By Adam Gaffney, M.D., M.P.H.
Vice, August 16, 2019

Ana felt that she had to make a choice: obtain desperately-needed health services—like therapy—for her nine-year old daughter with autism, or risk that her family would have to leave the country or be separated, NPR reported last January. As an immigrant living in Texas, Ana feared that seeking more services for her daughter could jeopardize the process of obtaining legal permanent residency status (a “green card”), even though her daughter was a citizen enrolled in Medicaid.

Such fears—well-founded or not—may be growing. On Monday, the Trump administration fanned them when it released a new regulation branding legal immigrants “public charges,” and hence persona non grata, as punishment for using programs like Medicaid or food assistance. The rule also makes wealth a key criterion by which immigrants will be sorted when it comes to determining who can stay, and who must go.

In response, some immigrants will predictably avoid or disenroll from social programs—including healthcare—to which they are entitled. But even immigrants who are not targeted by the rule will invariably be confused and fearful of it, said Leah Zallman, a colleague at Harvard Medical School and the Cambridge Health Alliance who studies immigrant health. Like Ana, some will be afraid that even enrolling family members in government programs could jeopardize their immigration status—potentially leading to the separation of their family. And so, Zallman told me, parents “are dis-enrolling kids even when the kids have legal access to these benefits and are not subject to the rule.”

This “chilling effect,” as researchers call it, is a feature of such programs, not a bug. It would be a mistake to see the public charge rule as the consequence of ignorance among administration policymakers, or a failure to read the relevant public health literature. Their obvious purpose—in design if not in word—is redistribution: taking healthcare from low-income families in order to pad the bank accounts of the rich. This was the story of the 2017 Obamacare repeal bills, just as it is the story of Medicaid work requirements, and the public charge rule today.

A few months after the public charge rule was proposed last October, for instance, a study from the Urban Institute found that about a fifth of adults in low-income immigrant families were already avoiding government programs out of fear of sinking their prospects of obtaining legal permanent residency.

One recent study in JAMA Pediatrics, led by Zallman, found that more than eight million children are at risk of losing access to health coverage or food assistance because of the rule. Those at risk include children with serious medical conditions—including hundreds of thousands with asthma and epilepsy. Without treatment, children with asthma can struggle to breathe, miss school, wind up in the ER or hospital—even asphyxiate. Failure to treat epilepsy, in turn, can lead to recurrent, dangerous, life-disrupting seizures. But that is simply a price the administration is willing to pay.

In 1882, in an earlier age of flourishing nativism, Congress passed the first “public charge” exclusion into federal law. However, the “public charge” rule has had a narrow scope in recent years, applying only to those who received cash assistance or public nursing-home care. The Trump administration’s new regulation upends that, casting legal immigrants who use a broad range of services—ranging from food stamps to housing assistance to Medicaid—as undesirables. Such “public charges” can then be denied a change in immigration status, such as issuance of a “green card.”

The new public charge rule hence weaves the administration’s xenophobic agenda into its broader regressive economic agenda. The administration’s head immigration official Ken Cuccinelli defended this draconian approach in an interview on NPR Tuesday by revising the famous quote inscribed on the Statue of Liberty’s pedestal. “Give me your tired and your poor,” he said, “who can stand on their own two feet, and who will not become a public charge.”

Not surprisingly, the rule mirrors the administration’s other health policies, such as the Medicaid work requirements championed by CMS administrator Seema Verma. Just like the public rule, Medicaid work requirements are ostensibly designed to reward a good work ethic. But in reality, both mainly serve to confuse working-class people—and squeeze them out of health coverage.

More than 18,000 individuals lost Medicaid coverage after work requirements went into effect in Arkansas last year, even though few were actually targeted by the policy as written. A failure to understand the arcane requirements and exclusions “may explain why thousands of persons lost coverage even though more than 95% of the target population appeared to meet the requirements or qualify for an exemption,” as a recent study in the New England Journal concluded.

The stakes are high, because programs like Medicaid can be a lifeline for working-class families, immigrant and non-immigrant alike. Activist Kristian Hernandez, whose parents both emigrated from Mexico and who today helps guide immigrants applying for asylum through the legal process in Texas, told me how important food and healthcare benefits were for her working-class family growing up: “[W]e wouldn’t have been able to survive otherwise,” she said. Hernandez fears that the rule could keep immigrant families in a similar position from such benefits today.

The public charge rule is cut from the same cloth as the administration’s larger redistributive agenda. Together, these policies are engineered to take healthcare (and other benefits) from the working class—disproportionately immigrants and people of color—so as to benefit the privileged few. It’s class warfare, and the kids with asthma and epilepsy are the collateral damage.

Adam Gaffney is a physician and public health researcher at Harvard Medical School and the Cambridge Health Alliance. He serves as president of the advocacy organization, Physicians for a National Health Program.

https://www.vice.com…

By Joyce Frieden
MedPage Today, August 16, 2019

The American Medical Association has dropped out of the Partnership for America’s Health Care Future, a coalition of healthcare stakeholders dedicated to torpedoing the idea of a single-payer healthcare system such as Medicare for All.

The coalition “has extensively highlighted the many serious problems with Medicare for All and other proposals that would lead to a single payer health care system,” James Madara, the AMA’s executive vice president and CEO, said in a statement about the move, which was first reported by Politico. “Missing in the recent debate is an ongoing discussion of practical solutions that will result in more affordable insurance options.”

“Practical solutions have been identified and continue to be championed by the AMA,” Madara continued. “The AMA decided to leave the Partnership for America’s Health Care Future so that we can devote more time to advocating for these policies that will address current coverage gaps and dysfunction in our health care system.” He emphasized that the association “[remains] opposed to Medicare for All, and policies that reduce patient choice and competition, and are built on flawed financing policies.”

In response, the coalition issued a cordial statement saying it “strongly agrees with the American Medical Association (AMA) that Medicare for all is the wrong approach for America’s healthcare and we have appreciated the opportunity to work with them throughout the past year.” The partnership’s members include America’s Health Insurance Plans, the American Hospital Association, the BlueCross BlueShield Association, the Biotechnology Innovation Organization, and other groups that would be affected by any move to a publicly financed health insurance program.

“Today, too many individuals and families who do not have employer sponsored insurance and are ineligible for government subsidies face costly premiums and high deductibles that restrict their access to care. Action is needed now to assist this population without disrupting coverage that works for most Americans,” he said. “Additional policy improvements will further the goal of expanding coverage and offering more affordable options for the uninsured and those struggling to secure meaningful health insurance coverage.”

Such options could possibly include a “public option” that would allow people to buy into a public program such as Medicare if they would like. At its annual meeting in June, the AMA House of Delegates referred the AMA Board of Trustees to a resolution calling for the organization to “study the impacts of various approaches that offer a public option … including but not limited to a Medicare buy-in; a public option offered on health insurance exchanges; and buying into either the Federal Employees Health Benefits Program or a state employee health plan.” (The Partnership for America’s Health Care Future opposes a public option, which it says could “decimate” rural hospitals’ finances.)

The resolution also reaffirmed AMA policy which states that coverage options offered in a health insurance exchange “be self-supporting; have uniform solvency requirements; not receive special advantages from government subsidies; include payment rates established through meaningful negotiations and contracts; not require provider participation; and not restrict enrollees’ access to out-of-network physicians.” The board will report back to the delegates on the resolution, possibly as early as the association’s interim meeting in November.

Medicare for All was a flashpoint at the June meeting, as several hundred protesters gathered outside the meeting hotel to demand that the AMA support Medicare for All; several dozen protesters came inside the main meeting room and staged a “die-in” on the House of Delegates floor.

At least one group was happy with the AMA’s exit from the partnership. “This is a big victory for single-payer supporters,” Adam Gaffney, MD, president of Physicians for a National Health Program (PNHP), which supports single-payer, said in a statement. “For decades, the AMA has been on the wrong side of history, fighting efforts to establish Medicare and Medicaid in the 1960s, and resisting movements to bring racial equality to the delivery and practice of health care … The AMA’s exit from this explicitly anti-single payer lobbying group shows that change is within reach.” PNHP was one of several groups that organized the protest at the AMA meeting.

https://www.medpagetoday.com…

By Ken Lefkowitz
New York Times, Letters, August 16, 2019

August 15, 2019

Emergency medicine physician assistant and Maryland Progressive Healthcare Coalition founder Kristy Fogle discusses her recent organizing work and reminds listeners that all private health insurance plans pale in comparison to improved Medicare for All. Hosted by Joseph Sparks. Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

By Jeneen Interlandi
New York Times, August 14, 2019

The smallpox virus hopscotched across the post-Civil War South, invading the makeshift camps where many thousands of newly freed African-Americans had taken refuge but leaving surrounding white communities comparatively unscathed. This pattern of affliction was no mystery: In the late 1860s, doctors had yet to discover viruses, but they knew that poor nutrition made people more susceptible to illness and that poor sanitation contributed to the spread of disease. They also knew that quarantine and vaccination could stop an outbreak in its tracks; they had used those very tools to prevent a smallpox outbreak from ravaging the Union Army.

Smallpox was not the only health disparity facing the newly emancipated, who at the close of the Civil War faced a considerably higher mortality rate than that of whites. Despite their urgent pleas for assistance, white leaders were deeply ambivalent about intervening. They worried about black epidemics spilling into their own communities and wanted the formerly enslaved to be healthy enough to return to plantation work. But they also feared that free and healthy African-Americans would upend the racial hierarchy, the historian Jim Downs writes in his 2012 book, “Sick From Freedom.”

Federal policy, he notes, reflected white ambivalence at every turn. Congress established the medical division of the Freedmen’s Bureau — the nation’s first federal health care program — to address the health crisis, but officials deployed just 120 or so doctors across the war-torn South, then ignored those doctors’ pleas for personnel and equipment. They erected more than 40 hospitals but prematurely shuttered most of them.

White legislators argued that free assistance of any kind would breed dependence and that when it came to black infirmity, hard labor was a better salve than white medicine. As the death toll rose, they developed a new theory: Blacks were so ill suited to freedom that the entire race was going extinct. “No charitable black scheme can wash out the color of the Negro, change his inferior nature or save him from his inevitable fate,” an Ohio congressman said.

One of the most eloquent rejoinders to the theory of black extinction came from Rebecca Lee Crumpler, the nation’s first black female doctor. Crumpler was born free and trained and practiced in Boston. At the close of the war, she joined the Freedmen’s Bureau and worked in the freed people’s communities of Virginia. In 1883, she published one of the first treatises on the burden of disease in black communities. “They seem to forget there is a cause for every ailment,” she wrote. “And that it may be in their power to remove it.”

In the decades following Reconstruction, the former slave states came to wield enormous congressional power through a voting bloc that was uniformly segregationist and overwhelmingly Democratic. That bloc preserved the nation’s racial stratification by securing local control of federal programs under a mantra of “states’ rights” and, in some cases, by adding qualifications directly to federal laws with discriminatory intent.

As the Columbia University historian Ira Katznelson and others have documented, it was largely at the behest of Southern Democrats that farm and domestic workers — more than half the nation’s black work force at the time — were excluded from New Deal policies, including the Social Security and Wagner Acts of 1935 (the Wagner Act ensured the right of workers to collective bargaining), and the Fair Labor Standards Act of 1938, which set a minimum wage and established the eight-hour workday. The same voting bloc ensured states controlled crucial programs like Aid to Dependent Children and the 1944 Servicemen’s Readjustment Act, better known as the G.I. Bill, allowing state leaders to effectively exclude black people.

In 1945, when President Truman called on Congress to expand the nation’s hospital system as part of a larger health care plan, Southern Democrats obtained key concessions that shaped the American medical landscape for decades to come. The Hill-Burton Act provided federal grants for hospital construction to communities in need, giving funding priority to rural areas (many of them in the South). But it also ensured that states controlled the disbursement of funds and could segregate resulting facilities.

Professional societies like the American Medical Association barred black doctors; medical schools excluded black students, and most hospitals and health clinics segregated black patients. Federal health care policy was designed, both implicitly and explicitly, to exclude black Americans. As a result, they faced an array of inequities — including statistically shorter, sicker lives than their white counterparts. What’s more, access to good medical care was predicated on a system of employer-based insurance that was inherently difficult for black Americans to get. “They were denied most of the jobs that offered coverage,” says David Barton Smith, an emeritus historian of health care policy at Temple University. “And even when some of them got health insurance, as the Pullman porters did, they couldn’t make use of white facilities.”

In the shadows of this exclusion, black communities created their own health systems. Lay black women began a national community health care movement that included fund-raising for black health facilities; campaigns to educate black communities about nutrition, sanitation and disease prevention; and programs like National Negro Health Week that drew national attention to racial health disparities. Black doctors and nurses — most of them trained at one of two black medical colleges, Meharry and Howard — established their own professional organizations and began a concerted war against medical apartheid. By the 1950s, they were pushing for a federal health care system for all citizens.

That fight put the National Medical Association (the leading black medical society) into direct conflict with the A.M.A., which was opposed to any nationalized health plan. In the late 1930s and the 1940s, the group helped defeat two such proposals with a vitriolic campaign that informs present-day debates: They called the idea socialist and un-American and warned of government intervention in the doctor-patient relationship. The group used the same arguments in the mid-’60s, when proponents of national health insurance introduced Medicare. This time, the N.M.A. developed a countermessage: Health care was a basic human right.

Medicare and Medicaid were part of a broader plan that finally brought the legal segregation of hospitals to an end: The 1964 Civil Rights Act outlawed segregation for any entity receiving federal funds, and the new health care programs soon placed every hospital in the country in that category. But they still excluded millions of Americans. Those who did not fit into specific age, employment or income groups had little to no access to health care.

In 2010, the Affordable Care Act brought health insurance to nearly 20 million previously uninsured adults. The biggest beneficiaries of this boon were people of color, many of whom obtained coverage through the law’s Medicaid expansion. That coverage contributed to a measurable decrease in some racial health disparities, but the success was neither as enduring nor as widespread as it might have been. Several states, most of them in the former Confederacy, refused to participate in Medicaid expansion. And several are still trying to make access to the program contingent on onerous new work requirements. The results of both policies have been unequivocal. States that expanded Medicaid saw a drop in disease-related deaths, according to the National Bureau of Economic Research. But in Arkansas, the first state to implement work requirements, nearly 20,000 people were forced off the insurance plan.

One hundred and fifty years after the freed people of the South first petitioned the government for basic medical care, the United States remains the only high-income country in the world where such care is not guaranteed to every citizen. In the United States, racial health disparities have proved as foundational as democracy itself. “There has never been any period in American history where the health of blacks was equal to that of whites,” Evelynn Hammonds, a historian of science at Harvard University, says. “Disparity is built into the system.” Medicare, Medicaid and the Affordable Care Act have helped shrink those disparities. But no federal health policy yet has eradicated them.

Jeneen Interlandi is a member of The Times’s editorial board and a staff writer for the magazine.

https://www.nytimes.com…

By James G. Kahn, M.D. and Elliot Marseille, Dr.P.H.
The Hill, August 14, 2019

Each candidate has their own way to fix what ails health insurance. Everyone claimed “Medicare” at the heart of their strategy. Sen. Bernie Sanders (D-Vt.) and Sen. Elizabeth Warren (D-Mass.) urged sweeping reform, while former Vice President Joe Biden and others advocated tinkering at the margins, stoking fear of big change.

What does it all mean?

After the first Democratic debate, we wrote a Cheat Sheet to clarify key concepts, and reviewed the minimal role of private insurance under “Medicare for all.” This time, we’re tackling people’s fears about reform and comparing the proposed plans.

Let’s start with three fears raised in the debate:

Should I be afraid of losing my insurance? Yes — under the current system. Unless you’re on Medicare, your health insurance is not guaranteed. Your employer can cancel the plan you like, forcing you to find a new doctor.

You may change jobs, or be laid off and lose your insurance. The premium may rise so much that you can no longer afford it. Coverage that’s guaranteed wherever (or whether) you work requires insurance that covers people based on U.S. residency rather than employment, like Rep. Pramila Jayapal’s (D-Wash.) Medicare for All Act of 2019.

Should I worry that taxes will go up? With Medicare for all, taxes will replace rising premiums, copays and deductibles.

These taxes will be progressive. The more you earn, the higher rate you pay. That’s fairer than charging for health insurance based on age, without regard to income, like now. The Affordable Care Act provides premium subsidies for some poorer people, but not for all and requires high deductibles and copays. For most people, the new taxes for health care will be less than what they currently pay in premiums and out-of-pocket costs. Low and middle-income families will save money. High-income families will pay more.

Should I fear losing choice of doctor? Sadly, we already have. Unless you’re on traditional Medicare, you can’t choose any doctor or hospital you like (except if you pay the costs yourself). Some presidential candidates say the choice worth making is between health insurers. Isn’t it more important to choose the doctor and hospital that provides your care, as permitted under Medicare for all?

Now, let’s compare the candidates’ plans. There are three approaches (see side-by-side table):

Medicare for all (single payer) provides coverage for life, regardless of health, wealth, or work status. Everyone has a comprehensive benefit package, accepted by all doctors. A public agency directly pays doctors and hospitals’ negotiated rates. Medicare for all combines superb coverage with lower costs. How? By simplifying every aspect of insurance, from enrollment to coverage to billing.

This results in massive administrative savings ($400-500 billion per year) and lower drug prices. How we pay for health care would also change. Taxes would rise, especially on the wealthy, but premiums and out-of-pocket costs would disappear. Most importantly, health care would cost our society less — 5 to 8 percent less in most studies, while covering everyone.

Public Option (or Medicare expansion) means we keep the current super-complex mix of private and public plans, while letting some people buy into Medicare. This protects private insurance companies, and so keeps the bad stuff — restricted doctor networks, deductibles and copays, and administrative bloat.

Medicare Advantage for all: Sen. Kamala Harris (D-Calif.) recently proposed an approach based on Medicare Advantage, the HMO part of Medicare. This assures a large role for private insurers. Thus, it has most of the same drawbacks as the Medicare public option, with few savings opportunities. It would leave private insurers and all their unnecessary expenses burdening Americans for another decade.

Is Medicare for All “fairytale economics,” as former Rep. John Delaney said? It’s a system widely used in other countries — and works incredibly well. The real fairy tale is that we can still afford insurance middlemen taking a cut out of our health-care budget.

Is it too drastic? During the Great Depression, we launched America’s biggest social insurance program: Social Security. It’s a great example of how the government can protect us against economic risk and improve our lives. Medicare for all is a grand solution in a grand American tradition. This kind of health-care reform is not only possible, it’s essential.

James G. Kahn, M.D., is an emeritus professor of health policy at the University of California San Francisco. Elliot Marseille, Dr.P.H., is CEO of Health Strategies International.

https://thehill.com…