Behind Legislative Collapse: An Angry Vow Fizzles for Lack of a Viable Plan
by Matt Flegenhaimer, Jonathan Martin and Jennifer Steinhauer - NYT - July 28, 2017
WASHINGTON — The closing argument was a curious one: Vote yes, Republican leaders told the holdouts in their conference. We promise it will never become law.
After seven years of railing against the evils of the Affordable Care Act, the party had winnowed its hopes of dismantling it down to a menu of options to appease recalcitrant lawmakers — with no more pretenses of lofty policy making, only a realpolitik plea to keep the legislation churning through the Capitol by voting to advance something, anything.
They ended up with nothing.
By the early morning hours of Friday, the animating force of contemporary Republican politics lay in ashes, incinerated by three Republican senators — John McCain of Arizona, Susan Collins of Maine and Lisa Murkowski of Alaska. But the spark can be traced back to the hot summer of 2009, and to Winterset, Iowa.
It was there, and at town hall forums that tested fire marshals’ collective patience across the country, that the Republican rage ignited in earnest. Senator Charles E. Grassley, the state’s senior senator, was scorched after protracted negotiations with Democrats on what would become the Affordable Care Act. He peeled away, other Republicans followed, and Democrats were left to pass the health law on their own.
The anger persisted. Cohesive policy never came.
“You had 300 to 700 people and one time 900 people” at the town halls of 2009, Mr. Grassley recalled in an interview on the history of the Affordable Care Act. “We had to hold the town meetings outdoors, and the audience, I never had that sort of anger.”
In Winterset, Mr. Grassley fanned the flames about so-called death panels, saying, “You have every right to fear.”
“We should not have a government program that determines you’re going to pull the plug on Grandma,” Mr. Grassley said then.
The election of Mr. Trump was supposed to be the unlikely answer to a seven-year question for Republicans: how to make good on their agenda-defining oath to undo President Barack Obama’s signature achievement.
But if the death knell came with Mr. McCain’s downward-turned thumb early Friday morning, the bill’s failure has far deeper roots in this star-crossed era of unified Republican government.
A ruling party that never expected to win. A conservative base long primed to accept nothing less than a full repeal. An overpromising and often disengaged president with no command of the policy itself and little apparent interest in selling its merits to the public.
By the time the end came, Vice President Mike Pence — dispatched to the Senate to cast a tiebreaking vote — instead seemed resigned. Ms. Collins had clustered with the other two “no” Republicans, waiting to cast their votes.
“All of the sudden someone tapped on my back and it was the vice president,” Ms. Collins said. “He obviously had heard that John has decided to vote no. He was well aware of my vote and Lisa’s position and he was there to talk to John.
“He said, ‘Boy, are you tough,’ but he softened it by putting his arm around me as he said it.”
For months before that moment, the distress signals had flared.
Days after Mr. Trump’s inauguration, Republicans gathered in Philadelphia for their annual retreat, exulting in their November victories as liquor flowed and Trump-themed socks were tucked into gift bags for lawmakers.
“Think of everything we can achieve,” Mr. Trump told them, predicting the busiest Congress in recent history and placing repeal-and-replace at the front of the line.
Yet in private sessions that week, Republicans worried about being saddled with a politically toxic “Trumpcare,” with some acknowledging that their dual promises — repealing the law swiftly without pulling the rug out from Americans — could not be reconciled.
“Republicans will own it,” Representative Tom McClintock of California said, according to an audio recording from the gathering. “Lock, stock and barrel.”
The House pressed on, slogging through boiling town halls that called to mind the Democrats’ fate in 2009.
Speaker Paul D. Ryan gamely played the salesman, delivering a slide-show presentation on live television with his sleeves rolled up for a bill that his president would eventually deride as “mean.” After pulling a planned vote in March, the House passed its version in May.
Mr. Trump celebrated the one-chamber triumph with a Rose Garden victory ceremony.
Senators were less convinced. From the start, a fissure emerged between those hoping to repeal the law and sort out a replacement later and those who insisted they must be done in tandem. Republican leaders in Congress planned to take the first approach. But that strategy quickly unraveled, with Mr. Trump demanding a simultaneous repeal and replacement.
In the upper chamber, where Republicans hoped to develop their own bill, the stumbles arrived quickly. Senator Mitch McConnell of Kentucky, the majority leader, assembled a working group of 13 senators to draft the legislation — all of them male — excluding Ms. Murkowski and Ms. Collins.
Concerns came not just from moderates like Ms. Collins but from reliable Republicans in some unlikely places: Senator John Hoeven of North Dakota, Senator Jerry Moran of Kansas, Senator Ron Johnson of Wisconsin, who told any reporter within earshot that he did not have enough information to even form a firm opinion.
At the same time, Russia-tinged scandal shadowed Mr. Trump with increasing urgency, delivering a deluge of distractions.
In mid-May, Mr. McCain, who was at the time not considered a potential swing vote on health care legislation, was asked if Republicans might be more willing to buck Mr. Trump on policy matters given the circumstances.
“Are you kidding me?” the senator shot back. “Do you think that I am not known — you think my reputation is that I go along?”
Even on matters specific to health care, Mr. Trump was not helping. At a lunch with Republican senators at the White House in June, he savaged the House measure and called for a more “generous” bill in the Senate, injecting himself into the chamber’s delicate negotiations.
Ms. Murkowski was seated directly to Mr. Trump’s right. As he ticked off soaring premiums in different states, the president leaned over to her. “I hate to say this to you, Lisa, but in Alaska, they’ve gone up 207 percent on Obamacare,” he said.
Weeks later, at another White House lunch, another fence-sitting Republican, Senator Dean Heller of Nevada, was seated in the same position. “Look, he wants to remain a senator, doesn’t he?” Mr. Trump said.
The recruitment efforts grew more ham-fisted with time. After a vote on Tuesday to proceed to a debate on health care repeal, which only Ms. Murkowski and Ms. Collins opposed among Republicans, Ms. Murkowski received a phone call: Mr. Trump had directed his interior secretary, Ryan Zinke, to remind the senator of issues affecting her state that are controlled by the Interior Department, according to people familiar with a phone call between the two.
And Mr. McCain’s startling diagnosis of brain cancer had an impact — and not just on him.
“That was the low point,” Ms. Collins said, recalling a phone call with Mr. McCain after the diagnosis. “It made me realize that even though I was under a lot of pressure, it didn’t compare to what he was going through. It reminded me of how very personal and important health care is.”
On that initial vote, Mr. McCain had been a qualified yes, returning from treatment to deliver a short-term balm to Mr. Trump and his fellow Republicans.
But his final decision awaited. At home in Arizona, Mr. McCain had been fielding calls from senators wishing him well. He joked, on his return, that he would soon give them cause to regret all the nice things they had said about him.
Mr. McCain had come back to the Capitol with a plea for his colleagues, delivered on Tuesday in a soaring address from the floor: “Let’s trust each other,” he said, lamenting the state of the institution. “Let’s return to regular order.”
All week after that, Democrats approached him, praising the speech, with a request of their own: Help the Senate get there.
“I know,” Mr. McCain told them repeatedly. “I know.”
As Thursday night slid toward Friday morning, a group of Republicans, including Mr. McCain, demanded assurances from Mr. Ryan that the House would not simply pass the slapdash legislation that many viewed as a placeholder.
The White House thought it had persuaded Mr. McCain by assuaging him on two fronts: Administration officials had been in touch with Gov. Doug Ducey of Arizona, whom Mr. McCain had looked to for guidance, and nudged the governor to make clear to Mr. McCain that he was in favor of keeping the process going. And Trump aides made certain that Mr. Ryan assured Mr. McCain in a phone call that the so-called “skinny” repeal bill at hand would not become law. Mr. McConnell appeared confident as well, for a time.
But Mr. McCain’s decision was so shrouded in mystery that his closest friend in the Senate, Lindsey Graham, and longtime aide and muse, Mark Salter, were not quite sure early Thursday evening how he would vote.
“Wait for the show,” Mr. McCain told reporters asking for a preview.
When Mr. McCain entered the floor in the wee hours of Friday morning, Mr. Pence was eager to speak to him. The vice president made clear that he, too, thought little of the bill at hand but that it was more important to go to a bicameral conference committee where a new measure could be hashed out, Mr. Graham said.
Before long, Mr. McCain left the floor to take a call in the cloakroom. It was Mr. Trump, echoing Mr. Pence’s argument.
Democrats stirred. “Not sure how vote will turn out,” Senator Claire McCaskill, Democrat of Missouri, said on Twitter, “but we have a shot.”
Mr. Trump has spoken often of leverage in negotiations. On Friday, he had none. It is difficult, in the best of circumstances, to strong-arm an octogenarian war hero battling brain cancer.
And two years ago this month — in Iowa, inevitably — Mr. Trump had disparaged him for being captured in combat.
“The three who voted against it have a very negative relationship with the president,” said Senator Bill Cassidy, Republican of Louisiana. For Mr. McCain in particular, he said, “He’s not one where you’d expect a phone call to make the difference.”
Shuffling across the chamber, Mr. McCain convened with Democrats, informing them of his choice. “They can read my lips,” he said to laughs, fearing his hand would be tipped ahead of time from inside the gallery.
At one point, the senator joined Ms. Collins and Ms. Murkowski, telling them they had done the right thing.
“We talked about how if anyone knew about doing the right thing it was John McCain,” Ms. Collins recalled. “It was very moving.”
By 1:30 a.m., Mr. McCain returned to the middle of the floor, a few feet from where he had spoken of bipartisanship and comity on Tuesday. Mr. McConnell stared straight ahead, motionless, as the Republican promise fell away.
Mr. McCain held out his arm, waiting to be recognized once more, and dropped his thumb.
McCain Provides a Dramatic Finale on Health Care: Thumb Down
by Carl Hulse - NYT - July 28, 2017
WASHINGTON — All week long, Senate Democrats had quietly groused that Senator John McCain made a stirring return to the Senate after a brain cancer diagnosis, that he preached the virtues of bipartisanship — and that he then backed a Republican-only push to replace the Affordable Care Act.
But early Friday morning, Mr. McCain, showing little sign of his grave illness, strode onto the Senate floor as the vote was being taken to repeal it, and shocked many of his colleagues and the nation. He sought recognition from the vote counters, turned his thumb down, and said “no.” There were gasps and some applause.
He had just derailed the fevered Republican effort to undo the Obama-era health care law.
It was a stunning moment that will be long remembered in the Senate, a flash of the maverick John McCain, unafraid of going his own way despite the pleas of his fellow Republicans. In teaming up with Senators Susan Collins of Maine and Lisa Murkowski of Alaska, who had already opposed the bill, Mr. McCain made good on his earlier promise to help defeat the measure if it didn’t meet his personal test.
No amount of arm-twisting by his peers, Vice President Mike Pence or even President Trump could sway him from the decision that he had telegraphed to some Democrats and Republicans in the anxious buildup to the vote.
Ms. Collins said Mr. McCain told her that he felt compelled to “do the right thing.” It probably didn’t hurt that it was also a measure of cold revenge against Mr. Trump, a man who on the campaign trail in 2015 had mocked Mr. McCain’s ordeal as a prisoner of war in Vietnam. Mr. McCain made no mention of that, however, and instead used his time of maximum impact in the spotlight to say that the spectacular collapse of the health bill provided a chance for renewal, an opening to get the Senate out of its dysfunctional and partisan rut.
“The vote last night presents the Senate with an opportunity to start fresh,” Mr. McCain said in a statement on Friday. “I encourage my colleagues on both sides of the aisle to trust each other, stop the political gamesmanship, and put the health care needs of the American people first. We can do this.”
Leading up to the vote, Mr. McCain, not untypically, had confounded both critics and admirers. His speech Tuesday had the potential to go down as a Senate classic, a call to restore the work-across-the-aisle traditions of the past.
“We’ve been spinning our wheels on too many important issues,” Mr. McCain scolded his colleagues. “We’re getting nothing done, my friends, we’re getting nothing done.”
Mr. McCain’s vote that day left Senator Mitch McConnell, the majority leader, smiling as his sometime foe, sometime friend from Arizona helped rescue the Kentucky Republican’s reputation as a master strategist.
He provided the vote to move the Republican measure forward and seemed to work throughout the week with his constant ally, Senator Lindsey Graham, Republican of South Carolina, to explore ways to get the legislation out of the Senate and over to the House as Mr. McConnell so badly wanted.
A hastily scheduled Thursday evening news conference set off alarm bells among Democrats that Mr. McCain was going to back the last-ditch “skinny” repeal effort and sustain the drive to overturn the Affordable Care Act.
But he had also been working back channels with Senator Chuck Schumer of New York, the Democratic leader, about his intentions. A relieved Mr. Schumer praised Mr. McCain after the vote.
“John McCain is a hero and has courage and does the right thing,” Mr. Schumer told reporters. “He is a hero of mine.”
Mr. McConnell was no longer smiling.
“So yes, this is a disappointment,” the majority leader said in an emotional speech after the vote. “A disappointment indeed.”
Other Republicans, while crediting Mr. McCain with a flair for the dramatic, said it was Republican voters who would be left disappointed by Mr. McCain’s act.
“The losers tonight are the people who believed in the democratic process, believe that actually when candidates run and say, ‘I will fight to repeal Obamacare,’ that that actually means they will fight to repeal Obamacare,” said Senator Ted Cruz, the Texas Republican who has clashed with Mr. McCain in the past. Mr. McCain was re-elected last year after making the repeal and replacement of the health care law a central element of his campaign.
As a senator from a state with a large population of older Americans, Mr. McCain has long involved himself in health policy, although the fine points are far from his chief area of expertise, military affairs. In this health care fight, Mr. McCain’s resistance appeared to be driven partly by concerns raised by Gov. Doug Ducey of Arizona about the potential loss of coverage in the state.
After turning Washington upside down over the last few days, Mr. McCain planned to be in Arizona on Monday for what his office described as a “standard post-surgical regimen of targeted radiation and chemotherapy.” Mr. McCain intends to keep working but does not plan to be back on Capitol Hill before September.
The question now is whether Mr. McCain’s vote will produce the results he wants: a more bipartisan approach to making changes in the health law that both sides acknowledge are needed. Or will it simply produce a stalemate that leads to a failure of the current system and a chorus of “we told you so” from Republicans?
The president made clear his unhappiness and issued a warning of what would come, predicting the current system would implode.
But for now, it was Mr. McCain who had seized the moment and set the course of the Senate.
Why Obamacare Is Still in Peril
by The Editorial Board - NYT - July 29, 2017
In a dramatic last-minute spectacle, the latest Republican plan to destroy the Affordable Care Act was defeated early Friday because of the courageous votes of three senators: Susan Collins, John McCain and Lisa Murkowski. This will come as an immense relief to millions of Americans who stood to lose their health insurance, but it would be naïve to think that this is the end of the road for the repeal-Obamacare movement.
For the last seven years, Republican leaders have engaged in a fraudulent campaign against the A.C.A. based on the lie that the law is either unworkable or collapsing. The law, which is based on conservative market-based ideas, is certainly flawed and could be improved, but it has helped 20 million people gain insurance and, as a result, provided needed medical care to the poor and the sick. Not only was the Republican diagnosis wrong, but also leaders like the House speaker, Paul Ryan, and the Senate majority leader, Mitch McConnell, tried to push through legislation that was devoid of any ideas and would have weakened the health care system and left millions unable to afford health care. One telling sign: Insurance companies, hospitals, doctors and public interest groups like AARP opposed pretty much every proposal the Republicans put out over the last seven months.
Ultimately, this deceitful campaign ran aground by the narrowest of margins in the Senate thanks to the three Republicans and all 48 Democrats and independents. Much attention has rightly focused on Mr. McCain. Returning to the Senate after surgery and a brain cancer diagnosis, he delivered a stirring speech on Tuesday calling on lawmakers from both parties to reach “agreements made in good faith that help improve lives and protect the American people.” He seemed to go against those sentiments early in the process when he voted to start debate. But, when it really counted, Mr. McCain did the right thing. An equal or larger amount of credit ought to go to Ms. Collins and Ms. Murkowski, who stood firm despite immense political pressure and, in Ms. Murkowski’s case, shameful threats by the Trump administration.
By contrast, senators like Shelley Moore Capito, Dean Heller and Rob Portman who had made a big show of protecting their constituents readily gave in to party leaders. They allowed the Senate to come within one vote of passing a bill that would have left 16 million more people uninsured and driven up insurance premiums by about 20 percent a year.
Though one threat has been put off, the A.C.A. is far from safe. President Trump and his health and human services secretary, Tom Price, have made it their mission to undermine the law. On Friday, the president again threatened to let Obamacare “implode” in order to make a deal. And Mr. Price, who worked closely with his former colleagues in Congress to devise repeal proposals, has been spreading lies about the law and making changes that would reduce benefits and lead to fewer people signing up for coverage.
By contrast, senators like Shelley Moore Capito, Dean Heller and Rob Portman who had made a big show of protecting their constituents readily gave in to party leaders. They allowed the Senate to come within one vote of passing a bill that would have left 16 million more people uninsured and driven up insurance premiums by about 20 percent a year.
Though one threat has been put off, the A.C.A. is far from safe. President Trump and his health and human services secretary, Tom Price, have made it their mission to undermine the law. On Friday, the president again threatened to let Obamacare “implode” in order to make a deal. And Mr. Price, who worked closely with his former colleagues in Congress to devise repeal proposals, has been spreading lies about the law and making changes that would reduce benefits and lead to fewer people signing up for coverage.
It would be foolish to underestimate the administration, which has the power to do substantial damage. The administration could stop making subsidy payments to insurance companies authorized by the A.C.A. to help reduce deductibles for lower-income people. And it could stop enforcing the penalty for people who do not buy insurance, which would result in fewer young and healthy people signing up, leading insurers to stop offering policies in some parts of the country.
Or the administration could decide to work with Congress and state governments to improve the law. Congress could strengthen the insurance market by voting to make the subsidy payments, which it never explicitly did. The 19 states that have not expanded Medicaid could reconsider and help four million more people gain health insurance. And the administration and state governments could enact reinsurance programs and other policies to lower the risk to insurers and encourage them to sell coverage in rural and suburban areas.
After this failure, Republicans must figure out whose example they will follow. They can adopt Mr. Trump’s call for yet another scorched-earth campaign. Or they can listen to the likes of Mr. McCain about the benefits of bipartisanship and cooperation.
Trump Supporters Furious That They Still Have Health Care
by Andy Horowitz - The New Yorker - July 28, 2017
WASHINGTON (The Borowitz Report)—With a fury that could spell political trouble for Republicans in the midterm elections, Trump voters across the country on Friday expressed their outrage and anger that they still have health coverage.
“I went to bed Thursday night and slept like a baby, assuming that when I woke up I would have zero health insurance,” Carol Foyler, a Trump voter, said. “Instead, this nightmare.”
Harland Dorrinson, who voted for Trump “because he promised that he would take my health care away from me on Day 1,” said that he was “very upset” that he will still receive that benefit.
“I woke up this morning, and my family and I could still see a doctor,” he said. “This is a betrayal.”
Many Trump supporters said that congressional Republicans “gave up too soon” in their efforts to deprive ordinary Americans like them of their health care.
“They should not take August off,” Calvin Denoit, a Trump supporter, said. “They should stay in Washington and keep working until I totally lose my coverage.”
For Trump voters like Benoit, the abject disappointment of continuing to have health care raises fears about which other campaign promises might soon be broken.
“Now I don’t know what to believe,” he said. “Are we still going to get to pay billions of dollars in taxes for that wall?”
Single-payer system – Medicare for All – is the only remedy for U.S.
We need to put politics aside and join the rest of the industrialized world by taking care of our citizens.
by Chuck Radis - Portland Press Herald - July 28, 2017
PEAKS ISLAND — This spring, a patient of mine, Richard Gardner, called me regarding a prescription I wrote for him. The drug was Plaquenil, a medication for rheumatoid arthritis, and he was frustrated and angry. The medication was working fine – the problem was that the price of generic Plaquenil had increased from $30 per month to $85 per month. The brand-name Plaquenil would now cost him $200 a month.
And this was after his health insurance picked up a portion of the cost.
Raise your hand if you can relate to Richard Gardner (whose experience is described here with his permission). Maybe you’re on four or five medications with yearly out-of-pocket payments of thousands of dollars. Maybe you’re on a Tier 5 “specialty drug” where your insurance picks up 80 percent of the cost and you are left with, let’s see, 20 percent of $30,000 per year for a biologic drug in rheumatoid arthritis is … $6,000 per year.
We, the purchasing public, frankly, are being swindled. Martin Shkreli, a former hedge fund manager and founder of Turing Pharmaceuticals, justified his price increase of the anti-parasitic drug, Daraprim, from $13.50 to $750 per pill at a congressional hearing in 2015 with the simple statement: “Because I can.”
Of course, it’s not just the price of medications that contributes to our ever-rising insurance premiums and $5,000 deductibles. It’s everything.
Let’s spin the wheel of health care expenses and it lands on “administrative costs.” In my former private practice in Portland, the job of one of our employees was to obtain prior approvals for medications and necessary tests. On the other end of the phone was an employee of the insurance company whose job was to say “no.” Eventually, our office was usually able to get our patients’ needs met, but it was a lot of work. Is it any wonder that roughly 18 percent of the cost of your private health insurance goes toward administrative costs?
Let’s not leave out hospital costs. As the Press Herald noted in a recent editorial, “Americans pay on average $1,119 for an MRI. An Australian pays $215.” The editorial quoted Sarah Kiff writing in Vox: “It’s the exact. Same. Scan.”
Several years ago I underwent successful same-day surgery at Maine Medical Center. The charge was $12,791.46. But as I pored over the three-page bill and realized that I had incurred 39 separate charges, I decided to break down the costs. For instance, I was charged $194 for 2 liters of lactated Ringer’s solution infused during my surgery. When I returned to work the next week, I asked our office manager how much our private practice paid for a liter of lactated Ringer’s solution for our patients receiving IV infusions in our office. Her answer: “Under 4 dollars.”
Hospitals see thousands of patients each year without insurance, and balanced billing is unavoidable if they are to stay afloat. I get that. But come on, $194 versus $4?
Thankfully, there is a way out of this morass. And it’s not repealing and replacing the Affordable Care Act or even improving the Affordable Care Act. It’s a single-payer system, Medicare for All.
We need to join the rest of the industrialized world and provide health care to all of our citizens. Implement new laws and allow Medicare to negotiate the prices of medications as the Veterans Affairs and Medicaid programs do. Let Medicare, with its extraordinarily low administrative costs (estimated at 1 to 5 percent, as compared to nearly 18 percent for private insurance), streamline our system so that we get more for less.
In my vision of a healthy America, private health insurance companies remain in the mix and compete as secondary payers for the 20 percent Medicare traditionally does not cover. Heck, keep private health insurance available as primary insurance for those who want to avoid Medicare entirely, just as many people pay for private school even as they contribute taxes toward our public schools.
I don’t underestimate how difficult this transition may be. A large portion of our economy is dependent on the health care industry. Perhaps the transition can be phased in by dropping the Medicare age by 10 years at regular intervals until we cover all Americans. I don’t pretend to have all the answers – no one does.
But we’re reaching a point where the Richard Gardners in our country are going to demand major change, and that doesn’t mean squeezing into an old pair of jeans that no longer fit. As a nation, let’s buck up and do the right thing. Republicans and Democrats need to come together and adopt a simpler, less costly system, and that’s Medicare for All.
The obvious Obamacare replacement has been here all along
by John Garamendi - Sacramento Bee - July 27, 2017
The ongoing uncertainty in Congress surrounding health care legislation, and the intentional sabotage of the Affordable Care Act, is destabilizing the insurance marketplace, driving up costs, discouraging new enrollments, and making Americans worried about the future of their health care.
To be clear, any of the existing efforts to repeal the Affordable Care Act would be disastrous. The Congressional Budget Office estimates that under the repeal plan passed by the House of Representatives, 14 million people would lose their insurance in the first year of implementation, and 24 million fewer would be insured by 2026.
In the short term, Congress should shore up the Affordable Care Act with bipartisan, commonsense improvements, such as a reinsurance program to stabilize the market for high-risk policyholders, legislation to make cost-sharing reductions permanent, and government permission to negotiate for lower prescription drug prices. But in the longer term, the time is right to think about ways to make access to health care truly universal and cover those who are still left behind. By far the simplest solution is Medicare For All.
Medicare is one of our most trusted and popular government programs. For more than 50 years, Americans have trusted Medicare to provide care to the elderly and disabled, funded by the payroll taxes of American workers. Numerous studies conducted by the nonpartisan Congressional Budget Office (CBO), the Centers for Medicare/Medicaid (CMS), and respected independent analysts show that Medicare spending rises at a much slower rate than private insurance – a remarkable achievement given the higher risk pool within the program. There is no question that Medicare is a more efficient system than the private insurance market.
Medicare’s durable and popular framework could be modified and expanded to cover more people, and form the basis for a true universal medical insurance program.
In Congress, this idea is more popular than ever: In every Congress since 2003, Rep. John Conyers has introduced H.R.676, the Medicare for All Act. When he first introduced the bill, he got 38 co-sponsors. This year, I joined 114 of my fellow Democratic members – more than half the Democratic caucus – to lend my support. It is an idea whose time is coming.
Opponents may point to the difficulties California has had in trying to implement its own state-based universal health care system. A stand-alone plan in California would somehow have to incorporate existing federal health insurance programs – an impossible task given the political realities of the Trump Administration.
But a federal Medicare for All program would face no such obstacles: It would simply use the existing Medicare infrastructure and expand it to cover everyone. Seniors on Medicare would find that their health insurance is made more secure by bringing a statistically healthier population into the Medicare risk pool and by having greater buy-in for Medicare from younger voters.
Right now, Democrats in Congress need to be laser-focused on preserving and securing the Affordable Care Act. We are universally opposed to Republican repeal efforts that would gut Medicaid, make prescription drug costs more expensive in Medicare, and kick tens of millions of people off their insurance just so the wealthy can get a massive tax cut. We don’t want to go back to the bad old days when Americans could be denied health insurance for having a pre-existing condition.
But we also need to look beyond the immediate horizon and envision how we can make lives better for more Americans. Medicare for all would do this. Seniors know the peace of mind that comes from having the guarantee of health insurance. Imagine if all Americans could say the same.
John Garamendi, a Walnut Grove Democrat, represents the 3rd Congressional District. He can be contacted at jrg@mail.house.gov.
‘I Am Totally Burned Out’:
Patients Watch Health
Care Debate With Dread
by Jan Hoffman - NYT - July 28, 2017
Ever since the November election, when the fate of her family’s health coverage was suddenly up for grabs, Meghan Borland has been consumed by each twitch and turn of the political debate. She has gone to protests, met with her congressman, lost sleep, shed tears.
“My emotions are like a Ping-Pong ball being bounced back and forth between the players,” said Mrs. Borland, who, with her husband, owns a karate school in Pleasant Valley, N.Y., and whose younger daughter, Amelia, 2, is receiving chemotherapy for leukemia.
“For months it’s been: ‘Here’s a bill, we’ll vote. No, we won’t. Now it will change. Maybe not. Will that one person vote or not?’ Except that for us, this is not a game.”
The months-old war in Congress over repealing and replacing the Affordable Care Act has had more standoffs, stand-downs and bare-knuckled battles than any other legislative fight in recent memory. But for people whose health insurance is at risk, it has brought the anguish of protracted uncertainty.
Most Americans who are insured — including many who have plans through their employers or Medicare, for example — do not seem to be at immediate risk of losing coverage. But millions of people who get coverage through the marketplaces created by the Affordable Care Act or through the expansion of Medicaid under the law could lose it.
In interviews, some said they did not know from one day to the next whether they would be able to continue screenings and treatment. They are postponing or accelerating major medical decisions, weighing whether to move to more insurance-friendly states, or to close modest businesses and search for employment with health benefits. Millions of Americans feel held hostage to Washington’s wrangling and, consequently, to their own inability to control critical matters in their own lives.
“I’m so done,” moaned Cathy McPherson, 58, a retired court clerk in Sonora, Calif., with hypertension, who has been covered by plans under the health care act from the outset. “It’s what I think about all the time and I am totally burned out. They go over and over it. Can you stop? Just stop it for a little bit? Go on vacation! Relax! Because I’d like a vacation from it, too!”
On Thursday, as a vote loomed on a last-ditch repeal measure, many suspected the uncertainty would not end. If the measure squeaks through, it will move to the next step of the legislative process — a House-Senate conference committee that will try to negotiate a broader health bill that can pass both chambers. If it fails, many think that their relief will be only temporary, and chances are that Republicans will try again.
For the last few weeks, as the Senate Republican health effort was twice pronounced dead only to be revived a day or two later, Nancy Molitor, a psychologist in Wilmette, Ill., has heard escalating anxiety about health care from all of her patients. Many want to spend entire sessions discussing it: how to handle the stress and the feelings of fear, powerlessness, rage and frustrated paralysis.
“They know they should turn off the TV and their news feeds, but they can’t,” said Dr. Molitor, an assistant clinical professor of psychiatry and behavioral health at the medical school at Northwestern University.
On Wednesday, the day after the Senate narrowly voted to begin floor debate on health legislation, she saw eight patients who each brought up the issue, regardless of whether they would be directly affected by the repeal efforts. She noted that her patients worried about caring for parents as well as for children with severe mental illness. “But the situation is so fluid and volatile that it is a recipe for stress.”
And yet conventional therapeutic wisdom for managing stress does not translate well to health care-related anxiety, she said. In more typical periods of life agitation — death, divorce, job loss — a therapist tries to get patients to identify what is in their control, what is not, and how then to get information and make a plan.
“But with health care, even the therapists don’t know the answer. We haven’t experienced this before,” Dr. Molitor said. “It’s hard to be a therapist in this environment because we’re worried about the same things, too. We have to make sure our own anxiety isn’t infecting the session.”
In response to a callout to New York Times readers on Wednesday, many people talked about stockpiling medications, postponing surgeries so as not to set up a pre-existing condition, or racing to see specialists for fear of losing their coverage.
Angela Wilson Gyetvan has decided to move ahead with gallbladder surgery, even though she has so far been managing her gallstones — a side effect of medication she has been taking since she finished chemotherapy several years ago — with diet. But Ms. Wilson Gyetvan, a Los Angeles-based consultant for digital companies who has coverage through the Affordable Care Act, does not have the financial wherewithal to take a wait-and-see approach.
She has been assiduously monitoring the Washington debate for months, incapable of putting herself on a social media diet. “During the good moments, it was such a relief — ‘It’s dead!’” she said. “Several of us were ready to go for a drink and celebrate. But we were scared. And lo and behold, we were right.”
Dr. Leigh H. Simmons, a primary care physician who teaches at Harvard Medical School, has been trying to adapt her approach to patients as each new upheaval in Washington brings fresh concerns to her office. The day before the House bill passed in May, she saw more patients in her practice than ever. “Some were for urgent reasons, others less so,” she said. “But they knew they had health care this year and they wanted to take care of things.
“I say, ‘For the time being, since you have coverage, why don’t we get the mammogram or the colonoscopy done?’ I don’t mean it to be frightening, but as an incentive.”
As a physician, Dr. Simmons has been feeling drained, concerned about her patients — some with diabetes have been taking less insulin than the prescribed dose, to make supplies last. Some patients question whether they will be able to continue with her. “It’s a very powerless feeling, as a doctor,” she said. “We are as worried as our patients about what this all will mean.”
In Mosier, Ore., Joe Eckert, a technology consultant, and his wife, Tammie, who owns a fabric shop in Hood River, keep drafting and ripping up life plan after life plan, as they train their eyes on Congress. Currently they buy insurance through the state’s Affordable Care Act marketplace for themselves and their son, 23.
But, they worry, what if it goes down in flames? What if protections for pre-existing conditions disappear? What if they are thrown into the high-risk pool? Several years ago Mr. Eckert, 54, developed diabetes; Mrs. Eckert, 50, had a malignant skin cancer removed and is screened every three months.
Plan A: Close the store and Mrs. Eckert will scour want ads for a job that will give them benefits. Plan B: Sell the house and move to Washington State, where, they say, health coverage seems to be more stable. Plan C: Delay a vacation, to save money.
“The ups and downs of the debating have been the worst,” Mr. Eckert said. “You’re happy one minute — ‘We won!’— and then it’s not over yet. It just keeps dragging on. Being in limbo is the hardest place of all.”
Diane Smith, of Lafayette Hill, Pa., is a social worker who counsels families in severe crisis because of catastrophic illness. Her own son, Luke Hoban, has congenital muscular dystrophy and needs considerable assistance, including a wheelchair and a ventilator. She has an autoimmune disorder for which she must take very expensive injections.
She recently purchased insurance through the Affordable Care Act. “I’ve watched my life play out on the national stage,” she said, “knowing I was getting divorced and would get kicked off my husband’s health insurance and that my son”— who just graduated from the University of Pennsylvania — “was about to go out into the world and possibly lose his Medicaid coverage too.”
She has been almost sleepless throughout the recent siege of debates, following the voting in real time, heart in throat, while caring for Luke and going to work.
She said that the density of legislative proposals drove her crazy. She was in bed the other night, tracking Twitter, and yelled out to her younger son, Christian, a junior majoring in economics and political science: “‘What does this mean?’ He got up in his underwear and I held out my phone. He just shook his head and said, ‘Mom, we went through this!’”
As emotionally draining as the protracted debates have been, Mrs. Borland, the mother of the 2-year-old leukemia patient, keeps trying to find meaningful outlets for her frustration and fear. The Facebook group where she gathers with other mothers of children with cancer will not let her vent about insurance. The moderator has said that the topic is too upsetting for parents who need the space to be safe and supportive.
Back in November, when her internal alarms over insurance began clanging, she assumed that both she and her husband were the family’s vulnerable ones, as small-business owners who had purchased coverage through New York’s Affordable Care Act marketplace. Her daughter’s coverage through Medicaid would be fine, a hospital social worker assured her.
But many months, debates, treatments and bills later, big Medicaid cuts are still on the table. She does not know how they could affect her daughter.
Choking back tears, Mrs. Borland gathered herself. “The way that treatment for a child with cancer goes, you never think about tomorrow,” she said. “You just think about today. Because thinking that she’ll lose coverage is like thinking she’ll relapse. I’ll deal with it when the time comes. That’s a cancer mom’s thinking.”
Lawmakers Have Bipartisan Health Ideas. Now to Persuade Their Leaders ...
by Robert Pear and Thomas Kaplan - NYT - July 28, 2017
WASHINGTON — Congressional lawmakers said on Friday that the collapse of Republican efforts to demolish the Affordable Care Act had created an opening for bipartisan work to shore up health insurance markets and protect consumers against sharp increases in premiums.
But any such effort would have to overcome the firm resistance of President Trump and Republican leaders on Capitol Hill who have refused to participate in any effort to fortify President Barack Obama’s health law.
The professions of a desire for bipartisan cooperation were as profuse on Friday as the short-term outlook for tangible results was grim.
“On health care, I hope we can work together to make the system better in a bipartisan way,” said the Senate Democratic leader, Chuck Schumer of New York, who led efforts to preserve the Affordable Care Act. “And I’m optimistic that that can happen,” he added, saying that he recognized flaws in the law.
The Republicans’ seven-year promise to repeal the Affordable Care Act seemed to come to an end in the early hours of Friday when 51 senators — including three Republicans — blocked a narrow version of repeal that would have rolled back only a few provisions of the sweeping health care law.
Without a Republican majority to approve either a comprehensive replacement for the health law or a repeal-only bill, Republican leaders had fallen back on what they called the lowest common denominator. And that failed, too.
Senator John McCain, Republican of Arizona, who cast the decisive vote against the Republican bill around 1:30 on Friday morning, appealed for a bipartisan approach. “The vote last night presents the Senate with an opportunity to start fresh,” he said.
The Affordable Care Act “was rammed through Congress by Democrats on a strict party-line basis without a single Republican vote,” Mr. McCain said, and Republicans must not make the same mistake.
But there was no hint of an olive branch from the Senate majority leader, Mitch McConnell, who this summer suggested that a failure to repeal the Affordable Care Act would force him to work with Mr. Schumer.
“Bailing out insurance companies with no thought of any kind of reform is not something I want to be part of,” Mr. McConnell said in the early hours of Friday. He suggested that many Democrats secretly wanted a single-payer health care system, with a much larger role for the government.
President Trump reiterated his threat to force the health law to collapse. “3 Republicans and 48 Democrats let the American people down. As I said from the beginning, let ObamaCare implode, then deal. Watch!” he wrote on Twitter.
And some Republicans did not sound ready to close the door on repeal, despite the exceedingly slim hopes of reviving, yet again, an effort that on Friday morning seemed doomed.
“I am disappointed and frustrated, but we should not give up,” said the House speaker, Paul D. Ryan of Wisconsin. “I encourage the Senate to continue working toward a real solution that keeps our promise.”
If a bipartisan coalition can coalesce around changes to the Affordable Care Act, lawmakers see several vehicles to force such proposals to the floors of the House and Senate. Spending bills for the fiscal year that starts Oct. 1 will have to be signed, and the popular Children’s Health Insurance Program will need additional funds.
And the ideas are out there. Democrats want to provide money to insurers to reduce out-of-pocket expenses for poorer consumers, a proposal with some Republican backing. An earlier version of the Senate Republican repeal bill would have continued such cost-sharing payments through December 2019.
Two Democratic senators, Thomas R. Carper of Delaware and Tim Kaine of Virginia, have introduced legislation that would authorize the federal government to help pay the largest health insurance claims through a backstop known as reinsurance. That, they argue, could substantially reduce insurance premiums.
An earlier version of the Senate Republican bill included a similar concept, a $182 billion “state stability and innovation program.” Senators assumed that much of the money would be used for reinsurance arrangements.
Senators of both parties want to help consumers in counties where no insurer offers health plans under the Affordable Care Act marketplace — a real possibility next year as insurers retreat from the health law’s marketplaces.
Senators Lamar Alexander and Bob Corker of Tennessee, both Republicans, want to allow consumers in such counties to use tax credits to buy insurance outside the public marketplace. Senator Claire McCaskill, Democrat of Missouri, would allow them to obtain coverage through the insurance exchange in the District of Columbia, which serves many members of Congress.
Moderates in both parties have been talking behind the scenes, but it is unclear whether they would need or receive permission from their party leaders to cooperate more. Party leaders are continually weighing the implications of health care for next year’s midterm elections.
Mr. Alexander, a former governor who is the chairman of the Senate health committee, is seen as a possible deal maker. He intends to hold hearings on possible solutions to the problems plaguing insurance markets in some states including his own.
Senator Joe Manchin III, Democrat of West Virginia and another former governor, said he saw the Senate’s 11 former governors as a potential source of pragmatic bipartisan solutions.
Senator Susan Collins, Republican of Maine, who voted against repeal, said: “The A.C.A. is flawed and in portions of the country is near collapse. Rather than engaging in partisan exercises, Republicans and Democrats should work together to address these very serious problems.”
But some Republicans may not be so eager to collaborate. Representative Mark Meadows, Republican of North Carolina and the chairman of the hard-line Freedom Caucus, made clear that he was not ready to step away from the repeal effort, and said Mr. Trump shared that view.
“I’m optimistic we can still get it done,” Mr. Meadows said on Fox News. “The people are losing faith, but we’re going to stay in. I can tell you who’s staying in: The president is staying in on this fight. He’s going to deliver.”
Senator John Kennedy, Republican of Louisiana, also vowed to keep trying. “Being defeated is temporary,” he said. “Tell you what’s permanent. What’s permanent is giving up, and I can tell you I’m not going to give up.”
Mr. Trump has repeatedly threatened to cut off the payments that compensate insurance companies for reducing out-of-pocket costs for low-income people. He wants to stop these cost-sharing reduction payments, and senior administration officials seriously discussed the idea at recent meeting that ended without a decision.
Administration officials said they fully expected insurers to sue if the government halted the payments, whose legal status is already in doubt because of a lawsuit filed by House Republicans during the Obama administration. Insurers say that cutting off the payments could cause havoc in insurance markets.
In the House, Republican lawmakers pointed fingers at their Senate colleagues on Friday for letting down their voters. For House Republicans — who succeeded in passing a repeal bill in May, at no small political peril to some of their vulnerable members — the message was clear: We did our job. And the Senate must not give up.
“They’ve got to get back at it,” said Representative Tom MacArthur of New Jersey.
Some Republicans, left to deal with the fallout of the repeal failure, opted instead for collective self-flagellation. Representative Brian Mast of Florida was asked if lawmakers might face consequences in next year’s midterm elections if they could not keep their promise to undo the law.
“Everybody should,” he said. “If we don’t get the No. 1 job that we said that we would do done, yeah, people should be held accountable.”
Then there was the scene at a meeting of Republican House members on Friday morning. According to lawmakers, the gathering included a recitation of lyrics from “The Wreck of the Edmund Fitzgerald,” a Gordon Lightfoot song about a sinking ship, which was likened to the Senate’s stumble.
Does the Affordable Care Act Need Improvement? Tell Us.
by The New York Times - July 28, 2017
The Senate in the early hours of Friday morning rejected a new, scaled-down Republican plan to repeal parts of the Affordable Care Act.
The vote may spell the end of the party’s seven-year effort to repeal Barack Obama’s signature legislation.
Since the law’s major provisions took effect in 2014, New York Times readers who have gotten health insurance under it have told us about their frustrations, including about the requirement to buy insurance, the rising premiums and deductibles and the lack of access to certain hospitals or doctors.
While Republicans remain stymied by their inability to repeal and replace the health care law, frustrations are mounting for some Americans. Times reporters would like to hear from people with insurance under the Affordable Care Act about their experience with their coverage.
Please share your story using the form below. Your name and comments may be published, but your contact information will not. A reporter or editor might contact you to learn more about your story.
Why Health Care Policy Is So Hard
by N. Gregory Mankiw - NYT - July 28, 2017
“Nobody knew that health care could be so complicated.” President Trump said that in February, yielding more than a few chuckles from pundits and late-night comedians.
In fact, anyone who has spent some time thinking about the issue sees its complexity. With the collapse of the Senate health care bills this week, the president has certainly been reminded of it.
But Mr. Trump’s epiphany raises some questions: Why is health care so complicated? How does it differ from most of the other goods and services that the economy produces? What makes health policy so vexing?
In Econ 101, students learn that market economies allocate scarce resources based on the forces of supply and demand. In most markets, producers decide how much to offer for sale as they try to maximize profit, and consumers decide how much to buy as they try to achieve the best standard of living they can. Prices adjust to bring supply and demand into balance. Things often work out well, with little role left for government. Hence, Adam Smith’s vaunted “invisible hand.”
Yet the magic of the free market sometimes fails us when it comes to health care. There are several reasons.
Externalities abound. In most markets, the main interested parties are the buyers and sellers. But in health care markets, decisions often affect unwitting bystanders, a phenomenon that economists call an externality.
Take vaccines, for instance. If a person vaccinates herself against a disease, she is less likely to catch it, become a carrier and infect others. Because people may ignore the positive spillovers when weighing the costs and benefits, too few people will get vaccinated, unless the government somehow promotes vaccination.
Another positive spillover concerns medical research. When a physician figures out a new treatment, that information enters society’s pool of medical knowledge. Without government intervention, such as research subsidies or an effective patent system, too few resources will be devoted to research.
Consumers often don’t know what they need. In most markets, consumers can judge whether they are happy with the products they buy. But when people get sick, they often do not know what they need and sometimes are not in a position to make good decisions. They rely on a physician’s advice, which even with hindsight is hard to evaluate.
The inability of health care consumers to monitor product quality leads to regulation, such as the licensing of physicians, dentists and nurses. For much the same reason, the Food and Drug Administration oversees the safety and effectiveness of pharmaceuticals.
Health care spending can be unexpected and expensive. Spending on most things people buy — housing, food, transportation — is easy to predict and budget for. But health care expenses can come randomly and take a big toll on a person’s finances.
Health insurance solves this problem by pooling risks among the population. But it also means that consumers no longer pay for most of their health care out of pocket. The large role of third-party payers reduces financial uncertainty but creates another problem.
Insured consumers tend to overconsume. When insurance is picking up the tab, people have less incentive to be cost-conscious. For example, if patients don’t have to pay for each doctor visit, they may go too quickly when they experience minor symptoms. Physicians may be more likely to order tests of dubious value when an insurance company is footing the bill.
To mitigate this problem, insurers have co-pays, deductibles and rules limiting access to services. But co-pays and deductibles reduce the ability of insurance to pool risk, and access rules can create conflicts between insurers and their customers.
Insurance markets suffer from adverse selection. Another problem that arises is called adverse selection: If customers differ in relevant ways (such as when they have a chronic disease) and those differences are known to them but not to insurers, the mix of people who buy insurance may be especially expensive.
Adverse selection can lead to a phenomenon called the death spiral. Suppose that insurance companies must charge everyone the same price. It might seem to make sense to base the price of insurance on the health characteristics of the average person. But if it does so, the healthiest people may decide that insurance is not worth the cost and drop out of the insured pool. With sicker customers, the company has higher costs and must raise the price of insurance. The higher price now induces the next healthiest group of people to drop insurance, driving up the cost and price again. As this process continues, more people drop their coverage, the insured pool is less healthy and the price keeps rising. In the end, the insurance market may disappear.
The Affordable Care Act (a.k.a. Obamacare) tried to reduce adverse selection by requiring all Americans to buy health insurance or pay a penalty. This policy is controversial and has been a mixed success. More people now have health insurance, but about 12 percent of adults aged 18 to 64 remain uninsured. One thing, however, is certain: The existence of a federal law mandating that people buy something shows how unusual the market for health care is.
The best way to navigate the problems of the health care marketplace is hotly debated. The political left wants a stronger government role, and the political right wants regulation to be less heavy-handed. But policy wonks of all stripes can agree that health policy is, and will always be, complicated.
3 Things Trump Is
Already Doing to ‘Let
Obamacare Implode’
by Haeyoun Park and Margaret Sanger-Katz - July 28, 2017
After the failure early Friday of the latest Republican plan to repeal the Affordable Care Act, President Trump said that he wants to “let ObamaCare implode, then deal.” Mr. Trump has already been doing three things to undermine important provisions of the health law, and there is more he could do.
What Trump can do
|
Status
|
|---|---|
Weaken enforcement of the individual mandate.
|
In progress
|
Impose work requirements for Medicaid recipients.
|
In progress
|
Fail to do advertising or outreach.
|
In progress
|
Make tax credits for premiums less generous.
|
Proposed
|
Defund subsidies that help people pay out-of-pocket costs.
|
Not in progress
|
Redefine essential health benefits.
|
Not in progress
|
In progress
1. Weaken enforcement of the individual mandate.
How this hurts Obamacare: Fewer healthy people may sign up for insurance, driving up prices for those who need it most, like older people and the sick.
The Affordable Care Act requires all Americans to buy health insurance or pay a penalty, with exceptions for people with hardships.
While Mr. Trump cannot eliminate the mandate, as Republicans in Congress sought to do, the Internal Revenue Service has said it will continue accepting tax returnsthat do not say whether a filer has been uninsured, weakening its enforcement of the provision.
The administration could also allow for more exceptions, making it easier to avoid the tax penalty. It could instruct the I.R.S. to scrutinize people’s returns less closely. And it could signal publicly that it does not care about the mandate, which may cause people to be less likely to sign up, even if they later get hit with a tax penalty.
In progress
2. Impose work requirements for Medicaid recipients.
How this hurts Obamacare: Many people who gained coverage through Medicaid expansion may not be able to afford insurance or participate in the program.
Under the Affordable Care Act, 31 states expanded Medicaid coverage to poor adults who were previously uncovered. And Republicans in Congress sought to sharply curtail federal support for the expansion, likely causing many states to end it.
Mr. Trump cannot unilaterally prevent states from expanding Medicaid in the future. He could, however, allow states that apply to impose work requirements or charge premiums for more Medicaid beneficiaries, through a process that lets the government waive the normal Medicaid rules. Those changes might make it difficult for as many poor Americans to access the system.
In March, the Health and Human Services Department said it would be open to states’ proposing work requirements for Medicaid recipients.
In progress
3. Fail to do advertising or outreach.
How this hurts Obamacare: Without outreach, the number of Americans who learn about the Affordable Care Act and sign up for coverage could dwindle.
The last sign-up period for the Affordable Care Act ended 11 days after Mr. Trump was inaugurated. During the those final days of enrollment, the Trump administration pulled advertisements and outreach off the air that encouraged people to sign up for health insurance under the law.
In the last few years, large number of consumers generally signed up just before the deadline, and sign-ups for health plans in states managed by the federal government were down slightly compared to the same period the previous year. Lower signups tend to mean higher prices, since the sickest customers are more likely to investigate their insurance options, regardless of government outreach.
The administration could keep quiet again when open enrollment begins this fall. The Department of Health and Human Services, which is in charge of administering the Affordable Care Act, has also been circulating bad news about the program.
Proposed
4. Make tax credits for premiums less generous.
How this hurts Obamacare: Many customers may end up with plans with higher deductibles and co-payments.
The Affordable Care Act gives tax credits to middle-income Americans to offset the cost of premiums. Those subsidies are based on a particular plan, meant to cover 70 percent of the average customer’s medical bills.
Mr. Trump has proposed making the credits apply to a slightly less generous plan for all Obamacare customers. The size of the changes is much smaller than reductions proposed in the Republican health care bills, but still means that many customers will end up with either more expensive insurance or plans that have higher deductibles and co-payments.
Not in progress
5. Defund subsidies that help people pay out-of-pocket costs.
How this hurts Obamacare: Insurance companies would take a big financial hit, since they assumed they would get the subsidies when pricing their plans.
Obamacare provides subsidies to help insurance companies reduce out-of-pocket costs, like deductibles and co-payments, for lower-income customers. Insurance companies price their plans assuming payments will be based on how many eligible customers they serve. The House and Senate health bills would have eliminated the subsidies, allowing insurers to charge those customers higher deductibles.
Mr. Trump could effectively defund the subsidies if he stops the appeal of a lawsuitthat was started under the Obama administration. President Barack Obama’s lawyers had appealed a court ruling that said the subsidy payments were made without proper congressional authority.
Removing the subsidies this year would cause insurers to lose money right away, and could cause some smaller insurers to go bankrupt. Removing them for next year would cause insurance premiums to spike, and might cause some carriers to exit the markets.
The White House has declined to say whether it will continue to pay the subsidies.
Not in progress
6. Redefine essential health benefits.
How this hurts Obamacare: Customers with health problems may end up with really high insurance costs.
Under the current law, all insurers must offer 10 categories of essential health benefits, like maternity treatment and hospital care. Conservatives considered the requirements too restrictive.
Congress tried to loosen these rules by letting states apply to waive them. Republicans in the Senate also tried to let insurers get away with offering plans that don’t meet the rules as long as they offered ones that did.
Mr. Trump cannot eliminate the 10 broad categories of benefits, but his administration has some discretion on how the categories are defined.
For example, the administration could redefine preventive care in a way that eliminates a current rule requiring insurers to cover every form of contraception that is approved by the Food and Drug Administration.
The US Has the Highest Maternal Death Rate of Any Developed Country. Why Aren't We Doing More About It?
by Lauren Longo - Truthout - July 27, 2017
The United States of America loves babies. We can't get enough of them. We love them so much, we'll do anything we can to produce more of them -- restrict access to contraceptives, abortion and even information just for the sake of more babies, no matter the cost. No price is too high; we'll risk women's health, safety and futures because as much as we care about babies, we really don't care about the human beings growing them.
If we did, we wouldn't keep letting them die.
Women in the US are eight times more likely to die due to pregnancy-related causes than women in countries like Sweden, Norway, and the Netherlands. An American woman is three times more likely to die than a Canadian woman. In so many ways, the US is an anomaly when it comes to maternal mortality.
Between 2000 and 2014, 157 countries around the world decreased their maternal death rates. The UK combated maternal death so effectively, a British man is more likely to die while his partner is pregnant than she is.
Meanwhile, the US was the only developed country to increase its maternal death rate, and one of only 13 total countries including North Korea. And the rate didn't just increase slightly; it shot up 27 percent. In places like Texas, which has been actively fighting women's access to healthcare, the maternal death rate doubled.
This dramatic increase isn't a coincidence, it's the result of our priorities -- which don't include women.
"The argument we make internationally is that [a high maternal death rate] is often a reflection of how the society views women," says maternal health expert and Boston University researcher Eugene Declerq. "In other countries, we worry about the culture -- women are not particularly valued, so they don't set up systems to care for them at all. I think we have a similar problem in the US."
We're making it harder and harder for women to access critical healthcare and to prevent and terminate unwanted or complicated pregnancies, and the result is lethal.
In the US, half of pregnancies are unplanned, meaning women are unable to address chronic health problems before becoming pregnant. Making it easier for women to control their own reproduction would make it more likely that those babies we love so much grow up with mothers to love them too.
Our "fragmented" healthcare system makes it harder for pregnant women and new mothers to access the care they need, particularly for low-income women and minority women -- who have significantly higher rates of maternal death.
There's also an over-confidence in our healthcare system that maternal death is a thing of the past, which leads to a lot more attention for babies but not enough for mothers.
Programs, both federal and medical, intended to improve fetal and maternal health are overwhelmingly prioritizing babies over mothers. Some doctors specializing in maternal-fetal medicine don't even have to learn about caring for birthing mothers or ever spend time in a labor-delivery unit.
When they're discharged, women are commonly given information on how to tell if their infants are sick, but not how to monitor their own health postpartum.
"We worry a lot about vulnerable little babies, we don't pay enough attention to those things that can be catastrophic for women" said Barbara Levy, vice president for health policy/advocacy at the American Congress of Obstetricians and Gynecologists.
Part of this has to do with our policies and procedures, or lack thereof.
According to Vox, "childbirth is one of the most common reasons women go into hospitals, and yet the American healthcare system handles complicated pregnancies with a stunning lack of preparation and precision."
Researchers looking into maternal death found that most hospitals just aren't prepared for pregnancy-related complications and don't have simple things on hand that could save women's lives. Or, they just don't have the necessary procedures in place to act quickly.
California decided to address these problems years ago. Now, their maternal death rate is one-third the national average.
The California Maternal Quality Care Collaborative (CMQCC) analyzed the causes of maternal death in California, then created "evidence-based, step-by-step" toolkits to help healthcare providers prepare for and handle pregnancy and childbirth complications.
They also found that most hospitals just don't have the necessary tools quickly accessible to save women's lives during an obstetric hemorrhage, one of the leading causes of maternal death. So, they borrowed the idea of a "code blue cart" and made one for mothers.
Essentially, a group of California medical professionals decided to save women's lives, and they have. Other states could too.
The decision we're making to sacrifice women's health, their access to healthcare and ability to make critical life decisions, is costing 700 to 900 American women their lives every single year. According to the CDC, 60 percent of those deaths could have been prevented. Those women aren't just numbers, they were real people with names, with people who loved them. They also had stories, and ProPublica is working to make sure we know them.
So far, ProPublica and NPR have compiled the names and stories of 120 women who died as the result of pregnancy or childbirth in 2016. Women like Krystine Toledo-Gonzalez a part-time post-op nurse and mother of three who died six days after her daughter was born from a staph infection diagnosed too late.
Or Kira Dixon Johnson, who raced cars and jet skis, flew planes, and spoke five languages. Her husband describes her as "the closest thing I've ever met to Wonder Woman." Soon after giving birth, she began to hemorrhage and died just 12 hours after giving birth. Obstetric bleeding is one of the most common causes of maternal death; 70 percent of cases are preventable.
Christen Vogel, 21, had a headache 38 weeks into her pregnancy and decided to take a bath to relax. Her husband, a US Marine, found her unresponsive in the bathtub. Christen and the baby both died, and doctors were unable to explain why.
If Americans Love Moms, Why Do We Let Them Die?
by Nicholas Kristof - NYT - July 28, 2017
HOUSTON — We love mothers, or at least we say we do, and we claim that motherhood is as American as apple pie.
We’re lying. In fact, we’ve structured health care so that motherhood is far more deadly in the United States than in other advanced countries. An American woman is about five times as likely to die in pregnancy or childbirth as a British woman — partly because Britain makes a determined effort to save mothers’ lives, and we don’t.
Here in Texas, women die from pregnancy at a rate almost unrivaled in the industrialized world. A woman in Texas is about 10 times as likely to die from pregnancy as one in Spain or Sweden, and by all accounts, the health care plans proposed so far by Republicans would make maternal mortality even worse in Texas and across America.
Women die unnecessarily in Texas for many reasons, but it doesn’t help that some women’s health clinics have closed and that access to Medicaid is difficult.
I spent a day in Houston shadowing Dr. Lisa Hollier, the president-elect of the American Congress of Obstetricians and Gynecologists, in her Center for Children and Women. Dr. Hollier is on a mission to make motherhood safer, because of an experience she had as a young medical resident many years ago.
Amy, 23, had arrived at the hospital with a headache near the end of an uncomplicated pregnancy, her first. Her husband was there, and everything seemed normal — and then Amy collapsed and lost consciousness.
Doctors performed an emergency C-section and saved the baby, a daughter, and Dr. Hollier struggled to keep Amy alive. She failed. Amy had suffered a preventable massive stroke, related to severe high blood pressure.
“I remember her husband,” Dr. Hollier said, and she wiped her eyes at the memory. “Here’s this dad, and it’s supposed to be the happiest day of his life, and there’s this look on his face. He’s just so lost.”
That happens somewhere in the United States on average twice a day.
My day with Dr. Hollier underscored that there’s one very simple and inexpensive starting point: Help women and girls avoid pregnancies they don’t want. “You can’t die from a pregnancy when you’re not pregnant,” Dr. Hollier noted.
Almost half of pregnancies in America are unintended. And almost one-third of American girls will become pregnant as teenagers. (Meanwhile, President Trump slashed $213 million in funding for teenage pregnancy prevention programs.)
One patient, Monica Leija, told Dr. Hollier that she had been on the pill but switched jobs, and her new position didn’t offer insurance for the first three months. That meant she would have had to pay the $40-a-month cost herself, and she figured the odds were against her becoming pregnant during that window.
“I just didn’t think it would happen,” she said. Now she’s bulging with a pregnancy at almost full term.
I heard a lot of comments like that. Derrion Harris, 21, has a year-old child who was not planned, and now Harris is sexually active again. Dr. Hollier asked if she uses birth control.
“I use condoms,” she said, then corrected herself: “I use condoms sometimes.”
Some of you readers are thinking this is outrageous irresponsibility. But we should also look at society’s irresponsibility in failing to help all women and girls get access to long-acting reversible contraceptives, or LARCs.
The U.S. failure on maternal mortality is particularly striking because around the world, maternal mortality has plunged by almost half since 1990; the U.S. is a rare country in which maternal deaths have become more common in recent years.
Granted, saving lives in childbirth is often complicated. Dr. Hollier examined one pregnant patient, Sarvia Alonzo, who had had three previous C-sections, increasing the risk of a condition called placenta accreta that can lead women to bleed to death very rapidly. Alonzo is due for a C-section again and will have two surgeons perform it so that if there is a crisis, it will be easier to manage.
Saving lives also requires better prenatal care, yet more than a third of women in Texas don’t have a single prenatal visit in the first trimester. One factor is that Texas politicians, on a rampage against Planned Parenthood, have in effect closed a number of women’s health clinics.
The result seems to be more pregnancies as well as more Medicaid births. And, after the number of abortions declined for several years, the loss of clinics also apparently led to a slight increase in abortions in 2015, the most recent year with reported figures. Texas also has high rates of deaths from cervical cancer.
Within the U.S., California has done an outstanding job cutting maternal deaths and showing what is possible. A crucial step is careful counting of maternal deaths and investigation of each one to learn what could have been done differently.
Obstetrics & Gynecology, a medical journal, says that the U.S. ranks below every member of the Organization for Economic Cooperation and Development industrialized club in maternal mortality, except for Mexico.
Obamacare helped tackle maternal mortality by expanding insurance coverage and by making contraception free. The Republican health care plans would instead follow the path of Texas, making motherhood more dangerous across America.
And this is pro-life?
How to Repair the Health Law (It’s Tricky but Not Impossible)
by Reed Abelson, Abby Goodnough and Katie Thomas - NYT - July 29, 2017
Republicans have failed to repeal and replace the Affordable Care Act. Now, can it be repaired?
The seven-year-old law has survived Supreme Court decisions and aggressive attempts to extinguish it by Republicans in Congress and the White House. But even people who rely on its coverage agree that it still has big problems. The question for the roughly 20 million Americans who buy their own health coverage — and for millions of others who remain uninsured — is what can realistically be done to address their main concerns: high prices and lack of choice in many parts of the country.
“Everyone feels really scrunched by the prices we’re paying, and we have no options in Iowa,” said Catalina Ressler, 39, a psychologist outside Des Moines who pays $1,567 in monthly premiums. “Next year is going to be even worse.”
Ms. Ressler’s plan, which covers her family of four, also comes with a $7,000 deductible. Their insurer, Wellmark Blue Cross and Blue Shield, is pulling out of the Affordable Care Act marketplace in Iowa next year, leaving just one company, Medica, to possibly remain.
Citing the protracted uncertainty over the law’s future, many insurers have proposed big rate increases again for next year even though many are no longer incurring big losses in its marketplaces. People covered by one insurer in Maryland could see premiums rise by more than 50 percent if proposed rate increases go into effect, and premiums for plans in Virginia and Connecticut could increase more than 30 percent. In North Carolina, where rates are already among the nation’s highest, Blue Cross and Blue Shield of North Carolina wants an increase of nearly 23 percent but said it would have sought less than half that amount under more predictable circumstances.
Cost is irrelevant in several dozen counties in Indiana, Nevada and Ohio; not a single insurer has agreed to sell plans through the Affordable Care Act marketplaces there next year, potentially leaving thousands of customers with no coverage option.
Among the hardest hit are those who do not qualify for subsidies to help with premiums or out-of-pocket costs, which rise along with rate increases. Michael Lawson, an independent consultant for local governments in Washington, D.C., said the monthly premiums for his basic plan from CareFirst jumped to $527 this year from $290 last year. He is 60 and earns too much to get a subsidy, but because of various health problems he has already reached his $5,000 deductible for the year. He likes his plan but thinks that to keep rates more stable, Congress and the Trump administration need to do a better job of enforcing the law, particularly its requirement that most people have health insurance.
“They need to enforce the A.C.A. as it’s written,” he said. “Don’t kill it by benign or even malicious neglect.”
The politics are exceedingly tricky in a divided and dysfunctional Washington, but economists, insurers, doctors and health policy experts across the political spectrum agree that immediately addressing three or four basic shortcomings in the existing system would go a long way toward making the law more effective and financially stable.
Stabilize the Markets
There is widespread agreement that the first order of business is to calm very jittery insurance markets. “You need to stabilize things before we change them,” said Michael Neidorff, the chief executive of Centene, one of the few insurers that are aggressively expanding in the market.
Time is of the essence: Next month, insurers must decide what they charge for 2018 or whether they want to stay in the marketplaces at all.
The most significant step would be to guarantee continued funding to reimburse insurers for waiving deductibles and co-payments for low-income customers, as the health law requires companies to do. The Trump administration has threatened to stop making the payments; insurers are now getting them on a month-to-month basis.
If these so-called cost-sharing reductions are not paid for the remainder of the year or in future years, people will see premiums go up by nearly 20 percent to cover them, according to the Kaiser Family Foundation.
Companies could also decide to leave the market, creating a potential collapse, said Mike Kreidler, the insurance regulator for Washington State. In a statement issued Friday, state regulators urged lawmakers to move quickly. “We have insurers who are very apprehensive and very nervous,” he said.
While insurers are hopeful that Congress will pass legislation guaranteeing the payments, they would also welcome a commitment from the administration that it, too, wanted to stabilize the market. “There seems to be a conflict internally: Are they going to sabotage the market or are they going to help the market?” said Gary Cohen, a former Obama administration official who is now an executive at Blue Shield of California.
President Trump has hinted he is unwilling to help. His Twitter post on Friday reacting to the Senate vote, like others he has posted recently, suggested a willingness to watch the market collapse: “As I said from the beginning, let ObamaCare implode, then deal.” In another post on Saturday, he warned that bailouts “for insurance companies” could “end very soon.”
But the fundamental problem that many insurance customers face is sky-high deductibles or premiums that are simply out of reach. Health economists and others say there are ways to lower premiums so more people can afford coverage.
“One of the best quick fixes that is not controversial is reinsurance,” said Paul Ginsburg, a health economist who directs the Center for Health Policy at the Brookings Institution. That would involve the government helping insurers pay for the sickest, most expensive people, whose costs can drive up premiums in places where there are not enough healthy customers to balance them out.
The Affordable Care Act provided the funding for three years, but many people think reinsurance needs to be permanent. A bipartisan agreement seems possible now because in their failed replacement bills, both House and Senate Republicans had supported the idea of providing assistance to insurers, as well as extra “stabilization” funding for states to potentially help lower people’s premiums and deductibles.
Over the longer term, lawmakers need to find a way to encourage more people, especially those who are healthier, to enroll, said Dr. Martin Hickey, the chief executive of New Mexico Health Connections, one of the few remaining start-up insurers created by the law. He said he was proposing rate increases of anywhere from 20 to 25 percent, although they were proposed before the Senate bill failed.
“The pool needs to get stabilized or otherwise we will see year after year of double-digit increases,” he said.
Reduce Drug Prices
Mark Dalessandro, an adjunct professor at a community college in Tucson, saw his out-of-pocket expenses for the asthma medication Advair jump to $292 per month this year from $50 per month last year, after he was forced to switch plans because his insurer, Blue Cross Blue Shield of Arizona, left the market in his area. He said he had little choice but to pay for it. “For just a month’s supply, for something that helps me breathe, what are you going to do?” he said.
Mr. Dalessandro, 54, pays $405 per month in out-of-pocket costs to cover everything from the Advair to cholesterol drugs. That is on top of the $1,462 he pays in monthly premiums for coverage for himself, his wife and his two teenage children.
The fluctuating drug cost makes him feel as if he were on a “roller coaster,” he said. “You just kind of feel like you can’t get ahead of the game.”
If there is one health care issue that both Republicans and Democrats have vowed to fix, it is the rising cost of prescription drugs. During the presidential campaign, Hillary Clinton and Mr. Trump railed against outrageous prices set by pharmaceutical executives like Martin Shkreli and drug companies like Mylan, the maker of the EpiPen.
But there is little agreement on the best way to fix the problem. Democratic proposals, such as allowing Medicare to directly negotiate drug prices with pharmaceutical companies and allowing cheaper drugs to be imported from overseas, are fiercely opposed by the drug industry — a potent lobbying power in Washington — as well as Republicans in Congress.
And though Mr. Trump has excoriated the industry, his administration has not yet put forward a plan to address the issue. A draft executive order on drug prices that was obtained by The New York Times in June revealed a far more industry-friendly approach, easing regulations in the hopes the drug companies would lower prices on their own.
Democratic leaders in Congress identified rising drug prices as one of their economic priorities in a new campaign, “A Better Deal,” that was made public this past week. Under their plan, a new federal agency would take action against companies that engaged in egregious “price gouging,” Medicare would be allowed to directly negotiate the price of drugs for seniors, and companies that raised their prices significantly would have to warn the federal government in advance, as well as give a reason for their planned price hike.
That is not to say the parties have not found some areas of agreement. There is bipartisan support for measures that would speed more generic drugs to market, including a proposal that would crack down on brand-name manufacturers that bar generic companies from gaining access to the samples they need to make copycat versions. And Dr. Scott Gottlieb, the new commissioner of the Food and Drug Administration, is taking steps to encourage more competition among generic manufacturers.
Expand Access for Poor
Although the Affordable Care Act has greatly expanded access to coverage — the nation’s uninsured rate fell to 10.9 percent last year, according to Gallup, from 17.1 percent in late 2013 — many Americans remain shut out. One of the biggest reasons is the refusal of 19 states to expand Medicaid to virtually all low-income citizens, as the law’s authors intended. Some may be reconsidering now that repeal of the health law seems unlikely.
The Supreme Court ruled in 2012 that it was unconstitutional to require states to expand the program, leaving it to each governor and legislature to decide. As a result, more than 2.6 million of the nation’s poorest citizens remain in a coverage gap: They cannot qualify for Medicaid, but because the law was written with the assumption that they would all get it under a national expansion of the program, they are not eligible for subsidies to help them buy private coverage.
About half these people are black and Hispanic, according to the Kaiser Family Foundation; about two-thirds live in Florida, Georgia, North Carolina and Texas.
In Alabama, Lee Thrasher, 40, is wedged firmly in the gap. She and her husband, Brandon, have been uninsured since 2011, when he had to quit his job at a Lowe’s because of a degenerative spine disease. Ms. Thrasher works independently as an inspector for property insurance companies and cannot get insurance through her job. Her two children get coverage through Medicaid, but with an income of about $18,000 a year she and her husband make too much to qualify. If they lived in a state that had expanded the program, they would be covered.
Ms. Thrasher said she was supposed to see the doctor for blood work and prescription refills at least four times a year but could afford to go only twice, paying a flat fee of $85.
“Sometimes it might as well be $1 million,” Ms. Thrasher said. “When you’re broke, you’re broke.”
Under the terms of the health law, the federal government covers 95 percent of the cost of expanding Medicaid and will always pay at least 90 percent. But with many state lawmakers anxious about taking on even a small share of the expansion costs, one alternative that could possibly win bipartisan support is extending subsidies for private coverage to people whose income is below the poverty level.
Regardless, some holdout states will most likely reconsider expanding Medicaid with repeal of the Affordable Care Act off the table for now. In Maine, for example, voters will decide whether to do so in a ballot measure this fall. Republican lawmakers in Kansas, North Carolina and South Dakota have also expressed growing interest, partly because many of their hospitals are starving for revenue and have relentlessly pressured them to expand the program. Such pressure is likely to ramp up again now.
In Alabama, though, Ms. Thrasher remains pessimistic.
It's Time for the Adults in This Nation To Talk Seriously About Medicare for All
by Dr. Carol Paris - Common Dreams - July 28, 2017
Hundreds of people slept overnight in cars, or camped for days in a field. They told stories of yanking out their own teeth with pliers, of reusing insulin syringes until they broke in their arm, of chronic pain so debilitating they could hardly care for their own children. At daybreak, they lined up for several more hours outside a white tent, waiting for their chance to visit a doctor. For many, this was the first health care provider they’ve seen in years.
Is this a place torn by war, famine or natural disaster? No, this charity medical clinic was last weekend in southwest Virginia, in the wealthiest country in the world, where we spend nearly three times as much money on health care as other similar countries.
"It’s as if our system was designed to deny care."
And what do we get for our money? The very definition of health care rationing: 28 million Americans without insurance, and millions more insured, but avoiding treatment because of sky-high deductibles and co-pays. Compared to ten other wealthy countries, the U.S. ranks dead last for life expectancy, and access to care. We even have the lowest number of hospital beds per capita, a way that health experts measure the capacity of a nation’s health system. It’s as if our system was designed to deny care.
America does hit the top of the list in some areas. Compared to other nations, American doctors and patients waste the most hours on billing and insurance claims. We have the highest rate of infant mortality, and the highest percentage of avoidable deaths—patients who die from complications or conditions that could have been avoided with timely care.
Clearly, this system is broken. Like a cracked pipe, money gushes into our health care system but steadily leaks out. Money is siphoned into the advertising budgets of insurance companies and the army of corporate bureaucrats working to deny claims. Even more dollars are soaked up by the pockets of insurance CEOs who have collectively earned $9.8 billion since the Affordable Care Act was passed in 2010. Nearly a third of our health care dollars go to something other than health care.
President Trump recognized voters’ frustration and campaigned on a promise of more coverage, better benefits, and lower costs. We couldn’t agree more with these goals. However, instead of trying to fix our broken system, GOP leaders are acting more like toddlers, mid-tantrum, smashing our health system into smaller and smaller pieces, threatening to push even more Americans—the most vulnerable among us—through the cracks. Last night, a few Senate Republicans stood up and acted like adults, putting an end to this dangerous game.
Today, we breathe a quick sigh of relief. But we cannot celebrate a return to the status quo, a system that rations health care based on income and allows 18,000 Americans to die each year unnecessarily.
Where do we go from here?
Republicans had eight years to come up with a plan that achieves more coverage, better benefits and lower costs. Have our elected leaders simply run out of ideas?
The good news is that we already have a proven model for health financing that is popular among both patients and physicians. It provides medically-necessary care to the oldest and sickest Americans with a fraction of the overhead of private insurance. It’s called Medicare, and I can tell you as a physician that it has worked pretty darn well for more than 50 years.
Not only do we have a model, we have a bill that would expand Medicare to cover everyone and improve it to include prescriptions, dental, vision, and long-term care. It’s called H.R. 676, the Expanded and Improved Medicare for All Act, a single-payer plan that would provide comprehensive care to everyone living in the U.S. The bill would yield about $500 billion annually in administrative savings while covering the 28 million currently uninsured. Medicare for all is gaining steam with a record 115 co-sponsors, a majority of House Democrats.
Now that Republican senators have finally worn themselves out, Sen. Bernie Sanders plans to file his own single-payer Medicare for all bill. Senators from both parties will be asked to choose a side: Do you support the current system of health care rationing, medical bankruptcies and unnecessary deaths; or a program proven to work both here and in every other developed country?
A majority of Americans now believe that health care is a human right, and that it is our government's responsibility to achieve universal coverage. We’ve tried everything else except Medicare for all. What are we waiting for?
The single biggest lesson from repeal-and-replace
by The Editorial Board - Washington Post - July 28, 2017
CONGRESSIONAL REPUBLICANS’ misguided effort to reshape the U.S. health-care system, which appeared to collapse early Friday, had the virtue of clarifying where the country stands nearly two decades into the 21st century: Americans want universal health-care coverage, including for the poor and the sick, and they expect the government to ensure that it is provided. Republicans and Democrats can argue about how to meet this end — but if they are wise they will no longer dispute the goal.
This ground truth was visible in Friday’s climax on the Senate floor, in which Sen. John McCain (Ariz.) unexpectedly issued a third, decisive Republican vote against moving forward with a GOP bill. Mr. McCain later explained that he objected to the GOP’s partisan effort to ram through changes to the nation’s health-care system, which only became more unseemly at each desperate step. It could also be that he decided to take heat for some of his moderate colleagues, who did not want to significantly cut Americans’ health coverage but who also did not want to draw primary challengers by opposing the repeal of Obamacare. Either way, the GOP approach simply did not reflect what the majority of the country wants.
Even before Friday, Republicans sensed where the nation is. To the extent President Trump said anything specific about health-care policy during his 2016 campaign, he promised to make coverage better and more available. During the repeal-and-replace debate, Republicans decried rising premiums and deductibles, criticized health-care plans that were too stingy for people to use and denied that their proposals would harm people. They made these statements even though their proposals would have raised deductibles, made insurance plans far more stingy and curtailed vulnerable people’s access to coverage. They generally did not sell their policy on its substance, because its foundation was the notion that the government should be less involved in providing health coverage. The fact that they had to pretend their goal was advancing, not degrading, the availability of health care says as much as one needs to know about the national mood.
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For much of the past decade, Congress has acted on the principle that beating the other side is more important than practical results, which require compromise. Friday’s vote was a victory for the opposite view, and it opens a thin window of opportunity for fixing, rather than upending, the health-care system. That would start with Republicans rejecting Mr. Trump’s calls to “let Obamacare implode,” by which he means continuing and probably intensifying the GOP’s seven-year effort to sabotage the law.
Republicans would then have to accept the hand some key Democrats have extended in recent days, offering to work in good faith to shore up the existing system. If the goal were to pass Obamacare fixes with 60 Senate votes rather than dismantle the system with 51, many compromises were conceivable. Backstopping insurance markets, reducing uncertainty, relaxing some regulations, making the individual mandate less objectionable to conservatives, adopting automatic health-insurance enrollment — these are just a few of the ideas that could be in a compromise package. The pivot might be difficult for the GOP, but then there’s this: It very likely would be popular.
Why Obamacare won and Trump lost
by E.J. Dionne, Jr. - Washington Post - July 19, 2017
The collapse of the Republican effort to repeal the Affordable Care Act is a monumental political defeat wrought by a party and a president that never took health-care policy or the need to bring coverage to millions of Americans seriously. But their bungling also demonstrates that the intense attention to Obamacare over the past six months has fundamentally altered our nation’s health-care debate.
Supporters of the 2010 law cannot rest easy as long as the current Congress remains in office and as long as Donald Trump occupies the White House. On Wednesday, the president demanded that the Senate keep at the work of repeal, and, in any event, Congress could undermine the act through sharp Medicaid cuts in the budget process and other measures. And Trump, placing his own self-esteem and political standing over the health and security of millions of Americans, has threatened to wreck the system.
“We’ll let Obamacare fail, and then the Democrats are going to come to us,” Trump said after it became obvious that the Senate could not pass a bill. But if Obamacare does implode, it will not be under its own weight but because Trump and his team are taking specific administrative and legal steps to prevent it from working.
As long as “repeal Obamacare” was simply a slogan, what the law actually did was largely obscured behind attitudes toward the former president. But the Affordable Care Act’s core provisions were always broadly popular, particularly its protections for Americans with preexisting conditions and the big increase in the number of insured it achieved. The prospect of losing these benefits moved many of the previously indifferent to resist its repeal. And the name doesn’t matter so much with Obama out of office.
Trump: 'We'll just let Obamacare fail'
President Trump on July 18 said he is “very disappointed” after the Senate GOP's effort to revamp the Affordable Care Act collapsed. "We'll just let Obamcare fail. We're not going to own it," he said. (Photo: Jabin Botsford/The Washington Post)
To the surprise of some on both sides, the debate brought home the popularity of Medicaid, which for the first time received the sort of broad public defense usually reserved for Medicare and Social Security. The big cuts Republicans proposed to the program paradoxically highlighted how it assisted many parts of the population.
This creates an opening for a new push to expand Medicaid under the ACA in the 19 states that have resisted it, which would add 4 million to 5 million to the ranks of the insured.
Republicans also found, as they did during the budget battles of the 1990s, that when they tie their big tax cuts for the wealthy to substantial reductions in benefits for a much broader group of Americans, a large majority will turn on them and their tax proposals. For critics of the GOP’s tax-cutting obsession, said Jacob Leibenluft of the Center on Budget and Policy Priorities, this episode underscores “the importance of making clear the trade-offs of Republican fiscal policy.” To win on tax cuts, the GOP has to disguise their effects — or pump up the deficit.
One Democratic senator told me early on that Republicans would be hurt by their lack of accumulated expertise on health care, since they largely avoided sweating the details in the original Obamacare debate after deciding early to oppose it. This showed. They had seven years after the law was passed and could not come up with a more palatable blueprint.
The popular mobilization against repeal mattered, too. With Republican senators discovering opposition to their party’s ideas in surprising places, pro-ACA activists drove two wedges into the Republican coalition.
One was between ideologues and pragmatic conservatives (Republican governors as well as senators) who worried about the impact of Senate Majority Leader Mitch McConnell’s designs on their states.
The other divide was within Trump’s own constituency, a large share of which truly believed his pledge to make the system better. They were horrified to learn that they could be much worse off under the GOP proposal. A Post-ABC News poll this month found that 50 percent of Americans preferred Obamacare and only 24 percent picked the Republican bill. Trump’s approval ratings are dismal, but the GOP plan’s were even worse. Defectors in the Trump base may have been the silent killers of this flawed scheme.
And that is why a scorched-earth approach from the president would be both cruel and self-defeating. Americans now broadly support the basic principles of Obamacare. Republicans, including Trump, would do well to accommodate themselves to this reality.
Maine Voices: State’s ill-advised to neglect its responsibilities for public health
by Rebecca Boulos - Portland Press Herald - July 29, 2017
SOUTH PORTLAND — Do you know how many local health departments are in Maine? Two. Just two. One in Portland and one in Bangor. Two health departments for a state of 1.3 million residents, across a geographic span of 35,385 square miles.
Just last year, the state dismantled 27 health coalitions that served every community in Maine and ensured local oversight and coordination of public health efforts. Not surprisingly, the termination of those coalitions dramatically cut Mainers’ access to public health resources. Mainers’ lifeline to these critical services then became solely through nine District Coordinating Councils, one in each of Maine’s public health districts. Each council is staffed by just one person. Although volunteers assist the lone staff member, many do not have training in public health.
During the most recent legislative session, the attack on Maine’s public health system continued: This time, when legislators approved a $10 million funding cut. These funds are not from taxpayers – they come from an annual payment Maine receives from the tobacco industry to reduce the state’s burden of chronic illness (incidentally, this funding is also what supported the 27 health coalitions).
This $10 million cut meant that district coordinators lost their jobs. It means that school-based health centers will close. It also means the state is more vulnerable to emerging public health threats, including infectious disease outbreaks, which is particularly concerning at a time when more parents are opting out of vaccinations for their children. While legislators voted to keep 48 public health nursing positions in the budget (passed to be enacted), they also voted to eliminate more than 100 positions from the Maine Department of Health and Human Services.
To make all of this even worse, the $10 million cut wasn’t even needed to balance the budget. Just in the month of June, General Fund revenue, and individual income tax and corporate income tax, were over budget by $72.7 million.
The $10 million cut from Maine’s public health system was, in theory, redirected to fund direct care worker wages. Ensuring adequate living wages is a public health priority; however, these wage increases occurred at the expense of full-time jobs of other Mainers serving in our most underserved areas. What’s more, there were sufficient funds available to pay for both. The budget negotiation was a short-term solution to a now very long-term problem.
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Last week, about two weeks after this budget was passed, I sat in on meetings of the Joint Standing Committee on Marijuana Legalization. Legislators were reviewing a list of policy recommendations from substance-use prevention experts. Despite having recently voted to cut public health programs and funding, legislators were under the impression that the state was already investing in local efforts to enforce public health laws, collect and track data and implement other critical components of responsible drug policy.
Legislators made frequent comparisons to Colorado. For a point of reference, Colorado has a state Board of Health, a state Public Health Department and 18 local public health agencies, and they put their annual payment from the tobacco industry into an escrow account.
Maine does not have a state Board of Health. Maine’s state Health and Human Services Department has forfeited nearly $2 billion in federal funds since 2011 for public health initiatives (e.g., child care and opioid treatment). Maine has only two local health departments. And our payment from the tobacco master settlement continues to be gutted for uses other than those outlined in statute. In addition, unlike Colorado, Maine has not expanded Medicaid under the Affordable Care Act, leaving our most vulnerable citizens with even fewer resources.
Colorado is an excellent example of how to organize a responsible and responsive public health system that makes sure that all residents have the opportunity to lead a healthful life; the Joint Standing Committee on Marijuana Legalization is right to look to them. However, Maine’s public health system is nowhere close to Colorado’s. With this latest reduction in funding, policymakers have completely dismantled the state’s public health infrastructure, jeopardizing the health of all Mainers, particularly those who are most vulnerable.
There is currently no system in place to assure local oversight, coordination or assessment, which is a serious problem, particularly if Maine were to be faced with an infectious disease outbreak or other public health emergency. We need to restore funding for Maine’s public health infrastructure and rebuild a system that protects and promotes the health of all Maine people, regardless of where they live.
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