By Andrew Purcell
The (Glasgow, Scotland) Herald, June 24, 2017

WITHIN five days, Trumpcare could well be on the US statute books. It hasn’t taken long to get there. The journey began on May 4, when the Republican caucus in the House of Representatives gathered to vote on the American Health Care Act (AHCA). For seven years, they had promised to repeal Barack Obama’s signature legislative achievement, but now they had control of both houses of Congress and the White House, they couldn’t agree on a replacement. To conservative hardliners, the bill was too timid. Moderates worried that supporting it could cost them their seats.

Whips played Eye Of The Tiger on the stereo to harden their resolve, and projected an image of General George Patton urging them to “accept the challenge so that you can feel the exhilaration of victory.” Later, once the bill had scraped through 217-213, Republican Congresswoman Ann Wagner said: “The line of the day was out of Braveheart: ‘Freedom!’”

In their minds, these privileged few were Rocky entering the ring, William Wallace leading the charge at Stirling Bridge. Republican Congressman Jason Chaffetz rode in on a scooter, fresh from foot surgery covered by his subsidised government health insurance, to vote for a bill that will make the same operation unthinkably expensive for tens of millions of Americans. If it becomes law, thousands more will die each year because they cannot afford to see a doctor.

In the Rose Garden, President Donald Trump touted the AHCA as “a really incredible health care plan” and promised “we’re going to get this finished.” Then, for six weeks, as the media focused on the investigation into Russian interference in the presidential election, a group of thirteen senators met to draft the Senate’s version of the bill in total secrecy. On Thursday, it was released for the briefest possible period of discussion. By this Friday, it could be law.

The renamed Better Care Reconciliation Act (BCRA) will deprive at least twenty million people of health insurance. It drastically cuts Medicaid, which provides low cost health care for those least able to afford it, reduces subsidies to the working poor and lower middle-class, allows insurers to charge old people five times as much as the young, and lets states opt out of a list of ‘essential health benefits’ so insurers can sell policies that don’t cover maternity or outpatient services, mental health treatment or prescription drugs. Premiums and out of pocket expenses will continue to rise, but people making $200,000 a year will get a tax cut.

Obamacare took a year to draft. Democrats tried to work with Republicans on a bi-partisan bill for months, and when that failed, debated the legislation on the Senate floor for five weeks. Then Minority Leader Mitch McConnell complained that they were “ramming through” the law. Now he is doing everything in his power to shield the Republican alternative from scrutiny. The hypocrisy is stunning, the cynicism absolute.

Polls show only 29% of voters have a favourable opinion of the Republican bill, making it even more disliked than the bank bailout of 2008. The American Medical Association, American Nurses Association, American Academy of Family Physicians, American Association of Retired Persons and American Hospital Association have all spoken out against it.

Even insurers are opposed, despite the many sweeteners to the industry it contains, because the cuts to Medicaid, a reliable source of income, are so deep. “To me, this is not a reform,” Michael J. Dowling, the chief executive of Northwell Health, said. “This is just a debacle.”

A survey of 1,100 doctors found that 66% had a “negative impression” of the AHCA. The Sunday Herald interviewed five medical professionals from five states, all registered Republicans. They were unanimously critical of Obamacare, but even more dismayed by its proposed replacement.

“I consider myself a fiscal conservative, and fiscally this is a horrible thing, because it’s going to keep increasing the cost curve. The only thing conservative about it is it will lower the tax rate for those in the top percent,” said Roger LaBonte, president of the West Tennessee chapter of Physicians for a National Health Plan.

“It’s already a disaster for the Republican Party. If they pass something, it’s a total disaster. If they don’t, it makes them look like a bunch of clowns,” said Jack Bernard, former director of health planning for the state of Georgia.

Republicans have been predicting Obamacare’s collapse from the beginning, and since taking power have helped it along the way, introducing instability in the insurance market by threatening to remove federal subsidies. Insurers, citing losses, have been pulling out of the state exchanges. Next year, more than 30,000 people in Missouri and Ohio will qualify for a government subsidy but have nowhere to spend it, as not one company is selling insurance.

In Arizona, Obamacare cut the number of uninsured in half. More than 600,000 benefited from the expansion of Medicaid to cover those earning up to 133% of the federal poverty level – around $32,000 for a family of four. People buying insurance on the state exchange have been less fortunate, as Blue Cross Blue Shield now enjoys an effective monopoly, and can charge what it likes.

Daniel Derksen, Director of the Arizona Centre for Rural Health, said the proposed cuts to Medicaid, more than $800 billion over a decade, would be disastrous for the state. “This goes beyond repealing Obamacare: it’s really dismantling an essential title of the Social Security Act.” Medicaid will be capped, tied to inflation and guaranteed to buy a little less each year, but not until 2021, after the next presidential election, to soften the political blow.

When Derksen was asked why Republicans are so determined to pass such an unpopular bill, knowing it will hit older people in rural areas – Trump voters – particularly hard. “Well, if you’re going to do a ginormous tax cut, you’ve got to do a ‘pay-for,” he said, “and one of the largest federal expenditures is our Medicaid and Medicare programmes.”

This is the key to understanding the bill. By cutting subsidies and Medicaid, it lowers the projected deficit by roughly $1.2 trillion over a decade. This creates space for a permanent ‘revenue-neutral’ tax cut that can be passed in the Senate with a simple majority. The 3.8% tax cut on investment income in the bill, back-dated to the start of this year, is just an appetiser.

From 2010-2016, Obamacare reduced the number of uninsured from 48.6 million to 28.6 million and eliminated many of the insurance industry’s most egregious abuses, but as a market-based solution, devised in a conservative think tank and pioneered by Republican Governor Mitt Romney in Massachusetts, it stopped far short of meaningful reform.

According to the Organisation for Economic Co-operation and Development, the USA spends $9,500 per capita on health care each year, compared with $5,300 in Germany, $4,000 in the UK and $2,500 in Israel, but has the lowest life expectancy and highest infant mortality rate in the developed world. That is a sick and broken system.

“About 48,000 Americans die every year because of lack of health care. The biggest cause of bankruptcy in this country is people who can’t pay their medical bills,” said Rade Pejic, a chest surgeon from New Orleans. He told how the wife of a doctor friend recently had an outpatient hip operation and received a bill for $97,000, and that his cousin’s appendectomy cost $32,000. These are not extreme cases.

The number of people with no health insurance at all – close to fifty million by 2026 if the GOP bill passes – is the tip of the iceberg. Tens of millions more, on all but the most expensive plans, are under-insured, with high deductibles (the first few thousand dollars the policy holder has to pay before the insurance kicks in) and yawning gaps in their coverage.

A Kaiser Family Foundation survey found that one in five people with health insurance received medical bills last year that they struggled to pay. Of these, 63% reported using up most of their savings, 38% said they ran up credit card debt and 37% asked friends for money. Under the GOP plan, the poor, the sick, the elderly – everyone but the richest – will pay more for meaner and less reliable insurance.

“We’re facing higher and higher deductibles, narrowing networks, because the insurance companies run the show. They dictate health care that doctors practice,” said Alan Kenwood, an emergency room doctor at a hospital in Morris County, New Jersey. “There is a fear of standing up for what’s right because of the power of the lobbies, the insurance and pharmaceutical industries, and they have such deep infiltration into both parties.”

Last year, the chief executive of insurer Centene, Michael Neidorff, earned $22 million. Humana’s Bruce Broussard got $19.7 million. Alan Miller, CEO of hospital chain Universal Health Services, received $51.3 million in salary and stock options.

Most of the senators who drafted the BCRA have received substantial campaign contributions from the health care industry. From 2011-2016, Kindred Healthcare gave McConnell $104,650. Sanford Health gave Senator John Thune $40,246. Blue Cross Blue Shield paid Senator Lamar Alexander $36,250. The list goes on.

The question now is whether Republicans can agree on a bill that will pass the Senate, and then the House, with its fanatically tax-averse Freedom Caucus. McConnell can only afford two “no” votes, and at the last count, seven senators were wavering: three because the BCRA is too much like Obamacare and four worried that the Medicaid cuts will harm their constituents and hamper their re-election chances.

Bernard predicted dire political consequences: “I think if the Republican Party is dumb enough to pass this, they will lose the presidency and a whole series of senatorial seats. When people who are working-class start to see their brothers and sisters and children getting booted off health insurance, you’re gonna hear screaming.”

“It’s quite possible that the level of anger is going to be so great that it’s going to push reform and there’s going to be a strong reaction against the Republican party for pushing the legislation,” said Kenwood.

For a taste of irony amid all this, we should maybe hark back to January 2015, five months before Trump announced his presidential campaign, when he told an anecdote on David Letterman’s show about a friend who spent four days in a Scottish hospital: “He was really in trouble, and they released him and he said, ‘Where do I pay?’ And they said, ‘There’s no charge.’ Not only that, he said it was like great doctors, great care.”

For now, though, as congressional Republicans prepare to put a bill on Trump’s desk that will make health care more expensive, more stressful and less secure for the vast majority of Americans, the President’s talk of “insurance for everyone” is just one more empty promise.

http://www.heraldscotland.com…

Interview With Dr. Steffie Woolhandler

By Amy Goodman
Democracy Now!, June 23, 2017

PNHP Note: To view video of this interview, click here.

Health experts say, given the shortcomings of both the Affordable Care Act and Republican proposals, now is the time to move forward with a simple Medicare-for-all system, known as single payer. In 2015, even Donald Trump appeared to come out in favor of a form of single-payer health insurance. About 20,000 U.S. physicians now support single-payer healthcare, and National Nurses United, the biggest nursing union in the country, is also pushing for the program that would guarantee universal coverage. We speak with Dr. Steffie Woolhandler, a key advocate for Medicare for all.

TRANSCRIPT
This is a rush transcript. Copy may not be in its final form.

AMY GOODMAN: During a 60 Minutes interview in 2015, Donald Trump appeared to come out in favor of a form of single-payer health insurance for the uninsured. I wanted to play this clip.

DONALD TRUMP: Obamacare is going to be repealed and replaced. Obamacare is a disaster, if you look at what’s going on with premiums, where they’re up 45, 50, 55 percent.

SCOTT PELLEY: So how do you fix it?

DONALD TRUMP: There’s many different ways, by the way. Everybody’s got to be covered. This is an un-Republican thing for me to say, because a lot of times they say, “No, no, the lower 25 percent, they can’t afford private.” But—

SCOTT PELLEY: Universal healthcare.

DONALD TRUMP: I am going to take care of everybody. I don’t care if it costs me votes or not. Everybody’s going to be taken care of, much better than they’re taken care of now.

SCOTT PELLEY: The uninsured person—

DONALD TRUMP: Right.

SCOTT PELLEY: —is going to be taken care of how?

DONALD TRUMP: They’re going to be taken care of.

SCOTT PELLEY: How?

DONALD TRUMP: I would make a deal with existing hospitals to take care of people. And you know what? This is probably—

SCOTT PELLEY: Make a deal? Who pays for it?

DONALD TRUMP: The government is going to pay for it. But we’re going to save so much money on the other side. But for the most part, it’s going to be a private plan, and people are going to be able to go out and negotiate great plans with lots of different competition, with lots of competitors, with great companies. And they can have their doctors. They can have their plans. They can have everything.

AMY GOODMAN: That was Donald Trump in 2015. Dr. Steffie Woolhandler, can you respond? You’re one of the key advocates for Medicare for all. Where does that fit into this picture today? Do you think this is a moment where the time for Medicare for all can be pushed around the country in a very big way, as people across the political spectrum are horrified by the specter of, among other things, tens of millions of people losing their health insurance?

DR. STEFFIE WOOLHANDLER: Yeah, well, the ACA made some modest improvements to the healthcare system, and the Republicans would pull those all back. But the Affordable Care Act was never a very good bill. It left 28 million Americans completely uninsured and tens of millions more with these unaffordable gaps in their coverage, like copayments and deductibles and uncovered services. And that’s why the Affordable Care Act has been vulnerable to these Republican attacks, because people look at their own situation and say, “Even under Obamacare, under the Affordable Care Act, healthcare still not affordable to me.”

So the best way to fight the Republican attacks is to say, “Let’s move forward from the Affordable Care Act to a single-payer system, rather than backward through repeal.” The single-payer system works, because by having a single, simple Medicare-for-all system, you save so much money on administrative costs and overhead that you can cover all of the uninsured and improve coverage for everybody else who has gaps in their coverage without raising total healthcare costs. And that’s why about 20,000 U.S. physicians have come together into Physicians for a National Health Program to advocate single payer. That’s why the National Nurses United, the biggest nursing union in the country, is pushing single payer. It’s why Senator Sanders ran on single payer. And it’s why Congressman John Conyers has introduced a bill into Congress, with 112 co-sponsors, for single payer. So now is the time to be saying to the electorate, the ACA was a step forward, but not a big enough step. We need to be moving forward from the ACA to that single-payer, Medicare-for-all plan that Americans need and deserve.

AMY GOODMAN: And how feasible do you think this is? I mean, Senator Bernie Sanders has yet to introduce this bill, the type that Conyers already has introduced in the House.

DR. STEFFIE WOOLHANDLER: OK, my understanding is Sanders is planning to introduce a bill over the summer. The Conyers bill has gained a lot of co-sponsors. More than half of all the Democrats in the House of Representatives now co-sponsor the Conyers bill. That’s more co-sponsors than any time in history. We’re seeing a lot of public support for the idea of single payer. We’re seeing a big movement for single payer at the state level in California. Obviously we’re getting a whole lot more discussion of single payer now than we’ve ever had before.

AMY GOODMAN: Let me ask you—

DR. STEFFIE WOOLHANDLER: I think we’re—

AMY GOODMAN: Let me ask you, very quickly. In California, it’s passed the state Senate. It’s got to go through the Assembly, and then it has to go to Governor Brown. Do you think that he will sign off on it, unlike what happened in Nevada, where the Republican senator, in that case, said no to Medicare for all, even though it was passed by the Nevada Legislature?

DR. STEFFIE WOOLHANDLER: OK, well, we’re only going to get single payer if the populace keeps the pressure on the politicians. It’s not going to happen automatically. It’s not going to happen because Governor Brown has occasionally in the past said he likes single payer. It’s going to happen because we have a movement that’s strong enough to counter the political power of these rich people, who are getting these huge tax cuts; of the insurance industry, who would have no place in an efficiently run single-payer system; of Pharma, who thinks that they’re going to have to accept lower prices under single payer. In fact, they’re right. So that’s a lot of political power. And the only way to push through that is to really build a movement. But, you know, that really seems possible right now, with polls showing that two out of every three Americans who have an opinion on healthcare think we need some sort of Medicare-for-all program. So, now is really the time to be pushing this—in fact, the only way to really counter the Republican momentum at this point.

AMY GOODMAN: Well, Dr. Steffie Woolhandler, I want to thank you for being with us, key advocate for Medicare for all—and again, when she referred to Pharma, meaning Big Pharma, the drug companies—and Dr. Willie Parker, who happens to be joining us from Aspen, Colorado, who is the chair of the board of Physicians for Reproductive Health.

https://www.democracynow.org…

The relationship of the Republican bills to tax breaks resembles that of water crackers to cheese: a delivery device with little independent function of its own

By Adam Gaffney, M.D.
The Guardian, June 23 2017

“Dead on arrival,” some said. That was to be the fate of the House’s Obamacare repeal bill in the Senate. Yet Trumpcare has risen again: on Thursday, the Senate released its Obamacare repeal bill, though its fate is still uncertain. The Senate draft is in some respects a watered-down version of the House’s, yet it is no less toxic: watering down cyanide, you see, only makes it so safe.

But first, some credit where it is due. Senate majority leader Mitch McConnell was faced with a daunting task after the American Health Care Act (AHCA) slithered its way through the House last month: the creature was about as popular as Count Dracula.

In a late May Quinnipiac poll, a measly 20% of voters approved the bill, not surprising when one considers that the AHCA was arguably more vampiric than the Romanian nobleman. Whereas the latter would drain his victims one by one, the AHCA would extract health coverage from some 23 million to engorge the bank balances of the wealthy few.

Yet McConnell and colleagues rose to the challenge, and it is hard to not be impressed by their ruthless stealth and speed. The baker’s dozen of white men that crafted the bill kept it hidden not only from the public, but from their fellow Republican Senators.

The secrecy – nary a single committee hearing! – kept it out of the headlines, an admittedly savvy strategy in light of the AHCA’s utter unpopularity. As one senior aide told Axios, “We aren’t stupid.” Certainly not, though they are a coldblooded bunch.

Now the Senate bill is with us, and suffice it to say that Trumpcare hasn’t much changed. There is one major exception: the Senate bill features subsidies to help people buy private insurance plans that resemble those under Obamacare, though they are less adequate.

These subsidies would be indexed to income and available to those earning under 350% of the federal poverty level (as opposed to under 400% with Obamacare). Libertarians can whine with some justification that, in this respect, they are being served a glass of Diet Obamacare.

But in other respects, the Senate bill looks very much like the House’s, retaining, of course, the lavish tax cuts for healthcare corporations and the rich. Over a decade, the House version of the bill was estimated to redistribute $230.8bn to high income earners, $144.7bn to insurance companies, $28.5bn to pharmaceutical companies, and $19.6bn to medical device manufacturers (healthcare stocks are jumping accordingly).

The relationship of the Republican bills to these tax breaks increasingly seems to be that of water crackers to cheese: an effective delivery device with little independent function of its own.

Yet hundreds of billions of dollars of tax cuts do not, as the saying goes, grow on trees. And who easier to take the money from then the poor? Thus, the Senate bill, like the House’s, goes for Medicaid’s jugular, and in the long term, actually sinks its teeth deeper.

To be fair, the Senate bill does bleed the program a bit slower at first – funding for Obamacare’s Medicaid expansion will be phased out over three years. Yet like the House bill, it ends Medicaid as an entitlement program wherein state spending is matched by federal dollars, constraining it instead to a per capita capped system – a long-winded way of saying that Republicans will shrink the program. Indeed, the hemorrhage of cash will ultimately be more brisk in the Senate version, as the bill dials down the rate of growth of the program beginning in 2025.

Like the House bill, the Senate bill also aims to appease conservative true believers by allowing states to apply for waivers to weaken Obamacare’s insurance regulations (albeit now via Obamacare’s 1332 waiver program). The true believers assert that jettisoning such regulations – like those that require coverage of a full set of healthcare benefits – would bring down premiums.

They are obviously right. Similarly, as Megan McArdle recently argued in Bloomberg, requiring sprinklers in tall residential buildings like the one that burned to a crisp in London last week (current death toll: 79) increases, to some extent, the cost of housing construction.

Which is not to say that, as with housing, the affordability of healthcare is not an issue. When conservatives critique Obamacare by asserting that premiums and deductibles are unaffordable for many, they are right, albeit disingenuously so. Just as the solution to unaffordable housing is not to let more buildings go up in flames, the solution to high healthcare costs is not to make health insurance plans increasingly worthless.

In the case of healthcare, the answer to this conundrum is simple: fund the healthcare system not through premiums or deductibles, but instead through progressive taxes, such that nobody is liable to pay more for healthcare than they can afford.

Of course, if you are trying not to reduce inequality, but to exacerbate it, this makes little sense: better to bleed Medicaid, transfuse the cash into the pockets of the rich, and call the whole bloodsucking endeavor an exercise in “freedom.”

https://www.theguardian.com…