Category Archives: Obamacare

Kamala Harris Says ‘Medicare for All’ Wouldn’t End Private Insurance. It Would! and More on Healthcare and the Democratic Debate!

harris314Sahil Kapur reported that Kamala Harris says she supports “Medicare for All,” and she has cosponsored legislation with Bernie Sanders. But unlike her Democratic presidential rival, she says the plan wouldn’t end private insurance.

That’s misleading. The measure would outlaw all private insurance for medically necessary services but allow a sliver to remain for supplemental coverage. It would force the roughly 150 million Americans who are insured through their employer to switch to a government-run program.

Harris is trying to find a narrow path between two competing constituencies in the Democratic Party. On one side are progressives who passionately support so-called single payer insurance and are pushing the party to the left. On the other is the party establishment, which believes that calling for an end to private insurance for millions would be political suicide against President Donald Trump in 2020.

Her attempts to please both camps could become a vulnerability for a campaign that is surging after a strong performance in last week’s debates, though allies say her rhetoric about a role for private insurance would be more politically viable in a general election.

Misunderstood Question

The issue has tripped up the California senator almost from the moment she began her candidacy. During the debates in Miami last week, Harris and Sanders raised their hands when NBC’s Lester Holt asked which candidates would “abolish their private health insurance in favor of a government-run plan.” She retreated the next day, saying she thought Holt was referring to her personal insurance plan and answered “no” when asked if private coverage insurance should end.

She ran into a similar problem in January, when her campaign walked back a comment she made at a CNN town hall calling for getting “rid of” private insurance structures.

Larry Levitt, a health policy expert at the nonpartisan Kaiser Family Foundation, said the intent of the Sanders bill is clear.

“As a practical matter, Senator Sanders’ Medicare for all bill would mean the end of private health insurance,” he said. “Employer health benefits would no longer exist, and private insurance would be prohibited from duplicating the coverage under Medicare.”

Splitting Hairs

Sanders last week criticized Harris for splitting hairs, without mentioning her by name.

“If you support Medicare for All, you have to be willing to end the greed of the health insurance and pharmaceutical industries,” he said. “That means boldly transforming our dysfunctional system by ending the use of private health insurance, except to cover non-essential care like cosmetic surgeries.”

In an email, Harris spokesman Ian Sams responded: “Kamala’s position is and has always been every American would get insurance through the single payer plan, and private insurance would exist to cover anything supplemental, as is expressly outlined in the Medicare for All bill. Seems like Bernie is saying that, too.”

Other 2020 candidates — Elizabeth Warren, Cory Booker, and Kirsten Gillibrand — also cosponsored Sanders’s bill.

‘I’m With Bernie’

Warren has given a far more direct endorsement than Harris of the idea of eliminating private insurance.

“I’m with Bernie on Medicare for All,” she said on the first night of the Democratic debates. “There are a lot of politicians who say, oh, it’s just not possible, we just can’t do it, have a lot of political reasons for this. What they’re really telling you is they just won’t fight for it.”

At the other end of the spectrum is former Vice President Joe Biden, who said he wants to build on Obamacare by adding a government-run plan to the menu of options, a provision that progressives tried and failed to add in 2009 amid opposition from centrist Democrats.

“Everyone, whether they have private insurance or employer insurance and no insurance, they, in fact, can buy in the exchange to a Medicare-like plan,” Biden said in the debate.

Hedging her position, Harris has also cosponsored “Medicare X” legislation by Senator Michael Bennet of Colorado, another Democratic presidential candidate who’s running as a moderate. That measure would preserve private coverage while allowing Americans to buy into a government-run plan. But she said Friday on MSNBC she favors single payer with only supplemental private insurance.

An issue that united the party in 2018 has the potential to fracture it in 2020.

Abby Goodnough and Thomas Kaplan reported on the Democratic party debate and that It was a command as much as a question, intended to put an end to months of equivocating and obfuscating on the issue: Which of the Democratic presidential candidates on the debate stage supported abolishing private health insurance in favor of a single government-run plan? Show of hands, please.

Just four arms went up over the two nights — Senator Elizabeth Warren of Massachusetts and Mayor Bill de Blasio of New York on Wednesday, and Senators Bernie Sanders of Vermont and Kamala Harris of California on Thursday — even though five candidates who kept their hands at their sides have signed onto bills in Congress that would do exactly that.

And after the debate, Ms. Harris said that she had misunderstood the question, suggesting she had not meant to raise her hand either.

The response and ensuing confusion reflected one of the deepest fault lines among Democrats heading into 2020 — on an issue the party hopes to use as a cudgel against President Trump as effectively as it did last fall when their vow to protect the Affordable Care Act helped them recapture the House.

Though Democrats owned the health care issue in 2018, pointing a way forward — tear up the current system and start over or build on gains in coverage and care that the Obama health law achieved — is proving tricky for the party’s presidential candidates.

The challenge is to avoid alienating both the progressives, whose support they will need in the primary and the more moderate voters, without whom they cannot survive the general election.

We surveyed all the candidates for details of their positions on health care. Here’s what they said:

‘Medicare for All’ vs. ‘Public Option’: The 2020 Field Is Split, Our

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In shooting up her hand and saying, “I’m with Bernie,” Ms. Warren seemed to have made the calculation that proving herself as unequivocal as Mr. Sanders in the quest for universal government-run health insurance was crucial to building the left-wing support she needs, including from some of his loyalists.

During the early months of the Democratic primary race, Ms. Warren has gained attention with her steady stream of detailed policy plans on a variety of subjects. But before Wednesday’s debate, she had been less than crystal clear about how she would expand access to health care— and particularly on the role, that private insurers should play under the type of Medicare-for-all system that she is calling for.

“I think lots of progressives were very happy to see her clarify her position,” said Waleed Shahid, the communications director for Justice Democrats, a group that seeks to elect progressive House candidates.

Ms. Harris had more overtly waffled on the future of private insurance before the debates, yet raised her hand just as quickly as Mr. Sanders when one of the moderators asked who favored abolishing it.

After the debate, she immediately walked it back, saying she understood the question to be asking whether she would give up her own private insurance.

Asked point-blank on MSNBC’s “Morning Joe” on Friday morning whether she believed that private insurance should be eliminated in the United States, Ms. Harris responded, “No.”

“I am a proponent of ‘Medicare for all,’” she said. “Private insurance will exist for supplemental coverage.” Mr. Sanders’s Medicare for All Act, which she co-sponsored, would allow private coverage for elective procedures, like cosmetic surgery, not covered by the government plan.

John Delaney, a former Maryland congressman who is also seeking the Democratic presidential nomination, is taking every possible opportunity to warn that the party is at risk of turning health care from a winning issue into a liability.

“We won on health care in 2018, and if we go down the path with Medicare for all, we’ll lose on it in 2020,” he said in an interview. “Right now, about half of our citizens have private insurance and most of them like it. And you just can’t win elections on taking something away from the American people that they like. It’s just not common sense.”

Ironically, support for universal government-run health insurance could provoke the same counterattack from Republicans that the Democrats used so potently after the Trump administration tried to repeal and replace the Affordable Care Act.

“Trump and the Republicans will spend a billion dollars telling the American people that the Democrats want to take away your health insurance,” Mr. Delaney said, “and he would be correct.”

Mr. Trump appears to be adopting just such a strategy. In a recent Rose Garden appearance, he warned that more than 120 Democrats had signed onto Medicare for all legislation — a “massive government takeover of health care,” as he put it — that would expand Medicare to cover all Americans, make the program’s benefits more generous and eliminate most deductibles and co-payments.

“That’s going to hurt a lot of people,” Mr. Trump said. “Their plan would eliminate Medicare as we know it and terminate the private health insurance of 180 million Americans.”

Remaining imprecise on the issue could have been a vulnerability for Ms. Warren in particular as she tries to compete with Mr. Sanders. “Elizabeth Warren Has a Plan for Everything — Except Health Care,” read the headline of a recent article published by Jacobin, the socialist magazine.

But her outright call for eliminating private coverage would create new risks if she were to become the Democratic nominee.

“She didn’t have to fall into that trap,” said Paul Starr, a professor of sociology and public affairs at Princeton who was a health policy adviser in the Clinton White House.

Not only would abolishing private insurance disrupt coverage for many people who are satisfied with their private coverage, Mr. Starr said, but generating the revenue needed to finance a single-payer health care system “would be just an overwhelming political task.”

“If in coming weeks and months it’s that raising of the hand that gets replayed again and again, then I think it’s going to damage her,” he said.

With Mr. Trump and his surrogates likely to step up their attack in the coming months, it was not particularly surprising to hear most of the Democrats walk a more cautious line — even the ones who have co-sponsored Mr. Sanders’s single-payer bill or a House version that would, in fact, put everyone into government-run coverage, including Senator Cory Booker of New Jersey, Senator Kirsten Gillibrand of New York and Representative Tulsi Gabbard of Hawaii.

All three were more vague when questioned about eliminating private insurance. Mr. Booker said he favored keeping it but did not explain why and Ms. Gabbard said merely that it deserved “some form of a role.”

Many candidates — including some who say their ultimate goal is a government-run system — support a system in which people would have the option to buy into Medicare or a similar public insurance program, but private insurers could still compete for their business.

Ms. Gillibrand was eager to point out that she had written the portion of the Sanders bill allowing four years for Americans to transition to their new government coverage by providing such a choice.

“I believe we need to get to universal health care as a right and not a privilege — to single-payer,” Ms. Gillibrand said. “The quickest way you get there is you create competition with the insurers. God bless the insurers. If they want to compete, they can certainly try.”

More likely, though, she contended, is that “people will choose Medicare, you will transition, we will get to Medicare for all.”

The hesitancy to fully embrace the abolition of private insurance isn’t surprising considering the polling on the issue, which has consistently found that support for Medicare for all drops off quickly when voters are told it would eliminate their private, employer-provided plans and most likely raise taxes.

The poll results also help explain why so many candidates — including former Vice President Joseph R. Biden Jr., Senator Michael Bennet of Colorado, Mayor Pete Buttigieg of South Bend, Ind., Gov. Jay Inslee of Washington, Senator Amy Klobuchar of Minnesota and former Representative Beto O’Rourke of Texas — say they would keep private insurance but add a “public option” to buy coverage in a government-run health plan that would create competition and potentially drive down prices.

Some candidates support bills that would allow people who do not get insurance through a job, or those 50 and older, to pay a premium to buy a Medicare plan that would be the same as what is now available to people 65 and older. Others prefer the idea of setting up a new public plan, run by the government, that anyone could buy — a “Medicare-for-all-who-want-it” approach.

Mr. Buttigieg used that very phrase on Thursday and suggested he was fine with keeping private insurance for everything but the most basic care.

“Let’s remember,” he said, “even in countries that have outright socialized medicine — like England — even there, there’s still a private sector. That’s fine. It’s just that for our primary care, we can’t be relying on the tender mercies of the corporate system.”

Mr. Biden noted that creating a public option to compete with private insurance could be done much quicker than a complete overhaul of the health care system.

“Urgency matters,” Mr. Biden said, referring to people like his son Beau, who died of brain cancer in 2015. “We must move now.”

How might Medicare for All reshape health care in the U.S.?

As the Democrats pummel us all with their various forms of a single-payer, Medicare for All, healthcare systems, Sharita Forrest noted that a recent Kaiser Family Foundation poll indicates that support for a single-payer health system is increasing among American consumers, but many people are confused about how a program like “Medicare for All” would actually affect them. University of Illinois professor emeritus of community health Thomas W. O”Rourke, an expert on health policy analysis, spoke with News Bureau research editor Sharita Forrest.

How might a single-payer system such as Medicare for All differ from what we have now?

Under a true single-payer program, coverage would be universal, with every resident covered from birth to death. Health care would become a public service funded through taxes, much like the public schools, the fire department and the military.

It would detach health care from employment. Most Americans receive private health insurance under a shared-cost arrangement with their employers or through Medicare. If you lose or change your job, you may lose your insurance and access to care unless you can pay the full cost yourself.

Coverage would be portable and accessible across the country, without geographical, economic or bureaucratic obstacles such as narrow provider networks.

Various politicians are proposing different types of health care programs. What are the key differences to watch for?

Many politicians and think tanks have proposed plans that are not actual single-payer plans but have similar-sounding names such as “Medicare Extra.”

The key questions to ask are: Who is covered? What benefits are included? How is it funded? Who pays? And what are the roles of the government and the private sector in controlling and managing costs?

A true single-payer plan:

  • Provides universal coverage for everyone.
  • Covers all medically necessary care—including inpatient and outpatient services, drugs, mental health, reproductive health, dental, vision, and long-term care—and virtually every provider is in the network.
  • Covers 100 percent of costs without premiums, copays or deductibles.
  • Maximizes administrative efficiencies and exerts cost-control measures such as global budgeting for hospitals, negotiated fee schedules, and drug prices, and bulk purchasing of drugs and other supplies.
  • Is nonprofit and does not include a role for private health insurance except that private insurers could offer supplemental plans that pay for extras like cosmetic surgery that aren’t covered by the government plan.

What would the federal government’s role be in a single-payer system?

The government would finance the system, but, importantly, not own or operate it. It would be publicly funded but privately operated.

There are many options for funding it, including payroll taxes, taxes on Wall Street trades, increased taxes on high-income earners or taxes on investments and interest.

If the program followed other countries’ examples, it would reduce costs by consolidating administrative tasks and eliminating insurers’ profits. Because there would be one payer instead of multiple payers with thousands of plans, the government could leverage its purchasing power to exert cost controls that currently don’t exist.

Critics argue that a single-payer program would end up costing consumers more. Can such comprehensive care be provided without burdensome tax hikes?

It would require a modest tax increase, true, but eliminating health insurance premiums, copays, high out-of-pocket costs would offset that and runaway price increases. The taxes would be progressive, based on income. Therefore, many families would experience broader coverage with comparable or reduced expenditures.

Our current system wastes hundreds of billions of dollars annually, in part because providers have to deal with many different insurance carriers and bill each patient individually.

A 2003 study in the New England Journal of Medicine estimated that administrative costs are responsible for 31 percent of U.S. health care costs, compared with about 17 percent in Canada. Through simplified administration and greater efficiency, some researchers estimate that Medicare for All would save more than $500 billion a year.

According to a Commonwealth Fund report, the U.S. ranks last among 11 industrialized countries on health care quality, efficiency, access to care, equity and outcomes such as infant mortality and longevity.

If the U.S. were in the Health Olympics, we would never make it to the medal podiums.

By 2025, health care costs in the U.S. are expected to rise to one-fifth of our economy. Some people say we can’t afford to provide universal coverage when actually we can’t afford not to provide it.

Opponents deride single-payer plans as socialized medicine that facilitates greater government encroachment into their lives and deprives them of choice. Is that an accurate depiction?

Americans are concerned about affordability, access, and quality. They value their relationship with their clinicians, not their health insurance companies.

Currently, we have the illusion of choice. Our employers choose our health plan, and our insurance companies determine which providers we can see and when—unless we want to cover all of the costs ourselves.

Under a true Medicare for All program, choice and access would expand.

What are the main obstacles to implementing a single-payer system?

There seems to be a lack of public understanding. Health care is a complex topic, and there are so many different proposals and so much misinformation and disinformation. Expect much more in the months ahead.

Entrenched interests—including insurers, many health care providers, the pharmaceutical industry and medical device makers—don’t want to give up their profits. We’re already seeing the pushback in the media.

Many lawmakers aren’t going to get behind a single-payer plan until it’s politically expedient.

There was an interesting comment made this past week, President Trump can’t win the 2020 election but the Democratic Party policies will be responsible for their loss, where they reach into all of our pockets and pick every cent and dollar that we have earned. How true!!

Some more history regarding Medicare and now, Medicaid!

Title XIX: Medicaid. The 1965 legislation provided states a number of options regarding their level of participation in Medicaid, ranging from opting out of the program entirely to including all covered services for all eligible classes of persons. The federal government provided matching funds for two of the three groups stipulated in the legislation (the “categorically needy” and those “categorically linked,”) while in the case of the third group (“not categorically linked but medically indigent”) only administrative funds (and no medical expenses) were matched. Each state was required to include members of the first group, the categorically needy, in the medical care program acceptable to the Department of Health, Education, and Welfare, while the inclusion of the other groups was optional. Eligibility standards varied (and continued to vary) from state to state, depending on the state legislation. The three groups were:

  1. The Categorically Needy. This group included all persons receiving federally matching public welfare assistance, including Families and Dependent Children, the permanently and totally disabled, the blind, and the elderly whose resources fell below welfare-stipulated levels. The federal government matched state expenditures from 50 to 80 percent, depending on the state’s per capita income.
  2. The Categorically Linked. This class included persons who fell into one of the four federally assisted categories whose resources exceeded the ceiling for cash assistance. Should the state designate members of this class as medically indigent, benefits had to be extended to all four subgroups. The amount of federal matching funds was determined by the same formula as was used for the Categorically Needy.
  3. Not Categorically Linked but Medically Indigent. Members of this group could include those eligible for the statewide general assistance and those between the ages of twenty-one and sixty-five deemed medically indigent. State operating expenses were not matched by the federal government, who confined their grants to match the costs of administering the program if the benefits extended to members of this group were comparable to those provided to other groups.

Next, I will cover the benefits that the various states were required to provide recipients.

These all sound like great ideas unless one realizes the limitations of reimbursements to hospitals, physicians and other care givers.

Why Mention Failed Obamacare When Democrats Can Debate Shiny New Medicare-for-All? And More About the Medicare Bill and Its Provisions.

fourth297Reporter Megan McArdle noted that there’s one thing you didn’t hear at the first two Democratic presidential debates unless you were listening carefully to what candidates didn’t say: Obamacare is a failure.

The Affordable Care Act barely came up. What candidates wanted to talk about was Medicare-for-all.

That is nothing short of extraordinary. In 2010, President Barack Obama signed into law the biggest entitlement expansion, and the most significant health-care reform, since the 1960s. You’d think Democrats would be jostling to claim that mantle for themselves. Instead, it was left in a corner, gathering dust, while the candidates moved on to the fashion of the moment.

In fairness, they may have found the garment an uncomfortable fit. The rate of Americans without health-care insurance is now within a percentage point of where it was in the first quarter of 2008, a year before Obama took office. Yet in 2008, the unemployment rate was more than a full percentage point higher than it is now. Given how many people use employer-provided health insurance, the uninsured rate ought to be markedly lower than it was back then.

Overall, the effect of Obamacare seems to be marginal, or perhaps nonexistent.

You can chalk that up to Republican interference since the uninsured rate has risen substantially in the Trump era. But Democrats weren’t really making that argument, perhaps because they realized that a system so vulnerable to Republican interference isn’t really a very good system.

But even before January 2017, Obamacare was failing to deliver on many of its key promises. At its best point, in November 2016, the reduction in the number of the uninsured was less than the architects of Obamacare had expected. And the claims that Obamacare would “bend the cost curve” had proved, let us say, excessively optimistic.

Adjusted for inflation, consumer out-of-pocket expenditures on health care have been roughly flat since 2007. Obamacare didn’t make them go up, but it didn’t really reduce them, either. The rate of growth in health-services spending has risen substantially since 2013 when Obamacare’s main provisions took effect. And since someone has to pay for all that new spending, premiums have also risen at about the same pace as before Obamacare. So much for saving the average American family $2,500 a year!

Meanwhile, the various proposals that were supposed to streamline care and improve incentives have produced fairly underwhelming results. Accountable-care organizations, which aimed to reorient the system around paying for health rather than treatment, have produced, at best, modest benefits. Meanwhile, a much-touted program to reduce hospital readmissions not only failed to save money but may also have led to thousands of unnecessary deaths.

Nine years in, when you total up all the costs and benefits, you end up with . . . a lot of political aggravation for very little progress. No wonder Democrats would rather talk about something else.

And yet, it’s startling that the something else is health care. The U.S. system is a gigantic, expensive mess, but experience indicates that politicians who wade into that mess are apt to emerge covered in toxic sludge, without having made the mess noticeably tidier.

That could be a good argument for Medicare-for-all: The health-care mess has grown so big, so entangled with the detritus from decades of bad policymaking that it can’t be straightened out. The only thing to do is bulldoze the steaming pile of garbage into a hole and start over.

The argument isn’t unreasonable, even if I don’t agree with it. But it is a policy argument, not a political argument. The political argument in favor of launching into another round of health-care reform is, purely and simply, that a certain portion of the Democratic base wants to hear it.

And a fine reason that is in a primary race. But it then comes to the general election, filled with moderate voters who get anxious when people talk about taking away their private health insurance in favor of a government-run program — as Elizabeth Warren (D-Mass.), Bernie Sanders (I-Vt.) and Kamala D. Harris (D-Calif.) have all done. (On Friday, Harris said she misheard a debate question and changed her position, a flip-flop she has tried before.)

More to the point, whatever the merits of Medicare-for-all, the political obstacles to even the comparatively modest reforms of Obamacare very nearly overwhelmed it — and probably cost Democrats their House majority in 2010. And the compromises that Democrats were forced to make to get even that through Congress left them with a badly drafted program that had insufficient popular support — one that was, in other words, almost doomed to fail. At an enormous political cost. It takes either a very brave politician or a very foolish one, to look at the Obamacare debacle and say, “I want to do that again, except much more so.”

Health Care Gets Heated On Night 2 Of The Democratic Presidential Debate

Reporter Shefali Luthra pointed out that on Thursday, the second night of the first Democratic primary debate, 10 presidential hopefuls took the stage and health issues became an early flashpoint. But if you listen to both nights it was embarrassing. These 25 potential candidates could be the answer to the President’s campaign. Some of their ideas are just too expensive and plain dangerous!!

Sen. Bernie Sanders (I-Vt.) opened the debate calling health care a “human right” — which was echoed by several other candidates — and saying “we have to pass a ‘Medicare for All,’ single-payer system” — which was not.

Just as on Wednesday night, moderators asked candidates who would support abolishing private insurance under a single-payer system. Again, only two candidates — this time Sanders and California Sen. Kamala Harris — raised their hands.

Former Vice President Joe Biden also jumped on health care, saying Americans “need to have insurance that is covered, and that they can afford.”

But he offered a different view of how to achieve the goal, saying the fastest way would be to “build on Obamacare. To build on what we did.” He also drew a line in the sand, promising to oppose any Democrat or Republican who tried to take down Obamacare.

Candidates including South Bend, Ind., Mayor Pete Buttigieg, New York Sen. Kristen Gillibrand and Colorado Sen. Michael Bennet offered their takes on universal coverage, each underscoring the importance of a transition from the current system and suggesting that a public option approach, something that would allow people to buy into a program like Medicare, would offer a “glide path” to the ultimate goal of universal coverage. Gillibrand noted that she ran on such a proposal in 2005. (This is true.)

Meanwhile, former Colorado Gov. John Hickenlooper used the issue of Medicare for All to say that it is important to not allow Republicans to paint the Democratic Party as socialist but also to claim his own successes in implementing coverage expansions to reach “near-universal coverage” in Colorado. PolitiFact examined this claim and found it Mostly True.

“You don’t need big government to do big things. I know that because I’m the one person up here who’s actually done the big progressive things everyone else is talking about,” he said.

But still, while candidates were quick to make their differences clear, not all of their claims fully stood up to scrutiny.

Fact-checking some of those remarks.

Sanders: “President Trump, you’re not standing up for working families when you try to throw 32 million people off the health care that they have.”

This is one of Sanders’ favorite lines, but it falls short of giving the full story of the Republican effort to repeal and replace Obamacare. We rated a similar claim Half True.

I’ll write more about half-truths next week.

Scrapping the Affordable Care Act was a key campaign promise for President Donald Trump. In 2017, as the Republican-led Congress struggled to deliver, Trump tweeted “Republicans should just REPEAL failing Obamacare now and work on a new health care plan that will start from a clean slate.”

The Congressional Budget Office estimated that would lead to 32 million more people without insurance by 2026. But some portion of that 32 million would have chosen not to buy insurance due to the end of the individual mandate, which would happen under repeal. (It happened anyway when the 2017 tax law repealed the fine for the individual mandate.)

In the end, the full repeal didn’t happen. Instead, Trump was only able to zero out the fines for people who didn’t have insurance. Coverage has eroded. The latest survey shows about 1.3 million people have lost insurance since Trump took office.

Bennet, meanwhile, used his time to attack Medicare for All on a feasibility standpoint.

Bennet: “Bernie mentioned the taxes that we would have to pay — because of those taxes, Vermont rejected Medicare for All.”

This is true, although it could use some context.

Vermont’s effort to pass a state-based single-payer health plan — which the state legislature approved in 2011 — officially fell flat in December 2014. Financing the plan ultimately would have required an 11.5% payroll tax on all employers, plus raising the income tax by as much as 9.5%. The governor at the time, Democrat Peter Shumlin, declared this politically untenable.

That said, some analysts suggest other political factors may have played a role, too — for instance, the fallout after the state launched its Affordable Care Act health insurance website, which faced technical difficulties.

Nationally, when voters are told Medicare for All could result in higher taxes, support declines.

And a point was made by author Marianne Williamson about the nation’s high burden of chronic disease.

Williamson: “So many Americans have unnecessary chronic illnesses — so many more compared to other countries.”

There is evidence for this, at least for older Americans.

A November 2014 study by the Commonwealth Fund found that 68% of Americans 65 and older had two or more chronic conditions, and an additional 20% had one chronic condition.

No other country studied — the United Kingdom, New Zealand, Sweden, Norway, France, Switzerland, the Netherlands, Germany, Austria or Canada — had a higher rate of older residents with at least two chronic conditions. The percentages ranged from 33% in the United Kingdom to 56% in Canada.

An earlier study published in the journal Health Affairs in 2007 found that “for many of the most costly chronic conditions, diagnosed disease prevalence and treatment rates were higher in the United States than in a sample of European countries in 2004.”

‘Medicare For All’ Is The New Standard For 2020 Democrats

In 2008, single-payer health care was a fringe idea. Now, its opponents are the ones who have to explain themselves.

Jeffrey Young pointed out that the last time there was a competitive race to be the Democratic presidential nominee, in 2008, just one candidate called for the creation of a national, single-payer health care program that would replace the private health insurance system: then-Rep. Dennis Kucinich (D-Ohio).

This time around, “Medicare for All” is the standard against which all the Democratic candidates’ plans are measured. There’s also a very real chance that, for the first time since Harry Truman, Democrats will nominate a presidential candidate who actively supports the creation of a universal, national health care system.

During Kucinich’s long-shot bid against leading contenders like then-Sens. John Edwards (N.C.), Hillary Clinton (N.Y.) and Barack Obama (Ill.), his opponents barely felt the need to counter his single-payer position. It was seen as too much, too fast, too disruptive and too expensive. Edwards, Clinton, and Obama all instead promoted plans reliant on private insurers. In 2010, President Obama enacted those principles in the form of the Affordable Care Act.

That split still exists, with current Democratic presidential hopefuls like Sen. Amy Klobuchar (Minn.) and former Vice President Joe Biden as the proponents of a more cautious, incremental approach to achieving universal coverage and lower health care costs.

But as the two nights of presidential debates between the 2020 candidates illustrated, it’s Sen. Bernie Sanders (I-Vt.) and his sweeping Medicare for All plan that is now the benchmark for progressive health care reform. It’s appropriate, considering that Sanders’ serious challenge to Clinton in 2016 moved the notion of single-payer health care into the Democratic mainstream.

Sen. Elizabeth Warren (Mass.) acknowledged as much in her response to a question about health care on Wednesday: “I’m with Bernie on Medicare for All,” she said.

The case Sanders made for Medicare for All is essentially the same Kucinich made years ago during his presidential campaign, the difference being that Sanders has earned the right to have his ideas taken seriously, and did a lot of the work to force those ideas into the mainstream.

“The function of health care today from the insurance and drug company perspective is not to provide quality care to all in a cost-effective way. The function of the health care system today is to make billions in profits for the insurance companies,” Sanders said Thursday. “We will have Medicare for All when tens of millions of people are prepared to stand up and tell the insurance companies and the drug companies that their say is gone, that health care is a human right, not something to make huge profits on.”

Among the Democratic candidates, Warren, and Sens. Cory Booker (N.J.),  Kirsten Gillibrand (N.Y.) and Kamala Harris (Calif.) are co-sponsors of Sanders’ bill and Reps. Tulsi Gabbard (Hawaii), Tim Ryan (Ohio) and Eric Swalwell (Calif.) are co-sponsors of a similar House bill introduced by Rep. Pramila Jayapal (D-Wash.).

Biden is a leading representative of the other side of this debate, which also is appropriate. The White House in which he served carried out the biggest expansion of the health care safety net since Democratic President Lyndon Johnson’s Great Society initiatives, which included the creation of Medicare and Medicaid.

And while the Affordable Care Act was nowhere near as far-reaching as single-payer would be, the changes it brought created widespread anxiety among those who already had health coverage, a political dynamic that dogged Obama’s White House.

Like other moderates including Sen. Michael Bennet (Colo.), Biden insisted he supported universal coverage even while opposing Sanders’ Medicare for All plan, and suggested another path.

“The quickest, fastest way to do it is built on Obamacare, to build on what we did,” Biden said Thursday, highlighting his preference for a public option that would be available to everyone in lieu of private insurance.

It was Klobuchar who articulated the political argument that replacing the entire current coverage system with a wholly public one would be disruptive. “I am just simply concerned about kicking half of America off of their health insurance in four years, which is what this bill says,” she said Wednesday.

Although just four of the 20 candidates raised their hands when asked if they supported eliminating private health insurance during the two debates ― Sanders, Warren, Harris and New York Mayor Bill de Blasio ― the very fact that this was the question shows how much has changed since Kucinich’s opponents could safely brush off the notion of single-payer without alienating Democratic primary election voters. (Harris later recanted her answer, claiming to have misunderstood the question.)

Medicare for All proponents learned from the GOP’s relentless attacks on the Affordable Care Act that even incremental change will bring accusations of rampant socialism, so they might as well go for the whole thing.

The question that was seemingly designed to expose the differences in their points of view had the effect of highlighting how much broad agreement there is within the Democratic Party about what to do about high health care costs and people who are uninsured or under-insured.

It’s also a bit of an odd litmus test in the context of other nations’ universal health care programs, which are meant to be the models for plans like Medicare for All. Private insurance even exists as a supplement to public programs in countries like the United Kingdom and Canada.

Even so, while the question of whether private coverage can coexist with broadened public plans in the United States is a genuine sticking point among Democrats, the responses from the candidates who addressed the issue Wednesday and Thursday nights also highlighted their apparently universal conviction that the federal government should play a much larger role in providing health coverage.

In 2008, the top candidates all supported what’s now considered the moderate position, which was some form of government-run public option as an alternative to private insurance. Centrist Democrats in Congress killed that part of the Affordable Care Act, and Obama went along with it. This year, the public option is the bare minimum.

And every Democratic candidate’s proposals are a far, far cry from the policies President Donald Trump and the Republican Party seek, which amount to dramatically reducing access to health care, especially for people with low incomes.

Likewise in contrast to Trump, all 10 Democrats who appeared at Thursday’s debate endorsed allowing undocumented immigrants access to federal health care programs, which would mark a major shift in government policy. Under current law, undocumented immigrants are ineligible for all forms of federal assistance except limited, emergency benefits.

Just nine years ago, the Democrats who wrote the Affordable Care Act included specific provisions denying undocumented immigrants access to the health insurance policies sold on the law’s exchange marketplaces, even if they want to spend their own money on them.

Medicare for All proponents views the reticence of the candidates who haven’t joined their side as a lack of courage. They also learned from the GOP’s relentless attacks on the Affordable Care Act that even incremental change will bring accusations of rampant socialism, so they might as well go for the whole thing.

“There are a lot of politicians who say, ‘Oh, it’s just not possible. We just can’t do it,’” Warren said Wednesday. “What they’re really telling you is they just won’t fight for it.”

Health care may or may not be a determining factor in which of these candidates walks away with the Democratic nomination. Also unknown is whether Democratic voters’ uneven support for Medicare for All will benefit the more moderate candidates, or whether the progressive message of universal health care and better coverage will appeal to primary voters.

Both camps may actually benefit from the public’s vague understanding of what Medicare for All is and what it would do compared to less ambitious approaches like shoring up the Affordable Care Act and adding a public option.

For moderate candidates like Biden, support for greater access to government benefits may be enough to satisfy all but the most ardent single-payer supporters. But voters who are uncertain about the prospect of upending the entire health coverage system with Medicare for All may also be unconcerned about candidates like Sanders because they don’t realize how much change his plan would bring.

The debates didn’t shed much light on the answers to those questions. Voters will get their first chance to weigh in by February when the Iowa caucuses begin and campaign season kicks into high gear.

Remember that last we talked; the Medicare Bill was passed and signed by President Johnson. Next, I reviewed the main provisions starting with Title XVIII, Part A.

Now on to Title XVIII, Part B: Supplementary Medical Insurance (SMI). This provided that all persons over sixty-five were eligible for participation in this program on a voluntary basis, without the requirement that they had earlier paid into the Social Security program. Benefits included physicians’ services at any location and home health services of up to one hundred visits per year. Coverage also included the costs of diagnostic tests, radiotherapy, ambulance services, and various medical supplies and appliances certified as necessary by the patient’s physician. Subscribers were at first required to pay one-half the monthly premium, with the government underwriting the other half. After July 1973 premium increases levied on subscribers were limited to “the percentage by Social Security cash benefits had been increased since the last…premium adjustment.” Each enrollee was subject to a front-end deductible ($50 per year originally, $100 in 1997). After having met this payment, patients were responsible for a coinsurance of 20 percentage of the remaining “reasonable” charges. Limits were set on the amount of psychiatric care and routine physical examinations. Among the exclusions were eye refraction and other preventive services, such as immunizations and hearing aids. The cost of drugs was also totally excluded. Similar financing arrangements as prevailed for Part A coverage were put in place for Part B for the payment of benefits. Premium payments were placed in a trust fund, which made disbursements to private insurance companies—carriers—who reimbursed providers on a “reasonable cost” or, in the case of physicians, “reasonable charge” basis. Physicians were permitted to “extra bill” patients if they regarded the fee schedule established by the carriers as insufficient payment. (William Shonick, Government and Health Services: Government’s Rule in the Development of U.S. Health Services, 1930-1980, New York, Oxford University Press, 1995. pp 285-91.)

Note that Medicare has further discounted physician fees, which makes it difficult to run a practice based on Medicare reimbursement. We need to remember this when we discuss the new healthcare system, Medicare for All, which almost all of the Democratic presidential candidates propose. Realize also, that not one of those candidates knows anything about Medicare and what Medicare for All really means in its application. Be very careful all you voters!!!

And next on to Title XIX: Medicaid.

And a Happy Fourth of July to All. Remember why we celebrate this day and enjoy our Freedom!

The Conversation We Refuse to Have About War and Our Veterans, Hospital Billing and More on the History of Medicare.

Screen Shot 2019-05-26 at 11.34.05 PMMemorial Day and the latest redeployment of soldiers and a carrier group to the Middle East is a perfect time to realize that Veterans bear the burden of war long after they leave the battlefield. It’s time for America to acknowledge it.

I went to the market

Where all the families shop

I pulled out my Ka-bar

And started to chop

Your left right left right left right kill

Your left right left right you know I will

-Military cadence

“You can shoot her…” the First Sergeant tells me. “Technically.”

Benjamin Sledge wrote reflecting, we’re standing on a rooftop watching black smoke pillars rise from a section of the city where two of my teammates are taking machine gun fire. Below, the small cluster of homes we’ve taken over is taking sporadic fire as well. He hands me his rifle with a high powered scope and says, “See for yourself.”

It’s the six-year-old girl who gives me flowers.

We call her the Flower Girl. She hangs around our combat outpost because we give her candy and hugs. She gives us flowers in return. What everyone else at the outpost knew (except for me, until that day) was that she also carried weapons for insurgents. Sometimes, in the midst of a firefight, she would carry ammunition across the street to unknown assailants.

According to the rules of engagement, we could shoot her. No one ever did. Not even when the First Sergeant morbidly reassured them on a rooftop in the middle of Iraq.

Other soldiers didn’t end up as lucky.

Sometimes they would find themselves paired off against a woman or teenager intent on killing them. So they’d pull the trigger. One of the sniper teams I worked with recounted an evening where he laid up a pile of people trying to plant an IED. It was a “turkey shoot,” he told me laughing. But then he got quiet and said, “Eventually they sent out a woman and this dumb kid.” I didn’t need to ask what happened. His voice said it all.

I often wonder what would have happened if the Flower Girl pointed a rifle at me, but I’m afraid I already know. The thought didn’t matter anyway. There was enough baggage from tours in Afghanistan and Iraq that coming home was full of uncertainty, anger, and confusion — and not, as I had been led to believe, warmth and safety.

“People only want to hear the Band of Brothers stories. The ones with guts and gusto! Not the one where you jam a gun in an old woman’s face or shoot a kid.” I pause, then add, “Look around the room for a second…”

Andy surveys the restaurant we’re in for a moment while I lean in with a sardonic half-smile.

“How many people can even relate to what we’ve been through? What would they rather hear about? How Starbucks is giving away free lattes and puppies this week? Or how a soldier feels guilty because he pulled a trigger, lost a friend, or did morally questionable things in war? Hell, I want to hear about the latte giveaway… especially if it’s pumpkin spice.”

This eases the tension and he smiles.

Andy and I feel like we don’t fit in. We met a few years ago at the church where he works, and where I volunteer. Of the thousands of people in the congregation, we are a handful of veterans. The veterans I meet are few and far between, and we typically end up running in the same circles.

How do you talk about morally reprehensible things that have left a bruise on your soul?

Years ago, Andy fought in the siege of Fallujah. We never readjusted to normal life after deployment. Instead, we found ourselves angry, depressed, violent and drinking a lot. We couldn’t talk to people about war or its cost because, well, how do you talk about morally reprehensible things that leave a bruise on your soul?

The guilt and moral tension many veterans feel is not necessarily post-traumatic stress disorder, but a moral injury — the emotional shame and psychological damage soldiers incur when we have to do things that violate our sense of right and wrong. Shooting a woman or child. Killing another human. Watching a friend die. Laughing about situations that would normally disgust us.

Because so few in America have served, those who have can no longer relate to their peers, friends, and family. We fear being viewed as monsters or lauded as heroes when we feel the things we’ve done were morally ambiguous or wrong.

The U.S. is currently engaged in the longest running war in the history of the United States. We are entering our 15th year in Afghanistan, and we still station troops in some Iraqi outposts. In World War II, 11.5% of U.S. citizens served in four years. In Vietnam, 4.3% served in 12 years. Since 2001, only 0.86% of our population has served in the Global War on Terror. Yet, during World War II, 10 million men were drafted, and over 2 million men were conscripted during Vietnam. Despite the length of the Iraq and Afghan Wars, there has been no draft, whereas, in times past, shorter wars cost us millions of young men. Instead, less than 1% of the population has borne this burden, with repeated tours continually deteriorating our troops’ mental health.

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The gap between citizens and soldiers is growing ever wider. During WWII, the entire nation’s focus was on purchasing war bonds and defeating the Nazis. Movie previews and radio shows gave updates on the war effort. Today’s citizens, however, are quickly amused by the latest Kardashian scandal on TV, which gives no reminder of the men and women dying overseas. Because people are more concerned about enjoying their freedoms and going about their day to day lives, veterans can feel like outcasts. As though nothing we did matter to a country that asked us to go.

This is part of the problem with a soldier’s alienation. People quickly point out that we weren’t forced to join the military and fight in a war. We could have stayed home. The counterpoint is that, because the U.S. has now transitioned to an all-volunteer force, those opposed to war should be thanking their lucky stars that volunteers bear the burden of combat.

Additionally, regardless of whether you’re Republican, Democrat, Libertarian, Communist, Liberal, Conservative, Conscientious Objector, or Pacifist, we all sent the soldier overseas. Because we live in a democracy, we vote to put men and women in charge of governing our affairs, and those elected representatives send troops overseas. We may have voted for someone else, but it does not change the fact that we’ve put ourselves under the governance of the United States. When you live in a country, you submit yourself to their governing body and laws — even if you don’t vote.

The citizen at home may not have pulled the trigger, but they asked the soldier to go in their place.

By shirking responsibility, civilians only alienate our soldiers more. The moral quagmire we face on the battlefield continues to dump shame and guilt onto our shoulders while they enjoy the benefits of passing the buck and asking, “Whose fault is it, really?”

On March 3, 1986, 11 years after the end of the Vietnam War, Metallica released their critically acclaimed album Master of Puppets. On the album, a song entitled “Disposable Heroes” tells the story of a young man used as cannon fodder in the midst of war and the terror that enveloped him on the battlefield. Three years later, Metallica released “One,” a song about a soldier who lost all his limbs and waits helplessly for death. The song won a Grammy for Best Metal Performance.

In an odd twist, both songs are amazingly popular among members of the United States military. During my time at the John F. Kennedy Special Warfare Center, we had an entire platoon that could practically sing every last lyric to “One.” In Afghanistan and Iraq, these songs were on playlists made to get soldiers amped before missions. We sang songs about dying on behalf of the people or coming home a vegetable. As crazy as that sounds, we sang those songs because they felt true. And they felt true because of the conversation we refuse to have as a country.

As Amy Amidon, a Navy psychologist stated in an interview regarding moral injury:

Civilians are lucky that we still have a sense of naiveté about what the world is like. The average American means well, but what they need to know is that these [military] men and women are seeing incredible evil, and coming home with that weighing on them and not knowing how to fit back into society.

Most of the time, like the conversation Andy and I had, people only want to hear the heroics. They don’t want to know what the war is costing our sons and daughters in regard to mental health, and this only makes the gap wider. In order for our soldiers to heal, society needs to own up to its part in sending us to war. The citizen at home may not have pulled the trigger, but they asked the soldier to go in their place. Citing a 2004 study, David Wood explains that the “grief over losing a combat buddy was comparable, more than 30 years later, to that of a bereaved spouse whose partner had died in the previous six months.” The soul wounds we experience are much greater. Society needs to come alongside us rather than pointing us to the VA.

Historically, many cultures performed purification rites for soldiers returning home from war. These rites purified a broad spectrum of warriors, from the Roman Centurion to the Navajo to the Medieval Knight. Perhaps most fascinating is that soldiers returning home from the Crusades were instructed to observe a period of purification that involved the Christian church and their community. Though the church had sanctioned the Crusades, they viewed taking another life as morally wrong and damaging to their knights’ souls.

No one in their right mind wants war. We want peace. And no one wants it more than the soldier.

Today, churches typically put veterans on stage to praise our heroics or speak of a great battle we’ve overcome while drawing spiritual parallels for their congregation. What they don’t do is talk about the moral weight we bear on their behalf.

Dr. Jonathan Shay, the clinical psychologist who coined the term moral injury, argues that in order for the soldier and society to find healing, we must come together and bear the moral responsibility of what soldiers have done in our name.

Whether you agree or disagree with the war, you must remember that these are our fellow brothers and sisters, sons and daughters, flesh and blood. As veterans, we are desperate to reconnect with a world we feel no longer understands us. As a country, we must try and find common ground. We’re not asking you to agree with our actions, but to help us bear the burden of carrying them on behalf of the country you live in. A staggering 22 veterans take their lives every day, and I can guarantee part of that is because of the citizen/soldier divide.

But what if it didn’t have to be this way? What if we could help our men and women in uniform bear the weight of this burden we carry? We should rethink exactly what war costs us and what we’ve asked of those who’ve fought on our behalf. In the end, no one in their right mind wants war. We want peace. And no one wants it more than the soldier. As General Douglas MacArthur eloquently put it:

“The soldier above all other people prays for peace, for he must suffer and bear the deepest wounds and scars of war.”

And what do we offer our Veterans for their healthcare when they come home? A truly horrid attempt at a government-run healthcare system, which now is pushing to get our Vets to private healthcare programs!!

Surprise! House, Senate Tackle Hospital Billing

Senate bill also addresses provider directories, drug maker competition

Our friend Joyce Frieden wrote that responses are generally positive so far regarding draft bipartisan legislation on surprise billing and high drug prices released Thursday by the Senate Health, Education, Labor, and Pensions (HELP) Committee.

“We commend this bipartisan effort to address several of the key factors associated with rising health care costs,” Richard Kovacs, MD, president of the American College of Cardiology, said in a statement.

“We agree with and support many of the principles outlined by the HELP Committee,” Matt Eyles, president, and CEO of America’s Health Insurance Plans, a trade group for health insurers, said in a statement. “We agree patients should be protected from surprise medical bills, and that policy solutions to this problem should ensure premiums and out-of-pocket costs do not go up for patients and consumers.”

The HELP Committee draft bill, known as the Lower Health Care Costs Act, would:

  •  Require that patients pay only in-network charges when they receive emergency treatment at out-of-network facilities, and when they are treated at an in-network facility by an out-of-network provider that they did not have a say in choosing/
  • Ban pharmacy benefit managers (PBMs) from “spread pricing” — charging employers, health insurance plans, and patients more for a drug than the PBM paid to acquire the drug.
  • Require insurance companies to keep provider directories up to date so patients can easily know if a provider is in-network.
  • Require healthcare facilities to provide a summary of services when a patient is discharged from a hospital to make it easier to track bills, and require hospitals to send all bills within 30 business days, to prevent unexpected bills many months aftercare.
  • Ensure that makers of branded drugs, including insulin products, are not gaming the system to prevent generics or biosimilars from coming to market
  • Eliminate a loophole that allows the first company to submit a generic drug in a particular class to enjoy a monopoly
  • Give patients full electronic access to their own health claims information.

Although the patient will only need to pay in-network charges when receiving service from an out-of-network provider, that in-network amount won’t pay for the entire out-of-network bill, so lawmakers still must decide how to deal with the rest of the out-of-network charge. The committee says it’s considering several options, including having insurance companies pay the out-of-network providers the median contracted rate for the same services provided in that geographic area, and, for bills over $750, allowing the insurer or the provider to initiate an independent dispute resolution process. The insurer and provider would each submit a best final offer and the arbiter would make a final, binding decision on the price to be paid.

The bill’s provisions “are common-sense steps we can take, and every single one of them has the objective of reducing the health care costs that you pay for out of your own pocket,” committee chairman Lamar Alexander (R-Tenn.) said in a statement. “We hope to move it through the health committee in June, put it on the Senate floor in July and make it law.” The bill is co-sponsored by Sen. Patty Murray (D-Wash.), the HELP Committee’s ranking member.

Over on the House side, legislators also released a bipartisan bill Thursday on surprise billing. This bill, known as the Protect People From Surprise Medical Bills Act, mirrors the Senate bill in prohibiting balance billing to patients receiving emergency care out of network or anticipated care at in-network facilities that use out-of-network providers without the patient’s knowledge or consent.

The patient would pay in-network rates in those situations, and then the health plan would have 30 days to pay the provider at a “commercially reasonable rate.” If either party is dissatisfied with that rate, the plan and doctor would settle on a payment amount; if that didn’t work, the parties could go to arbitration.

This legislation “will ban these bills and keep families out of the middle by using a fair, evidence-based, independent, and neutral arbitration system to resolve payment disputes between insurers and providers,” Rep. Raul Ruiz, MD (D-Calif.), the bill’s main sponsor, said in a statement. “As an emergency doctor, patients come first and must be protected.”

Co-sponsors of the bill include representatives Phil Roe, MD (R-Tenn.), Donna Shalala (D-Fla.), Joseph Morelle (D-N.Y.), Van Taylor (R-Texas), Ami Bera, MD (D-Calif.), Larry Bucshon, MD (R-Ind.), and Brad Wenstrup (R-Ohio). The group expects to introduce the final legislation in the next few weeks.

The American Society of Anesthesiology (ASA) praised the House bill. “The approach to addressing the problem of surprise medical bills outlined by Congressmen Ruiz and Roe is a fair proposal that puts patients first by holding them harmless from unanticipated bills,” ASA president Linda Mason, MD, said in a statement. “The proposal doesn’t pick winners or losers but instead places the dispute where it should be — between the health care provider and the insurance company.”

The American Medical Association (AMA) also liked the bill. “The outline released today represents a common-sense approach that protects patients from out-of-network bills that their insurance companies won’t pay while providing for a fair process to resolve disputes between physicians and hospitals and insurers,” AMA president Patrice Harris, MD, said in a statement.

Now, back to Medicare and the history of healthcare reform. Next, there was a convening of a National Health Conference, which had earlier approved a report of its Technical Committee on Medical Care, urging a huge extension of federal control over health matters. Sound familiar? Here we are in 2019 urging more control of the federal government over health care again in the form of a government-run health care system as either Obamacare or Medicare for All. The conference in 1938 opened with a statement by President Roosevelt describing the ultimate responsibility of the government for the health of its citizens.

The “technical committee” advised the Conference recommended that the federal government enact legislation in several areas:

  1. An expansion of the public health and maternal and child health programs including the original Social Security Act.
  2. A system of grants to the various states for direct medical care programs.
  3. Federal grants for hospital construction.
  4. A disability insurance program that would insure against loss of wages during illness.
  5. Grants to the states for the purpose of financing compulsory statewide health insurance programs.

The total costs of the program were about $850 million tax-funded and now compare this to the cost of Medicare for All at about $34 trillion. We should have adopted Medicare for All then. We would have saved a boatload of money.

It was interesting to learn that in order to placate the majority of medical practitioners the Committee urged the adoption of these programs on the state level. The reason why physicians opposed a program on the national level was the fear of becoming government salaried employees with not much to say in the administration of the program.

As predicted in 1943 when Senator Robert Wagner of New York, together with Senator James Murray of Montana and Representative John Dingle of Michigan, introduced a bill, which called for compulsory national health insurance/ mandatory health insurance as well as a federal system of unemployment insurance, broader coverage and extended benefits for old-age insurance, temporary and permanent disability payments underwritten by the federal government, unemployment benefits for veterans attempting to reenter civilian life, a federal employment service, and a restructuring of grants-in-aid to the states for public assistance.

Roosevelt wasn’t against the bill but he wasn’t prepared to endorse a bill quite so sweeping and so the bill dies in committee. But interestingly Roosevelt wanted to save the issue of national health care for the next presidential campaign in 1944. During the campaign he then called for an “Economic Bill of Rights,” which would include “the right to adequate medical care and the opportunity to achieve and enjoy good health” and the right to adequate protection from the economic fears of old age, sickness, accident, and unemployment” and in his budget message of January 1945 he announced his intention of extending social security to include medical care.

However, Roosevelt died in April 1945 and then Harry Truman took over the presidency committed to most of the same domestic policies as Roosevelt. But then came politics and party and the attempts to enact a health insurance bill during the Truman era came to a definite end with the election of 1950 where a number of the proponents of the mandatory national health insurance were defeated as well as a vigorous and costly campaign by the American Medical Association which was against compulsory health insurance associating the plan in the mind of the public with notions of socialism. Sound familiar?

More next week!

Let us all thank our veterans, our heroes, our real Avengers for all that they have done to assure us all of living in such a great free country. Happy Memorial Day!!

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The Democrats’ single-payer trap and Why Not Obamacare?? Let’s Start the Discussion of Medicare!!

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Richard North Patterson’s latest article started off with the statement- back in 2017-Behold the Republican Party, Democrats — and be warned.

The GOP’s ongoing train wreck — the defeat of its malign health care “reform,” the fratricidal troglodyte Roy Moore, and Donald Trump’s serial idiocies — has heartened Democrats. But before commencing a happy dance, they should contemplate the mirror.

They will see the absence of a compelling message. The party desperately needs a broad and unifying economic agenda — which includes but transcends health care — to create more opportunity for more Americans.

Instead, emulating right-wing Republicans, too many on the left are demanding yet another litmus test of doctrinal purity: single-payer health care. Candidates who waver, they threaten, will face primary challenges.

As regarding politics and policy, this is gratuitously dictatorial — and dangerously dumb.

The principle at stake is universal health care. Single-payer is but one way of getting there — as shown by the disparate approaches of countries that embrace health care as a right.

Within the Democratic Party, the discussion of these choices has barely begun. Senator Bernie Sanders advocates “Medicare for all,” expanding the current program for seniors. This would come at considerable cost — Sanders includes a 7.5 percent payroll tax among his list of funding options; others foresee an overall federal tax increase of 25 percent. But the dramatically increased taxes and the spending required, proponents insist, would be offset by savings in premiums and out-of-pocket costs.

Skeptics worry. Some estimate that Sanders’s proposal would cost $1.4 trillion a year — a 35 percent increase in a 2018 budget that calls for $4 trillion overall. It is not hard to imagine this program gobbling up other programs important to Democrats, including infrastructure, environmental protection, affordable college, and retraining for those dislocated by economic change.

For these reasons, most countries aspiring to universal care have multi-payer systems, which incorporate some role for private insurance, including France, Germany, Switzerland, and the Netherlands. The government covers most, but not all, of health care expenditures. Even Medicare, the basis for Sanderscare, allows seniors to purchase supplemental insurance — a necessity for many.

In short, single-payer sounds simpler than it is. Yet to propitiate the Democratic left, 16 senators have signed on to Sanders’s proposal, including potential 2020 hopefuls Elizabeth Warren, Cory Booker, Kamala Harris, and Kirsten Gillibrand. Less enthused are Democratic senators facing competitive reelection battles in 2018: Only one, Tammy Baldwin of Wisconsin, has followed suit.

This is the harrowing landscape the “single-payer or death” Democrats would replicate. Like “repeal and replace,” sweeping but unexamined ideas are often fated to collapse. Sanderscare may never be more popular than now — and even now its broader appeal is dubious.

Democrats must remember how hard it was to pass Obamacare. In the real world, Medicare for all will not become law anytime soon. In the meanwhile, the way to appeal to moderates and disaffected Democrats is not by promising to raise their taxes, but by fixing Obamacare’s flaws.

To enact a broad progressive agenda, the party must speak to voters nationwide, drawing on both liberals and moderates. Thus candidates in Massachusetts or Montana must address the preferences of their community. Otherwise, Democrats will achieve nothing for those who need them most.

Primary fights to the death over single payer will accomplish nothing good — including for those who want to pass single-payer. Parties do not expand through purges.

Democrats should be clear. It is intolerable that our fellow citizens should die or suffer needlessly, or be decimated by financial and medical calamity. A compassionate and inclusive society must provide quality health care for all.

The question is how best to do this. The party should stimulate that debate — not end it.

Generous Joe: More “Free” Healthcare For Illegals Needed

Now, R. Cort Kirkwood notes that Presidential candidate Joe Biden wants American taxpayers to pay for illegal alien healthcare. Indeed, he doesn’t just want us to pay for their healthcare, he says we are obliged to pay for their healthcare.

That’s likely because Biden thinks illegals are American citizens and doesn’t much care how many are here as long as they vote the right way.

What Biden didn’t explain when he said we must pay for illegal-alien healthcare is how much such beneficence would cost.

Answer: A lot.

The Question, The Answer

Biden’s demand that we pay for illegal-alien healthcare answered a question earlier this week from a reporter who wanted to know whether the “undocumented” deserve a free ride.

The question was this: “Do you think that undocumented immigrants who are in this country and are law-abiding should be entitled to federal benefits like Medicare, Medicaid for example?”

Answered Biden, “Look, I think that anyone who is in a situation where they are in need of health care, regardless of whether they are documented or undocumented, we have an obligation to see that they are cared for. That’s why I think we need more clinics in this country.”

Biden forgot to put “free” before clinics, but anyway, the candidate then suggested that Americans who disagree likely have a nasty hang-up about the border-jumping illegals who lie with the facility of Pinocchio when they apply for “asylum.”

“A significant portion of undocumented folks in this country are there because they overstayed their visas,” he continued. “It’s not a lot of people breaking down gates coming across the border,” he falsely averred.

Then came the inevitable. “We” need to watch what we say about all those “undocumented folks.”

“The biggest thing we’ve got to do is tone down the rhetoric,” he continued, because that “creates fear and concern” and ends in describing “undocumented folks” in “graphic, unflattering terms.”

Biden thinks those “undocumented folks” are citizens, as Breitbart noted in its report on his generosity with other people’s money.

In 2014, Biden told the worthies of the Hispanic Chamber of Commerce that entering the country illegally isn’t a problem, and Teddy Roosevelt would agree.

“The 11 million people living in the shadows, I believe they’re already American citizens,” Biden said. “Teddy Roosevelt said it better, he said Americanism is not a question of birthplace or creed or a line of dissent. It’s a question of principles, idealism, and character.”

Illegals “are just waiting, waiting for a chance to be able to contribute fully. And by that standard, 11 million undocumented aliens are already American.”

Roosevelt also said that “the one absolutely certain way of bringing this nation to ruin, of preventing all possibility of its continuing to be a nation at all, would be to permit it to become a tangle of squabbling nationalities,” but that inconvenient truth aside, Biden likely doesn’t grasp just what his munificence — again, with our money — will cost.

The Cost of Illegal-Alien Healthcare

I mentioned the cost of healthcare for the illegal-alien population and  Biden is right that visa overstays are a big problem: 701,900 in 2018, the government reported. But at least those who overstay actually entered the country legally; border jumpers don’t.

But that’s beside the point.

The real problem is the cost of the healthcare, which Forbes magazine estimated to be $18.5 billion, $11.2 billion of it federal tax dollars.

In 2017, the Federation for American Immigration Reform reported a figure of $29.3 billion; $17.1 in federal tax dollars, and $12.2 billion in state tax dollars. More than $15 billion on that total was uncompensated medical care. The rest fell under Medicaid births, Medicaid fraud, Medicaid for illegal-alien children, and improper Medicaid payouts.

The bills for the more than half-million illegals who have crossed the border since the beginning of fiscal 2019 in October are already rolling in.

Speaking at a news conference in March, Brian Hastings, operations chief for Customs and Border Protection (CBP), said about 55 illegals per day need medical care, and that 31,000 illegals will need medical care this year, up from 12,000 last year. Since December 22, he said, sick illegals have forced agents to spend 57,000 hours at hospitals or medical facilities. Cost: $2.2 million in salaries. Between 25 percent and 40 percent of the border agency’s manpower goes to the care and maintenance of illegals, he said.

CBP spent $98 million on illegal-alien healthcare between 2014 and 2018.

Hastings spoke before more than 200,000 illegals crossed the border in March and April.

NYC Promises ‘Guaranteed’ Healthcare for All Residents

Program to bring insurance to 600,000 people, including some who are undocumented

As the Mayor of New York City considers whether he wants to run for President and join the huge group of 21 candidates Joyce Frieden noted that the city of New York is launching a program to guarantee that every resident has health insurance, as well as timely access to physicians and health services, Mayor Bill de Blasio announced Tuesday.

“No one should have to live in fear; no one should have to go without the healthcare they need,” de Blasio said at a press conference at Lincoln Hospital in the Bronx. “In this city, we’re going to make that a reality. From this moment on in New York City, everyone is guaranteed the right to healthcare — everyone. We are saying the word ‘guarantee’ because we can make it happen.”

The program, which will cost $100 million annually, involves several parts. First, officials will work to increase enrollment in MetroPlus, which is New York’s public health insurance option. According to a press release from the mayor’s office, “MetroPlus provides free or affordable health insurance that connects insurance-eligible New Yorkers to a network of providers that includes NYC Health + Hospitals’ 11 hospitals and 70 clinics. MetroPlus serves as an affordable, quality option for people on Medicaid, Medicare, and those purchasing insurance on the exchange.”

The mayor’s office also said the new effort “will improve the quality of the MetroPlus customer experience through improved access to clinical care, mental health services, and wellness rewards for healthy behavior.”

For the estimated 600,000 city residents who don’t currently have health insurance — because they can’t afford what is on the Affordable Care Act health insurance exchange; because they’re young and healthy and choose not to pay for insurance, or because they are undocumented — the city will provide a plan that will connect them to reliable care at a sliding-scale fee. “NYC Care will provide a primary care doctor and will provide access to specialty care, prescription drugs, mental health services, hospitalization, and more,” the press release noted.

NYC Care will launch in summer 2019 and will roll out gradually in different parts of the city, starting in the Bronx, according to the release. It will be fully available to all New Yorkers across the city’s five boroughs in 2021.

Notably, the press release lacked many details on how the city will fund the plan and how much enrollees would have to pay. It also remained unclear how the city will persuade the “young invincibles” — those who can afford insurance but believe they don’t need it — to join up. Nor was arithmetic presented to document how much the city would save on city-paid emergency and hospital care by making preventive care more accessible. At the press conference, officials mostly deflected questions seeking details, focusing instead on the plan’s goals and anticipated benefits.

“Every New Yorker will have a card with [the name of] a… primary care doctor they can turn to that’s their doctor, with specialty services that make a difference, whether it’s ob/gyn care, mental health care, pediatric care — you name it, the things that people need will be available to them,” said de Blasio. “This is going to be a difference-maker in their lives. Get the healthcare you need when you need it.” And because more people will get preventive care, the city might actually save money, he added. “You won’t end up in a hospital bed if you actually get the care you need when the disease starts.”

People respond differently when they know something is guaranteed, he continued. “We know that if people don’t know they have a right to something, they’re going to think it’s not for them,” de Blasio said. “You know how many people every day know they’re sick [but can’t afford care] so they just go off to work and they get sicker?… They end up in the [emergency department] and it could have been prevented easily if they knew where to turn.”

As to why undocumented residents were included in the program, “I’m here to tell you everyone needs coverage, everyone needs a place to turn,” said de Blasio. “Some folks are our neighbors who happen to be undocumented. What do they all have in common? They need healthcare.”

Just having the insurance isn’t enough, said Herminia Palacio, MD, MPH, deputy mayor for health and human services. “It’s knowing where you can go for care and feeling welcome when you go for care… It’s being treated in a language you can understand by people who actually care about your health and well-being.”

De Blasio’s wife, Chirlane McCray, who started a mental health program, ThriveNYC, for city residents, praised NYC Care for increasing access to mental health services. “For 600,000 New Yorkers without any kind of insurance, mental healthcare remains out of reach [but this changes that],” she said. “When New Yorkers enroll in NYC Care they’ll be set up with a primary care doctor who can refer them [to mental health and substance abuse services], and psychiatric therapy sessions are also included.”

“The umbrella concept is crucial here,” said de Blasio. “If John or Jane Doe is sick, now they know exactly where to go. They have a name, an address… We want it to be seamless; if you have questions, here’s where to call.”

Help will be available at all hours, said Palacio. “Let’s say they’re having an after-hours issue and need understanding about where to get a prescription filled. They can call this number and get real-time help about what pharmacy would be open,” or find out which urgent care center can see them for a sore throat.

Mitchell Katz, MD, president, and CEO of NYC Health and Hospitals, the city’s public healthcare network, noted that prescription drugs are one thing most people are worried about being able to afford, but “under this program, pharmaceutical costs are covered.”

Katz noted that NYC Care is a more encompassing program than the one developed in San Francisco, where he used to work. For example, “here, psychotherapy is a covered benefit; that’s not true in San Francisco… and the current program [there] has an enrollment of about 20,000 people; that’s a New York City block. In terms of scale, this is just a much broader scale.”

In addition, the San Francisco program required employers to pay for some of it, while New York City found a way around that, de Blasio pointed out. The mayor promised that no tax increases are needed to fund the program; the $100 million will come from the city’s existing budget, currently about $90 billion.

Now on to Medicare for All as we look at the history of Medicare. I am so interested in the concept of Medicare for All as I look at my bill from my ophthalmologist, which did not cover any of my emergency visits for a partial loss of my right eye. Also, my follow-up appointment was only partially covered; they only covered $5 of my visit. Wonderful Medicare, right?

The invoice was followed this weekend with an Email from Medicare wishing me a Happy Birthday and notifying me of the preventive services followed with a table outlining the eligibility dates. And the dates are not what my physicians are recommending, so you see there are limitations regarding coverage and if and when we as patients can have the services.

Medicare as a program has gone through years of discussion, just like the Europeans, Germany to start, organized healthcare started with labor. In the book American Health Care edited by Roger D. Feldman, the German policy started with factory and mine workers and when Otto von Bismark in 1883, the then Chancellor of newly united Germany successfully gained passage of a compulsory health insurance bill covering all the factory and mine workers. A number of other series of reform measures were crafted including accident insurance, disability insurance, etc. The original act was later modified to include other workers including workers engaged in transportation, and commerce and was later extended to almost all employees. So, why did it take so long for we Americans form healthcare policies for our workers?

Just like in Germany and then Britain, the discussion of healthcare reform began with labor and, of course, was battered about in the political arena. In 1911, after the passage of the National Health Act in Britain, Louis Brandeis, who was later to be appointed to the Supreme Court, urged the National Conference on Charities and Corrections to support a national program of mandatory medical insurance. The system of compulsory health insurance soon became the subject of American politics starting with Theodore Roosevelt, head of the Progressive or Bull Moose. H delivered his tedious speech, “Confession of Faith”, calling for a national compulsory healthcare system for industrial workers.  The group that influenced Roosevelt was a group of progressive economists from the University of Wisconsin, who were protégés of the labor economist John R. Commons, a professor at the university.

Commons an advocate of the welfare state, in 1906, together with other Progressive social scientists at Wisconsin, founded the American Association for Labor Legislation (AALL) to labor for reform on both the federal and state level. Roosevelt and other members of the Progressive Party pushed for compulsory health insurance, which they were convinced would be endorsed by working-class Americans after the passage of the British national program.

The AALL organization expanded membership and was responsible for protective labor legislation and social issues. One of the early presidents of the organization was William Willoughby, who had authored a comprehensive report on European government health insurance scheme in 1898.

The AALL next turned its attention to the question of a mandatory health insurance bill and sought the support of the American Medical Association. The AMA  was thought to support this mandatory health insurance bill if it could be shown that the introduction of a mandatory health insurance program would in fact profit physicians. This is where things go complicated and which eventually doomed the support of the AMA and all physicians as a universal health insurance plan failed in Congress. Why? Because the model bill developed by the AALL had one serious flaw. It did not clearly stipulate whether physicians enrolled in the plan would be paid in the basis of capitation fee or fee-for-service, nor did it ensure that practitioners be represented on administrative boards.

I discuss more on the influence of the AALL in health care reform and what happened through the next number of Presidents until Kennedy.

More to come! Happy Mother’s Day to all the great Mothers out there and your wonderful influence on all your families with their guidance and love.

 

 

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Peter Sullivan reported that Congressional Republicans don’t want to talk about attacks on ObamaCare. But President Trump isn’t making that easy.

The Trump administration on Wednesday filed its official legal argument calling for the entirety of the Affordable Care Act to be struck down, once again thrusting the issue back in the spotlight at a time when GOP lawmakers are trying to turn the page.

Republicans would much rather focus on criticizing the “Medicare for All” proposal backed by more and more Democrats, something they see as a winning line of attack compared to reigniting an ObamaCare debate that contributed to the GOP losing its majority in the House last year.

Trump, though, is not playing along with that strategy; instead, he is keeping up his attacks on ObamaCare in court and in his speeches.

Asked if he wished the Trump administration was not arguing so forcefully against the 2010 health care law in court, Sen. John Thune(S.D.), the No. 2 Senate Republican, separated congressional Republicans from the White House.

“They’re going to do what they’re going to do,” Thune said. “What we have to worry about is what our members are working on, what we’re trying to do and how we’re communicating that to the American people.”

Sen. Chuck Grassley (R-Iowa), chairman of the Senate Finance Committee, declined to say he supported the administration’s move.

“The president can message whatever he wants to message, and there’s no control I have over what he can message,” Grassley said.

With all the talk of collusion, lies, threats of impeachment our Congress is really doing nothing for real healthcare improvement. And Republicans have been beating the drum almost daily to get across their main health care message: that Medicare for All would take away people’s private health insurance and come with an enormous price tag.

Republicans this week seized on a new report from the nonpartisan Congressional Budget Office examining projected costs associated with Medicare for All. While the report did not put a specific price tag on the proposal, it said government spending on health care would “increase substantially.”

Previous studies have put the cost to the government around $32 trillion over 10 years. I will try to break down the numbers.

But one side effect of the GOP’s attacks on Medicare for All is that it comes close to defending the status quo, which includes ObamaCare.

This is the problem with the GOP, they have no real plan for healthcare and although that they have had many months for the solution-they have none.

Rep. Tom Cole (R-Okla.) asked at a hearing this week on Medicare for All why lawmakers don’t just focus on bipartisan fixes to ObamaCare instead of pursuing the sweeping new system that’s championed by progressives like 2020 presidential candidate Sen. Bernie Sanders (I-Vt.).

“We have a chance, I think, to make some fixes that we probably all agree on,” Cole said.

Over the past few months, though, GOP lawmakers had been mostly silent on ObamaCare, a law they aggressively attacked for eight years.

The Affordable Care Act’s popularity has been rising in recent years, with a Kaiser Family Foundation poll in April finding that 50 percent of adults have a favorable view of the law, compared to 38 percent with an unfavorable one.

Most Democrats last year campaigned on maintaining the law’s popular protections for people with pre-existing conditions.

“The last thing Senate Republicans want to be doing is participating in an exercise that would potentially remove coverage from people with pre-existing conditions that they already have,” said a Senate GOP strategist. “Candidates in tough races will be emphasizing how to improve on what currently exists.”

Senate Majority Leader Mitch McConnell (R-Ky.) last month said the GOP health care message is “preserving what works and fixing what doesn’t,” a very different slogan than the party’s long-time mantra of “repeal and replace.”

Trump, though, is on the attack against ObamaCare. In a speech last week, he touted the 2017 repeal of the law’s mandate to have coverage before adding, “Now we’re going for the rest.”

His administration is also supporting the lawsuit brought by a coalition of GOP-led states calling for overturning the law. That case, which legal experts in both parties dismiss as unlikely to succeed, is now making its way through the 5th Circuit Court of Appeals.

Vulnerable Republican lawmakers are not eager to talk about the administration’s efforts on that front.

Sen. Cory Gardner (R-Colo.), perhaps the most vulnerable GOP senator up for reelection next year, said Thursday that he had not seen the administration’s legal filing, declining to comment on it and on his views on the lawsuit. His office did not respond to a follow-up inquiry.

Rep. John Katko (R-N.Y.), a moderate who is facing a potentially competitive race next year, distanced himself from the lawsuit.

“I don’t agree with anything being taken out without a replacement ready,” he said.

Sen. Shelley Moore Capito (R-W.Va.) noted the failure of the GOP’s repeal attempt in 2017.

“Obviously the repeal-and-replace discussion wasn’t successful, so let’s put that behind us and let’s make this one work,” she said.

Thune, though, suggested that if Republicans were in control of both chambers again, they would likely attempt another repeal-and-replace measure.

“Obviously, if and when we have the votes, we’d like to take a different direction, one that would create more competition and more choices and lower costs,” Thune said.

So, the Real Question is Would ‘Medicare for All’ Save

Josh Katz, Kevin Quealy, and Margot Sanger-Katz last month reviewed U.S. Health Care Expenditures in 2019

Total cost under current law out of pocket$1.00Private health insurance$1.00Other health spending$514 billion other health insurance$149 billionMedicaid$1.00Medicare for All$3.87 trillion

How much would a “Medicare for all” plan, like the kind being introduced by Senator Bernie Sanders on Wednesday, change health spending in the United States?

Some advocates have said costs would actually be lower because of gains in efficiency and scale, while critics have predicted huge increases.

We asked a handful of economists and think tanks with a range of perspectives to estimate total American health care expenditures in 2019 under such a plan. The chart at the top of this page shows the estimates, both in composition and in total cost.

In all of these estimates, patients and private insurers would spend far less, and the federal government would pay far more. But the overall changes are also important, and they’re larger than they may look. Even the difference between the most expensive estimate and the second-most expensive estimate was larger than the budget of most federal agencies.

Annotation 2019-04-13 234119.Estimates of cost of medicare for all.a

The big differences in the estimates of experts reflect the challenge of forecasting a change of this magnitude; it would be the largest domestic policy change in a generation.

The proposals themselves are vague on crucial points. More broadly, any Medicare for all system would be influenced by the decisions and actions of parties concerned — patients, health care providers, and political actors — in complex, hard-to-predict ways. But seeing the range of responses, and the things that all the experts agree on can give us some ideas about what Medicare for all could mean for the country’s budget and economy.

These estimates come from:

Gerald Friedman, a professor of economics at the University of Massachusetts, Amherst, whose estimates were frequently cited by the Bernie Sanders presidential campaign in 2016.

Charles Blahous, a senior research strategist at the Mercatus Center at George Mason University, and a former trustee of Medicare and Social Security.

Analysts at the RAND Corporation, a global policy research group that has estimated the effects of several single-payer health care proposals.

Kenneth E. Thorpe, the chairman of the health policy department at Emory University, who helped Vermont estimate the costs of a single-payer proposal there in 2006.

Analysts at the Urban Institute, a Washington policy research group that frequently estimates the effects of health policy changes.

Right now, individuals and employers pay insurance premiums; people pay cash co-payments for drugs, and state governments pay a share of Medicaid costs. In a Sanders-style system or one recently introduced by Representative Pramila Jayapal and the Congressional Progressive Caucus, nearly all of that would be replaced by federal spending. That’s why some experts describe such a system as single-payer. (Other Democrats who are supporting coverage expansion through Medicare have offered more modest proposals that would preserve some out-of-pocket spending and a role for private insurance.)

The economists made their calculations using different assumptions and methods, and you can read more about those methods at the bottom of this article.

These two estimates, for example, from the Mercatus Center and the Urban Institute, differ by about $730 billion per year, roughly 3 percent of G.D.P. The two groups don’t often agree on public policy — Mercatus tends to be more right-leaning and Urban more left-leaning.

Annotation 2019-04-13 234303.estimates for medicare for all.b

The biggest difference between the Mercatus estimate and the Urban one is related to how much the new system would pay doctors, hospitals and other medical providers for health services. Mr. Friedman’s estimate, the least expensive of the group, assumed that the government could achieve the largest cost savings on both prescription drugs and administrative spending.

How much would doctors and hospitals and other providers be paid?

Pay too little, and you risk hospital closings and unhappy health care providers. Pay too much, and the system will become far more expensive. Small differences add up.

The estimated increase in Medicare payment rates paid to medical providers

FRIEDMAN BLAHOUS THORPE URBAN RAND
6% 0% 5% 7% 9%

In our current system, doctors, hospitals and other health care providers are paid by a number of insurers, and those insurers all pay them slightly different prices. In general, private insurance pays medical providers more than Medicare does. Under a Medicare for all system, Medicare would pick up all the bills. Paying the same prices that Medicare pays now would mean an effective pay cut for medical providers who currently see a lot of patients with private insurance.

For a Medicare for all system to save money, it needs to reduce the health care industry’s income somewhat. But if rates are too low, hospitals already facing financial difficulties could be put out of business.

Neither Mr. Sanders’s legislation nor the Jayapal House bill specifies what the Medicare for all system would pay, but they say that Medicare would establish budgets and payment rates. So our estimators offered their best guess of what they thought such a plan might do.

Mr. Thorpe said he picked a number higher than current Medicare prices for hospitals because he thought anything lower would be unsustainable. Mr. Blahous said he constructed his starting estimate at precisely Medicare rates, though he thought the real number would most likely be higher. He also reran his calculations with a more generous assumption: At 111 percent of Medicare, around the average amount all health insurers pay medical providers now, the total shot up by hundreds of billions of dollars, about an additional 1.5 percent of G.D.P.

How much lower would prescription costs be?

By negotiating directly on behalf of all Americans, instead of having individual insurance companies and plans bargain separately, the government should be able to pay lower drug prices.

The estimated reduction in drug spending

FRIEDMAN BLAHOUS THORPE URBAN RAND
31% 12% 4% 20% 11%

Patients in the United States pay the highest prices in the world for prescription drugs. That’s partly a result of a fractured system in which different payers negotiate separately for drug benefits. But it also reflects national preferences: An effective negotiator needs to be able to say no, and American patients tend to want access to the widest array of cutting-edge drugs, even if it means paying more.

A Medicare for all system would have more leverage with the drug industry because it could bargain for the whole country’s drug supply at once. But politics would still be a constraint. A system willing to pay for fewer drugs could probably get bigger discounts than one that wanted to preserve the current set of choices. That would mean, though, that some patients would be denied the medications they want.

All of our economists thought a Medicare for all system could negotiate lower prices than the current ones. But they differed in their assessments of how cutthroat a negotiator Medicare would be. Mr. Friedman thought Medicare for all could reduce drug spending by nearly a third. The Urban team said the savings would be at least 20 percent. The other researchers imagined more modest reductions.

How much more would people use the health care system?

By expanding coverage to the uninsured, adding new benefits and wiping out cost sharing, Medicare for all would encourage more Americans to seek health care services.

The estimated increase in the use of health care

FRIEDMAN BLAHOUS THORPE URBAN RAND
7% 11% 15% 8%

Medicare for all would give insurance to around 28 million Americans who don’t have it now. And evidence shows that people use more health services when they’re insured. That change alone would increase the bill for the program.

Other changes to Medicare for all would also tend to increase health care spending. Some proposals would eliminate nearly all co-payments and deductibles. Evidence shows that people tend to go to the doctor more when there’s no such cost sharing. The proposed plans would also add medical benefits not typically covered by health insurance, such as dental care, hearing aids, and optometry services, which would increase their use.

The economists differ somewhat in how much they think people would increase their use of medical services. (Because of the way the Urban Institute team’s estimate was calculated, it couldn’t easily provide a number for this question.

What would Medicare for all cost to run?

Right now, the health care system is complicated, with lots of different payers and ways to negotiate prices and bill for services. A single payment system could save some money by simplifying all that.

Estimated administrative costs as a share of all spending

FRIEDMAN BLAHOUS THORPE URBAN RAND
2% 6% 6% 5%

The complexity of the American system means that administrative costs can often be high. Insurance companies spend on negotiations, claims review, marketing and sometimes shareholder returns. One key possible advantage of a Medicare for all system would be to strip away some of those overhead costs.

But estimating possible savings in management and administration is not easy. Medicare currently has a much lower administrative cost share than other forms of insurance, but it also covers sicker people, distorting such comparisons. Certain administrative functions, like fraud detection, can have a substantial return on investment.

The economists all said administrative costs would be lower under Medicare for all, but they differed on how much. Those differences amount to percentage points on top of the differing estimates of medical spending. On this question, there was rough agreement among our estimators that administrative costs would be no higher than 6 percent of medical costs, a number similar to the administrative costs that large employers spend on their health plans. Mr. Blahous said a 6 percent estimate would probably apply to populations currently covered under private insurance but did not calculate an overall rate.

But what will it cost me?

All of these estimates looked at the potential health care bill under a Sanders-style Medicare for all plan. In some estimates, the country would not pay more for health care, but there would still be a drastic shift in who is doing the paying. Individuals and their employers now pay nearly half of the total cost of medical care, but that percentage would fall close to zero, and the percentage paid by the federal government would rise to compensate. Even under Mr. Blahous’s lower estimate, which assumes a reduction in overall health care spending, federal spending on health care would still increase by 10 percent of G.D.P., or more than triple what the government spends on the military.

How that transfer takes place is one of the least well-explained parts of the reform proposals. Taxation is the most obvious way to collect that extra revenue, but so far none of the current Medicare for all proposals have included a detailed tax plan. Even if total medical spending stayed flat overall, some taxpayers could come out ahead and pay less; others could find themselves paying more.

Raising revenue would require broad tax increases that are likely to be partly borne by the middle class, potentially impeding passage. Advocates, including Mr. Sanders, tend to favor funding the program with payroll taxes.

For some people, any increase in federal taxes might be more than offset by reductions in their spending on premiums, co-payments, deductibles, and state taxes. There is evidence to suggest that premium savings by employers would also be returned to workers in the form of higher salaries. But, depending on the details, other groups could end up paying more in tax increases than they save in those reductions.

After Mr. Sanders’s presidential campaign released a tax proposal in 2016, the Urban Institute tried to calculate the effects on different groups. But it found that the proposed taxes would pay for only about half of the increased federal bill. That means that a real financing proposal would probably need to raise a lot more in taxes. How those are spread across the population would change who would be better or worse off under Medicare for all.

About the estimates

Our economists differed somewhat in their estimation methods. They also examined a couple of different Medicare for all proposals, though all the plans had the same major features.

Gerald Friedman calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. A 2018 paper with his analysis of several different variations on Medicare for all is available.

Kenneth E. Thorpe calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. A 2016 paper with more of his findings on Mr. Sanders’s presidential campaign proposal is available.

The Urban Institute built its estimates using a microsimulation model, which estimates how individuals with different incomes and health care needs would respond to changes in health insurance. The model does not consider the effects of policy changes on military and veterans’ health care or the Indian Health Service, so its totals assumed those programs would not change. It also measures limits on the availability of doctors and hospitals using evidence from the Medicaid program. The team at Urban that prepared the calculations includes John Holahan, Lisa Clemans-Cope, Matthew Buettgens, Melissa Favreault, Linda J. Blumberg and Siyabonga Ndwandwe. Its detailed report on Mr. Sanders’s presidential campaign proposal from 2016 is available.

Charles Blahous calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. His calculations were made based on Mr. Sanders’s 2017 Medicare for All Act, which indicated that states would continue to pay a share of long-term care costs. A 2018 paper with more of his findings is available and includes both sets of estimates for Medicare provider payments.

The RAND Corporation built its estimates by making adjustments to previous single-payer analyses. The original estimates used a microsimulation model, which estimates how individuals with different incomes and health care needs would respond to changes in health insurance. The RAND model, which it uses to estimate the effects of various health policy changes, is called RAND COMPARE. Calculations were made assuming a Medicare for all plan that offers coverage with no cost-sharing and long-term care benefits. The RAND team that prepared the estimate includes Christine Eibner and Jodi Liu. A copy of the report is available; Ms. Liu’s 2016 study of how different.

Maybe we should spend some time reviewing the history of Medicare to get a better idea of the system. I’ll do that over the next few weeks.

Most Americans don’t want Congress to overhaul health care, despite ‘Medicare for All’ plans, GOP push to repeal Obamacare

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Ashley Turner pointed out in her article that maybe the voters don’t want a whole new healthcare system even though Bernie and the rest are touting Medicare for All.

KEY POINTS

  • A majority of Americans say they don’t think Congress should prioritize revamping the entire U.S. health care system, according to a new Kaiser Family Foundation poll.
  • Instead, voters would rather see lawmakers focus on protecting pre-existing conditions and tackling rising prescription costs and surprise medical bills.

As Democrats and Republicans battle over which health care proposal should replace the Affordable Care Act, a majority of Americans say they don’t think Congress should revamp the entire U.S. health care system, according to a new Kaiser Family Foundation poll.

Instead, voters would rather see lawmakers focus on a handful of changes, like protecting pre-existing conditions and tackling rising prescription costs and surprise medical bills.

Most Americans felt high drug costs are the most important issue for Congress to address, with 68% of those polled believing lawmakers should take targeted actions on rising prices. 64% believe Congress should focus on protecting pre-existing conditions, while half believe surprise medical bills should also be a “top priority.”

“Everybody is concerned about drug prices because they’re really feeling the pinch here,” Robert Laszewski, president of Health Policy and Strategy Associates, said. He said the dramatic rise in drug costs over the last 10 years has made the issue a prime focus for Americans.

Though pre-existing conditions are protected now under the Affordable Care Act, also known as Obamacare, Laszewski said voters became worried after Republicans proposed to replace it in 2017. The legislation included a provision that under certain conditions would have undone Obamacare’s ban on letting insurers charge more for people with those conditions. The bill failed to pass the Senate.

The recent poll shows Americans are more concerned about rising medical costs than access to health care, Ashley Kirzinger, associate director for the Public Opinion and Survey Research team at the Kaiser Family Foundation, said.

The health care debate has taken lawmakers by storm as the 2020 elections approach with both Democrats and Republicans promising to replace Obamacare. Though there have been some issues that have seen bipartisan support, like seeking to lower drug costs, lawmakers on both sides of the aisle have otherwise viciously attacked each other’s attempts to reform the health care system.

President Donald Trump and Republicans have pledged to repeal Obamacare, though top Republicans have said the GOP will wait until Republicans regain control of the House of Representatives to unveil a replacement proposal. Republicans currently hold control of the Senate but need 21 more seats in the House to win the majority.

Lawmakers believe Republicans’ failed attempt to overturn Obamacare in 2017 led to Democrats taking control of the House in last year’s midterm elections. The law is now in jeopardy once again after the Trump administration supported a lawsuit questioning its constitutionality.

More than half, 54%, of those polled by the Kaiser Family Foundation said they don’t want to see the Supreme Court overturn Obamacare.

Meanwhile, some progressive Democrats like presidential hopeful Sen. Bernie Sanders are looking to replace Obamacare with “Medicare for All,” which seeks to create a government-run health care plan that would cover every American. The proposal has support from fellow Democratic presidential candidates like Sens. Kamala Harris, D-Calif., Cory Booker, D-N.J., Elizabeth Warren, D-Mass., and Kirsten Gillibrand, D-N.Y., though Republicans and centrist Democrats have spoken against Sanders’ legislation.

As lawmakers jockey over which overhaul of the health care system is best, Americans would rather Congress just fix the basics.

Less than a third of the people surveyed think a complete overhaul of the health care system should be a top priority in Congress, according to the poll. More than a third, 31%, think that the implementation of Medicare for All should be Congress’ focus, while 27% think lawmakers should prioritize repealing Obamacare.

Though there has been talk from top politicians about completely redoing the health care system, lawmakers have also looked to fix the issues Americans want them to spotlight.

The Senate Finance Committee earlier this year held two hearings with the nation’s top pharmaceutical companies and pharmacy benefit managers in an attempt to discover the source of rising drug costs. Protecting pre-existing conditions is also a bipartisan issue, with Democrats touting protections under Obamacare and Republicans offering an alternative protection plan in case the health care law is overturned.

Lawmakers have also introduced legislation to stop patients from getting hit with surprise medical bills and the White House promised to make the issue a priority for the Trump administration to tackle.

Laszewski said protecting pre-existing conditions, Medicaid expansion, providing subsidies for those who can’t afford insurance and tackling rising drug costs are “crucially important” to Americans, but he noted that not every citizen is the same.

“Different people are impacted differently here,” Laszewski said. “We can’t just say all Americans are exactly alike.”

House Dems to hold a hearing on ‘Medicare for All’ next week

The House Rules Committee will hold a hearing on “Medicare for All” legislation next week, a step forward for the legislation that is gaining ground in the progressive wing of the party.

The hearing on Tuesday will examine a bill from Reps. Pramila Jayapal (D-Wash.) and Debbie Dingell (D-Mich.) that has over 100 co-sponsors in the House.

According to the Rules Committee, the hearing will be the first ever that Congress has held on Medicare for All legislation.

“It’s a serious proposal that deserves serious consideration on Capitol Hill as we work toward universal coverage,” Rep. Jim McGovern (D-Mass.), the chairman of the Rules Committee and a co-sponsor of the Medicare for All bill, said in a statement. Notably, the hearing will occur in a committee that is not one of the primary committees overseeing health care.

The main health care panels, the Ways and Means Committee and Energy and Commerce Committee, have so far declined to commit to holding a hearing on Medicare for All, illustrating the divide among House Democrats over the legislation.

But McGovern has been more supportive of the bill, ultimately bringing it to a hearing in the Rules Committee. The House Budget Committee is also expected to hold a hearing.

“Health care is a human right and I’m proud the Rules Committee will be holding this hearing on the Medicare for All Act as this Majority discusses ways to strengthen our health care system for everyone,” Jayapal said in a statement.

While Speaker Nancy Pelosi (D-Calif.) supports hearings on Medicare for All, she has declined to support the legislation itself and has raised doubts about the bill, including its price tag. She has also noted she wants to build on her signature legislation, the Affordable Care Act. Still, she has not outright opposed Medicare for All, saying that different ideas should be on the table.

Well, this Fox & Friends Twitter poll on “Medicare for All” didn’t go as planned Christopher Zara reported that in today’s edition of “Ask and Ye Shall Receive,” here’s more evidence that support for universal health care isn’t going away. The Twitter account for Fox & Friends a few weeks ago ran a poll in which it asked people if the benefits of Bernie Sanders’s “Medicare for All” plan would outweigh the costs. The poll cites an estimated cost of $32.6 trillion. Hilariously, 73% of respondents said yes, it’s still worth it—which is not exactly the answer you’d expect from fans of the Trump-friendly talk show.

Granted, this is just a Twitter poll, which means it’s not scientific and was almost certainly skewed by retweets from Twitter users looking to achieve this result. At the same time, it’s not that far off from actual polling around the issue. In March, a Kaiser Health tracking poll revealed that 6 in 10 Americans are in favor of a national healthcare system in which all Americans would get health insurance from a single government plan. Other polls have put the number at less than 50% support but trending upward.

If you’re still unsure, you can read more about Sanders’s plan and stay tuned for more discussion on “Medicare for All”.

Medicare for All? For Some? Many Plans for Universal Coverage. But nothing likely to happen soon, suggests former CMS chief Tom Scully

News Editor of MedPage Joyce Frieden brings some reality to the discussion. Talk has been heating up on Capitol Hill about how to get to universal coverage, with “Medicare for All” being a popular option. But what exactly does that phrase mean, and what other universal coverage plans are out there?

So far, four different types of universal coverage bills have been introduced, although “nothing is going to happen in the next 2 years,” Tom Scully, partner in the Welsh, Carson, Anderson & Stowe private equity firm here and a former administrator of the Centers for Medicare & Medicaid Services (CMS), predicted at a press briefing Thursday. However, Scully added that he hoped the introduction of the bills would be “based on substance and details.”

The Four Types of Plans

Karen Pollitz, MPP, a senior fellow for health reform and private insurance at the Kaiser Family Foundation, laid out the four types of plans aimed at getting closer to universal coverage.

Medicare for All. Under these plans, private insurance coverage would be replaced by a single federal program; the program would also replace most other public plans such as Medicaid. Benefits would be comprehensive, with some bills offering additional coverage currently not in Medicare, such as dental care, vision care, and long-term care. The program would be taxpayer-funded — requiring substantial tax increases — but would also require few or no premiums and copays. Healthcare would be under a global budget, and a national system for paying providers — at rates yet to be determined — would be set up. Examples of Medicare for All bills include one from Sen. Bernie Sanders (I-Vt.) and one from Rep. Pramila Jayapal (D-Wash.)

Federal Public Plan Option. Under this set of options, a federally funded health insurance plan would be offered alongside current public and private healthcare The plan would be designed to be affordable — with premium subsidies and cost-sharing subsidies — and would be available to both individuals and employer

The plan would cover all of the Affordable Care Act’s “essential health benefits,” and some bills include additional coverage. Examples of a public plan option include a bill from Sen. Jeff Merkley (D-Ore.), one from Rep. Jan Schakowsky (D-Ill.), and one from Sen. Michael Bennet (D-Colo.) Medicare Buy-In for Older Adults. These bills would allow older adults — either ages 55-64 or 50-64, depending on the bill — to buy into the Medicare program. One bill, sponsored by Rep. Brian Higgins (D-N.Y.) would allow buy-in from people who also have access to employer-sponsored health coverage, and would permit employers to pay part of all of the premiums for these employees. Both the Higgins bill and one from Sen. Debbie Stabenow (D-Mich.) would allow for eligible enrollees to receive subsidies for the buy-in plan from the Affordable Care Act (ACA) marketplaces. Enrollees could choose between traditional Medicare and Medicare Advantage plans

State Medicaid Buy-In Plan. Under this approach, outlined in a bill sponsored by Sen. Brian Schatz (D-Hawaii), states would have the option of allowing state residents to buy into the Medicaid program. The buy-in option would be available through the ACA marketplaces to people of all income levels and would cover the ACA’s essential health benefits. States would receive federal matching funds to cover any costs that are not recouped through premiums and copays. States could vary premiums by the same factors as ACA marketplace plans (age, geography, family size, and tobacco use)

How to Pay Providers?

Panelists at the briefing disagreed on the best way to pay providers under these proposals, most of which don’t offer many specifics on the issue. “The idea of Medicare fee-for-service for all is completely wacky,” Scully said. “The government is [already] moving away from fee-for-service price-fixing because it never works … Paying every doctor the same thing has been shown to be part of the problem.”

Instead, Scully suggested that the government should pay private insurers to run plans, as is done in the Medicare Advantage program. He noted that 85% of Medicaid spending goes to Medicaid managed care plans, with some liberal states such as Oregon being among the first to jump on the Medicaid managed care bandwagon. “Why? Because they’re better off having Kaiser do it,” Scully said. “It’s a better deal with more coverage, so the idea that we should have the government set prices centrally to me is totally counter-intuitive.”

Mark Miller, Ph.D., executive vice president of healthcare at Arnold Ventures, philanthropy here that works on healthcare and other issues, begged to differ. “I’m not arguing that the best method is fee-for-service, but a strong argument is that one thing Medicare has done right controls the prices paid for providers, and for hospitals and physicians in particular; private plans have failed at this,” said Miller, who is also the former executive director of the Medicare Payment Advisory Commission (MedPAC).

Linda Blumberg, Ph.D., a fellow at the Urban Institute, a left-leaning think tank here, said in a phone interview that the idea that price regulation hasn’t worked “is a fallacy because if you look at how the Medicare program works, it’s very successful and has price regulation at its core.”

She noted that studies performed by MedPAC have found that “when you change reimbursement rates, hospitals do adjust their underlying costs … They become more efficient when they’re constrained. That doesn’t mean you can turn down the dial from 200% of Medicare down to 50%, but looking at the enormous variation in pricing going on in the commercial market, we know we can do better than where we are. The system isn’t rational at the moment.”

A Public/Private Alternative

Blumberg and colleagues have developed a plan called Healthy America, which would replace the Medicaid and CHIP programs, as well as the ACA marketplaces, with a public option that would allow people to buy a comprehensive insurance plan that covers hospital care, physician care, prescription drug coverage, and a wide range of other healthcare services. In addition, “other private insurers — which I would expect largely to be managed care organizations — would contract with the federal government and be alternatives to the public option,” she said.

One problem with the ACA’s marketplaces is that in many geographic areas, there are not enough enrollees to make for a competitive marketplace, Blumberg said. So the Healthy America plan pulls in additional people through the Medicaid program and also offers no cost-sharing for very-low-income enrollees, “basically pulling a much larger population into this same pool” in order to increase private-plan competition. The researchers estimate the annual cost of the fully phased-in plan at about $98 billion.

Changing the healthcare system incrementally rather than switching everyone over to a Medicare for All plan offers several advantages, she said. “There are a lot of people who are quite satisfied with their employer-based insurance and also with their Medicare program and when you tell them you’re going to replace it with something new, it causes a lot of anxiety.” In addition, “the federal government costs needed to put a plan like this in place are reduced” compared with Medicare for All.

So, these are some options but what about what all the Democrat presidential hopefuls are touting for the 2020 election?

Next week let’s break down the real cost of health care under Medicare for All.

Obamacare, Trump and a lawsuit: How industry is reacting, Mental Health and Back to Court!

Picture1.Trump and obamacare the wasps nestSorry for the delay with this week’s post but with all my travels through Europe the Internet connection was not secure enough to send this edition. So, here it is with a bit more regarding Obamacare and President Trump. However, it was interesting again to hear from some of my travel associates how they were satisfied with their type of socialized medicine, but that there were many shortcomings including long wait to see their doctors and with the care that they received. One additional point was made that the dental care had become unreliable since the dentists finally decided not to participate in the national dental plan in England due to the poor payment schedule and the government regulations. My wife and I were warned to be careful as a nation for what we really want the government to control. Also, the Brits told us that there wasn’t enough money to cover the needs of health care for all in their country.

Susannah Luthi’s piece on Obamacare and Trump deserves mention as we go on to discuss alternatives. The Trump administration’s decision to support eliminating the entire Affordable Care Act has riled lawmakers and industry alike as they navigate the line between politics and the potential practical impact of the lawsuit.

The Justice Department’s politically volatile move last week to agree with a Texas judge’s ruling against the law sparked a political firestorm not likely to end soon in the ramp-up to 2020 elections. It has already inspired calls for a GOP replacement plan.

But as the case wends its way through the 5th U.S. Circuit Court of Appeals, and potentially the U.S. Supreme Court after that, healthcare business goes on as usual across the country and likely will continue to do so as legal experts are skeptical the lawsuit will succeed.

“From my perspective, anything that would happen to the law is at best a year away,” said Dave Schreiner, CEO of Katherine Shaw Bethea Hospital, an 80-bed rural facility in Dixon, Ill. He is also the chair of the American Hospital Association’s Section for Small or Rural Hospitals. “It’s hard from a strategy perspective to react to anything like that.”

Last week, just after the Justice Department made its statement, Schreiner held a three-year strategic planning retreat with his board of directors.

“The ACA was not part of that discussion,” he said.

Instead, the organization’s discussion delved into the Trump administration’s regulations that touch industry’s day-to-day operations — such as last year’s regulation to cut Medicare Part B reimbursement to 340B hospitals and setting some Medicare site-neutral payment rates.

“Those have the opportunity to impact us very urgently and negatively,” Schreiner told Modern Healthcare, noting the 340B drug discount program in particular.

But in Washington, the industry trade groups on the front-lines of policy battles say there is plenty of reason to worry or at least keep their guard up.

“The important thing for the industry is to keep in mind the old saw about, ‘Don’t listen to what they say, watch what they do,'” said Chip Kahn, president, and CEO of the Federation of American Hospitals. “And that being the case, this position is a reminder that the administration ultimately supports policies that are likely to mean less coverage rather than more. And we need to prepare ourselves for that to continue.”

Ceci Connolly, president, and CEO of the Alliance of Community Health Plans which represents not-for-profit insurers, is also taking the administration’s position extremely seriously. On Monday her group filed an amicus brief in the lawsuit on Monday, supporting the ACA and the Democratic state attorneys general who will defend it.

America’s Health Insurance Plans (AHIP), the American Medical Association and the American Hospital Association also filed amicus briefs on Monday.

“If you look at small nonprofits, we don’t have a lot of extra dollars to spend on filing court briefs, so I think this indicates how seriously we are taking this threat — that we have taken this step to articulate, we hope very clearly, to the court that this would be incredibly detrimental on so many levels,” Connolly said.

She called the president’s move a “complete game-changer, with no replacement plan.”

Axios over the weekend reported that President Donald Trump doesn’t expect the lawsuit to succeed and made the move out of political considerations. Joseph Antos of the American Enterprise Institute characterized the lawsuit move as a “particularly awkward play” aimed at Trump’s political base and the administration’s approach as a “short track to nowhere.”

Last week, Trump over Twitter and in Congress declared the Republican party the “party of healthcare,” and promised a new and better plan, although Republicans failed to pass a replacement in 2017 when they controlled both chambers of Congress.

The gap between political rhetoric around the lawsuit and what’s likely to happen next makes for a confusing landscape for GOP lawmakers to navigate.

Sen. Susan Collins (R-Maine), a moderate, urged Attorney General William Barr in a letter Monday to reject the administration’s stance on the Obamacare lawsuit.

“This surprising decision goes well beyond the position taken by the department last June, and puts at risk not only critical consumer provisions such as those protecting individuals suffering from pre-existing conditions but also other important provisions of that law,” Collins wrote to Barr.

Sen. Roy Blunt (R-Mo.), a member of Republican leadership in the Senate, last week emphasized that the lawsuit’s fate depends on the 5th Circuit rather than the president.

“From my point of view, I don’t want to presuppose what the courts are going to do,” he said. “Certainly, the Court of Appeals has the entire record that is not dependent on the government’s arguing its past position.”

On the regulatory side, the administration is pushing for industry-specific policies on healthcare, including site-neutral payment policies and 340B cuts, as well as policies hospitals favor like rolling back Medicare red tape.

Not all of the rules are partisan: the site-neutral payments, in particular, have bipartisan support from policy analysts.

On the insurance front, the White House has homed in on expanding association health plans and short-term, limited duration plans.

But industry representatives in Washington, who watch those regulations for their impact on profits, characterize the president’s stance on the lawsuit as part of the regulatory picture.

“When you couple (the lawsuit) with other efforts on association health plans and short-term plans, you begin to have a higher degree of concern,” Connolly said.

Kahn also argued that the administration’s regulations are in line with its strategy on the lawsuit.

“I think when you look at the different issues (around the regulations), I don’t think my concern about this lawsuit necessarily overshadows my concern about any of those other matters,” he said. “There’s a strategic reason why the president chose to take this position on the lawsuit, and it reflects a policy that HHS carries out every day, in its attitude toward coverage provisions of the ACA.”

Attacking the ACA Is an Attack on Mental Health: The Sequel

The threat is even more real

This article is adapted from a blog post on Sept. 20, 2018, when the author anticipated the consequences of a possible federal court ruling declaring the unconstitutionality of the Affordable Care Act.

Micheal Friedman had reported that the Affordable Care Act(a.k.a. Obamacare) was ruled unconstitutional by a federal court in Texas in December. That ruling has been appealed, and now the Justice Department has asked that the ruling is upheld. If that happens, millions of people will lose health coverage, including coverage for mental health and substance abuse treatment.

Amazing! At a time when everyone agrees that access to treatment is critical to fighting the opioid epidemic and that mental health services fall woefully short of meeting America’s need; a court ruling could deprive tens of millions of people of coverage for mental health and substance abuse services.

The Affordable Care Act increased access for these services for those tens of millions by increasing coverage generally, by mandating that the health coverage purchased through the federal and state health exchanges include coverage for mental health and substance abuse treatment, and by requiring coverage of pre-existing conditions — including mental disorders. It also required parity — i.e., that payment for behavioral health services be on a par with physical health services, making such services more affordable.

Before the Affordable Care Act, many health insurance plans for small groups or individuals and occasionally for large groups did not cover the behavioral cost at all or only at a great additional cost. The amount of coverage was also usually very limited. Typically, there were caps on numbers of covered outpatient visits and of inpatient days per year. Co-pays were typically 50% rather than 20%. Annual and lifetime caps were common, which might not be a problem for occasional acute disorders but left people with chronic conditions without coverage very quickly.

Mental and substance use disorders were also among the pre-existing conditions for which coverage could be and often was denied.

Federal legislation prior to the Affordable Care Act addressed some of the problems related to lack of parity, but not all. And parity was only required if a health plan included behavioral health coverage, not if the health plan covered only physical health conditions — a widely used option open to the purchasers of health plans.

And, prior to the ACA, no one — not large employers or small employers or individuals — was legally obliged to buy health insurance at all.

The ACA addressed all of these problems. Employers — except very small employers — were required to provide coverage for their employees (some with subsidies). Medicaid eligibility was extended to more working poor people. Individuals who did not have coverage through work, Medicare, Medicaid, the State Child Health Insurance Program, or the VA were required to purchase coverage (some with subsidies). And the small group and individual plans purchased through the federal or state health exchanges were required to include coverage for mental health and substance abuse disorders.

The original expectation was that changes under the ACA would provide behavioral health coverage for as many as 62 million people. The decision of several states not to extend Medicaid to larger populations and a subsequent decision not to penalize people who did not purchase insurance resulted in some shortfall. Nevertheless, there are still tens of millions of people with behavioral health coverage today who did not have it prior to the ACA.

Of course, not all will lose coverage if the ACA falls. Some employers who previously did not provide behavioral health coverage may decide to do so. Some individuals could continue to buy plans with such coverage — if such plans are affordable.

But that is unlikely. If people who do not believe they need coverage for mental health or substance abuse services opts for cheaper plans without behavioral health coverage — or no plans — the cost of plans with such coverage will rise because the people who buy them are likely to use them. The insurance industry refers to this as “adverse selection.”

If our nation really wants to have a health insurance system that will help to address the opioid epidemic and the vast underserviced of people with mental disorders, it must make sure that behavioral health coverage is affordable. It must also require coverage of people with pre-existing conditions. And it must enforce parity requirements.

To do this, the Affordable Care Act must stay in place unless or until a viable alternative is created. Swatting it down suddenly by court decree will have devastating consequences for millions.

 

Trump’s battle with ‘Obamacare’ moves back to the courts

Ricardo Alonso-Zaldivar noted that after losing in Congress, President Donald Trump is counting on the courts to kill off “Obamacare” as I started off this post. But some cases are going against him, and time is not on his side as he tries to score a big win for his re-election campaign.

Two federal judges in Washington, D.C., this past week blocked parts of Trump’s health care agenda: work requirements for some low-income people on Medicaid, and new small business health plans that don’t have to provide full benefits required by the Affordable Care Act.

But in the biggest case, a federal judge in Texas ruled last December that the ACA is unconstitutional and should be struck down in its entirety. That ruling is now on appeal. At the urging of the White House, the Justice Department said this past week it will support the Texas judge’s position and argue that all of “Obamacare” must go.

A problem for Trump is that the litigation could take months to resolve — or longer — and there’s no guarantee he’ll get the outcomes he wants before the 2020 election.

“Was this a good week for the Trump administration? No,” said economist Gail Wilensky, who headed up Medicare under former Republican President George H.W. Bush. “But this is the beginning of a series of judicial challenges.”

It’s early innings in the court cases, and “the clock is going to run out,” said Timothy Jost, a retired law professor who has followed the Obama health law since its inception.

“By the time these cases get through the courts there simply isn’t going to be time for the administration to straighten out any messes that get created, much less get a comprehensive plan through Congress,” added Jost, who supports the ACA.

In the Texas case, Trump could lose by winning.

If former President Barack Obama’s health law is struck down entirely, Congress would face an impossible task: pass a comprehensive health overhaul to replace it that both Speaker Nancy Pelosi and Trump can agree to. The failed attempt to repeal “Obamacare” in 2017 proved to be toxic for congressional Republicans in last year’s midterm elections and they are in no mood to repeat it.

“The ACA now is nine years old and it would be incredibly disruptive to uproot the whole thing,” said Thomas Barker, an attorney with the law firm Foley Hoag, who served as a top lawyer at the federal Health and Human Services department under former Republican President George W. Bush. “It seems to me that you can resolve this issue more narrowly than by striking down the ACA.”

Trump seems unfazed by the potential risks.

“Right now, it’s losing in court,” he asserted Friday, referring to the Texas case against “Obamacare.”

The case “probably ends up in the Supreme Court,” Trump continued. “But we’re doing something that is going to be much less expensive than Obamacare for the people … and we’re going to have (protections for) pre-existing conditions and will have a much lower deductible. So, and I’ve been saying that, the Republicans are going to end up being the party of health care.”

There’s no sign that his administration has a comprehensive health care plan, and there doesn’t seem to be a consensus among Republicans in Congress.

A common thread in the various health care cases is that they involve lower-court rulings for now, and there’s no telling how they may ultimately be decided. Here’s a status check on major lawsuits:

— “Obamacare” Repeal

U.S. District Court Judge Reed O’Connor in Fort Worth, Texas, ruled that when Congress repealed the ACA’s fines for being uninsured, it knocked the constitutional foundation out from under the entire law. His ruling is being appealed by attorneys general from Democratic-led states to the 5th U.S. Circuit Court of Appeals in New Orleans.

The challenge to the ACA was filed by officials from Texas and other GOP-led states. It’s now fully supported by the Trump administration, which earlier had argued that only the law’s protections for people with pre-existing conditions and its limits on how much insurers could charge older, sicker customers were constitutionally tainted. All sides expect the case to go to the Supreme Court, which has twice before upheld the ACA.

— Medicaid Work Requirements

U.S. District Court Judge James E. Boasberg in Washington, D.C., last week blocked Medicaid work requirements in Kentucky and Arkansas approved by the Trump administration. The judge questioned whether the requirements were compatible with Medicaid’s central purpose of providing “medical assistance” to low-income people. He found that administration officials failed to account for coverage losses and other potential harm, and sent the Health and Human Services Department back to the drawing board.

The Trump administration says it will continue to approve state requests for work requirements, but has not indicated if it will appeal.

— Small Business Health Plans

U.S. District Court Judge John D. Bates last week struck down the administration’s health plans for small business and sole proprietors, which allowed less generous benefits than required by the ACA. Bates found that administration regulations creating the plans were “clearly an end-run” around the Obama health law and also ran afoul of other federal laws governing employee benefits.

The administration said it disagrees but hasn’t formally announced an appeal.

Also facing challenges in courts around the country are an administration regulation that bars federally funded family planning clinics from referring women for abortions and a rule that allows employers with religious and moral objections to opt out of offering free birth control to women workers as a preventive care service.

I thought that I laid out fixes for the Affordable Care Act in my last three posts so now let us look at “alternative solutions”.