Why an Open Market Won’t Repair American Health Care
by Jacob Hacker - NYT - April 4, 2017
How Healthcare Became Big Business and How You Can Take It Back
By Elisabeth Rosenthal
406 pp. Penguin Press. $28.
By Elisabeth Rosenthal
406 pp. Penguin Press. $28.
A few years back, the future of American health policy appeared to hinge on how similar medical care was to broccoli. It was March 2012, and the Affordable Care Act (a.k.a. Obamacare) was before the Supreme Court. Justice Antonin Scalia zeroed in on its controversial requirement that all Americans purchase health insurance. Yes, everybody needs health care, Scalia conceded, but everybody needs food too. If the government could make people buy insurance, why couldn’t it “make people buy broccoli”?
The Affordable Care Act survived, of course — though not before a fractured court made the expansion of Medicaid optional, leaving millions of poorer Americans without its promised benefits. But the question Justice Scalia asked remains at the heart of a debate that has only intensified since: Why is health care different? Why does it create so much more anxiety and expense, heartache and hardship, than does buying broccoli — or cars or computers or the countless other things Americans routinely purchase each day?
For those leading the charge to roll back the 2010 law, the question has a one-word answer: government. President Trump’s point man on health policy, the former congressman (and ultrawealthy orthopedic surgeon) Tom Price, has said that “nothing has had a greater negative effect on the delivery of health care than the federal government’s intrusion into medicine through Medicare.” Senator Rand Paul (another surgeon) and House Speaker Paul Ryan have claimed that the affordability of Lasik eye surgery — generally not covered by health insurance — shows that a much freer health care market would be much less expensive. Their idea of “reform” is to cut back public and private insurance so consumers have “more skin in the game” and thus shop more wisely.
The physician-turned-journalist Elisabeth Rosenthal offers a very different answer in her eye-opening “An American Sickness.” Rosenthal — formerly a reporter for The New York Times, now the editor in chief of the nonprofit Kaiser Health News — is best known for a prizewinning series of articles, “Paying Till It Hurts.” In them, Rosenthal chronicled the seemingly endless pathologies of America’s medical-industrial complex, from prescription drugs that grew more costly as they became more dated to hip-replacement surgery so expensive it was cheaper for a patient to fly to a hospital in Belgium.
Rosenthal thinks the health care market is different, and she sums up these differences as the “economic rules of the dysfunctional medical market.” There are 10 — some obvious (No. 9: “There’s money to be made in billing for anything and everything”); some humorous (No. 2: “A lifetime of treatment is preferable to a cure”) — but No. 10 is the big one: “Prices will rise to whatever the market will bear.” To Rosenthal, that’s the answer to Scalia’s question. The health care market doesn’t work like other markets because “what the market will bear” is vastly greater than what a well-functioning market should bear. As Rosenthal describes American health care, it’s not really a market; it’s more like a protection racket — tolerated only because so many different institutions are chipping in to cover the extortionary bill and because, ultimately, it’s our lives that are on the line.
Consider the epicenter of America’s cost crisis: the once humble hospital. Thanks in part to hit TV shows, we think of hospitals as public-spirited pillars of local communities. Yet while most are legally classified as nonprofits, they are also very big businesses, maximizing surpluses that can be plowed into rising salaries and relentless expansion even when they are not earning profits or remunerating shareholders. And they have grown much bigger and more businesslike over time.
Rosenthal tells the story of Providence Portland Medical Center, a Northwest hospital system founded by nuns. Four decades ago, its operational hub in Portland, Ore., consisted of two modest hospitals: Providence and St. Vincent. As it happens, my mother was a nurse at St. Vincent for more than half those years, and thus had a front-row seat as Providence transformed from a Catholic charity into one of the nation’s largest nonprofit hospital systems, with annual revenues of $14 billion in 2015.
Along the way, Providence jettisoned most of its original mission, replacing nuns with number crunchers. Once run mainly by doctors, it filled its growing bureaucracy with professional coders capable of gaming insurance-reimbursement rules to extract maximum revenue. Meanwhile, Providence stopped paying doctors as staff and reclassified them as independent contractors (though not so independent they could skip a “charm school” designed by its marketers). Yet even as its C.E.O. earned more than $4 million, Providence touted itself as a “not-for-profit Catholic health care ministry” upholding the “tradition of caring” started by the nuns (now listed as “sponsors” in promotional materials). Rosenthal sums up the result as “a weird mix of Mother Teresa and Goldman Sachs.”
Actually, not much of Mother Teresa: Providence-like consolidation in every part of American health care has created a structure at least as concentrated as the European systems conservatives decry, yet without the economy or coordination of care such concentration might offer if it were focused on people rather than profits. The Yale economist Zack Cooper has shown that prices paid by private insurers are not just massively higher than those paid by Medicare. (They’re in a different orbit from those paid abroad.) They are also hugely variable from place to place and even institution to institution, without any evidence that higher prices produce better care. Providers charge high prices not when and where they need to; but when and where — courtesy of consolidation — they can.
Rosenthal’s book doesn’t conclude with conglomerates. She also provides an eye-opening discussion of skyrocketing drug prices, as well as the less-familiar pathologies of excessive medical testing and overpriced medical devices, such as artificial hips and knees — a market dominated by a few manufacturers that, like big drug companies, shun direct competition in favor of building cozy relationships with the people who prescribe their products. In each case, Rosenthal diagnoses the incentives of the system by recalling the professional advice of Willie Sutton, who said he robbed banks because “that’s where the money is.” What outsiders might see as inefficiency or a conflict of interest, she shows, insiders have carefully constructed to maximize their bottom line. She also weaves in moving tales of those who are paying dearly for that enhanced bottom line — which, in the end, includes all of us.
Where Rosenthal’s account falls short is in explaining why this deeply broken system persists. Early on, Rosenthal seems to side with Speaker Ryan and Senator Paul, describing “the very idea of health insurance” as “in some ways the original sin that catalyzed the evolution of today’s medical-industrial complex.” But, as Rosenthal (too briefly) discusses, countries where people are much better insured don’t have anything like our self-dealing, upside-down incentives and outrageous costs. Somehow, despite largely keeping citizens’ skin out of the game, other rich democracies manage to have much lower costs per person — as well as greater utilization of physician and hospital services and better basic health measures.
The fact is that people need insurance for the highest costs they face. They may be able to pay for Lasik, a nonessential, nonemergency procedure for which consumers have plenty of time to shop around. But the biggest-ticket items — cancer care, cardiac surgery, organ transplants — are beyond the reach of all but the richest, and not so easy to shop around for when they’re needed. Just as we shouldn’t blame the idea of mortgages for the financial crisis, we shouldn’t blame the idea of health insurance for the health care crisis.
The difference between the United States and other countries isn’t the role of insurance; it’s the role of government. More specifically, it’s the way in which those who benefit from America’s dysfunctional market have mobilized to use government to protect their earnings and profits. In every country where people have access to sophisticated medical care, they must rely heavily on the clinical expertise of providers and the financial protections of insurance, which, in turn, creates the opportunity for runaway costs. But in every other rich country, the government not only provides coverage to all citizens; it also provides strong counterpressure to those who seek to use their inherent market power to raise prices or deliver lucrative but unnecessary services — typically in the form of hard limits on how much health care providers can charge.
In the United States, such counterpressure has been headed off again and again. The industry and its elected allies have happily supported giveaways to the medical sector. But anything more, they insist, will kill the market. Although this claim is in conflict with the evidence, it is consistent with the goal of maximum rewards to (and donations from) the industry. As a result, Medicare beneficiaries have prescription drug coverage (passed by Republicans in 2003), but Medicare administrators have no ability to do what every other rich country does: negotiate lower drug prices. In January, President Trump said drug companies were “getting away with murder” because they had “a lot of lobbyists and a lot of power,” insisting he would get Medicare to bargain. Should we really be surprised that the dealmaker in chief dropped the subject after meeting with pharma executives earlier this year?
Without a clear view of the political economy of health care, it’s easy to see the problem as Justice Scalia did. If we could just start treating health care like broccoli, the market would solve the problem. But as Rosenthal’s important book makes clear, the health care market really is different. Speaking of her Times series in 2014, Rosenthal told an interviewer her goal was to “start a very loud conversation” that will be “difficult politically to ignore.” We need such a conversation — not just about how the market fails, but about how we can change the political realities that stand in the way of fixing it.
Why the alt-right loves single-payer health care
by Dylan Matthews - VOX - April 4, 2017
When Mike Cernovich, one of the most prominent alt-right internet trolls supporting Donald Trump, was interviewed on 60 Minutes, he used the platform to spread conspiracy theories about Hillary Clinton's health and to allege that she is involved with pedophilic sex trafficking operations. But he also declared his belief in single-payer health care.
"I believe in some form of universal basic income," he told CBS’s Scott Pelley, citing concerns about technological unemployment. "I’m pro-single-payer health care. Is that right-wing or is that left-wing anymore? Well, if you have a lot of people, a large swath of the company, or country, are suffering, then I think that we owe it to all Americans to do right by them and to help them out."
This might seem like a bizarre position for a far-right conspiracy theorist to take. Single-payer health care, after all, entails nationalizing most or all of the health insurance industry and having the government set prices for doctors’ services. Conservatives in America have spent the better part of the past century arguing that the idea is socialistic, would lead to long waits for lifesaving treatment, and would give the government power over the life and death of its citizens.
But Cernovich is less a traditional conservative than he is a Trumpist — and Trumpism in its purest, alt-right variety cares more about white working-class identity politics than traditional conservatism. More and more, Trump fans are seeing single-payer as part of that.
Alt-rightists and other Trump-loyal conservatives — Richard Spencer, VDARE writer and ex–National Review staffer John Derbyshire, Newsmax CEO and Trump friend Christopher Ruddy, and onetime Donald Trump Jr. speechwriter and Scholars & Writers for Trump head F.H. Buckley — all endorsed various models of single-payer in recent months and years.
Even elites in the alt-right mold who once deplored single-payer are changing their tune. Pat Buchanan, the paleoconservative three-time presidential candidate whose white identity politics and fiercely anti-trade and anti-immigration stances helped inspire the modern alt-right, had free market views on health care in the 1990s and condemned Obamacare as a scheme to kill Grandma in 2009. This week, he told me in an email he has “not taken any position on single-payer, and [has] pretty much stayed out of the Obamacare repeal-and-replace debate.”
Curtis Yarvin, a Silicon Valley programmer whose writings under the pen name Mencius Moldbug helped launch the neoreactionary branch of the alt-right, told me he welcomes the movement’s trend toward single-payer, viewing it as a “sincere effort to think realistically in the present tense rather than in abstract ideology.”
Insofar as the alt-right, and the Trump-supporting right more generally, have a coherent economic agenda, it’s a vehement rejection of the free market ideology crucial to post–World War II American conservatism. While Paul Ryan reportedly makes all his interns read Atlas Shrugged, figures like Cernovich, Spencer, and Derbyshire are trying to build an American right where race and identity are more central and laissez-faire economics is ignored or actively avoided.
This has been most obvious on immigration and trade, where libertarians’ opposition to most or any government restrictions is in tension with the alt-right’s economic nationalism. But it’s also true on health care, where the pure alt-righters are joined by more mainstream pro-Trump voices like Ruddy and Buckley and even some Trump-wary conservatives such as Peggy Noonan.
The Trump-supporting right’s case for single-payer is part of a vision of a party where ideological purity on economic issues is much less important, and where welfare state expansion can be accommodated if it serves other goals — like building a political base among working-class whites.
The welfare state has always been more popular with the Republican base than with its elected officials. Trump arguably won the presidency in part by being the first Republican in years to promise to protect Social Security and Medicare. My colleague Sarah Kliff has run focus groups with Trump voters where participants bring up their admiration for Canadian-style single-payer unprompted. The alt-right single-payer fad suggests that elites are finally catching up.
Some of the arguments that the Trumpists and alt-rightists offer for single-payer are the standard concerns about the plight of sick and suffering Americans that wouldn’t feel out of place in a Bernie Sanders speech — like Cernovich’s insistence that “we owe it to all Americans to do right by them, and to help them out.”
Other arguments are offered more in sorrow than in anger. Derbyshire, for example, laments the fact that Americans are unwilling to accept a true free market in health care — but argues that single-payer makes more sense than the current hodgepodge of insurance subsidies and regulations and tax breaks.
“Citizens of modern states will accept no other kind of health care but the socialized or mostly socialized kind,” he said on a 2012 episode of his podcast, Radio Derb.“This being the case, however regrettably, the most efficient option is to make the socialization as rational as possible.” Single-payer, he concludes, would involve “less socialism, and more private choice,” than “what we now have.” (Derbyshire doesn’t really explain why socializing insurance is less socialist than not socializing insurance.)
But the main argument offered by Trumpists is about their movement. Donald Trump famously promised in May 2016 to turn the Republican Party into a “workers’ party.” The implication was clear: Republican elites before him like Paul Ryan and Mitt Romney prioritized deregulation for businesses and tax cuts for the rich, and offered little or nothing for working-class people, specifically working-class whitepeople. Instead, the party relied on social issues like abortion and immigration to earn their votes.
F.H. Buckley, the George Mason University law professor who led Scholars & Writers for Trump, even approvingly cites the leftist writer Thomas Frank’s What’s the Matter With Kansas? on this point. “Frank asked how it was that the poor folks of his home state voted for a Republican Party that cared so little for their economic interests,” Buckley wrote in the New York Post. “Become the jobs and the health-care president, and you [Trump] will have answered Frank’s question.”
“Steve Bannon has said the Republicans will become a party of ‘economic nationalism,’” Buckley continued. “No one has bothered to define this, but here’s one thing it must mean: We’re going to treat Americans better than non-Americans. We’re going to see that Americans have jobs, medical care and an enviable safety net.”
Of course, the Trumpists are big fans of using racialized, not explicitly economic appeals on issues like immigration and crime to win votes. But whereas they see mainstream Republicans like Paul Ryan or Jeb Bush making those appeals as a smokescreen for unpopular economic policies, they want to pair the appeals with an nationalist economic agenda that is actually popular with these voters.
“Unlike Paul Ryan and Rich Lowry, who masturbated to Atlas Shrugged in their college dorms and have no loyalty to their race, Donald Trump is a nationalist,” Richard Spencer writes. “We can’t ignore the politics of this. If Trumpcare passes, leftists can credibly claim that Trump has betrayed his populist vision. They will recycle the hoary script about nationalism and ‘scapegoating’ immigrants as a means of pushing through a draconian agenda. And they’ll have a point!”
Single-payer, Spencer insists, would "serve our constituency" (read: white people), give the right an answer to the appeal of social democrats like Bernie Sanders, and encourage the growth of the alt-right movement: "So many writers, activists, and content creators on our side shy away from becoming more involved, not just out of fear of social punishment, but out of fear of being fired and losing their health insurance."
Moreover, as soon as health care becomes a public issue, an alt-right government could use that power to promote a more vigorous, healthy white race on a number of dimensions. "When single-payer healthcare is implemented, issues like food safety, nutrition, and obesity become matters of public concern,” Spencer writes. “It will draw more attention to the alternative we are presenting to America’s current lowest-common-denominator society."
Of course, single-payer would overwhelmingly benefit a lot of nonwhite Americans as well. But programs like Social Security and Medicare do too, and their universal nature and the fact that they’re tied to work have led them to be less racialized and stigmatized than cash welfare or Medicaid. Single-payer’s universality is appealing because it helps the white working class without making them enroll in means-tested programs traditionally associated with black and Latino beneficiaries.
The ideological vision being offered here is hardly original. The political scientist Sheri Berman has argued that fascism and nationalism succeeded in Europe before World War II largely because unlike traditional conservative parties, fascist parties could provide a real challenge to the social democrats’ promise of relief from the suffering of the Great Depression.
"Across Europe nationalists began openly referring to themselves as 'national' socialists to make clear their commitment to ending the insecurities, injustices, and instabilities that capitalism brought in its wake, while clearly differentiating themselves from their competitors on the left," she writes in The Primacy of Politics.
And more recently, this strategy been adopted by some far-right parties in Europe. Marine Le Pen, the leader of France’s Front National, has relied heavily on "welfare chauvinism” in her presidential bids, a promise to protect and expand social programs for (white) native workers against migrants who might exploit them and drain money that should be going to noble French citizens. Geert Wilders, the far-right leader in the Netherlands, used to be a small-government conservative but began publicly fighting cuts to health programs and calling for expanded pensionsonce it became clear that this appealed to the lower-income voters who loved his anti-Islam message.
This trend isn’t universal; the Freedom Party in Austria, for example, was a traditional laissez-faire party on economics. But it’s become a popular strategy for several parties, from the Finns Party in Finland to the Danish People’s Party to the Sweden Democrats, whose leader once tweeted, “The election is a choice between mass immigration and welfare. You choose.”
And American far-rightists have noticed. James Kirkpatrick, a fellow writer of Derbyshire’s at VDARE (an anti-immigration site named after the first white person born in the American colonies), has approvingly cited the nationalist, authoritarian Polish Law and Justice Party’s strategy of tacking left on welfare to tack right on everything else. The country’s “patriotic government,” he swoons, “outflanked the Left and strengthened its grip on power with universal health care.”
The difference between those parties and Trump’s would-be workers’ party is that European countries already have universal health care. And one thing that happened once it was established is that mainstream conservative parties got on board with its preservation. The British Conservatives and the Gaullists in France and the Christian Democrats in Germany don’t try to repeal their countries’ universal health care systems. At most, they push for market-based reforms that retain universality but maybe introduce some more copays or an increased role for private insurers and providers.
When that’s the mainstream right-wing alternative, a right-wing party that calls for expanding welfare and health benefits seems more plausible. More to the point, most of the countries enjoying a far-right resurgence employ some system of proportional representation, which allows new parties without much political base to quickly gain ground in the legislature. Tellingly, while Le Pen does well in France’s presidential elections, there are only two Front National members in its National Assembly, which elects by district à la the US or UK.
So even if Trump were to be persuaded by his followers and embrace single-payer, he’d face a tough task. He can’t form a new right-wing party and sweep the legislative elections; he has to change the policies of the existent Republican Party, which has spent decades fighting proposals for universal health care, and get a quorum of members in the House and Senate on his side. That’s much harder, and suggests that the Spencers, Buckleys, and Derbyshires of the world won’t get their wish on this anytime soon.
Beyond Washington Politicking, the Real Health Care Story Is in the States
by Ben Palmquist - The Progressive - April 3, 2017
Although Paul Ryan’s plan to take health care away from 24 million people came up short, Congress and the Trump Administration are already planning a series of executive actions and legislation that, perhaps more quietly, will achieve many of the same ends. The question is not whether they will cut and privatize health care, but how deeply they will drive the knife.
The health care tumult in Washington has sucked up media attention, but a bigger story—and a much more inspiring one—is developing in the states. From Maine to Hawaii, people are not only resisting Republican attacks on health care, but are laying the foundations for a profound transformation of the American health care system. By redefining health care as a human right—one that state and local governments, as well as Washington, have an obligation to meet—grassroots campaigns are challenging the core logic of the private insurance industry: that health care is a commodity that should be available only to those who can afford it.
Though calls for replacing private insurance with universal, publicly financed coverage are not new, this political moment offers a unique opportunity. In the face of Congress’s sinister attacks on health care, people are turning out to town halls in droves, demanding more public involvement in health care, not less. Polls consistently show that a large majority of people recognize that government has an obligation to make sure that everyone can get care, Bernie Sanders’ call for “Medicare for All” helped make him the most popular politician in the country, and the insurance and drug industries have approval ratings even lower than Donald Trump. The public is way ahead of both parties.
The future of health care hinges not on polling, however, but on power. The insurance industry and its allies hold powerful control over both parties, and have so far successfully blocked every attempt at universal health care since the days of Harry Truman. To win, we need a mass people’s movement. But with Washington under the control of free-market ideologues dead set on an oligarchic agenda that is wildly out of step with the values of the public—and even of their party’s base—our path to power runs through the states.
Campaigning for universal health care in our states is both a moral cause and a strategic one. On a moral level, the for-profit insurance system systematically and brutally denies necessary health care to tens of millions of people. Tens of thousands of people die every year because the insurance system withholds life-saving care.
Strategically, health care offers progressives leverage to create a tectonic political shift not only in how we pay for care, but in how our society thinks about the role of government and the purpose of our economy. Organizing for universal health care challenges our economy’s tragic devaluing of human lives and recenters public policy on people and our wellbeing.
What’s more, because the private insurance system has hurt so many people, health care organizing opens a tremendous opportunity to build unity across lines of race, gender, class, age, geography, ability, and immigration status, and provides a large base of people who have the passion to do the long, hard work of fighting for change.
In just about every state in the country, there is an active and organized grassrootscampaign for universal health care, and state campaigns have already achieved significant success. The Vermont Workers’ Center passed a bill setting Vermont on the path toward universal health care, the Campaign for New York Health has twice passed a bill for universal health care through the State Assembly, and the Healthy California campaign has just introduced a bill in Sacramento that has powerful backing from the coalition’s 150 member organizations and their 4 million members.
Some of the most remarkable organizing is being led by the members of the Vermont Workers’ Center, Put People First! Pennsylvania, and Southern Maine Workers’ Center, whose Healthcare Is a Human Right campaigns (which I support) center around the leadership of poor and working class people who are directly impacted by the injustices of the health care system. It turns out that if you spend time listening to the concerns of everyday people rather than to the partisan rhetoric, you find remarkable agreement across the political spectrum and all walks of life. Nobody yearns for “choice” between inadequate insurance plans, high-deductible catastrophic coverage, unrestrained free-market drug pricing, or the other red herrings of Republican wet dreams. What people want is access to health care based on their medical needs, not their wealth; more redistributive taxes and spending; the protection and expansion of Medicaid and Medicare; and price controls to rein in the extortionate rates charges by insurance, drug, and hospital corporations.
Universal health care has long been a dream of the American left. We now have the chance of a lifetime, but if we’re going to win universal health care and refocus our economy on meeting human needs, we can’t afford to be passive, and we certainly can’t follow the lead of the Democratic Party. It’s time to turn down the Washington rhetoric, tune into our friends and neighbors, and get to work.
Ben Palmquist is a campaign manager with the National Economic and Social Rights Initiative (NESRI) and helps coordinate the Healthcare Is a Human Right Collaborative.
Ceding to One Side on Health Bill, Trump Risks Alienating Another
by Robert Pear and Thomas Kaplan NYT - April 4, 2017
WASHINGTON — The White House stepped up its push on Tuesday to revive legislation to repeal the Affordable Care Act by placating the most conservative House members, but the effort risked alienating more moderate Republicans whose votes President Trump needs just as much.
Vice President Mike Pence met for about two hours on Tuesday night with lawmakers, including leaders of three groups of House Republicans. But lawmakers leaving the conclave in the basement of the Capitol said that no deal had been reached and that talks would continue on Wednesday.
“It was a very good exchange of ideas, with concerns that represent the broad spectrum of our conference,” said Representative Mark Meadows, Republican of North Carolina and the chairman of the conservative House Freedom Caucus. “There were no agreements tonight, and no agreements in principle,” he added.
Mr. Pence has been meeting continually with House Republicans this week to rework and resuscitate the repeal bill that collapsed on the House floor on March 24. But the House speaker, Paul D. Ryan, acknowledged that changes intended to gain support on one side of the House Republican Conference could lose votes on another.
“It’s important that we don’t just win the votes of one caucus or one group, but that we get the votes and the consensus of 216 of our members,” Mr. Ryan said.
In negotiations with members of the Freedom Caucus this week, administration officials have discussed allowing states to opt out of two bedrock requirements in the Affordable Care Act. One requires insurers to cover a standard minimum package of benefits, known as essential health benefits. The other generally requires insurers to charge the same price to people of the same age who live in the same geographic area, with a possible surcharge for tobacco users. Under this provision, known as community rating, insurers cannot vary premiums based on a person’s health status, insurance claims history or gender.
Mr. Meadows said earlier Tuesday that he was pleased the administration was willing to eliminate more of the mandates in the Affordable Care Act, which Republicans have been trying to repeal ever since it was signed by President Barack Obama in 2010.
“Lower premiums have to be our first and only priority,” Mr. Meadows said. “By repealing community rating and the essential health benefits, it allows for lower premiums across the board.”
But Mr. Meadows said Freedom Caucus members wanted to see the language that would be added to the repeal bill before promising to vote for it, and no such language was made available at the meeting on Tuesday night.
At the same time, more moderate Republicans were expressing concern for other reasons. Administration officials say they want to preserve one of the most popular provisions of the Affordable Care Act, which bars insurers from denying coverage to people with pre-existing medical conditions. But without a requirement for some form of community rating, insurers could effectively do that, simply by increasing the cost of policies for sick or risky customers.
“I don’t think we will have something that eliminates community rating,” said Representative Tim Murphy of Pennsylvania, a member of the caucus of moderate Republicans known as the Tuesday Group. “That just can’t be.”
Mr. Murphy, a psychologist, has successfully championed legislation to improve treatment for mental illness and drug abuse, including opioid addiction. He said he wanted to be sure that any changes to the bill protected mental health care and treatment for substance abuse disorders, as well as maternity care — benefits that are guaranteed under the Affordable Care Act.
Mr. Ryan and the White House tried to play down expectations of a breakthrough, saying the talks on a new health care bill were at a preliminary, conceptual stage.
Sean Spicer, the White House press secretary, said the vice president and the chief of staff, Reince Priebus, were “very optimistic” about the possibility of developing a health care bill that could win a majority of votes in the House.
“The president would like to see this done,” Mr. Spicer said. “If we can get a deal and it gets to those votes — which, again, I’m not going to raise expectations, but there are more and more people coming to the table with more and more ideas about how to grow that vote.”
New York adopted community rating under a state law in the 1990s, and the policy caused serious problems in the individual insurance market, but state officials have come to accept it.
Representative Tom Reed, a New York Republican who supported the original version of the repeal bill last month, said on Tuesday: “Community rating is one of those things that is a very significant reform in the Affordable Care Act. I appreciate the states’ rights argument, but recognize that there is a reason behind community rating and the benefit that it brings to the insurance reforms.”
Democrats say that relaxing federal standards for benefits and rates would, in effect, eviscerate protections for people with pre-existing conditions.
And some Republicans appear to share that concern. Allowing states to opt out of the federal requirements for minimum benefits and community rating “could greatly erode the safeguards Obamacare put in place for those with pre-existing conditions,” said Representative Leonard Lance, Republican of New Jersey, who opposed the earlier House repeal bill and has not moved from that position.
Representative Chris Collins of New York, a Trump ally and member of the Tuesday Group, said he too was concerned about allowing states to obtain waivers from the community rating requirement.
“It’s one thing if you have car crashes and you pay higher car insurance,” Mr. Collins said. “Health is a different animal.”
The version of the repeal bill that went to the House floor last month died after Republican leaders, in a bid for conservative support, agreed to eliminate federal standards for minimum benefits. Under the proposal now under consideration, states could obtain waivers from the federal requirements.
Republicans try to revive health-care effort as leaders seek to temper expectations
by Mike Debones and John Wagner - Washington Post - April 4, 2017
Republicans led by Vice President Pence pushed to revive a moribund health-care bill on Tuesday, meeting late into the night with key lawmakers eager to build new GOP consensus to repeal the Affordable Care Act.
Pence spent much of Tuesday on Capitol Hill meeting with key groups of lawmakers, as well as with House Speaker Paul D. Ryan (R-Wis.), a day after visiting separately with conservative hard-
liners and moderates to gauge the potential for a revamped version of legislation that collapsed last month.
liners and moderates to gauge the potential for a revamped version of legislation that collapsed last month.
The crux of the new proposal would be to allow states to seek exemptions from certain mandates established under the Affordable Care Act — including a requirement that insurers cover 10 “essential health benefits” as well as a prohibition on charging those with preexisting medical conditions more than the healthy.
While the largely behind-the-scenes effort generated optimistic talk, no clear path has emerged toward House passage of the Republican bill. On Tuesday evening, key players said they were still waiting to see new proposals in writing, and some lawmakers said they were wary of rushing the process.
“There is a value sometimes to the vetting process,” said Rep. Mark Sanford (R-S.C.), a member of the hard-right House Freedom Caucus, a group targeted by President Trump last week for its opposition to the bill. “That having been said, we’ll see what comes our way.”
Republicans withdrew the American Health Care Act moments before a scheduled vote on March 24, after failing to woo enough lawmakers to support it. Here are the key turning points in their fight to pass the bill. (Jenny Starrs/The Washington Post)
Pence and other Trump administration officials attended a meeting late Tuesday in the Capitol with member of key House GOP factions, including the Freedom Caucus. But the meeting broke after two hours without a clear resolution, though several participants said there was progress and plan to continue the discussions on Wednesday.
Rep. Mark Meadows (R-N.C.), the Freedom Caucus chairman, said before the meeting that his group was still seeking broad relief from the ACA’s insurance mandates. Afterward, he said there was debate but no real accord on that contentious issue.
“There were no agreements tonight, and no agreements in principle, and certainly no agreements in terms of a foundation,” he said. “There was a general agreement that the progress we’re making is certainly progress, and there are good discussions, but understanding that there’s a whole lot of things that we have to work out.”
Others — both Republicans and Democrats — objected to the idea of undoing protections for people with preexisting conditions. That ACA requirement, known as “community rating,” prohibits insurers from segregating healthy subscribers from sick ones or charging the latter higher prices. Instead, they may vary their prices based only on age, geographic location and tobacco use, allowing the premiums paid by the healthy to subsidize the sick.
Sen. Patty Murray (Wash.), the ranking Democrat on the Senate Health, Education, Labor and Pensions Committee, said in a statement that the proposal would “give power back to the insurance companies, increase costs, and undermine care for people with preexisting conditions.”
Rep. Tom Reed (R-N.Y.), a member of the Ways and Means Committee, called the provision “a very significant reform” that he was concerned about rolling back, even if states would have to be granted a waiver.
The new proposal could also allow states to strip back other mandates, including requirements that insurers provide coverage for mental-health care, substance abuse treatment, maternity care and prescription drugs.
The changes were largely calibrated to win over the hard-liners in the Freedom Caucus, who blame the mandates for driving up insurance premiums. But the proposal also takes into account the qualms of moderates who are wary of undermining the ACA’s key reforms by requiring states to apply for waivers and to justify why insurers should not be required to provide certain coverage.
Those moderates helped defeat the original version of the American Health Care Act nearly two weeks ago, largely out of concern over a similar provision governing essential health benefits. And advocates of the new proposal appeared to be making little headway Tuesday.
“While we haven’t picked up any votes yet, this concept is already showing signs of losing a ton of them,” said a House Republican leadership aide, who requested anonymity to speak more candidly.
Ryan said Tuesday that the talks were in the “conceptual stages” and did not commit to a timeline for resolving the differences that sank the bill last month. “It’s important that we don’t just win the votes of one caucus or one group,” he said.
Pence sounded a similarly nonspecific note, telling a gathering of business executives at the White House that he and President Trump “remain confident” that Congress would repeal and replace the ACA.
White House press secretary Sean Spicer offered no timetable either, saying only that administration officials would continue meeting with lawmakers in hopes of advancing the bill.
“The president would like to see this done if we can get a deal,” Spicer said. “I’m not going to raise expectations, but I think that there are more and more people coming to the table with more and more ideas about how to grow that vote.”
Though aides said Trump has been in touch with both House and Senate members in recent days, he was playing a much less visible role in deliberations than in the days leading up to the aborted vote. Aides said that was partly because of a string of visits this week from three world leaders.
Pence, White House Chief of Staff Reince Priebus and budget director Mick Mulvaney began the two-day push to revive the repeal effort late Monday, with a trip to Capitol Hill to attend a Freedom Caucus meeting. Meadows said they offered a “solid idea” in that meeting to build a potential compromise around.
But both Freedom Caucus members and moderates emerged from a Tuesday morning House GOP conference lacking clarity on the path forward.
“Right now there are really just discussions, there’s no deal in the works, there’s been no deal on anything,” said Rep. Justin Amash (R-Mich.), a Freedom Caucus member.
Rep. Steve Womack (R-Ark.), a House leadership ally, said he didn’t get the sense that a compromise was near.
“I didn’t get any vibe this morning of ‘hold the phone, we may be close to a deal here,’ ” he said. “There’s no white smoke coming out of any leadership office that I’m seeing.”
Meadows said late Monday that he expected that the proposal would be drafted into legislative text within 24 hours, but he said after the Tuesday-night meeting that no such text had been offered by the White House or congressional leaders, leaving “unanswered questions” for hard-liners.
While addressing reporters, Spicer was asked whether a deal that rolled back protections for preexisting conditions would violate a campaign pledge by Trump. “We’re not there yet,” he said. “We’re having discussions.”
Two other moderate House members also said they remained opposed: Rep. Frank LoBiando (R-N.J.) tweeted that he had “seen nothing in terms of reported possible changes to American Health Care Act warranting reconsideration.” And Rep. Leonard Lance (R-N.J.) said changes to community rating would undermine protections for those with preexisting conditions.
On the flip side, it was unclear just how many Freedom Caucus members could be swayed with the softened provision to give states the option of requesting exemptions to some of the ACA’s mandates.
“I don’t think that a long-term solution consists of allowing states to ask the federal government for waivers, because presidents change,” said Rep. Mo Brooks (R-Ala.). “States ought to have as a matter of right the ability to determine what insurance policies for their citizens should contain.”
A health-care industry official argued that the proposed changes to the bill appear to leave in place most of the core problems with the original bill and exacerbate others by making changes that would effectively make insurance either too expensive or too skimpy for sick people.
“To put it simply, this is making a bad bill worse,” said the industry official, who spoke on the condition of anonymity in order to speak frankly. The official added that his industry is waiting to see the details of the revised bill before weighing in publicly: “You don’t want to rain on a parade until you know it’s headed into town.”
As part of his push to revive the bill, Pence also arranged on short notice a meeting and phone call Tuesday with some leading conservative activists who have been skeptical of the health-care proposals floated so far.
The group included Marjorie Dannenfelser, president of the Susan B. Anthony List; Jim DeMint, president of the Heritage Foundation; Grover Norquist, president of Americans for Tax Reform; Tim Phillips, president of Americans for Prosperity; and Matt Schlapp, chairman of the American Conservative Union.
The flurry of activity Monday and Tuesday raised some hopes that the closely watched legislation could be revived and passed through the House quickly. But with lawmakers ready to leave town Thursday for a two-week Easter recess, others questioned the rush.
“A lot of people would love to get this done this week — kind of unrealistic given all the changes that are being discussed,” said Rep. Ken Buck (R-Colo.), a Freedom Caucus member who supported the original version of the AHCA. “Some people want to come back next week — kind of unrealistic given all of the plans everybody has in their district for next week. And then the most realistic thing, I think, is to try and get something done when we get back.”
Meadows said Tuesday night that it was “premature” to rule out a vote this week but also made clear no deal was at hand and there are “no real discussions” about potentially keeping the House in session to push the bill through.
Ryan has taken a less direct role in the renewed negotiations, aides involved in the discussions say, out of a desire to let the various GOP factions work matters out on their own timetable rather than forcing a deal that could backfire.
Trump took aim at the Freedom Caucus in tweets Thursday, pledging to “fight them” at the polls in the 2018 midterms. He remained active on Twitter over the weekend, suggesting that the situation was still fluid — and that he is looking at ways to move forward with the help of either moderate Democrats or conservative Republicans.
The president also played a round of golf Sunday with Sen. Rand Paul (R-Ky.), the libertarian-oriented former presidential candidate who has been a sharp critic of the House bill and celebrated its failure less than two weeks before.
Maine Voices: In the trenches of the health care battle, Medicare for all would heal many wounds
by Cathleen London - Portland Press Herald - April 4, 2017
MILBRIDGE — Once again the Republican Party is pounding its collective chest and saying repeal and replace of Obamacare is close. If it is anything like the last disaster they presented, what they really mean is a watered-down weakened version called RyanCare, consisting of tax breaks for wealthy Americans, 24 million fewer insured Americans and rising premiums for the rest of us. That hardly solves the issue.
The Affordable Care Act was passed after many provisions were struck from the original version – including a public option. If the current administration were truly serious about engendering competition and bringing costs down, then a public option should be in play. Let people buy into Medicare.
Frankly we could have a single-payer, Medicare for all system: Simply increase the Medicare tax by 3.5 percemt (about $59 per $20,000 earned) and everyone is covered. I just don’t think either side of the aisle will bite given the strength of the insurance lobby. Given that the government already pays the majority of health care costs, between Medicare, Medicaid, Tricare, the Veterans Affairs system and the various federal employee programs, it would be logical to have single-payer – but logic has not always been a strong point of government.
In overhauling the morass of health care, Washington would do well to do something about the enormous administrative burden that has been placed on those of us who provide the care. Lost in all the discussion of insurance and coverage is physician burnout. The more spent on administration as opposed to actual care, the worse the experience for both physicians and patients.
Physician dissatisfaction is directly related to this increase in administrative burden. Physicians are dropping out, retiring and committing suicide. This is an additional financial toll. The cost of training physicians is only partly covered by tuition. The rest is covered by Medicare funds that the hospitals receive. If you do not have physicians, you do not have health care. Wake up, Washington.
Physicians are tired of chasing payment for services rendered – especially when it is a fraction of what we bill. We are tired of prior authorizations. We cannot make sense of why a medication was on the plan last week but is not there this week – particularly generic medications that cost pennies. When this decision is being rendered by a customer service representative with no medical (or other) degree, it is particularly degrading.
None of us spent thousands of hours training for this. That is not the calling we answered. The mind-numbing waste of our time is obscene. According to the Commonwealth Fund, the United States ranks last among 11 developed nations on measures of access to care, efficiency of care and equity of care. We should be embarrassed.
We fought for the ACA to keep insurance companies from canceling consumers’ coverage retroactively. We fought to stop lifetime caps. We fought to stop gouging patients with pre-existing conditions (including babies born with them).
We fought to stop gender discrimination – being a woman should not be a pre-existing condition! I will not go back to that. I personally was affected by that. When I graduated from medical school, I was 12 weeks pregnant. I arrived for residency and could not get insurance because my pregnancy was a pre-existing condition. You cannot make this up.
When I finally did get insurance (through the hospital I was working for), they did not want to cover the newborn exams we required as a hospital. Yes, I was just as mystified as you are reading this.
By definition, insurance companies collect your money and try not to pay out. With health care, this is just a no-win proposition. When they are answering to shareholders and paying exorbitant CEO salaries, that money is not available to those actually providing care.
If we were to join the rest of the developed world with single-payer, then the government would cover most of the cost, private insurance companies could compete for the co-pays (or offer more extensive products) and consumers could elect to purchase these policies or not. This would allow a true free market to develop – one that could actually cross state lines. Perhaps I am dreaming but it really is time to put patients over politics.
Letter to the editor: Mainers deserve expanded MaineCare – vote yes in fall referendum
Portland Press Herald - April 5, 2017
The Portland Press Herald recently published an Associated Press article (March 20) citing Norway as the happiest nation on earth. Why? The Norwegians believe in part it is because they have universal health care, child care and education. They think all Norwegians deserve it.
Thousands of our fellow Mainers could have gotten Medicaid if Gov. LePage would have agreed to the MaineCare expansion in Maine. Instead, LePage has done the opposite – cut thousands of Mainers off MaineCare.
The same goes for our fellow Americans. If the Republicans in Congress shrink Medicaid nationwide, other states will suffer the same fate. Many more will lose their health care. Mainers and Americans deserve more care, not less!
In my 18 years as a mental health professional, I have seen what Maine-Care can do. MaineCare doesn’t just treat your diabetes or mend a broken limb; it can also help mend hearts, homes and minds. MaineCare helps elders stay in their homes. MaineCare helps the homeless find homes. MaineCare helps the lonely find company. MaineCare helps to heal families. MaineCare helps to heal addiction. MaineCare helps. Period.
Let’s vote “yes” in November’s referendum to expand Medicaid for Maine. Maine deserves better. We deserve to be just as happy as the Norwegians. Expanding MaineCare is a step towards expanding our state of happiness.
Meghan Walsh, LCSW
Portland
Conyers: Medicare for All's time has come
by John Conyers, Jr. - Detroit Free Press - April 3, 2017
I’m as happy as anyone with the way the Republicans’ plan to wreck our healthcare system crashed and burned last week. And President Donald Trump is right: Republicans lost because Democrats beat them. We beat them because we were organized, we were unified and we were backed by unprecedented grassroots energy. Members of the U.S. Congress hosted dozens of rallies, advocacy organizations hosted hundreds more and constituents showed up in overwhelming numbers at town halls across this country to make their voices heard.
And what exactly was their message? One of the most poignant moments came at a town hall hosted by U.S. Rep. Diane Black, Republican of Tennessee, where a constituent explained her opposition to the GOP bill using faith. As a Christian, she said, her faith was rooted in helping the unfortunate, not cutting taxes on the rich, so why not expand Medicaid and allow everyone to have insurance? And she’s not alone. Last week, a Quinnipiac survey found that voters overwhelmingly oppose cuts to Medicaid -- 74% of them -- including 54% among Republicans.
Given the record high support for publicly funded healthcare, economists, policy experts and commentators everywhere have called on the Democratic party to build on our momentum by supporting a single payer system. But perhaps the most convincing case I heard came from Jessi Bohan, the teacher from Cookeville, Tennessee who spoke at Rep. Black’s town hall.
The week after her question went viral she wrote to the Washington Post that she was troubled to see her comments used as a "defense of Obamacare" instead of what they were: an indictment of any healthcare policy that leaves anyone out. As Bohan so eloquently put it, "it is immoral for health care to be a for-profit enterprise" that allows insurance companies to make "enormous sums of money off the sick while people are struggling to pay their medical bills." If she had it to do over again, she wrote, she would have explained to Black "the Christian case for universal, single-payer health insurance, which would protect all Americans."
While her message was targeted at Republicans, it is one that many of my colleagues in the Democratic Party need to hear as well. For two weeks, I’ve watched Democrats point to the Congressional Budget Office’s analysis of the Paul Ryan bill and express righteous outrage that it would lead to 24 million Americans losing their insurance. But that same CBO score says that 28 million Americans will still be without insurance even under the Affordable Care Act. I’m impressed that the ACA has expanded Medicaid eligibility in states that have adopted it and more than 20 million previously uninsured now have insurance, but universal healthcare it is not.
Time and time again I’ve heard Democrats dodge questions about their support for universal healthcare by saying they’re focused right now on defending the ACA. Now that we have repelled Paul Ryan’s attack and Donald Trump has signaled that Republicans will move on, the time for those excuses has passed.
For years, I’ve also watched as Democrats, including our presidential nominee last year, have avoided putting their name behind single payer by saying they’re focused on politically achievable short-term goals.
Single payer is politically achievable.
Gallup, the Kaiser Family Foundation, and other polling organizations have found that there is majority support for Medicare for All in America today. But more important, elected officials are not supposed to move to the political center, we are supposed to stake out the moral center and convince others to join us there.
November’s election results showed that we can’t just say "the other side is awful," however true that may be, and expect Americans to flock to us. To win again, we must be a party of principles and present bold ideas and a vision for the future.
It is true that single-payer healthcare has been implemented in virtually every other advanced democracy on Earth. It is also true that in those countries, people live longer andhealthcare is dramatically less expensive than it is here. And finally, it is true that Medicare for All is the direction Americans overwhelmingly want us to go. Nevertheless, I want my colleagues to join me in supporting single-payer not to save money or to win elections, but because it is the moral and just thing to do. If, like me, you believe healthcare is a right to everyone and not a privilege to those who can afford it, let’s be organized and let’s be unified in our support for Medicare for All.
John Conyers represents Michigan's 13th District in the U.S. Congress. He has introduced H.R. 676 Medicare for All bill in every Congress since 2003.
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