PNHP

Will repealing Obamacare really kill 60,000 people?

Will repealing Obamacare really kill 60,000 people?

By Carolyn Y. Johnson
The Washington Post, March 22, 2017

Is repealing Obamacare going to kill people?

If you’re one of the millions projected to lose your health insurance under the health care law’s proposed repeal, that’s the big question. And Washington has plenty of politicians, partisans and wonks ready to answer it for you.

Sen. Bernie Sanders (I-Vt.) tweeted his take: 36,000 more deaths per year. An analyst at the conservative Manhattan Institute analysis argued the true answer was zero. Individual anecdotes abound: Obamacare saved my life.

In a new analysis published this week in the American Journal of Public Health, a pair of doctors who advised Sanders’s presidential campaign found that a repeal of the law without a replacement could cost anywhere from 14,000 to 60,000 lives — in the next year alone.

It’s unsurprising that partisans arguing over what to do with the law — known officially as the Affordable Care Act — would disagree about the effect’s of repealing it. But even nonpartisan health policy experts are at a loss when asked for a figure on how many people would perish if the ACA comes off the books.

That’s because the law’s most widespread feature is helping people buy health insurance, and the link between being covered by health insurance and actually being healthier is not fully understood.

It isn’t that the question hasn’t been studied or that individual benefits of health insurance aren’t known. An Institute of Medicine report in 2009 rounded up the evidence that uninsured people fared worse after a heart attack, stroke, cancer, diabetes, congestive heart failure and trauma. But what does all that harm add up to in lives lost or saved?

To make their estimate, physicians Steffie Woolhandler and David Himmelstein extrapolated from a handful of studies published during the past 15 years that used a variety of data sets and situations — such as the expansion of Medicaid in Oregon through a lottery and the effects of health reform in Massachusetts.

“The common sense belief that if you lose your health insurance, it’s going to make your health worse and it might even kill you — that’s a common-sense belief that happens to be true,” Woolhandler said in an interview. “People cannot say we’re going to take health care away from 24 million people and say nobody’s going to die.”

But health is a cumulative, complex and long-term outcome, determined not only by health insurance status, but by socioeconomic factors, genetics, lifestyle and the neighborhoods where people live. The differences between having insurance and not having insurance often encapsulates a broad swath of other factors that affect people’s well-being.

“When you ask the question, then, what would be the effect of repealing the ACA, there’s no perfect way to answer this question,” said Benjamin Sommers, an associate professor of health policy and economics at the Harvard T.H. Chan School of Public Health.

One of the studies the researchers drew on to make their estimate was led by Amy Finkelstein, an economist at the Massachusetts Institute of Technology. Finkelstein said that the body of research, including her work on the effects of the 2008 Medicaid expansion in Oregon, have made her confident that health insurance improves health. That study found a significant drop in depression and an increase in people’s self-reported health among those who randomly received Medicaid compared with those that did not.

But receiving insurance did not lead to improvements in other areas, such as better management of blood pressure, cholesterol levels or blood sugar control over the two years of the study. And since death was — fortunately — a relatively rare event for people between the ages of 19 and 64 in the Oregon study, where the survival rate was higher than 99 percent, measuring the effect of insurance on mortality may not be the right way to make the case it was working.

“You can’t rule out that Medicaid saves a bunch of lives, but you also can’t rule out that it kills a bunch of people,” Finkelstein said of the Oregon data. She argued that while health insurance is aimed at improving health, it is also fundamentally a product aimed at protecting people against financial ruin, and another way to measure its effects — particularly in the short term — would be to examine how it helped financial security.

The Oregon study showed reductions in financial strain, and a working paper published last year estimated that people who gained coverage through the broader Medicaid expansion had anywhere from a $600 to $1,000 reduction in collection debt.

Sommers, whose work was also used to estimate the effect of ACA repeal, said that another challenge is knowing whether giving someone insurance — which is what happened in his study of health reform in Massachusetts — will have directly the opposite effect as taking it away.

Two of the studies the researchers cited examined large data sets and found an association between longer life and having health coverage, but could not determine that the insurance drove the effect. That leaves open the possibility that it isn’t coverage itself that caused the disparity, but might also be explained by other differences between people who have insurance and those who don’t.

In his work, Sommers compared the death rates of people in Massachusetts before and after the state implemented health reform in 2006 with people in similarly matched counties that did not expand insurance coverage. He found a decrease in deaths in Massachusetts — in just the kinds of deaths, such as cancer, diabetes, heart disease that they expected might shift due to access to insurance.

“The short answer is, these are challenging extrapolations,” Sommers said. “But I think what’s fair to say, based on our studies, is that giving people insurance can reduce mortality, so likely taking it away will cause an increase. … The exact number is much harder to pin down.”

https://www.washingtonpost.com…

Sticking points with multi-payer contracting in health care

Common-Agency Problems and Contracting in the U.S. Healthcare System

By Brigham Frandsen, Michael Powell, and James B. Rebitzer
National Bureau of Economic Research, NBER Working Paper No. 23177, February 2017

Abstract

We propose a “common-agency” model for explaining inefficient contracting in the U.S. healthcare system. In our setting, common-agency problems arise when multiple payers seek to motivate a shared provider to invest in improved care coordination. Our approach differs from other common-agency models in that we analyze “sticking points,” that is, equilibria in which payers coordinate around Pareto-dominated contracts that do not offer providers incentives to implement efficient investments. These sticking points offer a straightforward explanation for three long observed but hard to explain features of the U.S. healthcare system: the ubiquity of fee-for-service contracting arrangements outside of Medicare; problematic care coordination; and the historic reliance on small, single specialty practices rather than larger multi-specialty group practices to deliver care. The common-agency model also provides insights on the effects of policies, such as Accountable Care Organizations, that aim to promote more efficient forms of contracting between payers and providers.

From the Conclusion

In this paper we have developed a common-agency model for explaining inefficient contracting in the U.S. healthcare system. In our setting, common agency problems arise when multiple payers seek to motivate a shared provider to invest in improved care coordination. Our approach differs from other common-agency models in that we analyze sticking points, that is, equilibria in which payers coordinate around Pareto dominated contracts that do not offer providers incentives to implement efficient investments. These sticking points offer a straightforward explanation for three long-observed but hard to explain features of the US healthcare system: the ubiquity of fee-for-service contracting arrangements outside of Medicare; problematic care coordination; and the historic reliance on small single-specialty practices rather than larger multi-specialty group practices to deliver care. The common-agency model also provides insights on the effects of policies (such as Accountable Care Organizations) that aim to promote more efficient forms of contracting between payers and providers.

We have examined the common-agency market failure in the context of payers trying to induce providers to make efficient investments in care coordination. We focused on incentives for these investments because they have played an important role in recent health care reform initiatives. The common-agency market failure is, however, much broader than this specific application and is likely to play a role wherever multiple payers seek to influence the actions of a shared provider.

Given the number and diversity of payers, exploring more broadly the implications of common-agency problems in the U.S. healthcare system is likely to be a fruitful avenue for future research. For example, Cutler and Ly (2011) remarks that “insurers have little incentive to coordinate their credentialing and billing requirements, because the costs of imposing different rules are spread across insurers as a whole, not partitioned to any single insurer,” leading to persistently high administrative expenses.

http://www.nber.org/…

Comment:

By Don McCanne, M.D.

You do not have to be an economist to understand an important conclusion of this technical paper. Our complex multi-payer financing system results in persistently high administrative expenses.

In a health care system with multiple payers, sticking points result in the ubiquity of fee-for-service contracting arrangements outside of Medicare; problematic care coordination; and the historic reliance on small single-specialty practices rather than larger multi-specialty group practices to deliver care. The costs of imposing different rules are spread across insurers as a whole, not partitioned to any single insurer, leading to persistently high administrative expenses.

Rather than trying to understand and apply the economic theory of the common-agency model, Pareto-dominated contracts, sticking point equilibria, and the onerous quest for more efficient forms of contracting between multiple payers and providers, we can simply eliminate the multi-payer model by enacting a single payer national health program – an improved Medicare for all. That does away with the administrative excesses and inequities of the sticking points that would never be totally eliminated in a multi-payer system.

Mayo discriminates against Medicaid patients

Mayo to give preference to privately insured patients over Medicaid patients

By Jeremy Olson
StarTribune, March 15, 2017

Mayo Clinic’s chief executive made a startling announcement in a recent speech to employees: The Rochester-based health system will give preference to patients with private insurance over those with lower-paying Medicaid or Medicare coverage, if they seek care at the same time and have comparable conditions.

Mayo will always take patients, regardless of payer source, when it has medical expertise that they can’t find elsewhere, said Dr. John Noseworthy, Mayo’s CEO. But when two patients are referred with equivalent conditions, he said the health system should “prioritize” those with private insurance.

“We’re asking … if the patient has commercial insurance, or they’re Medicaid or Medicare patients and they’re equal, that we prioritize the commercial insured patients enough so … we can be financially strong at the end of the year to continue to advance, advance our mission,” Noseworthy said in a videotaped speech to staff late last year.

Mayo reported a sharp increase in the amount of unreimbursed costs related to Medicaid patients, from $321 million in 2012 to $548 million in 2016. The figures include its campuses in Arizona and Florida. Mayo nonetheless remained profitable in 2016, with income of $475 million.

(Allan Baumgarten, a Twin Cities health analyst) added that complaints about the rise in Medicaid patients should be tempered by the corresponding decline in uninsured patients. “Aren’t you better off having bad payment through Medicaid compared to next to nothing from a patient who is uninsured?” he asked.

http://www.startribune.com…

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Cherry-picking patients? Mayo Clinic aims to ‘prioritize’ privately insured

By Elizabeth Whitman
Modern Healthcare, March 20, 2017

Late last year, CEO John Noseworthy had a message for the staff of the Mayo Clinic: We want patients with commercial insurance over Medicare or Medicaid.

For the Mayo Clinic health system to articulate its preference for patients with commercial insurance, which pays better than government insurance, was disappointing and surprising, said Arthur Caplan, head of the bioethics division at NYU Langone Medical Center.

“A cornerstone of our ethical thinking is you get the same care whether you’re rich or you’re poor, and we don’t triage by the size of your wallet,” Caplan said.

Noseworthy’s statement was a rare articulation of a broader trend – trying to make up for losses from Medicare or Medicaid patients with commercially insured patients – that the industry tends to try to conceal.

“I’ve heard of hospitals trying to do this behind the scenes, but I’ve never heard anybody say it up front,” Caplan said. “This statement is taking that dirty secret and bringing it into the open.”

http://digital.modernhealthcare.com

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Comment:

By Don McCanne, M.D.

The mission of our health care delivery system should be to provide everyone with the highest quality care possible within the limits of the finite resources available. That is an opinion not shared by all. The fact is that the mission of some sectors of our health care delivery system is to maximize revenues, and that may mean that patients of limited resources without generous public or private insurance coverage would be avoided by them.

This is a view not often expressed in public. In fact, Mayo’s CEO expressed it only in private to Mayo employees. But from decades of my exposure to conversations in physician dining rooms and locker rooms and in confidential board meetings, you can be assured that it is an exceptionally prevalent view, particularly regarding Medicaid, uninsured, and undocumented patients. This reality drives many of us to carry on the fight for an equitable system that serves everyone well.

Under a well designed single payer system in which payment is the same for all and capital improvements are distributed efficiently and equitably, everyone would have access to the highest quality care available within the limitations of our resources. We must intensify our advocacy efforts because we are a long, long way from that ideal.

American Physicians Want Medicare for All

By Ed Weisbart, M.D.
LinkedIn, March 20, 2017

Why do so many physicians prefer single payer national health insurance? The answer is simple: we are on the front lines, seeing the needless suffering created by our current system, and we know the evidence points to a better way. We want to do better, and we know that requires a better system.

There is little more demoralizing than seeing the patient I saw the day before I wrote this piece. This was a 30 year-old construction worker who gradually began to have trouble with balance and cognition. He lost his steady job, lost the health insurance provided by that job, and finally presented with daily seizures. He was admitted, stabilized on an expensive antiepileptic regimen, and found to have a brain tumor. The hospital sent him home with a prescription that he could not afford to fill. He was instructed to file an application for public assistance, but navigating that process was beyond his increasingly limited cognitive abilities. He saw me at another hospital’s safety net clinic one month later, still having untreated daily seizures, and with nowhere to turn for further evaluation and treatment of his lesion.

Had he been insured, the first hospital would likely have completed his evaluation and offered definitive treatment. Instead, he was sent home with an unaffordable prescription, no follow-up plan, and continued daily seizures. It breaks my heart to see someone in America unable to get life-saving healthcare due to insurance barriers.

We each have endless stories like this, we have to take them in stride, but they corrode our passion for medicine. We want to be proud of the system we’ve built, but instead we see tragedies that should never happen. And we know there is a better way.

Physicians in nations that have adopted single payer systems are shocked when they hear such stories from us. They know that medicine is hard enough without the financial barriers and confusing paperwork we impose on care.

Physicians in those nations have no need to assess the economic value or liability their patients represent to their practice, spend far less time on non-clinical administration, have comparable earning potential, and are proud of their nations’ health outcomes. Small wonder so many of us support single payer.

American physicians are an unhappy lot. Other than German physicians, we’re the least satisfied in the modern world.1 One recent time/motion study suggested that we spend 48% of our time on our electronic health records and other desk work, and only 26% of our time with patients.2 Our career satisfaction inversely correlates with the hours we spend on non-clinical documentation and communication. Our most satisfied physicians average eight such weekly hours, and it gets worse after that.3 We’re unhappy because we know this is not necessary: Canadian family physicians average 2.4 hours per week on non-clinical administrative tasks.4

It’s easier to practice in Canada, and it’s also less expensive. Our practices’ overhead average 55% of our revenue;5 Canadians’ average 28.2%.6 In part this is because we absorb extraordinary costs for insurance billing and administration,7 and in part because Canadian malpractice insurance is dramatically less expensive.8 In Missouri, where I practice, the typical single physician practice has over $200,000 in accounts receivable, averaging nearly 12 months old.9 This is unheard of in single payer nations like Canada.10 At the end of the day, the average fee for service billings per full time Canadian physician was $337,767 in 2014 (Canadian dollars), with family physicians at $271,417, Internal Medicine at $378,468, Pediatrics at $292,242, and OB-Gyne at $405,504.11

Perhaps this explains the increased migration of American physicians into Canada since 2006,12 and the net repatriation of Canadian physicians since 2004.13 Or perhaps it’s because of the broader societal impact of a system modeled on universal access as compared to one modeled on managed care. Notice that these patterns preceded the enactment of the Affordable Care Act.

In 1971, President Richard Nixon signed into law the HMO Act, creating our managed care movement. At roughly the same time, Canada’s national health insurance was fully implemented across all provinces. Prior to 1971, outcomes in our two nations were remarkably similar. We were both spending roughly the same 6% of our GDP on healthcare and following the same overall cost trends. Our life expectancies were within one year of each other. Since 1971, our paths have diverged. Canadians now spend roughly half of what we spend,14 and live nearly three years longer than we do.15 They have fewer unmet health needs than we do; theirs are largely due to waiting lists, ours to unaffordable costs. Anecdotal evidence aside, we must remember that Canadian waiting lists are generally not for life-threatening concerns or their life expectancies would not now be so much better than ours.16 We were the same, we adopted different models, and now we are quite different.

There is a bill in the US Congress, HR676, that would improve the problems with Medicare (financial barriers, gaps in benefit design, and needless bureaucracy) and provide that to all Americans. Twenty-five analyses at the state and federal level confirm that the new savings of such a strategy would easily pay for the new expenses.17 It is a matter of political will, not economics.

To learn more, join Physicians for a National Health Program (www.pnhp.org), the non-profit organization of more than 20,000 physicians, medical students and others who support single-payer national health insurance.

Dr. Ed Weisbart is chair of Physicians for a National Health Program — Missouri chapter.

https://www.linkedin.com…

Endnotes

1. http://www.commonwealthfund.org…

2. Sinsky et al. Ann Int Med 9/6/2016

3. Woolhandler & Himmelstein. Int J Health Serv. 2014;44:635

4. 2013 National Physician Survey. CFPC, CMA, Royal College; http://www.cma.ca…

5. http://medicaleconomics.modernmedicine.com…

http://www.merritthawkins.com…

6. http://www.cmpa-acpm.ca

7. Jiwani et al. BMC Health Services Research 2014, 14:556 at http://www.biomedcentral.com…

8. Canadian Medical Protective Association at http://www.cmpa-acpm.ca

9. Private communication with Missouri State Medical Association

10. Glauser, W. Canadian Medical Association Journal. June 19, 2014

11. Canadian Institute for Health Information

12. https://www.cma.ca…

13. https://www.cma.ca…

14. Statistics Canada, Canadian Inst. for Health Inf., and NCHS/Commerce Dept.

15. http://stats.oecd.org…

16. NBER Joint Canada / US Survey of Health; http://www.nber.org… Table 12

17. https://www.pnhp.org…

Repeal or replace? Wrong question

Offer Medicare’s single-payer system to all

By Jonathan D. Walker, M.D.
Fort Wayne Journal Gazette, March 19, 2017
In my specialty of retinal diseases, we can do much more to treat blindness than even 10 years ago. But if patients don’t come in, we can’t help them.

Unfortunately, going to the doctor in America can be scary – there are confusing rules, networks, copays and deductibles, and they all change depending on which policy you have this year. I can’t tell you how many times I see patients who have lost vision permanently because they were afraid to get checked, or how many times I offer to write off a bill so patients will show up and we can save their vision.

In the meantime, our politicians are arguing over repealing and/or replacing the Affordable Care Act (”Obamacare”), which is like arguing over which thermometer to use when a patient is dying of septic shock. Obamacare is a Band-Aid placed over our dysfunctional health care system. We need to push the reset button and look at things in a completely different way.

And that different way is called single-payer, where instead of multiple payers – you, your employer, the government, different insurance companies – we all put money into the same pot that then pays doctors and hospitals. Medicare is our single-payer national insurance for people over 65, and we all pay into it so they can get the care they need without going bankrupt. But the rest of us are forbidden to use that insurance. A single-payer system would simply expand Medicare, and improve it, so that we can all have a basic level of coverage.

The February issue of Annals of Internal Medicine has an article explaining the advantages of such a system. People would have access to the care they need, without the confusing rules and networks. There would be no exclusions for pre-existing conditions, and we would be freed from the massive administrative costs caused by our complex system. Nor would we have to pay money to for-profit insurance companies for executive salaries, advertising, underwriting, and all those other costs that have nothing to do with providing care.

Of course, there would be increased costs to Medicare, but those costs would be more than offset by the savings on administration and overhead. We might even begin to pay attention and fix public health problems that drive up costs. Or we might actually do something about special-interest groups that cost us so much money – for instance, the way the pharmaceutical industry had Congress pass a law that forbids Medicare to bargain over drug prices.

In his 2000 book “The America We Deserve,” Donald Trump said that “We need, as a nation, to re-examine the single-payer plan.” And, in an interview the same year, he said, “I would put forth a comprehensive health care program and fund it with an increase in corporate taxes.” Since then, he says he doesn’t favor single payer, but as recently as an interview in 2015, he praised both the Canadian and Scottish health care systems.

Indeed, businessmen are looking at single payer as a way of freeing themselves of the burden of providing insurance to employees and allowing themselves to concentrate on what they do best: run their business.

In spite of these possibilities, a single-payer system is something that we don’t even talk about. It is dismissed as too expensive or not politically feasible. It is neither of those things – the savings would outweigh the costs, and a recent Gallup poll showed that 58 percent of Americans favor replacing Obamacare with a federally funded health care system. But every time politicians dismiss the idea, you are going to continue to pay thousands of dollars more for your care than you need to, and you are going to increasingly worry about networks, copays and deductibles when you see a doctor.

Now, even though there is a lot of data that indicates the benefits of single payer, some people find the idea impossible to consider. (I’m sure there will be some irate letters in response to this op-ed, and I’ve even been asked to hire off-duty police in order to talk about the subject in case fights broke out. At a church!) But there is one thing that is indisputable: we need to at least include the idea of single payer in any discussion about how to fix our system – it has too many advantages for politicians to continue to ignore it.

So as you find yourself paying more and more for health care, take a minute to explore the subject for yourself. Go to the Physicians for a National Health Program website (www.pnhp.org), and look at the FAQ section; it only takes about 20 minutes. You may realize that we’ve been pointing our health care system in the wrong direction for so long that we can’t see – let alone talk about – a real solution.

Jonathan D. Walker, M.D., is a retinal surgeon and assistant clinical professor with the Indiana University School of Medicine in Fort Wayne. He wrote this for The Journal Gazette.

http://www.journalgazette.net…

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…

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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.