Editor's Note:
I've been traveling for the past couple of weeks, and a lot has happened in the Health Care Reform Articles world, so the post today is much longer than it should be. That said, a lot of good articles have been written - so just scan the headlines, pick and choose, and enjoy and learn.
- SPC
Forget Taxes, Warren Buffett Says. The Real Problem Is Health Care.
by Andrew Ross Sorkin - NYT - May 8, 2017
OMAHA — “The tax system is not crippling our business around the world.”
That was Warren E. Buffett, the chairman and chief executive of Berkshire Hathaway, over the weekend at the company’s annual meeting, known as “Woodstock for capitalists.”
Mr. Buffett, in a remarkably blunt and pointed remark, implicitly rebuked his fellow chief executives, who have been lobbying the Trump administration and Washington lawmakers to lower corporate taxes.
In truth, Mr. Buffett said, a specter much more sinister than corporate taxes is looming over American businesses: health care costs. And chief executives who have been maniacally focused on seeking relief from their tax bills would be smart to shift their attention to these costs, which are swelling and swallowing their profits.
It was clarifying to hear Mr. Buffett frame things this way. The need for corporate tax relief has become the lodestar of the corner office, with C.E.O.s rhapsodizing over President Trump’s plan to try to stimulate growth by cutting tax rates for businesses.
But as Mr. Buffett pointed out, these chief executives are missing the bigger issue — the one that should be their Holy Grail. As a percentage of our gross domestic product, the cost of maintaining our American health care system — hospitals, H.M.O.s, doctor visits, prescription drugs, medical devices, insurance companies, Medicare, Medicaid — is rising at an alarming rate. And Corporate America pays a big (and growing) chunk of the bill.
We’re not talking about the cost of health insurance, which is a fraction of the overall cost.
Today’s corporate tax rates, Mr. Buffett seemed to suggest, are a distraction, not a true impediment to growth.
“If you go back to 1960 or thereabouts, corporate taxes were about 4 percent of G.D.P.,” Mr. Buffett said. “I mean, they bounced around some. And now, they’re about 2 percent of G.D.P.”
By contrast, he said, while tax rates have fallen as a share of gross domestic product, health care costs have ballooned. About 50 years ago, he said, “health care was 5 percent of G.D.P., and now it’s about 17 percent.”
His is one of the most cogent arguments for renewing attention on the underlying costs of our health care system — an issue far beyond the debate around the Affordable Care Act and what it is going to look like if it is repealed and replaced.
Mr. Buffett said our global competitiveness had fallen largely because our businesses were paying far more for health care — a tax by another name — than those in other countries.
Corporate Tax Rates Are Falling Worldwide
The United States has the highest corporate tax rate among the world’s industrialized nations, several of which have recently cut their rates.
At his annual shareholders’ conference, which drew tens of thousands of people to Omaha, he gave a virtual seminar on the economics of health care that chief executives and lawmakers would be helped by hearing. He demonstrated in stark terms that the constant refrain from the business community about taxes should probably be redirected toward trying to bend the cost curve of health care.
“When American business talks about strangling our competitiveness, or that sort of thing, they’re talking about something that as a percentage of G.D.P. has gone down,” Mr. Buffett said. “While medical costs, which are borne to a great extent by business,” have swelled.
He is right: In 1960, corporate taxes in the United States were about 4 percent of G.D.P., which is probably the best way to measure the burden on businesses. Then the percentage fell steadily, reaching its bottom in 1983 before rising slightly over the last several decades. Today, it is 1.9 percent.
In the meantime, health care costs as a percent of G.D.P. have skyrocketed, significantly diverging with those of other industrial countries. Our health care costs stand at 17.1 percent of G.D.P., up from 13.1 percent in 1995.
The figure in Germany is only 11.3 percent, up from 9.4 percent during the same period. Japan’s is 10.2 percent, up from 6.6 percent. Britain’s health care costs are 9.1 percent of G.D.P., up from 6.7 percent in 1995. And China’s is only at 5.5 percent, up from 3.5 percent.
That puts the United States at a material disadvantage far beyond the tax differential. And it harms American companies in particular, since they bear such a big share of those costs. Corporations spend $12,591 on average for coverage of a family of four, up 54 percent since 2005, according to a study by the Kaiser Family Foundation.
“Medical costs are the tapeworm of American economic competitiveness,” Mr. Buffett said, using a metaphor he has employed in the past to describe the insidious and parasitic costs of our health care system.
Mr. Buffett is a Democrat, but his business partner, Charles T. Munger, is a Republican — and a rare one who has advocated a single-payer health care system. Under his plan, which Mr. Buffett agrees with, the United States would enact a sort of universal type of coverage for all citizens — perhaps along the lines of the Medicaid system — with an opt-out provision that would allow the wealthy to still get concierge medicine.
Our bloated health care system, Mr. Buffett asserted, is the true barrier to America’s world competitiveness as well as “the single biggest variable where we keep getting more and more out of whack with the rest of the world.”
But people don’t talk about it enough. “It’s very tough for political parties to attack it, but it’s basically a political subject,” Mr. Buffett said in reply to a question I had posed. (I was one of three journalists and three analysts who, along with shareholders, peppered Mr. Buffett and Mr. Munger with questions during the meeting.)
That’s not to say corporate tax reform won’t help, but it is tiny relative to fixing health care.
Indeed, Mr. Buffett said, even if Washington put in place a tax credit for capital investment, he did not think that BNSF — the railroad company he owns, which spends billions on fixing rail tracks — would do its job faster or better because of the potential tax credit.
“I can’t recall sending anything out to our managers saying, ‘Let’s do this because the tax law is going to change,’” Mr. Buffett said.
Mr. Munger, the vice chairman of Berkshire Hathaway, added: “We’re not going to change anything at the railroad just for some little tax jiggle.”
Neither man, however, is expecting the bigger tax — health care — to be fixed anytime soon.
“On this issue, both parties hate each other so much that neither one can think rationally, and I don’t think that helps, either,” Mr. Munger said.
Jimmy Kimmel’s Emotional Monologue: His New Son’s Heart Condition
by Giovanni Russonello - NYT -
‘We Had Atheists Praying for Us’
“Jimmy Kimmel Live!” was off the air last week. What fans didn’t know was why.
Mr. Kimmel revealed on Monday’s show that his wife had given birth to a son, who, within hours of delivery, was found to have severe heart defects. He needed emergency surgery, leading to a torturous series of events — then, ultimately, a happy ending.
Mr. Kimmel shared the experience in an emotional opening monologue. “We had atheists praying for us, O.K.?” he said. “And I hate to say it — even that son of a [expletive] Matt Damon sent flowers.”
Mr. Kimmel eventually turned toward politics, decrying the idea that anyone should be denied access to health insurance and to coverage for pre-existing medical conditions, about which President Trump has been unclear. Many people are concerned about the loss of such coverage, and Mr. Kimmel captured their fears:
“We were brought up to believe that we live in the greatest country in the world, but until a few years ago, millions and millions of us had no access to health insurance at all. Before 2014, if you were born with congenital heart disease like my son was, there was a good chance you’d never be able to get health insurance because you had a pre-existing condition. You were born with a pre-existing condition. And if your parents didn’t have medical insurance, you might not live long enough to even get denied because of a pre-existing condition.If your baby is going to die, and it doesn’t have to, it shouldn’t matter how much money you make. I think that’s something that, whether you’re a Republican or a Democrat or something else, we all agree on that, right?”
“This isn’t football,” Mr. Kimmel added. “There are no teams. We are the team, it’s the United States. Don’t let their partisan squabbles divide us on something every decent person wants.”
Patients Who Rely on Obamacare Protections Are Worried
by Abby Goodnough and Reed Abelson - May 2, 2017
Fran Cannon Slayton, a children’s book author with brain cancer, has summoned a hopeful energy since her diagnosis last year. But she is near despair about the resurfaced Republican plan to repeal and replace the Affordable Care Act, which the White House and Republicans are pushing for a vote as soon as this week.
“I don’t think people really understand how serious this is,” said Ms. Slayton, 50, of Charlottesville, Va.
Her chief concern is the amendment to the Republican bill that would allow states to opt out of several requirements, including what some say is the crux of the current health law: the ban on insurance companies charging higher premiums to people, like Ms. Slayton, with pre-existing medical conditions.
The complex amendment to the bill has stunned Ms. Slayton and other Americans with cancer, heart disease, diabetes and other illnesses who rely on the law’s protections, not least because President Trump and Republican leaders in Congress have consistently promised to make sure sick people will not face the same discrimination they did in the past.
With most polls finding that both Republicans and Democrats favor protecting coverage for people, the proposed changes to such protections have become the flash point that could derail yet another attempt by the Trump administration and Republican lawmakers to vanquish President Barack Obama’s signature domestic achievement.
The change was negotiated as part of an amendment to attract the support of conservative House members who opposed an earlier Republican health bill because it retained too much federal insurance regulation. But in gaining their support, it has repelled a number of moderates and sent Mr. Trump flailing as he insisted in a series of interviews that the bill would still protect people with pre-existing conditions.
Most major patient advocacy groups have come out against it, and on his late-night talk show, the comedian Jimmy Kimmel made a tearful case for retaining the protections, recounting his infant son’s recent open-heart surgery and noting that before the Affordable Care Act, “If you were born with congenital heart disease, like my son was, there was a good chance you’d never be able to get health insurance because you had a pre-existing condition.”
While insurers would not be able to deny coverage altogether under the Republican bill, the revised legislation allows states to seek a waiver from the existing rule that requires them to charge the same price to everyone who is the same age in the same region, regardless of how healthy they are. People who went uninsured for 63 days or more in the previous year could be charged based on their health status and see their premiums increase sharply. Healthier people might see their prices drop.
To get a waiver, a state would need some other way to cover people with potentially serious medical conditions, ranging from a reinsurance program that helps pay for customers needing very expensive care to a high-risk pool. Such pools existed in 35 states before the Affordable Care Act, but they served only a small fraction of the people who needed coverage and most were underfunded, according to an analysis by the Kaiser Family Foundation.
States could also seek to opt out of a requirement that all insurance plans cover 10 “essential health benefits,” including prescription drugs, maternity care, mental health care and addiction treatment. By allowing insurers to cover less, the change could bring down premium prices, but also leave people without access to services that hundreds of thousands have received under the Affordable Care Act, including treatment for opioid addiction.
It is hard to predict how broadly the waivers would affect the millions of people with pre-existing conditions. Many people do have lapses in coverage between jobs or at other times, and they could be priced out of any program a state set up. Healthy people would most likely gravitate to plans that offered minimal coverage, which could greatly increase costs for those who need more comprehensive care.
Governors have so far remained quiet about whether they would seek waivers, but for many people who rely on the individual insurance market, these provisions hark back to a time when insurers scrutinized the health of all individuals before they could sign up. In some states, policies were available with riders that excluded a given condition. Insurers could also just charge those with medical conditions much higher prices.
Larisa Thomason, of New Market, Ala., remembers the day 15 years ago when her husband got a letter from Humana informing him that his policy would not cover any cancer care because a preventive colonoscopy had turned up several benign polyps. Likewise, an insurer in Wisconsin refused to cover any treatment related to Alice Thompson’s reproductive system, starting in 2003, because a doctor had written in her medical record that she should have a hysterectomy to eliminate painful menstrual periods.
“Had I gotten ovarian or uterine cancer, I wouldn’t have been covered,” said Ms. Thompson, 62, of South Milwaukee. “For 10 years, I was living under this uncertainty of ‘what if.’”
Ms. Thompson, an environmental consultant who is now being treated for vision problems and headaches, added that when she switched to an Affordable Care Act plan in 2014, “I just remember the sense of relief being huge. Now the specter of all this coming back is horrifying. I don’t think I’m being overly paranoid to think, what if I have to move my business to a different state to get coverage?”
Before the Affordable Care Act mandated essential benefits to help make sure people had broad coverage, insurers routinely excluded various medical services. Almost two-thirds of people who bought their own policies did not have maternity benefits, a third did not have coverage for substance abuse services and about a fifth did not have care for mental health issues, according to a federal analysis of coverage before the law.
Ellen Paquette, 48, remembers losing her insurance when she moved back to Pennsylvania in the late 1990s. A freelance artist and musician who lives in Warren, she has never gotten coverage through an employer. Because she had depression, “I had a terrible time finding insurance,” she said, even though she had never been hospitalized and was otherwise in good health.
When Ms. Paquette eventually found a policy, it had a rider that excluded any treatment for mental health.
The prospect of allowing insurers to once again determine which benefits to cover “feels like such a raw kind of discrimination,” she said.
She and her husband, Thomas, 58, are now covered under the federal law. Studying the details of the replacement bill, she said, “I’ve gone through phases where I feel almost panicky.”
In the past, excluding certain conditions from coverage sometimes left people with crushing medical debts. John Gillespie and his wife, Beth, ran their own small auto repair shop. In the late 1990s, the couple, who live in Beaver Falls, Pa., could not find an insurance company willing to cover her epilepsy.
At one point, Ms. Gillespie had to go to the emergency room because she was having seizures, and the doctors worried that she had developed meningitis. She was in the intensive care unit for three days. Her seizures were in fact because of the epilepsy, and the couple faced nearly $20,000 in medical bills. “We ended up making payments on that for several years,” Mr. Gillespie said.
When the couple was finally able to find a plan that covered her disease, the premiums were astronomical — about $2,400 a month for both of them. “It was easily the single largest expense we had,” Mr. Gillespie said. The couple could barely make ends meet, despite his working 60 hours a week and teaching some night classes. They refinanced their house three times.
The couple now pay $1,200 for coverage. They are both 58 and semiretired, with little in the way of savings if they were to face another medical emergency.
Ms. Slayton and her husband, a lawyer, are paying nearly $1,500 a month for a plan that covers their 13-year-old daughter and them. They earn too much to qualify for a subsidy to help with the cost. While more expensive than they would like, the plan covered her surgery last year to remove a brain tumor, and Ms. Slayton, who has been blogging about her experience, is doing well.
In the past, even the state high-risk pools proved an unaffordable solution to many people. Janice Elks, 50, a small-business owner in Omaha, had cervical cancer and suffered from neuropathy when she looked for a policy. “I could not get insurance at all, of any type, for years,” she said. “I would apply over and over.”
Her only option was Nebraska’s high-risk pool. Ms. Elks calculated it would cost her about $15,000 in premiums a year for a policy, while her medical expenses amounted to only a few thousand dollars a year for her seizure medications and some steroid shots. She now pays just $640 a month.
Ms. Elks, who describes herself as a “liberal-leaning independent,” says she is “terrified” over the talk about changing the protections for people like her. She now has tachycardia, which causes her heart to beat faster than normal when under stress, and worries she will eventually need an operation.
“Those kinds of surgeries are expensive,” Ms. Elks said. But, at 50, she is 15 years away from being eligible for Medicare. “Will I live to get Medicare?”
House Passes Measure to Repeal and Replace the Affordable Care Act
by Thomas Kaplan and Robert Pear - NYT - May 4, 2017
WASHINGTON — The House on Thursday narrowly approved legislation to repeal and replace major parts of the Affordable Care Act, as Republicans recovered from their earlier failures and moved a step closer to delivering on their promise to reshape American health care without mandated insurance coverage.
The vote, 217 to 213, held on President Trump’s 105th day in office, is a significant step on what could be a long legislative road. Twenty Republicans bolted from their leadership to vote no. But the win keeps alive the party’s dream of unwinding President Barack Obama’s signature domestic achievement.
The House measure faces profound uncertainty in the Senate, where a handful of Republican senators immediately rejected it, signaling that they would start work on a new version of the bill virtually from scratch.
“To the extent that the House solves problems, we might borrow ideas,” said Senator Lamar Alexander of Tennessee, chairman of the Senate health committee. “We can go to conference with the House, or they can pass our bill.”
Even before the vote, some Republican senators had expressed deep reservations about one of the most important provisions of the House bill, which would roll back the expansion of Medicaid under the Affordable Care Act.
But a softening of the House bill, which could help it get through the Senate, would present new problems. For any repeal measure to become law, the House and the Senate would have to agree on the language, a formidable challenge.
Just before the House vote, the Senate gave final approval on Thursday to a $1.1 trillion spending bill that will finance the government through September, and unlike the health care legislation, the spending bill had broad bipartisan support.
After weeks of negotiations and false starts, Mr. Trump and House Republicans were not about to dwell on the tough road ahead. Passage of the health care bill completed a remarkable act of political resuscitation, six weeks after House leaders failed to muster the votes to pass an earlier version of the measure, a blow to Mr. Trump and Speaker Paul D. Ryan of Wisconsin.
“Yes, premiums will be coming down; yes, deductibles will be coming down, but very importantly, it’s a great plan,” Mr. Trump boasted on Thursday at the kind of White House Rose Garden victory ceremony typically reserved for legislation that is being signed into law, not for a controversial bill that passed just one chamber.
“We want to brag about the plan,” Mr. Trump said, after asking those assembled how he was doing in his debut as a politician. “Hey, I’m president!”
Mr. Trump quickly turned his attention to pressuring the Senate to act, calling the majority leader, Mitch McConnell, Republican of Kentucky, to talk about the way forward for the health plan.
Democrats, who voted unanimously against the bill, vowed to make Republicans pay a political price for pushing such unpopular legislation. As Republicans reached the threshold for passage, Democrats serenaded them with, “Na na na na, na na na na, hey hey hey, goodbye!”
“I have never seen political suicide in my life like I’m seeing today,” Representative Louise M. Slaughter, Democrat of New York, said on the House floor before the vote.
Representative Nancy Pelosi of California, the Democratic leader, warned moderate Republicans who supported the measure: “You have every provision of this bill tattooed on your forehead. You will glow in the dark on this one.”
The House bill would eliminate tax penalties for people who go without health insurance. It would roll back state-by-state expansions of Medicaid, which covered millions of low-income Americans. 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 over $75,000 a year and families making over $150,000.
The nonpartisan Congressional Budget Office said the first version of the bill would trim the federal budget deficit considerably but would also leave 24 million more Americans without health insurance after a decade. Average insurance premiums would be 15 percent to 20 percent higher in 2018 and 2019, but after that, they would be lower than projected under current law.
Mr. Alexander of Tennessee, chairman of the Senate health committee, said Thursday that Republicans had been quietly working for several months on their own bill and would take the House measure under consideration for ideas and components.
Senate Republicans will face some of the same dynamics that stymied the House for weeks. Moderate senators will demand significant concessions, which in turn could alienate three hard-liners: Senators Ted Cruz of Texas, Rand Paul of Kentucky and Mike Lee of Utah.
Republican senators are certain to face pressure from governors worried about constituents on Medicaid losing their coverage. Republican leaders changed the House bill to woo hard-line conservatives, allowing state governments to roll back required coverage for essential services like maternity and emergency care. States could also seek waivers that would let insurers charge higher premiums for some people with pre-existing medical conditions.
“We cannot pull the rug out from under states like Nevada that expanded Medicaid, and we need assurances that people with pre-existing conditions will be protected,” said Senator Dean Heller, Republican of Nevada, who is up for re-election next year.
Senator Bill Cassidy, Republican of Louisiana, said he wanted to ensure that the final repeal bill “fulfills President Trump’s promises to lower premiums, maintain coverage and protect those with pre-existing conditions.”
Democrats are confident that some provisions of the House bill will be found to violate special budget rules that Republicans must follow in order to skirt a Senate filibuster.
“This bill is going nowhere fast in the United States Senate,” the Democratic leader, Chuck Schumer of New York, said. He said his Republican colleagues “should refuse to follow their House colleagues over a cliff, reject repeal, and work with Democrats to improve our health care system in a bipartisan way.”
Republicans have promised for seven years to repeal the Affordable Care Act, under which around 20 million Americans gained health coverage. But they had no consensus on how much of the law should be repealed and had great difficulty devising a comprehensive replacement. Their doubts were reinforced by constituents who said the health law had saved their lives.
Doctors, hospitals and other health care providers joined patient advocacy groups like the American Cancer Society and AARP in opposing the repeal bill.
But House Republicans said that insurance markets in many states were already melting down, and they pointed to Iowa, where the last major insurer under the Affordable Care Act has threatened to pull out.
There may be “nobody to write insurance for people that are in the Obamacare exchanges” in 94 of Iowa’s 99 counties, said the House Republican whip, Steve Scalise of Louisiana.
The House vote on Thursday occurred before the Congressional Budget Office had released a new analysis of the revised bill with its cost and impact. Democrats angrily questioned how Republicans could vote on a bill that would affect millions of people and a large slice of the American economy without knowing the ramifications.
The Republican bill, the American Health Care Act, would make profound changes to Medicaid, the health program for low-income people, ending its status as an open-ended entitlement. States would receive an allotment of federal money for each beneficiary, or, as an alternative, they could take the money in a lump sum as a block grant, with fewer federal requirements. The bill would also repeal taxes imposed by the Affordable Care Act on high-income people, insurers and drug companies, among others. And it would cut off federal funds from Planned Parenthood for one year.
Many defenders of the bill focused less on its details than on what they saw as shortcomings of the Affordable Care Act.
“Obamacare has hijacked the free market and has taken some Americans’ liberties with it,” Representative Doug Collins, Republican of Georgia, said on the floor, adding that the health law “replaced our doctors with bureaucrats, because that’s what socialized medicine does.”
Democrats worked to link House Republicans’ actions to an unpopular president. “The Pied Piper of Trump Tower is playing a tune today, and they must dance,” said Representative Lloyd Doggett, Democrat of Texas.
Representative Jim McGovern, Democrat of Massachusetts, told Republicans: “You are taking away essential health care protections. You are allowing insurance companies to discriminate against people with pre-existing conditions.”
In truth, Republicans argued, with so many problems afflicting the Affordable Care Act, the status quo is unsustainable, regardless of what Congress does. Hours before the vote, Mr. Trump pointed to Aetna’s announcement this week that it would no longer offer policies on Virginia’s Affordable Care Act exchange.
“Death spiral!” the president wrote on Twitter.
Atul Gawande can’t believe how illogical the American Health Care Act is
A bill “no one would ever propose as a sane solution.”
by Atul Gawande - The New Yorker - May 4, 2017
Surgeon, New Yorker writer, and top health care wonk Atul Gawande unleashed a devastating critique of the American Health Care Act as House Republicans are poised to pass it.
The bill would replace Obamacare with a plan that would cut taxes for the wealthy and endanger health care coverage for millions. Gawande expressed baffled rage against the bill in a tweetstorm on Thursday.
Gawande’s assessment isn’t so different from other health care experts, who say that the version of the AHCA that the House is voting on Thursday hasn’t fixed the problems with the version they nearly voted on (but pulled back at the last minute) in March — and has added new problems of its own.
This isn’t a wonk in fact-checking mode. It’s a person who cares about the health care system trying to wrap his head around a huge cognitive dissonance. Many Republicans in Congress claim they want to replace Obamacare with something that will get Americans cheaper, better health insurance. Gawande grimly observes, in his interpretation of the available information from the Congressional Budget Office, that the bill could increase early death for many Americans.
It’s a “travesty.” It’s not a “sane solution.” It is not something about which Gawande feels inclined to be polite.
Here’s what you need to know about preexisting conditions in the GOP health plan
by Glenn Kessler - The Washington Post - May 4, 2017
With House Republicans prepared to take a vote Thursday on yet another version of a plan to overhaul the 2010 Affordable Care Act, attention has been especially focused on whether Obamacare’s popular prohibition against denying coverage based on preexisting medical conditions will remain in place. Republicans, from President Trump to lawmakers pushing for the bill, insist that it remains intact, just in different form. Democrats and opponents of the bill say the guarantee is gone or greatly weakened.
Here’s a tweet by House Speaker Paul D. Ryan (R-Wis.), referring to an amendment added to the bill to attract votes.
The reality is more nuanced and complicated, as is often the case in Washington policy debates. Despite Ryan’s tweet that people with preexisting conditions are protected, there is no guarantee that they will not face higher costs than under current law. The impact of recent tweaks to the proposed legislation is especially unclear because lawmakers are rushing ahead without an assessment by the nonpartisan Congressional Budget Office. So here’s The Fact Checker’s guide to the debate.
What’s the issue?
Before the Affordable Care Act, insurance companies could consider a person’s health status when determining premiums, sometimes making coverage unaffordable or even unavailable if a person was already sick with a problem that required expensive treatment. The ACA prohibited that, in part by requiring everyone to purchase insurance.
But that “individual mandate” was unpopular and Republicans would eliminate that requirement in their proposed American Health Care Act. As a replacement, the AHCA initially included a continuous coverage provision that boosted insurance rates by 30 percent for one year if he or she has a lapse in coverage. (We explored this interaction between the provisions earlier.)
As part of an effort to attract more votes, Republicans have added an amendment, crafted by Rep. Tom McArthur (R-N.J.), that instead allows states to seek individual waivers from the law. One possible waiver would replace the continuous coverage provision so that insurance companies for one year could consider a person’s health status when writing policies in the individual market. Another possible waiver would allow the state to replace a federal essential benefits package with a more narrowly tailored package of benefits, again limited to the individual and small-group markets.
The theory is that removing sicker people from the markets and allowing policies with skimpier options would result in lower overall premiums.
Who would be affected?
If the law passed, a person generally would not be affected unless they lived in a state that sought a waiver. Moreover, they would need to have a lapse in health coverage for longer than 63 days and they would need to have a preexisting condition. Finally, they would have to purchase insurance in the individual market – such as the health exchanges in Obamacare – that currently serves about 18 million Americans.
Someone who got their insurance from an employer – and that’s most Americans under 65 (155 million) – presumably would not be affected, though the CBO did project that under the initial version of the AHCA 7 million fewer people would be covered by employers than under current law by 2026.
Then, for a period of one year, a person who fell into this category would face insurance rates that could be based on their individual condition. But states that seek a waiver are required to operate a risk mitigation program or participate in what is called an invisible risk sharing program. Alaska currently has such a program that helps cover the bills for one of 33 conditions (such as HIV/AIDS or metastatic cancer). The individual with the condition still submits bills to the insurance company, which then turns around and bills the state. But then the insurance company does not consider the cost of this care as part of its calculation for premiums to other individuals in the state.
All told, the AHCA would allot $138 billion over 10 years for a variety of funds that would seek to keep premiums lower or to assist with cost-sharing. Just this week, $8 billion over five years was added to the pot to woo wavering lawmakers, with the idea that the additional funds could be used for so-called high-risk pools. Many states had such pools to help people with preexisting conditions before the ACA. But the proposal does not require a state with a waiver to set up such a pool.
There are many uncertainties about this path. The health insurance market has a lot of churn, so many people may experience a gap in coverage of just a few months. One estimate, by the Commonwealth Fund, indicated that 30 million adults would have had such a gap in 2016, potentially exposing them to a surcharge or being placed in a high-risk pool. On top of that, the Kaiser Family Foundation estimated that 27 percent of the people in the individual market have existing conditions that would have been uninsured before the ACA.
The AHCA eliminates cost sharing and offers a stingier tax credit to defray premium costs, likely resulting in higher overall health costs that may make insurance unaffordable for many people. (The CBO projected that 24 million more people would be without health insurance than under current law by 2026.)
Then, if people get sick, they may suddenly find themselves for a year being priced on their illness if they live in a state that sought a waiver. Depending on the approach taken by a state, some people might find it difficult to keep up their coverage for a full year before they qualify for prices at the community rate.
A big question is whether the funding to cover these folks is adequate. High-risk pools were big money losers and underfunded in the pre-Obamacare days, even though many had restrictions, high premiums and waiting lists. A $5 billion federal pool, established by the ACA as a bridge to the creation of the exchanges in 2013, covered about 100,000 people but was suspended when it ran out of money.
The Center for American Progress, a left-leaning group that opposes the AHCA, produced an analysis that indicated that even with the additional $8 billion, the maximum enrollment the AHCA’s funds would cover is about 700,000 people. If just 5 percent of the people currently in the individual market ended up in high-risk pools – and all states sought a waiver – that would overwhelm the proposed funding.
Avalere Health, a consulting firm, said in an analysis that $23 billion is specifically allocated in the bill for helping people with pre-existing conditions. That would cover about 110,000 people. If states allocated all of the other available funding, that would cover 600,00 people. “Approximately 2.2 million enrollees in the individual market today have some form of pre-existing chronic condition,” the analysis said.
When states had high-risk pools, people in those pools represented just 2 percent of the non-group health insurance participants. But given the limitations of those funds, that percentage may not be a good guide for what would happen under the AHCA.
Whenever health-care laws are changed, there are unknown and unintended consequences. The current system does not take into account a person’s health status when assessing premiums. But, as a Brookings Institution analysis suggested, under the AHCA’s provisions, healthy people might have an incentive to join plans based on health status. That would leave sicker people in the community rated plans, which in turn would face higher premiums. Over time, that could make the community rating meaningless. Another possible outcome: If the pool of money is used to pay insurance companies for the difference in costs for patients with preexisting conditions, there may be little incentive for companies to keep their prices low; the difference would be made up by U.S. taxpayers.
The Bottom Line
When it comes to health care, readers should be wary about claims that important changes in health-care coverage are without consequences and that people are “protected” – or that the changes will result in massive dislocation and turmoil. There are always winners and losers in a bill of this size. In this case, if the bill ever became law, much would depend on unknown policy decisions by individual states – and then how those decisions are implemented.
A conservative case for single-payer health care
by Matthew Walther - The Week - May 4, 2017
The GOP's latest health-care push is a magic show featuring the same malnourished rabbit being pulled from the same shabby top hat Republicans have been reaching their fingers into for years before pronouncing their now-familiar incantations.
Abracadabra! they always say. Allowing companies to sell insurance across state lines! Alakazam! Block-granting — is there an uglier formulation in the English language? — Medicare to the states! Presto-chango! Medical malpractice reform! Hocus-pocus! Health savings accounts! And for my last trick, keeping the expansion of Medicaid but not paying for it!
For Republican members of Congress and the kinds of people with whom they tend to be well acquainted — defense contractors, up-and-coming fracking magnates, lawyers, purple-tied megachurch pastors — all of that sounds very convenient. For millions of other Americans, the reality is very different.
What is a 25-year-old making burritos at Chipotle for Heritage Foundation bros at $12 an hour supposed to do with the chance to funnel an unlimited amount of his meager wages into a tax-free health-savings account? Pay the rent with catheters? If he saved diligently for two or three years, he might be able to buy himself half a blood test. A colleague whose friend recently decided to open a health-savings account was forced to upgrade to a premium version of TurboTax in order to fill out the proper forms, which cost her $25 more than she had managed to put away during the previous year.
In the grand sweepstakes that is America's health-care system, I am one of the winners. My family is covered by a premium plan for which my employer pays every month without deducting so much as a penny, pre-tax or otherwise, from my paycheck. We have negligible co-pays and a whopping $500 deductible. Having two children at one of the best midwiferies in the D.C. metro area cost us virtually nothing out of pocket. If, like most Americans of my age and class, I went in for yearly check-ups, I could actually get the insurance company to pay me!
But even we have had our fair share of hang-ups. When my wife was pregnant with our first daughter, she went in for a routine ultrasound. Months later a bill arrived for something like $1,000. When I called the insurance company, they told me to disregard it because there was no out-of-pocket charge. Copies of the erroneous bill continued to pour in every few weeks regardless. Eventually they crossed paths with a much smaller bill for a second ultrasound that we were supposed to pay, but who could tell the difference? Somehow it escaped our attention and ended up with a debt collector, another black mark on a young family's credit score. This sort of thing happens to responsible people every day.
Nearly everyone agrees that our semi-private insurance-driven system is mad. It makes all the logistical sense of having the clerk at the Shell station file a claim with Geico every time you put gas in your car. The Affordable Care Act exacerbated everything wrong with the present arrangement by creating a permanent carve-out for insurance companies. Millions of Americans were left feeling the way villagers would have if the Magnificent Seven had shown up at the last minute and thrown in their lot with the bandits.
Meanwhile, conservatives insist on getting rid of the only good part of the legislation: the expansion of Medicaid. This is not because it hasn't worked but because it conflicts with Republicans' increasingly ethereal principles. Put aside for a moment the question of whether it would be desirable to return to those halcyon days when simple country doctors gave big bills to the rich, smaller ones to ordinary people, and treated the poor gratis. Is it even possible, much less feasible? No one, not even Tea Party members during the movement's heyday, has been clamoring at the door to get rid of Medicare. Even if their wildest dreams came true and they managed to get government out of health care altogether, what would happen to people in the meantime while their hypothetical army of altruist medicos mustered its forces?
The solution should be obvious. Single payer is the only way forward. The U.S. government should provide health insurance for every one of its citizens.
Already I hear the chorus of well-rehearsed objections from the right. Who's going to pay for it? Please. Every other wealthy country in the world ensures universal health-care coverage, and we are spending far more than any of them to let people above the bottom and well into what remains of the middle fall through the cracks. What about innovation? they say, as if Costa Rica, with a GDP smaller than New Hampshire's, were not a leader in the treatment of diseases such as pancreatic cancer and a destination for innovation-seeking medical tourists from around the world. (It is curious how this objection never seems to spring up in the case of the military. Should we privatize that too, lest we fall behind the denizens of the SeaOrbiter in the quest for better fighter jets?)
Single payer just isn't "conservative." Of course it is, at least if the word still means anything. Conservatism is about stability and solidarity across class boundaries, not a fideistic attachment to classical liberal dogma. When Winston Churchill's Conservative Party returned to power in the U.K. in 1951, they did not attempt to dismantle the National Health Service established six years earlier by the post-war Labour government. They tried to do a better job of running it. Conservatives in this country should get used to the idea of being prudent stewards of the welfare state, not its would-be destroyers.
Then there is the old concern about "rationing," with which I must admit to very little patience, probably because, like the claret-soaked Tories of old, I am not myself terribly interested in health. I have no doubt that if America were to adopt a single-payer system, those with sprained ankles or runny noses would indeed face longer lines. This is a good thing. Health is not the be-all end-all of human existence, and half the reason care costs what it does is that providers across the country know that they can charge BlueCross whatever they want when wealthy suburban mothers bring Dylan in after soccer practice for X-rays, MRIs, CT scans, and goodness knows what other radiological marvels, when what he really needs is a $1 ice pack.
Putting the government in charge of health care would restore it to its proper place in our lives. If conservatives' worst fears turn out to be justified, then visiting the doctor will become a very occasional half-day-long exercise in mandatory tedium, like going to the DMV or having your passport renewed. I do not visit the clinic down the street for aches or minor ailments, much less stop in to see my non-existent family physician to engage in morbid speculations concerning the potential diseases to which I might one day succumb — and neither should you.
"In the long run we are all dead," Lord Keynes said. To quote a marginally more cheerful writer, "There is nothing better for a man, than that he should eat and drink, and that he should make his soul enjoy good in his labor." There are a thousand more important things in life than fussing about health. Exercise if you want — or don't. Have a nice lunch; order a drink or two; smoke; relax with a ball game or a good book. If you're sick, go wait in line. You'll be glad not to get a bill four months later.
G.O.P. Cheers a Big Victory. But Has It Stirred a ‘Hornet’s Nest’?
by Carl Hulse - NYT - May 5, 2017
WASHINGTON — No one knows better than House Democrats how a contentious health care vote can exact a steep political price — losing control of the House in the first midterm election of an untested new president’s tenure for example.
As they hooted derisively at their Republican colleagues on Thursday after a narrow, party-line approval of legislation to roll back the Obama-era health care law, Democrats glimpsed the mirror image of their own politically disastrous health care experience. They also saw a prime opportunity to avenge their ugly 2010 loss and possibly recapture the House majority.
“I think they are staring death in the face,” Representative Gerald E. Connolly, Democrat of Virginia, said about the political prospects of dozens of House Republicans who were persuaded to back the bill by Republican leaders anxious to deliver a legislative win. “They asked their vulnerable members to take an enormous gamble and risk on an act of faith that I guarantee will not pay off.”
Relieved Republicans celebrated on the House floor and at the White House and said they had been in danger of retaliation from their own conservative base if they had not delivered on the pledge to repeal the law they had been promising to strike from the books for seven years. They say their candidates will have the experience and resources to fight off Democratic challengers.
But Democrats were confident many colleagues across the aisle would come to regret this vote, particularly in an election cycle where the president’s party is typically on the defensive and when Republicans will need to protect nearly two dozen districts carried by Hillary Clinton last year. Those districts alone, including some in places like California, Texas and Illinois, are almost enough to determine who runs the House.
“Republicans kicked a hornet’s nest, and it is not too soon to begin saying goodbye to some of my Republican colleagues from moderate districts, because this will cost them dearly,” said Representative Luis V. Gutiérrez, Democrat of Illinois.
The 2018 campaign is only now beginning, and the political climate is highly volatile. The outlook for the House bill in the Senate is uncertain, and it could be significantly rewritten. But Democrats believe that the potential ramifications of the House-passed measure — millions losing insurance coverage, a diminished array of benefits, no definite guarantee of coverage for those with pre-existing conditions — provide them with powerful ammunition against Republicans.
Democrats point out that Republicans will have to defend a reduction in federal help for people who have come to rely on it. That is a most unusual position for politicians since federal benefit programs are rarely scaled back once they are established — certainly not a program with the reach of the health care law.
“It is a pretty big mistake,” said Representative Steny H. Hoyer of Maryland, the No. 2 Democrat, about the Republican bill. “They are taking something away.”
It wasn’t just Democrats who were complaining about retrenching on health benefits. In a statement that might well resurface in Democratic campaigns, Representative Ileana Ros-Lehtinen, a Florida Republican who is retiring, delivered a blistering critique of the bill, saying it has “potential to severely harm the health and lives of people in South Florida.”
“My constituents should not have to take a step backward in their ability to obtain treatment for any illness,” she said.
Ms. Ros-Lehtinen was among 20 Republicans who opposed the legislation, most of them in politically divided districts where they hoped their “no” vote might insulate them from any voter fury. But that might not be a successful strategy since it could alienate Republican supporters while failing to win over Democrats.
The fate of Democrats who opposed the Affordable Care Act is instructive and shows that bucking the party on a difficult vote doesn’t necessarily protect a lawmaker in the next election. Of 34 House Democrats who opposed the health law in 2010, half still lost their re-elections that November.
“Every Republican is going to have to carry the burden of this,” said Representative Rick Larsen, Democrat of Washington.
House Democrats have struggled since losing the majority in 2010, failing to capitalize on opportunities to expand their numbers. There is no guarantee that they can take full advantage of these circumstances. But top Democrats point to one promising development: They say they are seeing new enthusiasm among possible candidates rather than having to search for contenders.
“We have too many wanting to run,” Mr. Hoyer said. “They are just coming out of the woodwork because they smell victory in the air and they are angry about what the Republicans are doing.”
Even as they saw the advantages, some Democrats were careful to say they would have preferred that the repeal bill had failed rather than provide them with a political upper hand.
“They will pay the political consequences, but it would be better if it didn’t pass,” said Representative Kathy Castor, Democrat of Florida.
The similarity to past defining votes in the House was unmistakable. While Republicans cheered their win, Democrats, in a bit of precooked theater, chanted “na na na na, hey hey, goodbye” from the 1969 song to give voice to their view that multiple Republicans were goners after the vote.
The scene brought to mind the 1993 Clinton administration budget clash: Republicans chanted “Goodbye Marjorie” when Marjorie Margolies-Mezvinsky, Democrat of Pennsylvania, cast the deciding vote. She later lost her seat. In a 2009 climate vote pushed by House Democrats, Republicans offered the refrain “BTU” to remind Democrats of a 1993 energy vote that hurt their party.
This time, Democrats say they will have the last word. They believe that in delivering a win demanded by President Trump, House Republicans have opened the door to Democratic control of the House, a reversal that would put them in a position to challenge Mr. Trump in a way that would be impossible were they kept in the minority.
In Rare Unity, Hospitals, Doctors and Insurers Criticize Health Bill
by Reed Abelson and Katie Thomas - NYT - May 4, 2017
It is a rare unifying moment. Hospitals, doctors, health insurers and some consumer groups, with few exceptions, are speaking with one voice and urging significant changes to the Republican health care legislation that passed the House on Thursday.
The bill’s impact is wide-ranging, potentially affecting not only the millions who could lose coverage through deep cuts in Medicaid or no longer be able to afford to buy coverage in the state marketplaces. With states allowed to seek waivers from providing certain benefits, employers big and small could scale back what they pay for each year or reimpose lifetime limits on coverage. In particular, small businesses, some of which were strongly opposed to the Affordable Care Act, could be free to drop coverage with no penalty.
The prospect of millions of people unable to afford coverage led to an outcry from the health care industry as well as consumer groups. They found an uncommon ally in some insurers, who rely heavily on Medicaid and Medicare as mainstays of their business and hope the Senate will be more receptive to their concerns.
“The American Health Care Act needs important improvements to better protect low- and moderate-income families who rely on Medicaid or buy their own coverage,” Marilyn B. Tavenner, the chief executive of America’s Health Insurance Plans, the industry’s trade group, said in a strongly worded statement.
Others were even more direct about the effects the bill would have, not only on patients but also on the industry. “To me, this is not a reform,” said Michael J. Dowling, the chief executive of Northwell Health, a large health system in New York. “This is just a debacle.”
Hospitals that serve low-income patients “will just be drowning completely when this happens,” Mr. Dowling said, noting that more people would become uninsured at the same time that government payments to cover their costs were reduced.
In contrast to hospital and doctor groups, insurers had largely remained silent about their reservations, perhaps in the hopes of bartering their low profile in exchange for assurances that billions of dollars in subsidies for low-income coverage would continue. The White House and Congress have gone back and forth about their willingness to pay for the subsidies, prompting anxiety among some companies. Several, including Anthem, have threatened to sharply raise their prices or leave markets altogether without the funding.
But a few, including Blue Shield of California, came out in opposition to the bill before the vote. “We feel compelled to oppose it,” said Paul Markovich, the company’s chief executive. “It raises the specter that the sickest and neediest among us will be disproportionately hit in losing access.”
After the House passed the bill on Thursday, the industry’s two major trade groups urged lawmakers to increase the tax credits available to help people pay for coverage, and to adjust them to assist those who are older, live in high-cost areas or have lower incomes.
But the overriding concern — for insurers, many workers and officials throughout the health care systems in many states — is the broad reductions proposed for Medicaid. Even for insurers that have largely abandoned the individual market, like UnitedHealth Group and Aetna, a substantial portion of their business is providing coverage under Medicaid. The same is true for many local nonprofit plans, said Ceci Connolly, the chief executive of the Alliance of Community Health Plans.
Employers and others said they were also concerned about the effects on freelancers, who do not have a traditional employer but are self-employed or contract workers in the so-called gig economy.
Depending on their income, those workers have shuttled between Medicaid and the individual insurance market under the federal health care law, which offered a greater level of stability, said Nell Abernathy, vice president for research and policy at the Roosevelt Institute, a left-leaning economic research organization.
“A huge swath of Americans are in insecure work arrangements,” she said. “This repeals that level of security, which was not perfect, but it was a step in the right direction.”
Small businesses, which were sharply divided over the original law, remained mixed in their response to the Republican bill, and there seemed little doubt that some companies would drop coverage in the absence of any penalty. The National Federation of Independent Business, which opposed the Affordable Care Act, said the House legislation was “a crucial first step toward health care reform.”
In other people’s view, employees of small businesses would lose out if Medicaid were rolled back or the exchanges became threadbare, because many smaller companies rely on employees’ ability to obtain coverage through the government program or individual market.
The Main Street Alliance, a group of small-business owners that supported the Affordable Care Act, said four million small-business owners, employees and self-employed entrepreneurs had gained insurance under the law, and that an additional six million small-business workers had signed up for Medicaid through the law’s expansion.
“This bill leaves small-business owners in a terrible position, one they were all too familiar with before the A.C.A.: unable to afford premium hikes year to year, unsure their employees will be healthy and able to work, and uncertain of the future of their businesses,” said Amanda Ballantyne, national director of the Main Street Alliance.
The recent amendments to the bill also raised questions about coverage for people with pre-existing medical conditions, which has become an emotional flash point for opposition. The bill would allow states to waive some of the current rules banning insurers from charging sick people more or excluding certain benefits, and those waivers could have broad effects if employers are no longer required to provide comprehensive coverage. Before the Affordable Care Act, many employers capped how much they would pay for care over a person’s lifetime at $2 million, said Tracy Watts, a senior partner at Mercer, a benefits consultant.
While it is unclear what states would allow under a waiver or when such waivers would go into effect, employers could revisit the limits and drop types of benefits if a state deemed them nonessential.
A January survey of 666 employers by Willis Towers Watson, a benefits consultant, found that while many employers planned to keep most of the mandatory benefits, a significant minority were already mulling changes. While half indicated that they were unlikely to reinstate lifetime limits, 15 percent said they would consider doing that.
And employer groups generally favored provisions of the bill that would reduce taxes, particularly the so-called Cadillac tax on high-cost health plans, which was delayed for several years. Employers favor its overall repeal.
Some health care groups, like medical device manufacturers, supported the bill because of specific provisions like the repeal of a 2.3 percent device tax under the Affordable Care Act. That tax was suspended for two years in 2015, but the industry wants a permanent repeal. The Pharmaceutical Research and Manufacturers of America, the drug industry’s largest trade group, said it had not taken a position on the bill.
Unlike doctors and hospitals, which would most likely experience an immediate hit if millions of Americans lost insurance, medical device manufacturers and the drug industry would probably feel a more muted effect. The drug industry, for example, might sell fewer products and lose revenue.
“Fewer patients are treated, so it’s bad for them, but it’s a lot worse for hospitals and the impact on physicians,” said Ronny Gal, an analyst for Bernstein who covers the drug industry. “They’re a little bit on the tail end of this.”
What’s in the AHCA: The Major Provisions of the Republican Health Bill
by Robert Pear - NYT - May 4, 2017
The House health care bill up for a vote on Thursday would roll back the Affordable Care Act’s expansion of Medicaid, eliminate tax penalties for people who do not have health insurance and end taxes on certain high-income people, insurers, drug companies and manufacturers of medical devices to finance the current health law.
Here is a summary of major provisions of the House bill, the American Health Care Act.
■ To help people buy insurance, if they do not have coverage at work or under a government program like Medicare or Medicaid, or through the Department of Veterans Affairs, the bill would offer $2,000 to $4,000 a year in tax credits, depending mainly on age. A family could receive up to $14,000 a year in credits. The credits would be reduced for individuals making over $75,000 a year and families making over $150,000.
■ Under current rules, insurers cannot charge older adults more than three times what they charge young adults for the same coverage. The House bill would allow them to charge five times as much. The Congressional Budget Office said this change would reduce premiums for young adults and increase premiums for older Americans.
■ The bill would end Medicaid as an open-ended entitlement to health careand would put the program on a budget. States would receive an allotment of federal money for each beneficiary, or, as an alternative, they could take the money in a lump sum as a block grant, with fewer federal requirements. Medicaid cuts would total $880 billion over 10 years.
■ The bill encourages people to maintain “continuous coverage” by requiring insurers to impose a 30 percent surcharge on premiums for those who experience a gap in coverage.
■ Under the bill, states could opt out of certain provisions of the Affordable Care Act, including one that requires insurers to provide a minimum set of health benefits, such as maternity care and emergency services, 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.
■ The bill would provide states with $138 billion over 10 years that could be used for various purposes like subsidizing premiums, providing coverage to people with pre-existing conditions and paying for mental health care and the treatment of drug addiction.
■ The bill would cut the taxes of high-income people by nearly $300 billionover 10 years by repealing a payroll tax increase and a tax on their investment income imposed by the Affordable Care Act.
Who Wins and Who Loses in the Latest G.O.P. Health Care Bill
by Margot Sanger-Katz - NYT - May 4, 2017
The American Health Care Act, which narrowly won passage in the House on Thursday, could transform the nation’s health insurance system and create a new slate of winners and losers.
While the Senate will probably demand changes, this bill, if it becomes law in its current form, will repeal and replace large portions of the Affordable Care Act (Obamacare). It will change the rules and subsidies for people who buy their own insurance coverage, and make major cuts to the Medicaid program, which funds care for the poor and disabled.
Any sizable change in our complex health care system leaves some people and businesses better or worse off. For some, insurance will become more affordable — or their taxes will be lower. Others will lose out on financial support or health care coverage. You can see how you might be affected in our summary of winners and losers.
Winners
High-income earners: The bill eliminates two taxes on individuals earning more than $200,000 or couples earning more than $250,000: a 0.9 percent increase on the Medicare payroll tax, and a 3.8 percent tax on investment income. It also allows people to save more money in tax-excluded health savings accounts, a change most useful to people with enough money to have savings.
Upper-middle-class people without pre-existing health conditions: The Affordable Care Act cut off subsidies to help people buy their insurance at an income of around $48,000 for a single person. The American Health Care Act would let people get government subsidies much higher up the income scale — up to about $150,000. But the bill allows states to waive rules on minimum benefit standards and rules that prevent insurance companies from charging higher prices to customers with pre-existing illnesses. That means, over all, the gap between the tax subsidies and the cost of needed care could widen, even for some people who will get extra financial help.
Young, middle-class people without pre-existing health conditions: The bill would change how insurance companies price their products in a way that would lower prices for young customers. It also gives them a flat subsidy that is, in many cases, higher than what they would receive under Obamacare. There is some variation by region, and people with pre-existing conditions could be charged higher prices in some states.
People who wish to go without insurance: The bill would eliminate the individual mandate, which charges a tax penalty to Americans who can afford insurance but do not obtain it.
People who want less comprehensive health coverage: The bill allows insurers to offer health plans with higher deductibles and co-payments, a change likely to lower premiums. Customers in states that waive benefit rules may also be able to buy plans not covering as many medical services, like maternity coverage.
Large employers: The bill eliminates Obamacare’s employer mandate, which required large employers to offer affordable coverage to their workers. If the bill becomes law, companies that do not wish to cover their workers will face no penalty. It frees all large employers of the complex reporting necessary to enforce the provision. It also pushes back enactment of a tax on high-cost employer health plans.
Medical device companies, indoor tanning companies and a few other medical industries: The bill rolls back taxes on devices, tanning, prescription drugs and health insurance products. Some of those industries may lose a little as well — insurance companies, for example, may have fewer paying customers.
Losers
Poor people: Many states would be expected to roll back their expansions of the Medicaid program to cover childless adults without disabilities. The bill would also substantially reduce subsidies available for Americans just over the poverty line, the group that benefited most from Obamacare’s subsidies. Poor Americans are much more likely to become uninsured under the bill, according to the Congressional Budget Office, and those who retained coverage would pay much more of their limited incomes on premiums and deductibles.
Older Americans, in most states: The same factors that make the bill better for many young Americans make it worse for those who are older. Insurance companies could charge a 64-year-old customer five times the price charged to an 18-year-old one, to cite the most extreme example. The changes in the subsidy formula would also require older middle-class Americans to pay a much larger share of their health insurance bill. The Congressional Budget Office estimates that far fewer older Americans would have insurance coverage under this bill than under the Affordable Care Act.
People with pre-existing health conditions, particularly in some states. The bill allows states to waive rules on minimum benefit standards and rules that prohibit insurance companies from charging higher prices to customers with a history of serious illness — or even minor diseases. And it could mean their insurance covers fewer medical services. The benefit changes could also affect Medicaid beneficiaries, and they could mean cutbacks on coverage for mental health and drug addiction treatment. States that waive the rule about prices would be required to set up a program for high-risk customers, and would get some federal funding to do so, but the details are unclear.
State governments: The bill cuts back substantially on federal funding for state Medicaid programs, while offering states only limited new flexibility in how they manage them. Over time, the changes are likely to shift an increasing share of Medicaid costs onto states.
Hospitals: Assessing an earlier version of the bill, the Congressional Budget Office estimated that some 24 million fewer people would have health insurance in a decade. Some of those people would still have medical emergencies and require hospital care. Obamacare made substantial cuts in how much Medicare pays hospitals, on the theory that they would make up the difference with more paying customers. The Republican bill does not restore any of the Medicare cuts. Hospitals in poor communities where a lot of people signed up for Medicaid would probably experience the biggest hit.
Planned Parenthood: The bill would prevent Planned Parenthood from receiving any federal money for one year, a major hit for a health care provider that relies substantially on payments from Medicaid and the Title X family planning grant to provide contraception, cancer screenings and other women’s health services. The bill would also seek to reduce access to abortions, by preventing federal subsidies from going to any health plan that covers abortions.
The Trumpcare Disaster
Editorial Board - NYT - May 4, 2017
The House speaker, Paul Ryan, and other Republicans falsely accused Democrats of rushing the Affordable Care Act through Congress. On Thursday, in a display of breathtaking hypocrisy, House Republicans — without holding any hearings or giving the Congressional Budget Office time to do an analysis — passed a bill that would strip at least 24 million Americans of health insurance.
Pushed by President Trump to repeal the A.C.A., or Obamacare, so he could claim a legislative win, Mr. Ryan and his lieutenants browbeat and cajoled members of their caucus to pass the bill. Groups representing doctors, hospitals, nurses, older people and people with illnesses like cancer opposed the bill. Just 17 percent of Americans supported an earlier version of the measure, and Republicans have made the legislation only worse since that poll was conducted. Neither Mr. Trump nor Mr. Ryan seemed bothered by this overwhelming criticism of their Trumpcare bill, the American Health Care Act. They seemed concerned only about appeasing the House Freedom Caucus, the far-right flank of their party.
Mr. Trump in particular has been spreading misinformation and lies about health care, arguing that the legislation would lower costs while guaranteeing that people with pre-existing health conditions could get affordable health insurance. It would do the opposite. Here is what the bill actually does:
Takes a machete to Medicaid. The bill would cut $880 billion over 10 years from Medicaid, the program that provides health care to about 74 million poor, disabled and elderly Americans. That’s one-fourth of its budget. As a result, 14 million fewer people would have access to health care by 2026, according to a C.B.O. analysis of the earlier bill, which contained similar Medicaid provisions. The cuts would also hurt special education programs, which receive about $4 billion from Medicaid every year.
Slashes insurance subsidies. It would provide $300 billion less over 10 years to help people who do not get insurance through employers and have to buy their own policies. This would hurt lower-income and older people the hardest. For example, a 60-year-old living in Phoenix and earning $40,000 would have to pay an additional $12,370 a year to buy a policy, according to the Kaiser Family Foundation. Many people who find themselves in this situation would have no choice but to forgo insurance.
Eliminates the individual mandate. Many people hate that the A.C.A. requires people to buy health insurance or pay a penalty. But without the mandate, fewer younger and healthier people would buy coverage. This would lead to what health experts call a “death spiral” as insurers raise rates because they are left covering people who are older and sicker, leading to even more people dropping coverage. Eventually, companies could stop selling policies directly to individuals in much of the country.
Guts protections for people with pre-existing conditions. An amendment by Representative Tom MacArthur of New Jersey would allow states to waive the requirement that insurers sell policies to people with prior health problems and not charge them higher rates. The chief executive of Blue Shield of California said the bill “could return us to a time when people who were born with a birth defect or who became sick could not purchase or afford insurance.” Republicans say they will require that states with waivers offer high-risk pools and find other ways to help treat these people. The bill offers $138 billion over 10 years to help states pay for such programs. Experts say this is far too little; Larry Levitt of the Kaiser Foundationestimates it would take at least $25 billion a year.
Makes insurance less comprehensive. The bill would also let states waive a requirement under Obamacare that insurers cover a list of essential services. This means people in some places might not have access to maternity care or cancer treatment. This provision could also hurt people who get insurance through work, because federal regulations allow employers to opt into the rules of any state for the purposes of determining annual and lifetime limits on coverage, according to an analysis by the Brookings Institution.
Defunds Planned Parenthood. Republicans have included a provision that takes federal money away from the organization, which provides birth control, cancer screenings and other health services to 2.5 million people, mainly women. About 60 percent of people who use Planned Parenthood depend on government programs like Medicaid.
Despite this catalog of the bill’s horrors, many Republicans have embraced it so they can claim they fulfilled their promise to repeal Obamacare. They aren’t bragging that the bill would reduce tax revenue by $880 billion over 10 years, according to the C.B.O. A vast majority of those tax cuts would go to wealthy Americans.
The bill now moves to the Senate, where several centrist Republicans are opposed to it. The best hope for defeating this legislation rests with lawmakers like Shelley Moore Capito of West Virginia, Susan Collins of Maine, Lisa Murkowski of Alaska and Rob Portman of Ohio. But Mr. Trump and far-right groups will put tremendous pressure on them to pass this dreadful bill or something similarly terrible. The health of millions of Americans is now in their hands.
The New Study That Shows Trumpcare’s Damage
by David Leonhardt - NYT - May 3, 2017
When Massachusetts expanded health insurance a decade ago, state officials unknowingly created an experiment. It’s turned out to be an experiment that offers real-world evidence of what would happen if the House Republicans’ health bill were to become law.
The findings from Massachusetts come from an academic paper being released Thursday, and the timing is good. Until now, the main analysis of the Republican health bill has come from the Congressional Budget Office, and some Republicans have criticized that analysis as speculative. The Massachusetts data is more concrete.
Unfortunately for those Republicans, the new data makes their health care bill look even worse than the C.B.O. report did. The bill could cause more people to lose insurance than previously predicted and do more damage to insurance markets. The $8 billion sweetener that Republicans added to the bill on Wednesday would do nothing to change this reality. President Trump and Speaker Paul Ryan are continuing to push a policy that would harm millions of Americans.
Here are the basics of the new study, and why it matters:
The Massachusetts law subsidizes health insurance for lower-income households, and does so via four different income categories. Everyone in a category — for example, a family of four earning between $44,700 and $55,875 a year — would pay the same price for insurance. A family earning less would pay less, and a family earning more would pay more.
This system creates what economists call a “discontinuity.” People who have only slightly different incomes pay very different prices for an insurance plan. A family earning $44,701 could pay a couple of hundred dollars more per year than a family making $44,699.
Discontinuities are a social scientist’s friend, because they set up natural experiments. The price difference faced by the similar families I just described allows researchers to analyze how much the cost of insurance affects people’s willingness to sign up.
And price ends up mattering a lot. When plans become even slightly more expensive, far fewer lower-income families sign up. “Most low-income people aren’t willing or able to pay much for health insurance,” says Mark Shepard, a Harvard economist and an author of the new study.
Why? Partly because people know that they have an alternative. They can instead rely on last-minute emergency-room care, in which hospitals typically treat them even if they lack insurance. Such care is problematic: It tends to be expensive, raising costs for other patients, and it’s often not as good as preventive care. But many poorer families choose E.R. care over taking money from their stretched budgets for health insurance.
The Republican health bill wouldn’t raise people’s costs by only a small amount, either. It would force many low-income families to pay hundreds or thousands of dollars more for insurance — and most of them would likely respond by not buying insurance. The people who still buy plans would disproportionately be sick people, which would then cause costs to rise even higher. “When premiums go up, it’s the healthier enrollees who drop out,” said Amy Finkelstein of M.I.T., another author of the study.
The authors didn’t specifically compare their data to the estimates by the C.B.O. But the magnitude of the new results suggests the C.B.O. estimates of insurance losses were conservative. Nathaniel Hendren of Harvard, the paper’s third author, said that the Republican proposal would effectively end enrollment in the insurance markets for families that make less than $75,000 a year.
It’s important to note that the study’s three authors aren’t political animals. Finkelstein has won the John Bates Clark Medal, an award for the top academic economist under the age of 40, and her research on Medicare is frequently cited by conservatives.
The Republican health bill is simply a bad bill. It’s been blasted by conservative and liberal health experts, as well as groups representing patients, doctors, nurses and hospitals. Above all, the bill cuts health benefits for the poor, the middle class, the elderly and the sick, and it funnels the savings to tax cuts for the rich.
In the name of a political victory for themselves and Trump, House Republicans may now be on the verge of passing the bill anyway. The only things that can keep it from becoming law — and harming millions of Americans — is the United States Senate.
The Next Step for the Republican Health Care Bill: A Skeptical Senate
by Matt Flegenheimer - NYT - May 4, 2017
WASHINGTON — As House Republicans on Thursday shoved their health care bill across the finish line, stuffing it with amendments and extra dollars to secure a hard-won majority, the lawmakers who will inherit the legislation delivered their own message from across the Capitol:
That’s cute.
On the Senate side, where several Republicans have long been deeply skeptical of the House effort, the bill is expected to undergo sweeping changes that might leave it unrecognizable — perhaps stripping away some of the provisions that helped earn the support of hard-right House members and ultimately secure its passage.
The Republicans’ narrow 52-member majority in the Senate leaves little room for defections, and several Republican senators have worried aloud about the House measure. Their concerns include insurance costs for poorer, older Americans and funding issues in states with high populations of hard-to-insure people.
Another chief obstacle is reconciling the reservations of Republican senators from states that expanded Medicaidunder the Affordable Care Act — including Senators Rob Portman of Ohio, Lisa Murkowski of Alaska, Cory Gardner of Colorado and Shelley Moore Capito of West Virginia — whose constituents would face rollbacks under the House bill. (Aides to Mr. Portman and Ms. Capito said on Thursday that their concerns remain; the offices of Ms. Murkowski and Mr. Gardner did not immediately respond to messages.)
More immediately pressing on Thursday, it seemed, was getting senators up to speed on what, exactly, the House had voted on.
“Don’t know what’s in it,” Senator Lindsey Graham, Republican of South Carolina, said hours before the vote. “Waiting to see if it’s a boy or a girl.”
He said it appeared as though the House was “moving in a better direction,” gravitating toward state control over the health care system.
“But any bill that has been posted less than 24 hours — going to be debated three or four hours, not scored — needs to be viewed with suspicion,” he said, noting that the House vote came without an assessment from the Congressional Budget Office on the latest version’s price and impact.
Some members were less concerned.
“I’m praying for it every day,” Senator David Perdue, Republican of Georgia, said of the health care legislation.
In fact, a handful of wavering Republicans in the House seemed to take heart in recent days that revisions might come in the Senate.
Others have chafed at the suggestion that the upper chamber would be responsible for cleanup duty.
“They tell us they’re so smart and they’re so good at this stuff and we’re so incapable that they need to work on it — and I agree with them,” Representative Michael C. Burgess, Republican of Texas, said last week. “They need to work on it. I want them to. I’m anxious to see what they’re going to do with finishing the job that we started.”
Senator Lamar Alexander, Republican of Tennessee and the chairman of the Committee on Health, Education, Labor and Pensions, said he would “review” the House bill before proceeding.
“Then we’ll go work on the Senate bill,” he said.
One possible roadblock is the Senate parliamentarian. Republicans have pursued a procedural tool known as reconciliation in the hopes of passing the bill with a simple majority, rather than having to clear a 60-vote threshold with Democratic assistance. Reconciliation rules allow for changes on matters of taxes and spending but not broader policy changes. Some elements of the House bill had already threatened to draw the parliamentarian’s attention, and Democrats have strategized about specific components to target on these grounds.
If the threshold for passage is raised, requiring Democratic help, the minority party is unlikely to offer a lifeline.
“I hope this thing is dead on arrival, and I hope that a ton of House members lose their seat for voting for something this inhumane,” Senator Chris Murphy, Democrat of Connecticut, said.
It was up to Democrats, he said, “to tell this story and drive its approval ratings down from 18 to 8.”
A Little-Noticed Target in the House Health Bill: Special Education
by Erica L. Green - NYT - May 3, 2017
WASHINGTON — While House Republicans lined up votes Wednesday for a Thursday showdown over their bill to repeal the Affordable Care Act, Vickie Glenn sat in her Murphysboro, Ill., office and prayed for it to fail.
Ms. Glenn, a Medicaid coordinator for Tri-County Special Education, an Illinois cooperative that helps more than 20 school districts deliver special education services to students, was worried about an issue that few in Congress were discussing: how the new American Health Care Act, with its deep cuts to Medicaid, would affect her 2,500 students.
With all the sweeping changes the Republican bill would impose, little attention has been paid to its potential impact on education. School districts rely on Medicaid, the federal health care program for the poor, to provide costly services to millions of students with disabilities across the country. For nearly 30 years, Medicaid has helped school systems cover costs for special education services and equipment, from physical therapists to feeding tubes. The money is also used to provide preventive care, such as vision and hearing screenings, for other Medicaid-eligible children.
“If I could have 10 minutes with President Trump, I could help him understand what we do, why it’s important,” Ms. Glenn said. “If he understood, he would protect it, because this isn’t Republicans and Democrats. It’s just kids.”
The new law would cut Medicaid by $880 billion, or 25 percent, over 10 years and impose a “per-capita cap” on funding for certain groups of people, such as children and the elderly — a dramatic change that would convert Medicaid from an entitlement designed to cover any costs incurred to a more limited program.
AASA, an advocacy association for school superintendents, estimates that school districts receive about $4 billion in Medicaid reimbursements annually. In a January survey of nearly 1,000 district officials in 42 states, nearly 70 percent of districts reported that they used the money to pay the salaries of health care professionals who serve special education students.
Republicans say federal health programs must be restructured to curb their soaring costs — the biggest driver of projected budget deficits — and force a smarter allocation of limited resources.
But in a letter sent to top lawmakers this week, a coalition of school educators and advocacy organizations said such efforts would force states to “ration health care for children.”
The advocates argued that under the House bill, the federal government would transfer the burden of health care to states, which would result in higher taxes, eligibility cuts or curtailed services for children. And they said that schools would have to compete for funding with other entities, like hospitals and clinics, that serve Medicaid-eligible children.
The ability of school systems to provide services mandated under the federal Individuals With Disabilities Education Act would be strained. The law is supposed to ensure that students with disabilities receive high-quality educational services, but it has historically been underfunded.
“School-based Medicaid programs serve as a lifeline to children who can’t access critical health care and health services outside of their school,” said the letter sent this week by the Save Medicaid in Schools Coalition, which consists of more than 50 organizations, including the American Civil Liberties Union, the Disability Rights Education and Defense Fund, and the School Superintendents Association.
Ms. Glenn said she believed that Medicaid should be reined in. But, she said, schools are already reimbursed for only a fraction of the costs of services they provide.
The National Alliance for Medicaid in Education estimates that 1 percent of all Medicaid reimbursement goes to local school districts. Even without the funding, school districts would be legally required to provide special education services.
“I realize there have to be cuts, because Medicaid’s been out of control,” Ms. Glenn said. But, she added: “We have so many more demands. We’re not in it making money. We’re constantly in the hole.”
John George, executive director of the Montgomery County Intermediate Unit in Pennsylvania, said Medicaid primarily paid for speech, physical and behavior therapists.
Special education students make up roughly 16 percent of his student population, he said, and his most recent Medicaid reimbursement was about $5.4 million.
“It’s devastating,” Mr. George said of the potential impact of losing Medicaid funding. “Our most vulnerable citizens are going to be suffering the most. If any legislator votes for this, it’s unconscionable.”
THE HOUSE G.O.P.’S SHAMEFUL HEALTH-CARE VICTORY
by John Cassidy - The New Yorker - May 4, 2017
When the House Republican Conference gathered in Washington, D.C., on Thursday morning, it was greeted by a couple of motivational songs: “Eye of the Tiger” and “Taking Care of Business.” On Twitter, the A.P.’s Erica Werner also relayed the message that the Party’s leadership sent to the rank and file, which was equally lacking in subtlety: “It’s time to live or die by this day.”
A number of House Republicans, especially those from competitive districts, weren’t overly enthusiastic about fulfilling the health-care suicide pact that Paul Ryan, the House Speaker, was forcing on them. Ultimately, though, a number of countervailing factors won out: loyalty to the Party, eagerness to score a legislative win, hostility toward Barack Obama, free-market ideology, and a reluctance to antagonize wealthy G.O.P. donors. On Thursday afternoon, when it came time to vote on the American Health Care Act of 2017, only twenty Republicans broke ranks, allowing the bill to pass by the slightest of margins.
In the most immediate of terms—congressional whip counts—that was a victory for Ryan and his ally in the White House, Donald Trump. On their third attempt at passing an Obamacare-repeal measure, and after much drama and humiliation, the House Republicans had assembled a majority. But at what cost? The vote represented a moral travesty, a betrayal of millions of vulnerable Americans, and a political gift to the Democrats. And if it ultimately costs the House G.O.P. its majority in next year’s midterms, that would be a richly deserved outcome.
Ryan and his sidekick, the House Majority Leader Kevin McCarthy, pushed through a bill that, if it ever goes into effect, could upend one-sixth of the American economy and result in tens of millions of Americans losing their health coverage. Since the Republicans failed to give the Congressional Budget Office time to “score” the bill before voting on it, we don’t have any official estimates of its likely effects. But the bill that was passed on Thursday was an amended version of a bill that the C.B.O. had previously determined would raise the number of uninsured people by twenty-four million over ten years, and increase premiums for many others, particularly the old and the sick, as well.
In recent days, a lot of the media coverage was focussed on an amendment to the revised bill that allows individual states to seek a waiver from the Affordable Care Act stipulation that insurers have to cover people with preëxisting conditions. This is a truly hideous feature of the legislation, and a last-minute amendment addressing this issue—intended to convince the Republican congressman Fred Upton to support the legislation—was merely a fig leaf to cover it.
Upton secured eight billion dollars in additional funding for “high-risk pools” at the state level, which would cover people with serious illnesses. But, even with the extra Upton money, these pools would be grossly underfunded, and would leave many sick people without coverage—more than eight hundred thousand, according to one analysis. And that wouldn’t be all. If a seriously ill person did find an insurer, he or she could well face prohibitively high premiums. Many states operated high-risk pools before Obamacare went into effect, and the premiums were often set at fifty or a hundred per cent above the going market rate.
In jettisoning the principle that everybody, regardless of age or health, should be legally entitled to purchase insurance coverage, the House Republicans did something truly awful. The bill would give insurers a lot more leeway to charge higher premiums to old people. Many people in their sixties would see their premiums rise by thousands of dollars; some could see their premiums double. And, even then, they wouldn’t necessarily be getting the same level of coverage that they currently receive. The bill would allow states to opt out of providing all the benefits and treatments that were listed as “essential” under the Affordable Care Act.
On top of all this is another huge issue, which I’ve pointed to before. The bill passed on Thursday includes a substantial tax cut for the rich, financed by big cuts in Medicaid, the federal program that provides health care to the poor and indigent. Obamacare expanded Medicaid and CHIP, the children’s version of the program, and, to pay for these and other provisions, the law imposed a tax of 3.8 per cent on the investment incomes of wealthy households and a 0.9-per-cent surtax on their ordinary incomes. That money has helped sixteen million struggling Americans, many of them kids, obtain health coverage since the start of 2014.
The House bill eliminates the Obamacare taxes, reverses the Medicaid expansion, and converts the financing of the program from a per-capita subsidy to a block-grant system. What impact would this have? Since the treatment of Medicaid in the bill that passed is basically unchanged from the original version, we can rely on the C.B.O.’s analysis, which showed that, over ten years, spending on Medicaid would be reduced by almost nine hundred billion dollars. Of the roughly twenty-four million people the C.B.O. estimated would lose their health coverage under the original version of the bill, fourteen million were Medicaid recipients.
In short, the bill the House just passed is one of the most regressive pieces of legislation in living memory. When Republicans cut taxes on the rich and slash funding for programs aimed at the poor, they usually go to great lengths to argue that the two things are unconnected. But in this instance they have done away with the subterfuge. It’s reverse Robin Hood, in plain view.
Speaking on the House floor just before the bill passed, Ryan thanked Trump for his “steadfast leadership” in supporting the legislation. He also said, “This bill delivers on the promises that we have made to the American people.” It does nothing of the sort, of course; it merely passes the buck to the Senate, where the bill faces an uncertain future.
It’s fair to assume that even some of the Republicans who voted for Ryan’s legislation on Thursday will be fervently hoping that their colleagues in the Senate take the bill and bury it in a very deep hole. Should that happen, though, the Democrats will be sure to dig it up in time for next year’s midterm elections. Speaking shortly before Thursday’s vote, Nancy Pelosi, the House Minority Leader, singled out Republicans from swing districts and said, “They have this vote tattooed on them. This is a scar they will carry.” And a horrible, ugly scar it is, too.
House Health Care Bill Is ‘Us Keeping Our Promises,’ Paul Ryan Says
by Noah Weiland - NYT - May 7, 2017
WASHINGTON — Speaker Paul D. Ryan said on Sunday that criticism of the way the House passed its health care bill — no hearings were held on the final version, and it has yet to receive an evaluation from the Congressional Budget Office — was “kind of a bogus attack from the left.”
“This is a rescue mission” as “Obamacare is collapsing,” Mr. Ryan said on ABC’s “This Week.” “This is a crisis. We are trying to prevent this crisis.”
“We’re proud of this effort,” Mr. Ryan added, dismissing reports that some House Republicans had not fully read the bill. “It’s us keeping our promises.”
But top senators in his own party said the House’s legislation, which is widely unpopular among voters, would be rewritten and more carefully considered, a process that could take months.
Senator Susan Collins, a moderate Republican from Maine, said her colleagues were “starting from scratch.”
“We’re going to draft our own bill,” Ms. Collins said on “This Week.” “And I’m convinced that we’re going to take the time to do it right.”
She and three other Senate Republicans introduced in January their own alternative to the Affordable Care Act that would preserve certain protections, including for those for people with pre-existing conditions. The House bill would allow states to seek waivers for many such provisions, and although it would set aside billions for “high-risk pools,” critics say care could still be unaffordable for those with pre-existing conditions.
Senator Roy Blunt, a Missouri Republican and the chairman of the Senate subcommittee on health and human services, said on NBC’s “Meet the Press” that the Senate would work on its own version of the bill and examine a budget office analysis of it before moving toward a vote.
“This is the way legislation used to be passed,” he said.
Amid the volleys between the House and the Senate, White House officials said on Sunday that the legislative process was moving along as it should. Reince Priebus, the White House chief of staff, who pushed hard to get a revised version of the health care bill through the House, said he had already spoken to six Republicans who are part of a group tasked with writing the Senate’s version of the bill.
“Everyone is excited and ready to go to work and take the time necessary to look at the bill, make improvements where they need to be made, and then the bill will be brought back for conference,” Mr. Priebus said on “Fox News Sunday.”
“It’s up to the Senate, if there are improvements to be made, to make those improvements,” Mr. Priebus added. “I think that everyone is committed to getting this thing done and getting it done as soon as possible.”
Another administration official, Tom Price, the health and human services secretary, joined Mr. Ryan in defending the House bill, saying it would offer “a better way to cover an individual with pre-existing illnesses and injuries.”
He said it would do so “because it allows for every single person to get the access to the kind of coverage that they want,” not coverage “that their government forces them to buy.”
Asked on CNN’s “State of the Union” about hundreds of billions of dollars in cuts to Medicaid in the House measure, Mr. Price said Americans were tired of their tax dollars going to failing programs.
“The winners under Obamacare were the federal government and insurance companies,” he said. “The winners under the program that we provide and that we believe is the most appropriate will be patients and families and doctors.”
When asked about Republican governors worried about the Medicaid cuts, Mr. Price said the administration had “listened very intently and had wonderful meetings with Republican governors.”
But Gov. John Kasich, Republican of Ohio, said on CNN that the outcome in the House was “not great,” adding that he was worried about those who might lose their health coverage. A budget office analysis of a previous version of the House bill said millions would lose coverage.
“It is going to go to the Senate,” he said. “And I hope and pray they are going to write a much bigger bill.”
Democrats last week joined with an unusually simpatico group of hospitals, insurers and doctors’ groups that came out against the House Republican plan.
Senator Joe Manchin III, a moderate West Virginia Democrat whose constituents voted heavily for President Trump, said he “couldn’t believe” what was in the House’s health care bill.
“Every dynamic in every demography of my state gets absolutely slammed with this piece of legislation,” Mr. Manchin said on CBS’s “Face the Nation.”
Mainers on a mission: Universal, high-quality health care
by Jill Goldthwait - Ellsworth American - May 5, 2017
Maine AllCare is on a mission. About six years ago, a group of Mainers became the official Maine chapter of Physicians for a National Health Program, an organization representing some 20,000 physicians across the United States.
The goal of the nonprofit Maine AllCare is no less than “achieving universal, high-quality and affordable health care for the people of Maine.” To Maine AllCare, that means devising a way for every Mainer to get health care without the risk of “financial ruin.” It means practitioners who are free from having “their clinical judgment second-guessed by insurance company bureaucrats.” It means “everybody in, nobody out.”
The board of Maine AllCare is diverse. There are five MDs and one osteopath. There are a nurse/Ph.D. (Moira O’Neill of Surry) and a retired science professor, a Realtor and an insurance broker, and four legislators, former and current. There are four Maine AllCare chapters in the state; Hancock County’s is in Blue Hill (jlendval@maineallcare.org).
For the health care providers, it could be the dream of a lifetime — to create health care policy out of whole cloth, based on their education and experience rather than on politics. Well, not quite out of whole cloth. They do take for a starting point the Affordable Care Act, and hope to devise improvements that will help meet their goals.
There is not a patient care provider in the country who could not recite a litany of war stories from the front lines of his profession. The paperwork. Wasted time and money. Cumbersome rules and regulations that deny patients the care their providers know they need. Yet every attempt to reform the system falls far short of the mark.
Some of this has to do with the fact that few policy makers have experience in direct health care. Their policy proposals may be well-intentioned, but they fail to meet the straight-face test with health care providers; hence the necessary engagement of the health care community in this work.
Then there are the powerful lobbyists from the insurance industry, the pharmaceutical industry, medical equipment suppliers and so many others who are making a fortune from each and every legislative advantage they can create, and would like to keep it that way.
The Affordable Care Act is undoubtedly not the legislation that its sponsoring President envisioned. It is the legislation that could, and did, pass, replete with all the compromises with industry and members of Congress that afflict every major policy initiative.
There is some hope among reformers that the road to success, stymied at the national level, could happen state by state. To that end, Maine AllCare is supporting LD 1274, An Act to Promote Universal Health Care, Including Dental, Vision and Hearing Care.
Two Maine AllCare board members are bill co-sponsors: Sen. Geoff Gratwick of Bangor (a doctor) and Sen. Troy Jackson of Aroostook. Better known as the “Healthy Maine Act,” an entity would be established to finance and administer a health care program for all Mainers with a comprehensive list of required services.
There would be co-payments for some services, but no deductibles. Beneficiaries would choose their own providers. The proposal would take effect in July of 2020. Maine AllCare has been working the grass roots, giving presentations on its proposal from one end of the state to the other to groups large and small.
This is big. It is nothing less than the chance to polish up our Dirigo chops and give the country a health care model that really is a step forward. No one is under the illusion that this bill will sail through, but the proposal has been fleshed out in sufficient detail that it can, and should, get deep attention from the Insurance and Financial Services Committee.
A few other states have entertained similar proposals. Financing is generally the obstacle. At this point, with the ACA having a bad case of the blind staggers and the only replacement proposal dead on arrival, the populace is nervous.
The ACA may have its flaws, but it did accomplish the goal of extending health care coverage to millions. So far, Republican proposals to “repeal and replace” have all involved a third “R” — for “remove.” Their plans all contract coverage in one way or another, leaving some of the people newly covered by the ACA out in the dark again.
This is proving challenging for Republican members of Congress, especially in the House, who will all face re-election soon and do not relish the idea of showing up in their districts to face constituents who, thanks to them, just lost their health care.
House Republican nerves led to the embarrassing collapse of their health care proposal despite Republican control of the White House and both branches of Congress.
LD 1274 is a bill that will require extended study by the Legislature. If the committee rises to the occasion, it could be the best piece of work the 128th Legislature produces. A dedicated committee with the staff resources to really dig into this could produce a magnum opus. The public hearing on the bill is being held May 4 in Augusta. They are expecting a crowd.
Measure on Pre-existing Conditions Energizes Opposition to Health Bill
byAlexander Burns and Abby Goodnough - NYT - May 5, 2017
From the moment the Republican-controlled House of Representatives approved a plan to overhaul the health care system, an onslaught of opposition to the bill has been focused on a single, compact term: pre-existing conditions.
The Democratic Congressional Campaign Committee began running digital ads warning that the legislation would leave “no more protections” for people with a history of illness or injury. Pointing to the power that states could have to set the terms for insurers under the G.O.P. bill, Democratic leaders announced they would make pre-existing conditions an issue in every gubernatorial and state legislative race in the country.
Groups on the left posted graphics online listing pre-existing conditions that could, in theory, threaten health care coverage, with some shared hundreds of thousands or millions of times. In one exaggerated claim circulating widely on social media on Friday, a post from a group called The People for Bernie Sanders listed nearly 100 conditions, from AIDS to ulcers, and said that for anyone who suffered from them, Republicans had voted “to end your health care.”
Individuals took up the call, too: More than 100,000 people posted on Twitter using the hashtag #IAmAPreexistingCondition, with many naming their own long-term illnesses or medical conditions.
The blast of organized and grass-roots energy in opposition to the bill had all been generated by one measure, added to the legislation to assure its passage, that allowed states to seek federal waivers to ignore certain mandates in the Affordable Care Act — including the one blocking insurance companies from charging people more because of pre-existing conditions.
More than anything else in the bill, Democrats and health care advocates have used that provision as a rallying cry, warning that it could inflict punishing costs on people with ailments from asthma to cancer, as well as on pregnant women.
Gov. Dannel P. Malloy of Connecticut, chairman of the Democratic Governors Association, said the issue was so resonant because every voter has at least “an uncle or an aunt or a distant cousin who’s a diabetic or has a heart condition.” He said he was urging Democratic candidates to press their opponents to take a categorical position on the health care bill, which President Trump endorsed forcefully.
“Either you agree with the president or you don’t agree with the president,” Mr. Malloy said in an interview. “If you don’t agree with the president, you need to say it.”
Opponents of the bill have depicted its potential impact in nightmarish and sometimes overstated terms, suggesting it would completely void protections for sick people. In reality, insurers would still not be able to deny people coverage altogether, and states seeking waivers would have to show they had alternative programs to aid the people most at risk. People could be charged based on their health status only if they bought coverage through the individual market and had experienced a gap in coverage.
But many of the Democrats’ dire warnings are not far off the mark: Prices could indeed prove prohibitive.
And the political potency of these attacks is undeniable. Where the Affordable Care Act draws an iron rule governing coverage for people with pre-existing conditions, the Republican plan would create an opening for state-level programs that would likely offer far thinner protections for the roughly eight percent of Americans who rely on the individual market for coverage.
A host of health advocacy groups, including the American Lung Association and the American Cancer Society, reviewed the legislation and concluded it would weaken protections for people with ongoing medical issues.
States could also seek waivers from requirements that insurers cover 10 “essential health benefits,” including maternity, mental health and prescription drugs, and that they charge their oldest customers no more than three times more than their youngest ones. Waiving the essential benefits could also potentially weaken prohibitions on insurers limiting the amount of care they cover, even in employer plans.
Ben Wikler, the Washington director of MoveOn.org, said that by imperiling the protections for people with a history of illness, Republicans had turned the health care bill into “something that feels like a life-or-death struggle,” even for people who would have been unaffected by the rest of the bill.
“This whole bill was already radioactive, but pre-existing conditions make it a nuclear power plant for the resistance movement,” Mr. Wikler said.
The criticism has not come only from the left: A number of Republicans who voted against the bill specifically cited the possibility that it could make it harder for people with serious medical conditions to buy insurance. On Friday, chapters of the AARP, which also lobbied against the bill, criticized individual House members on Twitter for voting “yes on harming ppl w/preexisting conditions.”
Public polling has found those protections to be among the most popular elements of the Affordable Care Act, even in the first years after its passage when it faced tremendous blowback from voters. A poll last month by The Washington Post and ABC News found that seven in 10 Americans believed that all 50 states should be covered by regulations preventing insurers from setting higher rates for people with pre-existing conditions.
Even at the height of Republican opposition to the Affordable Care Act, leading members of the party, including Mitt Romney, the 2012 presidential nominee, vowed not to roll back protections for sick people.
John McDonough, a professor of public health at Harvard and a former Senate aide who advised the authors of the Affordable Care Act, said he thought the issue had developed potency in the last few years as more Americans came to value the protections the law had brought.
“I don’t think people really appreciated, back in 2008, 2009 and 2010, the role of pre-existing conditions and medical underwriting,” he said. “But there’s been a societal shift underway. American society has become committed to this notion that your ability to get medical coverage should not be conditioned on your medical history.”
It is far from certain that the House-approved, White House-backed legislation will become law in anything resembling its current form. Even if it did, it is unclear that states would actually seek to waive the most popular regulations protecting sick people.
Gov. Scott Walker of Wisconsin, a Republican, said Friday that he might be open to seeking such a waiver. But his was a lonely voice, and Mr. Malloy, of the Democratic governors’ group, leveled a taunting dare at Mr. Walker: “He should run on that.”
Joseph Antos, a health economist at the conservative American Enterprise Institute, said it was “very questionable” that any state would seek such a waiver.
“It’s an opportunity for great political risk,” Mr. Antos said. “Why would a state want to take full responsibility for anything that goes wrong, without being able to blame the federal government?”
Mr. Antos said he saw a parallel between some of the Democrats’ “overhyped” warnings and the fears stoked by Sarah Palin and other conservatives that the Affordable Care Act would lead to “death panels.”
“I’ve heard claims that Republicans don’t want your grandmother to have cancer treatment,” Mr. Antos said. “It’s pretty insane.”
But the warnings of death panels were blatantly false, while warnings about insurers again being able to price sick people out of the market could prove true, depending on the state.
The Kaiser Family Foundation, a nonpartisan research group, has estimated that 27 percent of Americans younger than 65 have health conditions that would likely leave them uninsurable if they applied for individual market coverage under the system that existed before the Affordable Care Act.
Political strategists and organizers in both parties have long viewed protections for people with pre-existing conditions as a uniquely delicate issue, affecting not just low-income Americans or people who lack health coverage, but also people with coverage who fear it could suddenly become unaffordable.
Anna Greenberg, a Democratic pollster, said the protections for pre-existing conditions had always appealed to a broad population of middle-class people who had insurance before the Affordable Care Act, and therefore did not benefit from components of the law like Medicaid expansion.
“With people who are not liberal Democrats and not low-income – that’s the most important piece to them,” she said of the popular regulations on insurers.
Republicans supportive of the health care overhaul have defended its handling of pre-existing conditions in a range of ways, with some even stressing that the Senate is likely to transform the legislation dramatically. A handful of Republicans who opposed an earlier version of the bill, like Representatives Fred Upton of Michigan and Billy Long of Missouri, ultimately voted for it after adding an additional $8 billion in funding that could be used to shore up coverage for sick people.
But many Republicans outside the House have balked at publicly embracing the measure, and some have pointed to its handling of pre-existing conditions as a particular sticking point.
Senator Bill Cassidy of Louisiana, a Republican who is a physician by training, said on CNN Friday that a final health care bill would have to pass “the Jimmy Kimmel test,” alluding to the late-night comedian who made a tearful on-air appeal to the Congress, telling the story of his infant son’s heart condition and asking lawmakers to protect people with grave ongoing ailments.
50 Preexisting Conditions That Can Make You Lose Your Insurance If Trump and GOP Have Their Way
The House Health Care Disaster Is Really About Taxes
by Peter Suderman - NYT - May 6, 2017
have been a critic of Obamacare since it became law, but the Republican alternative is worse in nearly every way.
The American Health Care Act, which was narrowly passed in the House last week, would worsen Obamacare’s problems rather than fix them. Coverage would be disrupted for millions almost immediately, according to a Congressional Budget Office analysis of a previous iteration of the legislation.
The bill would end Obamacare’s individual mandate, already too weak as a policy mechanism, and impose a fee on those who go without coverage and want to re-enter the insurance market — creating an incentive for relatively healthy people to remain uncovered. As a result, the instability that already exists in Obamacare’s exchanges as insurers scale back around the country would only be increased.
It’s unclear what health policy problem this bill would solve. Even for an opponent of Obamacare, it is difficult to understand why House Republicans chose this path to revamping the nation’s health care system.
It’s difficult to understand, that is, if you think they were passing a health care bill. It makes more sense when you realize that isn’t what they were doing at all. They were passing a tax cut — one intended to pave the way for more tax cuts.
The flaws of the bill, then, can be understood as a symptom of the flaws of the Republican Party, which has for decades maintained a myopic focus on tax cuts at the expense of nearly all else. Too often, it is a party of people who seem to confuse governing with cutting taxes.
The health care bill is a policy mess, but as politics, it’s even worse. A poll published in March showed the bill with an approval rating below 20 percent. It’s likely to be heavily rewritten in the Senate. It wouldn’t fulfill President Trump’s campaign promises to provide coverage for everyone or to reduce premiums and deductibles. It doesn’t even fulfill the Republican Party’s goal of fully repealing Obamacare: It leaves many key insurance regulations in place at the federal level. (States would have the option to apply for a waiver of these rules.)
Republicans have consistently had difficulty making the case for the bill on health policy merits. It’s not even clear that most House Republican lawmakers know what’s in the legislation. “I don’t think any individual has read the whole bill,” Representative Tom Garrett of Virginia said. Why then did House Republicans push so hard to pass this health care bill?
Because it cuts taxes — especially for the top 20 percent of earners — and so sets up the broader tax reform legislation Republicans hope to pass later in the year.
To understand how this might work, it helps to understand a little bit about Senate procedure.
The Senate effectively requires 60 votes to pass most legislation, but Republicans hold only 52 seats. However, Senate rules allow for the passage of certain types of legislation using a process known as reconciliation, which requires only a simple majority. Republicans planned to use the reconciliation process to go it alone on both health care and tax reform.
But that process comes with conditions. There’s a ticking clock; the reconciliation instructions that allow for the passage of the health care bill expire as soon as the next budget resolution is introduced. And the process does not allow for the passage of legislation that raises the deficit outside the 10-year budget window via a simple majority.
This, for example, is why the tax cuts passed under President George W. Bush in 2001 were set to expire after a decade. For tax cuts to be permanent, they must be deemed “revenue neutral.”
That is where the American Health Care Act comes in: It would eliminate roughly $1 trillion in taxes used to pay for the additional spending in Obamacare. As a result, it would significantly lower the federal government’s tax revenue baseline. The baseline is an important figure in congressional budgeting, because it sets expectations for how much the government is projected, on paper, to spend and raise if current law remains the same.
The trick, then, is to make the health care bill’s tax cuts part of that baseline by passing them into law before a tax-reform package. This would provide Republicans with far more room to permanently cut taxes later in the year. In short, Republicans would be able to devise a tax bill that collects about $1 trillion less in revenue but that would still qualify as revenue-neutral under Senate procedure.
This is why Republicans put health care reform at the top of their agenda. Without the bill to reset the federal government’s baseline tax revenue, Republicans would be much more constrained when it came time to overhaul the tax code.
Republicans have often struggled to recommend their health care plan on its own terms. Representative Dave Brat of Virginia, a member of the conservative House Freedom Caucus, called the initial version of the bill “dead on arrival” and the current version “not the repeal bill we all wanted.” On Thursday, he voted to pass it anyway.
But Republicans have consistently promoted their health care bill’s advantages as a tax cut and a setup for tax reform. After the House’s passage of the bill, President Trump said it “really helps” to get the biggest tax cut in the nation’s history.
In March, for the earlier version of the bill, Speaker of the House Paul Ryan explained the need to move quickly. “The schedule that we have here is very aggressive, and we can’t get to tax reform until we do this,” Mr. Ryan said.
The desire to set up tax reform is not the only reason Republicans pushed forward on the bill. Many were motivated by a desire to make good on a promise to repeal a law that they had spent years opposing.
But the focus on tax cuts explains why they were so eager to move on an unpopular bill that they had not read and struggled to defend or even describe. And it explains why the bill is so poorly conceived as health policy.
The Senate may rewrite the bill, but it’s difficult to imagine a version in which most of Obamacare’s taxes are left in place. Remember the primary debate moment in 2011 when all of the Republican presidential contenders said they wouldn’t trade $1 in taxes for $10 in spending cuts? The principle applies in 2017: Tax cuts are the one thing every Republican agrees on.
To be clear, I believe there are good reasons to support both cutting taxes and reforming the tax code. But I also think Republicans often do themselves a disservice by prioritizing those goals above all else.
It is not too hard to imagine, for example, that if the Republican bill becomes law in something like its current form, and the exchanges melt down, disrupting coverage for millions in the process, that the result will be calls for further government intervention — for bailouts and, if the system collapses into complete chaos, movement toward a government-run public option, or single payer.
Those options would require tax increases of a size that might otherwise make even many Democrats think twice — and would make the higher taxes included in Obamacare seem paltry by comparison.
That’s why tax-focused supporters of the American Health Care Act should be wary: It is not only flawed as a health care bill. In the long run, it is flawed as a tax policy plan, too.
Where’s Ivanka When We Need Her?
by Gail Collins - NYT - May 5, 2017
Ivanka’s got a new female empowerment book, and Dad’s going to war against women. Great week, gang.
In just the last few days, the Trump administration has taken steps to restrict health insurance coverage for contraceptives, while bullying the House into passing legislation that could send insurance rates for maternal health care soaring. Meanwhile, the president picked a new official to disseminate the administration’s thoughts about public health, and it’s a woman who believes that abortions cause breast cancer.
Triple score for the extreme right. I believe in hockey they call that a hat trick.
And wait, there’s more: Trump’s reported choice to run the government’s programs on family planning is someone who doesn’t believe contraception works. And of course that House-passed health care bill is going to defund Planned Parenthood. The measure now goes to the Senate, where Republicans have put together a special 13-man committee to draft their version.
It was, at minimum, deeply ironic that while all this was happening, Ivanka Trumpreleased a new book that calls on readers to fight against “barriers that disproportionately affect women” at work. Everybody who thinks unwanted pregnancies are a barrier, please raise your hands.
Under normal circumstances, we’d give Ivanka’s slim tome, “Women Who Work,” a pass. Or link you to Jennifer Senior’s review in The Times, which calls it “not really offensive so much as witlessly derivative.” It’s stuffed with obvious tips and multitudinous inspirational quotes on leadership, one of which comes from John Quincy Adams, an unsuccessful president who nobody liked. His wife was so empowered she wrote a White House memoir titled “Adventures of a Nobody.” One of his sons called him “the Iron Mask.” Do you think Ivanka’s a John Quincy Adams fan? Or has another Trump ghostwriter been over-Googling?
Ivanka’s a major power in the administration, and she ought to be mobilizing support for things like easy access to contraceptives. “Women Who Work” isn’t exactly aimed at the people who have problems paying for their prescriptions — its target readers need tips on massage priorities and getting the nanny to send Mom pictures of how the kids are spending their day. But she’s not witless and she obviously knows that birth control plays an important role in working women’s lives. You think she’d put in a word.
No sign. The president has directed departments like health and human services to consider whether the government should allow employers who cite religious objections to cut contraceptives out of their health care plans. What do you think said agencies will decide? Here’s a hint: The new head of H.H.S., Tom Price, is a guy who once claimed there was “not one” woman who had ever had a problem paying for birth control on her own. (Getting an intrauterine device implanted can cost $1,000 in some parts of the country.)
The reproductive rights war is always promoted publicly as a battle against abortion. But many religious conservatives hate birth control in general. Some just want to stop sex outside of marriage. Some don’t believe even married couples should use artificial methods like pills or condoms. Some believe that all fertilized eggs are humans and that many forms of contraception, from IUDs to morning-after pills, cause the equivalent of murder. It’s a theological principle that most Americans don’t accept. “Personhood” amendments giving the eggs constitutional rights have been defeated even in very conservative states.
Yet the president has just named, as one of the top officials in H.H.S., a woman who believes IUDs kill. Charmaine Yoest described intrauterine devices to Emily Bazelon in a Times interview as having “life-ending properties.” Yoest, who’s going to be assistant secretary for public affairs, also refuses to consider whether increased access to contraception will actually help reduce abortion rates. It would, she told PBS, “be, frankly, carrying water for the other side to allow them to redefine the issue in that way.”
Teresa Manning, a former official at National Right to Life, is said to be Trump’s pick for another high post at H.H.S., deputy assistant secretary for — are you ready? — population affairs. Manning, who, like Yoest, has argued that abortions cause breast cancer, is going to be in charge of all federal family planning programs. She’s the one who once claimed in a radio interview that “contraception doesn’t work.” The idea that “contraception would always prevent the conception” was, she said, “preposterous.”
Nobody thinks these appointees reflect Trump’s own personal convictions, and the president doesn’t need to go this far to satisfy his voter base. It’s just that he doesn’t care, and figures he can concede to the ultraright on women’s reproductive issues in return for stuff he really wants. So he’s working toward a world where low-income women won’t be able to afford contraceptives. And aren’t allowed to have an abortion if they get pregnant. Where there’s no Planned Parenthood to go to for help, or insurance to cover prenatal care or delivery.
Other than that, no problem.
Republicans are accidentally paving the way for single-payer health care
by Eugene Robinson - Washington Post - May 9, 2017
Sooner or later, we will have universal, single-payer health care in this country — sooner if Republicans succeed in destroying the Affordable Care Act, later if they fail.
The repeal-and-replace bill passed by the House last week is nothing short of an abomination. It is so bad that Republicans can defend it only by blowing smoke and telling lies. “You cannot be denied coverage if you have a preexisting condition,” House Speaker Paul D. Ryan (R-Wis.) said — true in the narrowest, most technical sense but totally false in the real world, since insurance companies could charge those people astronomically high premiums, pricing them out of the market if, as often happens, they let their coverage lapse. “There are no cuts to the Medicaid program,” Health and Human Services Secretary Tom Price said — a bald-faced lie, given that Republicans want to cut $880 billion from Medicaid in order to offset a big tax cut for the rich.
The nonpartisan Congressional Budget Office predicted that an earlier version of the American Health Care Act, as Trumpcare is officially called, would result in 24 million Americans losing health insurance over the next decade, with 14 million of those unfortunates losing coverage within the first year. Republicans rushed to vote Thursday on the final bill before the CBO had a chance to score it, doubtless fearing the projected decimation could be worse.
I can’t think of a more effective way to drive the nation toward a single-payer system. In their foolish haste to get rid of Obamacare, Republican ideologues are paving the way for something they will like much less.
The country will ultimately be much better off, though. Every other rich industrialized nation has found that truly universal health coverage is like what Churchill said about democracy: It’s the worst system except for all the others that have been tried.
When President Barack Obama decided to tackle health care, he chose a framework that had been developed at the right-leaning Heritage Foundation. The ACA is based on what began as Republican ideas: maintain the basic system of employer-based health insurance provided by private-sector companies; set up exchanges to service the individual market; provide subsidies to help the working poor afford insurance; expand the reach of Medicaid; guarantee reasonably priced coverage to those with preexisting conditions; and impose an individual mandate to ensure that younger, healthier people either buy insurance or pay a fine.
It’s a complicated scheme but it can work, as Republican Mitt Romney proved when he enacted a similar plan as governor of Massachusetts. And because the ACA maintained the basic private-sector structure of our health-care system, Obama reasoned that surely it would win some GOP support in Congress.
He was wrong. Only Democrats voted for the ACA, and Republicans turned its repeal into a partisan crusade — leading, eventually, to Thursday’s vote.
I have always believed, however, that Obama was prescient in seeing that the ACA would have a larger impact that would be difficult if not impossible to erase, no matter what Republicans did to the law itself: It established the principle that health care, as Obama said in accepting the Profile in Courage Award at the John F. Kennedy Presidential Library and Museum on Sunday, is “not a privilege but a right for all Americans.”
Ryan and other House Republicans obviously disagree, but polling suggests they are increasingly out of step with the nation. In Gallup’s most recent survey, the ACA had an approval rating of 55 percent, its highest to date. Perhaps more significantly, 52 percent of those polled a few months ago agreed with the statement that “it is the responsibility of the federal government to make sure all Americans have health care coverage,” vs. 45 percent who disagreed — a sharp turnaround in the past couple of years.
Those majorities may seem less than overwhelming, but the trend lines are clear. If tens of millions of Americans lose their insurance coverage and the most popular provisions of Obamacare are nullified, how do you think opinion will evolve?
If nervous Senate Republicans refuse to walk the plank, Obamacare will remain in place. But President Trump and the GOP majorities in Congress now own the health-care issue, and if they don’t stop trying to sabotage the ACA and instead try to make it work, voters will be angry. And if the Senate does go along with the House, I believe many Democrats will run in the 2018 midterms — and win — on Sen. Bernie Sanders’s pledge of “Medicare for all.”
'Enjoy the health-care win, Republicans. It's the last one you'll have in a while.'
As President Trump and Republicans celebrate the passage of the GOP health-care bill in the House, The Post’s Jonathan Capehart offers this piece of advice: Enjoy it while you can. (Video: Adriana Usero, Bastien Inzaurralde/Photo: Jabin Botsford/The Washington Post)
With their anti-Obamacare fanaticism, Republicans are putting single-payer on the table. Thanks, GOP.
Republican Death Wish
by Charles Blow - NYT - May 8, 2017
The obscene spectacle of House Republicans gathering last week in the Rose Garden to celebrate the House’s passage of a bill that would likely strip insurance coverage from tens of millions of Americans, while simultaneously serving as a massive tax break for the wealthy, had the callous feel of the well-heeled dancing on the poor’s graves.
Republicans had painted themselves into a corner. For seven years they had incessantly defamed the Affordable Care Act as nothing short of a dispatch from the devil. They told their constituents that they had a better plan, one that provided everything people liked about the A.C.A. and eliminated everything they didn’t.
As Donald Trump claimed in January, “We’re going to have insurance for everybody.” He continued, “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”
That, like so much else coming from these folks’ mouths, was a lie.
The bill passed by the House eliminates popular features like guaranteed price protections for people with pre-existing conditions, by allowing states to apply for waivers to remove these protections. Instead of universal insurance coverage, regardless of whether one could “pay for it” as Trump promised, the bill would move in the opposite direction, pricing millions out of coverage.
The A.C.A. had made a basic societal deal: The young, healthy and rich would subsidize access to insurance for the older, sicker and poorer. But this demanded that the former gave a damn about the latter, that people genuinely believed that saving lives was more important than saving money, that we weren’t living some Darwinian Hunger Games of health care where health and wealth march in lockstep.
Once again, the party that is vehemently “pro-life” for “persons” in the womb demonstrates a staggering lack of empathy for those very same lives when they are in the world. What is the moral logic here? It is beyond me.
Let’s cut to the quick: Access to affordable health care keeps people alive and healthy and keeps families solvent. Take that away, and people get sick, run up enormous, crippling debt and in the worst cases, die. It is really that simple.
People may conveniently disassociate a vote cast in marbled halls from the body stretched out in a wooden box, but make no mistake: They are linked.
In House Speaker Paul Ryan’s feckless attempt to defend this moral abomination of a bill during his floor speech last week, he said, “Let’s give people more choices and more control over their care.”
But this so-called restoration of choice would be in practice, for many, a sentence to death.
Republicans like the Idaho congressman and House Freedom Caucus member Representative Raúl R. Labrador deny this most basic of truths. Labrador said last week at a town hall, “Nobody dies because they don’t have access to health care.” It was a stunning expression of idiocy.
According to a 2009 study conducted by Harvard Medical School and Cambridge Health Alliance, “nearly 45,000 annual deaths are associated with lack of health insurance,” and “uninsured, working-age Americans have a 40 percent higher risk of death than their privately insured counterparts.”
An analysis last month by the Center for American Progress estimates removing price protections for pre-existing conditions would mean that “individuals with even relatively mild pre-existing conditions would pay thousands of dollars above standard rates to obtain coverage.”
Republicans are likely to pay dearly for this outrage. Nate Silver expressed his thoughts in a piece headlined: “The Health Care Bill Could Be A Job-Killer For G.O.P. Incumbents,” pointing out that the Republican bill is even more unpopular than the Affordable Care Act was when it was being debated, and if Republicans face the same electoral backlash that Democrats faced, “it could put dozens of G.O.P.-held seats in play.” Silver acknowledges that there are “mitigating factors” that could soften the blow for Republicans, but conversely adds, “There’s even a chance that Republicans could suffer a bigger penalty than Democrats did.”
On Friday, The Cook Political Report changed its ratings in 20 districts “all reflecting enhanced opportunities for Democrats” and pointed out:
“House Republicans’ willingness to spend political capital on a proposal that garnered the support of just 17 percent of the public in a March Quinnipiac poll is consistent with past scenarios that have generated a midterm wave.”
Not only is the bill unpopular among voters, it’s also unpopular in the medical establishment. As The New York Times reported on Thursday: “It is a rare unifying moment. Hospitals, doctors, health insurers and some consumer groups, with few exceptions, are speaking with one voice and urging significant changes to the Republican health care legislation that passed the House on Thursday.”
Whatever eventually comes of the bill, the death threat it poses for many Americans may well be a death wish Republicans have just issued for their own careers. As House Democrats sang as their Republican colleagues made their self-immolating votes: “Na, na, na, na, hey, hey, hey, goodbye.”
As Health Bill Goes to Senate, Maine Groups Hope for Fixes
by Patty Wight - Maine Public - May 5, 2017
A day after House Republicans passed their health care overhaul bill, the spotlight is now on the U.S. Senate. Advocacy groups for Maine physicians, hospitals and consumers say the American Health Care Act would have disastrous consequences for patients and are looking to the Senate to fix it.
Democratic U.S. Rep. Chellie Pingree of Maine’s 1st District, who opposed the bill, says advocacy groups aren’t the only ones looking to the Senate to improve the AHCA. She says some House Republicans are as well.
“I talked to many of my colleagues individually who said, ‘Oh, don’t worry about this. It’s not that good of a plan, but the Senate will fix it,’” she says.
To many opponents, “fixing it” means scrapping the whole bill altogether. At a press conference in her Portland office Friday, Pingree was joined by advocacy groups Consumers for Affordable Health Care and Maine Equal Justice Partners, as well as Planned Parenthood and the Maine Medical Association.
MMA’s Gordon Smith says the Republican bill creates more losers than winners.
“This bill, the losers are the poor, those who are sick, those who are old, and women. And in the state of Maine, we have a lot of all four,” he says.
Physicians and hospitals also lose, he says, because fewer people will have insurance coverage.
Republican U.S. Rep. Bruce Poliquin of Maine’s 2nd District sees it differently. On a conference call with reporters Thursday, he said he supports the AHCA because it will improve access to health care in rural Maine.
“Hundreds of Maine families in our Congressional District, which I represent, have asked me to help make sure they have access to health insurance at a cost they can afford, and that they will have coverage for pre-existing health conditions,” he said.
Poliquin also said the bill would only affect the 7 percent of Mainers who purchase insurance on the individual market. But Smith and others dispute his claims.
“This bill is not about 7 percent of people in Maine. It’s about every single Mainer. Because every single one of us, whether we have insurance or not, we’re gonna pay for health care. And all of our costs will go up, because people will wait too long to get care, they won’t get good primary care, but they’re still going to show up in the hospital. And that cost is all going to be shifted onto the rest of us,” he says.
Critics say the American Health Care Act eliminates many of the protections under Obamacare that made insurance affordable.
The Republican bill would allow insurance companies to charge older consumers five times as much as younger consumers. Insurance companies could also charge consumers based on their health status. Tax credits would be based on age instead of income. The 10 essential health benefits insurance companies are required to cover would be optional.
And the AHCA cuts Medicaid by converting it into a per capita cap, or block grant program.
“And what that means for Maine is that $1 billion will be lost for our state,” over the next 10 years, says Ann Woloson of Maine Equal Justice Partners.
Woloson says it would affect the 50,000 seniors, 65,000 people with disabilities, and 100,000 children on MaineCare.
The AHCA also blocks federal Medicaid reimbursements to Planned Parenthood, which covers preventive care. Federal money is not used to pay for abortions except in extreme circumstances. Planned Parenthood of Northern New England’s Nicole Clegg calls the AHCA the worst bill for women’s health in a generation.
“We are gravely concerned about the fact this is moving forward to the Senate. And we look to Maine’s senators to take a leading role in fixing what’s wrong and standing up for Planned Parenthood,” she says.
In terms of fixing, those at the press conference, including Smith, couldn’t identify a single aspect of the AHCA to retain.
“This bill is good for young, healthy, and wealthy individuals. It’s bad for the very people that government is supposed to be helping. And a lot of those people are in rural Maine,” he says.
As for a new policy that would improve health care, Woloson says the Senate should eliminate the provision in Medicare that blocks the U.S. from negotiating drug prices.
“If we got rid of that clause, and enabled the United States to negotiate on behalf of our elderly people to bring down the cost of drugs, that would save us billions of dollars,” she says.
Independent U.S. Sen. Angus King of Maine has criticized the AHCA, calling it a “shift and shaft” that will cost Maine people their health insurance. Republican U.S. Sen. Susan Collins of Maine says she has more questions than answers about whether the bill will make health care more affordable and increase access to quality care.
Health Act Repeal Could Threaten U.S. Job Engine
by Nelson D. Schwartz and Reed Abelson - NYT - May 6, 2017
From Akron to Youngstown and Canton to Cleveland, as in cities and towns across the country, workers who once walked out of factories at the end of each shift now stream out of hospitals.
While manufacturing employment has fallen nearly 40 percent in northeastern Ohio since 2000, the number of health care jobs in the region has jumped more than 30 percent over the same period. In Akron, the onetime rubber capital of the world, only one of the city’s 10 largest employers still makes tires. Three are hospitals.
“People who used to make deliveries to factories are now making them to hospitals,” said Samuel D. DeShazior, Akron’s deputy mayor for economic development.
Akron’s transformation is echoed in places as varied as Los Angeles, Birmingham, Ala., and Pittsburgh, along with rural areas like Iron County, Mo., where health care accounts for one-fifth of all employment.
The outsize economic role of the American health care industry heightens the risks posed by the Republicans’ effort in Washington to repeal the Affordable Care Act, enacted in 2010 under President Barack Obama, and it comes at a delicate moment for the broader economy.
While the government reported Friday that unemployment was at its lowest point in more than a decade, the health care industry has been an engine for much of that hiring, adding jobs at more than three times the rate of the rest of the economy since 2007.
Nor is the growth limited to hospitals. With help from the vast expansion of Medicaid enrollment that began three years ago, nursing homes, outpatient centers and medical labs have also grown, turning a fragmented industry into a strong political force.
Governors on both sides of the aisle, as well as many moderate Republicans on Capitol Hill, have expressed concern over whether the repeal will hurt local economies, especially in places where health care has softened the blow from struggling industries like retailing now or manufacturing in the past.
Moreover, in a recovery plagued by uneven growth and widening income inequality, the sector has been a reliable source of steady gains. Health care now equals almost one-fifth of gross domestic product, up from 13 percent in 2000, and it is poised to leapfrog retailing and leisure and hospitality as the second-largest source of overall employment, after professional and business services, accounting for one in eight private sector jobs.
The boom in health care did not begin with the Affordable Care Act. The industry was among the only parts of the economy to emerge relatively unscathed from the Great Recession, and it has flourished under Democratic and Republican presidents alike.
“Demographics and the expansion of Medicare and Medicaid in past decades contributed to the rise of health care’s share of the economy, and Obamacare extended that,” said Michael Gapen, chief United States economist at Barclays. Nevertheless, he warned that if the legislation approved by the House on Thursday were to become law, which is far from certain given skepticism of the bill in the Senate, it could undermine overall economic growth.
“It’s not trivial, and it’s much easier to constrain activity than to promote it,” Mr. Gapen said. “Reversing Obamacare is negative for the economy in the next year or two.”
The cost of providing coverage to millions more Americans has its own economic consequences.
Many employers, particularly small businesses, complain that they are straining under the demands imposed by the law. They argue that the A.C.A. stifles economic growth by forcing companies to pay heavy taxes and meet cumbersome regulatory burdens. Critics of the law, including many of the Republican backers of the proposed overhaul, say businesses and individuals are also being forced to pay for overly generous coverage.
Whatever the macroeconomic dangers, economists say the potential effects on individual consumers are just as worrisome. The House version of the repeal legislation does include significant tax cuts, which usually stimulate economic activity, but with most of the savings going to wealthier households, that bounty is likely to be saved, not spent.
At the same time, losing insurance coverage tends to constrain household spending while increasing financial insecurity among families, according to Matt Notowidigdo, a professor of economics at Northwestern.
A 2016 paper Mr. Notowidigdo worked on showed that an uninsured hospital stay doubles the risk of bankruptcy for individuals, while lowering credit scores and leaving consumers with an average of $6,000 in unpaid bills.
The proposed legislation poses more risks for some parts of the country than others, said Mark Duggan, a professor of economics at Stanford.
For example, about 9 percent of the population in Florida buys coverage through the new exchanges created under the Affordable Care Act, more than any other state. “If you lower the subsidies for coverage of 1.8 million Floridians, that will reduce what they can spend on other goods and services,” he said.
Mr. Duggan said states like Kentucky, Arkansas, New Mexico and West Virginia would be hard hit by the planned cuts in Medicaid, estimated at more than $880 billion over 10 years.
Another vulnerable slice of the population is workers who are a few years away from 65, when Medicare kicks in. “If there is a group that loses out the most, it’s near-seniors,” said Craig Garthwaite, director of the Healthcare Program at Northwestern’s Kellogg School of Management. “Their health care is so expensive, but the tax credit in the House bill caps out at $4,000.”
Mr. Garthwaite, who is a registered Republican and describes himself as a conservative economist, said there were few benefits for local economies in the bill, “and from an individual standpoint, it will be financially crippling for the poor.” Already, he added, “we’re seeing hospitals pause and adjust to the uncertainty by rethinking expansion plans.”
Hospitals in particular have been able to grow in recent years, with more of their patients now covered by either Medicaid or insurance purchased in the new exchanges.
At the same time, an aging population and expensive new treatments like drugs to treat hepatitis C and once-fatal forms of cancer have increased demand from consumers at many health care providers, even as they have strained budgets. Health care now accounts for nearly a fifth of overall consumer spending.
The potential loss of billions of dollars in federal money to states like New York, where large health systems like Northwell and Mount Sinai Health are among the biggest private employers, has helped turn state officials like Gov. Andrew M. Cuomo into vehement critics of the repeal efforts. The state estimated that the repeal could shift more than $2.4 billion in costs onto taxpayers and hospitals each year.
Economists on both the left and right say the Affordable Care Act needs substantial changes to ensure its long-term sustainability. They warn, however, that the current House legislation is so sweeping and its changes so abrupt that it carries economic risks of its own, especially given the size of the health care sector and how slowly other parts of the economy are growing.
Health care workers, too, have been watching the developments in Washington warily.
Oscar Onteveros, 37, began working as a nursing assistant at the Los Angeles County-University of Southern California Medical Center three years ago, after working for years in factories and in temporary jobs.
“I thought it would be more stable than working in labor and I would be able to move up,” he said. “I am worried about what happens next because nothing seems certain.”
In assessing the impact of the Republican House bill in an earlier form, the Congressional Budget Office estimated that 24 million people would lose insurance over the next decade as a result of cuts to the Medicaid program and the decline in people able to pay for individual coverage.
Potential changes to Medicaid are “going to put incredible pressure on the states, that will put incredible pressure” on what hospitals receive in payments, said Daniel Steingart, who follows the industry for Moody’s Investors Service. How states would react could vary significantly, he said, with some doing more to make up for the shortfall from the federal government.
Safety-net hospitals and academic medical centers that cater to low-income populations are likely to be hardest hit by any cuts, Mr. Steingart said.
The overall industry has benefited from the strong economy and the coverage expansions under Medicaid, he said. “People have jobs and they have insurance,” he said. About 20 million people gained coverage under the federal health care law. Hospitals have seen significant demand, and they “are hiring like crazy,” Mr. Steingart said.
Hospital executives said they faced tremendous uncertainty. Many, like Dr. Akram Boutros, the chief executive of the MetroHealth System in Cleveland, were talking with lawmakers to make the case against the bill’s abrupt cuts to Medicaid, hoping for some relief in the Senate. The Ohio Medicaid expansion has “been incredibly important to the health of the community,” he said.
Like other executives, Dr. Boutros argues that health system groups need to find ways of reducing the overall cost of care.
“The system as constituted today is underperforming and failing the American public,” he said. Hospitals could deliver better care for less money, he said, pointing to a program at MetroHealth that improved the health of people with hypertensionand diabetes while saving $1,500 a patient a year.
Mr. Steingart agreed, arguing that with Washington fixated on the issue of coverage, the difficult debate over how to control costs has not yet taken place. “What’s been missing is what makes health care so expensive in this country,” he said. “We haven’t tackled that issue, and it’s a big one.”
The House health care bill faces an uphill battle in the Senate, which seemed likely to soften some large cuts outlined in the House version that were put in to make the legislation more palatable to conservative Republicans.
Still, the prospect of cuts of any size has challenged hospitals to try to provide lower-cost care while preparing themselves to absorb the loss of paying patients.
Many health systems say their expenses are climbing much faster than the payments from government programs like Medicare and Medicaid. This month, Advocate Health Care, one of the Chicago area’s largest employers, announced plans to cut expenses by $200 million. Advocate Health blamed the cost of providing care for which it was not reimbursed. “Our expenses must be adjusted to meet current and projected Medicare, Medicaid and commercial insurance payment rates,” Jim Skogsbergh, the chief executive, said in a memo to employees.
Atlantic Health System in Morristown, N.J., which benefited from the expansion of Medicaid and the falling number of people without insurance, faces the possibility of losing $65 million a year in revenue.
The system’s chief executive, Brian Gragnolati, talked to his staff on Thursday about the possible impact of the House bill. “What I worry about in our organization is how are we going to lean into the changes we need to make while we have this uncertainty hanging there,” he said.
But Mr. Gragnolati also worried about the health bill’s potential effects on patients, some of whom have gained access to care for the first time.
“What is going to happen here is when people don’t have access now to care, they will go back to the emergency departments for their primary care, waiting and waiting and waiting” to get a condition treated, Mr. Gragnolati said. “I just feel like we’re going back in time to a place where we were a decade ago. It’s an absolute shame.”
Free-standing ERs offer care without the wait. But patients can still pay $6,800 to treat a cut.
by Carolyn Y. Johnson - Washington Post - May 7, 2017
Not far from neighborhood streets lined with million-dollar homes here lies an open-air mall where people go to eat, shop and — when needed — get emergency medical treatment. People pull up to the front door, park next to a gleaming antique ambulance and enter a waiting room that feels more like a graceful hotel lobby than a holding area for sick people.
It isn’t a clinic or an urgent care — it’s an emergency room, without the hospital.
When lawyer Richard Yount opened the facility, called Elite Care Emergency Center, in 2009, the idea was simple: Emergency rooms were crowded, with miserable waits and rushed doctors. He could fix that — and make a lot of money — by carving the department out of the hospital, putting it in a neighborhood where people without insurance were unlikely to show up and charging hospital-level prices.
There was just one problem: People assumed it would be cheap, especially at first. “No matter how many times you tell people you’re an emergency room, they have a tendency to think: If you’re in that kind of an environment, you’re an urgent care,” said Yount, who now operates four free-standing ERs.
Free-standing ERs, stand-alone facilities where people can receive acute care any time of day, have increased in Texas in recent years as a result of a 2009 law that permitted the establishment of emergency rooms independent of hospitals. They join a host of other on-demand facilities — including hospital ERs, hospital-owned satellite ERs, “microhospitals” and urgent-care facilities — where people can receive care, especially if they have robust health insurance.
Texas’s wild west of competition, with lit-up signs advertising “SHORT WAIT TIME FOR LACERATIONS” and highways punctuated by warring billboards, is a leading example of how an emerging wave of convenient medical-care options for Americans can also create confusion and lead people to seek expensive treatment for conditions that might not merit it, pushing up costs across the health-care system.
Across 32 states, more than 400 free-standing ERs provide quick and easy access to care. But they also are prompting complaints from a growing number of people who feel burned by hospital-size bills, like $6,856 for a cut that didn’t require a stitch or $4,025 for an antibiotic for a sinus infection.
Emergency care requires costly imaging and laboratory equipment and facilities that are open 24 hours a day and staffed round the clock by a physician — and the costs reflect that. Prices for an average free-standing ER visit have grown and are now similar to hospital ERs, but patients with the same diagnosis rack up bills 10 times higher than at an urgent care, according to an analysis of one insurer’s Texas data by Rice University economist Vivian Ho. She found use of the facilities in Texas more than tripled between 2012 and 2015.
The high cost raises the question of whether people are seeking out more expensive care only because it’s convenient, not because it’s necessary.
“If there had not been a close, convenient emergency department, would that person have gone to an emergency department, or sought care somewhere else?” said Jeremiah Schuur, an emergency medicine physician at Boston’s Brigham and Women’s Hospital who studies the industry.
Texas’s flowering of free-standing ERs leads a debate about whether convenience makes people healthier or needlessly drives costs up — a central dilemma in health-care innovation. Health-care specialists want people to seek care that’s necessary. But with U.S. health-care spending surpassing $3 trillion this year, new attention is focused on how making health care a better consumer product might simply increase its use. Research shows, for example, that walk-in retail health clinics and telephone medicine, which might seem to replace more expensive options, actually tend to slightly drive up health-care spending.
“The vast majority of people who get sick on a monthly basis don’t go get care, don’t even think about getting care — and among those who do think, ‘I should go get care,’ only two-thirds of them end up getting a visit of some type,” said Ateev Mehrotra, a physician and researcher at Harvard Medical School who did that research. “There is an enormous market of people out there who . . . choose to get care when it’s convenient.”
Texas’s crowded landscape of ERs and clinics may seem like a consumer paradise, in which people are able to shop around. But it lays bare a simple truth: It’s hard to shop when no one knows what anything costs.
Bryan Piccola of Frisco, Tex., sliced his left pointer finger on July 4 when his knife slipped cutting tightly wound zip ties off a toy for his year-old daughter. He debated cleaning the wound up and sticking a bandage on it, but he went to a free-standing First Choice Emergency Room a few miles from his house. He asked beforehand how much it would cost, since he is a veteran and didn’t have separate insurance, and says he was assured it wouldn’t be too bad. He received five stitches and, later on, the bill: more than $5,000. The company discounted it to $2,888.
“You drive by them all the time. There’s a bunch of these little pop-up clinics,” Piccola said. “If they would have told me [how much it would cost], I wouldn’t have gone — I’d have gone home and wrapped it up and waited for the scar.”
Adeptus Health, the company that owns First Choice Emergency Room, declared bankruptcy in April. It declined a request for an interview.
‘Money just fell in your lap’
Richard Yount embarked on his career as an emergency room entrepreneur as Texas’s access to emergency care was hitting rock bottom, given a failing grade by the American College of Emergency Physicians. He had watched other hospital services, such as imaging centers, being spun into separate, lucrative businesses.
“You had not a lot of competitors and you had all the patients you’d ever want, and they paid a lot. Money just fell in your lap,” Yount said. “I watched this train go by for 30 different services, and I only caught onto the caboose.”
Yount’s insight was simple: In addition to the physician’s bill, hospitals were paid a “facility fee” to cover X-rays, CT scanners, laboratories, and round-the-clock staffing by physicians and nurses. Free-standing emergency rooms shared many of these costs, since they strive to deliver the same care available in a hospital ER, and the facility fee made the business viable.
By situating in well-off neighborhoods, they could largely avoid patients who couldn’t pay. Without a hospital affiliation, they cannot bill Medicare or Medicaid for emergency care, and many carry warnings on the front door that they do not accept those less-lucrative plans. And as a start-up, the free-standing ERs weren’t encumbered with the high administrative costs of a hospital.
Complicated cases, such as surgeries or trauma, could be sent by ambulance to a hospital, but stand-alone emergency room operators argue they can see people faster, keep them out of the hospital altogether and save money.
Yount, 68, is a jumble of contradictions. He is an unapologetic capitalist who operates four free-standing emergency rooms in Texas and is in the process of finding a site in Las Vegas to build a “microhospital” — an ER with some inpatient beds.
He is also a supporter of Sen. Bernie Sanders of Vermont and a strong believer in universal health care whose office is still decorated with light-blue signs from Sanders’s presidential campaign.
“I can believe in one thing on a macro level, as to what this country needs to do. But if I want to operate, I’m operating within the current system that we have. So I make the economic decisions based on the current system we have,” Yount said. “Doesn’t mean I have to like the current system — and I don’t.”
Yount says the start-up costs are about $5 million. In the early days, the business could break even with just seven or eight patients a day. The break-even point today is up to eight or nine, and Yount expects the number to rise as pressure from insurers increase.
The model appeals to many physicians and nurses.
“The mind-set is totally different here,” said Aaron Schwartz, an emergency physician at Elite Care. “In the hospital, it’s driven by surveys and scores, efficiency and throughput times and volume. . . . We can spend as long as the patients want us to spend with them.”
Some patients appreciate the convenience. Miguel Balli, 24, of Houston had spent a miserable night, vomiting and ill, when he showed up at Elite Care one Monday morning. Within an hour, he was getting an IV drip and beginning to feel better.
“These setups are a lot more beneficial for the patient as far as time concern and quickness and availability,” Balli said. “If you’re not the most serious person at the ER, if you’re not the one bleeding out or having a heart attack, you’re probably going to get last on the totem pole.”
A ‘misleading’ factor on costs
The problem is the flip side of the success: People who would have thought twice before navigating down to Houston’s crowded medical hub, the world’s largest medical center, have a surfeit of options right in the neighborhood.
In Sugar Land, an affluent suburban city south of Houston, there is St. Michael’s Emergency Center, right next to Emerus 24HR Emergency Hospital, a former free-standing ER that’s been converted into a small hospital. In the driveway, two identical signs look like mirror images, each directing people with an “EMERGENCY” in a different direction. A mile away, in both directions, are two hospitals.
The ease of access is a good thing if it is moving people to seek care for symptoms that would be dangerous to ignore.
Many free-standing emergency room operators say they do their utmost to stress to people that they are in an emergency room, with emergency room prices, and they refer patients with minor conditions to urgent-care facilities. The buildings have “emergency” signs on them and are required by state law to carry written warnings that they will charge a facility fee — although the amount is not disclosed.
But Ho of Rice University has found a big overlap in the types of conditions for which people seek care: Three-quarters of the 20 most common diagnoses at free-standing ERs were the same as at urgent-care centers. A slightly smaller overlap existed for hospital-based emergency rooms.
“It’s fine if it generates the value of the price that is paid, but if it’s not generating that value, then all it does is raise costs for everybody,” Ho said. “There needs to be more transparency in terms of the cost. Why should it be comparable to what a hospital ER is charging?”
But even as free-standing emergency rooms defend themselves, the model appears to be evolving, in part in response to the confusion. Yount provided a tour of what he says is the future: a large free-standing ER that stands apart from shopping malls and wouldn’t easily be mistaken for an urgent-care clinic. One of his competitors, Emerus, switched to building “microhospitals.”
Free-standing ERs blame insurers for big bills, arguing they deny claims or underpay them. Insurers, in turn, blame the facilities for charging high prices.
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“There’s this misleading factor, or I’d go so far as to say deception,” said Shara McClure, a vice president at Blue Cross Blue Shield of Texas. “A member who’s having an incident, having an acute condition, they go into these free-standing ERs thinking they’re a cost-effective solution.”
The Texas legislature is considering bills that would help protect consumers from surprise bills and regulate the industry.
That points to the biggest lesson emerging from Texas’s experiment.
“We need to do more to make prices extremely visible to patients,” said Schuur, of Brigham and Women’s Hospital. “But it also calls into question the ability of patients to be smart consumers, particularly in the time when they have what they perceive as an acute health-care need.”
U.S. life expectancy varies by more than 20 years from county to county
by John Achenbach - Washington Post - May 8, 2017
Eight counties with the largest decreases in life expectancy since 1980 are in Kentucky. (Michael S. Williamson/The Washington Post)
Life expectancy is rising generally in the United States, but in some areas, death rates are going conspicuously in the other direction. These geographical disparities are widening, according to a report published Monday in JAMA Internal Medicine.
Life expectancy is greatest in the high country of central Colorado, but in many pockets of the country, life expectancy is more than 20 years lower, according to the report from the University of Washington’s Institute for Health Metrics and Evaluation.
“Life expectancy in many places in this country is declining. It’s going backward instead of forward,” said Ali Mokdad, a co-author of the report and a professor at the university. “These disparities are widening, so this gap is increasing.”
People are less likely to live longer if they are poor, get little exercise and lack access to health care, but even with those factors taken into account, geography matters. Mokdad said that, even where health care is available, the quality of that care varies significantly. For example, women have much better health outcomes when they have regular screenings for breast cancer and a better chance at detecting any cancer early, he said.
“Once somebody has a condition, how long did it take to get into the medical care? To receive that intervention that they need?” Mokdad said.
The researchers looked at death certificates from 1980 through 2014. Among the places with sharply increased life expectancy and lower deaths over that period are the District of Columbia and Loudoun County, Va. — where life expectancy is up 12.8 and 12.4 percent, respectively. Fairfax County has the lowest all-cause death rate in the metropolitan Washington region, significantly lower than the national average.
Of the 10 counties where life expectancy has dropped the most since 1980, eight are in Kentucky. The other two are in Oklahoma and Alabama. The report includes aninteractive map of death rates county by county (and sometimes by city, when a city is not part of a county). The areas with the worst mortality metrics include central Appalachia, the Mississippi Delta and areas in the Dakotas with large Native American populations.
The list of counties with the most improved life expectancy includes a number of remote locations in Alaska, including the North Slope and the Aleutian Islands, and the boroughs of Manhattan (aka “New York County”) and Brooklyn (Kings County), as well as San Francisco.
An earlier study from the same research organization showed a huge disparity in the death rate from lung cancer. Summit County in Colorado, home to ski resorts and the town of Breckenridge, had almost no lung cancer mortality — a death rate of 11 per 100,000 population in 2014. The county with the highest rate, 231 per 100,000, was rural Union County, Fla., a small county that is home to a large prison population.
Collins: U.S. Senate Will 'Start From Scratch' On Health Care Bill
by Maine Public Staff - May 8, 2017
WASHINGTON - As the contentious debate over overhauling the nation's health care system shifts to the Senate, moderate Republican Sen. Susan Collins, of Maine, says the Senate will not take up the House bill and will instead start from scratch.
Collins is among some senators who have already voiced displeasure with the health care bill that cleared the House last week. Collins told host George Stephanopoulos that some of the bill's provisions will hit hard in states with older, rural populations such as Maine.
Critics cite concerns about potential higher costs for older people and those with pre-existing conditions, along with cuts to Medicaid.
In addition, Collins said the Congressional Budget Office has not yet released its assessment of the impact of the bill.
Meanwhile, President Donald Trump is urging Senate Republicans to "not let the American people down." Trump's budget director, Mick Mulvaney, says the version of the health care bill that gets to the president will likely differ from the House measure. Such a scenario would force the House and Senate to work together to forge a compromise bill.
A health advocacy group is launching a six-figure advertising campaign this week targeting 24 Republican House members who voted to repeal Barack Obama's health care law.
Save My Care says the campaign will include a mix of TV and digital advertising, costing more than a half million dollars.
A health advocacy group is launching a six-figure advertising campaign this week targeting 24 Republican House members who voted to repeal Barack Obama's health care law.
Save My Care says the campaign will include a mix of TV and digital advertising, costing more than a half million dollars.
Maine 2nd District Rep. Bruce Poliquin, a Republican, supported the GOP health care bill. First District Democratic Rep. Chellie Pingree voted against it.
Barack Obama urges Congress to find courage to defend his healthcare reforms
by Sarah Betancourt - The Guardian - May 8, 2017
For the first time since leaving office, President Barack Obama has addressed his landmark healthcare legislation in a speech, reminding supporters of the courage and integrity of junior congressmen that it took to pass the bill.
Speaking at the John F Kennedy Presidential Library and Museum in Boston on Sunday night, where he was given the Profiles of Courage award, he said: “Because of that vote, 20 million people got healthcare who didn’t have it before.
“And most of [the congressmen who voted for it] did lose their seats. But they were true to what President Kennedy defined in his book – desire to maintain integrity that is stronger than the desire to maintain office – the faith that the right course will be vindicated. Personal sacrifice.”
“It is my fervent hope and the hope of millions ... such courage is still possible, that today’s members of Congress regardless of party are willing to look at the facts and speak the truth, even when it contradicts party positions.”
Obama spoke of what is at stake for the millions of Americans who stand to lose coverage if a repeal passes, without naming Donald Trump specifically.
And he implored members of Congress to demonstrate political courage even if it goes against their party’s positions.
The former president focused much of his address on the legacy of Kennedy, as the library prepared to mark the 100th anniversary of his birth later this month. Obama noted the Kennedys had long advocated for healthcare reform, and in particular, the late Senator Edward Kennedy, who died of brain cancer before passage of the Affordable Care Act.
Obama’s comments come a few days after the House squeaked through a partial repeal and replacement of Obamacare with a 217-213 vote, a long-promised goal of Republicans who have decried the bill since its passing.
The former president was awarded the Profiles of Courage by JFK’s daughter Caroline Kennedy, a former ambassador to Japan, and her son Jack Schlossberg.
Schlossberg, 24, introduced Obama to the crowd of 700 people in a rare public speech. He said, “My life changed in 2008 because a young candidate was fired up and ready to go, and he told me, ‘Yes we can.’ Without Barack Obama, I might still be sitting on my couch, eating Doritos and watching baseball games.” He cited Obama’s policy choices on healthcare reform, nuclear disarmament and gun control as reason for why he deserves the award.
The John F Kennedy Library Foundation, a nonprofit organization, created the Profile in Courage Award in 1989 to honor President Kennedy’s commitment to public service. The award is named for Kennedy’s 1957 Pulitzer prize-winning book Profiles of Courage, which recounts the stories of US senators he believed risked their careers by taking principled stands for unpopular positions. This year’s event marks the 100th anniversary of Kennedy’s birth on 29 May, 1917.
Previous recipients include Presidents Gerald Ford and George HW Bush, US representative Gabrielle Giffords and US senator John McCain.
The foundation said of Obama, “He picked up the rock from President Kennedy –affirming our belief in an America that is more than a collection of red states and blue states, and reminding all of us that no matter what we look like, where we come from, or what faith we practice, we are our brother’s and sister’s keeper.”
Democrat senator Edward Markey from Massachusetts did not mince his words on the red carpet outside of the event. “The healthcare bill that passed in the House of Representatives is dead on arrival in the US Senate,” he said.
“It is cruel, the cuts to Medicaid to seniors and disabled, it will take people who need health insurance and make these families live lives of misery.”
Congressman Joe Kennedy III said that Obama “exemplified the values we’re here to celebrate,” and how politicians on both sides of the aisle were inspired by his great-uncle who “challenged” his country.
Republicans Are Building An Alternate Reality Around Their Health Care Bill
by Dave Jamieson - Huffington Post - May 8, 2017
President Donald Trump pledged on the campaign trail that he would not cut Medicaid, the government program that provides health coverage to millions of Americans. But now Trump and Republicans are moving a health care bill that would slash Medicaid funding dramatically.
Confronted with Trump’s campaign promise on Sunday, the president’s health secretary Tom Price insisted there would be no Medicaid cuts at all under the GOP plan, even though the cuts are undeniable.
“Remember that there are no cuts to the Medicaid program,” Price told CNN’s Jake Tapper Sunday morning on “State of the Union.” “There are increases in spending. What we’re doing is apportioning it in a way that allows states to have greater flexibility… to care for their Medicaid population.”
In fact, the Republican bill that was passed in the House last week would cut federal funding for Medicaid by an estimated $839 billion, according to the Congressional Budget Office. The plan would shift costs onto states by capping Medicaid payments per recipient. It would also unwind the Medicaid expansion made possible by Obamacare, which extended health coverage to millions of people in 31 states and the District of Columbia.
Price noted that the CBO numbers assume that the Medicaid program continues in its current state. He seemed to be suggesting that the program would become so efficient as to make the cuts cited by the CBO irrelevant. His assertion that there would be increases in Medicaid funding may be based in the idea that the per-recipient caps would rise over time, even if the overall federal funding becomes woefully inadequate.
“Imagine a Medicaid system that actually works better for patients,” Price said. “What we’re fashioning is a system that would allow states to tailor the Medicaid system to those individuals.”
“Are you actually saying that $880 billion in cuts … however you want to talk about that not being a cut,” Tapper asked, “that that won’t result in millions of Americans not getting Medicaid?”
“Absolutely not,” Price responded.
Republicans had no easier time defending what their plan would do to people with pre-existing conditions.
Obamacare forbade insurance companies from rejecting or charging higher rates to people because of their medical histories. The GOP plan would allow states to waive that provision for insurers, enabling them to charge much higher rates to those with pre-existing conditions. In states with waivers, there would be what are known as high-risk pools to help cover the sickest people.
House Speaker Paul Ryan, speaking on ABC’s “This Week,” said people with pre-existing conditions should have “peace of mind” with the GOP plan.
“We have multiple layers of protections for people with pre-existing conditions,” Ryan said.
Ryan noted that under the Republican plan “you can’t charge people more if they keep continuous coverage.” But anyone with a pre-existing condition could be charged much higher rates if they had a lapse in their coverage for more than 63 days.
What’s more, high-risk pools have been traditionally underfunded, and the federal funding put forward in the GOP plan may not be enough to make the pools viable, even though a late amendment added another $8 billion over five years. Even some Republicans were willing to acknowledge this on Sunday.
Sen. Susan Collins (R-Maine) was asked on ABC’s “This Week” whether she thought the coverage for people with pre-existing conditions would be as good under the GOP plan as it is under Obamacare. “I think that’s unlikely,” Collins said.
Ohio Gov. John Kasich couldn’t keep a straight face when he was asked about the high-risk pools and whether the federal funding would be sufficient.
“Let me just tell you, this business of these [high]-risk pools, they’re not enough,” Kasich said on “State of the Union,” and he started to laugh. “Eight billion dollars is not enough to fund… it’s ridiculous.”
Donald Trump's homicidal healthcare bill will kill some, and enrich others
by Adam Gaffney - The Guardian - May 5, 2017
Let us imagine that you would like to redistribute hundreds of billions of dollars from working class people to the rich, and wouldn’t hesitate to risk the lives of tens of thousands of people to do so. Well, as luck would have it, there is a bill— the “American Health Care Act” (AHCA)—that does precisely that.
On Thursday, it squeezed through the House of Representatives. Trumpcare – at least for the moment – has been triumphant.
Many of us thought – or hoped – that Paul Ryan’s bill was as good as dead on 24 March, when, in a pleasurable political moment (a rare event these days), he admitted he lacked the votes to push it through. But where there is a will to degrade the healthcare safety net, there is a way. And, to the House Republicans’ credit, they indeed found a way to ram this grotesquerie through.
To do so, the hard right had to compromise with the harder right, which made the current version of the AHCA fouler than the original.
The harder right found much to like about the original bill – like its historic gouging of Medicaid. The problem was that it left too much of the regulatory infrastructure of the Affordable Care Act (ACA) intact. Rules that insurers must cover 10 “essential health benefits” and cannot discriminate against those with pre-existing conditions? Eliminate those provisions, and let healthcare freedom reign.
The compromises worked. First, there was the MacArthur amendment, which permits states to redefine “essential health benefits” (this would allow insurers to exclude coverage of some types of healthcare, such as maternity care), or to allow insurers to charge people with pre-existing conditions higher premiums if they failed to maintain coverage.
As Timothy Jost noted on the Health Affairs blog, the latter provision “could effectively make coverage completely unaffordable to people with pre-existing conditions”, notwithstanding the clearly inadequate high-risk pools.
So far, so good.
However, in appeasing the harder right, the House leadership risked estranging the less hard right. But the latter proved to be a cheap date: they were bought off by the Upton amendment, added at the eleventh hour, which gave another $8bn to the fund theoretically designed to cover those left behind by the AHCA. Though this was a drop in the bucket relative to the size of the problem created by the AHCA, it brought just enough moderates back on board to secure a winning vote.
If the AHCA were signed into law by Trump – an unlikely but not impossible proposition given the headwinds it faces in the Senate – the negative impact on ordinary Americans would be enormous.
Given that the House GOP didn’t bother to wait for the Congressional Budget Office (CBO) score before voting, we don’t know just how bad it will be. But relying on the CBO’s initial estimates, we can say that the AHCA will, over a decade, reduce spending on Medicaid alone by more than $800bn.
Together with savings from having less adequate, skimpier insurance subsidies, these reductions will allow hundreds of billions of dollars to be channeled to the wealthy and corporations in the form of tax cuts.
By enriching the rich in this manner, the AHCA would leave an estimated 24 million more uninsured by 2028. Similar calculations have already been done, but it’s worth briefly revisiting the blood-arithmetic on this.
Colleagues of mine recently reported estimates, in the American Journal of Public Health, of how many newly insured people there would have to be to prevent one death per year. These estimates, which, being estimates, aren’t perfect, were based on five studies. The numbers ranged from 300 to 1,239 people.
If we were to pick a round number on the conservative end of that range – say 1,000 – we would estimate that stripping insurance from 24 million people would produce an estimated 24,000 additional deaths annually. That is 40% more than the sum total of all murders, estimated by the FBI at 14,429 for 2014 (using somewhat different numbers, Vox’s Julia Belluz makes this point and comes to the same figure).
Now, in all fairness to House Republicans, as a critical care physician, I too get blood on my hands when I go to work. The only difference is I can wash mine off.
Modern medicine saves lives, while stripping healthcare coverage from millions to fund tax breaks for millionaires takes lives. There’s no way around it, whatever some may tell themselves to help them sleep at night.
This, of course, raises an even larger issue, namely the injustices of the healthcare status quo, wherein 28 million remain uninsured and even more without adequate coverage – shortcomings that leave open the door to continued attack from the right.
This execrable, homicidal bill must obviously be stopped. But that’s not all we must do. The most enduring defense against the rightwing saboteurs is not continued championship of a flawed status quo, but instead the promise of a better tomorrow: healthcare for all, through a single-payer universal system. That alone will put an end to these deadly assaults on healthcare.
https://www.theguardian.com/commentisfree/2017/may/05/donald-trumps-homicidal-healthcare-bill-enrich
Divided Senate Republicans Turn to Health Care With a Rough Road Ahead
by Robert Pear - NYT = May 9, 2017
WASHINGTON — The top Republican in the Senate, Mitch McConnell of Kentucky, has a reputation as a shrewd tactician and a wily strategist — far more than his younger counterpart in the House, Speaker Paul D. Ryan.
So the Senate majority leader’s decision to create a 13-man working group on health care, including staunch conservatives and ardent foes of the Affordable Care Act — but no women — has been widely seen on Capitol Hill as a move to placate the right as Congress decides the fate of President Barack Obama’s signature domestic achievement.
But Mr. McConnell, with only two votes to spare, could find that the Senate’s more moderate voices will not be as easily assuaged as the House’s when a repeal bill finally reaches a vote. Republican senators like Susan Collins of Maine, Lisa Murkowski of Alaska and Bill Cassidy of Louisiana may prove less amenable to appeals for party unity and legislative success when the lives and health of their constituents are on the line.
And certain issues, like efforts to reverse the expansion of Medicaid under the Affordable Care Act, are sure to receive more attention in the Senate than they got in the House. The prospect of higher premiums for older Americans living in rural areas will also loom larger in a chamber where Republicans from sparsely populated states hold outsize power.
“This process will not be quick or simple or easy,” Mr. McConnell said Monday.
Senator Mike Rounds, Republican of South Dakota, suggested that the Senate would spend at least two months working on the legislation.
The Senate Republican working group on health care includes the party’s top leaders, as well as three committee chairmen and two of the most conservative senators, Ted Cruz of Texas and Mike Lee of Utah.
Mr. McConnell’s decision to include himself and his top three lieutenants — but not Ms. Collins, Ms. Murkowski or more junior women Republicans like Deb Fischer of Nebraska and Shelley Moore Capito of West Virginia — speaks volumes about his direction and has raised eyebrows.
“The leaders have the right to choose whomever they wish,” Ms. Collins said Monday. “It doesn’t mean that I’m not going to work on health care.
“I’ve worked on health care for many years,” she continued. “I spent five years in state government overseeing the Bureau of Insurance many years ago, and I think I can bring some experience to the debate that will be helpful.”
By excluding Ms. Collins and Mr. Cassidy, perhaps viewed as potential troublemakers for the bill, Senate leaders may have inadvertently created a dangerous alliance. The two senators now have no obligation to fall in line behind the working group’s final product and will almost surely continue to work on their own ideas. Together, they and their allies could hold near-veto power.
Beyond neglecting Republican women, Senate Republican leaders overlooked Senator Tim Scott of South Carolina, the only black member of their conference. Before his congressional career, Mr. Scott sold insurance and owned one of the most successful Allstate insurance branches in South Carolina.
Mr. McConnell also left out of the group the only two Republican senators clearly in the Democrats’ cross hairs for 2018 — Dean Heller of Nevada and Jeff Flake of Arizona. With re-election campaigns looming, they will have their own political calculus to make. Both states have expanded Medicaid under the Affordable Care Act, providing coverage to hundreds of thousands of people.
Republicans, holding 52 seats in the Senate, can afford to lose only two members of their party on a vote to undo the health care law they have assailed for seven years. They will not receive any support from Democratic senators or the Senate’s two independents, but they can count on support from Vice President Mike Pence to break a tie, if needed.
Reince Priebus, the White House chief of staff, has said he expects the Senate to make improvements in the repeal bill that the House passed last week by a vote of 217 to 213. But senators have gone much further: The Senate is starting from scratch.
“Let’s face it,” Senator Orrin G. Hatch of Utah, chairman of the Finance Committee, said Monday. “The House bill isn’t going to pass over here.’’
Hospital executives, among the most outspoken critics of the House bill, are in town for the annual meeting of the American Hospital Association and will lobby the Senate this week. Thomas P. Nickels, an executive vice president of the association, predicted that the Senate would produce an “utterly different version” of the legislation.
Mr. McConnell is likely to find the same tricky dynamic that Speaker Ryan confronted in the House: Any bill that satisfies conservatives like Mr. Cruz and Mr. Lee risks alienating moderates like Ms. Collins and Ms. Murkowski.
Medicaid will also vex Republican leaders in the Senate in ways it did not in the House. Senators in both parties from states that have expanded the health care program for low-income people have expressed deep misgivings about the House bill, which essentially unravels the expansion.
Democrats said the Republicans’ failure to include women in the working group showed that they were politically clueless.
Senator Kamala Harris, Democrat of California, wrote on Twitter: “The G.O.P. is crafting policy on an issue that directly impacts women without including a single woman in the process. It’s wrong.”
The House bill would cut off federal funds for Planned Parenthood for a year and prohibit the use of federal tax credits to buy insurance that includes coverage of abortion. It would also allow states to seek waivers of provisions of the Affordable Care Act that require insurers to cover maternity care.
David Popp, a spokesman for Mr. McConnell, said on Monday that many Republicans were involved in devising a replacement for Mr. Obama’s health care law.
“Senators from throughout the conference have been working on solutions,” Mr. Popp said. “Those meetings and efforts continue.”
The Republicans’ working group includes Mr. McConnell and three other members of the Republican leadership: John Cornyn of Texas, the majority whip; John Thune of South Dakota, the chairman of the Senate Republican Conference; and John Barrasso of Wyoming, the chairman of the Senate Republican Policy Committee, who has been a point man for the party on health care.
The group also includes three committee chairmen: Mr. Hatch; Senator Lamar Alexander of Tennessee, chairman of the Senate health committee; and Senator Michael B. Enzi of Wyoming, the head of the Budget Committee.
The other senators in the Republican working group are from states that have expanded Medicaid under the Affordable Care Act: Tom Cotton of Arkansas, Cory Gardner of Colorado, Rob Portman of Ohio and Patrick J. Toomey of Pennsylvania.
The House bill would roll back the expansion of Medicaid, which has provided coverage to about 11 million people. The Congressional Budget Office said the bill’s Medicaid changes would save more than $800 billion over 10 years.
Savings would shrink if Congress allowed states to keep some or all of the Medicaid expansion.
For several weeks, senators have been working on possible changes to the tax credits offered in the House bill to help people buy insurance. Mr. Thune, for example, is drafting a proposal that would make the tax credits more progressive.
To people who do not have coverage at work or under a government program, the House bill would offer tax credits ranging from $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 over $75,000 a year and families over $150,000.
Mr. Thune, not wanting to create a new middle-class entitlement, would like to provide more financial assistance to lower-income people and less to higher-income people.
Senators are also focusing on the difficulty of administering the tax credits in the House bill, which could be used either inside or outside the public insurance marketplaces, or exchanges.
Under the Affordable Care Act, the exchanges perform a vital role, determining whether consumers are eligible for premium tax credits, which, in most cases, are paid directly by the Treasury to insurance companies on their behalf. Under the House bill, consumers could get the tax credits without going through an exchange.
The Internal Revenue Service has expressed concern. The House bill, it said, “appears to greatly expand I.R.S.’s current responsibilities” and “could impose significant costs and administrative burden” on the agency.
Bill Would Create Single-Payer Health Care System in Maine
by The Associated Press - Maine Public - May 9, 2017
AUGUSTA, Maine - A Democrat's lofty bill aims to create a single-payer health care system in Maine by 2020.
Democrat Rep. Heidi Brooks says her bill would create a pathway to a system financing health care for most Mainers.
Last week, dozens of Mainers testified in support of the bill, which has nine Democratic co-sponsors. The bill would direct legislative committees to submit another bill later this year to get the system going.
A legislative committee will decide whether to recommend the bill during a Wednesday work session.
The National Federation of Independent Business says Vermont abandoned pursuing a universal health care system after finding the taxes and premiums could hurt its economy.
The nonprofit Consumers for Affordable Health Care says a few meetings this year wouldn't be enough to draft comprehensive legislation.
Democrats target those who backed GOP health bill
by The Associated Press - NYT - May 9, 2017
WASHINGTON — Viewing Republican efforts to rein in the federal health care program as a political mistake, Democratic lawmakers and at least one outside group began laying the groundwork to challenge the GOP for control of the House in the 2018 midterm election.
The health advocacy group Save My Care on Monday announced the launch of a six-figure TV and digital advertising campaign beginning this week. It will target 24 Republican House members who voted last week to repeal the health care law enacted under President Obama.
White House chief of staff Reince Priebus scoffed at the notion that Republicans will lose control of the House in 2018.
He said the bill that narrowly cleared the House last week and that faces significant revision by the Senate will be an improvement over the current system of limited choice and rising costs.
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‘‘There are some times in life you have to do what’s right, not what’s politically expedient,’’ Priebus said. ‘‘We’re going to do something better, and we’re going to do our job as legislators to get this thing done. I think that the Republican Party will be rewarded.’’
House Speaker Paul Ryan, said he was not concerned about political fallout because of the vote.
‘‘We’re keeping our word,’’ Ryan said. ‘‘People expect their elected leaders, if they run and campaign on doing something, they expect them to do that. And that’s what we’re doing.’’ Ryan argued that ‘‘we would spell disaster for ourselves, politically . . . if we go back on our word.’’
House Minority Leader Nancy Pelosi of California, gleeful at the prospect of potentially reclaiming the House gavel in 2018, told Republicans they will ‘‘glow in the dark’’ over the vote.
The party that controls the White House traditionally loses seats in Congress in the election that follows a presidential inauguration. Unknown at this point, 18 months before the election, is how the health care vote could complicate that.
Among the lawmakers being targeted by Save My Care’s campaign is Tom MacArthur of New Jersey, the moderate Republican who helped revive the bill. MacArthur wrote an amendment that satisfied some lawmaker’s concerns about how the bill would treat people with pre-existing medical conditions.
Another target is Representative Dave Brat of Virginia, a member of the House Freedom Caucus, the group of conservative Republicans whose objections to an earlier version of the bill helped scuttle a House vote scheduled for late March.
Save My Care says it will emphasize the lawmakers’ support for a bill that congressional auditors have said will cause 24 million people to lose coverage over 10 years. The campaign is slated to run in congressional districts in 15 states.
A political group with ties to the House Republican leadership, American Action Network, said Sunday it was buying $500,000 in television time to promote the health care bill. The ad will focus on key elements of the American Health Care Act and thank Ryan and fellow Republicans for ‘‘keeping their promise’’ on the health care issue, the group said.
Express Scripts to Offer Cheaper Drugs for Uninsured Customers
by Katie Thomas - NYT - May 8, 2017
It is one of the most acute indignities of being uninsured in this country: Those with the least ability to pay are asked to spend the most for their prescription drugs.
That’s because people without health insurance are forced to pay the list price for brand-name drugs, while insurers have access to a lower, negotiated rate for the same products.
On Monday, one of the biggest pharmacy benefit managers in the drug world, Express Scripts, said it would begin offering a lower rate for a select group of frequently used drugs to people without health insurance, or to those who are stuck in plans with such high deductibles they couldn’t otherwise afford their medications.
The move by Express Scripts, which has been widely criticized as one of the major drivers of rising drug costs, is particularly well timed. It comes just days after Republicans passed a health care bill that some estimate could leave millions of Americans without health insurance, and when there is considerable uncertainty among various layers of the nation’s health care industries.
Timothy C. Wentworth, the chief executive of Express Scripts, said about 30 million Americans either have no insurance or high deductible plans. He said the program was not initiated with the changes to the health care law in mind, but rather to help people who are in need. “We launched this with an idea that we can get those 30 million people similar discounts to what good-sized payers get, and provide them relief," he said in an interview.
The program, InsideRx, is a subsidiary of Express Scripts and will work when consumers sign up for the service, which is free, and present a discount card or a mobile app to pharmacies around the country — including major chains like CVS and Walgreens, and at Kroger supermarkets — to get discounts that average around one-third off the list price. Commonly prescribed drugs, including the cholesteroltreatment Crestor and some brands of insulin, are included on the list about 40 products. The program will allow Express Scripts to expand its customer base. A company spokesman said it would take a “small fee” from pharmacies for every transaction.
It is being started in partnership with GoodRx, a technology company that has been offering similar discounts on mostly generic drugs through deals it previously struck with competitors to Express Scripts.
The new program was greeted with skepticism by Ben Wakana, executive director of Patients for Affordable Drugs, a nonprofit that does not accept funding from organizations that profit from the development or distribution of prescription drugs.
“Drug prices are so high that even with a discount, medication will unfortunately be out of reach for many uninsured or underinsured Americans,” Mr. Wakana said, questioning the motives of pharmacy benefit managers such as Express Scripts, which are known as P.B.M.s. “We continue to believe the most effective way to make drugs more affordable is to bring down drug prices, not to give P.B.M.s more leverage and hope for the best.”
Adam J. Fein, a drug-distribution expert with Pembroke Consulting, noted that some of the drugs on the list, like Nexium, have similar versions that are available as prescription generics or over-the-counter drugs. Still, he said, the program “is a positive development because the system is set up to soak the poor, and this is a way to pass some of the rebates down to the point of sale.”
But the plan comes with important caveats. Patients who are covered by government programs such as Medicare and Medicaid will not be able to use it because drug companies, which helped negotiate the rates, could be seen as violating anti-kickback laws. And the payments also may not count toward a consumer’s deductible, which could end up raising costs for them in the long run.
The move could also be a way for Express Scripts to find new business. The company recently announced that its biggest customer, the insurance giant Anthem, would not renew its contract in 2020, news that sent Express Scripts stock down significantly and has raised questions about whether the company needs to change its business model. Express Scripts is the nation’s largest pharmacy benefit manager — its main business is negotiating with drug companies on behalf of insurers and large employers — but other top players are part of larger companies with other businesses. CVS Health, for example, also has a large pharmacy chain, and OptumRx, the third-largest player, is part of the health insurer UnitedHealth.
The news that Express Scripts was offering a program to help offset the high prices of prescription drugs struck some as odd, given that the company has been criticized for contributing to those high costs in the first place. Express Scripts and other benefit managers design plans that help insurers and employers reduce costs, and in recent years those companies have opted to shift much of that burden to consumers. Critics of pharmacy benefit managers have also noted that Express Scripts and others keep a slice of the rebates that are negotiated with drug companies and are based on a percentage of the list price — meaning that they make more money when drug prices go up.
Mr. Wentworth disputed the idea that Express Scripts contributes to rising drug costs and said the InsideRx plan is evidence that it is acting in consumers’ interests. “From our standpoint, we see the challenges, and that’s why we are trying to do something about it,” he said.
With no deductibles or expensive co-pays, everyone wins
by Heather Denkmire - Bangor Daily News - May 3, 2017
On Thursday, the Legislature’s Committee on Insurance and Financial Services will hear testimony from the public about a bill proposing universal health care — including dental, behavioral health, vision and hearing care — for Maine. The intention of the “Healthy Maine Act,” LD 1274, is to change our health care system from one dependent on private insurance companies into one that is publicly funded. It would be like an improved Medicare system for all of us.
When I learned about the bill, proposed by Lewiston Democrat Rep. Heidi Brooks, I was giddy. We can do this, Maine! We can make sure everyone in Maine has high quality medical (and behavioral health, dental and vision) care without dealing with insurance companies or deductibles or expensive co-pays.
Of course, not everyone supports the idea of universal health care, which is sometimes referred to as “single payer” or “Medicare for all.” While a majority of Americans support it, I’ve been trying to understand the 40 percent of Americans who don’t. Somehow, there are people who must want to keep dealing with insurance companies, while paying insanely high insurance premiums, co-pays and deductibles.
Is it because universal health care seems too good to be true? Certainly people don’t enjoy paying their hard-earned money to insurance companies whose method of profit making is denying claims, do they?
Maybe the reason people aren’t madly calling their representatives insisting they vote for universal health care is because of what we call it. A Kaiser Family Foundation survey in 2016 showed that more than 70 percent of Americans support “Medicare for all,” but weren’t as fond of “ single payer” or “universal” health care. Perhaps some big marketing firm should come up with a catchy name for it and we’d all support it?
The issue must be that people don’t understand what “universal health care” means. I don’t mean this as an insult to anyone. I think it must simply be that good information hasn’t gotten through to everyone.
Whatever we call it, universal health care — or single payer, or Medicare for all — would mean never paying deductibles; copays would be set on a sliding scale. It would mean you can keep your doctor, or choose any primary care doctor or hospital you want because the government will pay them. It’s worth noting that more than 20,000 doctors, medical students and health care workers support universal health care. Universal health care means pre-existing conditions would absolutely be covered; all necessary medical care will be covered.
But how would we pay for it? We would pay for everyone’s health care through taxes. The taxes would be much less than any insurance premiums we are paying now, even less than those slightly lower rates made available through the Affordable Care Act.
Referring to the legislation being considered in Maine, “The taxpayers of Maine who would be paying through a ‘health tax,’ for want of a better phrase, and in lieu of paying insurance premiums,” notes Maine AllCare’s, Joe Lendvai, “all insurance premiums would go away and people would pay less and get more — real comprehensive health care for every Maine person.”
The fact is, we already do pay taxes for health care for many people. We pay for health care for seniors and veterans, as we should. In fact, about 60 percent of our health care system is financed by public money.
With universal health care, doctors and patients could make medical decisions together without consulting insurance companies. There would be no insurance companies in the business of denying medical claims. Serious illnesses or accidents would not put anyone at risk of bankruptcy.
Seeing your doctor, dentist, or therapist without deductibles or expensive co-pays is not too good to be true. It’s a real possibility. We just need to let our representatives know we want them to support universal health care.
Why I’m finally ready to agree a single-payer healthcare system would be better for business
by Gene Marks - Washington Post - May 2, 2017
My wife is English and one of the biggest surprises she had when moving to this country was healthcare. “I don’t understand why my employer is involved in my healthcare,” she said back then–and still says today. After years of listening to that argument, I’m starting to understand what she means.
I can’t believe I’m saying this. I consider myself a smaller-government, fiscally right-of-center guy. I own a small business. I want lower taxes and less regulations. And yet, after watching and studying and writing about healthcare reform for going on 10 years I think I’m finally to the point of caving in and admitting that maybe, just maybe, a single-payer system would be what’s best for businesses, including businesses like mine.
A single-payer system is one in which the government or some quasi-government entity manages the financing and the care is still supplied by the private sector. Of course, if this is anything like what we’ve already seen with the Veterans Administration, then forget about it. There’s no argument that government-run healthcare programs, like the VA and the one in the United Kingdom, are far from perfect. Read the British media and you’ll find regular reports of shoddy service, underpaid doctors, long waiting periods for surgery, out-of-date equipment, huge budget issues and a number of other challenges. Moving to a system like the ones in the U.K., Canada, Sweden or France will likely just replace many of the problems we have in our system with new problems.
But I know from first-hand experience that the system in the U.K. does work. My in-laws have relied on the country’s National Health plan for their basic medical needs. But here’s the twist: they are fortunate enough to be able to afford additional insurance (called BUPA, an acronym for British United Provident Association) so that they could avoid waits and go to better hospitals for their healthcare. In the U.K., those that can afford it can get better care. But everyone is still able to get healthcare, regardless of their income. Is that the best solution? Probably not. But it does seem to work. There is no perfect healthcare solution. Not everyone will be happy.
Which is why I think a single-payer system could be better for businesses here.
Every year I speak and work with thousands of business owners and managers and each and every one of them are terrified come summertime when healthcare rates for the next year are announced. Every year–and I mean every year–my clients have suffered with double-digit increases in their healthcare costs. Sure, they are pushing more of these costs down to their employees. But most are still covering a large part of the health insurance offered to their people. Those that aren’t make up for it by contributing to corporate Health Savings or Healthcare Reimbursement accounts. In addition to the cost of premiums, even companies with as little as five or 10 people wind up paying for the time a manager has to spend internally dealing with the administrative headaches of their health plans.
We spend too much time trying to figure out ways to reduce our healthcare insurance–which, to many represents a significant line item on our income statements. This time distracts us from ways to grow our businesses. But we have to do this because we have to offer a healthcare benefit. Our employees expect it. Our competitors are offering theirs. The labor pool is tight. My wife asks “why?” So do I.
According to the Kaiser Foundation, the typical U.S. company paid about $5,000 per employee for health insurance in 2016, net of employee contributions. So a business owner with 25 full-time employees paid about $125,000 last year. This cost is deductible, but the remainder comes right out of his pocket for this employee benefit. Business owners in the U.K., Canada and other countries with single-payer systems don’t have this cost, or the cost of administration.
No question people who live in these countries pay a lot more in taxes. In the U.K, for example, tax rates range from between 20 to 45 percent and then there’s an additional 12 percent to pay for national health. In the U.S., we have slightly lower individual federal rates but then again we pay local and state taxes. Even though we already pay a Medicare tax, adding another 10 to 12 percent on top of that for a national healthcare system would be burdensome on individuals. But wouldn’t it be a relief for businesses like mine?
“If we choose to have a single-payer system, big government will make a mess of it like they always do,” people say. More than the mess we already have? More than the mess of Obamacare or what Congress is currently proposing? All I see in the eyes of my clients is fear and uncertainty and more dollar signs when the topic of healthcare is brought up.
Everybody has their opinions, but no one really knows the answers to these questions. One thing, however, is for sure: healthcare is a mess, Congress isn’t solving the problem and few business owners I know believe it ever will. We’re at the point where many of my clients –and many who are fiscally right-of-center like me–would seriously consider an individual tax increase and all the risks of a single-payer system just to take this headache away from our businesses so we can focus on…well…our businesses.
Maine policymakers try to assess impact of health care bill
by Eric Russell - Portland Press Herald - May 6, 2017
Although its fate in the U.S. Senate is far from certain, Thursday’s narrow passage of the Republican-led American Health Care Act has prompted lawmakers and industry officials in Maine to begin thinking about how a new law might be implemented here.
Democrats have been deeply critical of the plan, saying it could make health insurance unaffordable for many people, including those who are ill, elderly or have pre-existing conditions.
Republicans are optimistic that the law would give states like Maine more flexibility and increase competition that they say would help drive down rates for everyone. They also say the state is in a good position to adopt a so-called high-risk pool to subsidize insurance for low-income people because it already had a system in place, Public Law 90, prior to the passage of the Affordable Care Act.
“When the ACA passed, it trumped PL 90, but for a year or so many people saw reductions in their private insurance premiums,” said Rep. Deborah Sanderson, R-Chelsea, the ranking House Republican on the Health and Human Services Committee. “The initial results were positive.”
PRE-EXISTING CONDITIONS ARE KEY
One major sticking point in the AHCA, which passed the House 217-213 on Thursday, is how it could adversely affect those with pre-existing conditions. Amendments were included in the bill last week that would replace the protections for those individuals under the Affordable Care Act with federally funded high-risk pools that subsidize care.
One of the ACA’s most popular provisions prevents insurers from rejecting people or charging higher rates based on their health.
Under the House bill, states could apply for federal waivers that would allow insurers to charge higher premiums to people with pre-existing illnesses who have let their health insurance lapse. They would then receive federal money to fund government-operated insurance programs for expensive patients called “high-risk pools.”
Opponents of the House bill say that means people with pre-existing conditions could be priced out of purchasing insurance plans altogether. The nonpartisan Congressional Budget Office has yet to analyze the cost of the AHCA, but health experts say premium costs could skyrocket, with estimates on illnesses ranging from an additional $4,000 for asthma to $142,000 for some cancers.
Whether Maine would apply for a waiver, or how state officials would apply, is still uncertain. Maine, like many states, has a law that prevents insurers from charging higher premiums or denying insurance based on pre-existing conditions.
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The question, however, is whether Maine would first need to repeal that law to implement the provisions of the AHCA, or whether the federal waiver effectively eliminates the state law.
“It’s a good question,” said Emily Brostek, executive director for the health care advocacy group Consumers for Affordable Health Care. “It looks like it will be up to the states.”
The law also says that the “state” could apply for a waiver, without specifying whether a governor could apply, or whether legislative approval would first be needed.
Under the AHCA, federal spending on Medicaid would also be cut by an estimated $880 billion over the next 10 years.
Sanderson, the state representative from Chelsea, said that because Maine already has made cuts to the program and did not expand it, as some states did under the Affordable Care Act, it’s better positioned financially than those that would lose those funds.
She also said that if Maine were to obtain a waiver to run its Medicaid program, known as MaineCare, like a block grant, it could prioritize the most vulnerable people, such as the elderly and disabled.
Democrats, however, say the AHCA would be catastrophic for the vulnerable for several reasons.
“The idea that Maine wouldn’t be affected as much because we didn’t expand Medicaid, that’s just wrong, wrong, wrong,” said Sen. Geoff Gratwick, D-Bangor, a retired physician. “It may be correct financially but we’re talking about people. I think it’s unconscionable.”
OLDER, RURAL RESIDENTS AT RISK
Under the House bill, older Mainers in rural areas could see their premiums increaseup to seven times what they’re paying under the ACA, going from about $200 to $300 per month to about $1,300 per month, the Kaiser Family Foundation says.
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Cuts to insurance subsidies and tax credits could cause some members of Community Health Options, which provides health plans under the ACA in Maine, to drop their policies, said Kevin Lewis, the company’s president and chief executive officer. About 24,000 Mainers receive subsidies under CHO individual plans.
Brostek said that assessing the potential impact of the AHCA in Maine is difficult because so many questions remain – and the legislation hasn’t even gone through the Senate, where it is almost guaranteed to be changed.
“In health care policy, there are always winners and losers,” she said. “We need to understand who’s going to be better off and who’ll be worse off. It certainly matters a great deal if the people who need health care the most are the least able to access it or afford it.”
Already, a major concern about the high-risk pools is whether there would be enough money to fund them.
“The concern is that the funding will be insufficient to finance the high-risk pool,” CHO’s Lewis said.
An analysis by the health care consulting group Avalere found that the amount that the AHCA allocates over nine years to create high-risk pools would cover only 110,000 of the estimated 2.2 million people with pre-existing conditions who have ACA insurance.
“Shared risk isn’t a terrible idea, but I’m not confident it would ever be funded adequately,” Gratwick said.
Brostek worries about people who would be stuck in the “family glitch,” the term used for people who make too much to qualify for an ACA subsidy or free care, but who can’t afford the high cost of treatment for a serious injury or illness such as cancer.
Sanderson believes the high-risk pool option would work in Maine, in large part because it’s based on PL 90, which was in place for about 18 months before being supplanted by the ACA.
That law, pushed by Gov. Paul LePage and legislative Republicans, set up a high-risk pool and subsidized the insurance with a fee on all individual health insurance plans in Maine. That law also loosened the rules on insurance carriers that sell coverage to the thousands of Maine companies with fewer than 50 workers – the so-called small-group market.
While conservatives argued that PL 90 was working and lowering insurance rates in Maine, critics said it gave insurance companies too much latitude to raise rates for companies with older workers or those in rural, high-cost health markets, while lowering rates for younger, urban companies that tend to have lower health care costs.
HIGH-RISK POOL’S EFFECT UNCLEAR
But since the law was in effect for only a short time, its actual success or failure – or whether there was enough money in the pool to cover people – can’t be assessed.
PL 90, however, was always intended to work in concert with the Maine law mandating that insurers provide coverage for people with pre-existing conditions.
Sanderson said she has always been critical of the Affordable Care Act because she believes its cost is simply not sustainable.
“Good policy isn’t always fiscally appropriate,” she said. “You have to set priorities.”
The conflict comes when lawmakers have to decide who is most vulnerable and who needs the most help getting health care.
“I believe it should be people who have no choice – people who are elderly and people who are disabled,” she said. “There are no easy decisions either way.”
Gratwick said it’s clear to him that the AHCA’s provision that allows insurers to charge higher premiums for older individuals and those in rural areas could have a massive impact on Maine, the nation’s oldest state and one of its most rural.
Brostek said it’s hard to assess the impact of a health policy that, by almost every account, is likely to change in the Senate.
And even if it doesn’t, she said, “Any changes would not take place the next day, so there would be some time to sort this out.
“But the uncertainty is really troubling.”
Republican health care plan would leave states on the hook
States just don't have the money right now to make up for the health insurance subsidies the federal government could cut back on.
by Amber Phillips - The Washington Post - May 6, 2017
Even if a watered-down version of House Republicans’ health-care legislation becomes law, states are probably going to be on the hook for billions of dollars of health-care costs, especially for the poor and sick. And that means they’re going to have to make some hard choices: Do you find a way to raise taxes/cut other services to keep your most vulnerable population insured? Or do you just stop insuring them?
That’s the heart of the question facing all 50 states as Republicans in Washington unwind the federal government’s involvement in health care. Legislatures trying to answer it could get ugly.
States just don’t have the money right now to make up for the health insurance subsidies the federal government could cut back on. Thirty-one states started 2017 with deficits – a couple are closing in on $1 billion, according to a MultiState Associates study.
But the House Republicans’ health-care plan would whack almost every state’s budget in potentially big ways:
“We’ll have a crisis for states as they confront this without a federal partnership,” said Judy Solomon, vice president of health-care policy for the nonpartisan Center on Budget and Policy Priorities.
Democratic- and Republican-controlled states seem split on what to do about it. In California, one of the most liberal states in the nation, Democratic lawmakers already think they’ll try to make up the cost for people who could lose their insurance under this plan. But trying to stretch out a safety net for those people could cost the state at minimum $20 billion, an amount that could wreck the state’s budget.
It’s still early, but as Washington barrels toward changing how involved it gets in health care, state leaders are just now grappling with what to do about it. And so far, there are no easy answers.
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