Health Care Reform Articles - September 19, 2017

Republicans Demand Another Vote to Repeal the Affordable Care Act

by Robert Pear - NYT - September 18, 2017

WASHINGTON — Just when the effort to repeal the Affordable Care Act appeared to be dead, a last-ditch push to dismantle the law could be nearing a showdown vote in the Senate, and a handful of Republicans insist they are closing in on the votes.

The effort received a jolt of energy on Monday when Gov. Doug Ducey of Arizona, a Republican, strongly endorsed the latest repeal bill. That put pressure on Senator John McCain, Republican of Arizona, who cast the deciding vote in July that seemed to stop the repeal movement, but who has said he would seriously consider the views of his governor.

The leaders of the latest repeal effort, Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, say their drive is gaining momentum. But it is still a long shot. Under their bill, millions could lose coverage, Medicaid would see the same magnitude of cuts that earlier repeal bills extracted, and insurers in some states could charge higher premiums to people with pre-existing conditions.

Already, Senator Rand Paul, Republican of Kentucky, has said he will not vote for the measure because it leaves too much of the Affordable Care Act in place.

And Mr. McCain expressed misgivings that the Senate would try again to pass a bill that had not been examined by committees with expertise — and with no Democratic support.

“Why did Obamacare fail? Obamacare was rammed through with Democrats’ votes only,” he said on CBS’s “Face the Nation” on Sunday. “That’s not the way to do it. We’ve got to go back. If I could just say again, the way to do this is have a bill, put it through committee.”

Senators Susan Collins of Maine and Lisa Murkowski of Alaska, Republicans who steadfastly opposed previous repeal efforts, have not said where they stand. But the new bill holds the same provisions that they opposed this summer: deep cuts to Medicaid and a temporary elimination of federal funding to Planned Parenthood.

Mr. Graham and Mr. Cassidy express a sense of urgency. If the Senate does not vote by the end of next week, it will become nearly impossible to repeal the law because the drive to kill the Affordable Care Act will lose the procedural protections that allow it to pass the Senate with a simple majority, rather than the 60 votes that would otherwise be needed.

In a Twitter post on Monday, Governor Ducey of Arizona said: “Graham-Cassidy is the best path forward to repeal and replace Obamacare. I will continue to work with the Congress and the administration to give states more flexibility and more options moving forward. Congress has 12 days to say ‘yes’ to Graham-Cassidy. It’s time for them to get the job done.”

Mr. Graham welcomed the governor’s support, saying Mr. Ducey and his team were “providing the conservative leadership that will get us over the top.”

The House passed a repeal bill in early May, by a vote of 217-213. But the seven-year Republican push to undo President Barack Obama’s signature health care law appeared to reach a dead end in July, when multiple versions of repeal legislation failed to gain even a simple majority in the Senate.

Refusing to accept defeat, Mr. Graham and Mr. Cassidy have come up with yet another bill. The Senate majority leader, Mitch McConnell of Kentucky, has told them he will find time for it on the Senate floor if they can muster 50 votes, which would ensure passage with Vice President Mike Pence on hand to break a tie.

Mr. McConnell is pressing the Congressional Budget Office for a quick analysis of the Graham-Cassidy bill.

But on Monday the Democratic leaders, Senator Chuck Schumer of New York and Representative Nancy Pelosi of California, asked the budget office for detailed answers to these questions: “How many people will lose health insurance under the Graham-Cassidy bill? How much will premiums and out-of-pocket health costs increase, particularly for older Americans? How much will Medicaid be cut?” And how would the bill affect people with pre-existing conditions and the stability of insurance marketplaces?

The Graham-Cassidy bill has two major elements, one that is new and one that was found in many other Republican repeal bills this year.

The new element is a block grant. Mr. Graham and Mr. Cassidy would give each state a fixed amount of federal money for health care and health insurance each year from 2020 to 2026. The allotments total $1.2 trillion over the seven years. That is slightly less than what the federal government is expected to spend under the Affordable Care Act on the expansion of Medicaid, on premium tax credits and on subsidies to reimburse insurers for reducing the out-of-pocket costs of low-income consumers.

States would have sweeping new discretion over how to use the money, and they could receive federal block grant funds without putting up state money.

In addition, the Graham-Cassidy bill would make deep cuts in Medicaid. It would end the expansion of eligibility under the Affordable Care Act, which has extended coverage to 13 million people. And it would put the entire program, which serves more than 70 million people, on a budget, ending the open-ended entitlement that now exists. States would receive a per-beneficiary allotment of federal money.

The Congressional Budget Office has estimated that 15 million fewer people would have Medicaid as a result of similar proposals in other Republican bills. It is not clear when the budget office will issue a report on the Graham-Cassidy bill, showing its effects on federal spending and the number of people without insurance.

Mr. Graham and Mr. Cassidy would distribute federal block grant funds to the states using a complex formula that, like any such formula, creates winners and losers. It is difficult for any state to be sure how much it would receive. The authors of the bill say they intend to reduce expected federal payments to high-cost states like Massachusetts and increase federal payments to states that have not expanded Medicaid.

“Right now, 37 percent of the revenue from the Affordable Care Act goes to Americans in four states” — California, New York, Massachusetts and Maryland, Mr. Cassidy said. “That is frankly not fair.”

With the proposed block grant, Mr. Cassidy said, “we equalize how much each American receives toward her care, irrespective of where she lives.” By 2026, the per-beneficiary amount for each state would be within 10 percent of the national average.

Mr. Graham and Mr. Cassidy said that their bill would also enhance the ability of states to waive “Obamacare regulations.” Insurers would still have to offer insurance to anyone who applied, but states could obtain federal waivers allowing insurers to charge higher premiums to sick people or to omit some of the benefits they are now required to provide, like maternity care, mental health care or treatment for drug addiction.

Coverage, while theoretically available, could become unaffordable for some people with costly conditions like cancer or AIDS, health policy experts say. “Less-healthy people would face extremely high premiums” in states that obtained waivers involving both benefits and premiums, the Congressional Budget Office said in analyzing a similar provision of the bill passed by the House.

Mr. Cassidy played down that concern. Under the Graham-Cassidy bill, he noted, a state seeking a waiver would have to describe how it intends to “maintain access to adequate and affordable health insurance coverage for individuals with pre-existing conditions.”

But critics have taken notice. Sixteen groups representing patients and heath care providers came out Monday in opposition to the bill. Among those who issued a joint statement opposing it were the American Heart Association, the American Diabetes Association, the March of Dimes and the lobbying arm of the American Cancer Society.

“Much of the proposal just repackages the problematic provisions of the Better Care Reconciliation Act,” which the Senate rejected in July, the groups said.

Aides to Senator Collins said she was concerned about cuts to Medicaid and protections for people with pre-existing conditions under the Graham-Cassidy bill.

The Cassidy-Graham bill would eliminate the requirement for most Americans to have health insurance and for larger employers to offer it to employees. Like prior Republicans bills, it would also cut off federal funds for Planned Parenthood for a year.

The House is unlikely to accept the bill in its current form. Some Republicans from states that lose money under the block grant could balk. But passage of the bill in the Senate could lead to negotiations with the House, reviving prospects for repeal of the Affordable Care Act.

The block grant would be established under a part of the Social Security Act that provides money to states for the Children’s Health Insurance Program, but it would dwarf that program. Republicans said they took that approach because the child health program serves a low-income population, is popular with governors and provides states with a high degree of flexibility.

https://www.nytimes.com/2017/09/18/us/politics/obamacare-repeal-vote.html?

The Latest Health Care Repeal Plan Would Give States Sweeping Discretion

by Haeyoun Park and Margot Sanger-Katz - NYT - September 18, 2017

In a new Republican effort to repeal the Affordable Care Act, Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana have released a plan that would essentially allow states to come up with their own health care plans using a federal block grant.

The grant money would replace federal dollars currently being spent on Medicaid expansion and on subsidies to help people afford insurance under the health law, also known as Obamacare. All of this funding would expire in 2027.

Like earlier Republican health care overhaul bills, the new bill would also make permanent, structural changes to the Medicaid program for beneficiaries who qualified before the expansion, converting it from an open-ended federal health care program to one that caps federal spending on each beneficiary.

How the bill would alter major parts of Obamacare

Repeal	Change	Keep
Medicaid expansion	Taxes created under Obamacare	Dependent coverage until 26
Subsidies for out-of-pocket costs	Essential health benefits
Tax credits for premiums	Prohibitions on annual and lifetime limits
Individual mandate	Pre-existing conditions policy
Employer mandate	Restrictions on charging more for older Americans
	Health savings account

Repeal

Medicaid expansion

OBAMACARE Changed Medicaid’s eligibility requirements to allow more people to enroll if a state chose to expand the program. The federal government pays at least 90 percent of the costs for newly eligible beneficiaries.

SENATE BILL The Cassidy-Graham bill would repeal Medicaid expansion. And instead it would create a big block of money for health coverage that states could use as they saw fit. The money would be used for residents who are currently eligible for the Medicaid expansion or the Affordable Care Act markets.

Money would be redistributed among states, using a complex formula, and the funding would expire entirely in 2027. Over all, states that expanded Medicaid would receive less money than they would under the Affordable Care Act.

Repeal

Subsidies for out-of-pocket costs

OBAMACARE Provides subsidies to help people with lower incomes pay for out-of-pocket costs like deductibles and co-payments.

SENATE BILL Would repeal the subsidies in 2020. States could use money from their block grants to lower cost-sharing for low-income beneficiaries, but they would not be required to do so.

Repeal

Tax credits for premiums

OBAMACARE Gives tax credits to middle-income Americans to offset the cost of premiums, based on their income and the cost of insurance in their area.

SENATE BILL Would repeal premium tax credits in 2020. But states could use the new block grant money to create their own subsidy programs.

Change

Taxes created under the Affordable Care Act

OBAMACARE Imposed new taxes to help pay for expanding coverage to more people. They include taxes on investment income, wages above $200,000, medical devices, prescription drugs and indoor tanning.

SENATE BILL The measure would repeal the tax on medical devices but leave most other Obamacare taxes in place.

Change

Essential health benefits

OBAMACARE Requires all insurers to offer 10 categories of essential health benefits, like maternity treatment and hospital care.

SENATE BILL States would be allowed to obtain waivers to eliminate the essential health benefits.

Change

Prohibitions on annual
and lifetime limits

OBAMACARE Bars insurers from setting a limit on how much they have to pay to cover someone.

SENATE BILLThe provision would not technically be repealed. But the caps would be less meaningful in states that pursued waivers and did not choose to guarantee coverage for essential health benefits. That’s because the annual and lifetime limits and essential health benefits are interrelated.

Change

Pre-existing conditions

OBAMACARE Requires insurers to cover people regardless of pre-existing medical conditions and bars them from setting prices based on a person’s health history.

SENATE BILL The requirement that insurers must cover people with pre-existing conditions would not be eliminated everywhere, but states would be able to obtain waivers to charge different premiums based on health status. Such waivers would effectively eliminate Obamacare’s protections, since people with prior health problems could be priced out of the market.

Change

Restrictions on charging more for older Americans

OBAMACARE Bans insurers that sell policies directly to individuals from charging their oldest customers more than three times what they charge their youngest ones.

SENATE BILL While it would not eliminate the restriction, the bill would allow states to obtain waivers that let insurers charge different premiums based on age.

Repeal

Individual mandate

OBAMACARE Requires all Americans to buy health insurance or pay a tax penalty, with exceptions for people who have experienced hardships.

SENATE BILL Would eliminate the penalties retroactive to 2016.

Repeal

Employer mandate

OBAMACARE Requires larger companies to provide affordable insurance to their employees, or face financial penalties.

SENATE BILL Eliminates the penalties retroactive to 2016.

Change

Health savings account

OBAMACARE In 2017, allows an individual to put $3,400 and a family to put $6,750 into a tax-free health savings account.

SENATE BILL The bill would increase the amounts people could put into their health savings accounts. It would also allow people to use health savings account money to pay insurance premiums, a change from current law.

Keep

Dependent coverage until 26

OBAMACARE Allows children to stay on their parents’ insurance policies until age 26.

SENATE BILL The provision would stay.

https://www.nytimes.com/interactive/2017/09/18/us/cassidy-graham-health-plan-aca-repeal.html?_r=0

The Republican Health Care Zombie Is Back

by The Editorial Board - NYT - September 19, 2017

Republican lawmakers have wasted much of the year trying to repeal the Affordable Care Act, a move that would deprive millions of people of health insurance. They’re back at it. Like a bad sequel to a terrible movie, a proposal whose main architects are Bill Cassidy of Louisiana and Lindsey Graham of South Carolina would in many ways be worse than bills that came before. It would punish states like California and New York that have done the most to increase access to health care and set in motion cuts to Medicaid, the federal-state program that provides insurance to nearly 70 million people, many of whom are disabled and elderly.

This is not an idle threat. President Trump wants this bill passed by the end of next week, before the expiration of a budget rule that allows the chamber to pass a health care bill with only 50 votes (and a tiebreaker from the vice president). It’s unclear whether the votes are there, but the bill’s chances increased on Monday when Gov. Doug Ducey of Arizona said he supported it. His endorsement is important because it could convince Senator John McCain, who cast the decisive vote against repealing the A.C.A. in July, to vote for this version.

It is hard to overstate the cruelty of the Graham-Cassidy bill. It would eliminate the mandate that even healthy people buy health insurance, end the subsidies that help people purchase coverage and stop the expansion of Medicaid. It would offer states block grants they could use to help people get insurance but would leave people at the mercy of individual state legislatures and, over all, would provide $239 billion less than what the federal government would spend under current law between 2020 and 2026, according to the Center on Budget and Policy Priorities.

Worse, the formula for determining state grants would penalize the 31 states that expanded Medicaid under the A.C.A. so as to provide more money to the 19 states that did not. This is a cynical attempt to win votes by taking money from generous states that are more likely to be governed by Democrats and giving some of it to representatives of stingier states that are more likely to elect Republicans. The block grants would disappear entirely in 2027, and it is by no means certain, given the pitched partisan battles over health care in recent years, that Congress would be inclined to reauthorize them.

Graham-Cassidy would further cripple Medicaid by putting a per-person cap on what the federal government spends on the program. Under current law, federal spending increases automatically to keep up with the rise in medical costs; a per-capita cap would leave governors, who are ultimately in charge of administering Medicaid, in the unenviable position of denying care to poor and older Americans.

The rush job proposed by Mr. Cassidy and Mr. Graham and endorsed by the president is deeply unfair and leaves other lawmakers with little time to understand what’s in the bill or its true costs. The Congressional Budget Office says it will not be able to determine the full impact of the legislation, including its effect on premiums and the number of people who have insurance, for several weeks.

The Senate should show a little patience; a better, more humane option awaits it. Senators Lamar Alexander, Republican of Tennessee, and Patty Murray, Democrat of Washington, are working on a bill that would strengthen the A.C.A. by appropriating money for health subsidies that help low-income families; Mr. Trump has threatened to end those payments administratively. Mr. Alexander and Ms. Murray expect to produce their legislation this week.

https://www.nytimes.com/2017/09/19/opinion/editorials/republican-healthcare-graham-cassidy.html?

The 3 Americans Who Should Pay for Medicare-for-All

by Paul Buchheit - Common Dreams - September 18, 2017

Universal health care is getting closer to reality at the state level, in California. The Political Economy Research Institute (PERI) has analyzed a proposal for a statewide single-payer health care system that would reduce current costs by at least 8 percent. It would be funded in two ways: (1) a continuation of Medicare and MediCal; and (2) gross receipts and sales taxes, both at 2.3 percent, with exemptions for small businesses, low-income residents, and purchases of basic necessities. Unfortunately, California has postponed the plan, at least until January, 2018. 

At the national level, Bernie Sanders' single-payer plan is forecasted to save $6 trillion over 10 years. It could be funded in part by the elimination of special treatment for capital gains, payroll taxes, and multi-million dollar estates. While anticipating inevitable resistance from monied interests, it can nevertheless be accurately demonstrated that three Americans—or, rather, groups of Americans—have received the most benefits from years of national productivity, and should provide most of the initial funding. 

1. The Main Beneficiary of America's $31 Trillion Wealth Gain since the Recession 

The 57 percent increase in U.S. wealth since the recession (from $54 to $85 trillion) was driven mainly by stocks and other financial investments. Most of this wealth is untaxed, deferred until a capital gain is realized. But it represents a return on U.S. productivity that has overwhelmingly benefited the nation's richest 10%—especially the highest tiers of that 10%: in 2016, the 1% gained nearly $4 trillion while everyone else lost wealth. 

Taxing the nation's total financial wealth at 1 percent would bring in 2/3 of a trillion dollars. For the average member of the 1% with a net worth of $14,000,000, this is 1 percent of a portfolio that has grown at an 8 percent annual rate since the recession. 

2. The Recipient of Tax Subsidies that Exceed the Entire Safety Net 

The entire 2017 safety net is about $850 billion, compared to over $1.5 trillion for tax subsidies. A recent analysis found that:

• The Poorest 20% of U.S. Households Get up to $3,000 Each in Tax Subsidies 
• The Richest 20% of U.S. Households Get at least $18,000 Each in Tax Subsidies 
• The Richest 1% of U.S. Households Get over $120,000 Each in Tax Subsidies 

The Congressional Budget Office itemizes the ten main tax expenditures, including mortgage interest, capital gains, employer health insurance, pension deductions, and state and local tax breaks. In addition, there's a mortgage interest deduction for second homes, which can even be a YACHT; up to a half-million dollars tax-free when a couple sells their home; over $10 million TAX-FREE when a couple's estate is passed on to heirs; deductions on rental properties for landlords, who are unlikely to be low-income people; the $127,200 limit on Social Security taxes, which benefits only the richest 10% of Americans; and higher education financial aid, especially from the prestigious universities that admit more students from families in the top 1% than the entire bottom 50%. 

One good reason for wealthier Americans to support a better health care system: as the longevity of higher-earning Americans increases relative to low-income Americans, wealthy households benefit more and more from Medicare. A Brookings report estimates that lowest-quintile Americans born in 1960 will receive "only 78 percent of the lifetime Medicare benefits received by the top income quintile." 

3. The Investor Who Pays ZERO Sales Tax on a Million-Dollar Sale 

Illinois is mired in $15 billion of debt while the traders on LaSalle Street, who generate billions of dollars in profit from Chicago's technology and infrastructure and legal system, and who trade with a company that made a quadrillion (1,000 trillion) dollars in sales last year and kept a greater percentage of profit than any of the largest corporations in America, don't have to pay a penny of sales tax. 

To help subsidize the traders, Illinois residents pay the 2nd-highest property taxes in the nation, and Chicago parents pay a 10 percent sales tax on school supplies for the kids. 

A tiny financial transaction tax (FTT) of perhaps a tenth of a percent on the trading of financial securities could generate billions of dollars of revenue. Collecting many of the taxes in Illinois would be the Chicago Mercantile Exchange (CME), which handles a volume of trades worth many times the world economy, while profiting from transfer fees, contract fees, brokerage fees, Globex fees, clearing fees, and surcharges. Yet there are no sales taxes. 

Will the Super-Rich Support American Health? 

Not likely, one might think. But the financial speculation tax works in some of the most prosperous nations in the world; many tax subsidies are indefensible, even by the recipients; and available records on financial holdings make a 1 percent wealth tax feasible. We must do something to keep Americans alive.

https://www.commondreams.org/views/2017/09/18/3-americans-who-should-pay-medicare-all

Canadian Doctor to U.S.: Try Single-Payer Health Care Instead Of Trashing It

by Danielle Martin - Common Dreams - September 18, 2017

There’s a joke we sometimes tell in Canada: What’s a Canadian? An apologetic American with health care.

It’s funny because we half-believe it’s true. The United States and Canada are about as similar as two countries get. But Canada has had a publicly funded, single-payer health care system in each of our provinces and territories since the 1960s. It works. Maybe it can work for you too.

I was in the room on Capitol Hill last week when Sen. Bernie Sanders, I-Vt., introduced new legislation that would seek to enact a single-payer health care systemin the U.S. If Sanders’ bill moves forward, all Americans would have access to Medicare, regardless of their age or financial situation. Is it that simple? In some ways, yes.

In Canada, the notion that access to health care should be based on need, not ability to pay, is a deeply ingrained value that crosses party lines right and left, and is a source of collective pride. The single-payer, publicly funded health care systems in Canada cover virtually every resident of our country, at a much lower cost than the U.S. model.

There are plenty of nasty rumors in the American media about the quality of health care in Canada. In fact, Canadians live longer than Americans, and according to a recent study published in The Lancet, the Canadian system outperforms the U.S.on quality and access to care overall. 

As a practicing physician and a hospital administrator in Canada, I see the cracks in our system just as American doctors see the cracks in yours. It’s true that sometimes Canadians wait too long for non-urgent or elective investigations or procedures. That is why across Canada, governments, health care providers and citizen groups are working hard to improve access for procedures like hip replacements, cataract surgery or non-urgent advanced imaging. But we don’t believe that the solution lies in dismantling universal health care and creating a system where some cannot afford the care they need.

Most importantly, Canadians don’t wait for urgently-needed care. When Canadians get sick they get the care they need, and the care they get is good. When my patients need to see a doctor, they don’t have to worry about paying for the visit. And when they are admitted to the hospital, they don’t see a bill.

Is it true that Canadians get health care in the United States? Occasionally. When it happens, it’s often because our senior Snowbirds happen to fall ill while they are enjoying your better winter weather in Florida or Hawaii. More rarely — so rare that it’s hard to accurately measure — people do travel by choice just to buy immediate care.

Of course, Americans travel for health care too, sometimes because they can’t afford it at home. The U.S. Centers for Disease Control and Prevention has estimated that about 750,000 U.S. patients travel abroad each year for medical treatment. That’s a larger proportion of the U.S. population than even the highest estimates of Canadians seeking treatment abroad. 

Single-payer health care is also much less administratively onerous and expensive. The billing office in the clinic where I work serves more than 40 primary care doctors, and employs only two billing clerks — because billing is so simple. Every month my practice sends one bill to the public insurance plan, and every month we get paid on time. 

Compare that to the multiplicity of private insurance plans my American colleagues deal with. The costs of administering this system are much lower — in Canada overhead is less than 2% in public plans, compared to the 18% spent by private insurance firms in the U.S. Overall, health care spending in Canada accounts for 10% of our GDP, compared to 17% in the U.S. Per capita we spent about $4,644 in U.S. dollars in 2016, compared to $9,892 in the U.S. Yet more than 1 in 10 Americans are uninsured.

Like all industrialized countries, Canada needs to meet the challenges of an aging population while contending with rising costs, advances in technology, and an imperative to keep people longer in their homes. No nation has figured out the magic formula: There is much we need to do to improve our system, and even where we know our outcomes are good, it isn’t very Canadian to be boastful.

But Canadians, along with others all over the world, will be watching as the conversation around single-payer health care continues to unfold in the U.S. As we have long ago discovered, everyone should have equal access to health care when they need it — it is a basic human right.

https://www.commondreams.org/views/2017/09/18/canadian-doctor-us-try-single-payer-health-care-instead-trashing-it

The Sanders Single-Payer Plan Is No Miracle Cure

by Lanhee J. Chen and Micah Weinberg - NYT - September 19, 2017

Last week, Senator Bernie Sanders introduced “Medicare for all” legislation, which would enroll all Americans into the nation’s Medicare program within four years. Senator Sanders, the Vermont independent, argues that his proposal would create a system that “works not just for millionaires and billionaires, but for all of us.”

Elizabeth Warren of Massachusetts, Kamala Harris of California and over a dozen of their Senate Democratic colleagues have co-sponsored the legislation. Representative John Conyers, Democrat of Michigan, and state lawmakers in California have also proposed “single payer” health plans.

Though we have widely divergent views on health policy — one of us preferring a German-style system (Dr. Weinberg), the other a more consumer-directed one (Dr. Chen) — we both believe that single-payer health care, including the proposal advanced by Senator Sanders, is the wrong choice for the country.

We recently conducted an analysis of international health systems and concluded that single-payer advocates are substantially overstating the prevalence and success of such systems. While many other countries have universal health systems and feature more government control over individual health care decisions, almost none are actually single-payer. And all of them are wrestling with largely the same challenges Americans are, making different but equally difficult trade-offs on cost, quality and access.

As Democrats and other policy makers debate the merits of Senator Sanders’s proposal, here are a few important observations about international systems that they ought to consider.

First, a vanishingly small number of countries actually have single-payer systems. In fact, almost all feature some role for private-sector insurance companies and providers. Britain, which employs providers in its National Health Services, has a parallel private payment system. In countries like Canada — the system most similar to the one that Mr. Sanders seeks to create — private corporations provide insurance for services that fall outside of government guarantees. And these guaranteed benefits are substantially more limited than those in the Sanders proposal. Canada, for example, has no national prescription drug benefit but instead a patchwork of provincial systems.

Some of the highest-rated international systems rely on private health insurers for most health care coverage — Germany’s, for example, is something like Obamacare exchanges for everyone, but significantly simpler and truly universal. The Netherlands and Switzerland have both moved recently to add more competition and flexibility to systems that were already built on the use of private insurers.

Second, single-payer countries have also failed to control rising health care costs. This is important, given that Mr. Sanders’s proposal was released without a cost estimate or financing plan. For historical reasons, many other countries started with lower levels of health care spending than we did. Several analyses have shown that this has almost nothing to do with higher administrative costs or corporate profits in the United States and almost everything to do with the higher cost of health care services and the higher salaries of providers here.

Although they started at a lower base — with, for example, doctors and nurses receiving lower salaries — countries around the world have all struggled with rising costs. From 1990 to 2012, the United States’ rate of health care cost growth was below that of many countries, including Japan and Britain. In 2015, the Organization for Economic Cooperation and Development warned that rising health care costs across all countries were unsustainable.

Third, it is simply untrue that single-payer systems produce a better quality of care across the board. Most health-policy lectures in American universities start with a slide showing that we rank poorly on a broad number of public health measures and outcomes. Yet the United States scores much more highly on different measures, including innovation, patient-centered care and preventive health.

Specialty care is better in many categories, although more needs to be done to create broader access to these services. The American health system excels, for example, in cancer care. And while we spend more on it than any other country, we find ourselves at the top of most international rankings in reducing the death rate of patients with preventable cancer deaths, as a product of this spending.

In truth, all systems make trade-offs when it comes to allocating health care resources, and they all largely get what they pay for. To the extent that other countries achieve better public health outcomes, they do it primarily through more generous, rather than more efficient, social spending. When you add together health and social spending across countries, the United States is no longer a major outlier when it comes to per capita costs spent on factors that promote health.

American policy makers can and should look abroad for examples of reforms that work. For example, many other countries have encouraged smarter public and private investments into factors that promote health and wellness, like stable housing and employment opportunities, rather than spending more overall on health care once people are sick.

But just as trade-offs must be made to improve health care, so are other countries struggling with balancing the cost and quality of care and universal access. All Americans should bear one important precept in mind: If the Sanders plan sounds too good to be true, it probably is.

https://www.nytimes.com/2017/09/19/opinion/sanders-health-care-medicare.html?

One Reason to Take the Latest Obamacare Repeal Seriously, and Three Reasons It Could Fail

by Margot Sanger-Katz - NYT - September 19, 2017

How seriously should Americans take the Republicans’ last-ditch effort to repeal and replace the Affordable Care Act?

The party has until the end of the month to repeal the health law without needing 60 Senate votes. That’s why the latest proposal, by Senators Bill Cassidy of Louisiana and Lindsey Graham of South Carolina, is getting so much attention.

Their bill would eliminate the two big coverage programs created by Obamacare, and instead give blocks of money to state governments, with few limitations on how they can distribute them to provide health coverage to their residents. States would be free to eliminate Obamacare rules requiring that insurance cover a minimum package of benefits, and they could charge sick customers more than healthy customers.

It would also make major changes to Medicaid, reducing federal funding even for populations that were covered before Obamacare. The results would most likely be substantial reductions in the number of Americans with health coverage, and new challenges for Americans with pre-existing health conditions in some states.

There are elements of the bill that are likely to attract support from Republican lawmakers, and from some Republican governors. The policy is in line with many Republican lawmakers’ views that states are better able to manage their health programs than the federal government.

But the bill faces substantial challenges, both political and procedural. Here are three reasons the effort may not succeed — and one very important reason it might.

1) Rand Paul is a hard no, which makes the math difficult.

Senator Rand Paul of Kentucky has been making a big point of how he dislikes this bill and won’t vote for it. He said so in a series of tweets on Monday. Then he held a news conference, saying he was immovable.

Without his vote, Senate leadership can afford to lose only one more. Senator John McCain of Arizona has offered mixed messages on the bill, and suggested on Monday that he was not yet endorsing the bill but might eventually.

So far, Senator Lisa Murkowski of Alaska and Senator Susan Collins of Maine have voted against every previous repeal attempt. They even voted against opening debate on the process that permitted consideration of the Graham-Cassidy option. If Mr. Paul holds firm, one of those two will need to change her mind.

It’s possible that Mr. Paul will switch sides, but he’s made it hard for himself to do so. Ms. Murkowski and Ms. Collins have said nothing about their intentions. But both raised objections about cuts to Medicaid in the earlier bill, and the new bill contains similar reductions. The bill’s funding formula also appears to be unkind to both Alaska and Maine.

2) There’s a huge redistribution of money between states in the bill’s formula. Losers include states with must-get senators.

The legislation sets up a complex formula for who gets what chunk of federal health care spending. The formula is devised to “equalize” spending among states. Currently, some states spend much more on Medicaid and the exchanges than others, either because they cover more people or because their systems are more generous or expensive. That redistribution of money means that some states would come out as big winners, but others would absorb big reductions.

Mr. Cassidy has pointed out that more than a third of Affordable Care Act spending goes to four states: California, New York, Massachusetts and Maryland. That’s roughly true. These are populous states that expanded their Medicaid programs and tend to have costly health care systems.

But it’s not just big, blue states that would lose out. According to estimates from the Center on Budget and Policy Priorities, a left-leaning think tank, Alaska, Arizona, Kentucky, Ohio and West Virginia, for example, would end up with less money by the end of a decade.

Those states all contain Republican senators who have expressed some unease with earlier versions of Obamacare repeal, and they might wish to keep the bill off the floor to avoid a tough vote that would pit their broad political commitments to repeal against the more parochial concerns of their constituents. (Similar concerns might also crop up in the House, where a final vote would eventually need to be held.)

Over the long term, every state would lose money under the proposal. The big block grants would expire altogether in 2027.

3) The timing is tight, and the bill still has a long way to go, leaving little room for error.

Republicans are trying to pass the bill using a special budget procedure called reconciliation. That process allows them to pass the bill without needing any Democratic support, but it comes with a number of rules.

Under the reconciliation process, the bill requires an estimate of costs from the Congressional Budget Office. The office indicated that it would offer an initial assessment by “early next week,” but could not provide detailed estimates about what would happen to insurance coverage or premiums for several weeks. The score could discourage some senators from supporting the bill; an incomplete assessment might discourage others.

The bill will also need to be reviewed by the Senate’s parliamentarian to ensure that its provisions adhere to rules for the budget process. Some provisions, including restrictions on funding for abortion providers and the new option of work requirements for Medicaid beneficiaries, could run afoul of the rules and be scrubbed out in the “Byrd Bath.”

Any funding formula changes made to the bill to please reluctant senators could slow down the works.

The parliamentarian has said that the Senate process needs to be wrapped up by the end of the month. That means that the bill needs a score, a Byrd Bath rules review and a vote in the Senate by the end of Saturday, Sept. 30. Then the legislation would need to go back to the House, where, after midnight of that day, it could not be changed again, only voted up or down.

1. But Obamacare repeal is a core promise for Republicans.

Republicans have been running on a promise to repeal Obamacare since 2010, and this bill appears to be their last chance to achieve that goal in the foreseeable future. Though they could initiate a new budget process to try again with health care, the president and congressional leadership want to use the process instead to pass tax reform.

Many members of Congress (and their staffs) are weary of the recent health care fight, which has been bruising and has yielded little political upside. But even for lawmakers with doubts about this particular piece of legislation, the prospect of a win on an issue dear to their base — not to mention getting President Trump to stop jeering that they are “wasting time” and “couldn’t get it done” — could be a powerful motivating force.

https://www.nytimes.com/2017/09/19/upshot/one-reason-to-take-the-latest-obamacare-repeal-seriously-and-three-reasons-it-could-fail.html?

Letter to the editor: Bernie Sanders ran on his beliefs, not to undercut Democrats

by Nancy O'Kane - Portland Press Herald - September 19, 2017

In Hillary Clinton’s new book, she attempts to disparage Bernie Sanders by stating that he “didn’t get into the race to make sure a Democrat won the White House.” She’s correct.

Nor, however, did Bernie run “to disrupt the Democratic Party,” as Hillary accuses him of doing. He ran for what he believes would help the American people. Period. That’s why he was, and still is, so popular and trusted. He puts the well-being of the American people before politics or big-money donors – and always has.

His current Medicare for All plan is a perfect example of this. If that is at odds with the Democratic establishment, so be it. But such integrity is priceless. It is to be cherished, not admonished.

Nancy Bennett O’Hagan

Portland

http://www.pressherald.com/2017/09/19/letter-to-the-editor-bernie-sanders-ran-on-his-beliefs-not-to-undercut-democrats/