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Monday, August 28, 2017

Health Care Reform Articles - August 28, 2017

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.


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.






Tuesday, August 22, 2017

Health Care Reform Articles - August 22, 2017

CBO confirms canceling Obamacare's cost-sharing subsidies would be a disaster — for Republicans
by Michael Hiltzik - LA Times - August 15, 2017


The Congressional Budget Office weighed in Tuesday with another of its long-awaited analyses of aspects of repealing or tinkering with the Affordable Care Act. This time the topic is the ACA’s cost-sharing reduction subsidies, which reduce deductibles and co-pays for the lowest-income buyers of health coverage on the exchanges.
The CBO’s findings are timely because the so-called CSRs are the subsidies that President Trump continually threatens to withhold, as a tool for forcing Obamacare to “implode.” And, as expected, the CBO finds that canceling the subsidies would be a disaster — but for Republicans favoring that approach, not Democrats.
Its conclusion is especially germane to the question of what congressional Democrats should trade in return for a GOP agreement to keep the CSRs funded. Earlier this month, healthcare analyst Avik Roy argued that Republicans should demand lots of concessions, including repeal of the individual mandate and enactment of “premium-lowering regulatory reforms.” Roy didn’t specify these, but Republicans have talked about paring down the ACA’s list of essential health benefits, such as maternity, hospitalization and prescription coverage, which are mandated to be offered by any qualified health plan.
The CBO’s analysis, however, suggests that Democrats should take Michael Corleone’s approach from “The Godfather, Part II.” His line to a corrupt senator overplaying his hand was: “My offer is this: nothing.”
Obamacare supporters haven’t fully internalized this reality. The Democratic National Committee responded to the CBO report by quoting the agency as finding that if cost-sharing reduction subsidies were ended, millions of Americans would face skyrocketing premium increases of 20% by 2018 and 25% by 2020. Actually, the CBO didn’t say that. The premium increases it cited were gross increases, not factoring in premium subsidies, which would reduce the actual impact in many cases to zero.
Health insurance expert David Anderson of Duke got it exactly right: “Democrats have no reason to trade CSR funding for policies that they don’t prefer,” he observed. “Inaction gives them an incredible policy victory. Conservatives are the ones who need to make concessions to fully fund CSR.”


The fallout from CSR cancellation already is visible in early rate requests filed by insurers in several states. California insurers are seeking an increase averaging about 12.5% for next year — but almost double that if the CSRs are ended. Those rates are pre-subsidy, and Covered California, which manages the state’s insurance exchange, said that the average buyer could avert all or most of the increases through the subsidy and smart shopping.
The CBO says its analysis is based on the assumption that CSRs would be paid through the end of this year, but not thereafter. If the scenario changes — say the payments are cut off in midyear, after insurers already have set their annual premiums and signed up customers, the results could be more dire. In that event, however, Republicans would probably be blamed for the resulting market carnage, since it would be associated directly with GOP action.
Before we get into the counterintuitive details, a quick primer.
Cost-sharing reductions are offered to buyers in the individual market with incomes between 100% and 250% of the federal poverty limit. For a family of four, the eligible income range is $24,600 to $61,500. These subsidies are in addition to the ACA’s premium subsidies, which cover those with incomes up to 400% of the poverty level, or $98,400 for a family of four. Unlike the premium assistance, which technically is paid to the policyholder, the CSRs are advanced to the insurers based on the co-pays and deductibles they would otherwise charge. About half of all buyers of ACA plans are eligible for the CSR assistance, and about 90% receive premium subsidies.


The subsidies this year are expected to come to $7 billion, to be paid to insurers covering 7 million customers. The subsidies are authorized under the healthcare act, but House Republicans filed a lawsuit in 2014 asserting that because the money hadn’t been specifically appropriated, paying the money is illegal. They won the first round in U.S. District Court last year, but the judge stayed her ruling pending an appeals court decision.
Since his inauguration, Trump has dithered over whether to pay out the subsidies and continue fighting for them in court. On occasion, he’s threatened to kill the payments as a bargaining chip to force Democrats to negotiate an Obamacare repeal. Periodically, the plaintiff and government lawyers have to return to the appeals court to ask for a three-month hold in the case; the next scheduled appearance is Aug. 20. Recently, 17 states and the District of Columbia won the right to step in to defend the CSR payments if the Trump administration tries to withdraw from the case.
The CBO found that canceling the CSR subsidies might drive some insurers out of the individual market because of “uncertainty about the effects of the policy on average healthcare costs for people purchasing plans.” Those facing higher deductibles and co-pays might be less inclined to buy coverage. Regions with about 5% of the U.S. population might end up with no insurers in the individual market next year, the agency said. But by 2020, enough insurers would return to the market that almost no one would be left without insurance availability.


Insurers would, however, raise premiums to compensate for the loss of subsidies for deductibles and co-pays. It’s likely that insurers would load these higher premiums onto silver plans, the only plans that provide CSR subsidies. That would drive up gross premiums for silver plans by 20% next year, compared to their expected level without a policy change.
But because premium subsidies are tied to buyers’ incomes and rise as premiums rise, the subsidies would also increase — in fact, more Americans would be eligible. The CBO reckoned that many silver-plan buyers receiving subsidies would pay net premiums “similar to what they would pay if the CSR payments were continued.” Some buying skimpier, bronze plans, would receive sufficient subsidies to cover premiums and some of their deductibles and co-pays too. “The average subsidy would be greater, and more people would receive subsidies in most years.”
The federal government, however, would take a hit. Over 10 years, the CBO said, canceling the CSR payments would increase the federal deficit by $194 billion. So much for the fiscally responsible Republican Party.
The picture could be materially different if Trump follows through on his threat to cancel CSRs immediately. Any decision to terminate CSRs after insurers had begun charging premiums based on continued CSR funding, the CBO said, would cause them “significant financial losses.” Some would leave the marketplace immediately, leaving their enrollees without coverage in the middle of the year and causing a spike in the ranks of the uninsured.
Is Trump prepared to explain the consequences to the public? It’s doubtful. Many congressional Republicans know that for Trump to cancel the CSRs in midstream would hand them a poisoned chalice. Sen. Lamar Alexander (R-Tenn.), chair of the Senate Health, Education, Labor and Pensions Committee, told Roy he favors an affirmation by Trump of the CSRs at least through September, followed by congressional extension of the CSRs for one year. That would provide sufficient stability, Alexander said, to persuade the insurers to lower their rates.


Richard Master: A businessman makes the case for a single-payer health care system
by Richard Master - The Morning Call - August 1, 2017

With all due respect to President Trump, he is wrong about the single-payer model of health insurance. 


Single payer — centralized public financing of a continued privately operated health system — will not "bankrupt the United States." In fact, the opposite is true. 

Single payer is the only internationally proven strategy to transition the U.S. out of its current crisis of runaway health care costs to economic sustainability, where overall system cost growth is consistent with overall economic growth and inflation. 
At one-sixth of our economy and over 25 percent of the federal budget, health care will continue to be a focus in Congress until real progress is made and the angst of the American people about the system is resolved. It is clear to most Americans that runaway health care costs translate into flat wages and also a deterioration of real disposable income that drags down our 70 percent consumer-driven economy.
But recent efforts in Congress to confront the crisis have been misguided. Congress has focused on cost shifting — moving the burden of our health system away from the federal government to the states and also to employers and to working families across the country, who will pay higher private insurance premiums to cover the expected cost of increased uncompensated care as the system absorbs the loss of Medicaid funds.
Going forward, the focus of the administration and its allies in Congress should be on controlling the real drivers of cost of care, such as prices of pharmaceuticals, which are rising at double digits a year, and addressing wasteful administrative costs associated with our complex, multipayer-financing model, which costs U.S. private doctors $83,000 a year to interact with multiple health plans vs. $22,000 for doctors in Canada, according to a 2011 Commonwealth Fund study. And it costs hospitals nearly double in administrative costs vs. other countries, according to a 2014 Commonwealth Fund study
We do not need to reinvent the wheel. Single payer is the recognized best practice. Warren Buffet points out that, in the 1970s, Canada and the U.S. had roughly equivalent health system expense — 7 percent of gross domestic product. Canada went the single-payer route; the U.S. did not. Canada covers all of its citizens, has better health outcomes and today spends 11.4 percent of GDP. Our cost went to 18 percent of GDP. France, the highest ranked health system in the world, spends 11.8 percent of GDP, and Japan, 8.5 percent
We need to investigate and follow the examples of successful health systems operating throughout the world where all citizens are covered, public health outcomes are measurably superior and the overall cost to society is less.
We need to also review closely the many in-depth studies by prominent American economists reporting overall system savings from a transition to centralized financing. Consider in particular the May study, "Economic analysis of the healthy California single-payer health care proposal (SB-562)." That study, from four economists at the University of Massachusetts, demonstrated how single payer would reduce California's overall health care expense by 10 percent, even with universal care for all residents and assuming comprehensive benefits. (The bill has been referred to a legislative committee.)
The study found substantial savings in administration and pharmaceutical pricing and on mitigating the current high variance in fees for service providers. Today 7.5 percent of Californians have no health coverage and an additional 30 percent of those insured are considered underinsured and are particularly vulnerable to the economic consequence of serious illness. The status quo in California and throughout the country is unacceptable. The solution is single payer. 
What do Americans want? According to an April Economist/YouGov poll, 60 percent of Americans favor a Medicare-for-all solution to replace the Affordable Care Act, and only 24 percent oppose it. Medicare for all is single payer.
During his campaign, President Trump promised to take on cronyism and refresh Washington. No better place to start than with the health care commercial sector. They spend more on lobbying Congress than any other business sector, and they get what they pay for — a Congress that focuses more on the commercial interests of an industry than it does on the well-being of patients, working families and the overall economy. 
This is our big chance to do something great. Let's fix health care with single payer.
Richard Master is founder and CEO of MCS Industries Inc., Palmer Township, and executive producer of two documentaries,"Fix It: Healthcare at the Tipping Point" and "Big Pharma: Market Failure."

Democrats are starting a fierce internal debate. Finally.
by Katrina Vanden Heuvel - Washington Post - August 22, 2017

With President Trump flailing and even Republicans panning the GOP-controlled Congress, Democrats have begun a long-overdue debate about the party’s platform and strategy. Citizen movements and progressive political leaders such as Sens. Bernie Sanders and Elizabeth Warren are driving this debate. United in opposition to Trump’s reactionary agenda, they are calling on Democrats to embrace a bolder agenda for change. While many Beltway pundits warn against Democratic division, the party’s congressional leaders — Nancy Pelosi and Charles E. Schumer — understand that this has been a long time coming.
The “Better Deal” platform put forth by Senate Minority Leader Schumer (N.Y.) and House Minority Leader Pelosi (Calif.) received justified gibes on its framing and language. But its premise was exactly right. As Schumer put it in the New York Times, “In the last two elections, Democrats, including in the Senate, failed to articulate a strong, bold economic program [and] failed to communicate our values to show that we were on the side of working people, not the special interests. We will not repeat the same mistake.” 
The Better Deal essentially endorses the big debate about a reform agenda that has already begun inside and outside the Democratic Party. Democratic failure isn’t about Vladi­mir Putin or James B. Comey or Hillary Clinton’s emails. Since Barack Obama was elected in 2008, Democrats have lost the White House, both houses of Congress and about 1,000 state legislative seats. Republicans now have total control in a record 26 states. Clearly, a major debate about the party’s agenda, strategy and leadership is sorely needed.
Pelosi and Schumer are trying to corral this debate. Progressives such as Sanders (I-Vt.) and Warren (D-Mass.) and the Congressional Progressive Caucus are trying to expand it. But citizen movements are the ones truly driving it.
The first priority of these groups has been to stiffen the spines of Democrats and enforce unity in opposition to the right-wing agenda of Trump and the Republican Congress. The mobilization against the Republican health-care plan, which would have stripped millions of health care to pay for tax cuts for the few, included virtually the entire activist base of the party — unions, senior groups, women’s and civil rights groups, online activists such as MoveOn.org, grass-roots groups such as People’s Action, and more. They enforced Democratic unity while challenging Republicans in their offices and town-hall meetings.
Democrats unveiled an economic platform on July 24 that included plans to address unfair market competition, rising pharmaceuticals costs and stagnant wages.(Reuters)
The second priority has been to push Democrats and their agenda. Fight for $15 has pushed the plight of low-wage workers onto the national agenda. Black Lives Matter demonstrations forced Democrats to address police brutality and sentencing reform. Planned Parenthood and NARAL Pro-Choice have led opposition to Republican efforts to roll back women’s right to control their bodies. The Rev. William Barber’s Moral Mondays movement in North Carolina provides a model of an interracial coalition fighting for political and economic reform. National Nurses United and former Sanders campaign activists have driven Medicare-for-all onto the national agenda. 
The challenge hasn’t been limited to single-issue groups. The insurgent Sanders campaign has unleashed activist energy across the country. Sandernistas are running for party offices, challenging sitting legislators and pushing to rewrite state platforms. Warren, Sanders, Jeff Merkley (Ore.) and Sherrod Brown (Ohio) in the Senate and Keith Ellison (Minn.), Mark Pocan (Wis.), Raúl M. Grijalva (Ariz.) and Congressional Progressive Caucus members in the House have challenged the limits of the Democratic agenda on everything from antitrust policy to money in politics to breaking up Wall Street. 
Now a broad collection of groups, the Millions of Jobs Coalition, has begun pushing Democrats to unite on a set of principles, detailed in House Concurrent Resolution 63 on how to rebuild America the right way. They demand public investment, not corporate giveaways, prioritize 21st-century clean-energy programs and jobs, want guarantees for racial and gender equity, would put the needs of disadvantaged rural and urban communities first, and call for enforcing “buy-American” and basic labor agreements to ensure that good American jobs are created.
Of course, Trump and Republicans still set the national agenda, with tax cuts and infrastructure being two possibilities. A broad coalition of more than 400 groups called Americans for Tax Fairness champions progressive tax reform that helps make the rich and corporations pay their fair share — a stance that enjoys overwhelming public approval. Similarly, activists will challenge Trump’s infrastructure plan, which appears to feature the worst forms of crony capitalism: “public private partnerships” that privatize highways and bridges and impose tolls on users; tax giveaways to companies stowing profits abroad. 
Pelosi and Schumer have already embraced the $15 minimum wage, a $1 trillion public infrastructure agenda, an aggressive antitrust agenda and a balanced trade agenda that begins to unpack the corporate trade policies championed by Presidents Bill Clinton and Obama. But these battles on economic issues — as well as the continuing debate over social issues such as choice and money and politics — will continue to roil Democrats. Activists will fight to put Medicare for all, progressive tax reform and public infrastructure investment on that agenda. The debate about strategy, about money in politics, about the Wall Street wing of the party will grow ever more fierce. 
Already Beltway voices are fretting about division, about Democrats shooting at one another, about the need for unity in order to win in 2018. But a fierce debate is unavoidable. The party establishment won’t change on its own, despite its remarkable record of consistent failure. The money wing of the party won’t cede its hold without a fight. Democratic leaders won’t see the light unless they feel the heat. 
Establishment Democrats count on Trump’s grotesqueries to unify and mobilize Democrats. But if Hillary Clinton’s campaign taught us anything, it is that simple opposition or “resistance” to Trump is not enough. Democrats can’t even mobilize their own base to vote — particularly in off-year elections — unless they champion a bold program that offers a credible promise of change to the vast majority of Americans. Pelosi and Schumer have recognized that. The resulting debate is not only long-overdue, it is also utterly necessary if Democrats are to begin winning elections again.

Where Are the Single-Payer Wonks?

by Clio Chang - New Republic - August 3, 2017

In the heat of the 2016 Democratic primary, Bernie Sanders released one of his signature proposals: Medicare-for-All. In response, economists, policy experts, and the liberal media all hammered the plan: Vox’s Ezra Klein called it “puppies-and-rainbows” and Paul Krugman wrote at The New York Times that “Sanders ended up delivering mostly smoke and mirrors.” The Urban Institute released an analysis that contended that Sanders’s proposal would have cost twice what the campaign had projected. Sanders’s plan was dragged for being vague, unrealistic, and light on the nuts and bolts.
Now, Sanders is gearing up for another go. Following the latest death of the zombie-like Trumpcare, he has stated that he will introduce single-payer legislation to the Senate. A lot is riding on the hope that Sanders’s new bill will be a robust piece of legislation. The political landscape has changed drastically since 2016, with progressives demanding more radical action to shore up and build upon the gains made by Obamacare. Among Democrats, support for single-payer has increased by 19 percentage points over the past three years. And for the first time in history, a majority of Democrats in the House have signed on as co-sponsors to Representative John Conyers’s Medicare-for-All bill.
But it’s hard to deny that single-payer is an area where progressive politics has outstripped policy. Conyers’s bill is largely seen as a symbolic piece of legislation, and not only because Democrats would first have to win back Congress and the White House to even begin passing it. As Joshua Holland wrote on Wednesday in The Nation, the momentum for single-payer is “tempered by the fact that the activist left, which has a ton of energy at the moment, has for the most part failed to grapple with the difficulties of transitioning to a single-payer system.”
We have seen this dynamic play out in real time in California, where the country’s most promising single-payer bill floundered on the details of the legislation. And on a national level, there is little clarity around an actual plan with comprehensive steps to genuine universal coverage. For a party that prides itself on being the country’s only rational, empirical party, where are the Democrats’ famed wonks on single-payer?
As Harold Pollack, a health policy researcher at the University of Chicago, told Holland, “There has not yet been a detailed, single-payer bill that’s laid out the transitional issues about how to get from here to there. We’ve never actually seen that. Even if you believe everything people say about the cost savings that would result, there are still so many detailed questions about how we should finance this, how we can deal with the shock to the system, and so on.” 
This failure to sketch out a plan speaks less to the pie-eyed idealism of activists than to the lack of an existing policy infrastructure in support of single-payer. This lack is most evident in the think tank class. Large policy shops like the Brookings Institution and the Center for American Progress have focused instead on criticizing Republican health care efforts or pushing for bipartisan reform options
Smaller and more explicitly progressive think tanks, such as the Economic Policy Institute, Demos, and the Roosevelt Institute, are stacked with left-leaning scholars on subjects like the minimum wage, voting rights, and anti-trust policy, but are less in the business of churning out policy proposals for legislators, especially when it comes to health care. While some groups, such as the Physicians for a National Health Program (PNHP), an organization that pushes for single-payer, have been at the forefront of the issue, the bulk of the think tank world has been focused on defending the ACA.
As Adam Gaffney, an instructor at Harvard Medical School and board member of PNHP, told the New Republic, “When something seems very far away, the need for that kind of detailed policy work sometimes seems less.” But now that single-payer is no longer an idea on the fringe, the actual mechanics have to be in place to maintain its credibility. “Bernie is going to come out with a bill and I want it to be as strong as possible,” Vijay Das, senior campaign strategist at Demos, told me. “I want it to live up to scrutiny of the right and the left.”
This weakness in left-leaning policy work goes beyond single-payer. “Broadly speaking, I think left politics needs more detailed, thorough, and rigorous policy work,” Gaffney says. “We absolutely need better and more policy on the left.” While the Heritage Foundation and the Center for American Progress are seen as policy feeders for right-wing and center-left politicians, respectively, there is no such equivalent for the more progressive space. Jacob Hacker, a political scientist at Yale, points out that there are many academics doing this work outside of the think tank sphere, but as scholars they are often removed from late-in-the-pipeline policy development that is essential for politicians and policy-makers. “There is a problem in terms of progressive policy development, but it’s not a problem of there being an absence,” Hacker says. “The problem is where it’s coming from and what its character is.”
Part of the problem may stem from the Democratic Party’s technocratic bent. No one would accuse Democrats of lacking in the ability to churn out detailed and complex policy work: In the 2016 election, Hillary Clinton released dozens of policy blueprints, which continue to stand in sharp contrast to the Republicans’ brazen ignorance of the most elementary policy details. But this kind of in-the-weeds work is often removed from the long-term vision that comes with grassroots mobilizing. Liberal think tanks often work in the realm of political possibility, rather than setting ideological goals and then working towards them. This means that, with the sudden burst of energy on the left for more far-reaching policies, Democratic politics has left much of the think tank world scrambling to keep up.
Contrast this with right-wing think tanks, many of which are couched within a larger Koch network that has spent the last few decades waging a war of ideas. As detailed in Jane Mayer’s Dark Money, the Koch brothers have tirelessly poured hundreds of millions of dollars not only into electing candidates, but also into the policy arena of think tanks and universities. This investment is part of a long-term strategy to push libertarian policies, once residing on the far-right fringe, into the mainstream. While liberal policy is lagging behind liberal politics, the Kochs engineered the opposite situation, in which policy pushed politics toward their corporate-libertarian vision of society. 
Much of this difference in strategy is due to the fact that the wealthy donor class is more naturally inclined to lean right. A Demos study found that Republican donors are much more conservative than Republican voters, whereas Democratic donors are more closely aligned to Democratic voters.
The right wing, led by a fantastically wealthy coterie of industrialists, has essentially weaponized policy. “Historically conservatives, particularly the Koch network, have been better at thinking of policy as a way to not only achieve technical ends but to also change the political landscape, either by weakening their opponents or strengthening their allies,” Alexander Hertel-Fernandez, political scientist at Columbia University, told me. Hertel-Fernandez sees an opportunity for the left to learn from the right by conceiving of policy as a way to shift politics in a durable way. He points to the payroll tax cuts in Barack Obama’s 2009 stimulus plan, which achieved a technical end of providing workers with more disposable income, but failed to convince Americans that the equivalent of handing out cash to people is a great way to fight recessions. A majority of voters did not even know that their taxes had actually gone down. “People fixate on what are the technical fixes, but policies have to be popular,” Hertel-Fernandez says. 
This shift might require bringing the grassroots into the policy shops. Experts in both the spheres of organizing and policy work emphasized that the solution does not necessarily lie in the creation of a new “left” think tank, which would only add to a crowded and fragmented ecosystem. Instead, many believe that the answer is greater integration between existing movements and policy organizations. “There’s often a disconnect between think tanks and real organizing that’s happening on the ground,” Ben Palmquist, campaign manager at the National Economic & Social Rights Initiative, told the New Republic. “We need more cross-fertilization, not just conversations and sharing of information, but actual collaboration.” 
The Democratic policy infrastructure has proven itself extremely capable at churning out white papers for the center-left. Left-leaning activists and donors should be pushing this infrastructure to make an investment in more transformative progressive ends. It took years to lay the groundwork for Obamacare, and it will take years to do the same for single-payer or a similar program. Now is the time for the left to finally start waging its own war of ideas.


A Start-Up Suggests a Fix to the Health Care Morass

by Farad Manjoo - NYT - August 16, 2017

WINFIELD, Kan. — If you watched the drama in Washington last month, you may have come away with the impression that the American health care system is a hopeless mess.
In Congress, a doomed plan to repeal the Affordable Care Act, President Obama’s health care law, has turned into a precarious effort to rescue it. Meanwhile, President Trump is still threatening to mortally wound the law — which he insists, falsely, is collapsing anyway — while his administration is undermining its being carried out.
So it is surprising that across the continent from Washington, investors and technology entrepreneurs in Silicon Valley see the American health care system as the next great market for reform.
Some of their interest is because of advances in technology like smartphones, wearable health devices (like smart watches), artificial intelligence, and genetic testing and sequencing. There is a regulatory angle: The Affordable Care Act added tens of millions of people to the health care market, and the law created several incentives for start-ups to change how health care is provided. The most prominent of these is Oscar, a start-up co-founded by Joshua Kushner (the younger brother of Mr. Trump’s son-in-law, Jared Kushner), which has found ways to mine health care data to create a better health insurance service.
But perhaps the most interesting and potentially groundbreaking company created in connection with the Affordable Care Act is Aledade, a start-up founded in 2014 by Farzad Mostashari, a doctor and technologist who was the national coordinator for health information technology at the Department of Health and Human Services in the Obama administration.
Aledade, which has raised about $75 million from investors, has an agenda so ambitious it sounds all but impossible: Dr. Mostashari wants to reduce the cost of health care while improving how patients are treated. He also wants to save the independent primary care doctor, whose practices have been battered by the perverse incentives of the American health care system.
And here is the most interesting part: His plan is working.
A few weeks ago, I visited two primary care practices in southeast Kansas that have worked with Aledade for more than a year. Their operations had been thoroughly remade by the company. Thanks to Aledade, the practices’ finances had improved and their patients were healthier. On every significant measure of health care costs, the Aledade method appeared to have reduced wasteful spending.
“The whole idea is to align incentives between society and doctors and patients,” Dr. Mostashari said, adding that Aledade has helped reduce hospital readmissions and decrease visits to specialists in many of its markets. “We’re reducing unnecessary and harmful utilization and improving quality of care.”
Of course, such promises are not new at the intersection of health and technology. Many companies have made big bets and blown up — among them Theranos, the lab testing start-up, which turned out to have been more puffery than product. Aledade faces its own share of hurdles, including whether its investors can ride out a long and costly expansion before it starts to realize any big paydays.
Still, its plan — which mainly involves using software to achieve its goals — looks promising.
The American health care system is a fragmented archipelago, with patients moving through doctors’ offices and hospitals that are often disconnected from one another. As a result, many primary care physicians — who often see themselves as a kind of quarterback who calls the shots on a patient’s care — have no easy way to monitor a patient’s meandering path through the health care system.
Aledade’s software addresses that by collecting patient data from a variety of sources, creating a helicopter view. Doctors can see which specialists a patient has visited, which tests have been ordered, and, crucially, how much the overall care might be costing the health care system.
More important, the software uses the data to assemble a battery of daily checklists for physicians’ practices. These are a set of easy steps for the practice to take — call this patient, order this vaccine — to keep on top of patients’ care, and, in time, to reduce its cost.
For example, say you’re a doctor at a small practice in rural Kansas and one of your patients, a 67-year-old man with heart disease, has just gone to the emergency room.
“In the past, we’d only find out our patients were at the hospital maybe weeks afterward,” said Dr. Bryan Dennett, who runs the Family Care Center in Winfield, Kan., with medical partner, Dr. Bryan Davis. With Aledade, Dr. Dennett is now alerted immediately, so “we can call them when they’re at the emergency room and say, ‘Hey, what are you doing there? Come back here, we can take care of you!”
It is not just emergency room visits. Aledade tells doctors which of their patients is eligible for preventive care like vaccines or an “annual wellness visit.” The doctors said that during such visits they have discovered several conditions that would have ballooned into much bigger problems without treatment. The software lets doctors know when their patients have been discharged from the hospital, allowing them to schedule “transitional care management” visits.
Such visits are a gimme for the health care system — they have been proved to reduce hospital readmissions (which are extremely costly), and patients say they find them valuable in navigating the health care system. And because these visits are so effective at lowering overall health care costs, Medicare pays doctors a higher rate to provide such care — meaning that primary care doctors can make money by following Aledade’s alerts.
Yet even though Aledade thinks of itself as a technology company, its doctors said its software is the least interesting thing it does. Independent primary care doctors tend to be cautious about technology, especially if it seeks to thoroughly alter how they work. So the real battle Aledade faces is to integrate technology into doctors’ practices — and to do so in an nonintrusive and pleasing way. The software’s instructions must also prove financially rewarding for clinics, while still somehow saving money for the overall health care system.
To do all this, Aledade — which now operates in 15 states and has relationships with more than 1,200 doctors — has had to become more than a software company. It has hired a battalion of field coordinators who visit practices and offer in-depth training and advice.
The company has also taken advantage of several health care ideas that were introduced or accelerated by the Affordable Care Act. One of these is known as the accountable care organization, or A.C.O., which lets groups of health care providers unite to coordinate care for a patient. Studies have shown that such a structure lowers overall medical costs; under the Affordable Care Act, Medicare encouraged the formation of these organizations by promising to share any savings it realizes with doctors. Aledade took the accountable care organization idea and made it its primary business model. (The structure was reaffirmed by a 2015 law passed overwhelmingly by Congress, so a repeal of the Affordable Care Act would not have affected its structure.)
For Aledade, the upshot is that it will only make a lot of money if it actually succeeds in reducing health care costs.
“Say Medicare thinks that it’s going to spend $100 million next year on our patients in Kansas,” Dr. Mostashari said. “A lot of this is from bad stuff — hospitalization, complications, you know, bad stuff. So we come in and say, if we can work with the primary care doctors to reduce bad things from happening while increasing quality, then we can save money for Medicare. Medicare says we thought we were going to spend $100 million on those patients, and we only spent $90 million. So, Medicare keeps half of the savings, and the other half of it goes to Aledade — which we split with the doctors.”
In addition to Medicare, Aledade has begun signing up several commercial health insurance companies under similar cost-savings plans. But given that the company gets paid only when it cuts health care costs (while improving health outcomes), Aledade and its investors are making a gamble.
In its first year of operation, for instance, Aledade managed to cut many costly procedures, yet its savings did not meet Medicare’s benchmark — meaning it realized virtually no revenue from the savings program.
The results for its second year are due in October. This time, because Aledade said its savings grow over time, the company is likely to begin making money. “We’re very confident in our model,” Dr. Mostashari said.

Republicans organize to raise concerns about Medicaid expansion in Maine

by Scott Thistle - Portland Press Herald - August 21, 2017

AUGUSTA — Several Republican lawmakers are expected to announce their concerns Tuesday about expanding Medicaid, a first step toward what could become a formal campaign to oppose the question voters will face on the Nov. 7 ballot.
Rick Bennett of Oxford, a former Maine Senate president and former chairman of the Maine Republican Party, will join three sitting Republican lawmakers at an 11 a.m. State House news conference to make an announcement of “importance to Maine taxpayers, senior citizens and families,” said Brent Littlefield, a Washington-D.C.-based political consultant who also advises Gov. Paul LePage and Maine’s 2nd District U.S. Rep Bruce Poliquin.
The news conference is not meant to be a kickoff event for a campaign opposing Question 2, which would expand Medicaid in Maine under the federal Affordable Care Act, also known as Obamacare, Littlefield said.
“It’s going to be much more specific than that,” he said. But he noted that a campaign may follow.
Joining Bennett at the news conference will be Reps. Heather Sirocki, R-Scarborough; Paula Sutton, R-Warren; and Stephanie Hawke, R-Boothbay Harbor.
Maine Equal Justice Partners, a progressive advocacy group for low-income people, gathered more than 67,000 signatures of registered Maine voters to put the Medicaid expansion question on the Nov. 7 ballot. The proposal would expand Medicaid coverage to adults under 65 who earn below $16,000 for a single person and $22,000 for a family of two.
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Currently, 19- and 20-year-olds, individuals with disabilities, the elderly and certain low-income parents qualify for Medicaid, which operates as MaineCare.
David Farmer, a spokesman for the expansion campaign, has said it will “reduce the number of people without health insurance, it will create jobs.”
The federal Centers for Disease Control and Prevention has called Maine’s uninsured rate of 8.8 percent in 2015 an all-time low, but Maine Hospital Association President Steven Michaud has said state eligibility rules cut MaineCare enrollment by 75,000 people in recent years, according to The Associated Press.
Michaud said that move shifted costs to Maine hospitals, which are providing about $250 million a year in charity care while Medicaid payments to hospitals are decreasing.
Expanding Medicaid is estimated to cost Maine $54 million each year once it is fully implemented, according to the ballot question’s fiscal note.
That figure includes $27 million in estimated savings and the cost of 103 new state positions to administer the expansion. The federal government would chip in $525 million each year, and lawmakers would have to appropriate the $54 million if the ballot question passes.
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But Republican opponents to the expansion, including Gov. Paul LePage, have said the expansion, even with the matching federal funds, would decimate the state budget and cause the Legislature to increase state tax rates to cover the shortfalls.
LePage has repeatedly told radio talk show hosts the expansion would set the state’s fiscal house in disarray for decades to come. Also in question is whether the Affordable Care Act will remain in place under President Trump and a Republican-controlled Congress, where both lawmakers and Trump have promised to repeal and replace the landmark law, which is considered a key accomplishment of former President Obama.
The ACA provides federally matching Medicaid funds for states that expand the health insurance program for the nation’s poorest citizens, and while the repeal effort has yet to succeed, the issue remains a top concern for lawmakers in Washington. Under the ACA, states that expand Medicaid would see a gradual tapering of the federal reimbursement rate to a low of 90 percent of a state’s expansion costs in 2020