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The Choice Ahead: A Private Health-Insurance Monopoly Or A Single Payer

The Choice Ahead: A Private Health-Insurance Monopoly Or A Single Payer

By Robert Reich
The Huffington Post, July 6, 2015

The Supreme Court’s recent blessing of Obamacare has precipitated a rush among the nation’s biggest health insurers to consolidate into two or three behemoths.

The result will be good for their shareholders and executives, but bad for the rest of us – who will pay through the nose for the health insurance we need.

We have another choice, but before I get to it let me give you some background.

Last week, Aetna announced it would spend $35 billion to buy rival Humana in a deal that will create the second-largest health insurer in the nation, with 33 million members.

The combination will claim a large share of the insurance market in many states – 88 percent in Kansas and 58 percent in Iowa, for example.

A week before Aetna’s announcement, Anthem disclosed its $47 billion offer for giant insurer Cigna. If the deal goes through, the combined firm will become the largest health insurer in America.

Meanwhile, middle-sized and small insurers are being gobbled up. Centene just announced a $6.3 billion deal to acquire Health Net. Earlier this year Anthem bought Simply Healthcare Holdings for $800 million.

Executives say these combinations will make their companies more efficient, allowing them to gain economies of scale and squeeze waste out of the system.

This is what big companies always say when they acquire rivals.

Their real purpose is to give the giant health insurers more bargaining leverage over employees, consumers, state regulators, and healthcare providers (which have also been consolidating).

The big health insurers have money to make these acquisitions because their Medicare businesses have been growing and Obamacare is bringing in hundreds of thousands of new customers. They’ve also been cutting payrolls and squeezing more work out of their employees.

This is also why their stock values have skyrocketed. A few months ago the Standard & Poor’s (S&P) 500 Managed Health Care Index hit its highest level in more than twenty years. Since 2010, the biggest for-profit insurers have outperformed the entire S&P 500.

Insurers are seeking rate hikes of 20 to 40 percent for next year because they think they already have enough economic and political clout to get them.

That’s not what they’re telling federal and state regulators, of course. They say rate increases are necessary because people enrolling in Obamacare are sicker than they expected, and they’re losing money.

Remember, this an industry with rising share values and wads of cash for mergers and acquisitions.

It also has enough dough to bestow huge pay packages on its top executives. The CEOs of the five largest for-profit health insurance companies each raked in $10 to $15 million last year.

After the mergers, the biggest insurers will have even larger profits, higher share values, and fatter pay packages for their top brass.

There’s abundant evidence that when health insurers merge, premiums rise. For example, Leemore Dafny, a professor at the Kellogg School of Management at Northwestern University, and his two co-authors, found that after Aetna merged with Prudential HealthCare in 1999, premiums rose 7 percent higher than had the merger not occurred.

The problem isn’t Obamacare. The real problem is the current patchwork of state insurance regulations, insurance commissioners, and federal regulators can’t stop the tidal wave of mergers, or limit the economic and political power of the emerging giants.

Which is why, ultimately, American will have to make a choice.

If we continue in the direction we’re headed we’ll soon have a health insurance system dominated by two or three mammoth for-profit corporations capable of squeezing employees and consumers for all they’re worth – and handing over the profits to their shareholders and executives.

The alternative is a government-run single payer system – such as is in place in almost every other advanced economy – dedicated to lower premiums and better care.

Which do you prefer?

Robert Reich is Chancellor’s Professor of Public Policy at the University of California at Berkeley. He has served in three national administrations, most recently as secretary of labor under President Bill Clinton. He has written thirteen books, including “The Work of Nations”, “Locked in the Cabinet,” “Supercapitalism,” and his most recent book, “Aftershock.” His “Marketplace” commentaries can be found on publicradio.com and iTunes. He is also Common Cause’s board chairman. His website is: http://robertreich.org

http://www.huffingtonpost.com/robert-reich/private-health-insurance-monopoly-or-single-payer_b_7734742.html

Medicare for All would end fighting over ACA

By Pamella Gronemeyer, M.D.
St. Louis Post-Dispatch, Letters, July 2, 2015

As a physician, I felt compelled to write a letter concerning the King v. Burwell case decision announced last week. The Supreme Court upheld the right for citizens of all states to benefit from the federal subsidies.

While Chief Justice John Roberts did not state that health care is a human right, he did state that the purpose of the Affordable Care Act was “passed to strengthen insurance markets, not destroy them.”

This decision magnifies the poor decision made by many states, including Missouri, to not accept the Medicaid option. By refusing to take the federal subsidy, the states leave a large number of people who earn salaries around the poverty level not eligible for either subsidies or Medicaid. The first thing that should happen is these states should reconsider the health and welfare of their citizens rather than the gamesmanship of politics and accept the Medicaid expansion.

The King v. Burwell decision does not mean that many physicians, nurses, health care workers, labor unions and average Americans will stop working for Medicare for All, a single-payer health care system, which would insure that all Americans would receive health care (not just insurance coverage) from birth until death.

The ACA is incredibly complex and still relies on a multitude of third-party payers providing a variety of plans with a mélange of different, unequal benefits. There will still be 24 million uninsured people in the United States if every state accepted the Medicaid option. Single-payer would slash the administrative bloat in our private-insurance-based system and would allow us to pay for health care, not insurance. It is the only way that we can curb the still rising costs of health care.

The legality of the Medicare system has already been tested. It will be 50 years old this year. Currently Medicare covers the 20 percent of the population who require 80 percent of the cost of health care in the United States. Medicare for All would put an end to the efforts that will still be ongoing by some politicians to destroy or repeal the ACA legislatively.

Dr. Pamella Gronemeyer resides in Glen Carbon, Ill.

http://www.stltoday.com/news/opinion/mailbag/medicare-for-all-would-end-fighting-over-aca/article_1864faab-a0d9-5718-b42d-0a34d3b01209.html

Cream skimming under “perfect” risk scoring

Beyond Statistics: The Economic Content of Risk Scores

By Liran Einav, Amy Finkelstein, Raymond Kluender, and Paul Schrimpf
National Bureau of Economic Research, June 2015, NBER Working Paper No. 21304

From the Conclusions

Our objective in this paper was to highlight the fact that risk scores that are commonly used in credit and insurance markets are not merely statistical objects, as they are generated by economic behavior. We illustrated this point empirically in the specific context of Medicare Part D, the public prescription drug insurance program that covers over 30 million individuals, and explored their implications theoretically. We exploited the famous “donut hole” where insurance becomes discontinuously much less generous at the margin.

Using this research design, we empirically illustrated two conceptual points. First, analyzing the average demographic and health characteristics of individuals as a function of annual drug spending, we showed that spending differences across individuals reflect not only heterogeneity in underlying health but also heterogeneity in the underlying behavioral response to the insurance contract. Second, we show that the current (statistical) risk scores – which are designed to predict spending under a given contract – do not capture this second dimension of heterogeneity.

In the second part of the paper, we use a highly stylized theoretical example to explore some of the potential implications of these findings for the standard use of risk scores: to predict outcomes out of sample under other contracts and use these predictions to set reimbursement rates. We showed that standard risk scoring can create incentives for private insurers to cream-skim individuals whose (unpriced) behavioral response to the contract they offer will make them lower cost than what is predicted by the risk score that was generated under a different contract. A key point is that, when there is heterogeneity in the behavioral response to the contract, these cream-skimming incentives can still exist even in the presence of “perfect” risk scoring under a given contract.

http://www.nber.org/papers/w21304

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Comment:

By Don McCanne, MD

A innate characteristic of a fragmented, multi-payer system of health care financing is that health risks vary between insurance pools, creating an opportunity for private insurers to profit by cream skimming healthier population subsets. Risk scoring is used to compensate for this heterogeneity, but this study shows that even when risk scoring is “perfect” under current standards, opportunities for cream skimming still exist.

A single payer system creates a single “homogenized” risk pool which eliminates cream skimming – another compelling reason to dismiss the private insurers and expand an improved version of Medicare to cover everyone.

Is it time to nationalize the drug industry?

Novartis to test new pricing model with heart failure drug

By Ben Hirschler
Reuters, June 30, 2015

Novartis plans to test a novel pricing model with some customers when it launches its keenly awaited new heart failure drug Entresto, the Swiss company’s head of pharmaceuticals said on Tuesday.

Entresto, also known as LCZ696, is the first new drug in decades for helping patients whose lives are in danger because their hearts cannot pump blood efficiently. As a result, it is widely expected to generate billions of dollars in annual sales.

How the product should be priced, however, is a dilemma for Novartis, since the company wants to reach as many patients as possible and it knows it will be competing with very cheap – though less effective – older medicines.

David Epstein said he was talking to several healthcare customers about a system under which they would get the drug at a discount but then pay Novartis more if, as expected, it successfully reduces the need for costly hospital visits.

“We are beginning to share the risk,” he said in an interview.

The idea of moving from a simple pay-per-pill model to one based on clinical outcomes is being considered by several drugmakers, and Novartis already has such a system in place for one customer using its multiple sclerosis drug Gilenya.

But Entresto could be an important test case because the drug will push up immediate drug costs markedly for a large number of patients, while having the potential to reduce their long-term medical bills.

The issue of drug pricing has come to a head recently, thanks to the launch of extremely expensive new medicines for cancer and hepatitis C, which are straining healthcare systems and adding to co-payment costs for patients.

Epstein, whose team is in the final stages of deciding the price for Entresto, declined to detail a likely cost per pill. But he said it would take into account “cost offsets”, such as fewer hospitalizations, as well as the value added from improving patients’ lives.

“We going to try and be fair and reasonable,” he said.

http://in.reuters.com/article/2015/06/30/us-novartis-heart-idINKCN0PA1N720150630

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Cost-Offsets of Prescription Drug Expenditures: Data Analysis Via a Copula-Based Bivariate Dynamic Hurdle Model

By Partha Deb, Pravin K. Trivedi and David M. Zimmer
Health Economics, October 2014

Summary

In this paper, we estimate a copula-based bivariate dynamic hurdle model of prescription drug and nondrug expenditures to test the cost-offset hypothesis, which posits that increased expenditures on prescription drugs are offset by reductions in other nondrug expenditures. We apply the proposed methodology to data from the Medical Expenditure Panel Survey, which have the following features: (i) the observed bivariate outcomes are a mixture of zeros and continuously measured positives; (ii) both the zero and positive outcomes show state dependence and inter-temporal interdependence; and (iii) the zeros and the positives display contemporaneous association. The point mass at zero is accommodated using a hurdle or a two-part approach. The copula-based approach to generating joint distributions is appealing because the contemporaneous association involves asymmetric dependence. The paper studies samples categorized by four health conditions: arthritis, diabetes, heart disease, and mental illness. There is evidence of greater than dollar-for-dollar cost-offsets of expenditures on prescribed drugs for relatively low levels of spending on drugs and less than dollar-for-dollar cost-offsets at higher levels of drug expenditures.

http://onlinelibrary.wiley.com/doi/10.1002/hec.2982/abstract

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Comment:

By Don McCanne

With the marketing success of outrageously priced drugs, the pharmaceutical industry is now devising schemes to be sure that their new products that are protected by patents will continue to be introduced with similar outrageous prices. This concept of adding “cost offsets” to the pricing is not new, but it now has a label that supposedly legitimizes its inclusion in pricing decisions.

In the past, pharmaceutical firms have cited the high costs of drug research as an excuse for high prices of new products (though the high prices of the past were nothing compared to the five and six digit prices of today’s new products). As the public discovers that the drug industry’s advertising budgets are typically three times their research budgets, and much of the research is funded through government programs such as those of the NIH, the firms apparently have decided that this argument is no longer as persuasive, and so they have to find another reason to justify outrageous pricing.

“Cost offsets” is a convenient label for adding to the the research, marketing, administration and profit costs of the products. These “cost offsets” include such concepts as money saved by fewer hospitalizations, fewer expensive interventions for progression of disease processes, and for the added value of prolonged lives or the added value of higher quality lives.

Think about that. What gall it takes for these pooh-bahs of the pharmaceutical world to suggest that they are entitled to capture, for themselves, not just the costs and legitimate profits, but the value of the benefits of their products, through higher consumer prices, whether paid individually or through some form of public or private insurance.

This perverse type of thinking is not limited to Novartis’ David Epstein. Bayer’s Marijn Dekkers 18 months ago said, about their expensive cancer drug, Nexavar, “we did not develop this product for the Indian market – let’s be honest – we developed this product for Western patients who can afford this product, quite honestly.” 

Perhaps more despicable is this entry from a draft of the infamous Trans-Pacific Partnership Agreement, which contains the following in its statement of principles: “(d) the need to recognize the value of pharmaceutical products and medical devices through the operation of competitive markets or by adopting or maintaining procedures that appropriately value the objectively demonstrated therapeutic significance of a pharmaceutical product or medical device.”

Not only did the pharmaceutical industry buy off Congress when they went the route of the market-based Affordable Care Act instead of an efficient single payer Medicare for all, they have demonstrated to us that their primary goal is to achieve the greatest returns for their executives and shareholders no matter the cost to the ultimate consumers – the patients.

There could not be an industry that cries out more for government intervention to protect consumers than the pharmaceutical industry (oh wait, the private insurance industry, of course, but that’s another topic). Many suggest that it is time to demand negotiation of drug prices, or even to dictate fair prices. But should that be our opening position? How about calling for nationalization of the industry, at least their U.S. subsidiaries. That should get their attention. They have to know that we’re serious about wanting relief from their greed.

The Fight Over Obamacare Was a Giant Political Charade

By Sonali Kolhatkar
Truthdig, July 2, 2015

When the U.S. Supreme Court ruled on June 25 that the Affordable Care Act’s (ACA) subsidies for health insurance for the poor were indeed constitutional, liberals cheered. The last-ditch attempt by the right to gut President Obama’s signature act failed. In his weekly address, Obama triumphantly announced that “after more than 50 votes in Congress to repeal or weaken this law; after a presidential election based in part on preserving or repealing this law; after multiple challenges to this law before the Supreme Court, we can now say this for certain: the Affordable Care Act still stands, it is working, and it is here to stay.”

The case at the heart of the ruling was King v. Burwell, a legal challenge that was based on a technicality. The Los Angeles Times explained that legal experts saw it “as a fatuous misreading of the law and a tortured effort to bend the process of statutory interpretation for ideological ends.” But the constant attacks on the ACA, including this last attempt, were less ideological than political, and in the end, the Supreme Court ruling was an affirmation of the supremacy of capitalism over human needs.

It is true that 6.4 million Americans currently receiving subsidies for insurance would have lost their coverage had the court not voted to preserve the ACA. The vote was 6-3, with conservative Chief Justice John Roberts joining swing voter Anthony Kennedy and the four liberal stalwarts (Sonia Sotomayor, Elena Kagan, Ruth Bader Ginsburg, and Stephen Breyer). The fact that Roberts voted for it, and wrote the majority opinion, speaks volumes about what the ruling really means. According to him, “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.”

That single sentence clearly lays out the problem with what the right has sardonically named “Obamacare.” In voting to preserve the health care reform law, the court sought to “improve health insurance markets,” not access to health care.

Paul Y. Song is the executive chairman of the Courage Campaign, executive board member of Physicians for a National Health Program, and co-chair of Campaign for a Healthy California. He told me in an interview on Uprising that “this was really less about protecting patients and more about protecting the health insurance industry, hospitals and all of the medical corporations.” The subsidies at stake are our tax dollars filling the coffers of private corporations in exchange for profit-based “managed care.”

As Michael Moore wrote, “Obamacare is awful. That is the dirty little secret many liberals have avoided saying out loud for fear of aiding the president’s enemies.”

Song concurred, saying, “This is less of a government-run program, but it’s a corporate bailout. It really is giving people money to buy a product from a for-profit industry that only makes money by denying care.”

The right-wing attacks on Obamacare were always about attempting to delegitimize the president rather than the actual substance of a pro-corporate health reform law. Indeed, Republicans long ago suggested similar reform proposals, such as the health exchanges, to those at the heart of the ACA. “Had anyone else proposed this,” said Song, “I think the Republicans would have said, ‘Wow this is a great idea.’”

The GOP’s relentless attacks on the ACA left progressives in the awkward position of having spent the last five years defending a pro-corporate law that the right would have ordinarily salivated over. As Michael Moore wrote in the New York Times, “Obamacare is awful. That is the dirty little secret many liberals have avoided saying out loud for fear of aiding the president’s enemies.”

When the Supreme Court ruled to preserve the ACA, privately some Republicans expressed relief, knowing that if 6.4 million Americans relying on subsidies had suddenly lost them, the GOP would have paid a stiff political price.

The act of opposing the law at any cost has given Republicans legitimacy among their right-wing supporters for targeting Obama while ultimately getting what they want, which is a pro-corporate law. For Democrats, supporting Obamacare has given them the appearance of caring about medical bankruptcies and the plight of the uninsured. And Obama has won by achieving the seemingly impossible task of passing health care reform, while also propping up private industry. In the end, the fight over the ACA has resulted in wins for the Republican Party, the Democratic Party, the health insurance industry and the president.

Among the losers are Americans who remain dependent on their employers for health insurance, and those who have bought plans from the ACA’s exchanges but pay through the nose for minimal coverage. Even plans available to those who used to be denied them because of pre-existing conditions are expensive and the deductibles extremely high.

Most unfortunate of all are the nearly 13 percent of Americans who remain uninsured. Song pointed out that “the one thing that Democrats and Republicans could agree on was to exclude our undocumented brothers and sisters.” It’s no surprise that Latinos are among the least insured communities in the nation.

Compared with the lack of regulations that the health insurance industry used to enjoy, Obamacare has imposed some minimal limits. But in the end, it leaves companies stronger than ever, as evidenced by the buoyancy of insurance stocks in the aftermath of the Supreme Court ruling.

In other words, Obamacare is a win for the 1 percent, and a loss for the rest of us.

Our health care system places an entirely needless middleman between us and our doctors, whose sole function is to vacuum up as many dollars as possible in the interest of capital enterprise. But if our interest is health care, a simpler equation is in order. It goes by the innocuous name of “single-payer health care,” and it takes the elegant form of “tax dollars in, health care out.“

Given the long-drawn-out fight Obama had over a pro-corporate law secretly favored by Republicans, he might have been better off expending his energy on passing a Medicare-for-all bill.

Thankfully, Obamacare’s provision allowing states to design their own health care systems starting in 2017 could result in state-by-state adoptions of single-payer systems. California has twice passed legislation that would have established a single-payer system, only to be vetoed by Republican Gov. Arnold Schwarzenegger in 2006 and 2009. Activists like Song are determined to build momentum toward that end in the next two years.

As Obama, in his weekly address, said of the Supreme Court ruling, “We strive to do better, to be better, than the generation before us, and we try to build something better for the generation coming behind us. With this behind us, let’s come together and keep building something better right now.”

Those words ring true: Obamacare is not good enough to pass to the next generation. It’s time to build something much better.

Sonali Kolhatkar is the founder, host, and producer of KPFK Pacifica’s popular morning drive time program Uprising, based in Los Angeles.

http://www.truthdig.com/report/item/the_fight_over_obamacare_was_a_giant_political_charade_20150702

Healthcare financing study bill clears difficult hurdle with $300,000

A study first conceived by Sen. Michael Dembrow in 2013 that passed without funding, has repassed with $300,000 in state money after private donations came up short. Support for the study has a bipartisan history, but as a thorough and objective study comes closer to a reality, the political pressure mounts against it. The state money, however, is enough for the study to move forward.

By Chris Gray
The Lund Report (Portland, Ore.), July 1, 2015

The Oregon universal healthcare financing study bill cleared the top budget committee after a contentious hearing Monday, with $300,000 attached to design the best way of financing a universal healthcare system in Oregon.

House Bill 2828 has been a top priority of Sen. Michael Dembrow, D-Portland, as well as single-payer activists, who believe it will lead to their preferred method of healthcare financing system through a government-managed health insurance plan. But the bill specifically asks for an objective study weighing four options, pointedly not recommending any option such as single payer.

The hearing was subject to an array of misinformation about the bill, perhaps the result of behind-the-scenes pressure from the hospital and insurance industry lobbies, which could stand to lose millions if Oregon adopted single-payer. Now, a substantial amount of money spent by government and Oregon businesses intended for patient care is being diverted to industry profits and lucrative salaries for hospital management even at non-profit hospitals.

In particular, Sen. Betsy Johnson, D-Scappoose, who had previously supported an unfunded study in 2013, joined all but one of the Republicans in opposing HB 2828 in the Ways & Means Committee, telling her colleagues she was worried that private money could bias the outcome, since the study was projected to cost twice as much as the state allocation — $600,000 — and was relying on private sources for the reminder.

“What I’m worried about is a tsunami of private contributions that could come flooding in to influence the outcome,” Johnson posited.

“I would be a yes if I thought the study would be objective, but I don’t see there’s any way,” said Sen. Fred Girod, R-Stayton, a dentist. “I think right now we’re a bunch of lemurs heading off the cliff, and you’re going to have a bunch of lemurs doing the study.”

In fact, HB 2828 came about because that unfunded 2013 study only attracted about $50,000 in pledges and donations, too little to do a study. As Dembrow explained later to The Lund Report, the $300,000 in state money will be enough for the Oregon Health Authority to move forward with the study. And if any additional private donations were to influence the outcome, it would defeat the purpose of the study and discredit the outcome, which is informational and non-binding.

“I think we will be prepared to go forward with the study with the $300,000, and money we’ve already raised. The more we put into the study, the more the researchers will be able to answer,” Dembrow said. “The results of the study won’t do any good if they’re perceived to be tainted. We’re hoping it will put forward credible, Oregon-focused information.”

“That’s enough to do a good study,” agreed Dr. Sam Metz, a Portland anesthesiologist who has had the difficult task of soliciting private funds since 2013. “Most of the Legislature who are aware of the study know that it’s a value.”

Dembrow said since a lot of scholarship has already been completed on healthcare financing in the United States, the researchers could piggyback on that work, although with more money, they could do a more thorough analysis. The study could possibly be conducted by healthcare researchers at Oregon State University,by another university or by health financing experts at a private firm such as Wakely Consulting, but any contract would be awarded through an open bidding process.

The concept for a study has a much more bipartisan history than what appeared at Monday’s hearing, when just one Republican, Sen. Jackie Winters of Salem, supported the measure. In 2013, Johnson as well as two Republicans who are now on the Ways & Means Committee supported an unfunded predecessor health financing study, Sen. Bill Hansell of Pendleton and Rep. Gene Whisnant of Sunriver.

On the floor, Republicans such as Sen. Jeff Kruse of Roseburg and Rep. Andy Olson of Albany had supported House Bill 3460, paying deference to part of the study that will look at a bare-bones universal health coverage plan that could potentially be funded by a sales tax — a longtime goal of former Sen. Frank Morse, a progressive Republican from Albany. It also had the support of 2014 GOP gubernatorial candidate Rep. Dennis Richardson of Central Point.

https://www.thelundreport.org/content/healthcare-financing-study-bill-clears-difficult-hurdle-300000

Capital District Alliance for Universal Healthcare to celebrate Medicare’s 50th anniversary

By Danielle Sanzone
The Record (Troy, N.Y.), June 29, 2015

COHOES — A local committee is working to raise more awareness about Medicare in the hopes that the program will continue into the next decades and expand it to include all American citizens.

The organizing committee of the Capital District Alliance for Universal Healthcare is planning an event for July 30 in Cohoes to mark the 50 years that Medicare has been offered.

“We view Medicare as a very viable system for the country,” said Dr. Richard Propp, chair of the Capital District Alliance for Universal Healthcare.

Propp said it was a big victory this past state legislative session to have the Assembly approve single-payer healthcare.

“It’s a historic event,” he said, noting that, though the victory took years, he felt that it showed single-payer is inevitable in the Empire State.

Medicare is a national social insurance program, administered by the U.S. federal government since 1966, currently using about 30 private insurance companies across the United States. Medicare provides health insurance for Americans aged 65 and older who have worked and paid into the system. It also provides health insurance to younger people with disabilities, end-stage renal disease and amyotrophic lateral sclerosis. In 2010, Medicare provided health insurance to 48 million Americans — 40 million people age 65 and older and eight million younger people with disabilities, according to Wikipedia.

“It’s efficient,” said Herb Hyde with the organizing committee about Medicare. He cited the three percent overhead costs, compared with 13 to 20 percent overhead with insurance programs.

About 30 million people in the United States, nearly 10 percent of the population, are uninsured.

“We want the younger generation to have Medicare and Social Security,” said Hyde.

The group talked about how they feel an issue in the U.S. is that many insurance companies are for-profit, unlike years ago when groups such as Blue Cross were non-profit.

“I’m a retired teacher with a good pension. I can’t imagine how people are doing who have a low hourly rate,” said Karen Wojcik-Hess, president of the Capital District Chapter of the New York State Alliance for Retired Americans. “As our shirts say, we don’t want to be the last generation to retire.”

Hyde and the rest of the committee voiced concerns about misconceptions of the financial status of Social Security’s longevity when the program has more than $1 trillion.

“Medicare and Social Security are under assault. We want to have this Medicare celebration to bring more awareness of it,” added Hyde. “I worry about my grandchildren.”

The universal healthcare organization holds a Medicare event every year that’s similar to a birthday party, complete with a cake. Its first Medicare party was in 2005.

This year’s party, for the 50th anniversary, is July 30 at from noon to 2:30 p.m. at Canal Square in Cohoes. The event will include local stories, visits from some of the area politicians in support of the effort, and a history of Medicare.

Danielle Sanzone is a news reporter who covers Albany County and education for The Record. 

http://www.troyrecord.com/government-and-politics/20150629/capital-district-alliance-for-universal-healthcare-to-celebrate-medicares-50th-anniversary

Sound the alarm: The private insurance exchanges are coming!

Towers Watson merges with London-based consulting firm in $18 billion deal

By Aaron Gregg
The Washington Post, June 30, 2015

Towers Watson, the Arlington-based professional services company that operates a private health insurance exchange covering about 1.2 million people, announced an $18 billion all-stock merger with Willis Group Holdings, a London-based insurance and benefits firm.

The merger is the latest in a series of what Willis chief executive Dominic Casserley called “carefully targeted mergers and acquisitions” to expand his company’s international footprint. Last month, Willis Group acquired Evolution Benefits Consulting, a Pennsylvania health and welfare benefits advisory firm, and in late April it announced it would fully acquire Gras Savoye, one of France’s largest insurance brokerage firms.

Casserley said in a news release that the new company “will advise 80 percent of the world’s top-1,000 companies,” operating as a one-stop shop for large employers managing complex aspects of their human resources mix, benefits such as employer-provided health insurance and a range of other costs that affect companies’ bottom lines.

Because the new company will be based in Ireland, Towers Watson’s corporate tax rate will drop from 34 percent to a projected 25 percent.

This merger “is driven by business purpose, not from a tax planning standpoint but from serving customers,” said John Greene, chief financial officer of Willis. “The tax benefits that are derived just happen to be a nice consequence of the transaction.”

Towers Watson Chairman John Haley will lead the new company as chief executive, and Casserley will serve as president and deputy chief executive of the new company, which will operate under the name Willis Towers Watson.

Casserley said in a conference call that the merger was first conceived while Willis worked in partnership with Towers Watson on a health exchange.

The exchange “has rapidly grown to serve more than 1 million members in the United States,” Casserley said. “Many independent analysts believe that this is just the start, and that the business is at an inflection point, with the total market likely to grow significantly within five to seven years.”

http://www.washingtonpost.com/business/capitalbusiness/towers-watson-merges-with-london-based-consulting-firm-in-18-billion-deal/2015/06/30/747118e2-1f5a-11e5-aeb9-a411a84c9d55_story.html

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Comment:

By Don McCanne, MD

This mega-merger of benefits consulting firms is designed to capture the rapidly expanding market in private health insurance exchanges. Why should we be concerned?

The Affordable Care Act (ACA) was designed to protect the sectors of health care coverage that allegedly were functioning well – especially employer-sponsored health care plans. The greater changes enacted in ACA were aimed at the much smaller sector of dysfunctional individual and small group plans, plus expanding Medicaid for low-income individuals and families.

So how has it gone for the stable, well functioning employer-sponsored plans? Not so well. Even though there has been some slowing in the increase in health care costs, the increases have been in excess of inflation, and there appears to be a return to an accelerating pace of cost increases. Most employers are very concerned about the costs of their employee benefit packages, and they are already taking action to slow their nominal portion of the increases (though most economists contend that the employers’ portion is actually paid by the employees in forgone wage increases).

The most important measure already taken by many employers is to increase cost sharing, especially by requiring high deductibles that must be paid before most benefits kick in. This reduces the insurance premiums (or the contributions to the self-insured health trust) for the employer-sponsored plans since a significant portion of actual health care spending is shifted to the employees and their families. Other innovations such as tiering of drugs also shift more costs away from the employer. Plan beneficiaries also are reducing their utilization of beneficial health care services when they are exposed to high deductibles – a perverse disincentive that reduces spending.

The use of narrower provider networks also helps to reduce the employers’ contribution to health care payments. The employers’ representatives are able to contract for lower provider rates in exchange for a promise of oligopolistic exclusivity. Also the responsibility for payment of costs for care obtained outside of the networks is shifted almost entirely to the employees. In addition, providers known for managing expensive chronic disorders can be excluded from the networks, impairing the ability of patient beneficiaries to obtain the care that they need.

The employers are still not satisfied. Some are now beginning to implement the use of private insurance exchanges. In this model, the employer no longer offers an employer-sponsored health plan but instead provides the employee with a voucher or voucher-equivalent to purchase from a selection of plans in the private insurance exchanges. Since the value of the voucher is fixed, the employee must bear the additional costs of plans that have greater benefits. Thus this is a shift from a defined benefit program to a defined contribution program; by controlling the value of the voucher, the employer is able to shift much of the future health care cost increases onto the employees.

If you look at the insurance exchanges set up by ACA, you will see that the standard plans are low actuarial value plans. The benchmark silver plan has an actuarial value of 70 percent – the patient is responsible for paying an average of 30 percent of the costs (though many qualify for subsidies). The bronze plans have an actuarial value of only 60 percent. Employer-sponsored plans formerly had an actuarial value closer to 90 percent, but with the plans offered in the private exchanges, employees usually will select plans that the voucher will cover. This is a great opportunity for employers to gradually shift the value of the voucher so that it would cover 60 or 70 percent actuarial value plans, just like in the ACA exchanges (except that no government subsidies would be available for the private exchange plans).

This move to private insurance exchanges represents a tremendous business opportunity for benefits consulting terms, as today’s article indicates (not to mention offshoring to Ireland!) That’s just what we need: more administrative complexity and costs in our system already tremendously overburdened with administrative excesses. These benefits consulting firms are selling health insurance products without bearing any of the insurance risk of those products. The private insurers, with all of their administrative waste and insurance product perversions, remain prominent players in the system.

These benefits consulting firms tout choice. The employees are free to upgrade to a high actuarial value Cadillac health plan if they so desire. Little does it matter that most of them have hardly enough funds to be able to purchase a low actuarial value roller-skate health plan.

As if the deterioration in employer-sponsored plans has not already been enough, this switch to using a defined contribution voucher in private insurance exchanges will be a disaster for affordable health care for employees and their families.

Rather than accelerating the move toward private health insurance exchanges, we need to accelerate the transition to a single-payer improved Medicare for all program. Or do we just sit back and watch people go broke and suffer?

Healthcare financing study bill clears difficult hurdle with $300,000

A study first conceived by Sen. Michael Dembrow in 2013 that passed without funding, has repassed with $300,000 in state money after private donations came up short. Support for the study has a bipartisan history, but as a thorough and objective study comes closer to a reality, the political pressure mounts against it. The state money, however, is enough for the study to move forward.

By Chris Gray
The Lund Report (Portland, Ore.), July 1, 2015

The Oregon universal healthcare financing study bill cleared the top budget committee after a contentious hearing Monday, with $300,000 attached to design the best way of financing a universal healthcare system in Oregon.

House Bill 2828 has been a top priority of Sen. Michael Dembrow, D-Portland, as well as single-payer activists, who believe it will lead to their preferred method of healthcare financing system through a government-managed health insurance plan. But the bill specifically asks for an objective study weighing four options, pointedly not recommending any option such as single payer.

The hearing was subject to an array of misinformation about the bill, perhaps the result of behind-the-scenes pressure from the hospital and insurance industry lobbies, which could stand to lose millions if Oregon adopted single-payer. Now, a substantial amount of money spent by government and Oregon businesses intended for patient care is being diverted to industry profits and lucrative salaries for hospital management even at non-profit hospitals.

In particular, Sen. Betsy Johnson, D-Scappoose, who had previously supported an unfunded study in 2013, joined all but one of the Republicans in opposing HB 2828 in the Ways & Means Committee, telling her colleagues she was worried that private money could bias the outcome, since the study was projected to cost twice as much as the state allocation — $600,000 — and was relying on private sources for the reminder.

“What I’m worried about is a tsunami of private contributions that could come flooding in to influence the outcome,” Johnson posited.

“I would be a yes if I thought the study would be objective, but I don’t see there’s any way,” said Sen. Fred Girod, R-Stayton, a dentist. “I think right now we’re a bunch of lemurs heading off the cliff, and you’re going to have a bunch of lemurs doing the study.”

In fact, HB 2828 came about because that unfunded 2013 study only attracted about $50,000 in pledges and donations, too little to do a study. As Dembrow explained later to The Lund Report, the $300,000 in state money will be enough for the Oregon Health Authority to move forward with the study. And if any additional private donations were to influence the outcome, it would defeat the purpose of the study and discredit the outcome, which is informational and non-binding.

“I think we will be prepared to go forward with the study with the $300,000, and money we’ve already raised. The more we put into the study, the more the researchers will be able to answer,” Dembrow said. “The results of the study won’t do any good if they’re perceived to be tainted. We’re hoping it will put forward credible, Oregon-focused information.”

“That’s enough to do a good study,” agreed Dr. Sam Metz, a Portland anesthesiologist who has had the difficult task of soliciting private funds since 2013. “Most of the Legislature who are aware of the study know that it’s a value.”

Dembrow said since a lot of scholarship has already been completed on healthcare financing in the United States, the researchers could piggyback on that work, although with more money, they could do a more thorough analysis. The study could possibly be conducted by healthcare researchers at Oregon State University,by another university or by health financing experts at a private firm such as Wakely Consulting, but any contract would be awarded through an open bidding process.

The concept for a study has a much more bipartisan history than what appeared at Monday’s hearing, when just one Republican, Sen. Jackie Winters of Salem, supported the measure. In 2013, Johnson as well as two Republicans who are now on the Ways & Means Committee supported an unfunded predecessor health financing study, Sen. Bill Hansell of Pendleton and Rep. Gene Whisnant of Sunriver.

On the floor, Republicans such as Sen. Jeff Kruse of Roseburg and Rep. Andy Olson of Albany had supported House Bill 3460, paying deference to part of the study that will look at a bare-bones universal health coverage plan that could potentially be funded by a sales tax — a longtime goal of former Sen. Frank Morse, a progressive Republican from Albany. It also had the support of 2014 GOP gubernatorial candidate Rep. Dennis Richardson of Central Point.

https://www.thelundreport.org/content/healthcare-financing-study-bill-clears-difficult-hurdle-300000

Did you miss the important PNHP statement on the King v. Burwell decision?

‘Subsidies upheld, but health needs still unmet’: doctors group

Physicians for a National Health Program, June 25, 2015

Although the Supreme Court has upheld the premium subsidies under the Affordable Care Act, the law remains incapable of remedying the U.S. health crisis, physician group says

Physicians for a National Health Program, an organization of 19,000 doctors who support single-payer national health insurance, released the following statement today:

Today’s decision by the Supreme Court in King v. Burwell to uphold the Affordable Care Act’s premium subsidies in about three dozen states will spare more than 6 million Americans the health and financial harms associated with the sudden loss of health insurance coverage.

For that reason alone the decision must be welcomed: Having health insurance is better than not having coverage, as several research studies have shown.

That said, the suffering that many Americans are experiencing today under our current health care arrangements is intolerable, with approximately 35 million people remaining uninsured, a comparable number underinsured, and rapidly growing barriers to medical care in the form of rising premiums, copayments, coinsurance and deductibles, and narrowing networks.

The unfortunate reality is that the ACA, despite its modest benefits, is not a remedy to our health care crisis: (1) it will not achieve universal coverage, as it will still leave at least 27 million uninsured in 2025, (2) it will not make health care affordable to Americans with insurance, because of high copays, deductibles and gaps in coverage that leave patients vulnerable to financial ruin in the event of serious illness, and (3) it will not control costs.

Why is this so? Because the ACA perpetuates a dominant role for the private insurance industry. Each year, that industry siphons off hundreds of billions of health care dollars for overhead, profit and the paperwork it demands from doctors and hospitals; denies care in order to increase insurers’ bottom line; and obstructs any serious effort to control costs.

In contrast, a single-payer system – an improved Medicare for All – would achieve truly universal care, affordability, and effective cost control. It would put the interests of our patients – and our nation’s health – first.

Single payer is simple: everyone in the U.S. would be covered for all medically necessary care in a single program financed by equitable taxes.

By replacing multiple private insurers with a single, nonprofit agency like Medicare that pays all medical bills, we would save approximately $400 billion annually by slashing the administrative bloat in our current private-insurance-based system. That money would be redirected to clinical care. Copays, coinsurance and deductibles would be eliminated.

Further, such a single, streamlined system would be able to rein in costs for medications and other supplies through the system’s strong bargaining clout – again, to our patients’ benefit.

A single-payer system would also be legally robust.

Because of the ACA’s administrative complexity and flaws – largely reflecting its accommodation to the private health insurance industry and other corporate, profit-oriented interests in U.S. health care – it is particularly vulnerable to the kind of legal challenge we saw today.

Our patients, our people and our national economy cannot wait any longer for an effective remedy to our health care woes. The stakes are too high. We need to move beyond the administratively wasteful, complex and inadequate ACA to a more fundamental, rational single-payer national health program.

Contrary to the claims of those who say we are “unrealistic,” a single-payer system is within practical reach. The most rapid way to achieve universal coverage would be to improve upon the existing Medicare program – which is celebrating its 50th anniversary this year, showing it has stood the test of time – and expand it to cover people of all ages. There is legislation before Congress, notably H.R. 676, the “Expanded and Improved Medicare for All Act,” which would do precisely that.

What is truly unrealistic is believing that we can provide universal and affordable health care in a system dominated by private insurers and Big Pharma.

The American people desperately need a universal health system that delivers comprehensive, equitable, compassionate and high-quality care, with free choice of provider and no financial barriers to access. Polls have repeatedly shown an improved Medicare for all, which meets these criteria, is the remedy preferred by two-thirds of the population. A solid majority of the medical profession now favors such an approach, as well.

We pledge to step up our work for the only equitable, financially responsible and humane cure for our health care ills: single-payer national health insurance, an expanded and improved Medicare for all.

https://www.pnhp.org/news/2015/june/%E2%80%98subsidies-upheld-but-health-needs-still-unmet%E2%80%99-doctors-group

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Comment:

By Don McCanne, MD

Before the release of the Supreme Court decision on King v. Burwell, there was extensive speculation on the relatively narrow topic of what would happen if some individuals lost their subsidies for purchasing plans in the insurance exchanges. Following the decision supporting the subsidies, much of the reporting has shifted to the view that the Affordable Care Act (ACA) is here to stay; the inherent infrastructure of ACA will guide further reform. Unfortunately, this framing of the issues has diverted us from the conversation that we need to be having.

When considering what needed to be done, ACA fixed very little of our health care financing system. This victory being celebrated now upheld premium subsidies that will allow less than two percent of the population to keep their ACA exchange plans – mostly low-actuarial-value underinsurance plans. To characterize this as the make-or-break Supreme Court decision for health care reform is entirely missing the essence of an equitable health care financing system.

On the day that the Supreme Court decision was announced, a link to the PNHP statement was included in the Quote of the Day message. That was not enough. The PNHP statement does catch the essence of the problem and thus is being distributed in full as today’s message. It should be shared widely with others since true health care equity is what the nation now needs to be talking about.

Undocumented immigrants help keep Medicare solvent, according to new study

By George Lauer
California Healthline, June 29, 2015

Undocumented immigrants pay billions more into Medicare every year than they use in health benefits, and in fact they subsidize care for other Americans, according to researchers.

A study published in the Journal of General Internal Medicine contends that undocumented immigrants generated surplus Medicare contributions of $35.1 billion from 2000 to 2011, extending Medicare’s estimated life span by one full year. The study appeared earlier this month as an “online first” article in the Journal of General Internal Medicine and will appear in a forthcoming print edition of the journal.

Researchers from Harvard Medical School, the Institute for Community Health and City University of New York’s School of Public Health at Hunter College found that in one year alone — 2011 — undocumented immigrants generated an average surplus of $316 apiece for Medicare. Other Americans generated an average deficit of $106 apiece. Undocumented immigrants contributed $3.5 billion more than they received in care in 2011, according to the study.

Researchers concluded that restricting immigration would be bad for Medicare’s financial health. They estimated that contributions from undocumented immigrants during the first decade of the century prolonged Medicare’s trust fund solvency by one year. The trust fund is predicted to be insolvent in 15 years.

Background and study methodology

Undocumented immigrants are not eligible to participate in government health programs, including Medicare and the Affordable Care Act, but they do contribute by paying taxes. Payroll taxes are the major revenue source for Medicare’s trust fund, used primarily to pay hospital bills. Using an Individual Tax Identification Number or an unauthorized Social Security number, most undocumented immigrants — the estimate in California is 90% — pay payroll taxes.

Researchers examined Medicare trust fund contributions and expenditures from 2000 through 2011, comparing data from the Census Bureau’s Current Population Survey to calculate tax contributions. They used the HHS Medical Expenditure Panel Survey to determine medical expenses paid by Medicare.

“For years I have seen my unauthorized immigrant patients be blamed for driving up health care costs,” lead author Leah Zallman, a faculty member at Harvard Medical School and researcher at the Institute for Community Health said in a prepared statement. “Yet few acknowledge their contributions. Our study demonstrates that in one large sector of the U.S. health care economy, unauthorized immigrants actually subsidize the care of other Americans.”

CMS officials declined to comment on the research, citing a standing policy against commenting on “outside studies.”

Implications for Medi-Cal

Although the research dealt exclusively with Medicare — the federal health coverage program for seniors and those with disabilities — the findings have implications for Medicaid — the state-federal partnership providing health care for those with low incomes — according to California Insurance Commissioner Dave Jones (D).

“While these are two different programs with different funding sources, I think there’s no question that this study lends support to the efforts to extend Medi-Cal coverage to undocumented immigrants. I think many of the same points in this research — that undocumented immigrants contribute tax money to support government programs — applies to Medicaid and California’s Medicaid program, Medi-Cal,” Jones said.

Zallman said the study’s underlying message — that undocumented immigrants’ contributions should be recognized and appreciated — applies to Medicaid, as well.

“I think our study should cause us to re-examine our assumptions about the impacts of unauthorized immigrants in other sectors such as Medicaid,” Zallman said.

Daniel Zingale, senior vice president at the California Endowment, said the Medicare research showed similar results to the Endowment’s own efforts to secure health coverage for undocumented Californians.

“These findings mirror what we found in California — that undocumented people contribute far more than they take out,” Zingale said.

As part of its Health4All campaign, the California Endowment did similar research in California and found undocumented Californians paid $3.2 billion in state and local taxes in 2012.

The Endowment’s statistics are included in a You Tube video, California’s Hidden Truth.

Research may affect immigration reform

Jones and Zingale predicted the Medicare research would help advance immigration reform efforts.

“I believe this may be the first study to analyze the impact of unauthorized immigrants on the national Medicare program,” Jones said. “The information is well researched and well documented and clearly shows they have had a very positive impact.”

Jones said the study goes one step further and predicts that immigrants will continue to bolster Medicare’s trust fund under President Obama’s immigration reforms.

“This study also analyzes the potential impact of the president’s efforts if the courts allow him to move forward with immigration reform to enable some portion of the unauthorized population to stabilize their status and move forward on a path to citizenship. The net contributions persist even if there’s a path to citizenship,” Jones said.

Zingale said Medicare’s national status will help broaden the immigration arguments his organization has been making in California.

“This is another installment in a mounting number of facts that show how undocumented people are good for the health of our country,” Zingale said. “Because Medicare is a big deal, it will advance that progress toward a greater understanding.”

Zingale and Jones both pointed to California’s budget agreement last week that includes health coverage for undocumented children.

“Clearing the way for children of unauthorized immigrants to join Medi-Cal is a good first step,” Jones said.

“We’re calling that the first ever health for all kids budget,” Zingale said. “That shows you how far we’ve come. That budget received Republican votes. Indeed, we are in a very different place than we were just a few years ago. Remember Proposition 187?”

In 1994, California voters approved Prop. 187, a controversial ballot measure denying public services — including health care and education — to undocumented immigrants. Courts declared much of the initiative unconstitutional and last year, Gov. Jerry Brown (D) signed legislation repealing unenforceable provisions of the proposition.

Ties to national physicians group

Physicians for a National Health Program, a national advocacy organization, is helping spread the word about the Medicare research.

Although the group “had no role in conducting, financing or otherwise supporting the research, it decided to help publicize the study and its findings because they are consistent with PNHP’s mission statement,” Zallman said.

The organization’s mission statement, in part, says:

“PNHP believes that access to high-quality health care is a right of all people and should be provided equitably as a public service rather than bought and sold as a commodity.”

Two of the Medicare study authors — Steffie Woolhandler and David Himmelstein, both professors of public health at City University of New York and lecturers in medicine at Harvard Medical School, are co-founders of PNHP.

George Lauer is California Healthline features editor.

http://www.californiahealthline.org/insight/2015/undocumented-immigrants-help-keep-medicare-solvent-according-to-new-study

Does Justice Scalia’s dissent help us understand political polarization in the U.S.?

Justice Scalia, dissenting

Supreme Court of the United States, No. 14-114, King v. Burwell

(The following paragraphs are not in continuity in the dissent.)

Faced with overwhelming confirmation that “Exchange established by the State” means what it looks like it means, the Court comes up with argument after feeble argument to support its contrary interpretation. None of its tries comes close to establishing the implausible conclusion that Congress used “by the State” to mean “by the State or not by the State.”

The Court’s next bit of interpretive jiggery-pokery involves other parts of the Act that purportedly presuppose the availability of tax credits on both federal and state Exchanges.

The Court persists that these provisions “would make little sense” if no tax credits were available on federal Exchanges. Ante, at 14. Even if that observation were true, it would show only oddity, not ambiguity.

The Court claims that the Act must equate federal and state establishment of Exchanges when it defines a qualified individual as someone who (among other things) lives in the “State that established the Exchange,” 42 U. S. C. §18032(f)(1)(A). Otherwise, the Court says, there would be no qualified individuals on federal Exchanges, contradicting (for example) the provision requiring every Exchange to take the “‘interests of qualified individuals’” into account when selecting health plans. Ante, at 11 (quoting §18031(e)(1)(b)). Pure applesauce. 

The Court has not come close to presenting the compelling contextual case necessary to justify departing from the ordinary meaning of the terms of the law. Quite the contrary, context only underscores the outlandishness of the Court’s interpretation. Reading the Act as a whole leaves no doubt about the matter: “Exchange established by the State” means what it looks like it means.

On the other side of the ledger, the Court has come up with nothing more than a general provision that turns out to be controlled by a specific one, a handful of clauses that are consistent with either understanding of establishment by the State, and a resemblance between the tax-credit provision and the rest of the Tax Code. If that is all it takes to make something ambiguous, everything is ambiguous.

The Court protests that without the tax credits, the number of people covered by the individual mandate shrinks, and without a broadly applicable individual mandate the guaranteed-issue and community-rating requirements “would destabilize the individual insurance market.” Ante, at 15. If true, these projections would show only that the statutory scheme contains a flaw; they would not show that the statute means the opposite of what it says.

So even if making credits available on all Exchanges advances the goal of improving healthcare markets, it frustrates the goal of encouraging state involvement in the implementation of the Act. This is what justifies going out of our way to read “established by the State” to mean “established by the State or not established by the State”?

Worst of all for the repute of today’s decision, the Court’s reasoning is largely self-defeating. The Court predicts that making tax credits unavailable in States that do not set up their own Exchanges would cause disastrous economic consequences there. If that is so, however, wouldn’t one expect States to react by setting up their own Exchanges? And wouldn’t that outcome satisfy two of the Act’s goals rather than just one: enabling the Act’s reforms to work and promoting state involvement in the Act’s implementation? The Court protests that the very existence of a federal fallback shows that Congress expected that some States might fail to set up their own Exchanges. Ante, at 19. So it does. It does not show, however, that Congress expected the number of recalcitrant States to be particularly large. The more accurate the Court’s dire economic predictions, the smaller that number is likely to be. That reality destroys the Court’s pretense that applying the law as written would imperil “the viability of the entire Affordable Care Act.”

Perhaps sensing the dismal failure of its efforts to show that “established by the State” means “established by the State or the Federal Government,” the Court tries to palm off the pertinent statutory phrase as “inartful drafting.” Ante, at 14. This Court, however, has no free-floating power “to rescue Congress from its drafting errors.”

It is entirely plausible that tax credits were restricted to state Exchanges deliberately—for example, in order to encourage States to establish their own Exchanges. We therefore have no authority to dismiss the terms of the law as a drafting fumble.

Our only evidence of what Congress meant comes from the terms of the law, and those terms show beyond all question that tax credits are available only on state Exchanges. More importantly, the Court forgets that ours is a government of laws and not of men. That means we are governed by the terms of our laws, not by the unenacted will of our lawmakers.

Much less is it our place to make everything come out right when Congress does not do its job properly. It is up to Congress to design its laws with care, and it is up to the people to hold them to account if they fail to carry out that responsibility.

Congress could also do something else altogether, entirely abandoning the structure of the Affordable Care Act. The Court’s insistence on making a choice that should be made by Congress both aggrandizes judicial power and encourages congressional lassitude.

The Act that Congress passed makes tax credits available only on an “Exchange established by the State.” This Court, however, concludes that this limitation would prevent the rest of the Act from working as well as hoped. So it rewrites the law to make tax credits available everywhere. We should start calling this law SCOTUScare.

And the cases will publish forever the discouraging truth that the Supreme Court of the United States favors some laws over others, and is prepared to do whatever it takes to uphold and assist its favorites.

I dissent.

http://www.supremecourt.gov/opinions/14pdf/14-114_qol1.pdf

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Justice Scalia is the Supreme Court’s real loser in Obamacare ruling

By William Yeomans
Reuters, June 26, 2015

It is reasonable to suspect that Scalia’s distaste for the Affordable Care Act, which likely inclined him to bring it down rather than save it, made his textual argument easier for him to make here.

William Yeomans served as Senator Edward M. Kennedy’s chief counsel on the Senate Judiciary Committee and as a Justice Department official.

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Political Polarization in the American Public

Pew Research Center, June 12, 2014

Overall, the public is divided over how far the government should go in providing health care. About half (47%) say the government has a responsibility to make sure all Americans have health care coverage, while 50% say that is not the responsibility of the federal government.

While half say it isn’t the government’s responsibility to make sure all have health care coverage, relatively few want the government to get out of the health care system entirely. Rather, 43% say it’s not the government’s responsibility to ensure health care coverage for all, but believe the government should “continue programs like Medicare and Medicaid for seniors and the very poor.” Only 6% of Americans go so far as to say the government “should not be involved in providing health insurance at all.”

Even among consistent conservatives, there is minimal support for the government having absolutely no role in providing health care. Three-quarters of consistent conservatives (75%) say the government should continue Medicare and Medicaid while just 20% think the government should not be involved in providing health insurance.

http://www.people-press.org/2014/06/12/section-4-political-compromise-and-divisive-policy-debates/

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Comment:

By Don McCanne, MD

In his dissent, Justice Antonin Scalia placed the importance of a negligible textual drafting error over the importance of the clear intent of the Affordable Care Act (ACA) to expand health care coverage to more people while trying to keep insurance affordable. With a full reading of both the majority opinion and Scalia’s dissent, it is clear that Justice Scalia’s opposition was based on ideology, with only token references to law. That is likely true with Justices Thomas and Alito as well, although they did not explain the basis of their votes.

When the same set of justices review the same laws in arriving at their decisions, yet quite consistently align themselves in two different camps, it is difficult to draw any conclusion other than that the decisions are being based primarily on ideology.

This divide also permeates not only Congress but the entire nation as revealed last year by the Pew Research Center in their comprehensive study of political polarization.

It is difficult for those of us who are ideologically inclined to support social justice goals, such as health care for everyone, to understand those who are opposed. Many try to give both views equal credibility, yet when standing for a principle such as universal health care, it is difficult to assign the same cogency to a view in opposition.

The Pew study suggests that there is greater agreement on the fundamental moral principles  such as ensuring health care coverage. Three-fourths of conservatives say that the government should continue Medicare and Medicaid. Yet half of the nation continues to support politicians who campaign using conservative and libertarian rhetoric.

We have been traveling the last ten days and have engaged in many conversations with individuals holding widely varying political views. Specifically on health care, those opposed to reform seemed to explain their positions through empty rhetorical memes such as those that are frequently present in the selected Fox News programs that are ideologically biased. In attempting to ferret out the reasoning behind these statements, it seemed to me that these individuals were not well informed on actual facts and policy implications, often admitting that they didn’t understand the details. This in no way is meant to criticize them but rather is an observation that many important principles of reform have not been widely distributed to the public.

But can we assume that Justice Scalia did not understand the adverse consequences that his warped interpretation of the intent of ACA would potentially have on the health of millions of Americans? Does it not represent an uncaring view when he ridicules the majority decision with terms such as “jiggery-pokery,” “pure applesauce” and “SCOTUScare”? It is very difficult to assume that there is no fundamental ethical transgression here.

Politicians frequently bury their advocacy for harmful public policies under rhetorical memes, thereby hiding their support for the rich and powerful. But the public at large? When they understand the issues, they do seem to support doing the right thing. But all too often it seems too easy for them to accept and spread the rhetoric assuming that there is not much more behind the memes which represent “the truth,” and thus it is not worth their time to learn more.

Living in Orange County, many of our friends are conservative. Most of them do support health care for everyone, just as, nationally, three-fourths of conservatives support Medicare and Medicaid. Wouldn’t it be nice if, after some introspection, caring conservatives selected candidates who do share their values on health care for all? Maybe some of the politicians already do and would gladly change their rhetoric if they thought their constituents agreed.