by Robert Pear and Thomas Kaplan - NYT - February 10, 2017
Mr. Price will be the first physician to lead the Department of Health and Human Services since Dr. Louis W. Sullivan stepped down at the end of the first Bush administration in January 1993.
As secretary, Mr. Price will be responsible for a department with an annual budget of more than $1 trillion. Agencies within the department regulate food and drugs, sponsor much of the nation’s biomedical research and combat public health threats, including the Zika virus, opioid drug abuse and bioterrorism.
Some of the Democrats’ animus against Mr. Price stems from experience. Working with him over the last 12 years, they say, they have found him to be an effective advocate for conservative policies that they abhor.
“Buying and selling health care stocks as a member of Congress while you’re voting and helping those companies, that’s bad enough,” said Senator Sherrod Brown, Democrat of Ohio. “But what he wants to do to maybe the greatest program in American history, Medicare, is much, much worse.”
Senator John Cornyn of Texas, the No. 2 Senate Republican, said that Democrats were dragging their feet on confirming Mr. Trump’s nominees because of a desire to “block, stall and obstruct this president at every turn.”
“You could say his chief qualification for the job of replacing Obamacare is he had the good sense to oppose it in the first place,” said Senator Tom Cotton, Republican of Arkansas.
Democrats see it differently. “This is the first vote in the dismantling of the Affordable Care Act,” said Senator Maria Cantwell of Washington. Senator Jeanne Shaheen, Democrat of New Hampshire, said Mr. Price had been “a rabid supporter of defunding Planned Parenthood” and “seems to have no higher priority than to terminate health coverage for millions of people.”
As chairman of the House Budget Committee, Mr. Price supported proposals to shift Medicare away from its open-ended commitment to pay for medical services and toward a fixed government contribution for each beneficiary, which could be used for either private insurance or traditional Medicare. Such proposals could increase costs for some people.
The Senate Democratic leader, Chuck Schumer of New York, said Mr. Price had “dedicated his life to destroying Medicare as we know it.”
To make their case, Democrats highlighted a 2009 op-ed article in which Mr. Price said, “Nothing has had a greater negative effect on the delivery of health care than the federal government’s intrusion into medicine through Medicare.”
However, Mr. Trump, as a presidential candidate, often said he did not intend to cut Medicare.
Mr. Price has endorsed the idea of giving each state a fixed amount of federal money in the form of a block grant to provide health care to low-income people on Medicaid. That would be a radical change. Since its creation in 1965, Medicaid has been an open-ended entitlement. If more people become eligible, states receive more federal money.
Democrats have expressed outrage at many of Mr. Trump’s cabinet picks but have not mustered the votes to stop them.
Senator Orrin G. Hatch, Republican of Utah and chairman of the Finance Committee, said Democrats had smeared Mr. Price with “a vague patchwork of allegations of ethical impropriety.” He discerned a pattern: Democrats, he said, “have appeared to be apoplectic about almost every single nominee we’ve had before us.”
The Senate already had confirmed Mr. Trump’s nominees to lead six other departments — defense, education, homeland security, justice, state and transportation — as well as his picks for director of the Central Intelligence Agency and United Nations ambassador. After confirming Mr. Price, the Senate turned to the nomination of Steven T. Mnuchin, Mr. Trump’s pick to be Treasury secretary.
Senate confirmation is expected early next week for Mr. Mnuchin, a former hedge fund manager and Goldman Sachs executive who was national finance chairman for Mr. Trump’s presidential campaign.
But Mr. Mnuchin, like Mr. Price, has been criticized by Democrats, who boycotted a Finance Committee vote on his nomination. Mr. Mnuchin initially failed to disclose nearly $100 million of his assets to the committee, and he faced scrutiny over the foreclosure practices of the OneWest bank when he was its chairman.
by Robert Pear and Alan Rapport - NYT - February 10, 2017
Tom Price Is Sworn in as Health Secretary Amid Senate Disunity
WASHINGTON — President Trump’s secretary of health and human services, Tom Price, took office on Friday with a promise to fix what he called a “broken health care system” that was “harming Americans and their families.”
Mr. Price was sworn in by Vice President Mike Pence just hours after the Senate, by a party-line vote of 52 to 47, confirmed his nomination in the early hours of Friday morning.
Republicans said that Mr. Price, 62, an orthopedic surgeon, would bring a physician’s insights to managing a federal agency that they said had become addicted to heavy-handed federal regulation and blind to problems spawned by the Affordable Care Act, also known as Obamacare.
“Dr. Price has a thorough understanding of health care policy and the damage that Obamacare has caused,” said Senator Lamar Alexander, Republican of Tennessee, where consumers this year saw rate increases averaging 44 percent to 62 percent in the law’s marketplace.
Mr. Alexander, the chairman of the Senate health committee, said Mr. Price would be “an excellent partner” as Congress tries to devise a replacement for the health care law championed by former President Barack Obama.
Senate Democrats and the chamber’s two independents said they feared the worst, based on Mr. Price’s 12-year record as a Republican member of the House of Representatives from Georgia. They said that Mr. Price had led efforts to repeal the health care law and slow the growth of Medicare and Medicaid by shifting some costs to beneficiaries and trimming payments to some health care providers.
“This is a sad evening,” said Senator Chuck Schumer of New York, the Democratic leader. “People will look back and say that the Republicans’ war on seniors began at 2 a.m. Friday morning when the Senate unfortunately confirmed Representative Price.”
The depth of concern about Mr. Price was illustrated by the comments of Senator Angus King, independent of Maine, who caucuses with Democrats but is not given to hyperbole.
“To put somebody in charge of the Department of Health and Human Services that is inimical to Medicare, Medicaid and the Affordable Care Act — this guy is a wrecking ball,” Mr. King said. “He is not a secretary. He is going into this agency to destroy it. He wants to undercut and diminish and, in some cases, literally destroy some of the major underpinnings of providing health care to people in this country.”
By contrast, at the swearing-in ceremony, the vice president said Mr. Price had emerged as “the most principled expert on health care policy in the House of Representatives, if not the entire Congress.”
Mr. Trump said again on Friday that the Affordable Care Act was “a total and complete disaster.” With the confirmation of Mr. Price, he said, the administration will “get down to the final strokes,” devising a plan that can provide “tremendous health care at a lower price.”
In a farewell address to the House submitted for publication in the Congressional Record, Mr. Price said that, as chairman of the Budget Committee, he had begun an important effort to “fix our nation’s broken health care system” and “get Washington out of the way” of patients and doctors.
One of the first challenges facing the new secretary is to stabilize insurance markets and decide the future of financial assistance provided to insurance companies that say they have lost large amounts of money treating patients under the Affordable Care Act.
A judge on the United States Court of Federal Claims ruled on Thursday that the Obama administration had illegally reneged on a promise to pay subsidies to an Oregon insurer, Moda Health Plan. Many other insurers have filed similar claims. The Obama administration’s failure to pay the claims was cited as a reason for the collapse of many nonprofit insurance cooperatives created under the Affordable Care Act.
In the Moda case, Judge Thomas C. Wheeler ordered the government to pay $214 million that the company was expecting under a program meant to limit insurers’ losses in their first few years operating under the Affordable Care Act. Federal officials’ failure to keep their promise was “hardly worthy of our great government,” the judge wrote.
he Trump administration has not decided whether to appeal the decision.
The next prospective member of Mr. Trump’s cabinet to be voted on will be Steven T. Mnuchin, the Treasury secretary nominee, on Monday evening.
Congressional reaction to Mr. Mnuchin, as to Mr. Price, has been divided along party lines. Republicans have been impressed with the former Goldman Sachs banker’s business acumen, while Democrats have argued forcefully that he is ill-equipped to steer America’s economy.
Those divisions were on stark display during Mr. Mnuchin’s confirmation hearing at the Senate Finance Committee last month, when Democrats questioned him over his business record and ultimately boycotted votes on his nomination.
The most significant concern among Democratic critics of Mr. Mnuchin was that hefailed to disclose nearly $100 million of his assets and that he did not mention his role as a director of an investment fund based in the Cayman Islands, a well-known tax haven.
Mr. Mnuchin has also been accused by Senate Democrats of lying to Congress when he said during his hearing that OneWest Bank did not engage in the foreclosure practice of “robo-signing” when he was its chief executive. Local news reports suggested that the bank did engage in such practices in some states.
Senator Elizabeth Warren, Democrat of Massachusetts, said on Friday that such discrepancies should disqualify Mr. Mnuchin, who she said was unlikely to look out for working-class Americans.
“There’s nothing in Mr. Mnuchin’s record to suggest that he would want to stand up to Wall Street,” Ms. Warren said in a speech on the Senate floor. “Mr. Mnuchin is the ultimate Wall Street insider.”
The Medicare-for-All Imperative: Beyond "Saving" the Affordable Care Act
by RoseAnn DeMoro - Common Dreams - February 10, 2017
Forget the market-based mythologies, the Sanders vs. Cruz debate showed us there is only one true way to secure quality healthcare for every person in society
by RoseAnn DeMoro - Common Dreams - February 9, 2017Sen. Bernie Sanders' CNN health care debate with Sen. Ted CruzTuesdaynight was a case study of the competing visions of social justice and free market fundamentalism.
The ostensible frame of the debate was on the expected repeal of the Affordable Care Act.
But the presence of Sanders on the stage changed the discourse to a broader contrast of compassion or a ruthless you’re on your own society.
Speaking on behalf of the repeal and replace crowd, Cruz hammered away at the central Tea Party theme, “freedom” from “government” mandates (unless it is dictating the rules of women’s health choices, of course). Accompanied by the misleading mythology of the market, that with private insurance you have the “freedom” to choose your doctor, to design the health plan you want, and to pay what you want.
The sad irony of the ACA is that it was a convoluted attempt to straddle both worlds – public mandates, including the expansion of Medicaid, curbs on many insurance abuses, and a number of required benefits for ACA plans, with multiple handouts to entrench and enrich healthcare corporations, from insurers to hospitals to drug companies.
Only one replacement plan would actually fix the real holes in the ACA, and the far greater pre-ACA disaster that saw the U.S. plummet to 37th in world rankings on access, cost, and quality early in this century. That is, of course, as Sanders emphasized in his campaign, and in the debate, an improved Medicare for all.
Here’s a table, comparing and contrasting health care before the ACA, with the ACA fixes and limitations, what the Republicans propose today, and what an actual humane system would look like.
Health Insurers Face 'Massive Confusion' As GOP Wavers On Obamacare
by Jay Hancock - MPBN - February 9, 2017
Premiums for Obamacare plans sold by New Mexico Health Connections could rise as little as 7 percent next year, said Martin Hickey, the insurance company's CEO. Or they might soar as much as 40 percent, he said.
It all depends on what happens in Washington. Such is the vast uncertainty about how the Trump administration and Republican-controlled Congress are approaching their promises to repeal, repair and replace the Affordable Care Act, also known as Obamacare.
There is "pretty massive confusion," said Hickey, whose 45,000-member plan is one of the few nonprofit insurance co-ops created by the ACA to still be in business. "The more uncertainty they create, the higher the rates" will be for 2018, he said.
Insurers have a hard enough time making the normal predictions of who will get sick and how much care will cost. Now the usual fog of rate setting is compounded by the possibility that basic rules of coverage could get overhauled or even disappear before anything takes their place.
Consumers and patients could ultimately pay the price.
The stakes include how much plans sold through the health law's online marketplaces and similar coverage will cost in 2018 — or even whether insurance will be available. Challenges during the recently completed enrollment period, in which some carriers canceled plans and rates rose 20 percent on average, increase the urgency, executives say.
"This is nothing less than a nightmare scenario for the carriers," said Robert Laszewski, a former insurance executive and consultant who works with large plans. "The Republicans don't seem to understand that they've got to stabilize the market."
Coverage for 2017, which has already been finalized, won't change. People covered through job-based insurance or the private Medicare plans for seniors won't be much affected by the uncertainty.
In some states, preliminary 2018 rates are due in less than two months. But prospects for policymaking clarity recede each day that Republicans deliver contradictory messages or fail to agree on a plan, industry officials say.
While some in the party want to go slow on an overhaul and ensure they've thought out a replacement before abolishing the health law, others favor immediate repeal.
If the administration and Congress scrap the ACA's coverage requirement for most people or its subsidies helping people buy care, the market could deteriorate or collapse, say insurance consultants and executives.
A month ago President Trump toldThe New York Times that Obamacare is "a catastrophic event," adding, "we have to get to business" in repealing it. On Feb. 5, he seemed to advocate a more measured approach, telling Fox News that "at least the rudiments" of a replacement would be in place by 2018.
Even that could spook insurance executives contemplating plans for next year in the Obamacare marketplaces, also known as exchanges. They want to know the rudiments of a replacement plan now and details not much later.
"I don't think there's a real clear path to repeal or replace or repair or anything," said Kevin G. Fitzgerald, an insurance lawyer with Foley & Lardner. "Some of our clients will probably move forward on the assumption that something will happen to maintain the exchanges more or less the way they are. Others may pull out early."
Big, national insurers have said it would be hard to commit to the marketplaces next year unless they get a much better idea of what they'll look like.
Several had already scaled back coverage for this year, leaving many parts of the country with only one company selling through the marketplaces. Continued uncertainty could prompt even those holdouts to bail, said Fitzgerald.
"If in those states those carriers decide, 'We've lost enough and we're going to sit this year out,' there are no exchanges," he said. "And that certainly is a possibility."
The Trump administration has proposed regulations, initiated in the last days of the Obama regime, intended to steady the market. Tweaks may include crackdowns on sick consumers who join plans outside open-enrollment periods and allowing insurers to charge slightly more for older members, Huffington Post and Politicohave reported.
Those changes — plus assumptions that Republicans will eventually have a replacement plan helping Obamacare patients maintain coverage — could reassure insurance companies, said Dan Mendelson, CEO of Avalere Health, a consulting firm.
"I'm not saying it would be completely pain-free," he said. "You probably would see some plans get out of the market. But if plans start to believe there's a long-term solution, they're going to want to stay in because getting in and out of the market costs money."
What industry really wants is certainty government will continue helping consumers pay for coverage — one of the most contentious and uncertain aspects.
For two years the Republican-controlled House of Representatives has legally challenged one type of subsidy — federal payments to reduce out-of-pocket costs for lower-middle income consumers. The Obama administration defended the subsidies in court, but insurers worry that Trump officials could drop the defense or that a judge could declare the payments illegal.
Industry interest in the suit "is incredibly high," said Todd Van Tol, a partner with Oliver Wyman, a consultancy with many insurers as clients. The disappearance of those subsidies, he said, "would likely trigger a fairly significant insurer pullback in fairly rapid order."
Even the most publicly minded insurers might cease offering individual Obamacare plans if an uncertain market threatened their financial stability, said Ceci Connolly, CEO of the Alliance of Community Health Plans, a trade group of nonprofit carriers.
"We want to be able to do this, but if there's potential for significant losses it would be irresponsible to maybe do it," she said. "There seems to be a growing recognition of the challenge ahead and also the need for stability, but boy — this clock is coming up fast."
Addiction Treatment Grew Under Health Law. Now What?
by Katherine Q. Selye and Abby Goodnough - NYT - February 10, 2017
MANCHESTER, N.H. — Chad Diaz began using heroin when he was 12. Now 36 and newly covered by Medicaid under the Affordable Care Act, he is on Suboxone, a substitute opioid that eases withdrawal symptoms and cravings, and he is slowly pulling himself together.
“This is the best my life has gone in many, many years,” Mr. Diaz, a big man wearing camouflage, said as he sat in a community health center here.
If Congress and President Trump succeed in dismantling the Affordable Care Act, he will have no insurance to pay for his medication or counseling, and he fears he will slide back to heroin.
“If this gets taken from me, it’s right back to Square 1,” he said. “And that’s not a good place. I’m scary when I’m using. I don’t care who I hurt.”
As the debate over the fate of the health law intensifies, proponents have focused on the lifesaving care it has brought to people with cancer, diabetes and other physical illnesses. But the law has also had a profound, though perhaps less heralded, effect on mental health and addiction treatment, vastly expanding access to those services by designating them as “essential benefits” that must be covered through the A.C.A. marketplaces and expanded Medicaid.
“Of all the illnesses, this is one where we’ve seen very dramatic changes and where we stand to lose the most ground if we lose the A.C.A.,” said Linda Rosenberg, president and chief executive of the National Council for Behavioral Health, adding that treatment programs have begun to be integrated into primary care clinics and health care systems nationwide.
During the presidential campaign, Mr. Trump pledged to rid the country of Obamacare but also to address the opioid epidemic and expand access to drug treatment. Many of the states hardest hit by opioids — including Ohio, West Virginia and Kentucky — voted for Mr. Trump, but some Republican governors have expressed concern about what might happen to people being treated for addiction if their party repeals or scales back the health law.
John Kasich, the Republican governor of Ohio, where the Medicaid expansion has covered 700,000 people, has been particularly outspoken about its success in his state. “Thank God we expanded Medicaid because that Medicaid money is helping to rehab people,” Mr. Kasich said during a bill signing in January.
There is still a long way to go. Waiting lists for treatment persist, and many people still lack access, particularly in the 19 states that have opted not to expand Medicaid. Nationwide, 78 people die every day from opioid overdoses, according to the surgeon general, and the number is still rising. And paradoxically, even as the number of opioid prescriptions in the United States has finally started falling, expanded health coverage has probably made it easier for some people to obtain the drugs.
“There’s no doubt in my mind that improving access to health care during an era in which opioids are being overprescribed would lead to more addiction,” said Dr. Andrew Kolodny, the director of Physicians for Responsible Opioid Prescribing and an addiction specialist.
While 23 million Americans suffer from a substance use disorder, the surgeon general said in a report last year that only one in 10 was receiving treatment as of 2014, the first year people got coverage through the health law. “Now what we’re doing is playing catch-up,” said Michael Botticelli, director of the White House Office of National Drug Control Policy during the last two years of the Obama administration.
In the past, a third of private insurance plans sold on the individual market did not cover addiction treatment, according to federal health officials, and those that did imposed strict limits. Medicaid covered little besides inpatient detox. Now, more health care providers are offering and getting reimbursed for outpatient counseling and medications like Suboxone and Vivitrol, which have been shown to reduce the potential for relapse.
The health law encourages primary care doctors to incorporate addiction treatment into their practices. It provided grants to several hundred community health centers around the country, many in rural areas, to begin or expand mental health and medication-assisted treatment, which combines counseling and drugs like Suboxone.
This is a big improvement from the days when treatment typically was offered through scattered, poorly funded stand-alone clinics that did not necessarily provide evidence-based treatment and had long waiting lists, said Richard Frank, a professor of health economics at Harvard Medical School.
“The whole system is being pushed more toward looking like modern health care,” said Dr. Frank, who worked at the Department of Health and Human Services in the Obama administration.
The 21st Century Cures Act, which Congress passed in December with strong bipartisan support, could build on the progress by providing $1 billion nationwide over the next two years to expand drug treatment around the country, with an emphasis on medication-assisted treatment. The federal government will soon begin distributing the money to states, which will allot it to treatment programs, particularly in high-need areas. But if people lose their insurance, Dr. Frank said, they may well lose access to these new options.
In Kentucky about 11,000 people were receiving addiction treatment through Medicaid by mid-2016, up sharply from 1,500 people in early 2014, according to the Foundation for a Healthy Kentucky, a health policy research group. In West Virginia, Ms. Rosenberg of the National Council for Behavioral Health said, her group’s member organizations — nonprofit providers of mental health and addiction treatment — are now treating 30,000 people a year, up from 9,000 before the health law.
Here in New Hampshire — which Mr. Trump won resoundingly in the Republican primary and lost by a hair in November — more than 10,000 people have received addiction treatment after gaining coverage through the Medicaid expansion, said Michele Merritt, senior vice president and policy director at New Futures, a nonprofit advocacy group. Small treatment centers throughout the state that had never been able to bill insurance before have started doing so, she said, allowing them to hire more counselors and accept more patients.
“We’re just beginning to implement these exchanges in a way that people know about them,” said Senator Jeanne Shaheen, a New Hampshire Democrat, referring to the exchanges created under the health law. Getting rid of them, she said, “makes no sense.”
Others note that even with more treatment options, the number of deaths in places like New Hampshire continues to rise. The state ranks first nationwide in per capita overdose deaths from fentanyl, a powerful synthetic opioid that is now killing more people here than heroin. Republicans here have also criticized state health officials for not tracking how many Medicaid enrollees who receive addiction treatment end up relapsing.
In Pennsylvania, where 124,000 people have received addiction treatment under the Medicaid expansion, health officials were disturbed by early data showing that two-thirds of those who went to detox got no other treatment services. So Gov. Tom Wolf, a Democrat, is designating 45 “Centers of Excellence” — primary care clinics where people can also get addiction and mental health treatment, with frequent follow-up and a team of providers closely tracking their progress.
The new model is in use here at the Manchester Community Health Center, where Mr. Diaz receives treatment. The center had offered minimal services for substance abuse before the health law.
Now, three years later, it has undergone substantial changes. More than 40 percent of its patients had been uninsured; today, only 20 percent are. The center used to have one building, a staff of 55 and 7,500 patients; today, it has clinics in four locations, a staff of 230 and more than 16,000 patients, about 800 of whom have substance abuse issues.
It has two providers who are licensed to prescribe medication-assisted treatment, which it is expanding to 60 patients, including pregnant women, the center’s priority. “The number may sound low as far as how many we’re treating,” said Julie Hazell-Felch, director of behavioral health at the center. “But it’s a multitude of services they’re receiving and they’re in here weekly,” she said, seeing nurses, a behavioral health clinician and a medical provider, and giving urine samples and receiving their medications.
If the Affordable Care Act is repealed, the center stands to lose more than $6 million in funding, mostly Medicaid revenue, about a third of its $18 million annual budget.
“We would not be able to keep all four sites open,” said Kris McCracken, president and chief executive of the health center.
She added: “There are only two avenues to go: You either prevent and treat, or you street. That’s what will happen. People will end up back on the street.”
Republicans, Aiming to Kill Health Law, Also Work to Shore It Up
by Robert Pear - NYT - February 12, 2017
WASHINGTON — After denouncing the Affordable Care Act as an abomination for seven years, Republicans in Congress, working with the Trump administration, are urgently seeking ways to shore up health insurance marketplaces created by the law.
While President Trump said as a candidate that “Obamacare is certain to collapse of its own weight,” Republicans fear such an outcome because, now that the fate of the health law is in their hands, they could be blamed by consumers and Democrats.
The administration is poised to issue a proposed regulation to try to stabilize insurance markets, and House Republicans are drafting legislation with a similar purpose. The regulation and the bills are intended to hold down insurance premiums and to lure insurers back into the public marketplaces from which they have withdrawn in the past couple of years.
The Republican proposals address concerns that insurers have been expressing for several years, among them what they call costly abuse of special enrollment periods. But markets could still be undermined, insurers say, if Congress simultaneously repeals the health law’s requirement for most Americans to have coverage.
That requirement, known as the individual mandate, is one of the more unpopular features of the law, signed in 2010 by President Barack Obama. But insurance companies like it because it requires people to buy their product, bringing in healthy people who pay premiums and do not use much care.
Analyzing the Republican strategy, Joel L. Michaels, a health lawyer at the firm McDermott Will & Emery, said there was “a tension” between efforts to repeal the health law and shore up its insurance marketplaces, where more than 10 million people obtained coverage last year.
“A political agenda premised on the Affordable Care Act being unworkable could conflict with efforts to support the A.C.A. exchanges, even on an interim basis,” Mr. Michaels said. “How far do you go with short-term fixes, which could make the law work better in the long term? It’s a delicate political dance.”
Insurers are seeking immediate governmental action because they must decide by early May what kinds of health plans they will offer on the exchanges in 2018.
The proposed rule drafted by the Trump administration and one of the bills drafted by House Republicans would make it more difficult for consumers to obtain insurance outside the annual open enrollment period. Consumers would have to provide documents to show they were eligible for a special enrollment period. Under existing rules, people can sign up after the deadline if they experience certain “life changes” like having a baby, getting married, losing employer-sponsored insurance or moving to a new state.
But insurers say that some consumers have misused these special enrollment periods, signing up when they became sick and dropping coverage after they received the care they needed.
Insurers say people who sign up in a special enrollment period use up to 50 percent more services than those who sign up in the standard enrollment season.
In documents provided to the White House at a meeting last week, Blue Cross and Blue Shield executives said federal officials should limit the number of special enrollment periods and “require all individuals to show proof of eligibility before coverage starts” — an idea endorsed by several governors.
Gov. Bill Haslam of Tennessee, a Republican, said that “special enrollment periods are an absolute necessity for individuals who experience a change in life circumstance.” But, he said, they have been “so broadly defined that they are almost akin to a permanent open enrollment period, allowing individuals to access health insurance benefits only when health care is an immediate necessity.”
Judith Solomon, a vice president at the Center on Budget and Policy Priorities, a liberal-leaning research and advocacy group, said she had not seen convincing evidence of abuse.
Moreover, she said, the documentation requirements “will decrease enrollment, for sure, and will disproportionately deter younger and healthier people” from trying to sign up.
Under another Republican proposal, it would be easier for insurers to terminate coverage for people who fail to pay their premiums. The Affordable Care Act says insurers generally must allow a three-month grace period before ending coverage for people who receive federal subsidies to help pay premiums.
About 85 percent of people who obtain insurance through the Affordable Care Act’s marketplaces receive such subsidies, and the three-month grace period is longer than that typically required by state laws.
Under a bill introduced last month by Representative Bill Flores, Republican of Texas, the federal government would recognize any grace period set by state law, and if a state did not have a law, the grace period would be one month.
Several governors, including Brian Sandoval of Nevada and Gary R. Herbert of Utah, both Republicans, endorsed this change. “Reducing the grace period from 90 days to 30 days, which is standard industry practice for most other insurance products, would assist in stabilizing the individual market,” Mr. Herbert said.
Republicans in Congress are also warming to the idea of continuing payments to insurance companies to help cover the out-of-pocket costs for people with low incomes.
House Republicans filed suit against the Obama administration to stop these payments, saying Congress never appropriated money for them, and a federal district judge ruled for the lawmakers in May.
The payments reimburse insurers for certain discounts they are required to provide to low-income people, and without the payments, which are expected to total $9 billion this year, insurers say they would drop out of the market or sharply increase premiums.
Representative Mark Meadows, a conservative Republican from North Carolina and a fierce critic of the health care law, said he wanted to avoid disrupting coverage for consumers while Republicans repeal the law and devise a replacement.
“As long as we have a real repeal and replacement strategy,” Mr. Meadows said, he might accept a temporary continuation of the cost-sharing subsidies.
“I would be more flexible and could swallow some short-term heartburn for longer-term fiscal responsibility and lower health care costs for the people I represent,” he said.
Senator Lamar Alexander, Republican of Tennessee and the chairman of the Senate health committee, said he, too, was willing to allow a “temporary continuation of cost-sharing subsidies for deductibles and co-payments.”
How to Fix (or Wreck) Obamacare: Advice for Tom Price
by Reed Abelson and Margot Sanger-Katz - NYT - February 10, 2017
Dear Secretary Price,
Congratulations on your new job. We hear you want to replace the Affordable Care Act — or Obamacare, as you call it.
Congress isn’t going to help you in the immediate future. Though several health overhaul bills have been introduced, and others are being discussed behind closed doors, Republicans in Congress are not close to voting on a legislative package. The new deadline for action appears to be months, or even a year, in the future.
What should you do in the meantime?
You might want things to coast along as is, to smooth the path for whatever program comes next, especially if it’s going to take a while. If you prefer this course, you’ll want to take steps to reassure insurance companies and help keep markets stable.
Or you might want to see the Obamacare markets burn to the ground, the better to prove that wholesale change is needed. If you want this outcome, you’ll want to take steps to rattle insurers and destabilize markets.
So far, President Trump, while waiting for your confirmation, has taken pieces from both playbooks. An executive order suggested that you may undermine incentives for healthy people to buy insurance, and your department pulled advertisementsencouraging people to sign up. Your department is also apparently taking some steps to shore up the markets: A regulation, currently under review by the Office of Management and Budget, has provisions to try to stabilize markets, according to its title.
The clock is ticking. Insurers must start deciding this spring whether they want to sell Obamacare policies next year and how they should price the plans. That means they are looking for clear signs about the policy environment you will create.
Here are the big choices facing you next as you think about which path to choose:
Should you cut off cost-sharing subsidies?
If you want to break the Obamacare markets, this is your best bet.
The easiest way is to decide to stop providing the money that goes to insurers to help shield low-income customers from large medical bills. The House has sued to stop the administration’s payments on the grounds that they were illegal because they were never appropriated. You can decide to stop defending the administration’s position, effectively cutting off billions of dollars in spending. Insurers have made it clear that they believe they would have little choice but to leave the market. “Much of the marketplace will simply collapse,” said Dr. J. Mario Molina, the chief executive of Molina Healthcare, a California-based insurer. “It will be fast.”
Should you defang the individual mandate?
The health law’s requirement that all Americans obtain health insurance or pay a penalty is very unpopular. But it’s also crucial to an interlocking set of policiesdevised to keep insurance affordable.
There are various options available if you wish to weaken the mandate. The easiest would be to simply make it easier for people to get exemptions to the policy. You have a lot of discretion to decide whether people’s personal circumstances represent “hardships” that make it difficult for them to buy insurance. If you broaden these categories, and widely advertise these changes, you might cause many more Americans to forgo insurance coverage.
Doing this won’t immediately sting insurers, as removing cost-sharing subsidies would. But it would hurt them in two major ways: It would reduce the number of customers buying their products. And it would make the remaining buyers, on average, sicker and more expensive to cover. Insurers could respond to this change by simply raising their prices, but some will probably respond by exiting the Obamacare markets altogether.
Eventually, if you do not have some effective way of enticing people to sign up for insurance, you will destroy the market, said Karen Ignagni, the chief executive of EmblemHealth, who represented the insurers when the law was first drafted. Whenever a state has forced insurers to cover everyone without having a mandate, “there was a death spiral,” she said, in which the prices got so high no one could afford them and the market collapsed.
Without legislation, your options for replacing the mandate are quite limited.
Will you keep Obamacare websites, outreach and other functions running smoothly?
The Obama administration often looked under budgetary couch cushions to find money to help Obamacare programs thrive. They funded advertising to bring people into the market, made frequent updates to their website to make it easier to use, and provided grants to outside groups that helped people sign up for coverage.
Pulling back on any of these functions could make it harder for eligible people to find out about Obamacare options and harder for them to find the right plan for their needs. That would also tend to suppress signups among healthy people, and increase the cost of insurance coverage.
Will you take actions to reduce ‘gaming’ of the system?
Health insurers have long complained that consumer protections in the Affordable Care Act make it too easy for people to wait until they are sick to sign up and to cancel their plans once they are well again. Your department’s coming regulation seems to be an effort to respond to some of these concerns.
Such actions will probably reassure some nervous insurers by making the market rules more favorable to them. But you may want to avoid making very big changes. There is little time available for carriers to recalculate how they want to price their policies before the filing deadline, and provisions likely to spur court battles may not give them the comfort they are intended to provide.
Time is tight
If you’ve been listening to your boss, President Trump, or your old boss, Paul Ryan, you may be under the impression that Obamacare’s markets are in free fall. But a growing bodyofevidence suggests they may actually be stabilizing, even in the wake of some really high premium increases in 2017. Matthew Fiedler, the former chief economist for the Council of Economic Advisers, argued in a recent analysis that there is “strong evidence that premium increases did not cause dramatic enrollment declines, much less spark a death spiral.”
Insurers seem to be turning a corner. Anthem says it is likely to break even or make money on individual coverage next year, and Centene assured investors that it was “not backing off at all.” Where they head next will be largely determined by your choices.
Angry Town Hall Meetings on Health Care Law, and Few Answers
by Thomas Kaplan - NYT - February 13, 2017
PEWAUKEE, Wis. — Michelle Roelandts had a question for her congressman: If the Affordable Care Act and its premium subsidies were repealed, what would happen when her daughter turns 26 this year and needs to get her own health insurancewhile attending law school?
Representative Jim Sensenbrenner, a durable Wisconsin Republican who has served in the House since 1979, had little to offer in response. “If I could give you an answer today, I would, but I can’t,” Mr. Sensenbrenner said at a town-hall-style meeting on Saturday, where about 70 people packed a room at the Pewaukee Public Library.
Ms. Roelandts’s question and others like it are being asked with increasing anger and urgency across the country, and Republicans have found themselves on the defensive — for all their fury aimed at repealing the law, so far they have not agreed on an alternative.
In California, Representative Tom McClintock was escorted by police officers after a town-hall-style meeting this month; in Utah, the crowd chanted “Do your job!” at Representative Jason Chaffetz, the chairman of the Oversight Committee. At a meeting last week, House Republicans were advised on security precautions so they would be prepared for protesters at town-hall-style meetings or their district offices.
During Mr. Sensenbrenner’s exchange with Ms. Roelandts, a man yelled to him: “How many times did you vote to repeal without knowing what the replacement would be? How many times? Dozens!”
The congressman, who prides himself on his prolific schedule of town-hall-style meetings, banged his gavel and insisted that his rules for civility be obeyed.
While Mr. Sensenbrenner did not face the kind of anger that some of his peers did in recent days, he must answer the same question: Is this resistance a sign of a sustainable organic movement, or one that will soon flame out? And like his colleagues, he is also coming to grips with how much he will be saddled with the combative comments made by President Trump.
Mr. Sensenbrenner, in an interview, attributed the turnout at his gatherings to “organized opposition by people who were on the losing side of the election.”
Facing restive audiences in public meetings is not new, but in the age of social media, an ugly scene in one congressional district can quickly attract widespread attention.
“I’d be lying to you if I told you it was fun,” he said.
The questions from voters on display this weekend at a series of town-hall-style meetings in Wisconsin’s Fifth Congressional District, many of which were focused on the future of the health care law, underscored the quandary many lawmakers are facing even in solidly Republican districts.
The imminent problem: Constituents want answers, and without any consensus on how to go about replacing the law, Republicans have little to say.
“It’s kind of like, you know, getting a 30,000-piece jigsaw puzzle for Christmas,” Mr. Sensenbrenner said, “and, you know, cleaning off the dining room table and seeing how long it takes to put all the 30,000 pieces together in the right place. It’s not going to be easy.”
Mr. Sensenbrenner won re-election last year by 37 percentage points. His right-leaning district, which includes suburbs around Milwaukee, voted decisively for Mr. Trump over Hillary Clinton.
At three town-hall-style meetings over the weekend, Mr. Sensenbrenner sat at the front of the room to take questions from people who submitted slips of paper listing their name and address. When he called on people, he read their names and where they live — a practice that makes people “less likely to make fools of themselves,” he said in the interview.
At the meetings, he faced crowds that were adversarial but generally civil, and he fielded questions on a range of issues. At moments when the gatherings grew a bit unruly, he did not hesitate to bang his gavel. Like a frustrated grade-school teacher, he offered some unsolicited advice about comportment.
“This is not a session on who can cheer or boo the loudest,” he said as he began the Pewaukee meeting on Saturday, urging people to “be respectful of opinions that you do not share.”
The tough questioning of Republican lawmakers has been driven partly by concerns over health care, but also by outrage over Mr. Trump’s presidency.
That was true in Wisconsin, too. Mr. Sensenbrenner, who has long worked on immigration issues in Congress, said the executive order on immigration was “completely messed up” and a “train wreck.” And he suggested he would be of little assistance in reining in Mr. Trump.
“Do you think I’m able to control anybody else’s mouth, from the president on down?” he asked.
Repeatedly, the questions Mr. Sensenbrenner faced over the weekend showed the challenge that lawmakers have in explaining the effects of repealing the Affordable Care Act, especially now, when Republicans have yet to coalesce around a replacement plan.
Pressed by one questioner to oppose a replacement for the health care law if that replacement would raise costs for sick people, he explained that “there are winners and losers” when bills are passed.
A woman told him she learned she had skin cancer in 2005, and she asked about coverage for people with pre-existing conditions. Another woman told him that her 97-year-old mother was in a nursing home, and she wondered whether changing Medicaid to give each state a fixed amount of money, called a block grant, could cause her mother to be “put out on the street.”
“I’ve been sending him postcards with her photo, because I think he needs to see the people that it affects,” Ms. Levas said after the Pewaukee meeting.
Mr. Sensenbrenner offered a reassurance that some popular aspects of the health care law would remain: insurers would not be able to deny coverage because of pre-existing conditions, young adults could stay on their parents’ health plan until they are 26, and lifetime limits on coverage would not be allowed. And he acknowledged the stakes of the repeal effort.
“From a political standpoint, we Republicans know that we will own whatever the replacement will be, just as Obama and the Democrats own the A.C.A.,” he told Ms. Roelandts, who asked about health coverage for her daughter. “We got to get it right, and we got to get it right the first time.”
Ms. Roelandts, an accountant, said later that she was not happy with his answer. “I kind of interpret it as they don’t really know what they’re going to do yet,” she said, adding that she was alarmed by the comparison to a 30,000-piece jigsaw puzzle.
“Don’t talk about repealing something until you have valid ideas on the table for replacing it,” she said. “I mean, it’s causing me to literally lose sleep at night.”
Still, Mr. Sensenbrenner was blunt and unapologetic about the Republican push for dismantling President Barack Obama’s signature domestic achievement.
“I won by 146,000 votes,” he said in the interview. “I represent the majority. Now, they’re a vocal minority.”
by Vann R. Newkirk II - The Atlantic - February 14, 2017
The Senate confirmed Tom Price as secretary of health and human services at 2 a.m. on Friday. After a contentious confirmation process, the Trump administration and the Republican-controlled Congress had finally installed one of the leading generals in its war on Obamacare in the department that oversees its programs. Price is a titan in the GOP camp that wants to repeal the health law, and is perhaps one of the few Republican lawmakers with both the vision and the experience needed to begin the daunting task.
But the battlefield under Price’s feet has shifted substantially in the past few weeks. Republicans have splintered, the timeline for repeal has dragged on and on, alternative plans have propagated in the fertile soil of disunion, and some have lost their resolve. And in the turmoil over the fate of Obamacare, the idea of universal health care has emerged as a third way among voters in both parties. The health system the mainstream GOP opposes most is now one some of its voters support—potentially making Price’s task of replacing Obamacare all the more complicated.
The political appeal of a single-payer, universal health-care system is perhaps best outlined by Jessi Bohon, a high-school teacher who attended a raucous and often angry town hall with Republican Representative Diane Black in Murfreesboro, Tennessee, last week:
Bohon was able to ask Black a question, and she began with a defense of Obamacare. “As a Christian, my whole philosophy in life is pull up the unfortunate,” she said, referencing the law’s individual mandate and how requiring healthy Americans to purchase insurance lowers costs for the sick. But Bohon went a step further in her support of expanding coverage and her criticisms of the private insurers who’ve complicated the law: “Why don’t we expand Medicaid, and have everybody have insurance?” she asked.
It’s possible that Bohon’s question was simply an attempt to ask Black to implement policies that already exist in the Affordable Care Act. States have the option to expand Medicaid to more low-income adults under Obamacare, though Tennessee, among others, has chosen not to accept federal funds to do it. But her query and criticisms of market-based plans raise a broader question: Why rely on private insurers at all?
Senator Bernie Sanders had also made the case for government-run health care in a CNN debate on Obamacare just the night before. Although he was ostensibly brought on to defend the law against interlocutor Senator Ted Cruz’s criticisms, Sanders used his platform to argue for Medicare for all. His strategy was not to forcefully defend the law against critiques from Cruz, CNN, and the audience; rather, he often agreed with Cruz that those critiques were valid. But his solution undercut Cruz’s message of limited government. Why continue a system that relies on premiums at all, Sanders asked—and why continue to enrich insurers that simply cannot be relied upon to act in patients’ best interests?
Although Bohon—a self-identified Hillary Clinton voter—and Sanders certainly represent liberal sensibilities, several polls show that universal coverage is gaining traction among Democratic and Republican voters. A January Pew Research Center survey showed that 60 percent of Americans believe that government “should be responsible for ensuring health-care coverage for all Americans”—the highest mark in nearly a decade—though they are divided on whether government should be the sole provider of insurance. The recent increases nationally in support for universal coverage are mostly attributable to low-income Republicans. Over half of all Republicans surveyed who have family incomes of less than $30,000 agreed with the idea. Twenty-eight percent of all people polled in a recent Gallup survey expressed support for a single-payer system run by the government.
To be sure, the conclusions that can be gleaned from the polling here are a bit murky. Last year, my colleague Olga Khazan explored how support for a single-payer, Medicare-like plan decreases dramatically when such a plan would necessitate tax increases, which it almost certainly would. Also, a Kaiser Family Foundation survey from February 2016 showed that the label matters as well. Over 70 percent of Americans support Sanders’s “Medicare for all” plan. But they weren’t as enthusiastic about “universal health care” or “single-payer” health care. Although there are some real potential differences in these concepts that voters might be responding to—the term “universal health care” doesn’t specify financing or delivery, and “single-payer” doesn’t specify how the scheme is actually administered—the KFF poll potentially illustrates that there are barriers to understanding whether the public actually wants and understands a universal health-care system.
Still, the upswing in support for the government provision of health care among low-income Republicans provides a real opportunity for politicians in both parties. Trump himself once promised to implement “insurance for everybody.” Though it’s easy to view that one-time vow as fluff or a misunderstanding of his own party line, it could be a lifeline for Republicans facing revolts back home in poor districts where constituents are fearful of losing their insurance coverage. An Obamacare replacement with an expanded public-insurance system would follow through on promises to repeal the ACA. And it could also replace an unstable and weakening exchange system—dominated by reviled insurance companies—with Medicare or state-branded Medicaid programs like Kentucky’s Kynect, which tend to be widely trusted.
That route might be too far-fetched or expensive for Republicans to pursue en masse. Although their current repeal plan might bend Republican rules on passing legislation that increases the deficit, demolishing or controlling health-care markets and extending tax-funded insurance would be outright heresy against the party line. The resistance to such an idea in the health-care industry, and among its lobbyists, might threaten Republicans in Congress who rebel, thereby reinforcing the market-based status quo.
But it’s not too far-fetched for Democrats, who could, by embracing universal coverage, force Republicans to at least consider altering the party line. Democrats don’t face the same political risks with health care as Republicans do, not only because universal health care exists within liberal theory of government, but because a Republican-dominated Congress effectively renders many of their platforms, votes, and draft bills symbolic. The same dynamic in reverse created the anti-Obamacare fervor among congressional Republicans in the first place, and has been one of the largest factors in the GOP’s electoral strength since 2010.
Were they to take the plunge, Democratic candidates could run as challengers in upcoming elections on a third way of health reform: neither extending unpopular pieces of a program nor rolling back coverage, but giving everyone Medicare. And if the Democratic Party were to support universal health care, that might put pressure on Republicans, who wouldn’t want to lose voters who fear loss of coverage or doctors under a massive repeal.
Thus the precariousness of the Republicans’ position. With Price atop the national public-health system and already empowered by an executive order from the White House, Republicans in the executive branch and Congress have run out of excuses to do the job they came to do. But they face an ever-mobilizing opposition that extends across both parties, and immediate decisive action carries significant risks of causing a conflagration if people lose coverage. Paradoxically, delays give more time for the party to splinter and lose momentum, and for the idea of universal care to take root as a viable alternative as the stresses of an unfixed existing system mount. For at least some Republicans, that option might now be the most attractive now.
Ryan faces major test in selling Obamacare repeal and replacement
by Kelsey Snell and Mike Debones - Washington Post - February 14, 2017
House Speaker Paul D. Ryan (R-Wis.) spent Tuesday on a door-to-door tour of the Capitol in hopes of salvaging his plan to repeal and largely replace the Affordable Care Act by spring.
The day-long blitz comes as Republicans in Congress have made virtually no visible progress in recent weeks on overhauling the health-care system, according to interviews with several senior GOP aides.
That is largely because the party remains sharply divided over how much of the ACA should be repealed and how much — if any of it — should be replaced. The stalemate has lawmakers questioning whether the law known as Obamacare can be effectively gutted by Ryan’s self-imposed deadline of the end of March.
“I don’t think you can fully repeal and replace it in that amount of time,” said Rep. Tom Cole (R-Okla.). “It took months to write Obamacare, the original bill, and years to phase it in. It is going to take time to unwrite it and replace it with something else.”
Ryan’s efforts are being stymied by a host of factors, including a familiar revolt from his most conservative members, who want to keep their promises to eliminate Obamacare regardless of the pace of a replacement measure. Meanwhile, Senate Republicans are not ready to act on any kind of repeal without a consensus replacement plan. The Washington infighting is playing out against a backdrop of rowdy GOP town halls across the country showcasing people worried about the impact on their lives of potentially losing their health insurance.
For Ryan, the stakes could not be higher. While trying to satisfy his right flank, the speaker also must consider the potentially explosive impact of the health-care debate on his quest to maintain and grow the GOP majority in the 2018 midterm elections. Further confusing things is President Trump, who has both vowed to repeal and replace the ACA immediately, and said that such a process would take until 2018.
Dozens of GOP members attended an afternoon briefing Tuesday on Medicaid. The issue is one of the biggest sticking points among Republicans, opening divides between lawmakers in states who have accepted the program’s expansion under Obamacare and those who have opted out, forgoing hundreds of millions of federal dollars a year in protest against the law.
Inside the closed-door sessions, senior lawmakers walked through a variety of options for replacement — including a radical reorientation of the Medicaid program, an open-ended insurance entitlement and a fixed “block grant” that would let states decide how to apportion health-care dollars for the needy. They also considered an indefinite extension of the ACA Medicaid expansion that would allow those now covered to remain so.
“They got to see a lot of the details of the plans that we’re working on,” said House Majority Whip Steve Scalise (R-La.), who hosted the session. He added, “There’s a lot of work left to be done.”
Republican senators who represent states that expanded Medicaid — including Bill Cassidy (La.), Rob Portman (Ohio) and Lisa Murkowski (Alaska) — huddled last week to discuss concerns that a House GOP repeal bill could leave millions of their constituents without insurance. While no consensus emerged, many lawmakers said they could not support an aggressive repeal bill that could harm so many of their constituents.
“We’ve added 27,000-some-odd Alaskans to the covered rolls,” Murkowski said Tuesday. “I want to make sure whatever we do post-ACA, we don’t leave these good folks hanging.”
The debate is playing out against a backdrop in which the proportion of Americans without health insurance through most of last year remained at the same low level as in 2015, according to survey data released Tuesday by the National Center for Health Statistics. The data, covering January through September 2016, showed that 8.8 percent of people of all ages were uninsured compared to the 9.1 percent uninsured through 2015, according to the U.S. Census’s most recent annual report on health insurance rates.
It is unclear how much of that improvement is the result of an improving economy and how much was brought about by the ACA’s impact. Meanwhile, the insurer Humana announced it would stop selling individual plans under the ACA after this year.
On Capitol Hill, Republicans are locked in a battle for control over the repeal process. Conservatives are seeking to reassert their influence after several weeks where more-moderate lawmakers — and Trump himself — have seemingly argued for a more deliberate process.
Members of the hard-right House Freedom Caucus and conservative Republican Study Committee are insisting that a repeal bill should go at least as far as a measure they approved in 2015. That bill ended with a veto from President Obama, but GOP leaders touted it as a test run for what could be possible with a Republican president.
“What we’re trying to do is really create some urgency,” said Rep. Mark Walker (R-N.C.), chairman of the Republican Study Committee. “We’re okay with talking through that and hearing what they [House leaders] have for us, but ultimately, we’ve promised to the American people that we’re going to get this thing off the books as quick as possible. That’s what we’re asking the leadership to do.”
Leaders are using a quirk in the budget process to repeal Obamacare without the threat of a blockade by Senate Democrats.
Budget legislation is considered under special rules in the Senate that allow a simple majority of 50 senators to support passage rather than the normal 60 needed for almost everything else. While there are 52 Republicans in the Senate, some of them are unlikely to support a rapid repeal without a replacement in place.
Ryan set out Tuesday to rally the GOP to consensus, starting the day by launching several policy sessions to offer rank-and-file members some details of what could be included in the replacement plan. He outlined several common ideas that unite the GOP, such as expanding health savings accounts and allowing insurers to sell plans across state lines. He also announced plans for a Thursday meeting where members will be briefed on further details just before they leave for a week-long recess where many plan to hold events with constituents.
Ryan told reporters after the meeting that the plan for a “step-by-step” process to replace ACA was still on track.
“We have to stop the collapse, and we have better ideas that have beentime-tested that will make sure that we give the American people the kind of relief they deserve,” Ryan said.
He then headed to a closed-door lunch in the Senate where he pitched the outlines of his vision for replacement.
But Republicans largely left the meetings unable to identify any specific proposals that go beyond a small number of general ideas. “There was a lack of specificity,” Cassidy said after the meeting. “Ideas are bubbling together.”
The conversation was not as specific as would be expected at this point in a major policy negotiation, according to several GOP aides. One aide described the talks as remaining in “the very beginning stages.”
Could the most conservative members of Congress save Obamacare?
by Paul Waldman - Washington Post - February 14, 2017
ry to wrap your head around this possibility: the House Freedom Caucus, the most conservative members of an extremely conservative Republican majority, might be the saviors of the Affordable Care Act.
How is such a thing possible? The answer is their devotion to ideological purity, which it turns out may be as disruptive a political force when the GOP is the ruling party as it was when they were the opposition.
As Republicans have flailed about trying to figure out how to fulfill their promise to repeal the ACA, the chamber’s most conservative members have gotten increasingly frustrated. After all, control of both ends of Pennsylvania Avenue was supposed to produce an orgy of legislating, with no priority more important than driving a wooden stake through the heart of Obamacare. Yet here they stand almost a month after achieving absolute power, and not a single bill has been sent to the White House for Donald Trump’s signature.
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So last night, in an apparent attempt to get the repeal train moving, the House Freedom Caucus voted to oppose any repeal bill that would be less comprehensive than the bill both houses of Congress passed in late 2015, which President Obama vetoed (more on what that means in a moment). They threw down a gauntlet before their timid colleagues: either we go big or we don’t go at all.
If the 30 members of the Freedom Caucus stuck together to vote against a repeal/replace bill, it would be more than enough to defeat it, assuming that they’d be joining all of the Democrats in the House. And Obamacare would be saved.
That’s obviously not their preferred outcome, but what they want is something that right now Speaker of the House Paul Ryan and much of the rest of House Republicans are terrified of delivering. The Freedom Caucus is pressuring Ryan to forget about trying some kind of piecemeal approach and just go ahead and repeal as much as possible of the damn thing. This is an approach Ryan has already discarded, since throwing 20 million people off their coverage and destroying the individual health insurance market — all without being able to tell them what will replace it — might not be such a wise move politically.
Republicans still need more time to untie their Gordian Knot, having finally learned that health care reform is complicated and involves tradeoffs (who knew?). But the Freedom Caucus doesn’t care.
That’s for a couple of reasons. First, they come from extremely conservative districts where the only threat they face is a challenge from the right. And second, they spent the last eight years fetishizing hard-line politics, where the only appropriate stance to take was total and complete opposition to anything Barack Obama wanted to do, and compromise was inherently evil, no matter what the particulars of a given situation.
Obama may be gone, but their feelings about compromise remain. So when someone like Ryan says that maybe there are a few parts of the ACA we should hold on to, their natural response is, “NO!” That puts them right back in their happy place: fighting the power, standing up for their principles, refusing to yield no matter the consequences.
So they’ve decided to make their courageous stand. “If it’s less than 2015″ — meaning the bill Congress passed that year — “we will oppose it,” said Rep. Mark Meadows (R-N.C.), the chairman of the Freedom Caucus. The trouble is that Republicans passed the 2015 bill knowing full well that Obama would veto it, which meant it was without risk.
Because that bill was passed under “reconciliation” rules, it couldn’t repeal the entire law, only the provisions that have a direct effect on the budget. But that was an enormous amount: it did away with all the taxes that paid for the ACA, the individual and employer mandates, the subsidies that allowed millions of people with moderate incomes to afford coverage, and the expansion of Medicaid that insured millions more.
Now that they’ll be held accountable for the changes they make, Republicans aren’t all sure they want to get rid of all that. Republicans might want to kill the taxes, but that would mean they’re going to have trouble paying for a replacement. Republicans would like to convert those subsidies to refundable tax credits, but it’s not yet clear how Republicans would design them. Many Republican states took the Medicaid expansion — and saw their uninsured rates plunge. They like the flexibility involved in Republican plans to turn Medicaid into a block grant, but they don’t want to give up the money they’re getting from the federal government.
In short, this stuff is complicated, especially if you want to avoid the enormous public backlash that would increase exponentially if you just repealed the law. There may be no way to avoid that backlash, particularly since everything Republicans are considering is guaranteed to produce more uninsured people, higher out-of-pocket costs, and enormous disruption to the system (and that’s if it works as planned). But Ryan and other GOP leaders are hoping to finesse it all with a carefully constructed Jenga tower of a bill that minimizes the political damage they’ll suffer. Some parts of the ACA (the popular ones) will likely be kept in some form, and the whole thing will be rolled out gradually, perhaps with a delay that pushes the most dangerous parts of the transition past the 2018 midterm elections (or even the 2020 elections). And it’s already clear that Ryan doesn’t want to rush into anything when the political stakes are so high.
To the Freedom Caucus folks, however, nothing is complicated. A compromise with the public’s desires or with their party’s leaders is just as repugnant to them as a compromise with Obama. The only question is whether they’re being pure and true. And if what Ryan comes up with feels like a compromise, they may just decide that knocking down the tower is what it takes to remain pure and true — even if it means the ACA would stay in place, at least for a while.
Medical Mystery: Why Is Back Surgery So Popular in Casper, Wyo.?
by Austin Frakt and Jonathan Skinner - February 13, 2017
You might think that once drugs, devices and medical procedures are shown to be effective, they quickly become available. You might also think that those shown not to work as well as alternatives are immediately discarded.
Reasonable assumptions both, but you’d be wrong.
Instead, innovations in health care diffuse unevenly across geographic regions — not unlike the spread of a contagious disease. And even when studies show a new technology is overused, retrenchment is very slow and seemingly haphazard.
Back surgery is a great example. In the early 1990s, when John Wennberg’s Dartmouth Atlas of Healthcare first started tracking treatment rates among older Medicare users, back surgery was relatively uncommon; 1992 rates were as low as one case per thousand in cities as diverse as New York and Johnson City, Tenn.
By 2006, average rates of back surgery had increased to 4.9 per thousand. The procedure had spread rapidly across the Northern Plains and Mountain States. Growth was especially significant in certain cities elsewhere — like Lubbock and Harlingen, Tex. Yet rates in New England and some parts of the Midwest had barely budged.
Even as back surgery’s popularity as a treatment for back pain began to rise in the 1990s, there was little solid evidence of its effectiveness. It wasn’t until 2006 that the first large randomized trial on the subject was published.
That study showed relatively modest benefits of surgery for many conditions that lead to back pain. While many patients felt better after a year, so did a nearly equal proportion of people in the control group who didn’t have surgery. However, years before that evidence was available, some regions had adopted back surgery at a high rate, while others had not.
The rates of back operations performed in hospitals began to flatten after 2006, but little was known about growth in the treatment in outpatient clinics, the same-day facilities with greater convenience and lower costs. Recently, Brook Martin and Sandra Sharp, two Dartmouth researchers funded by the National Institute of Aging, tracked outpatient as well as inpatient procedures through 2014. The finding: Rates of Medicare back surgery had grown 28 percent since 2006, with no decrease in regional variations; rates in 2014 ranged from 3 per 1,000 in the Bronx to 11.5 per 1,000 in Casper, Wyo.
The puzzling thing is why back surgery became more popular in certain broad regions, but not in others. Why, for example, did rates grow so rapidly in the Northern Plain states while rates in New England barely budged?
Our best guess comes from a study by Harvard and Dartmouth researchers, not on back surgery, but on cardiac treatments. It found that regional variation in Medicare spending is associated with variation in physician preferences for intensity of cardiac treatments, and to a greater degree when the evidence is ambiguous. Patient preferences exerted almost no influence. It’s likely that the pattern holds for back surgery, too, though it has not been studied in the United States.
It’s tempting to conclude that there are simply regions where the intensity of care of all types is higher — that some regions invest in all of the latest shiny technologies, while others don’t. This is too simple; Miami and McAllen, Tex., the two most expensive regions in the United States for overall Medicare spending, also clock in with among the lowest spine surgery rates. Instead, we see what Mr. Wennberg calls a surgical signature: Casper Wyo., has the highest back surgery rate in the country, but its cardiac bypass surgery is well below the national average.
This puzzling pattern once again points toward idiosyncratic physician beliefs. Orthopedic surgeons in a particular hospital may be more aggressive, while the cardiologists there are less so.
Though we can’t say this is the answer with 100 percent certainty, we can rule out some other explanations. One is how much surgeons are paid. Since Medicare pays the same price for the procedure (adjusted for cost of living) across the country, prices can’t explain the paradox. The high rates in Denver could also be explained by back pain sufferers who flock to star surgeons and well-known hospitals there, but this doesn’t hold water either. The way the statistics are compiled, if a medical tourist traveled from Des Moines to Denver, the Medicare record keepers would assign that operation back to the tourist’s home in Iowa.
Maybe it’s differences in health. Perhaps areas with rapid growth in back surgery were those where more people had back pain. Yet northern New England retirees had similar histories of hard physical labor in farming, lumbering and manufacturing, and were no more affluent than their counterparts in the Northern Plains states.
Another explanation might be that patients prefer surgery in some regions of the country. One study observed large variations in back surgery across small regions in Ontario, but these weren’t explained by patient preferences. That study, like others, found physician beliefs about the benefits of surgery were associated with surgical variations.
If physicians are driving back treatment choice, even for procedures not supported by evidence, what can be done? One approach is to provide patients with unbiased information about the potential benefits and risks of back surgery relative to nonsurgical therapy so they can make informed choices. But the concern remains that for people in intense pain, when the doctor says that “I get good results with surgery, and my patients generally feel much better,” the back surgery option, with little out-of-pocket cost, will be hard to resist.
Another option is for hospitals or insurance companies to audit outlier physicians, as in a recent example of a back surgeon with a pattern of unusually high billing. In his audit, nine of 10 procedures were deemed not medically necessary.
A third option is to push people toward high-quality back surgery centers. Walmart created a network of high-quality spine centers for its employees that includes Virginia Mason Hospital in Seattle and the Mayo Clinic. It charged hefty co-payments to anyone getting surgery outside the network. The company found about a third of referrals didn’t need back surgery.
Often discussed, the big challenge in health care is to reduce spending by cutting wasteful care. It seems just as important, though, not to let more waste creep in as it did with back surgery. Once it spreads widely, it’s very hard to undo.
Lower Back Ache? Be Active and Wait It Out, New Guidelines Say
by Gina Kolata - NYT - February 13, 2017
Dr. James Weinstein, a back pain specialist and chief executive of Dartmouth-Hitchcock Health System, has some advice for most people with lower back pain: Take two aspirin and don’t call me in the morning.
On Monday, the American College of Physicians published updated guidelines that say much the same. In making the new recommendations for the treatment of most people with lower back pain, the group is bucking what many doctors do and changing its previous guidelines, which called for medication as first-line therapy.
Dr. Nitin Damle, president of the group’s board of regents and a practicing internist, said pills, even over-the-counter pain relievers and anti-inflammatories, should not be the first choice. “We need to look at therapies that are nonpharmacological first,” he said. “That is a change.”
The recommendations come as the United States is struggling with an epidemic of opioid addiction that often begins with a simple prescription for ailments like back pain. In recent years, a number of states have enacted measures aimed at curbing prescription painkillers. The problem has also led many doctors around the country to reassess prescribing practices.
The group did not address surgery. Its focus was on noninvasive treatment.
The new guidelines said that doctors should avoid prescribing opioid painkillers for relief of back pain and suggested that before patients try anti-inflammatories or muscle relaxants, they should try alternative therapies like exercise, acupuncture, massage therapy or yoga. Doctors should reassure their patients that they will get better no matter what treatment they try, the group said. The guidelines also said that steroid injections were not helpful, and neither was acetaminophen, like Tylenol, although other over-the-counter pain relievers like aspirin, naproxen or ibuprofen could provide some relief.
Dr. Weinstein, who was not an author of the guidelines, said patients have to stay active and wait it out. “Back pain has a natural course that does not require intervention,” he said.
In fact, for most of the people with acute back pain — defined as present for four weeks or less that does not radiate down the leg — there is no need to see a doctor at all, said Dr. Rick Deyo, a spine researcher and professor at the Oregon Health and Science University in Portland, Ore., and an author of the new guidelines.
“For acute back pain, the analogy is to the common cold,” Dr. Deyo said. “It is very common and very annoying when it happens. But most of the time it will not result in anything major or serious. ”
Even those with chronic back pain — lasting at least 12 weeks — should start with nonpharmacological treatments, the guidelines say. If patients still want medication, they can try over-the-counter drugs like ibuprofen or aspirin.
Scans, like an M.R.I., for diagnosis are worse than useless for back pain patients, members of the group said in telephone interviews. The results can be misleading, showing what look like abnormalities that actually are not related to the pain.
Measures that help patients get back to their usual routines can help along the way, as Sommer Kleweno Walley, 43, of Seattle, can attest. Last spring, she slipped on the stairs in her house and fell down hard, on her back.
“After a couple of hours I could barely walk,” she said. “I was in real pain.”
She saw a physical therapist, but the pain persisted. Eleven days later, she showed up at the office of Dr. Christopher J. Standaert, a spine specialist at the University of Washington and Harborview Medical Center. She expected to receive an M.R.I., at least, and maybe a drug for pain.
But Dr. Standaert told her an M.R.I. would not make any difference in her diagnosis or recovery and that the main thing was to keep active. She ended up getting anti-inflammatory medication and doing physical therapy. A few months later, her back stopped hurting.
It is surprising, some experts in back pain say, how often patients are helped by treatments that are not medical, even by a placebo that patients are told at the start is really a placebo.
Dr. Standaert cited a study in which patients with chronic low back pain were offered a placebo, and were told it was a placebo, along with their usual treatment — often an anti-inflammatory drug like ibuprofen or naproxen. Or, the patients remained with their usual treatment alone.
Those taking the placebo reported less pain and disability than those in the control group who did not take it. The placebo effect, although modest, was about the same as the effect in studies testing nonpharmacological treatments for back pain like acupuncture, massage or chiropractic manipulations.
Many people with chronic back pain tend to shut down, avoiding their usual activities, afraid of making things worse, Dr. Standaert said. Helping them is not a matter of prescribing drugs but rather teaching them to set goals and work toward returning to an active life, even if they still have pain.
“They have to believe their life can get better,” Dr. Standaert said. “They have to believe they can get to a better state.”
The question is: Will the new guidelines be adopted?
“Patients are looking for a cure,” said Dr. Steven J. Atlas, a back pain specialist at Massachusetts General Hospital, who wrote an editorial accompanying the article on the new recommendations. “The guidelines are for managing pain.”
Added to the problem are the incentives that push doctors and patients toward medications, scans and injections, Dr. Deyo said. “There is marketing from professional organizations and from industry,” he said. “‘We have the cure. You can expect to be cured. You can expect to be pain free.’”
Medical insurance also contributes to the treatment problem, back experts say, because it does not pay for remedies like mindfulness training or chiropractic manipulations which, Dr. Deyo added, “are not cheap.”
Even if doctors want to recommend such treatments, there is no easy referral system, Dr. Atlas said.
“It is much easier at Mass General to get a shot than to get a mind-body or cognitive behavioral therapy,” he added.
Dr. Weinstein has a prescription: “What we need to do is to stop medicalizing symptoms,” he said. Pills are not going to make people better and as for other treatments, he said, “yoga and tai chi, all those things are wonderful, but why not just go back to your normal activities?”
“I know your back hurts, but go run, be active, instead of taking a pill.”
When Canadian Scientists Were Muzzled by Their Government
by Wendy Palen - NYT - February 14, 2017
VANCOUVER, British Columbia — Less than a month into the Trump presidency, and the forecast for science seems ominous.
Scientists at federal agencies have been hit with gag orders preventing them from communicating their findings, or in some cases, attending scientific conferences. Social media accounts and websites have been censored, and at least one agency was asked to identify personnel who worked on climate policies. Now there are proposals for slashing research budgets and gutting funding that could affect the training of the next generation of scientists. To top it all off, President Trump’s cabinet nominees and senior advisers include many who are climate deniers or doubters.
Canadians experienced a similar assault on science a decade ago under Prime Minister Stephen Harper.
Just as the American science community is now struggling with whether to speak out and march or stay quiet and do its work, Canadian scientists wrestled with the same questions. Ultimately, Canada’s scientific community came together to save our research, galvanized support to fight back, and captured the attention and concern of the public. I hope our experience — in the spirit of science transcending borders — can be instructive.
Starting in 2007, shortly after Mr. Harper became prime minister, new rules were issued that prevented federal scientists from speaking freely with the media about their research without clearing it with public relations specialists or having an administrative “minder” accompany the scientists on interviews or to scientific conferences. More often, the government would simply deny permission for a scientist to speak with reporters if that person’s findings ran counter to Mr. Harper’s political agenda. Inquiries from journalists became mired in an obstinate bureaucracy, and media coverage of government climate research dropped 80 percent after the rules were imposed.
This censorship also had a chilling effect on scientific inquiry. A survey of federal Canadian scientists revealed that 90 percent felt they could not speak freely to the media about their work. If they were to speak up about science that affected public health or the environment, 86 percent felt that they would suffer retaliation. Nearly half of the scientists knew of specific cases of political interference hampering efforts to protect the public.
One of the biggest blows came when research libraries were closed and historical data and reports, many unique and irreplaceable, were literally thrown into Dumpsters. This purge of environmental data was justified as a “cost-saving” measure. Additionally, many crucial data-gathering institutions were closed or saw their funding cut. To the outrage of the international science community, this included cutting all funding for the Experimental Lakes Area, a world-renowned research facility where scientists run experiments on pollution and environmental contaminants in more than 50 small lakes in northwestern Ontario. Other casualties included our northernmost Arctic monitoring station and our national census.
Reluctant to engage in politics, most scientists kept their heads down and tried to wait it out. It was when Mr. Harper’s government passed a sweeping bill that eliminated or amended our marquee environmental protection laws that we reached our boiling point.
Fearing the continued erosion of even the most basic protections for food inspection, water quality and human health, Canadian scientists filled Ottawa’s streets in the Death of Evidence march. That theatrical mock funeral procession became something of a cultural touchstone. It was a turning point that galvanized public opinion against Prime Minister Harper’s anti-science agenda. By the next election, Justin Trudeau’s center-left government swept in on a platform that put scientists’ right to speak and the promise of evidence-based decisions alongside job creation and economic growth.
So here’s our advice as the Trump administration gears up. Spotlight and champion scientists’ refusal to kowtow to intimidation. I’m encouraged by what has already emerged: When Mr. Trump’s transition team circulated a questionnaire intended to identify staff members who had worked on climate change policies under President Obama, Department of Energy employees refused to release their names. When National Park Service employees were prevented from sharing information on social media, they created alternative Twitter accounts overnight and tweeted the truth about climate change and pollution from dusk to dawn.
Scientists who usually shy away from political engagement are condemning President Trump for handing the Environmental Protection Agency, the Department of Agriculture, the Department of Energy and the State Department to a group of men who have denied climate change or questioned the extent to which humans are responsible for global warming. Now scientists from across the country are planning a March for Science in the nation’s capital.
In some quarters, scientists advise their colleagues to remain quiet, keep their noses to the microscope and at most venture out to local meetings so that the “average voter” will know that they’re people, too, and that their work is valuable. But our experience leads to a different conclusion: Come together, speak up and speak out.
Scientists must recognize and fight political censorship, while they remain vigilant for political interference. Many federal science agencies have rules against political meddling in the scientific process. And whistle-blower protections provide federal (and some state) scientists with an additional safety net to report unethical suppression of scientific information. Researchers should confirm that reports they submit are the same as those published, and if changes have been made for political reasons, let the public know.
Share documents widely and back up data in a secure location if the administration politicizes or interferes in research. Encrypted chats, phone calls from home lines and face-to-face meetings can help spread information without the fear of political meddling. Speaking out, especially through scientific organizations, tells colleagues they need not be afraid. The warmth of community staves off the chill of censorship. Don’t let science be silenced.
Evidence and objective reality are the foundation of successful policy and governance. Openness is as vital to science as it is to democracy. We cannot allow hard-won knowledge to be ignored or distorted. To fight the snuffing of the light of scientific inquiry, learn from your neighbors to the north. Reject interference. Stay vigilant and stay vocal. In other words, stay scientists.
Greg Kesich: Bernie Sanders’ agenda can win in Maine if a candidate can pull it off
by Greg Kasich - Portland Press Herald - February 15, 2017
Remember back when Bernie Sanders was too liberal?
It was just last year, when the presidential campaigns rolled into Maine for the quadrennial caucuses. Some smart people warned that even though they agreed with Sanders on substance, he was a risky choice because he would not be able to appeal to moderates in a November match-up against a Republican. So Maine Democrats were advised to help nominate Hillary Clinton, who would be liberal enough.
We know how that worked out. People waited in line for hours in the freezing cold at the Democratic Caucus just to get a chance to vote for Sanders, and he won the state easily. After Clinton won the nomination, Sanders gamely endorsed and campaigned for her, but whatever magic he had did not rub off, and most of his supporters either grudgingly backed Clinton or just stayed home. Some voted for a third-party candidate or even Donald Trump – out of disgust for the whole system.
Nursing post-election hangovers, many of the same smart people were heard to mutter, “… shoulda picked Bernie.” OK, maybe we weren’t that smart.
As 2018 Democratic candidates to be Maine’s next governor start to peek out of their holes, the Bernie Sanders phenomenon deserves some attention. Is there enough of an energized base of progressives in Maine ready to undo eight years of Paul LePage’s mean-spirited trickle-down economics? And if so, is there anyone out there who could lead it?
The answer to the first question appears to be “yes.”
Sanders didn’t just win the Maine caucus last March: Seven months before that, he came here and, with very little advance work, packed the Cumberland County Civic Center. Even the 2007 version of Barack Obama stuck with the Expo.
Sanders didn’t compete with charisma. He spoke for 45 minutes, told no jokes, revealed no personal anecdotes, shared no names of suffering people he has met along the campaign trail.
Instead, he laid out the problem he saw – a system that enriches the people at the top while everyone else struggles – and said what he would do about it.
That was universal health care, free college tuition, strong labor unions and expanded Social Security. To blunt the impact of corporate money that would be marshaled against any of those goals, Sanders financed his campaign with microdonations from individuals and called for a constitutional amendment that would ban corporate money from politics.
Could an agenda like that work in a statewide race?
Maine’s last election suggests that it could.
Remember, four out of five referendum questions passed in November. Imagine a Legislature that legalized marijuana, added a surtax on high incomes, increased the minimum wage and instituted ranked-choice voting. Smart people might say that it was out of touch and way more liberal than the people. But now it’s the people who are more liberal than their government.
And take note of the way the presidential race played out here. Yes, it’s true that Donald Trump won the 2nd Congressional District by 9 points, earning him a single electoral vote. But Clinton still won the state, thanks to a more modest 6-point win in southern Maine.
How did she do it? Because a lot more people voted in the reliably liberal 1st District than in the more conservative 2nd. Clinton picked up 30,000 votes more in the district she won than Trump got in the district he won. That shows how someone could win a statewide race by dominating the southern Maine vote even if they got smoked up north.
And the street demonstrations since the Trump inauguration suggest that there is a mobilized force demanding change, much like the tea party wave that carried Gov. LePage to the Republican nomination in 2010. This year’s protests have a lot of overlap with the people who turned out for Sanders and who were disappointed that he was not the nominee.
The harder question is whether there is a Maine Democrat who could take advantage of these trends.
The Bernie voters are notoriously difficult to corral. Sanders was not even a Democrat himself, and many of his supporters don’t consider themselves to be members of a party. They may not turn out for a primary, and they probably won’t get excited about a middle-of-the-road Democrat, no matter who the Republican is.
With the Ghost of Bernie Past hanging over this election, Democrats have a lot to think about. Candidates could find themselves wondering whether they are too liberal for Maine, or whether they are liberal enough.
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