If basic healthcare is a privilege, what rights do we have?

by Jamie Peck - The Guardian - May 16, 2017

A rightwing hero was born this past Sunday during the combination bikini contest and civics test that is the Miss USA pageant. In an effort to investigate how she would solve our nation’s problems, host Julianne Hough asked Miss Washington DC (aka Kara McCullough) if she believed “affordable healthcare for all US citizens” was “a right or a privilege”, and why. McCullough answered by saying:

“I’m definitely going to say it’s a privilege. As a government employee, I’m granted healthcare and I see firsthand that for one to have healthcare, you need to have jobs. So therefore, we need to continue to cultivate this environment that we’re given the opportunity to have healthcare as well as jobs to all American citizens worldwide.”

Currently unemployed people, as well as those with bad jobs that don’t provide healthcare, are presumably out of luck. That McCullough wants to help women find work in Stem jobs is admirable, but does nothing to help the vast majority of people.

Of course, her statement is technically true. As things currently stand in the US, healthcare is a privilege, and one you likely need a job to access. (And not just any job … a salaried and/or union one, a holy grail that’s fast disappearing.) As a person with both a job and healthcare, she’s observed this firsthand. But as McCullough is a nuclear scientist, I will assume she understood the question was about how she believes things should be, not how they are. In which case, she’s as wrong and out of touch as any DC royalty currently making policy on this issue.

Now, I’ll admit it’s tough to prove beyond the shadow of a doubt that people deserve basic levels of physical safety simply by virtue of being human. To do so would require a philosophical deep dive above my level of expertise. But our founding documents – which I’d hope someone with the surname “USA” respects – have already sided with the “yeas” on the existence of certain inalienable rights, chief among them “life”. And an estimated 45,000 Americans die each year from lack of health insurance. This is not just another commodity, but a necessity on the level with food and shelter. Which, to be fair, Republicans also want to take away from the poor.

Beyond that, it comes down to a simple matter of preference: do you want to live in a society that codifies some level of responsibility to our fellow citizens, or would you rather roll the dice on a Randian dystopia where the lazy, unlucky or otherwise uncompetitive are liquefied into paleo shakes for rich people? Maybe I can’t objectively prove which is “better”, but I know which I’d prefer. Contrary to what social Darwinists would tell you, one cool thing about being human is we (theoretically) get to decide which ideals we want to pursue.

When healthcare is a for-profit enterprise, costs skyrocket and access plummets. While the Affordable Care Act reined in some of the industry’s worst abuses, an estimated 27 million are left uninsured under it, a number that’s slowly climbing as companies raise premiums and pull out of exchanges.

Even those who are insured report problems paying for care due to high deductibles, and, more generally, to being insured by companies whose business model is to dole out as little coverage as they can legally get away with. The Republican party is currently in the process of turning 27 million into 52 million with their ironically named American Healthcare Act. Soon, 45,000 deaths a year will seem like the good old days.

As every other country in the developed world knows, the only way to increase coverage to 100% – as well rein in absurdly high per capita spending on a bloated private industry – is with a system of state-funded healthcare. It works everywhere else, and many experts say it would work here.

The American people are on board. A 2017 Economist/YouGov poll found about 80% of Democrats and 40% of Republicans – yes, Republicans! – favor a federally funded health insurance system that covers all Americans. All race, age, income, and gender demographics favor it by simple majorities, and many – particularly the most marginalized – by strong ones. Even Republicans and conservatives approach 50%. Those who voted for Hillary Clinton favor it at a rate of some 85%.

Unfortunately, this is one of many areas where the country’s political class refuses to even remotely entertain the will of the people. Neither Democrats nor Republicans are willing to do the empathetic, fiscally responsible thing.

We all know Republicans will happily let people die to pay for oligarchs’ tax breaks. But even most elected Democrats remain irrationally committed to compromising with an industry that wants you dead. This becomes more comprehensible when you look at the amount of money the insurance lobby gives to both parties. Despite its immense popularity with voters, single-payer will be on neither party’s agenda in 2018.

In stating that affordable healthcare is a privilege that should be reserved for gainfully employed people, McCullough showed she’ll fit in just fine with the other undemocratically elected rulers in DC. Trump might not own the Miss USA pageant any more, but his cutthroat spirit lives on.

https://www.theguardian.com/commentisfree/2017/may/16/health-care-human-rights-miss-washington-dc-kara-mccullough

Heidi Brooks sponsors single-payer health care bill for Maine

by Steve Collins - Lewiston Sun-Journal - M ay 5, 2017

AUGUSTA — As Congress debates the merits of the Affordable Care Act and its potential successor, some lawmakers think the time is ripe to create a single-payer health care system in Maine.

“Here in Maine many people are struggling to get the care they need when and where they need it. Universal health care ideally includes everyone in an equitable fashion,” said Rep. Heidi Brooks, D-Lewiston, the sponsor of a measure that calls on the state to adopt a single-payer system by 2020.

The controversial Healthy Maine Act would finance health care for most Mainers. However, many of the details about how it would work are left to figure out later.

“Our current health care system is inefficient, too expensive, and unfair,” Sen. Geoffrey Gratwick, D-Bangor, told colleagues. He said that “much of it is geared toward profit, not health” and is “destroying our business competitiveness.”

But many businesses are none too keen on shifting to a system they fear will wind up costing too much. They point to Vermont’s failed effort to adopt a single-payer system as evidence that it won’t work in Maine, either.

David Clough, state director of the National Federation of Independent Businesses, said the legislators pushing for the measure “may be proven right someday about this vision for the future of health care.”

But, he said, it’s likely the state would find “that the costs are far beyond what taxpayers and the Maine economy could support.”

That’s what happened in Vermont, which pulled the plug in 2015 on its bid to create a new system that would provide nearly everyone in the state with coverage. Eyeing an 11.5 percent payroll tax hike and an increase in individual income taxes, the state gave up on the idea.

A single-payer system, which is used in many countries, would eliminate most private insurance and instead have the government pay for health care services using tax money. Exactly what sort of taxes or how much money would be needed in Maine is not clear.

The proposal by Brooks and other legislators aims to do a lot, including the creation of a state-run pharmacy benefits management program, electronic medical records sharing and coverage that doesn’t require deductibles and covers all of the costs for primary care.

The nonprofit Community Health Options told lawmakers it supports universal health coverage but doesn’t think a single-payer system is the best approach.

The Lewiston-based provider told the Legislature’s Insurance and Financial Services Committee that “competition amongst carriers produces a market imperative for higher levels of efficiency, improved service levels and constant pressure to reduce administrative costs while stretching the premium dollar.”

Legislators, though, are hearing from people across the state who are unhappy with the current system and are convinced that single-payer is the way to go.

Kristi Clifford of Lisbon Falls told the committee that in a compassionate country, health care would be guaranteed for everybody.

She described how a family member’s health declined over the years “because she couldn't afford to pay for preventive checkups and tests,” leading to costly emergency room trips and no way to deal with pain.

Medical bills would go unpaid, Clifford said, “because people need money to eat. Food or health care: Hope your loved ones survive or you never have to choose.”

“The for-profit insurance companies and pharmaceutical companies are never going to be the answer to affordable health care for everyone," she said. "There is just too much money to be made by too few. All people should be taken care of when they are sick, not just those who are lucky enough to afford insurance or whose jobs pay for it.”

Renee Cote, a self-employed editor in Auburn, told lawmakers she’s simply going without insurance at age 59 because buying it would be too costly.

Last year, she said, she paid $500 monthly for a policy “with a huge deductible and co-pays” and this year, it could be $750 a month for even worse coverage. It would cost her $1,000 monthly for a decent policy, Cote told legislators.

Like many people her age, she said she is not willing “to devote a large part of my income to paying an insurance company for crummy coverage” and is looking for the state or federal government to provide an affordable, universal health care plan.

“In the richest country in the world, there has to be a better way to provide health care than to have this for-profit system that benefits very few people,” she said.

Many supporters point to Medicare as a model for what Maine could do for all of its citizens.

Lynn Cheney of Blue Hill told legislators that “many of the people I work with say they can't wait to be 65 years old to enroll in Medicare and this makes me think that people shouldn't have to wait.”

“With private health care premiums spiraling out of control, Medicare covers the oldest and sickest at a fraction of the overhead expense of free-market insurance,” she said.

Michael Bacon of Westbrook said his five years on Medicare have convinced him it “is the best model we have for true universal health care. Our long experience with it has proven that it works.”

“Some fear that a government-run insurance program would lead to a socialist state, in which freedom and personal ambition and energy would be diminished,” Bacon told lawmakers. He said, though, that “quite the opposite is true.”

“Having more security and less risk in our lives makes us freer to apply our talents and energies for the good of the economy and our communities. It also makes us happier. And we probably live longer,” Bacon said.

“The political will to fix our broken health care system does not exist now in Washington, but it could happen at the state level,” Cheney said, urging Maine to take the lead.

The committee plans a work session Tuesday to discuss the bill.

http://www.sunjournal.com/news/maine/2017/05/08/heidi-brooks-sponsors-single-payer-health-care-bill-maine/2126332

A Whistle-Blower Tells of Health Insurers Bilking Medicare

by Mary Williams Walsh - NYT - May

When Medicare was facing an impossible $13 trillion funding gap, Congress opted for a bold fix: It handed over part of the program to insurance companies, expecting them to provide better care at a lower cost. The new program was named Medicare Advantage.

Nearly 15 years later, a third of all Americans who receive some form of Medicare have chosen the insurer-provided version, which, by most accounts, has been a success.

But now a whistle-blower, a former well-placed official at UnitedHealth Group, asserts that the big insurance companies have been systematically bilking Medicare Advantage for years, reaping billions of taxpayer dollars from the program by gaming the payment system.

The Justice Department takes the whistle-blower’s claims so seriously that it has said it intends to sue the whistle-blower’s former employer, UnitedHealth Group, even as it investigates other Medicare Advantage participants. The agency has until the end of Tuesday to take action against UnitedHealth.

In the first interview since his allegations were made public, the whistle-blower, Benjamin Poehling of Bloomington, Minn., described in detail how his company and others like it — in his view — gamed the system: Finance directors like him monitored projects that UnitedHealth had designed to make patients look sicker than they were, by scouring patients’ health records electronically and finding ways to goose the diagnosis codes.

The sicker the patient, the more UnitedHealth was paid by Medicare Advantage — and the bigger the bonuses people earned, including Mr. Poehling.

In February, a federal judge unsealed the lawsuit that Mr. Poehling filed against UnitedHealth and 14 other companies involved in Medicare Advantage.

“They’ve set up a perfect scheme here,” Mr. Poehling said in an interview. “It was rigged so there was no way they could lose.”

A spokesman for UnitedHealth, Matthew A. Burns, said the company rejected Mr. Poehling’s allegations and would contest them vigorously.

How Medicare Payments Work

The traditional Medicare program reimburses doctors directly for procedures they perform — but that can promote unnecessary treatments and inflate costs. So Medicare Advantage was set up differently: The government contracts with for-profit insurers to manage health care for the elderly, and pays insurers a yearly fee for each member they enroll. That fee is higher for patients recently treated for certain conditions, creating an incentive for Medicare Advantage insurers to search for diagnoses of illness in their patients, even where none may exist.

“We are confident our company and our employees complied with the government’s Medicare Advantage program rules, and we have been transparent with C.M.S. about our approach under its murky policies,” he said, referring to the Centers for Medicare and Medicaid Services, which administers Medicare Advantage.

Mr. Burns also said Mr. Poehling’s complaints and similar ones held UnitedHealth and other Medicare Advantage participants to higher standards than the ones used by the original Medicare program.

Mr. Poehling’s suit, filed under the False Claims Act, seeks to recover excess payments, and big penalties, for the Centers for Medicare and Medicaid Services. (Mr. Poehling would earn a percentage of any money recovered.) The amounts in question industrywide are mind-boggling: Some analysts estimate improper Medicare Advantage payments at $10 billion a year or more.

At the heart of the dispute: The government pays insurers extra to enroll people with more serious medical problems, to discourage them from cherry-picking healthy people for their Medicare Advantage plans. The higher payments are determined by a complicated risk scoring system, which has nothing to do with the treatments people get from their doctors; rather, it is all about diagnoses.

Diabetes, for example, can raise risk scores by varying amounts, depending on a patient’s complications. So UnitedHealth gave people with diabetes intensive scrutiny, to see if they had any other conditions that the diabetes might have caused.

As Mr. Poehling’s lawyer, Mary Inman, described it, the government would pay UnitedHealth $9,580 a year for enrolling a 76-year-old woman with diabetes and kidney failure, for instance, but if the company claimed that her diabetes had actually caused her kidney failure, the payment rose to $12,902 — an additional $3,322. Ms. Inman is with the law firm of Constantine Cannon in San Francisco.

Mr. Poehling said the data-mining projects that he had monitored could raise the government’s payments to UnitedHealth by nearly $3,000 per new diagnosis found. The company, he said, did not bother looking for conditions like high blood pressure, which, though dangerous, do not raise risk scores.

He included in his complaint an email message from Jerry J. Knutson, the chief financial officer of his division, in which Mr. Knutson urged Mr. Poehling’s team “to really go after the potential risk scoring you have consistently indicated is out there.”

“You mentioned vasculatory disease opportunities, screening opportunities, etc., with huge $ opportunities,” Mr. Knutson wrote. “Let’s turn on the gas!”

There were bonuses when Mr. Poehling and his team hit their revenue targets, Mr. Poehling said, but no bonuses for better health outcomes or for more accurate patients’ charts.

“You or I or the average person is probably appalled by this,” Mr. Poehling said. “But the scheme here was not about delivering better care to members — the thing you would expect from a health care company. It was about increasing the bottom line.”

He went to work for UnitedHealth in 2002, filed his lawsuit in 2011 and left the company at the end of 2012, while the case was still under seal.

Mr. Poehling’s allegations, if true, could help explain why insurers are staying in the Medicare Advantage program even as they pull out of the Affordable Care Act exchanges in some states: Medicare Advantage offers a way to get extra money from the federal government.

When a whistle-blower succeeds in recovering money for the government, the False Claims Act calls for him or her to receive a percentage. Many whistle-blower cases fail to reach that point, but when the Justice Department joins a case, in general, the odds of a recovery go up.

Already the Justice Department has declined to intervene in some smaller whistle-blower cases with similar allegations. But in March, it did say it would join a whistle-blower suit filed by James Swoben, a former data manager of SCAN Health Plan, accusing UnitedHealth and several other companies of cheating Medicare Advantage by looking improperly for ways to raise people’s risk scores.

In 2016, the United States Court of Appeals for the Ninth Circuit vacated a lower court’s decision to throw out Mr. Swoben’s case. After reviewing the allegations, Judge Raymond C. Fisher wrote, “We do not see how a Medicare Advantage contractor who has engaged in such conduct can in good faith certify” that the diagnosis codes it reports to the Centers for Medicare and Medicaid Services “are accurate, complete and truthful.”

That ruling did not decide Mr. Swoben’s case, but merely sent it back to a district court to be adjudicated. His case and Mr. Poehling’s case are both now being handled by the United States District Court in Los Angeles.

Meanwhile, UnitedHealth has sued the Centers for Medicare and Medicaid Services, seeking to vacate a 2014 rule that requires insurers to make sure the diagnoses they report to the government are borne out by what is in people’s charts, and imposing penalties for overstatements. UnitedHealth argues that this rule unlawfully departs from the program’s statutory mandates requiring “actuarial equivalence” with the traditional Medicare program.

“That case could provide further clarity on the program rules,” Mr. Burns of UnitedHealth said. He added that the government seemed to be trying to delay so that the two whistle-blower lawsuits could go first.

The Justice Department has said it is investigating four other Medicare Advantage insurers: Aetna, Humana, Health Net and Cigna’s Bravo Health. That suggests that there are more whistle-blowers in the wings, potentially snarling more insurers in litigation and ultimately forcing a rethinking of the entire program.

“C.M.S. could do a lot to change the rules so it’s not so easy to get away with this stuff,” said Timothy Layton, an assistant professor at Harvard Medical School who researches insurer behavior in health-insurance markets. He is not involved in Mr. Poehling’s lawsuit.

“It’s a huge waste of money,” Professor Layton said of the quest for higher risk scores. “What the insurers are doing is not socially valuable at all.”

The Centers for Medicare and Medicaid Services declined to comment for this article.

Auditors and analysts have warned for at least a decade that Medicare Advantage has been vulnerable to cheating since risk scoring was phased in, from 2004 to 2008. The inspector general of the Department of Health and Human Services, where the centers reside, audited a small sample of Medicare Advantage plans early on and found overpayments of up to $650 million in 2007. It predicted even more in 2008, but then came budget cuts and those audits stopped.

The Government Accountability Office reported last year that the Centers for Medicare and Medicaid Services had identified $14.1 billion of overpayments to insurers in 2013 and did not have a clear plan for recovering the money. It also faulted the agency’s auditing methods.

“I recall a feeling of frustration verging on outrage,” said Ted Doolittle, the deputy director of the Medicare and Medicaid agency’s Center for Program Integrity at that time.

In 2014 the Center for Public Integrity, a nonprofit research group, analyzed the only available Medicare Advantage data and reported that insurers had reaped about $70 billion in overpayments from 2008 to 2013.

Fred Schulte, who led the center’s research and now works for Kaiser Health News, also sued the Centers for Medicare and Medicaid Services to get more data. In January, he reported getting confidential documents showing that the agency had tried to recover $128 million of overpayments to five insurers in 2007 but, “under intense pressure from the health insurance industry,” settled for just $3.4 million in 2012.

Last month, Senator Charles E. Grassley wrote to the agency’s administrator, Seema Verma, complaining that it had trumpeted the $3.4 million recovery to him as a sign of good fiscal oversight, without mentioning that it could have gone after $128 million.

“The difference between the assessment and the actual recovery is striking and demands an explanation,” Mr. Grassley, an Iowa Republican, wrote.

As lawmakers and others try to get their arms around the issue, few insurance insiders have come forward with firsthand accounts. Mr. Poehling said he had done so reluctantly.

“I came to the point where I just couldn’t participate in what they were asking me to do anymore,” he said.

The Price of Risk

The Medicare Advantage program pays insurance companies a yearly fee for each person they enroll. And it pays more for people who are sick, to keep insurers from rejecting them because their care will cost more. The practice, called “risk adjustment,” gives insurers an incentive to tell the government that people are sicker than they may, in fact, be.

MEDICARE ADVANTAGE PROGRAM

ANNUAL RATE

Male, age 70-74

$3,866

ADDITIONAL PAYMENT TO INSURER FOR SELECTED CONDITIONS

Diabetes without complications

$1,058

Breast, prostate and other

cancers and tumors

1,490

Diabetes with acute complications

3,251

Drug/alcohol dependence

3,910

Major depressive, bipolar and

paranoid disorders

4,039

Lung and other severe cancers

9,904

Metastatic cancer and acute leukemia

26,795

https://www.nytimes.com/2017/05/15/business/dealbook/a-whistle-blower-tells-of-health-insurers-bilking-medicare.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0

Trump(Don't)Care: How the AHCA Should Reinvigorate the Push For Universal Health Care

by Nick Schroeder - Portland Phoenix - May 16, 2017

It’s a stretch to say the firing of FBI director James Comey and Trump’s declassification of sensitive information to Russia are stratagems meant to distract you from the AHCA. But in case it’s having that effect, let’s gloss over the brutality in store for Americans if TrumpCare passes the Senate.

In simple terms, the AHCA would position Mainers and Americans vulnerable to a health care system that could be so inaccessible that it infringes on a person's basic right to live — which is, lest we forget, constitutionally inalienable. Though Democratic leadership has settled on a weak-sauce position toward the adoption of a universal health care plan (like single-payer), the majority of Americans support it, and there’s no better time to push for it.

If Democrats don’t renew their support for single-payer and away from a market-based, consumer-driven health care, the consequences could be dire. But astonishingly, Democrats have seemed to all but abandon the fight for single-payer, which has been a touchstone of their platform since the Truman Administration.

It’s a long road they’ve taken toward conceding this principle. In 1994, Hillary Clinton herself was reportedly a proponent of single-payer coverage, saying in a statement to the Lehman Brothers Health Corporation that “...I believe that by the year 2000 we will have a single-payer system in this country … I think the momentum for a single-payer system will sweep this country.”

But something caused her to change her tune. It could be political expertise, or it could be that from 2013 to 2015, Clinton pocketed over $2.8 million from 13 paid speeches to the health industry.

Meanwhile, Democrats’ insistence on distancing themselves from universal health care has become commonplace. After the AHCA passed the House last week, Minority Leader Nancy Pelosi had a golden opportunity to pin support for a single-payer system to the Democratic platform after issuing the soundbite that TrumpCare was “Robin Hood in reverse.” But she demurred. Instead, Pelosi stated that the political reality is that Congress “isn’t ready” for a single-payer system.

Whether a Republican-controlled Congress is “ready” is arguably besides the point. Democrats controlled both the House and Senate in 2010, yet President Obama still failed to pass a single-payer system, or even a public option.

Writes Branko Marcetic in a treatise this spring in the lefty journal Jacobin: “The particularly bizarre thing about many of these attacks on single-payer from prominent liberals and Democrats is that they’re fundamentally conservative arguments: single-payer is too radical and farreaching a change; it’s too expensive; it’ll mean raising taxes; it’ll involve giving the federal government too much power.”

Despite these cries, a 2016 Gallup poll found that 58 percent of Americans support it. Even a recent survey by The Economist, ideologically aligned with market-driven systems, reported that a majority of Americans support “expanding Medicare to provide health insurance for every American.”

Of course, Bernie Sanders hitched his campaign to the hopes of establishing a single-payer system. In an op-ed for the Brookings Institute in January, 2016 Henry J. Aaron wrote that a single-payer system would cost the government 4.1 trillion a year, “or 1.4 trillion more than the federal government now spends on programs Sanders” would have replaced. “New money would come from taxes.” Opponents say that specifics were fuzzy and the proposal too radical.

But radical is what’s happening now. Rep. Bruce Poliquin voted for the AHCA, which passed the House by a 217-213 vote in early May, despite the fact that the majority of his constituency, elderly and low-income Mainers, would be hardest hit. Rep. Chellie Pingree, who voted no, has gone on record as saying she was “disappointed that we did not accomplish single payer health care or a public option” in the Affordable Care Act. Angus King has said the Affordable Care Act was “not ambitious enough” but has not endorsed single-payer. And Susan Collins, ever the political expedient, has made statements on both sides of the fence.

IT STARTS LOCALLY

If Democratic leadership won’t fight for single-payer, then someone has to. This month, the Portland-based Southern Maine Workers’ Center released a lengthy report titled “Enough For All: A People’s Report on Health Care” as part of the organization’s Health Care Is a Human Right campaign. In it, they surveyed 1300 Mainers in 13 Maine counties about their relationship to health care and their difficulties finding adequate, comprehensive, affordable coverage.

Consisting of plentiful data attesting to the hardship of receiving quality, affordable care and a litany of personal testimonies, the report is powerful. According to the SMWC’s findings, 90 percent of respondents believe “that it is the government’s job to protect our human right to health care," and 83 percent like the idea of a universal, publicly-funded health care system.

States the report: “Our understanding of universal human need leads us to the conclusion that health care is a human right for every person.” In one succinctly put testimony, credited to Rachel in York County, “wealth is created from our health needs.”

Elsewhere in the report, they write that “Our current system of coverage, rather than care, deepens racial health disparities and promotes worse health outcomes for people of color and immigrants. Nationally, more than half of the total 32.3 million nonelderly uninsured are people of color [a demographic representing five percent of the population in Maine]. Black people are twice as likely to fall into the coverage gap that exists in the 19 states, including Maine, that have not expanded Medicaid.” This means lower-income people go to emergency rooms, or delay care because of concerns about cost. This, of course, turns into a system of entrenched debt for people who can least afford to take it on, with the benefit of profit for those in the insurance and medical industries.

The Southern Maine Workers’ Center argues for an equity-based system, one where those participating in the health care system put in what they can and take what they need. Focusing on principles of equity, universality, transparency, accountability, and participation, some of the principles they argue for include:

All state residents are enrolled. There are no exceptions, including people who are homeless, do not have employment or income, and immigrants with or without documentation. Everyone benefits, including those enrolled in existing public programs such as Medicare and MaineCare. There is no convoluted enrollment process.

Care is comprehensive. There is a focus on our right to safe, effective, and therapeutic preventative care. Baseline services include dental, vision, hearing, mental health services, reproductive health and family planning services like abortion and contraceptives, as well as gender affirming care.

“A new system must evolve in response to people’s experiences with it,” they write. “To ensure accountability to residents, communities, and Mainers’ human right to health, local community boards, statewide commissions, and annual public hearings will be created. Representatives will reflect the diversity of Maine’s patients and providers.”

How do we get there? They offer three proposals:

“1. A progressive income tax, where higher wage earners pay more than workers who earn less. This is a sliding scale that goes down to zero for people living at a certain level of poverty. 2. A progressive payroll tax, where larger employers with significant wage disparities pay more than smaller employers who pay their workers higher wages. This incentivizes larger employers to fairly compensate workers, while accounting for the benefits small businesses make to local economies. 3. A tax on non-wage wealth. There is a small percentage of the state population who accumulate wealth from stocks, interest, dividends, etc. rather than through working hourly or salaried jobs. This tax ensures that a wealthy minority don’t leave the ordinary, working majority to cover all the costs.”

Other local initatives resisting the AHCA are cropping up too. This week, Maine Public Radio reported that state lawmakers are considering a bill (proposed by Eloise Vitelli, D-Arrowsic) that would enfore greater transparency in drug costs, requiring drug makers to disclose how they arrived at prices for prescription medication.

RIGHT VS. GOOD

Opponents of a single-payer system — and there are many — have long held that health care is a commodity, not a right. This is, essentially, an argument conservatives hold dear: People with poor health have brought their health concerns upon themselves with bad choices, and that “individual responsibility” dictates that those in healthy, “low-risk” pools shouldn’t be required to pay for anyone else.

Girding this is a belief that health care is a consumer good, and is thus governed by the innate logic of the market and its system of price determinations. Conservative economist Kevin D. Williamson argues we’re dealing with a scarce good, not a right. “Health care is physical, not metaphyiscal,” he writes in a May 7 article in the right-wing journal The National Review. “It consists of goods, such as penicillin and heart stents, and services, such as oncological attention and radiological expertise.”

“Rich people always get better stuff. That’s what it means to be rich,” Williamson adds.

A fight for universal health care is nothing less than a determination of the immorality of using statements like this to determine health. Of course goods and services cost money, but strict market fundamentalism, as the AHCA is set to prove, is a sort of violence of its own, and those directly affected are soon to be the majority of the population. In another article (titled “Why Shouldn’t Women Pay More For Health Insurance?” on May 5), Williamson argues that “women have radically higher lifetime medical expenses than men do, about one-third higher, on average.” Therefore, they should accept the logic that they should have to pay more.

This argument absolves conservatives of the responsibility of dealing with fundamental injustices in American social life, from wage and lifestyle inequity among women, LGBTQ people, and people of color, to reproductive services, to health and wellbeing affected by domestic abuse and rape.

If there’s a silver lining to TrumpCare — at least in the current proposal existing between the House and Senate — it’s that it’s primed to expose the flawed logic and basic immorality of this thinking more than any time in history.

In our current system, no insurer can make a profit off someone who is sick. But putting an insurer’s right to profit over the health and wellbeing of American citizens is fundamentally immoral. People are catching on.

GUESS WHO'S PRIORITIZED

Some of the people who will suffer the most under the AHCA are the elderly. In Maine, that’s the second highest state demographic in the country. A huge portion of this comes from the $900 billion cut to Medicaid. But don’t be fooled into thinking those who retain coverage have it any easier. Under the ACA, it was forbidden for insurance companies to charge more than three times the rate of a low-risk individual in the same region. Under TrumpCare, they can charge five times that.

Literally being a woman isn’t a pre-existing condition, but it’s close. It’s not that the GOP will admit it has anything against women; they just believe that women need to fend for themselves, with fewer resources than anyone else.

The AHCA would harm women dramatically. For all Obamacare’s entanglements, it drastically improved women’s access to health care. According to the Kaiser Family Foundation, the total rate of women who went without health care coverage fell from 17 percent in 2013 to 11 percent across the board in 2015. (For single mothers, the rate fell from 24 to 16 percent; for Black women, it fell 19 to 14 percent; for Latino women, it fell 31 to 20 percent.)

Of course, the GOP is also going hard after Planned Parenthood, proposing to cut off federal Medicaid payments to the organization entirely. In 2015, Planned Parenthood comprised only six percent of the 10,708 health centers providing family planning and reproductive health care, a group that also includes community health centers and specialized centers. Yet 32 percent of women who sought care at any of these facilities were treated at Planned Parenthood, a testament to its value.

The AHCA would starve off federal payments to Planned Parenthood, for what seem like purely ideological reasons. It’s already federal law that patients cannot use federal money for abortion services (other than cases of rape, incest, or a threat to the woman’s life). The bill would provide additional funds to community health centers (CHCs) — a point for which right-wing advocates are crowing will “give women more options.” There's nothing wrong with CHC's, but there’s also nothing that states that additional federal dollars given to CHCs under the AHCA would be used for women’s health care, as Planned Parenthood supporters are quick to point out. In a report by the Congressional Budget Office in March, cutting off access to Planned Parenthood would result in the loss of access in lower-income communities. It would also result, health experts estimate, in a significant boost in unintended pregnancies.

In short, those who aren’t wealthy, or who aren’t young, healthy white men, will be hit hard.

THE TRUE COST OF CARE

If there’s a silver lining to the AHCA, it’s that it’s such a transparent transfer of wealth to the insurance industry that it risks widespread exposure for its failed moral logic. When pundits like Williamson pedantically argue that women cost more to insure, ergo they should pay more, it takes a special kind of person to ignore that women earn 78 percent of what men make for the same work, and are systematically excluded from protections across the board. What the AHCA truly exposes is the immorality inherent in the doctrinal conservative belief in personal responsibility. Dating back to the late 19th century, conservative thought has attempted to stave off the notion that federal government has a responsibility to ensure the health and wellbeing of its people. But if the alternative is a sick and ravaged country, then it it’s clearer than ever who profits off a consumer-driven system.

Said Tim Faust, a Brooklyn writer who studies health care, in a recent lecture at SUNY, “the federal government is the only actor that recognizes the cost of care and the cost of not providing care.” Faust believes that a consumer-driven health care model compels doctors to unwittingly make choices that ultimately harm their patients.

Shades of this are echoed in the Southern Maine Workers’ Center report. Sandra from Westbrook articulates a common issue with citizens receiving appropriate care, and the concerns they have about getting priced out.

“When I went to the doctor to have some standard screenings done, I was told, ‘We don’t think you have cancer, but we want to do one more thing… just to put it to rest.’ No conversation about how much this will cost or contacting my insurance to see if it’s covered. Then I get this bill for almost $3,000! I sure didn’t get peace of mind. When I think about all the things I could do for my health with that $3,000 … Our healthcare system needs to be transparent about the cost of the services prior to receiving services.”

The ideology that health care is a consumer good follows that making patients bear a higher share of medical costs will ultimately bring those costs down. This presumes that a “rational” health care consumer exists and will shop for coverage in the same way we shop for toothpaste or avocados.

In reality, no one does this. The need for health care coverage is often pinned to anxiety, illness, worry, in-the-moment reaction, and so on. As much as the GOP wants to reduce it to an a la carte menu of goods and services, people living in a society are largely dependent on the health and wellbeing of one another. Put another way, if you’re a thirty-something white bro with the resources to eat organic and do CrossFit, you might not need insurance coverage for awhile, but you’re still living in — and beholden to — a system that ensures people who need care, from penicillin to contraceptives to cancer screenings, receive it.

Terralyn, a registered nurse who works in a small emergency room in Millinocket, says in the same report: “I care for patients who often arrive to our facility sicker than they should be. They are from working families afraid to seek care sooner due to concerns about medical bills, or elderly patients already struggling to pay. Regular physician office care treatment would have made ER services unnecessary. These people, however, are fearful of losing their savings, or their homes after a major illness. I have seen patients leave our ER against medical advice and die within a day or two. Their financial situation and lack of affordable health insurance was the deciding factor in their choice. Our healthcare system is broken, and even when you pay for health insurance there is no guarantee that your care will be covered. There needs to be a fair system for everyone.”

A HIDDEN SIDE-EFFECT

There’s also evidence that those who with a precarious relationship to coverage are made sicker by that relationship. Viewed in this light, cost of care can be seen as a “negative side-effect” of an ineffective health care system. Zack Buck, Associate Professor at the University of Tennessee College of Law, calls this an example “financial toxicity,” or the idea that “individuals experiencing financial distress as a result of the cost of their care experience higher rates of mortality than those who do not.” Essentially, this means that long-term health care-related financial debt is itself deleterious to your health.

HOW IT'S GONNA GO DOWN

Though the AHCA leaves roughly four-fifths of the ACA intact, it cannot be overstated how difficult average people will have it under the proposed changes, particularly the poor and elderly. There’s a lot of details we can’t cover here, but early reports by the Congressional Budget Office estimate that roughly 24 million people will lose coverage. Besides the roughly $900 billion decrease in Medicaid coverage, essentially a tax cut for insurance companies and the already-wealthy, the plan penalizes those who go more than 63 days without insurance, further disincentivizing them from obtaining health care when they’re able to.

In Maine, this will have a pronounced effect on the opioid crisis. Quoted in a recent article in Mother Jones, Richard Frank, Professor of Health Economics at Harvard University, estimates that roughly three million Americans with addiction disorders would lose some or all of their coverage, according to a recent report in Mother Jones as part of the shifting to states’ ability to determine “essential benefits.” Under the Affordable Care Act, insurers were prevented from denying coverage or charging people higher rates based on pre-existing conditions. The ACHA, of course, guts those provisions. Health experts believe that premiums, which were the major talking point behind the push to dismantle Obamaare, would increase dramatically.

Instead of the individual mandate in the ACA, the AHCA introduces continuous enrollment penalties. Insurance companies would now be able to charge new enrollees a 30 percent mark-up on their premiums the next year.

Under the ACA, the elderly could only be charged three times what young people were charged. Now they can be charged five times. Instead of subsidies based on income, recipients of health care under the AHCA would receive subsidies based on age: up to two thousand to four thousand, which is often insufficient.

Additionally, the Affordable Care Act had community ratings, which meant that premiums were the same for a region. Insurers could adjust cost for age but nothing else. Under the AHCA’s McArthur Amendment, states have the option to use waivers to get out of a community rating for people who don’t have continuous coverage. When you re-enroll, your state has a waiver to ask people questions to determine your premium.

In the cases where insurers can’t literally deny coverage, they would be able to theoretically offer an exorbitant, astronomical premium. This would apply for a host of possible preconditions, like if someone had a cancer scare, was assaulted or raped, and so on.

Writes Matthew Friedler, a fellow for the Center for Health Policy (Schaeffer Initiative) in a report published by the Brookings Institute, “a single state’s decision to weaken or eliminate its essential health benefit standards could weaken or effectively eliminate the ACA’s guarantee of protection against catastrophic costs for people with coverage through large employer plans in every state. The two affected protections are the ACA’s ban on annual and lifetime limits, as well as the ACA’s requirement that insurance plans cap enrollees’ annual out-of-pocket spending. Both of these provisions aim to ensure that seriously ill people can access needed health care services while continuing to meet their other financial needs.”

AND THEN THERE'S MAINECARE

At the local level, the AHCA has embolded conservatives to put up even more barriers to adequate care. The Department of Health and Human Services has proposed a series of rule changes, currently under review. Under those proposals, the new rules would require “able-bodied adults” to meet “community engagement or work requirements” to be eligible for MaineCare, as well as pay monthly premiums as an individual contribution toward health care costs. For a program designed as a social safety net, the fabric is thin. “Members who fail to make timely premium payments will be disenrolled from MaineCare.” It would also institute a number of “asset tests” to determine eligibility, cease to provide retroactive coverage, and eliminate the option for hospitals to make presumptive eligibility determinations. (This means more of those determinations would be made by Mary Mayhew and the DHHS, which has been far more concerned with saving taxpayer money than ensuring Mainers get adequate coverage.)

A public hearing opposing these rule changes will be held at the Cross Insurance Arena on Wednesday, May 17 at 9 am, and at the Augusta Civic Center on Thursday, May 18 at 9 am.

The AHCA is in limbo while the Senate considers it, and many expect its provisions to change mightily. In the meantime, Americans have an opportunity to closely examine the conflicting philosophies behind the health care debate — is it a right or is it a commodity — while the stakes have never been higher.
http://portlandphoenix.me/news/cover-story/item/6699-trump-don-t-care-how-the-ahca-should-reinvigorate-the-push-for-universal-health-care

Letter to the editor: Single-payer health plan already works for many

by Chuck Radis, D.O.

Dr. Ronald Housley’s May 6 letter to the Portland Press Herald, warning that the movement to create a single-payer system is a violation of our “strong, individual rights-protecting nation,” is a stretch.

Democrats and Republicans supported the creation of a Veterans Affairs single-payer system of health care for our veterans. Medicare was created as a safety net for our elders. If one adds in Medicaid, nearly 60 percent of our population is already covered by one form or another of government health insurance.

Medicare, in particular, has functioned well with cost controls and low administrative expenses. As traditional health insurance and the cost of medications are priced out of an average person’s ability to pay, a single-payer system is the only answer. If a single-payer system is good enough for our veterans, our elders and our poor, it is good enough for the average Jane and Joe.

Charles Radis, D.O.

Peaks Island

http://www.pressherald.com/2017/05/15/letter-to-the-editor-single-payer-health-plan-already-works-for-many/

What’s causing Maine’s community nursing crisis

by Jackie Farwell- Bangor Daily News - May 18, 2017

PORTLAND, Maine — Courtney Wilson and Josselyn Agura will graduate from nursing school Saturday, and already they’re worried about burning out from their chosen profession.

Nursing often means caring for patients who are sicker than in years past, with more complex health problems, in a shorter amount of time. Then there are the long hours on their feet and physical challenges of lifting and tending to patients.

But if Maine is to employ enough nurses to care for its aging population in the coming decades, it needs people like Wilson and Agura. Without action, the state will face a critical shortage of nurses by 2025, according to recent estimates.

Not only burnout threatens their ranks. Maine nurses are aging right along with the patients they treat — a coming wave of patients older than 65 will boost demand for nurses just as many are nearing retirement. In 2015, about a third of all registered nurses in Maine were age 55 or older, and younger workers who make up the biggest potential pool of new registered nurses are projected to drop by nearly 5 percent. Many nursing instructors, too, are approaching retirement age.

“What draws me to the profession and what I want to keep continuing with is developing a relationship that’s trusting and really getting to see the whole picture of each patient, as opposed to just what disease they’re being treated for,” Agura said.

That can prove a tall order in a hospital setting. So Agura and Wilson are taking a different tack in their nursing education, by getting clinical experience at Greater Portland Health’s community health centers during their final year of education at the University of New England. Rather than the pressure cooker environment of the ER or ICU, they’re focused on “community nursing” — primary care, preventing chronic diseases and ensuring patients stay or get healthy outside the walls of a hospital.

On a recent day at the Park Avenue clinic, Wilson stood in a narrow exam room, inflating a blood pressure cuff as patient Randy Cramm waited for the results.

“140 over 106,” Wilson said. That’s high. Cramm seemed unsurprised.

Then nurse practitioner Gretchen Speed stepped in, showing Wilson how to evaluate the swelling in Cramm’s legs. Speed suggested to Cramm that he get back on his medications and ordered some basic lab work.

This kind of nursing may not be as riveting as tending to a trauma patient in the emergency room, but Wilson values the ability to help people prevent or manage illness. For those who can’t avoid a hospital stay, community nurses are there to check in after patients are discharged, she said.

“You have to have people who can go out there and help people with their new medication regimens or diabetes education,” she said. “A little half-hour snippet about that when they’re being discharged, I mean they’re already stressed out. The hospital’s a stressful environment. We need more community nurses.”

Under the program, called Upstream and funded by a federal grant, Wilson and Agura spent about four weeks in Greater Portland Health’s clinics, which serve vulnerable populations including immigrants, refugees and the homeless. The students learn to scrounge up medical records and ask patients about their health histories, as well as help administer regular checkups and vaccinations.

They also learn how to communicate with patients and initiate sometimes difficult conversations. But seeing patients repeatedly over time allows for the building of a relationship that makes those conversations easier and ultimately improves their health, the women said.

After graduation, Wilson will head north to Bangor for a residency program at Eastern Maine Medical Center. Agura is still deciding where she’ll land next. Both recognize their transition to the working world may not be smooth, as they continue to learn on the job from seasoned nurses with less time and sometimes willingness to teach them.

“There’s a big learning curve,” Wilson said. “Some nurses are just there to work, and us being new students, we need that education and we want to be able to ask questions. The other staff may not as willing to teach us.”

“We know it’s hard to take on a new graduate and teach them,” Agura added.

Their coursework at UNE has included discussions about how to ease the transition, such as by learning how to identify stress triggers and either avoid or cope with them.

“If that’s five minutes alone in a stairwell, then that’s what it is,” Agura said.

Despite the challenges of the profession, both women see a future for themselves in community nursing.

“It’s such a huge part of nursing,” Agura said. “What’s happening when people leave the hospital?”

http://bangordailynews.com/2017/05/18/the-point/whats-causing-maines-community-nursing-crisis/print/

DHHS has blocked lawmakers from public data on nursing program

by Matthew Stone - Bangor Daily News - May 18, 2017

As the Maine Legislature get closer to deciding on what to do with a diminished health program that helps Maine’s infants and people with infectious diseases, the state agency charged with protecting Maine’s health has repeatedly failed to give lawmakers, and others, public information that could inform their course of action.

Last month, a legislative aide for state Sen. Brownie Carson emailed a Maine Center for Disease Control and Prevention staff member with a straightforward request: He sought copies of two public reports prepared by a national health organization that accredited Maine’s public health nursing program in 2009 and again in 2012.

The CDC staff member, who works for Maine’s public health nursing program, responded the same afternoon, April 19: “I forwarded your document request to my administrative superiors (Deb Wigand, Maryanne Harakall, Stacy Thibodeau) this morning. I have not been authorized to respond to your request.”

Carson, a Democrat from Harpswell, still hasn’t received a copy of either report.

The experience of requesting public information and not receiving it has become the norm in recent months for Carson and others who have sought details and basic documents about public health nursing from the Maine CDC, an office within the Maine Department of Health and Human Services.

Carson is sponsoring legislation this year that would restore Maine’s corps of state-employed nurses whose responsibilities include preventing the spread of infectious diseases such as tuberculosis, responding to disease outbreaks and public health emergencies, and improving the health of moms and their newborns by visiting them in their homes.

The legislation, LD 1108, follows several years in which the LePage administration has left nurse positions vacant even as the Legislature has appropriated funds to fill them. When Gov. Paul LePage took office in 2011, Maine employed about 50 public health nurses spread across the state. Earlier this year, according to the Legislature’s nonpartisan Office of Fiscal and Program Review, only 23 of the program’s 48 funded positions — fewer than half — were filled.

A Bangor Daily News’ Maine Focus article last summer, citing several former public health nursing employees, described DHHS managers’ efforts to largely hobble program operations — including by instituting a policy of not allowing the program’s former manager to email employees without approval from staff in Commissioner Mary Mayhew’s office, and eliminating office space and desks for public health nurses.

DHHS officials rarely spoke publicly about their plans for the public health nursing program as they let the program shrink by more than half and as health care providers throughout the state started noticing limited availability of nurses to follow up with patients infected with latent tuberculosis (which becomes active TB in 5 to 10 percent of those infected) and to provide home visits to drug-affected newborns.

DHHS, whose budget represents more than a third of state spending, didn’t respond to the BDN’s requests for public health nursing information last summer.

Later in 2016, DHHS terminated the staff member who coordinated the release of public information within the CDC, alleging she breached agency protocol for allowing a public document requested by the BDN to be sent to the newspaper.

And in preparing his nursing legislation this year, Carson has found it nearly impossible to get specific details about public health nursing operations from the CDC, the state office in which the nursing program is housed.

“I am in a position now of being responsible not only to the voters of my district, but the people of the state of Maine, for knowing whether the Maine Center for Disease Control is wisely managing disease prevention for the people of Maine,” said Carson, who is serving his first term in the Maine Senate, “and I can’t tell because they won’t give me stuff that is public.”

In February, Carson sent a list of 45 questions seeking specific details about public health nursing, including the number of nurses currently employed, the process used by the CDC to decide whether to assign a nurse after receiving a patient referral from a hospital or doctor’s office, data on the number of referrals accepted and rejected for public health nursing services, and information the CDC has used to inform its decision to cut public health nurse staffing.

Sheryl Peavey, the Maine CDC’s chief operating officer, responded to Carson nearly a month later with a letter that contained none of the details Carson sought but described in broad terms “a comprehensive overhaul” of public health nursing.

“Your letter referenced several topics including: accreditation, the vision for public health nursing, staffing, productivity and other data metrics, and emergency preparedness,” read Peavey’s response. “These are the areas of focus the Department has worked to address and I assure you were are moving in the right direction.”

“[N]early two years ago this administration made the decision to prioritize public health nursing services to focus on our most vulnerable infants, substance affected newborns, infectious diseases and refugee health,” Peavey wrote.

A DHHS spokeswoman didn’t respond to questions from the BDN this week seeking much of the same information sought by Carson.

In March, the Maine CDC deleted its public health nursing web page, which housed a handful of old annual reports for the program, a program brochure and contact information for public health nurses.

The reluctance to provide public information about a public program marks a departure from how the public health nursing program operated before the LePage administration, said Jan Morissette, who served as public health nursing director from 2005 to 2011.

“My recollection was, when there was a request for information, it was, ‘Drop what you were doing and provide it,’ and especially when it came from the Legislature,” she said. “You were expected to provide the information, whatever they were asking for. Usually, it was data, and we had data. We had the information.”

“We’re providing a public service,” Morrissette said. “We’re a public entity. We’re not a private entity, so when information is asked for, you respond.”

Since Carson introduced his legislation earlier this year, Peavey and Dr. Christopher Pezzullo, the state health officer at DHHS, have spoken on a few occasions before the Legislature’s Health and Human Services Committee about public health nursing. In March, Pezzullo described public health nursing as “really broken” and said, “We have been taking [it] apart to put it back together.”

On April 26, during a committee work session on Carson’s bill, Peavey spoke of boosting the number of patient visits per day to a national standard that she said Maine’s public health nurses weren’t meeting and wanting to use program data to inform hiring decisions. She and Pezzullo have discussed shifting more public health and emergency preparedness responsibilities to private organizations, instead of relying on state-employed nurses.

Meanwhile, a number of health care providers who testified in support of the legislation earlier in April described a state program that could no longer meet its mission. A number of medical providers said they could no longer refer patients — including, in one instance mentioned by a Portland doctor, a substance-using mother of a newborn — to public health nurses because no nurses were available. If they referred patients, they had no idea whether they ultimately received a nurse’s services.

Decades of research have shown that sending a nurse into a new parent’s home, both prenatally and postpartum, is associated with a range of positive outcomes, from reduced likelihood of preterm births, infant deaths and child abuse, to improved language development and school readiness for the child and improved health for the mother.

Peavey provided no data on patient referrals in response to Carson’s request for the information. Carson sought the accreditation reports from 2009 and 2012 in hopes of reading the assessment of Maine’s public health nursing program by an independent third party with public health credentials.

“Sheryl Peavey and the current management of CDC, with all their criticism, have never produced one shred of data, not one piece of evidence to back up their claim that public health nurses are inefficient, that they’re not somehow doing their jobs,” Carson said.

http://bangordailynews.com/2017/05/18/mainefocus/dhhs-has-blocked-lawmakers-from-public-data-on-nursing-program/

Trumpcare Is Already Hurting Trump Country

Editorial - NYT - May 19, 2017

The mere threat that Obamacare will be dismantled or radically changed — either by Congress or by President Trump himself — has persuaded several big insurance companies to stop selling policies or significantly raise premiums. The practical effect is that some lower-income and middle-class families may have no good options for insurance and will have to spend more on health care.

There’s no new Affordable Care Act yet; the House passed a very bad bill, but the Senate has yet to act. Still, in places like Iowa, Nebraska and Tennessee, companies such as Aetna and Wellmark are so spooked by the uncertainty that they are considering abandoning the market. Other insurers are asking state regulators for permission to raise premiums by as much as 53 percent. This should trouble not just the 12.2 million people who have bought insurance on federal and state exchanges, but also policy makers, since Washington may have to spend more on subsidies if premiums go up.

Mr. Trump, not surprisingly, describes things differently. He claims that uncertainty in the insurance industry is evidence that Obamacare is collapsing and needs repeal, not that he and his allies have created the uncertainty. This is disingenuous nonsense. On the whole, insurance markets in much of the country are on stable footing and will remain so if Congress doesn’t do things to undermine Obamacare, according to a March report by the Congressional Budget Office. And insurers selling policies under the A.C.A. actually did better financially in 2016 than in the year before, according to an April report by Standard & Poor’s.

So, why are insurers fearful and threatening to quit Obamacare or jack up premiums? There are a few big reasons. First, the House passed a bill this month that would take insurance away from at least 24 million people by slashing spending on Medicaid and cutting the subsidies the government uses to help people buy insurance. Second, Mr. Trump has threatened to stop making about $7 billion in payments to insurance companies to help lower the cost of co-pays, deductibles and other out-of-pocket costs for lower-income and middle-class families. If the administration carries out that threat, insurers would raise premiums by about 19 percent, according to the Kaiser Family Foundation. Third, insurers are worried that the Trump administration will stop enforcing the A.C.A. provision that requires people to buy health insurance or pay a penalty. That could hurt them by reducing the number of younger and healthier people who sign up.

It can be hard to feel sympathy for bureaucratic and faceless insurance companies. After all, they often deny people access to medical procedures and drugs. But Mr. Trump and his Republicans in Congress have left them with little choice. They can stay with the exchanges and risk large losses if elected leaders blow them up, or they can pull out now, or raise rates, in parts of the country where it is harder to make money.

What’s bizarre about the Republican strategy is that it is likely to cause the most damage where many of Mr. Trump’s supporters live. Rural and suburban areas are more likely to lose insurers and see big premium increases if Obamacare goes down, because companies have less incentive to stay in markets where there are fewer potential customers and where it is harder to put together networks of hospitals and doctors.

Republicans might hope that blame for any future problems with Obamacare will fall on former President Barack Obama and the Democrats. A Kaiser poll, however, shows that 61 percent of Americans already know where the fault should lie: with the Republicans who are now in charge. Another poll from Gallup found that Obamacare became more popular than ever after Republicans began trying to destroy it. Senate Republicans ought to keep these polls in mind as they come up with their version of Trumpcare.

https://www.nytimes.com/2017/05/19/opinion/trumpcare-health-care-bill.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0

Executive Summary - Milliman Health Care Cost Report

In 2017, the cost of healthcare for a typical American family of four covered by an average employer- sponsored preferred provider organization (PPO) plan is $26,944 (see Figure 1), according to the Milliman Medical Index (MMI).1

KEY FINDINGS OF THE 2017 MMI INCLUDE:

The MMI’s annual rate of increase is 4.3%. This is the lowest rate since we began tracking the MMI in 2001. Yet the total dollar amount is still bracingly high. Of the $26,944 spent by the MMI’s family of four, $11,685 is paid by the employee, through a combination of $7,151 in payroll deductions for premium, and $4,534 in out-of-pocket costs incurred at time of care.
Prescription drug trends are lower, but still high. For the first time since 2013 and 2014, the family of four’s prescription drug trends have decreased in two consecutive years. Still, the 2017 prescription drug cost increase of 8% is more than double the medical increase of 3.6%.2
Employees pay a bigger piece of the healthcare cost pie. Through their payroll deductions and through out-of-pocket expenses incurred when care is received, employees now pay for about 43% of expenses and employers pay the other 57%. The difference between these two shares has gradually narrowed since 2001, when employees contributed 39% and employers contributed 61%. High growth in per-employee healthcare expenditures have pushed employers to limit their contribution increases to amounts below the rate of healthcare inflation.

Some stakeholders have held out hope that federal healthcare reform efforts would help control healthcare cost growth. So far, those efforts have had relatively little direct impact on the MMI, because the MMI represents healthcare costs in an employer-sponsored health plan, while the primary focus of healthcare reform has been on the individual insurance marketplace and Medicaid. The employer market tends to be one of the most stable markets for health insurance companies, and one of the most financially important for healthcare providers such as hospitals and physicians. As discussed in a later section of this report, providers receive higher payment for patients in employer-sponsored plans, for the exact same basket of services, than they do for other insured patients. Employers and employees have been subsidizing other markets for many years.

http://us.milliman.com/uploadedFiles/insight/Periodicals/mmi/2017-milliman-medical-index.pdf

Comment by Don McCanne - PNHP - May 19. 2017

Much attention is paid to premiums and deductibles of insurance plans in the United States. A much more important number is what we are actually paying for health care. The Milliman Medical Index (MMI) represents the total average cost of actual health care for a hypothetical family of four with an employer-sponsored PPO. For 2017, that cost is $26,944 ($27,000 rounded - the number to remember).

Although not comparing identical population sectors, nevertheless the burden of health care costs can be approximated by contrasting the MMI with the median household income, which is $56,516 for 2015 - thus health care costs for a typical family of four are close to one-half of the median household income.

Of interest is the fact that the MMI does not include plan administrative expenses nor insurance company profits - just health care costs (the portion of the premium nominally paid by the employer, the portion of the premium paid by the employee through payroll deductions, and the out-of-pocket medical expenses paid by the employee). Also the percentage that families nominally pay has been increasing - now 43 percent - though they also actually pay for the employers’ contributions as well through forgone wage increases. Also, though the increase in the MMI from last year was only 4.3 percent, in dollars it is an $1118 increase - an amount that would add an additional significant burden to most household budgets.

Although current negotiations for replacement health care legislation are taking place behind closed doors, numerous sources have indicated that the most important goal stated by the negotiators is to reduce the premiums paid for insurance. Very little attention is being paid to actual health care costs (except for rhetoric about markets and competition, which has very little application to health care spending).

Why this emphasis on premiums? Frankly, when people need to buy health insurance, they want to know what it is going to cost them. For the 80 percent of people who remain relatively healthy, that means that they want to know what the premium, or their share of the premium, will be. Studies have shown that the healthy will accept higher deductibles and narrower networks in order to get lower premiums.

So how do you keep premiums low? You shift the costs from the insurer to the patient, and there are several methods of doing that, all of which are currently under consideration. As mentioned, the most obvious is to increase the deductibles, and that is why we are now seeing deductibles in the thousands of dollars. Other cost sharing such as copayments and coinsurance also shift costs to the patients. The negotiators are also considering reducing the essential health benefits that the plans are required to cover so that individuals can “buy only the insurance that they need.” Not only does this defeat the purpose of pooling risk, but nobody can predict their own health care requirements for the following year, so benefits omitted again would have to be covered out-of-pocket by the patient. Also insurers can reduce spending by establishing narrow networks and contracting with the cheapest providers, but sometimes care must be obtained out-of-network, and, again, that shifts costs to the patients. Tiering of benefits is used to place more expensive benefits in a higher tier level for which the patient must bear a much greater out-of-pocket cost (not to mention that it discourages individuals who will need the expensive services or products from purchasing those plans, saving the insurer money, thus lowering premiums). In essence, you lower the price of insurance premiums by destroying the insurance function of sharing risk equitably. Is this really what Americans want?

Making health care less affordable for patients has two adverse consequences: it creates financial hardships for patients who cannot avoid expensive health care, and it causes patients to forgo beneficial health care services that they really should have, thus impairing health outcomes.

A well designed single payer national health program avoids both of these consequences while using policies that are even more effective in slowing the increases in actual health care spending (substantial reduction in administrative waste, global budgeting of national health expenditures, separate, more effective budgeting of capital improvements and system capacity, negotiated and administered budgets for hospitals and other institutions, and negotiated rates for health care professionals, pharmaceuticals, and medical supplies).

When they talk about premiums and say it’s about “access” (but remain silent on paying for health care), challenge them. It’s about health care reform that works for all of us - an improved Medicare for all

- Don McCanne - Senior Healt Policy Fellow - Physicians for a National Health Program

Health Care Reform Articles

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Friday, May 19, 2017

Health Care Reform Articles - May 19, 2017