The Unhealthy Politics of Pork: How It Increases Your Medical Costs

by Dhruv Khullar - NYT - October 25, 2017

No industry in America spends more on lobbying than health care.

In 2016, the health care industry spent half a billion dollars on lobbying, with pharmaceutical companies, hospitals and health professionals making the largest contributions. In 2009, the year the Affordable Care Act was debated, health care lobbying exceeded $550 million. (Last year, by comparison, defense lobbying totaled $129 million, and the gun lobby spent just $10.5 million.)

Closely related to industry lobbying is the political maneuvering that congressional leaders use in an effort to pass legislation — specifically, targeted provisions known as earmarks, “sweeteners” or pork barrel spending.

The final version of the Graham-Cassidy health bill, for example, would have sent extra money to Alaska and Maine for the crucial votes of senators from those states, Lisa Murkowski and Susan Collins. In 2010, Democrats hoping to secure votes from reluctant rural state senators added the “Frontier States” provision to the A.C.A., which increased Medicare payments to five states with low population densities.

We all know earmarks and lobbying influence policymakers and policy. In health care, this has critical implications: who gets care, how much they get, how we pay for it. But there’s little hard data on exactly who benefits and how large the effects can be. A new study illuminates the ways these political dynamics can change congressional and hospital behavior — and how they can increase health care costs for the rest of us.

Research by Zack Cooper, Amanda Kowalski and Jennifer Wu at Yale and by Eleanor Powell at the University of Wisconsin-Madison analyzed a provision in the Medicare Modernization Act of 2003 (M.M.A.), known as Section 508, that helped secure Republican votes for the law’s passage.

The M.M.A., which created Medicare Part D and provided prescription drug coverage for seniors, was a political priority for President George W. Bush ahead of his 2004 re-election campaign. But fiscally conservative Republicans were hesitant to sign on to what amounted to the largest expansion of Medicare in its history, and the bill seemed unlikely to pass.

That’s when Section 508 was added.

The rate at which Medicare pays individual hospitals is determined largely by a hospital’s location and the labor costs, or wage index, in its area. Hospitals can, however, request to be reclassified into a different wage index area to raise their payments. Sometimes there are good reasons for this: Two hospitals might be competing in the same region, and because they’re separated by an arbitrary bureaucratic line, one gets paid more than the other.

But Section 508 waivers created new, more ambiguous ways that hospitals in specific districts could appeal their assigned wage index, and gave the executive branch considerable discretion about which requests would be granted and how big the pay increases would be.

The Section 508 waivers had large effects on how both politicians and hospitals operated. About 400 hospitals applied for a Medicare pay increase, and 120 waivers were granted. Hospitals in districts represented by a Republican member of Congress who voted for the M.M.A. were seven times more likely to receive a waiver compared with those in districts of members who voted against it. On average, these hospitals saw a 6.5 percent increase in Medicare payments, but the 29 hospitals with the biggest payment increases — “high 508 recipient hospitals” — received a 10 percent boost.

How did hospitals spend the extra money? Perhaps unsurprisingly, they started treating more Medicare patients — about 8 percent more per year. They also expanded nursing staffing by roughly a third, and invested in new technologies. But extra cash also meant big raises for hospital C.E.O.s: nearly half a million dollars per year at each hospital. Over all, “high 508 recipient hospitals” had $1.25 billion in additional spending from 2005 to 2010 — about 25 percent more than they otherwise would have. There was no evidence of improved quality or outcomes.

“If you told me in advance that we’d find this tight a link between Congress and hospitals, I would have been very surprised,” Mr. Cooper said. “We knew there was some connection, of course, but the more we kept digging, the stronger and more precise the link became.”

Section 508 payment changes were supposed to expire after three years. But hospitals with lucrative waivers had considerable interest in seeing the program extended, and worked together to form the Section 508 Hospital Coalition.

In the years between passage of the M.M.A., and its reauthorization in 2007, legislators in districts with a Section 508 hospital saw a 22 percent rise in total campaign contributions, and a 65 percent increase in donations from the health care sector specifically. In the end, a provision that budgeted $900 million over three years led to billions in extra spending for nearly a decade.

Pork, it seems, is as bad for budgets as it is for waistlines.

“Every time you pass legislation, big or small, these elements are added in,” Mr. Cooper said. “It’s not that any single one is hugely offensive. It’s their accumulation and continuation over time.”

Although Mr. Cooper’s research offers perhaps the clearest empirical glimpse of the links between lobbying, earmarks and medical spending, this political maneuvering is not new — and Medicare hospital payment seems to be a particularly susceptible target.

Both Democrats and Republicans have won pay increases for hospitals they represent. In the 1999 budget, the House Republican whip, Tom DeLay, and House Speaker Dennis Hastert reclassified hospitals in their districts into other regions, leading to hundreds of thousands of dollars of extra funding per year.

About a dozen years later, in what was called the Bay State Boondoggle, John Kerry, then a senator, succeeded in lobbying for Medicare to pay Massachusetts’ urban hospitals at the same rate it paid the state’s rural hospitals. The catch: There was only one hospital that qualified as “rural” in Massachusetts — on the wealthy island of Nantucket.

None of this is surprising. A primary motive of elected representatives is getting re-elected. Passing expansive legislation — like Medicare Part D or the A.C.A. — is hard, especially when legislators can’t point to specific benefits for their constituents. But a critical flaw in our current system is that payments are hugely influenced by politicians who have every incentive to increase them for their own districts.

“You can’t get upset at a snake for having fangs,” Mr. Cooper told me. “We need to design a system that takes payment decisions out of the hands of elected representatives. We think of interest rates as so important and complicated that we’ve tried to remove politics and give the responsibility to the Fed. The same argument holds for health care. When the government spends a trillion dollars on health care, it’s too easy for members to direct funds to their districts.”

We’ve been close to a possible solution. The A.C.A. called for establishing an Independent Payment Advisory Board, a 15-member panel charged with making changes to Medicare to control costs. The proposed reforms would have been put into effect unless Congress introduced alternate policies to achieve the same savings. But the advisory board faced fierce bipartisan opposition and was never created.

America’s increasingly burdensome health care spending has many roots: new technologies, high drug prices, fragmented care, administrative expenses and the like. But lobbying and political maneuvering can increase costs, too — without clear benefits for patients, communities or society at large.

Often these costs are borne by all of us, while the benefits — if any — go to a favored few. Excess medical spending, then, is driven not only by inefficiencies in our health system, but also by those in our political system. Our solutions, it seems, must confront that uncomfortable reality.

Dhruv Khullar, M.D., M.P.P., is a physician at NewYork-Presbyterian Hospital and a researcher at the Weill Cornell Department of Healthcare Policy andResearch. Follow him on Twitter at @DhruvKhullar.

https://www.nytimes.com/2017/10/25/upshot/the-unhealthy-politics-of-pork-how-it-increases-your-medical-costs.html?

Bipartisan Health Proposal Is Too Late for 2018, but a Salve for 2019

by Reed Abelson and Margot Sanger-Katz - NYT - October 21, 2017

The new bipartisan health proposal is far from a cure-all for Obamacare’s problems, but if it passed it would send health insurers a message they have sought all year: that it’s safe to stay in the marketplaces.

Insurers have already signed contracts and are making final arrangements to sell their products in time for next year’s enrollment period, which begins on Nov. 1. Though the proposal would guarantee payments to health insurers that President Trump canceled last week, and restore funding for Obamacare advertising that his Health and Human Services Department slashed, those changes would probably come too late to lower insurance prices or increase sign-ups significantly.

But the deal proposed this week by Senator Lamar Alexander, a Tennessee Republican, and Senator Patty Murray, a Washington Democrat, has reassured insurance executives. It is aimed at quieting nervous markets and making clear that the Obamacare market will exist beyond this year.

“It’s the first signal we’ve seen in a long time to insurers that the government is not going to actively disrupt the market,” said Craig Garthwaite, a health economist at the Kellogg School of Management at Northwestern University. While two years of funding may not be critical to the market’s stability, it shows “there is some future market,” he said.

A widely circulated draft of the proposed legislation has attracted both compliments and scorn from the president. The legislation is intended to lower premiums and encourage insurer participation. It would guarantee federal payments to insurance companies to offer plans to low-income individuals that reduce their out-of-pocket costs through 2019. The loss of those payments has sent insurance premiums soaring, and is likely to increase federal spending on a different form of Obamacare subsidy, used to help middle-income Americans pay their insurance premiums.

It would make it easier for state governments to tweak Obamacare’s rules on how they run their markets, easing the way for more experiments. The draft bill would make the application process for such “state innovation waivers” easier to complete, but would still require that the state plans cover a similar number of residents and offer insurance with “comparable affordability” to plans established under the Affordable Care Act.

It would allow more Americans to sign up for very high-deductible insurance plans known as catastrophic insurance under the Affordable Care Act. The current law limits those plans to customers under 30 years old, or those who have demonstrated they cannot afford other insurance options.

The draft legislation would also ensure that the federal government assigns money for advertising about the Obamacare enrollment period and for hiring professionals to help customers select and sign up for plans; the money would be a portion of the fees it collects from insurers selling plans on HealthCare.gov. The Trump administration had slashed the budget for both programs in August.

It does not include one of the industry’s biggest requests: funding that would protect insurers from high costs associated with very expensive patients. Insurers and other experts who testified before the Senate health committee said such a program could help substantially lower premiums. But states may be able to use innovation waivers to establish such programs themselves. Alaska has already had such a waiver approved by the Trump administration.

The insurers were generally supportive of the plan, and one of the main associations, America’s Health Insurance Plans, came out with a statement in favor of the proposed bill. But some emphasized that the legislation does not fix all of what ails the market. “We’ve stated repeatedly that the individual market is not stable,” said Joseph R. Swedish, the chief executive of Anthem, a large for-profit insurer that offers Blue Cross plans in several states, although he praised lawmakers’ efforts to provide more certainty in 2019.

The deal’s prospects in Congress remain uncertain. Though some senators from each party have endorsed its approach, several Republicans have spoken out against it. In the House, a spokesman for Speaker Paul Ryan said that “the Senate should keep its focus on repeal and replace of Obamacare.”

But even if the deal moves forward quickly, it is unlikely to affect next year’s health plans. Carriers in most states have raised their prices substantially to make up for the canceled federal payments, and there is little time for them to lower them again if the payments are restored. (The draft bill tries to address this problem, by asking states to establish a new rebate program, where carriers who get paid twice would need to pay back the federal government.)

“For 2018, it probably won’t happen in time,” said Timothy Jost, an emeritus professor of law at Washington and Lee University, who monitors health legislation closely. “The carriers are thinking now about 2019, and it’s very important for 2019.”

Insurance plans for each year go on sale during the prior fall, but the process of devising plans and setting prices begins months earlier. This year, many current insurers announced their exits from the 2018 Obamacare markets months ago, some explicitly naming President Trump’s threats about the cost-sharing payments as a reason. Analysts said it was unclear whether the plan might lure reluctant insurers back into the markets, but they said the funding would cause many insurance premiums to fall in 2019.

But the lengthy planning process of insurers means that the proposed bill’s two-year funding cycle could lead to another round of price increases in 2020, if an extension bill isn’t passed far in advance. Many insurers had been hoping that the Alexander-Murray legislation would make the funding permanent.

While Mr. Trump has insisted he will not support any legislation that he believes to be a bailout to the insurers, policy experts say the insurers are getting only what they are due under the law. Because the insurers set the prices for their 2017 plans assuming they would receive the federal funding, the president’s decision represents more than $1 billion in lost payments, according to a recent analysis from Avalere Health, a consulting firm.

The funding has not contributed to outsize profits for the insurers selling individual policies under the law, in spite of Mr. Trump’s recent tweet about the insurers “who have made a fortune w/ O’Care.” “Most insurance companies have lost money trying to pursue these exchange markets,” said Dan Mendelson, Avalere’s president. Under the Affordable Care Act, insurers are not allowed to pocket more than 20 percent of their premium dollars for overhead and profits. If they earn more, they are required to return the excess to consumers through rebates.

The insurers generally lost money in the first three years of the Obamacare market, said Deep Banerjee, an analyst for Standard & Poor’s, though it appears they were faring better this year, before the cancellation of government payments. “It is not a market that has been profitable for them,” he said. While there are exceptions, most insurers are making their money in other insurance markets like the government programs Medicare and Medicaid as well as in the much larger employer market.

“It gives the market some measure of predictability,” Mr. Banerjee said, but he emphasized that the legislation “is not a permanent solution.” Much of what it does is restore the funding that already existed before President Trump’s announcement that he was cutting it off. “It’s not a huge additional support for the market.”

https://www.nytimes.com/2017/10/19/upshot/bipartisan-health-proposal-is-too-late-for-2018-but-a-salve-for-2019.html?

Single-payer would drastically
change health care in
America. Here’s how it works.

by Kim Soften - The Washington Post - October 17, 2017

As Republican efforts to repeal and replace the Affordable Care Act continue in the background, some Democrats are starting to eye a new health policy goal: implementing a single-payer system. Sen. Bernie Sanders (I-Vt.) introduced a single-payer bill in mid-September with 16 Democratic co-sponsors — 16 more than he got when he introduced the bill two years earlier. But how is the health-care system funded now, and how would “single-payer” change that?

How health-care systems are funded

The payer pays for a portion of the patient’s treatment.

Patients periodically pay premiums (or taxes) to the payer.

When a patient goes to the doctor, they might have to pay a co-pay.

How multi-payer systems work

Virtually all health-care systems follow this general pattern, but who the payers are can vary widely. In the U.S. private insurance market, patients typically purchase coverage from one insurance company among many competing insurers. Because different people end up with different insurers, there are multiple payers throughout the U.S. health-care system.

INSURANCE COMPANIES

Pay for treatment

A patient typically selects one of these insurers to pay.

How single-payer systems work

In a purely single-payer system, there is, as the name would indicate, just one payer — typically the government. This is analogous to how the United States administers some portions of Medicaid: The government provides coverage, and no private insurers are involved.

Pay for treatment

The government covers everyone’s medical expenses, so private plans are not necessary.

Sanders’s bill takes universal coverage close to this extreme: The government insurance would cover so many services with such small co-pays that private insurance would be almost universally unnecessary. Accordingly, it would also be quite expensive — $32 trillion over 10 years, according to an Urban Institute report. That’s more than a 50 percent increase in federal spending — all federal spending — according to spending projections by the Congressional Budget Office. That would be partially offset by people no longer needing to pay premiums to private insurers, however, and the government’s monopoly could allow it to implement cost-saving measures.

But most universal-coverage systems don’t look quite like this. It’s expensive for a government to fund a comprehensive health-care system, especially somewhere like the United States, where costs are so high.

So many governments instead pay for most but not all of their residents’ medical treatment. In those countries, people have the option to buy “supplementary” private insurance, which pays for services such as dental care that the government health-care program excludes. People often also have the choice to buy “complementary” private insurance, which pays for the co-pays and deductibles in the government’s insurance plan.

INSURANCE COMPANIES

Insurers fill

the gaps left by the government.

Pay for treatment

This is analogous to how traditional Medicare (as opposed to Medicare Advantage) operates in the United States. The government pays for a large portion of medical services, but it’s common for people to buy complementary Medigap plans from the private insurance market. And it’s common for people to buy supplementary Medicare Part D plans from private insurers to cover prescription drugs, which are not covered by traditional Medicare.

Countries with universal coverage sit on a spectrum from the least pure to the most pure single payer — that is, governments that offer the least comprehensive care, where complementary or supplementary insurance is more necessary, to those that offer the most comprehensive health-care coverage, with little need for private insurance. (Where one draws the line for “single-payer” vs. merely “universal coverage” is debatable, and largely a semantic problem.)

Some countries, such as Norway, are closer to the “pure” end. They offer such comprehensive coverage that complementary or supplementary private insurance makes up just a small piece of the system. In Canada, by contrast, 29 percent of health-care spending comes from the private sector, and about two-thirds of Canadians hold some sort of private supplementary insurance according to a report from the Commonwealth Fund.

It’s yet to be seen whether Democrats will coalesce around a single-payer plan, and if so, where it will fall on this spectrum.

Icons by Aaron Steckelberg.

About this story

Private-sector spending abroad from the Commonwealth Fund. Private-sector spending domestically from the Center for Medicare and Medicaid Services.

https://www.washingtonpost.com/graphics/2017/national/single-payer-explainer/?

Why ‘Medicare for All’ Will Sink the Democrats

by Steven Rattner - NYT - October 24, 2017

Repeal-and-replace may be done for now, but for Senator Bernie Sanders, the war is just beginning — and it has already become a fracas that is dividing the Democratic Party, to its detriment.

Mr. Sanders — who, of course, isn’t even a registered Democrat — is banging on about what he calls “Medicare for All,” a government-run plan that would provide health care coverage for every American.

But now the crusty Vermont independent wants to be a senatorial pied piper for Democrats. He has made his proposal into a kind of litmus test for who is a “good Democrat,” inveigling 16 of his colleagues — more than a third of Senate Democrats — into endorsing it.

A goodly number of those senators are presidential hopefuls, leaving their prospective campaigns open to attack from Republicans salivating to capitalize on an idea that has historically been a political graveyard. Remember Hillarycare?

As a centrist Democrat, I’m scared to see my party pulled into positions that are both bad politics and dubious policy. And I’m disappointed that few of our party’s moderates are willing to resist the freight train coming at us from the left.

I understand why Mr. Sanders and his acolytes believe that sweeping progressive ideas — however unrealistic they may be — might capture the public imagination better than the more carefully constructed proposals of centrists, policies that are harder to articulate and can come across as mushy.

But the Sanders approach didn’t work for George McGovern in 1972 or Michael Dukakis in 1988, and I don’t believe it will work for Democrats in 2018 or 2020.

Yes, recent polls seem to indicate rising support for single payer. But when factors like whether taxes would be raised or the Affordable Care Act would be repealed are introduced, the consensus swings to opposition.

Spellbound Democrats should also consider the fate of past single payer proposals. In Sanders’s home state of Vermont, a single payer plan was abandoned after an analysis found that it would require a near doubling of the state budget (and increasing taxes similarly).

In Colorado last November, a whopping 80 percent of voters rejected a universal plan, again over taxes and costs. And for similar reasons, California recently shelved a single-payer proposal.

Amid the many complications of Medicare for All, the question of what would happen to the 157 million Americans who get their insurance from their employers and the 19 million who are enrolled in Medicare Advantage loom large.

To be sure, some Democratic senators seem to be supporting Medicare for All as a lever to achieve more modest goals, like a public option within the existing health care exchanges.

For example, Al Franken of Minnesota called the Sanders proposal “aspirational” and “a starting point for where we need to go as a country.”

More like the starting point of a political nightmare for Democrats. For one thing, Mr. Sanders has been unabashed in his attacks on “the establishment wing of the Democratic Party” and has intimated that primary challenges may be in the offing.

For another, when the Republicans unleash their inevitable blitzkrieg, I doubt voters will recognize the subtleties in positions like Mr. Franken’s.

Privately, many moderate Democratic senators are harshly critical of Sanders’s tactics. “It’s radioactive for me,” one Democrat facing re-election in 2018 told me.

But publicly, even Democratic senators who have declined to endorse Medicare for All have done so in measured terms to avoid antagonizing the progressives.

“The first thing has to be to protect the health care people have now and stabilize markets,” said Debbie Stabenow of Michigan.

Instead of Medicare for All, we Democrats should be focused on “Better Jobs for All” — big ideas for addressing our most pressing economic challenge. That is: the wage stagnation that has left too many Americans behind, particularly white working-class men.

That’s not an easy problem to solve, but we know the solutions revolve around people-centric initiatives like improving education, providing more training and retraining and increasing worker mobility.

To buttress those programs, it’s time to move ahead with rebuilding our infrastructure and restoring government investment spending on research and development.

In doing so, let’s not forget that only about a quarter of voters consider themselves liberals; the balance self-identify as moderates or conservatives.

Our model of democratic capitalism has stood us well for more than two centuries; now is not the time to embrace the kinds of ideas, often involving deep government economic intervention, that have often fallen short elsewhere, notably in much of Europe.

On present course and speed, we can take back the House of Representatives in 2018 and defeat President Trump in 2020 — unless we Democrats do something stupid, like nominating candidates from the fringe of our party.

https://www.nytimes.com/2017/10/24/opinion/medicare-for-all-democrats.html?

Iowa Withdraws Request to Leave Obamacare Market

by Abby Goodnough - NYT - October 23, 2017

WASHINGTON — With just over a week until the Affordable Care Act’s enrollment season begins, Gov. Kim Reynolds of Iowa said Monday that she had withdrawn the state’s request to opt out of the law’s insurance marketplace next year by offering customers a single plan with lower premiums and a high deductible.

The waiver request had been closely watched by health policy experts as the most far-reaching effort by a state to sidestep requirements of Obamacare. Governor Reynolds, a Republican, said the Trump administration had tried hard to approve it, but had found it impossible to do so without violating the terms of the law.

“Unfortunately, it now appears Obamacare’s waiver rules are as inflexible as the law itself,” Ms. Reynolds said at a news conference in Des Moines. “I’m extremely disappointed.”

Iowa wanted to create a state-run system for 2018 that its insurance commissioner said would lower premiums for most of the 72,000 residents of the state who currently have Obamacare health plans, including 28,000 who earn too much to get subsidies to help with the cost.

High premiums have frustrated many customers, especially those who receive no subsidies. But these cheaper premiums would have come with a trade-off: higher out-of-pocket costs. The plan available would have been one with deductibles of $7,350 for a single person and $14,700 for a family. The proposal would also have reallocated federal dollars that lower costs for people with modest incomes, using the money to help even the wealthiest customers pay their premiums.

Critics said approving the Iowa waiver would have paved the way for other states to follow, eroding the health law’s protections for low- and middle-income Americans. Some had planned on filing a legal challenge if the Trump administration had said yes to the request, known as a “state innovation waiver.”

“This is a case of the law’s guardrails protecting people and their coverage,” said Sarah Lueck, a senior policy analyst at the Center for Budget and Policy Priorities, a left-leaning group that had opposed the waiver. “Hopefully now Iowa can start looking at more practical and less disruptive solutions to deal with the challenges in its market.”

The Washington Post reported recently that President Trump in August had asked Seema Verma, the federal official in charge of reviewing Iowa’s plan, to reject it. Some supporters of the law saw that as a deliberate effort to keep premiums high; Mr. Trump frequently cites sharply rising premiums as proof that the health law is failing.

But Ms. Reynolds said the Trump administration had worked with Iowa “to the greatest extent possible” to get the waiver approved. The health law allows such waivers only if a state proves the alternative coverage will be as comprehensive and affordable, covers a comparable number of people and does not increase the federal deficit.

Last week, the administration informed the state that its plan would likely increase the federal deficit, but that it would take several weeks to figure out by how much. That, Ms. Reynolds said, prompted her to withdraw the request.

In a joint statement with Ms. Reynolds, Ms. Verma echoed Mr. Trump’s contempt for the 2010 law, calling it “unaffordable, unsustainable and unworkable.”

The individual insurance market is particularly fragile in Iowa, partly because the state has allowed tens of thousands of healthy people to keep old plans that do not comply with the health law. Aetna and Wellmark Blue Cross & Blue Shield, the state’s most popular insurer, are both withdrawing at the end of the year.

The only insurer remaining in Iowa’s Affordable Care Act marketplace for next year, Medica, is seeking premium increases that average 56 percent, blaming Mr. Trump’s decision to stop paying subsidies known as cost-sharing reductions that lower many people’s deductibles and other out-of-pocket costs. Most Iowa customers will not feel the increase, however, because they qualify for premium subsidies that will rise to cover it. But state officials have predicted that most of the 28,000 people who receive no subsidies will cancel their coverage.

So far, the Trump administration has granted state innovation waivers to three states, Alaska, Minnesota, and Oregon; they will use federal money to help insurers cover the claims of their most expensive customers next year, with the intent of lowering premiums. Oklahoma abruptly withdrew a similar request last month — one that state officials said would have reduced premiums by an average of 30 percent — saying that the Trump administration had been too slow to approve it.

The administration on Monday also deemed a similar waiver request from Massachusetts incomplete and said there would not be enough time for the state to put in place a so-called reinsurance program for 2018.

https://www.nytimes.com/2017/10/23/health/iowa-waiver-obamacare-health-insurance.html?

Medicaid expansion a rare opportunity to improve health of Maine’s people and economy

by Elizabeth Gilbreth - Bangor Daily News - October 24, 2017

An objective look at the referendum to expand Medicaid, Question 2 on the November ballot, shows that it is a good deal for Maine and would improve both the health of our state’s people and our economy at a reasonable cost.

Question 2 would expand the state’s Medicaid program, known as MaineCare, to individuals with annual incomes at or below $16,643 and families with annual incomes at or below $22,412.

The federal government will pay 94 percent of the cost of expansion in the first year, with the federal share declining to 90 percent by 2021 and thereafter. The increase in state spending required for this expansion, by 2021, would be 5 percent more than what the state is currently spending on Medicaid. An estimated 80,000 Mainers would benefit from this expansion, according to the Legislative Office of Fiscal and Program Review.

Medicaid expansion is a rare opportunity for the state that would deliver a real and sustained positive economic impact. Its implementation would inject $490 million in new federal money into Maine’s economy in 2018 and 2019, with similar amounts going forward, according to the fiscal office. This economic stimulus is expected to generate 6,000 new jobs, according to the Maine Center for Economic Policy.

The impact would be broader than just the health care sector because a ripple effect of increased consumer buying power would benefit businesses in other sectors, as well. Further, because rural areas in the state have higher proportions of low-income uninsured people, the economic impact would be greatest in rural areas.

Opponents attack the proposed expansion as a “welfare” giveaway to able-bodied adults when, in fact, what it really does is give an opportunity for health insurance to those who aren’t offered health benefits through work and can’t afford the cost of individual insurance policies. Who among us would willingly give up our health coverage when a routine visit to a doctor’s office can cost more than $100 and a visit to the emergency room cost thousands? Why should hard-working Mainers have to go without health coverage just because they work in a business without health benefits, are self-employed, or work part time in several different jobs?

Opponents of expansion have distorted the record on Maine’s earlier experience with changes to the Medicaid program. When Maine previously expanded Medicaid, the state hired analysts every year of the expansion to comb through data to see if Medicaid was substituting for private insurance. They found no evidence that people were dropping private coverage to enroll in Medicaid. Studies in states that have expanded Medicaid in the past few years have found that employment has increasedand new Medicaid enrollees report that their ability to find and retain work has improved as they get treatment for pre-existing conditions.

Maine’s earlier expansion of Medicaid has been cited as a warning that costs will inevitably spiral out of control. That’s a misreading of the data. Maine’s budget crisis experienced between 2008 and 2011 was a result of the worst recession since the Great Depression. Around 23,800 Mainers lost their jobs and the poverty rate in Maine increased from 12 percent to 14 percent.

The growth in Medicaid spending was primarily a result of more enrollment in traditional Medicaid, not newly eligible people under the previous expansion in the 2000s. This same phenomenon was experienced nationwide. Maine’s 4 percent growth in Medicaid spending during this period was right in line with the national average of 4.1 percent.

State revenues also plummeted during the recession, straining state spending across the board. The impact of economic cycles on state programs — decreasing state revenues just when need is highest — is an argument for maximizing access to federal dollars, a steady payment source through economic slumps.

Thirty-one states have already expanded Medicaid, and the evidence from these states points overwhelmingly to positive economic benefits from this program. Hospitals in expansion states have seen their levels of bad debt go down and their operating margins go up. States have added thousands of new jobs. The economic stimulus in the form of new federal funding increases state tax revenues and helps off-set the state cost of expansion.

This November Maine voters have an opportunity not only to help assure access to health care coverage to a wider segment of the Maine population, but to help expand Maine’s economic horizons. A “yes” vote on Question 2 is a vote to support your neighbors, businesses and hospitals.

Elizabeth Kilbreth is an associate research professor emerita in the Muskie School of Public Service at the University of Southern Maine in Portland. She is the author of the report “The Real Impact of Medicaid Expansion in Maine.”

http://bangordailynews.com/2017/10/24/opinion/contributors/medicaid-expansion-a-rare-opportunity-to-improve-health-of-maines-people-and-economy/

1332 Reinsurance Waivers Revisited: Could Oregon’s Approval Beget An Oklahoma Do-Over?

by Joel Ario - Health Affairs - October 23, 2107

Just three weeks ago, CMS came under severe criticism for failing to act expeditiously on Oklahoma’s 1332 reinsurance waiver and only approving part of Minnesota’s waiver. I was among the critics, suggesting that the agency’s action threatened the delicate bonds of trust between CMS and the states. Channeling the Oklahoma letter withdrawing its pending waiver, I said the agency had some serious fence-mending to do if it wanted states to continue pursuing 1332 waivers.

The agency has responded and I want to be among the first to commend CMS Administrator Seema Verma and her tireless staff for their prompt approval of Oregon’s waiver. It took the agency nine months to approve Alaska’s pioneering reinsurance waiver, three months to partially approve Minnesota’s waiver, and just 40 days to approve Oregon’s proposal. This is precisely the streamlined process that the Alexander-Murray bipartisan bill envisions for relatively simple “look-alike” waivers. (To be clear, this process should not apply to complex waivers that raise new issues meriting more extended review.)

While the Oregon approval is important, I expect a residue of doubt will remain as states soak in the news. Were the Oklahoma and Minnesota decisions the new norm and Oregon an aberration? Or does the Oregon decision represent a return to the consistent support that CMS had provided to states on reinsurance waivers?

Most importantly, can states rely on the checklist published in May 2017? Can they be confident that if they go through the hard work of identifying a state funding source and standing up a state-based reinsurance program, they can count on the federal government to “pass through” the federal cost savings? Even better, will Congress follow through on fixing the statutory ambiguity that caused CMS to backtrack on passing through the federal savings related to Minnesota’s Basic Health Plan (BHP)?

A Step CMS Could Take To Reassure States

CMS cannot control whether Congress and the President enact the Alexander-Murray bill that would clarify a state’s right to get BHP savings as well as tax credit savings. But there is one more step the agency could take that would go a long way to removing the ongoing concerns that states have about the processing of reinsurance waivers.

CMS could invite Oklahoma to immediately reinstate its waiver application, expeditiously approve it, and then work with the state to adjust 2018 rates. I recognize that it is late in the day to be adjusting 2018 premiums, but this past week’s experience with CSRs suggests that late adjustments are possible, and doing so for a single state with a single carrier should be manageable. If it is truly impossible, CMS should approve the waiver for 2019-2022.

I do not know how Oklahoma would respond to such an invitation, but I do know that Oklahoma should be offered the same expeditious treatment that Oregon received. Unless there are substantive flaws in Oklahoma’s application that only came to CMS’s attention after the pre-approval materials were prepared and shared with Oklahoma, there is nothing that distinguishes Oklahoma from the other three approved states.

The Complications Presented By Oklahoma’s Waiver Are Not Unique To That State

The fact that the current projections in Oklahoma’s application are outdated is not a distinguishing feature, since that is emphatically the case for all three approved waivers given the President’s recent termination of CSR payments. CMS did not include a pass-through funding number in Oregon’s approval letter, presumably because it depends on how the CSR complications are resolved this fall. Those complications include last-minute rate increases to load CSR costs into Oregon rates, as well as the potential that Congress will restore CSR payments or act in some other way that requires adjusting the numbers yet again. The same complications may require adjustments for Alaska and Minnesota.

CMS would have to work through those complications with Oklahoma too, but nothing is gained from requiring Oklahoma to start over from scratch with a 2019 waiver. Indeed, Oklahoma should have the same legal rights to work through whatever adjustments are necessary in the same way that Alaska, Minnesota, and Oregon will — within the context of an approved five-year waiver that requires mid-course corrections.

As a former state regulator with an abiding faith in state innovation, my hope is that CMS and Oklahoma can patch up any misunderstandings from last month and put Oklahoma back on the path to expedited approval of its waiver. The beneficiaries would be not just Oklahomans but also the dozen or more states with their eyes on 2019 reinsurance waivers, not to mention a much larger audience hoping for constructive state-federal partnerships in the next phase of bringing health security to all Americans.

http://healthaffairs.org/blog/2017/10/23/1332-reinsurance-waivers-revisited-could-oregons-approval-beget-an-oklahoma-do-over/

Preaching to The Choir

By Rebecca Solnit - Harper's Magazine - November 2017 Issue

Once, on a river-rafting trip through the Grand Canyon, I traveled with a charming, good-humored man who happened to run an oil rig in the Gulf of Mexico. He liked to rail against Nancy Pelosi, who had recently become the Speaker of the House. One day I told him that I, too, disliked Pelosi, because she was well to my right on many issues. The man was staggered; he’d imagined that she defined the leftmost rim of the universe, beyond which nothing existed.

When the oilman was on land he lived in Colorado Springs; I’m a San Franciscan. Geography alone made us exotic species to each other. And the river trip came during a period in 2009 when I frequently found myself telling strangers, in frustration, that people in my hometown could be as closed-minded as any right-wing community. We were all living in our respective bubbles, preaching to our respective choirs; I was looking for more substantive exchange. Yet what transpired in my conversations on the raft was not, in the end, especially illuminating. I enjoyed the oilman’s Texas vernacular, and we found common ground in our appreciation for buttermilk biscuits, but neither of us changed the other’s mind about the fossil fuel industry, and neither tried to, which may be why the encounter seems so pleasant in recollection.

The phrase preaching to the choir properly means hectoring your listeners with arguments they already agree with, and it’s a common sin of radicals, the tendency to denounce others as a way of announcing one’s own virtue. But it can be applied too widely, to malign conversation between people whose beliefs happen to coincide. The phrase implies that political work should be primarily evangelical, even missionary, that the task is to go out and convert the heathens, that talking to those with whom we agree achieves nothing. But only the most patient and skillful among us can alter the views of those who disagree profoundly. And is there no purpose in getting preached to, in gathering with your compatriots? Why else do we go to church but to sing, to pray a little, to ease our souls, to see our friends, and to hear the sermon?

I asked Katya Lysander, who sings ancient and modern Eastern European music with a Chicago choral group, what she thought of the phrase. She pointed out that there are in fact four audiences in a church service — the congregation, the choir, the preacher, and God. A priest preaching directly to the choir would be facing the wrong way, away from the congregation, as the choir is usually behind or on either side of the pulpit. And, as Lysander might have added, the preacher also listens to the choir, to her bishops, her colleagues, her congregation. And then everyone catches up on the church steps after the service. The ecclesiastical conversation, that is to say, consists of a series of exchanges among people in many different roles.

What’s more, to suggest that you shouldn’t preach to the choir is to misunderstand the nature of preaching. Conversion or the transmission of new information is not the primary aim; the preacher has other work to do. Classically, the sermon is a kind of literary criticism that regards the key sacred texts and their meanings as inexhaustible. Adults, like children, love hearing the great stories more than once, and most religions have prayers and narratives, hymns and songs that are seen as wells of meaning that never run dry. You can go lay down your sword and shield by the riverside one more time; there are always more ways to say how once you were blind and now can see.

Karen Haygood Stokes, a minister in Grand Rapids, Michigan, who formerly belonged to the San Francisco Symphony Choir, explained to me that her aim is not so much to persuade people to believe as it is to encourage them to inquire into existing beliefs. “My task as a preacher is to find the places of agreement and then move someplace from there. Not to change anybody’s mind, but to deepen an understanding.” The common ground among her parishioners is not the destination; it’s the starting point: “Have we thought critically about why we agree?” It’s a call to go deeper, to question yourself.

Page 2 of 4

( 2 of 4 )

The primary assumption behind the idea that we shouldn’t preach to the choir is that one’s proper audience is one’s enemies, not one’s allies. This becomes especially true during election season, the prevailing view being that elections are won not by focusing on the base but by flipping the opposition. By this reasoning, all that I write and say during those cycles should be pitched at my adversaries, to recruit them. I have often been admonished that my statements should give no offense to strangers with whom I have little in common, that I should say things — I’m not sure what these cottony words would be, or whether I contain them — that will not irritate or alienate. I should spend my efforts on people who disagree passionately with me, because why waste time on those with whom I’ve already formed relationships and share interests?

One of the most excruciating rites of recent presidential elections was the debates in which “undecided” or swing voters were brought in to ask questions of the candidates. The premise behind the spectacle is that candidates win by competing for those not sure of whether they are for or against civil rights, tax cuts for the rich, and so on. Yet much evidence suggests that political organizations benefit most from motivating those who already agree with them, and that the Democrats in particular find the most success by pursuing people who don’t know whether they’ll vote, rather than how they’ll vote. This means reaching constituents who, historically, have been less likely to go to the polling booth: the poor, the young, the non-white. Republicans know this, which is why they’ve worked hard to perfect voter suppression tactics that target those populations.

Nevertheless, centrist Democrats often go wooing those who don’t support them, thereby betraying those who do. It’s as though you ditched not only your congregation but your credo in the hope of making inroads among believers of some other faith. You think you’re recruiting; really, you’re losing your religion. This has been true with welfare “reform,” with the war on terror, with economic policy, with the fantasy of winning over “the white working class”: time and again, misguided attempts to bring in new voters have offended existing constituencies.

This year, in an effort to appeal to a more conservative demographic, some Democrats went so far as to slacken their commitment to reproductive rights, dismissing them as “identity politics” and deeming them less important than economic justice. As many women have pointed out, however, such a stance constitutes a failure to understand that until and unless this half of the population can control their bodies and plan their families, they cannot be economically equal. The question is one of both strategy and principle: Do you win by chasing those who don’t share your views, or by serving and respecting those already with you? Is the purpose of the choir to sing to the infidels or inspire the faithful? What happens if the faithful stop showing up, donating, doing the work?

Page 3 of 4

( 3 of 4 )

One reason we emphasize conversion is that we tend to believe that ideas matter more than actions, that beliefs directly determine behavior, that a preponderance of agreement will result in political and social change. In years past, I’ve often heard people obsess over polls that revealed how many Americans think climate change is real. They seemed convinced that if everyone could be made to believe, the crisis would be solved. But if people who believe climate change is real and pressing do nothing to address the problem, nothing happens. Not only is it unlikely that everyone will agree, it doesn’t matter whether they do, and it isn’t worth waiting for. There are still people who don’t believe that women are endowed with the same inalienable rights as men, and this hasn’t prevented us from creating policies that are based on the principle of equality between the sexes.

What matters is that some of us act. In 2006, the political scientist Erica Chenoweth set out to determine whether nonviolence was as effective for regime change as violence. She found, to her surprise, that nonviolent strategies worked better. Organizers were enthralled by her conclusion that only around 3.5 percent of a population was needed to successfully resist or even topple a regime. In other words, to create change, you don’t need everyone to agree with you, you just need some people to agree so passionately that they will donate, campaign, march, risk arrest or injury.

The majority of Americans, according to Gallup polls from the early 1960s, did not support the tactics of the civil rights movement, and less than a quarter of the public approved of the 1963 March on Washington. Nevertheless, the march helped push the federal government to pass the 1964 Civil Rights Act. It was at the march that Martin Luther King Jr. gave his “I Have a Dream” speech — an example of preaching to the choir at its best. King spoke to inspire his supporters rather than persuade his detractors. He disparaged moderation and gradualism; he argued that his listeners’ dissatisfaction was legitimate and necessary, that they must demand drastic change. White allies were needed, but black activists didn’t need to wait for them. Often, it’s an example of passionate idealism that converts others. The performance of integrity is more influential than that of compromise. Rather than meet people where they are, you can locate yourself someplace they will eventually want to be.

The choir is made up of the deeply committed: those who show up every Sunday, listen to every sermon, and tithe like crazy. The time the choristers spend with one another, the sum of their sympathy and shared experience, is part of what helps them sing in unison and in tune. To win politically, you don’t need to win over people who differ from you, you need to motivate your own. There are a thousand things beyond the fact of blunt agreement that you might need or want to discuss with your friends and allies. There are strategy and practical management, the finer points of a theory, values and goals both incremental and ultimate, reassessment as things change for better or worse. Effective speech in this model isn’t alchemy; it doesn’t transform what people believe. It’s electricity: it galvanizes them to act.

Page 4 of 4

( 4 of 4 )

“Correspondence,” that beautiful word, describes both an exchange of letters and the existence of affinities; we correspond because we correspond. As a young woman, I had long, intense conversations with other young women about difficult mothers, unreliable men, about heartaches and ambitions and anxieties. Sometimes these conversations were circular; sometimes they got bogged down by our inability to accept that we weren’t going to get what seemed right or fair. But at their best, they reinforced that our perceptions and emotions were not baseless or illegitimate, that others were on our side and shared our experiences, that we had value and possibility. We were strengthening ourselves and our ties to one another.

In an intellectual exchange, disagreement doesn’t mean tearing down a rival but testing and strengthening the structure of a proposal, an analysis. It is what you do when you agree with people in general but have specifics to work out; and that work can be a joy. It’s an arrangement in which no one is the preacher or the choir, in which everything is open to question, in which ideas are beautiful and precision is holy.

Though great political work and useful debate about ideas and ethics is happening over social media, much of the time we spend together (or in solitude) has been replaced by the time we spend online, in arenas not conducive to subtlety or complexity. We have shifted to short declarative statements, to thinking in headlines, binaries, catch-all categories, to viewing words as pieces in a game of checkers rather than, say, gestures in a ballet. If you’re confident that everything not black is white, discussions about shades and hues seem beside the point. This absolutism presumes that our only position on those with whom we don’t have complete agreement is complete disapproval, and also that agreement is simple, past which there is no nuance, strategy, possibility to explore.

Absolutism is obviously antithetical to practical politics, which, of course, depend on understanding and sometimes working alongside those with whom you may not agree, or with whom you agree on some things and not on others (as I learned in antinuclear political gatherings in the 1980s, when downwinder Mormons, punks, pagans, Japanese Buddhist monks, Franciscan priests and nuns, and Western Shoshone elders worked together pretty well). Maybe it’s antithetical to the human condition, where we must coexist with difference and make the most of our journeys in increments.

To dismiss the value of talking to our own is to fail to see that the utility of conversation, like that of preaching, goes far beyond persuasion or the transmission of information. At its best, conversation is a means of accomplishing many subtle and indirect things. The painter Rudolf Baranik, who died twenty years ago, once told me a story about a ferry ride he took in New York City on a bitter winter day in the late 1930s, soon after he had arrived as a refugee from Eastern Europe. “It is very cold, is it not?” he said in his formal English to a black man standing next to him on the deck. “Yeaaahh, man,” his fellow passenger replied. “Why is that man singing?” Baranik wondered. The moment remained with him — the unfamiliar musicality of the New Yorker’s intonation had made memorable what was otherwise an ordinary exchange. Why comment to a stranger about the weather, when the conditions are obvious to both of you? Because it’s an affirmation that you exist in the same place, that no matter what else might separate you, you have this in common. And because it’s an opening, if not to understanding, then at least to the place where it might begin.

Karen Stokes told me she thinks of the choir as providing a space that is the near opposite of the combative culture of the internet. “In so many churches that I’ve served, the choir is the primary support group. They meet every week; they hang out together, put in extra time on Sunday, have made a commitment to one another. You can’t just drop in and say, ‘Let’s sing this or I’m leaving.’ Everyone has submitted themselves to something bigger: to the creation of music and, in the church setting, music for the worship of God.”

Within most examples of broad consensus lie a host of questions and unresolved differences. Agreement is only the foundation. Yet from here we can build strong communities of love, spirited movements of resistance. “We cannot walk alone,” Dr. King said that day in 1963. Find people to walk with — and talk with — and we find power as well as pleasure.

https://harpers.org/archive/2017/11/preaching-to-the-choir/

Statement From The Labor Campaign For Single Payer - by Mark Dudzik - October 24, 2017

Stating that , "We have a real opportunity to achieve the labor movement's historic demand for health care as a basic human right," delegates at the AFL-CIO Convention today approved a resolution promising that America's largest labor federation will play a leading role in the fight for Medicare for All.

This resolution, said USW President Leo Gerard on behalf of the Resolutions Committee, "commits the AFL-CIO to work with sponsors of single payer legislation...to move expeditiously towards a single payer Medicare for All system."

National Nurses United (NNU) Secretary Treasurer Martha Kuhl was the first to speak in favor of the resolution, "Every day at the bedside, nurses see the impact of a private insurance-based healthcare industry that denies care and diverts resources away from patients to profits. We must guarantee healthcare as a human right. Patient need, not profit, must be the cornerstone of any medical system."

Jill Charboneau, President of the Vermont State Labor Council, AFL-CIO, thanked Senator Bernie Sanders for his leadership on this issue and called on the Federation to stand with him in this signature fight for social justice.

"Each time we go to the bargaining table, it's a battle over the rising cost of healthcare," said Yvonne Williams of the Amalgamated Transit Union (ATU), "ATU is convinced that Medicare for All is the solution to our healthcare crisis."

Speaking for the American Postal Workers Union (APWU), Judy Beard stated that she was proud that her union supported HR 676 The Expanded and Improved Medicare for All Act and S 1804 The Medicare for All Act of 2017. "We look forward to working with the AFL-CIO to secure their passage." She also reminded the convention delegates that the Coalition of Labor Union Women (CLUW) has been a strong supporter of Medicare for All.

South Carolina AFL-CIO President Erin McKee said that she was fortunate to have always been covered by good union health benefits but told the stories of her family members without coverage. "To be without health insurance is terrifying. We need to be on the right side of history and lead the fight for healthcare for all."

AFL-CIO Executive Council member Clyde Rivers of the California School Employees Association (CSEA) stressed that "We can't bargain our way out of this healthcare crisis." Greg Junemann, the President of the International Federation of Professional and Technical Engineers (IFPTE) added that, "We face a nightmarish scenario every time we go into negotiations. The only cure is to make access to Medicare a right for every man, woman and child in America." And Art Pulaski of the California AFL-CIO reminded delegates that, "Our union employers can't compete with non-union employers who pay nothing for healthcare."

In urging support of the resolution, NNU President Jean Ross spoke of the sea change of popular support for Medicare for All that has emerged in response to the debates over the future of the Affordable Care Act. "Even 52% of Trump supporters who earn less that $30,000 per year support a federal guarantee of healthcare."

Convention delegates were brought to tears by the story of District Columbia nurse Sandra Falwell who told of the death of a young toddler under her care because his private insurance company refused to authorize adequate treatment.

Eighteen national unions, state labor councils and central labor councils submitted a Making Healthcare a Right resolution for consideration at the convention and several additional labor councils sent letters of support. The Labor Campaign for Single Payer worked with its national union supporters to lobby the AFL-CIO Resolutions Committee for its passage. The Resolution passed today incorporates much of the language and intent of that resolution into a broader resolution that also supports a wide range of transitional healthcare issues of importance to workers and their unions.

As the movement to establish a single payer Medicare for All system moves beyond the aspirational and begins to wrestle with serious opportunities to implement healthcare for all legislatively, today's convention action will prove to be an important step forward in that fight. We thank all of our supporters who made this advance possible and commit to redouble our efforts at this historic moment.

In Solidarity,

Mark Dudzic
National Coordinator

Siding With Trump, Judge Clears Way for Trial Over Health Subsidies

by Robert Pear - NYT - October 24, 2017

WASHINGTON — A federal judge sided with the Trump administration on Wednesday in a ruling against 18 states that sought to compel the federal government to pay subsidies to health insurance companies for the benefit of millions of low-income people.

“It appears initially that the Trump administration has the stronger legal argument,” Judge Vince Chhabria of Federal District Court in San Francisco wrote in the ruling.

He refused to issue a preliminary injunction requested by the states, leaving the dispute to be resolved in a trial in his courtroom over the next few months.

The states, led by the attorney general of California, Xavier Becerra, contend that the payments are needed to prevent chaos and confusion in insurance markets during the annual open enrollment period, which starts on Nov. 1.

But Judge Chhabria said at a hearing on Monday that California and other states had found “a very clever way” to protect their residents against immediate harm from termination of the subsidies by President Trump. As a result, he said in his Wednesday ruling, many low-income people will be “better off or unharmed.’’

The subsidies reimburse insurers for reducing deductibles, co-payments and other out-of-pocket costs for seven million low-income people who buy midlevel silver plans on the Affordable Care Act marketplace. Under the law, insurers will still have to provide the discounts, known as cost-sharing reductions, but may be unable to collect reimbursement from the government.

Mr. Trump ordered federal officials two weeks ago to stop making the monthly payments. Another federal district judge, in Washington, ruled in 2016 that the payments were unconstitutional because Congress had never appropriated money for them.

On Wednesday, Judge Chhabria concluded that “both sides have reasonable arguments’’ on the main legal question: Whether Congress appropriated money for the cost-sharing payments.

Two senior senators, Lamar Alexander of Tennessee, a Republican, and Patty Murray of Washington, a Democrat, announced last week that they had agreed on a bill to extend the cost-sharing payments through 2019 and make it easier for states to obtain waivers from requirements of the Affordable Care Act. After initially endorsing the deal, Mr. Trump backed off a day later, and the White House demanded changes as a condition of its support.

The Congressional Budget Office said Wednesday that the Alexander-Murray bill would produce a modest reduction in federal budget deficits, but would not substantially change the number of people with coverage.

The budget office estimated that the legislation would reduce deficits by a total of $3.8 billion over the next decade. With the deficit for the last fiscal year alone reaching $666 billion, that is a relatively small number, but supporters of the bill made the most of it.

“The Congressional Budget Office has found that our proposal benefits taxpayers, it benefits consumers — not insurance companies,” said Mr. Alexander, the chairman of the Senate health committee.

The proposal has broad support from Democratic senators and at least a dozen Republican senators. But conservative Republicans in the House and the Senate have denounced it as a bailout for insurers, and Mr. Trump has sent mixed signals about whether he supports it. Representative Dave Brat, Republican of Virginia, called the measure “a nonstarter.”

The budget office said that continuing the cost-sharing payments would not change its estimate of federal spending because it had already assumed that the government would pay the subsidies: $9 billion a year in 2018 and 2019, and a total of $99 billion from 2018 to 2027.

The Trump administration on Wednesday unveiled a new version of the HealthCare.gov website showing premiums and other details of health insurance plans that will be offered for sale in the open enrollment period that starts next week.

In many markets, consumers will have few choices and will see high sticker prices before taking account of financial assistance for which they may qualify. But by carefully shopping around, consumers will often be able to find bargains — a point highlighted in the case in California, where the state runs its own marketplace.

During Monday’s hearing, state officials told Judge Chhabria that cutting off the subsidy payments would cause immediate and irreparable harm to states and to consumers, increasing the likelihood that insurers would pull out of the marketplace.

But Judge Chhabria said California and most of the other state plaintiffs “saw the writing on the wall a long time ago — that the administration was going to terminate these payments to insurance companies to subsidize co-payments and deductibles.”

“California is doing a really good job of responding to the termination of these payments in a way that is not only avoiding harm for people, but actually benefiting people,” the judge added.

In his Wednesday ruling, Judge Chhabria wrote that low-income people who now have silver plans in some cases may be able to find gold plans with lower premiums and lower deductibles for 2018.

To offset the expected loss of cost-sharing subsidies, California added a surcharge to the price of midlevel silver plans sold on its Affordable Care Act marketplace. When premiums go up, consumers receive more financial assistance to help with premium costs, so in many cases they will be no worse off.

“Nearly four out of five consumers will see their premiums stay the same or decrease, since the amount of financial help they receive will also rise,” California’s insurance marketplace announced earlier this month. In addition, it said, three-fourths of consumers in the state who are eligible for assistance will be able to buy low-cost bronze health plans next year for less than $10 a month.

“The state of California is standing on the courthouse steps denouncing the president for taking away people’s health care,” Judge Chhabria said at Monday’s hearing, “when the truth is that California has come up with a solution to that issue that is going to result in better health care for a lot of people.”

Many other states have taken similar steps to minimize harm to consumers, the judge said. He was appointed in 2014 by President Barack Obama.

https://www.nytimes.com/2017/10/25/us/politics/alexander-murray-congressional-budget-office-deficit-savings.html?

Trump to Declare Opioid Crisis a ‘Public Health Emergency’

by Julie Hirschfeld Davis - NYT - October 26, 2017

WASHINGTON — President Trump on Thursday will announce he is directing his Department of Health and Human Services to declare the opioid crisis a public health emergency, senior administration officials said, a move that would free up some federal money and ease certain laws and regulations to address a rapidly escalating epidemic of drug use in the United States.

Mr. Trump’s long-anticipated directive, to be announced in an address at the White House on Thursday afternoon, would fulfill a vow that he made when he assumed office to make tackling opioid abuse one of his top priorities, but has so far taken limited action to carry out.

But it falls short of declaring a national emergency on the crisis, even though a presidential commission he created had recommended that, and Mr. Trump pledged in August to follow through. Such a step would have unlocked additional emergency funding and federal authority to take urgent action on opioids.

The officials argued that a national emergency declaration was not necessary or helpful in the case of the opioid crisis, and that the powers associated with a public health emergency were better suited to address the issue. They outlined Mr. Trump’s announcement on condition of anonymity to avoid pre-empting his formal speech.

The president in August called the opioid crisis a “national emergency,” but did not sign a formal declaration designating it as such, allowing the prospect to languish amid divisions in his administration about the potential costs. It is not clear how much impact the public health declaration will have in the short term, given that Mr. Trump has yet to name the central players who will be charged with carrying it out, including a drug czar to steer a broader strategy on opioids and a secretary of Health and Human Services who would tailor policies and identify funding streams to carry it out.Representative Tom Marino, the Pennsylvania Republican who Mr. Trump had named to head his Office of National Drug Control Policy, withdrew last week after reports that he did the bidding of the pharmaceutical industry in weakening law enforcement’s ability to curb drug sales in efforts to block black-market sales of opioids. The White House has yet to announce a new candidate.

And Tom Price resigned last month as health secretary after it was revealed he was flying on private jets paid for with taxpayer dollars; a nominee has not been named for that post as well.

But the officials said a public health emergency declaration would quickly lead to crucial changes, including the provision of federal grant money and the expansion of access to telemedicine services, which would broaden the reach of medical treatment to rural areas ravaged by opioid use where doctors are often in short supply.

Mr. Trump’s promises to focus on the opioid crisis helped propel him to victory in New Hampshire’s primary last year. The crisis has claimed tens of thousands of lives—– more than 59,000, according to a Times study of drug deaths in 2016 — and appears to be growing worse by the day.

Mr. Trump formed an opioid commission in March and installed Gov. Chris Christie of New Jersey, a rival for the Republican nomination who had championed the issue during the 2016 race, at the helm. In July, the commission recommended that the president declare a national emergency, something Mr. Price had ruled out in part because of concerns about an open-ended commitment of federal dollars. But Mr. Trump surprised his advisers by telling reporters soon after that he was ready to take just such a step.

There have been few major actions to match those words, even as administration officials have worked feverishly behind the scenes to come to agreement on an opioid policy that would reflect the president’s position.

In the meantime, members of Mr. Trump’s opioid commission and lawmakers in both parties have grown impatient for action. On Wednesday, a group of Democrats led by Senator Debbie Stabenow of Michigan released a letter they wrote to the president asking him to allow the government to negotiate lower prices for naloxone, a drug that quickly counteracts the effects of opioid overdoses. Declaring a state of emergency would give the secretary of Health and Human Services the power to seek such price reductions, they said.

https://www.nytimes.com/2017/10/26/us/politics/trump-opioid-crisis.html?

Why ‘Medicare for All’ Will Sink the Democrats

by Steve Rattner - NYT - October 24, 2017