PNHP

Can the actuaries design a more effective and equitable financing system?

Can the actuaries design a more effective and equitable financing system?

Actuarial Challenge: Announcement of Round One Results

Robert Wood Johnson Foundation

The Actuarial Challenge, sponsored by the Robert Wood Johnson Foundation (RWJF), brings actuaries together to explore approaches to stabilize the individual health insurance market. The Challenge is administered by Milliman, Inc. and actively promoted by the American Academy of Actuaries and the Society of Actuaries. Support for the Actuarial Challenge is being provided by the Robert Wood Johnson Foundation.

The Challenge kicked off in late September. Almost 70 participants registered, comprising 20 teams. Initial papers were submitted by December 9th. The papers each presented a proposal of various ways in which the individual health insurance market could be reformed. The proposals were not intended to be comprehensive, but to offer ideas on different ways to improve certain aspects of the current system. A panel of five judges (all actuaries) reviewed each paper and ultimately selected five papers to move on to the next round. Round Two involves the selected teams working with Milliman to model their proposals to illustrate the potential financial impact on the individual health insurance market.

Round Two Proposals

Individual Market Redux
Revises rating to allow a wider premium range by age (5-to-1) and limited consideration of an enrollee’s health status in setting premium rates via an automated process (up to an additional 50% of premium). Uses contributions to individual health savings accounts for mid/low income consumers to replace premium and cost sharing subsidies. Revises risk adjustment methodology and restores a reinsurance mitigation program. Uses Medicaid reimbursement levels and increases health cost transparency. Increases penalties for not obtaining health insurance, but allows more benefit plan design flexibility. Reduces mandated benefits based on scientific evidence and use of an independent board. Incentivizes payment reform, integration of healthcare information, implementation of clinical best practices, and value-based care.

Why Not BE HIP?
Establishes a nationwide Basic Essential Health Insurance Plan (BE HIP) covering a core set of services/benefits set by federal regulation. Allows purchase of state regulated standardized supplemental plans (benefit riders) to offset cost sharing (i.e., upgrade to richer benefits). Automatic enrollment and/or penalty of full cost of basic plan if not enrolled. Uses a risk adjustment program and reinsurance to protect insurers. Premium equalization process to account for socioeconomic variations between insurers in a given market. Premium subsidies use similar methodology as the Patient Protection and Affordable Care Act (ACA), although percentages may differ.

The Simplifiers
All residents receive a fully publicly-funded preventive plan and must purchase an insurance plan for non-preventive services. Insurers must offer a standard plan but may offer additional plans subject to state regulations such as actuarial soundness, minimum coverage levels and loss ratios. Premiums will be limited to significantly lower and more affordable levels. A simplified, permanent publicly funded risk mitigation program based on reinsurance formulas will result in reduced premium. Hospital costs will be reduced by payment at Medicare reimbursement levels. Drug costs will be lowered by allowing purchase from qualified international locations. Simplified low-income premium discounts will be available. Penalties equal to the lowest cost insurance plan will apply for non-coverage. Lifetime universal Medical ID cards will be used to monitor enrollment, provide electronic medical records, and act as low-interest credit cards to pay for premiums and out-of-pocket medical expenses. Exchanges will act simply as informational websites.

Panoptic
Uses auto enrollment into newly defined catastrophic plans to enforce participation, and combines the individual and small group markets (with no self-funding allowed in the small group market). Consumer can add benefits through purchase of supplemental benefit riders. Block funds for subsidies provided from federal to state for the state to administer. Elimination of dual regulation to reduce expenses. Allows wider rating for age (5-to-1) and lowers or eliminates minimum medical loss ratios. Continues risk adjustment and restores reinsurance for up to five years. The equivalent of cost-sharing reduction (CSR) funds would be deposited into a consumer’s health savings account (HSA), if eligible. Use reference-based benefit pricing for provider fees. Encourages risk contracting with both upside and downside risk to the provider. Eliminates direct-to-consumer advertising. Eliminates grandfathered and transitional business. Focuses on consumer accountability by providing consumers with improved cost transparency and other resources to help them make educated decisions regarding their healthcare.

King of Carrot Flowers
Creates three pools in the individual market: (1) Over 250% FPL (federal poverty level) with state regulated underwritten market, (2) Under 250% FPL with federally funded underwritten and subsidized market, and (3) Special Needs (High Risk) Pool with a federally-funded, highly-subsidized market for individuals with persistent high costs or uninsurable conditions. Guarantee issue, but requires continuous enrollment. Incentivizes providers to manage care. Encourages tax parity between individual and group market by capping group tax deductions. Allows more tax-favored health savings account contributions.

Milliman will work with these five selected teams to model their proposals in February and March. The five Round Two teams will be able to incorporate the modeling results in their final papers.

Other Proposals

Nine other teams have the opportunity to refine their papers for possible exposure on the Actuarial Challenge website (which is hosted by the American Academy of Actuaries) or as decided by the RWJF at the end of the Challenge.

The Mod Squad
Increases incentives to first-time enrollees, but with significant penalties for not obtaining coverage after first year…

JHU Actuarial Club
Provides enhanced benefits (e.g., gym membership, fitness classes, preventive services, etc.) in insurance coverage to encourage younger individuals to purchase…

Policy Proposal for Healthy Behavior Incentive (“HBI”) Plans
Healthy Behavior Incentive Plans encourage a partnership between the insured, insurer, and health care provider to maintain well-being rather than just reimbursement for expenditures…

Underwriting and Premium Rating using Risk Adjustment
Focuses on improving market stability through increased enrollment of lower cost individuals by revising the rating basis to better align with expected costs…

Team DC
Increases individual market penalties to encourage more enrollment by young and healthy uninsured, and mitigate developing anti-selection spiral in the individual market…

Team ACA Version 2.0
Proposes changes to the subsidy and risk adjustment programs…

Consulting Actuaries for Sustainable Healthcare
Insurance reforms to improve actuarial soundness, and provider price & quality reforms, to address unsustainable underlying healthcare spending…

True Health
Develops actuarial incentive compensation for physicians who are effective at addressing the underlying cause of patient health conditions by using the “food as medicine” concept…

A Social Insurance Solution To Health Care Finance
Proposes to use a social insurance model to replace all current health insurance (across all markets). Covers all legal residents in the program through a payroll tax for funding. Insurance plan would cover preventive care and catastrophic care (exceeding 7.5% of income). Low income families would receive additional assistance similar to Supplemental Nutrition Assistance Program (SNAP) benefits. Routine care would be funded by individuals, but administered through a central fund, billing patients as with a credit card. Administrators must negotiate with providers, but must make all fees available to the public.

http://challenge.actuary.org…

About the Actuarial Challenge:
http://challenge.actuary.org

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Comment:

By Don McCanne, M.D.

In designing a health care financing system that is efficient and effective in ensuring affordable access to health care, it seems that the nation’s actuaries should be up to the task. So it is informative to see what recommendations were elicited when the Robert Wood Johnson Foundation, assisted by Milliman, Inc., issued the Actuarial Challenge, calling for an exploration of approaches to stabilize the individual health insurance market.

Of the proposals submitted, five were selected to move into the second round to work with Milliman to model their proposals to illustrate the potential financial impact on the individual health insurance market. Although some proposals would introduce improvements into the individual insurance market, they all would increase administrative complexity and none would ensure affordable coverage for all participants in the individual market.

Nine other proposals were selected for possible posting on the Actuarial Challenge website, although they do no move into round two. They too are quite disappointing except for one proposal – A Social Insurance Solution To Health Care Finance – that seems to acknowledge the importance of a universal system. Though even that proposal requires cash payments for all routine care except preventive care and catastrophic care charges exceeding 7.5% of income. We have plenty of studies to show that the excessive out-of-pocket costs of this model would leave too many people broke and without the care they need.

Except for the social insurance model, the authors of the proposals limited themselves to solutions for the individual market – a relatively small sector of health care – which is understandable since that was the challenge they were given.

There are two predominant disappointments with the submissions for this challenge. The first is that it should be intuitive that the problems of the individual market cannot be resolved with patches limited to that market. The solutions require a fundamental change of the financing infrastructure of our entire health care system, and the actuaries should acknowledge that in their proposals.

The other disappointment is in the nature of the various recommendations. They seem to lack a sensitivity to the imperative to address issues of health care justice, ensuring an equitable system to bring affordable care to everyone, whether just in the individual market or throughout the entire system – the latter actually being the moral imperative.

The model that would work is already well understood – a single payer national health program, aka an improved Medicare for all. Maybe we can teach the actuaries something, though it would be difficult. I will say that I once was a speaker at a national meeting of actuaries, and I did find that there was some insight amongst the members, but that didn’t translate into policy recommendations.

Lawmakers ignore better health care reform plan

By Stephen B. Kemble, M.D.
Honolulu Star-Advertiser, Feb. 20, 2017

Hawaii’s once-exemplary health care system is now starting to fall apart due to policies pushed by Medicare, HMSA, the Ige administration and a few key legislators, including the chairwomen of the Senate and House health committees.

The Legislature passed a bill in 2009 to create the Hawaii Health Authority (HHA), intended to plan for a universal health care system covering everyone in Hawaii. However, the Abercrombie administration stripped the HHA of its funding and refused to allow it to influence policy, and now the Ige administration has introduced bills to repeal the HHA. Sen. Roz Baker, chairwoman of the Senate Health Committee, strong-armed this bill through her committee despite overwhelming testimony against repeal. Rep. Della Au Belatti, chairwoman of the House Health Committee, refused to schedule a bill to revitalize the HHA.

It is now clear that key political leaders are determined to protect the HMSA government echo chamber that is aiding and abetting HMSA in its health care “transformation” reforms. Medicare is now imposing similar reforms.

These are the reforms that are “fixing” a fabricated, fake problem – fee-for-service payment of doctors – by piling on more and more of the real problem, crushing administrative costs and burdens and escalating micromanagement and interference in day-to-day patient care.

These are the cause of an epidemic of physician “burnout,” driving older doctors out of practice, and deterring younger doctors from entering primary care and specialties such as psychiatry that are being subjected to the worst micromanagement and administrative burdens.

Primary care practices in Hawaii are closing to new referrals at an accelerating pace. Crown Care, a physician finder service on Oahu, found that as of five months ago, 31 percent were already closed to all referrals and almost half were closed to new Medicare referrals. As older doctors retire, their patients are dumped into a shrinking pool of remaining primary care practices, which then start closing to new referrals also. As the availability of doctors collapses, we will see tremendous pressure on already overloaded emergency rooms and hospitals from those who cannot get care anywhere else, and our once-exemplary health care system will collapse.

In contrast, HHA’s proposal would focus on administrative simplification by keeping payment for physicians and hospitals as incentive-neutral as possible, eliminating the justification for micromanagement of care. The proposal would base physician pay on professional education and training and time spent on patient care, and end “pay-for documentation.”

It would eliminate pay-for-performance and most prior authorizations by removing unaccountable middle men – such as prior authorization contractors and pharmacy benefits managers – from health care, and greatly simplify billing and collections. Physician practice overhead could be reduced by 10-20 percent. With incentive-neutral pay, doctors would be guided by professional ethics and concern for the best interest of their patients, instead of manipulation with financial incentives controlled by clueless bureaucrats.

Given that administrative costs now consume about a third of the health care dollar, the administrative simplification recommended by the HHA could save 20-30 percent of Hawaii’s health care cost without harming doctors and hospitals, and free doctors from the suffocating administrative burdens now being imposed. Hawaii would become a magnet for doctors wishing to practice in a state that supported them instead of micromanaging them.

The public needs to know that it is bad government policy that is causing Hawaii’s worsening doctor shortage. It is time for a change, and we need the reforms proposed by the Hawaii Health Authority more than ever.

Stephen B. Kemble, M.D., is a psychiatrist and former Hawaii Health Authority member.

http://www.staradvertiser.com…

UnitedHealth’s gaming of Medicare is now in court

Scheme Tied to UnitedHealth Overbilled Medicare for Years, Suit Says

By Mary Williams Walsh
The New York Times, February 16, 2017

UnitedHealth Group, one of the nation’s largest health insurers, is accused in a scheme that allowed its subsidiaries and other insurers to improperly overcharge Medicare by “hundreds of millions — and likely billions — of dollars,” according to a lawsuit made public on Thursday at the Justice Department’s request.

The accusations center on Medicare Advantage, a program through which people 65 or older agree to join private health maintenance organizations, or H.M.O.s, whose costs the government reimburses.

The program was created in 2003 after UnitedHealth and other insurers said that managed care could help contain the overall cost of Medicare, which has strained the federal budget by rising faster than the rate of inflation.

Instead of slowing Medicare costs, UnitedHealth may have improperly added excess costs in the billions of dollars over more than a decade, according to the lawsuit, which was unsealed in Federal District Court in Los Angeles.

The newly public accusations were first made in 2011, when a former UnitedHealth executive, Benjamin Poehling, filed a complaint under the False Claims Act, a federal law that allows private citizens to take legal action when they believe a government program has been defrauded.

The Justice Department’s court notice that it was joining the case involving UnitedHeath was filed by Chad Readler, a lawyer who joined the agency’s civil division as part of the Trump administration.

Mr. Poehling was finance director for UnitedHealthcare Medicare and Retirement, a subsidiary that works with the Medicare Advantage program. His complaint describes “a corporate culture that demands and rewards financial success from its employees,” including initiatives to increase a billing practice known as “risk adjustment.”

Mr. Poehling said that he and other employees were given “risk adjustment” targets and their performance was evaluated based on how well they achieved them.

Attached to his complaint was an email message from his division’s chief financial officer, Jeffrey J. Knutson, urging staff members “to really go after the potential risk scoring that you have consistently indicated is out there.”

“Let’s turn on the gas!” Mr. Knutson wrote. “What can we do to make sure we are being reimbursed fairly for the members and risk we take on more than what we are currently doing.

“When we meet next on our steering committee, I’d like to see what it would take to add another $100M to our 2008 revenue from where we are. What would be doable? What resources would you need? What technology would you need?”

Medicare initially paid the H.M.O.s a fixed rate per member, no matter what chronic conditions members had. That made the H.M.O.s avoid signing up unhealthy people, because they required more care, reducing the companies’ profits.

The approach changed in 2003, when the Centers for Medicare and Medicaid Services added a “risk adjustment factor” to its reimbursement schedules for managed care. That made H.M.O.s more willing to sign up unhealthy people, but it also gave them a new incentive: to make people appear sicker than they were. UnitedHealth had a unit that helped its subsidiaries and other insurance companies perform risk adjustment calculations.

Medicare Advantage’s rules require that for patient care to qualify for risk adjustment factors, a patient’s condition must be verified in person on a regular basis by a qualified professional.

But Mr. Poehling said that coding specialists would instead mine patient records, looking for hints of a possible long-term condition. When they found one, they would request the higher payment without going through the required in-person evaluation.

The realization that medical records could be mined for extra money appears to have given rise to a cottage industry of consulting firms offering to screen patient histories and look for indications of long-term health problems that could be used to increase Medicare reimbursements.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Innumerable studies that we’ve written about have shown that the private Medicare Advantage plans have gamed the system at the expense of taxpayers by surreptitiously selectively enrolling healthier, less costly patients, and then, when risk adjustment was introduced to correct for this favorable selection, the plans upcoded to qualify for higher payments by making the patients appear sicker than they really were.

Finally, the legal system has caught up with them. First a whistleblower suit was filed under the False Claims Act, and now, under the Trump administration, the Justice Department has joined in that action.

UnitedHealth contends that they complied with the program rules. Technically, that may be true. The Bush and Obama administrations along with Congress were complicit with efforts to ensure success of the private Medicare Advantage plans as a first step toward eventually privatizing the Medicare program. Insurance innovation has been praised by the privatizers. In this instance, innovation is enhanced by interpreting quite loosely the federal regulations on favorable selection and risk adjustment.

We need a little perspective here. There is no question that the insurers manipulated the system to gain a greater return than the actual health of their enrollees warranted. But private for-profit corporations have a responsibility to their shareholders to do precisely that – maximize returns – and they will every time.

Whether or not there is a technical violation of the regulations, it is the insertion of a rent-seeking intermediary that is the fundamental flaw here. Gaming favorable selection and risk adjustment does not occur in the traditional Medicare program. Gaming the system is expensive because it requires more administrative efforts to pull it off. The private plans have about five times the administrative costs of the traditional Medicare program, and we taxpayers are footing the bill.

The inferiority of the private Medicare plans is not a newly discovered fact. My very first Quote of the Day (before I realized what I was starting) was Congressman Pete Stark’s response to Karen Ignagni of AAHP (precursor to AHIP) who was boasting about Medicare + Choice plans (precursor to Medicare Advantage). She said that the the early results of the plans provided proof that the private sector could provide higher quality at lower costs. (In fact the evidence was the opposite in that Medicare + Choice plans soon began to pull out of the market because they could not deliver on that promise. But the market was saved by converting to Medicare Advantage on terms much more favorable to the insurers.) Pete Stark, not known for mincing words, responded to Ignagni’s praise of private Medicare plans by saying, “She’s full of more s*** than a Christmas goose.”

Obviously the insurers violated what should have been the intent of the laws and regulations. But they will always do that if it accrues to their benefit. The solution is simple: throw them out, fix Medicare, and then expand it to include all of us. An immediate benefit is that it would also end discussion of all of the flawed policies being considered under repeal and replace.

California legislation would create single-payer health care system

By Emily Green
San Francisco Chronicle, Feb. 17, 2017

President Donald Trump caused a stir when he suggested Sunday that the Republican quest to repeal and replace the Affordable Care Act could continue through 2018. However, some Republicans think he’s on to something. Some think it’s more realistic to think that way. The current plan is a multi-step path, requiring the GOP to use the budget reconciliation process to partly repeal Obamacare by a majority vote.

A push for a single-payer health care system in California is making a comeback.

State Sen. Ricardo Lara, D-Bell Gardens (Los Angeles County) plans to introduce legislation Friday to create a single system that would provide health insurance to every California resident.

“This is our opportunity to put ourselves on the record and be proactive against a Trump administration that is hellbent on eliminating the Affordable Care Act,” Lara said.

The two-page bill contains no specifics. Friday was the deadline for introducing new legislation, and the bill will be fleshed out over the coming month, Lara said. It will first head to the senate Health Committee and then to the senate Appropriations Committee, which Lara chairs.

Previous efforts to create a single-payer system have failed. At least eight bills were introduced between 1992 and 2009 that attempted to create one. They failed to get through the Legislature or were vetoed by Republican governors.

Efforts to create a single-payer system in California ended after the passage of the Affordable Care Act under President Obama.

RoseAnn DeMoro, executive director of National Nurses United, the largest U.S. organization of registered nurses, said the union would mount a “major mobilization” to try to enact a single-payer system in California.

She said she believed it had a better chance than in years past because of President Trump’s efforts to overturn the Affordable Care Act, a more active political base, and a new crop of state legislators who are younger and more open-minded.

“It is one of the most salient issues of our time,” she said.

http://www.sfgate.com…

See also:

California Healthline: Single-Payer Health Care Bill To Be Introduced In California Senate
http://californiahealthline.org…

The Mercury News (Sacramento, Calif.): California lawmakers to introduce universal health care plan today
http://www.mercurynews.com…

Dismal projections for national health expenditures and the numbers of uninsured

National Health Expenditure Projections, 2016–25: Price Increases, Aging Push Sector To 20 Percent Of Economy

By Sean P. Keehan and colleagues at the CMS Office of the Actuary
Health Affairs, February 15, 2017

Abstract

Under current law, national health expenditures are projected to grow at an average annual rate of 5.6 percent for 2016–25 and represent 19.9 percent of gross domestic product by 2025. For 2016, national health expenditure growth is anticipated to have slowed 1.1 percentage points to 4.8 percent, as a result of slower Medicaid and prescription drug spending growth. For the rest of the projection period, faster projected growth in medical prices is partly offset by slower projected growth in the use and intensity of medical goods and services, relative to that observed in 2014–16 associated with the Affordable Care Act coverage expansions. The insured share of the population is projected to increase from 90.9 percent in 2015 to 91.5 percent by 2025.

http://content.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Over this decade, with no further changes in our health care financing system, national health expenditures are expected to increase to one-fifth of our GDP. Unfortunately, our current health care financing system remains incapable of containing health care costs.

Perhaps more alarming is that this decade will reduce the numbers of uninsured by only six-tenths of one percent. Eight and one-half percent of the population will remain uninsured in 2025. Without change, our system will continue to fail to ensure that health care is a right for all.

On a personal note, our daughter-in-law is in Taiwan – her native country – where today she had major surgery for cancer. All went well.

Our son just sent a photo of the mission statement that is posted on the wall of her post-op room.

It begins,

Objective: To promote the basic human right of health

If only President Trump and his colleagues in the District of Columbia truly supported that concept and would act upon it…

Repealing Obamacare will create harm for millions

By Gene Bishop, M.D.
The Philadelphia Inquirer, Letters, Feb. 16, 2017

How can a physician oppose people getting health care? It’s a puzzle to me.

The nomination and confirmation of Dr. Tom Price – widely described in the media as a fierce Obamacare critic – as secretary of Health and Human Services set my physician mind to thinking how two people (Price and I) both trained as physicians, yet have come to dramatically different conclusions on what Americans want and need as patients.

Price once ran the orthopedic clinic at Emory Hospital in Atlanta. I once ran a primary care clinic at a Philadelphia hospital. Patients in both these settings are usually low-income – uninsured, if the clinic will take them, or insured by Medicaid. Before the Affordable Care Act – or “Obamacare,” as it has come to be known – low-income working adults were not eligible for Medicaid.

Without Medicaid either for the individual patients, or under a program of support to hospitals serving low-income populations, there is no care for these folks. The Affordable Care Act – in states that chose to do so – expanded Medicaid to the low-income working population. Repealing Obamacare would end this insurance.

In my training as a physician, I rejoiced to see my patients able to receive care for diabetes, hypertension and cancer.

Tell me, Dr. Price: If you oppose Obamacare and Medicaid expansion, do you envision the poor of Atlanta (or Pennsylvania) letting fractures heal without medical care or anesthesia? In your world, will only those able to pay be allowed to have a new knee or a new hip?

In my primary-care practice, patients and I made decisions together about the best treatment. I can’t remember a single instance – in over 30 years in practice – where the government (Medicare or Medicaid) interfered with that decision, except when a woman wanted an abortion and Medicaid did not pay. But I can think of numerous instances where private insurance companies – the very companies Price wants to strengthen – interfered with my decision-making. And most of the successful appeals were based on government regulations that safeguarded the rights of patients when private insurance ran amok.

So when Price is concerned that the government has “commandeered medical decision-making” – I ask him how? By protecting our seniors from astronomical medical bills because Medicare limits what physicians can charge? I was taught in medical school to put my patients first. Price, under the clever phrase of “empowering patients,” wants to put physicians first.

In medical school, I was taught to respect all patients, to take care of all those who needed care, regardless of income. Price must have been absent that day. I can’t imagine otherwise how he can propose a health-care system that discriminates against the sick, will be unaffordable for the more than 20 million people who have gained insurance under Obamacare and will favor doctors over patients.

Is there anything on which we might agree? He wants to “modernize” Medicare. But if we look closely, Price aims to replace Medicare – the most popular health-insurance plan in the country – with vouchers that will let people buy the amount of care “they need.” He doesn’t say whether we can all buy crystal balls, along with the vouchers, to see into the future. And me? I’d like to see improved Medicare for All – without private insurance companies, co-pays or deductibles. It would save our country, and individuals, billions of dollars. And allow all of us doctors to take care of everyone. I’d rather have that dream than the nightmare I see with Price in charge of health care.

It’s too late to send Price back to medical school to learn what it means to really support patients. But the prescription I write today is for everyone to let their elected officials know that health care for all is important – that we need to improve on Obamacare, but that the health of our state and nation will not be improved with millions losing health care.

Dr. Gene Bishop is clinical professor of medicine at the Perelman School of Medicine, University of Pennsylvania. He can be reached at drgenephilly@gmail.com.

http://www.philly.com…

Obamacare’s Original Sin

We can resist Republican efforts to repeal Obamacare without providing cover for the law’s deep ideological flaws.

By Adam Gaffney
Jacobin, Feb. 15, 2017

Republicans are struggling to find the proper pitch for their attack on the Affordable Care Act (ACA). “Repeal and replace” — the tried and true formulation — may be mutating into something mellower, albeit more vacuous. “Americans want the ACA repealed and repaired,” Republican strategist Frank Luntz recently told the Associated Press, using the new nomenclature.

Should this right-wing retreat — or rather, recalibration — be construed as a victory, however minor? Probably not, for two reasons.

First, whatever the tweak in marketing, the crux of the matter hasn’t changed: Republicans seem poised to engineer an enormous increase in uninsurance in the coming years (at the cost of countless lives).

And second, “repeal and repair” will double down on the worst elements of the status quo. Whatever term they use, Republicans never intended to remove the central pillar of the US health care system (and the ACA): private health insurance.

As two of my colleagues, David Himmelstein and Steffie Woolhandler, put it shortly after Trump’s election:

We suspect that the [Republican’s] likeliest replacement [for the ACA] 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.

The 2016 health care reform framework of Paul Ryan and the House Republicans, for instance, would provide tax credits to help individuals and families purchase private plans “through multiple portals, including private exchanges.” Ryan’s tax credit scheme amounts to a more regressive version of the ACA’s subsidies for plans bought on the “marketplace” (also known as “exchange” or “Obamacare” plans).

In other words, we should expect the looming GOP health care overhaul to be more right-wing regression than reactionary revolution.

This relative continuity highlights an important point: one of the ACA’s key mechanisms for moving us toward universal health care — publicly subsidized, privately sold “marketplace” plans — was never going to achieve its goal.

Millions now rely on these plans, and we should defend them until we can win something better. But we also shouldn’t entertain any illusions: the ACA marketplaces rest on a flawed health care ideology that tellingly attracts many adherents on the Right, including Ryan.

What are the roots of this ideology — sometimes known as “managed competition” — and how can we move beyond it?

full article:
https://www.jacobinmag.com…

Adam Gaffney is an instructor in medicine at Harvard Medical School, a pulmonary and critical care doctor at the Cambridge Health Alliance, and a national board member of Physicians for a National Health Program. He blogs at theprogressivephysician.org.

New CMS rules take good care of insurers

CMS Issues Proposed Rule to Increase Patients’ Health Insurance Choices for 2018

Centers for Medicare & Medicaid Services (CMS), Press release, February 15, 2017

The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for 2018, which proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients. This proposed rule would make changes to special enrollment periods, the annual open enrollment period, guaranteed availability, network adequacy rules, essential community providers, and actuarial value requirements; and announces upcoming changes to the qualified health plan certification timeline.

“Americans participating in the individual health insurance markets deserve as many health insurance options as possible,” said Dr. Patrick Conway, Acting Administrator of the Centers for Medicare & Medicaid Services. “This proposal will take steps to stabilize the Marketplace, provide more flexibility to states and insurers, and give patients access to more coverage options. They will help protect Americans enrolled in the individual and small group health insurance markets while future reforms are being debated.”

The rule proposes a variety of policy and operational changes to stabilize the Marketplace, including:

Special Enrollment Period Pre-Enrollment Verification:  The rule proposes to expand pre-enrollment verification of eligibility to individuals who newly enroll through special enrollment periods in Marketplaces using the HealthCare.gov platform. This proposed change would help make sure that special enrollment periods are available to all who are eligible for them, but will require individuals to submit supporting documentation, a common practice in the employer health insurance market. This will help place downward pressure on premiums, curb abuses, and encourage year-round enrollment.

Guaranteed Availability:  The rule proposes to address potential abuses by allowing an issuer to collect premiums for prior unpaid coverage, before enrolling a patient in the next year’s plan with the same issuer. This will incentivize patients to avoid coverage lapses.

Determining the Level of Coverage:  The rule proposes to make adjustments to the de minimis range used for determining the level of coverage by providing greater flexibility to issuers to provide patients with more coverage options.

Network Adequacy:  The proposed rule takes an important step in reaffirming the traditional role of states to serve their populations. In the review of qualified health plans, CMS proposes to defer to the states’ reviews in states with the authority and means to assess issuer network adequacy. States are best positioned to ensure their residents have access to high quality care networks. Also plans will now be required to include only one0fifth of essential community providers (ECPs) within their networks, removing from the patient the option of receiving care from the other four-fifths of ECPs.

Qualified Health Plan (QHP) Certification Calendar:  In the rule, CMS announces its intention to release a revised proposed timeline for the QHP certification and rate review process for plan year 2018. The revised timeline would provide issuers with additional time to implement proposed changes that are finalized prior to the 2018 coverage year. These changes will give issuers flexibility to incorporate benefit changes and maximize the number of coverage options available to patients.

Open Enrollment Period:  The rule also proposes to shorten the upcoming annual open enrollment period for the individual market. For the 2018 coverage year, we propose an open enrollment period of November 1, 2017, to December 15, 2017. This proposed change will align the Marketplaces with the Employer-Sponsored Insurance Market and Medicare, and help lower prices for Americans by reducing adverse selection.

https://www.cms.gov…

CMS Proposed Rule:
https://s3.amazonaws.com…

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Comment:

By Don McCanne, M.D.

CMS today released a new proposed rule allegedly designed to “protect patients” by stabilizing the plans offered in the ACA insurance exchanges. A cursory reading of the press release would tend to confirm this intent, but a careful reading of the release and especially the executive summary of the proposed rule will reveal that the rule is designed to improve the market for the insurers with a detrimental impact on potential enrollees of the insurance plans.

Revising the CMS rhetoric to match more accurately the actual impact on patients:

* Special Enrollment Period Pre-Enrollment Verification: Qualifying categories for special enrollment will be reduced, and documentation requirements increased. This will reduce the number of individuals with greater needs that the insurers would be required to accept outside of open enrollment – reducing adverse selection, but it will prevent many individuals who missed open enrollment because of the administrative burden from becoming insured.

* Guaranteed Availability: Insurers may apply premiums paid as a credit against unpaid premiums for the prior year, and then deny coverage because of non-payment for the current year. This will protect insurers from individuals who have difficulty paying the premiums, but at a cost of leaving individuals uninsured in spite of a good faith effort to pay current premiums.

* Determining the Level of Coverage: The insurers will be allowed greater flexibility in the variation of the actuarial values for the metal tiers. This greater flexibility will likely translate into less generous benefits for the beneficiary.

* Network Adequacy: The responsibility for regulatory oversight of network adequacy would be further shifted to the states. Although that would reduce the regulatory burden for the insurers, it would also threaten the adequacy of provider networks in states that have relaxed standards of how many physicians and hospitals would have to be included in the networks. Patients may find access to be impaired.

* Qualified Health Plan (QHP) Certification Calendar: Insurers would be allowed more time to incorporate benefit changes and maximize the number of coverage options available to patients. Allowing insurers more time to manipulate the benefits would allow them to reduce services more likely needed by the beneficiaries while increasing coverage for those services less likely to be used.

* Open Enrollment Period: The open enrollment period will be terminated six weeks earlier. This will protect insurers from many individuals with greater health care needs who often enroll later in the open period. This reduces adverse selection for the insurers but at a cost of leaving uninsured more individuals who have greater needs.

It is not only CMS that is catering to the insurers. Right now Congressional staff members are negotiating with representatives of the insurance industry to help write the replace and repair provisions promised by the politicians. It appears that the legislative proposals will be designed to protect and enhance the market for insurers, though at a cost of reducing the adequacy of coverage for the patients.

Why are we taking such good care of the insurers? We don’t even need them. We need a program that takes good care of patients – all patients. That would be an improved Medicare that includes everyone.

As a Christian, I defended Obamacare. But I really support single-payer.

Jesus doesn’t just love the poor. He loves them more.

By Jessi Bohon
The Washington Post, Feb. 15, 2017

A video of me questioning Rep. Diane Black (R-Tenn.) about how her party will replace the Affordable Care Act went viral last Friday. I had gone to her town hall meeting on Thursday near my home to ask what the poor and sick would do once they’re left without the law’s protections. The next night, I had the really weird experience of seeing myself on national television, and the even weirder experience of hearing and reading other people’s interpretation of my own words. My town hall question has been described as a “Christian defense of Obamacare” and “an impassioned case for the ACA’s individual mandate.”

But the truth is that I do not actually believe that the ACA is the best way to insure people. In fact, I am ashamed and afraid that this video might have done more harm than good. In my view, Christians shouldn’t be satisfied with health-care policy that leaves anyone out, especially those who need care most but can afford it least. Christians should support a universal, single-payer system.

I know what it’s like to need a hand. I grew up on an Appalachian hillside in a run-down trailer home with my mom and my two siblings. My mom was orphaned at a very young age, and we had no other family to help us, so we relied almost exclusively on government assistance to survive. Our little church had a van that would pick us up on Sunday, but that’s about all the charity that it could afford. We collected aluminum cans to exchange, walked for hours to and from the grocery store and wrapped up household items in old coupon ads to give to each other as Christmas presents. At age 12, I helped my grandfather, who had suffered a stroke, to walk to and from the bathroom because he and my grandmother couldn’t afford home health care. We were industrious and thrifty like the majority of people receiving government assistance who are working to barely get by. Growing up, I was surrounded by Christians whose politics informed their faith, not the other way around — conservatives who expect poor churches and charities to look after their poor congregations while wealthy people live in luxury.

But my mom cared about politics, especially issues affecting the working class: She used to tell us that Jesus didn’t just love the poor — he loved them more. I’ve always carried that message with me, and I’ve paid attention to politics on and off over the years. I was unhappy with the Bush administration, but when Barack Obama won the election in 2008, I assumed things would look up, and I stopped paying attention. I worked hard, went to school and did my best to give back to my community as a high school teacher — something I felt I had to do as a Christian. But this election startled me out of my complacency. I followed the Democratic primary closely and cast my vote for Hillary Clinton in the general, but I was horrified by the outcome. I realized that if people of faith want a moral government, we can’t rely on people who call themselves Christians to build one for us. We’ll have to do it ourselves.

That’s why I went to speak to my representative directly. When I got up to speak to Black, I was nervous. My question came out a little jumbled, and I did end up making a faith-based argument for the individual mandate portion of the ACA. I was simply trying to point out the hypocrisy of Republican politicians who claim to be Christians and yet, time and time again, advocate for policies that hurt people.

This wouldn’t be the first time Republicans, who so often campaign under the banner of Christianity, have hurt needy people. Republicans’ refusal to expand the Medicaid component of the ACA in various states solely in the name of politics punished some of our nation’s poorest and likely led to thousands of untimely deaths. This indefensible decision to withhold insurance to millions of people also likely led to an increase in premiums for many people who were insured not only through the public exchanges but also privately.

These were grave injustices, and rolling back the ACA will be another. But refusing to expand Medicaid and threatening to place vulnerable people into high-risk insurance pools are wrong in my view because Christianity calls on us to look after the weakest and neediest people, including the poor and sick. If I had a chance to address our leaders directly again, I would say this: Christianity demands that we make sure all people have health coverage. In other words, I would have focused instead on the Christian case for universal, single-payer health insurance, which would protect all Americans. And if Republicans want to campaign as Christians, they should lead the way.

In my view, it is immoral for health care to be a for-profit enterprise. Insurance companies are making enormous sums of money off the sick while people are struggling to pay their medical bills. Patients even die sooner when nonprofit hospitals switch to making money.

Switching to single-payer wouldn’t necessarily be easy: Perhaps the hardest part of the reorganization of our health-care system to single-payer would be asking physicians to make much less money than they do now.1 But the directive in Luke 12:48 states that “everyone to whom much was given, of him much will be required, and from him to whom they entrusted much, they will demand the more.” America is one of the richest countries in the world. We have been given more than enough, and we need to share it with our most vulnerable. With what is left of the minute of fame that I have been given, I feel compelled to ask for forgiveness for not using my belief system to advocate more clearly for what I think is the best thing to do.

Jessi Bohon is a French teacher who lives in Cookeville, Tennessee.

https://www.washingtonpost.com…

1. PNHP Note: On the basis of the Canadian experience under national health insurance, we expect that average physician incomes should change little. However, the income disparity between specialties is likely to shrink. For more information, click here.

Senators Sanders, Cruz show fundamental differences on health care

By Jonathan Mizrahi, M.D.
St. Louis Post-Dispatch, Feb. 15, 2017

I hope many people were able to watch the debate that CNN hosted last week between U.S. Sens. Bernie Sanders and Ted Cruz. They spent over an hour fielding questions from spectators and moderators about the present and future of health care in the United States. Sen. Cruz provided a couple misleading answers and suggestions that I believe are worth clarifying.

First, he stated that his primary goal in repealing the Affordable Care Act was to remove government from the equation so that health care would be back in the hands of patients and their physicians. As appealing as he makes it sound, removing government-funded insurance would hardly make a dent in the amount of autonomy patients and their physicians have over their health care.

This is the case because nearly two-thirds of Americans have private insurance. The ever-present middlemen, these insurance companies very much dictate what medications you will have covered, which physicians and specialists you will be able to see and which exams and lab tests will be paid for. Removing government from the equation will not change this.

Second, Sen. Cruz used impressive-sounding statistics to make the case that the health care system in the U.S. is the best in the world. He quoted the higher number of mammograms and MRI scans that are performed in the U.S. compared to other developed countries.

While larger numbers surely do sound exciting, the number of MRIs physicians order for their patients in the U.S. is far too high. These are not true markers of health care performance, and instead are emblematic of the waste in our system. Do not get me wrong, MRIs are an invaluable tool in the arsenal of a physician, but they are too often ordered because our system of payment does not yet place a premium on cost-effectiveness.

This has caused the U.S. to spend more money per capita on health care than any other country in the world, while being ranked 11th out of 11 in overall health care among countries studied by the nonpartisan Commonwealth Fund, largely due to our poor rankings in access, equity and efficiency.

It is important to note that the U.S. indeed delivers effective and innovative health care. However, too often, only the wealthiest citizens with the most expensive insurance are able to benefit from it. There are still about 28 million uninsured Americans who are unable to access the best tests and treatments that physicians have to offer.

The Affordable Care Act has brought the number of uninsured down by 20 million, a significant number to be sure, but one that still has room for improvement. This is why building on the present law is needed, but calls to completely repeal it represent a callous and dangerous approach to those who have benefited most.

I point these two above examples out from the CNN special, but there were many other important takeaways from listening to these two senators debate. There is a fundamental difference in the approaches of Sens. Sanders and Cruz to U.S. health care. Sen. Sanders emphatically views the delivery of health care as an American right, while Sen. Cruz stated he views access to health care (i.e. through less expensive options by way of increased competition) as an American right. This distinction is not trivial.

A particular organization with a sensible solution that I would like to highlight is Physicians for a National Health Program. With chapters across the country, including one here in Missouri, PNHP is a group of physicians that advocate for consideration of moving toward a single-payer system, similar to Medicare-for-all. Benefits of such a system include removing private insurers from the marketplace, helping to drive down costs, and allowing the national insurance program to negotiate drug prices with pharmaceutical companies, helping to curb the often-astronomical prices that patients must pay for brand-name therapies. This proposal is similar to the system that Canada has in place, and is essentially the same as what Sen. Sanders has been advocating for throughout his career. Reasonable people can disagree about the advantages and disadvantages of such a system, which takes me back to the debate.

While Sen. Sanders’ argument for universal health care will guarantee that no American is uninsured, Sen. Cruz’s plan will leave the number of Americans uninsured up to the marketplace. Whether the latter seems desirable or fair in the richest nation in the history of the world is the question we must ask ourselves.

http://www.stltoday.com…

We still know little about accountable care

Moving Forward With Accountable Care Organizations

By Carrie H. Colla, PhD; Elliott S. Fisher, MD, MPH
JAMA Internal Medicine, February 13, 2017

During the past 4 years, we have made great strides in advancing our understanding of the changes that hospitals and physician groups implement in response to changes in payment and how providers perform under alternative payment models. Accountable care organization contracts, one type of alternative payment model, hold groups of health care professionals responsible for the cost and quality of care delivered to patients. Accountable care organization programs attract a diverse array of providers with differing legal and governance structures, varied contracts, and mixed capabilities that span service dimensions. These capabilities may include care management personnel and programs, adoption of advanced analytics (eg, to estimate the risk of hospitalization), or support for shared decision making. On average, ACO patients are spending modestly less on health care services and are associated with improved patient satisfaction and other patient-reported measures, with gains often concentrated in high-need, high-cost populations. Previous exposure to risk-bearing contracts, greater numbers of dually eligible or disabled patients, and higher initial financial benchmarks have been associated with greater savings. At the same time, these results mask variation in performance, with some ACOs saving while others spend over their benchmark following ACO formation. In addition, these modest savings have come at a net cost to the Medicare program (both program costs and shared savings rewards) and, although some quality measures have improved, many have not.

The research presented in this issue of JAMA Internal Medicine provides insights from 3 different ACO payment models: the Medicare Shared Savings Program (MSSP), Colorado’s Accountable Care Collaborative, and Oregon’s Coordinated Care Organizations. All 3 programs show some degree of success, although the results continue to be modest in magnitude.

These findings are relevant to 3 major considerations facing policymakers: (1) concerns about the harms of consolidation, (2) the amount of risk bearing needed to produce changes in behavior, and (3) how to manage potential conflicts between alternative payment models.

Consolidation between clinical providers, such as purchase of physician groups by hospital systems, and striking the proper balance between facilitating clinical integration and limiting market power is a major concern. Many believe that continued survival of independent practices is critical, yet economic incentives favor consolidation due to higher reimbursement for the same service in a hospital-based office compared with a physician office. Hospital-physician group consolidation can also raise prices in less-competitive commercial markets through increased bargaining power vis-à-vis insurers.

Accountable care organizations are defined by their accountability for the cost and quality of care, but the degree of accountability for spending varies dramatically across contracts. The amount of financial risk bearing necessary to achieve behavior change is an important area of inquiry, in part because so little is known. The incentives in most existing alternative payment models, including ACOs, are commonly considered insufficient to result in behavior change.

A third issue concerns potential conflicts between Medicare alternative payment models and the poorly understood interplay of incentives across these reforms. Currently, hospitals retain savings within inpatient-initiated bundles for patients attributed to an MSSP ACO. Although incentivizing value within a bundle, bundled payment models do not eliminate the incentive to provide more bundles. As the Centers for Medicare & Medicaid Services expands alternative payment models, it is possible that bundled payment programs will undermine overall savings.

In summary, we still have much to learn. Accountable care organizations have been established across diverse market settings, using a multitude of organizational structures and approaches to governance and operations, and this heterogeneity is reflected in the heterogeneity of their performance. The 2 articles published in this issue add to a growing body of evidence on overall performance, several dimensions of quality, and spending. Nevertheless, we know little about the effects of ACOs on patients’ health and quality of life. Perhaps most important for ACO leaders and the long-term success of these programs, we know little about the key ACO capabilities that are important to ensuring their success in different organizational or market contexts. Although the Centers for Medicare & Medicaid Services has conducted rigorous evaluations of the Pioneer program, generalizable findings tailored to organizational contexts are few. A long-term commitment to alternative payment model evaluation is necessary to ensure effective, sustainable payment and delivery system reform.

http://jamanetwork.com…

***

Comment:

By Don McCanne, M.D.

This lesson on accountable care, from the Dartmouth Institute, shows us that we still have much to learn. The respected authors state that a long-term commitment to alternative payment model evaluation is necessary. In the meantime, “we know little about the key ACO capabilities that are important to ensuring their success in different organizational or market contexts.”

We actually do have quite a bit of information, and it is unimpressive. What we cannot do is to allow a protracted course of many years or decades of studying accountable care to distract us from the urgent need to make changes that will ensure that everyone has affordable access to health care while dramatically reducing the profound administrative waste in our system.

The Affordable Care Act made some improvements, but not nearly enough as witnessed by the tens of millions uninsured and underinsured, by the failure to make health care affordable for too many of us, and by the perpetuation of the costly administrative excesses.

The next phase of reform being undertaken by our current Congress seems to be pending enactment of policies that would make markets work better for insurers but at a cost of leaving patients exposed to excessive out-of-pocket spending. They do not seem to be even pretending that accountability in shifting from volume to value is anything more than rhetoric (and the studies to date suggest this is true).

First things first. Let’s do what really works – enact a single payer national health program, an improved Medicare for all. It is a far better infrastructure to tease out data that might be used to actually improve quality while containing costs. But let’s not stall any longer on enacting the fundamental reform that we really need to make health care affordable for all of us.

A Political Opening for Universal Health Care?

The winner in the fight between keeping Obamacare and rolling it back might be something else entirely

By Vann R. Newkirk II
The Atlantic, Feb. 14, 2017

The Senate confirmed Tom Price as secretary of health and human services at 2 a.m. on Friday. After a contentious confirmation process, the Trump administration and the Republican-controlled Congress had finally installed one of the leading generals in its war on Obamacare in the department that oversees its programs. Price is a titan in the GOP camp that wants to repeal the health law, and is perhaps one of the few Republican lawmakers with both the vision and the experience needed to begin the daunting task.  

But the battlefield under Price’s feet has shifted substantially in the past few weeks. Republicans have splintered, the timeline for repeal has dragged on and on, alternative plans have propagated in the fertile soil of disunion, and some have lost their resolve. And in the turmoil over the fate of Obamacare, the idea of universal health care has emerged as a third way among voters in both parties. The health system the mainstream GOP opposes most is now one some of its voters support—potentially making Price’s task of replacing Obamacare all the more complicated.   

The political appeal of a single-payer, universal health-care system is perhaps best outlined by Jessi Bohon, a high-school teacher who attended a raucous and often angry town hall with Republican Representative Diane Black in Murfreesboro, Tennessee, last week:

Bohon was able to ask Black a question, and she began with a defense of Obamacare. “As a Christian, my whole philosophy in life is pull up the unfortunate,” she said, referencing the law’s individual mandate and how requiring healthy Americans to purchase insurance lowers costs for the sick. But Bohon went a step further in her support of expanding coverage and her criticisms of the private insurers who’ve complicated the law: “Why don’t we expand Medicaid, and have everybody have insurance?” she asked.

It’s possible that Bohon’s question was simply an attempt to ask Black to implement policies that already exist in the Affordable Care Act. States have the option to expand Medicaid to more low-income adults under Obamacare, though Tennessee, among others, has chosen not to accept federal funds to do it. But her query and criticisms of market-based plans raise a broader question: Why rely on private insurers at all?

Senator Bernie Sanders had also made the case for government-run health care in a CNN debate on Obamacare just the night before. Although he was ostensibly brought on to defend the law against interlocutor Senator Ted Cruz’s criticisms, Sanders used his platform to argue for Medicare for all. His strategy was not to forcefully defend the law against critiques from Cruz, CNN, and the audience; rather, he often agreed with Cruz that those critiques were valid. But his solution undercut Cruz’s message of limited government. Why continue a system that relies on premiums at all, Sanders asked—and why continue to enrich insurers that simply cannot be relied upon to act in patients’ best interests?

Although Bohon—a self-identified Hillary Clinton voter—and Sanders certainly represent liberal sensibilities, several polls show that universal coverage is gaining traction among Democratic and Republican voters. A January Pew Research Center survey showed that 60 percent of Americans believe that government “should be responsible for ensuring health-care coverage for all Americans”—the highest mark in nearly a decade—though they are divided on whether government should be the sole provider of insurance. The recent increases nationally in support for universal coverage are mostly attributable to low-income Republicans. Over half of all Republicans surveyed who have family incomes of less than $30,000 agreed with the idea. Twenty-eight percent of all people polled in a recent Gallup survey expressed support for a single-payer system run by the government.

To be sure, the conclusions that can be gleaned from the polling here are a bit murky. Last year, my colleague Olga Khazan explored how support for a single-payer, Medicare-like plan decreases dramatically when such a plan would necessitate tax increases, which it almost certainly would. Also, a Kaiser Family Foundation survey from February 2016 showed that the label matters as well. Over 70 percent of Americans support Sanders’s “Medicare for all” plan. But they weren’t as enthusiastic about “universal health care” or “single-payer” health care. Although there are some real potential differences in these concepts that voters might be responding to—the term “universal health care” doesn’t specify financing or delivery, and “single-payer” doesn’t specify how the scheme is actually administered—the KFF poll potentially illustrates that there are barriers to understanding whether the public actually wants and understands a universal health-care system.

Still, the upswing in support for the government provision of health care among low-income Republicans provides a real opportunity for politicians in both parties. Trump himself once promised to implement “insurance for everybody.” Though it’s easy to view that one-time vow as fluff or a misunderstanding of his own party line, it could be a lifeline for Republicans facing revolts back home in poor districts where constituents are fearful of losing their insurance coverage. An Obamacare replacement with an expanded public-insurance system would follow through on promises to repeal the ACA. And it could also replace an unstable and weakening exchange system—dominated by reviled insurance companies—with Medicare or state-branded Medicaid programs like Kentucky’s Kynect, which tend to be widely trusted.

That route might be too far-fetched or expensive for Republicans to pursue en masse. Although their current repeal plan might bend Republican rules on passing legislation that increases the deficit, demolishing or controlling health-care markets and extending tax-funded insurance would be outright heresy against the party line. The resistance to such an idea in the health-care industry, and among its lobbyists, might threaten Republicans in Congress who rebel, thereby reinforcing the market-based status quo.

But it’s not too far-fetched for Democrats, who could, by embracing universal coverage, force Republicans to at least consider altering the party line. Democrats don’t face the same political risks with health care as Republicans do, not only because universal health care exists within liberal theory of government, but because a Republican-dominated Congress effectively renders many of their platforms, votes, and draft bills symbolic. The same dynamic in reverse created the anti-Obamacare fervor among congressional Republicans in the first place, and has been one of the largest factors in the GOP’s electoral strength since 2010.

Were they to take the plunge, Democratic candidates could run as challengers in upcoming elections on a third way of health reform: neither extending unpopular pieces of a program nor rolling back coverage, but giving everyone Medicare. And if the Democratic Party were to support universal health care, that might put pressure on Republicans, who wouldn’t want to lose voters who fear loss of coverage or doctors under a massive repeal.

Thus the precariousness of the Republicans’ position. With Price atop the national public-health system and already empowered by an executive order from the White House, Republicans in the executive branch and Congress have run out of excuses to do the job they came to do. But they face an ever-mobilizing opposition that extends across both parties, and immediate decisive action carries significant risks of causing a conflagration if people lose coverage. Paradoxically, delays give more time for the party to splinter and lose momentum, and for the idea of universal care to take root as a viable alternative as the stresses of an unfixed existing system mount. For at least some Republicans, that option might now be the most attractive now.

https://www.theatlantic.com…