McCain Announces Opposition to Republican Health Bill, Likely Dooming It
by Thomas Kaplan and Robert Pear - NYT - September 22, 2017
WASHINGTON — Senator John McCain of Arizona announced on Friday that he would oppose the latest proposal to repeal the Affordable Care Act, leaving Republican leaders with little hope of succeeding in their last-ditch attempt to dismantle the health law and fulfill their longstanding promise to conservative voters.
For Mr. McCain, it was a slightly less dramatic reprise of his middle-of-the-night thumbs-down that killed the last repeal effort in July. This time, the senator, battling brain cancer and confronting his best friend in the Senate, Lindsey Graham of South Carolina, issued a statement saying that he could not “in good conscience” support the proposal by Senators Graham and Bill Cassidy of Louisiana.
“I believe we could do better working together, Republicans and Democrats, and have not yet really tried,” Mr. McCain said. “Nor could I support it without knowing how much it will cost, how it will affect insurance premiums, and how many people will be helped or hurt by it.”
With two other Republican senators likely to vote no, Mr. McCain’s opposition to the bill could be fatal. With Democrats united in opposition, Senate Republicans can afford to lose only two of their members.
Senator Rand Paul, Republican of Kentucky, has said that he would not vote for the bill because it did not dismantle enough of the Affordable Care Act. And Senator Susan Collins, Republican of Maine, has expressed broad concerns about the legislation, strongly suggesting that she, too, would vote against it, just as she voted no in July along with Mr. McCain and a third Republican senator, Lisa Murkowski of Alaska. Ms. Collins said on Friday that she was “leaning against” the proposal.
For months, Mr. McCain has lamented a Senate legislative process that avoided hearings or formal bill-drafting procedures and excluded Democrats. On Friday, he said those tactics were intolerable.
“We should not be content to pass health care legislation on a party-line basis, as Democrats did when they rammed Obamacare through Congress in 2009,’’ Mr. McCain said. “If we do so, our success could be as short-lived as theirs when the political winds shift, as they regularly do.’’A bill of this magnitude “requires a bipartisan approach,’’ Mr. McCain added.
Those concerns were compounded by the decision of Republican leaders to press forward with a vote next week before the nonpartisan Congressional Budget Office could complete a full analysis of the Graham-Cassidy legislation. The budget office is expected to provide a preliminary fiscal assessment early in the week, but it indicated that it would not be able to complete an analysis of the bill’s effects on health insurance coverage or premiums by Sept. 30.
That date is critical because Republicans, who hold 52 seats in the Senate, have until the end of this month to make use of special budget rules that would allow them to pass a repeal bill in the Senate with only a simple majority, rather than 60 votes. If Republicans could get 50 votes, Vice President Mike Pence would break the tie in their favor.
“Of course, I’m disappointed,” Mr. Cassidy said in an interview, “but that doesn’t mean that I’m going to stop working for those folks who can’t afford their premiums. We are still working. We are still hoping.”
Mr. Graham, mindful of their longstanding relationship, was gracious. “My friendship with John McCain is not based on how he votes,” Mr. Graham said, “but respect for how he’s lived his life and the person he is.”
President Trump, who has promised to scrap President Barack Obama’s signature domestic achievement, said late Friday he would not abandon his goal.
“Maybe we’re going to do it now — it’s a little tougher without McCain’s vote, I’ll be honest,” he said Friday night at a campaign rally for Senator Luther Strange, Republican of Alabama, who is locked in a tough primary runoff for his seat.
“The most we’ll be is one or two votes short,” Mr. Trump said. “You can’t quit when you have one or two votes short. You can’t do it. And those people are not going to be liked by the communities that they come from.”
A spokeswoman for the Senate majority leader, Mitch McConnell of Kentucky, declined to comment on whether he would press forward with a vote.
Democrats have vowed that if the repeal legislation could be killed, they would press to resume bipartisan negotiations on legislation to stabilize health insurance markets under the Affordable Care Act. Republican leaders squelched those talks, led by Senators Lamar Alexander, Republican of Tennessee, and Patty Murray, Democrat of Washington, as they pushed for passage of a full repeal bill.
“John McCain shows the same courage in Congress that he showed when he was a naval aviator,” said Senator Chuck Schumer of New York, the Democratic leader. “I have assured Senator McCain that as soon as repeal is off the table, we Democrats are intent on resuming the bipartisan process.”
If the bill dies at the hands of Senators McCain, Paul and Collins, it would be another blow to Mr. Trump, who has tried to pressure Republicans to fall in line.
It would also be another setback for a party that now controls the White House and both houses of Congress, but has not been able to produce any major legislative achievements. Republican lawmakers have promised for seven years to repeal and replace the Affordable Care Act, but they have found that verbally assailing the health law is far easier than actually undoing it, even with a president who shares their goal.
“It’s a loss for Republicans,” said Representative Mark Walker of North Carolina, the chairman of the conservative Republican Study Committee. “I think we’re all going to be held accountable to some degree. What that means in next year’s elections, I don’t know. But this is going to bite for a while.”
The Graham-Cassidy bill would take much of the money provided under the Affordable Care Act and send it to the states, with vast discretion over how to use it for health care or coverage. The bill has been met in the last few days with a torrent of criticism from consumer groups, doctors, hospitals, insurance companies, governors and state Medicaid officials.
Under the bill, states would have more authority over how to use federal funds, but most states — including Arizona — would receive less money under the bill than under the Affordable Care Act, according to studies by the Kaiser Family Foundationand health policy consulting firms.
The bill would also give states the ability to opt out of insurance regulations under the health law. States could seek federal waivers that would allow insurers to charge higher premiums to people with pre-existing medical conditions or to omit certain benefits that they are now required to provide, such as maternity care or mental health care.
Republican leaders will now likely have to change an opponent’s mind, but if anything, more opponents could emerge, with Ms. Murkowski on the top of the list. Alaska’s governor, Bill Walker, an independent, publicly opposes the bill and has joined nine other governors in signing a letter urging the Senate to reject the proposal. In an interview, Mr. Walker said he did not believe any special accommodation could be reached for his state, because the overall structure was so damaging to Alaska. He said he had communicated his concerns extensively to Ms. Murkowski.
“Alaska would fare very, very poorly,” he said. “Nothing has been brought to my attention that would increase my comfort level.”
A spokeswoman for Ms. Murkowski, Karina Petersen, said the senator is studying the matter. “Senator Murkowski is still focused on how the bill will impact Alaska, specifically,” Ms. Petersen said. “She’s continuing to gather data and is looking at the details of the bill to determine what’s best for her state.”
Gov. Doug Ducey of Arizona, a Republican, supports the Graham-Cassidy proposal, and Mr. McCain had made a point of emphasizing that he was keenly interested in the views of his state’s governor when contemplating whether to vote for repeal legislation. But Mr. Ducey’s position was not enough to sway Mr. McCain.
“I take no pleasure in announcing my opposition,” Mr. McCain said. “Far from it. The bill’s authors are my dear friends, and I think the world of them. I know they are acting consistently with their beliefs and sense of what is best for the country. So am I.”
Mr. McCain said that if the repeal attempt failed, he hoped the leaders of the Senate health committee would resume their efforts to devise a short-term bipartisan solution to some of the problems plaguing insurance markets under the Affordable Care Act. Mr. Alexander and Ms. Murray have been working on a bill to stabilize markets by providing money for subsidies paid to insurers so they can reduce out-of-pocket costs for low-income people.
Mr. Alexander, the chairman of the Senate health committee, and Ms. Murray, the top Democrat on the panel, held four hearings in two weeks and were nearing an agreement on legislation. But their efforts were derailed when the White House and Senate Republican leaders pushed hard for a vote on the Graham-Cassidy bill, in the face of opposition from every Democrat in the Senate.
Trump Laces Into McCain Over His Opposition to Health Care Bill
by Julie Hirschfeld Davis - NYT - September 23, 2017
SOMERSET, N.J. — President Trump on Saturday morning lashed out at Senator John McCain of Arizona for breaking with him and opposing Republicans’ latest plan to roll back the Affordable Care Act, saying the senator had let his state down and been deceived by Democrats into abandoning a promise.
In a series of angrily worded tweets sent from his golf resort in Bedminster, N.J., Mr. Trump argued that Mr. McCain, whose announcement on Friday that he would not back the health care measure most likely doomed it, had knowingly misled members of his own party about where he stood on the legislation.
In a separate tweet, Mr. Trump noted the large increases in health care premiums and deductibles experienced in Arizona last year. “Chuck Schumer sold John McCain a bill of goods,” the president said, referring to the New York senator and minority leader, who was opposed to the measure.
The president defended the measure’s approach, which envisions the federal government sending grants to states to administer their own health care systems, and allowing them vast discretion over how to use the money. It would allow them to seek federal waivers to let insurers charge higher premiums to people with pre-existing medical conditions or to omit certain benefits that they are now required to provide, such as maternity care or mental health care.
“Better control & management,” Mr. Trump wrote. “Great for Arizona.”
“McCain let his best friend L.G. down!” the president added, referring to Mr. McCain’s close relationship with Senator Lindsey Graham of South Carolina, one of the bill’s sponsors.
Mr. Trump’s latest weekend Twitter fusillade came the morning after Mr. McCain surprised the president and his top aides by abruptly announcing that he could not “in good conscience” support the health care proposal by Mr. Graham and Senator Bill Cassidy of Louisiana, saying it was a partisan plan whose costs and impacts on the health care of millions of Americans were unknown.
The move by Mr. McCain, whose “no” vote against an earlier iteration of a health care repeal bill killed that effort in July, dealt yet another setback to Mr. Trump’s effort to fulfill his promise to do away with Barack Obama’s signature health care law. Senator Rand Paul, Republican of Kentucky, had already come out in opposition to his party’s last-ditch health care effort, and Senate leaders can afford to lose only three of their members in a chamber that is divided 52 to 48.
Mr. Trump, speaking at a rally in Alabama on Friday night, recalled Mr. McCain’s earlier defection with dismay, imitating the Arizona senator’s thumbs-down gesture to indicate his opposition on the Senate floor, and saying it was “terrible, honestly, terrible” when he cast the deciding “no” vote.
“That was a totally unexpected thing,” Trump said, to boos from the Huntsville crowd.
The president had embraced the legislation in recent days, making telephone calls to wavering senators and dispatching Vice President Mike Pence to Capitol Hill to try to build support for its passage. Mr. McCain’s announcement that he would not vote for it came just hours after the president had warned in a Friday post on Twitter that any Republican who opposed the measure “will forever (future political campaigns) be known as ‘the Republican who saved ObamaCare.’ ”
On Saturday, Mr. Trump appeared to be nurturing hopes that the legislative effort could be kept alive. He expressed hope that Mr. Paul would rethink his opposition to the Graham-Cassidy measure, without explaining why the Kentucky senator, who had complained that the bill left the Affordable Care Act’s essential structure intact, might do so.
Ms. Murkowski was one of three Republican senators who voted against the repeal proposal in July, and she has come under an intense spotlight yet again as Mr. Trump and Republican leaders push for passage of the Graham-Cassidy bill. But while Mr. Trump hopes she will support the bill, the governor of Alaska, Bill Walker, an independent, opposes it and has said he has communicated his concerns to Ms. Murkowski.
A spokeswoman for Ms. Murkowski, Karina Petersen, said early Friday evening that the senator was continuing to study the Graham-Cassidy bill and its projected effects.
“Senator Murkowski is still focused on how the bill will impact Alaska, specifically,” Ms. Petersen said. “She’s continuing to gather data and is looking at the details of the bill to determine what’s best for her state.”
Latest Obamacare Repeal Effort Is Most Far-Reaching
For decades, Republicans have dreamed of taking some of the vast sums the federal government spends on health care entitlements and handing the money over to states to use as they saw best.
Now, in an 11th-hour effort to repeal the Affordable Care Act, the party has come up with a way to repackage the funding for the law it loathes into a trillion-dollar pot of state grants.
The plan is at the core of the bill that Senate Republican leaders have vowed to bring to a vote next week. It was initially seen as a long-shot effort by Senators Lindsey Graham and Bill Cassidy. But for all its ad hoc, last-minute feel, it has evolved into the most far-reaching repeal proposal of all.
It dismantles the Medicaid expansion and the system of subsidies to help people afford insurance. It gives the states the right to waive many of the consumer protections under President Obama’s landmark health law. And it removes the guaranteed safety net that has insured the country’s poorest citizens for more than half a century.
“This is by far the most radical of any of the Republican health care bills that have been debated this year,” said Larry Levitt, a senior vice president with the nonpartisan Kaiser Family Foundation. “And the reason for that is that this would be the biggest devolution of federal money and responsibility to the states for anything, ever.”
The White House and Senate leaders are now in an intensive final push to repeal the Affordable Care Act by September 30. After that, under Senate rules, they will need 60 votes, which they acknowledge is an impossibility. Senator Graham said in a statement on Thursday that the legislation was gaining “momentum and support” because it would send “money and power back to the states, and closer to patients, to deliver quality health care.”
The legislation would turn over more than $1 trillion that would have been spent on the law known as Obamacare over the next seven years — everything from the funds for the expansion of Medicaid to the subsidies to help people buy private insurance — to states as “block grants” with very few strings attached. They would then use the money to set up their own health care programs. Congress would have to reauthorize the money after 2026 or it would go away.
“The decisions about individual mandates, mandated benefits, and all the other decisions the ACA moved to Washington are best made at the state level by governors who understand the unique needs of their states,” said Gov. Asa Hutchinson of Arkansas, a Republican. Arkansas expanded Medicaid under Obamacare, and would lose roughly $6 billion under the bill, but Governor Hutchinson supports the legislation nonetheless.
“Graham-Cassidy is putting federal spending on a budget,” he said. “That is the fiscal discipline the federal government and states both need to ensure the sustainability of Medicaid and other state health care programs.”
Like previous Republican proposals, the bill would also cancel the federal government’s commitment to the open-ended funding of the traditional Medicaid program, capping an entitlement for the poor and disabled that now covers one in five Americans. States could choose to take some of that Medicaid money in a block grant too.
For decades, Republicans have dreamed of taking some of the vast sums the federal government spends on health care entitlements and handing the money over to states to use as they saw best.
Now, in an 11th-hour effort to repeal the Affordable Care Act, the party has come up with a way to repackage the funding for the law it loathes into a trillion-dollar pot of state grants.
The plan is at the core of the bill that Senate Republican leaders have vowed to bring to a vote next week. It was initially seen as a long-shot effort by Senators Lindsey Graham and Bill Cassidy. But for all its ad hoc, last-minute feel, it has evolved into the most far-reaching repeal proposal of all.
It dismantles the Medicaid expansion and the system of subsidies to help people afford insurance. It gives the states the right to waive many of the consumer protections under President Obama’s landmark health law. And it removes the guaranteed safety net that has insured the country’s poorest citizens for more than half a century.
“This is by far the most radical of any of the Republican health care bills that have been debated this year,” said Larry Levitt, a senior vice president with the nonpartisan Kaiser Family Foundation. “And the reason for that is that this would be the biggest devolution of federal money and responsibility to the states for anything, ever.”
The White House and Senate leaders are now in an intensive final push to repeal the Affordable Care Act by September 30. After that, under Senate rules, they will need 60 votes, which they acknowledge is an impossibility. Senator Graham said in a statement on Thursday that the legislation was gaining “momentum and support” because it would send “money and power back to the states, and closer to patients, to deliver quality health care.”
The legislation would turn over more than $1 trillion that would have been spent on the law known as Obamacare over the next seven years — everything from the funds for the expansion of Medicaid to the subsidies to help people buy private insurance — to states as “block grants” with very few strings attached. They would then use the money to set up their own health care programs. Congress would have to reauthorize the money after 2026 or it would go away.
“The decisions about individual mandates, mandated benefits, and all the other decisions the ACA moved to Washington are best made at the state level by governors who understand the unique needs of their states,” said Gov. Asa Hutchinson of Arkansas, a Republican. Arkansas expanded Medicaid under Obamacare, and would lose roughly $6 billion under the bill, but Governor Hutchinson supports the legislation nonetheless.
“Graham-Cassidy is putting federal spending on a budget,” he said. “That is the fiscal discipline the federal government and states both need to ensure the sustainability of Medicaid and other state health care programs.”
Like previous Republican proposals, the bill would also cancel the federal government’s commitment to the open-ended funding of the traditional Medicaid program, capping an entitlement for the poor and disabled that now covers one in five Americans. States could choose to take some of that Medicaid money in a block grant too.
Winners and Losers
One of the most striking things about the bill is how it redistributes federal money among states. Some states that have invested a lot in expanding coverage under Obamacare (many of them Democratic) would lose big to others (mostly Republican) that have fiercely resisted going along with the law and are hostile to federal spending in general.
The biggest spoils would go to Texas, which refused to expand Medicaid under the Affordable Care Act and had the nation’s highest uninsured rate last year at 16.6 percent. The health data firm Avalere estimated that Texas would receive an additional $35 billion by 2026 under the bill’s formula. California, which has expanded coverage to an additional 3.7 million under the A.C.A. would get $78 billion less through 2026 than under current law, and New York would see $45 billion less, Avalere found.
In Mississippi, which Avalere calculated would reap an extra $6 billion through 2026, some public health officials were skeptical that the state would even want the money.
Mississippi has one of the nation’s sickest populations and has historically resisted federal funding for social welfare programs. After the Affordable Care Act became law, Gov. Phil Bryant, a Republican, rejected not only the chance to expand Medicaid but also his own state insurance commissioner’s attempt to create a state-based insurance marketplace with federal funds offered under the law.
“Year after year we have fought to get our policy makers to take money from the feds,” said Roy Mitchell, executive director of the Mississippi Health Advocacy Program. “I could just see another scenario like that with this bill. These states that would see more money are just rife with ideologues that do not want to see this specific population get any kind of opportunity for affordable coverage. That’s my stark reality.”
In an emailed statement on Wednesday, Governor Bryant said his priority if the Senate bill passed would be “to implement a system of health care that best fit the specific needs of Mississippi’s most vulnerable citizens, and did not endanger coverage for those with pre-existing conditions.”
In Iowa, state officials have already filed a formal application to opt out of the Obamacare insurance market next year. The insurance commissioner, Doug Ommen, said he liked the idea of a health care block grant even though under the bill’s formula, Iowa stood to lose some federal funding. The proposal he submitted to the Trump administration would use the federal money that helps cover lower-income people’s deductibles to instead provide more premium subsidies and help insurers cover their most expensive customers’ costs. It could be an early example of something states might try to do under the Senate bill, if the money was sufficient.
“I think we would make it work here,” Mr. Ommen said of the bill. “We are a proponent of flexibility.”
In Alabama, another winner under the Senate bill, Jim Carnes, policy director at Arise Citizens’ Policy Project, an advocacy group, described the bill as “a bait and switch” for the state.
“The early gains from the redistribution will take a nose-dive 10 years out and we will lose billions,” he said. “No state is a winner in the end.”
One of the most striking things about the bill is how it redistributes federal money among states. Some states that have invested a lot in expanding coverage under Obamacare (many of them Democratic) would lose big to others (mostly Republican) that have fiercely resisted going along with the law and are hostile to federal spending in general.
The biggest spoils would go to Texas, which refused to expand Medicaid under the Affordable Care Act and had the nation’s highest uninsured rate last year at 16.6 percent. The health data firm Avalere estimated that Texas would receive an additional $35 billion by 2026 under the bill’s formula. California, which has expanded coverage to an additional 3.7 million under the A.C.A. would get $78 billion less through 2026 than under current law, and New York would see $45 billion less, Avalere found.
In Mississippi, which Avalere calculated would reap an extra $6 billion through 2026, some public health officials were skeptical that the state would even want the money.
Mississippi has one of the nation’s sickest populations and has historically resisted federal funding for social welfare programs. After the Affordable Care Act became law, Gov. Phil Bryant, a Republican, rejected not only the chance to expand Medicaid but also his own state insurance commissioner’s attempt to create a state-based insurance marketplace with federal funds offered under the law.
“Year after year we have fought to get our policy makers to take money from the feds,” said Roy Mitchell, executive director of the Mississippi Health Advocacy Program. “I could just see another scenario like that with this bill. These states that would see more money are just rife with ideologues that do not want to see this specific population get any kind of opportunity for affordable coverage. That’s my stark reality.”
In an emailed statement on Wednesday, Governor Bryant said his priority if the Senate bill passed would be “to implement a system of health care that best fit the specific needs of Mississippi’s most vulnerable citizens, and did not endanger coverage for those with pre-existing conditions.”
In Iowa, state officials have already filed a formal application to opt out of the Obamacare insurance market next year. The insurance commissioner, Doug Ommen, said he liked the idea of a health care block grant even though under the bill’s formula, Iowa stood to lose some federal funding. The proposal he submitted to the Trump administration would use the federal money that helps cover lower-income people’s deductibles to instead provide more premium subsidies and help insurers cover their most expensive customers’ costs. It could be an early example of something states might try to do under the Senate bill, if the money was sufficient.
“I think we would make it work here,” Mr. Ommen said of the bill. “We are a proponent of flexibility.”
In Alabama, another winner under the Senate bill, Jim Carnes, policy director at Arise Citizens’ Policy Project, an advocacy group, described the bill as “a bait and switch” for the state.
“The early gains from the redistribution will take a nose-dive 10 years out and we will lose billions,” he said. “No state is a winner in the end.”
Remaking Medicaid
The bill would make the most sweeping changes to Medicaid since the program’s inception in 1965. It goes farther than previous Senate proposals, and a bill passed by the House in May, by eliminating the expansion of Medicaid set up by the Affordable Care Act, which has extended the program’s coverage to 11 million more lower-income people, and putting the money into block grants starting in 2020.
The states could use that money for a variety of health care expenses, including creating high-risk pools to cover particularly expensive patients, to create a health care exchange run by the state, or to subsidize the cost of premiums or out of pocket costs for people with private insurance.
In all, Medicaid now covers 74 million Americans, most of them poor but also middle class people with disabilities and in nursing homes. The federal government shares the cost of Medicaid with states, and has traditionally paid between 50 and 75 percent of the costs, with poor states receiving more money. The commitment was open-ended; the government covered its share no matter the cost, or how many people enrolled. The federal government picked up the entire cost of the Medicaid expansion at first, with that share ultimately tapering to 90 percent.
Like previous Republican proposals, Graham-Cassidy would cap traditional Medicaid spending on a per-person basis, based on a complex formula.
That provision worries many hospital systems. “These funding reductions are unsustainable for many Ohio hospitals,” said John Palmer, a spokesman for the Ohio Hospital Association, adding that nearly 20 percent of hospitals in the state already spend more than they take in.
It’s hard to overstate the potential effects. Medicaid now provides medical care to four out of 10 American children, and covers the costs of nearly half of all births in the United States, as well as care for two-thirds of people in nursing homes and also for 10 million children and adults with physical or mental disabilities.
“It would unleash massive health care debates in every state capital,” said Mr. Levitt, at Kaiser. “All these tough decisions would no longer be on Congress’ plate but on the plates of governors.”
The bill would make the most sweeping changes to Medicaid since the program’s inception in 1965. It goes farther than previous Senate proposals, and a bill passed by the House in May, by eliminating the expansion of Medicaid set up by the Affordable Care Act, which has extended the program’s coverage to 11 million more lower-income people, and putting the money into block grants starting in 2020.
The states could use that money for a variety of health care expenses, including creating high-risk pools to cover particularly expensive patients, to create a health care exchange run by the state, or to subsidize the cost of premiums or out of pocket costs for people with private insurance.
In all, Medicaid now covers 74 million Americans, most of them poor but also middle class people with disabilities and in nursing homes. The federal government shares the cost of Medicaid with states, and has traditionally paid between 50 and 75 percent of the costs, with poor states receiving more money. The commitment was open-ended; the government covered its share no matter the cost, or how many people enrolled. The federal government picked up the entire cost of the Medicaid expansion at first, with that share ultimately tapering to 90 percent.
Like previous Republican proposals, Graham-Cassidy would cap traditional Medicaid spending on a per-person basis, based on a complex formula.
That provision worries many hospital systems. “These funding reductions are unsustainable for many Ohio hospitals,” said John Palmer, a spokesman for the Ohio Hospital Association, adding that nearly 20 percent of hospitals in the state already spend more than they take in.
It’s hard to overstate the potential effects. Medicaid now provides medical care to four out of 10 American children, and covers the costs of nearly half of all births in the United States, as well as care for two-thirds of people in nursing homes and also for 10 million children and adults with physical or mental disabilities.
“It would unleash massive health care debates in every state capital,” said Mr. Levitt, at Kaiser. “All these tough decisions would no longer be on Congress’ plate but on the plates of governors.”
Consumer Protections
The proposal is much more aggressive than some of the other Republican plans in rolling back the Affordable Care Act’s consumer protections, say health care lawyers and other experts who have studied the bill. It would allow states to stop requiring insurers to cover “essential” health care needs like hospitalization, prescription drugs, maternity care and mental health treatment.
Senator Bill Cassidy of Louisiana, a co-author of the legislation, has insisted that it would continue to provide vital protections to people with chronic illnesses so they would be able to find health insurance. But lawyers say the bill would allow states an almost unfettered ability to permit insurance companies to charge someone with, say, cancer or diabetes much higher rates — or to exclude certain expensive conditions like pregnancy or addiction from the plans they offer.
Though it is unclear how many would do so, states would be able to waive the existing rules much more easily because the bill would only require a state to explain how it intended to cover people with pre-existing conditions. “It’s not at all required that their explanation or plan meets any kind of standard,” said Richard J. Zall, a partner at the law firm Proskauer.
Moreover, unlike previous proposals, the bill would pave the way for insurers to adjust their prices every time someone renewed a policy, based on the individual’s changing health status. People could sign up for a plan and see the price skyrocket if they developed a potentially serious condition like cancer, said Karen Pollitz, a senior fellow at the Kaiser foundation.
Even the way people bought insurance would change in states that relied on the current federal insurance marketplace, which allows people to buy subsidized plans through HealthCare.gov. It would be dismantled in 2020. “The federal exchanges go away,” said Timothy S. Jost, an emeritus professor at Washington and Lee University law school who opposes to the bill.
Instead of setting up their own website so people can shop for a plan, the state could use the money to set up high-risk insurance pools for people with expensive chronic conditions or pay hospitals and doctors directly for care.
But even with the best of intentions, the time frame is very short for states to come up with an alternative plan, he said. “The biggest problem is how are states are going to do this in two years,” Mr. Jost said.
The proposal is much more aggressive than some of the other Republican plans in rolling back the Affordable Care Act’s consumer protections, say health care lawyers and other experts who have studied the bill. It would allow states to stop requiring insurers to cover “essential” health care needs like hospitalization, prescription drugs, maternity care and mental health treatment.
Senator Bill Cassidy of Louisiana, a co-author of the legislation, has insisted that it would continue to provide vital protections to people with chronic illnesses so they would be able to find health insurance. But lawyers say the bill would allow states an almost unfettered ability to permit insurance companies to charge someone with, say, cancer or diabetes much higher rates — or to exclude certain expensive conditions like pregnancy or addiction from the plans they offer.
Though it is unclear how many would do so, states would be able to waive the existing rules much more easily because the bill would only require a state to explain how it intended to cover people with pre-existing conditions. “It’s not at all required that their explanation or plan meets any kind of standard,” said Richard J. Zall, a partner at the law firm Proskauer.
Moreover, unlike previous proposals, the bill would pave the way for insurers to adjust their prices every time someone renewed a policy, based on the individual’s changing health status. People could sign up for a plan and see the price skyrocket if they developed a potentially serious condition like cancer, said Karen Pollitz, a senior fellow at the Kaiser foundation.
Even the way people bought insurance would change in states that relied on the current federal insurance marketplace, which allows people to buy subsidized plans through HealthCare.gov. It would be dismantled in 2020. “The federal exchanges go away,” said Timothy S. Jost, an emeritus professor at Washington and Lee University law school who opposes to the bill.
Instead of setting up their own website so people can shop for a plan, the state could use the money to set up high-risk insurance pools for people with expensive chronic conditions or pay hospitals and doctors directly for care.
But even with the best of intentions, the time frame is very short for states to come up with an alternative plan, he said. “The biggest problem is how are states are going to do this in two years,” Mr. Jost said.
Senator Cassidy, Please Stop Lying about Health Care
by David Leonhardt - NYT - September 21, 2017
First, health care: Here’s a giveway about how bad the new Senate health care bill is: Bill Cassidy, one of its authors, keeps trying to sell it by telling untruths.
“The relatively new phenomenon of just ‘up is down’ lying about your bill’s impacts is jarring,” says Loren Adler of the USC-Brookings-Schaeffer Initiative on Health Policy.
Most egregiously, Cassidy is claiming that the bill would not ultimately deprive sick people of health insurance. That’s false, as NPR calmly explained when Cassidy said otherwise.
In fact, the bill — known as Graham-Cassidy — would free states to remove insurance protections for people with pre-existing conditions. Without those protections, insurers could price such people out of the market.
If you get cancer (or even have a family history of it) or your child is born with a birth defect — among many, many other health issues — you could find yourself unable to buy insurance. Without insurance, you could be denied crucial treatments. In a tangible way, Graham-Cassidy would harm millions of Americans.
Aviva Aron-Dine and Sarah Kliff have both written good explainers on this issue. As Kliff notes, “There is literally no analysis” to support Cassidy’s claim that the bill would expand the number of insured.
Jimmy Kimmel, the country’s most unexpected health wonk, has urged Cassidy to stop “jamming this horrible bill down our throats.”
Insurers came out against the bill yesterday, joining doctors, hospitals, AARP, patient advocates, multiple governors and others.
Meanwhile, Republican leaders are trying to win the vote of Lisa Murkowski — one of three Republican senators who voted against a previous Obamacare repeal bill, in July — by funneling money to Alaska.
In the least surprising development of all, President Trump is now repeatingCassidy’s falsehoods.
The last word on health care this morning goes to Nicholas Bagley of the University of Michigan. “Graham-Cassidy is a brazen effort to block any level of government, state or federal, from achieving near-universal coverage,” he writes.“That’s what the debate is about. Everything else is just noise.”
Graham-Cassidy Has One Great Idea
by Philip Klein - NYT - September 21, 2017
The latest Republican stab at overhauling the Affordable Care Act manages to be both more timid and more sweeping than previous efforts to replace Obamacare. Known as Graham-Cassidy, it was written by a quartet of Republican senators led by Lindsey Graham of South Carolina and Bill Cassidy of Louisiana.
In the timid sense, the proposal would keep much more of Obamacare’s taxes and spending in place than previous Republican plans this year. Yet Graham-Cassidy makes more sweeping changes by turning money currently used on insurance subsidies and the Medicaid expansion into block grants to states. This change would give states more flexibility to design their own health care systems.
The prospects for Graham-Cassidy remain in doubt, but the battle over whether states or the federal government should have more control over health care policy will remain no matter what happens in the coming weeks. There is a strong case for a system that takes a less Washington-centric approach to health care and turns more decisions over to the states.
Commentators often bemoan how divided the nation is, pointing to our bitter elections and the toxic nature of political discourse. But the current level of partisan and regional polarization is a natural consequence of a political system that cedes so much power to the federal government. When distant lawmakers and unelected bureaucrats are in a position to make decisions that have enormous implications for the entire nation, the stakes of any decision become much higher. This is especially true when it comes to health care policy, which has the most personal and life-altering effects on individuals and their families.
A more flexible system would give states latitude to pursue health care programs that are a better fit for their populations’ ideological sensibilities. And there are practical reasons to think of health care as a state-based issue: Every one has its own demographics, health challenges and other unique characteristics.
For instance, median household income is much higher in New Hampshire than in Arkansas; heart disease and obesity are much bigger problems in Mississippi than in Colorado; the opioid epidemic is much worse in West Virginia than in Nebraska. Relatively sparsely populated areas struggle with the closings of rural hospitals, leaving large geographic areas underserved, while urban areas have a high concentration of large hospitals, many of which struggle with overcrowding.
Some states have both major cities and vast rural areas. Some skew younger while others skew older. State-specific factors help explain why even under the centralized Obamacare, premium increases and the participation of insurers have varied widelyacross the country. It makes sense to allow states to set their priorities and direct their resources based on the characteristics of their populations.
As states come up with innovative solutions to their health care problems, it means there are 50 opportunities to experiment. States can test solutions that worked elsewhere, or steer clear of ideas that failed. This path makes more sense than having politicians and distant regulators impose one giant experiment on the entire nation that is harder to undo if it fails.
The idea of turning more power over to the states has long been advocated by conservatives, but there are compelling reasons for liberals to get behind devolving power from the federal government.
When Congress passed the Affordable Care Act in 2010, it left many of the details to the discretion of the Department of Health and Human Services, giving vast powersto the secretary to determine everything from fast-food menu labeling requirements to when individuals could purchase insurance. During the Obama years, the administration used its regulatory discretion — pushing and arguably exceeding the limits of the law — to prop up the president’s signature legislative accomplishment as the program ran into implementation problems.
When President Trump took office, he appointed Tom Price, a longtime foe of Obamacare during his time in Congress, to run H.H.S. In the past several months, liberals have shouted “sabotage” as they have witnessed Mr. Price take actions such as slashing Obamacare’s advertising budget, tweaking the rules on the types of plansinsurers are allowed to offer and cutting in half — to six weeks — the program’s open enrollment period. Mr. Trump himself has created uncertainty over whether he will continue to authorize payments to insurers that congressional Republicans sued Mr. Obama over.
Any national health care system that assumes one party will control Washington for all eternity is doomed to fail. New Yorkers would have much less to fear about a Trump presidency if the president didn’t control agencies that set policies for the entire country.
From the perspective of somebody who wants to see genuine federalism in health care, Graham-Cassidy leaves a lot to be desired. Because it keeps many of Obamacare’s regulations on the books at the national level, it limits the amount of innovation that can occur at the state level. The fact that it keeps most of Obamacare’s taxes means that states preferring to take a more free market approach will still be paying for a big government footprint in other states. Under one scenario, for instance, Texans could be subsidizing single-payer health care in Vermont.
But the idea of giving states more control over their health care systems should survive no matter what happens with Graham-Cassidy.
Cruelty, Incompetence and Lies
by Paul Krugman - NYT - September 22, 2017
Graham-Cassidy, the health bill the Senate may vote on next week, is stunningly cruel. It’s also incompetently drafted: The bill’s sponsors clearly had no idea what they were doing when they put it together. Furthermore, their efforts to sell the bill involve obvious, blatant lies.
Nonetheless, the bill could pass. And that says a lot about today’s Republican Party, none of it good.
The Affordable Care Act, which has reduced the percentage of Americans without health insurance to a record low, created a three-legged stool: regulations that prevent insurers from discriminating against people with pre-existing conditions, a requirement that individuals have adequate insurance (and thus pay into the system while healthy) and subsidies to make that insurance affordable. For the lowest-income families, insurance is provided directly by Medicaid.
Graham-Cassidy saws off all three legs of that stool. Like other Republican plans, it eliminates the individual mandate. It replaces direct aid to individuals with block grants to states, under a formula that sharply reduces funding relative to current law, and especially penalizes states that have done a good job of reducing the number of uninsured. And it effectively eliminates protection for Americans with pre-existing conditions.
Did Graham-Cassidy’s sponsors know what they were doing when putting this bill together? Almost surely not, or they wouldn’t have produced something that everyone, and I mean everyone, who knows anything about health care warns would cause chaos.
It’s not just progressives: The American Medical Association, the insurance industryand Blue Cross/Blue Shield have all warned that markets would be destabilized and millions would lose coverage.
How many people would lose insurance? Republicans are trying to ram the bill through before the Congressional Budget Office has time to analyze it — an attempt that is in itself a violation of all previous norms, and amounts to an admission that the bill can’t bear scrutiny. But C.B.O. has analyzed other bills containing some of Graham-Cassidy’s provisions, and these previous analyses suggest that it would add more than 30 million people to the ranks of the uninsured.
Lindsey Graham, Bill Cassidy, and the bill’s other sponsors have responded to these critiques the old-fashioned way — with lies.
Both Cassidy and Graham insist that their bill would continue to protect Americans with pre-existing conditions — a claim that will come as news to the A.M.A., Blue Cross and everyone else who has read the bill’s text.
Cassidy has also circulated a spreadsheet that purports to show most states actually getting increased funding under his bill. But the spreadsheet doesn’t compare funding with current law, which is the relevant question. Instead, it shows changes over time in dollar amounts.
That’s actually a well-known dodge, one that Republicans have been using since Newt Gingrich tried to gut Medicare in the 1990s. As everyone in Congress — even Cassidy — surely knows, such comparisons drastically understate the real size of cuts, since under current law spending is expected to rise with inflation and population growth.
Independent analyses find that most states would, in fact, experience serious cuts in federal aid — and everyone would face huge cuts after 2027.
So we’re looking at an incompetently drafted bill that would hurt millions of people, whose sponsors are trying to sell it with transparently false claims. How is it that this bill might nonetheless pass the Senate?
One answer is that Republicans are desperate to destroy President Barack Obama’s legacy in any way possible, no matter how many American lives they ruin in the process.
Another answer is that most Republican legislators neither know nor care about policy substance. This is especially true on health care, where they never tried to understand why Obamacare looks the way it does, or how to devise a nonvicious alternative. Vox asked a number of G.O.P. senators to explain what Graham-Cassidy does; the answers ranged from incoherence to belligerence to belligerent incoherence.
I’d add that the evasions and lies we’re seeing on this bill have been standard G.O.P. operating procedure for years. The trick of converting federal programs into block grants, then pretending that this wouldn’t mean savage cuts, was central to every one of Paul Ryan’s much-hyped budgets. The trick of comparing dollar numbers over time to conceal huge benefit cuts has, as I already noted, been around since the 1990s.
In other words, Graham-Cassidy isn’t an aberration; it’s more like the distilled essence of everything wrong with modern Republicans.
Will this awful bill become law? I have no idea. But even if the handful of Republican senators who retain some conscience block it — we’re looking at you, John McCain — the underlying sickness of the G.O.P. will remain.
It’s sort of a pre-existing condition, and it’s poisoning America.
The G.O.P. Bill Forces States to Build Health Systems From Scratch. That’s Hard.
by Margot Sanger-Katz - NYT - September 21, 2017
In 2003, health care policy makers in Massachusetts agreed that the state should build a system to expand coverage to its uninsured residents.
It took four years before Romneycare was fully up and running.
In between, politicians had to think hard about how they wanted the system to work: how money would be raised and spent, what benefits would be offered, whether and how markets should be used to distribute coverage, whether people who didn’t buy coverage should be penalized. They had to build a computer system to help people check their eligibility and understand their options. They had to recruit insurers to participate. And they needed to find uninsured residents and persuade them to enroll.
A new health care bill before the Senate would require all the states in the country to make a similar soup-to-nuts evaluation of how they’d like their health care systems to work, to build such a system and be ready to open their doors in substantially less time — just over two years. That may not be realistic.
“The answer is absolutely no,” said Jon Kingsdale, who ran Massachusetts Connector, the system that matched Massachusetts residents with health insurance, and is now a public health professor and a consultant. “That’s not enough time for most states to figure it out.”
The bill, proposed by Bill Cassidy and Lindsey Graham, would eliminate Obamacare’s expansion of state Medicaid programs to cover poor adults and its system of subsidies to help middle-income Americans buy their own insurance in state marketplaces. Instead, it would allow states to apply for big block grants of money once they have developed a plan to use the money to provide health care or health insurance coverage.
The language of the bill provides them with a nearly unlimited range of policy options to use the money in the service of providing health care access, and no templates or fallback options.
Republican governors from 15 states have endorsed the bill, saying that “adequately funded, flexible block grants to the states are the last, best hope to finally repeal and replace Obamacare.”
States could use the money in any number of ways: state insurance programs, subsidies for private insurance, direct payments to health providers, high-risk pools or more. They would be free to preserve the central consumer protections created by Obamacare, or to decide to allow insurers to limit benefits or charge higher prices to sicker customers than healthier ones.
The challenges would fall into two major categories. First, states would need to make political choices about what they want their system to look like. Next, they would need to submit applications, hire contractors and build new systems to run them. Neither would be easy.
The bill would make health care an active, high-stakes political debate in all 50 states. Under Obamacare, states had limited, rather binary policy choices, and even those were hard for state governments to make quickly. States had to decide whether to run their own insurance marketplaces or to let the federal government do it for them. After a Supreme Court ruling in 2012, they had a choice about whether to expand their Medicaid programs to cover more childless adults, or to stick with their prior programs. Many states took longer than two years to answer even those comparatively simple questions.
Consider, for example, a state like Virginia, where a Democrat sits in the governor’s office but Republicans run the legislature. Political consensus might prove elusive. Fights could erupt even among more politically homogeneous states that support Obamacare. One house of the California legislature recently voted to adopt a single-payer health care system. The flexibility presented by the bill might open a heated debate about whether to adopt such an approach — or build something more like the Affordable Care Act, which is currently working well there. There are also the challenges of state legislative calendars: Texas’ legislature, for example, is not scheduled to convene until 2019.
“In some ways, a clean slate is much more complicated than very discrete decisions,” said Larry Levitt, an executive vice president at the Kaiser Family Foundation, a nonpartisan health research group. Mr. Levitt described the challenges facing states under this legislation as “formidable.”
In contrast with an earlier bill from Mr. Cassidy, which offered a default option for uncertain states, there is no backup plan in the bill. The Obamacare coverage programs would disappear everywhere in 2020, and any state unable to make a plan and submit an application would be ineligible for the new grant funding. If a state succeeds in obtaining the funding but doesn’t have a functioning new system on Jan. 1, 2020, consumers and markets would be thrown into chaos.
Under the bill’s block grant formula, Mississippi would be one of the biggest winners, eligible for substantially more health care money than it gets now. Still, Mike Chaney, the state’s insurance commissioner, said that he was wary about the change. “Which evil do you like better, the one you know or the one you don’t know?” Mr. Chaney said. “There are better ways to do this.”
Once states choose a policy approach, they would need to bring it to life. If they adopt a government-run approach, in which people can enroll in a single public health plan, they will need to develop the parameters for that program and put it out to bid. If they select something similar to Obamacare — some sort of insurance market with income-based subsidies — they will need technology systems that allow them to verify people’s eligibility and income, and link state assistance with their insurance purchases.
Most states have lengthy contracting processes, in which they must request proposals and review multiple bids before signing up vendors. Those deals would need to be in place before any software building begins. The Obama administration had nearly four years to develop and build its enrollment system, HealthCare.gov, which barely functioned at the outset.
Peter Lee, the executive director of the California marketplace, Covered California, which is considered one of the country’s most successful, said that his system was barely finished in time, and he had the ability to call up local technology C.E.O.s for advice.
Andy Slavitt, who joined the Obama administration in 2014 to help rebuild the ailing HealthCare.gov, and is strongly opposed to the Republican bill, said it would be close to impossible for most states to build meaningful systems for providing health insurance on such a timeline. “This is a fantasy document developed without the benefit of talking to people who have actually had to operationalize these things before,” he said.
Passage of the bill would set off a state rush for help from the limited group of contractors who have built big systems. Mike Leavitt, a Republican who was Secretary of Health and Human Services under George W. Bush, and a governor of Utah, now runs a consulting firm that helps states build and manage exchanges. He said he supported the general idea of giving states more power.
He was optimistic that some states could adopt out-of-the-box systems within two years, but probably not all. “There are different levels of complexity involved in states, and there’s different levels of capacity, and there’s different levels of experience,” he said.
Many experts I spoke with were confident that most states would find some way to get the federal money, given how big the stakes were. They were less sure about whether states would be able to use it in a way that would provide health coverage quickly to the people currently served by Obamacare.
“The metaphor I think about is it’s saying, ‘We’re going to continue having a freeway full of fast-moving cars, but we’re going to remove the lane line and the speed limits and say we hope things work out,’ ” Mr. Lee said.
Red-state Medicaid directors sound the alarm about Cassidy-Graham
by Greg Sargent - The Washington Post - September 22, 2017
THE MORNING PLUM:
One of the most destructive and awful things that Cassidy-Graham would do — and there are a lot of them — is put intense pressure on states to implement a radical transformation of Medicaid delivery to their constituents in only two years. This is widely seen by health-care policy experts as a recipe for chaos.
It turns out that this aspect of Cassidy-Graham has many Medicaid directors very, very worried — even in multiple red states.
I’m told that many Medicaid directors from states with Republican governors privately blessed a statement from the National Association of Medicaid Directorsthat sharply criticizes Cassidy-Graham as unworkable and deeply destructive.
The NAMD statement argues that Cassidy-Graham, which would end the Medicaid expansion and replace it with block grants to states, starting in 2020, is simply not doable for most of them. The NAMD says that the scope of implementing this change “cannot be overstated,” adding that “the vast majority of states will not be able to do so within the two-year time frame envisioned here.”
This statement from the NAMD is being widely reported on today, but people are getting crucial nuances of the story wrong. Many have said this statement represents a consensus of all of the Medicaid directors across the country. Not true: When the NAMD puts out a statement such as this, it often reflects what its board of directorssays, not any consensus among all of the Medicaid directors. That is the same here. Indeed, the statement says as much in its first sentence.
But in this case, something unique has indeed happened — and it is more damning than this statement first appeared to be.
Matt Salo, executive director of the NAMD, tells me that the organization privately conferred with many Medicaid directors around the country, in advance of releasing this statement. It is politically sensitive for a Medicaid director to differ with his or her state’s governor on a high-profile matter. While some GOP governors have come out against Cassidy-Graham, many others have not, and some have backed it. Given that Cassidy-Graham is a high priority of President Trump and congressional Republican leaders, it is not easy for a red-state Medicaid director to oppose it.
But in this case, Salo tells me, many Medicaid directors from red states privately said they were comfortable with this statement getting out to the public and lawmakers, and in many cases, they eagerly wanted this to happen. Salo emailed me this:
In preparation for the Board’s statement on Graham-Cassidy, we heard from many Medicaid Directors in red states that they were very concerned about the impacts of the legislation and were at the very least comfortable, if not overwhelmingly supportive of sending a message communicating these concerns.
To be clear, this is actually unusual. As Salo explained to me, these statements require affirmation from only two-thirds of NAMD’s dozen-strong elected board of directors — only eight people — and generally do not represent the consensus view of the nation’s Medicaid directors.
But in this case, many of them, including many appointed by Republican governors, did want the statement’s message out there. That message is encapsulated by these lines from the statement:
How these block grants will be utilized, what programs they may fund, and the overall impact they will have on state budgets, operations, and citizens are all uncertain. Taken together, the per-capita caps and the envisioned block grant would constitute the largest intergovernmental transfer of financial risk from the federal government to the states in our country’s history. …The Graham-Cassidy legislation would require states to operationalize the block grant component by January 1, 2020. The scope of this work, and the resources required to support state planning and implementation activities, cannot be overstated. States will need to develop overall strategies, invest in infrastructure development, systems changes, provider and managed care plan contracting, and perform a host of other activities. The vast majority of states will not be able to do so within the two-year timeframe envisioned here, especially considering the apparent lack of federal funding in the bill to support these critical activities.
To understand what this would entail, read this piece by Margot Sanger-Katz, which explains how Cassidy-Graham would require states to essentially rebuild their health-care systems from scratch. As Sanger-Katz notes, this would instantly “make health care an active, high-stakes political debate in all 50 states,” and in any state that failed to realize this formidable challenge, “consumers and markets would be thrown into chaos.”
It turns out that the people who would be tasked with implementing these radical changes — including many appointed by Republicans — share this view. The question is whether that will weigh on the few remaining undecided GOP senators. It should — if they care in the least about the real-world consequences of their votes.
Letters to the Editor
from The Boston Globe - September 23, 2017
Could single-payer plan be the prescription?
Medicare is not
all it’s cracked up to be
Bernie Sanders has started moving his single-payer health care plan through the Senate and has begun to garner some support (“Health proposal: single payer, multiple doubts,” Page A1, Sept. 14). But the devil is in the details. Sanders likes to simplistically describe his plan as “Medicare for all,” which is catchy but, in all probability, also misleading.
As a Medicare recipient for more than 13 years, and as a trained and certified volunteer Medicare health insurance counselor, I am only too aware of the holes in Medicare that require either supplemental “Medigap” or replacement “Medicare Advantage” (Part C) private insurance.
A simple example is that Medicare is an 80 percent plan. That’s easy if one goes in for a Medicare-approved procedure of $100, where the patient’s cost is $20. But if the procedure is $100,000, the patient’s share is $20,000, and that is uncapped.
I believe that the United States eventually needs to go to a single-payer system. But I don’t believe the country is ready for it yet, and Medicare as it currently exists is not the right model.
A satisfied participant wants Medicare for all
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Articles on Bernie Sanders’ single-payer health care bill describe the proposal as “government-run health care” and imply that a “gargantuan” government program is not feasible in the United States. But we do have a huge government-run health insurance system here. It’s called Medicare. And just try to take Medicare away from seniors like me, in the name of giving us the so-called freedom to buy our own private insurance on the market. No thanks. We love this “gargantuan” government program.
What would make the most sense in terms of covering everyone in the country at the cheapest cost would be to gradually bring younger and younger groups into the Medicare program until everyone is in. It would help reduce the astronomical cost of health care that is going to drive the country broke. Sure, our taxes would go up to cover such an “everybody in, nobody out” health insurance system. But many Americans would accept the increase if it meant that, to cover everyone, they paid less in taxes than they pay now in premiums for private insurance that leaves millions uninsured.
The reality is that only government-run health care can provide all of us with good basic health coverage, such as seniors now enjoy, at the lowest possible price.
Single payer would do away with costly overhead
Evan Horowitz’s Sept. 14 Quick Study (“Single-payer sounds appealing to some, but it is not a simple solution”) misses a key difference between single-payer and multi-payer models, including universal coverage. That difference is the overhead cost associated with administering the two payment models.
Our current multi-payer model for most of us comes with administrative overhead costs of around 30 percent. Medicare, much closer to a single-payer model, comes in at 2 percent.
In other words, for every dollar spent in the health care system on those under 65, only about 70 cents is actually spent on delivering care, whereas for those over 65, the amount increases to around 98 cents.
Horowitz ends his article posing the question of whether Democrats will want to go to single-payer sooner or later. This independent’s 2 cents worth? The sooner the better.
For health insurance companies, a moment of truth
The Globe has done a fine job covering Bernie Sanders’ introduction of a single-payer plan and its practical and political implications, with one exception. By all accounts, current insurance providers are doing just fine under the Affordable Care Act, but by increasingly focusing their services on the more profitable regions while threatening to pull out of rural and low-income areas, they have done little to ensure the ACA’s survival.
Given the possibility of a Democratic takeover of both houses of congress during the Trump presidency, industry leaders should choose to do everything possible to ensure the success of the ACA. If the idea of “Medicare for all” continues to gain political traction, it will become clear that insurers need the support of the American people more than the people need their services. They should be working now with rural and economically depressed areas to find creative solutions to expand health coverage. Continuing to succumb to greed may lead to their well-deserved demise.
For the sake of US companies, GOP should embrace government plan
Concerning the current debate over health care, it seems to me that there is a good case for Republicans, on behalf of their business supporters, embracing the idea of single-payer, government-funded health care.
As it stands now, American companies, in order to attract talented employees, must offer some kind of a health care plan. No matter how the cost is divided between employees and company, there is a cost that comes off the company’s bottom line.
By contrast, businesses in other parts of the developed world with which American companies might compete do not have this cost to consider, since their health care is funded by the public at large. Thus American companies are at a competitive disadvantage.
It would be reasonable to expect the companies’ Republican friends to eliminate this disadvantage.
Democrats need a bold issue to rally around
Re “Pelosi says focus is Obama health law” (Page A9, Sept. 13): House Minority Leader Nancy Pelosi said that single-payer health care is not a litmus test for Democrats.
Now is not the time to be timid. Democrats badly need a bold issue to rally around, something more than “not Trump.”
Medicare for everyone — finally.
Behind New Obamacare Repeal Vote: ‘Furious’ G.O.P. Donors
by Carl Hulse - NYT - September 22, 2017
WASHINGTON — As more than 40 subdued Republican senators lunched on Chick-fil-A at a closed-door session last week, Senator Cory Gardner of Colorado painted a dire picture for his colleagues. Campaign fund-raising was drying up, he said, because of widespread disappointment among donors over the inability of the Republican Senate to repeal the Affordable Care Act or do much of anything else.
Mr. Gardner is in charge of his party’s midterm re-election push, and he warned that donors of all stripes were refusing to contribute another penny until the struggling majority produced some concrete results.
“Donors are furious,” one person knowledgeable about the private meeting quoted Mr. Gardner as saying. “We haven’t kept our promise.”
The backlash from big donors as well as the grass roots panicked Senate Republicans and was part of the motivation behind the sudden zeal to take one last crack at repealing the health care law before the end of the month. That effort faltered Friday with new opposition from Senator John McCain of Arizona, the perennial maverick who had scuttled the Senate’s first repeal effort. Now Republicans must confront the possibility that they will once again let down their backers with no big win in sight.
The latest unsightly pileup over health care was exactly what some Republicans had wanted to avoid by abandoning the repeal effort and skipping straight to tax cuts after the previous embarrassing health care collapse about eight weeks ago. Instead, Senate Republicans got caught up in a rushed, last-ditch repeal attempt that not only seems unlikely to prevail, but will only serve to remind disillusioned donors about the party’s governing difficulties.
This was not what Republicans had envisioned. Preparing for the 2018 midterm elections, they had thought they were in a strong position to maintain or expand their majority. Democrats must defend 25 seats — including 10 in states won last year by President Trump — while just eight Republican-held seats will be on the ballot. But their governing struggles — and attacks on congressional leaders by Mr. Trump — have soured their base, leaving the Senate majority feeling desperate.
Addressing his anxious colleagues at their weekly meeting on Sept. 12, Mr. Gardner had a simple message: If we don’t have something to run on, we are going to squander this opportunity.
Republican senators strive to keep discussions at their weekly luncheons secret to allow for candid discussions. This meeting was held off the Capitol grounds, at the headquarters of the National Republican Senatorial Committee, to enable a broad discussion of politics. Neither lawmakers nor staff would go on the record to discuss it, but the session was described by multiple people knowledgeable about what occurred.
They said Mr. Gardner did not specifically urge approval of the so-called Graham-Cassidy health proposal that Republicans were considering bringing to the Senate floor next week. He was seen as speaking more generally and mainly looking forward to the coming debate over tax cuts.
But the fund-raising drought has become a growing worry and lawmakers have not been reticent about noting that their political fate could be tied to the outcome on health care and how Senate Republicans handle other issues ahead.
Senator Charles E. Grassley of Iowa, who has been deeply involved in health policy for years, told reporters back home that he could count 10 reasons the new health proposal should not reach the floor, but that Republicans needed to press ahead regardless in order to fulfill their longstanding promise to replace and repeal President Barack Obama’s Affordable Care Act.
“Republicans campaigned on this so often that we have a responsibility to carry out what you said in the campaign,” Grassley said in a conference call with Iowa reporters. “That’s pretty much as much of a reason as the substance of the bill.”
Senator Pat Roberts of Kansas, was even more blunt in a conversation with Vox. “If we do nothing, it has a tremendous impact on the 2018 elections, and whether or not Republicans still maintain control and we have the gavel,” he said.
Republicans say the fund-raising drop-off has been steep and across the board, from big donations to the small ones the party solicits online from the grass roots. They say the hostile views of both large and small donors are in unusual alignment and that the negative sentiment is crystallized in the fund-raising decline.
One party official noted that Senate Republicans had a lucrative March, raising $7 million — an off-year record for the organization. But in the aftermath of the failed health repeal effort before the August recess and other setbacks, the take dropped to $2 million in July and August — a poor showing for a majority party with a decided advantage on the midterm map.
The totals have left Republicans increasingly worried about having the funds they need next year. Mr. Gardner told his colleagues that a major Colorado contributor who played a role in his own campaign says party donors are reluctant to give any more money until congressional Republicans demonstrate results.
Party operatives say it is hard to assess the full impact of Mr. Trump’s summer attacks on Senator Mitch McConnell of Kentucky, the majority leader, as well as the president’s frustration at the inability of the Republican-led Congress to repeal the health care law. But they assume his criticism has been a factor in driving down support.
Senate Republicans are entering a pivotal week. They have been scrambling to find the votes for the contentious new repeal effort before the Sept. 30 expiration of special budget authority, which would allow the bill to pass with a simple majority and not 60 votes. But Mr. McCain’s decision to join at least two other Republicans — Senators Susan Collins of Maine and Rand Paul of Kentucky — in finding fault with the measure put its fate in real peril.
If the bill is short of votes, Mr. McConnell could choose not to bring it to the floor at all to prevent a second embarrassing defeat on health care and spare Republicans a difficult vote.
Mr. McConnell faces other immediate challenges as well. A primary on Tuesday in Alabama pits his candidate, Senator Luther Strange, against Roy Moore, a former chief justice of the state Supreme Court challenging him as an outsider. The defeat of Mr. Strange would further rattle his colleagues and be seen as a major rebuke to Mr. McConnell and the Republican establishment in Washington for their failure to deliver on health care repeal and other issues.
Republicans are also set to roll out their income tax overhaul plan next week in an effort to build support for it and find something the party can deliver to the president’s desk. They see the tax plan as their best opportunity to win back the allegiance of donors.
With health care repeal teetering yet again, the one thing they know for sure is that they need to show some accomplishments, and they need to do so fast.
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