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Wednesday, May 31, 2017

Health Care Reform Articles - May 31, 2017

Editor's Note: 

The following study has just been released.  Click on the hot-link at the end of the Abstract to see the full study.

-SPC

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ECONOMIC ANALYSIS OF THE HEALTHY CALIFORNIA SINGLE- PAYER HEALTH CARE PROPOSAL
(SB-562)
May 2017
By
Dr. Robert Pollin
Distinguished Professor of Economics and Co-Director, Political Economy Research Institute (PERI) University of Massachusetts-Amherst
Dr. James Heintz
Andrew Glyn Professor of Economics and Associate Director PERI University of Massachusetts-Amherst
Dr. Peter Arno
Senior Fellow and Director of Health Policy Research, PERI University of Massachusetts-Amherst
Dr. Jeannette Wicks-Lim Assistant Research Professor, PERI University of Massachusetts-Amherst
We are grateful for the contributions to this project and comments on a preliminary draft by Amal Ahmad, Michael Ash, Megan Baier, Brian Callaci, Shouvik Chakraborty, Don DeMoro, Jerry Epstein, Jerry Friedman, David Himmelstein, Dan Johnston, Jim Kahn, Ian Lewis, Michael Lighty, and Stephanie Woolhandler. We also appreciate the financial support for this project from the California Nurses Association. All errors remain our own.
Pollin, Heintz, Arno and Wicks-Lim, “Economic Analysis of Healthy California” May 2017
Page 1
ECONOMIC ANALYSIS OF THE HEALTHY CALIFORNIA SINGLE- PAYER HEALTH CARE PROPOSAL
(SB-562)
By
Robert Pollin, James Heintz, Peter Arno, and Jeannette Wicks-Lim Department of Economics and Political Economy Research Institute (PERI) University of Massachusetts-Amherst
May 2017
JEL CODES: I11, I13, I14, H71ABSTRACT: The State of California is considering a bill to create a statewide single-payer health care system. This study provides an economic analysis of the proposed measure, The Healthy California Act (SB-562). The study includes four major sections: 1) Cost Estimate of Universal Health Care Coverage in California; 2) Cost Saving Potential under Healthy California; 3) Financing Healthy California; and 4) Impact on Individual California Families and Businesses. The primary goal of Healthy California is to provide high-quality health care to all California residents, including those who are presently either uninsured or underinsured. The study finds that the providing full universal coverage would increase overall system costs by about 10 percent, but that the single payer system could produce savings of about 18 percent. The study thus finds that the proposed single-payer system could provide decent health care for all California residents while still reducing net overall costs by about 8 percent relative to the existing system. We propose two new taxes to generate the revenue required to offset the loss of private insurance spending: a gross receipts tax of 2.3 percent and a sales tax of 2.3 percent, along with exemptions and tax credits for small business owners and low-income families to promote tax-burden equity. Within this proposed tax framework, Healthy California can achieve both lower costs and greater equity in the provision of health care in California for both families and businesses of all sizes. Thus, net health care spending for middle-income families will fall by between 2.6 – 9.1 percent of income. Small firms that have been providing private health care coverage for their workers will experience a 22 percent decline in their health-care costs as a share of payroll. The small firms that have not provided coverage will still make zero payments for health care under Healthy California through their gross receipts tax exemption. Medium-sized firms will see their health care costs fall by between 6.8 and 13.4 percent as a share of payroll relative to the existing system. Firms with up to 500 employees will experience a 5.7 percent fall, and the largest firms, with over 500 employees, will experience a 0.6 percent fall as a share of payroll relative to the existing system.

 http://www.healthycaliforniaact.org/wp-content/uploads/Pollin-Economic-Analysis-SB-562.pdf

The Trump administration just imposed a massive tax increase. You may have missed it.
by Andy Slavic - Washington Post - May 26, 2017
This week the Trump administration managed to impose a massive tax increase on middle-income families beginning in 2018. You could be excused for missing this story if you were focusing instead on President Trump’s draconian budget or Republican efforts to take away health care from tens of millions of people. But, indeed, on Monday, the Trump Health Care Tax was born.
The new tax, 19 percent or more of premiums, will be added on top of the cost of policies purchased through the individual-market health insurance exchanges. It is a result of Trump’s decision to create as much chaos as possible in the health-care market — in this case by not committing to continue to reimburse billions of dollars of cost-sharing payments owed to insurers just as they set prices for next year. And the president couldn’t have been more clear about why he’s imposing this tax: He thinks disrupting the Affordable Care Act exchanges, which serve more than 12 million Americans, will force Democrats to agree to proposals in his budget and in the House health-care bill that would take coverage away from tens of millions.
There is something even more troubling about this tax. In an unusual twist, it will not be paid to the government but to insurance companies. That’s because, under the ACA, 83 percent of people who are insured on the exchanges are protected from premium increases by tax credits provided by the government. If premiums go up, government payments to insurers go up with them. Trump is even willing to sacrifice federal dollars to sink the ACA.
But let’s take a step back. This all started as a cynical ploy by Congress that got further out of hand when Trump won the presidency. In between more than 50 votesto adjust or outright repeal the ACA, Congress used a number of budget tricks and lawsuits to undermine the law. The effect was to eliminate billions of dollars in funding designed to keep rates lower, prevent millions of Americans eligible for Medicaid from accessing coverage and force a dozen co-ops designed to increase competition out of business.
Even with these headwinds, the exchanges are far from failing. Four million new people were added during last year’s open enrollment. Insurers have consistently reported profitability, putting the market on track for lower premium increases and more competition in 2018. Independent analysts at Standard & Poor’s affirmed, “If it remains business as usual, we expect 2018 premiums to increase at a far lower clip than in 2017.” But as bipartisan insurance commissioners and the nonpartisan Congressional Budget Office just confirmed, Trump’s tampering is badly destabilizing things.
When Trump became president, many of us wondered publicly whether the administration would at least carry out the law in ways that served the interests of the American public. We didn’t have to wonder for long.
Trump made clear right away what his strategy was. “The best thing we can do, politically speaking, is let Obamacare explode,” he said from the Oval Office. And Trump and his team proceeded to pour the oil and light the match.
Step one was to stop outreach during the week of open enrollment when the biggest number of young and healthy people get covered. Trump quickly took steps to stop enforcing the ACA’s individual mandate and adopted regulations increasing paperwork for consumers, reducing tax credits that help people pay premiums and shortening the period for consumers to sign up. And Trump’s budget indicates he is planning more cuts to outreach and consumer assistance. All of these steps reduce coverage and increase costs.
Worst of all for consumers, Trump’s move this week may be the last straw for insurers. Faced with an administration that has made clear it will do what it can to cause the exchanges to fail, insurers are questioning whether they can continue to participate. The administration is proving that the one thing it can succeed at is failure.
Remarkably, all of this is in service of something even worse: a plan to take health-care from 23 million Americans, raise costs for tens of millions more and eliminate access to care in large parts of the country.
With the CBO score of the House health-care bill out, it’s now time for senators to cry foul. Foul on a secretive process; foul on a bill that hurts millions of people; foul on ripping apart Medicaid coverage for kids, seniors and people with disabilities; and foul on taking away substance-abuse treatment and mental-health care from millions of people who need it. For a bill that could impact the course of Americans for generations to come, this is no time to “voice concerns” or “discuss challenges.” And it’s no time to act as a ratifying body for a president who doesn’t have the best interests of its constituents in mind.

The only way to alter the self-fulfilling, destructive course that Trump has set us on is for senators to publicly say that they will never vote for a bill that robs people of coverage and to tell the administration to undo the Trump tax, stop the antics that are driving instability in the exchanges, and do the real work of improving Americans’ access to high-quality health care.

The GOP masterminds behind the Obamacare sabotage
by Dana Milbank - Washington Post - May 14, 2017

 President Trump says, “ObamaCare is imploding and will only get worse,” and he should know: He’s the one who placed the explosives under Obamacare’s foundation.
House Energy and Commerce Committee Chairman Greg Walden (R-Ore.), co-author of the GOP health-care bill, says of Obamacare: “We’ve arrived at the scene of a pretty big wreck.” And he, too, should know: He’s the one who dumped oil and tire spikes on the road.
This is some prodigious cynicism, even by Washington standards. In the past couple of months, the Trump administration and the new GOP Congress have done all they could to undermine Obamacare, and now that their efforts are beginning to succeed they’re claiming Obamacare is collapsing under its own weight.
The Affordable Care Act may or may not be in the death spiral Republicans have long craved, but it has definitely deteriorated since the Trump administration and the new GOP Congress assumed power. And no wonder: They sabotaged it.

While defending the GOP health-care plan on March 9, House Speaker Paul Ryan said that Obamacare is in a "death spiral" because healthy people are forced to pay for the people who are sick. (The Washington Post)
They withdrew TV and online advertising encouraging people to sign up for coverage during the crucial period before the deadline. The White House issued an executive order and took other actions that strongly implied it would no longer enforce the “individual mandate” requiring people to sign up for coverage. And the constant promises of imminent repeal have spooked both insurers and individuals from participating.
Trump and congressional allies have, in short, created a self-fulfilling expectation of collapse. “What’s happened since the Trump administration took power is tremendous uncertainty about the future of the ACA,” said Larry Levitt of the Kaiser Family Foundation, which conducts health-care research but takes no position on the law. “For people who were on the fence about participating, the future uncertainty pushes them over. Many insurers, meanwhile, were willing to suffer short-term losses with the promise of future profits, but if the ACA’s future is uncertain there’s little reason to stick around.”
Now opponents of the law are using the wreckage they created to justify their own plan, which the nonpartisan Congressional Budget Office projects would cause 24 million more people to go without coverage than would have under Obamacare. It would dramatically cut coverage for poor and middle-class Americans, increase costs sharply for older Americans and give hundreds of billions in tax breaks to the wealthy and corporate interests. There would actually be more people without health insurance under the GOP plan than there were before Obamacare. 
Confronted with the task of selling this cruel plan to the public, the administration and its allies are doing what they’ve done before: attempting to deny reality. They’re seeking to discredit the CBO, perhaps hoping people won’t recall that Republicans picked the man who runs it: Keith Hall, a conservative former George W. Bush administration economist .
Worse, they’re perpetuating the canard that Obamacare was collapsing on its own, leaving them no choice but to repeal it. Walden argued that “if we don’t intercede now, fewer will have access to insurance — period.” Ryan said the “law is collapsing” and asked: “Are we going to stay with Obamacare and ride out the status quo?” And Trump floated a fallback plan: pass nothing, let Obamacare fail and blame Democrats for it. 
But they aren’t “letting” Obamacare fail; they’re causing it. As I wrote six months ago, Obamacare extended coverage to more than 20 million, and it works well for most. Slightly more than 2 million people, mostly in rural areas, don’t have competitive plans to choose from and are seeing huge premium increases. Congress could have fixed that by giving insurers incentives to participate in those markets. Instead, Republican lawmakers refused to help insurers and then crowed when insurers complained.
Last month, Aetna chief executive Mark Bertolini said Obamacare was in a “death spiral” — and Trump gleefully tweeted about it. But the CBO, in its report Monday, said the exchanges would remain “stable in most areas” if the current law were left intact, because subsidies and the individual mandate would sustain demand.
At a listening sessions at the White House, March 13, President Trump said the best thing Republicans in Congress "could do politically is wait a year," to alter the Affordable Care Act, but that that would be "the wrong thing to do for the country."(The Washington Post)
The problem is that the administration has been working aggressively to suppress demand, by suggesting the mandate to buy insurance won’t be enforced and by ending government attempts to enroll people. A Brookings Institution analysis said a decline in enrollment for 2017 likely wasn’t caused by premium increases. Joshua Peck, former chief marketing officer for HealthCare.gov, estimated in a post on Medium that Trump deterred 480,000 people from signing up. 
Obamacare isn’t failing; it’s being destroyed. And those committing the sabotage ought to own whatever happens next, whether they pass a replacement or not.


The US healthcare system is at a dramatic fork in the road

by Adam Gaffney - The Guardian - May 25, 2017

The US healthcare system – and with it the health and welfare of millions – is poised on the edge of a knife. Though the fetid dysfunction and entanglements of the Trump presidency dominate the airwaves, this is an issue that will have life and death consequences for countless Americans.
The Congressional Budget Office’s (CBO) dismal “scoring” of the revised American Health Care Act (AHCA) on Wednesday made clear just how dire America’s healthcare prospects are under Trump’s administration. But while the healthcare debate is often framed as a choice between Obamacare and the new Republican plan, there are actually three healthcare visions in competition today. These can be labelled healthcare past, healthcare present, and healthcare future. 
Let us begin with healthcare past, for the dark past is precisely where Republicans are striving to take us with the AHCA. The bill – narrowly passed by the House on 4 May – is less a piece of healthcare “reform” than a dump truck sent barreling at high speed into the foundation of the healthcare safety net. 
Wednesday’s CBO score reflects the modifications made to the AHCA to pacify the hard-right Freedom Caucus, changes that allowed states to obtain waivers that would relieve health insurers of the requirement that they cover the full spectrum of “essential healthcare benefits”, or permit them to charge higher premiums to those guilty of the misdemeanor of sickness, all purportedly for the goal of lowering premiums. 
In fairness, the CBO report did find that these waivers would bring down premiums for non-group plans. This, however, was not the result of some mysterious market magic, but simply because, as the CBO noted, covered benefits would be skimpier, while sicker and older people would be pushed out of the market. 
In some states that obtained waivers, “over time, less healthy individuals … would be unable to purchase comprehensive coverage with premiums close to those under current law and might not be able to purchase coverage at all”. Moreover, out-of-pocket costs would rise for many, for instance whenever people needed to use services that were no longer covered – say mental health or maternity care. 
Much else, however, stayed the same from the previous reports. Like the last AHCA, this one would cut more than $800bn in Medicaid spending over a decade, dollars it would pass into the bank accounts of the rich in the form of tax cuts, booting about 14 million individuals out of the program in the process. And overall, the new AHCA would eventually strip insurance from 23 million people, as compared to the previous estimate of 24 million. 
It’s worth noting here that Trump’s budget – released Tuesday – proposed additional Medicaid cuts in addition of those of the AHCA, which amounted to a gargantuan $1.3tn over a decade, according to the Center on Budget and Policy Priorities. 
The tax plan and budget – best characterized as a battle plan for no-holds-barred top-down class warfare drawn up by apparently innumerate xenophobes – would in effect transform the healthcare and food aid of the poor into bricks for a US-Mexico border wall, guns for an already swollen military, and – more than anything – a big fat payout to Trump’s bloated billionaire and millionaire cronies. 
What becomes of this violent agenda now depends on Congress – and on the grassroots pressure that can be brought to bear upon its members. 
But assuming the AHCA dies a much-deserved death – quite possible given the headwinds it faces in the Senate – we will still have to contend with healthcare present. 
Last week, the Centers for Disease Control released 2016 results from the National Health Interview Survey, giving us a fresh glimpse of where things stand today. And on the one hand, the news seemed good: the number of uninsured people fell from 48.6 to 28.6 million between 2010 and 2016. 
On the other hand, it revealed utter stagnation: an identical number were uninsured in 2016 as compared with 2015, with about a quarter of those with low incomes uninsured last year (among non-elderly adults). It also suggested that the value of insurance is declining, with “high-deductible health plans” rapidly becoming the rule and not the exception: for the privately insured under age 65, 39.4% had a high-deductible in 2016, up from 25.3% in 2010.
Healthcare present, therefore, is an unstable status quo: an improvement from healthcare past, no doubt, but millions remain uninsured and out-of-pocket health costs continue to squeeze the insured. 
Which takes us to the third vision, that of healthcare future. As it happens, another recent development provided a brief glimmer of hope for that vision. As the Hillreported, the Democratic congressman John Conyers held a press conference yesterday (Physicians for a National Health Program, in which I am active, participated) to announce that his universal healthcare bill – the “Expanded & Improved Medicare For All Act” – had achieved 111 co-sponsors, amounting to a majority of the House Democratic Caucus and the most in the bill’s history.
This bill – like other single-payer proposals – is the precise antithesis of Paul Ryan’s AHCA. Rather than extract coverage from millions to provide tax breaks for the rich, it would use progressive taxation to provide first-dollar health coverage to all. 
Which of these three visions will win out is uncertain, but the outcome of the contest will have a lasting impact on the country. We can only hope that the thuggish, rapacious vision championed by Trump and his administration does not prevail.


C.B.O. Has Clear Message About Losers in House Health Bill

by Margot Sanger-Katz - NYT - May 25, 2017

The Senate now has a clearer sense of who would win and lose under the health bill the House sent them. It also got a startlingly direct message from government analysts about how destabilizing one of the House ideas could be.
The Congressional Budget Office published its assessment of the House health bill on Wednesday, and warned that a last-minute amendment made to win conservative votes would result in deeply dysfunctional markets for about a sixth of the population. In those places, insurance would fail to cover important medical services, and people with pre-existing illnesses could be shut out of coverage, the budget office said.
It found that about half the country would face thinner coverage for people who buy their own insurance, as it would be unlikely to include mental health and addiction treatment services, maternity care or rehabilitation services. Medical deductibles would also increase.
As in the original version of the bill, winners would include people who are young, healthy and earn higher incomes. They would be better off, assuming they didn’t develop serious health problems. The bill makes big cuts to taxes on payroll and investment income for those earning more than $200,000, and provides more subsidies to buy insurance for people earning between about $50,000 and $150,000. On average, premiums for health plans people buy for themselves would decline over the 10-year period, as coverage becomes less generous.
Losers would include poor Americans who use Medicaid, as 14 million fewer people would be in the program after 10 years. Poorer and older Americans who buy their own insurance, particularly those in both categories, would also lose coverage. The cost of insurance for a 64-year-old earning about $27,000 would increase to more than $13,000, from $1,700 under the Affordable Care Act, even for states that pared back insurance rules.
The report was sharply critical of the idea that sicker patients could be protected in a system that allowed insurers to charge them higher premiums. In the minority of states it predicted would pursue broad waivers of Obamacare’s insurance regulations, the office said that sick customers would face far higher prices and many would be priced out of the market altogether.
“Over time, less healthy individuals (including those with pre-existing or newly acquired medical conditions) would be unable to purchase comprehensive coverage with premiums close to those under current law and might not be able to purchase coverage at all,” the report said.
Republicans have argued that the bill’s waivers would not hurt insurance access for people with pre-existing health conditions, thanks to state funding devoted to high-risk pools subsidizing their coverage. The C.B.O. essentially dismissed that idea, saying that the state funds would not be enough to protect sick customers from huge bills.
Premiums for healthier customers would go down in those states, though some people might end up buying plans so flimsy that the budget office said they didn’t count as insurance. A second set of states that pursued more limited waivers of insurance rules could enjoy premiums some 20 percent lower than expected under the Affordable Care Act in exchange for more limited benefits, it said.
Republicans have argued that letting states waive the insurance rules would lead to a more robust and attractive insurance market. The C.B.O. disagreed with that argument, too. It said that markets in the states with waivers would become smaller than under an earlier version of the bill that did not include the waivers. In response, more employers would offer workers coverage, it said, since they would see individual coverage as an unattractive alternative.
Over all, the budget office found that the law would mean 23 million more peoplewould lack insurance than under current law, a slight decrease from its assessment of an earlier draft that did not include the waivers. But it noted that the group without insurance would not be precisely the same as it would under the earlier bill. The uninsured would be more likely to be the kind of patients who rely on health insurance most.
Does the health care bill passed by the House live up to Republicans’ promises? We checked the facts.
By DAVE HORN, NATALIE RENEAU and MARK SCHEFFLER on  May 25, 2017. Photo by Stephen Crowley/The New York Times. Watch in Times Video »
The Medicaid changes make up the bulk of the coverage reductions in the estimate. The bill reduces funding for a new group of poor adults who were covered by most states under the Affordable Care Act, but it also reduces funding to states for children, disabled adults, poor elderly Americans and parents of young children, who have long been covered by Medicaid as well.
For those who buy their own insurance, the bill’s changes to government subsidies would mean huge price increases for many older people, particularly those with low incomes living in expensive markets.
The budget office’s hardest task was estimating how many states would waive their insurance rules and in what ways. Such judgments take guesswork about the choices state officials will make, and they almost certainly involve some degree of error. So it’s reasonable to see its one-sixth estimate as fuzzy. But the budget office, which consults with state governments in preparing its estimates, was certain that at least some states would pursue such waivers. And in the states that did, the market would become inhospitable to the sick.
Senate leaders, aware of the criticism already leveled at the House bill, say they are writing their own bill. This analysis is likely to offer guidance in where they will and won’t want to go.


Trumpcare’s Cruelty, Reaffirmed

Editorial Board - NYT - May 27, 017

Any doubts about the senseless cruelty underlying the health care agenda put forward by President Trump and Congress were put to rest last week by two government documents. The fantasy that Mr. Trump intends to fight for the health of long-suffering working people should be similarly interred.
One document was the administration’s budget. The other was the Congressional Budget Office’s detailed analysis of the Trumpcare bill passed by the House earlier this month. The budget proposes billions of dollars in cuts to programs that fund research into new cures, protect the country from infectious diseases and provide care to the poor, the elderly and people with disabilities. The analysis said that Trumpcare — formally the American Health Care Act — would rob 23 million people of health insurance while leaving millions of others with policies that offer little protection from major medical conditions. All of this would be done in service of huge tax cuts for the richest Americans.
Consider the fate of Medicaid, a program that provides health insurance to more than 74 million people, among them 60 percent of nursing home residents and millions of people with disabilities. Trumpcare would slash Medicaid spending by $834 billion over 10 years, according to the C.B.O. The president’s budget would take a further $610 billion from the program under the pretext of reforming it. Taken together, this amounts to an estimated 45 percent reduction by 2026 compared with current law, the Center on Budget and Policy Priorities says.
Trumpcare, the C.B.O. says, would make it impossible for millions of people with pre-existing conditions like heart disease or diabetes to buy health insurance. That’s because the law would let states waive many of the requirements in the Affordable Care Act, the 2010 law known as Obamacare. It would also greatly increase the cost of insurance policies for older and poorer people, no matter where they live. By way of illustration, a 64-year-old earning $26,500 a year and living in a state not seeking waivers would have to pay $16,100 a year for coverage, nearly 10 times as much as she would under Obamacare.
The House speaker, Paul Ryan, would argue that Trumpcare is an improvement over the A.C.A. because it would lower premiums for many people, especially the young and healthy. The C.B.O. says he’s right, noting that plans would include fewer benefits. In effect, Mr. Ryan and his colleagues are patting themselves on the back for lowering health insurance premiums by taking away people’s access to medical services.
Apart from inflicting hardship, what would Trumpcare and the president’s budget achieve? Mainly a windfall for wealthy families. The administration has not provided enough information to make good estimates, so it’s hard to say how much the rich would gain from the budget, although it would be a lot. We know more about Trumpcare. The Tax Policy Center estimates that almost all of the tax cuts in that legislation would flow to the rich: The top 1 percent would take home an average of $37,200 a year, while people with middle-class incomes would get a measly $300.
The White House and Republicans in the House of Representatives agree on Trumpcare and are aligned on many parts of the president’s budget. The Senate, however, is still up for grabs. A handful of more moderate senators like Susan Collins of Maine, Lisa Murkowski of Alaska, Shelley Moore Capito of West Virginia, Lamar Alexander of Tennessee and Rob Portman of Ohio are all that stand in the way of this retrograde assault on American health care.

In ‘Drop Out Club,’ desperate doctors counsel each other on quitting the field
by Sarah Kwon - STAT - May 
“Burned out cardiac surgeon seeks opportunities or empathy,” one message reads. “I feel stuck,” another confides. A third says simply, “I don’t want to be a doctor anymore!”
The posts come in from across the globe, each generating its own thread of commiseration and advice. “I just wanted to reach out and let you know I feel your pain,” a doctor-turned-MBA replies to one surgeon. “Your story is so similar to mine,” a respondent marvels to a fellow trainee. “Before you quit, think about what motivated you in the first place, and what changed,” cautions an emergency physician to an early-career doctor.
This networking site, and others like it, is where doctors come to discuss the verboten: leaving the medical profession. There are posts from medical school students questioning their career path, and from trainees unable to find a full-time job. And predominantly there are posts by physicians who, after years in the field, are desperate, at the end of their rope, looking for a way out.
Some of them are suffering from what doctors know simply by the shorthand of burnout — loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. Burnout is on the rise among doctors: One study found that over half of all US physicians are experiencing it, for reasons such as long work hours and an increasing burden of bureaucratic tasks. With no nationally available, peer-reviewed data on physician turnover, it’s not clear precisely how many doctors leave because of burnout.
But more than most, doctors may find a career change daunting. There’s the time invested — four years of medical school and as many as nine more years of specialty training — and perhaps a lucrative salary that’s hard to leave behind. Doctors’ specialized skills may seem less obviously transferrable to another field. And the perceived virtuousness of a career in medicine may make some feel guilty to consider leaving.
So they come to Drop Out Club to air their worries, seek solace from those who’ve made the leap — and just feel less alone. The site’s forum is where they ask for and offer advice; there’s also a job board where employers post positions, and members can converse privately in individual messaging. Among its 37,000 members, about half are doctors, said Heather Clisby, a company spokesperson.
Two recently established Facebook groups aim to meet a similar need. Since their founding last year, Physician Nonclinical Career Hunters and PMG Physicians and Non-Clinical Careers have amassed nearly 3,000 members combined. (The latter group is visible only to those who are invited by current members.)
“The frustration with medicine is fueling our growth,” said Dr. Laura Fijolek McKain, the founder of Physician Nonclinical Career Hunters. “Doctors are frustrated with how much time they’re spending on paperwork and other activities that have little to do with patient care.”
And on the web they can find what is often hard to come by in daily life: a ready-made community of people grappling with the same questions.

Finding solidarity online

Dr. Maryam Shapland initially loved her job as an emergency physician. It was busy, exciting, and important. But after a few years, the work felt less exciting and more stressful. She reduced her work hours, but still felt worn out all the time. Then, seven years into her practice, one of her patients sued her.
Devastated, she decided to start searching for a new career.
At first, she felt guilty for wanting to leave. “People thought I made good money, helped people, and had a nice life,” she said. “All the checkboxes were marked off, so what did I have to complain about?”
Then she found Drop Out Club. She quickly became a “lurker” on the member forum, reading messages posted by others. “Reading all these stories of people trying to leave made me realize I wasn’t crazy for being unhappy in this career I had worked so hard for,” she said.
Shapland hired a career coach, started actively using LinkedIn, and in 2015 was hired as a medical director at a life insurance company. “Leaving medicine felt like giving up a big part of my identity,” she said. “But I’m proud of what I do now. Most importantly, I’m happy and thriving.”
And now that’s a message she’s hoping to transmit to others in her shoes. In retrospect, Shapland said, Drop Out Club suffered from too many mentees and not enough mentors. Once she made it to the other side, she decided to regularly provide career advice — and her email address — on the forum. Since her first post in 2015, she said she gets approximately one new person a week emailing her to seek advice on leaving medicine.

Grappling with leaving

One of those was Dr. Ashwini Zenooz, a radiologist who had practiced for over 10 years. Surrounded by colleagues who seemingly loved their jobs, Zenooz felt that she couldn’t discuss wanting to leave medicine with them. Finding Drop Out Club “was a way to extend my network to people closer to my needs,” she said. Browsing the forum, Zenooz saw Shapland’s email address and sent her a note — which became an extended email conversation, and, eventually, an hourlong phone call one afternoon. Zenooz ultimately took a job in health policy.
Many of the inquiries Shapland receives are related to financial concerns. Medical education can leave doctors with up to a half million dollars of debt, making many feel tied to a high-paying job. Others struggle with the “golden handcuffs” of medicine, unable to leave lifestyles supported by comfortable incomes.
Fear of the unknown can also be daunting, especially to those who have spent their entire careers in medicine. “Leaving behind the familiar and going into the unknown was scary at first. I had been doing this job for decades, and there was a certain comfort level with that,” says Dr. Joshua Schechtel, a hospitalist who left clinical practice this year.
Dr. K.K., an oncologist who requested anonymity in case she returns to clinical practice in the future, found Drop Out Club while trying to make sense of the various nonclinical career options. She posted questions and read stories of members’ career paths out of medicine. “I saw proof that a lot of people who left medicine found other jobs and were happy,” she said. “It made me realize that I, too, could find a way out.” She recently left clinical practice and now works as a consultant for health insurance companies. “Leaving my patients and their families was very hard,” she said — but “my new role allows for a much healthier work-life balance.”
Still, not everyone finds meaningful support through online communities.
Some simply want more hands-on support than a peer-to-peer site can provide. Dr. Mary Schultheis, a colorectal surgeon, joined Drop Out Club after 10 years in private practice. “The hardest part of leaving was accepting that it didn’t mean I was a failure,” she said. “Drop Out Club couldn’t help me come to terms with this, but working with a career coach did.” She left clinical practice this year and now balances part-time consulting and health insurance industry roles.
Others find there aren’t enough people to provide advice. “There were a lot of people who piled on to commiserate, but it was hard to find actionable advice on Drop Out Club,” said a dermatologist in California. She reverted to networking the “old-fashioned way, meeting people locally and building a Rolodex,” which ultimately led to her current mix of part-time consulting and part-time medicine.
Shapland agrees that the site — and the medical field more generally — needs doctors who have left clinical practice to speak up and share their unconventional career paths. They need to make themselves available to help as she did, she said. “Just being a living, breathing example of someone who made it to the other side and will answer a couple questions can help someone take that leap of faith.” She’s proof of it.

Drug Lobbyists’ Battle Cry Over Prices: Blame the Others

By Eric Lipton and Katie Thomas - NYT - May 29, 2017

WASHINGTON — Hundreds of independent pharmacists swarmed the House and Senate office buildings one recent afternoon, climbing the marble staircases as they rushed from one appointment to the next, pitching lawmakers on their plan to rein in the soaring drug prices that have enraged American consumers.
As they crowded into lawmakers’ offices, describing themselves as the industry’s “white hats,” they pointed a finger at pharmacy benefit managers like Express Scripts and CVS Health, which handle the drug coverage of millions of Americans.
“Want to reduce prescription drug costs?” the pharmacists argued during their visits. “Pay attention to the middlemen.”
A civil war has broken out among the most powerful players in the pharmaceutical industry — including brand-name and generic drug makers, and even your local pharmacists — with each blaming others for the rising price of medicine.
It is an industry that was already spending nearly double what other business sectors in the United States economy allocate on lobbying, and those sums continue to rise. President Trump has only heightened anxiety by accusing the drug industry of “getting away with murder,” even though he has not weighed in with his own proposal.
For now, lawmakers are facing an almost daily assault.
“Everyone is very eager to maximize their profits and get a piece of the pie, and sorting it all out is complicated,” said Senator Susan Collins, Republican of Maine.
The question is whether a rare confluence of public outrage, political will and presidential leadership can bring about a meaningful change that will slow the drain on consumers’ pocketbooks.
“You remember that old photograph of the Three Stooges, their faces cracked sideways and they are pointing at each other?” asked Chester Davis Jr., the president of the Association for Accessible Medicines, sitting in the basement cafeteria of the Russell Senate Office Building at the start of a day in which he would make his own pitches on behalf of generic drugmakers. “Everyone is doing the finger-pointing, when in fact there is a lot of blame to go around.”
In polls, Democrats and Republicans alike have lowering drug prices near the top of their health care priorities. Public anger has risen along with the skyrocketing prices for many essential medicines — insulin for diabetes, for example, and EpiPens for severe allergic reactions. But will efforts to reduce drug costs surmount the industry’s aggressive lobbying and campaign contributions?
“It’s still a very uphill fight,” said Representative Lloyd Doggett, Democrat of Texas, who like Ms. Collins has been pushing Congress to increase competition and lower prices, “given the millions they have spent on lobbying, advertising and campaign contributions.”
With billions in profit on the line, the pharmaceutical and health products industry has already spent $78 million on lobbying in the first quarter of this year, a 14 percent jump over last year, according to the Center for Responsive Politics. The industry pays some 1,100 lobbyists — more than two for each member of Congress.
In the 2016 election cycle, the industry poured more than $58 million into the election campaigns of members of Congress and presidential candidates, as well as other political causes, the Center for Responsive Politics data shows. That was the biggest investment in the industry’s history and a 20 percent jump from the last presidential election cycle in 2012.
No single proposal has emerged as a clear winner in the bid to lower prices. Mr. Trump has sent conflicting signals: On one hand, he has accused the industry of“price fixing” and has said the government should be allowed to negotiate the price of drugs covered by Medicare. At other times, he has talked about rolling back regulations and named an industry-friendly former congressman, Tom Price, to head the Department of Health and Human Services, and a former pharmaceutical consultant, Scott Gottlieb, to lead the Food and Drug Administration.
Members of Congress have put forward a grab-bag of options, each of which would help or hurt different industry players.
Some address minor aspects, such as a bipartisan bill that would force brand-name drugmakers to hand over samples of their drugs to generic competitors. One would allow for the importing of cheaper drugs. Another would force pharmacy benefit managers to disclose more information about how they did business.
For now, it is a free-for-all.
The brand-name drug industry is the dominant player. It spends the most on campaign contributions, has the largest army of lobbyists and has the biggest pile of chits among lawmakers to try to protect its own interests.
Its trade group, the Pharmaceutical Research and Manufacturers of America, or PhRMA, was so concerned about its vulnerability this year that it increased its annual dues by 50 percent — generating an extra $100 million to flood social media, television stations, as well as newspapers and magazines with advertising that reminds consumers of the industry’s role in helping to save lives. A second set of PhRMA ads point blame for price increases elsewhere, like benefit managers and health insurers.
In doing so, PhRMA is seeking to rehabilitate a reputation that was damaged by the actions of companies like Turing Pharmaceuticals, which sharply hiked the price of a decades-old medicine. Its unapologetic former chief executive, Martin Shkreli, came to be seen as the ultimate illustration of the industry’s bad deeds.
Though Turing was never a member of the group, PhRMA recently purged nearly two dozen companies from its membership after it voted to exclude investor-driven drug companies like Turing.
Nearly every week that Congress is in session, the industry holds fund-raisers at private clubs and restaurants to help bankroll the re-election campaigns of its allies. One former lobbyist for PhRMA recently boasted that he had once organized six fund-raising events in a two-day period. (He asked that he not be named because the fund-raising efforts are supposed to be confidential.)
In late April, for example, a PhRMA Industry Breakfast was hosted for Representative John Shimkus, Republican of Illinois, at the National Republican Club of Capitol Hill, a members-only hot spot across the street from the Capitol.
The industry had reason to thank Mr. Shimkus. Last year, he helped save pharmaceutical companies billions of dollars by persuading the Obama administration to kill a project that was meant to test ways to lower the cost of the so-called Medicare Part B program, which spent $24.6 billion on prescription drugs in 2015.
Mr. Shimkus, who received nearly $300,000 in drug-industry contributions in the last election cycle, led an effort to collect signatures from 242 members of the House challenging the effort. He also co-sponsored legislation that threatened to block it,which became moot after the Obama administration backed down.
A spokesman for Mr. Shimkus said his actions were intended to protect cancerpatients — pointing to a clinic in his district he said might close if the Medicare program had gone into effect — not the pharmaceutical industry.
But other participants said industry influence — as drug companies attempted to preserve their bottom line — had played a decisive role.
“When we first proposed this, people were warning me, ‘Be careful, everybody on K Street is going to be gunning for you now,’ and I did not really know what they meant,” said Andy Slavitt, a top Obama administration official who pushed the prescription drug price experiment. “Now I know. When you take on pharma, you take on this whole town.”
Stephen J. Ubl, the chief executive of PhRMA, acknowledged that his group had been “very engaged” in defending his member companies’ interests, and blamed a few bad actors — not his own members — for the public’s disapproval.
“The researchers wake up every day working for better treatments and cures,” he said, echoing his organization’s multimillion-dollar advertising campaign, “Go Boldly.”
The pharmacy benefit managers are giants themselves. Two of the biggest, Express Scripts and CVS Health, which are among the nation’s 50 largest companies, have initiated their own counteroffensive.
In February, Mark Merritt, the president of the Pharmaceutical Care Management Association, the trade group for benefit managers, outlined a strategy to “engage the new administration” and to build “a political firewall on Capitol Hill,” according to a confidential memo that was first made public by BuzzFeed.
The memo bragged about the group’s courting of senior Trump administration officials. It also said it had met with Capitol Hill staff members and lawmakers, formed a partnership with conservative advocacy groups and created an advertising campaign called “Drug Benefit Solutions.”
Last month, the group hosted several hundred government officials and other industry players at a fancy “policy forum” a few blocks from the Capitol, where it detailed just why its members were “uniquely positioned” to save consumers money.
When the independent pharmacists descended on Capitol Hill in late April, they came with a brochure depicting benefit managers as sharp-toothed dogs, grabbing bags of money.
Yet even as they walked the halls, a group calling itself Ask Your Independent Pharmacist sent a blast email to some of the same lawmakers the pharmacists had just met with. “Whose interests are they on the Hill to champion — the pharmacist’s pocketbook or the patients they claim to serve?” an email asked.
When The New York Times called a public relations firm, Kivvit, which operates out of an address listed on the email, staff members repeatedly hung up when asked who had paid for the message. After a reporter called the firm’s Chicago headquarters, Tracy Schmaler, a Justice Department aide in the Obama administration who now works at Kivvit, responded: Express Scripts had paid for the message.
Jonah Houts, the head of government affairs at Express Scripts, said the company’s role as a middleman drew fire from all sides.
“We were designed to create tension,” he said. “We’re successful at what we do, and that’s why we want to make sure the lawmakers who are considering legislation that affects us understand that.”
The generics industry has also come under attack. Though its drugs are generally cheap, some have also risen sharply in price, and prosecutors have been investigating claims of price-fixing by some of the largest players, including Mylan.
Heather Bresch, the chief executive of Mylan and a former chairwoman of the generics trade group, has been pilloried on social media for her role in hiking the price of EpiPens, even though EpiPens sold as branded drugs, not generics.
As the controversy over EpiPens unfolded, Ms. Bresch shifted criticism toward what she called the “broken system” of brokers, distributors and pharmacists who take a cut of the price, too. In January, the generics trade group shed its old name for one that reflects the changed political climate: the Association for Accessible Medicines.
Mr. Doggett, the Texas Democrat, said the industry war was in some ways a positive sign.
“We have moved from ‘There is no problem’ to ‘It’s not my fault,’ ” he said. “It begins to focus attention on what so many of my constituents already know the problem is, which is price gouging.”

page1image440 page1image608 page1image768 page1image928
Economic Analysis of the Healthy California Single-Payer Health Care Proposal
(SB-562)
MAY 2017
Dr. Robert Pollin
Distinguished Professor of Economics and
Co-Director, Political Economy Research Institute (PERI) University of Massachusetts-Amherst
Dr. James Heintz
Andrew Glyn Professor of Economics and Associate Director, PERI
University of Massachusetts-Amherst
Dr. Peter Arno
Senior Fellow and Director of Health Policy Research, PERI University of Massachusetts-Amherst
Dr. Jeannette Wicks-Lim
Assistant Research Professor, PERI University of Massachusetts-Amherst


Posted by at 1 comment:

Friday, May 26, 2017

Health Care Reform Articles - May 26, 2017

Will the Republican Health-Care Debacle Pave the Way for ‘Medicare for All’?

by Robert L. Borosage - The Nation - May 25, 2017

This week, the Congressional Budget Office confirmed what was already apparent: The revised House Republican health-care bill will still deprive millions of Americans—23 million in the CBO estimate—of health insurance. Senate Republicans are devising their plan in secret, because it too will likely deprive millions of health coverage. During the campaign, Donald Trump pledged, “I am not going to cut Medicaid”; now Trumpcare and his budget would slash it by 45 percent. In contrast with Republican horrors, Obamacare has grown in popularity, but premiums are rising as insurance companies consolidate monopolies in various states and Trump works to sabotage it. Surely, now is the time for progressives to wage a fierce campaign for Medicare for All.
Americans are more than ready. A January poll by the Pew Research Center found that 60 percent of Americans surveyed agree that the government should be responsible for ensuring health care for all, with support at its highest levels in a decade. An April Economist/YouGov poll found 60 percent of Americans favored “expanding Medicare to provide health insurance for every American.” Support was consistent across lines of race, age, and income. Fifty-eight percent of self-identified independents and 60 percent of moderates were in favor. Forty-six percent of Republicans and 43 percent of self-described conservatives signed on as well.
The popularity of expanding Medicare is surprising, given how little support it has received from the political class. In 2016, Bernie Sanders stumped for it, but Hillary Clinton dismissed it out of hand, arguing it “will never, ever come to pass.” Democratic leaders in the House and Senate want Democrats to defend Obamacare, not talk about Medicare for All. Even the Congressional Progressive Caucus, which has championed single-payer health care, decided not to include it in its 2017 budget.
Churchill is erroneously quoted as saying that “Americans will always do the right thing, only after they have tried everything else.” On health care, we’ve pretty much exhausted “everything else.” ACA still leaves over 20 million without health insurance, and leaves Americans to the tender mercies of entrenched insurance and drug companies. The House Republican bill would leave 51 million Americans without health insurance by 2026. It “saves money” largely by depriving people of health insurance or leaving them with inadequate plans that don’t cover preexisting conditions. With Trump’s draconian budget, Republicans would put about half of the 70 million who receive Medicaid at risk, despite that fact that a vast majority of Americans and over 40 percent of Republican voters say that Medicaid expansion is important to them or their family. Republicans are likely to pay a big price politically in 2018 if they actually try to defend depriving millions of working and poor people of health insurance while using the savings to finance obscene tax cuts for the rich.
Now, with the Republican debacle as backdrop, support for fundamental reform has picked up. Democratic state legislators in California are on the verge of passing a state single-payer plan, although Governor Brown remains skeptical. In January, Representative John Conyers (D-MI) reintroduced a single-payer bill that would create a publicly financed universal health-care system funded by a payroll-tax increase, tax hikes on the rich, and a financial-transactions tax. Conyers now has 104 cosponsors, with the backing of unions and progressive groups.
Bernie Sanders will introduce a “Medicare-for-all, single-payer program” in the Senate soon, and he recently called on Donald Trump to join him to fulfill his campaign promise to provide health care for all. Sanders suggested Trump start by embracing efforts to negotiate discounts in drug prices: “Let’s work together. Let’s end the absurdity of Americans paying by far the highest prices in the world for prescription drugs.” Senator Elizabeth Warren has joined Sanders in support of Medicare for All. All this led CNN to predict that “Democrats eying the 2020 presidential contest could soon face a ‘Medicare-for-all’ litmus test from the party’s progressive base.”
Most politicians are still wary of defending “bureaucratic heath care,” or explaining the cost of “paying for it.” In fact, Medicare is far more efficient than private health insurance, and a single-payer system would capture massive savings from eliminating the administrative overhead and profit margins raked off by insurance and drug companies. Recipients would receive affordable comprehensive coverage at far less cost than under Obamacare. But the financing is vulnerable to attack, as Sanders discovered during the campaign.
That is why it is vital for progressive political leaders and progressive grassroots groups to coalesce around a campaign for Medicare for all. Our Revolution, MoveOn, Democrats for America, Credo, Color of Change, People’s Action, the Progressive Congressional Campaign Committee, and others could turn the CNN prediction into reality and make support for Medicare for all a centerpiece of their candidate screening. Extensive public education efforts are needed to explain to people the advantages of the transition, even as the horrors of Republican reforms are revealed.
Democrats should be pushed to go beyond merely a defense of Obamacare. They need to learn how to link exposure of Republican deforms with a call for moving to a more rational system. Those who support partial reforms—expansion of Medicaid, lowing the eligibility age of Medicare to 50 or 55, reviving the public option in the Obama exchanges—should be pushed to frame them as steps towards Medicare for all.
None of this will be easy. The popular support offered up in a poll will be shaken by multimillion-dollar scare campaigns launched by insurance and drug companies. Those happy with their employer-based insurance will be wary. Seniors worried about diluting Medicare will be major targets. Legions of lobbyists—Democratic and Republican—will dine out on devising legislative, administrative, and judicial obstacles to fundamental reform. But as Sanders has shown, insurance and drug companies and their lobbyists are good enemies to take on.
Will Republican efforts to repeal and replace Obamacare pave the way to Medicare for All? Only if progressives force the debate. Americans are looking for sensible reform. Medicare for All is the right answer. Now is the time for progressives to educate and enlist to take on the entrenched interests that stand in the way.

How the G.O.P. Sabotaged Obamacare

by Abby R. Gluck - NYT - May 25, 2017

Obamacare is not “collapsing under its own weight,” as Republicans are so fond of saying. It was sabotaged from the day it was enacted. And now the Republican Party should be held accountable not only for any potential replacement of the law, but also for having tried to starve it to death.
The Congressional Budget Office on Wednesday released its accounting of the House Republicans’ replacement bill for the Affordable Care Act, and the numbers are not pretty: It is projected to leave 23 million more Americans uninsured over 10 years, through deep cuts to insurance subsidies and Medicaid. The report underscores how the bill would cut taxes for the rich to take health care away from the less well-off.
The A.C.A. is not perfect, and improvements to it would be welcome. But it worked in many respects and would have worked much better had Congress been a faithful guardian of the law.
It is worth making a record of those Republican saboteurs’ efforts. The A.C.A.’s opponents brought a lawsuit against its requirement that people buy insurance — a Republican idea — the very day the statute was signed into law. The Supreme Court rejected that claim. But the court gave opponents a major victory on another front, ruling that Obamacare’s expansion of Medicaid was optional for states. Yet another lawsuit seized on some sloppy language in the law to make the implausible argument that Congress did not provide for the insurance subsidies on which the law depends. The Supreme Court also rejected that challenge.
But if the Republicans lost those cases, they succeeded in sowing the insurance markets with doubt and forcing states to slow down implementation while awaiting the court’s decisions. That in turn may have reduced sign-ups, further destabilizing the insurance market. The second case challenging the subsidies was not decided until 2015, more than a year after the statute’s critical 2014 deadline for implementation.
Even worse, these lawsuits helped make the A.C.A. the salient partisan issue of the Obama administration, turning the law into the ultimate Republican litmus test: Implementing a state insurance exchange or expanding Medicaid, even when it seemed in a state’s interest, became treasonous for the party. Nevertheless, about a dozen principled Republican governors bucked their party and expanded their programs.
In 2014, the House brought a lawsuit, arguing that a critical piece of A.C.A. funding — the cost-sharing subsidies that pay insurers to lower premiums — had not been properly appropriated. For insurers, not knowing whether that money could be cut off — President Trump is still threatening not to pay them — has caused anxiety about whether to remain in the A.C.A. markets. More than 100 other suits have been filed, including challenges to contraception provisions and the requirement that employers provide insurance.
On the political front, the Republicans targeted provisions of the law that provided crucial transitional financing to steady the insurance markets early in the program. Senator Marco Rubio of Florida, calling the money an insurance “bailout,” sponsored a measure that prevented appropriation of some of those funds. The courts have issued mixed rulings on whether the federal government must pay, adding yet more instability to the insurance markets.
The Affordable Care Act, like any major statute, surely could use adjustments. For example, the insurance subsidies were probably set too low initially. The Obama administration’s decision to allow more people to stay on their old plans than originally expected may also have narrowed the new pool of insurance customers in ways that contributed to premium hikes. The Republican-controlled House never provided any additional implementation money after the initial appropriation set forth in the Affordable Care Act itself, forcing the Department of Health and Human Services to scrounge for needed funds.
A caretaking Congress would have fixed what wasn’t working. Instead, opponents did everything possible to shut off all the A.C.A.’s financing — starvation intended to wreak havoc in the insurance markets and to make it falsely appear that the A.C.A.was collapsing because it was just bad policy.
The irony is that the A.C.A. was vulnerable to this strategy because the Democrats had tried to compromise with the Republicans in an ultimately unsuccessful effort to build bipartisan support for the law. If the Democrats had instead enacted a single-payer policy — such as Medicare for all — the entire health care system would have been in the hands of the federal government, instead of dependent on the states and private insurers.
Now the Republicans find themselves in a mess. The Affordable Care Act has brought health care to an estimated 20 million more Americans and has expanded services — including access to drugs and preventive screening — for many more. A good number of Americans, including Republicans and the president himself, say they like elements of the law. It’s not a coincidence that the Trump administration’s first proposed health care regulation was aimed at stabilizing the insurance markets.
Still, Republicans are using the Affordable Care Act’s so-called collapse as an argument for a much stingier law, one that would leave states responsible for paying many health care costs. Some conservatives are using the assault on the A.C.A. not to assail its novel insurance provisions — which many people like — but rather to grind an old ax against the entire Medicaid program, which was enacted in 1965 to help the poor.
As the Senate turns to its own bill, it still has time to preserve the parts of the Affordable Care Act that are working and, more importantly, strengthen those that could succeed with proper support. That would be responsible — and, indeed, is what should have happened all along.


G.O.P. Health Bill Would Leave 23 Million More Uninsured in a Decade, C.B.O. Says

by Robert Pear - NYT - May 24, 2017

WASHINGTON — A bill to dismantle the Affordable Care Act that narrowly passed the House this month would increase the projected number of people without health insurance by 14 million next year and by 23 million in 2026, the Congressional Budget Office said Wednesday. That 10-year figure is slightly less than originally estimated.
It would reduce the federal deficit by $119 billion over a decade, less than the $150 billion in savings projected in late March for an earlier version of the bill. And in states that seek waivers from rules mandating essential health coverage, the new law could make insurance economically out of reach for some sick consumers.
“Premiums would vary significantly according to health status and the types of benefits provided, and less healthy people would face extremely high premiums,” the budget office concluded.
The new forecast of the nonpartisan Congressional Budget Office, Capitol Hill’s official scorekeeper, is another blow to Republican efforts to undo President Barack Obama’s signature domestic achievement. The Senate has already said it will make substantial changes to the measure passed by the House, but even Senator Mitch McConnell of Kentucky, the majority leader, is sounding uncertain about his chances of finding a majority to repeal and replace the health law.
“I don’t know how we get to 50 at the moment,” Mr. McConnell told Reuters on Wednesday. “But that’s the goal.”
The new report from the budget office is sure to influence Republican senators, who are writing their own version of the legislation behind closed doors. The report provided fresh ammunition for Democrats trying to kill the repeal bill, which they have derided as “Trumpcare.”
Republicans in Congress generally focus more on reducing health costs than on expanding coverage. Their proposals will inevitably cover fewer people than the Affordable Care Act, they say, because they will not compel people to buy insurance.
Republicans have been trying to repeal Mr. Obama’s health law since the day he signed it in March 2010. But the task is proving more difficult than they expected. Many parts of the law have become embedded in the nation’s health care system, and consumers have risen up to defend it, now that they fear losing its protection. At the same time, other consumers, upset about the mandate to buy insurance they can barely afford, are demanding changes in the law.
The budget office issued two reports on earlier versions of the House bill in March. Both said that the legislation would increase the number of uninsured by 14 million next year and by 24 million within a decade, compared with the current law.
Republican senators appear as determined as ever to replace the health law.
“The status quo under Obamacare is completely unacceptable and totally unsustainable,” Mr. McConnell said Wednesday, a few hours before the budget office issued its report. “Prices are skyrocketing, choice is plummeting, the marketplace is collapsing and countless more Americans will get hurt if we don’t act.”
“Beyond likely reiterating things we already know — like that fewer people will buy a product they don’t want when the government stops forcing them to — the updated report will allow the Senate procedurally to move forward in working to draft its own health care legislation,” he added.
The instability of the health law’s insurance marketplaces was underscored again on Wednesday when Blue Cross and Blue Shield of Kansas City, a nonprofit insurer, announced that it would not offer coverage under the law for 2018. The insurer lost more than $100 million in 2016 selling individual policies under the law, said Danette Wilson, the company’s chief executive.
“This is unsustainable,” she said in a statement. “We have a responsibility to our members and the greater community to remain stable and secure, and the uncertain direction of the market is a barrier to our continued participation.”
While the vast majority of people the company covers get insurance through an employer or a private Medicare plan, Blue Cross of Kansas City covers about 67,000 people in Kansas City and western Missouri under the federal health care law. The company’s departure could leave 25 counties in western Missouri without an insurer, said Cynthia Cox, a researcher at the Kaiser Family Foundation.
Democrats say much of that instability stems from Republican efforts to repeal and undermine the Affordable Care Act. The Senate minority leader, Chuck Schumer of New York, harshly criticized House Republicans for voting on their revised repeal measure without an updated analysis from the budget office.
“Republicans were haunted by the ghost of C.B.O. scores past, so they went ahead without one,” Mr. Schumer said. That action, he said, was reckless — “like test-driving a brand-new car three weeks after you’ve already signed on the dotted line and paid the dealer in full.”
The House repeal bill was approved on May 4 by a vote of 217 to 213, without support from any Democrats. It would eliminate tax penalties for people who go without health insurance and would roll back state-by-state expansions of Medicaid, which have provided coverage to millions of low-income people. And in place of government-subsidized insurance policies offered exclusively on the Affordable Care Act’s marketplaces, the bill would offer tax credits of $2,000 to $4,000 a year, depending on age.
A family could receive up to $14,000 a year in credits. The credits would be reduced for individuals making more than $75,000 a year and families making more than $150,000.
Senior Republican senators say they want to reconfigure the tax credits to provide more financial assistance to lower-income people and to older Americans, who could face much higher premiums under the House bill.
The House bill would roll back a number of insurance requirements in the Affordable Care Act, which Republicans say have driven up the cost of coverage.
In the weeks leading up to passage of the House bill, Republican leaders revised it to win support from some of the most conservative members of their party.
Under the House bill, states could opt out of certain provisions of the health care law, including one that requires insurers to provide a minimum set of health benefits and another that prohibits them from charging higher premiums based on a person’s health status.
Insurers would not be allowed to charge higher premiums to sick people unless a state had an alternative mechanism, like a high-risk pool or a reinsurance program, to help provide coverage for people with serious illnesses.
Senate Republican have been meeting several days a week, trying to thrash out their differences on complex questions of health policy and politics, like the future of Medicaid.
Asked why Democrats had been excluded, Mr. McConnell said, “We’re not going to waste our time talking to people that have no interest in fixing the problem.”
Democrats have said they would gladly work with Republicans if the Republicans would renounce their goal of repealing Mr. Obama’s health care law.

CBO verdict: 51 million uninsured by 2026 under House health care bill

by Laura Lanthanum - PBS - May 24, 2017

As many as 14 million people would lose health insurance coverage by 2018 if the latest Republican effort to overhaul Obamacare becomes law, according to the Congressional Budget Office’s latest analysis released Wednesday. 
By 2026, the plan would reduce the federal deficit by $119 billion while leaving a total of 51 million people without health care coverage, the budget office report said after it scored the plan the House passed earlier this month. Under the Affordable Care Act, analysts projected 28 million people would be uninsured by 2026. 
On May 4, the House of Representatives voted 217-213 to pass a revised health care reform bill that then went on to the Senate. It was passed before the CBO could score it. Sen. Mitch McConnell said the Senate would wait until the budget office scored the plan before they decided how to proceed with the bill.
Two months earlier, on March 13, the budget office said House Speaker Paul Ryan’s American Health Care Act would trim federal spending by more than $337 billion over the next decade. But 24 million Americans would also lose health insurance by 2026 under the plan, according to the office’s analysis. By comparison, 20 million Americans gained health insurance under the Affordable Care Act, also called Obamacare.
Republicans later pulled the bill before it reached a vote. President Donald Trump had pressured Republicans to vote on March 24 before they secured enough support to pass the bill. 
On Twitter, Ryan said the budget office score confirmed that he and House Republicans delivered on their promise to “lower premiums and the deficit.”
Mark Mazur directs the Urban-Brookings Tax Policy Center, and he pushed back on this idea. In a blog post, Mazur said the House bill “is largely a tax bill paired up with Medicaid cuts to offset the costs and the new CBO estimates confirm that point. And, as in the earlier version of the bill, almost all the benefits go to the highest income households in the country.”

Senate Republicans have all the evidence they need to reject the House-passed health-care 

overhaul

by Paul Kane - Washington Post - May 24, 2017

The Republican bid to overhaul the health-care industry took one small step forward Wednesday and then essentially went two steps backward.
For a week now, some congressional insiders had been whispering that the critical “score” from the Congressional Budget Office, on the legislation that narrowly passed the House earlier this month, might not provide any real deficit savings. Such a finding would have violated the Senate’s more arcane rules for considering budgetary items under fast-track rules — and it might have forced House Speaker Paul D. Ryan (R-Wis.) to redraw the legislation and hold another vote.
So there were a few sighs of relief late Wednesday afternoon when the CBO declared the legislation would find $119 billion in savings over 10 years, more than enough to allow it to pass muster under the Senate’s so-called reconciliation rules, which allow a simple majority for passage rather than the usual 60-vote majority. That’s an important feat for Senate Republicans, who control just 52 seats.
But that’s also where the good news ended and reality set in about the rest of the legislation. The congressional analysts — led by a Republican handpicked by Ryan —found that 23 million more people would be left uninsured than under current law, the Affordable Care Act.
The $119 billion in savings would result mostly because fewer people would be covered under the ACA’s expansion of Medicaid — and because the new legislation would loosen requirements on the quality of coverage that insurers would have to provide.
Here's what's in the new CBO report on the Republican health-care bill
The Congressional Budget Office has released its score on the revised American Health Care Act. Here's what's in the report. (Daron Taylor/The Washington Post)
For a core group of Senate Republicans, those facts may be all they need to bury the House version of a health-care overhaul once and for all. They also highlight just how high the hurdle is to get a health-care bill to President Trump’s desk.
These senators already had built up staunch opposition to Ryan’s House-passed bill, when CBO estimates back in March suggested that the initial draft would leave 24 million more uninsured than under the ACA. After Wednesday’s updated estimates, those Senate Republicans, predominantly from states with large populations of people who benefited from Medicaid expansion, dug in even further against the House bill because millions of their constituents would be left in the lurch by the GOP proposal.
“That’s tough to swallow,” said Sen. Shelley Moore Capito (R-W.Va.), who has 180,000 constituents relying on the Medicaid expansion for insurance coverage.
Capito, part of a bloc of 20 Republicans from Medicaid-expansion states, has been a vocal opponent of the House bill for too quickly transitioning away from that ACA benefit. She says this updated estimate puts steel in the spines of those Republicans, including Sens. Rob Portman (Ohio), John McCain (Ariz.) and Lisa Murkowski (Alaska).
“It strengthens my resolve,” Capito said. “To say, what are we doing to people here, particularly to our most vulnerable or those that don’t have the wherewithal?”
“Yeah, I think it helps. I think it helps the Medicaid states,” McCain said.
With every Democrat opposed to his effort and just 52 Republicans, Senate Majority Leader Mitch McConnell (R-Ky.) knows that the Capito-McCain wing is the most critical to getting close to the 50 votes he needs from his side of the aisle — which would allow Vice President Pence to cast the tie-breaking vote.
But each move to appease these Republicans risks losing a few more votes on the conservative end of McConnell's caucus, including his home-state colleague, Sen. Rand Paul (R-Ky.), who seems dead set against supporting anything that is not seen as a complete gutting of the bill Republicans derisively call Obamacare.
Sens. Ted Cruz (R-Tex.) and Mike Lee (R-Utah) have been more aligned with the House Freedom Caucus, which negotiated key portions of the legislation.
The jigsaw puzzle has left McConnell expressing rare bouts of public pessimism about such a big piece of legislation, something he campaigned on himself in his 2014 reelection — repealing and replacing Obamacare.
In a Wednesday interview with Reuters, the Republican leader began by telling his interviewers not to bother with questions about the ongoing health-care negotiations. “There’s not a whole lot of news to be made on health care,” McConnell said, adding later that he was struggling to find a path to getting those 50 votes. “I don’t know how we get to 50 at the moment. But that’s the goal.”
Even if he can finesse the divide between his rock-ribbed conservatives and his Republicans from Medicaid-expansion states, McConnell risks blowing up what had been a meticulously crafted coalition in the House, where Ryan won, after weeks of fits and starts, by a two-vote margin.
Sen. Bill Cassidy (R-La.), a physician who has been trying to find common ground, said that the CBO report would probably provide some good news that Senate negotiators could seize on. “Those conservative families that voted for Trump need relief from $20,000-a-year premiums,” Cassidy said, giving Senate negotiators the chance to exhume parts of the mostly dead-on-arrival bill from the House.
“You want to look at different components of it, it may be that some of it you keep and some of it you discard,” Cassidy said.
However, the CBO was clinical in its explanation for the lower premiums: “because the insurance, on average, would pay for a smaller proportion of health care costs.”
That means worse coverage, and many Senate Republicans are wary of passing a law that will stick their working-class voters — many of whom come from regions that voted overwhelmingly for Trump — with deteriorated coverage.
Now Republicans are left to their working groups in the Senate, trying to find the right mix. Veteran Republicans including McCain know that what they need to do is put together a draft piece of legislation where almost all of it is agreed upon, then start getting into the final wheeling and dealing on the last critical details.
“Right now there’s a lack of cohesion. Now, once they get a base bill, then I think you’re going to see a lot of back and forth,” McCain said. “But so far they haven’t come up with a piece of legislation to work with.”

It is time for physicians to fight back. Now.

by Matthew Hahn - Physician - May 14, 2017

The American health care system is broken, but it is not really “health care” that is the problem.|
The science of medicine, the tests, and the treatments available are better than ever. It is health care bureaucracy that is the problem. But doctors, nurses, and patients bear the brunt of the dysfunction. Medical professionals are unable to practice, and patients are denied the care they need, even though it is readily available. Careers are being ruined, and lives lost along the way. It is time to fight back.
Instead of focusing on ways to improve patient care, medical professionals today have to wade all day through a jungle of red tape just to get paid, order tests, and deliver treatments. Cumbersome government rules control the details of how we write notes, use a computer, calculate a bill, how much we can charge, who we can admit to the hospital, how long we can treat them, and much, much more.
And for everything we do, there must now be data. The bureaucracy is obsessed with data, to the detriment of everything else. It is tyranny through data. We spend so much time collecting data and running after all of these things that it is a challenge to find the time to actually care for patients!
On top of that, newer health insurance policies with high premiums, high deductibles, prior authorizations, and narrow, inscrutable coverage block us from delivering the care patients need. It is health care by government and insurance company fiat. Medical professionals and patients have few choices and little control.
And now, on top of everything else, we face Medicare’s complicated new MACRA “value-based payment” program, which collects data across four categories: quality measures, advancing care information, performance improvement activities, and cost. A physician’s annual score will be compared to the scores of other physicians to determine future Medicare pay increases or penalties. There is a huge effort being made to explain the intricacies of the new program, the first sign that it is too complicated to be of benefit.
Has American health care improved under this rule-bound and data-crazed regime? No! These approaches have demonstrated little of their intended effect. What is the bureaucracy’s answer to this? More rules and more data collection, and now, even penalties! They are trying to box us in like lab rats, and with rewards and punishments, make us perform tricks in our cages.
What has been the medical profession’s response? Adjust, learn the rules, and do it again, and again. We grumble. We retire early. We hide in bigger organizations that are supposed to protect us from it all. We look to our professional organizations for leadership. But this is not working. We lose more and more ground. We are now on a tiny island — but many of us are falling into the water and drowning.
When we begin our careers in the medical profession, we take an oath to do no harm. But today we practice in a system that is harmful by design. To honor our oath, we must find ways to fight back.
I think the answer is to better organize — even to form unions (though they are legal for physicians only in certain circumstances) — to find ways to actively fight against this out-of-control bureaucracy. We must bring balance to a system where today we have absolutely no control. What we must demand is a system that works for us rather than against us at every turn, that helps us to deliver better care rather than blocks us and then penalizes us when we fail.
I am sick and tired of worrying about the system, and not my patients. We must organize to turn things around. We can have the best health care in the world. It starts by organizing the system around those it affects most, patients and their health care teams.

Don’t Let Trump Drama Distract You While Congress Dismantles Medicaid

by Mark Truant - Common Dreams - May 22, 2017

Reality TV works for one simple reason: The antics of the characters are beyond what’s believable in fiction. It’s compelling drama because normal people do not do such things. So part of watching is to find out when the story arc ends, to discover when the situation becomes “normal” again. (Even though the story does go on and on and on.)
That’s why the presidency of Donald J. Trump would make a terrible novel or screenplay: There’s no mechanism to suspend disbelief. Tell the story about a four-month term in the White House, a time marked by so much chaos, unprofessionalism, and distraction, and a reader (and especially an editor or producer) would shake their head and say, “Try again. This story is not believable.”
That’s why only the metaphor of reality TV works. America the unbelievable.
This weekend, the best moment of the new Trump administration was the one where the president smiled in Saudi Arabia and said only 26 words. This was terrible reality TV, but we all watched knowing that it was likely just a pause. Something outrageous must be coming up next.
The White House Reality Show is entertaining.
Meanwhile, more important stories are still being written and played off-screen. That’s why our focus must return to the policy fights ahead: How this country (and our planet) deal with climate change, how we stop the rigging of elections, and how we make certain the court system is fair.
This week, the White House will formally send Congress its budget plan for the next year. We already know this plan will be nonsense. Another distraction. The real work of budgeting will occur in Congress and will require votes from both Democrats and Republicans to make it so.
At a House hearing last week, for example, Rep. Tom Cole (R-Oklahoma) said he was disappointed in a White House recommendation to cut $5.8 billion from next year’s funding for the National Institutes of Health. He such a draconian cut would stall so much progress from recent investments. In other words: No sale. Across the Congress, across the government, this same notion is being repeated. Eliminate the Corporation for Public Broadcast? No sale. On down the list of cuts, the message is much the same. Eliminate the Denali Commission? No sale.

Paying for health care

But while Congress might rewrite the budget in some areas, there are real dangers ahead. I’m obsessed with what this bunch is doing to the funding streams for health care, especially Medicaid.
This is what the Trump Show hides: The House GOP’s American Health Care Act does much more than roll back the Affordable Care Act (or “Obamacare,” as they like to say). It ends a Medicaid program that works. It’s the single most effective form of “government” insurance that secures health care options for 62.3 million Americans. To add a little perspective here: Medicare — supposedly untouchable in politics — insures 43.3 million seniors.
These are huge numbers. Through taxes, we all pay for this plan, as we should. It’s one of the best things this country does.
Medicaid is expensive and requires a lot of taxes to pay for it. So it’s no wonder that Speaker Paul Ryan and Republicans are eager to make this go away.
Philosophical divisions on Medicaid run deep. Every Republican wants to spend less federal money on this program. Significantly less. Once you do that, there will be fewer people who participate in this public insurance program. That’s math, not politics.
The House GOP health care plan (according to the Congressional Budget Office)strips $880 billion from Medicaid funding in order to reduce taxes on wealthy people by $883 billion. Tit for tat.
Watch this debate closely. Parse every word. The Republicans in the Senate who say they champion Medicaid often only talk about Medicaid expansion. And that’s followed by: “There should be a transition to something else.” What else? How does that work? And who pays?  Usually, the answer is block grants, which states cannot afford.
At a town hall in Anchorage last week, Sen. Dan Sullivan (R-Alaska) followed this script to the letter. According to The Alaska Dispatch News , he told a contentious town hall that he wanted to make sure the people who received health care coverage under Medicaid expansion “do not have the rug pulled out from under them.” Medicaid for now, then something else. But what else, how does that work, and who pays?
The answer is to protect the framework of Medicaid (and if we were smart, enhanced and expanded). It’s the one part of Indian health funding that’s growing and already accounts for the insurance of record for more than half of all our children. And this is really important: Third-party insurance billing, which includes Medicaid, is money that stays at a local Indian Health Service clinic or hospital. It does not go into the general budget.
Medicaid is a partnership between the federal government and the states. So states set many of the rules. Federal government then agrees or not and pays only a portion of the bill. But patients within the Indian Health Service system are usually eligible for a 100 percent reimbursement.
So states set the rules for Indian Country — including limitations — but don’t pay the costs. Already six states are already looking to tighten Medicaid rules. Arizona is keen on adding work requirements. Wisconsin wants drug testing (imagine the trap that sets for patients in opioid treatment programs). Maine wants to test assets beyond income. The goal of each new regulation is to shrink the number of people insured by Medicaid.

Medicaid works, especially in Indian Country

I’ve heard Republicans say they like the results of Medicaid but that we as a country cannot afford it. That’s particularly troubling because Medicaid is more efficient that private insurance, even with its convoluted payments from the federal government to states and Indian health programs. How can that be?
Julia Paradise, associate director of the Program on Medicaid and the Uninsured for the Kaiser Family Foundation, says Medicaid acts as a “high risk pool.” Because so many people are excluded (or out-priced) from private insurance, Medicaid is the only option. “Among adult Medicaid enrollees who are not working, illness or disability is the main reason. By covering many of the poorest and sickest Americans, Medicaid effectively serves as a high-risk pool for the private health insurance market, taking out the highest-cost people, thereby helping to keep private insurance premiums more affordable.”
And, as Paradise notes in the recent report, “10 Things to Know about Medicaid: Setting the Facts Straight,” evidence continues to mount that Medicaid improves health outcomes. This is especially true when it comes to detecting and treating diabetes and mental health problems. Research has found that Medicaid expansions for adults were associated with significant reductions in mortality.
The Senate is now busy rewriting the House’s awful health bill. It will be a different entity, that’s for sure. But will the Senate protect (and if they are smart, enhance and expand) the best basic public health insurance program that we have now? There is no evidence to suggest that. And too many people are watching the White House Reality Show to even notice.

How GOP can win on health care

by Judd Gregg - Seacoast Online - May 21, 2017

Ted Kennedy must be looking down and chuckling as he watches how the Republicans in the House have headed into a box canyon with their health care bill.
The original ObamaCare bill had its genesis in the ideas of the former Democratic senator from Massachusetts, who died in 2009.
Although he was not there to write the bill, his staff did – under the tutelage of his close friend and confidant, then-Sen. Chris Dodd, D-Conn. Their goal was to move healthcare in the United States toward Kennedy’s long-held ambition: a single-payer system.
ObamaCare was to be a giant leap in that direction. It was built on the theory that because a single-payer, totally nationalized system of health care was not politically palatable, a stepping-stone should be designed.
At the time, there were 40 to 45 million Americans who did not have health care insurance and thus, at least theoretically, did not have adequate health care.
This was not a homogeneous group.
A large percentage of the uninsured were people between the ages of 22 and 35 who simply did not want to spend their discretionary dollars on health insurance because they did not expect to need it.
Another large group was comprised of people who did not qualify for Medicaid but whose employers did not cover their insurance.
Others included older people who had retired early and did not yet qualify for Medicare.
The purpose of ObamaCare was to gather all these people into some type of health care coverage and have that coverage be highly subsidized by the rest of the population.
This was to be accomplished either directly, through subsidies that depended on taxes; or indirectly, through increasing the premiums of those who had insurance.
The outcome would be that most of these 40 to 45 million would have new benefits that they themselves paid little for.
This effort was to be undertaken by creating exchanges, which were actuarially unsound; and by expanding by 50 percent the Medicaid enrollment, which was grossly underfunded.
The creators of ObamaCare knew of the structural failures of the proposed approach. It was their expectation that the financial stress on the insurance industry and the huge tax subsidies needed to pay for the migration from private insurance into exchanges would lead to some sort of reordering of the system.
They knew that states, and especially doctors, could not handle the underfunded addition of millions of patients.
They also understood political reality, in which it is extremely difficult to take back a subsidized benefit once it has been given. This is especially true when it involves millions of people.
Thus, as ObamaCare crumbled, a single-payer system would be the default position to which the country would turn.
Huge numbers of people would be on some sort of system that was government-dependent, whether Medicare, Medicaid, the ObamaCare exchanges or other government programs such as the VA. And it would be politically impossible to take those benefits away.
Thus, the logical choice would be to simply move to a totally nationalized system. Kennedy’s dream would be realized.
But along came a Republican president, House and Senate.
The irony is that even though this new group in town is insistent on repealing ObamaCare, they cannot repeal the benefits it bestowed.
Benefits are never taken away, especially when they are highly subsidized so the beneficiaries do not feel the cost.
It will of course not be a nationalized system, as such, that will be set up. But it will be expensive and most likely an underfunded system.
In fact, the House bill with its tax credits and illusory future Medicaid savings is just that – a giant hole in the federal budget.
It would be better if the Republican Congress and president, who one suspects is not aware of the trap he has walked into, admit that they have been sent up a box canyon by the legacy of Ted Kennedy.
They should acknowledge that there will be coverage in the future for those who are covered now.
People who are near-poor will get insurance. People whose employers are not covering them but want coverage will be able to get health care. Younger Americans will have access to coverage. People with pre-existing conditions will have real, affordable access to care.
The politics of reelection will cause this to happen one way or another – and the “another” is replacing members of Congress who stand in the way.
In doing this, one hopes that the Republicans in the Senate will have the good sense to deliver an actuarially sound system that uses the market to drive better healthcare.
The Senate is right to pledge to start over. It should begin by paying for a system which, whether one likes it or not, has dramatically expanded coverage – and subsidies – to millions of people.
This can be done with one simple adjustment: reduce the deductibility of high-end plans to the mean cost of health care plans generally, thus generating approximately $1 trillion. Then use these funds to fully support a market system for all of Medicaid and give small business the incentive to cover its low-income employees.
This is the escape route from the box canyon Republicans find themselves in.
It is expensive but it is also realistic.
It will also cause those who thought a nationalized system was the inevitable outcome of the failure to ObamaCare to grimace.
Republican Judd Gregg, of Rye, is a former governor and three-term senator from New Hampshire who served as chairman and ranking member of the Senate Budget Committee, and as ranking member of the Senate Appropriations Foreign Operations subcommittee. This column first appeared in The Hill and is reprinted by permission of the writer.

Expanding Medicare would be a win for everyone
by Thomas Clairmont - Pharmacy News - May 24, 2017

The op-ed written by Senator Gregg outlines his proposals for a GOP "win" on health care.
Physicians for a National Health Program has a proposal for you, the hardworking citizen, to win by reducing your cost and your stress over health care. Political wins be damned.
The senator is wrong about the genesis of the ObamaCare bill. I refer the interested reader to the Republican bill of 1993, introduced by Sen. Chafee, R-RI. Here we have individual and employer mandates, a standard benefits package, a ban on pre-existing conditions exclusions, exchanges, subsidies, etc, with a goal of 94 percent coverage. Republicans should have thanked the president for getting their bill into law.
The Senator forgot that working with the Bush 43 administration the number of uninsured rose by 7.9 million to 46.3 million citizens. And he forgot that under his watch the average cost of insurance rose 131 percent while inflation was 28 percent. Who was the winner there?
The senator forgot that he voted for the Medicare D program that specifically prohibits the government from negotiating prices on drugs. How is that "win" working for you? We will be discussing this issue at the New Hampshire Premiere of Big Pharma Market Failure on May 31 at 6:30 p.m. at the Service Credit Union headquarters in Portsmouth.
The senator includes the usual disparaging remarks about single payer (Medicare expanded to everyone). Here we have another pontificating politician using code words to throw you off base.
What would your participation in Medicare mean to you? Full coverage of all medically necessary benefits for life, with no deductibles, co-payments, co-insurance, narrow networks, or other deterrents to good care. This program also covers dental and long-term care. The bond between employment and insurance is broken forever, you are free to move to another job or open your own business. Your taxes are already paying for coverage for 22 million federal, state, and local employees, over a million on active duty, and Medicare A takes 2.9 percent of your income. Why not coverage for you? Keep in mind that expanding Medicare saves over $600 billion every year by reducing insurance overhead (12.4 percent for private insurers, 2.2 percent for Medicare), cuts hospital administrative costs in half, virtually eliminates hospital billing, and reduces prescription costs by 31 percent.
Winston Churchill once famously observed that Americans will always do the right thing, only after they have tried everything else. We have now reached that point. There are only three choices left. Obamacare, Trumpcare, or Medicare expansion to cover everyone with tremendous savings and satisfaction. Now there is a win for YOU. Please call Rep. Carol Shea-Porter to add her name to the 110 co-sponsors of HR 676.
Thomas Clairmont, MD
Portsmouth


THE REPUBLICANS’ WAR ON MEDICAID

by John Cassidy - The New Yorker - May 25, 2017

Many people who don’t use Medicaid think of it as a federal health-care program for the impoverished and destitute, but it’s much more than that. In the past couple of decades, as incomes have stagnated and health-care costs have accelerated, Medicaid has turned into an essential support mechanism for millions of Americans who can’t be classed as poverty-stricken, strictly speaking, but who also can’t afford to bear the costs of private health coverage.
The numbers involved are huge. In March of this year, according to official figures, 74.6 million people were enrolled in plans supported by Medicaid or its sibling, the Children’s Health Insurance Program. That’s more than one in five of the U.S. population. Since 2013, the number of Medicaid and CHIP enrollees has risen by almost twenty million. That’s largely because the Affordable Care Act of 2010 significantly increased the programs’ income-eligibility thresholds.
The expansion under Obamacare focussed on working families with incomes just above the official poverty line. But many Medicaid beneficiaries are elderly and infirm individuals living in nursing homes. In fact, about sixty per cent of all nursing-home residents now receive some sort of assistance from Medicaid. Kids are also big beneficiaries: Medicaid and CHIP now help to provide medical coverage for about a third of all the children in America.
Some of the families who benefit from Medicaid might not even realize they are receiving federal aid. Take New York State’s Child Health Plus program, which provides medical insurance for the children of low- to middle-income families who don’t qualify for regular Medicaid. The program is partially funded by New York taxpayers, but it also receives matching funds from CHIP. Other states have similar programs.
Many Republican-run states have refused to accept Obamacare’s expansion of Medicaid, but some—including Arizona, Iowa, Ohio, and Pennsylvania—have agreed to participate. Although the details differ from place to place, the common thread is that Republican governors and legislatures in these states have seized the opportunity get more of their citizens health-care coverage.
At the national level, however, the Republican Party remains implacably opposed to Medicaid expansion. As the House Republicans’ health-care-reform bill, called the American Health Care Act, makes clear, the Party doesn’t merely want to roll back the Obamacare reforms; it wants to shrink the entire program, transferring it to the states and imposing tight caps on the payments they receive from the federal government.
That is the blueprint for Medicaid laid out in the latest version of the A.H.C.A., which Paul Ryan, the House Speaker, and his colleagues voted through, earlier this month. According to the nonpartisan Congressional Budget Office’s scoring of the A.H.C.A., which it released on Wednesday, the bill would reduce over-all federal spending on health care by about $1.1 trillion over ten years. Of that, eight hundred and thirty-four billion dollars—fully three-quarters of the savings—would come from cuts to Medicaid.
The political battle over the A.H.C.A., and much of the media coverage, has focussed on the individual-insurance market—and the bill would have alarming consequences there, such as forcing much higher premiums on people with preëxisting conditions and old people of modest means. But, in terms of over-all money spent and numbers of people affected, the bigger story lies elsewhere. From a financial and human perspective, the Republican bill is, above all else, an assault on Medicaid.
The C.B.O. estimates that by 2026, if the A.H.C.A. were enacted, spending on Medicaid would be reduced by a quarter compared to current spending. In the same time period, the number of people covered by Medicaid and CHIP would fall by about fourteen million—accounting for almost two-thirds of the total decrease of twenty-three million predicted by the C.B.O.
Why is the Republican Party so hostile toward Medicaid? It can’t simply be reflecting the wishes, and interests, of its voters, many of whom are now beneficiaries of the program. Donald Trump appeared to understand this when, from the beginning of his campaign, he promised not to cut Medicaid. (Of course, this pledge turned out to be worth about as much as a marketing flyer for Trump University.)
The two keys to the Republican attitude are money and ideology. If you view the modern G.O.P. as basically a mechanism to protect the wealthy, Medicaid is an obvious target for the Party. The program caters to low- and middle-income people, and its recent expansion was financed partly by an increase in taxes on the richest households in the country.
Under the Affordable Care Act, households with taxable incomes of more than a quarter of a million dollars a year were obliged to pay a 3.8-per-cent tax on their investment income—money from things like stock dividends and interest payments on bonds—and a 0.9-per-cent surtax on their other earnings. The A.H.C.A. would abolish these taxes, providing significant handouts to families in the top one per cent. From a fiscal perspective, the cuts to Medicaid pay for these handouts.
Some analysts would leave it there and say that you don’t need to get into the nature of conservative ideology; that ideology is merely a pretext for taking from the poor and giving to the rich. I have some sympathy for this view, but I don’t think it’s the whole story.
What conservative Republicans like Ryan dislike about Medicaid isn’t just that it’s fiscally progressive. They also dislike that it’s working. As medical costs have risen and the private sector has failed to cover an increasing number of Americans, the Medicaid and CHIP programs have filled some of the coverage gap, and have done so relatively cheaply. (Studies show that covering people with private insurance plans costs somewhere between a quarter and a third more than Medicaid.)
For any politician who loathes government interventions in the economy, and whose real goal is to head off socialized medicine, the expansion of Medicaid represents a serious threat. Here is an embryonic single-payer system that is growing fast and could be further expanded pretty easily. That means it has to be crippled now, before it gets more firmly established. Hence, the A.H.C.A.
Of course, the A.H.C.A. isn’t yet law. The measure now goes to the Republican-controlled Senate, where attention will again focus on premiums and coverage in the individual market. These are important issues, to be sure. But also keep a keen eye on what happens to the Medicaid provisions of the bill. If you want to know where today’s G.O.P. ultimately stands, that will be the biggest tell.

It Turns Out That Critics of the GOP Health Care Plan Were Right All Along
By Jonathan Cohn - Huffington Post - May 25, 2017

Wednesday’s report from the Congressional Budget Office ought to erase any lingering doubt about how Republicans are trying to change American health care. 
If they get their way, they will protect the strong at the expense of the weak ― rewarding the rich and the healthy in ways that punish the poor and the sick.
Republicans have tried mightily to deny this, and accused their critics of dishonesty. President Donald Trump, Vice President Mike Pence, House Speaker Paul Ryan (R-Wis.) ― they and their allies have insisted over and over again that their proposals would improve access to health care and protect people with pre-existing medical conditions.  
But it’s the Republicans who are lying about what their plan to repeal Obamacare would do.
They were lying back in March, when they introduced the initial version of the legislation ― a bill GOP leaders had to pull at the last minute because it didn’t have enough votes to pass. And they have been lying since early May, after they revised that proposal and rushed to vote on it before the CBO, Washington’s official scorekeeper, had time to evaluate it formally.
Now the budget office analysts have done their work. And if they are right, then the revised legislation would punish economically and medically vulnerable Americans more than the earlier version would have ― leaving many millions without insurance and unraveling the market for insurance for people with pre-existing medical conditions.
To be clear, CBO’s overall assessment didn’t change much, since the basic framework of the bill hasn’t changed much either.
Older people would still face higher premiums, as insurers would gain more leeway to vary prices based on age. Lower-income people buying private insurance on their own would still lose financial assistance, as a new formula for tax credits would steer money away from them. And the very poor would still lose access to Medicaid, as states would lose funding they otherwise would have gotten from the federal government. 
Some people would feel better off as a result of these changes ― young people in relatively good health would get access to cheaper coverage, for example, while more affluent people who get little or no financial assistance from the government today would start to get more. Wealthy people would get extra money in their pockets, since the GOP legislation would undo the taxes that finance the Affordable Care Act’s coverage expansion. 
But the net effect would be 23 million fewer people with health insurance ― many of whom, as a result, would face financial or physical hardship because they could no longer afford medical care. That’s nearly identical to the 24 million that the CBO estimated would lose coverage from the bill’s previous version. 
The one big change Congress made to that bill is a set of amendments that would allow states to waive some of the Affordable Care Act’s most important regulations, including rules that prohibit insurance companies from charging higher premiums to people with pre-existing medical conditions. 
Republican leaders have insisted that these amendments, so essential to winning over holdout lawmakers in the House, wouldn’t actually make much difference to consumers. 
Even in states that sought the waivers, GOP leaders promised, insurers could engage in “medical underwriting” ― that is, varying premiums based on health status ― only for people who allowed their coverage to lapse for more than two months. And that was bound to be a small number of people, Republicans said.
On Wednesday, the Congressional Budget Office indicated just how wrong that argument is.
For one thing, coverage lapses of more than two months would be pretty common under the GOP bill, because lower-income consumers who struggle to pay premiums would be getting less financial assistance than they do today. More important, the CBO pointed out, allowing insurance companies to vary premiums based on medical conditions even in some cases would inevitably create a bifurcated insurance market.
Insurers would end up setting up two sets of plans ― one with medical underwriting and one without. Healthy people would flock to the underwriting plans, since they’d be eligible for cheaper coverage there. The older plans would be left with a relatively sicker population, forcing them to raise premiums for everybody still enrolled in them and thereby encouraging more healthy people to leave ― until, eventually, those plans had shrunk to small groups of people with big medical problems. 
Premiums in these plans would be much more expensive, and in many cases downright unaffordable, making access to them for people who had maintained continuous coverage essentially meaningless. As a result, the CBO concluded, “People who are less healthy ... would ultimately be unable to purchase comprehensive non-group health insurance at premiums comparable to those under current law, if they could purchase it at all.”
The finding echoes an analysis that Matthew Fiedler, a former Obama administration economist who now works at The Brookings Institution, published shortly before the House bill passed. And on Wednesday, in an email to HuffPost, Fiedler noted that the people the GOP bill would marginalize are those that, in theory, an insurance system should prioritize. “Those markets would no longer fulfill one of their fundamental purposes, which is ensuring that people can get health care when they need it,” he said.
Of course, insurance markets under the Republican scheme would serve other purposes ― like limiting the size and scope of government, offering cheap coverage to younger and healthier people, and allowing wealthier Americans to keep some money they now pay to the federal government in the form of taxes. 
Republicans may think that pursuing those goals ultimately does society more good than guaranteeing health insurance for the people who need it most. Such thinking would be consistent with the way they have tried to govern more generally, with their constant efforts to strip down programs for the poor and middle class while showering the wealthy with tax cuts. 
But when talking about health care over the past few years and especially in the past few months, Republicans have pretended they have different priorities ― a deception the CBO exposed quite clearly on Wednesday.

Single-payer healthcare in California? Time to take a cold shower and return to the real world
by George Skelton - LA Times - May 25, 2017

A state-run universal healthcare system? California only? It’s fantasy.
Current legislation in Sacramento is fatally flawed and foolhardy.Why? It would be astronomically expensive, politically impossible and beyond state government’s competence.
But it’s a rallying cry for many liberal followers of Bernie Sanders. And some Democratic legislators are seriously pursuing the idea, urged on by the politically powerful California Nurses Assn.
The nurses were marching and shouting at last weekend’s Democratic Party state convention in Sacramento. Their hero is Lt. Gov. Gavin Newsom, whom the nurses have endorsed to replace the termed-out Gov. Jerry Brown in next year’s election.
They like Newsom because he installed a local universal healthcare system as San Francisco’s mayor.
The activist nurses have also endorsed state Sen. Ricardo Lara (D-Bell Gardens) for California insurance commissioner. He and Sen. Toni Atkins (D-San Diego) are sponsoring the universal healthcare legislation. It’s called “single payer” because the state would pay for all healthcare in California.
Lara is chairman of the Senate Appropriations Committee, where his bill, SB 562, is expected to be approved and sent to the Senate floor. It’s up against a June 2 deadline for Senate passage to the Assembly.
But Lara’s own committee staff may have dealt the bill a mortal blow Monday with a candid analysis of the legislation.
The annual cost was eye-popping: $400 billion. Of that, $200 billion would come from existing federal, state and local funding for healthcare. The remaining $200 billion would have to be raised from higher taxes.
OK, let’s put those dollars in perspective. The governor is proposing total spending of $290 billion for everything — schools, prisons, healthcare etc. — in the next fiscal year. That includes about $107 billion from the federal government and $183 billion from the state.
Spending on Medi-Cal healthcare for the poor is projected at about $106 billion. It covers a third of Californians. Of the spending, $68 billion is expected from the Trump administration. Yeah, right! The state general fund is down for just $18.6 billion. Still, that’s 15% of the $124-billion general fund.
The game plan of universal healthcare activists is to convince President Trump and the Republican-controlled Congress to transfer all the Medi-Cal billions to help leftist California finance a single-payer system, something they’d fear and deride as socialized medicine. A non-starter.
In fact, Trump proposed Tuesday to chop Medicaid — the national umbrella of Medi-Cal — by $616 billion over 10 years. So it’s doubtful California will be able to even hold on to all the federal Medi-Cal dollars it has.
Moreover, California’s Trump-bashing Democratic leaders aren’t exactly on genial negotiating terms with the White House or Congress.
But that aside, there’s the matter of finding the remaining $200 billion to be raised.
The committee analysis assumed a 15% payroll tax on income. This in a state that already suffers from the highest income tax rates in the nation. To raise them even higher would require a two-thirds legislative vote. And taxes would be hiked, in part, to provide healthcare for roughly 2 million people who migrated here illegally. Not a good political scenario.
Actually, the number-crunchers theorized, companies would probably increase employees’ salaries because they’d be freed from paying for healthcare premiums and have spare money for compensation. So that would help workers pay the higher taxes. Sure, of course. They’d be more likely to buy a corporate jet.
But if all this dream-world stuff happened, there’d still be between $50 billion and $100 billion in new money needed to fund a single-payer healthcare system. There’d be no premiums, co-pays or deductibles — and therefore no self controls. So who knows how steep new medical costs would climb?
Supporters point out, however, that the idea is to eliminate insurance company profits and reduce overall healthcare costs. A good argument.
Don’t get me wrong. I’m all for national Medicare for everybody of all ages. You don’t hear many gripes about Medicare. But this wouldn’t be Medicare. It would be a program run by one state. And whether it’s up to the job is questionable.
Anyway, Brown would probably veto the bill.
“Where do you get the extra money?” he asked rhetorically when queried by reporters in March.
The governor totally dismissed the idea and lapsed into Latin: “This is called ignotum per ignotius…. In other words, you take a problem and say, ‘I’m going to solve it by something that’s even a bigger problem,’ which makes no sense.”
The legislative committee’s analysis shocked the Capitol.
“People are running around with their hair on fire because of the numbers,” one Democratic aide told me.
Supporters took refuge in the report’s opening line that the dollar estimates “are subject to enormous uncertainty.”
Lara and the nurses association said they are awaiting a more comprehensive report from the University of Massachusetts, Amherst. “It will identify potential funding sources and savings that will allow California to reach universal coverage,” the senator predicted.
“We’re not deterred,” asserted Michael Lighty, public policy director for the nurses union. He said the aim is to pass a bill by the end of summer.
Forget it. Don’t waste the effort. Take a cold shower and return to the real world. Focus on what’s doable.

New C.B.O. Score: G.O.P. Health Bill Would Save Government Billions but Leave Millions Uninsured

by Haeyoun Park and Kevin Quealy - NYT - May 24, 2017

Here are key findings from the Congressional Budget Office’s analysis of the Republican health care overhaul bill passed by the House on May 4.

The bill would save the federal government $119 billion in a decade. 


The largest savings would come from cutting Medicaid and reducing tax credits for middle-income insurance buyers.
Because Republicans are using a special legislative process to avoid a filibuster in the Senate, the bill had to comply with special rules. They include saving the federal budget at least $2 billion over 10 years.
An initial version of the bill would have saved the federal government $337 billionover a decade, and a subsequent version would have saved half that amount. House Republicans pulled an earlier bill from the floor because they did not have enough votes to pass it.
In the final bill, however, lawmakers added more spending in various areas to get enough votes to pass, including $8 billion over five years to help cover insurance costs for people with pre-existing conditions.
One of the bill’s most expensive items is a provision that would eliminate about $600 billion in taxes imposed under the Affordable Care Act, including taxes on investment income, prescription drugs and indoor tanning.

23 million more Americans will be uninsured in 10 years.


The budget office projected that in 2018, the number of uninsured would increase to 41 million and would continue to grow. In 10 years, it would become closer to what it was before the Affordable Care Act, President Barack Obama’s signature health law, took effect.

Cost of insurance could rise more than nine-fold for some older people with low incomes.


The House bill included last-minute amendments that let states seek changes to certain insurance regulations.
The C.B.O. estimates that premiums could go down about 10 to 30 percent for people in states that make moderate changes to these regulations. This is largely achieved by offering skimpier plans and pricing out the old and sick from the insurance market.

Insurance cost for a single individual with annual income of $26,500


Age
Under Obamacare
States with no regulation changes
States with some regulation changes
21 years old
$1,700
$1,750
$1,250
40 years old
$1,700
$2,900
$2,100
64 years old
$1,700
$16,100
$13,600
Premiums would become significantly higher for older people with low incomes, according to an example cited in the C.B.O. report, whether or not states made some changes to regulations, and even higher in states that did not.
The C.B.O. analysis did not include an estimate for people in states that decide to substantially alter the insurance regulations. But the report said that although average premiums would be lower, premiums would rise rapidly for less healthy people.

McConnell May Have Been Right: It May Be Too Hard to Replace Obamacare

by Jennifer Steinhauer and Robert Pear - NYT - May 26, 2017

WASHINGTON — Shortly after President Trump took office, Senator Mitch McConnell of Kentucky, the majority leader, met privately with his colleagues to discuss the Republican agenda. Repealing the Affordable Care Act was at the top, he said. But replacing it would be really hard.
Mr. McConnell was right.
The many meetings Republicans held to discuss a Senate health care bill have exposed deep fissures within the party that are almost as large as the differences between Republicans and Democrats. Elements of a bill that passed the House this month have divided Republicans.
Mr. McConnell faces an increasingly onerous math problem. He can afford to lose only two Republicans if he is to get a bill through the Senate, and that would require the help of Vice President Mike Pence, who would have to cast the tiebreaking vote. But at least three senators in the party are diametrically opposed to the views of at least another three, so the path to agreement is narrow.
Republicans are roughly split over whether the expansion of Medicaid under the Affordable Care Act should be rolled back or continued, at least in the short run. They disagree about how the federal government should grant states more control over setting insurance standards. They are also divided over a critical portion of the House bill, which would allow states to obtain waivers from two of the most important federal mandates: a requirement to provide a minimum set of health benefits and a prohibition against charging higher prices to people with pre-existing medical conditions.
The challenges facing Senate Republicans are so great that overhauling the tax code is starting to look easier by comparison. “I allow that’s a possibility,” said Senator Pat Toomey, Republican of Pennsylvania, who is closely involved in negotiating both issues and favors a rollback of the Medicaid program.
This week, the normally circumspect Mr. McConnell conceded that it was going to be difficult to get the votes needed from Republicans to pass a health care bill. A Congressional Budget Office report on the House bill, forecasting an increase of 23 million Americans without insurance in a decade and significantly higher premiums for older and sick people, bolstered the resolve of Republican senators who have been skeptical of the House effort.
Most Republicans in Congress would like to keep their vow to repeal and replace the Affordable Care Act, but they face a more urgent challenge: to stabilize insurance markets that, in some states, are in danger of melting down next year.
Every week brings word of insurers seeking big rate increases or announcing plans to pull out of another market in 2018. It is conceivable that the two parties could work together on short-term fixes outside the repeal process at some point.
“I don’t think we want the market to fail,” said Senator Orrin G. Hatch, Republican of Utah and chairman of the Finance Committee, which is responsible for tax legislation and much of the Affordable Care Act. “We don’t want premiums to be so high that people can’t afford them.”
Republicans could pass a repeal measure and return to the health care system that was largely in place before the Affordable Care Act became law. But Speaker Paul D. Ryan, among others, has repeatedly stated that his party has a plan to make the system better, which would require the replacement part of the repeal-replace equation.
With health care negotiations sputtering, many Republicans are quietly turning their attention to changes in the tax code as a possible path for legislative success. Generally, Republicans are more unified around the fundamentals of a tax overhaul than on the details of health policy. The White House team working on tax issues is far less ideological than the team directing health care efforts, and it has worked harder to build early momentum, Republicans aides say.
Though Republicans have been calling for a repeal of the health care law almost since President Barack Obama signed it in 2010, those calls have become more urgent as some of the insurance exchanges have struggled.
But with millions of Americans newly insured under the law, many governors, including some Republicans, are loath to roll it back, and many senators agree. Twenty Republican senators come from states that have expanded Medicaid under the Affordable Care Act.
The House bill, starting in 2020, would sharply reduce federal payments to states to cover those who became eligible for Medicaid as a result of the Affordable Care Act.
The law also has provisions to help drug addicts, and the opioid crisis sweeping many states with Republican senators has been a key motivator.
“The opioid issue definitely plays a role,” said Senator Susan Collins, Republican of Maine. “A lot of the young population that is being insured under Medicaid has problems with substance abuse or mental illness.”
While fixing the nation’s tax code has long been considered even harder than passing health care legislation on Capitol Hill, the opposite could end up being the case.
Treasury Secretary Steven Mnuchin and Gary D. Cohn, the director of the president’s National Economic Council, have held numerous meetings with lawmakers — including Democrats — on the matter and have attended several hearings against the backdrop of the contentious health care talks.
“Taxes has more consensus with Republicans and some Democrats,” said Senator Rob Portman, Republican of Ohio.
Republican senators have been watching closely as House Republicans have twisted themselves in knots over the tax “blueprint” that they released last summer. Many lobbyists and tax experts are hoping that the Senate emerges as a voice of reason.
Republican senators continued free-flowing conversations among themselves this week to analyze their options and search for consensus on a health care bill that they said would be significantly different from the one passed by the House.
Senator John Cornyn of Texas, the majority whip, and Senator Ron Johnson of Wisconsin said they expected staff experts to draft legislative language for Republicans to consider when the Senate returns from a weeklong recess on June 5.
“We’re talking about this nonstop between ourselves,” Mr. Johnson said of the Republicans. “It’s an appropriate time now to have leadership and committee staff, working with leadership and committee chairmen, sit down and draft a bill, a proposal, for discussion.”
If the Senate decided not to vote on a health care bill, it would be likely to enrage the White House, as it did when Mr. Ryan at first failed to produce a bill that could pass. However, Mr. Trump has considerably less leverage with Mr. McConnell than he did over House leaders, as Mr. McConnell and Republican senators are less susceptible to pressure from the White House.



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