Single-payer health care would have an astonishingly high price tag
By The Editorial Board - The Washington Post - June 19, 2017
OBAMACARE LOOKS shaky, mostly because Republicans are sabotaging it. This, in turn, has rekindled calls on the left to create a European-style “single-payer” system, in which the government directly pays for every American’s health care. California lawmakers, for example, are considering such a plan for their state.
The single-payer model has some strong advantages. It is much simpler for most people — no more insurance forms or related hassles. Employers would no longer be mixed up in providing health-care benefits, and taxpayers would no longer subsidize that form of private compensation. Government experts could conduct research on treatments and use that information to directly cut costs across the system.
But the government’s price tag would be astonishing. When Sen. Bernie Sanders (I-Vt.) proposed a “Medicare for all” health plan in his presidential campaign, the nonpartisan Urban Institute figured that it would raise government spending by $32 trillion over 10 years, requiring a tax increase so huge that even the democratic socialist Mr. Sanders did not propose anything close to it.
Single-payer advocates counter that government-run health systems in other developed countries spend much less than the United States does on its complex public-private arrangement. They say that if the United States adopted a European model, it could expand coverage to everyone by realizing a mountain of savings with no measureable decline in health outcomes, in part because excessive administrative costs and profit would be wrung from the system.
In fact, the savings would be less dramatic; the Urban Institute’s projections are closer to reality. The public piece of the American health-care system has not proven itself to be particularly cost-efficient. On a per capita basis, U.S. government health programs alone spend more than Canada, Australia, France and Britain each do on their entire health systems. That means the U.S. government spends more per American to cover a slice of the population than other governments spend per citizen to cover all of theirs. Simply expanding Medicare to all would not automatically result in a radically more efficient health-care system. Something else would have to change.
The Congressional Budget Office has released its score on the revised American Health Care Act. Here's what's in the report. (Daron Taylor/The Washington Post)
With monopoly buying power, the government could tighten up on health-care spending by dictating prices for services and drugs. But the government already has a lot of leverage. A big reason it does not clamp down now on health-care spending is that it is hard to do so politically.
Republicans have tarred the Affordable Care Act’s Medicare cuts as attacks on the cherished entitlement program. Doctors and hospitals have effectively resisted efforts to scale back the reimbursements they get from federal health programs. Small-town America does not want to give up expensive medical facilities that serve relatively few people in rural areas. A tax on medical device makers has been under bipartisan attack ever since it passed, as has the “Cadillac tax” on expensive health-insurance plans. When experts find that a treatment is too costly relative to the health benefits it provides, patients accustomed to receiving that treatment and medical organizations with a stake in the status quo rise up to demand it continue to be paid for.
A single-payer health-care system would face all of these political barriers to cost-saving reform and more. To realize the single-payer dream of coverage for all and big savings, medical industry players, including doctors, would likely have to get paid less and patients would have to accept different standards of access and comfort. There is little evidence most Americans are willing to accept such tradeoffs.
The goal still must be universal coverage and cost restraint. But no matter whether the government or some combination of parties is paying, that restraint will come slowly, with cuts to the rate of increase in medical costs that make the system more affordable over time. There are many options short of a disruptive takeover: the government can change how care is delivered, determine which treatments should be covered, control quality at hospitals, drive down drug costs and discourage high-cost health-care plans even while making the Obamacare system better at filling coverage gaps.
Editor's Note:
I am posting preceding Editorial from the Washington Post not because I agree with everything they say (especially the conclusions they draw), but because I think it is significant that they have finally been forced to argue against "single payer" (I prefer "improved Medicare-for-All"), an idea they usually ignore or dismiss out of hand as "unrealistic", on substantive grounds - a discussion that should have taken place in 2009 during the run-up to ObamaCare.
Much (but not all) of what they say in the editorial is correct - especially the part about creating a "single-payer" system being politically difficult. If it were easy it would have been done a long time ago. It would certainly require moving much of our private sector spending on health care (including private insurance premiums, out-of-pocket expenses such as services now uncovered by private insurance and co-pays and deductibles) to tax-supported public budgets. While such a large tax-increase will inevitably be resisted by those opposed to "big government" on ideological grounds, the American public also has a history of being quite fond of the services those taxes fund - including pubic education and libraries, pubic roads, police, firefighters, the military, the judiciary and other branches of government. Oliver Wendell Holmes once said "Taxes are the price of civilization". Most Americans seem to be happy to support at least a bit of tax-supported civilization.
But here's what the Post editorialists forgot to say: Like our existing Medicare program, "Improved Medicare-for-All" would be a political uniter, unlike our existing fragmented system (including ObamaCare), that treats different people differently based on age, place of residence, health status, income and other factors taken into account during the process of "medical underwriting", the core business of insurance companies. Because Medicare, Medicaid and other public programs are tax-funded, inherently divisive medical underwriting is eliminated.
That, in turn, would eliminate much of the expensive complexity and ruinous divisiveness of our existing system. That is why, unlike a private-insurance based system (including extremely controversial ObamaCare), Medicare is so popular and so relatively invulnerable to political attack. Although many conservative politicians would be happy to find a way to subvert Medicare, very few are willing to attack it directly due to its overwhelming popularity.
I spend a lot of time talking to ordinary Mainers in their own communities. Based on that, and on a lifetime of experience thinking and learning about American health policy, I believe that after watching the food-fight going on in Washington over health care, Americans are now more ready than ever to accept the limitations that would be necessary to return American health care to affordability, if in return they got a health care system that is perceived to be fair, transparent, affordable and truly universal - none of which can be said of the mess we have now.
The benefits of such an "Improved Medicare-for- All" system would include having a health care system that provides affordable coverage for everybody, financial security, increased freedom to pursue the livelihood we would like, unshackled from the need to find employment linked to good health care coverage, increased efficiency of the labor market and a boost in take-home pay due to removing health care from from employers' cost of labor.
One other benefit of a government-financed system would be the creation of a budget for health care for all Americans, a feature found in almost every other country. That would provide a macro-economic tool to constrain further increases in health care costs, a constraint that would affect everybody equally in a truly universal system. That in turn would permit the elimination of much of the uniquely American micro-management of medical care, often disguised as "quality improvements" but that are really ineffective attempts to control our now out-of-control costs, that now afflict doctors and patients alike.
So let the belated debate begin - but let it be about the real advantages and disadvantages of health care as a public good - not arguments ginned up to bolster one or another political ideology.
-SPC
GOP Senate leaders aim to bring health-care legislation to the floor by end of June
by Sean Sullivan and Kelsey Snell - The Washington Post - June 15, 2017
Senate Republican leaders are aiming to bring a major revision to the nation’s health-care laws to the Senate floor by the end of June even as lingering disagreements, particularly over Medicaid, threaten to derail their efforts, several Republicans familiar with the effort said Thursday.
President Trump and Senate Majority Leader Mitch McConnell (R-Ky.) are pressing for an ambitious timeline to complete the bill, although it is being drafted in the Senate with little assistance from the White House.
The push has been laden with secrecy — and rank-and-file Republican senators are increasingly frustrated that McConnell and a small group of GOP aides are crafting a bill behind closed doors.
“My primary concern is writing a bill and not having enough time to analyze it,” Sen. Ron Johnson (R-Wis.) said in an interview this week. “I don’t want to get jammed.” Asked to describe his concerns with the process, Johnson quipped, “How much time do you have?”
Impassioned policy disputes have flared among some GOP senators in large group meetings at which McConnell has floated ideas from the drafting process. But those disputes have not deterred him from the goal of a floor vote before the July 4 recess, said the Republicans familiar with the process, who spoke on the condition of anonymity to talk candidly about private conversations.
In public this week, McConnell and other Republican leaders have hedged their aggressive timeline. But, as McConnell’s team sees it, the options have all been vetted. Now, the difficult decisions about what to put in and leave out of the final bill are all that remain.
“We’ve been dealing with this issue for seven years,” McConnell said this week. “We’re now working on coming up with a solution.”
Another X factor is Trump’s shifting position on the legislation. Just this week, he called the House version “mean” — causing concern about how forcefully he will support the Senate bill in the coming weeks.
By all accounts, the Senate bill will be dramatically different from the measure that emerged from the House in May, and it is entirely unknown how and whether the two chambers can reconcile their differences and actually enact legislation revising the Affordable Care Act, known commonly as Obamacare.
Equally unclear is how McConnell can get to 50 votes in his chamber, with Vice President Pence at the ready to cast a tiebreaking vote.
The difficulties underscore the tension between Republicans’ long-standing goal of repealing and replacing Obamacare and their growing sense that enacting legislation that knocks millions of Americans off insurance rolls is politically treacherous. Because of that tension, the Senate bill is far more likely to revise the Affordable Care Act than to replace it.
The largest, most enduring clash within the Senate is over the future of Medicaid. Republican senators are at odds over how much and how quickly to pare back federal spending on the program, which expanded under Obamacare and added millions of Americans to the rolls of the federally insured.
Other questions to be resolved include how many and which of the ACA taxes to keep and which regulations to eliminate. McConnell has proposed preserving protections for people with preexisting medical conditions in the current law, which the House bill does not do.
The Medicaid fight has flared frequently in recent weeks as two Rust Belt senators with starkly different views of the program have become leaders of competing factions in the closed-door meetings: Rob Portman (R-Ohio) and Patrick J. Toomey (R-Pa.). Portman and others from states that expanded Medicaid under the ACA want more time to unwind the program, while Toomey and his conservative allies want to slow the growth of the program’s cost.
The two have clashed several times in closed-door gatherings, according to several Republican senators and aides familiar with the meetings. Portman is fighting a proposal from Toomey and conservative Sen. Mike Lee (R-Utah) to cut Medicaid spending by capping federal payments at a rate slower than Medicaid costs are expected to rise. Toomey and his supporters say their plan would help curb the long-term costs of Medicaid.
Portman and several other moderate senators say the proposed cuts would give states no choice but to cut services, benefits or provider payments and could leave people with insufficient care.
“We need to come together around a more workable system that not only lowers costs, but also protects the most vulnerable in our society,” Portman said in a statement.
The intense disagreement has also included Sen. Tom Cotton (R-Ark.), who is allied with Toomey, and who recently engaged Portman in a frank and lengthy exchange.
Portman is also working with Sen. Shelley Moore Capito (R-W.Va.) to push for $45 billion over 10 years to address opioid addiction. Capito told reporters Tuesday that opioid money is among her top priorities.
“It’s absolutely critical to my state, and we’ve got huge problems,” Capito said.
Sen. Roy Blunt (R-Mo.), a top McConnell deputy, said confrontations such as those between Toomey and Portman are the result of senators spending the past several years learning the minute details of the health-care policies that work best in their states.
“These debates have a higher quality of intensity on detail than they would have in the past,” Blunt said.
Republican leaders have no plans to hold committee hearings on their bill. They feel as if they have spent plenty of time presenting GOP senators with different options. No Democrats are expected to support it.
But some Republican senators say they have been left in the dark about what is in the emerging bill or are concerned about moving ahead too quickly.
“You really would need to ask Senator McConnell or his staff that,” said Sen. Susan Collins (R-Maine), a potential swing vote, when asked about how much of the bill has been written. “I’m not part of his working group.”
Leaders have also been in frequent contact with the nonpartisan scorekeepers at the Congressional Budget Office. The constant dialogue is expected to make it easier for the CBO to determine the cost of the final bill and further speed up the timeline before a final vote.
Some have also complained about overly general material in PowerPoint presentations delivered quickly during policy lunches.
McConnell, top aides from the offices of Republican Whip John Cornyn (R-Tex.) and staffers from three key committees have maintained tight control of the process, going to great lengths not to put anything on paper to avoid leaks. At least one senator complained that the digital slides are flashed across the screens so quickly that they can hardly be committed to memory.
Trump met with senators this week at the White House to talk about health care, and he supports a quick timeline, according to one senior administration official. But compared with earlier this year, when the House bill was under debate, he has taken a more hands-off approach, leaving much of the work to the senators.
Trump called the House bill “mean” during a lunch with GOP senators on Tuesday — despite having championed the legislation and celebrating its passage in a Rose Garden ceremony. He also said that the Senate bill needed to be more generous.
That language led to worries in both chambers that Trump might not support members who take tough votes on health care, even if it is not as popular as he had hoped, according to one Republican policy expert who is close to both the White House and the congressional process.
“The president’s off-handed comment to a group of senators was actually a huge shock to the system,” that person said. “That confirmed a worry that a lot of people have had on the Hill about Trump and what he would do if the bill they’re working on turned out to be less popular than they expected.”
Senate leaders argued that they are keeping a tight grip on emerging bill language a secret because they are writing several different policy options for each section of the bill. They worry that sharing any one piece out of context could give a distorted impression of what the final bill will include.
“There’s going to be trade-offs,” Cornyn said. “We’re trying to do this in a careful, thoughtful sort of way.”
Secrecy Surrounding Senate Health Bill Raises Alarms in Both Parties
by Thomas Kaplan and Robert Pear - NYT - June 15, 2017
WASHINGTON — As they draft legislation to repeal the Affordable Care Act, Senate Republican leaders are aiming to transform large sections of the American health care system without a single hearing on their bill and without a formal, open drafting session.
That has created an air of distrust and concern — on and off Capitol Hill, with Democrats but also with Republicans.
“I’ve said from Day 1, and I’ll say it again,” said Senator Bob Corker, Republican of Tennessee. “The process is better if you do it in public, and that people get buy-in along the way and understand what’s going on. Obviously, that’s not the route that is being taken.”
The secrecy surrounding the Senate measure to repeal and replace the Affordable Care Act is remarkable — at least for a health care measure this consequential.
In 1993, President Bill Clinton empowered the first lady, Hillary Clinton, to assemble health care legislation in private, with input from a group of more than 500 experts. That approach won scathing reviews from Republican lawmakers and others shut out of the deliberations. But it took place at the White House, not in Congress. Once the Clintons’ health plan reached Capitol Hill, it died in the public spotlight.
Republican leaders this week defended their actions.
“Look, we’ve been dealing with this issue for seven years,” said the Senate majority leader, Mitch McConnell of Kentucky. “It’s not a new thing.”
Mr. McConnell said there had been “gazillions of hearings on this subject” over the years — a less-than-precise tabulation that offered little comfort to Democrats who want hearings held now, in this particular year, on the contents of this particular bill.
In the summer of 2009, when Democratic members of Congress were defending their effort to remake the nation’s health care system, they were taunted by crowdschanting, “Read the bill, read the bill.”
Now Democrats say they would love to read the Republicans’ repeal bill, but cannot do so because Republicans have not exposed their handiwork to public inspection.
“They’re ashamed of the bill,” the Senate minority leader, Chuck Schumer of New York, said. “If they liked the bill, they’d have brass bands marching down the middle of small-town America saying what a great bill it is. But they know it isn’t.”
The Senate’s decisions could have huge implications: Health care represents about one-sixth of the American economy, and about 20 million people have gained insurance under the 2010 health law, President Barack Obama’s signature legislative achievement.
In theory, the bill-writing process is open to any of the 52 Republican senators, but few seem to have a clear, coherent picture of what will be in the legislation.
Senator Ron Johnson, Republican of Wisconsin, offered a hint of the same frustration felt by Democrats seeking more information about the bill.
“I come from a manufacturing background,” Mr. Johnson said. “I’ve solved a lot of problems. It starts with information. Seems like around here, the last step is getting information, which doesn’t seem to be necessarily the most effective process.”
At a Senate hearing on Thursday, Tom Price, the secretary of health and human services, said that he also had not seen the Senate bill.
Senate Republican leaders say the bill is still a work in progress, and they have not said exactly how it will differ from the one approved last month in the House. President Trump raised the stakes when he told senators this week that the House version was “mean.”
The Senate bill is likely to phase out the Affordable Care Act’s Medicaid expansion more slowly than the House version. It is also expected to include larger tax credits to help older Americans buy health insurance.
The legislation will be considered in the Senate under an expedited procedure that precludes a Democratic filibuster and allows passage by a simple majority. But, Republicans say, Democrats will still be able to offer numerous amendments once the bill is on the Senate floor.
It is not unusual for lawmakers to draft major legislation in private, but they usually refine, debate and amend it in open committee sessions. The House bill to repeal the Affordable Care Act did not receive a hearing, where outside experts could have testified. But lawmakers dissected its contents and were able to propose changes at three stages: in the Ways and Means, Energy and Commerce, and Budget Committees.
Senate Republican leaders evidently think their back-room approach gives them the best chance to devise a health care bill that can squeak through the Senate, given their narrow majority and the policy differences in their conference.
However Republicans feel about their coming bill — and they are far more comfortable criticizing the Affordable Care Act than talking up the virtues of their still-incomplete replacement — the process playing out in the Senate is quite different from the way Democrats went about passing the Affordable Care Act.
The Senate health committee approved its version in July 2009 after considering hundreds of amendments over 13 days. The Senate Finance Committee cleared its version in October 2009, after more than a year of hearings, round-table discussions and other spadework. A group of Democrats and Republicans from the Finance Committee had met for months behind closed doors, trying — but ultimately failing — to draft bipartisan legislation.
The full Senate passed the Affordable Care Act on Dec. 24, 2009, on the 25th consecutive day of floor debate.
While much of the Affordable Care Act was written in the open, some important provisions were hashed out in private, just before the Senate vote, by Senator Harry Reid, the Nevada Democrat who was then the majority leader.
Republicans complained bitterly at the time, and Democrats threw those complaints back at them this week.
“This massive piece of legislation that seeks to restructure one-sixth of our economy is being written behind closed doors, without input from anyone, in an effort to jam it past not only the Senate but the American people,” Mr. McConnell said in December 2009, using words that could be spoken by any Democrat today.
The repeal efforts this year have moved much faster, though not as quickly as Mr. Trump or Republican leaders might have hoped.
In March, days before House Republicans released their repeal bill, Democrats and an exasperated Senate Republican hunted around the Capitol for the elusive legislation. The senator, Rand Paul of Kentucky, brought with him a copy machine, just in case he found his prize.
Asked this week about the Senate bill, Mr. Paul replied, “Have you seen it?”
Mr. Paul said he had no plans to bring out the copy machine again, but he suggested that the Senate’s current course left something to be desired. “My preference would be a more open process in committees,” he said, “with hearings and people on both sides.”
In February, the Senate health committee held a hearing on stabilizing the individual insurance market. But since the House passed its repeal bill and the focus shifted to the other side of the Capitol, Senate Republicans have done their work out of public view.
Their efforts drew unwanted attention early last month because of the composition of the working group they assembled to chart a path on health care: It consisted entirely of men.
Since then, Republican senators have shared bits and pieces of the ideas being mulled in their private lunches and meetings.
Asked his level of comfort with the process, Senator John McCain, Republican of Arizona, cut off a reporter before he could finish his sentence. “None,” he said.
“We’ve got a divided caucus,” Mr. McCain said. “I listen avidly at lunch as we go over the same arguments over and over and over again.”
Doctors: You have a PR problem
by Kaci Durbin, M.D. - Physician - June 12, 2017
Over the last few decades, public perception of physicians has been on the decline. Many issues are to blame, but a largely overlooked contributing factor is the media. Physicians are often portrayed negatively, with stories of narcotic abuse, greed and medical mistakes dominating the news. Rather than fight back, physician organizations have stood silently and allowed their reputations to be tarnished. On the other hand, nursing organizations have been busy pursuing many successful public relations campaigns, which have resulted in an image of compassion and intelligence. They have done this, however, at the expense of physicians.
During the mid-20th century, to be a doctor was one of the most prestigious careers one could achieve. Yet, survey data from 2012 revealed that only 34 percent of Americans have “great confidence” in physicians, compared with 73% in 1966 (Blendon 2014). News, social media and magazines are filled with negative stories about doctors. Bloggers tell patients to ignore their physicians’ advice and “do that home birth” or “say no to that vaccine.” It seems that the public trusts actors and Playboy playmates more than their doctors. This loss in social status and negative public perception has greatly affected physicians, and subsequently changed the care they provide to their patients. In a 2008 survey, only 6% of physicians described their morale as positive.
While physician image has been on the decline, public perception of nurses has continued to grow. As the last few years of Gallup polls have shown, nurses are consistently rated highest on honesty and ethical standards while the opposite trend has been observed for physicians. As the latest Gallup poll in 2014 revealed, over 80% of American state nurses have “very high” or “high” standards of honesty and ethics, while only 65% of Americans feel the same way about doctors. Various nursing organizations including the American College of Nurse-Midwives (ACNM) and the American Association of Nurse Practitioners (AANP) have been active when it comes to improving the image of nursing, and it has paid off. Unfortunately, physician reputation was damaged.
The “ACNM Project,” launched by the ACNM, has focused on making nurse midwives the “norm for women’s health care service in the United States.” Their aggressive public relations campaign has been successful. Midwives attended 3% of births in 1989 compared with 10% today. Rather than show patients the benefits of their profession, however, they have focused on negative rhetoric towards obstetricians. Many midwifery websites discuss high Cesarean rates or “unnecessary” interventions of physicians. The website of the American College of Nurse-Midwives is very clear on “disruptions to a normal healthy birth” which include medications and Cesarean delivery. Rather than seeing an obstetrician as a doctor that has a woman and her baby’s best interest at heart, the doctor is painted as an overbearing, controlling surgeon.
Nursing organizations have also been active on social media. Facebook and Twitter have been overrun with rhetoric that builds up the nursing profession while tearing down physicians. The AANP promoted themselves on social media with the slogan “brains of a doctor and heart of a nurse,” implying that physicians are lacking in the heart department. Memes stating: “Be nice to nurses. We keep the doctors from accidentally killing you,” and “Behind every great doctor is an even greater nurse,” shed physicians in a negative light, painting a picture of a dim-witted doctor who needs a smart nurse to help him do his job.
For public perceptions of physicians to change, doctors as a group need to focus on a public relations campaign. The American Medical Association (AMA), the largest physician organization in the country lacks a true public relations department that represents physicians. Does anyone represent our interests? We, as physicians, can make a comeback in the public eye. We need a public relations department.
A PR department needs to research why the public distrusts and has negative feelings toward physicians. Once the causes are known, physician organizations can work to correct the problem.
If, based on nursing organization rhetoric, the public believes physicians are uneducated or just as experienced as a nurse, then the public needs to be informed otherwise. The average nurse practitioner has 1.5-3 years of training in a Master’s’ program, or about 500-1000 clinical hours, after college. A family medicine physician, on the other hand, will work 6,000 clinical hours in medical school, which lasts four years, followed by a 3-year residency, averaging an additional 9,000-10,000 clinical hours. Those numbers would be even higher for specialists.
Perhaps, the public has a negative view of physicians because they lack in a specific area of knowledge. Maybe people do not like most doctors’ “bedside manner” or speaking styles. Whatever the issue, we need to know about it and address it.
In addition, as nursing organizations have used rhetoric to improve their public perception, physician organizations can do the same. Positive stories of a physician saving lives can change the view from impatient surgeon to caring and skilled patient advocate. A social media image of an obstetrician crying with her patient after a fetal loss could go a long way. Where are the memes, Facebook posts and tweets praising doctors?
Medicine has gone from a paternalistic field in which complete decision-making power was placed in the hands of the doctor to the “customer is always right” model that is happening now. A middle ground is needed. Once this occurs, physicians will not only be more satisfied in their careers, but patients will be more satisfied with their care. Physician organizations need to fight back
GOP Medicaid Cuts Hit Rural America Hardest, Report Finds
by Phil Galewitz - Kaiser Health News - June 15, 2017
Rural America carried President Donald Trump to his election night upset last November.
Trump Country it may be, but rural counties and small towns also make up Medicaid Country — those parts of the nation whose low-income children and families are most dependent on the federal-state health insurance program, according to a report released Wednesday.
Medicaid’s enrollment has swollen to more than 72 million in recent years, and the ranks of uninsured Americans has fallen to 9 percent in 2015 from 13 percent in 2013. That’s largely due to the Affordable Care Act, which allowed states to expand Medicaid eligibility with federal funds. Thirty-one states plus the District of Columbia did so.
Those gains may be in jeopardy under a GOP- and White House-backed health care measure called the American Health Care Act that would replace major parts of the ACA — known as Obamacare — and dramatically cut federal funding for Medicaid. The House passed the bill in May.
“There is no doubt that children and families in small towns would be disproportionately harmed by cuts to Medicaid,” said Joan Alker, executive director of the Georgetown University Center for Children and Families.
According to the center’s new report, Medicaid covered 45 percent of children and 16 percent of adults in small towns and rural areas in 2015. Those figures are lower in metropolitan areas — 38 percent of children and 15 percent of adults.
Rural areas have larger Medicaid populations because more people with disabilities live there, household incomes tend to be lower, unemployment rates higher and jobs with employer-paid insurance less common, the Georgetown report said.
In states that expanded Medicaid under Obamacare, the rate of uninsured people in small towns and rural areas fell by 11 percentage points between 2008-09 and 2014-15 — from 22 percent to 11 percent, the report said. That was slightly larger than the decrease in metro areas of expansion states.
If the House-passed bill became law, Medicaid would be cut by more than $800 billion over 10 years. Alker said that would lead to higher uninsured rates and reduce Americans’ access to health care.
The Republican-controlled Senate is expected to circulate a preliminary proposal of their repeal-and-replace legislation to members as early as this week. Compared with House members, senators are typically more sensitive to issues facing rural Americans because they represent entire states rather than districts often dominated by urban areas.
With the Senate edging closer to creating its own bill, disability and health advocates and Medicaid enrollees on Tuesday held “Don’t Cap My Care” rallies in nine cities imploring Congress to reject efforts to cut Medicaid funding.
About 400 people gathered outside the U.S. Capitol in Washington, D.C. — blind, disabled, elderly people among them — with many holding signs reading “Don’t Mess With Medicaid” and “No Cuts, No Caps to Medicaid.”
Ten million people with disabilities rely on Medicaid to help them live, work, attend school and participate in their communities.
Cindy Jennings, 53, of Lititz, Pa., who attended the Washington rally, said she fears the loss of Medicaid coverage under the Republican plan or reduced coverage for her son, Matthew. He is disabled and unable to speak because he was born with a chromosome abnormality.
“It’s frustrating and scary,” she said. “I need to stay healthy to care for him.”
Erickia Bartee, 31, of Owings Mills, Md., said Medicaid enables her to live in a group home and get drugs and other health services to live with cerebral palsy. “I will struggle to survive if my Medicaid benefits are cut,” she said.
Other findings from the report:
- Thirteen states have at least 20 percent of adults in rural areas enrolled in Medicaid. Arizona leads the nation with 34 percent in the program.
- Rural Oregon saw the biggest gain in adults with insurance over the study’s period. Its uninsurance rate dropped 19 percentage points, while adults in the state covered by Medicaid increased 17 percentage points.
- In 14 states, more than half of children in rural areas are covered by Medicaid. Of those, Arkansas and Mississippi were the only states with 60 percent or more of children in rural areas on Medicaid.
The report defined America’s rural areas and small towns as non-metropolitan counties, whose main urban areas have no more than 50,000 people.
Universal Health Care Can Heal Our Divided Democracy
by Cathleen London, M.D. - The Hill - June 1, 2017
This Memorial Day weekend I have time to ruminate about those who have given their lives for the American dream.
What is that dream? Have we lost sight of it?
Are we now a county comprised of an upper class — an aristocracy — and a lower class in poverty. A country where All the middle class seems to be forgotten.
Our infrastructure is crumbling, and the administration wants to sell it to the highest bidder.
Shall we have our bridges, tunnels and highways owned by other countries? And what of caring for society’s sick? Are we to outsource that too?
It seems not.
Instead we are trending towards dividing our sick between deserving and undeserving poor. How tragic. How cold hearted. In fact, how disgusting. When I hear politicians declare that diabetes is the fault of the person who has it, due to their lifestyle, I think of my great uncles — skinny, active men with diabetes.
It is in my genes. I run marathons. My diet is healthy.
If I develop diabetes will they consider it my fault?
How dare they.
I think of my patients who live in food deserts. We live in a poor rural county with virtually no public transportation and horrible walking conditions. Yet they would blame my patients.
Patients who have shown up to their visits with “providers” who changed nothing despite out of control diabetes because any further medication cost more.
The more I encounter this after 22 years as a physician the more I am convinced in universal healthcare.
I am tired of being embarrassed that the United States ranks so low in every measure. I am tired of trying to explain to my patients why I cannot order the medication; why I cannot order a test I deem appropriate for them through my training as a physician because I am overruled by the intricate insurance companies.
I am tired of medical treatment being a political football.
It is time for the United States to join the rest of the developed world with universal healthcare for all citizens. Stop the piecemeal of government spending on Medicare, Medicaid, Tricare, Veterans Association and Federal Employee Benefits (including Congress) and create a single payer system providing coverage for everyone.
Keep our hospitals open. Simplify billing. Simplify all the rules — have one set instead of the multitude of complexities with intricacies needing a doctorate in economics to understand.
We are the United States.
How better to prove that than to come together on this issue and declare healthcare a human right? How better to unify our divided nation than to care for the population? How better to heal our divide than to provide preventive services?
On this Memorial Day let us remember why lives were lost, and remember to put patients over politics.
Time for a Doctors’ March on Washington
by Danielle Ofri, M.D. - June 16, 2017
Recently, a patient with end-stage kidney disease told me that his insurance company stopped covering one of his essential medications. It took me hours of phone calls to reinstate this lifesaving treatment. Another patient — frail and elderly — was on the verge of having to move to a nursing home. An intensive blitz to coordinate visiting nurse services, physical therapy, Meals on Wheels and home hospice allowed her to stay in her home.
Advocating for patients is as much a part of medical care as the medical care itself. Diagnosing the problem and prescribing the treatment helps only if the patient can actually get the care. So doctors and nurses spend much of their time fighting on patients’ behalf with hospitals, specialists and insurance companies.
Should that advocacy extend beyond the doctor’s office, when politics has palpable effects on patients’ health? If my patient with kidney disease loses his health insurance, it would be just as life-threatening as the loss of his medications. As his doctor, am I equally obliged to advocate politically to ensure that health insurance remains available?
Right now, the Senate is considering health care legislation that threatens the coverage of millions of Americans. The American Health Care Act, which the House passed in May, would slash Medicaid, raise rates, increase deductibles, cut subsidies and weaken patient protections. Losing insurance — or being priced out of the market — is tantamount to losing health care. For patients with cancer, heart disease or diabetes, disruptions in medical care are as grave a threat to health as blood clots, metastases and sepsis.
Most doctors see an intrinsic distinction between calling an insurance company and calling a senator. The former is part and parcel of patient care, while the latter feels like acting on one’s personal interests or opinions.
But in terms of our patients’ health, there is a moral argument that they are equivalent. In our day-to-day lives, doctors and nurses put our patients’ needs first. We must do the same when our government proposes health care legislation.
Medicine is often practiced in what feels like a cocoon. There’s good reason for this — illness involves exquisite vulnerability, and patients discuss things they do not reveal elsewhere. When doctors and nurses close the exam room door, we are trying to block out the outside world metaphorically as well as physically.
Lately, however, the outside world has been muscling its way in. My patients frequently bring up politics — both those who support President Trump and those who think he is bulldozing our country to the ground. I try to stay out of it because these discussions could swamp what little time we have and because politics should never get in the way of the doctor-patient relationship.
There was a big hoo-ha late last year about a study with the erroneous title “Democratic and Republican Physicians Provide Different Care on Politicized Health Issues.” The study, in fact, demonstrated nothing about the medical care provided to patients. Rather, it surveyed doctors’ responses to hypothetical cases and then correlated that to their voter registration.
It found, for example, that Republican doctors were more likely than Democrats to say they would warn patients about mental health issues connected to abortion, while Democrats were more likely to say they would warn patients about the danger of storing firearms. While this study does remind us to be on the lookout for biases, it should not be taken as a call to minimize political advocacy on the part of medical caregivers.
Regardless of our own political affiliation, doctors need to examine how legislation affects our patients’ health. Texas, for example, now has the highest maternal death rate in the country, and perhaps in the developed world. If this were the result of a new virus or a side effect of a medication, the medical profession would be sounding the alarm. That the death rate is probably in part because legislation intended to restrict abortion has resulted in the closing of women’s health centers doesn’t make it any less of a medical emergency.
It’s heartening to see that medical groups are voicing their opposition to the American Health Care Act. But what about individual caregivers? Members of Congress need to hear from us, en masse, in our professional capacity. Just as we do not stand silent when insurance companies deny necessary medications, we cannot stand silent while our legislators’ actions threaten medical access. It might be time for the Medical March on Washington.
The mission statement for nearly every health care organization contains some variation on commitment to patient care. In the United States there are just under a million practicing doctors and more than four million nurses. An additional seven million or more are employed in the health care system. That’s a lot of voices that could be advocating for patients.
Daughters Will Suffer From Medicaid Cuts
The Editorial Board - NYT - June 15, 2016
Nearly one in five adult children at some point provide care for at least one elderly parent, according to a new study by the Center for Retirement Research at Boston College. The burden is particularly demanding for daughters, who spend as much time on such care as spouses of older adults, and as much time as sons, in-laws, grandchildren and other relatives combined.
House Republicans’ proposal to slash federal spending on Medicaid by some 25 percent over 10 years, shifting costs to states that could not afford them, would be devastating, because nursing homes, home care and community-based programs for the elderly account for almost two-thirds of Medicaid spending. One of the few ways that adult children can get help with caregiving duties is Medicaid’s support for seniors, which many middle-class people qualify for after spending most of their income and assets on long-term care. Cutting Medicaid could make it more difficult to qualify, so more adult children would have to care for their parents.
The stresses, which are already significant, would become extreme. The researchers at Boston College found that these caregivers spend an average of 77 hours per month with their parents, the equivalent of about two weeks of full-time work. That time is money. Calculations based on the American Time Use Survey indicate that caregivers effectively forfeited $522 billion in 2012 due to such duties; that is more than double the total cost of formal care, at $211 billion. Women caregivers were more likely than men to retire because of these demands, and those who kept working reduced their workweeks by three to 10 hours on average. Beyond this sacrifice, caregivers spend 35 percent of their own budget on parental care, surveysindicate.
Caregiving also takes a toll on physical and mental health. Women who care for parents report more pain, and significantly higher out-of-pocket costs for their own health care. Both women and men say they are more depressed and had poorer health because of parental care.
Even if Medicaid spending were not cut, demand for long-term care would rise as baby boomers age, leading to increased reliance on adult children and formal caregiving arrangements. That unfolding dynamic is not a concern for the distant future. The youngest baby boomers are now 52, the oldest are 71. More than half of 85-years-olds need help with one or more basic self-care tasks, including getting out of bed, walking across a room, going to the bathroom, bathing, dressing, eating, taking medicine, using a phone, shopping and cooking.
In the face of deep Medicaid cuts, a system of caregiving that is already clearly strained would implode.
If health, prosperity and dignity were driving policy making, lawmakers would be looking for ways to increase Medicaid coverage, not destroy it.
How Did Health Care Get to Be Such a Mess?
by Christie Ford Chapin - NYT - June 19, 2017
The problem with American health care is not the care. It’s the insurance.
Both parties have stumbled to enact comprehensive health care reform because they insist on patching up a rickety, malfunctioning model. The insurance company model drives up prices and fragments care. Rather than rejecting this jerry-built structure, the Democrats’ Obamacare legislation simply added a cracked support beam or two. The Republican bill will knock those out to focus on spackling other dilapidated parts of the system.
An alternative structure can be found in the early decades of the 20th century, when the medical marketplace offered a variety of models. Unions, businesses, consumer cooperatives and ethnic and African-American mutual aid societies had diverse ways of organizing and paying for medical care.
Physicians established a particularly elegant model: the prepaid doctor group. Unlike today’s physician practices, these groups usually staffed a variety of specialists, including general practitioners, surgeons and obstetricians. Patients received integrated care in one location, with group physicians from across specialties meeting regularly to review treatment options for their chronically ill or hard-to-treat patients.
Individuals and families paid a monthly fee, not to an insurance company but directly to the physician group. This system held down costs. Physicians typically earned a base salary plus a percentage of the group’s quarterly profits, so they lacked incentive to either ration care, which would lose them paying patients, or provide unnecessary care.
This contrasts with current examples of such financing arrangements. Where physicians earn a preset salary — for example, in Kaiser Permanente plans or in the British National Health Service — patients frequently complain about rationed or delayed care. When physicians are paid on a fee-for-service basis, for every service or procedure they provide — as they are under the insurance company model — then care is oversupplied. In these systems, costs escalate quickly.
Unfortunately, the leaders of the American Medical Association saw early health care models — union welfare funds, prepaid physician groups — as a threat. A.M.A. members sat on state licensing boards, so they could revoke the licenses of physicians who joined these “alternative” plans. A.M.A. officials likewise saw to it that recalcitrant physicians had their hospital admitting privileges rescinded.
The A.M.A. was also busy working to prevent government intervention in the medical field. Persistent federal efforts to reform health care began during the 1930s. After World War II, President Harry Truman proposed a universal health care system, and archival evidence suggests that policy makers hoped to build the program around prepaid physician groups.
A.M.A. officials decided that the best way to keep the government out of their industry was to design a private sector model: the insurance company model.
In this system, insurance companies would pay physicians using fee-for-service compensation. Insurers would pay for services even though they lacked the ability to control their supply. Moreover, the A.M.A. forbade insurers from supervising physician work and from financing multispecialty practices, which they feared might develop into medical corporations.
With the insurance company model, the A.M.A. could fight off Truman’s plan for universal care and, over the next decade, oppose more moderate reforms offered during the Eisenhower years.
Through each legislative battle, physicians and their new allies, insurers, argued that federal health care funding was unnecessary because they were expanding insurance coverage. Indeed, because of the perceived threat of reform, insurers weathered rapidly rising medical costs and unfavorable financial conditions to expand coverage from about a quarter of the population in 1945 to about 80 percent in 1965.
But private interests failed to cover a sufficient number of the elderly. Consequently, Congress stepped in to create Medicare in 1965. The private health care sector had far more capacity to manage a large, complex program than did the government, so Medicare was designed around the insurance company model. Insurers, moreover, were tasked with helping administer the program, acting as intermediaries between the government and service providers.
With Medicare, the demand for health services increased and medical costs became a national crisis. To constrain rising prices, insurers gradually introduced cost containment procedures and incrementally claimed supervisory authority over doctors. Soon they were reviewing their medical work, standardizing treatment blueprints tied to reimbursements and shaping the practice of medicine.
It’s easy to see the challenge of real reform: To actually bring down costs, legislators must roll back regulations to allow market innovation outside the insurance company model.
In some places, doctors are already trying their hand at practices similar to prepaid physician groups, as in concierge medicine experiments like the Atlas MD plan, a physician cooperative in Wichita, Kan. These plans must be able to skirt state insurance regulations and other laws, such as those prohibiting physicians from owning their own diagnostic facilities.
Both Democrats and Republicans could learn from this lost history of health care innovation.
Letter to the editor: Job choice should not have to be based on health insurance
Letter to the Editor - Portland Press Herald - June 19, 2017
I’m writing in support of affordable health care, not just for my family, but for everyone in the state of Maine, because health care coverage should not be a privilege for a small percentage of the population in America.
I’ve worked for large and small companies in Maine, and prefer the entrepreneurial environment of a smaller, privately owned workplace. I shouldn’t have to choose where I work based on the need for affordable insurance.
When I worked for larger, high-stress corporations in the past, I had more illness than I have now. I’m fulfilled and productive working for a small business, yet rather than staying with a job that better fits my work style, I may be faced with the need to move to a job that provides my family with affordable coverage if the Affordable Care Act is repealed.
The ACA has provided the opportunity for people to do work that better fit their skills. I would think the economy benefits when its workers are doing what they love in a workplace that supports innovation and creativity the way small-business environments do.
For a period of time, I was not working, without insurance for my family which was frightening at best. The emotional and financial stress of not having coverage, and paying monthly premiums equivalent to the cost of a mortgage is enough to cause serious illness.
Everyone says the cost of health care in America is the highest in the world, and we have worse medical outcomes than in any developed country. Could it be in part because we are the only developed country where people have to worry about what will happen financially if they end up in the hospital, or where people are in a constant state of anxiety over not getting good health care? I believe so.
Kim Filippone
Falmouth
Senate Democrats Try to Gum Up Works Over Affordable Care Act Repeal
by Thomas Kaplan and Robert Pear - NYT - June 19, 2017
WASHINGTON — Democrats vowed on Monday to slow work in the Senate to a crawl to protest the secrecy surrounding the Republican effort to repeal and replace the Affordable Care Act, as Republican leaders raced to prepare a bill for a vote as soon as next week.
Without the votes to stop the majority party from passing a bill, Democrats can only draw attention to the way Republicans are creating their bill — behind closed doors without a single hearing or public bill-drafting session.
Senate Republican leaders hope for a showdown vote before lawmakers leave town at the end of next week, an ambitious timeline that would spare Republicans from constituent pressure over the Fourth of July recess.
Democrats fear that Republicans will unveil a bill that would have sweeping effects on health care, then within days try to pass it with only limited debate.
“Every Republican is trying to get to yes,” Senator John Barrasso of Wyoming, a member of the Senate Republican leadership, said Monday on Fox News, expressing his belief that the Senate would vote on a repeal bill before the recess. He acknowledged that “there are some differences of opinion on specific details of this.”
If Republicans do not hold a vote before the Fourth of July, Democrats hope the pressure over the recess will weaken support. Then lawmakers would have just three weeks to pass a Senate bill and work out differences with the House before the planned August recess. The Trump administration also wants Congress to raise the government’s statutory borrowing limit before August, another fight that could collide with the Affordable Care Act repeal.
“If Republicans won’t relent and debate their health care bill in the open for the American people to see, then they shouldn’t expect business as usual in the Senate,” said Chuck Schumer of New York, the Senate Democratic leader.
He said the actions planned by Senate Democrats, such as procedural maneuvers to slow down routine work, were “merely the first steps we’re prepared to take in order to shine a light on this shameful Trumpcare bill.”
Republicans are working on their bill as insurers around the country are announcing their intentions for 2018. On Monday, the last major insurer remaining in Iowa said it planned to stay in the Affordable Care Act’s marketplace next year. The insurer, Medica, said that it expected to offer plans statewide, even after two competitors said they would pull out, but that it was seeking rate increases averaging 43.5 percent.
“Iowa’s individual market remains unsustainable and needs a fix from Congress,” said the state’s insurance commissioner, Doug Ommen.
Republicans, who hold 52 seats in the Senate, are planning to pass their repeal bill using special budget rules that would bypass a Democratic filibuster. But they can afford to lose only two votes, with Vice President Mike Pence breaking a tie, and more than two Republican senators have expressed qualms, from moderates like Susan Collins of Maine and Lisa Murkowski of Alaska to conservatives like Rand Paul of Kentucky and Mike Lee of Utah.
So far, Republican senators have been unable to reach a consensus on a repeal bill, facing internal divisions over issues like the future of the expansion of Medicaidunder the Affordable Care Act, the rate at which Medicaid payments to states would grow in future years and federal funding for Planned Parenthood.
In impassioned speeches on the Senate floor on Monday night, Democrats complained that the bill was being developed out of public view. Before Congress adopted the Affordable Care Act, Democrats held numerous public hearings, and the Senate debated the measure on the floor for 25 days.
Senate Republican leaders plan to push through their repeal bill under arcane budget rules that would limit debate on it to 20 hours.
On the Senate floor on Monday, Mr. Schumer asked the Senate majority leader, Mitch McConnell of Kentucky, if senators would have more than 10 hours to review the Senate bill before voting on it. Mr. McConnell said only that there would be “ample opportunity to read and amend the bill.”
The opaque process playing out now has drawn criticism not only from Democrats, but also from some Republican senators.
“I think it’s much better to have committee consideration of bills, public hearings and to have a full debate,” Ms. Collins told The Portland Press Herald on Friday. “That’s the process for most well-considered legislation.”
Democrats, meanwhile, have been pressing the issue, pushed by liberal advocacy groups that are demanding a more confrontational approach.
Last week, Mr. Schumer sent a letter to Mr. McConnell inviting Republicans to an all-senators meeting on health care. Mr. McConnell did not take him up on the offer.
On Monday, in a jab at Republicans for proceeding without any public hearings on their bill, Senate Democrats released a letter to Republican committee leaders in which they helpfully provided a list of rooms in the Capitol complex that could be used to hold hearings.
A coalition of groups representing patients said they had been rebuffed when they requested a meeting in Washington with Mr. McConnell.
Sue Nelson, a vice president of the American Heart Association, said on Monday that her organization had requested the meeting on behalf of more than a dozen patient advocacy groups. They were told that the majority leader was too busy, she said.
Don Stewart, a spokesman for Mr. McConnell, said the senator and his staff had met with numerous groups representing patients, doctors and hospitals, especially those in Kentucky, and would continue to do so. “The notion that we are not meeting with patient groups is ridiculous,” he said.
Senate leaders have refrained from going into detail about the bill they are drafting, but some provisions being considered have become known in recent days.
The Senate bill would give states sweeping new authority to opt out of federal insurance standards established by the Affordable Care Act, congressional aides said. In that way, it appears to go further than the House-passed bill in giving states latitude to regulate their health insurance markets.
It builds on a section of the Affordable Care Act that allows states to obtain waivers for innovative health programs. But it would relax many of the requirements for such waivers that Democrats wrote into the law, signed by President Barack Obama in 2010.
Republican senators are still discussing exactly which standards could be waived. Many Republicans want to allow states to prescribe a more limited, less expensive package of health benefits than is required under the Affordable Care Act. Republicans disagree on whether states should be able to allow insurers to set higher premiums for some people with pre-existing conditions.
A Democrat, Senator Ron Wyden of Oregon, proposed “innovation waivers” in 2007, to allow states to find their own ways to near-universal coverage.
“The point was to say that the states, the laboratories of democracy, would have an opportunity to show that they could do better than the Affordable Care Act,” Mr. Wyden said. Republicans, he said, want “to use the waiver process so that states could do not better, but worse.”
GOP senator warns against rushed vote on health care bill
by Hope Yen - The Associated Press - June 19, 2017
WASHINGTON (AP) — A Republican senator on Sunday warned against rushing a vote on a GOP bill to repeal and replace the nation’s health care law, saying both parties deserve a chance to fully debate the bill and propose changes after it was drafted in secret.
“The Senate is not a place where you can just cook up something behind closed doors and rush it for a vote,” said Sen. Marco Rubio, R-Fla. “So the first step in this may be crafted among a small group of people, but then everyone’s going to get to weigh in.”
His comments come as Senate Republicans are working hard to finalize legislation to replace the Affordable Care Act, also known as Obamacare, without a formal, open drafting session. Senate Majority Leader Mitch McConnell, R-Ky., has said he hopes to bring a bill to the floor for a vote within the next two weeks.
But Rubio said he believes the process could take longer and urged the Senate to slow down. These are striking comments from a Republican senator whose party is seeking to push through legislation without the help of Democrats.
President Donald Trump has been eager for quick action, although in a closed-door luncheon with 15 GOP senators last week, he described a House-passed bill as “mean.” Trump said he wanted the Senate version to be “more generous,” according to congressional sources.
“It is going to take days and weeks to work through that in the Senate,” Rubio said on CBS’ “Face the Nation.”
The bill passed by House Republicans last month would phase out in 2020 a Medicaid expansion to additional low-income people. The Congressional Budget Office has estimated the House bill would cause 23 million people to lose insurance over a decade and leave many sicker and older consumers with much higher costs.
Hoping to doom the GOP effort, a consumer health group said Sunday it was launching a $1.5 million campaign aimed at pressuring five Republican senators in the closely divided chamber to vote against the bill. It was among several groups that in recent weeks have announced stepped-up efforts to oppose the bill.
Community Catalyst Action Fund said it will run television and radio ads beginning Monday. They are targeting Sens. Lisa Murkowski of Alaska; Jeff Flake of Arizona; Susan Collins of Maine; Dean Heller of Nevada; and Shelley Moore Capito of West Virginia.
“The Senate is working in secret and rushing to pass a bill,” said Robert Restuccia, executive director of the group. “We think it’s critical that Americans across the country understand what’s at stake for them and their families if the U.S. Senate passes this bill.”
Several of the senators being targeted have expressed some concern about the evolving Senate legislation or its process. All of them except Collins also represent states which expanded Medicaid under Obamacare.
Republicans hold a narrow 52-48 majority in the Senate, meaning the party can only afford to have two senators oppose the repeal and replace bill for it to pass with Vice President Mike Pence casting the tie-breaking vote. No Democrat is expected to support the repeal effort.
The ads seek to cast the GOP effort as having a negative impact on families and older Americans. The TV ad features a mother with a child with asthma who faces difficult choices between filling prescriptions or paying their mortgage due to rising premiums.
GOP senators have been divided over pivotal questions about dismantling and replacing chunks of former President Barack Obama’s health care overhaul. These include disagreements over phasing out the Medicaid expansion, easing some of the law’s coverage requirements and reshaping subsidies the statute provides to millions of individuals buying policies.
The ads will run over the next two weeks.
Republican health bill: Democrats pledge Senate standstill over secrecy
by Lauen Gambino - The Guardian - June 19. 2017
Democrats have vowed to bring Senate business to a halt this week, in protest against secrecy around a Republican attempt to repeal Barack Obama’s Affordable Care Act (ACA) that will affect access to coverage for millions of Americans.
Beginning on Monday night, Democrats will begin an effort to delay a vote on the Senate health bill by forcing the House-passed healthcare bill into committee, a senior Democratic aide said. Tactics will include procedural maneuvers that will disrupt routine order and late-night floor speeches demanding greater transparency.
Senior party figures, who were reported to be planning to focus on Donald Trump’s reported description of the House bill as “mean”, also launched a campaign urging Americans to speak out against the healthcare plan and share their stories about how the ACA, known as Obamacare, has helped them. In a video, several female senators shared their constituents’ stories.
The White House press secretary, Sean Spicer, said he did not know whether legislative staff had been briefed on the Senate healthcare bill. He added that he was unaware of the president’s view on the lack of transparency around the Republican healthcare bill. He declined to comment on whether the president believed the House-passed bill was “mean” and said the administration felt “very good” about the progress the Senate is making on the bill.
Also on Monday, Bernie Sanders of Vermont and Elizabeth Warren of Massachusetts rallied supporters against the Republican plan in a Facebook Live event.
“Republicans are drafting this bill in secret because they’re ashamed of it, plain and simple,” said Chuck Schumer, the Senate minority leader, in a statement.
“These are merely the first steps we’re prepared to take in order to shine a light on this shameful Trumpcare bill and reveal to the public the GOP’s true intentions: to give the uber-wealthy a tax break while making middle class Americans pay more for less health care coverage.
“If Republicans won’t relent and debate their healthcare bill in the open for the American people to see, then they shouldn’t expect business as usual in the Senate.”
It’s unclear how long Democrats will continue their protest, but the aide said the senators are unlikely to relent as long as Republicans continue to shield their bill from the public.
Mitch McConnell, the Senate majority leader, has said he would like to hold a vote before the chamber leaves for a week-long recess over the Fourth of July holiday. That leaves just 10 business days to draft a final version of the bill, receive a “score” from the Congressional Budget Office and hold a vote. The Senate is not expected to hold any hearings.
In a floor speech on Monday, McConnell outlined why Republicans are working to “move in a different direction on healthcare” but did not offer any details on the substance of their plan.
“The Obamacare status quo is simply unsustainable,” McConnell said. “The American people deserve relief and we’ll keep working to provide it.”
An all-male group of Senate Republicans has worked privately for months to craft its version of the House healthcare bill, which narrowly passed to the upper chamber in May, under increasing pressure from Trump. Sticking points for Republicans are centered around proposed cuts to Medicaid, taxes related to the ACA, and funding for Planned Parenthood.
The same lawmakers are facing growing criticism from both sides of the aisle for not releasing more details about the healthcare plan and refusing to hold public hearings. The Senate has said it will not vote without a CBO score. A CBO analysis of the House healthcare bill estimated that it would cause 23m Americans to lose health insurance over the next decade and said some of the country’s sickest people could face significantly higher premiums and out-of-pocket costs.
The Democratic effort to slow the agenda will begin on Monday afternoon, when the Senate reconvenes. The Democrats plan to object to all requests for unanimous consent and in turn offer their own requests for unanimous consent in an attempt to force the bill before a committee, where debate can take place in public, the senior aide said.
Democrats also intend to hold control of the Senate floor until late in the evening, delivering a series of speeches urging Republicans to make the health bill public.
McConnell has brushed off accusations that his party was crafting its bill in secret, a highly unusual move for legislation with such broad and sweeping implications.
“Nobody’s hiding the ball here,” the Kentucky Republican said last week.
He added: “There have been gazillions of hearings on this subject, when [Democrats] were in the majority, when we were in the majority. We understand this issue pretty well and we’re now working on coming up with a solution.”
On Monday, Schumer and three other Democrats on the Senate committee on health, education, labor and pensions sent a letter addressed to Republican leaders demanding that they “schedule hearings to discuss, debate and hear testimony about the healthcare bill that you are currently drafting in secret”.
The Democrats then listed all the hearing rooms in the Senate where Republicans could hold a debate on the bill.
On Monday morning, Trump again said the ACA was dead, and that rising premiums were unaffordable.
“The Dems want to stop tax cuts, good healthcare and Border Security,” the president tweeted. “Their ObamaCare is dead with 100% increases in [premiums].”
Experts have said uncertainty among insurers over how the Trump administration will handle healthcare repeal has contributed to rising premiums.
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