by Robert Pollin - LA Times - June 21, 2017
The California Senate recently voted to pass a bill that would establish a single-payer healthcare system for the entire state. The proposal, called the Healthy California Act, will now be taken up by the state Assembly.
The plan enjoys widespread support — a recent poll commissioned by the California Nurses Assn. found that 70% of all Californians are in favor of a single-payer plan — and with good reason. Under Healthy California, all residents would be entitled to decent healthcare without having to pay premiums, deductibles or copays.
But as critics of the bill have pointed out, a crucial question remains: Is Healthy California economically viable? According to research I conducted with three colleagues at the University of Massachusetts, Amherst, the answer is yes.
Enacting Healthy California would entail an overhaul of the state’s existing healthcare system, which now constitutes about 14% of California’s GDP. In particular, it would mean replacing the state’s private health insurance industry with government-managed insurance. Our study — which was also commissioned by the California Nurses Assn. — concludes not only that the proposal is financially sound, but that it will produce greater equity in the healthcare sector for families and businesses of all sizes.
California will spend about $370 billion on healthcare in 2017. Assuming the state’s existing system stayed intact, the cost of extending coverage to all California residents, including the nearly 15 million people who are currently uninsured or underinsured, would increase healthcare spending by about 10%, to roughly $400 billion.
That’s not the full story, though. Enacting a single-payer system would yield considerable savings overall by lowering administrative costs, controlling the prices of pharmaceuticals and fees for physicians and hospitals, reducing unnecessary treatments and expanding preventive care. We found that Healthy California could ultimately result in savings of about 18%, bringing healthcare spending to about $331 billion, or 8% less than the current $370 billion.
How would California cover this $331-billion bill? For the most part, much the same way it covers healthcare spending right now. Roughly 70% of the state’s current spending is paid for through public programs, including Medicare and MediCal. This funding — totaling about $225 billion — would continue, as is required by law. It would simply flow through Healthy California rather than existing programs.
The state would still need to raise about $106 billion a year to cover the cost of replacing private insurance. This could be done with two new taxes.
First, California could impose a gross receipts tax of 2.3% on businesses, but with an exemption for the first $2 million of revenue. Through such an exemption, about 80% of all businesses in California — small firms — would pay nothing in gross receipts tax, and medium-sized businesses would pay an effective tax rate of less than 1%.
Second, the state could institute a sales tax increase of 2.3%. The tax would not apply to housing, utilities, food purchased for the home or a range of services, and it could be offset for low-income families with a 2% income tax credit.
Relative to their current healthcare costs, most Californian families will end up spending less, even with these new taxes, and some will even enjoy large gains. Net healthcare spending for middle-income families would fall by between 2.6% and 9.1% of income. Most businesses would also see a drop in spending. Small firms that have been providing health insurance for their workers will see costs fall by 22% as a share of payroll. For medium-sized firms, costs will fall by an average of between 6.8% and 13.4% as a share of payroll. Even most large firms will see costs fall, by an average of between 0.6% and 5% of payroll.
At the moment, about 2.7 million of California’s residents, or about 8% of the population, have no health insurance. Another 12 million residents, or about 33% of the population, are underinsured. A large proportion of the remaining 60% of the population who are adequately insured still face high costs, as well as anxiety over President Trump’s proposal to repeal and replace Obamacare.
Healthy California is capable of generating substantial savings for families at most income levels and businesses of most sizes. These savings are in addition to the benefits that the residents of California will gain through universal access to healthcare.
Robert Pollin is a distinguished professor of economics at the University of Massachusetts, Amherst, and a coauthor of “Economic Analysis of the Healthy California Single-Payer Health Care Proposal.”
Insurers Battle Families Over Costly Drug for Fatal Disease
by Katie Thomas - NYT - July 22, 2017
Nolan and Jack Willis, twins from upstate New York, and just 10 other boys took part in a clinical trial that led to the approval last fall of the very first drug to treat their rare, deadly muscle disease.
Now the Willis boys are again test cases as a different type of medical question comes to the fore: whether insurers will cover the controversial drug, Exondys 51, which can cost more than $1 million a year even though it’s still unclear if it works.
The boys’ insurer, Excellus BlueCross BlueShield, refused to cover the cost of the drug because the twins, who are 15, can no longer walk. Their disease, Duchenne muscular dystrophy, overwhelmingly affects boys and causes muscles to deteriorate, killing many of them by the end of their 20s.
“I’m cycling between rage and just sadness,” their mother, Alison Willis Hoke, said recently, on the day she learned that an appeal for coverage had been denied. For now, the company that sells the drug, Sarepta Therapeutics, is covering the treatment’s costs, but Mrs. Hoke does not know how long that will last.
The desperation in Mrs. Hoke’s voice reflects a sobering reality for families of boys with the disease since their elation last fall over the drug’s approval. Because the Food and Drug Administration overruled its own experts — who weren’t convinced the Exondys 51 had shown sufficiently good results — and gave the drug conditional approval, many insurers are now declining to cover it or are imposing severe restrictions that render patients ineligible.
The story of Exondys 51 raises complex and emotionally charged questions about what happens when the F.D.A. approves an expensive drug based on a lower bar of proof. In practice, health insurers have taken over as gatekeeper in determining who will get the drug.
Disputes like the one over the Duchenne drug are likely to become more commonplace in the coming months. A federal law, passed last year, directs the agency to remove barriers to approving drugs and medical devices, and its new commissioner, Dr. Scott Gottlieb, has called on the F.D.A. to be more lenient, especially when it comes to rare pediatric diseases.
While insurers once covered drugs for rare diseases as a matter of course, that may be changing now that a wave of expensive drugs have reached the market. The pharmaceutical industry has been in hot pursuit of an increasingly enticing demographic target: An estimated 30 million people in the United States — about 10 percent of the population — are living with one of roughly 7,000 rare diseases.
The agency’s approval of Exondys 51, though, prompted a rebellion among some insurers, who are refusing to play along and saying they are concerned about the cumulative impact of such breathtakingly expensive drugs on health care costs. Anthem, one of the nation’s largest insurers, calls Exondys 51 “investigational”because the F.D.A. reserved the right to withdraw it from the market if future clinical trials fail to show it works.
Another insurer, Premera Blue Cross, went so far as to tie coverage to an invasive procedure — a muscle biopsy — but then rescinded the requirement.
“I’m reading a lot of denial letters,” said Christine McSherry, who until recently served as executive director of the Jett Foundation, an advocacy group that guides families through the insurance appeal process. Her insurer, Blue Cross Blue Shield of Massachusetts, is covering the drug for her son, Jett, through next April. “It’s very disheartening to have worked that hard, and to have sacrificed that much, and to now have to battle the insurance companies.”
The drug’s high cost is driving the resistance. While the drug manufacturer, Sarepta, has said Exondys 51 costs about $300,000 a year per child, the price, based on a child’s weight, can be much higher. For the dozen boys in the main clinical trial, the average list price would be more than double Sarepta’s quote — $750,000 each, according to an analysis by the drug benefit firm Prime Therapeutics.
“I think a lot of the advocates in this space maybe thought that getting a drug on the market was the goal of their advocacy,” said Dr. Aaron S. Kesselheim, an associate professor of medicine at Harvard University who voted against the drug’s approval as part of an F.D.A. advisory committee. “The goal of the advocacy should have been getting a product on the market, and making sure that it’s available at a reasonable cost.”
The agency’s acceptance of Exondys 51, also known as eteplirsen, followed a highly polished, passionate campaign by patient advocates. Dr. Robert Califf, the former F.D.A. commissioner, ignored the agency’s career experts who viewed the drug as little more than a “scientifically elegant placebo.”
The conditional green light granted to Exondys 51 is part of an accelerated pathway that allows the agency to clear much-needed drugs based on early, if inconclusive, evidence of efficacy.
Until then, there was no approved treatment for boys with Duchenne; Exondys 51 may be helping protect muscle cells from deterioration by producing a form of dystrophin, a protein largely lacking in those with the genetic mutation. The boys typically need wheelchairs by their teenage years, and their hearts and lungs eventually give out. Between 9,000 and 12,000 people are estimated to be living with Duchenne in the United States; about 13 percent have the genetic mutation receptive to the new drug.
Skeptics argued that the small clinical trials did not demonstrate meaningful improvement, showing just a minuscule increase in dystrophin. But others, including parents of boys on the drug, insist that it is working — or at the very least, that it can’t hurt to try.
“It makes me feel like I have a chance to live longer than I thought I would,” said Patrick Denger, 22, who has been receiving weekly infusions since December. His costs were covered until his father got a new job and the family switched to Aetna, which has said it won’t pay because he is too old and cannot walk.
Mr. Denger’s treatment was being paid for by Sarepta while he appealed. On Wednesday, he learned that Maine Care, the state Medicaid program, would cover his treatment.
He believes his condition has stabilized, affording him the luxury of contemplating a future. Mr. Denger, who uses a wheelchair, drives his own van and works part time at a supermarket doing administrative work. He recently graduated from the University of New England, near his home in Biddeford, Me.
In addition to Anthem, Express Scripts, which manages the drug benefits for insurers and large employers, excluded the medication from its national coverage list. Other insurers, including UnitedHealth, Aetna and Humana, will cover it only under limited circumstances — if the boy is under 14, for example, or can walk a certain distance. After six months, in many cases, the insurers require evidence that the drug appears to be working.
Insurers are also restricting coverage of a similarly expensive drug, Spinraza, which treats another rare disease, spinal muscular atrophy. The F.D.A. granted broad approval to that drug in December, but many insurers are covering only babies and young children with the most severe forms of the disease, where the clinical evidence of efficacy is strongest.
Jim Redmond, a spokesman for Excellus, said the company did not comment on individual cases and said its policy on Exondys 51 — which requires that the patient be able to walk — was determined by pharmacists and physicians who examined the evidence.
Mrs. Hoke, who is a pharmacist near her home in Fayetteville, near Syracuse, noted that many new cancer drugs offer little long-term hope but are still covered. “It extends their life for three months, and that’s covered,” she said. “My kids can live for years with this drug.”
Whether Exondys 51 can indeed give boys more years to grow up remains an unknown. Sarepta has a lot riding on the drug. It is the biotech’s only approved product, and the company must prove to investors that sales will be enough to finance a pipeline of drugs that could treat a wider range of boys with Duchenne.
Perhaps that’s why Sarepta’s executives have claimed in statements that the average price for Exondys 51 is $300,000 per patient per year.
“That’s not accurate,” said David Lassen, the chief clinical officer at Prime Therapeutics, which manages the drug plans for more than 20 million Americans. “Based on just the few claims that we’ve evaluated, we think that’s low.” He cited a range from $750,000 to $1.5 million a year, far greater than breakthrough drugs like, for instance, cystic fibrosis treatments sold by Vertex that cost more than $250,000 a year.
Sarepta contends that the $300,000 estimate is a net price, accounting for discounts to insurers and the fact that not everyone will follow the weekly regimen. It also includes the assumption that younger boys who weigh less will begin taking the drug.
“What we have seen is that for some of the older, sicker boys who have been using it, the price is more,” said Dr. Ed Kaye, the chief executive of Sarepta.
Many Duchenne parents worry that insurers will balk if other costly drugs are approved to complement the treatment from Exondys 51. Already, they are reeling from the decision by PTC Therapeutics to price a once-cheap steroid, deflazacort, at about $35,000 per year. Many families had been importing it for about $1,600 a year.
In the end, they say, they have no choice.
“We need something to stop as much progression as possible, until something better can come along,” said Michelle Lessner-Gonzales, whose 14-year-old son, Nicolas Gonzales, is waiting for the Illinois Medicaid program to decide how it will cover Exondys 51. In the meantime, her son is losing his ability to walk, a common prerequisite for coverage.
Several insurance companies noted the lack of clinical evidence that the drug works, especially in older boys or those who cannot walk. Anthem, which has said the clinical benefit from Exondys 51 “has not been demonstrated,” said that it relied on outside experts to reach its decision, and that it “eagerly awaited” the results of future studies.
Craig Burns, vice president for research at America’s Health Insurance Plans, a trade group for insurers, said his members were in a difficult spot. “There’s more about this drug that we don’t know than we do know,” he said. “And that’s where payers are really struggling.”
Dr. Kaye, who announced he would resign from Sarepta later this year, said he had spent the past several months traveling the country, making his case to insurance executives. Like other companies marketing rare-disease drugs, Sarepta hired a team of employees who assist patients in getting covered, and the company will pay the out-of-pocket costs of those who can’t afford it.
“I think the insurance companies do worry; they are worried about their bottom line, and trying to make sure they are very thoughtful about the money they spend,” Dr. Kaye said. But when faced with individual stories, “it’s hard to say ‘No, you can’t do it,’ because there are no alternatives.”
Brian Denger, Patrick’s father, said he had hoped for more when Exondys 51 arrived as a treatment. He lost another son, Matthew, to Duchenne in 2013, at age 20.
“I just believed that it was going to be more celebratory,” he said. “And we’re back to the point where it seems like we’re fighting again.”
Nolan and Jack Willis, twins from upstate New York, and just 10 other boys took part in a clinical trial that led to the approval last fall of the very first drug to treat their rare, deadly muscle disease.
Now the Willis boys are again test cases as a different type of medical question comes to the fore: whether insurers will cover the controversial drug, Exondys 51, which can cost more than $1 million a year even though it’s still unclear if it works.
The boys’ insurer, Excellus BlueCross BlueShield, refused to cover the cost of the drug because the twins, who are 15, can no longer walk. Their disease, Duchenne muscular dystrophy, overwhelmingly affects boys and causes muscles to deteriorate, killing many of them by the end of their 20s.
“I’m cycling between rage and just sadness,” their mother, Alison Willis Hoke, said recently, on the day she learned that an appeal for coverage had been denied. For now, the company that sells the drug, Sarepta Therapeutics, is covering the treatment’s costs, but Mrs. Hoke does not know how long that will last.
The desperation in Mrs. Hoke’s voice reflects a sobering reality for families of boys with the disease since their elation last fall over the drug’s approval. Because the Food and Drug Administration overruled its own experts — who weren’t convinced the Exondys 51 had shown sufficiently good results — and gave the drug conditional approval, many insurers are now declining to cover it or are imposing severe restrictions that render patients ineligible.
The story of Exondys 51 raises complex and emotionally charged questions about what happens when the F.D.A. approves an expensive drug based on a lower bar of proof. In practice, health insurers have taken over as gatekeeper in determining who will get the drug.
Disputes like the one over the Duchenne drug are likely to become more commonplace in the coming months. A federal law, passed last year, directs the agency to remove barriers to approving drugs and medical devices, and its new commissioner, Dr. Scott Gottlieb, has called on the F.D.A. to be more lenient, especially when it comes to rare pediatric diseases.
While insurers once covered drugs for rare diseases as a matter of course, that may be changing now that a wave of expensive drugs have reached the market. The pharmaceutical industry has been in hot pursuit of an increasingly enticing demographic target: An estimated 30 million people in the United States — about 10 percent of the population — are living with one of roughly 7,000 rare diseases.
The agency’s approval of Exondys 51, though, prompted a rebellion among some insurers, who are refusing to play along and saying they are concerned about the cumulative impact of such breathtakingly expensive drugs on health care costs. Anthem, one of the nation’s largest insurers, calls Exondys 51 “investigational”because the F.D.A. reserved the right to withdraw it from the market if future clinical trials fail to show it works.
Another insurer, Premera Blue Cross, went so far as to tie coverage to an invasive procedure — a muscle biopsy — but then rescinded the requirement.
“I’m reading a lot of denial letters,” said Christine McSherry, who until recently served as executive director of the Jett Foundation, an advocacy group that guides families through the insurance appeal process. Her insurer, Blue Cross Blue Shield of Massachusetts, is covering the drug for her son, Jett, through next April. “It’s very disheartening to have worked that hard, and to have sacrificed that much, and to now have to battle the insurance companies.”
The drug’s high cost is driving the resistance. While the drug manufacturer, Sarepta, has said Exondys 51 costs about $300,000 a year per child, the price, based on a child’s weight, can be much higher. For the dozen boys in the main clinical trial, the average list price would be more than double Sarepta’s quote — $750,000 each, according to an analysis by the drug benefit firm Prime Therapeutics.
“I think a lot of the advocates in this space maybe thought that getting a drug on the market was the goal of their advocacy,” said Dr. Aaron S. Kesselheim, an associate professor of medicine at Harvard University who voted against the drug’s approval as part of an F.D.A. advisory committee. “The goal of the advocacy should have been getting a product on the market, and making sure that it’s available at a reasonable cost.”
The agency’s acceptance of Exondys 51, also known as eteplirsen, followed a highly polished, passionate campaign by patient advocates. Dr. Robert Califf, the former F.D.A. commissioner, ignored the agency’s career experts who viewed the drug as little more than a “scientifically elegant placebo.”
The conditional green light granted to Exondys 51 is part of an accelerated pathway that allows the agency to clear much-needed drugs based on early, if inconclusive, evidence of efficacy.
Until then, there was no approved treatment for boys with Duchenne; Exondys 51 may be helping protect muscle cells from deterioration by producing a form of dystrophin, a protein largely lacking in those with the genetic mutation. The boys typically need wheelchairs by their teenage years, and their hearts and lungs eventually give out. Between 9,000 and 12,000 people are estimated to be living with Duchenne in the United States; about 13 percent have the genetic mutation receptive to the new drug.
Skeptics argued that the small clinical trials did not demonstrate meaningful improvement, showing just a minuscule increase in dystrophin. But others, including parents of boys on the drug, insist that it is working — or at the very least, that it can’t hurt to try.
“It makes me feel like I have a chance to live longer than I thought I would,” said Patrick Denger, 22, who has been receiving weekly infusions since December. His costs were covered until his father got a new job and the family switched to Aetna, which has said it won’t pay because he is too old and cannot walk.
Mr. Denger’s treatment was being paid for by Sarepta while he appealed. On Wednesday, he learned that Maine Care, the state Medicaid program, would cover his treatment.
He believes his condition has stabilized, affording him the luxury of contemplating a future. Mr. Denger, who uses a wheelchair, drives his own van and works part time at a supermarket doing administrative work. He recently graduated from the University of New England, near his home in Biddeford, Me.
In addition to Anthem, Express Scripts, which manages the drug benefits for insurers and large employers, excluded the medication from its national coverage list. Other insurers, including UnitedHealth, Aetna and Humana, will cover it only under limited circumstances — if the boy is under 14, for example, or can walk a certain distance. After six months, in many cases, the insurers require evidence that the drug appears to be working.
Insurers are also restricting coverage of a similarly expensive drug, Spinraza, which treats another rare disease, spinal muscular atrophy. The F.D.A. granted broad approval to that drug in December, but many insurers are covering only babies and young children with the most severe forms of the disease, where the clinical evidence of efficacy is strongest.
Jim Redmond, a spokesman for Excellus, said the company did not comment on individual cases and said its policy on Exondys 51 — which requires that the patient be able to walk — was determined by pharmacists and physicians who examined the evidence.
Mrs. Hoke, who is a pharmacist near her home in Fayetteville, near Syracuse, noted that many new cancer drugs offer little long-term hope but are still covered. “It extends their life for three months, and that’s covered,” she said. “My kids can live for years with this drug.”
Whether Exondys 51 can indeed give boys more years to grow up remains an unknown. Sarepta has a lot riding on the drug. It is the biotech’s only approved product, and the company must prove to investors that sales will be enough to finance a pipeline of drugs that could treat a wider range of boys with Duchenne.
Perhaps that’s why Sarepta’s executives have claimed in statements that the average price for Exondys 51 is $300,000 per patient per year.
“That’s not accurate,” said David Lassen, the chief clinical officer at Prime Therapeutics, which manages the drug plans for more than 20 million Americans. “Based on just the few claims that we’ve evaluated, we think that’s low.” He cited a range from $750,000 to $1.5 million a year, far greater than breakthrough drugs like, for instance, cystic fibrosis treatments sold by Vertex that cost more than $250,000 a year.
Sarepta contends that the $300,000 estimate is a net price, accounting for discounts to insurers and the fact that not everyone will follow the weekly regimen. It also includes the assumption that younger boys who weigh less will begin taking the drug.
“What we have seen is that for some of the older, sicker boys who have been using it, the price is more,” said Dr. Ed Kaye, the chief executive of Sarepta.
Many Duchenne parents worry that insurers will balk if other costly drugs are approved to complement the treatment from Exondys 51. Already, they are reeling from the decision by PTC Therapeutics to price a once-cheap steroid, deflazacort, at about $35,000 per year. Many families had been importing it for about $1,600 a year.
In the end, they say, they have no choice.
“We need something to stop as much progression as possible, until something better can come along,” said Michelle Lessner-Gonzales, whose 14-year-old son, Nicolas Gonzales, is waiting for the Illinois Medicaid program to decide how it will cover Exondys 51. In the meantime, her son is losing his ability to walk, a common prerequisite for coverage.
Several insurance companies noted the lack of clinical evidence that the drug works, especially in older boys or those who cannot walk. Anthem, which has said the clinical benefit from Exondys 51 “has not been demonstrated,” said that it relied on outside experts to reach its decision, and that it “eagerly awaited” the results of future studies.
Craig Burns, vice president for research at America’s Health Insurance Plans, a trade group for insurers, said his members were in a difficult spot. “There’s more about this drug that we don’t know than we do know,” he said. “And that’s where payers are really struggling.”
Dr. Kaye, who announced he would resign from Sarepta later this year, said he had spent the past several months traveling the country, making his case to insurance executives. Like other companies marketing rare-disease drugs, Sarepta hired a team of employees who assist patients in getting covered, and the company will pay the out-of-pocket costs of those who can’t afford it.
“I think the insurance companies do worry; they are worried about their bottom line, and trying to make sure they are very thoughtful about the money they spend,” Dr. Kaye said. But when faced with individual stories, “it’s hard to say ‘No, you can’t do it,’ because there are no alternatives.”
Brian Denger, Patrick’s father, said he had hoped for more when Exondys 51 arrived as a treatment. He lost another son, Matthew, to Duchenne in 2013, at age 20.
“I just believed that it was going to be more celebratory,” he said. “And we’re back to the point where it seems like we’re fighting again.”
McConnell’s Calculation May Be That He Still Wins by Losing
by Jennifer Steinhauer - NYT - June 22, 2017
WASHINGTON — When it comes to managing Republicans’ best interests, Senator Mitch McConnell of Kentucky, the majority leader, rarely loses. So it is possible that Mr. McConnell views the potential failure of a hastily written health care bill as an eventual boon.
His presentation on Thursday of the Senate’s health care measure to Republican colleagues — after the White House and key lobbyists got a peek the night before — was met with something other than unbridled enthusiasm. According to lawmakers who were at the unveiling, members from the left and right ends of the party’s spectrum were deeply critical of the effort.
As Democrats immediately took to the Senate floor to excoriate the bill and the secretive process in which it was put together, few Republicans, even those involved in crafting it, came to defend it.
A handful of Republicans — more than Mr. McConnell can afford to lose — were quick to disparage the measure. “I have serious concerns about the bill’s impact on the Nevadans who depend on Medicaid,” Senator Dean Heller, his party’s most vulnerable incumbent in the 2018 elections, said of his constituents.
Senator Susan Collins of Maine rendered her own lukewarm judgment, while Senator Shelley Moore Capito of West Virginia simply said she would read it, with all the enthusiasm of a college senior faced with a weekend assignment of Proust.
Four others went further. Senators Ted Cruz of Texas, Ron Johnson of Wisconsin, Mike Lee of Utah and Rand Paul of Kentucky all said they would not vote for the bill as currently proposed.
Mr. McConnell plays his strategic cards so close to the vest that a queen of hearts must be tattooed on his tie. He may, of course, be convinced that the Senate can pass this bill. Perhaps after some moaning, and some changes to the bill through amendments, the 51 senators needed to get the bill over the line (or 50 if Vice President Mike Pence is summoned) will choose a good-enough effort over being tarred as the person who declined to make good on a seven-year promise to unravel President Barack Obama’s signature domestic policy achievement.
When it comes to voting yes, a majority of members of Congress have a policy price, and leaders often will write the check. “There’s the natural frustrations that people have” at the start of a process that often ends in legislative victory, said Senator Bob Corker, Republican of Tennessee.
But there are potential costs for senators like Mr. Heller and others in repealing a law that has grown in popularity over recent years, and Mr. McConnell has always taken pride in protecting his members. Trying to come to a meeting of the minds with the House — which crafted a far more conservative bill in many respects — would be time-consuming and unpleasant.
Mr. McConnell and many of his aides are also eager to get to the business of changing the tax code, which they view as less difficult than health care, and have been working with the White House behind the scenes to get that effort started. For Mr. McConnell, cutting taxes is a much higher priority than health care, which time and President Trump have turned into quicksand for him and his fellow Republicans.
Just hours after the presentation of the Senate health care bill, Mr. McConnell met with Speaker Paul D. Ryan and White House officials to talk taxes.
Mr. McConnell is not fond of bringing bills to the floor that he does not think can pass. Should he be unable to pull together enough support on the health care bill over the next week, it would seem likely at first glance that he would make the dreaded call to the White House to let the president know that he lacked the votes.
When Mr. Ryan made that move, it was received with anger and pressure to get something — anything — off the floor, and indeed Mr. Ryan did. But Mr. McConnell and senators are generally more resistant to pressure from the White House and will keep their own interests in mind. Forcing senators from states where the Medicaid law was expanded to take that vote and have the bill fail could be costly.
“It’s a short bill,” said Mr. Corker, who, like most other members, said he still had to plow through it and talk to state insurance officials, among other steps. “But it has a big impact on a lot of people.”
However, Mr. McConnell may also decide that the matter cannot be closed without a vote and take his chances that recalcitrant members can be pulled along. Not voting would also leave House Republicans, who voted for a deeply unpopular bill in their chamber, exposed.
Simply put, coming up with a final version of the bill that pleases Ms. Collins, who is concerned that it is still too punitive for many residents of her old and relatively poor state, and Mr. Paul, who feels it is still too generous, is a tough task.
“I think everybody wants to get to yes,” said Senator John Thune of South Dakota, a member of the Republican leadership. “And there are some things that we’ve said all along that are dialable on this bill that we can hopefully tweak a little bit before it comes to the floor.”
He added, however, “I’m not sure that, you know, Rand will ever be there.”
Many Republicans say privately that they are eager to work with Democrats on fixes to the current law to keep the insurance exchanges from imploding. They may well wish to call Democrats’ bluff as they have insisted they want that to work in a bipartisan fashion, too.
But most instructive of all may be Mr. McConnell’s own words. In his 2016 memoir, “The Long Game,” he noted that, as minority leader, he went out of his way to make sure that one party owned the health care issue. “I wanted a clear line of demarcation — they were for this, and we were against it,” he said. Perhaps he is not excited to let that one party now be his own.
WASHINGTON — When it comes to managing Republicans’ best interests, Senator Mitch McConnell of Kentucky, the majority leader, rarely loses. So it is possible that Mr. McConnell views the potential failure of a hastily written health care bill as an eventual boon.
His presentation on Thursday of the Senate’s health care measure to Republican colleagues — after the White House and key lobbyists got a peek the night before — was met with something other than unbridled enthusiasm. According to lawmakers who were at the unveiling, members from the left and right ends of the party’s spectrum were deeply critical of the effort.
As Democrats immediately took to the Senate floor to excoriate the bill and the secretive process in which it was put together, few Republicans, even those involved in crafting it, came to defend it.
A handful of Republicans — more than Mr. McConnell can afford to lose — were quick to disparage the measure. “I have serious concerns about the bill’s impact on the Nevadans who depend on Medicaid,” Senator Dean Heller, his party’s most vulnerable incumbent in the 2018 elections, said of his constituents.
Senator Susan Collins of Maine rendered her own lukewarm judgment, while Senator Shelley Moore Capito of West Virginia simply said she would read it, with all the enthusiasm of a college senior faced with a weekend assignment of Proust.
Four others went further. Senators Ted Cruz of Texas, Ron Johnson of Wisconsin, Mike Lee of Utah and Rand Paul of Kentucky all said they would not vote for the bill as currently proposed.
Mr. McConnell plays his strategic cards so close to the vest that a queen of hearts must be tattooed on his tie. He may, of course, be convinced that the Senate can pass this bill. Perhaps after some moaning, and some changes to the bill through amendments, the 51 senators needed to get the bill over the line (or 50 if Vice President Mike Pence is summoned) will choose a good-enough effort over being tarred as the person who declined to make good on a seven-year promise to unravel President Barack Obama’s signature domestic policy achievement.
When it comes to voting yes, a majority of members of Congress have a policy price, and leaders often will write the check. “There’s the natural frustrations that people have” at the start of a process that often ends in legislative victory, said Senator Bob Corker, Republican of Tennessee.
But there are potential costs for senators like Mr. Heller and others in repealing a law that has grown in popularity over recent years, and Mr. McConnell has always taken pride in protecting his members. Trying to come to a meeting of the minds with the House — which crafted a far more conservative bill in many respects — would be time-consuming and unpleasant.
Mr. McConnell and many of his aides are also eager to get to the business of changing the tax code, which they view as less difficult than health care, and have been working with the White House behind the scenes to get that effort started. For Mr. McConnell, cutting taxes is a much higher priority than health care, which time and President Trump have turned into quicksand for him and his fellow Republicans.
Just hours after the presentation of the Senate health care bill, Mr. McConnell met with Speaker Paul D. Ryan and White House officials to talk taxes.
Mr. McConnell is not fond of bringing bills to the floor that he does not think can pass. Should he be unable to pull together enough support on the health care bill over the next week, it would seem likely at first glance that he would make the dreaded call to the White House to let the president know that he lacked the votes.
When Mr. Ryan made that move, it was received with anger and pressure to get something — anything — off the floor, and indeed Mr. Ryan did. But Mr. McConnell and senators are generally more resistant to pressure from the White House and will keep their own interests in mind. Forcing senators from states where the Medicaid law was expanded to take that vote and have the bill fail could be costly.
“It’s a short bill,” said Mr. Corker, who, like most other members, said he still had to plow through it and talk to state insurance officials, among other steps. “But it has a big impact on a lot of people.”
However, Mr. McConnell may also decide that the matter cannot be closed without a vote and take his chances that recalcitrant members can be pulled along. Not voting would also leave House Republicans, who voted for a deeply unpopular bill in their chamber, exposed.
Simply put, coming up with a final version of the bill that pleases Ms. Collins, who is concerned that it is still too punitive for many residents of her old and relatively poor state, and Mr. Paul, who feels it is still too generous, is a tough task.
“I think everybody wants to get to yes,” said Senator John Thune of South Dakota, a member of the Republican leadership. “And there are some things that we’ve said all along that are dialable on this bill that we can hopefully tweak a little bit before it comes to the floor.”
He added, however, “I’m not sure that, you know, Rand will ever be there.”
Many Republicans say privately that they are eager to work with Democrats on fixes to the current law to keep the insurance exchanges from imploding. They may well wish to call Democrats’ bluff as they have insisted they want that to work in a bipartisan fashion, too.
But most instructive of all may be Mr. McConnell’s own words. In his 2016 memoir, “The Long Game,” he noted that, as minority leader, he went out of his way to make sure that one party owned the health care issue. “I wanted a clear line of demarcation — they were for this, and we were against it,” he said. Perhaps he is not excited to let that one party now be his own.
The Senate’s Unaffordable Care Act
by The Editorial Board - NYT - June 23, 2017
It would be a big mistake to call the legislation Senate Republicans released on Thursday a health care bill. It is, plain and simple, a plan to cut taxes for the wealthy by destroying critical federal programs that help provide health care to tens of millions of people.
The Senate majority leader, Mitch McConnell, and other Republicans have pitched the bill as a fix for the Affordable Care Act, or Obamacare. But their true ambition is not to reform Obamacare, which, whatever its shortcomings, has given 20 million Americans access to health insurance. If passed in its current form, the Senate bill would greatly weaken Medicaid, the federal-state program that provides insurance to nearly 69 million people, more than any other government or private program. It would do this by gradually but inexorably shifting more of the financial burden of Medicaid to states, in effect, forcing them to cover fewer people and to provide fewer services. Over all, the Senate would reduce federal spending by about $1 trillion over 10 years and use almost that much to cut taxes for rich families and health care companies.
In the days ahead, while the Congressional Budget Office totes up the bill’s cost, and before a floor vote, some Republicans, President Trump included, might be tempted to see the Senate bill as an improvement over the draconian House measure passed in May that would take insurance away from 23 million people. Mr. Trump previously expressed the hope that the Senate version would be less brutal.
It isn’t. True, Mr. McConnell and his colleagues have made a few superficial improvements; the rollback of Obamacare’s intended expansion of Medicaid would proceed more slowly than under the House’s timetable. But the long-term damage might be worse. That is because the Senate bill would cap federal spending on Medicaid on a per-person basis. Currently, federal spending varies from year to year based on demand for medical services and the cost of care. Starting in 2025, the cap would be allowed to increase at the rate of inflation in the economy. But the overall inflation rate has typically been much lower than the inflation rate for medical services; in 2016, the overall inflation rate was 1.3 percent, whereas medical costs increased by 3.8 percent. Over time, this would means states will get a lot less money than they do under current law.
The inevitable shrinkage in Medicaid will be particularly devastating to older Americans. Contrary to what many people think, the program does not just benefit the poor. Many middle-class seniors depend on it after they have exhausted their savings. Medicaid pays for two-thirds of the people in nursing homes. The disabled and parents who have children with learning disabilities also rely on Medicaid. The program covers nearly half of all births in the country. And in recent years, it has played a very important role in dealing with the opioid epidemic, especially in states like Kentucky, Massachusetts, Maryland, Ohio and West Virginia. Medicaid pays between 35 percent and 50 percent of the cost of medication-assisted addiction treatment, according to two professors, one from Harvard and one from New York University.
Like its House counterpart, the Senate bill would also hurt millions of non-Medicaid beneficiaries of Obamacare, those who buy insurance on federal and state marketplaces. It would greatly reduce federal subsidies that help low-income and middle-income families buy health coverage, while allowing insurers to increase deductibles, forcing people to pay more for medical services. It would let states waive rules that now require insurers to cover essential health services like maternity care, cancer treatment and mental health care, which is likely to happen because this will be the only way that states can lower premiums. In sum, it will make health insurance more expensive and less useful, to the great misfortune of the poor, elderly and sick.
Mr. McConnell seems determined to steamroll this travesty through the Senate before July 4, despite complaints by conservatives and moderates. Expect him and his colleagues to try to buy support of wavering lawmakers by offering sweeteners like a few billion dollars for addiction treatment and some extra cash for states with high medical costs. Republican senators like Susan Collins of Maine, Lisa Murkowski of Alaska, Shelley Moore Capito of West Virginia, Rob Portman of Ohio and Dean Heller of Nevada ought not to fall for these cheap gimmicks. Instead, they should vote no on a bill that will take a devastating toll on millions of Americans and that no amount of tinkering around the edges can make better.
Senate Republicans’ Obamacare replacement is bad for America’s health
by The Editorial Board - The Washington Post - June 23, 2017
SENATE REPUBLICAN leaders released on Thursday a draft health-care bill, supposedly designed to repeal and replace the Affordable Care Act. It includes a range of mostly unwise and ungenerous changes to the nation’s health-care system, but it might, if enacted, end up as mostly a massive, unpaid-for tax cut for wealthy people and industries with pull on Capitol Hill.
The bill proposes rolling back nearly all of the taxes that supported Obamacare’s health-care coverage expansion, on everything from high wages and investment income to medical devices and tanning services. It would in theory retain the “Cadillac tax” on expensive insurance plans, which is meant to discourage taxpayer-funded overspending on health care, but would delay its implementation for nearly another decade. Though the scorekeepers at the Congressional Budget Office will count the revenue the Cadillac tax would eventually raise, it is a good bet the federal government will never see any of that money. The tax has already been delayed once, and Congress has shown little interest in restraining health-care costs when doing so poses any threat to middle-class benefits.
The tax cuts are supposed to be financed by slashing health-care spending for people of limited means. Federal assistance that helps people afford insurance premiums would be scaled back, and the quality of taxpayer-subsidized insurance plans would decline. As deductibles rise, federal help with out-of-pocket medical expenses would also disappear. Meantime, Medicaid, the state-federal program covering the poor and near-poor, would endure punishing cuts over time, likely leading states to reduce enrollment, benefits or both. The only option for those falling off the Medicaid rolls would be skimpy insurance plans they could rarely if ever use.
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If future Congresses allowed this policy to phase in fully, it would do away with Obamacare’s individual mandate requiring all Americans to carry insurance coverage, which could throw insurance markets badly off-kilter. States would have so much more flexibility in setting insurance rules that insurers might be able to sell plans that cover few treatments sick people really need. Even if these sorts of negative consequences were mitigated, the policy would still boil down to eroding health-coverage access and quality in order to pay for tax cuts.
The cynicism of this exercise is evident in its staging. The bill would kill a variety of taxes right away, but the subsidy and Medicaid cuts would not phase in until after the 2018 midterm election. It would be left to future Congresses to allow severe cuts to the safety net or major expansion of the federal debt, or a combination of the two. Instead of forcing this choice between Americans’ physical health and the nation’s fiscal health, senators should end this repeal-and-replace disaster now.
Our Fake Democracy
by Timothy Egan - NYT - June 23, 2017
We tell ourselves stories in order to live, as Joan Didion said. We do this as a nation, as individuals, as families — even when that construct is demonstrably false. For the United States, the biggest institutional lie of the moment is that we have a government of the people, responding to majority will.
On almost every single concern, Congress — whether it’s the misnamed People’s House, or the Senate, laughably mischaracterized as the world’s greatest deliberative body — is going against what most of the country wants. And Congress is doing this because there will be no consequences.
We have a fake democracy, growing less responsive and less representative by the day.
The biggest example of this is the monstrosity of a health care bill, which a cartel of Republicans finally allowed us to peek at on Thursday. The lobbyists have seen it; of course. But for the rest us, our first look at a radical overhaul of one-sixth of the economy, something that touches every American, comes too late to make our voices heard.
Crafted in total darkness, the bill may pass by a slim majority of people who have not read it. Inevitably, with something that deprives upward of 23 million Americans of health care, people will die because of this bill. States will be making life and death decisions as they drop the mandated benefits of Obamacare and cut vital care for the poor, the elderly, the sick and the drug-addicted through Medicaid. The sunset of Obamacare is the dawn of death panels.
It would be understandable if Republicans were doing this because it’s what most Americans want them to do. But it’s not. Only about 25 percent of Americans approved of a similar version of this bill, the one passed by the House. By a nearly 2 to 1 margin, people would prefer that the Affordable Care Act be kept in place and fixed, rather than junked for this cruel alternative.
The Senate bill is “by far, the most harmful piece of legislation I have seen in my lifetime,” said Senator Bernie Sanders. At age 75, he’s seen a lot.
Remember when Republicans used to pretend to care about crafting the people’s business in sunlight? “It’s simply wrong for legislation that will affect 100 percent of the American people to be negotiated behind closed doors.” That was Mike Pence in 2010.
Why are they doing it? Why would the people’s representatives choose to hurt their own people? The answer is further evidence of our failed democracy. About 75 million Americans depend on Medicaid. This bill will make their lives more miserable and perilous in order to give the top 2 percent of wealthiest Americans a tax cut.
And where are the 75 million now? They are nowhere. The sad fact is, the poor don’t vote. Up to 80 percent of low earners do not show up at the polls, and it’s even worse in midterm congressional elections. The Republicans can screw the poor, whose population is disproportionately large in red states, because those citizens will not fight back.
So, little surprise that Republicans are also working to make it even harder for the poor to vote. They can seek to disenfranchise one class of Americans, and get away with it from the safety of gerrymandered seats.
The symptoms of democratic collapse — from the opioid crises of people who long ago checked out of active citizenship to the stagnation of class mobility — cry for immediate action.
It takes the median worker twice as many hours a month to pay rent in a big city today than it did in the early years of the baby boomer era, as Edward Luce notes in his new book, “The Retreat of Western Liberalism.” Add towering increases in health care and college costs to that and you’ve got an unclimbable wall between low-income limbo and a chance at the middle class. The United States, once known for our American Dream, now has the lowest class mobility of any Western democracy, according to Luce.
What is Congress doing? Nothing on wages. Nothing on college tuition. And the health care bill will most surely force many people to choose between buying groceries and being able to visit a doctor.
Our fake democracy reveals itself daily. Less than a third of Americans support President Trump’s decision to withdraw from the Paris Climate Agreement. In a truly representative government, you would see the other two-thirds, the common-sense majority, howling from the halls of Congress.
Most Americans are also against building a wall along the Mexican border. They would prefer putting taxpayers’ billions into roads, bridges, schools and airports. But the wall remains a key part of President Trump’s agenda.
Trump is president, of course, despite losing the popular vote by nearly 3 million people. Almost 60 percent of the public is against him now. In a parliamentary system, he’d be thrown out in a no-confidence vote. In our system, he’s primed to change life for every citizen, against the wishes of a majority of Americans. Try calling that a democracy while keeping a straight face.
The Republicans’ Jekyll-and-Hyde Health Care Plan
by Drew Altman - NYT - June 23, 2017
The Senate Republicans’ health bill that was made public today is a Jekyll-and-Hyde plan: in some ways kinder than the House Republican plan, and in some ways meaner, to use President Donald Trump’s yardstick. Overall the plan will benefit the wealthy and young adults, but hurt larger numbers of people who are old or poor.
On Medicaid, the federal-state health program covering 69 million lower-income people, the Senate plan is harsher than the House plan. Like the House bill, the Senate bill would effectively kill the expansion of Medicaid that was allowed under the Affordable Care Act. It will do this by phasing out, over four years, the law’s requirement that the federal government cover 90 percent of the cost for people added under Medicaid expansion — many of them single adults below or just above the poverty line. Medicaid expansion covers 14 million people in 30 states and the District of Columbia. (The remaining states chose not to expand their programs.) Expansion states would have to come up with hundreds of millions, in some states billions, of dollars from their own budgets to replace those lost federal funds. Based on my experience as a state human services commissioner — for a Republican governor — I predict that few if any states will be able to do that. It is also highly unlikely that other states will join the expansion once the federal match is gone.
Both the Senate and the House plans also impose a per capita cap on future federal Medicaid spending. The Senate plan imposes a harsher formula for its cap than the House plan, which already cuts Medicaid spending by $834 billion over 10 years. Because states have to balance their budgets every year, unlike the federal government, many will struggle to compensate for reductions in federal aid caused by a spending cap. Many states will be forced to choose between Medicaid and other priorities, like education, law enforcement and prisons. The inevitable result will be a reduction in health care spending on low-income people. And you cannot cut over $800 billion from Medicaid without adversely affecting health services for the poor.
Governors might be expected to loudly protest these Medicaid cuts, but the Senate bill delays the harshest cuts until 2025, after the current governors are gone. We will see how those governors balance their states’ health care futures and their own political interests.
That’s Mr. Hyde. Now for Dr. Jekyll. The part of the Senate bill that deals with the individual insurance market and the A.C.A. marketplaces is in some respects Obamacare-lite. The House bill was sharply criticized for replacing Obamacare’s system of tax credits and subsidies, intended to make insurance more affordable, with a system of tax credits that were far less generous. The Senate bill would maintain Obamacare’s tax credit system, but it would scale back the value of the credits. And as under the A.C.A. but not the House plan, the tax credits will be adjusted for income and geography — which will benefit people in parts of the country with high premiums, especially rural areas. Still, deductibles are likely to rise under the Senate plan.
Another key difference involves community rating, which prohibits insurance companies from charging sick people more than healthy people. The House bill would authorize states to apply for waivers allowing insurers to charge sick people more. The Senate bill would not allow such waivers. But it would make it easier for states to seek exemptions from other provisions of the law, including the essential benefits insurers must cover, such as maternity care and mental health. How this would play out nationally would vary greatly from state to state, but it seems certain that some states would allow significant reductions in essential benefits.
Each of the plans would eliminate funding for Planned Parenthood for one year, as well as prevent plans participating in the insurance marketplaces from providing abortions.
Conservatives may like the idea of capping and cutting Medicaid, but they will not like the Senate bill’s Obamacare-lite tax credits. Liberals and moderates will resist what they consider the near decimation of the Medicaid program. Nor will they like the idea of handing so much control over Medicaid to the states. They will see little logic in reducing eligibility for the A.C.A.’s tax credits. How, they will rightly ask, would that “fix Obamacare” when middle-class consumers who buy their own insurance are struggling to pay their bills now?
Overall, it’s important not to focus too much on the differences between the Senate and House plans. Both plans will reduce federal health care spending and cap Medicaid while shifting greater responsibility to the states. And both plans will cause more Americans to go without coverage and struggle with health care bills. Both bills are likely to increase the number of Americans having problems paying medical bills — about a quarter of the public today. For voters, that is the single most important barometer of the performance of the health care system.
If the plan passes and is signed into law, congressional Republicans and the president will win plaudits from their base for repealing Obamacare. But then they will own the problems in the health care system, including those created by their own legislation.
Get Cancer Now, Before Congress Cuts Your Insurance
by Justin Ordonez - NYT - June 23, 2017
SEATTLE — I’m 35 years old. I didn’t go to college after high school. Instead I got a job in insurance, and I’ve spent half my life on the business side of keeping people healthy. Only once have I felt that the industry took positive steps toward insuring America, and that was when Obamacare mandated it.
I assumed Donald Trump’s presidency would doom the law. A Republican replacement, which could cut off insurance for millions of people, may pass the Senate as soon as next week. And I fear that most Americans, who don’t really worry about their health until they get sick, won’t be willing to fight against it.
Only when you’ve done what I’ve done will you understand what will happen if the Republicans destroy Obamacare.
My first job in the industry was at a company that helped businesses administer their employees’ insurance benefits. It needed people to man the call center during the open enrollment season, when those lucky enough to have insurance through their jobs made coverage elections for the coming year. I had no experience, but I smiled when I thought it was appropriate and tried to look as if I belonged.
I had thought America was a country where people made choices for themselves. The training course taught me that, on the contrary, people typically obtained health insurance from their employer and had the cost and the coverage largely dictated to them. I learned about “pre-existing conditions,” a term that would soon be notorious. I paid attention because, although I was 19, I already knew that I would eventually need to have my hip replaced. If I had a break in medical coverage, I could be facing those costs on my own.
The job got tedious quickly. When one major corporation stopped covering Viagra, the service center was flooded with calls. One of my colleagues tore off her headset, shouting, “I can’t talk to old men about erections any longer!”
After open enrollment ended, the calls became more serious. They came from all around the country. A man asked to switch plans because his wife desperately needed treatment at an out-of-network clinic. Parents had delayed adding newborn children to their policy and now worried they couldn’t get coverage. The answers I gave were based not on steadfast rules and regulations but on the generosity of the callers’ employer — some people I could help, others I had to hurt.
Our database gave me the callers’ age, race, gender, date of hiring, spousal and dependent information, current coverage and hourly wage or salary. I developed a habit of crunching numbers to pass the time. A female caller made, say, $21,840 a year with a monthly premium of $225, leaving her with $19,140. Like me, she had injured her hip. Add up her deductible, co-payment, likely hospital bills, prescriptions, physical therapy and a few weeks of missed work, and she had less than $13,500 left over. I would be at my desk, thinking: “My rent is $685 a month. What’s hers?”
My next job was as a workers’ compensation claims examiner. Many claims had vague accident descriptions and no witnesses. I had one claimant, a data-entry clerk, file for wrist pain caused by carpal tunnel syndrome after having been employed for only a few days. When asked if she had experienced any symptoms before, she never wavered: “No.” Her surgeries were covered.
I was surprised, and not. I had been doing the math. It never added up. For many of these people, the only way they were going to get the care they needed was to feign being injured at work.
In workers’ comp, doctors were passive, employers were punitive, employees juiced the system, and I had to close cases. I found a physician at an independent medical examination company who almost always signed off on my cases, as long as they included appropriate leading data. I referred to him as “Dr. Fixed and Stable.” (“Fixed and stable” was the magic term that allowed me to close a claim.) I never met this doctor, but I sensed he was down with the game. We paid him a few hundred dollars a pop, and my cases got closed.
In 2007, I decided to give college a shot. I needed a flexible work schedule, but because of my pre-existing condition, I couldn’t let my insurance lapse. I found a job with benefits at a smoking cessation company, working nights and weekends.
Funded mostly by the ’90s tobacco settlements, the stop-smoking hotlines helped everyone, not just those with insurance or those who could manipulate the system. But luck still played a role. Radio commercials would air promising free samples of patches and gum. The phones lit up, but the samples soon ran out. I thought: Why is acquiring health care like visiting a casino? Why does it feel as though you have to win to get it?
Then Barack Obama was elected. He spent his presidency building and defending the Affordable Care Act. It was ambitious legislation, but I was concerned. The employer-driven insurance industry had no clue how to provide sufficient health care to the people who were already insured. Now we needed to include the uninsured, too?
In 2012, I had the hip replacement — a $44,000 procedure. Thankfully, I had kept my insurance coverage, as the A.C.A. wouldn’t prohibit pre-existing condition exclusions until 2014. I am still amazed that losing insurance for two months could have excluded me from medical care forever. I was proud that America would no longer be a country where a 19-year-old wondered if a lapse in insurance would leave him crippled.
Also thanks to the A.C.A., I began buying my insurance through my state’s health care exchange website. Like the healthcare.gov site, it had a rocky start and was widely panned, but I loved it. It was an actual marketplace and not a shadowy industry where brokers and H.R. departments hammered out deals. I had several insurers offering me coverage, with transparent plan information and pricing. It was almost as if they were competing.
And still, I worried. With this new transparency, people would see the blemishes in the industry. What would they blame for these flaws, the new law or the system it was designed to repair?
When the marketplace was unable to transfer enrollee information from its computers to the health care insurers, it was viewed as a failure of government. But all my colleagues had war stories about failed data feeds. Getting these systems to communicate could be so difficult that sometimes companies didn’t even try; they hired people to re-enter the information manually.
By now I had moved on to a new job focused on Medicaid clients, which meant I encountered a pillar of Obamacare, the Medicaid expansion. Many more chronically ill people were now being covered by the government. This was my opportunity to see the costs of uninsured America, a giant pool of liability so muddied by the complexities of coding and poor data tracking that no one knew if it was two or 20 feet deep. I suspected America was far sicker than the politicians described.
One issue that stood out was the number of patients who had contracted sepsis, a blood infection. Unable to get medical care, patients had lived with infections for weeks, maybe months, until bacteria caught a ride into their blood streams. Now Medicaid was paying bills as large as $100,000, and those patients who did not die were facing months of recovery, and not a premium payment had been made to compensate for it.
President Trump has portrayed Obamacare as a cesspool. The problem was never Obamacare. It was uninsured America — people who had been cut out of the system, but who were nonetheless pushing us toward collective bankruptcy. Obamacare just cleaned the water enough for us to finally see the time bomb in the depths.
Republican plans to fix health care simply put mud back into the pool, finding new ways to stop covering sick Americans. Medicaid rolls will shrink again; insurers in certain states may cut what they cover. Even pre-existing conditions could become a problem again. While the draft of the Senate bill still technically requires insurers to cover these patients, it would let states petition to limit that coverage — who knows by how much. And the House version would let insurers charge them much more, putting private insurance out of reach for many.
In the short term, all this is beneficial from the industry’s perspective. It’s easier to balance the books if you don’t count the sick. In the long term, everyone gets sick, and for those people to be profitable, they need to be making premium payments throughout their entire lives — not just when they’re sick and not just when they have a job that offers benefits. This is why no health care legislation can work if it drops the mandate to buy coverage, as both the House bill and the draft of the Senate bill do.
When you work in insurance, patients become statistics. At 2:30 on a Thursday afternoon, when I’m slouched in my chair, looking at my 20th case of the day, am I envisioning a person? No. I see white, female, 40s, Medicaid recipient, with a request for Code 77059, bilateral breast M.R.I., and I hope it isn’t cancer, but I can’t linger. Sentimentality is another form of inefficiency. That’s how I’ve survived my first decade and a half in this industry, and I suppose that’s how I’ll survive however long I remain.
But when I think of an America without Obamacare, I feel the weight of a human tragedy that is so much larger than the thousands of individual tragedies I’ve taken part in. I want to believe Americans will come to their senses, but I doubt it. The America I know is a place where you have to fake an injury at work to get treatment, where you have to hear a radio commercial at the right time, where you need a Dr. Fixed and Stable. There’s a madness to it that will drive you insane if you let it. This isn’t an industry. It’s a lottery.
White/female/45 looking for 77059? If it is cancer, she’s lucky she got it now, before her government decides to cut off her health insurance. She’s lucky she won the lottery.
Your Health May Be in Susan Collins’ Hands. And That’s Not Good News
by Neal Gabler - Common Dreams - June 23, 2017
Susan Collins says she’s disturbed.
That’s not exactly news. The Republican senator from Maine is frequently disturbed. She was disturbed by the Benghazi raid; by the Republican shutdown of the government in 2015; by the “cruel comments” of Republican nominee and now president Donald Trump; by political polarization; and most recently by Republican plans to repeal Obamacare and strip tens of millions of Americans of their health insurance.
To be disturbed when nearly all one’s Republican colleagues are sanguine about injustice is not a bad thing. Collins, though, could have something to say about this last matter, Obamacare, beyond hollow expressions of concern. When the 13-man cabal of her fellow Republicans, who have been crafting a new repeal bill, finally emerges, she could announce that she will refuse to vote for any bill in which Americans would lose their insurance. She could say that Trump’s cruel comments are nothing against the cruelty of putting poor Americans’ lives at risk. She could say that since Obamacare provided insurance for millions, she is going to side with the Democrats against her own party.
Because Senate Republicans have only a three-vote majority margin, this wouldn’t necessarily be hot air. She could say all of these things, but I would wager that she won’t do any of them. In the end, Susan Collins is likely to retreat and join the conservatives in trashing health insurance.
"Polarization isn’t the problem. Orthodoxy is the problem."
Of course, that is not how she is portrayed in the media. Collins is often introduced as Exhibit A of Republican moderation, a throwback to the way things used to be in Washington when the GOP had Jacob Javits, Clifford Case, Ed Brooke, Kenneth Keating, Charles Mathias, Lowell Weicker and other empathetic lawmakers in its ranks, reaching across the aisle. In truth, Collins is no anachronism. For all her apparent personal compassion, she may well be Exhibit A of what is wrong in Washington: the triumph of party ideology over common decency, conscience and even political expediency. Collins knows better than most of her benighted Republican colleagues. It doesn’t make any difference.
Collins is certainly not the worst offender, which is largely the point. In fact, she may be the best of the Senate Republicans. From 1997 through 2015, she voted with her party just 60 percent of the time — hardly lockstep.
The conservative group Heritage Action gave her only a 16 percent score last Congress, the lowest among congressional Republicans, and the American Conservative Union scored her 23 percent on bills of importance to the organization, while on the whole, Republicans averaged 75 percent. (Dems averaged 4 percent.)
Already, she has voted against Trump more than any other Senate Republican, including votes against the confirmation of Education Secretary Betsy DeVos and EPA head Scott Pruitt, and she voiced disapproval of Trump’s travel ban. So what is the problem?
The problem is that Collins all too often stands up to her fellow Republicans on the small issues, while she shakes her head and frets about the big ones, only to toe the party line in the end. Yes, she wrote an op-ed declaring that she could not vote for Trump, and then said she wrote in on her ballot the name of Paul Ryan (!), one of the few party figures worse than Trump. Yes, she voted against DeVos and Pruitt, but introduced attorney general-designate Jeff Sessions at his confirmation hearings and gave him full-throated support, despite his long record of racism. Yes, she opposes Trump more than her fellow Republicans, but she still votes with him 85 percent of the time. She has a checkered record on immigration, opposed net neutrality, and got only a 38 percent rating from the Leadership Conference on Human Rights.
Newsmax CEO Christopher Ruddy, challenging the characterization of Collins as some apostate conservative, assured his readers that she is “one of us.”
But it is on health insurance where Collins could arguably make her biggest political mark and establish a legacy as a defender of the vulnerable, including the vulnerable among her own constituents, who have benefited enormously from Obamacare in a state that has the oldest population in the nation. But don’t hold your breath. Collins has been as doggedly resistant to Obamacare as any Republican. She voted against Obamacare in 2009 and then against the Senate-House reconciliation act. She voted for repeal in 2011 and 2015 and again this past January.
When her fellow Republicans shut down government in 2013, insisting that they wouldn’t approve funding without an Obamacare repeal, she claimed, disingenuously, to have bucked her party. What she really did, according to Mother Jones, is vote three times to keep the government running but if and only if Democrats defunded or delayed Obamacare.
“There is no denying that the Affordable Care Act has made insurance available to millions of Americans and allowed people to leave corporate jobs and start businesses,” she told The New York Times. But Collins claims that she worries about instability in the health markets, rising premiums and the dearth of facilities in Maine — all of which might be legitimate concerns if the instability of the markets wasn’t largely the result of Republican sabotage, if premiums had risen anywhere near as much as critics contend, and if access to facilities had anything to do with Obamacare. Oh, and one more thing. Collins opposed Obamacare before it was implemented, so none of these criticisms makes much sense.
To shore up her moderate credentials, Collins, who opposed the House Republican bill, has introduced her own replacement bill along with Louisiana Republican Bill Cassidy. She calls it a “compromise,” but it is clever window-dressing. Its big features are Health Savings Accounts instead of direct subsidies, a Republican panacea for all ills, and waivers for states to construct their own insurance systems. Without getting into details, the first has been largely discredited as a sop to the wealthy, since everyone knows Republicans would never adequately fund these accounts, and the second is already a feature of Obamacare as well as an exit strategy for Republican governors.
"The Republican health plan may be top secret, but their real motives aren’t."
Meanwhile, Collins has said she agrees with a letter signed by Republicans Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Linda Murkowski of Alaska promising not to support a plan that “does not include stability for Medicaid expansion populations or flexibility for states” — two things that might very well be mutually exclusive. In any case, I wouldn’t bet on them following through on the threat.
None of this is to pick on Collins. Rather, it is to state the unfortunately obvious. Republicans are likely to pass a repeal bill with weak provisions for existing conditions and no provision for long-term Medicaid. It is almost certain to receive the votes of the entire caucus — yes, every last one, including Collins, unless Rand Paul, who opposes government insurance of any sort, sticks to his guns. And it definitely will not be an attempt to improve upon Obamacare, as we so often hear, but to remove it.
The Republican health plan may be top secret, but their real motives aren’t. What Republicans want, what they lust after, is to destroy Medicaid and any government effort to aid the vulnerable while wiping their fingerprints from the scene of the crime. This has never been about policy. This has always been about an unholy blend of ideology and partisanship — an ideology that boasts about harming the powerless to fellow conservatives and a partisanship that opposes anyone who tries to help the powerless.
Collins talks a good game. She said she came to politics when, as a high school student, she visited Maine’s Republican Sen. Margaret Chase Smith, who gave her a copy of a 1950 speech in which Smith lacerated red-baiting Sen. Joseph McCarthyfor relying on the “four horsemen of calumny — fear, ignorance, bigotry and smear.” Smith called it her “Declaration of Conscience,” and it dealt a blow against McCarthy when others were loath to do so.
Conscience is in short supply now, and Collins sadly hasn’t exhibited much, her exemplar notwithstanding. Every major medical organization opposes Obamacare repeal. So does every organization that represents the aged, the sick and the poor. According to The New York Times, the majority of every single state opposes it, so there is no political gain, other than the gain of appealing to the worst elements of the party and the country. Everyone knows that lives are at stake. And yet, Republicans are determined to eviscerate health insurance, regardless of the political consequences, which could be severe.
As for Collins, she would probably not face any consequences at all were she to demonstrate a conscience like Margaret Chase Smith’s. Even if she were “primaried” from the right — that great terror among Republican incumbents — she would almost certainly win, and in any case, she reportedly is considering a run for governor.
So: If not now, when? If not on this issue, on which? If not her, who? The answers are likely never, none and no one. The best, indeed, “lack all conviction,” as Yeats wrote.
And that is why the ever-disturbed, much-dismayed Susan Collins is an object lesson in the failure of our politics. She will express her concerns. She will propose empty compromises. She will take no evident joy in hurting the defenseless like most Republicans. But in the end, even when the country is nearly uniform in opposition, she will fall in line because that is what Republicans always do, if only to prove they don’t have bleeding hearts, or any hearts at all.
Pure Class Warfare, With Extra Contempt
by Paul Krugman - NYT - June 23, 2017
The Senate version of Trumpcare – the Better Care Reconciliation Act – is out. The substance is terrible: tens of millions of people will experience financial distress if this passes, and tens if not hundreds of thousands will die premature deaths, all for the sake of tax cuts for a handful of wealthy people. What’s even more amazing is that Republicans are making almost no effort to justify this massive upward redistribution of income. They’re doing it because they can, because they believe that the tribalism of their voters is strong enough that they will continue to support politicians who are ruining their lives.
In this sense – and in only this sense – what we’re seeing now is a departure from previous Republican practice.
In the past, laws that would take from the poor and working class while giving to the rich came with excuses. Tax cuts, their sponsors declared, would unleash market dynamism and make everyone more prosperous. Deregulation would increase efficiency and lower prices. It was all voodoo; the promises never came true. But at least there was some pretense of working for the common good.
Now we have none of this. This bill does nothing to reduce health care costs. It does nothing to improve the functioning of health insurance markets – in fact, it will send them into death spirals by reducing subsidies and eliminating the individual mandate. There is nothing at all in the bill that will make health care more affordable for those currently having trouble paying for it. And it will gradually squeeze Medicaid, eventually destroying any possibility of insurance for millions.
Who benefits? It’s all about the tax cuts, almost half of which will go to people with incomes over $1 million, the great bulk to people with incomes over 200K.
So, is this bill good for you? Yes, if you meet the following criteria:
1.Your income is more than $200,000 a year
2.You have a job that comes with good health insurance
3.You can’t imagine any circumstances under which you lose that job or income
4.You don’t have any family members or friends who don’t meet those criteria
5.You have zero empathy for anyone else
2.You have a job that comes with good health insurance
3.You can’t imagine any circumstances under which you lose that job or income
4.You don’t have any family members or friends who don’t meet those criteria
5.You have zero empathy for anyone else
The set of people who can check all these boxes is not a winning political coalition. But Republican leaders believe that their voters are tribal enough, sufficiently walled off from information, that they’ll ignore the attack on their lives and keep voting R – indeed, that as they lose health care, get hit with crushing out-of-pocket bills, see their friends and neighbors face ruin, they’ll blame it on Democrats.
I wish I were sure that this belief was false.
Goodbye, Medicaid
by David Leonhardt - NYT - June 23, 2107
There’s a harsh irony about the current health care battle. Just as many people have begun to realize how politically popular Medicaid is, the program is at risk of shrinking radically — really, of ceasing to exist as we know it.
Democrats have always been a little insecure about Medicaid, which covers the poor, as well as many nonpoor elderly, disabled and special-needs children. Democrats have worried that the American public views the program as welfare rather than a deserved benefit like Medicare or Social Security. But Medicaid turns out to be quite popular, as I’ll detail in a moment.
Now Congressional Republicans are on the verge of gutting the program, which would ultimately deny medical care to millions of Americans.
This gutting of Medicaid is central to the health care bill that Senate Republicans released, at long last, yesterday. The Senate bill cuts Medicaid even more than the House bill would, as Drew Altman explains in an op-ed. The money saved by the Medicaid cut would then finance tax cuts for the affluent.
The Senate bill would not merely repeal a central part of Obamacare, which expanded Medicaid, but it would also undo major parts of the program that have existed for decades.
Perhaps the clearest evidence of Medicaid’s popularity came in a recent poll by the Kaiser Family Foundation, which Altman runs. Kaiser asked a direction question about how people see Medicaid:
Which comes closer to your view:
— Medicaid is more similar to other health insurance programs, like Medicare, that help people pay for health care.
— Medicaid is more similar to welfare programs like food stamps that help people pay for food.
By a wide margin, 60 percent to 37 percent, people chose the first option. Democrats and independents overwhelmingly did so, while almost half of Republicans also did.
That one question is hardly the only sign of Medicaid’s popularity. By an even wider margin, people say the recent expansion of Medicaid should be protected, Kaiser found.
And 58 percent of Americans say Medicaid is important to them or their family. That’s a rational view, too, given the wide variety of people who receive care through the program. Jonathan Cohn recently profiled one of them — an inspiring student at Kenyon College.
No wonder that Republican senators have taken to using misleading descriptions for their own bill. To take one example, Shelley Moore Capito of West Virginia has used the phrase “transitional period” to describe the cuts, as Peter Sullivan of The Hill reported.
In truth, the cuts would represent “the largest single reduction in a social insurance program in our nation’s history,” as three health care experts recently wrote in The Times.
If you want to read more on the Senate bill, I recommend — as I often do on health care — both Margot Sanger-Katz of The Times and Sarah Kliff of Vox.
For those of you who prefer video, I guest-hosted Charlie Rose’s show earlier this week and talked about the Senate’s health care plans with Kliff, Peter Suderman of Reason and Sara Collins of the Commonwealth Fund.
Four GOP senators oppose Senate health care measure in its current form
by By Sean Sullivan, Juliet Eilperin and Kelsey Snell - The Washington Post - June 23, 2017
WASHINGTON — Four Republican senators from the conservative wing of their party say they oppose the Senate health care bill as it was introduced by Senate Majority Leader Mitch McConnell on Thursday, which places the effort to overhaul the American health care system in jeopardy as it heads for an anticipated vote in the Senate next week.
Those senators — Rand Paul of Kentucky, Ted Cruz of Texas, Ron Johnson of Wisconsin and Mike Lee of Utah — released a statement stating that while they cannot support the bill as it’s currently written, they are open to negotiating changes that could ultimately win their support.
“Currently, for a variety of reasons, we are not ready to vote for this bill, but we are open to negotiation and obtaining more information before it is brought to the floor,” the statement read. “There are provisions in this draft that represent an improvement to our current healthcare system but it does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their healthcare costs.”
Their opposition is enough to place the GOP measure in serious jeopardy as McConnell can afford to lose only two Republicans and still pass the measure. The bill is being moved under arcane budget rules that allows it to be passed with a simple majority or 50 votes, if Vice President Mike Pence is relied on as a tiebreaker.
“The current bill does not repeal Obamacare. It does not keep our promises to the American people. I will oppose it coming to the floor in its current form, but I remain open to negotiations,” said Paul.
Maine Sen. Susan Collins has concerns about the bill and will continue to review it in the coming days.
“Senator Collins will carefully review the text of the Senate health care bill this week and into the weekend,” said her press secretary Annie Clark. “She has a number of concerns and will be particularly interested in examining the forthcoming [Congressional Budget Office] analysis on the impact on insurance coverage, the effect on insurance premiums, and the changes in the Medicaid program. She has met with and heard the concerns of many Mainers about their health care challenges, and she will continue to do so as she studies the impact of this legislation on Maine and the nation.”
Maine’s junior senator, independent Angus King, said in video posted on his Facebook page Thursday that the measure is “a really cruel bill” that will have “devastating” economic effects on Maine.
“All this week we’ve been hunting around here for the Republican health care bill. This morning we found it, and I’m kind of sorry we did because it’s pretty bad,” King said in the video. “It basically increases the cost of health care, particularly for seniors; massively cuts Medicaid, which supports people in nursing homes, disabled people, children — I mean, it is a really cruel bill. The president called the House bill ‘mean.’ I think this one is cruel.
“And it’s going to have a devastating effect economically on Maine, on our hospitals, and on our rural health care system — and all of this in the name of a huge tax cut for the wealthiest Americans.” King said in the video. “The top 2 percent are the ones who get the benefit. And really, to be taking health care away from disabled people, the elderly in nursing homes, so very wealthy people can get a tax cut just doesn’t make sense for me.
“So we’re going to look at it carefully,” he said. “We’re going to get a Congressional Budget Office score next week, and review the provisions, but it doesn’t look very hopeful right now.”
McConnell introduced draft text — crafted behind closed doors among a small circle of lawmakers and aides — of the Senate GOP bill in a private meeting with Republican senators on Thursday morning.
Initial signs indicated the bill could be in trouble if the Kentucky Republican intends to subject it to a vote before lawmakers leave Washington for the July 4 recess. According to two Republicans in close contact with Senate GOP leadership granted anonymity to describe private conversations, McConnell is threatening to bring the bill to a vote next week even if he doesn’t have the necessary votes.
But some believe that message is aimed at trying to pressure Republicans to support the bill rather than an absolute commitment — and that the majority leader would end the push if he doesn’t have the votes. A McConnell spokeswoman declined to comment.
“Right now the challenge is how we get to 50,” said Sen. John Thune, R-South Dakota, a top McConnell deputy, referring to the number of senators needed to pass the bill, with Vice President Pence standing ready to cast a tiebreaking vote.
No Democrats are expected to support the measure, which dramatically scales back the 2010 Affordable Care Act that was President Barack Obama’s signature domestic achievement and helped ensure coverage for roughly 20 million Americans through a combination of Medicaid coverage and subsidized private plans.
One potentially ominous sign for leadership was the reaction of Nevada Sen. Dean Heller, a Republican, who is up for re-election in 2018. Heller released a statement saying he has “serious concerns” about the bill’s Medicaid provisions.
The 142-page bill would curtail federal Medicaid funding, repeal taxes on the wealthy and eliminate funding for Planned Parenthood as part of an effort to fulfill a seven-year promise to undo Barack Obama’s signature health care law.
It abolishes two of the law’s central mandates — that individuals must show proof of insurance when filing their taxes, and that firms with 50 workers or more must provide health coverage — while providing less money for moderate and low-income Americans buying insurance on the individual market.
The bill is an attempt to strike a compromise between the ACA and a measure passed by the GOP-controlled House in May. The Senate proposal largely mirrors the measure that passed the House — with some significant differences.
“Republicans believe we have a responsibility to act — and we are,” said McConnell in a speech on the Senate floor. He underscored the taxes and regulations in the ACA that the GOP measure would repeal.
Senate Democrats swiftly protested the bill, criticizing Republicans for crafting it under very secretive conditions and asking for more time to debate and vet the measure than McConnell plans to allow. Minority Leader Charles Schumer, D-New York, said Republicans were “turning truth upside down” with their promises of an open amendment process next week.
But McConnell faces the prospect of an open revolt from key conservative and moderate GOP senators, whose concerns he has struggled to balance in recent weeks. Senate leaders have more work to do to secure the votes needed to pass the measure, Republicans familiar with the effort said.
Many GOPers reserved judgment on the measure as they exited McConnell’s private presentation. In the days leading up to the bill’s release, some Republicans have intensified their complaints about the substance of the emerging bill and the tightly controlled process under which McConnell and only a small handful of aides wrote it.
Sen. Tim Scott, R-South Carolina, said the mood in the room made for an “interesting morning, a little tense.” He was one of several Republicans who pushed for the Senate measure to be “more gracious” than the House bill, an aim he feels was satisfied. But Scott predicted there was “a long way to go” before concluding whether it could pass.
Senate leaders plan to move the bill to the floor after receiving an analysis from the nonpartisan Congressional Budget Office, which said Thursday it will do “early next week.” The CBO is expected to release a comprehensive estimate of how many people are expected to lose coverage as a result of the bill and how much it is expected to cost.
The CBO concluded the House bill would leave 23 million more Americans uninsured by 2026 than under current law, while also concluding that premiums would drop overall.
Like the House bill, the Senate measure would make big changes to Medicaid that in effect would reduce federal spending on the program. The Senate measure would cut off expanded Medicaid funding for states more gradually than the House bill by phasing out the higher federal match between 2020 and 2024, but would enact deeper long-term cuts to a program that provides health care coverage for 74 million Americans.
It also would eliminate House language aimed at prohibiting federally subsidized health plans from covering abortions, a provision that may run afoul of complex Senate budget rules.
While the House legislation would peg federal insurance subsidies to consumers’ age, the Senate bill would factor in income as well,as the ACA does. But younger people would still get more generous subsidies than they do under current law.
The measure would preserve two of the ACA’s most-popular provisions: insurers could not deny coverage based on preexisting conditions and children may stay on their parents’ plans until the age of 26. Insurers must set prices based on the overall insurance pool rather than charging sicker Americans more.
But the bill would allow states to use an existing ACA program, known as 1332, for states to file waivers with the Centers for Medicare and Medicaid Services to scale back what sort of plans insurers offer. Through these waivers states could eliminate elements of the ACA’s essential health benefits package, which includes preventive and maternity as well as newborn care, along with substance abuse and mental-health treatment. Such changes would make plans cheaper, though they could lead to higher out-of-pocket expenses for consumers.
Insurance subsidies are currently available to Americans earning between 100 percent and 400 percent of the federal poverty level. Starting in 2020, that threshold would be lowered to 350 percent under the Senate bill — but anyone below that line could get the subsidies if they’re not eligible for Medicaid.
In a move that will please the health care industry, the Senate bill also proposes repealing all the ACA taxes except for its “Cadillac tax” on high-cost health plans in language similar to the House version. Senators had previously toyed with the idea of keeping some of the ACA’s taxes.
It would also eliminate Medicaid reimbursements for Planned Parenthood for one year. Federal law already prevents taxpayer funding to pay for abortions except to save the life of the mother or in the case of rape or incest. But some Republicans want to ban all federal funding for Planned Parenthood, which also provides health services such as birth control and preventive screening.
In a move that is critical to insurers, the Senate measure would continue to fund for two years cost-sharing subsidies that help 7 million Americans with ACA plans. House Republicans have challenged the legality of the $7 billion in subsidies — which help cover consumers’ deductibles and copays — in court, and insurers warned they would have to increase premiums dramatically next year unless the federal government commits to continuing the payments.
Outside criticism of the GOP effort has been mounting. The heads of 10 managed care organizations penned a letter to McConnell and Schumer this week saying they were “united in our opposition to the Medicaid policies currently being debated by the Senate.”
The health care chart you need to read to understand Trumpcare’s damage
by Amy Fried - Bangor Daily News - June 23, 2017
Now that the Senate version of Trumpcare, we see that one of its central elements is the slashing of Medicaid, a program that 74% of Americans see favorably.
In the House version, which Rep. Bruce Poliquin voted for, 14 million of the 23 million losing coverage were people receiving Medicaid.
The dollars in the 25% Medicaid cut roughly equal the tax cut that overwhelmingly would go to people with the top 1% of income.
As CNBC reports, “The tax cuts include a repeal of a 3.8 percent investment tax — such as capital gains — and a 0.9 percent Medicare payroll tax. Both of those apply to individuals earning $200,000 or more a year and couples earning more than $250,000.” The investment tax break is retroactive to the start of 2017.
There is also a specific tax break for the portion of insurance company executives’ incomes’ over $500,000.
This makes any claims that “we can’t afford Medicaid” to be absurd on their face. Rather, Trumpcare is a flat out transfer of wealth upward.
This chart shows who gets Medicaid and who will get hurt by the 25% cut.
Behind all of these statistics are personal stories of challenge and struggle.
Chart: Percentage of People Medicaid Covers l Source: Margot Sanger-Katz. “G.O.P. Plan is Really a Rollback of Medicaid” June 20, 2017. New York Times. Data sources for chart: Kaiser Family Foundation; Medicaid and CHIP Payment and Access Commission
Thinking about the people in the chart (source), it’s clear that others connected to them will be hurt by the cuts.
For example, the parents of the 60% of children with disabilities getting Medicaid will be hit by losing resources. They’re already dealing with a lot and will have more to contend with.
So will the families of the 64% of nursing home residents getting Medicaid, as will nursing homes themselves. Some family members will have to quit working to take care of their loved one. Some nursing homes will go out of business.
There are other aspects of the bill that are important.
There are cuts in support for people buying insurance.
The law also reduces what plans must cover and what proportion of medical costs have to be covered by insurance plans.
Those provisions will lead to huge increases in costs for many, no matter how one gets coverage.
All of that will be detailed when the CBO score is released.
So this chart doesn’t show all of the damage from Trumpcare — just one part that will be devastating to health care providers, patients and their families.
Without changes, Senate health care bill must be rejected
by The Editorial Board - Bangor Daily News - June 23, 2017
As suspected, a Senate bill to repeal the Affordable Care Act was crafted in secretbecause, like the House Republican version, it will leave millions of Americans without health insurance and force others to pay far more for skimpier health insurance policies. It will also gut Medicaid, defund Planned Parenthood for a year — and lower taxes on wealthy Americans.
Given the destructive consequences that would result, the bill must be significantly altered before it deserves serious consideration in the Senate. If Republican leadership continues to push for a quick vote on the bill, without hearings, debate or full consideration of amendments, responsible senators like Susan Collins must reject it.
“I can’t support a bill that’s going to greatly increase premiums for older Americans or out-of-pocket costs for those who aren’t quite old enough for Medicare yet,” Collins said on Meet the Press Daily Thursday evening. “I cannot support a bill that’s going to result in tens of millions of people losing their health insurance. And I cannot support a bill that is going to make such deep cuts in Medicaid.”
Collins is also concerned that the bill could put more pressure on rural hospitals that are already struggling to provide care. She is also frustrated that there is little attention to reducing health care costs.
Like many others, Collins is upset by the rushed and secret process that resulted in the bill revealed Thursday. There were no hearings while the bill was being drafted. Hearings offer an opportunity for lawmakers to hear from experts and those affected by proposed legislation. This enables them to make more thoughtful and informed decisions.
Unlike the House, the Senate is awaiting an analysis from the Congressional Budget Office before taking action. Its report is expected early next week.
The CBO estimated that the House Republican bill would leave 23 million more people without health insurance by 2026 than if the ACA remains in place. It also concluded that “less healthy people would face extremely high premiums.” Given that the Senate bill is not vastly different in many respects, we expect the CBO will conclude that significant negative consequences will arise from the Senate version as well.
Unlike House Republicans, their Senate colleagues should not brush these consequences aside.
The Senate bill, which was negotiated by a handpicked group of 13 Republican men, does have a couple improvements over the House Republican bill. The biggest is that insurers would not be able to deny coverage to people with pre-existing conditions, nor could they raise premiums for these people. States would, however, be allowed to pare down what are known under the ACA as essential benefits, which insurers must cover. These include maternity care, prescriptions and preventative care. Without coverage, people will have to pay more for these services.
The Senate bill would allow insurers to charge older customers five times more than their younger peers. The House Republican bill allowed states to raise this ratio. The Affordable Care Act capped it at three times more.
Like the House bill, the Senate version will end the current Medicaid expansion, although it will phase out the elimination beginning in 2021. Thirty-two states, but not Maine, participated in the Medicaid expansion. More Americans received health insurance through the expansion than through the marketplaces set up under the Affordable Care Act. The expansion helped many people with substance abuse disorder begin treatment.
Worse, states would be allocated Medicaid funding on a per capita basis, with inadequate adjustments for cost increases over time. Currently, funding is based on recipients’ health care needs, so states with sicker populations, like Maine, would be especially hard hit. About 263,000 Mainers, many in Maine’s poorest counties, rely on Medicaid for care. Nearly a third of Washington County residents are covered by Medicaid; more than a quarter of residents in Aroostook, Piscatquis, Somerset, Oxford and Androsscoggin counties are covered by the public program.
Maine providers already struggle to provide care for the state’s poor, elderly and disabled because Medicaid reimbursement rates are so low. Further reducing them will only make this problem worse, harming vulnerable citizens and health care providers, which are the largest employers in many communities.
The measure of the Senate bill isn’t whether it is better than the House Republican version. It is whether it is better than the Affordable Care Act it would replace. It fails this test.
Shifting Dollars From Poor to Rich Is a Key Part of the Senate Health Bill
by Margot Sanger-Katz - NYT - June 23, 2017
The Affordable Care Act gave health insurance to millions of Americans by shifting resources from the wealthy to the poor and by moving oversight from states to the federal government. The Senate bill introduced Thursday pushes back forcefully on both dimensions.
The bill is aligned with long-held Republican values, advancing states’ rights and paring back growing entitlement programs, while freeing individuals from requirements that they have insurance and emphasizing personal responsibility. Obamacare raised taxes on high earners and the health care industry, and essentially redistributed that income — in the form of health insurance or insurance subsidies — to many of the groups that have fared poorly over the last few decades.
The draft Senate bill, called the Better Care Reconciliation Act, would jettison those taxes while reducing federal funding for the care of low-income Americans. The bill’s largest benefits go to the wealthiest Americans, who have the most comfortable health care arrangements, and its biggest losses fall to poorer Americans who rely on government support. The bill preserves many of the structures of Obamacare, but rejects several of its central goals.
Like a House version of the legislation, the bill would fundamentally change the structure of Medicaid, which provides health insurance to 74 million disabled or poor Americans, including nearly 40 percent of all children. Instead of open-ended payments, the federal government would give states a maximum payment for nearly every individual enrolled in the program. The Senate version of the bill would increase that allotment every year by a formula that is expected to grow substantially more slowly than the average increase in medical costs.
Avik Roy, the president of the Foundation for Research on Equal Opportunity, and a conservative health care analyst, cheered the bill on Twitter, saying, “If it passes, it’ll be the greatest policy achievement by a G.O.P. Congress in my lifetime.” The bill, he explained in an email, provides a mechanism for poor Americans to move from Medicaid coverage into the private market, a goal he has long championed as a way of equalizing insurance coverage across income groups.
States would continue to receive extra funding for Obamacare’s expansion of Medicaid to more poor adults, but only temporarily. After several years, states wishing to cover that population would be expected to pay a much greater share of the bill, even as they adjust to leaner federal funding for other Medicaid beneficiaries — disabled children, nursing home residents — who are more vulnerable.
High-income earners would get substantial tax cuts on payroll and investment income. Subsidies for those low-income Americans who buy their own insurance would decline compared with current law. Low-income Americans who currently buy their own insurance would also lose federal help in paying their deductibles and co-payments.
The bill does offer insurance subsidies to poor Americans who live in states that don’t offer them Medicaid coverage, a group without good insurance options under Obamacare. But the high-deductible plans that would become the norm might continue to leave care out of their financial reach even if they do buy insurance.
The battle over resources played into the public debate. Mitch McConnell, the Senate majority leader, said the bill was needed to “bring help to the families who have been struggling with Obamacare.” In a Facebook post, President Barack Obama, without mentioning the taxes that made his program possible, condemned the Senate bill as “a massive transfer of wealth from middle-class and poor families to the richest people in America.”
In another expression of Republican principles, the bill would make it much easier for states to set their own rules for insurance regulation, a return to the norm before Obamacare.
Under the bill, states would be able to apply for waivers that would let them eliminate consumer protection regulations, like rules that require all health plans to cover a basic package of benefits or that prevent insurance plans from limiting how much care they will cover in a given year.
States could get rid of the online marketplaces that help consumers compare similar health plans, and make a variety of other changes to the health insurance system. The standards for approval are quite permissive. Not every state would choose to eliminate such rules, of course. But several might.
“You can eliminate all those financial protections,” said Nicholas Bagley, a law professor at the University of Michigan. “That would be huge.”
Americans with pre-existing conditions would continue to enjoy protection from discrimination: In contrast with the House health bill, insurers would not be allowed to charge higher prices to customers with a history of illness, even in states that wish to loosen insurance regulations.
But patients with serious illnesses may still face skimpier, less useful coverage. States may waive benefit requirements and allow insurers to charge customers more. Someone seriously ill who buys a plan that does not cover prescription drugs, for example, may not find it very valuable.
There are features that would tend to drive down the sticker price of insurance, a crucial concern of many Republican lawmakers, who have criticized high prices under Obamacare. Plans that cover fewer benefits and come with higher deductibles would cost less than more comprehensive coverage.
But because federal subsidies would also decline, only a fraction of people buying their own insurance would enjoy the benefits of lower prices. Many middle-income Americans would be expected to pay a larger share of their income to purchase health insurance that covers a smaller share of their care.
The bill also includes substantial funds to help protect insurers from losses caused by unusually expensive patients, a measure designed to lure into the market those insurance carriers that have grown skittish by losses in the early years of Obamacare. But it removes a policy dear to the insurance industry — if no one else. Without an individual mandate with penalties for Americans who remain uninsured, healthier customers may choose to opt out of the market until they need medical care, increasing costs for those who stay in.
The reforms are unlikely to drive down out-of-pocket spending, another perennial complaint of the bill’s authors, and a central critique by President Trump of the current system. He often likes to say that Obamacare plans come with deductibles so high that they are unusable. Subsidies under the bill would help middle-income consumers buy insurance that pays 58 percent of the average patient’s medical costs, down from 70 percent under Obamacare; it would also remove a different type of subsidy designed to lower deductibles further for Americans earning less than around $30,000 a year.
Out-of-pocket spending is the top concern of most voters. The insurance they would buy under the bill might seem cheap at first, but it wouldn’t be if they ended up paying more in deductibles.
Mr. McConnell was constrained by political considerations and the peculiar rules of the legislative mechanism that he chose to avoid a Democratic filibuster. Despite those limits, he managed to produce a bill that reflects some bedrock conservative values. But the bill also shows some jagged seams. It may not fix many of Obamacare’s problems — high premiums, high deductibles, declining competition — that he has railed against in promoting the new bill’s passage.
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