Doctors, Nurses Still Divided on Tom Price
Trump's choice for HHS secretary ignites debate
By Shannon Firth
MedPage Today, Jan. 5, 2016
WASHINGTON -- When President-elect Trump chose Rep. Tom Price (R-Ga.) to be Secretary of Health and Human Services, he poked an already buzzing hornet's nest.
Like the rest of the country, doctors, nurses, and medical students have very divided opinions about the government's role in healthcare. Price's nomination amplifies that division.
The American Medical Association (AMA) voiced immediate support for Price, while the American Medical Students Association (AMSA), Physicians for a National Health Program (PNHP), and National Nurses United (NNU) roundly condemned the nominee. Most other physician and nurse organizations voiced something between concern and resignation.
MedPage Today spoke with the leadership of several physician and nursing groups to understand their concerns and in some cases highlight areas of agreement.
Line In the Sand
On Nov. 29, the AMA backed Price, a member of the association's House of Delegates, in a press statement: "Dr. Price has been a leader in the development of health policies to advance patient choice and market-based solutions as well as reduce excessive regulatory burdens that diminish time devoted to patient care and increase costs," wrote Patrice Harris, MD, a psychiatrist from Atlanta and chair of the AMA Board of Trustees.
That statement infuriated many physicians, including AMA members and nonmembers alike.
For example, the Clinician Action Network, led by Manik Chhabra, MD, Navin Vij, MD, and Jane Zhu, MD, MPP, posted a letter that has since gathered 5,000 signatures from clinicians across the country: "We believe that in issuing this statement of support for Dr. Price, the AMA has reneged on a fundamental pledge that we as physicians have taken -- to protect and advance care for our patients."
The letter criticized Price's record and presumed agenda, such as "the dismantling of Medicaid" and "proposals to reduce funding" for the Children's Health Insurance Program. The group also worried that essential benefits such as opioid use disorder treatment, prenatal care, and access to contraception would be threatened.
Harris explained that the AMA's support should not be viewed as a blanket endorsement for every one of Price's positions. She also recalled the "flurry of objections" that targeted another physician nominee, C. Everett Koop, MD, who served as surgeon general under President Ronald Reagan. Koop is now remembered for his efforts to prevent tobacco use and to promote safe sex for AIDS prevention.
Initially, many physicians were alarmed by Koop's anti-abortion stance, Harris noted. But "Dr. Koop's one-time opponents later cited him as a role model for how the U.S. surgeon general can help the nation face serious health care challenges."
Some Docs Enthusiastic
Others, like Jane Orient, MD, executive director of the Association of American Physicians and Surgeons, who practices in Tucson, Ariz., offered unqualified support for Price's nomination.
Orient said she shares Price's views on reproductive rights and does not believe taxpayers should pay for another person's abortion or birth control, which she said "is quite reasonably priced."
She said she considers Price's critics' concerns for health equity "laughable."
"Instead of trying to have the optimal medical care for everybody and [giving] people the right to choose their own medical care and the right to control of their own money, they want to take these resources out of the hands of people making decisions for themselves and put it in the hands of bureaucrats who have this whole formula to decide what they think is equitable. And they don't think it's equitable for people to spend their own money for their own medical care," Orient said.
"Tom Price has been in favor of allowing people to do this, even if they're on Medicare," she said, referring to Price's support for Medicare privatization.
Red Flags for Others
While PNHP has been critical of the Affordable Care Act, wholesale repeal is not the solution the group has in mind -- that is, unless the ACA were replaced with a single-payer system, Robert Zarr, MD, a pediatrician based here and a past PNHP president, said in a phone interview with MedPage Today.
Instead, Zarr anticipates an acceleration of healthcare privatization: "We'll see it go a lot faster now that we have a House and a Senate and a White House presumably agreeing on this one premise -- which is 'private is good, public is bad.'"
"People who have HIV, who have advanced kidney disease ... people who are living in devastated communities economically ... If access to healthcare is made harder and harder, then they're going to have a shorter lifespan, and they're going to suffer more before they die."
Many nurses also oppose Price's nomination, Deborah Burger, RN, of Santa Rosa, Calif., and co-president of National Nurses United, the largest nurses union in the country, told MedPage Today in a phone interview.
If the ACA is repealed, one of the first steps in that repeal will likely involve a reversal of the tax increases that fund subsidies that help people afford their premiums.
And the revenue for Republicans' proposed block grants for Medicaid won't be there, she continued.
Seeking Common Ground
Other nurses like Pamela Cipriano, PhD, RN, president of the American Nurses Association, also criticized Price's record on diversity and inclusion, as well as his opposition to gay marriage.
As more people declare their gender identity and sexual identity, they have been ostracized and stigmatized by clinicians, said Cipriano: "The healthcare community really needs to step up to make sure that these [LGBTQ] individuals ... are being adequately cared for, and if there's an inherent bias in the leaders of our Health and Human Services [Department], that doesn't bode well for the healthcare community really embracing their needs."
Price will very likely be confirmed, said Cipriano. She hopes that he will listen to nursing groups. In addition to supporting continued federal funding for nursing education, Cipriano hopes Price will set partisanship aside and embrace the "triple aim" -- improving access, quality, and affordability of healthcare -- and continue to advance value-based payment.
The American Congress of Obstetricians and Gynecologists (ACOG), in a letter to Price concerning his opposition to federal funding for abortion and for Planned Parenthood, sounded a warning: "Planned Parenthood clinics provide critical preventative healthcare services to women and men. Abortion is healthcare. ACOG remains committed to protecting each of these critical aspects of women's health."
The group also acknowledged areas where Price's views aligned with its own: Medicare physician payment reform, repeal of the Independent Payment Advisory Board, and medical liability reform.
"Your consistent efforts to find common ground and work together on shared goals are laudable, and your commitment to accomplishments, rather than talking points, is unfortunately all too rare in Washington. We hope that you will use your new role as an opportunity to expand on these collaborative practices," ACOG wrote.
Laura Wooster, MPH, executive vice president of public policy for the American Osteopathic Association, also sounded a cautious tone in a phone call with MedPage Today. "Other than stating our priorities, it seems premature to really start getting vocal," she said, explaining that the group doesn't normally endorse or oppose nominees.
She noted, though, that many of the group's members have echoed one of Price's talking points, the "administrative burden" that government involvement in healthcare can sometimes bring.
Senate Opposition Brewing?
Even though confirmation seems assured, Price still must face grilling and probable opposition from Senate Democrats.
On Thursday, Democrats in Congress called for an ethics probe into Price's financial holdings and investments. Price traded $300,000 worth of shares in health-related companies while in the House, according to The Wall Street Journal.
"There's enough evidence here that cries out for an investigation. Whether the law was actually broken, whether there [were] quid pro quos or inside information is the better way to put it -- we don't know," said Senate Minority Leader Chuck Schumer (D-N.Y.) at a news conference, as reported by CNN.
By Shannon Firth
MedPage Today, Jan. 5, 2016
MedPage Today, Jan. 5, 2016
WASHINGTON -- When President-elect Trump chose Rep. Tom Price (R-Ga.) to be Secretary of Health and Human Services, he poked an already buzzing hornet's nest.
Like the rest of the country, doctors, nurses, and medical students have very divided opinions about the government's role in healthcare. Price's nomination amplifies that division.
The American Medical Association (AMA) voiced immediate support for Price, while the American Medical Students Association (AMSA), Physicians for a National Health Program (PNHP), and National Nurses United (NNU) roundly condemned the nominee. Most other physician and nurse organizations voiced something between concern and resignation.
MedPage Today spoke with the leadership of several physician and nursing groups to understand their concerns and in some cases highlight areas of agreement.
Line In the Sand
Line In the Sand
On Nov. 29, the AMA backed Price, a member of the association's House of Delegates, in a press statement: "Dr. Price has been a leader in the development of health policies to advance patient choice and market-based solutions as well as reduce excessive regulatory burdens that diminish time devoted to patient care and increase costs," wrote Patrice Harris, MD, a psychiatrist from Atlanta and chair of the AMA Board of Trustees.
That statement infuriated many physicians, including AMA members and nonmembers alike.
For example, the Clinician Action Network, led by Manik Chhabra, MD, Navin Vij, MD, and Jane Zhu, MD, MPP, posted a letter that has since gathered 5,000 signatures from clinicians across the country: "We believe that in issuing this statement of support for Dr. Price, the AMA has reneged on a fundamental pledge that we as physicians have taken -- to protect and advance care for our patients."
The letter criticized Price's record and presumed agenda, such as "the dismantling of Medicaid" and "proposals to reduce funding" for the Children's Health Insurance Program. The group also worried that essential benefits such as opioid use disorder treatment, prenatal care, and access to contraception would be threatened.
Harris explained that the AMA's support should not be viewed as a blanket endorsement for every one of Price's positions. She also recalled the "flurry of objections" that targeted another physician nominee, C. Everett Koop, MD, who served as surgeon general under President Ronald Reagan. Koop is now remembered for his efforts to prevent tobacco use and to promote safe sex for AIDS prevention.
Initially, many physicians were alarmed by Koop's anti-abortion stance, Harris noted. But "Dr. Koop's one-time opponents later cited him as a role model for how the U.S. surgeon general can help the nation face serious health care challenges."
Some Docs Enthusiastic
Others, like Jane Orient, MD, executive director of the Association of American Physicians and Surgeons, who practices in Tucson, Ariz., offered unqualified support for Price's nomination.
Orient said she shares Price's views on reproductive rights and does not believe taxpayers should pay for another person's abortion or birth control, which she said "is quite reasonably priced."
She said she considers Price's critics' concerns for health equity "laughable."
"Instead of trying to have the optimal medical care for everybody and [giving] people the right to choose their own medical care and the right to control of their own money, they want to take these resources out of the hands of people making decisions for themselves and put it in the hands of bureaucrats who have this whole formula to decide what they think is equitable. And they don't think it's equitable for people to spend their own money for their own medical care," Orient said.
"Tom Price has been in favor of allowing people to do this, even if they're on Medicare," she said, referring to Price's support for Medicare privatization.
Red Flags for Others
Red Flags for Others
While PNHP has been critical of the Affordable Care Act, wholesale repeal is not the solution the group has in mind -- that is, unless the ACA were replaced with a single-payer system, Robert Zarr, MD, a pediatrician based here and a past PNHP president, said in a phone interview with MedPage Today.
Instead, Zarr anticipates an acceleration of healthcare privatization: "We'll see it go a lot faster now that we have a House and a Senate and a White House presumably agreeing on this one premise -- which is 'private is good, public is bad.'"
"People who have HIV, who have advanced kidney disease ... people who are living in devastated communities economically ... If access to healthcare is made harder and harder, then they're going to have a shorter lifespan, and they're going to suffer more before they die."
Many nurses also oppose Price's nomination, Deborah Burger, RN, of Santa Rosa, Calif., and co-president of National Nurses United, the largest nurses union in the country, told MedPage Today in a phone interview.
If the ACA is repealed, one of the first steps in that repeal will likely involve a reversal of the tax increases that fund subsidies that help people afford their premiums.
And the revenue for Republicans' proposed block grants for Medicaid won't be there, she continued.
Seeking Common Ground
Seeking Common Ground
Other nurses like Pamela Cipriano, PhD, RN, president of the American Nurses Association, also criticized Price's record on diversity and inclusion, as well as his opposition to gay marriage.
As more people declare their gender identity and sexual identity, they have been ostracized and stigmatized by clinicians, said Cipriano: "The healthcare community really needs to step up to make sure that these [LGBTQ] individuals ... are being adequately cared for, and if there's an inherent bias in the leaders of our Health and Human Services [Department], that doesn't bode well for the healthcare community really embracing their needs."
Price will very likely be confirmed, said Cipriano. She hopes that he will listen to nursing groups. In addition to supporting continued federal funding for nursing education, Cipriano hopes Price will set partisanship aside and embrace the "triple aim" -- improving access, quality, and affordability of healthcare -- and continue to advance value-based payment.
The American Congress of Obstetricians and Gynecologists (ACOG), in a letter to Price concerning his opposition to federal funding for abortion and for Planned Parenthood, sounded a warning: "Planned Parenthood clinics provide critical preventative healthcare services to women and men. Abortion is healthcare. ACOG remains committed to protecting each of these critical aspects of women's health."
The group also acknowledged areas where Price's views aligned with its own: Medicare physician payment reform, repeal of the Independent Payment Advisory Board, and medical liability reform.
"Your consistent efforts to find common ground and work together on shared goals are laudable, and your commitment to accomplishments, rather than talking points, is unfortunately all too rare in Washington. We hope that you will use your new role as an opportunity to expand on these collaborative practices," ACOG wrote.
Laura Wooster, MPH, executive vice president of public policy for the American Osteopathic Association, also sounded a cautious tone in a phone call with MedPage Today. "Other than stating our priorities, it seems premature to really start getting vocal," she said, explaining that the group doesn't normally endorse or oppose nominees.
She noted, though, that many of the group's members have echoed one of Price's talking points, the "administrative burden" that government involvement in healthcare can sometimes bring.
Senate Opposition Brewing?
Even though confirmation seems assured, Price still must face grilling and probable opposition from Senate Democrats.
On Thursday, Democrats in Congress called for an ethics probe into Price's financial holdings and investments. Price traded $300,000 worth of shares in health-related companies while in the House, according to The Wall Street Journal.
"There's enough evidence here that cries out for an investigation. Whether the law was actually broken, whether there [were] quid pro quos or inside information is the better way to put it -- we don't know," said Senate Minority Leader Chuck Schumer (D-N.Y.) at a news conference, as reported by CNN.
Dismantling Obamacare would be a nightmare for Maine families
by Emily Brostek - Consumers For Affordable Health Care
Here in Maine, we value independence and hard work. We want to make our own way, get a fair shot and provide for our families. So it’s easy to agree that everyone should have the opportunity to purchase affordable health insurance. Insurance gives us the peace of mind that one serious illness or event won’t lead to bankruptcy. It offers stability in an uncertain world.
Alyce and Andrew, a young couple who are self-employed and trying to build their lives here in Maine, had never been able to afford the expensive premiums for insurance to cover themselves — until the Affordable Care Act came along. With the help of the health care law’s tax credits, they were able to get coverage they could actually afford and continue to work for themselves, rather than giving up their business for a job that offered insurance benefits.
In 2015, Alyce gave birth to their son, Sam, and their family enjoyed the certainty of knowing that all insurance plans cover maternity services and childbirth, thanks to the Affordable Care Act. They were young and healthy. Every test and doctor’s visit before his birth gave Sam a clean bill of health. Nevertheless, this Maine family spent the first part of Sam’s life in emergency care at the hospital because of previously undetected congenital birth defects.
Without the Affordable Care Act, the best-case scenario would have left Alyce and Andrew drowning in more than $100,000 in hospital bills and medical debt as they cared for their first child. Instead of peace of mind from insurance coverage, they would have faced another long nightmare for their family.
President-elect Donald Trump, House Speaker Paul Ryan and many members of Congress appear to be rushing headlong into dismantling the Affordable Care Act. If they go forward with their plan to repeal the health care law with no plan to replace it, there will be real and life-threatening consequences for Mainers from Fort Kent to Kittery and everywhere in between.
Like almost all businesses, insurance companies and the health care industry dislike volatility and uncertainty. Repealing the exchanges without knowing what might replace them will kick the individual health insurance market into a tailspin. Insurers will spike premiums or flee the individual market entirely, leaving people such as Alyce, Andrew and Sam with no options. People who have been able to buy private health plans through the health care exchanges could see their insurance and financial security ripped away or face skyrocketing premiums that force them to choose between staying healthy or paying their oil bill. The ripple effect will be felt across our entire economy.
The Affordable Care Act’s benefits go far beyond the health exchanges that help people without insurance get tax credits and subsidies to lower the cost of their plans. The Affordable Care Act gives people control over their health decisions. It ensures that nobody can be denied coverage because of pre-existing conditions. It makes it illegal for insurers to raise premiums if someone has a break in coverage. It lets kids stay on their parents’ plan until they turn 26. Whether you get your insurance from your job, the health care exchanges, MaineCare or Medicare, or directly from an insurer, the odds are good that you’ve felt the benefits of the Affordable Care Act.
Let’s not forget that this landmark legislation was a major overhaul of a broken health care system. Could the law be improved? Certainly. Too many in our state still struggle with unaffordable premiums and rising health care costs. But the consequence of repealing the Affordable Care Act will be a massive step backward, one that endangers the health and lives and financial security of millions of people across America, including tens of thousands here in Maine.
Emily Brostek is the executive director of Consumers for Affordable Health Care, a consumer health advocacy organization based in Augusta.
Here in Maine, we value independence and hard work. We want to make our own way, get a fair shot and provide for our families. So it’s easy to agree that everyone should have the opportunity to purchase affordable health insurance. Insurance gives us the peace of mind that one serious illness or event won’t lead to bankruptcy. It offers stability in an uncertain world.
Alyce and Andrew, a young couple who are self-employed and trying to build their lives here in Maine, had never been able to afford the expensive premiums for insurance to cover themselves — until the Affordable Care Act came along. With the help of the health care law’s tax credits, they were able to get coverage they could actually afford and continue to work for themselves, rather than giving up their business for a job that offered insurance benefits.
In 2015, Alyce gave birth to their son, Sam, and their family enjoyed the certainty of knowing that all insurance plans cover maternity services and childbirth, thanks to the Affordable Care Act. They were young and healthy. Every test and doctor’s visit before his birth gave Sam a clean bill of health. Nevertheless, this Maine family spent the first part of Sam’s life in emergency care at the hospital because of previously undetected congenital birth defects.
Without the Affordable Care Act, the best-case scenario would have left Alyce and Andrew drowning in more than $100,000 in hospital bills and medical debt as they cared for their first child. Instead of peace of mind from insurance coverage, they would have faced another long nightmare for their family.
President-elect Donald Trump, House Speaker Paul Ryan and many members of Congress appear to be rushing headlong into dismantling the Affordable Care Act. If they go forward with their plan to repeal the health care law with no plan to replace it, there will be real and life-threatening consequences for Mainers from Fort Kent to Kittery and everywhere in between.
Like almost all businesses, insurance companies and the health care industry dislike volatility and uncertainty. Repealing the exchanges without knowing what might replace them will kick the individual health insurance market into a tailspin. Insurers will spike premiums or flee the individual market entirely, leaving people such as Alyce, Andrew and Sam with no options. People who have been able to buy private health plans through the health care exchanges could see their insurance and financial security ripped away or face skyrocketing premiums that force them to choose between staying healthy or paying their oil bill. The ripple effect will be felt across our entire economy.
The Affordable Care Act’s benefits go far beyond the health exchanges that help people without insurance get tax credits and subsidies to lower the cost of their plans. The Affordable Care Act gives people control over their health decisions. It ensures that nobody can be denied coverage because of pre-existing conditions. It makes it illegal for insurers to raise premiums if someone has a break in coverage. It lets kids stay on their parents’ plan until they turn 26. Whether you get your insurance from your job, the health care exchanges, MaineCare or Medicare, or directly from an insurer, the odds are good that you’ve felt the benefits of the Affordable Care Act.
Let’s not forget that this landmark legislation was a major overhaul of a broken health care system. Could the law be improved? Certainly. Too many in our state still struggle with unaffordable premiums and rising health care costs. But the consequence of repealing the Affordable Care Act will be a massive step backward, one that endangers the health and lives and financial security of millions of people across America, including tens of thousands here in Maine.
Emily Brostek is the executive director of Consumers for Affordable Health Care, a consumer health advocacy organization based in Augusta.
The Republican Study Committee’s ACA Replacement Proposal (Updated)
One of the most popular provisions of the ACA has been its requirement that insurers cover people with preexisting conditions, which is supported by almost 70 percent of Americans. Even President-elect Trump has expressed support for this requirement. A particularly challenging problem for ACA replacement plans, therefore, is what form of protection, if any, should be offered to people with preexisting conditions.
On January 5, 2017, the HHS Assistant Secretary for Planning and Evaluation released an issue brief analyzing how many Americans actually have preexisting conditions and how these Americans have been affected by the ACA. The report employs both a narrow definition of preexisting conditions based on the eligibility criteria used by pre-ACA high-risk pools and a broader definition similar to that used by insurers for underwriting purposes prior to the ACA.
The report concludes that 23 percent of Americans (61 million) have preexisting conditions using the narrow definition, 51 percent (133 million) using the broader definition. These numbers are similar to those reported in a recent Kaiser Family Foundation analysis. Common medical conditions included in the broader definition include arthritis, asthma, high cholesterol, hypertension, obesity, alcohol and substance use disorders, depression, and Alzheimer’s. For example, 46 million Americans have hypertension and 45 million some form of behavioral health disorder.
Older people are particularly at risk, with 49 to 84 percent having some type of preexisting condition. Non-Hispanic Whites are the ethnic group most at risk for having a preexisting condition (28 to 56 percent) and people with incomes above 400 percent of the federal poverty level are the most at-risk income group (25 to 56 percent).
Prior to the ACA, federal law offered some protection from preexisting condition exclusions for people with employer coverage as long as they maintained continuous coverage, and some states offered additional protection. The ACA’s ban on preexisting condition exclusions and health status underwriting, however, had a particularly dramatic effect. Between 2010 and the end of 2014, the percentage of Americans with preexisting conditions who were uninsured dropped from 13.8 to 10.7 percent, a drop of 22 percent and 3.6 million individuals. The gain came entirely from increased coverage through Medicaid and through the individual insurance market. Although 2015 and 2016 data are not yet available, there is every reason to believe that coverage for people with preexisting conditions has expanded further.
The report has particular relevance for two of the most common proposals for addressing preexisting condition coverage. One of these is that the continuous coverage requirements of pre-ACA law be expanded to cover all markets. The report notes that about 23 percent of Americans with a preexisting condition (31 million people) experienced at least a one-month gap in coverage in 2014, and nearly one third (44 million) had at least a one-month gap of coverage during the two-year 2013 to 2014 period. About 93 percent of those ever uninsured have had a gap in coverage of at least two months and 87 percent a gap of three or more months. Clearly maintaining continuous coverage for people with preexisting conditions is not easy.
A second proposal is for states to offer high-risk pool coverage to uninsured individuals with preexisting conditions. The large number of people identified by the report shows that covering uninsured individuals with preexisting conditions would be costly, and that states would need substantial assistance from the federal government for high-risk pool coverage to avoid problems of inadequate and unaffordable coverage characteristic of pre-ACA high-risk pool experience.
Original Post
The 115th Congress convened on January 3 and as already reported one of their first orders of business was to begin the process of repealing parts of the Affordable Care Act (ACA) through the budget reconciliation process. A big question left unanswered, however, is what would replace the ACA?
On January 4, 2017, the House Republican Study Committee, a caucus of conservative Republican House members, introduced the American Health Care Reform Act (AHCRA), their replacement proposal.
This is only one of several Republican replacement proposals. It is similar to proposals made by the Study Committee in 2013 and 2015, which have been analyzed elsewhere. I will, therefore, only describe it in brief.
The proposal would:
Repeal the ACA entirely, effective January 1, 2018
This would not just repeal the ACA’s Title I insurance reforms and affordability provisions and the Title II Medicaid expansions and improvements, but would also repeal provisions closing the Medicare doughnut hole and expanding Medicare coverage and titles dealing with health care quality, prevention of chronic disease, fraud and abuse, scholarships and grants to expand the medical workforce, and approval of generic biologics. It would further repeal the ACA’s taxes, including taxes on people making more than $200,000 a year amounting to $346 billion over 10 years.
Replace the ACA’s means-tested premium tax credits and the current tax exclusion for employer-sponsored coverage
The proposal would instead institute an above-the-line standard income and payroll tax deduction for people who have “qualified health plans” of $7,500 for individuals or $20,500 for families. The tax credits would apparently not be adjusted for income, age, geography, or health status and would only be adjusted annually for growth in the consumer price index, not for increases in the cost of health care or coverage. “Qualified health plans” would only need to cover inpatient and outpatient hospital care, emergency care, and physicians’ services and “meaningfully limit individual economic exposure to extraordinary medical expenses.”
As part of equalizing the playing field for those purchasing insurance on their own and through employers, AHCRA would allow employees to exclude from taxation only the value of employer-sponsored coverage up to the above amounts, replacing the current tax exclusions for employer-sponsored coverage.
Expand access to and tax-subsidized contributions and expenditures for health savings accounts
The proposal would allow individuals to use tax-subsidized HSAs to pay for health insurance premiums and up to $1,000 a year in exercise equipment and fitness club membership fees.
The proposal would also:
- Increase the incentives that employers could offer employees for participation or penalties they could impose for non-participation in a wellness program to 50 percent of the value of benefits of employer coverage;
- Authorize (but not appropriate) $25 billion over 10 years for state high-risk pools for people who will be unable to obtain affordable insurance once health status underwriting is reinstated, and cap premiums in the high-risk pools at 200 percent of standard premiums;
- Allow people with preexisting conditions to move from employer to individual market coverage (or vice versa) as long as they maintain continuous coverage, without having to exhaust COBRA coverage. No limit is imposed on the premiums that insurers could charge individuals with preexisting conditions;
- Allow the sale of insurance across state lines subject to certain consumer and fraud and abuse protections;
- Permit small businesses to purchase coverage through association health plans;
- Provide additional health care options for category-1 veterans and Medal of Honor recipients;
- Amend the McCarran-Ferguson Act to provide that federal antitrust laws apply to health insurance;
- Increase transparency for Medicare claims and payment data and provide funding to the states to provide information on insurance plans;
- Block the federal government from denying coverage for health services based on lack of effectiveness;
- Make it harder for patients claiming to be injured by medical negligence to sue their doctors; and,
- Provide that health plans do not have to cover abortion services and that federal programs do not cover abortions except in cases of rape, incest, or when the life of the mother is jeopardized.
Most of these proposals have been discussed here already. I add only a comment as to one feature of the AHCRA not found in most other proposals — the use of deduction rather than a tax credit or exclusion to help individuals purchase health care.
Tax Deductions Versus Tax Credits
The ACA offers lower- and moderate-income Americans means-tested tax credits which are also effectively adjusted for variation in costs based on age or geography, since the credits are keyed to the actual cost of the second-lowest cost-silver plan that will cover a particular individual or family. The ACA also offers reductions in cost-sharing such as deductibles and coinsurance to lower-income individuals and families.
The current employer-sponsored coverage tax exclusion is not means tested; indeed, it is worth more in dollar value to higher-income enrollees because it reduces their taxes to a greater extent. But the exclusion is tied to the actual cost of coverage, and thus its value varies based the age and geographic location of covered employees. Moreover, non-discrimination requirements tend to ensure relatively generous coverage for lower-income employees, although it is not always affordable.
The value of the proposed deduction in the AHCRA would be inversely related to income, as all deductions are. A millionaire in the 39.6 percent tax bracket would receive almost $3,000 in income tax reductions for purchasing individual coverage and over $8,000 for purchasing family coverage. An individual in the 15 percent bracket would receive a maximum of $1,125 in tax reduction for an individual or $3,075 for a family. An individual without earned income would get no help at all. All individuals who had income subject to payroll tax would additionally receive a reduction in their payroll taxes (The payroll tax reductions would presumably reduce the funding of the Medicare and Social Security trust funds.)
Most individuals with low incomes would not be able to afford coverage with this level of assistance. Moreover, low-income individuals would not have the capital to pay premiums for health insurance until they realized the deduction at tax filing time. Finally, they would get no help with cost sharing unless they had enough money to save through an HSA.
One analysis of a similar proposal by President-elect Trump found that it would increase the number of the uninsured by 15.6 million, mainly through loss of coverage by lower-income individuals, although it would increase the number of higher-income insureds by 2.7 million. Of course, lower-income individuals with health problems would be doubly disadvantaged by the AHCRA as they would have to pay higher premiums for high-risk pool coverage as well. In sum, the AHCRA would flip the redistributional effects of the ACA, moving resources away from the sick and poor to the healthy and wealthy.
Potential Effects On Employer Coverage
It could also undermine employer coverage, which covers the majority of Americans. The caps imposed on tax deductions in the AHCRA are well below those currently imposed by the ACA’s yet-to-be-implemented high-cost health plan (Cadillac plan) tax. Employers with older or less healthy employees, or who are located in high-cost areas of the country, may well conclude that the deduction is not generous enough to make health coverage feasible and drop coverage. This would leave employees to the individual market, where they in turn would not be able to afford coverage.
On the other hand, because the AHCRA tax exclusion limits are lower than the Cadillac tax thresholds, they could prove more effective at reducing the growth in premium costs.
Other Republican replacement plans offer tax credits rather than deductions, which in some proposals are adjusted for age and even for income. Tax credits have very different distributional consequences than deductions. It will be up to Congress and the Trump administration which course to pursue.
New Marketplace Enrollment Snapshot
In other news, HHS released an enrollment snapshot on January 4 covering the first eight weeks of the 2017 open enrollment period. As of December 31, 2016, 8,762,355 consumers had selected plans through Healthcare.gov, including 2,205,244 new consumers and 6,557,111 renewing consumers. Florida and Texas continued to have the highest enrollments, with over 1.6 and 1.1 million enrollees respectively. The totals now includes 2.2 million individuals who were automatically reenrolled in coverage as well as 4.4 million active re-enrollees, but do not yet include state marketplace enrollees. Enrollments are still running ahead of last year. Americans have not given up on the ACA, even though their leaders apparently have.
Robert Reich: The 3 Big Reasons Republicans Can’t Replace Obamacare
by Robert Reich - Alternet
Republicans are getting skittish on repealing Obamacare. As they should.
by Aaron Blake - Washington Post
President Obama and Vice President-elect Mike Pence each met with lawmakers from their parties, Jan. 4, to discuss plans for the Affordable Care Act. (Video: Sarah Parnass/Photo: Matt McClain/The Washington Post)
Politics can sometimes resemble a smoldering pile of broken promises. And the GOP's long-standing pledge to repeal Obamacare on Day One of a GOP administration is suddenly looking like it might be thrown on the heap.
Over the past 24 hours, several GOP senators made big news by urging their party to actually hold off on repealing Obamacare until a replacement can be crafted.
“I think when we repeal Obamacare we need to have the solution in place moving forward,” Sen. Tom Cotton (R-Ark.) said on Chuck Todd's MSNBC show. “Again, the solution may be implemented in a deliberate fashion, but I don't think we can repeal Obamacare and say we'll get the answer two years from now.”
Joining Cotton in this sentiment are Sens. Susan Collins (R-Maine), Rand Paul (R-Ky.) and Bob Corker (R-Tenn.) — the latter who joined the crowd Friday morning by saying, “Repeal and replacement should take place simultaneously.”
What's significant about this group is that, if they want, they can thwart the immediate repeal of Obamacare. Republicans have 52 senators, so losing three or four of them would do the trick. It's not clear how most of these members will actually vote — only Paul has gone there and said he'd vote accordingly — but there appears to be a growing possibility that Obamacare won't be repealed right away.
Which would seem to be the prudent course politically, given the minefield that replacing the health-care law represents. Republicans have floated the idea of a three- or even four-year delay to give themselves time to craft a replacement. Of course, Congress is great at giving itself future deadlines and then failing to meet them (see: sequestration). Rep. Kevin Cramer (R-N.D.) put it well this week. “I’ve stopped underestimating our ability to screw up good things,” he told Bloomberg.
The best way to foreclose the possibility of repealing Obamacare and failing to install a good replacement, then, would seem to be to hold off on repealing it until you've got that replacement. And a new poll from the Kaiser Family Foundation shows that's what the vast majority of Americans would prefer.
The poll, as Wonkblog's Carolyn Y. Johnson writes, shows that 49 percent of Americans support repealing Obamacare, but only 20 percent want instant repeal while working out the details of a replacement later. By contrast, 28 percent prefer Congress would do as Collins, Cotton, Corker and Paul are urging and wait until there's a replacement. Combine them with the 47 percent who don't want repeal at all, and that's a very healthy popular desire for Congress to leave the law in place, at least for now.
But what's prudent from a policy standpoint isn't always politically practical. The fact is that Republicans have been promising this repeal for years, and backing off that promise risks alienating the base voters they've long stirred with their anti-Obamacare rhetoric.
“On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare,” Trump's website still reads.
There's also the very real possibility that if the GOP can't come up with a replacement, Obamacare would stay on the books indefinitely, continuing to become more and more difficult to repeal. Some conservatives would certainly view this as a delay tactic that could result in never repealing the law. And if Democrats know that saving Obamacare is as easy as preventing the passage of a replacement, that gives them all kinds of incentive to dig in and try to block it at all turns rather than work with Republicans.
By contrast, instantly repealing Obamacare could put some onus on Democrats to play ball, for hopes of crafting something that is acceptable to them and preventing 20 million Americans from losing their coverage. (Of course, President Obama is urging Democrats not to work with Republicans on this.)
Plenty will play out in the days ahead, but this growing group of cautious Republicans is certainly worth keeping an eye on. The party as a whole seems to be confronting the unhappy reality of their campaign rhetoric, and it's not fun.
Top US Cancer Center Cuts 1000 Staff
January 05, 2017
The University of Texas MD Anderson Cancer Center in Houston is cutting its staff by about 1000 people, including 800 to 900 layoffs, and the rest via retirement and other forms of attrition, center officials announced today.
No doctors or clinical-care nurses are losing their jobs. "In no way are we compromising the high quality and safety of patient care," said Thomas Buchholz, MD, the center's physician-in-chief, at a televised press conference today.
The layoffs will be finished by next week, the officials said.
MD Anderson, rated as America's top cancer hospital by US News & World Report this year, has been suffering from revenue shortfalls. In September and October, the first 2 months of fiscal 2017, the center had a combined $100 million in losses, as income did not cover operating expenses.
Ron DePinho, MD, president of MD Anderson, said the announcement of layoffs was a "sobering day" for the institution. Dr DePinho, who makes more than $2 million a year in salary, received a $208,000 performance bonus this week. But the Houston Chronicle reports that he has donated the bonus back to the center.
According to the Cancer Letter , an online trade publication, MD Anderson's top management recently told faculty via email that, "like other major health care institutions locally and nationwide, we are facing decreasing clinical reimbursement from government and insurance companies, a shrinking pool of potential patients as insurance providers restrict coverage, and record rates of automatic denials by insurance companies contributing to bad debt."
But the Cancer Letter report observes that other major cancer centers, such as Memorial Sloan Kettering Cancer Center in New York City and Fred Hutchinson Cancer Research Center in Seattle, Washington, are not reporting operating losses.
Len Zwelling, MD, a medical oncologist and former vice president for research administration at MD Anderson, said on his online blog that he was not impressed with today's press conference.
"It has been known for quite some time that this imbalance between revenues and expenses was on-going [at MD Anderson]," he writes.
"The leadership of MD Anderson got before the microphones and from what I could see explained nothing as to why this happened and why now," added Dr Zwelling, who has criticized MD Anderson management in the past.
At the press conference, Dr DePinho said that the implementation of an electronic health record system in 2016 was a key factor in the losses, according to the Houston Chronicle .
The EHR system, known as Epic, has forced physicians and other staff to spend significant time learning the system and less time with patients, he said.
How Caring for Dogs and Cats Explains Human Health Spending
by Austin Frat - NYT
In almost every year since the 1960s, health care spending has grown at least as fast as the overall economy, and often much faster. Health economists have long debated why.
Strange as it may sound, how we care for our pets offers some answers.
The pet care markets look a little like the market for human health care. Health spending by American households has grown 50 percent between 1996 and 2012. Pet care spending has grown by a similar amount, 60 percent, though from a much smaller base. (Americans spent more than $15 billion on pet health care in 2015, but $3.2 trillion on human health care.)
An estimated 68 percent of households have pets; those families with higher incomes spend more, which is also true of human care. And they spend more toward the end of humans’ and pets’ lives alike.
The supply of both physicians and of veterinarians has grown at a more rapid rate than overall employment. Since 1996, the number of physicians has grown by about 40 percent. The number of veterinarians is up 100 percent.
“These commonalities made us think that something else may be behind the rapid growth in human health care spending,” said Amy Finkelstein, an M.I.T. economist and one of the authors of a recent study on pet care.
She, along with her co-authors Liran Einav and Atul Gupta of Stanford, tried to find what that something else could be in their study on pet health care presented at the American Economic Association annual meeting in Chicago. “We often blame generous insurance and significant public sector involvement, but those are absent from pet care,” Ms. Finkelstein said.
Some health economists say generous health insurance and significant government intervention in the health care market promote unnecessary spending. They note the United States spends more of its G.D.P. on health care than other similar advanced economies yet does not exhibit broadly better health outcomes, a sign of inefficiency. But other economists argue that health care is so valuable that we might reasonably spend even more on it than we do today.
Which camp is right?
The three economists pointed out that, in contrast with the market for human health care, there is much less government involvement in pet care.
Pet health insurance is also much less common. More than 90 percent of Americans now have health insurance, an industry that has been with us since before World War II. But only 1 percent of dogs and cats are insured for pet care, a relatively new product. (According to the North American Pet Health Insurance Association, the first pet health insurance policy in the United States was written for Lassie, the TV dog star, in 1982.)
So the economists’ focus turned to the commonalities. Human and pet health care are both provided by experts — doctors and veterinarians — who’ve undergone lengthy and expensive training and occupational licensing. That expertise commands high salaries. It also gives them the authority to recommend treatments and tests, the need for which most consumers cannot independently judge.
You trust your vet as you would trust your doctor to do what is best, especially when an emotional decision is being made. Both human and pet health care are accompanied by strong emotions, making it hard to rationally weigh the value of options. Moreover, the need for care, whether it is for a pet or a human, is difficult to predict and often urgent, again threatening our ability and willingness to shop for the best deals.
Technology plays a role, too. Complex procedures, new pharmaceuticals and high-tech imaging, which drive human health care spending, are no longer uncommon in pet care, increasing those costs.
Though routine veterinary visits might cost pet owners only a couple of hundred dollars per year, a serious condition can be very expensive. A dog’s kidney transplantcan run $25,000, and a cat’s cancer treatment can cost $10,000 or more. Even if such high costs are extremely rare, it is not as uncommon for a pet owner to encounter a $2,000 to $4,000 bill at some point, particularly near the end of a pet’s life.
“It makes you think that the emotional nature of the treatment decision may be important in explaining high and sometimes heroic end-of-life health care spending,” Ms. Finkelstein said, “whether on your dog or on your mother.”
If emotions are in fact driving the higher spending, will it hasten the trend toward more pet insurance? The pet health insurance industry is growing, with total premium volume up about 17 percent in each of the last two years. It’s one of the fastest-growing employee benefits; Delta Air Lines, Hewlett-Packard, Microsoft, U.P.S. and Xerox now offer it.
The most common policies cover care for injuries due to accidents, as well as care for illnesses like arthritis or cancer, with monthly premiums starting around $22 for dogs and $16 for cats. But premiums can be higher depending on breed, age and where you live. Some other policies also cover preventive care, like vaccinations.
In general, plans won’t cover pre-existing conditions, pregnancy and birth-related costs, or animals less than a couple of months old. Typically owners pay 20 percent of treatment costs, with plans picking up 80 percent, though some insurers offer other cost-sharing options.
Is pet insurance a good deal? Consumer Reports explored its value last year and concluded it’s typically not worth the price. Only if your pet has very high care costswill insurance pay out more than you would pay in premiums. According to analysis by Ms. Finkelstein and her Stanford colleagues, nearly two-thirds of all pet care costs is spent by just 20 percent of households with pets. This guarantees that most policyholders won’t get back what they pay in. This is true of human health insurance, too, and for the same reason.
But the point of health insurance — whether for humans or their pets — is to protect against the risk of catastrophically high costs, not to make money.
Consumer Reports suggests an alternative when it comes to pet care: self-insuring. Many pet owners could probably build up several thousand dollars in an emergency fund that could be used to help cushion the blow of unusually high pet care costs. Saving enough to weather a serious, human medical condition that could cost tens of thousands of dollars year after year or more is not something most Americans could do.
Though you might reasonably avoid pet care insurance, you really can’t do that with human health insurance. Human and pet health care may have some commonalities, but this isn’t one of them.
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