PNHP

My Turn: There’s nothing ‘patient centered’ about Trumpcare

My Turn: There’s nothing ‘patient centered’ about Trumpcare

By Dr. Ken Dolkart
Concord (N.H.) Monitor, March 19, 2017

Have you ever heard people talk nonsense? Perhaps you’ve had a laugh when you hear people talking through their hat about a machine you work on, or a technique you know. Primacy care doctors recently found it less than amusing to hear politicians misapply the concept of “patient-centered care” to promote a poorly designed replacement for Obamacare.

The idea of “patient-centered care” dates back at least half a century, and was widely disseminated in 2001 by the article “Beyond the Healthcare Chasm.” Patient-centered care was defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. ”

In the context of safe, effective, equitable, efficient and timely care, “patient centered” means the moral obligation to respect the values, wishes and unique needs of the person before them. It promotes communication and care systems to help honor those values as possible.

In an era of increasing complexity of care and care delivery, this goal can sometimes be undermined by health care systems. For instance, fee-for-service billing might give a doctor incentive to do more procedures for more reimbursement, but not necessarily the right overall care.

With capitated HMO systems there exists a potential to provide the incentive of withholding of valuable services to limit insurance pay-outs or physician penalties. Such perverse incentives can interfere with the fiduciary responsibilities of some all-too-human clinicians. And it’s true that medical systems can be poorly designed to serve the needs of the hospital or clinic rather than their patients. But none of this has anything to do with Obamacare.

The ACA

The ACA is certainly not perfect, but it does not prescribe which insurance types are offered in a particular state marketplace, nor the choice of which medical practices to attend, nor what tests, procedures or hospitals a clinician can use.

The ACA does mandate that insurances sold in the government-subsidized marketplace provide a minimum of 10 essential services, not just profit for the seller. Preventive services, outpatient and inpatient care, mental health and substance abuse services are among them.

The GOP argues that this restricts “patient choice.” Why not allow underinsurance to be sold, as in the bad old days? Why not circumvent state consumer protection law by selling near valueless insurances across state lines?

Perhaps because it is immoral. Primary care clinicians have watched their patients go bankrupt by illness by coverage not worth the paper it was printed on. It is not “patient centered” nor “patient choice” when the person needs to delay or forego lifesaving tests or therapy not affordable under such flimsy coverage.

The ACA does increase the income level above previous poverty benchmarks at which Medicaid can be provided. And the ACA does encourage states to develop their own unique experiments in care delivery, such as the Hoosier Indiana Plan in Mike Pence’s own state of Indiana or of that in Vermont.

The actual “patient-centered medical home” arose in the 1960s when pediatricians encountered complex, very sick kids requiring multiple specialists. There was natural confusion over who was responsible for care issues. The “medical home” was designed to enable the primary care provider to respond to acute and chronic problems, and coordinate the complex care provided among specialists.

This care team concept was applied thereafter to the adults and the elderly, who often have complex, multiple competing medical issues, and receive numerous, potentially interacting medicines provided by various sub-specialists.

The patient-centered medical home is often made up of nurses, medical assistants, clinicians (physicians, nurse practitioners, physician assistants and social workers) working with pharmacists.

There is certification by the Agency for Healthcare Research and Quality in this designation. There is a defining necessity to provide comprehensive, patient-centered and coordinated care that is easily accessible and provides expertise. Many doctors believe this type of practice provides the best, patient-centered care for the complex patient.

The reader may not be aware that many programs recommended by the Institute of Medicine were incorporated by the AHRQ into Obamacare. These have resulted in at least 50,000 lives saved yearly from improved hospital safety incentives, 150,000 fewer avoidable hospital readmissions due to incentives for coordination of care and reforms to provide reimbursement for overall quality rather than quantity in our national Medicare health system.

Perhaps it is simply ignorance when “patient-centered care” is invoked by politicians to promote the withdrawal of expanded Medicaid and other critical measures.

However, Tom Price, the former senator-orthopedist, and secretary of health and human services, is not so ignorant of terminology or health policy.

One of the earliest stated goals of Price and conservatives was to defund the AHRQ, which sponsors research and accreditation for the patient-centered medical home and the U.S. Preventive Services Task Force. Is it ironic or just cynical for Price to roll out and erase the meaning of the word “patient centered” as they decimate AHRQ?

There is consensus that there are workable ways to improve the ACA. The major sticking point for conservatives remains the mandate to purchase insurance.

However, for insurance to accomplish eliminating pre-existing condition clauses, cover the costs of prevention and also treat illness, there must be enough premiums coming in from healthy people to keep the system solvent. The costs of private health premiums has been rising independent of the ACA, largely related to drug and technology costs. Lack of competition in any state’s marketplace can certainly contribute. But predictions of economic catastrophe and “death spirals” of the ACA are about as factual as Sarah Palin’s claims of “death panels.”

Medicare for all

Simply allowing Medicaid and Medicare to negotiate prices with drug producers, as does the Veterans Administration, would rein in medical costs dramatically.

New Hampshire is now covering 50,000 citizens via expanded Medicaid. Ten thousand New Hampshire residents are having their treatment for opioid addiction covered under these services. As to what to do about the working poor who will lose their coverage under expanded Medicaid, Paul Ryan states, “We’re going to have to find solutions that accommodate (those) concerns.”

Stay tuned for the return of the “high-risk pool,” unused and unobtainable, which died a deserved death with the ACA. It will likely return as a zombie to pretend to exist as coverage for various unsolved problems under Trumpcare.

A randomized, bipartisan survey of 1,000 primary care physicians was performed this year by the American Medical Association, and published in the New England Journal of Medicine. Only 15 percent of primary care physicians (all Republicans) supported outright repeal of the ACA, and 74 percent favored minor changes that maintained the key elements.

Since 1965, Medicare was gradually developed into the popular national system that serves those Americans with the greatest intensity of medical need, and is widely accepted by care providers. Seventy percent of New Hampshire primary care clinicians support a single-payer, universal health care program, as do 60 percent of all Americans. Even two-fifths of all Republicans would opt for expanded Medicare for all.

Since Secretary Price and the right is intent on repealing Obamacare and Medicare thereafter, know that this is not “patient centered” and that Americans and their first-line doctors would prefer Medicare for all.

Ken Dolkart of Grantham is a recently retired geriatrician and primary care doctor who practiced in New Hampshire for 34 years. He is also a member of Granite State Physicians for a National Health Program.

http://www.concordmonitor.com…

CRISIS IN U.S. HEALTH CARE: Corporate Power vs. The Common Good

By John Geyman, M.D.
March 15, 2017

Excerpts from the Preface

There is widespread acknowledgement today that our current health care system is dysfunctional and broken, and I believe that we have reached a crisis point in U.S. health care. We need to better understand why this has come to pass if we are to avoid continuing in the same directions. The sixty years we will discuss have had many policy choices in how we finance and deliver care in this country.

It is still a pervasive myth that U.S. health care is the best in the world – part of the American exceptionalism argument – but, as we will see, this is far from the case. Technology does not necessarily make things better, and we will look at how the traditional values of medicine as a profession have held up over the years.

How our health care system is organized and conducted should be above politics as a non-partisan issue, but we know that that is certainly not the case today nor has it been in earlier years. Despite ongoing national debates, we still have been unable to answer, as a society, even the most basic questions about health care, such as – Should we establish universal access to care for all Americans? Should health care be for-profit or not-foe-profit? Is health care a right or a privilege based on ability to pay?

The results of the 2016 election cycle, which turned over the White House and both chambers of Congress to the Republicans, has placed our already broken health care system in continuing crisis.

This book is organized in three parts. Part One includes reflections on system changes over sixty years. Part Two, then and now, gives my personal perspective from direct experience over those sixty years. In Part Three, today’s realities are described, as are lessons that can be learned from the evolution of health care, three major alternatives for financing health care, and projections for future health care reform.

As the ongoing debates over the future of health care continue across the political spectrum, I hope this book is of use in cutting through the smoke and mirrors to the basic questions we still need to answer. Although the health care establishment may appear to be too imposing to be amenable to change, we have well documented evidence over the years that this most expensive system in the world compares poorly with other advanced industrialized countries in access, cost, quality, equity, and outcomes of care. We have had pro-market forces well entrenched for more than three decades that want to preserve deregulated markets that serve corporate interests more than patients and families. How to reverse that in the public interest is a matter of education and political will.

https://www.amazon.com…

***

Comment:

By Don McCanne, M.D.

Our health care system is designed to serve first the market stakeholders and only secondarily the patients. John Geyman explains to us the history and flawed policy decisions that brought this about. As an icon in family medicine, both in patient care and in the academic arena, he adds his invaluable personal experiences to provide us with a crystal clear picture of what is wrong and what we can do about it – finally placing patients first, where they belong.

This book is particularly timely since it is becoming more obvious to the nation that the modest changes under the Affordable Care Act were grossly inadequate, and that the Republican promises that health care would be much better and much less expensive under repeal and replace have represented nothing more than deceptive political rhetoric as it is clear that their replacement proposals would only compound the problems and deficiencies of our system.

John Geyman shows us that we must move beyond the debate over only two options – continue with the current deficient system under ACA or modify it through detrimental reductions in funding and regulatory oversight. We should be able to recognize the mess that we are in and how the third option – a single payer national health program – would take us out of this quagmire. A national health program is inevitable. We should make the move now while the glaring deficiencies are front and center on the national scene and highly visible to all.

Health care choice comes with a cost

By Miles M. Weinberger, M.D.
The San Diego Union-Tribune, March 17, 2017

The position of House Speaker Paul Ryan and his colleagues is that people should have choice regarding medical care, and that the efficiencies of competition will make health insurance more affordable than government-controlled health services.

Since that is a goal to which we Americans should strive, I suggest that we extend that philosophy to other services.

Let’s have competition in fire and police services. Instead of the government controlling these services, let’s privatize them.

Instead of taxes, people will choose fire and police insurance to buy from the companies of their choice.

Of course, there may be a problem for those who don’t purchase that insurance, but that is their choice, isn’t it?

Perhaps we can even extend that to the military. Since the federal government is so inefficient, privatizing the armed services with competition so that Americans can choose the military service they want to protect them.

That seems to be popular in some African countries.

Does any of this relate to medical care? Like the police and fire services, we expect the hospitals, emergency rooms, physicians, nurses and other health care personnel to be there when we need them, whether we’ve subscribed to a service for health care or not.

We also expect the police and fire services to be there when we need them, and we choose to support those services with taxes.

Is having a multitude of private medical insurance companies better than a central service, for example such as Medicare?

Medicare isn’t perfect, but its overhead costs are far below that of profit-oriented private insurance companies. Medicare provides universal coverage for those over 65.

What is magic about age 65? Why not extend Medicare to all?

The money saved in administrative fees, by physicians and hospitals having to manage their billing for hundreds of policies from dozens of private profit-oriented insurance companies and the administrative costs and profits of the companies themselves, could be directed to the actual delivery of medical care.

What would such a system do to the quality of medical care?

A new study published by the Annals of Internal Medicine explores differences in survival between patients with cystic fibrosis in the U.S. and Canada.

The research, which was funded by the Cystic Fibrosis Foundation, found that Canadians with cystic fibrosis will likely live an average of 10 years longer than their U.S. counterparts.

Cystic fibrosis is a progressive genetic disease of predominantly Caucasians (those of Northern European descent) associated with eventual disability and early fatalities. Considerable progress has been made in improving survival.

Whereas few survived childhood just 50 years ago, survival has resulted in the number of adults now equaling the number of children with cystic fibrosis.

Having access to specialized medical care is critical for survival of individuals with this disease. Universal insurance in Canada provides payment for universal access that is not assured in the U.S.

Those who expect universal access to police and fire services should consider the advantage of similar expectations for universal access to health care, as is present in our Northern neighbor whose health benefits are apparent at lower cost than in the U.S.

Dr. Weinberger is professor emeritus of pediatrics, University of Iowa, and a visiting clinical professor of pediatrics, University of California, San Diego.

http://www.sandiegouniontribune.com…

Trump: One protester (but what a protester!)

Meet the protester who interrupted Trump’s rally

By Kirk A. Bado
The Tennessean, March 15, 2017

Trump: “OK, let’s go. One person and they will be the story tomorrow. Did you hear? There was a protester.”

A protester interrupted President Donald Trump’s Nashville rally at the Municipal Auditorium Wednesday night.

Holding up a banner proclaiming “Improved Medicare for All,” a demonstrator was met with a chorus of boos from the crowd and led the president to stop mid-speech.

“One person” he said as security confronted the protester, “and that will be the story tomorrow.”

That one person was Dr. Carol Paris. She is the current president of the national organization Physicians for a National Health Program.

She said she wrote a letter to the president weeks ago seeking a meeting to discuss healthcare reform. She said she never received a response. After she read that the president would be coming to Nashville, she decided to take matters into her own hands.

“This is important,” she said. “People are dying in this country for lack of healthcare, I’m a physician and I can’t stand by that.”

http://www.tennessean.com…

Comment:

By Don McCanne, M.D.

Go Carol!

Meet the protester who interrupted Trump’s rally

By Kirk A. Bado
The Tennessean, March 15, 2017

A protester interrupted President Donald Trump’s Nashville rally at the Municipal Auditorium Wednesday night.

Holding up a banner proclaiming “Improved Medicare for All,” a demonstrator was met with a chorus of boos from the crowd and led to the president to stop mid-speech (video here).

“One person” he said as security confronted the protester, “and that will be the story tomorrow.”

That one person was Dr. Carol Paris. She is the current president of the national organization Physicians for a National Health Program and is on the steering committee of Health Over Profit for Everyone.

“It was nerve racking, I was frighted,” Paris said in a telephone interview after the speech. “But I believe this is important.”

She said she wrote a letter to the president weeks ago seeking a meeting to discuss healthcare reform. She said she never received a response. After she read that the president would be coming to Nashville, she decided to take matters into her own hands.

“It was nerve racking, but I had to do it,” she said.

This is not the first time Paris has demonstrated for healthcare reform. When the Affordable Care Act was working its way through Congress in 2009 and 2010, she went to several demonstrations and protests.

“This is important,” she said. “People are dying in this country for lack of healthcare, I’m a physician and I can’t stand by that.”

Before the rally, an announcement over the arena’s public address system asked attendees to shout down protesters but not to touch them and let the police take care of them.

Shortly after raising her sign, security approached Paris and led her out of the auditorium, she said. The police took down her information, but did not arrest or cite Paris. They took her to the door and asked her to leave, Paris said. But she isn’t deterred in her advocacy mission.

“The same thing I always do,” she said. “I’m going to continue to educate and write.”

http://www.tennessean.com…

Kentuckian still championing single-payer; calls GOP plan ‘horrible’

By Berry Craig, AFT Local 1360
Daily Kos, March 15, 2017

When Republicans tout their “free market” based American Health Care Act, they sometimes claim that swarms of Canadians flee their single-payer government health care system for medical treatment stateside.

Kay Tillow of Louisville just chuckles.

“It’s a myth,” says the longtime champion of a U.S. single-payer system.

The Kentuckian is not a fan of the Affordable Care Act. But she says the newly unveiled GOP alternative “is horrible—more cruel and diabolical than the ACA.”

Tillow, who is also a veteran labor and civil rights leader, heads Kentuckians for Single Payer Health Care, an affiliate of Physicians for a National Health Program. She said Canada’s single-payer system is a good model for the U.S. 

Meanwhile, Tillow invites single-payer naysayers to take a gander at Phantoms In The Snow: Canadians’ Use Of Health Care Services In The United States, an in-depth 2002 study directed by Steven J. Katz of the University of Michigan.

Katz and his team of U.S. and Canadian researchers debunked the “popular perception” that our northern neighbors routinely flock our way “seeking necessary medical care not available at home because of either lack of resources or prohibitively long queues.”

They found that the number of “refugees” seems “to be relatively small, indeed infinitesimal when compared with the amount of care provided by their own system.” They concluded that evidence doesn’t back up “the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.”

Though Phantoms in the Snow is 15-years-old, a new north-of-the-border poll seems to back up its premise that most Canadians evidently like their single-payer system. Conducted by Toronto-based Nanos Research, the survey showed that 86.2 percent of respondents favored strengthening public health care instead of increasing for-profit services.

The Canadian Health Coalition, a nonpartisan organization that supports Canada’s public health system, commissioned the poll.

Tillow rues the fact that the U.S. is the “the only developed country without some kind of single-payer system. It’s insanity.”

Tillow added that a May, 2016, Gallup poll showed that 58 percent of adults in the U.S. “favor the idea of replacing the [ACA]…with a federally funded healthcare system that provides insurance for all Americans.”

“But we have not been able to translate majority opinion into a program that will get this filthy money out of health care,” she lamented.

Tillow said single-payer is especially popular with union members. She has a list of 628 union bodies that have endorsed a single-payer system, including the AFL-CIO, the Kentucky State AFL-CIO and the Greater Louisville Central Labor Council.

She faults the Democrats, labor’s traditional allies, for not pushing harder for single-payer. “The ACA helped some people but didn’t do right by all of us. But this crazy Republican plan puts us between the devil and the deep blue sea.”

Tillow said the insurance industry and its allies in the GOP and the right-wing media try to convince Americans that they have the best health care system in the world.

But Tillow says Americans pay more—and get less—for health care than citizens of other developed countries. Statistics back her up.

In 2016, the U.S. spent more on health care than 190 other nations, according to the CIA World Factbook online. Canada ranked 15th.

Also last year, the Factbook put the U.S. 42nd among 224 countries in life expectancy. Canada was 19th.

In infant mortality, the U.S. trailed Canada, the European Union and 54 other countries in 2016, said the Factbook. 

“We are not doing a good job of taking care of our people,” Tillow said.

Tillow has been tirelessly campaigning for a U.S. single payer system for many years. She has barnstormed the country coast-to-coast, talking up universal health care to any group that will listen to her.

Her travels have often taken her to union halls. Though she is an organizer, not a nurse, she represents the Nurses Professional Organization on the All Unions Committee for Single Payer Health Care.

“Jesus healed, and he did it for free,” she said.

In blasting the Republican alternative to the ACA, Tillow cites the non-partisan Congressional Budget Office which, according to National Public Radio, reported that the GOP plan could strand 24 million more Americans without health care coverage by 2026.

“It is going to make health care more expensive, particularly for older people. Older people are going to pay through the nose.

“Younger people may get a cheaper premium, but then if they get sick, they’re going to have huge deductibles and out of pocket expenses.”

Tillow, who grew up in Metropolis, Ill., and went south to work in the civil rights movement in the ‘60s, argues that health care is a right, not a privilege. 

“We have allowed insurance companies to put their moral standards on our health care system,” she said. “The companies see somebody using their health care insurance as money coming out of [the companies’]…pockets. So they put up co-pays and deductibles and that keeps people from going to the doctor.”

In other words, they self-ration their health care.

Tillow said proponents of private health care also claim that care is rationed in single-payer countries, thus endangering patient lives. That, too, is a bogus claim, according to Tillow.

She points to Canada. “There is no rationing of care or delay of care if you got into an accident or you have some urgent need. The only delay is if the need is not urgent, like knee or hip surgery.

“There is no rationing of care if you need immediate treatment for an injury or for cancer or some other disease.”

Tillow said gutting Medicaid is the worst part of the Republican bill. The CBO also said that the GOP bill would trim federal spending on Medicaid by $880 billion over the next 10 years, a 17.6 percent cut. As a result, by 2026, “Medicaid beneficiaries would be reduced by about 14 million people–or about half of the additional uninsured under the GOP bill,” NPR also said.

“Under this bill, the poorest people will be hurt the most,” Tillow said. “The insurers and executives will make out like bandits, and the rest of us will be struggling to get care.”

Based on the CBO analysis, the American Health Care Act “offers billions of dollars’ worth of tax cuts to health insurers, pharmaceutical companies, investors and even tanning salon operators,” The New York Times reported. “The cuts amount to nearly $1 trillion over a decade. The beneficiaries would be the richest Americans who for years have complained that the Affordable Care Act unfairly burdened them with the responsibility of subsidizing insurance for the poor.”

A POSTSCRIPT: On out vacation in Fort William, Scotland, last summer, my wife experienced the United Kingdom’s National Health Service, which for years U.S. conservatives have decried as “socialized medicine.” Melinda suspected she had a kidney infection and went to the local hospital. She didn’t have an appointment. There were four people ahead of her in the queue and she got in to see the doctor in about 45 minutes. He examined her, took a urine sample, diagnosed a kidney infection, wrote her a prescription and sent her on her way. Knowing that British citizens didn’t have to pay, she figured that as a foreigner, she would. “We have no mechanism for payment,” the receptionist said with smile. Melinda expected that she’d surely have to pony up for the medicine at a local drug store. She didn’t.

Berry Craig is webmaster-editor for the Kentucky State AFL-CIO and a member of the Kentucky State AFL-CIO Executive Board.

https://www.dailykos.com…

CBO analysis of Republican replacement legislation

Cost Estimate: American Health Care Act

Congressional Budget Office, March 13, 2017

The Congressional Budget Office and the staff of the Joint Committee on Taxation (JCT) have produced an estimate of the budgetary effects of the American Health Care Act.

Effects on the Federal Budget

CBO and JCT estimate that enacting the legislation would reduce federal deficits by $337 billion over the 2017-2026 period. That total consists of $323 billion in on-budget savings and $13 billion in off-budget savings. Outlays would be reduced by $1.2 trillion over the period, and revenues would be reduced by $0.9 trillion.

The largest savings would come from reductions in outlays for Medicaid and from the elimination of the Affordable Care Act’s (ACA’s) subsidies for nongroup health insurance. The largest costs would come from repealing many of the changes the ACA made to the Internal Revenue Code—including an increase in the Hospital Insurance payroll tax rate for high-income taxpayers, a surtax on those taxpayers’ net investment income, and annual fees imposed on health insurers—and from the establishment of a new tax credit for health insurance.

Effects on Health Insurance Coverage

CBO and JCT estimate that, in 2018, 14 million more people would be uninsured under the legislation than under current law. Most of that increase would stem from repealing the penalties associated with the individual mandate.

Later, following additional changes to subsidies for insurance purchased in the nongroup market and to the Medicaid program, the increase in the number of uninsured people relative to the number under current law would rise to 21 million in 2020 and then to 24 million in 2026. The reductions in insurance coverage between 2018 and 2026 would stem in large part from changes in Medicaid enrollment — because some states would discontinue their expansion of eligibility, some states that would have expanded eligibility in the future would choose not to do so, and per-enrollee spending in the program would be capped. In 2026, an estimated 52 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.

Although the agencies expect that the legislation would increase the number of uninsured broadly, the increase would be disproportionately larger among older people with lower income; in particular, people between 50 and 64 years old with income of less than 200 percent of the FPL would make up a larger share of the uninsured.

Effects on Premiums

In 2018 and 2019, according to CBO and JCT’s estimates, average premiums for single policyholders in the nongroup market would be 15 percent to 20 percent higher than under current law, mainly because the individual mandate penalties would be eliminated, inducing fewer comparatively healthy people to sign up.

Starting in 2020, the increase in average premiums from repealing the individual mandate penalties would be more than offset by the combination of three main factors. First, the mix of people enrolled in coverage obtained in the nongroup market is anticipated to be younger, on average, than the mix under current law. Second, premiums, on average, are estimated to fall because of the elimination of actuarial value requirements, which would result in plans that cover a lower share of health care costs, on average. Third, reinsurance programs supported by the Patient and State Stability Fund are estimated to reduce premiums. If those funds were devoted to other purposes, then premium reductions would be smaller. By 2026, average premiums for single policyholders in the nongroup market under the legislation would be roughly 10 percent lower than the estimates under current law.

Although average premiums would increase prior to 2020 and decrease starting in 2020, CBO and JCT estimate that changes in premiums relative to those under current law would differ significantly for people of different ages because of a change in age-rating rules. Under the legislation, insurers would be allowed to generally charge five times more for older enrollees than younger ones rather than three times more as under current law, substantially reducing premiums for young adults and substantially raising premiums for older people.

Major Changes to Medicaid

CBO estimates that several major provisions affecting Medicaid would decrease direct spending by $880 billion over the 2017-2026 period. That reduction would stem primarily from lower enrollment throughout the period, culminating in 14 million fewer Medicaid enrollees by 2026, a reduction of about 17 percent relative to the number under current law. Some of that decline would be among people who are currently eligible for Medicaid benefits, and some would be among people who CBO projects would be made eligible as a result of state actions in the future under current law (that is, from additional states adopting the optional expansion of eligibility authorized by the ACA). Some decline in spending and enrollment would begin immediately, but most of the changes would begin in 2020, when the legislation would terminate the enhanced federal matching rate for new enrollees under the ACA’s expansion of Medicaid and would place a per capita-based cap on the federal government’s payments to states for medical assistance provided through Medicaid. By 2026, Medicaid spending would be about 25 percent less than what CBO projects under current law.

Changes to Actuarial Value Requirements

Actuarial value is the percentage of total costs for covered benefits that the plan pays when covering a standard population. Under current law, most plans in the nongroup and small-group markets must have an actuarial value that is in one of four tiers: about 60 percent, 70 percent, 80 percent, or 90 percent. Beginning in 2020, the legislation would repeal those requirements, potentially allowing plans to have an actuarial value below 60 percent. However, plans would still be required to cover 10 categories of health benefits that are defined as “essential” under current law, and the total annual out-of-pocket costs for an enrollee would remain capped. In CBO and JCT’s estimation, complying with those two requirements would significantly limit the ability of insurers to design plans with an actuarial value much below 60 percent.

Nevertheless, CBO and JCT estimate that repealing the actuarial value requirements would lower the actuarial value of plans in the nongroup market on average. The requirement that insurers offer both a plan with an actuarial value of 70 percent and one with an actuarial value of 80 percent in order to participate in the marketplace would no longer apply under the legislation. As a result, an insurer could choose to sell only plans with lower actuarial values. Many insurers would find that option attractive because they could offer a plan priced closer to the amount of the premium tax credit so that a younger person would have low out-of-pocket costs for premiums and would be more likely to enroll. Insurers might be less likely to offer plans with high actuarial values out of a fear of attracting a greater proportion of less healthy enrollees to those plans, although the availability of the Patient and State Stability Fund grants in most states would reduce that risk. The continuation of the risk adjustment program could also help limit insurers’ costs from high-risk enrollees.

Because of plans’ lower average actuarial values, CBO and JCT expect that individuals’ cost-sharing payments, including deductibles, in the nongroup market would tend to be higher than those anticipated under current law. In addition, cost-sharing subsidies would be repealed in 2020, significantly increasing out-of-pocket costs for nongroup insurance for many lower-income enrollees. The higher costs would make the plans less attractive than those available under current law to many potential enrollees, especially people who are eligible for the largest subsidies under current law.

Effects of Changes in the Nongroup Market on Employers’ Decisions to Offer Coverage

CBO and JCT estimate that, over time, fewer employers would offer health insurance because the legislation would change their incentives to do so. First, the mandate penalties would be eliminated. Second, the tax credits under the legislation, for which people would be ineligible if they had any offer of employment-based insurance, would be available to people with a broader range of incomes than the current tax credits are. That change could make nongroup coverage more attractive to a larger share of employees. Consequently, in CBO and JCT’s estimation, some employers would choose not to offer coverage and instead increase other forms of compensation in the belief that nongroup insurance was a close substitute for employment-based coverage for their employees.

https://www.cbo.gov…

***

Comment:

By Don McCanne, M.D.

Since the CBO release yesterday of their analysis of the Republican replacement legislation – the American Health Care Act – major impacts have been widely reported. By 2026, an additional 24 million people would be uninsured compared to the projected uninsured under present law, whereas the federal budget deficit would be reduced by $337 billion. Some details of the analysis warrant a closer look.

Policies in the legislation that would result in leaving a total of 52 million uninsured are not applied evenly. Premiums would increase disproportionally for older individuals, who happen to have greater health care needs, thus this segment of the population would have a greater likelihood of being uninsured. Insured rates would increase for the younger, healthier population because of the lower premiums they would face. Thus the blunt targeting of the legislation would reduce coverage rates for those with greater needs.

Some are celebrating the fact that the legislation would eventually reduce premiums by 10 percent compared to what they would be under current law. But it is important to understand that the legislation removes the actuarial tiers under the Affordable Care Act and allows insurers to market plans below the minimum actuarial value of 60 percent – the patient pays over 40 percent of the costs. The analysis explains that the insurers would cluster their products in this low range (to maintain competitive premiums), which will leave patients exposed to greater cost sharing. Affordable premiums translate to unaffordable health care access. Also, as explained above, the premiums would be lower for younger, healthier individuals, but for older, sicker individuals the premiums would be higher than they are under the current law. When people with higher premiums drop out, the average premium becomes artificially lower.

Perhaps the greatest harm of this legislation is the attack on Medicaid – a program designed to help meet then health care needs of lower-income individuals and families. The largest reductions in federal spending would come from cuts to the Medicaid program. These reductions would result in 14 million fewer individuals being enrolled in the Medicaid program. Many of these would remain uninsured because of the lack of options that are affordable for them.

The legislation would also negatively impact the mainstay of health insurance in America – employer-sponsored health plans. The employer mandate to provide insurance would be eliminated, and employees would be eligible for the new tax credits under this legislation only if employers did not offer health care coverage. Since employers could offer wage increases in lieu of health care benefits, it is anticipated that the employer offer rate of health care coverage would decline. That would be unfortunate since the plans dominating the marketplace would have very low actuarial values that would make actual health care much less affordable.

Finally, since the CBO analysis is primarily concerned about the impact on the federal budget, it would seem to be good news that the federal deficit would be reduced by $337 billion. But when you look at what that means, that’s a number that only budget hawks could love considering what the real impact is on the citizens of this nation. That deficit reduction is the difference between a $1.2 trillion decrease in direct spending for health care – spending which is shifted to patients – and a $883 billion reduction in revenues – primarily a reduction in taxes paid by the wealthy. An important part of ACA was the progressive taxes that made health care more affordable for lower-income individuals and constituted a very modest correction of our problematic wealth transfer to the rich. Although the CBO was correct to calculate the difference in the numbers as far as the federal balance sheet is concerned, actually both of the numbers represent a negative impact on working families. Families have to pay more out-of-pocket for health care, and they have to make up the difference in the tax benefit received by the wealthy. Thus working families collectively are worse off by the sum of these two numbers – over $2 trillion!

This legislation has been characterized as representing health care cuts for the people and tax cuts for the rich. Paul Ryan dismisses that by saying, “Read the bill.” Well, we have. It’s even worse because it also leaves in place our profoundly expensive, highly dysfunctional, very inequitable method of financing health care – wasting over $500 billion in administrative excesses alone. We desperately need a much better designed financing system – a single payer national health program.

Republicans call kicking millions off their healthcare ‘freedom’? That’s perverse

Trumpcare does nothing but serve the rich at the expense of the poor and the sick. This is no freedom – it is a form of oppression

By Adam Gaffney, M.D.
The Guardian, March 14, 2017

Paul Ryan is promoting Trumpcare as if it were some sort of medical Magna Carta – a brave declaration of healthcare freedom. “We’re not going to make an American do what they don’t want to do. You get it [healthcare] if you want it. That’s freedom” he recently said on Face the Nation. Freedom to die uninsured, that is.

It’s not that House Republicans are proposing some libertarian healthcare promised land wherein open heart surgeries and rounds of chemo are bartered and traded like tubes of toothpaste – far from it. Instead, the bill largely relies on Obamacare’s blueprint, although it mangles its details for the benefit of the rich while stripping coverage from a staggering 24 million people by 2026 (according to Monday’s estimates from the Congressional Budget Office).

Ryan’s healthcare bill would, like the Obamacare, provide subsidies (or tax credits) for the purchase of private insurance policies. Yet these tax credits would be comparatively more regressive and less generous than those in the Affordable Care Act (ACA); many Americans would thus be freed from having affordable premiums.

The Republican bill also discards Obamacare’s cost sharing subsidies for low-income individuals, who would henceforth have the freedom to pay higher copayments and deductibles. Additionally, it prevents tax credits from being used for the purchase of plans that cover abortion, freeing more women from control over their own reproductive systems.

The bill would also punish those with low incomes by squeezing federal funding of Medicaid beginning in 2020, effectively emancipating millions of poor people from the ranks of the insured.

Trumpcare would at the same time cut the ACA’s taxes on the wealthy, which, as the New York Times recently reported, would redistribute upward some $144bn over a decade to millionaires. Now in fairness, this provision would increase freedom for some: freedom, for instance, to buy a second vacation home, or a first yacht.

And finally, what Ryan seems to see as Trumpcare’s greatest emancipatory element – the elimination of the ACA’s unpopular individual mandate – would simply be replaced by a 30% premium penalty, assessed by insurers, for those who spent time uninsured. As Patrick Henry might have put it: give me a continuous coverage premium surcharge as opposed to a tax penalty, or give me death.

Unbelievably, Ryan sees “freedom” in all of this devastation.

For Ryan and those in his ideological camp, freedom in healthcare is basically the freedom of the consumer, who should be free to buy – or not buy – the particular insurance plan that suits his or her needs and tastes. Hence the bewilderment of Representative John Shimkus who recently asked why, exactly, men should be compelled to buy plans that cover maternity care (Trump’s pick to lead the Center for Medicare and Medicaid Services, Seema Verma, has said something similar).

Ryan thus offers a peculiar vision of healthcare freedom. For the medical literature tells us – to no one’s surprise – that the uninsured are more likely to die. And as noted, the CBO has now estimated that Trumpcare will increase the ranks of the uninsured by 24 million in a decade from now.

The bill would thus increase our freedom to die of health conditions that are amenable to modern medical care, and thereby liberate tens of thousands of people a year off of the face of the planet.

The Ryan formulation of healthcare freedom is thus a false freedom. Real healthcare freedom would look vastly different, though it would also go well beyond what the ACA has accomplished.

Healthcare freedom worthy of the name would mean knowing that one will never – and can never – be uninsured. It would provide the liberty to choose the doctor and hospital of one’s choice.

Healthcare freedom would ensure women’s control over their reproductive health. And critically, true healthcare freedom would mean that we can all make healthcare choices based on our medical needs and personal preferences – not our bank balances – which means eliminating today’s increasingly onerous copayments and deductibles.

Trumpcare would take us in the opposite direction on each of these fronts.

This more egalitarian vision of healthcare freedom may sound utopian, but it is entirely achievable: it emerges when societies create social rights to healthcare through the development of universal healthcare systems.

The conservative vision of healthcare freedom offered by Ryan and company, in contrast, is not a form of freedom at all: indeed, by serving the class interests of the rich at the expense of the welfare – and the very lives – of the poor and the sick, it is better seen as a form of oppression.

https://www.theguardian.com…

Why are they attacking Medicaid?

The American Health Care Act And Medicaid: Changing A Half-Century Federal-State Partnership

By Sara Rosenbaum
Health Affairs Blog, March 10, 2017

Based on page length alone, it is evident that Medicaid is a focal point of the American Health Care Act, released on March 6. Although its fate is uncertain, the bill provides a clear sense of where the Affordable Care Act repeal and replace strategy is heading. Where Medicaid is concerned, what has been discussed for years has now become real: using ACA repeal/replace as the vehicle for a wholesale restructuring of the very financial foundation of the Medicaid program as it has existed over an unparalleled, half-century federal/state partnership.

As expected, the House bill essentially eliminates the enhanced funding levels that made possible states’ expansion of Medicaid to their poorest working-age adult residents, something that 31 states and the District of Columbia now have done. Expansion states could face up to a 40-point difference between the federal funding enhancements they expected to receive in 2020 for the expansion population and what they actually would receive under the bill. What is at stake is continued coverage for some 11 million of the more than 16 million people who have gained eligibility since full implementation of the ACA Medicaid expansion.

Even more fundamentally, the bill — as expected given the draft that was leaked in mid-February — radically restructures Medicaid’s federal financing system. Along with its withdrawal of the ACA’s adult eligibility funding enhancement, the bill would shift an estimated $370 billion in financial risks to the states over the coming decade, according to the Center on Budget and Policy Priorities. And aside from several targeted and harmful restrictions on federal funding for specific state activities, the bill does nothing to provide states with the additional flexibility they would need to absorb these cuts. States have built their programs and designed their complex health care delivery systems for the poor over a half century, entirely depending on this federal/state funding arrangement. Under the bill, they either would have to accept the terms of a seriously diminished financial deal or give up federal funds entirely.

Concluding Thoughts

There’s no doubt about it: Medicaid is a big program. But its size is a reflection of the number of people it covers; the extent of poverty in the U.S.; the greater survival of children and adults with profound disabilities; the greater life spans of the elderly who need decent long-term care in nursing home and community settings; advances in technology; and a program design strategy pursued over five decades by federal and state lawmakers alike that has deliberately positioned Medicaid to function as what has been described as the “workhorse” of the American health care system.

On a per capita basis, Medicaid actually operates quite efficiently, costing less than other forms of insurance. But Medicaid is big because collectively we have asked that it assume a vast range of jobs, from financing care for the highest-risk babies to being the first line of health care defense when natural disasters strike. Some day we may spread these responsibilities across public and private insurers alike, thereby reducing the burden on the program and on states as well. But in light of the decisions we collectively have made about how best to respond to pressing national health needs, the potential effects of such a seminal shift federal Medicaid funding policy point to the importance of a slower, more carefully crafted process of change.

http://healthaffairs.org…

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Watch Paul Ryan’s Adam’s Apple When He’s Asked Why His Health Plan Cuts Taxes for the Rich

By Jonathan Chait
New York, March 9, 2017

Tucker Carlson: The overview here is that all the wealth [in] basically the last ten years basically has stuck to the top end, that’s one of the reasons we’ve had all this political turmoil, as you know. Kind of a hard sell to say, ‘Yeah, we’re gonna repeal Obamacare but we’re gonna send more money to the people who’ve already gotten the richest over the last ten years.’ I mean, that’s what this does, no? … I’m not leftist, that’s just, that’s true!

Paul Ryan: I–I–I’m not concerned about it because we said we were gonna repeal all the Obamacare taxes, this is one of the Obamacare taxes. The other point I’d is, this dramatically helps tax reform,

http://nymag.com…

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Comment:

By Don McCanne, M.D.

In the past most conservatives have agreed that the government must provide assistance to low-income individuals for them to be able to obtain the health care that they need, that you can’t simply just cut them loose in the health care marketplace to fend for themselves. Thus the Medicaid program – a low cost program that does largely meet the health care needs of this vulnerable population. But now Congress wants to begin ratcheting down this program – a move that can have only disastrous consequences for the health care and the finances of these people in need.

Why are they doing this? Is it ideology? Isn’t that just an abstraction? Is it improving access to health care, as implied by their false rhetoric? It actually does the opposite.

Paul Ryan has explained more than once what they are doing. They are cutting “Obamacare taxes” which are progressive taxes that were designed to help pay for the health care that lower-income individuals otherwise could not afford. In fact, the two main policy features of the Republican legislation are to decrease government contributions to health care for lower-income individuals while decreasing taxes on the wealthy that would be used to pay for that care.

Even Tucker Carlson recognizes that this is a transfer of wealth from the masses to the rich. Thus it seems that their ideology is more than an anti-government abstraction, it is to prioritize greed over health care justice. Wealth for the wealthy and health care for the, well… wealthy.

Obamacare replacement would benefit wealthy

By F. Douglas Stephenson, LCSW
The Gainesville (Fla.) Sun, March 10, 2017

President Donald Trump and the Republican Congress seek to protect profits by replacing Obamacare. They propose to dismantle core aspects of Obamacare, including its subsidies to help people buy coverage, its expansion of Medicaid, its taxes and its mandates for people to have insurance.

Huge benefits would result for corporations and the very rich. The richest 1 percent would qualify for an average of $33,000 in tax cuts this year alone, according to former U.S. Labor Secretary Robert Reich, and a whopping $197,000 of tax cuts would be given to the top 0.1 percent.

“The 400 highest-income taxpayers (with incomes averaging more than $300 million each) will each receive an average annual tax cut of about $7 million.” Reich wrote. “It would also increase the taxes of families earning between $10,000 and $75,000 — including just about all of Trump’s working class voters.”

When Republicans dismantle Obamacare, Reich estimates that 32 million people will lose their health insurance, tens of thousands of Americans will die because they don’t get the medical care they need, Medicare will fall into worse shape and the rich will become far richer.

A major national figure in academic family medicine, Dr. John Geyman of the University of Washington, Seattle, anticipates that the proposed GOP plan will make an imploding Affordable Care Act system even worse, with a possible huge backlash from the public and even the private insurance industry when it doesn’t get all that it wants.

House Speaker Paul Ryan, R-Wisc., has called for a continuation of consumer-directed health care (with patients having “more skin in the game”), health savings accounts, high-risk pools, selling insurance across state lines, association health plans among businesses, and further privatization of Medicare and Medicaid. Health and Human Services Secretary Tom Price, as leader of the House Budget Committee in 2015, proposed the complete repeal of the ACA, as well as privatization of Medicare, sharp cuts in Medicaid funding and defunding of Planned Parenthood.

Geyman’s problem with GOP replacements is simple: They won’t work!

“Each of these directions has been used for years, and have all failed to assure Americans with better access to affordable health care,” he wrote. “They have been discredited by long experience.”

Geyman notes that the ACA was modeled closely on a health plan created by the conservative Heritage Foundation and enacted in Massachusetts Health Plan by Republican Gov. Mitt Romney in 2006. Three years later, a study comparing safety net and non-safety net hospitals found that the former played a disproportionately large role in caring for disadvantaged patients and were hurting financially.

As Geyman wrote, there are many reasons for the ACA’s failure. It relies on a multi-payer financing system with around 1,300 private insurers, which are mostly dedicated to profits instead of coverage of patients’ health needs. They continue to discriminate against the sick, profiteer and inflate their overhead to the point where the industry is unsustainable without taxpayer support.

Geyman argues that contrary to experience, evidence and GOP ideology, privatization is less competitive, less efficient and more expensive for patients than the public sector. That has already demonstrated by private Medicare and Medicaid plans, which are more volatile, offer less choice and less accountable than their public counterparts. They game the system and demand ongoing overpayments, all of which amounts to corporate welfare at taxpayer expense.

There are already wide variations in states’ definitions of coverage and eligibility, which Geyman suggests are likely to increase further as more restrictive federal Medicaid block grants to states become widespread. This will hit safety net resources will hard, seriously impacting the most vulnerable among us.

The GOP’s replacement plan will cost patients, families and taxpayers more, and we will all get less — tax cuts for the rich, and benefit cuts for the poor and middle class. Yet Republicans are blinded by ideology and seemingly unaware of the failed policies already proven by the last 25-plus years’ experience, including those of the ACA.

Of the Organisation for Economic Co-operation and Development nations, the United States ranks near the bottom in health-care justice. And yet the new Congress is moving forward with legislative action that not only increases costs and reduces benefits for the 99 percent, but further diminishes justice within our health-care system when the 1 percent become far richer.

The solution is a not-for-profit, one-tier public system of universal Medicare coverage, based on medical need, not ability to pay. Please strongly support “The Expanded and Improved Medicare for All Act”, H.R. 676, a bill now filed in Congress that resolves these problems.

F. Douglas Stephenson is a former instructor of social work in the University of Florida Department of Psychiatry and a current member of Physicians for a National Health Plan.

http://www.gainesville.com…

Nobel laureate Angus Deaton supports single payer

Nobel economist takes aim at rent-seeking banking and healthcare industries

By Greg Robb
MarketWatch, March 6, 2017

Income inequality is not killing capitalism in the United States, but rent-seekers like the banking and the health-care sectors just might, said Nobel-winning economist Angus Deaton on Monday.

If an entrepreneur invents something on the order of another Facebook, Deaton said he has no problem with that person becoming wealthy.

“What is not OK is for rent-seekers to get rich,” Deaton said in a luncheon speech to the National Association for Business Economics.

Rent seekers lobby and persuade governments to give them special favors.

Bankers during the financial crisis, and much of the health-care system, are two prime examples, Deaton said.

Rent-seeking not only does not generate new product, it actually slows down economic growth, Deaton said.

“All that talent is devoted to stealing things, instead of making things,” he said.

Another prime example of rent-seeking is that the Medicaid is funding opioid prescriptions for low-income workers, Deaton said. The results are workers who are becoming addicted and overdosing while profits are going to the Sacker family which owns Purdue Pharma that makes OxyContin.

Deaton said he favors a single-payer health system only because our current part-private and part-public system is exquisitely designed to give opportunities for rent-seeking.

“So I, who do not believe in socialized health-care, would advocate a single-payment system…because it will get this monster that we’ve created out of the economy and allow the rest of capitalism to flourish without the awful things that healthcare is doing to us,” he said.

Raising taxes on the wealthy is not a good way to combat rent-seeking because it taxes the legitimate profits of entrepreneurs along with rent-seekers.

“The key is to somehow find a way of tackling rent-seeking, crony capitalism, and corruption legal and illegal and build fairer, more equal society without compromising innovation or entrepreneurship,” he said.

http://www.marketwatch.com…

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Comment:

By Don McCanne, M.D.

Nobel laureate Angus Deaton’s primary message is that we need to tackle rent-seeking (where “talent is devoted to stealing things, instead of making things”) to build a “fairer, more equal society without compromising innovation or entrepreneurship.” But look at how he applies that to the health care system. “Deaton said he favors a single-payer health system only because our current part-private and part-public system is exquisitely designed to give opportunities for rent-seeking.”

He says, “So I, who do not believe in socialized health-care, would advocate a single-payment system…because it will get this monster that we’ve created out of the economy and allow the rest of capitalism to flourish without the awful things that healthcare is doing to us.”

Although he says that raising taxes on the wealthy is not a good way to combat rent-seeking, other economists believe that the tax system is still a very important tool to combat rent-seeking. Tax policies can be targeted toward rent-seekers without over-taxing the legitimate profits of entrepreneurs, though legitimate profits need to be taxed equitably just as legitimate wages are taxed for workers.

Nevertheless, it is a very important lesson that Deaton teaches us and that is that our highly dysfunctional health care financing system is ripe for rent-seekers for whom we need a single payer system to improve fairness and equity in health care, even though he himself does not believe in socialized health care (just social insurance apparently). He does, in fact, believe in a fairer, more equal society.

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…