Category Archives: Universal health care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Fact-checking some of those remarks.

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

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

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

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

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

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

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

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

This is true, although it could use some context.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

And next on to Title XIX: Medicaid.

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

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

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

I went to the market

Where all the families shop

I pulled out my Ka-bar

And started to chop

Your left right left right left right kill

Your left right left right you know I will

-Military cadence

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

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

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

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

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

Other soldiers didn’t end up as lucky.

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

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

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

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

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

This eases the tension and he smiles.

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

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

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

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

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

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

Screen Shot 2019-05-25 at 8.13.38 PM

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Surprise! House, Senate Tackle Hospital Billing

Senate bill also addresses provider directories, drug maker competition

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

More next week!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Generous Joe: More “Free” Healthcare For Illegals Needed

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

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

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

Answer: A lot.

The Question, The Answer

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

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

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

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

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

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

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

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

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

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

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

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

The Cost of Illegal-Alien Healthcare

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

But that’s beside the point.

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

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

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

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

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

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

NYC Promises ‘Guaranteed’ Healthcare for All Residents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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!

Special Report—8 ways to fix the Affordable Care Act

psycho097Gienna Shaw back in August of 2017 stated that even former President Barack Obama knew that his signature healthcare reform law, the Affordable Care Act, had problems.

Democrats can fix the Affordable Care Act, so how come they are now touting Medicare for All?

So, the Mueller report is out but the fighting will go on with the Psychos of both parties will continue to destroy our system and continue to hate and refuse to be civil and do what we the voters paid them to do. I don’t know about any of you out there on the Internet, but I am really tired of the lack of process improvement, especially since I just published a book on process improvement. I should probably go down to D.C. and give every member of the House and the Senate a copy. But back to our topic of discussion the fixes for the Affordable Care Act!

Jon Kingsdale in his review last December noted that Federal District Judge Reed O’Connor’s determination last Friday overturning the entire Affordable Care Act won’t actually affect much — unless it is upheld at the Supreme Court, probably not until 2020 — but it ought to spark a substantive legislative response from House Democrats.

President Trump was quick to gloat and to invite Democrats to negotiate a replacement. With more and more Democrats dreaming of “Medicare-for-all” and the remaining Republicans in Congress after 2018 representing the far right, the prospects for “negotiating” a replacement are nil. This is simply an opportunity to blame Democrats for failing to “step up” and negotiate their own defeat.

Which is one reason that newly empowered House Democrats should use O’Connor’s radical decision as a call to action — specifically, to pass a bill they can put on the table now and campaign on in 2020.

That’s smart politics. There’s a substantive reason to act as well. Unfortunately, ACA enrollment has peaked, leaving 28 million Americans uninsured, and marketplace enrollment in private plans now falling. Premiums are too high and consumer choice too limited in many parts of the country.

It is time to put a real fix on the table, recognizing that this probably cannot become law until Democrats regain control of the Senate and White House. Simply proposing Medicare-for-all may galvanize the Democratic base, but it might not even pass the House and could well cost Democrats dearly in the 2020 election. But Medicare is popular, and the ACA can be improved by borrowing from it.

First, let’s be clear about objectives: The ACA needs to cover more people and bring down premiums. Both goals require addressing the root cause of runaway health care spending: prices.

The United States spends twice the average per person of our peer countries, not because we use more medical services, but because of higher prices for the medical services we do use. In fact, we see the doctor far less often, use half the hospital days, and swallow roughly the same number of pills as Europeans and Canadians. We pay on average twice what other advanced economies do for each visit, day, operation, scan, or pill.

Medicare-for-all would change that, but it is still a bridge too far for many voters, even moderate Democrats. Having come so close with the ACA — 91 percent of Americans are covered — a wholesale switch would be very disruptive. Rather, a reinvigorated ACA should build on tested elements of existing federal programs, just as the ACA built on tested elements of Massachusetts’ reform, to achieve the twin goals of coverage and cost.

To start with here are three relatively simple fixes that would materially improve the ACA, building on some of the best policies in other programs:

First, concede the individual mandate. Get rid of this unpopular “stick” and increase the ACA’s carrots. For 12 years now, Massachusetts has offered higher subsidies than the ACA’s national schedule of tax credits. As a result, nearly everyone (97 percent) in the Commonwealth is covered. So let’s replace the mandate with more generous premium subsidies under the ACA and, if some sort of stick is still required, then the ACA should allow insurers to surcharge premiums for those who wait until they get sick to buy coverage, just as Medicare drug plans do now.

Second, to ensure competition and choice in marketplaces across the country, bring back the “public option” that was originally considered for the ACA. This doesn’t have to be government-run insurance; rather, we could deploy private Medicare Advantage plans on the ACA marketplace. These private plans now enroll half of all newly eligible Medicare beneficiaries. They combine competition and relatively low (Medicare) pricing levels for hospitals, doctors, and other care providers. (Remember, it’s high pricing that accounts for our high total medical spending.) So let’s have these same Medicare replacement plans compete for younger individuals in the ACA marketplace.

Third, let the government negotiate drug prices, as the Veterans Affairs department and so many of our peer countries do, both for Medicare and private Medicare replacement plans. The VA pays far less than commercial insurers for the same drugs. Let’s share those savings with current Medicare enrollees and the individuals who chose Medicare replacement plans in the ACA marketplace.

These are three easy-to-understand, workable fixes for the ACA. Are they controversial? Of course. Lowering the costs of coverage means taking money away from powerful interests, including people who save lives for a living. We revere them — when we’re not cursing them for overcharging.

But America now faces the choice of making coverage affordable or halting recent coverage gains — likely to slide backward in the next recession. Or we can build on the ACA, using some proven health policies from the federal tool chest.

No one is saying the Affordable Care Act is perfect. As the introduction to this post stated, even former President Barack Obama admitted Obamacare has its shortcomings. So why have efforts to repeal, replace or repair it failed in such spectacular fashion?

Part of the problem is that healthcare is hard. (Who knew?) It’s a big, expensive, complex and highly regulated industry that accounts for one-sixth of the nation’s economy and, quite literally, involves matters of life and death.

As the summer winds down and Congress prepares to get back to business, we hope that healthcare reform doesn’t fall off the agenda. President Donald Trump vacillates between demanding that Congress take immediate action—suggesting he’ll sign just about anything that crosses his desk—and threatening to let the ACA fail.

Neither tactic is viable.

In this special report, FierceHealthcare’s editors—experts on the business of healthcare who cover hospitals, health systems, physician practices, insurance companies, health information technology, and healthcare finance every day—outline some of the ideas, programs and reforms that hold the most potential to heal the nation’s healthcare system.

It starts with politics, as in knock off the bipartisan bickering and gets to work. Hold hearings and get input from the people who are the heart of healthcare, from doctors and nurses to health insurance executives to patients and their advocates.

And while the nature of compromise is that no one will be totally happy with the outcome, buy-in is more likely when there’s real dialogue, transparency, and honesty.

That dialogue can start with the ideas presented in this report, which explains how the U.S. can:

  • Work to find common ground and easy wins … and cool off the political rhetoric.
  • Stabilize the individual insurance marketplace while lowering premiums and staving off the “death spiral.”
  • Fix healthcare regulations so they free, rather than strangle, those who are trying to make the system better.
  • Continue to build reimbursement models that encourage providers to improve quality and lower costs.
  • Harness the power of technology and innovation to cut costs and improve access to care.
  • Reform how—and control how much—the country pays for healthcare, including tests, procedures, and prescriptions.
  • Ask industry stakeholders for the input—especially the clinicians who are the heart of the healthcare system.
  • Let states lead the way with Medicaid innovation and other reforms.

The most important thing to fix the ACA is to find a bipartisan solution

         The Affordable Care Act has problems, but the right and the left must work together to find a solution. Over the next few weeks, I am going to expand on the 8 suggestions for improving the Affordable Care Act. But it has to come from both parties and not be a battle to get reelected or to shame former President Obama or to shame and embarrass president Trump and the Republicans.

Gienna Shaw noted in August of 2017 that in the 7 years after it was passed in October 2009, the House of Representatives voted more than 50 times to repeal or amend the Affordable Care Act. As the count climbed toward 40, the editors at FierceHealthcare began to debate whether we should continue to write about each and every House effort, knowing that no bill would ever pass the Senate, let alone get by then-President Barack Obama’s veto pen.

This year, the GOP—with majorities in the House and the Senate and a Republican in the White House—came closer to repeal (or at least “skinny repeal”) than ever before. But they still haven’t managed to repeal or replace the healthcare reform law, which has been steadily growing in popularity among voters.

Over the years, the debate shifted focus from intrusive big-government boondoggle to the right to affordable and equitable healthcare. Yet many lawmakers are reluctant to recognize that and change gears.

But here’s the thing: The Affordable Care Act really does need to be fixed. Premiums for individual insurance plans really are skyrocketing. The United States really does spend more on health care than other wealthy nations, yet ranks dead last on equity, access, efficiency, care delivery, and healthcare costs.

The only way to reverse those trends and fix the Affordable Care Act is for Republicans and Democrats to come together and find a bipartisan solution.

Even Obama has said the healthcare reform law needs a bipartisan fix, although, at the time, Republicans panned that overture. Perhaps that attitude is changing in the wake of more failed efforts to repeal the ACA and the emergence of a group of Democratic and Republican lawmakers who’ve dubbed themselves the Problem Solvers Caucus.

Co-chaired by Rep. Tom Reed, R-N.Y., and Rep. Josh Gottheimer, D-N.J., they’ve already come up with a set of recommendations that draws on ideas from both sides of the aisle. “The last great hope for this country is that Republicans and Democrats prove they can work together,” Reed said recently.

It’s a good start, but fixing healthcare will require a dedicated, sustained effort, and that starts with two immediate steps:

Tone down the rhetoric

The right uses “Obamacare” as a pejorative, and “Trumpcare” is a dig when it comes from the left. President Donald Trump is fond of calling Democrats obstructionists and has said they have “no good ideas.”

And although it’s difficult to participate in the debate when you’re largely barred from deliberations, Democrats could stand to be more open about the ACA’s problems and must be very clear about what policies and solutions they’re willing to back, taking steps beyond their opposition to full-on repeal.

And let’s not forget that both sides have suffered their share of marketing missteps. (Think Obama saying, “If you like your doctor, you can keep your doctor,” and Senate Majority Leader Mitch McConnell describing one version of his own party’s repeal efforts as a “pig in a poke.”)

Hold hearings

It’s astounding that this even has to be said, but rather than crafting legislation behind closed doors and asking members to vote for it even if they do not want it to ever become law, it’s time to let the sunshine in.

Sen. Lamar Alexander, a Republican from Tennessee, has promised that the Senate Health Committee will hold bipartisan hearings on how to repair the individual insurance market, but talks need to go much further than that. And testimony should come from health insurance industry leaders and providers, including the nurses, doctors and other clinicians who are at the heart of the healthcare system. Listen to health information technology innovators, from the big-name companies to the scrappy startups that are trying to improve care quality and lower costs, and don’t forget to include employers.

And take a best-practice lesson from those in the healthcare industry: Focus your discussions around caring for patients, always.

Many organizations have a patient advisory board or put patients on their boards of trustees. Some payers and providers even have rules that every meeting must include at least one patient. Patients and their advocates need a seat at the table in Washington, too.

Consider tax, regulatory relief

Some lawmakers want to raise the employer mandate threshold so that businesses with fewer than 500 employees don’t have to provide coverage to their employees.

Starting with the first suggestion Leslie Small suggested that if lawmakers want to tweak the Affordable Care Act without kicking up too much controversy, they could consider targeting some of the law’s wonkier provisions.

There’s common ground to be found in several of the law’s taxes, which are unpopular with the healthcare industry and politicians. There are plenty of provisions that are easy to hate.

One low-hanging fruit: the medical device tax, which is largely reviled by device manufacturers and was set to be done away with in several iterations of Republicans’ Affordable Care Act repeal bills.

Insurance companies would be happy if lawmakers did away with the health insurance tax, which they say contributes to higher premiums. Even some conservative groups have recently begun to call for a repeal of this tax.

Employer groups, meanwhile, have called for a full repeal of the so-called Cadillac tax on high-cost health plans. That tax is so unpopular that it’s never actually been implemented: It was delayed for 2 years as part of a 2016 spending bill that also delayed the health insurance tax and the medical device tax for a year.

Speaking of employer-sponsored coverage, some business groups would likely approve of an idea floated by the self-dubbed Problem Solvers Caucus composed of GOP and Democratic lawmakers.

The caucus wants to change the employer mandate so that only those with 500 employees or more—rather than 50 or more—are required to provide coverage to their employees. Proponents argue that would stimulate the economy: Small businesses accounted for 64% of the net new jobs created between 1993 and 2011, according to the U.S. Census Bureau.

“The current employer mandate places a regulatory burden on smaller employers and acts as a disincentive for many small businesses to grow past 50 employees,” the caucus said in an announcement.

Ramp up technology, innovation, and data

Healthcare reforms aren’t likely to succeed without accounting for health IT innovations like telemedicine and data analytics.

Evam Sweeney continued the discussion in that there’s no question the Affordable Care Act is in need of some legislative fixes, but underneath those policy bandages, technology is already transforming the way the industry treats patients and pays for care.

That undercurrent of innovation could use some nurturing as well, particularly as payers and providers look for ways to provide more efficient, value-based care.

The rise of telehealth is a perfect example. This year alone, lawmakers have submitted half a dozen bills to expand or reform telehealth payment in some way. Medicare and Medicaid coverage for telehealth services is still sorely lacking, and the nation’s top insurance companies have been pleading with the feds to remove the barriers to telehealth reimbursement.

States have made some progress when it comes to paying for telehealth and enacting parity laws, but those laws aren’t keeping pace with the relentless advancements of virtual care.

That’s not stopping providers from investing in telehealth technology, and most healthcare executives will admit that even though reimbursement is a struggle, the thought of being left behind is even more unsettling.

Admittedly, the CBO scores for telehealth bills are messy, but there’s little doubt that virtual care brings a slew of benefits by keeping patients at home and opening up access in rural parts of the country, where patients would otherwise spend hours traveling to the nearest medical center or forgo care altogether. Expanding payment models—a notably bipartisan issue—will provide support to local initiatives that are already well underway.

At the same time, data have become tools that both payers and providers can’t live without. The problem: Most healthcare data are still unusable.

Quantity is not an issue—there’s a seemingly endless stream of healthcare data, and more on the way as patient-generated data gain a bigger foothold. The problems boil down to quality and usability.

Solving these two issues will be critical as the industry turns to data analytics to improve care, reduce costs and validate new payment models. Although there have been pockets of success thanks to burgeoning data-sharing partnerships between payers and providers, medical data are still difficult to untangle, and cleaning patient data is still incredibly burdensome.

Obtaining clean, usable data will serve as the backbone to deploying predictive analytics and machine learning that can predict illnesses, reduce unnecessary hospital visits, support population health initiatives, streamline care and reveal the best treatment options for patients with chronic illnesses.

Better data-sharing arrangements between payers, providers, researchers, government agencies and patients will speed the discovery of cutting-edge treatment options and advance precision medicine. But all of those efforts will be slow to mature without concerted (and coordinated) efforts to standardize data collection and dissemination across multiple platforms.

Ask the doctors

How would doctors fix the Affordable Care Act? It’s time to ask them. Joanne Finnegan asked the question How would doctors fix the ACA? The politicians in Washington have struggled and failed to come to an agreement about how to fix the Affordable Care Act. Now it’s time to call the doctor. Why? Because you can’t fix the healthcare system without involving the physicians, nurses and others who are at its very heart.

“Would you want to fly in a plane with no input from a pilot?” Matthew Moeller, M.D., a gastroenterologist, asked in a post on the popular doctor’s blog KevinMD. “Or design a curriculum without a teacher’s input?”

Throughout the fight over the ACA, physicians—or at least the medical organizations that represent more than half a million frontline doctors—have stood in opposition to plans that would result in patients losing healthcare coverage.

Doctors want a healthcare system that supports the physician-patient relationship that drew most of them to medicine in the first place.

While they are strong advocates for their patients, doctors can still make a difference in controlling costs. If you want to change the “more is more” culture in medicine, doctors can help.

Physicians are the ones who order tests, write prescriptions, hand out referrals and perform complex treatments. They can adjust their clinical practices to accommodate cost considerations without shortchanging patient care.

Does a patient with high blood pressure really need to come to the doctor’s office every 3 months? Wouldn’t it make economic sense to teach a capable patient how to check his or her own blood pressure at home and fax or email results into the office?

In fact, some of the most revolutionary healthcare reform ideas center on doctors. For example, Jody Tallal, a personal finance manager, says the country could ensure healthcare for low-income Americans by offering tax credits to doctors. Instead of reimbursing doctors through Medicare and Medicaid, the country could provide a dollar-for-dollar income tax credit to doctors who provide care for the poor.

Many doctors like the idea of a single-payer system, even if it’s a pipe dream for now.

Fred N. Pelzman, M.D., of Weill Cornell Internal Medicine Associates in New York City, for instance, says it’s time the country moves toward providing Medicare for everyone in order to provide a baseline level of care, which could be supplemented by private insurance for those who want and can afford it.

“This country needs a safety net that is a little less exclusive,” he says. “You should be able to get the care you need and if you want to see the world’s greatest heart surgeon, you figure that out.”

Doctors are already central to one reform movement: the change away from fee-for-service medicine to value-based payment. They’re in the first year of a new Medicare payment system established under the Medicare Access and CHIP Reauthorization Act of 2015, which will determine how clinicians get reimbursed under the Medicare program.

But the regulatory and administrative burdens continue to increase. For many doctors, the start of any healthcare reform needs to ensure there is less regulation, with its demoralizing administrative requirements dictating how they provide care, drowning them in paperwork and leaving them struggling with poorly designed electronic health record systems.

Doctors have long complained that all of it takes them away from providing care for their patients. The goal of any healthcare reform legislation should be to ensure that the patient-provider relationship remains sacrosanct.

Next week I will continue the discussion on fixing the ACA/ Obamacare!