PNHP

Why Trumpcare Will Only Make the Rich Richer

Why Trumpcare Will Only Make the Rich Richer

By Adam Gaffney, M.D.
Fortune, March 9, 2017

House Republicans this week unveiled their long-awaited bill replacing the Affordable Care Act, also known as Obamacare. Blandly titled the American Health Care Act—or as many have already taken to calling it, Trumpcare—the House GOP bill is effectively a concession that the right lacks a workable health care vision of its own: The program they offer would retain the fundamental structure of Obamacare, albeit with an ugly and regressive twist. While it would dramatically fail to achieve President Donald Trump’s stated goal of “insurance for everybody,” it would be strikingly successful in redistributing wealth to make the rich even richer.

Among Obamacare’s numerous provisions, the most well-known (and beneficial) were those that expanded coverage. Between the Medicaid expansion and subsidization of the private insurance industry (together with various insurance regulations and mandates), the law effectively reduced the number of uninsured by an estimated 20 million (albeit still leaving some 29 million uninsured as of 2015).

Trumpcare would take us in precisely in the opposite direction. For the private insurance market, the GOP plan follows Obamacare in subsidizing the purchase of health insurance plans for those who are otherwise uninsured. However, while Obamacare provides income-based premium subsidies that are tied to the price of the plan (such that those with lower income receive bigger subsidies), Trumpcare would provide flat subsidies—which it calls refundable tax credits—to all but high-income earners. Older recipients would receive twice the subsidies of younger recipients, but the subsidy otherwise wouldn’t be tied to the actual price of the plan, making insurance unaffordable for many.

Moreover, the GOP plan would also eliminate Obamacare’s cost-sharing subsidies that lower out-of-pocket medical costs for millions, leaving even more people with insurance that they can’t afford to use and worsening the epidemic of underinsurance. And whereas under Obamacare, the government penalizes you for being uninsured, under Trumpcare the penalty would instead be inflicted by insurers: Those who fail to maintain continuous coverage would have their premiums jacked up by 30%.

Finally, Obamacare’s penalty for large employers that fail to provide insurance would end. All of which is to say that the old, the sick, and those with low incomes lose out, while big businesses that don’t provide healthcare to their employees benefit.

Trumpcare would more radically restructure Medicaid. Indeed, as health care lawyer Timothy Jost puts it in the Health Affairs blog, “the bill is not so much an [Obamacare] repeal bill as it is an attempt to change dramatically the Medicaid program.” First, beginning in 2020, funding for Obamacare’s Medicaid expansion would start to dial down. Second, the bill would fundamentally change the way Medicaid is funded. Currently, the federal government provides a set percentage of state Medicaid spending; if Medicaid spending rises, so does the flow of federal dollars to the state, which is how it should be.

Under Trumpcare, by contrast, federal Medicaid spending would be provided on a per capita basis, and so funding will not match growing healthcare needs and spending. Together, these provisions would gradually push participants out of the program. Even though Republicans have made the case that per capita caps might drive state Medicaid “innovation,” as a recent article in the New England Journal of Medicine asserts, “the historical experience in the United States suggests per capita caps would simply shrink the program.”

With one hand the GOP law would thus squeeze the poor, while with the other hand it would gently massage the rich. For as Jost describes, the bill includes an extensive array of tax cuts for the benefit of various groups that need (or deserve) no help: medical device manufacturers, tanning salons, pharmaceutical companies, health insurance executives (whose salaries would again be tax-deductible over $500,000), and the very well-off more generally (through the repeal of Obamacare’s tax on unearned income for the wealthy).

The bill would not be complete, however, if it lacked a line aimed at restricting reproductive healthcare: It includes a provision that would cut funding for large nonprofit reproductive health care-oriented providers that also provide abortions (in other words, Planned Parenthood).

Trumpcare is thus a curious beast. On the one hand, despite Republicans’ endless rancor over Obamacare, this is essentially a proposal to worsen that law, and not a revolutionary right-wing rupture with the status quo. Many of Obamacare’s protections would remain and subsidies (albeit less adequate and more regressive) to purchase private health insurance would still be available. On the other hand, Trumpcare would effectively redistribute wealth to the top by providing tax cuts for the health care industry and the rich, while simultaneously imposing subsidy and Medicaid cuts for the middle class and poor. Until the legislation is scored by the Congressional Budget Office, we won’t know the full extent of harm, but it seems highly likely that many millions will lose coverage (some of whom will lose their lives as a result).

That Republicans were unable to produce a bill that was a least a bit more original is the result of various historical and political factors. First, passing the bill in the Senate through the reconciliation process, which evades a potential filibuster, limits what Republicans can change. It is probably for this reason that many Obamacare insurance reforms (for instance, protections for those with preexisting conditions or prohibitions on lifetime benefit caps) are retained in the bill. Second, there is the pesky problem that Obamacare is, at its core, very similar to a Republican health care reform bill introduced in the Senate in 1993.

Third, free-market healthcare dystopias are unpopular among the U.S. population, which holds strikingly left-wing views on health care. According to a Gallup poll from last year, “58% of U.S. adults favor the idea of replacing [Obamacare] 
 with a federally funded healthcare system that provides insurance for all Americans.” Republicans thus find themselves in an admittedly thorny predicament: What do you do when your country wants a single payer health care system, and the Democrats already cribbed your plan?

As a result, the GOP may come to find that it may have, through its health care muddling, inadvertently pushed the country toward a reform that it loathes far more than Obamacare. For if Obamacare is felled—whether in word or in deed—and when Trumpcare flounders or implodes, a universal health care system will be the last option remaining.

Adam Gaffney is a writer on health care politics and policy, instructor in medicine at Harvard Medical School, and a pulmonary and critical care physician.

http://fortune.com…

PNHP’s open letter to President Trump

An Open Letter To Trump: The GOP Health Plan Won’t Work, Replace ACA With Single Payer

The Huffington Post, March 9, 2017

Dear Mr. President,

You vowed to replace the Patient Protection and Affordable Care Act (ACA) with something great that would provide Americans with universal coverage and lower deductibles and copayments. As leaders of Physicians for a National Health Program (PNHP), a nonpartisan organization of 20,000 physicians and medical students, and as a business leader who desires fundamental health reform, we request an opportunity to meet with you to explain why single-payer, Medicare for all, is a great solution that will meet your stated goals.

Health care reform is urgently needed. Seven years after the passage of the ACA, 26 million Americans remain uninsured, tens of millions more are underinsured, and health care costs – already twice as high as the average of other wealthy nations – continue to rise. In a recent survey, Americans were more likely to report financial barriers to health care than citizens of any of the 11 other nations surveyed. One-third of Americans, including 43 percent of low-income persons, went without health care due to cost last year.

Unfortunately, “The American Health Care Act” (AHCA) would be a big step in the wrong direction. The bill would shrink Medicaid benefits for millions of poor and low-income families. It would sharply reduce the value of government subsidies, leaving millions of near poor and middle income Americans unable to afford coverage, and shifting millions of others to the kind of bare bones plans that you have decried. Meanwhile, it would give hundreds of billions of dollars of tax breaks to the wealthiest 2 percent of Americans, and reward insurance firms that pay outrageously high executive salaries.

In sum, this legislation will degrade already inadequate coverage, increasing financial barriers to care and endangering tens of thousands of lives, merely to reduce taxes on rich individuals and corporations.

The working people of America are looking to you for something better.

In contrast, a single-payer system, essentially an expanded and upgraded version of traditional Medicare, could meet your stated goals of more coverage, better benefits and lower costs. Such reform would drastically cut insurance overhead and the paperwork insurers inflict on doctors and hospitals, saving more than $500 billion annually. Those savings would cover the cost of universal, first-dollar coverage – including dental services and long-term care – upgrading coverage for the vast majority of Americans.

And a single-payer reform would allow the U.S. to use proven-effective tools to control costs. Instead of disrupting the delivery of care by shoehorning every doctor and hospital into a gigantic corporation, it would support practices and hospitals of all sizes with negotiated fees and global budgets. Negotiating prices with drug firms as other countries do would save another $150 billion annually. Controlling costs is the only way to make our health care system sustainable for future generations.

Single payer would lift the burden of health benefit costs from employers, making U.S. business more competitive. Richard Master, a business owner in Pennsylvania, produced the film “Fix It” to explain the benefits of single payer to business. Adopting a single-payer system would help keep jobs in the U.S.

Legislation for “improved Medicare for all,” H.R. 676, was introduced in the Congress last month by Rep. John Conyers. Polls have shown that 58 percent of Americans favor replacing the ACA with a single-payer system, as do 59 percent of physicians, 81 percent of Democrats, and a rapidly growing share of Republicans.

Single payer has proven effective in countries around the world, as evidenced by experience in Canada and Scotland, which spend far less than we do, cover everyone, and provide care free at the point of delivery. Tommy Douglas, the founder of Canada’s system, is ranked the most popular figure in that nation’s history, and Sen. Bernie Sanders attracted a huge following with his support for single payer, Medicare for all in his run for the Democratic primary.

PNHP has, from the outset, been strongly critical of the ACA’s failure to solve our nation’s health care crisis. The AHCA would divert us even further from the goal of solving that crisis and tarnish your legacy. Single-payer reform is the only solution.

Sincerely,

Steffie Woolhandler, M.D., M.P.H., Co-founder PNHP

David Himmelstein, M.D., Co-founder, PNHP

Carol Paris, M.D., President, PNHP

Don McCanne, M.D., Senior Health Policy Fellow, PNHP

Adam Gaffney, M.D., Board member, PNHP

Janine Petito, Medical student board member, PNHP

Richard Master, Chairman & CEO, MCS Industries, Inc.

http://www.huffingtonpost.com…

***

Comment:

By Don McCanne, M.D.

President Trump was not well informed on health policy when he took office. He has been too busy with other things. He did know that serious problems persisted in spite of Obamacare – too many uninsured, insurance plans that left people with excess medical debt, too many had impaired access to the health care they needed, and health care costs were too high. So he promised that Obamacare would be repealed and replaced with a really terrific plan – “insurance for everybody
 much less expensive and much better.”

He is surrounded by advisors who have given him lessons on health policy, but, unfortunately, all the wrong lessons. He now understands that health reform is very complicated, so he left it to his advisors and Congress to provide the details. They are currently trying to pass a program that insures fewer people and makes access to health care much more expensive because of high out-of-pocket costs – a program that is much worse for the American people – the opposite what he promised us.

The primary goal of his advisors is to reduce the role of government – fewer regulations and less government spending. They thought that they could cover their misdeeds with rhetoric that did not reveal their nefarious intentions – like making sure that everyone had “access” though remaining silent on the fact that for many actual health care would not be affordable even if accessible.

If President Trump is sincere in wanting everyone to have better health care that is affordable, then he needs a crash course in beneficial health policy.

Physicians for a National Health Program has a mission of educating the public and policymakers on the truth behind health care financing – that we are already spending enough to provide high quality health care for absolutely everyone without causing anyone to face financial hardship because of the costs of health care.

We even have a very successful businessman, Richard Master of MCS Industries, who can explain the advantages of single payer in terms that Donald Trump can really understand.

PNHP’s open letter needs to make it to the President’s desk, or better, directly handed to him so that he realizes that he was correct when he mentioned that single payer systems seemed to work well in other nations.

Time to make some noise – social media, community action, or whatever. He needs to see this letter.

Dude, where’s my democracy?

By Jeff Jane, M.D.
The (Grass Valley, Calif.) Union, March 9, 2017

Rep. Doug LaMalfa wants to repeal the Affordable Care Act, better known as Obamacare.

I agree with much of his position. His principal criticism is that insurance under the ACA is already too expensive and even rising.

Indeed, the Department of Health and Human Services estimates that premiums, deductibles, and copays will rise about 25 percent during this year. As Mr. LaMalfa correctly observes, “We spend over 17 percent of our economy on health care, nearly twice the level of other developed countries, yet our system fails to provide consistently high-quality care.”

Along with many other people, Mr. LaMalfa blames the surreal expense of healthcare insurance on government. That’s a false charge. The government only sets up rules for the private insurance corporations’ participation, such as covering pre-existing conditions or covering children under their parents’ policies until age 26. It’s the corporations that set the rates.

Health insurance carriers have a fiduciary responsibility to provide a return on investment — that is, profit — to their shareholders. No matter how politicians slice and dice healthcare financing — such as reducing excessive regulations, allowing purchase of insurance across state lines, offering tax breaks and health savings accounts, establishing high-risk pools — profit-making entities will continue to take in far more than they give out, and patients will suffer an even more complex system.

Experts estimate the operating costs of healthcare insurance corporations to be 30 to 35 percent. In contrast, the operating costs of Medicare, a government agency, is around 5 percent.

That means 25 to 30 cents of each dollar we pay goes not to healthcare, but to corporate overhead, profits, and windfall executive compensation. For example, Aetna Insurance profited $31 billion in 2008, and in 2010 paid its CEO $24 million.

We’ve run out of options. Our choice has narrowed between what we have now, a system operated by companies that are certain to raise costs indefinitely, and a single-payer system equivalent to Medicare for all of us, and costing 30 percent less.

In fact, a recent Gallup poll disclosed that 58 percent of Americans favor replacing the ACA with a federally-funded system.

But healthcare reform isn’t exactly what I’m writing about now; it’s something more basic.

For several weeks, I’ve been trying to contact Mr. LaMalfa in order to initiate a dialog about the health insurance costs he’s correctly criticized. I’ve written him emails, spoken with people on his D.C. staff and formally requested face time.

Although his aides seem intelligent, concerned and friendly, I feel like my messages have dropped into a mysterious black box that may as well be a shredder.

Of course, someone who represents over 300,000 people can’t see each individual.

And further, it seems sensible for a representative to vote his or her conscience at times without checking the polls. But sometimes it’s necessary to dialog with well-informed voters, since a representative can be stuck in an obsolete way of thinking or just flat-out wrong.

Without such a conversation, it’s senseless to advocate for any issue whatsoever, since one is only talking to a wall.

Jeff Kane, M.D. lives in Nevada City, Calif.

http://www.theunion.com…

Doctors group: House GOP health plan is a re-branded and far meaner version of the ACA

The ‘American Health Care Act’ perpetuates the basic structure of the Affordable Care Act, including the subsidization of the private health insurance industry, while cutting benefits to the poor and middle class, and giving hundreds of billions in tax breaks to the rich

FOR IMMEDIATE RELEASE, March 8, 2017
Contact: Mark Almberg, communications director, PNHP, mark@pnhp.org, (312) 782-6006

Physicians for a National Health Program decries the recently released Republican Obamacare replacement bill, the “American Health Care Act” (AHCA). That plan would constitute a major backward step in health policy, compounding the problems of uninsurance and underinsurance while handing over hundreds of billions of dollars to the wealthiest 2 percent of Americans.

Proposed as a replacement of the Affordable Care Act (ACA), the AHCA would maintain its basic structure. The bill would:

‱ Continue to channel billions of taxpayer dollars through wasteful private insurers;
   
‱ Sharply reduce the ACA’s subsidies (or “tax credits”) available to lower-income persons, particularly older adults, to purchase coverage;

‱ End the ACA’s cost-sharing subsidies for copayments and deductibles, increasing the cost of care for those with chronic medical conditions;
    
‱ Replace the ACA’s “individual mandate” penalty on the uninsured with a 30 percent surcharge on insurance premiums for those who experienced a lapse in insurance coverage;

‱ Slash federal funding for the Medicaid expansion beginning in 2020, and move towards a “per capita” cap on Medicaid spending that would squeeze state Medicaid budgets and push millions of enrollees out of the program;

‱ Increase the tax-favored status of Health Savings Accounts, which mostly benefit people in high income brackets;

‱ Reduce taxes on pharmaceutical, medical device and health insurance companies;

‱ Offer tax reductions totaling $274.6 billion over 10 years to the wealthiest 2 percent of Americans.

These and other provisions would take the nation in the wrong direction. Even with the ACA in place, 29 million remained uninsured in 2015; the ACHA would only push that number higher. And today, even many Americans with coverage face bankrupting medical bills for copayments, deductibles and uncovered services. By lowering the standards of private insurance plans and ending cost sharing subsidies, the ACHA would only intensify the problem of “underinsurance.”

The AHCA would replace the ACA with a worse, more regressive version of the original bill. This is not what Americans want or need. PNHP instead urges Congress to replace the ACA with a single-payer national health care program. Unlike the ACA or the AHCA, single-payer, Medicare for All reform could effectively control costs while creating a right to high-quality health care for everyone in America.

A more detailed, point-by-point summary of the contents of the GOP House bill, prepared by Drs. Steffie Woolhandler and David Himmelstein, is available here.

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 20,000 doctors who support a single-payer national health program. It was founded in 1986.

PNHP on GOP’s re-branded and far meaner version of ACA

Doctors group: House GOP health plan is re-branded and far meaner version of ACA

The ‘American Health Care Act’ perpetuates the basic structure of the Affordable Care Act, including the subsidization of the private health insurance industry, while cutting benefits to the poor and middle class, and giving hundreds of billions in tax breaks to the rich

Physicians for a National Health Program, March 8, 2017

Physicians for a National Health Program decries the recently released Republican Obamacare replacement bill, the “American Health Care Act” (AHCA). That plan would constitute a major backward step in health policy, compounding the problems of uninsurance and underinsurance while handing over hundreds of billions of dollars to the wealthiest 2 percent of Americans.

Proposed as a replacement of the Affordable Care Act (ACA), the AHCA would maintain its basic structure. The bill would:

‱ Continue to channel billions of taxpayer dollars through wasteful private insurers;
   
‱ Sharply reduce the ACA’s subsidies (or “tax credits”) available to lower-income persons, particularly older adults, to purchase coverage;

‱ End the ACA’s cost-sharing subsidies for copayments and deductibles, increasing the cost of care for those with chronic medical conditions;
    
‱ Replace the ACA’s “individual mandate” penalty on the uninsured with a 30 percent surcharge on insurance premiums for those who experienced a lapse in insurance coverage;

‱ Slash federal funding for the Medicaid expansion beginning in 2020, and move towards a “per capita” cap on Medicaid spending that would squeeze state Medicaid budgets and push millions of enrollees out of the program;

‱ Increase the tax-favored status of Health Savings Accounts, which mostly benefit people in high income brackets;

‱ Reduce taxes on pharmaceutical, medical device and health insurance companies;

‱ Offer tax reductions totaling $274.6 billion over 10 years to the wealthiest 2 percent of Americans.

These and other provisions would take the nation in the wrong direction. Even with the ACA in place, 29 million remained uninsured in 2015; the ACHA would only push that number higher. And today, even many Americans with coverage face bankrupting medical bills for copayments, deductibles and uncovered services. By lowering the standards of private insurance plans and ending cost sharing subsidies, the ACHA would only intensify the problem of “underinsurance.”

The AHCA would replace the ACA with a worse, more regressive version of the original bill. This is not what Americans want or need. PNHP instead urges Congress to replace the ACA with a single-payer national health care program. Unlike the ACA or the AHCA, single-payer, Medicare for All reform could effectively control costs while creating a right to high-quality healthcare for everyone in America.

https://www.pnhp.org…

***

Comment:

By Don McCanne, M.D.

Although the Republican leadership has made feeble attempts at crafting rhetoric to sell their American Health Care Act (AHCA) – their legislation intended to repeal and replace the Affordable Care Act (ACA) – nobody is fooled into thinking that they are proposing an improvement over ACA. Millions would lose their insurance and millions more would have worse coverage that leaves them even more exposed to unaffordable out-of-pocket expenses.

AHCA is being sold as an improvement in access yet clearly access to health care would be further impaired because of the financial barriers to care that it erects. Also, when we already greatly burden American workers with policies that shift wealth from the workers to the wealthy, AHCA would introduce numerous tax changes that would further benefit the wealthy, compounding the injustices of income and wealth inequality.

Although the Democrats are unified in their opposition to AHCA, there is considerable opposition from within the Republican ranks as well. Heartless conservative Republicans want even more cuts in the beneficial programs advanced by ACA, diminishing further protection against health care insecurity and financial insecurity for those with medical needs. Other more moderate Republicans are concerned that the cuts are too deep and heartless, and some are also concerned about the attacks on women’s health care.

The Republicans have been unable to resolve these conflicts behind closed doors. But they did promise that they would repeal ACA immediately and so they are moving ahead with this legislation. If it fails, then they cannot be accused of not having made the effort. Then they can move on to legislation that they are really passionate about – tax reform benefitting the very wealthy.

We must not lose perspective. The nation desperately wants better and more affordable health care. The subject is hot. Although Americans have been dissatisfied with ACA, they now recognize that the Republican proposals would be worse. Many of those who are doing well under ACA have changed from opposition to support of ACA. But those who continue to face financial hardship and impaired access to health care clearly want more and are particularly disappointed that Trump and his fellow Republicans are not delivering on their promise.

ACA was an improvement, but not enough. Its administrative complexity makes it nearly impossible to achieve high quality affordable care for all merely by enacting administrative tweaks. The seven years of Republican strategy has failed to improve on ACA, and their proposals would only make health care access and affordability worse. We need something more.

An improved Medicare for all – a well designed single payer national health program – is precisely what we need. With it we would have affordable, high quality health care for everyone. While the topic of health reform is hot, we need to get this message out. Now.

Obamacare’s flaws could be repaired far more simply and cheaply with a single-payer plan

By Robert Needlman, M.D.
The (Cleveland) Plain Dealer, March 8, 2017

I am proud to be a pediatrician at MetroHealth Medical Center. I think a lot about health and health care. I’m an educated person, with undergraduate and medical degrees from Yale. And yet I can’t really get a grasp on how health care financing in this country works! I read articles, get confused, scratch my head, drink more coffee.

Then I fall back on my personal experience:

Under the Affordable Care Act (Obamacare), my 27-year-old daughter was able to stay on our family’s health plan until age 26, just in time for her to get her first full-time job with benefits (hurrah!).

But a close friend, who is self-employed, hasn’t been able to find an insurance plan under the ACA that is anything other than, well, outrageous, with sky-high premiums and deductibles to match.

So I get that something has to change.

But I just can’t figure out how the changes being talked about could possibly lower prices without cutting people off. And by “people,” I mean people I care about and take care of every day.

The new Republican proposals to give tax credits based on family income sound OK to me, but only if the credits are large enough to actually allow people to purchase decent health insurance. With proposed credits of only about $2,000 per year for a person under age 30, they aren’t.

Replacing existing subsidies with tax credits does save the government money, but only if the credits are less than the subsidies. Getting even less help with insurance bills isn’t going to make it any easier for my friends or my patients to get health care.

Under the new proposal, people who benefited from Medicaid expansion would continue to have good insurance coverage, but only until 2020. After that, who knows? When you’re my age, three years goes by really fast!

On the plus side, it sounds like the new proposals would keep the ACA protection for people with pre-existing conditions. That’s great. But I haven’t heard where the money would come from.

By taking away the requirement that everyone get insurance (the “individual mandate”), the new proposals would reduce the number of healthy people who purchase insurance. But the premiums paid by healthy people provide the money for the medical care used by sick people. Take away the healthy people, and the money goes away too.

The government could try to solve this problem by making people with pre-existing conditions get their care from a high-risk pool. But the money for the high-risk pool would still have to come from somewhere; and if the pool were capped, that would mean that some people with cancer or diabetes, say, might not get the care they need.

And the process for deciding who qualifies as high-risk is murky. Would “high risk” mean my patients whose chronic asthma lands them in the emergency room now and then? Or my patients with ADHD who take expensive medicine? Or the parents who have Lupus, or chronic depression, or colon cancer? Who makes these decisions?

So, with all my degrees, I’m left scratching my head.

But one thing is clear: We spend an enormous amount of money in the United States paying insurance companies to run a health insurance system which is too complicated for us mortals to understand!

In July 2016, for example, just one company (UnitedHealth) reported quarterly revenues of $46.5 billion. (You can look it up yourself; just google “health insurance company profits.”)

In countries like Canada and the United Kingdom, where there is universal health care, big insurance companies play a much smaller role, and take a much smaller cut. Everyone gets a baseline level of health insurance, and people who can afford more can buy it if they want it. Single-payer plans like Canada’s get criticized for being “socialized medicine.” But that’s just name-calling. What these plans are is reasonable, fair, and understandable. Even by someone like me.

Dr. Robert Needlman practices and teaches developmental and behavioral pediatrics at MetroHealth Medical Center and is a professor of pediatrics at Case Western Reserve University. He is the co-founder of Reach Out and Read and the author of “Dr. Spock’s Baby Basics,” and co-author of “Dr. Spock’s Baby and Child Care.” The views expressed in this op-ed are solely his own, not those of the institutions with which he is affiliated.

http://www.cleveland.com…

As Republicans prepare to gut Obamacare, visiting doctor says he has a better idea

By Karen Garloch
The Charlotte Observer, March 7, 2017

Many people scoffed recently when President Donald Trump, while addressing plans to replace the Affordable Care Act, made this unwitting understatement: “Nobody knew that health care could be so complicated.”

But Dr. Robert Zarr – who knows health care complexity from the inside – saw it as an opportunity.

“I couldn’t agree more with the president that we need a much more simplified system,” he said.

To Zarr, that means single-payer, universal health insurance.

It’s not a new idea, of course. Single-payer is the basis of Medicare – the popular federally funded health program for people 65 and older. And it’s also the foundation for health coverage in many other developed countries. But in the United States, the idea of single-payer insurance for all is vilified as “socialized medicine” and an unaffordable government takeover of health care.

“That’s a myth,” Zarr said.

As a past president of Physicians for a National Health Program, Zarr has been pushing for single payer for more than 10 years. He will be in Charlotte Thursday to speak at a meeting of Health Care Justice-North Carolina. The free talk is at 6:30 p.m. at Midwood International and Cultural Center, 1817 Central Ave. RSVP: denisefinck@hotmail.com.

With Republicans preparing to repeal and replace the ACA, Zarr says it could be the right time to switch from the current system, with multiple insurance companies and duplicative administrative costs, to a single-payer, government-financed system that would reimburse private doctors and hospitals to care for people from “cradle to grave.”

Republicans have indicated no interest in a single payer plan – although Trump did flirt with the idea in years past. This week, House Republicans unveiled their proposed replacement plan, which would keep some popular features of the ACA but do away with the mandate to buy insurance. Predictions are that fewer people would have insurance coverage than under the ACA.

In a phone interview, Zarr, a Washington D.C., pediatrician, remained optimistic about getting support for single payer. “In poll after poll, the majority of American physicians and the majority of the American public want single payer,” he said.

He said single-payer insurance would cost no more than people are paying right now. Instead of paying premiums, deductibles and co-pays, Zarr said they would pay taxes to provide health care for everyone. “We’re spending enough,” he said. “We’re just not getting what we deserve.”

Total U.S. health care expenditures amount to $3.2 trillion annually, much more than in other developed nations that provide universal health care. In the United States, despite that higher cost and the expansion of insurance under the ACA, many millions remain uninsured – or underinsured with high deductible plans that result in out-of-pocket costs they can’t afford.

Under a single payer plan, everybody would get care without confusing out-of-pocket expenses. And it would save money by reducing administrative costs in every doctor’s office, hospital and insurance company.

“We can’t afford not to have single payer,” Zarr said. “
The only opponents of the single-payer plan are the misinformed.”

http://www.charlotteobserver.com…

Timothy Jost explains the GOP repeal and replace legislation

Examining The House Republican ACA Repeal And Replace Legislation

By Timothy Jost
Health Affairs Blog, March 7, 2017

On March 6, 2017, the House Republican leadership introduced Affordable Care Act repeal and replacement budget reconciliation bills in the Ways and Means (W&M) and Energy and Commerce (E&C) committees. The bills, collectively titled the American Health Care Act, are the committees’ responses to the instructions they received in the Budget Resolution passed by both houses of Congress in mid-January to prepare budget reconciliation legislation to repeal the ACA.

The committees will begin markup of the bills on March 8, 2017.

If the bills are passed by the committees they will be combined by the House Budget Committee and sent to the House Rules Committee, and then to the full House for a vote. The Congressional Budget Office has not released cost estimates of the legislation and it appears that committee markups will proceed without out CBO reports.

Summing Up

In summary, the legislation’s tax cuts will be very attractive to wealthy Americans and health insurers and providers, who would get a trillion dollars in tax breaks. It could cause consternation for Medicaid recipients and state Medicaid programs, which would see federal funding for Medicaid steadily diminish, potentially thinning out coverage. The legislation could be bad news for recipients of current tax credits who are older, sicker, and poorer, and who live in areas where care is expensive. They may be able to afford low actuarial value coverage with the tax credits the bills would provide them, but they are unlikely then to be able to afford the cost sharing that coverage will impose.

Higher-income younger people, on the other hand, would find coverage much more affordable than it is now under the legislation—the tax credits might fully cover their premiums and leave extra for their health savings accounts. Some insurers could find the state reinsurance money and continuous coverage requirement enough of an incentive to stay in the market, but others may not

Finally, one cannot know without a CBO report how this all works out.  But it is hard to see how the bills pay for themselves, and they could result in significant losses in coverage.

http://healthaffairs.org…

Ways and Means summary of their portion of the “American Health Care Act”:
https://waysandmeans.house.gov…

Ways and Means proposed legislation:
https://waysandmeans.house.gov…

Energy and Commerce summary of their portion of the “American Health Care Act”:
https://energycommerce.house.gov…

Energy and Commerce proposed legislation:
https://energycommerce.house.gov…

***

G.O.P. Repeal Bill Would Cut Funding for Poor and Taxes on Rich

By Margot Sanger-Katz
The New York Times, March 6, 2017

Legislative language for what House leaders call the American Health Care Act, released Monday evening, would substantially cut back funding to states that cover poor adults through their Medicaid program. It would cut back on financial assistance for relatively low-income insurance shoppers above the poverty line.

It would offer new financial benefits for the upper-middle class and the rich. Americans higher up the income scale would be eligible for subsidies to help them buy health insurance. Taxes on high incomes would be reversed. And the law would allow people to save more money each year in tax-free health savings and flexible spending accounts — accounts that are most valuable to people who pay high income tax rates and have money to save.

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NYT Reader Comments:

By Don McCanne, M.D.
San Juan Capistrano, CA

That’s enough. Single payer.

https://www.nytimes.com…

‘Financial counselors’ add to administrative overload in health care

Got health insurance? That doesn’t mean you’ll be able to pay your medical bills.

By John Murawski
McClatchy DC Bureau, March 4, 2017

Hospitals around the country are reporting record levels of debt on their books from an unlikely source: patients with health care coverage.

As health insurers and employers have shifted health care costs to patients through high deductibles and other out-of-pocket expenses, people who in the past may not have worried about paying for a hospital visit or a surgical procedure are getting hit with massive medical bills that they can’t pay.

Duke University Health System has seen patient interest-free payment plans rise from $19 million in June 2010 to $43 million in January. The increase is largely attributable to rising deductibles, said Keith Stover, Duke’s vice president of finance and chief financial officer.

Duke is fielding 1,500 patient calls a day, most of them asking why they got a bill since they’re insured, Stover said.

WakeMed Health & Hospitals also is experiencing a spike in patients needing help, setting up an average of 1,810 payment plans per month since October.

Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, started offering zero-interest loans through Commerce Bank in November in response to patient deductibles as high as $14,300.

Southeastern Regional Medical Center in Lumberton, North Carolina, in December began assigning “financial counselors” to patients’ rooms to explain insurance benefits and payment options.

Duke Health’s 225 financial counselors contact patients before their scheduled procedures to discuss insurance benefits and payment options; every Duke clinic now has a full-time financial counselor on staff to work with patients.

UNC Health Care has 200 financial counselors to assist patients. “It’s going to be our responsibility to collect,” said Mark Miller, chief financial officer of UNC Health Care in Chapel Hill, North Carolina. “So much is getting left on the table because we can’t get it from the patient, or because they have chosen not to pay it, or they can’t.”

Republicans in Congress have been unable to coalesce around a single proposal to replace the ACA. But their proposals so far could drive up deductibles by lifting the ACA mandated cap on the out-of-pocket costs patients have to pay.

Consumer advocates say the high deductible trend is unsustainable. “They can be a barrier to care for people,” said Mark Rukavina, principal, Community Health Advisors, a Boston organization that advises nonprofit hospitals on billing, collections and finance.

http://www.mcclatchydc.com…

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Comment:

By Don McCanne, M.D.

In a system already tremendously overburdened with administrative excesses, we now have an escalating need for “financial counselors” because of the explosion in medical debt due to the expansion in the use of high deductibles – a tool to protect insurers by slowing the increase in insurance premiums, but at the cost of reducing the financial protection that is the very reason that insurance exists in the first place.

In crafting the Affordable Care Act (ACA) it was recognized that the actuarial value of the plans would have to be decreased (code language for introducing very high deductibles) to keep premiums affordable, and that required fairly generous subsidies and credits for lower-income individuals if they were going to be able to afford health care. But that left moderate-income families exposed to the larger, less affordable deductibles.

What has really increased the need for financial counselors is that employer-sponsored plans – the mainstay of insurance in the United States – have accelerated the adoption of high deductibles with which many working families struggle. It is now a problem in mainstream America. ACA did not directly address the problem of high deductibles in employer-sponsored plans, but it did compound the problem by tightening up on insurance regulation and design. Without higher deductibles, the premiums for employer-sponsored plans would have been driven up even higher.

So ACA made the problem of high deductibles worse. What about the Republican replace proposals? We will find out this week, but it doesn’t look good. The exchange plans will probably have a less generous tax subsidy, making plans less affordable for lower-income individuals. There will also likely be reduced regulatory requirements for private insurance, allowing them to market plans with lower premiums, but that will shift even more costs to individuals and families through yet higher deductibles and other cost sharing and through a reduction in plan benefits – requiring greater out-of-pocket spending.

So what are we getting? Exactly what we don’t need – more administrative costs in the form of financial counselors who assist us in handling the debt that health insurance was supposed to prevent.

We don’t need this. We should get rid of private insurance and replace it with a well-designed single payer national health program that provides first dollar coverage while containing medical spending through much more patient-friendly policies. We can simply fix Medicare and provide it for everyone.

‘Medicare for all’ is still the best solution

By The Editorial Board
The Capital Times (Madison, Wis.), March 6, 2017

Given the choice between maintaining the Affordable Care Act, as many Democrats propose, or eliminating it, as many Republicans propose, The Cap Times favors retaining as much of the current health care program as is possible and practical.

But we have no illusions. We know that the ACA is more costly and inefficient than it needs to be. We are with the plurality of Americans that favors retaining the parts of the ACA that work well and then reforming it so that it can do more.

The best way to do more is to move, as quickly as is politically possible, toward a single-payer “Medicare for all” program.

The single-payer model treats health care as a basic human right and guarantees that everyone is afforded that right. That’s the correct approach and we are pleased that Congressman Mark Pocan, D-town of Vermont, is a co-sponsor of HR 676 — The Expanded and Improved Medicare for All Act.

While Pocan opposes the efforts of Republicans like Vice President Mike Pence and House Speaker Paul Ryan to gut the Affordable Care Act and usher in a new era of profiteering by insurance companies and for-profit health care corporations, the Democrat from Wisconsin recognizes that the best way to provide health care for all while keeping costs down is to build on the successful Medicare model.

Medicare is not perfect. But the government-run program is treasured by Americans because it is so much more reliable and efficient than private programs. That reliability and efficiency, as well as genuine access to quality care, can be enjoyed by all Americans if reforms of the ACA move us in the direction of a “Medicare for all” system.

http://host.madison.com…

Doctor’s prescription for health insurance: Remove the profit motive

Single-payer advocate speaks in Charlotte March 9

By Herbert L. White
The Charlotte (N.C.) Post, March 5, 2017

Is single-payer health insurance inevitable?

American lawmakers are consumed about repealing and replacing the Affordable Care Act. One path that has been regularly touted as a solution is the single-payer model, which advocates say will assure every citizen has access to equal and quality health care.

One of those advocates, Robert Zarr M.D., a practicing pediatrician in Washington, D.C., and an expert on international health and universal health care, will speak March 9 at 6:30 p.m. at Midwood International and Cultural Center, 1817 Central Ave.

Zarr, who provides care for mostly low-income patients, is also an adjunct professor at George Washington University and Children’s National Medical Center. He is also immediate past president of Physicians for a National Health Program.

A February Kaiser Health Tracking Poll finds attitudes towards ACA have shifted, with 48 percent of respondents favoring the law while 42 percent found it unfavorable. The favorable response is the highest measured in more than 60 Kaiser Health Tracking Polls since 2010. Independent voters are driving the change, with 50 percent now viewing the law favorably.

A May 2016 Gallup Poll found 58 percent of Americans favor replacing ACA with a federally funded healthcare system – such as Medicaid and Medicare – that provides insurance for all. Critics, however, contend such a program amounts to “socialized medicine” which leaves government in control of the delivery of service and weakens care.

Zarr spoke with The Post by telephone from Washington, D.C. Responses are edited for clarity and brevity.

Polling suggests the idea of single payer insurance is popular. Why is that?

Zarr: “The reason why it’s so popular is because one, it’s so easy to understand. The second is that it just makes common sense. We remove the shackles from the insurance companies for the delivery of care, which in our opinion, should be left to the private domain. We feel doctors should be able to open up their own practices if they wish. We feel strongly that a pharmacy should be able to provide medicines and medical supplies without having to worry about bankruptcy themselves.

“We feel this can best be done most efficiently by looking at the data and evidence, not just with Medicare but across the world. The only way we can efficiently do this is by publicly financing it, removing it from the private domain in terms of finance. Private delivery, public finance – that is the easy way for us to understand single payer.”

Why isn’t single payer the law of the land now?

“Probably the best way to answer that is that there is a lot of momentum among the moneyed interests in this country to keep status quo. ACA really is and really was the beginning of a prolongation of our status quo. There’s nothing magical about ACA. It took what we already had and it expanded it. It expanded Medicaid in 20-plus states, and I might add, did not expand it in 20-plus states as well and it relied heavily on the private insurance model. The private exchange model is not just what we see in the exchanges that have been set up but also in Medicare and Medicaid as well, so two-thirds of the recipients in Medicaid are receiving their health insurance through private, for-profit plans and it’s about one-third in Medicare.”

Why isn’t there more political will to remove the profit motive from health insurance?

“I think we need to exert our democratic right through pressure on legislators to make sure they understand they’re jeopardizing their next campaign if they don’t support single payer. The strongest thing we can do right now is raise the temperature so that legislators understand that single payer, HR676, is what this country wants and what we need, both by the people and the delivery community – the doctors, the hospitals, the pharmacies. We need to make it politically toxic to not support 676.”

Has the battle over repeal and replace overwhelmed advocacy for single payer?

Because ACA is under threat right now, with all its faults and all its reliance on for-profit insurance industry, which is not leading us to single payer, it still did put an insurance card in the wallet or purse of 20 million Americans. When we remove that against the people’s will, for every million uninsured, you’re looking at 1,000 deaths per year. There’s a lot of pressure going on right now and congressmen are feeling it because constituents are worried, they are anxious about what’s going to happen.”

What do you see four years into the future for health insurance?

“There is a chronic burnout and fatigue in physicans and it’s bad, very bad. We’re spending more of our time trying to get the simplest of tasks done where you’ve got 15 minutes to get this done. As a patient, it’s getting more and more frustrating with the cost shifting with the difficulty of knowing there’s no transparency. I don’t know the coverage my health plan has until I get sick and I get the bill. My crystal ball tells me if we keep going down this same path, it’s a path to destruction, it’s a path to suffering, it’s a path to early death, and that’s not something I want.

“My crystal ball tells me there is only one end point to this and that is to provide every American an equitable and affordable comprehensive health care that will not bankrupt us. We can put this off another few years, four years, six to eight years, but at some point we’re going to have to get to the only solution that anyone’s been able to come up with, and that’s efficient and not going to bankrupt us and it’s fair for everyone.”

http://www.thecharlottepost.com…