When a Tax Cut Costs Millions Their Medical Coverage
by The Editorial Board - NYT - November 24, 2017
Though their ham-fisted attempts to repeal the Affordable Care Act failed in September, Republican lawmakers and the Trump administration won’t give up on efforts that would take away health care from millions of people. They’re now out to do it through the equally sloppy and cruel tax bills barreling through Congress.
The Senate could vote as soon as next week on a bill that, according to one government estimate, would increase the number of people who don’t have health insurance by 13 million and cause insurance companies to raise premiums substantially. The House passed a tax-cut bill last week that would eliminate the medical expense deduction, which is used by nearly nine million people with medical problems so severe they spend more than 10 percent of their income on health care. Further, because of the amount of revenue both bills would vaporize, they would also prompt automatic spending cuts to Medicare and other government programs that low-income and middle-class Americans rely on.
Why have Republican leaders set their sights on health care again? They have a serious accounting problem on their hands. Congressional leaders and the Trump administration want to give corporations and wealthy families a giant tax cut, but they have committed to not adding more than (a whopping) $1.5 trillion to the federal deficit over the next decade. So they’re trying to increase revenue by raising taxes on many middle-class families and would compound that harm by cutting spending on things like health care, all in service of further enriching the wealthiest Americans through a plan they’re selling as a break for the middle class. We’d say you can’t make this stuff up, but it turns out they can.
Let’s start with the Senate bill. It would eliminate the Affordable Care Act’s requirement that people have health insurance or pay a penalty. Republicans assert that doing this would free people from an onerous government mandate. What they don’t say is that without the mandate, some younger and healthier people would not sign up for coverage, so insurers would raise premiums knowing that their remaining customers would be more likely to have health problems. Those price increases would make coverage unaffordable to many middle-class families. The Congressional Budget Office estimates that 13 million Americans would lose coverage — although it could lower that estimate — and, based on the current projection, the government would save about $338 billion over 10 years because it would spend less on insurance subsidies and Medicaid.
Since many of those newly uninsured people would still get sick and injured, they would receive care at emergency rooms and public hospitals, with the federal, state and local governments bearing that cost. As Mitt Romney pointed out when he was running for president, “It is fundamentally a conservative principle to insist that people take personal responsibility as opposed to turning to government for giving out free care.”
The House bill would not repeal the individual mandate, but it would cause other problems. By getting rid of the medical expense deduction it would penalize people who need nursing home care, expensive specialty drugs and other health services. About 6 percent of taxpayers earning between $20,000 and $50,000 claimed an average medical deduction of $8,121 in 2014, according to the Congressional Research Service. Nearly half of the people who claimed that deduction in 2015 earned less than $50,000 and slightly more than half were 65 or older, according to AARP.
The other big threat to health care comes from a 2010 law that requires spending cuts when Congress passes laws that increase the deficit. These tax bills would require a $25 billion cut to Medicare and many billions more to other programs, according to the C.B.O.
The bigger threat to Medicare, Medicaid and other health care programs could come when Congress decides to slash spending to make up for the ballooning deficit the tax cuts cause. The House speaker, Paul Ryan, is already raising that threat. No lawmaker who cares about the health of low-income and middle-class families ought to fall for this awful charade.
Where Brexit Hurts: The Nurses and Doctors Leaving London
by Katrin Bennhold - NYT - November 21, 2017
LONDON — Tanja Pardela is leaving London. Her last day is Nov. 26. She wells up talking about it. She will miss jacket potatoes, and Sunday roasts, and her morning commute — past playing fields, small children in school uniforms and a red telephone box — to the hospital where she has been a pediatric nurse for 11 years.
Ms. Pardela does not want to leave the country she came to over a decade ago. But that country no longer exists. On June 24 last year, she said, “We all woke up in a different country.”
Seventeen months after Britain voted to leave the European Union, many Europeans are voting to leave Britain — with their feet. Some 122,000 of them packed their bags in the year through March, according to the latest figures available, while the stream of new arrivals has slowed.
In London, a city long sustained by European bankers, builders and baristas — “a place that makes you dream,” Ms. Pardela said — the departures are beginning to hurt. Construction companies and coffee shops are struggling to recruit. Top universities worry about retaining talent. And nowhere are the concerns more elemental than in Britain’s treasured and already overstretched National Health Service.
Long before Brexit, the N.H.S. suffered from chronic staffing shortages, and today the country has 40,000 nursing vacancies. But recruiting nurses from the European Union had helped plug the gap — especially in London, where the share of nurses from the Continent is about 14 percent, or twice the national average. King’s College Hospital, the massive institution where Ms. Pardela works, is short of 528 nurses and midwives, and 318 doctors.
Brexit seems certain to make it harder and costlier to recruit from the Continent, assuming that people will still want to come from there. Even the legal status of European Union citizens already living in Britain remains unclear, entangled in the stalled Brexit talks between Brussels and London. Many fear they could lose rights, job security, pensions and access to free health care.
This uncertainty is one reason that some European health care professionals are either leaving, or thinking about leaving. In the year following the referendum, almost 10,000 quit the N.H.S. The number of nurses from other European Union countries registering to practice in Britain has dropped by almost 90 percent.
As yet, there is no mass exodus back to the Continent — the number of European Union staff in the health service even grew slightly in the year after the referendum. But the trends are unmistakable: The number of Europeans leaving the system is rising, and the number joining it is falling.
“With London in the grip of its worst ever staffing crisis, nurses are being pushed to breaking point on understaffed wards,” said Tom Colclough, regional spokesman for the Royal College of Nursing in London. “If those E.U. colleagues who have not yet left are not given an unequivocal right to remain, the very safety of the capital’s care settings will be under threat.”
The N.H.S., with its philosophy of free universal health care, is a pillar of postwar British identity, once described by a former minister as the closest thing the English had to a national religion. When London hosted the 2012 Olympics, a highlight of the opening ceremony was a dance performanceby real nurses whose bodies eventually coalesced into three giant letters: N.H.S.
During the Brexit campaign, an argument about the N.H.S. helped tip a tight vote. Brexit advocates said leaving the European Union would allow the government to repatriate 350 million pounds a week from Brussels — about $463 million at current exchange rates — and spend it on health care. It was a powerful promise, plastered in bold across the side of a campaign bus — but it was false: Britain pays only about £166 million a week net into the European budget and there was little chance that even a lesser amount would go solely to the N.H.S.
“It was clearly the most effective argument not only with the crucial swing fifth but with almost every demographic,” the chief strategist of Vote Leave, Dominic Cummings, wrote in The Spectator earlier this year. “Would we have won without immigration? No. Would we have won without £350m/NHS? All our research and the close result strongly suggests No.”
Founded in 1840, King’s treated shell shock victims during World War I and victims of German air raids during World War II. More recently, survivors of London’s terror attacks and the Grenfell Tower fire were treated here.
The hospital is a complex of two dozen buildings in southeast London with Europe coursing through its circulatory system. Dutch workers built the state-of-the-art helipad on the roof. Eastern Europeans are helping to build a new intensive care wing and serving cappuccino as baristas in the four coffee shops. Of the 9,300 clinical staff, one in seven holds a non-British European passport.
Brexit is forcing a stark reassessment in every department. In the emergency room, Cyril Noël, a French doctor, is wrestling with how a country he loved rejected him. He describes the grieving process as the Five Stages of Brexit. In critical care, Georg Auzinger, an Austrian physician, has built a world-class facility but now worries about finding enough doctors and nurses.
Many worry that a health service they cherish may be existentially at risk. During a recent Sunday service in the hospital chapel, the priest said a prayer to guard against the “effects of Brexit.”
“The N.H.S. is in Britain’s DNA,” said Shelley Dolan, chief nurse and executive director of midwifery at King’s. “Europe is in the DNA of the N.H.S.”
The Five Stages of Brexit
When Dr. Noël, the French emergency doctor, started his shift early one recent afternoon, the department was already two dozen beds short. He surveyed the scene: seven stroke patients, two casualties from traffic accidents and a couple of stabbing victims. An elderly lady had been run over by her own car after forgetting to put on the hand brake. A toddler had swallowed a fridge magnet. A man had almost died after being punched in the face.
And the emergency room was four nurses down.
“Just a regular Friday,” said Dr. Noël, 45, as someone behind him mopped up the blood stains in Bay 4.
Working with Dr. Noël that Friday night were a Czech doctor and nurses from Ireland, Poland, Spain and Portugal. Several had spent their summer vacations scouting job opportunities in their home countries. “Everyone is nervous,” said Alexandra Cunderlikova, a senior nurse from Slovakia.
Ms. Cunderlikova came to Britain in 2003, a year before her country joined the European Union. She remembers lining up outside the Home Office at 4 a.m. for her work visa.
“I wonder,” she said. “Will it go back to that?”
There are still more Europeans migrating into Britain than leaving. But, as in the N.H.S., arrivals are slowing and departures accelerating, said Madeleine Sumption, director of the Migration Observatory at the University of Oxford, especially among Eastern Europeans like Ms. Cunderlikova.
The day before the Brexit referendum, feeling anxious and powerless because he was not allowed to vote, Dr. Noël did something he had never done before: He placed a bet.
Dr. Noël wagered £200 on Brexit. “That way, I thought, if it actually happens, at least there is one positive thing in it,” he said. To his dismay, he won. The £1,500 he made would roughly cover the fee for a British passport. But Dr. Noël is in no mood to become British — at least not now.
“I feel very strongly European,” he said.
He grew up as an Anglophile in the Jura region of France, near the German border, in a family badly scarred by two world wars. When he was 5, he paraded across the local market, pretending to speak English. At 30, he fell in love with a British student who had come to France on the Erasmus program, the European Union’s university exchange scheme. Twelve years ago, they moved to Britain and Dr. Noël instantly felt “at home.”
But now, when he works outside London in places where people voted for Brexit, resentment rises in his throat.
“I’ve had very torn feelings about helping people who expressed the wish to get rid of us,” Dr. Noël said.
“Psychologically Brexit has had a huge impact,” he said. “You feel rejected as a group.”
He talks about the “five stages of Brexit.”
First there was shock, he said. Then there was denial. (“Don’t worry,” he would tell the young nurses from Portugal and Spain in his department who fretted in the months after the vote. “Nothing is going to change.”) Eventually, Dr. Noël reached the anger stage, following a cascade of nasty news reports: about a government request for companies to compile lists of foreign nationals (later retracted); about a man being stabbed for speaking Polish; about a Finnish professor who, along with scores of other Europeans, was served a deportation notice.
The notice was a bureaucratic mistake. “But after Brexit, such mistakes are not easily forgotten,” Dr. Noël said.
If the N.H.S. has consistently managed to produce health outcomes comparable to countries with vastly more resources — like France, which has a similar population but more than twice the number of hospital beds — it is in large part because of the people, said Dr. Noël, who has worked in both systems.
“The N.H.S. is an incredibly resilient system,” he said. “People are so dedicated. When the system is squeezed, they work even harder.”
But Brexit has made many European employees reconsider. If anger was the third stage of Brexit, and depression was the fourth, Dr. Noël said he had now reached the final stage, acceptance.
For him, that means leaving Britain early next year. He has a new job at a hospital in Dubai.
Replacing One Immigrant Group With Another
Up two floors from the emergency room, down a warren of hallways and through a pair of locked wing doors is the liver intensive care unit.
Dr. Georg Auzinger, the clinical head of critical care, was checking on two patients who were recovering from emergency liver transplants on extracorporeal membrane oxygenation, a pioneering bypass technology. Their blood, liters of it, was being drained from their bodies, oxygenized in an external pump and then reintroduced. Anywhere else in the world they would have been kicked off the transplant list and have died.
The liver department at King’s is world famous. It is also very European. “The English are in the minority,” Dr. Auzinger said.
Dr. Auzinger, a lanky 51-year-old from Salzburg, Austria, has a clipped accent and speaks in Briticisms (“I was gobsmacked,” he says of the Brexit result). The liver department’s clinical director is Irish. Its academic director is Spanish. The hospital recently tried to hire a German as academic head of department, but he declined: He had been awarded a high-value European grant that he could not take to Britain after Brexit.
This worries Dr. Auzinger, who has to hire 407 nurses and doctors for the hospital’s new intensive care wing. Last month, not a single European applied for an advertised position as a senior consultant. “Before, at least a third of applicants were European,” he said.
Dr. Auzinger is happy to hire qualified Britons. “But there are not enough doctors and nurses in this country,” he said. “The numbers being trained do not cover the needs.”
In March, the government announced a plan to hurriedly train more British nurses. Yet in September, enrollment at nursing schools dropped, because the government also cut grants to nursing students. That is one reason Peter Absalom, associate director for recruitment at King’s, is now trying to replace one immigrant group with another. “We are looking to the Philippines, Australia and India,” he said. Three major recruitment drives are planned over the next 12 months.
Every time Mr. Absalom hires someone from overseas he has to pay for their visas and a collection of other charges, which add up to more than £4,000 per person over three years. It can take a year before the nurses start work. Europeans could be hired with no visa costs and no extra paperwork. Over the last five years, nurses from Portugal, Spain, Ireland and other European Union countries have accounted for about a third of the total intake.
Now King’s has stopped its hiring campaigns in the European Union.
“What is particularly difficult is that we cannot give candidates any certainty on their future status,” Mr. Absalom said.
Dr. Auzinger has been in London for 18 years. He, too, would consider going back to Austria if he could transplant his job there, but he cannot. He thinks the way Brexit is affecting the N.H.S. is symptomatic of a poor treatment plan. Britain is ailing. People are angry. Brexit was the treatment offered to them. What worries Dr. Auzinger is the lack of a diagnosis.
“If you think Brexit is the medicine, my concern is that you’re treating something blindly,” he said. “If you don’t have a diagnosis, you cannot treat the patient properly.”
‘Why Am I Still Doing This Here?’
Ms. Pardela, the pediatric nurse, still needs to stop by the post office so that her mail can be forwarded to Germany. She is keeping her British bank account open because she hopes that one day the pound will rise again. It has lost as much as 20 percent of its value against the euro since the referendum. So have her savings.
After the Brexit vote, a British colleague urged Ms. Pardela to apply for citizenship. Her skills were needed. No way, she answered. “I respect the vote,” she had said. “But I’m not going to bend to it.”
Last September, she called an old friend from nursing school and asked about job opportunities back in Germany.
“Brexit was a trigger,” said Ms. Pardela. “It makes you reassess your life. You find yourself thinking: ‘I’m working really hard. I haven’t had a pay raise in four years. Now they’re telling me they don’t want immigrants? Why am I still doing this here?’ ”
“And then you think: ‘I’m 45. I better move now. It will be harder when I’m 55.’ ”
In her small apartment, now filled with moving boxes, Ms. Pardela was packing photos of Big Ben and the London Eye, as well as a series of trashy romance novels that helped her learn English. Still on the fridge was a magnet featuring Florence Nightingale, the mother of modern nursing in Britain: an Englishwoman who was born in Italy and trained in Germany.
One reason Ms. Pardela thinks the N.H.S. is one of the best health care systems in the world is that it empowers nurses. “The range of opportunities and responsibilities is much greater here,” she said. In Germany, many of the things she has been doing — assessing blood results, adjusting treatment plans for transplant patients — would be handled by a doctor.
On Ms. Pardela’s ward, a third of the doctors are European. Twice a year they hold an International Food Day where everyone contributes dishes from their country. This year, Ms. Pardela brought sausage and sauerkraut. A Greek colleague made tzatziki. An Italian cooked spaghetti.
When the latest bout of cost savings required the department to cut one nurse from every shift, Ms. Pardela fought hard to win the role back. It took a year. In the end, she was successful.
“The irony,” she said, “is that now we can’t find anyone to fill it.”
The position has been empty since September.
https://www.nytimes.com/2017/11/21/world/europe/nhs-brexit-eu-migrants.html?
Access, Quality and Cost in the Era of Consumerism
California Medical Association
8th Annual Leadership Academy
Acceleration: Access, Quality and Cost in the Era of Consumerism.
La Quinta, California
November 18-21, 2004
8th Annual Leadership Academy
Acceleration: Access, Quality and Cost in the Era of Consumerism.
La Quinta, California
November 18-21, 2004
Keynote Presentation
Can a "Consumer-Driven" Health Care System Succeed?
Uwe E. Reinhardt, Ph.D., Professor of Political Economy, Princeton University:
"What should be the goal of a health system? It should improve health status. It should protect families from financial ruin over illness. It should leave people satisfied with the care they got. But it should also make them feel good about a sense of fairness in their society, as Canadians fiercely feel proud of the sense of fairness in their system, whatever problems they have. And the Germans and the Swiss are fiercely proud of the social contract of solidarity.
"Intermediate goals are access to timely care, that feeds into health status and that. See, these are not goals, they're just instruments to reach these goals: efficiency and fairness, fairness in financing health care...
"We don't talk enough about financial protection, about people who have cancer also going broke, and the insult and hurt that that represents.
But, you know, 'It wasn't my fault that I got cancer, now I have to sell my house.' That's an insulting thing for a Canadian and German like me to think about. And it happens. Many, many American families go broke over health care.
"We don't ever talk enough about fairness and equity, not at all about the social ethic. We talk about the Judeo-Christian ethic as if it were something else. It should really be ours, and, incidentally, there is a confusion in all kinds of other ethics. But they all ask for the same.
"In the present instance, I think we should ask how these goals are affected relative to the status quo and relative to alternative policy options that we might consider, like traditional, comprehensive coverage with managed care, single payer system, and so on. And I think we need to have some debate; which of these approaches actually gets us closer to those goals...
"A major problem in the U.S. is we never discuss ethics; that's somehow a taboo topic, because here we get ideological and then we get political. And I say, 'Bullshine.'That is at the core of health care. That is the foundation that should surround health care, because that's how physicians,among others, are trained.
"So, to me, we can't really judge whether this will succeed. Some people will say, 'It succeeds.' It's like beauty and honor, the evaluation of consumer-directed health care will be driven much more by ideology than by data. And that's where we are right now. And I wish it were more driven by two things: data, to tell us what this thing really does, and, secondly, what would we like to be like as a people.
"Do we want to be the kind of people that treats soldiers the way we do ($8000/year pension after losing a limb)? Do we want to be the kind of people that leaves a mother, who raises three children for America, sitting there without health insurance or (with only) the policy that she can find on eHealthInsurance.com (leaving her with $20,000 out of pocket on $26,000/year income)? Is that what we're about as a people? I'm just an immigrant here. I can't tell you. This is your problem, not mine. I'm well to do; I buy out of this. But I urge you to reflect on those aspects of it before we get into the technique.
"We can do this. When you tell me the ethics; we can implement it, or the people who spoke yesterday (see comment). We know how to do this. But ethics first. And I think we put ethics last."
For tape or CD recordings of the Leadership Academy:
http://www.audio-digest.org/cgi-bin/htmlos/01203.1.1018082396615917308/cma
http://www.audio-digest.org/cgi-bin/htmlos/01203.1.1018082396615917308/cma
Comment: The first day of the plenary sessions began with speakers well known to those of us who have studied consumer-driven health care (CDHC). John Goodman of the National Center for Policy Analysis and Grace-Marie Turner and Greg Scandlen of The Galen Institute explained consumer-driven health care, especially health savings accounts and high-deductible health coverage. They did not present any new information on CDHC.
The plenary sessions closed with Uwe Reinhardt's presentation. Mentioned here are only a few of his many important points. He questioned whether patients could be empowered decision makers since current information systems are too primitive to allow individuals to make truly informed decisions about their health care. He provided considerable data to demonstrate that current high-deductible policies leave low income individuals exposed to the potential of insurmountable medical debt. He demonstrated how health savings accounts reward higher income individuals with progressive tax benefits to the detriment of lower income individuals. He showed that those in the lower one-third of income levels will bear
the financial brunt of the CDHC model. Then he ended his presentation with the message transcribed above.
the financial brunt of the CDHC model. Then he ended his presentation with the message transcribed above.
The majority of those attending represented the leadership of medical associations and health care providers. I would describe their response to the presentations on CDHC as mixed, at best. Yes, some passionate supporters were in the audience.
But there is great news. With this audience of physician leaders, Uwe Reinhardt was the only speaker to receive a standing ovation!
There is hope for the future of our health care system.
States prepare to shut down children’s health programs if Congress doesn’t act
by Colby Itkowitz and Sandhaya Somashekhar - The Washington Post - November 23, 2017
Officials in nearly a dozen states are preparing to notify families that a crucial health insurance program for low-income children is running out of money for the first time since its creation two decades ago, putting coverage for many at risk by the end of the year.
Congress missed a Sept. 30 deadline to extend funding for CHIP, as the Children’s Health Insurance Program is known. Nearly 9 million youngsters and 370,000 pregnant women nationwide receive care because of it.
Many states have enough money to keep their individual programs afloat for at least a few months, but five could run out in late December if lawmakers do not act. Others will start to exhaust resources the following month.
The looming crunch, which comes despite CHIP’s enduring popularity and bipartisan support on Capitol Hill, has dismayed children’s health advocates.
“We are very concerned, and the reason is that Congress hasn’t shown a strong ability to get stuff done,” said Bruce Lesley, president of Washington-based First Focus, a child and family advocacy organization. “And the administration is completely out, has not even uttered a syllable on the issue. How this gets resolved is really unclear, and states are beginning to hit deadlines.”
Others paying close attention to the issue remain hopeful that Congress will extend funding before January, but states say they cannot rest on hope.
“Everybody is still waiting and thinking Congress is going to act, and they probably will, but you can’t run a health-care program that way,” said Linda Nablo, chief deputy director at Virginia’s Department of Medical Assistance Services. “You can’t say ‘probably’ everything is going to be all right.”
Most CHIP families, who earn too much for Medicaid but too little to afford private insurance, are not aware lawmakers’ inaction is endangering coverage. They’re about to find out, though. Virginia and several other states are preparing letters to go out as early as Monday warning families their children’s insurance may be taken away.
The Centers for Medicare and Medicaid Services (CMS), which administers the program at the federal level, issued a notice to state health officials on Nov. 9 detailing their options if CHIP funding does run dry. States forced to end the program will need to determine whether enrolled children are eligible for Medicaid or whether their family will need to seek insurance through an Affordable Care Act marketplace, the guidance said.
Longtime physician William Rees remembers the years before CHIP’s safety net, when families without coverage would put off bringing a sick child to the doctor until symptoms were so severe they would end up in a hospital emergency room.
“Pediatrics is mostly preventive medicine, it’s so important what we do,” said Rees, who has practiced in Northern Virginia since 1975. “It’s about trying to keep up with routine visits. If [children] don’t have insurance, that often doesn’t happen, so CHIP keeps them in the system and they get their vaccines when they’re due.”
The program, which is credited with helping to bring the rate of uninsured children to a record low of 4.5 percent, has been reauthorized several times over the years. And under the ACA, the federal government sharply boosted its match rate. It now provides 88 percent or more of every state’s CHIP costs.
Congress has been unable to agree on how to pay for the $15 billion program moving forward, however. President Trump’s 2018 budget proposed to cut billions from CHIP over two years and limit eligibility for federal matching funds.
The uncertainty has states scrambling. Arizona, California, Minnesota, Ohio, Oregon and the District of Columbia will run out of CHIP money by Dec. 31 or early January, according to Georgetown University’s Center on Children and Families. At least six more plan to take some sort of action to address the potential funding loss, including notifying parents their children are at risk of losing coverage.
Some states operate CHIP as an independent program and would have to shut theirs down if federal dollars dry up. In Virginia, resources are expected to be exhausted by late January. Nablo said she has no choice but to send notices Dec. 1 to the families of the 66,000 children and 1,100 pregnant women in the state who are covered.
“We don’t want to act too fast if Congress is going to restore this, but we also want to give families enough time,” she said. “We have kids in the middle of cancer treatment, pregnant women in the middle of prenatal care.”
Texas plans to notify families in January that the program could end. Funding problems there were exacerbated by Hurricane Harvey because the state asked the federal government that it be allowed to waive co-pays and enrollment fees for CHIP children in counties declared disaster areas. With less money coming in, funds could be exhausted even sooner than the state first projected, according to Christine Mann, spokeswoman for the Texas Health and Human Services Commission.
In West Virginia, where CHIP funds are expected to run out in March, officials overseeing the program voted this month to shut it down Feb. 28 if Congress hasn’t acted.
Other states, including Maryland, developed their CHIP program as an extension of Medicaid and so are required by law to find a way to keep it going. The same applies to the District, which will need to come up with as much as $12.5 million in local funds to cover the approximately 14,000 children enrolled, the D.C. Department of Health Care Finance said. The agency will begin looking next month at where money can be diverted.
“It’s pretty chaotic out there,” said Joan Alker, executive director at the Georgetown center. “What really troubles me about it is [CHIP] is successful. Everyone should feel good about it. There’s no reason for this to be lagging on like this. This should be an easy win for Congress.”
CHIP has become a political issue in the gubernatorial race in Maryland, where funding would run out in March. Gov. Larry Hogan (R) has pressed for Congress to pass a reauthorization. A potential Democratic opponent, Ben Jealous, has criticized him for not having a backup plan to protect the 140,000 children who would be left uninsured.
In Washington, lawmakers in both parties agree on the program’s merits but are at an impasse over how to pay for it. The House passed a bill this month along largely party lines to extend CHIP funding for five years in part by cutting an ACA prevention fund and raising Medicare rates for wealthier seniors.
That measure is unlikely to be taken up by the other chamber. Senators, led by Finance Committee Chairman Orrin G. Hatch (R-Utah), are working to find a bipartisan solution. Hatch was one of the authors of the original CHIP legislation in 1997. The other was Sen. Edward M. Kennedy (D-Mass.), who died in 2009.
“I am working with my colleagues to advance this bill in a fiscally responsible manner so we can ensure coverage is maintained,” Hatch said in a recent statement. Yet during a heated exchange last week in a committee meeting on the GOP tax overhaul, he voiced little urgency.
Back up your concern for the poor by starting with an extension for CHIP, Sen. Sherrod Brown (D-Ohio) told Hatch.
Hatch responded angrily, “I’m not starting with CHIP.”
Andy Slavitt, who was acting CMS administrator under President Barack Obama, can’t believe there is anything to debate. That Congress would hold up popular legislation that has never before been subject to politics speaks to the “very fragmented culture of lawmaking,” he said.
“It’s a core program that many low-income families rely on. It’s widely acclaimed to be a success,” he said. “We’re operating in a mode that we don’t do anything until it’s an absolute crisis, and we’re creating more crises that don’t need to happen.”
When Congress failed to extend funding in late September, CMS was able to provide several states and U.S. territories with emergency money to keep their programs going a bit longer. The agency has used about $542 million in leftover funds from previous years, but it has limited resources to assist much longer.
Marbell Castillo, who often takes her granddaughter Maia to her doctor appointments, worries about future health coverage for the little girl if CHIP is not funded. (Matt McClain/The Washington Post)
As families hear that their children could lose health insurance, they’re shaken. Marbell Castillo learned about the possibility during a recent checkup with her granddaughter Maia Powell at Burke Pediatrics in Fairfax County, Va.
The appointment, in an exam room decorated with “Toy Story” and “Finding Nemo” decals, covered the gamut. A nurse practitioner asked about what the 16-month-old was eating and when she slept. Maia got her height, weight and temperature taken. She also got her chubby thighs stuck once, twice, three times with vaccinations for diphtheria and other illnesses.
Castillo walked out with Maia balanced on one hip and worries on her mind. She often takes the little girl to appointments so her 23-year-old daughter, who works two jobs, doesn’t have to take off.
Without CHIP, Castillo wondered, what would they do for affordable health insurance for Maia?
“They can’t leave people without this program,” she said.
Analyses: Repealing Individual Mandate Would Leave 50,000 More Mainers Uninsured
by Patty Wight - Maine Public - November 17, 2017
nalyses: Repealing Individual Mandate Would Leave 50,000 More Mainers Uninsured
About 50,000 Mainers would lose health insurance under the proposed Senate Republican tax bill, according to progressive-leaning state and national policy organizations. They say the tax bill’s provision to eliminate the Affordable Care Act’s individual mandate tugs at a thread that would significantly unravel the federal health law.
Both the Maine Center for Economic Policy and the Washington, D.C.-based Center for American Progress crunched the numbers from a Congressional Budget Office analysis to get state-specific data on the effect of repealing the individual mandate. They arrived at the same conclusion.
“Even a small state like Maine would have 50,000 more uninsured residents by 2025,” says Emily Gee, an economist at the Center for American Progress. The Maine Center for Economic Policy projected the same number of uninsured by 2027.
Analyst James Myall says that assumes Maine will expand Medicaid. If the state doesn’t, the number of uninsured will be even higher. Those hardest hit, he says, are middle class Mainers who don’t qualify for subsidies on the ACA marketplace or only qualify for small subsidies.
“The worst-hit folks are people who live in rural parts of the state, in western Maine or The County, or Down East, because that’s where premiums are already high,” he says.
If the individual mandate is repealed, Myall says younger, healthier people will likely opt out of buying health insurance. That will leave older, sicker consumers in the marketplace. To cover the cost of their care, insurance companies will likely raise premiums.
The Center for American Progress estimates the average marketplace premium for a family in Maine will increase about $2,300. Steve Butterfield of Consumers for Affordable Health Care says that will wipe out any benefit the tax bill might provide middle class families.
“That is not a path to any kind of solution except causing chaos,” he says.
Myall says plucking out the individual mandate from the ACA may seem like an easy way to reduce costs to help fund the tax bill. But he says unraveling the mandate will bring hidden costs. Hospitals will see a rise in uncompensated care, and sicker employees will find it difficult to work.
“What it really means is undermining the whole system and making the insurance market and ultimately public health in Maine worse for everyone,” he says.
Republican U.S. Sen. Susan Collins of Maine expressed concern earlier this weekthat repealing the individual mandate would increase premiums, though she has not announced whether she’ll vote for or against the tax bill.
As Walmart Buys Online Retailers, Their Health Benefits Suffer
by Noam Scheiber and Michael Corkery - NYT - November 27, 2017
The steady growth of e-commerce has been a source of jobs and benefits as employment in traditional stores declines. But at online retailers taken over by Walmart, workers are finding one benefit in retreat: their company-sponsored health coverage.
In little more than a year, Walmart has spent nearly $4 billion acquiring e-commerce companies with thousands of workers. Last month, many learned that their potential out-of-pocket costs for medical expenses would increase in 2018 at a rate far exceeding the overall rise in health care costs — reaching thousands of dollars in many cases.
Walmart has periodically struggled against the perception that it skimps on health care benefits. Facing criticism from state legislators and worker advocates that too many of its employees relied on public programs like Medicaid — a critique that a 2005 internal memo conceded had a kernel of truth — the company began expanding access to coverage and making it more affordable about a decade ago.
But with costs rising in recent years, Walmart has reversed course in some ways. In 2011, it raised some premiums by more than 40 percent. Three years ago, it ended coverage for employees working fewer than 30 hours per week on average. Other large retailers, such as Target and Home Depot, made similar changes.
Health care benefits tend to be harder to come by in retail than in any other industry, with just over half of all retail employees eligible for company plans, versus more than 90 percent in manufacturing, according to a survey this year by the Kaiser Family Foundation. Retail workers also opt into their company plans at a far lower rate than any other industry’s workers, possibly suggesting that the insurance is not very attractive or affordable even when companies do offer it.
Walmart says the share of its employees eligible for company-sponsored coverage, and of those choosing it, is slightly above the industry norm. But the health benefits it offers in its online operations appear to be inferior to those of many e-commerce competitors.
At Bonobos, an online men’s wear retailer that Walmart agreed to buy in June for $310 million, workers currently pay nothing in premiums for medical coverage in exchange for a deductible — that is, the level below which they are responsible for covering their own expenses — of $2,000 for individuals and $4,000 for families. A similar policy under Walmart’s plan will cost an individual about $750 more per year in premiums and a family nearly $4,000 more, according to documents on Walmart’s employee benefits website. Both plans will also feature a deductible that is 50 percent higher than the current one.
Some of the biggest changes appear to be occurring at another recent acquisition, ModCloth, an online retailer that made its name selling hip, vintage-inspired apparel to millennial women. To keep biweekly premiums for ModCloth’s roughly 300 workers relatively close to what they pay now, their deductibles will rise from nothing to several thousand dollars per year.
Some economists say that as Walmart amasses such properties, its practices could put pressure on benefits throughout the e-commerce sector, which had been a relative bright spot for low-wage workers.
“My concern is they bring their model with them regardless of what was going on before they got there,” said Jared Bernstein, a senior fellow at the left-leaning Center on Budget and Policy Priorities, who served as chief economic adviser to former Vice President Joseph R. Biden Jr.
Blake Jackson, a Walmart spokesman, said: “We’ve put a lot of thought into creating a total package, including both compensation and benefits, that offers more than what we’ve had in the past.”
Mr. Jackson pointed out that as new employees of the retail giant, many of the workers had gained benefits like a 401(k) retirement plan with a company match and a stock purchase plan.
Mr. Jackson said that the company would make sure its benefits largely kept up with those of competitors, and that the benefits that Walmart offered hourly e-commerce workers were essentially the same benefits it offered hourly workers in its traditional stores.
In addition to its standard health insurance benefits, Walmart covers 100 percent of the cost of certain types of major surgery, like transplants, at a top facility.
The group OUR Walmart, which prods the company to improve wages and benefits, alerted The New York Times to the changes in coverage. The group’s current campaign seeks to make ModCloth’s customers aware of Walmart’s policies. Neither Walmart nor any of its recent e-commerce acquisitions is unionized.
The new Walmart options for hourly workers prominently feature what are known as consumer-driven plans, in which workers cover all their medical expenses out of pocket, up to a relatively high deductible. A medical-expense account to which the company contributes money helps defray these costs.
One coverage option for a worker and a child, including dental and vision, has a biweekly premium of about $67 (assuming no use of tobacco products). Walmart would in turn contribute $600 to a health reimbursement account. Once that $600 is exhausted, however, the worker would have to shoulder the full amount of family medical expenses up to $5,500.
At companies with 200 or more workers, only 10 percent of those enrolled in such plans face deductibles of $5,000 or higher for family coverage, according to the Kaiser Family Foundation’s 2017 survey.
Larry Levitt, a health insurance expert at the foundation, said that such high-deductible plans had increasingly become the cost-containment strategy of choice among many employers, but that the particulars of Walmart’s plan made it especially ungenerous.
At Walmart’s archrival, Amazon, workers typically pay less for more coverage. A similar type of plan would cost an Amazon worker with a child about $60 in biweekly premiums, with Amazon contributing $1,000 into a reimbursement account, according to the company. (The plan includes dental and vision coverage.) After exhausting that account, the worker would pay all expenses out of pocket up to $3,000.
If a ModCloth worker with a child wanted to lower the annual deductible to $3,500 — the lowest the company offers for this type of plan — and receive a $1,000 company contribution, the biweekly premium would be about $136, or just under $2,000 more per year than the Amazon plan.
ModCloth workers were also given the option of sticking with a more conventional insurance plan, but those who do will face premiums that are roughly double their old premiums for family coverage, and their deductible will rise from nothing to $2,000.
The average full-time hourly wage at ModCloth is $13.64. (Walmart put the average wage for its full-time store employees at $13.85 per hour.) But ModCloth employees say Susan Gregg Koger and Eric Koger, who started the company when they arrived in Pittsburgh to attend college in 2002 and later married, saw generous health insurance benefits as central to their feminist values. (Ms. Koger declined to comment.)
“The health benefits were really, really good,” said Alicia Faust Ogg, who worked in returns and customer service at ModCloth between 2012 and 2014.
Ms. Ogg, who had a baby while at the company, said that she had paid nothing out of pocket for her prenatal visits and that her hospital bill for the delivery had been below $1,000.
Under ModCloth’s current insurance, workers pay biweekly premiums ranging from $6.65 for the employee alone to $144 to cover a spouse and children as well. They pay no deductible within the company’s network and a modest co-payment for most doctor visits.
But in a tough retail environment, online operations were under pressure even before Walmart’s buying spree.
In 2014, ModCloth imposed the first of several rounds of layoffs and, according to several current and former employees, gradually made its perks less generous. That included cutbacks in health coverage, they said, but it remained comprehensive and affordable before the company was sold.
Time to return to New Deal principles: Unrelenting pursuit of the public good
by Charles Hoffacker - Portland Press Herald - November 30, 2017
NEWCASTLE — Years ago I learned something about the Masai warriors of Africa that I have never forgotten. These formidable warriors were considered second to none in their fearlessness and intelligence. Yet they greeted one another with a curious phrase. “Kasserian ingera?” one would always say to another. This means “And how are the children?”
The answer to this greeting was “All the children are well.” Even warriors with no children of their own would participate in these exchanges. This custom bore witness to the high value the Masai placed on the well-being of the children among them. “All the children are well” meant that safety and peace prevailed, that the Masai had not forgotten their responsibility for the youngest members of their society.
To this day, “Kasserian ingera?” remains the tribe’s traditional greeting.
What if, in our great country, we would take to greeting each other in this way: “And how are the children?” Perhaps if we heard this question and spoke it a dozen times a day, we would develop a new attitude as a nation toward how we treat the youngest people among us.
Take this a step further. What if the president of the United States, at every news conference, were asked, “And how are the children?” What if that happened with governors, members of Congress and elected representatives at all levels?
As a nation, our current treatment of children leaves much to be desired. This is a nation where many children go hungry, receive a woefully inadequate education, lack health insurance, end up in prison, live in environmental sacrifice zones or die from gunshot wounds. We cannot be a truly great nation until the day comes when anyone can hear that question, “And how are the children?” and respond with the words “All the children are well,” knowing deep down that this is the truth.
The Frances Perkins Center in Newcastle keeps alive the memory of a time when, despite mistakes and shortcomings, our federal government successfully reoriented itself to serve the welfare of every American during a time of national economic catastrophe and beyond. This massive reorientation is known as the New Deal of President Franklin D. Roosevelt.
Frances Perkins was secretary of labor throughout the 12 years of Roosevelt’s presidency and is recognized as “the woman behind the New Deal.” Appalled by how children were abused through factory employment, she contributed to the 1938 Fair Labor Standards Act, which prohibited the employment of children under 16 and required safe working conditions for employed youth.
The Perkins Center focuses on a remarkable period in American history, but it is actively concerned with the present and the future as well. Why? Because the New Deal story contains abiding American principles that have been eclipsed in recent decades. These principles once helped to transform a failing social order into a more gracious and generous society. They can do so again.
New Deal principles can reconnect our nation to the moral norm that Masai warriors upheld when they asked each other “And how are the children?” and responded “All the children are well.” All the children. No exceptions.
The Masai lacked many resources of our so-called “advanced” society, yet their morality insisted that they care for their children. Can we, who claim membership in an “advanced” society, go further and insist on the best possible life for people of all ages? Some countries directly embrace this goal and have achieved significant success in realizing it. The U.S. can do the same. We have the necessary resources.
The Frances Perkins Center is not alone in promoting America’s New Deal heritage and not alone in advocating for a more just social order. People and organizations across the land are engaged in this patriotic endeavor. Yet the Perkins Center has something distinctive to offer in the pursuit of the public good, because of the powerful witness of its namesake.
The 2020s may turn out to resemble the 1930s. The 1930s saw a hard-won transition from the Great Depression to a new and better deal for Americans. The 2020s can be the time when America leaves behind its current season of troubles and we become a people able to respond “All the children are well,” knowing in our hearts that this is the truth.
