Category Archives: Socialized health care

2020 Dems Grapple with How to Pay for ‘Medicare for All’ and the Biden and Sanders Argument, and Yes, More on Medicare

rights328I recently spoke with a friend in the political world of Washington and his comment was that “there is a war here in D.C.” After listening to whatever news reports that you and yes I, listen to I can certainly believe it!! I’m wondering who is really in charge!!

Reporter Elena Schor noticed that the Democratic presidential candidates trying to appeal to progressive voters with a call for “Medicare for All” are wrestling with the thorny question of how to pay for such a dramatic overhaul of the U.S. health care system.

Bernie Sanders, the chief proponent of Medicare for All, says such a remodel could cost up to $40 trillion over a decade. He’s been the most direct in talking about how he’d cover that eye-popping amount, including considering a tax hike on the middle class in exchange for healthcare without co-payments or deductibles — which, he contends, would ultimately cost Americans less than the current healthcare system.

His rivals who also support Medicare for All, however, have offered relatively few firm details so far about how they’d pay for a new government-run, a single-payer system beyond raising taxes on top earners. As the health care debate dominates the early days of the Democratic primary, some experts say candidates won’t be able to duck the question for long.

“It’s not just the rich” who would be hit with new cost burdens to help make single-payer health insurance a reality, said John Holahan, a health policy fellow at the nonpartisan Urban Institute think tank. Democratic candidates campaigning on Medicare for All should offer more specificity about how they would finance it, Holahan added.

Sanders himself has not thrown his weight behind a single strategy to pay for his plan, floating a list of options that include a 7.5% payroll tax on employers and higher taxes on the wealthy. But his list amounts to a more public explanation of how he would pay for Medicare for All than what other Democratic presidential candidates who also back his single-payer legislation have offered.

Kamala Harris, who has repeatedly tried to clarify her position on Medicare for All, vowed this week she wouldn’t raise middle-class taxes to pay for a shift to single-payer coverage. The California senator told CNN that “part of it is going to have to be about Wall Street paying more.”

Her contention prompted criticism that she wasn’t being realistic about what it would take to pay for Medicare for All. Colorado Sen. Michael Bennet, a rival Democratic presidential candidate, said Harris’ claim that Medicare for All would not involve higher taxes on the middle class was “impossible,” though he stopped short of calling her dishonest and said only that candidates “need to be clear” about their policies.

A Harris aide later said she had suggested a tax on Wall Street transactions as only one potential way to finance Medicare for All, and that other options were available. The aide insisted on anonymity in order to speak candidly about the issue.

Another Medicare for All supporter, New York Sen. Kirsten Gillibrand, would ask individuals to pay between 4% and 5% of their income toward the new system and ask their employers to match that level of spending. Gillibrand’s proposal, shared by an aide who requested anonymity to discuss the campaign’s thinking, could supplement the revenue generated by that change with options that hit wealthy individuals and businesses, including a new Wall Street tax.

Gillibrand is a cosponsor of Sanders’ legislation adding a small tax to financial transactions, while Harris is not.

New Jersey Sen. Cory Booker, who also has signed onto Medicare for All legislation but said on the campaign trail that he would pursue incremental steps as well, could seek to raise revenue for the proposal by raising some individual tax rates, changing capital gains taxes or expanding the estate tax, according to an aide who spoke candidly about the issue on condition of anonymity.

The campaign of Massachusetts Sen. Elizabeth Warren, who used last month’s debate to affirm her support for Sanders’ single-payer health care plan, did not respond to a request for more details on potential financing options for Medicare for All.

Meanwhile, Sanders argued during a high-profile Medicare for All speech this week that high private health insurance premiums, deductibles, and copayments, all of which would be eliminated by his proposal, amount to “nothing less than taxes on the middle class.”

Medicare for All opponents are also under pressure to explain how they’d pay for changes to the health insurance market. Former Vice President Joe Biden is advocating for a so-called “public option” that would allow people to decide between a government-financed plan or a private one. He would pay for his $750 billion proposals by repealing tax cuts for the wealthy that President Donald Trump and the GOP cut in 2017, and by raising capital gains taxes on the wealthy.

Inside Biden and Sanders’ Battle Over Health Care—and the Party’s Future

Sahil Kapur noted that Joe Biden and Bernie Sanders are engaged in open warfare over health care that could harden party divisions and play into the hands of President Donald Trump.

In the latest iteration of the battle, Biden’s communications director posted an article on Saturday, entitled “Let’s Get Real About Health Care,” that delved into the potential costs of the proposals favored by the Democratic party’s left flank.

The tension points to a broader power struggle in Washington and on the campaign trail that pits long-dominant moderates like Biden against an insurgent wing led by Sanders and Elizabeth Warren. But a prolonged battle risks entrenching bitterness between the factions that threatens party unity heading into the general election.

Many prominent Democrats fear that backing an end to private health insurance means defeat in the presidential race and the competitive districts that won the party a House majority in 2018. They prefer more modest legislation to expand government-run insurance options.

Biden favors that approach, calling for largely preserving the popular Obamacare while adding a “public option” that would compete with private insurers. Sanders, a Vermont senator and the chief architect of a Medicare for All plan that would cover everybody under a single government plan, wants to replace the 2010 law.

Aimee Allison, who runs She the People, an activist group that seeks to elevate women of color and recently hosted a Democratic presidential forum, said young voters and minorities are eager for change.

“The Democratic Party leadership is more concerned about moderate to conservative Democratic voters, who are a shrinking and less reliable part of the party base than they are about people of color, women of color, younger voters who are inspired by these kinds of ideas,” Allison said.

“That decision led to the loss in 2016,” she said. “There were plenty of black voters who could be inspired to vote and weren’t — and that’s why we lost.”

Climate Change

The split extends far beyond health care. Democrats also differ on how aggressively to tackle climate change and whether to support mass cancellation of student debt.

Dan Pfeiffer, a former senior adviser to President Barack Obama, said the differences among Democrats reflect meaningful policy disagreements rather than just political calculations.

“Bernie Sanders should be applauded for pushing the debate” about how bold to be, Pfeiffer said in an email. “But I do think some of the opposition among the candidates to Sanders’ version is about policy as much as politics.”

The health care debate grew heated earlier this week when Biden, who as vice president helped steer the Affordable Care Act, or Obamacare, through Congress, told voters that the “Medicare For All Act” authored by Sanders “means getting rid of Obamacare — and I’m not for that.” He said the bill would end private insurance and ensure that “Medicare goes away as you know it.”

Fear-Mongering’

Sanders responded by accusing Biden of “fear-mongering” and parroting the “lies” of Trump and the insurance industry. His campaign website posted a “who said it” quiz on health care mocking Biden as being aligned with Senate Majority Leader Mitch McConnell and Trump.

Biden argues that Medicare for All would cancel plans for the 150 million people on private insurance and that he’d give them the option to keep their plan. Sanders says adding a public option to Obamacare would be less effective at covering the 27 million uninsured Americans or cutting costs. While a tax increase would be required to pay for single-payer, eliminating premiums and out-of-pocket costs would offset it, he says.

Biden pressed his argument Thursday, insisting he wasn’t criticizing Sanders but rather conveying what his plan would do.

“Bernie’s completely honest about saying he’s going to raise taxes on the middle class and just straightforward about it,” the former vice president told reporters in Los Angeles.

The Biden campaign went after Sanders’ plan again on Saturday in a Medium.com post, saying that defending Obamacare is a way for Democrats to win in 2020.

“We all understand the appeal of Medicare for All, but before we go down that road we should take a clear-eyed and honest look at what the plan actually says and what it will cost,” wrote Biden communications director Kate Bedingfield. She suggested Biden’s view would prevail “once voters look beyond Twitter and catch-phrases.”

A similar power struggle is unfolding in the House of Representatives, where Speaker Nancy Pelosi and moderate Democrats have clashed with the “Squad” of newly elected progressive women – Representatives Ayanna Pressley, Alexandria Ocasio-Cortez, Ilhan Omar and Rashida Tlaib.

The new lawmakers have used their large social media followings to elevate far-reaching ideas while challenging party leaders to be more tactically aggressive with Trump on issues like immigration and impeachment.

“The Squad — they’re a proxy for the millions of us who want to see a bolder, more progressive set of policies and changes,” Allison said, arguing that limiting the Democratic Party’s vision based on what appears politically possible would prevent new voters from getting engaged and turning out.

Conditional Support

Polling on Medicare for All illustrates the party’s dilemma. Surveys indicate that a majority of Americans favor the idea. But support plummets when people are told the program would eliminate private insurance and rises again when they are told that switching to a government-run plan doesn’t necessarily mean losing their doctors and providers.

Pelosi and other Democratic leaders back Biden’s approach. 2020 rivals Warren, and Senators Kamala Harris, Cory Booker, and Kirsten Gillibrand cosponsor sanders’ single-payer plan. Harris says she prefers single-payer but has also cosponsored legislation for a public option as a route to extending coverage.

Ocasio-Cortez said Americans she talks to “like their health care, they like their doctor,” but that they aren’t “heartbroken” about the prospect of having to transition off an Aetna or Blue Cross Blue Shield plan.

Trump and his allies have sought to make the Squad the face of the Democratic Party, believing that they alienate moderate voters. House GOP campaign chairman Tom Emmer called the four women the “red army of socialists” at a Christian Science Monitor breakfast for reporters.

The four women are among the 114 cosponsors of the Medicare For All Act in the House, but the legislation has stalled out and is unlikely to be brought to a vote, which suggests that the moderate wing is winning the battle in Washington.

Andy Slavitt, a former acting head of the Centers for Medicare and Medicaid Services under Obama, said Democrats unanimously agree on the goal of universal coverage but differ on how best to get there.

“Primaries are about calling out differences in approach. There should be sufficient oxygen to say how would Joe Biden or Michael Bennet do it versus how would Bernie Sanders do it,” he said in an interview.

Slavitt warned that while a debate was healthy, Democrats shouldn’t lose sight of the ultimate goal.

“It’s important that we don’t get so overwhelmed with the distinctions around ‘how’ that we forget there is a massive gulf between what the visions are,” Slavitt said, “between Democrats and the president’s position to repeal the ACA, make coverage more expensive.”

Surprise! Here’s Proof That Medicare for All Is Doomed

Ramesh Ponnuru discovered that there’s a high-profile debate over health care playing out in the presidential race, and a lower-profile one taking place in Congress. Several Democratic presidential candidates are telling us that they are going to provide health care that is free at the point of service to all comers. In little-noticed congressional mark-ups, members of both parties are demonstrating why these promises will not be met.

The legislation under consideration is aimed at so-called surprise medical bills” – charges a patient assumes were covered by insurance but turn out not to have been. My family got one last year: The hospital where my wife delivered our son was in our insurer’s network, but an anesthesiologist outside the network-assisted. The bill had four digits.

Surprise bills seem to be something of a business model for some companies. A 2017 study showed how bills rose when EmCare Inc. took over hospitals’ emergency rooms, with the percentage of visits incurring out-of-network charges jumping “like a light switch was being flipped on.”

Policy experts from across the political spectrum have devised ways to prevent this sticker shock. Benedic Ippolito and David Hyman have a short paper for the American Enterprise Institute (where I am a fellow) that suggests providers of emergency medicine should have to contract with hospitals, reaching agreement on prices and folding them into the total bill, rather than sending separate bills to patients and their insurers. In incidents where the surprise bill is the result of an emergency involving treatment by an out-of-network hospital (or transportation by an out-of-network ambulance), their solution would be to cap payments at 50% above the level that in-network providers get paid on average. In both cases, prices would be determined by negotiation among parties that are informed and not in the middle of a medical emergency.

Senator Lamar Alexander, a Tennessee Republican, has introduced a bill that includes a version of that cap. But provider trade groups favor a different measure introduced by Representative Raul Ruiz, a Democrat from California, which would create a 60-day arbitration process to determine what insurers should pay out-of-network providers, and instructs arbiters to first consider the 80th percentile of list prices for a service in a given market. It is a generous approach that analysts with the USC-Brookings Schaeffer Initiative for Health Policy conclude “would likely result in large revenue increases for emergency and ancillary services, paid for by commercially-insured patients and taxpayers.” It would, therefore, mean higher premiums and federal deficits, while Alexander’s alternative has been estimated to reduce both. Ruiz has 52 co-sponsors who range from liberal Democrats to conservative Republicans.

Turn from this dispute, for a moment, to the Medicare for All proposal (which has some of the same co-sponsors as the Ruiz bill). It envisions sharp cuts in payments to providers – as high as 40%. Those cuts enable advocates to say they will cover the uninsured and provide added coverage to the insured while reducing national health spending.

Is this at all likely? The Alexander bill would try to rein in billing by one subset of providers in cases where the bills are especially unpopular. But the House Energy and Commerce Committee is watering down its surprise-billing legislation, accepting a provider-backed Ruiz amendment to add arbitration. It’s not as generous as Ruiz’s own bill, but its effect would be to keep payments at today’s rates.

The House is following a long line of precedents. For years, bipartisan majorities in Congress voted down planned cuts in provider-payment rates under Medicare; ultimately, they got rid of the planned cuts altogether. Now even modest measures like Alexander’s face determined and effective resistance.

There is, in short, very little appetite for cutting payments to providers. If medical-provider lobbies can force Congress to back off from addressing surprise bills – which are, in the grand scheme of our health-care system, a small kink – what are the odds lawmakers will force a much larger group of providers, including the powerful hospitals lobby, to accept the much larger reductions that Medicare for All would have to entail? Maybe the Democratic presidential hopefuls should be asked that question at the next debate so that we can judge whether Medicare for All is a fantasy or a fraud.

Those of us who are covered by Medicare, we realize the limitations of coverage as well as the discounted reimbursements paid to physicians, hospitals, nursing facilities, etc. Do we think that Medicare for All is going to make it any better for “All”?

Back to Medicare History

By 1972 the costs associated with Medicare had spiraled out of control to such a rate that even the administration and Congress were expressing concern as I pointed before. Then as a consequence, a number of studies were undertaken to examine what were the causes. The conclusions were that this rise was due to hospital service charges that rose much faster than the Consumer Price Index and especially the medical care component of the index as well as physicians’ charges over the first five years of Medicare ending in 1971. The charges rose 39 percent as compared with a 15 percent rise in the five years before the advent of Medicare. If you adjust for the increase in CPI, the Medicare physicians’ charges rose by 11 percent during that first five years of Medicare.

Also as important is that the proportion of total health care expenditures of the elderly that originated in public sources rose far more sharply than had been expected prior to Medicare’s passage. In fact in the fiscal year 1966, the government programs provided 31 percent of the total expended on health care for the elderly and just one year later this proportion had risen to 59 percent. Also, consider that Medicare alone accounted for thirty-five cents of every dollar spent on health services by or for those over the age of 65. There were even more dramatic increases occurred in the Medicaid program during its first few years.

The wording of Title XIX provided that the federal government had an open-ended obligation to help underwrite the costs of medical care for a wide range of services to a large number of possible recipients, depending on state legislation. Therefore, there was no accurate way of predicting the ultimate costs of the program and I will leave this discussion here. Why? Because age we have an older and older population we will have a bigger group in which Medicare will cover. Now if we enlarge the demographic to include “All” Americans the main question is how will we pay for that program?

 

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.

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.

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”.

And A Few More Suggestions to Fix the Affordable Care Act- Keep improving healthcare quality

 

 

clueless145[458]Republican response to Trump’s declaration of war on the Affordable Care Act-McConnell to Trump: We’re not repealing and replacing ObamaCare
This last week Alexander Bolton reported that Senate Majority Leader Mitch McConnell (R-Ky.) told President Trump in a conversation Monday that the Senate will not be moving comprehensive health care legislation before the 2020 election, despite the president asking Senate Republicans to do that in a meeting last week.
McConnell said he made clear to the president that Senate Republicans will work on bills to keep down the cost of health care, but that they will not work on a comprehensive package to replace the Affordable Care Act, which the Trump administration is trying to strike down in court.
“We had a good conversation yesterday afternoon and I pointed out to him the Senate Republicans’ view on dealing with comprehensive health care reform with a Democratic House of Representatives,” McConnell told reporters Tuesday, describing his conversation with Trump.
“I was fine with Sen. Alexander and Sen. Grassley working on prescription drug pricing and other issues that are not a comprehensive effort to revisit the issue that we had the opportunity to address in the last Congress and were unable to do so,” he said, referring to Senate Health Committee Chairman Lamar Alexander (R-Tenn.) and Finance Committee Chairman Chuck Grassley (R-Iowa) and the failed GOP effort in 2017 to repeal and replace ObamaCare.
“I made clear to him that we were not going to be doing that in the Senate,” McConnell said he told the president. “He did say, as he later tweeted, that he accepted that and he would be developing a plan that he would take to the American people during the 2020 campaign.”
After getting the message from McConnell, Trump tweeted Monday night that he no longer expected Congress to pass legislation to replace ObamaCare and still protect people with pre-existing medical conditions, the herculean task he laid before Senate Republicans at a lunch meeting last week.
“The Republicans are developing a really great HealthCare Plan with far lower premiums (cost) & deductibles than ObamaCare,” Trump wrote Monday night in a series of tweets after speaking to McConnell. “In other words, it will be far less expensive & much more usable than ObamaCare Vote will be taken right after the Election when Republicans hold the Senate & win back the House.”
Trump blindsided GOP senators when he told them at last week’s lunch meeting that he wanted Republicans to craft legislation to replace the 2010 Affordable Care Act.
The only heads-up they got was a tweet from Trump shortly before the meeting, saying, “The Republican Party will become ‘The Party of Healthcare!’”
The declaration drew swift pushback from Republicans like Sen. Susan Collins (Maine), who said the administration’s efforts to invalidate the entire law were “a mistake.”
Other Republicans, including Sen. Mitt Romney (Utah), said they wanted to first see a health care plan from the White House.
Senate Republican Whip John Thune (S.D.) on Tuesday said the chances of getting comprehensive legislation passed while Democrats control the House are very slim.
“It’s going to be a really heavy lift to get anything through Congress this year given the political dynamics that we’re dealing with in the House and the Senate,” he said. “The best-laid plans and best of intentions with regard to an overhaul of the health care system in this country run into the wall of reality that it’s going to be very hard to get a Democrat House and a Republican Senate to agree on something.”
Back to our/my suggestions to improve the Affordable Care Act.
Healthcare organizations like the Cleveland Clinic have made front-end investments to change their approaches to care delivery.
Another writer on healthcare reported that the GOP’s proposals to replace the Affordable Care Act have so far focused on health insurance coverage, cutting federal aid for Medicaid and targeting subsidies for those who purchase private insurance through the health insurance marketplace.
But there’s a lot more to the ACA than health insurance. Republican lawmakers would do well to take a closer look at other parts of the healthcare reform law, which focus on how the United States can deliver high-quality care even while controlling costs.
The ACA helped spur the transition away from fee-for-service reimbursement models that rewarded providers for treating large numbers of patients to value-based care payments, which reward providers who deliver evidence-based care with a focus on wellness and prevention.
And any revisions to the law should continue to support these endeavors—such as programs to reduce hospital readmissions and hospital-acquired conditions—that aim to improve patient outcomes while lowering overall healthcare costs.
It’s true that some physicians are reluctant to embrace value-based contracts, which they argue increase their patient loads and hold them responsible for overall wellness, which is often beyond their typical scope of practice or beyond their control if patients aren’t compliant. Smaller hospitals and health systems may have trouble implementing quality-improvement changes, too.
But it’s too soon to give up on a model of care that strives to meet the Triple Aim and improve individual care, boost the health of patient populations and reduce overall costs.
The country must do something to address the quality of its healthcare. Although the United States spends more on healthcare than other wealthy nations do, we rank last in quality, equity, access, efficiency and care delivery. And we’ve come in dead last in quality for the past 13 years.
But it’s not for lack of trying.
The Centers for Medicare & Medicaid Services is still experimenting with advanced payment models that reward providers for quality of care. Although the results have been a mixed bag, there are signs of progress.
Yes, several of the Pioneer accountable care organizations exited the model early on after suffering financial losses and struggling to meet the demands of the program. But other participants of the Pioneer model and the Shared Savings Program reported clinical successes as well as significant savings.
In response, CMS has adapted the models, offering providers options for lower and higher risk tracks.
Whereas some healthcare organizations took a wait-and-see approach to value-based care until one successful model emerged, many leaders say it takes time to see results and that what works in one region or for one organization won’t necessarily work somewhere else.
But the organizations that have made front-end investments to change their approaches to care delivery and have stuck with it are beginning to see their efforts pay off.
Donald Berwick, M.D. noted that Ohio’s Cleveland Clinic, for instance, has standardized care pathways to reduce variations in care, lower costs and increase quality. Its stroke care pathway has led to a 43% decrease in stroke mortality and a 25% decline in the cost of care.
And California-based Dignity Health has developed community partnerships to discharge homeless patients to a recuperation shelter and address the social determinants of health via a referral program to connect patients in need with outside agencies.
“All three [aims] are achievable, all three show progress and all three are vulnerable,” Donald M. Berwick, M.D., president emeritus and senior fellow at the Institute for Healthcare Improvement, said recently.
“It seems to me incumbent upon those who claim to lead healthcare and healthcare systems to defend that progress against threats.”
Improve payment models and cut costs
We must all remember there is no silver bullet that will cut costs and improve care. But allowing the Center for Medicare & Medicaid Innovation to keep working on it is key.
Reporter Paige Minemyer went on to state that if they really want to repair the Affordable Care Act, lawmakers must focus on the transition to value-based care, which has accelerated under healthcare reform.
The first step? Support the Center for Medicare & Medicaid Innovation (CMMI) as it tests new payment models that will cut costs. There is no silver bullet that will cut costs and improve care. But allowing CMMI to keep working on it is key.
Payment model innovation
Providers that have seen the benefits of CMMI’s initiatives, including bundled payments, say they’re sticking with it regardless of what the White House or Congress decide. Helen Macfie, chief transformation officer for Los Angeles-based Memorial Care Health System, is taking that route: She says her organization is “bullish” on continuing the model voluntarily.
Bundled payments get specialists together with providers “to do something really cool,” she says.
Providers have seen mixed success in accountable care organizations (ACOs), the most complex advanced payment model (APM) there is. But their longevity requires commitment to reduced regulations.
On that point, the Donald Trump White House and the healthcare industry agree: Less is sometimes more. A reduced regulatory burden can also make it easier for providers to balance multiple APMs at once, which can improve the effectiveness of each.
Providers that have found success with ACOs may not see the benefits immediately, studies suggest, but the savings instead compound over time. ACO programs may require significant startup costs upfront.
However, the evidence is growing that these advanced value-based care models do pay off in both cost reduction and quality improvement, even if there’s still much for researchers to learn about what really makes an ACO model succeed.
Cost-cutting measures
Also lost in the debate over insurance reform is the growing cost of healthcare in the U.S., which far outpaces that of other developed nations despite lagging behind in quality. An element of this that is totally untouched in Republican-led reform is drug pricing, which providers argue is one of the major drivers of increased costs.

And now a suggestion from President Donald Trump!
As part of the party’s updated platform for 2018, Democrats unveiled plans to allow Medicare to negotiate drug prices. The suggestion has been championed both by former President Barack Obama and by President Donald Trump, whose vacillating views on health policy have been known to buck the party line.
But not everyone is convinced that this is the best solution. Experts at the Kaiser Family Foundation noted that negotiating drug prices could have a limited impact on savings, and even the Congressional Budget Office has been skeptical.
And if you ask pharmaceutical companies, they’re not the problem when it comes to rising healthcare costs, anyway; hospitals are.
Harness the power of Medicaid
Leslie Small noted that for Medicare & Medicaid Services Administrator Seema Verma is a big advocate for expanding the use of state innovation waivers to reimagine Medicaid. (Office of the Vice President)
By now, a laundry list of studies chronicles all the benefits of expanding Medicaid eligibility under the Affordable Care Act. Thanks to a previous Supreme Court decision, the remaining 19 states aren’t obligated to follow suit, but now that legislative attempts to repeal the ACA have failed, they would be foolish not to.
Not only have Medicaid expansion states experienced bigger drops in their uninsured rates relative to nonexpansion states, but hospitals in these states have also seen lower uncompensated care costs. In addition, low-income people in Medicaid expansion states were more likely than those in nonexpansion states to have a usual source of care and to self-report better health, among other metrics.
Crucially, the Trump administration has even given GOP governors who might be worried about the political fallout a convenient reprieve, as it’s signaled openness to approving waivers that design Medicaid expansion programs with a conservative twist.
Previous HHS Secretary Tom Price suggestion had a suggestion.
“Today, we commit to ushering in a new era for the federal and state Medicaid partnership where states have more freedom to design programs that meet the spectrum of diverse needs of their Medicaid population,” Centers for Medicare & Medicaid Services Administrator Seema Verma and Department of Health and Human Services Secretary Tom Price said in a joint statement in March.
In fact, Vice President Mike Pence and Verma both designed such a program in Indiana, which requires beneficiaries to pay a small amount toward their monthly premiums.
Other states, meanwhile, have applied for a more controversial Medicaid tweak—enacting work requirements for beneficiaries—and it remains to be seen whether those experiments will be approved and if so, face backlash.
But under the 1332 and 1115 waivers in the ACA, states have plenty of latitude to dream up other ways to better serve Medicaid recipients, such as integrating mental and physical health services for this often-challenging population.

So, I have laid out a number of real options to improve the health acre bill that was passed already and by all data imputed it seems to be working with reservations. My biggest reservation is that over time the Affordable Care Act/ Obamacare needs definite tweaking and needs revenue of some sort to make the healthcare system affordable and sustainable without putting the burden on our young healthy hard-working Americans.
I’ve heard the suggestion that all big government has to do is print more money. Ha, Ha, this sounds like the suggestions of the new socialists like Ocasio-Cortez and all her buddies. Maybe we can keep borrowing money as we have in the past from Social Security Funds, Medicare or shifting funding for other projects like the Pentagon. I am kidding, but there are people in high places who would suggest these options not knowing much about what comes out of there ignorant mouths or social media posts.
We as a Country have to get smart, ignore the idiots yelling and screaming about their poorly thought out suggestions to get re-elected or just elected as potential presidential hopefuls, gather the intelligent forces in healthcare to come up with solutions and get Congress to come to their senses to achieve a bipartisan solution for the good of all Americans. It seems as though both political parties are truly clueless, especially the Nancy Pelosi and her Democrats who have taken over power in Congress, and yes both the House and the Senate!
Next on the agenda is looking more into Medicare For All, Single Payer Healthcare Systems and Socialized Healthcare. And even more on the status of the Affordable Care Act/Obamacare. Joy, Joy!!

Continuing the Discussion on How to Fix the Affordable Care Act. With all the liberals in the Democrat Party declaring Free everything for All our President has stepped in to create more confusion!

college147GOP senators were blindsided by Trump on ObamaCare this week. This past week as President Trump was feeling good and relieved about the Mueller report so what does he do? He starts the promise to throw out Obamacare! And what does that do to all the Republicans trying to support him and about to campaign for another term? Confusion?

Republican lawmakers were caught completely off guard by President Trump’s renewed push to repeal and replace ObamaCare and privately complain it’s a dumb political strategy heading into the 2020 election. Senate Finance Committee Chairman Chuck Grassley (R-Iowa), whose panel has jurisdiction over health care, said he received no heads-up from Trump or the White House that the president would call Tuesday for the GOP to become “the party of health care.”

“I don’t think there was any heads-up on anything that he was going to say,” said Grassley, who added that he didn’t even know Trump was meeting with the GOP conference on Tuesday until Monday night.

Sen. Lamar Alexander (R-Tenn.), the chairman of another key panel that handles health care, said he didn’t know about Trump’s new health care push until the president tweeted about it at 11:58 a.m. Tuesday, shortly before he walked into a Republican conference lunch to announce it in person.

If Trump had told GOP senators of his plans, they say they would have sought to convince him not to throw their party back into a war over health care — the issue Democrats believe was instrumental to their takeover of the House in last year’s midterms.

A safe 2018 Senate map that had Republican incumbents defending just a handful of seats and Democrats trying to protect senators in deep-red states helped the GOP overcome the blue wave in the House. Republicans actually gained two seats in the Senate.

But the 2020 map is seen as more challenging, and many in the GOP can’t understand why Trump would plunge them into a fight over health care just as he was surfing a wave of good news brought by the end of special counsel Robert Mueller’s investigation.

“It doesn’t seem to make sense politically,” said one Republican senator, who questioned why Trump would give Democrats a new avenue of attack.

Another Republican senator said, “We would be crazy to try to go through what we went through again,” referring to the failed 2017 effort to repeal ObamaCare, which fell one vote short in the Senate.

A third Republican senator expressed hope that Senate Majority Leader Mitch McConnell (R-Ky.) will join House Minority Leader Kevin McCarthy (R-Calif.) in pressing Trump to back off his aggressive push to defeat the 2010 health care law in court.

“I would think McConnell and crew would be using their influence to get the administration to stop this,” the source said.

The lawmaker said Trump is “throwing down a challenge in advance of the elections which makes it even more difficult,” describing the current politic environment as “toxic” for passing ambitious legislation.

“If you look at past history, we don’t really know how to do it,” the senator added, referring to broad health care legislation.

McCarthy urged Trump in a phone call to drop his administration’s effort to have the law struck down in the courts, arguing the strategy makes little sense after Democrats won control of the House in November after campaigning on health care, according to reports Wednesday by Axios and The Washington Post.

Trump, nevertheless, doubled down on his position Wednesday. He defended the Justice Department’s argument for striking down the law he called a “disaster,” arguing that it had sent premiums soaring and has turned out to be “far too expensive for the people, not only for the country.”

“If the Supreme Court rules that ObamaCare is out, we’ll have a plan that is far better than ObamaCare,” the president promised at the White House on Wednesday.

Trump told Republican senators at the Tuesday meeting that he wants GOP lawmakers to come up with a health care package to replace the Affordable Care Act (ACA) if the courts strike down former President Obama’s signature law.

Sen. Susan Collins (R-Maine), who is up for reelection in a state Democrat Hillary Clinton carried in 2016, said Trump’s bold promise that Republicans will have a plan to replace ObamaCare if it’s struck down by the Supreme Court has “got the cart before the horse.”

She said, “There are some very important, good provisions of the ACA that have helped to expand health insurance for low-income Americans” and also “provide important consumer protections to virtually all of us, and I would not want to see those abandoned.”

“For the administration to advocate for invalidating a duly enacted law is a mistake, in my view,” she added.

Sen. Cory Gardner (R-Colo.), who is also up for reelection in a state that voted for Clinton in 2016, declined to comment on whether he agrees with the administrative support for striking down protections for people with pre-existing conditions and other ACA reforms.

Senate Majority Whip John Thune (R-S.D.) warned that the issue of health care reform hasn’t worked for Republicans in the past.  “It’s historically probably not been a great issue for Republicans,” he said.

Thune did say the GOP could turn it around “if we’re providing solutions that create lower premiums and copays and deductibles for people.”

Alexander said he had not planned to grapple with the thorny problem of insurance reform this Congress and instead wanted to focus on finding ways to lower health care costs by looking at prescription drug costs, surprise billing and the 340B drug pricing program.

Grassley said he had planned to work primarily on prescription drug costs — not finding a new plan to replace ObamaCare.

McConnell has counseled colleagues that it is smarter to play offense by attacking Democrats for their most liberal proposals, such as providing Medicare for all, instead of playing defense on the GOP’s own plan, said a Republican senator familiar with McConnell’s advice on the subject.

Republican senators say the onus should be on Trump to come up with a health care plan since it’s his idea.

“I’d like to see what the administration brings forward. The first step is to see what the president and the White House have with regard to their health care plan and be able to respond to that,” said Sen. Mitt Romney (R-Utah).

Sen. Joni Ernst (R-Iowa), who is up for reelection next year, agreed that it would be “reasonable” for the White House to take the lead on health care reform.

“What we don’t want to do is start working in 50 different directions this Congress and not have it supported by the administration,” she said.

Republicans face an uphill battle in their bid to fulfill President Trump’s prophecy that the GOP will become “the party of health care.”

The presidential directive, handed down in a tweet on Tuesday, came at an inopportune time for Republicans, less than a day after the Trump administration called for the courts to invalidate the Affordable Care Act (ACA) in its entirety.

Taken together, that announcement and Trump’s ambitious call to resurface a campaign promise that has eluded Republicans for years underscores the political peril facing the GOP in 2020, as well as the long road the party faces if it hopes to, in fact, become “the party of health care.”

“People already believe that Republicans have the wrong approach to health care,” Doug Thornell, a longtime Democratic strategist, and adviser, said. “When the White House makes the kind of announcement it just did, it reinforces that.”

For Democrats, the GOP’s posture on health care has already proven to be one of their most incisive lines of attack, helping them win 40 House seats in the 2018 midterm elections.

With 2020 fast approaching, Democrats are eager to revive the issue.

“I would love it if the Republicans want to make this campaign about health care,” Thornell said. “That would be fantastic. I think any Democrat would love to have that debate.”

By and large, available polling data shows Democrats with an edge in the health care debate. An NBC News/Wall Street Journal poll released earlier this month found that 56 percent of respondents see Democratic positions on health care as being “in the mainstream,” compared to only 38 percent who said the same of the Republican Party’s views on the issue.

A Harvard CAPS/Harris poll released exclusively to The Hill this week brought similarly good news for Democrats.

Fifty-eight percent of respondents in that survey said they trust the Democratic Party more to handle health care. Meanwhile, 48 percent said they trust Republicans on the matter.

The polls are reflective of a larger trend in public opinion.

Democrats have largely seen support for their handling of health care tick upwards in recent years, available polling data shows. For Republicans, the numbers have either remained stagnant or trended downwards.

Despite those trends, Republicans have sought to turn the tables in recent months as some in the Democratic Party, including several presidential hopefuls, lurch to the left on health care and embrace a single-payer, Medicare for All approach.

That approach, favored by the party’s progressive and activist base, has received mixed receptions among the broader electorate.

A Quinnipiac University poll released Tuesday found 45 percent of Americans opposing Medicare for All and 43 percent backing the proposal.

“That’s the rhetoric that really scares a lot of voters – I would think a lot of independent voters, a lot of suburban voters, voters that Dems did really well with last time,” Doug Heye, a Republican strategist, said.

While Republicans had hoped to seize on public unease with such sweeping reforms, Heye said that the Trump administration’s legal shift on the ACA could complicate that effort by putting the onus on Republicans to stake out their own position on health care.

“It’s why the announcement from the White House was surprising,” said Heye, who also served as an aide to former House Majority Leader Eric Cantor (R-Va.). “If your opponent is running off a cliff, it’s best to stay out of their way.”

It also forces the party to wrestle with a frustrating reality for many of its members: After multiple failed attempts to repeal the ACA, Republicans are still largely divided on exactly how to replace former President Obama’s signature health care law, which has seen its favorability tick upwards in recent years.

A Quinnipiac University poll released Tuesday found that 55 percent of Americans support improving the country’s current health care system, rather than replacing it entirely.

If Republicans ultimately decide to take another crack at replacing the ACA, it’s unclear where such a plan will originate.

Marc Short, a former White House aide who is now Vice President Pence’s chief of staff, said on CNN Wednesday that Trump will submit a plan to Congress sometime “this year.”

But Rep. Mark Meadows (R-N.C.), the chair of the ultra-conservative House Freedom Caucus, said on Thursday that any plan to replace the ACA would be in collaboration with congressional Republicans.

“It’s my impression there will be a plan the president and White House endorses, but I think it will be a collaborative effort between House and Senate Republicans,” Meadows said.

Heye said that if Trump wants to define the Republican Party with a robust health care agenda, it would have to be the White House —rather than GOP lawmakers — that takes the lead.

“We were never able to agree on a white paper — and that’s when we had the [House] majority,” Heye said. “If we weren’t able to do that on our own, the only way that this gets done is if the White House goes all in and long term.”

“Is the White House prepared to do that? We haven’t really seen a whole lot of other examples of where they have.”

It brings up one of last week’s suggestion for repairing the Affordable Care Act, which applies to whatever we design for a health care system-Listen to the Doctors. Doctor’s Orders: Don’t Repeal Obamacare/Affordable Healthcare Act Until You Have A Plan To Replace It!

Jonathan Cohn noted that a major physicians group is also asking GOP leadership to preserve the law’s historic coverage gains. The largest and most influential organization of American physicians has sent two stark messages to the Republican Party: Don’t mess with Obamacare until you know what you’re putting in its place.

And don’t do anything that would backtrack on the law’s most important accomplishment ― bringing the number of uninsured Americans to a historic low.

The American Medical Association delivered these messages on Tuesday, in an open letter addressed to congressional leaders of both parties. But its intended audience was GOP leadership and members President-elect Donald Trump’s incoming administration who have said repealing the Affordable Care Act would be their first order of business.

Two days into the new congressional session, GOP leaders have already started the legislative process that would eventually allow them to kill Obamacare, by stripping out it’s funding and spending with simple majority votes in both houses.

Vice President-elect Mike Pence met with GOP leaders, including House Speaker Paul Ryan, on Wednesday to discuss strategy and rally rank-and-file members.

But Republicans have promised for nearly seven years that they could replace Obamacare with something better, and even party leaders acknowledge that they have no consensus on how to do that.

In the letter, AMA CEO and vice president James Madara warned Republicans not to repeal the law until they could “layout for the American people, in reasonable detail, what will replace current policies.”

Patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform. AMA CEO James Madara announced that with its warning against a hasty repeal vote, the AMA joins a chorus that includes other industry groups and even some well-known conservative experts on health policy. But the AMA’s letter was striking in two key respects.

One was its explicit call for Republicans not to let the number of uninsured Americans increase again. “In considering opportunities to make coverage more affordable and accessible to all Americans, it is essential that gains in the number of Americans with health insurance coverage be maintained,” Madara wrote.

None of the serious Obamacare alternatives circulating in conservative think tanks or on Capitol Hill could meet that standard, except perhaps by offering insurance that left individuals more exposed to crippling medical bills.

The other striking element of the AMA letter was its insistence that Republicans reveal their replacement plan before repealing the law ― not simply to avoid the insurance chaos that a quick repeal vote could unleash, but also to give the public an opportunity to decide whether it actually prefers GOP-style health care to what exists now.

“We … recognize that the ACA is imperfect and there a number of issues that need to be addressed,” Madara wrote.

But, Madara went on to say, “patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform.”

Doctors speaking up for expansions of health insurance might sound like the ultimate dog-bites-man story. But until relatively recently, the AMA hasn’t been a big cheerleader for government-run or government-managed health care plans.

On the contrary, in two of history’s biggest fights over health care reform ― President Harry Truman’s failed effort to create national health insurance in the 1940s and President Lyndon Johnson’s successful effort to create Medicare in the 1960s ― the AMA was among the most vocal and effective opponents of new laws.

Sentiments shifted over time, however, and the AMA, like most of the health care industry, ended up supporting the ACA. But the AMA still has a conservative streak ― it issued a quick, if ultimately controversial, endorsement of Rep. Tom Price (R-Ga.), Trump’s nominee for secretary of Health and Human Services.

Price, an orthopedist, is a leader of the GOP’s conservative wing. In addition to seeking Obamacare repeal, he has called for turning Medicare into a voucher program and dramatically downsizing Medicaid. Posted by:  The Wealthy Doctor

Summary: The largest and most influential organization of American physicians has sent two stark messages to the Republican Party: Don’t mess with Obamacare until you know what you’re putting in its place. And don’t do anything that would backtrack on the law’s most important accomplishment ― bringing the number of uninsured Americans to a historic low.

Stabilize the individual marketplaces

Leslie Small noted that getting young, healthy people to purchase coverage on the ACA exchanges is a tough sell and was the reason for the rejection of the Individual Mandate by President Trump and the Republicans and for good reason.

With Republicans’ efforts to repeal and replace the Affordable Care Act all but dead, both Democrats and some GOP lawmakers have acknowledged that now is the time to try to make changes that will help shore up the law’s individual marketplaces.

The most obvious step, which healthcare industry groups, policy experts, politicians, and actuaries have all endorsed, is to continue funding cost-sharing reduction (CSR) payments. Though a recent appeals court decision allows state attorneys general to defend these subsidies’ legality, the Trump administration could still stop funding them, and insurers likely can’t count on receiving the payments as they file their rates for next year.

Congress could settle the issue by passing a bill to appropriate the funds, but that approach would likely face an uphill battle. And it may come too late to prevent major premium hikes and insurer exits next year.

Other viable steps to stabilize the individual marketplaces include:

Enforcing the individual mandate but have reasonable premiums that don’t increase by 75-125% each year, which is nonsustainable!!

As long as the ACA is the law of the land, its signature individual exchanges depend upon the “three-legged stool” comprised of the individual mandate (which requires all citizens to have health coverage or pay a fine), guaranteed issue (which bans insurers from denying coverage based on health status) and community rating (which bans insurers from charging higher premiums based on health status).

One surefire way to help stabilize the ACA exchanges is to have the IRS enforce the individual mandate. Knock out one of those legs, and the resulting adverse selection collapses the whole system, likely leading to the much-feared “death spiral.” Enforcing the individual mandate is simple: The Trump administration just has to direct the IRS to keep assessing tax penalties on the uninsured—politically unpopular as that may be.

Implementing a stabilization mechanism

The most popular option among policy experts seems to be the creation of a reinsurance program—or recreation since the ACA implemented a temporary one. It works by issuing payments to insurers that have enrollees whose costs exceed a certain level, and its market-stabilization potential is already on display in Alaska, which recently got the go-ahead from CMS to extend its reinsurance program.

A popular idea among some conservatives, meanwhile, is to create a high-risk pool for individuals with pre-existing conditions. Pre-ACA, Maine did this successfully, but the secret ingredient to its program was adequate funding—a feature that did not characterize other states’ attempts.

Encouraging more young, healthy enrollees

Just like the individual exchanges depend upon having an individual mandate, they also require younger, lower risk individuals to purchase coverage to balance out the risk pool. But getting them to actually purchase coverage is a tough sell, requiring robust outreach efforts and the availability of affordable options—the latter made even tougher by premium spikes likely to result from uncertainty over CSRs.

One idea that policy experts might endorse—but nearly everyone else would hate—would be to nix the ACA’s provision that allows young adults to stay on a parent’s plan until age 26, effectively forcing those without job-based insurance into Medicaid or the individual markets.

And now Joyce Frieden noted that what I already mentioned when I began this post, President Trump delivered a rousing healthcare message to his followers at a Thursday night rally in Grand Rapids, Michigan, capping off a week of other presidential actions on healthcare.

“We’re going to get rid of Obamacare,” the president told the cheering crowd. “And I said it the other day, the Republican Party will become the party of great healthcare. It’s good; it’s important.”

Trump was referring to comments he made Tuesday to reporters shortly before a meeting with Senate Republicans. A reporter asked him what his message was to Americans concerned about their healthcare. “Let me tell you exactly what my message is: The Republican Party will soon be known as the ‘Party of Healthcare,'” he said. “You watch.”

Justice Dept. Files Letter in ACA Case

The reporter asked the question in the wake of a letter filed Monday by the Justice Department relating to a lawsuit by a group of Republican attorneys seeking to overturn the entire Affordable Care Act (ACA). A federal district court judge in Texas sided with the attorneys, declaring that because Congress had reduced the fine to zero, people were required to pay if they didn’t have health insurance — a provision is known as the “individual mandate” — and the rest of the law was now invalid.

That decision was appealed to the Fifth Circuit Court of Appeals in New Orleans, which is now considering the case. In its letter, the Justice Department said it “has determined that the district court’s judgment should be affirmed.” This was a change from the department’s earlier position, which was that only certain provisions of the law — including the individual mandate, the provision requiring insurers to cover preexisting conditions, and the provision requiring insurers to issue policies to anyone who applies for them — should be struck down. Whatever the appeals court decides, the case is widely expected to make its way to the Supreme Court.

“We won the case; now it has to be appealed, and then we’ll go to the United States Supreme Court. We have a chance of killing Obamacare,” Trump said at the rally. “We almost did it [in Congress], but somebody, unfortunately, surprised us with a thumbs down, but we’ll do it a different way.” Trump was presumably referring to the late Sen. John McCain (R-Ariz.), who cast the deciding vote against a Republican effort to repeal and replace the ACA. (Two other GOP senators also voted against it.)

Again, I ask what the other doctors are asking-why try to destroy Obamacare if you all have no workable alternative?

Next week more suggestions!