PNHP

It’s time for Medicare for all

It’s time for Medicare for all

By Jonathan Michels
Winston-Salem (N.C.) Journal, Feb. 20, 2018

For more than 100 years, Americans have searched for a cure for health care inequality. Instead, we’ve been prescribed placebos: watered-down poverty programs and party politics.

Despite attempts to ease the pain with reforms like Medicaid and the Affordable Care Act (ACA), we continue to rely on a market-driven health care system. After stitching together the remnants of various poverty programs we are left with a system so dysfunctional and freakish it would make Dr. Frankenstein recoil.

After signing the Health Reinsurance Act — the result of a contentious battle for a national health program that was ultimately foiled by the American Medical Association — Republican President Dwight Eisenhower handed the pen to Esther Lape, a social scientist and longtime universal health care advocate. Disappointed that the bill fell far short of her expectations, Lape reportedly waved the souvenir in the air and declared, “This represents a puny little bone in the vertebrae of what I had in mind!”

What Lape envisioned would be transformative: quality health care for everyone.

The ACA reforms initiated by Democrats provided some patient protections and increased health access for 20 million Americans since it was implemented in 2010. Its primary mission, however, was to ensure that Americans would have to rely on the for-profit insurance market.

Merely protecting the ACA would leave the most marginalized populations behind. Despite the ACA’s improvements, 28 million Americans remain uninsured, without access to primary care that could prevent costly and life-threatening diseases. Those fortunate enough to have insurance are assaulted by prohibitively expensive co-pays, premiums and deductibles that limit access to care.

This past year we saw an upsurge in popular resistance against Republican attacks on important—if imperfect—social welfare initiatives, especially health care for the most vulnerable. Activists pushed back attempts to repeal and replace the ACA with bills that would lead to the loss of health coverage for at least 22 million Americans.

As a premedical student and a health care worker, I bear witness to a broad spectrum of suffering; the kind that we are all likely to face at some point during our lives. But what haunts me at the end of each shift is the pain that could have have been prevented if patients who are uninsured or under-insured had been able to access care sooner.

Take for instance the young woman who checked into the emergency room because she was uninsured and couldn’t afford the anti-inflammatory drugs that her doctor prescribed for her Crohn’s disease. Her symptoms worsened and when I x-rayed her, she was likely headed for invasive surgery.

Based on my personal experiences working in health care, I believe that the prescription for our collective heartache is improved Medicare for all: An insurance system that is government-financed but privately delivered and could save the U.S. nearly $600 billion annually while providing all Americans with access to quality health care.

Our health care system is once again at a crossroads.

Here in North Carolina, the General Assembly refused to expand Medicaid under the ACA, denying thousands access to basic care.

State Rep. Donny Lambeth, a Republican, recently proposed House Bill 662, also known as Carolina Cares, that would finally expand Medicaid. However, as the Winston-Salem Journal reported earlier this month, some members of the General Assembly say that even if work requirements like those in Kentucky and Indiana are put into place, they won’t support providing health care to the state’s neediest citizens. Meanwhile, the majority of Americans are increasingly realizing what 100 years of struggle has taught Medicare-for-all supporters already know: any measure other than national health insurance will fail.

Support for single payer is growing. According to the Pew Research Center, 60 percent of Americans believe that the federal government has a responsibility to provide health coverage to everyone. H.R. 676, the single-payer bill in the House, now has a record 120 co-sponsors; Sen. Bernie Sanders’ Medicare for All Act has 16 co-sponsors, including potential candidates for the presidential nomination.

It’s true that in our time, just as in Lape’s era, embracing single payer demands not only a radical revision of how health care is financed but the courage to move beyond half-measures.

As the popular saying goes, “You can’t cross a chasm in two small jumps.” Imagine a health care program that provides affordable, quality care to every person—ourselves, our families and our neighbors—regardless of age, income or employment; a model proven to work in every other developed nation. Isn’t that reason enough to take a leap?

http://www.journalnow.com…

Robert Reich on ‘the common good’ – appropriate for Presidents day

The Meaning of America

By Robert Reich
robertreich.org, February 17, 2018

When Trump and his followers refer to “America,” what do they mean?

Some see a country of white English-speaking Christians.

Others want a land inhabited by self-seeking individuals free to accumulate as much money and power as possible, who pay taxes only to protect their assets from criminals and foreign aggressors.

Others think mainly about flags, national anthems, pledges of allegiance, military parades, and secure borders.

Trump encourages a combination of all three – tribalism, libertarianism, and loyalty.

But the core of our national identity has not been any of this. It has been found in the ideals we share – political equality, equal opportunity, freedom of speech and of the press, a dedication to open inquiry and truth, and to democracy and the rule of law.

We are not a race. We are not a creed. We are a conviction – that all people are created equal, that people should be judged by the content of their character rather than the color of their skin, and that government should be of the people, by the people, and for the people.

That idealism led Lincoln to proclaim that America might yet be the “last best hope” for humankind. It prompted Emma Lazarus, some two decades later, to welcome to American the world’s “tired, your poor/ Your huddled masses yearning to breathe free.”

That idealism sought to preserve and protect our democracy – not inundate it with big money, or allow one party or candidate to suppress votes from rivals, or permit a foreign power to intrude on our elections.

It spawned a patriotism that once required all of us take on a fair share of the burdens of keeping America going – paying taxes in full rather than seeking loopholes or squirreling money away in foreign tax shelters, serving in the armed forces or volunteering in our communities rather than relying on others to do the work.

These ideals compelled us to join together for the common good – not pander to bigotry or divisiveness, or fuel racist or religious or ethnic divisions.

The idea of a common good was once widely understood and accepted in America. After all, the U.S. Constitution was designed for “We the people” seeking to “promote the general welfare” – not for “me the narcissist seeking as much wealth and power as possible.”

Yet the common good seems to have disappeared. The phrase is rarely uttered today, not even by commencement speakers and politicians.

There’s growing evidence of its loss – in CEOs who gouge their customers and loot their corporations; Wall Street bankers who defraud their investors; athletes involved in doping scandals; doctors who do unnecessary procedures to collect fatter fees; and film producers and publicists who choose not to see that a powerful movie mogul they depend on is sexually harassing and abusing women.

We see its loss in politicians who take donations from wealthy donors and corporations and then enact laws their patrons want, or shutter the government when they don’t get the partisan results they seek.

And in a president of the United States who has repeatedly lied about important issues, refuses to put his financial holdings into a blind trust and personally profits from his office, and foments racial and ethnic conflict.

This unbridled selfishness, this contempt for the public, this win-at-any-cost mentality, is eroding America.

Without binding notions about right and wrong, only the most unscrupulous get ahead. When it’s all about winning, only the most unprincipled succeed. This is not a society. It’s not even a civilization, because there’s no civility at its core.

If we’re losing our national identity it’s not because we now come in more colors, practice more religions, and speak more languages than we once did.

It is because we are forgetting the real meaning of America – the ideals on which our nation was built. We are losing our sense of the common good.

http://robertreich.org…

The Common Good, by Robert B. Reich (Publication date February 20, 2018)
https://www.amazon.com…

Crisis in U.S. Health Care: Corporate Power vs. The Common Good, by John Geyman, M.D.
https://www.amazon.com…

***

Comment:

By Don McCanne, M.D.

Contrasting our presidents, past and present, it is easy to see why Robert Reich says that we are losing our sense of the common good. He writes, “Yet the common good seems to have disappeared. The phrase is rarely uttered today, not even by commencement speakers and politicians.”

Well, that doesn’t apply to all of us. If you type “common good” into the search window at the PNHP website (www.pnhp.org) you will find many references to the common good. Even one of our own, John Geyman, has written a book, “Crisis in U.S. Health Care: Corporate Power vs. The Common Good.”

Tomorrow is the publication date of Robert Reich’s new book, “The Common Good.” It is liberally excerpted at the Amazon website (link above).

Presidents Washington and Lincoln helped us to understand the common good. Now President Trump, in his own style, unintentionally reminds us of the importance of this concept. We should use this Presidents Day as a starting point on our renewed quest for the common good.

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

David Cutler: What is the health spending problem?

What Is The U.S. Health Spending Problem?

By David M. Cutler
Health Affairs, Published Ahead of Print February 14, 2018

Abstract

Is increased spending on medical care harmful to the US economy? The overall share of the gross domestic product spent on medical care is not a problem, provided that the services bought are worth more than their cost. However, high and rising costs expose two often-overlooked problems. First, spending is too high because many dollars are wasted. Estimates suggest that unnecessary medical spending costs the typical American family thousands of dollars each year. Second, high medical costs combined with stagnant incomes for a large share of the population and the inability of governments at all levels to raise tax dollars leads to increased health and economic disparities: fewer people covered by private insurance, the rationing of care in public health programs, and the lack of funds for other social programs. These distribution issues, coupled with the large waste, imply that efforts to address medical spending need to be among our highest priorities.

A Large Part of Spending Is Wasteful

A large number of studies have estimated the waste in health care. Estimates suggest that between one-quarter and one-half of medical spending is not associated with improved health, although this view is not without controversy.

High prices are a second form of wasteful spending.

Excessive administrative costs are a third form of wasteful spending.

The fact that there is so much waste in medical care does not mean that spending more is necessarily bad.

But neither should we assume that all spending increases reflect value, as indicated by the rising prices of established drugs or of services from newly merged hospitals. Most fundamentally, the presence of significant waste argues that we ought to pay at least as much attention to ways of improving efficiency as we do to whether and how people should get covered.

Rising Spending Worsens Inequality

The second problem with medical spending is that it feeds into the already severe harms caused by growing income inequality. The most important fact about the income distribution in the United States is that it is becoming increasingly unequal: Real incomes have soared at the very high end, risen modestly in the next few deciles, and been stagnant or falling at the bottom.

Rising medical costs combined with stagnant incomes for a large share of the population mean that more people will need help paying for medical care. A family at the median income level, whose income is relatively constant, has had no easy way to pay the roughly $10,000 rise in the cost of a family health insurance policy between 1999 and 2017.

At the same time that needs are increasing, however, government resources are being cut. Governments at all levels are loath to raise taxes, and some are even cutting them. Total government revenue as a share of GDP has been relatively constant for several decades and is projected to fall with enactment of the federal tax bill in December 2017.

This combination of increased need for help and fewer resources to spend inevitably creates problems. Three problems are particularly apparent.

Fewer People Are Covered by Private Insurance

Public Programs Turn to Rationing

Other Social Programs Are Crowded Out

Even with both explicit and implicit rationing, rising costs for medical care translate into higher overall government spending. Given the constraint on raising money, this necessarily means that less money is available for other government services—for example, spending on early childhood education or income subsidies for low-income workers.

Conclusion

Additional medical spending brings both benefits and costs to society. For this reason, the question about how much money a country such as the United States can afford to spend on medical care is not well formulated. But that ambiguity does not mean that additional medical spending is innocuous. The United States is being pulled apart as a country, separating into rich and poor. Every dollar that is spent on medical care is one less dollar available for addressing the problems of an unequal society, and one more dollar that is difficult for much of the population to pay. One of the goals for health policy must be to reduce social and economic disparities, not increase them.

https://www.healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

In this article David Cutler reminds us of two problems with health care spending that demand our attention: Wasted dollars on health care could be better spent on the typical American family, and high medical costs along with stagnant incomes and limits on government funding lead to increased health and economic disparities.

Reducing waste is relatively straightforward under a single payer national health program. Cutler calls for improving efficiency and two of the ways that single payer would do that include a tremendous reduction in administrative waste by converting to a well designed single financing system, and a reduction in services of negligible value by improving allocation of our resources such that services of greater value displace those of little value.

But look at the potential single payer would have at helping to address our social and economic disparities. Although David Cutler remains silent on single payer, it is obvious to us that the problems he discusses cry out for single payer reform.

The publishers have granted free access to this article. You should take advantage of that to read the full article.

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How should we use the CMS National Health Expenditures projection?

CMS Office of the Actuary releases 2017-2026 Projections of National Health Expenditures

Centers for Medicare & Medicaid Services (CMS), February 14, 2018

Today the independent CMS Office of the Actuary released the projected national health expenditures for 2017-2026.

National health expenditure growth is expected to average 5.5 percent annually over 2017-2026, according to a report published today as an “Ahead Of Print” by Health Affairs and authored by the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS).

Growth in national health spending is projected to be faster than projected growth in Gross Domestic Product (GDP) by 1.0 percentage point over 2017-2026. As a result, the report projects the health share of GDP to rise from 17.9 percent in 2016 to 19.7 percent by 2026.

The outlook for national health spending and enrollment over the next decade is expected to be driven primarily by fundamental economic and demographic factors: trends in disposable personal income, increases in prices for medical goods and services, and shifts in enrollment from private health insurance to Medicare that result from the continued aging of the baby-boom generation into Medicare eligibility.

“Personal healthcare spending” measures spending for medical goods and services provided directly to patients. Over the projection period, growth in personal healthcare prices and growth in the use and intensity of care provided collectively explain about three quarters of the growth in personal healthcare spending.

The report also found that by 2026, federal, state and local governments are projected to finance 47 percent of national health spending, up from 45 percent in 2016.

“Today’s report from the independent CMS Office of the Actuary shows that healthcare spending is expected to continue growing more quickly than the rest of the economy,” said CMS Administrator Seema Verma. “This is yet another call to action for CMS to increase market competition and consumer choice within our programs to help control costs and ensure that our programs are available for future generations.”

https://www.cms.gov…

***

National Health Expenditure Projections 2017-2026; Forecast Summary; Major Findings for National Health Expenditures: 2017-2026

Centers for Medicare & Medicaid Services (CMS), Office of the Actuary

* Under current law, national health spending is projected to grow at an average rate of 5.5 percent per year for 2017-26 and to reach $5.7 trillion by 2026. While this projected average annual growth rate is more modest than that of 7.3 percent observed over the longer-term history prior to the recession (1990-2007), it is more rapid than has been experienced 2008-16 (4.2 percent).

* Health spending is projected to grow 1.0 percentage point faster than Gross Domestic Product (GDP) per year over the 2017-26 period; as a result, the health share of GDP is expected to rise from 17.9 percent in 2016 to 19.7 percent by 2026.

* Projected national health spending and enrollment growth over the next decade is largely driven by fundamental economic and demographic factors: changes in projected income growth, increases in prices for medical goods and services, and enrollment shifts from private health insurance to Medicare related to the aging of the population.

* Among the major payers for health care, growth in spending for Medicare (7.4 percent per year) and Medicaid (5.8 percent per year) are both substantial contributors to the rate of national health expenditure growth for the projection period. Both trends reflect the impact of an aging population, but in different ways. For Medicare, projected enrollment growth is a primary driver; for Medicaid, it is an increasing projected share of aged and disabled enrollees.

* The recent enactment of tax legislation that eliminated the individual mandate is expected to lead to a reduction in the insured rates. Economic factors, such as projected GDP growth and employment trends, are the primary factors contributing to a slight projected decline in the insured share of the population from 91.1 percent in 2016 to 89.3 percent in 2026.

https://www.cms.gov…

***

National Health Expenditure Projections, 2017–26: Despite Uncertainty, Fundamentals Primarily Drive Spending Growth

Health Affairs, February 14, 2018

Projections

National Health Expenditures (NHE)
2018 – $3,675.3 billion
2026 – $5,696.2 billion

NHE per capita
2018 – $11,193.2
2026 – $16,167.6

NHE as percent of GDP
2018 – 18.2%
2026 – 19.7%

https://www.healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

The Office of the Actuary of CMS remains the best source of predictions for the future of our health care spending. Reasonable economic and demographic analyses indicate that growth of spending will continue to be driven especially by price increases and by growth in use and intensity of care related to demographic changes. By 2026, national health expenditures as a share of GDP are expected to rise to 19.7 percent – almost one-fifth of our GDP.

Although we continue to have a national discourse on the amount of our health care spending, other important variables include the accessibility of health care and the financial barriers which influence that access. The design of the nation’s health care financing system is even more crucial than the amount we are spending.

Because of the high costs of health care, the great variability in individual health care needs, and and the unequal distribution of income and wealth, a health care system that takes care of everyone requires an egalitarian transfer from the healthy and wealthy to the sick and poor. A well designed single payer national health program does precisely that, but it requires the implementation of an effective public (government) program.

Can the private sector accomplish the transfer in an effective and equitable manner? Absolutely not, and we have a century of experience with the private sector to prove this. Even with the high level of government involvement that we now have (the government funds about two-thirds of our health care) the design of our health care financing system has failed to implement the tools that would increase the effectiveness and efficiency in allocation of our health care funds and resources.

What does this have to do with the report on our national health expenditures? The press release quotes CMS Administrator Seema Verma: “Today’s report from the independent CMS Office of the Actuary shows that healthcare spending is expected to continue growing more quickly than the rest of the economy. This is yet another call to action for CMS to increase market competition and consumer choice within our programs to help control costs and ensure that our programs are available for future generations.” Get the government out and turn it over to the private sector – a recipe for disaster – as the policies already put into place by the current administration and previous administrations are now demonstrating, and they promise much more.

Using standard economic and demographic analyses can predict a certain amount of stability in health care financing, but the political variables can greatly distort the future. Depending on who we select to lead our nation, we could have comprehensive, affordable health care for absolutely everyone, or we could have a system designed primarily to enrich the medical-industrial complex while threatening the health and financial security of the majority of us.

Don’t let a sterile report on national health expenditures lull you into complacency.

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‘Medicare for All’ event is well-attended

By Gillian Pomplun
Crawford County (Wisc.) Independent, February 14, 2018

A ‘Medicare for All’ event held on Saturday, Jan. 27, at the American Legion in Viroqua drew over 80 participants.

Speakers at the event included Megan Grinde of La Crosse; Darrin Von Ruden, president of the Wisconsin Farmers Union; Dr. Taryn Lawler, family physician at the La Farge Medical Clinic; and State Senator Kathleen Vinehout of Alma, Wisconsin.

Representatives from U.S. Senator Tammy Baldwin’s office, and U.S. Representative Ron Kind’s office were also on hand.

Medicare v. Medicaid

Kind’s Deputy Chief of Staff Brad Pfaff explained to the group that U.S. citizens generally access health care in one of five ways: Medicare, Medicaid, the Veteran’s Administration, employer, or a Health Care Exchange.

Medicaid (Badgercare in Wisconsin) provides health coverage to eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements.  The program is funded jointly by states and the federal government.

Medicare is the federal health insurance program for people who are 65 or older. Certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD) are also covered under the program.

Military veterans receive insurance through the Veteran’s Administration. Also, since passage of the Affordable Care Act, individuals and families can sign up for health insurance through state health care exchanges.

Healthcare reform

There is nothing new about the topic of healthcare reform, and the same cast of organizations and companies seem to reassemble perennially to carry the debate forward. Politicians from all political stripes, lobbied by the American Medical Association (AMA), representatives of pharmaceutical and health insurance companies, farmer and labor organizations, and more, seem unable to reach any successful political consensus on the topic.

The idea of following the rest of the industrialized world in creating a ‘Medicare For All,’ or national healthcare program has always battled with the entrenched economic imperatives of the for-profit corporations who would stand to lose if a national single payer health care program was enacted.

Americans became used to associating insurance with employers over the years. This trend paved the way for the beginning of third-party health insurance in the 1930s. In this period, during the Great Depression, more and more people could not afford medical services. In 1933, President Franklin D. Roosevelt directed members of his team to help draft provisions to his pending Social Security legislation to include publicly funded health care programs.

These reforms were at-tacked by the AMA as “compulsory health insurance.” Roosevelt ended up removing the health care provisions from the bill in 1935. Fear of organized medicine’s opposition to universal health care has been a standard feature ever since.

During this time, individ-ual hospitals began offering their own insurance pro-grams, the first of which became Blue Cross. Groups of hospitals as well as phy-sician groups (i.e. Blue Shield) soon began selling group health insurance poli-cies to employers, who then offered the insurance to their employees and collected pre-miums.

During World War 2, the federal government intro-duced wages and price con-trols. In an effort to contin-ue attracting and retaining employees without violating those controls, employers offered and sponsored health insurance to employ-ees in lieu of gross pay. This was a beginning of the third-party paying system that began to replace direct out-of-pocket payments for health care services.

Following World War II, President Harry Truman called for universal health care as a part of his Fair Deal in 1949 but strong opposition stopped that part of the Fair Deal. Then, when Lyndon B. Johnson was elected president, the bills establishing Medicare and Medicaid were passed in 1965.

The health care reform issue continued to be batted around Congress for the next 40 years. The same cast of business interests, lobbying organizations, and even some of the same elected representatives played their predictable roles. Medical and pharmaceutical industry campaign contributions continued to flow into the pockets of candidates seeking public office.

Finally, in January 2007 U.S. Representative John Conyers, Jr. (D-MI) introduced The United States National Health Care Act (HR 676) in the House of Representatives. As of October 2008, HR 676 had 93 co-sponsors. Also in January 2007, U.S. Senator Ron Wyden introduced the Healthy Americans Act (S. 334) in the Senate. As of October 2008, S. 334 had 17 cosponsors.

Start with the state

Wisconsin State Senator Kathleen Vinehout told the audience present at the ‘Medicare for All’ event about her work over the years to craft single-payer health care proposals in the state legislature. She also described the barriers she faced both from Repbulicans and members of her own party.

“My goal was to ensure the same insurance I received as a state senator to every resident of the state,” Vinehout said.

Vinehout told the inspiring story of Tommy Douglas, a Canadian Social-Democratic politician and Baptist minister. Douglas was elected to the Canadian House of Commons in 1935, as a member of the Co-operative Commonwealth Federation (CCF). He left federal politics to become the Saskatchewan CCF’s leader and then the seventh Premier of Saskatchewan from 1944 to 1961.

His government was the first Social-Democratic government in North America, and it introduced the continent’s first single-payer, universal health care program.

“From the time Tommy Douglas started his campaign for health reform in Saskatchewan, until it was enacted into law took twenty-six years,” Vinehout said. “After that, it only took another four years until it was expanded to the entire nation.”

After the Affordable Care Act was passed in 2010, Vinehout advocated for the creation of a state health care marketplace, with Badgercare as a public option. Instead, when Scott Walker was elected Governor in 2011, he repealed all the reforms in health care that Vinehout and others had worked to put in place, and refused to take the Medicaid expansion dollars from the federal government.

Vinehout explained that she supports creation of a single-payer system, but beyond seeing healthcare as a right, she also sees it as “an obligation or responsibility we all have to each other in a civilized society.”

“Just as in our democracy, there’s a lot of talk about our rights,” Vinehout said. “But what is often missed is that along with our rights come responsibilities to be an informed participant in our democracy. It’s the same with healthcare.”

Businesses for it

Vinehout told a story about a recent experience she had in Madison. One day, a woman who worked as an aide for a Republican colleague and who is a personal friend, told her a story while they were discussing health care.

“Before I had my current position, I worked for for a lobbying group that paid me to lobby the Wisconsin Manufacturers & Commerce against your Healthy Wisconsin legislation,” the person told Vinehout. “They paid me to do that because the business community was all for a single-payer system.”

Vinehout explained that businesses like the idea of a single-payer system because it eliminates all the administrative costs and challenges of managing a health insurance program in their company. It also gives them a competitive advantage in employee recruitment when they have branches in other countries where universal health care is available.

A list of some of the other countries in the world that have moved forward with a national single-payer health care program, guaranteeing all of their citizens access to healthcare, includes Norway, Japan, Germany, Belgium, United Kingdom, Sweden, Canada, Netherlands, Austria, Finland, Denmark, Luxembourg, France, Australia, Ireland, Italy, Portugal, Greece, Spain, Switzerland and Israel, to name a few.

Keep telling your story

Vinehout encouraged audience members to keep sharing their health care stories. She had her own story to tell about medical bills and keeping the family farm.

When Vinehout was first running for the state senate, she and her husband were dairy farmers. She remembered when they had to make the choice either to lose their health insurance or lose their cows – they chose to keep the cows.

“I would lie awake at night and worry about my family,” Vinehout remembered. “Farming can be a dangerous occupation and anyone can get sick or get injured.”

Vinehout rememberd that she took a call six weeks before the election, during a campaign meeting, and learned that her son’s appendix had ruptured and he needed emergency surgery.

“My son came through just fine, but the family was faced with a $15,000 medical bill,” Vinehout recalled. “Fortunately for us, we were able to take out a second mortgage on the farm. Not everyone has that kind of equity in their farm, though.”

Weight of the world

Megan Grinde, who grew up on a small, diversified farm north of Melrose, started the presentation out with a personal story.

 Grinde told the audience about how her family’s farm had been in the family for five generations. She explained how her family worked hard, and took pride in that history. In the 1980s, Grinde says, she watched as, one after the next, her neighbors lost their farms due to family illnesses and cancer.

“One day between the end of school and the beginning of softball practice, I fell and ruptured my spleen,” Grinde recalled. “I took an ambulance ride and spent a week in pediatric ICU at Gundersen.”

While lying in her hospital bed, with her worried loved ones around her, Grinde recalled seeing people with clipboards and paperwork talking with her parents.

“At some point, I realized that the family wasn’t just worried about me,” Grinde said. “I realized that they were also worried about how they would pay my medical bills, and worried that it might mean they would lose the farm.”

“We shouldn’t have 13-year-olds trying to recover from an injury carrying the weight of the world on their shoulders,” Grinde recounted tearfully.

Other examples

Darrin Von Ruden told the audience that the Wisconsin Farmers Union has been advocating for a single-payer or ‘Medicare for All’ health insurance system for years. Von Ruden shared several experiences with the health care delivery systems in other countries.

“When I was travelling in Norway with a Farmers Union association, the man broke his ankle and had to seek emergency care,” Von Ruden remembered. “After he got home, he kept expecting to receive a bill, but one never came because the service was covered.”

Von Ruden told the audience that the U.S. needs to take a good look at single-payer health care systems in other countries to find what would work best here in our country.

“Another example is when I spoke with the President of the Dairy Farmers of Ontario, who had needed knee replacement surgery,” Von Ruden said. “He wanted to have the surgery in December so he would have the winter to recuperate, but wound up having to wait a little longer than that because it was not an emergency situation.”

Von Ruden explained that advocating for health insurance for farmers was complicated by the fact that nationally farmers now represent less than one percent of the U.S. population.

“And frankly,” Von Ruden said, “we have farmers that sit on both sides of the aisle, politically speaking.”

Doctor’s dilemma

Dr. Taryn Lawler of the LaFarge Medical Clinic spoke of the angst of health care professionals who make diagnoses and dispense care instructions and prescriptions.

“I see so many people, especially the people whose income is just over the threshold for Badgercare, who are in critical need of care and medications, but just can’t afford it,” Lawler said. “Co-pays are just too high, and many people have to make hard choices about buying their needed medications or paying the rent or putting food on the table for their children.

Lawler shared a story of a young patient who suffered from asthma and needs an inhaler.

“When I first started seeing him, he was on Badgercare,” Lawler said. “He was getting the regular tests and inhalers that he needed.”

Lawler said that the young man started to do a little better economically, and his income went up just enough to disqualify him for Badgercare.

“Now he isn’t getting the tests he needs, and he isn’t using the inhalers that he needs,” Lawler says. “And as his doctor, I have to just worry about him. I worry that there is someone out there in our community that may not be able to breathe. Someone who is my patient.”

Lawler supports making Badgercare available as an option for all state residents. She says that 90 percent of state residents would get more and pay less, and there would be no premiums or deductibles.

http://www.swnews4u.com…

Copayments can kill

Weatherford teacher dies from flu effects

By Christin Coyne and Jelani Gibson
Weatherford Democrat, February 5, 2018

A second grade teacher at Ikard Elementary School, 38-year-old Heather Holland, died Sunday due to complications of the flu.

In addition to a classroom of second graders, Holland left behind husband Frank Holland, a 10-year-old daughter, and a 7-year-old son.

Holland fell ill about a week ago and planned to pick up flu medication but felt the $116 copay was too high, her husband said.

Frank Holland bought the prescription himself when he found out, but things worsened.

“Friday night, things escalated and she ended up in the ICU,” Holland said. “The doctors got the blood cultures back and they had to put her on dialysis early Saturday.” 

Heather Holland died Sunday morning.

“I have to be strong for the kids but it’s still surreal, it hasn’t all set in,” Holland said. “We’ve been together a long time, over half my life. She’s my best friend, my soulmate, my everything.”

http://www.weatherforddemocrat.com…

***

Comment:

By Don McCanne, M.D.

It is difficult to discuss policy issues in the face of tragedies such as this. Heather Holland’s husband, children and students come first. A moment of silent contemplation seems appropriate here.

***

We will never know whether earlier initiation of her flu medication could have improved her outcome. Evidence suggests that the medication shortens duration of symptoms, but reduction of complications is not quite so clear.

What we do know is that treatment was available, but it was delayed because of a $116 copayment. We do know that erecting financial barriers to care such as cost sharing through deductibles, copayments and coinsurance reduces access to care and can result in adverse outcomes – suffering and sometimes even death.

In this case we would have much preferred to have never heard about this tragedy because taking medication, getting well, and going back to work is not a newsworthy story. Again, we will never know for sure.

One of the most fundamental principles of a national health program such as the model supported by PNHP is that the financing of health care and the delivery of health care are totally separated. People should have health care when they need it without a need to arrange personal finances as a condition of accessing that care. Instead, the entire health care system should be financed in advance of need through equitable taxes based on ability to pay.

This concept is so simple, yet across the political spectrum voices tell us that patients need to fulfill their personal financial responsibilities before they access care. In a well designed single payer national health program they have already done that by paying their taxes. All of our policies should be oriented to helping people get the care they need when they need it. Why do we make that so complicated?

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Stephen Miller has to go

Letter to the White House: Stephen Miller must be removed

National Council of Jewish Women

On February 8, 17 Jewish organizations sent a letter authored and organized by NCJW to White House Chief of Staff General John Kelly expressing our deep concern that Senior Policy Advisor Stephen Miller does not belong in national leadership due to his extreme viewpoints and advocacy of racist policies.

February 8, 2018

General John F. Kelly
White House Chief of Staff
The White House
1600 Pennsylvania Avenue
Washington, DC 20500

Dear General Kelly:

We, the undersigned Jewish agencies and organizations, are writing to share our deep concern that Senior Policy Advisor Stephen Miller does not belong in national leadership due to his extreme viewpoints and advocacy of racist policies.

As Jews, we are in solidarity with immigrants and refugees and believe that our nation must be a refuge and welcoming home for new Americans. Our people have been persecuted too many times in history for us to do otherwise. Not only our history but our holy texts teach us this: we are commanded by the Torah to welcome the stranger, for we were once strangers in the land of Egypt. We believe that we are all made b’tzelem Elohim, or “in the image of God.” Every person is deserving of a dignified and safe life, regardless of race, religion, nationality or any other identity.

Stephen Miller’s views on immigration are extreme and dangerous, and he has been an obstacle to passing widely-supported, bipartisan, popular, badly-needed immigration policy changes throughout his time in the administration. There will be no forward motion for immigrants and refugees while he advises the president, despite bipartisan support, to the detriment of all who live and work in this country. Immigrants are a vital part of American society and crucial to our country’s businesses. They are also human beings deserving of a decent life, out of the shadows.

Miller’s views are anathema to our Jewish and American values. They’re outside the mainstream, and they have no place in the White House. Throughout his professional career, Miller has made no secret of his belief that immigration should be restricted and that immigrants are bad for our country. With then-Senator Sessions, Miller helped orchestrate the defeat of comprehensive immigration reform in 2014. He worked closely with Breitbart Media, a platform for the alt-right and white supremacist movements, and was a reliable media presence to comment on anti-immigrant and nativist policies. During the 2016 election, Miller was a frequent warm-up act at Trump’s campaign rallies, revving up the crowd by invoking the image of immigrants as criminals, telling rally attendees “We’re going to build [the wall] out of love for every family who wants to raise their kids in safety and peace.”

During his time in the White House, Miller’s hard line stance against immigrants has informed and even directed the administration’s policies. Miller was the architect of the first and second Muslim and Refugee bans, which blocked people from seven Muslim-majority countries from entering the US. He orchestrated cuts to the refugee program, resulting in the lowest admissions number in modern history during the worst refugee crisis since World War II. Miller helped author the now infamous list of the administration’s immigration priorities, which include building a border wall, defunding sanctuary cities, eliminating the diversity visa program, and changing the nation’s entire immigration system from one based on family unification to one based on speaking English and being light-skinned. These priorities have been cited as a prerequisite to any immigration negotiations. They are grotesquely anti-immigrant, and against the values of most Americans and certainly the Jewish community which our organizations represent.

Miller’s racist views should be enough to disqualify him from the White House, and his sway over President Trump has made it nearly impossible for Congress to move forward on a bipartisan deal to protect Dreamers — which 70-80% of Americans support. Senator Lindsey Graham held up Miller as an outlier even within their own party, and other Members of Congress point to Miller as a barrier to any type of agreement on immigration.

Our organizations, and the millions of Jews we represent, are in solidarity with immigrants and refugees as a reflection of our Jewish values and our American values. When our nation opens its doors, our families, communities, schools, and congregations thrive. Unlike Miller, we believe that the Statue of Liberty, by which so many of our own families passed during their journeys to the United States, is a potent symbol of the best our country has to offer — welcome and hope.

Stephen Miller opposes the beliefs we hold dear, and while he advises President Trump there will be no forward movement on immigration — to the detriment of this great nation founded by immigrants. We urge you to remove Miller from your team and the White House as soon as possible.

Sincerely,

Ameinu
American Jewish World Service
Americans for Peace Now
Bend the Arc Jewish Action
Habonim Dror North America
IK AR
J Street
Jewish Community Action
Jewish Council on Urban Affairs
Jewish Labor Committee
Jews for Racial & Economic Justice (JFREJ)
Jews United for Justice
Keshet
National Council of Jewish Women
Open Hillel
T’ruah: The Rabbinic Call for Human Rights
The Workmen’s Circle

https://www.ncjw.org…

***

The National Council of Jewish Women (NCJW) is a grassroots organization of volunteers and advocates who turn progressive ideals into action. Inspired by Jewish values, NCJW strives for social justice by improving the quality of life for women, children, and families and by safeguarding individual rights and freedoms.

NCJW believes that the moral test of a nation is how it treats its most vulnerable members. In recent years, the United States has failed that test, cutting the budgets of human needs programs and diverting critical federal dollars to military spending. Federal investments must ensure that human needs programs are fully funded including health care, lifelong education, opportunities to work, income supplements when work is not possible, and affordable necessities, including food, housing, and caregiving for children, seniors, and people with disabilities.

https://www.ncjw.org

***

Trump takes immigration cues from ‘Pres. Stephen Miller’

By Paul Begala
CNN, January 23, 2018

In a remarkable bipartisan meeting on January 9, the President said he would sign what Sen. Dianne Feinstein, D-California, called “a clean DACA bill,” which would allow the Dreamers to stay with no strings attached. After that, he said, we would move to “Phase Two, which would be comprehensive immigration reform. … But I think we need to do DACA first.”

In that January 9 meeting, President Trump promised to take the heat and sign a bipartisan immigration reform bill. Acting on his urging, Senators Graham and Dick Durbin, D-Illinois, hammered out a compromise. At 10:15 a.m. on January 11, Durbin phoned the President and said they had a deal. He was receptive and invited the senators to brief him.

By the time Durbin and Graham came to the White House at noon, the President’s tone had changed radically. Surrounded by hardline staffers like Mr. Miller, and bolstered by anti-immigration Republicans like Senator Tom Cotton, R-Arkansas, and Rep. Bob Goodlatte, R-Virginia, the President launched into a racist tirade, saying he wanted more immigrants from overwhelmingly white Norway, rather than black and brown immigrants from “shithole countries” in Africa, the Caribbean and Central America.

“Every time we have a proposal, it is only yanked back by staff members,” Graham said. How can it be that the President, who ran as a deal-maker, is being overruled by a young man who seems to want to upend every deal?

https://www.cnn.com…

***

This two and one-half minute video from BBC reveals Stephen Miller’s character

http://www.bbc.com…

***

Comment:

By Don McCanne, M.D.

Although this is an unusual selection for a blog on single payer it is very apropos since Stephen Miller is one of the most influential advisors to President Trump and is a primary source of his speeches and some of his inflammatory rhetoric. Although the NCJW letter targets Miller’s “extreme viewpoints and advocacy of racist policies,” in a larger sense it represents a protest against the warped mores he brings to the White House that negatively impact other issues of social justice, including our issue of health care justice.

Our president needs help in making this a better nation. Stephen Miller “opposes the beliefs we hold dear.” He has to go.

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

Why Internists Might Want Single-Payer Health Care

By Paul Sorum, M.D., Ph.D.
Annals of Internal Medicine, Feb. 13, 2018
 
Single-payer health care is back in the news thanks to the efforts of the president and Republicans to cripple if not kill the Patient Protection and Affordable Care Act and Bernie Sanders’ introduction of a new Medicare for All bill in the Senate. I aim to explain why internists in particular should consider working for a single-payer health care system.

Physicians and their staff are experiencing increasingly high levels of dissatisfaction and burnout. Much of this burnout is caused by the administrative burdens and other frustrations caused at least in part by our incoherent, inefficient, and inequitable multipayer system.

Continue reading:
http://annals.org…

Health care documentary in Flat Rock looks to heal a broken system

By Sammy Feldblum
Mountain Xpress (Asheville, N.C.), Feb. 13, 2018

Dr. Marsha Fretwell addressed a crowd of 25 in blunt terms Monday in Flat Rock: “We need to get for-profit health insurance out of the marketplace.”

Fretwell, a former geriatric physician and a member of Healthcare for All Western North Carolina, crystallized the thesis of the documentary Fix It: Health Care at the Tipping Point, which had finished a double feature at Flat Rock Cinema. The film, sponsored by the Henderson County chapter of Our Revolution, the progressive political organization spun off from Bernie Sanders’ presidential campaign, made a businesscentric case for single-payer health care.

With dark musical undertones thrumming, the documentary opened with the story of Richard Master, the increasingly distressed owner of a framing business. He described watching his employees’ premiums double over 10 years, even as his margins thinned, and worried what that price tag meant for the business.

Master was not alone. The documentary bounced among academics, economists and business executives who trotted out a series of grim and disturbing statistics about the cost and effectiveness of health care in the United States. More than 60 percent of bankruptcies in the United States are connected to medical bills, the documentary warned, before showcasing a man whose hemophilia medications cost him $50,000 a month. At that number, the audience let out an audible gasp.

The numbers piled up: In 1971, health care in the United States accounted for 7 percent of the country’s total economic activity; now, it accounts for 18 percent. (In other industrialized countries, that number hovers around 10 percent.) The increase, we learn, corresponds with the rise of for-profit health insurance companies’ control of the marketplace. Those health insurance companies, said Michael Lighty, director of public policy for National Nurses United, act like “an invisible force in the room,” directing health care decisions for patients instead of health care professionals doing so, inevitably worsening care.

When the documentary mentioned single-payer health care, its score turned buoyant, and the onscreen scenery took on a decidedly brighter tone — grass began to grow around sick cartoon stick figures. Canadian practitioners raved about their experience with single-payer in stark contrast to their harrowed American counterparts. In perhaps the most striking interview of the documentary, Wendell Potter, a former CIGNA executive, told the audience, “I regret what I did…I misled people.” Now, he works toward universal health care.

A Republican lawmaker, Dave Steil of Pennsylvania, urged the business-minded toward single-payer, noting that it would save money for both the country and for businesses — who would not have to pay expensive premiums for employees. The single-payer supporters were ahead by a landslide when the lights came up, so when Fretwell asked,“How many people are already convinced that we need health care reform?” every hand in the room shot up.

But Dr. Becky Love, a family physician based in Shelby, had concerns. She wondered what a transition to a national single-payer system might look like since powerful industry interests will surely oppose such a move. “Bernie says: ‘Drop Medicare to people 50 and over,’” Fretwell responded. “And, actually, if I were queen, that’s what I would do too.”

Love, though, invoked monthslong delays in payment by Medicare, which gave her pause. Her proposal for a transition involved putting a single-payer option on the Affordable Care Act’s insurance marketplace, offering a cheaper option for primary care. If it worked for a subset of the population, she suggested, it could be expanded accordingly.

Fretwell stressed that health care is not a political issue but a health and moral issue. “We need to get together on this as a country,” audience member Jim Kane said to Xpress. “If North and South Korea can go to the Olympics together…”

Still, the politicians in attendance were Democrats. Amy Donaldson, wife of Hendersonville urologist Scott Donaldson, who is running for Mark Meadows’s 11th District House of Representatives seat, told a story about a relative getting a year of treatment for lymphoma in Korea for the same amount that each of his annual follow-ups now costs in the United States (and stumped for her husband a bit in the aftermath). Sam Edney, a hopeful for the state House of Representatives in North Carolina’s 113th District, showed up as well. His main health care focus, he said, was expanding Medicaid, which he described as urgent thanks to rampant middle-income job loss in his district.

“We’re sending, this year, $3 billion to states that did expand Medicaid,” Edney told Xpress. “Arizona, Kentucky, Ohio: John McCain, Mitch McConnell, John Kasich. So why did we get all the dumb Republicans? We’re doing the exact opposite of what we should be doing, because of the ideologues in Raleigh.”

But Kyra Moore of Hendersonville, who organized the event, has a plan to reach across the aisle. “We’re going to take this into all the churches around here,” she said, her ubiquitous dog, Dusty, hanging placidly at her ankles. “Then we’re going to take this film into the conservative areas. And we’re the type of people that when we say we’re going to do something, we’re going to do it.”

https://mountainx.com…

Are Medicaid work requirements legal?

Experimenting On The Health Of The Poor: Inside Stewart v. Azar

By Sara Rosenbaum
Health Affairs Blog, February 5, 2018

As the complaint in Stewart v. Hargan (now Stewart v. Azar), filed on January 24 in federal district court in Washington D.C. makes abundantly clear, both the work experiment solicitation and the approval of Kentucky’s 1115 waiver in its wake are remarkable for the clarity of their intent to use punishment—in the form of denial or loss of health insurance coverage—to promote work. It doesn’t take a wealth of empirical research to conclude that people who are healthy probably are more likely to hold jobs and work more. Furthermore, there is actual empirical research that suggests that the very act of providing access to health care under the ACA expansion has had a positive effect on health and work. There simply is no evidence to support any reasonable hypothesis that health can be promoted by threatening the future and stability of health care for people whose health is worse to begin with and who—owing to the concentrated nature of poverty in the U.S.—tend to live in communities with higher unemployment and reduced job prospects.

Every dimension of the Kentucky demonstration is in play, with no hypothesis other than the assumption that people are healthier when they work. The evidence regarding how Medicaid actually promotes work is not even acknowledged.

This design combines work requirements with new program features that, according to the state, reflect the far less forgiving world of commercial health insurance. In this version of Medicaid, its core objective becomes the inverse of its statutory aim: to limit access as much as possible so that people will stop relying on it.

These hoops are multiple: Work requirements with few, poorly defined exemptions; lengthy loss of coverage for failure to follow additional reporting requirements; stripping away essential benefits with little hope of regaining them; using Medicaid to expose people to the limits of commercial insurance through escalating premiums, delayed enrollment, and elevated cost-sharing; and selectively withholding benefits from people considered undeserving.

(To better understand the lawsuit, an explanation of the plaintiffs’ legal arguments, omitted here, can be accessed at the link below.)

The Limits Of 1115

Medicaid’s core features, essential structure, and express prohibitions on certain types of experiments essentially put the brakes on how far 1115 experiments can go. Furthermore, as the complaint notes, 1115 as an experimental statute has its own brakes. Its agency powers can be invoked only for experiments that further program objectives.

Kentucky’s Aim: Selectively Culling The Eligible Population

Given the fact that federal law bars states from selecting winners and losers among the eligibility groups they cover, what is so striking about the Kentucky experiment is the lengths to which the state and its federal partner have gone to come up with a strategy, under the guise of experimentation, for selectively culling the Medicaid population.

Final Thoughts

Despite its historic role in shaping Medicaid policy, however, 1115 is a statute that grants limited powers. At its heart, 1115 is designed to fulfill a specific purpose: to enable Medicaid to better achieve its objectives. What makes the January 11 Medicaid work solicitation and the Kentucky approval such outliers is the singular absence of an experiment that promotes Medicaid’s core objectives. The relationship between work and health is axiomatic but this axiom alone cannot serve as the basis for threatening insurance coverage for people who cannot fulfill work requirements.

Indeed, so far afield from Medicaid’s objectives are the Administration’s work experiments that, in its solicitation, the Administration makes clear that it will permit no federal funds to be claimed for costs associated with work supports, nor will it permit states to keep savings attributable to the loss of eligibility for reinvestment in other Medicaid activities. These two fundamental caveats drive home the degree to which the Trump Administration has essentially admitted that, rather than advancing policy goals involving health care for the poor, Medicaid work experiments undermine them.

https://www.healthaffairs.org…

For another opinion on the legality of Medicaid work requirements, by Nicholas Bagley, JD:
https://jamanetwork.com…

Nicolas Bagley writes, “But the courts have not been moved by the argument—true though it may be—that Congress never meant for section 1115 to be a vehicle for the adoption of sweeping, controversial, and partisan reforms to Medicaid. Instead of winning in court, the opponents of work requirements may need to win some elections.”

***

Comment:

By Don McCanne, M.D.

Medicaid was established to help low-income individuals receive the health care that they need. Section 1115 waivers were established to allow states to make modifications within the Medicaid program to better achieve that goal. The Trump administration is now undermining that goal by using the waivers to punish Medicaid beneficiaries by denying health care if unemployed. The legality is being challenged.

In her full article Sara Rosenbaum describes the legal principles and how HHS/CMS is undermining them. Nicholas Bagley also discusses the legal issues while making the very important point that the moral foundation ultimately is determined by our action as voters. We get what we choose.

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BMJ: Failing health of the United States

The role of challenging life conditions and the policies behind them

By Steven H Woolf, Laudan Aron
BMJ, Editorial, February 7, 2018

Life expectancy in the US has fallen for the second year in a row. This is alarming because life expectancy has risen for much of the past century in developed countries, including the US. The decline in US health relative to other countries, however, is not new; it has been unfolding for decades. In 1960, Americans had the highest life expectancy, 2.4 years higher than the average for countries in the Organisation for Economic Cooperation and Development (OECD). But the US started losing ground in the 1980s. US life expectancy fell below the OECD average in 1998, plateaued in 2012, and is now 1.5 years lower than the OECD average.

A joint panel of the National Research Council and Institute of Medicine investigated the US health disadvantage in 2013. It found that Americans had poorer health in many domains, including birth outcomes, injuries, homicides, adolescent pregnancy, HIV/AIDS, obesity, diabetes, and heart disease. It also found that many factors contribute to the health disadvantage; for example, Americans are more likely to engage in unhealthy behaviors (such as heavy caloric intake, drug abuse, and firearm ownership), live in cities designed for cars rather than pedestrians or cyclists, have weaker social welfare supports, and lack universal health insurance.

The panel reported high death rates in the US from drugs, a problem that has grown over time. Between 2000 and 2014, the rate of fatal drug overdoses rose by 137%, a crisis fueled by the growing use of highly addictive opioid drugs. In 2015 alone, more than 64 000 Americans died from drug overdoses, exceeding the number of US casualties in the Vietnam war. Drug addiction is devastating families and the social fabric of communities. The country is belatedly scrambling to reduce access (with, for example, prescription drug monitoring and drug take back programs), improve emergency responses to reverse overdoses (such as naloxone programs), and enhance access to effective addiction treatment (such as medication assisted treatment).

But the opioid epidemic is the tip of an iceberg, part of an even larger public health crisis in the US: death rates from alcohol abuse and suicides have also been rising. Between 1999 and 2014, the suicide rate rose by 24%. These “deaths of despair,” as some have called them, are disproportionately affecting white Americans, especially adults aged 25-59 years, those with limited education, and women. The sharpest increases are occurring in rural counties, often in regions with longstanding social and economic challenges.

Why white Americans are dying at higher rates from drugs, alcohol, and suicides is unclear, complex, and not explained by opioids alone. The answer—likely some combination of factors in American life—must explain why the rise in mortality is greatest in white, middle aged adults and certain rural communities. Possibilities include the collapse of industries and the local economies they supported, the erosion of social cohesion and greater social isolation, economic hardship, and distress among white workers over losing the security their parents once enjoyed. By contrast, greater resilience might explain why black Americans—who have contended with longstanding structural disadvantages, discrimination, and higher all cause mortality—have not experienced a surge in drug deaths or suicides.

Other data are also enlightening. Over the three decades in which survival advances slowed in the US, educational performance weakened, social divides (including income inequality) widened, middle class incomes stagnated, and poverty rates exceeded those of most rich countries. The US is rich, but its wealth is not inclusive. Its social contract is weaker than in other countries—those in need have less access to social services, healthcare, or the prevention and treatment of mental illness and addiction. The “American dream” is increasingly out of reach, as social mobility declines and fewer children face a better future than their parents.

In theory, policy makers jolted by the shortening lifespan of Americans would hasten to correct these conditions. They would promote education, boost support for children and families, increase wages and economic opportunity for the working class, invest in distressed communities, and strengthen healthcare and behavioral health systems. But the pro-business policy agenda favored by elected officials rarely prioritizes these needs. On the contrary, recent legislation and regulations may prolong or intensify the economic burden on the middle class and weaken access to healthcare and safety net programs.

Ironically, leaders are outspoken about ending the opioid epidemic and bemoan spiraling and unsustainable healthcare costs. Solutions to both problems—which involve investment to support struggling families and communities and thereby improve public health—are often rejected, usually by leaders with competing self interests or ideological objections. The consequences of these choices are dire: not only more deaths and illness but also escalating healthcare costs, a sicker workforce, and a less competitive economy. Future generations may pay the greatest price.

http://www.bmj.com…

***

Comment:

By Don McCanne, M.D.

This editorial states that lack of universal health insurance is one cause of declining health and life expectancy in the United States, especially when contrasted with the superior performance of other OECD nations. But it is only one cause. We have much more that we need to do to reverse the increasing disparities and their unwelcome outcomes.

The people of the United States need an epiphany – the realization that we need to join together to improve understanding of our deficiencies and then to resolve to work together to fix them. The solutions lie primarily in the public arena. That means we need national political leadership that is dedicated to this cause. But that also means that the people will have to fire the obstructionist partisans. That would be easy except for the plethora of obstructionist partisan voters who are immune to epiphanies.

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

Seema Verma’s policies can kill people

Trump Administration Says States May Impose Work Requirements for Medicaid

By Robert Pear
The New York Times, January 11, 2018

In a speech to state Medicaid officials in November, (CMS Administrator Seema) Verma indicated that the Trump administration would be receptive to work requirements and other conservative policy ideas to reshape Medicaid. And she criticized the Obama administration, saying it had focused on increasing Medicaid enrollment rather than helping people move out of poverty and into jobs.

“Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” Ms. Verma said. “Those days are over.”

https://www.nytimes.com…

CMS letter to Medicaid Directors; “Opportunities to Promote Work and Community Engagement Among Medicaid Beneficiaries” (10 pages):
https://www.medicaid.gov…

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State Waivers As A National Policy Lever: The Trump Administration, Work Requirements, And Other Potential Reforms In Medicaid

By Billy Wynne and Taylor Cowey
Health Affairs Blog, February 6, 2018

Despite repeat campaign promises from then presidential candidate Donald Trump that he had no interest in altering Medicaid and other entitlements, it was evident from the start of his administration that there would be big plans in the works for the low-income insurance program. This was evident, most notably, in his appointment of health policy consultant Seema Verma—architect of the uniquely conservative Medicaid expansion waiver in Indiana—to run the Centers for Medicare and Medicaid Services (CMS). Now, one year into the Trump presidency, after Congress’s attempts to cut and restructure Medicaid through legislation have proved unsuccessful, the administration has begun in earnest to pursue a regulatory pathway to state-by-state Medicaid reform grounded in Verma’s approach to Section 1115 Medicaid waiver design.

Alignment with the program’s purpose—defined in statute (42 US Code Section1396) as “to furnish medical assistance on behalf of families … and … individuals … whose income and resources are insufficient to meet the cost of necessary medical services”—is a key requirement for waiver approval. CMS’s newly stated criteria no longer places an emphasis on coverage levels. Instead, it focuses on Medicaid’s sustainability over the long term, upward mobility, greater independence and beneficiary engagement, incentive structures and “responsible decision-making,” and commercial health insurance design features to “facilitate smoother beneficiary transition” off of Medicaid.

At the outset of the administration’s second year, CMS has unveiled highly anticipated guidance on how states can implement work, education, and job training requirements through Section 1115 waivers. Shortly after, HHS announced the approval of the first work requirement demonstrations in Kentucky and Indiana.

Pending Waivers to Watch

Work Requirements

Besides Kentucky and Indiana, eight other states—Arkansas, Arizona, Kansas, Maine, Mississippi, New Hampshire, Utah, and Wisconsin—have waivers pending at CMS that would impose a work requirement on Medicaid expansion or traditional adult Medicaid populations. As a feature of their proposed work requirements, some of these states are seeking to impose specific time limits on how long beneficiaries may stay enrolled in Medicaid coverage if they fail to meet engagement requirements.

Lifetime Caps

Several states, including Arizona, Kansas, and Utah, have gone a step beyond time limits tied to work and have proposed lifetime limits on Medicaid coverage for able-bodied adults, ranging from three to five years. If approved in Medicaid, it would constitute another monumental shift of the program design away from being a vehicle for health care and toward being treated as a conditional welfare program.

Lockouts

Time-limited periods of Medicaid ineligibility, or “lockouts,” resulting from nonpayment of premiums were previously approved by the Obama administration for certain expansion adults in only a small number of states. However, with approval of the Kentucky HEALTH waiver, premiums and lockouts may now apply to the traditional population as well. These policies present an additional administrative burden for states and create a yearly hurdle for enrollees to retain their coverage, which could lead to increased disenrollment and churn.

Hospital Presumptive Eligibility

Under the ACA, hospitals gained the option to make presumptive eligibility determinations for patients in need of immediate care. The policy provides greater access to Medicaid benefits for low-income individuals and protects participating hospitals from a percentage of uncompensated care costs. Where some states have previously been allowed to waive presumptive eligibility enrollment and retroactive coverage for pregnant women and children, it has not yet allowed a state to eliminate presumptive eligibility conducted by hospitals, as Maine and Utah are currently proposing to do.

Partial Expansion

Arkansas, which expanded its Medicaid program in 2014, has proposed to reduce eligibility for its expansion population down from the 138 percent of federal poverty level dictated by the ACA to 100 percent of poverty, while still maintaining the enhanced expansion funding for those who remain. Massachusetts later included a similar provision in its own pending waiver. Critics worry that approval of this “partial expansion” would set a precedent with budgetary and coverage consequences for low-income individuals in other states.

Exclusion Of Planned Parenthood

Separately from its actions on 1115 waivers, CMS recently issued a letter to state Medicaid directors rescinding previous guidance issued by the Obama administration regarding the “Free Choice of Provider” requirement in Medicaid, particularly in relation to providers of family planning and abortion services. The guidance had clarified that states may not exclude family planning providers from Medicaid reimbursement “solely because they separately provide family planning services or the full range of legally permissible gynecological and obstetric care, including abortion services.” This was widely understood to be in response to certain states seeking to prevent Medicaid dollars from going to Planned Parenthood. Citing “legal issues under the Administrative Procedure Act,” CMS has removed this guidance and opened the door to states that were previously seeking to exclude the organization.

Medicaid Drug Formularies

In response to the rising cost of prescription drugs, Massachusetts has proposed adopting a closed formulary for its Medicaid population. This would involve a waiver of the statute that otherwise requires Medicaid coverage of Food and Drug Administration-approved outpatient drugs provided the manufacturer participates in the Medicaid Drug Rebate Program.

Conclusion

From a state perspective, the Medicaid landscape has grown ever more complex as the program is increasingly found at the nexus of partisan debate and made the subject of major reform efforts that swing with the party controlling the White House or Congress.

With its solicitation of work requirement proposals and the other waiver reforms implemented in 2017, Verma and the Trump administration have decidedly swung the pendulum once more. Many states are responding in kind and ushering in an era of profound change for the decades-old program. But it remains to be seen if we will truly see work requirements and related reforms tested in the states as the legal and regulatory framework upon which this new paradigm is built is called into question in the courts. At the heart of the matter, as always, will be the question of how our nation views the core objectives of the Medicaid program—as health care or welfare for the nearly 70 million Americans enrolled.

https://www.healthaffairs.org…

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After approving Medicaid work requirements, Trump’s HHS aims for lifetime coverage limits

By Tony Pugh
Lexington Herald-Leader, February 5, 2018

After allowing states to impose work requirements for Medicaid enrollees, the Trump administration is now pondering lifetime limits on adults’ access to coverage.

The move would continue the Trump administration’s push to inject conservative policies into the Medicaid program through the use of federal waivers, which allow states more flexibility to create policies designed to promote personal and financial responsibility among enrollees.

“I think you have to be very thoughtful here in a way that’s quite different from cash assistance,” said Gail Wilensky, a senior fellow at Project HOPE who ran the Medicaid program from 1990 to 1992 under President George H.W. Bush. “It depends on what the safeguards and defaults are in a program like this. Otherwise it does not make a lot of sense and seems to be cruel and inappropriate.”

http://www.kentucky.com…

***

Comment:

By Don McCanne, M.D.

CMS Administrator Seema Verma is critical of the Obama Administration because it used the Medicaid program to help low-income people receive the health care that they needed, just as the law requires. Referring to this as the “soft bigotry of low expectations,” Verma is encouraging states to apply for waivers that would use the deprivation of Medicaid benefits as a whip to move individuals out of poverty and into jobs. Instead of looking at Medicaid as a health care program that should be expanded to all who need it, she looks upon it as a welfare program that needs to be ratcheted down (presumably to reduce taxes for the benefit of the rich).

It is not only the work requirements that would reduce access to care for Medicaid eligible individuals; Verma is also considering other policies that would further reduce access. As the article by Billy Wynne and Taylor Cowey indicates, CMS also encourages lifetime caps that would arbitrarily throw individuals off of the program based simply on a time limit rather than on need; they would require premiums which could be a hardship for these vulnerable individuals; they would use lockouts perhaps as punishment for failure to comply with all details of the application process; they would eliminate presumptive eligibility prohibiting individuals from receiving coverage in an emergency even though obviously eligible; they would allow states to reduce their Medicaid expansion programs, keeping otherwise eligible individuals out of the program; they would allow states to exclude family planning and preventive services provided by Planned Parenthood, and they would allow closed drug formularies preventing individuals from obtaining excluded medications.

Obstructing the path to health care results in financial hardship, physical suffering, and sometimes even death.

Not even all of the conservatives can stomach this. Gail Wilensky, head of HCFA (precursor of CMS) under President George H.W. Bush, recognizes the difference between capping “cash assistance” welfare and capping a program designed to help people get the health care they need. As she says, a program capping health care “does not make a lot of sense and seems to be cruel and inappropriate.”

It’s true. Either actively or passively denying health care to anyone does not make a lot of sense and seems to be cruel and inappropriate. We need a well designed single payer national health program that takes care of everyone.

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