Medicare for All policy has become politics' sticking point
by Jessica Glenza - The Guardian - October 30, 2018
Pramila Jayapal is a first-term congresswoman from one of the most progressive districts in Washington state. As such, it might seem easy to dismiss the political action committee she started in September, called Medicare for All Pac. That would be a mistake.
Jayapal is one of hundreds of Democrats now running on single-payer healthcare, a monumental shift to the left for the party which – even when it controlled Congress and the White House in 2009 – passed a health policy overhaul which buttressed the private insurance system for almost a decade – Obamacare.
“We did a poll in swing districts,” said Jayapal, “The numbers were off the charts.” Not only did the Pac’s survey find liberals supported Medicare for All, she said, but “independents responded incredibly well.”
A recent survey by the union National Nurses United found 225 Democratic candidates in the House running explicitly on single-payer healthcare.
“It is a very, very popular policy, and it’s popular out of necessity,” said Jayapal. “People see what we have just doesn’t work. It’s costing way too much.”
“Medicare for All” refers to the popular public health insurance program for the elderly, called Medicare. Passed in 1965 with Medicaid, its sister program for the impoverished and disabled, the single-payer program covers all Americans older than 65, and many more who are disabled.
Along with other public health insurance programs, such as for veterans, the military and Native Americans, the US already provides health insurance for nearly 100 million people, said Chris Sloan, a director at the health consulting company Avalere.
“Public opinion has shifted.,” he said. “That is why [healthcare has] become more of a defensive issue for Republicans and an offensive issue for Democrats”.
Democrats who support Medicare for All are some of the party’s most recognizable figures – Alexandria Ocasio-Cortez; Senators Bernie Sanders, Elizabeth Warren and Kamala Harris, and the former New York gubernatorial candidate and actor Cynthia Nixon.
Meanwhile, Republicans who have attacked the policy online have been roasted by advocates. When Representative Paul Ryan recently tweeted Medicare for All would “destroy and obliterate the private health insurance system”, one user responded: “Yes, that’s why we want it”.
The US has the world’s most expensive health system. Where the UK spends about 9.8% of GDP on healthcare, the US spends a whopping 17.9%, or more than $10,000 per person per year. Most Americans get insurance through an employer. Even after Obamacare’s reforms, 28 million people are uninsured.
Insurance is so integral to financial stability in America, people make career decisions based on health insurance and delay retirement to maintain health insurance. Conversely, serious illness can also drive people into personal bankruptcy.
Even people who have insurance can face steep costs. The average American workerpays $5,547 a year in monthly health insurance fees and more than $1,500 in once-a-year fees before insurance even begins to cover complex or expensive care.
Further, the opacity of American healthcare leaves patients with “surprise bills” after they get to hospital, use an ambulance or have surgery.
As just a few examples: a Texas hospital sent a man a bill for more than $108,000; a New Jersey woman owed more than $51,000 after the premature birth of triplets; and an injured doctor taken to hospital via air ambulance owed more than $56,000to the helicopter company. All of those patients had health insurance at the time they incurred those bills.
Financial strain is particularly acute for the seriously sick. A recent study from the Commonwealth Fund, a foundation which promotes affordable healthcare, found of people with serious illnesses, 62% felt “confused and helpless”, 53% faced the “risk of financial ruin”, and 61% experienced “serious problems with their care”.
Some international figures have expressed exasperation with the American system of privately financed care, the only one in the industrialized world which lacks universal health coverage.
“It’s not easy to understand why such a country like the United States, the most resourceful and richest country in the world, does not introduce universal health coverage,” Ban Ki-moon told the Guardian. “Nobody would understand why almost 30 million people are not covered by insurance.”
Advocates believe patients’ financial strains, the threats of returning to a pre-Obamacare era and the spiking costs of health insurance have all led to Medicare for All to pick up steam.
Proposals differ among candidates. In some instances, it would more closely resemble the UK’s National Health Service. In others, it might include an expansion of Medicare, which people could purchase.
Further, many other Democrats are running on “universal coverage” rather than Medicare for All. Policies which promote universal coverage usually focus on shoring up the Affordable Care Act (Obamacare), or expanding Medicare to cover more people – just not everyone.
That debate is well reflected in a policy document from Community Catalyst, a centrist healthcare advocacy group. The group put out a guide on how to deal with single-payer advocates who “are strongly critical of any other alternative”, and fail to acknowledge single-payer is “not politically viable at this time”.
“Right now, Medicare for All and Medicare-for-more are proposals, but they’re missing key details,” said Sloan. “When that stuff gets filled in, it gets a little more controversial.”
Nevertheless, even with internal division, Jayapal believes the issue is at the heart of current politics and is not going to go way.
“Every time I send out an email to my campaign list on Medicare for All, it would go crazy. Every email resonates incredibly well, so we just knew we had something real here,” Jayapal said. “Medicare for All will be one of the most defining – if not the defining – issue of the 2020 presidential [election].”
Jayapal is one of hundreds of Democrats now running on single-payer healthcare, a monumental shift to the left for the party which – even when it controlled Congress and the White House in 2009 – passed a health policy overhaul which buttressed the private insurance system for almost a decade – Obamacare.
“We did a poll in swing districts,” said Jayapal, “The numbers were off the charts.” Not only did the Pac’s survey find liberals supported Medicare for All, she said, but “independents responded incredibly well.”
A recent survey by the union National Nurses United found 225 Democratic candidates in the House running explicitly on single-payer healthcare.
“It is a very, very popular policy, and it’s popular out of necessity,” said Jayapal. “People see what we have just doesn’t work. It’s costing way too much.”
“Medicare for All” refers to the popular public health insurance program for the elderly, called Medicare. Passed in 1965 with Medicaid, its sister program for the impoverished and disabled, the single-payer program covers all Americans older than 65, and many more who are disabled.
Along with other public health insurance programs, such as for veterans, the military and Native Americans, the US already provides health insurance for nearly 100 million people, said Chris Sloan, a director at the health consulting company Avalere.
“Public opinion has shifted.,” he said. “That is why [healthcare has] become more of a defensive issue for Republicans and an offensive issue for Democrats”.
Democrats who support Medicare for All are some of the party’s most recognizable figures – Alexandria Ocasio-Cortez; Senators Bernie Sanders, Elizabeth Warren and Kamala Harris, and the former New York gubernatorial candidate and actor Cynthia Nixon.
Meanwhile, Republicans who have attacked the policy online have been roasted by advocates. When Representative Paul Ryan recently tweeted Medicare for All would “destroy and obliterate the private health insurance system”, one user responded: “Yes, that’s why we want it”.
The US has the world’s most expensive health system. Where the UK spends about 9.8% of GDP on healthcare, the US spends a whopping 17.9%, or more than $10,000 per person per year. Most Americans get insurance through an employer. Even after Obamacare’s reforms, 28 million people are uninsured.
Insurance is so integral to financial stability in America, people make career decisions based on health insurance and delay retirement to maintain health insurance. Conversely, serious illness can also drive people into personal bankruptcy.
Even people who have insurance can face steep costs. The average American workerpays $5,547 a year in monthly health insurance fees and more than $1,500 in once-a-year fees before insurance even begins to cover complex or expensive care.
Further, the opacity of American healthcare leaves patients with “surprise bills” after they get to hospital, use an ambulance or have surgery.
As just a few examples: a Texas hospital sent a man a bill for more than $108,000; a New Jersey woman owed more than $51,000 after the premature birth of triplets; and an injured doctor taken to hospital via air ambulance owed more than $56,000to the helicopter company. All of those patients had health insurance at the time they incurred those bills.
Financial strain is particularly acute for the seriously sick. A recent study from the Commonwealth Fund, a foundation which promotes affordable healthcare, found of people with serious illnesses, 62% felt “confused and helpless”, 53% faced the “risk of financial ruin”, and 61% experienced “serious problems with their care”.
Some international figures have expressed exasperation with the American system of privately financed care, the only one in the industrialized world which lacks universal health coverage.
“It’s not easy to understand why such a country like the United States, the most resourceful and richest country in the world, does not introduce universal health coverage,” Ban Ki-moon told the Guardian. “Nobody would understand why almost 30 million people are not covered by insurance.”
Advocates believe patients’ financial strains, the threats of returning to a pre-Obamacare era and the spiking costs of health insurance have all led to Medicare for All to pick up steam.
Proposals differ among candidates. In some instances, it would more closely resemble the UK’s National Health Service. In others, it might include an expansion of Medicare, which people could purchase.
Further, many other Democrats are running on “universal coverage” rather than Medicare for All. Policies which promote universal coverage usually focus on shoring up the Affordable Care Act (Obamacare), or expanding Medicare to cover more people – just not everyone.
That debate is well reflected in a policy document from Community Catalyst, a centrist healthcare advocacy group. The group put out a guide on how to deal with single-payer advocates who “are strongly critical of any other alternative”, and fail to acknowledge single-payer is “not politically viable at this time”.
“Right now, Medicare for All and Medicare-for-more are proposals, but they’re missing key details,” said Sloan. “When that stuff gets filled in, it gets a little more controversial.”
Nevertheless, even with internal division, Jayapal believes the issue is at the heart of current politics and is not going to go way.
“Every time I send out an email to my campaign list on Medicare for All, it would go crazy. Every email resonates incredibly well, so we just knew we had something real here,” Jayapal said. “Medicare for All will be one of the most defining – if not the defining – issue of the 2020 presidential [election].”
A Voter’s Guide to Health Care
by The Editorial Board - NYT - October 31, 2018
“I support forcing insurance companies to cover all pre-existing conditions,” Josh Hawley, the Republican attorney general of Missouri who’s running for the Senate against Claire McCaskill, assured voters in an emotional ad featuring his son, a kindergartner who suffers from such a condition.
It’s a promise that Mr. Hawley has repeated again and again on the campaign trail this fall, and it’s a popular one — national poll results released in September found that three-quarters of Americans want to retain protections that prevent insurers from discriminating against people based on their medical history.
Yet, while Josh Hawley the candidate might be a fan of saving such protections, Josh Hawley the attorney general plainly isn’t — he’s one of 20 Republican state attorneys general suing to overturn the Affordable Care Act and abolish the pre-existing condition protections that go with it.
Health care is routinely cited by voters as their top issue as they head to the polls next Tuesday, and rightly so — the midterms could help decide whether many Americans will have access to care and how much it will cost. Mr. Hawley is only one of many candidates on both sides of the aisle eager to convince them that he’s in their corner.
Given that interest, it’s worth clarifying the record on these issues so voters are informed heading into the polls. Will Republicans try to repeal the Affordable Care Act again? Will Democrats push hard toward a single-payer system — and, if so, what will that mean for employer-based insurance and Medicare as we know it? And which party will be more likely to protect Americans with pre-existing medical conditions from insurance discrimination?
by The Editorial Board - NYT - October 31, 2018
“I support forcing insurance companies to cover all pre-existing conditions,” Josh Hawley, the Republican attorney general of Missouri who’s running for the Senate against Claire McCaskill, assured voters in an emotional ad featuring his son, a kindergartner who suffers from such a condition.
It’s a promise that Mr. Hawley has repeated again and again on the campaign trail this fall, and it’s a popular one — national poll results released in September found that three-quarters of Americans want to retain protections that prevent insurers from discriminating against people based on their medical history.
Yet, while Josh Hawley the candidate might be a fan of saving such protections, Josh Hawley the attorney general plainly isn’t — he’s one of 20 Republican state attorneys general suing to overturn the Affordable Care Act and abolish the pre-existing condition protections that go with it.
Health care is routinely cited by voters as their top issue as they head to the polls next Tuesday, and rightly so — the midterms could help decide whether many Americans will have access to care and how much it will cost. Mr. Hawley is only one of many candidates on both sides of the aisle eager to convince them that he’s in their corner.
Given that interest, it’s worth clarifying the record on these issues so voters are informed heading into the polls. Will Republicans try to repeal the Affordable Care Act again? Will Democrats push hard toward a single-payer system — and, if so, what will that mean for employer-based insurance and Medicare as we know it? And which party will be more likely to protect Americans with pre-existing medical conditions from insurance discrimination?
Obamacare
After failing to repeal the Affordable Care Act in 2017, congressional Republicans went on to undermine the law in crucial ways. They eliminated the individual mandate, which required most people either to have insurance or to pay a small tax penalty. They allowed more non-A.C.A. plans — cheaper, skimpier options that don’t have to cover pre-existing conditions or provide essential benefits — into the marketplace. And they scrapped federal subsidies that compensated insurance companies for offering lower premiums to Americans earning between 100 percent and 250 percent of the federal poverty level.
These and other maneuvers have destabilized the insurance market and created confusion among both insurers and citizens. Bipartisan efforts to address these problems have fallen victim to politics.
At the same time, Republican state attorneys general, like Mr. Hawley, are seeking to repeal the A.C.A. entirely. Most legal experts agree that their lawsuit is a long shot, but that won’t necessarily stop Republicans from pursuing other avenues to repeal. On Oct. 17, the Senate majority leader, Mitch McConnell, floated the idea of mounting another campaign to overturn the law, should the Republicans hold on to both chambers of Congress. As Morning Consult noted, the move was most likely meant to rally Republican voters, most of whom still want to repeal the law despite the growing popularity of protections for people with pre-existing conditions.
If Democrats win at least one chamber of Congress, Obamacare as it stands now is probably safe, though it’s unlikely to see the fixes and improvements that such a far-reaching government initiative requires. If Republicans prevail, all bets are off.
After failing to repeal the Affordable Care Act in 2017, congressional Republicans went on to undermine the law in crucial ways. They eliminated the individual mandate, which required most people either to have insurance or to pay a small tax penalty. They allowed more non-A.C.A. plans — cheaper, skimpier options that don’t have to cover pre-existing conditions or provide essential benefits — into the marketplace. And they scrapped federal subsidies that compensated insurance companies for offering lower premiums to Americans earning between 100 percent and 250 percent of the federal poverty level.
These and other maneuvers have destabilized the insurance market and created confusion among both insurers and citizens. Bipartisan efforts to address these problems have fallen victim to politics.
At the same time, Republican state attorneys general, like Mr. Hawley, are seeking to repeal the A.C.A. entirely. Most legal experts agree that their lawsuit is a long shot, but that won’t necessarily stop Republicans from pursuing other avenues to repeal. On Oct. 17, the Senate majority leader, Mitch McConnell, floated the idea of mounting another campaign to overturn the law, should the Republicans hold on to both chambers of Congress. As Morning Consult noted, the move was most likely meant to rally Republican voters, most of whom still want to repeal the law despite the growing popularity of protections for people with pre-existing conditions.
If Democrats win at least one chamber of Congress, Obamacare as it stands now is probably safe, though it’s unlikely to see the fixes and improvements that such a far-reaching government initiative requires. If Republicans prevail, all bets are off.
Medicare-for-All
As health care costs rise, more Americans are voicing support for a single-payer system: Fifty-three percent now support such a plan, compared with less than 40 percent in the early 2000s. Both parties have noted the trend. Republicans are scared enough by the prospect that Mr. Trump wrote a scathing and wildly inaccurate op-ed in USA Today, denouncing the concept.
Democrats, for their part, advocate a range of single-payer options that include true Medicare-for-All — which would expand the existing government program to cover everyone — and a “public option” that would allow people to opt in to Medicare. So far, details on each are fuzzy; it remains to be seen how various such proposals would grapple with costs, consumer choice and doctor pay. Vermont’s single-payer experiment, for instance, largely failed because it ran out of money. But if Democrats take the House, expect to see a lot of pressure from the progressive end of the party to introduce legislation. Only then will we see how single-payer might actually play out, and by 2020, whether voters are truly willing to go down that path.
As health care costs rise, more Americans are voicing support for a single-payer system: Fifty-three percent now support such a plan, compared with less than 40 percent in the early 2000s. Both parties have noted the trend. Republicans are scared enough by the prospect that Mr. Trump wrote a scathing and wildly inaccurate op-ed in USA Today, denouncing the concept.
Democrats, for their part, advocate a range of single-payer options that include true Medicare-for-All — which would expand the existing government program to cover everyone — and a “public option” that would allow people to opt in to Medicare. So far, details on each are fuzzy; it remains to be seen how various such proposals would grapple with costs, consumer choice and doctor pay. Vermont’s single-payer experiment, for instance, largely failed because it ran out of money. But if Democrats take the House, expect to see a lot of pressure from the progressive end of the party to introduce legislation. Only then will we see how single-payer might actually play out, and by 2020, whether voters are truly willing to go down that path.
Pre-existing Condition Protections
Republicans have long insisted that they want to protect people with pre-existing conditions from insurance discrimination — just not through the Affordable Care Act. This is not, by itself, an indefensible position. The current law provides ironclad protections to people with serious medical conditions, but it also has forced a lot of the burden of that coverage onto the shoulders of middle-income Americans who earn too much to qualify for the law’s subsidies and whose premiums and deductibles are now soaring.
But it’s tough to argue that one is for pre-existing condition protections when one is actively fighting the only federal law to ever have guaranteed those protections in the first place. There may well be a better way to prevent insurance companies from discriminating against the sick — one that doesn’t price middle-class Americans out of the market. But so far, Republicans have not found it.
One of their more recent proposals would require insurers to cover people with pre-existing conditions, but would allow the insurers to exclude coverage of the condition itself — so it would be possible for a given person to be covered, even while their cancer relapse is not. Other suggestions include having the federal government pick up the tab for pre-existing condition coverage. But so far, those offerings range from vague to inadequate.
Far more concrete are the many ways that Republicans have sought to undermine pre-existing condition protections over the past two years, including by trying to overturn the Affordable Care Act itself.
Republicans have long insisted that they want to protect people with pre-existing conditions from insurance discrimination — just not through the Affordable Care Act. This is not, by itself, an indefensible position. The current law provides ironclad protections to people with serious medical conditions, but it also has forced a lot of the burden of that coverage onto the shoulders of middle-income Americans who earn too much to qualify for the law’s subsidies and whose premiums and deductibles are now soaring.
But it’s tough to argue that one is for pre-existing condition protections when one is actively fighting the only federal law to ever have guaranteed those protections in the first place. There may well be a better way to prevent insurance companies from discriminating against the sick — one that doesn’t price middle-class Americans out of the market. But so far, Republicans have not found it.
One of their more recent proposals would require insurers to cover people with pre-existing conditions, but would allow the insurers to exclude coverage of the condition itself — so it would be possible for a given person to be covered, even while their cancer relapse is not. Other suggestions include having the federal government pick up the tab for pre-existing condition coverage. But so far, those offerings range from vague to inadequate.
Far more concrete are the many ways that Republicans have sought to undermine pre-existing condition protections over the past two years, including by trying to overturn the Affordable Care Act itself.
Prescription Drug Costs
Donald Trump took office on a promise to dramatically lower the cost of prescription medicine. Since then, Mr. Trump and Congress have made only minimal progress on this goal. They’ve abolished gag rules that prohibit pharmacists from advising customers on how to pay less for prescriptions, and cracked down on drug companies that try to block cheaper, generic versions of their product from making it to market. But neither of those measures, nor any of the others that Mr. Trump has proposed as the election draws near, are likely to make much of a dent in what average consumers pay at the pharmacy counter.
Most experts agree that to truly lower drug costs, the federal government — that is, Medicare and Medicaid — will have to negotiate directly with drug makers. This is what other countries do, and it’s why their citizens all pay far less than Americans for the same medications. Mr. Trump campaigned on this idea, and Democrats have been pushing it for years. But so far, Americans have shown little appetite for the trade-offs this approach would require. Successful negotiations would require a willingness to forego coverage of certain medications — namely, those whose costs outweigh their benefits.
It does not help that there are more pharmaceutical lobbyists than lawmakers on Capitol Hill. Those lobbyists give generously to both political parties. And this year, with more than $21 million spent, they are on track to break their own spending record.
Democrats are promising to finally hold the industry’s feet to the fire if they take the House. Their track record is certainly better than Republicans’ on that front, but given that the problems of prescription drug pricing predate the Republican takeover of Congress — by many years — it’s right to be skeptical.
Donald Trump took office on a promise to dramatically lower the cost of prescription medicine. Since then, Mr. Trump and Congress have made only minimal progress on this goal. They’ve abolished gag rules that prohibit pharmacists from advising customers on how to pay less for prescriptions, and cracked down on drug companies that try to block cheaper, generic versions of their product from making it to market. But neither of those measures, nor any of the others that Mr. Trump has proposed as the election draws near, are likely to make much of a dent in what average consumers pay at the pharmacy counter.
Most experts agree that to truly lower drug costs, the federal government — that is, Medicare and Medicaid — will have to negotiate directly with drug makers. This is what other countries do, and it’s why their citizens all pay far less than Americans for the same medications. Mr. Trump campaigned on this idea, and Democrats have been pushing it for years. But so far, Americans have shown little appetite for the trade-offs this approach would require. Successful negotiations would require a willingness to forego coverage of certain medications — namely, those whose costs outweigh their benefits.
It does not help that there are more pharmaceutical lobbyists than lawmakers on Capitol Hill. Those lobbyists give generously to both political parties. And this year, with more than $21 million spent, they are on track to break their own spending record.
Democrats are promising to finally hold the industry’s feet to the fire if they take the House. Their track record is certainly better than Republicans’ on that front, but given that the problems of prescription drug pricing predate the Republican takeover of Congress — by many years — it’s right to be skeptical.
Medicaid Expansion
So far, 34 states have chosen to opt in to the Affordable Care Act’s Medicaid expansion program, which provides coverage for working-age adults who earn up to 138 percent of the federal poverty line. On Tuesday, three more states — Idaho, Nebraska and Utah — will decide whether to join those ranks, and several others — including Florida, Georgia, Wisconsin and Maine — will decide whether to replace a Republican governor who has opposed Medicaid expansion with a Democratic one who supports it.
Republican officials have opposed Medicaid expansion for the same reason they’ve opposed most large social safety-net programs: It’s expensive. The federal government pays 90 percent of expansion costs, but even so, states have spent more than expected on the program. Mr. Trump has changed the rules to allow individual states to attach work requirements to Medicaid coverage, and has proposed turning the program into a block grant (the federal government would give each state a fixed amount of money, rather than paying a percentage of the total cost).
But while Medicaid expansion isn’t cheap, it has produced substantial benefits, among them expanded access to health care, improved financial security for low-income families and economic gains for the health care industry.
In any case, sweeping changes to the program are likely to prove tough: Medicaid is increasingly popular among voters, in part because so many of them — roughly one in five Americans, as of June — now receive benefits through the program.
Editor's Note:
Here is my comment to the New York Times on the preceding editorial:
"The statement in this editorial that "Vermont’s single-payer experiment, for instance, largely failed because it ran out of money." is flat-out wrong. It couldn't have run out of money because it was never implemented.
Governor Shumlin lost his nerve and pulled the plug on the Vermont plan, after having his narrow re-election thrown into the legislature, because he had failed to adequately immunize the public and the legislature against the shock of having to have implemented a very large tax-increase to fund the program. He didn't adequately explain that most Vermont voters would actually have paid less than they do under the present system, in addition to all of the other advantages of their proposed system, such as automatic universal coverage, the elimination of medical underwriting (pre-existing condition exclusion) and most out-of-pocket expenses, and the linkage of health insurance to employment.
In other words, the reasons for the failure of the Vermont program were political, not economic as the editorial implies."
-SPC
So far, 34 states have chosen to opt in to the Affordable Care Act’s Medicaid expansion program, which provides coverage for working-age adults who earn up to 138 percent of the federal poverty line. On Tuesday, three more states — Idaho, Nebraska and Utah — will decide whether to join those ranks, and several others — including Florida, Georgia, Wisconsin and Maine — will decide whether to replace a Republican governor who has opposed Medicaid expansion with a Democratic one who supports it.
Republican officials have opposed Medicaid expansion for the same reason they’ve opposed most large social safety-net programs: It’s expensive. The federal government pays 90 percent of expansion costs, but even so, states have spent more than expected on the program. Mr. Trump has changed the rules to allow individual states to attach work requirements to Medicaid coverage, and has proposed turning the program into a block grant (the federal government would give each state a fixed amount of money, rather than paying a percentage of the total cost).
But while Medicaid expansion isn’t cheap, it has produced substantial benefits, among them expanded access to health care, improved financial security for low-income families and economic gains for the health care industry.
In any case, sweeping changes to the program are likely to prove tough: Medicaid is increasingly popular among voters, in part because so many of them — roughly one in five Americans, as of June — now receive benefits through the program.
Editor's Note:
Here is my comment to the New York Times on the preceding editorial:
"The statement in this editorial that "Vermont’s single-payer experiment, for instance, largely failed because it ran out of money." is flat-out wrong. It couldn't have run out of money because it was never implemented.
Governor Shumlin lost his nerve and pulled the plug on the Vermont plan, after having his narrow re-election thrown into the legislature, because he had failed to adequately immunize the public and the legislature against the shock of having to have implemented a very large tax-increase to fund the program. He didn't adequately explain that most Vermont voters would actually have paid less than they do under the present system, in addition to all of the other advantages of their proposed system, such as automatic universal coverage, the elimination of medical underwriting (pre-existing condition exclusion) and most out-of-pocket expenses, and the linkage of health insurance to employment.
In other words, the reasons for the failure of the Vermont program were political, not economic as the editorial implies."
-SPC
Congress Has No Clue What Americans Want
People in the U.S. House and Senate have wildly inaccurate perceptions of our opinions and preferences.
By Alexander Hertel-Fernandez, Matto Mildenberger and Leah C. Stokes - NYT - October 31,2018
Whether the Democrats or the Republicans seize control of Congress after the midterms, you can be sure of one thing: They will have very little idea what laws the public actually wants them to act on.
The current Republican-controlled Congress is a good example. Its signature accomplishment is a tax-cut bill that hardly anyone likes or asked for and that is estimated to add about $2 trillion to the national debt over the next decade.
Only about 30 percent of Americans supported it — unlike the well over 70 percent of Americans who consistently support raising the minimum wage, background checks for gun sales and taking action on the climate crisis. Bills were actually proposed on these issues, but you would hardly know it; they were barely considered, and it goes without saying that none passed.
Congress doesn’t know what policies Americans support. We know that because we asked the most senior staff members in Congress — the people who help their bosses decide what bills to pursue and support — what they believed public opinion was in their district or state on a range of issues.
In a research paper, we compared their responses with our best guesses of what the public in their districts or states actually wanted using large-scale public opinion surveys and standard models. Across the board, we found that congressional aides are wildly inaccurate in their perceptions of their constituents’ opinions and preferences.
For instance, if we took a group of people who reflected the makeup of America and asked them whether they supported background checks for gun sales, nine out of 10 would say yes. But congressional aides guessed as few as one in 10 citizens in their district or state favored the policy. Shockingly, 92 percent of the staff members we surveyed underestimated support in their district or state for background checks, including all Republican aides and over 85 percent of Democratic aides.
The same is true for the four other issues we looked at: regulating carbon emissions to address the climate crisis, repealing the Affordable Care Act, raising the federal minimum wage and investing in infrastructure. On climate change, the average aide thought only a minority of his or her district wanted action, when in truth a majority supported regulating carbon.
Across the five issues, Democratic staff members tended to be more accurate than Republicans. Democrats guessed about 13 points closer to the truth on average than Republicans.
People in the U.S. House and Senate have wildly inaccurate perceptions of our opinions and preferences.
By Alexander Hertel-Fernandez, Matto Mildenberger and Leah C. Stokes - NYT - October 31,2018
Whether the Democrats or the Republicans seize control of Congress after the midterms, you can be sure of one thing: They will have very little idea what laws the public actually wants them to act on.
The current Republican-controlled Congress is a good example. Its signature accomplishment is a tax-cut bill that hardly anyone likes or asked for and that is estimated to add about $2 trillion to the national debt over the next decade.
Only about 30 percent of Americans supported it — unlike the well over 70 percent of Americans who consistently support raising the minimum wage, background checks for gun sales and taking action on the climate crisis. Bills were actually proposed on these issues, but you would hardly know it; they were barely considered, and it goes without saying that none passed.
Congress doesn’t know what policies Americans support. We know that because we asked the most senior staff members in Congress — the people who help their bosses decide what bills to pursue and support — what they believed public opinion was in their district or state on a range of issues.
In a research paper, we compared their responses with our best guesses of what the public in their districts or states actually wanted using large-scale public opinion surveys and standard models. Across the board, we found that congressional aides are wildly inaccurate in their perceptions of their constituents’ opinions and preferences.
For instance, if we took a group of people who reflected the makeup of America and asked them whether they supported background checks for gun sales, nine out of 10 would say yes. But congressional aides guessed as few as one in 10 citizens in their district or state favored the policy. Shockingly, 92 percent of the staff members we surveyed underestimated support in their district or state for background checks, including all Republican aides and over 85 percent of Democratic aides.
The same is true for the four other issues we looked at: regulating carbon emissions to address the climate crisis, repealing the Affordable Care Act, raising the federal minimum wage and investing in infrastructure. On climate change, the average aide thought only a minority of his or her district wanted action, when in truth a majority supported regulating carbon.
Across the five issues, Democratic staff members tended to be more accurate than Republicans. Democrats guessed about 13 points closer to the truth on average than Republicans.
Out of Touch on the Hill
Both Republican and Democratic congressional staffers underestimated — in some cases, wildly underestimated — their constituents’ support for action on several prominent domestic issues. Differences in percentage points.
AVERAGE CONSTITUENT’S VIEW
UNDERESTIMATED SUPPORT
OVERESTIMATED SUPPORT
Support background checks for gun sales
Democratic staffers
Republican staffers
A large majority in most districts supported gun background checks. However, Republican staffers believed that their constituents were 49 points less likely to support background checks than they really were. Even Democrats underestimated support by 11 points.
Regulate carbon emissions as pollutant
Support infrastructure spending package
Raise minimum wage to $12
Repeal the Affordable Care Act
Americans were divided on Affordable Care Act repeal. Still, Republicans assumed that their constituents were more favorable to A.C.A. repeal than was actually the case. By contrast, Democrats underestimated their constituents' support for A.C.A. repeal.
Both Republican and Democratic congressional staffers underestimated — in some cases, wildly underestimated — their constituents’ support for action on several prominent domestic issues. Differences in percentage points.
AVERAGE CONSTITUENT’S VIEW
UNDERESTIMATED SUPPORT
OVERESTIMATED SUPPORT
Support background checks for gun sales
Democratic staffers
Republican staffers
A large majority in most districts supported gun background checks. However, Republican staffers believed that their constituents were 49 points less likely to support background checks than they really were. Even Democrats underestimated support by 11 points.
Regulate carbon emissions as pollutant
Support infrastructure spending package
Raise minimum wage to $12
Repeal the Affordable Care Act
Americans were divided on Affordable Care Act repeal. Still, Republicans assumed that their constituents were more favorable to A.C.A. repeal than was actually the case. By contrast, Democrats underestimated their constituents' support for A.C.A. repeal.
Our research isn’t unique: As a similar study showed, state politicians also do a poor job guessing public opinion of their constituents. We found two key factors that explain why members of Congress are so ignorant of public preferences: their staffs’ own beliefs and congressional offices’ relationships with interest groups.
Aides usually assumed that the public agreed with their own policy views. If an aide did not personally support acting on climate change, he or she was less likely to think that constituents wanted action. This self-centered bias is common in other areas of life — we all tend to think that other people share our preferences. But we aren’t all charged with understanding what the public wants to ensure democratic representation.
Interest groups also played an important role in explaining congressional staffs’ errors. Aides who reported meeting with groups representing big business — like the United States Chamber of Commerce or the American Petroleum Institute — were more likely to get their constituents’ opinions wrong compared with staffers who reported meeting with mass membership groups that represented ordinary Americans, like the Sierra Club or labor unions. The same pattern holds for campaign contributions: The more that offices get support from fossil fuel companies over environmental groups, the more they underestimate state- or district-level support for climate action.
Since most congressional offices cannot regularly field public opinion surveys of their constituents, staff members depend heavily on meetings and relationships with interest groups to piece together a picture of what their constituents want. And if offices hear from only deep-pocketed interest groups, they are likely to miss out on the opinions of ordinary Americans.
We should not place all the blame on Congress. The public contributes to the problem by not taking the time to express its opinions to politicians or vote. For example, recent polling shows that supporters of tighter gun regulations are much less likely to contact Congress than those who oppose gun control. Without citizen participation, it’s hard to imagine how political staffs can accurately gauge public attitudes in their districts and states.
The forthcoming midterm elections are an important opportunity for the public to make its policy choices clear to Congress. But political action can’t end on Election Day. Citizens need to keep writing, calling and meeting with elected officials and their staffs long after the midterms. Otherwise, Congress will continue to misunderstand the public’s preferences. And if Congress doesn’t know what the public wants, it’s hard to imagine it will do a good job representing all Americans.
by The Rand Corporation - October 24, 2018
Physician payment models are becoming more complex and the pace of change is increasing, creating challenges for physician practices that might hamper their ability to improve the quality and efficiency of care despite their willingness to change, according to a new joint study by the RAND Corporation and the American Medical Association.
“The complexity and pace of change in how physicians are paid for their services has required practices to spend substantial resources just to keep up with program details,” said Dr. Mark W. Friedberg, the study's lead author and a senior physician policy researcher at RAND, a nonprofit research organization. “While the practices in our sample generally voiced support for the goals of alternative payment models, these implementation challenges could make it difficult to achieve them.”
The study is a follow-up to a similar one conducted in 2014 to assess how physician practices were responding to alternative payment models. These models are changing how physicians are compensated for the care of their patients to create stronger incentives for efficient, high-quality medicine. They often involve either bonuses for meeting quality goals or penalties for falling short.
Researchers from RAND examined 31 physician practices in six geographic markets to describe the effects of alternative health care payment models on physician practices. Whenever possible, researchers re-interviewed the same physicians and practice leaders that participated in the previous study.
The findings are intended to help guide system-wide efforts by the AMA, which sponsored and co-authored the study, and other health care stakeholders to improve alternative payment models and help physician practices successfully adapt to the changes.
“Physicians tell us that it's more difficult than ever to understand the growing complexity of payment models and they are straining against a conflicting muddle of public and private value-based policies and rules that are continually in flux,” said AMA President Dr. Barbara L. McAneny. “The resulting administrative burdens take physicians away from patient care. Today's report is a call to action to align multiple payers and payment models with consistent measures aimed at improving patient care. It is clear the long-term sustainability of payment reform hinges on value-based payment models that must be operationally and financially sound, sustainable over time, aligned across payers, and must work for physician practices and patients. The AMA is committed to spearheading and engaging these efforts.”
Across the markets studied, leaders perceived an acceleration in the pace of change in alternative payment models from both private insurers and government programs since 2014, at least partially driven by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program.
As in 2014, many physician practices—especially those that are small and independent—reported that they lacked the skills and experience with data management and analysis that are needed to perform well in alternative payment methods, according to the report. Building in methods to help these practices master the use of health data would improve the potential success of many alternative payment methods.
The study found that medical practices increasingly were averse to the financial risks posed by alternative payment methods that include penalties for cost of care overruns. In some cases, practices renegotiated contracts with payers to reduce their downside risk or transfer some of that risk to partners such as hospitals or device manufacturers.
In addition to finding ways to reduce the complexity of alternative payment methods, study findings suggest that a slower and more-predictable pace of change might benefit medical practices, payers and other stakeholders.
As in their previous study, researchers found that physicians were broadly supportive of alternative payment methods that enabled their practices to make noticeable improvements in patient care. They voiced satisfaction with clinical improvements, even when they did not result in financial bonuses.
However, when the alternative payment methods created new reporting and documentation burdens or when they created no perceptible improvements in patient care, physicians reported disengagement and skepticism.
Allowing practicing physicians and other practice leaders to help design alternative payment methods might help improve physician engagement and improve the likelihood that such strategies will produce improvements in patient care, according to the report.
The project conducted interviews between January and June 2018, speaking with 84 people from 31 physician practices in six markets throughout the country: Little Rock, Arkansas; Orange County, California; Miami, Florida; Boston, Massachusetts; Lansing, Michigan; and Greenville, South Carolina. Researchers also spoke to leaders of eight health plans, 10 hospitals or hospital systems, 10 state and local medical societies, and four Medical Group Management Association chapters.
A Sense of Alarm as Rural Hospitals Keep Closing
by Austin Frakt - NYT - October 29, 2018
Hospitals are often thought of as the hubs of our health care system. But hospital closings are rising, particularly in some communities.
“Options are dwindling for many rural families, and remote communities are hardest hit,” said Katy Kozhimannil, an associate professor and health researcher at the University of Minnesota.
Beyond the potential health consequences for the people living nearby, hospital closings can exact an economic toll, and are associated with some states’ decisions not to expand Medicaid as part of the Affordable Care Act.
Since 2010, nearly 90 rural hospitals have shut their doors. By one estimate, hundreds of other rural hospitals are at risk of doing so.
In its June report to Congress, the Medicare Payment Advisory Commission foundthat of the 67 rural hospitals that closed since 2013, about one-third were more than 20 miles from the next closest hospital.
A study published last year in Health Affairs by researchers from the University of Minnesota found that over half of rural counties now lack obstetric services. Another study, published in Health Services Research, showed that such closures increase the distance pregnant women must travel for delivery.
And another published earlier this year in JAMA found that higher-risk, preterm births are more likely in counties without obstetric units. (Some hospitals close obstetric units without closing the entire hospital.)
Ms. Kozhimannil, a co-author of all three studies, said, “What’s left are maternity care deserts in some of the most vulnerable communities, putting pregnant women and their babies at risk.”
In July, after The New York Times wrote about the struggles of rural hospitals, some doctors responded by noting that rising malpractice premiums had made it, as one put it, “economically infeasible nowadays to practice obstetrics in rural areas.”
Many other types of specialists tend to cluster around hospitals. When a hospital leaves a community, so can many of those specialists. Care for mental health and substance use are among those most likely to be in short supply after rural hospital closures.
The closure of trauma centers has also accelerated since 2001, and disproportionately in rural areas, according to a study in Health Affairs. The resulting increased travel time for trauma cases heightens the risk of adverse outcomes, including death.
Another study found that greater travel time to hospitals is associated with higher mortality rates for coronary artery bypass graft patients.
In many communities, hospitals are among the largest employers. They also draw other businesses to an area, including those within health care and others that support it (like laundry and food services, or construction).
A study in Health Services Research found that when a community loses its only hospital, per capita income falls by about 4 percent, and the unemployment increases by 1.6 percentage points.
Not all closures are problematic. Some are in areas with sufficient hospital capacity. Moreover, in many cases hospitals that close offer relatively poorer quality care than nearby ones that remain open. This forces patients into higher-quality facilities and may offset negative effects associated with the additional distance they must travel.
Perhaps for these reasons, one study published in Health Affairs found no effect of hospital closures on mortality for Medicare patients. Because it focused on older patients, the study may have missed adverse effects on those younger than 65.Nevertheless, the study found that hospital closings were associated with reduced readmission rates, which is regarded as a sign of increased quality. So it seems consolidating services at larger hospitals can sometimes help, not harm, patients.
“There are real trade-offs between consolidating expertise at larger centers versus maintaining access in local communities,” said Karen Joynt Maddox, a cardiologist and health researcher with the Washington University School of Medicine in St. Louis and an author of the study. “The problem is that we don’t have a systematic approach to determine which services are critical to provide locally, and which are best kept at referral centers.”
Many factors can underlie the financial decision to close a hospital. Rural populations are shrinking, and the trend of hospital mergers and acquisitions can contribute to closures as services are consolidated.
Another factor: Over the long term, we are using less hospital care as more services are shifted to outpatient settings and as inpatient care is performed more rapidly. In 1960, an average appendectomy required over six days in the hospital; today one to two days is the norm.
Part of the story is political: the decision by many red states not to take advantage of federal funding to expand Medicaid as part of the Affordable Care Act. Some states cited fiscal concerns for their decisions, but ideological opposition to Obamacare was another factor.
In rural areas, lower incomes and higher rates of uninsured people contribute to higher levels of uncompensated hospital care — meaning many people are unable to pay their hospital bills. Uncompensated care became less of a problem in hospitals in states that expanded Medicaid.
In a Commonwealth Fund Issue Brief, researchers from Northwestern Kellogg School of Management found that hospitals in Medicaid expansion states saved $6.2 billion in uncompensated care, with the largest reductions in states with the highest proportion of low-income and uninsured patients. Consistent with these findings, the vast majority of recent hospital closings have been in states that have not expanded Medicaid.
In every year since 2011, more hospitals have closed than opened. In 2016, for example, 21 hospitals closed, 15 of them in rural communities. This month, another rural hospital in Kansas announced it was closing, and next week people in Kansas, and in some other states, will vote in elections that could decide whether Medicaid is expanded.
Richard Lindrooth, a professor at the University of Colorado School of Public Health, led a study in Health Affairs on the relationship between Medicaid expansion and hospitals’ financial health. Hospitals in nonexpansion states took a financial hit and were far more likely to close. In the continuing battle within some states about whether or not to expand Medicaid, “hospitals’ futures hang in the balance,” he said.
Why Private Equity Is Furious Over a Paper in a Dermatology Journal
by Katie Hefner - NYT - October 26, 2018
Early this month, a respected medical journal published a research paper on its website that analyzed the effects of a business trend roiling the field of dermatology: the rapid entrance of private equity firms into the specialty by buying and running practices around the country.
Eight days later, after an outcry from private equity executives and dermatologists associated with private equity firms, the editor of the publication removed the paper from the site. No reason was given.
Furor over the publication and subsequent removal of the article has deepened a rift in the field over what some see as the “corporatization” of dermatology and other areas of medicine.
The paper was published on the website of the Journal of the American Academy of Dermatology on Oct. 5, posted along with numerous other articles labeled “In Press Accepted Manuscript.” Most articles with this designation eventually appear in a print edition of the journal; some remain online.
Dr. Dirk Elston, the journal’s editor, said in an email that he replaced the article with a notice of “temporary removal” after receiving multiple calls and emails “expressing concerns about the accuracy of a few parts” of the article.
On Wednesday, nearly two weeks after removing the article, Dr. Elston told the authors they had a choice: They could correct “factual errors” or retract the paper.
The authors maintain that the article does not contain any factual errors and that several of the corrections requested had to do with protecting the reputation of the specialty and the leaders of the American Academy of Dermatology, the association that publishes the journal. Later on Wednesday, they submitted some revisions.
The article had gone through the standard editorial process of academic journals, undergoing multiple revisions based on feedback from peer-reviewers selected by the journal, before being accepted for publication. It presents data to support a conclusion that private equity firms acquire “outlier” practices — that is, practices that perform an unusually high number of well-reimbursed procedures and bill high amounts to Medicare.
“It was interesting when we ran the numbers and we were counting how many practices with billing outliers were being acquired by private equity,” said Dr. Joseph Francis, a dermatologist in Florida who is a co-author on the paper. “With every revision of the paper, that number kept increasing. So it didn’t seem like an anomaly.”
He added, “It wasn’t clear whether these investors realized that the high billing might point to anything irregular. They might have just seen that this was a practice with booming business.”
The paper also notes that many practices backed by private equity firms have opened or acquired labs to process pathology specimens, potentially another source of profit.
Among those who objected to the article was Dr. George Hruza, the incoming president of the American Academy of Dermatology. Dr. Hruza, whose one-year term as president begins in March, is a dermatologist in Chesterfield, Mo. In 2016 he sold his own dermatology practice to United Skin Specialists, a firm that manages dermatology practices and is backed by private equity. He currently serves on the board of directors of United Skin Specialists, which he said is an unpaid position.
Dr. Hruza is not named in the journal article, but he said he is easily identified by the authors’ reference to his pending presidency of the academy, and to United Skin Specialists.
In an interview, Dr. Hruza said he did not ask that the paper be taken down. He did, however, confirm that he expressed his concerns to Dr. Elston, the editor, after it was posted. Two days later, Dr. Elston removed the paper. A flurry of intense conversations ensued among Dr. Elston; Dr. Hruza; the current academy president, Dr. Suzanne Olbricht; a lawyer for the dermatology academy; and the paper’s authors.
Specifically, Dr. Hruza said, he objected to one of the paper’s conclusions: Influential dermatology leaders are being recruited to work for and promote dermatology practices backed by private-equity firms.
“Implying motivation is a stretch,” he said. Dr. Hruza has asked for specific wording changes to that section of the paper.
Among the changes the editor of the journal asked the authors to make was the removal of identifiable references to influential dermatologists, including Dr. Hruza.
Interference with a scientific paper from within the ranks of a medical society is highly unusual, say experts in the medical publishing field. The sudden disappearance of the paper has others in the medical publishing world scratching their heads.
“The process of science requires that people be allowed to publish their data as long as it has been reviewed by peers who find it accurate in that moment,” said Dr. Mitchell Katz, president and chief executive of NYC Health & Hospitals and Deputy Editor of the journal JAMA Internal Medicine.
As for corrections, Dr. Katz added, “usually you would post a correct copy rather than removing a paper for days on end.”
Dr. Elston said others who objected to the article included Dr. Darrell Rigel, a prominent dermatologist in New York who is a former president of the academy and whose practice is now owned by Schweiger Dermatology, a private equity-backed practice. Dr. Rigel did not respond to requests for comment.
Dermatologists account for one percent of physicians in the United States, but 15 percent of recent private equity acquisitions of medical practices have involved dermatology practices. Other specialties that have attracted private equity investment include orthopedics, radiology, cardiology, urgent care, anesthesiology and ophthalmology.
One of the paper’s five supplemental tables lists 32 dermatology practices in the United States that have been formed or acquired by private equity firms. Many are large practices with dozens of physicians.
Shortly after the article disappeared from the journal’s website, a copy was posted to a Facebook group composed of some 3,500 dermatologists. Several participants in the Facebook group praised the article for shining a light on the effects of private equity on their specialty, and were outraged that the article had been withdrawn.
“If this were an article on psoriasis no one would be questioning it, but this was going to ruffle some feathers,” said Dr. Curtis Asbury, a dermatologist in Selbyville, Del., and an active participant in the Facebook group.
The lead author of the paper was Dr. Sailesh Konda, an assistant clinical professor of dermatology at the University of Florida College of Medicine. Dr. Konda, 34, said he first grew interested in the topic when several of his trainees went to work for private equity-backed practices and told him of clinical environments that emphasized profits at the expense of patient care. He said that over the past year he had given 16 talks around the country to medical residents and dermatology societies about private equity. Dr. Francis has joined him for some of the sessions.
Dr. Konda said he and his co-authors spent a year working on the paper. After the paper went out for review, he said, “we received constructive feedback.” Most of the comments, he said, were about maintaining a neutral tone.
“We strived to not use any polemic words, which could be interpreted as bias,” he said. “We decided to just deal with the facts, which would speak for themselves.”
This week a lawyer for Advanced Dermatology and Cosmetic Surgery, which is backed by private equity and is the largest dermatology practice in the United States, called the general counsel at the University of Florida, where two of the authors are employed, demanding specific changes to the paper. The general counsel for the university declined to comment. Dr. Matt Leavitt, the chief executive of Advanced Dermatology, did not respond to requests for a comment.
Dr. Konda says he plans to continue his research into private equity. “I am passionate about this topic,” he said. “I realize we live in a capitalist society and money is a driving force behind many decisions regardless of the industry. However, I believe there has to be a balance between profit and patient care.”
It’s Not Just Pre-Existing Conditions. Voters Weigh Many Health Issues on State Ballots
by Abby Goodnough and Jan Hoffman - NYT - November 1, 2018
Health care has been a dominant issue on the campaign trail this fall, with voters particularly worried about continuing insurance protections for people with pre-existing medical conditions. But on Election Day, they will decide a number of other important health care questions for their states through ballot initiatives.
Among the most significant are referendums that would expand Medicaid in Idaho, Nebraska and Utah. If voters in all three states approve, an estimated 340,000 additional low-income adults would be eligible for free health coverage through the government program, as the health law allows, starting next year.
But the ballot questions also cover a wide range of other issues: whether to ease penalties for low-level drug offenders in Ohio; consider a ban on vaping in indoor work spaces in Florida; and whether to remove abortion protections from state constitutions in Alabama and West Virginia.
Medicaid Expansion
In addition to the ballot questions in Idaho, Nebraska and Utah, the outcome of tight governor’s races in seven states that have so far resisted expanding Medicaid could change the equation there.
In Maine, a win for the Democrat, Janet Mills, would most likely result in at least 70,000 low-income adults quickly becoming eligible for Medicaid. Voters in the state had approved an expansion of the program last year, but the outgoing governor, Paul LePage, a Republican, has blocked it.
Other states that could see Medicaid expand if Democrats win include Florida, Georgia, Kansas, Oklahoma, South Dakota and Wisconsin. In all, election results could extend Medicaid coverage to 2.7 million additional Americans, including more than a million in Florida alone.
On the other hand, a ballot question in Montana could abruptly end expanded Medicaid there. Voters will decide whether to continue providing it to low-income childless adults beyond this year by considering a measure that would double the cigarette tax to pay for the state’s share of the cost. The tobacco industry has poured more than $17 million into fighting the measure.
Depending on how many states join Virginia, where the legislature voted in May to expand Medicaid and an estimated 400,000 people will become eligible Jan. 1, the program could see its biggest enrollment growth since 2014, when the Affordable Care Act first allowed Medicaid expansion.
Abortion
Two states, Alabama and West Virginia, will ask voters whether to amend their state constitutions to remove protections for the right to an abortion or require the funding of abortions. The questions come amid speculation that the newly reconfigured Supreme Court could overturn Roe v. Wade, allowing each state to decide whether to allow abortion.
In the more liberal state of Oregon, voters will decide whether to ban public spending on abortion except when medically necessary or required by federal law. If the initiative is approved, Medicaid would no longer cover abortions for low-income women; abortion might also no longer be a covered benefit for state employees.
Soda Taxes
In Oregon and Washington State, big beverage companies are pushing ballot initiatives that would prevent localities from imposing taxes on sugar-sweetened drinks as well as a wide range of groceries. Backed in large part by Coca-Cola and PepsiCo, the measures are a new front in the soda industry’s war on the taxes that health advocates see as an effective way to decrease the consumption of sugary beverages — products that have been linked to obesity and a range of diet-related illnesses.
Opioids and Illegal Drugs
Ohio, a state hard hit by overdose deaths, is asking voters whether drug possession cases should be prosecuted only as misdemeanors. The savings from a reduced inmate population would be used for drug rehabilitation and victims’ aid programs.
The Democratic candidate for governor, Richard Cordray, says the measure, which would amend the state’s constitution, is needed not least because the Legislature has failed to address the opioid crisis in a meaningful way. But opponents, among them the chief justice of the Ohio Supreme Court, some Democrats and the Republican candidate for governor, Mike DeWine, are concerned about unintended consequences, including the effects on the state’s drug courts, which lean heavily on the threat of incarceration to compel treatment and drug-free behavior.
The initiative has received considerable out-of-state support, including $1 million each from foundations run by George Soros, the billionaire investor and Democratic donor, and Mark Zuckerberg, the founder of Facebook.
Tobacco and E-Cigarettes
Tobacco companies and their products continue to be a target. South Dakota voters are being asked to approve substantial tax increases on cigarettes and wholesale tobacco goods, with a portion of the revenue to fund technical training schools for high school graduates. The state, which last raised cigarette taxes in 2006, has among the lowest such taxes in the country.
Florida voters will consider a bundled amendment that seems to be confounding many: Tucked into an initiative that would ban offshore drilling for oil and natural gas in state waters is a proposal that would extend a longstanding smoking ban in indoor work places to e-cigarettes and vapes.
Passage is uncertain, not only because many voters do not understand why both issues should be linked — proponents say they are both environmental topics — but because, pragmatically speaking, Amendment 9 is near the bottom of a long list of races and questions on the state ballot.
Dialysis Costs
It may not be single payer, but it’s a step toward regulating health care prices. California voters will have the opportunity to weigh in on a proposition limiting how much dialysis companies can charge private insurers to treat patients with serious kidney disease.
State Democrats and labor unions, notably the Service Employees International Union-United Healthcare Workers West, are backing the proposition aimed at the two largest dialysis chains, DaVita and Fresenius. They claim the companies are overcharging for their care.
Both the California Medical Association and the California Hospital Association, as well as business groups and others, are opposed, and more than $100 million has been spent trying to defeat the measure. They say the proposition could hurt patients’ ability to get a lifesaving treatment.
Patient Safety
Massachusetts voters will decide whether hospital nurses should be limited to a set number of patients they can care for at once. The number would range from one to six, depending on the type of medical unit or care needed.
Hospital groups have strenuously fought the proposal, saying that the cost of hiring enough nurses to meet the requirement would be close to $900 million, with the burden falling heavily on community hospitals. The Massachusetts Nurses Association, the union and professional group that drafted the question, argues that such limits protect patients and ultimately save money by reducing hospital stays.
Medical Marijuana
Two generally conservative states, Utah and Missouri, will consider proposals to legalize cannabis products for medicinal use.
The Missouri ballot question focuses on potentially lucrative tax revenue, with voters being asked to chose among three tax-and-spend proposals, with recipients including biomedical research, veterans’ health care, early childhood education and drug treatment.
The Utah question concentrates on the mechanics of prescribing and possession: If the referendum is approved, for example, then patients with medical cards would be allowed to grow up to six plants, by Jan. 1, 2021.
Other states are looking beyond medical use. Voters in Michigan and North Dakotaface measures that would legalize recreational marijuana for adults 21 and older.
Sales Tax Exemptions
Nevada is poised to become the 10th state to provide sales tax exemptions specifically for feminine hygiene products, if voters approve a ballot initiative there. Opponents of eliminating the so-called pink tax say that it could cost the state from $72 million to $104 million annually.
The state’s voters are also being asked to approve sales tax exemptions for medical equipment like oxygen tanks and ventilators.
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