A proposal for true patient freedom
Letter to the Editor - Ellsworth American - March 31, 2017
Dear Editor:
We of Maine AllCare believe in health care for everyone in Maine. Both Democrats and Republicans in Congress have seemingly surrendered on any national initiative to cover all Americans. One state will probably lead the way by covering its residents. Why not Maine?
America treats health care as a commodity like automobiles, where profits, return to investors and sales and marketing initiatives are king. Yet millions who cannot afford this commodity suffer untreated illnesses, even death, or financial ruin due to health care costs. Economic impacts such as lost workdays cost employers and employees billions, and uncompensated care is crippling hospitals that are major employers. Universal health care coverage is more than an inspiration of morality, it is an economic necessity.
“The status quo is unsustainable, for patients, for workers and for employers,” said Henk Goorhuis, MD, board chairman of Maine AllCare, at a recent national meeting of the activist organization Healthcare Now. “Further, the ideas pushed by the Republican majority in Congress, which are based on even more privatization and patient cost-sharing, would only exacerbate our citizens’ health care access problems.” Available data show that this could mean an additional tens of thousands of unnecessary, preventable deaths, according to a Jan. 23 Washington Post article by NYU physicians David Himmelstein and Steffie Woolhandler.
Medicare provides health care coverage for older Americans, and created funding outside of the “commodity” system. Publicly funded, operating with low administrative costs and delivering private care, Medicare covers millions of satisfied citizens. With an “expanded and improved Medicare for everyone,” as thoughtfully and carefully detailed in a bill reintroduced by Rep. John Conyers (D-MI) and co-sponsored by 57 others, including Rep. Chellie Pingree, proposing a national universal health care system, everyone could win. Despite strong public support in many surveys, stronger forces in Washington successfully suppress any discussion of “Medicare for all.”
The Affordable Care Act (ACA) tweaked the commodity system by making federal subsidies for insurance available. Over 20 million more Americans, including about 75,000 Mainers, have coverage, many for the first time ever. ACA required states to expand eligibility for Medicaid, but the Supreme Court gave states the option to decline, and Maine declined. Although a success for millions, the ACA, and Maine’s failure to fully implement it, leaves in excess of 100,000 Mainers — 8-9 percent of us (2015 Census data shows 111,000) – with no coverage. A total of 70,000 would be covered had we expanded MaineCare under the law. And many who signed up will drop out because of backbreaking deductibles and prohibitive premium hikes that only satisfy for-profit insurance companies.
What about a replacement? All Republican proposals, such as “vouchers” and “block grants,” merely tweak the current market-based system. This includes Sen. Collins’ Patient Freedom Act of 2017 that favors people who can afford to participate. The act’s proposed subsidies for health savings accounts require that people continue to purchase market-based insurance plans. Hard working Mainers living paycheck to paycheck, as well as those without any paychecks, will still be left behind. In federal budget battles, appropriations for vouchers and block grants and subsidies for Freedom Act health savings accounts will be forever unreliable.
However, with a section 1332 “waiver” allowed by the ACA, federal health care money designated for Maine could be used to chart Maine’s own course to universal coverage. With comprehensive health care for all, which will include all Mainers — even the healthy — the per capita cost is lowered at the same time the commodity problem is eliminated. Everyone will be in. No one will be out. Access will be simple. Coverage will be comprehensive. Everyone will pay with equitable financing. No one sector will be overburdened. Health care providers will return to a professional mission. They will care for patients without the shackles of running a complicated billing operation.
If we want the best, most affordable and efficient health care, Medicare is the best model. Here in Maine, we are ready to move ahead. Medicare’s original rollout took less than a year to enroll everyone. They used postcards! President Harry Truman was the first enrollee! Surely we could top that.
In this legislative session, Maine Rep. Heidi Brooks and Sen. Geoff Gratwick are proposing legislative action that promotes universal health care. If the Legislature and the Governor will not care for their constituents, it will be up to us, as private citizens. Maine AllCare will explore the citizen initiative process. It’s time to fulfill the Maine state motto and lead this nation in establishing the people-centered, business friendly, rational, moral, affordable, equitable health care system we all deserve.
William Clark, MD, Woolwich
Moira O’Neill, Ph.D., Surry
Joe Lendvai, Brooklin
The writers are members of Maine AllCare, a nonprofit nonpartisan organization dedicated to comprehensive, affordable health care for everyone in Maine.
Why America’s Sick Health Care System Turns British Conservatives Queasy
Why America’s Sick Health Care System Turns British Conservatives Queasy
The National Health Service is the UK’s ‘religion’. US Republicans despise it.
Graeme Demianyk - Huffington Post - March 31, 2017
If the cornerstones of your culture include the world’s most famous spy, its best-loved wizard and the band that redefined pop music, it might seem like a desperate piece of state propaganda to celebrate a health care system at the same time.
But the opening ceremony of the London Olympics in 2012 underlined a truism: Brits love the National Health Service. Alongside trumpeting James Bond, Harry Potter, and The Beatles, director Danny Boyle found space in his show to pay tribute to the doctors and nurses that help provide the universal, ‘free’ service.
Perhaps more surprising still is the cross-party support for this single-payer system that is reviled elsewhere, notably among the political right in the US. Sure, Conservative Party MP Aidan Burley tweeted how it was “the most leftie opening ceremony I have ever seen”. But Burley, who is no longer an elected politician, was shunned by his party elders. The party line is clear: UK conservatives believe in the NHS as much as anyone else.
It’s not a recent conversion either. Nigel Lawson, Margaret Thatcher’s free marketeer Chancellor of the Exchequer, described the NHS as the nearest thing that modern Britain has to a religion in an increasingly secular society. This was the 1980s.
To Republicans in the US, currently engaged in a bruising fight over the future of health care, this must be baffling.
How could the Conservative Party, which holds dear the same principles of market preeminence, stand by something so left-wing? After all, Nye Bevan, the 1940s Labour Party health minister seen as the NHS’s founding father, described a ‘free’ health service as “pure socialism, and as such it is opposed to the hedonism of capitalist society”. And yet, the prospect of the US having to consider a system akin to the UK’s ‘socialised’ care, while unlikely to happen, is in vogue.
When Republican leader Paul Ryan’s plan to repeal and replace Obamacare collapsed last Friday, America reached a fork in the road. The Affordable Care Act was simultaneously hailed and condemned for providing cover for 15 million Americans who didn’t have it, chiefly through an extension of Medicaid, the taxpayer-funded health care plan devoted to low-income families. But it is poised to “explode”. At least that’s Donald Trump’s view, referring perhaps disingenuously to the unstable private insurance market that underpins the system.
But the same President has also vowed “insurance for everyone”. The pledge has unintended echoes of Bevan. In the face of divided Republicans bringing down Ryan’s plan to torch Obamacare, Bernie Sanders, Vermont senator and big beast of the Democrat left, has announced he will introduce a bill to create a single-payer system. His “Medicare for All” has its roots in the NHS.
HuffPost UK has spoken to politicians and experts to find out why there’s consensus in the UK on the NHS and why they think US Republicans loathe it. The Conservative Party and the G.O.P. are not so different in their support for small government. But the Conservative Party appears convinced that the state is best-placed to provide care for its citizens. “I’ll cut the deficit, not the NHS,” was the Conservative Party election slogan emblazoned on billboards in 2010, alongside David Cameron’s face. Put in context, UK conservatives embrace the kind of single-payer system that even some liberals in the US wouldn’t support.
While the London Olympics demonstrate it would be bad politics for the Conservative Party to make state-funded health care its enemy, Tories point to evidence on cover, costs and results - and personal experience - to justify backing ‘free’ care. American observers may think the UK is less burdened by ideology and takes a more kindly view of the state’s ability to run things. But that would overlook the sell-off of publicly-owned assets that began in earnest thirty years ago and continues today. Perhaps the prospect of off-loading a ‘religion’ is just too daunting.
So how did we get here? There are generally two ways to run a health service: either the taxpayer finances it or the individual takes out insurance, with most being a mix of the two. While presidents Franklin D Roosevelt in the 1930s and Harry Truman in the 1940s flirted with publicly-funded health care programmes, the US opted for private insurance as its mainstay. If cover isn’t provided by an employer, people buy health insurance as they would a policy for their house or car. But it’s not cheap. Annual premiums reached $18,142 (£14,533) in 2016 for an average family. And despite Republican protestations, Obamacare is no NHS by the backdoor: 27 million Americans are still uninsured.
The NHS, by contrast, was founded by the post-war Clement Attlee government as the cornerstone of the welfare state. Decades later, 99 per cent of care is paid for through general taxation and National Insurance. In short, there is no prospect of the eye-watering bills for care that strikes fear among millions of American families.
Speaking to HuffPost UK, ex-Conservative Party health minister Alistair Burt explained it would be “suicidal” to suggest the party does not support the NHS. “Accordingly the pledge that the NHS should be ‘free at the point of delivery’ is absolute,” the MP said.
The Conservative Party manifesto three years ago spoke volumes. It pledged an extra £8 billion of taxpayers’ money to fund the NHS each year until 2020. Questions remain over whether the promise was genuine, and whether that’s enough to fund a system under pressure. There are stories daily about underfunding, targets missed, and more patients suffering. But it was the party’s clearest and most striking policy promise in the document, a move to outflank Labour Party claims the Tories wanted to destroy the NHS. Winning the argument on the NHS was not only central to general election success. A promise of securing more money for the NHS was at the heart of the successful Vote Leave campaign to quit the European Union.
The Labour Party claims ownership of the NHS, but Burt points to the “broad national consensus” that was accepted under the Winston Churchill and Harold MacMillan Tory governments of the 1950s. “The notion of ‘free’ access to health care is now untouchable,” he says.
“My father is a family doctor, now 94 years of age,” he adds. “He remembers debt collectors still operating when he joined his practice in 1949, a hangover from pre-NHS days. He is as Conservative as you get. But he says ‘never again’.”
The appetite in the UK to adopt anything similar to the US is almost zero. “A hundred per cent of our population has free access to medical care, from accident to cancer to mental health,” says Burt. “There is no call for a wholesale move to health insurance. Everyone would need to be covered, as now. So why should we?”
That’s not to say there is no private sector involvement, or that it lacks US influences. Privately-run hospitals and treatments are popular among those who choose to pay. Big businesses run out-of-hours family doctor cover and provide non-urgent operations to reduce waiting lists, which Tony Blair’s Labour government in part introduced. The current NHS chief executive, Simon Stevens, was a senior executive with UnitedHealth, the US giant. But Burt stresses the difference when business is involved in the NHS: care is “paid for by Government, but free to patients”.
“The left of the Labour Party are quite fanatical about anything which could be termed ‘privatisation’,” says Burt. “These extremes make it difficult to give modern health the scrutiny and answers it deserves.”
In a CNN town hall debate in February, Republican senator Ted Cruz pointed to the UK’s waiting lists for operations, and the US delivering more operations, as evidence for single-payer health care being inferior. On why US conservatives take a different view, Burt emphasises it’s hard to compare conservatives in an individual country, let alone those from different continents. UK Conservative Party MP Simon Burns campaigned for Hillary Clinton, for example. In any case, he’s dismissive of Cruz’s critique. “It is not fair. Comparisons are notoriously difficult between health systems, and there are a number of reasons for poor outcomes, beyond the payment system.
“We have an overworked and quite efficient system, but it is creaking under the pressures of finance and above all an ageing population. All health systems have difficulties. How you measure the NHS deficiencies against the agony of facing a bill for cancer care you cannot pay, I just don’t know.”
But don’t the Republican and Conservative parties share a view that the market delivers the best results? “This opens a can of worms,” Burt admits, pointing to the NHS’s ‘internal market’ that provides competition. “Pure market forces, however, are very unlikely to gain acceptance if there is any serious risk of ‘losers’ or an extensive ‘two-tier’ system based on wealth or privilege.”
Conservative policy experts also think there is little to suggest the UK right would nudge anywhere close to a US-style insurance system, even if the faults in the US system are overblown.
Warwick Lightfoot, director of research at the modernising conservative think-tank Policy Exchange, explained how Tory devotion to the NHS was renewed even when it let capitalism rip in the 1980s. In that decade, the government sold off Jaguar, British Telecom, British Aerospace, British Gas, British Steel, British Petroleum, Rolls Royce, British Airways, and water and electricity utilities. Margaret Thatcher’s advisers had written a paper suggesting that some health services might be charged for, and a story was leaked to The Economist magazine. “She was swift to squash any suggestion that the ideas in it had legs, saying ‘the NHS is safe with us’,” he told HuffPost UK, adding how it set the template for her successors.
David Cameron’s commitment to the NHS was as much personal as political. He came to rely on the state to help care for his disabled and seriously-ill son, Ivan, during his short life. “Cameron saw the very best of the NHS,” says Lightfoot. “He joined the ranks of a number of very privileged rich people who had to deal with a potentially ruinous chronic health condition within their own family if it were handled by private insurance and any substantive element of co-payment.”
Key to Conservative Party loyalty is not just the NHS’s popularity - more cherished than the monarchy and the army - but that it doesn’t cost that much. The UK spends less on health than European neighbours, including Germany and France, and much less than the US. In return, the UK achieves comparatively good health results. Lightfoot points to the Commonwealth Fund health study in 2014 that suggested the UK offered the best overall health provision out of 11 western nations it studied. The report also showed the UK had the second-cheapest health expenditure on the list, spending $3,405 per capita - less than half the $8,508 spent in the US.
While noting the criticism of the Organisation for Economic Co-operation and Development, which says the UK’s ‘command and control’ system means it is slower to respond to patient demand and new technologies, he says: “The NHS has been very effective in providing comprehensive health care at a reasonable cost.”
But Lightfoot thinks UK politicians sometimes overstate the US’s deficiencies. “British politicians perceive the US health care system to be ruinously expensive, patchy in its coverage and erratic in its outcomes,” he says. “They often share the naïve perception that there is little in the way of a health safety net for elderly people or low income households and do not fully appreciate the range of care available through Medicaid and Medicare.”
Publicly-funded care is often less strictly rationed in the US through Medicaid and Medicare than compared to the UK, he says. “This partly explains the cost of the US system,” he adds.
It’s rationing of care US conservatives really abhor. The US-owned right-wing website Breitbart News has written about patients being the victim of ‘death panels’, an infamous phrase evoked by one-time Vice Presidential candidate Sarah Palin to describe Obamacare. “Conservatives in the US dislike the NHS because of Nye Bevan’s expression,” he said, making clear it is the ideology of a state-run system “supplanting the market provision of health care that American conservatives fear”.
Not that every UK conservative holds the NHS in such high esteem, and many also resist the binary choice of UK or US. The Institute of Economic Affairs think-tank argues the NHS would save thousands more lives a year by emulating more mixed systems in Switzerland and the Netherlands.
Daniel Hannan, a Conservative politician who represents Britain in the European Parliament, has long characterised the NHS as a “relic”. From his vantage point in Brussels, he sees no mainstream socialist party in Europe proposing a “state monopoly in health care” based on the British model. The NHS is only beloved of “some Green and Marxist parties”. He suggests few would adopt an NHS model if the UK stopped short of full nationalisation in the late 1940s.
Not that US-style private insurance is the way forward. He told HuffPost UK: “It’s odd that people in both countries hold up the other’s model as if it were the only alternative. In fact, neither the US nor the UK has the best system. There are plenty of alternatives out there that produce better outcomes at lower cost.”
He backs individual health care savings accounts, deducted from salaries, which contain a small insurance component in case of catastrophic illness, but that otherwise pay out as needed. The system operates in Singapore, and has critics, but has been ranked the most efficient in the world by Bloomberg.
Of course, many of the left are not willing to give the Conservative Party the benefit of the doubt, and argue it would have sold the NHS by the pound if not curbed by public opinion and repeated protest. New figures this week showed that roughly half of new cash pumped into the system was spent on private sector treatment.
In an unlikely twist, Bernie Sanders’ brother has an informed view on both the UK and US systems. Brooklyn-born Larry Sanders has lived in the UK since the 1960s, and is the Green Party’s national spokesman for health care. He argues the “extraordinarily expensive” US system is a result in part of the surfeit of profitable yet unnecessary operations and scans, a counter to one of Ted Cruz’s key arguments.
“Bernard (his brother) is right, there’s so much extra money spent in the US. You could be so generous to everybody because of all those extra hundreds of billions. You could have a Rolls Royce system,” he told HuffPost UK.
Two things hold back the US, he argues: ideology and the profits the private sector makes. “There are large groups of people who think the government is a problem and they can’t do anything right. There are vast amounts of money to be made from having that viewpoint - you don’t have to be very corrupt to be inclined to a system which is very good to you financially.”
Sanders does, however, fear Conservative Party enthusiasm for more private sector involvement. “The NHS is very strongly rooted, but in some ways it’s fragile. We could be near a tipping point. If the service gets poor, you will get people who can afford it will use private care. Then you begin to weaken the NHS.”
But a US-style system where universal care free at point of care is abolished? “I don’t think they could do that, but I think they could weaken it.”
When in the UK, Trump likes to celebrate his British lineage thanks to his late Scottish-born mother. If Trump made American health care more British, it would stun commentators - perhaps more than the fact he was elected to do it in the first place.
http://www.huffingtonpost.co.uk/entry/uk-us-health-care-nhs-obamacare_uk_58d93c57e4b02a2eaab62f9b?8k
Trump was right about health care for most of his life
by Fareed Zakaria - Washington Post - March 30, 2017
The recent Republican debacle on health care could prove to be an opportunity. It highlighted, yet again, the complexity of the U.S. system, which continues to be by far the most expensive and inefficient in the advanced world. But President Trump could actually use the legislative collapse to fix health care if he went back to basics and to his core convictions on the topic, which are surprisingly intelligent and consistent.
There is an understandable impulse on the right to assume that health care would work more efficiently if it were a free market, or a freer market. This is true for most goods and services. But in 1963, economist Kenneth Arrow, who later won a Nobel Prize, offered an explanation as to why markets would not work well in this area. He argued that there was a huge mismatch of power and information between the buyer and the seller. If a salesman tells you to buy a particular television, you can easily choose another or just walk away. If a doctor insists that you need a medication or a procedure, you are far less likely to reject the advice. And, Arrow pointed out, people think they don’t need health care until they get sick, and then they need lots of it.
Every advanced economy in the world has implicitly acknowledged his argument because they have all adopted some version of a state-directed system for health care. Consider the 16 countries that rank higher than the United States on the conservative Heritage Foundation’s Index of Economic Freedom. All except Singapore (which has a unique state-driven approach) have universal health-care systems that can be described as single-payer (Medicare for all), government-run (the British model) or Obamacare-plus (private insurance with a real mandate that everyone opt in). Hong Kong, often considered the most unregulated market in the world, has a British-style government-run system. Switzerland, one of the most business-friendly countries, had a private insurance system just like the United States’ but found that, to make it work, it had to introduce a mandate.
While producing a CNN documentary on health-care systems around the globe, I was particularly struck by the experience of Taiwan, another free-market haven. In 1995, 41 percent of its population was uninsured and the country had very poor health outcomes. The government decided to canvass the world for the best ideas before instituting a new framework. It chose Medicare for all, a single government payer, with multiple private providers. The results are astonishing. Taiwan has achieved some of the best outcomes in the world while paying only 7 percent of its gross domestic product on health care (compared with 18 percent in the United States). I asked William Hsiao, an economist who helped devise the country’s model, what lessons they took, if any, from the United States. “You can learn what not to do from the United States rather than learn what to do,” he replied.
Americans often assume that despite its costs, American health care provides better services than others. We often hear about the waiting time for care in other countries. But according to the Commonwealth Fund, among industrialized countries the United States is in the middle of the pack for wait times, behind even Britain . Moreover, one of the world’s leading experts, Uwe Reinhardt of Princeton, has found that Americans use less care than the average for developed countries when it comes to things such as seeing a doctor and spending time in the hospital. The problem with the free market is that there is little profit in prevention and lots in crisis care.
Trump has now taken up the call to repeal Obamacare. But until recently, health care was actually one of the rare issues on which he had spoken out, before his campaign, with remarkable consistency. In his 2000 book “The America We Deserve,” he wrote:
“I’m a conservative on most issues but a liberal on this one. We should not hear so many stories of families ruined by healthcare expenses. . . . We must have universal healthcare. . . . The Canadian plan . . . helps Canadians live longer and healthier than Americans. There are fewer medical lawsuits, less loss of labor to sickness, and lower costs to companies paying for the medical care of their employees. . . . We need, as a nation, to reexamine the single-payer plan, as many individual states are doing.”
Trump was right on this issue for much of his life. He has now caved to special interests and an ideology unmoored by facts. He could simply return to his convictions, reach out to Democrats and help the United States solve its health-care crisis.
Virginia Republicans’ position on Medicaid expansion is indefensible
by The Editorial Board - Washington Post - March 30, 2017
FOUR HUNDRED THOUSAND more Virginians could get health-care coverage, quickly and at minimal cost to the state. All that’s needed is for anti-Obamacare dead-enders in the General Assembly finally to put the well-being of their people over partisanship, as Republicans in a variety of deep-red states now are doing.
Gov. Terry McAuliffe (D), not for the first (or 10th, or 50th) time, is making the argument for this totally reasonable expansion of health-care coverage to people who desperately need it. Some analysts suggest he knows he still can’t win in the legislature and is only teeing up the issue for the coming gubernatorial election. If so, that will be the fault of intransigent Richmond Republicans, whose position on the issue is now even less defensible than it used to be.
The Affordable Care Act extended the state-federal Medicaid program to cover a swath of low-income people, but the Supreme Court ruled that each state could decide whether to accept this expansion. Despite the fact that the federal government has offered to pay nearly the entire cost of covering newly eligible people, only 31 states and the District have taken the bargain. Because of GOP opposition in the General Assembly, Virginia has been one of the holdouts.
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That, however, was before congressional Republicans failed to advance a repeal-and-replace bill. “We’re going to be living with Obamacare for the foreseeable future,” House Speaker Paul D. Ryan (R-Wis.) admitted last week, after pulling the bill from the floor .
The Medicaid expansion was only temporary, Republicans used to argue; Congress would repeal it or federal budget constraints would require rollback. So, the logic went, state leaders should not risk expanding Medicaid only to pull the rug out from under vulnerable people when congressional Republicans unraveled the program. This argument never made much sense: It is better to cover people for some time than none at all. With a swift repeal off the table, it is now thoroughly discredited. Indeed, more than ever, Medicaid looks like a sure bet. Protecting the program turned out to be a priority for moderate congressional Republicans in the House and Senate alike.
If the failure of the repeal-and-replace bill diminished Republicans’ policy case against expansion, it decimated their strategic rationale. Fighting Medicaid expansion across the country was a central part of the GOP plan to resist Obamacare, limiting the number of people who benefited from the law and therefore making it easier to tear up once Republicans took control of Washington. But the ACA proved too hard to eliminate anyway.
It is unsurprising that the week after the repeal-and-replace bill failed, the Kansas state legislature voted overwhelmingly to expand Medicaid in that ruby-red state. Kansas is unlikely to be the last place where GOP opposition softens as Republicans process the reality that Obamacare is the law of the land. The benefits are so clear, the costs to states are so low, the reasons to continue resisting are so insubstantial. It is time Richmond Republicans admitted as much.
Obamacare Choices Could Go From One to Zero in Some Areas
by Margot Sanger-Katz - NYT -March 30, 2017
Parts of the country are in jeopardy of not having an insurer offering Obamacare plans next year.
Many counties already have just one insurer offering health plans in the Obamacare marketplaces, and some of those solo insurers are showing signs that they are eyeing the exits.
Humana announced this year that they’d be leaving the markets altogether next year. That means there are parts of Tennessee that will have no insurance options unless another insurer decides to enter.
And Anthem, which operates in 14 states, is getting nervous, an industry analyst told Bloomberg News this week. Its departure would be a much bigger problem. According to an analysis of government data by Katherine Hempstead at the Robert Wood Johnson Foundation, Anthem is currently the only insurance carrier in nearly 300 counties, serving about a quarter of a million people.
As you can see on our map of those counties, an Anthem departure could leave coverage gaps in substantial parts of Georgia, Missouri, Kentucky, Ohio and Colorado, as well as smaller holes in other states. In places where no insurance company offers plans, there will be no way for Obamacare customers to use subsidies to buy health plans.
Without an option for affordable coverage, they would become exempt from the health law’s mandate to obtain coverage. A result could be large increases in the number of Americans without health insurance.
The Affordable Care Act set up new markets for people who don’t get insurance through work or the government. About 11 million people bought coverage on those state markets last year. But the system depends on the voluntary participation of private insurance companies. And some parts of the country have proved more popular for insurers than others.
In the last year, several large commercial insurance companies decided to stop offering insurance in the markets. And some carriers that continued to offer Obamacare plans scaled back on the number of counties they served. In general, the places without much remaining insurance competition tend to be rural and expensive. (These areas tend to have fewer hospitals and doctors to choose from, reducing the ability of insurers to negotiate lower prices.)
There are a number of solo-carrier counties served by other companies, but none by as many as Anthem, Ms. Hempstead’s analysis shows. Cigna, the company with the next-largest potential impact, is the only carrier in 14 counties, containing about 100,000 insurance customers.
Anthem could well stay in the markets. It may simply be floating the option of departure to improve its negotiating position with the Trump administration over various regulatory requests. Or it may be expressing anxiety about the future. Insurers around the country are worried about the policy environment surrounding the Affordable Care Act. Mr. Trump has said that the health law “will explode” — a comment that may suggest he will do little to help the markets, or could even set the fuse.
When insurers left communities in recent years, the Obama administration and local officials worked hard to recruit replacements. The Trump administration might not do the same. So far, no carrier has come forward publicly to say it will serve the counties in Tennessee that Humana is leaving.
Insurers are making initial decisions about where to sell their products and how much to charge. But the final lineup of insurers is still several months away. Some states require companies to file initial requests this month, and the Trump administration has asked for price proposals in late June. If, after that, insurers decide the political or regulatory outlook looks less favorable, they will still have several months to leave the markets.
Trump’s Trainwreck
by Frank Bruni - NYT - March 24, 2017
For seven years — seven years — Republicans thundered about the evils of Obamacare, yearned for the day when they could bury it and vowed to do precisely that once the ball was in their hands.
Last week proved that this had all been an emotional and theatrical exercise, not a substantive one. The ball was in their hands, and they had no coherent playbook. No real play. They scurried around the Capitol with their chests deflated and their tails between their legs.
For the entirety of his campaign, Donald Trump crowed about his peerless ability to make deals, one of which, he assured us, was going to be a replacement for Obamacare that would cut costs without leaving any Americans in the lurch.
Last week proved that there was no such swap, that he hadn’t done an iota of work to devise one and that he was spectacularly unprepared to shepherd such legislation through Congress. As his promise lay in tatters at his feet, he gave a delusional interview to Time magazine about what an infallible soothsayer he is, then tried to shift the blame to Democrats, who, he said, would soon be the ones hankering for an Obamacare replacement.
On Saturday morning he tweeted: “ObamaCare will explode and we will all get together and piece together a great healthcare plan for THE PEOPLE. Do not worry!”
THE PEOPLE shouldn’t hold their breath.
He’s not delivering Americans from cynicism about government. He’s validating that dark assessment, with a huge assist from Paul Ryan and a cast of House Republicans who had consistently portrayed themselves as sober-minded, mature alternatives to those indulgent, prodigal Dems, if only they had a president from their party who would let them work their magic.
They have that president. Behold their magic.
Their exact complaints about the birth of Obamacare became the actual details of the stillbirth of Trumpcare or Ryancare or whatever we’re supposed to call the botch that they came up with.
It was a bill of far-reaching consequence stitched together behind closed doors, with a flurry of last-minute deals struck only to placate holdouts. It was pushed on lawmakers not as essential policy but as essential politics: The president needed a win, and the party had to make good on an incessantly repeated pledge.
“Because we said we would” became the motivating force for the legislation. If that’s the way self-proclaimed grown-ups govern, give me toddlers.
Trump is indeed prophetic. Washington under him doesn’t resemble the same old swamp. It looks like a sandbox. There’s commotion aplenty, noise galore and not much evidence of adult supervision.
What happened last week wasn’t governance. It was petulance. Republicans floundered in their attempts to come up with a replacement for Obamacare because the truth, which they know but refuse to say out loud, is that many of their constituents have benefited from, and have come to depend on, the changes wrought by Obamacare.
That’s not some rose-colored endorsement of what always was a messy, imperfect response to this country’s health care woes. But that’s the fact of the matter, and it’s a principal reason for the confusion and delays of last week. Ryan, Trump and others who had devoted so much oratorical energy to demonizing Obamacare felt that they needed a symbolic victory — any symbolic victory — but discovered that they couldn’t ignore the price.
Some Republican governors, many Republican moderates and voters far and wide were balking. In one Quinnipiac poll, only 17 percent of them said that they favored the emerging Republican alternative to Obamacare, while 56 percent opposed it.
Dazed by developments, the president who had recently opined that “nobody knew that health care could be so complicated” just wanted an end to things. Late Thursday he issued an ultimatum, decreeing that on Friday, the House had to vote on the bill — which had been revised to remove maternity care and mammograms as benefits that insurers had to provide — or forevermore forfeit its chance to do away with Obamacare. The art of the deal devolved into the spectacle of the tantrum.
Then, late Friday, the bill was withdrawn, because it was a lost cause — barring some miracle. “We’re going to be living with Obamacare for the foreseeable future,” Ryan admitted.
Never mind that House Republicans had voted dozens of times — back when Barack Obama was president and the action was meaningless — to end Obamacare. Never mind that they have a remarkable majority, one created, in part, through their Obamacare opposition. They still couldn’t deliver.
That Trump isn’t good at follow-through comes as no surprise. Ryan’s miscalculations are the greater revelation. He knows Congress, purports to know policy and yet produced a wretched bill that smelled as bad to the more centrist members of his caucus as it did to the most conservative ones.
And he moved it to the front of the line, ahead of other initiatives, so that the public’s first glimpse of negotiations between the president and Congress in a government under a single party’s control was an ugly sight indeed.
For the two terms of the Obama presidency, Republicans in Congress perfected their posture as the party of no, becoming so comfortable in that role that they still seem somewhat baffled to find themselves in a new one.
And no isn’t enough, especially not when it comes to Obamacare, which has been around long enough to plant deep roots in American life. There’s no repealing without some replacing, and Republicans were so fixated on the first part of the equation that they never grappled adequately with the second.
Their limited preparation and lack of agreement would matter less if they had strong leadership in the White House. Instead they have Trump, who lashed out at Democrats and pretended that the collapse of the health care bill was some sort of perverse or eventual triumph. He’s thrashing around, looking for narratives that let him off the hook. CNN reported that he was upset that his daughter, Ivanka, and her husband, Jared Kushner, were away from Washington on a ski vacation in Aspen, Colo., during such a crucial time. Give him a few more days. He’ll come up with a scenario — or at least a tweet — that casts Rosie O’Donnell as the culprit.
Of course there has been murmuring from his advisers about how Ryan led them all astray, and it bodes ill for the Trump-Ryan relationship going forward.
“Convenient how Trump flips from an all-powerful master negotiator to well-intentioned simpleton duped by Snidely Ryan at the drop of a hat,” tweeted the conservative columnist Ben Shapiro.
So very convenient and so very Trump, who manages to strut regardless of circumstances. There’s an inverse relationship between his adoration of himself and the prospects for his presidency. As the latter wanes, the former waxes.
“I assume this is going to be a cover,” he said to Michael Scherer of Time, referring to the interview. “Have I set the record? I guess, right? Covers — nobody’s had more covers.”
Scherer responded that, to the best of his knowledge, “Richard Nixon still has you beat. But he was in office for longer, so give yourself time.”
“O.K., good,” Trump said. “I’m sure I’ll win.”
Just spell his name right, folks. Just put him on the cover. That’s all that matters, and if Nixon is the yardstick, that’s fine, so long as Trump measures bigger.
He assured Scherer that all was swell, telling him, “I’m president and you’re not.”
That’s a rare Trump statement that will survive fact-checking. And that clinches it: If ever we name a poet laureate of the sandbox, the title will be Trump’s.
Editor's Note:
You may wonder, after reading the first few paragraphs, why I've included the following post in this blog. Read on to the end!
-SPC
The humble Farmer: My wife’s father – one of the most laid-back men you’d ever meet
He was the soldier who threw away his helmet in the South Pacific war and wore a straw hat instead.
by Robert Skoglund - Portland Press Herald - April 1, 2017
One day my mother-in-law, Muriel, returned from a trip and discovered that her husband, Bill, had sold their home on the lake and had moved them into a place next to the exhaust fans of a Burger King.
No one who knew Bill Paradis was surprised. My wife’s father was one of the most laid-back, off-the-wall men you’d ever meet.
Another time, without saying a thing, he sold her kitchen stove and replaced it with another one – that she didn’t want.
He met his wife, the valedictorian of her class, when he called the women’s dormitory and asked if anyone would like to go to the movies. Muriel, who just happened to pick up the phone, said, “Yeah, I’ll go.”
At the time, Bill and Muriel were enrolled at a college in Burlington, Vermont. He typified your Vermont college boy of the mid- to late ’40s because he’d already been to war and had two troop ships torpedoed beneath him in the South Pacific. When one of them was hit, he was in the chow line with his meal ticket in his pocket. He carried the ticket in his pocket for years, claiming he still had a meal coming to him.
Roland, one of Bill’s Army buddies, told me that he was once looking through binoculars at a column of U.S. troops as they slowly worked their way down a steep mountain trail. It was hot there in the South Pacific, and he could see that one of the soldiers had thrown away his helmet and was wearing a straw hat. Roland said, “Yup, there’s Bill Paradis.”
Bill stayed in the Army Reserve for years, ending up as a master sergeant and tank commander. He said that a tank could go over anything.
The Veterans of Foreign Wars was very important to him, as was the Shrine Club. When he was well along in years, a doctor checking his heart was surprised that he’d never smoked – because the hundreds of hours he’d spent at the VFW and Shrine had given him the same damaged heart as a two-pack-a-day smoker.
Marsha says that her father was the adult who got the neighborhood kids together for football and baseball games. As a teacher he got home earlier than her mother, who was a nurse and had different hours. He dug up their lawn and made the kids a miniature golf course with cans in the holes. In the summer, he took the family on a cross-continent camping trip.
When Bill came to live with us, I built a private apartment for him on the back of the house. We had three cats, which had been trained to never enter an open doorway because I’m deathly allergic to cats. But so Bill could watch them, I built a wooden catwalk right beneath the windows. One day I was watching a cat outside Bill’s window when the window opened and two arms came out, grabbed the cat and hauled the cat back in. The excitement of being bad gave him a heart attack, and he was carted off to the hospital in an ambulance.
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Another night, around midnight, Marsha and I got a call from the hospital with the news that Bill was being treated for another heart attack. He’d called 911 and, while we slept upstairs 30 feet away, the entire St. George ambulance crew had parked, with flashing lights, beneath our window, entered our home and wheeled away a 180-pound man. I later mentioned to the chief that ambulance people who could enter a house and carry off anything they wanted without waking the residents were in the wrong business.
Marsha says he was one of the greatest armchair athletes in the neighborhood and was always watching sports on TV. I thought that he’d watched golf on TV so long that he’d forgotten how to walk. He died without being diagnosed with oculopharyngeal muscular dystrophy, a disease passed down in families of French-Canadian descent. Symptoms are droopy eyelids, difficulty swallowing and weak arms and legs.
We know this only because it took doctors two years to diagnose it in my wife, Marsha. Actually, it only took one year to diagnose. Doctors spent the second year learning how to pronounce it.
Bill would have never lived with us had not Muriel died suddenly of a brain tumor. He lived alone for a while, but because Muriel was not old enough for Medicare, the horrendous medical bills had wiped him out, and when we finally took a close look at how he was getting along, this is what we found:
What do you do when the system in the country you fought to defend and have supported with your taxes for years suddenly takes your life savings?
Bill taught bookkeeping, and he did taxes for his friends. With Muriel gone and the hospital in possession of his savings, over a period of years he gradually accumulated a stack of credit cards. By astutely manipulating the payments, always keeping them up to date, and by constantly applying for more credit cards, he was able to run up a debt almost equal to his medical loss.
Just before he died, he declared bankruptcy and stuck them with it.
The humble Farmer can be heard Friday nights at 7 on WHPW (97.3 FM) and visited at his website:
Republicans lied about healthcare for years, and they're about to get the punishment they deserve
by John Barro - Business Insider - March 22, 2017
It's hard to decide which would be the more politically damaging outcome for Republican politicians: passing the American Health Care Act, and therefore owning the premium increases and coverage losses it would cause; or not passing the bill, and therefore failing to do anything that can be framed as "repealing Obamacare."
Each option is a political nightmare for Republicans for the same reason: Each would amount to an admission that Republicans cannot deliver what they have promised for years on healthcare.
For years, Republicans promised lower premiums, lower deductibles, lower co-payments, lower taxes, lower government expenditure, more choice, the restoration of the $700 billion that President Barack Obama heartlessly cut out of Medicare because he hated old people, and (in the particular case of the Republican who recently became president) "insurance for everybody" that is "much less expensive and much better" than what they have today.
They were lying. Over and over and over and over, Republicans lied to the American public about healthcare.
It was impossible to do all of the things they were promising together, and they knew it.
Then they unexpectedly won an election and had to face the question of whether they would break all of their promises — or only some of them.
If the AHCA passes, Republicans will have delivered on a couple of promises: lower taxes (mostly for people who make over $200,000 a year) and lower public expenditure (mostly because of Medicaid cuts, the main reason the bill could leave 24 million more Americans uninsured). All the rest of the promises will be broken.
And if they don't pass the AHCA, well, then they'll have broken all of the promises.
Either way, Republicans will have to face an angry electorate in 2018 and 2020 that did not get what it was promised. The exposure of Republican healthcare lies will do grave damage to the party, and that damage will be richly deserved.
A politics of bad faith
I want to draw a distinction between healthcare and most other issues.
Take, for example, tax policy. Even though I find some of the economic modelsRepublicans use to evaluate taxes unconvincing, I think the tax debate is mostlyconducted in good faith: Republicans sincerely believe taxes are bad morally and bad for the economy. So they roundly denounce taxes and, when they are elected, they try to lower them.
Republicans say they oppose abortion and, when elected to state legislatures, they vote for restrictions on it. They praise conservative judicial philosophies and, when elected president, they nominate conservatives to the bench.
The Republican Party is not wholly in the business of claiming to be for one thing and then doing another.
The difference on healthcare is that Republicans never had an ideology about it. So they were willing to lie, and there are two facts about the healthcare debate that a liar can exploit quite effectively until he is actually expected to make policy. People are always upset about how much healthcare costs, and healthcare is very complicated, so it is hard for voters to tell whether a politician is actually able to keep his or her promises about it.
If you went around telling abortion opponents that you would ban abortion and abortion-rights advocates that you would give abortions out free, the two sides might notice you were promising two incompatible policies. But for years, Republicans were able to capitalize on public ignorance and get away with promises that amounted to "much less expensive and much better."
Their political strategy was cynically brilliant until it led to their getting elected.
Saying one thing and doing another
The need to actually make policy is exposing the fact that Republicans made many healthcare promises they never intended to keep.
Republicans have denounced insurance plans sold under Obamacare as insufficient, because the deductibles and co-payments under some plans are so high that many people feel they can't afford care even if they are insured. But the AHCA would allow insurers to sell plans that would cover an even smaller fraction of insured people's healthcare expenses.
The Kaiser Family Foundation estimates that deductibles for an individual-market insurance plan on average would rise by $1,550 under the AHCA.
Republicans complained that premiums were too high for people to afford, and then they proposed a law that would cut premium subsidies by hundreds of billions of dollars and would leave some people near retirement age with insurance premiums of more than half their income.
But in my view, the most galling lie was about Medicare.
Early in Obama's term, Democrats sought to implement a significant expansion of subsidized health insurance without growing the budget deficit, so they imposed substantial cuts to Medicare spending as part of the Affordable Care Act.
Republicans were outraged, and they made opposition to Medicare cuts the centerpiece of their (successful) 2010 campaign to retake the House of Representatives. When Paul Ryan ran on the Republican presidential ticket in 2012, he and his running mate promised to restore the cuts if elected, out of a desire to protect seniors.
But once Ryan was actually in a position to shape legislation on healthcare that might become law, he decided to leave the Medicare cuts in place, because he would rather have the money for tax cuts for rich people.
Actually, wait, that was only the second-most galling lie. The most galling lie was when Trump said he would provide "insurance for everybody" and then endorsed a plan that would take away coverage from 24 million people, according to the Congressional Budget Office's estimates.
I told you so
Back in 2013, I wrote a column for Bloomberg View titled "There Is Still No Republican Health Policy Agenda." It began:
"There's no surer way to make a conservative health wonk huffy than by saying Republicans don't have a health policy agenda. They insist they do, and an important part of it is high-risk pools: government entities that provide subsidized insurance to people with health risks who couldn't be covered affordably in private markets."
At the time, a mini version of the AHCA debacle had played out in the House of Representatives. In one of their many symbolic votes to "repeal Obamacare," Republicans had rolled out one of their typical pieces of healthcare vaporware: those high-risk pools.
These pools can get people covered in theory, but because sick people are expensive to give medical coverage to, you need very large subsidies if you wish to make the pools both affordable to the insured and profitable for the participating insurers. That is, it's easy to establish the pool, but you need to spend a lot of money if you actually want the pool to work.
Experts will differ on exactly how much a robust, national program would cost, but the figure is somewhere in the hundreds of billions of dollars for a decade. House Republicans were proposing a "demonstration" for $5 billion.
But then-Majority Leader Eric Cantor pulled the bill from the floor before it got a vote. He wasn't going to be able to get his caucus to vote for it. It was too expensive.
The Republican commitment to high-risk pools, like nearly everything else Republicans have said about healthcare for a decade, was a lie all along.
The speaker has no clothes
Through the years, healthcare experts on the right have allowed themselves to be used as window dressing for a party that was never actually interested in taking their policy advice.
The experts would write white papers about conservative approaches to healthcare. Republican politicians would indignantly wave the white papers around and insist that they had not only one plan for healthcare but many plans, and they involved high-risk pools and selling insurance across state lines and something something patient-centered mumble mumble mumble and whatever was in the paper was going to be way better than Obamacare.
Ryan even developed an undeserved reputation as a healthcare "wonk."
But those white papers were always just paper. The plans described in them were never going to be implemented by an actual Republican government, which would not be interested in paying for the plans the papers described. The only thing Republicans ever intended to use them for was indignant waving.
It was all a lie. And the lie is finally about to be punished.
Editorial: Take the lead on health care as a right
Editorial - National Catholic Reporter - April 1, 2017
Breathe a sigh of relief for the American people. For now, the Affordable Care Act is safe. On March 24, House Speaker Paul Ryan, Republican of Wisconsin, announced that he and the White House were shelving their effort to replace the current law known as Obamacare.
For now, 24 million Americans can keep their health insurance; states can count on Medicaid expansion; and essential benefits, like maternity and mental health services, are still guaranteed. Yes, let's pause, catch our breath and fully appreciate the disaster that was avoided.
Ryan's bill, the American Health Care Act, would have brought misery to millions of Americans, and not just the 52 million who would not have health coverage in 2026. The bill proposed by House leadership and endorsed by the Trump administration would have repealed tax penalties for people without health insurance; rolled back federal insurance standards; reduced subsidies for the purchase of private insurance; and set new limits on spending for Medicaid, the federal-state program that covers more than 70 million low-income people. The bill would have taken hundreds of billions of dollars from the public coffers. In short, it would have eased the tax burden of the wealthy at the expense of the most vulnerable, especially the poor, the elderly and the chronically ill.
The survival of the Affordable Care Act means that millions of people who have never had health coverage before can continue to buy plans from HealthCare.gov or find relief from an expanded Medicaid.
So, yes, let's breathe a short sigh of relief. But then let's roll up our sleeves and prepare for the next battle in the war that has been declared on the American middle class and people living in poverty.
As with all complicated legislation, whether on the social side like Social Security and food stamps, or the regulatory side like bank finance and trade laws, the drafters of the Affordable Care Act knew it would have to be revisited, tweaked and whole parts rewritten if it were to remain relevant and useful. Premiums, copays and deductibles are too high. That needs to be fixed. Twenty-nine states have yet to take advantage of expanded Medicaid. They must be persuaded to join. Insurance marketplaces need to offer more choice. That must be addressed.
Regrettably, many of the forces that have impeded any fixes to the original legislation remain in place. The irony of contemporary politics is that many of those forces actually enabled Obamacare to survive this round.
The yearslong fight over comprehensive health care reform for this nation continues. Using old and new weapons, Republican obstructionists can continue to work against the fixes the Affordable Care Act desperately needs. The night the legislation he fought for was pulled from consideration, President Donald Trump said, "The best thing that could happen is exactly what happened — watch."
"Obamacare unfortunately will explode," he said later in the day.
Ample evidence exists that the Affordable Care Act will not explode, but if it is not enforced and improved with fixes everyone agrees need to be made, it will become increasingly less effective. Republicans, now in control of the legislature and the White House, could cause a slow demise of the law by discontinuing the marketing campaigns and encouragement from the president essential to maintaining enrollment in the exchanges. Trump could also stop enforcement of the penalty for people who don't have insurance, and he could discontinue subsidy payments to insurers.
Congresspeople who want to fix our health care system may be open to persuasion as never before. In the last two months, as people have come to realize what they have to lose, the general population has grown bolder in pressuring their representatives to defend the Affordable Care Act. That was much in evidence in raucous constituent meetings and town halls that House members and senators witnessed.
Moderate Republicans, especially those facing midterm elections in 2018, rejected the Ryan-Trump plan. Democrats and those who back a fair and equitable health care law must learn from the GOP failure. They must start now to write new, workable legislation, and to retake the lead on this issue. Democrats and moderate Republicans could become the foundation for necessary reforms. It won't be easy, but it could be possible.
Media reports March 28 that Ryan and Trump would reintroduce legislation make this task urgent.
Independent Sen. Bernie Sanders of Vermont promises to introduce a bill that would move health care coverage to a single-payer, Medicare-like system. Now is the time for Democrats to come back into the spotlight and use this opportunity to work with Sanders to create a system that works — that works for those who can afford health care insurance and, more vital, for those who cannot.
Other industrialized nations, such as Canada, France and Japan, treat basic health care as a human right for all people. They built their health care systems on that tenet. It's time for the U.S. to recognize that right in this nation. The right to receive care can no longer be predicated on one's financial situation. Everyone in this country deserves the same treatment in the emergency rooms, hospitals, and medical and dental offices in all 50 states.
Once we've taken our deep breath, that should be the next fight.
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