Health Care Reform Articles - March 28, 2017

Republicans for Single-Payer Health Care

by David Leonhardt - NYT - March 28, 2017

Without a viable health care agenda of their own, Republicans now face a choice between two options: Obamacare and a gradual shift toward a single-payer system. The early signs suggest they will choose single payer.

That would be the height of political irony, of course. Donald Trump, Paul Ryan and Tom Price may succeed where left-wing dreamers have long failed and move the country toward socialized medicine. And they would do it unwittingly, by undermining the most conservative health care system that Americans are willing to accept.

You’ve no doubt heard of that conservative system. It’s called Obamacare.

Let me take a step back to explain how we got here and how the politics of health care will most likely play out after last week’s Republican crackup.

Passing major social legislation is fantastically difficult. It tends to involve taking something from influential interest groups — taxing the rich, for example (as Obamacare did), or reducing some companies’ profits or hurting professional guilds. Those groups can often persuade voters that the status quo is less scary than change.

But when big social legislation does pass, and improves lives, it becomes even harder to undo than it was to create. Americans are generally not willing to go backward on matters of basic economic decency. Child labor isn’t coming back, and the minimum wage, Social Security and Medicare aren’t going away. Add Obamacare to the list. “Americans now think government should help guarantee coverage for just about everyone,” as Jennifer Rubin, a conservative, wrote.

Trump seemed to understand this during the campaign and came out in favor of universal coverage. Once elected, though, he reversed himself. He turned over health care to Price, a surgeon and Georgia congressman with an amazing record, and not in a good way.

Price had spent years proposing bills to take away people’s insurance. He also had a habit of buying the stocks of drug companies that benefited from policies he was pushing. Preet Bharara, the federal prosecutor, was investigating Price when Trump fired Bharara this month, ProPublica reported.

Price and Ryan were the main architects of the Republican health bill. They tried to persuade the country to return to a more laissez-faire system in which if you didn’t have insurance, it was your problem. They failed, spectacularly. Again, Americans weren’t willing to abandon basic economic decency.

But Price may not be finished. This weekend, Trump tweeted that “ObamaCare will explode,” and Price, now Trump’s secretary of health and human services, has the authority to undermine parts of the law. Here’s where the irony begins: He can more easily hurt the conservative parts than the liberal parts.

Obamacare increased coverage in two main ways. The more liberal way expanded a government program, Medicaid, to cover the near-poor. The more conservative way created private insurance markets where middle-class and affluent people could buy subsidized coverage.

The Medicaid expansion isn’t completely protected from Price. He can give statessome flexibility to deny coverage. But Medicaid is mostly protected. On Friday, after the Republican bill failed, Andy Slavitt, who ran Medicaid and Medicare for Obama, was talking on the phone to a former colleague. “Virtually the only words either of us could say,” Slavitt relayed, “were ‘Medicaid is safe.’ ”

The private markets are less safe. They have already had more problems than the Medicaid expansion. Price could try to fix those problems, and I hope he does. Or he could set out to aggravate the problems, which he has taken initial steps to do. Above all, he could make changes that discourage healthy people from signing up, causing prices to rise and insurers to flee.

Now, think about the political message this would send to Democrats: It’s not worth expanding health coverage in a conservative-friendly way, because Republican leaders won’t support it anyway.

Politics aside, private markets in many areas of the economy have substantive advantages over a government program. They create competition, which leads to innovation and lower prices. But private markets in medical care tend to be more complicated and less successful.

And government health care programs turn out to be very popular, among both Democratic and Republican voters. Medicare is a huge success. Medicaid also works well, and some Republicans have defended it in recent weeks.

So if voters like government-provided health care and Republicans are going to undermine private markets, what should Democrats do? When they are next in charge, they should expand government health care.

They should expand Medicaid further into the working class. They should open Medicare to people in their early 60s. They should add a so-called public option to the private markets. They should push the United States closer to single-payer health insurance. It will take time and involve setbacks, but they are likely to succeed in the long run.

Until then, the future of socialized medicine is in the hands of Dr. Tom Price.

https://www.nytimes.com/2017/03/28/opinion/republicans-for-single-payer-health-care.html?

In Health Bill’s Defeat, Medicaid Comes of Age

by Kate Zernike, Abby Goodnough and Pam Bullock - NYT - March 27, 2017

When it was created more than a half century ago, Medicaid almost escaped notice.

Front-page stories hailed the bigger, more controversial part of the law that President Lyndon B. Johnson signed that July day in 1965 — health insurance for elderly people, or Medicare, which the American Medical Association had bitterly denounced as socialized medicine. The New York Times did not even mention Medicaid, conceived as a small program to cover poor people’s medical bills.

But over the past five decades, Medicaid has surpassed Medicare in the number of Americans it covers. It has grown gradually into a behemoth that provides for the medical needs of one in five Americans — 74 million people — starting for many in the womb, and for others, ending only when they go to their graves.

Medicaid, so central to the country’s health care system, also played a major, though far less appreciated, role in last week’s collapse of the Republican drive to repeal and replace the Affordable Care Act, also known as Obamacare. While President Trump and others largely blamed the conservative Freedom Caucus for that failure, the objections of moderate Republicans to the deep cuts in Medicaid also helped doom the Republican bill.

“I was not willing to gamble with the care of my constituents with this huge unknown,” said Representative Frank A. LoBiondo of New Jersey, a member of the centrist Tuesday Group caucus, noting that in three of the counties in his district in the state’s more conservative southern half, over 30 percent of all residents are covered by Medicaid.

In the Senate, many Republicans, echoing their states’ governors, had worried about jeopardizing the treatment of people addicted to opioids, depriving the working poor, children and people with disabilities of health care and in the long run reducing funding for the care of elderly people in nursing homes.

The Republican bill would have largely undone the expansion of Medicaid under the A.C.A., which added 11 million low-income adults to the program and guaranteed the federal government would cover almost all of their costs. It would have also ended the federal government’s open-ended commitment to pay a significant share of states’ Medicaid costs, no matter how much enrollment or spending rose. Instead, the bill would have given the states a choice between a fixed annual sum per recipient or a block grant, both of which would have almost certainly led to major cuts in coverage over time.

The nonpartisan Congressional Budget Office predicted that the Republican bill would have cumulatively cut projected spending on Medicaid by $839 billion and reduced the number of Medicaid beneficiaries by 14 million over the coming decade.

Many Republicans could not stomach those consequences. Even some conservatives — Christopher H. Smith of New Jersey, for example, and Daniel Webster of Florida — expressed concerns about the number of Medicaid recipients who could suffer.

The Trump administration will likely still seek to rewrite Medicaid rules and give states more leeway to limit benefits or eligibility, for example, allowing them to require certain adults in the program to have jobs or pay monthly premiums. And many Republican governors and members of Congress remain determined to curb Medicaid spending, including by methods proposed in the bill. In 2015, the nation spent more than $532 billion on Medicaid, of which about 63 percent was federal money and the rest from the states.

Still, last week’s defeat reflected how hard it is to take away an entitlement. It also showed the broad and deep reach of Medicaid, which covers about six times as many people as the private marketplaces created under the A.C.A. but, perhaps because the markets are more strongly associated with President Barack Obama and his law, got less attention in this month’s contentious debate.

Medicaid now provides medical care to four out of 10 American children. It covers the costs of nearly half of all births in the United States. It pays for the care for two-thirds of people in nursing homes. And it provides for 10 million children and adults with physical or mental disabilities. For states, it accounts for 60 percent of federal funding — meaning that cuts hurt not only poor and middle-class families caring for their children with autism or dying parents, but also bond ratings.

The program is so woven into the nation’s fabric that in 2015, almost two thirds of Americans in a poll by the Kaiser Family Foundation said they were either covered by Medicaid or had a family member or friend who was. The program not only pays for 16 percent of all personal health care spending nationwide, but also accounts for 9 percent of federal domestic spending.

Because it has always covered a patchwork of groups — and many of its beneficiaries are poor and relatively powerless — Medicaid lacks the unified, formidable political constituency that Social Security and Medicare have. States often have different names for the program, and many who rely on it don’t realize that MassHealth in Massachusetts or TennCare in Tennessee are just Medicaid by another name.

But in Kaiser’s polling since 2005, the percentage of people who support cutting Medicaid spending has never exceeded 13 percent. “The conventional wisdom that there’s a great deal of stigma attached to this program does not bear out in the public opinion data,” said Mollyann Brodie, who oversees polling for the foundation.

President Trump led the charge for the bill that would have slashed Medicaid, but he recognized the program’s political potency during his campaign, proclaiming when he announced his candidacy that Medicaid should be saved “without cuts” and repeatedly taking to Twitter to declare his support for it. “The Republicans who want to cut SS and Medicaid are wrong,” he wrote in July 2015.

The C.B.O. report made it clear that within a few years, the cuts to Medicaid in the Republican bill would have been felt by millions of Americans.

“It’s health care for a huge chunk of the country,” said James A. Morone, a political-science professor at Brown University, “and as Donald Trump discovered, it’s really, really complicated to mess around with.”

Facing Need Back Home

As he waited to see what would happen to the Republican proposal last week, Myrone Pickett said, “I’ve got a question mark hanging over my head.”

Mr. Pickett, of Bloomfield, N.J., got health insurance under the A.C.A.’s expansion of Medicaid, and has used it for monthly shots of Vivitrol, a drug that reduces cravings for opioids and alcohol. A heroin addict for 16 years, Mr. Pickett, 51, said the treatment had helped him stay clean for the past year, get medication for bipolar disorder and land a job at a grocery store.

The A.C.A. offered a tempting deal to states that agreed to expand Medicaid eligibility to everyone with incomes up to 138 percent of the poverty level — $16,400 for a single person — mostly low-wage workers like cooks, hairdressers and cashiers. The federal government would initially pay 100 percent of the costs of covering their medical care, and never less than 90 percent under the terms of the law. Over the past three years, 31 states and the District of Columbia took the deal.

The move was especially helpful to states overwhelmed by the opioid epidemic. It required Medicaid to cover addiction and mental health treatment for those newly eligible.

Announcing his vote against the G.O.P. proposal last week, Representative Brian Fitzpatrick, a Pennsylvania Republican who represents a politically moderate district north of Philadelphia, said his top concern was “the impact on the single most important issue plaguing Bucks and Montgomery Counties, and the issue that I have made my priority in Congress: opioid abuse prevention, treatment and recovery.”

The Republican bill would have allowed Medicaid payments to grow per person at an inflation rate that would have eroded their value over time. The C.B.O. estimated that states would have gradually had to devote more of their own money to Medicaid, cut payments to doctors, tighten eligibility or cut services covered.

In 2020, states would have started losing the 90 percent federal match for anyone who had gained Medicaid under the A.C.A. expansion but was dropped from the rolls, even briefly. And the bill required beneficiaries in the expansion population to re-enroll every six months, instead of annually, increasing the likelihood that many would be dropped.

As a result, the C.B.O. estimated that by 2026, less than 5 percent of Medicaid recipients enrolled under the A.C.A. would have been covered at the higher matching rate. But more broadly, the cuts would have almost inevitably affected every group covered by Medicaid, including the biggest block of recipients: 36 million children as of last year.

Representative Jaime Herrera Beutler, a Washington State Republican, announced her “no” vote on the bill Thursday, saying, “Protecting vulnerable children is a core purpose of the Medicaid program and when the program fails to do so, it fails entirely.”

The cuts would also likely have eventually hit poor, chronically ill mothers like Tracie Scott of Paulding, Ohio. She has multiple sclerosis and quit her job at a dollar store two years ago because of it. Medicaid covers her and her four children, including her 2-week-old daughter and an 8-year-old son with brittle-bone disease who has needed expensive medication and care for frequent fractures.

“I’d be afraid to see some of the bills for my son,” Ms. Scott, 30, said as she cradled her newborn, Izabella, in their hospital room recently. “It’s been a lifesaver.”

For more than six million Americans older than 64, Medicaid pays for nursing homes and other long-term care that they would never otherwise be able to afford, while Medicare covers their medical care.

The threat to such care propelled Representative Webster, whose Central Florida district includes The Villages, a retirement community with more than 150,000 residents, to lean “no” on the bill.

“This uniquely impacted Florida and our growing senior population that’s only going to explode in years to come,” said Jaryn Emhof, his spokeswoman.

Representative Smith of New Jersey said he was voting no because of concerns about the impact on people with disabilities, who make up just 15 percent of all Medicaid recipients but account for 42 percent of spending, making them particularly vulnerable to cuts.

For millions of disabled people, Medicaid covers services provided at home or through local programs — aides who help them walk, eat and bathe, for example, and physical and speech therapy — that allow them to stay out of institutions, where care is often more expensive. But those services are optional for states, while the cost of institutional care is not. The law would have given states an incentive to place them in institutions.

Medicaid pays for Barbara Theus, 67, to attend a day program in Southfield, Mich., so that her son and caregiver, Royale Theus, can work. Ms. Theus sustained a serious head injury in a car accident 11 years ago and has not been able to care for herself since then. Medicaid also pays for home health aides who help Ms. Theus, a former nurse who did not have much savings at the time of her accident, get showered and fed.

Mr. Theus was relieved when the bill failed. Had his mother lost coverage, he said, he would have had to leave his job to care for her. “I was hopeful that the powers that be would make the best decisions for the people, and that’s what happened,” he said.

The Battle Against Medicaid

This was the third major effort by Republicans to end Medicaid as an open-ended entitlement. The first was under President Ronald Reagan, the second was in 1995, after President Bill Clinton’s unsuccessful attempt to expand health care coverage. But this was the first time Republicans tried it while they controlled the White House and both houses of Congress.

For all the battles over the years, Medicaid started as something of an afterthought.

By 1960, both parties were worried that the country’s growing reliance on employer-based insurance was leaving out elderly people, who were unable to pay the rapidly rising cost of health care.

The night of President John F. Kennedy’s assassination in November 1963, Lyndon Johnson returned to his home in Washington and, unable to sleep, summoned three aides. “That’s when he took out his pen and wrote down the priorities that he was going to pursue,” one of those aides, Bill Moyers, recalled in an interview. Among them was government health insurance.

President Harry S. Truman had sought to establish national health insurance — and failed. Democrats decided to take on a more limited goal: insurance for elderly people. They called it Medicare. Democrats pushed for it to cover hospital bills for the elderly; Republicans wanted it to pay for private doctor’s bills.

The American Medical Association had long lobbied against Medicare, hiring Reagan, then a Hollywood actor, to be the face of its campaign, producing a 1961 LPtitled “Ronald Reagan Speaks Out Against Socialized Medicine.”

And the doctors’ group had an ally in Wilbur Mills, a conservative Democrat who was chairman of the powerful House Ways and Means Committee, who like the doctors’ group did not think that well-off elderly people should have their bills covered. In 1960, Mr. Mills had co-sponsored a law that established a small programto help the states treat the needy, as a way to stave off proposals for Medicare. The doctors’ group suggested expanding this program, preferring it because it would be administered by states, not the federal government.

Mr. Mills had a change of heart after Johnson’s landslide victory in 1964. Johnson’s Republican opponent, Senator Barry Goldwater of Arizona, had denounced Medicare, and Mr. Mills, and many Republicans, were eager to distance themselves from him.

In early 1965, Mr. Mills proposed what became known as the three-layer cake: Medicare for hospital insurance, Medicare for doctor’s bills and a broadened version of the law that helped states pay for the care of the poor, the program that would become Medicaid.

“Hardly anybody talked about Medicaid,” said Paul Starr, a sociology professor at Princeton. “It just got added on.”

At first, Medicaid helped states provide medical care only for single parents and children on welfare.

Over the next 25 years, Democrats — sometimes working with Republicans — gradually pushed to expand benefits — to two-parent families, to children with speech and development delays, to home treatment for people who would otherwise be institutionalized, to children up to age 5, then to age 8 and later to age 18, and to pregnant women.

Ironically, some of the biggest expansions in Medicaid came in the 1980s under Reagan, the onetime A.M.A. mouthpiece.

After Republicans failed to turn Medicaid into a block grant, Democrats, who still controlled Congress, worked on compromises with the president and other Republicans, sometimes allowing cuts in programs like Medicare in exchange for expanding Medicaid, said former Representative Henry Waxman, a Democrat who shepherded many of those expansions.

Democrats carefully calibrated each expansion to fit within the annual budget, submitting plans to the Congressional Budget Office for “scoring,” to see how much each would cost. “We couldn’t do it all at once because we didn’t have enough money in the budgets,” Mr. Waxman said. But eventually, the goal to decouple Medicaid from the welfare system was achieved. “We broke the link to welfare,” he said.

By the 1980s and ’90s, health insurance was becoming prohibitively costly, and wages were starting to stagnate. Employer-based health insurance was eroding. States led by Republicans as well as Democrats began to expand their Medicaid programs.

“What people began to accept, including Republicans, was that the assumption that you could afford health insurance if you were an able-bodied adult was not true,” said Colleen M. Grogan, a professor at the School of Social Service Administration at the University of Chicago, who has written extensively on health care. “You could be working and still not afford health insurance.”

In 1996, Mr. Clinton expanded Medicaid to cover more working families as part of his welfare overhaul. Campaigning for re-election that year, he depicted Medicaid as a middle-class program, telling audiences it was helping their grandparents.

“He is the first Democrat to start calling Medicaid one of ‘our programs,’” said Professor Morone of Brown. “There was a sense that Medicaid had sort of grown up as an entitlement.”

The expansion of Medicaid in the Children’s Health Insurance Program, passed with Republican sponsorship in 1997, set the stage for the sweeping expansions of the Affordable Care Act 13 years later.

But politics during Mr. Obama’s presidency had become highly polarized. While earlier expansions of Medicaid had sometimes been bipartisan, the A.C.A. passed without a single Republican vote in Congress. The Tea Party had risen in opposition to the legislation, and later helped elect many of those who now form the conservative Freedom Caucus.

Gradually, though, Republican-led states have adopted the expansion. And now that the law known as Obamacare has survived the effort to repeal it, more states may choose to expand Medicaid. In Maine, voters will decide this fall whether to do so, and in Kansas, the Legislature has all but approved an expansion, although Gov. Sam Brownback could veto it.

Last week, despite their desire to repeal Mr. Obama’s biggest domestic legacy, some Republicans recognized that any bill that would lead to such drastic cuts in Medicaid would simply hurt too many of their constituents.

In Ashland, Va., Medicaid made it possible for Kim Goodloe and her husband, Tom, to start a small company making metal parts for semiconductors and medical devices after the birth of twin boys with tuberous sclerosis 27 years ago. The genetic disorder causes tumors in vital organs, leading to frequent seizures, and Mrs. Goodloe had quit her job to take care of the boys when they were 4 — Medicaid did not cover services for them back then. But now, Medicaid provides a home aide for Matthew, who is incontinent and nonverbal, suffers daily seizures and needs help walking.

For the other twin, Christopher, who is less severely developmentally disabled, Medicaid provided a job coach, helping him to work at their company and earn enough money that he now pays taxes.

The Goodloes have private insurance, but it is not required to pay for the twins’ services, she said. With Virginia facing such steep cuts to its federal Medicaid payments, Mrs. Goodloe worried about losing the home health aide. They would have had to downsize the business, which employs 30 people.

“Even within my own family, when you say ‘Medicaid’ it comes with some, ‘Those people don’t want to work.’ They believe there’s a lot of fraud, there’s people that don’t deserve it.”

“But then,” she said, “They’ll say, ‘How could they take it away from Matthew?’”

https://www.nytimes.com/2017/03/27/health/medicaid-obamacare.html

SAMUELSON: Transfer Medicaid’s long-term care to federal government

Robert Samuelson - The Washington Post - March 19, 2017

WASHINGTON - It’s time to take control of Medicaid before it takes control of us. Unless we act — and there is little evidence that we will — Medicaid increasingly becomes another mechanism by which government skews spending toward the old and away from the young. In the raging debate over the Affordable Care Act, this is a subject that neither Republicans nor Democrats dare touch. It’s an ominous omission.

Medicaid is the sleeping giant of U.S. health care. Created in 1965, it provides health insurance for the very poor. Here are some basic Medicaid facts:

• It is the nation’s largest health insurance program by beneficiaries, with 68 million recipients compared with Medicare’s 55 million (Medicare provides insurance for the 65 and over population).
• Medicaid’s costs are shared between the federal government (roughly 60 percent) and state governments (40 percent). In 2015, Medicaid spending totaled $545 billion compared with Medicare’s $646 billion, reports the Kaiser Family Foundation.
• Although the Obamacare debate has focused on private insurance subsidized through health exchanges, the expansion of Medicaid — adopting more liberal eligibility requirements — resulted in the largest gain of insurance coverage, about 11 million people. 

But the most significant Medicaid fact is this: Although three-quarters of Medicaid recipients are either children or young adults, they account for only one-third of costs. The elderly and disabled constitute the other one-quarter of recipients, but they represent two-thirds of costs.

How could this be? Doesn’t Medicare — not Medicaid — cover the elderly and disabled? Well, yes, but there’s a giant omission: nursing home and other long-term care. Medicaid covers these for the poor elderly and disabled.

Here’s where the past and future collide. As the population ages, the people needing long-term care will soar. From 2015 to 2030, the number of Americans 85 and older will rise about 50 percent to 9 million, projects the Census Bureau. Many will end up in nursing homes, with high costs. The average health costs of Americans 85 and over are 2.5 times greater than for people 65 to 74, says the Center on Budget and Policy Priorities.

At the federal level, spending on the elderly — mainly for Social Security, Medicare and Medicaid — is already crowding out non-elderly spending, as the Trump administration’s new 2018 budget shows. Now pressures are tightening on states.

Because they pay 40 percent of Medicaid, its escalating costs compete directly with state and local services — schools, roads, police, parks, sanitation — and lower taxes. Medicaid’s “entitlement” nature means that anyone who qualifies for support must get it. By contrast, schools and other state services get what seems affordable.

Fortunately, there’s a sensible solution to this problem. It isn’t to gut care for the elderly. Instead, we should transfer Medicaid’s long-term care to the federal government, which would pay all costs, probably by merging with Medicare. In return, the states would assume all Medicaid’s costs for children and younger adults, give up some or all of their federal aid for K-12 schools and, if needed, trim other federal grants to ensure financial neutrality.

For states, spending would no longer be tied to demographic trends — an aging society — they can’t change. Controlling schools and a child-centered Medicaid, they would be in the best position to fight child poverty, which is arguably the nation’s most serious social problem. The rising costs of long-term care, a national problem, would not handcuff them.

As for the federal government, it would control all major programs for the elderly and disabled. If benefits for the elderly are to be cut (say, by raising eligibility ages), that job is best done if the federal government can choose from all programs for the old.

Unfortunately, national politicians seem uninterested. They prefer instead to bleed the states.

http://www.app.com/story/opinion/columnists/2017/03/19/samuelson-transfer-medicaids-long-term-care-federal-government/99396812/

Trumpcare is dead. May it forever stay in its shallow grave

by Adam Gaffney - The Guardian - March 27, 2017

The American Health Care Act – a bill engineered to transform the healthcare of the poor into precious metal for the rich – has departed. Let us hope it stays in its admittedly shallow grave. 

Its implosion on Friday – attributable to some combination of the intransigence of the House hard right, an extraordinary lack of popular support, and an impressive show of grassroots antagonism – will prove to be a pivotal moment in healthcare history, for at least two reasons. 

First, it is tantamount to a societal rejection of the conservative healthcare ethos. Second, it may very well open the door to more progressive, fundamental healthcare change in the years to come.

Would-be Trumpcare had three main pillars: continue the Affordable Care Act’s (ACA) subsidization of private health plans (though recalibrated along highly regressive lines), shrink Medicaid by about 25% over a decade, and provide lavish tax breaks to the rich. 

It was thus the evil cousin of Obamacare: it would have benefited the well-off at the expense of the working class and sick, it is true, yet it would also have conserved Obamacare’s overall organization, and left many of its insurance regulations intact. 

This last fact played a major role in the bill’s fate, for it alienated hard-right true believers in the “House Freedom Caucus”. Conservatives contended that it would only be by eliminating Obamacare’s various insurance regulations – including the one that requires that plans cover “essential health benefits“ like hospitalizations, maternity care and medicines – that premiums would fall. 

They are not entirely wrong on this point: skimpier plans are cheaper. Likewise, we could lower rent if landlords weren’t expected to provide heat, running water and a low risk of structural collapse. 

And ideologically, for true believers in the conservative ideal of healthcare freedom, governments shouldn’t mandate that plans cover particular benefits any more than they should require that all pizzas be sold with some arbitrary assortment of toppings (which would admittedly not be to everyone’s tastes). 

Why, for instance, should I be forced to pay for coverage of prenatal care, if I have no uterus? And no emphysema coverage for me, thank you very much! – as a pulmonologist I’m wise enough to have other vices than cigarettes. Of course, even putting aside old-fashioned notions like solidarity and basic decency, as policy such sentiments are puerile nonsense. 

We cannot know what medical problems we will encounter: a system wherein we all select coverage tailored to our unique gonads, bad habits or unlucky genes would be as dysfunctional as it was cruel. 

Yet to the dismay of many on the right, the Trumpcare bill did little, at least initially, to let a thousand health insurance plans bloom. These hard-right House Republicanswere unimpressed, seeing the bill as little more than Obamacare reincarnate.

In the 18 days between the introduction of his bill and its death, Speaker of the House Paul Ryan strove to mollify them: he offered modifications including a Victorian-era themed provision to encourage states to impose work requirements on Medicaid participants, an option for states to more radically degrade Medicaid through “block granting”, and – at the eleventh hour – a provision to shred Obamacare’s “essential health benefits” requirements. 

All was to no avail. For Trumpcare had almost no popular support – a widely cited poll found that pathetically few Americans (a mere 17%) liked what they heard – and each slide to the right risked shedding more support from so-called “moderates”, who probably mostly feared for their own necks (electorally speaking) by lining up behind such a widely detested bill (which could have been a factor among hard-right lawmakers as well). With an excess of defectors on both sides, Ryan and Trump were forced to declare a humiliating defeat.

Trumpcare, it is clear, belongs in the dustbin of history. But with it should go the pernicious principle at the heart of conservative healthcare policy. The right promises “choice”, which is intrinsically appealing, for we all want choice in healthcare: the right to choose our doctor, and to receive care that comports to our unique needs and beliefs. 

Yet what the right – and, for that matter, the center – promise is the mostly empty choice of insurance coverage. But coverage choice dictated by one’s wallet is frequently no choice at all. More importantly, the greatest choice in care is found in a universal system with a single tier of comprehensive coverage.

And so, it may be the second legacy of Trumpcare’s defeat – the opening of a window for progressive healthcare change – that will prove even more consequential. Trump lied – he was never going to deliver “insurance for everybody”, as he promised in an interview with the Washington Post – but that’s what people want. 

The only feasible path to that goal – the one that would produce the savings needed to cover the new costs – remains a universal system with single-payer financing. The next move for progressives is therefore a no-brainer, both politically and morally: coalesce behind single-payer as the healthcare vision of tomorrow.

https://www.theguardian.com/commentisfree/2017/mar/27/trumpcare-dead-forever-stay-in-shallow-grave?CMP=Share_iOSApp_Other

Maine Voices: The problem isn’t Obamacare; it’s the insurance companies

by Cathleen London - Portland Press Herald - November 28, 2016

Patients and primary care physicians are getting the raw end of the deal for the sake of corporate profits.

MILBRIDGE — With the recent news about increases in premiums for health plans sold through the Affordable Care Act marketplace, everyone wants to vilify the ACA. The ACA is but a symptom of the issue. Where are our policy dollars going?

As a primary care physician, I am on the front lines. Milbridge is remote. In good weather, we are 30 to 40 minutes from the nearest emergency room, so my office operates as an urgent care facility as well as a family medical practice.

It can take 20 minutes for an ambulance to get here (as it did one time when I had a patient in ventricular tachycardia — a fatal rhythm). I have to be stocked to stabilize and treat.

We are also about two hours from specialist care. Fortunately, I am trained to handle about 90 percent of medical problems, as my patients often do not want or do not have the resources to travel. I have to be prepared for much more than I did in Boston or New York City, where I had colleagues and other materials down the hall or nearby. No longer do I have a hospital blocks away.

One evening I was almost home after a full day’s work. Around 7:30, I got a call on the emergency line regarding an 82-year-old man who had fallen and split his head open. His wife wanted to know if I could see him, even though he was not a patient of mine.

Instead of sending them to the ER, I went back to the office. I spent 90 minutes evaluating him, suturing his wound and making sure that nothing more sinister had occurred than a loss of footing by a man who has mild dementia. When I was sure that the man would be safe, I let them go.

I billed a total of $789 for the visit, repair, after-hours and emergency care costs. Stating that the after-hours and emergency services had been billed incorrectly, Martin’s Point Health Care threw out the claims and reimbursed me $105, which does not even cover the suture and other materials I used.

I called them about their decision, said that it was not right and let them know they’d lose me if they reimbursed this as a routine patient visit. They replied, “Go ahead and send your termination letter” – which I did.

The same day, Anthem Blue Cross kept me on the phone for 45 minutes regarding a breast MRI recommended by radiologists on a woman whose mother and sister had died of breast cancer. She’d had five months of breast discharge that wasn’t traceable to anything benign (and it turns out the MRI is highly suspicious for cancer).

Anthem did not want to approve the MRI unless it was to localize a lesion for biopsy, even though the mammogram had been inconclusive! This should have been a slam-dunk fast track to approval; instead, dealing with Anthem wasted a good part of my day.

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Then Aetna told me there is no way to negotiate fees in Maine. I was somewhat flabbergasted. I do more here than I did in either Brookline, Massachusetts, or New York. The rates should be higher given the level of care I am providing. I have chosen not to participate with them. This only hurts patients; however, I cannot keep losing money on visits.

I do lose money on MaineCare – their reimbursement is below what it costs me to see a patient. For now, that is a decision that I am living with.

I had thought those losses would be offset by private insurance companies, but their cost shifting to patients is obscene. I pay half of my employees’ health insurance, though I’m not required to by law – I just think it is the right thing to do.

My personal policy costs close to $900 a month for me and my sons (all healthy), and each of us has a $6,000 deductible. This means I am paying rack rate for a policy that provides only bare-bones coverage.

Something is wrong with the system. In one day, I encountered everything wrong with insurance. I am not trying to scam the system. I am literally trying to survive. I am trying to give care in an underserved area.

This is not the fault of Obamacare, which stopped the most egregious problems with insurance companies. Remember lifetime caps? Remember denials for pre-existing conditions? Remember the retroactive cancellation of insurance policies? Returning to that is not an option.

One answer is direct primary care: contracting straight with patients to provide their care, instead of going through insurance companies to get paid. I offer it (though I still accept Medicare, MaineCare and some private insurers). Many of my colleagues have also opted for direct primary care – they’ve experienced the same frustrations I have.

Something has to change if we are to attract up-and-coming medical students to primary care and retain practicing physicians. When both patients and physicians are frustrated, we know that only greed is winning, and the blame for that lies with corporations.

http://www.pressherald.com/2016/11/28/maine-voices-the-problem-isnt-obamacare-its-the-insurance-companies/

Pushing Obamacare Over the Cliff

by Steve Rattner - NYT - March 28, 2017

After Republicans pulled their legislation to repeal and replace the Affordable Care Act last Friday, President Trump told The Washington Post, “The best thing politically is to let Obamacare explode.”

Or he could light a match. Republicans may have conceded defeat in their legislative effort to get rid of Obamacare, but their guerrilla war to achieve its demise remains underway.

The stealth battle began on Inauguration Day, when Mr. Trump signed an executive order giving his agencies wide latitude to weaken the law.

Almost immediately, the Department of Health and Human Services scaled back advertising aimed at encouraging people to enroll in a health insurance plan by the Jan. 31 deadline for 2017.

No surprise, then, that sign-ups for this year came in a bit short of expectations.

Next, the Internal Revenue Service announced that it would continue to allow taxpayers to file their returns without indicating whether they had complied with the mandate to have insurance. Assertions to the contrary notwithstanding, this was quickly interpreted to mean that those failing to comply with the health care act’s insurance requirement would not be assessed penalties.

These may sound like small potatoes, but the requirement that all Americans have insurance is at the heart of Obamacare. Without maximum participation of healthy, young Americans in the insurance exchanges, insurers cannot afford the cost of covering older, less healthy individuals.

That’s the essence of why companies have been dropping out of the marketplace, creating the risk that counties in states like Tennessee and Arizona may have no insurers participating.

Much more seems on the horizon. This month, Tom Price, the secretary of the Health and Human Services Department, tweeted: “There are 1,442 citations in the #ACA where it says. ‘The secretary shall …’ or ‘The secretary may …’ @HHSGov, we’ll look at every single one.”

Through that pathway, the Trump administration can chip away at other parts of Obamacare, notably the expansion of Medicaid.

While Medicaid expansion can’t collapse the way that the exchanges could, Mr. Price could diminish it by taking steps like allowing states to impose a work requirement on enrollees or to limit lifetime benefits. He could also water down the 10 essential benefits required for all policies by the law, like maternity care and mental health coverage.

Even if my worries are misplaced, remember that Obamacare worked, in part, because it had the active support of the entire executive branch.

It’s no surprise that, like every huge new social program, the A.C.A. needs some tuneups.

For example, the well-intentioned decision to limit the size of the premiums that can be charged to older people to three times what can be charged to younger people has resulted in higher premiums for younger Americans, which has in turn discouraged sign-ups.

Raising that limit (as Republicans have proposed) would be a plus if coupled with higher subsidies for deserving older people, as would be increasing the penalties on those who opt out. At present, those fees are far less than the cost of insurance.

Conservatives say they want states to have more flexibility. One meritorious idea would be allowing states to create reinsurance pools that would cushion insurers against losses, thus lowering premiums.

To be fair, the administration’s actions to date have not been completely one-sided. In February, to provide more certainty to insurers, H.H.S. set stricter limits on sign-ups outside the defined enrollment periods. The Republicans even incorporated one good idea in their failed bill: a $100 billion pool that states could use to help cover the cost of insuring very sick people, thereby shoring up weak exchanges. There seems little chance of that happening now.

But the White House has been silent on a major issue: whether it will continue to fight a lawsuit by House Republicans intended to eliminate subsidies to low-income Americans to help cover their deductibles and co-payments.

If the effectiveness of the A.C.A. is diminished — whether by affirmative moves by the Trump administration or passive resistance to needed improvements — rest assured that the Republicans will try to blame Obamacare’s supporters. Mr. Trump may not know how to govern, but he’s proven his ability to conduct Twitter wars.

Supporters of the A.C.A. — perhaps the greatest single legislative achievement in many decades — need to counter that, informing Americans that any deterioration in their coverage will be the fault of the Trump administration.

https://www.nytimes.com/2017/03/28/opinion/pushing-obamacare-over-the-cliff.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-right-region&region=opinion-c-col-right-region&WT.nav=opinion-c-col-right-region

2018 Dilemma for Republicans: Which Way Now on Obamacare?

by Jonathan Martin - NYT - March 28, 2017

WASHINGTON — As they come to terms with their humiliating failure to undo the Affordable Care Act, Republicans eyeing next year’s congressional campaign are grappling with a new dilemma: Do they risk depressing their conservative base by abandoning the repeal effort or anger a broader set of voters by reviving a deeply unpopular bill even closer to the midterm elections?

The question is particularly acute in the House, where the Republican majority could be at risk in 2018 if the party’s voters are demoralized, and Democratic activists, energized by the chance to send a message to President Trump, stream to the polls.

Sifting through the wreckage of a disastrous week, Republican strategists and elected officials were divided over the best way forward. Some House Republicans pressed to move on to other issues and notch some victories that could delight their own loyalists while not turning off swing voters.

“We’ve got a lot of time to do real things on infrastructure, to do real things on tax reform, on red tape reform, and really get the American economy moving,” said Representative Steve Stivers of Ohio, chairman of the National Republican Congressional Committee, the House campaign arm. “We do those things and we still have a lot of time to recover.”

“If you’re going to fumble the ball,” he added, “better to do so in the first quarter of a football game.”

Devising health care legislation that could appeal to both wings of the House Republican Conference — the hard-line conservatives and more moderate members — would require a nearly superhuman feat, added Representative Billy Long, Republican of Missouri.

“Not unless Harry Houdini wins a special election to help us,” Mr. Long said about the prospects of cobbling together a coalition that could agree on how to repeal and replace the health care law.

But other longtime Republicans warned that if the party did not address what they have derided as Obamacare, an issue that has been central to their campaigns for the last seven years, they would incur a heavy political price in the midterm elections.

Midterm campaigns have increasingly become akin to parliamentary elections — referendums on the party in power rather than on individual candidates, where turnout by dependable partisan voters is the deciding factor.

“If they fall on their sword on this, they’re going to get slaughtered,” said former Representative Thomas M. Davis III, a Virginia Republican who himself was once at the helm of the House campaign committee.

“Where parties get hurt in midterms is when their base collapses,” Mr. Davis said. “Democrats are going to show up regardless of what you do. If our voters don’t see us fulfilling what we said we were going to do, they’ll get dispirited.”

What troubles many Republican strategists is the specter of the party’s most reliable voters being bombarded by reminders of their leaders’ failure to address the health law. They fear a recurring story line sure to pop up every time insurance premiums increase, providers leave local networks, or, most worrisome, Republicans fund President Barack Obama’s signature achievement.

Conservatives, many of whom opposed the House repeal bill, now warn that it is untenable to stand pat on the issue — and that lawmakers will face retribution if they do not return to the repeal-and-replace effort.

“If people are looking at a situation where there’s no action on this, there are going to be conversations about primaries,” warned Michael A. Needham, the chief executive of Heritage Action for America, the Heritage Foundation’s political arm, which worked to scuttle the Republican health bill last week.

That Republicans even find themselves in such a quandary just over two months after Mr. Trump was sworn in is at once extraordinary and not altogether surprising. Republicans who were then in office opposed the Affordable Care Act when it was enacted in 2010, yet they were paralyzed in efforts to undo it.

The paradox is predictable for a party that has been at war with itself since the final years of President George W. Bush’s administration. Mr. Trump transcended those divisions last year in his campaign, but congressional Republicans remain riven between their hard-liners and mainstream conservatives.

Perhaps it was inevitable that these factions would clash over an issue as sensitive as remaking the American health care system. The purists — often from politically safe districts — believe the government should play almost no role in providing health insurance to its citizens. Placating them without endangering more pragmatic lawmakers worried about depriving constituents of their health coverage may be an impossible task.

“I think we need to start negotiating with Democrats instead of the Freedom Caucus,” said a frustrated Mr. Stivers, referring to the most conservative bloc of House Republicans. “They don’t know how to get to yes.”

Democrats, though, have no appetite for conciliation: They see the Republican disarray over health care, and the broader tensions on display in the clash over the health care law, as a path back to the House majority.

Seizing on the Republicans’ American Health Care Act, which according to a Quinnipiac University survey last week was supported by only 17 percent of Americans, Democrats have started digital advertising against the 14 potentially vulnerable House Republicans who supported the legislation in committee votes.

Some of these lawmakers represent districts that Hillary Clinton carried last year. They are as concerned about the consequences of casting a vote for the bill as they are about inviting a backlash from their bases for not addressing the issue at all.

Indeed, though much of the frustration from mainline Republicans has been directed at the Freedom Caucus, Republican lawmakers from pro-Clinton districts played just as big a role in torpedoing the American Health Care Act.

“I don’t want to vote for a bill that has no chance of passing the Senate,” explained Representative Leonard Lance of New Jersey, one such lawmaker who invoked the haunting tradition of House members’ casting risky and, in some cases, career-ending votes, only to see their Senate colleagues sit on the proposals.

Mr. Lance, whose district Mrs. Clinton carried, and other Republicans insisted after the bill’s collapse last week that they still wanted to wrestle with the Affordable Care Act in this Congress.

But former Representative Earl Pomeroy of North Dakota, a Democrat who lost his seat in 2010 in part because of his vote for the Affordable Care Act, said he thought Republicans like Mr. Lance were actually “breathing a sigh of relief” for averting a floor vote.

“It’s a very, very tough vote for somebody in a competitive race,” Mr. Pomeroy said. “They may alienate their base by voting against it, but if they support a bill resulting in people losing their coverage, there will be electoral hell to pay.”

https://www.nytimes.com/2017/03/28/us/politics/2018-dilemma-for-republicans-which-way-now-on-obamacare.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=first-column-region&region=top-news&WT.nav=top-news

"Thunderous Applause" Welcomes Sanders' Call for Medicare-for-All

'We have got to end the international disgrace of being the only major country on earth not to guarantee healthcare to all people as a right not a privilege'

by Deirdre Fulton - Common Dreams - March 27, 2017

A cheering crowd gave a rousing endorsement to Sen. Bernie Sanders' plan to introduce Medicare-for-All, or single-payer, legislation to Congress in the coming weeks, announced this weekend at a Vermont town hall meeting.  

"We have got to end the international disgrace of being the only major country on earth not to guarantee healthcare to all people as a right not a privilege," Sanders (I-Vt.) told the 1,000-strong audience in Hardwick, Vermont, where he appeared alongside the other members of the state's congressional delegation. "Within a couple of weeks I am going to be introducing legislation calling for a Medicare-for-All, single-payer program."

Vermont Public Radio said the announcement "drew thunderous applause" from the crowd at Hazen Union High School. 

As Common Dreams reported, last week's defeat of TrumpCare (also known as the American Healthcare Act or AHCA) left an opening for such a push. Multiple analyses have shown that replacing the Affordable Care Act (ACA or Obamacare) with a universal, single-payer health system is in fact the only way to increase coverage and fulfill President Donald Trump's campaign promises on healthcare. And as Physicians for a National Health Program (PNHP) co-founders David Himmelstein and Steffie Woolhandler asserted in an editorial on Wednesday, "Democratic politicians are feeling pressed and emboldened to embrace progressive policies" as the resistance shows its strength.

That call will only grow louder. The Huffington Post reported Saturday that a broad array of progressive groups—including the Working Families Party, the Progressive Change Campaign Committee, Credo, Social Security Works, and the National Nurses United (NNU)—is coalescing behind the single-payer goal in the wake of last week's political wrangling.

"The problem is the insurance companies, Big Pharma—they're gonna come back and use the chaos to their advantage," Social Security Works executive director Alex Lawson said to HuffPo. "If Democrats go with a half-a-loaf policy, Republicans are going to blame them for the failures of Big Pharma. They have to immediately pivot to expanding Medicare."

Meanwhile, Sanders' Democratic colleague in the House, Rep. Peter Welch, said that once Sanders' measure is introduced in the Senate, he'd put forth a companion bill in his chamber.

"It's a goal," Welch told Vermont Public Radio after the Hardwick town hall meeting. "In this Congress, we won't pass it. But I think we have to keep the goal out there, because we need in this country, like any industrialized country, a healthcare system that's affordable, accessible, and universal."

VPR reported:

Sanders told the audience that the defeat of the Republican healthcare bill demonstrates widespread dissatisfaction among Americans with GOP healthcare policies. And he says he thinks his "Medicare-for-All" bill will have strong appeal even among the red-state voters that put President Donald Trump in the White House.

Indeed, at a televised town hall forum in West Virginia earlier this month, that appeal was on display as a roomful of Trump voters cheered loudly for Sanders' assertion that universal healthcare is a right.

Sanders reiterated his plan on CNN's "State of the Union" on Sunday, telling anchor Dana Bash: "Ideally, where we should be going is to join the rest of the industrialized the world and guarantee healthcare to all people as a right. And that's why I'm going to introduce a Medicare-for-All, single-payer program."

Watch below:

Sanders also spoke of shorter-term goals in his interview on CNN: "Let us do, among other things, a public option. Let us give people in every state in this country a public option from which they can choose. Let's talk about lowering the age of Medicare eligibility from 65 to 55. Let's deal with the greed of the pharmaceutical industry."

The senator from Vermont also tweeted on Saturday, "Right now we need to improve the Affordable Care Act and that means a public option."

But corporate crime watchdog and single-payer advocate Russell Mokhiber warned against embracing the public option as a stand-in or even a stepping stone for Medicare for All.

In a piece published Sunday, Mokhiber quoted pediatrician and PNHP member Margaret Flowers, who co-directs the group Health Over Profit for Everyone. She said:

Introducing a public option will divide and confuse supporters of Medicare-for-All. Senators who should co-sponsor Medicare-for-All will be divided. Sanders seems to be urging a public option to please the Democratic Party, but Sanders cannot serve two masters—Wall Street's Chuck Schumer and the people. Sanders must decide whom he is working for.

While it might seem politically pragmatic to support a public option, it is not realistically pragmatic because a public option will not work. Senator Sanders knows that and he knows that the smallest step toward solving the healthcare crisis is National Improved Medicare for All. This would fundamentally change our health system that currently treats health as a commodity so that people only have access to what they can afford to a system that treats health as a public necessity so that people have access to what they need. Medicare-for-All achieves the savings needed to provide comprehensive coverage to everyone.

"We look to Senator Sanders to act on what he promised during his presidential campaign, a national improved Medicare-for-All now, not tomorrow," Flowers said. "Tomorrow never comes. It is not up to him to decide if single-payer can pass in Congress. That task is for the people to decide."

http://www.commondreams.org/news/2017/03/27/thunderous-applause-welcomes-sanders-call-medicare-all

Bernie Sanders, Top Progressives Announce New ‘Medicare For All’ Push

Lowering the Medicare age could be a starting point.

by Daniel Marans - Huffington Post - March WASHINGTON ― In the wake of the Republican failure to repeal the Affordable Care Act on Friday, leading figures in the progressive wing of the Democratic Partyare rallying behind a single-payer health insurance and a raft of other bold reforms.

These lawmakers and grassroots leaders have long believed that the problems plaguing the Affordable Care Act, also known as Obamacare, are rooted in the original health care law’s attempt to accommodate, rather than gradually replace, the private, for-profit health insurance system.

Now that efforts to eliminate the law wholesale are effectively dead, they are again arguing that the best way to improve the country’s health care system is to confront the power of corporate health care providers more directly.

“We have got to have the guts to take on the insurance companies and the drug companies and move forward toward a ‘Medicare for all,’ single-payer program,” Sen. Bernie Sanders (I-Vt.) said on MSNBC’s “All In with Chris Hayes” on Friday night. “And I’ll be introducing legislation shortly to do that.”

Sanders added on CNN’s “State of the Union” on Sunday that he would “absolutely” seek President Donald Trump’s cooperation on expanding Medicare and lowering prescription drug prices.

Even before the Republicans withdrew their Obamacare repeal bill, Rep. Keith Ellison (D-Minn.), the deputy chair of the Democratic National Committee and a close Sanders ally, previewed this message at a rally in defense of Obamacare on Thursday.

“Don’t just be satisfied with defeating Trumpcare ― set your sights on creating real Medicare for all!” he told a cheering crowd of hundreds of activists. Ellison is a co-sponsor of a “Medicare for all” bill in the House.

Representatives of several major progressive organizations ― the Working Families Party, the Progressive Campaign Change Committee, Credo, Social Security Works and the National Nurses United ― all echoed this push in conversations with The Huffington Post on Friday and Saturday.

“The problem is the insurance companies, Big Pharma ― they’re gonna come back and use the chaos to their advantage,” predicted Social Security Works executive director Alex Lawson. “If Democrats go with a half-a-loaf policy, Republicans are going to blame them for the failures of Big Pharma. They have to immediately pivot to expanding Medicare.”

During the debate over repeal, Rep. Ro Khanna (D-Calif.) used some of his time during a Budget Committee hearing to note that if Trump wanted to follow through on his campaign promise to repeal Obamacare and replace it with something “terrific,” he could fall back on an idea Trump himself endorsed in a 2000 book: single-payer. 

On Monday, Khanna said that now is the moment to drive the single-payer message home. “To resist Trump, we need to play offense and not just defense,” he told HuffPost.

“As I pointed out in the Budget Committee hearing on Trumpcare a few weeks ago, Donald Trump supported a single payer system modeled after Canada in 2000 in his book [The America We Deserve],” Khanna went on. “He knows that is the only system that would fulfill his promise of more benefits, more coverage, and less costs. We should have every Democrat quoting Trump on a single-payer system as a mantra, and support Senator Sanders and Congressman Welch in their vision for Medicare for All, or at least, a public option. Senator Sanders is the leader of the Democratic Party currently in offering a conviction-based, affirmative vision. We should follow his direction.”

Notwithstanding the support of the influential groups for the proposal and ― according to a May 2016 Gallup poll ― even a majority of the American people, Medicare-for-all legislation is a non-starter in the current Congress. Single-payer health insurance still lacks support from many, if not most, Democrats, let alone from the Republican lawmakers who control both chambers.

But the proactive strategy speaks to increasing confidence among progressives that if they stick to their ideals and build a grassroots movement around them, they will ultimately move the political spectrum in their direction.

“It does take time for social change,” said Chuck Idelson, communications director of National Nurses United, a 150,000-person labor union that has long advocated for a single-payer health insurance system. 

NNU is partnering with Justice Democrats and Brand New Congress on an online petition campaign demanding that Democrats back Medicare for all. The union is also advocating for a state level single-payer plan that is making its way through the California legislature.

“We didn’t end slavery overnight,” Idelson said. “It took from Seneca Falls in 1848 ’til 1920 until women won the right to vote. But they only won it by building a movement.”

The Washington Post reported Sunday that activists around the country urged their representatives over the weekend to get behind a single-payer program.

In the meantime, a potential benefit of this ambitious approach is what’s known as shifting the “Overton Window” ― a political science term for the narrow range of acceptable political views at a given moment in time.

By adopting a position that is considered extreme by contemporary standards, politicians and activists can make more attainable policy goals start to seem reasonable by comparison.

That phenomenon already seems to be working in progressives’ favor.

Sen. Jeff Merkley (D-Ore.), the only one of Sanders’ Senate colleagues to endorse his presidential bid, discussed the possibility of lowering the Medicare eligibility age or empowering Medicare to negotiate drug prices in his statement on the Republican bill’s collapse.

“There are plenty of ideas already on the table that would make health care more affordable for working families, from a public option, to prescription drug negotiations, to offering older Americans the chance to buy into Medicare,” Merkley said on Friday. “I’m happy to work with anyone, from either side of the aisle, to explore these or any other ideas that would improve health care for working Americans.”

Lowering the Medicare eligibility age from its current level of 65 is a “very interesting” idea, because of the positive financial effect it would have on the Obamacare insurance exchanges, said Austin Frakt, a health economist for the Department of Veterans Affairs.

By allowing the oldest exchange participants to enroll in Medicare, lowering the Medicare age would relieve the health insurance marketplaces of some of their costliest customers, said Frakt, who also has academic posts at Boston University and Harvard.

“It would reduce the premiums in those markets,” he predicted. (Frakt noted, however, that absent measures to offset the cost of the additional beneficiaries, the change would increase Medicare’s financial burden.)

Social Security Works’ Lawson praised the idea as an incremental step toward Medicare for all. 

“Start by lowering the age to 62 and get it down to zero,” he said.

Republicans, meanwhile, believe they can score points against Democrats on the issue.

“We aren’t even 3 months into the 2018 cycle and House Democrats have already begun calling for a single-payer healthcare system,” said Jesse Hunt, a spokesman for the National Republican Congressional Committee, in an email to reporters Monday.

“Obamacare is collapsing as a result of [its] top-down, government centered approach and the Democrats’ only answer is more government,” Hunt went on. “The question remains, how many other Democrats will join the chorus to appease the activist base of the Party that’s clamoring for far-left policies?”

If Democrats go with a half-a-loaf policy, Republicans are going to blame them for the failures of Big Pharma. Alex Lawson, Social Security Works

Another progressive policy gaining mainstream traction is legislation permitting the importation of prescription drugs from Canada, where the existing single-payer system keeps prices lower. Sen. Cory Booker (D-N.J.) was one of several Democratic senators to endure heavy criticism in January for helping block a resolution supporting drug importation. In late February, Booker became a co-sponsor of legislation Sanders introduced that would legalize prescription drug importation from Canada and other countries.

Trump talked about getting tough with pharmaceutical companies over the price of prescription drugs as recently as early January.

But he has remained silent on the matter since his inauguration, including the 17-day period when he was trying to pass House Republicans’ Obamacare repeal bill. What’s more, the ordeal cast serious doubt on Trump’s willingness to take on the GOP’s ultraconservatives, who no doubt would oppose any form of government intervention to reduce drug prices.

Trump now claims he is counting on Democrats to negotiate over Obamacare on his terms, since, in his telling, the law is on the brink of collapse.

Obamacare’s insurance exchange markets have major problems in some states and regions, but the nonpartisan Congressional Budget Office characterized them as stable overall.

Still, Senate Minority Leader Chuck Schumer (D-N.Y.) suggested in a CNN interviewon Friday night that Democrats would be open to working with Trump and congressional Republicans on reforming the law.

“We’re not gloating that they failed. We’re sad that they won’t work with us to improve Obamacare,” he said.

Murshed Zaheed, political director of Credo, warned Democratic leaders that any Democratic efforts to work with Republicans would not get any help from grassroots groups like his.

“If Democrats want to push their version of so-called moderate proposals ― good luck to them,” Zaheed said. “I don’t think anybody should be under any illusion that Schumer or [House Minority Leader Nancy] Pelosi will get anything from collaborating with the right-wing extremists that control Congress.”

http://www.huffingtonpost.com/entry/bernie-sanders-progressives-medicare-for-all_us_58d6f5c1e4b03692bea68fd2?

California Today: Considering a Single-Payer Insurance System

by Jonah Engel Bromwich - NYT - March 28, 2017

“We’re going to be living with Obamacare for the foreseeable future,” Paul Ryan, the Republican speaker of the House announced minutes after the legislation to repeal the law collapsed in Congress last week. Now some political leaders in California want to go even further. Last month State Senators Ricardo Lara and Toni Atkins introduced legislation to replace private health insurance with a publicly funded health care system run by the state government known as a single-payer system.

The bill does not include any details of how the state would pay for the multibillion program, instead simply declaring “it is the intent of the Legislature to enact legislation that would establish a comprehensive universal single-payer health care coverage program and a health care cost control system for the benefit of all residents of the state.”

Gov. Jerry Brown, who is both a fiscal hawk and an ardent supporter of Affordable Care Act, has already spoken about his skepticism of a single-payer program, saying it would be prohibitively expensive.

But at least one candidate running for governor next year plans to make universal health care a centerpiece of the campaign. Earlier this month Lt. Gov. Gavin Newsom said he was working with health care experts to craft a plan for a single-payer system. While he was mayor, the city approved a plan to offer universal health care for all of its residents.

Mr. Lara said the Republican defeat in Congress could pave the way for a single-payer system.

“It’s easier to expand health care than make up lost ground as we would have had to do,” he said. “We really have the chance to make universal health care a reality now.”

The proposal differs from existing programs in one big way: It would include all residents, regardless of their immigration status. Obamacare explicitly excluded undocumented immigrants from benefits of the program, though children in California can receive basic coverage even if they are undocumented.

Advocates of a single-payer program argue that it would bring down costs and encourage preventive care. But opponents say there would be less choice and efficiency in medical care, and that taxes would rise significantly for all residents.

This is not the first time state leaders have pressed for a single-payer bill. Similar legislation was passed in 2006 and 2008, though it did not include a way to pay from the system. Gov. Arnold Schwarzenegger vetoed the bill.

https://www.nytimes.com/2017/03/28/us/california-today-considering-a-single-payer-insurance-system.html?

Here’s How Trump Could Make Obamacare Better – Or Worse

With repeal off the table, the president needs to choose whether to help or hurt people.

by Jeffrey Young - Huffington Post - March 25, 2017

It’s President Donald Trump’s health care system now. The question is: What’s he going to do with it?

After the collapse of the GOP effort to repeal the Barack Obama administrations’sAffordable Care Act and enact a different set of reforms to the health care system Friday, Trump inherited programs that aren’t going anywhere and that serve tens of millions of Americans.

Trump reacted to his defeat by practically threatening to stand aside and do nothing to address the shortcomings of the law, like rising premiums and declining choices of insurers in some states. “The best thing we can do politically speaking is let Obamacare explode,” he said at the White House Friday. He made a similar statement on Twitter the next day.

Despite claims by Trump and House Speaker Paul Ryan (R-Wis.) that the Affordable Care Act is unfixable, the Trump administration has tools at its disposal it could use to make the Affordable Care Act’s health insurance exchanges more attractive to health insurers and potentially less costly for consumers. Or Trump could go in the other direction and undermine the law to bolster their case for “replacing” it later.

“I’m quite confident that unless the administration decides to not steward the exchanges because they have some draconian negotiating strategy that the exchanges will be fine next year,” said Andy Slavitt, who oversaw the exchanges as acting administrator of the federal Centers for Medicare and Medicaid Services under President Barack Obama.

“If they choose to screw with them, they control all the branches of government and I think they’ll be judged very harshly,” Slavitt said.

The White House and Department of Health and Human Services so far have sent mixed messages to the industry and consumers about what to expect.

The program doesn’t work for consumers if there are no insurers participating. Larry Levitt, Henry J. Kaiser Family Foundation

Trump issued an executive order on his inauguration day directing federal agencies to relax Affordable Care Act rules, and the IRS responded by announcing it wouldn’t reject tax returns that failed to include information about health coverage under the law’s individual mandate, for example.

But the administration also has taken some steps to quiet anxiety among health insurers that the exchanges next year won’t function properly and that losses some have suffered ― and that drove some insurance companies out of the market entirely ― will continue. Insurers have until late June to decide whether to sell policies on the exchanges next year.

And the key to shoring up the health insurance exchanges right now is catering to the carriers, even if those same changes make the law less consumer-friendly. 

“The program doesn’t work for consumers if there are no insurers participating,” said Larry Levitt, senior vice president of the Henry J. Kaiser Family Foundation.

There are limits to how much improvement, or damage, Trump could make to the health insurance exchanges, but there are several key actions that will go a long way to determining whether his administration wants to make the markets work better or worse.

How To Make It Better

Pay the subsidies

In addition to the tax credits the Affordable Care Act offers to low- and middle-income households to reduce their monthly health insurance premiums, the law provides extra subsidies to the poorest enrollees that cut their out-of-pocket costs like deductibles and copayments.

These subsidies are paid to health insurance companies directly, and the law requires them to reduce eligible customers’ cost-sharing whether the federal government makes the payments or not. And nonpayment isn’t a theoretical problem; it’s a real one.

House Republicans sued the Obama administration in 2014 to halt these payments, arguing the funding needs congressional approval it didn’t receive. A federal judge sided with House Republicans last year, prompting an appeal from Obama’s Justice Department. When Trump took office, his administration became the defendant, so he and congressional leaders got the court’s permission to delay the proceedings.

What they do next is crucial. If House Republicans drop the lawsuit or appropriate the money to keep the subsidies flowing, it not only would make sure low-income families keep their benefits, but it would quell a major source of worry for insurance companies.

Enforce the mandate

The individual mandate (and the fines taxpayers owe if they aren’t covered and don’t qualify for an exemption) is the least popular part of the Affordable Care Act, especially among Republicans. But it’s also vital for keeping the exchanges operating, because it pushes people with less medical need into the insurance pool, where their premiums offset the costs of treating sicker people.

The IRS announcement earlier this year made insurers nervous, but a strong signal now from the administration that it will make people comply with the law could alleviate that. “It’s insurer perceptions that matter here. If they’re not confident that this market is going to work, then they’re going to run for the exits or raise premiums,” Levitt said.

Work with the states

Alaska and Minnesota already are taking matters into their own hands to improve the health insurance markets in their states. Health and Human Services Secretary Tom Price has invited states to apply for “waivers” the Affordable Care Act created that could give them flexibility to redesign the exchanges themselves.

“That gets states more engaged,” Slavitt said. “It creates different solutions and, as far as I’m concerned, so long as you’re meeting the core requirement of covering more people with high-quality benefits, let the states experiment.”

One form that could take, Levitt explained, is helping states set up “reinsurance” funds like the one in Alaska. These compensate insurers that experience higher-than-expected costs, which allows them to charge lower premiums. And lower premiums mean less federal spending on tax credits, so these programs can actually save the federal government money, Levitt said.

Sign up more people

Enrollment on the health insurance exchanges dipped this year, partly because the Trump administration halted some outreach and advertising the Obama administration planned for the end of the 2017 sign-up period.

They could choose a different path for the coming enrollment campaign and work to sign up more customers, especially younger, healthier ones, which would strengthen the market for everybody, Levitt said.

“It’s potentially the most stabilizing thing the Trump administration could do,” Levitt said. 

Be flexible with insurers

Not all consumers would like this, but Price has some leeway to allow health insurance companies to offer policies with fewer benefits, which would lower premiums in exchange for less coverage.

The Affordable Care Act requires health plans to cover 10 “essential health benefits,”like hospitalizations and prescription drugs, but gives the Department of Health and Human Services the authority to specify how that works. 

Price would, for example, allow insurers to sell policies that only cover generic prescription drugs or that set limits on how many rehabilitation service visits a patient could have in a year, Levitt said.

“There are tradeoffs and consequences in all these changes,” Levitt said. “There’s a big difference between taking administrative steps to sabotage the law and moving it in a more conservative direction,” he said.

They control all the branches of government and I think they’ll be judged very harshly.Andy Slavitt, former administrator of the Centers for Medicare and Medicaid Services

How To Make It Worse

Cut off the subsidies

If Trump gives in on the House Republican lawsuit or if Congress refuses to fund the cost-sharing reductions, it could blow up the insurance exchanges quickly. Health insurance companies might be able to leave the markets right away, tossing millions off their plans to prevent facing billions of dollars in losses. And they wouldn’t come back.

“If they wanted to destroy the insurance market immediately, then the easiest thing they could do would be to stop paying,” said Timothy Jost, a professor at Washington and Lee University Law School.

Ignore the mandate

Trump could continue along the path the IRS started by making clear to the public that his administration won’t penalize people who don’t get health coverage. 

“Weakening the individual mandate could very well sabotage the individual insurance market,” Levitt said. 

“Insurers would perceive weakening the individual mandate as a sign that the administration is trying to sabotage the law,” he said. Fear that healthier consumers would opt out without the threat of a fine would spook insurers into avoiding the exchanges, he said.

Let enrollment stagnate

The next sign-up period for the health insurance exchanges begins Nov. 1. The administration could choose to pick up where Obama’s team left off and engage in a nationwide campaign to publicize health insurance enrollment and help people apply for coverage.

Or they could scale back this work, as they did early this year, and leave enrollees to their own devices, which would result in lower enrollment overall and likely make the insurance pool sicker, because those with the greatest health care needs would be the most prone to sign up without help or reminders. 

“It will be Secretary Price’s legacy forever if he acts in ways that are destructive to the American people. And he knows that people will die if they lose their coverage,” Slavitt said.

http://www.huffingtonpost.com/entry/heres-how-trump-could-make-obamacare-better-or-worse_us_58d7fea5e4b02a2eaab4f5b9?section=us_politics&utm_medium=email&utm_campaign=Politics%2032717&utm_content=Politics%2032717+Version+A+CID_968922887961451a662fbfe8241b3431&utm_source=Email%20marketing%20software&utm_term=Read%20More&

Trump’s rage over his health-care fiasco could hurt his own voters. Here’s how.

by Greg Sargent - Washington Post - March 28, 2017

President Trump has convinced himself that the Affordable Care Act is collapsing of its own accord, and once it does, Democrats will fall on their knees before him and grovel for a deal in which they will help remake the health-care system on Trump’s own terms. As his new tweet on the topic puts it: “The Democrats will make a deal with me on healthcare as soon as ObamaCare folds — not long.” Thus, the GOP health-care fiasco will be miraculously transformed into a Trump victory.

But despite all the bravado, what’s really happening now is that the failure to pass the GOP repeal-and-replace plan has ensnared Trump and Republicans in a trap. And it may force a course of action that ultimately boomerangs on Republican voters — on Trump voters.

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This trap is illuminated by some new reporting in the New York Times, which tells us that GOP strategists are divided over the way forward. Some are convinced Republicans must continue to wage war on the ACA, to avoid demoralizing the GOP base, while others fear doing that could alienate swing voters:

Sifting through the wreckage of a disastrous week, Republican strategists and elected officials were divided over the best way forward. Some House Republicans pressed to move on to other issues and notch some victories that could delight their own loyalists while not turning off swing voters. …

But other longtime Republicans warned that if the party did not address what they have derided as Obamacare, an issue that has been central to their campaigns for the last seven years, they would incur a heavy political price in the midterm elections. …

What troubles many Republican strategists is the specter of the party’s most reliable voters being bombarded by reminders of their leaders’ failure to address the health law. They fear a recurring story line sure to pop up every time insurance premiums increase, providers leave local networks, or, most worrisome, Republicans fund President Barack Obama’s signature achievement.

Conservatives, many of whom opposed the House repeal bill, now warn that it is untenable to stand pat on the issue — and that lawmakers will face retribution if they do not return to the repeal-and-replace effort.

Either Republicans keep targeting the law by reviving their repeal plans, which are unpopular outside the GOP base (and even among some Republican voters), and illustrate their own divisions and incompetence — or they put off repeal, which reminds their base of their feckless failure to come through on a campaign promise. Exacerbating this problem, if Republicans put off repeal, they immediately blunder into another dilemma: whether to take steps to shore up the ACA’s individual markets — or to do nothing at all or even actively undermine them.

The rub of the matter, as the Times story reports, is that GOP strategists fear that Republicans cannot be seen helping the law succeed. It’s not hard to see why. Shoring up the exchanges would amount to helping the law remain in place, after seven years in which one of the party’s touchstones was absolute rhetorical devotion to the law’s total and immediate destruction. It would also amount to a tacit admission that the law is not inherently or inevitably destined to implode. It would be a concession that the law can be made to work if Republican officials want to participate in making that happen.

Many Republicans are politically locked in a place where such a concession is unthinkable. This is why Trump continues to rage at the law as an ongoing disaster. It’s why he and other Republicans continue robotically repeating that its extinction is imminent, despite the fact that the catastrophic failure of their replacement effort has revealed them to have no alternative to it.

This ideological prison of sorts requires unwavering fealty to a future in which the ACA has collapsed and vanished from American life. Which means that, absent a revived repeal push, there could be more pressure on Trump and Republicans to refrain from participating in fixes to the law or, worse, more pressure on them to sabotage it. As Michael Hiltzik explains, the Trump administration has sent mixed signals as to what it will do on this front, but sabotage is clearly an option, and there are many tools it has to destabilize the individual markets.

But here yet another problem intrudes: Such a course of action could end up hurting a lot of Republican and Trump voters. By encouraging insurers to exit the marketplaces, it could leave many of the 12 million people who have obtained coverage on the individual markets with no remaining options — no way to get coverage or to access subsidies to cover that coverage. And Larry Levitt, a senior vice president at the Kaiser Family Foundation, tells me that this would hurt marketplaces in all regions of the country, which means deep red Trump territory, too, particularly because some of that includes rural areas where there are fewer insurers.

“Trump country tends to be areas where there’s less competition,” Levitt says.

This humanitarian impact would give Democrats an opening to propose their own fixes or even more ambitious long-term reforms. As Brian Beutler points out, Democrats can not only attack Republicans for “abdicating their obligation to faithfully execute the law” in the interests of the American people; they can also “point to solutions Republicans are intentionally shunning.” We don’t know how much the prospective human toll of inaction or outright sabotage will weigh on Trump and Republicans. But you’d think it would matter, at least to some degree.

https://www.blogger.com/blogger.g?blogID=3936036848977011940#editor/target=post;postID=3222874394256361940

In This Next Phase Of Health Reform, We Cannot Overlook Long Term Care

Everette James, Walid Gellad, and Meredith Hughes

March 16, 2017

It is becoming apparent that President Trump and the 115th Congress cannot start over with health care reform. Whether you love, begrudgingly support, or fervently hate the Affordable Care Act (ACA), a clean slate is not possible. First, ACA implementation is well underway and has benefited many patients and providers alike. Second, it is unlikely that Republicans in Congress can fully repeal the ACA without a 60 vote, filibuster proof super majority in the Senate. Starting over entirely with health reform is just not feasible.

Trying to address every problem facing the health care system at once is a tall—if not impossible—order. History has taught us that U.S. health reform is an incremental process. With the focus of Congress once again turning to health reform, we have an opportunity to fix the problems with the ACA, and find solutions to health care challenges that the ACA failed to address.

A Growing Need

Long-term care for America’s growing elderly population is a critically important issue for Congress to address in health reform proposals currently taking shape. While the ACA’s insurance expansion focused on providing coverage for the uninsured, the law’s progress on long-term care has been minimal. The ACA tried to address long-term care (LTC) by creating a voluntary system of LTC insurance, but the ill-fated CLASS Act was ultimately determined to be financially unviable and abandoned.

Although policy solutions have been elusive, the need for long-term care is constantly growing. According to current estimates, over two-thirds of elderly Americans will need LTC assistance at some point in their lives. Between 2014 and 2040, the portion of Americans over age 65 is expected to increase from 14.5 to 21.7 percent. At upwards of $60,000 annually, long-term care costs can quickly exhaust personal savings.

As policymakers throughout our history have debated health reform, these efforts have almost entirely centered on questions of medical coverage. They ask which benefits to cover, how much the coverage should cost, and how we can ensure people are not locked out of coverage because of their health status. We must take the same approach to LTC, examining the availability and affordability of services. LTC services include nursing home care and in-home care, as well as what is often referred to as “long-term services and supports” (LTSS). LTSS include assistance with daily activities, such as eating, bathing, dressing, doing laundry, paying bills, and taking medications.

Current Republican health reform proposals appear to do little to push the ball forward on long-term care. As Congress considers proposals to reduce federal spending on Medicaid, they should carefully consider the role of Medicaid in financing LTC.

Medicaid’s Role

Few Americans know that Medicaid is the largest single payer for LTC in the United States. Because of the high costs of LTC, Medicaid is no longer the safety net just for individuals with very limited savings. Medicaid has become the de facto long-term care safety net in the U.S. health system. Individuals who are forced to spend down their life savings on LTC can, and often do, qualify for Medicaid coverage. As illustrated by the chart above, Medicaid pays for 43 percent of national LTC costs. Medicare also pays for some nursing home and home based care, but only for a short duration following a hospitalization. If you exclude these short term Medicare payments, Medicaid’s share of ongoing LTC costs is even bigger – upwards of 60 percent of all LTC costs. Medicaid also covers two-thirds of all nursing home costs in the United States.

LTC is a costly aspect of Medicaid, accounting for 6 percent of Medicaid enrollees and 40 percent of Medicaid spending. Many aging individuals will turn to family members for assistance, which can place a significant physical, emotional, and financial strain on these family caregivers. Only 7.2 million Americans had LTC insurance coverage as of 2015. Individuals who anticipate needing LTC insurance are more likely to purchase private LTC insurance, leading to an imbalance in the marketplace of individuals utilizing benefits and individuals paying in premiums. As a result, few insurers have been willing to stay in the marketplace and LTC insurance premiums increased by 54 percent between 1995 and 2015.

Existing evidence on feasible options for financing LTC are sparse. Many states have implemented “Long-Term Care Partnerships,” which enable individuals to qualify for Medicaid coverage as soon as they have exhausted their private LTC insurance policy. Other current options include combined life insurance and LTC insurance policies, which reduce life insurance payouts depending on LTC utilization, or life settlements, which allow individuals to sell their life insurance policy once they reach a certain age. State and national policies to support family caregivers are limited in scope and often underutilized.

Key Recommendations

A solution for sustainable and affordable LTC that meets the needs of America’s aging population must be included in the next iteration of comprehensive health reform. In the past several years, a number of promising strategies to address LTC have been proposed. Congress and the Trump Administration should give these recommendations full consideration:

1) Stabilize The LTC Insurance Market

Strategies to encourage the purchase of private LTC insurance policies would require changes to both federal and state law. Some promising strategies include: creating a lower cost, more limited benefit package LTC insurance product which could be purchased by retirees; allowing employees to use retirement account funds to pay LTC insurance premiums without a federal tax penalty; and encouraging employers to offer LTC insurance plans to employees by lowering barriers to automatic enrollment and protecting plan sponsors in the event that too many employees choose to opt out of coverage. For those with significant LTC needs and high costs, a universal, publicly funded catastrophic benefit plan could help reduce Medicaid and out-of-pocket spending by families.

2) Strengthen Provision Of LTC In Medicare And Medicaid

Currently, the Medicaid statute pays only for LTC in an institutional setting. States need special permission in the form of a waiver or other authority to deliver care in an individual’s home or community. Over the past few decades, Medicaid spendingon LTC has shifted from majority-institutional to majority home and community-based services (HCBS). Policymakers could encourage states to offer care in the community, either by changing the Medicaid statute to place HCBS and institutional care on equal footing, or by making it easier for states to get permission to deliver care in the community. Traditionally, only Medicaid has had the authority to offer HCBS to beneficiaries. HCBS costs less than institutional care, but some argue it raises overall state spending, because it encourages state Medicaid programs to serve more individuals than it would have in an institutional setting. However, HCBS also helps individuals with disabilities to live more integrated lives in their communities, and results in better outcomes, such as patient and caregiver satisfaction. Additionally, a proposed pilot program would allow Medicare to offer HCBS to beneficiaries.

3) Support For Family Caregivers

Over 17 million Americans currently provide LTC assistance to an elderly family member. Family caregivers provide LTC services at little or no cost to public programs. However, the cost of family caregiving can be felt in other areas, such as reduction or loss of work productivity or increased risk of illness and injury. Absent a comprehensive strategy for LTC financing and delivery reform—or to complement such a strategy—supporting family caregivers should be considered. The recent Institute of Medicine (IOM) report on family caregiving calls for increased support for current family caregiver programs, such as the National Family Caregiver Support Program (NFCSP). Experts recommend further study on expanding tax credits for LTC expenses and assessing the cost of employee family caregiving responsibilities on employers.

Whatever path “repeal and replace” takes, health reform will continue to seek strategies to provide health care coverage and access to all Americans, improve the affordability of health care and prescription drugs, reduce fragmentation and waste, and increase price and quality transparency. These have always been the bipartisan goals of U.S. health policy, and finding common ground is not only achievable — it is imperative. This time around, we urge policymakers not to overlook the looming crisis of aging and long-term care.

http://healthaffairs.org/blog/2017/03/16/in-this-next-phase-of-health-reform-we-cannot-overlook-long-term-care/

LePage considers starting state health insurance plan to replace Obamacare

'We are just going to withdraw the state and just go do our own thing,' he says.

by Scott Thistle - Portland Press Herald - March 28, 2017

Maine Gov. Paul LePage said Tuesday he may pursue a state health insurance system as a replacement to the federal Affordable Care Act after Congress failed to repeal and replace the federal program that critics say is steadily collapsing.

“We are just going to withdraw the state and just go do our own thing,” LePage said. “The federal government obviously is broken so they are not going to stand in the way, they can’t get anything done.”

LePage also took aim at his fellow Republicans and rebutted President Trump’s suggestion that the ACA, known as Obamacare by critics, should be allowed to fail and collapse. 

Speaking with Ric Tyler on the Bangor-based WVOM radio station, LePage said letting Obamacare fail made “no sense.”

“So let’s keep hurting the American people,” LePage said. “That’s about as sensible as go jump off a bridge, that makes no sense. If you are telling people let it fail so the American people can get hurt more and when they get hurt more maybe we’ll do something. Why don’t you go jump off a bridge, that’s just about as sensible.”

LePage voiced his displeasure with fellow Republican governors and those in Congress who stood on the sidelines last week as Trump and Republican House Speaker Paul Ryan withdrew their replacement bill, called the American Health Care Act, which LePage first opposed and then supported after several amendments were made, including ones giving states more latitude to manage federal health care funds sent their way.

“I am very discouraged with a lot of Republican governors because they sat on the sidelines,” LePage said, claiming he was the most conservative governor in the U.S. – or “arguably one of the most conservative. And to have the Freedom Caucus sit on the sidelines and let the Democrats win, I honestly hope every single one of them gets defeated next year. There’s no difference between a Democrat and a Republican if you hide in the closet.”

It was not immediately clear what LePage would propose for legislation at the state level but suggested he would model it after the state’s insurance system for workers’ compensation, which was created in 1993. The Maine Employers Mutual Insurance Company was the result of a bill created under Republican Gov. John McKernan and resulted in a statewide insurance system for workers who sustain an injury on the job that leaves them unable to work. 

According to the company’s website, “the legislation called for the creation of MEMIC as a private company that would serve as the guarantor of workers’ compensation insurance for Maine companies. With its private structure, MEMIC serves as a competitive force within the workers’ compensation insurance market.”

Later Tuesday, LePage was expected to join Maine Department of Health and Human Services Commissioner Mary Mayhew at the State House to roll out a package of new welfare reforms.

http://www.pressherald.com/2017/03/28/lepage-considers-starting-health-insurance-program-to-replace-obamacare/

Anthem says it might ‘surgically extract’ itself from individual marketplace

by Portland Press Herald staff - March 27, 2017

One of Maine’s three health care insurers says it will begin to “surgically extract” itself from the individual marketplace if changes aren’t made to the Affordable Care Act.

Anthem CEO and President Joseph R. Swedish sent a letter to Republican leaders in Congress this month, telling them it is increasingly difficult for his company to stay in the individual market.

“As I have said publicly, without significant regulatory and statutory changes to the individual market, we will be begin to ‘surgically extract’ Anthem from that market beginning in 2018,” Swedish wrote to Rep. Greg Walden, R-Ore., chairman of the House Energy and Commerce Committee, and to Rep. Kevin Brady, R-Texas, chairman of the House Ways and Means Committee.

In the letter dated March 9, Swedish cited provisions of the American Health Care Act promoted by President Trump and House Speaker Paul Ryan that he believed would address the challenges facing the ACA. The Republican leadership abandoned the plan on Friday when it became clear it wouldn’t pass a House vote.

Maine Community Health Options and Harvard Pilgrim Health Care are Maine’s two other ACA marketplace insurance providers.

Community Health Options has about 50,000 of the roughly 80,000 Mainers with insurance on the individual marketplace. Anthem and Harvard Pilgrim have the rest.

http://www.pressherald.com/2017/03/27/anthem-says-it-might-surgically-extract-itself-from-individual-marketplace/

Italy’s Struggling Economy Has World’s Healthiest People

by Wei Lu and Vincent Giudice - Bloomberg - March 20, 2017

When it comes to living a long life, Italy is the place to be.

The high-heeled boot surrounded by five seas is ranked the healthiest country on Earth in the Bloomberg Global Health Index of 163 countries. A baby born in Italy can expect to live to be an octogenarian. But 2,800 miles south in Sierra Leone, the average newborn will die by 52.

While Italy is among the most developed countries, growth has stagnated for decades, almost 40 percent of its youngsters are out of jobs and it’s saddled with one of the world’s highest debt loads relative to the size of its economy. Yet Italians are in way better shape than Americans, Canadians and Brits, who all suffer from higher blood pressure and cholesterol and poorer mental health.

Italy also has “an excess of doctors,” said Tom Kenyon, a physician and CEO of the global relief organization Project Hope. Case in point, one of the country’s most watched and long-running television shows is called “A Doctor in the Family.”

Then there is the diet, rich in vegetables and drizzled with extra virgin olive oil. Adam Drewnowski, director of the Center for Public Health Nutrition at the University of Washington, has written about the importance of consumers having access to fresh produce, fruit, lean meats and fish.

Each country in the index was graded based on variables such as life expectancy, causes of death and health risks ranging from high blood pressure and tobacco use to malnutrition and the availability of clean water.

Iceland, Switzerland, Singapore and Australia rounded out the top five most-healthy countries in the index.

The developed world isn’t without its risks — obesity among them. The U.S. placed No. 34 with a health grade of 73.05 out of 100. It's ranking for prevalence of overweight people is 67.3 — tipping the scale as one of the world’s heaviest nations.

The poorest states — Louisiana, Mississippi, Alabama and West Virginia — are heaviest with more than 35 percent of their populations considered obese, according to U.S. Centers for Disease Control.

https://www.bloomberg.com/news/articles/2017-03-20/italy-s-struggling-economy-has-world-s-healthiest-people

Lacking E.M.T.s, an Aging Maine Turns to Immigrants

by Katherine Selye - NYT - March 27, 2017

SOUTH PORTLAND, Me. — Jolly Ntirumenyerwa ran her fingers over the stethoscope that she had slung around her neck. It was a comforting connection to her career as a physician in her home country, the Democratic Republic of Congo, where she worked in emergency medicine.

Her credentials did not transfer when she moved to the United States in 2012, and she could not work as a doctor. So, she took jobs as a health aide in an assisted living facility.

Now, thanks to an unusual program that is training immigrants to become emergency medical technicians, she is preparing to make better use of her medical background and, she hopes, work her way up to becoming a physician assistant if not, someday, a doctor.

“I want to do what I was trained to do,” Ms. Ntirumenyerwa, 37, said the other day as she took a break from her E.M.T. class, being conducted in a cavernous ambulance bay at Southern Maine Community College. “I put in a lot of years training to be a physician, and I don’t want to throw them away.”

But the program goes beyond helping Ms. Ntirumenyerwa (pronounced t-roo-may-YAY-rwa) achieve her personal career goals. It is also helping to address some serious problems in Maine.

One is a shortage of E.M.T.s. Another is a shortage of a work force in general, particularly of young people who can help sustain the state economically as its population ages. Maine is the nation’s oldest state, with the highest median age and the highest concentration of baby boomers, and its birthrate is dropping; in 2016, just two of its 16 counties had more births than deaths.

Economists regard Maine’s rapidly aging population as a demographic tsunami that has severe implications for the state’s labor pool, health care system and overall socioeconomic well-being. But the state can grow, they say, with more international immigration — though that may become more difficult under the Trump administration.

Thanks mainly to a small influx of immigrants, the state’s population inched up last year by about 2,000 people over 2015, despite the anti-immigrant sentiments expressed by Gov. Paul R. LePage. But the state recorded 1,300 more deaths than births, a downward trend in which Maine and West Virginia lead the nation. Like other graying states in New England, Maine is struggling to keep its young people living and working here.

This is where the E.M.T. program comes in.

“This program is a win-win-win,” said David Zahn, chairman of the global languages department at the community college, which started the program.

He said he basically put two and two together. Surveys showed that employers, especially municipal and private ambulance services, needed more E.M.T.s; other surveys showed that many immigrants in the Portland area are underemployed and have medical backgrounds.

When the E.M.T. course for immigrants was announced, three times as many people applied as could be accommodated.

The first class is small, with 13 participants. But to Dana Connors, the president of the Maine State Chamber of Commerce, the program is a big step in the right direction. “It may be a small number, but it looms large in message and significance,” Mr. Connors said. The program, he said, illustrates what opportunities exist “when we recognize immigrants as part of our solution.”

Many of those opportunities are in health care. As residents live longer, the need for health care workers — and E.M.T.s — is only increasing.

The E.M.T. shortage stems in part from the low pay — $10.50 an hour for an entry-level job, a result of low federal reimbursement rates, said Robert Russell, the chief executive of North East Mobile Health Services, a private medical transport company in nearby Scarborough. In addition, he said, training involves a major commitment of time. This course requires eight hours a week for 16 weeks.

Mr. Russell said his company would interview the immigrants who successfully completed the course. He said he was grateful to have an expanded pool of applicants, especially people who are multilingual (Ms. Ntirumenyerwa, for example, speaks French, Lingala and Swahili, in addition to English) and who can bridge cultural divides. “It’s a huge added benefit,” he said, when employees reflect the customers they are serving.

Paul Froman, the course instructor, said that he did not vary the program for the immigrants, and that they must pass the same tests and meet the same requirements for licensing as American-born participants. But because of their medical backgrounds, he said, the immigrants “are informed, and you can get a lot deeper.”

David Ngandu, 33, who was also a doctor in the Democratic Republic of Congo and is taking the E.M.T. course, said that in some ways, it was easier to treat patients here than in Africa because of the availability of equipment and supplies.

“For example,” he said, “oxygen is very expensive in the Congo. I knew what needed to be done, but I didn’t always have the equipment.”

The course is financed by a work force development grant of $29,000 through the Maine Community College System and additional support from the John T. Gorman Foundation, which helps disadvantaged people in Maine. Most of the immigrants cannot pay for the course on their own.

While many work force development programs help immigrants learn English, Mr. Zahn said, this is the first of which he is aware that teaches English in the context of E.M.T. training, with participants learning high-level terminology and a higher level of English than those in, say, the food services industry.

“Because of their extensive medical backgrounds, we’ll have people on ambulances who have a higher level of skill” than some other newly minted E.M.T.s, Mr. Zahn said.

And, he added, the program might help restore an underemployed immigrant’s sense of dignity.

“They are doctors,” he said. “And they’re cleaning toilets? We’re taking advantage of their skills and getting them back into their own arena.”

https://www.nytimes.com/2017/03/27/us/maine-immigrants-emergency-medical-technicians.html?