The obvious Obamacare replacement, but when?

Posted by on Friday, Jul 28, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

The obvious Obamacare replacement has been here all along

By John Garamendi
The Sacramento Bee, July 27, 2017

The ongoing uncertainty in Congress surrounding health care legislation, and the intentional sabotage of the Affordable Care Act, is destabilizing the insurance marketplace, driving up costs, discouraging new enrollments, and making Americans worried about the future of their health care.

In the short term, Congress should shore up the Affordable Care Act with bipartisan, commonsense improvements, such as a reinsurance program to stabilize the market for high-risk policyholders, legislation to make cost-sharing reductions permanent, and government permission to negotiate for lower prescription drug prices. But in the longer term, the time is right to think about ways to make access to health care truly universal and cover those who are still left behind. By far the simplest solution is Medicare For All.

Opponents may point to the difficulties California has had in trying to implement its own state-based universal health care system. A stand-alone plan in California would somehow have to incorporate existing federal health insurance programs – an impossible task given the political realities of the Trump Administration.

But a federal Medicare for All program would face no such obstacles: It would simply use the existing Medicare infrastructure and expand it to cover everyone.

Seniors know the peace of mind that comes from having the guarantee of health insurance. Imagine if all Americans could say the same.

John Garamendi represents the 3rd congressional district in California.…

As soon as John McCain joined Susan Collins and Lisa Murkowski and cast the vote that defeated the Republican effort to repeal and replace Obamacare, Senate minority leader Chuck Schumer repeated McCain’s earlier plea to return to regular order and reform health care on a bipartisan basis through the usual committee process. That inevitably leads to incremental change, if any change at all, which would have only a negligible impact compared to the need that exists.

Americans previously understood the deficiencies of the Affordable Care Act, and now they have been shown that reducing a government role in oversight of the private insurance industry would never fulfill the promise by the politicians of better care at a lower cost. Americans are ready for a national health program, and that is reflected in the response of the 115 members of Congress who are cosponsoring John Conyers’ HR 676, the Expanded & Improved Medicare for All Act.

Congressman John Garamendi of California represents the enthusiasm for a federal Medicare for All as he explains in his op-ed. But he joins other members of Congress in qualifying his support by saying, “In the short term, Congress should shore up the Affordable Care Act with bipartisan, commonsense improvements.” “But in the longer term, the time is right to think about ways to make access to health care truly universal and cover those who are still left behind.” Now is not that time?

“Single payer but not now” has become the byword of the incrementalists. If we move forward with an emasculated public option or an unaffordable Medicare buy-in, the process will come to halt, likely for decades, while we “see how this works.” We do not need more policy experimentation. We know what works. Single payer, Medicare for all, or whatever you want to call it, but let’s do it now!

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Senate defeats single payer amendment

Posted by on Thursday, Jul 27, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

In the Senate an amendment to the Republican repeal and replace legislation was introduced by Sen. Steve Daines (R-MT) that would establish a single payer system in the United States – an expanded and improved Medicare for all – using the exact same language as in HR 676 introduced in the House by Rep. John Conyers.

The vote:
0 – Yes
57 – No
43 – Present

All Republicans, including Sen. Daines, voted against it. Democratic Senators Donnelley, Manchin, Tester, and Heitkamp, along with Independent Senator King, voted against it. All other Democrats voted Present.

Sen. Bernie Sanders had said before the vote that failure of Sen. Daines and other Republicans to vote for their amendment would demonstrate that this was a sham to be used to campaign against moderate Senators in the next election. When no Republican voted for it, most Democrats plus Independent Sen. Sanders voted Present.

It is a sad commentary that the most important health policy legislation ever introduced in Congress – legislation that would have brought health care justice to all – was used by the Republicans as a tool for political chicanery.

Do they think this was some kind of a joke? They just rejected legislation that would have prevented hundreds of thousands of people over the years from facing physical suffering due to lack of medical care, financial hardship, and even death. Death!

We could forgive them for a bad joke, but this?

Mobilize the forces. This is war! Not the guns and bombs type of war but a war against man’s inhumanity to man.


Man was made to mourn: A Dirge

Many and sharp the num’rous ills
Inwoven with our frame!
More pointed still we make ourselves
Regret, remorse, and shame!
And man, whose heav’n-erected face
The smiles of love adorn, –
Man’s inhumanity to man
Makes countless thousands mourn!

–  Robert Burns, 1784

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Jimmy Carter on board for single payer

Posted by on Wednesday, Jul 26, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Jimmy Carter Believes U.S. Will Eventually Go to Single-Payer Health System

By Louise Radnofsky
The Wall Street Journal, July 23, 2017

Former President Jimmy Carter said he believed the U.S. would in time adopt a fully government-run health insurance system, or “Medicare for all,” in remarks ahead of his Sunday school class here. “I think eventually we’ll have a single-payer system,” said the former U.S. leader.…

President Carter, welcome aboard.

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Should PNHP postpone single payer and advocate for incremental reform?

Posted by on Tuesday, Jul 25, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Single payer can’t happen in California. At least, not right away

By Steve Tarzynski
Los Angeles Times, July 25, 2017

Given the dismal state of healthcare reform in Washington, liberal Californians have rallied around the idea that the state should establish a single-payer program. Although in the future such a system would be workable and desirable, the reality is that at the moment a single-payer bill cannot pass. Fighting for one in the immediate term is a waste of time.

But by 2020, California might just be ready for single payer — if advocates achieve a string of smaller but important legislative victories to build power.

Such steps might include: a state individual mandate; a state employer mandate that also covers part-time workers and their dependents; continued guaranteed coverage for children in the country illegally; giving the state insurance commissioner the power to regulate insurance premiums; setting a process to negotiate drug and medical device pricing; administrative reforms to streamline Medi-Cal so that there is less waste and better coordination and continuity of care; engaging the state’s tech sector to assist with such streamlining; advancing nonprofit delivery systems and moving away from fee-for-service practice; and opening up Medi-Cal to everyone, which would effectively create a state public option robust enough to compete on a level playing field against private insurers.

We do not need yet another devastating loss. Time, treasure and effort would be better spent winning the series of smaller victories that create the pathway to single payer. And in four years, a substantially stronger single-payer movement could successfully lobby a new Congress and president for federal waivers.

More than a century ago, Theodore Roosevelt called for a system of national health insurance. Single-payer advocates have been working for decades. They’ll have to work a few years more.

Steve Tarzynski is a physician and president of California Physicians Alliance.

(For a fair representation of Steve Tarzynski’s views, be sure to read the full article available at the link below.)…

How much incremental reform do we need before we are ready to enact a single payer system, whether at the state or federal level? Or are we ready now?

The California chapter of Physicians for a National Health Program (PNHP) struggled with these questions without resolve, and it was decided to split the chapter into two organizations – PNHP California and California Physicians Alliance (CaPA), CaPA having been a predecessor organization in California. PNHP is a single issue organization advocating for single payer reform whereas CaPA advocates for incremental reforms with an ultimate goal of single payer.

There is legitimacy for both organizations.

CaPA leadership believes that advocating for incremental reforms would establish a better working relationship with other organizations supporting health care justice. Joint advocacy efforts supposedly should reduce the resistance to the more comprehensive reform that a single payer system would bring us. More importantly, incremental reforms can be beneficial during the interim before transition to a single payer system clears the political hurdles.

PNHP leadership believes that we should do all that we can to expedite the transition to a bona fide single payer system. We have a long history of incrementalism and each step has resulted in postponement of a serious consideration of single payer. Right now the battle in Congress is between supporting the incremental policies in the Affordable Care Act or replacing them with measures that would set us back even further. Yet the concept that the government should play a greater role has gained traction amongst Americans, and we should be moving forward with a process that will accomplish that instead.

There are many individuals and organizations who support the various incremental proposals. They do not want for lack of a voice. On the other hand, there is a need for a loud, clear and unwavering voice for single payer reform, lest the message be lost in the incremental mishmash. PNHP will remain a major contributor to the clarion call. CaPA should as well though Steve Tarzynski in his op-ed says that fighting for single payer in the immediate term is a waste of time. But if we expect results by 2020, there is much work to be done now.

For full disclosure, I should say that I am a member of the transitional steering committee for PNHP California as we revitalize our chapter, and I am also a member of the advisory board for CaPA. I believe that both organizations play important but somewhat different roles in the California health care reform movement.

As a former national president of PNHP, I do have a bias. Both organizations support single payer as the ultimate goal, and I am going for that. I do support beneficial measures that may provide transitional relief, but devoting time, resources, and effort to single payer is not a waste of time; it is an absolute moral imperative. We need to go all out, now!

PNHP California


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What does the health policy literature tell us about consumer shopping?

Posted by on Monday, Jul 24, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

From The Archives: Prices And Consumer Shopping

By Rachel Dolan
Health Affairs Blog, July 19, 2017

The American Health Care Act and the proposed Better Care Reconciliation Act would both result in higher premiums and deductibles for many individuals in the private nongroup market according to the Congressional Budget Office. While the path forward for health reform is now somewhat unclear, the trend of higher consumer cost sharing will likely continue. Higher deductibles and cost sharing are often touted as ways for individuals to have “skin in the game” in health care costs and to help consumers be better shoppers. But what does the research say about the ability to truly shop for health care services? Is it possible? Does it save money? And do consumers even want to do it? Here’s what we know based on research published in the pages of Health Affairs.

Health Care Prices Vary A Lot – And Not Because Of Quality

Shopping For Health Care Has Serious Limitations

Consumers Don’t Really Use Price Tools

The trend of increased consumer cost sharing along with increased expectations that those consumers should engage in price shopping is not going away. But it’s naïve to believe that just increasing the cost burden on consumers and providing them with online tools to compare doctors is going to fix the serious cost problem we have in the US health care system.…

The politicians would have us believe that the health care battle is between those who would protect the policies of the Affordable Care Act and those who would replace Obamacare with a system that places a greater duty on the health care consumer to be a responsible purchaser. In fact, supporters of both approaches tout consumer price sensitivity.

The Affordable Care Act was designed specifically using lower actuarial value plans which require greater cost sharing, especially higher deductibles, supposedly driving the patient to be a more prudent health care shopper. The replacement proposals would merely magnify that – increasing cost sharing in order to reduce insurance premiums. In fact, the supporters of replacement would go so far as to require 100 percent cost sharing for the 22 million who would become uninsured – the nadir (zenith to some) of consumer-directed health care.

This article by Rachel Dolan, the Special Assistant to the Editor-in-Chief at Health Affairs, summarizes some of the studies from the Health Affairs archives, while providing links to those studies, concluding, “it’s naïve to believe that just increasing the cost burden on consumers and providing them with online tools to compare doctors is going to fix the serious cost problem we have in the US health care system.”

The intensity of the obsession with this ideology is demonstrated by the efforts of the Trump administration to introduce cost sharing into Medicaid – a program designed for low-income individuals with no discretionary income. How do they shop with money they do not have at hand?

Americans are not demanding a health care financing system in which they have to look into their own pockets to see what health care they can afford. They want a system that removes financial barriers to care so they can receive the care they actually need. Many Americans were relatively unhappy with the inadequacies of the Affordable Care Act, creating support for repeal and replacement. But when they learned that the proposed replacement would be even worse, they realized more than ever that government programs that have been successful in other nations may be just what we need.

Instead of price shopping it would be much better to have government oversight to make sure that our health care spending is fair, and to leave to the patient-consumers choices in the selection of their health care professionals and institutions, just as we now have with our traditional Medicare program. Tell the politicians to forget consumer price shopping; it doesn’t belong in health care. We can do far better with an equitable, publicly financed program.

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Americans say that health care coverage is the responsibility of the federal government

Posted by on Friday, Jul 21, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Views on Replacing the ACA

The Associated Press-NORC Center for Public Affairs Research, July 13-17, 2017

Q44. Is it the responsibility of the federal government to make sure that all Americans have health care coverage, or not?

March 2017
52% – Yes, a federal government responsibility
47% – No, not a federal government responsibility

July 2017
62% – Yes, a federal government responsibility
37% – No, not a federal government responsibility…

In only four months support of the view that it is the responsibility of the federal government to make sure that all Americans have health care coverage has gone from a 5 percentage point spread to a 25 point spread. The Republicans want to take credit for health care reform, and they actually may be able to take credit for this shift in opinion, even though it is in the opposite direction of their passionate support for further privatization of health care financing.

The years of unrelenting criticism of Obamacare by the Republicans along with the recognition that too many people are facing problems with affordability and access led to the concerns about the adequacy of the Affordable Care Act. In calling for repeal, the Republicans promised that they would replace Obamacare with a much better program, presumably bringing improved access at lower costs.

But then what happened this year now that Republicans have control of the House, Senate and the White house and can act on their promises? They tried to hide their actual policy positions behind closed doors shielded with false rhetoric. They were exposed when it became clear to all that their bucket of promises was empty.

It took only four months for Americans to realize that Bernie Sanders and all of the other Medicare-for-all advocates were right. The private sector can’t deliver, and the Republicans proved it. We need the federal government to take the responsibility of seeing that all Americans have health care.

It is our job to make sure that this American epiphany does not fade.

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Carol Paris: We have to take the lead, and they will follow

Posted by on Thursday, Jul 20, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

We Must Make It Toxic for Politicians to Not Get on Board with Single Payer

Democracy Now!, July 19, 2017

AMY GOODMAN: Proponents of a single-payer healthcare plan are organizing to urge Congress not only to stop the effort to repeal Obamacare, but to pass a bill that would guarantee Medicare for all. On Tuesday, former Vice President Al Gore became the latest prominent Democrat to speak in favor of single payer.

AL GORE: The private sector has not shown any ability to provide a good, accessible, affordable healthcare for all. I believe, for example, we ought to have a single-payer healthcare plan.

AMY GOODMAN: Well, for more, we go to Washington, D.C., where we’re joined by Dr. Carol Paris, president of Physicians for a National Health Program. She was arrested Monday at the Hart Senate Office during a protest against the Republican healthcare bill.

Dr. Paris, welcome to Democracy Now! Can you talk about your latest arrest, what you were calling for?

DR. CAROL PARIS: I’d be happy to. The reason that I decided to get arrested was to really make it clear that, as physicians, we not only oppose any bill that is going to be hurtful to Americans—and this bill clearly is hurtful, leaving 22 million people off of insurance—but we also champion and advance Medicare for all. That is really the plan that’s going to accomplish what both President Obama and President Trump have said that they support, which is better benefits, lower costs and more coverage. It’s just that the ACA hasn’t been able to accomplish that, and neither is what the Republicans are doing.

AMY GOODMAN: Senator Bernie Sanders said on MSNBC’s All In show last night that while the [Affordable] Care Act is not perfect, it should be improved, not destroyed. He laid out his suggestions for how.

SEN. BERNIE SANDERS: What we need to do is, among other things, in my view, lower the cost of prescription drugs, save consumers, save the government substantial sums of money. What we need to do is provide for a public option in every state in this country. What we need to do is lower the cost, lower Medicare eligibility from 65 to 55, and then begin the process of doing what every other major country on Earth is doing, and that is guaranteeing healthcare to all people as a right, through a Medicare-for-all, single-payer program.

AMY GOODMAN: So, Dr. Carol Paris, if you can parse that out? First of all, is that what you are calling for? And explain what this would mean, what it means to save Obamacare and then move forward with single payer or Medicare for all.

DR. CAROL PARIS: What it means to save Obamacare, or to save the ACA, is to continue the cost-sharing subsidies, to continue to support Medicaid expansion. But I absolutely don’t agree with Senator Sanders that the way forward is to have a public option and lower the Medicare age from 65 to 55. That is more incremental steps, and it absolutely fails to accomplish what a national single-payer, Medicare-for-all plan does, which is put everyone in the same risk pool. That’s how we garner the half-a-trillion dollars, $500 billion, of savings in administrative waste and profit of the for-profit insurance industry. If we create a public option, we’re just creating another opportunity for the insurance companies, the health insurance companies, to put all the sickest people in the public option and keep all the healthiest young people in their plans. So, no, I don’t agree that doing this incrementally is a good idea. We really need to go forward now to a national, improved Medicare for all. And really, the bill in Congress, HR 676, Congressman Conyers’s bill, is the way we need to go.

AMY GOODMAN: Well, also, Elizabeth Warren of Massachusetts has expressed her support for single payer. But we don’t see that movement in the Senate or the House, even with 676, which has been introduced for years. It would take political capital on the part of many senators and congressmembers to push this forward.

DR. CAROL PARIS: It would. And I think the way we’re going to do this is, we’re not going to wait around for our members of Congress to say, “Now it’s politically feasible.” If we wait for that, we’re going to be waiting for the rest of my life, your life and many more lives. What we have to do is more of what is happening in Congress right now. It’s like Occupy Congress. And that is, having the American people join in a movement of movements. I got arrested. I was sitting in the paddy wagon with four other people, including three young millennials, incredibly energetic young people, and we discovered that we all represented different organizations and didn’t know anything about each other’s organizations. And yet, we had all been arrested together, championing—opposing the BCRA and championing Medicare for all. So, it’s going to take a movement of movements, and it’s going to take the American people making it toxic for our elected officials not to get on board with this.

We have to take the lead, and they will follow.…

PNHP’s president, Dr. Carol Paris, has a very important message for all of us, and she is willing to be arrested to be certain that message is delivered. What is her message?

WE CANNOT repeal the Affordable Care Act, as some Republicans would, and walk away, leaving tens of millions of Americans in a more precarious situation for their health care.

WE CANNOT walk away if and when we win the battle to save the Affordable Care Act since it has failed to deliver to all of us the promised better benefits, lower costs and more coverage.

WE CANNOT stand idly by as members of Congress profess pragmatic, “politically feasible” incrementalism while barely moving the process.

WE CANNOT incrementally enact the insufficient measures of a public option and lowering the age of Medicare eligibility from 65 to 55, as Bernie Sanders says he would do, because that would bring to an abrupt halt the drive for single payer reform, delaying reconsideration for decades, if ever.

WE MUST MAKE IT TOXIC for members of Congress to not immediately get on board with championing single payer – an improved Medicare for all.

WE HAVE TO TAKE THE LEAD, and they will follow.

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Single payer in Harvard Business Review

Posted by on Wednesday, Jul 19, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Is the U.S. Ready for a Single-Payer Health Care System?

By Sandro Galea
Harvard Business Review, July 18, 2017

Ironically, as congressional Republicans have been trying to replace the Affordable Care Act, the ACA’s popularity is at an all-time high, and the majority of Americans now believe that it is the federal government’s responsibility to provide health care for all Americans. This shift in sentiment suggests that a single-payer system — a “Medicare for all” — may soon be a politically viable solution to America’s health care woes.

This system has long been an aspiration of the far left, yet even the right now seems to acknowledge its growing likelihood.

Although congressional Republicans remain uncomfortable with universal coverage as a concept, some seem to understand that the American people are coming to see health care as a right. It is very difficult to imagine how universal coverage could be sustainable over the long run without a central payment system.

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.

Opponents warn that a single-payer model could lead to a wholesale bureaucratization of the health care system by the federal government, or even to socialized medicine.

But are these concerns warranted? Doctors who fear losing their autonomy need only look north to see how a single-payer system can work without encroaching on the independence of physicians. Canada has had a single-payer model for decades, and there’s no government takeover of its health care system in sight. Most services are still provided by the private sector, and most physicians are still self-employed. While health expenditures remain high, Canadians nevertheless enjoy better health outcomes at lower cost than the United States, whose population’s health is mediocre despite ever-higher spending on medical care.

Canada’s success stems from a few basic tenets. Its system is structured around a federal requirement to provide coverage for necessary services such as doctor and hospital visits. While the cost of this care is covered by the taxpayer, the task of providing it is decentralized to each of the country’s 13 provinces and territories. Each region has wide latitude to innovate — as long as it honors the basic guarantee of providing free point-of-care treatment to all citizens for certain essential services, funded through a central payer. This is an important point. 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.

If implemented correctly, a centralized payment structure can create a health care system that is genuinely organized around health. It may seem counterintuitive to suggest that the U.S. system is not organized around health, but this truth has long been obvious to anyone who follows this issue or to anyone who has ever had to seek care in a time of need. Over and over, we have seen how the U.S. health care system produces a vast array of increasingly expensive drugs and treatments that few can access without high-quality insurance.

Decades of opposition have tinted Americans’ view of a single-payer system’s potential. But there is no reason to think that the status quo is immutable. It did not, after all, come about organically; it is the product of years of influence strategically wielded by powerful stakeholders in business, medicine, and politics. These stakeholders were able to advance their agenda in large part because Americans had not come to view health care as an essential collective right. This is changing. Turning this growing view into policy will require a national agreement that health care is a value worth paying for. The country is not there yet, but it no longer feels that far off.

Sandro Galea, MD, is the Robert A. Knox professor and dean of the Boston University School of Public Health.…

This article is of significance not only because it states well the rationale of the single payer model of health care reform, but it also demonstrates the high level of acceptance that the concept has attained, both by having been written by the dean of the Boston University School Public Health and by having been published in one of the more prestigious publications in the business community – Harvard Business Review.

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

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Where now on health care reform?

Posted by on Tuesday, Jul 18, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

By Sen. Mitch McConnell
Press Release, July 17, 2017

U.S. Senate Majority Leader Mitch McConnell (R-KY) made the following statement regarding a vote to repeal Obamacare:

“Regretfully, it is now apparent that the effort to repeal and immediately replace the failure of Obamacare will not be successful.

“So, in the coming days, the Senate will vote to take up the House bill with the first amendment in order being what a majority of the Senate has already supported in 2015 and that was vetoed by then-President Obama: a repeal of Obamacare with a two-year delay to provide for a stable transition period to a patient-centered health care system that gives Americans access to quality, affordable care.”…


By Donald J. Trump
Twitter, July 17, 2017

Republicans should just REPEAL failing ObamaCare now & work on a new Healthcare Plan that will start from a clean slate. Dems will join in!…

Just what Quote of the Day readers need – one more opinion amongst the plethora of reactions to the failure of Sen. McConnell’s effort to herd through a bill that could be labeled as “repeal and replacement of Obamacare.” But instead of predicting what might or will happen, let’s skip forward to what the response of single payer advocates should be. There will be no surprises here.

The Republicans want something that they can cite as fulfilling their six year long promise to repeal Obamacare, but that has been complicated by the revelation that their replacement proposals are “mean” and thus opposed by the majority of Americans.

Without going into the various permutations and combinations of what the politicians may do, a few facts stand out:

* The Republican replacement proposals really are mean. Through several mechanisms they would make paying for health care more of an individual responsibility when health care has become so expensive that many Americans simply would be unable to pay the out-of-pocket expenses that the Republican proposals would require. More physical suffering and financial hardship would be inevitable.

* The desire to repeal and replace the Affordable Care Act has been based on the very real deficiencies that have left too many Americans uninsured and underinsured. The Democratic politicians are making overtures that they are willing to work with the Republicans as long as the Medicaid expansions and the improvements in the individual insurance market are protected. Although a few Republicans might find some common ground here on policy, the majority would reject this as an acknowledgement of the defeat of their effort to repeal Obamacare, a bitter pill to swallow considering the intensity and passion of their opposition.

* The concept of single payer – an improved Medicare for all – continues to grow in popularity and is now favored by a majority of Americans. Even a majority of Democrats in the House of Representatives have now agreed to cosponsor John Conyers’ H.R. 676 – the Expanded & Improved Medicare for All Act.

* Although the Democrats in Congress are now coming out and saying that they support single payer, most of them say that our task now instead is to protect the Affordable Care Act. And after this crisis has been averted? They say that we should elect more Democrats in  2018 1n 2020 so that we can move forward with real reform – enacting a “public option” and maybe even enacting a Medicare buy-in for those over 55! Sorry. You can consult the PNHP website to see why these proposals would have hardly even a negligible impact on the health care problems that face us today. The Democratic position is essentially an endorsement of the unsatisfactory status quo.

So what are we to do? Just what we are doing, but a whole lot more of it. We cannot let Americans forget that the Democrats’ Affordable Care Act is grossly inadequate and fundamentally is not amenable to patches. We cannot let Americans forget that the Republican replacement promises proved to be mean (catching even Republicans off guard).

But, above all, we have to emphatically reinforce in the minds of Americans what it is that they find captivating in the single payer model of reform – affordable, accessible, equitable health care for all. That’s right. No surprises. Just health care justice for all.

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Importance of Medicaid in public health emergencies

Posted by on Monday, Jul 17, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

U.S. Senate, July 2017

H.R. 1628


This Act may be cited as the “Better Care Reconciliation Act of 2017.”




(A) IN GENERAL.—During the period that begins on January 1, 2020, and ends on December 31, 2024, the Secretary may exclude, from a State’s medical assistance expenditures for a fiscal year or portion of a fiscal year that occurs during such period, an amount that shall not exceed the amount determined under subparagraph (B) for the State and year or portion of a year if—

(i) a public health emergency declared by the Secretary pursuant to section 319 of the Public Health Service Act existed within the State during such year or portion of a year; and

(ii) the Secretary determines that such an exemption would be appropriate.

(B) MAXIMUM AMOUNT OF ADJUSTMENT.—The amount excluded for a State and fiscal year or portion of a fiscal year under this paragraph shall not exceed the amount by which—

(i) the amount of State expenditures for medical assistance for 1903A enrollees in areas of the State which are subject to a declaration described in subparagraph (A)(i) for the fiscal year or portion of a fiscal year; exceeds

(ii) the amount of such expenditures for such enrollees in such areas during the most recent fiscal year or portion of a fiscal year of equal length to the portion of a fiscal year involved during which no such declaration was in effect.

(C) AGGREGATE LIMITATION ON EXCLUSIONS AND ADDITIONAL BLOCK GRANT PAYMENTS.—The aggregate amount of expenditures excluded under this paragraph and additional payments made under section 1903B(c)(3)(E) for the period described in subparagraph (A) shall not exceed $5,000,000,000.…


Medicaid And The Latest Version Of The BCRA: Massive Federal Funding Losses Remain

By Sara Rosenbaum
Health Affairs Blog, July 14, 2017

Where Medicaid is concerned, the most notable thing about the latest version of the Better Care Reconciliation Act (BCRA) is that despite the drama of the past two weeks—the flood of news coverage regarding the potential impact of the losses; mounting concerns raised by Senators from expansion and non-expansion states alike; and the massive outcry from hospitals, physicians, insurers, and health care organizations—the new iteration leaves untouched the fundamental Medicaid contours of the earlier version.

By 2036, CBO reports, federal Medicaid funding would be about 35 percent below current law, a catastrophe of epic proportions.

The Illusion Of A Public Health Emergency Exemption To The Per Capita Cap

One of Medicaid’s most important dimensions is its irreplaceable role in addressing the immediate and long-term effects of public health crises. Medicaid is by far the nation’s biggest single source of health care financing for dealing with critical public health threats. These threats may begin with an initial, recognized period of a formally declared emergency. They then can morph into events with very long-term effects felt for years or decades after. This was the case with the World Trade Center attacks, which led to an immediate surge in health care spending, followed by years of elevated spending to address the long-term health fallout triggered by the emergency itself. One need think only about Zika or the opioid crisis now gripping the nation to understand the near-term/long-term nature of public health threats.

Medicaid enrollees are disproportionately likely to live in poor communities, and poor communities are disproportionately likely to face public health threats ranging from environmental hazards to infectious disease. These communities also are inherently less likely to have resources to cope with the effects of an emergency. Thus, a program such as Medicaid is crucial in its ability to deploy health care financing resources to the hardest-hit populations. Indeed, two thirds of all Louisiana Medicaid beneficiaries lived in the parishes affected by Hurricane Katrina.

Section 319 of the Public Health Service Act authorizes the HHS Secretary to declare the existence of a public health emergency arising from events such as a “disease or disorder,” “significant outbreaks of infectious diseases or bioterrorist attacks,” or other events identified as public health emergencies by the HHS Secretary. Whether to declare an emergency is entrusted to the Secretary’s judgment, and during the immediate emergency period, the Secretary enjoys expanded powers to deploy resources to designated populations or geographic areas. These special powers end when the declared emergency period ends. In the aftermath, states and local communities effectively are on their own, relying on the resources they have.

In and of itself, a loss of federal health funding as large as that imposed by BCRA elevates the threat risk. This risk grows exponentially when a true crisis hits, if Medicaid is crippled in its ability to provide a large-scale surge in public health care spending both during the emergency and thereafter. To understand how little the revised bill does to mitigate the crippling impact of the initial draft one need only look carefully at what the revisions would do when a true emergency strikes.

The press release accompanying the new draft states that “if a public health emergency is declared, state medical assistance expenditures in a particular part of the state will not be counted toward the per capita caps or block grant allocations for the declared period of the emergency.” But a close read of the actual bill text reveals its fundamental inadequacy.

First, the period of exemption lasts only five years, from January 1, 2020 through December 31, 2024. Emergencies happening after this date won’t qualify for the spending adjustment. Second, the bill provides no additional federal spending during the period of a declared emergency. The draft simply allows states to eventually qualify for additional federal funding in the years following the emergency if they can prove to the Secretary that their spending on the affected population went up compared to prior years and then only for immediate emergency costs. What state will have the money in advance? And what state will be able to take a chance on spending more given the purely speculative nature of whether an emergency will be declared and emergency expenditures recognized?

Third, states would receive no additional funding ever unless the HHS Secretary actually declares an emergency in the affected portion of the state or for the state’s affected populations. Many public health threats may not rise to a level that triggers a formal Secretarial determination, and the Secretary may be inclined not to make such a determination because of other, spillover effects that come with such a determination, such as the elevated demand for other types of resources.

Fourth, the additional amount of federal funding made available would be limited to the difference between what the state spent on the population in connection with the emergency and the state’s previous expenditures for the same population. Expenditures to cope with the emergency aftermath would not count, and of course these expenditures likely would not occur simultaneously with the emergency expenditures. For example, Zika has triggered emergency expenditures aimed at preventing the spread of the virus, but the true costs of Zika will roll out slowly in the form of babies left permanently and severely disabled by the virus.

And here is where the public health implications of BCRA become clear: other than exempting state expenditures on children classified as disabled from the caps, the revised bill, like its predecessor, makes no adjustment for long-term consequences. To be sure, as just mentioned, BCRA does exempt state expenditures on severely disabled children from the federal cap. But because the vast majority of children qualify for Medicaid based on poverty, this type of cramped classification system for measuring exemptions is sure to exclude spending for millions of children in severely compromised health from the exemption process.

Fifth, the bill allows only $5 billion in the aggregate for all additional federal funding over the five-year time period covered by the emergency exemption. In other words, the bill essentially creates a five-year, $5 billion mini-block grant to help all states address Medicaid spending for all emergencies occurring during this time period. The incredibly small size of the block grant alone would be likely to incentivize the HHS Secretary to avoid declaring emergencies out of concern that the money won’t be there to cover them.

In the end, the newest iteration of BCRA does nothing to alleviate the catastrophic effects of its predecessor: the difference in magnitude between what Medicaid can do today and what it will be capable of doing in the future is incalculable.…

Based on some of the rhetoric being tossed around during the debate on repealing and replacing the Affordable Care Act you might think that the politicians currently in charge of the process do not believe that the government should play much of a role in health care. However, based on today’s excerpt from their “Better Care Reconciliation Act,” it almost seems that they do believe that the government should step up during a public health emergency. Or do they?

There are many government agencies that might play a role during a public health emergency. One of the more important is providing victims with Medicaid funding during these emergencies and for the essential services required in followup. Yet the massive reductions proposed for the Medicaid program by the Republican legislation (close to a trillion dollars over the next decade – “a catastrophe of epic proportions”) would cripple this important resource for emergency coverage.

The Republicans seem to have been caught off guard by the intensity of the reaction to the cruelty inherent in their reform proposals. Taking a second look at what they crafted, it apparently occurred to them that their substitute legislation should be modified to be sure that public health emergencies were covered.

So what did they propose? A mini-block grant capped at a maximum of $5 billion over five years, and, at that, with many restrictions. As Sara Rosenbaum states in her Health Affairs article, “the incredibly small size of the block grant alone would be likely to incentivize the HHS Secretary to avoid declaring emergencies out of concern that the money won’t be there to cover them.” Based on his track record, it would not be difficult to imagine HHS Secretary Tom Price withholding funds for an emergency just because there wouldn’t be any funds left over for inevitable public health emergencies to come, providing him with an excuse for being the heartless skinflint that he is.

Thus, amongst the many other profound deficiencies, the Republicans in their repeal and replace legislation do not make a serious attempt to ensure that the government would have the ability to respond in fulfilling one of the more crucial essential functions of government – providing assistance in a public health emergency. These guys really don’t believe in government.

We need to replace not only the health care financing infrastructure with one that ensures that government will be there for us when we have health care needs, but we also need to replace the stewards of the program with people who understand that we are all in this together and we take care of each other in times of need. We do believe that don’t we?

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