Robert Borosage on paving the way to Medicare for All

Posted by on Friday, May 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.

Will the Republican Health-Care Debacle Pave the Way for ‘Medicare far All’?

By Robert L. Borosage
The Nation, May 25, 2017

This week, the Congressional Budget Office confirmed what was already apparent: The revised House Republican health-care bill will still deprive millions of Americans — 23 million in the CBO estimate — of health insurance. Senate Republicans are devising their plan in secret, because it too will likely deprive millions of health coverage. In contrast with Republican horrors, Obamacare has grown in popularity, but premiums are rising as insurance companies consolidate monopolies in various states and Trump works to sabotage it. Surely, now is the time for progressives to wage a fierce campaign for Medicare for All.

Americans are more than ready. The popularity of expanding Medicare is surprising, given how little support it has received from the political class.

Will Republican efforts to repeal and replace Obamacare pave the way to Medicare for All? Only if progressives force the debate. Americans are looking for sensible reform. Medicare for All is the right answer. Now is the time for progressives to educate and enlist to take on the entrenched interests that stand in the way.

https://www.thenation.com…

With the backlash against the Republicans for their ongoing failure to deliver effective health care reform, and with the failure of ACA to provide affordable health care for everyone, the pathway to Medicare for All may now have been paved.

Robert Borosage suggests that it is time for progressives to push the process – force the debate, educate, and enlist. But that should not be limited to progressives in the Democratic party. We should work with Republican progressives, independent progressives, Democratic Socialist progressives, and even, albeit rare, libertarian progressives. By forcing the debate, educating, and enlisting, even conservatives and others who do not usually assign to themselves the “progressive” label, should be ready for a serious consideration of single payer.

Assured health care, at a price we could all afford, who could be against that? Neither ACA nor AHCA would bring us that. Members of Congress will be home on a break this next week. Let them hear from you, though you may not want to announce yourself using the “progressive’ label.

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In this time of bitter partisan debate over the future of U. S. health care, the Republican Party is deeply split within its ranks while the Trump administration gives mixed signals as to its goals. On the one hand, President Trump says that the ACA, or Obamacare, is already a dead duck while his selected Secretary of Health and Human Services, Dr. Tom Price, plans to use whatever administrative means are available to kill it altogether. The GOP’s American Health Care Act (AHCA), narrowly passed in the House, has little support in the Senate, where secret discussions, likely to take months, are proceeding to develop its own plan to replace the ACA.

Within this confusing debate, there are three basic options to finance our health care system: (1) continue the ACA, with some possible revisions; (2) replace it with the AHCA, as modified within Congress; or (3) adopt a single-payer Medicare for All plan for national health insurance (NHI).

Today’s Crisis in U. S. Health Care
Unfortunately, this debate continues with U. S. health care already in a crisis mode, as shown by these markers:

  • Soaring costs of care in our market-based system without significant price or cost controls; one in four Americans rank health care costs as their top concern, even above job security and unemployment.
  • The cost of health insurance and care for a typical family of four on an average employer-sponsored PPO plan has reached almost $27,000 (1), while the median U. S. household income is about $53,000, clearly a major disconnect in any family budget.
  • Almost two million Americans go through bankruptcy every year because of medical bills and illness, despite most having had insurance, owning their own homes, having attended college, and having held responsible jobs.
  • Under the ACA, insurers have consolidated and narrowed networks, resulting in restricted access to care.
  • There are still about 28 million Americans without any health insurance.
  • Many physicians refuse to see uninsured patients, even those with Medicaid coverage, and waiting times can be lengthy if they are to be seen.
  • There are still widespread disparities of care, including by race/ethnicity, socioeconomic status, age, gender, location, and disability status, that lead many people to forgo necessary care and suffer worse outcomes.
  • Studies by the Commonwealth Fund find that the U. S. ranks #11 among 11 advanced countries in overall ranking, cost-restricted access, efficiency, equity, and healthy lives (2).
  • Under our multi-payer system with some 1,300 private insurers seeking to enroll healthier patients and avoid sicker patients, the health care bureaucracy is massive and expensive—the overhead of the private health insurance industry is $792 per capita, more than five times that of Canada with its single-payer public financing system.
  • Facing uncertainty over the future of government funding for cost-sharing payments under the ACA, the extent of deregulation that will come out of the current political debate, and the future of Medicaid, insurers are planning sharp premium increases in 2018 and threatening to exit even more markets than they have left already. People living in rural areas are especially vulnerable to these changes.
  • The new Trump budget proposal would cut federal spending by $3.6 trillion over ten years, with deep cuts to Medicaid and other safety net programs.

Comparison of Three Financing Alternatives
1. Continuing the ACA (ObamaCare)
The ACA brought important improvements in access to care, providing new coverage for 24 million Americans, especially through expansion of Medicaid in 31 states. It established ten categories of essential health benefits, and also required insurers to stop denying coverage for pre-existing conditions and allow children to stay on their parents’ coverage until age 26. Cost-sharing reduction (CSR) payments were made to help 7 million people afford coverage through the exchanges, about 60 percent of all new enrollees.

Despite these improvements, the ACA falls far short of our needs on many counts. Costs and prices of health care services have continued to soar, forcing many people to forgo necessary care and incur worse outcomes. Although the ACA expanded funding for community health centers, we still have a porous safety net that will become even more so under the proposed Trump budget proposal. Most Democrats are strongly defending the ACA against Republican attacks, calling for continuation of CSR payments and reconsideration of the public option, which was dropped in 2009 due to strong opposition from the insurance industry. That opposition remains today, and if put in place, the public option would attract more expensive, high-needs patients, relieving private insurers of the costs of covering them.

2. Repeal and replace the ACA with the AHCA (TrumpCare)
This has been the consistent goal of the GOP since the passage of the ACA in
2010, but repeal has failed on some 60 occasions in Congress. Since the 2016 elections, despite having control of both chambers of Congress and the White House, Republicans have had great difficulty in coming up with a replacement plan. The provision of subsidies or tax credits, definition of essential health benefits, and cutbacks to Medicaid have been especially controversial.

After the first GOP plan for the AHCA was pulled from the floor without enough votes, House Republicans hastily drafted a revised bill, hoping to appease the hard right Freedom Caucus while gaining enough support from more moderate Republicans. That bill barely passed by a vote of 217 to 213, with these provisions:

  • Eliminates the individual mandate and requirement that larger employers offer employer-sponsored coverage.
  • Allows states to limit essential health benefits through waivers (such as hospital care or maternity care).
  • Reduces funding for Medicaid by $839 billion.
  • Allows insurers to charge seniors up to five times the rates for younger patients.
  • Defunds Planned Parenthood.
  • Replaces the ACA’s subsidies with less generous tax credits.
  • Allows insurers to raise premiums on patients with pre-existing conditions, while providing (inadequate) funds for high-risk pools.
  • Repeals taxes on pharmaceutical and medical device industries.
  • Provides wealthy taxpayers $882 billion in tax breaks.

That bill has gone on to the Senate, where it is receiving little support. A 13-man (no women) working group is charged with writing a new bill. The CBO has recently scored the House bill, noting that 23 million people will lose coverage by 2026, including 14 million who would otherwise have had it through Medicaid. That 23 million, plus today’s 28 million uninsured under the ACA, totals 51 million uninsured (even more than when the ACA was passed!), plus tens of millions more underinsured as insurers reduce benefits. The CBO projects a 20 percent increase in insurance premiums in 2018, and that sicker patients can expect huge increases in costs. It also recognizes that costs for skimpier coverage may be unaffordable for many in states that get waivers to back away from some essential health benefits and/or cut CSR payments. If ever a final GOP bill is passed by both chambers of Congress, its main elements will likely include such already discredited approaches as further deregulation of the insurance industry, increased cost sharing with patients, health savings accounts, high-risk pools, selling insurance across state lines, and more privatization of Medicare and Medicaid.

3. Single-payer national health insurance (NHI), or Medicare for All
It has become clear that neither the ACA nor the AHCA can ever make health care accessible and affordable for all as long as they rely on a multi-payer, profiteering market-based system, and that either approach will leave out increasing numbers of Americans. We can expect the AHCA or whatever version might eventually clear both chambers of Congress will be even worse than the ACA, while giving huge tax breaks for the wealthy.

Single-payer NHI (H.R. 676 in the House, with 112 co-sponsors) is the only financing alternative to effectively reform U. S. health care. It is a common sense approach to long overdue fundamental system reform. When enacted, all Americans will gain universal access to affordable, comprehensive health care regardless of their health status or income, with full choice of physician and hospital anywhere in the country. They will be part of a single risk pool of 320 million Americans that accommodates the needs of the sickest patients while saving enough money to provide health care to our entire population. Benefits will include physician and hospital care, outpatient care, dental and vision services, rehabilitation, long-term care, mental health care, and prescription drugs. Today’s huge bureaucracy and wasteful overhead of a failing private insurance industry will be a thing of the past.

According to the latest projections, NHI will save $616 billion a year ($503 billion by eliminating administrative overhead and $113 billion on outpatient prescription drugs through negotiated drug prices). (3) It will be funded by a progressive funding plan whereby 95 percent of Americans will pay less than they do now for insurance and care. As an example, those with annual incomes of $50,000 will pay $1,500 in taxes.

If either of our two major political parties would inform themselves of previous and current health care reform experience and evidence—instead of reflexively defending the ACA or promoting the AHCA—they could perhaps see the obvious merits of real reform—NHI—which if enacted would benefit the public common good on a long-term sustainable basis and bring credit to legislators and the parties making it happen.

Adapted in part from my recently released pamphlet, Common Sense about Health Care Reform in America, available in a few days from Amazon.com and CreateSpace.com, and my 2017 book, Crisis in U. S. Health Care: Corporate Power vs. the Common Good.

John Geyman, M.D. is the author of Crisis in U.S. Health Care: Corporate Power vs. The Common Good, and The Human Face of ObamaCare: Promises vs. Reality and What Comes Next

visit: http://www.johngeymanmd.org

Other References:

  1. Girod, C, Hart, S, Waltz, M. Milliman Medical Index, May 2017.
  2. Davis, S, Stremikus, K, Squires, D et al. Mirror, Mirror on the Wall, 2014 update: How the U. S. Health Care System Compares Internationally. The Commonwealth Fund, June 16, 2014.
  3. Woolhander, S, Himmelstein, DU. Single-payer reform is ‘the only way to fulfill the President’s pledge’ on health care. Annals of Internal Medicine online, February 21, 2017.

HHS Secretary Price on the CBO Report

Posted by on Thursday, May 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.

H.R. 1628, American Health Care Act of 2017

Congressional Budget Office, May 24, 2017

CBO and JCT estimate that enacting the American Health Care Act would reduce federal deficits by $119 billion over the coming decade and increase the number of people who are uninsured by 23 million in 2026 relative to current law.

CBO Summary:

https://www.cbo.gov…

CBO Full Report (41 pages):
https://www.cbo.gov…

***

HHS Secretary Price Statement on CBO Report

U.S. Department of Health and Human Services, May 24, 2017

Following the release of the Congressional Budget Office (CBO) report analyzing the American Health Care Act, Health and Human Services (HHS) Secretary Tom Price, M.D. released the following statement:

“The CBO was wrong when they analyzed Obamacare’s effect on cost and coverage, and they are wrong again. In reality, Americans are paying more for fewer healthcare choices because of Obamacare, and that’s why the Trump Administration is committed to reforming healthcare. In a new analysis released just last night, HHS reported that premiums in the individual market have more than doubled since many of Obamacare’s regulations and mandates were implemented.”

HHS released a new analysis yesterday that shows premiums have doubled for individual health insurance plans since 2013, the year before many of Obamacare’s regulations and mandates took effect.

https://www.hhs.gov…

Even though we spend far more on health care than other nations, the market has not been effective in allocating our funds in a manner that would ensure adequate health care for all. This is a time and circumstance wherein we clearly need government leadership.

In response to a Congressional Budget Office report showing that the current proposed health reform legislation – American Health Care Act of 2017 – would likely cause another 23 million people to lose their health insurance, besides its other deleterious effects, HHS Secretary Tom Price fails to acknowledge the severe deficiencies of the legislation and instead condemns the report as being “wrong.” This is not a casual comment; he distributes this through an official HHS release of the U.S. government.

Of course, the report isn’t wrong; it’s a prediction, based on the best available information.

What is wrong is that we have in place a public servant who would destroy whatever he can of the important public health role served by the Department of Health and Human Services. He is driven by his nutty anti-government ideology and would sacrifice the health services of tens of millions of Americans simply for the expediency of implementing his destructive agenda.

Although there are some checks and balances, nevertheless he is in a position to do considerable harm to America’s health care. He should not be left in office for four to eight years while we wait for the next president to replace him. Citizen action is required – now.

This is the opinion of the author is not an official view of Physicians for a National Health Program.

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Ethics of equitable versus equal in health care

Posted by on Wednesday, May 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.

Health Insurance Benefits Should Be Equitable, Not Necessarily Equal

By Betsy Q. Cliff, Michael Rozier, and A. Mark Fendrick
Health Affairs Blog, May 22, 2017

As policy makers grapple with potentially undoing or modifying the largest expansion of health insurance in a generation, the cost and generosity of benefits hold center stage. Traditional underpinnings of insurance plans — premiums, deductibles, copayments, and coinsurance — frequently create barriers to the optimal use of these plans by consumers. They also can exacerbate inequities in health care, by inhibiting the use of services known to benefit health. Novel approaches to insurance plan design to produce a more equitable and efficient distribution of health care expenditures are warranted.

Following the principle of equality, insurance benefit designs traditionally have offered the same benefit structure to all enrollees. Consumer cost sharing at the point of service is typically uniform regardless of need or potential clinical benefit — often it’s based on the acquisition cost. This one-size-fits-all mentality seems like a great idea on the surface but can create deeply unfair outcomes.

Instead, we should be designing insurance coverage in a way that provides access to care for people who need it, when they need it. That requires a subtle but important shift from equal access to equitable access. The first approach treats all people, regardless of clinical need, the same. The second recognizes that clinical need is an essential factor in determining where to direct resources and does not apologize for treating people with different needs differently.

A feasible and effective approach to better aligning expenditures with patient-centered outcomes is value-based insurance design (VBID). VBID structures consumer cost sharing around the idea of clinical nuance, which recognizes that the value of medical services depends on who receives it, who provides it, and where it is provided. This nuanced strategy supports the goals of equity by reducing financial barriers to specific services for targeted populations who need them most. This approach can also be used to deter the use of services when there is low or no expected clinical benefit to the patient.

Equity Versus Equality

The concept of equity is most often applied to health outcomes, in terms of addressing the burden of disease borne by one group compared to another. The solution to these inequities often involves assessing the distribution of health determinants and allocating resources accordingly.

Equity is also embedded in the financing of our health system. For example, Medicaid Disproportionate Share Hospital payments follow the principle of equity rather than equality: Health care organizations that bear the greatest share of uninsured or underinsured patients receive the largest share of funds from this program.

In most situations, a fair health care system ought to concern itself more with equity than equality. If people responded identically to, and had equal need for, clinical services, then access to those services should be equal. Since this is clearly not the case, it makes sense to discriminate based on the likelihood of clinical benefit. In other words, we should not let the potential negative effects of “bad” discrimination (for instance, failing to prescribe a drug based on a person’s racial or sexual identity) obscure the potential advantages of “good” discrimination, which would make it easier for some groups to obtain a service based on clinical need. Equity is premised on the idea that some types of discrimination — treating unequals unequally — is not only good but also necessary.

In particular, tailoring insurance benefits in this way allows individuals to access the best care for their clinical situation. To help ameliorate disparities, patients who are in the most need and services shown to have the most benefit should be supported by their insurance coverage at the most generous levels.

Ensuring Access Through Equitable Benefits

Allowing benefit programs to adapt to those who are most likely to benefit from care could allow physicians to better tailor treatment to each patient and allow patients to better respond to evidence-based recommendations. Using VBID promotes this goal in three distinct ways.

First, VBID reduces cost sharing for specific services that are shown to have the highest clinical benefit.

Second, VBID enhances benefits for specific patient populations.

Third, whereas traditional benefit designs can keep people from accessing innovative medications due to higher cost, VBID can help tailor cost sharing to the specific clinical circumstance.

Coverage arrangements in most insurance plans are designed under principles of equality rather than equity. To fully realize the benefits of medical advances, ensure access for those who could benefit most, and enhance the efficiency of our health care expenditures, we need to change this paradigm. Equitable benefit design recognizes that many chronic conditions often require tailored therapies for achieving results and allows for discrimination based on clinical need. Better health outcomes, especially for those most in need, require us to apply principles of equity in all aspects of our health care system, including benefit design.

http://healthaffairs.org…

The concepts of equitable and equal, as applied to health care, are certainly crucial. It is imperative that health care and the financing of it be equitable – fair – but it does not necessarily have to be equal. This article discusses these concepts in regard to value-based insurance design (VBID), appropriately reflecting the biases of a University of Michigan health management and policy professor (and a partner in V-BID Health), A. Mark Fendrick, and two of his graduate students.

It is clear that our fragmented, multi-payer health care system is neither equitable nor equal. Because of the great variety of health care financing systems in the United States, or lack thereof, people certainly do not have equal access to health care services and products. Nor is the system equitable since some are served very well when in need, and others are served poorly, if at all. There is an inherent unfairness in having impaired access to the most expensive health care system in the world.

The authors recognize that insurance design contributes to these inequities. They suggest that they could be diminished by redesigning benefits so that they are value-based. But they limit their considerations by adhering to the ideology of consumer-directed health care in which patients share in the costs of health care services as they are accessed (deductibles, copayments, coinsurance, tiering of benefits, penalties for out-of-network care, etc.). Thus their emphasis is on insurance design rather than on more direct financing of essential health care services.

This approach perpetuates and adds to the complexity and waste of our uniquely American health care financing system that is weighted down by profound administrative excesses. Tweaking benefits within an individual plan certainly does not make the benefits equal to those in a multitude of other private and public plans. Even if value-based tweaks were adopted by many other plans and programs, the overall impact on health care would be almost infinitesimal compared to the great needs we have in health care reform.

Much more important than not creating equality, VBID also would have too small of an impact on health care equity. Jiggering benefits would not begin to address the deficiencies that the uninsured and underinsured face, perpetuating our profound unfairness in health care access and affordability.

So let’s set private insurance plans aside and look at these concepts in the single payer model of health care financing. How do you make the system equitable – fair? You make it accessible and affordable for everyone. Central planning and budgeting of capital improvements ensures that health care facilities and professionals are as available as the logistics and resources would allow.

Affordability? Considering the profound inequality in income and wealth and the very high costs of health care, payment into the common risk pool must be based on ability to pay if financing of the system is to be equitable. This is accomplished through progressive tax policies. There could not be a more ethical example on why our health care system must be equitable, but not necessarily equal. An equitable system would be designed to make sure that essential health care benefits are available to all, and thus equal (though benefits that should not be funded by a public system would not be equal), but the financing, to be equitable, must not be equal.

We can forget about the value-based benefit tweaks for private consumer-directed health plans. We need real fixes in our health care system that are universally equitable.

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Would California’s proposed single payer system bankrupt businesses?

Posted by on Tuesday, May 23, 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.

California Senate Committee on Appropriations: SB 562 (Lara) – The Healthy California Act

By Brendan McCarthy (Consultant)
May 22, 2017

Bill Summary: SB 562 would create a universal, single-payer health care system in California.

Fiscal Impact: The fiscal estimates below are subject to enormous uncertainty. Completely rebuilding the California health care system from a multi-payer system into a single payer, fee-for-service system would be an unprecedented change in a large health care market.

The projected costs and revenue needs for the proposed Program are as follows. For a discussion of the underlying assumptions, see Staff Comments (link below).

* Total annual costs of about $400 billion per year, including all covered health care services and administrative costs, at full enrollment.

* Existing federal, state, and local funding of about $200 billion could be available to offset a portion of the total program cost.

* About $200 billion in additional tax revenues would be needed to pay for the remainder of the total program cost. Assuming this tax was raised through a new payroll tax (with no cap on the wages subject to the tax), the additional payroll tax rate would be about 15% of earned income.

It is important to note that the overall cost of those new tax revenues would be offset to a large degree by reduced spending on health care coverage by employers and employees. Although precise estimates of total spending for employer sponsored health insurance are not available, the best available information indicates that existing spending is between $50 and $100 billion per year. Therefore, total new spending required under the bill would be between $50 and $100 billion per year.

Administrative cost savings would be real, but limited

Under a single payer system, the overall administrative cost of the system would likely be lower than it is in the current multi-payer system. In the United States, the cost of the health insurance industry is about 7% of total costs. In addition, providers, such as hospitals and physicians, incur significant administrative costs to negotiate contracts and comply with health insurer billing requirements. If we assume that the costs on the provider side are equal to the costs of the insurance industry, then current administrative costs are likely to be about 15% of total spending. Administrative costs in the Medi-Cal fee-for-service system and Medicare are about 6% of spending. Assuming that dealing with a single payer system reduced provider administrative costs by half, total administrative costs of the system in the bill would likely be about 9-10% of total spending. This does represent a significant savings in a $400 billion health care system. However, administrative savings are not likely to substantially lower the overall cost of providing health care to the state, compared to costs associated with expanding coverage to the uninsured and increased utilization of services under the bill.

https://ww2.kqed.org…

With the release of this fiscal analysis of SB 562 – The Healthy California Act – the expected loud protests to the high costs of a single payer system have been forthcoming, especially that the costs would exceed the California state budget and that raising the additional funds required through a 15% payroll tax would bankrupt businesses. The opponents conveniently ignore the opening caution that “the fiscal estimates below are subject to enormous uncertainty.”

In fact, this 8 page analysis is loaded with assumptions and uncertainties based on the lack of detail specified in the proposed legislation, as the author indicates. Health care is almost one-fifth of our gross domestic product, and, by any accounting, that is very expensive. But this does not change fundamental single payer principles. All of the health care funds are moved into a single, publicly-administered system which is administered much more efficiently and which is funded on an equitable basis (which requires progressive taxes because of the decades-long shift of income and wealth to the top).

The opponents have already declared that this legislation is a failure based on the high global costs and the assumption that a payroll tax would replace current private spending. Reading the full report would provide a more objective perspective, in spite of the multitude of uncertainties.

At any rate, those who dismiss this legislation based on spending greater than the California state budget and a 15% payroll tax must be challenged. Our response? This bill would provide each Californian with all essential health care services at a price that each can afford.

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What do leaders of the medical-industrial complex think about reform?

Posted by on Monday, May 22, 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.

Healthcare Strategy in the Year of Uncertainty; Even amid significant legislative ambiguity, reform remains a market-driven issue.

By Aamer Mumtaz, Alan London, MD, and David Fairchild, MD
Healthcare Financial Management Association, May 2017

Among the dozen C-suite leaders from leading health systems and AMCs in nine states who we interviewed over the past two months, most believe that the healthcare market has many of the same characteristics and challenges as it did in 2011: Cost growth is an issue, quality and value are ongoing concerns, and breaking even on government programs is a challenge. With some critical caveats, the appropriate short-term provider response thus will not be fundamentally different from the past seven years:

• The search for value will continue, with clinical integration, care coordination, and high-quality care still the paths to get there.

• Scale will become even more important as systems look for ways to reduce the per unit cost of care.

• Commercial insurance will remain the main engine of growth for providers, with Medicare Advantage the most attractive government program financially.

• Medicaid and the ACA marketplaces are wild cards. What happens in those spaces will be felt disproportionately by systems serving high numbers of underprivileged patients, including systems operating in rural areas.

• The move toward quality will continue despite the potential waning of government support for innovation.

• Speed to market for new initiatives in the pipeline will be important.

• Cost reduction and asset redeployment will be essential in an increasingly cash-strapped environment.

“No regret” moves

Providers are focused on moves that transcend the ongoing legislative and regulatory uncertainty and instead address more fundamental economic forces. Such moves include:

• Achieving scale through partnerships and alliances

• Commercial market growth (e.g., through targeted ambulatory expansion)

• Continued focus on Medicare Advantage

• Aggressive cost control

• Partnerships with health plans to share more risk

• Building the clinical network

• Slowdown or halt on long-term investments

Economics overshadows politics

Our preliminary discussions with leaders from major health systems around the country have cofirmed that healthcare reform remains driven primarily by market forces as opposed to legislative initiatives. As one West Coast executive told us, “The challenges facing health care are more economic than political.”

Just as in 2011, imperatives to reduce costs and to achieve profitable growth through the delivery of value remain key. In fact, cutting costs, improving clinical integration, and addressing quality and customer service needs — all while focusing on profitable markets for growth — arguably will be even more important strategies in 2017 and going forward than they were in 2011.

http://www.bdcadvisors.com…

So who really determines the nature and scope of the health care delivery system? Is it the doctors and nurses? They are busy trying to make the system we have work for their patients, and they are having difficulties with that. Is it the politicians? They continue to feed the largest share of money into the system (taxes – often opaque – to pay for health care) while turning much of it over to the medical-industrial complex.

The medical-industrial complex is composed of interwoven, overlapping organizations and their executives that make spending decisions through various financing vehicles such as commercial insurance, managed care organizations, accountable care organizations, health plan administrators for public and private programs, and the like. According to this survey of C-suite leaders, they want more of it – more integration (anti-competitive consolidation), more care coordination (care management prioritizing executive business decisions), shifting care to where the money is (outpatient services now epitomized by the most expensive of all – free-standing emergency departments), more programs to promote “quality” (think MACRA and MIPS), more government financing of private insurance (prominent examples being Medicare Advantage and Medicaid managed care), while achieving scale in all of this (more and more of it), and they want it right now (before the social movement for health care as a right – single payer – can gain traction).

Many of the measures are touted as methods of controlling costs when the real cost containment efforts are directed to reducing volume and price as a method of ratcheting down the growth of spending on the actual health care delivery system. Although excessive prices and over-utilization are problems, so are under-utilization and inadequate pricing. Establishing barriers to care and not compensating the delivery system adequately do a disservice to patients and their health care professionals, especially when there are far more patient-friendly methods of containing spending, which also reduce the abuses.

Our current bearing will leave these people in charge, with more of the same. So what should we do? What should be our strategy and tactics? Is sticking placards in the faces of politicians and shouting “single payer” enough? Can we truly organize and coordinate with the greater social justice movement? Can we convince the medical-industrial complex that they need to be active participants and even leaders in a sincere movement for health care justice for all? They are going to be there whether or not we want them involved, though we should be able to cull those who really care for patients from those who are simply after acquisition of substantial personal wealth.

Regardless, take another look at what these C-suite executives have in store for us. It is terrible for health care professionals who really do care and even worse for patients. We can do far better with the $3.2 trillion we are already spending on health care (it’s our money!) than to turn it over to the medical-industrial complex and let them do with it what they will. As these authors state, “reform remains a market-driven issue” when we know that markets are anathema to health care justice.

No more feeble organizing. Let’s have the real thing.

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America’s ranking on amenable mortality is an embarrassment

Posted by on Friday, May 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.

First-ever global study finds massive health care inequity

By the Institute for Health Metrics and Evaluation (IHME)
EurekAlert, May 18, 2017

A first-ever global study finds massive inequity of access to and quality of health care among and within countries, and concludes people are dying from causes with well-known treatments.

“What we have found about health care access and quality is disturbing,” said Dr. Christopher Murray, senior author of the study and Director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. “Having a strong economy does not guarantee good health care. Having great medical technology doesn’t either. We know this because people are not getting the care that should be expected for diseases with established treatments.”

Professor Martin McKee, from the London School of Hygiene & Tropical Medicine, who participated in the study, commented: “Using deaths that could be avoided as a measure of the quality of a health system is not new but what makes this study so important is its scope, drawing on the vast data resources assembled by the Global Burden of Disease team to go beyond earlier work in rich countries to cover the entire world in great detail, as well as the development of a means to assess what a country should be able to achieve, recognizing that not all are at the same level of development. As the world’s governments move ahead to implement the goal of universal health coverage, to which they committed in the Sustainable Development Goals, these data will provide a necessary baseline from which they can track progress.”

The United States had an overall score of 81, tied with Estonia and Montenegro. As with many other nations, the US scored 100 in treating common vaccine-preventable diseases, such as diphtheria, tetanus, and measles. But the US had nine treatment categories in which it scored in the 60s: lower respiratory infections (60), neonatal disorders (69), non-melanoma skin cancer (68), Hodgkin’s lymphoma (67), ischemic heart disease (62), hypertensive heart disease (64), diabetes (67), chronic kidney disease (62), and the adverse effects of medical treatment itself (68).

“America’s ranking is an embarrassment, especially considering the US spends more than $9,000 per person on health care annually, more than any other country,” Dr. Murray said. “Anyone with a stake in the current health care debate, including elected officials at the federal, state, and local levels, should take a look at where the US is falling short.”

The study was published today in the international medical journal The Lancet, and represents the first effort to assess access and quality of services in 195 countries from 1990 to 2015. Researchers used a Healthcare Access and Quality (HAQ) Index, based on death rates from 32 causes that could be avoided by timely and effective medical care, known as “amenable mortality.”

https://www.eurekalert.org…

***

Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015

The Lancet, May 18, 2017

Drawing from GBD 2015 (Global Burden of Diseases, Injuries, and Risk Factors Study), we constructed a novel measure of personal health-care access and quality — the HAQ Index (Healthcare Quality and Access Index) — by using highly standardised estimates of 32 different causes that are amenable to personal health care. Compared with previous efforts, the HAQ Index provides a clearer signal on personal health-care access and quality over time and place because GBD provides enhanced comparability of cause of death data, helps to account for variation due to behavioural and environmental risk factors, and includes 195 countries and territories over time. Our analysis showed large differences in personal health-care access and quality, spanning from a low of 23·1 in Ethiopia in 1990 to higher than 90 in Andorra, Iceland, Switzerland, Norway, and Sweden in 2015. The global HAQ Index improved from 40·7 in 1990 to 53·7 in 2015, and 167 of 195 countries and territories significantly increased their HAQ Index during this time. Although the HAQ Index and SDI (Socio-demographic Index) were highly correlated, we noted substantial heterogeneity for geographies at similar SDI.

The Healthcare Access and Quality Index (HAQ Index) for the highest quartile of the Socio-demographic Index (SDI):

95  Andorra
94  Iceland
92  Switzerland
90  Sweden
90  Norway
90  Australia
90  Finland
90  Spain
90  Netherlands
89  Luxembourg
89  Japan
89  Italy
88  Ireland
88  Austria
88  France
88  Belgium
88  Canada
87  Slovenia
87  Greece
86  Germany
86  Singapore
86  New Zealand
86  South Korea
86  Denmark
86  Israel
85  Cyprus
85  Qatar
85  Malta
85  Czech Republic
85  United Kingdom
85  Portugal
82  Kuwait
82  Croatia
81  Estonia
81  United States
81  Montenegro
80  Lebanon
80  Hungary
80  Poland
79  Saudi Arabia
79  Bermuda
79  Bahrain
79  Slovakia
78  Latvia
78  Taiwan
77  Puerto Rico
77  Lithuania
76  Macedonia
76  Chile
75  Serbia
74  Romania
74  Belarus
74  Cuba
73  Ukraine
72  United Arab Emirates
72  North Mariana Islands
72  Russia
71  Bulgaria
71  Greenland
70  Virgin Islands
70  Brunei
68  Argentina
68  Armenia
67  Barbados
67  Antigua and Barbuda
67  Malaysia
66  Seychelles
64  Azerbaijan
64  The Bahamas
63  Guam
62  Georgia
62  Trinidad and Tobago
61  Kazakhstan
58  Grenada
58  Turkmenistan

The full PDF of this Lancet article (36 pages) can be downloaded for free at this link:
http://www.thelancet.com…

This study establishes a new landmark in health policy research. It provides a basis of determining how all nations are doing in reducing premature deaths by providing timely and effective health care, that is, in improving their “amenable mortality” rates.

To no surprise for those who follow health policy, the Healthcare Access and Quality Index (HAQ Index) for the United States falls about in the middle of nations in the highest quartile of the Socio-demographic Index (SDI). Although our per capita spending on health care is about twice the average of these nations, our access and quality are only average. We do not have the best health care system in the world, in spite of what reform opponents say.

As Christopher Murray, a senior author of this study, states, “America’s ranking is an embarrassment.” Look at the countries that rank above us. If, like them, we used our public resources more effectively we would no longer have to be ashamed of our performance. Just through the tax system alone we are already spending more per capita than almost all of the other nations do in both public and private spending combined.

It’s not that we need to make a decision to finance health care through our taxes; we already largely do that. Instead we need to improve the allocation of our tax funds plus our private spending. We can do that best by enacting and implementing a well-designed single payer national health program – an improved Medicare for all. With all that we are spending, we should be at the top of the list.

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Health care legislation being shaped in secrecy

Posted by on Thursday, May 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.

Secret Republican Senate Talks Are Shaping Health Care Legislation

By Susan Davis
NPR, May 15, 2017

The Senate is negotiating its own legislation to repeal and replace much of the Affordable Care Act in secret talks with senators hand-picked by party leaders and with no plans for committee hearings to publicly vet the bill.

Most Republicans see no political advantage to attempting to craft bipartisan legislation that could aid vulnerable Red State Senate Democrats heading in to the midterm elections. In other words, there is mutual disinterest in bipartisanship when it comes to the fundamentals of Obamacare.

The GOP health care talks are expected to roll through the summer months in the Senate. The long-term strategy — according to senior GOP aides in both the House and Senate — is to pass a Senate bill and send it back to the House for an up-or-down vote.

http://www.npr.org…

***

Hope You Don’t Expect The Senate GOP To Be Transparent About Obamacare Repeal

By Jonathan Cohn
HuffPost, May 13, 2017

House leaders wrote legislation privately and then pushed it through the two committees of jurisdiction with markup sessions that lasted just one day each. Leaders had to pull the bill from the House floor at the last minute, because it lacked enough support to pass, but their response was to return to private negotiations, hash out the additional amendments, and then proceed quickly with the final vote.

Of course that was precisely what House Speaker Paul Ryan (R-Wis.) and his allies were trying to accomplish ― to avoid public scrutiny, to get legislation through the House before either the media or the public could recognize and seize on its shortcomings. Now it looks like Senate Republicans are intent upon doing the same thing.

Democrats are furious, in part because most of them were around in 2009 and 2010 when they spent more than a year writing and debating what eventually became the Affordable Care Act. For all of the discussion that took place behind closed doors back then, quite a lot took place in public ― over the course of more than 130 hearings, spanning five committees, according to a Democratic tally that didn’t even include administration events like the daylong, bipartisan session at Blair House that President Barack Obama presided over personally.

The deciding factor could be public reaction, but the public can’t react to a bill unless it gets a good look at it. It appears Republican leaders are trying not to let that happen.

http://www.huffingtonpost.com…

Health policy is difficult enough for the public to understand without our politicians going behind closed doors to hash it out. As Jonathan Cohn states, “The deciding factor could be public reaction, but the public can’t react to a bill unless it gets a good look at it.”

Polls do show that the public is reacting favorably to the policy features of single payer. They understand that an improved Medicare for all would bring each of them essential health care that is affordable and that allows free choice of health care professionals and hospitals. Many even believe that health care should be a right, but they don’t have to believe that as long as they themselves can be assured of life-long affordable access to essential health care services.

Maybe someone should slip under the Senators’ door the Physicians’ Proposal, so that they can take a good look at it in privacy.

A Physicians’ Proposal for Single-Payer Health Care Reform:
http://www.pnhp.org/nhi

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2017 Milliman Medical Index: $27,000

Posted by on Thursday, May 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 Chris Girod, Sue Hart, Scott Waltz
May 2017

In 2017, the cost of healthcare for a typical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan is $26,944, according to the Milliman Medical Index (MMI).

Key findings of the 2017 MMI include:

1. The MMI’s annual rate of increase is 4.3%. This is the lowest rate since we began tracking the MMI in 2001. Yet the total dollar amount is still bracingly high. Of the $26,944 spent by the MMI’s family of four, $11,685 is paid by the employee, through a combination of $7,151 in payroll deductions for premium, and $4,534 in out-of-pocket costs incurred at time of care.

2. Prescription drug trends are lower, but still high. For the first time since 2013 and 2014, the family of four’s prescription drug trends have decreased in two consecutive years. Still, the 2017 prescription drug cost increase of 8% is more than double the medical increase of 3.6%.

3. Employees pay a bigger piece of the healthcare cost pie. Through their payroll deductions and through out-of-pocket expenses incurred when care is received, employees now pay for about 43% of expenses and employers pay the other 57%. The difference between these two shares has gradually narrowed since 2001, when employees contributed 39% and employers contributed 61%. High growth in per-employee healthcare expenditures have pushed employers to limit their contribution increases to amounts below the rate of healthcare inflation.

Some stakeholders have held out hope that federal healthcare reform efforts would help control healthcare cost growth. So far, those efforts have had relatively little direct impact on the MMI, because the MMI represents healthcare costs in an employer-sponsored health plan, while the primary focus of healthcare reform has been on the individual insurance marketplace and Medicaid. The employer market tends to be one of the most stable markets for health insurance companies, and one of the most financially important for healthcare providers such as hospitals and physicians. As discussed in a later section of this report, providers receive higher payment for patients in employer-sponsored plans, for the exact same basket of services, than they do for other insured patients. Employers and employees have been subsidizing other markets for many years.

Footnote 1: The Milliman Medical Index is an actuarial analysis of the projected total cost of healthcare for a hypothetical family of four covered by an employer-sponsored preferred provider organization (PPO) plan. Unlike many other healthcare cost reports, the MMI measures the total cost of healthcare benefits, not just the employer’s share of the costs, and not just premiums. The MMI only includes healthcare costs. It does not include health plan administrative expenses or insurance company profit loads.

http://us.milliman.com…

Much attention is paid to premiums and deductibles of insurance plans in the United States. A much more important number is what we are actually paying for health care. The Milliman Medical Index (MMI) represents the total average cost of actual health care for a hypothetical family of four with an employer-sponsored PPO. For 2017, that cost is $26,944 ($27,000 rounded – the number to remember).

Although not comparing identical population sectors, nevertheless the burden of health care costs can be approximated by contrasting the MMI with the median household income, which is $56,516 for 2015 – thus health care costs for a typical family of four are close to one-half of the median household income.

Of interest is the fact that the MMI does not include plan administrative expenses nor insurance company profits – just health care costs (the portion of the premium nominally paid by the employer, the portion of the premium paid by the employee through payroll deductions, and the out-of-pocket medical expenses paid by the employee). Also the percentage that families nominally pay has been increasing – now 43 percent – though they also actually pay for the employers’ contributions as well through forgone wage increases. Also, though the increase in the MMI from last year was only 4.3 percent, in dollars it is an $1118 increase – an amount that would add an additional significant burden to most household budgets.

Although current negotiations for replacement health care legislation are taking place behind closed doors, numerous sources have indicated that the most important goal stated by the negotiators is to reduce the premiums paid for insurance. Very little attention is being paid to actual health care costs (except for rhetoric about markets and competition, which has very little application to health care spending).

Why this emphasis on premiums? Frankly, when people need to buy health insurance, they want to know what it is going to cost them. For the 80 percent of people who remain relatively healthy, that means that they want to know what the premium, or their share of the premium, will be. Studies have shown that the healthy will accept higher deductibles and narrower networks in order to get lower premiums.

So how do you keep premiums low? You shift the costs from the insurer to the patient, and there are several methods of doing that, all of which are currently under consideration.  As mentioned, the most obvious is to increase the deductibles, and that is why we are now seeing deductibles in the thousands of dollars. Other cost sharing such as copayments and coinsurance also shift costs to the patients. The negotiators are also considering reducing the essential health benefits that the plans are required to cover so that individuals can “buy only the insurance that they need.” Not only does this defeat the purpose of pooling risk, but nobody can predict their own health care requirements for the following year, so benefits omitted again would have to be covered out-of-pocket by the patient. Also insurers can reduce spending by establishing narrow networks and contracting with the cheapest providers, but sometimes care must be obtained out-of-network, and, again, that shifts costs to the patients. Tiering of benefits is used to place more expensive benefits in a higher tier level for which the patient must bear a much greater out-of-pocket cost (not to mention that it discourages individuals who will need the expensive services or products from purchasing those plans, saving the insurer money, thus lowering premiums). In essence, you lower the price of insurance premiums by destroying the insurance function of sharing risk equitably. Is this really what Americans want?

Making health care less affordable for patients has two adverse consequences: it creates financial hardships for patients who cannot avoid expensive health care, and it causes patients to forgo beneficial health care services that they really should have, thus impairing health outcomes.

A well designed single payer national health program avoids both of these consequences while using policies that are even more effective in slowing the increases in actual health care spending (substantial reduction in administrative waste, global budgeting of national health expenditures, separate, more effective budgeting of capital improvements and system capacity, negotiated and administered budgets for hospitals and other institutions, and negotiated rates for health care professionals, pharmaceuticals, and medical supplies).

When they talk about premiums and say it’s about “access” (but remain silent on paying for health care), challenge them. It’s about health care reform that works for all of us – an improved Medicare for all.

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Expansion of the Mexico City Policy

Posted by on Tuesday, May 16, 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.

Trump to Expand Funding Ban Tied to Abortion Overseas

By Gardiner Harris and Somini Sengupta
The New York Times, May 15, 2017

The Trump administration said on Monday it would vastly expand the so-called global gag rule that withholds American aid from health organizations worldwide that provide or even discuss abortion in family planning. The new policy could disrupt hundreds of clinics in Africa and around the world that fight AIDS and malaria.

It affects about $8.8 billion in global health funding, up from about $600 million during the administration of President George W. Bush.

The rules, issued by the State Department, mean that any foreign nongovernmental group that wants American money for any of its health activities — from AIDS treatment to malaria prevention to safe childbirth practices — must promise not to “promote abortion as a method of family planning.” Already, American taxpayer dollars cannot be used for abortion services abroad.

The global gag rule was introduced by President Ronald Reagan in 1984 at the International Conference on Population in Mexico City, and is also known as the Mexico City Policy. Since then, Republican administrations have kept or reimposed it, while Democratic ones have rescinded it.

Mr. Bush visited Botswana and Namibia only last month to highlight the need for aid under the President’s Emergency Plan for AIDS Relief, or Pepfar, to treat cervical cancer. He also argued that care for cervical cancer should be provided right along with care for H.I.V.

But under the policy announced Monday, that could be impossible.

The policy “risks undoing years of progress on women’s health in Pepfar countries,” said Asia Russell, executive director of the Health Global Access Project, a public health group.

https://www.nytimes.com…

***

Background Briefing: Senior Administration Officials on Protecting Life in Global Health Assistance

U.S. Department of State, May 15, 2017

MODERATOR: Thank you very much, and thanks to all those who have joined us for this afternoon’s call. This will be an on-background conference call on Protecting Life in Global Health Assistance. I’ll introduce our participants this afternoon, but as a reminder, for attribution they will be senior administration officials, and the rules for this call will be on background.

Today we are joined by [Senior Administration Official One]. We are also joined by [Senior Administration Official Two], and finally, by [Senior Administration Official Three].

SENIOR ADMINISTRATION OFFICIAL ONE: Thank you, [Moderator], and good afternoon.

On January 23rd, 2017, President Trump issued a presidential memorandum reinstating the 2001 presidential memorandum on the Mexico City policy, and directed the Secretary of State to implement a plan to extend to the extent allowable by law the Mexico City policy to global health assistance furnished by all departments or agencies.

Secretary Tillerson has approved a plan to implement the manner in which U.S. Government departments and agencies will apply the provisions of the Mexico City policy to foreign nongovernmental organizations that receive U.S. funding for global health assistance. The policy, now known as Protecting Life in Global Health Assistance, implements what the President has made very clear: U.S. taxpayer money should not be used to support foreign organizations that perform or actively promote abortion as a method of family planning in other nations.

Under this policy, global health assistance includes funding for international health programs, such as those for HIV/AIDS, maternal and child health, malaria, global health security, family planning, and reproductive health. Protecting Life in Global Health Assistance applies to global health assistance to or implemented by foreign NGOs, including those to which a U.S. NGO makes a sub-award with such assistance funds.

Once all appropriate steps have been taken, the policy will apply to all new funding agreements, grants, cooperative agreements, and contracts, and gradually to existing agreements when they are amended to add funding.

Protecting Life in Global Health Assistance applies to approximately $8.8 billion in funds appropriated to the Department of State, the U.S. Agency for International Development, and the Department of Defense. Previously, the policy applied only to family planning assistance provided by USAID and the Department of State.

Given the expansive nature of the new policy, the department will undertake a thorough and comprehensive review of the effectiveness and impact of the policy’s application over the next six months, which could include identifying implementation issues and any other new information affecting implementation going forward. Newly covered programs, including PEPFAR, the President’s Malaria Initiative, and other global health programs, will be given special attention under this review.

MODERATOR: And with that, we’ll open this up for questions. Thank you.

OPERATOR: Ladies and gentlemen, once again, it’s *1 for questions. And our first question will come from the line of Yeganeh Torbati of Reuters. Please, go ahead.

QUESTION: Thanks so much. A couple quick questions: Can you – you said that now it applies to $8.8 billion in funding. Other – some critics have said and I’ve seen the wording that previously it applied to $600 million in funding. Can you confirm that? And also, you mentioned that PEPFAR and the malaria – the President’s Malaria Initiative are new programs that will be added to this or newly covered under this. Can you name a few other specific programs that weren’t covered before and now will be? Thank you.

SENIOR ADMINISTRATION OFFICIAL ONE: Okay, thank you very much. Yes, the $8.8 billion includes primarily the PEPFAR program, which is approximately $6 billion. Additional funding included in this $8.8 billion is USAID family planning, reproductive health, maternal health, and other types of programs.

The $600 million figure that you mentioned was approximately the amount of money that was covered under the previous Mexico City policy that only affected USAID’s and State Department’s family planning program.

SENIOR ADMINISTRATION OFFICIAL THREE: Just to add on, the other programs affected also would include exactly as [Senior Administration Official One] said – the maternal child health programs, malaria, PEPFAR, as well as other infectious disease programs and the full array of global health assistance provided through USAID.

OPERATOR: Okay. Next, we’ll go to the line of Jina Moore of BuzzFeed.

QUESTION: And just a quick follow-up. I know this came up a little earlier, but can you talk a little bit more specifically about how you will measure compliance?

SENIOR ADMINISTRATION OFFICIAL THREE: So compliance is measured by the ongoing monitoring of programs, right. We do – typically we do visits to our partners on a regular basis, and [Senior Administration Official Two] can talk about this more specifically with regard to PEPFAR. But it is certainly routine visits, if you will, routine monitoring of what the programs are doing, paying attention to what kinds of information they – the partners put out in the general press and those kinds of things. So it really is part of the routine monitoring.

SENIOR ADMINISTRATION OFFICIAL TWO: Just to pick up on that, and this is talking from the PEPFAR standpoint, we’ve extended our monitoring very much down to the site of where we deliver services. We think that’s absolutely critical. So our – both our U.S. Government personnel who are in country as well as our large implementing partners and host governments actually go to the sites. And we require quarterly reporting from the sites so we know exactly what’s being provided at the site, the gender of the person receiving those services, and the age band that they’re in so that we can monitor the quality of our services. So this would be one more element of monitoring. So I just want to really make it clear that this is not new to us about ensuring quality global health assistance services provisions, whether it’s for TB, HIV, malaria, or immunizations. So that’s a standard component of our program, to ensure high quality of services that the U.S. Government funds.

OPERATOR: Thank you. And now we have Rachel Oswald of the Congressional Quarter.

QUESTION: Okay, great. What, if any, outreach was had with PEPFAR receiver countries, the governments there, like Uganda, about the expansion of the Mexico City policy? And what feedback did those foreign governments give to you about any concerns they may have about the new policy?

SENIOR ADMINISTRATION OFFICIAL TWO: Yeah, thank you. So we’re in dialogue with our countries all along about implementation of PEPFAR, because obviously this is done in cooperation with host governments but also civil society. So I think we were waiting for the guidance from the Secretary; so now that we have guidance on the implementation, we will circle back to all of our countries.

And we have, of course, people in all of our countries well-represented by the ambassadors that are in that country from the U.S. State Department, who are poised to talk immediately to our host countries but also to our communities and civil society, because we implement all of our programs in conjunction both with the host government but also the communities that we’re serving.

MODERATOR: All right. If there are no further questions, as one final reminder, attribution for today’s call is on background to senior administration officials. And now that this call has concluded, the embargo is lifted. Thanks very much, everyone. Have a nice day.

U.S. Department of State Background Briefing:
https://www.state.gov…

U.S. Department of State Fact Sheet:
https://www.state.gov…

PEPFAR – The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) is the U.S. Government initiative to help save the lives of those suffering from HIV/AIDS around the world:
https://www.pepfar.gov…

Today’s topic is not on abortion per se, but rather it is on Donald Trump’s expansion of Ronald Reagan’s Mexico City Policy, which pertains to abortion, and the impact this will have on George W. Bush’s Emergency Plan for AIDS Relief (PEPFAR). So what are these programs?

The global gag rule introduced by President Reagan in 1984 at the International Conference on Population in Mexico City prohibited foreign nongovernmental organizations that receive U.S. aid funds from promoting abortion as a method of family planning.

PEPFAR is an important public health program initiated by President Bush which has helped to stem the world-wide epidemic of HIV/AIDS.

President Trump has expanded the Mexico City Policy to apply to PEPFAR. Since it is virtually impossible to eliminate all references to termination of pregnancy from the PEPFAR program, this means that about $6 billion of U.S. aid will be denied to this program. That can have only tragic results in turning back some of the progress we have made in countering the scourge of HIV/AIDS.

This is highly nefarious, and the Trump administration seems to understand that. Look at the excerpts from the State Department teleconference announcing the expansion of the Mexico City Policy. Although they introduced three senior officials to explain the expansion, they established rules for attribution in which these administrators would be referred to only as SENIOR ADMINISTRATION OFFICIAL ONE, SENIOR ADMINISTRATION OFFICIAL TWO, and SENIOR ADMINISTRATION OFFICIAL THREE. That’s bizarre. Is this to protect these administrators from potential personal attacks? If so, they seem to understand that there must be considerable passionate opposition to this policy change. Or is this simply more evidence of this dysfunctional administration simply moving forward with the implementation of obviously detrimental policies while  trying to hide in order to avoid blame? Clearly they are not attempting to invite accolades.

This is really sad. As we try to advocate for health care for all in America, how can we expect to make any progress when we have a Congress and an Administration that are tearing down our fortresses of health care justice – here, and throughout the world.

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