Editor's Note -
Lot's of disturbing stuff in today's blog post. I suggest you scan the "headlines" and pick out anything that catches your eye.
- SPC
Defeating Trump Is Just a Start
by Jamelle Bouie - NYT - December 20, 2023
The easy and obvious way to understand the various Republican power grabs underway in states across the country is to look at them as attempts to secure as much unaccountable political power as possible and to curtail the expression of identities and beliefs Republicans find objectionable. That’s how we get the “Don’t Say Gay” laws and attacks on gender-affirming care and aggressive efforts to gerrymander entire state legislatures.
But there is another angle you can take on the Republicans’ use of state power to limit political representation for their opponents or limit the bodily autonomy of women or impose traditional and hierarchical gender relations on those who would prefer to live free of them. You could say the point is the cultivation of political despair.
Now, it is too much to say that this is premeditated, although you do not have to look hard to find Republican officeholders expressing the belief that political participation should be made more onerous.
At the same time, it is hard not to miss the degree to which attempts to nullify popular referendums or redistrict opponents into irrelevance can also work to inculcate a sense of hopelessness in those who might otherwise seek political change. Yes, it is true that many people will push back when faced with a sustained challenge to their right to participate in political life or exercise other fundamental rights. But many people will resign themselves to the new status quo, persuading themselves that nothing has fundamentally changed or concluding that it is not worth the time or effort involved to pick up the fight.
It does not help that many of our political institutions seem almost to be designed to exacerbate a feeling of hopelessness. The American political system, as I’ve written many times before, is riddled with veto points and counter-majoritarian rules that can stymie even the largest legislative majorities. One of the key institutions of American government, the Supreme Court, is not only empowered to strike down congressional legislation but also can, if the circumstances are right, limit or even eliminate the constitutional protection of cherished rights. And that’s when it’s not deciding the outcome of presidential elections.
But this isn’t just a problem of the Republican Party, our political institutions or the broader sense in which the entire system just isn’t responsive to the way ordinary people see things. It is also a problem of the lack of countervailing forces to political despair in present-day American society.
Democracy, remember, is not just a set of rules and institutions. It is, as the philosopher John Dewey argued throughout his life, a set of habits and dispositions that must be cultivated and practiced if they are to survive and endure. “The struggle for democracy,” Dewey observed in his 1939 book “Freedom and Culture,” “has to be maintained on as many fronts as culture has aspects: political, economic, international, educational, scientific and artistic, religious.”
We do not practice democracy alone, of course. We do it together, in community, as equals. “Democracy as a way of life,” wrote Dewey in a later essay, “is controlled by personal faith in personal day-by-day working together with others.”
Unfortunately, as the law professor Aziz Rana observes in a recent essay on political freedom in Boston Review, there are scarcely any spaces in the contemporary United States where ordinary Americans practice the habits of democracy and inhabit a more reciprocal, participatory and solidaristic vision of freedom. Decades after Ronald Reagan led a sweeping attack on the idea of the commons in American life, Rana writes, “there are vanishingly few sites in American life — at work or in politics — where these experiences actually exist.”
“We are simply not raised in cultural worlds in which collective agency is a meaningful reality,” Rana goes on to say.
Recent expressions of labor militancy have been heartening, but they have also come at the same time that conservative politicians, entrenched financial interests and neoliberal ideologues have targeted what’s left of our commons — and in particular, our public schools and universities — to be stripped for parts.
Democrats have already framed the coming presidential election as a battle for the future of American democracy, and for good reason. Donald Trump, who threatened not to accept the results in 2016 and actively tried to overturn them in 2020, will almost certainly be on the ballot. And he has no intention of honoring the democratic traditions of the United States. Instead, he has promised his supporters to be their “retribution” in the White House. He says he’ll be a “dictator,” on “Day 1” at least, and his allies are busy devising plans to radically empower the executive branch and punish the former president’s political enemies.
The American republic is genuinely at stake. But as Democrats and their allies gear up for that battle, they should understand that beating Trump is the beginning of the beginning. We need to fight political despair everywhere we find it, which means this country needs an overhaul of its economic system, its political institutions and its public life.
We need to recognize, as Dewey did, that it is wrong to think that “democratic conditions automatically maintain themselves” or that “they can be identified with fulfillment of prescriptions laid down in a constitution.” Beliefs of this sort, he continued,
merely divert attention from what is going on, just as the patter of the prestidigitator enables him to do things that are not noticed by those whom he is engaged in fooling. For what is actually going on may be the formation of conditions that are hostile to any kind of democratic liberties.
Defeating Trump is only the first step toward saving — and revitalizing — American democracy. It’ll be hard. The next steps may well be even harder.
https://www.nytimes.com/2023/12/15/opinion/trump-democracy-dewey.html
The Senate Is Getting Less Democratic by the Minute
by Jamelle Bouie - November 21, 2023
Democrats and the independents who caucus with them will be playing defense in 23 of the 34 Senate seats on the ballot in the 2024 congressional elections. Four of the 23 are in swing states that Joe Biden won narrowly in 2020. Three are in states that Donald Trump won in both 2016 and 2020.
If Democrats were to lose all seven of those, a catastrophic defeat, they would start the next session in Congress with a weak minority of senators — its fewest since the days of President Herbert Hoover — who would nonetheless represent nearly half the population of the United States.
Depending on where you stand in relation to partisan politics in this country, you may not find this disparity all that compelling. But consider the numbers when you take political affiliation out of the picture: Roughly half of Americans, some 169 million people, live in the nine most populous states. Together, those states get 18 of the 100 seats in the United States Senate.
To pass anything under simple majority rules, assuming support from the sitting vice president, those 18 senators would have to attract an additional 32 votes: the equivalent, in electoral terms, of a supermajority. On the flip side, it is possible to pass an item out of the Senate with a coalition of members who represent a small fraction of the total population — around 18 percent — but hold a majority of the seats. And this is before we get to the filibuster, which imposes a more explicit supermajority requirement on top of this implicit one.
Last week, The Washington Post published a detailed look at the vast disparities of power that mark the Senate, which was structured on the principle of equal state representation: Regardless of population, every state gets two members. A carry-over from the Articles of Confederation, the principle of equal state representation was so controversial that it nearly derailed the Philadelphia Convention, where James Madison and others were trying to build a national government with near total independence from the states.
It is not for nothing that in the Federalist Papers, neither Madison nor John Jay nor Alexander Hamilton attempts to defend the structure of the Senate from first principles. Instead, Madison wrote in Federalist No. 62, you should consider it a concession to the political realities of the moment:
A government founded on principles more consonant to the wishes of the larger states, is not likely to be obtained from the smaller states. The only option, then, for the former, lies between the proposed government and a government still more objectionable. Under this alternative, the advice of prudence must be to embrace the lesser evil; and, instead of indulging a fruitless anticipation of the possible mischiefs which may ensue, to contemplate rather the advantageous consequences which may qualify the sacrifice.
Today, the Senate is a distinctly undemocratic institution that has worked, over the past decade, to block policies favored by a large majority of Americans and even a solid majority of senators. And while there’s no immediate hope of changing it, a cleareyed analysis of the chamber’s structural faults can help answer one of the key questions of American democracy: Who, or what, is this system supposed to represent?
As the Post piece notes, equal state representation has never been equitable: “In 1790, Virginia, the most populous state, had roughly 13 times the population of Delaware, the least populous, with a difference of about 700,000 people.” But as the country has grown larger and more diverse, the disparities have grown greater and more perverse. The population difference between the states is so large now that a resident of the least populous state, Wyoming, as many observers have pointed out, has 68 times the representation in the Senate as does a resident of California, the largest state by population. In fact, a state gets less actual representation in the chamber the more it attracts new residents.
There is not just a disparity of representation; there is a disparity in who is represented as well. The most populous states — including not only California but also New York, Illinois, Florida and Texas — tend to be the most diverse states, with a large proportion of nonwhite residents. The smallest states by population — like Maine, Vermont and New Hampshire — tend to be the least diverse. And the structure of the Senate tends to amplify the power of residents in smaller states and weaken the power of those in larger states. When coupled with the potential for — and what is in truth the reality of — minority rule in the chamber, you have a system that gives an almost absolute veto on most federal legislation to a pretty narrow slice of white Americans.
One response to these disparities of power and influence is to say that they represent the intent of the framers. There are at least two problems with this view. The first is that the modern Senate reproduces some of the key problems — among them the possibility of a minority veto that grinds governance to a halt — that the framers were trying to overcome when they scrapped the Articles of Confederation. The second and more important problem is that the modern Senate isn’t the one the framers designed in 1787.
In 1913 the United States adopted the 17th Amendment to the Constitution, providing for the direct election of senators at the ballot box rather than their selection by state legislatures. This change disrupted the logic of the Senate. Before, each senator was a kind of ambassador from his state government. After the amendment went into effect, each senator was a direct representative of the people of that state.
If each member was a kind of ambassador, then you could justify unequal voting power by pointing to the equal sovereignty of each state under the Constitution. But if each member is a direct representative, then it becomes all the more difficult to say that some Americans deserve more representation than others on account of arbitrary state borders.
This brings us back to our question: Who, or what, is the American system supposed to represent? If it is supposed to represent the states — if the states are the primary unit of American democracy — then there’s nothing about the structure of the Senate to object to.
It’s plain as day that the states are not the primary unit of American democracy. As James Wilson of Pennsylvania observed during the Philadelphia Convention, the new national government was being formed for the sake of individuals rather than “the imaginary beings called states.” And as we’ve expanded the scope of democratic participation, we have affirmed — again and again — that it is the people who deserve representation on an equal basis, not the states.
There is no realistic way, at this moment, to make the Senate more democratic. But if we can identify the Senate as one of the key sources of an unacceptable democratic deficit, then we can look for other ways to enhance democracy in the American system.
I know that, given the scale and scope of the problem, that does not sound very inspiring. But we have to start somewhere.
https://www.nytimes.com/2023/11/21/opinion/senate-2024-inequality-madison.html
Opinion: Tax reform key to solving housing, health care crises
We have two systems of support in this country: welfare and tax breaks.
by - Portland Press Herald - December 14, 2023
We’re all part of a broken system that has spawned not only the current national houseless tragedy, but the long-standing drug addiction crisis. We need a new paradigm that recognizes the human potential that we’re losing as these issues fester. That new paradigm also has to include an honest appraisal of where we invest our money as a state and country. It will require that we reject the “scarcity mindset” that we’ve been trained to believe in.
If adequate mental health and/or addiction treatment options were readily available, some houseless problems probably could have been prevented. As a country, we spend twice as much on health care as any other developed nation. What exactly are we getting for all that money? Mental health is certainly one of the metrics where we fall devastatingly short. The Maine chapter of the American Medical Association recently released a policy statement calling for universal health care insurance coverage, acknowledging the deep inadequacy of a system that leaves thousands of Mainers without primary or specialist care or hospital care for serious illness without “taking on the risk of bankruptcy.”
Among the houseless people are the working poor who have been priced out of the housing market, in part because of our proclivity for building high-end condos and for creating a housing shortage by refusing even sensible development. According to an analysis by the Furman Center, there’s no evidence that multiple unit developments affect property values.
Maybe Gov. Healey of Massachusetts has the right idea in enforcing the MBTA Communities Act. The act required communities along the transit line to allow multi-family housing to be built in their communities. The governor warned communities that they must comply with the act or the state will withhold money “for any number of programs that you’re used to receiving money for,” such as schools and roads. The clear goal is to increase supply to bring down costs. Basic economics.
How can we possibly find the money to pay for housing and related costs to make up for the massive holes in our social safety net? We could start by closing the “tax gap” at the national level. That’s the difference between taxes owed and taxes collected. It currently amounts to around $600 billion annually and is projected to be $7 trillion in lost revenue over the next decade, according to an analysis by the U.S. Department of the Treasury. The IRS lacks the technology and manpower to correct this abomination.
Here’s what we do have money for though, according to Matthew Desmond, Princeton sociologist and Pulitzer Prize winning author of “Evicted” and author of the new book, “Poverty, By America,”: the mortgage interest deduction, even on second homes, with a $750,000 cap, often claimed for decades – a deduction that in 2020 cost the Treasury $193 billion, most of it going to people making six-figure incomes; 529 savings plans available to those with cash to set aside; and employer-sponsored health insurance, the cost of which is exempt from a corporation’s taxable income, thereby robbing the Treasury again of money to start stitching up that safety net. Then there’s government-subsidized retirement benefits. If you have money to invest, you avoid some taxes. Good for you! Bad for Treasury.
And the most egregious tax loophole of all: “carried interest,” a term coined, perhaps, because it’s just too embarrassing to admit these investment earnings are taxed at a lower rate than money earned through actual work.
And sure, you’ve worked hard for your money. But so have a lot of others who fall behind because of circumstances beyond their control. Both tax breaks and money devoted to the safety net boost household income. We have two systems of supports: one we call welfare and one we call tax breaks.
There is money enough to make sure every American has enough food, access to timely health care, with a focus on prevention, and a modest roof over his head. Those saying otherwise are either tragically misinformed or simply lying.
https://www.pressherald.com/2023/12/14/opinion-tax-reform-key-to-solving-housing-health-care-crises/
What Happened to My Health Insurance?
by Bryce Covert - NYT - December 20, 2023
Tamikka Burks was in an Arkansas emergency room when she found out she had lost her Medicaid coverage. In mid-September, she went in to deal with a cyst in her toe, and someone at the hospital informed her that the state’s Department of Human Services had cut off her coverage on Sept. 1. She felt, she said, “just exhausted. Scared.”
A few days later, it got worse. Ms. Burks discovered she was pregnant, a pregnancy that was considered high risk because she has high blood pressure. She takes two medications to keep her condition under control that can endanger a pregnancy further. Her doctor told her to switch to a different medication while she was pregnant, but without insurance it would cost about $45, instead of the $5 maximum copay she had spent under Medicaid. Ms. Burks, a 35-year-old single mother of two, doesn’t have anyone she could borrow that kind of money from, and “I literally have $50 from now until Friday,” she told me on a Tuesday.
She started taking just one of the two medications she was on, in the hope that it would be less dangerous, but she became too afraid of what it might do to her or the baby. In late September, she drove 10 hours round trip to Kansas to get an abortion.
“I don’t believe in abortion, so it doesn’t sit right with me at all,” she told me. She wanted three children and was excited for a new baby. But she was terrified of the health implications, afraid that if she kept her baby they would both die in the second or third trimester. “That would be just my luck,” she said.
Ms. Burks hadn’t even heard of the Medicaid unwinding until she was caught up in it. But she’s among nearly 427,500 people in Arkansas, and at least 12 and a half million people nationwide, who have been disenrolled from Medicaid since April, when states had to start verifying everyone’s eligibility again after the pandemic health emergency officially ended. The Biden administration has given states 12 months to go through the unwinding process, but Republican lawmakers in Arkansas decided to get it done in six months — the shortest timeline announced by any state — to reduce, in Gov. Sarah Huckabee Sanders’s words, “government dependency.”
Some states have tried to move more slowly and carefully to find ways to keep people enrolled. But “there are some states,” Joan Alker, the executive director of Georgetown University’s Center for Children and Families, said, “where the politics are just about kicking people off quickly.”
One of the first things Congress did in reaction to the Covid-19 pandemic was to require states to keep people enrolled in Medicaid no matter what. At the time, it was seen as the right way to react to an all-engulfing public health emergency. But the multiyear pandemic proved that even absent an emergency, Americans can be kept on Medicaid for long periods of time without having to constantly prove their eligibility.
And keeping people enrolled reaps huge benefits. After enrollment in Medicaid and the Children’s Health Insurance Program fell in the years leading up to the pandemic, the trend reversed and more than 21 million people were added during the crisis. This ensured that people had health insurance while reducing churn. Churn — when recipients cycle in and out of the program because of administrative hassles — costs as much as $773 per person in today’s dollars. This represents “a significant share of Medicaid expenses,” according to one study.
There’s the fiscal savings, and then there’s what it means for people to have health coverage they can rely on. Jamila Michener, an associate professor of government at Cornell, and a colleague interviewed Medicaid recipients in 2021 in Kentucky, North Carolina and Pennsylvania. “The main thing we get from people is just relief — they’re relieved that they have Medicaid and it seems like they might not lose it for a while,” Dr. Michener said. Many were in tears. “This is just such an important part of your ability to survive.” People took full advantage of the coverage; they told her that they had finally scheduled a much-needed surgery, sought out mental health care or picked up medications they had been waiting on.
Not having to deal with the hassle of regularly recertifying their eligibility also “opens up a whole world of possibilities” for people to pursue, Dr. Michener said. No longer did a slight increase in income risk their benefits. That meant they could take new jobs or accept raises they would have otherwise avoided in order to keep coverage.
Ms. Burks has been on Medicaid on and off since her son was born 18 years ago. Before the pandemic, she had to regularly fill out paperwork and send in documentation proving she was still eligible. “It’s always a hassle,” she said. But during the public health emergency, when that process was suspended, she received a letter every month saying she still had coverage without having to do anything. It was “just a little piece of heaven,” she said.
But at the end of 2022, Congress struck a deal to end the requirement that states keep people enrolled. By August, Arkansas had already disenrolled more people than the total increase in enrollment it saw during the pandemic. Nationally, as many as 15 million people could eventually lose their Medicaid or CHIP coverage. Refusing to learn the lesson that keeping people enrolled in health insurance helps them take care of themselves while generating fiscal savings, we’ve reverted to a fragmented health care system that denies too many people care.
The consequences have been immediate and devastating.
Charles and Phyllis Wells were also affected by Arkansas’s effort to thin its Medicaid ranks as quickly as possible. Mr. Wells, who is 70 and has physical limitations that require him to use a walker or a wheelchair, has been caring for Phyllis, his sister, who is nonverbal, for the last eight years.
“Before my mom died she made me promise to do everything possible to keep her out of a nursing home,” he said of his sister. Fulfilling that promise requires the help of health aides. Medicaid covers someone coming to their house five days a week, eight hours a day, to give Ms. Wells a shower, ensure she’s clean after using the bathroom, cook for the two of them and do tasks like laundry that are challenging for Mr. Wells. These aides take Ms. Wells to doctor appointments and care for her when Mr. Wells goes to the doctor himself. On weekends, when the aides don’t come, Ms. Wells doesn’t get a shower.
In December of last year, before the unwinding process had begun, one of their aides got a call from her office while she was at the Wells’s house, saying that Ms. Wells’s coverage had been cut off and that the aide was not to bathe or care for Ms. Wells that day — if she did, the company might be forced to drop the family as clients. They lost Ms. Wells’s care for nearly a month; Mr. Wells had to miss doctor appointments for his heart and kidneys, including his monthly catheter replacement, because he didn’t have anyone to stay with Ms. Wells. It was so difficult to schedule new appointments that after a few months he had to go to an E.R. to get a new catheter. He was later told that Ms. Wells’s coverage loss was a mistake.
But then it happened again in late June, after the unwinding process was underway. Once again, their aide got a call telling her she could no longer care for Ms. Wells, “just out of the clear blue sky,” Mr. Wells said. “I mean, I got upset.” So much so that he started having chest pains and difficulty breathing. Afraid he was having a heart attack, he ended up in an E.R. overnight, although it was more likely an anxiety attack. His sister went without coverage for a little over two weeks. The Arkansas Department of Human Services told him the coverage loss this time was the result of a computer glitch.
Both times Mr. Wells and the aide tried to reinstate the coverage on their own, but it took reaching out to a Legal Aid lawyer who had direct channels to state officials to get it fixed, an inefficient process that isn’t available to most people. Mr. Wells now worries that Ms. Wells’s coverage could once again get cut off at any time. “It’s happened twice in less than a year, so yeah,” he said.
He also knows their story is not unique. “There are more people out there just like Phyllis. They need this,” he said. State officials “don’t understand — maybe they don’t care — that they are actually hurting people, they’re impacting people’s lives.”
Outrageously, most of the Medicaid losses we’ve seen since the unwinding began are not necessarily because people are ineligible but because they’re getting tripped up by how complicated it is to stay enrolled. First, they need to know that they have to recertify to keep their coverage, even though they haven’t had to do that for the past three years, and to compound the problem, many letters from state governments about the new requirement go to the wrong addresses. Then they have to understand the letters they receive, many of which are overly complex, and then they must gather the right documents and fill out the right forms. If they need any help or have any questions, call-center lines are often jammed. More than three-quarters of Arkansans who were kicked off Medicaid lost coverage because they didn’t make it through that process, not because they were found to be ineligible, a rate that is just higher than the 71 percent rate for all states that have reported data.
Getting back on Medicaid after being culled in the unwinding means wading through a sea of red tape. Sholonda Woods and her 16-year-old daughter were cut off in February. Ms. Woods has always been on top of sending in paperwork to stay eligible, so when she got a letter saying they had lost their Medicaid coverage, she had to “take my anger out on the wall and just cry,” she said. “I was heated.”
Ms. Woods moved to Arkansas from Missouri three and a half years ago. To get back on Medicaid, Arkansas required her to get a letter from Missouri noting that her Medicaid case there was closed, which took months — getting through to Missouri’s Department of Social Services required staying on the phone for two or three hours, she said.
After that, Arkansas made her get her former employer at a Days Inn, where she worked for just a month in September, to sign a form saying that she no longer worked there. Ms. Woods doesn’t own a car, so she had to take the bus a half-hour to the Days Inn, only to have her former boss refuse to sign.
It wasn’t until Ms. Woods spoke to a government official at a protest with the nonprofit Arkansas Community Organizations that she was able to get her coverage restored, in April. But her daughter’s case didn’t get fixed until August. For months, Ms. Woods was unable to get her daughter’s asthma inhaler or A.D.H.D. medication. “I was hurt. I was mad,” she said.
Many other parents have gone through what Ms. Woods has gone through. Among the 38 states that have reported data, more than three million children have lost Medicaid or CHIP coverage. One driver of the big losses is technical: States are required to use data they already have — from, say, a family’s food stamps application or wage information — to determine whether people are eligible. But as part of that process, 30 states and Washington, D.C., have examined eligibility only for the head of the household and then cut the entire family off, even though children are far more likely to be eligible than their parents. Those parents are then forced to fix the problem.
And if anything goes wrong when they try, there’s little help available to them. In May, one study showed, the average wait time to reach someone on the phone in 10 states was 20 minutes or longer, and in nine states a quarter or more of callers hung up without getting through to a person. According to the nonprofit UnidosUS, the average wait for Spanish-speaking callers in Florida is nearly two and a half hours. “Folks don’t have that time,” Ms. Alker pointed out. “They’re working in jobs where they can’t get a break, they’re not allowed to take phone calls, they get 30 minutes for lunch.”
Reverting to the norm after the pandemic experience doesn’t just mean people will go without care, although that’s terrible enough; it could harm our democracy. “One of the things people say to us again and again is: If they could help us all along, why haven’t they been doing it?” Dr. Michener said. She co-wrote a study that found voter turnout decreased when Medicaid recipients lost their coverage. “I don’t know that there’s as striking a message as people received in the past years: It is in our power to help you, but we choose when to and how to and you have very little control over that,” she said.
There are some immediate steps that could lessen the devastation of the unwinding. The Biden administration has given states flexibility to make the process go more smoothly, like the ability to pause the unwinding. So far, only Kentucky and North Carolina have taken up the option, and only for children. In December, the Biden administration told states that if they didn’t comply with federal policies, they would be docked funding and also warned states with particularly high disenrollment numbers. But it didn’t take any enforcement action. The administration has begun to bark; now it needs to bite. At some point, it must start cracking down on states that are recklessly pushing so many people off the rolls. “Optional’s no good anymore,” Ms. Alker said. One power the administration has is to require states to pause the process, which has happened for some found to be improperly kicking children off Medicaid based on their parents’ data.
The Biden administration also has the power of the purse; it can create a corrective plan, and if a state doesn’t comply with the plan, the federal government can pull the extra funding states are currently receiving. The government can also order a state to reinstate people who have “been erroneously terminated,” Ms. Alker said.
But while such measures can offer some relief, it doesn’t change the country’s reversion to a status quo where health care is not a given and keeping it requires navigating a labyrinth. Ultimately, the United States needs universal health care akin to what every other developed country has already committed to. At the very least, we can learn the lessons from the pandemic: Getting more people on Medicaid — and making it easy for them to stay on — benefits us all.
Ms. Burks tried to figure out what happened to her Medicaid coverage. “Getting through to D.H.S. is like pulling teeth,” she said. She never reached anyone; she always waited at least an hour on hold, and the line sometimes disconnected. Going to a physical office requires “gas and time that I just didn’t have,” she said. Ms. Burks never received any mail from the state about losing Medicaid, she told me, and still hadn’t by the time she ended her pregnancy. She eventually got a call telling her that she had been removed because her income was too high thanks to her job at a nonprofit.
Now her only option to get health insurance is to enroll in an Affordable Care Act marketplace plan. She doesn’t plan to enroll anytime soon because of the cost, though. Instead, she’s working on weaning herself off the medication she takes to address past addiction, medication that allows her to be a present parent and a “productive member of society,” as she put it, but which costs $400 a month without insurance. She’s been sober for six years, but “I’m going to risk my sobriety and get off it because that’s $400 a month that I need,” she said.
Ultimately, she feels like she’s being penalized for working and earning an income. She could quit her job and get back on Medicaid. “But,” she said, “that’s not who I am.”
https://www.nytimes.com/2023/12/20/opinion/health-insurance-medicaid.html
U.S. health care spending hits $4.5 trillion in 2022
Physician and clinical services made up about 20% of $4.5 trillion spent on health care in 2022, according to the U.S. Centers for Medicare & Medicaid Services (CMS).
Medical spending grew by 4.1% last year, faster than the 2021 growth of 3.2%, but less than the 2020 spending growth of 10.6% due to the COVID-19 pandemic. The figures were part of the National Health Expenditures 2022 report issued by CMS.
The report said spending on physician and clinical services increased 2.7% to $8.84 billion, though that was slower than the increase of 5.3% in 2021, according to CMS. Medicare, Medicaid, private health insurance, and out-of-pocket expenditures all were part of the slower growth in 2022.
Hospital services
Hospital care hit $1.4 trillion, accounting for 30% of all health care spending. The 2022 growth rate of 2.2% was lower than the 4.5% rise in 2021, according to CMS.
“The slower growth in 2022 reflected a slowdown in spending for hospital care by private health insurance, Medicare, and Medicaid and by a decline in other private revenues,” the CMS report said. “Slower growth in hospital prices and a decline in hospital days and discharges contributed to the lower growth in 2022.”
Prescription drugs
Retail prescription drug spending accounted for 9% of all health care spending, rising by 8.4% to $405.9 billion in 2022. That increase was more than the 6.8% growth in 2021, with more Medicare and out-of-pocket spending for prescription drugs, but slower growth in Medicaid and private health insurance.
“The faster growth in 2022 was influenced by faster growth in the number of prescriptions dispensed and an increase in retail prescription drug prices (1.2% in 2022) after four consecutive years of decline,” the report said.
Health insurance
Health insurance rates hit a record high in 2022, with 92% of the population covered. There were 26.6 million people uninsured, down from 28.5 million the year before. Private health insurance enrollment grew by 2.9 million people and Medicaid enrollment rose by 6.1 million last year.
Funding sources
Private health insurance covered $1.3 trillion, or 29%, of health care spending. That amount grew by 5.9% last year, down from 6.3% growth in 2021. Growth was slower for private health insurance coverage of costs for hospital care, physician and clinical services, and dental services, the report said.
Medicare spending made up 21% of all health care expenditures, increasing 5.9% to hi $944.3 billion in 2022. That growth rate was down from a 7.2% increase in 2021.
Fee-for-service spending dipped 1.9% last year, while Medicare private plan spending grew by 15.1% and accounted for half of all Medicare spending. Enrollment in private plans rose by 8.5% and fee-for-service enrollment dropped by 3%. Total Medicare enrollment rose by 1.2 million people, or 1.9%, up from growth of 1.7% in 2021.
Medicaid spending accounted for 18% of all health care spending, growing 9.6% to reach $805.7 billion in 2022. It was the third consecutive year of growth above 9%. Enrollment grew by 7.2%, down from 11.1% growth in 2021 but more than 4.6% growth in 2020.
“This amounts to about 18 million individuals gaining Medicaid coverage between 2019 and 2022,” the report said. “Faster Medicaid enrollment growth since 2019 reflects the newly enrolled as well as the continuous enrollment requirement of the Families First Coronavirus Response Act that took effect on March 18, 2020 and ended on March 31, 2023.”
Health care in the GDP
Health care spending in 2022 decreased as a proportion of the U.S. gross domestic product (GDP). It was 17.3% of the 2022 national GDP, lower than the 18.2% share in 2021 and the record 19.5% in 2020. GDP grew at strong rates, 10.7% in 2021 and 9.1% in 2022, and the health care spending share for 2022 was slightly less than the recent average share of 17.5% from 2016 to 2019.
https://www.medicaleconomics.com/view/u-s-health-care-spending-hits-4-5-trillion-in-2022
The following link is to a NYT video opinion piece about the state of the UK's National Health Service, and a cautionary story about its future, with important lessons for the US healthcare system..
https://www.nytimes.com/2023/12/07/opinion/nhs-britain-universal-health-care.html
‘Don’t get sick. It’s too expensive’: medical debt is putting more Americans in financial crisis
by Jessica Glenza - The Guardian - December 11, 2023
In a few short months, 37-year-old Kimberly Cooley went from sprinting up stairs to faltering after several steps. Unbeknownst to her, she was experiencing a cascade of symptoms related to autoimmune hepatitis, a rare and chronic inflammation of the liver.
She was diagnosed, shot to the top of the liver transplant list, and quickly realized she could not handle the financial repercussions of such a surgery alone. A private person by nature, Cooley took the extraordinary step of publicizing her condition – a step she understood well as a marketing consultant.
In a matter of days, her loved ones raised more than $17,000 for her liver transplant surgery.
“I did have the support of friends and family,” said Cooley, 42, who lives in rural Duck Hill, Mississippi. “So it wasn’t as bad as it could have been.” Cooley is doing well. But her finances are another story.
She is more than $4,000 in debt to AccessOne, a private-equity backed medical credit card company. As transplant patients need ongoing medication and care, she expects that debt to roughly double next year.
“I start referring to it as ‘transplant life’,” said Cooley. “Things are going to pop up, and that’s just part of it.”
As a new year and presidential election approach, Americans face a worsening crisis: the affordability of healthcare. More Americans than ever, about 92%, now have health insurance – and simultaneously face enormous bills.
Over the last decade, insurers and employers have pushed more cost-sharing onto individuals and families. Now, squeezed by medical costs and inflation, more than 100 million Americans have medical debt and roughly the same proportion report avoiding a prescription because of it.
Sara Collins, a health policy scholar and vice-president at the Commonwealth Fund, said “those are the trends we’ve seen”, referring to “growth in healthcare costs, household incomes that haven’t kept pace with those costs, and employers’ use of increased cost-sharing”.
Cooley’s story represents the intersecting issues that plague the health system, as high prices and a push to offload those costs to patients collide.
For ‘Obamacare’ plans, deductibles can range up to $9,050 per year. Photograph: Stock4B Creative/Getty Images
“Those trends are all still there, they haven’t changed, and unless they’re addressed”, problems will continue, added Collins.
The Biden administration has sought to make these struggles a centerpiece of the upcoming campaign. His administration has taken aim at medical credit card companies, like AccessOne; instructed Medicare to negotiate prescription drug prices for the first time; and is writing rules to stop medical debt from appearing on credit reports.
Biden’s administration also continued the rollout of the No Surprises Act, originally signed by Donald Trump, which bans doctors and hospitals from sticking consumers with a “balance bill” when they can’t agree with insurers on a fair price.
Trump, the leading Republican presidential candidate, also has an extensive record on healthcare. He led a failed repeal of the Affordable Care Act (ACA), better known as Obamacare, which would likely have left tens of millions of Americans uninsured and effectively worsened healthcare rationing by income. He infamously tilted the balance of the supreme court to the right, which led to the reversal of a constitutional right to an abortion and the severe abortion restrictions across a large swath of conservative southern states.
Now, campaigning for a second term, Trump has said “Obamacare sucks”, and vowed to try to “replace” it. He’s offered no details of such a policy.
Neither candidate has squarely tackled the biggest issue in American healthcare: its cost.
The US health system sucks up a whopping 16% of gross domestic product (GDP). That’s more – by a long shot – than any other wealthy, developed nation. France and Germany are the next closest, according to the Organisation for Economic Co-operation and Development (OECD), which each spend around 12% of GDP on healthcare.
Over roughly the last decade, insurers and employers have sought to push more of those growing costs onto patients, which has in turn revealed the unfinished work of Obamacare.
The focus of the ACA was to get more people insured, and was very effective at doing so through both Medicaid and markets for individuals to buy health insurance, which is where Cooley got her health plan.
It did not focus on employer-based health coverage, since those were generally comprehensive and heavily subsidized by tax breaks to companies. Since the ACA, as health insurers have been required to provide more comprehensive coverage, they have also pushed costs onto the insured.
More than half of Americans (51%) now have trouble handling out-of-pocket insurance expenses, according to a survey by the Commonwealth Foundation. High-deductible health plans offer a flagrant example of why.
Laurie, a 62-year-old resident of the Atlanta, Georgia, metro area, is required to spend $7,450 each year before her insurance kicks in. As a result, she buys her ulcerative colitis medications from Canada at roughly a 90% discount from the American price – which is typically around $1,800 for a 90-day supply.
“The insurance companies are now sticking it to everyone with the maximum out-of-pocket and deductibles,” said Laurie, who asked that her last name not be used because she worried about the legality of buying drugs internationally. “By the way, I pay $120 a month for the privilege of having this plan.”
In another case, a mother of six in Ohio said she faced a $6,000 deductible for an employer plan that “barely pays anything”. She now avoids taking her children to the doctor for small colds, because she has to pay a $95 co-pay for each doctor’s visit.
“We feel as if we are being forced to carry this insurance for fear that one of us may have an accident or illness and have no insurance to cover it at all,” she said, adding her husband’s pay as a welder would be much more “sufficient” if insurance costs weren’t so high.
A slew of studies show how high-deductible plans can make a family’s life precarious. One study found that such plans “substantially and problematically” reduce how often low-income diabetics seek care. Another found that children enrolled in their parents’ high-deductible plans scored worse on seven out of 10 health metrics. A third found that people with high-deductible health plans are more likely to be in medical debt, and subsequently have difficulty affording food and housing.
Still, a shockingly high number of health plans, especially on marketplaces, include these provisions. For “Obamacare” plans, like Laurie’s, deductibles can range up to $9,050 per year.
The chronically ill also face special challenges. Cooley has no deductible, and out-of-pocket expenses are capped at $3,150 per year. A healthy person might never hit that limit. But Cooley will reach it every year.
What’s more, Laurie points out, she still faces dental bills, for which health insurance is useless.
“That insurance doesn’t cover your hearing, your teeth, your eyes,” said Laurie, who said a dentist told her that replacing a single problematic crown would cost her $5,000. “I’m like, those aren’t part of my body?”
Hundreds of millions of American adults will likely nod in agreement with a conclusion Laurie reached : “Don’t get sick. It’s too expensive.”
https://www.blogger.com/blog/post/edit/3936036848977011940/8659172798602818168
Behind the Shortage Keeping Cancer Patients From Chemo
Stephanie Scanlan learned about the shortages of basic chemotherapy drugs this spring in the most frightening way. Two of the three drugs typically used to treat her rare bone cancer were too scarce. She would have to go forward without them.
Ms. Scanlan, 56, the manager of a busy state office in Tallahassee, Fla., had sought the drugs for months as the cancer spread from her wrist to her rib to her spine. By summer it was clear that her left wrist and hand would need to be amputated.
“I’m scared to death,” she said as she faced the surgery. “This is America. Why are we having to choose who we save?”
The disruption this year in supplies of key chemotherapy drugs has realized the worst fears of patients — and of the broader health system — because some people with aggressive cancers have been unable to get the treatment they need.
Those medications and hundreds of other generic drugs, including amoxicillin to treat infections and fentanyl to quell pain during surgery, remain in short supply. But the deepening crisis has not fostered solutions to improve the delivery of generic drugs, which make up 90 percent of prescriptions in the United States.
Dr. Robert Califf, commissioner of the Food and Drug Administration, has outlined changes the agency could make to improve the situation. But he said the root of the problem “is due to economic factors that we don’t control.”
“They’re beyond the remit of the F.D.A.,” he said.
Senator Ron Wyden, a Democrat of Oregon and chairman of the Senate Finance Committee, agreed. “A substantial portion of these market failures are driven by the consolidation of generic drug purchasing among a small group of very powerful health care middlemen,” he said at a hearing this month.
In interviews, more than a dozen current and former executives affiliated with the generic drug industry described many risks that discourage a company from increasing production that might ease the shortages.
They said prices were pushed so low that making lifesaving medicines could result in bankruptcy. It’s a system in which more than 200 generic drugmakers compete, at times fiercely, for contracts with three middleman companies that guard the door to a vast number of customers.
In some cases, generic drugmakers offer rock-bottom prices to edge out rivals for coveted deals. In other instances, the intermediaries — called group-purchasing organizations — demand lower prices days after signing a contract with a drugmaker.
The downward pressure on prices — no doubt often a boon to the pocketbooks of patients and taxpayers — is intense. The group purchasers compete against one another to offer hospitals the lowest-priced products, which intermediary companies say also benefits consumers. They earn fees from drugmakers based on the amount of medications the hospitals buy.
“The business model is broken,” said George Zorich, a pharmacist and retired generic drug industry executive. “It’s great for G.P.O.s. Not great for drug manufacturers, not great for patients in some cases.”
Ms. Scanlan’s cancer was deemed curable for about 65 percent of patients after cisplatin was added to the cocktail. But during her treatment, Ms. Scanlan got only one dose of a sister drug, carboplatin.
Many doctors wish they could do more to give cancer patients the medicines they need.
“Every clinician I know would be thrilled to pay more money for a reliable supply of a quality drug,” said Dr. Andrew Shuman, a University of Michigan oncology surgeon and expert on drug shortages.
In a speech to drug supply intermediaries last month, Dr. Califf exhorted them to “pay more," saying it would enhance access to medical products and would be “good for business.”
Prices fell in recent years for two of the three drugs that Ms. Scanlan was initially offered to treat her cancer. During those years, Intas Pharmaceuticals, a generics giant in India, steadily gained market share as other companies left, according to data from the U.S. Pharmacopeia, a nonprofit that tracks drug shortages.
But the company had to halt U.S. production to deal with quality issues that the F.D.A. cited after a surprise inspection of one of its sprawling plants in India. Inspectors had discovered quality-control staff workers shredding and throwing acid on key records. The manufacturing shutdown set off a supply shock in February that would be felt nationwide.
Nearly every major U.S. cancer center reported in surveys that they faced chemotherapy shortfalls last spring and summer. One survey released in August found that nearly 60 percent of more than 1,000 pharmacy respondents deemed chemotherapy drug shortages “critically impactful.”
Intas recently resumed production, but the F.D.A. still lists the drugs as being in short supply. Major cancer centers report that the shortages are easing, though concerns persist about stock in rural areas.
The scarce drugs are cheap and essential and revolutionized their field decades ago, for the first time curing some patients with testicular, lung, ovarian, pancreatic and breast cancers, oncologists say.
Ms. Scanlan’s cancer, called osteosarcoma, was deemed curable for about 65 percent of patients after cisplatin was added to the cocktail regimen in the 1970s.
Ms. Scanlan’s medical records outline her care. For treatment in the spring and summer, she received only one infusion in March of a sister drug, carboplatin, at University of Florida Shands Hospital in Gainesville.
As months passed, Ms. Scanlan’s cancer spread deeper into her bones. She was referred to Tallahassee Memorial Hospital, which, because of the shortages, treated her with one chemotherapy drug. The center then referred Ms. Scanlan to the Mayo Clinic site in Jacksonville in April, according to her medical records.
Yet even at the gleaming Florida outpost of the elite medical system, Ms. Scanlan could not get her chemo treatments.
By May, she was facing surgery, but might have been eligible to have her wrist repaired rather than amputated. Notes in her records by her Mayo oncology surgeon, Dr. Courtney Sherman, said it would depend on how Ms. Scanlan responded to treatment, though “she is not receiving standard chemotherapy given shortages.”
In May and June, both Ms. Scanlan and Dr. Sherman pressed Dr. Steven Attia, a Mayo oncologist, to order the infusions. Ms. Scanlan emailed Dr. Attia: “One question, does Mayo not have the chemo that I actually need?”
Dr. Attia declined requests for comment. Samiha Khanna, a Mayo spokeswoman, denied that its site in Jacksonville experienced a cancer drug shortage and confirmed that Mayo did not administer chemotherapy to Ms. Scanlan. Ms. Khanna also referred questions back to Tallahassee Memorial.
A market transformed
Over the course of his career in the generic drug field, Jeff Herzfeld, a pharmacist and former generics executive who works as a consultant, watched it morph from a field with modest profits to one that is cutthroat.
At first it seemed no one was going to make high profits in the generic industry. As drug patents expired, companies entered the market and won customers by offering low prices.
But the field of customers began to shrink about 15 years ago. Intermediary companies realized that they could organize hospitals to wield their mass-buying power to get even lower prices.
Those intermediaries, or G.P.O.s, charged fees to drugmakers that could access a vast swath of customers. The G.P.O.s competed with one another for hospital clients — enticing them with the lowest prices.
The competition stiffened as generic drugmakers vied for each huge deal, emerging victorious if they came in with the lowest price. “They had a winner-take-all approach,” Dr. Herzfeld said.
Big deals also came with tough contract terms. One allowed the G.P.O.s to return to the generic drugmaker days after a deal with an ultimatum: Lower the price more or lose the contract. It could happen repeatedly. “You don’t have a lot of room for error,” Dr. Herzfeld said.
Generic drug executives said common contract terms deterred them from helping out in a shortage. If they fail to supply promised medications, they can face hefty fines. Yet if they produce more drugs than hospitals buy, they are left with a hole in their balance sheet.
These routine contract clauses “really penalize or punish” generic drugmakers, said David Gaugh of the Association for Accessible Medicines, which represents the generics industry.
Todd Ebert, president of the Healthcare Supply Chain Association, which represents G.P.O.s, disputed those views, arguing that some generic drugmakers offered very low “predatory” prices to force competitors out of the business.
Without knowing the cost of producing the drugs, companies cannot be certain if a price is a bargain — or a tactic to hobble the competition, he said. Vizient, a major group purchaser, referred comment to Mr. Ebert.
Jessica Daley, a supply chain vice president with Premier, a leading drug-purchasing company, said the company strove to foster healthy markets and wanted “reasonable prices that support supply resiliency and protect patient care.”
Aside from the group purchasers’ terms, generic drugmakers also point to other costs they face, including long lists of fees they pay companies that ship drugs from drug factories to hospitals.
The current drug shortages have exposed the pressures on the generic market, and the scarcity of cancer treatments has put the spotlight on the troubled growth of Intas Pharmaceuticals in India. It produced two chemo therapies that Ms. Scanlan was to receive early on.
Its market share for one of the drugs, methotrexate, which is also used in pediatric cancers and rheumatoid arthritis, grew to 35 percent last year from about 7 percent in 2018, according to the U.S. Pharmacopeia. The data shows the price per dose also fell, to $20 in 2022 from about $25 in 2018.
Prices also fell during those years for carboplatin and cisplatin, which tumbled to $15 a dose. Intas’ market share grew, particularly for cisplatin, to 62 percent of the U.S. supply in 2022 from 24 percent in 2018.
Not ‘a first-world nation’
Dr. Julie Gralow, chief medical officer of the American Society of Clinical Oncology, discovered signs of stockpiling in some health systems as early as February when the F.D.A. first announced the shortage, while shelves were empty at other health centers.
“We’re calling it a maldistribution based on who has access — who can afford to create a little stockpile at their site,” Dr. Gralow said.
By May her group and others relied on established tenets of bioethics to help cancer centers decide which patients should get scarce treatments, favoring patients with a shot at a cure over those staving off death. Dr. Gralow said researchers were beginning to study whether the chemo shortages are affecting patient survival. Results could take years.
The emotional impact has varied widely. Some people with cancer were too focused on paying rent or feeding a family to fight for the medications they desperately needed, said Danielle Saff, a social worker with CancerCare, a nonprofit that supports patients.
Others, like Lucia Buttaro, 60, a professor at Fordham University, were furious. She did not get her prescribed carboplatin for a reoccurrence of ovarian cancer in May or June, even though cancer was spreading in her lungs.
“In my opinion, we don’t qualify as a first-world nation if you can’t get what you need,” she said.
In the case of Ms. Scanlan in Florida, because her cancer was rare, invasive and advanced rapidly, it remains unclear whether the shortages played a role.
Still, cancer experts expressed concerns that she had not received standard chemotherapy cocktail regimens before her amputation in September.
Failure to use the three “modern miracle” generic chemotherapies for osteosarcoma patients “is a real problem,” said Dr. Lee Cranmer, a sarcoma expert at Fred Hutch Cancer Center in Seattle, who was not involved in Ms. Scanlan’s treatment.
She has since received radiation. Last month, she learned the cancer already in her rib and spine had not spread further. Although her new care team at Moffitt Cancer Center in Tampa recently recommended palliative care, she said she felt defeated and terrified.
The shortages took a toll, she said, adding: “I can’t help but think about what if something different happened from the beginning.”
https://www.nytimes.com/2023/12/19/health/cancer-drug-shortage.html
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