‘Medicare for All’ Isn’t Sounding So Crazy Anymore
by Suzy Khimm - NYT - July 15, 2017
During the 2016 campaign, Andrea Barton Gurney thought that single-payer health care was simply out of the question. A self-described moderate, Ms. Gurney, 56, assumed that Hillary Clinton and the Democrats would keep trying to make the Affordable Care Act work.
Now she has changed her mind. She believes the best solution to America’s health care woes is government-financed coverage for everyone. “I wasn’t thinking big enough,” said Ms. Gurney, a marketing professional from New Jersey. “I don’t see anything else that’s going to get us out of this.”
Single payer is now poised to become the standard position for the Democratic base. More elected Democrats are following suit as Republicans struggle to get their deeply unpopular health care bill past Congress. The prevailing assumption is that the G.O.P. effort will ultimately implode, clearing the way for a bold alternative. Senator Dick Durbin, the upper chamber’s second-highest-ranking Democrat, told me that he’d happily sign onto a single-payer bill — and might even bring one to the floor himself.
But while liberals have spent decades pining for single payer — Ted Kennedy drew up a bill in 1970 — there are surprisingly few detailed proposals.
During the 2016 campaign, Senator Bernie Sanders released a skeletal framework for single payer that went into great detail on new taxes while skating over most everything else. In the House, Representative John Conyers’s single-payer proposal has 114 co-sponsors, but it’s essentially a messaging bill that signals a political position but is not expected to pass.
While billed as “Medicare for All,” both these plans would be more generous than traditional Medicare and most private insurance plans: They would eliminate all co-pays and deductibles and include costly services like long-term care, which Medicare doesn’t cover.
What’s far less clear is how we’d get there. To be able to deliver on its promises, single payer would not only require trillions in new revenue through higher taxes, but also huge cost savings from slashing payments to drug companies, doctors and hospitals. “There are a million and one complexities” to single payer that no one has really dealt with, said Dean Baker, co-director of the Center for Economic and Policy Research, a left-leaning think tank. “All of those are really morasses when you get down to that level of detail.”
Senator Sanders went out of his way to list all the tax hikes he’d use to pay for his 2016 proposal, including an across-the-board 2.2 percent income tax. But two prominent policy analysts said the plan would cost about twice as much as the senator claimed.
Underlying the dispute are different assumptions about how single payer would work. How much could we save if the government negotiated directly with drug companies? How much care would patients seek in a world without co-pays?
These aren’t minor details; they get to the heart of the most common attack on single payer — that it’s too costly and too disruptive. Moving to true single payer would effectively end the current role of the private insurance industry, not only getting rid of Obamacare’s exchanges but also the employer-based plans that cover more than half of non-elderly Americans.
Single-payer advocates believe that radical change is necessary, pointing out that the United States spends more on health care than any other wealthy country, with some of the worst health outcomes. But many advanced, industrialized democracies with universal coverage don’t have a pure single-payer system. France, for instance, has health care for all that is largely state-financed, but most people also buy private supplemental coverage.
While “single payer” has become an effective political rallying cry, advocates still need to figure out what it would mean for one of the largest, most complex health care systems in the world. Senator Sanders himself is preparing to introduce a single-payer bill that will be “far more detailed than the campaign plan” and include changes to address cost concerns, said a spokesman, Josh Miller-Lewis.
Mr. Baker believes the top priority is a credible transition plan. “If you just take everyone with employer-provided insurance and put all of them on a public plan, you’re going to freak people out,” he said. He’s interested in reviving the public option — a government-run plan that would compete with private insurance on the exchanges — as well as opening up Medicare or Medicaid to those who want to buy in.
It’s unclear how receptive the base would be to incremental reforms. They could be a reminder of what’s hamstrung Democrats in the past: ceding ground to centrists who insist on largely unobjectionable — and uninspiring — white papers. Jeff Hauser, a progressive strategist, argues that the movement should come before the details. “You don’t build a political coalition around wonks,” he says.
What Democrats need to emphasize above all, Mr. Hauser argues, are big ideas that can energize their supporters. More than anything, “single payer” has become shorthand for the notion that everyone deserves health care. “Health care should be a right. It should never be a privilege,” Senator Kirsten Gillibrand, Democrat of New York, and a potential 2020 presidential candidate, recently asserted. “We should have Medicare for all in this country.”
But the more political headway that single payer makes, the more supporters will need to explain how it could actually work in practice. Otherwise, Democrats risk making the same mistake on health care as Republicans: big promises without a plan to follow through.
McCain’s Surgery Will Delay Senate Votes on Health Care Bill
by Robert Pear - NYT - July 15, 2017
WASHINGTON — The Senate will delay votes on a bill to dismantle the Affordable Care Act, the Senate majority leader, Mitch McConnell, announced Saturday night, because of a new obstacle to winning enough support for one of the Republican Party’s most cherished goals.
Mr. McConnell said the Senate would “defer consideration” of the bill, scheduled for this week, because Senator John McCain, Republican of Arizona, would be absent, recovering from surgery that he had on Friday to remove a blood clot above his left eye.
Mr. McConnell had said that he wanted to begin debate on the bill and pass it this week, using special fast-track procedures. But without Mr. McCain, Senate Republicans would not have the votes they need to take up or pass their bill to repeal and replace major provisions of the health care act that was the signature domestic achievement of President Barack Obama.
It was unclear how long the delay will be. “The leader has not announced a date” for the Senate to take up the legislation, said an aide to Mr. McConnell. “Just that we will defer.”
The announcements, first by Mr. McCain, then by Mr. McConnell, dealt another setback to the effort to repeal the Affordable Care Act, which once seemed inevitable after years of promises by congressional Republican leaders that they would dismantle it.
With control of the White House and both houses of Congress, Republican leaders foresaw a quick strike coming as soon as January or February. But the House struggled to pass its version of the bill, and the Senate has had even more troubles. Mr. McConnell had to postpone the first votes before the July 4 recess when it was clear he did not have enough support for a procedural motion to take up the bill.
A revised measure unveiled last week was supposed to win over more Republicans, but it was greeted quickly with two Republican defections: Senators Susan Collins of Maine, a moderate, and Rand Paul of Kentucky, a conservative. Both have said they oppose the bill in its current form, for very different reasons, and will not vote even to begin debate.
That left Mr. McConnell without a vote to spare. Mr. McCain’s ailment cost him the final vote — at least for now.
Mr. McCain’s absence will give the forces of opposition — which include scores of health care provider organizations and patient advocacy groups — more time to mobilize.
On Friday, in a joint letter, the insurance industry lobby and the association that represents Blue Cross Blue Shield plans came out strongly against one of the innovations in the latest draft. They joined consumer groups, patient advocates and organizations representing doctors, hospitals, drug abuse treatment centers and religious leaders who have expressed opposition to the bill.
With Mr. McCain missing, Senate Republicans would have only 49 potential votes to move ahead with the legislation because all Senate Democrats and the two independent senators oppose it.
Mr. McCain, 80, announced Saturday night that he had the surgery at Mayo Clinic Hospital in Phoenix. He is at home with his family and, “on the advice of his doctors,” will be recovering in Arizona this week, a spokeswoman said.
Mr. McConnell said that “while John is recovering, the Senate will continue our work on legislative items and nominations.”
But congressional aides, lobbyists and state officials said Saturday night that Senate leaders should rethink their strategy after being forced to postpone consideration of the repeal bill, which opinion polls show to be highly unpopular.
The House passed a repeal bill, broadly similar to the Senate measure, by a vote of 217 to 213 in early May. Mr. McConnell has had a more difficult time rounding up support in the Senate.
Mr. McCain has been decidedly noncommittal in his comments on the bill. Asked last month about the chances for a quick agreement among Republican senators on a bill, he said that “pigs could fly.”
A number of other Republicans have expressed serious reservations about the bill in its current form. They include Senators Shelley Moore Capito of West Virginia, Dean Heller of Nevada, Lisa Murkowski of Alaska and Rob Portman of Ohio.
Governors from both parties have sharply criticized the Senate bill, drafted mainly by Mr. McConnell. Trump administration officials are frantically trying to win over state officials gathered in Providence, R.I., this weekend for a meeting of the National Governors Association.
The administration is trying to discredit estimates by the Congressional Budget Office that more than 20 million people would lose insurance coverage by 2026 as a result of the Senate and House bills.
When Senate Republican leaders unveiled a revised version of their health care bill on Thursday, Mr. McCain said it did not include the measures he had been seeking to protect the people of Arizona and newly eligible Medicaid beneficiaries, in particular.
Tens of thousands of people in Arizona have gained coverage through the expansion of Medicaid under the Affordable Care Act, and Mr. McCain was planning to propose amendments to the bill to protect his constituents.
In all, 20 Republican senators come from states that have expanded Medicaid.
Mr. McCain also criticized the unusual process by which the bill was developed: in the majority leader’s office, without the benefit of public hearings or the expertise of Senate committees.
“Have no doubt,” Mr. McCain said in a statement. “Congress must replace Obamacare, which has hit Arizonans with some of the highest premium increases in the nation and left 14 of Arizona’s 15 counties with only one provider option on the exchanges this year.”
“But if we are not able to reach a consensus,” he continued, “the Senate should return to regular order, hold hearings and receive input from senators of both parties, and produce a bill that finally provides Americans with access to affordable and quality health care.”
In Clash Over Health Bill, a Growing Fear of ‘Junk Insurance’
by Reed Abelson - NYT - July 15, 2017
Julie Arkison remembers what it was like to buy health insurance before the Affordable Care Act created standards for coverage. The policy she had was from the same insurer that covers her now, but it did not pay for doctor visits, except for a yearly checkup and gynecological exam.
“I couldn’t even go to my regular doctor when was I sick,” said Ms. Arkison, 53, a self-employed horseback-riding teacher in Saline, Mich.
The plan did not cover her exams before and after hip surgery, her physical therapyafter her operation, the crutches she needed while she recovered, or any of her medications. She estimates that she spent $20,000 on medical care in the seven years before she could buy a plan through the marketplaces created by the Affordable Care Act.
As Senate Republican leaders struggle to secure enough votes to repeal and replace the health law, the centerpiece of their effort to win conservative support is a provision that would allow insurers to sell such bare-bones plans again. The new version of the bill released on Thursday incorporates an idea from Senator Ted Cruz of Texas that would permit insurers to market all types of plans as long as they offer ones that comply with Affordable Care Act standards. The measure would also allow companies to take into account people’s health status in determining whether to insure them and at what price.
State insurance regulators say the proposal harks back to the days when insurance companies, even household names like Aetna and Blue Cross, sold policies so skimpy they could hardly be called coverage at all. Derided as “junk insurance,” the plans had very low premiums but often came with five-figure deductibles. Many failed to pay for medical care that is now deemed essential.
One Aetna plan, for example, defined hospitalization coverage as mainly for room and board. It capped coverage at $10,000 for “other hospital services,” a category that included such routine care as medication and operating room expenses.
The Affordable Care Act drastically changed the health insurance landscape by requiring insurers to offer a set of comprehensive benefits — including hospitalization, doctor visits, prescription drugs, maternity care and mental healthand substance abuse treatment — in order to formally qualify as insurance. “The new bill opens the door to junk insurance,” said Dave Jones, the California insurance commissioner.
Ned Scott, 34, who lives in Tucson, said the health plan he had before the Affordable Care Act left him with $40,000 to $50,000 in unpaid medical bills after he learned he had testicular cancer when he was in his late 20s.
“I thought it would cover things,” Mr. Scott said. But once he needed it, he learned the plan limited what it paid for outpatient care to $2,000 a year, and all of his treatment, from chemotherapy to CT scans, seemed to fall in that category.
Many Republicans, including President Trump, say giving insurers the leeway to offer less-comprehensive plans will give people greater choice and cheaper options. The Senate bill “ensures consumers have the freedom to choose among more affordable plans that are tailored to their individual health care needs,” Mr. Cruz said.
Proponents of the bill argue that it would allow people to buy insurance they could not otherwise afford. Senator Jeff Flake, Republican of Arizona, said he supported the idea of allowing insurers to sell plans that do not comply with the rules under the Affordable Care Act. The current proposal, Mr. Flake told The Arizona Republic in a recent interview, would allow “183,000 Arizonans who can’t afford insurance because it’s just too expensive to buy a product that meets their needs.”
But both consumer advocates and insurers — forces that are not often allied — are wary. They predict that healthy, younger people would most likely gravitate to the cheaper policies, believing they do not need the more comprehensive and expensive coverage, while older people with health conditions would see their premiums soar for more comprehensive plans.
On Friday evening, the insurance industry’s two main trade associations, America’s Health Insurance Plans and BlueCross BlueShield Association, sent a letter to the Senate voicing adamant opposition to the plan, which they say would create two distinct markets. The proposal “is simply unworkable in any form and would undermine protections for those with pre-existing medical conditions, increase premiums and lead to widespread terminations of coverage for people currently enrolled in the individual market,” the groups wrote.
Plans with much lower premiums are certain to be attractive to many people. But Elizabeth Imholz, a health policy expert for Consumers Union, warned, “The reality for consumers is that they can be stuck with huge, unexpected out-of-pocket costs.”
The Republican proposal also encourages the sale to small businesses of cheaper, less-comprehensive plans modeled after so-called association health plans that were in vogue decades ago, allowing associations or groups of like businesses to come together to buy insurance. The Republican bill would allow small businesses and people who are self-employed to buy plans that would be largely exempt from the current Affordable Care Act rules as well as state oversight.
That, too, has drawn concern. The National Association of Insurance Commissioners, which represents state regulators, wrote a letter to the Senate contending that the provision “appears to block the ability of states to preserve important consumer protections, effectively oversee the plans, or ensure a level playing field.”
Association plans, which had been virtually unregulated because they were not under the purview of any state rules, have had a mixed history. Some plans failed because they did not have the money to pay for their customers’ medical bills, while some insurance companies were accused of misleading people about what they would cover.
These plans are “just the classic example of insurance that disappears exactly when you need it,” said Jay Angoff, a former state insurance official in Missouri and New Jersey, who also worked in the Obama administration overseeing the insurance marketplace.
Antony Stuart, a lawyer who lives in California, has brought more than a dozen lawsuits accusing insurance companies of misleading consumers by selling them policies that provided much less coverage than they realized.
Mr. Stuart recalled one case involving a man, Doug Christensen, who bought a policy from Mega Life and Health Insurance, which was the subject of numerous lawsuits and state regulatory actions. Mr. Christensen, who previously had bone cancer, was assured by the insurance agent selling the policy that he would have adequate coverage if the cancer returned. But the plan limited payments toward chemotherapy to just $1,000 a day of treatment when the actual cost was sometimes 10 times that amount. Mr. Christensen was left with nearly $500,000 in unpaid medical bills.
“These plans lacked the necessary transparency that would give consumers an idea of what they were actually purchasing,” said Ashley Blackburn, a senior policy analyst with Community Catalyst, a consumer advocacy group. People buying plans now benefit not only from the standards the federal law sets but also from the fact that policies are clearly divided into categories with set levels of coverage. “We’re really moving back to a market where people are going to have a hard time reading through their plan options.”
The association plans, in particular, would make small businesses and self-employed individuals more vulnerable to policies that would leave them unprotected. State regulators cracked down after some of these plans became insolvent. Four associations in the early 2000s left their customers with nearly $50 million in unpaid medical bills, according to researchers in an overview of the plans’ history published in the journal Health Affairs.
Many states adopted a more aggressive stance as a result, but the Senate proposal would make plans largely exempt from state oversight. “There are a lot of consumer protection laws that states have passed that would have to be overruled or ignored,” said Rebecca Owen, a health research actuary with the Society of Actuaries.
A few weeks ago, Ms. Arkison came down with a bad cough. Her doctor prescribed antibiotics, steroids and an inhaler. She is thankful that her current insurance lets her see the doctor when she becomes ill. Under her old plan, she said, “I could not have gone in.”
Governors Give Chilly Reception to Health Bill Push
by Jonathan Martin and Alexander Burns - NYT - July 15, 2017
PROVIDENCE, R.I. — A handful of Republican governors rebuffed on Saturday an attempt by their Democratic counterparts to issue a joint statement from the nation’s governors expressing opposition or even concern about the Senate health care bill. But a smaller, bipartisan group of influential governors still may release a statement of their own in the coming days, a move that would greatly imperil passage of a measure that is already listing.
While Republican governors stopped well short of declaring common cause with Democrats on health care, state executives from both parties gave a brusque reception to Trump administration officials who trekked to Rhode Island to lobby governors for their support.
Gov. John W. Hickenlooper of Colorado, a Democrat who is part of a group of seven governors who have been outspoken about their discomfort with the legislation to repeal the Affordable Care Act, said he expected an even larger bloc of the state chief executives to voice their unease about the proposal after the annual summer gathering of the governors concludes here this weekend.
“I think there’s an appetite for more people to express themselves, it’s just so important to governors,” said Mr. Hickenlooper.
The timing is critical because the Senate is expected to take up its health care overhaul this week, and Republicans — who control the body with a slim 52-vote majority — have already lost the support of two of their senators. Losing one more Republican senator would effectively sink the legislation, and a handful of Republican senators from states that have expanded Medicaid under the Affordable Care Act have signaled they will closely follow the lead of their state’s governor.
At a private luncheon for governors on Saturday, three Democratic governors called for the group to release some sort of joint, bipartisan statement on the health bill. Gov. Dannel P. Malloy of Connecticut proposed a letter formally opposing the Senate legislation, while Gov. Terry McAuliffe of Virginia, the chairman of the National Governors Association, and Gov. Steve Bullock of Montana suggested a more restrained approach that would communicate their unease with the measure. But a handful of Republican governors opposed making a collective statement, noting there was no broad agreement about the nature of their opposition.
“It’s important if anything goes out under the name of the N.G.A. that it has the endorsement of members certainly, and I think there was not consensus on that,” Gov. Matt Bevin of Kentucky, a Republican who voiced his discomfort with a joint communiqué during the lunch, said after the session.
Nonetheless, many of the Republican governors appear to be opposed to the current Senate legislation, and there is widespread skepticism in their ranks that the bill will pass.
Gov. Scott Walker, Republican of Wisconsin, who has previously voiced his irritation that the Trump administration did not originally seek the views of governors on health care, said at the luncheon that the best time for the governors to collectively weigh in would be after the Senate bill fails, according to officials in the room.
Earlier in the day, Tom Price, the secretary of health and human services, and Seema Verma, the Medicaid administrator, received a cold reception from governors of both major parties at a closed-door meeting. The governors pressed the officials about spending cuts to states, and voiced acute skepticism about the argument — advanced by supporters of the health care bill — that states could make up for any fiscal changes by experimenting with new ways of administering Medicaid.
Ms. Verma opened her presentation by urging the governors not to accept the conclusions of a private study — commissioned by the governors association — that warned states they would experience drastic cutbacks in Medicaid money under the Senate proposal, according to a person present in the room. The study, conducted by the consulting company Avalere Health, concluded that governors would probably have to either eliminate services or raise taxes to compensate.
Mr. Price and Ms. Verma also criticized the conclusions of the Congressional Budget Office, which found that an earlier version of the Senate bill would lead to about 15 million people losing coverage they currently receive through Medicaid. Both administration officials insisted that funding shifts would have limited impact on the states, because the bill would help move Medicaid recipients into the private insurance market.
But the governors, including Republicans Charlie Baker of Massachusetts and Asa Hutchinson of Arkansas, pushed back on the administration’s sunnier assessments.
Gov. Bill Walker of Alaska, an independent and former Republican, said the Senate and White House should slow its march toward a health care vote to give governors more time to analyze the proposed changes. But Mr. Price, the health secretary, replied that there was no time to wait.
“I think it’s fair to say the governors aren’t buying it,” said Gov. Gina Raimondo, Democrat of Rhode Island. “I’m certainly not.”
Wealthy, Corporations Still Win Big Under Revised Senate GOP Health Bill
by Brandon DeBot - Common Dreams - July 14, 2017
Senate Republicans have removed two of their health bill’s many regressive tax cuts — those repealing the so-called Medicare taxes (the additional 0.9 percent Hospital Insurance payroll tax on high-income people and the 3.8 percent tax on unearned income) — to address concerns that the bill favors the wealthy. “It’s not an acceptable proposition to have a bill that increases the burden on lower-income citizens and lessens the burden on wealthy citizens,” Senator Bob Corker has stated. But even with that change, the bill would fail Corker’s standard. It would still include nearly $400 billion in tax cuts overwhelmingly for high-income households and corporations, including new tax cuts for Health Savings Accounts favoring the wealthy. The core of the bill would remain tax cuts for the wealthy and corporationsthat are financed by cutting assistance to help millions of low- and moderate-income families afford health coverage and care.
The bill’s tax breaks include:
- Repealing the tax on insurers. The bill would eliminate the tax on insurers that helps finance the Affordable Care Act’s (ACA) coverage expansions, at a cost of $145 billion over ten years. The biggest insurers would receive the biggest tax cuts. Even while cutting taxes on insurers, the bill cuts subsidies that help low- and moderate-income families afford insurance.
- Eliminating a tax on drug companies, which would cost $26 billion from 2017 to 2026. Manufacturers and importers of brand-name prescription drugs pay this tax based on their brand-name drug sales to government health programs. Wealthy shareholders and other investors likely would ultimately enjoy the benefit of this tax cut as company profits expand, since they own the bulk of company stock and other investments. In 2022, the cost of this tax break would roughly equal the bill’s savings from cutting tax credits and subsidies that help low- and moderate-income families in 20 states and the District of Columbia combined afford quality coverage and care (see chart).
The companies benefiting from this tax cut would likely include several that state Attorneys General have sued for their role in the opioid crisis. And, the bill pays for the tax cut in part by deeply cutting Medicaid, which has a crucial role in combating the opioid crisis. - Significantly expanding Health Savings Accounts (HSAs), which do little or nothing to help the uninsured afford coverage but create lucrative tax-sheltering opportunities for wealthy people. High-income households receive the bulk of HSA benefits under current law, and the Senate bill would tilt those benefits even further to the top by roughly doubling the annual contribution limit, which would only help people wealthy enough to “max out” their contributions under the current limits. The provision would cost $19 billion over ten years. Senators also added another HSA expansion to the bill, which would provide even more lucrative benefits to the wealthy by letting HSA account holders use the funds to pay their health insurance premiums, at a reported cost of $60 billion over ten years.
- Letting filers claim medical expenses exceeding 7.5 percent of their adjusted gross income (AGI) as an itemized deduction, reversing an ACA provision that had raised the threshold from 7.5 percent of AGI to 10 percent. That would overwhelmingly benefit higher-income taxpayers, at a cost of $36 billion over ten years. Over three-quarters of the tax savings from lowering the threshold to 7.5 percent would go to taxpayers with incomes over $100,000, the Tax Policy Center estimates; less than 3 percent would go to taxpayers with incomes below $50,000.
- Repealing the medical device tax. The tax is intended to ensure that the medical device industry, which benefits from higher sales due to the ACA’s improved health coverage, contributes to health reform provisions that enable millions of Americans to afford that coverage. Repeal would cost $20 billion over ten years.
While Senate Republicans may have decided not to repeal the Medicare taxes in their health bill, they may seek to repeal them in a future tax bill. Both the Trump Administration’s tax plan and the House GOP “Better Way” tax plan would repeal the 3.8 percent tax on unearned income. In response to the reported dropping of the Medicare-related tax cuts from the Senate health bill, Americans for Tax Reform President Grover Norquist said, “there’s a tax cut coming, so we’ll get this. . . . This is three-dimensional chess.” In short, the wealthy and corporations would be big winners under the Senate GOP health bill, even with its revisions, and could get even bigger tax cuts in an upcoming GOP tax package.
Among Wealthiest Nations, US Healthcare System Comes in Dead Last
"The United States spends far more on healthcare than other high-income countries. Yet the U.S. population has poorer health than other countries."
by Jake Johnson - Common Dreams - July 14, 2017
No, in turns out, the United States does not have the "best healthcare system in the world."
In the midst of a deeply unpopular attempt by the Republican Party to pass legislation that could leave 22 million more Americans uninsured and as support for Medicare for All soars, a new analysis published on Friday by the Washington-based Commonwealth Fund finds that the U.S. healthcare system currently ranks last among 11 other advanced countries in healthcare outcomes, access, equity, and efficiency.
No, in turns out, the United States does not have the "best healthcare system in the world."
In the midst of a deeply unpopular attempt by the Republican Party to pass legislation that could leave 22 million more Americans uninsured and as support for Medicare for All soars, a new analysis published on Friday by the Washington-based Commonwealth Fund finds that the U.S. healthcare system currently ranks last among 11 other advanced countries in healthcare outcomes, access, equity, and efficiency.
"Your level of income defines the healthcare you receive far more in the United States than in other wealthy nations."
—Commonwealth Fund
—Commonwealth Fund
The U.S. "fell short" in almost every domain measured, the Commonwealth Fund's senior vice president for policy and research Eric Schneider, M.D., told the New Scientist.
The study examines the healthcare systems of the U.S., the United Kingdom, France, Sweden, and several other nations, utilizing surveys of physicians and patients as well as data accumulated by the World Health Organization (WHO) and the Organization for Economic Cooperation and Development (OECD).
The report's conclusion echoes those of previous studies, which have indicated that despite spending far more on healthcare than other advanced nations, the U.S. continues to lag behind in a variety of measures, from infant mortality rate to overall life expectancy.
Schneider and his co-authors—Dana Sarnak, David Squires, Arnav Shah, and Michelle Doty—observed that "[t]he U.S. healthcare system is unique in several respects. Most striking: it is the only high-income country lacking universal health insurance coverage."
The researchers went on to summarize their findings:
The United States spends far more on healthcare than other high-income countries, with spending levels that rose continuously over the past three decades. Yet the U.S. population has poorer health than other countries. Life expectancy, after improving for several decades, worsened in recent years for some populations, aggravated by the opioid crisis. In addition, as the baby boom population ages, more people in the U.S.—and all over the world—are living with age-related disabilities and chronic disease, placing pressure on health care systems to respond.
Timely and accessible healthcare could mitigate many of these challenges, but the U.S. health care system falls short, failing to deliver indicated services reliably to all who could benefit.
As opposed to nations that guarantee healthcare to all, the authors concluded that Americans' ability to attain quality healthcare is almost entirely dependent on financial status.
"Your level of income defines the healthcare you receive far more in the United States than in other wealthy nations," the authors note.
While acknowledging that the Affordable Care Act (aka Obamacare) had much success in providing coverage to low-income Americans—particularly through the law's expansion of Medicaid—Commonwealth Fund President David Blumenthal, M.D., said the U.S. healthcare system is "still not working as well as it could for Americans, and it works especially poorly for those with middle or lower incomes."
Underscoring this point, the Commonwealth Fund's analysis noted that "in the U.S., 44 percent of lower income and 26 percent of higher income people reported financial barriers to care." In the U.K., these percentages are seven and four.
"A higher-earning person in the U.S. is more likely to meet cost barriers than a low-income person in the U.K.," Schneider observed.
Commonwealth Fund
The survey comes as the Senate GOP is currently scrambling to convince enough Republicans to vote for a bill that, if enacted, would drastically cut Medicaid, defund Planned Parenthood, and potentially cause the deaths of thousands.
Blumenthal concludes that while there are substantial and urgent problems with the healthcare status quo, the Republicans' legislative efforts would "certainly exacerbate these challenges as millions would lose access to health insurance and affordable healthcare."
The Senate Health-Care Bill Would Be a Giant Step Backward
by John Cassidy - The New Yorker - July 14, 207
The draft of the Senate G.O.P. health-care bill that Mitch McConnell, the Majority Leader, released on Thursday is, in one way, an improvement on the previous version of the bill. The latest draft dropped a proposal to repeal two tax increases on very high earners, which were part of the Affordable Care Act. The revenue from those tax increases was used to help fund some of the A.C.A.’s most progressive features, including the expansion of Medicaid and the subsidies offered to families of modest means for the purchase of private insurance plans.
But the merits of the revised Senate bill stop there. Enacting it into law would be a disaster. The old and the sick would be forced to pay far higher premiums; deductibles would go up for almost everyone in the individual market; and many millions of Americans, many of them poor, would lose their health-care coverage entirely.
Before delving into the details, it is worth restating what is at stake here: the principle that society is made up of people with mutual obligations, including the duty to try to protect everyone from what Franklin Roosevelt called the “hazards and vicissitudes of life,” such as old age, unemployment, and sickness.
To deal with aging and joblessness, F.D.R. introduced Social Security and expanded unemployment insurance. Originally, he intended to include publicly funded health care as part of Social Security, but opposition from the medical profession persuaded him to leave it out. In the decades since F.D.R.’s fateful decision, it has become clear that private insurance works tolerably well for people who hold well-paid, steady jobs at large companies—especially when the tax authorities don’t treat employer-provided health insurance as taxable income. But for everybody else—the elderly, people with low-wage jobs that don’t offer benefits, the self-employed and employees of small companies, people who are employed intermittently or who are out of work—private insurance is costly, complicated, and often hard to obtain.
During the nineteen-sixties, the Lyndon Johnson Administration introduced Medicare, for senior citizens, and Medicaid, for poverty-stricken families with children. But people outside those categories were left to the mercies of the insurance market, the shortcomings of which eventually became glaringly obvious. By 2013, close to one in five adult Americans didn’t have any health-care coverage. The A.C.A. took a two-pronged approach to fixing that situation.
The A.C.A. raised the income thresholds for eligibility to Medicaid, allowing individuals and families with incomes just above the poverty line to qualify for the program. This policy worked wonders. Since going into effect, at the start of 2014, it has enabled about fourteen million Americans, most of them from working families, to obtain health-care coverage.
The A.C.A. also tried to make private insurance more affordable and accessible. One way it did this was by offering hefty federal subsidies to low-to-middle-income households. But it also issued a series of directives. To improve the quality of insurers’ risk pools, it forced everybody, including the young and the healthy, to purchase coverage. At the same time, it obliged insurance companies to offer standardized policies that provided a comprehensive set of benefits, banned them from turning away people with preëxisting conditions, and placed strict limits on how much more they could charge older people.
All of this was an effort to recognize the principle of mutual obligation while preserving a private insurance system. The revised Senate bill would largely dismantle this effort, reversing both the expansion of Medicaid and many of the reforms that were designed to make private insurance work more equitably. If it passed, the Republican reform would eventually return the country to a system a lot like the one in place before the A.C.A., when older people, sick people, and the working poor struggled to find coverage—or went without.
Despite objections from some Republican senators from states that have expanded Medicaid under the A.C.A., the revised bill leaves in place seven hundred billion dollars of cuts to the program, as well as the idea of converting it to a block-grant program. The consequences of these changes would be dramatic. By 2025, according to the Congressional Budget Office, about fifteen million fewer people would be covered by Medicaid and its sibling, the Children’s Health Insurance Program.
On the private-insurance side, the authors of the revised Senate bill took some of the money saved from dropping the tax cuts for the rich and allotted it to compensating insurers for covering high-risk individuals. But the revised bill also includes a new amendment championed by Senators Ted Cruz and Mike Lee: as long as an insurer offered a standardized, A.C.A.-compliant policy on a government-run exchange, it would be allowed to sell unregulated, catastrophic-care plans outside the exchanges.
To people unschooled in the economics of insurance markets, this proposal may look innocent enough, but it is a torpedo aimed at the exchanges, which are an essential part of Obamacare. For people in their twenties and thirties, the premiums on the unregulated plans, which would come with very large deductibles, would be fairly low. But the insurers would be allowed to charge less desirable customers—older and less-healthy individuals, including ones with preëxisting conditions—much higher prices for these plans, or even deny them coverage. As most of these people continued to buy comprehensive plans, while more and more young people chose the cheaper options available outside the exchanges, the risk pools in the Obamacare-type markets would deteriorate sharply.
This would have devastating consequences. Insurers would hike their premiums, and many people wouldn’t be able to afford them, including people with serious illnesses. A cycle of rising prices and falling enrollments could eventually cause the exchanges to collapse. The only way to prevent this from happening would be for Congress to offer bigger and bigger subsidies to the buyers of comprehensive plans and the insurers who offer them.
Whether this is Cruz and Lee’s intention is irrelevant. It is how private health care works when it isn’t regulated and the principle of mutual obligation is ignored, or relegated to a secondary consideration. “Choice always sounds so good, like with the Cruz amendment,” Larry Levitt, a senior vice-president at the Kaiser Family Foundation, explained on Twitter. “But in insurance, it's generally a recipe for instability and discrimination.” The United States lived for decades with a health-care system that discriminated against the old, the sick, and those too poor to afford coverage. Will Republican ideologues be allowed to plunge the country back into this dark past?
Governors From Both Parties Denounce Senate Obamacare Repeal Bill
by Jonathan Martin and Alexander Burns - NYT - July 14, 2017
PROVIDENCE, R.I. — The nation’s governors, gathered here for their annual summer meeting, came out strongly on Friday against the new Senate bill to repeal the Affordable Care Act, turning up the pressure on Republican leaders struggling to round up the votes to pass the bill next week.
Opposition came not just from Democratic governors but from Republicans who split along familiar lines — conservatives who said the legislation did not go far enough and moderates who said it was far too harsh on their state’s vulnerable residents.
Gov. Brian Sandoval of Nevada, who at the moment may be the most pivotal figure in the health care debate, said he had “great concerns” with the legislation, and all but declared that he could not support any bill that would scale back Nevada’s Medicaid program. His decision to expand Medicaid under the Affordable Care Act had been “a winner for the people of our state,” he said of the government health insurance program for poor and disabled people.
“I have to be comfortable that those 210,000 lives are going to continue to enjoy the quality of life and health care that they have right now,” he said, referring to the number of Nevadans who gained coverage through the expansion of Medicaid under President Barack Obama’s signature health law.
Conservative governors were not much more supportive. Gov. Scott Walker of Wisconsin suggested that Congress consider a better-funded version of the measure proposed this year by two Republican senators, Susan Collins of Maine and Bill Cassidy of Louisiana, that would offer states more flexibility over how to run their health care programs.
Pursuing that approach, Mr. Walker said, would obviate differences between the states that did and did not expand Medicaid while averting the intractable split between conservative and centrist members of Congress over how to structure a replacement. “None of these plans right now do us justice,” he said.
The response mirrored the struggles of congressional Republicans to forge consensus on legislation that would make good on a seven-year vow to repeal the health law. With two Senate Republicans already opposed, Senate leaders cannot lose any additional votes, and on Friday, some of the most influential Republican governors indicated a willingness to torpedo the bill entirely.
Mr. Sandoval’s views are likely to influence Nevada’s Republican senator, Dean Heller, while Mr. Walker’s could play on Wisconsin’s undecided Republican, Ron Johnson.
Recognizing how crucial Mr. Sandoval is, an array of senior federal officials planned to meet with him in Providence for 11th-hour lobbying. The National Governors Association conference, which more typically includes as much recreation as work, attracted Vice President Mike Pence, Health and Human Services Secretary Tom Price and Seema Verma, the administrator of the Medicaid program.
And in a sign of the furious efforts in Washington, Mr. Sandoval revealed that he had been lobbied personally by President Trump in a phone call. Mr. Sandoval declined to discuss the specifics of their discussion, which he said took place after his high-profile announcement last month with Mr. Heller that both would oppose an earlier version of the Senate bill.
Several of Mr. Sandoval’s Republican colleagues, from states that expanded Medicaid programs under the Affordable Care Act, were even more definitive in their opposition.
Gov. Phil Scott of Vermont, who won election in November even as Hillary Clinton carried his state by more than 20 percentage points, said the bill could cripple the health care system in Vermont.
“We’ve expanded Medicaid, and even a small tweak could have a devastating impact on us as a state,” Mr. Scott said. “We’ve made great strides at protecting the most vulnerable and I believe, in its present form, this would not be good for Vermont.”
Gov. Matt Bevin of Kentucky, who first emerged as a Tea Party-inspired challenger to Senator Mitch McConnell, the majority leader, came at the bill from the right. He sharply criticized his party’s decision not to eliminate a pair of taxes on high earners in the latest version of the bill.
“They’re going to lose as many votes as they’re getting,” Mr. Bevin said of the decision to keep the levies imposed by the Affordable Care Act. There was, he said, an “understanding that those two taxes were going to be gone.”
The governors have been playing an outsize role in shaping the congressional debate, with Republicans from states that expanded Medicaid often supplying the loudest voices. But some of the statehouse advice has plainly started to grate on Republican members of Congress.
“I don’t want to be irreverent, but, you know, people talk about their governors back home, are you kidding me?” said Senator Bob Corker of Tennessee. “I mean, if we can’t even deal with our governors back home, how will we ever deal with Medicareand Social Security?”
Every governor, Mr. Corker claimed, “would love for us to send free, unpaid-for money back home.”
Mr. Pence was notably more diplomatic as he spoke to the governors on Friday afternoon. He acknowledged the deep reservations in the room but branded the Senate bill a “rescue” measure. Mr. Pence detailed problems with the Affordable Care Act in Wisconsin and Ohio, two states where Republican governors have criticized the bill — and a pair of Republican senators, Mr. Johnson and Rob Portman, are wavering.
Mr. Pence, who as Indiana’s governor accepted federal funding to expand Medicaid, also acknowledged that the proposal would significantly change the population that receives health care coverage through the program. He insisted that the bill would hold Medicaid to its “original purpose” of covering the most severely vulnerable people and said too many “able-bodied adults” relied on the program.
The shift, he said, was aimed at “ensuring for the long run that Medicaid will be there for the neediest.”
“I really believe, as the president does, that we’re saving Medicaid,” Mr. Pence said.
It is unclear that such arguments are likely to move governors like Mr. Sandoval, who have resisted any pullback of Medicaid coverage.
And in a gentle gibe, Gov. Terry McAuliffe of Virginia, a Democrat who is chairman of the National Governors Association, noted in introductory remarks that Mr. Pence had been glad to take Medicaid funding when he was a governor.
“He showed true backbone himself in Indiana,” Mr. McAuliffe said, “when he expanded Medicaid for his citizens.”
Among Democratic governors, opposition to the legislation was unanimous and fierce, and party leaders declared anew on Friday that Democrats would pummel any Republican who dared support the bill in the more than three dozen governors elections unfolding over the next year and a half.
Gov. Dannel P. Malloy of Connecticut, the chairman of the Democratic Governors’ Association, accused Republicans in scorching language of being willing to let “people die in your state because they’re no longer eligible for health care.”
Other Democrats took a gentler approach, coaxing Republican senators from their states with do-the-right-thing appeals. Gov. John Bel Edwards of Louisiana invoked Mr. Cassidy’s years of work as a doctor in their state’s charity hospitals.
“They’re not just constituents that he and I have in common; these are the same people that he spent his adult life taking care of, and he knows how important it is for them to have meaningful access to quality health care,” Mr. Edwards said.
Gov. John Hickenlooper of Colorado, a Democrat, said he hoped his state’s Republican senator, Cory Gardner, would listen to his better angels and oppose the bill, calling Mr. Gardner “a compassionate and smart person.”
Mr. Hickenlooper, while saying he had no specific plans for the future, also declined to quash recent murmurs in Democratic political circles that he might challenge Mr. Gardner for re-election in 2020 if the senator votes in favor of the bill.
“This is something that matters a lot to me,” he warned.
What many Republicans fear is that action on what they have long derided as Obamacare also matters a great deal to their base. Failing to find consensus and act could prove just as risky politically, some here said.
“I do have concerns when Republicans have the House, the Senate, the presidency and 33 governorships across the country if we don’t govern,” Gov. Doug Ducey of Arizona said. “I think it’s time to lead and govern.”
https://www.nytimes.com/2017/07/14/us/politics/governors-oppose-senate-affordable-care-act-repeal.html?
https://www.nytimes.com/2017/07/14/us/politics/governors-oppose-senate-affordable-care-act-repeal.html?
Major insurance groups call part of health bill ‘unworkable in any form’
The 'Cruz Amendment' was designed to get votes from right-wing Republicans.
by Alan Fram - Associated Press - July 15, 2017
WASHINGTON — Two of the insurance industry’s most powerful organizations say a crucial provision in the Senate Republican health care bill allowing the sale of bare-bones policies is “unworkable in any form,” delivering a blow to party leaders’ efforts to win support for their legislation.
The language was crafted by conservative Sen. Ted Cruz, R-Texas, and leaders have included it in the overall bill in hopes of winning votes from other congressional conservatives. But moderates have worried it will cause people with serious illnesses to lose coverage, and some conservatives say it doesn’t go far enough.
Two of the 52 GOP senators have already said they will oppose the legislation. Senate Majority Leader Mitch McConnell cannot lose any others for the legislation to survive a showdown vote expected next week.
The overall measure represents the Senate Republicans’ attempt to deliver on the party’s promise to repeal President Barack Obama’s health care law, which they’ve been pledging to do since its 2010 enactment.
The criticism of Cruz’s provision was lodged in a rare joint statement by America’s Health Care Plans and the BlueCross BlueShield Association. The two groups released it late Friday in the form of a letter to McConnell, R-Ky.
“It is simply unworkable in any form,” the letter said. They said it would “undermine protections for those with pre-existing medical conditions,” increase premiums and lead many to lose coverage.
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The provision would let insurers sell low-cost policies with skimpy coverage, as long as they also sell policies that meet a stringent list of services they’re required to provide under Obama’s law, like mental health counseling and prescription drugs.
Cruz says the proposal would drive down premiums and give people the option of buying the coverage they feel they need.
Critics say the measure would encourage healthy people to buy the skimpy, low-cost plans, leaving sicker consumers who need more comprehensive coverage confronting unaffordable costs. The insurers’ statement backs up that assertion, lending credence to wary senators’ worries and complicating McConnell’s task of winning them over.
The two groups say premiums would “skyrocket” for people with preexisting conditions, especially for middle-income families who don’t qualify for the bill’s tax credit. They also say the plan would leave consumers with fewer insurance options, so “millions of more individuals will become uninsured.”
The bill provides $70 billion for states to use to help contain rising costs for people with serious conditions. But the insurance groups’ statement says that amount “is insufficient and additional funding will not make the provision workable for consumers or taxpayers.”
The Cruz provision language in the bill is not final. McConnell and other Republicans are considering ways to revise it in hopes of winning broader support.
McConnell and top Trump administration officials plan to spend the next few days cajoling senators and home-state governors in an effort to nail down support for the bill.
The nonpartisan Congressional Budget Office is expected to release its analysis of McConnell’s revised bill early next week, including an assessment of Cruz’s plan.
The office estimated that McConnell’s initial bill would have caused 22 million additional people to be uninsured.
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