President Trump reportedly floated the idea of expanding Medicare to cover everyone and initially appeared disinterested in repealing ObamaCare, according to a bombshell book about his first year in office. 

Michael Wolff writes in “Fire and Fury: Inside the Trump White House” that the president “probably preferred the notion of more people having health insurance than fewer people having it.”  “He was even, when push came to shove, rather more for ObamaCare than for repealing ObamaCare,” Wolff writes in his book, which was released midnight Thursday and has been attacked and dismissed as “fake news” by the White House.

Wolff wrote that Trump was disinterested in the details of the GOP’s repeal-and-replace legislation and went along with the plan so he could move on to other issues.  Trump frequently lamented in public that he wished he started with tax reform before ObamaCare repeal and often expressed his impatience with repeal efforts, which took up nearly a year before Republicans threw in the towel after a failed Senate vote.

“I want to get to taxes,” Trump said in a speech in March in Nashville.  “I want to cut the hell out of taxes. But before I can do that — I would have loved to put it first, to be honest — there is one more very important thing that we have to do, and we are going to repeal and replace horrible, disastrous ObamaCare.”

Trump also faced widespread mockery in February when he noted how difficult health-care reform was.  “It’s an unbelievably complex subject. Nobody knew health care could be so complicated,” he said.

Trump also asked aides about “Medicare for all,” Wolff said in the book, one of Sen. Bernie Sanders’s (I-Vt.) key issues in his 2016 presidential campaign. “Why can’t Medicare simply cover everybody?” Trump reportedly asked.

Trump criticized Sanders’s Medicare-for-all bill when it was introduced in September, calling it a “curse on the U.S.”  But Trump has previously made positive comments about single-payer. Trump said earlier this year that Australia, which has a single-payer system, “has better health care than we do.”

Trump also advocated for single-payer in his 2000 book “The America We Deserve,” writing, “We must have universal healthcare.”

Revelations from Wolff’s book have consumed Washington’s first week of the new year, with questions about it dominating White House press briefings on Wednesday and Thursday. Trump ripped the “phony book” on Twitter both Thursday and Friday, saying it was “full of lies.”

The GOP doesn’t have much time to repeal and replace the Affordable Care Act but the reaction to the removal of the Individual Mandate is already being felt, at least locally. Evidently, as reported by my former nurse who works for Care First is the “The Blues” have lost a lot of money and this week as the employees of Care First came into work and were told not to sit down… The outcome over a hundred employees were fired/let go with 6 months of severance pay.

They have lost a great deal of money taking on the riskiest patients and realizing that without the Individual Mandate with the enforced premiums would decrease revenues to cover Obamacare covered clients now and in the future.

Republicans start the year divided over whether to tear down or prop up Obamacare, a split that could derail their legislative agenda leading up to the 2018 midterm elections.

GOP leaders on Capitol Hill don’t want a repeat of last year’s Obamacare fumble: They spent precious time on a failed attempt to repeal the health care law every member of the GOP was presumed to hate.

But they also don’t want to take repeal off the table, which would provoke conservatives who are still determined to undo Obamacare.

The reality is the GOP is so divided on Obamacare, they don’t have the votes to achieve either objective — repeal or stabilization. That means former President Barack Obama’s signature legislative accomplishment could keep limping along, crippled by the repeal of the individual mandate in the tax law but lifted by the surprisingly strong enrollment for the coming year.

President Donald Trump has declared Obamacare “over,” saying that axing the individual mandate means the health law is basically repealed. But he hasn’t made clear precisely what he wants Congress to do next. He’s recently spoken favorably about a bill that would completely dismantle Obamacare and turn it into state block grants, as well as another measure that would shore up the Obamacare markets by restoring subsidies that he personally halted.

Nor is Obamacare the only health program the divided Congress must confront in 2018. The GOP is split over what other health and social programs should be atop its agenda, including whether to make another run at reshaping Medicare and Medicaid.

Republicans and Democrats alike promise to swiftly renew funding for the bipartisan Children’s Health Insurance Program — though they couldn’t agree on more than a short-term patch in December. Several Obamacare taxes take effect this year, though there’s bipartisan interest in delaying them. And the raging opioid crisis is driving a disturbing decline in U.S. life expectancy.

Yet it’s the caustic politics around Obamacare — including the constant threat of repeal — that might be most politically nettlesome, particularly as GOP lawmakers try to show voters they can get things done before the midterm elections in November.

Just last month, the House blocked a Senate-led effort to fund the health law’s cost-sharing subsidies for two years — a conservative victory that underscores how loath they are to do anything that props up the health law said Rep. Mark Walker (R-N.C.), who leads the conservative Republican Study Committee.

“You can see the difference on this side versus the Senate side as far as how much energy there is” for repeal, Walker said.

That rift could reappear almost immediately. Moderates — who say they have Trump’s backing — want to try again this month to fund those subsidies, which help low-income people pay out-of-pocket medical bills.

Republican Sen. Lamar Alexander of Tennessee and Democratic Sen. Patty Murray of Washington say they will resume talks on the Obamacare payments with a goal of shoring up the health markets. Trump called Alexander in late December to encourage him to keep at it, the Tennessee Republican said. But even if he and Murray reach a new deal, the bill stands little chance of getting through the House without Trump’s public and consistent cheerleading.

“If they can get their heads together and President Trump endorses it, it will pass,” Sen. Roger Wicker (R-Miss.) predicted.

So far, House Republicans aren’t on board. “Alexander-Murray is a really tough one, I think, in this chamber,” said Rep. Kevin Cramer (R-N.D.). House Republicans would want to add abortion restrictions, Cramer and other GOP lawmakers say, and they don’t want to send “bailout” money to insurance companies.

Meanwhile, Sen. Lindsey Graham (R-S.C.) is already working on resurrecting a fast-track procedural motion to pass the Graham-Cassidy proposal, which would tear up much of Obamacare and block-grant smaller sums to the states. It was the heart of a last-ditch repeal effort in September, but the GOP ran out of time and shelved the idea. Graham and Sen. Bill Cassidy (R-La.) argue the idea has promise because Sen. Lisa Murkowski of Alaska, one of three Republicans who voted against the repeal effort over the summer, was open to the idea of block grants as long as she felt her state’s interests were protected.

Graham argues that after repealing the mandate in tax reform — and thus weakening how the Obamacare market functions — Republicans have to live up to a “you break it, you buy it” contract with Obamacare.

“The Republican Party cannot avoid the obligation to replace,” Graham said.

But are Republicans crazy to try repeal again in 2018 with one less vote in the Senate — Alabama Sen.-elect Doug Jones is a Democrat — after spending nine months of last year in a fruitless effort?

“I think it would be crazy if you don’t,” Graham said. “How can you repeal the individual mandate and say we’re done? The thing’s going to crumble. We better find a replacement that works.”

But to dramatically shift the dynamic of division, Graham and Cassidy would have to be able to go to Senate Majority Leader Mitch McConnell with an ironclad promise of 50 votes for their Obamacare repeal.

A handful of moderate Republicans told POLITICO that they’d like to move away from Obamacare and on to legislation like infrastructure. But they don’t want to be quoted saying that repeal is dead.

And that’s the crux of leadership’s Obamacare problem. GOP leaders don’t have a solution, but they don’t have an exit ramp, either; not after Republicans made repeal a central campaign pledge again and again for years.

Even McConnell, in his year-end news conference, said twice that he would love to uproot more of Obamacare, but indicated that it’s unlikely.

“I’d love to be able to make more substantial changes to Obamacare than we have,” he said. “As soon as we have the votes to achieve it, I’d like to do it.”

How will our health care system be reshaped in 2018? Rebecca Zisser reported that 2018 is going to be a long year, and probably a hard one to keep up with the ever-evolving world of healthcare.                                                                                                            Let’s take a step back from the minute-by-minute onslaught and take stock more broadly of the big, overarching trends that will animate this year in health policy.

1. Politically induced chaos

The most consistent theme in the politics of health care last year was uncertainty, and that seems highly unlikely to change in 2018.

• The Affordable Care Act’s exchanges are a mess of competing priorities that no longer reflect any cohesive policy vision.
• The individual mandate is about to disappear; Congress still has to make a decision about cost-sharing payments and reinsurance. And we’ll see new regulations from the Trump administration that will make the landscape even harder for insurers to predict.
• That will push a lot of the action to the states, where insurers will lobby for reinsurance funding, regulatory waivers (on which the Trump administration would have to agree) and state-level coverage requirements. The inevitably mixed results mean an increasingly uneven playing field from one state to the next — and from one county to the next.

And that’s just the individual market. Open gubernatorial races in this year’s midterms will have an enormous effect on health policy for years to come. Medicaid expansion will be explicitly on the ballot in a handful of states. House Speaker Paul Ryan wants to take another crack at Medicare and Medicaid cuts.

Buckle up. These are just the battles we already know about, barely 24 hours into the year.

2. Industry consolidation

The healthcare industry is consolidating rapidly — hospitals are merging with each other and with insurers; pharmacies are buying insurance companies, and drug companies are snapping up other drug companies.

The big question: Are these deals good for consumers?

• What happens to networks of hospitals, doctors, and pharmacies? Those options will likely narrow as different types of health care businesses end up under the same roof.
• Regulators ultimately will have to consider whether merged companies are gaining too much negotiating power and whether these deals will lead to lower health care costs.

What’s next: Regulatory reviews of all these mega-mergers will fall to the Federal Trade Commission — which already has limited resources — and the Department of Justice.

• Many current deals, including CVS-Aetna, don’t present the same antitrust issues that sunk previous health care mergers.
• The end of 2017 was among the busiest seasons of mega-mergers in a long time. Expect the trend to continue, while the deals announced last year moved closer to reality.

Don’t forget: Many people have overlooked the part of President Trump’s healthcare executive order that said his administration will “focus on promoting competition in health care markets and limiting excessive consolidation.”

3. A pipeline full of expensive drugs

This year will see crucial clinical trials — and potential FDA approval — for a host of drugs, including highly watched therapies in oncology and immunology.

Retail drug spending growth has actually been mild over the past two years, but the pending arrival of expensive new treatments, including CAR-T therapies, will add new fuel to the drug-pricing fire, much like expensive new hepatitis treatments helped blow the issue open in 2014 and 2015.

The impact: This isn’t just a political debate: These products can place a real strain on insurance premiums, and could cripple taxpayer-funded health care programs.

• Two academic doctors who study drug economics, Walid Gellad, and Aaron Kesselheim, offered in May 2017 some policy ideas to keep spending in check.
• Value-based drug contracts — in which drug companies are only paid if their drugs are effective — are the policy du jour. But we still don’t know a lot about how they are designed or whether they work.
• Drugmakers often point out that some of these new products are more expensive but also far more effective than their predecessors. But there still is nothing stopping drug companies from buying old, inexpensive drugs and jacking up their prices — the type of behavior that made Martin Shkreli infamous. And that only gives the industry’s critics more ammunition.

What to watch: Policymakers, including HHS secretary nominee Alex Azar, have supported some proposals to crack down on price-inflating tactics, including drugmakers’ patent strategies and the secretive rebate system used by pharmacy benefit managers.

4. A new era in Medicaid

The Trump administration has barely gotten started on what might end up being one of its biggest healthcare legacies — a new, more conservative vision for Medicaid. But those changes are just around the corner.

• Seema Verma, who leads the Centers for Medicare & Medicaid Services, has already said CMS will begin allowing states to impose some form of work requirements on Medicaid recipients.
• Using Medicaid “as a vehicle to serve working age, able-bodied adults does not make sense,” Verma said in November.
• Most states already rely on private managed-care organizations — that is, insurance companies — to administer their Medicaid programs. This has quietly become a big line of business for the insurance industry, giving insurers a growing stake in the kinds of regulatory flexibility states are seeking from CMS.

5. The opioid crisis goes on

The opioid crisis is so bad, nationwide, that Americans’ life expectancy is going down, despite myriad advances in medical technology.

• There are pieces of a response in place — FDA commissioner Scott Gottlieb has taken an aggressive stance on promoting medication-assisted therapy, and some states have developed comprehensive plans.

Yes, but: There’s no coordinated national strategy to try to get this crisis under control, much less reverse the rising tide of addiction, overdoses, and death.

• Neither Congress nor the Trump administration has put much federal money behind an opioid response.
• The White House has declared it an emergency and released a long, detailed set of policy recommendations that cut across a broad swath of federal, state and local agencies. But no one is in charge of putting those ideas into practice.

 

Look at what is already happening,! The new health insurance rule aims to deliver on Trump’s promise. The Trump administration is proposing regulations to facilitate the interstate sale of health insurance policies that cost less but may not cover as much.

But it’s not immediately clear whether the new proposal from the Labor Department will fulfill President Donald Trump’s long-standing promise to promote competition across the country.

The rule would make it easier for groups — or associations — to sponsor health plans that don’t have to meet all consumer protection and benefit requirements of the Affordable Care Act.

Those requirements improve coverage, but they also raise premiums.

Insurers are skeptical of Trump’s idea. Patient groups are concerned about losing protections. And some state regulators object to federal interference.

There’s another wrinkle: Health insurance, like real estate, reflects local costs, which vary widely.

These are all interesting but what is more interesting was an article appearing in The Week. It described Britain’s National Health Service, which the article proclaims is in “chaos”, as described by Denis Campbell and Sarah Marsh in the Guardian.

Remember, this is a health care system that the proponents of the single-payer system keep pointing to as evidence and of the benefits of such an option. A surge in flu patients, colder weather, and high levels of respiratory illness has slammed hospitals across the country. Beds are full, patients are waiting on trolleys in hallways, and ambulances can’t respond quickly to emergency calls. The pressure has led the NHS in England to take the “unprecedented” step of postponing up to 55,000 non-urgent surgical procedures.

This mess is the result of seven years of austerity by the ruling Conservative Party, said Dr. Ravi Jayaram. The NHS has been consistently underfunded in a way that seems purposeful, as the government wants a crisis so it can declare socialized medicine a failure and speed up the privatization of services. Just last fall, the boss of NHS England asked for an extra $5.5 billion for the winter crush, but the government gave only about a third of that. “Primary care services have been compromised,” so people go to the ER instead of their own doctor. And with Brexit approaching, we’re losing many doctors and nurses from European Union countries who no longer feel welcome in the UK.

Money alone won’t solve the problem, said The Mail on last Sunday. The NHS is antiquated. It was designed “for a population of manual workers” who died young. Now, though, it must treat “millions of well-housed sedentary workers who eat too much and exercise too little”-and still live into their 80”s. The whole system needs a redesign, said Camilla Cavendish in The Times.

So, maybe we should be careful which health care system is best as we design our own “ The Best Health Care System” for our wonderful country. Now on to a discussion of single payer systems. Yes, there are different systems.