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About that actuarial value

About that actuarial value

Marketplace Plans Provide Risk Protection, But Actuarial Values Overstate Realized Coverage For Most Enrollees

By Maria Polyakova, Lynn Mei Hua, and M. Kate Boundary
Health Affairs, December 2017

Abstract

The Affordable Care Act (ACA) has increased the number of Americans with health insurance. Yet many policy makers and consumers have questioned the value of Marketplace plan coverage because of the generally high levels of cost sharing. We simulated out-of-pocket spending for bronze, silver, or gold Marketplace plans (those having actuarial values of 60 percent, 70 percent, and 80 percent, respectively). We found that for the vast majority of consumers, the proportion of covered spending paid by the plans is likely to be far less than their actuarial values, the metric commonly used to convey plan generosity. Indeed, only when annual health care spending exceeds $16,500 for bronze plans, $19,500 for silver plans, and $21,500 for gold plans do plans in these metal tiers cover the proportion of costs matching their actuarial values. While Marketplace plans substantially reduce consumers’ exposure to financial risk relative to being uninsured, the use of actuarial values to communicate plan generosity is likely to be misleading to consumers.

From the Introduction

While the Affordable Care Act (ACA) has increased the number of Americans with health insurance, policy makers and consumers have questioned the value of Marketplace coverage because cost sharing in many plans is generally high. In a recent survey, 22 percent of people who purchased health insurance on their own reported having problems paying medical bills; copayments, deductibles, and coinsurance were the most frequently reported sources of problems.

The standard metric for measuring the generosity of a plan’s coverage is the plan’s actuarial value—that is, the ratio of a plan’s covered spending that is paid for by the plan, divided by the plan’s total covered spending for a standardized population. For example, an actuarial value of 70 percent indicates that for a standardized population, enrollees as a group pay 30 percent of total covered expenditures out of pocket, and the plan pays 70 percent. For Marketplace plans, actuarial values are used to define product tiers. Bronze plans must have an actuarial value of 60 percent, while silver, gold, and platinum plans must have actuarial values of 70 percent, 80 percent, and 90 percent, respectively—although as of 2018 some variation (from 4 percent below to 5 percent above the value, depending on the metal tier) is permitted.

Metal levels and their corresponding actuarial values are intended to provide standardized information on coverage generosity to help consumers choose among plans. The actuarial value simplifies cross-plan comparisons by aggregating complex cost-sharing features—including deductibles, copays, and coinsurance (which can vary across types of health care services)—into a single metric based on out-of-pocket spending. Using a standardized population for the calculation ensures that differences in actuarial values across plans are not driven by differences in the types of people enrolled.

In practice, however, the effect of cost sharing on out-of-pocket spending can vary substantially across people based on the number and types of services they use. As a result, the actuarial value, which is calculated at the population level, might not accurately represent the proportion of covered expenditures paid by a plan for any given enrollee. The distinction between population- and individual-level measurement, however, is often overlooked in the popular media and even in some of the information that insurers provide to consumers. For example, the Blue Cross Blue Shield Blue Care Network of Michigan’s website states, “If you choose a bronze plan, overall you’ll pay about 40 percent of your health care costs, and your insurance company will pay about 60 percent. If you choose a gold plan, overall you’ll pay about 20 percent and your insurance company will pay about 80 percent.”

From the Study Results

We found that although the actuarial value accurately describes the experience of the standardized population as a whole, it does not reflect what most people experienced in their plan. For each of the three metal tiers, plans covered the fraction of the costs corresponding to their actuarial value only for enrollees who had substantial annual health care spending. For example, in the average gold plan, an enrollee would have to spend approximately $21,500 before the plan covered 80 percent of spending, its actuarial value. For the silver and bronze tiers, the spending levels required for plans to reach their actuarial value were $19,500 and $16,500, respectively. Because more than 90 percent of people had annual spending of less than $15,000, for the vast majority of enrollees, the proportion of expenditures covered by a plan would have been much lower than its actuarial value. For the enrollees with the highest spending, assumed to be those using the most services because of illness, plans in all three metal tiers covered more than 85 percent of their spending. However, very few people used that much care.

From the Discussion

While Marketplace plans provide significant financial risk protection, communicating plans’ generosity based on actuarial value may create a mismatch between coverage people expect and coverage they experience. Health care expenditures are highly skewed: As noted above, only a small percentage of people have very high spending in a given year. In other words, an adverse health event that causes very high spending is rare, but it represents a substantial financial risk. Marketplace plans provide relatively comprehensive coverage, as measured by the proportion of total expenditures they cover, for the small proportion of people who experience very high spending. The remainder of the covered population (the vast majority of enrollees) get protection from the risk of catastrophic health care expenditures but experience relatively little direct benefit from their coverage in any given year. They pay premiums but ultimately pay for most of their services out of pocket because their expenses fall below the deductible limits.

More generally, a weakness of using actuarial value is that doing so distracts consumers from the key purpose of insurance, which is financial risk protection. Actuarial value is driven by the average across the population and provides no information on the likelihood of different levels of spending or how specific consumers would fare financially under different scenarios.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The actuarial value of a health plan is the percentage of covered health care costs paid by the insurer, but for the entire population covered, not necessarily for the insured individual. As this study shows, the overwhelming majority of individuals with plans in the ACA exchanges pay a much higher percentage of their covered costs than they might expect to based on the actuarial values of their plans.

The insurers depend heavily on the amount of the deductible to adjust the actuarial values of their plans. Those with low or modest expenses will have a much smaller percentage of costs covered because of their deductibles, whereas those with high medical costs who have already exceeded the deductible will have their additional costs covered at a percentage greater than the actuarial value. Although about 80 percent of spending occurs amongst the 20 percent of individuals with high costs, the other 80 percent of us will find that a much higher percentage of our costs will be out-of-pocket because of the deductible that must be paid.

If it seems like health insurance doesn’t work very well for the 80 percent of individuals who have modest expenses, that’s because it doesn’t. Other studies have shown that modest expenses can create a financial hardship for many individuals and families. And those with higher expenses? They may have a higher percentage of the charges beyond the deductible covered, but they still have the up front out-of-pocket expenses which may constitute a hardship for many of them as well.

Why do we continue to leave in charge the private insurers who have figured out a way to pay less than the actuarial value for the care that most of us receive? It wouldn’t be an issue if we all had first dollar coverage – simply get the care we need when we need it without having to worry about deductibles and other cost sharing.

We should all have prepaid health care through a well designed single payer system instead of being victims of a numbers racket.

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The feminist case for single payer

By Natalie Shure
Jacobin, December 8, 2017

In June, Planned Parenthood of California refused to endorse a bill for a statewide single-payer system, contending that it was critical to focus on defending the Affordable Care Act (ACA) against GOP attacks instead. Vice cast it as a job-crusher for the mostly women of color who work in healthcare administration. In 2016, presidential candidate Hillary Clinton — whose campaign foregrounded her feminist credentials — famously declared single-payer would “never, ever come to pass.” More recently, Senator Bernie Sanders’s release of an expansive Medicare for All bill has been met with skepticism by media personalities who backed Clinton for her feminist credentials. At the very least, it seems clear that single-payer health care is rarely framed as a feminist issue.

Some mainstream feminists knock single payer as a distraction from the fight to defend the ACA. But while the Affordable Care Act undeniably improved some women’s lives, it could not dismantle gendered barriers to care.

Of all systems, single-payer is capable of going furthest to eliminate them. That’s the vision that Our Bodies, Ourselves adopted nearly half a century ago, and it must be taken up again today.

One of the pervasive ways women are disadvantaged under the ACA is its reliance on employer-based coverage. In the United States, World War II–era wage freezes helped entrench a system of employer-provided health insurance, a perk meant to attract workers in a squeezed labor market.

Eventually, Medicare and Medicaid were devised as a safety net for those shut out of private plans, and the ACA expanded that safety net. Still, job-based plans remain the bedrock on which our insurance system is built.

Under this system, it’s harder for women to get health insurance in the first place. The strains of childrearing and elder care make women more likely to seek more flexible employment, like part-time, remote, or freelance work. These forms of employment tend not only to pay less, but are less likely to include health insurance benefits.

Those that do provide inferior ones: companies with majority-female workforces tend to offer less generous health-care coverage than those that are majority male. And less than one-third of low-income workers receive any health insurance through work. Jobs paying at or around the minimum wage are most often occupied by women, the majority of whom are women of color. Trans women face even higher levels of poverty than cis women, and are frequently saddled with impossibly high out of pocket costs.

Then there are the 25 percent of non-elderly adult women insured as dependents of a working spouse, which weakens their control over both their insurance coverage and their relationship. Health insurance has been found to be a common reason for getting married — and for staying married when one would rather not — especially among low-income people. Upon the loss of a spouse’s coverage, it’s difficult and expensive to continue receiving the same care. COBRA coverage — a program that allows people who lose employer-based insurance to remain on it, so long as they pony up the amount formerly contributed by employers — is often the only way to maintain provider networks, but it’s wildly expensive and eventually expires. Ultimately, divorce leaves some sixty-five thousand women uninsured each year, with men being far more likely to maintain coverage after their marriages dissolve.

Women’s unpaid domestic work puts further pressure on the contradictory demands of home, work, and the need to access coverage. Women disproportionately shoulder the responsibility of caring for others, putting them in an impossible situation when it comes to child and elder care: in order to maintain health insurance, they can’t take too much time off work. As a result, they’re forced to spend a significant portion of their wages on private care for the hours they’re on the job. For low-income women who don’t qualify for insurance through employers, the problem can be severe, made worse still by right-wing efforts to impose higher copays and out-of-home work requirements on Medicaid recipients, or to defund programs like CHIP that help parents pay for their children’s health insurance.

During particularly urgent health episodes, like childbirth or a relative’s protracted illness, women opt to take unpaid time off instead of risking their jobs. Notoriously, the United States is one of only a handful of countries that doesn’t guarantee paid maternity leave, exacerbating the financial stress of an already pricey phase of life. The Labor Department has found that nearly one-third of women who take unpaid time off for their own or dependents’ health issues fall into serious credit card debt.

While state ACA exchanges offer an alternative to employer-provided plans, the exchange plans remain inferior. Both tiers of insurance are plagued by narrowing provider networks, and ever-rising out of pocket costs – leading millions to forego insurance because it’s too unaffordable, or find themselves stuck with plans they can’t even afford to use. And that’s with the ACA.

In short, the dynamics that make the American health-care system so hostile to women remain largely unscathed after the ACA: the pervasive commodification of healthcare and dependent care in the United States, coupled with employment-based gatekeeping, engineers an impossible bind for women: they face more challenges accessing the health-care system and pay more for their care when they do, out of lower incomes that are further squeezed by child and elder care costs.

By removing power over health care from employers and spouses, and replacing unequal tiers with one unified insurance pool, we could fund our health-care system with progressive taxes. That way, we could guarantee everyone the care they need, and make it free at the point of service. Ability to pay, pre-existing conditions, employment status, and gender would cease to be barriers. Building Medicare for All — with robust guarantees for tougher-to-access services like abortion and gender affirming care — would force American society as a whole to address the care disparities women face.

Natalie Shure is a TV producer and writer.

https://www.jacobinmag.com…

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Comment:

By Don McCanne, M.D.

Feminists, male and female, should be leading the way on single payer reform.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Urgent call for action on Paul Ryan’s attack on Medicare

Ryan eyes push for 'entitlement reform' in 2018

By Nathaniel Weixel
The Hill, December 6, 2017

House Speaker Paul Ryan (R-Wis.) on Wednesday said House Republicans will aim to cut spending on Medicare, Medicaid and welfare programs next year as a way to trim the federal deficit.

“We’re going to have to get back next year at entitlement reform, which is how you tackle the debt and the deficit,” Ryan said during an interview on Ross Kaminsky’s talk radio show.

Health-care entitlements such as Medicare and Medicaid “are the big drivers of debt,” Ryan said, “so we spend more time on the health-care entitlements, because that’s really where the problem lies, fiscally speaking.”

Ryan said he’s been speaking privately with President Trump, who is beginning to warm to the idea of slowing the spending growth in entitlements.

House and Senate Republicans are currently working on their plans for tax reform, which are estimated to add more than $1 trillion to the deficit. Democrats have voiced concerns that the legislation could lead to cuts to the social safety net.

Ryan is one of a growing number of GOP leaders who have mentioned the need for Congress to cut entitlement spending next year.

Sen. Marco Rubio (R-Fla.), last week, said “instituting structural changes to Social Security and Medicare for the future” will be the best way to reduce spending and generate economic growth.

Rep. Jeb Hensarling (R-Texas), chairman of the House Financial Services Committee, told Bloomberg TV that “the most important thing we can do with respect to the national debt, what we need to do, is obviously reform current entitlement programs for future generations.”

http://thehill.com…

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Comment:

By Don McCanne, M.D.

Talk about chutzpah. Speaker of the House Paul Ryan is going to reduce our nations’ debt by attacking Medicare and other social programs at the very time he is increasing the debt by reducing taxes on the very wealthy when the profound inequities in income and wealth instead mandate an increase in taxes on the wealthy. Hurting seniors and persons with disabilities with program cuts while adding to he coffers of the rich is the ultimate manifestation of chutzpah.

The traditional Medicare program has been suffering from neglect while the private Medicare Advantage plans have been pampered. Ryan and his colleagues intend to introduce premium support – a voucher that decreases in value over time. Premium support vouchers would be used to purchase private health plans that over time would shift more and more of the costs of health care to the Medicare beneficiaries themselves. Medicare already has excessive cost sharing that makes health care less affordable, and this would make it even worse. It also would give an opening to the very wealthy to abandon Medicare as they seek their own care through private payment. Losing the support of this politically powerful sector would likely mean that Medicare would be transformed into a chronically underfunded welfare program, worse than Medicaid since the benefits would be spartan as well.

Ryan and friends are using the current deficit to dictate tax policy and spending policy. Deficits are reduced by increasing revenues (taxes) and/or decreasing spending. On the spending side, our budget is already relatively austere, and further reductions would largely be harmful. On the revenue side, we need more tax income to reduce the deficit. So their solution? Increase tax revenue by reducing taxes on the wealthy?! But this is a fallacy that has been discredited time and time again – most recently by Kansas.

Tax cuts will increase the deficits which then they can use as an excuse to cut spending. Medicare and Social Security are targets for these cuts since they are such large programs. But Ryan is not waiting for the deficits to increase. He already knows that they will. So he is calling for cuts this coming year.

When tax rates are too low, future governments can adjust them. But the structural changes that they want for a privatized Medicare would be very difficult to patch in the future. Although eventually we will enact a well designed, single payer, improved Medicare for all program, in the interim, the damage that they could do to the existing Medicare program could be devastating for those with current health care needs.

The tax cut that they intend to enact before Christmas will expand deficits to the extent that a political opening will have been made for their premium support privatization program. It is imperative that we let Congress know immediately that they must block these unfair tax cuts for the rich. Then our members of Congress will need to stand firm to guard against the Medicare voucher scheme.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

The Feminist Case For Single Payer

It's time to take health care away from the power of bosses and spouses.

By Natalie Shure
Jacobin, December 8, 2017

In the spring of 1969, a dozen feminists gathered at a women’s conference in Boston and came to a sober conclusion: their encounters with the United States health-care system had been overwhelmingly negative. They felt unsettled by doctors, alienated from their bodies, grifted by fees, and altogether powerless to navigate an industry they believed objectified them just as popular culture did.

The conference launched a years-long project, with each participant delving into some aspect of anatomy, sexuality, or society related to women’s health. The result was a self-published volume of essays called Women and their Bodies, which the Boston Women’s Health Book Collective used to provide women with a resource produced from their own perspectives and experiences.

Within a few years, the landmark feminist booklet was re-dubbed Our Bodies, Ourselves, released by Simon and Schuester, and sold millions of copies. In 2012, the Library of Congress named it one of the most significant works in American history. In recent years, it has inspired Trans Bodies, Trans Selves, which similarly seeks to be a health-care guide “by and for” the transgender community.

While Our Bodies, Ourselves is remembered for its role in the history of women’s health and culture, less attention is paid to its political context. In the 1970s, the small collective became one of the first feminist organizations to demand a single-payer health-care system: “Suffice it to say that capitalism is incapable of providing good health care, both curative and preventive, for all people,” one entry read. “Cost-benefit analysis trades off the benefit to the people of collective public health in favor of the cost to the people of private, patch-up medical care. The capitalist medical care system can be no more dedicated to improving the people’s health than can General Motors become dedicated to improving the people’s public transportation.” In a subsequent edition, they expounded: “We believe that health care is a human right and that a society should provide free health care for itself . . . Health care cannot be adequate as long as it is conceived of as insurance.”

If the book’s then-radical content has so permeated mainstream culture that it would strike readers as obvious today, the same is not the case for its authors’ critique of American health care. In fact, nearly fifty years after the collective articulated its vision for a universal system, “feminist” arguments against single-payer pepper politics and the media.

In June, Planned Parenthood of California refused to endorse a bill for a statewide single-payer system, contending that it was critical to focus on defending the Affordable Care Act (ACA) against GOP attacks instead. Vice cast it as a job-crusher for the mostly women of color who work in healthcare administration. In 2016, presidential candidate Hillary Clinton — whose campaign foregrounded her feminist credentials — famously declared single-payer would “never, ever come to pass.” More recently, Senator Bernie Sanders’s release of an expansive Medicare for All bill has been met with skepticism by media personalities who backed Clinton for her feminist credentials. At the very least, it seems clear that single-payer health care is rarely framed as a feminist issue.

Some mainstream feminists knock single payer as a distraction from the fight to defend the ACA. But while the Affordable Care Act undeniably improved some women’s lives, it could not dismantle gendered barriers to care.

Of all systems, single-payer is capable of going furthest to eliminate them. That’s the vision that Our Bodies, Ourselves adopted nearly half a century ago, and it must be taken up again today.

The Double Bind

One of the pervasive ways women are disadvantaged under the ACA is its reliance on employer-based coverage. In the United States, World War II–era wage freezes helped entrench a system of employer-provided health insurance, a perk meant to attract workers in a squeezed labor market.

Eventually, Medicare and Medicaid were devised as a safety net for those shut out of private plans, and the ACA expanded that safety net. Still, job-based plans remain the bedrock on which our insurance system is built.

Under this system, it’s harder for women to get health insurance in the first place. The strains of childrearing and elder care make women more likely to seek more flexible employment, like part-time, remote, or freelance work. These forms of employment tend not only to pay less, but are less likely to include health insurance benefits.

Those that do provide inferior ones: companies with majority-female workforces tend to offer less generous health-care coverage than those that are majority male. And less than one-third of low-income workers receive any health insurance through work. Jobs paying at or around the minimum wage are most often occupied by women, the majority of whom are women of color. Trans women face even higher levels of poverty than cis women, and are frequently saddled with impossibly high out of pocket costs.

Then there are the 25 percent of non-elderly adult women insured as dependents of a working spouse, which weakens their control over both their insurance coverage and their relationship. Health insurance has been found to be a common reason for getting married — and for staying married when one would rather not — especially among low-income people. Upon the loss of a spouse’s coverage, it’s difficult and expensive to continue receiving the same care. COBRA coverage — a program that allows people who lose employer-based insurance to remain on it, so long as they pony up the amount formerly contributed by employers — is often the only way to maintain provider networks, but it’s wildly expensive and eventually expires. Ultimately, divorce leaves some sixty-five thousand women uninsured each year, with men being far more likely to maintain coverage after their marriages dissolve.

Women’s unpaid domestic work puts further pressure on the contradictory demands of home, work, and the need to access coverage. Women disproportionately shoulder the responsibility of caring for others, putting them in an impossible situation when it comes to child and elder care: in order to maintain health insurance, they can’t take too much time off work. As a result, they’re forced to spend a significant portion of their wages on private care for the hours they’re on the job. For low-income women who don’t qualify for insurance through employers, the problem can be severe, made worse still by right-wing efforts to impose higher copays and out-of-home work requirements on Medicaid recipients, or to defund programs like CHIP that help parents pay for their children’s health insurance.

During particularly urgent health episodes, like childbirth or a relative’s protracted illness, women opt to take unpaid time off instead of risking their jobs. Notoriously, the United States is one of only a handful of countries that doesn’t guarantee paid maternity leave, exacerbating the financial stress of an already pricey phase of life. The Labor Department has found that nearly one-third of women who take unpaid time off for their own or dependents’ health issues fall into serious credit card debt.

Our Health, Our Selves

None of this is to say that the Affordable Care Act was a total wash for women. The ACA’s Medicaid expansion provided public health insurance to anyone with income below 137 percent of the federal poverty line, and federal subsidies (however inadequate) to anyone making below 400 percent. Because of the gendered wage gap, the effect was to extend insurance to more women than men. The law also took on health discrimination, by mandating that men and women pay equal premiums, ending gatekeeping based on preexisting conditions or the ability to become pregnant, and requiring that plans sold on state exchanges cover maternity care and birth control.

The ACA’s overhaul of the individual insurance market has helped somewhat to delink insurance from employment. Before the ACA, reproductive-age women faced considerable difficulties getting coverage on the individual market, since insurers were free to charge sky-high premiums to hedge against the possibility of having to shell out for maternity care. But even if premiums are more highly regulated, increased cost-sharing still means that patients pay stiff prices simply for getting the care they need: reproductive-aged women still spend over 60 percent more than men do in out-of-pocket health-care costs.

At the same time, while state ACA exchanges offer an alternative to employer-provided plans, the exchange plans remain inferior. Both tiers of insurance are plagued by narrowing provider networks, and ever-rising out of pocket costs – leading millions to forego insurance because it’s too unaffordable, or find themselves stuck with plans they can’t even afford to use. And that’s with the ACA.

In short, the dynamics that make the American health-care system so hostile to women remain largely unscathed after the ACA: the pervasive commodification of healthcare and dependent care in the United States, coupled with employment-based gatekeeping, engineers an impossible bind for women: they face more challenges accessing the health-care system and pay more for their care when they do, out of lower incomes that are further squeezed by child and elder care costs.

By removing power over health care from employers and spouses, and replacing unequal tiers with one unified insurance pool, we could fund our health-care system with progressive taxes. That way, we could guarantee everyone the care they need, and make it free at the point of service. Ability to pay, pre-existing conditions, employment status, and gender would cease to be barriers. Building Medicare for All — with robust guarantees for tougher-to-access services like abortion and gender affirming care — would force American society as a whole to address the care disparities women face.

https://www.jacobinmag.com…

For-profit financing of health care is bad for our nation’s health

By Marsha Fretwell, M.D.
Citizen Times (Asheville, N.C.), December 7, 2017

Over the last several months, we have been reading, almost daily, about the payment negotiation conflict between Mission Hospital and Blue Cross Blue Shield of North Carolina. Now we are asked to feel gratitude and relief that this conflict is resolved and we are allowed to go back to “status quo.” But what is our “status quo” for health care in our country? What impact does this type of maneuvering for more profits have on the physical, emotional and spiritual health of our citizens?

Our true “status quo” for health care in the United States is that overall, as a country, we spend more money for poorer health outcomes. Providers of care at all levels are chronically stressed and choosing to leave their practices. We, the patients, have the ever increasing anxiety of obtaining and affording health care coverage in our current for-profit system. We have all of this anxiety, not mentioning, of course, the risk of financial bankruptcy even if one should have to use that insurance.

Humans have a very elaborate and effective physical and emotional system for dealing with life threatening stress which is known as the “Fright or Flight” response. The downside of this system is that when fear and anxiety become chronic and unrelenting, the chemicals produced begin to break down normal tissues and we are more likely to become ill, both physically and emotionally.

The result: The “status quo” profit driven financing of health care is literally causing our citizens physical and emotional illness, driving up the their need for services which they already know they cannot afford.

Finally, what about the spiritual health of our country? Recently, Terry Hash, a resident of Black Mountain who is a member of HealthCare for All WNC, wrote an excellent letter to the editor reviewing a recent presentation by a panel of faith leaders representing Christian, Jewish, Muslim, and Ethical Humanist traditions. All of them stated that caring for the sick, the poor and vulnerable were universally central to their moral tradition and practice.

I would suggest that just living in a country where the poor, sick and vulnerable are increasingly stressed for their survival is eroding the overall spiritual health of our country. History tells us that if we do not care for the vulnerable, we will become the vulnerable.

Polls indicate that a majority of citizens in the United States support a health care system in their country that is: affordable, excellent and supportive of patients and practitioners. Our current for-profit financing system has eroded all of these goals.

So, think systems change. Imagine a system where your dollars go to support excellent physical, emotional and spiritual health for yourselves, your families, your friends and for all citizens of the United States rather than the exorbitant profits for a company’s CEO and share holders.

Dr. Marsha Fretwell is a longtime member of Physicians for a National Health Program. Retired from active practice in geriatric medicine, she is now activity working with Healthcare for All of Western North Carolina seeking fundamental change in the financing of health care.

http://www.citizen-times.com…

National Health Expenditures for 2016

National Health Care Spending In 2016: Spending And Enrollment Growth Slow After Initial Coverage Expansions

By Micah Hartman, Anne B. Martin, Nathan Espinosa, Aaron Catlin, and The National Health Expenditure Accounts Team
Health Affairs, January 2018 (Online December 6, 2017)

Abstract

Total nominal US health care spending increased 4.3 percent and reached $3.3 trillion in 2016. Per capita spending on health care increased by $354, reaching $10,348. The share of gross domestic product devoted to health care spending was 17.9 percent in 2016, up from 17.7 percent in 2015. Health spending growth decelerated in 2016 following faster growth in 2014 and 2015 associated with coverage expansions under the Affordable Care Act (ACA) and strong retail prescription drug spending growth. In 2016 the slowdown was broadly based, as spending for the largest categories by payer and by service decelerated. Enrollment trends drove the slowdown in Medicaid and private health insurance spending growth in 2016, while slower per enrollee spending growth influenced Medicare spending. Furthermore, spending for retail prescription drugs slowed, partly as a result of lower spending for drugs used to treat hepatitis C, while slower use and intensity of services drove the slowdown in hospital care and physician and clinical services.

Out-of-pocket Spending

Total out-of-pocket spending (which includes all direct consumer payments such as copayments, deductibles, coinsurance, and spending for noncovered services) increased 3.9 percent in 2016 — the fastest rate of growth since 2007 and higher than the average annual growth of 2.0 percent in 2008–15. In 2016, out-of-pocket spending continued to account for 11 percent of all health care spending, unchanged since 2012.

In 2014 and 2015, out-of-pocket spending grew just 1.5 percent and 2.8 percent, respectively. Growth in both years was affected by changes in health insurance coverage, as the number of uninsured people (who pay out of pocket for a majority of their health care costs) was reduced from 44.2 million in 2013 to 29.5 million in 2015. Concurrently, however, increased utilization resulting from enrollment expansion and an ongoing shift toward enrollment in high-deductible health plans led to more out-of-pocket spending. In 2016, 29 percent of covered workers were enrolled in these high-deductible plans, up from 24 percent in 2015 and 20 percent in 2014, making these plans a likely contributor to the faster growth in out-of-pocket spending in 2016. At the same time, average private health insurance deductibles for single coverage plans increased 12 percent in 2016, compared to 8 percent in 2015 and 7 percent in 2014.

Notably, hospital services experienced more rapid growth in out-of-pocket spending in 2016, with a 4.8 percent increase in such spending following declines of 5.1 percent and 2.8 percent in 2015 and 2014, respectively. This faster growth in 2016 was below the longer-term average annual growth rate of 6.8 percent in 2008–13. The decreases in out-of-pocket hospital spending in 2014 and 2015 were due in part to the expansion in health insurance coverage, while hospitals’ uncompensated care costs declined. In 2016, out-of-pocket spending grew the fastest for durable medical equipment (6.9 percent) and declined for retail prescription drugs (−1.0 percent).

Conclusion

Within the ten-year period 2007–16, the US experienced, among other events, the most severe economic recession since the Great Depression, followed by a mild economic recovery; medical price inflation that was at historic lows; and major changes to the health care system associated with the ACA. During these years, health care spending increased at the lowest rates in the history of the National Health Expenditure Accounts, but low economic growth led to an increase of 2.0 percentage points in the share of the economy devoted to health care, from 15.9 percent in 2007 to 17.9 percent in 2016. The resulting average increase of 0.2 percentage point per year is nearly equal to the historical annual average over the past half-century.

In 2016, as expected, health care spending growth slowed following the major expansion of health insurance coverage in 2014 and 2015, when the ACA expanded eligibility for the Medicaid program and provided access to private health insurance Marketplaces. The insured share of the population stabilized at 91 percent in 2016, the same as for 2015 but higher than the shares of 89 percent in 2014 and 86 percent in 2013. Not surprisingly, federal government spending grew more slowly in 2016, as the initial impacts of enrollment expansion were realized and Medicaid enrollment growth (particularly for the newly eligible) decelerated. At the same time, private health insurance spending growth slowed, as enrollment growth decelerated and the impact of new hepatitis C drugs lessened.

The slower growth in health care spending in 2016 was more in line with the average annual rate of growth during the period 2008–15 and was higher than growth for the overall economy. Because the unique factors that influenced the health sector over the past decade did not have as great an effect in 2016, this may be an initial indication that this year marks a return to the more typical relationship between annual rates of growth in health care spending and growth in nominal GDP. As a result, future health care expenditure trends are expected to be mostly influenced by changes in economic conditions and demographics, as has historically been the case.

https://www.healthaffairs.org…

CMS.gov – National Health Expenditure Accounts (NHEA):
https://www.cms.gov…

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Comment:

By Don McCanne, M.D.

The numbers to remember for health care spending in 2016:

National Health Expenditures (NHE): $3.3 trillion
NHE per capita: $10,348
NHE as percent of GDP: 17.9%

The overall findings are pretty much as expected. We have moved past the Great Recession. The increase in spending due to the surge in enrollment in Medicaid and in the ACA exchanges has now leveled off. For pharmaceuticals, the surge in spending for hepatitis C drugs is leveling off. Our total national health expenditures continue to consume an ever greater part of our GDP – now about 18 percent (from 15.9 percent in 2007 to 17.9 percent in 2016).

One item of concern is the out-of-pocket spending. It “increased 3.9 percent in 2016 — the fastest rate of growth since 2007.”

Greater enrollment in high-deductible health plans led to more out-of-pocket spending. “In 2016, 29 percent of covered workers were enrolled in these high-deductible plans, up from 24 percent in 2015 and 20 percent in 2014, making these plans a likely contributor to the faster growth in out-of-pocket spending in 2016. At the same time, average private health insurance deductibles for single coverage plans increased 12 percent in 2016, compared to 8 percent in 2015 and 7 percent in 2014.”

Consumer-directed health care (high deductibles) is impairing the financial security of patients.

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Key Questions When Considering a State-Based, Single-Payer System

Introductory letter: Asking the important questions

By Sandra Hernandez, M.D., President and CEO
California Health Care Foundation, November 2017

California’s health care system has made great strides under the Affordable Care Act. Among many signs of progress, the state’s uninsured rate has been cut in half to 8.5%. Universal coverage in California is finally within reach, a goal that seemed like a long shot just five years ago.

Even with this progress, much work remains. Every Californian should be covered with a comprehensive set of benefits. We can and should do this while also ensuring that care is both affordable to California consumers and that the state’s health care budget does not crowd out other key state investments. Care must be easy to access, evidence based, and patient centered – regardless of a person’s place of residence, race or ethnicity, or type of health insurance.

Achieving universal coverage alone will not get us there, but the reforms needed to tackle costs, access, and quality are more likely to be successful when everyone is already included in the system.

There are many policy approaches to achieve universal coverage. Over the past year, mirroring growing national interest around a single payer system, there has been increasing momentum in California to create a state-based single-payer system. Our health care system affects tens of millions of lives, provides hundreds of thousands of jobs, and costs hundreds of billions of dollars each year. Any time major reforms to that system are proposed, a rigorous analysis is warranted.

The California Health Care Foundation (CHCF) commissioned this paper to provide a basic understanding of the core features of a state-based single-payer system as well as the major issues and values at play in the creation of such a system. The report does not take a stance, nor does it analyze specific single-payer legislation or proposals. Instead, it provides a baseline understanding of what a “single-payer” system is, what it isn’t, and what it might mean for California.

Like any policy, the feasibility and effectiveness of a state-based single-payer system in California ultimately depends on the problem it is attempting to solve. Different goals trigger different tradeoffs, as well as a variety of nuanced implementation choices. The paper surfaces what some of these tradeoffs might be. In doing so, it raises key questions that need to be answered about any single-payer proposal for California. Some of these questions are the same questions that should be asked about any major health care reform policy; others are more specific to implementation of a single-payer system.

It is our intention that this publication be a valuable resource across the political spectrum, as California’s Select Committee on Health Care Delivery Systems and Universal Coverage, and other key stakeholders, grapple with how to best move our health care system forward.

Regardless of your views on single payer, we encourage you to ask the important questions and consider the opportunities and challenges they present. By taking that approach together, we can start to gain clarity about what we are ultimately trying to achieve with further health care reforms – and what it will take to get there. This will only strengthen California’s chances of success, no matter what path we ultimately take to achieve universal coverage.

Full report (28 pages):
http://www.chcf.org…

***

Comment:

By Don McCanne, M.D.

Although this paper was written for California, most of the questions posed apply to any state that is considering enactment of a single payer system. It is specifically targeted to the Select Committee on Health Care Delivery Systems and Universal Coverage established by Assembly Speaker Anthony Rendon when he put on hold SB 562 – a single payer bill – because it was “woefully incomplete.”

Although the paper is not exciting reading for those well versed in single payer, its mere existence is of much greater significance. The California Health Care Foundation, which sponsored this report, was one of two foundations established when Blue Cross converted to a for-profit corporation and was required to return to Californians the tax benefits it had accrued as a nonprofit. The founding President and CEO, Mark Smith, had adamantly refused to cooperate with any consideration whatsoever of the single payer concept.

How far we have come. Sandra Hernandez, the current CHCF President and CEO acknowledges that much more must be done beyond the Affordable Care Act. By commissioning this paper on a state-based single payer system CHCF recognizes the need “to provide a basic understanding of the core features of a state-based single-payer system as well as the major issues and values at play in the creation of such a system.”

The report states, “A single-payer health care system in California could help the state meet a number of goals — universality of health care coverage, comprehensiveness of coverage, greater equity, greater access and quality, improved affordability, lower administrative costs, and slower growth in health care costs.” No other model of reform can meet those goals.

This is more evidence of the fact that single payer has now become politically feasible.

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‘Medicare for all’ proponents state their case

By Doug Hanneman
Litchfield (Minn.) Independent Review, Dec. 5, 2017

Nov. 1 was a day of relief for Gene Chrast. It was his 65th birthday, the first day he was entitled to Medicare benefits.

Retiring in 2009 after 38 years at 3M, Chrast, who lives in Meeker County, had been frustrated by his health insurance for too long. A couple years earlier, in an effort to shrug the tax impact of buying health coverage through MNsure, he turned to a broker, who found the only plan available to him on the open market. The down side: His doctor and the three nearest hospitals were out of network.

“I couldn’t come to Hutchinson, I couldn’t go to Glencoe, I couldn’t go to Litchfield,” Chrast told an audience attending a health care presentation Sunday at the Hutchinson Event Center.

“I could go to a clinic in Litchfield, and the doctor there told me, ‘Well, just call your insurance company and we’ll have your work done at the hospital there.’ He didn’t know they wouldn’t accept that.”

Chrast’s experience was familiar to the presentation’s hosts, Dr. Ken Engelhart and his wife, Carol, a registered nurse.

“People are happier and relieved when they get on Medicare,” Engelhart said. In all his years of practicing medicine, he noted, he never heard a patient wish to return to a private, employer-provided health plan.

The Engelharts, who have worked in rural and urban medical settings for more than 35 years, are part of Physicians for a National Health Program, which is pushing for single-payer national health insurance.

Under such a system, a tax would cover all or most health care expenses, every citizen would be covered, and delivery of care would largely remain in private hands. It would be similar to Medicare, but without the need for supplemental insurance. The approach is commonly called “Medicare for all.”

SINGLE-PAYER’S BENEFITS TOUTED

Under a single-payer system, Engelhart explained, “You aren’t restricted by networks where you can go. That’s the free market. What we have now is not the free market.”

The current situation — created by insurance companies and reinforced by Washington lobbyists and a reluctant Congress — are among the reasons Americans have the most expensive health care in the world, Engelhart said.

He offered numbers from various sources to back up the claim:

  • United States per capita health care spending, $9,024, is more than twice the average, $3,620, of other developed countries, according to the Organization for Economic Cooperation and Development.
  • National health expenditures consumed 17.8 percent of our nation’s gross domestic product in 2015, more than twice the rate in most other industrialized nations, according to the Centers Medicare and Medicaid Services.
  • At approximately $3 trillion a year, health care costs account for one-sixth of the American economy, a rate that’s expected to rise to one-fifth of the economy in the next seven years.
  • About 31 percent of that amount is spent on insurance administration, advertising, CEO/management salaries, profit making and other non-direct care costs that Engelhart described as “waste.” “That’s more money than we spend in this country on K-12 education,” he said.

Despite that high spending, Americans don’t realize the best health outcomes. Far from it, according to Engelhart:

  • Under the best circumstances, about 23 million Americans will remain uninsured in 2019, according to the Congressional Budget Office.
  • The U.S. life expectancy of 78 is ranked 30th highest in the world, right behind Costa Rica and ahead of Cuba.
  • A rate of 6.1 deaths per 1,000 infants gives the U.S. the world’s 26th lowest infant mortality rate.
  • Higher cost care doesn’t necessarily translate into more care. Americans, on average, see a doctor 4.2 times a year, while in Japan, where life expectancy is 83, patients see their doctor 13 times a year.
  • In terms of overall health care quality, France ranks No. 1, Australia ranks No. 2 and the U.S. trails at No. 19.

With lagging outcomes and high costs, more American businesses are wising up to the situation, according to a video the Engelharts showed to the 14 people in attendance. In the video, American business leaders, a retired insurance executive, physicians and others criticized the American system for its heavy rationing based on ability to pay, the plight of patients who defer needed care, and inefficiencies.

Businesses would fare better, according to the video’s speakers, if they could shift the burden of health care insurance to a single payer. They argue that through Medicare, Medicaid, the VA, public employees’ private health insurance coverage and other programs, government is already paying for 64 percent of all health care.

Under a single-payer system, according to the video, patients could see any doctor, visit any hospital, all costs would be covered, and nobody would be left out.

A handout distributed by the Engelharts estimated that if a single-payer program existed in Minnesota, an average business in 2014 would have saved $1,214 per employee annually. An average household would have saved $1,362 annually.

WHAT OPPONENTS SAY

Nobody attending the presentation spoke against the single-payer system. But opposition remains strong. Common arguments against it include long waiting times for specialized surgeries and other procedures, limitations in coverage for benefits such as mental care and prescription drugs, and public policies that ignore growth and innovation. Opponents also argue single-payers systems run the risk of fostering fraud, and because the government controls payments to providers, fewer people will want to become doctors, especially specialists.

Despite those objections, nationwide support appears to be growing. Kaiser Family Foundation Polls show 53 percent of poll respondents in June 2017 favored a single-payer program, while 43 percent opposed it. That contrasts with 40 percent support and 53 percent opposition in 2000.

“We’re gaining momentum now that people are seeing it’s wrecking our economy,” Engelhart said.

Chrast is among those who support it. Between dropping his first retirement insurance plan and enrolling in Medicare, he couldn’t afford to see his longtime doctor in Hutchinson.

“He was telling me, ‘Why aren’t you coming in? With your high blood pressure, you’re really due for a checkup.’ I said, “I’m sorry, you’re out of network.’ … I was willing to die before putting my family in jeopardy and losing everything I worked for all my life. I wouldn’t go to the doctor. I know people that have cancer who won’t go to the doctor until they hit the Medicare age.”

http://www.crowrivermedia.com…

Gallup: ‘Support for Government-Run Health System Edges Up’

By Frank Newport
Gallup News, December 1, 2017

Americans’ preferences for a government-run healthcare system versus a system based on private insurance are now divided. This marks a significant shift in attitudes from earlier this decade, when Americans consistently preferred the private insurance option.

Since 2010, Gallup updates have shown as much as a 27-percentage-point gap in favor of the private insurance system versus one run by the government. That gap shrank to 10 points last year and essentially disappeared in this year’s survey, conducted Nov. 2-8, with 48% preferring the private health insurance system and 47% preferring the government-run system.

Two-thirds of Democrats and independents who lean Democratic favor a government-run system. Three-quarters of Republicans and independents who lean Republican favor a system based on private insurance.

Predictable and Large Partisan Gap in Views on Government-Run Versus Private Insurance-Based Health System

Favor government-run system
22% – Republicans/Leaners
67% – Democrats/Leaners

Favor system based on private insurance
76% – Republicans/Leaners
29% – Democrats/Leaners

Although the 22% of Republicans who support a government-run system is low on an absolute basis, it is the highest in Gallup’s seven-year trend. Republicans’ shift in attitudes accounts for most of the overall increase in support for the government system in this year’s update.

Majority Doesn’t Know Enough to Have Opinion on “Medicare for All,” Single-Payer Health System

Question asked: As you may know, some senators have proposed a “Medicare-for-all,” single-payer health insurance program that would be administered by the federal government and financed through taxes. Please tell me if you favor or oppose this proposal, or if you don’t know enough to say?

17% – Favor
21% – Oppose
61% – Don’t know enough to say

http://news.gallup.com…

***

Comment:

By Don McCanne, M.D.

Although other polls suggest that there is about 60 percent support for single payer, the wording of this Gallup poll indicates that the nation is split between its preference for a “government-run system” versus a “system based on private insurance.” This is consistent with trends in other polls since it represents a significant shift in the results of Gallup polls away from a clear preference for private insurance to a point now where opinion is evenly divided (with this specific wording).

An important observation is that most of the change is due to an increase in support amongst Republicans and those leaning Republican, even though still a distinct minority. We should keep in mind that Republicans and independents need to be a targeted audience for the single payer message.

Another important result is that 61 percent of those polled “don’t know enough to say” whether they favor or oppose “a ‘Medicare-for-all,’ single-payer health insurance program that would be administered by the federal government and financed through taxes” that “some senators have proposed.” Although this may reflect the fact that people have not heard enough about the Sanders bill specifically, it does suggest that we have to make a greater effort to see that “single payer” becomes a meme that everyone understands and automatically supports.

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CVS purchase of Aetna may be even more ominous than it seems

CVS to Buy Aetna for $69 Billion in a Deal That May Reshape the Health Industry

By Michael J. de la Merced and Reed Abelson
The New York Times, December 3, 2017

CVS Health said on Sunday that it had agreed to buy Aetna for about $69 billion in a deal that would combine the drugstore giant with one of the biggest health insurers in the United States and has the potential to reshape the nation’s health care industry.

The transaction, one of the largest of the year, reflects the increasingly blurred lines between the traditionally separate spheres of a rapidly changing industry.

A combined CVS-Aetna could position itself as a formidable figure in this changing landscape. CVS operates a chain of pharmacies and retail clinics that could be used by Aetna to provide care directly to patients, while the merged company could be better able to offer employers one-stop shopping for health insurance for their workers.

But critics worry that customers could also find their choices sharply limited. The deal risks leaving patients with less choice of where to get care or fill a prescription if those with Aetna insurance are forced to go to CVS for much of their care.

The merger would establish a new way of delivering care, with nurses, pharmacists and others available to counsel people about their diabetes or do the lab work necessary to diagnose a condition, said (CVS Health’s chief executive, Larry J. Merlo). “We know we can make health care more affordable and less expensive.”

Mark T. Bertolini, Aetna’s chief executive, said that by using CVS’s locations, the company can provide people with a better way of accessing medical care.

The hope would be that consumers would not only be able to see savings by going to a retail store to treat a sore throat but also have better oversight of a chronic illness, such as diabetes or heart disease. They could get advice on how to lose weight, or undergo tests to monitor their health.

“If they can drive the adoption of the care delivery model, that’s a big deal,” said Ana Gupte, a senior health care analyst for Leerink Partners.

David A. Balto, an antitrust lawyer who has been sharply critical of combinations among insurers and pharmacy benefit managers, said that he was wary of having retailers in charge of people’s health. He argued that doctors may be in a better position to treat illness than retail executives.

“Who do you want to run the health care system?” he said.

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

When two for-profit mega-corporations merge, you can be sure that it is about the money, making more of it, much more. Although they may promise greater efficiency and lower costs through integration of services, the record so far suggests that such mergers provide greater market leverage and thus higher prices. That should certainly have us concerned, but there is something potentially much more ominous here.

Insurers today not only serve an intermediary role of processing claims, they also want to manage care. They benefit not only by selling us superfluous administrative services through higher insurance premiums, but also they game the system to increase profits, and they reduce patient access to beneficial health care services, allowing their insurance products to be more competitive.

But look at what is happening here. CVS not only has a huge pharmacy business, but they also have incorporated into their system Caremark, one of the nation’s largest pharmacy benefit managers – the middlemen that seem to be a major contributor to escalating drug costs. They also operate 1,100 retail health care clinics. What is particularly disconcerting is that they intend not only to provide walk-in and preventive services, they now want to provide oversight of chronic illnesses such as diabetes or heart disease. Chronic care is playing a much greater role in health care delivery, and CVS/Aetna wants in on the action. Care would be provided by nurses, pharmacists, and others (presumably lower-wage assistants – physicians have not been mentioned in the news reports).

Now add Aetna. Although the surviving organization will be CVS Health Corp., the Aetna division will remain intact with current Aetna executives, including Mark Bertolini, serving on the CVS board. Look at the package they will offer: insurance services, care management, bread and butter clinical services including the rapidly expanding field of chronic care, pharmaceutical services with their high prices and pharmacy benefit management, and a retail department of home health products.

This package is so complete that they could exclude everything else from their networks. Since some people will need highly specialized services or care in full-fledged emergency departments or in hospitals, the Aetna division could sell catastrophic plans as part of their deluxe package.

Aetna and CVS are not the only ones in this game. Other players or potential players include UnitedHealth with its surgery centers, urgent care clinics, and Optum pharmacy benefit manager, Anthem which is now forming its own pharmacy benefit manager, maybe Humana and Cigna, and now even Amazon is expected to move into the arena big time.

But what about physicians in their offices out in the community? Don’t need them. The primary care physicians could provide direct care or concierge care though they would have to rely on more affluent cash paying patients since the insurers would limit their networks to their own clinics staffed with lower cost professionals. And how many cash practices do you think could be supported in an economy with stagnant wages? Some of the specialists might survive as hospital employees, working in their outpatient clinics to see the really complicated cases referred by CVS-type retail clinics.

Can the for-profit corporate world really take over? To a great extent, it already has. With the pending tax legislation, the public seems to be accepting an even greater transfer of wealth to the top. How is this development in health care any different?

But if we really care, we could throw out the plutocrats and establish our own single payer national health program with free choice of our health care professionals and institutions, in a system that all of us could afford. If we care.

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Sen. Rubio explicitly confirms strategy to cut Medicare and Social Security

Playbook Interview: Sen. Marco Rubio

Politico, November 29, 2017

Jake Sherman: Let’s circle back to taxes for a second ’cause that’s what you guys in the Senate are going over this week. There’s concerns about deficits…it’s like Whack-a-Mole…you try to solve one problem and someone else has another issue. Besides the child tax credit, do you have any lingering concerns on the package you’re going to vote on, presumably this week?

Sen. Marco Rubio: Yah, except I analyze it very differently. People look at…Okay…Here’s…The argument would be that we can’t cut taxes because it would drive up the deficit. That assumes that somehow we could fix the deficit through higher taxes, and we can’t. The only way you’re going to deal with the debt is you have to do two things. You can’t do one; you’ve got to do both. You’ve got to…you’ve got to generate economic growth because growth generates revenue. But you also have to bring spending under control, and not discretionary spending, that isn’t the driver of our debt. The driver of our debt is the structure of Social Security and Medicare for future beneficiaries. We still have time, not just to save those programs, but responsibly structure them in a way that doesn’t impact current retirees, or people about to retire, but in a way that would probably impact it for me and people younger than me in ways that, quite frankly you really wouldn’t notice and you really wouldn’t object to, because it’s reasonable. And if we did that in combination with growth you could begin to bring the trajectory of the debt to a responsible and acceptable level. That is the only way forward. So I view tax reform as the economic growth component of it. That’s what will ultimately help to generate more revenue. You have more people working, you have more taxpayers. You have more taxpayers, you have more revenue. That’s the first part, but that alone won’t be enough. If you just do that, and you don’t do the other piece, you’re going to have a debt problem. That’s a fact, and we gotta do both. In the absence of that, we’re gonna to continue to be in the cycle, one way or another.

https://www.politico.com…

***

Comment:

By Don McCanne, M.D.

We’ve heard it many times. To eliminate the deficit, first we have to stimulate the economy by reducing taxes (for the rich), and then we need to reduce the driver of our debt, Social Security and Medicare.

One version of the tax legislation has already passed in the House, and, as of today, the Republicans have the votes to pass the other version in the Senate. Ironing out the differences in Joint Conference will not be much more than a formality. Then the first cuts in Medicare will soon follow automatically because of existing PayGo requirements.

It should be a great secular Christmas for the billionaires. Maybe we should join the celebration…with a hundred million person march on Washington. Don’t forget your placards.

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