Health Care Reform Articles - June 29, 2017

Editor's Note:

Sorry for the large number of articles in today's blog, but there's a lot happening and a lot being written about all of it.  There are two notable trends in today's clippings - first, some Republican Senators are saying publicly that it's more important to continue coverage for low and middle income Americans than it is to give tax-breaks to high income Americans - something that has been taboo in Republican orthodoxy (see Grover Norquist) for many years.

Second, Americans (according to public reaction and the polls cited in this blog) really, really dislike medical underwriting - especially the exclusion of patients with  pre-existing conditions from coverage.

Together, combination of the preference for tax-supported health care coverage and the dislike of medical underwriting is very bad news for insurance companies and their role providing coverage for health care.

-SPC

Whatever happens, the GOP is bringing us a whole lot closer to single-payer

by Paul Waldman - The Washington Post - June 27, 2017

The Republican health-care bill is not dead yet, but it’s in rough shape. Whether it passes or not, it has been an utter debacle for the GOP, making the Affordable Care Act they’re trying to undo more popular than ever, energizing the Democratic base, complicating the relationship between President Trump and Congress and sowing justified distrust of Republican motives among the broader public.

It has also done something else: moved the debate on health care in America to the left and made single-payer much more likely.

Even if the Senate bill fails, Republicans give up and move on to tax reform, and the status quo remains in place, this debate will have had profound effects on our politics. While the Democratic Party may have been moving to the left on health care anyway, its momentum in that direction may now be unstoppable. And the entire country will be more receptive than ever to the arguments Democrats will make. This, by the way, will also be the case if the GOP repeal effort succeeds, because it will make so much that people hate about our health-care system a lot worse.

Let me point to one politician as an illustration. For years, Sen. Elizabeth Warren’s position on single-payer has essentially been “Maybe someday” — not opposed to it, but focused in the short term on the more urgent priority of defending and enhancing the ACA. But in an article in today’s Wall Street Journal, we learn that she is now ready to take that plunge:

“President Obama tried to move us forward with health-care coverage by using a conservative model that came from one of the conservative think tanks that had been advanced by a Republican governor in Massachusetts,” she said during an interview in her Senate office last week. “Now it’s time for the next step. And the next step is single payer.”

Warren is not going to be the last Democrat to take this step. In fact, any Democrat who runs for president in 2020 — and there will be a lot of them — will have a hard time explaining to the primary electorate why they don’t want single-payer, and most or all of them will probably say they do.

We can make an analogy with what happened in the GOP after the failure of comprehensive immigration reform. In 2013, the Senate passed a comprehensive bill with the support of many Republicans. But after it died in the House, Republican politicians went in exactly the opposite direction, telling their base that the only question was how much they hated “amnesty” and how tough they would be on undocumented immigrants. Then their party nominated someone who said he would build a wall on our southern border, create a “deportation force” and ban Muslims from entering the country.

Senate Democrats blast GOP health-care bill following CBO forecast

Senate Minority Leader Charles E. Schumer (D-N.Y.), Sens. Patty Murray (D-Wash.) and Ron Wyden (D-Ore.) on June 26 criticized the Senate GOP health-care plan after the Congressional Budget Office released a report on the bill. (Reuters)

The situations aren’t exactly the same, but the point is that a dramatic political failure — whether it’s yours or the other party’s — can have profound effects on the choices politicians make about how to approach the electorate. And it’s important to understand that while there are some Democratic politicians who emphatically favor single-payer and would be unsatisfied with anything less, most of them would be willing to advocate for a range of policy options, depending on what looks politically achievable and what their base demands at a particular moment.

All the ups and downs of the past eight years, from the beginning of the debate on the ACA to the end of the debate on Republican repeal plans, hold many lessons for Democrats who are still eager to address the problems in the American health-care system. Among other things, we know that voters are risk-averse, that they’re extremely sensitive to out-of-pocket costs, that they want security and that arguments about the glories of the free market aren’t going to be persuasive to them. After seeing how desperately unpopular this Republican plan is, Democrats are going to be much less afraid to defend government health care and advocate its expansion.

And they know that whatever they propose next has to be simple and understandable. We can debate whether the ACA had to be as complex as it was, but next time around, no Democrat is going to believe that you can take on President Trump with a technocratic approach to health care. Saying “Here are the 10 tweaks I’d make to the ACA” isn’t going to cut it.

That isn’t to say that whatever plans they propose won’t be fully fleshed out under the hood, but they’ll have to be presented in a way that is easy for voters to understand. And, yes, Republicans will cry about “Washington bureaucrats making decisions for you,” but Democrats are less likely to be intimidated. Ask your parents or grandparents on Medicare how they feel about their coverage — Medicare is the most popular health insurance program we have, and it’s run by Washington bureaucrats.

It’s important to keep in mind that “single-payer” isn’t one thing — if you look around the world at highly developed countries, there is a spectrum of health systems with various levels of public and private involvement. But what they have in common is that they achieve universal coverage while working better and costing less than ours. We could well have 15 Democratic presidential candidates proposing 15 different kinds of single-payer. Some may be highly socialized systems — what Bernie Sanders would likely advocate if he runs again — but the ones that are most appealing could be hybrid systems of the kind that have been successful in countries such as France. The way it works is that there’s a government plan that covers everyone’s basic needs, but you can also buy supplemental private insurance to get as many more benefits as you want.

Among the advantages of a hybrid system is that one can actually see a path from where we are now to there. That path runs through Medicaid, which now covers nearly 75 million Americans. What if we auto-enrolled everyone under 65 in Medicaid — it’s there if you need it, but if you have different insurance you’d prefer, go ahead and use that instead. No one would be without coverage. Private insurance would evolve into something you buy to fill in the gaps and get perks that Medicaid wouldn’t provide. Instead of covering all your health care, employers could provide the supplemental private insurance.

As a political matter, you could sell this as something that we could transition to over an extended period, and as a system that satisfies the goals of both liberals and conservatives. Liberals get the universal coverage and security they want, and conservatives get the freedom they want — if you’re rich enough to buy a supplemental plan that includes deliveries of Dom Perignon during any hospitalization, go right ahead.

That isn’t to say that Republicans wouldn’t resist and there won’t be more intense arguments about health care, because they would and there will be. But by handling this debate so terribly and proposing something so monstrous, Republicans have opened up the space for Democrats to go much further than they’ve been willing to before. It’s not impossible to foresee Democrats winning the House in 2018, then taking the presidency and the Senate in 2020 — and then taking the first steps toward making single-payer health care in America a reality.

https://www.washingtonpost.com/blogs/plum-line/wp/2017/06/27/whatever-happens-the-gop-is-bringing-us-a-whole-lot-closer-to-single-payer/?

The GOP’s health-care bill is political kryptonite

by Aaron Blake - The Washington Post - June 28, 2017

Poll: Senate health-care bill is deeply unpopular

A new NPR/PBS NewsHour/Marist poll shows the Senate health-care bill is deeply unpopular — and not just among Democrats. (Video: Peter Stevenson/Photo: Jabin Botsford/The Washington Post)

We've just seen three new polls on the Senate GOP's health-care bill, and each of them paints an increasingly dire picture for Republicans.

Support for the bill is languishing between just 1 out of every 8 Americans and 1 out of every 6 Americans, according to polls from the Marist (17 percent), USA Today/Suffolk University (12 percent) and Quinnipiac University (16 percent). In each case, a majority opposes the bill. That's a level of popularity so low that it's difficult to believe the bill is being entertained.

It's all a pretty stunning indictment of the GOP's failure to sell the bill. Republicans have focused like a laser on passing the legislation quickly — and secretively — in hopes of getting to a conference committee where the House and Senate can negotiate the final product. In the meantime, the American people have soured on the bill, disliking almost everything about it.

Four key findings:

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1. Quinnipiac asked whether people supported cutting off federal funding to Planned Parenthood, as the Senate bill does; people opposed that 61 percent to 35 percent at first blush and then 80 to 15 when informed that such funds cannot be used for abortion.
2. The pollster asked how people felt about cutting funding for Medicaid, as the GOP bill does by some $772 billion over the next decade; people opposed that 71 percent to 24 percent.
3. Suffolk asked whether people supported requiring that people with preexisting conditions pay the same as everyone else, a requirement which the Senate bill allows states to opt out of; 77 percent said that was “very important” to them.
4. Quinnipiac found two-thirds of Americans said they were either “very concerned” (47 percent) or “somewhat concerned” (21 percent) that this bill was crafted almost completely behind closed doors in what some say was an unprecedentedly secretive process.

That's basically 7 in 10 Americans who oppose four central aspects of the GOP health-care push.

Perhaps as damningly, Republicans don't appear to have had much success in highlighting the more palatable aspects of their bill, such as decreasing premiums for many Americans over the long term. The Congressional Budget Office estimates premiums would go up for older and poorer people but overall would go down for most Americans. Nonetheless, Quinnipiac shows 41 percent feel their premiums would increase, while just 10 percent said they would go down.

And there is one finding I keep coming back to. The Quinnipiac poll shows nearly half of Americans (48 percent) strongly disapprove of this bill, versus just 6 percent — SIX — would strongly approve of it. Only 18 percent of Republicans support this bill and say they feel strongly about its passage.

Republicans made a calculated decision to try to pass health care quickly and without much of a public relations push. They are paying a heavy price for that.

https://www.washingtonpost.com/news/the-fix/wp/2017/06/28/the-gops-health-care-bill-is-political-kryptonite/?hpid=hp_hp-top-table-main_fix-650pm%3Ahomepage%2Fstory&utm_term=.bb614e0e7a2e

How Medicaid Works, and Who It Covers

by Abby Goodnough and Kate Zernike - NYT - June 23, 2017

How Medicaid Works, and Who It Covers

By ABBY GOODNOUGH and KATE ZERNIKEJUNE 23, 2017

One of the biggest flash points in the debate over Republican legislation to repeal and replace the Affordable Care Act is the future of Medicaid. Here are some basic facts about the 52-year-old program.

What is Medicaid? 

It’s a public health insurance program largely for low-income people, though some middle-class disabled and elderly people also qualify. States and the federal government share the cost.

Whom does Medicaid cover? 

■ Nearly one in five Americans, 74 million people, are on Medicaid.

■ Federal law guarantees Medicaid coverage to pregnant women, children, elderly and disabled people under certain income levels.

■ It covers more than a third of the nation’s children and pays for half of all births.

■ It also covers almost two-thirds of nursing home residents, including many who are middle class and spent of all their savings on care before becoming eligible.

■ States also have the option of covering other groups, like children and pregnant women whose household incomes are higher than the federal thresholds, or young adults up to age 26 who were once in foster care.

■ The Affordable Care Act allowed a new optional group: any adults with income up to 138 percent of the poverty level, which would be $16,643 for an individual this year. Thirty-one states now offer Medicaid to this group.

When was it created?

■ In 1965, as part of President Lyndon B. Johnson’s “Great Society.”

■ There was little political debate; the bigger fight was over creating Medicare, the program to cover the elderly, which Medicaid is often confused with.

Is Medicaid an entitlement 
program?

Yes. Anyone who meets the eligibility rules has a right to Medicaid coverage, and for now, states are guaranteed open-ended financial support from the federal government.

How much does it cost? 

■ Medicaid cost $553 billion in fiscal year 2016. Of that amount, $348.9 billion came from the federal government; the states paid $204.5 billion.

■ Medicaid accounts for 9 percent of federal domestic spending. For states, it is the biggest source of federal funding and the second-largest budget item, behind education.

■ The biggest costs in Medicaid are for the elderly and the disabled, often because of long-term care in nursing homes.

■ Washington pays 50 to 75 percent of Medicaid costs for most eligible groups, with poor states receiving more money.

■ Under the Affordable Care Act, the federal government initially covered all of the costs for the roughly 11 million people insured under the law’s expansion of Medicaid, who are largely adults without disabilities.

■ Under the law, Washington picks up 95 percent of state costs for the expansion of Medicaid this year, whittling down to 90 percent in 2020.

What changes are in store? 

■ Both the House and Senate health bills would fundamentally change the way the federal government pays its share of Medicaid costs, setting a per-person limit on spending that would adjust annually for inflation.

■ The bills would also effectively end the Medicaid expansion, by sharply reducing how much the federal government pays for that population starting in 2020.

■ The result of these changes, according to independent analyses, would be major reductions in federal Medicaid spending over time.

■ Enrollment would drop, too, according to the nonpartisan Congressional Budget Office, with states making it harder to qualify for the program and getting rid of certain benefits to make up for tightened federal spending.

https://www.nytimes.com/2017/06/23/health/medicaid-basic-facts.html?

Vote Delayed as G.O.P. Struggles to Marshal Support for Health Care Bill

by Thomas Kaplan and Robert Pear - NYT - June 26, 2017

WASHINGTON — Facing intransigent Republican opposition, the Senate majority leader, Mitch McConnell, on Tuesday delayed a vote on legislation to repeal the Affordable Care Act, dealing another setback to Republicans’ seven-year effort to dismantle the health law and setting up a long, heated summer of health care battles.

Mr. McConnell faced resistance from across his conference, not only from the most moderate and conservative senators but from others as well. Had he pressed forward this week, he almost surely would have lacked the votes even to begin debate on the bill.

“We will not be on the bill this week, but we’re still working toward getting at least 50 people in a comfortable place,” said Mr. McConnell, who is known as a canny strategist but was forced to acknowledge on Tuesday that he had more work to do.

The delay pushes Senate consideration of the bill until after a planned recess for the Fourth of July, but it does not guarantee that Republican senators will come together. Opponents of the bill, including patient advocacy groups and medical organizations, plan to lobby senators in their home states next week. Senators are likely to be dogged by demonstrators. Democrats vowed to keep up the pressure, and some Republican senators have suggested that their votes will be difficult to win.

After meeting with President Trump at the White House, Mr. McConnell told reporters that if Republicans could not come to an agreement, they would be forced to negotiate a deal with Senator Chuck Schumer of New York, the Democratic leader.

“The status quo is simply unsustainable,” Mr. McConnell said. “It’ll be dealt with in one of two ways: Either Republicans will agree and change the status quo, or the markets will continue to collapse, and we’ll have to sit down with Senator Schumer. And my suspicion is that any negotiation with the Democrats would include none of the reforms that we would like to make.”

Republicans have promised for seven years to repeal the health law, President Barack Obama’s signature domestic achievement. But Mr. McConnell’s announcement on Tuesday was yet another major stumble in the unsteady quest by Republican congressional leaders to deliver a repeal bill to the desk of Mr. Trump, who has yet to sign his first piece of marquee legislation.

Mr. McConnell, the chief author of the Senate repeal bill, can afford to lose only two of the 52 Republican senators, but more than a half-dozen have, for widely divergent reasons, expressed deep reservations about the bill.

Mr. Trump, meeting with Republican senators at the White House, declared, “We’re getting very close.”

“This will be great if we get it done,” he said. “And if we don’t get it done, it’s just going to be something that we’re not going to like, and that’s O.K., and I understand that very well.”

Mr. McConnell wrote his bill behind closed doors, betting he could fashion a product that would show significant improvement over the bill that was narrowly approved by the House last month. And he laid out an aggressive timeline for its passage, hoping to secure Senate approval roughly a week after unveiling the legislation.

Yet on Tuesday, just five days after releasing the bill, Mr. McConnell had to bow to reality: Republican senators were not ready to move ahead with the bill.

At least a small number might never be — raising questions about whether Mr. McConnell will be able to win over the votes for passage.

“It’s difficult for me to see how any tinkering is going to satisfy my fundamental and deep concerns about the impact of the bill,” said Senator Susan Collins, Republican of Maine, who was among the lawmakers prepared to vote against taking up the bill this week.

Mr. McConnell and his leadership team are hoping to replicate the feat of Speaker Paul D. Ryan, who revived the House’s repeal bill and pushed it to passage six weeks after it appeared to be dead.

“I would hope, by the end of the week, that we have reached basically a conclusion with regard to the substance and the policy of this,” said Senator John Thune of South Dakota, a member of the Senate Republican leadership.

Then, he said, it is just a question of timing.

Democrats are unified against the repeal bill, but they were not celebrating on Tuesday.

“The mantra on our side is never to underestimate Mitch McConnell,” said Senator Richard Blumenthal, Democrat of Connecticut.

Mr. Schumer said: “We know the fight is not over. That is for sure.” Over the next few weeks, he said, Mr. McConnell “will try to use a slush fund to buy off Republicans, cut back-room deals, to try and get this thing done.”

At least four Republican senators — Ms. Collins, Dean Heller of Nevada, Ron Johnson of Wisconsin and Rand Paul of Kentucky — had said they would vote against the motion to begin debate, enough to ensure it would fail. Other Republicans also appeared reluctant about moving forward with the bill.

“I’m just grateful leadership decided, let’s take our time, give this more thought and try and get this right,” said Mr. Johnson, who had been critical of the desire by Republican leaders to hold a vote this week.

After Mr. McConnell’s announcement, three other Republicans announced their opposition to the bill in its current form: Jerry Moran of Kansas, Shelley Moore Capito of West Virginia and Rob Portman of Ohio.

Ms. Capito and Mr. Portman, who announced their opposition together, expressed concern about how the bill would affect Medicaid and the opioid crisis, which has had devastating effects in their states.

The release of a Congressional Budget Office evaluation on Monday made it much more difficult for party leaders to win over hesitant Republican members. The budget office said the Senate bill would leave 22 million more people uninsured after 10 years, and many people buying insurance on the individual market would have skimpier coverage and higher out-of-pocket costs.

The Senate Democratic whip, Richard J. Durbin of Illinois, said the report by the Congressional Budget Office “did more to strike a dagger to the heart of this Republican repeal than anything else.”

In 2026, the budget office said, 15 million fewer people would have Medicaid coverage under the Senate bill than under the Affordable Care Act, and seven million fewer people would have coverage they purchased on their own. Faced with deep cuts in Medicaid, the report said, state officials would face unpalatable choices: restrict eligibility, eliminate services, reduce payments to health care providers and health plans, or spend more of their own money.

Appearing in Washington, Gov. John R. Kasich of Ohio cited the 22 million projection and expressed bewilderment that fellow Republicans would be on board with the bill.

“And they think that’s great?” he asked. “That’s good public policy? What, are you kidding me?”

Doctors, hospitals and other health care provider groups have come out strongly against the Senate bill, as have patient advocacy groups like the American Heart Association. But business groups were ramping up their support. In a letter on Tuesday, the U.S. Chamber of Commerce urged senators to vote for the bill.

The Senate bill “will repeal the most egregious taxes and mandates” of the Affordable Care Act, allowing employers to create more jobs, said Jack Howard, a senior vice president of the group. The bill, he noted, would repeal a tax on medical devices and eliminate penalties on large employers that do not offer coverage to employees.

A separate letter expressing general support for the Senate’s efforts was sent by a coalition of business and employer groups including the National Association of Home Builders, the National Restaurant Association and the National Retail Federation.

But Senate conservatives found themselves squeezed between business sentiment and their conservative base. The Club for Growth, a conservative group, came out against the Senate measure on Tuesday. The organization’s president, David McIntosh, noted that congressional Republicans had “promised to repeal every word” of the Affordable Care Act.

“Only in Washington does repeal translate to restore,” he said. “Because that’s exactly what the Senate G.O.P. health care bill does: It restores Obamacare.”

https://www.nytimes.com/2017/06/27/us/politics/republicans-struggle-to-marshal-votes-for-health-care-bill.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=first-column-region&region=top-news&WT.nav=top-news

The Health Care Hoax Has Been Exposed, Senator McConnell

by The Editorial Board - NYT - June 26, 2017

Senator Mitch McConnell hoped that keeping his wretched bill to destroy the Affordable Care Act secret until the last minute would make it easier for him to railroad fellow Republicans. The facts the majority leader had hoped to suppress came back to bite him on Monday when the Congressional Budget Office released a detailed review of the bill that confirmed what governors, doctors and indeed the American public had been saying for days: The bill is a cruel hoax that would help the wealthiest Americans at the expense of the poorest.

With members of his own party balking at even bringing the measure to the Senate floor, Mr. McConnell announced on Tuesday that a vote would be delayed until after the July 4 recess. A wiser course — for his party as well as the nation — would be to concede defeat and give up what now seems a desperate quest to fulfill a seven-year-old party commitment to kill an Obama-era program that, as it turns out, a large number of Americans would like to see preserved and improved.

The budget office said the measure would leave 22 million more Americans without insurance by 2026. Hit hardest would be lower-income people between the ages of 50 and 64 and people struggling with chronic illness or battling addiction — many of the same voters who believed President Trump’s promises to improve their health care. The bill would cut $772 billion over the next decade from Medicaid, which covers most of America’s poor children and nursing home patients, to help finance tax cuts for the wealthy.

Some Republican senators — Ron Johnson of Wisconsin, Rand Paul of Kentucky, Ted Cruz of Texas — actually complain that the bill is too generous and doesn’t deliver sufficient spending cuts. But others — Susan Collins of Maine, Rob Portman of Ohio, Dean Heller of Nevada — have listened to those who are outraged that they’d even consider such a harmful measure.

Having drafted a bill so indefensible on the merits, Mr. McConnell and his allies promoted it with fibs. Mr. McConnell, for instance, claimed it would “strengthen Medicaid.” John Cornyn of Texas said it would “save the people who are currently being hurt.”

It will be interesting to hear what the voters have to say during the July 4 break. Some states that would be most deeply hurt by the bill are represented by Republicans who back it. Looking at you, Richard Burr of North Carolina; Pat Toomey of Pennsylvania; and Mr. Cornyn, the majority whip hellbent on forcing a vote this week.

And then there’s Mr. McConnell. Under Obamacare, the majority leader’s home state, Kentucky, experienced one of the biggest reductions in the rate of uninsured people of any state in the nation, according to a study from the nonpartisan Kaiser Family Foundation, mostly because of gains in Medicaid coverage. Last year, more than 81,000 Kentuckians purchased coverage in the federal marketplace.

Even so, despite all evidence, Mr. McConnell seems determined to impose his will and deny these very same people access to the benefits of Obamacare when he returns to Washington.

What has blocked the bill’s progress on Capitol Hill, at least for now, is that ordinary Americans have begun to pay attention to the facts instead of the fearmongering and falsehoods emanating from the White House and the congressional leadership. Let’s hope the system works, and elected representatives listen to the people who stand to lose.

https://www.nytimes.com/2017/06/27/opinion/health-care-mcconnell-trumpcare-cbo.html?

Republicans, step away from the brink

by The Editorial Board - The Washington Post - June 28, 2017

REPUBLICAN SENATORS are regrouping after Majority Leader Mitch McConnell (Ky.) put off a vote on his Obamacare repeal-and-replace bill. The stumble was for the better. The bill was drafted in secret. Not a single hearing was held. Democrats were not consulted. With only a single week afforded to absorb the legislation’s contents before a vote, the timetable was absurd. Mr. McConnell’s attempt to jam it through stank of legislative malpractice and hypocrisy.

Republicans should treat this as an opportunity to step away from the brink and reevaluate their foolhardy push to rush through an ill-wrought overhaul of the nation’s health-care system without any input from the other side. Despite President Trump’s claims otherwise, GOP leaders have not engaged Democrats seriously on the health-care issue, as Democrats did for at least a time as they drafted Obamacare. Republicans have instead advanced coverage reductions and tax cuts that Democrats — and, indeed, most of the public — could never embrace.

The Congressional Budget Office has repeatedly exposed these ideas to be abjectly cruel, finding that they would result in north of 20 million more people uninsured in a decade, as government health-care assistance was rolled back to finance a large tax cut for the wealthy. Mr. McConnell has reportedly argued, however, that pressing forward would be better than negotiating with Democrats. What does it say about the Republican Party that even this bill is more appealing than reaching out to moderates on the other side of the aisle?

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Not all feel this way. Sen. Susan Collins (R-Maine), one of the Senate bill’s skeptics, this week suggested fixing Obamacare markets in cooperation with Democrats. She and Sen. Bill Cassidy (R-La.) released a compromise health-care proposal before Republicans began their mad repeal-and-replace rush. For his part, Senate Minority Leader Charles E. Schumer (D-N.Y.) urged Republicans Wednesday to “start over” and find a “new, bipartisan way forward on health care.” If Mr. Schumer wants to show that he is interested in doing more than trolling his GOP counterparts, he could appoint a group of moderate Democrats to serve as credible negotiators.

If both sides sat down in good faith, there would be a wide range of possible compromises. Senators could work off the Cassidy-Collins plan, which is not preoccupied with cutting taxes and allows states that want to keep the Obamacare system to do so, while letting others try a different course. In any compromise scenario, Democrats would seek commitments that health-care markets would be properly subsidized and administered, and Republicans would seek some loosening of Obamacare regulations, particularly if doing so allowed younger people to buy bare-bones coverage. That is grounds for an obvious trade.

Both sides have expressed interest in “reinsurance” programs, which would backstop insurance companies in cases of catastrophically large medical costs. Both may be interested in automatically enrolling everyone in a basic insurance plan unless they opt out. Both should seek a stronger and more durable mechanism to compel people to buy insurance, perhaps by withholding government tax benefits from people who refuse. 

Reforming the health-care system with Democratic buy-in would also mean the Senate would not have to worry about complex parliamentary rules relating to the “reconciliation” process, which Republicans are currently using to avoid a Democratic filibuster. That greatly expands the reforms that bipartisan negotiators could consider.

What should be off the table, permanently, is the Senate’s bad bill. The unilateral effort to cram it through must end.

https://www.washingtonpost.com/opinions/republicans-step-away-from-the-brink/2017/06/28/2f68503c-5c46-11e7-9fc6-c7ef4bc58d13_story.html?

Awkward moment at Trump meeting highlights GOP tensions over health bill

by Robert Costa, Sean Sullivan, Juliet Eilperin and Kelsey Snell - The Washington Post - June 29, 2017

Sen. Dean Heller was sitting two seats away from President Trump and facing his grim-faced colleagues this week when he decided to crack a pointed joke.

Heller — a square-jawed, ­sandy-haired moderate Republican — said the attack ads against him, paid for by a Trump-allied super PAC, should have used his own image instead of actor Matt Damon’s.

There were scattered laughs, including a chuckle from Trump. But many of the Republican lawmakers lining tables in the East Room stayed mute. 

The senator from Nevada then reiterated that he had deep reservations about the party’s major rewrite of the nation’s health-care laws, despite the Trump network’s efforts to pressure him to back the legislation.

Trump nodded and said he under­stood Heller’s view. A ­couple of hours later, the super PAC pulled the ads off the air.

Republicans push for speedy new health-care draft

Senate Majority Leader Mitch McConnell is trying to finalize a new version of the Republican health-care bill before the July 4th recess, but just what will sway both moderate and conservative hold outs remains unclear. (Video: Jenny Starrs/Photo: Jabin Botsford/The Washington Post)

Nearly everyone there Tuesday had a different take on the meeting, reflecting the Republican divide amid the struggle to fulfill a signature party promise. 

White House officials and Trump loyalists saw a president diving in to patch up strife and save legislation that had been curbed in the Senate. Some seasoned senators, however, saw a president unable to grasp policy details or the obstacles ahead, and talked with each other after the gathering about what they saw as a bizarre scene. That Republican disconnect has been a constant ever since the Senate health bill was unveiled. 

This account of the Senate measure’s shaky rollout is based on interviews with more than a dozen senators, aides and other well-connected Republicans, many of whom requested anonymity to offer candid perspective.

Senate Majority Leader Mitch McConnell (R-Ky.), who on Tuesday postponed a procedural vote on the health bill, continues to work with wary senators and the president’s team with the aim of moving an updated version to the Congressional Budget Office for scoring by the end of the week.

But the process so far has been messy and revealing of strains between Trump and the GOP Senate, as well as between McConnell and the senators he has long been known for managing with steely efficiency.

Instead of moving happily toward passage of the party’s rallying cry, Republicans are frozen and unsure of the political cost of passing the Senate bill — especially with swing voters who in many states have come to rely on aspects of Obamacare and its expansion of Medicaid.

“It’s sad, in a way,” Sen. Rand Paul (R-Ky.), a conservative critic of the bill, said in an interview Wednesday. “We control all three branches and yet we’re not interested or able to do what we’ve pledged. People are too focused on getting more federal subsidies and other things, not on the pledge itself.”

The GOP alarm on Capitol Hill over this week’s inaction was stoked further Tuesday when Trump told senators that he was eager for a vote but also hinted at the prospect of attempting to place the burden of problems with the current law on the Democrats in the coming months, should Republicans remain stalled.

“This will be great if we get it done. And if we don’t get it done, it’s just going to be something that we’re not going to like,” Trump told the room. “And that’s okay. I understand that very well.”

Trump’s aside prompted some senators to exchange concerned glances during the meeting, according to a person briefed on it. To a number of them, Trump’s remark had the same ring as his comment a week earlier about the House’s health bill being “mean.” His enthusiasm, to them, was debatable. 

Heller is a case study of the GOP turmoil. Heller, who is expected to face a tough reelection fight next year, wounded the bill’s chances of passage last week with a highly critical statement that left little room for compromise. The move irked leadership and soon the Trump-allied super PAC swooped in.

By Saturday, it was evident that the aggressive response to Heller was not blessed by McConnell, who called the ad buy “stupid” in a phone call with White House Chief of Staff Reince Priebus, who has long ties to the former Trump advisers who lead the super PAC, America First Policies.

“This has been way more difficult than it needs to be,” said Sen. Ron Johnson (R-Wis.), who has publicly opposed the bill from the right. 

McConnell unveiled the 142-page bill last Thursday after crafting it in secret. It came under immediate attack from conservative and moderate Republican senators, and from much of the health-care establishment. 

Sen. Ted Cruz (R-Tex.) joined forces with three other Republicans — Paul, Johnson, and Mike Lee of Utah — to issue a statement saying that although they could not support the bill as written, they were open to negotiating changes that could ultimately win their backing. 

On the other end of the GOP spectrum, Sen. Susan Collins (Maine) said she also had “concerns about some of the provisions.” She opposed blocking federal funding for Planned Parenthood, as the Senate bill would do, and said she was unsettled by changes to Medicaid that would result in long-term federal spending cuts to the program, echoing Heller’s objections.

Conversations among McConnell’s staffers concentrated on Cruz and others who said they were open to voting for it if changes were made. Things could have been far worse, one McConnell confidant reasoned. If it was a rebellion, it seemed small in scale. 

But the bill’s curtailing of Medicaid spending — including a $772 billion cut over the next decade — caused a lingering sense of heartburn for center-right Republicans.

Even before Senate GOP leaders debuted the bill, Republican governors from Medicaid expansion states had been issuing warnings. While some of these governors hailed from swing states, such as Ohio and Nevada, conservatives such as Arizona’s Doug Ducey (R) said that the proposed changes could prove too damaging for their states to handle.

McConnell’s advisers turned to the White House on Friday to assist with the cause but did not ask for a full-fledged push. Unlike when the House bill tottered and House Speaker Paul D. Ryan (R-Wis.) called on Trump to rally members, McConnell wanted to keep the negotiations inside the Senate.

“In the early stages, candidly, it’s been kind of a waste of his time,” McConnell told reporters Tuesday, explaining Trump’s more hands-off approach in the health-care discussions. “We needed to get this far enough down the path.”

Trump, who spoke with Cruz on Thursday, stayed in touch with the Texan, and aides planned calls by Trump to Paul and Lee. Paul, in particular, was seen as someone Trump could entice; they have a rapport from past rounds of golf, and Paul hails from a state that went heavily for Trump. A meeting was eventually arranged for Tuesday at the White House. 

Vice President Pence, meanwhile, also set a series of meetings and made calls. 

But Trump and his team ran into internal Senate GOP dramas that had little do with them, such as friction between McConnell and Johnson, who told reporters this week that he had never been contacted by the majority leader.

Senate GOP aides still worked through the weekend in hopes of teeing up a vote this week. But Heller’s discomfort and the subsequent threat from the Trump-aligned super PAC weighed on Republican minds. When McConnell associates and Trump’s legislative staffers reached out, conversations inevitably drifted to Heller and the confusion many senators felt about the White House’s role.

“My phone was blowing up!” one former Republican official said of the Heller fallout.

In Colorado, as hundreds of donors met for a three-day seminar organized by billionaire industrialist Charles Koch, leaders from the constellation of organizations that support his agenda also outlined concerns.

“In all candor, we’ve been disappointed that movement is not more dramatic toward a full repeal or rollback,” said Tim Phillips, president of Americans for Prosperity. “We still think this can get done, but the Senate bill needs to get better.”

As Senate leaders feared, the bill’s fate took a turn for the worse Monday, when the CBO released an analysis concluding that the Senate bill would cause an estimated 22 million more Americans to be uninsured in the coming decade — just 1 million fewer than similar legislation passed by the House in early May.

A lobbyist close to Senate Republicans said the score was a devastating blow to McConnell. Senators felt they had been “sold a bill of goods,” the lobbyist said, and had expected the Senate bill to have greater distance from the House bill. 

“It knocked the wind out of all the sails,” said a GOP aide.

Senators began to shift into two camps: those who wanted to attack the CBO’s methodology, and those who realized it would not matter once people back in their states heard the numbers.

Angst was apparent Monday afternoon and evening. In the hallway between McConnell’s office suite and the Senate chamber, reporters questioned grumbling Republican senators about what they planned to do next.

Sen. John Cornyn (Tex.), the chamber’s No. 2-ranking Republican, preemptively faulted Democrats for refusing to cooperate.

Around the corner, Cruz refused to directly answer a question about whether he would even vote to bring the bill to the floor and simply repeated his oft-stated goal of lowering premiums as the door to the elevator he was riding slowly closed.

“There were so many moving parts,” Paul said this week. “It’s not that it was impossible, but there wasn’t enough time.”

By Tuesday morning, Republicans were eager to avoid the topic as they headed to their usual Senate lunch, running from reporters who swarmed the elevators shouting questions.

McConnell’s final announcement of retreat at the Tuesday lunch was typically understated. He led off by saying that plans for a vote would be shelved until after the July 4 holiday but that deliberations would continue — and that the president would like to see everyone later that day.

Then it was time to vent. Some members ticked off their concerns about the CBO when four representatives from the nonpartisan agency joined the lunch. But, mostly, senators were caught off guard — rattled by the delay and by the knotty policy disagreements.

McConnell had led them to expect a vote this week, amid all the waffling. They had found it hard in recent days to determine the scope of the objections and sensed that Republican leaders, somehow, would announce a package of fixes that could get skeptics on board.

When asked when he realized the vote was off, Sen. Bill Cassidy (R-La.) said, “Not until the leaders said we weren’t going to vote this week.” 

The signs had been there, though, all along. So had the discontent about the entire endeavor: Heller and the super PAC barrage, the wrangling over Medicaid, the conservative outcry and the CBO. All of those issues hovered as Heller awkwardly tried to break the ice with Trump at the White House.

Heller knew the vote was off, but he was irritated by the pro-Trump super PAC and contended that he was only doing what some other senators were doing: listening to GOP governors who did not want to disrupt their states’ Medicaid funding.

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One person close to Heller described his thinking as “doing what’s best for his state and Heller,” since he believed he could not count on Trump or the GOP to save his seat. Like most Republicans, he had long been for ACA repeal, but the mounting complications that came with passing the bill were just too much.

“Actually, let’s face it,” Cassidy said Tuesday. “When you saw four people publicly coming out and saying they wouldn’t vote for the motion to proceed — and you knew there were others that had concerns that weren’t voicing them — you knew it probably won’t happen.”

And so it didn’t, at least for now.

https://www.washingtonpost.com/powerpost/how-the-push-for-a-senate-health-care-vote-fell-apart-amid-gop-tensions/2017/06/28/8cdf528e-5c18-11e7-9fc6-c7ef4bc58d13_story.html?hpid=hp_hp-top-table-main_healthtock-9pm-1%3Ahomepage%2Fstory&utm_term=.68509a9a98fb

McConnell’s Reputation as a Master Tactician Takes a Hit

by Jennifer Steinhauer - NYT- June 26, 2017

WASHINGTON — Senator Mitch McConnell of Kentucky, the majority leader, has long enjoyed a reputation as a master tactician. But when it comes to repealing the Affordable Care Act, he seems to have miscalculated in the first round of play.

He assumed that his conservative and moderate colleagues would come together to make good on their seven-year promise to repeal the health care law, and quickly.

But when he assembled a group of senators to cobble together a health care bill last month, he seemed to go out of his way to exclude some of the most knowledgeable members and moderate voices on health care, like Senators Bill Cassidy of Louisiana, a doctor, and Susan Collins of Maine, an insurance expert and one of the few women in the Senate Republican conference. Views outside of Mr. McConnell’s on health care did not receive extensive consideration.

When Republicans from states that had expanded their Medicaid programs quickly found themselves at odds with more conservative members who wanted a large rollback of Medicaid, Mr. McConnell did little to allay those worries. Conservatives generally wanted to rein in costs while moderate members wanted to increase spending, particularly in states where health care costs are high and opioid addiction is escalating.

On those key issues, Mr. McConnell put his legislative thumb on the scale in favor of conservatives, quickly alienating many senators from states that had expanded Medicaid, such as Senator Lisa Murkowski of Alaska and Ms. Collins, who became an early and vocal opponent of the bill.

Ms. Murkowski raised concerns on several levels. She expressed worries about soaring health care costs in rural areas, about women’s access to health care if Planned Parenthood were defunded, and about how the most vulnerable citizens, such as Alaska Natives, would get health care. Those concerns were largely unanswered.

“I certainly wasn’t ready,” Ms. Murkowski said of voting on the bill after Mr. McConnell announced on Tuesday that it would be put off until after the Fourth of July recess.

Conservatives point out that, compared with the House bill, the Senate bill delayed the phaseout of the expansion of Medicaid as detailed in the Affordable Care Act, and that preserving protections for patients with pre-existing conditions was something that moderates wanted. But over all, the bill was similar to the House version in broad strokes that moderates disliked, and conservatives won out on the key issue of reining in the growth of Medicaid in the long term.

Mr. McConnell may have been betting that pressure from a majority of Republicans — who have been promising for the better part of a decade to unravel President Barack Obama’s signature domestic policy achievement — would get senators from Medicaid expansion states on board to do just that.

But the forces arrayed against Mr. McConnell were many, including doctors and hospitals, patient advocacy groups and, perhaps more than anyone else, governors — many of them Republicans — from states where tens of thousands of residents have found themselves newly insured under the health care law and are not eager to see that evaporate.

“There may be some philosophical, you know, kind of textbook disagreement,” Gov. John R. Kasich, Republican of Ohio, said at a news conference in Washington on Tuesday. “But when you sit in a room and you say to people, ‘Should we strip coverage from somebody who’s mentally ill?’ I’ve never heard anybody say yes.”

Last week, Senator Dean Heller, Republican of Nevada, stood at a news conferencewith Brian Sandoval, the state’s extremely popular Republican governor, and said that the “bill that’s currently in front of the United States Senate is not the answer — it’s simply not the answer.”

Mr. Heller added, “It’s going to be very difficult to get me to a yes.”

Mr. Heller gave voice — an early and deeply unappreciated one, it seems, from Mr. McConnell’s perspective — to a number of senators from across the spectrum who were feeling pressure from their governors, and in some cases state insurance officials, to resist any bill that was going to raise premiums, increase the number of uninsured or anything else that officials there disliked.

Then there is the not-so-small matter of President Trump, who in any other universe would be the greatest asset Mr. McConnell could have, but has turned out to be quite the opposite. Republican senators all watched carefully as Mr. Trump at times berated, cajoled and mildly wooed House Republicans, who had their own divisions, to get to yes on their version of a health care bill.

After celebrating in the Rose Garden with Speaker Paul D. Ryan and a bevy of other Republicans, Mr. Trump turned around and told senators that the House bill was “mean.”

This allowed Republican senators to understand that, as in most areas, Mr. Trump is a mercurial force at best on health care policy. What is more, even though a group that supports him came out with a vicious ad attacking Mr. Heller — and hinted that it would spread to other senators who opposed the health care law — senators are also keenly aware that Mr. Trump did not win the White House by promising to take away voters’ Medicaid.

Then there was the fundamental math problem. Moderate senators simply want more money for the bill. Conservatives like Mike Lee, Republican of Utah, want policy changes that would not only alienate more moderates in the Senate, but also probably be impossible under the strict rules imposed by the process Mr. McConnell is using to try to repeal the law. Mr. McConnell chose that path because he needs a mere 51 votes — including one cast by Vice President Mike Pence — to get it done. Senator Rand Paul, Republican of Kentucky, insisted that the bill could not even fairly be called a repeal, so Mr. McConnell started his counting one vote down.

But Mr. McConnell cannot be counted out. Like House leaders, he may be able to push recalcitrant senators his way, but the issues, like fried fish, are not inclined to improve over time.

“It appears that we do not have the votes at the moment,” said Senator Patrick J. Toomey, Republican of Pennsylvania, who stood firmly in the conservative camp as a member of Mr. McConnell’s working group. Mr. Toomey said he thought there was some way that the Senate would eventually vote on a health care repeal bill, but conceded, “I can’t be certain of that.”

https://www.nytimes.com/2017/06/27/us/politics/mitch-mcconnell-health-care-repeal.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=first-column-region&region=top-news&WT.nav=top-news

Elizabeth Warren Calls For Democrats To Embrace Single-Payer Health Care

by Igor Bobic - Huffington Post - June 27, 2017

xSen. Elizabeth Warren (D-Mass.) says it’s time for Democrats to run on single-payer health care across the country.

President Barack Obama “tried to move us forward with health care coverage by using a conservative model that came from one of the conservative think tanks that had been advanced by a Republican governor in Massachusetts,” Warren, referring to Mitt Romney, said in an interview with The Wall Street Journal published Tuesday.

“Now it’s time for the next step. And the next step is single payer,” she said.

Warren’s comments represent a shift to her position on the U.S. health care system. In March, she said her support for switching to single-payer ― in which the government handles coverage of health care costs, rather than insurance companies ― would depend on whether Democrats could find Republican lawmakers willing to help fix the Affordable Care Act passed under Obama.

Republicans, however, have focused on trying to repeal and replace Obamacare. And neither a bill the House passed nor one the Senate is considering ― both of which would cause more than 20 million people to lose health insurance, according to Congressional Budget Office estimates ― has any support among Democrats.

Last week, a high-profile effort to establish a single-payer health care system in California stalled amid concerns from both Democratic and Republican lawmakers in the state over how to pay for the estimated $330 billion to $400 billion measure. California Assembly Speaker Anthony Rendon (D) called the measure “woefully inadequate.”

National Democrats have been reluctant to call for putting single-payer at the top of their party platform. House Minority Leader Nancy Pelosi (D-Calif.), who supports single-payer, rejected the idea earlier this year, saying the issue should be left up to the states because Congress is not ready for it yet.

Republicans say single-payer is unpopular and turns off voters. Matt Gorman, communications director at the National Republican Campaign Committee, goaded Democrats to heed Warren’s call for such a system.

The White House is also using the specter of single-payer to persuade Senate Republicans to vote for their party’s health care bill.

White House Press Secretary Sean Spicer tweeted that plans by Sen. Bernie Sanders (I-Vt.) to introduce a bill that would create a single-payer system “lays out” the choice for GOP senators wary of the bill their leaders unveiled last week.

In her Journal interview, Warren called on Democrats to ditch half-measures and commit to progressive policies that they believe in.

“It’s not like we’re trying to sell stuff that people don’t want. … It’s not that at all,” she said. “It’s that we haven’t gotten up there and been as clear about our values as we should be, or as clear and concrete about how we’re going to get there.”

Senate Democrats who spoke with HuffPost on Tuesday were cool to the idea of endorsing national single-payer at a time when the party is engaged in a heated battle over the Republican health care bill. Senate Majority Leader Mitch McConnell (R-Ky.) postponed a vote on the legislation on Tuesday, but he still intends to bring a retooled bill to the floor after the July 4 recess.

“If we succeed in stopping this bill, then we have to have a conversation about what’s the best alternative,” Sen. Chris Coons (D-Del.) said on Capitol Hill Tuesday. “But I think we should stay focused on helping our constituents understand what is wrong with [the GOP bill].”

Sen. Sherrod Brown (D-Ohio), another high-profile progressive in Congress, echoed the sentiment.

“My mission is to do all I can to defeat ACA repeal,” he said. “I don’t want to start putting alternatives out there. Right now I want to focus on defeating repeal. There’s 20 million people’s lives at stake.”

http://www.huffingtonpost.com/entry/elizabeth-warren-single-payer_us_595256bfe4b02734df2d528f?ncid=engmodushpmg00000003

When Cutting Access to Health Care, There’s a Price to Pay

by Eduardo Porter - NYT - June 27, 2017

Senators, the United States is a sick country.

Four years ago, a panel of experts convened by the Institute of Medicine and the National Research Council set out to assess the nation’s health compared with that of 16 other rich nations. Americans, they found, had the second-highest mortality from noncommunicable conditions — like diabetes, heart disease or violence — and the fourth highest from infectious disease. In terms of infant and maternal mortality, Americans are the worst off.

From adolescence to adulthood to old age, the chances of dying an early death are higher in the United States than in any of the other 16 countries. A 15-year-old American girl has a 1 in 25 chance of dying before she turns 50, twice the risk found in the comparison group.

And early death is hardly surprising, since Americans lead a pretty sickly life. Teenagers and young adults report higher rates of obesity, chronic illness, sexually transmitted infections, mental illness and injuries than in peer countries, according to the report. Americans in their 50s have higher rates of heart disease, stroke, diabetes, hypertension and obesity.

The figures also reflect a toll in the workplace. The United States ranks in the bottom fourth among the 30 industrialized nations in the Organization for Economic Cooperation and Development in terms of days lost to disability: Women will lose 362 days between birth and their 60th birthday; men about 336. Mental healthproblems like depression will account for most.

And the American deficit has been getting worse. “Each year, other high-income countries are improving their health at a much faster rate than the United States, and the United States currently ranks lowest on a variety of health measures,” the report by the Institute of Medicine and the National Research Council noted.

I bring this up, senators, because you are considering whether to drive a stake through the Affordable Care Act, cutting access to care for millions of mostly poorer, sicker and older Americans.

Of course, the dismal health situation is not all the fault of the health care system — which, until the passage of the Affordable Care Act, was the only one in the developed world that routinely barred access or limited care for millions of people of modest means.

That is because violence accounts for a large share of Americans’ excessive mortality, and accidents take a disproportionate toll. Nor is the health care system entirely to blame for the nation’s elevated obesity rate — a leading cause of problems like diabetes.

What’s more, the United States’ higher tolerance of poverty undoubtedly contributes to higher rates of sickness and death. Americans at all socioeconomic levels are less healthy than people in some other rich countries. But the disparity is greatest among low-income groups.

Still, senators, you are not off the hook. Limited access to health care may not entirely account for the poor health and the early deaths of so many of your fellow Americans. But it accounts for a good chunk.

A study about equity in access to health care for 21 countries in 2000 revealed that the United States had the highest degree of inequity in doctor use, even higher than Mexico — which is both poorer and generally more inequitable.

And as noted in a 2003 study by the Institute of Medicine, insurance status, more than any other demographic or economic factor, determines the timeliness and quality of health care, if it is received at all.

It doesn’t require an advanced degree to figure out what limited access to a doctor can do to people’s health. A review of studies published this week in Annals of Internal Medicine reported that health insurance substantially raises people’s chances of survival. It improves the diagnosis and treatment of high blood pressure, significantly cutting mortality rates. It reduces death rates from breast cancer and trauma. Over all, the review concluded that health insurance reduces the chance of dying among adults 18 to 64 years old by between 3 and 29 percent.

Another assessment, published last week in The New England Journal of Medicine, found that access to health insurance increases screenings for cholesterol and cancer, raises the number of patients taking needed diabetes medication, reduces depression, and raises the number of low-income Americans who get timely surgery for colon cancer.

It said that expansions in three states of Medicaid, the federal health insurance for the poor whose rolls Republicans are prepared to trim by 15 million over a decade, were found to reduce mortality by 6 percent over five years, mostly by increasing low-income Americans’ access to treatment for things like H.I.V., heart disease, cancer and infections.

I understand, senators, that this sort of analysis may not sway all of you. I’m aware of the view on the rightmost end of the political spectrum that ensuring people’s well-being, which I assume includes their health, is a matter of personal responsibility and not the government’s job.

Yet there is a solid economic argument for protecting your fellow citizens’ access to health care that does not rely on arguments from empathy, charity or the like. A sickly, poorly insured population can be expensive.

As noted by a study from the Joint Center for Political and Economic Studies, poor health and limited access to health care not only raise the cost of providing such care but also reduce productivity, eat into wages, increase absenteeism, weigh on tax revenues and generally lower the nation’s quality of life.

The study, which focused on the disadvantages of African-Americans, Latinos and Asians, added up the costs of inequalities in health and premature death between 2003 and 2006 and came up with a price tag of $1.24 trillion.

The good news, senators, is that solving these inequities needn’t be particularly expensive. The analysis relayed in The New England Journal of Medicine suggested that each additional life saved by expanding Medicaid costs $327,000 to $867,000. That is much cheaper than other public interventions, such as workplace safety and environmental regulations, which achieve a similar reduction in mortality for each $7.6 million spent on compliance.

Even better: Instead of taking away the health insurance of more than 20 million Americans, what if you could offer nearly universal access and still make that work within your broader agenda?

In 2015, according to the Organization for Economic Cooperation and Development, the United States government spent 8.4 percent of its gross domestic product to pay for health care for about half of all Americans, including Medicare, Medicaid and subsidies under the Affordable Care Act. That year, Britain spent 7.7 percent to cover virtually all of its citizens. Finland, Canada and Italy spent even less.

I understand, senators, that these places have what is known as single-payer systems — which tend to stick in the craws of some of you. But think about it. If your primary motivation to repeal the Affordable Care Act is to provide a large tax cut for high-income Americans, think what you could do with a full percentage point of G.D.P. It could even be worth the effort to provide health care for all.

https://www.nytimes.com/2017/06/27/business/economy/health-care-senate-mortality.html?hp

Public support for ‘single payer’ health coverage grows, driven by Democrats

by Jocelyn Kiley - Pew Research Center - June 26, 2107

A majority of Americans say it is the federal government’s responsibility to make sure all Americans have health care coverage. And a growing share now supports a “single payer” approach to health insurance, according to a new national survey by Pew Research Center.

Currently, 60% say the federal government is responsible for ensuring health care coverage for all Americans, while 39% say this is not the government’s responsibility. These views are unchanged from January, but the share saying health coverage is a government responsibility remains at its highest level in nearly a decade.

Among those who see a government responsibility to provide health coverage for all, more now say it should be provided through a single health insurance system run by the government, rather than through a mix of private companies and government programs. Overall, 33% of the public now favors such a “single payer” approach to health insurance, up 5 percentage points since January and 12 points since 2014. Democrats – especially liberal Democrats – are much more supportive of this approach than they were even at the start of this year. 

Even among those who say the federal government is not responsible for ensuring Americans have health care coverage, there is little public appetite for government withdrawing entirely from involvement in health care coverage. Among the public, 33% say that health care coverage is not the government’s responsibility, but that programs like Medicare and Medicaid should be continued; just 5% of Americans say the government should not be involved at all in providing health insurance.

The issue of the government’s responsibility in ensuring health coverage remains deeply divisive politically, according to the new survey, conducted June 8-18 among 2,504 adults. More than eight-in-ten Democrats and Democratic-leaning independents (85%) say that this responsibility falls to the federal government, while about two-thirds of Republicans and Republican leaners (68%) say it does not.

Still, most Republicans (57%) say the government “should continue programs like Medicare and Medicaid for seniors and the very poor.” Just 9% of Republicans say the government should not be involved in providing health insurance at all.

Among Democrats, 52% now say health insurance should be provided through a single national insurance system run by the government, while fewer (31%) say it should be provided through a mix of private companies and government programs. The share of Democrats supporting a single national program to provide health insurance has increased 9 percentage points since January and 19 points since 2014.

Nearly two-thirds of liberal Democrats (64%) now support a single-payer health insurance system, up 13 percentage points since January. Conservative and moderate Democrats remain about evenly divided: 38% prefer that health insurance continue to be provided by a mix of private insurance companies and government programs, while 42% favor a single-payer approach.

Overall, support for a single-payer health insurance system is much greater among younger adults than older people. Two-thirds of adults younger than 30 (67%) say the government has a responsibility to provide health coverage for all, with 45% saying coverage should be provided through a single national program.

Among those 65 and older, 54% say the government has a responsibility to provide coverage for all, with 30% favoring a single payer approach.

Both parties are divided by age in views of the government’s role in health care. Fully 66% of Democrats and Democratic leaners ages 18 to 29 say government health coverage should be provided through a single national system, compared with 48% of Democrats and Democratic leaners ages 30 and older.

Among Republicans, a greater share of those younger than 30 (39%) than those 30 and older (28%) say the government is responsible for providing health coverage for all; more young Republicans than older Republicans favor single payer (22% vs. 10%).

While the new survey finds no change since January in opinions about the government’s responsibility to provide health care coverage, the share viewing this as a government responsibility has increased 9 percentage points since 2016, from 51% to 60%.

As recently as 2013, during the flawed rollout of health insurance exchanges under the Affordable Care Act, just 42% said the government was responsible for providing health coverage, while a majority (56%) said it did not have this responsibility.

http://www.pewresearch.org/fact-tank/2017/06/23/public-support-for-single-payer-health-coverage-grows-driven-by-democrats/

The C.B.O. Did the Math.
These Are the Key Takeaways From the Senate Health Care Bill.

by Haeyoun Park and Wilson Andrews - NYT - June 26, 2017

Below are the four big numbers from the Congressional Budget Office’s analysis of the Senate Republican plan to repeal and replace the Affordable Care Act.

The bill would reduce the federal
deficit by $321 billion over 10 years.

The federal government would save billions, mostly by making deep cuts to Medicaid. Much of the savings would come near the end of the next decade.

Projected cumulative change in deficit, in billions

The savings could have been even larger, but the bill would repeal most of the tax increases that the Affordable Care Act imposed primarily on the wealthy to help pay for expanded coverage.

22 million more Americans
would be uninsured by 2026.

The budget office projects that by 2026, 49 million people would be uninsured, compared with 28 million people if the current law remained in effect. (The total increase is 22 million due to rounding.)

The increase in the number of uninsured would be disproportionately larger among older people with lower incomes.

Several major changes under the Senate plan would cause fewer people to have insurance.

The bill repeals the individual mandate, which requires all Americans to obtain health insurance if they can afford it or else face penalties. The mandate, which many Republicans criticize, was created to keep insurance affordable for those who are older or sick.

Without the mandate, many healthy people are expected to drop coverage, driving up prices for those who need it most and ultimately causing even more people to drop out of the individual market.

The bill would also substantially reduce spending on Medicaid and reduce the value of tax credits that individuals use to buy health insurance, pricing many out of the market.

15 million fewer people would
be enrolled in Medicaid by 2026.

The largest group to lose health insurance coverage would be people with Medicaid. In 10 years, the C.B.O. projects, there would be 15 million fewer Medicaid enrollees.

Currently, the federal government pays at least 90 percent of the costs for newly eligible beneficiaries in the 31 states that expanded the program under the Affordable Care Act.

Under the Senate plan, federal payments would be reduced for those enrollees beginning in 2021, and in 2024, federal support would be sharply curtailed, most likely causing many states to end the expansion.

Separate from the expansion, future federal spending would be capped per enrollee, based on how much each state has spent historically.

By putting Medicaid on a budget, the bill saves $772 billion over 10 years.

Average premiums would
decrease by 20 percent in 2026. 

Republican lawmakers cite rising premiums as a main reason for repealing the Affordable Care Act.

The C.B.O. estimates that average gross premiums would initially rise under the Senate bill, then drop by about 20 percent, compared with what it would be under the current law, in 2026.

This would largely be achieved by offering skimpier plans with higher deductibles, and by pricing the old and the sick out of the insurance market.

The Senate bill would make financial assistance for premiums less generous than under the current law. That means that average deductibles for the plans would be much higher. For many low- and middle-income Americans who currently receive subsidies, their share of premiums would rise.

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

Age	Under Obamacare	After tax credit	Under Senate bill	After tax credit
21 years old	$4,300	$900	$3,200	$1,300
40 years old	$5,500	$700	$5,000	$1,600
64 years old	$12,900	0	$16,000	$2,000

Note: Numbers are for a bronze plan.

The new subsidy structure would require older people to pay a larger share of their incomes for coverage, reducing the amount they get to help pay for premiums.

Changes in rules about insurance prices would also cause big premium increases for older Americans who don't qualify for subsidies.

Even though average premiums would decrease, the amount that many Americans spend on health care over all would increase as deductibles rise and plans cover fewer benefits in many states.

https://www.nytimes.com/interactive/2017/06/26/us/cbo-score-of-senate-health-care-bill.html?hp

Senate GOP health-care bill appears in deeper trouble following new CBO report

by Amy Goldstein and Kelsey Snell - The Washington Post - June 26, 2017

Senate Republicans’ bill to erase major parts of the Affordable Care Act would cause an estimated 22 million more Americans to be uninsured by the end of the coming decade, while reducing federal spending by $321 billion during that time, according to the Congressional Budget Office. 

The forecast issued Monday by Congress’s nonpartisan budget scorekeepers appeared to rapidly erode Republicans’ confidence in the bill, with at least four GOP lawmakers saying by the evening that they would vote against even starting debate on it.

By late Monday, several senators and aides appeared nervous and unsure about the path forward. They hedged on the timing of that procedural vote and suggested the workweek could stretch beyond Friday. Still, there was some hope for salvaging the effort, and GOP leaders were still looking for ways to make last-minute changes that might garner crucial support.

Yet the breadth of the resistance highlighted Majority Leader Mitch McConnell’s increasingly difficult challenge.

The projection of uninsured numbers and federal spending had been awaited as a crucial piece of evidence while McConnell (Ky.) and other Republican leaders try to hurry a vote on the bill this week. They already were navigating an expanding minefield of criticism from their party’s moderate and conservative wings.

The release of the 49-page CBO ­report late Monday afternoon seemed to worsen the bill’s prospects. No new senators immediately said they would back the legislation, and Sens. Susan Collins (Maine), Rand Paul (Ky.) and Ron Johnson (Wis.) signaled that they would vote against starting debate Tuesday on the bill in its current form. A fourth senator, Dean Heller (R-Nev.), had expressed his opposition last week.

Collins, a moderate Republican, tweeted that the measure would “hurt [the] most vulnerable Americans” and failed to solve the problems of access to care in rural Maine where, she wrote, “hospitals are already struggling.”

The Senate bill could undergo further changes before such a vote is scheduled, which could prompt these senators to reconsider. But if the Democrats vote as a bloc, McConnell can afford to lose no more than two Republicans for a procedural motion to succeed.

Asked whether McConnell and other Senate leaders had amassed enough support to pass the measure, Sen. Roy Blunt (R-Mo.) responded, “Anyone would tell you they don’t.”

The CBO estimated that two-thirds of the drop in health coverage a decade from now would fall on low-income people who rely on Medicaid. And among the millions now buying private health plans through ACA marketplaces, the biggest losers would roughly parallel those under legislation passed recently by the House: The sharpest spike in insurance premiums would fall on middle-aged and somewhat older Americans.

Its analysis of the Senate measure’s impact on federal spending — $321 billion saved over a decade — compared with $119 billion for the House’s version. 

See where the Senate health-care bill’s subsidy cuts will affect Americans most View Graphic 

Paul labeled the Better Care Reconciliation Act “a terrible bill” and repeated his contention that it would not go far enough in repealing the sprawling health-care law enacted seven years ago by a Democratic Congress and president.

McConnell took to the Senate floor just before the report’s release to press anew for rapid action. He made it clear that the bill, already tweaked early Monday, could be negotiated further to try to win over holdouts. 

“The American people need better care right now,” McConnell said. “This legislation includes the necessary tools to provide it.”

Democrats quickly seized on the CBO’s projection of how much the ranks of the uninsured would grow. 

“Republicans would be wise to read it as a giant stop sign,” Senate Minority Leader Charles E. Schumer (D-NY) told reporters. “No matter how the bill changes around the edges, it is fundamentally rotten at the center.”

Former CBO director Doug Holtz-Eakin, a Republican who is now president of the American Action Forum, said the report draws basically the same conclusions as the budget office’s earlier analysis of the House measure. He predicted that GOP senators are “going to get beaten on the head with the CBO report like it’s a club.”

The fresh figures come as President Trump, in a sharp pivot from the praise he initially lavished on the House bill, has been urging the Senate to provide Americans more generous help with health insurance. On Sunday, the president repeated during a “Fox and Friends” TV appearance a word he had used in a private White House lunch with a group of GOP senators earlier this month: that the House’s version is “mean.”

On Monday, the White House again sought to cast doubt on the budget office’s credibility. “The CBO has consistently proven it cannot accurately predict how healthcare legislation will impact insurance coverage,” it said in a statement. “This history of inaccuracy, as demonstrated by its flawed report on coverage, premiums, and predicted deficit arising out of Obamacare, reminds us that its analysis must not be trusted blindly.”

According to the latest report, the Senate bill would mean that an estimated 15 million fewer Americans would have coverage next year, compared with the number if the ACA, commonly called Obamacare, remained in place. At the end of the decade, the 22 million increase in the ranks of the uninsured would include 15 million low-income Americans who would otherwise be on Medicaid and 7 million with private insurance. That total is about a million less than the 2026 impact of the House plan. 

The Senate plan would reduce federal spending to help people afford premiums for individual health insurance policies significantly more than under the House version. The Senate’s version would cut spending on tax credits by $408 billion by 2026 — compared with a $276 billion reduction in the House plan. The difference lies, in part, because the Senate’s version would not permit people with incomes as high to qualify for tax credits and would restrict federal help to health plans sold through the ACA’s marketplaces. The Senate would tie the tax credits to skimpier health plans than the current subsidies.

And while the Senate bill would phase out the ACA’s Medicaid expansion more slowly than the House legislation, cuts to the public insurance program for the poor still would account for by far the largest share of the reduction in federal spending under the Senate bill — $772 billion over the coming decade. In a briefing for reporters, CBO staff members said that they had not analyzed the bill’s effects on Medicaid cuts beyond the coming decade but that the reductions inevitably would be greater for a second decade.

While they differ in important details, both the Senate GOP’s plan and the American Health Care Act narrowly passed by House Republicans in May share the goal of undoing central aspects of the ACA. 

Both bills would eliminate enforcement of the law’s mandate that most Americans carry health insurance, relying on subtler deterrents to keep people from dropping coverage. The House version would let insurers temporarily charge higher rates to those who let their coverage lapse, while the Senate added a provision Monday that would let health plans freeze out customers for six months if they let it lapse.

In different ways, both would replace federal subsidies that help the vast majority of consumers buying coverage through ACA marketplaces, instead creating smaller tax credits that would provide greater assistance to younger adults while making insurance more expensive for people from middle age into their 60s.

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After two years, both also would end subsidies that now help about 7 million lower-income people with ACA health plans afford deductibles and copays. And both would repeal an array of taxes that have helped to pay for the ACA’s benefits, including levies on health insurers and on wealthy Americans’ investment income.

For the Senate bill, the CBO’s estimates of insurance coverage and federal spending are influenced by the fact that its forecast covers a 10-year window and the legislation’s most profound changes for the nation’s health-care system are tilted toward the latter part of that period.

The bill would, for instance, leave in place the ACA’s expansion of Medicaid through 2020. After that, it would begin a three-year phaseout of the federal money that under the ACA has paid almost the entire cost of adding 11 million Americans to the program’s rolls in 31 states. 

That means the extra funding wouldn’t disappear until the mid-2020s — roughly when sharp new restrictions on federal payments for the entire Medicaid program would take effect.

Over the weekend, the senior Democrat on the Senate subcommittee that oversees the CBO said in a tweet that he had asked the budget office to estimate the Senate bill’s effect on insurance coverage over a longer time horizon. “GOP is hiding the worst Medicaid cuts in years 11, 12, 13 and hoping CBO stays quiet,” Sen. Chris Murphy (D-Conn.) wrote.

https://www.washingtonpost.com/national/health-science/imminent-cbo-report-could-prove-pivotal-for-senate-republicans-health-care-bill/2017/06/26/cb8d61e2-59f7-11e7-a9f6-7c3296387341_story.html?hpid=hp_hp-top-table-main_cbosenate-12pm-1%3Ahomepage%2Fstory&utm_term=.270009cf41fa

A Few Bright Spots for Republicans. The Rest Can Be Scored as Grim.

by Margot Sanger-Katz - NYT - June 26, 2017

In dry, stark language, the Congressional Budget Office on Monday punctured many of the stated goals for the Republican health care bill.

The budget analysis gave Republican senators just a few happy talking points. It found that average insurance premiums would be lower in 2020 than they are today. The bill would reduce the deficit by more than $300 billion over a decade. And it would produce a huge tax cut, albeit mostly for wealthier Americans.

But if you are a Republican senator looking for good news in this report, there are many more reasons to be glum than cheerful.

The Better Care Reconciliation Act, as the Senate version of the bill is called, would lead 22 million fewer Americans to have insurance in a decade, the C.B.O. found, almost no change from the earlier House bill that the Senators have been overhauling.

It said the legislation would increase deductibles, make insurance more skimpy and destabilize markets. Average premiums would go down largely because the insurance they would pay for would become thinner and less valuable. Older people more likely to need insurance would be priced out of the market.

President Trump asked the Senate to write a bill that was less “mean” than a version passed by the House last month. According to a White House news release, the budget office’s score is not disqualifying. But the fine print suggests the bill does not do much to help the people who would have been harmed under that earlier legislation. The Senate made major changes to the bill, but the budget office did not find that those changes would improve coverage much or increase the affordability of health care.

Although the Senate bill, unlike the House bill, would preserve rules prohibiting insurers from charging higher prices to customers with a history of illness, it would allow states to eliminate minimum standards for plan benefits and to permit annual and lifetime limits on coverage. Those changes mean that many Americans with serious illnesses would end up paying much more out of their own pockets for health care, even if they could buy coverage.

The budget office says that “most people” buying insurance in the new market would end up paying more for their care. For people with serious illnesses living in states with waivers, “some enrollees could see large increases in out-of-pocket spending.”

The Senate bill replaced flat, age-based premium subsidies with subsidies based on a sliding scale, according to income. That meant that some people who would have been priced out of the insurance market under the House bill — particularly poorer, older Americans, in states with expensive health care systems — would get more help buying insurance under this plan.

But the budget office didn’t think that many such people would use those comparatively more generous tax credits, because of the high deductibles. Low-income people, it said, would look at both the sticker price and the value of health insurance and tend to opt out of the market.

“As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan,” the analysts said. The bill also took away financial assistance for higher-earning middle-income Americans. That change would leave an average 64-year-old earning around $55,000 with no help paying a $20,500 annual premium.

The Senate bill slowed a retreat from Medicaid expansion that was part of the Affordable Care Act. Instead of instantly slashing federal funding for that new population in 31 states in 2020, the Senate bill would step down the federal share of spending over several years. But according to the budget office, the end result is quite similar.

By the end of a decade, the budget office estimates that 15 million fewer Americans would have Medicaid coverage; that’s 1 million more than under the House bill. The Senate bill pays for the more generous Medicaid phaseout in the early years by reducing the program’s overall spending more sharply later. The budget office’s estimates span only 10 years, but its analysts noted that they expect “that after 2026, enrollment in Medicaid would continue to fall relative to what would happen under current law.”

The president has decried unstable markets under Obamacare, pointing to places that have been left with only one insurance carrier — or are at risk of none. The budget office said that the individual markets under the Senate bill would be less likely to be stable and more likely to include coverage gaps, particularly in rural areas.

“Some sparsely populated areas might have no nongroup insurance offered because the reductions in subsidies would lead fewer people to decide to purchase insurance — and markets with few purchasers are less profitable for insurers.” Other places, it notes, insurance would be available only with “very high premiums.”

The 49-page assessment is full of other unfriendly news. It essentially suggests that one provision, to eliminate an Obamacare insurance regulation, would foster profiteering by insurance companies, by encouraging them to overcharge the government for certain plans. It says that a provision locking out Americans from getting coverage for at least six months if they let their insurance lapse for 63 days or more — added on Monday to help stabilize insurance markets — would have almost zero effect.

Contrary to statements by Kellyanne Conway and other Trump advisers that the bill contains no overall cuts to Medicaid, the budget office offered a chart highlighting the spending reductions for the program. It says explicitly that “states would not have substantial additional flexibility” under the bill’s Medicaid reforms, a typical selling point for a plan that would push more fiscal risk to state governments. It says that a waiver program for state insurance regulations would increase the deficit and would not reduce the uninsured rate in every state. In addition, the analysts wrote, “waivers would probably cause market instability in some areas.”

Several senators have expressed concern about the bill’s effects on residents affected by the opioid epidemic. The budget analysis noted that mental health services “could be at risk,” as states pare back their required benefits under the waivers.

Budget analysts estimated that about 15 percent of women in some areas would lose health care access because of provisions to defund Planned Parenthood, and would not find an alternative source of care. That estimate may worry two senators, Susan Collins and Lisa Murkowski, who have expressed concerns about the bill’s effects on women’s health. The Planned Parenthood cuts would also result in several thousand “additional births,” increasing Medicaid spending on maternity and pediatric care, the report said.

Analysts noted that the biggest tax cuts in the bill “are not directly related to health insurance coverage.”

The report also offers some unpleasant news about the next political window: While the longer-term premium and savings numbers may comport with Republicans’ policy preferences, the short-term numbers are less desirable. Despite substantial extra spending, meant to stabilize insurance markets, the budget office estimates that premiums would go up by 20 percent next year, and 15 million fewer Americans would have health coverage, in a year when voters are casting ballots in congressional races. (The deficit would increase in that period, too, according to the estimate.)

So far, Mitch McConnell, the Senate majority leader, has responded by applauding the deficit and premium numbers. And the White House has responded by assailing the credibility of the nonpartisan budget office. But the rewrite of the House bill has not led the budget office to revise its overall assessment of the effort: More than 20 million Americans would lose coverage, and many of those retaining it would end up with insurance that costs them more and covers less.

https://www.nytimes.com/2017/06/26/upshot/a-few-bright-spots-for-republicans-the-rest-could-be-scored-as-grim.html?hp

The G.O.P. Rejects Conservatism

by David Brooks - NYT - June 27, 2017

ASPEN, COLO. — There is a structural flaw in modern capitalism. Tremendous income gains are going to those in the top 20 percent, but prospects are diminishing for those in the middle and working classes. This gigantic trend widens inequality, exacerbates social segmentation, fuels distrust and led to Donald Trump.

Conservative intellectuals were slow to understanding the seriousness of this structural problem, but over the past few years they have begun to grapple with the consequences. Basically, many conservative intellectuals have come to terms with income redistribution.

Conservative income redistribution doesn’t look like liberal redistribution. Conservatives tend to like their redistribution done at the local level, and they like to use market-friendly mechanisms, like child tax credits, mobility vouchers and wage subsidies. But the intent is the same: to give those who are struggling more security and opportunity.

Conservative redistribution extends to health care. Over the past several years many plans have emerged from the various right-leaning thinking tanks that imagine consumer-driven health care that also has universal or near universal coverage.

These plans, from places like the American Enterprise Institute, use tax credits or pre-funded health savings accounts or some other method to give middle- and working-class people coverage, while reducing regulations and improving incentives throughout the system.

Republican politicians could have picked up one of these plans when they set out to repeal Obamacare. They could have created a better system that did not punish the poor. But there are two crucial differences between the conservative policy johnnies and Republican politicians.

First, conservative policy intellectuals tend to have accepted the fact that American society is coming apart and that measures need to be taken to assist the working class. Republican politicians show no awareness of this fact. Second, conservative writers and intellectuals have a vision for how they want American society to be in the 21st century. Republican politicians have a vision of how they want American government to be in the 21st century.

Republican politicians believe that government should tax people less. The Senate bill would eliminate the 3.8 percent tax on investment income for those making over $250,000. Republican politicians believe that open-ended entitlements should be cut. The Senate health care plan would throw 15 million people off Medicaid, according to the Congressional Budget Office. (This is the program that covers nearly 40 percent of America’s children.)

Is there a vision of society underlying those choices? Not really. Most political parties define their vision of the role of government around their vision of the sort of country they would like to create. The current Republican Party has iron, dogmatic rules about the role of government, but no vision about America.

Because Republicans have no governing vision, they can’t really replace the Obama vision with some alternative. They just accept the basic structure of Obamacare and cut it back some.

Because Republicans have no governing vision, they can’t argue for their plans. Health and Human Services Secretary Tom Price came to the Aspen Ideas Festival to make the case for the G.O.P. approach. It’s not that he had bad arguments; he had no arguments, no vision for the sort of health care system these bills would usher in. He filled his time by rising to a level of vapid generality that was utterly detached from the choices in the actual legislation.

Because Republicans have no national vision, they seem largely uninterested in the actual effects their legislation would have on the country at large. This Senate bill would be completely unworkable because anybody with half a brain would get insurance only when they got sick.

Worse, this bill takes all of the devastating trends afflicting the middle and working classes — all the instability, all the struggle and pain — and it makes them worse. As the C.B.O. indicated, the Senate plan would throw 22 million people off the insurance rolls. It would send them to private insurance plans that they could not afford to buy. Under the Senate bill, deductibles for poor families would be more than half of their annual income. The plans are so incompetently and cruelly designed that as the C.B.O. put it, “few low-income people would purchase any plan.”

This is not a conservative vision of American society. It’s a vision rendered cruel by its obliviousness. I have been trying to think about the underlying mentality that now governs the Republican political class. The best I can do is the atomistic mentality described by Alexis de Tocqueville long ago:

“They owe nothing to any man, they expect nothing from any man; they acquire the habit of always considering themselves as standing alone, and they are apt to imagine that their whole destiny is in their own hands. Thus not only does democracy make every man forget his ancestors, but it hides his descendants and separates his contemporaries from him; it throws him back forever upon himself alone and threatens in the end to confine him entirely within the solitude of his own heart.”

https://www.nytimes.com/2017/06/27/opinion/the-gop-rejects-conservatism.html

A Vote of Conscience and Courage

by David Leonhardt - NYT - June 27, 2017

Forget for a minute about partisan labels and listen to members of the United States Senate talk about why they work in politics.

Rob Portman talks about a 16-year-old constituent who died of a drug overdose — and about honoring his life by fighting drug use. Lisa Murkowski talks about protecting children from fetal alcohol disorders, and Lamar Alexander speaks about premature babies.

There are many more stories like these, and they’re not only for show. They reflect deeply held beliefs that senators have about themselves.

Republican or Democrat, they see themselves as public servants — their preferred term for politicians — trying to make life better for their fellow Americans. Sure, when they’re being honest, they admit that they enjoy the power and perks. But even with all of the cynicism Washington engenders, senators still take pride in the high ideals of politics.

This week, these senators will face a career-defining choice.

It is not an easy one for many of them. Republicans have spent years promising to repeal Obamacare. Now the Senate is nearing a decision on whether to do so. Opposing the bill risks marking any Republican as a traitor to the party.

By late Monday, enough Republicans were nonetheless expressing skepticism about the bill to put its success in serious doubt. Susan Collins of Maine, Rand Paul of Kentucky and Dean Heller of Nevada have all distanced themselves from the bill. But we’ve seen a version of this story before. House Republicans also expressed serious doubts — only to wilt after party leaders made superficial changes to the bill. The Senate bill remains alive until it’s dead.

In the meantime, I hope that each senator takes some time away from the daily swirl of Capitol Hill to think back to the reasons they entered politics. I hope they understand that this bill is a test of conscience and of courage.

A “yes” vote is still the politically easy vote for any Republican. But it is also a vote that will come back to haunt many senators when they reflect on their careers — and when more objective observers pass historical judgment on those careers.

There is little precedent for a bill like this one. That’s why Mitch McConnell kept it secret for as long as possible. Americans have often fought bitterly about how large our safety net should be and about the precise forms it should take. But once the country commits to a fundamentally more generous, decent safety net, it becomes an accepted part of society. Poverty, disease and misfortune that had been accepted as normal became rejected as cruel.

Once we stopped allowing 10-year-olds to work in factories and fields, we didn’t go back on it. Once we outlawed 80-hour workweeks at miserly pay, we didn’t reinstate them. Once we made health insurance and Social Security a universal part of old age, we didn’t repeal them.

The Senate health care bill would be a reversal on that scale.

Yes, Obamacare is flawed, and it needs to be improved. But the Senate bill would not fix those flaws. It would instead take away health insurance from millions of Americans — middle class and poor, disabled and sick, young and old — largely to finance tax cuts for the wealthy. Ultimately, the bill would lead many Americans to lose medical care on which they now depend.

I hope the senators will listen to some of these people’s stories. The most affecting that I’ve read recently is about Justin Martin, who has overcome cerebral palsy to become a thriving student at Kenyon College. As the HuffPost’s Jonathan Cohn reported, Martin depends on Medicaid to pay for a wheelchair that helps him get around and for health care aides who help him in the bathroom.

When history comes to judge today’s senators, do they want to have made life harder on Justin Martin?

I hope the senators will also take the time to ask themselves why virtually no health care expert supports the bill. Conservative health care experts have blasted it, along with liberal and moderate experts. The Congressional Budget Office says it will do terrible damage. Groups representing doctors, nurses, hospitals and retirees oppose the bill. So do advocates for the treatment of cancer, heart disease, lung disease, multiple sclerosis, cystic fibrosis and, yes, cerebral palsy.

I hope the senators will watch a two-minute video created by doctors around the country. In it, each one looks into the camera and explains how the bill would damage medical care. “This bill would dramatically affect my patients,” said Dr. Gregory Lam of Circleville, Ohio, “and my ability to care for them.”

I hope the senators grasp the weight of the decision they face, for the country and for themselves.

It takes only three Republican senators to prevent millions of their fellow citizens from being harmed. Which of them has the courage to make the right choice over the easy one?

https://www.nytimes.com/2017/06/27/opinion/senate-health-insurance-obamacare-vote-cbo.html?smprod=nytcore-iphone&smid=nytcore-iphone-share

How the Senate’s Health-Care Bill Threatens the Nation’s Health

by Atul Gawande - The New Yorker - June 26, 2017

To understand how the Senate Republicans’ health-care bill would affect people’s actual health, the first thing you have to understand is that incremental care—regular, ongoing care as opposed to heroic, emergency care—is the greatest source of value in modern medicine. There is clear evidence that people who get sufficient incremental care enjoy better prevention, earlier diagnosis and management of urgent conditions, better control of chronic illnesses, and longer life spans.

When more people get health-insurance coverage, as they did following the implementation of the Affordable Care Act, they get more incremental care. This week, the New England Journal of Medicine published a paper that I co-authored with Katherine Baicker and Ben Sommers, two health economists at the Harvard T. H. Chan School of Public Health, in which we analyzed the health effects of insurance coverage. We looked at dozens of studies put out over the last decade, and found that insurance-coverage expansions—including not just the A.C.A but also past Medicaid expansions and the health-care reform that Massachusetts passed in 2006—have consistently and significantly increased the number of people who have a regular source of care and who can afford the care they need. Insurance expansions have made people more likely to get primary and preventive care, chronic-illness care, and needed medications—including cancer screenings, diabetes and blood-pressure medicines, depression treatment, and surgery for cancer before it is too late.

These improvements in care help explain why people who have health insurance are twenty-five per cent more likely to report being in good or excellent health. It also explains why they become less likely to die. Proper health care saves lives, and the magnitude of the reduction in deaths increases over time. The longest study we looked at analyzed Medicaid expansions that occurred in the early two-thousands in Arizona, Maine, and New York. Five years after the expansions, mortality rates for recipients had fallen by six per cent compared with matched populations in states that didn’t expand Medicaid. More broadly, when we looked at the data from all the large studies in our set, we found that, for every three hundred to eight hundred people who gained coverage, one life was ultimately saved per year. The biggest gains came, as would be expected, among patients with chronic or semi-chronic conditions, such as heart disease, cancer, H.I.V., and other infections.

Conservatives often take a narrow view of the value of health insurance: they focus on catastrophic events such as emergencies and sudden, high-cost illnesses. But the path of life isn’t one of steady health punctuated by brief crises. Most of us accumulate costly, often chronic health issues as we age. These issues can often be delayed, managed, and controlled if we have good health care—and can’t be if we don’t.

Conservatives also dismiss Medicaid by arguing that it provides inadequate or unsatisfactory coverage. The opposite is true, according to the evidence. Compared with private coverage, Medicaid produces at least as much improvement in access to care, measures of health, and mortality reduction. And polls indicate that recipients like Medicaid more than private coverage, even with the difficulties finding doctors who take Medicaid, because the program provides them with better financial protection.

Despite these facts, the Senate reform bill, like the bill that House Republicans passed earlier this year, would hollow out or terminate coverage for tens of millions of Americans who rely on Medicaid or the private-insurance exchanges set up by the A.C.A. These bills are, in many ways, Medicaid-repeal bills masquerading as Obamacare-repeal bills. And Medicaid, remember, is not a program that the public is complaining about. It is immensely popular and works well. It provides coverage for sixty per cent of disabled children, and maternity coverage for half of pregnant women. Two-thirds of nursing-home residents end up relying on Medicaid coverage after their savings are spent. Among adult Medicaid recipients, sixty per cent work, and eighty per cent are part of working families.

President Trump, who has expressed his support for the Senate bill, campaigned on a specific promise not to cut Medicaid, and the White House continues to peddle a claim that, as Sean Spicer put it on Friday, the President is “committed to making sure that no one who currently is in the Medicaid program is affected in any way, which is reflected in the Senate bill, and he’s pleased with that.” But this statement does not reflect reality—the Senate proposal would not only roll back the A.C.A.’s Medicaid expansion but go even further, capping Medicaid expenditures at levels even lower than those that would have been in place without the A.C.A.

The Senate bill would also ultimately make people who buy insurance on the A.C.A. exchanges—people without coverage from an employer or from Medicaid—pay far more money for far worse coverage, especially if they are age fifty or older. The standard “reference” plan on the exchanges would cover barely more than half of medical costs, while cost-sharing subsidies for working-class people would be eliminated, and the level of tax credits available to them would be cut, too. The result: the median deductible would jump from the current five hundred dollars to more than six thousand dollars. The annual premium for a sixty-year-old earning fifty thousand dollars in my home town of Athens, Ohio, would triple, to fourteen thousand dollars. In many parts of the country, things would be much worse. (In Anchorage, Alaska, for example, premiums would be thirty-six thousand dollars.) The bill, in other words, promises terrible coverage at unaffordable prices. Millions of people would have to give up insurance, leaving them without protection and the entire individual-insurance market at risk of collapse.

The trade-offs here are indefensible. The bill would take a trillion dollars away from health coverage for the bottom fifty per cent of the population to give a tax cut to the top two per cent. The Center on Budget and Policy Priorities did the math: one consequence of the legislation is that three-quarters of a million people would be thrown off of the Medicaid rolls to give the four hundred highest earners in the country a thirty-three-billion-dollar tax cut. The bill would put thousands of nursing homes, clinics, and hospitals into financial trouble. And for patients it would mean more medical debts, more untreated sickness, and more deaths. A basic test of government is its ability to prevent large-scale harm to its citizens’ health and survival. This bill, and this Administration, are failing that test.

http://www.newyorker.com/news/news-desk/how-senates-health-care-bill-threatens-nations-health?

From Coast to Coast

by Ben Palmquist - Jacobin - June 17, 2017

The Congressional Budget Office has scored Republicans’ American Health Care Act, and the picture is bleak. If the House bill passes the Senate, it would take health insurance away from twenty-three million people, reduce others’ coverage, and further raise premiums and out-of-pocket costs on older people and those with more medical needs.

These attacks, which target poorer, older, and sicker people and women with almost surgical precision, would fall on tens of millions of people are already in a dire situation. Nearly thirty million people are uninsured, tens of millions more have insurance but still can’t afford needed care, health-care costs are rising unabated, crushing medical debt is forcing people out of their homes, and tens of thousands of people die every year because the insurance system denies them lifesaving care.

The root of all of these problems is the private insurance system, which by design prioritizes insurance companies’ profits over human lives. Moving to a national, publicly financed, single-payer insurance system would, in one fell swoop, solve all of this. Yet since the days of Harry Truman, no one has been able to muster the power to overcome the opposition of the insurance industry. Leaders like Congressman John Conyers and Senator Bernie Sanders who back universal health care are the exceptions that prove the rule: market-fundamentalist ideologies, lobbyists, and campaign donors still hold tremendous sway over both parties in Washington.

Winning universal health care will take a mass people’s movement, and building a movement means joining together with others where we live and work. The road to universal, publicly financed health care thus runs through the states. And no state is better positioned to lead than California.

States' Golden Opportunity

States have a moral obligation as well as a keen economic interest in improving public health and arresting the insane run-up in prices that insurance, drug, and hospital corporations charge to residents, employers, and state governments. Now, with widespread anger at soaring costs, Congress’s anti-health rampage, and a growing desire for government involvement in health care, the moment is ripe to build a new popular consensus around universal health care as a cornerstone for a just and healthy society.

Just about every state has an active and organized grassroots campaign for universalhealth care. New Yorkers just passed a bill through the assembly and are gaining ground in the senate, and both Vermont and Colorado have come close to creating universal, publicly financed health care in recent years.

Yet California’s political alignment and scale make it unique. Democratic officials hold supermajorities in both houses as well as the governor’s mansion, and are eager to portray themselves as the vanguard of the resistance to Trump. The powerful Healthy California campaign, which is leading the state’s fight for universal health care, has 150 coalition members who together boast four million members. And with its enormous economy and tax base, shifting health-care financing from private premiums to public taxes is an easier lift for California than for smaller states.

Now, with the Healthy California Act, which passed the state senate on June 2, the Golden State has a chance to prove itself. But victory is hardly assured: the insurance industry and its allies are hugely powerful, and nowhere has the Democratic Party yet taken a stand for human health over the interests of its corporate donors.

To succeed, Californians must overcome two pivotal challenges that have defeated every attempt at universal health care in recent years. They must protect against the opposition’s attempts to divide their coalition, and they must overcome and supplant anti-tax, anti-government rhetoric with a fundamentally different vision.

https://jacobinmag.com/2017/06/medicare-for-all-single-payer-healthcare-bernie-sanders-california

Patients With Pre-Existing Conditions Fear Bias Under GOP Health Proposals

by Charlotte Huff - NPR - June 29, 2017

Two years ago, Cheasanee Huette, a 20-year-old college student in Northern California, decided to find out if she was a carrier of the genetic mutation that gave rise to a disease that killed her mother. She took comfort in knowing that whatever the result, she'd be protected by the Affordable Care Act's guarantees of insurance coverage for pre-existing conditions.

Her results came back positive. Like her mother, she's a carrier of one of the mutations known as Lynch syndrome. The term refers to a cluster of mutations that can boost the risk of a wide range of cancers, particularly colon and rectal.

As Republican lawmakers advance proposals to overhaul the ACA's consumer protections, Huette frets that her future health coverage and employment options will be defined by that test.

She even wonders if documentation of the mutation in her medical records and related screenings could rule out individual insurance plans. She's currently covered under her father's policy. "Once I move to my own health care plan, I'm concerned about who is going to be willing to cover me, and how much will that cost," she says.

In recent years, doctors have urged patients to be screened for a variety of diseases and predisposition to illness, confident it would not affect their future insurability. Being predisposed to an illness — such as carrying the BRCA gene mutations associated with breast and ovarian cancer — does not mean a patient will come down with the illness. But knowing they could be at risk may allow patients to take steps to prevent its development.

Under the current health law, many screening tests for widespread conditions such as prediabetes are covered in full by insurance. The Centers for Disease Control and Prevention and the American Medical Association have urged primary care doctorsto test patients at risk for prediabetes. But doctors, genetic counselors and patient advocacy groups now worry that people will shy away from testing as the ACA's future becomes more uncertain.

Dr. Kenneth Lin, a family physician at Georgetown University School of Medicine in Washington, D.C., says if the changes proposed by the GOP become law, "you can bet that I'll be even more reluctant to test patients or record the diagnosis of prediabetes in their charts." He thinks such a notation could mean hundreds of dollars a month more in premiums for individuals in some states under the new bill.

Huette says she's sharing her story publicly since her genetic mutation is already on her medical record.

But elsewhere, there have been "panicked expressions of concern," says Lisa Schlager of the patient advocacy group Facing Our Risk of Cancer Empowered(FORCE). "Somebody who had cancer even saying, `I don't want my daughter to test now.' Or `I'm going to be dropped from my insurance because I have the BRCA mutation.' There's a lot of fear."

Those fears, which come in an era of accelerating genetics-driven medicine, rest upon whether a gap that was closed by the ACA will be reopened. That remains unclear.

A law passed in 2008, the Genetic Information Nondiscrimination Act, bans health insurance discrimination if someone tests positive for a mutation. But that protection stops once the mutation causes "manifest disease" – essentially, a diagnosable health condition.

That means "when you become symptomatic," although it's not clear how severe the symptoms must be to constitute having the disease, says Mark Rothstein, an attorney and bioethicist at the University of Louisville School of Medicine in Kentucky, who has written extensively about GINA.

The ACA, passed two years after GINA, closed that gap by barring health insurance discrimination based on pre-existing conditions, Rothstein says.

On paper, the legislation unveiled by Senate Majority Leader Mitch McConnell last week wouldn't let insurers set higher rates for people with pre-existing conditions, but it could effectively exclude such patients from coverage by allowing states to offer insurance plans that don't cover certain maladies, health analysts say. Meanwhile, the bill that passed the House last month does have a provision that allows states to waive protections for people with pre-existing conditions, if they have a gap in coverage of 63 days or longer in the prior year.

When members of a Lynch Syndrome social media group were asked for their views on genetic testing amid the current health care debate, about two dozen men and women responded. Nearly all said they were delaying action for themselves or suggesting that family members, particularly children, hold off.

Huette was the only one who agreed to speak for attribution. She says before the ACA was enacted, she witnessed the impact that fears about insurance coverage had on patients. Her mother, a veterinarian, had wanted to run her own practice but instead took a federal government job for the guarantee of health insurance. She died at the age of 57 of pancreatic cancer, one of six malignancies she had been diagnosed with over the years.

Huette says she doesn't regret getting tested. Without the result, Huette points out, how would she have persuaded a doctor to give her a colonoscopy in her 20s?

"Ultimately, my health is more important than my bank account," she says.

http://www

.npr.org/sections/health-shots/2017/06/29/534753016/patients-with-pre-existing-conditions-fear-bias-under-gop-health-proposals

As Affordable Care Act Repeal Teeters, Prospects for Bipartisanship Build

by Robert Pear andThomas Kaplan  - NYT - June 28, 2017

WASHINGTON — With his bill to repeal the Affordable Care Act in deep trouble, Mitch McConnell, the Senate majority leader, raised an alternate possibility on Tuesday: Either Republicans come together, or he would have to work with Democrats to shore up the deteriorating health law.

That raised a tantalizing prospect: bipartisanship.

The idea is not so far-fetched. For years, Republicans and Democrats have explored avenues for changing or improving President Barack Obama’s health care law, from tweaks to the requirement for employers to offer health insurance to revisions involving how the marketplaces created under the law operate.

Mr. McConnell had hoped the Senate would pass the repeal bill this week, but he met resistance from moderate and conservative members of his caucus. He spent much of his time on Wednesday in discussions with Republican senators, seeking agreement on the substance of a revised bill.

Republican senators said that Mr. McConnell wanted to finish work on the legislation by Friday, submit it for analysis by the Congressional Budget Office and then press the Senate to take it up after a weeklong break for the Fourth of July.

“I think it’s going to be very difficult” for Republicans to reach agreement on a bill this week, said Senator Susan Collins, Republican of Maine. But, she added, “you never know.”

Senator John McCain, Republican of Arizona, was even more skeptical. “Pigs could fly,” he said.

Republicans have talked for months about possible ways to repair the Affordable Care Act, although they would clearly prefer the wholesale replacement they have long promised.

Senator Lamar Alexander, Republican of Tennessee and the chairman of the Senate health committee, has said he would like to draft legislation geared toward stabilizing the marketplaces and providing a temporary continuation of subsidies paid to insurance companies to offset out-of-pocket medical expenses.

Just this week, Ms. Collins, in announcing her opposition to the repeal bill in its current form, said she wanted to work with members of both parties to “fix the flaws” in the Affordable Care Act.

Last month, senators from both parties met privately to hash out health care issues. The Democrats attending the session included Joe Donnelly of Indiana, Heidi Heitkamp of North Dakota and Joe Manchin III of West Virginia. Among the Republicans were Shelley Moore Capito of West Virginia, Bill Cassidy of Louisiana, Lindsey Graham of South Carolina, and Ms. Collins.

Any change to the existing law is likely to need Mr. McConnell’s participation — and Speaker Paul D. Ryan’s consent. Before that happens, an all-Republican push to repeal the health law may have to die a public death.

“At this stage,” said Senator Brian Schatz, Democrat of Hawaii, “there is general agreement among Democrats that it would be premature to meet with Republicans. We have to know that this repeal bill is dead.”

Ms. Capito, an opponent of the Senate repeal bill as it now stands, said on CNN on Wednesday that if the effort to pass a Republican bill failed, “the floodgates would probably open to reach a bipartisan compromise.”

Nearly everyone preaches the virtues of bipartisanship in Congress these days, but on the big issues that define the two parties, few practice it.

For now, party leaders remain bitter foes. Republican leaders say Democrats should have come to them to help undo what Republicans say is the damage caused by the law that Democrats adopted in 2010 at great political cost.

“It’s unfortunate that our Democratic colleagues refused to work with us in a serious way to comprehensively address Obamacare’s failures,” Mr. McConnell, the Senate bill’s chief author, said Wednesday on the Senate floor.

And Democrats are using the prospect of bipartisanship as something of a cudgel, baiting Republicans to come to them, but demanding a price for entry: Keep the Affordable Care Act largely intact.

On Wednesday, Senator Chuck Schumer of New York, the Democratic leader, reminded his colleagues of the daylong gathering in 2010 at Blair House, across the street from the White House, where Mr. Obama discussed health care specifics with members of both parties shortly before passage of the Affordable Care Act.

“President Trump, I challenge you to invite us — all 100 of us, Republican and Democrat — to Blair House to discuss a new bipartisan way forward on health care in front of all the American people,” Mr. Schumer said. “It would focus about what you, Mr. President, have talked about in your campaign: lower costs, better health care, covering ‘everybody’ — not on tax cuts for the rich, not on slashing Medicaid.”

Mr. Trump predicted on Wednesday that “a great, great surprise” would emerge from the Republican health care talks, and he did not take the bait from Mr. Schumer.

“He’s done a lot of talking, bad talking, and he just doesn’t seem like a serious person,” the president said.

Money is often a lubricant for legislation, and because the Senate health bill includes about $200 billion more in deficit reduction over 10 years than the House version, Mr. McConnell has billions of dollars that he could use to address concerns expressed by members of his caucus. Various Republican senators are seeking funds to combat the nation’s opioid epidemic, stabilize health insurance markets, help older Americans pay for health coverage and slow the pace of planned cutbacks to Medicaid.

But pouring more money into the bill to please some senators could antagonize others.

Some of the Senate’s most conservative members have radically different priorities. In a letter to Mr. McConnell, outlining changes he wanted to see, Senator Rand Paul, Republican of Kentucky, complained that the legislation contained $136 billion in assistance for insurers — what he called “insurance company bailouts.”

Another conservative, Senator Mike Lee of Utah, wants to give states more latitude to opt out of federal insurance regulations, so that insurers could charge higher premiums for people based on their health status. But making such a change risks inflaming Republicans who want to keep protections for people with pre-existing medical conditions, a key difference between the Senate bill and the one passed by the House last month.

The deep divisions could elevate Mr. McConnell’s bipartisan fallback from a political threat leveled to get his troops in line to a legislative reality.

While Mr. Trump has blustered about letting the Affordable Care Act “crash and burn,” senators from both parties want to protect consumers who would be the victims if insurance markets collapse in any states. Senior Republicans in the House and Senate have said that Congress should provide money for the so-called cost-sharing subsidies paid to insurers so they can reduce deductibles and other out-of-pocket expenses for low-income people.

The Senate bill would continue the payments through 2019. Mr. Trump has repeatedly threatened to stop the payments to force Democrats to negotiate with him over the Affordable Care Act’s future.

Lawmakers have also offered proposals to address the possibility that consumers in some counties will be left without any insurers offering coverage in their Affordable Care Act marketplace.

Mr. Alexander and Senator Bob Corker, Republican of Tennessee, have proposed allowing consumers in such areas to use federal tax credits to help pay for policies obtained outside the law’s marketplaces.

Democrats and Republicans could also conceivably work together on ways to rein in drug prices and help small businesses with employee health costs.

The overtures have begun — tentatively. Senator Thomas R. Carper, Democrat of Delaware, said that — in emails, text messages, phone calls and occasional meetings — he had been “reaching out to Republicans who would like to find a principled compromise to fix what needs to be fixed in the Affordable Care Act.”

Mr. Carper said on Wednesday that he was trying to “foster an environment in which conversation and collaboration could begin in earnest and continue over the Fourth of July recess.” He has been careful to keep party leaders informed.

“Our leaders are reluctant to have our members, however well intentioned, be lone rangers negotiating on our own,” Mr. Carper said.

https://www.nytimes.com/2017/06/28/us/politics/as-affordable-care-act-repeal-teeters-prospects-for-bipartisanship-build.html?

In McConnell’s Own State, Fear and Confusion Over Health Care Bill

by Cheryl Gay Stolberg - NYT - June 28, 2017

WHITESBURG, Ky. — Dewey Gorman, a 59-year-old banker who has struggled with opioid addiction, had just gotten out of the hospital in this tiny central Appalachian city when he heard the word from Washington: His fellow Kentuckian, Senator Mitch McConnell, had delayed a vote to repeal the Affordable Care Act. He felt torn about that.

“It’s broken. It’s broken very badly,” Mr. Gorman said of former President Barack Obama’s signature health care law. “But if they want to take away insurance from 22 million people — a lot of them would come from these mountains. That would be devastating to our area.”

Perhaps nowhere has the health care law had as powerful an impact as in Kentucky, where nearly one in three people now receive coverage through Medicaid, expanded under the legislation. Perhaps no region in Kentucky has benefited as much as Appalachia, the impoverished eastern part of the state, where in some counties more than 60 percent of people are covered by Medicaid.

And in few places are the political complexities of health care more glaring than in this poor state with crushing medical needs, substantially alleviated by the Affordable Care Act, but where Republican opposition to the law remains almost an article of faith. While some Senate moderates say the Republican bill is too harsh, Rand Paul, Kentucky’s other Republican senator, is among Senate Republicans who say they are opposed to the current bill for a different reason: They believe it does not go far enough to reduce costs.

Mr. McConnell, who was re-elected handily in 2014, seems committed to his party’s pledge to repeal the Affordable Care Act even if it might hurt some constituents back home. A study last year by the Kaiser Family Foundation found that the percentage of uninsured in Kentucky dropped from 18.8 percent in 2013, the year the health law was put in place, to 6.8 percent — one of the sharpest reductions in the country.

Here in Whitesburg, a city of roughly 2,000 people at the base of Pine Mountain, Mr. Gorman’s sentiment seems to be the prevailing one. In nearly two dozen interviews with health care workers and patients, at the hospital and at a nonprofit clinic run by the Mountain Comprehensive Health Corporation, Kentuckians sounded both fearful and flummoxed by the health care drama on Capitol Hill.

“It makes me very nervous,” said Brittany Hunsaker, 29, a clinic social worker who counsels pregnant women addicted to opioids. “Some of the most vulnerable people that we serve, we may not be seeing any more.”

Several clear themes emerged. Most people said they want everyone covered, and were appalled, as was Mr. Gorman, when they learned the Congressional Budget Office had estimated the Republican plan would leave 22 million more people uninsured over a 10-year period. They are happy that lawmakers are trying to fix Mr. Obama’s health law — rising premiums are a worry for many — but fear that Republicans, in their haste, will make a bad situation worse.

Sorting out the way forward is agonizingly complex. Kentucky’s Medicaid expansion and successes under the Affordable Care Act are largely the result of former Gov. Steve Beshear, a Democrat who is out of office now. Meanwhile, Gov. Matt Bevin, a Republican elected in 2015, is pushing for a Medicaid waiver from the federal government that includes requirements for many beneficiaries to work or participate in job training.

Dr. Van Breeding, the clinic’s director of medical affairs, lamented that the Republican bill in the Senate had gotten mixed up in “party politics,” while patients had been forgotten. He summed up the situation this way: “Senator Paul is worried about the financial aspect of it. Senator McConnell is worried about the political aspect of it. And I’m worried about patients not having access to basic health care.”

Kathy Collins, 50, who suffers from lupus, an autoimmune disease — and who was uninsured until she got Medicaid coverage through the law’s expansion — is among Dr. Breeding’s patients. Sitting in her hospital bed here Tuesday morning, she said she was surprised to hear that Mr. McConnell, whom she had voted for previously, was leading the charge to roll it back.

“He is?” she asked. “Well, then, he’s no good for Kentucky.”

Health care is a growing part of this region’s economy, and people here are also deeply concerned that the repeal will bring job losses to a region already decimated by unemployment from the coal industry downturn.

Dr. Breeding says the number of uninsured patients at the clinic dropped from 19 percent to 4 percent as a result of the health care law. He said Mountain Comprehensive was “barely getting by” financially before the law was passed; business is much better now. Mountain Comprehensive has hired more people and now offers extended weekend hours and an optometry clinic — services that have been financed by revenue brought in from the health law, Dr. Breeding said.

And those services mean more health care jobs.

“If they do what they say they are going to do, then we may lose our jobs,” said Vicki Roland, a surgical nurse. “I think what we have works pretty good for the people. If they revamp it, I’m not sure what’s going to happen.”

Mr. McConnell’s office did not respond to a request for an interview. But Mr. McConnell did make his case for why the bill would help Kentucky on the Senate floor last week, and in an opinion piece in The Cincinnati Enquirer on Sunday, in which he argued that the legislation would stabilize markets and “deliver flexibility” to state officials to address problems like the opioid crisis.

Despite his constituents’ concerns, Mr. McConnell has little reason to worry about a political backlash; he is widely credited with building the Republican Party in this state, and after three decades in the Senate, his seat is secure. In 2014, he clobbered his Democratic opponent, Secretary of State Alison Lundergan Grimes, winning by more than 15 percentage points.

“He ran on a clear platform to repeal and replace Obamacare, as did Matt Bevin, the governor, as did Rand Paul, the other senator, as did Donald Trump,” said Scott Jennings, a Kentucky Republican strategist with close ties to Mr. McConnell. “And they all have one thing in common: They have overwhelmingly won their elections in Kentucky.”

Still, there has been pushback. On Monday, nearly 100 opponents of the repeal protested outside Mr. McConnell’s northern Kentucky office. On Tuesday, more than a dozen organizations representing health care providers signed an open letter to Mr. McConnell, published in his hometown paper, The Courier-Journal of Louisville, imploring him to “STOP the mad rush to pass this bill” and instead seek advice from health care experts.

“You said you have a ‘responsibility to act,’” the letter said. “We believe you have a duty to act responsibly. Kentuckians deserve better.”

The local newspaper here in Whitesburg, The Mountain Eagle, published an editorial assailing Mr. McConnell for putting the bill together behind closed doors. “Why the secrecy, Sen. McConnell?” its headline read.

Dr. Breeding, recently named Country Doctor of the Year by Staff Care, a Dallas-based health care company, shares these sentiments. His message to Mr. McConnell: “Don’t rush it. Bring in the experts. Let’s hammer it out.”

To spend a day with Dr. Breeding is to get a glimpse of his patients’ challenges. His weekday mornings begin at 4:30 a.m., when he arrives at the hospital in Whitesburg. Dressed in his workout gear, he makes rounds, visiting patients whose ailments run the gamut: pneumonia, respiratory failure, colon cancer, lupus, black lung disease, dementia, heart attack, kidney infection and multiple myeloma, a bone cancer.

By 8:30 a.m., after a break for a brisk walk through town, he arrives at the clinic, where his nurse practitioner, Heather Yates, says she sees the health care debate from both sides.

Like her colleagues, Ms. Yates, 35, worries that undoing the Affordable Care Act will hurt patients. But she has had to cope with the high cost of premiums; when her husband was out of work, they qualified for subsidies under the Affordable Care Act but still paid $400 a month for an insurance policy with a deductible of as much as $1,500. Now the couple pays $1,000 a month, with a $6,000 deductible, for a plan that covers all expenses once the deductible is met.

“I’ve got a mix of emotions,” she said. “I do want everybody to have insurance, but I understand what it’s like to pay for it too.”

https://www.nytimes.com/2017/06/28/us/mcconnell-kentucky-health-care-bill.html?

The Republicans’ Uncertainty Strategy

by Craig Garthwaite and Nicholas Bag - NYT - June 29, 2017

In their ardor to undermine and abolish the Affordable Care Act, Republicans in Congress are causing inestimable damage. Specifically, they are damaging the United States’ reputation for reliability among private companies looking to do business with the government.

This is not a partisan statement. One of us is a Republican, the other a Democrat. We differ on many policies, including health care reform.

But we agree that the circus atmosphere surrounding the Affordable Care Act — exemplified this week by the abrupt decision by the Senate majority leader, Mitch McConnell, to delay the vote on the Senate’s replacement bill — is generating uncertainty, which in turn is jeopardizing the future of public-private partnerships.

The health care industry consists of a dense network of public-private partnerships. Even programs widely viewed as “government” insurance, like Medicare and Medicaid, depend on private hospitals, doctors and insurers.

Such arrangements can work only if private firms trust that the United States will be a reliable partner. Historically, this hasn’t been a problem.

That appears to be changing. A decline in trust has already caused health insurers to rethink their relationships with their increasingly erratic federal partner. They’re demanding higher premiums to account for the greater risk. Blue Cross Blue Shield in North Carolina, for example, has said that its planned rate increase of 23 percent next year would be only 9 percent if it had more certainty from the federal government.

Many other insurers have abandoned these partnerships altogether. According to Health Secretary Tom Price, 49 counties won’t have a single insurer on the exchanges in 2018.

Why are insurers so skittish? Though much maligned, insurers in the individual market have a tough job. When they set premiums, they have to guess how much health care their enrollees will need. If they set premiums too low, they’ll lose their shirts. Too high, and they won’t get customers.

Before Obamacare, insurers protected themselves from risk by gathering medical information and screening out people with pre-existing conditions. When Obamacare put a stop to that, insurers were in a bind. They had to set premiums without knowing in advance how sick their customers were. That’s not easy to do — which explains much of the fragility of the exchanges over the past three years.

Lawmakers feared all this uncertainty would cause insurers to stay out of the newly formed insurance exchanges. So Obamacare employed a number of tools — in particular, financial subsidies and a mandate requiring all individuals to get insurance — to reassure firms that the market would be stable and healthy.

Even with protective policies in place, insurers took a big risk entering the markets. At a minimum, insurers that took the plunge deserved the support promised in the law. Congressional Republicans, however, chose instead to sow uncertainty at every turn, hoping that a damaged reform law would be easier to repeal.

These efforts began soon after Obamacare was signed into law. To shield insurers from unexpectedly large losses, the law created a temporary “risk corridor” program: an upfront financial commitment from the government. Republicans denounced this as a “bailout” and eventually used an appropriations measure to prohibit the Obama administration from making the promised payments.

As a result, insurers are owed well in excess of $10 billion. Many have sued to recover the payments.

The government’s refusal to pay weighs heavily on insurers as they confront two new problems. First, there’s the individual mandate, which congressional Republicans hope to repeal. One insurer has already invoked concerns about the mandate as a reason for exiting Iowa’s market.

Second, Republicans are playing chicken with Obamacare subsidies that are meant to help low-income people cover their out-of-pocket costs. Because insurers don’t know whether the government will honor its commitment to pay those subsidies, they’ve had to ask for double-digit rate increases.

Republicans appear not to have reckoned with the broader consequences of their uncertainty strategy. For example, Paul Ryan, the House speaker, wants to convert Medicare into a voucher program in which the elderly will shop for private plans. How will that work if insurers, burned by the Obamacare experience, are unwilling partners?

This is perhaps the greatest irony of the Republican actions. Republicans (including one of us) have long believed in the benefits of even greater privatization of government services. But how can any company in any sector trust the United States after seeing health insurers treated so shabbily?

https://www.nytimes.com/2017/06/29/opinion/trump-care-mcconnell-obamacare.html?

Tie Congress’s Paychecks to Our Good Health

by Nicholas Kristof - NYT - June 29, 2017

Members of Congress are paid $174,000 a year, while members of Poland’s lower house of Parliament are paid $32,300 a year.

Hmm. It looks as if we’re getting ripped off. Members of Congress seem to underperform compared to members of Parliament in Poland and across the democratic world.

Conservatives are right to worry that feeding at the government trough breeds dependency and laziness. So I suggest we introduce pay for performance, using metrics like, say, health.

I cite Poland because so many Poles (including the Krzysztofowicz family, later renamed Kristof) came to America for a better life, yet today American babies are one-third more likely to die in their first year of life than Polish children are (and twice as likely as Italian, Portuguese and Czech babies!). Meanwhile, American women are four times as likely to die in pregnancy and childbirth as Polish women, according to the World Health Organization.

If we had Italy’s child mortality rate, we would save 12,000 American babies’ lives each year — that’s 33 children’s lives saved every day.

Meanwhile, the U.S. spends far more on health care — an average of nearly $10,000 per person — than other countries do. Poland spends just $1,680 per person.

This is a stain on America. Choose almost any modern country, and its people pay less for health care and its children are more likely to survive; the C.I.A.’s World Factbook ranks the U.S. 42nd in longevity, and we’ve had a smaller increase in life expectancy over 25 years than other industrialized countries have.

In short, we as taxpayers are getting cheated. Should we really be paying senators a base rate of $174,000 — Mitch McConnell as Senate majority leader gets more — to preside over such bad results?

It’s time to apply the discipline of markets. For the sake of our senators’ own characters, we should pay for work.

If we now pay almost six times as much per capita on health care as Poles do, and get outcomes that are far worse, hmm, what do you think? Maybe we pay our representatives one-tenth what the Poles get? That would be $3,200 a year for a member of Congress.

Good thing Congress has resisted raising the minimum wage!

O.K., I’m not really in favor of slashing congressional pay; we should pay officials well to attract the best talent.

But I offer this absurd proposal for two reasons. First, many Americans, including politicians, just don’t understand how poorly our health care system actually performs by international standards.

It’s true that American hospitals have the finest diagnostic equipment and the best specialists, but we falter at basics and at public health. We’re lousy at getting kids vaccinated, at reaching at-risk young people with contraception, at protecting citizens from lead and endocrine-disrupting chemicals — and simply at keeping people alive.

That leads to my second point: We need universal health care.

In Poland, Canada, Britain and virtually every other advanced democracy, there is a national health system, with single-payer coverage like Medicare for all.

Analysts find that Canada’s rollout of single-payer coverage cut infant mortality by 5 percent. Likewise, researchers have found that cystic fibrosis patients live 10 years longer in Canada than in the U.S., because of insurance gaps in America.

Granted, there are deep underlying problems in the U.S. that complicate health care. Inequality is immense, obesity is widespread and American teenagers have babies at several times the rate of European teens.

But one reason to think that universal health coverage would make a difference is that when Americans make it to age 65 — after they get Medicare — life expectancy of 18 more years for men and 20 more for women is roughly the same as in Europe. When Americans finally get single-payer care, we do fine.

Likewise, a new study in Annals of Internal Medicine finds that in the U.S., being insured significantly reduces death rates for young and middle-aged people.

All health care reform efforts — whether Obamacare or Trumpcare — struggle with the unwieldiness and inefficiency of the existing architecture, built on employer-provided coverage. The basic problem is that we’re spending almost $10,000 per person per year on health care, and somebody has to pay for it or else we ration care and people die.

Early research finds that Obamacare is helping: One study finds it saving the life of one millennial a day.

But ultimately the United States should follow the example of every other advanced country and ensure health coverage for all. “We’re going to have insurance for everybody,” President Trump promised a week before taking office. Now he backs plans that would lead to 22 million fewer people having coverage. But if Taiwan, Slovenia, Spain, Japan and just about every other modern country can have coverage for everyone, so can we.

And, members of Congress, here’s the deal: If you ever adopt Medicare for all, I’ll endorse a pay-for-performance pay raise for all of you along with guaranteed, subsidized health insurance.

Oh, never mind. That, you already have.

https://www.nytimes.com/2017/06/29/opinion/congress-salary-health.html?

The Mitch McConnell Sinkhole

by Thomas B. Edsall - NYT - June 29, 2017

More than a third of Americans believe that Medicaid is akin to welfare, with the implicit subtext that racial and ethnic minorities are the principal beneficiaries.

If that’s what they think, they’re dead wrong.

Many more Medicaid recipients are white than black or Hispanic.

Mick Mulvaney, a former congressman from South Carolina who is now the director of the Office of Management and Budget, promulgates the conservative view.

Writing on May 22 for his home state paper, the Charleston Post and Courier, in an opinion piece that fiercely defended the Trump administration’s proposed budget for fiscal year 2018, Mulvaney argued:

For years, we’ve focused on how we can help Americans receive taxpayer-funded assistance. Under President Trump’s leadership, we’re now looking at how we can respect both those who require assistance and the taxpayers who fund that support. For the first time in a long time, we’re putting taxpayers first.

After laying down this classic Republican framework, Mulvaney puts his own spin on it:

Taking money from someone without an intention to pay it back is not debt. It is theft.

In other words, recipients of Medicaid and other federal programs that the Trump administration proposes to cut are thieves, and Mulvaney, with the president’s backing, is determined to end this criminal activity:

So if you left for work this morning in the dark, if you came home after your kids were asleep, if you feel lucky to get overtime pay to support your aging parents or adult children, if you’re working part-time but praying for a full-time job, if your savings are as exhausted as you are, you have not been forgotten.

Mulvaney has little understanding of or respect for social insurance — certainly as it is defined by Merriam-Webster:

protection of the individual against economic hazards (such as unemployment, old age, or disability) in which the government participates.

So who actually gets Medicaid?

A plurality, 41 percent, of Medicaid recipients, are white; 22 percent are black; 25 percent are Hispanic; and 12 percent are other ethnicities, including Asian-American.

In 18 states, at least 60 percent of Medicaid beneficiaries are white: ranging from 98 percent in Idaho and 93 percent in West Virginia to 60 percent in Minnesota and Nebraska.

In Kentucky, which is represented by Mitch McConnell, the Senate majority leader, Medicaid covers a third of the population. Seventy-eight percent of Kentuckians on Medicaid are white.

Significantly, while 41 percent of beneficiaries of Medicaid are white, whites receive 51.8 percent of all dollars spent in the program, $149.5 billion out of a total of $288.9 billion in 2012, the most recent year for which such data is available. Whites participate at higher levels in the most costly Medicaid services, including the care of the elderly, of disabled children and of disabled working-age adults.

In the four key Rust Belt states that provided crucial Electoral College votes for Trump in 2016, whites are the decisive majority of Medicaid recipients: 67 percent in Ohio, 59 percent in Michigan and 58 percent in both Pennsylvania and Wisconsin.

Along similar lines, Medicaid provides benefits to significantly higher percentages of children in rural and small-town America, where Trump and Republicans generally won by their strongest margins. A recent Georgetown University study found that

In 2014-2015, Medicaid provided health coverage for 45 percent of children and 16 percent of adults in small towns and rural areas, compared to 38 percent and 15 percent, respectively, in metropolitan areas.

In McConnell’s Kentucky, the study found that Medicaid has become a crucial source of coverage for adults. Before the passage of Obamacare in 2010, 13 percent of adult Kentuckians were covered; after passage, in 2013-14, the percentage more than doubled to 28 percent. Over the same period, the percentage of uninsured adults in Kentucky fell from 26 to 10 percent.

Since its inception in 1965, Medicaid has become an integral and major part of the American safety net. Not only does it cover health care for the poor, it prevents millions of members of the working and middle classes from losing all their savings and falling into bankruptcy when they or their family members become too old, sick or disabled to work. Medicaid also provides essential help in family planning, preventing premature births and supporting infant and child health.

Diane Rowland, executive vice president of the Henry J. Kaiser Family Foundation, provided the following information on the demographics of Medicaid beneficiaries.

Medicaid covers 4.9 million of the 11.2 million children in the United States with special health needs, including those with autism, Down syndrome, cerebral palsy, spina bifida and muscular dystrophy. Nationally, 60 percent of children with special needs are white.

There are 6.9 million working-age disabled adults — many of them the siblings, cousins, aunts and uncles of Mulvaney’s “taxpayers” — who are covered by Medicaid. Fifty-seven percent of the working-age disabled covered by Medicaid are white. They suffer from disabilities ranging from missing limbs, blindness and progressive neurological disorders to traumatic brain and spinal cord injuries.

There are another 10 million elderly Medicaid recipients — many of them the parents of Mulvaney’s struggling taxpayers — who get Medicaid to cover long-term nursing home care, help with eating, bathing or dressing and care for cognitive or mental impairments like dementia. More than half, 56 percent, are white.

The care Medicaid provides to these elderly men and women does not come cheap. In 2011, according to Kaiser, these patients accounted for 36 percent of total Medicaid expenditures.

What all this data shows is that, contrary to the view that Medicaid is a welfare program, in real life Medicaid has become a financial, emotional and practical lifesaver for millions of Americans. This is especially the case for those with close relatives who need assistance and would otherwise be an enormous burden in one of the 29 states that have “filial responsibility” laws on the books that make it the responsibility of adult children to care for their indigent parents.

How is it possible, then, that Senate Republicans are continuing to weigh the consequences of passing health care legislation that would inflict harm on millions of low- to middle-income white voters essential to the conservative coalition?

On Monday, the Congressional Budget Office reported that the health care bill currently before the Senate would result in 22 million more people without coverage by 2026.

The measure would not only cut Medicaid by $772 billion over ten years, it would also eliminate $408 billion in subsidies for those with low incomes but above the poverty level. The likely result, according to the C.B.O.: “few low-income people would purchase any plan.”

Pressure on Congressional Republicans from conservative primary voters determined to repeal Obamacare, the continuing attractiveness to many Republicans of cutting taxes for the rich and the party’s commitment to reduce social spending all conspire to make it tough for Republican leaders to give up on this initiative. Their task is made easier by the fact that a majority of Republican voters stand apart from independents and Democrats in that they believe that Medicaid is indeed a welfare program. A survey conducted in May by the Kaiser Family Foundation asked voters this question:

Which comes closer to your view, Medicaid is more similar to other health insurance programs, like Medicare, that help people pay for health care; or Medicaid is more similar to welfare programs like food stamps that help people pay for food?

As noted above, just over a third of the 1,205 adults questioned, 37 percent, chose welfare, while 60 percent said Medicaid is like Medicare.

Democrats (73-25) and independents (62-35) were solidly in agreement that Medicaid is a health insurance program.

Republican were not. A majority of Republicans, 52 percent, said that Medicaid was a welfare program, and a minority, 46 percent, said it was a health insurance program.

Drew Altman, president and C.E.O. of the Kaiser Foundation, wrote about this finding in an essay last week on the recently created website, Axios:

Republicans want to roll back the Medicaid expansion, cap federal Medicaid spending increases, and add work requirements, drug testing, time limits, copays and premiums to some state Medicaid programs. But almost no one else wants to do these things. One poll finding goes a long way toward explaining why: Republicans view Medicaid as a form of welfare, and pretty much everyone else views it as a government insurance program.

What Mulvaney’s characterization of means-tested programs as larceny leaves out is that for all the hard working men and women putting in overtime to care for their aging parents, there are many who face catastrophic situations beyond anything that overtime pay or modern families are able to cover.

Think of the kind of full-time care provided to the 938,000 Medicaid beneficiaries currently in nursing homes in the United States. Nearly half suffer from dementia and more than half are confined to a bed or wheelchair. These men and women require, in addition to skilled nursing care, assistance with what are known as activities of daily living — bed mobility, transferring, dressing, eating and toileting — at $102,900 annually in a semiprivate room. In 2014, 78 percent of the 1.4 million nursing home residents in America were white.

The census reports that the number of people in the oldest old age group, those over 85, is projected to grow from 5.8 million in 2010, to 8.7 million in 2030, to 19 million in 2050.

If the Republican Congress cuts Medicaid along the lines of either the Senate or House legislation, Mulvaney’s hard-working taxpayers will face brutal choices.

Medicaid is not, to use Mulvaney’s term, thievery. Thievery is what folks like Paul Ryan and Mitch McConnell are proposing to inflict on their fellow Americans, a massive reduction in what has become a crucial source of support for those faced with impossibly high costs and impossible personal demands as caregivers.

And speaking of thievery, the non-partisan Tax Policy Center has found that the tax changes in the Senate health care bill would give those in the bottom fifth

an average tax cut of about $180, or 1 percent of their after-tax income. Middle-income households (making $55,000-$93,000) would receive an average tax cut of $280, raising their after-tax incomes by about 0.4 percent.

In contrast, the top 1 percent, making at least $875,000 would receive a tax cut of

more than $45,000, raising their after-tax incomes by 2 percent. And those in the top 0.1 percent (who will be making $5 million or more) would receive an average tax cut of nearly $250,000, boosting their after-tax incomes by 2.5 percent.

In an appearance on PBS Tuesday, Warren Buffett described the Senate health care bill as the “Relief for the Rich Act.”

All of which gives an ominous tenor to President Trump’s most recent statement on the pending health care legislation: “You’re going to have a great, great surprise. It’s going to be great.”

https://www.nytimes.com/2017/06/29/opinion/mitch-mcconnell-health-care-medicaid.html?

Political Clarity After the Grenfell Tragedy

by The Editorial Board - NYT - June 29, 2017

There are disasters that enter history as much for the political mark they leave as for the death and destruction they wreak. Such was Hurricane Katrina for George W. Bush, leaving an indelible image of a president slow and weak in response to human suffering. And such may be the Grenfell Tower fire for Prime Minister Theresa May, and more broadly for the infatuation with austerity and deregulation of British governments for the past four decades.

Mrs. May, like Mr. Bush, may have delayed visiting the disaster scene so as not to interfere with rescue efforts. But politics fixes on symbols, and the flames racing up the 24-story tower unleashed the pent-up anger of survivors and residents of other low-cost public housing, known in Britain as council flats, at an officialdom deaf to their complaints and conditions. The duty of national leaders at such a time is to be there, even if that means taking the brunt of the fury.

Mrs. May must have known the anger was there. She had just suffered a drubbing in a national election at the hands of Jeremy Corbyn, the Labour leader who had been dismissed as a relic of an obsolete hard left. It turned out that he was far closer than she was to the popular anger over the systematic shrinking of the old quasi-socialist state through privatization, deregulation and corporate tax cuts begun under Margaret Thatcher in the 1980s and continued under the “New Labour” of Tony Blair — policies generically known as “austerity” that have left Britain deeply divided into haves and have-nots.

Coming a week after the election, the Grenfell Tower fire seemed to summarize the political debate in a moment of terrifying clarity. As Jonathan Freedland wrote in The Guardian, the problem turned out to be not the European Union, or action on climate change, or immigration, but a local authority that decided to save 4,750 pounds — about $6,100 at today’s exchange rates — by opting for cheaper and more flammable cladding for the building, installed in 2015 and 2016. It did so fully aware of the risk of a catastrophic fire, since such cladding had resulted in many fires and many warnings. At a time when all governmental red tape, even that intended to protect the public, was seen as an evil to be shredded, saving money took precedence over safety.

In the wake of the catastrophe, municipal authorities have begun an emergency effort to replace cladding on other vulnerable buildings, the government has pledged a full inquiry, and the police have said they will consider bringing manslaughter charges after determining who was responsible. There is certainly no shortage of potential contributors to the disaster, from the manufacturers of the panels, the insulation and the Hotpoint brand refrigerator that set off the blaze, to the managers, contractors and inspectors who closed their eyes to the peril.

More important, perhaps, is that Grenfell Tower offers tragic evidence that the British state, in its relentless pursuit of less government, has gone too far in shedding its fundamental duties to protect public health and safety. That is where the political and moral investigation must start.

https://www.nytimes.com/2017/06/29/opinion/grenfell-fire-britain-theresa-may.html?

Analysis: Our health care is a bad example of American exceptionalism

by Ishaan Tharoor - The Washington Post - June 28, 2017

Washington has been consumed by a furious debate over the Senate’s recently unveiled health-care bill. The measure’s opponents – along with the nonpartisan Congressional Budget Office – warn that, if passed, the bill could lead to tens of millions of Americans losing health insurance.

Senate Majority Leader Mitch McConnell, R-Ky., had planned to vote on the bill this week. But Senate Republicans, chastened by the uproar from critics and dissent within their own ranks, said Tuesday they would put off voting until after they return from the July 4 holiday recess.

In the meantime, it’s worth considering the issue in a more global context. Health care is an essential need in any society. In many places, in both the developed and developing world, governments play active roles in providing care, lowering costs, or both.

No country has the exact system as the other, nor is any country’s system free of critics and detractors. But you’d be hard-pressed to find any other wealthy nation in the world where the very idea of universal coverage provokes such partisan division.

The Affordable Care Act, often known as Obamacare, was an effort to expand health insurance coverage to millions who would otherwise be too poor to pay for it – or too sick to afford what insurers may charge. (Its precursor, of sorts, was implemented by a Republican governor in his state.) But most Europeans would look at the power still given to private insurance companies, as well as the high costs many Americans still shoulder, and consider Obamacare to be a centrist, if not center-right, political compromise. Indeed, the ideas at the core of Obamacare were ones long championed by conservative health-policy wonks.

Yet many Republicans viewed Obamacare as a tyrannical “socialist” plan to force people to pay for insurance they didn’t necessarily want. For years, Republican politicians have espoused the principle of “personal responsibility” – the supposition being that if you want health care, you’ll get employment and do what’s needed to afford it. The free market, they argued, would naturally provide sufficient options – never mind the various ways insurance companies placed ceilings on coverage or punished those with preexisting conditions.

Vice President Mike Pence tweeted: Before summer’s out, we’ll repeal/replace Obamacare w/ system based on personal responsibility, free-market competition & state-based reform.

The “free-market competition” espoused by Pence has led to spiraling costs in a medical system run mostly by for-profit companies and hospitals. According to OECD data – indicators for a bloc of developed countries – the United States spends close to 20 percent of its gross domestic product on health care, nearly $10,000 per person, roughly twice as much as countries like Britain, which has a nationalized health service. Americans, as a whole, pay more to get less.

“It is not just that U.S. healthcare is expensive, with price tags often far higher than those in other developed countries,” wrote Elisabeth Rosenthal, editor in chief of Kaiser Health News. “At this point, Americans face astronomical prices that quite simply defy the laws of economics and … of decency and common sense.”

She goes on: “Our prices for tests, drugs, hospitalizations and procedures – old or new – have gone up dramatically year by year, and are vastly higher than in other developed countries. Indeed, prices for similar interventions in other countries have often declined.”

What explains the difference? Some observers point to a cultural gap between Americans and those across the Atlantic. A 2011 Pew survey found that Americans tended to value individual liberty more than Europeans, who saw a positive role for the state. “Nearly 6-in-10 in the U.S. (58 percent) believe allowing everyone to pursue their life’s goals without interference from the state is more important,” noted the report. “Majorities in all European nations polled in 2011 said guaranteeing that nobody is in need is more important.”

But this kind of American exceptionalism would be a lazy answer. Just north of the border, you have an English-speaking society that embraces its own pioneer myths of hard work and self-reliance on the frontier, but which also has a health-care system that seeks to provide universal coverage.

“Single-payer systems, like the Canadian version, or a single provider system, as seen in the United Kingdom and other countries, provides the means of bringing care under the umbrella of a single, accountable authority,” explained two Canada-based doctors in an article for STAT News, a health-care news site. “This is neither socialism nor an attack on individual liberty. It is simply making a promise: to protect each other from disease and preventable harm, recognizing that our capacity to do so is perhaps the most meaningful measure we have of our society’s worth.”

Or, as U.S. Sen. Bernie Sanders, I-Vermont, tweeted: Health care is a human right.

The profound unpopularity so far of the Republican-proposed replacements to Obamacare show that many Americans also want a system that better ensures the collective well-being of their society.

But the fact that it doesn’t yet exist is also a reflection of unhealed divisions in American society. In an article in the Atlantic, Vann Newkirk II points to a forgotten plank of the civil rights movements of the 1960s: access to health care.

Various countries in Europe had already instituted universal health-care schemes. But, as Newkirk noted, “America’s developing peculiar, private, decentralized, job-pension-based health-care infrastructure was the only fit for a modernizing society that could not abide black citizens sharing in societal benefits, and one where black workers had often been carved out of the gains of labor entirely.”

State-subsidized programs like Medicare and Medicaid, which came into existence a year after the 1964 Civil Rights Act, essentially forced hospitals to see black patients and helped “end formal segregation.” Decades later, Obamacare disproportionately helped expand coverage to people of color. But the new efforts pushed by the Republicans, wrote Newkirk, “will move America away from eliminating racial inequalities in health and health care.” It’s just another unfortunate way the U.S. system may distinguish itself from the rest of the world.

http://www.pressherald.com/2017/06/28/analysis-our-health-care-is-a-bad-example-of-american-exceptionalism/

The 20-Million-Plus Hurt by the Health Bills

Letters to the Editor - NYT - June 28, 2017

To the Editor:

Re “G.O.P. Pushes Back Health Care Vote as Support Wanes” (front page, June 28):

The one thing both parties agree on is that the Affordable Care Act is flawed. Then let’s all act like adults and support a select joint committee of Congress to explore and advocate fixes to the system that better the lives of all Americans and not simply political bases and wealthy donors.

That committee, made up of an equal number of members from both parties, should hold closed meetings to first agree on the areas that need addressing, and then hold public hearings to craft a bipartisan bill to be submitted to Congress.

Let’s demand action by responsible, informed adults to deal with an issue that affects all of us.

PAUL WRUBEL
HALF MOON BAY, CALIF.

To the Editor:

The G.O.P. health care plans forged in both the House and the Senate would leave well over 20 million Americans without health insurance.

Now, it’s hard to fathom why our government spends billions of dollars on security threats from terrorists at home and abroad, but then will ignore the prolonged sufferings and certain deaths caused by illnesses.

Whether a terrorist takes a life willfully, or a politician does so by policy, the result is the same since death is no respecter of intention.

BUCK RUTLEDGE, KNOXVILLE, TENN.

To the Editor:

Senator Mitch McConnell delayed a vote on the proposed health care bill to see if he can get “at least 50 people in a comfortable place.” The price of that, as the Congressional Budget Office points out, is getting 22 million people in an uncomfortable place.

DON L. DOERNBERG
PENN VALLEY, CALIF.

To the Editor:

Re “The Health Care Hoax Exposed” (editorial, June 27): Senator John Cornyn claims the G.O.P. bill in the Senate would “save the people who are currently being hurt.” Basically, Republicans are trying to sell this bill as a way to improve Americans’ health care. One easy way of testing the true intent of this bill would be to propose elimination of its tax cuts — the bulk of which will go to wealthier Americans — and instead use this money to increase access to health care for those who need it most.

I strongly suspect that the bill’s Republican supporters would come up with all sorts of interesting and contorted reasons as to why health care for the poor and middle class can only be improved if taxes for the wealthy are reduced.

MICHAEL BOURNAS-NEY, NEW YORK

https://www.nytimes.com/2017/06/28/opinion/the-20-million-plus-hurt-by-the-health-bills.html?

Kaiser Permanente’s Archetype for Health Care

Letter to the Editor - Kaiser Health News - June 28, 2017

To the Editor:

Re “How Health Care Went Wrong” (Op-Ed, June 19):

Christy Ford Chapin praises the innovation of prepaid physician group practices as “particularly elegant” models. She suggests that concierge medicine is their modern-day successor. Not so. No matter the payment structure, fragmented medical practice cannot deliver consistent quality to individual patients and larger populations.

Concierge medicine is not only a step backward, but it is also a move toward an unequal, two-tier system. Ms. Chapin criticizes Kaiser Permanente as different from and lacking the benefits of those earlier elegant models; in fact, Kaiser is the archetype.

Kaiser Permanente’s model is often heralded as focused on prevention and delivering the right care at the right time. Incentives are correctly aligned to help patients get and stay healthy, with care and coverage typically more affordable than elsewhere.

Our Permanente physician-led clinical teams constantly innovate to create integrated, person-centered and technology-supported care. The results are clear: Kaiser Permanente is first in more categories of care effectiveness than any other commercial health plan.

EDWARD ELLISON
RICHARD S. ISAACS
OAKLAND, CALIF.

Dr. Ellison is executive medical director of the Southern California Permanente Medical Group. Dr. Isaacs is chief executive and executive director of the Permanente Medical Group.

https://www.nytimes.com/2017/06/28/opinion/kaisers-medical-archetype.html?