Senate G.O.P. Leaders to Unveil Health Care Bill to Try Winning Over Skeptics
by Robert Pear and Thomas Kaplan - NYT - July 13, 2017
WASHINGTON — Senate Republican leaders were poised on Thursday to unveil a fresh proposal to repeal and replace the Affordable Care Act, revising their bill to help hold down insurance costs for consumers while keeping a pair of taxes on high-income people that they had planned to eliminate.
With the revised bill, the majority leader, Mitch McConnell, Republican of Kentucky, is trying to keep alive his party’s seven-year quest to dismantle the health law that is a pillar of former President Barack Obama’s legacy.
Republicans said the revised bill would provide roughly $70 billion in additional funds that states could use to help reduce premiums, hold down out-of-pocket costs and otherwise make health care more affordable. The bill already included more than $100 billion for such purposes.
The new bill, like earlier versions, would convert Medicaid from an open-ended entitlement to a system of fixed payments to states. But in the event of a public health emergency, state Medicaid spending in a particular part of a state would not be counted toward the spending limits, known as per capita caps.
In a departure from current law, the bill would allow insurers, under certain conditions, to offer health plans that did not comply with standards in the Affordable Care Act. Under that law, insurers sell regulated health plans through a public insurance exchange in each state.
A summary of Mr. McConnell’s bill, circulating on Capitol Hill, describes his proposal this way: If an insurer offered “sufficient minimum coverage” on the exchange that remains subject to federal mandates in the Affordable Care Act, it could also offer coverage outside the exchange that would be exempt from many of those mandates.
Policies that comply with the Affordable Care Act would provide more extensive coverage but would also attract sicker people with higher medical costs. To address this concern, the Republican bill would create a fund to make payments to insurers for the costs of covering high-risk people enrolled in health plans on the exchanges.
People who enroll in catastrophic health insurance plans would be eligible for federal tax credits to help pay premiums. Such plans typically have lower premiums and high deductibles. But under the Affordable Care Act, consumers generally cannot use the tax credits for such plans.
The bill would, for the first time, allow people to use tax-favored health savings accounts to pay insurance premiums. Republicans said this policy change would increase health care coverage.
The bill also provides $45 billion to help combat the opioid abuse crisis — a provision that is particularly important to two Republican senators who opposed the previous version of the bill, Rob Portman of Ohio and Shelley Moore Capito of West Virginia.
The new draft bill would not include any changes from current law to the net investment income tax or the additional Medicare payroll tax paid by certain high-income people. Nor would it change the limits on the tax deductions that insurers can take for salaries and other remuneration paid to top executives.
The Senate is, in effect, trying to catch up with the House, which on May 4 narrowly approved a bill to repeal and replace much of the Affordable Care Act.
To succeed, Mr. McConnell must win over almost all the holdouts in his caucus, a daunting and delicate task given the litany of complaints he faces and the sharp policy differences that he must find a way to bridge.
The revised bill is broadly similar to the earlier measure that Senate leaders hoped to vote on before the Fourth of July recess, though the new version includes some additional provisions meant to entice reluctant Republican senators with varying policy concerns.
Like the previous bill, it would end the requirement that most Americans have health coverage, and it would make deep cuts to Medicaid, capping payments to states and rolling back its expansion under the Affordable Care Act. Though some Republican senators expressed concern about how the previous bill would affect Medicaid, Senate leaders stuck with the same approach in the new version.
n a notable change, the bill would keep the two taxes imposed by the Affordable Care Act on people with high incomes: the 3.8 percent tax on investment income and the 0.9 percent payroll tax. The taxes apply to individuals with income over $200,000 and couples with income over $250,000.
Both of those taxes would have been repealed under the previous Senate bill, reducing federal revenue by about $231 billion over a decade, according to the congressional Joint Committee on Taxation.
Mr. McConnell is trying to avoid a repeat of his first attempt to push his bill through the chamber, when he was forced to delay a vote planned for late last month because of opposition from Republican senators.
Already, Senator Rand Paul of Kentucky has said he will vote against beginning debate next week, and Senator Susan Collins of Maine is viewed as likely to vote against it as well, though for different reasons. If one more Republican joined them, the bill could not even be considered.
During debate on the bill, senators are expected to propose numerous amendments on the Senate floor, some of which could modify provisions of the bill affecting Medicaid.
Republicans expect that an analysis of the new bill will be released by the nonpartisan Congressional Budget Office early next week. The previous bill would have increased the number of people without health insurance by 22 million in 2026 compared with the Affordable Care Act, the budget office found.
Mr. McConnell has said he intends to take up the revised bill next week, although it is unclear if he would try to move ahead if he did not know for sure whether he had the votes to begin debate — or to ultimately pass the bill.
A Scary New Senate Health Care Bill
by The Editorial Board - NYT - July 13, 2017
Republican leaders in the Senate have accomplished what seemed impossible a few weeks ago: They have made their proposal to destroy the Affordable Care Act even worse.
On Thursday, the majority leader, Mitch McConnell, produced revised legislationthat could effectively make it impossible for many people with pre-existing medical conditions to afford the treatment they need. Even people who are healthy now could find themselves unable to pay for comprehensive health insurance when they become sick. In addition, the bill still includes drastic cuts to Medicaid, which provides care to about 70 million people. In essence, the Senate leader just swatted away the concerns of Republican senators and governors who questioned those cuts.
The initial version of the Senate bill would have taken health insurance away from 22 million people, the Congressional Budget Office found. Experts say that the number could rise once Mr. McConnell’s changes are factored in.
It was always going to be hard for Mr. McConnell to pass his bill, given that he has a slim majority of 52 and refuses to work with Democrats. He has chosen to make the legislation more appealing to conservatives like Ted Cruz of Texas, rather than to centrists like Susan Collins of Maine.
Ms. Collins and Senator Rand Paul of Kentucky said on Thursday that they are opposed to the current version of the bill, so Mr. McConnell can’t afford to lose anyone else. The question now is, has he done enough to win over senators like Dean Heller of Nevada, Lisa Murkowski of Alaska, Shelley Moore Capito of West Virginia and Rob Portman of Ohio? The answer is most likely no. The changes meant to appeal to them amount to crumbs. For example, the new version includes $45 billion to help states fight the opioid epidemic. Gov. John Kasich of Ohio, who opposed the original bill, has said that this level of federal spending on this huge problem would be “like spitting in the ocean.”
Mr. McConnell is also trying to make his legislation look less extreme by continuing some of the taxes from the A.C.A., or Obamacare, rather than jettisoning them all. But this is not a big improvement, because a majority of the taxes in the Obama-era law that helped pay for expanded health coverage would still be lost. In addition, the revised bill would expand the use of tax-free health savings accounts, which primarily benefit rich families.
The biggest losers in the new bill are the sick. A provision by Mr. Cruz would let insurers discriminate against people with pre-existing conditions. And they would be allowed to sell plans that do not cover essential services, which would be cheaper and attract healthier people. They would still have to offer comprehensive plans to everyone, but those policies would cost a lot more because they would attract sicker patients. That is why the American Cancer Society’s Cancer Action Network said the bill “would significantly weaken the ability of millions of cancer patients, survivors and those at risk for the disease to find and afford adequate, meaningful health care coverage.”
Mr. McConnell wants to hold a vote on his legislation early next week. Congressional aides say he might even proceed before the C.B.O. can analyze all the changes. Senators who vote for this bill will send a simple message to their constituents: Get sick, and you are on your own.
McConnell to release new GOP health plan allowing bare-bones insurance policies
by Sean Sullivan, Kelsey Snell and Julie Eilperin - Washington Post-July 13, 2017
Senate GOP leaders plan to unveil a revised health-care proposal Thursday that would allow insurers to sell austere plans that do not comply with requirements imposed under the Affordable Care Act, according to three Republicans familiar with the plans.
The Republicans, who spoke on condition of anonymity because they were not authorized to speak on the record, said the proposal would incorporate a version of a controversial proposal from Sen. Ted Cruz (R-Texas), which conservatives have been pushing vocally during the last few weeks in an effort, they say, to lower premiums and give consumers more choices.
Details of the proposal were closely guarded Thursday morning, and it was unclear what precise form the Cruz idea would take in the final bill.
Cruz’s plan would allow insurers to sell plans that don’t comply with Obamacare coverage requirements, such as mandated coverage of preventive care and mental and substance abuse treatment, provided they offer at least one that does.
Critics, including insurers, believe that providing the option of skimpier plans would draw younger, healthier consumers into a separate risk pool. That development would drive up rates for the Americans buying more comprehensive coverage on the individual market, which could in turn destabilize the entire market. It remains unclear how the new McConnell bill would address concerns about the risk pools.
Senate Democrats attacked the amendment proposed by Sen. Ted Cruz (R-Tex.) to the Senate Republicans' health-care bill as "a hoax" that would eliminate protections for people with preexisting conditions on July 11. (The Washington Post)
Senate leaders are leaving themselves the option of jettisoning the Cruz proposal, however, after they get a Congressional Budget Office analysis early next week that will gauge its impact on both the budget and the overall number of uninsured.
Majority Leader Mitch McConnell (R-Ky.) is expected to brief Republican senators on the revamped bill to roll back key parts of the Affordable Care Act at 11:30 a.m., according to Republican senators and aides.
A GOP senator and other Republicans familiar with the effort said they expect the new bill to offer more generous insurance subsidies than the first version. Republicans also said McConnell is willing to preserve a pair of taxes on wealthy Americans that would have been repealed under the original bill.
Senate Majority Whip John Cornyn (R-Texas) said Thursday that he expects the CBO will release two scores for the bill but would not confirm what those scores would include or when when will be released.
“We are expecting a CBO score but I can’t tell you exactly what the format will be,” Cornyn told reporters. “The Lee and Cruz amendment will be scored.”
The Cruz amendment underwent several iterations in recent weeks and the proposal is still being considered by analysts at the CBO, according to two GOP aides familiar with the process. As a result, the CBO is expected to release one score without the Cruz provisions and another that will provide further details on the Cruz amendment.
The changes remain controversial among moderates who worry the Cruz proposal could drive up premiums for sicker, older Americans and Cornyn stopped short of promising the changes would be enough to ensure the bill will pass.
“We will have the votes when we start voting,” Cornyn said.
The release will come a day after President Trump intensified public pressure on McConnell to shepherd the bill to passage, even as it remains unclear that he will have the votes to do that next week, when he intends to bring it to the Senate floor.
“I am sitting in the Oval Office with a pen in hand, waiting for our senators to give it to me,” Trump said in an interview with televangelist Pat Robertson of CBN News. “It has to get passed. They have to do it. They have to get together and get it done.”
Conservative lawmakers and activists have voiced concerns that McConnell’s revamped measure will not undo the ACA, known as Obamacare, aggressively enough. Those worries, alongside lingering anxiety among centrist Republicans that the bill is going too far, has put McConnell at serious risk of losing more GOP votes than he can afford. If more than two GOP senators defect, the bill cannot pass.
Cruz has argued that his idea would provide consumers with more choice. But critics assert that it would lead to less healthy people ultimately paying more for coverage.
Sen. Bob Corker (R-Tenn.) said he believes McConnell will release two versions of the revised bill on Thursday — one with Cruz’s amendment and one without it. GOP leaders were more circumspect.
“It needs to be in the underlying text,” Cruz told reporters Wednesday, dismissing the suggestion that he could instead introduce it during an open amendment process if and when the bill heads to the Senate floor.
McConnell hopes to have a score on his revised bill from the nonpartisan Congressional Budget Office by the beginning of next week. The CBO will forecast what the bill will do to insurance coverage levels nationwide over the next decade. It will also predict the measure’s impact on the federal budget deficit.
Table Russia, Focus on Health Care
by David Leonhardt - NYT - July 13, 2017
Time for an update on the Senate’s health bill, and it’s not an encouraging one.
As I’ve feared, the Senate may try to repeat a version of the House’s “Upton strategy,” in which it makes modest, last-minute tweaks and pretends those tweaks fix the bill’s enormous problems.
In the House, an amendment from Fred Upton, a Michigan congressman, was the vehicle for doing so. In the Senate, changes to an amendment from Ted Cruz could be.
“As with the Upton Amendment in the House, these changes would do little or nothing to mitigate the harm the bill would cause,” Jacob Leibenluft, a former Obama administration official now at the Center for Budget and Policy Priorities, wrote to me.
“But Senate leadership would portray them as addressing concerns from both moderates and the right — without giving CBO (or the public) time to debunk their efficacy,” Leibenluft added.
The Cruz amendment would effectively remove insurance protections for sick people, hurting many middle-income people between the ages of 50 and 65. It would make a bad bill even worse. Yet fixing some of the Cruz amendment’s problems wouldn’t come close to fixing the overall bill.
The next few days seem crucial. Senate Republicans are meeting today and plan to unveil their new bill. Mitch McConnell, the Republican leader, has vowed to vote on a motion to proceed next week.
There is a risk that the Russia news, important though it is, will keep people from paying attention to what’s going on in the Senate. Millions of Americans’ access to decent health care is at stake.
If you want more details, the Twitter feeds of Topher Spiro and Andy Slavitt are informative and timely. So is the feed of Dr. Esther Choo, one of the forces behind the doctors’ video I described in a previous newsletter.
Today’s lead piece from The Times editorial board also addresses health care.
The Center on Budget and Policy Priorities has two helpful explainers. One, by Aviva Aron-Dine and Leibenluft, lays out why keeping some of Obamacare’s tax increases isn’t as big of a deal as it may seem. “Thus far,” they write, “none of the specific reported changes to the Senate health bill would alter its core structure or meaningfully reduce the severe harm it would do.”
The other analysis, by Sarah Lueck, details the many problems with the Cruz amendment. Margot Sanger-Katz of The Times has also analyzed Cruz’s plan, explaining his policy rationale.
The Cruelty and Fraudulence of Mitch McConnell’s Health Bill
by Paul Krugman - NYT - July 13, 2017
A few days ago the tweeter in chief demanded that Congress enact “a beautiful new HealthCare bill” before it goes into recess. But now we’ve seen Mitch McConnell’s latest version of health “reform,” and “beautiful” is hardly the word for it. In fact, it’s surpassingly ugly, intellectually and morally. Previous iterations of Trumpcare were terrible, but this one is, incredibly, even worse.
Before I get to what makes it worse, let’s talk about the one piece of the new bill that may sound like a step in the right direction, and why it’s largely a scam.
The original Senate bill got a lot of justified bad press for slashing Medicaid while offering big tax cuts for the rich. So this version rolls back some though by no means all of those tax cuts, which sounds like a concession to moderates.
At the same time, however, the bill would allow people to use tax-favored health savings accounts to pay insurance premiums. This effectively creates a big new tax shelter that mostly helps people with high incomes who (a) can afford to put a lot of money into such accounts and (b) face high marginal tax rates, and hence get big tax savings.
So this is still a bill that takes from the poor to give to the rich; it just does so with extra stealth.
Still, this tax shuffle does give McConnell a bit more money to play with. So how does he address the two big problems with the original bill — savage cuts to Medicaid and soaring premiums for older, less affluent workers? He doesn’t.
Aside from a few tweaks, those brutal Medicaid cuts are still part of the plan — and yes, they are cuts, despite desperate Republican attempts to pretend that they aren’t. The subsidy cuts that would send premiums soaring for millions are also still there.
The good stuff, such as it is, involves some new money for the opioid crisis, some (but not nearly enough) money for patients at especially high risk, and some additional aid for insurers — you know, the same thing Republicans denounced as outrageous corporate welfare when Democrats did it.
The most important change in the bill, however, is the way it would effectively gut protection for people with pre-existing medical conditions. The Affordable Care Act put minimum standards on the kinds of policies insurers were allowed to offer; the new Senate bill gives in to demands by Ted Cruz that insurers be allowed to offer skimpy plans that cover very little, with very high deductibles that would make them useless to most people.
The effects of this change would be disastrous. Don’t take my word for it: It’s what the insurers themselves say. In a special memo, AHIP, the insurance industry trade group, warned against adopting the Cruz proposal, which would “fracture and segment insurance markets into separate risk pools,” leading to “unstable health insurance markets” in which people with pre-existing conditions would lose coverage or have plans that were “far more expensive” than under Obamacare.
Or to put it another way, this bill would send insurance markets into a classic death spiral. Republicans have been predicting such a spiral for years, but keep being wrong: All indications are that Obamacare, despite having some real problems, is stabilizing, and doing pretty well in states that support it. But this bill would effectively sabotage all that progress.
And let’s be clear: Many of the victims of this sabotage would be members of the white working class, people who voted for Donald Trump in the belief that he really meant it when he promised that there would be no cuts to Medicaid and that everyone would get better, cheaper insurance. So why are Republican leaders pushing this? Why is there even a chance that it might become law?
The main answer, I’d argue, is that what would happen if this bill passes — a big decline in the number of Americans with health insurance, a sharp reduction in the quality of coverage for those who keep it — is what Republicans have wanted all along.
During the eight-year jihad against the Affordable Care Act, of course, the G.O.P. pretended otherwise: denouncing Obamacare for failing to cover everyone, attacking the high out-of-pocket expenses associated with many of its policies, and so on. But conservative ideology always denied the proposition that people are entitled to health care; the Republican elite considered and still considers people on Medicaid, in particular, “takers” who are effectively stealing from the deserving rich.
And the conservative view has always been that Americans have health insurance that is too good, that they should pay more in deductibles and co-pays, giving them “skin in the game,” and thus an incentive to control costs.
So what we’re seeing here is supposed to be the last act in a long con, the moment when the fraudsters cash in, and their victims discover how completely they’ve been fooled. The only question is whether they’ll really get away with it. We’ll find out very soon.
Revised Senate Health Bill Tries to Win Votes, but Has Fewer Winners
by Margot Sanger-Katz - NYT - July 13, 2017
The revised Senate health bill has a dwindling list of winners and a bigger pool of potential losers.
It would still make insurance much less affordable for poorer and older Americans who don’t get coverage through work or Medicare. It would make that insurance less valuable for many people with the most significant health care needs. The biggest beneficiaries of the original bill — the rich — would get less.
The new draft bill, released Thursday, is full of small tweaks and goodies throughout, but its most substantial policy change came at the behest of two Senate conservatives, Ted Cruz of Texas and Mike Lee of Utah. They wanted to roll back the Affordable Care Act’s regulations of health insurance, and largely got their wish. The Senate majority leader, Mitch McConnell, faced with objections to his original health care bill from both moderate and conservative Republicans, took a step to the right.
Mr. Cruz championed the change as a way to improve consumer choice and reduce the cost of insurance for Americans who do not have serious health care needs. It would, indeed, give some young and healthy consumers a chance to buy cheaper plans.
But the bill would partly roll back popular consumer protections that are required under Obamacare. Insurers would be free to offer skimpy, no-rules plans that could exclude people with prior illnesses, strip out major benefit categories, like prescription drugs, and limit the total amount of care they will cover. In exchange, carriers would also need to offer a set of more comprehensive plans, and the federal government would set aside a fund to help make those plans affordable for sicker Americans.
The Senate bill would still make fundamental changes to Medicaid, which covers poor and disabled Americans, including two-thirds of all nursing-home residents. And it would still ask middle-income Americans to pay a larger share of their incomes for health plans with higher deductibles. Moderate Republicans had asked for changes that would make the bill more generous to poor and elderly Americans who would lose out, and those requests were largely ignored.
But the bill eliminates big cuts in payroll taxes and investment taxes for the wealthy, blunting one of the most resonant Democratic lines of attack against the effort. Still on the winners ledger: tanning salons, medical device manufacturers, pharmaceutical companies and health insurers, which all still would get a tax cut.
The revision with the biggest implications for consumers is the Cruz amendment. Two of the biggest insurance industry groups, which have been largely silent as the health debate has played out, spoke out Wednesday in opposition to the amendment. America’s Health Insurance Plans and the Blue Cross Blue Shield Association indicated that they did not wish to operate in the regulatory landscape created by the bill, which they said would split the insurance market in two.
Sicker patients would be likely to flock to more comprehensive coverage, driving up prices, while healthier patients would be more likely to choose stripped-down plans with fewer benefits and financial protections. Those slimmer plans could be a good deal for some Americans in good health, particularly upper-middle-class professionals, whose premiums have risen under the Affordable Care Act.
But those customers could be at a disadvantage once they become sick, since the rules-free plans could be canceled at the end of the year, and premiums would be likely to rise sharply for the heftier plans that would take all comers.
(Mr. Lee, in a statement, said he was still unsure if he would vote for the bill, because he disagrees with some of the fine print in the wording of the provision.)
Actuaries were puzzling over the details Thursday afternoon. “How could this work? I don’t see how,” said Cori Uccello, senior health fellow at the American Academy of Actuaries.
Mr. McConnell’s decision to include Mr. Cruz’s idea mirrors the choice by House Speaker Paul Ryan, who added a deregulatory amendment to the House’s version of the health care bill to help it pass. But the two solutions, each designed to make insurance less expensive for the young and well, are different. The House bill would have asked states to fund special high-risk pools for customers shut out of a broadly deregulated market.
The Senate bill would establish open-ended federal funding for middle-income consumers in that market, by allowing them to use income-based tax credits to help them buy the heftier health plans. People earning more than about $42,000 a year, however, would face sharp premium increases. The bill also sets aside an additional $70 billion over a decade for the federal government to pay directly to insurers that offer plans in that market.
Mr. McConnell held firm against the principal request of Senate moderates: He did not give them substantially more money for state Medicaid programs. Since its creation in 1965, Medicaid has operated as an open-ended partnership between the federal government and the states, with each paying a share of beneficiaries’ medical bills.
The new bill would limit federal spending on the program, shifting an increasing share of its cost to states over time. It would also cut back new funding, established under the Affordable Care Act, to help states insure more poor adults. The nonpartisan Congressional Budget Office estimated that the changes would result in 15 million fewer poor Americans with coverage through the program by 2026.
But even with those cuts, the bill still spends a lot, in assorted inducements for votes. It adds $45 billion in funding for opioid addiction treatment and research, a response to concerns from moderate Republicans, particularly Rob Portman of Ohio and Shelley Moore Capito of West Virginia, who are worried that the drug overdose epidemic would be worsened by the bill’s cuts to Medicaid.
It includes exceptions to the spending caps for declared public health emergencies, a request from Senator Marco Rubio of Florida. His state has been hard hit by the mosquito-borne Zika virus, which causes birth defects. The bill changes a Medicaid formula in a way that benefits states that expanded Medicaid recently: Louisiana, Montana and Alaska, although the Alaska senator Lisa Murkowski has withheld support for the bill. It increases federal Medicaid spending on care for Native Americans, a change that would help states with large native populations, including Arizona, Alaska and North Dakota.
The bill sets aside extra money to help insurance markets with very high health care costs. That provision would benefit only Alaska, handing the state hundreds of millions of dollars in federal funding.
Whether moderates will be satisfied with these smaller sweeteners is unclear. Rand Paul of Kentucky has said he won’t vote for the bill, criticizing it from the right. Among more moderate Republicans, so far only Susan Collins of Maine has said she would block the bill if asked to vote on it in its current form. Mr. McConnell can spare only two defections if he hopes to pass the bill.
Health Care Compromise: Not Likely!
by Steve Rattner - NYT - July 13, 2017
The latest version of the Republican health care bill was unveiled today and within moments, two Republican senators announced their opposition. One more “no” and the bill goes down.
That may lead to renewed talk of the fanciful notion of a bipartisan compromise between the more moderate elements of each party. Before today’s release, Senate majority leader Mitch McConnell even suggested he might reach out to his Democratic counterpart, Chuck Schumer (who has reciprocated by signaling a willingness to work together.)
Yeah, and I’m about to discover oil in my backyard.
The chances of Republicans and Democrats finding common ground on almost any issue are small, and on health care they are infinitesimal.
For one thing, the two parties have become far more polarized across the spectrum of issues. That’s not just an oft-repeated perception; it’s a fact backed up by research.
As the chart below shows, political scientists have used voting records to demonstrate that the degree of extremism in the Congress is greater today than at any time since Reconstruction.
To be sure, the two sides still manage to agree occasionally. The Senate voted 98-2 to impose tougher sanctions on Iran and Russia. And some kind of compromise involving spending on infrastructure and reform of corporate taxation is vaguely imaginable.
But among the possibilities for common ground, health care isn’t one of them. Deep philosophical differences — particularly as to the role of government — separate the two sides.
Since the passage of the Affordable Care Act, the Democrats have, if anything, moved closer philosophically to the idea of a single-payer program in which the government provides all Americans with guaranteed health care in return for modest premiums, similar to what it does with Medicare.
To a considerable degree, that shift reflects the rising influence within the Democratic Party of its more progressive wing, led by Senators Bernie Sanders and Elizabeth Warren. Their faction believes that a more government-driven policy agenda would have led to a different outcome in the 2016 election.
On the other side, the Freedom Caucus in the House and its fellow travelers in the Senate led by Ted Cruz and Rand Paul want the federal government extricated from the health care sector to the fullest extent possible.
In their minds, regulatory oversight would largely be the province of the states, but even better, the free market would be left to work. In addition, programs like Medicaid would be transformed from entitlements (which just means that every qualified American would receive assistance) to block grants or per capita cap programs, leaving millions unaided.
Some serious people think that gap can be bridged. Really?
Not even the most centrist Democrats — senators like Joe Manchin of West Virginia and Heidi Heitkamp of North Dakota — have shown the slightest sign of backing off from the key elements of the Affordable Care Act.
The Republicans are divided between those who want to flat-out repeal Obamacare and those who want to eviscerate many of its key elements.
The differences between the two sides were not always so great. Remember that the core principles of Obamacare were embraced by conservatives back in the 1990s as a more market-based alternative to the more government-oriented plan promoted by Hillary Clinton when she was the first lady.
And the same conservative principles were adopted by Mitt Romney in his health care plan while he was governor of Massachusetts.
Those conservative ideas still make sense. If Republicans are serious about working across the aisle, they should recall the genesis of those ideas and accept that the fundamental core of the A.C.A. must remain intact.
Sure, some changes — even some alterations favored by Republicans — would make the national health care program work better.
In particular, to keep premiums down, we need to improve the functioning of the exchanges on which individuals not covered by employers can purchase insurance by encouraging greater participation by younger, healthier Americans. Accomplishing that would require greater enforcement of the requirement to buy insurance, including stiffer penalties, instead of the administration’s approach of essentially signaling that no one will be punished for not participating.
But we should also adopt a Republican proposal to scrap the current provision that insurance for older Americans can’t cost more than three times what younger Americans pay (and include higher subsidies for needy older Americans). That was a well-meaning attempt to keep premiums down for those nearer retirement, but instead it has meant prices so high for younger enrollees that many have chosen to drop out.
Other Republican ideas, like reforming how Medicaid services are delivered, are worthy of consideration, but let’s have genuine experiments, not clandestine efforts to eviscerate the program.
Last, the federal government needs to give more certainty to insurers by continuing to fund cost-sharing subsidies (for low-income people to cover their deductibles and co-pays) and help states create adequate reinsurance pools to cushion insurers against losses.
Most important, if the two sides genuinely want a better health insurance system, they need to provide all participants with an assurance that the rules won’t keep changing with every election.
Sen. Collins says she won’t support latest version of Senate health care bill
On Twitter, she says proposed cuts to Medicaid mean she could not vote for passage of the Republican-crafted Better Care Reconciliation Act, and says she would be willing to work with Democrats to fix the Affordable Care Act instead.
by Colin Woodward - Portland Press Herald - Portland Press Herald - July 13, 2017
Maine’s senior U.S. senator cites deep cuts to Medicaid as her reason, but offers to work with Democrats to fix Obamacare.
U.S. Sen. Susan Collins of Maine says she will not support passage of the newest version of a health care bill developed by her Senate Republican colleagues.
The reworked bill, unveiled Thursday, still proposes deep cuts in Medicaid, which would be converted to a block grant program to the states. Collins’ support was considered critical to the bill’s passage because Republicans can only afford to lose two of their members’ votes and still pass the bill in the face of universal opposition from Democrats.
“Still deep cuts to Medicaid in Senate bill. Will vote no on MTP,” Collins tweeted Thursday afternoon, referring to the necessary Motion to Proceed. “Ready to work w/ GOP & Dem colleagues to fix flaws in ACA,” the Affordable Care Act.
Collins was quoted by a Buzzfeed reporter as saying the “only thing that could change that is if (Congressional Budget Office) analysis … indicates that there would be far fewer changes in Medicaid than I believe.”
Collins had signaled earlier in the week that she was opposed to the proposed Medicaid cuts, and Senate Majority Leader Mitch McConnell’s decision to keep such cuts in the bill has been interpreted as a gamble that she and other moderates would back down. Other Republican senators who have expressed concerns about Medicaid cuts include Lisa Murkowski of Alaska, Dean Heller of Nevada, Rob Portman of Ohio, John Hoeven of North Dakota and Shelley Moore Capito of West Virginia, all representing states that expanded Medicaid under the ACA, also known as Obamacare.
Collins, who is entertaining a gubernatorial bid, has hinted that she might be open to expanding the program in Maine, a move that Gov. Paul LePage has consistently opposed. She did not respond to an interview request Thursday.
Sen. Rand Paul, R-Ky., announced just before 2 p.m. that he also would oppose the bill, although for different reasons, and Sen. John McCain,, R-Ariz., said he would not vote for it in its current form.
Maine’s other U.S. senator, independent Angus King, denounced the latest Republican version of the health bill in a prepared statement Thursday afternoon.
“This bill is no more encouraging than the last, which is to say it’s still terrible,” King said. “It still includes drastic cuts to Medicaid that will hurt Maine seniors, children and people with disabilities. It still shifts costs to the states. It still has inadequate funding for opioid treatment, and now, by presenting barebones plans, it’s going to drive up the cost of insurance for older, sicker people and likely put health care out of reach for them. None of this is good for Maine.”
King also criticized Senate Republican leaders for crafting a bill in secret that would affect millions of people’s lives and one-sixth of the U.S. economy, calling the process “simply atrocious” and “totally inconsistent with how the Senate was designed to make laws.”
“The Senate needs to abandon this approach and, instead, work in a bipartisan manner to make meaningful improvements to the Affordable Care Act,” he said.
Minutes before McConnell released the latest bill, two other Republican senators, Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, announced they were working with Republican colleagues on alternative legislation. Their bill, outlined in media interviews Thursday, appeared similar to one touted earlier this year by Cassidy and Collins, and would keep many of the ACA’s taxes in place while allowing individual states broader latitude in crafting their own health care plans.
“We’re going to see which one can get 50 votes,” Graham told CNN, referring to the number of Republican senators needed to pass the bill.
Collins’ office did not respond to a request for comment on the Graham-Cassidy bill.
Obamacare Is Not Collapsing, Imploding or Exploding
by The Editorial Board - NYT - July 13, 2017
The biggest lie that President Trump and other Republican leaders have been repeating about the Affordable Care Act for years is that it is collapsing, imploding or exploding. The truth is that the law is actually working reasonably well, and even the part that has shown the most weakness — the health insurance marketplaces — has been stabilizing.
Insurers that sell policies to individuals and families are doing better financially than in the first two years of the A.C.A. They are also doing better than they were before the federal and state governments opened the marketplaces in 2014, according to a Kaiser Family Foundation report published on Monday. The data showing improvement confirms earlier reports by Standard & Poor’s, the Congressional Budget Office and research groups that were based on 2016 numbers. While there are still problems in marketplaces in some states, the A.C.A., or Obamacare, is hardly coming undone.
Yet Republicans in Congress and the Trump administration continue to peddle horror stories about the A.C.A. as they try to gather the votes for repeal of major provisions of the law. To that end, the Senate majority leader, Mitch McConnell, says he will present a new version of his health care bill on Thursday. His earlier proposal would take health insurance away from 22 million people and raise premiums for millions of others, according to the C.B.O. There is no indication that the changes he has in mind will meaningfully improve that dreadful legislation.
Many Americans who do not get health insurance through employers have been frustrated with the marketplaces. The launch of HealthCare.gov by the Obama administration was disastrous. And the insurance policies have high deductibles and premiums that are unaffordable to many people, because the law did not provide enough subsidies to middle-income families. Insurers did a poor job designing their policies and suffered big losses initially, forcing them to raise premiums even more. Republicans also weakened the markets by repealing provisions meant to stabilize them and by filing a lawsuit to reduce federal subsidies. Despite these challenges, more than 10 million people have bought policies on the marketplaces. Most have been protected from big premium increases through subsidies.
Insurers suffered big losses in the early years, in part because many families who had not had comprehensive health insurance for years signed up and needed more care than the average family. Now, the medical costs for people with marketplace plans are more in line with those for people insured through employers.
But insurance markets in some states, like Arizona, Iowa and Tennessee, remain fragile, and few insurers are willing to sell policies there. There are several reasons. It is harder to do business in rural areas where there are few customers and fewer providers. Insurers fear that the Trump administration will make good on the president’s threats to stop making subsidy payments. And in some places, a few very sick and very expensive patients have driven up the cost of insurance.
Mr. McConnell’s bill would make things much worse. It would greatly reduce subsidies available to help people buy insurance. The new version might include a terrible proposal by Senator Ted Cruz of Texas to allow insurers to sell skimpy policies that are cheaper but do not meet the requirements of the A.C.A., if they also offer ones that do. That means comprehensive plans would be bought mainly by people with expensive medical needs, like pregnant women and cancer patients, and push premiums up. That would lead to fewer people buying policies, the industry group America’s Health Insurance Plans said Wednesday.
The A.C.A. is not perfect, but its problems are fixable. In fact, 71 percent of Americans want Republicans to work with Democrats to improve the law; just 23 percent want lawmakers to repeal and replace it, according to a Kaiser poll. Democrats have said they would be willing to work with Republicans to strengthen the law. But Mr. McConnell and his party have become so blinded by their rage against Obamacare that they are losing sight of what ought to be their goal: safeguarding the health of their constituents.
Medicare For All Is Coming, No Matter What They Say
by Richard Eskow - Common Dreams - July 12, 2017
The idea of Medicare for All, or single-payer health care, has grown in popularity so quickly that it was recently an answer on the quiz show Jeopardy:
More than half of all Americans, 53 percent, now want a single-payer plan, up from 40 percent in 1998-2000.
But at the same time, Medicare for All suffers from the rise of a new growth industry: telling Americans what can’t be done to make their lives better. It seems like the nation that used to pride itself on its “can-do” spirit is constantly being told, “No, we can’t.” Why do critics oppose this idea, which could improve the lives of so many?
Bernie Opens the Door
Bernie Sanders’ presidential candidacy injected the single-payer idea into the political discourse. That created an opening for Democrats to embrace the idea as they seek to oppose Republican efforts to dismantle Obamacare. These include, significantly, Sen. Elizabeth Warren of Massachusetts.
“President Obama tried to move us forward with health care coverage by using a conservative model that came from one of the conservative think tanks that had been advanced by a Republican governor in Massachusetts,” Warren recently said. “Now it’s time for the next step. And the next step is single-payer.”
Yet even as the idea grows in popularity, opposition to it has become more vocal. Much of that opposition adopts the world-weary pose of the seasoned professional who has abandoned the idealism of his youth and is regrettably forced pass his disillusionment on to those who are more naïve.
Krugman for the Opposition
One example of this world-weary opposition is a 2016 column by economist Paul Krugman column entitled “Health Reform Realities.” Krugman argues that Obamacare is the left’s “biggest political success in almost half a century,” that “incumbent players” like insurance companies are “too powerful,” that there would be disruption in a switch to single-payer (more about that shortly), and that it would be “difficult to make that case to the broad public” that they will save more money from out-of-pocket health costs than they will spend in new taxes.
Krugman reiterates this argument in a recent op-ed, writing: “Most of the health economists I know would love to see single-payer — Medicare for all. Realistically, however, that’s too heavy a lift for the time being.”
Elsewhere, Krugman approvingly quoted Ezra Klein, another healthcare “realist,” for dismissing a major overhaul of the health system as “puppies and rainbows.” Condescending phrases like that are a key element of the “world-weary” style.
Krugman argues that Medicare For All is politically unachievable, despite its growing popularity. But when he’s confronted with a real political problem – Republican governors’ unwillingness to work with Obamacare’s Medicaid provisions – he waves the problem away, saying only that “Republicans show no interest in making that happen.”
A health plan whose ultimate success relies on cooperation from Republican politicians and for-profit insurance companies? Now that’s “puppies and rainbows.”
False Hopes
But then Krugman has been misjudging the politics of healthcare for at least a decade now. In the 2007 primaries, a mandate-driven plan much like “Obamacare” was proposed by John Edwards and quickly embraced by Hillary Clinton. Krugman insisted on characterizing it as “universal health coverage.” We chided him for it at the time, since it was always clear (or should have been) that many people would remain uninsured under such a program.
Krugman also misinterpreted a 2009 poll somewhat. The poll, conducted by the Boston Globe and the Harvard School for Public Health, found that 79 percent of Massachusetts residents wanted to keep the law. A closer reading indicated the political dangers facing Obamacare. Support for the law had begun to slip, even without the Republican onslaught that everyone should have seen coming at the national level. Residents were “evenly split” on whether the law could continue without changes. A majority wanted to see the law changed, with cost reductions being the primary concern.
Health care costs, even after the Affordable Care Act, are at crisis levels. The actuarial firm Milliman calculates that the average family of four with “good” employer-based PPO coverage will pay more than $11,000 in out-of-pocket expenses this year. So when Krugman writes that “most Americans under 65 are covered by their employers and are reasonably happy with that coverage,” and that “they would understandably be nervous about any proposal to replace that coverage with something else” – well, I wouldn’t be so sure about that.
The Trillion-Dollar Miscalculation
The Washington Post Editorial Board took a harder line than Krugman, weighing in recently with an editorial entitled, “Single-payer health care would have an astonishingly high price tag.” The “astonishing” figure is derived, not from a dispassioned analysis of all health plans, but from a single, hihgly controversial analysis of a single plan. The Urban Institute reviewed Bernie Sanders’ single-payer proposal in 2016 and concluded that it would increase government spending by $32 trillion over ten years. Single-payer opponents have been citing that figure ever since.
But that figure is “ridiculous,” according to Steffie Woolhandler and David Himmelstein of the City University of New York School of Public Health and Harvard Medical School. In a detailed rebuttal, they note that the Urban Institute’s findings “project outlandish increases in the utilization of medical care, ignore vast savings under single-payer reform, and ignore the extensive and well-documented experience with single-payer systems in other nations – which all spend far less per person on health care than we do.”
The Post’s editors insist that “the public piece of the American health-care system has not proven itself to be particularly cost-efficient,” but this is misleading at best. Medicare, our country’s only nationally-run health system, has much lower overhead costs and inflation rates than private-sector health care. You could even say they’re “astonishingly” lower:
Medicare’s overhead amounts to 2 percent of total costs, versus 12-14 percent for private insurers, while annual cost increases between 2010 and 2015 were 1.4 percent for Medicare and more than double that (3.0 percent) for private insurance.
It’s true that our government’s healthcare programs are costlier than their European equivalents. But what the Post’s editors fail to mention is that private profit-seeking is largely responsible for the additional cost. Medicare is forced to share the road with private-sector insurers who can drive rates up, especially when for-profit corporations are increasingly driving every aspect of treatment from hospital care to provider practice management. A single-payer health system could set rates and design treatment guidelines that are based on best practices and are subject to public debate, unlike private plans.
A Change is Gonna Come
The transition to a single-payer system will be complex, but despite what the no-can-doers say, it is achievable. None of the obstacles that are cited are insurmountable.
One-third of our health economy is already managed through government programs. Our best minds should be tackling the challenge of reforming the remaining two-thirds. We have already have built some of the infrastructure and expertise we will need.
Medicare For All is not only achievable. It’s inevitable. Health care costs are already too high for most Americans, even those with “good” insurance . The demand for a better-run public system will only grow in the years to come.
It’s easy to understand why the Washington Post, with its history of hostility to social spending, would oppose Medicare For All./ But why is there such entrenched opposition among some liberals? Some Democrats want to defend the Affordable Care Act out of loyalty, because it’s a Democratic program.
Some people have developed deep expertise in the current, flawed system. Consciously or unconsciously, they will be inclined to resist changes that render their knowledge obsolete. Other people want to be proven right about politics, and they’ve staked their reputation on claiming that single-payer is a “hard sell” because it will raise taxes.
Actually, it’s an easy sell: I can save you thousands of dollars a year by replacing a terrible system with a much better one. People say Medicare For All is “politically unfeasible.” But the past ten years have taught us that it’s politically unfeasible to aim for anything less.
Many single-payer advocates are also defending the ACA today for a very simple reason: people will die if it’s repealed. But people are dying right now because we don’t have a national health care system.
The best way to defend the ACA is the way Bernie Sanders is doing it. Sanders is barnstorming the country condemning Republican plans to gut the law, a move that would cause tens of thousands of needless deaths to give millionaires and billionaires a tax cut. But he is also making it clear that the ultimate goal – the goal that reflects both the public’s needs and our shared progressive values – is Medicare For All.
Greg Kesich: If we let people die when it’s time, health care may cost a lot less
My father wanted simple, cheaper treatment at age 91, but the medical system pursued the wrong amount of care.
by Greg Kasich - Portland Press Herald - July 12, 2017
One morning five years ago, my 91-year-old father took a hard fall on a tile floor. In less than a week, he was dead.
It was not a surprise. He had an abnormally slow heart rate and had just been accepted to a hospice program, where his treatment was supposed to be limited to keeping him comfortable at the end of his life.
But even under those circumstances, it’s still amazing to me how hard it is to die and how much of our medical system is devoted to prolonging the inevitable.
During another national debate about health care and how to pay for it, I can’t stop thinking about my father’s last trip through the system. While millions of Americans get sick and die without even basic care, he spent his last year refusing services, not always with success.
He was twice dragged to the hospital even though he had signed a “Do Not Hospitalize” order. On one of those trips, he refused emergency surgery to get a pacemaker installed, saying that he didn’t want to do anything until he could talk with his doctor. After the consultation, he refused the operation again.
If he had said yes, he might be alive today. But would the device that made his heart beat regularly also have brought back his hearing, the loss of which had made normal conversation impossible? Would it have made the pain in his back go away? Would he still have desperately missed my mother, who had died six years earlier?
Would the people in the nursing home – where he would almost certainly have to be living – been able to understand his thick Eastern European accent better than the EMTs who took him to the hospital when he didn’t want to go?
Or would he have been a sad, isolated guy in a lot of pain, albeit one who had a regular heartbeat?
I’ve heard worse stories: Bedridden elders who are shocked back to life and attached to a ventilator, even though they have living wills. Or people with only months to live suffering through a colonoscopy even though they would have been too weak to survive surgery if the test had found a tumor.
I don’t know what the right amount of health care is, but I do know that in this country we make sure people get the wrong amount of care in more ways than one.
Whether you get too much care or not enough depends on a lot of things that have nothing to do with how sick you are.
How much money you have matters. How old you are matters. And weirdly, geography matters, too.
Researchers at Dartmouth Medical School have been compiling Medicare payment data for decades, and have been able to compare how conditions are treated in different places. They publish the Dartmouth Atlas of Health Care, available online, which shows that there are significant differences in the kind of treatment you receive depending on where you live.
For instance, southern Maine hospitals install pacemakers for people on Medicare at about the national average rate, 4.5 per 1,000 enrollees. They are used nearly twice as often in Lafayette, Louisiana (8.4 per thousand), and half as often in Dubuque, Iowa (2.2 per thousand).
The atlas shows it’s not just pacemakers that pop up at different rates in different places. Heart specialists are not evenly distributed around the country, either, and the places with the most doctors are also the ones where the most tests are ordered and procedures performed.
That’s not a response to real-world need. Doctors don’t usually move to the places where they think they’ll find the most disease. They go where they can make a living and tend to settle where they trained, working with local physicians who have a preferred approach. It’s the culture of the hospital near you – not just your specific illness – that will determine what kind of care you get and the size of your bill.
So, is installing pacemakers at about the national average something to celebrate? Or do they do it right in Dubuque and we’re pacemaker-happy in Maine? Or is it Lafayette where they know what’s going on and we’re way behind?
I don’t know, but I do know this: At the age of 91, it would have been far easier for my father to accept much more care than he needed – all covered by Medicare – than it was for him to get the much less expensive treatment he wanted. Meanwhile, 14,000 children in this state have no health insurance and won’t see a doctor unless they have an accident or disease serious enough to land them in an emergency room.
If you’re wondering why Americans pay more for health care than any of our industrialized peers and get worse outcomes, you don’t have to look much further than that.
U.S. Charges 412, Including Doctors, in $1.3 Billion Health Fraud
by Rebecca R. Ruiz - NYT - July 13, 2017
WASHINGTON — Hundreds of people nationwide, including dozens of doctors, have been charged in health care fraud prosecutions, accused of collectively defrauding the government of $1.3 billion, the Justice Department said on Thursday.
Nearly one-third of the 412 charged were accused of opioid-related crimes. The health care providers, about 50 of them doctors, billed Medicare and Medicaid for drugs that were never purchased; collected money for false rehabilitation treatments and tests; and gave out prescriptions for cash, according to prosecutors.
Some of the doctors wrote more prescriptions for controlled substances in a single month than entire hospitals wrote in that time, the acting director of the F.B.I., Andrew G. McCabe, said at a news conference in Washington of federal law enforcement and health care officials who announced the prosecutions.
“This event again highlights the enormity of the fraud challenge we face,” Attorney General Jeff Sessions said.
Arrests were made nationwide over the course of the last week, the Justice Department said, as part of a Medicare fraud task force established in 2007. The more than 400 prosecutions, a record for the task force, covered years of activity and were spread across more than 20 states.
In one case, prosecutors said, the owner and operator of a drug-treatment center in Delray Beach, Fla., recruited addicts to aid him in his schemes, attending Alcoholics Anonymous meetings and visiting “crack motels” to persuade people to move to South Florida to help him. He offered kickbacks in the form of gift cards, plane tickets, trips to casinos and strip clubs as well as drugs.
The owner, Eric Snyder, and an associate were charged with fraudulently billing insurance companies for more than $50 million for false treatment and urine tests over nearly five years, the authorities said.
Bruce Alan Zimet, a lawyer for Mr. Snyder, said that his client had been cooperating with investigators since 2014. “We anticipate having additional communications with the government,” Mr. Zimet said, “and we’re hopeful they’ll be listening carefully and evaluating whether this is a case that should go forward or not.”
In New York, a Queens cardiologist was arrested at Kennedy Airport on Thursday and accused of engaging in kickback schemes with medical diagnostic facilities to whom he referred business. In Maine, an office manager was charged with embezzling funds from a medical office. In Connecticut, Indiana, Iowa, Texas and other states, people were charged in schemes involving the distribution of medically unnecessary drugs, including opioids.
Opioid addiction is an escalating public health crisis in America, with drug deaths rising faster than ever. Hydrocodone and oxycodone, two powerful opioids, are among the most commonly abused prescription drugs, and the Centers for Disease Control and Prevention estimates that 91 Americans die each day of an opioid-related overdose.
Mr. Sessions has emphasized cracking down on drug crime as a priority, directing the nation’s prosecutors in May to pursue the toughest charges for such crimes, even when they may carry mandatory minimum prison sentences.
Last year, the fraud task force charged 301 people for some $900 million in false billings. Since its creation a decade ago, it has charged more than 3,500 people for what prosecutors said were over $12.5 billion in false billings.
“Thanks to these efforts, fewer criminals will be able to exploit our nation’s opioid crisis for their own gain,” said Tom Price, the secretary of health and human services. He cited the Trump administration’s budget request for a $70 million investment in the health care fraud control program as a sign of its commitment to rooting out such crimes.
“I know we overuse certain words in the lexicon like unprecedented and historic and unique,” said Chuck Rosenberg, acting administrator of the Drug Enforcement Administration, who cited an estimated 59,000 deaths from drug overdoses in the United States last year. “But this is an epidemic.”
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