Looking Beyond the Obamacare Debate to Improve Health Care
by The Editorial Board - NYT - August 27, 2017
Now that Republicans in Congress appear to have at least temporarily abandoned their crusade against the Affordable Care Act, it seems like a good time for lawmakers to come up with plans to fulfill their promises to increase access to health care and to lower costs.
Let’s stipulate up front that congressional leaders and President Trump are unlikely to lead that effort, given that they narrowly failed to take health insurance away from millions of people. This conversation would need to be led by senators who have committed to a bipartisan approach, and by state governments, some of which have already begun to take action.
Change might not come soon enough for the 29 million people without health insurance or the many millions who struggle to afford high premiums, deductibles and other health costs. But even the A.C.A., the 2010 health law also known as Obamacare, was the product of many years of spadework and was based on a Massachusetts health reform bill signed into law by Gov. Mitt Romney in 2006.
Obamacare has helped 20 million people gain access to insurance, and it appears to have helped slow the growth in health care costs. But even former President Barack Obama has said that there is still work to be done. The United States spends much more on medical care than other rich countries, like Britain, Australia and the Netherlands, according to a recent Commonwealth Fund report, yet its citizens live shorter lives and suffer from more illnesses and injuries than people in other industrialized nations.
One option that appears to have gained support among the public is a single-payer system, which proponents like Senators Bernie Sanders and Elizabeth Warren call “Medicare for All.” A Kaiser Family Foundation poll found in June that 53 percent of Americans favor such a system. This was up from 46 percent, according to an average of seven polls conducted in 2008 and 2009. But moving to a single-payer system from one dominated by employer-paid health coverage would be a big leap, and in any case the political climate is clearly not ready for it. Many Democratic voters as well as party leaders like Representative Nancy Pelosi and Senator Chuck Schumer have been reluctant to embrace the idea, and, no surprise, most Republican voters and lawmakers oppose it.
Single-payer advocates point out that the United States is the only advanced nation without universal health care, which is true. Germany, the Netherlands and Switzerland have achieved universal coverage and affordable health care with, essentially, more comprehensive and generous forms of Obamacare that require people to buy insurance, tightly regulate insurers and provide subsidies to the poor and middle class.
State and federal lawmakers are exploring ways to increase coverage and lower costs. For example, the Nevada Legislature passed a bill in June that would have allowed people who make too much money to qualify for Medicaid to buy into that program. The bill, which would have required a federal waiver, did not become law because Gov. Brian Sandoval, a Republican, vetoed it. But the idea has other backers. Senator Brian Schatz of Hawaii said on Tuesday that he would introduce a bill that would explicitly allow states to let people buy into Medicaid.
Another approach would be to let people buy into Medicare at some point before they become eligible for the program at age 65. Hillary Clinton proposed this during her presidential campaign. Congress could also provide more generous subsidies to help middle-class people buy insurance on Obamacare exchanges. At the state level, four million people would gain coverage if Florida, Georgia, Texas and the 16 other states that have not expanded Medicaid under Obamacare changed their minds and opted in.
Ms. Pelosi has said that some states could go even further by approving single-payer systems of their own. California, Colorado, New York and Vermont have considered such proposals in recent years. If one or two states moved in that direction, it could help demonstrate the feasibility of such an approach in much the same way that Romneycare in Massachusetts provided plausibility for Obamacare.
The Republican campaign to repeal Obamacare, for all its waste of time and energy, has at least gotten people to talk seriously about proposals to improve the health care system.
The bridge is burning: A physician’s perspective on our health care system and how to fix it
by Dr. Chuck Radis - The Ellsworth American - August 25, 2017
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, that wasn’t the problem. 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. 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 fleeced. 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 costs and it lands on “Administrative costs.” In my former private practice in Portland, one of our employees’ jobs 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. It was a lot of work. Is it any wonder that roughly 20 percent of the cost of your private health insurance goes toward administrative costs?
Let’s not leave out hospital costs. As Sarah Kiff recently wrote in Vox: “Americans pay on average $1,119 for an MRI. An Australian pays $215. 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 Ringers 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 Ringers solution for our patients receiving IV infusions in our office. Her answer: “Under four 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 now do. Let Medicare, with its extraordinary low administrative costs (estimated at 1-5 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 businesses 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.
Dr. Chuck Radis is a physician at Maine Coast Memorial Hospital in Ellsworth.
Republican group asks to strike ‘insurance’ from Medicaid expansion ballot wording
by Scott Thistle - Portland Press Herald - August 22, 2017
AUGUSTA — A group of Republican lawmakers led by former Maine Senate President Rick Bennett is asking Secretary of State Matt Dunlap to strike the word “insurance” from a ballot question that will ask voters in November to expand the state’s Medicaid program under the federal Affordable Care Act.
Bennett, also a former chairman of the Maine Republican Party, said at a news conference Tuesday that the proposed question, which is currently under a public comment period, should describe the expansion as either “taxpayer-funded health benefits” or as “government-funded health benefits” but not as insurance.
But supporters of the expansion said there was little question that Medicaid is a health insurance program for the poor, even though opponents prefer to label it “medical welfare.”
Bennett said Tuesday’s event was not the launch of an opposition campaign but an effort to draw attention to a four-page letter he and expansion opponents had sent to Dunlap asking him to consider a wording change to the ballot question. The question now reads:
“Do you want Maine to provide health insurance through Medicaid for qualified adults under the age of 65 with incomes at or below 138 percent of the federal poverty line (which is now about $16,000 for a single person and $22,000 for a family of two)?”
Currently, 19- and 20-year-olds, individuals with disabilities, the elderly and certain low-income parents qualify for Medicaid, which operates as MaineCare.
Lawmakers in attendance Tuesday included Assistant House Minority Leader Ellie Espling, R-New Gloucester, and Republican Reps. Heather Sirocki of Scarborough, Phyllis Ginzler of Bridgton, Paula Sutton of Warren, and Stephanie Hawke of Boothbay Harbor. The group said the state’s price tag for the change, estimated at about $54 million a year in the bill’s fiscal note, should also be included in the question.
“A welfare expansion will take money from Maine taxpayers, from their pockets and put it into the pockets of others who are not disabled and are working-aged adults,” Sirocki said.
Robyn Merrill, executive director of Maine Equal Justice Partners, a nonprofit that advocates for the poor and led the petition drive for the ballot question, said Sirocki is wrong. Merrill said Medicaid doesn’t provide cash payments to those who would be covered under the expansion, but instead reimburses health care providers, including Maine hospitals, many of which are struggling to cover the cost of the state’s uninsured as charity care.
Merrill and other supporters acknowledge the proposal’s $54 million annual price tag. However, they say that opponents frequently fail to mention that expansion would draw down $525 million each year in federal matching funds, while saving the state an estimated $27 million a year in costs once it is fully implemented.
In all, 31 states have expanded their Medicaid programs under the Affordable Care Act, including a number with legislatures controlled by Republican majorities and headed by Republican governors.
Maine Equal Justice Partners gathered more than 67,000 signatures of registered Maine voters in 2016 to put the Medicaid expansion question on the Nov. 7 ballot.
The Affordable Care Act, which passed in 2010, offers reimbursement rates for Medicaid expansions that taper from 100 percent to 90 percent in 2020. Since the ACA became law, the Maine Legislature has voted to expand Medicaid five times, only to see those expansions vetoed by Gov. Paul LePage – with support from minority Republicans in the House.
“The majority of the Legislature has passed this, it has been vetted,” Merrill said, “but the important thing is more people would have access to affordable health care.”
Merrill rebutted claims that Medicaid was not a health insurance program. “I disagree with the claim this isn’t insurance. Ask anybody who is covered by Medicaid – this is health insurance. Over 265,000 Maine people are covered by Medicaid and this is health insurance,” Merrill said. About one out five Mainers is now insured under the program.
Kristen Muszynski, a spokeswoman for Dunlap, said he would be reviewing all responses during a public comment period but not discuss specific concerns about wording.
The public comment period on the question’s wording closes at 5 p.m. on Sept. 1.
Bennett said he had no ulterior motives for entering the public fray over the ballot question and does not plan to run for office. Bennett had been considered a possible candidate for the governor’s race in 2018, and earlier this year said he was considering that, but on Tuesday he ruled that out as well.
“I’m not here for a campaign. I’m here as a former legislator, as a businessman, as a father and as a citizen who is just concerned about his state,” Bennett said.
As of Tuesday, no formal opposition to the ballot question had registered with the Maine Ethics Commission as a ballot question committee or as a political action committee, as required under state ethics and campaign finance laws.
LePage has also been an outspoken critic of expanding Medicaid in Maine in recent weeks, telling radio talk show hosts the expansion would be devastating to the state’s budget. LePage also once described Medicare and Social Security, which are funded with payroll taxes charged to employers and employees, as welfare.
In 2014, LePage’s office issued a press release after a report from the U.S. Bureau of Economic Analysis showed Maine’s personal income growth was below the U.S. average and last in New England. The release said the BEA report “claims the other five New England states saw higher personal income growth than Maine, but that growth was driven by an increase in welfare benefits, especially in the form of Medicaid expansion. The BEA conceals welfare benefits by calling them ‘Personal Current Transfer Receipts.’ These ‘Transfer Receipts’ include: Social Security benefits; Medicare payments; Medicaid; and state unemployment insurance benefits.”
LePage continued: “It doesn’t matter what liberals call these payments, it is welfare, pure and simple. Liberals from the White House all the way down to Democratic leadership in Augusta believe that redistribution of wealth – taking money from hard-working taxpayers and giving it to a growing number of welfare recipients – is personal income. It’s not. It’s just more welfare expansion.”
The governor, who was then running for re-election, later accused the Portland Press Herald of making an “erroneous interpretation” of his statement and sought to clarify, saying he didn’t believe Social Security and Medicare were welfare.
http://www.pressherald.com/2017/08/22/republican-group-asks-to-strike-insurance-from-ballot-wording-on-medicaid-expansion/
Bill Nemitz: Whine about insurance? How about survival?
by Bill Nemitz - Portland Press Herald - August 28, 2017
It had to happen. The moment Secretary of State Matthew Dunlap released the wording for this fall’s referendum on expanding Medicaid in Maine, you knew the opposition party would immediately start looking for nits to pick.
Not surprisingly last week, they came up with several. But a group of six Republicans, led by former Maine Senate President Rick Bennett, focused primarily on one single word: insurance.
In its current form, Dunlap’s question asks: “Do you want Maine to provide health insurance through Medicaid for qualified adults under the age of 65 with incomes at or below 138 percent of the federal poverty line (which is now about $16,000 for a single person and $22,000 for a family of two)?”
Responded Bennett & Co.: “We would ask that … the term ‘insurance’ be dropped and replaced with more appropriate language such as ‘government-funded health benefits,’ ‘taxpayer-funded health benefits’ or language which does not include the term ‘insurance.’ ”
Added state Rep. Heather Sirocki, R-Scarborough, during the State House news conference: “A welfare expansion will take money from Maine taxpayers, from their pockets and put it into the pockets of others who are not disabled and are working-aged adults.”
She’s wrong about the money-in-the-pockets part – in no way would expansion of Medicaid, known here as MaineCare, provide cash benefits for anyone.
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But Sirocki, by labeling the proposal “welfare expansion,” provided a ready translation for those wondering what all the fuss is about: “Taxpayer-funded health benefits” is code for “welfare,” which is code for “those shiftless bums are trying to pick my pocket again.”
So, on that note, allow me to introduce a word that needs no decoding whatsoever:
Survival.
I know this word well.
Two years ago at this time, I found myself preparing to die. As I’ve noted in this space before, I’d been diagnosed with Stage 4 melanoma and, after seven months of intensive treatment, things still were not going well.
I’ll never forget how cancer turned my life – and the lives of those dearest to me – upside down during those difficult months. As the saying goes, “Everyone wants to go to heaven, but nobody wants to die.”
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But at the same time, I’ll never forget how lucky I was.
I had insurance. Good insurance.
I had friends who threw me a fundraiser to cover the costs that my insurance didn’t, leaving me both humbled and, truth be told, a little bit embarrassed at this heartfelt outpouring of generosity.
What I didn’t have was a clue of what my many and varied treatments all cost, from the surgeries and blasts of radiation to the hospital stays, immunotherapy infusions and endless trips to my local pharmacy.
Was it in the hundreds of thousands of dollars? No doubt. More than that? Wouldn’t surprise me.
Beyond my deductibles, co-payments and out-of-pocket costs, you see, I didn’t have to worry about the ever-escalating price tag.
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I do remember coming across an article on a medical website that said the cost of nivolumab and ipipilimumab immunotherapy treatments, both of which I received, was thousands of times higher than the price of gold. And that had someone relied on Medicare for those treatments, that person would have been on the hook for around $60,000.
But not me. I had good insurance.
And better yet, the treatment eventually worked.
I survived.
Now let’s look at Mainers whose income, as the ballot question puts it, tops out “at or below 138 percent of the federal poverty line.”
That, according to Secretary of State Dunlap’s wording, means around $16,000 per year for a single adult. The nitpickers cry foul on that, too – claiming it’s $643 more than that.
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Fine. Let’s tack on the $643, which I’ll bet is less than a guy like Rick Bennett spends annually on haircuts.
Now, if you’re making $16,643 a year, life already is not very good.
Your weekly income is $320. Wherever you’re earning that money, you almost certainly don’t have health insurance, paid vacation, sick leave or any other buffer between you and flat-out catastrophe.
Then you get sick. Or hurt.
At first, you try to tough it out because the last thing you need is an emergency room bill hanging over your meager monthly budget.
Eventually, though, you’ll head for the nearest hospital because when it comes to the kind of pain that leaves you doubled up on the floor wishing you were dead, well, everyone has a threshold.
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The hospital is legally bound to treat you because, for all the griping about people getting something for nothing, we at least have not (yet) devolved into a society that compels you to die on the street.
So, better late than never, you get your diagnosis and treatment, which overnight can run into thousands of dollars that you don’t have.
Maybe you’re the motivated type who will spend countless hours each week on the computer searching for charitable organizations and other assistance to help you stay financially afloat. Except for one problem – you can no longer afford internet service.
Thus, you fall behind in your payments until you just give up. And your hospital, itself hanging by a fiscal thread, chalks another one up to “charity care.”
Then you get sick again. Really sick. Only this time, remembering what happened last time, you stay put until it’s too late.
Then you die.
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The local hospital, meanwhile, goes on serving others like you until it, too, can no longer stay open. Meaning other folks, now without immediate access to health care, also will die.
My guess is that none of this crossed the minds of those six Republicans – Bennett, Sirocki, Assistant House Minority Leader Ellie Espling of New Gloucester, and Reps. Phyllis Ginzler of Bridgton, Paula Sutton of Warren and Stephanie Hawke of Boothbay Harbor – as they stood in the State House on Tuesday and used their dictionaries to once again demonize the poor.
I’ll also bet that, like me, they take comfort in knowing that should one or another medical calamity befall them, they’ll at least have the necessary insurance – that word again – to protect them from financial ruin.
So enough of the word games.
Enough pitting the haves against the have-nots.
Enough whining from people with precious little to complain about.
In the end, we’re all just trying to survive.
Our View: Fight over wording is part of larger war on Medicaid
Republicans have tried to cut the program in Congress, and want to block its expansion here.
by The Editorial Board - Portland Press Herald - August 24, 2017
The Republican war on Medicaid came to Maine this week, as local opponents led by former state party chairman Rick Bennett tried to weaken the proposed wording of a referendum question that would expand eligibility to the health care program here with mostly federal funds.
For now, the fight is over a single word: Whether Medicaid (known here as MaineCare) should be called “insurance” on the ballot, or as the opponents insist “welfare.”
Words matter. As Mark Twain said the difference between the right word and the wrong one is like the difference between “lightning and a lightning-bug.” But don’t mistake this as a fight over linguistic precision.
Earlier this year, the majority of Republicans in Congress, including Maine Rep. Bruce Poliquin, tried to take advantage of dissatisfaction with aspects of the Affordable Care Act to pass a bill that would starve Medicaid of federal support, costing tens of millions of Americans their health coverage. Fortunately, their effort stopped short in the Senate, where three Republicans, including Maine’s Sen. Susan Collins, were able to kill it.
In Maine, the battle is now over whether Medicaid eligibility should be extended to people who earn slightly more then the federal poverty line, which is currently $24,600 a year for a family of four. Led by Gov. LePage, most Republicans (with notable exceptions including state Sens. Roger Katz of Augusta, and Thomas Saviello of Wilton) have prevented the program’s expansion under the ACA, claiming that it would cost too much, even if it was mostly funded by the federal government.
That’s still their objection, but that’s not the ground on which they are currently fighting. Now they are fighting over a word.
But it’s a loaded word. Ever since Ronald Reagan campaigned on stories of a “Welfare Queen,” who used multiple identities to defraud the system and live in luxury, political operatives have been reinforcing negative connotations attached to what seems on its face to be a neutral term. Polling tells them that the word “welfare” conjures association with laziness, greed and theft, and getting the word on the ballot would help defeat a question.
It’s easy to see why they would want that, but it is not an accurate description of Medicaid. Coverage under the program works just like insurance. Payments go to private doctors, pharmacies, nursing homes and hospitals, not to members of the plan themselves. The federal government refers to its expanded Medicaid eligibility for minors as the “Children’s Health Insurance Program.” The Health Insurance Association of America refers to Medicaid as “a government insurance program.”
Rather than fight over the propriety of the use of the word “insurance,” opponents of the referendum should explain why they think Maine would be better off if fewer people had coverage for their health costs. They should also state whether they agree with Poliquin and his Republican colleagues in Congress, who wanted to cut benefits to those who are already eligible.
This issue is too important for proxy fights: Rather than argue over language, the referendum’s opponents should come out and say what they mean.
http://www.pressherald.com/2017/08/24/our-view-fight-over-wording-is-part-of-larger-war-on-medicaid/
National Bureau of Economic Research
June 2017
NBER Working Paper No. 23530
The Role of Hospital and Market Characteristics in Invasive Cardiac Service Diffusion
By Jill R. Horwitz, Charleen Hsuan, Austin Nichols
Abstract
Little is known about how the adoption and diffusion of medical innovation is related to and influenced by market characteristics such as competition. The particular complications involved in investigating these relationships in the health care sector may explain the dearth of research. We examine diagnostic angiography, percutaneous coronary interventions (PCI), and coronary artery bypass grafting (CABG), three invasive cardiac services. We document the relationship between the adoption by hospitals of these three invasive cardiac services and the characteristics of hospitals, their markets, and the interactions among them, from 1996-2014. The results show that the probability of hospitals adopting a new cardiac service depends on competition in two distinct ways: 1) hospitals are substantially more likely to adopt an invasive cardiac service if competitor hospitals also adopt new services; 2) hospitals are less likely to adopt a new service if a larger fraction of the nearby population already has geographic access to the service at a nearby hospital. The first effect is stronger, leading to the net effect of hospitals duplicating access rather than expanding access to care. In addition, for-profit hospitals are considerably more likely to adopt these cardiac services than either nonprofit or government-owned hospitals. Nonprofit hospitals in high for-profit markets are also more likely to adopt them relative to other nonprofits. These results suggest that factors other than medical need, such as a medical arms race, partially explain technological adoption.
From the Discussion
Between 1996 and 2014, hospitals have continued to adopt new invasive cardiac services, although the rate of adoption slowed over the study period. Larger hospitals are more likely to adopt new services than are smaller hospitals. For-profit hospitals are more likely to adopt new services than are nonprofit hospitals, which, in turn, are more likely than government hospitals to adopt new services. On average, hospitals appear to make decisions regarding the adoption of new services based on the behavior of competitors in the markets in which they operate, controlling for population size and other characteristics.
The welfare effects of our findings regarding cardiac technology diffusion are uncertain. Although the spread of technology is generally good for social welfare, this has not always been the case with health care technology. Large geographic differences in the provision of care and in spending on care cannot be explained by differences in the population treated and have not led to differences in health outcomes, suggesting that there is a great deal of waste. Cardiac treatments are typically quite profitable services for hospitals, and oversupply is a particular worry for the provision of services that tend to be profitable for providers. In fact, at the extreme, there have been distressing cases of hospitals and physician providing services, particularly profitable services such as cardiac treatments, to patients who did not need the intervention.
Although our study does not measure social welfare directly, the results suggest that current patterns of cardiac technology diffusion can either increase or decrease social welfare, depending on conditions of a health care market. Social welfare is enhanced if hospitals base their decisions to adopt on the existence of unmet medical need in their markets. And, there is some evidence that they are doing so. They are less likely to adopt a new service if the patients in their markets already have geographic access to a service at another hospital.
However, previous research finding little increase in geographic access to care suggests that adoption decisions are in fact driven by a competitor’s decision to adopt. Our results strongly support this finding. Although hospitals respond to the needs of potential patients to be within sixty minutes driving time of an invasive cardiac service, they also respond to the behavior of their competitors and adopt even if doing so duplicates existing services, failing to increase geographic access.
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Comment by Don McCanne
Single payer reform, as envisioned by Physicians for a National Health Program, is much more transformative than merely changing the payment process. One of the more important recommended changes is to convert for-profit entities, such as hospitals, into nonprofit status. Why should that matter?
For-profit business entities must place the interests of their investors first. Nonprofit health care entities place the interests of their patients first. Greedy business decisions are fundamental in the for-profit model which often detracts from optimal patient care, whereas the nonprofit grapples with budget problems in order to make decisions that work best for the patients.
This NBER study is an excellent example of that difference. The authors looked at crucial cardiac interventions - technical innovations that save lives. For-profit hospitals introduced these interventions as part of their competitive involvement in the medical arms race. It did not matter that the community was already being served with these technological advances; they introduced them to increase profits. After all, they are for-profit entities.
In contrast, nonprofit hospitals were less likely to duplicate these technologies if the patient needs were already being served in the community. An exception is that nonprofit hospitals in high for-profit markets were more likely to adopt the for-profit culture and duplicate the services. If the for-profit culture did not exist, it is much more likely that the nonprofits would select technology based on community need rather than profit potentials.
Greed, wasteful duplication of services, and diversion of health care dollars to passive investors are characteristics of the market-driven medical-industrial complex. We do not need nor want that in our health care system. A well designed single payer system includes regional planning and separate budgeting of capital improvements. Efficient and economical uses of resources serve the patients well.
Although we have had a surge of interest in single payer reform, we are now seeing a plethora of opinions, especially from supposedly progressive sources, that the disruption of single payer is not necessary and that we can get to an ideal system merely by simple adjustments such as adding a public option or allowing citizens to purchase Medicare or Medicaid coverage. But this approach would leave in place our fundamentally flawed health care financing infrastructure - by far the most expensive and least efficient model of financing health care. It would accomplish very little of what the PNHP model would.
Individuals touting these incremental steps need to take another look at the PNHP proposal and then explain to us just how their baby steps would ever get us to health care justice for all. Just as the touted gains of the Republican proposals proved to be hallucinatory, these touted gains of the progressives will never fill the vast void that a high performance health care system should be filling.
“Beyond the Affordable Care Act: A Physicians’ Proposal for Single-Payer Health Care Reform”:
Obamacare’s Bare County Problem Looks Solved, for Now
by Margot Sanger-Katz - August 15, 2017
A few months ago, it looked as if large swaths of the country might end up without any insurers willing to sell Obamacare insurance in 2018. But in the last few weeks the “bare county” problem, which President Trump had cited as a sign the markets were failing, has nearly solved itself.
Now, every county in the nation has at least one insurer currently willing to sell coverage for next year.
The bare county problem had been an unplanned policy hole in Obamacare, which depends on private companies to provide insurance to people who don’t get coverage through a government program or work. The federal government provides subsidies on a sliding scale to help middle-income Americans pay their premiums, but it does not force insurers to offer coverage if they don’t want to. For a while, it seemed there would be a smattering of mostly rural places in the country where no company saw a reason to participate in 2018.
Economists argued that the bare county problem didn’t make much sense, at least in theory. It’s typically easy for a company to make money as a monopoly, especially if the government will pay most of the bills. But as some large insurers shifted away from the Obamacare markets, and others worried about policy uncertainty, vacancies started to mount.
Mr. Trump, who has been pointing to Obamacare’s weaknesses in efforts to marshal support for a health care overhaul, began seizing on the bare counties, frequently noting that Obamacare was set to “implode.” Republicans in Congress also often made note of the bare spots. The Centers for Medicare and Medicaid Services, the government agency that runs the marketplaces, has been periodically updating a map of insurer moves, marking potential bare counties in red.
But then, just as some insurers exited Obamacare markets, others began entering to fill the holes left behind. Centene, a company that has sold Medicaid managed care plans to states, has been a major player in the reversal. It alone has filled more than half of all identified bare counties, part of a big bet on Obamacare. Kevin Counihan, who ran the federal marketplaces in the final years of the Obamacare administration, recently joined the company as an executive. Last week, Centene agreed to fill 14 bare counties in rural Nevada. This week, smaller carriers have stepped up to fill the two last bare counties, in Wisconsin and Ohio.
Behind the scenes, state insurance commissioners have been twisting arms, trying to persuade reluctant insurers to cover the counties without an insurer. But some carriers also recognized advantages in being the sole provider in a given place.
“There are a number of companies that are seeing a business opportunity,” said Katherine Hempstead, a senior adviser at the Robert Wood Johnson Foundation, who studies insurance markets.
Insurer participation for next year is not final, however. That means that insurers could still change their minds and leave. (Others could enter, though that is less likely.) Contracts will not be signed until the end of September.
President Trump has issued repeated threats not to pay a form of insurance subsidy that helps insurers offer lower co-payments and deductibles to low-income customers. If he withdrew those payments, more carriers might flee, though how many is hard to predict. Several insurers have already built in risk charges in their rate proposals for next year. But the Congressional Budget Office, in a report issued last week, said it expected about 5 percent of the population to live in a bare county if the payments were withdrawn.
We need higher taxes
by Robert Samuelson - Washington Post - August 27, 2017
Can we get real about “tax reform,” the Republican promise to enact deep tax cuts that will spur economic growth? Probably not, but let’s give it a try.
For starters, we can stop calling it “reform.” That’s a charged word, implying that the new tax system will be superior to the old. We don’t know that for a fact; the new system might be worse. Better to call what we’re doing the “tax debate” or “tax overhaul.” (The point is a general one. Advocates of policy changes routinely label their proposals “reform.” This suggests improvement, which may be nonexistent.)
Second, we cannot afford a net tax cut. If we are to lower tax rates and simplify complex tax provisions, we must offset the revenue losses by plugging loopholes, raising other taxes or cutting spending. Under current policies, the Congressional Budget Office has projected $10 trillion in deficits from 2018 to 2027. Trump’s tax plan, including provisions that would raise revenue, would add an additional $3.5 trillion in deficits over a decade, estimates the nonpartisan Tax Policy Center (TPC).
Third, if tax cuts were initially financed by more deficit spending, the costs of today’s lower taxes would be transferred to future generations. “Tax cuts often look like ‘free lunches’ for taxpayers, but they eventually have to be paid for with other tax increases or spending cuts,” says a new report from the TPC. (The report is based on a broad outline of Trump’s plan, subject to change.) This is not “reform.” Social Security and Medicare — paid mainly by workers’ payroll taxes — already involve huge intergenerational transfers. Deficits are both a cause and consequence of those transfers.
Still, the superficial appeal of Trump’s tax plan is undeniable. For individuals, taxes would be reduced and simplified. There would be only three personal rates — 10, 25 and 35 percent — compared with today’s top rate of 43.4 percent. The top corporate rate would fall from about 35 to 15 percent. To help pay for these cuts, most itemized deductions would be ended (exceptions: the deductions for charitable contributions and mortgage interest payments).
President Trump unveiled his tax plan on April 26, after months of pledging to make drastic changes to the tax code. The Post's Damian Paletta explains why tax reform is so complicated. (Jenny Starrs/The Washington Post)
Roughly 71 percent of households would receive a tax cut, estimates the TPC. The trouble is that the tax cuts are regressive: That is, compared to household incomes and existing tax burdens, they favor the rich and upper middle class as opposed to the poor and lower middle class. The cuts for the richest fifth of Americans would average $19,510, with the cuts for the top 1 percent averaging $196,420, estimates the TPC. Meanwhile, the fifth of Americans in the middle of the income distribution would get an average cut of $1,320.
Actually, nothing would be wrong with this if there were convincing evidence that lower tax rates stimulate significantly faster economic growth. But there isn’t. Tax cuts may cushion a recession and improve the business climate, but they don’t automatically raise long-term growth. A 2014 study by the Congressional Research Service put it this way: “A review of statistical evidence suggests that both labor supply and savings and investment are relatively insensitive to tax rates.”
The truth is that we need higher, not lower, taxes. When the economy is at or near “full employment,” the budget should be balanced or even show a slight surplus. At 4.3 percent, the jobless rate is surely close to full employment, while the deficit for fiscal 2017 is reckoned to approach $700 billion, about 3.6 percent of the economy (gross domestic product). Both figures are expected to increase, despite continuous (assumed) economic growth. The gap can’t be blamed on the business cycle.
We are undertaxed. Government spending, led by the cost of retirees, regularly exceeds our tax intake. In the past, I have advocated a carbon tax — introduced gradually to minimize any recession risk — as a pragmatic way to pay for the government we want, while trying to cope with global climate change. Letting the federal debt buildup continue is an exercise in self-serving optimism. It presumes that the possibly adverse consequences (the crowding out of private investment, a currency crisis) will never materialize.
Given the complexities, the best we can probably expect from a tax overhaul is a modest reduction in tax rates paid by tightening or eliminating some tax preferences. This would not be undesirable; the fewer tax preferences, the less lobbying to keep or expand them. Washington’s “swamp” would be a tad drier.
But we should not delude ourselves that we are fixing the economy, the budget or the tax system. Mostly, through deficits, we would be shifting the costs of today’s lower taxes and higher benefits onto tomorrow’s Americans through higher taxes and lower benefits. Admitting this would require a more honest debate than most Americans are willing to abide.
