McConnell Says Republicans Are Giving Up on Health Bill
Thomas Kaplan - NYT - September 26,2017
WASHINGTON — Senate Republican leaders on Tuesday officially pulled the plug on the latest plan to repeal the Affordable Care Act, scrapping a planned vote on the measure and effectively admitting defeat in the last-gasp drive to fulfill a core promise of President Trump and Republican lawmakers.
The decision came less than 24 hours after a pivotal Republican senator, Susan Collins of Maine, declared firm opposition to the repeal proposal, all but ensuring that Republican leaders would be short of the votes they needed.
“We haven’t given up on changing the American health care system,” Senator Mitch McConnell of Kentucky, the majority leader, said. “We are not going to be able to do that this week, but it still lies ahead of us, and we haven’t given up on that.”
Mr. McConnell said Republicans would move on to their next big legislative priority: overhauling the tax code, a feat that has not been accomplished since 1986.
Democrats responded by calling for the resumption of bipartisan negotiations to stabilize health insurance markets under the Affordable Care Act. Republican leaders had squelched those talks as the latest repeal plan gained steam, hoping to present senators a single, take-it-or-leave-it decision on the legislation, written by Senators Bill Cassidy of Louisiana and Lindsey Graham of South Carolina.
“We hope we can move forward and improve health care, not engage in another battle to take it away from people, because they will fail once again if they try,” said Senator Chuck Schumer of New York, the Democratic leader.
Senate Republicans already tried once this year to approve repeal legislation, an exercise that ended in defeat when Senator John McCain of Arizona gave a thumbs-down in July to kill that repeal proposal.
This time, Mr. McConnell and his fellow Republicans were trying to make one more attempt at passing a bill, and a deadline was fast approaching: They have only until the end of this week to pass a repeal bill using special budget rules that shield it from a Democratic filibuster.
Mr. McConnell could afford to lose only two of his members. But when he conceded defeat on Tuesday, three members of his conference had already publicly declared their opposition: Ms. Collins, Mr. McCain and Senator Rand Paul of Kentucky.
None of the three senators seemed likely to drop their opposition: Mr. McCain detested the partisan process used to push the bill, Ms. Collins had broad concerns about the legislation’s effects on health care, and Mr. Paul objected to the fundamental architecture of the legislation.
And other senators might have opposed it without doing so publicly. Senator Lisa Murkowski, Republican of Alaska, released a statement after the bill was pulled, decrying “a lousy process.”
“The U.S. Senate cannot get the text of a bill on a Sunday night, then proceed to a vote just days later, with only one hearing — and especially not on an issue that is intensely personal to all of us,” she wrote, without saying which way she would have voted.
Mr. Cassidy was blunt: “We don’t have the votes,” adding, “ Am I disappointed? Absolutely.”
But Mr. Graham predicted their repeal proposal would still pass — just at a later date, after Republicans tackle the issue of taxes, and when Republicans have more time to consider the repeal plan.
“There are 50 votes for the substance,” Mr. Graham said. “There are not 50 votes for the process.”
But that could be months away — if not years. The tax effort will likely occupy Congress through the remainder of this year, and likely into next. Lawmakers may not be able to revisit a partisan effort to repeal the Affordable Care Act until they tackle a budget plan for fiscal 2019, which would put the fight into the center of the midterm elections.
Earlier Tuesday, with little hope of success in the Senate, Mr. Trump expressed his displeasure.
“At some point there will be a repeal and replace, but we’ll see whether or not that point is now or will it be shortly thereafter,” he said at the White House. “But we are disappointed in certain so-called Republicans.”
The failure in the Senate was also a disappointment to Republicans in the House, who managed to pass a repeal bill in May after their own struggles.
“We’re a little frustrated that the Senate has not acted on a seminal promise,” Speaker Paul D. Ryan said.
Then he returned to talking up the goal of overhauling the tax code.
https://www.nytimes.com/2017/09/26/us/politics/mcconnell-obamacare-repeal-graham-cassidy-trump.html?
How Failure of the Obamacare Repeal Affects Consumers
by Margot Sanger-Katz - NYT - September 26, 2017
Obamacare repeal is dead, again. But the months of Republican attacks on the health law will still have consequences for some consumers.
For now, people who get their insurance through Medicaid can rest easy. While some states have applied to make minor changes to their programs, the demise of the Graham-Cassidy legislation on Tuesday means no major cutbacks are on the immediate horizon. But almost every health bill that Republicans proposed this year called for subjecting the program to caps, so that idea seems unlikely to disappear.
Those with employer insurance can also coast along with the status quo; there have been no policy changes affecting the price or comprehensiveness of workplace health plans. The Republican bills would have eliminated rules requiring large employers to offer health benefits and could have weakened protections against annual or lifetime limits on workers’ coverage.
But the recent political cycle means it will probably be a tumultuous season for people who buy their own health insurance. The Trump administration remains deeply opposed to the Affordable Care Act, and it has taken steps that will mean higher prices for insurance and that will make it harder for consumers to get information about how to sign up.
Insurers wishing to sell policies in the individual market next year need to sign contracts with the government by Wednesday, confirming their participation and agreeing to prices. Early signals suggest that premiums are set to increase by double digits in most parts of the country.
Insurers say at least some of those increases were to account for the policy uncertainty brought by the Trump administration, which has indicated that it may hold back some routine payments to insurers and that it will reduce outreach to possible customers.
Complete market failure seems to have been averted: At least one insurer has agreed to sell health plans in every county of the country. But Republican critics of the law are right that many parts of the country will have just one insurer offering plans, and that single insurer may be charging very high prices for its products.
Most Obamacare customers won’t feel the sting of higher premiums, because government subsidies limit their exposure to a percentage of their income. But there are still millions of people who buy their own insurance and earn too much to qualify for subsidies. The rocky market will be worse for them, and possibly unaffordable.
Senators in the Health, Education, Labor and Pensions committee had been negotiating over a possible bipartisan deal to help stabilize the markets. The expected package would have guaranteed the disputed payments to insurers and provided states with some policy flexibility in future years.
But that effort was shelved by congressional leadership as part of the failed push to pass the Graham-Cassidy health care overhaul. Now, with contract signings imminent, it is probably too late for lawmakers to improve conditions much for next year. (On the flip side, it’s also probably too late for President Trump to create substantially more havoc for markets by declining to pay the insurance subsidies, as he has periodically threatened to do.)
The Trump administration has, so far, been a reluctant overseer of the Obamacare markets. It has slashed its budget for outreach and enrollment assistance for possible customers, meaning that consumers may have more trouble finding out when and how to sign up for health insurance. Its department of health and human services keeps sending news releases cheerfully noting the law’s shortcomings. (A recent one had the subject line “It’s not working...”)
Officials also recently announced that they expect to take the HealthCare.gov enrollment website offline for maintenance for up to 12 hours on five of the six Sundays during the enrollment period, substantially longer than was needed last year.
The administration argues that people eligible for Obamacare programs are already well-informed about their options, but there is substantial survey researchsuggesting that many may be confused or simply unaware of how the program works. That may be especially true now, given the months of news about efforts to repeal the law.
Taken together, higher prices and less outreach are likely to mean fewer people buying coverage on the individual insurance market. Insurers’ views on whether to participate in 2019 are likely to be shaped by their experience next year.
The Trump administration has tended to use the poor performance of the health care markets as a prod to legislators to move forward on repeal. But the timing of repeal’s collapse means that, even absent a legislative overhaul, the markets will suffer.
Is Health Care a Right?
by Atul Gawande - The New Yorker - September 25, 2017
Is health care a right? The United States remains the only developed country in the world unable to come to agreement on an answer. Earlier this year, I was visiting Athens, Ohio, the town in the Appalachian foothills where I grew up. The battle over whether to repeal, replace, or repair the Affordable Care Act raged then, as it continues to rage now. So I began asking people whether they thought that health care was a right. The responses were always interesting.
A friend had put me in touch with a forty-seven-year-old woman I’ll call Maria Dutton. She lived with her husband, Joe, down a long gravel driveway that snaked into the woods off a rural road. “You may feel like you are in the movie ‘Deliverance,’ ” she said, but it wasn’t like that at all. They had a tidy, double-wide modular home with flowered wallpaper, family pictures on every surface, a vase of cut roses on a sideboard, and an absurdly friendly hound in the yard. Maria told me her story sitting at the kitchen table with Joe.
She had joined the Army out of high school and married her recruiter—Joe is eleven years older—but after a year she had to take a medical discharge. She had developed severe fatigue, double vision, joint and neck pains, and muscle weakness. At first, doctors thought that she had multiple sclerosis. When that was ruled out, they were at a loss. After Joe left the military, he found steady, secure work as an electrical technician at an industrial plant nearby. Maria did secretarial and office-manager jobs and had a daughter. But her condition worsened, and soon she became too ill to work.
“I didn’t even have enough energy to fry a pound of hamburger,” she said. “I’d have to fry half of it and then sit down, rest, and get up and fry the rest. I didn’t have enough energy to vacuum one room of the house.” Eventually, she was diagnosed with chronic-fatigue syndrome and depression. She became addicted to the opioidsprescribed for her joint pains and was started on methadone. Her liver began to fail. In 2014, she was sent two hundred miles away to the Cleveland Clinic for a liver-transplant evaluation. There, after more than two decades of Maria’s deteriorating health, doctors figured out what the problem was: sarcoidosis, an inflammatory condition that produces hardened nodules in organs throughout the body. The doctors gave her immunosuppressive medication, and the nodules shrank away. Within a year, she had weaned herself off the methadone.
“It was miraculous,” she said. In middle age, with her daughter grown up and in the Army Reserves herself, Maria got her life back and returned to school. All along, she’d had coverage through her husband’s work. “They have amazing insurance,” she said. “I think one year the insurance paid out two hundred thousand dollars. But we paid out, too.”
This was an understatement. Between a six-thousand-dollar deductible and hefty co-pays and premiums, the Duttons’ annual costs reached fifteen thousand dollars. They were barely getting by. Then one day in 2001 Joe blacked out, for no apparent reason, at a Girl Scout meeting for their daughter and fell down two flights of stairs, resulting in a severe concussion. It put him out of work for six months. Given the health-care costs and his loss of income, the couple ran out of money.
“We had to file for bankruptcy,” Joe said. He told me this reluctantly. It took them more than five years to dig out of the hole. He considered the bankruptcy “pretty shameful,” he said, and had told almost no one about it, not even his family. (This was why they didn’t want me to use their names.) He saw it as a personal failure—not the government’s. In fact, the whole idea that government would get involved in the financing of health care bothered him. One person’s right to health care becomes another person’s burden to pay for it, he said. Taking other people’s money had to be justified, and he didn’t see how it could be in cases like this.
“Everybody has a right to access health care,” he allowed, “but they should be contributing to the cost.” He pointed out that anyone could walk into a hospital with an emergency condition, get treated, and be billed afterward. “Yes, they may have collectors coming after them,” he said. “But I believe everybody should contribute for the treatment they receive.”
Like her husband, Maria leans conservative. In the 2016 election, Joe voted for Donald Trump. Maria voted for Gary Johnson, the Libertarian candidate. But on health care she was torn. Joe wanted Obamacare repealed. She didn’t.
“I am becoming more liberal,” she said. “I believe that people should be judged by how they treat the least of our society.” At her sickest, she had been one of them. But she was reluctant to say that health care is a right. “There’s where the conservative side comes in and says, ‘You know what? I work really hard. I deserve a little more than the guy who sits around.’ ”
A right makes no distinction between the deserving and the undeserving, and that felt perverse to Maria and Joe. They both told me about people they know who don’t work and yet get Medicaid coverage with no premiums, no deductibles, no co-pays, no costs at all—coverage that the Duttons couldn’t dream of.
“I see people on the same road I live on who have never worked a lick in their life,” Joe said, his voice rising. “They’re living on disability incomes, and they’re healthier than I am.” Maria described a relative who got disability payments and a Medicaid card for a supposedly bad back, while taking off-the-books roofing jobs.
“Frankly, it annoys the crap out of me—they’re nothing but grasshoppers in the system,” Joe said, recalling the fable about the thriftless grasshopper and the provident ant.
The Duttons were doing all they could to earn a living and pay their taxes—taxes that helped provide free health care for people who did nothing to earn it. Meanwhile, they faced thousands of dollars in medical bills themselves. That seemed wrong. And in their view government involvement had only made matters worse.
“My personal opinion is that anytime the government steps in and says, ‘You must do this,’ it’s overstepping its boundaries,” Joe said. “A father, mother, two kids working their asses off—they’re making minimum wage and are barely getting by—I have no problem helping them. If I have someone who’s spent his whole life a drunk and a wastrel, no, I have no desire to help. That’s just the basics.”
Such feelings are widely shared. They’re what brought the country within a single vote of repealing major parts of President Obama’s expansion of health-care coverage. Some people see rights as protections provided by government. But others, like the Duttons, see rights as protections from government.
Tim Williams, one of my closest childhood friends, disagreed with the Duttons. Tim is a quiet fifty-two-year-old with the physique of a bodybuilder—he once bench-pressed me when we were in high school—and tightly cropped gray hair that used to be flame red. He survived metastatic melanoma, in the nineties, and losing his job selling motorcycles, during the great recession. He went through a year of chemotherapy and, later, three years without a job. He can figure out how to fix and build almost anything, but, without a college degree, he had few employment options. Hundreds of job applications later, though, he was hired as an operator at our town’s water-treatment plant, where I visited him.
The plant was built in the nineteen-fifties. We walked among giant pipes and valves and consoles that controlled the flow of water from local ground wells through a series of huge pools for filtration, softening, and chlorination, and out to the water towers on the tallest ridges surrounding the town. The low hum of the pump motors churned in the background.
People don’t think about their water, Tim said, but we can’t live without it. It is not a luxury; it’s a necessity of human existence. An essential function of government, therefore, is to insure that people have clean water. And that’s the way he sees health care. Joe wanted government to step back; Tim wanted government to step up. The divide seemed unbridgeable. Yet the concerns that came with each viewpoint were understandable, and I wondered if there were places where those concerns might come together.
Before I entered the field of public health, where it’s a given that health care is a right and not a privilege, I had grown up steeped in a set of core Midwestern beliefs: that you can’t get something for nothing, and that you should be reluctant to impose on others and, likewise, to be imposed upon. Here self-reliance is a totemic value. Athens, Ohio, is a place where people brew their own beer, shoot their own deer, fix their own cars (also grow their own weed, fight their own fights, get their own revenge). People here are survivors.
Monna French was one. She was fifty-three years old and the librarian at Athens Middle School. She’d been through a lot in life. She had started a local taxi company with her first husband, but they couldn’t afford health insurance. When she gave birth to her daughter Maggie and then to her son, Mac, the couple had to pay cash, pray that there’d be no unaffordable complications, and try to leave the hospital the next morning to avoid extra charges. When Monna and her husband divorced, litigation over the business left her with no income or assets.
“I had twenty-six dollars, two kids, and a cat,” she said.
She held down five part-time jobs, working as a teaching assistant for three different schools during the day, bartending at night, and selling furniture at Odd Lots department store on weekends, while her parents helped with the kids. Finally, she got the librarian job. It was classified as clerical work and didn’t pay well. But it meant that her family had health insurance, and a roof over their heads. She also met Larry, an iron worker and Vietnam veteran, who became her second husband. He had two children, but he was older and they were grown. Together, Monna and Larry had a child of their own, named Macie. Then, thirteen years ago, Maggie, at age sixteen, was killed in a car accident. Seven years ago, Larry’s son, Eric, who had spina bifida and multiple medical needs, died suddenly in his sleep, at the age of forty.
After twenty-two years as a librarian, Monna still makes only sixteen dollars and fifty cents an hour. Her take-home pay is less than a thousand dollars a month, after taxes and health-insurance contributions. Her annual deductible is three thousand dollars. Larry, now seventy-four, has retired, and his pension, military benefits, and Medicare helped keep them afloat.
For all her struggles, though, Monna is the kind of person who is always ready to offer a helping hand. When I visited her, there were stacks of posters on her porch, printed for a fund-raiser she was organizing for her daughter’s high-school marching band. She raised money for her township’s volunteer fire brigade. She was the vice-president of her local union, one of the largest in the county, which represents school-bus drivers, clerical staff, custodians, and other non-certified workers. She’d been deeply involved in contract negotiations to try to hold on to their wages and health benefits in the face of cutbacks.
“I don’t know anything about health care,” she protested when I asked her for her thoughts on the subject. In fact, she knew a lot. And, as she spoke, I thought I glimpsed a place where the health-care divide might just allow a bridge.
Monna considered herself a conservative. The notion of health care as a right struck her as another way of undermining work and responsibility: “Would I love to have health insurance provided to me and be able to stay home?” Of course, she said. “But I guess I’m going to be honest and tell you that I’m old school, and I’m not really good at accepting anything I don’t work for.”
She could quit her job and get Medicaid free, she pointed out, just as some of her neighbors had. “They have a card that comes in the mail, and they get everything they need!” she said. “Where does it end? I mean, how much responsibility do tax-paying people like me have? How much is too much?” She went on, “I understand that there’s going to be a percentage of the population that we are going to have to provide for.” When she was a young mother with two children and no home, she’d had to fall back on welfare and Medicaid for three months. Her stepson, Eric, had been on Medicaid and Social Security Disability Insurance before he died. Her eighty-three-year-old mother, who has dementia and requires twenty-four-hour care, was also on Medicaid. “If you’re disabled, if you’re mentally ill, fine, I get it,” Monna said. “But I know so many folks on Medicaid that just don’t work. They’re lazy.” Like the Duttons, she felt that those people didn’t deserve what they were getting.
But then we talked about Medicare, which provided much of her husband’s health care and would one day provide hers. That was different, Monna told me. Liberals often say that conservative voters who oppose government-guaranteed health care and yet support Medicare are either hypocrites or dunces. But Monna, like almost everyone I spoke to, understood perfectly well what Medicare was and was glad to have it.
I asked her what made it different.
“We all pay in for that,” she pointed out, “and we all benefit.” That made all the difference in the world. From the moment we earn an income, we all contribute to Medicare, and, in return, when we reach sixty-five we can all count on it, regardless of our circumstances. There is genuine reciprocity. You don’t know whether you’ll need more health care than you pay for or less. Her husband thus far has needed much less than he’s paid for. Others need more. But we all get the same deal, and, she felt, that’s what makes it O.K.
“I believe one hundred per cent that Medicare needs to exist the way it does,” she said. This was how almost everyone I spoke to saw it. To them, Medicare was less about a universal right than about a universal agreement on how much we give and how much we get.
Understanding this seems key to breaking the current political impasse. The deal we each get on health care has a profound impact on our lives—on our savings, on our well-being, on our life expectancy. In the American health-care system, however, different people get astonishingly different deals. That disparity is having a corrosive effect on how we view our country, our government, and one another.
The Oxford political philosopher Henry Shue observed that our typical way of looking at rights is incomplete. People are used to thinking of rights as moral trump cards, near-absolute requirements that all of us can demand. But, Shue argued, rights are as much about our duties as about our freedoms. Even the basic right to physical security—to be free of threats or harm—has no meaning without a vast system of police departments, courts, and prisons, a system that requires extracting large amounts of money and effort from others. Once costs and mechanisms of implementation enter the picture, things get complicated. Trade-offs now have to be considered. And saying that something is a basic right starts to seem the equivalent of saying only, “It is very, very important.”
Shue held that what we really mean by “basic rights” are those which are necessary in order for us to enjoy any rights or privileges at all. In his analysis, basic rights include physical security, water, shelter, and health care. Meeting these basics is, he maintained, among government’s highest purposes and priorities. But how much aid and protection a society should provide, given the costs, is ultimately a complex choice for democracies. Debate often becomes focussed on the scale of the benefits conferred and the costs extracted. Yet the critical question may be how widely shared these benefits and costs are.
Arnold Jonas is another childhood friend of mine. Blond, ruddy-faced, and sporting a paunch at fifty-two, he has rarely had a nine-to-five job and isn’t looking for one. The work he loves is in art and design—he once designed a project for the Smithsonian—but what usually pays the bills is physical labor or mechanical work. He lives from paycheck to paycheck. (“Retirement savings? Ha! You’re funny, Atul.”) Still, he has always known how to take care of himself. “I own my house,” he told me. “I have no debts.”
This is a guy who’s so handy that the cars he drives are rehabbed wrecks rebuilt from spare parts—including the old Volvo that he drove to the strip-mall Mexican restaurant near my family’s house, where we were catching up. But when I asked him about health care he could only shake his head.
“I just try not to think about it,” he said. He hadn’t seen a doctor in at least a decade. He got a health-care plan through an insurance-agent friend, but could only afford one with minimal benefits. He wasn’t sure whether he’d got an Obamacare subsidy. “I don’t read the fine print, because it’s going to be completely confusing anyway.” All he knew was that the plan cost him a hundred and ten dollars a month, and the high deductible (however many thousands of dollars it was, it was well beyond his savings account) made doctors’ visits almost out of the question.
“I am lucky I can get my teeth looked at because I’m dating a dental hygienist. But”—here he showed me his white-toothed grin—“I can’t date a dental hygienist and a cardiologist.”
Arnold, with his code of self-reliance, had eliminated nearly all sources of insecurity from his life. But here was one that was beyond his control. “The biggest worry I have would be some sort of health-care need,” he said. A serious medical issue would cost him his income. As an independent contractor, he isn’t eligible for unemployment benefits. And, having passed the age of fifty, he was just waiting for some health problem to happen.
So did he feel that he had a right to health care? No. “I never thought about it as a matter of rights,” he said. “A lot of these things we think are rights, we actually end up paying for.” He thinks that the left typically plays down the reality of the costs, which drives him crazy. But the right typically plays down the reality of the needs, which drives him crazy, too.
In his view, everyone has certain needs that neither self-reliance nor the free market can meet. He can fix his house, but he needs the help of others if it catches fire. He can keep his car running, but he needs the help of others to pave and maintain the roads. And, whatever he does to look after himself, he will eventually need the help of others for his medical care.
“I think the goal should be security,” he said of health care. “Not just financial security but mental security—knowing that, no matter how bad things get, this shouldn’t be what you worry about. We don’t worry about the Fire Department, or the police. We don’t worry about the roads we travel on. And it’s not, like, ‘Here’s the traffic lane for the ones who did well and saved money, and you poor people, you have to drive over here.’ ” He went on, “Somebody I know said to me, ‘If we give everybody health care, it’ll be abused.’ I told her that’s a risk we take. The roads are abused. A lot of things are abused. It’s part of the deal.”
He told me about a friend who’d undergone an emergency appendectomy. “She panicked when she woke up in the hospital realizing it would cost her a fortune,” he said. “Think about that. A lot of people will take a crappy job just to get the health benefits rather than start an entrepreneurial idea. If we’re talking about tax breaks for rich people to create jobs and entrepreneurialism, why not health care to allow regular people to do the same thing?”
As he saw it, government existed to provide basic services like trash pickup, a sewer system, roadways, police and fire protection, schools, and health care. Do people have a right to trash pickup? It seemed odd to say so, and largely irrelevant. The key point was that these necessities can be provided only through collective effort and shared costs. When people get very different deals on these things, the pact breaks down. And that’s what has happened with American health care.
The reason goes back to a seemingly innocuous decision made during the Second World War, when a huge part of the workforce was sent off to fight. To keep labor costs from skyrocketing, the Roosevelt Administration imposed a wage freeze. Employers and unions wanted some flexibility, in order to attract desired employees, so the Administration permitted increases in health-insurance benefits, and made them tax-exempt. It didn’t seem a big thing. But, ever since, we’ve been trying to figure out how to cover the vast portion of the country that doesn’t have employer-provided health insurance: low-wage workers, children, retirees, the unemployed, small-business owners, the self-employed, the disabled. We’ve had to stitch together different rules and systems for each of these categories, and the result is an unholy, expensive mess that leaves millions unprotected.
No other country in the world has built its health-care system this way, and, in the era of the gig economy, it’s becoming only more problematic. Between 2005 and 2015, according to analysis by the economists Alan Krueger and Lawrence Katz, ninety-four per cent of net job growth has been in “alternative work arrangements”—freelancing, independent contracting, temping, and the like—which typically offer no health benefits. And we’ve all found ourselves battling over who deserves less and who deserves more.
The Berkeley sociologist Arlie Russell Hochschild spent five years listening to Tea Party supporters in Louisiana, and in her masterly book “Strangers in Their Own Land” she identifies what she calls the deep story that they lived and felt. Visualize a long line of people snaking up a hill, she says. Just over the hill is the American Dream. You are somewhere in the middle of that line. But instead of moving forward you find that you are falling back. Ahead of you, people are cutting in line. You see immigrants and shirkers among them. It’s not hard to imagine how infuriating this could be to some, how it could fuel an America First ideal, aiming to give pride of place to “real” Americans and demoting those who would undermine that identity—foreigners, Muslims, Black Lives Matter supporters, feminists, “snowflakes.”
Our political debates seem to focus on what the rules should be for our place in line. Should the most highly educated get to move up to the front? The most talented? Does seniority matter? What about people whose ancestors were cheated and mistreated?
The mistake is accepting the line, and its dismal conception of life as a zero-sum proposition. It gives up on the more encompassing possibilities of shared belonging, mutual loyalty, and collective gains. America’s founders believed these possibilities to be fundamental. They held life, liberty, and the pursuit of happiness to be “unalienable rights” possessed equally by all members of their new nation. The terms of membership have had to be rewritten a few times since, sometimes in blood. But the aspiration has endured, even as what we need to fulfill it has changed.
When the new country embarked on its experiment in democracy, health care was too primitive to matter to life or liberty. The average citizen was a hardscrabble rural farmer who lived just forty years. People mainly needed government to insure physical security and the rule of law. Knowledge and technology, however, expanded the prospects of life and liberty, and, accordingly, the requirements of government. During the next two centuries, we relied on government to establish a system of compulsory public education, infrastructure for everything from running water to the electric grid, and old-age pensions, along with tax systems to pay for it all. As in other countries, these programs were designed to be universal. For the most part, we didn’t divide families between those who qualified and those who didn’t, between participants and patrons. This inclusiveness is likely a major reason that these policies have garnered such enduring support.
Health care has been the cavernous exception. Medical discoveries have enabled the average American to live eighty years or longer, and with a higher quality of life than ever before. Achieving this requires access not only to emergency care but also, crucially, to routine care and medicines, which is how we stave off and manage the series of chronic health issues that accumulate with long life. We get high blood pressure and hepatitis, diabetes and depression, cholesterol problems and colon cancer. Those who can’t afford the requisite care get sicker and die sooner. Yet, in a country where pretty much everyone has trash pickup and K-12 schooling for the kids, we’ve been reluctant to address our Second World War mistake and establish a basic system of health-care coverage that’s open to all. Some even argue that such a system is un-American, stepping beyond the powers the Founders envisioned for our government.
In fact, in a largely forgotten episode in American history, Thomas Jefferson found himself confronting this very matter, shortly after his Inauguration as our third President, in 1801. Edward Jenner, in England, had recently developed a smallpox vaccine—a momentous medical breakthrough. Investigating the lore that milkmaids never got smallpox, he discovered that material from scabs produced by cowpox, a similar condition that afflicts cattle, induced a mild illness in people that left them immune to smallpox. Smallpox epidemics came with a mortality rate of thirty per cent or higher, and wiped out upward of five per cent of the population of cities like Boston and New York. Jefferson read Jenner’s report and arranged for the vaccination of two hundred relatives, neighbors, and slaves at Monticello. The President soon became vaccination’s preëminent American champion.
But supplies were difficult to produce, and the market price was beyond the means of most families. Jefferson, along with his successor, James Madison, believed in a limited role for the federal government. They did not take expanding its power and its commitments lightly. By the time Jefferson finished his two terms as President, however, city and state governments had almost entirely failed to establish programs to provide vaccines for their citizens. Thousands of lives continued to be lost to smallpox outbreaks. Meanwhile, vaccination programs in England, France, and Denmark had dramatically curbed the disease and measurably raised the national life expectancy. So, at Jefferson’s prompting, and with Madison’s unhesitating support, Congress passed the Vaccine Act of 1813 with virtually no opposition. A National Vaccine Agent was appointed to maintain stocks of vaccine and supply it to any American who requested it. The government was soon providing free vaccine for tens of thousands of people each year. It was the country’s first health-care entitlement for the general population. And its passage wasn’t in the least controversial.
Two centuries later, the Affordable Care Act was passed to serve a similar purpose: to provide all Americans with access to the life-preserving breakthroughs of our own generation. The law narrowed the yawning disparities in access to care, levied the taxes needed to pay for it, and measurably improved the health of tens of millions. But, to win passage, the A.C.A. postponed reckoning with our generations-old error of yoking health care to our jobs—an error that has made it disastrously difficult to discipline costs and insure quality, while severing care from our foundational agreement that, when it comes to the most basic needs and burdens of life and liberty, all lives have equal worth. The prospects and costs for health care in America still vary wildly, and incomprehensibly, according to your job, your state, your age, your income, your marital status, your gender, and your medical history, not to mention your ability to read fine print.
Few want the system we have, but many fear losing what we’ve got. And we disagree profoundly about where we want to go. Do we want a single, nationwide payer of care (Medicare for all), each state to have its own payer of care (Medicaid for all), a nationwide marketplace where we all choose among a selection of health plans (Healthcare.gov for all), or personal accounts that we can use to pay directly for health care (Health Savings Accounts for all)? Any of these can work. Each has been made to work universally somewhere in the world. They all have their supporters and their opponents. We disagree about which benefits should be covered, how generous the financial protection should be, and how we should pay for it. We disagree, as well, about the trade-offs we will accept: for instance, between increasing simplicity and increasing choice; or between advancing innovation and reducing costs.
What we agree on, broadly, is that the rules should apply to everyone. But we’ve yet to put this moral principle into practice. The challenge for any plan is to avoid the political perils of a big, overnight switch that could leave many people with higher costs and lower benefits. There are, however, many options for a gradual transition. Just this June, the Nevada legislature passed a bill that would have allowed residents to buy into the state’s Medicaid plan—if the governor hadn’t vetoed it. A similar bill to allow people to buy into Medicare was recently introduced in Congress. We need to push such options forward. Maintaining the link between health coverage and jobs is growing increasingly difficult, expensive, and self-defeating. But deciding to build on what’s currently working requires overcoming a well of mistrust about whether such investments will really serve a shared benefit.
My friend Betsy Anderson, who taught eighth-grade English at Athens Middle School for fifteen years, told me something that made me see how deep that well is. When she first started out as a teacher, she said, her most satisfying experiences came from working with eager, talented kids who were hungry for her help in preparing them for a path to college and success. But she soon realized that her class, like America as a whole, would see fewer than half of its students earn a bachelor’s degree. Her job was therefore to try to help all of her students reach their potential—to contribute in their own way and to pursue happiness on their own terms.
But, she said, by eighth grade profound divisions had already been cemented. The honors kids—the Hillary Clintons and Mitt Romneys of the school—sat at the top of the meritocratic heap, getting attention and encouragement. The kids with the greatest needs had special-education support. But, across America, the large mass of kids in the middle—the ones without money, book smarts, or athletic prowess—were outsiders in their own schools. Few others cared about what they felt or believed or experienced. They were the unspecial and unpromising, looked down upon by and almost completely separated from the college-bound crowd. Life was already understood to be a game of winners and losers; they were the designated losers, and they resented it. The most consistent message these students had received was that their lives were of less value than others’. Is it so surprising that some of them find satisfaction in a politics that says, essentially, Screw ’em all?
I met with Mark, a friend of Arnold’s, at the Union Street Diner, uptown near the campus of Ohio University, which makes Athens its home. The diner was a low-key place that stayed open twenty-four hours, with Formica tables and plastic cups, and a late-night clientele that was a mixture of townies and drunken students. I ordered a cheeseburger and onion rings. Mark ordered something healthier. (He asked me not to use his last name.) The son of a state highway patrolman, he had graduated from Athens High School five years ahead of me. Afterward, he worked as a cable installer, and got married at twenty-three. His wife worked at the Super Duper grocery store. Their pay was meagre and they were at the mercy of their bosses. So, the next year, they decided to buy a convenience store on the edge of town.
Mark’s father-in-law was a builder, and he helped them secure a bank loan. They manned the register day and night, and figured out how to make a decent living. It was never a lot of money, but over time they built up the business, opening gas pumps, and hiring college students to work the counter part time. They were able to make a life of it.
They adopted a child, a boy who was now a twenty-five-year-old graduate of the local university. Mark turned fifty-seven and remained a lifelong conservative. In general, he didn’t trust politicians. But he felt that Democrats in particular didn’t seem to recognize when they were pushing taxes and regulations too far. Health-care reform was a prime example. “It’s just the whole time they were coming up with this idea from copying some European model,” he said. “And I’m going, ‘Oh shit. This is not going to end up good for Mark.’ ” (Yes, he sometimes talks about himself in the third person.)
For his health coverage, Mark trusted his insurance agent, whom he’d known for decades, more than he trusted the government. He’d always chosen the minimum necessary, a bare-bones, high-deductible plan. He and his wife weren’t able to conceive, so they didn’t have to buy maternity or contraceptive coverage. With Obamacare, though, he felt forced to pay extra to help others get benefits that he’d never had or needed. “I thought, Well, here we go, I guess I’m now kicking in for Bill Gates’s daughter’s pregnancy, too.” He wanted to keep government small and taxes low. He was opposed to Obamacare.
Then, one morning a year ago, Mark’s back started to hurt. “It was a workday. I grabbed a Tylenol and I go, ‘No, this isn’t going to work, the pain’s too weird.’ ” It got worse, and when the pain began to affect his breathing he asked his wife to drive him to the emergency room.
“They put me in a bed, and eight minutes later I’m out,” he recalled. “I’m dying.” Someone started chest compressions. A defibrillator was wheeled in, and his heart was given a series of shocks. When he woke up, he learned that he’d suffered cardiac arrest. “They said, ‘Well, you’re going to Riverside’ ”—a larger hospital, in Columbus, eighty miles away. “And I went back out again.”
He’d had a second cardiac arrest, but doctors were able to shock him back to life once more. An electrocardiogram showed that he’d had a massive heart attack. If he was going to survive, he needed to get to Columbus immediately for emergency cardiac catheterization. The hospital got him a life-flight helicopter, but high winds made it unsafe to fly. So they took him by ground as fast as an ambulance could go. On the procedure table, a cardiologist found a blockage in the left main artery to his heart—a “widow-maker,” doctors call it—and stented it open.
“The medicine is just crazy good,” Mark said. “By twelve-thirty, I was fixed.”
After that, he needed five days in the hospital and several weeks at home to recover. Although he had to take a pile of drugs to reduce the chance of a recurrence, he got his strength back. He was able to resume work, hang out with his buddies, live his life.
It was only after this experience that Mark realized what the A.C.A. had given him. Like twenty-seven per cent of adults under sixty-five, he now had a preëxisting condition that would have made him uninsurable on the individual market before health-care reform went into effect. But the A.C.A. requires insurers to accept everyone, regardless of health history, and to charge the healthy and the less healthy the same community rate.
“This would have been a bad story for Mark,” he said. “Because the same time you’re being life-flighted is the same time you lose value to an employer. Your income is done.”
He no longer opposed the requirement that people get insurance coverage. Fire insurance wouldn’t work if people paid for it only when their house was on fire, and health insurance wouldn’t work if people bought it only when they needed it. He was no longer interested in repealing protections for people like him.
In this, he was like a lot of others. In 2013, before the implementation of the A.C.A., Americans were asked whether it was the government’s responsibility to make sure that everyone had health-care coverage, and fifty-six per cent said no. Four years after implementation, sixty per cent say yes.
“But that doesn’t mean I have to sign on for full-blown socialism—cradle-to-grave everything,” Mark said. “It’s a balance.” Our willingness to trust in efforts like health reform can be built on experience, as happened with Mark, though we must recognize how tenuous that trust remains. Two sets of values are in tension. We want to reward work, ingenuity, self-reliance. And we want to protect the weak and the vulnerable—not least because, over time, we all become the weak and vulnerable, unable to get by without the help of others. Finding the balance is not a matter of achieving policy perfection; whatever program we devise, some people will put in more and some will take out more. Progress ultimately depends on whether we can build and sustain the belief that collective action genuinely results in collective benefit. No policy will be possible otherwise.
Eight years after the passage of the Vaccine Act of 1813, a terrible mistake occurred. The Agent accidentally sent to North Carolina samples containing smallpox, instead of cowpox, causing an outbreak around the town of Tarboro that, in the next few months, claimed ten lives. The outrage over the “Tarboro Tragedy” spurred Congress to repeal the program, rather than to repair it, despite its considerable success. As a consequence, the United States probably lost hundreds of thousands of lives to a disease that several European programs had made vanishingly rare. It was eighty years before Congress again acted to insure safe, effective supplies of smallpox vaccine.
When I told this story to people in Athens, everyone took the repeal to be a clear mistake. But some could understand how such things happen. One conservative thought that the people in North Carolina might wonder whether the reports of lives saved by the vaccine were fake news. They saw the lives lost from the supposed accident. They knew the victims’ names. As for the lives supposedly saved because of outbreaks that didn’t occur—if you don’t trust the government’s vaccines, you don’t necessarily trust the government’s statistics, either.
These days, trust in our major professions—in politicians, journalists, business leaders—is at a low ebb. Members of the medical profession are an exception; they still command relatively high levels of trust. It does not seem a coincidence that medical centers are commonly the most culturally, politically, economically, and racially diverse institutions you will find in a community. These are places devoted to making sure that all lives have equal worth. But they also pride themselves on having some of the hardest-working, best-trained, and most innovative people in society. This isn’t to say that doctors, nurses, and others in health care fully live up to the values they profess. We can be condescending and heedless of the costs we impose on patients’ lives and bank accounts. We still often fail in our commitment to treating equally everyone who comes through our doors. But we’re embarrassed by this. We are expected to do better every day.
The repeal of the Vaccine Act of 1813 represented a basic failure of government to deliver on its duty to protect the life and liberty of all. But the fact that public vaccination programs eventually became ubiquitous (even if it took generations) might tell us something about the ultimate direction of our history—the direction in which we are still slowly, fitfully creeping.
On Mark’s last day in the hospital, the whole team came in to see him. He thanked them. “But I didn’t thank them for taking care of me,” he said. “I thanked them for when I was smoking, drinking, and eating chicken wings. They were all here working and studying, and I appreciated it.”
“That’s what you thanked them for?”
“Yeah,” he said. “Because if Mark wasn’t going to stop this, they were going to have to keep working hard. Something had to happen because Mark was clogging up.” And those people did keep working hard. They were there getting ready for Mark, regardless of who he would turn out to be—rich or poor, spendthrift or provident, wise or foolish. “I said, I am glad they do this every day, but I’m hoping to do it only once.” ♦
Sanders-Klobuchar Shred GOP Cruelty in Lopsided Debate Against Graham-Cassidy
by Jake Johnson - Common Dreams - September 26, 2017
Shortly following Sen. Susan Collins' (R-Maine) announcement that she plans to vote against the latest iteration of Trumpcare—likely dealing a death blow to deeply unpopular legislation that was already teetering on the edge of collapse—Sens. Bernie Sanders (I-Vt.) and Amy Klobuchar (D-Minn.) piled it on the GOP Monday night in a CNN-hosted debate against the principal architects of the floundering bill, Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.).
"Our job as a humane society is to do a couple of things," Sanders said in the heat of a dispute with Cassidy over his bill's proposed cuts to Medicaid. "It's not to throw 30 million people off of health insurance. It's to do what every other major country on Earth does, guarantee healthcare to all people as a right. That's what we should be doing."
As Common Dreams reported last week, many Democratic officials and pundits expressed concerns about Sanders' decision to partipate in Monday's debate, worrying that his push for Medicare for All would distract from the immediate task of defeating Republican attempts to repeal the Affordable Care Act.
Sanders quickly proved these warnings to be entirely unfounded, however, as he deftly weaved between discussing the necessity of defeating the GOP's deeply unpopular plan, passing short-term fixes to Obamacare, and fighting for an ambitious alternative, embodied in the Medicare for All bill he—along with 16 Democratic co-sponsors—introduced earlier this month.
Though Klobuchar is one of the Democratic senators who has not sponsored Sanders' bill, the two senators aligned in defense of Planned Parenthood, Medicaid, and key provisions of the Affordable Care Act (ACA) that protect people with preexisting conditions.
"One in five women get their healthcare from Planned Parenthood. And I am strongly opposed to this bill's provisions to defund Planned Parenthood," Klobuchar said, adding also a defense of the ACA's essential benefits requirements.
Republicans, Sanders added, "want to tell 2.5 million women in the United States of America who today choose Planned Parenthood to get their healthcare they can't do that."
While much of the debate centered around Sanders' and Klobuchar's critique of the GOP's "absurd" bill and Graham's rebuttal that Medicare for All—and even tweaks to Obamacare—amounts to creeping socialism, there was at least one point of agreement: the current healthcare system puts too much money in the pockets of massive insurance companies.
After Graham rattled off the stock increases of insurance giants like Cigna, Anthem, and Aetna, Sanders replied: "See, Lindsey, there it is. You actually said something that was right."
"This system is designed to make billions of dollars in profits for the insurance industry," Sanders concluded. "So if we are serious about moving to a cost-effective universal healthcare, yeah, we do have to take on the insurance companies. They do not play a role in providing healthcare. Our money should be going to doctors, to nurses, to hospitals, not to the insurance industry or, in fact, the drug industry, which is charging us by far the highest prices in the world."
Time for Republicans to accept reality
by The Editorial Board - The Washington Post - September 26, 2017
WITH ONE more repeal-and-replace effort in flames, Republicans face a choice. They can continue to live in a fantasy world in which it is possible simultaneously to uproot Obamacare, slash federal spending on health care and widen health-care coverage. Or they can finally accept reality and strike a deal with Democrats to improve the Affordable Care Act.
Democrats, contrary to GOP rhetoric of recent weeks, are ready and willing. It was Republicans who shut down bipartisan negotiations this month in an attempt to push a repeal-and-replace bill through Congress. The bipartisan process could restart quickly.
Senate leaders decided Tuesday not to hold a vote on their most recent health-care bill, Cassidy-Graham, once it became clear that they lacked enough votes to pass it. Sen. John McCain (R-Ariz.) struck a blow against it last week by sticking to his principled stand in favor of a fair, bipartisan process — the opposite of what has taken place here. Then on Monday the Congressional Budget Office reported that the bill would result in “millions” losing coverage. Congress’s official scorekeeper has found the same about every major repeal-and-replace bill.
So now what? Senate Health, Education, Labor and Pensions Committee Chairman Lamar Alexander (R-Tenn.) and lead committee Democrat Patty Murray (Wash.) have held hearings on stabilizing Obamacare insurance marketplaces, gathered input from colleagues and bargained over the outlines of a deal. The emerging framework would satisfy neither Republicans calling for drastic reductions in government spending and regulation nor Democrats seeking a public-option health-care plan. But it is the obvious first step that an ideologically diverse yet functional Congress would take to stabilize the health-care system.
Under such a compromise, Republicans would agree to fund subsidies that help poor people with out-of-pocket expenses. Obamacare funding was intended to be permanent, but Republicans have threatened to eliminate it. More money might also go into programs to encourage insurance enrollment and to establish “reinsurance” programs, which help insurers cover high-cost enrollees. Reinsurance has driven down premiums in high-cost states such as Alaska.
Democrats, meanwhile, would allow states more room to experiment. For example, instead of forcing every state that wants to change rules within the Obamacare system to get a complex waiver, federal authorities could offer a pre-vetted “menu” of options. If a state did not like the menu, the waiver process itself would also get less onerous. These sorts of reforms could do a lot toward what Republicans insist their current health-care bill is meant to do — allow states freedom to design new health-care systems — while preserving the basic Obamacare guarantee of coverage for all.
Democrats might also allow Americans to buy into “copper” health-insurance plans, designed to cover fewer costs, but at lower premiums, than current Obamacare offerings. This would address another Republican complaint — that Obamacare is too prescriptive in the sort of coverage it forces Americans to buy.
If Republicans really want a solution, and not just someone to blame, a bipartisan deal is at hand.
Letter to the editor: To Trump and the rest of the Republicans – let someone else fix health care
Portland Press Herald - September 27, 2017
How many rounds have we gone through with the “repeal and replace Obamacare” farce, four or five? I’ve lost count. Yet here we are again with another Republican effort that’s different how?
All I see is another Republican attempt that guts the Affordable Care Act and replaces that troublesome product with something even worse. All the bills they have put forth so far would have resulted in less health care that is more expensive for fewer people and, usually, include tax cuts for the rich. Really, that’s all they’ve got?
For the wealthiest country in the world, it’s a shameful embarrassment. What happened to the Trump campaign rhetoric that we’d get better health care for everyone that was less expensive, and we’d get it fast? Remember that? “It’ll be the best health care ever – believe me” became a Trump mantra. It was either a bold-faced lie or he really had no idea what he was talking about. You choose.
Republicans have had eight-plus years to come up with something better and they have failed. If we want better health care, look to the Bernie Sanders Medicare-for-all movement or all the other industrialized nations that have figured out a universal coverage system.
These Republican health care efforts that are worse, more expensive, with less coverage for fewer people do nothing but prove, once again, that they are the party of the rich, by the rich, for the rich.
Roy Estabrook
North Monmouth
Now What? 5 Looming Challenges For The Affordable Care Act
by Julie Rovner - Maine Public - September 26, 2017
Republicans officially pulled the plug on their last-ditch effort to repeal and replace the Affordable Care Act on Tuesday.
"We don't have the votes," said Sen. Bill Cassidy, R-La., after a closed-door meeting of Senate Republicans. "And since we don't have the votes, we've made the decision to postpone the vote." Cassidy, along with Sen. Lindsey Graham, R-S.C., put together the proposal they hoped could pass the Senate.
As of Sunday, though, the Senate will no longer be able to pass a health law overhaul bill with only a simple majority. That means the bill is effectively dead, for now.
That message was underscored by Senate Majority Leader Mitch McConnell, R-Ky., who said, "Where we go from here is tax reform."
But that does not mean all is smooth sailing for the ACA. Here are five ongoing challenges the law faces.
1. Insurers still face tremendous uncertainty.
Wednesday is the deadline for health insurers to finalize rates for the 2018 individual market open enrollment season, which starts Nov. 1. Yet there has been no resolution to the question of whether the federal government will continue to reimburse insurers for subsidies known as cost-sharing reductions. Those are payments insurers are required to provide to moderate-income enrollees to help them afford deductibles and out-of-pocket costs. The law says the federal government is supposed to make those payments, but a lawsuit has left that an open question, and the Trump administration has repeatedly threatened to stop making the payments.
Without reimbursement of those subsidies, Pennsylvania Health and Human Services Secretary Teresa Miller told the Senate Finance Committee Monday, insurers in her state "reported they would need to request a statewide average increase of 20.3 percent" in the cost of health plan premiums. Those increases are similar nationwide.
A bipartisan effort led by Senate Health, Education, Labor and Pensions Committee Chairman Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., to advance legislation to affirmatively fund the payments was reportedly progressing until Republican leaders stopped them to concentrate on efforts to pass the Graham-Cassidy legislation.
But Alexander and Murray now appear back at it.
Murray said Tuesday she is "ready to keep working on the bipartisan path that could lead to results."
Alexander similarly released a statement that he would "consult" with Murray and others "on a limited bipartisan plan that could be enacted into law to help lower premiums and make insurance available to the 18 million Americans in the individual market in 2018 and 2019."
2. The Trump administration has cut funding for efforts to sign people up for insurance.
Administration officials announced earlier this month major cuts to the "navigator" program, which provides funding to community groups that guide people through the complex task of signing up for health insurance through the online marketplaces. Some groups are losing more than 90 percent of their budgets.
The cuts have forced many groups to lay off workers just before open enrollment begins and to limit the areas they serve.
3. The 2018 enrollment period is half the length of 2017's, and now it will be shorter still.
Trump officials are also slashing by 90 percent the advertising budget that reminds people about open enrollment and how to sign up — from $100 million to $10 million.
Those cuts are even more significant this year because for the first time since the law's implementation, open enrollment starts in November, rather than December, and lasts only 45 days.
"Most people don't know the open enrollment dates, and they don't know that the deadline this year is Dec. 15, not Jan. 31, like last year," wrote Lori Lodes, who ran outreach for the ACA in the Obama administration, in a recent op-ed for Vox.
Trump administration officials said they don't think advertising is cost-effective, but Lodes wrote that "my office produced reams of data that proved the overall effectiveness of outreach advertising."
Additionally, HHS announced late last week that it will shut down HealthCare.gov for maintenance from 12 a.m. to 12 p.m. every Sunday during open enrollment, except for Dec. 10 – a step critics say could further undermine enrollment efforts.
4. The Trump administration is dragging its feet on giving states flexibility to stabilize their markets.
Back in March, Health and Human Services Secretary Tom Price and Centers for Medicare & Medicaid Services chief Seema Verma, who oversees the ACA, sent a letter to states encouraging them to use the law's waiver process to improve the functioning of their individual insurance markets. In particular, they suggested states could create "reinsurance" programs that would help lower premiums by providing a payment mechanism for the most expensive patients.
But when Minnesota took up that invitation, the administration delayed its response. When it finally did grant permission last week, HHS also informed the state that it will lose significant funding for a program that provides insurance to the state's low-income residents.
Gov. Mark Dayton, a former Democratic senator, said in a letter to Price that "we have now been informed that Minnesota would lose more federal Basic Health Plan funding than we would receive in federal support for reinsurance," and described the entire waiver process as "nightmarish."
5. Republicans could take another shot at a full overhaul next year — or even this year.
While the acknowledgment that the GOP lacks the votes to overhaul the health law means an immediate vote will not happen, the Republicans have potentially two more shots to try to pass a bill with a simple majority vote.
What triggers the ability to pass a bill in the Senate without threat of filibuster is a formal budget resolution. Republicans have still not passed a budget resolution for fiscal 2018, which begins Oct. 1. The upcoming resolution is expected to call for a major tax cut bill. Some Republicans, notably Graham himself, have suggested adding health language to that resolution, which would be allowed.
But that would complicate efforts for both bills.
More likely is that Republicans could try again for a health overhaul via its fiscal 2019 budget resolution, which is due next April. That would leave them only a few months before the 2018 elections. Still, it's possible, particularly if they can use the time to reach consensus.
That is clearly what sponsors of the latest GOP bill have in mind.
"We're on a path to pass" his bill, Graham told reporters. "It's just a matter of when. It will be in this Congress, under a better process."
Americans have been fighting over government's role in medical care for decades. That fight will continue
by Steve Tarzynski - LA Times - September 27, 2017
In 1978, I was on overnight duty in the pediatric emergency room at Los Angeles County Hospital. It had been a busy night and I was looking forward to the end of shift. At about 4 a.m., a man with a frantic expression came rushing into the ER carrying what looked like a small log wrapped in a blanket. His 4-year-old son had suffered an asthma attack and the man had bypassed several private-hospital ERs on the way to the public hospital. He’d previously been refused emergency care at the private hospitals due to lack of insurance. On this occasion, the father did not want to waste time and took the much longer drive to Big County. I took the bundle from his arms and rushed into the treatment room.
As soon as I unwrapped the child, I could tell that he had died en route. I tried to resuscitate him, but to no avail. I informed the father that his son had died, and he responded as one might expect. Sometime later, as I was standing outside the ER watching the sun come up and trying to make sense of what had happened, the father stepped outside too. I stammered an apology for not being able to save his son. He said, “It’s OK, doc. It’s not your fault his father is a poor man.”
In the decades since I worked at Big County, government action has made it possible for today’s children and their parents to avoid the same fate of that little boy and his father. In 1986, the federal government passed the Emergency Medical Treatment and Active Labor Act, which prohibits private emergency rooms from refusing to provide care because of inability to pay. More recently, the Affordable Care Actextended insurance coverage to tens of millions of Americans.
Republicans have, of course, been trying to overturn the ACA, most recently with the Graham-Cassidy bill. Although that particular fight is over (enough Republicans came out against the bill to doom its prospects), it’s only the latest in a long war over the role of government in healthcare — and one that’s sure to continue.
Washington first acknowledged its responsibility in the domain of public health in 1798, when President John Adams signed “An Act for the relief of sick and disabled seamen.” It deducted 20 cents per month from seamen’s wages to fund their medical care and build hospitals dedicated to their welfare. (Sounds like the individual mandate, no?)
Despite this long tradition, many on the right have never accepted the idea that government should use its power to improve citizens’ physical well-being.
In 1929, “big-government” opponents in Congress defeated the Sheppard-Towner Act, which would have provided annual grants to local public health departments for maternal and child health programs.
In 1965, conservatives again banded together to fight the passage of Medicare. Despite a ferocious lobbying campaign and a right-wing grass-roots effort that foreshadowed the tea party movement, progressives won out. And thank God they did. Prior to Medicare, one out of three seniors lived in poverty and countless families abandoned their aging parents at the doors of the nation’s emergency rooms because they were unable to pay for their care. Such scenes disappeared with the passage of Medicare.
Many on the right, however, have never come around to Medicare or Medicaid, the health insurance program for the poor, much less the ACA. Republican opposition to government-regulated medical care is partially based on the view that government governs best which governs least. Conservatives associate liberty with markets.
They may not realize it but they have more than a little in common, ideologically, with the early 17th century British statesmen who crafted the Elizabethan Poor Laws. These laws gave local governments the power to raise taxes to maintain almhouses and provide relief for the “worthy” poor, including the elderly. But they also mandated that the “able-bodied poor” be set to work in a House of Industry and sent the “idle poor” to Houses of Correction. In their twisted logic, poor people were only desperate because they were lazy or morally inferior to the wealthy.
GOP legislators echo these obsolete ideas when they talk about indigent “able-bodied adults” needing to work to deserve health insurance. The Graham-Cassidy bill would devolve all Medicaid funding to the states and give them the option to place a “work requirement” before “able-bodied” adults can “deserve” health insurance. No other civilized nation makes such a demand on its people.
From my decades of experience as a doctor, it seems to me that no market-driven healthcare system can simultaneously limit costs, guarantee universal coverage and deliver desired outcomes. Overwhelming evidence demonstrates that the best way to reduce costs and guarantee healthcare to everyone is to have the largest risk pool — that is, the entire nation. These facts compel the United States to move to a single-payer system guided by comparisons with other countries’ experiences and by our own American successes, such as Medicare and Medicaid.
The preamble of our Constitution states that government exists to provide “domestic tranquility” and “promote the general welfare,” which certainly suggests constitutional support for healthcare for all, including poor children with asthma. Regardless of the outcome of the current effort against the role of government in medical care, the fight goes on.
Steve Tarzynski is a physician and president of the California Physicians Alliance.
Proposal Would Provide Universal Home Health Care to Mainers
by Jennifer Mitchell - Maine Public - September 27, 2017
The Maine People’s Alliance has launched a campaign to put a universal home health care initiative before voters in 2018.
“There are far too many Maine families right now that are going broke because they can’t afford to care for their elders,” says Mike Tipping with the Maine People’s Alliance.
Tipping says the citizen’s initiative would establish a program to provide in-home services and support for those with disabilities, and for those over age 65. He says the program would be funded through a 1.9 percent payroll tax on incomes over $127,000.
“The wealthy don’t like to pay more in taxes and I think they will definitely mount an opposition campaign to this,” he says.
Matt Gagnon with the Maine Heritage Policy Center says the proposal will discourage those with higher incomes at a time when the state needs more investment.
“If you’re disincentivizing people who are wealthy to live here, you’re also disincentivizing business — particularly small business — to be here, which does not help the people that are left in the state. So as with I think all of these proposals from them, it’s a very bad idea,” he says.
Initiative supporters say something must be done to fill gaps in Medicare and provide for better home health service, as Maine’s senior population is set to double by 2030.
Supporters must submit more than 61,000 valid signatures by Jan. 2018.
Anthem retreats from ACA market in Maine
by Jackie Farwell - Bangor Daily News - September 27, 2017
Anthem will not sell plans through the Affordable Care Act marketplace in Maine next year, the company announced Wednesday, the deadline for health insurers to decide where to offer coverage under the embattled law.
In retreating from the market in Maine, Anthem leaves just two insurers selling plans through the ACA marketplace. The company cited a “shrinking and deteriorating” customer base and uncertainty at the federal level over the fate of former President Barack Obama’s signature health reform law.
Anthem had previously announced intentions to withdraw or scale back its ACA offerings in several other states, including Nevada and Indiana.
Anthem was one of three insurers that previously sold coverage in Maine through Healthcare.gov, the Affordable Care Act marketplace, or “exchange.” The other two — Community Health Options and Harvard Pilgrim — confirmed they plan to remain in the marketplace in 2018.
Roughly 80,000 Maine residents purchased health insurance last year through Healthcare.gov. They are part of the “individual market,” or those who buy health insurance themselves rather than getting coverage through work or government programs such as Medicaid.
Anthem serves about 29,000 people in Maine’s individual market.
Anthem and the other insurers stated in earlier regulatory filings that they expect Maine’s individual market to dwindle while growing more expensive to cover. With the Trump administration signaling that it won’t enforce Obamacare penalties for failing to buy insurance, healthy people are already beginning to skip coverage, they stated. That’s expected to leave primarily sicker, older people who most need insurance as customers in the Obamacare market.
In announcing its decision, Anthem noted the uncertainty surrounding a federal tax on health insurers and subsidies that help consumers afford coverage.
About half of Maine residents insured under Obamacare relied on the subsidies in 2017.
The subsidies help low-income enrollees afford out-of-pocket costs such as deductibles and copays. Insurers cover the expense of the subsidies up front, with the understanding that the federal government will reimburse them.
But the future of those payments remains up in the air, due to a lawsuit filed by the U.S. House of Representatives and congressional Republicans’ repeated but so far unsuccessful efforts to repeal Obamacare.
“While we are pleased that some steps have been taken to address the long-term challenges all health plans serving the individual market are facing, the market remains volatile,” Colin Manning, a regional spokesman for Anthem, said. “A stable insurance market is dependent on products that create value for consumers through the broad spreading of risk and a known set of conditions upon which rates can be developed.”
Anthem will sell only one plan in Maine’s individual market next year, outside of the Obamacare marketplace. The plan is categorized as a “gold” policy under the ACA, generally providing generous coverage but with higher premiums. That plan will be available only in Aroostook, Hancock and Washington counties, the company said.
Existing customers who purchased Anthem plans through the exchange can renew their current plans in 2018 but only off the exchange, the company said. That means those customers will not receive the federal subsidies next year, even if the government continues to fund them, or tax credits that offset monthly premium costs.
In the wake of Anthem’s announcement, Maine Insurance Superintendent Eric Cioppa urged consumers in the individual market to compare their options before the open enrollment period, which begins Nov. 1, ends on Dec. 15.
“As most people are well aware, there has been quite a bit of turmoil in the insurance market this year. This has resulted in higher rates, and also in fewer choices,” Cioppa said.
The subsidies for out-of-pocket costs, known as “cost-sharing reductions” are attached to silver level plans under the ACA, Cioppa noted, which are among the more popular plans.
“The important thing for consumers to know is that because the CSR program has not been funded, silver plans might no longer be the best choice for many consumers, particularly those who are not eligible for CSRs,” Cioppa said.
Earlier this summer, Anthem and the other two insurers informed state regulators how much they planned to charge for ACA plans in 2018. All sought double-digit rate increases, calculated on the assumptions that the federal subsidy payments would continue and that the insurers would participate in the market next year.
Anthem proposed raising monthly premiums by 21.2 percent on average. Cioppa approved a lower increase of 18.8 percent.
Cioppa then asked the insurers to submit a second set of rates that assumed the subsidy payments would be eliminated. Anthem indicated it could leave the ACA market in Maine under those conditions.
“As the marketplace continues to evolve and adjust to changing regulatory requirements and marketplace conditions, we will reevaluate whether a more robust presence in the exchange is appropriate in the future,” Manning said Wednesday.
Community Health Options, a Lewiston health insurance “cooperative” created under the ACA and run by members, plans to increase rates by nearly 16 percent on average next year. Some customers will see increases as low as 6 percent, while rates for others will spike by about 50 percent.
Harvard Pilgrim plans to increase rates by nearly 40 percent.
“Current uncertainty in the market makes it difficult for us and other health insurers to plan constructively for the future, and indecision about subsidies for low-income individuals has further complicated matters,” Harvard Pilgrim Vice President Edward Kane said in a statement. “However, continuing to offer high-quality, high-value health insurance options that meet the varying needs of Maine residents is consistent with our mission and values.”
While many will likely blame Anthem for abandoning the market in Maine, the insurer is reacting to uncertainties created by the Trump administration’s “deliberate sabotage of ACA implementation,” said Mitchell Stein, an independent health policy consultant.
In addition to the unpredictability of the subsidies and requirement that everyone buy insurance, the administration also shortened the open enrollment period to sign up for ACA plans, scheduled Healthcare.gov to be offline for 12 hours of nearly every week of open enrollment, and slashed funding for advertising and navigators who assist consumers, he said.
“These all assure that enrollment for 2018 will be lower than it is in 2017,” Stein said.
Editor's Note:
Have you watched this video of Elizabeth Warren interrogating the Anthem CEO at a recent US Senate hearing? If not, I think you’ll find it instructive:
-SPC
Our View: Meddling from Washington scared Anthem away from Maine
by The Editorial Board - Portland Press Herald - September 28, 2017
Legislative attempts to repeal the Affordable Care Act appear to be dead for now, but that doesn’t mean the law that extended health coverage to 20 million Americans is out of danger.
All that’s changed is who’s spearheading the attacks. For the immediate future, the fight to dismantle Obamacare will be an inside job.
It’s well known that President Trump and his secretary of health and human services, Tom Price, are hostile to the program, and they are doing what they can to undermine its effectiveness – from cutting advertising and outreach that helps new members sign up, to creating uncertainty about whether the federal government can be counted on to continue to fund subsidies.
Not being able to predict how many people could be in the insurance pool, or how much it would cost to cover them, makes it very difficult to design an insurance product, so some companies in different parts of the country have stopped selling individual plans.
And whenever one does, the administration calls attention to it as proof that the program is collapsing under its own weight and not because of their mischief.
That’s the dynamic we’ve seen in Maine this week, with the announcement that Anthem Blue Cross Blue Shield would not sell plans on the individual market here next year.
“A stable insurance market is dependent on products that create value for consumers through the broad spreading of risk and a known set of conditions upon which rates can be developed,” Anthem spokesman Colin Manning said in a written statement. “Today, planning and pricing for ACA-compliant health plans has become increasingly difficult.”
Anthem has about 28,700 customers who would be affected, but that doesn’t mean they will lose their insurance. There are still two companies competing to sell plans on the exchange: Maine Community Health Partners, a consumer-owned cooperative, and the nonprofit Harvard Pilgrim.
But the news is still a big deal. The former Anthem customers will have to shop for new plans, and all consumers in Maine will have fewer choices. It leaves Maine one insurer away from a market with no competition at all.
Obamacare opponents are not wrong when they say there are problems with the law that need to be fixed by Congress to make coverage affordable. But the administration is doing what it can to make the situation worse so it can get the votes it needs to scrap the whole system. With the health and well-being of tens of millions of people at stake, that’s a lousy way to play politics.
Maine Sen. Susan Collins is taking a much better approach. She is part of a bipartisan group in the Senate that’s writing legislation that would stabilize the markets for next year and give Congress time to address the underlying problems.
Health insurance is expensive in this country because health care is expensive, and that’s a problem whether it’s the government or private citizens paying the bills. Hastening a collapse of the market and putting millions of lives in turmoil might win some political points, but it won’t do anything to fix what needs fixing in our health care system.
MCMH staffer loses job after her letter published
Steve Fuller - Ellsworth American - September 27, 2107
ELLSWORTH — A woman who worked at Maine Coast Memorial Hospital (MCMH) for more than 13 years was fired last Thursday after her letter to the editor ran in The Ellsworth American.
Karen Jo Young, a Corea resident, most recently worked in the rehab department at MCMH. She spent 10 years as activities director in the swing bed unit before that. She said she loved working at the hospital but felt that things had gone downhill in recent years, especially since Maine Coast joined forces with Eastern Maine Healthcare Systems (EMHS) in 2015.
She submitted a letter to the editor on Sept. 17. It appeared in the Sept. 21 edition of The American under the title “Unrest at MCMH not a surprise.” In it, she said a recent spate of doctors departing the hospital is causing “unrest, uncertainty and concern among the staff, patients and the community.”
Young also criticized hospital administrators “who work out of their offices and have meeting after meeting and who are not working where patients are being cared for.”
The edition with Young’s letter hit local newsstands on the afternoon of Sept. 20. The next morning, she said she was called down to a meeting in the administrative building.
Present for the meeting were a note taker, Young’s department head and Noah Lundy, regional human resources director for EMHS covering Maine Coast and Blue Hill Memorial Hospital.
Young was given a letter and told she was fired. The complete text of the letter she received is as follows:
“Dear Karen-Jo: This is to inform you that your employment is being terminated effective immediately for violation of EMHS Policy: News Release, External Publication and Media and in accordance with Maine Coast Memorial Hospital (MCMH) progressive disciplinary policy. I regret this action is necessary.”
The letter was signed by Lundy.
Young said getting fired took her by surprise.
“I really thought they would just ignore it,” she said, referring to hospital administrators and her letter. “But they don’t operate that way.”
Young said she did not feel valued as a hospital employee in recent years. She said she voiced concerns about patient safety and other issues inside the hospital prior to writing her letter. In some cases, she said, her concerns were ignored and in other instances she said she was rebuked.
“I did notice, once it switched to EMHS, that it really was, ‘Step in line,’” Young said. “They don’t like you to speak out about anything.”
Maine Coast and EMHS officials declined to provide The American with a copy of the policy that Young was said to have violated. The hospital also declined to address the issue of Young’s firing, saying it was a personnel matter.
“We do not share our policies as related to personnel, business, or other matters,” said Kelley Columber, director of communications for the Blue Hill and Ellsworth hospitals.
Asked Tuesday about Young’s firing, EMHS President and CEO Michelle Hood said she understood it was a result of Young violating the policy referenced in the letter she received.
“We have a policy that directs employees who want to have a public position to work with our community relations folks, and that was not followed,” Hood said.
The American obtained a copy of the “News Release, External Publication, and Media Contact” policy from Mercy Hospital in Portland, which is also an EMHS member. Though some of the language in it is specific to Mercy, it also refers to EMHS employees and says its applicability is “EMHS member-wide.”
The policy states “all news releases, media contacts, outreach and externally directed publications … relating to Mercy Hospital, EMHS and its member organizations” shall come from either the hospital’s or system’s communications staff.
The policy goes on to state that “in no case should a Mercy Hospital employee contact the news media on his/her own initiative regarding patient information or hospital business.”
Does an employee of a hospital or any business have a First Amendment right to free expression? Possibly not. A 2015 article in an American Bar Association magazine suggests otherwise.
In “A Chill Around the Water Cooler: First Amendment in the Workplace,” University of Dayton School of Law professor Jeannette Cox wrote that “to keep your job, you often can’t say what you like.”
The key reason for that, she said, is because the First Amendment only restrains the government — not private businesses — from placing restrictions on what people can and cannot say.
“Most workers have no protection from speech-related termination unless they can prove that their employer’s motive for firing them violates a federal, state or local law,” Cox wrote.
Cox said she thinks that is a bad situation, one that “creates a chilling effect that both dampens individual self-expression and inhibits public discourse.”
Businesses should be entitled to “a certain degree of employer control over employee speech,” Cox wrote. That includes protecting propriety information and barring speech seen as bullying or harassing.
“In most circumstances, however, the average employee’s speech poses little risk of harm to the employer,” Cox concluded. “The harm to the employee created by an employer’s ability to punish speech, by contrast, is significant.”
Young said she is not sure yet what action, if any, she may take in the wake of her firing.
“I’m in the process of seeking legal advice,” she said Tuesday.
Maine needs Medicaid expansion
Dear Editor: Maine law requires everyone in a motor vehicle to wear a seat belt. It is intended to prevent injuries and deaths. There are fines for not wearing seat belts. Imagine if some people were exempt from wearing seat belts because of their income, age or ability. What if adults under 65 who do not have a disability and make less than $16,643 were told not to wear seat belts and they would not be fined?
In that scenario we would be saying that the safety and lives of certain people is of no concern. It is not a problem if they are injured or die. The possibility of unbelted bodies strewn across Maine highways at accident scenes would be OK as long as they were working poor. Does this scenario sound ridiculous?
This November, Referendum Question 2, Medicaid expansion, addresses the very same scenario. Substitute health insurance for seat belts and you have the situation in Maine right now.
Individual adults under 65 who have no employer-sponsored health benefits, make under $16,643 per year and do not have a disability are ineligible for any health insurance at all.
Current federal law fines people for not being covered. Not these people. They are exempt because there is no health insurance for them. Instead of unbelted bodies cluttering highways, we have sick and injured people cluttering emergency rooms seeking service for which they cannot pay. The bills are devastating them and the hospitals.
Seat belt use is the single most effective way to minimize injuries and save lives in motor vehicle accidents. Access to health insurance is the most effective way to minimize the impact of injuries or illness. It saves lives. It saves money too.
Ninety percent of the cost of Medicaid expansion will be paid by the federal government. There are estimates of between $300 million and $500 million being infused into the Maine economy with expansion.
Today, 70,000 Mainers are ineligible for health insurance. That is morally ridiculous and fiscally foolish. Everyone needs a seat belt and everyone needs health insurance too. Let’s make this right. Vote Yes on Question 2 for Medicaid expansion.
Moira O’Neill Surry
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