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Sunday, March 31, 2019

Health Care Reform Article - March 31, 2019

What Happens if Obamacare Is Struck Down?

By Reed Abelson, Abby Goodnough and Robert Pear - NYT - March 26, 2019


The Affordable Care Act was already in peril after a federal judge in Texas invalidated the entire law late last year. But the stakes ramped up again this week, when President Trump’s Justice Department announced it had changed its position and agreed with the judge that the entire law, not just three pieces of it, should be scrapped.
A coalition of states is appealing the ruling. If it is upheld, tens of millions more people would be affected than those who already rely on the nine-year-old law for health insurance. Also known as Obamacare, the law touches the lives of most Americans, from nursing mothers to people eating at chain restaurants.
Here are some potential consequences, based on estimates by various groups.
Of the 23 million people who either buy health insurance through the marketplaces set up by the law (11.4 million) or receive coverage through the expansion of Medicaid (12 million), about 21 million are most at risk if Obamacare is struck down. That includes 9.2 million who receive federal subsidies.
On average, the subsidies covered $525 of a $612 monthly premium for customers in the 39 states that use the federal marketplace, HealthCare.gov, according to a new report from the Department of Health and Human Services. If the marketplaces and subsidies go away, a comprehensive health plan would become unaffordable for most of those people and many of them would become uninsured.
States could not possibly replace the full amount of federal subsidies with state funds.
Medicaid, the government insurance program for the poor that is jointly funded by the federal government and the states, has been the workhorse of Obamacare. If the health law were struck down, more than 12 million low-income adults who have gained Medicaid coverage through the law’s expansion of the program could lose it.
In all, according to the Urban Institute, enrollment in the program would drop by more than 15 million, including roughly three million children who got Medicaid or the Children’s Health Insurance Program when their parents signed up for coverage.
The law ensures that states will never have to pay more than 10 percent of costs for their expanded Medicaid population; few if any states would be able to pick up the remaining 90 percent to keep their programs going. Over all, the federal government’s tab was $62 billion last year, according to the Congressional Budget Office.
Losing free health insurance would, of course, also mean worse access to care and, quite possibly, worse health for the millions who would be affected. Among other things, studies have found that Medicaid expansion has led to better access to preventive screenings, medications and mental health services.
The health law took effect just as the opioid epidemic was spreading to all corners of the country, and health officials in many states say that one of its biggest benefits has been providing access to addiction treatment. It requires insurance companies to cover substance abuse treatment, and they could stop if the law were struck down.
The biggest group able to access addiction treatment under the law is adults who have gained Medicaid coverage. The Kaiser Family Foundation estimated that 40 percent of people from 18 to 65 with opioid addiction — roughly 800,000 — are on Medicaid, many or most of whom became eligible for it through the health law. Kaiser also found that in 2016, Americans with Medicaid coverage were twice as likely as those with no insurance to receive any treatment for addiction.
States with expanded Medicaid are spending much more on medications that treat opioid addiction than they used to. From 2013 through 2017, Medicaid spending on prescriptions for two medications that treat opioid addiction more than doubled: It reached $874 million, up from nearly $358 million in 2013, according to the Urban Institute.
The growing insured population in many states has also drawn more treatment providers, including methadone clinics, inpatient programs and primary care doctors who prescribe two other anti-craving medications, buprenorphine and naltrexone. These significant expansions of addiction care could shrink if the law were struck down, leaving a handful of federal grant programs as the main sources of funds.
As many as 133 million Americans — roughly half the population under the age of 65 — have pre-existing medical conditions that could disqualify them from buying a health insurance policy or cause them to pay significantly higher premiums if the health law were overturned, according to a government analysis done in 2017. An existing medical condition includes such common ailments as high blood pressure or asthma, any of which could require someone buying insurance on their own to pay much more for a policy, if they could get one at all.
Under the A.C.A., no one can be denied coverage under any circumstance, and insurance companies cannot retroactively cancel a policy unless they find evidence of fraud. The Kaiser Family Foundation estimated that 52 million people have conditions serious enough that insurers would outright deny them coverage if the A.C.A. were not in effect, according to an analysis it did two years ago. Its estimates are based on the guidelines insurers had in place about whom to cover before the federal law was enacted.
Most Americans would still be able to get coverage under a plan provided by an employer or under a federal program, as they did before the law was passed, but protections for pre-existing conditions are particularly important to those who want to start their own businesses or retire early. Employers would sometimes refuse to cover certain conditions, and companies would have to decide if they would drop any of the conditions they are now required to cover.
The need to protect people with existing medical conditions from discrimination by insurers was a central theme in the midterm elections, and Democrats attributed much of their success in reclaiming control of the House of Representatives to voters’ desire to safeguard those protections. Many Republicans also promised to keep this provision of the law, although exactly how was unclear. Before the law, some individuals were sent to high-risk pools operated by states, but even that coverage was often inadequate.
The 156 million Americans who get coverage through an employer, as well as the roughly 15 million enrolled in Obamacare and other plans in the individual insurance market, are protected from caps that insurers and employers used to limit how much they had to pay out in coverage each year or over a lifetime. Before the A.C.A., people with conditions like cancer or hemophilia that were very expensive to treat often faced enormous out-of-pocket costs once their medical bills reached these caps.
While not all health coverage was capped, most companies had some sort of limit in place in 2009. A 2017 Brookings analysis estimated that 109 million people would face lifetime limits on their coverage without the health law, with some companies saying they would cover no more than $1 million in medical bills per employee. The vast majority of people never hit those limits, but some who did were forced into bankruptcy or went without treatment.
About 60 million people are covered under Medicare, the federal insurance program that covers people over 65 years old and people with disabilities. Even though the main aim of the A.C.A. was to overhaul the health insurance markets, the law “touches virtually every part of Medicare,” said Tricia Neuman, a senior vice president for the Kaiser Family Foundation, which did an analysis of the law’s repeal. Overturning the law would be “very disruptive,” she said.
Medicare beneficiaries would have to pay more for preventive care, like a wellness visit or diabetes check, which are now free. They would also have to pay more toward their prescription drugs. About five million people faced the so-called Medicare doughnut hole, or coverage gap, in 2016, which the A.C.A. sought to eliminate. If the law were overturned, that coverage gap would widen again.
The law also made other changes, like cutting the amount the federal government paid hospitals and other providers as well as private Medicare Advantage plans. Undoing the cuts could increase the program’s overall costs by hundreds of millions of dollars, according to Ms. Neuman. Premiums for as many as 55 million people under the program could go up as a result.
The A.C.A. was also responsible for promoting experiments into new ways of paying hospitals and doctors, creating vehicles like accountable care organizations to help hospitals, doctors and others to better coordinate patients’ care.
If the groups save Medicare money on the care they provide, they get to keep some of those savings. About 12 million people are now enrolled in these Medicare groups, and it is unclear what would happen to these experiments if the law were deemed unconstitutional. Some of Mr. Trump’s initiatives, like the efforts to lower drug prices, would also be hindered without the federal authority established under the A.C.A.
The A.C.A. required employers to cover their employees’ children under the age of 26, and it is one of the law’s most popular provisions. Roughly two million young adults are covered under a parent’s insurance plan, according to a 2016 government estimate. If the law were struck down, employers would have to decide if they would continue to offer the coverage. Dorian Smith, a partner at Mercer, a benefits consulting firm, predicted that many companies would most likely continue.
Doctors and hospitals could lose a crucial source of revenue, as some people lose insurance. The Urban Institute estimated that nationwide, without the A.C.A., the cost of care for people who cannot pay for it could increase as much as $50.2 billion.
Hospitals and other medical providers would incur losses, as many now have higher revenues and reduced costs for uncompensated care in states that expanded Medicaid. A study in 2017 by the Commonwealth Fund found that for every dollar of uncompensated care costs those states had in 2013, the health law had erased 40 cents by 2015, or a total of $6.2 billion.
The health insurance industry would be upended by the elimination of A.C.A. requirements. Insurers in many markets could again deny coverage or charge higher premiums to people with pre-existing medical conditions, and they could charge higher rates to women. States could still regulate insurance, but consumers would see more variation from state to state. Insurers would also probably see lower revenues and fewer members in the plans they operate in the individual market and for state Medicaid programs.
The A.C.A. requires nutrition labeling and calorie counts on menu items at chain restaurants.
It requires many employers to provide “reasonable break time” and a private space for nursing mothers to pump breast milk.
It created a pathway for federal approval of biosimilars, which are near-copies of biologic drugs, made from living cells.
https://www.nytimes.com/2019/03/26/health/obamacare-trump-health.html?


The Case for Medicare for All

You’d be able to keep your doctor with no premiums or copays, and overall spending would decline.

by Robert Pollin - Common Dreams -  March 28, 2019

"Other countries currently provide good health care to residents at a fraction of the U.S. cost," writes Pollin. "As of 2017, the U.S. spent $3.3 trillion on health care—17% of gross domestic product. Germany, France, Japan, Canada, the U.K., Australia, Spain and Italy spent between 9% and 11% of GDP on health care. Yet some measures—like those based on the amenable mortality rate, which tracks medically preventable deaths—rank the U.S. well below those countries." (Photo: National Nurses United/Flickr/cc)
A single-payer health-insurance system can finance good-quality coverage for all U.S. residents while still reducing overall health-care spending by roughly 10%, according to a study I co-authored last November. All Americans would be able to get care from their chosen providers without having to pay premiums, deductibles or copayments.
Other countries currently provide good health care to residents at a fraction of the U.S. cost. As of 2017, the U.S. spent $3.3 trillion on health care—17% of gross domestic product. Germany, France, Japan, Canada, the U.K., Australia, Spain and Italy spent between 9% and 11% of GDP on health care. Yet some measures—like those based on the amenable mortality rate, which tracks medically preventable deaths—rank the U.S. well below those countries.
"Under Medicare for All [prescription-drug] prices could fall, conservatively, by about 40%."
The U.S. ranks so poorly in large part because so many Americans lack access to health care. Roughly 30 million people, 9% of the U.S. population, are uninsured. Another 26%, 86 million people, are underinsured—they have insurance but are unable to access medical care because their deductibles or copays are prohibitively high. If all these people were covered under a single-payer system, our study estimates that the overall cost of treatments would rise by about 12%, from $3.3 trillion to $3.6 trillion. Our 12% figure draws from our literature review and the 2016 estimates of Kenneth Thorpe of Emory University. It is modestly higher than the 11.3% estimate the Mercatus Center reported last July.
But Medicare for All could also eliminate 19% of total health-care spending. The largest saving, about 9% of total system costs, would come from dramatically reduced administrative costs in contracting, claims processing, credentialing providers and payment validation—all of which would be unified under one federal agency. Private insurers spend about 12% of their collective budget on administration, while Medicare operates much more efficiently, with administrative costs at around 2%.
Dramatic administrative cuts would mean far less paperwork for doctors and nurses. But administrative simplification would also entail large-scale job loses for the roughly two million people employed both by private health insurers and on the management side of hospitals and doctors’ offices. Our study proposes generous transitional support for these displaced workers, including income, retraining and relocation funds and pension guarantees. We estimate the full cost of this support would amount to about $120 billion, equal to a roughly 2% increase a year in total system costs if spread over a two-year transition phase.
The second major saving our study identified would come from the government negotiating down prescription-drug prices, which would eliminate about 6% of total system costs. Prescription-drug prices in the U.S. are about twice as high as in other advanced economies. Under Medicare for All these prices could fall, conservatively, by about 40%. Further savings would result through operating Medicare for All under a global budgeting system like the one in Canada. Such systems allow regulators to oversee billing and expenses industrywide, allowing them to control fees for physicians and hospitals, reduce unnecessary treatments and fraud, and encourage preventive care.
"Taking the cost reductions and expanded coverage into account, we estimated that Medicare for All could operate with an overall budget of $2.93 trillion—nearly 10% less than current spending."
Taking the cost reductions and expanded coverage into account, we estimated that Medicare for All could operate with an overall budget of $2.93 trillion—nearly 10% less than current spending. To finance this, the government begins with $1.9 trillion already in hand—nearly 60% of the total needed—that pays for Medicare, Medicaid and smaller public programs. The government would therefore need to take about $1 trillion out of what businesses and families now pay to private insurers.
Our study has a few ideas to generate those funds. We propose that all businesses that currently purchase health insurance for their employees be mandated to pay 92% of what they now spend into Medicare for All—saving 8% of their health-care expenditures. Larger firms that haven’t provided coverage for every worker would pay $500 for each uninsured worker, while small businesses would be exempt from these premiums. This measure would raise more than $600 billion. After two or three years, this system could make a transition to a 1.78% tax on gross receipts or an 8.2% payroll tax, either of which would generate the needed $600 billion.
The remaining $400 billion would come from two measures: a national sales tax of 3.75% on nonnecessities, which would generate about $200 billion, and a wealth tax of 0.38%, after exempting the first $1 million of all families’ net worth, for another $200 billion. We also propose taxing long-term capital gains as ordinary income. The sum of these revenue streams will allow Medicare for All to operate with a 1% budget surplus.
Families would pay these taxes instead of premiums, deductibles and copays to private insurers. Except for those in the highest income brackets, this will produce significant savings for families as well as for businesses. Net health-care spending for middle-income families that now purchase insurance for themselves would fall by fully 14% of their income.
Add it all up and Medicare for All is actually the cheaper option for good-quality care in the U.S.
https://www.commondreams.org/views/2019/03/29/healthcare-everyone-and-it-will-cost-less-economic-case-medicare-all

The doctor’s strike that nearly killed Canada’s Medicare-for-all plan, explained

Building a single-payer system is hard, but not impossible. Just ask Saskatchewan. 

by Sarah Kliff - VOX - March 29, 2019

A few weeks ago, New York Times columnist David Brooks anointed Medicare-for-all as the “impossible dream.”
“There is no plausible route from here to there,” he declared.
The argument that Brooks outlines makes sense. There are many interests lined up against a single-payer system in the United States. Hospitals don’t want it. Doctors don’t want it. And insurers definitely don’t want it, given that it would be a death knell for their industry.
Transitioning to a Medicare-for-all system would no doubt be really, really hard. It would require unwinding a multi-billion dollar health insurance industry that employs about a half-million Americans. Private health insurers exist at the core of the American economy; as the New York Times pointed out this weekend, insurers’ stocks are a staple of the mutual funds that often make up our retirement accounts.
Both the Medicare-for-all plans I’ve read and the interviews I’ve done with their authors in Congress suggest that more prep work is needed for the massive upheaval that would come with eliminating private insurance.
Building a Medicare-for-all system would be hard, but there is nothing about America that makes single-payer an impossibility. The experience of other health care systems suggests that, with enough political will, single-payer advocates can overcome the exact type of opposition Brooks discusses.
There is no better place to learn this lesson than from our neighbors to the North in Canada. Brooks cites Canada as a country where people “love their single-payer health care system.” Brooks brings up Canada as an example of a country that is different from ours, one where there is widespread acceptance of more government involvement in health care.
But it wasn’t always like that. Canada experienced massive upheaval and protest when its single-payer system launched in 1962. Back then, Canadian single-payer opponents were making the exact same arguments against the program as American single-payer opponents do today: that it was too much government in medicine, that physicians would no longer be able to practice medicine in the way they saw fit. The doctors even went on strike (for more than three weeks) when the system launched.
“It was a very close call,” says Greg Marchildon, a professor at the University of Toronto who studies the history of Canadian health care. “The doctors were totally against it, half the population was totally against it and the other half were totally for it. It could have gone either way.”
The history of Canadian health care, it turns out, can actually offer a glimpse of what America’s future could look like if a committed government tried to enact Medicare-for-all.

When Canada launched single-payer, thousands of doctors went on strike

In 1960, the Canadian province of Saskatchewan elected a socialist premier named Tommy Douglas who had campaigned on a promise to bring universal insurance to his province. (Incidentally — just because I couldn’t leave this fact out — Tommy Douglas turns out to be Kiefer Sutherland’s grandfather. Who knew!)
Douglas followed through on that promise: In late 1961, his government passed the Saskatchewan Medical Care Insurance Act. The province already had government-sponsored hospital insurance, but this new bill would layer on a plan to cover doctor visits.
There was no comparable insurance scheme for doctor visits, which meant that patients could still end up with a significant bill from the doctor who saw them in the hospital.
“Doctors continued to bill independently,” Marchildon, the historian, says. “If they worked in the hospital, the patient would end up getting a bill for that.”
Some doctors did participate in smaller, publicly-run health plans that cities offered, but many found it more lucrative to accept private payments from wealthier clients. 
Canadian doctors were not pleased with the new plan, which would move all Saskatchewan residents into a public health program. The Canadian Medical Association denounced the law, as did the provincial medical association. They produced pamphlets (like this one here) that said things like “Political medicine is the type of medicine this Province can expect if government—any government, controls you and your doctor. It would mean red tape, high costs and inferior medical care.”
The arguments doctors made back then sound an awful lot like the ones we hear against single-payer today. “It places the control of medicine in the hands of the government and its appointees,” one doctor warned at a public forum. “This we could never accept.”
But Douglas refused to back down. On July 1, 1962, Saskatchewan launched North America’s first universal, government-run health insurance scheme for hospital and doctor visits.
That same day, Saskatchewan’s doctors went on strike.
Groups sprung up around Saskatchewan to support the striking doctors known as KODs, which stood for “Keep our doctors.” They organized a rally at the provincial capital, and thousands attended. Some of the participants carried small effigies of Premier Douglas, hanging from a noose (you can see them in the archival clip from the Canadian Broadcasting Corporation below). 
“We would like to defend the freedom of the individual and the doctors,” one woman who spoke at that rally urged. “The majority of the people of the province desire an immediate dispension of this act.”
Day by day though, the strike seemed to lose momentum. Turnout for that rally wasn’t nearly as high as the organizers had hoped. Patients wanted their doctors back. Meanwhile, the government refused to back down on the idea of government-run health insurance for all.
Saskatchewan flew in a British doctor to act as negotiator, helping the government and the doctors broker a deal. That deal became known as the Saskatoon Agreement. The doctors acquiesced to the single-payer system. The government, for its part, agreed that the doctors would remain independent contractors (rather than government employees, similar to how the National Health Service in Britain employs their doctors).
The doctors went back to work and single-payer began to spread to other provinces. British Columbia created a medical insurance program in 1965, largely modeled on Saskatchewan’s system. In 1966, the federal government passed a law where it would kick in money to finance these provincial health systems. The promise of federal funding quickly encouraged more provinces to create their own Medicare programs (including the most populous province, Ontario, in 1969).
Within 10 years of the Saskatchewan doctor strike, all of Canada was covered with government-sponsored health insurance.

What Saskatchewan can teach the United States about health care: it’s hard, but it’s possible

Brooks is right: Canadians are really proud of their health care system. In 2004, the Canadian Broadcasting Corporation ran a primetime special where they had millions of viewers vote on who was the greatest Canadian.
The winner wasn’t a hockey player — it was none other than Tommy Douglas, the father of Canada’s health care system. There are foundations and even a four-hour biopic film all devoted to Douglas, who is a pivotal figure in Canadian history.
Canadians are so proud of their health care system that it makes it hard to remember that there was a time when it was really controversial. The moment that it launched was a moment when it seemed like the whole thing might collapse.
If a future president tries to pass a Medicare-for-all system, it will undeniably be a brutal fight. There was a bruising political battle over the Affordable Care Act when it was passed, and that plan was significantly less disruptive than single-payer would be.
As more Democrats endorse the idea, health care industries are already creating new coalitions to fight back. Who knows, maybe the doctors here would go on strike too!
A Medicare-for-all fight would be hard because that type of system requires massive change. That was true in Saskatchewan in 1962, and it’s true in the United States. But hard and impossible are two quite different things, and there isn’t much that convinces me that we fall into a different category.
I asked Marchildon how he felt about this comparison: Is it fair to compare pre-single-payer America to the pre-single-payer Canada of the 1960s?
“I think it’s quite similar,” he said. “I don’t think the interests are, quantitatively, so much more powerful in the US than they were in Canada. What’s missing in the US is the federal government being willing to pull the levers in a way that allows states to innovate with their own solutions.”

Judge Blocks Medicaid Work Requirements in Arkansas and Kentucky

by Abby Goodnough - NYT - March 27, 2019



WASHINGTON — A federal judge on Wednesday threw out Medicaid work requirements in two states, a blow to Republican efforts to profoundly reshape a program that has provided free health insurance to the poorest Americans for more than 50 years.
In twin rulings, Judge James E. Boasberg of the Federal District Court for the District of Columbia rejected for a second time Kentucky’s attempt to require recipients to work or volunteer as a condition of coverage and blocked a similar rule in Arkansas, which has resulted in more than 18,000 people there losing coverage since last summer.
So far, the Trump administration has allowed eight states to begin requiring many of their Medicaid recipients to work, volunteer or train for a job to be eligible for benefits. Seven other states are seeking permission from the Department of Health and Human Services to impose similar rules.
Seema Verma, the Trump appointee in charge of the Medicaid program, has described the goal as helping people “rise out of poverty and government dependence.”
Judge Boasberg, an Obama appointee, had already ordered the department to re-evaluate the impact of Kentucky’s work requirement in a ruling last June, saying it had not adequately considered whether it “would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid.”
In the first of his new decisions, he found the approval of Arkansas’s work rule by Alex M. Azar II, the health and human services secretary, was “arbitrary and capricious” for a similar reason. Mr. Azar had failed, the judge wrote, to “consider adequately” the impact of Arkansas’s plan on Medicaid coverage.
“The court finds its guiding principle in Yogi Berra’s aphorism, ‘It’s déjà vu all over again,’” Judge Boasberg wrote.
Arkansas officials had asked the judge to leave the work requirements in place in the event that he ordered Mr. Azar to further weigh their potential impact, saying that freezing them would cause too much disruption.
The judge disagreed, writing that “the road to cure the deficiency in this case is, at best, a rocky one” and that any disruption “must be balanced against the harms that plaintiffs and persons like them will experience if the program remains in effect.”
In the Kentucky case, Judge Boasberg said the state’s plan, with only minor changes since his last ruling, “has essentially the same features as it did before.” He said that Mr. Azar’s review and approval of the Kentucky program were fatally flawed because federal officials did not adequately consider “the coverage-loss consequences” of the work requirements.
The rulings presented a serious setback not only for President Trump and Mr. Azar, but for Ms. Verma, who has led the call for conditioning government health coverage on work.
She has insisted that Medicaid must not be “used as a vehicle to serve working age, able-bodied adults.” And she affirmed her goals Wednesday evening after the latest rulings came out.
“We will continue to defend our efforts to give states greater flexibility to help low income Americans rise out of poverty,” Ms. Verma said. “We believe, as have numerous past administrations, that states are the laboratories of democracy and we will vigorously support their innovative, state-driven efforts to develop and test reforms that will advance the objectives of the Medicaid program.”
Both states’ plans are aimed at hundreds of thousands of working-age adults who became newly eligible for Medicaid when the Affordable Care Act allowed states to expand it starting in 2014. Arkansas’s version requires most Medicaid recipients between the ages of 19 and 49 to spend 80 hours a month at a job or in “community engagement” activities, like volunteering or training for a job. Kentucky’s, which has not yet been rolled out because of the court case, does the same for people between 19 and 64.
Both the Kentucky and Arkansas rules allowed exemptions for people deemed too sick to work, pregnant women, full-time students or primary caregivers of dependent children or disabled family members.
The Trump administration had asserted that some people in Kentucky who lost Medicaid would gain commercial insurance coverage. But Judge Boasberg appeared skeptical, writing that federal officials “cited no research or evidence that this would happen.”
Kentucky officials, meanwhile, had made the case that the work requirements could save money for the state and thus make its expansion of Medicaid “fiscally sustainable.” Gov. Matt Bevin, a Republican whose Democratic predecessor expanded the program, has warned repeatedly that he will end the expansion for financial reasons if the work rules don’t survive in court.
But Judge Boasberg rejected the financial argument. Federal officials, he said, “made no finding” that the waiver would save any amount of money or make the program more sustainable.
In seeking federal permission to introduce work requirements, Kentucky had estimated that 95,000 fewer residents would have been enrolled in Medicaid within five years, although its lawyers said many of those people would have found jobs that offered insurance. Lawyers for the plaintiffs predicted the number would be much greater, and the early results in Arkansas — thousands losing coverage for either failing to meet the 80-hours-per-month requirement or failing to correctly report their compliance — bolstered their case.
Adam Meier, the secretary of Kentucky’s Cabinet for Health and Family Services, said in a statement, “Although a setback to our implementation schedule, we believe that we have an excellent record for appeal and are currently considering next steps.”
He added, “The judge illogically concluded that Medicaid is all about paying for health care for as many people as possible without regard to whether this coverage actually makes people healthier. We emphatically disagree because a health care program like Medicaid, by its very nature, must take into account whether it improves people’s health.”
Gov. Asa Hutchinson of Arkansas, a Republican, said that he was “disappointed” in the ruling and would discuss it further in a news conference on Thursday.
The other states that have won federal approval for Medicaid work requirements are Arizona, Indiana, Michigan, New Hampshire, Ohio and Wisconsin. New Hampshire’s requirement, the next to take effect, is the subject of a third lawsuit, filed last week.
https://www.nytimes.com/2019/03/27/health/medicaid-work-requirement.html?smid=nytcore-ios-share


Why Trump’s New Push to Kill Obamacare Is So Alarming 

by Nichols Bagley - NYT - March 27, 2019



Attorney General William Barr was supposed to be a voice of reason in the Trump administration. An old Washington hand, he had the stature and the backbone to protect the Justice Department from a White House that often seems to disdain the rule of law.
Turns out it isn’t so.
In a stunning two-sentence letter to a federal appeals court, the Justice Department announced on Monday that it would now seek the invalidation of the entire Affordable Care Act — every last one of its thousands of provisions.
The irresponsibility of this new legal position is hard to overstate. It’s a shocking dereliction of the Justice Department’s duty, embraced by Republican and Democratic administrations alike, to defend acts of Congress if any plausible argument can be made in their defense.
Nor is the Affordable Care Act some minor statute that can be shoved aside without disruption. It is now part of the basic plumbing of the American health care system. It guarantees protections for people with pre-existing medical conditions. It expanded Medicaid to cover 12.6 million more people, and it offers crucial protections to the 156 million Americans who get insurance through employers.
Beyond that, the law forces insurers to cover preventive care and contraception without charge; changed how hospitals and physicians bill for their services; requires fast-food restaurants to post calorie counts; cut hundreds of billions of dollars of Medicare spending; imposed hundreds of billions of dollars in taxes; and much, much more.
Unceremoniously ripping up the law would inflict untold harm on the health care system — and on all Americans who depend on it. Yet the Trump administration has now committed itself to doing just that.
The letter was submitted in a pending case, brought by a group of red states, in which a federal judge in Texas ruled that no part of the Affordable Care Act could stand. The judge reasoned that Congress created a constitutional problem when, in its big tax reform bill in 2017, it eliminated the financial penalty for going without insurance.
Because of that purported constitutional defect, the court held, the entire law had to fall. The ruling was indefensible: Legal scholars across the board criticized it as outrageous and predicted it would almost surely fall upon appeal.
Indeed, even the Trump administration couldn’t bring itself to argue that the entire law should be scrapped. It agreed there was a constitutional problem, but said that the right remedy was to keep most of the law in place. Only those parts requiring private insurers to sell coverage at the same price to healthy and sick people alike — the protections for people with pre-existing conditions — would have to be struck.
That, too, was an outrageous position. It flouted the Justice Department’s duty to defend, a solemn duty, and one that goes to the heart of the rule of law. Without it, the sitting administration could pick which laws it wanted to defend in the courts and which it wanted to abandon. Laws could rise or fall based on nothing more than partisan disagreement. That’s inconsistent with a constitutional system that assigns to Congress — not the president — the power to legislate.
And so, at the confirmation hearing on his nomination to become attorney general, Mr. Barr said that he would review the Justice Department’s position in the Texas lawsuit. Apparently he did just that — but instead of mounting a vigorous defense, he doubled down on killing Obamacare. It’s as if Mr. Barr said to his predecessor, Jeff Sessions: “You thought your position was crazy? Hold my beer.”
Does the administration really think that the very position it advanced just months ago is so untenable that it must now adopt one that is even more extreme?
The shift in legal position won’t make much of a difference in the lawsuit itself. Because a group of blue states has intervened, the appeals court will hear a full-throated defense of the law. Most observers expect the court to uphold the Affordable Care Act; if so, the Supreme Court may choose not to hear the case.
But the Trump administration has signaled loud and clear that its campaign against Obamacare is not over; that it will stop at nothing to achieve in court what it could not achieve in Congress; and that it doesn’t care how many people are hurt if the Affordable Care Act is undone.
It has also put health care back at the center of the political conversation. Republicans already took a beating on the issue in the fall midterm elections, and Democrats, who released a bill in the House to strengthen the Affordable Care Act, want to keep running on it. They’ll be sure to remind voters of the Trump administration’s zealous commitment to taking away their health care.
Along the way, the Justice Department has trashed the duty to defend. That’s not to be taken lightly. The duty is a close cousin to the president’s constitutional duty to enforce the law. If the Justice Department really thinks that Obamacare is so blatantly unconstitutional that it can’t be defended, that implies that the president is violating the Constitution whenever he applies it.
It’s not hard to see that as an incipient justification for refusing to enforce any law that the president believes to be unconstitutional, however ridiculous or partisan that belief might be. Hopefully it doesn’t come to that. But the failure to defend the Affordable Care Act is an ominous sign to anyone who cares about the rule of law.
https://www.nytimes.com/2019/03/27/opinion/trump-obamacare-affordable-care-act.html?


 
Building on the ACA to Achieve Universal Coverage

Matthew Fiedler, Ph.D., Henry J. Aaron, Ph.D., Loren Adler, B.A., Paul B. Ginsburg, Ph.D., and Christen L. Young, J.D. -
NEJM - March 28, 2019
For decades leading up to enactment of the Affordable Care Act (ACA), the United States failed to reduce the percentage of Americans
who lacked health insurance coverage. Since the 
ACA’s passage, the percentage of U.S. residents without coverage has fallen by almost half, from 16% to approximately 9%. Yet more needs to be done if we are to achieve universal coverage.

The bar graph, which draws on estimates by researchers at the Urban Institute, shows which groups remained uninsured in 2017.1 In our view, these estimates make clear that achieving universal coverage within the framework created by the ACA requires four basic steps: implementing the ACA’s Medicaid expansion in all states, increasing and expanding financial assistance to people who purchase coverage through the health insurance marketplace to make coverage more attractive, ensuring that people actually enroll in the affordable coverage for which they are eligible, and addressing coverage for undocumented immigrants.


The first step — ensuring that all states expand Medicaid cover- age to people with incomes be- low 138% of the federal poverty level, the standard set in the ACA — can be achieved with a combi- nation of carrots and sticks.4 The stick is a reduction in the base federal matching rate for Medic- aid spending in states that con- tinue to refuse to implement the Medicaid expansion. The carrot is an increase in the matching rate for states that expand Med- icaid coverage. These changes need not be particularly large to be effective; for example, increas-

ACA’s passage, the percentage of U.S. residents without coverage has fallen by almost half, from 16% to approximately 9%. Yet more needs to be done if we are to achieve universal coverage. 

The bar graph, which draws on estimates by researchers at the Urban Institute, shows which groups remained uninsured in 2017.1 In our view, these estimates make clear that achieving universal coverage within the framework created by the ACA requires four basic steps: implementing the ACA’s Medicaid expansion in all states, increasing and expanding financial assistance to people who purchase coverage through the healthinsurance marketplace to make coverage more attractive, ensuring that people actually enroll in the affordable coverage for which they are eligible, and addressing coverage for undocumented immigrants. 
 
Policymakers can tackle each of these steps and thereby finish the job of ensuring universal coverage by building on the ACA. The framework presented here has many elements in common with proposals put forward by others, including teams at the Urban Institute and the Center for American Progress.2,3 The similarities among these pro- posals reflect the fact that each seeks to fill the same gaps in the U.S. health insurance system. 

For people who are concerned about the fiscal cost, political feasibility, or disruption associated with a single-payer approaching expansion states’ base federal matching rate by about 2 per- centage points (or reducing non- expansion states’ base federal matching rate by the same amount) would make expansion effectively free for a typical state. The small size of these adjust- ments would insulate this ap- proach from being judged uncon- stitutionally coercive. The Supreme Court struck down the approach taken in the ACA, which condi- tioned the entirety of each state’s Medicaid funding on its willing- ness to expand coverage. Here, the vast majority of Medicaid fund- ing would be unaffected. The small size of the adjustments would also limit unintended con- sequences for Medicaid benefi- ciaries if, contrary to our expec- tations, some states continued to resist expansion. States would also need to be barred from im- plementing Medicaid-eligibility re- strictions such as work require- ments, substantial premiums, and limits on retroactive coverage of services delivered before formal Medicaid enrollment. 
 
The second step involves increasing and expanding eligibility for the subsidies available through the ACA’s health insurance marketplaces to encourage more people to take up coverage. This step includes increased tax credits to offset insurance premiums, high- er cost-sharing subsidies to offset out-of-pocket costs, and extension of subsidies to people with in- comes exceeding 400% of the federal poverty level, the current income limit on eligibility for marketplace assistance. Extensions along these lines are essential for achieving universal coverage, given that people who were eligible for subsidies but did not buy coverage accounted for fully one quarter of the non elderly uninsured population in 2017, and some people with incomes above the current income eligibility threshold also face burdensome premiums.
Marketplace subsidies would also need to be extended to workers who are currently ineligible because they are offered coverage at work that is considered “affordable” under the ACA’s standards but still imposes onerous premiums. This group accounted for roughly one tenth of the uninsured population in 2017. In addition to increasing coverage, this change would reduce premium and out-of-pocket costs for many currently insured low- and moderate income workers who face burdensome costs.
 
Even after these two steps are undertaken, some people would remain uninsured. Some would be eligible for Medicaid or the Children’s Health Insurance Pro- gram (CHIP) but would not en- roll in these programs. Though technically uninsured, they are financially protected against the costs of a serious illness because such coverage is generally retro- active. Even so, policymakers can streamline enrollment procedures to encourage more people to en- roll before the onset of illness. 

For higher-income people, however, a different approach is need- ed. Thus, the third step covers anyone who is not eligible for Medicaid or CHIP and who does not have other coverage. They would be automatically enrolled in a “backstop” insurance plan, which could be either public or private. Health care providers would submit claims to the backstop plan whenever people in this group used health care services. On each year’s income tax return, people who lacked coverage other than the backstop plan for at least 1 month during the year would pay a premium for the backstop plan for each month they lacked other coverage, whether or not they actually used the backstop coverage. The premium would be reduced by the amount of any tax credit for which they were eligible. The expansion of market- place subsidies described above would help make automatic enrollment in the backstop plan palatable by reducing these net premiums. 
 
In combination, these steps would expand coverage to all legal U.S. residents. However, they would not reach the one sixth of the population who were undocumented immigrants and there- fore ineligible for both Medicaid and marketplace subsidies. The final step to universal coverage would be to ensure this group access to insurance programs. This goal can be achieved by creating a path to citizenship or in other ways. Expanding insurance coverage is far from the only ra- tionale for reforming immigration policy, but without some such reform, genuinely universal cover- age is impossible.
How much this approach would cost the federal government de- pends on parameters we have not fully specified — notably, the size of the marketplace-subsidy expansions. However, we anticipate that legislation in line with this framework would have federal costs broadly similar to those of the ACA’s coverage expansions,as such legislation would drive the uninsured rate from about half its pre-ACA level to zero. These costs could be covered by measures similar to those that paid for the ACA, which included reforms to Medicare payments and revenue increases.
Policies aimed at reducing the unit prices of health care services, such as introducing a public plan that would pay the lower prices currently paid by public programs and that would com- pete with private plans, could also help to finance this agenda. Policies that successfully reduced health care prices would reduce the cost of providing marketplace subsidies and, if applied to the employer-sponsored insurance market, would also reduce the revenue lost to the tax exclusion for employer-sponsored coverage. 

In addition to expanding coverage, the proposals discussed above — notably those to expand marketplace subsidies and reduce the unit prices of health care services — would reduce premiums and out-of-pocket costs for many people who already have coverage. These reforms could be combined with other reforms to improve coverage for people who are already insured. The additional reforms could include implementation of rules to eliminate surprise out-of-network bills, lowered caps on annual out-of- pocket spending, and expansion of the list of services that insurers must cover without cost sharing to cost-effective services that pose little risk of overuse, such as generic drugs that treat chronic conditions.5
Nearly 9 years after the ACA became law,proposals to expand insurance coverage are again a major topic of public debate. The approach described here provides a blueprint for achieving the widely shared goal of universal coverage at a manageable fiscal cost and with minimal disruption for the hundreds of millions of Americans who are already insured.

                                                                   
The New England Journal of Medicine - March, 2019




Editor's Note;

What follows is a short inteview I did for Ruthanne Shpiner of KPFA Radio in Berkeley, California.  The statement that expanding Medicare to All would destroy the program is becoming an increasingly used Republican talking point. I also heard it during the Maine second district election race last year. Since the Democrat narrowly won using rank-choice voting, I guess it didn't work very well for the incumbent, Bruce Poliquin.

-SPC

Seema Verma was appointed to head up the Center for Medicare and Medicaid services by President Trump. Verma spoke at the Commonwealth Club in San Francisco on July 25th, 2018.
Ruthanne Shpiner has more.


Ruthanne: Verma has a great deal of power as head of CMS, overseeing a $1 trillion budget. The agency sets policy for Medicare, Medicaid, and the federal insurance exchanges under the Affordable Care Act. In the body of Verma's presentation, she addressed Medicare for all. Verma stated that expanding Medicare to include everyone would sabotage the program for those it was intended for, seniors and people with disabilities. Verma said quote, "We don't want to divert the purpose and focus away from you seniors." Close quote. She continued, "In essence, Medicare for all would become Medicare for none", close quote. Philip Caper is a physician in Maine and a founding board member of Maine All Care, a nonprofit   group committed to making health care in Maine, universal, accessible and affordable for all. Doctor Caper, Verma said quote, "I think a lot of the analysis has shown it, a single payer system is unaffordable." Continuing, quote, "it doesn't make sense for us to waste time on something that's not going to work." Close quote. What is your response to Ms. Verma's claims that Medicare for all is impractical and unaffordable?

Dr. Caper - Well, I disagree with Ms. Verma's assessment. There's not a scintilla of evidence that expanding Medicare would hurt the program. In fact, the evidence shows just the opposite. The more people who are on Medicare, the stronger it becomes and the less vulnerable to political attack it becomes. I find it deplorable that a public servant would use their bully pulpit to try to scare seniors into opposing expansion of one of the most popular and effective federal programs ever created. The greatest contribution she could make to the public welfare will be to return to the private sector where I'm sure she'd be more comfortable, as soon as possible.


Ruthanne: In addition to what you have written and spoken about, what is your response to Seema Verma's objections to expanding Medicare to include everyone. Wasn't the eventual expansion of Medicare part of the plan for Medicare back when it was created in 1965?
Yes, it was. The original architects of Medicare saw it being expanded to everybody eventually, people such as Dr. Philip Lee, who was one of the original architects of Medicare, but that's correct.


Ruthanne Shpiner, PACIFICA radio KPFA, Berkeley.


Surprise medical bills: The doctor is not in your insurance plan

by Liz Kowalczyk  - Boston Glove - March 29, 2019


The expectant mother was in labor at South Shore Hospital when she requested a common pain medicine, which was administered by an anesthesiologist. Home with a newborn days later, she was surprised when a bill arrived from the doctor’s group for $2,143.44.
Another patient who went to Emerson Hospital’s emergency department for what turned out to be a broken rib also received a surprise bill: $300.91, for the services of the doctor who read the X-ray.
Neither of the patients initially knew the reason behind the hefty additional charges, according to complaints they filed with state regulators. They sought care at hospitals that were fully covered by their insurance plans. What they didn’t know was that the two doctors were not — and had billed the patients directly for their services.
Getting an out-of-the-blue medical bill — such as when a hospital uses doctors that are outside a patient’s insurance network — has become a nationwide phenomenon. It’s one that has forced exasperated patients to fight with medical providers and insurers at a time when they are already paying for a greater share of their health care.
Patients should not have to “contact their health plan and complain,’’ said David Seltz, executive director of the Massachusetts Health Policy Commission, which monitors health care spending in the state. “Through no fault of their own they are being put in this situation.’’
An analysis by the policy commission found that 10,000 Massachusetts patients in just one year may have received surprise bills for so-called out-of-network care, and policy experts believe that figure underestimates the extent of the problem.
States are increasingly passing laws to protect patients from these charges, such as limiting the dollar amount of out-of-network fees. Massachusetts legislators last year considered doing just that, but failed to pass a sweeping health care bill by the end of the session. A key legislator said approving stricter rules around out-of-networking billing is a priority this year. A bipartisan group of US senators is also taking up the issue.
Over the past two years, about 115 patients have filed formal complaints about surprise medical bills with Massachusetts Attorney General Maura Healey’s office, including the two patients at South Shore and Emerson hospitals, according to a Globe review of the documents obtained through a public records request.
Some patients received surprise bills for so-called facility fees, assessed when a patient is treated in an ordinary physician’s office or urgent-care center, but then receives an expensive outpatient bill from the hospital that owns the facility. An investigation by Healey’s office into facility fees charged by Partners HealthCare and its hospitals, including Massachusetts General and Brigham and Women’s, led to a settlement in September requiring Partners to better notify patients of the fees.
More than 35 percent of complaints filed with Healey were over out-of-network charges, which can be up to 200 percent higher than what insurers pay in-network doctors. Among the physicians that were outside the patients’ insurance networks were anesthesiologists assisting in colonoscopies and emergency medicine doctors repairing broken bones and treating heart attacks, something that frustrated patients told Healey’s office they had no way of knowing in advance. Radiologists and pathologists also directly billed patients out-of-network charges.
It’s not unusual for a hospital to have practitioners working in their facilities who are not covered by all their agreements with insurers, a technicality that is often not apparent to patients.
In the South Shore and Emerson cases, the hospitals said out-of-network bills are unusual; most doctors accept the same insurance plans as the hospitals. The physicians’ groups that employ the anesthesiologists and emergency medicine doctors, South Shore Anesthesia Associates and Emerson Emergency Physicians, each said it works with patients and insurers to resolve uncovered charges.
But the Emerson and South Shore patients told Healey’s office that the physicians sent their bills to collection agencies after they refused to pay them. The hospitals and doctors said they could not respond fully to the Globe’s questions about the complaints because the patients’ names were removed by the attorney general’s staff to protect their privacy.
In another complaint, a man who arrived at the Newton-Wellesley Hospital emergency department with a fractured eye socket unknowingly saw an out-of-network doctor who billed him $796.
“Newton-Wellesley Emergency Medicine Specialists works with those patients to decrease the bill to an amount that is comparable to in-network regional payor rates,’’ hospital spokesman John Looney said in a statement.
Another patient with sepsis, a life-threatening infection, went to an undisclosed emergency department, where doctors advised admitting the person. The hospital did not have an open bed, so staff called Northeast Regional Ambulance to take the patient to another hospital. The ambulance company turned out to be outside the patient’s insurance network, resulting in a $2,079.08 bill.
“This was an emergent situation and there was no other ambulance service available within a 50-mile radius,’’ the patient wrote.
Most patients received surprise bills for hundreds of dollars, but a dozen were on the hook for thousands. The highest out-of-network bill reported was $4,600 for lab tests at a Cambridge Health Alliance facility.
Compounding their exasperation, patients often said that despite repeated calls, hospital and insurance company staff could not — or would not — explain the bills. One person wrote of making 20 phone calls, and many patients said they never received return calls.
Some of these complaints may have been resolved after the patient contacted Healey’s office, which tries to mediate disputes.
The policy commission analysis found that about 10,000 patients in 2014 may have ended up with hefty bills for out-of-network care. But that review covered only two insurers, Blue Cross Blue Shield of Massachusetts and Tufts Health Plan, both of which have broad networks of doctors.
“We have no evidence that this has gotten any better,’’ Seltz said.
The problem is more pronounced for consumers insured by large national companies such as Aetna, Cigna, and UnitedHealthcare, which contract with most hospitals but not all local physicians’ groups, experts said. Most of the complaints reviewed by the Globe were filed by patients with national insurers.
Massachusetts has a consumer protection law that provides some recourse for patients, but health care experts and state legislators believe it should be strengthened. And, it does not apply to self-insured companies, which account for 60 percent of patients with commercial insurance in Massachusetts, and are regulated under federal, not state law.
Michael Caljouw, vice president of government and regulatory affairs for Blue Cross, said the insurer will pay the out-of-network bill when the “member did not have a reasonable choice.’’ But he would not say if that includes, for example, a woman who ends up with an out-of-network anesthesiologist during childbirth.
Seltz called these measures “a woefully inadequate solution to the problem.’’ Even if an insurer pays the bill, it is still paying a higher fee to that out-of-network physician, which raises overall health care costs.
That begs the question of why doctors groups do not join all provider networks in the first place.
Several emergency medicine doctors and anesthesiologists blamed insurance companies for the problem, particularly the national companies, which they said want to keep their networks small as a way to shift costs to consumers.
Emerson in Concord contracts with groups of anesthesiologists, emergency medicine doctors, pathologists, and radiologists to provide those services. Dr. Joseph Bergen, Emerson’s chairman of emergency medicine, said that “some of these bigger companies, they will not pay rates that allow us to take care of their patients. We are happy to be in network,we just need to be paid a fair price,’’ he said.
But Aetna and UnitedHealthcare pointed to doctors’ groups, some of which chose not to join insurance networks simply so they can charge exorbitant fees, the companies said.
“We also believe that hospitals have the responsibility to be clear on the network status of all of the health care professionals that serve their patients,’’ said Aetna spokesman Ethan Slavin in a statement.
National doctors’ organizations, insurers, and policy experts agree that consumers should receive advance notice for non-emergency procedures when doctors are not covered by their insurance plan. And, that generally insurers, not patients, should have to pay a fair out-of-network rate. New York and Connecticut are among the states that have passed laws to this effect.
In Massachusetts, the disagreement has come over exactly how that rate is determined. State Senator James Welch, a West Springfield Democrat, said reaching consensus on the issue is a “major priority.’’
“People having health care procedures are in a very vulnerable state,” Welch added. “The last thing they need to worry about is any surprise payment.’’
https://www.bostonglobe.com/metro/2019/03/29/surprise-medical-bills-the-doctor-not-your-insurance-plan/pPjYw5ZzcnKljuzNdHiEJN/story.html?

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Wednesday, March 27, 2019

Health Care Reform Articles - March 27, 2019

Democrats Pivot Hard to Health Care After Trump Moves to Strike Down Affordable Care Act

by Robert Pear and Sheryl Gay Stolberg - NYT - March 26, 2019

WASHINGTON — A new fight over the future of the Affordable Care Act burst onto the Capitol Hill agenda on Tuesday morning, as Democrats tried to move past the Mueller report and pounce on the Trump administration’s legal motion to have President Barack Obama’s signature health care law invalidated by the federal courts.
“The Republicans did say during the campaign that they weren’t there to undermine the pre-existing condition benefit, and here they are, right now, saying they’re going to strip the whole Affordable Care Act as the law of the land,” Speaker Nancy Pelosi of California told reporters, just hours before Democrats were to unveil their own plan to lower costs and protect people with pre-existing conditions.
“This is actually an opportunity for us to speak to the American people with clarity,” Ms. Pelosi went on. “They say one thing and they do another. They say they’re going to protect pre-existing conditions as a benefit, and then they go to court to strip it and strip the whole bill.”
For Democrats, the Justice Department motion to invalidate the health law could not have come at a more opportune time. With the special counsel’s report failing to find a criminal conspiracy between President Trump’s campaign and Russia’s efforts to influence the election, Ms. Pelosi — who was celebrating her birthday on Tuesday — was already pressing to move her party back to the kitchen-table issues that they believe will shape the 2020 campaign.
In 2018, Democrats campaigned — and won — on their pledge to keep the law’s protections for pre-existing medical conditions, and are planning to roll out their own health care agenda with much fanfare at a news conference on Tuesday afternoon. Representative Hakeem Jeffries of New York, chairman of the House Democratic Caucus, promoted the plan on Tuesday morning, while also accusing Republicans of “launching an assault on health care in the United States of America.”
Ken Paxton, the attorney general of Texas who led the group of Republican state officials who challenged the Affordable Care Act, said he welcomed the Trump administration’s latest expression of support for a lawsuit that had already prompted a district court judge in Texas to strike down the health law. That judge’s December ruling has been on hold as the matter winds its way through the court system.
“We have always been confident that the district court’s extremely well-reasoned opinion was correct on the law, just as we have also always been confident that this administration takes its obligation to uphold the Constitution seriously,” Marc Rylander, a spokesman for Mr. Paxton, said Tuesday. “We applaud the Department of Justice’s faithful execution of that duty.”
Mr. Trump cryptically tweeted what may have been his support as well:
But House Republicans — who also campaigned on a pledge to protect people with pre-existing conditions — were far more eager on Tuesday to take an extended victory lap on the Mueller report than field thorny questions about an issue that helped cost them the majority.
“I haven’t read through what they — was it last night?” Representative Kevin McCarthy of California, the House Republican leader, said during his weekly news conference dominated by a series of long statements about the report. He added, “I think the president has always been very clear that he wanted to repeal Obamacare, and to put a system in that actually lowers the cost and protects individuals’ pre-existing conditions.”
The Democratic offensive came the morning after the Justice Department asked a federal court to strike down the law in its entirety. The administration had previously said that the law’s protections for people with pre-existing conditions should be struck down, but that the rest of the law, including the expansion of Medicaid, should survive.
If the appeals court accepts the Trump administration’s new arguments, millions of people could lose health insurance, including those who gained coverage through the expansion of Medicaid and those who have private coverage subsidized by the federal government.
“The Justice Department is no longer asking for partial invalidation of the Affordable Care Act, but says the whole law should be struck down,” Abbe R. Gluck, a law professor at Yale who has closely followed the litigation, said Monday. “Not just some of the insurance provisions, but all of it, including the Medicaid expansion and hundreds of other reforms. That’s a total bombshell, which could have dire consequences for millions of people.”
In addition to inciting a furor on Capitol Hill, the administration’s new position is also certain to take center stage as an issue in the 2020 elections. Democrats have been saying that Mr. Trump still wants to abolish the law, and they can now point to the Justice Department’s filing to support that contention.
The Justice Department disclosed its new stance in a two-sentence letter to the United States Court of Appeals for the Fifth Circuit, in New Orleans, and will elaborate on its position in a brief to be filed later.
In the letter, the Justice Department said the court should affirm a judgment issued in December by Judge Reed O’Connor of the Federal District Court in Fort Worth.
Judge O’Connor, in a sweeping opinion, said that the individual mandate requiring people to have health insurance “can no longer be sustained as an exercise of Congress’s tax power” because Congress had eliminated the tax penalty for people who go without health insurance.
Accordingly, Judge O’Connor said, “the individual mandate is unconstitutional” and the remaining provisions of the Affordable Care Act are also invalid.
In its letter to the appeals court, the Justice Department said Monday that it was “not urging that any portion of the district court’s judgment be reversed.” In other words, it agrees with Judge O’Connor’s ruling.
But on Tuesday, after a closed-door meeting, Democrats were piling on. Representative Cheri Bustos of Illinois, who leads the Democrats’ campaign committee, was quick to note Republicans’ vote in January to back a lawsuit repealing the Affordable Care Act, saying “their actions speak much louder than their lies.”
“Millions of hardworking families across America could see their health care costs explode because Washington Republicans sided with big insurance companies instead of everyday Americans,” Ms. Bustos added. “They simply cannot say they support protections for people with pre-existing conditions, lowering health care costs, or expanding access to care for more Americans, because they voted to destroy all of these things.
In the nine years since it was signed by Mr. Obama, the Affordable Care Act has become embedded in the nation’s health care system. It changed the way Medicare pays doctors, hospitals and other health care providers. It has unleashed a tidal wave of innovation in the delivery of health care. The health insurance industry has invented a new business model selling coverage to anyone who applies, regardless of any pre-existing conditions.
The law also includes dozens of provisions that are not as well known and not related to the individual mandate. It requires nutrition labeling and calorie counts on menu items at chain restaurants. It requires certain employers to provide “reasonable break time” and a private space for nursing mothers to pump breast milk. It improved prescription drug coverage for Medicare beneficiaries, and it created a new pathway for the approval of less expensive versions of biologic medicines made from living cells.
Lawyers said invalidation of the entire law would raise numerous legal and practical questions. It is, they said, difficult to imagine what the health care world would look like without the Affordable Care Act.
The Trump administration’s new position was harshly criticized by the insurance industry and by consumer advocates.
The government’s position “puts coverage at risk for more than 100 million Americans,” said Matt Eyles, the president and chief executive of America’s Health Insurance Plans, the industry lobbying.
Leslie Dach, the chairman of Protect Our Care, a consumer advocacy group, said: “In November, voters overwhelmingly rejected President Trump’s health care repeal and sabotage agenda. But he remains dead set on accomplishing through the courts what he and his allies in Congress could not do legislatively: fully repeal the law, devastate American health care and leave millions of Americans at risk.”
The Trump administration’s new stance appears to put Republicans in Congress in an awkward position. They have repeatedly tried to repeal the health law. But in the last year, they said over and over that they wanted to protect coverage for people with pre-existing conditions, and those protections are among the law’s most popular provisions.
The lawsuit challenging the Affordable Care Act, Texas v. United States, was filed last year by a group of Republican governors and state attorneys general. Officials from California and more than a dozen other states have intervened to defend the law.
The Texas lawsuit “is as dangerous as it is reckless,” Xavier Becerra, the attorney general of California, said Monday as he filed a brief urging the appeals court to uphold the law.
https://www.nytimes.com/2019/03/26/us/politics/democrats-trump-affordable-care-act.html 

How ‘Medicare for All’ went from pipe dream to mainstream

by Mary Ellen McIntire - Roll Call - March 26, 2019

Political candidates and activists in Maine, especially in rural areas, often got a sharp reaction five years ago when they knocked on doors to promote universal health care.
“The reaction was, ‘Oh, you’re a commie,’” said Phil Bailey, who back then advocated for various Democratic causes.
Now, voters in those same conservative areas have a different take.
“Of course” is a common response to calls for universal coverage, said Bailey, now executive director of Maine AllCare, part of a national coalition campaigning for single-payer health care. The organization saw enough growing momentum and received enough financial support to justify hiring Bailey and another full-time staffer last summer for the previously volunteer-led group.
What was once seen as a long-shot pitch from Vermont independent Sen. Bernie Sanders during his 2016 presidential campaign is now a proposal that at least four of his Senate colleagues also vying for the party’s 2020 nomination supported during the last Congress. The issue is driving the national political health care debate.
But to succeed in enacting a single-payer system such as the “Medicare for All” plan that Sanders backs, liberals would need an unprecedented grassroots movement propelling the effort forward and would have to work out complicated policy details affecting nearly one-fifth of the nation’s economy.
Democrats are already contending with industry groups hoping to shift the focus back to strengthening the current system. Most drug companies, hospitals and insurers oppose Medicare for All, which undoubtedly complicates progressives’ efforts. The party’s left wing is pushing a bold, pricey plan carrying political risks that make Democratic leaders shudder. Despite all the inevitable political hurdles, getting a single-payer law enacted may look easy compared to implementing it.
The most ardent advocates for a government-run, single-payer system are not content with incremental steps. They are seeking a wholesale reorganization of the nation’s health care system.
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The proposed two-year transition may be too fast for the entire industry to adapt to in an overhaul that experts warn would displace workers and jolt the economy.
“It is going to be a big administrative and logistical challenge. When you’re talking about moving everyone in the country into a new health insurance program, that is not a small feat,” said Linda Blumberg, an institute fellow at the Health Policy Center at the left-leaning Urban Institute.

Upending the industry

A single-payer health care plan would significantly change every sector of the health care industry. Hospitals and doctors would need to adjust to a new payment system, the insurance industry would shrink to a fraction of its size, and the government would bring drug companies to the negotiating table to determine prices.
The 2010 health care law left in place most of the existing health care infrastructure in the U.S. Still, experts warn that the lessons from that more incremental transition show how dramatic it would be to shift to a single-payer system.
Supporters aren’t intimidated by the seismic nature of the change. The hope is not just to ensure that everyone has coverage, but also to take on health care companies seeking to maximize their profits, said Adam Green, a co-founder of the Progressive Change Campaign Committee, a political action committee that supports liberal candidates.
“Medicare for All boils down to two things,” Green said. “One is universal coverage. The other is corporate accountability.”
Setting up a single-payer system would most likely require creating a new government program to serve as the payer and oversee the system. A House bill by the co-leader of the Progressive Caucus, Pramila Jayapal, would also establish a national health care budget to cap costs.
The Washington Democrat’s bill, like Sanders’ plan, doesn’t envision a large role for supplemental insurance.
It would be permitted, but aides say it would likely be unnecessary and used only to cover medically unnecessary treatments, such as cosmetic surgery. Unraveling the current insurance system is a Gordian knot-style task all its own.
Even public entitlement programs are often administered through private plans, with 68 percent of people in Medicaid and 34 percent of those in Medicare using comprehensive managed care plans.

Granddaddy of 2020 issues

The role of private insurance in a single-payer system has already emerged in the fledgling Democratic presidential primary race.
California Sen. Kamala Harris sparked the debate over the survival of private insurance earlier this year, saying she favors a single-payer system that would eliminate it. Harris has also backed other proposals, but called the single-payer plan her top choice.
Minnesota Sen. Amy Klobuchar said such a move is not feasible and supports a bill by Hawaii Democratic Sen. Brian Schatz to let people buy into Medicaid. Similarly, former Texas Rep. Beto O’Rourke, who previously supported a single-payer system, now says another path to universal coverage may be more efficient.
The single-payer bills introduced so far would not be based on the current Medicare program, but instead would greatly expand the program’s benefits.
Jayapal and Sanders both say the national health program would cover all medically necessary treatments. Those could be determined by a doctor or a newly formed national health program, said Jodi Liu, a RAND Corp. associate policy researcher.
Adam Gaffney, president of Physicians for a National Health Program, which supports a move to single-payer, said those decisions could resemble the way Medicare determines what care is medically necessary. He supports a national list of covered drugs.
Advocates for a single-payer system say that enrolling people in the program may be the easiest part. After all, decades ago, the government signed up seniors in the newly created Medicare program the year after it was enacted. Unenrolled patients could be signed up at a doctor’s office or hospital when they receive treatment, said Gaffney.
“Once you say you’re going to enroll everyone, it actually takes a lot of the administration out of it,” Gaffney said.

Compensation questions

One major challenge under a single-payer system would be how to pay medical providers. Advocates propose different types of plans, such as paying all providers at the same rate, possibly based on current Medicare rates, or global budgeting, through which institutions would regularly receive a lump sum of money as reimbursement for treatments.
Payment changes could benefit some doctors, such as those who currently treat many Medicaid enrollees and receive lower rates than Medicare. But providers who see mostly patients covered by commercial insurance could see payments fall.
The same goes for access to providers, said Liu. Since not all providers accept Medicaid, many patients would likely have an easier time finding doctors.
The government would face significant pressure to ensure that providers were compensated at the “right” rate, said Blumberg. Controlling health costs would be one goal, but the government would not want to skimp on quality or access to a sufficient number of providers.
In making decisions that affect the entire health care system, selecting the wrong payment rate could have serious ramifications, said Blumberg. “That process in and of itself is going to require a huge amount of attention and analysis and monitoring.”
Under the Jayapal bill, hospitals and the government would negotiate a budget based on factors like the historic volume of services over three years, a hospital’s normal expenditures and standard payment rates.
Hospitals would also get funding to cover their uncompensated care costs under an all-payer system.
Global lump-sum budgeting, which would give institutional providers an amount of money for health care services over a set amount of time, could contain costs, which advocates call a key benefit.
“If there was a national global budget, that’s certainly a direct lever to address how much spending there is on health care, but of course, there’s a lot of political issues that would come up,” such as budgetary pressures, Liu said.
While hospitals and other institutions would be paid quarterly through a capped budget under Jayapal’s proposal, individual doctors would be paid through a fee-for-service system for every procedure. The Health and Human Services secretary would have one year to set those providers’ fees. Hospitals are already sounding the alarm about receiving lower payments under Democratic proposals.
Whether Jayapal’s two-year transition is feasible is another question. A Jayapal aide said a fast transition provides less time for the industry to push back.
Still, Blumberg suggests a 10-year transition is more feasible. “The change for a lot of providers could be very substantial, and doing that in a very short period of time may have implications for disrupting the operation, the ability for these providers to continue to operate and the access for the patients,” she said.
Although the challenges are great, Medicare for All advocates note that other large developed countries ensure all citizens can access health care.
“Across industrialized countries, the hallmark of the health care system is universal coverage,” said Robin Osborn, a Commonwealth Fund vice president and director of international health policy and practice innovations.

Where’s the funding?

For all the questions around a single-payer system, the biggest question may be how to pay for it. Neither Jayapal or Sanders included a financing plan in their bills, although Sanders released a list of possible ways to pay for his.
The price tag for Sanders’ vision would be roughly $32 trillion over 10 years, according to two outside analyses of proposals Sanders put forward in 2016 and 2017, the first from the Urban Institute and the latter from the libertarian Mercatus Center.
That’s an eye-popping balance, although Sanders emphasizes findings that the U.S. would actually save money on health care spending over a decade. Single-payer advocates argue that the U.S. health care system is already the most expensive in the world and would be more efficient under a new program.
“When you think about the fact that people are already paying, you have to recognize that this is just a scare tactic, primarily from the right, saying you’re going to end up paying much more,” Jayapal said.
Still, asking taxpayers to pay the whole bill causes even some Democrats to balk.
Speaker Nancy Pelosi of California said in a recent Rolling Stone interview that a single-payer system may be easier administratively than other ways to reach universal coverage, but questioned how to pay for it.
Pelosi insists that Democrats should build on the 2010 health care law, which she helped shepherd through Congress a decade ago. Expanding the current Medicare program would not be as beneficial to Americans as that law, she argues.
“All I want is the goal of every American having access to health care,” she told the magazine. “You don’t get there by dismantling the Affordable Care Act.”
Critics will likely highlight the lack of a financing plan — and the expected high tax increase — that would come with implementing a system that covers essentially all medical expenses.
Sanders’ financing options include ending tax breaks that would become obsolete under a single-payer plan, adding a 4 percent income-based premium paid by households, imposing a wealth tax or a more progressive personal income tax, or leveraging fees on corporations, such as a one-time tax on offshore profits.
Other possibilities include sunsetting parts of the Republican 2017 tax overhaul or creating a tax on employers, which could mean that employers would not see much savings from not providing coverage to workers.
High-income earners are particularly at risk, said Larry Levitt, senior vice president for health reform at the Kaiser Family Foundation. “Depending on how it’s financed, high-income people could end up paying much more in taxes than they now pay for health care,” he said.
Because a transition to a single-payer plan would effectively eliminate most of the insurance industry, possibly 1 million to 2 million people who work in that industry would be displaced, according to Jayapal. Both Jayapal and Sanders proposed assistance for those workers with new job training, education or other programs.
Jayapal’s bill introduction in February led health insurance stocks to slip, although analysts did not express much concern. Spencer Perlman, director of health care research at Veda Partners, wrote to clients that he did not believe the bill to be a risk to managed care.
“The only conceivable analogues for the approach envisioned by House Progressives are the Medicare Act of 1965 and the ACA, each of which were generational policies that nevertheless largely left intact the commercial insurance paradigm and private control of healthcare services,” he wrote. That could be partially because a Medicare for All debate would draw in essentially every sector of the economy.
“It’s hard to imagine a bigger and more all-encompassing debate than over Medicare for All,” Levitt said. “Health care is such a big part of the economy, and you would just have every business and health care group weighing in.”

Political calculus

Some Democrats doubt that a Democratic president and Congress would implement a single-payer system.
Bob Kocher, a partner at Venrock and former senior Obama administration health care official, said actions in office typically don’t match the aspirations candidates invoke while campaigning.
“When you try to do it, the details matter and are hard and are often less disruptive and ambitious than what your poetry was,” he said.
Liberals insist that a single-payer system is the only path forward. “This is not a messaging event. We are going to get health care for every American,” Rep. Debbie Dingell, a Michigan Democrat, said at an event for the House bill.
If lawmakers were going to march toward a single-payer system, a massive shift in public opinion over a relatively short period of time would be needed.
Recent polls show that support for Medicare for All falls when people learn it would eliminate private insurance companies or raise taxes.
Whether Democrats decide to take up a single-payer plan would depend on how much a president campaigned on it, said Green.
A political boost could come if Medicare for All brought down “an old timer” who doesn’t support the policy, such as Ways and Means Chairman Richard E. Neal of Massachusetts, Green suggested.
“Now what we’re experiencing is there’s a lot of candidates who campaigned and won on Medicare for All, including flipping red seats blue, but ironically, there’s others who didn’t campaign on Medicare for All, got attacked anyway and won, but were kind of spooked from the whole experience,” Green said.
Still, Green added that if a “true progressive” wins the White House, he expects Medicare for All to be a priority.
Advocates hope that Medicare for All hearings in the coming months in the Rules and Budget committees will help the public understand the plan. Those hearings could also be a chance for single-payer opponents to raise concerns.
“Democrats are once again proposing fiscally irresponsible policies that will radically alter how hundreds of millions get their health care,” Rep. Steve Womack of Arkansas, the Budget Committee ranking Republican, said when Jayapal’s bill was released.
Mark Peterson, a political science professor at the University of California at Los Angeles, said historically, Americans have consistently said the health care system needs improvements, but they’re also afraid of what they don’t know.
“To the extent that what progressives are doing will stimulate that kind of action at the public level to really create that wave, a groundswell of support the way Social Security had, that can make an enormous political difference,” he said.
https://www.rollcall.com/news/campaigns/medicare-for-all-2020-election


'You're Damn Right': Sanders Doesn't Cower From Call to Get Rid of Private Insurance Companies

by Jake Johnson - Common Dreams - March 27, 2019

Arguing that piecemeal reforms to America's for-profit healthcare system will not be sufficient to address the needs of millions who are suffering due to lack of insurance and soaring drug costs, Sen. Bernie Sanders said Tuesday that the U.S. must "get rid of the insurance companies" and move to Medicare for All.
Asked by MSNBC's Chris Hayes why he favors single-payer over the incremental Medicare buy-in plans introduced by congressional Democrats in recent weeks—such as the so-called "Medicare for America" bill—Sanders said, "Because ultimately we have to recognize that the current system is incredibly dysfunctional and wasteful."
"Its goal is to make profits for the insurance companies and the drug companies," said the independent senator from Vermont. "You are not going to be able, in the long run, to have cost-effective, universal healthcare unless you change the system, unless you get rid of the insurance companies, unless you stand up to the greed of the drug companies and lower prescription drug costs."
"That's the only way that you can provide quality care to all people," Sanders continued. "All people people get it, regardless of their income. It is publicly funded. That is the most cost-effective way to provide healthcare to all."
After the Republican Party's research team posted a clip of Sanders' interview on Twitter, apparently believing it would somehow harm him, the senator didn't back down from his remarks.
"You're damn right," Sanders tweeted.
Sanders' clear call for the elimination of private insurance companies comes as incremental plans are gaining appeal among some congressional Democrats and presidential candidates.
Former Texas Rep. Beto O'Rourke, a 2020 presidential contender, has expressed support for "Medicare for America," which would leave employer-provided private insurance and premiums intact.
Writing for Common Dreams on Monday, Michael Lighty—former director of public policy for the California Nurses Association and a founding fellow at the Sanders Institute, started by Sanders' wife and son—argued that Medicare for America does not adequately address soaring out-of-pocket costs because it fails to confront the private insurance industry's profit-driven business model.
"Rather than contort policy into some hybrid, multi-payer regulatory scheme that generates complexity, fragmentation and waste, as it enshrines profit-making and high out of pocket costs, let's stop the care denials and the insurance company dictates to doctors and patients," Lighty wrote. "Medicare for All represents the best M4A way: lead and be swift."
"Yes, your premiums are gone, your co-pay to see the doctor is eliminated, you don't have to worry about your deductible or wait for insurance company approval to get that test," he concluded. "Very quickly, peace of mind will overwhelm that forgotten desire to keep your private insurance."
https://www.commondreams.org/news/2019/03/27/youre-damn-right-sanders-doesnt-cower-call-get-rid-private-insurance-companies


Republicans Really Hate Health Care

by Paul Krugman - NYT - March 27, 2019

Of all the political issues that divide us, health care is the one with the greatest impact on ordinary Americans’ lives. If Democrats hadn’t managed to pass the Affordable Care Act, around 20 million fewer Americans would have health insurance than currently do. If Republican-controlled states hadn’t refused to expand Medicaid and generally done as little as possible to support the act, national progress might have tracked progress in, say, California – so another 7 or 8 million people might have coverage.
You obviously know where I stand on this political divide. But I’m starting to believe that I misjudged Republican motives.
You see, I thought their behavior was cynical and strategic: They opposed Obamacare because they thought there was political mileage in scaring people about change, and also in denying Obama any successes. Oh, and their donors really hated the taxes on the rich that pay for the ACA’s subsidies. And right up through 2016 they could hope to convince voters that they had a secret plan for something much better than Obamacare.
Indeed, all of these things surely played a role in GOP health care strategy. But at this point they’ve clearly lost the political argument. In 2017, Republican attempts to repeal Obamacare made it clear to everyone that their party didn’t have any better ideas, and never did; everything they proposed would have devastated the lives of millions.
Then health care became the top issue in the 2018 midterms, and voters who considered it the most important issue went Democratic by a three to one margin.
So you might have expected Republicans to cut their losses. Maybe Trump could have done what he did with NAFTA: keep Obamacare basically intact, but make a few minor changes, give it a new name – the Yuge Maga Care Awesomeness, or something – and claim that it was totally different and better.
But no. Most Republican-controlled states are still refusing to expand Medicaid, even though Washington would bear the vast majority of the costs. Utah held a direct referendum on Medicaid expansion, which passed easily – so the will of the voters was clear, even in a very conservative state. Yet GOP legislators are blocking the expansion anyway.
And now the Trump administration, having failed to repeal the ACA when Republicans controlled Congress, is suing to have the whole thing declared unconstitutional in court – because what could be a better way to start off the 2020 campaign than taking insurance away from 20 million Americans?
As an aside, this latest Trump move completes his utter betrayal of the people who put him in office. Consider a place like West Virginia, where a lot of people gained health insurance thanks to Obamacare’s Medicaid expansion. The state went overwhelmingly for Trump anyway, because he promised not to cut health care, and also promised to bring back those good jobs in coal. So I made a little chart to show what he’s actually offering West Virginians:
Betraying the baseCreditBLS, Kaiser Family Foundation


The point is that it’s no longer possible to see any of this as part of a clever political strategy, even a nefariously cynical one. It has entered the realm of pathology instead. It’s now clear that Republicans just have a deep, unreasoning hatred of the idea that government policy may help some people get health care.
Why? The truth is that I don’t fully get it. Maybe it’s anger at the thought of anyone getting something they didn’t earn themselves, unless it’s an inheritance from daddy. Maybe it’s a sense that a lot of gratuitous suffering is or should be part of the human condition, or God’s plan, or something. I try to understand how others think, but in this case I really do find it hard.
Whatever the reason, however, the fact is that whatever they may claim, today’s Republicans hate the idea of poor and working-class Americans getting the health care they need.
https://www.nytimes.com/2019/03/26/opinion/republicans-really-hate-healthcare.html


House Democrats’ health-care bill hurts Trump and Bernie

by Jennifer Rubin - Washington Post - March 27, 2019

Speaker Nancy Pelosi (D-Calif.) held a news conference Tuesday with fellow Democrats on Tuesday to roll out their new health-care proposal in the wake of the administration’s announcement that it supported complete invalidation of the Affordable Care Act in a 5th Circuit case. The court move came as an unexpected political gift to Democrats.
Pelosi reminded the media:
Last night, in federal court, the Justice Department of the Trump Administration – you’d think they have more to do – decided to not only try to destroy protections for preexisting conditions, but to tear down every last benefit and protection the ACA affords.
The GOP will never stop trying to destroy the affordable health care of America’s families. I always think of Mr. Clyburn and John Lewis when they quote Martin Luther King, when he talks about, ‘of all the injustices, the most inhumane is the inequality of health care.’
What Democrats propose is the sort of step-by-step expansion of Obamacare that both Republicans and Sen. Bernie Sanders (I-Vt.) vehemently oppose. Republicans want nothing; Sanders wants to scrap everything in favor of single-payer health care.
The House Democrats’ bill sets out a proposal to, among other things, reduce health-care premiums (capping out-of-pocket costs at 10 percent of income) and expanding tax credits for those beyond 400 percent of the federal poverty line ($104,000 for a family of four). Protect Our Care, a progressive group backing the legislation, explains, “In all, the bill’s extended tax credits, reinsurance programs and premium assistance would cut premiums for all ACA-compliant plans sold on the individual market, reducing premiums or deductibles for 13 million with individual market coverage and creating lower cost options for 12 million uninsured people eligible for coverage through the marketplace.” The bill also reinstates the guarantee for those with preexisting conditions, disallows non-ACA compliant plans and reaffirms the list of essential health-care benefits to be covered by the ACA.
House Democratic caucus chairman Hakeem Jeffries (D-N.Y.) said March 26 Democrats are focused on health care following the special counsel’s report. (The Washington Post)
In contrast to the administration that has tried to discourage ACA exchange sign-ups, the Democrats’ bill would “restore marketing funding for health care sold through the marketplace, which the Trump administration has cut by 90 percent since taking office . . . [and] for health navigator groups that help people sign up for comprehensive care, which has been cut by 77 percent since the President Trump took office.”
Recent polling shows that voters want lower costs and expansion of coverage. There is little popular support for ripping out all private health-care coverage (obtained through employers or otherwise) and even less for taking health-care coverage away from 20 million people.
What have the Republicans got? Nothing except a desire to obliterate all of the ACA. If they whine that the Democrats’ plan is too expensive, Democrats (after guffawing at the nerve of the party that rang up the biggest deficits in history) are likely to suggest clawing back some of the tax cuts for the rich, which were so unpopular Republicans could not run on their handiwork in 2018.
The proposal should also serve as a warning to Democratic presidential candidates that following Sanders down the rabbit hole marked “Medicare-for-all” is foolish politically and unresponsive to voters’ demands. They should feel comfortable either endorsing the House plan or coming up with their own add-ons to Obamacare. At a time Republicans still are trying to repeal Obamacare, these steps are hardly insignificant.
To the contrary, as the latest Quinnipiac poll shows, “American voters say 55 - 32 percent they would prefer to improve rather than replace the health care system in the U.S. No listed group prefers replacing the health care system.” That includes 60 percent of Democrats. A public option gets support from 61 percent of Democrats and 51 percent overall. (While putting everyone in Medicare gets even higher support from Democrats and more than 40 percent of all voters’ support, poll after poll shows support nose-dives when it is explained that all private insurance would disappear.)
House Democrats would be wise to pass the bill, send it to the Senate and then hold Republicans accountable if they refuse to vote on it and the court strikes down the ACA. Meanwhile, presidential candidates should reassure voters that they can deliver real, meaningful relief that is also feasible — and much preferable to a bumper-sticker slogan with no chance of passing Congress.
As for Democratic incumbents and Democratic challengers up in 2020, the choice between nothing and Obamacare-plus will provide the stark contrast they seek to make with Republicans.
https://www.washingtonpost.com/opinions/2019/03/27/house-democrats-healhcare-bill-hurts-trump-bernie/?

In Divided White House, Trump Sided With Mulvaney in Push for Nullifying Health Act

by Maggie Haberman and Robert Pear - NYT - March 27, 2019

WASHINGTON — The Trump administration’s surprise decision to press for a court-ordered demolition of the Affordable Care Act came after a heated meeting in the Oval Office on Monday, where his acting chief of staff and others convinced President Trump that he could do through the courts what he could not do through Congress: Repeal his predecessor’s signature achievement.
Mick Mulvaney, the acting White House chief of staff and former South Carolina congressman, had spent years in the House saying that the health law should be repealed, and his handpicked head of the Domestic Policy Council, Joe Grogan, supported the idea of joining a Republican attorneys general lawsuit to invalidate the entire Affordable Care Act.
That suit, and the Justice Department, initially pressed to nullify only the part of the law that forces insurance companies to cover people with pre-existing medical conditions as well as a suite of health benefits deemed “essential,” such as pregnancy and maternal health, mental health and prescription drugs.
But a district judge in Texas ruled that the entire law was rendered unconstitutional when President Trump’s tax law brought the tax penalty for not having health insurance to zero, and the administration faced a choice: Stick with its more limited intervention or back the judge’s decision.
Mr. Trump has touted that he has kept his promises, Mr. Mulvaney and Mr. Grogan argued, and as a candidate, they said, he campaigned on repealing the health law. His base of voters would love it. Besides, they argued, Democrats have been campaigning successfully on health care, and Republicans should try to take it over themselves. This could force the issue.
Among those with concerns was Pat Cipollone, the White House counsel, who shared that it was opposed by the new attorney general, William P. Barr. Vice President Mike Pence was concerned about the political ramifications of moving ahead without a strategy or a plan to handle the suddenly uninsured if the suit succeeds.
That meeting was followed by a smaller one, where Mr. Mulvaney and Mr. Cipollone were among those voicing different opinions. But Mr. Trump had been sold, and on Monday night, the Justice Department issued a statement saying it supports the Texas judge’s decision.
On Wednesday, Mr. Trump doubled down on his support for the Texas suit while talking to reporters in the Oval Office.
“If the Supreme Court rules that Obamacare is out, we’ll have a plan that is far better than Obamacare,” he said.
[What happens if Obamacare is struck down? Read more.]
White House press aides did not immediately respond to a request for comment. And one official, who asked for anonymity to speak about the meetings, insisted that Mr. Mulvaney had simply been convening people with various views so that the president could make his own decision. But Mr. Mulvaney was described as leading the charge to back it, in an account of the two meetings that was described by a half-dozen people with knowledge of what took place.
Politico first reported that Mr. Mulvaney pushed Mr. Trump to get involved in the suit.
Mr. Barr did not favor the move but did not object to the White House decision once it had been made, people familiar with what took place said. And one White House official said that the administration faced a deadline imposed by the court if it wanted to support the suit.
But the decision to thrust Mr. Trump’s administration directly into the lawsuit caught several people inside the White House by surprise, and took the focus off what was arguably the best weekend of the Trump presidency after the delivery of the report by the special counsel, Robert S. Mueller III. Mr. Mueller, according to a letter by Mr. Barr, found no evidence of criminal conspiracy between the Trump campaign and the Russian government.
Mr. Trump did not seem to care about shifting the political focus toward an issue that Democrats far preferred to the aftermath of the Mueller report. He charged ahead at a Senate Republican luncheon, telling reporters as he went in, “Let me just tell you exactly what my message is: The Republican Party will soon be known as the party of health care. You watch.”
But Republicans in Congress have no obvious road forward on legislation to replace the Affordable Care Act that could pass the Democrat-controlled House. And House leaders have little political incentive to bow to Republican wishes on health care, an issue that they believe delivered their House majority and that they are eager to campaign on in 2020.
The Trump administration has tried to minimize and contain the Affordable Care Act over time. The president has been in favor of previous efforts to end the act. But the internal debate about the current suit also highlights a growing chasm between Mr. Mulvaney and Mr. Cipollone, according to administration officials. Mr. Mulvaney has built up over time his internal political capital, and he has grown his team of personal loyalists with new staff members.
https://www.nytimes.com/2019/03/27/us/politics/donald-trump-obamacare-mulvaney.html?e

My Friend’s Cancer Taught Me About a Hole in Our Health System 

by Aaron Carroll - NYT - March 25, 2019

Last year, one of my best friends learned he had cancer.
In many respects he was lucky. He had great insurance. He had enough money. Partly because one of his friends (me) is well connected in the health care system, he got excellent care.
So this is not a story about how the system failed, or how people need insurance or access. He had those. He got the care. This is the United States health care system at its peak performance.
But I was utterly floored by how hard it all was.
Americans spend so much time debating so many aspects of health care, including insurance and access. Almost none of that covers the actual impossibility and hardship faced by the many millions of friends and family members who are caregivers. It’s hugely disrupting and expensive. There’s no system for it. It’s a gaping hole.
My friend, Jim Fleischer, missed a few days of work as the diagnosis was made, then missed many more after surgery. His wife, Ali, had to take time off. His mother-in-law had to come and help take care of him and the children when Ali had to go back to work (she’s a teacher).
Every appointment required Jim and Ali to take off work. They live in Indiana, and at one point they had to pay for flights and a hotel room and everything else associated with a trip to New York — none of it covered by insurance — because no one would do the second opinion remotely. (He had a kidney removed in an initial operation, then doctors found he had a rare cancer, a neuro-ectodermal tumor, instead of the expected renal cell carcinoma).
Chemotherapy is rough. After each cycle, Jim would pretty much sleep or rest for a week, unable to work. Someone had to take the time to be with him. Sometimes it was Ali; sometimes it was my wife, or me, or other friends.
Jim is the C.E.O. of an international fraternity, so his colleagues and employees are his “brothers.” They were more than willing to fill in and hold the fort as he missed about three months of work total, so far.
By my count, other adults missed at least 30 days of work to get Jim to his appointments. The economic loss — the many months of work — is the least of it. Not included is all the strain that has been put on Jim’s relatives as they’ve shifted to care for him while still maintaining all the obligations and commitments any family of five has to deal with.
Again, I should be clear that this is how the system works in optimal conditions for people with a lot of privilege. Jim is now in remission, although he’ll need to be monitored for some time. This isn’t a story of how things went wrong. And yet on many occasions I’ve wondered how Jim’s family pulled it off.
If it was this hard for him, it’s probably unbearable for many others with fewer resources. People can be financially ruined by illness — and health insurance won’t fix that.
Last year, it’s estimated that more than 1.7 million people faced a cancer diagnosis. The year before, America spent more than $147 billion caring for people with cancer. But that doesn’t include the costs outside of health care.
This year, the National Cancer Institute will spend more than $5.7 billion on cancer research. Almost none of that will investigate how to support the families of those who have the disease.
On social media, I sought out people who had survived cancer in the last few years and asked them if they’d had similar experiences. Most said yes.
Dina Burns, a public affairs consultant from Granite Bay, Calif., learned she had Stage 2 breast cancer right before her 50th birthday. She missed four weeks of work for her operation and then two months for chemotherapy. But her support team collectively missed even more.
“My sister came up from Orange County for my surgery,” she said. “She stayed with me for almost two weeks. My daughters (one in college and one in a new post-college job) both took turns caring for me. And my husband came with me for every appointment, every hospitalization, even the trips to San Francisco to see the congenital heart defect specialist. He would sit in the recovery bay with his laptop, trying to stay on top of work and take care of me at the same time. We still had a son at home in his senior year of high school, so my husband was trying to help minimize the impact on him, too.”
Kevin O’Connor, an intellectual property lawyer from Evergreen Park, Ill, and a father of four, was found to have Hodgkin’s lymphoma when he was 34. He missed about two weeks of work because of testing. His wife accompanied him to all his visits, and friends and family had to take over child care duties. He missed 18 days for chemo, which, again, his wife also attended.
“We also needed to make sure that someone — usually a grandparent, aunt or uncle — was there to look after the kids,” he said. “During my six weeks of radiation after chemo, everyone had to juggle again.”
Candice B., a disabled Maine resident who is 38 and has had multiple bouts of cancer since 2004, told me: “When I got sick, my mother stopped working entirely to help me get treatment. She lost at least three years of being in the work force over all.” Now, her best friend is responsible for getting her to her operations, she said, forcing him to miss some time at work.
In a 2010 paper, researchers estimated the economic burden for caregivers of patients with lung and colorectal cancer. They reported that the average cost to a caregiver in the initial phase of treatment was more than $7,000. After treatment, almost an additional $20,000 was spent on “continuing” care. A study published in Cancer the year before found that over a two-year period, caregiving costs were more than $72,000 for lung cancer, $66,000 for ovarian cancer, $59,000 for lymphoma, and $38,000 for breast cancer.
The American Cancer Society’s page offers a lot of sympathy for caregivers in these situations, but it acknowledges that for many, there really aren’t any solid solutions other than asking for help from those around you.
As I learned, treating someone with cancer takes a team of supporters. But everything I’ve written here could easily apply to those with a host of other illnesses and chronic conditions. Policies that address this issue are rare.
In the United States, the Family and Medical Leave Act guarantees up to 12 workweeks of leave to care for a family member with a serious health problem. But that leave is unpaid; many people can’t afford not to work. It also applies only to a spouse, child or parent.
Moreover, the Family and Medical Leave Act applies only to employees of companies with 50 employees or more, which leaves out about 40 percent of the work force.
What about other nations? An Organization for Economic Cooperation and Development report from 2011 surveyed members, and found that even in the three-quarters of countries that had some form of paid leave, it was for no more than a month.
What seems more important is recognizing that the efforts of caregivers are probably just as important to health as the drugs and procedures the medical system provides. Rides to the hospital are care. The time spent at home with those recuperating after procedures is care. Watching and monitoring and caring for the ill in their home is just as much care as doing the same in a hospital. We are willing to pay a fortune for the former, and almost nothing for the latter.
https://www.nytimes.com/2019/03/25/upshot/my-friends-cancer-taught-me-about-a-hole-in-our-health-system.html



Medicare's Uncapped Drug Costs Take A Big Bite From Already Tight Budgets 

by Michelle Andrews - Kaiser Health News - March 27, 2019

Three times a week, 66-year-old Tod Gervich injects himself with Copaxone, a prescription drug that can reduce the frequency of relapses in people who have some forms of multiple sclerosis. After living with the disease for more than 20 years, the self-employed certified financial planner in Mashpee, Mass., is accustomed to managing his condition. What he can't get used to is how Medicare's coinsurance charges put a strain on his wallet.
Unlike commercial plans that cap members' out-of-pocket drug spending annually, Medicare has no limit for prescription medications in Part D, its drug benefit. With the cost of specialty drugs increasing, some Medicare beneficiaries could owe thousands of dollars in out-of-pocket drug costs every year for a single drug.
Recent proposals by the Trump administration and Sen. Ron Wyden, D-Ore., would address the long-standing problem by imposing a spending cap. But it's unclear whether any of these proposals will gain a foothold.
The 2006 introduction of the Medicare prescription drug benefit was a boon for seniors, but the coverage had weak spots. One was the so-called doughnut hole — the gap beneficiaries fell into after they accumulated a few thousand dollars in drug expenses and were then on the hook for the full cost of their medications. Another was the lack of an annual cap on drug spending.
Legislative changes have gradually closed the doughnut hole so that this year beneficiaries no longer face a coverage gap. In a standard Medicare drug plan, beneficiaries pay 25 percent of the price of their brand-name drugs until they reach $5,100 in out-of-pocket costs. Once patients reach that threshold, the catastrophic portion of their coverage kicks in, and their obligation drops to 5 percent. But it never disappears.
It's that ongoing 5 percent that hits hard for people, like Gervich, who take expensive medications.
His 40-milligram dose of Copaxone costs about $75,000 annually, according to the National Multiple Sclerosis Society. In January, Gervich paid $1,800 for the drug, and he paid another $900 in February. Discounts that drug manufacturers are required to provide to Part D enrollees also counted toward his out-of-pocket costs. (More on that later.) By March, he had hit the $5,100 threshold that pushed him into catastrophic coverage. For the rest of the year, he'll owe $295 a month for this drug, until the cycle starts over again in January.
That $295 is a far cry from the approximately $6,250 monthly Copaxone price without insurance. But, combined with the $2,700 he had already paid before his catastrophic coverage kicked in, the additional $2,950 he'll owe this year is no small amount. And that assumes he needs no other medications.
"I feel like I'm being punished financially for having a chronic disease," he says. He has considered discontinuing Copaxone to save money.
His drug bill is one reason Gervich has decided not to retire yet, he says, adding that an annual cap on his out-of-pocket costs "would definitely help."
Drugs like Copaxone that can modify the effects of the disease have been on a steep upward price trajectory in recent years, says Bari Talente, executive vice president for advocacy at the National Multiple Sclerosis Society. Drugs that five years ago cost $60,000 annually now cost $90,000, she says. With those totals, Medicare beneficiaries "are going to hit catastrophic coverage no matter what."
Specialty-tier drugs for multiple sclerosis, cancer and other conditions — defined by Medicare as those that cost more than $670 a month — account for more than 20 percent of total spending in Part D plans, up from about 6 percent before 2010, according to a report by the Medicare Payment Advisory Commission, a nonpartisan agency that advises Congress about the program.
Just over 1 million Medicare beneficiaries in Part D plans who did not receive low-income subsidies had drug costs that pushed them into catastrophic coverage in 2015 — more than twice the 2007 total — according to an analysis by the Kaiser Family Foundation.
"When the drug benefit was created, 5 percent probably didn't seem like that big a deal," says Juliette Cubanski, associate director of the Program on Medicare Policy at the Kaiser Family Foundation. "Now we have such expensive medications, and many of them are covered under Part D — where, before, many expensive drugs were cancer drugs" that were administered in doctors' offices and covered by other parts of Medicare.
The lack of a spending limit for the Medicare drug benefit sets it apart from other coverage. Under the Affordable Care Act, the maximum amount someone generally owes out-of-pocket for covered drugs and other medical care for this year is $7,900. Plans typically pay 100 percent of customers' costs after that.
The Medicare program doesn't have an out-of-pocket spending limit for Part A or Part B, which cover hospital and outpatient services, respectively. But beneficiaries can buy supplemental Medigap plans, some of which pay coinsurance amounts and set out-of-pocket spending limits. Medigap plans, however, don't cover Part D prescription plans.
Counterbalancing the administration's proposal to impose a spending cap on prescription drugs is another proposal that could increase many beneficiaries' out-of-pocket drug costs.
Currently, brand-name drugs that enrollees receive are discounted by 70 percent by manufacturers when Medicare beneficiaries have accumulated at least $3,820 in drug costs and until they reach $5,100 in out-of-pocket costs. Those discounts are applied toward beneficiaries' total out-of-pocket costs, moving them more quickly toward catastrophic coverage.
Under the administration's proposal, manufacturer discounts would no longer be treated this way. The administration says this would help steer patients toward less expensive generic medications.
Still, beneficiaries would have to pay more out-of-pocket to reach the catastrophic spending threshold. Thus, fewer people would likely reach the catastrophic coverage level at which they could benefit from a spending cap.
"Our concern is that some people will be paying more out-of-pocket to get to the $5,100 threshold and the drug cap," says Keysha Brooks-Coley, vice president of federal affairs at the American Cancer Society Cancer Action Network.
"It's kind of a mixed bag," says Cubanski of the proposed calculation change. "There will be savings for some individuals" who reach the catastrophic phase of coverage. "But for many, there will be higher costs."
For some people, especially cancer patients taking chemotherapy pills, the lack of a drug-spending cap in Part D coverage can seem especially unjust.
These cutting-edge, targeted oral chemotherapy and other drugs tend to be expensive, and Medicare beneficiaries often hit the catastrophic threshold quickly, says Brooks-Coley.
Patty Armstrong-Bolle, a Medicare patient who lives in Haslett, Mich., takes Ibrance, a pill, once a day to help keep in check the breast cancer that has spread to other parts of her body. While the medicine has helped send her cancer into remission, she may never be free of a financial obligation for the pricey drug.
Armstrong-Bolle paid $2,200 for the drug in January and February of last year. When she entered the catastrophic coverage portion of her Part D plan, the cost dropped to $584 per month. Armstrong-Bolle's husband died last year, and she used the money from his life insurance policy to cover her drug bills.
This year, a patient assistance program has covered the first few months of coinsurance. That money will run out next month, and she'll owe her $584 portion again.
If she were getting traditional drug infusions instead of taking an oral medication, her treatment would be covered under Part B of the program, and her coinsurance payments could be covered.
"It just doesn't seem fair," she says.
https://www.mainepublic.org/post/medicares-uncapped-drug-costs-take-big-bite-already-tight-budgets



 

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