Sedona, Ariz., who described himself as a lifelong Republican, told Speaker Paul D. Ryan on Thursday at a town-hall-style meeting televised on CNN.
Republicans acknowledge their constituents’ concerns, but they say supporters of the health law are manufacturing them. Representative Rob Woodall, Republican of Georgia, blamed Democrats for “amping up anxiety” with “fear mongering.”
“The anxiety is real,” Mr. Woodall said, “but it’s real based on the failures of the president’s health care law.”
Republicans will soon face a new challenge: maintaining anger at “Obamacare” without Mr. Obama in the White House to stir their passions.
Regardless of its provenance, the law’s support has until now received less attention. Appearing on the NBC News program “Meet the Press” five days after Mr. Obama signed the Affordable Care Act in 2010, Senator Chuck Schumer, Democrat of New York, predicted that as people learned about the law, “it’s going to become more and more popular.”
Around 20 million Americans have gained coverage through the Affordable Care Act’s online insurance marketplaces or through its expansion of Medicaid, and enrollment has continued to grow. About 11.5 million people have signed up for marketplace plans or had their coverage automatically renewed for this year, nearly 300,000 more than at this time last year, the Obama administration said this month.
But the popularity bounce never came. Public opinion remains deeply divided, with the law no more popular today than when it was passed. In December, according to a monthly tracking poll by the Kaiser Family Foundation, 46 percent of Americans had unfavorable views of the law, up from 40 percent in April 2010. The share with favorable views slipped to 43 percent, from 46 percent in April 2010.
“In the short term, the A.C.A. has been a political disaster for President Obama and the Democrats,” Dr. Ezekiel J. Emanuel, a health policy adviser in the Obama White House from 2009 to 2011, said in a 2014 book.
As Congress took a first step last week toward rolling back Mr. Obama’s signature domestic achievement, Mr. Trump celebrated. “The ‘Unaffordable’ Care Act will soon be history!” he said on Twitter.
Some Democrats distanced themselves from the Obama administration after HealthCare.gov crashed on its debut in 2013. More recently, with premiums soaring and insurers defecting from the Affordable Care Act marketplace in many states, Democrats were hard put to defend the law, which was passed without any Republican votes.
But as Mr. Trump and congressional Republicans race to repeal the law, Democrats are taking a more aggressive stance.
Senator Debbie Stabenow, Democrat of Michigan, told the story of Sonja L. Podjan, a 55-year-old blueberry farmer in Watervliet, Mich., who was in pain for several years until she got insurance under the Affordable Care Act, which covered the cost of surgery to repair a severe tear in the meniscus of her right knee.
In an interview, Ms. Podjan said she “started freaking out” after the election and sent an email to Ms. Stabenow. She said she was “flabbergasted” when she heard back from the senator’s office.
Ms. Podjan said that the premium for an insurance policy covering her and her husband was about $1,000 a month, but that they paid just $62 after receiving government subsidies provided under the law.
“I am scared to death we will lose our insurance, and what happens then?” said Ms. Podjan, who reported that she and her husband had medical expenses totaling $41,000 in the past two years.
Senator Tom Udall, Democrat of New Mexico, told the story of a constituent, Kevin Kargacin, whose daughter Amber takes drugs costing more than $60,000 a year for multiple sclerosis. “Kevin is scared because the cost of treating Amber’s disease is so high,” Mr. Udall said.
In an interview, Mr. Kargacin said he wrote to Mr. Udall because “we are terrified that without the Affordable Care Act, Amber could be denied insurance or run into lifetime caps on expenditures for her treatment.”
Senator Amy Klobuchar, Democrat of Minnesota, said: “Many Minnesotans have contacted me in the last few months, frightened about the future of their health care coverage. I heard from a man in Orono. His wife was diagnosed with cancer this year. On top of everything his family is now dealing with, he is terrified that his family will lose coverage if there is a repeal.”
Whether such concerns reflect a change in public opinion is difficult to say. Over the past six years, Republicans have collected stories from hundreds of constituents complaining that their insurance policies were canceled, their premiums have shot up and their deductibles are so high that the insurance is nearly worthless.
“Scott from Hickory has had his health insurance canceled three times now, disrupting his continuity of care,” said Representative Virginia Foxx, Republican of North Carolina. “Patricia from Kernersville now has a whopping $6,550 deductible.”
Representative Pat Tiberi, Republican of Ohio, reported that a constituent named Kimberly had difficulty obtaining treatment for a brain tumor because, she said, “virtually no doctors take the marketplace insurance.”
The differing accounts are not necessarily in contradiction. Some people have benefited from the law while others have seen their coverage disrupted.
Republicans said the Obama administration had been slow to recognize and acknowledge problems with the Affordable Care Act. Administration officials said insurance rate increases of 25 percent or more were not a significant problem because low-income people could get subsidies to help defray the cost — even though millions of people buying insurance on their own do not receive subsidies.
The administration insisted that insurance markets were “stable and vibrant” even as large insurers pulled out of Affordable Care Act exchanges where they were losing hundreds of millions of dollars. In 2015, the administration said that “claims data show healthier consumers” in the exchanges, but some insurers disputed that assessment, saying they had not seen an influx of healthy people to help cover the costs of sick people.

The G.O.P.’s Health Care Death Spiral

by J.B. Silvers
Last week, President-elect Donald J. Trump called Obamacare “a complete and total disaster,” and pushed for a swift repeal of the Affordable Care Act and a replacement within weeks. But at the moment, there is no workable replacement. So what happens to the individual insurance market — whose problems did not start with the Affordable Care Act and will not be easily solved — when it is destabilized so dramatically?
From my point of view as a former health insurance company chief executive, “total disaster” would also describe any Republican repeal-and-delay plan. Although my former colleagues in the insurance industry are too cowed by the president-elect to say so, Republican insistence on repeal without having a meaningful replacement at the same time will drive most insurers out of the individual market and leave the 10 percent of Americans now covered by some aspect of the A.C.A. without coverage — especially if Medicaid expansion is rolled back as well.
The proportion of uninsured Americans, which has dropped to less than 9 percent, the lowest on record, will at least double. By April, when filings from insurance company plans and premiums for 2018 are due, there will be a sizable exit — of insurers running away from the greatly increased and unpredictable risk and of individuals not able to afford insurance without the subsidies.
Of course, the A.C.A. has a number of flaws, and repair is critical. But delay is not an option if the replacers really want to use private insurers to meet society’s goals of access, affordability and quality in health care. All known Republican alternatives envision heavy reliance on the same insurers that are now ready to bolt and leave a total mess rather than a defective but repairable market.
After they leave, the damage will spread to doctors and hospitals, whose bad debt will skyrocket when patients miss copays and drop coverage while providers and hospitals still must continue care.
This is not speculation but based on my experience in the industry and as a member of the board of a public hospital that stands to lose substantial Medicaid payments if the state expansions are rolled back.
Let’s go back for a moment to pre-Obamacare days. Why did insurers refuse to cover individuals with pre-existing conditions, cancel policies if customers used them too much, set high premiums for women and old people, and so forth? These tools were the only way to limit risk when insurers didn’t have a ready-made pool of sufficient size to balance the sick and well as employer-sponsored plans do.
Refusing coverage and the like was good business, but it did not serve small businesses, the self-employed or other people unable to get the insurance they wanted. The Obamacare exchanges tried to fix this by requiring everyone to join the pool, providing premium and cost-sharing subsidies geared to income (the “affordable” in the law’s name) and limiting risk to insurers to entice them to offer policies.
It’s a tricky business to fine-tune a market and encourage buyers and sellers to do the right thing — both providing access to individuals in need and encouraging enough insurers to join to make competition work. But George W. Bush, with some bipartisan support, did it not so long ago with the Medicare drug plans.
But unfortunately, the A.C.A. law created by Democrats in Congress had several big flaws. Pricing restrictions — which essentially mandated that insurers overcharge younger customers relative to older ones — created the wrong incentives, and so too many older, sicker individuals joined, and younger, healthy people were discouraged.
This was compounded by a Republican Congress that reneged on its promise to help insurers in the first years of the program by limiting risk. Congress allowed only 12 percent of the backup that was promised to companies when they set their premiums on the Obamacare exchanges. This ramped up their risk dramatically.
If you’re wondering why insurers substantially increased premiums for this year, even far beyond the underlying health care inflation rate — now at around 4 percent — this shell game with risk is your answer.
Ultimately, if the risk is too high, exit is inevitable. That is what my top-rated plan, Qualchoice, did in Ohio in the late 1990s to stem multimillion-dollar losses from its participation in the Medicaid Advantage managed care program. It’s also what United Healthcare did and most others will do this spring when faced with the uncertainty of delay.
Finally, none of the participants, in government or business, want to recognize that in many parts of the country, only one insurer or a highly consolidated health system dominates, which eliminates meaningful competition and choice.
Since 2010, Republicans have made political hay by demonizing the mandate to buy insurance, subsidies to make it affordable and taxes on employers, suppliers, insurers and especially the wealthy to finance it. But now they own the problem and must fix it or do something better.
Obamacare, or any plan that replaces it that is reliant on private insurers and individual enrollment, will succeed only under the following conditions: a meaningful incentive to purchase insurance (the individual mandate or equivalent); help to make it affordable; risk reduction for insurers to stabilize premiums; and enough funding to pay for it all.
If any replacement plan doesn’t include these elements, private insurance will revert to the chaos of the pre-A.C.A. market. In business, managing risk is important; in insurance, it is everything. Whoever plays games with it — knowingly or inadvertently — is playing with fire.
If we manage this risk badly through repeal and delay, the damage to insurers, individuals, hospitals and professionals will be profound.

18 million would lose insurance in first year of Obamacare repeal without replacement, CBO report says
by Kelsey Snell - Washington Post

As Republicans in Congress gear up to repeal the Affordable Care Act, two Pennsylvanians reflect on their different experiences under Obamacare. (Alice Li/The Washington Post)
At least 18 million people would lose health insurance in the first year if Republicans move ahead with plans to repeal major portions of the Affordable Care Act without a replacement plan, estimates a report from the nonpartisan Congressional Budget Office.
The number of people without insurance would grow to about 32 million within the first decade if congressional Republicans follow a 2015 plan to repeal the health-care law without an alternative, the new report says. It also estimates that health insurance premiums for people buying individual non-group coverage would double within a decade, further complicating GOP promises that people will not lose coverage under their plan.
The report comes as Republican leaders in Washington are working furiously to tamp down concerns within their ranks that a speedy push to repeal major portions of the law known as Obamacare could create chaos in the insurance markets and provoke a backlash from voters.
Over the weekend, President-elect Donald Trump promised in an interview with The Washington Post that he was nearing completion of a plan to provide “insurance for everybody.” Trump did not provide any details of what that plan would include, but his timeline and promises of coverage for everyone clash starkly with the CBO report estimating that millions of people would lose coverage.
The report increases the pressure on Republicans to come up with a replacement plan that fills in the gaps for Americans covered by the ACA while adhering to GOP principles.
Sylvia Mathews Burwell, the outgoing secretary for health and human services, told reporters that the CBO report showed the importance of having a replacement health-care plan ready when the ACA is repealed. But as of now, “we really  haven’t seen a plan,” she said. “An outline is not a plan. A framework is not a plan.”
Repealing the law without a replacement in place would send the marketplaces into a “negative” spiral of falling enrollment and soaring premiums, Burwell said. But she added that she is “an optimist” and believes that Republicans will adjust their plans when faced with the realities. She added that she believes consumers, doctors, patients and insurers will increasingly be “the voices of reality” as the debate over health care continues.
Looking back on how the Obama administration handled the ACA, she said, it’s clear that officials underestimated the time it would take for consumers and insurers to adjust to a new system for the individual market. “We thought it would be faster,” Burwell said.
The report, which is an update of a previous analysis of the 2015 repeal legislation, sparked bickering among lawmakers Tuesday. Republicans dismissed it, arguing that the forthcoming GOP repeal plan will also include some elements of replacement. Senate Finance Committee Chairman Orrin G. Hatch (R-Utah), one of four committee chairman who will help draft the repeal and replacement measures, said the report was one-sided.
“Today’s report shows only part of the equation — a repeal of Obamacare without any transitional policies or reforms to address costs and empower patients,” Hatch said. “Republicans support repealing Obamacare and implementing step-by-step reforms so that Americans have access to affordable health care.”
AshLee Strong, a spokeswoman for House Speaker Paul D. Ryan (R-Wis.), said, “This projection is meaningless, as it takes into account no measures to replace the law nor actions that the incoming administration will take to revitalize the individual market that has been decimated by Obamacare.”
Senate Democrats, including Minority Leader Charles E. Schumer (D-N.Y.), requested the report to provide an updated estimate of the effect of a 2015 repeal measure that ended in a veto from President Obama. Republican leaders have said that bill was a “dress rehearsal” for efforts in 2017.
“Nonpartisan statistics don’t lie: it’s crystal clear that the Republican effort to repeal the Affordable Care Act will increase health care costs for millions of Americans and kick millions more off of their health insurance,” Schumer said in a statement.
But Republicans insist that they are working on a replacement plan. House Majority Whip Steve Scalise (R-La.), the third-ranking Republican in the House, responded Tuesday by dismissing the report on Twitter.

The GOP’s dilemma: As Obamacare repeal nears, government health care is suddenly in vogue
by Aaron Blake - Washington Post

We are closer than we have ever been to the repeal of Obamacare. And a funny thing happened along the way: Americans have suddenly decided that they're pretty cool with the government being involved in their health care, after all.
In fact, even many Republicans now say this.
This, of course, has been the GOP's biggest complaint about the Affordable Care Act — that it amounts to big government and government-run health care, ballooning costs and resulting in poorer care than the free market would provide. But now the impending repeal of Obamacare, combined with a big-government-loving Republican president-elect in Donald Trump, seems to have moved the needle toward government-involved health care — at the very same time as Republicans look to get rid of it (and replace it with their own, possibly scaled-back version).

Trump vows 'insurance for everybody'

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Speaking Jan. 16, incoming White House press secretary Sean Spicer sought to clarify comments Donald Trump made when he said his forthcoming health plan would provide “insurance for everybody.” (Reuters)
A Pew Research Center poll last week showed low- and middle-income Republicans, in particular, have warmed to the idea of a government role in health care. A majority of GOP and GOP-leaning voters making less than $30,000 a year — 52 percent — now say that they think the federal government should make sure all Americans have health coverage. That number is up from 31 percent in March of last year.
Among those making between $30,000 and $74,999, the number has risen similarly, from 14 percent to 34 percent. Overall, 60 percent of Americans would like the federal government to guarantee health-care coverage, up from 51 percent just 10 months ago.

FT_17.01.13_healthCoverage_govtRole

Then, on Tuesday, a new NBC News-Wall Street Journal poll showed people actually like the concept of Obamacare more than ever before.
For the first time ever, more respondents say the law was a good idea (45 percent) than say it was a bad idea (41 percent), and the number saying it was a good idea has risen double-digits from where it was in 2013 and 2014.
Three years ago, 50 percent said it was a bad idea, while just 34 percent said it was a good one.

For the first time, more say ACA is 'good idea' than 'bad idea'

This doesn't come, mind you, at a time when we're suddenly learning a bunch of great news about Obamacare. In fact, we're only a couple months removed from large increases in premiums. And polling has shown Americans are still split about evenly when it comes to keeping Obamacare vs.getting rid of it.
But as the reality of Obamacare repeal has begun to set in, the opposition seems to have morphed and taken its foot off the gas. We even saw this shortly after the 2016 election, when Republicans suddenly soured a bit on full repeal of Obamacare and embraced a more piecemeal approach. Previously, 7 in 10 Republicans had called for complete repeal; after the election, that number dropped to 52 percent.
The totality of the polling is crystal clear: About half the country liked the idea of getting rid of something they didn't agree with — at least in the abstract. But the reality has proven much more complicated. And the guarantees that come with government-involved health care are suddenly looking more and more attractive.
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As I've argued before, entitlement programs and government benefits have a way of sticking around and resisting change, because people become accustomed to them and taking them away or altering them is more difficult than never having given them in the first place. Twenty million Americans have become insured under the Affordable Care Act, and now Republicans are faced with getting rid of it — with an indeterminate replacement.
Also driving home this point is the new Congressional Budget Office estimate of the cost of repeal, which came out Tuesday. It shows 18 million people would lose insurance in the first year if Obamacare is repealed with no replacement, and 32 million would lose it over a decade. In addition, costs for those seeking non-group insurance would double.
This, it's important to emphasize, is if the GOP simply repeals Obamacare with no replacement, which is not the party's plan. It is now working to craft its alternatives, and we'll have to see what they are. At this point, it seems very unlikely Republican members of Congress would support repealing the Affordable Care Act without a replacement, so these estimates are very much in the realm of the hypothetical.
But it does demonstrate the stakes of getting rid of Obamacare without a solid alternative and without providing “insurance for everybody,” as Trump promised over the weekend.
That's a prospect that is clearly scary to a large number of Americans, who have apparently decided they're okay with government-involved health care. We'll have to see how much a Republican Party that has long decried such things will come around to the idea, too.

A Failed Cure for Health Care Costs

by Helene Olin- Slate

It’s a new year, and you know what that means: Your health insurance deductible just reset. Which for many of us means looking forward to paying a significant amount out of pocket for health care until we’ve spent enough for our insurance payments to kick in. According to the Henry J. Kaiser Family Foundation, in 2016, the average deductible for an American with employer-based insurance was $1,221. People covered through the Affordable Care Act exchange will likely pay more than that. Close to 90 percent of those enrolled will select a plan with an individual deductible of at least $1,300, or $2,600 for a family.
Can’t afford it? Feel squeezed? No worries. Your employer or insurer probably offers an online price-comparison information tool for you to find the best deal on everything from blood work to birth control. “Be a smart health care consumer,” reads the landing page for my insurance company’s price-comparison site. “Use our tools and information to help you save money.” But will it?
Less than five years ago, online price-transparency tools, with which patients can compare the costs of nonemergency procedures in advance of booking them, were heralded as miracle cures that would finally get health care costs under control. No longer would the cost of medical procedures be a mystery. It made sense. Online, we can compare prices for books and hotel rooms and TV sets. Why not doctors? “Life inside the fortress will increasingly be disrupted,” noted health care economist Uwe Reinhardt said of the concept in a 2013 Journal of the American Medical Association article.
The rush was on. A 2015 survey by human resources consultancy Mercer found that more than three-quarters of U.S. employers said they offer employees access to such tools. Numerous states jumped into the fray, passing legislation that mandated some form of transparent pricing.*
Yet this past spring, JAMA re-emerged with a less rosy diagnosis. In a study of how employees at two corporations actually made use of the health care cost-measurement tools made available to them, researchers at Harvard Medical School discovered that not only did few use them, their spending actually increased after the tools designed to encourage comparison-shopping were introduced. “There was no evidence that health spending declined in the settings where transparency tools were offered,” a JAMA editorial noted.
What went wrong? Comparison tools work by allowing people seeking nonemergency health care like hip and knee replacements, MRIs, physicals, and lab work—and even more mundane services like earwax removal—to compare the cost of the care at different practitioners and determine what their co-payment will likely total based on their insurance and whether they’ve met their deductible.
That should be easy enough. But do you really pick your doctors the way you bargain shop for electronics on the web? Of course not. A 2008 survey by the (now-defunct) Center for Studying Health System Change found that about half of us turned to friends and relatives for recommendations when seeking a new primary care doctor. And when it comes to specialists, almost everyone relied on the advice of other medical professionals, with less than 10 percent turning to online information to make a choice. Things haven’t changed much since then. A 2014 poll from the Associated Press and the NORC Center for Public Affairs Research found barely 1 in 4 identifying excellent ratings on sites like Yelp or Healthgrades.com as a decisive factor in deciding on a particular doctor.
Moreover, one man’s frivolity is another woman’s necessity. With health care, many of us are willing to pay extra for everything from convenience to communication skills. When the AP–NORC poll asked people what traits made for a high-quality doctor, “affordable” and “accepts my insurance” were the two least important qualities, outranked by more than a dozen other traits including attentiveness, office environment, and bedside manner. Yet another survey, this one by Healthgrades, found many patients prioritizing location over co-pay and quality ratings when they needed a hospital.
And when consumers do make cost-conscious decisions, their ability to make good ones is limited. A recent study released by the National Bureau of Economic Research makes the point. The researchers looked at a company that moved all its employees into a high-deductible health insurance plan. Yes, the workers spent about 15 percent less on health care. Unfortunately, they appeared to cut their medical consumption willy-nilly, making little distinction between needed treatments and ones they could forgo. They didn’t actually spend less on the services they sought out. “We show that consumers did not price-shop after the switch—that is, they did not move toward cheaper providers, for example, when they were going to undergo a specific procedure,” wrote Benjamin Handel, one of the authors of the study.
As for the JAMA paper on health care comparison tools, the researchers speculated that if consumers did attempt to price services, it’s quite possible they ended up paying more money. That’s actually not that surprising. Behavioral finance studies repeatedly find we use cost as a measure of quality. The more expensive an item, the better we think it is.
Yet even if consumers did use comparison tools as they were supposed to, it’s questionable how much they could actually impact prices. The medical system in the United States is a complex beast. The recipients of the services, even if they are the best shoppers around, have little actual control on the overall costs. For example, the Health Care Cost Institute determined the average knee replacements cost more almost $17,000 more in Palm Bay, Florida, than in Miami, which is 180 miles away. But few consumers, even if they do the research, are likely to sign up for a surgery that far from their home. How will they get there? Who will pay transport and house their families? What happens if there’s a complication after they return home?
That’s not even the big picture, because these tools aren’t actually taking on the American medical health care system itself. They’re simply offering customers some room to maneuver within their insurer’s fortress, to borrow Reinhardt’s phrase. When many of us use an insurer’s price-comparison tool, we’re receiving the prices the medical providers have agreed to charge people using that company. “A hospital can charge one person $500 for a cholesterol test and $10 for another,” says Steven Weissman, a former health care executive turned industry critic. “The problem with health care transparency tools is they do nothing to make health care providers compete the way other businesses compete.”
And how much does it really matter? It’s not, after all, the nonemergency MRIs and lab bills that are breaking the bank. Less than half of all medical services can even be priced in advance, according to the Health Care Cost Institute. Hip and knee replacements, which are an example frequently cited by price-transparency promoters, are a mere fraction of our annual tab. And getting an advance estimate for everything from emergency-room visits to strep tests at the doctor’s office is all but impossible—if an ill patient is even capable of that.
In many situations, the power remains with the providers. Pharmaceutical giants set the prices of their drugs. As long as the law permits a hospital that chooses to be in network with a particular insurer to service patients with out-of-network providers, consumers will remain at risk of receiving a surprise medical bill if they need to visit an emergency room.
Yet cheerleaders remain undeterred. Dr. Adam Bernstein, the chief medical officer of Rally Health, speculated that the problem the 2016 JAMA study revealed is that consumers need a “financial reward” in return for using the online price-comparison site, such as making the insured pay a greater share of the bill if they choose a provider charging more than a pre-determined amount for a particular medical service. Others say that as tools are able to include more information about pricing from providers, more people will use them. “Transparency hasn’t even started,” Dr. Giovanni Collela, a founder of Castlight Health, a publicly traded company that markets yet another online price guide, told the New York Times last year. Supporters say they hope that over time patients can be coached into using the tools more often.
Maybe. Maybe not. I’m all for transparent pricing of medical services, but I suspect that even at their most successful, price tools will only make a marginal difference in what we pay the doctor. Once again, we’re seeking an individual solution to an economic and political problem that our politicians not only don’t have the will to solve themselves, but which they might actively make worse by repealing the Affordable Care Act.

Health care isn’t a large-screen television that’s the same whether it comes from Amazon or Best Buy. It’s something that deeply impacts how we live our lives—or if, for that matter, if we continue to live one at all. No wonder these online sites don’t work. We don’t want to put a price on our own health.


Republicans are losing the argument over Obamacare repeal. Can that save it?
by Greg Sargent - Washington Post
THE MORNING PLUM:
I continue to believe that repeal of large chunks of the Affordable Care Act remains likely to happen within the next few weeks or months. But that doesn’t mean Republicans are winning the public argument over it. Indeed, the most likely outcome at this point is that Republicans end up forging ahead with repeal even though the politics of it have shifted against them.
A number of new data points this morning suggest that this is what is in the process of taking place. First, Mike DeBonis reports that congressional Republicans are shying away from holding town hall meetings, possibly because they fear that public blowback from constituents worried over repeal will create precisely the sort of bad optics that hit Democrats amid the Tea Party summer of 2009:
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Seven years after unruly Democratic town halls helped stoke public outrage over the Affordable Care Act, Republicans now appear keen to avoid the kind of dustups capable of racking up millions of views on YouTube and ending up in a 2018 campaign commercial. One week after the Republican Congress kicked off the process of repealing the landmark health-care legislation, only a handful of GOP lawmakers have held or are currently planning to host in-person town hall meetings open to all comers — the sort of large-scale events that helped feed the original Obamacare backlash in the summer of 2009….
That may be because such freewheeling events — especially with a hot topic like the ACA on the table — can devolve into chaos, with made-for-social-media moments brought to you by anyone with a smartphone in the audience….Since Congress took its first steps to unwind the ACA, Republicans have been publicly confronted by constituents — generating media reports and shareable videos that have been happily circulated by Democrats eager to turn the tables on the GOP.
As the piece details, a number of specific viral moments have already taken place involving people either upset about losing Obamacare, or, in one case, flatly claiming it saved his life. All of this is pretty unexpected. Wasn’t repeal supposed to be primarily greeted with a great outpouring of tearful public relief and catharsis over the glorious moment of liberation that is finally at hand after many long years of darkness and oppression?

Congress takes key step toward scrapping Obamacare

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A week before President-elect Trump's inauguration, lawmakers passed a preliminary budget measure that starts the process of repealing the Affordable Care Act. (Video: Sarah Parnass/Photo: Matt McClain/The Washington Post)
Most signs suggest that, as repeal looms as a reality, the terms of the debate are, if anything, shifting in favor of the law. One obvious tell is that Trump and his advisers continue to be almost comically cagey about the intentions for their replace plan. Trump and his political team continue to suggest that everybody will be covered under it, even as his own pick for health and human services secretary, Tom Price, plays semantic games designed to obscure whether this is really so. Other Republicans have employed all sorts of tortured talking points designed to shroud their true long-term intentions in impenetrable rhetorical fog. The bottom line is that Trump and Republicans appear deeply reluctant to associate themselves with an outcome in which lots of people would in fact end up losing coverage.
Here’s more: The Associated Press reports that GOP governors from states that expanded Medicaid “are adamant that Congress maintain the financing that has allowed them to add millions of low-income people to the health insurance rolls.” In other words, GOP governors still want the money that the Medicaid expansion has brought in to expand coverage to their constituents. The GOP replace plan would almost certainly roll back the Medicaid expansion, which might be replaced by some form of block-granting of Medicaid money to the states — an outcome GOP governors surely would like, since it would give them more implementation flexibility. But block-grants could mean cuts over time that leave fewer people covered. Their desire to avoid losing this money could figure into the debate over what a replacement might look like — and here again, Republicans don’t appear to want to be associated with an outcome that actually ends up knocking people off coverage. Remember, more than 20 GOP Senators come from states that expanded Medicaid.
The point here is not that these shifting politics will prevent ACA repeal. It still remains plausible or likely that Republicans will succeed, via a simple majority “reconciliation” process, in rolling back the Medicaid expansion and the subsidies that helped expand coverage. Rather, the point is that these shifting politics could matter to the debate over what comes next. Democrats hope that the fear of an outcome in which millions lose coverage — combined with the GOP need for some Dem votes to pass a replacement — will give them leverage to compel Republicans to embrace a replacement that does not represent a major backslide in human welfare.
Republicans still have all sorts of political tricks at their disposal. Repealing Obamacare on a delay could unleash turmoil in the insurance markets. This, plus any Trump administration executive actions that undermine the law, could create an atmosphere of chaos that Republicans can blame on Democrats, weakening their position in the coming replace battle. As Brian Beutler explains, Democrats need to prepare for this possibility now by “credibly establishing that Republicans are undermining the market through dithering and sabotage.” They also need to continue credibly establishing that the massive looming loss of coverage is rooted not in Obamacare’s supposed inevitable long-term collapse, as Republicans will argue, but rather in a simple fact: Republicans just don’t want to do what is necessary to cover nearly as many people as Obamacare does.
It’s still very possible that repeal will happen, no replacement will materialize, and many millions will lose coverage. But if Dems can manage this skillfully, they might have some leverage to try to bring about a less catastrophic outcome than we might have expected.

Maine fishermen hooked on Obamacare, but now benefits are threatened

by Joe Lawlor - Portland Press Herald

Kennebunk lobsterman Chris Welch, 28, never had health insurance until Obamacare was enacted. Now he’s among the thousands of people working in Maine’s fishing industries who could lose health benefits if the ACA is repealed without a comprehensive replacement. Jill Brady/Staff Photographer
Chris Welch, a Kennebunk lobsterman, had never purchased health insurance before the Affordable Care Act started offering individual marketplace insurance in 2013. He’s maintained the benefits ever since, even though as a healthy 28-year-old he doesn’t need to use his insurance that often.
Welch is among the thousands of people who work in Maine’s iconic lobster and fishing industries who could have their ACA insurance taken away if the law is repealed without a comprehensive replacement. Congress has set the wheels in motion to repeal the ACA, and lawmakers are debating whether to immediately replace it, and if so, with what plan. Lawmakers have yet to coalesce around a replacement plan, and the incoming Trump administration has not yet revealed a proposal.
There’s no exact count of how many fishermen or lobstermen have purchased ACA insurance, but U.S. Census data indicate robust enrollment in the industry.
Coastal communities with large numbers of self-employed workers have some of the highest percentages of residents signed up for ACA insurance, according to a ZIP code analysis of 2016 enrollment data from the federal government and workforce data from the U.S. Census.
For instance, on North Haven and Vinalhaven islands, both on the midcoast and known for the lobster industry, 22 percent and 21 percent of the people on each island, respectively, have ACA insurance, among the highest rates in the state. Forty-seven percent of Vinalhaven households include a person who is self-employed, while on North Haven it’s 38 percent, among the highest levels of self-employment in Maine.
Other coastal fishing communities with high ACA enrollment levels include Pemaquid, Round Pond, Beals and Brooklin.
The ACA’s individual marketplace was designed to be a place where those who can’t obtain insurance through an employer – such as a self-employed fisherman or a part-time worker – can purchase subsidized insurance. About 80,000 Mainers have health benefits through the ACA.
“If a repeal happens, it’s going to be a big hurt for these communities,” said Emily Brostek, executive director of Consumers for Affordable Health Care, an Augusta-based health advocacy nonprofit. “These are industries that we care about in Maine, but that don’t traditionally offer medical benefits.”
Alisha Keezer, center, a health insurance adviser, helps Cindy Welch sign up for coverage, joined by her lobsterman son, Chris Welch, at Maine Lobstermen’s Association headquarters. Jill Brady/Staff Photographer
Congressional Republicans and President-elect Donald Trump have vowed to repeal President Obama’s signature health care legislation, which could leave more than 20 million Americans without insurance, depending on what a replacement bill looks like.
Welch, who has operated his own lobster boat since he was 16, has had health insurance since 2014, seeing it as a way to protect his health and finances.
“I didn’t have insurance prior to the ACA, and I wouldn’t have got it if it weren’t for the ACA,” said Welch, who estimates he pays about $220 a month for the benefits.
Welch saw the value in health benefits when his aunt – who did not have health insurance at the time – was in a car accident and struggled financially with “huge” medical bills from the care she received to recover from her injuries.
VITAL BENEFITS, BUT FIXES NEEDED
Congresswoman Chellie Pingree, a Democrat who represents Maine’s 1st District, lives on North Haven and knows many in the lobster and fishing industries who have acquired ACA insurance.
“They are a group that’s really benefited from the ACA,” Pingree said. “I’m really frightened for them.”
Pingree said that before the ACA existed, insurance companies could bar people from purchasing insurance who had pre-existing conditions, or raise their premiums to sky-high levels because they worked in an industry – such as fishing – where there are many on-the-job injuries.
“If you’ve worked in the fishing industry for any length of time, it’s hard not to have a pre-existing condition,” she said. “They could have a bad back, rotator cuff, knee problems or any number of chronic conditions.”
Pingree said she’s “nervous” that Republicans will repeal the ACA and only agree to a replacement plan that offers far fewer services compared with what’s required under the current law. Under the ACA, preventive services such as screenings and annual checkups must be free, and the plans must include benefits such as mental health and substance abuse services.
Pingree, however, said she’s encouraged that Maine Sen. Susan Collins, a moderate Republican, is proposing a plan with Sen. Bill Cassidy, R-Louisiana, that is being touted as a bipartisan compromise. One of the tenets of the proposal is that states can choose to maintain the Affordable Care Act if officials believe the law is working well in their state. Details of the bill are expected to become available next week.
“It’s great that Susan Collins is one of the members actively looking for a solution,” Pingree said.
Alisha Keezer, a health insurance navigator for the Maine Lobstermen’s Association, said “having health insurance has meant so much” for many lobstermen, many of whom are in their 50s and need insurance. In addition to the health benefits, it protects their finances, she said.
“If you fall down and get hurt and don’t have insurance, you could lose your boat,” Keezer said.
She said the law does need fixing, and that some lobstermen are getting hit with high premium increases.
The law protects those who qualify for subsidies from premium increases, which is about 85 percent of those buying marketplace insurance.
But those just over the income limit for subsidies – 400 percent of the federal poverty level or $97,000 for a family of four – are bearing the full brunt of the increases. Keezer said some lobstermen who had a good year financially are upset to see such high premium increases because they no longer qualify for subsidies.
Keezer said a typical premium for a lobsterman who qualifies for subsidies is about $250 per month. But for those who earn more than the limit and don’t receive subsidies, premiums are usually about $400 to $500 per month.
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Still, Keezer said it’s better than nothing or the catastrophic insurance that was available before the ACA, when lobstermen had high premiums and paid for most medical services out-of-pocket.
“You can actually use this insurance, and there are so many services that are covered,” Keezer said.
Patrice McCarron, executive director of the Maine Lobstermen’s Association, said the organization is holding back on taking a position until there are more details about what would replace the ACA.
“The MLA does not want to see the ACA repealed, but we would like to see some reforms implemented,” McCarron said. “While the ACA has helped lots of lobstermen and their families, we have found that many could not afford to purchase coverage this year. It’s tough when you are self-employed because there are no other options.”
 

Brutal Austerity Is Coming to a Statehouse Near You

Most eyes are on federal politics, but big cuts could be coming to your state.
By Michael Arria /  AlterNet


The incoming Trump administration understandably frightens liberals, but right-wing successes at a state level would have moved forward regardless of who won the election. Only four states currently have a Democratic governor and a Democratic state legislature. What's more, bipartisan support for policies of austerity and neoliberalism have led to vast social spending cuts across the country regardless of political affiliation.
Here are five proposed budget cuts that should have progressives up in arms.
1. Maine's Tea Party Governor Wants to Kick Thousand of People Off Medicaid and Block a Tax Increase for the State's Richest Citizens: Maine's Question 2 vote was hailed by many as one of election day's only progressive victories. Maine voters approved a ballot initiative that would tax Maine residents making more than $200,000 an extra 3% a year and put the money toward the state's education budget.
The question was vigorously opposed by Paul LePage, Maine's infamous right-wing governor, and his new budget looks to retroactively defeat the measure despite the fact it was approved by voters. LePage’s new budget would delay the implementation of Question 2, while working in reductions to the state's income tax. In the end, Maine's education funding would be financed by the state's highest and lowest earners, a complete change from what citizens actually voted for.
LePage's budget would also cut eligibility for MaineCare, the state's Medicaid program for parents who are able to work and who currently earn over 40 percent than the federal poverty level. This would knock 19,000 people off of a Medicaid, in addition to the 40,000 LePage has already removed from the program.
2. Texas Is Cutting Disabled Kids' Therapy Service: Texas' GOP-controlled state legislature recently cut its Medicaid program by $350 million. Critics warn that the cuts could be particularly devastating for disabled children in the state, as it drastically reduces the amount of money paid toward therapists who assist vulnerable kids. 
A group of citizens attempted to block the cuts through a lawsuit, but the Texas Supreme Court refused to hear the case. Stephanie Rubin, CEO of an advocacy group called Texans Care for Children, sent the Texas Tribune an email about the potential impact of the cuts:
"This is terrible news for Texas kids with disabilities and developmental delays and their families. Kids with autism, speech delays, Down syndrome, and other disabilities and delays rely on these therapies to learn to walk, communicate with their families, get ready for school, and meet other goals."
3. Massachusetts Is Cutting $12 Million in Education: Massachusetts has a reputation as the bluest of blue states, but its governor is Republican businessman Charlie Baker. In December, Baker announced $98 million in budget cuts, with education taking a $12 million hit. Massachusetts' legislature voted to override many of these same cuts last summer, but the Baker administration has unilaterally made them all over again. The budget for a program designed to help immigrant students learn English skills was cut in half.
4. Connecticut Is Cutting $50 Million in School and Municipal Funding: Connecticut has a Democratic governor in Dannel Malloy, but he has been taken to task by local progressives for doubling down on policies of austerity. The latest dustup revolves around $50 million in new cuts, including a $20 million reduction in education spending. Mark Boughton, the mayor of Danbury, tells the Hartford Courant: "This is really horrible timing. Education is one of the most important things we do. I was shocked to see that. I'm going to have to tell our school superintendent he's going to have to cut $250,000 or start laying people off."
The Courant points out that the cuts primarily impact the state's wealthiest areas, but it also quotes Greenwich First Selectman Peter Tesei, who argues that this fact is deceptive. "What's going on is a redistribution of the burden," says Tesei, "The perception of Greenwich is that it's a super-affluent community. And yes, there's affluence, but there's also citizens living at or below state poverty levels."
5. New Mexico Is Cutting Take-Home Pay For State Workers and Teachers: New Mexico Governor Susana Martinez doesn't want to raise taxes so she's finding other ways to cut spending. The state has already cut millions of dollars from its budget over recent months, but Martinez wants to reduce the amount of money the state contributes to the retirement plans of teachers and state workers. 
Democrats retake control of New Mexico's House this year, so many expect a battle to ensue with Dems arguing for an alternative approach of raised taxes. NMPolitics.net quotes Rachel Minnaar, a teaching assistant in Albuquerque, who is deeply concerned about the proposal. “TAs get next to nothing and most have second or even third jobs,” she said, “We can’t afford to lower wages unless we want to put people out on the streets or make them completely reliant on social programs and welfare.”
http://www.alternet.org/economy/beyond-trump-many-state-governments-have-proposed-massive-budget-cuts-will-impact-their-most?akid=15122.109750.MJEyWH&rd=1&src=newsletter1070768&t=16

Maine Hospitals Tell Angus King They Expect ‘Devastating Effects’ if ACA is Repealed

by Patty Wight - MPBN
Hospitals, especially rural ones, are bracing for a possible repeal of the Affordable Care Act. If the 80,000 Mainers who have insurance through the marketplace lose coverage, hospitals say they will have to absorb more costs from patients who can’t afford care.
At Bridgton Hospital on Friday, administrators and staff met with independent U.S. Sen. Angus King to tell him that a repeal of the federal health care law, without a viable replacement, would be catastrophic for quality care and local economies.
When it comes to rural hospitals, Bridgton is one of the best. It was recently named among the top 20 critical access hospitals across the U.S. by the National Rural Health Association.
But President and CEO David Frum says the hospital will likely have to reduce services if the ACA is repealed without a viable replacement.
“Quite simply put, repealing without an option behind it has devastating effects,” he says, “not only in terms of the care for our community, but for this organization, in terms of its livelihood and its ability to continue to provide services as it has for the last 100 years.”
Frum says about 8 percent of the hospital’s patients have insurance through the Affordable Care Act’s marketplace. If those patients lose that insurance, the hospital won’t be able to absorb the cost of providing free care without reducing or cutting services.
Along with that, he says, will come layoffs for some of the hospital’s 300 employees.
“In our community, Bridgton is the largest employer, and it would have a certain impact on this community as well,” he says.
Statewide, hospitals are already operating at a loss or skating on thin ice, says Jeff Austin of the Maine Hospital Association. He says the average operating margin is 1 percent.
“The number of hospitals who are actually in the red, who are below zero, is around 15 to 20. So a third or more for the past several years,” he says.
And if Mainers who receive subsidized marketplace insurance coverage lose it, Austin estimates it will cost hospitals $200 million a year.
“That’s not even in the ballpark of something absorbable,” he says.
Beyond insurance coverage, the Affordable Care Act also extends a drug discount program to rural hospitals. If that goes away, Austin says, that will cost an additional $15 million a year for Maine’s rural hospitals.
“This is a serious, secondary result from repeal that people aren’t really talking about,” he says.
King says he’s concerned about the health and economic implications of repealing the ACA.
“In many rural towns in Maine, the hospital is the single largest employer. You take away 5, 10, 12 percent of their revenues, they’re going to have to shrink. The math just doesn’t work otherwise. And I don’t think the folks in Washington who are so hellbent for repeal aren’t really focusing on what’s going to happen,” he says.
King says he wants to improve the Affordable Care Act rather than replace it. Frum says the ACA isn’t perfect, but its benefits far outweigh the negatives. Keep people covered, he says, but protect patients against high deductibles.
“The average consumer, if they have a high-deductible plan of $5,000 or $10,000. Actually, most folks have available cash of about $2,000. So that ends up being bad debt. When you have a high-deductible plan, you can’t pay the high deductible, that ends up being a burden on the hospital,” he says.
Austin says he wants to see Congress hold off on striking the ACA until new language is ready to go and be adopted. Any uncertainty, even temporary, he says, is harmful.
Late Friday afternoon Congress joined the Senate in taking the fist step to repeal the health care law.



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  1. Linda R. NelsonJune 20, 2019 at 3:20 AM

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