So We are Back to Another Shutdown because of No progress on ‘Dreamers’. And What is a Single Payer System?

27332564_1437571719705816_3162371317698120639_nJames Oliphant and Amanda Becker stated the obvious that the U.S. Congress made no notable progress this week toward a deal on the status of 700,000 “Dreamer” immigrants, with President Donald Trump saying on Friday that one “could very well not happen” by a deadline next month.

Whether the lack of progress signaled the possibility of another federal government shutdown next week was unclear, but it worried the Dreamers, young people who were brought illegally into the United States as children.

Trump said last year that he would end by March 5 a program that was set up by former President Barack Obama to protect the Dreamers from deportation, and he urged Congress to act before that date. No action has resulted.

“We want to make a deal,” Trump said at an event in Virginia with U.S. Customs and Border Protection officials. And he blamed Democratic lawmakers for the impasse.

“I think they want to use it for political purposes for elections. I really am not happy with the way it’s going from the standpoint of the Democrats,” he said.

Democrats have said repeatedly that they want protections written into law for the Dreamers, who were given temporary legal status by Obama’s Deferred Action for Childhood Arrivals (DACA) program, which lets them study and work in the United States without fear of deportation.

Republicans, who control Congress, are undecided on what to do about DACA and the Dreamers. They ended a three-day retreat at a mountain resort in West Virginia on Friday not much nearer to consensus than they were a week ago.

The partisan standoff caused a partial shutdown of the federal government for three days last month after Congress failed to pass a stopgap spending measure needed to keep the lights on at federal facilities across the country.

The House of Representatives plans to vote on Tuesday on legislation to keep federal agencies operating beyond Feb. 8, when existing funds expire, a senior House Republican aide said.

The aide did not provide details, however, on the duration of this latest-in-a-series of temporary funding measures.

Democrats have leverage on the immigration issue because their votes are needed to pass spending measures in the Senate.

The next spending deadline looms on Thursday, with Democrats defiant in their demands and Republicans remaining divided.


Trump has offered the Dreamers a path to citizenship, but only on the condition he also gets funding for a wall along the U.S.-Mexico border, as well as other immigration-related measures that Democrats oppose.

Last month, he proposed letting 1.8 million Dreamers stay in the country and become citizens in exchange for $25 billion for the wall, curbs on family-sponsored immigration, and an end to a visa lottery program.

Some lawmakers want Trump’s four-part immigration framework pared back, while others want it approved or made even more strict on future immigration.

“If we can solve DACA and border security that may be the best I can hope for,” Senator John Thune, a member of the Republican leadership, told reporters at the retreat.

Senator James Lankford was among Republicans who said this week that Trump could give Congress more time to reach a deal by extending the Dreamers’ deadline beyond March 5.

Trump reiterated on Thursday at the retreat that all four components of his framework must be included in a deal, a stance viewed as unworkable by many lawmakers in both parties.

Some Republicans say the March 5 deadline lost its power last month when a federal court blocked the rescinding of DACA. That meant the law would remain in effect until the Supreme Court resolves the case, which is unlikely by March 5.

In a research note, financial firm Height Analytics set the odds of another shutdown next week at 65 percent.

Republicans are trying to call Democrats’ bluff on DACA, but the Democrats look even more willing to allow a shutdown than they were last month, the analysts said. “What this has become is a very absurd game of chicken,” they said in the note.

 We have to consider that Health care spending in the U.S. increased by about $933.5 billion between 1996 and 2013, according to an analysis published Tuesday in the medical journal JAMA. More than half of this surge was a result of generally higher prices for health care services.

Joseph L. Dieleman, the lead author of the study and an assistant professor at the Institute for Health Metrics and Evaluation at the University of Washington in Seattle, gathered information on 155 separate health conditions and six possible treatment categories: inpatient, outpatient (hospital), emergency services, dental care, prescriptions and nursing facilities.

The researchers also analyzed changes in five factors — population size, aging, disease incidence, use of services, and service price and intensity — as they relate to health care spending in the study period, 1996 through 2013.

“Intensity of care” refers to service variety and complexity.

“It’s the difference between a relatively simple X-ray as a compared to more complex MRIs and other forms of diagnostic services,” Dieleman wrote in an email.

The analysis resulted in four main takeaways about why US health care costs rose.

Rising price of services

“Price and the variety and complexity of services is the largest driver of health care spending increases,” Dieleman noted.

In fact, more than half of the total spending increase was due to price and intensity increases, which contributed $583.5 billion to the $933.5 billion total increase. Dieleman said price and intensity increased for most conditions “and especially for inpatient care.”

By comparison, the growth in population led to $269.5 billion of the total expenditures, while aging of the population equaled $135.7 billion of the total.

More spent on specific conditions

Diabetes was the condition with the greatest increase in spending, rising by $64.4 billion between 1996 and 2013. Most of this money went to pharmaceuticals prescribed to treat it.

The single most important risk factor for type 2 diabetes is obesity, noted Dr. Patrick H. Conway of Blue Cross Blue Shield of North Carolina in an editorial published alongside the new analysis.

Spending on low-back and neck pain surged by $57.2 billion in the 17-year time period, followed by hypertension ($47.6 billion), hyperlipidemia or high (“bad”) cholesterol ($41.9 billion), depressive disorders ($30.8 billion), falls ($30.4 billion), urinary diseases ($30.2 billion), osteoarthritis ($29.9 billion), sepsis or bloodstream infection ($26.0 billion), and oral diseases or disorders ($25.3 billion).

Outpatient treatment

Spending on ambulatory care, which includes ER and outpatient hospital services, also played a role in increased overall costs.

Annual spending on ambulatory care swelled from $381.5 billion in 1996 to $706.4 billion in 2013. This increase, about $324 billion, was higher than any of the other five types of care analyzed.

There’s a “significant payment differential” when a procedure, such as a colonoscopy, is performed at an outpatient hospital center compared with when it is performed in a physician’s office, “with the former being far more expensive than the latter,” Conway noted.

Pharmaceutical drugs

Another key driver of the total increase in health care expenditures between 1996 and 2013 was spending on pharmaceutical drugs. For example, $44.4 billion of the total $64.4 billion increased expenditure for diabetes was spent on medications meant to treat, as well as to prevent, the disease.

Part of the high price paid for pharmaceuticals “is a regulatory problem,” said Robert F. Graboyes, a senior research fellow at the Mercatus Center at George Mason University. Graboyes, who was not involved in the research, said that the FDA drug approval process makes pharmaceuticals far more expensive than they ought to be.

“The FDA has a very powerful motive to take things extremely slowly and extremely carefully,” he said. Although slow and careful has its virtues when it comes to something as “sensitive” as pharmaceutical drugs, Graboyes noted that the United States lacks something the European Union has. “There is a counterweight in the motive that says you also don’t want to be too slow about it,” he said.

In Europe, rather than a single agency, there are a number of “quasi-private entities approved by the governments of the EU,” and so there is a somewhat “competitive system.” The result: “They do tend to get things to market quickly without — as far as I can see — any loss of safety and security,” he said.

Graboyes described the overall spending report as “well-done.”

Household perspective best

Based on official US records, total health care spending reached $3.2 trillion in 2015 and constituted 17.8% of the US economy, Dieleman and his co-authors noted.

Graboyes said that when it comes to health care spending, it can be misleading to focus “on the percentage of GDP rather than a percentage of household consumption.”

He suggested we look instead at what Americans spend on health care as a percentage of household consumption expenditures. “It turns out that we’re not very far out of line with other countries,” he said.

This is not a criticism; “it’s more of an addition to the paper,” Graboyes said. “It’s an interesting factor to overlay on the work they’ve done.”

This chart of surging US health-care costs explains why titans of business are getting involved

The average American spends nearly $4,000 toward health care each year, a number expected to balloon to more than $5,000 in 2023, according to Evercore ISI

“We find this morning’s announcement fascinating as three behemoths are banding together to tackle a massive and highly complex problem,” said Evercore ISI’s Ross Muken.

Meg Tirrell reported that Warren Buffett, Jeff Bezos, and Jamie Dimon are launching their new health care initiative because health care costs are soaring for millions of their employees and Americans overall.

The average American spends nearly $4,000 toward health care each year, a number expected to balloon to more than $5,000 in 2023, according to Evercore ISI and the Centers for Medicare and Medicaid.


“We find this morning’s announcement fascinating as three behemoths are banding together to tackle a massive and highly complex problem. On a personal level, the mission seems remarkably well placed as the government has failed at managing costs in healthcare for decades,” Evercore’s Ross Muken wrote to CNBC Tuesday.

The companies made headlines Tuesday morning after their announcement.

“The three companies, which bring their scale and complementary expertise to this long-term effort, will pursue this objective through an independent company that is free from profit-making incentives and constraints,” said the press release from Amazon, Berkshire Hathaway, and J.P. Morgan.

The U.S. government now anticipates the health share of GDP to rise from 17.8 percent in 2015 to 19.9 percent by 2025. Prescription drug spending is projected to grow an average of 6.3 percent per year over the same time.

“While we expect much of the debate amongst investors to center on the impact to drug pricing or insurance rates given all of the public discourse, the reality is that is only a small portion of costs in the system,” Evercore’s Muken added. “Ultimately this effort will likely take many years to come to fruition and we hope the aim is to add transparency, efficiency and most important technology to healthcare, which we argue it broadly needs.”

So, what is a single-payer health care system?

Whether you call it single payer or Medicare for all, the idea of a government-sponsored universal health care system, no matter how contentiously debated, continues to infiltrate the health care discussion.

The idea of universal health care reemerged during the 2016 presidential primary campaign as one of Bernie Sanders’ main platforms. In September, Sanders, I-Vermont, introduced a “Medicare for All” bill into the Senate with the full knowledge it would likely go nowhere — for now. In August, Rep. John Conyers, D-Michigan, reintroduced an expanded and improved Medicare for All bill in the House.

Both bills would convert the current many-payer system — insurance companies, states, the federal government — into a government-sponsored, tax-supported health care system. As in many other countries, every US citizen would receive health care, and it would essentially be paid for by one source, the government.

In addition to these national legislative moves, which may be more symbolic than realistic, at least three states have been working toward a single-payer system, and those efforts can also help consumers understand how such a plan would work.

The most recent effort toward that goal came from the Massachusetts Senate early in November. Already known for its progressive health care policies, the state approved a broad health care reform bill that seeks to lessen price disparities between hospitals, address rising drug costs and lower the number of patients readmitted for hospital care within 30 days of a discharge.

An important amendment to the bill called for a study of what it would cost Massachusetts to implement a government single-payer health care system. The amendment, introduced by Sen. Julian Cyr, a freshman Democrat, passed by a surprising 33 to 6 vote. “When you consider every other developed nation has single-payer health care, we’ve just got to look at this,” said Cyr.

In addition, he pointed out that Massachusetts is a state that spends one of the highest amounts per capita on health care. Thus, it only makes sense to find out if that money could be spent more equitably and efficiently with a single-payer system.

Other states grappling with this issue haven’t been entirely successful. Back in 2011, Vermont was the first state to implement a universal health care system of its own, in which all citizens were insured under Green Mountain Care. But by 2014, the state abandoned its efforts, citing unmanageable higher taxes.

Now Vermont is moving toward an alternative system that offers healthcare providers lump sum payments that are designed to reward doctors for keeping patients healthy instead of solely treating illness.

California, however, may have had the country’s most ambitious plan for single-payer health care. Such a plan passed the Senate in June but was then stalled in the summer because of the potential increase in taxes and the lack of analysis on how the bill would be funded. The debate continues.

When asked in a recent interview on NPR if state efforts are the shortest way to get to a single-payer system, Linda Blumberg, senior fellow in the Health Policy Center at the Urban Institute, said implementing single-payer health care state-by-state may be far more difficult than a federal system. “High-income states that have a lot of private health care spending … are most likely to be able to do something like this,” she said. But other states without resources can’t just shift costs from one side of the ledger to the other, she added.

In the meantime, pundits such as Drew Altman, president, and CEO of the Kaiser Family Foundation, have other warnings about a national single-payer system. Most people worry about the increase in taxes a single-payer system would cause, Altman has written. But also, most people don’t realize they would need to change providers under a single-payer system, something that has always been complicated and uncomfortable for consumers.

For the moment, how single-payer would work is anyone’s guess. It may take months or years to answer these questions. But the earlier consumers can be aware of the issues involved in a big change like this, the better.

Next, I want to look at Bernie Sanders’ idea of a single-payer health care system. Things that we have to consider as was just stated was how to pay for it the responsibilities, restrictions, run by the states or the federal government and will it work.?


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