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