Dishonesty And Healthcare

As the blizzard of political television ads becomes ever more annoying–and less informative–one thing about them has become very interesting. Even Republicans who have previously made it clear that they don’t want government involved in healthcare are airing advertisements touting support for Medicare and willingness to protect pre-existing conditions.

I’ve been particularly struck by the U Turn in Indiana’s Fifth District, where a radically-reactionary, pro-Trump Republican noted for opposing “socialism” (which she has defined to include pretty much anything done by government) has begun running commercials supportive of Medicare and coverage of pre-existing conditions. Evidently, her polling has overcome her previously expressed belief that government should have no role in health care.

She’s not alone.

When the Affordable Care Act (aka Obamacare) passed, several Republicans went on record with their concern that its trajectory would mirror that of Medicare and Medicaid: despite initial resistance, the public would come to expect/demand/approve of the program. Survey research has confirmed those fears, which is why GOP officeholders continue to pretend that they will protect access to healthcare at the same time as they are feverishly working to eviscerate it.

The Brookings Institution recently published a report detailing six ways Trump has sabotaged the ACA.The report began by stressing that its authors did not use the term “sabotage” lightly.

For analytic purposes, the term “sabotage,” should not be used lightly. Presidents upon taking office typically have priorities that trigger executive actions strengthening some programs while weakening others. The losing programs often face resource reductions, pressure to deemphasize certain goals, directives to alter their administrative approaches, and other measures that can undermine their effectiveness. In doing so, a president often pays lip service to the program, claiming it has been “modernized” or otherwise improved. In contrast, Webster’s defines “sabotage” as efforts to foster “destruction and obstruction” and to “cause the failure of something.” In the context of the administrative presidency, it reflects a commitment to program emasculation and termination through executive action. As such, it sharply departs from the constitutional requirement that the president “take care that the laws be faithfully executed.”

There were six actions detailed in the report.

1) The administration dramatically reduced outreach about, and opportunities for enrollment in, the ACA’s insurance exchanges. The administration sharply reduced support for advertising and exchange navigators and reduced the annual enrollment period to about half the number of days. 

2) Together with Congressional Republicans, it reneged on commitments to private insurance companies. Those insurers had been offered various subsidies that reduced the risks of participating in the exchanges. The GOP failed to honor those commitments.

3) The administration has constructed what the report calls “off-ramps to cheaper, lower-quality insurance.” One goal of the ACA was to improve the quality of health insurance by specifying essential benefits, guaranteeing coverage of those with preexisting conditions at reasonable rates, and prohibiting insurers from imposing certain spending caps. The Trump administration expanded access to coverage that was cheaper because it didn’t meet these standards and that siphoned off the healthier enrollees whose participation is needed to make the ACA work.

4) It allowed–indeed, promoted– a variety of state waivers that decreased ACA enrollments and undermined its regulatory structure.

5) It discouraged legal “aliens” from enrolling in Medicaid. In a particularly evil move, Homeland Security promulgated a “public charge” rule authorizing officials to treat Medicaid enrollment as a negative factor when reviewing the requests of legal non-citizens to extend their stays or change their status (e.g., from temporary to permanent resident).

6) And then there’s the existential threat. The Trump Administration brought the lawsuit that is now pending at the Supreme Court, attacking the constitutionality of the ACA. If that suit is successful–despite a legal argument that has been widely characterized as ridiculous, despite its endorsement by an appellate court composed of Trump-appointed judges– millions of Americans will lose access to health care.

As a student once reminded me, the United States doesn’t have a health-care system; we have a health-care industry. As a result, millions of Americans remain underinsured or completely uninsured, other millions are bankrupted each year by medical costs, and our health outcomes are among the absolute worst in the developed world. 

Deeply dishonest political rhetoric to the contrary, the current Republican Party wants to keep it that way.


As The Bullets Find Their Mark..

I will never understand the GOP obsession with repealing Obamacare.

I could certainly understand efforts to improve it, or even replace it with a different mechanism (not the smoke and mirrors sort of replacement that Trump yammered about but was unable to describe, but a different way to deliver actual healthcare).

It is hard for me to accept that there are people who genuinely believe poor folks aren’t entitled to medical care, that being unable to afford a doctor means you don’t deserve one. On the other hand, I recall that telling–and chilling– moment in a GOP debate when Ron Paul was asked what should be done with people who don’t have insurance, and the audience members yelled “let them die.”

So there’s that…

Even though Paul Ryan and his cronies couldn’t manage a complete repeal of the Affordable Care Act, they did manage to make it less workable. They didn’t kill it–they just made it more incoherent and costly.

According to Michael Hiltzik in the L.A. Times,

Those fiscal geniuses in the White House and Republican-controlled Congress have managed to do the impossible: Their sabotage of the Affordable Care Act will lead to 6.4 million fewer Americans with health insurance, while the federal bill for coverage rises by some $33 billion per year.

Also, by the way, premiums in the individual market will rise by an average of more than 18%.

These figures come from the Urban Institute, which on Monday released the first estimate of the impact of two GOP initiatives. The first is the elimination of the individual mandate, which is an offshoot of the GOP tax-cut measure signed by President Trump in December. The measure reduced the penalty for not carrying insurance to zero as of next Jan. 1.

The second is Trump’s plan to expand short-term insurance plans, which don’t comply with many of the ACA’s essential benefits requirements and allow insurers to reject or surcharge people with preexisting medical conditions or histories.

Both of these provisions siphon younger, healthier people out of the insurance pool–an entirely foreseeable (and indeed, widely foreseen) consequence. When the pool of insured individuals contains older, sicker participants not offset by as many young healthy ones, insurers must raise premiums.

Because government premium subsidies rise in tandem with premium increases, the cost of subsidies borne by the government will rise by $33.3 billion next year, or 9.3% — to $391.4 billion from $358.1 billion under existing law.

It isn’t only taxpayers who will get hosed by the changes Trump is so proud of. The article goes through a variety of ways in which people needing health insurance will get screwed over, and I encourage you to click through and read the whole analysis.

It’s hard to disagree with Hiltzik’s conclusion:

The damage estimate can’t be restricted to the immediate impact on individuals and families, the researchers observed. “As healthier enrollees exit for short-term plans, insurers will by necessity reexamine the profitability of remaining in the compliant markets. This may well lead to more insurer exits from the compliant markets in the next years, reducing choice for the people remaining and ultimately making the markets difficult to maintain.”

In other words, the Republican sabotage will continue to undermine health coverage in the U.S. The only alternative, it becomes clearer with every day, is some form of single-payer, Medicare-for-all coverage. That’s increasingly becoming part of Democratic Party orthodoxy, and it’s about time.

One more reason why we need a wave election in November.


Up in the Air

The New Yorker ran an especially good cartoon recently: a man standing up in coach on a plane–and others evidently cheering him on–saying something like “Who else is fed up with the smug attitudes of the so-called pilots who fly this plane? Who else would prefer that I fly it?”

The parallels to our Presidential election are too obvious to require added discussion.

I thought about that cartoon when I read another airplane analogy, this time in connection with the Republicans’ hell-bent-for-leather determination to repeal the Affordable Care Act–aka “Obamacare”–without having the slightest idea what they will replace it with, without any evident concern for the more than twenty million people who will lose coverage, and without any concern for the financial chaos that even their allies have warned will ensue.

As Josh Marshall at Talking Points Memo put it:

“The AMA, which has been rather comically pro-Trump to date, came out today and told Republicans that they shouldn’t repeal Obamacare without a clear replacement. Notably, even two of the most conservative health care economists at AEI, came out yesterday and said that ‘repeal and delay’ would be a disaster. The truth is that ‘repeal and delay’ is the policy equivalent of taking off from JFK to Heathrow with 2,000 miles worth of gas and saying you’re going to figure it out en route. No one who knows anything about health care economics, even people who are staunch free marketeers and hate Obamacare, think that makes any sense.”

From time to time on this blog I have referred to my cousin, an eminent cardiologist (and former Republican). I consult him when addressing issues that require medical expertise that I lack. He has shared with me the following statements on the proposed repeal from both the AMA and the American College of Physicians:

Chicago, IL, January 3, 2017––The American Medical Association (AMA) released the following letter today to congressional leadership from Chief Executive Officer and Executive Vice President James L. Madara, MD, concerning legislative efforts to reform the health care system.

Dear Majority Leader McConnell, Leader Schumer, Speaker Ryan and Leader Pelosi:

On behalf of the physician and medical student members of the American Medical Association (AMA), I am writing regarding our ongoing commitment to reform of the health care system and potential legislative actions during the first months of the 115th Congress.

The AMA has long advocated for health insurance coverage for all Americans, as well as pluralism, freedom of choice, freedom of practice, and universal access for patients. These policy positions are guided by the actions of the AMA House of Delegates, composed of representatives of more than 190 state and national specialty medical associations, and they form the basis for AMA consideration of reforms to our health care system.

Health system reform is an ongoing quest for improvement. The AMA supported passage of the Affordable Care Act (ACA) because it was a significant improvement on the status quo at that time. We continue to embrace the primary goal of that law—to make high quality, affordable health care coverage accessible to all Americans. We also recognize that the ACA is imperfect and there a number of issues that need to be addressed. As such, we welcome proposals, consistent with the policies of our House of Delegates, to make coverage more affordable, provide greater choice, and increase the number of those insured.

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.

Consistent with this core principle, we believe that before any action is taken through reconciliation or other means that would potentially alter coverage, policymakers should lay out 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.

We stand ready to work with you to continue the process of improving our health care system and ensuring that all Americans have access to high quality, affordable health care coverage.

Sincerely, James L. Madara, MD

Washington, DC, January 3, 2017––In a letter sent today to leaders in the Senate, the American College of Physicians (ACP) implored them to vote no on a budget resolution that would start the process of repealing the Affordable Care Act (ACA). The College cautioned that this process could destabilize coverage, resulting in tens of millions of Americans losing coverage, benefits and protections established by current law.

The letter expressed concern that the pathway established by the resolution, which will lead to a subsequent vote on a budget reconciliation bill to repeal major elements of the ACA, with the effective date of such repeal being delayed while Congress attempts to develop an acceptable replacement plan, is unworkable and disruptive.

“Independent and non–partisan analyses show that enactment of such a ‘repeal, delay and replace’ bill, especially without an alternative being offered now that could be thoroughly evaluated based on its impact on quality, access, and coverage, would create chaos in insurance markets, causing plans to pull out of the markets with more than 7 million losing coverage in 2017 alone,” said Nitin S. Damle, MD, MS, MACP, president of ACP in the letter. “Full repeal could result in nearly 60 million people becoming uninsured.”

ACP noted that the College welcomed the opportunity to make improvements in the law. Specifically ACP welcomes discussion of ways to stabilize insurance markets by bringing more young people into them without disadvantaging older and sicker patients; to expand consumer choice of insurance products and of physician and hospitals; to ensure network adequacy; to support state innovation including in Medicaid provided that current eligibility, benefits, and protections for current and future enrollees are not undermined, to reduce administrative burdens on physicians and their patients, and to support the critical role played by primary care physicians in providing accessible, high quality and cost–effective care to all types of patients.

“While we acknowledge that the ACA is not perfect (and no law is) and improvements to it can and should be made, our continued support for the ACA is grounded in the fact that it has reduced the uninsured rate to the lowest ever, a major stride toward providing affordable coverage to all Americans,” said Dr. Damle. “We encourage Congress to first put forward ideas for improvements rather than committing to a process that would repeal the ACA’s coverage and protections for many millions of people.”

But what do pilots know about flying planes…?


Connecting More Dots

I’ve often argued that universal healthcare–Medicare for All–would spark an outpouring of entrepreneurship. If you want to open a shop, or go into the widget-making business, one significant barrier to doing so is the need to offer (very expensive) health insurance to your employees. Of course, you could decide not to provide that benefit, but you wouldn’t be very competitive in the market for good workers.

I understand, dimly, the historical reasons why the U.S. linked employment to health care, but it has always seemed to be a bad idea. What about people who don’t/can’t work? What about independent contractors? Why should an employer have to assume the costs–and risks–of employees’ health? Other countries do not couple jobs and insurance in this way–health insurance is provided as part of the social safety net, and the costs are spread much more widely.

Yesterday, in a Facebook post, a friend of mine explained why medical insurance provided through government–decoupled from employment–would boost the economy and make American businesses more competitive.

As he noted in his post, when you buy a product, all the costs of creating that product are reflected in the price: production, workers’ wages and benefits, materials. Most of the nations with whom we trade big-ticket items have had government-sponsored health care for decades, and at far lower cost. As a result, Saab and Mercedes, among others, are able to compete unfairly with American-made autos whose prices include a hefty private-sector health care premium. (I’ve seen numbers suggesting that this was one of the reasons GM and Chrysler went bankrupt; healthcare coverage for current and retired employees added over 2000 to the average price of their cars.)

If we really cared about keeping U.S. businesses competitive–and the health insurance system comprehensible–we’d have Medicare for All, or at least for anyone who wanted it.  Given our political environment, and the lobbying clout of Big Insurance and Big Pharma, that was never in the cards.

Obamacare was (barely) politically feasible because it was originally the Republican alternative. With all its warts, it’s a step in the right direction, but if we want America to remain competitive,  we will eventually need to separate access to health insurance from the vagaries of employment.


Making Other People Live By Your Interpretation of the Bible is NOT Religious Liberty

These are the times that try men’s souls…..Okay, that’s a bit much. But there are definitely letters to the editor that try both my woman’s soul and my (very limited)store of patience. One of them was in the Sunday Indianapolis Star.

It was the all-too-typical complaint that, by requiring “religous-based ministries” to offer birth control coverage, the hated Obamacare was violating the writer’s “right to practice our faith and not be persecuted with onerous fines if we won’t deny our faith and worship the national religion of casual sex.”

The profoundly misinformed woman who signed this letter got nearly everything wrong. For one thing, “ministries” aka churches are not subject to the regulation she so completely misunderstands. The First Amendment Free Exercise Clause exempts churches from all manner of secular law–no matter how reasonable–that those institutions deem inconsistent with their beliefs.

The Affordable Care Act does require that other religiously affiliated institutions–hospitals, universities and the like– include birth control coverage as part of their comprehensive health insurance policies. Despite the letter writer’s assertion, this is not a mandate to worship Mammon, nor does the inclusion of an option allowing female employees to get reimbursed for the costs of contraception equate to a requirement that they use it.

What we have here is a longstanding dispute about the nature of liberty and the definition of discrimination. The letter writer and other shrill moralists–the ones who believe they know precisely what their version of God wants–define liberty as freedom to do the “right” thing.  And that they should get to define what the “right thing” is.

Furthermore, they believe that if government isn’t imposing their definition of right behavior on the rest of us, it’s discriminating against them. (Think I’m exaggerating? Read one of Micah Clark’s newsletters some time. Bet you didn’t know that government recognition of civil marriage equality is really a war on Christians, Western Civilization and (probably) helpless puppies.)

Unfortunately for the Puritans, and fortunately for the rest of us, that pre-Enlightenment view of liberty isn’t the definition  that informed the Bill of Rights.  In the system bequeathed to us by the nation’s founders, liberty means personal autonomy–the right of each of us to make our own moral and ethical decisions, free of interference by government or our neighbors, so long as we aren’t thereby causing harm to others.

There can be genuine and difficult disagreements about what constitutes “harm to others,” but it takes real chutzpah to claim that covering the costs of birth control for those women who freely choose to use it constitutes an attack on religious liberty.