Health Care Reform Articles - June 15, 2017

Editor's Note:

In my blog dated June 9, I published an article from the California Policy Center (titled "Single Payer Bill Could Bankrupt California") making a series of arguments against the newly passed California "single payer" bill because I think it is important that we hear, and directly respond to criticism of such legislation.
Peter Shapiro offered a detailed response. Here is Peters response to the article  -SPC

"The California Policy Center, which published the screed against SB 562 posted above, is a conservative, business-oriented think tank in based in Orange County. Thanks to Phil Caper for posting it as we need to be prepared to answer these arguments. IMO they are misleading, specious, and flat-out wrong. My objections:
1. There is no evidence that significant numbers of people relocate to a state simply to take advantage of more generous health care access. It didn't happen in Massachusetts when Mitt Romney signed the Massachusetts health care reform bill after which Obamacare was modeled. And the assertion that the bill would encourage illegal immigration shows an appalling ignorance of what undocumented people have to go through to come to this country, and live under the radar once they're here. (Incidentally, such people can already get treatment at emergency rooms). 
2. Residency requirements in the bill are the same as current requirements for Medicaid (or MediCal, as it's known in Califiornia. Strangely, MediCal's residency requirements have apparently not provioked a massive influx of deadbeats into the state, even though MediCal is more generous with coverage than most state Medicaid plans.
3. "Incentives for overtreatment are strong." Medicare is a poor model because it is "racked by fraudulent and other improper treatments." Atul Gawande's widely read 2008 article on doctors in McAllen, TX who have taken advantage of Medicare's fee for service payment system to shamelessly soak the federal government makes a persuasive case for putting restrainst on what procedures providers can be paid for. On the other hand, Steve Kemble in Hawaii has argued that the downside of fee for service has been grossly exaggerated.It certainly has been less damaging to Medicare's bottom line than the diversion of Medicare dollars to private insurance (around 15% more expensive) under Part C, and the blatant handouts to the drug houses under Part D. In any case, whatever the waste, Medicare is still far cheaper and more efficient than private plans. 
4. "Kaiser would be obliged to become a fee for service provider." Not true. Kaiser could retain its current system of charging a fixed yearly per patient fee (capitation). Only the money would be paid by the state, not the patient. 
4. "Kaiser is not-for-profit. Neither is Blue Shield." Bunk. They compete with for-profit insurers for market shares, and behave accordingly. In the real world, their "non-profit" status serves mainly to exempt them from taxes.
5. Article questions whether California will be able to leverage federal funds from a GOP-controlled Congress. Maybe not, federal lasw does authorize it, Indiana has already gotten waivers for its own Medicaid plan, and in any case a GOP-lewd Congress seems poised to slash Medicaid funding regardless of whether SB 562 passes. If it does, California will be obliged to make the most efficient use of the funds still available, or face catastrophic cutbacks to health care access. Under such cirtcumstances, private insurance beach

mes an even bigger liability for the state. This is an argument in favor of Lara's bill, not against it. 
6. Notwithstanding the article's claim that the bill contains no cost controls, it does set up an administrative body to work out procedures for determining what is reimbursed, and how much. Administrative rules do not belong in a piece of enabling legislation; if they did no legislation would ever pass. The federal Center for Medicare and Medicaid Services makes these decisions where federal health care programs are concerned; they are not written into the federal law passed in 1965."

How the corporate sector is wrecking America’s health—and what to do about it

by Jeffrey Sachs and Vikas Saini - Quartz Ideas - June 7, 2017

The Obamacare repeal that passed the House is an unpopular and defective bill that would hurt the poor, the sick, and older workers, by raising deductibles and premiums on health policies for these highly vulnerable groups. Yet there is also a real opportunity in the Senate to make something beneficial out of this process. The public wants more and deserves better when it comes to health.

America’s health is in a crisis that has three parts.

The first is access: healthcare is far too costly for most Americans. The situation is worst for the poor and those with pre-existing health conditions, but it’s bad enough for almost everybody except the rich. Thus, tens of millions of Americans too young for Medicare cannot afford private health coverage. Their lives depend on government-financed health services, but with Republicans all too ready to throw them overboard in the name of budget savings.

The second challenge is unhealthy lifestyles, especially America’s fast-food diet. America has the highest obesity rates of any high-income country in the world—nearly 40%. The fast-food diet—French fries, sweetened beverages, and super-high meat consumption—is killing Americans.

The third challenge is the despair arising from working-class households falling further and further behind in incomes and jobs, with the associated behavioral consequences. As recent studies have shown, deaths rates have soared for working-class white, non-Hispanic Americans, especially around diseases related to falling incomes: suicide, substance abuse (including the shocking opioid epidemic), and depression.

Yet we would argue that all three of these crises arise from an even deeper problem: the corporate control of healthcare and politics more generally. Our health outcomes are the result of a society in the grips of several powerful corporate lobbies: the drug companies, the health providers, the health insurers, and the fast-food industry. Together they have promoted the unhealthy diets, opioid dependencies, and super-high-cost health insurance and healthcare that bars access to lifesaving services. In the past, your income determined how you lived; now it often determines if you live.

If we add in the political power of Wall Street and the mega-rich campaign donors, we complete the picture. We are getting what we pay for, or rather what the mega-rich and the lobbyists are paying for: a health crisis that is driven by the preferences of the healthcare industry, the food industry, and the rich in general, who pay low taxes and tend to their own health needs in private while most Americans suffer the consequences. And we shouldn’t forget that Wall Street has recently become a leading actor in the healthcare field, buying up drug companies in order to jack up prices, and financing the mergers of healthcare providers in order to boost monopoly power.

The question then is what to do. Our answer also lies in three parts.

The first: cut health care costs so that insurance coverage can be guaranteed to all. There are many dimensions of cost cutting. The Food and Drug Administration (FDA) should take drastic actions to open the way for generic drug competition, including imports from abroad. Medicare, Medicaid, and the VA together should be empowered to negotiate drug prices with big Pharma, thereby ending the abuse of the American people at the hands of the drug industry.

The Federal Government and state Medicaid should also move away from the current system that reimburses health providers for each disease episode to a system that shifts incentives of the health providers towards disease prevention and lower-cost primary care. One option is “capitation,” meaning that the health provider receives a fixed payment per year for each enrollee, and thus has an incentive to keep overall costs low by preventing diseases in the first place. Yet capitation also requires accountability of the health provider so that it doesn’t cut corners by denying needed services.

The second: bring substance abuse and unhealthy diets under control by reining in the corporate mismanagement that has brought about these conditions. The fast-food industry has had a free hand long enough. America’s very own McDonalds, Wendy’s, Subway, Coca Cola, Pepsico, and others need to answer for the greatest obesity epidemic in the world. They are not mere bystanders in this disaster, and they need to be agents of solutions. So too with the producers and marketers of the opioids now addicting and killing Americans by the millions. In addition to stopping new addictions, we urgently need a massive expansion of treatment facilities to help the victims of the current epidemic.

The third: recognize that a house divided cannot stand, as Abraham Lincoln noted long ago in a different context. America cannot thrive deeply divided between the rich and the poor, and between a professional class with a Bachelor’s degree or higher and a working class with a high-school diploma or less. Our health crisis is deeply intertwined with soaring inequality. The rich are getting healthier; the working class and poor are dying of despair.

Other countries face the very same tendencies towards inequality as in the US, including globalization of trade, offshoring of jobs, and automation of assembly lines. Yet Canada, Germany, the Netherlands, Denmark, Norway, and Sweden, all counteract these inequalities through public policies. Healthcare is financed by government revenues; college tuitions are low or zero, with the government picking up the tab. Vacation time, leisure, maternity leave, sick leave, and childcare are all ensured. How do they pay for it? Through tax revenues, including a clampdown on loopholes for the rich.

One can despair at the greed of the House vote, on a piece of legislation that was pushed through without a day of hearings or public deliberation. But now the Senate can weigh in. This is an opportunity to face up to the real health crises in this country, and to find solutions that go to the core issues—the need to control costs, force corporate responsibility, and reduce the grievous and growing inequalities in American society.

https://qz.com/991032/how-the-corporate-sector-is-wrecking-americas-health-and-what-to-do-about-it/

The big media lie about single-payer health care

by Tim Redmond - 48 Hills - June 4, 2017

The headlines were so consistent, so predictably bad, that I almost couldn’t read them. “Single-payer will cost $400 billion.” “Single-payer costs dwarf entire state budget.”

Even when the state Senate approved the measure, here’s what the Bay Area News Group had to say:

SACRAMENTO — As a legislative deadline loomed, California senators Thursday — in some cases, reluctantly — voted to pass a $400 billion plan to create a government-run health care system without a way to pay for it.

As the single-payer bill heads to the state Assembly, this is exactly the media message that the private insurance and pharma industry wants. And it’s utterly, completely, embarrassingly inaccurate.

California already spends $368 billion a year on health care, and that’s with 2.5 million uninsured people and about 12 million who have such limited insurance that they can’t always get the care they need.

In ten years, studies show, that price ticket will be $587 billion – half a trillion bucks, 20 percent of the state’s entire economy.

So private insurance already costs pretty close to $400 billion – and it’s failing and unsustainable.

With single-payer, the cost would drop to $331 billion — meaning the people and businesses in California would pay $37 billion less than they are paying now for health care, a new study shows.

That money we pay now for a dysfunctional system comes from the same place the state budget comes from – federal reimbursements and individuals and businesses who pay taxes. There’s no difference between money that I pay every month out of my pocket for health insurance and money that I could pay every month in taxes to the state so that everyone has health insurance – except for the fact that if I paid the money to the state, it would cost me a lot less.

In fact, a study by one of the most eminent economists in the country shows, nearly everyone in California would pay substantially less every year for health care if we went to a single-payer system.

Again, in simple language for my colleagues who can’t seem to understand this: That big-ticket dollar sign the insurance industry is putting out, that number way bigger than the state budget? We are already paying that. And we aren’t getting our money’s worth.

What single-payer would do is eliminate the middle-man. Instead of writing a big check to the insurance industry every month, businesses and individuals would write a smaller check to the state of California. Instead of dealing with a profit-seeking industry that goes out of its way to deny claims for care, your doctor would get paid by the state.

Oh, and all those government agencies that use taxpayer money to employ workers and pay their health care? They wouldn’t be paying massive bills to private companies for health care anymore. That means the workers could take home more money and the taxpayers would be on the hook for less.

This is how it works in most of the developed world, where costs are far lower and results far better than we see in the United States.

Is there anything about this that is even a bit confusing?

If you want to read a fascinating 85-page economic study that looks at how this would work, it’s right here. The principal author is Robert Pollin, distinguished professor of economics at UMass Amherst.

Yeah, you can get economists to argue about anything, but there is basic data here, and it reveals some basic truths.

The first is that the $400 billion figure is based on the existing system. Covering all of the uninsured and underinsured people would, indeed, increase overall spending by 9.1 percent, from $368 billion to $404.1 billion — if we just kept doing what we do now.

But if we got rid of the private insurance industry, the costs of delivering care would drop radically.

In fact, the total cost of providing care to everyone – which is a lot more than we do now – would drop to $331 billion. That means the people of the state of California would save $37 billion, more than ten percent, immediately, by implementing single-payer.

Where would that $331 billion come from? Most of it would come from the existing money that the federal government spends underwriting Medicare and Medi-Cal.

The rest, Pollin and his team suggest, would come from a modest increase in taxes on businesses and individuals. I like their gross receipts tax (which would exempt smaller businesses) and I’d prefer an income-tax increase, but either way, most Californians will do a lot better – and nobody will be worse off.

(Well, that’s not quite true. The insurance companies that are making a ton of money in this state will be worse off. Their chief executives, who make multiples of millions of dollars, might be worse off. There will be a period of transition when private companies shut down their state operations and the state expands its operations, but this is a case where skills are immediately transferable – most of the front-line workers in the insurance industry will be qualified for jobs with the state.

(The difference is that those workers will not be trained to deny claims. The last time data was available, the California Nurses Association found that the seven largest private insurers in the state denied 26 percent of all the claims that were put in by people who paid them money for health insurance.)

The typical middle-income California family spends between 3.4 and 9.9 percent of its income on health insurance. That would drop to 0.8 percent under single-payer – including the increase in sales taxes. A family with an income of $62,300 would wind up with $5,404 more in spending money, even after paying the higher sales taxes, the study shows.

Families with income of more than $340,000 would wind up about paying a tiny bit more, mostly because wealthy families that pay their own health insurance get a substantial tax break because they can write those expenses off their federal and state income taxes.

Small businesses would be the biggest beneficiaries: A company with nine employees and $811,000 in gross receipts that pays for employee health care would save $24,000 a year. A medium-sized business with 38 employees and $10 million in gross receipts would save $131,000.

Workers who have employer-paid health insurance would no longer have to pay their share of that (very few companies pay 100 percent). And unionized workers could argue for higher pay because a significant part of any contract includes the cost of health insurance.

Chuck Idelson, a spokesperson for the California Nurses Association, which is backing the single-payer bill, told me that the media coverage has been a problem. “Once a media narrative gets spun, anyone who tries to counter it is considered an outsider. That’s what we’re faced with, since so much of this is counter to the reality.”

The reality, he said, is that the current system is completely unsustainable. Hard to argue with that.

http://48hills.org/2017/06/04/big-media-lie-single-payer-health-care/

Every Democrat in America Should Support Medicare for All

by Sean King - New York Daily News - June 13, 2017

In a recent poll from the health insurance industry, only 8% of Americans actually want the United States Senate to pass the terrible Trumpcare bill, also known as the Affordable Health Care Act, that the House passed a few weeks ago.

That's about as bad as it gets — not just for a health care poll, but for anything. Have you ever seen a movie on Rotten Tomatoes with a score of 8%? Hell, even the new Baywatch movie has a 20% on Rotten Tomatoes. In fact, there's not a major movie out in theaters right now with a Rotten Tomatoes score of less than 10%. Nobody likes Trumpcare. Tens of millions of everyday people will lose their health insurance, rates will skyrocket for America's seniors, and pre-existing conditions will become a problem again.

Republicans, so hell-bent on destroying Obamacare for the past eight years, never really bothered to do the hard work of coming up with a better plan that lowers costs and insures more people. They've got nothing. In fact, what they are proposing is worse than nothing.

So it's great that Democrats are blasting it every chance they get, but constantly criticizing it isn't enough. We have a health care crisis in America. Everyday people are struggling to afford good coverage, and premiums and co-pays are kicking our butts. That's why smart, compassionate local Democrats across the country aren't just blasting Trumpcare, they are proposing Medicare for All.

With a groundswell of grassroots support from unions like National Nurses United, the California State Senate has passed a Medicare for All bill that is now awaiting a signature from Gov. Jerry Brown. An astounding 70% of Californians, including 53% of Republicans there, support the bill. Other polls show 60% of all Americans nowsupport health care coverage for all Americans. That's what this country wants — not Trumpcare.

Every single Democrat in the country would be smart to divert at least half of their energy away from blasting Trumpcare to fighting for Medicare for All. If it becomes law in California, that will change the game for the entire country. For the third year in a row, a similar Medicare for All bill has passed the New York State Assembly. Nevada is getting closer to its own plan to open up Medicare for All there.

Many wealthy developed nations in the world have universal health care with 100% enrollment. We can have that. We should have that. And don't believe the lie about how we can't afford universal health care — no nation in the world spends more money on health care and prescription drugs than we do right now. The United States spends nearly 20% of its entire GDP on health care — also the highest rate in the developed world.

Now is the time to propose bold solutions. Donald Trump and every single conservative who supports him should be roundly criticized, but Americans need hope. Americans don't just need a villain to fight against, they need a cause to fight for — and Medicare for All can and should be a principled part of that fight.

More than 110 Democrats in the House are currently co-sponsoring a Medicare for All bill created by Congressman John Conyers. That's the most ever to support Medicare for All in the House, and represents a majority of 193 members of the House Democratic Caucus, but it begs the question — what about the other Democrats in the House who aren't yet on record as supporting Medicare for All? What are they waiting on? And what about the Democrats in the Senate?

I'd like to see how much money the Democrats who are holding out their support for Medicare for All are receiving from the health insurance and prescription drug industries and lobbies. The reform is about as popular as it gets among rank and file Democrats — so the lack of support from some elected officials is puzzling at best.

As Trump's approval ratings continue to tank and the country unites around our desire to see him leave office, we must use this rare moment in time where people are deeply hungry for systemic change to make our fight not just about personalities, but about policies. Medicare for All is the biggest, boldest, best idea we've got right now. Rallying behind it just makes sense.

https://www.commondreams.org/views/2017/06/13/every-democrat-america-should-support-medicare-all

Trump Says Market Is Failing, but One Insurer Bets Big on Obamacare

by Margot Sanger-Katz and Reed Abelson - NYT - June 13, 2017

The Obamacare insurance markets aren’t as shaky as President Trump seems to believe.

On Tuesday, the insurer Centene announced plans to expand aggressively into the state marketplaces established under the Affordable Care Act. Centene said it intended to sell individual policies for the first time in Nevada, Missouri and Kansas, and to grow its presence in six other states, including Ohio and Florida.

The announcement contradicted a narrative Mr. Trump has pushed of a health care system in crisis.

The president, in a tweet and a televised meeting with more than a dozen Republican senators Tuesday, argued that the markets established under the health law were irretrievably broken and in need of replacement from Congress. In the afternoon, he spoke in Wisconsin beside two couples he described as the health law’s “victims.”

But in one of his classic mixed messages, Mr. Trump also reportedly told the senators that the House-passed bill to repeal the Affordable Care Act — one that he cheered in a Rose Garden ceremony last month — was “mean,” as he urged them to be more generous in their own bill.

In recent months, several insurers have said they will stop selling individual policies in the market in 2018, leaving dozens of counties with the possibility of no insurer. Tuesday morning, the Trump administration released a map, based on press reports, that showed bare areas of the country highlighted in red. The Centene announcement made that map almost instantly obsolete.

Pointing out insurer exits has become a refrain for the president and Republican leaders in Congress, who are seeking a health care overhaul.

But the Centene news underscores that, while some local markets are struggling to attract insurers, much of the country remains appealing to them. Several of the companies that had difficulty making money seem poised to start breaking even, and other insurers, like Centene, have been able to turn a profit.

“It’s a good business for us,” said Michael F. Neidorff, the company’s chief executive. He said Centene had “done well” in the market and saw continued opportunity. While he would not say which counties Centene planned to enter, he said it was looking at places where other insurers had exited to see if it could offer plans. “We want to help out where we are able to,” he said.

The Trump administration itself may be playing a role in the current instability. Several insurers that have left the markets said they chose to do so, in part, because of uncertainty over administration policies. Mr. Trump has declined to say whether he will continue making payments to insurance companies to help them cover low-income Americans. And insurers also worry that he may decline to enforce the health law’s individual mandate, the penalty people face if they choose not to have coverage.

No insurer decisions about next year are final yet. “This market is still resilient, despite some of the uncertainty that is scaring away other insurers,” said Cynthia Cox, an executive at the Kaiser Family Foundation.

Centene has experience being the only insurer in a market. It was the sole carrier in Maricopa County in Arizona, a place forsaken by its competitors and at risk of having no insurer willing to offer coverage. The company said its experience in Maricopa was no worse than it was elsewhere.

Economists generally view such so-called bare counties as a good bet for insurance companies, which would face no competition and little resistance from local regulators if they charged high prices for coverage.

Centene, which covers 1.2 million people through the state marketplaces, is among the few national players to have established a robust business under the Affordable Care Act. The company is betting that it is flexible enough to take advantage of the turmoil in the market.

“Centene recognizes there is uncertainty” in the new health care legislation, said Mr. Neidorff in a statement announcing its decision.

Much of the uncertainty is causing insurers to propose much higher rates, but the vast majority of Obamacare marketplace customers receive federal subsidies to help purchase their coverage and would essentially not be harmed by any price increases. The large number of subsidized customers also help insulate an insurer from losses if it raises prices. “Subsidies prevent what might otherwise be a death spiral,” Ms. Cox said.

But as insurers make decisions about participation in next year’s markets, Congress continues to consider legislation that would undo substantial portions of the health law. The White House meeting with senators was an effort to encourage them to pass a version of the American Health Care Act, a bill that would reshape regulations and funding for the individual insurance markets, and make substantial cuts to state Medicaid programs.

The bill’s text has not been made public, but Senate leaders have said they hope to hold a vote on the measure by the end of July.

Democrats have assailed the effort as opaque and rushed. “They don’t want the American people to see how poorly they would do under this bill,” said Chuck Schumer, the Senate minority leader, in a news conference Tuesday.

Health care legislation that passed the House in May would result in 23 million fewer Americans having health insurance in 2026, according to the Congressional Budget Office, and could cause market failures in some states that would make insurance inaccessible to Americans with a history of health problems. Senators are discussing various changes to the bill, which could change its effects, though the basic architecture is expected to be similar.

The budget office, at least, suggests that the current markets are more stable than the House’s legislative proposal to replace them.

https://www.nytimes.com/2017/06/13/upshot/trump-says-market-is-failing-but-one-insurer-bets-big-on-obamacare.html?hpw&rref=upshot

G.O.P. Senators Might Not Realize It, but Not One State Supports the A.H.C.A.

by Christopher Warsaw and David Bookman - NYT - June 14, 2017

It’s no secret that the American Health Care Act is unpopular. In recent national polls, only about 29 percent of Americans support the bill. It is the most unpopular piece of major legislation Congress has considered in decades — even more unloved than TARP (“the bailout”), and much more unpopular than the Affordable Care Act, also known as Obamacare.

Will Republican senators vote yes on a bill this unpopular? To hang on to their jobs, senators have to keep only voters in their own states happy, not the whole nation. Perhaps red-state senators, or even some senators in swing states, might think their states are friendlier to the bill than the nation as a whole.

Our research indicates that is not the case. To get a sense of support by state, we combined recent polls to estimate support for the A.H.C.A. in every senator’s home state. Our estimates indicate that not one state favors it.

Even though very few state polls have been conducted on views of the A.H.C.A., we are able to estimate views on the bill in each state using a statistical method called M.R.P. (multilevel regression and postratification) and eight national polls that the Kaiser Family Foundation, YouGov and Public Policy Polling shared with us on people’s views on the A.H.C.A.

While no polling system is infallible, our M.R.P. model combines respondents’ demographic characteristics, their state and their views of the A.H.C.A. to estimate the probability that a voter of a certain age, race and gender, and in a state with certain characteristics, would support the proposal. It then estimates support for the bill within every state based on each state’s demographics. Models like this have been used to accurately predict public opinion in states on other topics, and in last week’s election in Britain.

We found that Republicans have produced a rare unity among red and blue states: opposition to the A.H.C.A.

For example, even in the most supportive state, deep-red Oklahoma, we estimate that only about 38 percent of voters appear to support the law versus 45 percent who oppose. (Another 17 percent of Oklahomans say they have no opinion.) Across all the states that voted for President Trump last year, we estimate that support for the A.H.C.A. is rarely over 35 percent. A majority of Republican senators currently represent states where less than a third of the public supports the A.H.C.A. By comparison, President Trump received 33 percent of the vote in Massachusetts.

How many senators might lose their seats as a result of supporting the bill? A recent study found that Democrats who supported Obamacare lost about six percentage points in the vote in 2010 — a dangerous omen for the 15 sitting Republican senators who won their most recent elections by less than that number. For example, if the A.H.C.A. costs Republicans as much support as Obamacare cost Democrats, senators like Jeff Flake of Arizona and Dean Heller of Nevada might be in danger of losing their seats. We estimate that only 28 percent of the public in Nevada supports the A.H.C.A., while only 31 percent of Arizonans support it.

With this said, it’s hard to know just how politically damaging supporting the A.H.C.A. would be. On the one hand, no major bill this unpopular has passed in decades, but some voters might forget about the A.H.C.A., or change their opinions, by the time some senators face re-election.

But the picture of public support is bleak in the home states of many reported G.O.P. swing votes on the bill. In Susan Collins’s Maine, Lisa Murkowski’s Alaska, Mr. Flake and John McCain’s Arizona, Cory Gardner’s Colorado, Bill Cassidy’s Louisiana, Rob Portman’s Ohio, Lindsey Graham’s South Carolina and Mr. Heller’s Nevada, we estimate that public support is under a third, and clear pluralities oppose.

With A.H.C.A. support in the subbasement, Republican senators have indicated they hope to make changes to the law. Although we can’t be sure exactly what they will change or how it might influence public support, the YouGov data indicate that Republicans in the House had little success softening the public’s opposition with their own modifications. In fact, support for the A.H.C.A. was even lower in the three YouGov polls after the House made its changes than in the two YouGov polls conducted before it.

Cynics might worry that senators care too much about their donors or primary voters to pay heed to general public opposition in their states. But evidence shows that when politicians learn that a majority of their constituents oppose a bill, many change their votes as a result. In one study, academics randomly assigned some legislators to receive information on public opinion in their districts, and found that legislators were much more likely to vote along with constituency opinion when they were informed of it.

But critics of the bill shouldn’t assume Republican senators know where their states stand. Research shows that politicians are surprisingly poor at estimating public opinion in their districts and states, Republicans in particular. G.O.P. politicians tend to overestimate support for conservative health care views by about 20 percentage points — meaning Senate Republicans might see their states as just barely supporting the A.H.C.A. Our analysis indicates this view would be mistaken.

https://www.nytimes.com/2017/06/14/upshot/gop-senators-might-not-realize-it-but-not-one-state-supports-the-ahca.html?mabReward=CTM5&recp=6&src=rechp

What Republicans are doing while you’re distracted by Sessions and Comey

by Dana Milbank - The Washington Post - June 13, 2017

Monday was the first anniversary of the Pulse nightclub shooting in Orlando that left 49 dead. Saturday will be the second anniversary of the church shooting in Charleston, S.C., where nine were murdered at Bible study. 

In between these two somber remembrances, House Republicans will be commemorating the occasion in their own way: They will begin work relaxing restrictions on firearm silencers — thereby making it easier for shooters to shoot without being noticed. 

Classy. 

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To this injury, the legislators add insult with the bill’s name: a provision of the “Sportsmen’s Heritage and Recreational Enhancement Act” called the “Hearing Protection Act” — as if it were subsidizing earplugs. That’s like calling legislation that expands the availability of machine guns the “Carpal Tunnel Protection Act” because it spares would-be shooters the repetitive motion of trigger pulling.

With all the hullabaloo over Attorney General Jeff Sessions, the Russia scandal and President Trump’s latest tweets, few are likely to notice when the bill gets a hearingWednesday before a House natural resources subcommittee. And that’s the point. Trump, as candidate and president, has been a weapon of mass distraction.

Admittedly, nobody would wish on himself the kind of distractions Trump has been generating lately. The inquiries into his and his aides’ Russia ties and his firing of FBI Director James B. Comey could ultimately end his presidency. But though these are consequential and necessary matters — and though there’s no way to avoid attention going to the many other bizarre happenings in Trump world, such as the televised hosannas showered on him at Monday’s Cabinet meeting — these inevitably distract from serious matters that, in any normal time, would dominate headlines.

As the Comey craze and Sessions obsession entertain the nation, Senate Republican leaders have used the diversion to advance Trumpcare legislation in the shadows.

Senate Majority Leader Mitch McConnell (R-Ky.) invoked “Rule XIV,” a procedure that allows legislation to skip committees and go directly to the floor. McConnell is hoping to rush the health-care bill to a vote before the July 4 recess, and GOP senators working on the Senate legislation aren’t even sharing the specifics with their Republican colleagues.

The news outlet Axios this week reported that Senate Republicans don’t plan to divulge the details of their legislation publicly. “We aren’t stupid,” one senior GOP aide told Axios. No, they aren’t. And their subterfuge is working. Unnoticed by most, Senate Republicans believe they have cobbled together the 50 votes necessary to repeal Obamacare.

On the very day that Comey testified before the Senate, the House passed legislation largely repealing the Dodd-Frank financial reforms implemented after the 2008 crash. The bill would, among other things, remove the requirement that retirement advisers put their customers’ interests before their own. The House on Tuesday afternoon took up another controversial matter under cover of the Sessions distraction: As the attorney general testified in the Senate, the House voted along party lines to require a Social Security number for people to get Obamacare benefits. It is meant to block illegal immigrants from accessing health-care benefits. Opponents say it would also deny medical care for many newborn babies who are citizens.

The Comey contretemps has also obscured splits between mainstream and conservative Republicans that have made a budget resolution unlikely. House Republicans are moving on with appropriations legislation for 2018 without a budget. This split could jeopardize tax reform and increase the likelihood of a government shutdown or default later this year.

It’s difficult to focus on budget nuances, though, when Trump has turned the White House into a circus. In addition to the Comey and Sessions performances, there is also the clown show: At this week’s Cabinet meeting, nearly all of Trump’s Cabinet members offered praise for their boss. There were, in all, 46 occurrences of “thank you,” 32 of “great,” 15 of “honor” and seven of “privilege” as they extolled Trump and his virtues: “Just the greatest privilege of my life. . . . My hat’s off to you. . . . What an incredible honor . . . I can’t thank you enough for the privileges you’ve given me. . . . Thank you for the opportunity and the blessing that you’ve given us to serve your agenda.”

As we gape in astonishment at a president receiving tributes from his coterie — like a strongman from his junta — Americans might find it difficult to concentrate on an equally astonishing thing happening this week: that House “hearing protection” bill, which would end nearly a century of strict regulation of silencers and thwart the new gunfire-detection technology cities use to fight crime. 

It’s no small irony that those trying to make silencers more available are relying on noise — the din of Trump’s antics and the clatter of the Russia probes — so that most Americans don’t hear what’s happening until it’s too late.

https://www.washingtonpost.com/entertainment/theater_dance/milligans-health-care-monologues-give-voice-to-patient-and-doctor/2017/05/23/d07ba8fe-3f02-11e7-adba-394ee67a7582_story.html?hpid=hp_hp-cards_hp-card-arts%3Ahomepage%2Fcard&utm_term=.243596c1445d

The three pillars of Republican health care reform: sabotage, speed, secrecy

by The Editorial Board - Bangor Daily News - June 14, 2017

Secrecy breeds suspicion, so there is good reason to be very suspicious of a health care bill crafted by the Senate’s Republican leaders. They are being extremely secretive about the details of health care legislation that would repeal and replace the Affordable Care Act. We fear Republicans’ efforts to keep the bill hidden mean that, like the House Republican bill, their legislation will leave millions of American without health insurance while driving up costs and weakening protections for others.

Republicans have refused to make the bill’s language public. There are likely to be no hearings before the bill is brought to the floor for a vote, which leadership wants to hold before the July 4 recess, when few are likely paying attention. Debate will be limited.

On Tuesday, reporters were temporarily barred from interviewing senators in Senate hallways without prior permission from the Senate Rules Committee. It is fashionable among some circles to mock and denigrate the media. But reporters aren’t asking about the health care bill because they are busybodies or disrespectful. They are asking so they can tell Americans, the senators’ constituents, what is in a bill that will affect their lives.

Senate Majority Leader Mitch McConnell “could have started over and had the Senate develop its own legislation, perhaps even working with Democrats on a bipartisan alternative that could withstand the test of time. Instead, McConnell put a plan in place to pass something close to the House bill using three simple tools: sabotage, speed and secrecy,” Andy Slavitt, the former acting head of the Centers for Medicare and Medicaid Services, wrote in the Washington Post.

Why use “sabotage, speed and secrecy” instead? “We aren’t stupid,” a senior Senate aide told Axios. In other words, Senate Republican leadership learned a lesson from the rocky rollout of the House Obamacare repeal bill, which was supported only by Republicans, including Rep. Bruce Poliquin.

That bill, which the nonpartisan Congressional Budget Office concluded will leave 23 million more people without health insurance than if Obamacare remained in place, has been rejected by the public. Only 8 percent of Americans believe the Senate should pass the House Republican bill, which is packed with tax breaks for the wealthy that have nothing to do with health care

According to the latest polling, from Quinnipiac University, 44 percent of people expect health insurance costs will go up under the House Republican bill and 57 percent think fewer people with have insurance coverage. So the Republican secrecy isn’t fooling the American people.

Rather than hide their work because they know if it is faulty, Senate Republicans should spend their time improving the Affordable Care Act. First, they should recognize their rhetoric and shenanigans are destabilizing Obamacare. If the law’s individual health insurance marketplaces fail, as is close to happening in some states as insurers leave the market, it is because of the uncertainty caused by threats and attempts to undermine it.

Because of the ACA, 22 million more Americans have health insurance. This is largely because of subsidies that lowered the cost of insurance for millions and the expansion of Medicaid, in states that did so; Maine has not. Because an insurance pool can only function when it includes a mix of people — young and healthy and older and sick — there are also penalties for those who do not buy insurance in order to draw the young and healthy into the market.

Fixes to the ACA should focus on these areas, such as adjusting subsidies and penalties to better balance the mix of people in the individual insurance market.

The House Republican bill moved in the opposite direction by allowing insurers to charge older, sicker people much more and by ending the Medicaid expansion.

If the Senate’s Republican leadership follows along, with a plan written in secret by a hand-picked group of men, the chamber’s moderate Republicans must reject it.

Then, they can direct attention to where it has always belonged — to improving Obamacare rather than repealing it to settle political scores.

http://bangordailynews.com/2017/06/14/opinion/editorials/the-three-pillars-of-republican-health-care-reform-sabotage-speed-secrecy/

The GOP’s fantastically anti-democratic quest to kill health care in the dark

by E.J. Dionne, Jr. - The Washington Post - June 15, 2017

Senate Majority Leader Mitch McConnell once had passionate views about how carefully Congress should consider sweeping changes to the health-care system. 

“Fast-tracking a major legislative overhaul such as health care reform or a new national energy tax without the benefit of a full and transparent debate does a disservice to the American people,” McConnell said in 2009, referring to the two big issues of the moment. Democrats using such means, he added, “would make it absolutely clear they intend to carry out their plans on a purely partisan basis.” 

Republican hypocrisy is now so rampant that it’s typically ignored or, worse, granted the political class’s all-purpose form of absolution: “Everybody does it.”

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But everybody doesn’t do it. McConnell is trying to eviscerate the Affordable Care Act using methods completely at odds with how the law was originally brought to lifein the early Obama administration. The ACA was debated for more than a year and went through an elaborate hearing and amendment process that included some changes urged by Republicans.

By contrast, the bill Senate Republicans are writing is being held as close as the nuclear codes. In the meantime, President Trump and his administration (including, most recently, Attorney General Jeff “I don’t recall” Sessions) keep providing McConnell excellent cover as their assorted outrages dominate the news and deflect attention from Capitol Hill. The wrecking squad works in the shadows knowing that if the public were given time to absorb the damage in store for millions of Americans, the pushback would be enormous. 

Cleverly, Senate Republicans say their coverage-destruction bill will be better than the one Speaker Paul D. Ryan (Wis.) pushed through the House. (Trump helpfully described the House measure as “mean” during a meeting Tuesday with Republican senators.) Well, great, and a Category 4 hurricane is a bit less harrowing than a Category 5. Most of us would prefer to avoid both.

One of the so-called improvements that has leaked out: People will be thrown off Medicaid more slowly under McConnellcare than under Ryancare. But they’ll still be thrown off, and to pay for this reprieve, the Senate would reportedly include additional cuts to Medicaid elsewhere. To finance all their tax cuts for the rich, Republicans will have to gut insurance for a lot of people one way or another.

Why all the secrecy? McConnell is trying to keep the pressure off the many Republican senators who have offered pledges of varying degrees of specificity to protect Medicaid and other aspects of the ACA that benefit their constituents.

They include Dean Heller of Nevada and Jeff Flake of Arizona, both up for reelection next year, as well as Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Lisa Murkowski of Alaska, Cory Gardner of Colorado and Bill Cassidy of Louisiana. So far, Susan Collins of Maine has stood honorably as one of her party’s firmest skeptics of this fiasco-in-the-making, but even she seems to be wobbling.

Because Democrats have 48 votes against dismantling the existing law, any three Republican senators could put a stop to this fantastically anti-democratic process. They could walk into McConnell’s office and say they’ll oppose any bill that is not made public for at least a month of real scrutiny and discussion. Is this too much to ask of legislation that could threaten the health care of countless Americans (the exact number being unknowable because the bill’s architects won’t admit to what they’re doing)? 

There is work here for activists, politicians and the media. Activists must understand that they have less time to save the Affordable Care Act than they might think. Democratic senators must take every opportunity to force this issue to the fore. Disruption in the face of this violation of legislative norms is no vice.

As for the media, Jacob Leibenluft, a former Obama administration official, described the problem well in an interview: “If you don’t have hearings, and you don’t have big moments for television, you don’t have bandwidth for coverage.” Leibenluft, now at the Center on Budget and Policy Priorities, says individual reporters on the health-care beat are doing good work, but their stories are getting limited attention. Leibenluft spoke before the horror of Wednesday’s shooting of Rep. Steve Scalise (R-La.) and four others, which properly commanded the nation’s attention. His point was about the place of health care in the normal flow of political news.

Trump says Democrats are ‘destroying health care’

During a short address at Cincinnati Municipal Lunken Airport, June 7, President Trump accused congressional Democrats of “destroying health care.” (The Washington Post)

He added: “I hate to think that looking back on this period, we’ll realize that the most regressive piece of social legislation in modern American history was passed, and no one was paying attention.”

We know that the Trump/Russia story will still be there in a month. We cannot say the same about the health insurance millions of Americans count on. By then, it may be on the road to extinction.

https://www.washingtonpost.com/opinions/the-gops-fantastically-anti-democratic-attempt-to-kill-health-care-in-the-dark/2017/06/14/0903e284-5134-11e7-91eb-9611861a988f_story.html?hpid=hp_no-name_opinion-card-f%3Ahomepage%2Fstory&utm_term=.9d1d2e06d81c

Republicans are privately angry at Trump for accidentally unmasking their big scam

by Greg Sargent - The Washington Post - June 14, 2017

House Republicans are angry with President Trump for blurting out an inconveniently candid view of their health-care bill, Politico reports today. Trump reportedly told a closed-door gathering of GOP senators that the House repeal-and-replace bill is “mean” and called on them to make it “more generous.” This promptly leaked, and a lot of people are noting that Trump undercut House Republicans politically and provided Democrats with ammo for a thousand attack ads.

But I’d like to argue that this moment has broader significance than that. If you place Trump’s private candor in the context of the indefensibly opaque and secretive process that Republicans are using to get this health-care bill through, it reveals in a fresh way just how scandalous their approach to remaking one-sixth of the U.S. economy really has been.

Here’s how Politico characterizes the anger at Trump among House Republicans right now:

Imagine if you’re a House Republican, and voted for the leadership’s health-care bill in May after being told that you were doing the newly elected president a solid. You listened to the White House’s pleading — perhaps you got a phone call from Vice President Mike Pence, Chief of Staff Reince Priebus or even the president himself. The administration was on the Hill nonstop to push their legislation. You explained to your constituents that the late-in-the-game changes made to the bill helped cover more people. You celebrated with him in the Rose Garden after passage.

Now you hear the president has gone behind closed doors and told senators the House bill is “mean” and says it doesn’t do enough to cover people. Wouldn’t that anger you? Well, it’s angering a lot of House Republicans, who believe their president put them at political risk with that comment … If you’re a House Republican, are you going to help the White House next time after the president privately just dumped all over you after you cast a vote for him? A lot of GOP lawmakers are buzzing about it, and many are none too pleased with the president right now. 

The multiple reports on Trump’s comments differ slightly in the details, but not in their overall thrust. Sources who spoke to the Associated Press said Trump told GOP senators that the House bill is “mean, mean, mean” and must be made “more generous.” CNN adds that Trump told the lawmakers that the House bill would leave too many people vulnerable and that he wants more money spent on those people. One Republican senator related that Trump “talked about the need to take care of people.”

House Republicans are now angry at this, Politico reports, because they stuck out their necks making the case for a bill that would leave many millions without coverage and gut protections for people with preexisting conditions. They “explained to their constituents” that the last-minute changes to the bill (adding all of $8 billion) would make it less destructive to that latter group. But Trump has now upended all of this, putting them at greater political risk.

During a short address at Cincinnati Municipal Lunken Airport, June 7, President Trump accused congressional Democrats of “destroying health care.” (The Washington Post)

But their anger over this is particularly galling, because Republicans themselves do not want their constituents to actually know what is in the bill they are set to pass. And they are taking active, extensive and possibly unprecedented steps to make sure they don’t. Trump merely made this harder for them to get away with.

Let’s not forget that House Republicans deliberately voted on their bill before the Congressional Budget Office produced its final score of it. That analysis concluded that 23 million fewer people would be covered and that the bill’s provision allowing states to waive the ban on jacking up premiums for people with preexisting conditions would lead to soaring costs for many of them, leaving untold numbers without coverage entirely. After lying relentlessly about the bill — claiming that no one would be worse off and that it would strengthen protections for the sick — House Republicans deliberately held a vote before the CBO’s final analysis gave voters a way to evaluate those lies in the light of empirical analysis.

Now Senate Republicans are urgently working to soften the bill, because a number of moderates can’t be seen embracing something that cruel. But, if anything, they are going further than their House counterparts to forestall any kind of serious public awareness of what they are doing. Two GOP aides recently told Axios that there are no plans to publicly release the Senate version well in advance of the vote, because, as one of them put it, “we aren’t stupid.” There have been no public hearings. Even some Senate Republicans have expressed befuddlement about what’s in the bill that they will be voting on.

As Brian Beutler and Jonathan Chait have noted, avoiding public scrutiny and accountability is the whole legislative strategy — the process itself is a scandal, given how many millions of people, and how large a swath of the economy, it will impact. And as University of Michigan law professor Nicholas Bagley argues, that could have untold other consequences: The lack of scrutiny and debate could lead to major, destructive flaws in the bill itself and, more broadly, could further erode basic norms of legislative transparency.

We do know a few things about the Senate bill. It will likely phase out the Medicaid expansion more slowly, to allow moderates to argue that they have “softened” the House version, which cuts $800 billion in health-care spending on poor people while delivering to the rich an enormous tax cut. It may also nix the provision deregulating protections for preexisting conditions, but, by keeping the one that allows for skimpier health plans, it could end up nonetheless harming untold numbers of sick people who would need previously covered essential services.

Trump’s admission that the House bill is “mean” should not be taken seriously as an actual statement of values, because he himself has championed it in public, and thus simply means the Senate version needs to provide a way to pretend the final product is far more “generous” than it will surely end up being, which is a lot like the House bill. Indeed, the GOP’s extraordinary lack of transparency is itself a concession that Republicans know how “mean” it will be. Republicans are angry that Trump admitted, in a way guaranteed to leak, that he knows it will hurt huge numbers of people, when they had taken such great pains to obscure that. Trump’s real transgression was to provide the public with a glimpse of a reality that they themselves have gone to extraordinary lengths to keep hidden.

https://www.washingtonpost.com/blogs/plum-line/wp/2017/06/14/republicans-are-privately-angry-at-trump-for-accidentally-unmasking-their-big-scam/?tid=pm_pop&utm_term=.b2efe145136d

Health of many Mainers depends on bill in Congress, Medicaid expansion

by Malory Otteson Shaughnessy - Portland Press Herald - June 15, 2017

AUGUSTA — The nation watched May 4 as the U.S. House of Representatives narrowly approved legislation to repeal and replace integral parts of the Affordable Care Act. Now the replacement legislation, the American Health Care Act, is in the U.S. Senate’s hands. And there are rumblings that they might take it back up for passage with minimal changes before the Fourth of July.

If the AHCA passes in its current form, nearly 20,000 Mainers would lose critical access, gained through the ACA, to treatment for mental health concerns and substance use disorder, a number cited in research from both Harvard and New York universities in January.

As we have all heard by now, drug-related deaths in our state reached a new high of 376 lives lost last year, an increase of nearly 40 percent and 100 more people when compared with 2015’s total of 272 fatalities. More troubling, 2016 was the fifth straight year of an increase in fatal overdoses, mostly because of the illicit use of prescription painkillers, heroin and the potent synthetic drug fentanyl.

Behavioral health experts call what’s transpiring an acute crisis and recognize it as a devastating trend that must be halted. Medicaid and its unparalleled access to mental health and substance use disorder treatment needs to be protected, or expanded, to address this crisis.

Maine Sen. Angus King, an independent, has said that the iteration of the AHCA proposed by the House would make our state’s opioid problem worse. At present, at least one person dies every day from an overdose in Maine. This is already one too many. No more.

Opponents of the ACA repeal, including King and Maine’s Republican senator, Susan Collins, understand that about 75,000 Mainers receive ACA coverage in general, more than 20,000 are receiving treatment for behavioral health issues, and some 8,000 are actively getting treatment for substance use disorder. The ACA has allowed many who would have been denied coverage because of pre-existing conditions, which includes mental health and addiction issues, to keep their insurance.

Both senators decried the detrimental effects of the House proposal on the poor and on people over age 50. King called for meaningful improvements, while Collins said, “It really misses the mark.”

Because Maine is not a Medicaid expansion state, it only receives a 64.38 percent matching rate from the federal government for MaineCare (the state’s Medicaid program), a prime source of funding for our behavioral health services. These are critical funds, especially as pressures increase upon our already stretched state budget. Had Maine taken the Medicaid expansion, coverage for the newly eligible adults – an estimated 70,000 – would have been fully funded by the federal government for three years, then phased down to a 90 percent matching rate by 2020 and thereafter.

In February, Secretary of State Matthew Dunlap certified that enough signatures have been collected to place a citizen initiative for MaineCare expansion on the November ballot. It’s been passed five times in the Legislature, but vetoed five times by Gov. LePage.

If repeal and replacement of the ACA comes to pass, we’ll lose $5 billion in federal funding for Medicaid, the Children’s Health Insurance Program, financial assistance for marketplace coverage and the option to expand Medicaid. According to the Maine Center for Economic Policy, we have already lost nearly $2 billion that we would have received had the governor not vetoed Medicaid expansion.

The Maine Department of Health and Human Services has increased state funding for addressing our opioid crisis to the tune of millions of dollars, all without the match we would have had under an expansion. Our citizens simply can’t afford this.

Mainers are fortunate that our U.S. senators understand how necessary it is that provisions of the ACA are secured within a new plan, especially real coverage for pre-existing conditions like mental health. Please call Susan Collins and Angus King to affirm your support that any new health care plan protects us all – and especially our neighbors needing substance use disorder treatment and mental health care.

And make sure you go to the polls in November to expand coverage to the tens of thousands of Maine residents who need it.

http://www.pressherald.com/2017/06/15/maine-voices-health-of-many-mainers-depends-on-bill-in-congress-medicaid-expansion/