Our View: Health costs are the real problem, not Obamacare
Until we control escalating costs, reforming health insurance markets will not be enough.
by The Editorial Board - Portland Sunday Telegram - July 2, 2017
We still don’t know whether the Senate Republicans will be able to put together 50 votes for Mitch McConnell’s disastrous plan to deprive 22 million more Americans of health coverage in order to fulfill a much-made campaign promise to repeal Obamacare.
But even if McConnell fails, the nation will still be left with a problem: Obamacare’s critics are not completely wrong.
The Affordable Care Act has not made health care affordable enough, which is why, even with the law in place, 27 million Americans are still uninsured.
People cannot afford to buy insurance because we have not found a way to control the cost of the services that insurance pays for. It’s the out-of-control cost of health care services, not some heartless bureaucrat, that really rations care and decides who will live and who will die.
We pay much more for our health care than do people in any other country in the industrialized world.
We don’t regulate the prices of prescription drugs. The same medicine, even if it was developed and manufactured here, costs more in America than anywhere else.
The same is true for other services. Americans pay on average $1,119 for an MRI. An Australian pays $215. As Sarah Kiff writes in Vox: “It is the exact. Same. Scan.”
And although Americans go to the doctor less often than Canadians, they go to the hospital more, probably because we avoid low-cost preventive care until we have no choice but go to an emergency room.
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The Affordable Care Act has achieved some of its goals, expanding coverage to 20 million people, no doubt saving lives.
And it has lowered the rate at which health costs escalate. It is more popular today than the day it was signed, and even the Republican plans to dismantle it try to leave some of its key features in place, like guaranteeing coverage to people with pre-existing conditions.
The ACA aimed at expanding coverage among self-employed people and those who were not offered insurance at work. Most people who enrolled were eligible for subsidies, so even when premiums shot up by double-digit rates, the consumers were protected.
But anyone who makes more than four times the federal poverty limit (or $48,240 for an individual and $81,680 for a family of three) got no help and had to pay the full cost of the increases themselves.
These are the people choosing to drop coverage instead.
Escalating medical costs are a problem not just in the individual market, but also in the employer-provided coverage market, where half of the people too young for Medicare get their insurance.
According to a survey by the Kaiser Family Foundation, the average annual premium last year for employer-sponsored health insurance was $6,435 for an individual plan and $18,142 for a family. But that doesn’t tell the whole story.
As insurance premiums climb to cover medical expenses, employers have increasingly moved to cheaper plans that require more out-of-pocket spending by plan members.
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So even though there has been relatively slow growth in premiums – below 4 percent a year for five straight years – deductibles have increased dramatically.
The Republican plans that have been rolled out in the House and Senate would make these problems even worse.
They attempt to lower premiums by letting insurance companies sell policies that don’t cover as much, leaving individuals to bear even more out-of-pocket costs.
Meanwhile, prices for services continue to climb unchecked.
How do other countries do it? Most of the international models exist in some form already.
Some countries have socialized medicine, like the system we use for the Veterans Affairs Department. Some countries have a government-run single-payer insurance program, like our Medicare for seniors.
Some use highly regulated private markets, much like the Obamacare exchanges.
They buy drugs in bulk and negotiate for the best price. They regulate health care the way we regulate landline phone service, water and electricity.
Mainers can be proud that both of their senators, Republican Susan Collins and independent Angus King, are outspoken critics of the repeal-and-replace plan, and would not be won over with superficial tweaks to a bill that would hurt so many Americans.
But whether or not the Republican Congress can pass an Obamacare repeal bill, Americans will still be left with the problem of escalating costs. We need Congress to take that problem on.
The biggest winner in the current health-care debate: Single-payer
by Aaron Blake - The Washington Post - July 1, 2017
We still don't know who will ultimately prevail in the debate over the future of American health care: the Republicans who want to overhaul Obamacare, or the Democrats who want to keep it in place.
But after weeks of debate, there is one clear winner so far: single-payer health care.
No, single-payer isn't going to happen at the end of this debate — or even the end of this year or this decade, necessarily. But the logical foundations for it are being laid in our political debate just about every single day. And when you pair that with the rising public support for government-run health care, it's clear in which direction this whole debate is trending.
The most surprising aspect of the current health-care debate, for me, has been how Republicans have essentially given up on making the conservative case for their bills. They aren't even arguing that the free market would lead to higher-quality care, efficiency and medical advancements, as the GOP of old might have. Instead, they are trying to obscure the reality that their bills would cut Medicaid by hundreds of millions of dollars (versus where funding is currently set) and would increase the number of uninsured Americans by potential 20 million or more.
Part of this is because that's a losing argument. The reality of entitlement programs and government benefits is that, once they are instituted, it's very, very difficult to get rid of them or even scale them back. Just look at what happened to the GOP when it suggested privatizing Social Security last decade.
That political reality has also basically forced Republicans to concede this point: that people being uninsured is a very bad thing, and that cutting funding to Medicaid is a bad thing. They have basically conceded that government involvement in health care is a good thing — or, at least, a necessary thing. That wasn't the argument they were making against Obamacare eight years ago.
Democrats, meanwhile, are gradually talking themselves into supporting single-payer, it would seem. Their laser-like focus on the number who are uninsured and the Medicaid cuts has a logical conclusion. There is only one way to make sure nobody is uninsured, after all.
And there are signs that both parties' bases are indeed moving toward government health care. A Pew study in January showed 60 percent of Americans felt it was the government's job to guarantee health-care coverage for all Americans — up from 51 percent in early 2016. About 8 in 10 Democratic-leaning voters and 3 in 10 Republican-leaning voters agreed with this statement.
That's not quite single-payer, of course, so Pew broke it out a little bit more in its most recent study. It asked those who supported a government guarantee whether they backed single-payer or a mix of government and private programs. In this case, support for single-payer was 33 percent overall — 52 percent on the Democratic side and 12 percent on the GOP side.
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One of the realities of polling, though, is that when you give people more than two options, they will tend toward the middle-ground response. A "mix of government and private programs" is a pretty safe middle ground, it would seem, and may actually undersell single-payer support.
And sure enough, a Gallup poll from mid-2016 actually showed a 58 percent majority of Americans wanted a "federally funded healthcare program providing insurance for all Americans." A CBS News poll in February 2016 asked more directly about single-payer and found 44 percent support. NORC pegged it at 38 percent — but only 24 percent if people were told that it would greatly increase government spending. (Philip Bump summarized all of these data here.)
What we can say with certainty, though, is that the debate over this topic has taken on a new flavor as Republicans have been working to finally undo Obamacare. And it's a flavor that reflects a growing move toward government health care.
The GOP may yet move the needle away from government health care by the time all is said and done, but the center of this political debate has moved noticeably to the left.
Understanding Republican Cruelty
by Paul Krugman - NYT - June 30, 2017
The basics of Republican health legislation, which haven’t changed much in different iterations of Trumpcare, are easy to describe: Take health insurance away from tens of millions, make it much worse and far more expensive for millions more, and use the money thus saved to cut taxes on the wealthy.
Donald Trump may not get this — reporting by The Times and others, combined with his own tweets, suggests that he has no idea what’s in his party’s legislation. But everyone in Congress understands what it’s all about.
The puzzle — and it is a puzzle, even for those who have long since concluded that something is terribly wrong with the modern G.O.P. — is why the party is pushing this harsh, morally indefensible agenda.
Think about it. Losing health coverage is a nightmare, especially if you’re older, have health problems and/or lack the financial resources to cope if illness strikes. And since Americans with those characteristics are precisely the people this legislation effectively targets, tens of millions would soon find themselves living this nightmare.
Meanwhile, taxes that fall mainly on a tiny, wealthy minority would be reduced or eliminated. These cuts would be big in dollar terms, but because the rich are already so rich, the savings would make very little difference to their lives.
More than 40 percent of the Senate bill’s tax cuts would go to people with annual incomes over $1 million — but even these lucky few would see their after-tax income rise only by a barely noticeable 2 percent.
So it’s vast suffering — including, according to the best estimates, around 200,000 preventable deaths — imposed on many of our fellow citizens in order to give a handful of wealthy people what amounts to some extra pocket change. And the public hates the idea: Polling shows overwhelming popular opposition, even though many voters don’t realize just how cruel the bill really is. For example, only a minority of voters are aware of the plan to make savage cuts to Medicaid.
In fact, my guess is that the bill has low approval even among those who would get a significant tax cut. Warren Buffett has denounced the Senate bill as the “Relief for the Rich Act,” and he’s surely not the only billionaire who feels that way.
Which brings me back to my question: Why would anyone want to do this?
I won’t pretend to have a full answer, but I think there are two big drivers — actually, two big lies — behind Republican cruelty on health care and beyond.
First, the evils of the G.O.P. plan are the flip side of the virtues of Obamacare. Because Republicans spent almost the entire Obama administration railing against the imaginary horrors of the Affordable Care Act — death panels! — repealing Obamacare was bound to be their first priority.
Once the prospect of repeal became real, however, Republicans had to face the fact that Obamacare, far from being the failure they portrayed, has done what it was supposed to do: It used higher taxes on the rich to pay for a vast expansion of health coverage. Correspondingly, trying to reverse the A.C.A. means taking away health care from people who desperately need it in order to cut taxes on the rich.
So one way to understand this ugly health plan is that Republicans, through their political opportunism and dishonesty, boxed themselves into a position that makes them seem cruel and immoral — because they are.
Yet that’s surely not the whole story, because Obamacare isn’t the only social insurance program that does great good yet faces incessant right-wing attack. Food stamps, unemployment insurance, disability benefits all get the same treatment. Why?
As with Obamacare, this story began with a politically convenient lie — the pretense, going all the way back to Ronald Reagan, that social safety net programs just reward lazy people who don’t want to work. And we all know which people in particular were supposed to be on the take.
Now, this was never true, and in an era of rising inequality and declining traditional industries, some of the biggest beneficiaries of these safety net programs are members of the Trump-supporting white working class. But the modern G.O.P. basically consists of career apparatchiks who live in an intellectual bubble, and those Reagan-era stereotypes still dominate their picture of struggling Americans.
Or to put it another way, Republicans start from a sort of baseline of cruelty toward the less fortunate, of hostility toward anything that protects families against catastrophe.
In this sense there’s nothing new about their health plan. What it does — punish the poor and working class, cut taxes on the rich — is what every major G.O.P. policy proposal does. The only difference is that this time it’s all out in the open.
So what will happen to this monstrous bill? I have no idea. Whether it passes or not, however, remember this moment. For this is what modern Republicans do; this is who they are.
Boston Surgeon Argues Senate GOP Bill Threatens Nation's Health
by Atul Gawande - NPR - June 28, 2017
NPR's Robert Siegel talks with Atul Gawande, a surgeon at Brigham and Women's Hospital in Boston and a staff writer for The New Yorker, about what the health care industry learned from the Affordable Care Act.
ROBERT SIEGEL, HOST:
Senate Republicans will take their July Fourth recess without having passed a bill to repeal and replace the Affordable Care Act. It looks like we're in for a summer of trying to balance conservative Republican demands to get Washington out of the health care marketplace with more centrist Republican demands to deal more gently with Medicaid.
Atul Gawande has described both the Republican House bill that passed and the Senate bill that's been pulled as, in many ways, Medicaid repeal bills masquerading as Obamacare repeal bills. Gawande is a staff writer for The New Yorker, and he joins us from Boston, where he is also a surgeon at Brigham and Women's Hospital. Welcome back to the program.
ATUL GAWANDE: Glad to be back.
SIEGEL: You've written about the success of Medicaid and the Medicaid expansion. What are those successes?
GAWANDE: Well, the big ones just in terms of health - we actually as part of a scientific review looked at the past decade of studies, and they're especially in Medicaid. And a common criticism of Medicaid is that it is worth almost nothing because not all doctors take it and that people may not be treated as well as others. What we found, however, is that when people gain Medicaid, they have substantial improvements in their access to care of all kinds - primary care, preventive care, chronic illness treatment and needed medications.
SIEGEL: And it isn't a self-selecting group, that the people who are taking the effort to enroll are more likely to be concerned about such things.
GAWANDE: No. We in fact see that when people gain insurance of any kind, they all got substantial improvements in access to care. They report improvements in their overall health, both mental health and physical health. You have remarkable reductions in depression, improvements in heart disease and other conditions. And then if you wait long enough, four or five years out, you see measurable, substantial reductions in mortality, especially in the areas where you have chronic or semi-chronic illness like cancer, heart disease, HIV and other such conditions.
SIEGEL: How much would the Republican Senate bill alter Medicaid?
GAWANDE: Pretty dramatically. It would involve rolling back the expansion that was created under the ACA where it added coverage for people at the poverty line or near the poverty line and then cut it down even further below levels that would have been in place without the ACA being there at all. So it's a major transformation.
SIEGEL: Indulge me with a thought experiment here for a moment. If Medicaid is a very effective way of delivering medical care, what if it were the only way that we got medical care? What if there were no employer-provided health insurance benefits or no Medicare for the elderly? How would a nationwide Medicaid-for-all work?
GAWANDE: Well, it would be basically a lot like Canada, which is province-based health care. And Medicaid is state-based health care, and it's paid for with a fair amount of money from the national level. And so what we would have is a system that would be kind of state-based, single-payer health care. Having everybody in the system would mean that you would probably have all of the politics of what to pay doctors and everything else likely leading to people raising the amount of money that's paid to doctors and the health care system. It would be certainly a simplified system, and all the debates now we have about the single payer would be applied in that direction.
That said, Nevada actually created a system that passed and then was just vetoed by the governor that - the legislature passed a program that would have allowed anybody to buy into Medicaid. And that was the creation of a public option that very nearly became law and would have been an interesting experiment.
SIEGEL: Have you heard anything in the discussion this month over either the Senate bill or the House bill that the Republicans have passed or any of the discourse in Washington - anything encouraging at all to you in this discussion?
GAWANDE: No. And the reason it's discouraging is because at the end of the day, where the fundamental disagreement is isn't about the technical policy here. The fundamental disagreement is over, what is the goal? Is the goal to remove a trillion dollars in tax revenues from health coverage because you don't believe that is a good way to spend that money, and we ought to give it back as a tax cut for the wealthiest who've paid those tax revenues? Or should we keep that trillion dollars that have been allocated and raised for the purposes of providing health care coverage in order to provide these health benefits that I described?
I think the problem with the bill isn't just the 22 million uninsured. It's the vision of a health system where Medicaid is a shadow of what it used to be, and the average insured person is expected to have a $6,000 deductible and no primary care or chronic illness coverage. That is a world which is - it's not getting votes because for many people, it causes - it's a description of a health system that is a fundamental failure of a government purpose. And then for conservatives, it does not extract government from a role that they think it ought not to play at all.
The Blood on a Tax Cut
by Timothy Egan - NYT - June 30, 2017
Pretend you are that most improbable of combinations — a lovable billionaire. In other words, you’re Warren Buffett. The politicians who worship guys like you have another treat in store: They will cut your most recent tax bill by $679,999, making you even wealthier.
But it comes with a price. A fellow American of a certain age making $56,000 a year would have to pay three times more in annual health care premiums — $20,500 — to help finance your windfall. You don’t need the money. Cripes, you’re worth $76 billion! But that other citizen can’t live without health care.
Such is the bargain — your health care for my tax cut — that Republicans have proposed with their overhaul of the Affordable Care Act. The toxic Senate bill does nothing to fix a struggling system. But it is bold and quite daring: for this is the broadest attack on working Americans by a governing political party in our lifetime.
No surprise, the real Warren Buffett wants nothing to do with it. He calls it, the “Relief for the Rich Act.” Another eminently sensible Midwesterner, Gov. John Kasich of Ohio, is equally perplexed. Why take away vital services for the struggling middle class, the mentally ill, the poor and the elderly to give more money to people who don’t need it?
“And they think that’s great?” Kasich, a Republican, said. “That’s good public policy? What, are you kidding me?”
Lost in the usual banality of the Beltway box score this week are the moral dimensions of the plot to gut health care. The reprieve on a Senate vote, until after the July 4 recess, is momentary. Still, it gives people just enough time to consider the audacity of meanness behind what Republicans are trying to do.
There is blood on this tax cut. It’s a simple swap — taking away $700 billion from one class of people to give it to another. That swap would leave 22 million Americans without health care over the next decade, and many of them will die prematurely because they will not see a doctor in time. In turn, those making $875,000 a year would get an average tax cut of about $45,000. Those making $5 million a year would get a break of $250,000.
Americans don’t like talk of class warfare; it reminds us of those dreary, failed Marxists who seldom practice what they preach. But there’s no other way to look at this. Right now, a 64-year-old making $55,000 can afford to get health care, thanks to Obamacare subsidies.
But how is that person supposed to pay nearly half of his or her income in premiums, as Republicans propose? The bill would also allow states to eliminate minimum standards of health care. And the worst blow would fall on Medicaid, which one in five Americans depends on.
Think of it this way: Your car breaks down. You need it to get to work. Indeed, your livelihood depends on it. You call the Republicans. They scrap the car for cash and leave you on the road.
All for a tax cut. Not a tax cut on wages, which would actually help most Americans. But a cut of taxes that are painless to the small percentage of people who have to pay them — a 0.9 percent Medicare surtax, and 3.8 percent tax on net invested income for couples earning more than $250,000 a year.
And it’s not as if there’s been a great hue and cry to repeal those tax increases. “My wealthy clients barely noticed the taxes resulting from the Affordable Care Act and have not needed to make lifestyle adjustments,” wrote the Forbes contributorCarolyn McClanahan, a financial planner.
I bet if you asked rich people if they wanted to cut off health care for millions of their fellow citizens in exchange for a bit more money at the end of the year, most of them would say no, that’s crazy. Taxes don’t register among the top concerns of people, in poll after poll.
Why such a cruel bill, then? You can start at the top, with a petty, soulless president who showed with a tweet insulting a woman’s appearance this week that he has no more empathy than a sociopath. Nor does he have a clue about what Congress has been up to.
“We’re talking about a great, great form of health care,” President Trump said at midweek, with all the conviction of someone peddling the fraud of Trump University.
And you have a Congress that was largely paid for by influential groups for whom tax cuts are the only reason to get out of bed in the morning. Still, we have a moment of rare consensus in this country: An overwhelming majority hates the Republican overhaul. No state in the union has voiced majority support.
Where to start? Congress could begin by following the American Medical Association. They see the Republican plan as a violation of an ancient oath that the best doctors still swear by — first, do no harm.
A Price for the G.O.P.’s Health Care Insanity
by Bret Stephens - NYT - June 30, 2017
It costs as little as $10 and as much as $10,169 to get the same blood test in California. A lower-back M.R.I. priced at $199 at one Florida clinic goes for $6,221 in San Francisco. A shoulder X-ray can run anywhere between $21 and more than $700 across the United States.
In Spain, a 30-day supply of Truvada, which helps prevent H.I.V.-AIDS, costs an average of $559, according to data compiled by the International Federation of Health Plans. In the United States it’s $1,301. In Britain, the average price of an angioplasty is $7,264 versus $31,620 in the United States. Hip replacement in New Zealand is $15,465. The United States figure is $29,067.
Many things about health care delivery in the United States are insane. The economist Kenneth Arrow crisply described the biggest insanity back in December 1963. “Insurance,” he wrote, “removes the incentive on the part of individuals, patients, and physicians to shop around for better prices for hospitalization and surgical care.” When did you last go bargain-hunting for a urinalysis?
This is the third-party-payer problem, and if Republicans had been more modest and less inept in advancing a realistic health care agenda, they might have spent the past seven years understanding, explaining and changing it. Instead, it was “repeal and replace” all the way to the political Verdun in which they now find themselves.
What is it that Americans don’t like about their health care? Chiefly, skyrocketing insurance premiums, higher deductibles and decreasing access to services. Obamacare has made all this worse.
Average premiums for the benchmark Obamacare plan rose 8 percent in 2016 and 21 percent in 2017, according to Kaiser Family Foundation data, while deductibles were up by about 15 percent. For some markets and plans, the premium increases were considerably higher: 67 percent in Oklahoma City; 71 percent in Birmingham, Ala.; 145 percent in Phoenix.
Same deal for employer-sponsored plans. “While Sen. Obama promised during his campaign in 2008 that the average family would see health insurance premiums drop by $2,500 per year, the average family premium for employer-sponsored coverage has risen by $3,671,” noted Maureen Buff and Timothy Terrell in the Journal of American Physicians and Surgeons. That was back in 2014, and premiums continue to rise.
Meanwhile, insurers keep walking away from Obamacare’s unprofitable exchanges. Anthem and MDWise announced last month that they were withdrawing from Indiana, which will leave 76,000 Hoosiers in need of a new insurer. Anthem said it would be pulling out of the exchange in Ohio. Aetna warned it was pulling out of Virginia in May and Iowa in April. Humana did as much in Tennessee in February. More than 1,000 counties in the United States — a third of the total — are down to just one insurer, according to a Bloomberg analysis.
This was predictable. “Obamacare was sold using the language of choice and competition, but it is actually reducing both,” a Wall Street Journal editorial warned back in 2010, when the law was months old. Health insurance doesn’t work when it isn’t allowed to operate as insurance: when it cannot tailor its products to the preferences and budgets of consumers, and when it cannot make business decisions based on considerations of risk.
You do not get to insure your house after it’s on fire. Why should Americans have the unalienable right to wait till they get sick (at least during open enrollment) before buying health insurance?
Here, however, is where the philippic against the Affordable Care Act ends. Barack Obama inherited a broken health care model and made it worse, unless you count shunting millions of people into Medicaid as a triumph. For all the liberal angst about the Republican House and Senate bills, they are only tinkering with the same unfixable formula.
The only genuinely promising reform in the Republican health bills are proposals to nearly double contribution limits for heath savings accounts and allow them to be used to pay for premiums. Enrollment in tax-deductible, investable H.S.A.s has roughly doubled since Obamacare took effect, to about 20 million, because they help cover out-of-pocket costs for low-premium, high-deductible plans.
But as Peter Ubel of Duke pointed out last year, they’re mainly attractive to wealthier people with income to spare. Government subsidies of H.S.A.s for low-income people, Ubel writes, could turn H.S.A.s into something other than “another tax break for the wealthy” and “make our health care system more responsive to consumer needs.” This is what Singapore does, along with mandates for employees to set aside a portion of their income for H.S.A.s, and for employers to match it.
H.S.A.s can restore sanity to a market in which prices are invisible and costs keep rising, and in which the concept of “insurance” has lost its meaning. Republicans who want to salvage a conservative policy victory from their health care fracas would be wise to leave Obamacare alone, so that its authors can pay the price for its failure, just as the G.O.P. restores price to the rest of the health care system.
Five myths about health insurance
by Alexis Pozen - The Washington Post - June 1, 2017
It is no wonder so many myths about health insurance persist. The U.S. health insurance system is opaque and labyrinthine, and at times purposely so. The current debate over whether to repeal major provisions of the Affordable Care Act (ACA), otherwise known as Obamacare, comes down to whether consumers should subsidize services they never expect to use. But who pays for what, and how, is not straightforward.
Myth No. 1
The ACA has forced millions to buy insurance they don’t want.
House Speaker Paul Ryan deployed this myth when defending repeal — which the Congressional Budget Office estimated this past week would increase the number of uninsured people by 22 million by 2026. “It’s not that people are getting pushed off a plan,” Ryan said. “It’s that people will choose not to buy something they don’t like or want.”
That reasoning echoes the late Supreme Court justice Antonin Scalia, who during a 2012 challenge to the ACA suggested that the law’s individual mandate started the federal government down a slippery slope. “Everybody has to buy food sooner or later,” he said. “Therefore, you can make people buy broccoli.” And no one wants broccoli, right?
But both before and after the ACA, most of the uninsured consistently have reported that they want insurance. In a 2009 Department of Health and Human Services report, 48 percent of uninsured people under age 65 said they didn’t have health insurance because of the cost, 38 percent cited life changes (they had lost their jobs, left school or changed their marital status), and 12 percent said their employers didn’t offer it or they’d been denied coverage. Those who “did not want or need coverage” were lumped into an “other” category — along with people who had recently moved, were self-employed or didn’t specify — representing fewer than 8 percent of respondents.
Before the ACA, the uninsured rate had not budged since the passage of Medicare and Medicaid in 1965. Each year, 45 million people reported that they were uninsured for the entire year. Between 2010 and 2016, however, 20 million people gained coverage, almost entirely through Medicaid and marketplace subsidies.
Under both the House and Senate plans to repeal major funding provisions of the ACA, the Congressional Budget Office estimates that the uninsured rates will rise for all age groups, and most substantially for those who earn under 200 percent of the poverty line. That’s because the plans would both reduce the number of people eligible for Medicaid and lower (in some cases eliminate) the subsidies for people who buy insurance on the market. Of the 22 million Ryan was asked about, 15 million would lose Medicaid, and 7 million would lose market insurance.
Myth No. 2
Expanding health insurance coverage saves money.
The Obama administration sold the ACA to skeptics on the promise that it would limit health-care cost growth over time. Healthier people need less care, the argument goes. If lack of insurance is a barrier to health care, and if health care improves health, then expanding coverage should improve health. If poor health is costly, then expanding insurance should also lower costs.
Seemingly in vindication, real health spending growth remained historically low for several years after the ACA’s enactment. Compared with the prior decade, when health-care spending grew at an average annual rate of about 3 percent, from 2010 to 2013 annual growth averaged 1.6 percent. But evidence points to the dregs of the recession as the driver of these results, and, as the major insurance expansions took effect in 2014, cost growth again began to climb.
Costs from increased demand for health services overwhelmed savings from improved health (granted, it has been only three years since the major expansions, and health effects may take longer to manifest than budgetary effects). The Rand Health Insurance Experiment — which ran from 1973 through 1981 — and decades of subsequent work have shown that more generous insurance incentivizes greater use of health services and increases costs. Economists call this phenomenon, more generally, the law of demand.
The myth that insurance expansion will save money highlights the fallacy that a program must save money to be valuable. Expanding health insurance is costly, and perhaps costs even more than it saves, but it is also valuable, because it improves people’s access to care, financial stability and overall well-being.
Myth No. 3
Health insurance companies make massive profits by cheating consumers.
To strengthen the case for reform, proponents of the ACA scapegoated private insurers in the debate leading up to its passage, blaming outsize premiums and skimpy coverage on unethical behavior. In a 2009 radio address, Obama cited insurers’ undue “profits and bonuses.”
Insurers, however, were not earning particularly high profits then. A 2010 Congressional Research Service study showed that among large, publicly traded health insurers, profits averaged 3.1 percent of revenue. In comparison with other health-care players, that put them in the middle of the pack — well below pharmaceutical and biotech companies and medical-device manufacturers, on par with pharmacy companies, and above hospitals.
Yet this rhetoric has persisted in both liberal and conservative outlets. “The ACA gets blamed for rising premiums, while insurance companies are reaping massive profits,” a Salon article declared in October. A Weekly Standard piece published around the same time pointed to rising profits among the health insurers on the Fortune 500 as “another fine example of the natural alliance between Big Government and Big Business.”
But the beginning of the ACA coincided with the end of the recession. From 2007 to 2009, 8 of the 10 largest insurers had double-digit losses, and one — WellCare — had triple-digit losses. In a phenomenon economists call “regression to the mean” and financial analysts call “the business cycle,” profits across all industries recovered around the same time the ACA was implemented.
A nationwide study of insurers supports the argument that their profits are more aligned with economic growth than anything else. In 2013, when GDP growth was slower, insurers on average operated at a loss; but they recovered by 2014 when growth picked up. Moreover, the bulk of insurer profits were from investments rather than enrollees.
Myth No. 4
People are free-ridingon Medicaid.
The White House’s Kellyanne Conway is among those who have promoted this myth, telling Fox News this past week that Medicaid has expanded beyond the truly needy. “If you’re able-bodied and you would like to go and find employment and have employer-sponsored benefits, then you should be able to do that” and not rely on Medicaid, she said.
Historically, Medicaid has not required recipients to work, but the Trump administration and congressional Republicans have proposed a provision to encourage states to link benefits to work. “We believe it’s important for folks to have a job, that they contribute not just to society but they contribute to their own well-being,” Health Secretary Tom Price said in March.
These requirements, however, would not change much. Most Medicaid recipients who can work, do. Almost two-thirds have full-time or part-time jobs, and more than three-quarters come from families where someone has a job. (These jobs, though, tend to be in low-paying sectors, such as agriculture and food service, where employer-sponsored health insurance is generally not an option.)
Moreover, Medicaid is not a program that largely covers people who can “go and find employment.” Only 30 percent of enrollees are able-bodied adults, constituting 20 percent of spending. Children make up nearly half of enrollees (44 percent), while the aged and disabled account for more than half of spending (60 percent).
Myth No. 5
Job-based insurance means your employer pays — and the government doesn’t.
Although firms may boast about offering generous health-care benefits, the costs of coverage are largely borne by employees, in the form of lower wages than a competitive market would otherwise support. That helps explain why inflation-adjusted wages have remained flat, even while productivity has increased — it’s all going to cover rising health-care costs.
Also, the distinction between the public and private insurance sectors is not so sharp as many people imagine. By exempting employee and employer premiums from income and payroll tax, the government forgoes hundreds of billions of dollars in tax revenue each year. In 2016, this subsidy was worth $275 billion. (In contrast, the total savings projected from the either the House’s American Health Care Act or the Senate’s Better Care Reconciliation Act , which include savings from cutting federal cost-sharing subsidies in the state marketplaces, do not exceed this number in any year.)
The government subsidy is what ties employment to insurance. Taxing premiums would break the link, allowing individuals to choose jobs based not on the availability of health insurance but on their skills and preferences. Further, subsidies encourage overly generous policies, which put upward pressure on prices. Eliminating subsidies could help bring the costs of health-care premiums down.
As with any policy, there are disadvantages to taxing health insurance. For example, it may discourage younger, healthier workers from joining their job-based plans and prod them to seek insurance in the individual market, where they would not be pooled with older and sicker co-workers. Presumably, the benefit savings would be passed on in the form of faster wage growth, but this transition could be slow.
In rural Maine, fear of GOP Medicaid cuts runs deep
bu Victoria McGrane - Boston Globe - July 3, 2017
WASHINGTON — To measure how Republicans’ proposed cuts to the federal Medicaid program might harm rural Americans, Maine’s Piscataquis County is a good place to start.
Stretching from the center of Maine northward, it is one of only two counties east of the Mississippi that still qualify as “frontier” territory, with 17,000-odd residents scattered over an area the size of Connecticut. And the tiny, 25-bed Mayo Regional Hospital, in the county seat of Dover-Foxcroft, is responsible for providing the lion’s share of care on a diminutive budget.
So the prospect of deep cuts to Medicaid and other changes to the Affordable Care Act in Washington has Marie Vienneau, the hospital’s president, on edge, staring down the barrel of steep revenue losses: An outside consultant estimates the Senate bill’s Medicaid cuts alone would translate into roughly $846,000 a year in lost revenues for Mayo — nearly 2 percent of expected annual net revenues this year.
Such a large knock to her budget would lead to further layoffs and service cuts at a hospital that’s been operating at a slight loss for several years. Vienneau recently let go the hospital’s only pediatrician and will part ways with its sole psychiatrist in the fall, choosing to rely on less costly mental-health nurse practitioners.
“It just makes me sad. I feel like the rural areas are being forgotten,” Vienneau, who grew up in rural northern Maine, said in an interview. “It’s just very discouraging because you want to do everything you can for people, and they deserve it.”
As in many rural areas, people drive for miles to receive primary care, addiction counseling, and specialty services like cardiology and orthopedics. With three garages and nine ambulances, the hospital also runs emergency medical services for the entire county.
Based on median age, the folks of Piscataquis County also are among the oldest in the nation, with many suffering from chronic diseases such as diabetes, mental health issues, and, more recently, struggles with opioid addiction.
The county’s snapshot is repeated across the country, where rural health care advocates and hospital administrators say the Senate and House bills designed to replace the Affordable Care Act would deal a devastating blow to a fragile network. It’s a stark political irony for President Trump, who was lifted to the White House by the votes of rural America, part of the America who “will be forgotten no longer,” as Trump vowed in his inaugural address.
“Rural America was frustrated,” said Maggie Elehwany, vice president of government affairs for the National Rural Health Association, a Kansas-based advocacy group.
“They voted for somebody who was going to remember them, because they have felt forgotten,” which can be seen in the high rates of suicide and opioid addiction, she said. “And when you, on top of all of that, close that rural hospital, that’s a death sentence for many towns.”
The US Department of Health and Human Services, which administers Medicaid, did not respond to a request for comment about the impact the proposed Medicaid cuts and other changes would have on rural hospitals.
Battles among Republicans over the Medicaid cuts have prevented the Senate from holding a vote on the proposed bill. Among the most notable opponents: Maine’s senior senator, and a key moderate swing vote, Susan Collins, who cited the Senate bill’s threat to health care access in rural areas.
What’s already described as a rural hospital closure crisis — 80 have shuttered nationally since 2010 and more than 40 percent are operating in the red — would get worse, health advocates say.
“We think this will absolutely cripple rural hospitals and explode the closure crisis,” said Elehwany.
Medicaid is the federal-state health insurance program for the poor and disabled, and it also pays for nursing-home care for low-income elderly people, including many who were once middle class until they ran out of money for their long-term care. The nonpartisan Congressional Budget Office estimated that the Senate bill would slash $722 billion in projected federal spending on Medicaid programs over 10 years, resulting in 26 percent less funding than under current law. At the end of 20 years, the federal government would spend 35 percent less on Medicaid, the CBO said.
Republicans like the cuts because they represent a big step toward a long-held conservative goal of curbing federal entitlement spending, which they argue is necessary to keep the country from financial ruin.
They also like that the Medicaid reductions would reduce the federal deficit by $321 billion over 10 years and allow for big tax cuts for the wealthy and insurance companies — though some Senate Republicans have started to argue against keeping the tax cuts in the bill.
“The level of cuts that they are talking about are breathtaking,” said Steven Michaud, president of the Maine Hospital Association, noting that many of the state’s 26 rural hospitals are already on precarious financial footing. “We just do not see how you can take that amount of money out of rural Maine without severe consequences. And we’re not alarmist normally.”
The Senate bill — if it became law — would cost the nation’s roughly 2,200 rural hospitals a collective $1.3 billion in lost revenue in the first year, according to an analysis done by the Chartis Center for Rural Health, an advisory firm. The bill would trigger 34,000 job losses in the first year, according to the study.
California would be hardest hit in terms of total lost revenue, according to Chartis. The second biggest loss would be suffered by rural hospitals in Kentucky, the home state of Senate majority leader Mitch McConnell, who crafted the Senate bill behind closed doors.
A spokeswoman for McConnell said that the Senate bill, which is still being revised, aims to “strengthen Medicaid for those who need it most by slowing the growth of the program over a responsible period of time” and noted that Medicaid spending in 2026 would still represent a 26 percent increase over 2016 spending levels.
She also said the bill provides “substantial resources” to rural and other underserved areas, including funding for community health centers.
Critics say the potential consequences extend far beyond hospitals themselves: Without them, even more people will move out of rural regions, say critics.
“This is rural cleansing, because that’s what going to happen,” said Michaud, the Maine Hospital Association president. He pointed to a hospital in Calais that recently announced it was shuttering its obstetrics department and would no longer deliver babies, as an example of what is in store should the GOP plans become law.
What young family is going to live in a place where they don’t deliver babies? he asked.
“Those are the real-world implications. That is a recipe for the downward spiral of rural areas.’’
by David Dayen - The Intercept - June 30, 2017
In the days since California Assembly Speaker Anthony Rendon shelved for the year SB562, which intends to establish a state single-payer health care system, he’s been subject to mass protests and even death threats. The bill’s chief backers, including the California Nurses Association and the Bernie Sanders-affiliated Our Revolution, angrily point to Rendon as the main roadblock to truly universal health care.
They’re completely wrong. What’s more, they know they’re wrong. They’re perfectly aware that SB562 is a shell bill that cannot become law without a ballot measure approved by voters. Rather than committing to raising the millions of dollars that would be needed to overcome special interests and pass that initiative, they would, apparently, rather deceive their supporters, hiding the realities of California’s woeful political structure in favor of a morality play designed to advance careers and aggrandize power.
That may sound harsh. It’s gentle.
Amid an uncertain future for U.S. healthcare, California’s overhaul attempt has galvanized the left and received national attention. But the peculiarities of state law and process remain a mystery, allowing advocates to create a serious gap between the expectations of supporters and the very real obstacles in the way.
There’s a reason that every California single-payer bill in the last 25 years — and there have been at least seven, two of which passed the legislature and were vetoed, so we in the Golden State have seen this movie before — never includes a funding mechanism. It’s not necessarily because of fear of voting for higher taxes, or even the two-thirds threshold to increase a tax in the legislature.
It’s because you can’t do the funding without help from the voters, because of California’s fatal addiction to its perverse form of direct democracy. The blame, in other words, lies with ourselves.
To figure this out, you need only turn to the actual legislative analysis of the Senate bill, which passed in early June. It states very clearly what Rendon alluded to in his announcement shelving SB562: “There are several provisions of the state constitution that would prevent the Legislature from creating the single-payer system envisioned in the bill without voter approval.”
To cut through the clutter, let’s focus on the biggest constitutional hurdle, known as Proposition 98. Passed in 1988, Prop 98 requires that roughly 40 percent of all general fund revenues — money the state receives in taxes — must go to K-12 education. If you include community college spending, it must exceed 50 percent.
Prop 98 was itself a reaction to the notorious Prop 13, which sharply limited state property taxes. It was intended to ensure that education received its fair share of funding. But it also created a budgetary straitjacket that affects virtually anything that costs California money.
The actual Prop 98 budget formula is so byzantine, it is said that only the initiative’s author John Mockler truly understood it, and he died two years ago. And a review of Prop 98 from the Legislative Analyst’s Office this January found that it doesn’t even succeed in its intended purpose of increasing funding for schools. But we know this: if you double the state general fund by putting a single-payer system on budget, at least 40-50 percent of those new revenues have to go to education.
As the Senate legislative analysis states, “Any taxes raised to support this bill would be … subject to the requirements of Proposition 98.” That means that, in order to raise enough money to fund single payer in California, under current law you would have to raise twice as much to satisfy the Prop 98 formula.
Substituting a centralized state program for the skyrocketing premiums people pay today would actually be relatively affordable. But if half the money has to be siphoned off to education, that rationale becomes harder to sell.
Self-appointed experts have countered that the state can suspend Prop 98 with a two-thirds vote of the legislature. This has been done twice in the past, during downturns in the economy. But the suspension can last for only a single year; it would have to be renewed annually to keep single payer going. More important, as the California Budget and Policy Center explains, after any suspension, “the state must increase Prop 98 funding over time to the level that it would have reached absent the suspension.”
So legislators would have to vote year after year to suspend Prop 98, but add more money back to cover it in subsequent years. That backfill would grow with every budget, and over time lawmakers would need to vote for ever-increasing giant tax hikes. If this didn’t return Republicans to power in Sacramento within a few years, some enterprising lawyer would sue the legislature for violating the spirit of Prop 98. Suspension is not politically, legally, or financially sustainable.
There are other obstacles, like a long-dormant state spending cap (the Gann limit) that would only come into play with the massive sums single payer adds to the budget. And of course the state would have to get numerous waivers from the federal government to apply Medicaid and Obamacare subsidy funds to its system, which is, shall we say, unlikely under President Trump. There’s also no actual mechanism currently in law to shift Medicare to the states, and self-insured plans from big employers, which would shift to the state under SB562, by federal law can only be governed at the federal level. Congress would have to fix both of those hurdles.
But just to stick to one point, in order to fund single payer in California, you must loosen the Prop 98 budget straitjacket. There’s no secret decoder ring or safety valve around that. And the only way to truly get it done is with a ballot measure that either overhauls Prop 98 or exempts single payer from the formula.
Anybody with a day’s worth of experience in California government recognizes this. The Senate version of SB562 stated it in black and white. But every single denunciation of Speaker Rendon’s decision to delay the bill fails to mention this reality, that SB562 cannot become law without voter approval.
Sens. Ricardo Lara and Toni Atkins, co-sponsors of SB562, thundered: “California has the chance to lead our nation toward healthcare for all, and we will not turn our backs on this matter of life or death for families.” They never mentioned that their bill is an incomplete step. (They didn’t respond immediately to a request for comment; we will update if and when we hear back.)
The California Courage Campaign pleaded with Democrats in an email blast to “fight for single payer today, not next year.” But Democrats can’t pass single payer today or this year; under state law, ballot measures only occur during statewide elections in even-numbered years. Even the chair of the state Democratic Party, Eric Bauman, insisted that “SB562 must be given the chance to succeed,” even though it, um, can’t succeed.
The California Nurses Association, when not posting “stabbed in the back” imagery in reference to Rendon, called his decision “heartless,” “unconscionable,” and “disingenuous.” But there’s nothing more disingenuous in this debate than failing to level with people that SB562 cannot become law on its own.
Lara, incidentally — or more likely not incidentally — is running for Insurance Commissioner. Toni Atkins, a former Assembly Speaker, wants to become senate president when the current leader, Kevin de Leon, terms out next year. De Leon wants to run for … something; signs at the recent state Democratic Party convention read “Run Kevin Run” even though he hasn’t declared for any higher office. You don’t have to question their commitment to single payer to understand their motives to kick a shell bill without funding to the Assembly and bathe in the glory of the progressive faithful. Lara and Atkins claimed at one point SB562 would get a funding plan before becoming law, but they’ve continued to hide the reality of the necessary ballot measure.
As for outside groups, it’s clear that they have a strategy to make single payer a litmus test issue politically, while never acknowledging the process hurdles. With so many single-payer supporters in California and across the country unaware of the facts, playing this cat and mouse game is at best a sin of omission, at worst the kind of dishonesty that breeds cynicism in the public when it learns it was conned.
When asked straight-up about the obstacles, CNA Director of Public Policy Michael Lighty pointed to language in SB562 that would stall adoption of single payer unless adequate funding was available. He called it “a failsafe mechanism.”
Lighty is implicitly saying that SB562 can never create a single-payer system. The failsafe will always be triggered unless the state constitution gets changed at the ballot, because there will never be enough money under the current iteration of Prop 98. Saying that out loud would depress enthusiasm and lessen CNA’s perceived power. So they hide the ball.
Speaker Rendon is clearly taking the bullet for an Assembly Democratic caucus that is far more moderate than the Senate, and doesn’t want the burden of cleaning up the Senate’s shell bill. On the same day Donald Trump pulled out of the Paris Climate Agreement, the Assembly blocked an extension of the state’s cap and trade bill, and recently rejected legislation popular with progressives to end money bail. Rendon knows his caucus won’t pass anything that looks like single payer, and if they did, Jerry Brown would be likely to veto it anyway.
But those who villainize Rendon without telling the truth to their supporters are not blameless either. The entire debate is one big game of passing the buck, with single payer’s loudest champions earning plaudits from the liberal base but doing nothing to advance universal health care.
If there was real interest in getting single payer done, supporters wouldn’t focus on a shell bill, but would start raising the gobs of money you’d need for the ballot measure, which will come under massive assault from every industry affected by shifting away from for-profit health care (especially because messing with Prop 98 will allow providers to dishonestly claim that single payer “takes money from our kid’s schools”). Just last year, the pharmaceutical industry put over $100 million into stopping an initiative that simply would have limited state spending on prescription drugs to the price paid by the Veterans Administration. Hospitals, doctors associations and insurance companies could spend twice as much to stop single payer. That doesn’t mean it couldn’t win, but advocates don’t seem to want to talk about the fight.
Rendon actually delivered the perfect set piece to shift the conversation to the ballot. Single-payer backers could have said, “If we can’t go through the legislature, we’ll go around them to the people.” But the movement for universal health care has instead devolved into political theater, with no strategy for success. For those who support single payer — and that includes me — it’s not only frustrating, the deceit is an insult to our intelligence.
The CNA responds
Michael Lighty, the director of public policy at CNA, responds to Dayen:
If David Dayen had spoken with California Nurses Association, who are the sponsors of SB562, he would know that many of his assumptions about the California single-payer healthcare bill are wrong, his attack on single-payer supporters in California misguided, and his “one true path” analysis false. His outrage is misplaced. The only ones insulted here are the readers of The Intercept, who must wade through opinion masquerading as political intelligence.
First, the assumption that California Assembly Speaker Anthony Rendon will engage on the substance of SB562: Simply put, there is no good faith on Rendon’s part. He knew CNA had developed amendments when he stalled the bill, and his own staff had told us to focus on policy rather than financing, which we were doing with the bill’s co-authors. The Speaker talks of sending the bill back to the Senate but, under the rules, he knows it can only be amended in the Assembly now.
Having submitted extensive, detailed policy amendments in advance of the Assembly Health Committee, we expected to follow the legislative process. We prepared to address financing following policy committee approval. We were working to address all outstanding issues through the regular legislative process. Rendon halted that process, so it is disingenuous to claim the bill is incomplete; the process to complete it was stopped.
The accusation that SB562 is a “shell bill” reveals ignorance of the bill’s polices, status, and the legislative process. Like other significant legislation, including SB32’s cap-and-trade program, which was a 12-page bill, it’s appropriate to delegate some significant decisions to the governing board. For example, Dayen questions the SB562’s non-mandate of Electronic Health Records (EHR). Yet, EHR seems well-suited to regulatory delegation — particularly since an EHR for single payer would not be designed to maximize reimbursements, as they all are now, and so would likely be very different from the current tools.
Dayen’s assertion that the bill cannot become law without a ballot measure approved by voters is an assumption, not a fact. There are ways in the bill to address the constitutional issues posed by both Prop 98 and the Gann limit. Through consultations with the primary sponsor and constitutional legal experts, we are developing these legislative approaches. Those consultations would bear fruit in the legislation if Rendon ends his subversion of the democratic process.
Moreover, Dayen insists, “But we know this: if you double the state general fund by putting a single-payer system on budget, at least 40-50 percent of those new revenues have to go to education.”
No, we don’t know that. We can address those constitutional issues in the bill, and his cost estimate is exaggerated. A reading of the a study from the University of Massachusetts, Amherst, on SB562 would have corrected this mistake. Because of savings for individuals and businesses achieved by eliminating the insurance company premiums, deductibles, and co-pays, and because of slashed expenses in the system as whole by ending the waste, profit, and inefficiencies of the current healthcare industry, the cost is $37 billion less per year than what we spend now — while covering everybody with more comprehensive benefits.
Regarding waivers, there is authority under the Social Security Act for states to administer Medicare, and for the Healthy California plan to become a Part B provider, and provide subsidies under Part D. The Affordable Healthcare Act waivers enable states to improve upon Medicaid coverage and, yes, the Employee Retirement Income Security Act applies to employer-provided health benefits but does not impact programs that raise taxes from employers to fund universal healthcare. In fact, under ERISA states can regulate third-party administrators, which many self-insured employers use. Waiver authority under the ACA is also available to California, and exists in part to enable state single-payer. Congress, then, doesn’t have to do anything else.
In a cruel twist of words, Dayen wrote, “Lighty is implicitly saying that SB562 can never create a single-payer system” — when the reality is the reverse. Californians must receive the federal monies for healthcare for which they are eligible, and utilizing the existing waiver authority, as well as raising the necessary funds — financing options for which are contained in the University of Massachusetts study of SB562, among others — single payer can be implemented in California.
Tell thousands of committed Californians that supporters are doing nothing to advance universal health care when they have turned out to town halls and rallies in Sacramento and around the state, and are knocking on their neighbors’ doors every weekend. Or tell that to the hundreds of organizations including businesses that support SB562. Advocates have held dozens of meetings with legislative staff (including with the Health Committee and Speaker’s staff who knew we were addressing all his concerns before he pulled the plug), utilized the extensive study done by the University of Massachusetts on how to finance SB562, and explored how to obtain the necessary waivers. Despite Dayen’s certainty, Governor Jerry Brown has not taken a position on the bill. The only Democrats Rendon is protecting are those funded by the health insurance companies.
The 100,000 members of the California Nurses Association, part of National Nurses United, see the only inaction here coming from the legislature. As patient advocates committed to Medicare For All, they will not give up until all their patients have the healthcare we need, guaranteed.
Dayen responds to CNA:
To be clear, I assume no good faith on the part of Anthony Rendon. The long history of state Democrats making promises to its progressive base that they subsequently fail to keep has been a hobbyhorse of mine for 11 years. It continues with Rendon covering for corporate Democrats in his caucus, as noted in the original piece. It not only deserves to be called out, I’m usually the one doing it. Here I amwriting about Sheila Kuehl’s single payer bill and the importance of moving forward over legislator objections back in 2007.
However, in order to succeed on a goal so long in coming, at a time when the ground really has shifted and opportunities really do exist, you have to be passionate, smart, and clear-minded about the road ahead.
Denying that the political endgame will ultimately involve a ballot measure doesn’t set the movement up well for success. The office of SB562 co-author Sen. Ricardo Lara confirmed to me they recognize the constitutional issues that force a ballot option, joining Phillip Kim, at-large officer in the state Progressive Caucus, and Christine Pelosi, who drafted the single-payer plank of the party platform. Pelosi tweeted specifically, “We have discussed #sb562 for months in the context of needing to pass the bill AND a BALLOT measure to waive Prop98 funding.”
But Michael Lighty calls this an assumption, not a fact. (Though, in an email exchange, he said, “We’ve always acknowledged” that an initiative could prove necessary, and that they’ve done polling and secured verbal fundraising commitments, while maintaining that “the legislature can and should do this.”) Lighty alludes to “ways to address the constitutional issues” and “consultations with legal experts,” but avoids any specifics. This is an important question. It’s a $200 million question, in fact. If you can address Prop 98 and other issues within the bill, you should tell people how. Presumably Rendon didn’t ban the right to talk about single payer within California’s borders. Lighty and his colleagues keep claiming they have all these amendments ready to go to solve every problem raised but won’t show them to anyone. Why?
When I asked Lighty about this, he said, “We’re focused on moving the bill now so (we) haven’t considered steps beyond July 21,” the date of the legislative recess. If anything, that lets Rendon off the hook. Showing that there’s an engaged and committed (and public) process to amend the bill would put the lie to Rendon’s “woefully incomplete” charge. It would pressure Rendon to allow a vote.
So would a bill that came to the Assembly looking like actual policy. Lighty alludes to California’s cap-and-trade program being a 12-page bill, but here’s a better comparison: the aforementioned SB840, last decade’s single payer bill, written by then-Sen. Sheila Kuehl. Here’s the bill text of SB840, compared to the text of SB562. It’s no contest.
While Kuehl envisioned a similar framework of a commission charged with administrating the health care program, she included measures for cost control, patient advocacy, regional planning, quality of care, global budgeting, delivery system improvements, build-out of service networks, incentive payments to recruit health personnel, transition costs, statewide databasing, dispute resolution, fraud prevention, a formulary for prescription drugs, and a lot more. It was a serious bill that set real guidelines for the regulatory board to follow. It thought of almost everything.
SB562 kicks nearly all of these questions to its unelected board. It actually gives the more conservative Assembly first crack at modifying the policy, rather than putting something fully realized forward. SB840 imagined an integrated system; SB562 is a statement of principles that would result in worse policy if enacted.
CNA was the main sponsor of SB840. What changed over the past decade? Why was a legitimate bill substituted for something so vague?
One of the few places where SB562 is specific involves eliminating the Obama-era mandate for electronic health records. CNA and its parent organization National Nurses United have a long history of questioning EHRs, and nurses I’ve contacted agree it can be too overbearing and focused on billing. But there are dozens of state and federal health mandates; why does CNA focus only on this one? Lighty’s response that EHRs need to look different in a single payer world doesn’t scan; You could accomplish that under the existing mandate. Removing the EHR requirement potentially moves the state backwards to pen-and-paper medical record keeping. SB840 actually mandated electronic claims, payments, and records; why the change? And why put something so parochial into a single payer bill? Who benefits from that?
Rendon is politically daft for not allowing the bill to move forward. But CNA has every ability to move forward on their own. Show us the amendments. Fill in the policy. Excise irrelevancies. Be specific about the path forward. Don’t give Democrats an excuse to delay. Under state law, a ballot measure cannot go before voters until November 2018 anyway. There’s time to force Rendon’s hand by making the full, considered case. And you need that time, not only to get buy-in from the legislature, but to build a coalition with a chance of winning.
There’s one area where I will concede to Lighty’s criticism: I should have more sharply made a distinction between hardworking supporters on the ground — the ones making phone calls, knocking on doors, protesting in the streets for health care for all — and the bill sponsors. That’s because I want all that activist work to be in service to something meaningful, not a political litmus test or legislation standing on shaky constitutional ground. This process must not discredit the movement for health care for all. It has to be perfect. There’s time to get there. I hope it does.
Who thd hell is this guy from the Intercept and what has he get against CNA?
ReplyDeleteI've akways assumed the issue would eventually go to the ballot--not because of constitutional funding issues but because, if it oasses, the insurance industry will.almost certainly put forward an initiative to repeal it. But winning a "no" vote on such sn initiative is much easier than winning a "yes" vote on a complicated public policy which doe not reduce itself to a few sound bites.
I was involved in helping draft single payer legislation in Oregon. The experience left me convinced that actual drafting id best left to the legislative process, which allows for fine-tuning and public input and helps inoculate against inevitabke insurance industry attacks. Of course this is precisely what Rendon means to prevent.