Category Archives: Governor Gavin Newsom

Governors Weigh Health Care Plans as They Await Court Ruling, the Future of the ACA and San Francisco Experience with Healthcare Insurance and, Yes, More on Medicare

Screen Shot 2019-07-07 at 8.29.30 PMBrady McCombs reported that as they gather at a conference in Utah, governors from around the U.S. are starting to think about what they will do if an appeals court upholds a lower court ruling overturning former President Barack Obama’s signature health care law, the Affordable Care Act or Obamacare.

More than 20 million Americans would be at risk of losing their health insurance if the 5th U.S. Circuit Court of Appeals agrees with a Texas-based federal judge who declared the Affordable Care Act unconstitutional last December because Congress had eliminated an unpopular tax is imposed on people who did not buy insurance.

The final word on striking down the law will almost certainly come from the Supreme Court, which has twice upheld the 2010 legislation.

Nevada Gov. Steve Sisolak, a Democrat, signed a bill earlier this year prohibiting health insurers from denying coverage to patients due to pre-existing conditions, a pre-emptive move in case the Affordable Care Act was struck down.

He said this week in Salt Lake City at the summer meeting of the National Governors Association that he would ask his recently created patient protection commission to come up with recommendations for how to ensure patients don’t lose coverage if the law is overturned, which would impact about 200,000 people enrolled in Medicaid expansion in Nevada.

“To rip that away from them would be devastating to a lot of families,” Sisolak said.

Nevada is among a coalition of 20 Democratic-leaning states led by California that appealed the lower court ruling and is urging the appeals court to keep the law intact.

At a news conference Thursday, Democrats touted the protections they’ve passed to prevent people from losing health coverage.

New Mexico Gov. Michelle Lujan Grisham signed laws this year that enshrine provisions of the Affordable Care Act into state law, including guarantees to insurance coverage for patients with pre-existing conditions and access to contraception without cost-sharing. She said half of the state’s residents use Medicaid, prompting New Mexico officials to research creating a state-based health care system.

California Gov. Gavin Newsom said his state is already deep in contingency planning because five million people could lose health insurance if the law is struck down and the state doesn’t have enough money to make up for the loss of federal funds. He said the decision this year to tax people who don’t have health insurance, a revival of the so-called individual mandate stripped from Obama’s model, was the first step. That tax will help pay for an expansion of the state’s Medicaid program, the joint state, and federal health insurance program for the poor and disabled.

Newsom said the state is looking at Massachusetts’ state-run health care program and investigating if a single-payer model would work as possible options if the law were spiked.

“The magnitude is jaw-dropping,” Newsom said. “You can’t sit back passively and react to it.”

Arkansas Gov. Asa Hutchinson, a Republican, said states need Congress to be ready to quickly pass a new health care plan if the court overturns Obama’s law since doing so would cut off federal funding for Medicaid expansion.

A court decision in March blocked Arkansas from enforcing work requirements for its Medicaid expansion program, which has generated seemingly annual debate in that state’s Legislature about whether to continue the program.

“Congress can’t just leave that out there hanging,” Hutchinson said.

The 2018 lawsuit that triggered the latest legal battle over the Affordable Care Act was filed by a coalition of 18 Republican-leaning states including Arkansas, Arizona, and Utah.

Arizona Gov. Doug Ducey, a Republican, said he wants to see how the court rules before he makes any decisions about how his state would deal with the loss of Medicaid funds but that Arizona has backup funds available.

“They’re going to rule how they’re going to rule and we’ll deal with the outcome,” Ducey said. “The best plans are to have dollars available.”

It is unknown when the three-judge panel will rule.

The government said in March that 11.4 million people signed up for health care via provisions of the Affordable Care Act during open enrollment season, a dip of about 300,000 from last year.

Utah Gov. Gary Herbert, a Republican, said if the law is overturned, it would provide a perfect opportunity for Congress to try to craft a better program with support from both political parties.

He said his state, which rolled out its partial Medicaid expansion in April, probably will not start working on a contingency plan for people who would lose coverage until the appeals court rules.

“It’s been talked about for so long, people are saying ‘Why to worry about it until it happens?'” Herbert said. “I think there’s a little bit more of a lackadaisical thought process going on.”

President Donald Trump, who never produced a health insurance plan to replace Obama’s health care plan, is now promising one after the elections.

Newsom warned Americans not to rely on that.

“God knows they have no capacity to deal with that,” Newsom said. “The consequences would be profound and pronounced.”

Appeals Court Judges Appear Skeptical About ACA’s Future

Alicia Ault noted that if its line of questioning serves as a barometer, a three-judge panel of the US Fifth Circuit Court of Appeals here seemed to be more favorably inclined toward the arguments of a group of 18 Republican states and two individuals seeking to invalidate the Affordable Care Act (ACA) than to those bent on defending the law.

“I think the plaintiffs had a better day than the defendants,” Josh Blackman, an associate professor of law at the South Texas College of Law, Houston, told Medscape Medical News.

“I think they found that the plaintiffs had standing,” said Blackman, who attended the arguments. The judges also seemed to believe the plaintiffs have been injured by the ACA, and that the individual mandate still demanded that people buy health insurance, even though Congress has eliminated the penalty, he said.

“Short news is it went very badly,” said Ian Millhiser, a senior fellow at the liberal-leaning Center for American Progress, on Twitter, after attending the hearing.

“The two Republican judges appear determined to strike Obamacare,” he said, adding, “There is a chance they will be too embarrassed to do so, but don’t bet on it.”

At the outset, Judge Jennifer Walker Elrod asked Samuel Siegel, a lawyer with the California Department of Justice representing the 20 states and Washington, DC, who are defending the ACA, “If you no longer have the tax, why isn’t [the ACA] unconstitutional?”

Only two of the three judges on the panel asked questions during the 1-hour-and-46-minute hearing — Elrod, appointed by President George W. Bush in 2007, and Kurt Engelhardt, appointed by President Donald J. Trump in 2018. Carolyn Dineen King, appointed by President Jimmy Carter in 1979, did not ask a single question.

The defendants — led by California — were first to argue. They were given 45 minutes to make their case that District Court Judge Reed O’Connor in Texas had erred in December when he ruled that the ACA should be struck down because Congress had eliminated the penalty associated with the requirement that individuals buy health insurance.

Essentially, said Judge O’Connor, the mandate could not be severed from the rest of the ACA. O’Connor did not grant the plaintiffs’ request that the ACA be halted while the case made its way through the courts.

The plaintiffs — led by Texas Solicitor General Kyle Hawkins — also had 45 minutes before the appellate court judges.

Is the ACA Now a “Three-Legged Stool?”

Both Judges Elrod and Engelhardt interrupted Siegel several times while arguing for the ACA to ask him to explain why California and the other states had the standing to defend the federal law. Siegel said that if the law were to be struck down it would cost the defendants hundreds of billions of dollars.

The two judges seemed intent on getting both sides to explain why Congress would have eliminated the penalty that went along with the individual mandate but left the rest of the law standing. The plaintiffs contend that the law could not be severed into parts, that it lived or died with the mandate and its penalty.

When asked to assess congressional intent, Hawkins said, “I’m not in the position to psychoanalyze Congress.” But he said the US Supreme Court had already settled the question, ruling in King v Burwell that the ACA was like a three-legged stool without the penalty. And, he said, even without the penalty, the individual mandate remained part of the law, which he called “a command to buy insurance.”

Douglas Letter, the general counsel to the US House of Representatives, arguing in defense of the ACA, said the opposite: that the Supreme Court had determined in NFIB v Sebelius that the ACA presented a choice of buying health insurance or facing a penalty. Without the penalty, “The choice is still there,” said Letter, adding that individuals could choose to maintain insurance or not.

“We know definitively that ‘shall’ in this provision does not mean must,” Letter said.

Engelhardt disagreed and said that Congress perhaps should have revised the ACA after the penalty was removed. He also asked Letter why the Senate was not also a party to the defense of the ACA. “They’re sort of the 800-pound gorilla not in the room,” Engelhardt said.

What’s Next?

The judges are not expected to rule for several months and will be addressing several issues, including whether the Democratic states and the House of Representatives have proper standing to defend the law and whether the plaintiffs have the standing to challenge the law.

They also will address whether the individual mandate is still constitutional, and if the mandate is ruled unconstitutional, whether it can be severed from the rest of the ACA, or, on the other hand, whether other provisions of the ACA also must be invalidated, according to the Kaiser Family Foundation.

The court could dismiss the appeal and vacate O’Connor’s judgment, “in which case there wouldn’t be any decision in the case at all,” Timothy S. Jost, professor emeritus at the Washington and Lee University School of Law in Lexington, Virginia, told Medscape Medical News ahead of today’s hearing.

At the hearing, Texas’ Hawkins said it was wrong to say the plaintiffs were trying to strike the law. “There’s an erasure fallacy,” he told the judges. “We’re not asking the court to erase anything.”

Still, O’Connor did say in his ruling that the ACA was unconstitutional. The Trump administration announced in March that it would not defend the law, but said it would continue to enforce the ACA. August E. Flentje, a US Department of Justice lawyer, reiterated that position at the Fifth District hearing today.

But, in a briefing before the hearing, the administration argued that, if ultimately the law is ruled unconstitutional, it should only be struck down in the states seeking to overturn the law. Any ultimate judgment “should not declare a provision unlawful if it doesn’t impact the plaintiff,” Flentje said.

Douglas Letter, for the defendants, was agog. “The DOJ position makes no sense,” he said, noting, for instance, that that would mean that the US Food and Drug Administration — which is required to speed biosimilar drugs to market under the ACA — would approve drugs in California, but not Arizona.

Elrod pressed the point by asking Flentje, “What is the government planning to do?” if the ACA is halted.

“A lot of this has to get sorted out — it’s complicated,” he said.

Despite the outcome of today’s hearings, the case is still ultimately expected to go before the Supreme Court again, according to multiple legal experts.

Advocates: The Stakes Are Astronomical

Shortly after the hearing ended, California Attorney General Xavier Becerra issued a statement predicting disaster for American healthcare if the appeals court agrees that the ACA is unconstitutional. If that happens, “Millions of Americans could be forced to delay, skip, or forego potentially life-saving healthcare,” he said.

“Our state coalition made it clear: on top of risking lives, gutting the law would sow chaos in our entire healthcare system,” Becerra said, vowing to “fight the Trump administration tooth and nail.”

Physicians, consumer and patient advocates, and healthcare groups have voiced their support of the law through friend-of-the-court briefs, starting in June 2018, when the American Medical Association, the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry joined together in a brief.

Other organizations have also voiced their support for the ACA through amicus briefs, including: the American Hospital Association, the Federation of American Hospitals, the Catholic Health Association of the United States, the Association of American Medical Colleges, Americas Health Insurance Plans, the Disability Rights Education and Defense Fund, the Blue Cross Blue Shield Association, Families USA, AARP, the Children’s Partnership, 483 federally recognized tribal nations, and 35 cities, counties, and towns.

A coalition led by the American Cancer Society, and including the American Diabetes Association, the American Heart Association, the American Lung Association, the Crohn’s & Colitis Foundation, the Cystic Fibrosis Foundation, the Epilepsy Foundation, the Hemophilia Federation of America, the Leukemia & Lymphoma Society, the March of Dimes, the National Alliance on Mental Illness, the National Coalition for Cancer Survivorship, the National Hemophilia Foundation, the National Multiple Sclerosis Society, and The Kennedy Forum also filed an amicus brief and issued a joint statement ahead of the hearing.

“If allowed to stand, the lower court’s ruling would once again mean people could be charged more or denied coverage based on their health history,” said the statement. “Insurance plans could impose arbitrary annual and lifetime limits on patients’ coverage and could exclude whole categories of care — like prescription drugs — from their plans,” they said, adding that striking the law from the books would jeopardize tax credits used by 8 million Americans to buy health insurance on the individual market.

Millions more could be dropped from Medicaid, the coalition stated. In total, the groups said that some 27 million people could lose health insurance — a figure they said was calculated by the Congressional Budget Office.

The Kaiser Family Foundation estimated that 19 million people could lose insurance. Also at stake: requiring private insurance, Medicare, and Medicaid expansion coverage of preventive services with no cost-sharing, and a phase-out of the Medicare prescription drug “doughnut hole” coverage gap.

“All of these provisions could be overturned if the trial court’s decision is upheld, and it would be enormously complex to disentangle them from the overall health care system,” Kaiser said.

The Urban Institute estimated that if the ACA were overturned, the number of uninsured would increase by 65% — 20 million people; state spending on Medicaid/Children’s Health Insurance Program (CHIP) would fall by $9.6 billion — and that uncompensated care would rise by $50.2 billion, an increase of 82%.

Health Insurance for All: Learning From San Francisco

This last article is an interview with Dr. George Lundberg and the San Francisco healthcare insurance. Hello and welcome. I’m Dr. George Lundberg and this is At Large at Medscape.

You can pay me now or you can pay me later. Perhaps best known as a commercial promoting automobile maintenance, this statement could also apply to healthcare.

Everybody gets sick. If left alone, most acute human maladies fix themselves (automobiles don’t), but people with chronic diseases do better if managed sensibly, including with professional help. Some serious illnesses are fully preventable. The effects of many potentially serious diseases can be ameliorated by early diagnosis and intervention.

Who pays? In whose best interest is it for payment to be assured?

Medical expense insurance in the United States began in Dallas, Texas, in 1929 and Sacramento, California, in 1932. Hospitals needed to be paid; surgeons were particularly motivated early on to assure not only that patients who needed surgery would get it, but also that the surgeons would get paid. Surgical fees often exceeded more typical fees for medical care, so out-of-pocket costs (the normal way doctors and hospitals were paid back then) were more difficult for many patients to afford. Usual medical care did not cost much, but then again, neither did it offer much.

Growing up in small-town, lower Alabama in the 1930s and ’40s, I did not know anyone who had medical expense insurance. Oddly, many people had burial insurance, which was aggressively marketed and sold.

Once medical (health) insurance became common, medical services (and costs) increased and then flourished—an early example of supply-induced demand. Of course, there were benefits for many.

The enactment of Medicare and Medicaid legislation poured gasoline on the already upward-spiraling healthcare cost fire. That is how we arrived at nearly 20% of the US annual gross domestic product going to healthcare.

Our American Medical Association actually warned the country about that risk.[1] The incipient medical-industrial complex developed an insatiable capacity to transfer money by greatly increasing costs, often to gain small, incremental improvements.

Yet, lifesaving medical and surgical interventions do occur, they are often expensive, and someone has to pay for them. Ergo, health insurance. Everyone should have it. Why not?

I live in Silicon Valley. Many of the key innovations that have revolutionized how the world functions day by day have been begun and are headquartered here. Think Google, Apple, Facebook, Airbnb, Uber, Twitter, YouTube, Salesforce, Oracle, Intel, Cisco, Netflix, etc.

So why would it not make sense for San Francisco to pioneer healthcare for all via innovation?

Residents of San Francisco are expected to have health insurance coverage via employment-based insurance, Medicare, the Affordable Care Act (ACA), and Medi-Cal, if eligible, just like all other Americans, with all the pluses and minuses of those programs. But if they don’t, Healthy San Francisco is available regardless of immigration status, employment status, or preexisting medical conditions.

The 2008 Health Care Security Ordinance created the authority that underpins the Healthy San Francisco program. It requires businesses to pay a minimum set amount of money on healthcare benefits for their employees.

Restaurant users learn of this expense of doing business by seeing the note, “In response to employer mandates, including the San Francisco Health Care Security Ordinance, a 4% surcharge will be added to all food and beverage sales.”

Healthy San Francisco is administered by the San Francisco Department of Public Health and delivered via designated Medical Homes. Eligible annual income is set at 500% of the federal poverty limit.

Health insurance is not, a panacea it is not. It is a safety net below the other safety nets. By July 2010, 50,000 people had enrolled, but by 2019, that number declined to about 14,000. The drop probably represents both low unemployment and the success of California’s robust implementation of the ACA via Covered California.

Any other city or county in the United States that would like to provide economic access to basic medical care for its people, without such care being forgone, termed charity, or simply written off as bad debt by providers, could do well by learning from San Francisco’s experience.

Read through the last few paragraphs, especially as we consider elimination, i.e. the uncertain future of the ACA and the possibility of Medicare for All. Also, as I have pointed out in the past few weeks as I have discussed the history of Medicare and Medicaid remember the inability of the administration to accurately predict the true costs. The following addition to the discussion on Medicare and Medicaid will further emphasize the huge costs and expenses of the programs. The next question would be how would the additional up-ward healthcare spiraling costs/expenses be paid for.

Back to our Medicare and Medicaid discussion:

Remember as I just mentioned, that last week I discussed the underestimation of the Medicare program and even more increases which occurred in the Medicaid program. Remember also that because of the wording of Title XIX where the federal government had an open-ended obligation to help underwrite the costs of medical care for the wide range of services to such a large number of recipients, which made it very difficult to accurately predict the ultimate cost.

Then in 1965, the House Ways and Means Committee had estimated that if all of the states were to take advantage of the Medicaid program, including all of the services, that the additional federal costs of medical assistance would amount to $238,000,000. However, in the fiscal year 1967, the total cost of Medicaid payments amounted to $1,944,000,000. Realize that half of these payments were federal funds and realize that the program was operating in only twenty-eight states. Also, interestingly even with the decline in usage and expenditures of other programs by the end of the year 1968 forty-one states had opted into the Medicaid program the total expenditures amounted to $3,783,000,000. Compare this to the total federal outlays for all medical assistance programs in the fiscal year 1965, prior to the introduction of Medicare and Medicaid, amounted to $1,239,000,000.

The goal of the House and Ways Committee when they met in 1971 discussed the need to contain the spiraling costs of Medicare and Medicaid. Members of the individuals testifying were members of the Nixon administration who suggested a whole series of cost-control measures, among them that the new legislation promote a system of capitation payments to health maintenance organizations (HMOs) and that Medicaid introduces cost-sharing while Medicare expands its own cost-sharing policies. Interestingly many of these cost-saving recommendations eventually found their way into the final bill to reform these programs, which became law in October1972.

So, among these changes to the Medicare program was:

  • The inclusion of the totally disabled as eligible for Medicare benefits. Workers of any age and widows and disabled dependent widowers over the age of fifty were eligible to receive Medicare benefits after having received APTD (Aid to Permanently and Totally Disabled) assistance for twenty-four months. This added approximately 1,700,000 beneficiaries to Medicare rolls and was the first instance of any group under the age of sixty-five being made eligible benefits;
  • Beneficiaries of Part B (Supplementary Medical Insurance) who otherwise were ineligible for Part A (Hospital Insurance) by virtue of not qualifying for Social Security coverage could now voluntarily enroll in Part A by paying a monthly premium;
  • Provision was made for capitation payments to HMOs and certain limits were placed on the items that a health care facility could include in calculating its cost.

However, the most significant change in the Medicare program contained in the 1972 amendments was the repeal of a provision contained in the original legislation that made it mandatory that each state expands its Medicaid program each year until it offered comprehensive coverage for all the medically needy by 1977. Remember that when Medicare and Medicaid were first introduced, Congress had hoped to establish a universal hospital and medical insurance scheme for the needy using Medicaid as its foundation but largely as a result of the swelling costs of the program this design was abandoned in1972.

So, let’s see how this week’s set of debates evolve as the candidates make more promises for the answer to the health care problem. How will Kamala Harris pay for her health care system and will private insurance be a thing of the past?

The Democrats’ Gamble on Health Care for the Undocumented; but What About Our Own Citizens and Medicare?

health298Several 2020 candidates are proffering moral and policy arguments for providing coverage, but the politics of the move are another matter. “We” are now worried more about the undocumented immigrants than our own citizens? This is really an indication as to the idiocy seeping into all aspects of our society, especially during this competitive race for the Presidency.

Ronald Brownstein reported that anxiety spiked among many centrist Democrats when all 10 presidential candidates at a recent debate raised their hand as if pledging allegiance, to declare they would support providing health care to undocumented immigrants. The image, which drew instant ridicule from President Donald Trump on Twitter, seemed to encapsulate the primary’s larger lurch to the left during the early stages of the 2020 race, which has unnerved many moderates.

But opinion among the candidates on this polarizing question is actually much more divided than that moment suggested. And that division underscores a larger point: While the most left-leaning positions in the Democratic field have attracted the most attention in the race so far, it’s far from certain the party will pick a nominee who embodies them.

Led by Senator Bernie Sanders, nearly a half-dozen 2020 Democrats have embraced a clear position of offering full access to health-care benefits. Others, including former Vice President Joe Biden, the nominal front-runner, oppose full benefits, although that wasn’t apparent at the debate. The latter group would allow undocumented immigrants to purchase coverage through the exchanges established by the Affordable Care Act, but only with their own money. That approach would cover far fewer people, but also potentially create much less exposure to Republican counterattacks.

“If we are saying that we can put them into the pools and they can buy on the exchange, I don’t think voters are going to flip out on that because there is no subsidy,” says Matt Bennett, the executive vice president for public affairs at Third Way, a leading organization of Democratic centrists. “But I think beyond that gets pretty dicey.”

This debate affects millions of people. The Kaiser Family Foundation, using census data, has estimated that 47 percent of the country’s roughly 11 million undocumented immigrants are uninsured, compared with one-fourth of legally present immigrants and about one-tenth of American citizens. Similarly, the Urban Institute places the number of uninsured undocumented immigrants at nearly 4.9 million, or about one-sixth of the total population of uninsured people in America.

The case for expanding their health-care access rests on financial, public health, and moral arguments. Supporters contend that it’s cheaper to provide access to medical care upfront, rather than deal with health crises in emergency rooms; that allowing the undocumented to go untreated increases health risks for legal residents who come in contact with them; and that it is unjust to let people face health threats without care, regardless of their status. As Biden put it in a recent interview with CNN, “How do you say, ‘You’re undocumented. I’m going to let you die, man’? What are you going to do?” The counterargument, meanwhile, is that it’s unfair to ask taxpayers to subsidize their care, and that covering the undocumented will act as a “magnet” to incentivize more immigration.

Emergency rooms must provide aid to all who need it. But polls have consistently found that most Americans resist offering public benefits to the undocumented beyond that. In a recent CNN survey, Americans by a solid 3–2 margin said that “health insurance provided by the government” should not be available to immigrants here illegally. The idea faced resistance across a wide array of constituencies, including several that Democrats rely on: Just over half of college-educated white voters, half of young adults ages 18 to 34, and more than two-fifths of nonwhites said they opposed providing coverage for the undocumented. At the same time, three-fifths of voters who identified as Democrats or lean Democratic said they support the idea.

This mixed result leaves the 2020 candidates balancing competing political and policy considerations as they confront the question. In the process, they have reopened a debate that extends back to the consideration of the ACA during former President Barack Obama’s first year in office.

The original version of the ACA, passed by the Democratic-controlled House in November 2009, allowed undocumented immigrants to purchase insurance on the law’s exchanges with their own money. But it denied them eligibility for the subsidies the law established to help the uninsured afford such coverage, and it maintained their exclusion from Medicaid, which the ACA expanded to cover more of the working poor.

The Democratic-controlled Senate—and the Obama White House—would not even go as far as to allow them to buy into the exchanges. Republicans and conservatives had seized on the charge that the ACA would provide the undocumented with benefits as one of their talking points against the proposed law; when Republican Representative Joe Wilson of South Carolina famously yelled “You lie” at Obama during his 2009 speech to Congress about his health-care proposal, it was in response to Obama’s insistence that the law would not cover those in the U.S. illegally.

To a degree that’s been largely forgotten today, passing the ACA was a herculean political challenge. Presidents Bill Clinton, Richard Nixon, and Harry Truman had all failed to pass universal-coverage bills; indeed, none of them had even advanced their proposal as far as a floor vote in either chamber. Within the Obama administration, resolving the issue of health coverage for the undocumented was widely viewed as one brick too many on the load.

Rahm Emanuel, who directed the legislative fight for the ACA as Obama’s chief of staff, recalled in an interview that pressure for covering the undocumented never developed “in any concerted way,” and that “no one seriously demanded it.” Neera Tanden, who served as a senior adviser to former Health and Human Services Secretary Kathleen Sebelius, remembered the debate inside the administration in similar terms. “I don’t remember considering this at all,” said Tanden, now the president of the Center for American Progress, a leading liberal think tank.  The “whole issue was a lot more toxic then.”

The final ACA bill that Obama signed into law, on March 2010, completely excluded undocumented immigrants from the system. Even when Obama later instituted the Deferred Action for Childhood Arrivals program to block the deportation of young people brought into the country illegally by their parents, the administration denied them access to benefits under the ACA, notes Eric Rodriguez, the vice president for policy and advocacy at UnidosUS, a leading Latino group.

Toward the end of 2016, the Obama administration had an opportunity to reconsider at least one aspect of that policy. California passed legislation allowing the undocumented to buy coverage on state-run exchanges with their own money (without any public subsidy) and requested a waiver from the federal government to implement the policy. Anthony Wright, the executive director of the advocacy group Health Access California, which helped pass the law, said the state argued that opening up the exchanges made sense because as many as 70 percent of undocumented Californians were in “blended” families that included American citizens. “The argument we made was … isn’t there a benefit to allowing the whole family to buy into coverage at the same time? Rather than to tell these families we can cover the kid and maybe the mother, but the father has to go to buy coverage from a broker independently?” Wright recalled in an interview.

The issue was never resolved. The state submitted its waiver request too late in 2016 for the Obama administration to rule before it left the office. Once Trump took control, California withdrew its request because he was virtually certain to reject it.

Hillary Clinton had moved the party’s position in a more inclusive direction during the 2016 campaign, although her policy didn’t attract nearly as much attention as the hand-raising moment at last week’s debate. Clinton ran, essentially, on House Democrats’ initial proposal in the early days of the ACA debate: that the undocumented should be allowed to buy coverage on the exchanges, though without any subsidies to help.

Three years later, the current slate of candidates seems to have significant differences in how they would treat the undocumented, even if, as a group, they have moved beyond the Obama administration’s more cautious position on the ACA. Biden and Senator Michael Bennet of Colorado, both of whom raised their hand at the debate last month, are taking a similar position to House Democrats’ in 2009 and Clinton’s in 2016: In addition to opening the ACA exchanges to the undocumented, they would also allow them to buy into the new public insurance option they would create through an expanded Medicare system. But they would still deny the undocumented any public assistance. Biden, in his CNN interview, put greater emphasis on expanding federally funded community-health clinics as a means of delivering more health care to undocumented immigrants than he has on offering them insurance.

At the other pole of the debate is Sanders’s Medicare for All proposal, which would entitle the undocumented to the same health-care services as anyone else in America. The actual language of the bill is less definitive: It says that while “every individual who is a resident of the United States is entitled to benefits for health care services under this Act,” the federal government will promulgate regulations for “determining residency for eligibility purposes.” But in response to a health-care questionnaire from The New York Times, Sanders unequivocally included the undocumented in his system: “Medicare for All means just that: all. Bernie’s plan would provide coverage to all U.S. residents, regardless of immigration status,” his campaign wrote.

In response to my questions, the campaigns of Senators Kamala Harris of California, Elizabeth Warren of Massachusetts, and Cory Booker of New Jersey said they would provide full benefits to the undocumented; so would former Housing and Urban Development Secretary Julián Castro.

South Bend, Indiana, Mayor Pete Buttigieg made a passionate case for covering the uninsured during last month’s debate, but his campaign would not specify his exact plan for doing so, particularly whether he would subsidize coverage with public dollars. Former Representative Beto O’Rourke of Texas likewise would not nail down his position on that point.

“This issue is one of many reasons Beto believes that comprehensive immigration reform must be a top priority,” Aleigha Cavalier, his national press secretary, said in a statement. “Because our laws rightly require hospitals to provide care to everyone, the cost of care for uninsured individuals is currently shifted onto other consumers. Therefore, it is in everyone’s interest to provide a pathway for obtaining insurance, whether through the ACA, a new universal healthcare program, or on the private market.”

The rub for both health-care and immigration advocacy groups seems to be the matter of public subsidies. What has become the more centrist position—of allowing undocumented people to purchase coverage on their own—generates mixed feelings: The advocates consider it a valuable gesture, but little more than that, because so few could afford health coverage without assistance.

Wright, for instance, says, “any step toward inclusion is a positive one.” But he notes that when California offered its coverage proposal to the Obama administration, his group estimated that probably fewer than 30,000 of the estimated 1.5 to 2 million uninsured undocumented immigrants in California could afford to buy coverage.

Rodriguez stressed the limited practical impact of the position Biden and Bennet are endorsing now. “If you don’t have subsidies, there is no affordability to get into the system,” he says. “Symbolism these days are still important. The fact that all the candidates raised their hands [to cover the undocumented], that’s not insignificant. But what would be meaningful is proposals that would enable families [to] afford coverage.”

California pushed the debate into another front this week. Governor Gavin Newsom signed a budget that makes California the first state to cover undocumented young adults ages 19 to 26 under its Medicaid program; the state had already extended eligibility to undocumented children under 18 and to pregnant women.

Wright noted that the expansion was, from a cost perspective, a relatively small component of a much larger package, one that focused on providing middle-class families more financial help to afford health care. That linkage, he argues, is the key to winning public acceptance for greater aid to the undocumented.

“There will always be a group of folks who are animated by the immigration issue and that just might be something they are opposed to, period,” he said, basing his analysis on focus groups and polls his group has conducted in California. “But if they see an effort to help people broadly, most people don’t begrudge others being helped as part of that process.”

With either modest steps—or big leaps—toward providing undocumented immigrants health coverage, that may be exactly the wager Democrats are placing in 2020.

The poll of The Day: Faith in Trump’s Phantom Health Care Plan

Yuval Rosenberg of the Fiscal Times noted that American voters aren’t quite sure what to make of the latest lawsuit seeking to strike down the Affordable Care Act.

While legal experts have largely dismissed the lawsuit, now before a federal appeals court, as meritless, a new Morning Consult survey of 1,988 registered voters finds a much more divided electorate.

Nearly half of voters, 44%, say the GOP-led lawsuit isn’t likely to bring down Obamacare, compared to 37% who say it might. Those views fall along predictably partisan lines:

Screen Shot 2019-07-14 at 9.50.04 PM.pngMore surprising is that voters who expect the ACA to be overturned express a fairly high level of confidence that President Trump has a plan to replace it. The GOP has thus far failed to come to a consensus about how to replace Obamacare, and Trump has yet to reveal a promised health care plan. Yet 60% of voters who think Obamacare may be struck down are confident the administration has a plan of its own, including 87% of Republicans.

Analysts and pundits have warned that, if the lawsuit were to succeed, it would be a disaster for Republicans — and GOP lawmakers have shown little desire to grapple with a health care overhaul again before the 2020 elections.

The Morning Consult poll also found that voters are increasingly placing responsibility for the state of the U.S. health care system on Trump — and half of the voters say the system has gotten worse over the past decade.Screen Shot 2019-07-14 at 9.46.48 PM

And now back to our discussion on the history of Medicare:

The benefits that the various states were required to provide recipients were:

  1. Inpatient hospital care (other than in an institution for tuberculosis or mental disease),
  2. Outpatient hospital services
  3. Laboratory and x-ray services
  4. Nursing facility services for those over the ages of twenty-one (and, after July 1, 1970, to home health services
  5. Physicians” services, regardless of the location of treatment.

Also, the states could underwrite many other services such as physical therapy, dental care, diagnostic, preventive, and rehabilitative services, and the cost of prescribed drugs, dentures, prosthetic devices, and eyeglasses. Those elderly that were insured by Medicare but were also eligible because of the incomes for Medicaid had their hospital deductibles and copayments paid by Medicaid.

The Johnson administration then went on in 1967 to propose amendments to the Social Security program that included extending Medicare benefits to the disabled who were otherwise eligible for cash payments. To pay for this extension, a higher earnings base on which Medicare taxes would be levied was recommended. So, from then on the current $6,600, the amount as to rise to $7,800 in 1968, to $9,00 in 1971, and in 1974 and thereafter would rise to $10,800.

However, despite the strong support from the Johnson administration, the House Ways and Means Committee voted to defer consideration of the extension in light of the substantial costs associated with the amendment. The administration tried to present the case that the medical costs for each disabled beneficiary would be about the same as those associated with Medicare recipients over the age of 65. But a study released while the bill was before the committee indicated that in fact, these costs would be about two and a half to three times as high.

And to no one’s surprise looking at healthcare today, following the first year of operation of the Hospital Insurance program that its costs significantly exceeded the estimates put forward by the program’s proponents. You have to remember that the main purpose of enacting a national health insurance bill had been, after all, to encourage greater use of health care facilities by the elderly. It was therefore not surprising that with the measure’s passage there should have been an increased demand for hospital and medical services. However, not only was there greater utilization of medical facilities on the part of those covered by the Medicare program, but there followed a far higher increase in the prices of covered services than had been expected. Congress reviewed the data and increased the contribution schedule along the lines suggested by the administration despite its not having incorporated the disabled among the program’s beneficiaries.

By 1972 the costs associated with Medicare had increased at such a rate that even the administration and Congress were expressing concern. What followed was a number of studies to examine the causes and I will discuss this more next week. So, imagine the passage of Medicare for All and the true costs!!

I have finally decided that our society is crazy and I probably have said this before. I was reading about Nike’s decision to not sell the sneakers with the Betsy Ross flag on the back of the shoe because Mr. Kaepernick decided that the flag was racist. Did the company realize that Betsy Ross was a Quaker and that Quakers were Abolitionists who helped ban slavery in England? Also, Quakers were vital to the American Underground Railroad to free slaves. Objecting to the Betsy Ross flag, because it represents slavery, shows complete and utter ignorance of history!!

More next week!