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By Fareed Zakaria
The Washington Post, March 30, 2017

The recent Republican debacle on health care could prove to be an opportunity. It highlighted, yet again, the complexity of the U.S. system, which continues to be by far the most expensive and inefficient in the advanced world. But President Trump could actually use the legislative collapse to fix health care if he went back to basics and to his core convictions on the topic, which are surprisingly intelligent and consistent.

There is an understandable impulse on the right to assume that health care would work more efficiently if it were a free market, or a freer market. This is true for most goods and services. But in 1963, economist Kenneth Arrow, who later won a Nobel Prize, offered an explanation as to why markets would not work well in this area. He argued that there was a huge mismatch of power and information between the buyer and the seller. If a salesman tells you to buy a particular television, you can easily choose another or just walk away. If a doctor insists that you need a medication or a procedure, you are far less likely to reject the advice. And, Arrow pointed out, people think they don’t need health care until they get sick, and then they need lots of it.

Every advanced economy in the world has implicitly acknowledged his argument because they have all adopted some version of a state-directed system for health care. Consider the 16 countries that rank higher than the United States on the conservative Heritage Foundation’s Index of Economic Freedom. All except Singapore (which has a unique state-driven approach) have universal health-care systems that can be described as single-payer (Medicare for all), government-run (the British model) or Obamacare-plus (private insurance with a real mandate that everyone opt in). Hong Kong, often considered the most unregulated market in the world, has a British-style government-run system. Switzerland, one of the most business-friendly countries, had a private insurance system just like the United States’ but found that, to make it work, it had to introduce a mandate.

While producing a CNN documentary on health-care systems around the globe, I was particularly struck by the experience of Taiwan, another free-market haven. In 1995, 41 percent of its population was uninsured and the country had very poor health outcomes. The government decided to canvass the world for the best ideas before instituting a new framework. It chose Medicare for all, a single government payer, with multiple private providers. The results are astonishing. Taiwan has achieved some of the best outcomes in the world while paying only 7 percent of its gross domestic product on health care (compared with 18 percent in the United States). I asked William Hsiao, an economist who helped devise the country’s model, what lessons they took, if any, from the United States. “You can learn what not to do from the United States rather than learn what to do,” he replied.

Americans often assume that despite its costs, American health care provides better services than others. We often hear about the waiting time for care in other countries. But according to the Commonwealth Fund, among industrialized countries the United States is in the middle of the pack for wait times, behind even Britain . Moreover, one of the world’s leading experts, Uwe Reinhardt of Princeton, has found that Americans use less care than the average for developed countries when it comes to things such as seeing a doctor and spending time in the hospital. The problem with the free market is that there is little profit in prevention and lots in crisis care.

Trump has now taken up the call to repeal Obamacare. But until recently, health care was actually one of the rare issues on which he had spoken out, before his campaign, with remarkable consistency. In his 2000 book “The America We Deserve,” he wrote:

“I’m a conservative on most issues but a liberal on this one. We should not hear so many stories of families ruined by healthcare expenses. . . . We must have universal healthcare. . . . The Canadian plan . . . helps Canadians live longer and healthier than Americans. There are fewer medical lawsuits, less loss of labor to sickness, and lower costs to companies paying for the medical care of their employees. . . . We need, as a nation, to reexamine the single-payer plan, as many individual states are doing.”

Trump was right on this issue for much of his life. He has now caved to special interests and an ideology unmoored by facts. He could simply return to his convictions, reach out to Democrats and help the United States solve its health-care crisis.

https://www.washingtonpost.com…

Interview with Adam Gaffney, M.D. and Saurabh Jha, M.D.
The BMJ Podcast, March 29, 2017

Excerpt from Dr. Gaffney, responding to Dr. Jha’s charge that a single-payer national health program would provide overly generous benefits:

I agree that health care is not one size fits all. Health care is unique to the individual. We all have unique wishes, we all have unique wants, we all have unique medical problems, we all would want different things at the end of life, we all have different thoughts about various reproductive health care issues, and so on and so forth.

So health care is unique, but health coverage should be universal, and I think differentiating between those two things is fundamentally important.

Yes, we all have our own wishes and maybe someone who has different life experiences is going to seek out different care than someone who has another set of life experiences. But coverage should be universal. The full spectrum of comprehensive care should be covered.

[Opponents] might say that’s sort of a regressive tax on people who don’t use that much health care, but that is only true if the health care system is being funded in a regressive manner.

If we fund the health care system through progressive taxation, then people people pay in what they can afford to pay in on the basis of their income, and then they use the health care services that they need on the basis of their needs and of their wishes.

full interview:
https://soundcloud.com…

The BMJ Podcast is hosted by Peter Doshi. He was joined by Dr. Adam Gaffney, from Harvard Medical School, and Dr. Saurabh Jha, from the Hospital of the University of Pennsylvania.

By Jack Bernard and Doug Skelton, M.D.
The Telegraph (Macon, Ga.), March 28, 2017

We were encouraged by President Trump’s campaign promise to “cover everyone.” What happened, Mr. President? No wonder Trumpcare/Ryancare failed to even get a House vote.

Trumpcare/Ryancare has been rated by the Congressional Budget Office. It leaves an additional 24 million people out in the cold without insurance. Added to the 30 million now uninsured, that gives us over 50 million with no coverage.

For a “non politician,” you seem to be learning fast. Promise anything to get elected and then renege on your pledges of coverage.

Yes, Trumpcare/Ryancare reduces the deficit. But how: by eliminating the subsidies that enabled working people to afford to pay their premiums and cutting out Medicaid expenditures, dumping the fiscal and moral problem onto the states.

Not only that, but Trumpcare/Ryancare significantly cut taxes for those families making over $250,000 a year. Are these folks the “little man” that you pledged to help in your campaign?

Mr. President, you said health care reform is more complex than you originally thought. We agree. What was the rush to replace Obamacare? It has problems, but it has resulted in 22 million, mostly working-class people, getting insurance. These are the very people who voted you into office, by the way. And, they are the ones hurt by your bill.

The main problem with Obamacare is that it is derived from a free market concept emanating from the right-wing think tank, the Heritage Foundation. It was picked up and promoted by Bob Dole when he ran for president. Mitt Romney adopted it in Massachusetts. And it became Romneycare.

Obama decided he didn’t have the votes to get it through a Democratic Congress in 2009. So, he went with an adaptation of Romneycare which is based on private insurance company expansion, hoping to get GOP support. He did not. Sen. Mitch McConnell made sure he didn’t even get one GOP vote.

In any case, that is the wrong model, as shown by many well-documented studies that compare our health care system to that of other developed nations. Our health care cost per capita is much higher than any other nation and our health status (morbidity and mortality) is worse. Italy and Israel, for example, have fine health care, but their per capita costs are one-third of ours.

You recently had Carol Paris, M.D., ejected from your rally in Nashville for promoting single-payer health care (i.e. expansion of Medicare to cover all ages). Dr. Paris is president of Physicians for a National Health Program (PNHP, www.pnhp.org), a respected 20,000-member group advocating for Medicare for all. Why not consider what they have to say?

Before you became a politician, you advocated repeatedly for single payer. What changed? Are the lobbyists for drug and insurance companies influencing you? What happened to draining the swamp? Do you really want to be saddled with Trumpcare/Ryancare in the next election? Obviously, as shown by the House pulling back from the vote, they do not want to be associated with it in 2018.

Our suggestion is that you create a Health Advisory Council composed of the best health policy experts in the nation in order to evaluate the costs and benefits of true universal coverage, expansion of Medicare, as you promised in the campaign.

Mr. President, you are known for changing your positions frequently. We hope you change back to what really works, Medicare for all, before it is too late for you and our nation, not to mention your party in 2018.

Jack Bernard is a retired senior vice president with a national health care firm and the former director of Health Planning for the state of Georgia.

Doug Skelton is the former dean of Medicine for Mercer School of Medicine. He was also the commissioner of the Georgia Department of Human Resources and chancellor of the Trinity School of Medicine.

http://www.macon.com…

With the implosion of “repeal and replace,” the next logical step in Democratic health care reform is Medicare for All.

By Sarah Jones
The New Republic, March 28, 2017

Trumpcare is dead. President Donald Trump is humiliated and so is House Speaker Paul Ryan. The Democrats can hardly believe their luck: The Republicans have hobbled their own agenda, while Obamacare, aka the Affordable Care Act, lives to fight another day. But unlike the law’s previous brushes with death—most notably its bruising encounters with the Supreme Court in 2012 and 2015—this latest example of its resilience represents a turning point, if Democrats choose to seize the opportunity. For three reasons—political, structural, and moral—now is the time for the Democratic Party to begin building a proposal for a single-payer health care system.

Politically, the momentum clearly points left. Long derided by conservatives and centrists as socialist fantasy, single-payer health care (sometimes called Medicare for All) is having a moment. In January, 60 percent of Americans told Pew Research Center they believe the government has a “responsibility” to ensure health care access. That figure tracks with a 2015 Kaiser Health poll, which revealed that 58 percent of voters supported some version of Medicare for All. Democratic Socialists of America have experienced significant membership growth since Trump’s election, and its activists are canvassing for single-payer in New York and California. California gubernatorial candidate Gavin Newsom just added a version of the policy to his campaign platform. And Senator Bernie Sanders reigns as the country’s most popular politician—and he ran in the Democratic primary on a platform that included Medicare for All.

For long-time advocates of single-payer, this is all rare good news. Dr. Steffie Woolhandler, a co-founder of Physicians for a National Health Program, expressed tentative optimism in an interview with the New Republic. “We’ve been getting a lot of requests from professional journals and physicians and professional organizations to speak on the issue of single payer,” she said. “As someone who’s been doing this a long time, I’m seeing a lot of interest about single payer.”

There’s evidence that this is more than an anecdotal observation. Nobody except the White House and the insurance industry wanted Trumpcare. The bill, otherwise known as the American Health Care Act, would have in many ways returned the health care system to the pre-Obamacare status quo. By upending Medicaid and repealing the individual mandate, it would have taken insurance away from tens of millions of people and made it more expensive for the poor, the elderly, and the sick. A Quinnipiac University poll found that 56 percent of Americans opposed the bill, while a mere 17 percent supported it. Not even a majority of Republican voters supported the bill. Critics of the AHCA were outspoken: They swamped congressional offices with phone calls, an outgrowth of earlier town hall disruptions. Trump’s approval ratings sank to a miserable 37 percent.

Trumpcare failed for numerous reasons, starting with the incompetence of President Trump himself and the dysfunction of the Republican Party. But the defeat of Trumpcare points to a deeper, simpler politics surrounding health care. Most voters have no opinion on the efficacy of high-risk pools. They think in expansive terms: They want health care, and they want more of it, not less. Trumpcare threatened that basic interest. If Democrats are to capitalize on this moment, they can’t satisfy themselves with merely preserving Obamacare. The failure of Trumpcare proved that Obamacare is a floor, not a ceiling; in fact, Trump himself helped establish that floor by duping his supporters into believing that “everybody” would be covered under a Republican health care plan. What voters want is better, more generous care, and the smart response is to give it to them.

Is single-payer the policy answer to more and better coverage? Calls for single-payer invariably provoke concern over its practicality and expense, and it is true that single-payer proposals have to account for a drastic transition process. According to the University of Chicago’s Dr. Harold Pollack, there’s no doubt that “a well-functioning single-payer system would work better than the current American health system.” But he said advocates must account for the dysfunctional system they’ve inherited.

“The challenge that I have is that people often talk about single-payer as an alternative to the pathological political economy that drives American health care and American health politics,” he told the New Republic. “And a single-payer system would have to be a product of that exact same troubled political economy, and would have to bake in many of the defects that we have in our current system in order to come about.”

This dynamic is partially why then-President Barack Obama had to fight conservatives in his own party to pass the incremental reforms offered by the ACA. Obama himself became more conservative on the issue: Though he once supported what he called “a single-payer universal health care program,” he came to believe that single-payer would be “too disruptive” for the health care industry.

But this triangulation leaves us a patchwork system for a universal problem. Most Americans still get health insurance from their employers, but this coverage can still be expensive. Qualify for Medicaid, and you have to hope the government will provide the medications your doctor says you need. Qualify for Medicare, and you may still need to purchase supplemental Medicare plans to cover your expenses. If you qualify for neither, and don’t have insurance from an employer, then the ACA’s exchanges are your only option. But if you can’t afford the premium, you’ll have to pay a fine.

The system’s deficiencies are well-known. For one, this thin safety net doesn’t actually save the country any money. The World Bank reports that, in 2014, America spent more on health care as a total share of its GDP than any other nation save for the Marshall Islands. Our health care system is also one of the most inefficient on the planet: Bloomberg reported last September that America ranks 50th out of 55 nations its health care efficiency index. The question is not if the ACA and Medicare and Medicaid are inadequate. This is self-evidently true.

What is new is that Trumpcare’s failure proved, in the most emphatic way possible, that you can’t go further right than the Affordable Care Act without starting to drop people en masse from health insurance coverage. As David Leonhardt pointed out in the New York Times, Democrats have moved right on the issue for decades, culminating in the ACA—if you want to improve health care in this country, there is nowhere else to go but left. That is why the call from centrist liberals for more “market-based” health care reform makes little sense. People object to the status quo; they will not be content with its maintenance.

Pollack, who supports an incrementalist approach to reform, urged single-payer supporters to focus on defending the ACA’s Medicaid expansion and to demand a public option in the Obamacare exchanges, which would theoretically bring down the costs of health care plans in the individual market.

Woolhandler, meanwhile, says the answer is an improved and expanded version of Medicare. “Make the coverage cover all medically necessary services without copayments and deductibles and proscribe the participation of private health insurance industry in the Medicare program,” she suggested. The result, she argued, would be less expensive than America’s current system. Vijay Das, a strategist for the think tank Demos, suggested a similar strategy, with a particular focus on state-based policies. “I think expanding Medicare to children is a safe way of expanding the risk pool, getting healthy people into the system and lowering costs,” he explained.

All these proposals, in their own ways, logically lead toward single-payer. But they face numerous political obstacles, and Das says the Democratic Party is one of them. “It’s partly because the party that used to be the proponent of single-payer has been largely captured by the interests who think single-payer will destroy their profits,” he explained. “For me, it’s a money in politics issue, not as much as a mobilization issue.” As Lee Fang reported for The Intercept last year, Democratic consultants helped raise $1 million to defeat a single-payer proposal in Colorado. The same consultants had links to the Obama administration and the Clinton campaign.

Health care reform is a problem with a dual nature. It’s a matter of policy, yes, but of morality too, and there is an unassailable moral logic for single-payer. Opponents of single-payer must reckon with it, just as they ask advocates to reckon with political practicalities. Advocates must repeatedly ask: Is the status quo tolerable? “Even with the ACA’s advances,” Das said, “it’s really, really difficult to tell somebody who is in and out of work, is working class, and doesn’t qualify for Medicaid, that their $465 a month-even-with-subsidies-premium is something they should be happy about.”

There is a body count attached to every delay and half-measure. On February 17, Amy Schnelle suffered a seizure and died. She was 31 years old, reported WATE 6 of Knoxville, Tennessee, and unable to work due to the severity of her epilepsy. Medicaid covered her treatment and she lived relatively seizure-free—until September 2016, when Medicaid cut off one of her prescriptions. “I couldn’t imagine what would happen if I’m off of my medicine for a week,” she told the news station at the time. “I could roll into seizures.” She appealed the decision, but no luck. Medicaid’s decision can’t be attributed to Donald Trump, either. It occurred under the Obama administration.

Schnelle slipped through the system’s spiderweb cracks. She was lucky to even qualify for Medicaid: States aren’t required to expand it, and the ACA’s subsidies often aren’t generous enough to make up the difference for people who can’t use it. These cracks are numerous enough, and create a void wide enough, that crowd-funding campaigns proliferate as an alternative. In 2015, the Los Angeles Times reported an “uptick” in the use of websites like GoFundMe, Indiegogo, and YouCaring for health care needs. These campaigns bare the desperation of those in need—and the catastrophic consequences of their inadequacies.  After relocating to care for his dying mother, Shane Boyle, a type-1 diabetic, started a GoFundMe campaign to cover a month’s worth of insulin due to a gap in his insurance coverage. His mother died on March 11. Boyle died of diabetic complications one week later, without meeting his fundraising goal. His family has started a new GoFundMe to pay for his funeral.

The moral case for universal health care is too often obscured by red-baiting. But once you accept that everyone should be covered, and establish that the expansion of government programs is the only viable path to achieving that goal, that case is difficult to ignore. Trumpcare’s defeat offers Democrats a chance to move from a defensive crouch to a positive vision that affirms the moral significance of health care as a human right. The market can’t compensate for the system’s deficiencies. In fact, the market is precisely what restricts the ACA’s salvific properties, and that has deadly consequences for the sick. How many Shane Boyles must we accept in deference to it?

The seed is there if Democrats are willing to water it. The Washington Post’s Dave Weigel reported Sunday that Rep. Jim Langevin (D-RI) and House Minority Leader Nancy Pelosi (D-CA) recently told constituents they are either interested in or expressly support single-payer health care. Rep. Keith Ellison (D-MN) is on record supporting Medicare for All, and Sen. Elizabeth Warren (D-MA) also indicated she supports some version of a single-payer system.

They’ll have a test soon: Sanders has announced that he will re-introduce his Medicare for All bill, and a similar measure in the House has 72 co-sponsors. Neither will pass in a Republican Congress, but that’s not really the point. As Ryan Cooper recently argued in The Week, popular support for Medicare means that Medicare for All proposals are “an excellent organizing signpost.” The concept obviously appeals to the party’s base—and could be marketed in a way that appeals to low-income Republicans at odds with the GOP’s austerity.

The Democrats spent years preparing themselves for Obamacare. Now is the time to do the same for single-payer. Now is the time to organize and to develop evidence-based policies they can actually implement when they’re back in power. The transition will cause disruption, but it can and should be managed. The alternative is intolerable. “We need health care,” a West Virginia coal miner told Sanders during an MSNBC town hall earlier this month. “Everybody in this room needs free health care.” He gets it. Sanders gets it. It’s time everyone else did, too.

Sarah Jones is the social media editor at The New Republic.

https://newrepublic.com…

With the demise of Trumpcare, there’s no better time to fight for single-payer.

By Adam Gaffney, M.D.
Jacobin, March 27, 2017

We should take great pleasure in the fall of the American Health Care Act (AHCA). The AHCA was essentially what you would get if you convinced Ebenezer Scrooge to heavily edit the Affordable Care Act (ACA), which made it at the same time unoriginal, nasty to the poor, and generous to the rich.

In its original form, the AHCA would have, in Dickensian fashion, cut some $880 billion in Medicaid spending over a decade, thereby reducing enrollment by 14 million by 2026 and fulfilling Paul Ryan’s sick collegial dreams. It would have largely turned the ACA’s premium- and income-based tax credits into flat vouchers, leaving millions unable to buy a health plan. It likely would have blocked some women’s access to abortion. And it would have diverted some $883 billion in tax breaks to, for the most part, the very wealthy and the medical-industrial complex.

But now it is as good as dead. Good riddance.

At the same time, its demise does not mean we are moving forward, only that we are treading water. Here are five reflections on the death of the AHCA, and on the path ahead.

1. This was the right-wing plan.

Many described AHCA as hastily conceived and slapdash, which is to some extent true. However, in partial defense of Paul Ryan (words very reluctantly uttered), the AHCA was heavily based on a detailed blueprint, “A Better Way,” that he and the House GOP published nine months ago. The surprise over the bill’s content was itself surprising.

The truth is that in the context of strong popular support for Medicare — and given that the Right has no actual desire to undermine the private health insurance industry — the AHCA was about the most they could (or for that matter, wanted to) achieve: namely, a weird version of the ACA with more regressive funding and paltrier benefits, along with the partial strangulation of Medicaid and a middle finger to Planned Parenthood.

They really don’t have anything else up their sleeve. If they try to repeal Obamacare again, it will likely be with some variety of the same nonsense.

2. The AHCA’s collapse is not an endorsement of the health care status quo.

The AHCA was extremely unpopular, but its failure does not mean all is well with the US health care system. While the AHCA would have increased the ranks of the uninsured to an inhumane 52 million, an estimated 28 million will still remain uninsured by 2026.

Today, families are squeezed by rising drug prices and high copayments and deductibles, too often facing bankruptcy and financial strain. By slashing the health care safety net, the AHCA would have sharply exacerbated these problems. But Paul Ryan’s callousness doesn’t make the present state of affairs any less deplorable.

Indeed, a large part of the popular discontent with the ACA is less about what the law did than what it failed to do. Now fully implemented, the ACA modified — but did not remake — the US health care system. People remain justly angry that they’re still being squeezed.

Wrangling over the ACA’s positives and negatives is going to be less relevant with each passing year: it will remain, as Ryan admitted during a glum press conference last Friday, “the law of the land.” Moving forward, criticism should be aimed less at Barack Obama’s law (which, we should acknowledge, did some real good), and more at the persistent injustices and inequalities intrinsic to the American health care status quo: uninsurance, underinsurance, racial health inequalities, tiers of access based on insurance, extortionist drug prices, medical bankruptcies, inferior health outcomes, needless deaths, and so forth.

3. The Left is winning the discursive battle.

When the Congressional Budget Office reported that the AHCA would result in an additional 24 million uninsured, it was widely seen as a damning indictment. The notion that all should be covered — that there is a right to health care — is increasingly becoming common wisdom, such that even the Right has taken to cribbing the Left’s language: Republicans chattered nonsensically about “universal access,” while Trump vowed that he would cover everybody.

However, on the Left, it is critical that we not allow the language of universal health care to be adulterated. Many already speak of the ACA as a universal health care program, a puzzling assertion given the 28 million or so that remain uninsured.

In addition, we should envision health care universalism along much broader and more egalitarian lines: the elimination of uninsurance, the end of cost-sharing, and the creation of a single tier of coverage that provides equitable access to health care for all.

For instance, as critically important as Medicaid is to the more than 70 million Americans who rely on it, we shouldn’t forget that its participants sometimes receive segregated care, or are relegated to the back of the line. Clearly, health care equity necessitates equitable health care coverage.

And equitable systems save lives: as a widely reported study recently described, individuals with cystic fibrosis (CF) in Canada live on average an entire decade longer than their counterparts in the US. Canadians with CF also received more lung transplants, even though the US is allegedly king when it comes to high-tech care.

4. National single-payer is the next step.

In fact, this is already happening. “In the wake of the Republican failure to repeal the Affordable Care Act on Friday, leading figures in the progressive wing of the Democratic Party are rallying behind a single-payer health insurance,” a Huffington Post article over the weekend began. “Sanders to offer single-payer health care plan,” a headline in Politico yesterday read. Democratic congressman John Conyers reintroduced his single-payer bill in the House earlier this year.

And most importantly, activist groups are organizing with muscle and creativity throughout the country.

The iron is clearly quite hot. With the death of the right-wing challenge, single-payer is the alternative to the health care status quo. Various half-measures are not worth it at this point. For instance, a “public option” is sometimes described as a way to shore up private health insurance exchanges, but that’s precisely what we’re not trying to do. We’re trying to replace them.

5. This is a winnable battle.

A majority of the country wants single-payer. Both physicians and nurses voice strong support. And now the conservative alternative has been disgraced. Politicians have yet to follow the populace, but, with enough grassroots activism, they can be pressured and flipped, or — if recalcitrant — confronted with primary challenges or defeated at the polls.

The insurance industry will no doubt fight to the death, but it’s enormously unpopular, and surmountable.

A single-payer universal health care system would not, by itself, secure the much larger goal of health justice. To accomplish that, all types of oppressions — along racial, gender, economic, and environmental lines — would need to be undone.

But it would be an enormous first step.

Adam Gaffney is an instructor in medicine at Harvard Medical School and a pulmonary and critical care doctor at the Cambridge Health Alliance. He blogs at theprogressivephysician.org.

https://www.jacobinmag.com…