Geographical Distribution of Emergency Department Closures and Consequences on Heart Attack Patients

By Yu-Chu Shen Renee Y. Hsia
National Bureau of Economic Research, November 2016

NBER Working Paper 22861

Abstract

We develop a conceptual framework and empirically investigate how a permanent emergency department (ED) closure affects patients with acute myocardial infarction (AMI). We first document that large increases in driving time to closest ED are more likely to happen in low- income communities and communities that had fewer medical resources at baseline. Then using a difference-in-differences design, we estimate the effect of an ED closure on access to cardiac care technology, treatment, and health outcomes among Medicare patients with AMI who lived in 24,567 ZIP codes that experienced no change, an increase of <10 minutes, 10 to <30 minutes, and 30 minutes in driving time to their closest ED. Overall, access to cardiac care declined in all communities experiencing a closure, with access to a coronary care unit decreasing by 18.64 percentage points (95% CI -30.15, -7.12) for those experiencing 30-minute increase in driving time. Even after controlling for access to technology and treatment, patients with the longest delays experienced a 6.58 (95% CI 2.49, 10.68) and 6.52 (95%CI 1.69, 11.35) percentage point increase in 90-day and 1-year mortality, respectively, compared with those not experiencing changes in distance. Our results also suggest that the predominant mechanism behind the mortality increase appeared to be time delay as opposed to availability of specialized cardiac treatment.

From the Discussion

Our results suggested that when patients had to drive at least 10 more minutes to their next available ED upon local ED closure, time delay became the dominant mechanism in affecting health outcomes when local ED closure occurred, both directly (as time delays causes more severe infarction) and indirectly through its effect on access and treatment.

The adverse effect of time delay on mortality rates became evident in communities that experienced 10-30 min increase in driving time, and became substantial in communities that experienced more than 30-minute increase in driving time. The adverse effect did not resolve even after we controlled for access and treatment, suggesting that the time delays likely made the prognosis worse, directly affecting mortality rates.

Conclusions

Our study showed that patients with AMI whose driving time to the nearest ED after local ED closure increased by 10 minutes or more had a significant increase in mortality. Among those who experienced a closure that resulted in a drive time increase of 30 minutes or more, they experienced a 30% higher 90-day mortality and 21% higher 1-year mortality. Increased driving time due to a closure was also associated with an overall decrease in access to cardiac technology in the remaining hospitals. Our findings suggest that permanent ED closure has substantial consequences on patient outcomes, particularly among communities with limited resources for time-sensitive illnesses such as AMI. We find that the predominant mechanism by which patients’ outcomes decline is primarily due to time delay, as opposed to changes in availability of treatment. We can conclude that while provision of necessary cardiac technology is one important factor for remaining hospitals, the effects of a time delay due to an ED closure are not easily mitigated.

http://www.nber.org/papers/w22861

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Comment:

By Don McCanne, M.D.

Under our medical-industrial complex, decisions regarding location of facilities such as emergency departments are frequently based on business considerations of the market rather than on what would be optimal for the community. This NBER paper demonstrates that such decisions can be a matter of life or death. If closure of an emergency department results in more than a ten minute delay in access to the next closest hospital, mortality for an acute myocardial infarction is increased.

Under a well designed single payer system, planning is an integral part and is based on community need rather than on private profit potential. This is today’s message. What follows is a personal anecdote which you can skip unless you are curious.

Our community hospital in San Clemente, California – Saddleback Memorial Medical Center – is part of the MemorialCare Health System, located in Los Angeles and Orange Counties. It was decided that the San Clemente campus be converted from an acute care hospital into an outpatient center. After months of controversy and the inability to agree on this change, the owners decided to close our hospital, including the emergency department. It is now surrounded by a chain-link fence.

According to Google, the additional time required to travel to Mission Hospital in Mission Viejo is 13 minutes, longer than the ten minute delay than can increase mortality in the event of an acute myocardial infarction, according to this study. But our freeway is frequently heavily congested due to stop-and-go beach traffic, especially throughout the extended weekend. The alternate route over surface roads is 23 minutes, according to Google. People will die.

One tiny glimmer of hope is that the hospital has refused to release the portraits of the former chiefs of staff hanging in a hallway (mine included). This suggests that the hospital owners have not given up on the facility. However it is likely that they will continue their demand that it be converted to an outpatient facility.

Why would they do this? An outpatient facility can be used to feed lucrative elective cases to their larger facility – Saddleback Memorial Medical Center in Laguna Hills – whereas, as the only hospital in San Clemente, by virtue of EMTALA they would have to take all cases regardless of insurance status and profitability.

Even though MemorialCare is non-profit, it is still very much an active part of the medical-industrial complex. Although the delivery system can remain private, non-profit, we really do need a universal public financing system – a single payer improved Medicare for all. And we want our hospital back.

House Republicans seek delay in case to end ACA cost-sharing subsidies

By Harris Meyer
Modern Healthcare, November 21, 2016

To buy President-elect Donald Trump time to craft an Affordable Care Act replacement, House Republicans have asked a federal appellate court to delay considering the Obama administration’s appeal in a case that could end some payments to health plans and throw the individual insurance market into chaos.

The House Republicans’ general counsel filed a motion Thursday to temporarily hold in abeyance all briefings in the appeal of a federal district court’s May ruling in House v. Burwell that the Obama administration illegally compensated insurers for reducing low-income enrollees’ cost-sharing responsibilities. A U.S. District Court judge nominated by President George W. Bush unexpectedly held that the payments were unconstitutional because Congress had not appropriated the money.

If those cost-sharing reduction payments were eliminated, as House Republicans have sought, insurers either would have to sharply raise premiums or exit the ACA exchange markets, since the law requires them to reduce cost-sharing burdens for eligible members in silver plans.

Some Republicans and health policy experts fear that any hasty, drastic moves would crash the individual insurance markets. They warn that ending the cost-sharing reductions without any replacement system might panic insurers by causing them to lose lots of money.

http://www.modernhealthcare.com/article/20161121/NEWS/161129982

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If Republicans Repeal Obamacare, Ryan Has Replacement Blueprint

By Alison Kodjak
NPR, November 21, 2016

The absence of specifics on health care from the president-elect makes the 37-page plan that Speaker of the House Paul Ryan has released the fullest outline of what Republicans would like to replace Obamacare. Some health policy analysts say it looks a bit like Obamacare light.

http://www.npr.org/sections/health-shots/2016/11/21/502612264/if-republicans-repeal-obamacare-ryan-has-replacement-blueprint

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Comment:

By Don McCanne, M.D.

Republicans repeatedly voted for repeal of the Affordable Care Act (ACA) knowing that the severe adverse consequences would be prevented by serial vetoes by President Obama. They also filed  a lawsuit – House v. Burwell – to prevent the payment of cost-sharing subsidies for exchange plans since the funds were never authorized by Congress. But since, to their surprise, a judge has ruled in favor of the Republicans, they are concerned about being blamed for the ensuing disaster if the judge’s decision were to be upheld.

Since they have never advanced replacement legislation, it is clear that this has only been a game of political chicanery and not a legitimate effort to advance their own concepts of whatever they may truly believe would be a superior health care financing system.

Since winning the election, Trump has posted seven items for action which together would “completely repeal” ACA but would introduce changes that would have only a negligible impact in making insurance more available and affordable. The Republicans clearly do not want to be blamed for taking away the expansions in coverage made possible by ACA, so the Trump proposals are not being taken seriously.

The Republicans have been considering many proposals, and they have been aggregated into a 37 page white paper released by Speaker Paul Ryan. Many of the measures would reduce the effectiveness of insurance plans and shift many of the costs of health care onto the individual patients. But it is clear to the Republicans that there are many policy principles that must be met to have any semblance of a functioning insurance market. When they include these requirements, they end up with a proposal that is very similar to Obamacare, except with less coverage and less regulation. Thus the Republican plan is referred to as “Obamacare light.”

We don’t know yet what will happen, but the Republican effort to halt their own lawsuit against the ACA subsidies indicates that they realize that they will have to come up with an effective proposal before they begin to reverse (and then somewhat surreptitiously reinstate) the reforms in ACA. That will likely be Obamacare light.

The improvements under ACA were not enough and have left us with a terribly deficient health care financing system. Under the Republicans, it will be more of the same, but worse. We cannot let up on our efforts to inform the nation that a single payer, improved Medicare for all would be a vast improvement, but it will not happen unless the people demand it. Although there is support for single payer, their voices are not loud enough yet to move the politicians. We need to change that.

CMS’ Hospital Quality Star Ratings Fail To Pass The Common Sense Test

By Susan Xu and Atul Grover
Health Affairs Blog, November 14, 2016

In July of 2016, the Centers for Medicare and Medicaid Services (CMS) implemented a new overall star rating system on the Hospital Compare website. Almost all hospitals are now rated between one and five stars (higher is better) depending on performance on a series of quality metrics. CMS’ intent for the new star ratings is to “help patients and families learn about hospital quality, compare facilities side by side, and ask important questions about care quality.”

However, patients and families will find the newly released star ratings from CMS confusing at best and misleading at worst. Many well-known hospitals that are highly rated by other ranking systems are absent from the list of 102 hospitals that received five stars.

The star rating methodology intends to rate all hospitals based on 64 quality measures from seven quality domains and to make domain weight reflect relative importance of a quality domain to patients. CMS has assigned greater weight (66 percent of the overall star rating) to the three domains—mortality, readmission, and patient safety—that measure clinical outcomes such as whether a patient dies, contracts a hospital-acquired infection, or is readmitted to the hospital within 30 days of an inpatient stay. Other domains that focus on processes such as efficient use of medical imaging and timeliness of care are given less weight.

Nonetheless, CMS calculated and published star ratings for hospitals that had sufficient data to report on as few as three quality domains, including some hospitals that only had data from one clinical outcome domain. The fewer the clinical outcome domains a hospital reports, the less that hospital’s overall star rating is actually tied to performance on patient outcomes.

Among the 30 five-star hospitals that had sufficient data to report only the minimum number of quality domains required—three out of a total of seven (red bars)—14 had performed higher than the national average on only one quality domain, 15 performed above average on two domains, and a single hospital excelled at those three quality domains. Hospitals that reported all seven quality domains (yellow bars), however, needed at least three quality domains with above national average performance to receive a five-star rating.

This disconnect is a result of the fact that when a hospital has insufficient data to report on one or more quality domains, the “weights” of those missing domains are reallocated to the domains for which there is sufficient data.

Major teaching hospitals, a group that includes many of the nation’s most renowned hospitals, provide comprehensive services and thus are able to report on a majority of quality domains. In fact, 80 percent of major teaching hospitals reported on all seven quality domains. To receive ratings with more stars, these hospitals have to meet a higher standard than hospitals with fewer reported quality domains because of their narrower service areas and less diverse patient populations. Not only do major teaching hospitals need to achieve performance better than the national average in more quality domains, but their overall star ratings will also be heavily tied to the outcomes of their clinical services (e.g., mortality) instead of processes of care delivery (e.g., efficient use of medical imaging). While all improvement efforts can be challenging, we believe that it takes more to improve clinical outcomes—for example, saving a patient’s life—than to improve delivery process, such as reducing the use of imaging.

Many major teaching hospitals also serve a large population of patients who live in poverty and economically deprived neighborhoods. Study after study links low socioeconomic status (SES) to increased risk of readmission after inpatient discharge. Unfortunately, the readmission risk associated with patient SES is not currently adjusted for in quality domains like readmissions. That 70 percent of the major teaching hospitals with the highest share of low SES patients (top quartile) received one or two stars reflects more of the systematic bias in the ratings system.

To provide meaningful information for patients, families, and caregivers about hospital quality, a star ratings system has to make sense. At a minimum, quality performance among hospitals with the same star rating should be consistent. And higher star ratings should reflect better actual quality performance. Unfortunately, the CMS star ratings in their current form fail to meet this basic test and will do more harm than good to patients.

http://healthaffairs.org/blog/2016/11/14/cms-hospital-quality-star-ratings-fail-to-pass-the-common-sense-test/

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Comment:

By Don McCanne, M.D.

The Centers for Medicare and Medicaid Services (CMS) has been leading the charge to paying for quality instead of quantity, as if that will be the answer to our concerns about the high cost of health care. This report on CMS’s hospital quality star ratings reveals that the ratings are not only invalid, but they are potentially harmful because of the misinformation disseminated about the hospitals’ quality status.

This nonsense about paying for quality instead of quantity came about merely because our politicians and policy community refused to consider financing infrastructure changes that would control spending, while improving quality through better resource allocation – characteristics of a single payer financing system. Instead, they insisted on preserving the existing dysfunctional infrastructure that was not amenable to the mere tweaks provided by the Affordable Care Act.

CMS pretending that the hospital quality star rating will address our cost and quality problems is health policy malpractice. Let’s move on to a program that will work – a single payer national health program supervised by public stewards who care.

How California can survive Trumpcare

By Gerald F. Kominski
Los Angeles Times, November 18, 2016

No one knows exactly what Donald Trump’s pledge to “repeal and replace” the Affordable Care Act means. The hints, however, are troubling. No state has embraced the ACA — Obamacare — more enthusiastically and successfully than California. And no state has more to lose with Trumpcare.

The question is, what comes next? The Trump campaign was short on details. Suggestions included promoting health savings accounts linked to high-deductible health plans; allowing insurance to be sold across state lines in an effort to increase competition and thus affordability; and allowing everyone to deduct health insurance premiums from their taxes.

In one “replace” scenario — contained in Ryan’s 2016 “A Better Way” proposal — those tax credits would continue but would no longer be scaled to income as they are under Obamacare.

As for Medi-Cal, Trumpcare would fundamentally transform the program. Under Trumpcare, each state will instead receive a block grant program that fixes its allocation at a to-be-determined point in time. Because healthcare spending has always grown faster than inflation, the real value of Trumpcare block grants is guaranteed to shrink over time.

For Medi-Cal, the options are some combination of cutting eligibility, cutting benefits and raising taxes. Paying providers less won’t be viable because California already has some of the lowest rates in the country for its Medicaid program.

For Covered California, higher taxes will be required if the state wants to keep the program going with health plans and policies that meet Obamacare standards. Californians would have to agree to make up whatever the shortfall is between Trumpcare’s tax credits and Obamacare credits. The only other option is reduced benefits.

A brand new state “single payer” plan is another possibility, but it would face its own challenges, particularly under a Republican administration in Washington hostile to innovations that aren’t based on the mythical “free” market for health. The economics and administration of single payer work best if all government health insurance programs — including Medicare, the Veterans Administration system and the military’s Tricare program, as well as the state’s CalPERS program for public employees — are folded into one plan. The Trump administration is not going to easily grant permission for California to exit the federal programs taking its share of the taxes that support them.

California’s experience with Obamacare has been extremely positive, and there are already indications that state politicians will try to keep it alive regardless of what Washington does. As the details of Trumpcare come into focus, so will the state’s best strategies to close the expected funding gaps. All options need to be considered, and no option should be ruled out quickly because it appears too difficult or politically impossible. Californians dream big, and that’s what will be required to keep healthcare accessible in the Golden State.

Gerald F. Kominski is director of the UCLA Center for Health Policy Research.

http://www.latimes.com/opinion/op-ed/la-oe-kominski-how-california-can-survive-trumpcare-20161117-story.html

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Comment:

By Don McCanne, M.D.

Quoting Professor Gerald Kominski:

“No option should be ruled out quickly because it appears too difficult or politically impossible.”

“The economics and administration of single payer work best if all government health insurance programs — including Medicare, the Veterans Administration system and the military’s Tricare program, as well as the state’s CalPERS program for public employees — are folded into one plan.”

We need to consider the possibility of “a ‘brand new’ state single payer plan.”

Obviously a national single payer program is what we really need, but that would require a total turnabout by Sen. McConnell and Speaker Ryan – a political shift that would be about as likely as electing Donald Trump president. But think about that for a minute. Think about what that means when someone says that it’s not politically feasible.

At any rate, California politicians have an excellent track record of supporting optimal policies. Just because they have been very successful in implementing the Affordable Care Act doesn’t mean that they should rest on their laurels and simply accept the intolerable deficiencies that remain.

It’s time for California to initiate another effort to move forward with enactment of whatever single payer policies are possible within federal restrictions that Congress refuses to waive – as an interim measure until we have an enlightened Congress and administration that will bring us a single payer national health program – an improved Medicare for all.

Unfinished Business: More than 20 Million Children in U.S. Still Lack Sufficient Access to Essential Health Care

Children’s Health Fund, November 2016

Children’s Health Fund (CHF) estimates that, at minimum, 20.3 million children in the United States (28% of all children) face barriers to accessing essential health care. This estimate covers children who are a) uninsured; b) children who don’t receive routine primary care; and c) publicly insured children who are connected to primary care but have unmet needs for pediatric subspecialty care when needed, such as pediatric cardiology or pediatric endocrinology.

Based on the collective reach and impact of Medicaid, CHIP, and ACA, the child uninsurance rate fell from 13.9 percent in 1997 (9.6 million) to 4.5 percent (3.3 million) in 2015—a drop of more than 67%. But there is still much to be done. We need to find ways to cover that remaining 4.5 percent—some 3.3 million children, many of whom are from the most marginalized communities and regions in the United States. And while important, uninsurance figures often promote the false dichotomy of “insured” versus “uninsured” children, ignoring the millions of children who are counted as insured but go without coverage for some portion of the year. Such coverage gaps matter. Discontinuous health coverage can negatively impact timely receipt of preventative and other crucial health care services.

Beyond the issue of coverage is an equally important question: Do children who receive some form of coverage actually access the care that that coverage is supposed to provide? The answer is often no. Based on data and our analysis, Children’s Health Fund believes that there are two main categories of barriers to obtaining health care: Financial and Non-financial.

Financial barriers refer to the costs imposed by a coverage plan that prevents children from accessing the care they need. Such barriers refer to costs such as high copays, high deductibles, and unaffordable prescription drug prices. CHF calculates that there are over 13.1 million children whose families report either having problems paying medical bills or being unable to pay medical bills. Provider-based barriers also contribute to the financial burden when clinics or providers won’t accept certain forms of insurance or create environments that promote insurance stigma.

Non-financial barriers most often take the form of either geographic barriers or informational barriers. Geographic barriers include issues of transportation, such as a lack of a car or poor public transit options, and federal-designated Health Professional Shortage Areas (HPSAs) where the number of health professionals in a given geographical area is insufficient for that population’s healthcare needs. CHF estimates that over 14 million children live in HSPAs. Informational barriers include parents’ health illiteracy, dauntingly complex language used in information about coverage eligibility and accessing care, and parents’ limited English proficiency.

https://www.childrenshealthfund.org/wp-content/uploads/2016/11/Unfinished-Business-Final_.pdf

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Comment:

By Don McCanne, M.D.

In designing the Affordable Care Act, special attention was given to be sure that children were well covered by our system of public and private programs. Yet over 20 million children still have access barriers to essential health care services.

Look at some of the reasons for this impaired access and then imagine how it would be under a single payer system:

*  3.3 million children have no insurance at all. Single payer would automatically include everyone.

*  Millions who are counted as insured have frequent gaps in coverage for a variety of reasons related to the fragmented nature of health care financing post-ACA. Single payer covers everyone for life, so there would be no gaps in coverage.

*  High patient cost sharing and high prices frequently impair access to care. Under single payer, all essential services would be paid for in full, so there would be no financial barriers.

*  Frequently certain insurance plans are not accepted by many health care providers. Under single payer, there is only one plan that would be accepted by all providers since there is no other option.

*  The stigma of welfare plans such as Medicaid can interfere with access, especially for subspecialty care. Under single payer there is no separate welfare program for low-income individuals or families. Single payer would cover everyone, eliminating the stigma of assigning the poor to welfare programs.

*  Over 14 million children live in federally designated Health Professional Shortage Areas, potentially impairing access. A single payer system plans and budgets capital improvements, providing improved distribution of our health care resources.

The attitude today seems to be that we have done a pretty good job of covering children, though maybe we need a few more tweaks that might slightly improve access, though it is not practical to fill in all of the voids. Nonsense. All we need is a well designed single payer system. It would dramatically improve access for these 20 million children (and everyone else) without increasing spending over our current levels.

Our Revolution: A Future To Believe In

By Bernie Sanders

It has never made sense to me that the quality of care a person receives – indeed, whether that person receives any care – should be dependent upon the job that he or she has or the wealth of their family. It has never made sense to me that Americans should be forced into bankruptcy because of a serious illness. It has never made sense to me that some people will live and some people will die because of their health insurance status.

Most important, it has never made sense to me that our health care system is primarily designed to make huge profits for multibillion-dollar insurance companies, drug companies, hospitals, and medical equipment suppliers. Health care is not a commodity. It is a human right. The goal of a sane health care system should be to keep people well, not to make stockholders rich.

The bottom line is that in the United States we spend an enormous amount of money for a health care system that performs poorly. It’s time for a change – a real change.

According to a recent report drafted by thirty-nine physicians from the Physicians for a National Health Program (PNHP) and endorsed by some 2,500 medical doctors, a movement to “a single payer system would trim administration, reduce incentives to over-treat, lower drug prices, minimize wasteful investments in redundant facilities, and eliminate almost all marketing and investor profits. These measures would yield the substantial savings needed to fund universal care and new investments in currently under-funded services and public health activities – without any net increase in national health spending.”

From the Conclusion

Humanity is at a crossroads. We can continue down the current path of greed,consumerism, oligarchy, poverty, war, racism, and environmental degradation. Or we can lead the world in moving in a very different direction.

Yes. We can overcome the insatiable greed that now exists and create an economy that ends poverty and provides a decent standard of living for all. Yes. We can create a vibrant democracy where knowledgeable citizens actively debate the great challenges they face. Yes. We can create a health care system that guarantees health care for every man, woman, and child, and that focuses on disease prevention and keeping us healthy, not outrageous profits for insurance companies and the pharmaceutical industry. Yes. We can effectively combat climate change and transform our energy system away from fossil fuel and into energy efficiency and sustainable energy.

No. We will not be able to accomplish those goals if we look at democracy as a spectator sport, assuming others will do it for us. They won’t. The future is in your hands. Let’s get to work.

http://us.macmillan.com/ourrevolution/berniesanders

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Comment:

By Don McCanne, M.D.

May this book become the bible of “our revolution.”

In New Survey of 11 Countries, U.S. Adults Still Struggle with Access to and Affordability of Health Care

By Robin Osborn, David Squires, Michelle M. Doty, Dana O. Sarnak, Eric C. Schneider, M.D.
The Commonwealth Fund, November 16, 2016

The Issue

Asking people directly about their experiences with the health care system can reveal valuable information about how well a country is meeting the needs of its population. A new Commonwealth Fund study in Health Affairs examines patients’ experiences based on responses to a 2016 survey of adults in 11 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.

The Big Picture

Although the U.S. has made significant progress in expanding insurance coverage under the Affordable Care Act, it remains an outlier among high-income countries in ensuring access to health care. The authors point out that all of the other countries surveyed provide universal insurance coverage, and many provide better cost protection and a more extensive safety net.

The Bottom Line

Despite progress since passage of the Affordable Care Act, adults in the United States remain more likely to go without needed health care because of costs compared to adults in other high-income countries.

http://www.commonwealthfund.org/publications/in-the-literature/2016/nov/2016-international-health-policy-survey-of-adults

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Comment:

By Don McCanne, M.D.

The Affordable Care Act (ACA) is now essentially fully implemented. So how are we doing? According to a new Commonwealth Fund study, “adults in the United States remain more likely to go without needed health care because of costs compared to adults in other high-income countries.” Although ACA brought some improvements, they are grossly inadequate by international standards.

Congress is about to reopen the health care reform process. Mere tweaking cannot repair our highly dysfunctional health care financing infrastructure. We need to make sure that a model that does work – a single payer national health program – is front and center in their negotiations.

Health Reform in the Trump Era

A Big Step Back, But Possibilities for Bigger Steps Forward

By Steffie Woolhandler, M.D., M.P.H., and David U. Himmelstein, M.D.
Physicians for a National Health Program, November 16, 2016

The 2016 election turned on racism, xenophobia and anger at the status quo, including the Affordable Care Act (ACA). The law covered about 20 million, and modestly improved access to care. But it didn’t address the health care problems facing most working families, feeding the perception that the Democratic Party had neglected them. Trump seized on the ACA as a symbol of the establishment’s false promises, and has placed repeal at the top of his to do list.

There are many indicators of what Trump has in mind to replace the ACA, but they’re pointing in different directions. We suspect that the likeliest replacement is a meaner (and rebranded) facsimile of the ACA that retains its main structural element – using tax dollars to subsidize private insurance – while imposing new burdens on the poor and sick.

For Republicans, the ACA poses a difficult dilemma. Its model was conceived by Richard Nixon’s henchmen in 1971, celebrated and elaborated by the Heritage Foundation in 1989, and first implemented by Mitt Romney in 2006. Obama’s version, like these earlier ones, called for sliding-scale public subsidies to help low-income individuals purchase private coverage through insurance exchanges, along with a mandate that individuals (and sometimes employers) buy coverage. For the poor, Obama (like Nixon) relied on expanding Medicaid, but almost all of the ACA’s new Medicaid coverage was channeled through private Medicaid-managed-care insurers. And Obama added progressive elements to the Republican formula, e.g. requiring insurers to cover essential benefits (notably contraception and preventive care) and a new “Medicare” tax on some investment income.

Will Republicans reclaim their health care heritage after years spent rabidly attacking its Obamacare variant? Paul Ryan’s recent pronouncements (and the abiding interests of powerful insurance, drug and hospital firms) suggest that they will. Ryan would rebrand the Obamacare premium “subsidies” as “tax credits,” but make them available to anyone who lacks employer-paid coverage, including the wealthy. In essence, he’d shift some of the subsidy money up the income scale and undermine employer-based coverage. He’d maintain (at least for the time being) Obamacare’s boost to Medicaid funding, but let states cut Medicaid coverage and divert the funds to other uses. And he’d hasten the privatization of Medicare, which has already been proceeding apace.

If there’s a brighter side to this dark picture, it’s that Trump and his allies will reclaim ownership of the Nixon/Heritage/Romney/ACA model. This shift seems likely to unmuzzle single-payer supporters who closeted themselves during the ACA era, fearful that calls for more radical reform would fan right-wing attacks. Already Elizabeth Warren, previously reluctant to criticize the ACA, has been liberated: “Let’s be honest: [The ACA’s] not bold. It’s not transformative. … I’m OK taking half a loaf if our message was ‘Here’s half, now let’s go get the rest.’”

A similar strategic perspective motivated PNHP’s founding at a conference of clinicians caring for the poor. After years spent parrying Reagan’s assaults on Medicaid and community clinics, we concluded that a defensive stance was untenable. The U.S. health care system, even with Medicaid intact, prioritized corporate greed over patients’ needs, and was politically indefensible. It wasn’t possible to fix health care for the poor without fixing it for everyone.

That conclusion holds today. For the working class, incomes have stagnated and out-of-pocket costs have soared. For whites without a college education, death rates are rising, driven by diseases of despair like suicide and substance use. Trump spoke (disingenuously) to that despair; Clinton failed to. The resonance of Bernie Sanders’ single-payer message is backed up by polls that show three-fifths of Americans – including a majority of those who want the ACA repealed, and 41 percent of Republicans – favor a “federally funded healthcare program providing insurance for all Americans.”

In health care, reform must address the pressing problems of the majority who have private coverage and Medicare, as well as those who are uninsured or on Medicaid. Only single payer can do that.

A few suggestions for work in the months ahead:

1. Colleagues are, more than ever, receptive to the single-payer message. Let’s talk about it in corridors, conferences, lecture halls and national meetings; use Facebook, Twitter, email and snail mail to recruit new PNHP members; and push journal editors to end their virtual blackout on single payer.

2. With Medicaid under attack, in many states we’ll need to join in its defense. But we must simultaneously declare that this halfway measure is no substitute for real reform. Let’s not repeat the error of ACA backers who tried to convince people that their health care problems had been solved. Similarly, defense of Medicare should not paper over that program’s flaws.

3. We need to help focus the anger at elites onto the real health care elites: insurance and drug firms, and corporate health care providers.

4. In the past PNHP has focused narrowly on single-payer reform, avoiding participation in most broad-based coalitions. We should reconsider that stance in the context of the broad opposition to the Trump regime, and the urgency of threats to our communities. Effective action will require coalitions that span many issues. We should participate in those that include a demand for single payer.

5. It’s time to ramp up organizing for H.R. 676. Politicians can no longer seek refuge in the fiction that health reform is a “done deal” and is working. While work for state-based reforms can provide a useful organizing tool, it cannot address the nation’s most acute health care problems, which are concentrated in states with little hope of local legislation.

https://www.pnhp.org/news/2016/november/health-reform-in-the-trump-era

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Comment:

By Don McCanne, M.D.

Health care reform is once again on the national political agenda. It is time for action. The suggestions offered should provide guidance on how each of us can become personally involved.

We do not want a repeat of the process leading to the Affordable Care Act wherein the only ideas permitted were those supported by the medical-industrial complex – insurers and pharmaceutical firms being prime examples. We need to assume a leadership role, even if that means forcing our way into the process, figuratively.

The political insiders are moving into position with their highly flawed policy recommendations that will only make the situation worse. It will be easy to critique their proposals, but it will be crucial that we communicate loudly and clearly our very positive message of ensuring affordable and accessible care for all.

Those who can make it to the PNHP meeting in Washington, DC this weekend should try to do so. Although advance registration has closed, on site registration will be available. Use this link for more information:
https://www.pnhp.org/about/annual-meeting-leadership-training

Start this phase of your activism now.