HEJE Overview 7-23-17: Healthcare


Report from Wise County, Virginia’s Remote Area Medical clinic: “Patricia McConnell was having trouble speaking around the bloody gauze in her mouth. She had just had four teeth pulled. The unemployed former manager of a McDonald’s had driven eight hours from her home in Glen Burnie, Md., to attend the clinic. ‘My teeth were hurting,’ she said. McConnell, 63 and disabled, said she had health insurance through Medicaid but no dental coverage.

So this was her dental plan: She’d save for six months to afford a motel room and gas, then wait in line in the morning heat to see a volunteer dentist.”

Deedspeakout: This should not have to be anyone’s “dental plan.”

Healthcare Redux, version X.0

  • McConnell’s apparent BCRA / H.R. 1628 game plan as of this weekend (it may change)

“The vote Tuesday will be to start debate on Obamacare repeal. But it is unclear as of now which bill would serve as the actual policy — an extremely unusual move. McConnell said earlier this week the Senate would vote on a repeat of a 2015 bill that repealed much of the health care law. Since then, senators have floated the idea of voting on multiple options, including repeal, the Senate’s repeal-and-replace measure or a combination of these and other policies.”

It’s possible that the vote to proceed to debate will fail—but the Senate Majority leader will have forced his colleagues to reveal where they stand on repeal or repeal-and-replace, and that may be his more immediate goal.

  • KFF Summary of state-by-state reductions in Medicaid funding under BCRA

First, an important point that is sometimes overlooked by policy analysts concentrating on the (relatively) small individual marketplace: “While referred to as legislation to repeal and replace the Affordable Care Act (ACA), both the BCRA and the AHCA make more fundamental changes to Medicaid by phasing out the enhanced federal matching funds for the ACA Medicaid expansion and by setting a limit on federal funding through a per capita cap or, at state option, a block grant for some enrollees.”

In other words, the program that is really hurt by BCRA—the one that affects 70 million Americans—is Medicaid, whose death-knell the BCRA would sound within about a decade.

KFF considers the effect on the numbers of people insured through Medicaid from 2020 to 2029, including two key provisions of BCRA: (1) “the phase-out of enhanced federal funding for the ACA expansion from 90% to the state’s regular federal share of Medicaid spending (called the federal medical assistance percentage, or FMAP)” and (2) “the use of a per enrollee cap on federal funds for most enrollees, including those covered through the ACA expansion.”

This scenario foresees a total drop of $519 billion “if states maintain coverage and fill in gaps in federal funding reductions as a result of the decrease FMAP for the expansion and the imposition of a per enrollee cap.”

Also, “if in response to the reduction in federal support for the expansion, all states fully roll back coverage for the expansion population, federal funding would decline by an additional $685 billion over the 2020-2029 period to reach a change in federal funds of -$1.2 trillion and result in the loss of coverage for 19 million enrollees covered through the expansion.”

The latter figure is the worst-case scenario foreseen by Kaiser–remember, a number of states have so-called “trigger laws” that would eliminate  Medicaid expansion if federal subsidies were to cease. Such states include Illinois.

  • PNHP’s blog provides an excerpt from a Harvard Business Review article with a summary of the Canadian health care system, arguing that the U.S. status quo is not immutable

“The single-payer approach is often characterized as a gateway to Byzantine regulation. Yet the reality is it is a fundamentally simple, even elegant, concept: Everybody gets the coverage that everybody pays for. Within this framework, there is much room for maneuver.”

“While there may be openings for bipartisan compromise to address the weaknesses of the ACA, the core of the ACA framework is unstable — a hostage to the market and political fortune. By contrast, a single-payer model stands to be much more durable and provides a chance to build a health care system around the well-being of patients rather than the profits of providers and insurers.” [emphasis added]

Finally: “Single payer is a concept that is here to stay. The only question remaining regarding its enactment and implementation is when.”

  • National Medicare for All Day (July 24) will target Democratic congressmen who haven’t signed on as co-sponsors to Congressman John Conyers’ H.R. 676

In an interview on Democracy Now!, Physicians for a National Health Program (PNHP) President Dr. Carol Paris opposed the creation of a “public option” as a fix for the ACA: “We really need to go forward now to a national, improved Medicare for All,” Paris concluded. “And really, the bill in Congress, H.R. 676, Congressman Conyers’s bill, is the way we need to go.”

“The job of single-payer proponents now, Dr. Paris emphasized, is to make it politically damaging for Democrats who refuse to listen to their constituents and instead remain committed to a failed for-profit system, under which millions remain uninsured.”

This is complicated. Paris is basically suggesting a litmus test for Democratic primary candidates (presumably, in all House and Senate races). It might be more effective to start from more progressive, solid-blue districts, however, and build momentum over the next few election cycles.

  • It took a while for the Senate Parliamentarian to rule on this one

“The U.S. Senate’s Office of the Parliamentarian ruled Friday that some provisions of Senate Republicans’ Better Care Reconciliation Act (BCRA)—including one that would defund Planned Parenthood and two more that would restrict abortion tax credits—violate the ‘Byrd Rule’ and will need at least 60 votes to pass.”

  • Additional rulings by the Parliamentarian

A number of provisions beyond the defunding of Planned Parenthood for one year would require 60 votes to pass the Senate, given that the Parliamentarian has now ruled they are not just “budget-neutral” but involve actual policy changes. These include: (1) the bill cannot “appropriate” the cost-sharing subsidies employed to provide assistance with premiums/co-pays/deductibles low, it can only repeal them; (2) No to the “lock-out” provision requiring that anyone whose insurance lapsed would have to wait six months before buying new insurance; (3) No state-specific provisions allowed (sorry, Alaska).

“The parliamentarian has also not yet ruled on a controversial amendment from Sen. Ted Cruz (R-Texas) that would allow insurers to sell plans that do not meet ObamaCare regulations. If that provision were struck, conservative support for the bill would be in doubt.”

This refers to the option insurers would be given under BCRA (or whatever it’s called next week) to offer bare-bones “choice” plans which do not comply with the ACA’s Essential Heath Benefits (hospitalization, emergency room care, prescriptions, tests, rehab—you name it, it’s not covered without EHBs).

Dr. Adam Gaffney analyses the “public option” and finds it comes up short as a means of stabilizing the ACA marketplace. He highlights the looming divide among Democrats with the demise of BCRA: “On the one side are the most ardent supporters of Medicare for All; on the other, those who couple a defense of the ACA with advocacy for more incremental reforms, like the public option, which in most current iterations would be a government-run health care plan that would compete against private insurers on the ACA’s state-based marketplaces.”

After a historical overview which explains the basic concept (as a public, i.e. government-run alternate to private policies—so, as a competitor in the marketplace) and traces its origins to two different policy gurus in the 1960s, when it was touted as an “alternative” to Medicare, and to the earlier 2000s, when it came up again as “CHOICE”, developed in California as a “managed competition” model and subsequently adopted as more or less the national template during pre-ACA discussion.

“… both approaches [introducing a ‘public option’ to those over 65; introducing a public option and Medicare ‘buy-in’ to those under 65] have a common underlying flaw: the notion that ‘managed competition’ between a mixture of public and private insurance plans could save the American health care system. But we don’t need competing public and private insurance plans any more than we need competing public and private air traffic controllers.”

Gaffney then reviews the major problems with the ACA, starting from the fact that any version of the “public option” would do little if anything to address the problem of the 28.6 million people who remained uninsured under the ACA ,while insuring only 12.2 million—a significant number, but a small percentage of the U.S. population.

What would it do for the large number of those who remain underinsured—the approximately one-half of U.S. workers with employer-backed insurance plans who have seen their premiums rise by around 300% since a decade ago? Nothing.

What would it do to ameliorate problems with Medicare and Medicaid (high out-of-pocket costs for Medicare; lower reimbursements/legacy reputation of Medicaid as a “poor person’s program”)? Nothing .

And then there’s this highly-undesirable but entirely-possible outcome: “…if the public option winded up taking on people who are ‘less healthy — and therefore more costly, as the CBO assumes, the reform might succeed in ‘stabilizing’ the marketplaces by functioning as a ‘high risk pool.’ In other words, it would essentially subsidize the private insurance industry by socializing the larger health risks (and perhaps increase its profits).”

And that would be incredibly costly.

Gaffney, a member of PNHP, argues that the public option would entail a struggle that would not ultimately prove worth it—it might achieve at most a 10% savings for the 4 or 5 million people under the age of 65 who availed themselves of it.

And a “public option” would weaken the fight for single-payer, delaying its adoption for years to come.

The National Review has its own explanation for why single-payer never really got off the ground in the U.S.: Conservatives have FDR to thank—he instituted employer-based health insurance in the 1940s.

Useful starting statistical framework: “Today, 49 percent of Americans get insurance from their employer, with another 34 percent on Medicare or Medicaid and 9 percent uninsured. Only 7 percent participate in the individual market, 4 percent through the Obamacare exchanges. (Another 2 percent get health care from other public sources, such as the VA.) [Note: percentages don’t seem to add up to 100 …]

“Now that the GOP health-care reform is dead in all but name, some on both the right and the left are starting to wonder about the unthinkable: that a major Northern European–style health-care reform will finally take root in the United States.” (Note: the author could have said “Canadian-style”, of course—but Northern European = socialist)

Were such a thing (as single-payer) to happen, “[i]t would erase by far the biggest distinction between rugged, individualist America and the social democracies of northern Europe. One can only imagine what the political implications would be: the leftist movement in America would be emboldened for decades to come, while the Republican party and center-left Democrats would be discredited, perhaps permanently.”

Some of the text (by a National Review intern, Max Bloom) is devoted to discussing tax increases on the upper middle classes (the author states that 60% taxes might be imposed on those earning $60,000 or more …) and the loss of health insurance coverage through their employer by around 149 million Americans, who pay “only” around 27% of the cost of premiums on average. The standard arguments concerning rationing and inability to access cost-prohibitive treatments are employed.

It is proposed near the end of the article that a “public option” might be one acceptable way to go—on which, see link (above).

Deedspeakout: Nobody on the “left” is suggesting that single-payer would be cheap. (Canadian tax rates are about 10% higher than American ones.) Taxes on most incomes above some level would go up, but this must be offset by the fact that people would no longer pay premiums, or co-pays, or deductibles—all care would be free at point-of-delivery. No out-of-pocket costs–none.

OTOH, under single-payer: No medical bankruptcies.  No one without health insurance– providing health care to those who remain uninsured comprises a huge hidden cost of the current hodge-podge system.

It all comes down to values.

  • Remembering Appalachia when discussing BCRA/AHCA—or the ACA, for that matter

Health care in southwest Virginia, 2017: Update

Background and onsite reporting on Remote Area Medical’s 18th annual 3-day (July 21-23) free clinic in Wise County, Virginia, where medical, dental, and vision care is offered by volunteers once a year.

The clinic provides a heart-rending picture of the “broken center” at the core of the ACA: here, people who earn too much to qualify for Medicaid (note: Virginia is one of 19 non-Medicaid-expansion states) but too little to afford ACA premiums and deductibles comprise a microcosm of the millions who have not been helped by the program.

“Virginia Gov. Terry McAuliffe (D), who flew out to the clinic Friday morning, had invited Senate Majority Leader Mitch McConnell to join him but said that the Republican leader ‘politely’ declined. McAuliffe, who visits the clinic every year, spent nearly two hours touring it — twice as long as scheduled — and took every opportunity to proclaim that he’s been trying for three years to get the state legislature to agree to expand Medicaid under Obamacare.”

“’We need it,’ called out Tonya Hall, operations director for a hospice-care facility. ‘Let them come and visit some in southwest Virginia. Let them see the poverty. Let them see how we live. Let them come.’

“’This isn’t about politics,’ McAuliffe said.

“‘Right!’ Hall agreed. ‘It’s about people.’

“’It’s about people’s lives,’ McAuliffe said to a round of ‘Amens’ from the group.”

This piece was posted under “Virginia Politics,” not under “ Health Care.”

As we said, it all comes down to values.




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