Health care, not taxes, is killing American competition
by David Steil - WHYY News - December 5, 2017
Congressional Republicans’ biggest argument for their tax plan is that it will increase our country’s economic competitiveness. As a mid-sized business owner and Republican who represented the 31st legislative district in Pennsylvania for 16 years, I can tell you that nothing could be further from the truth.
There is no evidence to support Republicans’ claims that cutting taxes for wealthy individuals and large corporations will trickle down to create jobs and raise incomes. In fact, the state of Kansas tested this theory with disastrous consequences for its economy. Instead of increased wages and job creation, residents got cuts in crucial public services like shorter school calendars, delays in infrastructure repairs, and decreased aid to the state’s poorest residents. And never in the history of the United States has economic growth from tax cuts ever covered the loss of revenue.
If congressional Republicans want to encourage businesses to expand their markets and create jobs, they’re not looking in the right place. Until we solve the problem of our overburdened and complex health care system, it will always be a barrier to companies looking to expand here.
Radical increases to health insurance premiums are an overhead cost to businesses that is drastically underestimated.
If congressional Republicans want to encourage businesses to expand their markets and create jobs, they’re not looking in the right place.
The average annual premium to insure a single full-time employee was $6,345 in 2016. If that employee has a family, the average premium cost went up to $18,145. That means for a full time employee with a family, it costs $8.72 an hour to keep them insured.
That is money that could have gone to jump-starting the slow wage growth we have been experiencing since the “Great Recession.” In an economy that is close to 70 percent consumer driven, those increased wages could have helped to create new jobs in the service and consumer products industries. For those who are concerned about investing and innovating, that money could have gone to developing or purchasing new technologies, or expanding businesses to new markets.
Instead, it has gone into the $3.2 trillion void that is the American health system, where more money is spent per capita than anywhere else in the world with terrible outcomes to show for it.
If I were a business owner in a country with a stable, publicly funded health care system, and I was looking for a new market to expand my business, too, I’d be wary of choosing the U.S. We have more purchasing power than anywhere else in the world, and yet foreign companies are reluctant to create jobs here in the U.S. What is the incentive to open an office and employ U.S. residents when the cost of keeping them insured year to year is both enormous and unpredictable?
That doesn’t even begin to address the fact that health care costs are keeping our businesses from staying competitive in the international business community. We have created an insurance system where the primary motivation is profit, instead of one where we focus on minimizing costs and delivering high-quality health care.
If Congress wants to truly enhance American competitiveness, it should take up the Medicare-for-All bill, with its 16 co-sponsors in the Senate and 120 co-sponsors in the House.
If we switch from an employer-based insurance system, which puts a strain on businesses and employees while lining the pockets of huge insurance companies, to a single-payer system, health care would be cheaper and more accountable to our needs. It would allow doctors’ offices, hospitals, and other caregivers to continue to operate independently. It would allow patients to see any physician they want, instead of ones that are “in network,” and would place patients’ elected officials in the driver’s seat to better control costs and limit administrative burden.
Workers would have more money in their pocket to buy more goods and services. They would be able to advance their careers by switching jobs or starting their own businesses without worrying about losing their insurance. Businesses will have more flexibility to invest in new technologies. Entrepreneurs would be able to invest in their business without the debilitating costs of trying to keep their employees insured.
If we are really looking to kickstart the American economy and create jobs, it is well past time we eliminate the economic burden of the healthcare insurance system.
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David Steil is the CEO of Micro Trap Corporation in Pennsylvania, and is a former Republican member of the Pennsylvania State Legislature.
GOP tax bill cuts $400 billion from Medicare
by Diane Archer - JustCare - December 6, 2017
On Friday December 1, 51 Senate Republicans voted to slash Medicare as much as $400 billion over the the next ten years in order to pay for tax cuts to millionaires and billionaires. The tax bill undermines Medicare as we know it and threatens to increase costs to the nearly 60 million older adults and people with disabilities who depend on Medicare for their health security. It also destabilizes the health insurance exchanges, jeopardizes the health care of millions of younger Americans and is certain to increase the number of people who face medical bankruptcy.
How does the tax bill threaten Medicare? The Senate tax bill would add $1.5 trillion to the deficit over ten years. A “pay-as-you-go” rule currently in place requires Congress to pay for those deficits. It triggers automatic cuts to Medicare and other mandatory spending programs, including affordable housing, nutrition programs and student loans. The pay as you go rule allows Medicare cuts to be as much as 4 percent, $25 billion, beginning this fiscal year. Medicaid, Social Security and food stamps are exempt from the pay as you go rule.
With a cut to Medicare this large, doctor and hospital rates would likely decrease, reducing the number of doctors willing to treat older adults and people with disabilities. The cut cannot affect either Medicare benefits or premiums and out-of-pocket costs. Congress could waive the pay as you go provision, but it would require 60 votes and, it seems unlikely it would.
Before Congress takes its final vote on the tax bill, the Senate bill needs to be reconciled with the House bill. Americans need to pressure their members of Congress to oppose this bill. Here are the key differences between the two bills.
- The House bill eliminates the tax deduction for large medical expenses, which benefits many older adults, who use a lot of health care, and 8.8 million Americans in total. The Senate bill retains this deduction.
- The House bill retains the individual mandate in the Affordable Care Act. Everyone would continue to need to have health insurance coverage or pay a penalty. The Senate bill repeals the mandate, which the CBO projects would leave 4 million more people uninsured in 2018 and 13 million people uninsured by 2025. It would drive up premiums and out-of-pocket costs for everyone in the state health insurance exchanges and put Obamacare at serious risk. Many people who opted out of health insurance in the exchanges, would buy skimpy, limited coverage, which might not cover their basic medical needs or pre-existing conditions.
These dangerous threats to the nation’s health come with a multi-billion dollar cost to middle income Americans and a multi-billion dollar gain to millionaires and billionaires. A November 26, CBO report finds that people earning between $40,000 and $50,000 will pay $5.3 billion more in taxes than they currently would, while people earning $1 million or more would pay $5.8 billion less.
The Feminist Case For Single Payer
by Natalie Schure - The Jacobin - December 8, 2017
In the spring of 1969, a dozen feminists gathered at a women’s conference in Boston and came to a sober conclusion: their encounters with the United States health-care system had been overwhelmingly negative. They felt unsettled by doctors, alienated from their bodies, grifted by fees, and altogether powerless to navigate an industry they believed objectified them just as popular culture did.
The conference launched a years-long project, with each participant delving into some aspect of anatomy, sexuality, or society related to women’s health. The result was a self-published volume of essays called Women and their Bodies, which the Boston Women’s Health Book Collective used to provide women with a resource produced from their own perspectives and experiences.
Within a few years, the landmark feminist booklet was re-dubbed Our Bodies, Ourselves, released by Simon and Schuester, and sold millions of copies. In 2012, the Library of Congress named it one of the most significant works in American history. In recent years, it has inspired Trans Bodies, Trans Selves, which similarly seeks to be a health-care guide “by and for” the transgender community.
While Our Bodies, Ourselves is remembered for its role in the history of women’s health and culture, less attention is paid to its political context. In the 1970s, the small collective became one of the first feminist organizations to demand a single-payer health-care system: “Suffice it to say that capitalism is incapable of providing good health care, both curative and preventive, for all people,” one entry read. “Cost-benefit analysis trades off the benefit to the people of collective public health in favor of the cost to the people of private, patch-up medical care. The capitalist medical care system can be no more dedicated to improving the people’s health than can General Motors become dedicated to improving the people’s public transportation.” In a subsequent edition, they expounded: “We believe that health care is a human right and that a society should provide free health care for itself . . . Health care cannot be adequate as long as it is conceived of as insurance.”
If the book’s then-radical content has so permeated mainstream culture that it would strike readers as obvious today, the same is not the case for its authors’ critique of American health care. In fact, nearly fifty years after the collective articulated its vision for a universal system, “feminist” arguments against single-payer pepper politics and the media.
In June, Planned Parenthood of California refused to endorse a bill for a statewide single-payer system, contending that it was critical to focus on defending the Affordable Care Act (ACA) against GOP attacks instead. Vice cast it as a job-crusher for the mostly women of color who work in healthcare administration. In 2016, presidential candidate Hillary Clinton — whose campaign foregrounded her feminist credentials — famously declared single-payer would “never, ever come to pass.” More recently, Senator Bernie Sanders’s release of an expansive Medicare for All bill has been met with skepticism by media personalities who backed Clinton for her feminist credentials. At the very least, it seems clear that single-payer health care is rarely framed as a feminist issue.
Some mainstream feminists knock single payer as a distraction from the fight to defend the ACA. But while the Affordable Care Act undeniably improved some women’s lives, it could not dismantle gendered barriers to care.
Of all systems, single-payer is capable of going furthest to eliminate them. That’s the vision that Our Bodies, Ourselves adopted nearly half a century ago, and it must be taken up again today.
The Double Bind
One of the pervasive ways women are disadvantaged under the ACA is its reliance on employer-based coverage. In the United States, World War II–era wage freezes helped entrench a system of employer-provided health insurance, a perk meant to attract workers in a squeezed labor market.
Eventually, Medicare and Medicaid were devised as a safety net for those shut out of private plans, and the ACA expanded that safety net. Still, job-based plans remain the bedrock on which our insurance system is built.
Under this system, it’s harder for women to get health insurance in the first place. The strains of childrearing and elder care make women more likely to seek more flexible employment, like part-time, remote, or freelance work. These forms of employment tend not only to pay less, but are less likely to include health insurance benefits.
Those that do provide inferior ones: companies with majority-female workforces tend to offer less generous health-care coverage than those that are majority male. And less than one-third of low-income workers receive any health insurance through work. Jobs paying at or around the minimum wage are most often occupied by women, the majority of whom are women of color. Trans women face even higher levels of poverty than cis women, and are frequently saddled with impossibly high out of pocket costs.
Then there are the 25 percent of non-elderly adult women insured as dependents of a working spouse, which weakens their control over both their insurance coverage and their relationship. Health insurance has been found to be a common reason for getting married — and for staying married when one would rather not — especially among low-income people. Upon the loss of a spouse’s coverage, it’s difficult and expensive to continue receiving the same care. COBRA coverage — a program that allows people who lose employer-based insurance to remain on it, so long as they pony up the amount formerly contributed by employers — is often the only way to maintain provider networks, but it’s wildly expensive and eventually expires. Ultimately, divorce leaves some sixty-five thousand women uninsured each year, with men being far more likely to maintain coverage after their marriages dissolve.
Women’s unpaid domestic work puts further pressure on the contradictory demands of home, work, and the need to access coverage. Women disproportionately shoulder the responsibility of caring for others, putting them in an impossible situation when it comes to child and elder care: in order to maintain health insurance, they can’t take too much time off work. As a result, they’re forced to spend a significant portion of their wages on private care for the hours they’re on the job. For low-income women who don’t qualify for insurance through employers, the problem can be severe, made worse still by right-wing efforts to impose higher copays and out-of-home work requirements on Medicaid recipients, or to defund programs like CHIP that help parents pay for their children’s health insurance.
During particularly urgent health episodes, like childbirth or a relative’s protracted illness, women opt to take unpaid time off instead of risking their jobs. Notoriously, the United States is one of only a handful of countries that doesn’t guarantee paid maternity leave, exacerbating the financial stress of an already pricey phase of life. The Labor Department has found that nearly one-third of women who take unpaid time off for their own or dependents’ health issues fall into serious credit card debt.
Prescription Drugs May Cost More With Insurance Than Without It
by Charles Ornstein and Katie Thomas - NYT - December 9, 2017
This article was written through collaboration between The New York Times and ProPublica, the independent, nonprofit investigative journalism organization.
Having health insurance is supposed to save you money on your prescriptions. But increasingly, consumers are finding that isn’t the case.
Patrik Swanljung found this out when he went to fill a prescription for a generic cholesterol drug. In May, Mr. Swanljung handed his Medicare prescription card to the pharmacist at his local Walgreens and was told that he owed $83.94 for a three-month supply.
Alarmed at that price, Mr. Swanljung went online and found Blink Health, a start-up, offering the same drug — generic Crestor — for $45.89.
It had struck a better deal than did his insurer, UnitedHealthcare. “It’s completely ridiculous,” said Mr. Swanljung, 72, who lives in Anacortes, Wash.
In an era when drug prices have ignited public outrage and insurers are requiring consumers to shoulder more of the costs, people are shocked to discover they can sometimes get better deals than their own insurers. Behind the seemingly simple act of buying a bottle of pills, a host of players — drug companies, pharmacies, insurers and pharmacy benefit managers — are taking a cut of the profits, even as consumers are left to fend for themselves, critics say.
Although there are no nationwide figures to track how often consumers could have gotten a better deal on their own, one industry expert estimated that up to 10 percent of drug transactions involve such situations. If true nationwide, that figure could total as many 400 million prescriptions a year. The system has become so complex that “there’s no chance that a consumer can figure it out without help,” said the expert, Michael Rea, chief executive of Rx Savings Solutions, whose company is paid by employers to help them lower workers’ drug costs.
Pharmacy benefit managers, the companies that deal with drug benefits on behalf of insurers, often do negotiate better prices for consumers, particularly for brand-name medications, Mr. Rea said, but that’s not necessarily true for some generic drugs. Insurers’ clients are frequently employers overseeing large numbers of workers, and the companies are focused on overall costs. So when insurers seek deals for generic drugs, they do so in batches, reaching agreements for groups of different drugs rather than getting the lowest price on every drug.
As a result of these complicated layers of negotiation — which are not made public — different insurers end up paying different prices for individual drugs. Further compounding confusion for consumers, some insurers require a set co-payment for each prescription — say, $15 or $20 — even when the insurer reimburses the pharmacy at a much cheaper rate.
Several companies have emerged to capitalize on consumer anger over the confusing variations in price. The players include not only Blink Health and its better-known competitor GoodRx, but also veteran businesses like the benefit manager Express Scripts, which recently helped to start a subsidiary aimed at cash-paying consumers. Amazon, the online behemoth, is also said to be considering whether to join the fray.
Last Sunday, CVS Health announced plans to merge with health insurer Aetna, a move that would create a corporate behemoth that many have said would have little incentive to serve the needs of regular people. Some consumers say their experience with CVS already demonstrates how easy it is to fall through the cracks. In one case, a customer whose plan was managed by CVS Caremark, the drug benefit manager, would have had to pay more for a drug through her plan at a CVS than what she ended up paying at the same store, with a coupon from GoodRx.
Representatives for insurers and pharmacy benefit managers say cases like Mr. Swanljung’s are “outliers.” “There are three to four billion generic scripts written a year, and in the vast majority of cases, they are going to get a better deal by using insurance,” said Mark Merritt, chief executive of the Pharmaceutical Care Management Association, which represents benefit managers.
A spokesman for UnitedHealthcare, Mr. Swanljung’s insurer, noted that while Mr. Swanljung got a lower price for generic Crestor through Blink Health, he also takes four other prescriptions, for which he got a better deal by using his insurance. (Mr. Swanljung gave UnitedHealthcare permission to discuss his situation.) Having insurance is clearly valuable, said the spokesman, Matt Burns. In addition, the co-payment for generic Crestor, also called rosuvastatin, in Mr. Swanljung’s plan is set to decrease significantly in January, in large part because the price of the drug has dropped this year.
Consumers also may face penalties if they don’t use their insurance and pay cash to save money. In many cases, insurers won’t let them apply those purchases to a deductible or out-of-pocket spending maximum.
Still, many find that leaving their prescription card at home is worth it. Some have found a better deal even at pharmacies that are owned by their drug plan, like CVS.
Susan Thomson, 55, a university lecturer who lives in Summit, N.J., is covered by a high-deductible plan through her former employer. Her drug benefits are managed by CVS Caremark, a subsidiary of CVS Health. For at least a decade, she’s been using a prescription lotion called sulfacetamide sodium to treat rosacea, a skin condition.
Last year, each time she filled her prescription at a CVS, she paid $75.07. Checking the CVS Caremark website this year, she learned that the cost had gone up to $99.03 (or $81.51 if she used CVS’s mail order service).
Investigating further, she found that GoodRx offered the same prescription at the same drugstore for $75.57, without her insurance. The prices were even lower at other pharmacies.
“It just doesn’t seem right,” she said. “I just feel that the pharmaceutical industry and health care industry are pulling these numbers out of thin air.”
Michael DeAngelis, a spokesman for CVS, did not dispute the details of Ms. Thomson’s experience, but said it was rare and attributed the price disparity to her high-deductible plan. Because consumers are responsible for their costs in those plans until they hit their deductible, Mr. DeAngelis said it would take them longer to reach it and they might end up spending more in the long run.
Prices can also vary widely from month to month when consumers pay cash, he said.
Drug-discount cards have been around for decades, and retailers like Walmart have also offered cheap generic drug programs, but both were mainly used by people without insurance.
That is changing. Even as more Americans have health insurance since the Affordable Care Act was passed, insurers are increasingly asking consumers to pay a larger share of their costs. In 2016, about five million people in Medicare hit a stage in which they had to pick up a greater share of their expenses.
Reporters at ProPublica and The New York Times examined whether they could get better prices on 100 of the most prescribed drugs, identified by GoodRx, without using their insurance. ProPublica’s prescription claims are managed by OptumRx, a large pharmacy benefit manager owned by UnitedHealth Group; The Times’s medication coverage for reporters is managed by Express Scripts.
Both reporters found lower prices on GoodRx for at least 40 drugs on the list (many were drugs that can be purchased for $4 at Walmart, without any coupon).
Blink Health also sometimes beat the insurance out-of-pocket costs, but less often than GoodRx. Blink Health recently suffered a series of setbacks when two of the largest drugstore chains, CVS and Walgreens, stopped accepting its discounts, along with a grocery chain, Publix. In November, Blink Health sued its pharmacy benefit manager, which negotiates its prices, claiming that the company, MedImpact, had violated their agreement. MedImpact has not yet formally responded to the allegations in federal court in New York.
GoodRx, a private company founded in 2010, displays the deals it has with nine pharmacy benefit managers, each offering different prices for different drugs.
“We said, let’s see if we can gather all these prices and see if we can exploit the variation in these contracts,” said Doug Hirsch, GoodRx’s co-founder and co-chief executive, “to see if we can provide better value.”
Dr. Brad Wainer, a family-practice doctor in Berwyn, Ill., said that he frequently shows patients their options on GoodRx to see if they can get a better price. “Most of them don’t believe me until they go and they find it out for themselves,” he said.
Consumers may also pay more if they are covered by plans that require them to pay a set co-payment, no matter the cash price. In some of those cases, the insurers require the pharmacies to send them the difference between what they collect from the consumer and what the insurers have agreed to reimburse the pharmacies.
After a New Orleans television station, WVUE, reported last year on this practice, known as a clawback, lawyers across the country filed lawsuits accusing the insurers — including Cigna, Humana and UnitedHealthcare — of overcharging consumers. The companies are contesting the suits.
Several independent pharmacists said there might be safety issues if consumers buy drugs at different pharmacies. If those prescriptions are filled without an insurance card, pharmacy systems may not catch dangerous drug interactions. “That, to me, is a recipe for disaster,” said Craig Seither, who owns Fort Thomas Drug Center in Fort Thomas, Ky.
Mary Furman, a retired medical social worker in Charlotte, N.C., takes the drug celecoxib, the generic version of Celebrex, to treat her rheumatoid arthritis. When she went to fill a 90-day prescription in April, her pharmacy told her that her share would be $96.89 if she used her Medicare drug plan, offered by SilverScript, run by CVS Health.
Then the pharmacy offered her a deal — only $72.25 if she paid cash, a price the worker said was the same the pharmacy would offer to any customer. “I was flabbergasted,” said Mrs. Furman, who is 72.
Mrs. Furman took the deal, and afterward, her husband, Nelson, called SilverScript to report what happened. The representative told Mr. Furman he was “not surprised.”
The couple then reported the experience to a company hired by Medicare to investigate fraud, but a representative encouraged her to contact the health plan again.
After reporters sent details of Mrs. Furman’s case CVS, Mr. Furman said they received a call from the SilverScript president. Mr. DeAngelis, the CVS spokesman, blamed the pharmacy for charging the couple more than what their share should have been using their insurance. (Medicare rules require that consumers always get the lower price of their set co-payment and a pharmacy’s cash price.)
Now the Furmans are looking at drug coverage for next year, and once again, they see huge variation in prices for that drug and others.
“The prices are all over the map,” Mr. Furman said.
Susan Collins and the Duping of Centrists
by David Leonhardt - NYT - December 10, 2017
Susan Collins is often called one of the last centrists. She is a classic New England Republican, a senator who mostly votes with her party but is willing to buck it.
A couple of weeks ago, Collins made a classic Collins deal. It tried to split the difference between Democratic and Republican positions.
But it sure looks like a bum deal now. It also looks like a cautionary tale for anyone who wants to occupy the political center during the age of Donald Trump and a radicalized Republican Party.
Here’s the back story: Collins said that she would vote for the recent Senate tax bill so long as Republicans leaders promised to pass other legislation — in the near future — that would reduce the bill’s knock-on damage to health care programs.
She laid out three conditions. She wanted her colleagues to pass two separate bills that would shore up insurance markets for people who weren’t covered through their job. And she wanted congressional leaders to promise to undo the Medicare and Medicaid cuts automatically triggered by the deficit increase from the tax cut.
Her colleagues assured her they would pass the bills she wanted — not immediately but soon after the tax bill had passed. Collins decided that was good enough, and on Dec. 2, she became one of 51 yes votes on the tax bill.
When Collins describes her deal, she makes it sound both ironclad — her word — and substantial. She has spoken of a personal commitment from Mitch McConnell, the Senate majority leader. And she’s emphasized that the deal isn’t merely for show. It will, she insists, protect Medicaid and Medicare — two programs particularly important to Mainers, given the state’s large elderly population.
“I also got an ironclad commitment that we’re not going to see cuts in the Medicaid/Medicare program as a result of this bill,” Collins said on “Meet the Press.”
But some of Collins’s fellow Republicans evidently have a different definition of ironclad.
Within days of the Senate vote on the tax bill, conservative House Republicans started saying that they didn’t care about her deal. She did not make it with them, and they do not feel bound by it as they negotiate the bill’s final language with the Senate. These House members, as Politico put it Friday, have decided to “thumb their nose” at Collins.
Meanwhile, Paul Ryan, the speaker of the House, has been undermining Collins in his own way. He has made clear that he will use the new deficits created by the tax bill to justify the very thing Collins opposes: Medicare and Medicaid cuts. Those programs, Ryan told a talk-radio host, are “really where the problem lies, fiscally speaking.” Cutting them is a top priority for 2018.
If anything, Ryan’s snub is more significant. House conservatives might still fold and approve the narrow deal that Collins thought she had. But Republicans will not permit the more meaningful promise she’s made — that the tax bill won’t lead to health care cuts. Tax cuts and health care cuts are inexorably bound.
So in exchange for her vote, Collins received, at best, a cosmetic fix that she will have to pretend is something more.
What was her mistake? It was both tactical and strategic.
The tactical error was to fritter her moment of leverage, when the Senate bill’s fate was uncertain and she had the potential to influence other swing senators. Instead of demanding something real, she accepted vague promises.
She can still vote against the version of the bill that emerges from House-Senate negotiations, but she doesn’t have the sway she did before. Senators usually don’t switch their vote at this stage, and the tax bill will pass without her if no other Republican flips (with Vice President Mike Pence breaking a 50-50 tie.)
Her strategic error is the one that holds lessons for other would-be centrists. Namely, she defined the political center in relative terms rather than substantive terms. Republican leaders — not just Trump, but McConnell and Ryan too — have moved sharply to the right. They are rushing through a bill without the normal procedures. They are making verifiably false claims about it. And they have decided that taking health insurance away from Americans is a core Republican principle.
Collins made the mistake of chasing after an impossible deal. She wanted to position herself between the two political parties, and she wanted to protect Medicare and Medicaid. When it proved impossible to do both, she claimed otherwise — and put a higher priority on politics than policy.
In Trump’s Washington, other centrist Republicans are going to face a version of her dilemma, again and again. They are going to have decide which matters more to them: being a loyal Republican or being an actual centrist.
The Biggest Moments of 2017 in the Fight for Universal Healthcare
by Jonathan Michaels, Armide Storey - Common Dreams - December 13, 2017
In the face of a fiercely conservative administration, 2017 has seen an upsurge in popular resistance against measures that threatened to chip away at important--if imperfect--social welfare initiatives, chief among them the ability for Americans to receive quality healthcare.
Activists pushed back against a series of attempts by Republican lawmakers to repeal and replace the Affordable Care Act (ACA) with bills that the Congressional Budget Office estimated could have lead to the loss of health coverage for 22 to 23 millionAmericans.
While it is tempting to remain on the defensive in the face of an agenda that would rob us of our healthcare, citizen activists across the country recognize that merely protecting the ACA would continue to leave the most marginalized populations in this country behind. While many Americans continue to receive health coverage under the ACA, an estimated 28 million remain uninsured and medical bills continue to be the leading cause of bankruptcy in the United States.
According to a national survey conducted by the Pew Research Center, 60 percent of the population believe that the federal government has a responsibility to provide health coverage for all Americans. Despite continued assertions that universal healthcare in the United States is merely a liberal “pipe dream,” a Medicare-for-All health program--a healthcare insurance system that is government-run--remains the best option for ensuring that all Americans have access to quality health care.
“Overall,” the report stated, “33 percent of the public now favors such a “single payer” approach to health insurance, up 5 percentage points since January and 12 points since 2014.”
Speaking to a crowd at his church in Plains, Georgia, former President Jimmy Carter prophesied that the U.S. would one day adopt a single-payer health system. And while there are millions of stories of individuals and families who struggle daily for adequate healthcare, and though these stories indicate a health system that remains in the service of profits over patients, 2017 should nonetheless give hope to patients and advocates in the fight for universal healthcare.
Here are some of the highlights.
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Legislative support surges for Medicare-for-All bill in the House.
House Bill 676 currently has 120 co-sponsors--up from just 49 legislators in 2015. During a spate of attempts by Republican lawmakers to scrap Obama’s signature health law, Democrats needed an alternative plan that would offer a way forward: enter H.B. 676. Single-payer supporters such as Physicians for a National Health Program (PNHP) and National Nurses United (NNU) have long heralded the bill as being the most comprehensive single-payer legislation to date. Representative John Conyers of Michigan has introduced the single-payer legislation in every congress since 2003. Recently, Conyers agreed to resign his seat due to multiple charges of sexual harassment. His behavior is abhorrent and demands investigation and prosecution. It also serves as a harsh reminder to the movement that universal healthcare will not be won by the stroke of a lawmaker’s pen. Indeed, the movement is, at its core, a call for redistribution of the power and wealth that serves to protect men like this. The people’s vision of Medicare for All is much greater than a single man in power, it is the collective vision of a grassroots, broad-based coalition of activists and advocates.
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The Women’s March brings millions into the streets in defense of human rights.
The day following President Trump’s inauguration became the largest single-day demonstration in American history. The Women’s March was championed by women committed to an intersectional platform of justice and on January 21st, 2017, demonstrators across the globe called for a dismantling of systems of oppression. While single-payer healthcare was not in the guiding principles put forth by the march’s organizers, the emphasis on the importance of intersectionality in the fight justice should embolden healthcare advocates to re-envision universal healthcare through the lens of social and racial justice. Healthcare for all is a basic assertion of every person’s human right to health and wellness.
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Senator Bernie Sanders unveils the Medicare-for-All Act of 2017.
Amidst a seemingly endless stream of bills promising to repeal and replace Obamacare, Sanders put forth an alternative plan to improve and expand Medicare for all Americans. Sixteen other senators stood alongside Sanders when he introduced Senate Bill 1804, which represented a central and popular platform of his 2016 campaign. Despite garnering the support of several potential Democratic candidates for the 2020 presidential election, others on the left extolled the plan as being unrealistic or inopportune. The gains in popularity among Democrats prompted pundit Bill Scher to proclaim, “The Democratic Party now is, for all intents and purposes, the party of single-payer health insurance.” And it is a big mistake, he said. In this way, the latest attempt to pass universal health coverage mirrors its 100-year history, with advocates besieged from members of the media as well as elected officials on both the right and the left. Sanders readily admitted that the bill was doomed to fail in the Republican-controlled legislature, but it represents an important marker in changing attitudes in the U.S. towards universal healthcare.
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The opioid epidemic continues to rage with the National Center for Health Statistics reporting that 64,000 Americans died from opioids in 2016.
Although Trump declared the opioid epidemic a “public health emergency,” he refused to allocate funds to fight the onslaught of overdoses occurring around the country, despite a one-year death toll that exceeds the number of total American deaths in the Vietnam War. We already know that rampant profiteering by the pharmaceutical industry and over-prescribing by some physicians were key factors in fueling this epidemic. Thanks to a report released this year by The New York Times and ProPublica, we now know that insurance companies played a role, too, by limiting access to safer, and costlier, pain management options. Chronic pain treatment is a relatively new area of medicine and often requires long-term treatment and coordination between physicians, physical therapists, social workers, and other members of the healthcare team, something our current health system is ill-equipped to carry out. Eradicating such a devastating and widespread epidemic will only happen by implementing a healthcare system that is not hamstrung by the whims of party politic or health insurance companies but instead one that provides people with substance use disorders rehabilitative treatment that is scientifically proven, and allows physicians the freedom to provide their patients with this effective care.
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While continuing to wage war on Obamacare, Trump lauds Australia for having “better” healthcare--which happens to be a single-payer system.
Speaking to the press alongside the president of Australia, Trump admitted, "We have a failing health care — I shouldn't say this to our great gentleman and my friend from Australia, because you have better healthcare than we do." This isn’t the first time that Trump endorsed single payer. Unfortunately, his actions paint a different picture. In the wake of the legislature’s failure to drive a stake in the ACA, Trump made good on his campaign promise to thwart the healthcare program by cutting funding for enrollment groups to enroll individuals into the program and slashing money allocated for enrollment advertising. A recent Gallup poll showed an uptick in the number of people without insurance, reinforcing the need for an improved Medicare-for-All system that can provide us with real, long-lasting health reform.
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“Tom, you’re fired.” Health and Human Secretary Tom Price resigns amidst public outrage about his use of at least $400,000 in taxpayer money for travel expenses on privately chartered flights.
Although the first-class joyrides were the death knell for the former orthopedic surgeon and U.S. Representative, Price began his short tenure in the sights of activists who questioned his commitment towards advocating for the healthcare of all Americans. A member of the Association of American Physicians and Surgeonswhich is devoted to maintaining a free-market healthcare system, Price pushed to replace the ACA with a $1,200 per year tax-credit system that people could use to pay for a small percentage of their health insurance. This is in addition to Price’s stance against stem cell research, belief that life begins at conception, and lack of support for equal protections for lesbian, gay, bisexual, and transgender people. The Stop Price campaign was just one of many ways that healthcare advocates, including physicians and medical students, pointed a spotlight on the Trump administration’s close ties to powerful health insurance and pharmaceutical companies. Another successful campaign pressured the Cleveland Clinic to cancel its annual fundraising gala at Trump’s Mar-a-Lago club. Opposition is already being mobilized against Alex Azar, Trump’s pick to replace Price, who was a former president at the pharmaceutical giant, Eli Lilly.
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The student section of the American Medical Association (AMA)passes a resolution in support of single-payer healthcare and calls on the AMA to rescind its 170-year opposition towards single-payer healthcare.
This powerful resolution was no easy sell, given the clout and history of the AMA. Although membership has steadily declined since the 1950s, the AMA remains the most powerful physicians organization in the country, ranking number four among the top 50 lobbying organizations of 2016. The association’s weekly publication, the Journal of the American Medical Association (JAMA), also holds great influence within the medical community. Historically, the AMA has opposed every expansive social program passed during the 20th Century, from Social Security to President Truman’s national health insurance plan to Medicare and Medicaid. The Medical Student Section isn’t the first student arm of the AMA. Members of the AMA’s first student organization, the Student American Medical Association (SAMA), fled the organization in 1967 because of their opposition to the Vietnam War and because they supported issues that the AMA refused to embrace or actively thwarted like civil rights and universal healthcare. The group later changed their name to the American Medical Student Association (AMSA) and its members continue to promote universal healthcare. Meanwhile, members of the Medical Student Section, formed in 1979, continue to work under the auspices of the AMA to change the organization from the inside. "We hope that the passage of this resolution can show that with enough time, teamwork, effort, and organizing, even the most powerful healthcare organizations can come around to single payer," said Brad Zehr, a member of the AMA-MSS. The resolution will be debated at the AMA’s annual meeting next year in Chicago.
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In the face of a conservative administration that will undoubtedly quash federal universal healthcare legislation during the next three years, campaigns for state-based single payer healthcare gain steam.
These movements are invariably met with the question: If it didn’t work in Vermontand Colorado, why will it work here? Indeed, the failures in these states are a considerable setback in the movement for state single payer healthcare. While there are certainly barriers to implementing universal healthcare for states, there are no reasons to believe that it couldn’t happen once organizers have built the political will. Further, once a state can implement such a system, organizers hope it will serve as evidence for why a federal single payer system could thrive.
In New York, The New York Health Act (A. 4738 / S. 4840) passed the Assembly 92 to 52. A study shows that the bill would save 98% of New Yorkers money on the healthcare when compared to a policy through their employer or the marketplace. The bill now only needs one state senator to pass in the senate.
In California, grassroots education campaigns have shifted the popular opinion on universal healthcare, with now 70% of Californians supporting state single payer legislation. SB 562 or the Healthy California Act passed the state senate in July.
In Massachusetts, an amendment was adopted by the state Senate as part of a larger healthcare reform bill. The amendment charges the state to measure the impact that a single payer system would have on the cost and delivery of healthcare in Massachusetts. Should it prove to save costs when compared to current state spending, the legislature would be required to state the process of enacting a single payer plan.
In Vermont, organizers refocused after a devastating 2014 political abandonment by Governor Shumlin of Act 48 after its passage. Now organizers are looking at a more political feasible option: primary care for all; bills S53 and H248 have been introduced with tri-partisan support. The hope is that a plan like this would slowly be expanded to cover all sectors of healthcare.
In the face of a fiercely conservative administration, 2017 has seen an upsurge in popular resistance against measures that threatened to chip away at important--if imperfect--social welfare initiatives, chief among them the ability for Americans to receive quality healthcare.
Activists pushed back against a series of attempts by Republican lawmakers to repeal and replace the Affordable Care Act (ACA) with bills that the Congressional Budget Office estimated could have lead to the loss of health coverage for 22 to 23 millionAmericans.
While it is tempting to remain on the defensive in the face of an agenda that would rob us of our healthcare, citizen activists across the country recognize that merely protecting the ACA would continue to leave the most marginalized populations in this country behind. While many Americans continue to receive health coverage under the ACA, an estimated 28 million remain uninsured and medical bills continue to be the leading cause of bankruptcy in the United States.
According to a national survey conducted by the Pew Research Center, 60 percent of the population believe that the federal government has a responsibility to provide health coverage for all Americans. Despite continued assertions that universal healthcare in the United States is merely a liberal “pipe dream,” a Medicare-for-All health program--a healthcare insurance system that is government-run--remains the best option for ensuring that all Americans have access to quality health care.
“Overall,” the report stated, “33 percent of the public now favors such a “single payer” approach to health insurance, up 5 percentage points since January and 12 points since 2014.”
Speaking to a crowd at his church in Plains, Georgia, former President Jimmy Carter prophesied that the U.S. would one day adopt a single-payer health system. And while there are millions of stories of individuals and families who struggle daily for adequate healthcare, and though these stories indicate a health system that remains in the service of profits over patients, 2017 should nonetheless give hope to patients and advocates in the fight for universal healthcare.
Here are some of the highlights.
- Legislative support surges for Medicare-for-All bill in the House.
House Bill 676 currently has 120 co-sponsors--up from just 49 legislators in 2015. During a spate of attempts by Republican lawmakers to scrap Obama’s signature health law, Democrats needed an alternative plan that would offer a way forward: enter H.B. 676. Single-payer supporters such as Physicians for a National Health Program (PNHP) and National Nurses United (NNU) have long heralded the bill as being the most comprehensive single-payer legislation to date. Representative John Conyers of Michigan has introduced the single-payer legislation in every congress since 2003. Recently, Conyers agreed to resign his seat due to multiple charges of sexual harassment. His behavior is abhorrent and demands investigation and prosecution. It also serves as a harsh reminder to the movement that universal healthcare will not be won by the stroke of a lawmaker’s pen. Indeed, the movement is, at its core, a call for redistribution of the power and wealth that serves to protect men like this. The people’s vision of Medicare for All is much greater than a single man in power, it is the collective vision of a grassroots, broad-based coalition of activists and advocates.
- The Women’s March brings millions into the streets in defense of human rights.
The day following President Trump’s inauguration became the largest single-day demonstration in American history. The Women’s March was championed by women committed to an intersectional platform of justice and on January 21st, 2017, demonstrators across the globe called for a dismantling of systems of oppression. While single-payer healthcare was not in the guiding principles put forth by the march’s organizers, the emphasis on the importance of intersectionality in the fight justice should embolden healthcare advocates to re-envision universal healthcare through the lens of social and racial justice. Healthcare for all is a basic assertion of every person’s human right to health and wellness.
- Senator Bernie Sanders unveils the Medicare-for-All Act of 2017.
Amidst a seemingly endless stream of bills promising to repeal and replace Obamacare, Sanders put forth an alternative plan to improve and expand Medicare for all Americans. Sixteen other senators stood alongside Sanders when he introduced Senate Bill 1804, which represented a central and popular platform of his 2016 campaign. Despite garnering the support of several potential Democratic candidates for the 2020 presidential election, others on the left extolled the plan as being unrealistic or inopportune. The gains in popularity among Democrats prompted pundit Bill Scher to proclaim, “The Democratic Party now is, for all intents and purposes, the party of single-payer health insurance.” And it is a big mistake, he said. In this way, the latest attempt to pass universal health coverage mirrors its 100-year history, with advocates besieged from members of the media as well as elected officials on both the right and the left. Sanders readily admitted that the bill was doomed to fail in the Republican-controlled legislature, but it represents an important marker in changing attitudes in the U.S. towards universal healthcare.
- The opioid epidemic continues to rage with the National Center for Health Statistics reporting that 64,000 Americans died from opioids in 2016.
Although Trump declared the opioid epidemic a “public health emergency,” he refused to allocate funds to fight the onslaught of overdoses occurring around the country, despite a one-year death toll that exceeds the number of total American deaths in the Vietnam War. We already know that rampant profiteering by the pharmaceutical industry and over-prescribing by some physicians were key factors in fueling this epidemic. Thanks to a report released this year by The New York Times and ProPublica, we now know that insurance companies played a role, too, by limiting access to safer, and costlier, pain management options. Chronic pain treatment is a relatively new area of medicine and often requires long-term treatment and coordination between physicians, physical therapists, social workers, and other members of the healthcare team, something our current health system is ill-equipped to carry out. Eradicating such a devastating and widespread epidemic will only happen by implementing a healthcare system that is not hamstrung by the whims of party politic or health insurance companies but instead one that provides people with substance use disorders rehabilitative treatment that is scientifically proven, and allows physicians the freedom to provide their patients with this effective care.
- While continuing to wage war on Obamacare, Trump lauds Australia for having “better” healthcare--which happens to be a single-payer system.
Speaking to the press alongside the president of Australia, Trump admitted, "We have a failing health care — I shouldn't say this to our great gentleman and my friend from Australia, because you have better healthcare than we do." This isn’t the first time that Trump endorsed single payer. Unfortunately, his actions paint a different picture. In the wake of the legislature’s failure to drive a stake in the ACA, Trump made good on his campaign promise to thwart the healthcare program by cutting funding for enrollment groups to enroll individuals into the program and slashing money allocated for enrollment advertising. A recent Gallup poll showed an uptick in the number of people without insurance, reinforcing the need for an improved Medicare-for-All system that can provide us with real, long-lasting health reform.
- “Tom, you’re fired.” Health and Human Secretary Tom Price resigns amidst public outrage about his use of at least $400,000 in taxpayer money for travel expenses on privately chartered flights.
Although the first-class joyrides were the death knell for the former orthopedic surgeon and U.S. Representative, Price began his short tenure in the sights of activists who questioned his commitment towards advocating for the healthcare of all Americans. A member of the Association of American Physicians and Surgeonswhich is devoted to maintaining a free-market healthcare system, Price pushed to replace the ACA with a $1,200 per year tax-credit system that people could use to pay for a small percentage of their health insurance. This is in addition to Price’s stance against stem cell research, belief that life begins at conception, and lack of support for equal protections for lesbian, gay, bisexual, and transgender people. The Stop Price campaign was just one of many ways that healthcare advocates, including physicians and medical students, pointed a spotlight on the Trump administration’s close ties to powerful health insurance and pharmaceutical companies. Another successful campaign pressured the Cleveland Clinic to cancel its annual fundraising gala at Trump’s Mar-a-Lago club. Opposition is already being mobilized against Alex Azar, Trump’s pick to replace Price, who was a former president at the pharmaceutical giant, Eli Lilly.
- The student section of the American Medical Association (AMA)passes a resolution in support of single-payer healthcare and calls on the AMA to rescind its 170-year opposition towards single-payer healthcare.
This powerful resolution was no easy sell, given the clout and history of the AMA. Although membership has steadily declined since the 1950s, the AMA remains the most powerful physicians organization in the country, ranking number four among the top 50 lobbying organizations of 2016. The association’s weekly publication, the Journal of the American Medical Association (JAMA), also holds great influence within the medical community. Historically, the AMA has opposed every expansive social program passed during the 20th Century, from Social Security to President Truman’s national health insurance plan to Medicare and Medicaid. The Medical Student Section isn’t the first student arm of the AMA. Members of the AMA’s first student organization, the Student American Medical Association (SAMA), fled the organization in 1967 because of their opposition to the Vietnam War and because they supported issues that the AMA refused to embrace or actively thwarted like civil rights and universal healthcare. The group later changed their name to the American Medical Student Association (AMSA) and its members continue to promote universal healthcare. Meanwhile, members of the Medical Student Section, formed in 1979, continue to work under the auspices of the AMA to change the organization from the inside. "We hope that the passage of this resolution can show that with enough time, teamwork, effort, and organizing, even the most powerful healthcare organizations can come around to single payer," said Brad Zehr, a member of the AMA-MSS. The resolution will be debated at the AMA’s annual meeting next year in Chicago.
- In the face of a conservative administration that will undoubtedly quash federal universal healthcare legislation during the next three years, campaigns for state-based single payer healthcare gain steam.
These movements are invariably met with the question: If it didn’t work in Vermontand Colorado, why will it work here? Indeed, the failures in these states are a considerable setback in the movement for state single payer healthcare. While there are certainly barriers to implementing universal healthcare for states, there are no reasons to believe that it couldn’t happen once organizers have built the political will. Further, once a state can implement such a system, organizers hope it will serve as evidence for why a federal single payer system could thrive.
In New York, The New York Health Act (A. 4738 / S. 4840) passed the Assembly 92 to 52. A study shows that the bill would save 98% of New Yorkers money on the healthcare when compared to a policy through their employer or the marketplace. The bill now only needs one state senator to pass in the senate.
In California, grassroots education campaigns have shifted the popular opinion on universal healthcare, with now 70% of Californians supporting state single payer legislation. SB 562 or the Healthy California Act passed the state senate in July.
In Massachusetts, an amendment was adopted by the state Senate as part of a larger healthcare reform bill. The amendment charges the state to measure the impact that a single payer system would have on the cost and delivery of healthcare in Massachusetts. Should it prove to save costs when compared to current state spending, the legislature would be required to state the process of enacting a single payer plan.
In Vermont, organizers refocused after a devastating 2014 political abandonment by Governor Shumlin of Act 48 after its passage. Now organizers are looking at a more political feasible option: primary care for all; bills S53 and H248 have been introduced with tri-partisan support. The hope is that a plan like this would slowly be expanded to cover all sectors of healthcare.
Heading North: American Doctors Report Back From Canada
by Shefali Luthra - Maine Public - December 14, 2017
For Peter Cram, an American internist who spent most of his career practicing in Iowa City, Iowa, moving to Toronto in 2014 was an easy decision.
He says he is among a handful of American doctors who went north to practice in Canada's single-payer system. Now he doesn't worry about whether his patients can afford treatment. "Everyone gets a basic level of care," he says, which lets him focus on their medical needs instead of their finances.
Cram treats his move as a sort of life-size experiment. As an American-trained physician and a health system researcher, he is now studying how the United States and Canada – neighbors with vastly different health systems – compare in terms of results. Does one do a better job of keeping people healthy?
For all the political talk, it's in many ways still an unresolved question."The Canadian system is not perfect," Cram said over coffee in Toronto's Kensington Market. "Anyone who gives you a sound bite and says this system should be adopted by [the U.S.] ... I think they're being almost disingenuous."
Still, American support for government-run single-payer health care, once a fringe opinion, is picking up momentum. Sen. Bernie Sanders, the Vermont independent who emphasized single-payer health care in his 2016 presidential bid, helped move Canada's system into the U.S. spotlight.
Polls find that doctors and patients increasingly support single-payer, though the percentages in favor typically drop when questions are focused on paying for such a system.
In Canada, medical insurance is publicly funded. While covering everyone, Canada still spends far less on health care than the United States: just over 10 percent of its GDP, compared with the United States' 16 percent.
To American advocates, Canada's health system sounds like an answer to the United States' challenges.
But in Toronto, experts and doctors say the United States would first have to address a fundamental difference. In Canada, health care is a right. Do American lawmakers agree?
"The U.S. needs to get on with the rest of the world and get an answer on that issue before it answers others," said Dr. Robert Reid, a health quality researcher at the University of Toronto, who has practiced medicine in Seattle.
It's an obvious disconnect, said Dr. Emily Queenan, a family doctor now practicing in rural Ontario. Queenan, 41, grew up in the United States and did her residency in Rochester, N.Y. In 2014, after five years of frustrating battles with insurance companies over her patients' coverage, she found herself asking, why not Canada?
She moved north. Gone, she said, are the reams of insurance paperwork she faced in America. Her patients don't worry about affording treatment. "We have here a shared value that we all deserve access to health care," said Queenan. "That's something I never saw in the States."
Canadian doctors may earn less than do their American counterparts: A 2011 paperpublished in the journal Health Affairs found that primary care doctors and surgeons alike make more in the United States than in most other western countries. That's in part because, overall, American doctors charged more for each service they provide, and in part because they performed more of them.
Critics argue that's a sign of American inefficiency in paying for health care.
The fee gap is greatest for surgeons. Family doctors in Canada appear to charge similar amounts to their American counterparts.
Meanwhile, the doctors interviewed for this story — internists and family doctors – said they didn't experience any real change in their standard of living when moving north.
Sanders has pushed the single-payer discussion with a "Medicare-for-All" bill in Congress and in a visit to Toronto this fall. It was part fact-finding mission and part publicity tour. On that trip, doctors, hospital leaders and patients painted a rosy picture of Canada as a place where everyone gets top-notch care, with no worries about its cost to them.
"They have managed to provide health care to every man, woman and child without any out-of-pocket cost," Sanders told reporters on the ground floor of Toronto General Hospital.
The reality is more complicated.
While progressives tout Canada for efficiently providing universal health care, the Commonwealth Fund puts it just two spots above the United States — which ranks last among 11 developed countries— in the group's health system assessment. Canada still has room to improve in timeliness, health outcomes and equitable access to care.
"If you deny there are trade-offs, I think you're living in wonderland," Cram said.
The Canadian Vibe
In Canada, everyone gets the same, government-provided coverage. Provinces use federal guidelines to decide what's covered, and there's no cost sharing by patients.
"Come to our waiting room," said Dr. Tara Kiran, a family doctor at St. Michael's Hospital, in Toronto. "You will see people who are doctors or lawyers alongside people who are homeless or new immigrants. People with mental health issues or addiction issues together with people who don't."
But that insurance — which accounts for 70 percent of health spending in Canada —addresses only hospitals and doctors. Prescription medications, dentists, eye doctors and even some specialists aren't covered. Most Canadians get additional private insurance to cover those.
In countries such as Britain or Germany, people can opt out to buy private insurance. Canada prohibits private insurers from offering plans that compete with the government, a restriction some doctors are suing to lift.
In Canada, the debate focuses more on bringing down health spending. Canada's provinces put, on average, 38 percent of their budgets into health care, according to a 2016 report from the Canadian Institute for Health Information, a nonprofit organization. Canada's single-payer system is supported by a combination of federal and provincial funds, mostly raised through personal and corporate income taxes. (A few provinces charge premiums, which are based on income and collected with taxes.)
"We make improvements or change things only to have additional debates about other things. Those debates are constant, and they should be," said the University of Toronto's Reid. "[But] most of what you hear in the U.S. is back to the tenor of the insurance framework, whether [they] should have Obamacare or not."
Taxes in Canada are generally higher than in the United States. But many here call that a concession worth making. "We can't have what we have if we don't pay the taxes," said Brigida Fortuna, a 50-year-old Toronto resident and professional dog groomer, while on her way to a medical appointment.
The Trade-Offs
That said, it's not a perfect system. Canadian health care doesn't cover prescriptions, physical therapy and psychotherapy. And there's the concern that Canadians wait longer for health care than would Americans with robust health coverage.
There are cases, Reid said, when cancer care in Canada is delayed enough to yield health problems. Expat Cram pointed to research that suggests low-income people are likely to wait longer for medical care, which can result in worse health outcomes.
"We do have a two-tiered system," he said. "Most know it. Few will admit it."
Typically, experts said, people with serious medical needs will jump to the front of the line for medical care. Kathleen Wynne, Ontario's Liberal premier, said the Canadian government is actively trying to improve wait times.
But so far, it's unclear how effective that's been. A 2017 report from the nonprofit Canadian Institute for Health Information found that wait times had dropped for hip fracture repairs. But waits for, say, MRIs and cataract surgery have gotten worse. Depending on the province, the average wait for cataract removal ranged from 37 days to 148 days.
Many patients, though, said the waits were a trade-off they were willing to make. Toronto-based Nate Kreisworth, a 37-year-old music composer and producer, called it an obvious choice.
"You are not going to die because you're waiting," he said on a recent sunny morning while walking with his dog near Kensington Market. "Better wait times for everything? Sure, why not. But as long as the major issues are being covered, then I don't think it's really much of an issue."
As Fortuna put it: "If you go for a headache and someone else is going to lose their arm, of course they're going to take care of that person. I'm OK with that, because someday that could be me, too."
Waits aren't the only concern, though. There's financing – and what it would cost for the United States to implement a system like Canada's.
Because Americans have higher expectations about what a health plan should cover, it would be more expensive to adapt a Canadian approach, said Dr. Irfan Dhalla, an internist and health quality researcher in Toronto. And the quality may differ from what they are used to.
In Canada, "everyone gets Kmart care," Cram said. "There's no Neiman Marcus care."
Of course, some American amenities that drive up costs — fancier food, softer gowns or private rooms — don't necessarily produce better results
And there's perhaps the bigger question: Experts don't really know whether the Canadian system is an obvious improvement.
The research is limited, and not always recent. A 2006 paper suggests wealthy Canadians and Americans fare similarly, while poor Americans do worse. A 2007 paper found Americans more often liked their quality of health care. More recent research focuses on specific conditions – cystic fibrosis patients did better in Canada, while surgical outcomes were better in the United States. The Commonwealth Fund's most recent ranking places Canadian health outcomes above America's, but only two positions higher.
Even so, many Canadians said they couldn't imagine living with an American system. It's a question not just of efficiency, but of fairness. Kreisworth compared his experience to that of family members in the United States.
"I talk to my brother's girlfriend who is a part-time worker who has no [health] benefits — who would just be sick and not go to the doctor because she couldn't afford to pay," he said. "I can't imagine that here. It seems like — it's so wrong. It just seems utterly wrong."
Attempt to nail down Maine Medicaid expansion costs makes no progress
by Christopher Cousins - Bangor Daily News - December 13, 2017
Questions about how much expanding the state’s Medicaid program would cost took center stage Wednesday during the Legislature’s first discussion of last month’s referendum.
But the budget committee meeting ended with no answers.
The state cost during the next couple of years to expand Medicaid eligibility — passed by voters in a November referendum — depends on when Maine applies to the federal government for the expansion, how quickly newly eligible Mainers sign up, how much will be saved when Mainers move from current state-funded programs to Medicaid and, most importantly, whether the executive branch will do anything to spur the process.
“We’re a ways away from figuring out how much money we’re going to need and when we’re going to need it,” said Rep. Drew Gattine, D-Westbrook, who co-chairs the Legislature’s Appropriations Committee.
At issue is the fact the voter-approved bill mandates expansion but includes no language about how to fund it. Proponents of the measure considered proposing raising the income tax to pay for expansion but opted to omit any funding mechanism from the signature drive that put the question on the ballot.
Now, Gov. Paul LePage is issuing ultimatums about what kind of funding source he’d support. Meanwhile, the Legislature’s fiscal office and Department of Health and Human Services disagree about how much it will cost.
Luke Lazure, a health care policy analyst for the Legislature’s Office of Fiscal and Program Review, told Appropriations Committee members on Wednesday that much of the difference between the department’s estimates and his stem from the fact that the department is not taking into account savings that would be generated.
“We assume some savings and the department assumes none,” said Lazure. “That’s the big difference.”
In a Dec. 11 letter to legislative leaders, LePage also wrote that the money appropriated by the Legislature for Medicaid expansion must be based on the DHHS estimates, not OFPR’s.
OFPR pegged the cost after full implementation at more than $54 million in the first year, rising to more than $81 million by 2021, which would be matched with $525 million in federal matching funds.
The Department of Health and Human Services estimate the cost of expansion would be at least $63 million next year, $82 million in fiscal year 2020, $97 million in 2021 and more than $100 million every year after that, according to the governor’s office.
As for short-term fiscal impacts, Lazure said the amount of new money that must be appropriated during the current two-year budget cycle depends on how quickly expansion can take place. The numbers presented to date are based on the state moving quickly with the process, with Mainers making less than 138 percent of the federal poverty level first becoming eligible in July 2018.
No one from DHHS participated in Wednesday’s hearing despite a request for them to do so. LePage has said any questions for DHHS must be in writing and submitted directly to him.
Rep. John Martin, D-Eagle Lake, submitted some of the questions.
“I wonder if the department could let us know the timeline for the number of people necessary to implement the program and how they envision that will proceed,” Martin said, drawing a pithy response from Rep. Jeff Timberlake, R-Turner, who was sitting at the other end of the budget committee chamber.
“I think the chief executive answered that in his letter,” said Timberlake. “As soon as we put the money up and finance it, he’ll start.”
LePage, who has always firmly opposed expanding Medicaid because of the cost to taxpayers, laid out a number of conditions, including that there be no tax increases, that money from the budget stabilization fund not be tapped, that the funding mechanism be ongoing, and that waitlists for services for elderly and disabled people be eliminated before state government pays to expand Medicaid eligibility.
The budget committee doesn’t meet again until January when the full Legislature returns for a four-month session.
http://bangordailynews.com/2017/12/13/politics/attempt-to-nail-down-maine-medicaid-expansion-costs-makes-no-progress/
Paul LePage can’t thwart Maine voters
Editorial - Boston Globe - December 8, 2017
Governor Paul LePage of Maine got a sharp rebuke from voters last month, when they overwhelmingly approved a ballot question to expand the state’s Medicaid program under the Affordable Care Act. LePage had repeatedly vetoed legislative efforts to cover those up to 138 percent of the federal poverty level, despite the generous funding Obamacare provides.
Faced with LePage’s recalcitrance, advocates of expanded care then gathered signatures and went to the ballot with a question asking voters to approve such an expansion. They did, with 59 percent voting yes. (LePage, by contrast, hasn’t won an outright majority in either of his two gubernatorial campaigns.) The governor’s response has been to throw up obstacles and conditions, saying he won’t implement the expansion unless the Legislature first funds Maine’s share without raising taxes, using rainy-day funds, or diverting money from services for the elderly or disabled.
That stubborn stance puts him at odds not just with Maine voters but also with the state’s constitution, which doesn’t give the governor discretion over whether to follow through on ballot laws. Indeed, it specifically declares that “the veto power of the Governor shall not extend to any measure approved by vote of the people.”
he ballot law directs the state to submit its application for expanded Medicaid funds within 90 days and to have the new, expanded Medicaid program in place and covering people within 180 days. If LePage tries to thwart the new law, advocates say, he should expect to find his administration in court.
“We have formed a legal team that is ready if necessary,” notes Robyn Merrill, cochair of the Mainers for Health Care campaign.
In an e-mail, Peter Steele, LePage’s director of communications, disputed the idea that LePage was trying to thwart the will of the voters. “The Governor is simply asking the Legislature to be fiscally responsible in implementing Medicaid expansion,” he wrote. Asked twice via e-mail if LePage would propose his own funding plan, Steele did not reply. But LePage obviously has no interest in working toward a solution here.
The Maine Legislature, where the House is led by Democrats, the Senate by Republicans, seems more willing to step to the policy plate. The House Appropriations Committee meets next week to start focusing on how to fund and implement the new law.
Initially, that shouldn’t be horribly difficult. The first (half) year costs are estimated at $13.6 million, which even in Maine, where the annual budget is $6.8 billion, isn’t a huge sum. Maine’s nonpartisan Office of Fiscal and Program Review estimates that the cost will grow to $54 million or so when the law is fully implemented and the federal ACA reimbursement settles back to the long-term 90 percent federal, 10 percent state funding match, in 2020. For that sum, Maine could leverage more than a half-billion in federal health care dollars and cover an additional 80,000 people.
Finding the state money may take some work and willingness to compromise. But there’s good news on that front as well. LePage leaves office in the beginning of 2019. The new governor, be he or she a Republican or a Democrat, should be more respectful of the will of Maine voters.
Lawmakers looking for ways to fund Maine’s share of Medicaid expansion
by Scott Thistle - Portland Press Herald - December 14, 2017
AUGUSTA — Surpluses expected in the next two-year budget cycle could provide a starting point for funding the state’s share of Medicaid expansion, but it isn’t clear whether lawmakers would agree to use that money, or whether Gov. Paul LePage would veto such a move.
But the state’s share of expanding the health insurance program for low-income residents is an estimated $60 million, and the budget surplus is expected to be only about $12.5 million at the end of the coming two-year budget cycle in June 2019. Lawmakers will get a revised budget forecast in April.
The Legislature’s appropriations committee met Wednesday to start work on an official estimate of the costs and savings of Medicaid expansion. So far, lawmakers have offered no ideas about how to pay for it. The expansion funding battle is likely to consume much of the legislative session starting in January.
On Monday, LePage reiterated his opposition to expansion and in a letter to legislative leaders said they would have to find a way to pay the state’s share without raising taxes, cutting programs for disabled and elderly residents, or raiding the budget stabilization, or Rainy Day, fund – which LePage wants to increase to $300 million to lower the state’s borrowing costs. LePage also said he expects lawmakers to eliminate waiting lists for services for disabled and elderly residents before expanding MaineCare, the state’s Medicaid program.
Democrats say the state is obligated to expand MaineCare after it received the support of 59 percent of state voters in a November referendum. After the law takes effect on Jan. 3, the Department of Health and Health Services must apply to expand MaineCare by April 3 and expand the program by July 2, analysts say.
Expansion would provide coverage to about 80,000 low-income residents – those earning less than 138 percent of the federal poverty level, or about $17,000 a year for a single adult and $22,412 for a two-person household.
LePage, a staunch opponent of Medicaid expansion, is unlikely to cooperate by quickly providing data needed to figure out how to fund the state’s share.
The governor has said lawmakers must put questions in writing and that experts from both the Maine Revenue Service, which collects taxes, and the Department of Health and Human Services, which oversees Medicaid, will be barred from appearing before the budget-writing appropriations committee.
During its three-hour meeting Wednesday, the committee reviewed the state’s revenue forecast and the work of its non-partisan Office of Program and Fiscal Review, which has crunched the numbers on health care expansion costs at least five different times when lawmakers considered earlier Medicaid expansion bills. The state’s share of the expansion cost would be an estimated $55 million a year for the fiscal year beginning July 1, and would expand to an estimated $60 million a year by 2021. But that would draw down about $525 million in federal matching funds.
Appropriations committee members focused on how much expansion would cost the state and when it would need the money, and worked on questions for DHHS.
At the top of that list is why DHHS has not provided an accounting for any savings in other state health programs, such as mental health and addiction services for low income residents, that would be recouped if MaineCare is expanded. According to Luke Lazure, an analyst with the fiscal review office, the state spends about $35 million a year on those programs.
“I would like to understand, I would love to see the same kind of detail from the department on what their estimate of costs are, the same kind of detail that (Lazure) just gave us here,” said Rep. Drew Gattine, D-Westbrook, the House chairman of the Appropriations Committee. He said he hoped DHHS officials were at least listening to the meeting Wednesday. “Because I think the goal here is to get to the right number.”
Gattine and other lawmakers said they would put questions in writing, but that the process should be more open-ended because the answer to one question often generates another.
Gattine said he wants to get to a implementation timeline and a plan for rolling out expansion, but some Republicans on the committee clearly backed LePage’s demand that a way to pay for expansion be found first. Neither committee Republicans nor LePage have offered suggestions on how to pay for it.
Democrats noted that they are prohibited from estimating how much the state might save in costs to other programs because of expansion, or how much additional income tax revenue might be generated by the estimated 6,000 health care jobs it is expected to create.
Expansion would also create at least 103 new jobs in DHHS and at least one lawmaker, state Rep. John Martin, D-Eagle Lake, suggested Wednesday some of those jobs should be located in rural Maine and outside of Augusta.
Gattine said the projected two-year revenue surplus of $12.5 million may be a starting point for expansion-funding talks, but that dozens of other proposals will compete for that funding.
Our View: LePage’s Medicaid stance subverts the voters’ will
by The Editorial Board - Portland Press Herald - December 14, 2017
Gov. LePage’s ability to stand in the way of Medicaid expansion should have ended Nov. 7.
That’s the day nearly 60 percent of Maine voters said clearly that the state should extend health insurance coverage to about 70,000 low-income residents.
The governor vetoed Medicaid expansion five times against the wishes of a bipartisan group of lawmakers making up a majority of the Legislature. He delivered countless campaign speeches, radio show appearances and weekly addresses against expansion, using scare tactics and talking points only remotely connected to the facts.
Yet still an overwhelming number of Mainers voted to provide health insurance to poor residents locked out of the health care system only by a glitch in the Affordable Care Act and the LePage administration’s cruel eligibility guidelines.
When given the chance, Maine voted resoundingly against one of LePage’s chief public policy positions, and it is now the governor’s responsibility to make it work.
Given his history, though, it’s no surprise that the governor once again is putting up roadblocks.
While he said recently that he was “looking forward to expanding Medicaid,” or MaineCare, as it is known here, his actions tell a different story than those words do.
Immediately after the election, he issued a list of demands for funding expansion. On Monday, in advance of an Appropriations Committee meeting Wednesday on the issue, LePage reiterated those demands, which are so limiting that they can have only one purpose – to give legislators no way forward.
The governor says the legislative funding plan must not increase taxes, or use the rainy day fund or other one-time funding mechanisms. Lawmakers must fully fund home- and community-based services for elderly and disabled Mainers, too, and they can’t make any reductions for others already receiving state-funded health benefits.
Amazingly, LePage said lawmakers also must consider that the state may owe more than $60 million following the federal decertification of Riverview Psychiatric Center, an appalling situation that exists only because of the continued and long-term mismanagement of that facility by his administration.
And, the governor said, the Legislature must fund expansion not at the level estimated by the nonpartisan Office of Fiscal Program and Review, but according to the higher, questionable figures cooked up by the Maine Department of Health and Human Services, whose track record on accurate analysis is far from pristine.
That’s a good argument for implementing expansion through the budget, a more deliberate process that would have been fine with a majority of legislators had LePage not stood in the way again and again.
In any case, the governor simply is not making a good-faith effort to carry out the will of the people. Instead, he is trying to sabotage it. After all, that’s what he has done for the past four years, using specious arguments and power politics to uphold his five vetoes of the popular expansion bills.
But he couldn’t fool Maine voters, who understand exactly what Medicaid expansion means: healthier outcomes and less suffering for tens of thousands of Mainers, not “adults who should be working,” as LePage argues, but mostly working Mainers who earn too little to afford health coverage or doctor visits – less than $22,411 a year for a family of two.
Last month, Mainers made clear what they want. Now it is the governor’s duty to make it happen.
Maine task force to pursue state-based improvements to health care system
by Joe Lawlor - Portland Press Herald - December 15, 2017
As Congress decides whether to repeal a key provision of the Affordable Care Act, a Maine-based task force set to meet for the first time next week will be studying state-based fixes to the health care system. Included in the discussion would be long-shot proposals to establish a single-payer system in Maine.
The Health Care Coverage Task Force – created by the Legislature after a hearing on a single-payer bill that failed earlier this year – will meet Wednesday in Augusta to begin a wide-ranging discussion on health care. The task force includes residents, a bipartisan mix of eight lawmakers, and representatives from health care groups, hospitals, the insurance industry, and small and large employers.
Sen. Geoff Gratwick, D-Bangor, a physician who is on the task force, said that although he supports single-payer in theory, he’s looking for practical solutions that can be supported by Republicans, Democrats, patients, hospitals and health care professionals.
“No health care reform is going to work unless we bring everyone to the table,” Gratwick said.
Democrats tend to support single-payer, but Republicans are usually opposed.
While many European countries and Canada have established universal health care systems, the United States created the Affordable Care Act under then-President Barack Obama, reforming the existing system rather than creating a single-payer version. No state has adopted a single-payer system despite several attempts to do so.
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Single-payer means that a single entity – usually the federal government – is responsible for paying health care providers such as doctors and hospitals. Out-of-pocket costs for individuals go down, but taxes are increased to compensate. The U.S. has elements of a single-payer system in the Medicare and Medicaid systems for seniors, the disabled and low-income populations. The ACA reduced the number of uninsured by expanding Medicaid and offering subsidized insurance to working-class and middle-income families that didn’t have employer-based insurance.
SINGLE-PAYER PASSAGE FAILED IN OTHER STATES
Since congressional Democrats and Obama muscled the ACA through Congress on a party-line vote in 2010, many Republicans have argued that it doesn’t work well and have tried to dismantle it.
President Trump and congressional Republicans came within one vote of repealing the ACA this summer – with Republican Sen. Susan Collins of Maine a key “no” vote– and are trying to weaken the ACA in a number of ways, including by repealing the individual mandate in the pending tax reform bill.
Repealing the individual mandate – which requires people who can’t get insurance through an employer to purchase coverage or pay a penalty – would result in 13 million fewer Americans with health care coverage, the Congressional Budget Office estimates. The Trump administration also has cut ACA advertising and outreach budgets and slashed the enrollment period from 12 weeks to six.
Meanwhile, as Congress and the Trump administration consider ways to undermine the ACA, California is exploring adoption of a single-payer system. A bill to create single-payer stalled in the California Legislature this year, but Lt. Gov. Gavin Newsom is a strong supporter of universal health care and he is considered a leading Democratic candidate for governor next year.
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However, other efforts to create state-based single-payer systems have collapsed – including in Vermont in 2015, Oregon in 2002, Colorado in 2016 and California in 1994. Voters soundly rejected single-payer ballot initiatives in Oregon, Colorado and California.
John McDonough, professor of the practice of public health at Harvard University, said single-payer system proposals in the United States have failed when details start emerging.
“As much as people are attracted to the idea, it has always fallen apart when you get to the issue of finance. How are we going to pay for it? Then the exuberant support fades, people’s fears take over and it falls apart,” McDonough said.
OTHER TYPES OF REFORMS HOLD POTENTIAL
He said the referendums in Oregon, Colorado and California started with promising levels of public support before failing at the polls, with less than 30 percent of voters voting “yes.”
But Delene Perley, education and communications chair for Maine AllCare, a group that advocates for single-payer, said she looks to Canada, which started in the provinces before becoming a countrywide system in the 1980s.
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“If we can’t get universal health care done nationally, we can start in the states,” Perley said. She said she’s also encouraged by the Nov. 7 vote in Maine to expand Medicaid, which passed with 59 percent of the vote. Perley believes Maine AllCare eventually will launch a referendum drive.
“It’s headed that way,” she said. “That Medicaid vote was a good sign. People want health care that they can access and afford.”
Perley doesn’t hold out much hope that the Maine task force will recommend a single-payer system, but “it’s a start. It’s opening the discussion,” she said.
McDonough said there are many reforms that states can approve to improve health care affordability without going to a single-payer system, such as a robust reinsurance program in Alaska that allows people to “buy into” Medicare or Medicaid, or simply offering more generous subsidies on the ACA’s individual market.
For instance, the Massachusetts state government approved a system similar to the ACA in the 2000s under Republican Gov. Mitt Romney that offered enrollees more generous subsidies than what was later approved under the ACA. When the ACA’s individual market started in 2013, Massachusetts continued the generous subsidies – supplementing federal ACA funding with state dollars – so that enrollees wouldn’t see their health care costs go up, McDonough said.
He said the more generous system has led to Massachusetts having the lowest uninsured rate in the nation, at 2.8 percent.
McDonough said there’s nothing stopping any state from making reforms similar to the ones in Massachusetts, which would lower health insurance costs and make coverage more affordable for those buying on the individual market.
“You can go for the so-called ‘perfect system’ in single-payer, and end up with nothing,” he said. “Or you can make these other, more incremental, reforms.”
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