California confronts the complexities of creating a single-payer healthcare system
by Michael Hiltzik - LA Times - February 9, 2018
California Assembly Speaker Anthony Rendon may have expected to torpedo the idea of a statewide single-payer healthcare system for the long term last June, when he blocked a Senate bill on the issue from even receiving a hearing in his house.
He was wrong, of course. His shelving of the Senate bill created a political uproar (including the threat of a recall effort), forcing him to create a special committee to examine the possibility of achieving universal health coverage in the state. On Monday and Wednesday, the Select Committee on Health Care Delivery Systems and Universal Coverage held its final hearings.
The panel ended up where it started, with the recognition that the project is hellishly complex and politically daunting but still worthwhile — yet can't happen overnight. "I'm anxious to see what it is that we can actually be working on this year," committee Co-Chair Jim Wood (D-Healdsburg) said toward the end of Wednesday's seven-hour session. "Some of the logistics and the challenges we have to deal with are multiyear challenges."
Little has changed since last year, when a measure sponsored by the California Nurses Assn., SB 562, passed the Senate in June and was killed by Rendon (D-Paramount) in the Assembly. The same bill, aimed at universal coverage for all residents of the state, including undocumented immigrants, is the subject of the select committee's hearings and the template for statewide reform.
Backers of the Healthy California program envisioned by the bill feel as if they're in a race with federal officials intent on dismantling healthcare reforms attained with the Affordable Care Act, and even those dating from the 1960s with enactment of Medicare and Medicaid.
In just the last few weeks, the U.S. Department of Health and Human Services has approved adding a work requirement to Medicaid in Kentucky and begun considering a plan to place lifetime limits on Medicaid benefits — profound changes in a program traditionally aimed at bringing healthcare to needy families.
The Republican-controlled Congress effectively repealed the individual mandate in the Affordable Care Act. That is likely to drive up premiums for unsubsidized middle-income insurance buyers and has prompted California and other states to consider implementing such a mandate on their own. (Idaho is moving distinctly in the opposite direction from California, proposing to allow "state-based health plans" that allow insurers to discriminate against applicants with pre-existing conditions.
Healthy California would be the most far-reaching single-state project for universal health coverage in the nation. That's to be expected, since the state's nation-leading population (39 million) and gross domestic product ($2.6 trillion) provide the impetus to solve big social and economic issues on its own.
The program would take over responsibility for almost all medical spending in the state, including federal programs such as Medicare and Medicaid, employer-sponsored health plans, and Affordable Care Act plans. It would relieve employers, their workers and buyers in the individual market of premiums, deductibles and co-pays, paying the costs out of a state fund.
All California residents would be eligible to obtain treatment from any licensed doctor in the state. Dental and vision care and prescription drugs would be included. Insurance companies would be barred from replicating any services offered by the program.
Doctors and hospitals would be paid rates roughly analogous to Medicare reimbursements, and the program would be expected to negotiate prices with providers and pharmaceutical companies, presumably by offering them access to more than 39 million potential patients.
Wood stressed that the goal of reform is to lower healthcare prices, or at least to slow the rate of growth. Yet that may mean focusing on the wrong challenge.
The mechanics of cost reduction aren't much of a mystery. As several witnesses at the latest hearings observed, the key is reducing unit prices — lower prices per dose of drug, lower reimbursements for physicians and hospitals, all of which are higher in the U.S. than the average among industrialized countries. It will also help to remove insurance industry profit and overhead (an estimated 15% of healthcare spending), not to mention the expenses they impose on billing departments at medical offices and hospitals, from the system.
The real challenge, however, lies in the politics of transitioning to a new healthcare system. Advocates of reform often overlook an important aspect of how Americans view the existing system. Although it's roundly cursed in the abstract, most people are reasonably satisfied with their coverage.
That's because most people seldom or never experience difficult or costly interactions with the healthcare system. Horror stories of treatments denied and astronomical bills charged are legion. But the truth is that annual healthcare spending is very heavily concentrated among a small number of people.
The top 5% of spenders account for half of all spending, the top 20% of spenders for about 80%. According to the National Institute for Health Care Management, the bottom 50% of spenders account for only about 3% of all spending.
These are annual figures, so over a lifetime any person may have more contacts with the system. But that may explain why it's hard to persuade Americans to abandon a system many consider to be just good enough for something entirely new, replete with possibilities that it could turn out to be worse.
The nurses association is pegging its reform campaign to the uncertainties built into the existing system. "The experience of most Americans is that they're satisfied with what they're getting, but there's a great deal of anxiety," says Michael Lighty, the group's director of public policy. "The No. 1 experience missing from the American healthcare system is peace of mind. People are not afraid that what they have will be taken away, but that what they have will not be adequate for what they need."
In terms of funding, the idea is for the state to take over the $370 billion to $400 billion a year already spent on healthcare in California. (The higher estimate is from the state Legislative Analyst's Office, the lower from the nurses association.) That includes $200 billion in federal funds, chiefly Medicare, Medicaid, and Obamacare subsidies; and an additional $150 billion to $200 billion in premiums for employer insurance and private plans and out-of-pocket spending by families.
University of Massachusetts economist Robert Pollin, the nurses' program consultant, estimates that the program will be about 18% cheaper than existing health plans, thanks to administrative savings, lower fees for drugs, physicians, and hospitals, and a step up in preventive services and a step down in unnecessary treatments.
That would leave about $106 billion a year, as of 2017, needed to replace the employer and private spending that would be eliminated. Pollin suggests doing so through an increase of 2.3% in the sales tax and the addition of a 2.3% gross receipts tax on businesses (or a 3.3% payroll tax, shared by employers and workers), instead of the gross receipts tax. Each levy would include exemptions for small businesses and low-income families.
Anyone with experience in California tax politics knows this is a potential brick wall. Taxes of this magnitude will generate intense opposition, despite the nurses' argument that relief from premiums and other charges means that families and business will come out ahead.
But that's not the only obstacle. A workaround would have to be found for California Constitution requirements that a portion of tax revenues be devoted to education. A California universal coverage plan would require "a high degree of collaboration between the federal government and the state," Juliette Cubanski of the Kaiser Family Foundation told the committee Monday. Waivers from Medicare and Medicaid rules would have to be secured from the Department of Health and Human Services; redirecting Medicare funds to the state might require congressional approval.
A federal law that preempts state regulations of employee health benefits might limit how much California could do to force employer plans into a state system.
Obtaining the legal waivers needed from the federal government to give the state access to federal funds would take two to three years "with a friendly administration," Wood said. "We don't have a friendly administration now."
Advocates of change are understandably impatient in the face of rising healthcare costs and the federal government's hostility to reform. Shocked gasps went up from the hearing audience Wednesday when Wood casually remarked, "It is absolutely imperative that we slow this down." Startled by the reaction, he quickly specified that he meant "slow the costs down."
The desire to pursue the goal of universal coverage, whether through a single-payer model or a hybrid, plainly remains strong in Sacramento, in the face of the vacuum created by the Republican Congress and Trump White House.
As Betsy Estudillo, a senior policy manager for the California Immigrant Policy Center put it at Wednesday's hearing, "The nation needs California's leadership, now more than ever."
California Assembly Speaker Anthony Rendon may have expected to torpedo the idea of a statewide single-payer healthcare system for the long term last June, when he blocked a Senate bill on the issue from even receiving a hearing in his house.
He was wrong, of course. His shelving of the Senate bill created a political uproar (including the threat of a recall effort), forcing him to create a special committee to examine the possibility of achieving universal health coverage in the state. On Monday and Wednesday, the Select Committee on Health Care Delivery Systems and Universal Coverage held its final hearings.
The panel ended up where it started, with the recognition that the project is hellishly complex and politically daunting but still worthwhile — yet can't happen overnight. "I'm anxious to see what it is that we can actually be working on this year," committee Co-Chair Jim Wood (D-Healdsburg) said toward the end of Wednesday's seven-hour session. "Some of the logistics and the challenges we have to deal with are multiyear challenges."
Little has changed since last year, when a measure sponsored by the California Nurses Assn., SB 562, passed the Senate in June and was killed by Rendon (D-Paramount) in the Assembly. The same bill, aimed at universal coverage for all residents of the state, including undocumented immigrants, is the subject of the select committee's hearings and the template for statewide reform.
Backers of the Healthy California program envisioned by the bill feel as if they're in a race with federal officials intent on dismantling healthcare reforms attained with the Affordable Care Act, and even those dating from the 1960s with enactment of Medicare and Medicaid.
In just the last few weeks, the U.S. Department of Health and Human Services has approved adding a work requirement to Medicaid in Kentucky and begun considering a plan to place lifetime limits on Medicaid benefits — profound changes in a program traditionally aimed at bringing healthcare to needy families.
The Republican-controlled Congress effectively repealed the individual mandate in the Affordable Care Act. That is likely to drive up premiums for unsubsidized middle-income insurance buyers and has prompted California and other states to consider implementing such a mandate on their own. (Idaho is moving distinctly in the opposite direction from California, proposing to allow "state-based health plans" that allow insurers to discriminate against applicants with pre-existing conditions.
Healthy California would be the most far-reaching single-state project for universal health coverage in the nation. That's to be expected, since the state's nation-leading population (39 million) and gross domestic product ($2.6 trillion) provide the impetus to solve big social and economic issues on its own.
The program would take over responsibility for almost all medical spending in the state, including federal programs such as Medicare and Medicaid, employer-sponsored health plans, and Affordable Care Act plans. It would relieve employers, their workers and buyers in the individual market of premiums, deductibles and co-pays, paying the costs out of a state fund.
All California residents would be eligible to obtain treatment from any licensed doctor in the state. Dental and vision care and prescription drugs would be included. Insurance companies would be barred from replicating any services offered by the program.
Doctors and hospitals would be paid rates roughly analogous to Medicare reimbursements, and the program would be expected to negotiate prices with providers and pharmaceutical companies, presumably by offering them access to more than 39 million potential patients.
Wood stressed that the goal of reform is to lower healthcare prices, or at least to slow the rate of growth. Yet that may mean focusing on the wrong challenge.
The mechanics of cost reduction aren't much of a mystery. As several witnesses at the latest hearings observed, the key is reducing unit prices — lower prices per dose of drug, lower reimbursements for physicians and hospitals, all of which are higher in the U.S. than the average among industrialized countries. It will also help to remove insurance industry profit and overhead (an estimated 15% of healthcare spending), not to mention the expenses they impose on billing departments at medical offices and hospitals, from the system.
The real challenge, however, lies in the politics of transitioning to a new healthcare system. Advocates of reform often overlook an important aspect of how Americans view the existing system. Although it's roundly cursed in the abstract, most people are reasonably satisfied with their coverage.
That's because most people seldom or never experience difficult or costly interactions with the healthcare system. Horror stories of treatments denied and astronomical bills charged are legion. But the truth is that annual healthcare spending is very heavily concentrated among a small number of people.
The top 5% of spenders account for half of all spending, the top 20% of spenders for about 80%. According to the National Institute for Health Care Management, the bottom 50% of spenders account for only about 3% of all spending.
These are annual figures, so over a lifetime any person may have more contacts with the system. But that may explain why it's hard to persuade Americans to abandon a system many consider to be just good enough for something entirely new, replete with possibilities that it could turn out to be worse.
The nurses association is pegging its reform campaign to the uncertainties built into the existing system. "The experience of most Americans is that they're satisfied with what they're getting, but there's a great deal of anxiety," says Michael Lighty, the group's director of public policy. "The No. 1 experience missing from the American healthcare system is peace of mind. People are not afraid that what they have will be taken away, but that what they have will not be adequate for what they need."
In terms of funding, the idea is for the state to take over the $370 billion to $400 billion a year already spent on healthcare in California. (The higher estimate is from the state Legislative Analyst's Office, the lower from the nurses association.) That includes $200 billion in federal funds, chiefly Medicare, Medicaid, and Obamacare subsidies; and an additional $150 billion to $200 billion in premiums for employer insurance and private plans and out-of-pocket spending by families.
University of Massachusetts economist Robert Pollin, the nurses' program consultant, estimates that the program will be about 18% cheaper than existing health plans, thanks to administrative savings, lower fees for drugs, physicians, and hospitals, and a step up in preventive services and a step down in unnecessary treatments.
That would leave about $106 billion a year, as of 2017, needed to replace the employer and private spending that would be eliminated. Pollin suggests doing so through an increase of 2.3% in the sales tax and the addition of a 2.3% gross receipts tax on businesses (or a 3.3% payroll tax, shared by employers and workers), instead of the gross receipts tax. Each levy would include exemptions for small businesses and low-income families.
Anyone with experience in California tax politics knows this is a potential brick wall. Taxes of this magnitude will generate intense opposition, despite the nurses' argument that relief from premiums and other charges means that families and business will come out ahead.
But that's not the only obstacle. A workaround would have to be found for California Constitution requirements that a portion of tax revenues be devoted to education. A California universal coverage plan would require "a high degree of collaboration between the federal government and the state," Juliette Cubanski of the Kaiser Family Foundation told the committee Monday. Waivers from Medicare and Medicaid rules would have to be secured from the Department of Health and Human Services; redirecting Medicare funds to the state might require congressional approval.
A federal law that preempts state regulations of employee health benefits might limit how much California could do to force employer plans into a state system.
Obtaining the legal waivers needed from the federal government to give the state access to federal funds would take two to three years "with a friendly administration," Wood said. "We don't have a friendly administration now."
Advocates of change are understandably impatient in the face of rising healthcare costs and the federal government's hostility to reform. Shocked gasps went up from the hearing audience Wednesday when Wood casually remarked, "It is absolutely imperative that we slow this down." Startled by the reaction, he quickly specified that he meant "slow the costs down."
The desire to pursue the goal of universal coverage, whether through a single-payer model or a hybrid, plainly remains strong in Sacramento, in the face of the vacuum created by the Republican Congress and Trump White House.
As Betsy Estudillo, a senior policy manager for the California Immigrant Policy Center put it at Wednesday's hearing, "The nation needs California's leadership, now more than ever."
California Today: Health Care Proves Divisive Among Democrats
by David Leonhardt - NYT - February 17, 2018
In a Sandy Hook, Conn., firehouse in 2012, not long after another school shooting, a group of terrified parents was waiting for news about their children. Connecticut’s governor, Dan Malloy, then walked into the room and quietly told them, “If you haven’t been reunited with your loved one by now, that is not going to happen.” The room convulsed in grief.
That scene remains haunting because it hints at both the agony and the scale of mass shootings. Children keep dying. And our country won’t do anything about it.
The United States, to put it bluntly, has grown callous about the lives of its children. We mourn their deaths when they happen, of course. But it’s an empty mourning, because it is not accompanied by any effort to prevent more suffering — including straightforward steps that every other affluent nation has taken.
Guns are a big part of the callousness, but only a part of it. They are one of three main reasons the United States has become “the most dangerous of wealthy nations for a child to be born into,” according to a study in Health Affairs. The other two are vehicle crashes and infant mortality.
The chart here, from that study, shows just how much of an outlier the United States has become. This country suffers almost 21,000 “excess deaths” each year. That’s how many children and teenagers would be spared if the United States had an average mortality rate for a rich country.Here’s another way to think about those 21,000: Imagine the Sandy Hook firehouse, filled with the devastated families of 20 children. Now add two other Sandy Hook firehouses, each with 20 more families receiving the worst possible news. Now imagine that scene repeating itself every day, year after year after year.
Our outlier status is relatively new, too. In the 1960s, the United States had a child-mortality rate slightly below that of other rich countries. So it’s not as if the problem stems from an immutable American characteristic.
Other countries are simply trying harder to keep their children alive. They have studied major causes of death and then attacked them, in an evidenced-based way.
What would such an approach look like in this country?
On guns, it would start with universal background checks and tighter semiautomatic restrictions. The United States is always likely to have gun deaths, given the sheer number of guns, but we could have many fewer.
On vehicle deaths, we could mostly copy what other countries have already done: enforce speeding laws, crack down on “buzzed” driving, encourage seatbelts. Because we have lagged, American roads have gone from being average on safety to being the most dangerous in the affluent world.
On infant mortality, the solutions are more complex. They probably involve patching up the flawed safety net. Notably, infant mortality has fallen in states that expanded Medicaid under Obamacare — and risen slightly in states that didn’t, according to a study in the American Journal of Public Health.
When you look at the big causes of preventable childhood death, it’s hard not to notice a political pattern. One party — the Republican Party — is blocking sensible gun laws. The same party has been trying to take away people’s health insurance. And while traffic safety is a bipartisan problem, blue states are generally trying harder than red states.
All of which is a good reminder to get politically engaged. If the current crop of politicians isn’t willing to protect our children from harm, let’s replace them with politicians — from either party — who are.
As Some Got Free Health Care, Gwen Got Squeezed: An Obamacare Dilemma
by Abby Goodnough - NYT - February 19, 2018
MERRIMACK, N.H. — Gwen Hurd got the letter just before her shift at the outlet mall. Her health insurance company informed her that coverage for her family of three, purchased through the Affordable Care Act marketplace, would cost almost 60 percent more this year — $1,200 a month.
She and her husband, a contractor, found a less expensive plan, but at $928 a month, it meant giving up date nights and saving for their future. Worse, the new policy required them to spend more than $6,000 per person before it covered much of anything.
“It seems to me that people who earn nothing and contribute nothing get everything for free,” said Ms. Hurd, 30. “And the people who work hard and struggle for every penny barely end up surviving.”
A few miles away in another wooded suburb, Emilia DiCola, 28, an aspiring opera singer who scrapes by with gigs at churches and in local theaters, has no such complaints. She qualifies for Medicaid — free government health insurance that millions more low-income Americans have gained through an expansion of the program under the Affordable Care Act.
“I am very lucky to have the coverage I have,” said Ms. DiCola, who lives with her parents along the Merrimack River in Litchfield.
President Trump’s attempts to undermine the health law have exacerbated a tension at the heart of it — while it aims to provide health coverage for all, the law is far more generous to the poor and near poor than the middle class. By taking steps that hurt the individual insurance market, Mr. Trump has widened the gulf between people who pay full price for their coverage and those who get generous subsidies or free Medicaid. That, in turn, has deepened the resentment that has long simmered among many who do not qualify for government assistance toward those who do.
Such attitudes have helped shift white working-class voters to the right and were integral in the election of President Trump. They underlie the sharp cuts to social welfare programs in the budget proposal he released this week. They help explain why the national debate over health insurance has been so bitter, and why the only government programs with broad support are those that everyone benefits from, Social Security and Medicare.
They are also likely helping fuel the renewed Democratic push for a single-payer system, or at least one that provides broader access to government health insurance.
“Democrats have begun to recognize the political costs of playing into the narrative that they only care about the poor,” said Joan C. Williams, a professor at the University of California Hastings College of Law and author of a recent book, “White Working Class: Overcoming Class Cluelessness in America.”
Many Republican states plan to start requiring many Medicaid recipients to work, volunteer or take job-training classes. Along the same theme, Mr. Trump’s new budget proposal would make it harder for the so-called “able-bodied” poor who don’t work to receive food stamps and public housing.
Such proposals reflect a “very American” view — that only those who are severely disabled or struck by tragedy deserve government assistance, and that anyone else who gets it is shirking, said Mark Rank, a professor of social work at Washington University in St. Louis.
“Our social safety net is, in general, the weakest of any of the Western industrialized countries because we have these kinds of views,” Mr. Rank said.
Different Paths
The Affordable Care Act was supposed to help, and did, but not for those who earn too much to get financial assistance but are still on a tight budget. About 25,000 New Hampshire residents paid full freight for Obamacare plans last year, according to a legislative report, and their premiums increased by an average 52 percent this year. This group earns more than four times the poverty level — for a family of three, like the Hurds, that’s about $82,000 a year.
Another 29,000 were getting subsidized coverage through the Affordable Care Act marketplace, and many of them have seen their out-of-pocket costs drop this year. That is because when Mr. Trump forced premiums higher by cutting off a type of payment to insurers last fall that the law had guaranteed them, subsidies rose, too. About 53,000 are getting free Medicaid coverage through the health law’s optional expansion of the program.
Ms. Hurd remembers watching a documentary about people signing up for Obamacare coverage last year and bristling when someone who got a big subsidy gushed about the low price.
“I was like, ‘It’s not expensive for you because everybody else is paying for it,’” she said.
She also has problems with the Medicaid “expansion population,” made up of working-age adults who have no disability — particularly those who aren’t working as hard as she and her husband are. Cut off from the help Obamacare provided to everyone under a certain income level, as well as the contributions that employers make toward their employees’ health coverage, she was caught in what she saw as an unduly penalized subset.
“I’m totally happy to pay my fair share,” she said, “but I’m also paying someone else’s share, and that’s what makes me insane.”
Ms. Hurd finished college at the University of Massachusetts, with her parents paying for it, and has a master’s degree in communications, which she got tuition-free while working in admissions at Southern New Hampshire University. She’s been working about 30 hours a week at the outlet mall and a small remodeling firm while looking for a job with good benefits in communications or marketing.
Her husband, Matt, started his contracting business a few years ago and is finishing his undergraduate degree with the help of a loan. They bought a 1750s farmhouse just before they married; Ms. Hurd returned to work when their son, Harry, was eight weeks old.
Though roughly the same age, Ms. DiCola has followed a different course. She dropped out of the Manhattan School of Music in 2009 after her freshman year because she couldn’t keep up with the tuition. Now, to supplement the scant income she gets from singing gigs, she drives for Uber and Lyft a few nights a week, sometimes more, in Boston. She earned about $15,000 last year, making sure she stayed under the threshold to qualify for Medicaid.
“I feel like it’s no different from what corporations do all the time, taking advantage of tax breaks and that sort of thing,” Ms. DiCola, a soprano who talks animatedly about Verdi and Puccini, said of being on Medicaid. “Frankly, if they’re allowed to do it, why shouldn’t I?”
Medical care has been easy to access on Medicaid. She got physical therapy for an old injury, and when she needed to have an IUD surgically removed last year, she went to Dartmouth-Hitchcock Medical Center in Hanover, the state’s most prestigious hospital. She paid for none of it. She spends most of her income on paying off her car, a used 2012 Prius with 160,000 miles on it, and her last outstanding student loan.
“The coverage is actually really good,” she said. “I’m just kind of finding my way, so the health insurance is so helpful.”
For Ms. Hurd, health care has been something to avoid since she and her husband got the marketplace plan shortly after Harry’s birth last year. (Before that, she had a job with benefits but quit because of her difficult pregnancy.) She went to an urgent care clinic for a throat culture last fall because unlike at her primary care practice, she could find out the cost, $150, upfront. And when Harry was up all night sobbing with a fever recently, she hesitated briefly before seeking medical help, again at urgent care.
“That’s ugly,” she said. “I hate that I, even for a moment, considered waiting it out to save money.”
Constantly Close to the Edge
News stories in New Hampshire have stoked the resentment Ms. Hurd and others facing spiking premiums have felt. “Medicaid platinum, silver for the rest,” read a recent headline in The Union Leader, New Hampshire’s largest newspaper. The story was about a report that found Medicaid recipients used health care more aggressively than marketplace customers, presumably because their coverage was free.
Instead of giving its new Medicaid recipients traditional coverage through the program, New Hampshire uses Medicaid funds to buy them private plans through the Obamacare marketplace. The report, by an independent actuarial firm, found that average medical costs for the state’s expansion population were 26 percent higher than for the marketplace’s other customers in 2016.
The firm found this raised average claim costs — a proxy for premiums — for everyone by 14 percent.
One of the conditions that Gov. Chris Sununu has attached to continuing expanded Medicaid here is that most adult recipients without a disability or small children will have to work, volunteer or get job training, at least 20 hours a week. New Hampshire is among eight Republican-controlled states asking the Trump administration for approval to impose work requirements; two others, Kentucky and Indiana, already got permission last month.
Ms. Hurd — who says she thinks “work is everything, honestly” — is elated about the possibility.
“If there were actual repercussions aside from your personal self-worth — like ‘Hey, you may not be able to get the pills you need’ — people might be more inclined to work,” she said.
But research has found that most Medicaid recipients without disabilities, like Ms. DiCola, already work at least part-time.
“I know I live with my parents, but I’m not going on fancy trips or anything like that — I feel guilty when I buy a new lipstick,” she said. She worried when she had the flu in December and lost four days of income, she said, adding, “I’d like not to feel like I’m constantly so close to the edge.”
Ms. DiCola started driving for Uber and Lyft three years ago, after stints at a Panera and a train station cafe. She often shuttles customers around Boston until after midnight, making up to $25 an hour — enough to pay two or three times more than the $87.50 she owes on her student loan each month, plus buy gas. Her days include pitching in on cooking and other household duties, auditions, rehearsals and studying musical scores on her couch, a cat or two by her side. She hopes to get a college degree, find a more stable career and get access to employer health coverage. But for now, with a free place to live and with Medicaid, she said, “I’m able to throw all my money at paying off my debt.”
Anxiety and Peace of Mind
Ms. Hurd is a former Republican who volunteered for Mitt Romney’s campaign in 2012 and voted for Carly Fiorina in the 2016 primary, but now describes her politics as more libertarian. She’s pro-immigration, not least because she sees immigrants as having strong work ethics. She voted for Hillary Clinton in the general election, she said, because she finds President Trump deeply offensive, a “guy who bullied his way into power.”
Her father, a Trump voter from the Boston suburbs, sends her articles that are critical of the health law, and they resonate with her.
Even members of her own family take advantage of a flawed system, in her view, by getting Medicaid. “They don’t work because they don’t want to, and they get free health insurance.” She said. “What the heck? If my husband and I, who grew up with relatively middle-class backgrounds in wealthy states, know people that mooch off the system in our immediate families, imagine what it’s like elsewhere.”
Ms. DiCola’s father, a solo-practice lawyer, is also a Trump supporter, but she is a liberal Democrat and uneasily aware of the anger and frustration that unsubsidized Obamacare customers are feeling — so much so that at first, she worried about sharing her story with The New York Times and “being dragged through the mud on some 24-hour news channel” for being on Medicaid.
She described her state’s plan to impose work requirements on Medicaid recipients as “poor-shaming.” Her friends show more empathy, she said. When she needed a root canal and crown last year and Medicaid would not have paid for it (dental care is one area that Medicaid does not cover comprehensively, or sometimes at all), she posted about it on Facebook and her friends jumped in to help.
Ms. DiCola doesn’t expect to need much health care this year — just a physical and a new pair of glasses, which Medicaid will cover, she said. Still, she added, “You never know what could come up — my appendix could decide to burst tomorrow.” In which case, Medicaid would cover the emergency room visit, surgery and hospital stay, a huge relief to Ms. DiCola, who became so anxious as Republicans in Congress triedto repeal the Affordable Care Act last summer that she stopped working for a few weeks.
Ms. Hurd has had no such peace of mind. A burst appendix would likely cost at least her individual deductible of $6,300.
By late January, Ms. Hurd had begun to believe that the only way for her family to have any access to health care was to drop their insurance and save the $928 a month to spend on care when they need it. Harry’s recent illness had rattled her, and Matt wanted to see a chiropractor for back pain that was threatening his ability to work.
“We can’t afford to both treat his back issues and pay for insurance,” she said one morning. She was crying, and it was time to go to work.
The following week, after months of searching, Ms. Hurd got offered a full-time job with benefits, running social-media marketing for a company that sells plant nutrition products. The Hurds plan on dropping their Obamacare policy in April, when her new coverage, with a $300 monthly premium, should kick in. The deductible — $3,000 per person, up to $6,000 for the family — will still be higher than she’d like, but she didn’t complain. Her indignation seemed to be softening.
“I understand that some people cannot afford health care and shouldn’t just be left to suffer,” she said. “But there has to be a better way than asking a very small amount of people to foot that bill.”
How Dental Inequality Hurts Americans
by Austin Frakt - NYT - February 19, 2018
Even before any proposed cuts take effect, Medicaid is already lean in one key area: Many state programs lack coverage for dental care.
That can be bad news not only for people’s overall well-being, but also for their ability to find and keep a job.
Not being able to see a dentist is related to a range of health problems. Periodontal disease (gum infection) is associated with an increased risk of cancer and cardiovascular diseases. In part, this reflects how people with oral health problems tend to be less healthy in other ways; diabetes and smoking, for instance, increase the chances of cardiovascular problems and endanger mouth health.
There is also a causal explanation for how oral health issues can lead to or worsen other illnesses. Bacteria originating in oral infections can circulate elsewhere, contributing to heart disease and strokes. A similar phenomenon may be at the root of the finding that pregnant women lacking dental care or teeth cleaning are more likely to experience a preterm delivery. (Medicaid covers care related to almost half of births in the United States.)
“I’ve seen it in my own practice,” said Sidney Whitman, a dentist who treats Medicaid patients in New Jersey and also advises that state and the American Dental Association on coverage and access issues. “Without adequate oral health care, patients are far more likely to have medical issues down the road.”
There are also clear connections between poor oral health and pain and loss of teeth. Both affect what people can comfortably eat, which can lead to unhealthy changes in diet.
But the problems go beyond health. People with bad teeth can be stigmatized, both in social settings and in finding employment. Studies document that we make judgments about one another — including about intelligence — according to the aesthetics of teeth and mouth.
About one-third of adults with incomes below 138 percent of the poverty level (low enough to be eligible for Medicaid in states that adopted the Affordable Care Act Medicaid expansion) report that the appearance of their teeth and mouth affected their ability to interview for a job. By comparison, only 15 percent of adults with incomes above 400 percent of the poverty level feel that way.
Some indirect evidence of the economic effects of poor oral health comes from a study of water fluoridation, which protects teeth from decay. It found that fluoridation increased the earnings of women by 4 percent on average, and more so for women of low socioeconomic status.
Other evidence comes from a randomized study in Brazil. In that study, investigators showed one of two images to people responsible for hiring: pictures either of a person without dental problems or with uncorrected dental problems. Those with dental problems were more likely to be judged as less intelligent and were less likely to be considered suitable for hiring.
The relationship between oral health and work has gained new salience in light of Kentucky’s recently approved Medicaid waiver, which permits the state to impose work requirements on some able-bodied Medicaid enrollees. It’s a step that some other states are also considering.
Medicaid takes different forms in different states, and even within states, different populations are entitled to different benefits. Though all states must cover dental benefits for children in low-income families, they aren’t required to do so for adults.
As of January 2018, only 17 state Medicaid programs offered comprehensive adult dental benefits, and only 14 of those did so for the population eligible for Medicaid under the Affordable Care Act. More typically, states offer only limited dental benefits or none.
Dental coverage under most private health care plans isn’t comprehensive, either — people who want it have to buy separate dental plans. But compared with those enrolled in private coverage through an employer or on their own, the population eligible for Medicaid is much more likely to need dental care and much less likely to be able to afford it or coverage for it. People with incomes low enough to qualify for Medicaid are twice as likely to have untreated tooth decay, relative to their higher-income counterparts.
Kentucky offers limited dental benefits to Medicaid enrollees, including those on whom work requirements would be imposed. Those benefits exclude coverage for dentures, root canals and crowns, which could challenge some enrollees’ ability to maintain good oral health and lead to greater emergency department use.
One study found that after Kentucky’s Medicaid expansion in 2014, the rate of use of the emergency department for oral health conditions tripled. Another study found that about $1 billion in annual emergency department spending was attributed to dental conditions, and 30 percent of emergency department visits for dental problems were made by people enrolled in Medicaid.
Other states that have proposed imposing work requirements as a condition of Medicaid eligibility include Arizona, Arkansas, Indiana, Kansas, Maine, New Hampshire, North Carolina, Utah and Wisconsin. Of these, only North Carolina and Wisconsin offer extensive dental benefits, while Arkansas, Indiana and Kansas offer limited benefits. (The definition of “limited” varies by state, but in all such states benefits are capped at $1,000 per year and cover less than 100 of 600 recognized dental procedures.) Maine, New Hampshire and Utah offer emergency-only benefits. Arizona offers none.
Though emergency-only coverage is less than ideal, it is better than nothing, as documented in a recent study based on Oregon’s Medicaid experiment. The study used a random lottery to offer some low-income adult residents eligibility for Medicaid. Oregon offers dental coverage only for emergencies.
The study found that one year after the lottery, Medicaid coverage meant more people got dental care (largely through emergency department use), and the percentage of people reporting unmet dental needs fell to 47 percent from 61 percent. It also doubled the use of anti-infectives, which are used to reduce gum infections. Another study, published in the Journal of Health Economics, found that Medicaid dental coverage increased the chances that Medicaid-eligible people had a dental visits by as much as 22 percent.
It’s an accident of history that oral care has been divided from care for the rest of our bodies. But it seems less of an accident that the current system hurts those who need it most.
Continuing Sabotage of Americans' Healthcare, Trump Proposes Allowing Insurers to Offer 'Junk Plans'
by Jessica Corbett - Common Dreams - February 20, 2018
The Trump administration is under fire for its latest move to sabotage the American healthcare system with an "unconscionable" proposed rule that would allow health insurance providers to offer what critics describe as "junk plans" that will drive up costs for patients and threaten necessary medical care for millions of Americans.
On Tuesday, in response to an executive order that President Donald Trump signed in October, Health and Human Services Secretary Alex Azar—in coordination with the Labor and Treasury departments—unveiled a proposal "to expand the availability of short-term, limited-duration health insurance by allowing consumers to buy plans providing coverage for any period of less than 12 months, rather than the current maximum period of less than three months."
These short-term plans are exempt from certain essential coverage standards—meaning they often don't cover healthcare related to pregnancy, substance abuse, or mental illness—and providers can deny coverage for pre-existing conditions as well as set limits on maximum annual and lifetime benefits for patients. Critics warn the expansion will only benefit healthy people at the expense of the most vulnerable Americans.
Acknowledging a series of actions by the Trump administration that were designed to attack the national healthcare system, Eagan Kemp, a policy advocate for Public Citizen, said the proposal "further sabotages healthcare in America by damaging insurance markets and allowing unethical insurers to offer false promises that place consumers at risk."
"By allowing the sale of plans that offer only the illusion of coverage, more Americans will face unmet healthcare needs and many will face medical bankruptcy when they get sick and their plan does not cover the care they need."
—Eagan Kemp,
Public Citizen
—Eagan Kemp,
Public Citizen
"This rule further destabilizes the Affordable Care Act (ACA) marketplaces by allowing insurers to offer junk plans targeting the young and healthy without essential health benefits. As a result, only the sick will be covered under plans with full ACA protections, driving up the costs of those plans and potentially making them unaffordable," he explained.
"By allowing the sale of plans that offer only the illusion of coverage," Kemp added, "more Americans will face unmet healthcare needs and many will face medical bankruptcy when they get sick and their plan does not cover the care they need."
Calling the move Trump's "biggest assault to the ACA, American families, and the law" yet, Andy Slavitt, who oversaw the Centers for Medicare and Medicaid Services during the Obama administration, noted that while "2017 Trump aimed for a vote to repeal the ACA," which failed multiple times, "2018 Trump is just skipping the voting part and ignoring the law."
Slavitt also outlined some of the likely consequences should the rule take effect, emphasizing that "all of this is by design."
Others pointed out that the Trump administration's ability to continuously undermine the ACA partly demonstrates why there is growing support for overhauling the nation's healthcare system and implementing a "Medicare for All" single-payer system that would make medical care a guaranteed right for all Americans.
Nasty, Brutish and Trump
by Paul Krugman - NYT - February 22, 2018
On Wednesday, after listening to the heart-rending stories of those who lost children and friends in the Parkland school shooting — while holding a cue card with empathetic-sounding phrases — Donald Trump proposed his answer: arming schoolteachers.
It says something about the state of our national discourse that this wasn’t even among the vilest, stupidest reactions to the atrocity. No, those honors go to the assertions by many conservative figures that bereaved students were being manipulated by sinister forces, or even that they were paid actors.
Still, Trump’s horrible idea, taken straight from the N.R.A. playbook, was deeply revealing — and the revelation goes beyond issues of gun control. What’s going on in America right now isn’t just a culture war. It is, on the part of much of today’s right, a war on the very concept of community, of a society that uses the institution we call government to offer certain basic protections to all its members.
Before I get there, let me remind you of the obvious: We know very well how to limit gun violence, and arming civilians isn’t part of the answer.
No other advanced nation experiences frequent massacres the way we do. Why? Because they impose background checks for prospective gun owners, limit the prevalence of guns in general and ban assault weapons that allow a killer to shoot dozens of people before he (it’s always a he) can be taken down. And yes, these regulations work.
Take the case of Australia, which used to experience occasional American-style gun massacres. After a particularly horrific example in 1996, the government banned assault weapons and bought such weapons back from those who already had them. There have been no massacres since.
Meanwhile, anyone who imagines that amateurs packing heat can be counted on to save everyone from a crazed killer with a semiautomatic weapon — as opposed to shooting one another or third parties in the confusion — has seen too many bad action movies.
But as I said, this isn’t just about guns. To see why, consider the very case often used to illustrate how bizarrely we treat guns: how we treat car ownership and operation.
It’s true that it’s much harder to get a driver’s license than it is to buy a lethal weapon, and that we impose many safety standards on our vehicles. And traffic deaths — which used to be far more common than gun deaths — have declined a lot over time.
Yet traffic deaths could and should have fallen a lot more. We know this because, as my colleague David Leonhardt points out, traffic deaths have fallen much more in other advanced countries, which have used evidence-based policies like lower speed limits and tightened standards for drunken driving to improve their outcomes. Think the French are crazy drivers? Well, they used to be — but now they’re significantly safer in their cars than we are.
Oh, and there’s a lot of variation in car safety among states within the U.S., just as there’s a lot of variation in gun violence. America has a “car death belt” in the Deep South and the Great Plains; it corresponds quite closely to the firearms death belt defined by age-adjusted gun death rates. It also corresponds pretty closely to the Trump vote — and also to the states that have refused to expand Medicaid, gratuitously denying health care to millions of their citizens.
What I’d argue is that our lethal inaction on guns, but also on cars, reflects the same spirit that’s causing us to neglect infrastructure and privatize prisons, the spirit that wants to dismantle public education and turn Medicare into a voucher system rather than a guarantee of essential care. For whatever reason, there’s a faction in our country that sees public action for the public good, no matter how justified, as part of a conspiracy to destroy our freedom.
This paranoia strikes both deep and wide. Does anyone remember George Will declaring that liberals like trains, not because they make sense for urban transport, but because they serve the “goal of diminishing Americans’ individualism in order to make them more amenable to collectivism”? And it goes along with basically infantile fantasies about individual action — the “good guy with a gun” — taking the place of such fundamentally public functions as policing.
Anyway, this political faction is doing all it can to push us toward becoming a society in which individuals can’t count on the community to provide them with even the most basic guarantees of security — security from crazed gunmen, security from drunken drivers, security from exorbitant medical bills (which every other advanced country treats as a right, and does in fact manage to provide).
In short, you might want to think of our madness over guns as just one aspect of the drive to turn us into what Thomas Hobbes described long ago: a society “wherein men live without other security than what their own strength and their own invention shall furnish them.” And Hobbes famously told us what life in such a society is like: “solitary, poor, nasty, brutish and short.”
Yep, that sounds like Trump’s America.
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